Differentiating Among Surgery, RT, and Active Surveillance in Localized Prostate Cancer

Bertram Yuh, MD

Surgery and radiation therapy are standard treatment options for localized prostate cancer, but are not comparative to one another, explains Bertram Yuh, MD.

“The reason for that is there is not a lot of good literature looking at these 2 treatments together—looking at these side-by-side,” said Yuh, an assistant clinical professor of Urologic Oncology and a urologic oncology surgeon at City of Hope.

Yuh shed light on outcomes with surgery and radiation treatment in localized prostate cancer during the 2016 OncLive State of the Science Summit on GU Cancer.

OncLive: What are the standard treatments for localized prostate cancer?

Do the outcomes differ between surgery and radiation therapy?

In an interview with OncLive, Yuh discussed the selection of surgery or radiation therapy in patients with localized disease, as well as the potential for using active surveillance with these patients.Yuh: The most standard treatments for local prostate cancer include surgical treatment to remove the prostate, as well as radiation treatments to essentially burn areas in the prostate. There are also additional therapies that have been looked at, but a lot of the data are not as robust, such as focal therapies like cryotherapy or high-intensity focused ultrasound. Generally though, in the present day and age, the mainstays of treatment tend to be surgery and radiation.I discussed a lot about the outcomes of prostate cancer management and surgery and in radiation, but I mostly discussed the treatment outcomes separately. [Comparing the 2 treatments] is a type of study that is very difficult to run, in that it’s hard to tell a patient, “We are going to do an operation for you, but you might get radiation instead, and vice versa, all right?”

Because of that, what we tend to see is that patients who undergo surgery are a little different population than patients who undergo radiation treatments. Because they’re going into the operation or radiation treatment a little bit differently, it’s really hard to compare them side-by-side. We know that both treatments can be very effective. They both can play a major role in the management of patients.

As an oncologist, how do you decide which treatment a patient is better suited for? What are some of the things that you look for?

There may be certain patients who would be better served by one treatment or another, depending on their individual biases. Some patients may be very against having an operation, for instance. Or, some patients may be very scared of radiation therapy. Therefore, we want to be sensitive to that.One of the very important things is to try our best to set aside biases. This is a very big challenge. A lot of clinicians are going to have certain treatments that they feel may be better for one reason or another. When talking to patients, you really need to try to present the options to them as objectively as possible.

[You need to discuss] the effects of an operation, the effects of radiation therapy, and what to expect when they go through 1 of these different treatments.

What are some of the difficulties that you have to overcome in comparing the 2 groups and getting an accurate distinction?

How will treatment for prostate cancer evolve in the next 5 to 10 years?

You also discussed active surveillance at this meeting. When using this approach, how do you know when a patient may need to start active treatment?

You want to paint that picture for patients and explain to them, “This is what we would expect to see after 1 year, and this is what we would expect to see after 3 or 5 years.” They get a better idea of how to make a decision about these various treatments.Most of the comparison that we look at is not necessarily a straight side-by-side comparison. It’s more of an observational analysis in that we’re looking at patients who are undergoing surgery. We’re looking at patients who are undergoing radiation treatments. We are looking at how they do years down the line after their treatments. There are some studies that have been performed, and looking at retrospective data suggesting that surgery has some benefits in certain patients. Radiation therapy may have benefits in certain patients, but I don’t think that there’s a catchall treatment for all patients.I see that the realm of treatment for prostate cancer is going to change, as we know it. We will see that more advanced, higher-stage cancers are going to come into view for us clinicians. With that is going to come more challenges. We know that the more aggressive the disease, the less effective our treatments are, unfortunately. To be able to address that, to be able to continue to deliver the optimal care, we need to continue to search for novel treatments, and combinations of treatments that will really improve upon what is our current paradigm.Part of this comes with upfront counseling with patients. Because when we talk to patients about active surveillance, we tell them that it is a surveillance strategy, so we’re keeping an eye on things. It is active, so it involves them not just sitting around, they’re going to come in and be evaluated. They’re going to get some tests along the way. They understand that, over time, there’s a pretty good chance that they’ll potentially need some treatments. A lot of patients are able to rationalize the fact that if they don’t necessarily require a treatment immediately, they may be able to live and carry on their life just as they normally would without significant changes.

Therefore, even if you tell a patient, “We’re going to give you treatment, but we’re going to give that treatment to you in 5 years,” a lot of patients would take that. Setting the stage for that is important.

When it comes to understanding the cancer itself and we are watching it carefully—not that we will be able to detect every cancer that changes—but with a combination of various tools, such as blood or genomic tests that are disposable, we will get a pretty good sense of what the cancer is doing over time. With that knowledge in hand, we can understand if this cancer is actually looking more dangerous. Is it something we really need to then get addressed at this time point?

When we have objective information that we gather from these various tools, when we talk with patients about what happens if we keep watching it versus what happens if we stop watching it, a lot of times we can arrive on the same page with patients in terms of making a decision about treatment or not.