Many of our patients have their prostate cancer diagnosed early, giving them an extremely high chance of a long-term cure with limited side effects, if any. Once they are diagnosed and they have come to terms with their condition, their mind soon turns to the best way to treat it. There is a lot of information out there on what treatment is best, so I thought it sensible to compile a list of the key points for such a patient to consider.
In order of most important first, the answer to this question depends on a number of factors:
- Tumour grade: the Gleason grade assigned by a pathologist denotes its aggressiveness. The scale goes from Gleason 6 to Gleason 10 and is made up of 2 numbers. The first is what most of the cancer is composed of and the second number is what the second most common appearance of the cells is. So, for instance, a Gleason 3+3 or Gleason 6 tumour, which is the lowest grade or the least aggressive prostate cancer, would normally be managed by active surveillance. This involves checking the PSA level every 3 months, repeating the MRI scan every year and repeating the prostate biopsy every 2 years. More aggressive tumours are better managed by active treatment (such as radiotherapy, brachytherapy or surgery) because of their greater tendency to spread outside the prostate and to grow faster.Key point: aggressive cancers need active treatment (radiotherapy, brachytherapy or surgery) to target the cancer directly.
- Patient age: younger men have a greater life expectancy, so it is even more important for them to consider what treatment would be available if their first treatment option failed to cure them. Generally, radiotherapy after surgery is well-tolerated and associated with good results but the same does not apply to surgery after failed radiotherapy. This is because of delay in diagnosis and complications in operating on tissues that have been altered by radiotherapy. Additionally, pelvic radiotherapy increases the risk of developing bladder and rectal cancer. Since this risk increases with time, radiotherapy is not an ideal treatment for most younger (aged less than 70 years) men.
Key point: pelvic radiotherapy may increases the risk of cancer in other pelvic organs. Additionally, in younger patients, second-line treatment options should be kept in reserve for future. For men aged 70 or below, surgery is therefore preferable.
- Patient preference: many men will be attracted by the greater certainty of surgery (the analysis of the prostate after it has been removed allows us to clearly determine the exact grade (aggressiveness) and stage (extent) of the cancer), and the fact that it preserves the options of radiotherapy and hormonal therapy for later use, if needed.
Equally, other men choose to avoid surgery for its unintended potential consequences of bladder and/or sexual dysfunction. These risks can be substantially minimised by choosing an experienced surgeon i.e. one who has done at least 1,000 cases and continues to operate regularly, but cannot be excluded altogether.Key point: patient preference is also a big factor. Some may want the certainty of surgical removal; others may prefer to tackle the cancer while the prostate remains in the body.
- Reading scientific studies: the results of the only large, high-quality (randomised and controlled) study (the UK-based ProtecT study) of surveillance, radiotherapy and surgery for localised prostate cancer was published in the New England Journal of Medicine in 2016, and found that:
- out of the 82,429 men enrolled, only 1% died of prostate cancer
- there was no difference in the death rate between the monitoring, radiotherapy and surgical arms
- men who had radiotherapy or surgery had half the rate of metastasis (distant spread of the cancer outside the prostate) compared to men who just had monitoring.
Unfortunately, the great majority (about 75%) of men in this study had low-risk prostate cancer, which would be managed today by active surveillance, so the results of this landmark study actually help very few men with more aggressive prostate cancer in their decision-making process.
In conclusion, there are approximately 3 key factors to be considered when selecting the best treatment for prostate cancer in its early stage: how aggressive the cancer is; the age of the patient; and personal preference.
The best advice that I can personally give to men considering the above is to echo the conclusion of a multi-centre study published in 2011 that investigated the results of radiotherapy and surgery in 400,000 men treated over 18 years. This study stated that for most men, surgery provides better cancer control than radiotherapy in men under the age of 80 years old.