Just Cut it Out!

Radical prostatectomy is one of the most popular treatments for prostate cancer. Surgery is broadcasted all over the media as the gold standard of prostate cancer treatment. But does surgery really live up to the hype?

This episode of PROSTATE PROS covers the “Just Cut it Out!” mentality, the surgery versus radiation debate, and the side effects of the radical prostatectomy.

Dr. Scholz: Welcome to the PROSTATE PROS podcast. We’re guiding you to treatment success and avoiding prostate cancer pitfalls. I’m your host, Dr. Mark Scholz, here with my co-host Liz Graves.

Liz: Today on PROSTATE PROS, we’re addressing the desire to just cut the cancer out.

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Dr. Scholz: Why is surgery so popular for prostate cancer? The prostate cancer landscape is unusual because prostate cancer is the only cancer where surgeons are in the driver's seat. ALl the other cancers: lung cancer, colon cancer, brain cancers, all these other types of cancers are supervised by cancer experts called medical oncologists. Why is prostate cancer such a backwards industry? 40, 50 years ago, surgeons were running all the cancers, but as the world became more complex and technology progressed, one by one the medical oncologists started taking over the management and only referring speciality cases for surgery. The prostate cancer world is the only exception to this procedure and to this day, urologists, who are surgeons are in the driver’s seat and controlling the prostate cancer decision making process.

Liz: Yes, we’ve talked about that before, how urologists have this leadership in the prostate cancer world and so a lot of men get surgery because that’s the only advice they are hearing.

Dr. Scholz: It’s not really apparent to patients when they’re thrown into a diagnosis, the urologist is the one that did the biopsy and he’s the one sharing the bad news that prostate cancer has been diagnosed. So it seems very natural and a smooth transition to assume he will continue in the leadership position. It’s obvious why surgery is so popular. Is there any problem with that? I mean, surgery seem like a natural solution for just about any type of cancer. The problem is the location of the prostate is in such a sensitive area in the body and it’s nearly impossible for the surgeon to finesse the prostate out without causing some collateral damage to urinary or sexual function. Historically, that’s what you were stuck with. The other options like radiation were very antiquated, caused a lot of side effects, had poor cure rates. But as technology has advanced over the last 15 years, radiation therapy, in my professional opinion, has become much better than surgery. I suppose we shouldn’t be surprised that the urologists have been a little slow to adopt this new policy because it involved referring their patients to a specialist, and they, therefore lose the opportunity to practice their own craft.

Liz: Yeah, to someone who isn’t in the medical profession, it makes sense to just cut the cancer out. It seems like a one time procedure: you go in, you get it done, and it’s gone.

Dr. Scholz: Yeah, and about one third of the men that have operations have a fairly good result. They’ll be able to get erections, they won’t be leaking urine, but those sorts of odds are terrible. Imagine that, two-thirds of men either have the cancer come back or they’re having a terrible problem with urinary leakage or they’ve lost their ability to get an erection. It’s not a satisfying outcome at all. I’m glad we’re having this conversation and raising awareness about the fact that other newer, better options such as many of the radiation therapy options are really far superior. Assuming of course, you go to a center of excellence where they have state of the art equipment.

Liz: Ok, so surgery hypothetically removes the cancer. But then you have to deal with all these problems that are incontinence, impotence and you don’t even know if the procedure has removed all the cancer.

Dr. Scholz: That’s true, Liz. The problem is that the prostate is so close to the bladder and rectum they’re not able to cut a wide margin around the prostate like you can do with a colon cancer or a breast cancer. The problem of leaving cancer behind is really a frequent issue. Now the surgeons talk about, well we can just give some radiation therapy to kind of mop up afterwards but think about it, why wouldn’t you just do the radiation to start with and skip the surgery step all together?

Liz: That’s something I read a lot about on comments on our instagram, is that men hear that you can’t have surgery after radiation.

Dr. Scholz: Yeah, that is probably the most common argument I hear surgeons giving to patients to encourage them to proceed with surgery rather than radiation. The problem with that is two things. One is that the older time radiation, the stuff that was like fifteen years ago had really poor cure rates and so men were faced with having to fix a messed up, partial treatment that was ineffective and doing surgery at that juncture was very difficult. So it was a fair argument fifteen years ago when radiation technology had low cure rates. Modern radiation has very high cure rates. Especially the seed implant radiation, so the issue of having to go back and do a mop up procedure is really quite rare after modern radiation. The other point is that actually it is possible to treat men, the rare cases that cancer stays viable in the gland after radiation. It’s not like you’re out at sea without a paddle. There are surgical experts that can operate on people in this situation, but surgery usually isn’t the best choice. There’s a lot of other secondary options such as freezing with cryotherapy or High Intensity Focused Ultrasound, called HIFU. And these different therapies work quite well to salvage a situation, the rare cases when the radiation doesn’t get it all.

Liz: So between surgery and radiation, if you have the option of both of them at the same stage in your treatment why are men still choosing surgery over radiation despite cure rates being better with radiation and side effects being less?

Dr. Scholz: I think it’s because the surgeons have the first shot at selling their particular treatment. They did the original biopsy, they have an established relationship with these patients. And surgeons, inevitably are very optimistic about the results of surgery. It’s really their whole life, their identity is wrapped up in doing surgery. When patients don’t have the facts and information necessary to make a balanced decision and they’re talking to a surgery that’s very, very pro about doing surgery, you can see how a lot of people sort of end up in the operating suite.

Liz: Ok, but this is something that’s all over the media. Like, everybody knows that surgery is an option for prostate cancer. You hear Dr. Drew had successful surgery, Ben Stiller had surgery.

Dr. Scholz: Absolutely, it is very popular. It’s a big industry, a multi-billion dollar industry. The universities are heavily invested in these robot machines. And of course the men that undergo surgery aren’t talking about the fact that they’re wearing diapers or they’re ejactulating urine during sex, or that they’re impotent. These are extremely embarrassing, very private things and it isn’t widely known how bad the results are. Men simply just don’t want to talk about it. But, let’s go back to the idea of a very powerful financial industry, the multi-billion dollar prostate industry. There are places around Southern California, where I work, that are advertising for prostate surgery, advertising for prostate radiation. There are millions of dollars spent on marketing. There is a great impetus to encourage patients to come get treatment with these different centers that are trying to make a large profit and become successful and to basically have large numbers of patients getting treatment at their center, so it’s very natural with these sort of incentives that these places are going to kind of soft peddle the potential side effects because they know patients can go to another place right down the street. And I see a lot of mis-representation of the risks of surgery, occasionally radiation, but much more frequently with surgery. Many optimistic predictions which are really very inaccurate.

Liz: One would think that celebrities have a lot of access to this information, have more options than the normal person, but they’re still getting surgery?

Dr. Scholz: What happens is that obviously people go to prestigious centers and it’s only been ten or fifteen years ago that surgery was the best choice. So these centers have built up a lot of momentum operating on a lot of different people and they are slow to make a transition to giving radiation rather than surgery. So you have these experts that, supposed prostate cancer experts that are very excited about what surgery has always been in the past and aren’t very comfortable with the fact that maybe something is a better option. And this is slowly changing, the awareness is getting out there, but the surgical industry for prostate cancer is very powerful, it has a lot of momentum from the past, and it’s going to take a while before people start to realize that these other options, particularly the radiation options, are a much better choice.

Liz: Ralph Blum, your co-author of Invasion of the Prostate Snatchers, referred to robot surgery as high tech glam. He wrote a blog post about this. It was about how, kind of, there’s this opinion about robotic surgery being the next big thing, even outlasting the advances you’ve talked about in radiation. And one of my favorite quotes from it is: “So, yes, the robots have landed. And whatever else is still uncertain, one thing is for sure—they employ first-rate Madison Avenue publicists.”

Dr. Scholz: Back in 2004, radioactive seed implants were the most commonly used treatment for prostate cancer. And then, the Da Vinci Robot came on the market and the surgeons thought, wow we’ve finally rescued our favorite mode of therapy. And Da Vinci therapy became the way to go from a surgical perspective. What are the advantages? Well, there is a smaller scar and people go home from the hospital more quickly, but sadly they showed no improvement in potency rates or incontinence rates. So it’s more of a superficial advantage than a true leap forward. Now, it took ten years for all that data to come in and realize that the Da Vinci surgery is only a small, incremental improvement over older surgery. But the studies that have been done to compare standard, old fashion surgery with the Da Vinci are clear cut. Results are in now. And those results show only modest benefits over the traditional approach.

Liz: So this is robot assisted surgery we are talking about. Could you explain a little bit about how that works?

Dr. Scholz: Yeah, so one of the tricky things about operating on a prostate is that the gland is way down in the pelvis, surrounded by the bony pelvis and surgeons with small hands actually had a real advantage in operating on the prostate. The Da Vinci, is, they use little pincher devices to reach down into the pelvis so the surgeon doesn’t even have to be next to the patient. He can be at a remote site and these little robotic arms, under his control, can reach down into the pelvis and sew and cut and remove the prostate. This is why they can operate through much smaller incisions. In the old days, people would have a zipper type incision that would go all the way from the lower part of the breast bone down to the public bone and that’s why the healing time was much longer with older surgery. Robotic surgery has lead to quicker healing times. But sadly, as I stated before, there is no difference in the rate of preserving erectile function or maintaining urinary control.

Liz: Is there a difference in maintaining longevity of life with robotic surgery?

Dr. Scholz: Well, that speaks to the question of course of cure rates. And that has also been shown to be identical. The cure rates with old fashion surgery and with the new robotic surgery is the same.

Liz: I’d imagine that the doctor performing the surgery has something to do with cure rates and side effects as well.

Dr. Scholz: That is an established fact. And as we go through and talk about these different options like surgery and radiation, cure rates, side effects, and whatnot, I’m assuming that the patient has done due-diligence and has exercised a lot of care in the selection of the doctor that’s going to do the procedure because skill levels are paramount. But when we’re talking about comparing surgery with radiation, I’m talking about comparing the results from the best surgeons with the results from the best radiation therapists. And when you make that comparison, these results from surgery are far inferior to what modern radiation therapists can accomplish.

Liz: So you still have patients that are convinced that just getting the cancer out is the best way to go. How do you address those thoughts?

Dr. Scholz: I try to point out how much other forms of technology have changed over the last ten to twenty years. I pull out my iPhone and I show that a computer that I can hold in my hand that fifteen years ago would have taken up my whole desktop. The same type of progress has been made in radiation therapy. You can see why surgery would be kind of stuck in the past: surgery is just surgery. But the very refined pencil beams, the computerized targeting and all the different planning that is done with a modern radiation therapy machine has become so much more effective, precise, and has improved the delivery of high doses of radiation to exactly where you want it to go in such a fashion that the results are clearly superior.

Liz: So if that’s the case, why don’t the radiation oncologists argue this more clearly?

Dr. Scholz: So one of the problems we see in this industry is that the radiation oncologists are getting all their referrals from the surgeons. There’s a few exceptions, for example, many of the proton centers are advertising on the radio and they are getting their patients directly from the public, they are not referred from another urologist. And in those places, they market their treatment very aggressively and they will try to go toe-to-toe with the surgeons in explaining why their treatment is as good, or better, than surgery. But most radiation therapists have close relationships with urologists because radiation therapists don’t do biopsies and radiation therapists don’t diagnose prostate cancer the way urologists do. So the urologists control of the flow of referrals and if they send a patient to a radiation therapist who says a lot of negative things about surgery, to get a second opinion for example, they’re not going to refer to that doctor anymore. They’ll find another quote wiser radiation therapist who understands the way the industry works and who will say positive things about surgery. Well why would they do that? They’d never get any business at all, you’d think. Well the reason is that surgeons recognize that in more elderly men, men that are over 70 to 75, surgery is really not a prudent thing to do on anyone, let alone a prostate cancer patient, and so they’ll let the radiation therapists keep those patients and that’s where the radiation therapists get their patients, in the older population. The savvy business radiation therapists are referring the younger men back to the surgeon with encouragement to the patient saying really surgery is in your best interest, even though they know that the technology they have is better.

Liz: Dr. Scholz’s earlier you said only one-third of men are happy with their surgeries? Is that true?

Dr. Scholz: So this question of satisfaction rates after radical prostatectomy has been carefully researched at large universities. And the surgeons that’s able to get a good outcome on three levels that means, preserve sexual function, not leaking urine, and remaining in remission, or being cured. That has been termed the treatment trifecta. And trifecta rates, where all three of those things come out favorable have been reported from a number of large centers where they’re very good at doing surgery. And if you look at trifecta rates in young men, say 50 to 55, you’re looking at 50 to 60 percent satisfaction rates in these younger guys. But the average prostate cancer patient is 65 when he’s diagnosed and the chances of achieving satisfaction in all three of those areas is only around 30 to 35 percent. These numbers are really sad. It makes you wonder how can the doctors live with these kinds of numbers? And historically men didn’t have any other option. We were trying to save a life, we were afraid the cancer would spread and kill people, so paying a price in quality of life seemed to be totally acceptable. Now of course we realize there are better treatment options and maybe in another podcast we’ll talk about the newer thinking is that many of these men don’t need any treatment at all. They can pursue a type of therapy called active surveillance.

Liz: I hear that all the time, that once you get your prostate removed you don’t have to monitor it, you’re done. Men believe they’ll be done with monitoring. Regardless of whichever treatment men choose, they will need to continue ongoing surveillance for years after their treatment.

Dr. Scholz: As we are leaving this topic for today, let’s be reminded that many men mistakenly believe that after the surgery that the problem is gone. We should all be aware that there is a possibility that the cancer will be left behind. Men are going to need ongoing monitoring after the operation, checking their PSA every three to six months for up to five years afterwards to make sure that the cancer is not coming back. So surgery is not the final word. The cure rates with surgery are lower than modern seed implant radiation. So, if patients are looking for the holy grail of getting cured, they really should go a different direction than surgery. The fact that men need ongoing surveillance for years after treatment is really actually a good opportunity for men’s health in general. Men don’t like to go to the doctor, but when they’ve had a history of prostate cancer, they’re pretty good at showing up. And this is the time where men can have their blood pressure checked, their cholesterol, be screened for colon cancer, have appropriate vaccinations administered, and the like. Men’s health is greatly neglected and sometimes what seems to be a negative thing can actually work in men’s favor.

Liz: If you have additional questions to ask about this topic you can send them to [email protected]. Quick reminder, if you haven’t registered for the PCRI conference in September, the deadline is September first, visit pcri.org We’re excited for next time, so don’t forget to subscribe on Apple podcasts or Google Play.