A diagnosis of prostate cancer (PCa) can be shocking, even when the cancer is early stage, localized, and considered highly treatable. A secondary shock wave hits when the patient finds out he has a number of treatment choices, but they all have a variety of trade-offs. Suddenly, the man’s fate lies in his own hands because he has to choose one of them.
Of course, every patient wants to be rid of the cancer. The question is, what future price might he have to pay to be disease-free? This is particularly pertinent for surgery and radiation (radiotherapy) because these are the two most common treatments. An international panel of experts from prestigious institutions like the Harvard Medical School, Weill Cornell Medicine, the University of Toronto, Martini-Klinik Prostate Center in Germany, etc. tackled this question. They developed a “critical narrative review of evidence of the comparative effectiveness and harms of surgery and RT [radiotherapy] in the treatment of localized PCa.”[i]
The panel’s findings confirm what many of us have suspected all along: men with localized PCa don’t have access to enough facts and statistics to fully weigh the choices when they are offered surgery and radiation. Here are key points synthesized from their publication, and my interpretation of them.
- “Randomized trials are underpowered for clinically meaningful endpoints and have demonstrated no difference in overall or PCa-specific survival.” This means that the numbers of patients enrolled in randomized trials are too small to adequately test the underlying hypothesis, and are therefore considered scientifically useless. However, the authors point out that such studies demonstrate comparable oncologic control, meaning that the odds of surviving treatment and dying from either recurrent prostate cancer or any other cause are pretty much equal whether the patient has surgery or RT.
- “Observational studies have consistently demonstrated an absolute survival benefit for men treated with radical prostatectomy, but are limited by selection bias and residual confounding errors.” Non-comparison studies of either surgery patients or radiation patients consistently show that surgery patients have higher survival rates than RT patients, but such findings may be contaminated by a bias for selecting favorably qualified patients or other research/statistical errors.
- “Surgery and RT are associated with comparable health-related quality of life following treatment in three randomized trials. Randomized data regarding urinary, erectile, and bowel function show few long-term (>5 yr) differences, although short-term continence and erectile function were worse following surgery and short-term urinary bother and bowel function were worse following RT.” Basically, this means that over the long term, roughly the same number of patients will experience some urinary, sexual or bowel dysfunction following treatment. However, surgery patients have higher rates of short term incontinence and ED while RT patients have higher short term rates of bothersome urinary and bowed after effects.
- “There has been recent recognition of other complications that may significantly affect the life trajectory of those undergoing PCa treatment. Of these, hospitalization, the need for urologic, rectoanal, and other major surgical procedures, and secondary cancers are more common among men treated with RT.” Thanks to more recent studies that are looking at problems previously less well identified, there are longer term consequences of both surgery and radiation that can diminish quality of life. These include re-hospitalization, surgical procedures to repair damage done by treatment, and in the case of RT, late-onset secondary cancers such as bladder cancer or rectal cancer caused by radiation scatter. The authors also note that androgen deprivation therapy, frequently given to RT patients to reduce prostate size in hopes of increasing RT effectiveness, not only has its own unpleasant side effects but “may additionally contribute” to RT side effects.
- “Technological innovations in surgery and RT have shown inconsistent oncologic and functional benefits.” The bottom line is, don’t believe everything you hear about how robotic surgery is better at nerve sparing, or IMRT and proton beam have superior results with fewer side effects. In fact, many insurance companies no longer reimburse for proton beam because it is significantly more expensive yet has failed to demonstrate better cancer control.
One never likes to be the bearer of bad news, so it seems particularly brave of this collaborative team to publish their conclusion: “the question of which treatment provides better PCa control cannot be definitively answered now or in the near future” and “complications are common regardless of the treatment approach.”
The authors imply that future large, well-designed population studies free from bias will be needed if men are to make wise treatment choices and be content with the consequences. At the Sperling Prostate Center, we wholeheartedly believe that until a ‘silver bullet’ PCa treatment comes along, MRI-guided Focal Laser Ablation (FLA) offers a rational balance between whole gland surgery and RT vs. Active Surveillance. Thanks to multiparametric MRI (mpMRI) and in-bore MRI-targeted biopsy, we can identify appropriate patients, who are thus freed from the shocking possibility of what some might call a “devil’s bargain.”
[i] Wallis CJD, Glaser A, Hu JC, Huland H et a. Survival and complications following surgery and radiation for localized prostate Ccancer: an international collaborative review. Eur Urol. 2017 Jun 10. pii: S0302-2838(17)30495-5. doi: 10.1016/j.eururo.2017.05.055. [Epub ahead of print]