Surgery or radiation: is there really a choice for early prostate cancer

One of the most difficult tasks for the practicing urologist is to counsel the patient in a decision for the optimal treatment for his localized prostate cancer. After providing the patient with contemporary and unbiased information and data, it is important to find the preferred treatment based on his age, the medical realities and, last but not least, the patient's personal preference. Radical prostatectomy, radiotherapy and observation are standard treatment options. TRUS-guided brachytherapy and cryosurgery are considered investigational treatment options since follow-up is inadequate to provide sufficiently precise outcome estimates. The literature does not provide clear-cut evidence for the superiority of any one treatment. The patient most likely to benefit from radical prostatectomy would have a relatively long life expectancy, no significant surgical risk factors and a preference to undergo surgery. The major advantage of radical prostatectomy is its potential for total removal of the cancer and cure in properly selected patients. Potential harm includes urinary incontinence and impotence. The patient most likely to benefit from radiation therapy would have a relatively long life expectancy, no significant risk factors for radiation toxicity and a preference for radiotherapy. The advantages of radiotherapy are that it has a potential for cure and it is well tolerated in the majority of men when the modern techniques are used. Potential harm includes radiation cystitis, proctitis and impotence, persisting severe complications are only seen in 1% of patients. The patient most likely to benefit from surveillance are those with a shorter life expectancy and/or a low grade tumour. Benefits are lack of treatment related morbidity with only marginal compromise of disease-specific survival at 5-10 years follow-up.