Management of Localized Prostate Cancer

In this episode of BackTable Urology, Dr. Aditya Bagrodia interviews Dr. Jeff Cadeddu, professor of urology at UT Southwestern, about the management of localized prostate cancer.

First, the doctors discuss important considerations for an initial evaluation, such as lower urinary tract symptoms, a Gleason score, comorbidities, and a thorough family history. Dr. Cadeddu emphasizes that the main goal of the initial evaluation is to risk-stratify the prostate cancer patient. Although he does not consider any anterior surgeries as contraindications, he notes that abdominal perineal resection surgery may be challenging for surgeons.

For patients who have low-risk disease, he strongly advises choosing surveillance over surgery and radiation therapy, regardless of age. For him, active surveillance does not start until a second confirmatory biopsy, and his patients receive MRI at the beginning of every year as well as a PSA every month. Some triggers for ending the surveillance period and entering treatment are: a PSA over 10 or upstaging on an MRI or biopsy.

In patients with intermediate-risk disease, Dr. Cadeddu will either proceed with radiation therapy or prostatectomy. He notes that neither radiation nor surgery are risk-free. Although radiation does not involve pain, post-treatment incontinence, and or peri-operative risk, it can result in irritative symptoms as well as side effects from androgen deprivation therapy used in conjunction with radiation therapy. Radiation also presents a higher delayed risk of cancer recurrence, especially in younger patients. In contrast, surgery presents with more upfront perioperative risk and post-surgical complications but provides more long-term security, as post-surgical salvage radiation is possible. Although many patients have anxieties about post-surgical stress incontinence and sexual function, Dr. Cadeddu notes that 95% of patients will regain continence post-operatively by 6 months. Any incontinence after 6 months is correctable via a male urethral sling or an artificial sphincter. He explains that recovery of post-operative potency depends on the stage and volume of disease, pre-operative sexual performance, patient age, and the skill of the surgeon. If the patient experiences long-term sexual dysfunction, medicines and surgical intervention could possibly resolve the problem. For high risk patients, Dr. Cadeddu makes sure his patients are mentally prepared for multimodal therapy and recurrence.

Dr. Cadeddu is excited to see the future direction of the management of localized prostate cancer and advises surgeons to educate themselves about new studies and technologies associated with prostate cancer.