Radical Prostatectomy versus Brachytherapy for Early-Stage Prostate Cancer

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Abstract
Background and Purpose: The considerations in choosing a treatment for prostate cancer are potential for cure, acute toxicity, long-term morbidity, quality of life, and direct and indirect costs. The classic options are radical prostatectomy, external-beam radiation, and watchful waiting. During the last decade, technological advances have fostered another: brachytherapy. Methods: This article compares brachytherapy and radical prostatectomy in terms of cancer control, complications, and cost using series from medical centers that have pioneered and advocated particular procedures. Results: In the surgical series from Johns Hopkins, the 7-year success rate (no PSA >0.2 ng/mL) of anatomic radical prostatectomy was 97.8% in patients with stage T2c or lower disease and a Gleason score of ≤6. In the brachytherapy series from Seattle, the 7-year success rate (PSA ≤0.5 ng/mL) was 79%. Postoperatively, 68% of the patients who were potent preoperatively maintained erectile function, and 92% were fully continent. Urethral toxicity is slightly more common in patients treated by brachytherapy, but in the authors' series, no patient remained incontinent after 6 months. Some patients became impotent during follow-up. The cost of brachytherapy ($16,200) is less than that of ($27,000), although the difference may be reduced by the use of neoadjuvant hormonal therapy with the former. Conclusion: Patients receiving brachytherapy appear to have a slightly higher rate of disease progression. The side effects generally are acceptable and may be less severe than those of surgery. Further follow-up data are needed to define the roles of these two treatments for early-stage prostate cancer.