Are you a man with prostate cancer? Been told you can have either surgery or radiotherapy and need help to decide which one is right for you. Then read on.
I have just published an editorial in the world’s leading urology journal on this topic. I also published a paper in the BMJ comparing cancer outcomes in over 34000 men with prostate cancer who had either surgery or radiotherapy. So I’m a bit of an expert in this area. Or at least I feel I have some thoughts I’d like to share with you on it.
For men who have a high or moderate risk of dying of their prostate cancer if they left it alone (i.e. went on “surveillance”) then surgery and radiotherapy are usually both options for treatment. There are different types of radiotherapy, like external beam, intensity-modulated, stereotactic body ablative, high dose rate brachytherapy, and so on. I’m not a radiotherapist so I won’t wax lyrical about the nuances of their differences, but broadly speaking they have similar cancer control results. There are also different types of surgery, and they can be divided into two groups: radical prostatectomy where the entire prostate is removed and focal therapy where energy sources (like heat and cold) are used to ‘burn’ or ‘freeze’ the cancer to death. These latter focal approaches have no good evidence to support their use in moderate or high risk prostate cancer, and are generally reserved for lower risk and smaller cancers. The standard surgery, radical prostatectomy, can be done by a big incision (open radical prostatectomy), keyhole surgery (laparoscopic radical prostatectomy), or using a robot to help (robotic prostatectomy). The differences between these three approaches will be the subject of another blog- so watch out for that one! But the spoiler alert is that the robotic approach is usually best for most patients.
Now, when we compare the results of surgery and radiotherapy in terms of cancer control (how likely are you to die from prostate cancer if you have one or the other), then there’s not much in it. We have shown that if you take all men as a whole the results are pretty similar. Specifically, for men who are younger and fitter, surgery might be slightly better. The other thing about surgery is that if you do then need a further treatment you can have radiotherapy with no worse results, whereas if you have radiotherapy first, surgery becomes very difficult to do and the outcomes are much worse. So, in essence, surgery gives you “two bites of the cherry” and radiotherapy usually gives give you just one. Radiotherapy also has a risk of causing second cancers of the bladder and bowel which surgery doesn’t. So, in general, if you are fit for surgery and your cancer is of the moderate or high risk type, then surgery is usually preferred. But, for older men who have lots of other medical problems making surgery risky (remember it’s still a big operation even if the robot allows us to do it through small holes), radiotherapy is safer and might be preferred.
One other thing to consider is that the side-effects of surgery and radiotherapy are very different. Surgery is more likely to make you incontinent of urine, though in the vast majority of cases especially in my and other high-volume surgeons’ hands, this is temporary. Radiotherapy is more likely to give you bowel symptoms, and is usually also given with hormones which have yet more side-effects like hot flushes, breast tenderness, fatigue, weight gain, loss of muscle mass, and a bunch of other things.
After surgery, 94% of my patients go home the next day, 5% go home the day after, and 1% have to stay longer because of a side-effect that needs treating. With radiotherapy, you have to come to the hospital five days per week for 5-7 weeks usually.
So, there’s no straightforward answer to the question of which is better between surgery and radiotherapy. For some patients, it will be surgery, for others, it will be radiotherapy. What you need to do is go and see a prostate cancer specialist who can give you a balanced opinion tailored specifically to your prostate cancer, your general health, and your priorities for quality of life. The best surgeons will often send patients to radiotherapists because they will do what’s in your best interest, and as I’ve said above, for some men that is radiotherapy.
Rather than acting like used car salesmen selling one car brand over another, the best surgeons and radiotherapists work together and give measured advice to patients as to their options and what’s best for them. Oh, and one last thing, not all surgeons are created equal. Surgery is a learnt skill, we are not born surgeons. Hence, if you see a surgeon, always ask what his/her specific results are and if you get a woolly answer or one where he/she refers to published literature and not their own specific results, please do yourself a favour and go and see someone else. There are plenty of great surgeons out there, you deserve to see one of those.
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