Prostate Cancer Treatment: The Options

Prostate cancer is the most common cancer in men, and one out of six men will have prostate cancer sometime during their life. This represents a serious threat to men regarding their quality of life, and a serious threat of suffering and death to such individuals.

There has been an extensive debate as to which kind of treatment is best: watchful waiting (also called expectant management or active surveillance), surgery (the radical prostatectomy, robotic surgery, laparoscopic surgery, or video-assisted surgery), or radiation (external beam radiation, conformal radiation, IMRT, proton beam treatment, or brachytherapy). What kind of factors should a patient consider when they are facing decisions about prostate cancer treatment?

The most important factors to consider to decide if any treatment is needed include prostate size, PSA level, Gleason score (a measure of how rapidly growing the prostate cancer cells look under the microscope), how much of the prostate biopsy is involved by the cancer, and how long the patient is normally expected to live.

Prostate cancer treatment for younger men is usually surgery. Less intensive surgery with video-assisted surgery or robotic surgery can result in shorter lengths of stays in the hospital, but recent evidence indicates that it may be associated with increased complication rates later on. For patients who are over 65 or 70, radiation is usually the preferred mode of treatment. All patients should receive both a urology consultation and a radiation oncology consultation before considering the decision between surgery or radiation, and may even want to get more than just a single radiation oncology opinion to consider the different types of radiation therapies available.

Very often, radiation therapy is combined with hormonal therapy, since the long-term outcomes are better. Recent evidence from the national meeting of the American Society of Clinical Oncology (ASCO) indicates that three years of hormonal treatment may be more effective than shorter periods of hormonal therapy in association with radiation, depending of course on the extent of the cancer and the stage of the cancer prior to deciding how much treatment is necessary.

For cancer that has spread beyond the prostate itself, hormonal therapy is usually satisfactory without additional surgery or radiation, unless local factors (such as pain or obstruction) occur.

It is common for prostate cancer patients who have been treated with surgery to have a recurrence of their cancer first diagnosed as an elevation of the PSA to over 0.2 mg/mL. In such men, addition of hormones has been the standard treatment. However, a recent study by Dr. Bruce Trock and his co-authors (JAMA, Volume 299, page 2760, 2008) has indicated that radiation therapy to the prostate area produced a better survival than patients who received no additional treatment until tumors appeared in x-ray evaluations. The risk of dying from prostate cancer was reduced by 50%.

These results indicate that patients need extensive consultations prior to deciding whether they should have surgery, radiation, or hormone therapy versus just watching the known cancer for evidence of progression. Furthermore, these extensive consultations and second opinions can result in a better choice of which type of surgery, which type of radiation, and even which type of combination can be best. And even after treatment, close follow up is needed to make sure the prostate cancer has been cured, or give added treatments as soon as any recurrence has been found.

I recommend to my patients that they always get the second opinion to be totally confident that all of the treatment possibilities have been discussed with them. Surgeons should discuss the types of surgery and the advantages of surgery versus radiation. Radiation oncologists should discuss the various types of radiation, as well as the comparison with surgery, and the comparison with surgery plus hormonal treatments.

Medical oncologists are often useful to help guide patients through this decision process and to add hormonal therapy when it is appropriate. If patients decide to just watch and wait, careful follow up medical oncologist and/or urologist or radiation oncologist is mandatory, with visits every 3 months.