Survival was the highest-ranked factor, followed by no incontinence, not needing further treatment, and maintaining an erection.

Although survival was the most important factor, men were willing to trade 0.68% survival for a 1% chance of improving urinary function. Similarly, they were willing to trade 0.41% survival for a 1% chancing of requiring no further treatment, and a 0.28% survival for a 1% chance of keeping erections.

“It’s easy to assume that patients’ key motivation is survival, but this research shows the situation is more nuanced,” Dr Ahmed said in a prepared statement from NCRI.2

“Men do want long life but they highly value treatments that have low side effects, so much so that, on average, they were willing to accept lower survival if it meant the risk of side effects was low,” he said. “The amount of lower survival they were willing to accept is about the same as the small benefit they might expect from radical surgery or radiotherapy instead of active surveillance. Each patient differs as to what treatment they prefer but it may help them to know that many men think about the balance between the quantity and the quality of life, and they should not feel it is wrong to have similar thoughts.”

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Commenting on the results of the study, Dr Vapiwala said that it is known from QoL data collected from patients in studies from both the US and UK that the main risks with surgery are urinary incontinence and erectile dysfunction, but that both of these conditions could be temporary in the majority of patients.

“A small subgroup, about 8% to 10% of patients, may have prolonged incontinence or need for urinary pads, but the majority should recover in weeks to months after surgery,” Dr Vapiwala said. “For erectile dysfunction, it can be wide-ranging from 40% to 50% of patients having ongoing dysfunction, but some patients can respond to medications.”

For patients treated with radiation, patients do not typically experience urinary incontinence, but instead experience lower urinary tract symptoms, such as increased urgency or frequency, from swelling or irritation to the prostate, Dr Vapiwala said. The rate of erectile dysfunction in patients treated with radiation is similar, at 40% to 50%, but often occurs 1.5 years to 2 years after treatment as more scar tissue forms.

However, Dr Vapiwala pointed out that active surveillance is not without survival and QoL risks. Patients who are surveilled may see a decline in QoL as the disease spreads or may experience morbidity related to the repeat biopsies that are a part of active surveillance.

Studies like COMPARE, Dr Vapiwala said, and real-life decisions about care often depend on the specifics of how the hypothetical scenarios are worded. It is important for patients to know that data from the PROTECT trial, which looked at more than 80,000 men with localized disease, showed that prostate-cancer–specific mortality was similar despite whether men were treated with active monitoring, surgery, or radiotherapy.3

An analysis of QoL outcomes showed that although sexual function and urinary incontinence was worse in men with prostatectomy, sexual and urinary function also gradually declined among patients in the active monitoring cohort.4

“The effects end up leveling out in many respects in terms of quality of life,” Dr Vapiwala remarked.

References

  1. Ahmed H, et al. Evaluating the tradeoffs men with localized prostate cancer make between the risks and benefits of treatments: the COMPARE study. Presented at: the 2018 NCRI Cancer Conference; Glasgow, United Kingdom: November 4-6, 2018. Abstract 1967. 
  2. National Cancer Research Institute. Men with prostate cancer are willing to accept lower survival odds to avoid incontinence, impotence and repeat treatments. https://www.ncri.org.uk/wp-content/uploads/2018/11/Ahmed-prostate-risks-for-online.pdf. Published November 5, 2018. Accessed November 27, 2018.
  3. Hamdy FC, Donovan JL, Lane JA, et al. 10-year outcomes after monitoring, surgery, or radiotherapy for localized prostate cancer.  N Engl J Med. 2016;375:1415-1424.
  4. Donovan JL, Hamdy FC, Lane JA, et al. Patient-reported outcomes after monitoring, surgery, or radiotherapy for prostate cancer. N Engl J Med. 2016:375:1425-1437.