When discussing definitive prostate radiation, how do you respond to patients who mention that they heard that surgery is more difficult after radiation treatment?

I love this question! I hear it quite often, and it provides an opportunity to discuss the differences between radiation and prostatectomy, and the potential benefits and risks of both.

I start by stating that it is absolutely true that radiation causes scar tissue that can make surgery months to years later more difficult. But then I discuss the WHY of why someone would need surgery after RT, which leads into a discussion of risk of recurrence, likelihood of ECE/SVI, and patterns of recurrence...

I think the motivation for a urologist to raise this issue is to sway the patient towards surgery. The patients are led to believe that if surgery fails, they have options later—a second chance. I usually start out by acknowledging the fact that surgery IS more difficult after radiation but it is not impossible. I then tell them that there are options after radiation, and what that may be depends on the circumstances at the time of a recurrence. As has been pointed out, local recurrences are not...

This question is one of the most frequently asked ones—claims from urologists or medical oncologists conveyed to patients who are trying to decide between a surgical or non-surgical approach to manage their clinically localized disease. Indeed, salvage surgery after definitive radiation therapy is associated with higher likelihoods of urinary incontinence in the range of 30-50%, and the severity of the incontinence can be significant, requiring a least several pads per day. But often this is exa...

I tell them that surgery after radiation is more difficult, but that the issue is what psychologists would call a "squirrel" or a distraction. I refer them to review articles on post radiotherapy salvage of localized recurrence in the prostate (an unlikely occurrence to begin with) and post prostatectomy salvage of a localized recurrence in the tumor bed. Neither are terribly successful and both have more morbidity. I refer them to the Protect Trial where the 10 year cure rates were the same for...

While salvage prostatectomy is indeed more challenging after EBRT, it is only indicated when there is local only failure. In the RTOG 0126 trial, the 8-year cumulative incidence of local progression was 3% in the 79.2-Gy arm. So, I emphasize that this is an uncommon situation, and the decision for definitive therapy modality should not be based on the potential for local salvage therapies in isolation.

I often take a different approach. I suggest that there are surgical series on post radiation patients (Pontes et al., Woods et al., and several others), in which complication rates post operative are similar, and in some cases better, than those series reporting on up front surgical intervention.

I explain to the patients the reason why is that there are certain surgeons who have experience in this treatment and that counts for a lot. The surgical techniques vary from those in de novo patients ...

I agree with all of the above. Local recurrence in the prostate alone occurs, but is uncommon. In addition, I tell them that patients rarely die from local disease in the prostate. They die from distant disease which is equal with both forms of treatment. Furthermore, in addition to other local therapy options, there are better systemic treatments as well.

I would largely agree with the question in this regard.

This matter, operability post pelvic/prostate radiotherapy, was more of a problem for conversation when we used low energy pelvic treatments via cobalt and 4MV photon delivery machines, for examples. Tons of scarring, including intestinal and bladder damage back then. Now, not so much.

When the era of increased beam focus/guidance and higher beam energies emerged, I typically had/have this type of conversation(s) with patients less than 63 ...