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Commentary on: Chen RC, Basak R, Meyer AM, et al. Association between choice of radical prostatectomy, external beam radiotherapy, brachytherapy, or active surveillance and patient-reported quality of life among men with localised prostate cancer. JAMA 2017;317:1141–50.
Many patients with prostate cancer are diagnosed with low-risk disease only, for whom the benefit of surgery or radiation on life expectancy may be very limited, while still bringing the risk of side effects.1 2 Therefore, patients with low-risk prostate cancer are currently offered the option of active surveillance. This strategy delays therapy with curative intent until progression occurs, or it may completely avoid radical treatment.3 As a result, in the treatment decision-making process of patients newly diagnosed with prostate cancer, up-to-date and preferably personalised information about the possible positive and negative effects of the treatment options is vital.
Chen and colleagues conducted a US population-based, observational study on 1141 men diagnosed with mostly localised prostate cancer. The three accepted treatment options (prostatectomy (n=469), external-beam radiation therapy (EBRT) (n=249) and brachytherapy (n=109)) were compared against active surveillance (n=314) regarding health-related quality of life (QoL) outcomes. Of those undergoing radical therapy, most received the most modern treatment options (ie, 87% of surgical cases performed robotically, 70% of EBRT delivered image guided and intensity modulated). Validated questionnaires were conducted by telephone at fixed time points up to 2 years after diagnosis. A baseline measurement was also included and was used to stratify follow-up QoL scores for men with normal, intermediate or poor scores at diagnosis. The commonly used health-related outcome parameters sexual dysfunction, urinary obstruction and irritation, urinary incontinence, and bowel problems were assessed (scored from 0 to 100, with higher scores indicating more dysfunction). At least one follow-up survey was completed by 85%. Propensity scores were used to correct for the differences at baseline between the four treatment cohorts.
Active surveillance patients reported best sexual, urinary and bowel function scores. Mean sexual function scores worsened from baseline for patients who underwent surgery (36.2 (95% CI 30.4 to 42.0)), EBRT (13.9 (95% CI 6.7 to 21.2)) and brachytherapy (17.1 (95% CI 97.8 to 26.6)). Mean urinary incontinence scores also worsened from baseline for patients who underwent surgery (33.6 (95% CI 27.8 to 39.2)). The radiotherapy options increased the risk of bowel (4.9 increase (2.4–7.4)) and irritative urinary symptoms (11.7 increase (8.7–14.8)). Patients with poor baseline function, regardless of treatment option, are at increased risk of poor functioning at 24 months. However, men with baseline urinary obstruction and irritation seemed to be better off with surgery. The effects described above faded out over the period of up to 2 years after diagnosis.
The following points help to properly interpret the results.
First, not all patients are suitable for all treatment options. Among other factors, tumour and patient characteristics, symptoms, preferences and physical function are taken into account when considering the options in clinical practice. It is impossible to retrospectively correct for this selection process in a non-randomised study.
Second, the profile of patients is mainly low risk, 85.5% had a prostate specific antigen <10.0 ng/mL and 58.2% a Gleason score of only 6. Treatments for higher risk disease may more frequently include multimodal therapy or (neo)adjuvant hormones and have a larger impact, also on overall QoL and on anxiety and distress measures that are not considered in the current study.
Third, follow-up is relatively short. Side effects such as cystitis or proctitis, or the need for secondary treatments may surface later than 2 years.
Fourth, in order to assess the true advantage of active surveillance on an individual level, it would be interesting to compare the results of patients who started and remained on active surveillance versus patients who started radical treatment during active surveillance. In addition, it would be interesting to compare the men with delayed treatment with patients who primarily started a similar treatment.
Fifth, stratification of risks by treatment and baseline function level provides a significant contribution to the aim for personalised information in counselling patients newly diagnosed with localised prostate cancer.
This study essentially demonstrates a similar pattern of side effects as the randomised UK-based ProtecT study, despite the latter including lower frequencies of up-to-date treatment methods.4 Also, it confirms the findings of a systematic review performed by the European Association of Urology Guidelines Committee.5
Implications for practice
Distinctive side effects can be expected from the available treatment options for localised prostate cancer. Baseline function is an important predictor. Active surveillance spares different important health-related QoL domains compared with surgery or radiation and may therefore be the preferred option in those suitable.
Competing interests None declared.
Provenance and peer review Commissioned; internally peer reviewed.
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