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To Cut or Not To Cut: Radiation vs. Surgery for Prostate Cancer

Author Ishaan Sangwan covers To Cut or Not To Cut: Radiation vs. Surgery for Prostate Cancer on BackTable Urology

Ishaan Sangwan • Nov 16, 2021 • 85 hits

Since prostate cancer is a slow growing disease, the value of treatment is often questionable. While many patients can be managed with active surveillance, those who do require treatment often have radiation and surgery presented as their two options.

This article discusses the risks and benefits of these two treatments, with unique insights from Dr. Jeff Caddedu on the BackTable Urology Podcast. We’ve provided the highlight reel in this article, but you can listen to the full podcast below.

The BackTable Urology Brief

• Radiation and surgery can both be effective treatments for prostate cancer, and the decision should be made based on patient age and risk tolerance.

• While many patients fear incontinence, most are able to be continent either on their own or with a follow up procedure.

• Impotence, however, is a risk of surgery, and patients must be counselled on their options appropriately.

• As a general rule, patients below the age of 60 often benefit from surgery, whereas those over 70 prefer the reduced risk of radiation.

Man being treated with radiation for prostate cancer.

Table of Contents

(1) Recurrence Risk with Radiation vs. Surgery for Prostate Cancer

(2) Incontinence Risks after Prostatectomy

(3) Impotence Risks after Prostatectomy

(4) Counselling Patients about Radiation vs. Surgery for Prostate Cancer

Recurrence Risk with Radiation vs. Surgery for Prostate Cancer

While many patients fear that radiation is less effective than a prostatectomy, the ten year survival for both treatments is comparable. Age plays a factor in which treatment patients may prefer, as the risk of recurrence is less relevant for older patients, who are more likely to die of other causes before they die of prostate cancer, and may hence prefer radiation due to the lower morbidity. On the other hand, younger patients may prefer surgery in order to minimize the chances of a recurrence.

[Dr. Aditya Bagrodia]
Certainly a scenario that I find not infrequently is really across the age spectrum, but particularly in young patients, this fear of recurrence. Maybe not very aggressive cancer. And they like the idea of having radiation as an insurance policy, as a secondary option in their back pocket. How do you guide them through that process? Here, we're talking a little bit about adjuvant or salvage radiation versus salvage prostatectomy. Somebody told them that, "Well, if you get radiation and your cancer comes back, it's going to be a tough go at it."

[Dr. Jeff Cadeddu]
So I try to tell all patients and this depends, again, at the age of presentation, but I try to counsel patients in this following scenario. That is there is no trial that I am aware of where the disease free survival is different. That is the disease free survival at 10 years, between surgery and radiation in one of the formats is comparable. It's not 100%, of course in either scenario, but it's comparable.
So the fear of recurrence is legitimate, but it's no different in surgery or with radiation. And I tell patients that this is where the age comes in. So if they're presenting with initial diagnosis at 70 years old, and they have a recurrence, they're likely to have a recurrence at more advanced age, and any recurrence likely can be managed either conservatively with systemic therapy eventually such that the fact is that they will likely die of other causes before they would die of prostate cancer.
We know that. What you're hinting at is it's much more important for a man in his 50s and early 60s, because if they have a recurrence at 10 years, or they have a recurrence at five years, now they have to do the math. And yes, in that scenario, the one advantage of surgery is that it allows for a salvage modality that has low morbidity. Conversely surgery, radiation, if there's a salvage scenario that's necessary, the surgery morbidity is greater.

Listen to the Full Podcast

Management of Localized Prostate Cancer with Dr. Jeff Cadeddu on the BackTable Urology Podcast)
Ep 16 Management of Localized Prostate Cancer with Dr. Jeff Cadeddu
00:00 / 01:04

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Incontinence Risks after Prostatectomy

The fear of incontinence may be another deciding factor for some patients. Fortunately, especially with the advent of robotic surgery, most patients are able to become continent after a few weeks to months of stress incontinence. However, if a patient remains incontinent after 6 months, procedures like male urethral slings can also be performed to restore continence. Overall, almost no patients are rendered incontinent for life due to a radical prostatectomy, and should not avoid surgery due to this fear.

[Dr. Jeff Cadeddu]
I think the practice now is that most people get if they do surgery, they do it robotically. So the anastomosis is so well visualized that most of us just leave a catheter in for some five to seven days. So I tell a patient once the catheter comes out in my practice about 40% or more of the patients will have zero to minimal leakage for a few days, and then they do well.
What I try to do in fact is tell the patients that you can count on that. So what you want to do is focus on more of the intermediate term. So I counsel patients that, "Look, you're going to probably have some degree of stress incontinence for a couple of weeks, couple of months." In experienced hands, probably 95% of patients regardless of age are going to regain social continence by six months.
I think that's pretty fair. So I don't want to over promise them that they're going to have instant continence, though some do. And I try to prepare them that usually within three to four months that continence will recover, and there's a few guys who struggle at six months. But I think one of the biggest important things to tell people is that any incontinence that goes beyond six months is correctable, in my opinion.
The biggest knock on surgery, the biggest criticism and fear of the patients is that they're going to be incontinent for life. And as you know, that's incredibly unlikely, incredibly rare. It is also unfortunately incredibly common that the average urologist who does radical prostatectomy, including myself, do not know how to surgically correct stress incontinence in a male.
So having a partner, which we're fortunate to have, who can correct this, whether it be a male urethral sling, and in the rare occasion, patient with an artificial sphincter, I tell patients, "Look, surgery, you have a short-term risk of incontinence, but the only reason you're going to be in a diaper the rest of your life is if you choose to do so.
And any friend of yours who had surgery that is incontinent, and that's why you don't want to have surgery because your friend Joe has been incontinent for three years, Joe was never given the appropriate medical advice to seek surgical correction of his incontinence. I don't see any reason that man after radical prostatectomy should be incontinent beyond six to nine months.
And that's where the patients have misconceptions. I think that's an important point. Patients come in to see us so afraid of surgery because they think they're going to be a diaper forever. And that is farthest from the truth in the 21st century.

Impotence Risks after Prostatectomy

Unfortunately, impotence continues to be a risk for radical prostatectomy. The recovery of potency depends on the stage of disease, the age of the patient, and the skill of the surgeon. However, a loss of potency can be treated with a number of technologies including medications, injections, and erectile devices. Furthermore, only erectile function is lost, and the patient retains sensory function. It’s important to have a nuanced conversation with the patient so they understand the risk, and are able to make an informed decision.

[Dr. Aditya Bagrodia]
Can you give us a little bit of your counseling on timeline and statistics for recovery of potency?

[Dr. Jeff Cadeddu]
I'll tell patients all the time the following. The recovery of your potency depends upon the volume of disease and stage, depends on your preoperative performance status. I'm never going to make you better. It depends on your age. The younger guys take a licking and keep on ticking a lot easier than the older guy.
And then the last factor is depends on your surgeon. So I can't control their preoperative status. I can't control their age. I can not control the volume of disease. So there is value in counseling a patient when they're younger, back to the active surveillance in grade group two disease. Do you do active surveillance? Well, if you're young and if you're low volume, it's more likely I'm going to have a better outcome.
Then age, right? So the 40 year olds, 50, 40 year or decade to 50 decade to 60 decade to 70 decade, patients just incrementally do worse with every decade of life in all of the studies that have been done. So I try to nuance all that in. Unlike continence where I think almost no matter what age, 95% of those patients are going to be continent. It could be a week or six months.
Potency really is nuanced. So then you want to ask me, you have to give me a scenario. Is it a 55 year old low volume disease, perfect erections, is going to do, 80, 90%? And if you're 70 years old with high volume disease and preoperative PD, five inhibitors and 100 milligram dose of Viagra because it's already struggling, well, you know that guy is not going to be potent, no matter how good you think you are of a surgeon.
So it's a much more nuanced discussion. But I also tell the patients that just like continence, what you lose is erectile function, right? A whole lot of patients have a misconception that they'll never have sex again. A lot of patients have a misconception that they never have sensory function again. There are a plethora of technologies and needs to get erectile function restored, and we will start that immediately after surgery.
I think if you counsel patients that way and you really make sure they understand what the consequences are, I think they are much more accepting of that risk and knowing that they can regain function, particularly if they're in a stable relationship, their partner would be supportive.

[Dr. Aditya Bagrodia]
I kind of tell all my patients, it's a weird thing to wrap your brain around, but you can actually have an orgasm without having an erection and without having an ejaculation. And usually there's some kind of shock and disbelief that follows. And I wholeheartedly agree. Obviously, we work in the same practice. We've got a really nice support, but starting in with low dose phosphodiesterase inhibitors and ramping up based on prioritization, based on function with erection devices, injections, and ultimately if they do require surgical therapy, we've got people that do that routinely and are very, very good.

Counselling Patients about Radiation vs. Surgery for Prostate Cancer

Many patients may present having already decided on surgery over radiation, but it is important to ensure that they have truly understood and considered their options. Another common scenario that may occur is that the patient asks the physician what they recommend. In this situation, Dr. Cadeddu recommends explaining that age often determines the best course of action, with men under 60 often getting surgery, while men over 70 decide on radiation. The data is less clear on patients between the ages of 60 and 70, and the patient should decide based on their risk tolerance.

[Dr. Aditya Bagrodia]
It does. It does. In that vein, do you have everybody that has prostate cancer and a life expectancy that merits treatment see our colleagues in radiation oncology, or do you have that initial discussion with them?

[Dr. Jeff Cadeddu]
I definitely have the initial discussion with them and I fairly spend a fair amount of time discussing the advantages of radiation therapy, the risk of radiation therapy and offer every patient an appointment with radiation oncology.
It may be the scope of my practice, but most patients have already...by the time they come to see me have already decided to do a surgery. But if it's a newly diagnosed patient, I do offer it to everybody, and if I diagnosed it, I would say many patients do take that offer of consulting with the radiation oncologist. It's imperative that we offer the patient that. I don't think it's imperative that we mandate that consultation.

[Dr. Aditya Bagrodia]
Yeah. I certainly see a handful of patients that come in and their mind is made up on surgery or maybe a referring surgeon has told them that they need surgery, take a close look at their pathology and they've got some Gleason score three plus four equals seven and just a few cores, small component pattern four. Let's take a step back here and maybe considering surveillance.
I think I wholeheartedly agree that it's incumbent on us to really run through the whole gamut of options. You ever find yourself talking patients out of surgery or out of treatment altogether?

[Dr. Jeff Cadeddu]
Oh, certainly. I mean, the common one is patients who present with low or very low risk prostate cancer who were already advised that they should have surgery. I find myself counseling those patients and vigorously, aggressively trying to steer them towards surveillance.
Yeah, I think that's a low-hanging fruit. There are patients who come in, as we discussed already with hostile abdomen over hostile pelvis for whatever other procedure they've had three TURPs already. They're diabetic. You're worried about them being incontinent. Those patients, even though they may have come to see me with their heart set on surgery. I will spend an extra effort trying to counsel them on the long-term efficacy of radiation as a viable alternative. For sure.

[Dr. Aditya Bagrodia]
And what about when you get the... All right. You've talked to us about radiation. You've spent some time talking to us about surgery and they say, "Well, doc, you're the expert here? What would you do?

[Dr. Jeff Cadeddu]
Well, I always answer that question as that I'm 54 years old. So what I decide at 54 it may not be appropriate for where you decide at 65, 72. So I do try to steer that conversation away from that. But if the patient is 54, then I would say that, "Look, what I usually tell people is this, the majority of patients who would benefit from local therapy under the age of 60, the majority of those patients, I will be fair to say, 80 to 90% of those patients choose surgery. And the vast majority of patients over the age of 70, I think when counseled appropriately will choose a radiation therapy as an efficacious treatment.
So the people in their 60s I think have the hardest decision in terms of what is best for them. And this is basically a math question. It's a question of life expectancy. We know from many trials that the efficacy of treatment after the age of 65 is very questionable as it is, period. So I tried to steer patients, certainly in the late 60s and 70s. I don't encourage them aggressively to do surgery. I do encourage them to strongly consider radiation.

Podcast Contributors

Dr. Jeff Cadeddu discusses Management of Localized Prostate Cancer on the BackTable 16 Podcast

Dr. Jeff Cadeddu

Dr. Jeffrey A. Cadeddu is a practicing Urologist in Dallas, Texas and is affiliated with multiple hospitals in the area, including Veterans Affairs North Texas Health Care System-Dallas and UT Southwestern Medical Center.

Dr. Aditya Bagrodia discusses Management of Localized Prostate Cancer on the BackTable 16 Podcast

Dr. Aditya Bagrodia

Dr. Aditya Bagrodia is an associate professor of urology and genitourinary oncology team leader at UC San Diego Health in California and adjunct professor of urology at UT Southwestern.

Cite This Podcast

BackTable, LLC (Producer). (2021, September 22). Ep. 16 – Management of Localized Prostate Cancer [Audio podcast]. Retrieved from https://www.backtable.com

Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.

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