Choosing a Prostate Cancer Treatment: Surgery versus Radiation
Although many treatment options are available, patients with newly-diagnosed prostate cancer often narrow down the choices to two – surgical removal of the prostate or radiation therapy. Since many factors influence this decision, choosing which treatment to use can be daunting.
The biggest advantage to radiation therapy is that it is easier to undergo than surgery. Even with robotic technology, its small incisions are not as small as the openings made by a couple of dozen needles inserted into the skin behind the scrotum when radiation seeds are implanted. General recovery from robotic prostatectomy is usually 2-3 weeks, whereas recovery from radioactive seed implantation is 1-2 days. Many patients who choose the radiation route will also undergo daily external beam treatments for 6-7 weeks.
The biggest advantage to surgical removal is the information learned that is not available through other treatment methods. Once the prostate is removed, it can be fully analyzed to determine the extent, location, and grade of the disease within the prostate and seminal vesicles (and lymph nodes if necessary). More important, the ability to monitor a patient for possible recurrence is dramatically enhanced. When the prostate is removed, the PSA blood test should become undetectable (<0.1) within six weeks if all the cancer cells have been successfully eliminated. Prostate cells (normal or cancerous) are the only source of PSA, a protein made by these cells and partially released into the blood stream.
Following radiation, the PSA in some cases may never become undetectable since the prostate is still present in the body. Furthermore, even with a fully successful cure, the PSA can dramatically fluctuate for the first several years following the radiation treatment. Although most properly selected patients can be cured with either surgery or radiation therapy, detecting the minority of treatment failures in a timely fashion is critical to selecting the appropriate back-up option. With PSA as the only guide, it can be difficult to distinguish between the expected PSA changes – or “bounce” – following radiation from surviving prostate cancer cells lurking in the shadows.
The most significant disadvantage to removal of the prostate is the small possibility of long-lasting bladder control problems. For those below age 65, less than 5% will have any significant post-operative bladder problems. The risk of incontinence following radiation is 1-2%.
The most bothersome possible disadvantage to radiation therapy involves difficulty emptying the bladder. In severe cases, patients can experience debilitating frequent urination (including multiple disruptions of sleep), decreased urinary flow, and pain with urination. The urinary complications of radiation therapy occur in a small minority of patients on a permanent basis, but these conditions can be much more difficult to manage than the infrequent urinary issues associated with prostate removal. Furthermore, in those patients who already experience frequent urination (day or night) or decreased urinary flow, the likelihood of long-lasting symptoms following radiation therapy increases dramatically. In fact, patients with these pre-existing symptoms would most likely notice an improvement after prostate removal.
So, which treatment is better at curing prostate cancer? To determine this, we would need to conduct a very large study of patients (many thousands) willing to have their treatment chosen by the flip of a coin. Since that is not possible, several theories have been proposed. With radiation, since the areas around the prostate also receive a dose, cancer cells that have just penetrated through the capsule can potentially be eliminated. However, this theory is difficult to prove since we do not know which patients have this scenario (no examination of the prostate by the pathologist). In fact, there is some evidence to the contrary. As expected, the precision of radiation therapy has dramatically improved due to advances in technology and experience. If the radiation dose is being targeted better to the prostate and less to the tissues around the prostate, we would expect fewer side effects (less radiation to the nerves, bladder, and rectum) and a lower cure rate for those cancers extending just beyond the prostate. In fact, while the side effects have indeed decreased, the cure rates have remained stable, or improved, over the years. In addition, radiation can be given following surgery for those patients proven to have disease just outside of the prostate, thereby avoiding radiation to the surrounding areas in most patients.
Keep in mind, both procedures are designed for patients with disease confined to the prostate. Complete surgical removal is dependent on one factor for success – location of the cancer. If the cancer is solely contained in the gland, it cannot return following removal. With radiation therapy, three things must happen – the cancer must be confined to the treatment area (as with surgery), the cancer cells must respond by dying, and the entire normal portion of the prostate must die (eliminating any future source of prostate cancer).
Sometimes age can be a consideration in the treatment decision. By no means is the life of a 40 year-old more valuable than a 70 year-old. However, since prostate cancer is usually slow-growing, treatment failures can often be managed in older patients. In the younger patient, surgical removal provides an improved knowledge of disease status with potentially better and more timely back-up options. Whereas radiation can easily be given after surgery, rarely is surgical removal possible following radiation. In addition, younger patients are much more likely to avoid some of the side effects associated with prostate removal. Since some of the risks of radiation can be delayed by years, these issues can be more significant for younger patients. For instance, the risk of secondary cancers of the rectum, bladder, or prostate (a new prostate cancer) can increase many years after the radiation treatment. Of course, any of the potential side effects to the bladder or rectum from radiation therapy are avoided with surgical removal.
Many factors go into deciding the best course of action for treating prostate cancer. These include pre-existing symptoms, extent/volume of disease, Gleason grade, PSA level, age, and emotional factors. Whether choosing surgical removal or radiation therapy, extensive experience of the treating physician is essential in order to maximize a good outcome. Of course, there is no substitute for a direct conversation with your doctor. In the end, comfort with your decision is as important as the decision itself.