Prostate Cancer: Men need to be given more control over their treatment options

As a Prostate Cancer Surgeon I was somewhat disappointed in your article ‘The good doctors guide: Meet the best urologists in Britain and learn the pioneering treatments used in the battle against prostate cancer’. As an experienced robotic surgeon I was surprised to see that the piece only highlights higher volume robotic cancer surgeons and developments in this one particular treatment modality and has missed the significant opportunity to champion choice and make patients aware of the range of treatment options available. For example, data has consistently demonstrated that prostate brachytherapy, the implantation of tiny radioactive seeds into the prostate as a day case, not only has equivalent cure rates but better side effect profiles than prostatectomy whether robotic or other.
Whilst it should be noted that radical prostatectomy has been the default treatment for prostate cancer, the shift from open surgery to robotics has had minimal impact on the overall patient outcome. A recent randomised landmark prostate cancer study[1] (the ProtecT Study group) revealed that radical prostatectomy has the greatest impairment of sexual function and urinary continence when compared with active monitoring and radical radiotherapy with hormones. In addition, many radical prostatectomy patients go on to have further treatments at a later stage including ~25% requiring radiotherapy. Articles such as this, not only unfairly bias men and their families when they are at their most vulnerable, but it also highlights just how few patients are being offered alternative treatments. It’s important that men feel confident and informed to demand for better information and discuss all their treatment options
My Institution, the Royal Surrey County Hospital, Guildford, is one of the leading robotic surgery centres in the UK but it annually carries out more low dose rate brachytherapy (LDR-B) procedures, not only because of equal curative outcomes but also for its better quality of life results. The hospital has data on over 3500 patients, including publishing the latest data on LDR brachytherapy in high risk and younger patients.
In addition to offering significantly improved outcomes regarding both sexual function and incontinence, according to data from the Prostate Cancer Results Study Group, LDR-B treatment achieves >90% of patient’s disease free at over 10 years and unlike with surgery, < 1% ever need have further treatment such as a radical prostatectomy.
As many as 70% of younger patients treated for Prostate Cancer receive radical prostatectomy. Data we recently published in the British Journal of Urology concludes that LDR brachytherapy is an effective treatment with long-term control of prostate cancer in men aged ≤60 years at time of treatment. It was associated with low rates of treatment related toxicity and can be considered a first-line treatment for prostate cancer in this patient group.
So why are more patients not being offered this option? Probably because patients don’t know a better option to surgery exists! This article does nothing to dispel this imbalance. I suspect the situation would be very different if oncologists under took prostate biopsies, made the diagnosis and were first to council patients rather than urologists.
Prostate cancer and the potential side effects of treatment is highly intimate and whilst some men might feel embarrassed to discuss their symptoms and treatment options at length, patient choice is key. This demands accurate, informed discussion about the pros and cons of every treatment. All of the treatments approved by NICE, including surgery, clearly have a role to play in successfully treating prostate cancer. But before a patient is guided to robotic prostatectomy, the full breadth of options should be discussed in detail with every patient.
Professor Stephen Langley, Professor of Urology and Clinical Director, Royal Surrey County Hospital