If you’ve been diagnosed with localized or locally advanced prostate cancer, you have 3 main treatment options: active surveillance, radiation therapy, or surgery. If you and your medical team have decided that active surveillance is not right for you, and you are deciding between radiation and surgery, you may find yourself feeling stuck or overwhelmed with the choice.
Dr. Dan Spratt, an international leader in the treatment of prostate cancer and lead editor of the PCF Prostate Cancer Patient Guide, often discusses 4 factors that can help patients make this tough decision:
- Are you a surgical candidate? The older a patient is, and the more additional health problems he has—especially prior abdominal surgeries, heart or lung issues, and morbid obesity, among others—can increase the risk of complications from anesthesia and undergoing a major surgery. For example, in the US, less than 5% of men over 75 years old undergo surgery for prostate cancer.
- Your anxiety, bias, or beliefs. Even though surgery and radiation have similar cure rates, some patients believe that removal of their prostate is best for them. As long as you understand that the cancer can still come back after removal of the prostate, these patients should generally have surgery to avoid treatment regret. Other men do not wish to undergo a major operation with anesthesia, stay overnight in a hospital, have a catheter in place for at least 1 week, and wear diapers and/or pads for a period of time; the invasiveness concerns them. They should typically undergo radiotherapy to avoid treatment regret.
- Logistics. Surgery is an operation that lasts a few hours, and patients typically go home the next day. They are able to walk the next day, but typically have a catheter in place for 7-10 days, and then have an additional 6-8 weeks when physical activity needs to be largely restricted. In contrast, radiotherapy (especially external beam with stereotactic body radiation therapy [SBRT]) consists of as few as 6 to as many as 45 outpatient appointments that typically last less than 45 minutes car door to car door (treatment is usually less than 10 minutes). There is usually no downtime, catheters, diapers, pads, and you can be physically active every single day. Your lifestyle, if you are working or retired, your other responsibilities, your commute time, and the duration of radiation your center can deliver (SBRT in 5 treatments vs. conventional radiation in 40 treatments) may all impact your decision.
- Side effects. In general, both surgery and modern, high-quality radiation have less than 1% risk of rectal side effects. Sexual side effects are largely driven by how good a man’s erectile function is pre-treatment, but, in general, in the first 5 years after treatment will be 10-15% more likely to keep erectile function after radiation (+/- short-term androgen deprivation therapy, ADT) compared to surgery. Urinary function is simply different: surgery will typically improve urinary flow and may cause some long-term incontinence/leakage/drippling, while radiation will not do these things but may cause increase urgency, frequency, and/or nocturia.