Prostate cancer treatment: Surgery vs. radiation

When prostate cancer is found early and is still only in the prostate — called localized prostate cancer — two main treatments are used to try to cure it: surgery or radiation therapy. Both treatments offer excellent long-term survival for most men, and both treatments have the exact same effectiveness. In one study, survival at 10 years was greater than 99% for men with lower risk disease who had either surgery or radiation. Even among men with higher risk prostate cancer, survival remained high, at about 96% for both treatments.

The choice between the treatments often comes down to personal preferences, possible side effects, overall health and life expectancy.

Surgery for prostate cancer involves removing the entire prostate. This operation is called a radical prostatectomy, though many people simply call it a prostatectomy. Most prostatectomies today use robotic tools to help the surgeon be less invasive and more precise and help the person have a quicker recovery.

Radiation therapy treats cancer by directing strong, focused beams of radiation at the prostate. Most men with prostate cancer receive external beam radiation therapy (EBRT). Newer EBRT techniques, such as intensity-modulated radiation therapy (IMRT) or proton beam therapy (PBT), may help protect healthy tissue around the prostate. Some men with prostate cancer may receive a shorter course called stereotactic body radiation therapy (SBRT). Brachytherapy, another type of radiation therapy, places tiny radioactive seeds directly into the prostate. Radiation therapy is sometimes combined with hormone therapy.

EBRT, SBRT and brachytherapy provide similar long-term cancer control for most men with localized prostate cancer.

Surgery and radiation therapy both offer excellent long-term control for localized prostate cancer, and most men do well with either approach. Because outcomes are similar, differences that matter mostly relate to side effects, recovery and how each therapy affects your daily life. A few factors to consider:

• Surgery is more likely to cause urinary leakage in the short-term, especially early on after prostatectomy. Some men continue to notice leakage years later, but most men recover their urinary control within a year of surgery, if not sooner.
• Radiation usually causes few long-term leakage issues, though urinary urgency or burning can occur during or shortly after treatment. Some men experience urinary urgency, burning or occasional bleeding many years after radiation.

• Surgery generally does not affect bowel function.
• Radiation can irritate rectal tissue, which may lead to bowel urgency or occasional bleeding for some men. Modern techniques are designed to reduce rectal exposure and lower the likelihood of bowel side effects.

• Surgery can cause a more noticeable early decline in erections because nerves around the prostate may be affected during removal. Over time, many men recover some function. Long-term sexual outcomes after surgery become closer to those seen after radiation. Modern techniques to preserve the nerve tissue around the prostate can help promote recovery of erections after surgery.
• Radiation usually preserves erections better in the short term, though some men experience gradual changes in sexual function over several years.

• Surgery requires anesthesia and a healing period with temporary activity limits. However, it is completed after one treatment and does not require repeat visits.
• Radiation is completed through outpatient visits, allowing most people to maintain their usual routines. However, it usually requires several treatments spread out over several days or weeks.

Colon cancer is a common and serious disease around the world. But it also is one of the most preventable cancers. The tools for prevention are widely available.

Surgery may be preferred for men who want the entire prostate removed or who like the idea of the prostate-specific antigen (PSA) dropping to undetectable levels afterward. But surgery may not be a good fit for those with previous pelvic surgeries or for those who want to avoid the higher chance of short-term urinary leakage that can follow prostatectomy.

Radiation may be preferred for men who want to avoid surgery or who have other health conditions that make an operation risky. It also can be a good choice for people who want to keep up their usual routines during treatment. But radiation may not be ideal for men who already have significant urinary blockage, very large prostate glands or bowel conditions that could be irritated by treatment. Radiation also may not be ideal for very young men who want to avoid the long-term side effects of radiation treatment.

Both surgery and radiation are used to treat high-risk prostate cancer. Because high-risk prostate cancer has a greater chance of growing or spreading, your care team may recommend a combination of treatments rather than relying on only one.

Surgery to remove the prostate and nearby lymph nodes can be appropriate for people who are good candidates. Radiation therapy may follow surgery. Use of radiation therapy depends on the type of cancer cells or PSA changes.

Radiation for high-risk disease is often paired with hormone therapy. Using both therapies together improves cancer control. Some people also may receive radiation to nearby lymph nodes or brachytherapy as part of their treatment plan.

Meeting with a urologist and a radiation oncologist can help you decide which approach — or which sequence of treatments — best fits your health, preferences and goals. Shared decision-making is especially important with high-risk disease.

PSA behaves differently depending on which treatment is used.

After surgery, the PSA generally falls to undetectable levels because the prostate is removed. A rising PSA after prostatectomy may suggest recurrence and often leads to evaluation for possible salvage therapy.

After radiation, the PSA falls more slowly because the prostate remains in place. It may take 2 to 3 years for the PSA to reach its lowest point, also called the nadir. A temporary rise in PSA, sometimes called a bounce, can happen and does not always mean treatment has failed.

Both treatments allow for options if prostate cancer returns. Treating cancer recurrence is known as salvage therapy.

After surgery, if the PSA begins to rise, salvage radiation therapy is commonly recommended because it can treat microscopic cancer in the area where the prostate used to be. Beginning salvage therapy earlier in the course of PSA rise may improve outcomes.

After radiation, cancer recurrence is defined as a PSA increase of 2 nanograms per milliliter (ng/mL) above the nadir. Treatment for cancer recurrence after radiation is more individualized. Some men may be candidates for salvage radiation therapy, prostatectomy or other treatment options. The right choice depends on a person's health, prior treatments and where the cancer has come back.

Salvage surgery after radiation can be more complex because radiation causes scarring and stiffness in the tissues around the prostate. These changes can make it harder for the surgeon to separate structures safely and may increase the risk of complications and long-term side effects.

Because both treatments work well, the decision often depends on side effects, personal preferences and your overall health.

• How important is avoiding long-term urine leakage?
• Do you have bowel conditions that might be worsened by radiation?
• How important is sexual function to you?
• Do you prefer a one-time surgery with recovery time or multiple short visits?
• How do you feel about PSA monitoring?
• Do you have medical conditions that make surgery risky?

Talk with a urologist and a radiation oncologist. They can help you understand your options. Shared decision-making is encouraged so you feel confident about your treatment path.