Christopher J D Wallis1, Adam Glaser2, Jim C Hu3, Hartwig Huland4, Nathan Lawrentschuk5, Daniel Moon6, Declan G Murphy7, Paul L Nguyen8, Matthew J Resnick9, Robert K Nam10. 1. Division of Urology, Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management, & Evaluation, University of Toronto, Toronto, ON, Canada. 2. Leeds Institute of Cancer and Pathology, University of Leeds, Leeds, UK. 3. Department of Urology, Weill Cornell Medicine, New York, NY, USA. 4. Martini-Klinik Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany. 5. Department of Surgery, University of Melbourne, Austin Health, Melbourne, Australia; Olivia Newton-John Cancer Research Institute, Austin Health, Melbourne, Australia; Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Australia. 6. Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Australia; Central Clinical School, Monash University, Clayton, Australia; The Epworth Prostate Centre, Epworth Hospital, Richmond, Australia. 7. Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Australia; The Epworth Prostate Centre, Epworth Hospital, Richmond, Australia. 8. Department of Radiation Oncology, Dana-Farber/Brigham and Women's Cancer Center, Harvard Medical School, Boston, MA, USA. 9. Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA; Geriatric Research, Education, and Clinical Center, Tennessee Valley VA Health Care System, Nashville, TN, USA. 10. Division of Urology, Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management, & Evaluation, University of Toronto, Toronto, ON, Canada. Electronic address: robert.nam@utoronto.ca.
Abstract
BACKGROUND: Evaluation of treatment options for localized prostate cancer (PCa) remains among the highest priorities for comparative effectiveness research. Surgery and radiotherapy (RT) are the two interventions most commonly used. OBJECTIVE: To provide a critical narrative review of evidence of the comparative effectiveness and harms of surgery and RT in the treatment of localized PCa. EVIDENCE ACQUISITION: A collaborative critical narrative review of the literature was conducted. EVIDENCE SYNTHESIS: Evidence to clearly guide treatment choice in PCa remains insufficient. Randomized trials are underpowered for clinically meaningful endpoints and have demonstrated no difference in overall or PCa-specific survival. Observational studies have consistently demonstrated an absolute survival benefit for men treated with radical prostatectomy, but are limited by selection bias and residual confounding errors. Surgery and RT are associated with comparable health-related quality of life following treatment in three randomized trials. Randomized data regarding urinary, erectile, and bowel function show few long-term (>5 yr) differences, although short-term continence and erectile function were worse following surgery and short-term urinary bother and bowel function were worse following RT. There has been recent recognition of other complications that may significantly affect the life trajectory of those undergoing PCa treatment. Of these, hospitalization, the need for urologic, rectoanal, and other major surgical procedures, and secondary cancers are more common among men treated with RT. Androgen deprivation therapy, frequently co-administered with RT, may additionally contribute to treatment-related morbidity. Technological innovations in surgery and RT have shown inconsistent oncologic and functional benefits. CONCLUSIONS: Owing to underpowered randomized control studies and the selection biases inherent in observational studies, the question of which treatment provides better PCa control cannot be definitively answered now or in the near future. Complications following PCa treatment are relatively common regardless of treatment approach. These include the commonly identified issues of urinary incontinence and erectile dysfunction, and others including hospitalization and invasive procedures to manage complications and secondary malignancies. Population-based outcome studies, rather than clinical trial data, will be necessary for a comprehensive understanding of the relative benefits and risks of each therapeutic approach. PATIENT SUMMARY: Surgery and radiotherapy are the most common interventions for men diagnosed with prostate cancer. Comparisons of survival after these treatments are limited by various flaws in the relevant studies. Complications are common regardless of the treatment approach.
BACKGROUND: Evaluation of treatment options for localized prostate cancer (PCa) remains among the highest priorities for comparative effectiveness research. Surgery and radiotherapy (RT) are the two interventions most commonly used. OBJECTIVE: To provide a critical narrative review of evidence of the comparative effectiveness and harms of surgery and RT in the treatment of localized PCa. EVIDENCE ACQUISITION: A collaborative critical narrative review of the literature was conducted. EVIDENCE SYNTHESIS: Evidence to clearly guide treatment choice in PCa remains insufficient. Randomized trials are underpowered for clinically meaningful endpoints and have demonstrated no difference in overall or PCa-specific survival. Observational studies have consistently demonstrated an absolute survival benefit for men treated with radical prostatectomy, but are limited by selection bias and residual confounding errors. Surgery and RT are associated with comparable health-related quality of life following treatment in three randomized trials. Randomized data regarding urinary, erectile, and bowel function show few long-term (>5 yr) differences, although short-term continence and erectile function were worse following surgery and short-term urinary bother and bowel function were worse following RT. There has been recent recognition of other complications that may significantly affect the life trajectory of those undergoing PCa treatment. Of these, hospitalization, the need for urologic, rectoanal, and other major surgical procedures, and secondary cancers are more common among men treated with RT. Androgen deprivation therapy, frequently co-administered with RT, may additionally contribute to treatment-related morbidity. Technological innovations in surgery and RT have shown inconsistent oncologic and functional benefits. CONCLUSIONS: Owing to underpowered randomized control studies and the selection biases inherent in observational studies, the question of which treatment provides better PCa control cannot be definitively answered now or in the near future. Complications following PCa treatment are relatively common regardless of treatment approach. These include the commonly identified issues of urinary incontinence and erectile dysfunction, and others including hospitalization and invasive procedures to manage complications and secondary malignancies. Population-based outcome studies, rather than clinical trial data, will be necessary for a comprehensive understanding of the relative benefits and risks of each therapeutic approach. PATIENT SUMMARY: Surgery and radiotherapy are the most common interventions for men diagnosed with prostate cancer. Comparisons of survival after these treatments are limited by various flaws in the relevant studies. Complications are common regardless of the treatment approach.
Authors: Cristina Maranto; Vindhya Udhane; David T Hoang; Lei Gu; Vitali Alexeev; Kareem Malas; Karmel Cardenas; Jonathan R Brody; Ulrich Rodeck; Carmen Bergom; Ken A Iczkowski; Ken Jacobsohn; William See; Sara M Schmitt; Marja T Nevalainen Journal: Clin Cancer Res Date: 2018-02-26 Impact factor: 12.531