Prostate Cancer: Should I Have Radiation or Surgery for Localized Prostate Cancer?

Prostate cancer is the abnormal growth of cells in the prostate gland . Localized prostate cancer has not spread outside the gland. Early prostate cancer usually doesn't cause symptoms.

Prostate cancer is the most common cancer in men. Most men who get it are older than 65. If your father, brother, or son has had prostate cancer, your risk is higher than average.

African-American men have the highest rates of both prostate cancer and deaths from it.

About 13 out of 100 men in the U.S. will get prostate cancer.¹ But only 3 will die because of it.² That means about 97 out of 100 men will die of something other than prostate cancer.

Unlike many other cancers, prostate cancer is usually slow-growing. When prostate cancer is found early-before it has spread outside the gland-it may be cured with radiation or surgery.

Prostate cancer that has grown beyond the prostate is called advanced prostate cancer. Treatment choices are different for that stage of cancer.

Knowing whether your cancer is low-risk, medium-risk, or high-risk is important when you are making treatment choices.

The risk level of your cancer is based on the results from your tests and exams, such as the PSA test, digital rectal exam, and prostate biopsy.

• Low-risk means that the cancer isn't likely to grow right away. There is a chance it may grow so slowly that it never causes symptoms.
• Medium-risk means that the cancer is more likely to grow. Most men will likely need treatment with radiation therapy or surgery.
• High-risk means that the cancer will most likely grow right away. Men will likely need treatment with radiation therapy or surgery.

Your doctor can help you understand your test results and the risk level of your cancer. Then you can compare your treatment options and make the choice that seems best to you.

• Surgery takes out the prostate and any nearby tissue that may contain cancer, including lymph nodes. This surgery is called a radical prostatectomy (say "pros-tuh-TEK-tuh-mee"). A doctor can do it as open surgery by making a cut, or incision, in your belly or groin. Or he or she can do laparoscopic surgery by putting a lighted tube, or scope, and other surgical tools through much smaller cuts in your belly or groin. The doctor is able to see your prostate and other organs with the scope. In many places, robot-assisted laparoscopic prostatectomy is common. In this type of surgery, the surgeon controls the robotic arms that hold the tools and scope.
• Radiation uses X-rays and other types of radiation to kill the cancer cells. This may be done with:
  • External-beam radiation, in which a machine aims high-energy rays at the cancer.
  • Brachytherapy (say "bray-kee-THAIR-uh-pee"), in which tiny pellets of radioactive material are injected into or near the cancer.
  • Both kinds of radiation.

Radiation and surgery are treatments that destroy or remove localized prostate cancer. Both treatments also have long-term side effects, like bladder, bowel, and erection problems.

In the first 2 to 5 years after treatment, the chance of having erection or bladder problems is higher with surgery. And the chance of having bowel problems, such as an urgent need to move your bowels, is higher with radiation. But at 15 years, the chance of erection, bladder, or bowel problems is about the same with either treatment.³

One treatment may be better for you than the other because of how long you might live (your life expectancy), your other health problems, and how you feel about each treatment. You and your doctor can talk about your situation.

Follow-up treatment

After either treatment, you will need regular checkups. You will probably have:

• Physical exams.
• Prostate-specific antigen (PSA) tests.
• Digital rectal exams.

A radical prostatectomy has all the risks of any major surgery, including:

• Heart attack.
• A blood clot in an artery in the lung (pulmonary embolism).
• Bleeding.
• Infection.
• Reactions to anesthesia or other medicines.
• Death (rare).

Prostatectomy also may cause bladder problems and erection problems. More and more often, this surgery is being done in a way that saves the nerves that control erections.

• Erection problems. How much surgery affects a man's erections depends on his age, his sexual function before his surgery, and the location of his tumor. In one study, 67 out of 100 men had erections firm enough for intercourse before they had surgery. Six years later, 17 out of 100 men who had surgery had erections firm enough for intercourse.⁴
• Bladder control problems, such as not being able to hold urine (urinary incontinence). The degree of incontinence can range from needing to wear pads to dribbling urine now and then during stressful activities.

Surgery also can cause scar tissue that may narrow the outlet to your bladder. Or your rectum or urethra could be injured.

Studies show that men have fewer side effects when this surgery is done by a doctor who has done it many times.⁵

Radiation treatment for prostate cancer may increase a man's risk for having another cancer later in life, such as bladder or rectal cancer.

Some radiation side effects, like urinary problems, are usually short-term problems that go away with time. But a radiation side effect can become a long-term problem. Common side effects from radiation treatment include:

• Bowel problems, such as rectal pain, diarrhea, blood in your stool, and rectal leakage.
• Erection problems that develop over time. In one study, 67 out of 100 men had erections firm enough for intercourse before they had radiation. Six years later, 27 out of 100 men who had radiation had erections firm enough for intercourse.⁴

For men with high-risk prostate cancer, radiation treatment is given along with hormone therapy. Hormone therapy has side effects, such as the loss of bone density and muscle mass. It can also increase the risk for bone fractures, diabetes, and heart disease.

Men who choose either treatment have a low risk of dying from prostate cancer. One study found that the risk of dying was about the same no matter what treatment men with localized prostate cancer had.⁶

Your doctor might advise you to have surgery if:

• You are healthy enough to have major surgery.
• Radiation therapy isn't a good option for you because you have had previous radiation therapy to your pelvic area or you have a serious bowel disease such as ulcerative colitis.

Your doctor might advise you to have radiation if:

• You want to avoid the side effects of surgery, such as leaking urine and erection problems.
• You have other health problems that make surgery too risky.