Published on March 19, 2020
- Radiation and surgery are common treatment options for prostate cancer; despite being very different approaches, their side effects overlap.
- Doctor-patient communication is key—the doctor’s expert opinion along with the patient’s goals should guide the decision-making.
- It is recommended that the entire prostate be treated, not just the area identified by a scan. It is highly likely that a larger portion of the prostate is affected.
“A good doctor can present you with what we recommend as our expert opinion for what is right for your stage of cancer, but what’s really important is what you value as a person and as a patient,” says Dr. Benjamin King, explaining why prostate cancer treatment is not a one-size-fits-all approach.
Dr. King, a prostate cancer expert and radiation oncologist at Cedars-Sinai Samuel Oschin Comprehensive Cancer Institute, discusses radiation and surgery and the common side effects of both. He also shares some recommended questions for prostate cancer patients to ask their doctors. Watch now to learn from an expert.
Transcript | Which Prostate Cancer Treatment Is Best? It Depends
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Hello, I'm Andrea Hutton from Patient Power, and I'm here today with Dr. Benjamin King, who's the Assistant Professor and Medical Director of Radiation Oncology at Cedar Sinai in Tarzana, California. Dr. King, thank you so much for joining us today.
My pleasure. Thank you for having me.
So you are a radiation oncologist, specializing in prostate cancer and other cancers as well, but for our prostate cancer audience, can you please tell me kind of what the first thing that they can expect when they come in to see their radiation oncologist? Is there a conversation, or do you already have a treatment plan in place by the time they see you?
Yeah, that's a great question. When you come in to meet me as your radiation oncologist, I'm your doctor first and foremost. So I will have reviewed your medical record, including pertinent labs, like your PSA, and any imaging that might've been done, like an MRI scan as well as the biopsy from your prostate cancer. And then I will also have reviewed your pertinent medical history, and then I'll come in and talk with you to figure out if there are any holes in that history that I need, and then we'll proceed with the physical exam. And then after that, we'll have a discussion about possible treatments, and I'll tailor that to certain things that I find during my meeting with you and perceiving sort of what your values are.
What my values are, or what the patient's values are—can you talk a little bit about that? Because I know it can be super confusing for people when they come in and they are presented with options, and they're not the doctor. Is there something that they should be doing?
Yeah, that's a great question, and a lot of patients tell me that. They just say, "Well, doc, just tell me what you think is best." And I think especially for prostate cancer, but really for all medical treatment, I think a good doctor can present you with what we recommend as our expert opinion for what is right for your stage of cancer. But what's really important is what you value as a person and as a patient, and how that pertains to your treatment has to do with potential side effects of treatment, potential success of treatment and how you weigh those things. Because I can tell you what I think might be right for you, but depending on what you value with regards, again, to side effects and weighing that on the potential of cure, that's only something that you can tell me.
What are the side effects that patients worry about most for radiation treatment? And are there any things that they can do or that you can do to mitigate those side effects?
So just stepping back a little bit away from specific radiation side effects, the side effects for prostate cancer treatment can be very similar between the main two choices for treatment. And for prostate cancer that is surgery versus radiation, or the other sort of non-active treatment is something called active surveillance. But side effects between surgery and radiation overlap a significant amount, because the treatment depends. For prostate cancer, it depends a lot on anatomy. So what we're always treating for prostate cancer is the prostate. So whether you surgically remove the prostate and have to stitch back the tube that brings the urine out, or if we radiate the prostate, the tube that brings the urine out can be very irritated and inflamed. And so the main side effect with both treatments are urinary side effects. That's the most common for both.
There are other things that are specific to surgery versus radiation, and one specific thing that many patients are worried about is urinary incontinence or leakage of urine. And I always tell patients that the risk of that is much higher in surgery, because you're physically cutting the tube, and you have to repair it. And in that process the body needs to heal that, and the muscle that controls our control of urine gets irritated, and you have to regain control. With radiation there can be other urinary side effects, but leakage or having a catheter is extremely rare with radiation.
What about the sexual side effects for prostate cancer treatment? Are those radiation-induced, or is that more about surgery or infusion treatments, chemotherapy treatments?
Yeah. Unfortunately, sexual side effects, namely erectile dysfunction, are common to both surgery and radiation, and neither surgery nor radiation seems to be better for that. And again, the reason for that is anatomy. The prostate function is to secrete seminal fluid, but the mechanisms to control erections are controlled by nerves and blood vessels that are right behind the prostate. So whether you tried to you—whether you need to cut out the prostate and pull it off those nerves or blood vessels, or sometimes you have to cut them or if you radiate it to a high dose, those have a very high chance of getting damaged. And we can't avoid that area because if we do, then there's a very high risk that we would undertreat and miss cancer cells.
It's important to note that all of the standard treatments for prostate cancer, radiation or treatment, surgical treatments, treat the whole prostate. You may read about newer techniques to try to treat just where you can see the cancer, and those really are not standard because we know that even if you can only see a portion of that might be involved on an MRI or other scans, there's a very high chance that the other parts of the prostate will have cancer involved. So sexual side effects are, unfortunately, common after treatment, and they're the same between surgery and radiation.
One thing I will mention though is that it doesn't mean that we will eliminate all erectile function, and it doesn't mean that there aren't any treatments afterwards that can be very successful to help restore erectile function. And those can be things like something as less invasive as an oral medication to slightly more invasive things like various pumps or even surgical procedures. So there are many treatments afterwards, and it doesn't happen to everyone.
Can you tell me a little bit about rectal toxicity side effects as well?
Sure. It is important to know, as I said before, that some side effects from radiation or surgery could be specific to that treatment. So one side effect that surgery doesn't have that radiation does is potentially irritating the rectum, and that's because the prostate sits right between the bladder and the rectum. I already talked to you about how you can have urinary side effects from irritating the bladder or the tube that brings a urine out the urethra, but the other area that can be irritated is the rectum. We have been able to reduce rectal side effects significantly through the radiation technologies in shaping the dose and pulling the dose away from the rectum. But those side effects still can happen, and they could include something like a loose stools or diarrhea during treatment or afterwards—and in the very worst case, rectal bleeding after treatment.
Most of the time if that rectal bleeding does occur, it's something that is intermittent and can resolve on its own or with a small procedure like cauterization of some abnormal blood vessels that can form, but it could be more serious. One new technology which is quite interesting and has some early promise is the use of a hydro gel spacer. So, what that is is something that I or your urologist can place in the office. It's done under local anesthesia. We just inject this gel into the space between the prostate and the rectum. That gel forms into a matrix, and it pushes the prostate away from the rectum. And what that space does is it allows us to spare the rectum from most of the high-dose radiation. That gel stays there for about six months, it has very few side effects, and then it dissolves, and the body breaks it down after six months.
Some early data shows that it may decrease the risk of some of the rectal side effects, and especially in the cases where we're giving high doses of radiation in very few treatments. So that's another new technology that is very interesting. And you should ask your doctor what they think about that.
Are there any differences in the way you radiate the prostate? Are there any things that patients need to ask their radiation oncologist that maybe they don't know? What are the questions that you think patients should know to ask? If they're not seeing you, they might be sitting with another community doctor. What should they know?
I think in general what they should be asking about some basic questions are, “Do you recommend radiation at all?” And we don't always recommend radiation. A good doctor or radiation oncologist should not always say that my treatment option is the best. There are some patients in whom we don't think radiation would actually be the better option. And then just going back a little bit in talking about being overwhelmed by choices, I think in prostate cancer I tell all my patients this. That you may have a choice between surgery and radiation, and that may be overwhelming to think about all of the logistical concerns, the difference between the side effects, but that in general you can't make the wrong decision, because they're all good treatments, and they're equal with regards to cure.
That is another misconception that some people may just feel that if you have prostate cancer, the best is surgery which you need to cut it out. But that's not actually true. For every stage of prostate cancer in the non-metastatic setting, surgery and radiation are equal, and they're all good choices. Other things that I think they should ask specifically about radiation is, “What kind of radiation do you think would be appropriate?” And it can be confusing, but in general there is external radiation and internal radiation.
Probably more commonly delivered is external radiation, which is totally noninvasive. You lie on a table, and you don't feel anything when you're getting the treatment. It's like getting a CAT scan or an X-ray. And then there's internal radiation where we can actually put radiation sources directly into the prostate, and that's minimally invasive—not as invasive as a surgery, but we do have to get the radiation sources into the prostate and those are usually placed with a needle.
Are those seeds? Is that what seeds are? They're internal radiation?
Mm-hmm, yep. You may read about seeds. That is one way to do internal radiation, also known as brachytherapy. There's another way, and seeds are placed into the prostate, and they're left there permanently. They eventually give up their radioactivity, and they become inert, or they lack radioactivity, and they're just usually gold seeds that just stay there forever. But there's another way to do brachytherapy where we put in tubes, and then we pass radiation sources into the tube, they stay there for a little bit, give up the radiation, and then we pull them out. That one is also brachytherapy, and there's some terminology. That one's known as high-dose rate brachytherapy versus low-dose rate, which is where the permanent seeds are. So you should ask, “What do you think is the right way to give the radiation, what type of radiation?” And then again, “What are you going to treat?” Because one difference, one potential option for how to give radiation is we always treat the prostate, but then in some men we will also treat the pelvic lymph nodes, because that's one potential site of spread.
Thank you. That's really interesting and an excellent overview of the different kinds of radiation as well. And is there anything new on the horizon for treating prostate cancer from the radiation perspective? Or is this all there is?
Yeah, there's always a lot going on, and I think the most new is that radiation and medical imaging have improved significantly over the past five to 10 years. So the imaging portion is really important because before, we just had X-rays, and you can really only see bones well with X-rays. Sometimes we can have you drink some liquid that allows us to see some of the organs better. We can inject some dye that let us see some of the blood vessels, but you really couldn't see that much. And the prostate isn't a bone, so we couldn't really see it on any X-rays. So we made treatment decisions based on where the normal anatomy of the prostate is in reference to bones. But that's different for everyone and it can actually be different on a day-to-day basis.
So, with the advent of CAT scans and now more recently MRIs, we've been able to visualize the prostate itself, and with that we can be more accurate to make sure we're actually hitting the prostate, and then we can treat less of the surrounding normal structures. So that's been a huge gain into minimizing side effects and improving cures. From the radiation perspective, through computing technology, we've been able to incorporate much more complex ways to shape the radiation beam around the target, which is the prostate and the pelvic lymph nodes, and then avoid the normal structures. So if you're talking to relatives or even friends who've had radiation, maybe five, 10 or even longer than that, their side effects may be significantly different and potentially worse than they are now. So those two advents have been huge.
The more recent, I think exciting or newer things on the horizon, or actually are even in clinical practice now are new ways to give higher doses of radiation in fewer treatments. So shortening the treatment course, mostly in the external radiation setting. But something you may read about would be something called SBRT or SABR, S-A-B-R, or a CyberKnife is one machine that can give it this way. That's an exciting new way to treat mostly low and intermediate risk prostate cancer, where we can give very high doses of radiation in maybe only two weeks, whereas the standard treatment course may last something like nine weeks. So I think that's really exciting that we're discovering new ways to treat cancer, prostate cancer, effectively with the same cure rates as before, which are very good, and also minimize the toxicity and try to minimize the impact on our patient's lives.
Well, thank you so much. I really appreciate your time and for giving our patients some knowledge and hope. So thank you, Dr. King, for joining us.
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