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Prostate cancer: Should I have radiation or surgery for localized prostate cancer?

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Prostate cancer: Should I have radiation or surgery for localized prostate cancer?
1.Get the facts
2.Compare your options
3.What matters most to you?
4.Where are you leaning now?
5.What else do you need to make your decision?
1. Get the facts
Your options
•Have radiation treatment.
•Have surgery to remove your prostate.
This Decision Point is for men who have decided to treat their cancer and need to choose between radiation and surgery. Some men may choose instead to wait and see if the cancer gets worse. This is often called watchful waiting. For more information, see Prostate Cancer.

Treatment choices are different for prostate cancer that has grown or spread outside the prostate. For more information, see the topic Prostate Cancer, Advanced or Metastatic.

Key points to remember
•For many men, radiation and surgery work about equally well to treat localized prostate cancer. Both also have risks, such as loss of bladder control and erection problems.
•One treatment may be better for you than the other because of your age, your other health problems, and how you feel about each treatment. You and your doctor can talk about your situation.
•If one of your biggest concerns is that prostate cancer might come back after treatment, you may want to have surgery. During surgery, your doctor can look at the cancer and take tissue samples to test. The tests will help your doctor decide how likely it is that your cancer will come back.
•The chance of having erection or bladder problems may be higher with surgery. But these problems may get better over time.
•The chance of having erection or bladder problems may be lower with radiation. But these problems may get worse over time.
•If you already have bladder, bowel, or erection problems, radiation treatment may be better for you. Talk with your doctor about the kind of radiation treatment that may be best for you.
•Men have fewer problems from prostate surgery when they have a doctor who has done many of these surgeries.1
FAQs
What is localized prostate cancer?
Prostate cancer is the abnormal growth of cells in the prostate gland . Localized prostate cancer has not spread outside the gland. Early prostate cancer usually doesn't cause symptoms.

Prostate cancer is the most common cancer in men. Most men who get it are older than 65. If your father, brother, or son has had prostate cancer, your risk is higher than average.2

African-American men have higher rates of both prostate cancer and deaths from it.2

Unlike many other cancers, prostate cancer is usually slow-growing. Most men will die with it but not of it.3

When prostate cancer is found early—before it has spread outside the gland—it may be cured with radiation or surgery.

Prostate cancer that has grown beyond the prostate is called advanced prostate cancer. Treatment choices are different for that stage of cancer. For more information, see the topic Prostate Cancer, Advanced or Metastatic.

What are the treatments for localized prostate cancer?
•Surgery takes out the prostate and any nearby tissue that may contain cancer, including lymph nodes. This surgery is called a radical prostatectomy (say "pros-tuh-TEK-tuh-mee"). A doctor can do it as open surgery by making a cut, or incision, in your belly or groin. Or he or she can do laparoscopic surgery by putting a lighted tube, or scope, and other surgical tools through much smaller cuts in your belly or groin. The doctor is able to see your prostate and other organs with the scope. Some doctors may do robot-assisted surgery. The surgeon controls the robotic arms that hold the tools and scope.
•Radiation uses X-rays and other types of radiation to kill the cancer cells. This may be done with:
◦External-beam radiation, in which a machine aims high-energy rays at the cancer.
◦Brachytherapy (say "bray-kee-THAIR-uh-pee"), in which tiny pellets of radioactive material are injected into or near the cancer.
◦Both kinds of radiation.
For many men, radiation and surgery work about equally well to treat localized prostate cancer. Both also have risks, such as loss of bladder control and erection problems.

One treatment may be better for you than the other because of your age, your other health problems, and how you feel about each treatment. You and your doctor can talk about your situation.

Men who are younger than 70 and in good health can usually have either treatment. But if you're age 70 or older, you should consider any other health problems that you have, such as heart disease. They could make surgery too risky.

Follow-up treatment

After either treatment, you will need regular checkups. You will probably have:

•Physical exams.
•Prostate-specific antigen (PSA) tests.
•Digital rectal exams.
•Biopsies if needed.
When is surgery used to treat localized prostate cancer?
You may have surgery if:

•You are in good general health and expect to live at least 10 more years.
•It looks like all the cancer can be removed.
•You don't have other health problems that add to the risks of major surgery.
This surgery usually works well to treat cancer that has not spread beyond the prostate gland. In follow-up PSA tests done in the years after surgery, most men showed no sign of cancer.4

Some specially trained surgeons in large medical centers do robotic-assisted laparoscopic surgery. The surgeon controls robotic arms that hold the tools and scope. You may have less bleeding and a shorter recovery with robot-assisted surgery.

When is radiation used to treat localized prostate cancer?
Radiation may be used:

•Alone or along with hormone therapy.
•Along with surgery. This is rarely done.
•When you have other health problems that make surgery too risky.
Radiation works as well as surgery for localized prostate cancer.5

But radiation might not be used in younger men because of concerns that the prostate is still there and could get cancer again.

What are the risks of surgery?
A radical prostatectomy has all the risks of any major surgery, including:

•Heart attack.
•A blockage of blood flow in an artery in the lung (pulmonary embolism).
•Bleeding.
•Infection.
•Reactions to anesthesia or other medicines.
Prostatectomy also may cause bladder problems and erection problems. More and more often, this surgery is being done in a way that saves the nerves that control erections.

•Erection problems: Most men who have what's called nerve-sparing surgery will be able to have erections within 4 to 6 months after surgery.4 It takes some men up to 2 years to get back more function.
•Bladder problems: More than 30 out of 100 men who have surgery have bladder problems, while about 70 don't. Bladder problems range from needing to wear pads to dribbling urine now and then during stressful activities. Bladder problems after surgery tend to get better as time goes on.6
Surgery also can cause scar tissue that may narrow the outlet to your bladder. Or your rectum or ureters could be injured.

Studies show that men have fewer side effects when this surgery is done by a doctor who has done it many times.7

What are the risks of radiation treatment?
About half of men who have external radiation have erection problems within 5 years of treatment.4 Erection problems after radiation therapy tend to get worse over time.8

Most other side effects generally go away after treatment. But in some cases they may last. Other side effects include:5

•An irritated rectum and an urgent need to pass a stool.
•An inflamed bladder and trouble urinating.
•An inflamed intestine and diarrhea.
•Trouble controlling urine.
•Pain when you urinate.
Why might your doctor recommend one treatment over the other?
Your doctor might advise you to have surgery if:

•Surgery can remove all of the cancer.
•You are young and want to do all you can to make sure that the cancer doesn't come back.
•You don't have other health problems that would add to the risks of major surgery.
Your doctor might advise you to have radiation if:

•You have health problems that make surgery too risky.
•You already have bladder, bowel, or erection problems.
2. Compare your options
Have surgery Have radiation
What is usually involved? •You will be asleep for the surgery.
•You will stay in the hospital for 2 to 4 days.
•For 1 to 3 weeks after surgery, you will have a thin, flexible tube called a catheter in your bladder to drain your urine.
•After surgery, you will have regular tests and doctor visits to find out right away if the cancer has come back.
•With external-beam radiation, the radiation is aimed at the cancer. Treatment usually is five times a week for 4 to 8 weeks.
•For internal radiation, a doctor injects radioactive material into the prostate. You will be asleep for this procedure.
•You will have regular tests and doctor visits to find out right away if the cancer comes back.

What are the benefits? •Surgery works about as well as radiation for cancer that hasn't spread outside the prostate.
•The doctor can look at the tumor and take tissue samples to test it. This can help your doctor decide how likely it is that the cancer will come back.
•Removing the prostate makes it easier to look for future rises in PSA levels and to treat cancer that comes back.
•Radiation works about as well as surgery for cancer that hasn't spread outside prostate cancer.
•It may be a better choice for men who already have bladder, bowel, or erection problems.
•You avoid the risks of major surgery.

What are the risks and side effects? •The cancer could come back.
•You may have trouble controlling your bladder for a few months after the catheter is removed.
•Surgery often leads to longer-lasting urinary incontinence. How bad it is ranges from dribbling now and then to needing to wear incontinence pads.
•Many men have erection problems after surgery. But they may get back their ability to have erections within months or years.
•The urethra or the rectum could be damaged.
•Risks of any surgery include bleeding, infection, blood clots, and problems from anesthesia.
•The cancer could come back.
•You could have erection problems. For some men, this problem gets worse over time.
•It can cause urinary incontinence.
•Other risks can include diarrhea and trouble urinating.
•There could be problems from anesthesia.

Personal stories
Are you interested in what others decided to do? Many people have faced this decision. These personal stories may help you decide.

For more information, see the topic Prostate Cancer.

Personal stories about having a prostatectomy or radiation therapy
These stories are based on information gathered from health professionals and consumers. They may be helpful as you make important health decisions.

"My doctor told me I have prostate cancer. After I got over the shock, we talked about my treatment choices. My doctor told me the cancer is small, so I have taken a year to think about it. I could have surgery to remove my prostate or use radiation to try to kill the cancer. Except for this cancer, I am in good health and hope to live a good long while, so I have decided on a radical prostatectomy. I realize the surgery may cause problems with holding my urine or getting an erection, but I do not like the idea of cancer slowly growing in my prostate. I want to get rid of it and not just try to kill it with radiation. "

— Sam, age 50

"My doctor told me after my last checkup that I have prostate cancer. I did some reading and talked with my doctor about the best way to treat it. He said the cancer is pretty small and slow-growing, so I have lots of options available: watchful waiting, radical prostatectomy, or radiation therapy. Both my reading and my doctor suggested that there was not a lot of difference in outcomes between these choices. I want to do more than watchful waiting, but the high probability of urinary and erection problems from the surgery bother me. I'm choosing to use radiation therapy. We are also talking about using hormone therapy to try to increase the effectiveness of the treatment. "

— Mark, age 57

"I really was not all that surprised when my doctor told me I had prostate cancer. My father had prostate cancer, too. My doctor told me there were several treatment options available but that there is not a lot of difference in the results of the various treatments. Since I have a family history, I feel that I need to be as aggressive as possible in my treatment of the cancer. For me, that means having the radical prostatectomy. "

— David, age 62

"Lots of men get prostate cancer as they get older. I guess that makes me a statistic. My doctor told me there are several different ways to treat my cancer. I want to do something, but at my age I'm not keen on having surgery. I also thought about my age and how long most men live after being diagnosed with prostate cancer. For me, choosing radiation therapy is the best balance between doing something and not doing too much. "

— Steven, age 72

3. What matters most to you?
Your personal feelings are just as important as the medical facts. Think about what matters most to you in this decision, and show how you feel about the following statements.

Reasons to have surgery
Reasons to have radiation
I would rather have surgery.
I would rather have radiation.

More importantEqually importantMore importantI am more concerned about the risks of radiation than I am about risks from surgery.
I am more concerned about the risks of surgery than I am about the risks of radiation.

More importantEqually importantMore importantI want my doctor to be able to know what kind of tumor I have.
It's not important to me for my doctor to know what kind of tumor I have.

More importantEqually importantMore importantI'm not worried about the higher risks of erection problems from surgery.
I want to do what I can to stay sexually active.

More importantEqually importantMore importantMy other important reasons:
My other important reasons:

More importantEqually importantMore important4. Where are you leaning now?
Now that you've thought about the facts and your feelings, you may have a general idea of where you stand on this decision. Show which way you are leaning right now.

Surgery
Radiation

Leaning towardUndecidedLeaning toward5. What else do you need to make your decision?
Check the facts
1. In general, is one treatment better than the other for localized prostate cancer?

◦Yes
•No
◦I'm not sure
You're right. Radical prostatectomy and radiation therapy work about equally well for treating localized prostate cancer.
2. Does surgery have a greater risk of causing bladder control and erection problems than radiation?

•Yes
◦No
◦I'm not sure
That's right. The chances of having erection or bladder problems may be higher with surgery. But these problems may get better over time.
3. Does your surgeon's experience affect your risk of side effects?

•Yes
◦No
◦I'm not sure
That's right. The chances of side effects from surgery are lower if your doctor has done a lot of these surgeries.
Decide what's next
1. Do you understand the options available to you?

◦Yes
◦No
2. Are you clear about which benefits and side effects matter most to you?

◦Yes
◦No
3. Do you have enough support and advice from others to make a choice?

◦Yes
◦No
Certainty
1. How sure do you feel right now about your decision?

Not sure at allSomewhat sureVery sure2. Check what you need to do before you make this decision.

◦I'm ready to take action.
◦I want to discuss the options with others.
◦I want to learn more about my options.
3. Use the following space to list questions, concerns, and next steps.

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References
Citations
1.Agency for Healthcare Research and Quality (2008). Comparative Effectiveness of Therapies for Clinically Localized Prostate Cancer: Executive Summary (AHRQ Pub. No. 08-EHC010-1). Rockville, MD: Agency for Healthcare Research and Quality. Available online: http://effectivehealthcare.ahrq.gov/healthInfo.cfm?infotype=rr&ProcessID=9&DocID=79.

2.American Cancer Society (2006). Cancer Facts and Figures 2006, pp. 1–56. Atlanta: American Cancer Society. Available online: http://www.cancer.org/docroot/STT/stt_0.asp.

3.Frankel S, et al. (2003). Screening for prostate cancer. Lancet, 361(9363): 1122–1128.

4.Ohori J, Scardino PT (2002). Localized prostate cancer. Current Problems in Surgery, 39(9): 837–957.

5.National Cancer Institute (2007): Prostate Cancer (PDQ): Treatment—Health Professional Version. Available online: http://www.nci.nih.gov/cancertopics/pdq/treatment/prostate/healthprofessional.

6.Wilt T (2004). Prostate cancer (non-metastatic). Clinical Evidence (11): 1169–1185.

7.Kantoff PW (2007). Prostate cancer. In DC Dale, DD Federman, eds., ACP Medicine, section 12, chap. 9. New York: WebMD.

8.D'Amico AV, et al. (2007). Radiation therapy for prostate cancer. In AJ Wein et al., eds., Campbell-Walsh Urology, 9th ed., vol. 3, pp. 3006–3031. Philadelphia: Saunders Elsevier.

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Author: Bets Davis, MFA Last Updated: February 3, 2009
Medical Review: E. Gregory Thompson, MD - Internal Medicine
Christopher G. Wood, MD, FACS - Urology/Oncology
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