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No Single "Best" Option for Treatment of Localized Prostate Cancer


With screening with prostate-specific antigen (PSA) becoming more routine, prostate cancer is often detected at an early stage when it is clinically localized (CaP). Treatment options for localized CaP include active surveillance, radical prostatectomy, radiation therapy, and cyrotherapy.

Which option is best for localized prostate cancer treatment? Is it the same for each individual?

Leonard Gomella, MD, a member of the Urology Department of Thomas Jefferson University, Philadelphia, PA and colleagues have reviewed the literature to answer the question: Is there an optimal management for localized prostate cancer? Their conclusions are published in the July issue of the Clinical Interventions in Aging Journal.

Gomella and colleagues write, “At the present time, there is no single correct or “best” option for all men.”

This is in large part due to the limited availability of head to head randomized trials which makes picking the right treatment option more difficult.

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The comparisons of the risks and benefits of treatments for localized CaP must be considered by each individual and his doctor. Quality of life factors such as potency, urinary, or rectal bother should play an important role in any patient’s treatment decision.

The choice of active surveillance/watchful waiting avoids treatment of insignificant cancer and risks of side effects from surgery or radiation. The downside is the potential “anxiety” from not treating a diagnosed cancer.

The choice of radical prostatectomy will give allow obtaining tissue for accurate pathologic staging. There are some trials that demonstrate a reduction in prostate cancer specific deaths when this treatment choice is made. The downside includes surgical risks (infection, bleeding, reaction to anesthesia, etc) and postoperative complications of incontinence: 5%–20% (usually stress); erectile dysfunction: up to 50% at 5 years (with nerve preservation, may be improved by medical therapy); bladder neck contractures 1%–3%; lymphocele with retropubic approach; rare rectal injury.

The choice of external beam radiation therapy (EBRT) avoids a hospital stay and the risk of surgery, but will involve daily treatments for 6-8 weeks. There is no prostate tissue for staging information. There is a risk of incontinence (1-2%), erectile dysfunction (up to 50% at 5 years), bowel/rectal problems (5%–10% which can include urgency, pain, diarrhea, or bleeding), and bladder irritation (5% , includes urinary frequency, urgency, discomfort).

Gomella and colleagues note that outcomes for men with low risk disease treated by radiation or surgery appear to have similar cancer outcomes out to at least 10–15 years. They suggests that perhaps, the younger patient with greater than ten year life expectancy may benefit from accurate staging offered by surgery where tissue for staging can be obtained.

In the end, the treatment of localized, prostate cancer needs to be individualized for each patient, after weighing in the current information available to each patient’s expectations, overall health and quality of life.

Is there an optimal management for localized prostate cancer?, Clinical Interventions in Aging, July 2010 , Volume 2010:5 Pages 187 – 197; Jaspreet Singh, Edouard J Trabulsi, Leonard G Gomella