Patients Ask About Surgery Versus Radiation for Early Stage Prostate Cancer

Prostate Cancer Information

Advanced Prostate Cancer

Judd W. Moul, MD

Welcome to the Prostate Cancer Education Council's Article Series: 2000 website.

Below is the second in a series of six articles by a select panel of distinguished urologist addressing a topic related to advancements in prostate cancer treatment, research, and prevention. Informative sidebars throughout the article, along with highlighted technical vocabulary hyperlinked to a prostate cancer glossary, create an easily digestible format for consumers.

Article Series: 2000 is presented on behalf of the Prostate Cancer Education Council (PCEC). Founded in 1988, the PCEC is a consortium of physicians, health educators, scientists, and patient advocates dedicated to increasing prostate cancer awareness and knowledge. Here is a list of currently available and upcoming articles.

The author of this article is Col. Judd W. Moul. Dr. Moul is a Professor of Surgery at the Uniformed Services University of the Health Sciences (USUHS) in Bethesda, MD, and is an attending Urologic Oncologist at the Walter Reed Army Medical Center (WRAMC) in Washington, DC.

Dr. Moul is a Colonel in the US Army Medical Corps and has been at his current position since 1989 after having completed a Urologic-Oncology Fellowship at Duke University. Dr. Moul is a Summa Cum Laude graduate of the Pennsylvania State University and received his medical degree from Jefferson Medical College, having been elected to Phi Beta Kappa and Alpha Omega Alpha. Moul is Director of the Center for Prostate Disease Research (CPDR), a Congressionally-mandated research program of the Department of Defense based at USUHS and WRAMC and has a strong research interest in the molecular biology and clinical outcomes of prostate cancer.

Doctor Moul has had funded research projects related to testicular and prostate cancers from USUHS, WRAMC, the Department of Veterans Affairs and CaPCure and currently manages the 24 million dollar CPDR grant from the US Army Research and Materiel Command. Moul has authored or co-authored over 200 scientific manuscripts and book chapters including articles in the New England Journal of Medicine and the Journal of the American Medical Association.

Doctor Moul has received honors including the 1995 American Medical Association Young Physicians Section Community Service Award for his national involvement in prostate cancer patient support groups. He has also received the 1996 Sir Henry Wellcome Research Medal and Prize from the Association of Military Surgeons of the United States and was selected as a 1994 Fellow for the American Urological Association/European Association of Urology International Academic Exchange Program. Dr. Moul was selected as the 1997 recipient of the prestigious AGold Cystoscope Award by the American Urologic Association.

Doctor Moul is on the Editorial Board for the national journals Oncology, Techniques in Urology, and Prostate Cancer and Prostatic Diseases and the periodicals Oncology News International and Primary Care and Cancer. Moul is a medical advisor to the National Association for Continence (NAFC) and the US TOO International, Inc., prostate cancer support group network and is a member of numerous professional organizations. Moul has given numerous scientific presentations at national and international meetings, has been a visiting professor and invited lecturer at universities and national symposia, and has appeared on ABC, CNN, and other media as a prostate cancer authority.

The opinions and assertions contained herein are the private views of the authors and are not to be construed as reflecting the views of the U.S. Army or the Department of Defense.

INTRODUCTION

The American Cancer Society estimates fewer new cases of prostate cancer for 1999 than for 1997.

Although adenocarcinoma of the prostate gland, hereafter prostate cancer, is the most common solid tumor and second leading cause of cancer deaths, the PSA blood test has dramatically altered the face of this disease in the United States and in many other industrialized countries. The American Cancer Society (ACS) reported a peak of approximately 334,500 cases per year in early 1997, which was adjusted down to approximately 210,000 cases by mid 1997.¹ In 1999, the ACS estimates that there will be even fewer cases; they currently estimate 179,300 new cases for 1999.² Mortality for prostate cancer has been gradually rising until the period from 1991 and 1995, when the death rate declined 6.3%. ³

Parallel to the observed decrease in advanced prostate cancer, an increase in the rate of earlier stage disease has arisen.

The increase in detection of early stage prostate cancer has helped to create a debate between radical prostatectomy versus radiation treatment as alternatives for therapy.

The use of PSA, coupled with increased public awareness of the disease, has resulted in a stage-migration. There has been a declining rate of metastatic disease since 1990. At the same time that the rate of advanced prostate cancer declined, the rate of earlier-stage disease climbed. This huge increase in patients with early disease has sharpened the debate between surgery, i.e., radical prostatectomy versus radiation treatment, including external beam or brachytherapy.

A 70 year-old male who is found to suffer from prostate cancer has an eleven-year life expectancy and a greater than 50% chance to survive an additional ten years.

Most of the patients in the late 1990's are different from earlier era men; they are younger and healthier. A 70-year-old man, who is just above the average age of U.S. men who are diagnosed with prostate cancer, has an 11-year life expectancy. This same man has a 52.5% probability of living another 10 years. Curative treatment attempts with surgery or radiation are now relevant for most of these men. Treatment for prostate cancer is an individual decision between the patient, his family, and his providers. With these new facts about the changing demographics of prostate cancer in mind, I will review the two most commonly prescribed current treatments for localized prostate cancer: surgery and radiation.

MANAGEMENT OF PROSTATE CANCER

Treatments for prostate cancer may fail due to undetected occult metastatic disease, or if the chosen treatment does not completely destroy the cancer within the prostate.

The major determinant of whether a patient has curable prostate cancer is whether the disease is completely confined within the prostate gland and if the cancer is completely eradicated with treatment. Treated patients may not be cured for two reasons: either there was occult metastatic disease outside of the prostate that was not detected by current staging, or the treatment chosen did not completely eradicate the cancer within the gland. On the other hand, it must be kept in mind that depending on a man's age and co-morbidity status, non-curative therapies can be used in curable disease, with the objective to merely "slow down" the progression of prostate cancer so as to not impact quality of life and life expectancy.

Treatments for localized prostate cancer include radical prostatectomy, external beam or brachytherapy, cryotherapy, or watchful waiting.

Locally advanced prostate cancer is predominantly treated with external beam radiation therapy, and on occasion, with the addition of hormonal therapy.

Metastatic disease is normally treated with hormonal therapy.

Treatment for prostate cancer depends on the stage of the disease.⁴ Stage T1 and T2 prostate cancer may be treated by radical prostatectomy (RP), radiation therapy (either XRT or brachytherapy), cryotherapy, or watchful waiting. Stage T3 and T4 prostate cancer has been treated primarily with XRT with or without the addition of hormonal therapy (HT), while metastatic prostate cancer (Stage T1-4 N1 or M1) is treated primarily by hormonal therapy (HT). Hormonal therapy may include orchiectomy or medications to lower the production or block the effect of testosterone, considered the "fertilizer" for prostate cancer growth. We will focus on radical prostatectomy and radiation for early stage disease.

Radiation Therapy

Interstitial brachytherapy is gaining popularity as a curative approach for localized disease.

Conformal radiation therapy provides a higher prostatic dose of energy with less residual radiation affecting the surrounding tissue (ie, areas such as the rectum and bladder).

Radiation therapy is a potentially curative treatment for localized prostate cancer. Although external beam radiation has been the preferred route of delivery for the vast majority of patients, interstitial brachytherapy has gained in popularity over the last five years as a curative approach for localized disease.⁵ This resurgence in brachytherapy use is due to the development of transrectal ultrasound. This procedure allows clinicians to accurately place the radioactive seeds throughout the prostate gland by a transperineal approach under ultrasound guidance. External beam radiotherapy is delivered by a linear accelerator and a typical 6800-7200 cGy dose is given five days a week over a 6-7 week period.⁶ As with brachytherapy, technologic advances have changed the way external beam radiotherapy is delivered. Although conventional external beam therapy directs the radioactive energy to approximate the location of the prostate gland, more precise computer control and planning, known as "conformal radiation therapy," allows the delivery of a higher prostatic dose of energy with less radiation to the surrounding tissue, including the rectum and bladder.⁷ Some hospitals still provide conventional external beam treatment, while many larger hospitals and academic centers have switched to conformal radiation with the hope that side effects will be fewer and long-term efficacy will be improved.

The success of external beam radiotherapy or brachytherapy to cure localized prostate cancer is contingent upon the grade of the cancer, the PSA level before treatment, and other prognostic factors.

In the study performed by Stamey et al., 80% of patients showed rising PSA, coupled with concern that the radiation-recurrent disease had a faster tumor doubling-time.

A SEER study of over 59,000 patients indicated improved survival for those who were treated with radical prostatectomy versus those who received radiotherapy.

A study conducted by the Cleveland Clinic indicated that when disease grade, disease stage, and pretreatment PSA values were considered, there were no significant differences in disease-free survival rates between surgery and radiation at 5-year follow up.

The success of external beam radiotherapy or brachytherapy to cure localized prostate cancer depends on the stage and grade of the cancer, the PSA level before treatment, and, undoubtedly, other prognostic factors. Surgeons and radiation oncologists debate the merits of radical prostatectomy versus external beam radiation and/or brachytherapy in the sense of which treatment is best to cure the average man with localized disease. On one hand, Stamey et al showed that only 20% of external beam radiated patients had PSA levels less than 1.0 ng/ml, indicating complete remission at an average follow-up time of nine years after therapy. ⁸ The remaining 80% of patients had steeply rising PSA with the concern that the radiation-recurrent disease had a more rapid, aggressive tumor doubling-time.²¹ This raised a disturbing question of whether radiation therapy, which was helpful in 20% of patients, may have activated 80% to a faster growing, more aggressive phenotype. Furthermore, although a small, single-hospital study, the one randomized trial comparing radiation therapy to radical prostatectomy showed surgery provided improved survival.⁹ On the other hand, radiation oncologists criticize the above noted studies, claiming that they suffer from selection bias. Furthermore, they cite large case series of external beam radiation-treated patients which show that it is as effective as surgery for the carefully selected man with clinically organ-confined disease.^{10,
11,
12} A large SEER database review of radical prostatectomy, external beam radiotherapy, and conservative treatment has added to our understanding of this debate.¹³ Although not a randomized trial of surgery versus radiation, the SEER study is based on over 59,000 patients and is stratified by grade and clinical stage of cancer. There were over 24,000 men (average age 65.8 years) who received radical prostatectomy and 15,720 who received radiotherapy (average age 70.4 years). Using an intention-to-treat analysis, 10-year overall survival was 83% (81% to 84%) and 76 % (74% to 76%) for surgery vs. radiotherapy, respectively. Intention-to-treat eliminates the bias of patients who did not have radical prostatectomy due to positive nodal metastases at the time of surgery. In past comparison studies, those without this type of analysis surgery would have an advantage because many radiotherapy patients were treated without lymph node staging and had occult nodal disease. The cause-specific 10-year survival by grade and surgery vs. radiotherapy was 94% vs. 90%, 87% vs. 76%, and 67% vs. 53% for grades 1, 2, and 3, respectively.¹³ Unfortunately, data like these are not yet available stratified by pretreatment PSA level and/or Gleason grade. Aside from this study, clinical research centers are starting to report non-randomized series of surgery and radiation patients stratified by grade, stage and, perhaps most importantly, pretreatment PSA value. In one study from the Cleveland Clinic, when these three stratification prognostic factors were considered, there was no significant difference in the disease-free survival rates between surgery and radiation at 5-year follow-up.¹⁴ In another study of over 1600 patients stratified by pretreatment PSA value, biopsy Gleason grade, and clinical T-stage, there was no difference in the 2-year disease-free survival between surgery or radiation.¹⁵ It is still unknown if there will be any significant or meaningful difference between surgery or radiation using this stratification in longer follow-up.

For brachytherapy, the cure rate beyond the 5-year to 7-year period is still unknown.

These same issues hold for brachytherapy. Since transrectal ultrasound-guided brachytherapy is a relatively recent advance, the cure rate beyond 5-7 years is unknown. Furthermore, at this time, the only outcome data is from the centers of excellence who developed modern brachytherapy; therefore, we do not know the efficacy of this treatment in general practice as it has proliferated over the last three years.

A rising PSA level after treatment is a sign of recurrence of prostate cancer.

ASTRO considers recurrence as being three consecutive rises in PSA level after the post-treatment nadir has been achieved

For men who are not cured by radiation (or surgery), a rising PSA level after treatment is generally the first indicator of recurrence.¹⁶ The American Society for Therapeutic Radiology and Oncology (ASTRO) has defined a recurrence as three consecutive rises in PSA level after the post-treatment nadir had been achieved.¹⁷ The date of recurrence for outcome studies is the date halfway between the nadir date and the first rise in PSA. The PSA nadir is now recognized as an important prognostic factor.¹⁸A recently reported study of combination external beam and brachytherapy suggests that the nadir PSA should decrease to 0.5 ng/ml or less to predict a good long-term outcome of radiation therapy.¹⁹

Combination Radiation and Hormonal Therapy

Patients who received adjuvant hormones plus radiation showed a significant improvement of local and distance recurrence after five years.

Another advance changing the face of radiation is the addition of temporary reversible hormonal therapy to the treatment regimen. Hormonal medications may be given for a number of months before the start of radiation; this is termed neoadjuvant hormonal therapy (NHT).²⁰ Hormonal treatment may also begin concurrent with and continue for a variable duration after radiation; this is known as adjuvant hormonal therapy.^{21,
22} A number of studies published in the mid-1990's support NHT and adjuvant HT. The Radiation Therapy Oncology Group (RTOG) compared external beam radiation alone versus radiation plus 4 months of NHT with an LH-RH agonist and the antiandrogen flutamide in over 400 men with locally advanced (T3, T4) prostate cancer.²⁰ Progression-free survival was 36% in the radiation plus NHT arm and 15% in the radiation only patients (p<0.001). Another RTOG study examined 945 men with locally advanced prostate cancer (T3 and/or N1-3) and compared adjuvant hormonal therapy using an LH-RH agonist plus radiation to radiation alone with hormonal therapy given only at relapse.²¹ The patients who received the adjuvant hormones plus radiation had a significantly improved rate of local and distance recurrence at five years. Furthermore, even at the relatively short follow-up of 5 years, men with high-grade disease (Gleason 8-10) had an improved survival. Finally, a European study randomized over 400 men with locally advanced prostate cancer to radiation alone versus radiation plus adjuvant LH-RH agonist therapy for 3 years.²² At 5-year follow-up, the adjuvant hormonal therapy patients had a significantly higher disease-free and overall survival rate. Certainly, for locally advanced prostate cancer, there is a clear benefit to neoadjuvant and/or adjuvant hormonal therapy. Unanswered questions that remain include the optimal duration of hormonal therapy, whether LH-RH agonists alone or in combination with antiandrogens are most beneficial, and whether NHT and/or adjuvant hormonal therapy is beneficial in earlier stage patients (i.e., T1 and T2) who choose external beam or brachytherapy.

Radical Prostatectomy

Nomogram tables combine clinical stage, Gleason grade, and PSA level as a way to predict who can benefit from surgery.

40% to 50% who have prostate cancer do not have organ-confined cancer, and thus are at a risk for disease recurrence.

One study has shown that men with differentiated grade prostate cancer have a greater rate of survival after radical prostatectomy than those with moderate and poor grade cancer.

If the cancer is confined within the prostatic capsule, radical prostatectomy theoretically cures the patient. As with the previous discussion regarding radiation treatment, the pretreatment clinical T-stage category, cancer grade, pretreatment PSA value and possibly other prognostic factors such as the ethnicity of the patient determine the likelihood of organ-confined and curable disease. Urologists now use nomogram tables that combine clinical stage, Gleason grade, and PSA level to provide probabilities of organ confined cancer or other parameters such as seminal vesicle or pelvic lymph node cancer spread.²⁶ These nomograms provide general guidelines for predicting the success of surgical treatment, but because they are guidelines, they may or may not be accurate for individual men. As a consequence, 40% to 50% of contemporary men selecting radical prostatectomy do not have organ confined prostate cancer and are at substantial risk of disease recurrence. Cancer-specific survival for pathologic confined tumors treated with radical prostatectomy approaches 90% at 15 years 24, while those with pathologic extension beyond the capsule have an approximately 30% to 40% disease recurrence and progression rate.²⁵ Two recent studies document excellent 10-year outcomes for contemporary-era radical prostatectomy patients. The SEER survey alluded to earlier found 10-year disease-specific survival ranging from 67% to 94% depending on the grade of cancer.¹³ Another multicenter survey by Gerber and colleagues analyzed over 2,600 men who had undergone radical prostatectomy for 10-year disease-specific survival.²⁶ Men with well-differentiated grade cancer had a 94% chance of a 10-year disease-specific survival, while the rate for moderate and poor grade cancer was 80% and 77%, respectively.

Although we do not have long-term disease-specific survival for radical prostatectomy patients stratified by multiple prognostic factors, a number of recent studies are using prognostic equations to predict disease recurrence. Partin and associates initially developed a mathematical model using the pathological stage, surgery Gleason grade, and pretreatment PSA level to predict post-surgery recurrence.²⁷ This model was based only on patients from one referral hospital and one surgeon and was developed only for patients with clinical stage B2 (T2) disease. Our Department of Defense Center for Prostate Disease Research (CPDR) group created and validated a model that appears useful (even in the immediate postoperative period) for predicting the risk of recurrence after radical prostatectomy for all stages of disease.²⁸ The equation uses four prognostic factors - pretreatment PSA, Gleason sum, pathologic stage, and patient race to derive the relative risk of recurrence. In our study, the high-risk group had a 55.5% chance of recurrence at 3 years postoperatively and an 84.8% chance at 5 years. As information technology continues to improve, I believe these risk equations will become useful in everyday practice. The CPDR equation²⁸ is available on the Internet (http://surgery.usuhs.mil/cpdr.aspl) for use in daily practice to counsel patients.

Impotence and urinary incontinence are two primary disadvantages to radical prostatectomy.

One study reports that nerve-sparing surgery might preserve sexual function to a lesser extent than was previously thought.

The potential disadvantages of radical prostatectomy are the relatively high incidence of impotence (despite nerve-sparing techniques) and the possibility of urinary incontinence. In one large series of men undergoing the anatomic (nerve-sparing) technique of radical prostatectomy, 40% to 65% of men who were sexually potent before surgery retained potency adequate for vaginal penetration.²⁹ This same study reported only 6% of men required use of pads for urinary incontinence, but an unknown additional proportion of men had occasional urinary dribbling. Preservation of potency with this technique is dependent upon tumor stage and patient age, with the lower stage and younger patients experiencing less risk of impotence.²⁹ However, dramatically different results were obtained in a National Survey of Medicare patients in which over 60% of patients reported having no erections after surgery, and about 90% had erections insufficient for intercourse.³⁰ Also, over 30% of men reported the need for pads or clamps to treat urinary leakage, and 63% of all patients reported some degree of incontinence. Another recent controversial article reported on 94 radical prostatectomy patients operated on by multiple different surgeons, and found that nerve-sparing surgery preserved postoperative sexual function to a lesser extent than previously reported.³¹ The potency rate with nerve-sparing was 22%, and men who underwent only a unilateral nerve-sparing procedure did not have a significantly higher potency rate than those who did not have nerve-sparing procedures. Critics of this report contend that the results are much better than this with experienced surgeons. Technical advances appear to be reducing the incidence of urinary incontinence. Urologic surgeons have made improvements in the operation (particularly at the apex of the prostate) that appear to increase the chance that a man will regain full urinary control.³² Furthermore, younger, healthier men with early-stage cancer have a lesser chance of developing incontinence and impotence.

A number of therapeutic modalities are offered in the hopes of counteracting potential complications that can disrupt quality of life after treatment.

To counter these potential complications that can affect quality of life after prostate cancer treatment, multiple therapeutic modalities are offered. For impotence, medical therapy, penile injections, intraurethral suppositories, vacuum tumescence devices, and penile prosthesis can be offered. For urinary incontinence, periurethral injection of collagen, artificial urinary sphincter, and nonsurgical therapy can be offered.³³

CONCLUSION

With a healthier and longer-living population, prostate cancer will remain an important disease to consider.

Radical prostatectomy, external beam radiotherapy, and brachytherapy are the treatments of choice for localized disease (depending on stage, tumor grade, and pretreatment PSA level).

Neoadjuvant and/or adjuvant hormonal therapy are commonly used with radiation; initial results for this treatment look very promising.

Prostate cancer is a very common disease of older American men and is becoming more common in younger men as well. As our population ages and remains healthy longer, prostate cancer will continue to grow in importance. With the advent of PSA screening and increased public awareness, these cancers are being routinely discovered at an earlier clinical stage and more men are candidates for curative local therapies. Radical prostatectomy, external beam radiotherapy, and brachytherapy are the accepted treatments for clinically localized disease, depending on stage, tumor grade, pretreatment PSA level, and the desires of the man and his family. Success of these treatments largely depends on stage, grade, PSA, and perhaps other prognostic factors. The optimal treatment for an individual patient is best determined after careful counseling regarding the therapies and their side effects, including impotence and incontinence. neoadjuvant and/or adjuvant hormonal therapy is commonly used in conjunction with radiation; the intermediate-term efficacy is very promising.

REFERENCES

Wingo PA, Landis S, Ries L. An adjustment to the 1997 estimate for new prostate cancer cases. Cancer. 1997;80(9):1810-1813.
Landis SH, Murray T, Bolden S, Wingo PA. Cancer Statistics 1999. CA Cancer J Clin. 1999;49(1):6-31.
Hoeksema MJ, Law C. Cancer mortality rates fall: a turning point for the nation. J Natl Cancer Inst. 1996;88(23):1706-1707.
Wasson JH, Cushman CC, Bruskewitz RC, Littenberg B, Mulley AG Jr, Wennberg JE. A structured literature review of treatment for localized prostate cancer. Arch Fam Med. 1993;2(5):487-93.
Blasko JC, Ragde H, Luse RW. Should brachytherapy be considered a therapeutic option in localized prostate cancer? Urol Clin N America. 1996;23(4):633-650.
Zietman AL, Coen JJ, Dallow KC, Shipley WU. The treatment of prostate cancer by conventional radiation therapy: an analysis of long-term outcome. Int J Radiat Oncol Biol Phys. 1995;32(2):287-292.
Leibel SA, Zelefsky MJ, Kutcher GJ, Burman CM, Kelson S, Fuks Z. Three-dimensional conformal radiation therapy in localized carcinoma of the prostate: interim report of a phase I dose-escalation study. J Urol. 1994;152(5 Pt 2):1792-1798.
Stamey TA, Ferrari MK, Schmid HP. The value of serial prostate antigen determinations 5 years after radiotherapy: steeply increasing values characterize 80% of patients. J Urol. 1993;150(6):1856-1859.
Paulson DF, Lin GH, Hinshaw W, Stephani S. Radical surgery versus radiotherapy for adenocarcinoma of the prostate. J Urol. 1982;128:502-504.
Hanks GE, Perez CA, Kozar M, Asbell SO, Pilepich MV, Pajak TF. PSA confirmation of cure at 10 years of T1b, T2, N0, M0 prostate cancer patients treated in RTOG protocol 7706 with external beam irradiation. Int J Radiat Oncol Biol Phys. 1994;30(2):289-292.
Bagshaw MA, Cox RS, Hancock SL. Control of prostate cancer with radiotherapy: long-term results. J Urol. 1994;152(5 Pt 2):1781-1785.
Hanks GE, Hanlon A, Schultheiss T, Corn B, Shipley WU, Lee WR. Early prostate cancer: the national results of radiation treatment from the Patterns of Care and Radiation Therapy Oncology Group studies with prospects for improvement with conformational radiation and adjuvant androgen deprivation. J Urol. 1994;152(5 Pt 2):1775-80.
Lu-Yao GL, Yao SL. Population-based study of long-term survival in patients with clinically localised prostate cancer. Lancet. 1997;349(9056):906-910.
Kupelian P, Levin H, Zippe C, Klein E. External beam radiotherapy versus radical prostatectomy for localized prostate cancer: a single institution experience. J Urol. 1996;155:556A.
D'Amico AV, Whittington R, Kaplan I, et al. Equivalent biochemical failure-free survival after external beam radiation therapy or radical prostatectomy in patients with a pretreatment prostate specific antigen of >4-20ng/ml. Int J Radiation Oncol Biol Phys. 1997;37(5):1053-1058.
Kaplan ID, Cox RS, Bagshaw MA. Prostate specific antigen after external beam radiotherapy for prostate cancer: follow-up. J Urol. 1993;149(3):519-522.
ASTRO. Consensus statement: guidelines for PSA following radiation therapy. Int J Radiat Oncol Biol Phys. 1997;37(5):1035-1041.
Zietman AL, Tibbs MK, Dallow KC, Althausen AF, Zlotecki, RA. Use of PSA nadir to predict subsequent biochemical outcome following external beam radiation therapy for T1-2 adenocarcinoma of the prostate. Radiother Oncol. 1996;40(2):159-162.
Critz FA, Levinson AK, Williams WH, Holladay DA. Prostate-specific antigen nadir: the optimum level after irradiation for prostate cancer. J Clin Oncol. 1996;14(11):2893-2900.
Pilepich MV, Krall JM, al-Sarraf M, et al. Androgen deprivation with radiation therapy compared with radiation therapy alone for locally advanced prostatic carcinoma: a randomized comparative trail of the Radiation Therapy Oncology Group. Urology. 1995;45(4):616-23.
Pilepich MV, Caplan R, Byhardt RW, et al. Phase III trial of androgen suppression using goserelin in unfavorable-prognosis carcinoma of the prostate treated with definitive radiotherapy: report of Radiation Therapy Oncology Group protocol 85-31. J Clin Oncol. 1997;15(3):1013-1021.
Bolla M, Gonzales D, Warde P, et al. Improved survival in patients with locally advanced prostate cancer treated with radiotherapy and goserelin. N Engl J Med. 1997;337(5):295-300.
Partin AW, Yoo J, Carter HB, et al. The use of prostate specific antigen, clinical stage and Gleason score to predict pathological stage in men with localized prostate cancer. J Urol. 1993;150(1):110-114.
Gibbons RP, Correa RJ Jr, Brannen GE, Weissman RM. Total prostatectomy for clinically localized prostate cancer: long-term results. J Urol. 1989;141(3):564-566.
Paulson DF, Moul JW, and Walther PJ. Radical prostatectomy in clinical stage T1-2 NOMO prostatic adenocarcinoma: long term results. J Urol. 1990;144(5):1180-1184.
Gerber GS, Thisted RA, Scardino PT, et al. Results of radical prostatectomy in men with clinically localized prostate cancer. JAMA. 1996;276(8):615-619.
Partin AW, Piantodosi S, Sanda MG, et al. Selection of men at high risk for disease recurrence for experimental adjuvant therapy following radical prostatectomy. Urology. 1995;45(5):831-838.
Bauer JJ, Connelly RR, Sesterhenn, IA, et al. Biostatistical modeling using traditional pre-operative and pathological prognostic variables in the selection of men at high risk for disease recurrence after radical prostatectomy for prostate cancer. J Urol. 1998;159(3):929-933.
Catalona WJ, Basler JW. Return of erections and urinary continence following nerve-sparing radical retropubic prostatectomy. J Urol. 1993;150(3):905-907.
Fowler FJ, Barry MJ, Lu-Yao G, Roman A, Wasson J, Wennberg JE. Patient-reported complications and follow-up treatment after radical prostatectomy - The National Medicine Experience: 1988-1990. (Updated June 1993). Urology. 1993;42(6):622-629.
Talcott JA, Rieker P, Propert KJ, et al. Patient-reported impotence and incontinence after nerve-sparing radical prostatectomy. J Natl Cancer Inst. 1997;89(15):1117-1123.
Gaker DL, Gaker LB, Stewart JF, Gillenwater JY. Radical prostatectomy with preservation of urinary continence. J Urol. 1996;156(2 Pt 1):445-449.
Moul JW. For incontinence after prostatectomy, tap a diversity of treatments. Contemp Urol. 1994;6(4):78, 81-88.

Sponsored by the Prostate Cancer Education Council through an educational grant from Tap Pharmaceuticals.

Patients Ask About Surgery Versus Radiation for Early Stage Prostate Cancer

About PCEC

Prostate Cancer Information

Advanced Prostate Cancer

Support our Efforts

Programs and Events

General Colin Powell

For Our Fathers