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Expert Discusses QoL Benefits of Active Surveillance for Low-Risk Prostate Cancer

Angelica Welch
Published: Tuesday, Mar 28, 2017

Daniel A. Barocas, MD

Daniel A. Barocas, MD

A recently published study in the Journal of the American Medical Association compared differences in quality of life among patients who have undergone radical prostatectomy, external beam radiotherapy, brachytherapy or active surveillance for low-risk prostate cancer.

Daniel A. Barocas, MD, lead author of the study, suggests that patients with low-risk prostate cancer should consider active surveillance, as opposed to surgery or radiation, which may be unnecessary. To ease patients into the idea of active surveillance, he recommends that physicians counsel patients on their options before biopsy, as to alleviate any fear or stress that comes with a cancer diagnosis, especially when the suggested treatment option is essentially “no treatment.”

“There is some acceptance of risk on the part of the patient, but typically that risk of disease progression is small compared to the risk of side effects from treatment that they may not need,” said Barocas.

In an interview with OncLive, Barocas, associate professor, Vanderbilt-Ingram Cancer Center, discussed the study and the benefits of active surveillance in patients with low-risk prostate cancer.

OncLive: What was the intent of this study?

Barocas: For the patients that have low-risk prostate cancer, doctors are recommending active surveillance. We wanted to compare new treatments and active surveillance and the results are pretty nuanced. I think what is new here is that we are talking about the more contemporary, modern treatments. Side effects of other treatments have been studied previously, but they have not been studied systematically in the more contemporary treatments. Meaning, robotic surgery and the advanced radiation techniques of intensity modulated radiation therapy and sort of modern active surveillance as opposed to the older-style "watchful waiting."

One thing we can say fairly definitively is that these treatments have some side effects, and they are worth discussing with your doctor and ask if you need treatment at all, and if so, what the right treatment is.

What were the significant findings?

At face value, the findings show that surgery has a larger impact on sexual function than radiation treatment, and it also has a bigger impact on urinary incontinence. If you get a little bit more into the details, with sexual function for example, that difference was really only large enough to be clinically meaningful in patients that started out with great function. About 45% of men did not have good erections at the time of diagnosis, so there really is only a subset of patients for whom that difference might be important. 

Furthermore, some of the radiation patients get hormone therapy with their radiation treatment, which is appropriate particularly in the high-risk patients. In those patients, hormone therapy completely takes away the libido for the period of time the patient is on it. Some men are on it up to 2 or 3 years; for those men, the difference between surgery and radiation might not be significant. Men who had radiation had some side effects on bowel function, and side effects from the hormone therapy that occur in about 45% of men. Those side effects usually dissipated after a year. So, by the 3-year time point, they looked pretty similar to the active surveillance group. 

Another small finding was that men who had surgery to remove the prostate actually did better than men who were on active surveillance in terms of those bothersome symptoms of an enlarged prostate. That is intuitive—if you remove the prostate you do not have to deal with the symptoms.

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