BY ANKIT AGARWAL, MD
Men with prostate cancer have many treatment options. Active surveillance, surgery, external beam radiation therapy, and brachytherapy (seed implant) are options for many patients. How should patients compare treatment options? Men should ask their physicians these three critical questions:
- What are my chances for success with this prostate cancer treatment? What are my chances of bring cancer-free long term and not needing any additional treatments due to cancer relapse?
- What are the associated side effects with this prostate cancer treatment? What are my chances of side effects such as urinary incontinence or erectile dysfunction with this treatment?
- What data do you have to support your prostate cancer treatment recommendation? How does it compare to other treatment options available to me?
The answers to these questions very much depend on your specific prostate risk category and baseline health (such as your baseline urinary function). For example, some men with low risk prostate cancer can choose brachytherapy, surgery, or active surveillance as treatment options. However, each of these options comes with different rates of short term and long term side effects and understanding those differences is important before making a final treatment decision.
Men with high risk prostate cancer (determined by the PSA blood test and prostate biopsy result, among other factors) often need a combination of external beam radiation therapy, brachytherapy (seed implant), and androgen deprivation therapy (hormone therapy) for the best chance of achieving long term control of their prostate cancer.
What are some resources to rely on to compare prostate cancer treatment options? One of my favorite websites to refer patients to is prostatecancerfree.org. The Prostate Cancer Free Foundation is a non-profit organization dedicated to helping men with prostate cancer make well informed decisions about their prostate cancer treatment. The group publishes an ongoing meta-analysis of studies done throughout the world on prostate cancer treatment. The group shows patients, in graphical form, the chances of treatment success (defined as prostate cancer disease-free survival), by risk category. For example, for patients with “high risk” prostate cancer, this page shows the chances of success with various treatment options. I encourage patients to see which treatments have the highest chance of success for their specific risk category.
What about side effects? Prostate Cancer Free also outlines the typical short term and long term side effects associated with various treatment options here.
Are their other resources? Yes, researchers throughout the world continue to study the benefits and risks of various treatment options so that physicians and patients can make well informed decisions. For example, one of the largest randomized studies in prostate cancer, the PROTECT trial, a study of 2,565 patients with mostly low risk prostate cancer, recently published their long term quality of life outcomes here. The study found, among other things, that patients who received brachytherapy (radiation seed implant) had the best long term sexual quality of life outcomes. Another major study the ASCENDE-RT study, which showed that patients who received a brachytherapy boost in addition to external beam radiation therapy had a 50% lower risk of treatment failure compared to patients who received external beam radiation therapy alone. Another recent study published in the Journal of the American Medical Association (JAMA), where can be read here, showed that, among 1809 men treated for their Gleason 9-10 prostate cancer across 12 institutions, patients who received external beam radiation therapy with a brachytherapy boost were much more likely to remain free of distant metastatic disease compared to patients who received external beam radiation therapy alone or a radical prostatectomy.
However, I always caution men interpreting too much from individual studies, including the studies mentioned above, as many individual studies have bias. For example, many retrospective studies (studies that do not randomize patients to a certain study) may assign healthier, younger patients to treatment A and assign older, sicker patients to treatment B. Treatment A may appear superior in the study, but this may simply be due to the differences in the underlying patients and not a difference in the outcomes by treatment option! In addition, many older studies have published toxicity outcomes of outdated radiation techniques. Modern brachytherapy by expert brachytherapists is done by intraoperative interactive radiation planning, which vastly improves the outcomes and reduces the side effects of treatment. Similarly, techniques such as intensity modulated radiation therapy (IMRT) have decreased the side effects associated with external beam radiation therapy compared to older outdated modes of radiation delivery. Thus, meta-analyses which rely on the results of a compilation of studies, such as the one on The Prostate Cancer Free Foundation website, are often more accurate than any single individual studies you may find online.
Finally, men should ask their doctors how much experience they have with their recommended treatment option (whether it is external beam radiation, brachytherapy, or surgery). It is important to seek the opinion of high-volume physicians who specialize in the treatment of prostate cancer care. If you’re in California and would like to consult with one Western Radiation Oncology’s physicians, please contact us here.
By Ankit Agarwal, MD