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Original Investigation
March 21, 2017

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

Author Affiliations
  • 1Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
  • 2Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
  • 3Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston
  • 4Prostate Cancer Patient Advocate, Vanderbilt Ingram Cancer Center, Nashville, Tennessee
  • 5Department of Urology, University of California, San Francisco Medical Center, San Francisco
  • 6Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
  • 7Center for Health Policy Research and Department of Medicine, University of California, Irvine
  • 8Department of Preventative Medicine, Keck School of Medicine, University of Southern California, Los Angeles
  • 9Department of Family and Preventative Medicine, University of Utah, Salt Lake City
  • 10Health Policy Research Institute, University of California, Irvine
  • 11Rutgers Cancer Institute of New Jersey, Rutgers University, New Brunswick
  • 12School of Public Health, Louisiana State University Health Sciences Center, New Orleans
  • 13Tennessee Valley Veterans Administration Health System, Nashville, Tennessee
JAMA. 2017;317(11):1126-1140. doi:10.1001/jama.2017.1704
Key Points

Question  What are the comparative harms of contemporary treatments for localized prostate cancer?

Findings  In this prospective, population-based cohort study involving 2550 men, radical prostatectomy was associated with significant declines in sexual function compared with external beam radiation therapy (−11.9 points on a 100-point scale) and active surveillance (−16.2 points) at 3 years. Radical prostatectomy was also associated with significant declines in urinary incontinence compared with radiation and active surveillance, but there were no meaningful differences in bowel or hormonal function beyond 12 months, and no meaningful differences in health-related quality of life.

Meaning  These findings may facilitate treatment counseling of men with localized prostate cancer.


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 function (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.