Hi, I'm Dr. Scholz.
A common question we get at the PCRI is, "What's Better: Surgery or Radiation?" This has been
the perennial question, and I think actually I'm well positioned to answer that question.
Almost everybody in the prostate cancer world is either a surgeon or a radiation therapist.
As it so happens, I'm a medical oncologist specializing exclusively in prostate cancer.
I don't own a robot to operate with and I don't own a radiation machine that I can send
patients to and profit from. I'm just looking for what really is better, and I am immersed
in this field enough to actually have a good opinion and a lot of experience.
So why is there a controversy? Why is it difficult to figure out which is better? Why are there
arguments and disputes about this question?
Well, the real issue is how technology has evolved over the last 10-15 years. If you
go back 10 or 15 years, surgery was much better than radiation. The radiation back then was
scary. Men were getting burns; the cure rates were diminished; people were really unhappy
with the results, and then if they didn't get cured, they had a mess on their hands.
The surgery would be very difficult to do after the radiation, and most people are still
hearing about that as an argument for surgery to this day, "Do surgery first because if
you do radiation first, you can't do surgery afterward." That was a good argument, but
it's an outdated one now.
So the big change that we've seen over the last 10-15 years is an amazing progress in
the precision and the power of radiation therapy. We have these computerized pencil beams that
go precisely where they're supposed to go within a millimeter or two of their target.
So now you're getting cure rates that are even better than surgery. Remarkable. How
could this be? Well, surgeons are constrained by the fact that the bladder and the rectum
are within millimeters of the prostate surface. They can't cut a margin around the gland.
The radiation therapists are not constrained that way. They can put a field over the edge
of the bladder and over the edge of the rectum and ensure better coverage and thus achieve
higher cure rates. So if it's just cure rates we're looking at modern radiation is at least
as good as surgery, and if you look at what they're achieving with seed implants now,
it's better than surgery.
Well, what about the side effects? That's really the important thing in prostate cancer
since most men aren't going to die of prostate cancer, but they're going to have to live
with the side effects of this decision that they make—potentially irreversible side
effects like impotence, incontinence, damage to the rectum which is closely adjacent. So,
let's take those things one at a time. So let's take the sexual question first. Sexual
function after surgery is inferior in its outcome compared to the sexual functions that
can be achieved with radiation. Now, there's a spectrum of course, and men can be impotent
with either approach, but impotence is much more common after surgery than it is after
radiation. Another confounding factor is that surgery is associated with urinary leakage
after treatment, and this almost never occurs with radiation. Urinary leakage shouldn't
be minimized. It occurs in 5-10% of optimal candidates operated on by world-class experts.
Stress incontinence, where people leak when they jump, sneeze, laugh occurs in up to 50%
of men after surgery. Another problem with urinary leakage is during sexual activity.
About 20% of men leak urine during sexual activity. So these are really depressing effects
from surgery that don't happen with radiation.
One of the arguments the surgeons had in the past was that there's a very low incidence
of rectal damage whereas with radiation there could be a burn on the rectal wall, and this
is true. These rates were steadily reduced with better and better radiation, but never
completely eliminated until the advent of a new gel spacer that can be injected between
the rectum and the prostate—pushing the rectal wall away during radiation and essentially
eliminating the risk of rectal damage.
So in every category that we look at comparing these two different approaches, while surgery
in the past was better than radiation, in this modern era, radiation is better than
surgery.