A five-year follow-up study of more than 2,000 american men who received prostate cancer treatment is creating a road map for future patients regarding long-term bowel, bladder and sexual function in order to clarify expectations and enable men to make informed choices about care. The CEASAR (Comparative Effectiveness Analysis of Surgery and Radiation for Localized Prostate Cancer) study, coordinated by Vanderbilt University Medical Center, is a multi-site research study conducting long-term followup on men who were diagnosed with localized prostate cancer between 2011 and 2012. The five-year results published in JAMA, with lead author Karen Hoffman, MD, provide evidence on outcomes with radiation, surgery or active surveillance in patients of all ages and ethnicities. Senior author, associate professor and vice chair of Urology Daniel Barocas, MD, MPH, commented: “We are providing information about the side effects of different treatments for prostate cancer that men and their providers can use to make treatment decisions However, we have only illuminated one facet of a complex decision. There is more to a treatment decision than just the side effects, the most obvious being the effectiveness of the treatment, and that is something we hope to be able to demonstrate as we are now funded to look at 10-year cancer outcomes”.
Researchers studied 1,386 men who had favorable-risk prostate cancer and another 619 men with unfavorable-risk prostate cancer to evaluate the impact of their treatment decisions on urinary, sexual and bowel function over a five-year period. The favorable-risk group chose either:
- Active surveillance, an observation strategy in which treatment is only used if the cancer gets worse over time.
- Nerve-sparing prostatectomy, surgical removal of the prostate with attempt to protect nervous parts in hopes of minimizing the impact of surgery on erectile function.
- External beam radiation therapy (EBRT), a common therapy that uses daily doses of radiation to destroy cancer cells.
- Low-dose-rate brachytherapy, a type of radiation therapy involving implantation of radioactive seeds.
The unfavorable-risk disease group chose either prostatectomy or External Beam Radiation Therapy with androgen deprivation, which is radiation in combination with an anti-hormone therapy used to reduce local levels of testosterone and to enhance the effectiveness of radiation.
Men undergoing surgery experienced an immediate, sharp decline in erectile function compared to other groups. However, on average, men treated with prostatectomy improve with time, while those undergoing radiation decline, so that sexual function differences between treatment groups attenuated by 5 years. While the difference in sexual function between surgery and radiation was still measurable in the unfavorable risk group, most men had such poor scores at five years that the difference between treatments may not be clinically significant. For sexual function, all of the treatment options, even surveillance, were associated with significant declines. Indeed, the magnitude of decline over time within each treatment group was larger than the magnitude of difference between treatment groups at five years. In terms of urinary function, prostatectomy was associated with worse incontinence compared to other treatments through five years for both the favorable-risk and the unfavorable-risk groups. At five years, 10-16% of men who had surgery reported a moderate or big problem with leakage, compared to only 4-7% of men who had other treatments. Men undergoing radiation reported worse urinary irritative and obstructive symptoms within the first six to 12 months, particularly those undergoing the low-dose rate brachytherapy.
However, these urinary symptoms largely returned to baseline after one year. In addition, study authors reported no clinically meaningful bowel function differences at the five-year mark, suggesting that contemporary radiation therapy is associated with less urinary and bowel toxicity than older forms of radiotherapy. Looking at the side effect profile for external beam radiation, most of those men after a year have rebounded in terms of their urinary and bowel function, which is a novel finding of the study. The brachytherapy patients have a more difficult time with the urinary and bowel symptoms in that first year. For men with unfavorable risk disease, EBRT with ADT was associated with low hormonal function scores at six months and bowel function at one year, but these symptoms improved at later time points. The men who got EBRT with ADT also had better sexual function at five years and incontinence at each time point through five years than prostatectomy. Study authors said, overall, the estimates of long-term bowel, bladder and sexual function after localized prostate cancer treatment may clarify expectations and enable men to make informed choices about care.
David Penson, MD, chair of the Department of Urology at VUMC, concluded: “This work provides critical and understandable information to patients and providers to help them make better decisions in localized prostate cancer. The really exciting part is that Dr. Barocas has received funding from the NCI to explore longer-term outcomes in this population and is already working on developing a web-based interface to get this information to his patients”.
- Edited by Dr. Gianfrancesco Cormaci, PhD, specialist in Clinical Biochemistry.
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