Should I have Surgery or Radiation For Prostate Cancer?
What is this post all about?
This is a hard decision–surgery or radiation?
Now remember, what I am going to talk about here is for prostate cancer that hasn’t spread–LOCALIZED prostate cancer.
From a 30,000-foot view, surgery and radiation or both EXCELLENT treatment choices for prostate cancer. In general, you can pick and choose certain studies to support one treatment over the other but by and large they are both EQUAL in terms of cancer control.
Now remember, I am a urologist. I try my hardest to provide as unbiased as an opinion as I can but it’s impossible to remove the fact that I am urologist when providing this information. This is why I will always have my patient’s meet with a Radiation Oncologist as well as me to hear from them about what radiation is all about as I talk to them about what surgery is all about.
If you wanna learn about the ins and outs of a robotic prostatectomy then click over here. On the flip side, if you wanna learn more about the ins and outs of radiation then click here.
What are the advantages of going with a robotic prostatectomy?
One Stop Shop
One of the advantages of surgery is that the treatment is a one-time deal. There are no side effects that develop in a delayed fashion years and years from now (more on that down below).
Full pathology assessment
To diagnose prostate cancer, the urologist will perform a prostate biopsy. This provides a sampling of what is going on in the prostate. Based on this assessment, we will tell you what stage your prostate is in.
When surgery is performed, now the whole prostate is able to be evaluated to give the full Gleason Score (or Grade Group). Additionally, oftentimes the lymph nodes in the pelvis will be removed. The lymph node dissection can assess if the prostate cancer has spread to the lymph nodes.
So in essence, with a robotic prostatectomy you are getting a more accurate characterization of your cancer level.
Urinary Symptom Improvement
Now this is a complicated issue. It is very common to have leakage in the beginning after the surgery. The healing from this can take several months.
There is also a subset of men who will have some degree of leakage that is permanent. On the other hand, having an enlarged prostate can lead to bothersome symptoms for men at baseline.
There are many men who need to take medications and even have surgery to improve their urination. For these men, they will oftentimes see a benefit from urination after the prostate is removed.
Additionally, for people who have bad urinary symptoms at baseline having radiation can worsen that. For these patients, I will tend to either tell them to get a TURP or Urolift before radiation or just advise them to get a robotic prostatectomy rather than radiation.
Easier to have additional treatment
In a perfect world, all you will need is one treatment. However, cancer is cancer. So, we will follow your PSA to see if there is any sign that the cancer came back.
If the PSA starts to creep up, higher than 0.2, then we can always add radiation later. However, there is some trade off to this in that some of the side effects from radiation can become more common after the prostate has been removed.
Your preference
You gotta do some soul-searching.
For some men, for whatever reason they prefer to have surgery. They like the concept that the prostate is no longer in the body. If this is you, then surgery is the way to go.
What are the disadvantages or when would I not be a good candidate for a robotic prostatectomy?
Erectile Dysfunction
This a very personalized side effect. For some men, their sexual performance is understandably a big deal.
Notably after a prostatectomy, your erections will go away immediately before they can start to recover. For some men we are able to nerve spare and for these patients, a percentage will be able to regain sexual function over the course of the next 6-12 months.
The likelihood of recovery is also affected by your age or the quality of your erections before you have surgery. So, the younger you are and the better your erections were before surgery, the better the chances that you will be able to recover or maintain your erection function after.
If you meet a urologist who doesn’t talk about the chance of erectile dysfunction after a robotic prostatectomy–RUN AWAY. This is a major potential side effect that comes with the package of curing you from prostate cancer.
Does it happen to everyone? The answer is no. However, this is definitely possible and needs to be discussed before you consider surgery.
Your overall health
One of the first questions that I will ask a patient considering surgery is to assess his surgical fitness.
Are you able to walk around without getting short of breath or pain in your chest? Are you able to walk up a flight of stairs? Even though the robotic approach is only small incisions on the outside, it is still a major surgery.
You need to be strong enough to be able to safely go through the surgical process and recover without any surgical complications. For some patients, if the surgical risk is too high, then the better choice is to go with radiation.
Other robotic prostatectomy surgery considerations
There are some other factors that I will look into in deciding if a patient is a good fit for surgery.
One of those factors is your weight. If you are really obese, then this can make the surgery difficult for a couple reasons. First of all, it can be technically challenging if there is a lot of fatty tissue in the body for a variety of reasons.
Additionally, for patients who are morbidly obese, it can make it technically risky from an anesthesia perspective, meaning that it may be hard to manage your breathing mechanics while you are off to sleep.
When we do this surgery, we position you with your legs in the air and your head towards the ground. All the weight from your belly can make it hard to breathe in that position, which is why for some people due to their weight I will not offer surgery as an option.
Another technical factor that I will consider is your prior medical/surgical history.
If you have had surgeries and/or radiation in your belly in the past for any reason, this can lead to added scar tissue formation, which can make the technical aspects of getting exposure to the prostate difficult.
What are the advantages of having radiation therapy for prostate cancer?
Easier recovery
For external beam radiotherapy, there is no surgical or procedure intervention. So, there is less downtime than if you have surgery. So, I have seen some patients who are self-employed that are worried about the downtime that comes from surgery and for these folks the radiation treatment can be more appealing.
Nervous about having a robotic prostatectomy
This is one of the most fascinating aspects of being a urologist. I have some patients who hate the concept of radiation. On the other hand, I have other patients who hate the concept of being put to sleep and having surgery. Again, you need to reflect on what your thoughts are on this because this can play a big factor in how you make this decision.
Slower effect on erections
The sexual side effects associated with treatment are much slower with radiation. So, for those patients who worry about the immediate effect that comes from this, radiation may be an appealing option.
What are the disadvantages of having radiation therapy for prostate cancer?
Potentially worsening your urinary symptoms
For patients that have bothersome urinary symptoms at baseline, they are not the best candidates for radiation. The reason for this is that your prostate symptoms can worsen after radiation treatment. Additionally, doing a surgery to help with the urinary symptoms after radiation carries higher surgical risk like scarring or leakage.
For patients who have bothersome urinary symptoms, I will typically push them towards having surgery.
For patients who have bothersome urinary symptoms but aren’t good surgical candidates to have a prostatectomy, I will recommend treatment first with a TURP or Urolift prior to starting radiation to avoid the higher complication risk associated with this treatment after radiation.
Risk of longer term or delayed side effects
Once you have had radiation, you will have always had radiation. There are possible long-term developing side effects that can happen five or ten or even twenty years later.
These side effects can include radiation changes in the bladder or rectum that can lead to bothersome bleeding or bladder/bowel problems. Additionally, there is a very very small chance of getting a secondary cancer from the radiation itself in those regions as well. This is why my bias (and this is definitely a bias) is for surgery in younger patients.
On the other hand, for my older patients diagnosed with prostate cancer, I don’t worry as much about these long-term side effects. This is because, on average, their life expectancy is lower, so the risk of experiencing a side effect 10 or 20 years after radiation is much less.
Prior radiation history
Your body can only tolerate a certain amount of radiation over the course of your lifetime.
So, if you have had prior radiation in that region (most common example would be a colon cancer) than repeat radiation is not an option and you would need to have surgery to treat the prostate cancer.
Sexual side effects
What a second, that makes no sense. You just said above that if I am worried about the immediate effect on erections that I might prefer radiation. Well the answer actually depends.
For patients with higher-risk prostate cancer, you will likely need hormone therapy that will affect not only your erections but your sex drive as well. So unfortunately, you are kinda stuck in a crummy place with either treatment option. But if you are worried more about your sex drive, then surgery actually may be the better option.
Harder to add surgery later
It is definitely technically easier to add radiation after surgery, however the opposite is not the case.
Surgery after radiation can be technically more challenging and can carry a higher surgical risk. I mention this to my patients but oftentimes I personally don’t want this to sway your treatment choice because for the vast vast majority of patients, all you will need is one treatment.
So really pick the treatment that you prefer rather than focus on the potential of what could be.
The Dr. Jafri Wrapup
This is such a hard decision. But try and take some comfort in understanding that there is really no bad decision.
Both surgery and radiation are great treatments.
Once you have made your decision, trust it and trust your docs. Try and weigh all the pros and cons above and when you feel comfortable just take solace in knowing that, in general, men do really well with prostate cancer treatment and I pray that everything goes great for you. For some other high-quality resources to go over prostate cancer, click here.