A 5-year follow-up study of more than 2,000 U.S. men who received prostate cancer treatment—radiation, surgery, or active surveillance—in patients of all ages and ethnicities is creating a road map for the future regarding long-term bowel, bladder, and sexual function in order to clarify expectations and enable men to make informed choices about care. This analysis was published by Hoffman et al in JAMA.
The CEASAR (Comparative Effectiveness Analysis of Surgery and Radiation for Localized Prostate Cancer) study, coordinated by Vanderbilt University Medical Center, is a multisite research study conducting long-term follow-up on men who were diagnosed with localized prostate cancer between 2011 and 2012.
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“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,” said senior author Daniel Barocas, MD, MPH, Associate Professor and Vice Chair of Urology at Vanderbilt University Medical Center. “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.”
Treatment Types
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 5-year period. The favorable-risk group chose either active surveillance, nerve-sparing prostatectomy, external-beam radiation therapy, and low–dose rate brachytherapy. The unfavorable-risk disease group chose either prostatectomy or external-beam radiation therapy plus androgen-deprivation therapy (ADT).
Sexual Outcomes
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 5 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,” said Dr. Barocas. “Indeed, the magnitude of decline over time within each treatment group was larger than the magnitude of difference between treatment groups at 5 years.”
“Whether you get surgery or radiation, there is a chance of reduced erectile function,” he said. “While the time course is different for surgery and radiation, our study shows that only about half of men undergoing these treatments who had erections good enough for intercourse before treatment will still have an erection good enough for intercourse 5 years later. I have started using this sobering statistic in patient counseling about treatment choice.”
Urinary and Bowel Function
In terms of urinary function, prostatectomy was associated with worse incontinence compared to other treatments through 5 years for both the favorable-risk and the unfavorable-risk groups. At 5 years, 10% to 16% of men who had surgery reported a moderate or serious problem with leakage, compared to 4% to 7% of men who had other treatments.
Men undergoing radiation reported worse urinary irritative and obstructive symptoms within the first 6 to 12 months, particularly those undergoing low–dose rate brachytherapy. However, these urinary symptoms largely returned to baseline after 1 year. In addition, study authors reported no clinically meaningful bowel function differences at the 5-year mark, suggesting that contemporary radiation therapy is associated with less urinary and bowel toxicity than older forms of radiation.
“If you look at the side-effect profile for external-beam radiation, most of those men after 1 year have rebounded in terms of their urinary and bowel function, which is a novel finding of our study,” said Dr. Barocas said. “The brachytherapy patients have a more difficult time with the urinary and bowel symptoms in that first year.”
For men with unfavorable-risk disease, external-beam radiation with ADT was associated with low hormonal function scores at 6 months and bowel function at 1 year, but these symptoms improved at later time points. The men who received external-beam radiation with ADT also had better sexual function at 5 years and incontinence at each time point through 5 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.
Disclosure: For full disclosures of the study authors, visit jamanetwork.com.
