Implications for Clinical Practice

“It is important to remember that these new studies are specifically focusing on quality of life after treatment, which is an important piece of the puzzle, but not the only consideration,” Dr Loeb told Cancer Therapy Advisor. “Oncologic outcomes are also an important factor to consider when deciding on the best way to manage prostate cancer.”


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“It is unclear if these studies are practice-changing,” radiation oncologist Rahul Tendulkar, MD, of the Cleveland Clinic in Ohio, told Cancer Therapy Advisor.

A criticism of the ProtecT study was that its results would not generalize to the population of patients with prostate cancer, as it enrolled about 99% Caucasian men and the treatment modalities during the study course are now considered outdated.

The treatment modalities of the 2 recent studies, however, were expected to have improved effects: “…the findings from both studies were remarkably consistent with the ProtecT trial in terms of overall rates of symptoms and adverse effects, confirming that all options carry risks of adverse effects that affect quality of life,” the editorialists wrote.3

“Unlike prospective studies, which are difficult to undertake in prostate cancer, these population-based studies reflect real-world patients we see in the clinic and they reassure us on how we consult with our patients,” Dr Tendulkar said.

“The best treatment for each patient should be determined based on a combination of their prostate cancer features, general health status, and preferences,” Dr Loeb told Cancer Therapy Advisor. These new data will help oncologists to better counsel patients about what they can expect after each type of treatment, she added.

“…though with active surveillance, adverse effects of interventions can be initially avoided, there is a natural decline in urinary and sexual function over time, and the adverse effects of radical treatment will be experienced if those treatments are received,” the editorialists wrote.

Dr Loeb also pointed out that active surveillance is a good upfront strategy for men with low-risk prostate cancer. “These studies confirm that deferring treatment allows men to preserve quality of life, although it does not avoid age-related declines in sexual and urinary function,” she said.

She indicated that for intermediate-risk prostate cancer, other studies show a significantly higher risk of metastatic disease with active surveillance.6,7 “Therefore this [active surveillance] should be considered only in carefully selected patients who have been appropriately counseled.”

According to Dr Loeb, for newly diagnosed patients with high-risk disease, upfront treatment is recommended.  “The results of these studies are useful to explain to patients what they are likely to experience after each type of treatment over time,” she said.

For Dr Tendulkar, selection of treatment is largely patient-driven, but it is imperative for the physician to provide an accurate representation of treatment on quality of life.

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In his practice, patients are provided with a broad overview of treatment options and quality of life considerations are increasingly important as patients make these decisions.

“Each man can take time to assess carefully with his treating physician the risk of receiving treatment or active surveillance, taking into account the tumor risk category and his general health,” noted the editorial.

References

  1. Barocas DA, Alvarez J, Resnick MJ, et al. Association between radiation therapy, surgery, or observation for localized prostate cancer and patient-reported outcomes after 3 years. JAMA. 2017;317(11):1126-40.
  2. Chen RC, Basak R, Meyer A-M, et al. Association between choice of radical prostatectomy, brachytherapy, or active surveillance and patient-reported quality of life among men with localized prostate cancer. JAMA. 2017;317(11):1141-50.
  3. Hamdy FC, Donovan JL. Patient-reported outcomes following treatment for localized prostate cancer. Helping decision making for patients and their physicians. JAMA. 2017;317(11):1121-3.
  4. Donovan JL, Hamdy FC, Lane JA, et al. ProtecT Study Group. Patient-reported outcomes after monitoring, surgery, or radiotherapy for prostate cancer. N Engl J Med. 2016;375(15):1425-37.
  5. Sanda MG, Dunn RL, Michalski J, et al. Quality of life and satisfaction with outcome among prostate-cancer survivors. N Engl J Med. 2008;358:1250-61.
  6. Musunuru HB, Yamamoto T, Klotz L, et al. Active surveillance for intermediate risk prostate cancer: survival outcomes in the Sunnybrook experience. J Urol. 2016;196(6):1651-8.
  7. Godtman RA, Holmberg E, Khatami A, Pihl CG, Stranne J, Hugosson J. Long-term results of active surveillance in the Göteborg randomized, population-based prostate cancer screening trial. Eur Urol. 2016;70(5):760-6.