THE "NEW" PROSTATE CANCER INFOLINK

Three articles in this week’s Journal of the American Medical Association throw a little more light on issues related to quality of life after diagnosis and treatment for localized prostate cancer … but quite how much light it is difficult to tell.

The three articles are these:

• Barocas AD, et al. Association between radiation therapy, surgery, or observation for localized prostate cancer and patient reported outcomes after 3 years. JAMA. 2017;317(11):1126-1140
• Chen RC, et al. Association between choice of radical prostatectomy, external beam radiation therapy, brachytherapy, or active surveillance and patient-reported quality of life among men with localized prostate cancer. JAMA. 2017;317(11):1141-1150
• Hamdy FC, Donovan JL. Patient reported outcomes following treatment for localized prostate cancer: helping decision making for patients and their physicians. JAMA. 2017;317(11):1121-1123 (which is an editorial commentary on the prior two articles)

In the paper by Barocas et al., the authors report on the functional outcomes and adverse effects associated with surgery (radical prostatectomy), external beam radiation therapy (EBRT), and active surveillance at 3 years after enrollment among a prospectively enrolled cohort of 2,550 men, all diagnosed in 2011 or 2012 with localized, clinical stage cT1-2, prostate cancer, with PSA levels of < 50 ng/ml, who were ≤ 80 years of age, and who were enrolled into the trial within 6 months of diagnosis. The authors used the standard, 26-item, Expanded Prostate Cancer Index Composite (EPIC) questionnaire to obtain patient-reported data.

The basic results of this study are as follows:

• The average (mean) age of the patients was 63.8 years.
• 74 percent of the patients were white.
• 55 percent of the patients had intermediate- or high-risk disease.
• Of the 2,550 patients
  • 1,523 (59.7 percent) had radical prostatectomy.
  • 598 (23.5 percent) had EBRT.
  • 429 (16.8 percent) were managed on active surveillance.
• The patients treated with EBRT were, on average, 6.6 years older and had worse baseline sexual function than those treated by radical prostatectomy.
• At 3 years after enrollment,
  • The adjusted mean sexual domain score for the radical prostatectomy patients had decreased more than for the EBRT patients (mean difference, −11.9 points)
  • The decline in sexual domain scores between the EBRT and the active surveillance patients was not clinically significant (mean difference, −4.3 points).
  • The radical prostatectomy patients had worse urinary incontinence than the EBRT  patients (−18.0 points) and the active surveillance patients (−12.7 points).
  • The radical prostatectomy patients had better urinary irritative symptoms than the active surveillance patients (+5.2 points).
  • There was no evidence of clinically significant differences for bowel or hormone function after 12 months.
  • No differences were observed with regard to in health-related quality of life or disease-specific survival between the types of management.
• Three patients died of prostate cancer during the 3-year follow-up period.

Barocas et al. conclude that, based on their data

… radical prostatectomy was associated with a greater decrease in sexual function and urinary incontinence than either EBRT or active surveillance after 3 years and was associated with fewer urinary irritative symptoms than active surveillance; however, no meaningful differences existed in either bowel or hormonal function beyond 12 months or in in other domains of health-related quality-of-life measures. These findings may facilitate counseling regarding the comparative harms of contemporary treatments for prostate cancer.

In the paper by Chen et al. (see also this media release), the authors report on patient quality of life (QOL) after radical prostatectomy, EBRT, brachytherapy, and active surveillance in a cohort of 1,141 patients with newly diagnosed, localized prostate cancer enrolled between January 2011 and June 2013 in collaboration with the North Carolina Central Cancer Registry. Median time from diagnosis to enrollment was 5 weeks. In this study the authors used the validated Prostate Cancer Symptom Indices (PCSI) instrument to assess quality of life at baseline (pre-treatment) and at 3, 12, and 24 months after treatment.

The basic results of this study were:

• Average (median) age of the patients was 66 to 67 years across the different groups.
• 77 to 80 percent of the patients were white (again across the groups).
• Of the 1,141 patients
  • 469 (41.1 percent) had radical prostatectomy.
  • 249 (21.8 percent) had EBRT.
  • 109 (9.6 percent) had brachytherapy.
  • 314 (27.5 percent) were managed on active surveillance.
• Baseline (pre-treatment) PCSI scores across all groups were
  • 41.8 to 46.4 for sexual dysfunction
  • 20.8 to 22.8 for urinary obstruction and irritation
  • 9.7 to 10.5 for urinary incontinence
  • 5.7 to 6.1 for bowel problems.
• Compared with the men in the active surveillance group, at 3 months post-treatment
  • Mean sexual dysfunction scores
    • Had worsened among patients treated by radical prostatectomy (−36.2)
    • Had worsened among patients treated by EBRT (−13.9)
    • Had worsened among patients treated by brachytherapy (−17.1)
  • Urinary incontinence scores
    • Had worsened among patients treated by radical prostatectomy (−33.6)
    • Had worsened  among patients treated by EBRT (−11.7)
    • Had worsened among patients treated by brachytherapy (−20.5)Acute urinary obstruction and irritation scores
  • Bowel symptom scores
    • Had worsened among patients treated by EBRT (−4.9)
• By 24 months of follow-up, mean scores between treatment groups vs active surveillance were not significantly different in most domains.

Chen et al. conclude that, based on their data,

… each treatment strategy was associated with distinct patterns of adverse effects over 2 years. These findings can be used to promote treatment decisions that incorporate individual preferences.

Now it is certainly the case that the findings reported in these two studies could be helpful in informing patients (and their physicians) about  the side effects and complications associated with the differing “standard” types of treatment. However, this is only going to be the case if the relevant information is made available to the patients in a contextually appropriate and “neutral” manner. One of the biggest problems that patients face in the presentation of this type of information by members of the medical community is that each type of physician tends to bring his or her personal biases to the table and all such data are highly dependent on individual factors that are going to be critical for each patient. On top of that, the expanding availability of newer forms  of treatment and the risks and benefits of many of these forms of treatment are not addressed in either of these articles (an issue addressed to some extent by Hamdy and Donovan in their editorial).

On the one hand, The “New” Prostate Cancer InfoLink is delighted to see the increasing focus on quality of patient outcomes in the relevant urology literature. On the other hand, we continue to believe that currently available data and related factors make it extremely difficult for patients to come to “the best” decision for them as an individual about management for their particular prostate cancer — unless they are lucky enough to find professionals who are truly dedicated to helping their patients think through all of their possible management options in a completely neutral manner.

Filed under: Diagnosis, Living with Prostate Cancer, Management, Risk, Treatment | Tagged: decision-making, life, outcome, quality, side effects |