Localized prostate cancer treatment tied to long-term sexual dysfunction, incontinence

Initial active treatment is associated with generally worse long-term self-reported quality of life (QoL) in men with localized prostate cancer compared with those without a diagnosis of the disease, according to a study. Furthermore, radical prostatectomy results in some adverse effects, particularly in relation to sexual outcomes.

“The most apparent and persisting adverse association was a reduction in sexual function, although this caused limited bother to men,” the researchers said. “In contrast, while urinary incontinence was less prevalent, it was a greater cause of bother.”

This population-based, prospective cohort study included 1,642 men with localized prostate cancer aged <70 years and 786 controls from the New South Wales electoral roll. Participants self-reported their general health and disease-specific QoL at seven time points over a 15-year period using the 12-item Short Form Health scale, University of California-Los Angeles prostate cancer index, and expanded prostate cancer index composite short form (EPIC-26).

The researchers then calculated adjusted mean differences with controls as the comparison group. They assessed the clinical significance of adjusted mean differences by the minimally important difference, defined as one-third of the standard deviation from the baseline score.

Compared with controls, all treatment groups reported high levels of erectile dysfunction at 15 years, depending on treatment: active surveillance/watchful waiting (n=33/53; 62.3 percent) and non-nerve sparing radical prostatectomy (n=117/141; 83.0 percent) vs controls (n=44/103; 42.7 percent). [BMJ 2020;371:m3503]

Bowel problems frequently occurred among men who had external beam radiation therapy or high dose rate brachytherapy or androgen deprivation therapy as primary treatment.

Men who underwent surgery reported persistent urinary incontinence, while those who received androgen deprivation therapy reported an increase in urinary bother from 10 to 15 years (year 10: adjusted mean difference, –5.3, 95 percent confidence interval [CI], –10.8 to 0.2; year 15: adjusted mean difference, –15.9, 95 percent CI, –25.1 to –6.7).

Few studies have reported 10-year QoL outcomes in men with localized prostate cancer thus far, and only one study has provided 15-year comparative data between two treatment groups. [N Engl J Med 2013;368:436-445; Lancet Oncol 2011;12:891-899; Eur Urol 2015;68:600-608; Eur J Cancer 2016;63:143-153; Psychooncology 2020;29:444-449]

“Given the relatively high 15-year survival rate for men with localized prostate cancer, and the comparable mortality rates across treatment groups for men with low-risk disease, the longitudinal QoL changes discussed in this study are becoming vitally important to consider,” the researchers said. [N Engl J Med 2016;375:1415-1424; https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/annual-cancer-facts-and-figures/2019/cancer-facts-and-figures-2019.pdf]

These men have previously expressed a need for more involvement in treatment decision making and found many treatment options confusing or distressing, resulting in uncertainty over the best choice for them. [Urology 2004;63:751-756; Psychooncology 2014;23:1391-1398; BJU Int 2013;112:54-65]

“Further research exploring individual experiences and adjustment to changes in the long term is needed to identify where support and information gaps lie and what measures are likely to fill them,” the researchers said.

“Clinicians and patients should be fully informed of these long-term QoL outcomes when making treatment decisions and understand possible long-term consequences of the various management approaches,” they added.