Association Between Choice of Radical Prostatectomy, External Beam Radiotherapy, Brachytherapy, or Active Surveillance and Patient-Reported Quality of Life Among Men With Localized Prostate Cancer
Association Between Choice of Radical Prostatectomy, External Beam Radiotherapy, Brachytherapy, or Active Surveillance and Patient-Reported Quality of Life Among Men With Localized Prostate Cancer
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DOI：
10.1001/jama.2017.1652
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发表时间：
2017-03-21
影响因子：
120.7
通讯作者：
Godley, Paul A.
中科院分区：
文献类型：
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作者：
Chen, Ronald C.;Basak, Ramsankar;Godley, Paul A.
重要性 诊断为局限性前列腺癌的患者必须选择可能出现不良反应的可能性不同的治疗策略。 目的 比较根治性前列腺切除术、外照射放疗和近距离放射治疗与主动监测后的生活质量 (QOL)。 设计、设置和参与者 基于人群的前瞻性队列，由 1141 名新诊断前列腺癌男性（符合条件的男性中的 57% 参与）组成 与北卡罗来纳州中央癌症登记处合作，于 2011 年 1 月至 2013 年 6 月期间入组。从诊断到入组的中位时间为 5 周，所有男性均在治疗前签署了书面知情同意书。当前分析的最终随访日期为 2015 年 9 月 9 日。 暴露 采用根治性前列腺切除术、外照射放射治疗、近距离放射治疗或主动监测进行治疗。 主要结果和测量 使用经过验证的仪器前列腺癌症状指数在基线（治疗前）和治疗后 3、12 和 24 个月评估生活质量。该仪器包含 4 个领域——性功能障碍、尿路梗阻和刺激、尿失禁和肠道问题——每个领域的评分从 0（无功能障碍）到 100（最大功能障碍）。比较每个治疗组与每个时间点的主动监测之间的倾向加权平均域评分。 结果 在 1141 名入组男性中，314 名进行了主动监测（27.5%），469 名进行了根治性前列腺切除术（41.1%），249 名进行了外照射放射治疗（21.8%），109 名进行了近距离放射治疗（9.6%）。经过倾向加权后，各组的中位年龄为 66 至 67 岁，77% 至 80% 的参与者是白人。在各组中，性功能障碍的倾向加权平均基线得分为 41.8 至 46.4，尿路梗阻和刺激为 20.8 至 22.8，尿失禁为 9.7 至 10.5，肠道问题为 5.7 至 6.1。与主动监测相比，接受根治性前列腺切除术（36.2 [95% CI，30.4-42.0]）、外照射放疗（13.9 [95% CI，6.7-21.2]）和近距离放射治疗（17.1 [95% CI，7.8-26.6]）的患者平均性功能障碍评分恶化了 3 个月。与 3 个月时的主动监测相比，尿失禁恶化与根治性前列腺切除术相关（33.6 [95% CI，27.8-39.2]）；外束放疗 (11.7 [95% CI, 8.7-14.8]) 和近距离放射治疗 (20.5 [95% CI, 15.1-25.9]) 导致尿路梗阻和刺激急性恶化；外照射放疗导致肠道症状恶化（4.9 [95% CI，2.4-7.4]）。到 24 个月时，治疗组与主动监测之间的平均评分在大多数领域都没有显着差异。结论和相关性在这个患有局限性前列腺癌的男性队列中，每种治疗策略都与 2 年来不同的不良反应模式相关。这些发现可用于促进结合个人偏好的治疗决策。
IMPORTANCE Patients diagnosed with localized prostate cancer have to decide among treatment strategies that may differ in their likelihood of adverse effects.OBJECTIVE To compare quality of life (QOL) after radical prostatectomy, external beam radiotherapy, and brachytherapy vs active surveillance.DESIGN, SETTING, AND PARTICIPANTS Population-based prospective cohort of 1141 men (57% participation among eligible men) with newly diagnosed prostate cancer were enrolled from January 2011 through June 2013 in collaboration with the North Carolina Central Cancer Registry. Median time from diagnosis to enrollment was 5 weeks, and all men were enrolled with written informed consent prior to treatment. Final follow-up date for current analysis was September 9, 2015.EXPOSURES Treatment with radical prostatectomy, external beam radiotherapy, brachytherapy, or active surveillance.MAIN OUTCOMES AND MEASURES Quality of life using the validated instrument Prostate Cancer Symptom Indices was assessed at baseline (pretreatment) and 3, 12, and 24 months after treatment. The instrument contains 4 domains-sexual dysfunction, urinary obstruction and irritation, urinary incontinence, and bowel problems-each scored from 0 (no dysfunction) to 100 (maximum dysfunction). Propensity-weighted mean domain scores were compared between each treatment group vs active surveillance at each time point.RESULTS Of 1141 enrolled men, 314 pursued active surveillance (27.5%), 469 radical prostatectomy (41.1%), 249 external beam radiotherapy (21.8%), and 109 brachytherapy (9.6%). After propensity weighting, median age was 66 to 67 years across groups, and 77% to 80% of participants were white. Across groups, propensity-weighted mean baseline scores were 41.8 to 46.4 for sexual dysfunction, 20.8 to 22.8 for urinary obstruction and irritation, 9.7 to 10.5 for urinary incontinence, and 5.7 to 6.1 for bowel problems. Compared with active surveillance, mean sexual dysfunction scores worsened by 3 months for patients who received radical prostatectomy (36.2 [95% CI, 30.4-42.0]), external beam radiotherapy (13.9 [95% CI, 6.7-21.2]), and brachytherapy (17.1 [95% CI, 7.8-26.6]). Compared with active surveillance at 3 months, worsened urinary incontinence was associated with radical prostatectomy (33.6 [95% CI, 27.8-39.2]); acute worsening of urinary obstruction and irritation with external beam radiotherapy (11.7 [95% CI, 8.7-14.8]) and brachytherapy (20.5 [95% CI, 15.1-25.9]); and worsened bowel symptoms with external beam radiotherapy (4.9 [95% CI, 2.4-7.4]). By 24 months, mean scores between treatment groups vs active surveillance were not significantly different in most domains.CONCLUSIONS AND RELEVANCE In this cohort ofmenwith localized prostate cancer, each treatment strategywas associated with distinct patterns of adverse effects over 2 years. These findings can be used to promote treatment decisions that incorporate individual preferences.