Tough choices for prostate cancer

For men with prostate cancer, deciding whether to opt for radiation or surgical removal of the gland can be a daunting prospect, as both carry the risk of unpleasant side-effects such as urinary incontinence and erectile dysfunction.

TORONTO — For men with prostate cancer, deciding whether to opt for radiation or surgical removal of the gland can be a daunting prospect, as both carry the risk of unpleasant side-effects such as urinary incontinence and erectile dysfunction.

But a large study suggests that radiation treatment may lead to a higher incidence of other adverse effects in the years following treatment for localized prostate cancer, depending on a man’s age and other medical conditions.

The study, published Thursday in the journal Lancet Oncology, found men treated with radiotherapy had fewer minimally invasive urological procedures, compared to those who chose surgery. But over time, the radiation group had a higher proportion of hospital admissions, rectal or anal procedures, related surgeries and secondary cancers.

Lead researcher Dr. Robert Nam, a urologic oncologist at Sunnybrook’s Odette Cancer Centre in Toronto, says before patients make a choice, it’s important they understand all the risks associated with each treatment, to maximize their quality of life.

“Some people may say, ’You know what? I can live with a little leakage. I don’t need to have sex. That stuff is over for me, so I’m going to go ahead with (a particular) treatment,”’ Nam said. “That’s usually the logic of their thinking.

“But what this study now says is wait a minute. Do you want to be admitted to hospital all the time? Do you want to be bleeding from your bladder or bleeding from your rectum all the time? Do you want a second cancer?

“These are new things that people need to think about.”

To conduct the study, researchers analyzed hospital and physician administrative records for 32,465 Ontario men who were treated for localized prostate cancer between 2002 and 2009. Of those, 15,870 had surgery (median age 62), while 16,595 had radiotherapy (median age 70).

Nam said men who opted for radiotherapy had rates of these complications two to 10 times higher than patients who had their prostate surgically removed. There are two types of radiotherapy: external beam radiation and brachytherapy, which involves inserting radioactive material inside the prostate, allowing more targeted treatment.

“The rates of complications . . . were quite significant,” said Nam. “And this has never been described before. We knew about this happening. We knew patients would be admitted to hospital. We knew patients that had these procedures following the treatment. But we never knew the severity or the number.

“And what we found was that up to 30 per cent of patients ended up with one of these procedure-related complications.”

The study also found that five to nine years after treatment, a cumulative total of 4.5 per cent of men who had radiation had developed a second cancer, compared to 1.8 per cent in the surgery group, most often in the gastrointestinal tract.

Bob Maurice of Penetanguishene, Ont., was diagnosed with prostate cancer in March 2005 and opted for radiation, which was less invasive than surgery.

At first he had difficulty passing urine, but over time he developed other side-effects that ended up “being quite severe.”

“It was pretty tough,” said Maurice, now 78. “I went for quite a few years where I was bleeding and I was incontinent and then what happened was stones gathered because of the damage to my bladder.”

He had surgery three or four times to remove stones from his bladder and was put on antibiotics too many times to count.

“I had four really bad years where I was in and out of hospitals. I had to be cathetered. I had to wear pads — there was at times quite a bit of blood,” said Maurice, explaining he was often incapacitated and couldn’t leave the house.

“It just went on and on. It was four years of misery.”

In August 2010, Maurice had his prostate and bladder removed. He now has an internal pouch and he self-catheters, allowing him to resume his favourite outdoor activities, among them hunting and fishing.

“I feel great. I’m very thankful that I’ve reached this point in my life where I can function like a normal human being,” said Maurice, who attributes his being cancer-free to the radiation treatment.

Still, after going through so much difficulty, he said he would go with surgery if facing the choice today.

“There’s quite a great possibility that if I’d had surgery and had my prostate removed, that I may still have my bladder.”

Dr. Stuart Edmonds of Prostate Cancer Canada said the study “highlights the need for men and their families to consider treatment options very carefully, being aware that each treatment might increase the risk of certain complications.

“It also highlights some of the potential deficiencies of current treatments and the need to continue to improve on them to reduce these complications,” said Edmonds, the advocacy group’s vice-president of research, health promotion and survivorship.

Dr. Tom Pickles, a radiation oncologist at the BC Cancer Agency, said he was not surprised at the findings, because it’s known that any therapy for prostate cancer comes with its own set of complications.

“What I tell my patients is that all treatments have the potential to decrease quality of life,” Pickles said from Vancouver, adding that erectile dysfunction rates are higher with surgery, while bowel problems are more common after radiation.

“A lot of people have difficulty choosing because the cure rates are very similar and the side-effects, although it’s apples and oranges, are similar.”

And he doesn’t think this study will make the process of choosing easier for men.

“This just reinforces that all treatments come with side-effects and that a good discussion with the urologist and the radiation oncologist about those side-effects, up front, is part of the decision-making process,” Pickles said.

Nam agreed, stressing the study isn’t meant to say that surgery is better than radiation, but to identify and quantify their complications.

“We’re doing such a good job in curing the cancer, but then (men are) left with these types of problems surviving with cancer. And that needs to be part of the discussion with the patient.”