Twenty-year Patient-reported Outcomes After Surgery, Radiotherapy, or Brachytherapy for Localized Prostate Cancer

Abstract

Background and objective: Our objective was to compare the impact of open radical prostatectomy (RP), external beam radiotherapy (EBRT), and brachytherapy in patients with localized prostate cancer via patient-reported outcome measures up to 20 yr after treatment.

Methods: This was a prospective observational study (ClinicalTrials.gov NCT01492751) of men with localized prostate cancer (clinical stage T1-T2, low or intermediate risk). The Expanded Prostate Cancer Index Composite (EPIC-26) and Short Form-36 (SF-36) questionnaires were centrally administered via telephone interviews before treatment and then annually after treatment. Generalized estimating equation models were constructed with propensity score-based weights.

Key findings and limitations: The RP group reported gradual, statistically significant worsening for almost all EPIC-26 and SF-36 scores at most follow-up time points. Significantly lower urinary incontinence deterioration was observed in both radiotherapy groups than after RP. Urinary irritative/obstructive, sexual, bowel, and hormonal symptom patterns were similar regardless of treatment, except for less sexual deterioration in the brachytherapy group. The observational design is the main limitation, but propensity score weights mitigated treatment selection bias.

Conclusions and clinical implications: Our findings provide detailed novel evidence, measured over 20 yr, on the long-term impact of disease and treatment on patients with localized prostate cancer. While all treatment groups showed a general deterioration over time, important differences in urinary incontinence (highest after RP) and sexual decline (least after brachytherapy) persisted at 20 yr, and these should be incorporated into shared decision-making processes.

Patient summary: Our study provides new findings on outcomes of treatment for localized prostate cancer as reported by patients over a period of up to 20 years. There was a general deterioration over time, but worse urinary incontinence after radical prostatectomy and the lowest decline in sexual function after brachytherapy persisted over time. These findings can inform patients during shared decision-making on the most suitable treatment for localized prostate cancer.

Keywords: Brachytherapy; Comparative effectiveness; External radiotherapy; Localized prostate cancer; Patient-reported outcome measures; Radical prostatectomy.

Fig. 1

Unweighted results for EPIC-26 urinary domain. (A) Mean EPIC-26 urinary incontinence scores. (B) Percentage of men using one or more absorbent pads per day. (C) Mean EPIC-26 urinary irritative/obstructive scores. (D) Percentage of men reporting any pain or burning on urination. Superscript letters indicate p < 0.05 for the following comparisons: a) radical prostatectomy versus EBRT; b) radical prostatectomy versus brachytherapy; and c) EBRT versus brachytherapy. Error bars represent the 95% confidence intervals. EBRT = external beam radiotherapy; EPIC = Expanded Prostate Cancer Index Composite

Fig. 2

Unweighted results for EPIC-26 sexual, bowel, and hormonal domains. (A) Mean EPIC-26 sexual scores. (B) Percentage of men reporting erections not firm enough for intercourse. (C) Mean EPIC-26 bowel scores. (D) Percentage of men reporting any problem with fecal incontinence. (E) Mean EPIC-26 hormonal scores. (F) Percentage of men reporting any problem with hot flashes. Superscript letters indicate p < 0.05 for the following comparisons: a) radical prostatectomy versus EBRT; b) radical prostatectomy versus brachytherapy; and c) EBRT versus brachytherapy. Error bars represent 95% confidence intervals. EBRT = external beam radiotherapy; EPIC = Expanded Prostate Cancer Index Composite

Fig. 3

Unweighted results for the SF-36 (A) physical and (B) mental component summaries. Superscript letters indicate p < 0.05 for the following comparisons: a) radical prostatectomy versus EBRT; b) radical prostatectomy versus brachytherapy; and c) EBRT versus brachytherapy. Error bars represent 95% confidence intervals. EBRT = external beam radiotherapy; SF-36 = 36-item Short-Form health survey.