Times change, but old myths die hard. Especially in medical practice, old beliefs have a way of hanging around. They can still influence decision-making. However, we should be wary of throwing out the baby with the bath. Just because newer treatments have emerged and become established, it doesn’t mean there’s no longer a place for the conventional treatments that preceded them. Specifically, radical prostatectomy (RP) as a prostate cancer treatment is still the oldest and predominant treatment choice, and still serves as the statistical reference standard—called “the gold standard”—against which other treatments’ success and side effect rates are compared.

RP offers some benefits

As far as we can see into the future, there will be a place for RP. The surgery itself has evolved. It used to be a bloody open surgery with a post-surgery hospital stay and higher historical risks of incontinence and impotence. Thanks to today’s robotic-assisted laparascopic approach, with its extreme visual magnification and very small surgical implements, a patient may require only an overnight hospital stay, and go home with a few bandaids on his abdomen. Incontinence rates have some down significantly, and nerve-sparing approaches have increased the odds of returning to baseline erectile function in a matter of weeks to months for many patients.

The benefits of RP include:

• Examination of the removed gland for a comprehensive diagnosis, and in some cases, the prostate cancer (PCa) is found to be more aggressive or extensive than originally thought. This can have implications for a follow-up treatment such as radiation.
• Removal of nearby lymph nodes to inspect them for possible tumor spread. Again, this has implications for follow-up treatment.
• “We got all the cancer.” If there appears to be no spread, the risk of recurrence is very, very low—but not impossible, since microscopic tumor breakaway cells may have entered the bloodstream; there is also a theory that nanoparticles called tumor-derived exosomes may circulate in the body and convert healthy cells into PCa—but that’s a topic for a future blog. In any event, evidence from cellular biology may explain why a patient who had a “successful” RP experiences a rising PSA 5 years or more since the surgery. This may explain why there is no iron-clad guarantee that PCa won’t come back after RP.

Is RP the best treatment?

There are many reasons why urologic surgeons are biased in favor of RP. The problem is how RP is presented to patients. In 2007, a Swiss study was published showing that patient who chose surgery over other options such as beam radiation, seed implants, and Active Surveillance had better odds of long-term survival. It was tempting to translate this information into a one-size-fits-all RP prescription for men with PCa. In the minds of many patients—and probably their doctors—the study implied that RP is “the best” way to treat PCa.

Today, however, I doubt that a doctor exists who sees RP as “the best”. The American Cancer Society tells us that for men with early stage, low-risk disease, “Most doctors believe that surgery, external radiation, and brachytherapy all have about the same cure rates” for this population. Even for higher risk patients, advances in genomics and imaging often rule out RP as an option, if there’s reason to believe that the cancer has already left the gland. For these patients, alternative treatments such as immunotherapy or molecular targeting of PCa cells are promising.

The best treatment is…

What it boils down to is this: there is no universal “best treatment.” Instead, there is a universal principle called match the treatment to the disease. For each patient, the best treatment is the one that most closely fits his cancer in terms of its clinical factors (patient age, PSA, MRI/PI-RADS results, family history, etc.), genomic profile, and lifestyle choices. There are no cookie-cutter treatments. We are now witnessing a surge in the number of men who can safely choose a focal treatment. Our Center offers the three top focal procedure: Focal Laser Ablation, Exablate MRI-guided Focused Ultrasound, and TULSA-PRO.

Let’s toss out the belief that the “gold standard” means “the best.” RP can’t help being the gold standard, since we have the largest, longest body of data on this treatment for purposes of comparison. The reality is, when a treatment plan aligns with everything we can know about a patient and the biology of his PCa, this individualized approach guarantees he’s getting his personal best treatment.

NOTE: This content is solely for purposes of information and does not substitute for diagnostic or medical advice. Talk to your doctor if you are experiencing pelvic pain, or have any other health concerns or questions of a personal medical nature.