Prostate cancer treatment: "Decision regret" - There are alternatives to surgery

Created: 01/16/2023, 10:05 am

By: Pamela Dörhöfer

An employee looks at a cross-sectional image of a prostate on a monitor in a control room at the German Cancer Research Center (DKFZ).

Although prostate cancer is one of the most common forms of cancer in Germany, the chances of recovery are good if treated early.

(Archive image) © Uwe Anspach/dpa

Many men later regret radical surgery for prostate cancer.

The urologist Boris Hadaschik talks about alternatives and how to avoid "decision regret".

Essen – As long as it has not spread, prostate cancer is one of the tumors with very good chances of recovery.

Radical surgery is often not necessary, but many men have their prostate removed.

A decision that many later regret;

in professional circles this is called a “decision regret”.

A team from the Technical University of Munich recently presented results from the research project "Familial Prostate Cancer".

The patients were between 55 and 65 years old at the time of their diagnosis, and almost all opted for a prostatectomy, the removal of the gland.

The researchers asked the men after seven and 13 years how they felt about their previous decision.

The proportion of those among the more than 1,000 participants who regretted it increased over time: from 9 percent in 2007 to 12.1 percent in 2020. This was most common among men, who acted solely on the advice of their doctor had left - and among these especially those who only had a localized tumor.

Prostate Cancer: Many Men Regret Surgery Later

A study published in the journal

by a team from the United States and Canada comes up with even higher numbers.

In this case, the cohort included more than 2,000 patients who chose different approaches and were asked about them five years later: 16 percent of the patients who had a prostatectomy regretted this step, 11 percent of those who opted for radiotherapy would have made a different decision.

Those who only had their prostate cancer monitored were the most satisfied, with only seven percent struggling with it.

In an interview with

, Boris Hadaschik, Director of the Clinic for Urology at the University Medical Center Essen, talks about the options for prostate cancer - and how one can avoid "decision regret".

Professor Hadaschik, many cancer patients seem to later regret their decision to have their prostate removed.

Is "decision regret" a recent phenomenon or was it just not studied before?

I don't think it's anything new.

But people are simply more sensitive today and understand the patients better – also because more work has been published on this in recent years, especially in the USA.

It must be said that decision regret is not uncommon.

According to the German study, ten out of 100 men are not happy with their decision; in the US, the figure is even 16 out of 100.

The prostate is located just below the urinary bladder.

© Getty Images/Science Photo Library

In view of the large number of patients, this affects a large number of men.

These are particularly common in men in whom the carcinoma was discovered early and who were cured.

You realize afterwards that there was no danger to life and limb.

In this case, one is less willing to accept the limitations caused by radical therapy, such as unwanted urine loss or a deterioration in sexual function.

It is therefore an important task for us as doctors to give patients a clear picture of their illness and the various treatment options.

Side effects also need to be discussed.

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Patients often have misconceptions, especially when it comes to minimally invasive procedures, such as those usually performed today with prostatectomies.

They think: These are only small incisions, you will be released from the clinic after a few days and can maybe go back to work after four weeks.

Nevertheless, sexuality is permanently disturbed.

It must therefore be clear that this intervention has consequences for later life.

It is an important task for us as doctors to give patients a clear picture of their illness and the various treatment options.

Side effects also need to be discussed.

Boris Hadaschik, Director of the Clinic for Urology at the University Medicine Essen

What other options for therapy exist today?

We have many different options for localized prostate cancer.

Which one is suitable depends on the risk class of a tumor.

Its aggressiveness plays a role here, the so-called Gleason grade group.

It ranges from one for very slow-growing, usually non-spreading tumors to five for very aggressive tumors that spread earlier.

The assignment also depends on the palpation of the prostate and the level of the PSA value.

For the lowest risk group, the European guideline will recommend in its next update that these patients should only be monitored and no longer undergo surgery or radiation.

This is a paradigm shift.

In the German guidelines, radical surgery, radiation, focal therapy, and monitoring are listed as options.

Prostate cancer: Sexuality is least affected when monitored

A huge difference...

Surveillance has the great advantage that sexuality is least affected.

At the same time, however, it is a psychological burden when, after a cancer diagnosis, you are told: We're not doing anything, we're just being careful.

Ideally, this should be discussed during early detection using a PSA value.

In my opinion, their main problem is overdiagnosis and the subsequent overtreatment of harmless tumors.

In men who have PSA screening, the low-risk cancer rate is 40 to 50 percent.

So it's a big group that we should just monitor after the cancer diagnosis.

However, in patients with a medium risk, active therapy is required.

The choices are radiation therapy, which is now often combined with short-term hormone therapy, or removal of the prostate.

Radiation therapy can cause side effects in the rectum, which can be very distressing for patients.

But that only affects five percent.

To person

Boris Hadaschik is Director of the Urological Clinic at the University Medical Center in Essen and Deputy Head of the West German Tumor Center in Essen.

His focus is the interdisciplinary care of uro-oncological tumor patients.

Boris Hadashik.

© UK Food

Is there also room for maneuver in the case of high-risk tumors?

Here it is important to clarify whether a tumor is still locally limited or whether there are already spread foci that we cannot catch with surgery or radiation of the prostate alone.

To determine this, the patient should be offered improved imaging, a so-called PSMA PET-CT.

If a tumor has spread, various components must be combined: for example, an operation followed by radiation or radiation plus long-term hormone therapy.

Men with high-risk tumors are the least likely to show decision regret because they know that survival is at stake and they therefore accept a reduction in their quality of life.

One result of the German study was that many patients did not feel well advised.

Why isn't this happening enough?

Long talks with patients are not well rewarded.

But you have to take your time.

It's definitely the easiest way to say: There's cancer, it has to be operated on, so we can heal you well.

But then we get men who are unhappy.

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Prostate cancer: detailed discussions with the patient are important

As a doctor, how can you ensure that a patient makes a well-founded decision and, if possible, does not regret it afterwards?

You shouldn't just talk to the patient once at length.

Because in the beginning, a lot is lost under the shock of the cancer diagnosis.

You often don't pay attention to the side effects and only realize later that there were alternatives.

Options like active surveillance also need to mature.

My recommendation for patients is to have discussions with doctors from the various disciplines who offer possible therapies.

So not only to talk to the urologist and surgeon, but also to the radiotherapist.

It also makes sense to get a second opinion.

A decision should then be made within three months.

Luckily, there is no great rush when it comes to prostate cancer.

How far can a doctor leave such a serious decision to a medical layperson when you might have a different view yourself?

Our task is to convey the effects and side effects of a therapy in a way that is understandable to laypeople and to provide the patient with assistance so that he is clear about his goals and which side effects he is willing to accept.

Of course, as doctors, we often hear the question: "What would you do or what would you do with your relatives?" I can understand that very well, but I don't like to answer it because of course there is a bias

.

We know that urologists are more likely to operate and radiation therapists are more likely to irradiate.

But that doesn't mean it's best for the patient.

This is also a question of type.

There are men who say something is growing inside me that has to come out, and there are men who are very happy if the surgical procedure can be avoided.

Has anything changed in recent years in terms of quality of life becoming more important than safety?

In the past, it was more difficult to recommend the concept of active surveillance to younger patients with a long life expectancy because they did not want to take any risks.

That has changed – also because today we can quantify the risk much more precisely thanks to improved imaging and changes in pathological classification.

The trend is to be less active.

(Interview: Pamela Dörhöfer)