What is the best treatment for localized prostate cancer?

How do you choose between prostate cancer surgery and radiotherapy?

A common question in my clinics is, 'If you were suffering from localised prostate cancer, what would you choose: radical prostatectomy or radiotherapy?'

From clinical trials, if both radical prostatectomy or radiotherapy are possible options based on the prostate cancer information available (prostate-specific antigen, MRI and prostate biopsy) in terms of curing prostate cancer, they are equivalent.

The way forward is to keep an open mind. Humans are all different, and we react differently to our situations.

What steps should you take?

1. Learn about prostate cancer (is it localised prostate cancer, advanced prostate cancer or metastatic prostate cancer)
2. Ask what treatment options are available.
3. Ask for information leaflets, reliable online information to access and contact details of the people supporting your journey.
4. Make sure you meet with the surgeon performing radical prostatectomy and the oncologist who will prescribe radiotherapy. Prepare before the meeting and jot down any questions you wish to ask.
5. Take a period of reflection. See which treatment option you would prefer if complications or side effects arise. How would these impact your current quality of life? With what would you cope and not cope?

Knowing your prostate cancer and treatment options

1 in 8 white men and 1 in 4 black men are diagnosed with prostate cancer.

Prostate cancer is slow-growing cancer that may not cause symptoms for many years. However, in some cases, it can be more aggressive and spread quickly.

The aim is to relieve symptoms and slow cancer progression for prostate cancer that has spread outside the prostate to other parts of the body (metastatic prostate cancer).

On the other hand, for localised prostate cancer, several treatment options are available to cure prostate cancer—these include surgery and radiation. Clinical trials have cemented their role in localised prostate cancer and locally advanced prostate cancer.

Some men explore other treatments to cure prostate cancer, known as experimental targeted therapy, like High intensity focused ultrasound (HIFU), Nano Knife or cryotherapy. Clinical trials are still needed to prove their role. If one chooses these cancer treatment options and there is prostate cancer recurrence, one can still explore other treatments to treat cancer.

Prostate cancer treatment options based on stage

Prostate cancer is staged based on how far it has spread, with stage I being the earliest and stage IV being the most advanced.

The grade of cancer refers to how abnormal the cancer cells look under a microscope, with a higher grade indicating a more aggressive cancer.

Radical prostatectomy and radiation therapy are equally effective treatment options for patients with early-stage prostate cancer (stages I and II).

Radiation therapy is the preferred treatment option for patients with locally advanced prostate cancer (stage III) or those unsuitable for radical prostatectomy.

In the UK, the National Institute for Health and Care Excellence (NICE) guidelines state that the choice between surgery and radiation therapy should be made based on the patient's preference, overall health and each treatment option's potential risks and side effects.

Radical prostatectomy

Surgical removal of the prostate gland and surrounding tissues, the nearby lymph nodes can be removed in more aggressive prostate cancer cells. Nowadays, the standard approach is robotic prostatectomy; however, laparoscopic surgery or open surgical procedure approaches are equally effective as long as the surgeon operating is skilled and has high numbers.

Radical prostatectomy can be a nerve-sparing surgery in most patients with early-stage prostate cancer. Your surgeon will discuss if there is a need to remove nearby lymph nodes.

Robotic surgery has gained ground as there is less blood, shorter hospital stays and early return to everyday life. All of these have made it possible for robotic surgery to become the primary surgical approach to treating cancer.

Questions to ask your surgeon offering robotic surgery.

1. Which surgical procedure do you recommend for me and what are the reasons for this recommendation?
2. Will nerve-sparing surgery be attempted, and what type of surgical procedure do you suggest for me?
3. How many of these surgeries have you performed in the past, and how frequently do you perform them each year?
4. Is it possible for me to see the outcomes of the radical prostatectomies you have conducted?
5. What type of pain relief will I receive after the operation?
6. How and when will it be determined whether the operation has successfully removed all of cancer?
7. How frequently will my PSA level be monitored?
8. What is the likelihood of requiring further treatment following the surgery?
9. What is the potential for experiencing urinary or erectile difficulties, and what resources are available to support me in dealing with these problems?
   

Radiation therapy

Radiation therapy can be used as a primary or adjuvant treatment after surgery. Adjuvant therapy is used after the primary treatment (in this case, surgery) to kill any remaining cancer cells and reduce the risk of cancer returning.

Different types of radiation therapy exist, such as external radiotherapy (external beam radiation therapy) and brachytherapy (internal radiation therapy). Irrespective of the approach both destroy cancer cells effectively.

External beam radiation therapy involves directing high-energy radiation beams from outside the body towards the prostate gland, while brachytherapy involves the placement of radioactive seeds inside the prostate gland. The choice of radiation therapy will depend on the patient's circumstances and cancer stage.

What are the side effects of radiation therapy?

1. Erectile dysfunction: Radiation can damage the blood vessels and nerves responsible for erections, leading to difficulties in achieving or maintaining an erection. According to the NICE, around 40–60% of men who receive radiation therapy for prostate cancer experience erectile dysfunction; in some cases, this can be permanent erectile dysfunction.
2. Urinary problems: Radiation therapy can cause irritation and inflammation in the bladder and urethra, leading to various urinary problems. These may include increased frequency, urgency, blood in the urine (haematuria), or difficulty urinating. In severe cases, radiation can also cause urinary incontinence. According to NICE, up to 10% of men who receive radiation therapy for prostate cancer experience urinary incontinence.
3. Bowel problems: Radiation therapy can cause inflammation and damage to the rectum and surrounding tissue, leading to bowel problems such as diarrhoea, constipation, and rectal bleeding. According to NICE, around 5–10% of men who receive radiation therapy for prostate cancer experience bowel problems.
4. Fatigue: Radiation therapy can cause tiredness and fatigue, which may be more pronounced towards the end of treatment. The severity of fatigue can vary from person to person, but it typically resolves within a few weeks to a few months after treatment ends.
5. Skin changes: Radiation therapy can cause the skin in the treatment area to become red, dry, and itchy. In some cases, the skin may also become blistered or peeling. These changes usually resolve within a few weeks after treatment ends.
6. Secondary cancer formation. This depends on several factors, including the dose of radiation received, the patient's age, and the length of time since the radiation therapy was completed. Studies have shown that the risk of developing secondary cancer after radiation therapy for prostate cancer is around 1%. The most common secondary cancer that can occur after radiation therapy for prostate cancer is bladder cancer. The risk of developing secondary cancer is highest in the first ten years after radiation therapy. Other types of secondary cancers that can occur include rectal cancer, colon cancer, and lymphoma.
   

Hormone therapy

Radiation therapy is commonly combined with hormone therapy to treat prostate cancer effectively. The latter lowers the male sex hormones, testosterone, in the body, and prostate cancer cells need testosterone to thrive. Depriving them of testosterone weakens them, making them vulnerable to the radiation therapy effect. Whilst radiation treatments destroy prostate cancer cells, the healthy cells in the prostate tissue and other normal cells in adjacent organs repair themselves.

What are the side effects of hormone therapy?

1. Erectile dysfunction: Hormone therapy can cause a decrease in testosterone levels, which can lead to difficulties with achieving or maintaining an erection. According to to NICE, up to 90% of men who receive hormone therapy for prostate cancer experience erectile dysfunction.
2. Loss of libido: Hormone therapy can also cause a decrease in sex drive, which can impact sexual function and intimacy.
3. Hot flashes: Hormone therapy can cause sudden feelings of warmth and sweating, often accompanied by flushing. These symptoms can be mild to severe and can have a significant impact on quality of life. According to NICE, up to 80% of men who receive hormone therapy for prostate cancer experience hot flashes.
4. Fatigue: Hormone therapy can cause tiredness and fatigue, which may be more pronounced in the first few months of treatment. The severity of fatigue can vary from person to person, but it typically improves over time.
5. Breast enlargement: Hormone therapy can cause the breast tissue to grow, leading to breast enlargement and tenderness. This side effect is more common in older men who have been on hormone therapy for an extended period.
6. Osteoporosis: Hormone therapy can cause a loss of bone density, leading to an increased risk of fractures. According to NICE, up to 20% of men who receive hormone therapy for prostate cancer experience osteoporosis.
7. Metabolic X syndrome: Hormone therapy can cause changes in metabolism that may increase the risk of developing metabolic syndrome, a group of conditions that includes high blood pressure, high blood sugar, excess body fat around the waist, and abnormal cholesterol or triglyceride levels. Metabolic syndrome can increase the risk of heart disease, stroke, and other health problems. However, the risk of developing metabolic syndrome from hormone therapy for prostate cancer is generally low.
8. Moodiness: Some men may experience mood changes or emotional symptoms while on hormone therapy, such as depression, anxiety, irritability, or mood swings. The exact cause of these mood changes is poorly understood, but they may be related to hormonal changes during treatment.

It's important to note that not everyone will experience all of these side effects, and their severity can vary from person to person.

Questions to ask your oncologist if you are offered hormone treatment in combination with radiotherapy.

1. What type of radiotherapy treatment will I undergo?
2. How many sessions are required for my treatment? How much radiation treatment will I receive?
3. What other options for treatment do I have?
4. What are the possible side effects, and how long will they persist?
5. What treatments are available to manage the potential side effects of radiotherapy?
6. Will hormone therapy be administered, and will it continue after radiotherapy?
7. How and when will I know if radiotherapy has been effective?
8. What other treatments are available if radiotherapy is unsuccessful?
9. Who should I contact if I have any questions?
10. What support is available to help manage long-term side effects?
    

Can I have no treatment and be on active surveillance?

Active surveillance is a viable option for patients with low-risk low, volume prostate cancer caught at its early stages.

Active surveillance closely monitors the patient with regular PSA (prostate-specific antigen) blood tests, digital rectal exams, and MRI (magnetic resonance imaging) scans. Prostate biopsies can be ordered at any time if there is an increase in the PSA or progression on the MRI scan. Treatment is only initiated if cancer progresses or the patient wishes to opt out of the programme. Clinical trials have proven that active surveillance is safe.

Questions to ask your doctor if you are offered active surveillance

1. Will I be placed on active surveillance or watchful waiting?
2. How often will my PSA level be monitored?
3. Who will be responsible for scheduling my PSA tests?
4. Who will examine my PSA level and provide me with the results?
5. How frequently will I see my physician or nurse?
6. Will I have any other routine scans or tests? If so, which ones and how frequently?
7. What test findings would lead you to recommend treatment, and are there any specific outcomes that would necessitate further testing?
8. What treatment options are available if my cancer progresses?
9. What can I do to improve my overall health?

What do clinical trials for men with localised prostate cancer say?

How many would still be alive in 10 years?

Active surveillance (98%)

Radical prostatectomy (99%)

Radical radiotherapy (99%)

How many would their cancer progress ten years after treatment?

Active surveillance (21%)

Radical prostatectomy (8%)

Radical radiotherapy (8%)

Reflection from a prostate cancer specialist

Both prostate cancer surgery and radiotherapy are effective at cancer treatment. If there is a recurrence after radical prostatectomy, one can access radiotherapy. Doing it the other way around is still possible, but only highly specialised centres should perform the salvage surgery as the risks of complications are higher.