Adverse outcomes associated with treatments for localized prostate cancer remain unclear.
To compare rates of adverse functional outcomes between specific treatments for localized prostate cancer.
An observational cohort study using data from 5 US Surveillance, Epidemiology, and End Results Program registries. Participants were treated for localized prostate cancer between 2011 and 2012. At baseline, 1877 had favorable-prognosis prostate cancer (defined as cT1-cT2bN0M0, prostate-specific antigen level <20 ng/mL, and grade group 1-2) and 568 had unfavorable-prognosis prostate cancer (defined as cT2cN0M0, prostate-specific antigen level of 20-50 ng/mL, or grade group 3-5). Follow-up data were collected by questionnaire through February 1, 2022.
Radical prostatectomy (n = 1043), external beam radiotherapy (n = 359), brachytherapy (n = 96), or active surveillance (n = 379) for favorable-prognosis disease and radical prostatectomy (n = 362) or external beam radiotherapy with androgen deprivation therapy (n = 206) for unfavorable-prognosis disease.
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). Associations of specific therapies with each outcome were estimated and compared at 10 years after treatment, adjusting for corresponding 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.
A total of 2445 patients with localized prostate cancer (median age, 64 years; 14% Black, 8% Hispanic) were included and followed up for a median of 9.5 years. Among 1877 patients with favorable prognosis, radical prostatectomy was associated with worse urinary incontinence (adjusted mean difference, -12.1 [95% CI, -16.2 to -8.0]), but not worse sexual function (adjusted mean difference, -7.2 [95% CI, -12.3 to -2.0]), compared with active surveillance. 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 androgen deprivation therapy. Among patients with unfavorable prognosis, external beam radiotherapy with androgen deprivation therapy was associated with worse bowel (adjusted mean difference, -4.9 [95% CI, -9.2 to -0.7]) and hormone (adjusted mean difference, -4.9 [95% CI, -9.5 to -0.3]) function compared with radical prostatectomy.
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.
JAMA. 2024 Jan 23 [Epub]
Bashir Al Hussein Al Awamlh, Christopher J D Wallis, David F Penson, Li-Ching Huang, Zhiguo Zhao, Ralph Conwill, Ruchika Talwar, Alicia K Morgans, Michael Goodman, Ann S Hamilton, Xiao-Cheng Wu, Lisa E Paddock, Antoinette Stroup, Brock B O'Neil, Tatsuki Koyama, Karen E Hoffman, Daniel A Barocas
Department of Urology, Vanderbilt University Medical Center, Nashville, Tennessee., Division of Urology, Department of Surgery, University of Toronto, Toronto, Ontario, Canada., Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee., Office of Patient and Community Education, Patient Advocacy Program, Vanderbilt Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, Tennessee., Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts., Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, Georgia., Department of Population and Public Health Sciences, Keck School of Medicine at the University of Southern California, Los Angeles., Department of Epidemiology, Louisiana State University New Orleans School of Public Health, New Orleans., Cancer Epidemiology Services, New Jersey Department of Health, Rutgers Cancer Institute of New Jersey, New Brunswick., Department of Urology, University of Utah Health, Salt Lake City., Department of Radiation Oncology, The University of Texas MD Anderson Center, Houston.