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Surgery versus radiotherapy

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User
Posted 09 Nov 2019 at 15:40

In the case of localised or locally advanced prostate cancer, what are the main criteria for choosing between radical prostatectomy and external beam radiotherapy?

 

 

 

 

User
Posted 10 Nov 2019 at 01:58
For locally advanced:-

1. Surgeons are often not willing to operate if they don't think they can get it all out

2. If it is believed that adjuvant RT would be needed anyway, or there is a high risk of needing salvage RT, many believe there is no point putting the patient through unnecessary side effects of surgery

3. The adjuvant or salvage RT is more difficult if surgery leaves the man incontinent

4. Radical RT can be delivered in a differentiated way that captures the rogue cells outside the prostate

5. Surgeons have to publish their data including how many of their men had positive margins and / or needed salvage RT - a disincentive to many of them as it makes them look not very good at their job. The best surgeons may be those whose stats don't look very good because they take on men that others have refused to operate on

6. There is an emotional impact for a man who chooses surgery hoping the cancer will be removed, only to find it wasn't

For contained cancer:-

1. Personal preference / approach to risk

2. Deciding which side effects are tolerable / intolerable

3. Existing medical history (including previous abdominal surgery, heart problems, etc)

"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard

User
Posted 10 Nov 2019 at 08:52
In my own case, both my urologist and oncologist recommended RT, because my relatively high PSA (32 at diagnosis) suggested a distinct possibility of undetectable spread to the lymph nodes which surgery wouldn't be able to remove. When a surgeon recommends that surgery is not a good option it's as well to listen 😁.

Now, 7 months after the end of RT my PSA is down to 2.0, so things are looking pretty good.

I found the HT/RT route to be not too bad in terms of side-effects. Some bowel and bladder issues towards the end of treatment but they cleared up within a month of treatment ending. The only real side-effect from HT, other than the expected loss of libido, has been some breast enlargement, which is no big deal.

Best wishes,

Chris

User
Posted 10 Nov 2019 at 12:22
I was diagnosed T1c M0 N0 with a Gleason of 4+3 and a PSA of 18. I saw both a surgeon and an oncologist who outlined the pro's and con's of surgery and hormone / radiotherapy, then I was sent home to think about it for however long I needed. I got the invaluable 'toolkit' from Macmillan and spoke to one of their nurses about incontinence, and that is what swung it for me. I could not face the idea of being incontinent, so opted for radiotherapy. I have just had fraction 18 out of 20, with a review tomorrow and the final zapping on Tuesday. In the end, it has to be a personal decision, since the end result will be the same. Quick and (in my head) nasty (surgery) rather than drawn -out and less nasty (hormone / radiotherapy). If I had chosen surgery it would have been done within weeks. My chosen route has taken 9 months, but for me it was the right choice. As people have said, it must be a personal choice, if choice you have.
User
Posted 10 Nov 2019 at 11:08

Hi  I decided to have a Robotic Prostatectomy because and  in the event of Biochemical  Recurrence I felt that I had Salvage Radiotherapy Therapy to fall back on which for me proved to be the case  as my PSA started to rise after surgery.  Without doubt it was the most difficult decision that I have ever made and of course both treatments have their side effects. but 4 years on my PSA remains stable.

Edited by member 10 Nov 2019 at 20:11  | Reason: typos

User
Posted 10 Nov 2019 at 00:59

On the assumption that a man is offered both forms of treatment, it can come down to how he weighs up the pros and cons of each form of treatment. Generally speaking, overall treatments have similar success rates in terms of eradicating or slowing down the progression of cancer, although a patient may be more suited to one form of treatment than another. The bigger difference lies in possible side effects and a patient's attitude to risk of this. I feel you would benefit greatly by downloading or obtaining a hard copy of the 'Toolkit', which is very informative and may help you make a decision. https://prostatecanceruk.org/prostate-information/our-publications/publications/tool-kit?_ga=2.206109653.795867346.1564408880-1013787081.1564408880.

You will also note that there are other forms of treatment that some men are suitable for but these may not be available at the hospital you are attending so if interested in these you would then have to go to another hospital or clinic.

I note that you have not given any results of your diagnosis. If you show your PSA, Gleason score and staging under your profile, this will help us have a better idea of where you are and be able to answer your questions more meaningfully.

Edited by member 10 Nov 2019 at 01:01  | Reason: Not specified

Barry
User
Posted 10 Nov 2019 at 10:42

Don't think you can improve on Lyn's reply above as to the pros and cons. I understand that there can be "let's get rid of it" impulse and surgery does get rid of the prostate but not necessarily all the cancer if there has been a spread - however small.

I went down the RT route and there is some evidence that my treatment may not have been completely successful as my PSA is starting to rise. Does that mean I regret going down the RT route? Absolutely not. In some ways it vindicates my decision because it is entirely likely that recurrence would have occurred if I'd taken the surgical route. 

It's a very personal decision.

User
Posted 11 Nov 2019 at 20:13

I did not have a choice as there was slight spread to seminals so it was rt/ht for me. My psa was 21 with Gleason 8 later upped to 9. The rt, 37 sessions, at Clatterbridge were not too bad although luckily I live 10mins away, the rt finished Dec 2016. I still 'suffer' from tiredness, still have weight to lose, strength to get back, did have Achilles problems, sleep problems, emotional issues but these are all easing and along with the 3 years Zoladex I did have abiraterone, enzalutimide and steroids as part of trial. I should add that prior to treatment I was pretty active, fit, healthy, good weight etc and very slowly getting fitter. I am currently 63. I also suffered from bowel problems in that I had a handful of accidents but that cleared up.
Ultimately though, my psa has been undetectable so far but will obviously show, hopefully just a little, as I still have a prostate (although some was sliced away via turp prior to rt).
I did/do suffer from a few side effects but nothing unexpected. continence fine, ed fine once a bit of libido came back. It's just I suppose, rt/ht takes a while but worthwhile for me.
Peter

I should add that the Achilles problem was said to be due to the steroid rather than rt/ht.

Edited by member 11 Nov 2019 at 20:24  | Reason: Not specified

User
Posted 21 Nov 2019 at 12:02

Localised with 2 tumours to the front in my case, picked up with 2 PSAs 27 & 22 - in that order! Last year.
Biopsy with GA & Gleason 4+3. Been on Hormone, since May this year, Further PSA done early Sept 2019 = 1.3 PSA.
I decided on RT, rather than an OP - reason, don't like OPs !
Had 20 RT fractions at Addenbrooks, Cambridge - 1 hour trip to get there! In Sept - Oct 2019.
Side effects:, probably from Hormone - Heartburn, now & then.
2 weeks into RT, sore Rectum, got worse with bit of Blood with BMs over next 2 weeks. Pee more as well, slight pain at times.
Now one month after RT & no real side effects, all healed - but still some Heartburn ! A bit of good help, from Preparation H cream BTW...

Whilst at hospital, found some others had their prostate removed, then had to have RT as well (same sessions as myself). Moral, just have RT to do the whole job! - in my case, anyway! I did consider Gel, but that would have been yet another GA, & as the Tumours are on the opposite side of the Prostate, to the Bowel, & the Tumours get special attention, during the RT - in my case, I thought it wise not to go the Gel route.

It might be more wise, if the Tumours are on the bowel side of the Prostate?

Edited by member 21 Nov 2019 at 12:04  | Reason: Not specified

User
Posted 10 Dec 2019 at 20:03
Just a quick update, Had a PSA test last Fri, 0.06 - a pretty good result about 2 months after Radio therapy.

I hope I can get off the Hormone therapy now, as I'm putting on weight & heartburn is another side effect.

Otherwise, feel fine.

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User
Posted 10 Nov 2019 at 00:59

On the assumption that a man is offered both forms of treatment, it can come down to how he weighs up the pros and cons of each form of treatment. Generally speaking, overall treatments have similar success rates in terms of eradicating or slowing down the progression of cancer, although a patient may be more suited to one form of treatment than another. The bigger difference lies in possible side effects and a patient's attitude to risk of this. I feel you would benefit greatly by downloading or obtaining a hard copy of the 'Toolkit', which is very informative and may help you make a decision. https://prostatecanceruk.org/prostate-information/our-publications/publications/tool-kit?_ga=2.206109653.795867346.1564408880-1013787081.1564408880.

You will also note that there are other forms of treatment that some men are suitable for but these may not be available at the hospital you are attending so if interested in these you would then have to go to another hospital or clinic.

I note that you have not given any results of your diagnosis. If you show your PSA, Gleason score and staging under your profile, this will help us have a better idea of where you are and be able to answer your questions more meaningfully.

Edited by member 10 Nov 2019 at 01:01  | Reason: Not specified

Barry
User
Posted 10 Nov 2019 at 01:58
For locally advanced:-

1. Surgeons are often not willing to operate if they don't think they can get it all out

2. If it is believed that adjuvant RT would be needed anyway, or there is a high risk of needing salvage RT, many believe there is no point putting the patient through unnecessary side effects of surgery

3. The adjuvant or salvage RT is more difficult if surgery leaves the man incontinent

4. Radical RT can be delivered in a differentiated way that captures the rogue cells outside the prostate

5. Surgeons have to publish their data including how many of their men had positive margins and / or needed salvage RT - a disincentive to many of them as it makes them look not very good at their job. The best surgeons may be those whose stats don't look very good because they take on men that others have refused to operate on

6. There is an emotional impact for a man who chooses surgery hoping the cancer will be removed, only to find it wasn't

For contained cancer:-

1. Personal preference / approach to risk

2. Deciding which side effects are tolerable / intolerable

3. Existing medical history (including previous abdominal surgery, heart problems, etc)

"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard

User
Posted 10 Nov 2019 at 08:52
In my own case, both my urologist and oncologist recommended RT, because my relatively high PSA (32 at diagnosis) suggested a distinct possibility of undetectable spread to the lymph nodes which surgery wouldn't be able to remove. When a surgeon recommends that surgery is not a good option it's as well to listen 😁.

Now, 7 months after the end of RT my PSA is down to 2.0, so things are looking pretty good.

I found the HT/RT route to be not too bad in terms of side-effects. Some bowel and bladder issues towards the end of treatment but they cleared up within a month of treatment ending. The only real side-effect from HT, other than the expected loss of libido, has been some breast enlargement, which is no big deal.

Best wishes,

Chris

User
Posted 10 Nov 2019 at 10:42

Don't think you can improve on Lyn's reply above as to the pros and cons. I understand that there can be "let's get rid of it" impulse and surgery does get rid of the prostate but not necessarily all the cancer if there has been a spread - however small.

I went down the RT route and there is some evidence that my treatment may not have been completely successful as my PSA is starting to rise. Does that mean I regret going down the RT route? Absolutely not. In some ways it vindicates my decision because it is entirely likely that recurrence would have occurred if I'd taken the surgical route. 

It's a very personal decision.

User
Posted 10 Nov 2019 at 11:08

Hi  I decided to have a Robotic Prostatectomy because and  in the event of Biochemical  Recurrence I felt that I had Salvage Radiotherapy Therapy to fall back on which for me proved to be the case  as my PSA started to rise after surgery.  Without doubt it was the most difficult decision that I have ever made and of course both treatments have their side effects. but 4 years on my PSA remains stable.

Edited by member 10 Nov 2019 at 20:11  | Reason: typos

User
Posted 10 Nov 2019 at 12:22
I was diagnosed T1c M0 N0 with a Gleason of 4+3 and a PSA of 18. I saw both a surgeon and an oncologist who outlined the pro's and con's of surgery and hormone / radiotherapy, then I was sent home to think about it for however long I needed. I got the invaluable 'toolkit' from Macmillan and spoke to one of their nurses about incontinence, and that is what swung it for me. I could not face the idea of being incontinent, so opted for radiotherapy. I have just had fraction 18 out of 20, with a review tomorrow and the final zapping on Tuesday. In the end, it has to be a personal decision, since the end result will be the same. Quick and (in my head) nasty (surgery) rather than drawn -out and less nasty (hormone / radiotherapy). If I had chosen surgery it would have been done within weeks. My chosen route has taken 9 months, but for me it was the right choice. As people have said, it must be a personal choice, if choice you have.
User
Posted 11 Nov 2019 at 20:13

I did not have a choice as there was slight spread to seminals so it was rt/ht for me. My psa was 21 with Gleason 8 later upped to 9. The rt, 37 sessions, at Clatterbridge were not too bad although luckily I live 10mins away, the rt finished Dec 2016. I still 'suffer' from tiredness, still have weight to lose, strength to get back, did have Achilles problems, sleep problems, emotional issues but these are all easing and along with the 3 years Zoladex I did have abiraterone, enzalutimide and steroids as part of trial. I should add that prior to treatment I was pretty active, fit, healthy, good weight etc and very slowly getting fitter. I am currently 63. I also suffered from bowel problems in that I had a handful of accidents but that cleared up.
Ultimately though, my psa has been undetectable so far but will obviously show, hopefully just a little, as I still have a prostate (although some was sliced away via turp prior to rt).
I did/do suffer from a few side effects but nothing unexpected. continence fine, ed fine once a bit of libido came back. It's just I suppose, rt/ht takes a while but worthwhile for me.
Peter

I should add that the Achilles problem was said to be due to the steroid rather than rt/ht.

Edited by member 11 Nov 2019 at 20:24  | Reason: Not specified

User
Posted 21 Nov 2019 at 12:02

Localised with 2 tumours to the front in my case, picked up with 2 PSAs 27 & 22 - in that order! Last year.
Biopsy with GA & Gleason 4+3. Been on Hormone, since May this year, Further PSA done early Sept 2019 = 1.3 PSA.
I decided on RT, rather than an OP - reason, don't like OPs !
Had 20 RT fractions at Addenbrooks, Cambridge - 1 hour trip to get there! In Sept - Oct 2019.
Side effects:, probably from Hormone - Heartburn, now & then.
2 weeks into RT, sore Rectum, got worse with bit of Blood with BMs over next 2 weeks. Pee more as well, slight pain at times.
Now one month after RT & no real side effects, all healed - but still some Heartburn ! A bit of good help, from Preparation H cream BTW...

Whilst at hospital, found some others had their prostate removed, then had to have RT as well (same sessions as myself). Moral, just have RT to do the whole job! - in my case, anyway! I did consider Gel, but that would have been yet another GA, & as the Tumours are on the opposite side of the Prostate, to the Bowel, & the Tumours get special attention, during the RT - in my case, I thought it wise not to go the Gel route.

It might be more wise, if the Tumours are on the bowel side of the Prostate?

Edited by member 21 Nov 2019 at 12:04  | Reason: Not specified

User
Posted 10 Dec 2019 at 20:03
Just a quick update, Had a PSA test last Fri, 0.06 - a pretty good result about 2 months after Radio therapy.

I hope I can get off the Hormone therapy now, as I'm putting on weight & heartburn is another side effect.

Otherwise, feel fine.

User
Posted 10 Dec 2019 at 20:46

Bob,

I doubt you'll be finishing HT any time soon if you only started it in May this year. HT is typically given for between 18 months and 2 years, so 18 months for you would be November 2020. Best to follow your oncologist's advice. 

Cheers,

Chris

 

User
Posted 12 Dec 2019 at 17:26

Originally Posted by: Online Community Member

Bob,

I doubt you'll be finishing HT any time soon if you only started it in May this year. HT is typically given for between 18 months and 2 years, so 18 months for you would be November 2020. Best to follow your oncologist's advice. 

Cheers,

Chris

 

He said today my last HT will be in Feb, taking me up to May next year, pending a PSA result before my next appointment in June of course.

He also mentioned that there have been some problems with treating people that have had hydrogel spacer -but did not go into any great detail of the problems - I did not have it, preferring tried & tested treatment.

It is I believe still under NHS/NICE tests.

 
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