Which is Better – Surgery vs. Radiation for Prostate Cancer?

Hi, I’m Dr. Scholz. A common question we get at the PCRI is, “What’s
Better: Surgery or Radiation?” This has been the perennial question, and I think actually
I’m well positioned to answer that question. Almost everybody in the prostate cancer world
is either a surgeon or a radiation therapist. As it so happens, I’m a medical oncologist
specializing exclusively in prostate cancer. I don’t own a robot to operate with and I
don’t own a radiation machine that I can send patients to and profit from. I’m just looking
for what really is better, and I am immersed in this field enough to actually have a good
opinion and a lot of experience. So why is there a controversy? Why is it difficult
to figure out which is better? Why are there arguments and disputes about this question? Well, the real issue is how technology has
evolved over the last 10-15 years. If you go back 10 or 15 years, surgery was much better
than radiation. The radiation back then was scary. Men were getting burns; the cure rates
were diminished; people were really unhappy with the results, and then if they didn’t
get cured, they had a mess on their hands. The surgery would be very difficult to do
after the radiation, and most people are still hearing about that as an argument for surgery
to this day, “Do surgery first because if you do radiation first, you can’t do surgery
afterward.” That was a good argument, but it’s an outdated one now. So the big change that we’ve seen over the
last 10-15 years is an amazing progress in the precision and the power of radiation therapy.
We have these computerized pencil beams that go precisely where they’re supposed to go
within a millimeter or two of their target. So now you’re getting cure rates that are
even better than surgery. Remarkable. How could this be? Well, surgeons are constrained
by the fact that the bladder and the rectum are within millimeters of the prostate surface.
They can’t cut a margin around the gland. The radiation therapists are not constrained
that way. They can put a field over the edge of the bladder and over the edge of the rectum
and ensure better coverage and thus achieve higher cure rates. So if it’s just cure rates
we’re looking at modern radiation is at least as good as surgery, and if you look at what
they’re achieving with seed implants now, it’s better than surgery. Well, what about the side effects? That’s
really the important thing in prostate cancer since most men aren’t going to die of prostate
cancer, but they’re going to have to live with the side effects of this decision that
they make—potentially irreversible side effects like impotence, incontinence, damage
to the rectum which is closely adjacent. So, let’s take those things one at a time. So
let’s take the sexual question first. Sexual function after surgery is inferior in its
outcome compared to the sexual functions that can be achieved with radiation. Now, there’s
a spectrum of course, and men can be impotent with either approach, but impotence is much
more common after surgery than it is after radiation. Another confounding factor is that
surgery is associated with urinary leakage after treatment, and this almost never occurs
with radiation. Urinary leakage shouldn’t be minimized. It occurs in 5-10% of optimal
candidates operated on by world-class experts. Stress incontinence, where people leak when
they jump, sneeze, laugh occurs in up to 50% of men after surgery. Another problem with
urinary leakage is during sexual activity. About 20% of men leak uring during sexual
activity. So these are really depressing effects from surgery that don’t happen with radiation. One of the arguments the surgeons had in the
past was that there’s a very low incidence of rectal damage whereas with radiation there
could be a burn on the rectal wall, and this is true. These rates were steadily reduced
with better and better radiation, but never completely eliminated until the advent of
a new gel spacer that can be injected between the rectum and the prostate—pushing the
rectal wall away during radiation and essentially eliminating the risk of rectal damage. So in every category that we look at comparing
these two different approaches, while surgery in the past was better than radiation, in
this modern era, radiation is better than surgery.

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