Prostate Cancer Patients Have Lasting Problems

Most Who Had Surgery or Radiation Were Impotent 5 Years Later

By Salynn Boyles WebMD Medical News
Reviewed By Brunilda Nazario, MD on Tuesday, September 14, 2004


Sept. 14, 2004 — Most men treated for prostate cancer with surgery or radiation are impotent five years after having surgery or radiation, and a significant percentage have other health-related quality-of-life issues, according to a study led by researchers from the National Cancer Institute.

The findings suggest that the some of the consequences associated with external radiation or surgery for prostate cancer are longer lasting than has previously been believed. Both treatments were associated with similar declines in overall sexual function.

However, erectile dysfunction became more common with time in men who received external beam radiation, from half of all patients at two years after treatment to 63% at five years. For comparison, five years after surgery, four out of five men (80%) had erectile dysfunction.

“We were surprised to find that in terms of overall sexual function (including impotence, libido, and sexual frequency) there was not much difference between the surgery and radiation groups at five years,” lead researcher Arnold E. Potosky, PhD, tells WebMD. “Most people thought that the sexual side effects were worse with surgery because that is what early reports told us, but long-term the two treatments appear similar.”


Deciding on Treatment

This year, more than 200,000 men in the U.S. will face a diagnosis of prostate cancer, and each will have to decide on a treatment strategy. The main choices for men with localized cancer are surgical removal of the prostate, radiotherapy, radioactive seed implants, or simply doing nothing, known as watchful waiting.

Prostate cancers tend to be slow growing, with the time from diagnosis to death from the cancer averaging over a decade.

Frustratingly, patients have had little information on which course of action offers them the best chance of survival. No studies have directly compared long-term survival between surgically- and radiation-treated patients, and few have examined the long-term side effects associated with the two treatments.

In the newly reported study, published in the Sept. 15 issue of the Journal of the National Cancer Institute, Potosky and colleagues followed more than 1,100 localized prostate cancer patients who had either surgery or radiotherapy for five years following diagnosis.

No significant difference in the rates of erectile dysfunction was seen in men who received surgery or external beam radiation. At two and five years after diagnosis, roughly 80% complained of impotence. Impotence rose from 50% at two years to 63% among men who received external beam radiation.

The incidence of urinary incontinence at five years — defined as frequent leaking urine or no control of bladder function — was 15% for men undergoing surgery and 4% in men treated with radiation. However, almost a third of the men treated with radiotherapy complained of bowel urgency at five years compared with a fifth of the men who had surgery.


The Diagnosis Debate

The finding of lasting compromises in quality of life is sure to add to the already heated debate about the merits of aggressively diagnosing and treating localized prostate cancer.

In a group editorial accompanying the study, researcher Ian Thompson, MD, and colleagues write that the risks of treatment are now clear while the benefits are not well understood.

“Clinicians and researchers must now acknowledge that we have good evidence of treatment outcomes but poor evidence of treatment benefit,” the group wrote. “We cannot yet gauge benefit because we cannot identify the specific man for whom treatment is both necessary and sufficient.”

In an interview with WebMD, editorial co-authors Alan Kristal, PhD, and Steven Zeliadt, PhD, say it has become increasingly clear that prostate-specific antigen (PSA) screening has led to the overdiagnosis and overtreatment of prostate cancer.

“In my opinion PSA screening is a nightmare,” says Kristal, an epidemiologist who heads the cancer prevention program at Seattle’s Fred Hutchinson Cancer Center. “Some people think that it is decreasing prostate cancer mortality, but the most solid analyses to date suggest this is not the case.”

Earlier this year, Thompson and colleagues published findings that cast further doubt on the benefits of PSA screening. The researchers biopsied a large group of older men and found prostate cancer in roughly a quarter of them. Fifteen percent of the men with normal PSA tests actually had high-grade prostate cancers.

“Prior to this we had thought that PSA testing and tumor grade would give us a good idea of who should be treated, but we are finding that it isn’t as clear-cut as we had believed,” says Kristal.

“We know that people with low-grade disease have a long life expectancy,” Zeliadt says. “But we don’t have a clue how to identify men who need treatment and those who don’t.”

SOURCES: Potosky, A. Journal of the National Cancer Institute, Sept. 15, 2004; vol 96: pp 1358-1367. Arnold L. Potosky, PhD, epidemiologist, Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, Md. Alan R. Kristal, PhD, associate head, cancer prevention program. Steven B. Zeliadt, PhD, health services researcher, Fred Hutchinson Cancer Center, Seattle.