May 19, 2017
Which is better for prostate cancer – surgery or radiation therapy?
using a time horizon of 10 to 15 years, less than 3% of men diagnosed with Gleason score 6 and classified as low risk will die as a result of prostate cancer whether treated or not [Source]
Many former Gleason score 6 tumors are now reclassified as Gleason score 7 in the modified system. [Source]
Gleason score 4 + 3 = 7 demonstrates worse pathological stage and biochemical recurrence rates than 3 + 4 = 7 [Source]
Most cancers detected as a result of PSA screening are Gleason 6 (3 + 3) or 7 (3 + 4). [Source]
While surveillance may be stressful for some
men, the reality is that most patients with prostate
cancer, whether treated or not, are concerned
about the risk of progression. Anxiety about PSA
recurrence is common among both treated and
untreated patients. Patients who are educated to
appreciate the indolent natural history of most
good risk prostate cancers may avoid much of
this anxiety. [Management of Prostate Cancer – Eric A. Klein J. Stephen Jones
patients should consider that if they wait
to treat the cancer until the tumor grows, the bigger tumor may mean either an
increased risk of side eff ects (because it requires more extensive surgery) or it may
mean a shift from curable to incurable disease.
Men under 60, for example, are better candidates if
they fulfill the Epstein criteria for insignificant
prostate cancer – In my case this criteria is not fulfilled. Hence I am not suitable for active surveillance.
Further, “untreated, the… likelihood of disease progression is about three times greater than those without Gleason 4 pattern” [Management of Prostate Cancer – Eric A. Klein J. Stephen Jones Editors]
In my case there are two small sections with Gleason 4 pattern. Therefore, again, active surveillance is ruled out.
To be a candidate for active surveillance, the
patient must meet certain criteria (as in a study from the Royal Marsden Hospital
in London): 2
• Ages between 50 and 80 years
• Gleason’s score less than or equal to 7
• Clinical stage T1 or T2 disease
• Total PSA less than 15
• PSA score doubling time less than 2 years
• 50 % or less of the biopsy samples positive for cancer
• A reasonable state of health with no other major medical problems [After Prostate Cancer A WHAT-COMES-NEXT GUIDE TO A SAFE AND INFORMED RECOVERY – Arnold Melman, M.D. and Rosemary E. Newnham]
About 40 % of the men who are diagnosed with prostate cancer undergo either
radiation or have radiation combined with surgery. [After Prostate Cancer A WHAT-COMES-NEXT GUIDE TO A SAFE AND INFORMED RECOVERY – Arnold Melman, M.D. and Rosemary E. Newnham]
Victoria has a Prostate Cancer Registry and the most accurate data available about which treatment patients are choosing. Victorian data from 2014 showed that 48 per cent of men in the state with prostate cancer chose surgery compared with just 18 per cent who chose radiation therapy. [Source]
The 5-year biochemical risk-free survivals for the 5 Grade Groups based on radical prostatectomy were – Grade Group 1 – 96.6% –
Grade Group 2 – 88.1% –
Grade Group 3 – 69.7% –
Grade Group 4 – 63.7% –
Grade Group 5 – 34.5 % • (p < 0.001)
There is a real (albeit small) risk of prolonged illness or death would occur with surgery [After Prostate Cancer A WHAT-COMES-NEXT GUIDE TO A SAFE AND INFORMED RECOVERY – Arnold Melman, M.D. and Rosemary E. Newnham]
Removal of the prostate gland — a procedure called a prostatectomy — can offer patients the best chance to permanently cure their cancer. [After Prostate Cancer A WHAT-COMES-NEXT GUIDE TO A SAFE AND INFORMED RECOVERY – Arnold Melman, M.D. and Rosemary E. Newnham]
One of the principles of any cancer surgery is that all tissue within a half an inch of the cancer should be cut out to ensure all the cancer cells are removed. [After Prostate Cancer A WHAT-COMES-NEXT GUIDE TO A SAFE AND INFORMED RECOVERY – Arnold Melman, M.D. and Rosemary E. Newnham]
after removal of the prostate, when a man has sex, he will still have orgasm and all the good feelings that happen with sex, but he will not have the emission of any fluid. Th at means that during post-prostatectomy
sex, he will “shoot blanks” or have dry orgasms. [After Prostate Cancer A WHAT-COMES-NEXT GUIDE TO A SAFE AND INFORMED RECOVERY – Arnold Melman, M.D. and Rosemary E. Newnham]
I often recommend perineal surgery for all my patients because it can be done
rapidly (within 70 to 90 minutes) and with little bleeding. In general, you want
your surgery to be over quickly, because the longer you are under general anesthesia,
the higher the chance of complications. Also, a quicker surgery can mean a
shorter recovery time. From a surgeon’s point of view, the perineal approach
also provides a better angle to view the bladder and urethral area after the removal
of the prostate gland. [After Prostate Cancer A WHAT-COMES-NEXT GUIDE TO A SAFE AND INFORMED RECOVERY – Arnold Melman, M.D. and Rosemary E. Newnham]
- radical retropubic prostatectomy. – through abdomen
- radical perineal prostatectomy, – near anus – Th is is a more direct route yet is currently less common —
only 4 % of prostatectomies are done through the perineum — because most urological surgeons have not been trained in the approach.
Robotic surgery can be more likely to be nerve sparing given the higher magnification and ability to see. robotic-assisted radical prostatectomy has virtually supplanted the laparoscopic
prostatectomy. Men who have the laparoscopic, robotic,
or perineal surgery can return to work and daily living faster — usually within
2 weeks — because there is less pain with the smaller incisions. With a traditional
radical retropubic procedure, it might take the full 6 weeks.
urinary incontinence persists in up to 15 % of men 2 years after surgery.
Th e incidence of the incontinence is higher among older men who have surgery.
Your unique anatomy
also plays a role as the nerves can be in slightly diff erent positions in diff erent
people, and on some people more than others, it may be harder for the surgeon to
avoid touching them or possibly nicking them when removing the cancerous tissue.
Because nerves don’t show up on scans, this is one of the factors that the surgeon
faces in the operating room, and thus cannot predict with absolute certainty
whether there will be any nerve damage in your case. [After Prostate Cancer A WHAT-COMES-NEXT GUIDE TO A SAFE AND INFORMED RECOVERY – Arnold Melman, M.D. and Rosemary E. Newnham]
For those particularly concerned
about urinary continence after surgery, I might steer them toward robotic or
perineal surgeries as these aff ord the best possible view of the urethral-bladder area
so the surgeon can have the best possible chance of joining the urethra and bladder
tightly and smoothly. [After Prostate Cancer A WHAT-COMES-NEXT GUIDE TO A SAFE AND INFORMED RECOVERY – Arnold Melman, M.D. and Rosemary E. Newnham]
In the weeks or months leading up to the operation,
I usually suggest increasing the amount of exercise, such as walking or swimming,
to be as strong as possible going into surgery. Th e physical training will help
with breathing and muscle tone and perhaps will help you to lose a few unnecessary
pounds of weight — all of which will help your recovery. Th ere are other exercises
that may prove even more important to your recovery: pelvic fl oor exercises.
When started in the weeks before surgery, these exercises can help your body
regain urinary continence faster after the prostate is removed ( see page 98).
The two muscles that affect the control of urine are the bladder neck, which
is not under your voluntary control, and the external urinary sphincter. Th e latter
muscle can shut off the urinary fl ow while you are urinating. To help with control
of the starting and stopping of urination, the muscle needs to be strengthened as
if you were weight-lifting. Th e more lifting, the stronger the muscle. Of course
there are no tiny weights to lift, but muscle strength can be increased with repetitive
exercise like a Kegel exercise. Th e best program is starting and stopping the
urinary stream. Th is can be started long before surgery. Each time you urinate,
stop the stream several times. Th at action will increase the strength and size of the
sphincter muscle and help with control after the surgery.
When the prostate gland is
completely removed, as happens with radical prostatectomy, that buff er is also
removed and control of urine leakage becomes dependent on the muscles of the
pelvic fl oor, known as the external urinary sphincter. By strengthening this muscle,
you can lower your chances of post-operative incontinence, or if you strengthen
post-surgery, you will increase your chances of returning to full continence.
Generally the best case for urinary control is THREE MONTHS after surgery
OPTION TO USE RADIATION
For men who experience a recurrence of their cancer after surgery (meaning that
some cancer cells remained in the body after surgery and reproduced), then radiation
known as salvage radiation is the best course.
GOOD TO UNDERTAKE RADIATION JUST AFTER SURGERY
There is a debate between the benefits of robotic tools vs traditional surgery. Costs are quite different.
For a high-end operation in a top private hospital in Sydney men can expect to pay $7,000 to $30,000. In a public hospital the same operation can cost just $200. The out-of-pocket expenses of an open operation in a private hospital ranges from $3000 to $5000. [Source]
those with private health insurance tended to have double the out-of-pocket expenses than their public patient peers. [Source]
At Epworth, where most of Victoria’s private robotic surgery is performed, they’ve taken steps in past year to reduce its costs.” Moon says notes that paying for treatment for an early cancer can be far cheaper than paying for an advanced one. In Victoria, the average out of pocket cost for early treatment is $5000 compared to $14000 for advanced cancer. [Source]
There are major cost differences between the two main treatments, with surgery costing more than $20,000 in private hospitals, while radiation therapy is free in public hospitals. [Source]
it was not until after he told the surgeon he could not afford the operation that he was informed he could receive free radiotherapy in a public hospital.[Source]
After analysing claims data for the 12 months to last November, Bupa found 17 per cent of radical prostatectomies were fully covered but 28 per cent carried gap fees of $5001-$10,000 and 35 per cent gap fees of $2001-$5000. [Source]
CHOOSING THE PUBLIC HOSPITAL
The gender gap for Victoria was biggest at Geelong Hospital a comparison of wait times provided on the government’s MyHospital website shows. Prostatectomies, used in the treatment of prostate cancer in Geelong had a median wait time of 94 days compared to 7 days or breast cancer surgery — a difference of 87 days. [Source]
Because prostate cancer cells can be relatively resistant to radiation, high doses of energy are often used to kill the prostate cancer. Unfortunately these dosages can also cause damage to normal cells in the rectum and bladder. [After Prostate Cancer A WHAT-COMES-NEXT GUIDE TO A SAFE AND INFORMED RECOVERY – Arnold Melman, M.D. and Rosemary E. Newnham]
A recent study of more than 2,000 Australian prostate cancer patients, published in the Journal of Medical Imaging and Radiation Oncology, found no major difference in cure rates between each treatment. [Source]
brachytherapy, external beam radiation therapy and open radical prostatectomy were successful in the majority of patients. This was true for all risk groups, but higher dose radiation (EBRT + Brachytherapy) appeared to have better relapse-free survival outcomes in the higher risk and higher grade cancers.
patients in the surgical (radical prostatectomy) arms are typically younger and healthier before treatment than those in the EBRT or brachytherapy arms
the average age and health of the surgically treated patient (before surgery) is more favorable than the average age and health EBRT or brachytherapy patient. Multiple studies prove that younger, healthier patients recover from virtually any type of treatment better than older, sicker patients. So, all these studies have a built-in bias favoring the surgically treated patients.
patients treated with surgery suffer higher rates of incontinence and impotency than those treated with either seed implantation or IMRT radiation.
Those treated with radiation have higher rates of (usually temporary) increased urinary frequency and bowel frequency.
troubling is the higher rate of side effects associated with the radioactive seeds. Investigators from the Pacific Northwest Cancer Foundation reported that following interstitial brachytherapy, 5.1 percent of patients were incontinent, and in 1.7 percent, the incontinence was so severe that the men required a urinary diversion– attachment of a bag, worn under the clothes, to collect urine. Three other patients also required the urinary diversion procedure because of severe strictures or urinary retention. [Source]