Deciding on a Treatment

There are over a dozen different treatment options for prostate cancer, although they can be grouped into five big categories of surgery, radiation, ablation, hormonal therapy and observation:

    • Traditional surgery (+/- nerve sparing)
    • Robotic surgery / DaVinci (+/- nerve sparing)
    • Intensity Modulated Radiation Therapy (IMRT) 33 – 45 sessions
    • Hypofractionated IMRT (shorter course) of 20 – 28 sessions.
    • CyberKnife / Stereotactic Body Radiation Therapy (SBRT) of 5 sessions.
    • Proton Therapy
    • Temporary High Dose Rate (HDR) brachytherapy (+/- 25 sessions IMRT)
    • Permanent Seed Implant brachytherapy (+/- 25 sessions IMRT)
    • Cryotherapy (freezing)
    • High Intensity Focused Ultrasound (HIFU)
    • Given on its own for palliation or to slow down the cancer
    • Given in combination with IMRT to increase chance of cure
    • Watchful Waiting – don’t treat unless cancer causes symptoms.
    • Active Surveillance – monitor carefully and treat if cancer becomes more aggressive.

Usually you can have a choice between different treatments that are good for your particular situation.   Roughly speaking, by looking at the risk level of your prostate cancer and your age / health, you can come up with a list of options.

Here are some guidelines about choosing a treatment:

  • The biggest decision usually comes down to deciding between surgery or radiation.
  • There are virtually no good studies comparing radiation to surgery.  We cannot say if CyberKnife or prostatectomy has a higher cure rate.  We can say that the results seem to be in the “same ballpark”.
  • Many patients are good candidates for either surgery or radiation.
  • Physicians will usually recommend the treatment they perform and/or which they are biased towards.
  • Physicians may use scare tactics to steer you away from other treatments.
  • It is better to have an expert physician and team perform your treatment.  But it can be tricky to determine who is an expert.
  • Friends and family members who have had their prostate cancers treated will often be big proponents of the method and doctor they used.
  • You should ultimately decide on the treatment and physician you are comfortable with and that makes the most sense to you.

Myths about Radiation

Almost all men with prostate cancer have been diagnosed by a urologist, and the surgeon provides the first and often the only opinion about treatment to a patient.  Patients often hear the same phrases over and over from surgeons and others, and I sometimes spend much of a consultation providing counter-explanations:

You have to get surgery

False.  There are always options.

If you take out the prostate you have gotten rid of the problem

False.  After surgery the cancer can still come back in the tissues around where the prostate used to be, in the lymph glands, or in the bones.  In Dr. Walsh’s series of prostatectomy for stage 1 prostate cancer, 10 years after surgery only 70% of men had a zero PSA level.  The other 30% had developed a cancer recurrence or had an elevated PSA which meant that the cancer might recur somewhere in the body one day.

If you leave the prostate in there, cancer can come back in the prostate gland.

In Dr. Katz’s 10 year CyberKnife results the cancer came back in the prostate gland in less than 2% of men.

With radiation there is a chance it could cause other unrelated cancers of the bladder and rectum

True, but it’s about a 1% chance, and typically takes 10 years or longer for this to occur.  However it is something to consider especially for younger men.

When we take out the prostate we can also check to see if the cancer has spread outside of the prostate or to the lymph glands.  We can see if the PSA goes down to zero after surgery.

True, but this knowledge doesn’t make you live longer or improve your chances of cure.  It just gives you earlier information regarding whether you are more likely cured or not.

Radiation is just buying you more time

This is a weird one.  Curing any cancer will of course “buy you more time”.  The goal of radiation is to completely cure the cancer so that it never recurs.   The control rates are excellent for CyberKnife at 5 and 10 years, and there is no reason to think the results will suddenly worsen after 10 years.

If the cancer returns after surgery you can still have radiation.  If you have radiation first, we can’t do surgery if it comes back.  

True but with a large asterisk!   Whether you choose surgery or radiation, if the cancer comes back in the bones or lymph glands then the cancer is no longer curable, and the treatment will be hormonal therapy to slow the cancer down.  It is rare for the cancer to come back in the prostate gland after CyberKnife, and if it does we can still refer you for cryotherapy or HIFU.   So there are backup options.  Also look at the bottom line – the PSA control rate at 10 years was 93% in Dr. Katz’s CyberKnife study, and 70% in Dr. Walsh’s prostatectomy study.

Radiation can damage your bowel and you may need a colostomy bag

To the best of my knowledge I have never treated a prostate cancer patient who went on to require a colostomy bag due to bowel damage.  With modern precise techniques like CyberKnife and SpaceOAR hydrogel, rectal side effects are pretty minimal.  In Dr. Katz study (and SpaceOAR was not even available then), rectal function decreased an average of 4% over 10 years.

It is hard to monitor if the cancer is truly gone after radiation

This is somewhat true.  If you have surgery and the cancer was contained within the prostate gland, and the surgical margins were clear, and the PSA goes down to 0.0, (three big if’s) then you know early on that you were probably cured. Note that in the protectT trial, in men who had surgery 29% were found to have cancer outside the prostate gland, and 24% had positive surgical margins.  After radiation, the PSA can take 1 year to drop below 1.0 and up to 5 years to get down to 0.1, and you perhaps have to be more patient and zen in the knowledge that the cure rates are excellent with CyberKnife.   This situation does not suit everybody.  Some people feel more “sure” with surgery, and these men should perhaps choose surgery.

If I had prostate cancer / my dad had prostate cancer I would choose surgery

Specialists are biased towards their own treatment, and everyone is different and has to choose what makes sense to them.  What I would decide has little relevance to what you would decide.

With your high Gleason score (8 – 10) / aggressive cancer you need surgery

Um… why?  This is based on the false belief that radiation does not kill all the cancer cells in the prostate.  There are no studies comparing surgery to CyberKnife for high Gleason score cancers.   It is true that high Gleason cancers have a higher recurrence rate after any treatment, because the cancer has a higher chance of coming back in the bones or lymph glands.  Often multiple treatments are combined to maximize the chance of curing aggressive prostate cancer, whether that be with surgery + IMRT + hormonal therapy, or CyberKnife boost + IMRT + hormonal therapy, or HDR brachytherapy + IMRT + hormonal therapy.   See my high risk page.

So Who Should Choose Surgery?

  1. Men with a lot of urinary obstruction symptoms or severe prostatitis or prior TURP may benefit, because the prostate gland is removed and the urinary symptoms are improved.  Urinary symptoms may or may not improve with radiation.
  2. People who cannot live with uncertainty, and might feel better knowing early on if the cancer probably is or probably is not cured.
  3. Men who already have erectile dysfunction may have less worries about the risk of that possible side effect, which can be more likely with surgery.
  4. Men choosing surgery should have over a 10 year life expectancy, ie generally be less than 65 – 70 and healthy.