Association Between Radiation Therapy, Surgery, or Observation for Localized Prostate Cancer and Patient-Reported Outcomes After 3 Years

作者：Barocas, Daniel A.^*; Alvarez, Joann; Resnick, Matthew J.; Koyama, Tatsuki; Hoffman, Karen E.; Tyson, Mark D.; Conwill, Ralph; McCollum, Dan; Cooperberg, Matthew R.; Goodman, Michael; Greenfield, Sheldon; Hamilton, Ann S.; Hashibe, Mia; Kaplan, Sherrie H.; Paddock, Lisa E.; Stroup, Antoinette M.; Wu, Xiao-Cheng; Penson, David F.

来源：JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION, 2017, 317(11): 1126-1140.

DOI：10.1001/jama.2017.1704

• QUALITY-OF-LIFE
• INTENSITY-MODULATED RADIOTHERAPY
• HEALTH SURVEY SF-36
• RADICAL PROSTATECTOMY
• SHORT-FORM
• SEXUAL FUNCTION
• POPULATION
• URINARY
• INDEX
• METAANALYSIS

IMPORTANCE Understanding the adverse effects of contemporary approaches to localized prostate cancer treatment could inform shared decision making. @@@ OBJECTIVE To compare functional outcomes and adverse effects associated with radical prostatectomy, external beam radiation therapy (EBRT), and active surveillance. @@@ DESIGN, SETTING, AND PARTICIPANTS Prospective, population-based, cohort study involving 2550 men (<= 80 years) diagnosed in 2011-2012 with clinical stage cT1-2, localized prostate cancer, with prostate-specific antigen levels less than 50 ng/mL, and enrolled within 6 months of diagnosis. @@@ EXPOSURES Treatment with radical prostatectomy, EBRT, or active surveillance was ascertained within 1 year of diagnosis. @@@ MAIN OUTCOMES AND MEASURES Patient-reported function on the 26-item Expanded Prostate Cancer Index Composite (EPIC) 36 months after enrollment. Higher domain scores (range, 0-100) indicate better function. Minimum clinically important difference was defined as 10 to 12 points for sexual function, 6 for urinary incontinence, 5 for urinary irritative symptoms, 5 for bowel function, and 4 for hormonal function. RESULTS The cohort included 2550 men (mean age, 63.8 years; 74% white, 55% had intermediate-or high-risk disease), of whom 1523 (59.7%) underwent radical prostatectomy, 598 (23.5%) EBRT, and 429 (16.8%) active surveillance. Men in the EBRT group were older (mean age, 68.1 years vs 61.5 years, P<.001) and had worse baseline sexual mean score, 52.3 vs 65.2, P<.001) than men in the radical prostatectomy group. At 3 years, the adjusted mean sexual domain score for radical prostatectomy decreased more than for EBRT (mean difference, -11.9 points; 95% CI, -15.1 to -8.7). The decline in sexual domain scores between EBRT and active surveillance was not clinically significant (-4.3 points; 95% CI, -9.2 to 0.7). Radical prostatectomy was associated with worse urinary incontinence than EBRT (-18.0 points; 95% CI, -20.5 to -15.4) and active surveillance (-12.7 points; 95% CI, -16.0 to -9.3) but was associated with better urinary irritative symptoms than active surveillance (5.2 points; 95% CI, 3.2 to 7.2). No clinically significant differences for bowel or hormone function were noted beyond 12 months. No differences in health-related quality of life or disease-specific survival (3 deaths) were noted (99.7%-100%). @@@ CONCLUSIONS AND RELEVANCE In this cohort of men with localized prostate cancer, radical prostatectomy was associated with a greater decrease in sexual function and urinary incontinence than either EBRT or active surveillance after 3 years and was associated with fewer urinary irritative symptoms than active surveillance; however, no meaningful differences existed in either bowel or hormonal function beyond 12 months or in in other domains of health-related quality-of-life measures. These findings may facilitate counseling regarding the comparative harms of contemporary treatments for prostate cancer.

• 出版日期2017-3-21