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Abstract

IMPORTANCE:

Understanding the adverse effects of contemporary approaches to localized prostate cancer treatment could inform shared decision making.

OBJECTIVE:

To compare functional outcomes and adverse effects associated with radical prostatectomy, external beam radiation therapy (EBRT), and active surveillance.

DESIGN, SETTING, AND PARTICIPANTS:

Prospective, population-based, cohort study involving 2550 men (≤80 years) diagnosed in 2011-2012 with clinical stage cT1-2, localized prostate cancer, with prostate-specific antigen levels less than 50 ng/mL, and enrolled within 6 months of diagnosis.

EXPOSURES:

Treatment with radical prostatectomy, EBRT, or active surveillance was ascertained within 1 year of diagnosis.

MAIN OUTCOMES AND MEASURES:

Patient-reported function on the 26-item Expanded Prostate Cancer Index Composite (EPIC) 36 months after enrollment. Higher domain scores (range, 0-100) indicate better function. Minimum clinically important difference was defined as 10 to 12 points for sexual function, 6 for urinary incontinence, 5 for urinary irritative symptoms, 5 for bowel function, and 4 for hormonal function.

RESULTS:

The cohort included 2550 men (mean age, 63.8 years; 74% white, 55% had intermediate- or high-risk disease), of whom 1523 (59.7%) underwent radical prostatectomy, 598 (23.5%) EBRT, and 429 (16.8%) active surveillance. Men in the EBRT group were older (mean age, 68.1 years vs 61.5 years, P < .001) and had worse baseline sexual function (mean score, 52.3 vs 65.2, P < .001) than men in the radical prostatectomy group. At 3 years, the adjusted mean sexual domain score for radical prostatectomy decreased more than for EBRT (mean difference, -11.9 points; 95% CI, -15.1 to -8.7). The decline in sexual domain scores between EBRT and active surveillance was not clinically significant (-4.3 points; 95% CI, -9.2 to 0.7). Radical prostatectomy was associated with worse urinary incontinence than EBRT (-18.0 points; 95% CI, -20.5 to -15.4) and active surveillance (-12.7 points; 95% CI, -16.0 to -9.3) but was associated with better urinary irritative symptoms than active surveillance (5.2 points; 95% CI, 3.2 to 7.2). No clinically significant differences for bowel or hormone function were noted beyond 12 months. No differences in health-related quality of life or disease-specific survival (3 deaths) were noted (99.7%-100%).

CONCLUSIONS AND RELEVANCE:

In this cohort of men with localized prostate cancer, radical prostatectomy was associated with a greater decrease in sexual function and urinary incontinence than either EBRT or active surveillance after 3 years and was associated with fewer urinary irritative symptoms than active surveillance; however, no meaningful differences existed in either bowel or hormonal function beyond 12 months or in in other domains of health-related quality-of-life measures. These findings may facilitate counseling regarding the comparative harms of contemporary treatments for prostate cancer.

Comment in Patient-Reported Outcomes Following Treatment for Localized Prostate Cancer: Helping Decision Making for Patients and Their Physicians. [JAMA. 2017]​

Question 

What are the comparative harms of contemporary treatments for localized prostate cancer?

Findings

In this prospective, population-based cohort study involving 2550 men, radical prostatectomy was associated with significant declines in sexual function compared with external beam radiation therapy (−11.9 points on a 100-point scale) and active surveillance (−16.2 points) at 3 years. Radical prostatectomy was also associated with significant declines in urinary incontinence compared with radiation and active surveillance, but there were no meaningful differences in bowel or hormonal function beyond 12 months, and no meaningful differences in health-related quality of life.

Meaning 

These findings may facilitate treatment counseling of men with localized prostate cancer.​

Author information

Barocas DA1, Alvarez J2, Resnick MJ1, Koyama T2, Hoffman KE3, Tyson MD1, Conwill R4, McCollum D4, Cooperberg MR5, Goodman M6, Greenfield S7, Hamilton AS8, Hashibe M9, Kaplan SH10, Paddock LE11, Stroup AM11, Wu XC12, Penson DF13.

1 Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee.

2 Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee.

3 Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston.

4 Prostate Cancer Patient Advocate, Vanderbilt Ingram Cancer Center, Nashville, Tennessee.

5 Department of Urology, University of California, San Francisco Medical Center, San Francisco.

6 Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia.

7 Center for Health Policy Research and Department of Medicine, University of California, Irvine.

8 Department of Preventative Medicine, Keck School of Medicine, University of Southern California, Los Angeles.

9 Department of Family and Preventative Medicine, University of Utah, Salt Lake City.

10 Health Policy Research Institute, University of California, Irvine.

11 Rutgers Cancer Institute of New Jersey, Rutgers University, New Brunswick.

12 School of Public Health, Louisiana State University Health Sciences Center, New Orleans.

13 Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee13Tennessee Valley Veterans Administration Health System, Nashville, Tennessee.