Quality Of Life Is Better After Modern Radiotherapy Compared With Surgery
For decades, organ preservation has been an abiding principle of radiotherapy, with the underlying belief being that a person with preserved native anatomy has better physical functioning than one who has undergone surgical removal of organs followed by reconstruction. Comparing modern radiotherapy vs surgery for prostate cancer, we argue the following points: Head-to-head comparisons have shown modern radiotherapy to be much better than surgery in terms of urinary and sexual function.
While bowel toxicity has historically been moderately worse after radiotherapy, this decline in function can now be mitigated largely by using modern radiotherapy techniques, such as image guidance and possible additional rectal spacing.
Quality of life following radiotherapy has continued to improve as advances have been made in radiotherapeutic techniques, whereas prostate surgery-despite the availability of newer, once-promising techniques such as laparoscopic or robot-assisted radical prostatectomy-remains largely unchanged in regard to long-term impacts on quality of life. Thus, radiotherapy is the better choice for treatment of prostate cancer.
Financial Disclosure: Dr. Yu and Dr. Hamstra have served as paid consultants to Augmenix, Inc. Dr. Hamstra has also received grant funding from Augmenix, Inc.
The Cambridge Prognostic Groups
In the UK, doctors divide prostate cancer into 5 prognostic groups. This is the Cambridge Prognostic Group . The 5 groups are from CPG 1 to CPG 5. Your CPG depends on:
- the tumour stage. This is from the T stage from the TNM staging
- what the cancer cells look under a microscope. This is the Grade Group or Gleason score
- your PSA blood test level
The CPG helps your doctor recommend if you need treatment and the type of treatment you need. Doctors also consider other factors when recommending the best treatment for you:
- your age and general health
- how you feel about the treatment and side effects
If you cant have treatment because of your age or other health issues, your doctor might monitor the cancer with watchful waiting. They will only recommend treatment if the cancer starts to cause you symptoms.
What Should Patients Know About Msks Approach To Treating Prostate Cancer
At MSK, we manage prostate cancer in a very comprehensive way, tailored to each patients disease. There is no one specific therapy that is best for everyone.
Our initial assessment includes a carefully evaluated biopsy and a very detailed MRI to show the location of the disease, the integrity or soundness of the capsule surrounding the prostate, and the amount of disease. We will often obtain next-generation imaging and do genomic testing. Then, based on that information and with input from the urologist, the radiation oncologist, and the medical oncologist we can provide a comprehensive recommendation.
The radiotherapy we do here at MSK is state-of-the-art and unparalleled. We are one of the few centers in the world to do MRI-based treatment planning and one of the few centers in the US to offer MRI-guided treatment. When we give brachytherapy, we use computer software that provides us with real-time information about the quality and accuracy of the seed implant during the procedure. It requires a great deal of collaboration with our medical physics team to try to get the most accurate positioning of the prostate during the actual three or four minutes of the treatment.
We make adjustments while the patient is still under anesthesia, so that when the procedure is completed, we have been able to achieve ideal placement of the radiation seeds. This translates into improved outcomes.
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Study And Patient Characteristics
Three thousand three hundred sixty three records were identified, and 25 studies were finally included in this systematic review and meta-analysis . Due to a lack of data, 4 studies cannot be meta-analyzed, so we only presented the results of QoL in these studies. The flowchart of study inclusion was shown in Fig. . In total, there were 21 retrospective studies, 3 prospective studies, 1 RCT study published between 2006 and 2019. The median age was 58.271.8years for the RP group and 58.175.0years for the RT group. The median follow-up ranged from 23.89months to 15years. The characteristics of all included studies were shown in Table . Although the definitions of high-risk varied in each trial, most of them were consistent with the NCCN or DAmico criteria. Detailed comparison data can be found in Additional file 1: Table .
It seemed that EBRT+BT had similar or even better survival benefit than RP. RP showed obvious inferiority on CSS compared to EBRT+BT, and no significant difference between the two subgroups was observed on OS . As for other outcomes, Kishan and colleagues reported EBRT+BT was associated with longer MFS than RP .
Overall, most patients received EBRT in the included studies. Although RP was more beneficial to survival than EBRT, it was not as good as EBRT in PSA control, and the survival benefit of RP would no longer exist once EBRT was combined with BT.
Do We Know Which Treatment Is Best For Prostate Cancer Brachytherapy Or External Beam Radiation
Its not a question of which type of radiation therapy is best in general, but rather which therapy is best for the patients specific disease and quality-of-life concerns. We want to use the most tailored, pinpointed radiation to treat the prostate tumor effectively while minimizing side effects. This can depend on the tumors size and stage as well as other patient characteristics and even a patients individual preferences.
Why Choosing Surgery For Prostate Cancer
- With surgery you will get the accurate prostate cancer staging How much cancer do you actually have and whether it has spread to the surrounding tissues. Also, the follow up is much easier because the PSA has to be zero.
- Robotic radiosurgery is not surgery, is all radiation. After radiation, if cancer comes back, it is almost impossible to have surgery. Dr. David Samadi explains that he uses radiation as a back-up plan after surgery.
- A long-term side effect of radiation is that there is a small chance to have secondary cancer. You can get cancer from radiation. Patients need to be aware that they can have bladder or rectal cancer. With robotic prostatectomy surgery, side effects and risks are reduced over time, not increased.
Many people consider surgery as being the cause of cancer spreading, impotence and incontinence. The outcome depends on the experience of the surgeon. Dr. David Samadi has successfully treated thousands of prostate cancer patients with the best results. Now, the continence is up to 95-97%, potency is between 50-80%, depending on the surgeons experience. Whats the advice? For the best results, go to a center of excellence.
Dr. David Samadi uses genetic tools and MRI imaging studies to decide who should really go for surgery and who should go for radiation. Patients have to be carefully selected because individualized care is the best way to go.
Surgery Vs Radiation May Lower Risk Of Death From High
Radical prostatectomy is associated with improved cancer-specific survival compared with external beam radiation therapy among men with high-risk prostate cancer, a new study finds.
Investigators led by Francesco Chierigo, MD, of Policlinico San Martino Hospital, University of Genova in Genova, Italy, first studied cancer-specific mortality rates among 24,407 patients at high risk according to National Comprehensive Cancer Network criteria using the 2010-2016 Surveillance, Epidemiology, and End Results database. Second, they studied the same patients stratified by Johns Hopkins University criteria for high-risk and very high risk prostate cancer. To minimize confounding, patients were propensity score matched by age, PSA, biopsy Gleason score, and clinical T and N stages. The investigators also adjusted for mortality from other causes as a proxy for comorbidity burden.
In the entire NCCN high-risk cohort, 40% underwent RP and 60% underwent EBRT. At 5 years, CSM rates were lower among patients treated with surgery instead of radiation: 2.3% RP vs 4.1% EBRT. RP was significantly associated with a 32% reduced risk for CSM, Dr Chierigo and colleagues reported in The Journal of Urology.
The data suggest that RP holds a CSM advantage over EBRT in the combined NCCN high-risk cohort, and in its subgroup of Johns Hopkins very high-risk patients, according to Dr Chierigos team.
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External Beam Radiation Therapy
This is the most common type of radiation therapy, and it is painless. Before treatment, your radiation team will use computerized tomography scans and magnetic resonance imaging scans to map out the location of the prostate and tumor cells.
During each treatment session, X-ray beams are focused on the targeted cancer areas. Oncologists can change the intensity of doses and radiation beams to better deliver high doses of radiation to tumor cells while delivering lower doses to surrounding healthy tissues.
Some Things To Consider When Choosing Among Treatments
Before deciding on treatment, here are some questions you may want to ask yourself:
- Are you the type of person who needs to do something about your cancer, even if it might result in serious side effects?
- Would you be comfortable with watchful waiting or active surveillance, even if it means you might have more anxiety and need more frequent follow-up appointments in the future?
- Do you need to know right away whether your doctor was able to get all of the cancer out ? Or are you comfortable with not knowing the results of treatment for a while if it means not having to have surgery?
- Do you prefer to go with the newest technology , which might have some advantages? Or do you prefer to go with better proven treatments that doctors might have more experience with?
- Which potential treatment side effects might be most distressing to you?
- How important for you are issues like the amount of time spent in treatment or recovery?
- If your initial treatment is not successful, what would your options be at that point?
Many men find it very stressful to have to choose between treatment options, and are very fearful they will choose the âwrongâ one. In many cases, there is no single best option, so itâs important to take your time and decide which option is right for you.
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Cumulative Evidence On Oncological Outcomes Of Rp Versus Ebrt For Localized Pc
RP is the only definitive therapy that has been shown by RCTs to improve survival compared with watchful waiting . Given that PC is generally an indolent tumor and that median survival after diagnosis is 810 years, even if high grade and left untreated, current clinical guidelines generally recommend RP for patients with a life expectancy of > 10 years . EBRT has become established as a definitive therapeutic option for localized PC, based on long-term outcomes of several RCTs . However, few RCTs have directly compared RP with EBRT therefore, evidence on the relative merits of the techniques has been based on retrospective, population-based studies or meta-analyses .
Are There Side Effects Of The Combination Approach To Prostate Cancer Radiation Therapy
When it comes to early stages of disease, patients very frequently do well with either brachytherapy or external beam radiation. Success rates of around 90% or higher can be achieved with either approach. When the disease is somewhat more advanced based on the PSA level, Gleason score, extent of visible disease on magnetic resonance imaging we have learned over the years that higher doses of radiation are critical to achieving better results. Some evidence, including a large trial, suggests that for patients with intermediate- or high-risk prostate cancer, a combined approach using brachytherapy along with external beam radiation may be best compared to standard dose external beam radiation therapy alone.
Getting Help With Treatment Decisions
Making such a complex decision is often hard to do by yourself. You might find it helps to talk with your family and friends before making a decision. You might also find it helpful to speak with other men who have faced or are currently facing the same issues. The American Cancer Society and other organizations offer support programs where you can meet and discuss these and other cancer-related issues. For more information about our programs, call us toll-free at 1-800-227-2345 or see Find Support Programs and Services.
Itâs important to know that each manâs experience with prostate cancer is different. Just because someone you know had a good experience with a certain type of treatment doesnât mean the same will be true for you.
You might also want to consider getting more than one medical opinion, perhaps even from different types of doctors. For early-stage cancers, it is natural for surgical specialists, such as urologists, to favor surgery and for radiation oncologists to lean more toward radiation therapy. Doctors specializing in newer types of treatment may be more likely to recommend their therapies. Talking to each of them might give you a better perspective on your options. Your primary care doctor may also be helpful in sorting out which treatment might be right for you.
Radiation For Prostate Cancer: Procedure
Radiation options include using an external beam or internal therapy. In general, radiation is often recommended for stage I and II prostate cancer patients, since the cancer grows very slowly. External beam radiation therapy is when beams are emitted outside the body and pass through the skin and into the organ. Internal radiation is a process called high dose-rate brachytherapy in which radiation is administered through tubes placed directly into the prostate gland. Patients who have high grade cancer often receive both treatments, internal and external radiation treatment.
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What Is Stereotactic Body Radiation Therapy And What Advantages Does It Offer
Stereotactic body radiation therapy, or SBRT, involves the use of sophisticated image guidance that pinpoints the exact three-dimensional location of a tumor so the radiation can be more precisely delivered to cancer cells. Traditionally, external beam radiation has been delivered in anywhere from 45-48 sessions over multiple weeks. But large, randomized studies have shown that shorter courses of radiation are just as safe and effective. Therefore, at MSK, we have shortened all our radiation courses.
There is increasing interest in giving this radiation in very short courses of treatment using intense radiation doses, called hypofractionated radiation therapy. Many of the people we care for have a type of radiation therapy called MSK PreciseTM. This is a hypofractionated form of SBRT that can be given in five sessions. MSK has been doing this for the past 20 years, and the results in the several hundred people whove been treated have been excellent so far. The treatment is very well tolerated and quite effective
Because of its superior precision, MSK Precise can have fewer side effects than more conventional radiation techniques, with extremely low rates of incontinence and rectal problems. The sexual side effects are low, similar to what is experienced with more extended external radiation techniques. And of course, its much more convenient for patients.
Does Msk Offer Proton Therapy For Prostate Cancer
Some men with prostate cancer may choose to receive another form of external-beam radiation therapy called proton therapy. Proton therapy can deliver a high radiation dose to the prostate while lowering the radiation dose to normal surrounding tissue. It is unclear if there is any advantage to proton therapy compared with IMRT. We are now studying how these approaches compare in terms of side effects and outcomes at the New York Proton Center. These efforts are being led by radiation oncologist Daniel Gorovets.
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How To Decide If You Want Radiation Or Surgery For Prostate Cancer
There is still a debate on selecting the best options to go by. Research that has been conducted on the outcomes of both procedures shows that both of them are effective in the treatment of prostate cancer and the choice of either of these depends on your underlying health conditions and is different from person to person.
To better decide on the treatment option to follow, it is important to first understand the disease itself. You can also gather as much information about the recovery experiences on either of these methods. Having a deep understanding of what it takes during and after the surgery or radiation therapy will help you to make a solid decision on which path to follow.
Making the right decision comes down to understanding the options that you have and how each of them can affect the outcomes you get. That is the main reason why it is always important first to undergo intensive diagnosis and pre-screening. This helps you to make the right decisions based on the results from the tests.
If Treatment Does Not Work
Recovery from cancer is not always possible. If the cancer cannot be cured or controlled, the disease may be called advanced or terminal.
This diagnosis is stressful, and for some people, advanced cancer may be difficult to discuss. However, it is important to have open and honest conversations with your health care team to express your feelings, preferences, and concerns. The health care team has special skills, experience, and knowledge to support patients and their families and is there to help. Making sure a person is physically comfortable, free from pain, and emotionally supported is extremely important.
People who have advanced cancer and who are expected to live less than 6 months may want to consider hospice care. Hospice care is designed to provide the best possible quality of life for people who are near the end of life. You and your family are encouraged to talk with the health care team about hospice care options, which include hospice care at home, a special hospice center, or other health care locations. Nursing care and special equipment, including a hospital bed, can make staying at home a workable option for many families. Learn more about advanced cancer care planning.
After the death of a loved one, many people need support to help them cope with the loss. Learn more about grief and loss.
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