Can PROs help patients decide between treatment options for localized prostate cancer?

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Two recently published papers in JAMA shed light on the longer term quality-of-life outcomes following treatment of localized prostate cancer. In the two papers entitled 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 (1) and Association Between Radiation Therapy, Surgery, or Observation for Localized Prostate Cancer and Patient-Reported Outcomes After 3 Years (2) the authors explore how outcomes differ between patients receiving different treatment modalities.

In the first paper (1), a prospective population based cohort of 1141 men were enrolled with newly diagnosed localized prostate cancer. Of those enrolled 314 pursued active surveillance (27.5%), 469 radical prostatectomy (41.1%), 249 external beam radiotherapy (21.8%) and 109 brachytherapy (9.6%). Patient-reported outcomes were measured pre-treatment and at 3, 12 and 24 months after treatment using the Prostate Cancer Symptom Indicies (with 4 domains: sexual dysfunction, urinary obstruction and irritation, urinary incontinence and bowel problems, each scored from 0 (no dysfunction) to 100 (maximum dysfunction). They found that each treatment modality had a different profile of adverse effects over the two years follow-up period. For example they found that 3-months post-treatment, mean sexual dysfunction scores had worsened from a propensity-weighted average of 41.8 to 46.4 down to 36.2 for radical prostatectomy, 13.9 for EBRT and 17.1 for brachytherapy. By 24 months, mean scores between treatment groups vs active surveillance were not significantly different in most domains.

The second paper (2), similarly describes a prospective population-based cohort study of 2550 men diagnosed with cT1-2 localized prostate cancer with PSA <50ng/mL enrolled within 6 months of diagnosis. Treatment options were radical prostatectomy, external beam radiotherapy or active surveillance and outcomes were measured using the Expanded Prostate Cancer Index Composite 26 at baseline, 6, 12 and 36 months. They found that while there were some differences in the baseline scores between the different treatment modalities, radical prostatectomy was associated with worse sexual dysfunction and urinary incontinence but better urinary irritative symptoms than EBRT and active surveillance.

While these two studies are unable to fully account for underlying differences in the treatment groups, they do shed light on important differences in longer-term patient-centered outcomes between treatment modalities. As both papers posit, knowledge of these outcomes could be used to help enable shared decisions given the patient’s own preferences, for example, if preserving sexual function is a high priority. I believe it is crucial that we start routinely collecting this kind of data for the patients we treat, so we can be more informed about the potential negative effects of the treatments we perform and so patients can gain a more data driven understanding of what their outcomes are likely to be.

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