Surgery vs. Radiation for Treating Prostate Cancer

If you’re one of the 230,000 men diagnosed with prostate cancer every year, you’re probably dealing with a dilemma of which treatment option to choose. Your doctor has likely spoken with you about radiation and surgery, but how do you choose?

New data presented at the Canadian Urological Association annual meeting in Ottawa further suggests that prostate cancer patients who undergo radiotherapy have a higher risk of subsequent minimally invasive urologic procedures for treatment-related complications compared with those who undergo surgery.

The study led by Christopher J. D. Wallis, MD, of the University of Toronto and his colleagues used the Surveillance, Epidemiology and End Results (SEER)-Medicare registry to conduct a retrospective cohort study of 60,000 men between the ages of 65-79. The men had either underwent a radical prostatectomy (14,492) or radiotherapy (45,984)—either external beam or brachytherapy— for clinically localized prostate cancer.

They specifically measured whether or not patients had incidence of urologic procedures and hospital admissions for complications other than erectile dysfunction or urinary incontinence. Patients that had radiation had a 25-40% increased risk of requiring minimally invasive urologic procedures and an 80% increased risk of hospital admission compared with patients who underwent surgery.

This study is a key indicator that each treatment for prostate cancer can have various outcomes. Experts have long debated surgery versus radiation, especially when it comes to treating prostate cancer. Surgeons of course push surgery and radiation oncologists push radiation. But the truth is surgery is the only option that gives an accurate staging of the cancer.

Prostate cancer is the 2nd most common malignancy, second only to skin cancer, in men. Unfortunately over 230,000 men are diagnosed with the disease every year, translating into 1 in every 7 men being affected by prostate cancer. Being diagnosed with cancer usually sets off a cascade of emotions, making patients feel confused, anxious, and at times, even hopeless. All too often this is compounded by the challenges of determining a plan of action to treat ones disease.

Traditionally, patients had two main treatment options: surgery or radiation. Based on a patient’s goals, disease state, and health, an appropriate treatment plan would be made. However, over the past decade the marketplace has become flooded with new technologies for cancer treatment. Furthermore, patients are relying less on their physician to make the decision for them and are taking an active role. As newer therapies are introduced, patients are not always equipped to entangle marketing from medical facts.

Robotics is one such technology that has been quickly embraced and adapted to medical therapy. In the case of robotic prostate surgery, the robot builds on concrete oncologic principals. Early on it was shown that removal of the cancerous tissue, in this case the prostate, results in improved survival. Robotic surgery increases the magnification and visualization of the surgical field while allowing for precise and intentional movements. As a result, in the hands of a skilled surgeon, the prostate can be removed with greater attention resulting in improved functional outcomes, decreased blood loss, and a shorter recovery.

Robotic surgery continues to prove a better treatment for cancer over radiation. Following diagnosis, patients are presented with a lot of information, in order to make sense of the different treatment options. This can make even the most educated patient uncertain. While the internet contains many valuable resources, advertisements are often cloaked as educational tools, and patients should be cautious. While it is important to be educated regarding your disease, going to a search engine is not always the best first step. Talking with your physician and asking for recommended resources is a safer way to start your education.

Robotic radiosurgery or Cyberknife is a completely different adaptation of robotic technology. First the name radio surgery is misleading as this is not actually surgery but rather radiation therapy. In this treatment modality, a computer programed robot is employed to reposition the radiation beam in order to deliver targeted therapy. Originally the technology was developed for dynamic tissues, like the lung which are in constant movement.

While radiation therapy has been employed by oncologists for decades, the Cyberknife utilizes a dramatically different dosing regimen called hypofractionation. Traditionally, external radiation is given over approximately 40 treatments; with hypofractionation, patients receive less than half the traditional radiation dose in a significantly shorter period of time. Overall, radiation therapy for prostate cancer does not improve disease failure rates and causes significantly more urinary function problems in most patients.

So take the time to speak with your physician about the options that will most benefit you in the long run. As prostate cancer is often referred to as “The Silent Killer” the critical action men must make is an effort to get screened, to catch this disease early because in the end “the silent killer” doesn’t always have to kill.

Patients diagnosed with prostate cancer must weigh their treatment options with their personal treatment goals.  Regardless of therapy, strongly consider physician experience. Choose wisely: it is with the robot that a surgeon completes the surgery, not the robot itself. The experience of the surgeon is one of the most important factors to consider.

Surgery

·        Length of Treatment

o   One-time treatment for 2-4 hours, on average

o   1-2 night hospital stay, on average

·        Accuracy of Treatment

o   Very accurate: prostate gland is visualized and removed

·        Side Effects During Treatment

o   Anesthesia

·        Hormone Therapy Necessary?

o   No

·        Cancer Staging

o   Very accurate because entire specimen can be analyzed

·        PSA Follow-Up

o   Testing begins at 6 weeks post-operative

o   PSA remains <0.1

·        Side Effects After Treatment

o   Impotence and incontinence

·        Risk of Impotence & Incontinence   

o   Improves with time

·        Secondary Therapy Possible?

o   Yes, radiation is possible after surgery

·        Increased risk for second cancer?

o   No

Radiation

·        Length of Treatment

o   EBRT is typically administered 5 days a week for 5-6 weeks

o   CyberKnife® is typically done over the course of 1-5 treatments per day

·        Accuracy of Treatment

o   Not accurate: radiation is targeted at prostate based on imaging data, dosage and location is approximated

·        Side Effects During Treatment

o   Fatigue, skin inflammation, frequent/difficult/uncomfortable urination, rectal bleeding or irritation, hemorrhoids, diarrhea

·        Hormone Therapy Necessary

o   Lupron a prescription given along with RT, which has its own panel of side effects, similar to menopause

·        Cancer Staging

o   No accurate: exact type of prostate cancer not known, extensity not known, seminal vesicle and lymph node involvement not known

·        PSA Follow-Up

o   Testing begins ~2-3 months post-operative

o   Will not reach lowest point for 18-24 months

o   Majority of men experience a “PSA Bounce” (a temporary rise in PSA) where the PSA rises ~15% post-treatment, then declines again

·        Side Effects After Treatment

o   Bowel dysfunction

o   Impotence and incontinence

·        Risk of Impotence and Incontinence

o   Worsens with time

·        Secondary Therapy Possible

o   No: Surgery is very difficult to do post-radiation

·        Increased Risk for Second Cancer

o   Yes: a 5% increased risk of rectal or bladder cancer