“Which is the best treatment?” That is one of the most common questions that I hear from men during counseling for localized prostate cancer. My patients carefully listen to the risks and benefits of the various treatment options including radical prostatectomy, external beam radiation therapy, and brachytherapy. They then always turn to me to see which is the best treatment for them. For men with moderately aggressive, localized prostate cancer, there is no right answer. Studies have shown that for most men with a PSA less than 10 and Gleason 6 prostate cancer that is not palpable (or minimally palpable) on rectal exam, no single treatment option has been definitively demonstrated to cure prostate cancer better than the others. This information usually confuses many of my patients. After all, how can you choose between therapies when they all treat the cancer about the same?
The answer is side effects.
While the ability to cure cancer is fairly similar for the three mainstream treatment options, their side effect profiles tend to be very different. As I tell my patients, there is no free lunch in medicine. Any treatment you choose will result in some unpleasant outcomes. The key is determining which side effects you think you will best be able to tolerate. The treatment that you think will least impact your quality of life is probably going to be the best treatment option for you. In this post, I will review the different ways that radical prostatectomy, external beam radiation therapy, and brachytherapy affect quality of life.
Breaking Down Quality of Life
Treating prostate cancer can affect a man’s quality of life in many different ways. Urination, bowel function, and sexual performance can each be impacted by the various treatment options. Studies often evaluate these categories or “domains” separately to help determine a man’s quality of life after treatment for prostate cancer. Lets try to look at these categories individually.
Urination
As I have described in my previous posts, most treatments for prostate cancer affect urination. During a prostatectomy, one of the two muscles responsible for controlling the flow of urine is removed with the prostate. As a result, the work is left to the remaining muscle. This muscle is often not strong enough to control urination, at least not initially. As a result, most men leak after prostatectomy. Not surprisingly, studies have demonstrated that urinary function (a quality of life term for continence) is significantly worse for men undergoing surgery as compared with those men undergoing radiation therapy.
In contrast, radiation treatments such as external beam therapy or brachytherapy do not involve the removal of any muscles. Because the “plumbing” remains intact, men undergoing these treatments usually do not experience any incontinence of urine. However, radiation therapy does cause other problems with urination. The radiation often causes swelling of the prostate, which makes it harder for the urine to travel through it from the bladder. To better understand this concept, picture the bladder as an upside down fishbowl which empties through a donut (the prostate) into a straw (the urethra) and out the penis. Radiation therapy causes swelling of the donut (the prostate), making the donut hole smaller and slowing the flow of urine. While most men are not too bothered by this, those men that already have enlarged prostates and BPH (benign prostatic hypertrophy) symptoms often complain that their symptoms become worse with radiation. In a minority of men, the swelling induced by radiation can be so great as to completely obstruct the flow of urine and require the placement of a catheter in the bladder. Men with significant BPH should give definite consideration to these possibilities before proceeding with radiation therapy.
In addition to impacting the prostate, radiation therapy given for prostate cancer can also affect the nearby bladder. Although modern radiation technology is getting more and more precise in aiming radiation beams at the prostate, the bladder does invariably absorb some of the radiation. As a result, the bladder can become irritated or inflamed from the beams. Men experiencing such irritation of the bladder often complain of pain with urination and find themselves urinating more frequently, but in smaller quantities. Rarely, blood in the urine can also be seen due to the irritation of the bladder from the radiation beams. Of note, these symptoms of urinary irritation and obstruction are experienced more often by men undergoing brachytherapy than by those men treated with external beam therapy.
Bowel Function
Anyone who has ever undergone a prostate biopsy knows just how close the prostate is to the rectum. As a result, treatment for prostate cancer can affect bowel function and quality of life from a digestive standpoint. Fortunately, barring rectal injury (which occurs less than 1% of the time), a radical prostatectomy should not lead to any significant problems with bowel function. As a result, men undergoing prostatectomy usually express no long term detriment to quality of life from the standpoint of their digestive tract. The same cannot be said, however, for those men undergoing radiation therapy. Because the rectum is located just behind the prostate, radiation beams directed at the prostate can also hit the rectum and lead to side effects. Common complaints can include some transient (or, rarely, long term) diarrhea, pain with bowel movements, or blood in the stool. Fortunately, with improvements in radiation technology, the incidence and extent of bowel problems is seen less and less. Nonetheless, these therapies cause significantly more bother due to gastrointestinal side effects than does radical prostatectomy. When comparing the two types of radiation therapy, studies have demonstrated that external beam therapy tends to cause more bowel problems than brachytherapy.
Sexual Function
Because of the proximity of the nerves controlling erections to the prostate, all treatments for prostate cancer affect sexual function. Because the nerves can be damaged during a prostatectomy, erectile dysfunction is usually noted immediately after surgery. In some men, these nerves recover over time and some function is regained months to years after surgery. Nonetheless, at least half of the men undergoing prostatectomy do complain of some decrease in sexual function over the long term.
Radiation therapy, as well, can damage the nerves responsible for erections. Because the damage inflicted by radiation therapy occurs over time, however, the impact on sexual function is not usually experienced at the time of or immediately after treatment. Rather, erectile dysfunction after radiation therapy usually takes weeks to months to take hold. Nonetheless, studies have demonstrated that a similar percentage of men (50%) experience some long term decrease in erectile function after radiation therapy. As such, studies have not demonstrated any significant differences in sexually related quality of life between external beam radiation and radical prostatectomy. In contrast, some studies have demonstrated better sexual function after brachytherapy as compared to surgery or external beam therapy.
Aside from erectile function, another aspect of sexual quality of life that must be kept in mind is ejaculation. During a prostatectomy, the prostate and seminal vesicles are removed and the vasa deferentia are tied off. This effectively removes all potential fluid that is released during ejaculation. As such, while men can experience orgasms after prostatectomy, these orgasms feel different in that they are associated with a dry ejaculate. In my practice, many men have complained that the lack of ejaculated semen leads to decreased enjoyment from orgasm and from the sexual experience in general. While this is not a commonly discussed side effect of prostatectomy, it can significantly affect sexual quality of life and should be kept in mind by men considering prostatectomy.
Take Home Message
The abundance of treatment options available to men with prostate cancer can be a blessing and a curse. On one hand, it is always good to have options when battling a disease. On the other hand, however, it is difficult to choose between treatment options when you know that, at least in terms of cancer cures, the options yield very similar results. As such, in treating prostate cancer, the decision often comes down to side effects rather than cure rates. As I tell my patients, there is no free lunch in medicine. Any treatment has its own set of risks and side effects. However, for every individual, some risks are more daunting than others. While some men are deathly afraid of incontinence others are more concerned about erections. Still others would trade both for normal bowel habits. As such, the decision on how to proceed with treatment of prostate cancer is usually a very personal one. While the urologist can make recommendations in specific cases when one treatment may be more medically advantageous, the patient is best suited to make the final treatment decision, in most cases, after a careful review of the options and an honest look within.
