Recently I have seen multiple men in consultation for a second opinion regarding their prostate cancer. Interestingly, I’ve found that it’s not a second opinion they are seeking but a 4th or 5th. I have commended these well-informed men for exploring their options. They have met with surgeons, radiation oncologists, read through the medical literature online, but their anxiety regarding moving forward is consuming.
The anxiety around selecting a cancer treatment is understandable. Below is my attempt to summarize the treatment paradigm that I use to counsel my friends and family.
Caveat: Each person’s health and case is unique. I will attempt to be concise here but you can request a consultation through this site (virtual or in-person) to discuss specific details of your prostate cancer.
Step 1: Know your Risk Group
While your doctor may give your prostate cancer a “Stage”, we rely on the Risk group to determine the treatment. Risk is determined by your PSA, the biopsy, your multiparametric MRI (and by now you should have gotten a multiparametric MRI as part of your work up) and your projected lifespan.
Here are the risk groups used by urologists and oncologists and the recommended treatment options at a high level:
Step 2: How Long Do You Hope to be Alive? Do You Want Treatment?
Seriously. These questions may seem redundant however your physician will consider this when discussing treatment options.
Why? Because not all prostate cancer will become a problem. How do we know this?
The ProtecT trial was designed to evaluate the effectiveness of the three major contemporary treatment approaches to reducing prostate-cancer mortality and improving clinical outcomes in men with PSA-detected clinically localized disease. The results show that death from prostate cancer in such men remained low at a median of 10 years of follow-up, at approximately 1%, irrespective of the treatment.
Consequently, if you are about 70 years or older, your physician is looking at your medical history and trying to determine if you have another medical condition that is likely to end your life before your prostate cancer could ever grow enough to cause you a problem.
In addition, any treatment, doesn’t matter if it’s surgery (robotic, nerve-sparing, cryotherapy) or radiation (IMRT, Protons, Brachytherapy) incurs the risk of side effects.
So back to Question 2: How long do you hope to live? And are you willing to live with side effects of cancer treatment during that time period?
I recommend you and your partner discuss the answers to these questions. While this can be a tough discussion, I find patients feel much better about their decision when they answer the questions vs relying on their doctor to answer for them.
Step 3: What is the Best Prostate Cancer Treatment…. FOR ME?
Both radiation and surgery can “cure” your prostate cancer. For our purposes that means your PSA drops to a low level and stays low. Consequently, the question is not “What is the Best Prostate Cancer Treatment”? The question is “Which treatment is best for me?” Which leads me to…
Step 4: What Side Effects Are You Willing to Accept?
Here are the most common side effects experienced as a result of prostate cancer treatment
- Erectile dysfunction
- Incontinence (leaking urine, wearing a pad/pull up daily
- Changes in urination: increased frequency and urgency, getting up at night
- Changes in bowel habits: Loose stools, diarrhea, rectal bleeding
The ProtecT trial mentioned above examined the side effects reported by men who received treatment with radiation (yellow line), surgery (red line), or patients who were followed on “Active Monitoring” (blue line).
Here are the results.
Erectile dysfunction: worse with surgery
Incontinence: worse with surgery
Getting up at night to urinate (Nocturia)-: worse with radiation (though also occurred in men who didn’t get treatment at all –blue line- likely due to men aging).
Bowel issues: worse with radiation short term but improves over time
Finally, we would expect that bowel issues would be even less in the current treatment era due to SpaceOar hydrogel. Be sure to see if your radiation oncologist offers placement to protect the rectum from high dose radiation.
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.
 Hamdy FC, Donovan JL, Lane JA, Mason M, Metcalfe C, et al. ProtecT Study Group. 10-Year Outcomes after Monitoring, Surgery, or Radiotherapy for Localized Prostate Cancer. N Engl J Med. 2016 Oct 13;375(15):1415-1424. doi: 10.1056/NEJMoa1606220. Epub 2016 Sep 14. PMID: 27626136.
 Donovan JL, Hamdy FC, Lane JA, Mason M, etal. ProtecT Study Group*. Patient-Reported Outcomes after Monitoring, Surgery, or Radiotherapy for Prostate Cancer. N Engl J Med. 2016 Oct 13;375(15):1425-1437. doi: 10.1056/NEJMoa1606221. Epub 2016 Sep 14. PMID: 27626365; PMCID: PMC5134995.
Patient-focused treatment, and an individualized approach to oncology means Dr. Norleena Gullett is not just treating cancer, she's treating the whole person.