Active Surveillance or Another Prostate Cancer Treatment? Choices Linked to Quality of Life

Active Surveillance or Another Prostate Cancer Treatment? Choices Linked to Quality of Life

Active surveillance of low-risk prostate cancer is as good as treating it in many cases, and spares patients such distressing treatment side effects as sexual-functioning problems, according to a study on the quality of life impact of various treatments.

Surgery, although performed with robotic techniques designed to limit prostate damage, is associated with sexual side effects and urinary leaks, the study found. Other treatments were linked to different kinds of complications.

The study, “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,” was published in the journal JAMA.

“With all of the modern treatment options, patients should have accurate and realistic expectations about the frequency of side effects from treatment,” Ronald C. Chen, MD, MPH, the first author of the study, said in a press release.

“We found that the different treatment options have trade-offs in side effects. Each patient can look at these data to see what they care about most,” added Chen, an associate professor at the University of North Carolina School of Medicine and a member of the UNC Lineberger Comprehensive Cancer Center.

Most prostate cancer patients are diagnosed at early stages of the disease. Increasingly, studies are finding that active surveillance is an option for managing low-risk cancer cases.

But patients usually find themselves choosing one of a range of other treatment options. They include radical prostatectomy, or removal of the prostate; radiation treatment; and brachytherapy, which involves inserting radioactive seeds in the prostate.

“Patients diagnosed with early-stage prostate cancer—and that’s the vast majority of patients with this disease—face many treatment options that are thought to be similarly efficacious,” Chen said. “Therefore, the quality-of-life differences among these options become an important consideration when patients are trying to make their decisions.”

To better understand how various treatments impact quality of life, researchers recruited 1,141 men who had been diagnosed with early-stage prostate cancer between January 2011 and June 2013.

The team looked at how four treatment options affected the men’s bowel health, urination, and sexual function. The options were active surveillance, prostatectomy, external beam radiotherapy, and brachytherapy.

Nearly all patients opted for non-surveillance treatments. Robotic surgery was used to perform prostatectomies. Dose adjusted radiotherapy was used for radiation treatment.

Prostatectomy led to sexual side effects and urinary leaks more than other treatments. Two years after the treatment, 57 percent of men who had normal sexual function before the surgery had problems.

Twenty-seven percent of men treated with radiotherapy reported poor sexual function afterward. The figures were 34 percent with brachytherapy, and 25 percent with active surveillance.

“With modern robotic surgery, sexual dysfunction and urinary incontinence continue to be some of the side effects that surgery can cause,” Chen said. “While we do see improvement over time, even at the two-year point, surgery still causes more of these issues than other treatments.”

On the other hand, radiotherapy and brachytherapy caused more cases of temporary urinary tract obstruction and irritation. Radiotherapy caused more short-term gut problems.

The sexual-function and urinary problems of men in the active surveillance did worsen, but it took time. This may have mirrored normal aging, but also may have reflected the progression of the cancer, researchers said.

“At the two-year time point, patients who chose radiotherapy or brachytherapy actually had quality of life results similar to patients who chose active surveillance, and that may be surprising to some patients,” Chen said. “With advances in treatment technologies for both surgery and radiation, patients and physicians today must base their decisions on the quality-of-life results of modern treatments, not on results for outdated treatment modalities that caused much more side effects historically.”

Active surveillance involves doctors regularly monitoring a patient’s cancer growth. Many patients remain on active surveillance throughout their lives, without a need for other treatments. Others on active surveillance can forego more aggressive treatments — and the side effects that come with them — for years.

The American Society of Clinical Oncology has endorsed active surveillance as an appropriate option for most men with low-risk prostate cancer.

“There has not been a large-scale comparison of the quality-of-life impact for these modern options, until now,” Chen said. “Existing quality of life studies have studied older types of surgery and radiation that are no longer used, and patients need updated information regarding the impact of modern treatment options so they can make informed decisions about the choices they face today.”