Table 3.

Comparison of some prostate cancer treatment options for localized disease

Treatment	Benefits	Limitations
Active surveillance/watchful waiting	Avoids treatment of insignificant cancer Not risks of side effects from surgery or radiation	Potential “anxiety” from not treating a diagnosed cancer Regular rectal exams, PSA testing with periodic/multiple biopsy to monitor Possibility that “window of curability” may be missed
Radical prostatectomy	Accurate pathologic staging Allows PSA to be more reliable marker of disease control Trials demonstrate reduction in prostate cancer specific deaths Allows potential for nerve sparing procedure Long term outcome data available (for open radical prostatectomy) Compared to radiation treatments, less issues with urinary frequency or urgency, rectal and bowel irritation Salvage possible with EBRT	Surgical risks (infection, bleeding, reaction to anesthesia, etc) For laparoscopic/robotic technique: additional risk of intrabdominal injury or pneumoperitoneum related complications; limited long term outcome data at present Limited physical activity in recovery period (2–4 weeks) Post op complications of incontinence: 5%–20% (usually stress); erectile dysfunction: up to 50% at 5 years (with nerve preservation, may be improved by medical therapy); bladder neck contractures 1%–3%; lymphocele with retropubic approach; rare rectal injury
External beam radiation therapy (EBRT) (normofractionation)	Avoids hospital stay and risk of surgery Outpatient, limited impact on daily living Long term cancer control reported Addition of hormonal therapy improved cancer control for high risk Incontinence rare (1%–2%) Urinary retention less common than with brachytherapy	No post-treatment staging information Daily treatments for 6–8 weeks Fatigue may occur when treatment ends Erectile dysfunction: up to 50% at 5 years Bowel/rectal problems: 5%–10% (urgency, pain, diarrhea, or bleeding) but typically improve after treatment Bladder irritation: 5% (urinary frequency, urgency, discomfort) Salvage therapies limited or associated with high complication rate
Stereotactic body radiotherapy (hypofractionation)	“Convenient” outpatient treatments as short as five days	Utility and side effect profile not well studied
Brachytherapy	Minimal surgical risks, one time outpatient surgical procedure Best for low risk prostate cancer Delivers higher dose to prostate target, less to surrounding tissues Long term data available Low rate of incontinence (1%–2%)	Not useful for intermediate or high risk cancer Very small and very large glands (<20 cc, >80 cc) challenging No final pathologic staging Less favorable option for men with intermediate- or high-risk disease Not recommended for men with significant lower urinary tract symptoms Urinary tract side effects (retention, urgency, frequency) more common than with other therapies ED outcomes similar to EBRT Salvage therapies limited or associated with high complication rate
Proton beam therapy	Ability to deliver dose to prostate and avoid other structures	Most costly infrastructure of all treatments No trials to demonstrate superiority over current radiation modalities Limited number of facilities
Cryotherapy	One time treatment, often outpatient Can be repeated Allows for potential “focal” therapy	No final pathology Side effect profiles can be difficult to manage, but improving with newer techniques High rate of ED for whole gland therapy