surgery and radiation have both been shown to increase the longterm diseasespecific survival rate for men with din icaUy localized prostate cancer. Although both modalities have demonstrated favor able effects on canc...surgery and radiation have both been shown to increase the longterm diseasespecific survival rate for men with din icaUy localized prostate cancer. Although both modalities have demonstrated favor able effects on cancer control, questions regarding quality of life （QoL） and func tional outcomes remain incompletely answered. To date, no randomized prospective trials have been performed comparing the two treatment modalities and so indirect compar isons of longterm functional outcomes have served as a substitute to aid in patient coun seling and decisionmaking. As there is a pau city of longterm data comparing functional outcomes after radical prostatectomy and external beam radiation therapy, a recent art icle by Resnick et al.,1 has attempted to pro vide additional information about this topic in terms of continence, erectile function and bowel function. Utilizing the Prostate Cancer Outcomes Study cohort, a populationbased cohort of men diagnosed with prostate cancer in the pro statespecific antigen （PSA） era, the authors compared rates of urinary incontinence, erect ile dysfunction, and bowel urgency at 2, 5 and 15 years after primary therapy. They showed that men undergoing prostatectomy had higher rates of incontinence and erectile dys function at 2 and 5 years, but these rates were similar to those in the radiotherapy group at 15 years. More specifically, men were approxi mately five times more likely to have urinary continence issues if they underwent prostatec tomv versus radiotherapy and almost three anda half times more likely to develop erectile dys function in the short to intermediateterm following primary treatment. As expected, rates of bowel urgency were higher in the radio therapy group at 2 and 5 years, but not sig nificantly different from the surgery group at 15 years. In addition, the authors note that the rate of incontinence and erectile function pro gressively worsened over time, regardless of primary treatment modality. At 15 years of followup, the prevalence of erectile dysfunc tion was approximately 87% in the prosta tectomy group, and 94% in the radiotherapy group, a nonsignificant difference. Interes tingly, only approximately 40% of patients in either group reported being bothered by this. Without an appropriate control group, it is hard to distinguish the relative contribution of inter vention or age to the overall decline in sexual function. Shortterm studies have shown that men undergoing prostatectomy have larger declines in sexual and urinary function than agematched controls,2 but no such untreated control cohort was present in this study. The effects on sexual, urinary and bowel function are critical issues to address when counseling patients regarding prostate cancer treatment. Rather than looking at specific points in time, the overall decrement in each QoL domain can be evaluated as the area under the curve for each treatment type. Therefore, while values generally are similar at 15 years, men have a cumulative difference in preserved erectile and urinary function over that period that can be compared by area under the curve measurement. A calculation of the relative decrement in each domain over time would be valuable for patient counsel ing, but these are not provided by the authors. In addition, the generalizability of the authors＇ findings may be limited by thedramatic refinement of treatment modalities since study enrollment in the mid1990s. Robotassisted laparoscopic radical prostatect only is now the primary surgical therapy for prostate cancer, with a much smaller propor tion of prostatectomies being performed at lowvolume centers and those not offering robotic surgery.3 As the shift to higher volume surgeons has progressed, it is reasonable to con sider that the improvements in lengths of stay and shortterm outcomes after robotic surgery could be extrapolated to the continence and sexual function domains.4 Additionally, the advent of image modulation in radiotherapy has reduced late toxicity rates and, in the cur rent era, may lower the reported rates of erec tile dysfimction, urinary incontinence and bowel dysfunction reported in this study.5 Any assessment of QoL following prostate cancer treatment merits discussion of the overdiagnosis and overtreatment of clinically insignificant cancers. Less than 10% of patients in either cohort had a Gleason score /〉 8 and less than a third of patients had a PSA level 〉 10 ng ml 1. There has been an increas ing view that some Gleason 6 prostate cancers do not have metastatic potential. As such, active surveillance in men with lowrisk dis ease is an appropriate choice and minimizes treatmentspecific issues with the QoL para meters considered in this study.6 Selection of only those men who have a high likelihood of benefiting from treatment may have the most significant effect in reducing treatment related sexual, bladder and bowel dysfunction.7 The Prostate Cancer Research International Active Surveillance Project is the largest obser vational prospective study evaluating active surveillance as an alternative to radical treat ment for lowrisk prostate cancer. Their data show that surveillance is a feasible strategy that does not compromise cancer cure.展开更多
文摘surgery and radiation have both been shown to increase the longterm diseasespecific survival rate for men with din icaUy localized prostate cancer. Although both modalities have demonstrated favor able effects on cancer control, questions regarding quality of life （QoL） and func tional outcomes remain incompletely answered. To date, no randomized prospective trials have been performed comparing the two treatment modalities and so indirect compar isons of longterm functional outcomes have served as a substitute to aid in patient coun seling and decisionmaking. As there is a pau city of longterm data comparing functional outcomes after radical prostatectomy and external beam radiation therapy, a recent art icle by Resnick et al.,1 has attempted to pro vide additional information about this topic in terms of continence, erectile function and bowel function. Utilizing the Prostate Cancer Outcomes Study cohort, a populationbased cohort of men diagnosed with prostate cancer in the pro statespecific antigen （PSA） era, the authors compared rates of urinary incontinence, erect ile dysfunction, and bowel urgency at 2, 5 and 15 years after primary therapy. They showed that men undergoing prostatectomy had higher rates of incontinence and erectile dys function at 2 and 5 years, but these rates were similar to those in the radiotherapy group at 15 years. More specifically, men were approxi mately five times more likely to have urinary continence issues if they underwent prostatec tomv versus radiotherapy and almost three anda half times more likely to develop erectile dys function in the short to intermediateterm following primary treatment. As expected, rates of bowel urgency were higher in the radio therapy group at 2 and 5 years, but not sig nificantly different from the surgery group at 15 years. In addition, the authors note that the rate of incontinence and erectile function pro gressively worsened over time, regardless of primary treatment modality. At 15 years of followup, the prevalence of erectile dysfunc tion was approximately 87% in the prosta tectomy group, and 94% in the radiotherapy group, a nonsignificant difference. Interes tingly, only approximately 40% of patients in either group reported being bothered by this. Without an appropriate control group, it is hard to distinguish the relative contribution of inter vention or age to the overall decline in sexual function. Shortterm studies have shown that men undergoing prostatectomy have larger declines in sexual and urinary function than agematched controls,2 but no such untreated control cohort was present in this study. The effects on sexual, urinary and bowel function are critical issues to address when counseling patients regarding prostate cancer treatment. Rather than looking at specific points in time, the overall decrement in each QoL domain can be evaluated as the area under the curve for each treatment type. Therefore, while values generally are similar at 15 years, men have a cumulative difference in preserved erectile and urinary function over that period that can be compared by area under the curve measurement. A calculation of the relative decrement in each domain over time would be valuable for patient counsel ing, but these are not provided by the authors. In addition, the generalizability of the authors＇ findings may be limited by thedramatic refinement of treatment modalities since study enrollment in the mid1990s. Robotassisted laparoscopic radical prostatect only is now the primary surgical therapy for prostate cancer, with a much smaller propor tion of prostatectomies being performed at lowvolume centers and those not offering robotic surgery.3 As the shift to higher volume surgeons has progressed, it is reasonable to con sider that the improvements in lengths of stay and shortterm outcomes after robotic surgery could be extrapolated to the continence and sexual function domains.4 Additionally, the advent of image modulation in radiotherapy has reduced late toxicity rates and, in the cur rent era, may lower the reported rates of erec tile dysfimction, urinary incontinence and bowel dysfunction reported in this study.5 Any assessment of QoL following prostate cancer treatment merits discussion of the overdiagnosis and overtreatment of clinically insignificant cancers. Less than 10% of patients in either cohort had a Gleason score /〉 8 and less than a third of patients had a PSA level 〉 10 ng ml 1. There has been an increas ing view that some Gleason 6 prostate cancers do not have metastatic potential. As such, active surveillance in men with lowrisk dis ease is an appropriate choice and minimizes treatmentspecific issues with the QoL para meters considered in this study.6 Selection of only those men who have a high likelihood of benefiting from treatment may have the most significant effect in reducing treatment related sexual, bladder and bowel dysfunction.7 The Prostate Cancer Research International Active Surveillance Project is the largest obser vational prospective study evaluating active surveillance as an alternative to radical treat ment for lowrisk prostate cancer. Their data show that surveillance is a feasible strategy that does not compromise cancer cure.
