Choosing Between Surgery and Radiation

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It is not an easy decision

Surgery vs Radiation is the ultimate question men with prostate cancer face.  Obviously, you are hoping to pick the treatment that will cure your cancer but which will also result in the least pain, suffering, expense, and side effects.  For some people it is an easy decision.  Some men have been told by their surgeon to do surgery, and they trust their surgeon, so they go ahead with surgery without giving the other choices much thought.  Some men just want to “get it out”.  On the other hand some men want to avoid the downtime and side effects of major surgery so they go with radiation.  Some have heard horror stories about a particular treatment from family or friends and they don’t want that treatment. This is one of the hardest medical decisions that men can encounter in their lives. Some weigh the pros and cons, get multiple medical opinions, ask friends and family, and decision paralysis will set in.  At least, until something finally clicks for them.

Getting opinions

Asking the opinion of others can be… confusing. Friends and family who have undergone treatment for prostate cancer will tend to become zealous fans of the treatment they chose, whether that be radiation, surgery, or coffee enemas in Tijuana. Doctors tend to recommend the treatment which they themselves perform. One study showed that urologists recommend surgery as their top choice (or only choice) 93% of the time to their patients, even though studies show that surgery and radiation have very similar cure rates. Some surgeons may use scare tactics to steer a patient away from radiation and towards surgery, saying the prostate will turn to mush, a colostomy bag will be needed, radiation is only good for 10 years, etc. All false by the way. 

Can you have surgery after radiation? 

Surgeons will often tell their patients “You can always have radiation after surgery if you need it…  but you can’t do the opposite. You can’t have surgery afterwards if radiation doesn’t work.”  Many men therefore conclude:  “OK, let’s say I have an 80% chance of being cured by either radiation or surgery.  If the surgery fails, then I still have a plan B, radiation, and get another 80% chance of cure, and I’m good to go.  However if the radiation fails, then I can no longer have surgery, and that’s it, I’m done.  Therefore, I should start with surgery.”

This may seem quite logical at first glance, but there are several key pieces of information missing!  Consider firstly that the success of a treatment the second time around is not as good as the success rate the first time.  A cancers that recurs after radiation or surgery is more aggressive than average. A study by Stephenson found that the success of salvage radiation after surgery failure was 32% overall. Plan “B” after a surgery failure is not so clear cut.

For men who start with radiation it is uncommon for the cancer to recur in the prostate gland with modern radiation treatment.  In one study by Dr.Katz, the cancer came back in the prostate gland in less than 2% of stage 1 patients who received stereotactic radiation, during 10-years of follow-up.  So, we don’t often have the situation where we wish we could still do surgery.  If Plan “A” fails remember that there are still 25 letters remaining in the alphabet.  If the cancer does come back in the prostate gland after radiation there still are treatment options available like cryotherapy (freezing) or HIFU (heating) of the prostate gland.  If the cancer comes back in the bones or lymph glands (which can happen after either surgery or radiation!) then hormone therapy becomes the standard treatment. Prostate cancer also tends to be a slow growing cancer, so sometimes just doing surveillance can be the way to go if it recurs. 

The bottom line is that whether you choose radiation or surgery maybe you will be cured, or maybe the cancer will come back and you will be offered additional treatment. Ultimately at 10 – 20 years after being diagnosed your odds of being alive and cancer free will pretty much be the same whichever you start with. 

Side Effects of Radiation vs Surgery

Although the cure rates are similar, the side effects can differ. With surgery expect to be off work for 6 weeks, have a urine catheter in for a week or two, and then have a period of time where you must retrain your bladder to hold the urine.  With radiation therapy you can continue to work both during and after the treatment course with no recovery time. There is no urinary catheter. There is less pain. Radiation causes less urinary leakage (incontinence) than surgery. Surgery may cause immediate 100% erectile dysfunction (ED).  If a nerve sparing prostatectomy is an option and is successfully performed (two if’s), then erections can remain totally normal.  Radiation causes gradual weakening of the erections especially after 3 years which can progress to ED.  Radiation caused ED can often be helped with Viagra or Cialis. Unfortunately, all treatments (except surveillance) carry a risk of ED.

Surgery is Good for Some People!

Surgery is a good option for some.  For patients who have a lot of urinary symptoms, surgery may be a better way to go as it can improve the symptoms.  With radiation the urinary symptoms tend to remain similar in the long term. I also like surgery for healthy young patients (50s – early 60s) with a high Gleason score (Gleason 4+3 or higher), who do not have much cancer found on the biopsy and the PSA is less than 10 – 15. All doctors have their own biases about for whom they think radiation or surgery is better.  Having a good surgeon is important; studies show your chances of having complete removal (clean surgical margins) and smaller risk of incontinence will depend on the experience and skill of the surgeon. 

Surgery gives a clearer picture

Surgery offers a clearer PSA follow-up and more up-front information.  The PSA should drop down to 0.00 – 0.10 and stay there after surgery.  On the other hand, with radiation the PSA can take 5-years to get down close to 0.  After surgery you also know if the cancer was contained within the prostate or has broken out beyond the gland. This does not mean the cure rate is better for surgery, but it is reassuring for people who want more certainty as early as possible if their cancer is likely cured or not cured. 

Choosing surgery just to avoid radiation therapy + hormone therapy may backfire…

With unfavorable or high risk prostate cancer, follow-up radiation and hormone therapy may still be recommended after surgery, especially if the PSA does not drop all the way to 0.0 or if cancer is found in the lymph glands. So choosing surgery may or may not result in being able to avoid radiation.

What would I do? 

If you know very little the decision is easy. You follow your first doctor’s advice. As you learn more the decision becomes harder and harder. Until you have learned everything and become a master – then the decision can become easy once more.  I don’t know if anyone is there yet regarding prostate cancer. I too would agonize over the decision.

In Conclusion

Wait a while, think about your options, and choose the treatment that resonates with you the most! I won’t tell you which treatment you should choose. Choosing a skilled expert is important no matter what treatment you choose in order to have the best chance of cure and the lowest chance of life altering side effects.