Prostate Cancer Treatment Options

There are many options for the management of prostate cancer including active surveillance, watchful waiting or observation, surgery, radiation, cryotherapy, hormonal therapy and other investigational therapies. Sometimes multiple treatment types are used together in what is called multimodality therapy (such as surgery and radiation or radiation and hormone therapy). The best prostate cancer treatment depends on many factors such as the patient’s age, general health, how aggressive the cancer is and whether the cancer has spread beyond the prostate.

During prostate cancer treatment, there are two main goals:

• Cancer control (attempting to cure the cancer)
• Maintaining a high quality of life (minimizing any side effects of cancer treatment so the patient can live a more normal life after therapy)

How quickly must a treatment decision be made?

While patients shouldn’t unnecessarily put off making a choice, there is no need to rush into a decision. Remember, prostate cancer is typically a slow growing cancer and usually will not spread very fast. Therefore, there is time to gather information and make a good informed decision. In fact, for those deciding to have surgery, it is usually necessary to wait a minimum of six to eight weeks after the biopsy in order to allow the inflammation from the biopsy to resolve.

For patients who are candidates for both surgery and radiation, what are the differences and which one should a patient choose?

Radiation therapy and surgery are both excellent treatments for attempting to cure prostate cancer. They are the two most proven treatments for prostate cancer and both have demonstrated long-term cancer control. Although surgery and radiation have never been directly compared in a head-to-head trial, they have been shown to have similar rates of cancer cure and control. They also have comparable effects on patients’ quality of life with similar risks of urinary and erectile problems after treatment.

Cancer surveillance after treatment is somewhat different for patients who have surgery and those who have radiation. After surgery, if cancer is no longer present, the PSA level should decrease to undetectable levels six to 12 weeks after surgery. When the prostate has been completely removed, PSA becomes a very sensitive test to detect any cancer recurrence. Unlike surgery, after radiation treatment, the PSA level may not decrease to undetectable levels and may fluctuate up and down. After radiation treatment, it can be somewhat more difficult to define when or if a patient has recurrent cancer.

Radiation is also commonly used after surgery (adjuvant or salvage radiation) for aggressive or recurrent cancers. When radiation is used after surgery, it does not typically involve any increased risks compared to its use as primary treatment. While surgery after radiation is possible, most patients are not candidates for surgery in this setting, and the risks of surgery are greater in patients undergoing surgery who have already had radiation than when surgery is used as a front-line treatment. However, there are other options for recurrent prostate cancer after radiation, such as cryotherapy, which may still be used if surgery is not indicated.

Reasons to choose surgery over radiation:

• I am a young healthy man with a long life expectancy and without many health problems
• It is very important to me to have my cancerous prostate removed from my body
• I want the added information that removal of the prostate (and possibly lymph nodes) provides to better assess my prognosis
• I want to have radiation as a possible treatment option if I have a cancer recurrence

Reasons to choose radiation over surgery:

• I am somewhat older or have other health problems which may increase the risks associated with a major surgical procedure
• I would like to avoid being put to sleep and undergoing a major surgical procedure
• If the PSA fluctuates some after treatment or does not go all the way down to zero, this will not cause unnecessary anxiety for me

Both surgery and radiation are excellent treatments for prostate cancer. Patients uncertain about the best treatment for their situation may benefit from consulting with both a urologic surgeon and radiation oncologist to learn more about each treatment. What’s most important is to become educated about the options and for each patient to choose the best treatment for his particular situation and risk tolerance.