Treatment Options and Second Opinions

Deciding on a treatment option for their prostate cancer is one of the most stressful things a man can face.  Surgery?  Radiation?  Just watch it?

I am going to go out on a limb here.  Everybody knows that you should go for a second opinion when you have a serious illness, right?  Well, for men with prostate cancer I really don’t know if that is more help or will cause you more confusion.  This is because your second opinion will be biased!  There was a study that looked at which treatment urologists and radiation oncologists recommended to their prostate cancer patients.  93% of the urologists thought that surgery was better, but 72% of the radiation oncologists thought that radiation and surgery were equally effective.  In addition, most urologists thought that treatment was useless if your life expectancy was less than 10 years, whereas most radiation oncologists thought treatment could still be valuable.

All men diagnosed with prostate cancer will talk to a urologist first, and this will shape their thinking about what treatment to do.  Some will end up seeing a radiation oncologist for a second opinion.  However, there are more than just these two options to deal with prostate cancer, in fact there are at least 15, because of all the different flavors of surgery, radiation, ablation, and non-treatment.  Here is a partial list:

1. Radical prostatectomy (open surgery)
2. Robotic prostatectomy (laparoscopic surgery)
3. Permanent seed implant (also comes in different types of radioactive seeds)
4. High dose rate (HDR) brachytherapy temporary seed implant
5. 3D external beam radiation and older methods
6. IMRT external beam radiation
7. Cyberknife
8. Proton therapy external beam radiation
9. Cryotherapy
10. HIFU High intensity focused ultrasound ablation
11. Thermal ablation
12. Active surveillance (watchful waiting)
13. Passive surveillance (watchful waiting)
14. Hormonal therapy alone, continuous or intermittent, complete or partial blockage.
15. Alternative therapies, etc.

In addition, several of these treatments can be added together like combining different flavors of ice cream.  Brachytherapy is often combined with external beam radiation, hormonal therapy is often added to radiation therapy, external beam radiation often follows prostatectomy.

There are not a lot of studies that compare these treatments to each other.   In the right expert hands any of the surgery, radiation, or ablative techniques may work well for your cancer.

When you see a specialist for an opinion about your cancer he will typically recommend the treatment that he performs.  If you go to a Ford dealership, you know the salesman is not going to recommend that you check out the Camry’s across the street.  And that is why I think second opinions are not that helpful for prostate cancer, you are getting too many of the doctor’s biased opinions thrown into the discussion.  I have consulted with some men who have seen up to 20 different specialists trying to figure out what to do with their prostate cancer.  It can become overwhelming to weigh all the different opinions and determine which treatment and which doctor will cure the cancer quickly and easily and with the least side effects.

With most of these treatment options, it is also the doctor that is performing the treatment that makes a big difference.  For example, a well performed radioactive permanent seed implant will cure the cancer, and have a very small chance of impotence or urine leakage.  A bad seed implant can leave a hole in the rectum and require a colostomy bag. Expertise is everything when considering most of these treatments.  Any of the first 10 treatments I listed can have an excellent chance of curing early stage prostate cancer and producing low side effects, provided they are performed by an expert team.

I have found that there are three basic methods for deciding on particular treatment.  I’m sure there are more gut wrenching ways out there.

• The first method for choosing a treatment is to trust your urologist and follow the path that he recommends.  That is the simplest way and generally works out well.  Trust your doctor and go with the system.  This avoids the confusion of conflicting opinions.
• A second method is to talk with some other patients, family, and friends and find out who the local expert is and who has great results with some state-of-the-art treatment.  Go for a second opinion or two with your local expert(s).
• A third option is to take your time, read a lot of information on the internet and some books, and carefully consider what options are available around the state or the entire country.  Determine your preferred treatment and preferred expert.  Then consult with your expert of choice.  That is the most difficult and stressful, but may yield a better result.  You may end up Seeded in Seattle, HDR’d by Demanes, cut by Walsh, or even IMRT’d by Kelly.

This book is mostly about using IMRT treatment for prostate cancer, which is the treatment that I perform.  Hence, you know that I am biased toward that treatment.  In this chapter I give an overview of some of the competing treatments but you should look to other sources of information if you want detailed information about those options.

In summary:

• Don’t just consider the different treatment options, consider the doctor and team that does it.
• Doctors will recommend their own brand of treatment.
• Any of the curative treatment options can be successful if expertly performed.
• Once you decide on a treatment and go with it, don’t second guess yourself.  Everybody must follow their own path.