The treatment of prostatic cancer.

In this issue of the International Journal of Radiation Oncology, Biology and Physics, Hanks and Dunlap have supported a significant finding in the treatment of prostatic cancer.4 The significance rests in their finding that patients treated with radical radiation therapy for carcinoma of the prostate incur a significantly lower financial cost than patients treated by radical surgery or lymph node dissection and I”’ implant. Although cost containment is an important factor, the result of treatment vis a vis, recurrence-free survival, overall survival, and complications are major factors. Insofar as survival is concerned, the results of radiation for prostatic cancer are at least as good as surgery.3 The randomized study from the VA Hospital reports an advantage for the surgical patients. However, the statistical conduct of the study was flawed with transfer of patients after randomization from one category to another and the elimination of patients from analysis.9 Some discrepancies in the adequacy of treatment which affected the results were also possible. In any event, the Stanford results for a series of patients similar in Stage to the VA study demonstrated equivalent results to the surgical VA patients.’ Bagshaw reported an overall survival greater than 80% at 10 years in TITz NoMo patients. Perez has reported a 5-year tumor-free survival of 100% of Stage A2.’ Perhaps of greater interest are the results of radiation treatment, Stage Bl (the solitary nodule) treated by Bagshaw. Forty patients in this category had a 5-year actuarial overall survival of 90%, lo-year overall survival of 83% and a 15 year survival of 62%. The best surgical results are those of Walsh and Jewett who reported a 15-year survival of 5 1% in Bl solitary nodule patients.’ Elder et al. reported on radical surgical treatment for Stage A2 lesions in 25 patients whose median follow-up is 5 years and whose median Gleason grade is 4.2 One patient recurred at 5.5 years and is alive with disease and one patient died at 6 years, due to disease. Two patients are not accounted for in the follow-up. At the time of surgery, 12% of the patients were found to have extension of the disease outside the prostate. Thus, in this surgical series of obviously selected patient by stage and pathology, there seems to be no difference in survival compared to the radiation series of Bagshaw’s with more advanced disease. The effectiveness in controlling prostate cancer of less radical procedures such as those recommended by Walsh can also be questioned.5 Even when lesions are as small as Stage A2 and in institutions where surgical experience is vast, the complication rate seems inordinately high for radical prostatectomy. In a series of patients followed from 9 months to more than 10 years, Elder et al. reported 100% impotence, 16% incontinence, 20% urethral structures, and 12% perineal drainage; one patient required an operative procedure for correction of a vesico-cutaneous fistula. Even more serious is that greater numbers of complications can be expected in the hands of less experienced surgeons. It is perhaps too hopeful to expect that physicians can put aside their biases in the treatment of disease. To most radiation oncologists external beam radiation is the treatment of choice for prostate cancer. This concept is based on the similarity in survival for both treatments and the increased incidence of complications in surgically treated patients. The report by Hanks and Dunlap adds another practical logic to the choice of external beam radiation therapy that provides for a lesser cost for an equally effective treatment with fewer complications. One can only hope that this logic will prevail.