Prostate Cancer: Is Surgery REALLY the Most Effective Treatment?

Prostate cancer is an age-related illness and is the leading cancer in males. Thankfully, most prostate cancer is not fatal and is amenable to early diagnosis and treatment. Most doctors dealing with this problem are walking a fine line between (1) whether to treat the patient, (2) how to treat the patient, and (3) how to balance the treatment, particularly as it occurs frequently in an elderly population.

As a radiation oncologist, I find the decision a little easier than does a surgeon. Radiation oncology treatments use the most advanced technology in our field, have a very low complication rate, are easy for the patient to undergo, and produce cure rates similar to those of surgery.

The radiation oncologist can be slightly less concerned about the issue of over-treatment, since the patient is risking less in the way of serious morbidity. Therefore, most of the patients diagnosed with prostate cancer, who seek a consult at my center, usually decide in favor of potentially curative therapy using external beam radiation or seed implant therapy, after hearing the pros and cons of treatment.

Prostate cancer patients who have a biopsy positive cancer are ranked by the grade of the cancer under the microscope (Gleason’s Grade), the level of the prostate-specific antigen (PSA) blood test, the density of the PSA blood test, the percent of free PSA, the percent of the prostate gland involved with the cancer, the multi-centric nature of the tumor, whether the cancer is felt by the examiner, and finally, the likelihood that the cancer extends outside the prostate gland (Partin Tables).

Once that is determined, the patient is presented with an estimate of (1) the aggressiveness of the cancer and (2) the likelihood of cancer extension outside the prostate gland. That information, when coupled with the age and general health status of the patient, determines whether we recommend aggressive local therapy of the prostate gland, and whether we add a hormone blocking agent, and in what order. Hormone-blocking agents are used for intermediate and high-risk patients for varying lengths of time.

Radiation therapy is given in two ways: a linear accelerator delivers external beam therapy over approximately 40-42 treatments, using very highly targeted therapy, in order to spare most of the bladder, rectum and other pelvic structures from the highest dose of radiation. We use a technique called intensity-modulated radiation therapy (IMRT) that approaches the prostate from many angles and many different field shapes. It is a dynamic treatment and highly precise. In addition, we now place marker seeds in the prostate to help guide us even more precisely, in case the prostate moves during the treatment. We treat a small margin of normal tissue around the prostate gland.

The other non-surgical option is a prostate seed implant. We reserve those for the most low-grade tumors and in patients who qualify for a treatment that treats only the prostate gland and little margin around the gland. This is done by placing 60-80 radioactive seeds in the prostate while the patient is anesthetized in a surgical center.

Most patients do very well, and our usual result is a PSA that declines dramatically, and remains down for the rest of the patient’s life. But depending on the aggressiveness of the cancer, some of our patients will have a failure of control of the PSA at some point in the future. This all depends on the aggressiveness of the cancer. Even when that happens, however, the local disease in the prostate is generally controlled and there are other measures we can use to manage the PSA elevation.

It appears that prostate centers around the country are working on putting radiation oncologists out of business by finding chemical or immunologic means. This has not happened yet, and thus the patient, today, will need to make a rational decision about local therapy with a radiation oncologist and a urologist.

Posted in Cancer Treatment, Senior Health, Treatment Options