Genitourinary Cancer – 8 – Prostate Cancer

Genitourinary Cancer  – 8

(All the articles published in past are available at www.shyamhemoncclinic.com/blog/)
Question: Thank you Chiragbhai for several interesting points about prostate cancer treatment: 1. Definition of risk categories – based on a combination of Stage, Gleason score, and PSA. And how these are used to take treatment decisions. 2. Treatment options for localized cancer. 3. Option of Active Surveillance without any treatment, for patients with lower risk and lower life expectancy. 4. Surgery and Radiotherapy have equal cure rates – this is a BIG SURPRISE for most of the readers. 5. How to choose between two options – importance of patient factors like age, comorbidities, choice, availability of local expertise etc in decision making.
We discussed about above points in detail. You mentioned about certain pros and cons of surgery and radiotherapy. Can you elaborate on this?
Answer: Certainly. Both treatments have their advantages and disadvantages. When these are discussed with patients frankly, it helps them in taking decision. Major points include:
1. Surgery is a shorter treatment, requiring about 7-10 days of hospital stay. Then patient can return to their home town. This is especially attractive and important factor for patients coming from out of town. I recently had a patient from Africa who chose surgery over radiotherapy for this reason. Radiotherapy on other hand requires about two months stay close to hospital. This does not matter for local patients. However many out of town patients may still choose this option.
2. Some patients have fear of any surgery or undergoing anesthesia in general.
3. Older patients, over age 70-75, or with major comorbidities may have higher anesthesia risk. For these patients, even treating doctor will prefer radiotherapy.
4. Higher risk patients who undergo surgery, may end up requiring postoperative radiotherapy as well. When there is such a possibility raised, many patients may prefer to go for radiotherapy as initial option rather than surgery.
5. Surgery requires hospitalization, not required for radiotherapy. Complete radiotherapy treatment is outpatient with minimal disturbance in patient’s daily routine. This is an important factor for many patients, for various reasons – work related or social reasons etc.
6. Most important side effect of surgery is urinary incontinence, and impotence. Of course this does not happen to every patient, and with improving techniques, incidence is reducing. Many patients recover within initial few weeks, but not all. However prospect of incontinence i.e. inability to control one’s urine, is a serious issue for many adult patients especially if they need to continue to work or have very active social life. In spite of improved techniques, incontinence is still an important common side effect of surgery and can be long lasting too. I just met a patient last week, operated by a very famous good surgeon over a year ago. Patient still has incontinence after a year of surgery. His incontinence is now limited to when he is physically active i.e. playing golf, walking a lot, sports etc. So he is able to go to work but the above noted limitations are very important for his quality of life, at the age of about 65. Since these are the activities he used to enjoy before surgery. He also spoke about his concern with impotence which has still not recovered fully even after a year post surgery. Men are increasingly concerned about this side effect as well, even in their 60s.
7. Several studies show that surgical side effects are higher with higher age, especially after about 65-70. And lower recovery rate of these side effects, compared with younger adults.
8. Radiotherapy related concerns include long treatment, some patients think that diseased organ should not be left inside. Side effects in short term include gastrointestinal (in about 10-20 percent in various studies) i.e. painful defecation, urgency, blood in stool. These persist in only a small number of patients in long term requiring additional treatment. Short term urinary side effects include urgency, painful urination, increased frequency. These are more common but rarely continue long term, generally resolve in few weeks after radiotherapy completion. In the long term, most important side effect of Radiotherapy is impotence. Frequency increases with time, with over half of patients reporting this side effect after about 2 years. Pros and cons of Brachytherapy radiation are mostly similar, with some important differences related to size of prostate, technique used, experience of radiation oncologist.
9. So as we can see, different people attach different importance to various pros and cons.
May 15th 2018.

Dr. Chirag A. Shah; M.D. Oncology/Hematology (USA), 079 26754001. Diplomate American Board of Oncology and Hematology. Ahmedabad. drchiragashah@gmail.com