Prostate Treatment Comparisons

Comparing Surgery with Radiation
The problem in deciding between treatment options for prostate cancer is the diversity of choices from doing nothing at all (called surveillance or watchful waiting) to radical surgery to radiation (some one would consider this is an intermediate choice.) Surveillance is based on the fact that prostate cancer can be found in the prostate of men who die of old age in 60-80% of the men, and yet only 15-18% of men get prostate cancer as a disease. (There is an expression "more men die with it than of it".) The controversy about screening is based on the fact that some of the men who have a PSA test and are diagnosed and treated for prostate cancer, would have done just as well (with less side effects) if they had never been treated. A study on surveillance showed that for slow growing tumors (well differentiated or low Gleason score) who were not treated, the percent of men who would die of the disease would be small (9% by 10 years and 9% by 15 years.) More lives would be lost with faster growing tumors, moderate grade (24% by 10 years and 28% by 15 years) and poorly differentiated (46% by 10 years and 51% by 15 years, from Albertsen JAMA 1995;274:626.) For patients with a long life expectancy and a more rapid growing cancer, treatment (either surgery or radiation) is generally recommended. Traditionally for men 69 or younger surgery was chosen (based on the belief that the long term cure rate was higher) and for age 70 or older radiation (based on the assumption that radiation was as good as surgery for at least 10 year survival and less risky than surgery in older patients.) In the past it was argued that the cure rates with surgery were better than with radiation. But if comparisons are mades based on similar lveleles of PSA or grade (Gleason score) of the cancer, the results are the same. A recnet study from MD Anderson (Cancer 2001;91:1414) showed that the results after radical prostatectomy were quite poor if the PSA level was high (prior to the operation) or the grade (Gleason score) was high. Recently surgery has been used for older patients (based on improvements in surgical technique making it safer and with lower side effects) but radiation is also being used in younger patients (based on the belief that with more modern techniques, e.g. 3-D or conformal external beam irradiation and the use of seed implants, that the long term results are as good as surgery.) The best proof of cure is for the man's PSA level to fall to a very low level (usually 0 after surgery and < 1 after radiation) and to remain at this low level for 10 years or more. So far there is only a limited amount of data that compare similar stages of prostate cancer, treated with the different forms of treatment, and that have measured the PSA levels for 10 years or more. Some data is noted below. Some men assume that the cure rates are the same and choose therapy based on the risks of different side effects. (In general terms, surgery patients may have a higher risk of bladder problems or impotence, and radiation patients more problems with their bowels.) Some complication comparisons are noted below (additional information and comparisions of side effects can be found in the external beam section and seed section.)

Surgery	82%
External Beam Radiation	40 - 64%
Seed Implantation	50 - 90%
Surveillance	53%

Surgery	43 - 78%
External Beam Radiation	45 - 86%
Seed Implantation	80 - 93%

	Surgery	Ext. Radiation	Seed Implant
urinary incontinence	19 - 47%	0 - 11%	6%
rectal damage	1 - 3%	2 - 22%	1 - 5%
maintain potency	11 - 68%	22 - 70%	50 - 90%