Andrew Siegel MD 5/11/2024
This is my fifth and final entry on surgery vs. radiation for prostate cancer. I have dwelled on this topic — perhaps excessively — but remember that prostate cancer is the most common malignancy in men aside from skin cancer, and the decision between surgery and radiation can be challenging and daunting. I promise not to write any more prostate cancer entries for quite some time! Next week’s topic will be radically different and intriguing: “OCD (Obsessive Compulsive Disorder) and the Urogenital Tract.”
How would you treat your own localized prostate cancer? Surgery or radiation?
I posed the aforementioned question to radiation oncologists Thomas P. Kole, MD, PhD and Glen Gejerman, MD, as well to several of my urology colleagues including Gregory Lovallo, MD, Mubashir Shabil Billah, MD, and Michael Esposito, MD: What follows are their answers as well as my own answer to this challenging question. Note: responses have been minimally edited for clarity.
Today’s entry is the final one in this series of Surgery or Radiation. To view the previous entries:
Dr. Thomas Kole: Radiation Oncologist (age 46): As a radiation oncologist who specializes in the treatment of prostate cancer, there is no question that I receive more frequently from my patients than: “What would you do if you had prostate cancer, surgery or radiation?”
The first step in being able to answer the question is the consideration of whether I would be psychologically comfortable leaving my prostate intact in my body, knowing that cancer was once growing there, and having to watch my PSA kinetics (the rate of PSA change over time) for several years to determine if my disease has been effectively treated by radiation. I would be comfortable leaving my prostate intact; however, I recognize that as a radiation oncologist I am biased and have a particular advantage given that I understand post-treatment PSA kinetics somewhat differently than a patient with no background in prostate cancer.
The next step in being able to answer the question is the consideration of my quality of life from a urinary and sexual standpoint. Many patients focus on the risk of erectile dysfunction when contemplating their treatment options. I counsel them that while erectile function is important, there is no bigger quality of life game changer for men than urinary incontinence, a major source of anxiety that often leads to avoidance of activities that trigger the incontinence.
Other important considerations are that great strides have been made in the delivery of radiation treatment, the fact that the incidence of chronic urinary and bowel issues after modern radiation therapy is low, and that there are a myriad of options available should locally recurrent disease surface.
So, my answer to the question is that I would be more inclined to choose radiation therapy to maintain my current quality of life and avoid the potential risk of urinary incontinence. On the other hand, if I had significant obstructive urinary symptoms due to prostatic enlargement that had not responded to medical management, I would be more inclined to consider surgery as a means of curing my cancer and simultaneously fixing my plumbing issues.
Dr. Gregory Lovallo: Urologist (age 48): Many factors go into deciding to elect surgery vs radiation, including age, comorbid conditions, lower urinary tract symptoms, etc. That said, when all things are equal, including the anticipated surgical and radiation cure rates, I tend to favor radical prostatectomy as it offers a more active role in recovery for the patient.
As a surgeon, I obviously prefer to be an active participant in quick fixes: “If it shouldn’t be there, take it out.” When it comes to prostate cancer treatment, I prefer to take an active role in muscle and nerve preservation, bladder neck reconstruction, and all the risk-mitigating techniques we can offer to ensure the best outcomes. As a patient, I would hope to take a similarly active role. In experienced surgical hands, the major risks of incontinence and impotence are significantly lower than they were in decades past. With weight loss, an active lifestyle, pelvic floor physical therapy, and other pre-habilitation and rehabilitation programs, these risks can be reduced even further by a motivated patient.
While radiation is anything but passive for the team delivering the treatment (radiation oncologists, physicists/dosimetrists who plot, plan, map and deliver the therapy), for the patient receiving therapy it really becomes a “watch and wait to see” situation. Patients managed with radiation therapy are passive bystanders to an often slowly responding PSA; more importantly, they are vulnerable onlookers to the permanent and sometimes devastating tissue changes that can follow a course of radiation. Voiding symptoms, rectal pain, penile and pelvic discomfort along with other symptoms that might ensue are often unresponsive to standard treatments in the irradiated patient. While rare, patients with more severe cases of radiation cystitis may bleed, often finding themselves in and out of the office and emergency room for catheters, irrigation, and even frequent trips to the operating room for clot evacuation and fulguration/cauterization.
If I am diagnosed with prostate cancer, I want to go under the knife of an experienced robotic surgeon. Then leave the recovery to me. I don’t want to take the chance of the havoc radiation can leave in its wake and the helpless feeling of having no role in addressing the effects.
Dr. Mubashir Shabil Billah: Urologist (age 33): As a urologist, I am biased towards surgery, as I am the surgeon offering radical prostatectomy. When it comes down to my choice of treatment if I was diagnosed with prostate cancer, I would practice what I preach to my own patients.
Many factors go into the decision-making process of surgery versus radiation versus active surveillance: PSA level, PSA velocity, prostate size, Gleason score, volume of prostate cancer (number of cores involved, percentage of each core), imaging results, urinary and sexual status, age, medical comorbidities, history of prior surgery, etc.
For a patient without significant medical comorbidities, with localized intermediate-risk prostate cancer, no evidence of metastasis, and a PSA < 10, most urologists would recommend definitive treatment. If the patient is healthy and younger than 70 years old with an anticipated life expectancy of more than 10 years, I would recommend surgery. Surgery has short-term side effects – mainly erectile dysfunction and urinary incontinence — that improve with time and are treatable.
I would choose radiation if I was older, had a shorter life expectancy, or significant medical comorbidities. Radiation side effects may get worse with time and as a urologist I have witnessed significant side effects, even so extreme as to requiring the surgical removal of the bladder. This is not to say that radiation is not a great option. In summary, the question of surgery vs radiation is quite complex, and every patient is different. But typically, I would choose surgery if it was a viable option.
Dr. Michael Esposito: Urologist (age 55): My fervor for robotic prostatectomy is based upon a patient’s youth, excellent health, and the potential to enjoy significant longevity. Those patients with symptomatic prostate obstruction, those with high volume grade group 1 or a component of grade group 2 are excellent candidates for surgery. Aside from the urological criteria for selecting a patient for surgery, the appropriate selection of a patient for surgery also involves a patient with the proper mindset and psychological prejudice toward surgical treatment as opposed to radiotherapy.
Based upon many years of experience and thousands of cases of surgical treatment, outcomes can be excellent. With exquisite surgical technique, careful nerve sparing, significant attention to prostate anatomy to avoid capsular penetration and positive margins, and management of the apical sphincter complex, there is a high likelihood of achieving cancer free status, full continence, and satisfactory erections. These are some of the happiest and most satisfied patients following treatment. Of course, expectations must be managed and an important part of preparation for surgery is a pre-operative regimen consisting of physical conditioning, pelvic floor muscle training, and a discussion regarding using oral erectile dysfunction medications preoperatively. Patient preparation and proper informed consent is a crucial element for optimal postoperative recovery.
I find that radiation in younger men under age 60 portends some degree of treatment regret given that the disease process has not been removed and remains in one’s body. Following radiation there can be a plethora of side effects, including some degree of erectile dysfunction, bladder instability, and the possibility for future hemorrhagic cysto-prostatitis, especially given the fact that modern medicine has allowed longevity to be a reality. Given the prevalence of cardiovascular issues leading to the need for anticoagulants, bleeding complications in those patients with cysto-prostatitis can be exacerbated and difficult to manage.
So, at age 55, if I was diagnosed with localized prostate cancer the answer is clearly that I would elect surgery.
Dr. Glen Gejerman: Radiation Oncologist (age 61): As a radiation oncologist whose clinical and research career is dedicated to prostate cancer I am often asked what I would do if diagnosed.
I hope that I would have the presence of mind to heed the advice that I give my patients: try to remain objective and make a data driven decision.
A 2023 New England Journal of Medicine article reported that while after 15 years of follow-up, long term survival is excellent regardless of treatment choice, men treated with surgery or radiotherapy (as opposed to active surveillance) had lower rates of local progression or metastasis. It is therefore imperative to consider the tradeoff between oncologic benefits and treatment related sequelae.
The British Journal of Urology recently published 6-year patient reported side effects for patients enrolled on the ProtecT study (active surveillance vs surgery vs radiotherapy). Men managed with active surveillance experienced age-related gradual declines in sexual and urinary function without changes in bowel function or urinary incontinence. After prostatectomy, men developed immediate urinary incontinence with some improvement over time, but persistent symptoms remained in 20% of men at 6 years. Radiotherapy impacted urinary voiding during and shortly after treatment, but incontinence was not experienced. The impact on erectile function was significantly less than after surgery but worse than active surveillance. Bowel function and bother were worse after radiotherapy than after surgery.
Based on these data, I would review my Gleason score and ask for a Genomic test (such as Oncotype or Decipher) to assess my risk of disease progression. For a low Gleason and genomic score, I would pursue active surveillance. For intermediate or high-risk disease, given the similar long term cure rates, I would endeavor to avoid urinary incontinence and erectile dysfunction and would pursue definitive radiotherapy.
Dr. Andrew Siegel: Urologist (Age 68): I’m in good physical shape for my age and my father is alive and well at age 92 (and had a radical prostatectomy at age 65). In all honesty, I am not 100% sure of which pathway I would take. Some of my key thoughts are as follows:
I am troubled by the concept of removing an organ that I consider to be my male “center of gravity.” Whereas it’s one thing to remove an “end” organ whose removal has no collateral functional consequences (e.g., a kidney), it’s another thing entirely to remove an organ like the prostate – positioned smack at the crossroads of the urinary and reproductive tracts – the removal of which may incur significant urinary and sexual functional disturbances.
On the other hand, radiation therapy may adversely affect bowel function and sexual function, and although radiation cystitis is a rare long-term complication, nonetheless if you happen to suffer with this complication, it can cause extremely troublesome chronic bleeding and disability.
In the event of recurrent disease after primary treatment, which happens commonly enough, means of salvaging surgical failure to cure the disease are easier and preferable to the means of salvaging radiation failure to cure the disease.
So, should I one day be faced with a prostate cancer diagnosis, I – with the support of my loved ones – will need to carefully weigh all of these and the other considerations detailed in this series of entries in order to come to a decision. At this time, in the absence of obstructive lower urinary tract symptoms, I am leaning towards radiation.
Wishing you the best of health,
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Dr. Andrew Siegel is a physician and urological surgeon who is board-certified in urology as well as in female pelvic medicine and reconstructive surgery. His mission is to “bridge the gap” between the public and the medical community.
He is an Assistant Clinical Professor in the Department of Urology at Hackensack Meridian School of Medicine and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. He is a urologist at New Jersey Urology, a Summit Health Company. He is the co-founder of PelvicRx and Private Gym.
Dr. Siegel is the author of several books. The newly revised second edition (June 2023) of Prostate Cancer 20/20: A Practical Guide to Understanding Management Options for Patients and Their Families is now available in print and Kindle formats on Amazon.
Video trailer for Prostate Cancer 20/20
Preview of Prostate Cancer 20/20
Andrew Siegel MD Amazon author page
Dr. Siegel’s other books:
THE KEGEL FIX: Recharging Female Pelvic, Sexual, and Urinary Health
MALE PELVIC FITNESS: Optimizing Sexual and Urinary Health
Promiscuous Eating: Understanding and Ending Our Self-Destructive Relationship with Food
Our Greatest Wealth Is Health 