Choosing between the many variants of surgery or radiation, in case of prostate cancer, is a difficult decision. Often, doctors are biased towards the treatment they feel they’re more experienced in. Our discussion with Dr. David Samadi aims at making light of his stance as to why prostatectomy (removal of the prostate) is his preferred course of action. His website prostatecancer911.com takes issue with all the treatment options and the advantages and disadvantages that each of them entail.
Dr. Samadi, if a patient with prostate cancer chooses to get radiation treatment, what are the chances of him undergoing surgery, in case of remission?
Dr. Samadi: When we talk about prostate cancer, there are low risk prostate cancers and there are high risk prostate cancers. You’ve probably heard of the classification called Gleason score. We, urologists, use that to figure out exactly what type of prostate cancer we’re dealing with here. In my practice, I like to cure the patients by removing the prostate. There are many advantages for prostate removal. When you undergo a prostatectomy, you’re going to know exactly what type of prostate cancer you have. You will find out how much cancer you have in the prostate, because the needle biopsy is a random biopsy and doesn’t always give you the best picture. What’s important is, six weeks after prostate surgery, your PSA should go down to zero and should stay zero for the rest of your life. The advantages of the surgery is that the follow-up is very easy. If the cancer reoccurs after surgery, then I would use a low dose radiation as a back-up plan.
Some of the side effects of radiation is secondary chance of rectal cancer. Patients can get rectal bleeding and bladder bleeding. Side effects of radiation comes as time goes on. So, if I can avoid giving patients radiation and cure them with good quality of life, that’s what I would prefer. If you’re doing well, then I will just continue watching the PSA.
What if after radiation the PSA level doesn’t completely go to 0, but rather stays around 3.5? Will surgery still be an option?
Dr. Samadi: The PSA should go way down to 0.4 or 0.5. It’s a different measurement as what we use for surgery. If your PSA doesn’t go down or continues to go up, you need to schedule an appointment and do another biopsy.
I can perform surgery after radiation, but it’s a risky procedure which should be placed in the hands of a qualified surgeon. The answer is it’s possible, but it’s a complicated case and it should be done in Centers of Excellence, with qualified surgeons.
What about a patient that’s in his early 60’s and has underwent radiation or CyberKnife?
What type of prostate cancer are we talking about? A low risk or high risk? I think CyberKnife for individual patients is a good treatment, typically. If the patient is in his early 60’s, he’s still a very young patient, so especially for high-risk prostate cancer patients, I’d rather remove the prostate for many reasons. If the patient’s cancer reoccurs, which is sometimes the case with high-risk prostate cancer, after radiation or surgery, the choices are very limited after radiation. It’s very difficult to do surgery after radiation, but it’s very feasible and easy to give radiation after surgery.
Why can’t you perform surgery after radiation?
When you radiate the prostate like this, with CyberKnife or other modalities, the tissue turns into a cement. It gets very sticky to the rectum and when we go back to do the surgery, the anatomy has changed and it’s very difficult to do that operation. So the way I do it is first remove the prostate. You get tremendous amount of information as to what type of cancer, how much it is and get to that 0 level PSA. The continence and sexual function return in a short period, depending on the recovery. As long as their PSA is zero they are cured from this cancer.
If the cancer comes back after surgery, then you can give them radiation, so you haven’t burned any bridges and we have all the options open. The patient can go on for a few years. If the cancer comes back, our choices would be very limited and that’s why I don’t want to go through these options too quickly. A 60 year old man is a very young patient. We have people coming in in their 80’s and that’s because men are living longer now. We want to treat these patients in their 60s, remove the prostate and cure them indefinitely.