Evolution and Resolution of Side Effects Following Treatment of Localized Prostate Cancer

A recent study of prostate cancer survivors' long-term health-related quality-of-life (HRQOL) identified some important differences among men initially treated with radical prostatectomy, three-dimensional conformal radiotherapy, or brachytherapy, and a control group without prostate cancer. With all three treatments yielding excellent survival, HRQOL figures prominently in the preferences of men with localized prostate cancer.

Investigators from the University of Michigan and Beth Israel-Deaconess Medical Centers studied HRQOL among men who had been treated for localized prostate cancer, with a median time since treatment of 6.2 years. Analyses were done to identify any differences associated with initial treatment, and to compare long-term HRQOL with earlier evaluations done at a median time from treatment of 2.6 years. Several prostate-cancer–specific domains of HRQOL were considered—urinary irritative, urinary incontinence, bowel, sexual, and hormonal/vitality.

The key findings, reported in the Journal of Clinical Oncology (2005;23:2772–2780), relate to how the long-term side effects of various treatments develop and resolve over time.

“Perhaps our most novel and important finding is that disease-specific HRQOL continues to change and evolve among men treated with brachytherapy and 3-D conformal radiation, whereas postprostatectomy HRQOL remains relatively stable between 2 and 6 years of median follow up,” said first author David C. Miller, MD, Lecturer at the Michigan Urology Center, University of Michigan Medical Center.

At a median follow up of 6.2 years, men treated with radical prostatectomy had HRQOL summary scores significantly lower than those of controls in the urinary incontinence and sexual domains; conformal radiotherapy significantly diminished scores in the bowel and sexual domains; and brachytherapy had significant adverse impact on the urinary irritative, urinary incontinence, bowel, and sexual domains.

Compared with their responses 4 years earlier, men in the brachytherapy group reported a significant resolution in urinary irritative problems. During the same period, urinary continence became more problematic among men initially treated with conformal radiotherapy or brachytherapy. Bowel side effects improved in the brachytherapy group. Sexual function declined among controls and among men treated with conformal radiotherapy. None of the four groups reported any significant changes in the hormonal/vitality domain.

The item of “problem with pain or burning on urination” typifies trends in the urinary irritative domain. This problem was reported by 23% of survivors at 2.6 years after brachytherapy; 4 years later, this problem was reported by 10%. This problem was reported by no more than 3% of prostatectomy or conformal radiotherapy patients at both follow-up intervals.

During the same interval, “leakage of urine more than once a day” increased from 11% to 18% in the brachytherapy group. Corresponding values at 2.6 and 6.2 years were 17% and 16% for the prostatectomy patients, and 6% and 4% following conformal radiotherapy.

As an example of bowel concerns, “problem with urgency to have a bowel movement” declined from 19% to 10% during this period for brachytherapy patients. In each time period, 14% of men treated with conformal radiotherapy reported this problem; in the prostatectomy group, there was no substantial change in this side effect over time (3% and 5% at 2.6 and 6.2 years, respectively).

The percentage reporting “poor to no ability to have an erection” remained relatively unchanged over time following prostatectomy (62% and 65% at 2.6 and 6.2 years), but increased in the conformal radiotherapy group (from 65% at 2.6 years to 75% at 6.2 years) and in the brachytherapy group (from 71% to 82%). The control (no prostate cancer) group also reported an increase in this item, from 19% to 29%. In comparing the prevalence of this problem, however, it should be noted that the median ages differed among the control (69.1 years), prostatectomy (67.2 years), conformal radiotherapy (75.7 years), and brachytherapy (70.4 years) groups.

Although these results are generally consistent with those of previous studies, they provide a clearer view of likely outcomes than most earlier reports because the data are recent enough to reflect outcomes of modern technology for brachytherapy and conformal radiotherapy, yet mature enough to be relevant over a follow up interval of interest to men facing these decisions.

“We believe that this study is useful because it is one of the first to use a validated instrument (EPIC) to measure long-term, patient-report HRQOL changes during the late survivorship phase following contemporary therapies for localized prostate cancer, including brachytherapy and 3-D conformal radiotherapy,” said Miller. “These observations highlight the need for corroborative multi-institutional, prospective studies that further characterize HRQOL evolution among long-term (>5 years) prostate cancer treatment survivors. Until such studies mature in coming years, the observed HRQOL changes described herein may provide clinicians and patients that choose a specific treatment with an estimation of their long-term HRQOL outcomes.” 

Figure  .

Side effects from prostatectomy remain fairly stable over time, but those from prostate radiation may change.