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Active surveillance avoids urinary, sexual declines of radical prostatectomy
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Active surveillance and radical prostatectomy conferred similar mental health outcomes in patients with low-risk prostate cancer; however, the surgical procedure was linked to worse urinary and sexual outcomes, according to study results.
“It is important to consider health-related quality-of-life outcomes when deciding on an approach to minimize both the physical and psychological burden of the disease and its treatment,” Jennifer Cullen, PhD, MPH, of the Center for Prostate Disease Research at the Department of Defense, and colleagues wrote. “To help patients weigh the costs and benefits of [prostate cancer] management strategies, studies that examine the impact of treatment choice on short-term and long-term [health-related quality of life] are warranted. Patients who are managed with [active surveillance] may be spared some of the decline in physical [health-related quality of life] compared with patients who receive definitive treatments, such as radical prostatectomy, but they could concomitantly suffer greater mental health declines because of the anxiety of delaying therapy.”
Cullen and colleagues evaluated data from 389 patients with low-risk prostate cancer enrolled in the Center for Prostate Disease Research Multicenter National Database. Of the patients, 58.6% (n = 228) of patients underwent radical prostatectomy, whereas 19.8% (n = 77) received active surveillance. The remaining 84 patients selected other treatment options and were excluded.
The mean age at diagnosis was 58 years (range, 40-74) for patients who underwent radical prostatectomy and 65 years (range, 45-75) for patients who underwent active surveillance (P < .0001). The average interval between diagnosis and radical prostatectomy was 2.8 months.
Researchers noted patients who underwent active surveillance reported lower baseline sexual function (P = .002) and bother scores (P = .03) compared with patients who underwent prostatectomy. All other baseline quality of life scores were comparable between the cohorts.
Follow-up information was collected at 3, 6, 9, 12, 18, 24 and 36 months.
Men who underwent radical prostatectomy displayed lower sexual function and bother scores at all follow-up times. Although these scores improved at 6 months and stabilized by 24 months for patients in the prostatectomy cohort, sexual function (P = .01) and bother (P = .049) scores remained significantly lower at 36 months compared to active surveillance patients.
Men who underwent radical prostatectomy also displayed significantly worse urinary function at all follow-up intervals compared with men undergoing active surveillance. Urinary function scores appeared to recover between 3 and 12 months in the prostatectomy cohort but remained inferior at 36 months (P = .046).
Researchers observed no significant differences in mental health outcomes in either cohort. Although patients in the radical prostatectomy cohort initially reported worse bowel function, statistically significant differences were not observed at any other point, and bowel functions were equivalent after 24 months. No statistically significant differences in hormone function were observed at any point during follow-up between the cohorts.
Patients who underwent active surveillance demonstrate no statically significant or clinically meaningful declines in health-related quality of life overall from baseline; however, the radical prostatectomy cohort demonstrated clinically meaningful and statistically significant declines in sexual function, sexual bother and urinary scores that persisted for 3 years.
The researchers acknowledged limitations to their study, including non-randomization and a smaller active surveillance cohort. Patient use of erectile aid medication and other ancillary factors were not considered when measuring sexual function.
“The current data offer support for the management of patients with low-risk prostate cancer using active surveillance as a means of postponing the morbidity associated with radical prostatectomy without concomitant mental health declines,” Cullen and colleagues concluded. “Ultimately, patient preference remains a central consideration in treatment decision making, and the finding from this study can help inform and direct that choice.” – by Cameron Kelsall
Disclosure: The researchers report no relevant financial disclosures.
Perspective
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James A. Talcott, MD, SM
Compared with most cancers, choosing treatment for clinically localized prostate cancer is stressful for patients in two unusual ways. First, deferring treatment and opting for active surveillance — accepting the risk for cancer progression to avoid treatment-related toxicity — is plausible and increasingly common. For most cancers, the patient focuses not on whether to get treatment but on shortening the wait to get started. Second, selecting active treatment for prostate cancer requires choosing between surgery and radiation. To become informed, a patient must consult with specialists who discuss both their own treatment and that of the competing specialty. Not surprisingly, each overwhelmingly prefers his own treatment, and patients who consult a urologist and a radiation oncologist often depart with conflicting recommendations. Both treating specialists recommend treatment; patients who also see a medical oncologist are a little more likely to choose active surveillance. The result may be more stress for newly diagnosed patients, who expect definitive recommendations from the medical experts they consult.Jeldres and colleagues focus on the first dilemma, the choice between treatment-related dysfunction and the distress at leaving a potentially lethal — if low-risk — cancer untreated. Their 3-year cohort study of low-risk prostate cancer compares self-selected active surveillance and radical prostatectomy patients. They measured psychological distress with the Mental Component Scale of the widely used SF-36 and treatment-related dysfunction by the standard EPIC instrument. As expected, radical prostatectomy patients reported more sexual and urinary dysfunction, both well-known surgical complications. More interestingly, active surveillance and radical prostatectomy patients had no clinically meaningful differences (defined statistically) in distress. In this cohort, avoiding side effects came — on average — without a measurable mental health cost.
However, these data do not directly endorse active observation for all patients. These patients self-assorted. Active surveillance patients were, on average, 7 years older and had 7 fewer years at risk for cancer progression than radical prostatectomy patients. Prostate cancer — particularly if low risk — is a “proto-disease,” an asymptomatic diagnosis that signals a possible risk of symptoms years later. In randomized trials of radical prostatectomy vs. active surveillance published so far, mortality differences favoring surgery arose, but only in the second decade of follow-up. These patients, with their doctors, made decisions that reflected both their medical circumstances — including their risk and age — and their preferences for definitive treatment vs. the morbidity it produced. From what could be measured, they were equally at peace with their decisions. That may be the main clinical lesson. Early prostate cancer is the classic clinical paradigm for shared, informed decision-making. Patient-centered cancer care should start here. Patients, guided by the perspectives of all three cancer specialties, will find their way.
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