The Radiation Round-Up

BY RALPH BLUM

Despite the significant advances in treatment options, there is still considerable uncertainty—even among doctors—about how or even whether to treat prostate cancer. The treatment controversy is the prostate cancer equivalent of a Dempsey-Firpo fight: the proponents of surgery slugging it out with those who favor some form of radiation.

In recent years we’ve seen the arrival of the elegant robotic surgery. Instead of cutting half-blind in a field of blood, with the da Vinci robot a surgeon can observe the anatomy blown up 100 times on a big TV screen and, with the aid of the robot, perform the complex and intricate surgery more precisely.

There are, however, two problems with this sophisticated new surgical procedure. First, it’s hard to justify the significant additional cost of the robot because the results are not that much different from those obtained with traditional surgery.

The second problem is rather disquieting. I have observed the power of the robot as a selling tool—a blend of high visibility, big bucks, slick advertising—with the result that a considerable number of men who really do not (repeat, do not) need surgery in the first place are seduced, Pied Pipered into the O.R. by what one critic called the “bloodless glamor” guaranteed by the da Vinci robot. You might want to consider my earlier blog, “The Robots Have Landed.” 

My feeling —depending, of course, on your risk category—is that if you are going to opt for radical treatment you should be lining up for one of the state-of-the-art targeted radiation treatments: either radioactive seed implantation, or intensity modulated radiation therapy (IMRT).

So how do you determine which you should choose?

Not all men are candidates for radioactive seed implants, otherwise known as brachytherapy. It is not recommended for men with enlarged prostate glands, men with pre-existing urinary problems, or men with cancer outside the prostate. If, however, you are eligible, seeds have the advantage of a single hospital visit, whereas IMRT requires daily sessions at a specialized facility for two months. Also, with seeds, the radiation dose is minimally higher, giving you the possibility of slightly better cure rates.

Bottom line your decision to go for seeds versus IMRT is mainly influenced by your risk category. In my case, if, after all these years of “prostate cancer coexistence,” if I decided on treatment, I would choose IMRT because it can be administered to a slightly broader field, thus creating a wider margin around the gland and even, if necessary, radiating the surrounding lymph nodes.

You will undoubtedly hear conflicting opinions about which treatment is best for you, and your decision will inevitably be complicated by multiple factors. With any prostate cancer treatment there is the risk of side effects, but with targeted radiation therapies the risk is significantly reduced. Moreover, both of these therapies—seeds and IMRT—are at least as effective as surgery at curing the disease without the additional risks of a major operation.