Surviving prostate cancer doesn’t have to cost sexual function

5 minute read

Good outcomes can be achieved with different treatments, and for low risk prostate cancer patients, that could mean extra years of sexual and urinary function.

Men with low risk localised prostate cancer who opt for less invasive treatment to help retain sexual function don’t compromise survival, data collected over 10 years shows.

The latest CAESAR study paper, published in JAMA, shows that when functional outcomes for available treatments are compared, radical prostatectomy is associated with “significantly worse” sexual function at three years and five years, and bigger urinary leakage problems at 10 years compared with alternative treatments.

The CAESAR study, which has been following the progress of 2445 patients diagnosed with localised prostate cancer in 2011-2012, confirmed that the efficacy of treatments is similar across the board.

Most low-risk patients lived at least 15 years from diagnosis, whichever treatment option they chose.

But the functional outcomes, which greatly affect quality of life – sexual, urinary incontinence, urinary irritation, bowel, and hormone function – vary at 12 months, three years, five years and 10 years after diagnosis.

Treatment options for localised prostate cancer depend on whether a patient is diagnosed with low or high-risk cancer. In this cohort, 1877 were given a “favourable prognosis” and 568 an “unfavourable” one.

The low-risk group had low-dose-rate brachytherapy (96), external beam radiotherapy (359), active surveillance (379), or radical prostatectomy (1043). In the high-risk group, 206 had external beam radiotherapy (EBRT) and 362 underwent radical prostatectomy.

At 10 years after diagnosis, sexual function scores were about the same for these patients, regardless of treatment. But at three years, radical prostatectomy was associated with “significantly worse” sexual function scores compared with active surveillance, EBRT and brachytherapy.

At five years, the radical prostatectomy patients were still significantly worse off than the active surveillance patients, but not significantly worse off than the EBRT group and the brachytherapy group.

Urinary incontinence was significantly more likely at 10 years for men who had had a radical prostatectomy than for those on active surveillance and those who had had EBRT. Urinary incontinence was less of a problem for the EBRT cohort than those on active surveillance.

 About 10% of the active surveillance group and 14% of those who had had a radical prostatectomy said they experienced moderate or major problems with urinary leakage at 10 years, compared with only 4% of the EBRT group.

Urinary irritation was not significantly different at 10 years. However, at one year follow-up brachytherapy patients scored poorly against active surveillance and EBRT and at three years their scores were worse than the radical prostatectomy group.

EBRT patients experienced fewer moderate or big problems in urinary function, with only 5% reporting doing so compared with 12% of those on active surveillance and 13% of those who had had a radical prostatectomy. Urinary frequency was only a problem for 9%, compared with 17% of active surveillance patients and 14% of radical prostatectomy patients.

Bowel function scores were similar at 10 years. The significant difference was at one year, where brachytherapy patient scores dropped significantly compared to active surveillance and radical prostatectomy. More EBRT patients reported moderate or big problems with bowel function at 10 years than radical prostatectomy patients (8% vs 3%).

For those with high risk localised prostate cancer, there was no difference in sexual function between the available treatments. However, scores were significantly lower for bowel function in the group that had EBRT with androgen deprivation therapy than the radical prostatectomy group.

Moderate or major problems with a lack of energy were reported by 18% the EBRT+ADT group at 10 years compared with 9% of the radical prostatectomy group.

These findings backed up previous research findings but “perhaps also adds some nuances,” said radiation oncologist Professor Jeremy Millar, clinical lead at the Prostate Cancer Outcomes Registry Australia and New Zealand.

Professor Millar said the CEASAR findings were consistent with the registry’s.

“We see, for example, higher rates of urinary incontinence in men treated with prostatectomy than treated with either active surveillance or with radiation treatments, but we see higher rates of urinary irritation in men treated with radiation than with prostatectomy. And we see worse sexual function in men treated with prostatectomy versus radiation,” said Professor Millar.

“In terms of cancer control, GPs can reassure men with low-risk disease that they don’t have to have something done immediately.

“But the other thing [is] in the short term, men who are treated with radical prostatectomy are much more likely to end up with erections that aren’t sufficiently firm for intercourse. They’re much more likely to need to have a pad, if only for security, one year afterwards. And those are important things for men to think about.

“And in contrast, they might consider surgery because there’s a very slightly bigger problem with bowel bother with radiation compared with surgery or with active surveillance.”

The study showed that urinary incontinence continued to be a problem with radical prostatectomy out to 10 years.

“Once people have got it, it never really gets any better. There are treatments, but the underlying problem is that there’s damage done to important structures in the body that surgical brilliance just can’t turn around,” Professor Millar explained.

Of course, in terms of sexual function, “everything gets worse” in the long term for men who are, on average, in their late 60s, whether they have a prostatectomy or remain on active surveillance, he added.

Meanwhile, a new resource from the University of South Australia, the Prostate Cancer Outcomes Report Card, outlines the functional and survival outcomes for different treatments, presented in an easy-to-understand format.

“Patient preferences play a significant role in determining treatment choices, but often the available information is complex and overwhelming,” said UniSA researcher, Dr Tenaw Tiruye, who was part of the development team.

“Providing easy-to-understand, accessible information in a single consumer-oriented report will help men better understand the treatment options and shared decision making between patients and clinicians.”

JAMA 2024, online January 23

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