One of the blogs I subscribe to (but seldom take action on) is a stock analyst called gumshoe. Its not that his advice is necessarily better or worse than anyone else, it’s that I like his style of writing. Full disclosure: I have invested ~$1000 based on his advice and have never made any money….doctors are terrible investors! But we digress. The point is that unlike my usual blogs, it may take more time and words to cover a topic and I want to do that occasionally. So this one is on radiation therapy for prostate cancer.
Generally speaking, if you go to a baker you get bread. This is why urologists (at least those who don’t own and refer to their own radiation therapy units – be sure to read about this if you are seeing such a group) will usually tell patients about all options, but for a “standard patient” (example: 63 year old man with Gleason 7 prostate cancer and otherwise healthy) will most often tell the man they recommend surgery, while the same man would be told by a radiation oncologist that they recommend radiation therapy. Why is this dichotomy (which has been replicated over and over so strong?
Consider this: If you are a radiation oncologist, you have about an 85% chance of curing a “standard patient” with prostate cancer – almost identical to the cure rate experienced by a urologic surgeon. If you don’t believe this, go plug some numbers into the Kattan Nomogram system and look at disease free treatment results. On the other hand, consider what happens to the unfortunate patients who either have a complication from radiation or are not cured: they go to see a urologist. This means the urologist (who sees virtually all of the patients at initial diagnosis – after all, they are the ones who do the biopsies) sees a large number of his/her own patients and 85% are cured. This same physician really sees ONLY the failures and complications of the patients who choose radiation therapy. The 85% of patients who are doing well may never return to see the urologist.
What about the radiation oncologist? He/she has the same 85% success rate, but guess who is referred? The patient who had surgery 3 years ago and now has a rising PSA. Can this patient be salvaged by radiation therapy? (The answer is yes, at least some of the time, and there are nomograms to predict success rates)
And what about your friend or brother-in-law who had either of the techniques? Of course they have an excellent chance of being very satisfied with their choice. This is because for the most part, the side effects and outcomes of patients who choose either form of treatment is pretty good. If you want proof of this, I suggest you get your hands on an excellent article that I very often hand patients who come to me as a “neutral advisor” to help them make a decision. Of course sitting down with a physician you trust and who has had a lot of experience may help you lean one way or another in decision making, and there are always individual preferences that might make one choice better than another. For example, one 65 year old “standard patient” might have little interest in sexual activity and place a high premium on continence, while another might feel that he simply “wants to get this over with as quickly as possible” etc.
In the end, there may truly be no right or wrong choice in treating early (but potentially lethal) prostate cancer. One thing is sure at this point – there will never be a prospective randomized trial of surgery versus radiation therapy because of the built in biases I hope you now better understand.
If you like these longer blogs, please tell your friends to subscribe and join in the commentary – go ahead and make suggestions on topics you would like me to discuss. Thanks for reading this and have a great weekend – I’m off to the slopes for some Colorado powder!