March 2024
Adverse outcomes following curative treatment for prostate cancer

Functional outcomes at 10 years varied by type of treatment and prognosis.

Patients with clinically localised prostate cancer are typically offered an array of treatment options that may include active surveillance, radical prostatectomy and radiotherapy, with or without androgen-deprivation therapy (ADT). No prospective data on disease outcomes provide support for either surgery or radiotherapy, therefore many patients make treatment decisions based on their understanding of the potential impact on urinary, sexual or bowel function.

Investigators evaluated treatment-related functional outcomes in an observational study of 2445 patients treated for localised prostate cancer who were enrolled in the Comparative Effectiveness Analysis of Surgery and Radiation (CEASAR) study. Patients were divided into two groups at the time of diagnosis: favourable prognosis (cT1 or T2a/bN0M0, prostate specific antigen [PSA] 20 mcg/L or lower, and grade group 1 to 2) and unfavourable prognosis (cT2cN0M0, PSA 20 to 50 mcg/L or grade group 3 to 5). The primary outcomes were 10-year patient-reported sexual, urinary incontinence, urinary irritation, bowel and hormone function domain scores, measured with the validated Prostate Cancer Index Composite (EPIC-26).

Patients’ median age was 64 years; 14% were African American, 8% Hispanic. Patients in the favourable-prognosis group underwent radical prostatectomy (1088 patients), radiotherapy (380), active surveillance (414) and low-dose brachytherapy (96). Patients in the unfavourable-prognosis group underwent radical prostatectomy (387) and radiotherapy (220).

Among patients with favourable prognosis, those undergoing radical prostatectomy had worse urinary incontinence but no major difference in sexual function compared with patients followed with active surveillance. Among patients with unfavourable prognosis, those treated with radical prostatectomy had worse urinary incontinence but no major difference in sexual function compared with those treated with radiotherapy plus ADT; patients managed with radiotherapy plus ADT experienced worse bowel and hormone function than those treated with radical prostatectomy.

Comment: Patients faced with management decisions for clinically localised prostate cancer may seek out opinions from medical oncologists as ‘neutral arbiters.’ Large, well-done studies with long-term follow up are an important source of data to help us guide these decisions.

Robert Dreicer, MD, MS, FACP, FASCO, Deputy Director University of Virginia Cancer Center, Professor of Medicine and Urology University of Virginia School of Medicine, Charlottesville, USA.

Al Hussein Al Awamlh B, et al. Functional outcomes after localized prostate cancer treatment. JAMA 2024; 331: 302-317.

This summary is taken from the following Journal Watch title: Oncology and Hematology.