Study compares after-effects of prostatectomy, active surveillance, radiation, hormone therapy for prostate cancer

Prostatectomy was associated with worse incontinence and sexual function at five years than other treatment options for prostate cancer, a study found.

A prospective, population-based study included 1,386 men with favorable-risk prostate cancer (clinical stage cT1 to cT2bN0M0, prostate-specific antigen [PSA] level ≤20 ng/mL, and Grade Group 1-2) and 619 men with unfavorable-risk prostate cancer (clinical stage cT2cN0M0, PSA of 20-50 ng/mL, or Grade Group 3-5). The study compared outcomes with active surveillance (n=363), nerve-sparing prostatectomy (n=675), external beam radiation therapy (EBRT) (n=261), or low-dose-rate brachytherapy (n=87) for men with favorable-risk disease, and with prostatectomy (n=402) or EBRT with androgen deprivation therapy (n=217) for men with unfavorable-risk disease.

Researchers examined functional differences, measured by the 26-item Expanded Prostate Cancer Index Composite scores of patient-reported function (range, 0 to 100) five years after treatment. Minimum clinically important difference was 10 to 12 for sexual function, 6 to 9 for urinary incontinence, 5 to 7 for urinary irritative symptoms, and 4 to 6 for bowel and hormonal function. Results were published in the Jan. 14 JAMA.

Among men with favorable-risk prostate cancer, nerve-sparing prostatectomy was associated with worse urinary incontinence at five years (adjusted mean difference, −10.9; 95% CI, −14.2 to −7.6) and sexual function at three years (adjusted mean difference, −15.2; 95% CI, −18.8 to −11.5) compared to active surveillance. At one year compared with active surveillance, low-dose-rate brachytherapy was associated with worse urinary irritative symptoms (adjusted mean difference, −7.0; 95% CI, −10.1 to −3.9), sexual function (adjusted mean difference, −10.1; 95% CI, −14.6 to −5.7), and bowel function (adjusted mean difference, −5.0; 95% CI, −7.6 to −2.4).

EBRT was not associated with clinically different urinary, sexual, and bowel function changes compared to active surveillance at any time point through five years. For men with unfavorable-risk disease, EBRT with androgen deprivation therapy was associated with lower hormonal function at six months (adjusted mean difference, −5.3; 95% CI, −8.2 to −2.4) and bowel function at one year (adjusted mean difference, −4.1; 95% CI, −6.3 to −1.9). Compared to prostatectomy, it was associated with better sexual function at five years (adjusted mean difference, 12.5; 95% CI, 6.2 to 18.7) and incontinence at each time point through five years (adjusted mean difference, 23.2; 95% CI, 17.7 to 28.7). The study found no clinically meaningful bowel or hormonal functional differences at five years.

“Because the treatment options evaluated in this study were associated with similar prostate cancer survival and global health-related quality of life through the first 5 years, the differences in urinary, bowel, sexual, and hormonal function are the most salient outcomes during this period and may drive patient treatment selection,” the authors wrote. “Other factors, including patient preference, perception of long-term oncologic effectiveness, time commitment for treatment and recovery, out-of-pocket expenses, salvage treatment options, and provider biases and recommendation, also affect treatment choice.”