What are the risks and benefits of radical prostatectomy versus prostate radiation for a patient with intermediate risk prostate cancer and a greater than 10 year survival prognosis?

Radical Prostatectomy vs Radiation Therapy for Intermediate-Risk Prostate Cancer

For a patient with intermediate-risk prostate cancer and >10 year life expectancy, both radical prostatectomy and radiotherapy plus ADT are equally recommended standard treatment options with equivalent long-term cancer control outcomes. 1

Standard Treatment Options

Both treatments are endorsed as Grade A recommendations by the AUA/ASTRO/SUO guidelines:

• Radical prostatectomy with pelvic lymph node dissection (if predicted probability of lymph node metastasis ≥2%) 1
• Radiotherapy plus ADT (4-6 months of androgen deprivation therapy) 1

Important distinction: Favorable intermediate-risk disease can be treated with radiation alone, though the evidence is less robust than combining radiotherapy with ADT 1. For unfavorable intermediate-risk features, radiotherapy should include concurrent ADT 1.

Cancer Control Outcomes

Mortality and Metastasis-Free Survival

Real-world evidence demonstrates no significant differences in cancer-specific survival or metastasis-free survival between radical prostatectomy and radiation therapy when adjusted for patient characteristics 2. A 2020 propensity-matched study of 1,503 intermediate-risk patients showed equivalent 10-year metastasis-free survival and prostate cancer-specific survival between treatments 3.

Biochemical Control

• Brachytherapy (with or without supplemental external radiation) showed superior 10-year biochemical control (80.2%) compared to radical prostatectomy (57.1%) or external beam radiation (57.0%), though this did not translate to differences in metastasis-free or cancer-specific survival 3
• Biochemical recurrence rates alone should not drive treatment selection given equivalent survival outcomes 3, 4

Quality of Life Considerations

Radical Prostatectomy Side Effects

• Urinary incontinence: Most common early complication, typically improves over 12-24 months
• Erectile dysfunction: Occurs in majority of patients, even with nerve-sparing techniques
• No bowel toxicity: Surgery avoids radiation-related bowel complications 4

Radiation Therapy Side Effects

• Bowel dysfunction: Radiation proctitis, urgency, and bleeding can occur
• Urinary irritation: Acute urinary symptoms during treatment, potential for late stricture
• Erectile dysfunction: Gradual onset over 2-3 years, related to vascular damage
• ADT side effects: Hot flashes, fatigue, metabolic changes, osteoporosis risk when ADT is added 5, 4

Critical caveat: Brachytherapy can exacerbate pre-existing urinary obstructive symptoms and should be avoided in patients with significant baseline lower urinary tract symptoms 5.

Treatment Selection Algorithm

Patient Age and Comorbidities

• Younger patients (<65 years) with minimal comorbidities: Either option appropriate; surgery may be preferred if patient prioritizes avoiding bowel toxicity and ADT side effects
• Older patients (65-75 years) with comorbidities: Radiation may be preferred to avoid surgical risks, though both remain standard options 2
• Life expectancy ≤5 years: Observation or watchful waiting recommended instead of definitive treatment 1

Disease Characteristics

• Favorable intermediate-risk (single intermediate-risk factor, low-volume Gleason 3+4): Radiation alone is acceptable; active surveillance may be offered to highly selected patients with understanding of increased metastasis risk 1, 6
• Unfavorable intermediate-risk (multiple intermediate-risk factors, Gleason 4+3, high PSA density): Radiation should include ADT; surgery with lymph node dissection if predicted nodal involvement ≥2% 1, 6

Patient Preference Priorities

• Prioritizes avoiding incontinence: Radiation therapy preferred
• Prioritizes avoiding bowel dysfunction: Radical prostatectomy preferred
• Prioritizes avoiding ADT side effects: Radical prostatectomy or brachytherapy monotherapy (if favorable features) 3, 4
• Wants single-event treatment: Radical prostatectomy preferred over 8-9 weeks of daily radiation

Non-Standard Options to Avoid

Do not recommend the following outside clinical trials for intermediate-risk disease with >10 year life expectancy:

• Cryosurgery (conditional recommendation only, Grade C evidence) 1
• HIFU or focal therapy (not standard care, lacking comparative outcome evidence) 1, 6
• Active surveillance as routine option (carries higher metastasis risk: 6.3 vs 2.4-3.0 per 1,000 person-years with definitive treatment) 6

Common Pitfalls

• Failing to add ADT to radiation in unfavorable intermediate-risk patients reduces cancer-specific survival benefit 1
• Using PSA density <0.15 ng/mL/g as sole criterion for active surveillance without considering other high-risk features 6
• Recommending brachytherapy to patients with baseline LUTS or large prostate volumes (>60cc) leads to severe urinary morbidity 5
• Not performing pelvic lymph node dissection during radical prostatectomy when predicted nodal involvement ≥2% misses important staging information 1