美国德克萨斯大学安德森肿瘤中心Karen E. Hoffman联合范德比尔特大学医学中心Daniel A. Barocas课题组在研究中取得进展。他们对积极监测、手术、近距离放射治疗、伴或不伴雄激素剥夺的外部光束放射治疗局限性前列腺癌患者的预后进行了5年的随访。该项研究成果发表在2020年1月14日出版的《美国医学会杂志》上。

了解现代治疗方法对低危和高危局限性前列腺癌患者的不良影响，有利于为治疗选择提供更多的信息。

2011-2012年间，研究组进行了一项前瞻性、基于人群的队列研究，共招募了1386名前列腺癌低危患者（前列腺特异性抗原PSA≤20ng/mL）和619名高危患者（PSA为20-50ng/mL）。低危患者中有363名接受积极监测治疗，675名接受保留神经的前列腺切除术，261名接受外部光束放射治疗（EBRT），87名接受低剂量率近距离放疗；高危患者中有402名接受前列腺切除术，217名接受EBRT联合雄激素剥夺治疗（ADT）。治疗5年后，根据26项前列腺综合指数对疗效进行评估。

这2005名男性患者的中位年龄为64岁，77%为非西班牙裔白人。对于低危前列腺癌患者，与积极监测相比，保留神经的前列腺切除术治疗5年后的尿失禁和治疗3年后的性功能指标均较差；低剂量率近距离放疗1年后尿、性和肠功能均较差；EBRT5年内尿、性、肠功能则无显著差异。

对于高危患者，与前列腺切除术相比，ADT联合EBRT治疗6个月后的激素功能降低，1年后肠功能降低，但5年后性功能却有所改善，且5年内各时间点的尿失禁状况亦有所改善。

总之，对于局限性前列腺癌患者，现代治疗方案间的大部分功能差异在5年后有所减弱。然而，接受前列腺切除术的患者与其他选择方案相比，5年内尿失禁更严重，且接受前列腺切除术的高危患者5年后的性功能显著差于EBRY联合ADT方案。

附：英文原文

Title: 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

Author: Karen E. Hoffman, David F. Penson, Zhiguo Zhao, Li-Ching Huang, Ralph Conwill, Aaron A. Laviana, Daniel D. Joyce, Amy N. Luckenbaugh, Michael Goodman, Ann S. Hamilton, Xiao-Cheng Wu, Lisa E. Paddock, Antoinette Stroup, Matthew R. Cooperberg, Mia Hashibe, Brock B. O’Neil, Sherrie H. Kaplan, Sheldon Greenfield, Tatsuki Koyama, Daniel A. Barocas

Issue&Volume: 2020/01/14

Abstract:

Importance  Understanding adverse effects of contemporary treatment approaches for men with favorable-risk and unfavorable-risk localized prostate cancer could inform treatment selection.

Objective  To compare functional outcomes associated with prostate cancer treatments over 5 years after treatment.

Design, Setting, and Participants  Prospective, population-based cohort study of 1386 men with favorable-risk (clinical stage cT1 to cT2bN0M0, prostate-specific antigen [PSA] ≤20 ng/mL, and Grade Group 1-2) prostate cancer and 619 men with unfavorable-risk (clinical stage cT2cN0M0, PSA of 20-50 ng/mL, or Grade Group 3-5) prostate cancer diagnosed in 2011 through 2012, accrued from 5 Surveillance, Epidemiology and End Results Program sites and a US prostate cancer registry, with surveys through September 2017.

Exposures  Treatment with active surveillance (n?=?363), nerve-sparing prostatectomy (n?=?675), external beam radiation therapy (EBRT; n?=?261), or low-dose-rate brachytherapy (n?=?87) for men with favorable-risk disease and treatment with prostatectomy (n?=?402) or EBRT with androgen deprivation therapy (n?=?217) for men with unfavorable-risk disease.

Main Outcomes and Measures  Patient-reported function, based on the 26-item Expanded Prostate Index Composite (range, 0-100), 5 years after treatment. Regression models were adjusted for baseline function and patient and tumor characteristics. Minimum clinically important difference was 10 to 12 for sexual function, 6 to 9 for urinary incontinence, 5 to 7 for urinary irritative symptoms, and 4 to 6 for bowel and hormonal function.

Results  A total of 2005 men met inclusion criteria and completed the baseline and at least 1 postbaseline survey (median [interquartile range] age, 64 [59-70] years; 1529 of 1993 participants [77%] were non-Hispanic white). For men with favorable-risk prostate cancer, nerve-sparing prostatectomy was associated with worse urinary incontinence at 5 years (adjusted mean difference, ?10.9 [95% CI, ?14.2 to ?7.6]) and sexual function at 3 years (adjusted mean difference, ?15.2 [95% CI, ?18.8 to ?11.5]) compared with active surveillance. Low-dose-rate brachytherapy was associated with worse urinary irritative (adjusted mean difference, ?7.0 [95% CI, ?10.1 to ?3.9]), sexual (adjusted mean difference, ?10.1 [95% CI, ?14.6 to ?5.7]), and bowel (adjusted mean difference, ?5.0 [95% CI, ?7.6 to ?2.4]) function at 1 year compared with active surveillance. EBRT was associated with urinary, sexual, and bowel function changes not clinically different from active surveillance at any time point through 5 years. For men with unfavorable-risk disease, EBRT with ADT was associated with lower hormonal function at 6 months (adjusted mean difference, ?5.3 [95% CI, ?8.2 to ?2.4]) and bowel function at 1 year (adjusted mean difference, ?4.1 [95% CI, ?6.3 to ?1.9]), but better sexual function at 5 years (adjusted mean difference, 12.5 [95% CI, 6.2-18.7]) and incontinence at each time point through 5 years (adjusted mean difference, 23.2 [95% CI, 17.7-28.7]), than prostatectomy.

Conclusions and Relevance  In this cohort of men with localized prostate cancer, most functional differences associated with contemporary management options attenuated by 5 years. However, men undergoing prostatectomy reported clinically meaningful worse incontinence through 5 years compared with all other options, and men undergoing prostatectomy for unfavorable-risk disease reported worse sexual function at 5 years compared with men who underwent EBRT with ADT.

DOI: 10.1001/jama.2019.20675

Source: https://jamanetwork.com/journals/jama/article-abstract/2758599