Surgery or Radiation for Prostate Cancer: What Determines the Choice?

For localized disease, guidelines state that both surgery and radiation are acceptable forms of treatment, and men in this category make up a large number of cases. According to data from the Surveillance, Epidemiology, and End Results (SEER) program, localized disease accounts for about 80 percent of the nearly 221,000 new cases projected for 2015 in the United States.

“It’s mostly early-stage cancers in which radiation therapy is competing with surgery,” says Dorin Todor, director of the brachytherapy program at Virginia Commonwealth University’s Massey Cancer Center in Richmond. “Surgery doesn’t make much sense for anything but early-stage prostate cancer, because if more than the prostate is involved, you’ll need some form of systemic approach.”

To help make a sound decision, patients should consider the following factors.

> AGE: Younger patients can better tolerate the general anesthesia that’s used in the vast majority of surgical cases, but new minimally invasive techniques (such as robot-assisted surgery) have made surgery a broader option, says James B. Yu, assistant professor of therapeutic radiology at Yale University School of Medicine in New Haven, Conn.

> COST: Insurance coverage varies, but external beam radiation therapy of any type might be more expensive than surgery, according to a 2013 study in the British Journal of Urology International. Researchers found that the costs ranged from about $20,000 for a robot-assisted prostatectomy for low-risk cancer to approximately $50,000 for combined radiation therapy for high-risk cancer. Brachytherapy, however, may be cheaper than surgery. Patients should always discuss the cost of treatment with their health care providers.

> SIDE EFFECTS: Any side effects from surgery — even the nerve-sparing type — tend to show up immediately, whereas radiation takes time to produce some of the same changes, experts say. (Which side effects occur and their frequencies vary from patient to patient, regardless of the choice.) For example, about half the men who had normal erections prior to EBRT became impotent within five years, and about one-third of the men who received brachytherapy experienced incontinence.

“We’ve made great strides over the past couple of decades, and prostate cancer remains a very curable disease for the most part,” Yu says. “That’s why we’re focusing so much on side effects and cost. In a way, focusing on these subtle questions is a good problem to have, since so many of these men go on to live such good, long lives.”