JAMA study reveals side effect impact of localized prostate cancer treatments

A study published in JAMA comparing adverse event outcomes by treatment type for patients with localized prostate cancer reveals most functional differences diminish over time but differences in urinary incontinence and sexual function impairment persist through five years.  

“These findings are important because men consider the expected impact of treatment on urinary, sexual, bowel and hormonal function when selecting among the multiple treatments for localized prostate cancer,” says Karen Hoffman, M.D., associate professor of Radiation Oncology and the study’s lead and corresponding author.

The five-year disease-specific survival rate for localized prostate cancer is nearly 100%, but patients often experience treatment side effects that can decrease their quality of life. Comparing adverse event outcomes of various treatment options empowers patients to make an informed choice about their treatment plan.

“Since treatment options and treatment intensity vary based on cancer severity, we evaluated patient-reported function after treatment for favorable-risk prostate cancer separately from function after treatment for unfavorable-risk disease,” Hoffman says.

The Comparative Effectiveness Analysis of Surgery and Radiation (CEASAR) study addressed treatment-related side effects in the two groups of patients:

• Those with favorable-risk prostate cancer (1,386 patients), who were treated with active surveillance, low-dose-rate brachytherapy, nerve-sparing prostatectomy, or external beam radiation therapy (EBRT) alone.
• Those with unfavorable-risk prostate cancer (619 men) who must be treated more aggressively with EBRT exposure to a larger area plus androgen deprivation therapy or with more extensive surgical resection that may remove one or both of the nerves necessary for erectile function.

Participants completed surveys at baseline and at six months, one year, three years and five years after enrollment. Surveys included sociodemographic variables. Researchers used the validated 26-item Expanded Prostate Index Composite to evaluate the primary outcomes of the study: patient-reported urinary incontinence, urinary irritation, bowel function, sexual function and hormonal function.

Researchers also used the validated Medical Outcomes Study 36-Item Short Form Survey to evaluate quality of life, including the primary outcomes of the study for physical functioning, emotional well-being, energy levels and fatigue. Secondary outcomes included sexual function bother, erection insufficient for penetration, urinary function bother, urinary leakage, burning on urination, frequent urination, bowel function bother, bloody stools and bowel urgency.

Major findings include:

• Most urinary, bowel, sexual and hormonal functional differences across treatments diminished over five years.
• Patients who underwent prostatectomy experienced worse urinary incontinence than patients who received other treatment options, regardless of their disease risk.
• Less than 50% of men with unfavorable-risk prostate cancer, regardless of the treatment type, reported the ability to maintain erections sufficient for intercourse at five years. Men in this group who underwent prostatectomy experienced worse sexual function at five years than those who underwent radiation therapy and androgen deprivation.
• Generally, most men in the study experienced declines in sexual function, which can be attributed not only to prostate cancer treatment but also to increasing age.

Helping men make informed choices about prostate cancer treatment

“Physicians should use this information to counsel men on the anticipated side effects of contemporary prostate cancer treatment options and to help men make an informed treatment choice,” Hoffman says.

Participants were prospectively recruited from five Surveillance, Epidemiology, and End Results Program sites and the Prostate Strategic Urologic Research Endeavor, a U.S. registry.

CEASAR addressed some deficiencies in previous studies of adverse event outcomes, which were limited because they did not include relatively new treatment options (such as robotic prostatectomy and intensity-modulated radiation therapy delivered with image guidance), did not stratify patients by disease risk, did not include non-white participants, did not include active surveillance as a control, and/or had limited follow-up.

In CEASAR, 75% of prostatectomies employed robotic surgery, most men received intensity-modulated radiation therapy with image-guidance and 23% of study participants were non-white.

Refer a patient to MD Anderson online or by calling 1-877-632-6789.