In the United States

approximately 192,000 men will be diagnosed with prostate cancer in 2020.1

The average age at diagnosis is 66 and most men live to an average age of 78.6 years.2 That is over a decade men must live with the side effects of prostate cancer treatment. When choosing between Surgery or Radiation for prostate cancer, it is important to know that these treatments provide similar cure rates, however the side effects vary.3,4

Caveat: Active Surveillance is frequently an option for certain men and a way to avoid any side effects.

Historically both surgery and radiation have put men at risk of:

  • Urinary incontinence (leakage) requiring the use of a pad or diaper
  • Erectile dysfunction
  • Bladder and/or bowel damage

Many physicians have attributed the side effects listed above to older treatment techniques, so a newer study, comparing up-to-date radiation and surgical techniques was needed. Dr. Hoffman and colleagues5 recently published this study in JAMA looking at the difference in outcomes and side effects between modern day surgery and radiation treatments.

This was a large study of 1386 men with favorable-risk prostate cancer and 619 men with unfavorable-risk prostate cancer. (Note: your oncologist can tell you which “risk” category you fall in.) This first table (below) shows the number of men in each group and the treatment they received.

The men in the Favorable risk group, had less cancer in their prostate gland and were able to be treated with either:

  • Prostatectomy – surgery to remove prostate, “Nerve-sparing” refers to the surgical technique attempting to avoid the nerves that control erections.
  • EBRT – conventional external beam radiation therapy, using a technique called “IMRT” where the patient lies on a treatment table and receives daily radiation, typically 4-8 weeks.
  • LDR Brachytherapy – a type of internal radiation, where a patient is taken to the OR and radioactive seeds are inserted into the prostate gland. The seeds radioactively decay over the next 3 months and deliver the necessary radiation to kill the prostate cancer.
  • Active Surveillance – No treatment, just follow up visits and tests. This is an option for men with a low volume of cancer confined to the prostate gland. These men have a low risk of the cancer ever spreading (metastasizing) and causing a problem so treatment is avoided to prevent side effects.

The men in the Un-Favorable risk group have more cancer in their prostate gland and there is concern that there even could be cancer outside the prostate gland. Consequently, these patients received either EBRT, as described above, along with ADT, or androgen deprivation therapy. ADT is a series of injections that lower a man’s testosterone and help treat the prostate cancer throughout the body.

While the researchers focused on side effects, it’s important to note that their data did not show any difference between surgery and radiation cure rates. This is reflected in the table below if you look at the estimated 5-year disease-specific survival. The good news for prostate cancer patients is that close to 100% of men were alive 5 years later, so prognosis, regardless of treatment, is excellent.

Consequently, if cure rates are the same, what about side effects from surgery and radiation? Dr. Hoffman and colleagues examined this data and indeed there were differences in side effects. In general, side effects immediately after surgery or radiation improved over time. However, at 5 years post-treatment, surgery was associated with worse urinary incontinence for men with favorable- and unfavorable-risk prostate cancer. The results also showed that for men with unfavorable-risk prostate cancer, surgery resulted in worse sexual function at 5 years when compared to radiation with ADT. The radar plot is available below showing the results for radiation in the blue line and surgical (“radical prostatectomy”) results in the red.

In my practice, I counsel men to carefully consider their treatment options and obtain multiple opinions from both radiation oncologists as well as urologists. Too many men panic at hearing the “C” word and make uniformed, fear-based decisions. In addition, the plots show that even men who followed an “active surveillance” protocol, experienced urinary incontinence and erectile dysfunction, which can be due to age, heart disease, or other conditions un-related to their prostate cancer. It is important to explore all treatment options and understand your specific prostate cancer diagnosis, risk group, and discuss your overall health and lifestyle.

[1] http://www.cancer.org/cancer/prostate-cancer/about/key-statistics.html

[2]Ho JY, Hendi AS. Recent trends in life expectancy across high income countries: retrospective observational study [published correction appears in BMJ. 2018 Aug 22;362:k3622]. BMJ. 2018;362:k2562. Published 2018 Aug 15. doi:10.1136/bmj.k2562

[3] Hamdy FC, Donovan JL, Lane JA, et al; ProtecT Study Group. 10-Year outcomes after monitoring, surgery, or radiotherapy for localized prostate cancer. N Engl J Med. 2016

[4] Hamdy FC.The Prostate Testing for Cancer and Treatment (ProtecT) study: what have we learnt? BJU Int. 2016 Dec;118(6):843.

[5] Hoffman KE, Penson DF, Zhao Z, et al.  Patient-Reported Outcomes Through 5 Years for Active Surveillance, Surgery, Brachytherapy, or External Beam Radiation With or Without Androgen Deprivation Therapy for Localized Prostate Cancer. JAMA. 2020 Jan 14;323(2):149-163.

Patient-focused treatment, and an individualized approach to oncology means Dr. Norleena Gullett is not just treating cancer, she's treating the whole person.