Clinically significant localised prostate cancer: deciding what will provide the best clinical outcomes

Prostate cancer specialists working in collegiate, multidisciplinary teams are most likely to provide the best outcomes for patients

In the absence of formal comparative studies, there is no real evidence that the outcomes of surgery or radiotherapy for patients with localised prostate cancer differ significantly. However, most men in Australia with clinically significant localised prostate cancer undergo surgery rather than radiotherapy.

In the study reported in this issue of the MJA,1 Yap and colleagues found that New South Wales men with prostate cancer were more than twice as likely to undergo radical prostatectomy as external beam radiotherapy, and that the type of treatment received was related to a variety of socio‐demographic factors, including having private health insurance, and regional stage of disease. A Victorian study had previously found that a higher proportion of men treated in private hospitals than in public hospitals had radical prostatectomies.2

One might suspect that financial imperatives account for these differences, or that caseload levels for robot‐assisted radical prostatectomy are deemed necessary to maintain operator skills and to retain procedural accreditation. However, treatment choices are much more complex.

As urologists diagnose prostate cancer in biopsy tissue, they form an early relationship with the patient that unsurprisingly has a marked influence on later patient treatment decisions. But many factors can influence these decisions, including cancer‐related factors, such as prostate‐specific antigen level, clinical stage, and cancer grade, as well as patient factors, including age, comorbid conditions, life expectancy, and individual concerns about the impact of treatment.3 The presence of symptoms or a medical or surgical history of certain conditions may preclude a particular approach.

Treatment options are often dichotomised as surgery or radiotherapy, but this is too simplistic. Depending on the life expectancy and preferences of the patient, active surveillance or conservative approaches with watchful waiting or intermittent hormone therapy can still be the most appropriate choices. For surgery, men may consider the relative merits of open and robot‐assisted radical prostatectomy, and whether they require a nerve‐sparing or non‐sparing approach. For radiotherapy, they can choose external beam radiotherapy, brachytherapy, or both.

To reduce the risk of future decision regret, it is important that we help patients understand the pros and cons of each option and that individual factors may make certain treatment options more appropriate for them. Following the recent Medical Benefits Scheme (MBS) review, radical prostatectomy‐related item numbers include a note encouraging a multidisciplinary approach to decision making, and consultations with both a urologist and a radiation oncologist are recommended before making treatment decisions.4

For most patients, surgery and radiotherapy each offer good chances of disease control, but adverse effects with a lasting impact on quality of life are possible.5 Treatment choice may come down to the patient’s priorities and acceptance of certain side effects. As a general rule, most adverse consequences of primary surgery are apparent shortly after treatment, whereas some effects of primary radiotherapy may develop months to years later.6

Additionally, the availability of a salvage option, should primary treatment fail, may affect treatment choice. Radiotherapy can be safely delivered and with an acceptable adverse event profile after radical prostatectomy, particularly with improved targeting techniques.7 Surgery after radiotherapy, however, is associated with a particularly poor adverse events profile, and is not often performed.8 Similarly, salvage strategies after radiotherapy, including brachytherapy and stereotactic body radiotherapy, might only be offered in highly selected cases.9

As radiotherapy is typically provided over a number of consecutive days, distance to the nearest radiotherapy centre can be a problem for patients in regional areas, as also noted by Yap and her colleagues.1 Establishing regional radiotherapy centres, together with the development of hypofractionated radiotherapy (delivering the required biological radiation dose over a shorter period of time) and stereotactic radiotherapy, will improve accessibility to radiotherapy for patients outside urban areas. Similarly, establishing robotic surgical platforms in regional centres would improve access to surgical treatment.

As most radiation oncology services in NSW are located in public hospitals, and radiotherapy in private facilities is considered an outpatient treatment, access should not be affected by whether a patient has private health insurance, with out‐of‐pocket expenses capped under Medicare safety net arrangements.10

The cost of surgery in the private sector can be considerable, motivating patients to seek treatment in public hospitals. In NSW, however, only four public hospitals can provide robot‐assisted prostatectomy (personal communication from Nat McLay, general manager, Device Technologies, Sydney; 11 February 2021).

In conclusion, numerous factors influence patients when choosing the best treatment for their prostate cancer. Our own experience is that the model most likely to provide the best outcomes for patients involves prostate cancer specialists working in collegiate, multidisciplinary teams. We also advocate that clinicians participate in the Prostate Cancer Outcomes Registry – Australia and New Zealand (PCOR‐ANZ), a large registry for prostate cancer patterns of care and outcomes data.11 In the absence of relevant randomised controlled trials, the registry provides the best opportunity for clarifying the relative merits of the various options for treating localised prostate cancer.