more than 10 prostatectomies a year, he is in the tenth percentile for performance of radical prostatectomy in the United States. Likewise, there are radiation oncologists who have a particular focus on an area other than the prostate, such as head and neck cancer, bowel cancer or breast cancer, and may have had little experience in the management of prostate cancer after they graduated from residency training. Finding out who the top-level experts are is not difficult. Most major medical centers have at least one expert in surgery or radiation. Scanning through “Best Doctors” lists may also help you find an expert. This is not to say that physicians not on these lists are not excellent doctors; however, most doctors who make these lists are superior in the eyes of their peers. I would certainly never remove a surgeon or radiation oncologist from your list because he or she did not appear on one of these lists.
While checking out the medical literature (www.pubmed.org) may help you see who has written papers on prostate cancer treatments, this does not guarantee that the surgeon or radiation oncologist with the most papers is the best in his or her chosen field, nor does it mean that physicians who do not publish papers are not capable of giving you state-of-the-art medical care.
Asking your primary care clinician who he or she recommends you speak to is also sometimes fraught with problems. For example, the clinician that you are speaking to may be good friends with the local urologist or radiation oncologist, or may have a very close working relationship with him or her, so your clinician bias in favor of a particular physician may not be based upon outcomes after the treatment. It is said in medicine that the plural of anecdotes is not evidence, and by this, it is meant that speaking to family members or friends who have positive experiences from a particular surgeon does not necessarily mean that your outcomes will be identical.
Many world-class radical prostatectomists or radiation oncologists are difficult to make an appointment with, some do not take any form of insurance, their businesse are purely cash-based. However, it is not absolutely essential for you to see a world-renowned surgeon to obtain good outcome, provided that the physician who is conducting your treatment has good experience and significant expertise in the procedure that he or she is performing. Sometimes getting the best treatment requires that you move away from home base, and while there is a certain comfort level in using the medical center that you routinely use for your general medical care, this does not always translate into the best outcome for surgical or radiation treatment.
Another factor that is important to evaluate involves cancer statistics. On prostate biopsy there are three major factors that need to be evaluated. The first one is the Gleason grade, as we previously mentioned. The higher the Gleason grade, the more aggressive the cancer is, the more likely it is to spread rapidly, the more likely it is to be outside of the prostate, and the lower the survival is in general terms. Ten years after the diagnosis of prostate cancer, dying from the disease occurs in about 5% of men with a Gleason 5 tumor, 15% with a Gleason 6 tumor, 50% with a Gleason 7 tumor, and with a Gleason 8 cancer, it approaches 80% of men. It is also important to understand that in approximately one-third of cases, the Gleason score will be upgraded when the pathologist looks at the radical prostatectomy specimen if you have had surgery. That is, there are many men who have a Gleason 6 tumor on prostate biopsy examination, but when the surgery is performed, and the prostate is surveyed in its entirety, in fact, have a Gleason 7 cancer. This is very simply due to the fact that there is tremendous sampling error when the needle is placed into the prostate for biopsy, particularly if the prostate is large.
Historically, 10 to 20 years ago, six cores were obtained; now, at least 12 to 14 cores are routinely obtained during a prostate biopsy. Nevertheless, there are areas of the prostate that may harbor cancers that are not touched by the needle during biopsy. The extent of the cancer is important. This is often difficult to define on prostate biopsy and much more easily defined if the patient has had a radical prostatectomy and the pathologist examines the entire prostate. However, the volume of the prostate biopsy cores that are involved with cancer should be easily measured by the pathologist. It is important that you define how many cores are positive, and within each core, what is the volume of the cancer. Both of these factors can be factored into a prediction model (nomogram) that gives you an idea of whether the prostate cancer is confined to the prostate. As previously mentioned, a large Swedish trial recently found that radical prostatectomy had an advantage over watchful waiting in men with localized tumors of intermediate or high grade. Furthermore, the medical literature suggests that seed implantation may be less effective in patients with high-risk prostate cancers.
Another factor to consider is your life expectancy.This is impacted upon by many factors, probably the most important one of which is your general health. Medical conditions such as other cancers, coronary artery disease, diabetes, high blood pressure, high cholesterol or any other chronic illness may significantly negatively impact your life expectancy. A 40–year-old man has approximately a 37–year life expectancy. A 60–year-old man, on the other hand, has a life expectancy of about 20 years, and an 80–year-old has a life expectancy of about 7 years. These are purely statistics, and these figures may not apply directly to you depending on your genetic makeup, your family history of longevity and your medical and surgical history.
Your choice of treatment for prostate cancer may be further impacted upon by your current sexual function and sexual activity. For men who have poor sexual function before treatment and for men who are not particularly sexually active, sexual dysfunction tends not to be a major concern or factor that they consider when choosing a treatment. Patients see me frequently before they choose whether to have surgery or radiation and want to know which I would recommend. I say to all of them that they should never base their decisions regarding treatment on their future sexual function. While there does not exist any study directly comparing surgery and radiation in a randomized, controlled fashion, my review of the literature suggests at this time that the erectile dysfunction rates at three years after surgery and three years after radiation are approximately the same.
You should be very wary of a radiation oncologist who touts radiation therapy as being associated with lower rates of sexual dysfunction. Saying that, good radiation is probably better than poor surgery, and good surgery is probably always better than poor radiation. So choose a physician that has experience and expertise in whichever treatment you are receiving. Likewise, be cautious of robotic prostatectomy surgeons who tell you that erectile function recovery is better or quicker using the robot compared to the open approach. At this point in time, there is zero evidence to support that statement, although these statements appear on some robotic prostatectomy websites. My research of these websites has shown that about 50% of the sites devoted to robotic prostatectomy state or infer that erectile function recovery is better after robot surgery than open surgery. This is not true based on the best available evidence at the moment.
The older the patient, the less likely sexual function will play a role in deciding which treatment to undertake, as older men often have more baseline erectile problems and are generally with partners who are less interested in sex. However, for older men who have younger partners, sex often has a significant impact on the choice of treatment. If you have erectile dysfunction at the time of diagnosis and should sexual intercourse be an important part of your life, it may be worthwhile having this investigated and treated before you undergo treatment for prostate cancer. If you have been diagnosed with prostate cancer, you have several months at least to make a decision regarding which treatment to pursue, unless the cancer is very high grade. If you have erection problems during this“decision-making”time period,you may want to consider trying erection pills. If you try them and have significant side effects or they do not work, then you may wish to pursue some other treatment such as penile injection therapy or urethral suppositories. Men for whom pills and suppositories and/or shots fail and for whom sexual intercourse is important, may be considered candidates for simultaneous radical prostatectomy and placement of a penile implant reservoirs (see Chapter 13).
Another factor that plays a role in your decision is your lifestyle. For example, there are men who run small businesses, are self-employed and have a small number of employees, for whom
