April 25, 2007 -- Which side effects of prostate cancer treatment would bother you least? A new study points out the risks for each treatment option.
Here's one option you don't have: No current treatment for prostate cancer completely avoids the risk of serious side effects.
But there's also good news in the study from Mark Litwin, MD, MPH, and colleagues: During the first two years after treatment, the side effects tend to diminish or become less bothersome. So far, it seems this trend will continue over the study's next three years.
"It is not just survival that matters after treatment for prostate cancer -- quality of life matters, too," Litwin tells WebMD. "Not one of these treatments is better or worse over time. Each has its own unique impact on quality of life."
Those impacts differ between treatments.
"The main problem with brachytherapy is urinary irritation and some bowl irritation. The main problem for external-beam radiation is urinary irritation and, to a lesser extent, bowel irritation. And the main problem for surgery is sexual function -- the ability to get an erection -- and, to a lesser extent, urinary incontinence," Litwin says.
Litwin, professor of urology and public health at UCLA and a researcher at UCLA's Jonsson Cancer Center, and colleagues report their findings in the June 1 issue of the journal Cancer.
Prostate Treatments: Radiation and Surgery
There are three major treatments for prostate cancer:
- Radical prostatectomy or surgical removal of the prostate. This is usually performed by urologists. When possible, doctors perform a nerve-sparing procedure that reduces the side effect of sexual dysfunction.
- External-beam radiation. This is performed by a radiation oncologist and is designed to maximize radiation to the prostate and to minimize radiation to the bladder and rectum.
- Brachytherapy. A radiation oncologist implants some 100 tiny radioactive "seeds" into the prostate. This sometimes is done in combination with external-beam radiation or radiation applied via removable catheters.
Each technique is highly successful at curing early prostate cancer. Prostate cancer treatments continue to evolve, but Litwin says the evidence so far fails to show that any one treatment has a better cure rate than another.
That's not the case for treatment side effects. Previous studies showed that the different treatments have different side effects. But these studies had a serious problem: They didn't measure men's quality of life before they underwent treatment for prostate cancer.
"Men tend to romanticize how good their function used to be if you ask them to remember back," Litwin says. "For example, if you ask a man how good his sexual function was eight years ago, his answer may not give a precise picture of how it actually was."
Men in the Litwin study averaged 60 to 70 years of age. One thing that surprised the researchers was that many of the men had sexual, bowel, and/or urinary dysfunction before prostate cancer treatment.
"The average 65- to 70-year-old man's urinary, bowel, and sexual functions are simply not perfect. One has to be cognizant of that when looking at how a patient does after treatment," Litwin says. "If a 70-year-old patient asks me how good his sexual function will be after surgery, it's like the old story where the patient asks, 'Doc, will I be able to play Rachmaninoff after surgery?' I have to ask, 'Well, could you play it before?'"
Side Effects: Dysfunction, Other Annoyances
Perhaps because it's a newer treatment, brachytherapy burst onto the scene only a few years ago as the newest, greatest thing for prostate cancer. There's no doubt it's effective. But Litwin says that neither brachytherapy nor new external-beam radiation techniques avoid serious side effects.
"Brachytherapy and external-beam radiation have a much more profound and persistent effect on the bowel than patients realize," he says. "And brachytherapy tends to have more of an effect on patients' urinary voiding. Surgery, on the other hand, has a much greater effect on erections and urinary control."
Simply listing cancer treatment side effects doesn't give a full picture of a patient's quality of life. Litwin and colleagues also evaluated how much these symptoms actually bothered the men.
"After surgery, patients who have mild incontinence are somewhat bothered, but nowhere near as bothered as those with the severe urinary blockage problems sometimes caused by radiation treatments," he says. "On the other hand, even though we talk about bowel dysfunction being an issue for brachytherapy and external-beam radiation patients, at most only 20% of these patients experience severe bother from bowel symptoms."
Sexual dysfunction, however, severely bothered men in all of the treatment groups. Sixty percent of the surgery patients reported severe bother from sexual dysfunction -- but that tended to diminish over time.
Among men who had no sexual dysfunction before surgery and who underwent nerve-sparing surgery, sexual function improved over the first two years after treatment.
"At the 24-month time point, they are right up there with the brachytherapy and external-beam radiation patients," Litwin says.
Bottom Line: "Doc, How Well Will I Do?"
Of course, patients don't really want to know the percentage of men who get this or that symptom. What each man really wants to know is how well he will do after treatment
"We talk about sexual, urinary, and bowel function, but the main point is that the overall physical and mental recovery from any one of these three prostate cancer treatments is equivalent," Litwin says. "Patients get back to where they started and stay there -- pretty fast. So at least in terms of overall physical and mental well-being, they can expect a fairly rapid recovery."
This may be a bit overoptimistic, suggests Steven Zeliadt, MD, PhD, a research scientist at Seattle's Fred Hutchinson Cancer Research Center who has studied prostate cancer treatment outcomes.
"These men really are regaining function," Zeliadt tells WebMD. "But still, a considerable number of people do not regain function two years later. That is particularly true for urinary and sexual function. And this is something men are not picking up on in their decision making."
Zeliadt praises the Litwin study for focusing on something men usually don't think about until it's too late.
"Men, when making prostate cancer treatment decisions, really don't focus on side effects. They are focused on curing the cancer," he says. "This might help men consider the picture more thoroughly."
He also admires the Litwin study for asking men how well they were doing before treatment.
"A lot of the men we talk to complain of treatment side effects -- and in the next breath talk about how happy they are they had treatment," Zeliadt says. "So it is difficult, after the fact, to ask men if they had a hard time with their decision."
Timothy J. Wilt, MD, MPH, professor of medicine at the Minneapolis VA Center for Chronic Disease Outcomes Research, has studied the outcomes of prostate cancer treatments. He warns that the Litwin team's results come from only one institution -- the UCLA Jonsson Cancer Center -- and that other centers may get very different results. Litwin says this is, indeed, the case.
"We did a national study of prostate cancer treatment in almost 50 states, looking at the degree to which urologists and radiation oncologists complied with generally accepted standards of care," Litwin says. "We found they varied widely. So the quality of care provided varies -- and outcomes vary."
Litwin advises men seeking prostate cancer treatment to ask doctors and radiologists about their personal experience treating prostate cancer -- and about how often their patients suffer various dysfunctions.
"One indication of really good quality care in prostate cancer is that a surgeon or radiologist tracks his or her own outcomes and can say, 'Here is my track record.'"
This should be part of a very, very frank discussion in which men discuss with their doctors their own personal preference for the kinds of dysfunctions they are most and least willing to suffer in order to cure their prostate cancers.
"This study and other similar reports begin to provide useful information regarding adverse effects and patient perceptions of these adverse effects," Wilt tells WebMD. "Dr. Litwin and colleagues are correct in stating that this type of information needs to be discussed with patients so that they can make unbiased, informed treatment decisions. Physicians -- including primary care doctors -- should assist patients and their families in an informed decision-making process."