Radiation therapy and surgery are both used successfully to treat localized prostate cancer. The decision between surgery and radiation often is based on balancing the benefits with the possible side effects of each treatment option, including its effects on sexual activity, bladder control, and other aspects of your quality of life.

• If one of your biggest concerns is that prostate cancer might come back after treatment, you may want to have a radical prostatectomy. Your doctor will be able to evaluate your cancer more accurately by looking at it during surgery and taking tissue samples that can be tested. This information will help your doctor decide how likely it is that your cancer will return.
• If the possibility of having bladder problems and erection problems is a major concern, you may want to consider radiation therapy because these problems are less common with radiation than with surgery.

Treatment choices are different for prostate cancer that is more advanced (has grown or spread outside the prostate gland). For more information, see the topic Prostate Cancer, Advanced or Metastatic.

What is localized prostate cancer?

Prostate cancer is the abnormal growth of cells in the tissues of the prostate gland. Localized prostate cancer is cancer than has not spread beyond the prostate gland.

Prostate cancer is the most common cancer in men. Most men who get it are older than 65. If your father, brother, or son has had prostate cancer, you have a higher-than-average risk for developing the disease.¹

Unlike many other cancers, prostate cancer is usually slow-growing. Most men will die with prostate cancer but not of prostate cancer.²

African-American men have higher rates of both prostate cancer and deaths caused by prostate cancer.¹

Early prostate cancer usually does not cause symptoms. When prostate cancer is diagnosed early, before it has spread outside the prostate gland, it may be cured with radiation or surgery to remove the prostate. As prostate cancer grows or spreads, symptoms may develop, including urinary problems (such as blood in the urine) and bone pain.

Prostate cancer that has grown through the prostate is called advanced prostate cancer, and treatment choices are different for that stage of cancer. For more information, see the topic Prostate Cancer, Advanced or Metastatic.

What are the treatment choices for localized prostate cancer?

Localized prostate cancer may be treated with radiation therapy, surgery, or drugs. You may also choose to watch and wait.

• Watchful waiting, also called surveillance or observation, means you are being monitored closely by your doctor, but you are not receiving active treatment such as surgery or radiation therapy as long as symptoms do not occur or get worse.
• Radical prostatectomy is an operation to remove the entire prostate as well as any nearby tissue that may contain cancer. It may be done as open surgery, by making a large incision, or as laparoscopic surgery, by making several very small incisions in the belly and using a tiny camera and special instruments to remove the prostate. Sometimes lymph nodes in the area also are removed so they can be checked for signs of cancer.
• Radiation therapy uses X-rays and other types of radiation to kill the cancer cells. This may be done with:
  • External-beam radiation, in which a machine aims high-energy rays at the cancer.
  • Brachytherapy, in which tiny pellets of radioactive material are injected directly into or near the cancer.
  • A combination of external radiation and brachytherapy.

If you are young and in good health or if your prostate cancer is fast-growing (higher-grade), your doctor probably will recommend surgery and/or radiation therapy to remove or destroy the cancer. Even though prostate cancer is usually slow-growing, it may eventually spread and cause symptoms and may threaten your life.³

Age is not a reason to not have surgery or other treatment. But if you are around 70 or older, it is important to consider other medical conditions you may have, such as heart disease, as you make your treatment decisions.

When is prostatectomy used to treat prostate cancer?

Radical prostatectomy is most often recommended when a man is in good general health and has a life expectancy of at least another 10 years. In addition, there should be an expectation that the cancer can be entirely removed. If testing suggests that the cancer may have spread outside the prostate, or if you have other health problems that may add to the risks of major surgery, prostatectomy usually is not recommended.

Radical prostatectomy generally is effective in treating cancer that has not spread beyond the prostate gland. In follow-up PSA tests done in the years after prostatectomy, most men show no evidence of cancer.³

Laparoscopic radical prostatectomy sometimes is used instead of open prostatectomy, which requires a larger cut in the belly.

A few surgeons do robotic-assisted laparoscopic radical prostatectomy. The surgeon controls the arms that hold the surgery tools and laparoscope. There are reports that it helps the surgeon see very well and work with less error.

When is radiation therapy used to treat prostate cancer?

Radiation therapy is most effective in treating cancers that have not spread outside the prostate. It may be used alone or combined with hormonal treatment. Rarely, it is used with surgery. Radiation therapy works as well as surgery for the treatment of early-stage localized prostate cancer.⁴

What are the risks of prostatectomy?

A radical prostatectomy is a surgical procedure and carries all the risks of any major surgery, including heart attack, pulmonary embolism, bleeding, infection, and reactions to anesthesia or medications.

In addition, prostatectomy may cause bladder problems and erection problems. Increasingly, this surgery is done in a way that helps preserve the nerves that control erections. Most men who have nerve-sparing prostatectomies will regain the ability to have an erection within 4 to 6 months after surgery.³ It takes some men up to 2 years to regain full function.

More than 30% of men who have a radical prostatectomy develop bladder problems, ranging from a need to wear pads to occasional dribbling during stressful activities. Between 2% and 5% still have severe problems 6 months after having a prostatectomy. After 1 year, 92% no longer have problems.^{5, 6, 3}

Other possible complications include scar tissue that may narrow the outlet to your bladder and injury to the rectum or the ureters.

Evidence shows that the side effects of prostate surgery are lessened when the prostatectomy is done by a surgeon who is very experienced in this particular operation.⁷

What are the risks of radiation therapy?

About half of men who have external radiation develop erection problems within 5 years of treatment.³ Erection problems following radiation therapy increase over time.⁸

Most other side effects generally go away when treatment is finished. In some cases, however, they may become chronic. Other side effects include:⁴

• An irritated rectum and an urgent need to pass a stool. This is called proctitis.
• An inflamed bladder and urination problems. This is called cystitis.
• An inflamed intestine and diarrhea. This is called enteritis.
• Being unable to have an erection. This is called impotence.
• Being unable to control urination. This is called incontinence.
• Painful urination. This is called dysuria.

Follow-up treatment

Any type of treatment for prostate cancer will need to be followed by regular checkups. Your follow-up care probably will include physical exams, prostate-specific antigen (PSA) tests to monitor PSA levels and measure the speed of any changes, digital rectal exams, and biopsies as needed to examine suspicious tissue.

For more information, see the topic Prostate Cancer.

This discussion focuses your choice between:

• Having radiation therapy.
• Having a radical prostatectomy.

The decision about whether to have surgery or radiation treatment takes into account your personal feelings and the medical facts.

Deciding about treatment

Type of treatment	Reasons to choose	Reasons to not choose
Radiation therapy	External beam radiation does not require surgery or anesthesia and is an outpatient procedure. (Brachytherapy requires anesthesia.) Incontinence and erection problems are less likely to occur as side effects of radiation therapy than they are after radical prostatectomy (without nerve-sparing surgery). These problems do not happen right after radiation. Radiation therapy can be as effective as prostatectomy in controlling early prostate cancer. It is low-risk compared with major surgery. Are there other reasons you might want to choose radiation therapy?	Treatment usually continues for 4 to 6 weeks. Because no cancer cells are removed, a pathologist cannot tell the grade and stage of the cancer. It may make recurring cancer hard to detect. Long-term side effects may include erection problems and rectal irritation. Are there other reasons you might not want to choose radiation therapy?
Prostatectomy	Surgery to remove the prostate may remove the cancer completely. Removing the prostate often improves long-term survival in younger men who have rapidly growing cancer. Because the cancer tissue and nearby lymph nodes are taken out and looked at under a microscope, doctors can predict whether the cancer is likely to spread or come back. Removing the prostate makes it easier to detect future rises in PSA levels and to treat recurring cancer. Are there other reasons you might want to choose prostatectomy?	Side effects include urinary incontinence and erection problems. These may be temporary. Prostatectomy is major surgery, which carries the risk of complications and death. It is not possible to determine before surgery whether the cancer is confined to the prostate. Even after the prostate is removed, cancer cells may remain in the area near the prostate. Are there other reasons you might not want to choose prostatectomy?

These personal stories may help you make your decision.

Use this worksheet to help you make your decision. After completing it, you should have a better idea of how you feel about choosing between prostatectomy or radiation therapy. Discuss the worksheet with your doctor.

Circle the answer that best applies to you.

My heart condition may mean that I should not have surgery.	Yes	No	NA*
It is important to me that I can continue to be sexually active.	Yes	No	Unsure
Radiation therapy will fit into my busy life, and I can continue to work without needing to take a lot of days off.	Yes	No	NA
My doctor says my cancer will probably not spread outside of my prostate in the next 10 to 15 years.	Yes	No	Unsure
I may be too old to have major surgery.	Yes	No	Unsure
I'm concerned that if I have radiation therapy, I may never regain my ability to have an erection.	Yes	No	NA
Surgery might keep me from my normal activities for too long a time.	Yes	No	Unsure
I am willing to put up with urinary leakage if surgery will mean the cancer is gone and won't come back.	Yes	No	Unsure
I expect to live longer than 10 more years.	Yes	No	Unsure

*NA = Not applicable

Use the following space to list any other important concerns you have about this decision.

What is your overall impression?

Your answers in the above worksheet are meant to give you a general idea of where you stand on this decision. You may have one overriding reason to have or not have a prostatectomy or radiation therapy.

Check the box below that represents your overall impression about your decision.

Leaning toward prostatectomy

Leaning toward radiation therapy

Citations

1. American Cancer Society (2006). Cancer Facts and Figures 2006, pp. 1–56. Atlanta: American Cancer Society. Available online: http://www.cancer.org/docroot/STT/stt_0.asp.

2. Frankel S, et al. (2003). Screening for prostate cancer. Lancet, 361(9363): 1122–1128.

3. Ohori J, Scardino PT (2002). Localized prostate cancer. Current Problems in Surgery, 39(9): 837–957.

4. National Cancer Institute (2006): Prostate Cancer (PDQ): Treatment-Health Professional Version. Available online: http://www.nci.nih.gov/cancertopics/pdq/treatment/prostate/HealthProfessional.

5. Wilt T (2004). Prostate cancer (non-metastatic). Clinical Evidence (11): 1169–1185.

6. Jani AB, Hellman S (2003). Early prostate cancer: Clinical decision-making. Lancet, 361(9362): 1045–1053.

7. Kantoff PW (2002). Prostate cancer. In DC Dale, DD Federman, eds., Scientific American Medicine, section 12, chap. 9. New York: WebMD.

8. D'Amico AV, et al. (2002). Radiation therapy for prostate cancer. In PC Walsh et al., eds., Campbell's Urology, 8th ed., vol. 4, pp. 3147–3170. Philadelphia: W.B. Saunders.

Author	Kathe Gallagher, MSW
Author	Ralph Poore
Editor	Kathleen M. Ariss, MS
Editor	Renée Spengler, RN, BSN
Associate Editor	Michele Cronen
Associate Editor	Terrina Vail
Primary Medical Reviewer	Martin Gabica, MD - Family Medicine
Primary Medical Reviewer	Kathleen Romito, MD - Family Medicine
Specialist Medical Reviewer	Christopher G. Wood, MD, FACS - Urology/Oncology
Last Updated	July 24, 2006