Which Prostate Cancer Treatment is Best for Me?

Surgery Ranks as the Most Cost-Effective Type of Treatment, According to UCSF-Led Study

According to a new research published by the University of California, surgery is the best treatment for both high and low risk prostate cancers. Researchers completed the most comprehensive retrospective study ever conducted comparing how the major types of prostate cancer treatments stack up to each other in terms of saving lives and cost effectiveness.

Appearing in the British Journal of Urology International, the work analyzed 232 papers published in the last decade that report results from clinical studies following patients with low-, intermediate- and high-risk forms of prostate cancer who were treated with one or more of the standard treatments – radiation therapy, surgery, hormone therapies and brachytherapy.

The analysis shows that for people with low-risk prostate cancer, the various forms of treatment vary only slightly in terms of survival – the odds of which are quite good for men with this type of cancer, with a 5-year cancer-specific survival rate of nearly 100 percent. But the cost of radiation therapy is significantly more expensive than surgery for low-risk prostate cancer, they found.

For intermediate- and high-risk cancers, both survival and cost generally favored surgery over other forms of treatment – although combination external-beam radiation and brachytherapy together were comparable in terms of quality of life-adjusted survival for high-risk prostate cancer.

“Our findings support a greater role for surgery for high-risk disease than we have generally seen it used in most practice settings,” said urologist Matthew Cooperberg, MD, MPH who led the research. Cooperberg is an assistant professor of urology and epidemiology and biostatistics in the UCSF Helen Diller Family Comprehensive Cancer Center.

Many Treatment Options, but Few Cost Analyses

Localized prostate cancer accounts for about 81 percent of the quarter-million cases of prostate cancers that occur in the United States every year, according to the National Cancer Institute. It is defined by tumors that have not metastasized and spread outside the prostate gland to other parts of the body.

There are multiple types of treatment for this form of the disease, including various types of surgery (open, laparoscopic or robot-assisted); radiation therapy (dose-escalated three-dimensional conformal radiation therapy, intensity-modulated radiation therapy and brachytherapy); hormone therapies; and combinations of each of these. Many men with low-risk prostate cancer do not need any of these treatments, and can be safely observed, at least initially.

Treatment plans for localized prostate cancer often vary dramatically from one treatment center to another. As Cooperberg put it, one person may have surgery, while someone across town with a very similar tumor may have radiation therapy, and a third may undergo active surveillance. All treatment regimens may do equally well.

“There is very little solid evidence that one [approach] is better than another,” said Cooperberg. The motivation for the new study, however, was that there are also few data examining the differences in terms of cost-effectiveness – the price to the health care system for every year of life gained, with adjustment for complications and side effects of treatments.

The new study was the most comprehensive cost analysis ever, and it compared the costs and outcomes associated with the various types of treatment for all forms of the disease, which ranged from $19,901 for robot-assisted prostatectomy to treat low-risk disease, to $50,276 for combined radiation therapy for high-risk disease.

The study did not consider two other approaches for dealing with prostate cancer: active surveillance, where patients with low-risk cancer are followed closely with blood tests and biopsies and avoid any initial treatment; and proton therapy, which is much more expensive and has already been shown in multiple studies not to be cost-effective, said Cooperberg.

The article, “Primary treatments for clinically localised prostate cancer: a comprehensive lifetime cost-utility analysis” is authored by Matthew R. Cooperberg, Naren R. Ramakrishna, Steven B. Duff, Kathleen E. Hughes, Sara Sadownik, Joseph A. Smith and Ashutosh K. Tewari. It was published online on Dec. 28, 2012 by the British Journal of Urology International. The article can be accessed at: http://dx.doi.org/10.1111/j.1464-410X.2012.11597.x

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This study adds to our knowledge and will hopefully assist doctors and patients in choosing the right treatment option for them. Unfortunately, from our perspective, one key area is missing from their assessment… complication costs. Surgery is proving cheaper for many men; however, surgery comes with risks and costs that are sometimes hard to quantify.

According to the New York Times Health Guide, the main complications from radical prostatectomy are urinary incontinence and erectile dysfunction. Other complications include the usual risks of any surgery, such as blood clots, heart problems, infection, and bleeding.

Urinary Incontinence. Urinary incontinence is a common complication. When the urinary catheter is first removed following surgery, nearly all patients lack control of urinary function and will leak urine for at least a few days and sometimes for months. Normal urinary function usually returns within about 18 months. A percentage of men will continue to have small amounts of leakage with heavier exertion or possibly sexual activity. If incontinence persists beyond a year, patients may require drug therapy or surgery.

Erectile Dysfunction. Erectile dysfunction after radical prostatectomy is caused by nerves that were damaged or removed during the surgery. Virtually all men will have problems with erectile dysfunction after surgery. It can take up to one to two years to recover erectile function after surgery. Because seminal glands are removed along with the prostate gland during surgery, men who regain sexual function will not produce semen during orgasm (“dry ejaculation”).

With the use of effective nerve-sparing techniques, men who were sexually active before surgery and are involved in an ongoing relationship seem to have a better chance of returned sexual function. Drugs such as sildenafil (Viagra) may help some men regain erectile function. Use of these drugs three times a week accompanied by sexual stimulation is now commonly recommended. Other treatments for erectile dysfunction (alprostadil injections, vacuum devices, penile implants) may also be options.

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What’s best for you is a complicated balancing act, weighing risk against potential reward and a good amount of wishful thinking and guess work. The men we talk to are broadly post-surgery and dealing with long term incontinence. And we’re privileged to offer them a better alternative than pads, diapers and condoms that allows them to get back to living life to the fullest.

Prostate cancer is the second most common cancer among men, with more than 250,000 new cases diagnosed each year. The only thing I know for certain is that this debate is far from over.

What are your thoughts? What was your experience? Share your story below!

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