Andrew Stephenson, MD, discusses the impact of various approaches—radiation, surgery, and active surveillance—on patients’ quality of life 2 years following treatment.
Andrew Stephenson, MD
Treatment for localized prostate cancer often leads to adverse events impacting urinary, bowel, and sexual function, notes Andrew Stephenson, MD.
Stephenson shared research at the 2017 American Urological Association (AUA) annual meeting examining the impact of various approaches—radiation, surgery, and active surveillance—on patients’ quality of life 2 years following treatment.
Stephenson, director for the Center of Urologic Oncology at Cleveland Clinic’s Glickman Urology and Kidney Institute, discussed the findings of his research in an interview with OncLive at the AUA meeting.Stephenson: There are many treatment options for patients with prostate cancer. The most common treatment options involve either surgical removal of the prostate or radiation, which can be given through external beam radiation or through the implantation of radioactive seeds. These treatments, when done by experienced clinicians, are associated with very high cure rates. However, even in the hands of expert clinicians, there are potential impacts on a patient’s quality of life. These treatments can impact sexual function, bladder function, and rectal function to varying degrees.
Increasingly, active surveillance has been embraced as a treatment strategy because many of the cancers that we diagnose don’t represent an immediate threat to a patient’s longevity and well-being. The idea of active surveillance is you can defer treatment and therefore the side-effects of treatment, which can give the patients the highest likelihood that they’ll preserve their quality of life. Each of the treatments for prostate cancer can have an impact on urinary, bowel, and sexual function to varying degrees. Surgery is more commonly associated with incontinence of urine, such as leakage of urine if a patient coughs, sneezes, or does heavy lifting. Radiation treatments typically cause irritated and obstructive bladder symptoms, not typically incontinence. Patients can have frequent urination and an uncontrolled urge to urinate and may also have difficulty emptying their bladder. Radiation options are also more commonly associated with impacts on bowel function, such as loose stools or a discomfort with bowel movements.
In terms of sexual function, the impact of surgery on a man’s ability to get an erection is usually immediate. All men will have erectile dysfunction after surgery, even when a potency sparing or nerve sparing operation is performed. If that potency sparing surgery is successful, many men will recover their sexual function over the subsequent 6 to 12 months. Radiation typically does not impact sexual function immediately. This is something that becomes apparent 12 to 24 months after treatment, as men experience a gradual decline in the performance of their erections.
When you look at how men are doing 2 years after treatment, the outcomes with surgery and radiation are somewhat similar in terms of their sexual function. Men who have surgery have higher rates of incontinence, whereas men who have radiation have higher rates of bladder and bowel symptoms.
The unique aspect of our study was that we were also able to incorporate active surveillance as a comparative arm among these various treatment approaches for prostate cancer. As you would expect, men who were on active surveillance did have higher rates of sexual function [and] lower rates of incontinence.One important aspect of this study is it is the first comparative study among these different treatments and it gives patients information about what to expect over the subsequent 2 years. The caveat being that this is based on the expertise of the Cleveland Clinic and similar clinicians and hospitals.
In terms of what can be done if patients do suffer from one of these side effects, there are treatments for erectile dysfunction, incontinence, and bladder and bowel dysfunction. Of course, the ideal treatment would be the one that avoids these complications, but we also want to balance aspects of the cancer control. We don’t want to jeopardize a patient’s curability at the expense of quality of life. This is an important study for both clinicians and patients to experience the impact of treatment on quality of life. Many of the cancers that we diagnose do not represent an immediate threat to a patient’s well-being and may not represent an important problem for these patients over the course of their lifetime.
When I counsel patients, I am not an apologist for prostate cancer. I certainly want to aggressively treat those cancers that have the potential to harm patients and leave those patients alone that have an insignificant prostate cancer. This contributes to the emerging body of evidence of the benefits of active surveillance, which has a higher likelihood of preserving their quality of life compared to aggressive treatment. One of the spinoffs of this study is that we have tried to develop tools for clinicians and patients to predict how patients are going to do with each of these treatments. It would be great if we can say to a patient that based on their cancer features at baseline, we can predict with a high level of accuracy whether they will suffer erectile dysfunction or incontinence with surgery or bowel problems with radiation.
Again, giving patients accurate probabilities of these outcomes is just going to equip them with the knowledge to make a well-informed decision, which will lead to higher rates of patient satisfaction down the road. The nice thing about being a researcher in prostate cancer is that it is a field in constant evolution. It remains to be such a large problem for so many men as it is still the largest cancer that we currently diagnose in the United States. The challenge, is trying to identify the cancers that are destined to do harm and scale back intensity of therapy for those cancers that perhaps are not as aggressive. There are certainly a lot of developments in the fields of imaging, genomics, and biomarkers that are going to help answer some of these questions.
Also, at the other end of the spectrum for those men who have a lethal form of prostate cancer, the development of new treatment paradigms is in constant evolution and the available therapeutics for systemic disease are also increasing year by year. It’s an exciting time to be a clinician who treats patients with prostate cancer because I think there has been unprecedented acceleration in the developments that are ongoing for patients.