Debating How to Treat Prostate Cancer: A Significant New Study Argues for Surgery Plus Radiation

For people trying to figure out how to deal with their prostate cancer, there is a new piece of evidence which will add to the debate.

For one in 10 men with prostate cancer, their disease has become locally advanced and spread beyond the prostate but not metastasized. While men whose cancer is confined to the prostate have a survival rate that approaches 100%, the survival rate drops down significantly to 10 to 40% for men with locally advanced. So these men need treatment. Unfortunately there is no agreement on which is the most effective treatment. Choices include:

• Surgery
• Radiotherapy
• Hormone therapy

Surgery has serious side effects including incontinence and erectile dysfunction. In recent years, it has been used less and less. Radiation and hormone treatment have been used much more. And regardless of the treatment, evidence suggests the most effective approach is to combine two treatments.

A new study, published in the journal Cancer, supports greater use of surgery. “Our study suggest that removing the prostate followed by adjuvant radiotherapy is associated with greater overall survival in men with prostate cancer,” says senior author Dr. Grace Lu-Yao, of the Sidney Kimmel Cancer Center with Jefferson Health.

The study was done by examining the records of patients who were treated from 1992-2009 and then followed for nearly 15 years. This so-called “retrospective” approach differs from a randomized clinical trial, where patients are randomly assigned to one of two treatments and followed over a period of years.  Lu-Yao, said “one of the strengths of retrospective studies of patient data is that it reveals what happens in the real world rather than the carefully controlled context of a clinical trial.”

Researchers looked at the treatment for nearly 14,000 men whose cancer had spread beyond the prostate. After nearly 15 years, they found:

• There was a 15% survival advantage among the men treated with surgery followed by radiation compared to those who got radiation and hormone treatment.
• There were higher rates of erectile dysfunction and much higher rates of incontinence in the surgery/radiation group.
• 50% of the men received only one treatment – not two as recommended.

So is that 15% survival advantage important? Dr. David Crawford, head of urologic oncology at the University of Colorado Denver, doesn’t think the differences were very big in the various treatments. “Most patients survived in excess of 10 years,” he said.

As for whether this study should have impact on treatment decisions for patients, Dr. Stanley Liauw, Radiation oncologist from University of Chicago medicine said “for select patients, it is possible that an approach of surgery followed by radiation may lead to more favorable oncologic outcomes, but it would not be appropriate to promote this as a general rule based on this study alone.” Liauw also noted the study looked at data from 1992 and is “unlikely to represent practice patterns today.” For example brachytherapy, placing radioactive seeds into the prostate, was not included in the study. Liauw said “a recent randomized study demonstrates that this radiation modality results in a more favorable outcome than external beam radiation.”

There are studies currently underway trying to determine what is the best treatment for patients with this kind of prostate cancer. But the lack of any clear-cut “best therapy” underscores the importance of patients having a thorough discussion with their doctor about the benefits and the risks of the different treatments.

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