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Men with localized prostate cancer have reduced long-term quality of life

Reuters Health - 29/10/2020 - Men with localized prostate cancer, especially those who undergo radical prostatectomy, have generally worse long-term self-reported quality of life than men without a diagnosis of prostate cancer, according to new research.

"This study has provided an evidence base for the long-term effects of prostate cancer, and we hope these findings will be used in consultation with men regarding treatment decision making," Dr. Carolyn G. Mazariego of Cancer Council NSW, in Woolloomooloo, and the University of Sydney, Australia, told Reuters Health by email. "All appropriate treatment decisions should be discussed and considered through shared decision making, taking into account what to expect post-treatment and what preferences men have in relation to the risk of side effects."

Survival rates of localized prostate cancer exceed 95% at 15 years, so quality of life outcomes associated with different treatments are important. Few studies have evaluated quality of life and survival beyond 10 years after diagnosis, however.

To investigate, Dr. Mazariego and colleagues used prospectively collected data on 502 patients and 103 population-based controls who had completed surveys up until 15 years from baseline as part of the New South Wales Prostate Cancer Care and Outcomes Study.

"This is the first long-term study to have a disease-free control group for comparison; this allowed us to understand just how impacted men are by their prostate cancer diagnosis alone," Dr. Mazariego said.

Among the men diagnosed with localized prostate cancer, 66% were initially treated with radical prostatectomy (58% of these with nerve-sparing prostatectomy), 9% had external beam radiation therapy (EBRT) or high-dose brachytherapy, 9% had androgen-deprivation therapy (ADT), 5% had low-dose brachytherapy, and 11% had active surveillance/watchful waiting.

Erectile dysfunction was common and persisted in all treatment groups during follow-up, with rates ranging from 62.3% with active surveillance/watchful waiting to 83.0% following non-nerve-sparing radical prostatectomy, compared to 42.7% among controls.

Poor sexual outcomes in general were most pronounced among men who had radical prostatectomy, regardless of nerve-sparing techniques, and these outcomes were most severe during the early years of follow-up.

Most groups showed gradual improvement after the first year, compared with controls, but men treated with EBRT/high-dose brachytherapy reported little recovery across the entire follow-up period, the researchers report in The BMJ.

Self-reported urinary incontinence was prevalent, especially among men who underwent surgery. Urinary incontinence in these men improved somewhat up to five years, but then worsened at 10 and 15 years, but the difference from controls lessened somewhat as incontinence worsened in controls by 15 years.

Bowel problems were significantly worse for men who received EBRT/high-dose brachytherapy or ADT at all time points relative to controls, but only ADT remained clinically significant at year 15, when bowel problems were uncommon among surgical patients or controls.

Men who received ADT had lower physical well-being scores than did men in other treatment groups at almost all follow-up times, whereas men managed with primary active surveillance/watchful waiting and other treatments had physical well-being similar to controls through year 15 of follow-up.

At year 15, mental well-being tended to be worse in all treatment groups except those receiving active surveillance/watchful waiting and low-dose brachytherapy, compared with controls, although only the difference in the ADT group exceeded the threshold for clinically significant change.

"We hope that post-treatment, clinicians might be able to initiate frank conversations about sexual function, set out realistic expectations for recovery if appropriate, and refer men to psychosocial counselling when needed," Dr. Mazariego said.

"While this study reports the long-term quality of life of prostate cancer survivors, we examined the longitudinal unmet needs of the same group of survivors (published in the Journal of Supportive Care in Cancer), where we looked deeper into the needs of these men at 15-years post-diagnosis," she said. "We found that a third of prostate-cancer survivors need more support than they are currently getting."

"The most frequently reported unmet needs were related to comprehensive cancer care (34%), including lack of medical-team coordination and control over the treatment process," Dr. Mazariego said. "Another common concern was ongoing problems with sexual function (13%). Of the men who reported this, 87% rated their need as moderate or severe."

Dr. Nelson N. Stone of Icahn School of Medicine at Mount Sinai, in New York, who has researched prostate-cancer outcomes following radiation therapy and brachytherapy, told Reuters Health by email, "Current data do not show a long-term prostate-cancer mortality advantage of one type of therapy over another. Informed decision making needs to include long-term quality of life differences."

"This discussion has changed substantially over the past 10 years as most clinicians do not advocate definitive treatment to men with low risk disease (>50% of newly diagnosed prostate cancer)," said Dr. Stone, who was not involved in the new study. "However, for those who should be treated, urinary incontinence and erectile dysfunction is substantially higher for radical prostatectomy and EBRT compared to low-dose brachytherapy."

Dr. Rahul Tendulkar of Taussig Cancer Institute at Cleveland Clinic, in Ohio, who has also researched outcomes after radiation therapy for localized prostate cancer, told Reuters Health by email, "The goal of active surveillance is to avoid or delay the side effects of treatment, while still keeping close watch to ensure that the cancer does not progress too quickly. Because treatment can affect urinary, bowel, or sexual quality of life in various ways, it is important for patients and their physicians to clearly communicate the goals of care with one another."

"Prostate-cancer treatment is not 'one size fits all' - rather, each treatment option has distinct pros and cons, and so obtaining multidisciplinary opinions from both urologists and radiation oncologists is really important," he said. "It is not always easy for patients to make a decision about which treatment approach is best for them, so sometimes obtaining second opinions can be helpful as well."

By Will Boggs MD

SOURCE: https://bit.ly/3dwGhDi BMJ, online October 7, 2020.

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