Radiation or Surgery for Prostate Cancer?
Top marks for brachytherapy in prostate cancer
No other cancer has such a wide range of opinions. Large international studies have shown that radiotherapy has at least the same treatment rates for prostate carcinoma at an early stage and better treatment rates at an advanced stage compared to surgery1.
Why are most men diagnosed with prostate cancer still operated on despite the same cure rates?
Dr. Neubauer:"Despite the scientific consensus, many urologists are still convinced that only a radical removal of the prostate can lead to tumor healing. This attitude becomes even more incomprehensible if we take a close look at the study results with regard to complications and side effects of both types of treatment. In 2013, for example, a renowned scientific journal published a scientific study2 comparing the long-term effects of the operation with those of brachytherapy, a high-precision radiation, on 55,000 men. This comparative study, the largest to date, showed a clear superiority of brachytherapy with regard to urinary incontinence and sexual function. Even side effects on the rectum were less severe than after surgery.
What exactly does this mean for the patients?
Dr. Neubauer: This means that patients who have not had any problems with continence and potency so far will benefit enormously from brachytherapy. If these men are operated on, they will experience complications. A study by the Barmer GEK3 health insurance fund shows this very impressively: 70 percent of the operated patients complain about erection problems, 53 percent about sexual disinterest and about 16 percent about urinary incontinence. In addition, one in five confirmed surgical complications such as severe bleeding or intestinal injuries. Modern robot-assisted surgery, which is regarded as a "gentle" treatment option, also has more side effects than is often propagated. A US study4 found that impotence and incontinence are even more pronounced than in open surgery, despite the minimally invasive technique.
But especially for men under 65 years of age, the operation is the therapy of choice?
Dr. Derakhshani:"This is a mistake that, unfortunately, is still persistent. Especially younger, usually sexually active men benefit especially from the advantages of modern radiotherapy. These are: Better chances of cure for advanced tumors, practically no incontinence and significantly less frequent and delayed impotence. But also considerably shorter treatment and downtimes of brachytherapy compared to surgery are another plus point for men who are still in professional life. In patients with a high life expectancy, more gentle methods should be preferred for identical tumor healing because the patients suffer from the potential side effects for a particularly long time. But also men over 70 often enjoy good health. Brachytherapy with few side effects should not be withheld from them either.
Nevertheless, the population still has a strong mistrust of radiation therapy and many men prefer surgery "purely emotionally".
Dr. Derakhshani: Many men believe that cancer is gone when the prostate gland is removed from their bodies. This gives them a better feeling. Radiation, on the other hand, is not visible - this stirs up unfounded fears, which are not to be underestimated in the choice of therapy. The only thing that helps here is a well-founded clarification using scientific studies. Most people do not know that in patients with "advanced" tumours, the likelihood of individual tumour cells remaining at the incisions after surgery is relatively high. In brachytherapy, in order to minimize the risk of recurrence, the radiation dose is calculated in such a way that a kind of safety margin arises around the tumor, which destroys possible malignant cells.
Researchers at the Memorial Sloan-Kettering Cancer Center in New York were investigating the risk of developing a second tumor after prostate cancer therapy5 and investigating data from a total of 2,658 patients. The results: Ten years after treatment, an average of 10 to 15 percent of patients were diagnosed with cancer again. Bladder or rectal tumors were the most common. The risk was 3 percent for patients undergoing surgery and only 2 percent for patients after brachytherapy.
What has changed in radiation treatment over the past decades?
Dr. Neubauer: Hardly any other medical specialisation has undergone such rapid development in recent decades as radiation therapy. With brachytherapy, it is now possible to irradiate the tumour with high precision and protect surrounding tissue. Smallest radiation sources (seeds) are brought directly into the prostate gland under ultrasound control. A major advantage over surgery is that the exact distribution of the radiation dose allows us to irradiate the tumour without damaging surrounding structures such as the urethra or sphincter. While seed implantation is used in early stages, after-loading therapy is used to treat advanced stages or aggressive tumors. After accurate irradiation planning using state-of-the-art computer technology in real time, a highly active radiation source moves into the implanted needles and irradiates the tumor directly on site.
- Grimm P, Ignace Billiet I, Bostwick D et al. Comparative analysis of prostate-specific antigen free survival outcomes for patients with low, intermediate and high risk prostate cancer treatment by radical therapy. Results from the Prostate Cancer Results Study Group. BJUI 109, Suppl. 1, 22-29, 2012
- Steuten LMG. Comparative cost / QALY of guideline-recommended prostate cancer treatments: a UK cost perspective. PD 0371; 2nd ESTRO Forum, Geneva, Switzerland 2013.
- Barmer GEK Krankenhausreport 2012
- Jim C. Hu, MD, MPH; Xiangmei Gu, MS; Stuart R. Lipsitz, ScD; Michael J. Barry, MD; Anthony V. D’Amico, MD, PhD; Aaron C. Weinberg, MD; Nancy L. Keating, MD, MPH: Comparative Effectiveness of Minimally Invasive vs Open Radical Prostatectomy; JAMA. 2009;302(14):1557-1564.
- Zelefsky MJ, Pei X, Teslova T, Kuk D, Magsanoc JM, Kollmeier M, Cox B, Zhang Z: Secondary cancers after intensity-modulated radiotherapy, brachytherapy and radical prostatectomy for the treatment of prostate cancer: incidence and cause-specific sur-vival outcomes according to the initial treatment intervention. BJU Int. 2012 Aug 13