The Impact of Prostate Cancer Treatment on Quality of Life: A Narrative Review with a Focus on Randomized Data

Figures & data

Table 1 Treatment Selection for Localized Prostate Cancer, Stratified by Risk Group

Disease Group	Treatment Modalities
Low-Risk	If expected patient survival ≥ 10 years, active surveillance, external beam radiation (standard fractionation, hypofractionation, or SBRT), brachytherapy (HDR or LDR), and radical prostatectomy are all options; if < 10 years, observation is recommended
Favorable Intermediate-Risk	If expected patient survival ≥ 10 years, active surveillance, external beam radiation, brachytherapy, and radical prostatectomy are all options; if < 10 years, observation, external beam radiation, or brachytherapy is recommended
Unfavorable Intermediate-Risk	If expected patient survival ≥ 10 years, radical prostatectomy, external beam radiation with 4–6 months of ADT, external beam radiation and brachytherapy boost and 4–6 months of ADT are all options; if < 10 years, observation, external beam radiation with 4–6 months ADT, and external beam radiotherapy and brachytherapy boost and 4–6 months ADT are all options
High-Risk	If > 5 years or symptomatic, external beam radiation with 18–36 months ADT, external beam radiation and brachytherapy boost and 18–36 months of ADT, and radical prostatectomy are all options; if ≤ 5 years and asymptomatic, observation, external beam radiation and ADT are all options
Adjuvant/Salvage	If adverse features (positive margins, seminal vesicle involvement, and/or extraprostatic extension), consider adjuvant external beam radiation; otherwise, close monitoring with external beam radiation and 6–24 months of ADT recommended if clinical or biochemical evidence of failure

Figure 1 Surgical and Radiotherapeutic Approaches in the Treatment of Prostate Cancer. (A) pre- and post-prostatectomy anatomy with retropubic and perineal surgical approaches. (B) microsurgical anatomy at risk for injury with retropubic and surgical approaches. (C) clinical target volumes (CTV) for radiotherapy for intact prostate treated definitively with external beam radiotherapy (XRT). When indicated pelvic lymph node fields are added, increasing the potential for gastrointestinal toxicity. (D) CTV for radiotherapy for prostate fossa treated adjuvantly or in salvage cases. The utility of lymph node coverage in this setting is the subject of clinical investigation. (E) CTV for low-dose-rate brachytherapy with or without XRT treatment. High-dose-rate techniques are available using temporary catheter-based placement of an Ir-192 source with established fractionation schedules and fewer post-treatment radiation precautions.

Table 2 Key Prospective Studies Examining Quality of Life in Prostate Cancer

Author (Year)	Exposure	Erectile Dysfunction	Urinary Incontinence	Urinary Voiding Symptoms	Bowel Symptoms	HRQoL (Overall)	Study Limitations	Study Strengths
Randomized Trials
Donovan^Citation67 (2016)	1. RP 2. XRT + 4 months ADT 3. Active Monitoring	Worse in RP group at 6 months post-treatment and all time points	Worse in RP arm at 6-months post-treatment and all time points	Worse in the RT + ADT arm at 6 months with return to near baseline levels	Worse in RT + ADT arm at all-time points	Equivalent	Homogenous population	Large Series, Radiation arm included ADT, Modern techniques for surgery and radiation
Lennernäs^Citation70 (2015)	1. RP + ADT 2. XRT + BT Boost + ADT	Decreased in both groups, but equivalent	Equivalent	Equivalent	Equivalent	Equivalent across both groups	Small series (n=89), closed early due to low accrual	Entire cohort received ADT
Crook^Citation71 (2010)	1. RP 2. BT monotherapy	Worse after RP	Worse after RP	Equivalent	Equivalent	Not Reported	Small series, closed early due to poor accrual, only 19% of patients randomized	Outcome data at 5 years
Giberti^Citation72 (2009)	1. RP 2. BT monotherapy	Worse in RP at 2 and 5 years	Equivalent	Greater in BT arm on short follow-up, equivalent long term	Worse in BT arm on short-follow-up, equivalent long-term	Equivalent	Only used Brachytherapy,	Validated metric, Long term follow-up (15) years
Morris^Citation20 (2016) Rodda^Citation73 (2017)	1. XRT + ADT + XRT boost 2. XRT + ADT + LDR BT boost	Similar between arms	Worse with LDR Boost	Worse with LDR Boost	Equivalent	Not Reported	Only compared radiation techniques	Large study with long term follow-up
Prospective Studies
Hoffman^Citation74 (2020)	1. Active Surveillance 2. RP 3. XRT 4. BT 5. XRT + ADT	Worse in RP and BT arm	Worse in RP and BT	Worse in BT	Worse in XRT + ADT at 1 year	Equivalent at 5 years in domains: Physical function, emotional well-being, and energy	Non-randomized, population-based cohort study	Large study, 5-year follow-up

Abbreviations: ADT, androgen deprivation therapy; BT, brachytherapy; RP, radical prostatectomy; RT, radiation therapy; XRT, external beam radiation therapy.

Donovan JL, Hamdy FC, Lane JA, et al. Patient-reported outcomes after monitoring, surgery, or radiotherapy for prostate cancer. N Engl J Med. 2016;375(15):1425–1437. doi:10.1056/NEJMoa160622127626365

 PubMed Web of Science ®Google Scholar

Lennernäs B, Majumder K, Damber J-E, et al. Radical prostatectomy versus high-dose irradiation in localized/locally advanced prostate cancer: a Swedish multicenter randomized trial with patient-reported outcomes. Acta Oncol. 2015;54(6):875–881. doi:10.3109/0284186X.2014.97482725362844

 PubMed Web of Science ®Google Scholar

Crook JM, Gomez-Iturriaga A, Wallace K, et al. Comparison of health-related quality of life 5 years after SPIRIT: surgical prostatectomy versus interstitial radiation intervention trial. J Clin Oncol. 2010. doi:10.1200/JCO.2010.31.7305

 Web of Science ®Google Scholar

Giberti C, Chiono L, Gallo F, Schenone M, Gastaldi E. Radical retropubic prostatectomy versus brachytherapy for low-risk prostatic cancer: a prospective study. World J Urol. 2009;27(5):607–612. doi:10.1007/s00345-009-0418-919455340

 PubMed Web of Science ®Google Scholar

Morris WJ, Tyldesley S, Rodda S, et al. Androgen suppression combined with elective nodal and dose escalated radiation therapy (the ASCENDE-RT trial): an analysis of survival endpoints for a randomized trial comparing a low-dose-rate brachytherapy boost to a dose-escalated external beam boost for high- and intermediate-risk prostate cancer. Int J Radiat Oncol. 2017;98(2):275–285. doi:10.1016/j.ijrobp.2016.11.026

 PubMed Web of Science ®Google Scholar

Rodda S, Tyldesley S, Morris WJ, et al. ASCENDE-RT: an analysis of treatment-related morbidity for a randomized trial comparing a low-dose-rate brachytherapy boost with a dose-escalated external beam boost for high- and intermediate-risk prostate cancer. Int J Radiat Oncol. 2017;98(2):286–295. doi:10.1016/j.ijrobp.2017.01.008

 PubMed Web of Science ®Google Scholar

Hoffman KE, Penson DF, Zhao Z, et al. Patient-reported outcomes through 5 years for active surveillance, surgery, brachytherapy, or external beam radiation with or without androgen deprivation therapy for localized prostate cancer. JAMA. 2020;323(2):149. doi:10.1001/jama.2019.2067531935027

 PubMed Web of Science ®Google Scholar