When prostate cancer is diagnosed early enough to be treated, several options can be offered. Among them, radiotherapy plays an important role.
It's a well-known treatment, effective in many situations, and offers a clear advantage for many men: avoiding surgery and general anesthesia . But like any treatment, it also has its limitations, constraints, and potential side effects.
To make an informed choice, one needs to understand simply what radiotherapy is, how it works, in what cases it can be offered, and what its advantages and disadvantages are compared to prostate cancer surgery.
What is radiotherapy for prostate cancer?
The principle is relatively simple: irradiate the prostate with X-rays in order to destroy the tumor located inside the gland.
In other words, the aim is to destroy the prostate and the cancer it contains through targeted therapy. The goal is to treat the disease without removing the organ.
This is, in fact, what fundamentally distinguishes radiotherapy from surgery:
- Surgery removes the prostate .
- Radiotherapy treats the prostate in place .
The different forms of radiotherapy
There is not just one type of radiotherapy, but several treatment modalities .
Conventional radiotherapy
This is the most classic form. It is generally done from Monday to Friday , with one session per day for about 7 weeks .
The treatment is therefore divided into many sessions, which allows the necessary dose to be delivered while trying to limit the impact on surrounding tissues as much as possible.
Shorter protocols like CyberKnife
In certain cases, radiotherapy can be much shorter, with 3 to 5 sessions . This is known in particular as CyberKnife .
The principle remains the same: to treat the tumor by irradiation, but with a more condensed regimen.
Brachytherapy
Another possibility is to implant radioactive seeds into the prostate . This is called brachytherapy .
This technique is performed under brief general anesthesia . Again, the idea is to deliver radiation as close as possible to the tumor to destroy the cancer.
The main advantage of radiotherapy
The main advantage of radiotherapy is clear: it makes it possible to avoid surgery .
For some patients, this is a crucial point. This means:
- No surgery required.
- No general anesthesia is required in most cases.
- a treatment option that is often reassuring for those who fear surgery.
This is reason enough for it to be discussed very regularly in the management of prostate cancer .
The important limitation: the prostate is neither removed nor fully analyzed
This is one of the major disadvantages of radiotherapy compared to surgery.
When prostate cancer is treated with surgery, the removed prostate can be analyzed in its entirety . This allows for a more precise determination of the exact extent of the disease.
With radiotherapy, this is not possible, since the prostate remains in place.
Consequently, if the disease was initially underestimated by MRI or biopsies, it will not be discovered immediately. It may only be noticed at the time of a relapse .
This is a crucial point in therapeutic thinking.
The issue of relapse: a key element in the choice of treatment
When choosing an initial treatment, one must always consider what will be possible if the cancer recurs .
After surgery
If the prostate has been removed and the disease recurs, it is often possible to supplement this with radiotherapy .
In other words, surgery still leaves an important therapeutic option to be used afterwards.
After radiotherapy
The situation is more complicated. An area that has already been irradiated generally cannot receive standard radiotherapy again, as this would expose it to too much radiation and therefore too much toxicity.
As for surgery after radiotherapy, it is known to be extremely difficult .
Why? Because irradiated tissues are altered, fibrous, weakened, and much more difficult to dissect. In this context:
- The results regarding urinary continence are significantly less good.
- The results regarding erections are very poor.
- There is a risk of rectal injury , as the rectum is located just behind the prostate.
This point is extremely important in the overall treatment strategy.
Common side effects of radiotherapy and surgery
Like surgery, radiotherapy can cause some functional side effects.
Urinary incontinence disorders
They can exist, even if they remain rare . Continence is therefore a subject to be addressed before treatment, regardless of the option chosen.
Erectile dysfunction
Radiation therapy can also cause erectile dysfunction .
The mechanism is not exactly the same as in surgery, but the result can be similar.
In surgery, the risk comes from the proximity of the nerves of erection , which are attached to the prostate and can be damaged during dissection.
In radiotherapy, X-rays can spread around the targeted area and alter the quality of these nerves . Nerve impulses then pass less effectively, which can affect erections.
Specific side effects of radiotherapy
Radiotherapy also has its own specific side effects, due to the anatomical proximity of the prostate to other organs.
Even though techniques have progressed enormously, there is still a risk of radiation spreading to:
- the bladder , located above the prostate,
- the rectum , located just behind.
Radiation cystitis
When the bladder is irritated by radiation, it is called radiation cystitis .
This can manifest itself through:
- frequent and urgent urges to urinate,
- frequent needs,
- sometimes blood in the urine .
Radiation proctitis
When the rectum is affected, it is called radiation proctitis .
Possible symptoms include:
- urgent urges to defecate,
- rectal irritation,
- bleeding in the stools .
The specific case of patients on anticoagulants
Caution is particularly important in men taking long-term anticoagulant therapy .
Why? Because radiotherapy can promote urinary or digestive bleeding, and this can be more difficult to control in this context.
This is therefore an element to be seriously considered in the discussion before choosing this option.
For whom is radiotherapy a good option?
Radiotherapy is an interesting alternative to surgery as a first-line treatment . It has a valuable role to play in the management of prostate cancer.
It can be particularly relevant in several situations.
In addition to surgery
In a global strategy approach, it is often very useful as a second-line treatment , i.e., after surgery , when additional treatment is needed.
This is one of its major strengths in the therapeutic arsenal for prostate cancer .
In patients who cannot have general anesthesia
When there is a medical contraindication to general anesthesia , radiotherapy can represent an excellent first-line solution.
When surgery looks difficult
In some cases, surgery is considered likely to be more complex or less successful. Radiotherapy may then be offered as a first-line treatment.
For patients who are afraid of surgery
This aspect should not be overlooked. Even today, many men are afraid of surgery , even though surgical techniques have progressed considerably, particularly with robotic prostatectomy .
In this situation, radiotherapy is a perfectly acceptable option, provided that the patient has a clear understanding of what it offers and what it does not offer .
How to decide between surgery and radiotherapy?
There is no single answer that works for everyone.
The right choice depends on several factors:
- the characteristics of cancer,
- the results of the MRI and prostate biopsies,
- age and general health,
- the possibility or not of general anesthesia,
- the functional risk to continence and erections,
- the strategy envisaged in case of recurrence,
- and of course the patient's preferences.
The important point is not to reduce the choice to a simple opposition between "light" and "heavy" treatment. Radiotherapy is not a harmless treatment. It is an effective treatment, but one that must be chosen with a precise understanding of its benefits, constraints, and limitations .
Key takeaways
- Radiation therapy for prostate cancer involves irradiating the prostate to destroy the tumor.
- It can be done in conventional form, in a short protocol such as CyberKnife , or by brachytherapy .
- Its main advantage is avoiding surgery .
- Its main drawback is that the prostate is neither fully removed nor analyzed .
- In case of recurrence, surgery after radiotherapy is much more difficult .
- It can lead to incontinence, erectile dysfunction, as well as specific effects such as radiation cystitis and radiation proctitis .
- It is particularly interesting in patients who are not candidates for surgery, in those for whom surgery seems difficult, or in those who do not wish to have surgery.
The best decision is always made on a case-by-case basis, after a clear discussion about the expected benefits, possible side effects and the place of the treatment in the overall strategy for managing prostate cancer .