Reviews and ratings are very important in today’s world. Look at the internet. Whether it’s Yelp, Amazon, Ebay, Angie’s List or hundreds more, the number of stars or thumbs up are not as influential as the qualitative comments left by consumers. In similar fashion, radical prostatectomy is still upheld as the “gold standard” (click for an explanation of what it really means) but what prostate cancer (PCa) patients care about is what their quality of life will be like after surgery or radiation. For this, it’s best to get qualitative feedback from the patient’s point of view.
Two new studies shed light on the urinary and sexual side effects that can impair personal and social quality of life for a patient. The studies were published back-to-back in the Journal of the American Medical Association (JAMA), giving us a clue of how important they are.
The first study is a multi-institutional collaboration examining patient-reported outcomes at three years after radical prostatectomy (RP), external beam radiation therapy (EBRT), and active surveillance (AS).[i] The study was based on 2550 cases of men below age 80 who were diagnosed in 2011-12 with stage cT1-2 localized PCa who were enrolled in the study within 6 months of diagnosis. Of the total group, 1523 had RP, 598 had EBRT, and 429 opted for AS. To evaluate quality of life at 3 years post-treatment, the researchers administered a 26-item questionnaire called the Expanded Prostate Cancer Index Composite (EPIC) which was then scored for each patient and compared with his pretreatment baseline function. The categories include urinary function, bowel habits, sexual function, hormonal function and overall satisfaction. The highest possible domain score is 100, and the higher the score, the better the patient’s function. At three years after treatment, urinary incontinence and decline in sexual function were worst in the RP group than in the other two. As noted by lead author Daniel Barocas, the drop in sexual function was most evident in the “25% of men with excellent function before treatment…”[ii]
The second study, out of University of North Carolina, was similar in many respects to the first, and included brachytherapy as well as EBRT.[iii] A different instrument, the Prostate Cancer Symptom Indices (PCSI), was used to record patient-reported outcomes, but the categories are comparable to EPIC. In this study, the PCSI was administered pretreatment to capture baseline function, then again at 3, 12, and 24 months after treatment. 1141 patients were enrolled; 469 had RP, 249 had EBRT, 109 had brachytherapy, and 314 went on AS. Compared with the AS patients, the most marked declines in baseline function were noted at 3 months, with RP again being the worst:
- -36.2 points for RP patients
- -13.9 points for EBRT patients (bowel symptoms declined -4.9 in this group only)
- -17.1 points for brachytherapy patients.
However, at 24 months after treatment, differences appeared to have leveled out in most domains.
In the conclusion section of both studies, the authors recommended using their results on the differing side effect patterns among treatments for the purpose of informing patients about side effects as a way to help prioritize treatment choices for localized prostate cancer. There is a fly in this ointment, though. According to the “New” Prostate Cancer Info Link,
…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…[iv]
I want to emphasize the author’s last point about the absence of “newer forms of treatment” in the two studies I just described. While the writer did not specify, I assume that focal treatment is included. Image-guided focal therapy for prostate tumors is gaining a professional following among urologists and radiologists, as evidenced by the recent Delphi consensus project in which 47 international experts helped lay out principles for selecting patient candidates.
I am proud that the Sperling Prostate Center offers MRI-guided Focal Laser Ablation (FLA) and that the hundreds of patients we’ve treated report few-to-no side effects—generally within a few weeks of treatment—providing lasting patient satisfaction. I am optimistic that focal therapy will become an increasing part of physician-patient dialogue and informed decision making, and I look forward to the day when it is presented to qualified candidates as an option with an extremely low impact of quality of life.
[i] Barocas DA, Alvarez J, Resnick MJ, Koyama T et al. Association between radiation therapy, surgery, or observation for localized prostate cancer and patient reported outcomes after 3 years. JAMA. 2017 Mar 21;317(11):1126-1140. doi: 10.1001/jama.2017.1704.
[iii] Chen RC, Basak R, Meyer AM, Kuo TM et al. Association between choice of radical prostatectomy, external beam radiotherapy, brachytherapy, or active surveillance and patient-reported quality of life among men with localized prostate cancer. JAMA 2017 Mar 21;317(11):1141-1150. Doi: 10.1001/jama.2017.1652.