A frequent concern of patients who come to our Center for focal laser ablation is the risk of side effects from whole gland treatments. Men commonly tell me things like:
“I don’t want surgery because I don’t want to wear diapers, even temporarily.”
“I don’t think the urologist is telling me all the facts about ED after surgery. It scares me.”
“I worry that if I have radiation, I’m exposing myself to something dangerous.”
“A friend had seed implants six years ago, and now he has bowel problems.”
These are very personal concerns because a man’s identity, masculinity and quality of life are affected if he has to deal with urinary, sexual and bowel dysfunction as a result of prostate cancer treatment. Harm to these systems is a risk the prostate is nestled in among other structures to protect its contribution to pleasure and procreation. In order to surgically remove the gland, the surgeon has to reattach the urethra (tube that carries urine from the bladder out of the body) because a section of it passes through the prostate. In nerve-sparing surgery, the doctor must delicately tease away from the gland the nerve bundles that control erection and they are not happy about being disturbed; they go into a sort of “paralysis” from which, hopefully, they recover. Radiation, including seed implants, always has some scatter effect. This can lead to cumulative harm for the nerves, urinary sphincter, bladder and rectum.
A Canadian review of 36,984 prostate cancer cases shows that radiation led to the greatest number of side effects over a 5 year period. [i] The study population was divided into those who had surgery alone (42.9%), surgery followed by radiation (12.2%) or radiation alone (44.9%). The authors found that surgery-radiation combination increased side effects over surgery alone. However, incidence rates were highest in the radiation only group, which had higher rates of all complications at 5 years post-therapy. Men who choose radiation in hopes of avoiding surgical risks are often not aware that radiation can result in late-onset side effects as tissue damage from radiation accrues over time.
Another sobering article describes how low-dose brachytherapy (the permanent implantation of radioactive pellets, or “seeds”) exposes the rectal wall to radiation.[ii] Over time, this can result in bowel irritation or proctitis. Rarely, the damage culminates in transfusion-dependent rectal bleeding, ulcers or fistulas, which can lead to a permanent colostomy. In the study reported by a team from several respected U.S. institutes, the authors describe a “promising” intervention intended to reduce radiation exposure to the rectal wall by injecting biodegradable materials into the tissue between the posterior (back side) of the prostate gland and the rectal wall in order to widen the space. This strategy is still under investigation, but the need to resort to such measures helps me understand why patients continue to be concerned about the risks of whole gland surgical and radiation therapies.
[i] Wallis CJ, Cheung P, Herschorn S et al. Complications following surgery with or without radiotherapy or radiotherapy alone for prostate cancer. Br J Cancer. 2015 Mar 17;112(6):977-82.
[ii] Schutzer ME, Orio PF, Biagioli MC et al. A review of rectal toxicity following permanent low dose-rate prostate brachytherapy and the potential value of biodegradable rectal spacers. Prostate Cancer Prostatic Dis. 2015 Feb 17. doi: 10.1038/pcan.2015.4. [Epub ahead of print]