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Why do Men with Prostate Cancer Choose Surgery?

Every week in my office I see men recently diagnosed with prostate cancer who are looking for options for how to deal with it. Usually, these men have been told that they need to have surgical removal of the prostate gland, a procedure known as the Radical Prostatectomy. They are told that this is what they need to save their life, and that they should schedule it as soon as possible. Somehow, some of these men end up in my office instead of on the operating table. I specialize in non-surgical treatment options for prostate cancer. For one reason or another they have come to have doubts, and have heard through fellow patients, books or the Internet that there may be other effective ways to deal with their cancer. When I see one of these patients I wonder how many others never even had a second opinion about other options to prostate cancer surgery.

If you have just been diagnosed with prostate cancer you are in good company. Prostate cancer is the most common non-skin cancer in America, diagnosed in 200,000 each year. Most men do not have any symptoms to start with, but instead have a PSA blood test that is a little abnormal, and as a result have a biopsy. Suddenly many of these men are told they have cancer, even though they feel as healthy as usual. There is usually shock, denial, depression, and then gradual accepting of the fact that they have been diagnosed with a potentially deadly disease. Life can follow a couple of roads at this point. The common scenario is that the urologist will recommend that the cancer be dealt with speedily, by removing the tumor and the offending prostate gland. The logic is simple. Remove the cancer and you are cured. There are possible side effects, but this is cancer we are dealing with. A life threatening illness requires a drastic treatment, like the Radical Prostatectomy, total surgical removal of the prostate gland. Most patients trust their physicians, and believe the doctor when he explains that this is the best treatment option. The majority of patients diagnosed with prostate cancer will choose this route. Many will be anxious to proceed with treatment as quickly as possible, and schedule the surgery for the soonest possible date.

There is a less common and more difficult road. This involves taking the time to learn and understand more about the cancer and the different treatment options available, and come to a careful conclusion about what is personally best. Through learning, patients see that prostate cancer is not really like other cancers. Many men die with it, rather than from it. It is a very slow growing cancer compared with other common cancers such as those of the lung, colon, and pancreas. It can take many years or decades for the cancer to spread, cause symptoms, or become life threatening. Only 20% of men currently diagnosed will actually die from their prostate cancer; the remainder will die from other common causes like heart disease. Treatment does not even offer a guarantee that you will be cured, but it may modestly reduce the chances of dying. With the introduction of the PSA blood test and prostate cancer screening, men are now being diagnosed with earlier stages of prostate cancer than ever before. By diagnosing cancer earlier, men have even less symptoms of cancer, will live even longer without treatment, and importantly may have a better chance of cure with any of the various treatment options available. Prostate cancer is also unique in that there are multiple choices available for how to treat it, including surgery, radiation, radioactive implants, freezing, hormonal therapy, and no treatment at all. No option has been proven to be more successful than the others. Yet, all the treatments can cause side effects in men who usually have no symptoms to begin with. These symptoms are a threat to the quality of life, and include incontinence, impotence, and damage to the rectum. Because only a minority of those with prostate cancer will actually die from it, and most will live several years after being diagnosed, possible side effects become extremely important factors in choosing a treatment. Men desperately want to choose the treatment that will offer the greatest chance of cure, yet will have the lowest chance of side effects. With increased knowledge of these different treatment options comes a blessing and a curse. The blessing is being able to choose a successful treatment that will cause you less side effects. The curse is trying to decide which treatment that will be. It can be a daunting undertaking, and some men feel that it is the most difficult decision of their life. This is the more difficult road.

With all the options for treating prostate cancer, why has surgical removal become even more popular than ever? I believe that it largely has to do with physician biases, and these biases and beliefs are in turn passed on to their patients. Men want to choose the best treatment for their cancer, and they are lead to believe that the Radical Prostatectomy has been proven to be the best treatment.

Physician Bias

When a man first learns that he has been diagnosed with prostate cancer, it is with a sense of shock and dread. The word "cancer" conjures up images of pain, suffering, and death. It is an immediate awakening to the fact that life is only for a limited time, and that its end may have to be acknowledged, and quickly. It is a very painful and disturbing event.

In most cases, it is a urologist who evaluates a patient for an abnormal PSA level, or an abnormal prostate exam. It is the urologist himself who will normally perform the prostate biopsy and inform the patient of the results. The urologist will then usually invite the patient to his office to discuss the diagnosis and the available treatment options. In many or most cases, the patient forms a significant bond of trust with his physician. Prostate cancer is an unknown and alien condition to most newly diagnosed men. Most people usually know very little about the treatments or even about what a prostate gland is supposed to do. They may have, however, witnessed friends or family members suffer through cancer and die. Many patients will put their complete trust into their physician’s hands at this point, and pray that he has the wisdom and ability to guide them through the shadow of cancer, and grant them freedom from this disease.

Urologists are surgeons by training. They prefer to treat prostate cancer with surgical removal of the prostate gland. Urologists will also administer hormonal therapy and monitor some patients who decide not to have treatment. Some are also involved in freezing and radioactive implant procedures. However, by and large, the radical prostatectomy is the preferred tool of the urologist to deal with prostate cancer. A study published in 2000 indicated that medical specialists usually recommend the treatment that they themselves specialize in. Urologists preferred prostatectomy 93% of the time. Radiation oncologists on the other hand, mostly believed that prostatectomy and radiation therapy were equivalent options. (1)

A typical situation then is that a urologist will biopsy and diagnose a patient with prostate cancer, and the patient will put his trust in the physician to guide him. The urologist will usually recommend prostatectomy, as long as the cancer is not too advanced and the patient can tolerate it. Patients frequently indicate that they are encouraged to have surgery through comments such as "if it was my father I would want him to have surgery", or "your best chance to live is to have surgery".

I believe that most urologists, like most physicians, are ethical and sincerely believe in their treatment. They were trained in years of residency to perform what they do and to believe in it. They identify their self with their chosen profession and they feel that what they have to offer is important and makes a difference to the lives of patients. Most have faith in their own hands and mind and they would sooner treat a patient themselves rather than let another physician do it. These statements are true across the medical specialties.

Yet, there are problems that arise. Medical care in America still mostly works on a free-enterprise model. Physicians get paid according to consultation time and procedures that they perform. Prostate cancer treatment generates significant amounts of money for a physician and his hospital. There can be a financial motive in directing patients to choose one treatment or another. Again, this is true across the medical sphere. Any disease that has competing treatments (which generate revenue) will result in competing specialists who promote their own treatment. The problem with prostate cancer is that the newly diagnosed prostate cancer patient will have only heard about treatment options through his urologist, and he has placed his faith in the urologist to be fully objective and guide him to choose the best treatment. There is a level of trust that can be taken advantage of. How many patients have had a prostatectomy without having had so much as a second opinion? If a surgeon refers a patient for a second opinion, frequently it is with an oncologist who works with that urologist -- an oncologist who depends on the urologist for patient referrals and will be very careful about what he says and recommends.

The Gold Standard

Radical Prostatectomy is frequently referred to as the "gold standard" of treatment choices. By gold standard what is meant is the model of excellence against which all others should be compared. I do not know who conferred this honorary title upon this procedure. Nonetheless, this label has been ingrained in the minds of generations of physicians, and hence their patients. You have probably been told by several well meaning doctors and acquaintances that surgical removal is what you need to do.

Andy Grove, chairman of Intel Corp. wrote in Fortune magazine about his experiences in choosing a prostate cancer treatment. His radiation oncologist offered him brachytherapy, but confessed that he might choose surgery if he were in his shoes. Mr. Grove writes, "Why" I asked, "would you have surgery done to yourself then?" The doctor thought about it. Finally, he said, "You know, all through medical training they drummed into us that the gold standard for prostate cancer is surgery. I guess that still shapes my thinking." (2)

One of the most influential urologists in the prostate surgery field is Dr. Patrick Walsh. In his book, Guide to Surviving Prostate Cancer, he describes how he spent a summer vacation reviewing hundreds of hours of video footage of his operations, so that he may perfect his technique. Dr. Walsh may actually be considered to be the gold standard of urologists, and his devotion has done much to improve the procedure. He admits that the results of radical prostatectomy are very uneven across the country and that the results are best in the hands of experts. However, it is not uncommon for urologists to quote Dr. Patrick Walsh's own success rates when they are informing patients about the possibilities of cure and side effects. They are implying that these are the results their own patients can hope to obtain. I believe that in an ideal world it would be more honest for physicians to tell patients their own results, which they have kept track of with a standardized and up-to-date database of their numbers of cases, patient characteristics, and results. Very few physicians have the resources or willingness to do this. It is very inaccurate for a physician to just guess his results without using statistical methods to keep track. Dr. Walsh quotes a 1% rate of incontinence for his procedure. The national Medicare incontinence rate is 32% for patients who have had a prostatectomy. This is the rate for an average patient who is 65 or older with an average urologist. Many (or most) urologists will tell their patients that they will have a 1 – 2% rate of incontinence, and this clearly does not mesh with the national average figures.

There is no good explanation why prostate removal should be considered the model treatment. Perhaps at one time when radiation therapy techniques were more primitive, surgery may have offered a higher chance of cure. Currently, the cure rates of other non-surgical choices are often indistinguishable from those of the radical prostatectomy, yet the impotency and incontinency rates and recovery time tend to be better.

After radiation or surgery, a rising PSA level is usually the first sign that prostate cancer has recurred somewhere in the body. Dr. Walsh's group at Johns Hopkins has obtained a 74% chance of being free from a rising PSA within 10 years of surgery. With a modern form of radiation, permanent seed implantation, Dr. Blasko in Seattle has obtained an 87% chance of being free from a rising PSA within 10 years for patients with early cancers. (3) Both are examples of centers with excellent techniques, and consequently excellent results. For the real world, we can look at national surveys of Medicare patients. Both radiation and surgery patients report an equal need to have further treatment for cancer recurrence within 3 years of having treatment, 24% and 26% respectively. Incontinence rates were 7% vs. 32% and impotence rates were 23% vs. 56% for radiation and surgery. (4) Certainly these large reviews of average results across the country do not suggest that surgery is a superior treatment. As well, comparing the results from the very best specialists doing different treatments does not show that surgery is better. The best specialists using different methods have quite similar results.

I fear that I am perpetuating a myth by even associating radical prostatectomy as being called the gold standard. My goal is to demonstrate that prostate removal does not deserve this recognition, and that surgery is merely one of several options available, not the best. Yet that is precisely what many physicians and patients have come to think, and that is what drives many patients to choose this treatment.

Fear of Making the Wrong Choice

A patient who is told that he needs to have his prostate removed and goes ahead, often has a much easier time psychologically than the man who becomes informed and researches the different treatment options. The more reading a prostate cancer patient does, the more he will learn about the different treatment options, the pros and cons of each, and the fact there is little evidence showing which treatment is better. It can become impossible to decide which treatment is best. There is discomfort in having the freedom to decide between the different choices. Men with prostate cancer desperately want to choose the treatment that will cure their cancer, and cause the least side effects. It can be easier to place your faith in your physician who diagnosed you, not seek a second opinion, and proceed with the treatment he recommends.

With choices comes the fear of the consequences from choosing the wrong treatment. The consequences of inadequately treating a cancer can be death. The right treatment choice will hopefully cure the cancer, yet leave urine control and erections intact.

If you have done all you possibly can do for the cancer and it still comes back, you can sleep better at night knowing that you have chosen the most aggressive treatment possible. Even the name Radical Prostatectomy sounds like a radical and aggressive treatment, one in which the prostate cancer is not given half a chance. There may be a real risk of side effects, but the solution to a life threatening problem is the most radical treatment possible, to minimize the chances of dying, right? Surprisingly, some patients think that a prostatectomy is almost a guarantee of cure, and hence worth the possible side effects. They may not realize that prostate cancer can recur even if the prostate gland is taken out. Yet it can recur, frequently in the tissues surrounding where the prostate gland used to be, or in the lymph nodes or the bones.

There is a common impression that by simply removing the prostate gland, the cancer will be removed and cured. Surgeons frequently say "We got it all" after doing surgery. It is true that if the cancer is totally contained in the prostate gland, then complete removal will cure the cancer. Unfortunately, there is no way to tell if the cancer is totally contained within the gland without actually removing it and having it analyzed by a pathologist. Cancer by its very nature will mutate and eventually invade beyond the gland and spread. Even in patients with a low PSA value and an early stage there can still be a significant risk that the cancer has spread outside of the prostate gland into the tissues surrounding it. A review of Medicare patients in New York State who underwent prostatectomy showed that 54% had "positive margins." (5) This means that the cancer came right to the edge (or margin) of the tissue that was surgically removed from the body. This in turn means that there were cancer cells left behind in the body, just beyond where the surgeon cut. Cancer cells left behind in the body can slowly grow and divide, and form new tumors in the area where the prostate gland was removed.

Doctors also fear recommending the wrong treatment choice, although to a lesser degree than patients. They are not dealing directly with their own chances of dying and losing the ability to have erections, so these concerns are only experienced second-hand. Many doctors deal with the fear of making a wrong recommendation by only offering treatments that are considered to be the norm. There are published guidelines that are called "standards of care." If a physician does not deviate from these published standards and if his treatment does not work he can feel free from responsibility. However, these published guidelines are frequently based on older and more researched treatments, such as surgery. It takes a while for guidelines to catch up with the most modern forms of treatment, and they certainly would not recommend anything that is considered alternative. Those physicians who are recommending less common treatments that are considered "outside the box" of conventional thinking are risking greater personal responsibility in the outcome. This is why many prostate cancer specialists may temper their recommendations with statements such as "you are young so you should consider having a radical prostatectomy." The younger a patient is or the more life threatening a cancer is, the more responsibility a physician assumes if he recommends a less common treatment. It is safer psychologically to recommend a treatment which the majority of prostate cancer patients currently receive, and which the majority of urologists trust.

Scare Tactics

When medical specialists speak to patients about treatment options for prostate cancer, they typically recommend their own form of treatment. Often drawbacks are emphasized for the alternate treatment options, and sometimes even exaggerated. This plays on the fears of cancer patients that they may make the wrong choice, and secondly worries patients that they may choose a treatment that their physician does not approve of.

Urologists will be the first to counsel patients about their disease and their information is taken to heart. Patients have reported to me that their urologists have told them the following:

"You need surgery or you will die."

"Radiation can burn your bladder and rectum and leave you with a bag for your feces."

"Radiation won't work with your Gleason score."

"The cancer has a higher chance of coming back after radiation than with
surgery."

"If your cancer comes back after radiation, we won't be able to operate on it then."

These statements are either untrue, or need large asterisks beside them. For example, there is absolutely no proof that radical prostatectomy offers a better chance of survival than does radiation. The odds of requiring a colostomy bag after prostate radiation are miniscule - I have never personally seen it happen. Surgery can often be performed if radiation fails to cure the cancer in the prostate, just as radiation can often be performed if surgery fails.

Radiation oncologists are not innocent in this regard and will also typically emphasize the risks of side effects that may occur with the radical prostatectomy, and will stress the limitations of the surgery. Radioactive seed implant specialists (brachytherapists) may stress that the other treatments (including external beam) can cause more collateral damage and impotence.

These statements by specialists have a huge impact on patients in shaping their decision. Many physicians try to avoid using scare tactics and try to present the data in an unbiased manner, although there is always some bias. Some who use scare tactics will presumably believe that what they are saying is true. They may feel they are doing their moral duty to steer a patient away from what their training has taught them is a sub-standard treatment.

The Solutions

The solution to these problems is education. Before scheduling treatment patients should be encouraged to have a second (or third) opinion, to read books, and to talk with other prostate cancer survivors who have had various forms of treatment. Prostate cancer is slow growing, and it would be quite wise in the long run to research the options for a month or two before deciding on a treatment. Patients need to understand that every case of prostate cancer is unique and some treatments may be better than the others for a particular stage. Results they read about will apply only to a specific group of patients treated by specific doctors. There can be tremendous differences between national average Medicare rates, and the rates of highly skilled perfectionists.

It is fine for a urologist to quote Dr. Walsh's excellent results, or for a brachytherapist to quote Dr. Blasko's results, but he should also quote his own results and possibly the national averages. How does he keep track of his own results? Has he published them in a medical journal? Is he willing to put down in writing what his rates are for 5 year freedom from cancer recurrence, impotence, incontinence, and incomplete removal (positive margins)? Would your own situation tend to be better or worse than for his average patient?

Men need to understand that there is no proof that the prostatectomy is a superior treatment or will offer some guarantee that they will live longer. Physicians are humans and will tend to recommend and believe in their own treatment, which they are devoting a portion of their life and career to. Education can help men understand the benefits and limitations of their physicians and treatments, and to overcome the natural instinct of not questioning what their physician recommends. Prostate cancer is a journey. Like all journeys there can be many roads, and sometimes your choice can make all the difference.

References

1. Comparison of recommendations by urologists and radiation oncologists for treatment of clinically localized prostate cancer. Fowler FJ Jr, McNaughton Collins M, Albertsen PC, et al. JAMA 2000 Jun 28;283(24):3217-22

2. Grove A. Taking on Prostate Cancer. Fortune 1996 May 13

3. Grimm PD, Blasko JC, Sylvester JE, et al. 10-year biochemical (prostate-specific antigen) control of prostate cancer with (125)I brachytherapy. Int J Radiat Oncol Biol Phys 2001 Sep 1;51(1):31-40

4. Fowler FJ Jr, Barry MJ, Lu-Yao G, et al. Outcomes of external-beam radiation therapy for prostate cancer: a study of Medicare beneficiaries in three surveillance, epidemiology, and end results areas. 1 Clin
Oncol 1996 Aug;14(8):2258-65.

5. lMperatO PJ, Waisman J, Nenner RP. Radical prostatectomy specimens among Medicare patients in New York State: a review of pathologists' reports. Arch Pathol Lab Med 1998 Nov;122(11):966-7.

Notes are written by Dr. Doug Kelly, unless otherwise stated. These reflect my own opinions and not necessarily those of CTCA or my colleagues.