In an observational cohort study reported in JAMA, Al Awamlh et al identified adverse functional outcomes after localized prostate cancer treatment among patients with favorable- and unfavorable-prognosis disease.
Study Details
The study included 2,445 patients from five SEER (Surveillance, Epidemiology, and End Results) program registries treated between 2011 and 2012. At baseline, 1,877 patients had a favorable prognosis (defined as cT1-cT2bN0M0, prostate-specific antigen [PSA] level < 20 ng/mL, and grade group 1–2) and 568 had an unfavorable prognosis (defined as cT2cN0M0, PSA level of 20–50 ng/mL, and grade group 3–5). Follow-up data were collected via questionnaire through February 2022.
Patients with a favorable prognosis received radical prostatectomy (n = 1,043), external-beam radiotherapy (n = 359, with no androgen-deprivation therapy [ADT]), brachytherapy (n = 96), or active surveillance (n = 379). Those with unfavorable prognosis received radical prostatectomy (n = 362) or external-beam radiotherapy with ADT (n = 206). Outcomes were patient-reported sexual, urinary, bowel, and hormone function measured using the 26-item Expanded Prostate Cancer Index Composite (range = 0–100; 100 = best). Outcomes were estimated and compared at 10 years after treatment, adjusting for baseline scores and patient and tumor characteristics. Minimum clinically important differences were 10 to 12 for sexual function, 6 to 9 for urinary incontinence, 5 to 7 for urinary irritation, and 4 to 6 for bowel and hormone function.
Selected outcomes by treatment are reported below.
Key Findings
At 10-year follow-up among 1,877 patients with favorable prognosis, radical prostatectomy was associated with worse urinary incontinence (adjusted mean difference = −12.1, 95% confidence interval [CI] = −16.2 to −8.0) but not worse sexual function (adjusted mean difference = −7.2, 95% CI = −12.3 to −2.0) or bowel function (adjusted mean difference = 0.8, 95% CI = −1.3 to 2.8) compared with active surveillance. Prostatectomy was also associated with worse urinary incontinence but not worse sexual function compared with radiotherapy.
At 10-year follow up among 568 patients with unfavorable prognosis, radical prostatectomy was associated with worse urinary incontinence (adjusted mean difference = −26.6, 95% CI = −35.0 to −18.2) but not worse sexual function (adjusted mean difference = −1.4, 95% CI = −11.1 to 8.3) compared with external-beam radiotherapy with ADT. External-beam radiotherapy with ADT was associated with worse bowel function (adjusted mean difference = −4.9, 95% CI = −9.2 to −0.7) and hormone function (adjusted mean difference = −4.9, 95% CI = −9.5 to −0.3) compared with radical prostatectomy.
The investigators concluded, “Among patients treated for localized prostate cancer, radical prostatectomy was associated with worse urinary incontinence but not worse sexual function at 10-year follow-up compared with radiotherapy or surveillance among people with more favorable prognosis and compared with radiotherapy for those with unfavorable prognosis. Among men with unfavorable-prognosis disease, external-beam radiotherapy with androgen-deprivation therapy was associated with worse bowel and hormone function at 10-year follow-up compared with radical prostatectomy.”
Daniel A. Barocas, MD, MPH, of the Department of Urologic Surgery, Vanderbilt University Medical Center, is the corresponding author for the JAMA article.
Disclosure: The study was supported by the National Institutes of Health and National Cancer Institute. For full disclosures of the study authors, visit jamanetwork.com.
