Carlos G. Arcangeli, MD & Mark A. Rosen, MD

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• How do patients choose the “right” prostate cancer treatment?

How do patients choose the “right” prostate cancer treatment?

There are a number of standard treatments for localized prostate cancer, including surgery, radiation treatments, and cryosurgery. There is still controversy over which treatment offers the best chance of curing prostate cancer, and each of the treatments carries certain risks. Balancing the chance for cure and the risks of the treatments is the difficult dilemma for men with prostate cancer, and the urologist’s job is to help each man find the treatement that will be best for him.

There are no randomized trials comparing the standard treatments, but there is data available on thousands of patients treated with surgery, radiation therapy, radioactive seed implant, and cryosurgery. The study shown above is from 2004 and shows results from a single institution. This study found little difference in cure between the different treatments. On the other hand, a study published in 2009, analysing data on 8,321 men from multiple institutions, showed that men treated by external beam radiation had a nearly two-fold higher chance of dying of prostate cancer than men treated with surgery. Other studies show a high chance of long-term cure with prostate seed implant and prostate cryosurgery for most men. These studies, and others, show that all of the standard treatments have a good chance of curing prostate cancer when it has been caught early. A prostate treatment nomogram developed at Memorial-Sloan Kettering Cancer Center allows men to enter information about their cancer and predicts the chance of cure from each of the standard treatments. Men may click here to use the prostate treatment nomogram.

The difficult decision that patients have to make between treatment choices is not only about which treatment has the higher chance of cure, but is also about which risks the patient wants to take, how they feel about the various treatments, and how his overall health affects the treatment results. It is very important that patients understand that there are advantages and disadvantages, or risk and benefits of each of the standard treatments. Studies have shown that at least 90% of patients are satisfied with the treatment choice they make if they are adequately informed about the advantages and disadvantages of each. We feel that our role is to help each patient choose the treatment that is right for him.

Advantages and Disadvantages of Standard Treatments for Localized Prostate Cancer

The table below outlines the advantages and disadvantages of the standard treatments for localized prostate cancer. The treatment of advanced prostate cancer (cancer that has spread beyond the prostate and is detected in lymph nodes, bones, or other organs) usually starts with hormonal therapy. Click here to learn more about treatment of advanced prostate cancer.

Treatment	Advantages	Disadvantages
Observation	risk of spread of cancer in 5 years is very low	risk of spread of cancer or death is higher than other treatments by 15 years may lose chance to cure cancer requires biopsies every few years as part of followup most patients end up choosing a different treatment within 3 years
Surgery
Open radical retropubic prostatectomy	find out more detail about extent of cancer can have radiation after surgery if necessary short surgery time (2 hours) extremely low risk of long-term bowel or bladder problems Available in SC but rarely performed anymore	small risk (<5%) of incontinence significant risk of impotence (age related) risks of surgery (e.g. 5% risk of transfusion) 6 weeks recovery, 2-3 weeks with catheter
da Vinci prostatectomy (robot-assisted laparoscopic prostatectomy)	same benefits as open surgery one-tenth blood loss of open surgery less post-op pain than open surgery shorter hospital stay than open surgery shorter catheter time (usually 7 days) than open surgery shorter time to full recovery than open surgery same chance of urinary control and recovery of sexual function Available in SC since 2003	longer operation (3-5 hours) may not be suitable for men with multiple prior surgeries or very large prostates
Cryosurgery (freezing of prostate)
cryosurgery of entire prostate	single outpatient treatment minimal risk of incontinence (<5%) may be repeated in future if necessary no risk of long-term prostate pain as can happen after radiation treatments radiation treatments possible in future if necessary Available in SC	high risk of impotence 1-2 weeks to regain good urination after treatment 3-6 months of mild urinary symptoms surgery to remove prostate after cryosurgery is more difficult
focal cryosurgery (treatment of only area with cancer)	more limited treatment lower risk of impotence can be repeated in future Available in SC	requires extensive “mapping” of prostate to locate all areas of cancer requires more frequent biopsies to monitor cancer surgery to remove prostate after focal cryosurgery may be more difficult
Radiation Treatments
External Beam Radiation	no surgery or anesthesia easily tolerated by older men (80-90 yrs) no risk of incontinence cutting ege IMRT available in Santa Cruz	long treatment time (40 minutes per day, 5 days per week, 8 weeks) 30-50% chance of mild diarrhea during treatment 30-50% chance of mild urinary symptoms during treatment 4-6 weeks to recover to normal “energy levels” after treatment low risk (5%) of permanent intestinal side effects (rectal pain, diarrhea, bleeding) or urinary side effects (bleeding, scar tissue, bladder irritation) may make urinary symptoms worse 50% risk of impotence by 3 yrs. surgery after radiation is risky
proton-beam external radiation	treatment exactly same as standard 3-D conformal external beam	requires patient to move to Loma Linda, CA for 8 weeks usually given as half standard external beam, half proton-beam side effects same as external beam cure rate same as external beam
radioactive seed implant	single, outpatient treatment no risk of incontinence lower risk of impotence than external beam or surgery for many men (30% no change in erections, 50% require medication, 20% become impotent) minimal risk of rectal side-effects Available in SC	all patients have some urinary side-effects (slow stream, mild burning, frequent voids) for 3-6 months after implant small risk (5%) of long-term prostate pain or irritation surgery after seed implant is risky not suitable for larger prostates
high dose-rate brachytherapy (HDR)	temporary prostate implant no risk of incontinence similar risk of impotence as seed implant low risk of rectal side effects may be suitable for larger prostates	requires overnight hospital stay usually requires external beam radiation also surgery after HDR is risky not available in Santa Cruz

How do patients decide which treatment is “right”?

A man with localized prostate cancer has a difficult decision deciding which of the treatments is best for him. It is important to spend as much time as necessary to make the right decision, and some men may spend several weeks considering options and getting opinions from their urologist, radiation oncologist, friends, and family. Some of the more important elements in the decision making process are listed below.

“Feelings” about surgery versus less invasive treatments

Some patients feel strongly that they want surgery if they have cancer because they want the cancer “cut out” and feel uncomfortable with less invasive treatments. Other men decide they do not want surgery under any circumstance. Each man feels differently and it is important to listen to your “inner voice” regarding the treatments. Information from friends, relatives, and other sources is valuable but each man with prostate cancer should listen to his own “gut feelings” about the different treatments.

Which risks do patients feel comfortable with?

Different men value the advantages and disadvantages differently. For example, some men consider the small risk (5%) of incontinence after surgery to be fairly minor. Other men might feel that even the very small chance of incontinence after surgery is too risky for them. Some men who already have bowel problems might find the risk of intestinal side effects after radiation to be a serious consideration. Each men should consider the risks of each of the different treatments and try to determine which risks he feels comfortable taking before a decision is made.

Age and Overall health

Patient age can play a role in how patients recover from treatments. For example, men over 70 may recover slower from prostate cancer surgery than younger men. Men with serious heart or breathing problems are usually not good candidates for surgery. Men with less than 5 years of life left should strongly consider observation instead of treatment.

Urinary symptoms

Men with moderate to severe urinary symptoms are often better off choosing surgery, because men urinate with a strong stream and less trouble after surgery. Men with small prostates and less symptoms will usually do well with any of the treatments, including laparoscopic surgery or cryosurgery. Men can click here to calculate the AUA Symptom Score, a standard way that urologists estimate the severity of a man’s urinary symptoms.

Sexual Function

For some men the preservation of good sexual function is an important or primary goal, and may be a major factor in their decision about treatment. For other men who are not sexually active or are already impotent, the risk of impotence may play little or no role in their decision about treatment.