Quality of life outcomes 


In addition to analyses of the comparative oncologic efficacy of surgery and radiation therapy for PCa increasing attention has focused on the relative toxicities of treatments as well. Since the advent of PSA screening, treatment-related impact on quality of life (QoL) is particularly amplified by the younger age at diagnosis for patients with PCa.

Unfortunately, little exists in terms of randomized trial data to evaluate QoL measures following RRP and RT. Studies have moreover historically also been limited by a lack of baseline functional assessment of patients. Nevertheless, several recent prospective series have been reported, using validated QoL instruments and incorporating pretreatment functional data, which merit mention here.


Litwin et al evaluated 580 men with clinically-localized PCa who were undergoing RRP (307), external beam RT (n=78), or BT (n=90).44 Assessments were conducted before and through 24 months after treatment using the Short Form-36 Health Survey (SF-36), which reports scores for physical and mental components, as well as the University of California-Los Angeles Prostate Cancer Index (PCI), which measures urinary, sexual, and bowel habits with function and bother scores. These investigators found that obstructive and irritative urinary symptoms were more common after BT, while men who underwent RRP had worse urinary control and sexual function than either radiation cohort (p<0.001).44


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Interestingly, however, beyond four months post-treatment, the proportion of men reporting severe urinary bother did not differ significantly among treatment groups, while beyond eight months post-treatment, the proportion of men reporting severe sexual bother did not differ significantly among treatment groups.44 Bowel dysfunction, meanwhile, was more common among patients who underwent either form of radiation versus RRP (p<0.001).44

A separate study, which has attracted considerable attention, was a multicenter prospective evaluation by Sanda and colleagues.3 These study prospectively measured outcomes reported by 1,201 patients and 625 spouses or partners before and after RRP, BT, or EBRT. Outcome measures included the Service Satisfaction Scale for Cancer Care, as well as the Expanded Prostate Cancer Index Composite (EPIC),45 an QoL instrument that involves 50 items grouped into two urinary subscales (incontinence and irritative-obstructive) and three summary scores (bowel, sexual, and hormonal). Sexual QoL was adversely affected after each treatment compared to baseline (p<.0.001), with nerve-sparing mitigating some of the adverse effects of RRP.3

While urinary incontinence was noted after surgery, mean scores on urinary irritation or obstruction improved after RRP.3 In fact, at one year after treatment, moderate or worse distress from overall urinary symptoms was reported by 18% of BT patients, 11% in the radiotherapy group, and 7% of RRP patients.3 Both forms of RT were associated with a reduced QoL related to bowel function after treatment, while no change in bowel symptoms was noted after RRP.3 Importantly, the study also found that changes in QoL were significantly associated with the degree of outcome satisfaction among patients and their spouses or partners.3

The Spanish Multicentric Study of Clinically Localized Prostate Cancer prospectively enrolled 435 patients treated with RRP, EBRT, and BT without neoadjuvant or adjuvant hormonal therapy for evaluation.46 QoL was assessed before and at 1, 3, 6, 12, 24, and 36 months after treatment using the SF-36 version 2 and EPIC. Investigators found that, compared with patients undergoing RRP, patients treated with BT or EBRT demonstrated significantly worse urinary irritative-obstructive and bowel scores, respectively, during the last two years of follow-up.46

In fact, among patients with urinary irritative-obstructive symptoms at baseline, improvement was noted in 64% who underwent nerve-sparing RRP.46 Sexual and urinary incontinence deterioration, however, were greater among surgical patients.46

These data suggest that each of the most common PCa treatment modalities has the potential to adversely impact patients’ QoL. Treatments have been shown to uniquely affect various outcome measures, with RRP demonstrating a greater impact on urinary continence and erectile function, while radiation, particularly EBRT, resulting in a greater degree of bowel dysfunction.

The relative benefit of RRP for irritative-obstructive symptoms, particularly on longer-term follow-up versus EBRT, requires further study. Additional large-scale prospective evaluations, ideally in a randomized clinical trial setting, are needed to provide better evidence for counseling patients regarding the comparative toxicities of the various treatment options for newly-diagnosed PCa.


Conclusions


The ideal assessment of the relative efficacy and toxicity of surgery versus radiation for PCa would be in a prospective clinical trial. However, given the existing lack of relevant outcome data from randomized trials comparing RRP and RT, and the noted difficulties with organizing such studies, observational series remain the primary current means of comparative evaluation.

Increasing data from such studies suggest improved survival following surgery, albeit with considerable bias in patient mix and disease characteristics between cohorts inherent to retrospective cohorts. As such, it is important to note that differences in age, comorbidity status, and tumor variables may be responsible for the worse survival noted among patients treated with RT in the series reviewed here.


Additionally, the overall risk of cancer-specific mortality 10 years after primary treatment in most patients is relatively low regardless of the primary treatment modality, suggesting the importance of considering competing causes of mortality, as well as the treatment-related toxicities, into discussions regarding PCa management.

Continued investigation into the differing impact of treatments on QoL measures3 and non-cancer morbidities26 will be necessary going forward to help determine the optimal approach to PCa treatment for an individual patient.

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