EAU 2018: AUA Lecture: Patient-Reported Outcomes After Prostate Cancer Therapy: How Good Are We Doing?
Dr. Chang believes that studying these outcomes are important for shared decision making between patient and physician, and they can help determine the overall impact of treatment on patient choices. Furthermore, it is a way to compare contemporary treatments, such as active surveillance, radical prostatectomy, and radiotherapy. Finally, patient reported outcomes often capture and detect many more symptoms and effects of treatment than a physician assessment alone.
He discussed the Comparative Effectiveness Analysis of Surgery and Radiation (CEASAR) trial, which is an ongoing prospective, population-based observational trial which began enrolling men undergoing prostate cancer treatment in 2011 and will follow them for 10 years. He believes that by compiling the data from this trial, it can help patients and physicians work together in shared decision making to decide which treatment is best for an individual based on their expectations, goals, and personal values. Because short term (5 year) oncologic outcomes are equivalent for men with prostate cancer regardless of their treatment options, mitigating and managing the side-effects becomes an important quality of life measure for these men, and should factor into their decision for which treatment they choose. He notes that for the first 5-10 years after treatment, side-effects of treatment may be the only meaningful outcomes for men undergoing treatment because of the slow nature of prostate cancer. Chang reviewed the typical time course of the side effects of treatment for urinary function, sexual function, and bowel function for each of the three main treatment options for prostate cancer including active surveillance, surgery, and radiotherapy. He notes that the decisions for treatment are often made based on perceived tradeoffs between benefits and harms.
Dr. Chang then reviewed some of the 3-year data from the CEASAR trial regarding urinary continence and sexual function. For urinary continence, as expected, men after radical prostatectomy have a decrease in urinary continence immediately after surgery and this slowly improves and plateaus around 12-18 months, however, remains lower, on average, than a man who underwent external beam radiotherapy (EBRT) or active surveillance. For sexual function, post-operative function is highly dependent on pre-operative function, regardless of the treatment option that is chosen. Outcomes are equivalent between prostatectomy and EBRT when stratified by pre-operative function, except for men with the highest quartile of pre-operative function, who had slightly better post-operative sexual function with EBRT. Interestingly, when stratified by severity of disease, men with worse disease tended to have worse functional outcomes (both urinary and sexual) than men with low risk disease.
Dr. Chang concluded by showing an online calculator that he and colleagues are working on in which men can input variables such as age, ethnicity, PSA value, Gleason score, sexual and urinary function and can receive personalized estimates of post-operative functional outcomes based on their information. He believes that this tool can be extremely helpful for men in comparing treatment options and deciding based on their personal goals and values. He believes that patient reported QOL outcomes are extremely important to study in order to power discussions regarding treatment. 10 year data from the CEASAR trial will be available in 2023 and will further add to our understanding of the differences in treatment options for prostate cancer.
Presented by: Sam Chang, MD, MBA, Patricia and Rodes Hart Endowed Chair of Urologic Surgery, Professor, Department of Urology, Vanderbilt University in Nashville, Tennessee, United States
Written by: Brian Kadow, MD. Society of Urologic Oncology Fellow, Fox Chase Cancer Center at the 34th European Association of Urology (EAU 2019) #EAU19 conference in Barcelona, Spain, March 15-19, 2019.