Introduction
If you or a loved one has been diagnosed with prostate cancer, one of the first questions you may have is: “Which type of specialist should I see?”
Two of the main physicians involved in prostate cancer care are urologists and radiation oncologists. Both play important roles, but they approach treatment from different perspectives:
- Urologists are surgeons and interventional specialists who diagnose and treat prostate cancer using a variety of tools, including surgery, focal therapies like Pulsed Electrical Field Ablation (PEFA), and in some centers, brachytherapy.
- Radiation oncologists specialize exclusively in radiation therapy, which is a valuable treatment but represents just one option.
This article explores the differences between urologists and radiation oncologists, the treatments they provide, and why seeing a urologist first often makes the most sense for men considering all their options.
Section 1: The Urologist’s Role in Prostate Cancer Care
Urologists are physicians who specialize in diseases of the urinary tract and male reproductive system. In prostate cancer, they are often the first specialists involved because:
- They perform diagnostic work-up (PSA blood tests, digital rectal exams, prostate biopsies).
- They interpret imaging studies like multiparametric MRI.
- They help stratify risk by reviewing biopsy pathology, Gleason scores, and cancer stage.
But most importantly, urologists have the broadest toolbox for prostate cancer treatment:
Surgical Options
- Robot-Assisted Laparoscopic Prostatectomy (RALP):
A minimally invasive surgery to remove the prostate. Urologists are the only physicians trained to perform this.
Focal Therapy Options
- Pulsed Electrical Field Ablation (PEFA):
A non-thermal, minimally invasive procedure that destroys cancer cells while preserving nerves and urinary function. Urologists are leading the way in offering this new technology for men with low-volume Gleason 6 and 7 cancers with MRI-visible lesions.
Radiation-Based Option Within Urology
- Brachytherapy (Seed Implantation):
Some urologists, often in collaboration with radiation oncologists, provide brachytherapy — implanting tiny radioactive seeds into the prostate for localized treatment.
Active Surveillance
- For men with very low-risk prostate cancer, urologists guide active surveillance, using regular PSA tests, imaging, and biopsies to monitor cancer safely without immediate treatment.
Bottom line: Urologists offer surgery, focal therapy, surveillance, and in some practices even radiation-based brachytherapy — a true spectrum of care.
Section 2: The Radiation Oncologist’s Role
Radiation oncologists are physicians who specialize in using high-energy radiation to kill cancer cells. Their role is focused and valuable, but also limited.
Main Treatment Offered
- External Beam Radiation Therapy (EBRT):
Delivered over several weeks in daily sessions, radiation beams are precisely targeted to the prostate to damage cancer DNA. - Brachytherapy (in collaboration with urologists):
In some cases, radiation oncologists participate in seed implantation, though many programs are urology-led.
Strengths of Radiation Oncologists
- Deep expertise in planning and delivering radiation safely.
- Long-term data showing excellent cancer control for intermediate and high-risk patients.
- Non-surgical option for men who are poor candidates for surgery.
Limitations
- One primary tool: Radiation oncologists only offer radiation. If you see them first, you’re most likely to be recommended radiation — whether or not it’s the ideal choice for you.
- Side effects: Radiation can cause bowel, urinary, and sexual side effects over time.
- Future treatment limitations: If cancer returns after radiation, salvage options (surgery, ablation) are more complex and carry higher risks.
Section 3: Comparing the Toolkits
Here’s how the scope of each specialty stacks up:
| Treatment Option | Urologist | Radiation Oncologist |
|---|---|---|
| Active Surveillance | ✅ Yes | ❌ No |
| Surgery (RALP) | ✅ Yes | ❌ No |
| Pulsed Electrical Field Ablation (PEFA) | ✅ Yes | ❌ No |
| Other Focal Therapies (HIFU, Cryo in some centers) | ✅ Yes | ❌ No |
| External Beam Radiation | ❌ (refer if indicated) | ✅ Yes |
| Brachytherapy | ✅ Often yes | ✅ Often yes |
| Systemic Therapies (ADT, chemo, immuno)* | ✅ Sometimes co-managed | ✅ Sometimes co-managed |
*Note: systemic therapies are often co-managed with medical oncologists.
Section 4: Why Starting With a Urologist Makes Sense
1. Access to All Options
A urologist can review your diagnosis and offer the full spectrum of treatments — from “do nothing yet” (active surveillance), to surgery, to focal therapies like PEFA, to radiation referrals when appropriate.
2. Personalized Matching of Risk and Treatment
- Low-risk cancers (Gleason 6): Active surveillance or focal therapy (PEFA).
- Favorable intermediate-risk (Gleason 7, 3+4): Focal therapy (PEFA) or surgery.
- High-risk (Gleason 7 [4+3] or higher): Surgery or radiation, often combined with hormone therapy.
3. Technology Leadership
Urologists are at the forefront of new minimally invasive technologies. PEFA is a prime example — offering cancer control with fewer side effects than surgery or radiation.
4. Continuity of Care
Because urologists also manage urinary and sexual function, they’re better positioned to guide recovery and address side effects, regardless of treatment choice.
Section 5: The Case for Pulsed Electrical Field Ablation (PEFA)
Among the options urologists provide, PEFA is generating the most excitement for select patients:
- Ideal candidates: Men with low-volume Gleason 6 and 7 (3+4) cancers visible on MRI.
- Advantages:
- Outpatient, minimally invasive.
- Preserves nerves, sphincter, and sexual function.
- Rapid recovery (back to activities in days).
- Repeatable if needed.
- Comparison with Radiation:
- Radiation treats the whole prostate; PEFA targets only the cancer.
- Radiation side effects accumulate over years; PEFA preserves quality of life.
- Future treatments after PEFA remain possible; post-radiation salvage is harder.
Section 6: When Radiation Still Makes Sense
Radiation therapy is an important tool and remains a strong choice for:
- Older men who are not surgical candidates.
- Intermediate-to-high risk cancers (especially Gleason 7 [4+3] and above).
- Men preferring non-surgical treatment who accept the long-term side effect profile.
But for men with early, low-volume cancers, radiation is often too much treatment, exposing them to lifelong side effects when focal therapies like PEFA could have been enough.
Section 7: Quality of Life Considerations
Men consistently rank quality of life among their top concerns.
- Radiation: Erectile dysfunction, bowel leakage, and urinary irritation can worsen years later.
- Surgery (RALP): Excellent cancer control, but risks of incontinence and erectile dysfunction.
- PEFA: Designed to minimize these risks, making it attractive to men in their 50s and 60s who want treatment without sacrificing function.
Section 8: How to Decide
- Step 1: Risk Assessment
Confirm Gleason score, PSA, MRI findings, and volume of disease. - Step 2: Specialist Consultation
Meet with a urologist to learn the full menu of options. - Step 3: Individual Goals
Consider age, health, lifestyle, and priorities (cure vs. function preservation). - Step 4: Shared Decision-Making
Decide together with your physician which path aligns best.
Section 9: Frequently Asked Questions
Q: If I see a urologist first, will they still tell me about radiation?
A: Yes. Urologists refer to radiation oncologists when it’s appropriate — but you’ll also hear about surgery, surveillance, and focal therapy.
Q: Is PEFA experimental?
A: No. PEFA is an FDA-cleared technology that is gaining adoption in leading urology centers.
Q: Can I have PEFA first and radiation later if needed?
A: Yes. One of PEFA’s biggest advantages is that it preserves future treatment options.
Q: Which doctor should I trust most?
A: Both urologists and radiation oncologists are highly trained. But only urologists offer the full spectrum of prostate cancer treatments.
Conclusion
Both urologists and radiation oncologists play important roles in prostate cancer care. But when you are first diagnosed, the doctor who can show you all of your options — from surveillance, to focal therapy like PEFA, to surgery, to radiation — is the urologist.
Radiation oncologists are experts in radiation, but that’s just one tool. Urologists bring the full arsenal:
- Active Surveillance for safe monitoring.
- Robot-Assisted Laparoscopic Prostatectomy (RALP) for surgical cure.
- Pulsed Electrical Field Ablation (PEFA) for focal, minimally invasive treatment.
- Brachytherapy in selected cases.
Our recommendation: See a urologist first. That way, you’ll hear the whole story, not just one chapter.
👉 Contact Atlanta Prostate Center today to learn whether PEFA, surgery, or another approach is right for you.
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