Different types of prostate cancer treatments are recognized by the International Scientific Society, so which one should a patient choose between surgery, active surveillance, external radiotherapy, and curie therapy?
In fact, for a same pathology, different treatment options are available. To decide, the patient should know the different treatments and their toxicities. To do so, we advise him to consult his doctor or oncologist and ask about the different procedure, their efficiency and their side effects that could impact his standard of living.
The New England Journal of Medicine published the study “10 years outcomes after monitoring surgery or radiotherapy for localized prostate cancer” highlighting that the survival rates of the patients were identical for surgery, radiotherapy treatment and active surveillance. Even if the survival rates were the same, the patients who chose the active surveillance were those who developed the highest number of metastasis requiring for 60% of them the use of surgery or radiotherapy during the follow up as stipulated on the below curves.
Considering the treatments have the same efficiency, selecting a treatment will depend on the toxicities and their impact on the standard of living.
The patient can compare the impact of the three methods on the following graphic; the blue curve is representing the radiotherapy, the red one represents the surgery, and the yellow one the active surveillance.
As you can see on those graphics extracted from the study mentioned earlier, the sexual potency 2 years after the randomization was similar for patients who were treated by radiotherapy and the ones who were in active surveillance.
Moreover, the radiotherapy shows less urinary incontinence than the surgery which includes an anaesthetic risk, but it gave some rectal bleeding called proctitis to the patient. Usually, this side effect does not present any vital consequence.
Considering all we explained, which treatment should a patient choose?
First, the treatment choice will vary from a patient to another, depending on the personal preferences regarding the side effects and the impact it has on his personal life.
In the factors to be examined, the patient should keep in mind that the radiotherapy results presented earlier were delivered during 35 sessions. It corresponds to approximately 7 or 8 weeks of treatment which can be long for some patients.
Also, the toxicities of each option must be examined.
Does the patient think that the urinary incontinence or rectal bleedings are unpleasant and is the patient ready to live with those side effects for a certain time?
The treatment selection is a personal judgment according to the patient’s priorities regarding the toxicities. It is to remind that the treatment might not be available nearby the patient’s dwelling.
In the New England Journal of Medicine, the patients were treated more than 20 years ago, in the 1990s.
Since then, new techniques have been developed such as the implementation of intensity modulated radiation therapy. Those methods considerably improved radiotherapy treatments, allowing them to be more precise and to reduce margin around the tumour. This leads to less toxicities around 3 to 5% for rectal bleeding, 0% of urinal incontinence and 30% of erectile dysfunction.
Those new techniques also permit to reduce the overall treatment time by increasing the doses per session: 4 weeks instead of 7 or 8. Thanks to last generation techniques, such as stereotactic radiation therapy, the treatment can even be reduced to two weeks (5 sessions).
The stereotactic radiation therapy implies a sub-millimetric precision that could be achieved by tracking gold seeds implanted in the prostate or by following the prostate with ultrasound during the session.
With this technic, the whole treatment can be achieved in less than 9 sessions.
Stereotactic radiotherapy efficiency and safety is being proved each day by the scientific community.
For example, the following meta-analysis published in 2019 in the International Journal of Radiotherapy (IJROBP) shows that 7 years after treatment, on 93% of over 6,000 patients in biochemical control of the PSA, only 1.1% of them still had intestinal gastro disease and 0.2% had urinary toxicities.
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