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Choosing the Best Prostate Cancer Treatment

By Durado Brooks, M.D., M.P.H.

More than 238,500 men in the United States will be diagnosed with prostate cancer this year. Most of these men will have to weigh a variety of treatment options and make a series of decisions about managing their disease. Here are some of the important questions men need to ask when facing a diagnosis of prostate cancer, and information they can use to help make these important decisions.

Question:  “Does my cancer need to be treated?”

Answer: The fact that this is even a question comes as a big surprise to many men. The idea that they have cancer — but not treating the cancer — runs counter to the widely held belief that doing something is always better than doing nothing. In fact, most prostate cancers grow very slowly, and men diagnosed with prostate cancer often have other health concerns (like heart disease or lung disease). In many cases these other health issues pose a greater threat to a man’s health than does the prostate cancer.

It is also clear that the most commonly used treatments for prostate cancer can all cause significant side effects and complications (detailed in the next sections) in some men. This combination of slow growing cancer + other health issues + possible treatment complications means that, many times, treating the cancer will cause harm to the man but will not improve his health or extend his life. In other words, for some men, the treatment can actually be worse than the disease.

This conundrum has led to the investigation of “observational approaches” to managing localized prostate cancer (cancer that has not spread outside of the prostate gland at the time of diagnosis). Observation is also referred to as “watchful waiting” or “active surveillance.” A man choosing observational management does not initially receive any active treatment for his cancer. Instead, he is followed by his doctors, and treatment is offered only if he develops symptoms, or if new test results suggest the cancer is growing or spreading.

In one recent study of this approach, a group of men with prostate cancer who chose not to receive treatment were followed closely by their doctors, and their health status was compared with a similar group of men who underwent surgery for their cancers. After 10 years of follow up, about half of the men in each group had died, but most of these deaths were due to heart disease or other health problems. Only a small number of men (less than 10 percent) in either group died from prostate cancer.

These findings reinforce the old saying that many more men die with prostate cancer than from prostate cancer. This study and others have demonstrated that observation is a reasonable management strategy for many men with early stage prostate cancer. However, many men with prostate cancer either are not offered or are not accepting this approach, and 9 out of 10 men with prostate cancer choose to be treated with surgery, radiation, hormones, or some combination of these.

Q: “What’s the best treatment for prostate cancer?”

A: For men with localized prostate cancer who are not candidates for observation alone, or who aren’t comfortable with this approach, there are a number of options to treat their disease. The most common treatments chosen by men in the us are surgery (nearly half of all men), followed closely by radiation treatment (about 40 percent).

There is at present no reliable evidence that one of these treatments is “better” than the other for the long-term management of prostate cancer. Instead, studies show that most men with localized prostate cancer will do well for at least 10 to 15 years no matter which of these treatments they choose. Indeed, the 5-year survival rate for localized prostate cancer in the U.S. is nearly 100 percent (meaning fewer than 1 of 100 men with prostate cancer will die of this disease in the first five years after diagnosis), and the 10-year survival is nearly 98 percent.

So the decision between surgery and radiation often comes down to how men think and feel about the potential short-term and long-term side effects and complications of these treatments — not the risk of dying.

Q: “What are the most common side effects of prostate cancer treatment?“

A: The two most common complications of both surgery (called prostatectomy) and radiation are sexual and urinary difficulties — but there are differences in the timing of their appearance. During prostatectomy, it is common for some damage to occur to the bladder, the urethra (the tube that carries urine) and the nerves that control erections. This is because the bladder is next to the prostate gland, and the urethra and erection nerves run through the gland. For many men normal urine function returns, and normal sexual function comes back over time as well. However, it is estimated that 200 to 300 out of every 1,000 men undergoing prostatectomy will have long-term difficulties with urine control, having erections, or both. It has also been shown that up to 5 in 1,000 men will die within one month of prostate cancer surgery from infections, heart attacks, strokes, or other non-cancer related issues.

Radiation for prostate cancer can be delivered in different ways. All of these treatment approaches are designed to kill cancer cells in the prostate and to minimize damage to the nearby bladder, urethra, and nerves that control erections, but damage to these structures still occurs. Regardless of which form of radiation treatment is chosen, the chances of these complications are similar to the rates seen after surgery — with 200 to 300 out of every 1,000 men experiencing long-term urinary or sexual difficulties.

The main difference between surgical and radiation-related complications is when they occur. Difficulty getting erections appears immediately following surgery, and, in many cases improves over time. In contrast, sexual difficulties related to radiation usually begin months to years after the initial treatment. By about 5 years after treatment, the rates of sexual difficulties are similar for men treated with surgery or radiation. There is often a similar delay for urinary problems after radiation treatment. Damage to sensitive rectal tissues is an additional risk with radiation; some men will develop rectal pain, bleeding, and bowel problems that may last for months or years.

Q:  “Is robotic surgery better than other types of surgery?”

A: Prostate surgery can be done in a number of different ways, but over the past 10 years, “robotic” prostatectomy has become the most common approach and is now used for more than 80 percent of prostate removals in the U.S. This procedure uses a mechanical arm and magnification system that is operated by the surgeon from a control panel set up in the operating room. This system allows the surgeon to have a better view of the prostate gland and surrounding structures and to remove the diseased gland while causing little harm to the adjacent normal tissues and organs. In theory, this decreases the risk of urinary and sexual complications, but there is little evidence that these goals are routinely achieved. Most studies that have compared robotic surgery with a traditional surgical approach have not found a lot of difference between the two in the chance of the cancer coming back or the likelihood of sexual or urinary complications.

Q.  “Is proton therapy better than other types of radiation?”

A: Just as the use of robotic surgery has increased rapidly in recent years, there is a new method of radiation treatment called proton beam therapy that is growing dramatically. Instead of the photons used in traditional radiation treatments, proton beam therapy uses different sub-atomic particles (protons) that are designed to deliver a very high dose of radiation to the cancer cells but release very little radiation on the way to the tumor; the idea is that this limits the damage to normal surrounding tissues. But as with robotic surgery, these theoretical benefits have not yet been proven.

Only a few studies have looked at the impact of proton beam therapy on prostate cancer, and most research suggests that treatment with protons is probably equal to other forms of radiation treatment at controlling the growth and spread of prostate cancer — but there is no evidence that proton therapy is better. There is also no convincing evidence that complication rates are lower with proton therapy.

Q: “What other prostate cancer treatments are available?”

A: Hormone treatment, called androgen deprivation therapy or “ADT”, is sometimes used for localized cancer, usually in addition to radiation treatment. Other approaches approved to treat early stage prostate cancer in the U.S. include cryotherapy, which kills cancer cells by freezing the prostate gland; and stereotactic body radiation therapy (SBRT, sometimes referred to as “cyberknife” treatment), which is designed to deliver high doses of radiation to tumors. Only about 1 in 10 men currently choose these methods as the first choice to treat prostate cancer. For more about these treatments, please read “How is prostate cancer treated?” at cancer.org/prostatecancer.

Q: “How do I choose a doctor and facility to treat my prostate cancer?”

A: Experience is the best teacher when it comes to treating prostate cancer — whether with surgery or radiation. Studies show that patients of surgeons and hospitals that perform more surgeries have better outcomes (lower complication rates and less likelihood of the cancer returning). The experience of the surgeon is also more important than the type of surgery: surgeons who perform a high number of surgeries (30 or more every year) have better outcomes, whether using a robotic or a traditional approach. Many men are not aware of the benefits of choosing an experienced surgeon, or simply assume that their doctor has the needed experience, which explains why nearly half of prostate removals in the U.S. are done by surgeons who do fewer than 5 such operations per year.

Men should ask their doctor the following questions:

•How many prostate cancers do you treat each year with the method that I’m considering (e.g. brachytherapy or external beam radiation or traditional surgery or robotic surgery)?

•How many are done each year in the hospital/treatment facility where I will be receiving care?

•Do you keep track of how many patients have sexual problems, urinary issues, or recurrence of their cancer?

•How do these outcomes compare with those reported by other doctors providing the same type of care (locally and nationally)?

For more information, please visit cancer.org/cancer/prostatecancer.l

Dr. Brooks is director of prostate and colorectal cancers for the American Cancer Society.

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