The 3 Treatment Paths for Prostate Cancer: Surgery, Radiation, and Hormones

When I was diagnosed with a Gleason 9 prostate cancer, I had a choice to make, and I am a surgeon who has spent his life helping other people make exactly this kind of choice. It humbled me anyway. The hardest part of prostate cancer is not always the disease. It is that, unlike many cancers, it usually offers more than one reasonable path, and somebody has to decide. That somebody, to a large extent, should be you.

This article lays out the three frontline treatment paths in plain language so you can understand what your doctors are offering. It is education, not a recommendation. The right choice depends on your tumor, your body, and your values.

Why Prostate Cancer Has More Options Than Most Cancers

With many cancers, the path is narrow. With prostate cancer, several treatments are often considered roughly equal in their effect on long-term survival. That is good news and a burden at once. Good, because you have choices. A burden, because choices require understanding.

When multiple treatments are considered equal in outcome, the final decision should rest, at least in large part, with you.

There are three modalities used at the beginning: surgery, radiation therapy, and hormone therapy. Chemotherapy exists, but it is usually reserved for cancer that has spread widely or recurred far down the road, not for frontline treatment. My strongest piece of advice is this: speak with a specialist from each of the three before you decide.

Path One: Surgery

Surgery means removing the prostate, most often today with a robotic radical prostatectomy. The surgeon works from a console guiding robotic arms through small incisions, with a magnified three-dimensional view. It has become the standard surgical approach and has improved outcomes compared with the old open operation.

Surgery appeals to many men for a reason I felt personally: it lets the pathologist examine the removed tissue and the lymph nodes, giving you concrete information about whether the cancer has spread. I chose surgery in part because I wanted to know my lymph node status. The main trade-offs are incontinence and erectile changes, which I cover in their own articles.

Path Two: Radiation Therapy

Radiation is one of the most common frontline treatments, and modern radiation barely resembles what was given 20 years ago. There are two broad types:

• External beam radiation, delivered over several weeks, including highly targeted modern techniques like SBRT and image-guided IMRT
• Brachytherapy, where radioactive seeds are placed directly into the prostate

Radiation can also treat isolated spots where cancer has spread. It avoids surgery and its recovery, but it carries its own side effects, including urinary, rectal, and erectile changes. For many men with lower or intermediate-grade tumors, radiation is the only treatment needed.

Path Three: Hormone Therapy (ADT)

Prostate cancer feeds on testosterone, so androgen deprivation therapy starves it of that fuel. It is rarely the whole answer by itself for frontline cure, but it is often combined with radiation, used before or after other treatment, or used when cancer recurs. It is powerful and comes with significant side effects, from hot flashes to fatigue to loss of libido, which I describe in detail elsewhere.

How I Made My Decision, and How You Might Make Yours

For my high-grade tumor, the radiation oncologists told me that full pelvic radiation plus two years of hormone therapy would likely give me the same long-term survival as surgery. My own reading of the literature agreed. So why did I choose surgery? Because I wanted the lymph node information, and because that was the right answer for me. I would not necessarily recommend it to anyone else.

Here is how to approach your own decision:

• Consult all three specialists - a surgeon, a radiation oncologist, and a medical oncologist - before committing.
• Ask whether the options are considered equal for your specific tumor grade and stage.
• Weigh the side effect profiles against your own life and priorities.
• Do not fear a second or third opinion. Confidence in your decision matters as much as the decision itself.
• Remember the time you have. In prostate cancer, the weeks spent gathering opinions are almost never dangerous.

You are going to sign forms called Informed Consent. The word that matters there is informed. Take the time to earn it.

References

• Hamdy FC, et al. 15-Year Outcomes after Monitoring, Surgery, or Radiotherapy for Prostate Cancer. N Engl J Med. 2023;388(17):1547-1558.
• Sanda MG, et al. Clinically Localized Prostate Cancer: AUA/ASTRO/SUO Guideline. J Urol. 2018;199(3):683-690.
• Mottet N, et al. EAU Guidelines on Prostate Cancer. Eur Urol. 2021;79(2):243-262.
• Wallis CJD, et al. Surgery versus radiotherapy for clinically-localized prostate cancer. Eur Urol. 2016;70(1):21-30.
• Ng KL. The Etiology of Prostate Cancer. In: Bott SRJ, Ng KL, editors. Prostate Cancer. Brisbane (AU): Exon Publications; 2021.