Ask the Experts – Karen E. Hoffman, MD, MHSc, MPH

Expert Perspective
Comparative Harms of Prostate Cancer Management Approaches

Karen E. Hoffman, MD, MHSc, MPH

Practice Community: Houston, Texas

Hospital and Institutional Affiliations: Associate Professor, Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston

Practice Niche: Radiation Oncology

Dr Hoffman published a prospective, population-based study of 1386 men with favorable-risk prostate cancer and 619 with unfavorable-risk prostate cancer that examined the comparative harms of contemporary treatments for localized prostate cancer through 5 years. Treatments included active surveillance, nerve-sparing radical prostatectomy, external beam radiation therapy (EBRT), or low-dose-rate brachytherapy for men with favorable-risk cancer and prostatectomy or EBRT with androgen deprivation therapy (ADT) for men with unfavorable-risk cancer. Patients who underwent prostatectomy reported worse urinary incontinence through 5 years compared with other management options. Patients with unfavorable-risk disease reported worse sexual function at 5 years after surgery compared with EBRT plus ADT. The investigators published their findings recently in the Journal of the American Medical Association.1

Question 1. What was your rationale for conducting the study?
We wanted to understand, from the patient perspective, the adverse effects that men experience after contemporary treatments for localized prostate cancer and how these adverse effects compare across contemporary treatments. Surgical and radiotherapy techniques for localized prostate cancer have changed over the last few decades, and these techniques have been adopted, in part, because they are believed to reduce treatment side effects. There is also increasing acceptance of active surveillance as a management option. We undertook this study to inform men selecting among the multiple contemporary treatment options for localized prostate cancer.
Question 2. Did any of your findings surprise you?
Most of the early functional differences across treatments seen in our study dissipated over time; I was somewhat surprised that we were still seeing some clinically meaningful differences in incontinence function and sexual function 5 years after treatment.
Question 3. What do your findings add to the literature?
These findings improve our understanding of the adverse effects men experience through 5 years after contemporary prostate cancer treatment, including active surveillance, nerve-sparing robotic prostatectomy, and radiation therapy delivered with intensity modulation and image guidance. This population-based study reflects a diverse patient population and real-world clinical practice.

Importantly, we evaluated patient-reported function after treatment for favorable-risk prostate cancer separately from function after treatment for unfavorable-risk disease since treatment options and treatment intensity vary based on cancer severity. Reporting our results in this way makes them clinically relevant to patients selecting among treatment options for their cancer.

We hope physicians will use this information to counsel men on the anticipated side effects of contemporary prostate cancer treatment options, and to help men make an informed treatment choice.
Question 4. As you point out in your paper, a number of factors affect patient treatment choice, including perception of long-term oncologic outcomes, time commitment for treatment and recovery, physicians’ biases, etc. Might urinary and sexual problems be a relatively minor consideration for patients?
In my experience as a clinician, patients do weigh the potential impact of treatment on urinary function and sexual function when selecting prostate cancer treatment. However, future sexual and urinary function is more important to some men than others, and men take many other factors into account when selecting treatment including time commitment for treatment and their perception of likelihood of cancer control. It is critical to take a patient-centered approach when counseling men on prostate cancer treatment options, to help men select treatment based on what is most important to them.
Question 5. Previous studies also have demonstrated worse patient-reported urinary and sexual function with prostatectomy vs radiation. Yet most men with localized prostate cancer who undergo upfront treatment choose surgery instead of radiotherapy (in your study, 48.7% vs 25.1% of men with favorable-risk disease). Any thoughts on why that is?
We did not investigate why men selected a specific treatment for their prostate cancer in our study. As mentioned previously, there are a number of factors in addition to expected impact on urinary and sexual function that men take into consideration when determining which prostate cancer treatment is the best fit for them. We also did not investigate which treatments were recommended to patients by their physicians. Other studies have reported that physician recommendation is an important reason why men select a prostate cancer treatment and physicians tend to recommend treatments that they themselves deliver. The diagnosing urologist is often the first physician to discuss prostate cancer treatment options with patients. Some men with prostate cancer never meet with a radiation oncologist so may not be aware of their radiation treatment options.
Question 6. As a radiation oncologist, do you think urologists as a group discuss the advantages and disadvantages of EBRT adequately during patient counseling?
As a radiation oncologist, nearly all of my patients with localized prostate cancer have met with a urologist to discuss prostate cancer treatment prior to meeting with me. Many of my patients who have met with a urologist are informed about radiation treatment options and the anticipated side effects of radiation therapy while others do not realize that radiation is an appropriate treatment option for their prostate cancer. Therefore, it is my impression that there is variation across urologists regarding how much detail they provide about advantages and disadvantages of radiation treatment options for prostate cancer.


  1. Hoffman KE, Penson DF, Zhao Z, et al. Patient-reported outcomes through 5 years for active surveillance, surgery, brachytherapy, or external beam radiation with or without androgen deprivation therapy for localized prostate cancer. JAMA. 2020;323:149-163). doi: 10.1001/jama.2019.20675