Why choosing the CORRECT prostate cancer treatment option at the start can avoid potential problems in the future?
Prostate Cancer is one of the leading cause of cancer related death among men. The risk of death is substantially reduced following early treatment. There are several options including active surveillance, radical prostatectomy, radiation, and cryotherapy. Each treatment option has benefits and risks. For cancer that has not spread outside the prostate, Robotic radical prostatectomy is most effective in achieving cancer control. Robotic radical prostatectomy is considered the gold standard for treatment of prostate cancer with randomized control studies demonstrating its efficacy in achieving cancer control. In experienced hands, erections and urinary control are adequately preserved while achieving cancer cure, achieving what is called “Trifecta”. Removing the prostate gland and examining it under a microscope reveals the actual cancer grade and stage. This further gives valuable information for further treatment options. Additional treatments if needed based on the cancer stage (eg: radiation, hormonal therapy) can be easily provided after surgical removal of the gland with good outcomes even in locally advanced disease. Once the treatment is successful, the PSA blood test becomes undetectable – immediately demonstrating the effectiveness of the cancer surgery the patient underwent.
Among other treatments for prostate cancer, radiation, and focal forms of treatment such as cryotherapy and High Intensity Focused Ultrasound (HIFU) offer variable degrees of suboptimal success. HIFU as a treatment for prostate cancer is not yet FDA approved and it is used for prostate cancer in an off label manner. The side effects of radiation treatment can manifest after several years, which include irritative bladder symptoms, blood in urine, possibility of secondary cancers due to exposure to radiation, and/or cancer recurrence due to inadequate cancer control. Cryotherapy has a high risk of erectile dysfunction and is therefore not recommended for patients with good baseline erections. With both these treatment options, the prostate gland is not removed and therefore, the actual cancer grade and stage is not known. Current imaging modalities are not accurate in predicting the true cancer stage either, and this is a major limitation in providing appropriate cancer treatment. One has to rely on PSA test for any evidence of cancer recurrence. However, PSA blood test does not become undetectable unlike following surgical removal of prostate as the prostate gland is still present within the patient. Therefore, the PSA test has to be monitored over time to assess for residual or recurrent cancer, thus losing valuable time in the process.
If the cancer does recur following either radiation, HIFU or cryotherapy, one of the treatment options includes salvage prostatectomy. Because of the extensive scarring and adhesions from previous treatment with radiation or cryotherapy, performing salvage prostatectomy becomes challenging. The operative time, blood loss, and risks of injury to surrounding structures are all higher. Preserving any residual erectile function is also challenging due to distorted anatomy and scarring. Most importantly, achieving negative margins is also very difficult in this setting. All of these lead to suboptimal cancer control.
Randomized studies with radiation and cryotherapy are lacking unlike the evidence published for radical prostatectomy. Without removal of the prostate in these two treatment options, it would not be possible to directly compare the efficacy with radical prostatectomy.
In summary, Robotic radical prostatectomy offers the single best initial chance at achieving cancer control with minimal or no side effects in the hands of an experienced robotic urologist. Offering it in the salvage setting after other suboptimal treatments such as radiation, HIFU or cryotherapy does not offer similar outcomes and increases the risk of complications. It is therefore important for the patients to be aware of these risks and choose their initial treatment option after much thought. Remember, you have “one prostate and you get only one shot at achieving the best results”, so choose wisely.