Treatment of Prostate Cancer: Options and Outcomes in Early Stage with Surgery Vs Radiation
Prostate cancer (PC) is the most commonly diagnosed cancer among men. Prostate cancer is found, in most men, when the cancer is still in its early stages and has not spread beyond the prostate gland itself has been termed “localized prostate cancer (LPC)”. The most common treatments for LPC are surgery and radiation therapy.
In LPC, treatment options offered must take into consideration the individual patient’s age, overall general health, cancer aggressiveness, and possible side-effects that might arise with the type of treatment chosen. Prostatectomy, the surgical removal of the entire prostate gland, is associated with greater risk of urinary incontinence and erectile dysfunction, whereas radiotherapy is more likely to cause bowel problems.
The modern day Radiotherapy techniques have evolved to precision and accuracy to such an extent that the bladder and bowel side effects seen in yonder years are not so common now. These preference-sensitive choices can cause serious concern in a patient with LPC.
Although, both prostatectomy and radiotherapy seem to offer similar cure rates, they both have different impacts on the quality of life. The recent landmark randomized clinical trial, the Prostate Testing for Cancer and Treatment (ProtecT) trial, compared treatments for LPC and found no difference in prostate cancer-specific mortality based on treatment option at a median of 10-year follow-up. Furthermore, there is evidence that the 5-year survival for men with LPC is very high at 95%.
Treatment options for men diagnosed with early LPC include:
- Conservative active surveillance (very low risk disease)
- Radical prostatectomy surgery via open, laparoscopic, or robot-assisted (robotic) procedure (intermediate and low risk disease)
- Radiotherapy delivered by externally using external beam(IGRT) or stereotactic radiotherapy(SBRT / Cyber knife therapy) or internally via brachytherapy (low, intermediate &high risk disease)
International guidelines do not indicate a single most appropriate treatment for managing LPC. The recommendation is that patients be informed about all treatment options based on the cancer severity, and their preferences to finally guide decision-making.
In this complex situation, many patients face a big dilemma. Shared decision making with family, friends, and other men who have undergone similar situations can certainly help. More than one medical opinion may also be a fair choice; surgeons will favor the latest robotic surgery which delivers precise removal of the gland. On the other hand, radiation oncologists will prefer offering proton beam therapy or one of the short SBRT treatments. It has been reported that treatment choice is heavily influenced by clinician specialty, and treatment preference varies based on the number and type of specialists consulted.
Robotic prostatectomies have become increasingly popular in the last decade. But the clinical evidence in its favor remains mixed. Robotic prostatectomy has been associated, in some observational studies, to cause slightly lower rates of intraoperative and perioperative complications and other adverse events than other open or laparoscopic surgeries. However, positive surgical margin rates appear similar to open prostatectomy.
A recent report found no difference in urinary or sexual function 12 weeks after either a robotic or open prostatectomy.
Early LPC patients are well served by external beam radiation. The 10-year outcome is equal to that obtained by radical prostatectomy in similar patients without the operative mortality or incontinence. Ten-year cure has been confirmed by PSA studies in irradiated patients.
Radiotherapy appears to be a viable alternative to surgery, offering excellent long-term cancer control, even in patients younger than 70 years.