Choosing a Treatment for Prostate Cancer: What to Consider

Phillip Koo, MD [00:00:00] So, a patient comes into the office, they see a urologist, usually the urologists presents the surgical options for the patient. Before we get into sort of what surgery looks like, just tell us about, you know, in general who is most appropriate for surgery from your perspective. 
 
Jim Hu, MD, MPH [00:00:19] Absolutely, so it’s gonna be the people that, going back to the individual preferences, you value cure of cancer number one. Usually, the second preference is preservation of urinary continence. And typically, the third patient elicited value is that of erectile function. And so, in these patients, we typically will see younger patients, for example, compared to those who may opt for radiation therapy. For example, those men who have had multiple surgeries, or they have a lot of heart disease, they have chronic obstructive pulmonary disease, if they’re poor surgical candidates and have an increased risk of surgical complications, that’s a clear, I think, stratification for who has surgery versus radiation. Beyond that, a lot of this is patient preferences. I mean, someone may not want general anesthesia, they may not want to be admitted to the hospital, and modern radiation therapy techniques is- as Dr. Vapiwala will get into, have really reduced, I think, the inconvenience of radiation. 
 
Phillip Koo, MD [00:01:22] Great. So, you know, it is such a nuanced conversation and discussion, and I don’t think there’s clearly a, you know, one, there’s no way for us to say, all right, this is the right person for radiation. Sometimes on the extremes it’s very easy, but there’s so much gray in the middle. Just in general, Dr. Vapiwala, radiation treatment for the primary tumor in order to cure the disease, who’s sort of the ideal patient? 
 
Neha Vapiwala, MD [00:01:44] Sure. Well, just again, picking up on exactly what Dr. Hu said, you know, it starts with, but certainly if there are medical reasons why someone’s not a great candidate for surgery, there similarly can be medical reasons why someone may not be a great candidate for primary radiotherapy. So, you have someone say with prior history of radiation for another cancer or somebody who perhaps is on very high doses of blood thinners, anticoagulants for, you know, typically cardiac reasons and has a history of bleeding. You might have folks with history of inflammatory bowel disease, such as ulcerative colitis is one that we, again, consider to not be a great candidate for radiation. And then certain autoimmune diseases that are prone to scarring or what we call fibrosis development might be somebody where you think, you know, all things being equal, I’d really prefer not to. And then for me, in my practice, certainly younger patients and to me, 65 and younger, who’s patients that are healthy, that are okay with what surgery entails, right? They understand what they’re signing up for. I feel like if, again, if it’s generally organ confined or thought to be clinically localized, which is our topic today, I do tend to not only favor surgery but give them the reasons from my perspective, why I think surgery makes sense for them. And oftentimes, as you probably know, in your own practice, if you’re promoting something you don’t do, it almost carries more weight, right? Because the patient feels like, oh, wow, you’re not biased and you’re giving me an opinion on something that you don’t even actually do, but feel is best for me. So those are the patients where I’m not keen on radiotherapy, but pretty much most other patients who are, look, a lot of them come in and they are very scared of the idea of a resection, of a big operation. And even with, of course, very modern robotic assisted laparoscopic approaches, you might still get patients who are just wary of what that can entail. And others who, again, they’re older, they’re not necessarily ready to pop on the operating table, but they very much still have a, you know good longevity that’s expected and desire treatment that’s a definitive intent. So, for us, you know, it really is now, as was mentioned by Dr. Hu, possible to not only treat patients more conveniently, but with increasing number of techniques that we use and other strategies that we use to protect the nearby tissues, the bladder, the rectum, et cetera. I feel like, you know, the therapeutic index, which is how we think about chances for benefit versus relative chances of side effects. We’ve been trying to continually improve that therapeutic index for patients so that those who do choose radiation hopefully will have great outcomes. But we, again, no treatment, I always say to patients, no treatment comes free of side-effects. And so that is something to get back to the active surveillance conversation. It is something that we have to always be honest about. 
 
Phillip Koo, MD [00:04:57] I think that’s a great point that we should reiterate. No treatment comes without some sort of adverse event. And we often hear this often, like a surgeon is going to want to operate, a radiation oncologist is going want to radiate. But you’re right, when they sort of support something else that is not what they do, it does carry some more weight. For patients out there, I will say, you know, it’s important to listen, get these second opinions. I think it’s to go visit both specialists. Sometimes you might want to visit multiple surgeons or multiple radiation oncologists, even after you decided. It’s important to learn. I will even when you go online or go to whatever resources, there is often conflicting information out there as well. So, it is really, really challenging, but just find a trusted resource and lean on them and again, try to make that best decision.