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Re: Association between Radiation Therapy, Surgery, or Observation for Localized Prostate Cancer and Patient-Reported Outcomes after 3 Years
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JAMA 2017; 317: 1126e1140. doi: 10.1001/jama.2017.1704
Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/28324093
Re: Association between Choice of Radical Prostatectomy, External Beam Radiotherapy, Brachytherapy, or Active Surveillance and Patient-Reported Quality of Life among Men with Localized Prostate Cancer R. C. Chen, R. Basak, A. M. Meyer, T. M. Kuo, W. R. Carpenter, R. P. Agans, J. R. Broughman, B. B. Reeve, M. E. Nielsen, D. S. Usinger, K. C. Spearman, S. Walden, € rmer and P. A. Godley D. Kaleel, M. Anderson, T. Stu Departments of Radiation Oncology, Urology, and Health Policy and Management, Division of Hematology and Oncology, Department of Medicine, Lineberger Comprehensive Cancer Center, Cecil G. Sheps Center for Health Services Research, Department of Epidemiology, Gillings School of Global Public Health and Carolina Survey Research Laboratory, University of North Carolina at Chapel Hill, Chapel Hill and Prostate Cancer Coalition of North Carolina, Raleigh, North Carolina JAMA 2017; 317: 1141e1150. doi: 10.1001/jama.2017.1652
Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/28324092 Editorial Comment: Historically comparisons of functional outcomes of surgery and radiation have been based on large, single institution centers of excellence, thereby decreasing the generalizability of the findings and minimizing the accuracy of the comparison owing to wide selection biases. Efforts to compare outcomes from large population data sets have similarly been limited by the inadequacy of the recorded data fields, inaccuracy of recording instruments, and wide skill sets and therapeutic approaches of the represented operators. A few things have changed with time that may allow more accurate comparison of the impact of treatment on quality of life, ie a leveling of the operative playing field (partly enabled by the robot), standardization of radiation dose and delivery method (to some extent), and efforts to prospectively record data across populations rather than single institutions. Importantly surveillance cohorts can now be used to serve as effective controls for nontreated men with prostate cancer. In these 2 studies the authors take a similar approach to comparing the short-term outcomes of active surveillance, surgery and radiation in 2 separate cohorts. Not surprisingly, during the first 2 to 3 years of followup men undergoing surgery have the worst sexual function and urinary incontinence, while those undergoing radiation tend to report urinary irritative symptoms and bowel symptoms. It is noteworthy that men treated with radiation often start with worsened sexual function, and, therefore, the magnitude of change after treatment is inherently smaller. Interestingly urinary irritative symptoms improved in operated patients compared to men on surveillance. In 1 study side effect profiles persisted at 3 years, while in another no significant differences were noted between groups by 2 years, indicating the side effect profiles continue to become comparable through time. The authors of both studies suggest the reported data can be used to counsel patients weighing treatment decisions for prostate cancer. I agree but I would caution readers that such counseling cannot occur in a vacuum. The studies for the most part do not incorporate the influence of pretreatment factors such as severity of voiding symptoms, preoperative erectile function and skill set/ experience of the treating physician. However, the trends are consistent with my experience. Longer followup would likely show continued leveling of side effect severity as radiation side effects typically increase beyond the interval reported for both of these studies. Samir S. Taneja, MD
Editorial Comment: Radiation and surgery can have negative effects on quality of life in men with localized prostate cancer. Specifically surgery can be associated with sexual dysfunction and urinary incontinence, while radiation can be associated with irritative voiding symptoms and bowel and sexual dysfunction. However, when clinicians speak to patients, they often quote data from high volume surgeons and single center series. Whether these outcomes reflect what happens in the
Dochead: Urological Survey
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community is unclear. These 2 studies inform us about current “average” community outcomes following a diagnosis of localized prostate cancer and will be useful when counseling patients regarding treatment choices. Barocas et al used data from the population based CEASAR (Comparative Effectiveness Analysis of Surgery and Radiation) study to compare outcomes following surgery, radiation and active surveillance. The study included 2,550 men identified in 5 SEER (Surveillance, Epidemiology and End Results) registries and the CaPSUREÔ database who were followed for 3 years after a new diagnosis of localized prostate cancer. At 3 years patients undergoing surgery were more likely to report sexual dysfunction and urinary incontinence than those undergoing external beam radiation therapy (EBRT) or active surveillance. Patients undergoing EBRT reported significantly more irritative voiding symptoms at 3 years than those who elected active surveillance. Chen et al reported outcomes in 1,147 men diagnosed in the state of North Carolina and followed for 2 years after diagnosis. In general the results of the latter study were similar to the former. Chen et al also included 109 men who underwent brachytherapy who had outcomes similar to those undergoing EBRT. Importantly all 3 aggressive treatment groups in their study (surgery, EBRT and brachytherapy) had worse outcomes than the active surveillance group. There are 2 important take home messages. First, these data provide further important evidence that men with low risk disease should strongly consider active surveillance and perhaps should be actively dissuaded from choosing aggressive treatments if possible. Recent data from the ProtecT (Prostate Testing for Cancer and Treatment) study demonstrate that at 10 years there are no differences in survival between patients undergoing surgery, radiation and active surveillance. Given the clear differences in quality of life, one wonders if we are doing more harm than good in these patients. In addition, low volume surgeons should be quoting impotence and incontinence rates from these larger, population based studies, that is unless they collect their own data in a rigorous manner using the proper tools. Currently many urologists counsel patients using data from high volume surgeons who either have better outcomes than the community average or select their patients better. Either way, it strikes me as somewhat disingenuous for someone who does 5 to 10 prostatectomies yearly to expect to achieve the same outcomes as someone who performs 100 or more. Better and more honest counseling will undoubtedly help patients to set reasonable expectations and ultimately improve satisfaction, if nothing else. David F. Penson, MD, MPH
Suggested Reading Feldman AS, Meyer CP, Sanchez A et al: Morbidity and mortality of locally advanced prostate cancer: a population-based analysis comparing radical prostatectomy versus external beam radiation. J Urol 2017; doi: 10.1016/j.juro.2017.05.073. Penson DF, McLerran D, Feng Z et al: 5-Year urinary and sexual outcomes after radical prostatectomy: results from the Prostate Cancer Outcomes Study. J Urol, suppl., 2008; 179: S40. Hollenbeck BK, Dunn RL, Wei JT et al: Determinants of long-term sexual health outcome after radical prostatectomy measured by a validated instrument. J Urol 2003; 169: 1453.
Re: Presence of Invasive Cribriform or Intraductal Growth at Biopsy Outperforms Percentage Grade 4 in Predicting Outcome of Gleason Score 3+4[7 Prostate Cancer € mmerlin, D. Nieboer, E. W. Steyerberg, C. H. Bangma, L. Incrocci, C. F. Kweldam, I. P. Ku T. H. van der Kwast, M. J. Roobol and G. J. van Leenders Departments of Pathology, Public Health, Urology and Radiotherapy, Josephine Nefkens Institute, Erasmus Medical Centre, Rotterdam, The Netherlands, and Laboratory Medicine Program, University Health Network, Toronto, Ontario, Canada Mod Pathol 2017; Epub ahead of print. doi: 10.1038/modpathol.2017.29
Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/28530220 Editorial Comment: We are learning that beyond Gleason grade variant prostate cancer patterns can predict outcome and distinguish patients within individual Gleason grade groups. The significance of intraductal prostate cancer on biopsy has been known for some time in that it is often associated with occult high grade invasive disease and poor clinical outcomes. Recently the literature Dochead: Urological Survey
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JAMA 2017; 317: 1126e1140. doi: 10.1001/jama.2017.1704
Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/28324093
Re: Association between Choice of Radical Prostatectomy, External Beam Radiotherapy, Brachytherapy, or Active Surveillance and Patient-Reported Quality of Life among Men with Localized Prostate Cancer R. C. Chen, R. Basak, A. M. Meyer, T. M. Kuo, W. R. Carpenter, R. P. Agans, J. R. Broughman, B. B. Reeve, M. E. Nielsen, D. S. Usinger, K. C. Spearman, S. Walden, € rmer and P. A. Godley D. Kaleel, M. Anderson, T. Stu Departments of Radiation Oncology, Urology, and Health Policy and Management, Division of Hematology and Oncology, Department of Medicine, Lineberger Comprehensive Cancer Center, Cecil G. Sheps Center for Health Services Research, Department of Epidemiology, Gillings School of Global Public Health and Carolina Survey Research Laboratory, University of North Carolina at Chapel Hill, Chapel Hill and Prostate Cancer Coalition of North Carolina, Raleigh, North Carolina JAMA 2017; 317: 1141e1150. doi: 10.1001/jama.2017.1652
Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/28324092 Editorial Comment: Historically comparisons of functional outcomes of surgery and radiation have been based on large, single institution centers of excellence, thereby decreasing the generalizability of the findings and minimizing the accuracy of the comparison owing to wide selection biases. Efforts to compare outcomes from large population data sets have similarly been limited by the inadequacy of the recorded data fields, inaccuracy of recording instruments, and wide skill sets and therapeutic approaches of the represented operators. A few things have changed with time that may allow more accurate comparison of the impact of treatment on quality of life, ie a leveling of the operative playing field (partly enabled by the robot), standardization of radiation dose and delivery method (to some extent), and efforts to prospectively record data across populations rather than single institutions. Importantly surveillance cohorts can now be used to serve as effective controls for nontreated men with prostate cancer. In these 2 studies the authors take a similar approach to comparing the short-term outcomes of active surveillance, surgery and radiation in 2 separate cohorts. Not surprisingly, during the first 2 to 3 years of followup men undergoing surgery have the worst sexual function and urinary incontinence, while those undergoing radiation tend to report urinary irritative symptoms and bowel symptoms. It is noteworthy that men treated with radiation often start with worsened sexual function, and, therefore, the magnitude of change after treatment is inherently smaller. Interestingly urinary irritative symptoms improved in operated patients compared to men on surveillance. In 1 study side effect profiles persisted at 3 years, while in another no significant differences were noted between groups by 2 years, indicating the side effect profiles continue to become comparable through time. The authors of both studies suggest the reported data can be used to counsel patients weighing treatment decisions for prostate cancer. I agree but I would caution readers that such counseling cannot occur in a vacuum. The studies for the most part do not incorporate the influence of pretreatment factors such as severity of voiding symptoms, preoperative erectile function and skill set/ experience of the treating physician. However, the trends are consistent with my experience. Longer followup would likely show continued leveling of side effect severity as radiation side effects typically increase beyond the interval reported for both of these studies. Samir S. Taneja, MD
Editorial Comment: Radiation and surgery can have negative effects on quality of life in men with localized prostate cancer. Specifically surgery can be associated with sexual dysfunction and urinary incontinence, while radiation can be associated with irritative voiding symptoms and bowel and sexual dysfunction. However, when clinicians speak to patients, they often quote data from high volume surgeons and single center series. Whether these outcomes reflect what happens in the
Dochead: Urological Survey
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community is unclear. These 2 studies inform us about current “average” community outcomes following a diagnosis of localized prostate cancer and will be useful when counseling patients regarding treatment choices. Barocas et al used data from the population based CEASAR (Comparative Effectiveness Analysis of Surgery and Radiation) study to compare outcomes following surgery, radiation and active surveillance. The study included 2,550 men identified in 5 SEER (Surveillance, Epidemiology and End Results) registries and the CaPSUREÔ database who were followed for 3 years after a new diagnosis of localized prostate cancer. At 3 years patients undergoing surgery were more likely to report sexual dysfunction and urinary incontinence than those undergoing external beam radiation therapy (EBRT) or active surveillance. Patients undergoing EBRT reported significantly more irritative voiding symptoms at 3 years than those who elected active surveillance. Chen et al reported outcomes in 1,147 men diagnosed in the state of North Carolina and followed for 2 years after diagnosis. In general the results of the latter study were similar to the former. Chen et al also included 109 men who underwent brachytherapy who had outcomes similar to those undergoing EBRT. Importantly all 3 aggressive treatment groups in their study (surgery, EBRT and brachytherapy) had worse outcomes than the active surveillance group. There are 2 important take home messages. First, these data provide further important evidence that men with low risk disease should strongly consider active surveillance and perhaps should be actively dissuaded from choosing aggressive treatments if possible. Recent data from the ProtecT (Prostate Testing for Cancer and Treatment) study demonstrate that at 10 years there are no differences in survival between patients undergoing surgery, radiation and active surveillance. Given the clear differences in quality of life, one wonders if we are doing more harm than good in these patients. In addition, low volume surgeons should be quoting impotence and incontinence rates from these larger, population based studies, that is unless they collect their own data in a rigorous manner using the proper tools. Currently many urologists counsel patients using data from high volume surgeons who either have better outcomes than the community average or select their patients better. Either way, it strikes me as somewhat disingenuous for someone who does 5 to 10 prostatectomies yearly to expect to achieve the same outcomes as someone who performs 100 or more. Better and more honest counseling will undoubtedly help patients to set reasonable expectations and ultimately improve satisfaction, if nothing else. David F. Penson, MD, MPH
Suggested Reading Feldman AS, Meyer CP, Sanchez A et al: Morbidity and mortality of locally advanced prostate cancer: a population-based analysis comparing radical prostatectomy versus external beam radiation. J Urol 2017; doi: 10.1016/j.juro.2017.05.073. Penson DF, McLerran D, Feng Z et al: 5-Year urinary and sexual outcomes after radical prostatectomy: results from the Prostate Cancer Outcomes Study. J Urol, suppl., 2008; 179: S40. Hollenbeck BK, Dunn RL, Wei JT et al: Determinants of long-term sexual health outcome after radical prostatectomy measured by a validated instrument. J Urol 2003; 169: 1453.
Re: Presence of Invasive Cribriform or Intraductal Growth at Biopsy Outperforms Percentage Grade 4 in Predicting Outcome of Gleason Score 3+4[7 Prostate Cancer € mmerlin, D. Nieboer, E. W. Steyerberg, C. H. Bangma, L. Incrocci, C. F. Kweldam, I. P. Ku T. H. van der Kwast, M. J. Roobol and G. J. van Leenders Departments of Pathology, Public Health, Urology and Radiotherapy, Josephine Nefkens Institute, Erasmus Medical Centre, Rotterdam, The Netherlands, and Laboratory Medicine Program, University Health Network, Toronto, Ontario, Canada Mod Pathol 2017; Epub ahead of print. doi: 10.1038/modpathol.2017.29
Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/28530220 Editorial Comment: We are learning that beyond Gleason grade variant prostate cancer patterns can predict outcome and distinguish patients within individual Gleason grade groups. The significance of intraductal prostate cancer on biopsy has been known for some time in that it is often associated with occult high grade invasive disease and poor clinical outcomes. Recently the literature Dochead: Urological Survey
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