Effect of Prostate Cancer Severity on Functional Outcomes After Localized Treatment: Comparative Effectiveness Analysis of Surgery and Radiation Study Results

Abstract

Background: Whether prostate cancer severity modifies patient-reported functional outcomes after radical prostatectomy (RP) or external beam radiotherapy (EBRT) for localized cancer is unknown.

Objective: The purpose of this study was to determine whether differences in predicted function over time between RP and EBRT varied by risk group.

Design, setting, and participants: The Comparative Effectiveness Analysis of Surgery and Radiation (CEASAR) study is a prospective, population-based, observational study that enrolled men with localized prostate cancer in 2011-2012. Among 2117 CEASAR participants who underwent RP or EBRT, 817 had low-risk, 902 intermediate-risk, and 398 high-risk disease.

Outcome measurements and statistical analysis: Patient-reported, disease-specific function was measured using the 26-item Expanded Prostate Index Composite (at baseline and 6, 12, and 36 mo). Predicted function was estimated using regression models and compared by disease risk.

Results and limitations: Low-risk EBRT patients reported 3-yr sexual function scores 12 points higher than those of low-risk RP patients (RP, 39 points [95% confidence interval {CI}, 37-42] vs EBRT, 52 points [95% CI, 47-56]; p<0.001). The difference in 3-yr scores for high-risk patients was not clinically significant (RP, 32 points [95% CI, 28-35] vs EBRT, 38 points [95% CI, 33-42]; p=0.03). However, when using a commonly used binary definition of sexual function (erections firm enough for intercourse), no major differences were noted between RP and EBRT at 3 yr across low-, intermediate-, and high-risk disease strata. No clinically significant interactive effects between treatment and cancer severity were observed for incontinence, bowel, irritative voiding, and hormone domains. The primary limitation is the lack of firmly established thresholds for clinically significant differences in Expanded Prostate Index Composite domain scores.

Conclusions: For men with low-risk prostate cancer, EBRT was associated with higher sexual function scores at 3 yr than RP; however, for men with high-risk prostate cancer, no clinically significant difference was noted. Men with high-risk prostate cancer should be counseled that EBRT and RP carry similar sexual function outcomes at 3 yr.

Patient summary: In this report, we studied the urinary, sexual, bowel, and hormonal functions of patients 3 yr after undergoing prostate cancer surgery or radiation. We found that for patients with high-risk disease, sexual function was similar between surgery and radiation. We conclude that high-risk patients undergoing radiation therapy should be counseled that sexual function may not be as good as low-risk patients undergoing radiation.

Keywords: Comparative effectiveness; Disease risk; Patient-reported function; Prostate cancer; Radiation; Surgery.

Fig. 1 –

Sexual function by risk and treatment modality. Sexual function trajectories were adjusted for patient age at diagnosis, comorbidity tumor characteristics (PSA corrected for 5α-reductase inhibitor use, Gleason score [≤6, 3 + 4, 4 + 3, or ≥8], and T stage [T1 or T2]), psychosocial measures (educational attainment, insurance type, employment type, marital status, Short Form-36 physical function score, social support, CES-D score, and participatory decision-making index [16]), and study site. CES-D = Center for Epidemiologic Studies Depression Scale; EBRT = external beam radiotherapy; EPIC = expanded prostate index composite; PSA = prostate specific antigen; RP = radical prostatectomy.

Fig. 2 –

Urinary incontinence by risk and treatment modality. Urinary incontinence trajectories were adjusted for patient age at diagnosis, comorbidity tumor characteristics (PSA corrected for 5α-reductase inhibitor use, Gleason score [≤6, 3 + 4, 4 + 3, or ≥8], and T stage [T1 or T2]), psychosocial measures (educational attainment, insurance type, employment type, marital status, Short Form-36 physical function score, social support, CES-D score, and participatory decision-making index [16]), and study site. CES-D = Center for Epidemiologic Studies Depression Scale; EBRT = external beam radiotherapy; EPIC = expanded prostate index composite; PSA = prostate specific antigen; RP = radical prostatectomy.