Radical Surgery: Severe side effects but no survival benefit.

Whether radiation therapy, surgery or active surveillance - the first ten years, disease-free survival remains independent of the type of treatment for localised prostate cancer. While the efficacy of surgery and radiotherapy is comparable, there are major differences in complications in favour of radiotherapy, however.

More than 60,000 men in Germany are confronted with the diagnosis of prostate cancer every year and face the difficult task of choosing the "right" treatment. If the tumor is limited to the prostate (localized prostate carcinoma), brachytherapy (internal radiation), external radiation and surgery are available to the patient with several established therapy methods. Another option is to closely monitor low-risk tumors (active surveillance) and only initiate treatment when the disease progresses. But which method is best suited for the individual?

Long-term comparison between irradiation, surgery and active monitoring

Patients are still being suggested that radical prostatectomy is the only way to cure cancer,"says Dr. Stephan Neubauer from the West German Prostate Center in Cologne. That this is clearly wrong is shown once again by a large-scale study from Great Britain, which was recently published in the New England Journal of Medicine. For the first time, the so-called ProtecT study (Prostate Testing for Cancer and Treatment) enables a direct long-term comparison between tumor irradiation and surgical removal of the prostate gland.

Scientists from the University of Oxford and Bristol investigated a total of 1643 patients with localized prostate cancer who were randomly assigned to either radical prostatectomy, external radiation therapy or active monitoring over a period of 10 years. In active monitoring, the PSA values were checked every three months in the first year, and then every six to twelve months, in order to initiate therapy if the increase was more than 50 percent.

Risk of mortality and disease progression

As the British scientists were able to show, the survival probability for a localized prostate carcinoma is very high at 99 percent, regardless of which of the three types of treatment were used. In the first ten years only 17 of the 1643 patients died from prostate cancer: These included eight from the group with active monitoring, five from the radical prostatectomy group and four patients who received radiation. Even in view of the fact that the radiotherapeutic methods used in the study no longer correspond to the current state of scientific knowledge, there is no survival advantage for the operation,"emphasizes Dr. Neubauer from Cologne. 

Neither were there any differences in the progression of the tumour (including the formation of metastases, the need for additional hormone therapy) between surgery and radiation after 10 years.   However, most men in the group with active surveillance are likely to die before their tumours spread and settle in other organs,"said the Cologne urologist. However, active monitoring should only be considered for low-risk tumors."

Sexual function and ability to hold urine after surgery significantly restricted

While the likelihood of survival of surgery and radiation therapy is almost the same, there are large differences in complications, as a further research group at the University of Bristol has shown. Patients from the ProtecT study were asked for more than 5 years about side effects and complications. 

Thereafter, the radical surgery has serious effects on urinary tract and sexual function. After six years, 17 percent of patients who had undergone surgery were still dependent on insoles and only 4 percent who had received radiation therapy. The effects on men's sexual function were also greatest after the operation. Before the start of the study, 67 percent had an erection that enabled them to perform sexual intercourse, but after six years it was only 12 percent compared to 22 percent after irradiation and 52 percent after active monitoring. Here, too, it should be borne in mind that the incontinence rate is virtually zero due to modern radiotherapeutic methods such as brachytherapy, and that sexual function also achieves significantly better results today,"said Neubauer.

Conclusion

In the past, radical removal of the prostate was regarded as a preferred solution to completely remove the carcinoma and prolong life span, but modern radiotherapy offers not only the same and, in the case of advanced tumours, even better cure rates, but also significantly lower side effects such as incontinence and impotence 3,"Dr. Neubauer summarizes. 

Literature: 

  1. Hamdy FC, Donovan JL, Lane JA et al.: 10-Year Outcomes after Monitoring, Surgery, or Radiotherapy for Localized Prostate Cancer. ProtecT Study Group. N Engl J Med. 2016 Sep 14. 
  2. Donovan JL, Hamdy FC, Lane JA, et al.: Patient-Reported Outcomes after Monitoring, Surgery, or Radiotherapy for Prostate Cancer; ProtecT Study Group. N Engl J Med. 2016 Sep 14. 
  3. 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 pros-tate cancer treatment by radical therapy. Results from the Prostate Cancer Results Study Group. BJUI 109, Suppl. 1,22-29,2012

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