Even 'active surveillance' may have risks, such as anxiety
TUESDAY, March 21, 2017 (HealthDay News) -- The long-term side effects of different prostate cancer treatments vary -- and knowing that may help men decide which one is right for them.
That's the conclusion of two new studies published March 21 in the Journal of the American Medical Association.
Both followed men who had early stage prostate cancer treated with "modern" approaches -- including the latest surgical and radiation techniques. And both found that side effects sometimes persisted for up to three years.
The specifics, however, varied.
Many men had surgery to remove the prostate. Overall, they tended to have greater declines in their sexual function, versus men who chose radiation or "active surveillance."
They were also more prone to urinary incontinence.
On the other hand, men treated with radiation typically had more problems with bowel function. If they also received hormonal therapy, they were also at risk of hormone-related symptoms -- such as hot flashes and breast enlargement.
On the brighter side, the issues with radiation were mainly limited to the first year after treatment, said Dr. Daniel Barocas, the lead researcher on one of the studies.
Not surprisingly, both studies found, men who opted for surgery or radiation had more long-term symptoms than those who chose active surveillance.
With that approach, men put off treatment in favor of having their cancer monitored with periodic blood tests and biopsies.
Active surveillance is an option for prostate cancer because the disease is often slow-growing and may never progress to the point where it threatens a man's life.
But that doesn't necessarily mean active surveillance is the best option for any one man, said Barocas. He's an associate professor of urologic surgery at Vanderbilt University in Nashville.
Much depends on whether the cancer is "low-risk" or not, he explained. Low-risk prostate cancers have characteristics that mark them as less aggressive.
"If you're in that low-risk group," Barocas said, "active surveillance might be the best choice, to avoid treatment side effects."
But for men with more aggressive prostate tumors, treatment is typically advised to boost their long-term survival.
For those patients, Barocas said, "it's pretty clear that treatment is better than no treatment."
Dr. Freddie Hamdy is a professor of surgery at the University of Oxford in England.
In general, he said, research suggests that when men with low-risk prostate cancer are carefully selected for active surveillance, they have "very low" death rates from the disease.
For some men, active surveillance might be anxiety-provoking, said Hamdy, who wrote an editorial published with the studies.
But, he added, his own research has found that men on active surveillance do not have higher rates of anxiety or depression than prostate cancer patients who choose immediate treatment.
"The anxiety generated in many of these patients is more likely to be related to the diagnosis of cancer, and the fact that [they] have to live with its consequences, irrespective of the treatment that they receive," Hamdy said.
For their study, Barocas and his colleagues followed 2,550 men diagnosed with prostate cancer between 2011 and 2012. All had tumors that were confined to the prostate. Almost 60 percent had surgery; another 23.5 percent had external radiation; and 17 percent chose active surveillance.
Three years later, men who'd had surgery gave lower ratings to their sexual function, versus the two other groups. They also had more trouble with urinary incontinence: 14 percent said they had a "moderate or big problem" with urine leakage, compared with 5 to 6 percent of men in the other groups.
Radiation, meanwhile, carried the biggest risks of bowel problems and hormonal side effects. But that faded by year three.
The second study -- of more than 1,100 men with early stage cancer -- had similar findings.
Surgery carried higher risks of sexual dysfunction and urine leakage. For instance, of men with normal sexual function before surgery, 57 percent reported "poor" function two years later, the University of North Carolina researchers found.
External radiation, again, caused more short-term bowel problems. The study also included men who'd undergone brachytherapy -- a type of internal radiation that implants radioactive "seeds" in the prostate. Those patients had more issues with urinary tract obstruction and irritation.
So what's a man to do with that information? According to Barocas, patients can talk to their doctor about the types of side effects that might occur with each treatment -- then decide what they can personally live with.
"If, for example, you already have poor sexual function -- as many patients in our study did -- that side effect might not mean as much to you," Barocas said.
For a man with low-risk prostate cancer, he noted, the risk of any treatment side effect might not be "acceptable."
Hamdy made another point: While robot-assisted surgery has become the go-to approach, it has the same types of side effects that traditional open surgery always had.
The American Cancer Society has an overview of prostate cancer. ( https://www.cancer.org/cancer/prostate-cancer.html )
SOURCES: Daniel Barocas, M.D., M.P.H., associate professor, urologic surgery, Vanderbilt University, Nashville, Tenn.; Freddie Hamdy, M.D., professor, surgery, University of Oxford, England; March 21, 2017, Journal of the American Medical Association