Evaluating treatment options

Advantages and disadvantages

Examination of the treatment options for prostate cancer requires an analysis of the specific advantages and disadvantages of each modality. As shown in Table 24.4, each modality has specific issues which may make the modality more or less advantageous. RRP has an advantage in that it offers accurate pathologic prognostic information, which is lacking with both radiotherapy modalities, and offers the most data on long-term (>10 year) cancer control. Conversely, XRT and brachytherapy carry much less risk of peritreatment morbidity or mortality, with quicker recovery and return to work. The issues of incontinence and erectile dysfunction, as mentioned previously, differ between modalities, with acute occurrence and delayed recovery for RRP, and delayed occurrence in either radiotherapy modality.

Indications and contraindications

Apart from patient preference, there are several clinical parameters that may exclude a treatment modality from the decision-making process. Several commonly held indications and contraindications for RRP, XRT and brachytherapy are listed in Table 24.5. While precise data regarding each of these issues are lacking, most practitioners abide by these indications when offering treatment options for prostate cancer. Relative indications and contraindications are denoted, for which the data or commonly held opinions are not concrete. Thus, some urologists would not feel comfortable offering RRP to anyone refusing a potential blood transfusion, on the grounds that operative blood loss may potentially be high, which would place the patient at risk. Additionally, the age of the patient is used commonly as a deciding factor between treatment modalities, but these 'loose' age ranges may change as medical care improves with improved life expectancies in the future. Specific patient comorbidities are listed as well, including inflammatory bowel disease as a contraindication for radiotherapy, owing to concerns of exacerbating this condition. An irreversible bleeding diathesis is also considered a contraindication for radiotherapy, owing to concerns over the risk of chronic bowel or bladder bleeding after treatment.

Availability of services

The services available to a patient in his local area are another factor to be considered in the decision-making process. As mentioned previously, XRT dose and technique, specifically 3D conformal XRT and IMRT, are important parameters for good outcomes in prostate cancer, including the ability to deliver higher radiation doses accurately with less toxicity to surrounding normal tissue, but are not universally available nationwide. Similarly, recent data confirm that complications after RRP inversely correlate with hospital and surgeon volume of RRP.101 Lastly, there are wide variations in outcome after prostate brachytherapy, owing to practitioner experience and variations in technique, impacting on the precise placement of seeds. Thus, a patient living in an area with a busy well-trained surgeon operating at a high-volume hospital, without access to the newest radiotherapy techniques, may be well served to opt for RRP. Conversely, in another part of the country possessing good radiotherapy facilities and the availability of IMRT or brachytherapy, with no busy surgical practices, a patient may get a better outcome opting for one of the radiotherapy modalities.

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