Treatment Options for Prostate Cancer: Evaluating the Evidence



FREE PREVIEW Log in or buy this issue to read the full article. AAFP members and paid subscribers get free access to all articles. Subscribe now.


FREE PREVIEW Subscribe or buy this issue. AAFP members and paid subscribers get free access to all articles.

Am Fam Physician. 2005 May 15;71(10):1915-1922.

  Patient information: See related handout on prostate cancer, written by the authors of this article.

  Related Editorial

Controversy surrounds the management options for localized prostate cancer—conservative management, prostatectomy, and radiation. Choosing among these options is difficult because of long-term side effects that include sexual, urinary, and bowel dysfunction. Some recent studies suggest that patients who have chosen treatment (i.e., radical prostatectomy or radiation) have longer disease-free survival compared with patients who have chosen conservative management (i.e., watchful waiting). However, several biases may artificially enhance the perceived value of treatment and make the interpretation of studies on treatment outcomes difficult. Sources of bias include lead time, length time, and patient selection. Because of the uncertain efficacy of management options and the risk of long-term treatment complications, family physicians need to engage their patients in the decision-making process.

Although prostate cancer is a commonly diagnosed malignancy, its management remains controversial. The majority of patients with prostate cancer are older than 65 years (median age of diagnosis is 71 years for white American men and 69 years for black American men).1 Approximately 220,000 American men were diagnosed in 2003, but because of the long natural history of prostate cancer, there were only 28,900 deaths in that year.2 Conservative management, or watchful waiting, has been suggested as an alternative to more aggressive therapies such as radical prostatectomy or radiation because many patients with prostate cancer will die from other causes (most commonly heart disease). Conservative management also may be favorable for older men with a life expectancy of less than 10 years because they are unlikely to benefit from, and perhaps less able to tolerate, aggressive interventions.3

Strength of Recommendations

Key clinical recommendationLabelReferencesComments

Radical prostatectomy should be considered for patients with moderately and poorly differentiated localized prostate cancer.

B

4,5,17

Better disease-free survival rates and fewer deaths from prostate cancer after radical prostatectomy compared with conservative management. Probable small difference in overall survival.

External radiation therapy and radical prostatectomy are equally recommended.

B

6,7,21

Treatments appear to be similar with respect to disease-free survival rates. Radiation therapy probably has a lower risk of erectile dysfunction compared with radical prostatectomy but carries a higher risk of chronic bowel symptoms.

Conservative management should be considered for patients with well-differentiated, localized prostate cancer.

B

12,13

No difference in overall survival in patients with well-differentiated cancer (i.e., Gleason score of 2 to 4) compared with patients without cancer. Shorter life expectancies and higher risk of death in patients with poorly differentiated cancer. Intermediate outcomes in patients with moderately differentiated cancer (i.e., Gleason score of 5 to 6).

Brachytherapy and external radiation therapy are equally recommended.

B

22,23,35

Treatments appear to be similar with respect to disease-free survival rates. Risk of erectile dysfunction similar to conformal radiation therapy; risk of irritative urinary symptoms following brachytherapy may be higher. Chronic bowel symptoms appear to be rare.


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, opinion, or case series. See page 1865 for more information.

Strength of Recommendations

View Table

Strength of Recommendations

Key clinical recommendationLabelReferencesComments

Radical prostatectomy should be considered for patients with moderately and poorly differentiated localized prostate cancer.

B

4,5,17

Better disease-free survival rates and fewer deaths from prostate cancer after radical prostatectomy compared with conservative management. Probable small difference in overall survival.

External radiation therapy and radical prostatectomy are equally recommended.

B

6,7,21

Treatments appear to be similar with respect to disease-free survival rates. Radiation therapy probably has a lower risk of erectile dysfunction compared with radical prostatectomy but carries a higher risk of chronic bowel symptoms.

Conservative management should be considered for patients with well-differentiated, localized prostate cancer.

B

12,13

No difference in overall survival in patients with well-differentiated cancer (i.e., Gleason score of 2 to 4) compared with patients without cancer. Shorter life expectancies and higher risk of death in patients with poorly differentiated cancer. Intermediate outcomes in patients with moderately differentiated cancer (i.e., Gleason score of 5 to 6).

Brachytherapy and external radiation therapy are equally recommended.

B

22,23,35

Treatments appear to be similar with respect to disease-free survival rates. Risk of erectile dysfunction similar to conformal radiation therapy; risk of irritative urinary symptoms following brachytherapy may be higher. Chronic bowel symptoms appear to be rare.


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, opinion, or case series. See page 1865 for more information.

Recent studies47 have suggested that patients with clinically localized prostate cancer have a longer disease-free survival following radical prostatectomy or radiation. Direct comparisons of treatment options with conservative management generally have favored treatment, partly because of study design issues often found in observational prostate cancer studies: lead-time, length-time, and selection bias. With these biases in mind, this analysis discusses outcomes and long-term side effects associated with the primary management options for clinically localized prostate cancer, including external radiation and interstitial seed radiation (or brachytherapy).

Sources of Bias

LEAD-TIME BIAS

Screening generally detects early disease in asymptomatic patients. Survival length typically is calculated from the date that disease is diagnosed until death. Therefore, the interval between cancer detection and death is longer in screened patients than in unscreened patients (Figure 1). Prostate-specific antigen (PSA) screening has shifted the diagnosis of prostate cancer toward clinically localized (i.e., T1 and T2) disease.58 The lead time resulting from PSA screening has been estimated to be between three and five years.9 Increased survival rates after treatment in the post-PSA era, when compared with the pre-PSA era, may be the result of earlier diagnosis and not necessarily early detection and treatment. A large randomized trial comparing treatment with conservative management for patients diagnosed by PSA screening has not been completed.10

Lead-Time Bias

Figure 1.

Two men develop prostate cancer in 1988 and die in 2003. One patient was not screened; he developed symptoms and was diagnosed with prostate cancer in 2000 and he died three years later. A second patient was screened and diagnosed with early prostate cancer in 1990; after diagnosis, he lived 13 additional years. The screened patient has a longer interval between the diagnosis of prostate cancer and death, a longer disease-free survival. This may be the result of early diagnosis and not necessarily the result of screening and early treatment.

View Large

Lead-Time Bias


Figure 1.

Two men develop prostate cancer in 1988 and die in 2003. One patient was not screened; he developed symptoms and was diagnosed with prostate cancer in 2000 and he died three years later. A second patient was screened and diagnosed with early prostate cancer in 1990; after diagnosis, he lived 13 additional years. The screened patient has a longer interval between the diagnosis of prostate cancer and death, a longer disease-free survival. This may be the result of early diagnosis and not necessarily the result of screening and early treatment.

Lead-Time Bias


Figure 1.

Two men develop prostate cancer in 1988 and die in 2003. One patient was not screened; he developed symptoms and was diagnosed with prostate cancer in 2000 and he died three years later. A second patient was screened and diagnosed with early prostate cancer in 1990; after diagnosis, he lived 13 additional years. The screened patient has a longer interval between the diagnosis of prostate cancer and death, a longer disease-free survival. This may be the result of early diagnosis and not necessarily the result of screening and early treatment.

LENGTH-TIME BIAS

Diseases with long preclinical phases are more likely to be detected by screening (Figure 2).11  For example, screening may not be able to detect rapidly progressing disease because the window of opportunity to detect asymptomatic disease is small. Because of differences in tumor differentiation (Gleason score), prostate cancer tumors progress at different rates (Table 1).12 A greater proportion of cancers diagnosed as a result of PSA screening are moderately differentiated (i.e., Gleason score of 5 to 6) than are poorly differentiated.58 It is not clear whether all patients with Gleason 5 to 6 cancer benefit from aggressive management.13 Therefore, better disease-free survival rates after treatment in the post-PSA era may be the result of treatment for less aggressive tumors (length-time bias) and not necessarily because of early detection and treatment.

Length-Time Bias

Figure 2.

Differences in tumor differentiation may result in length-time bias. In this example, the broken line represents the rapid growth of a poorly differentiated tumor. These tumors are less likely to be diagnosed by screening and (because of the rapid growth) are more likely to be diagnosed as a result of clinical symptoms. Slow-growing tumors(solid line) are more likely to be diagnosed by screening. Differences in survival that are observed in screened and unscreened populations may be caused in part by different cancer types (and not by early screening and treatment).

View Large

Length-Time Bias


Figure 2.

Differences in tumor differentiation may result in length-time bias. In this example, the broken line represents the rapid growth of a poorly differentiated tumor. These tumors are less likely to be diagnosed by screening and (because of the rapid growth) are more likely to be diagnosed as a result of clinical symptoms. Slow-growing tumors(solid line) are more likely to be diagnosed by screening. Differences in survival that are observed in screened and unscreened populations may be caused in part by different cancer types (and not by early screening and treatment).

Length-Time Bias


Figure 2.

Differences in tumor differentiation may result in length-time bias. In this example, the broken line represents the rapid growth of a poorly differentiated tumor. These tumors are less likely to be diagnosed by screening and (because of the rapid growth) are more likely to be diagnosed as a result of clinical symptoms. Slow-growing tumors(solid line) are more likely to be diagnosed by screening. Differences in survival that are observed in screened and unscreened populations may be caused in part by different cancer types (and not by early screening and treatment).

TABLE 1
Gleason Scoring (Tumor Differentiation) and Prognosis Under Conservative Management*

The rightsholder did not grant rights to reproduce this item in electronic media. For the missing item, see the original print version of this publication.

SELECTION BIAS

Observational studies may be biased because of patient selection. Outcomes in patients from tertiary care institutions may not be directly comparable with those in patients from community settings. For example, urinary complication rates following surgery have been shown to be lower in high-volume hospitals.14 Surgical studies tend to select only patients who have had a radical prostatectomy; patients with advanced disease generally are excluded because surgery often is stopped upon the discovery of extensive disease.15 More importantly, surgically managed patients will have pathologic evaluation of resected tissue and pelvic lymph nodes. Only 40 to 60 percent of patients with clinically localized disease (T1 and T2) remain classified with localized disease because of capsular (T3) or nodal (T4) involvement.45 Thus, patients with localized cancer based on surgical staging (after radical prostatectomy) generally will have better outcomes compared with patients with clinically localized cancer (during conservative management or after radiation) because patients with advanced disease have been excluded from the surgical cohort.

Methods

A structured review was used to evaluate treatment outcomes based on literature published in the past 15 years. Search terms included “prostate cancer and prostatectomy,” “radiation,” or “watchful waiting,” and “prostate cancer and quality of life” or “treatment complications.” Titles and abstracts were scanned to select papers that considered treatment outcomes or treatment complications. Papers considering hormonal, combination, or salvage therapies were not included.

Management Options

CONSERVATIVE MANAGEMENT

Conservative management, with or without androgen ablation reserved for symptomatic disease, is one option for prostate cancer patients.3 One study,16 based on the Connecticut Tumor Registry, documented outcomes for 451 patients (between 65 and 75 years of age) who were diagnosed with clinically localized prostate cancer from 1971 to 1976 and managed conservatively. Compared with an age-matched cohort of men without prostate cancer, patients with well-differentiated prostate cancer (i.e., Gleason score of 2 to 4) did not have an increased risk of death; patients with Gleason scores of 8 to 10, however, had about a two- and threefold increase in the risk of death, respectively. A more recent analysis12  of 767 patients from the same registry has shown that patients with Gleason 2 to 4 and Gleason 5 to 6 cancers under conservative management had a relatively small risk of dying from prostate cancer; patients with Gleason 7 to 10 cancers under conservative management, however, were more likely to die from prostate cancer than other causes (Table 1).12

PROSTATECTOMY

Surgical removal of the prostate is an option for patients with clinically localized cancer. A large randomized trial in the post-PSA era comparing radical prostatectomy with conservative management is under way, but will not be completed for several years.10 A recently published Scandinavian trial17 randomized 695 patients with clinically localized prostate cancer (median age, 65 ± 5 years) to radical prostatectomy or conservative management (median follow-up, 6.2 years). The majority of patients had Gleason 5 to 6 cancer. More than one third of these men were diagnosed with prostate cancer because of symptoms; only about 5 percent were diagnosed by PSA screening. At eight years, about 14 percent of patients whose disease was conservatively managed (95 percent confidence interval [CI], 7 to 15 percent) and 7 percent of prostatectomy patients (95 percent CI, 3 to 11 percent) developed metastases. The relative (radical prostatectomy compared with conservative management) hazard rate of death from prostate cancer (adjusted for age, Gleason score, and cancer stage) was 0.45 (95 percent CI, 0.25 to 0.84).17 However, differences in overall survival between the two treatment groups were not statistically significant. It is important to note that the study may not have been adequately powered to detect differences in overall survival. Furthermore, it remains to be determined whether an overall survival difference after radical prostatectomy may occur with a longer follow-up period.

Several case series have suggested that patients with early prostate cancer have a good disease-free survival rate following radical prostatectomy. The Mayo Clinic followed 2,518 patients with prostate cancer (mean age, 63 years) who underwent radical prostatectomy between 1990 and 1993 (mean follow-up, 5.6 years). The majority of patients had clinically localized Gleason 5 to 6 cancer. Less than 20 percent of these men were diagnosed as a result of PSA screening. After radical prostatectomy, 73 to 83 percent of patients diagnosed with clinically localized (T1 and T2) cancer were alive and free of disease at five years. For comparison, 63 percent of patients with locally advanced T3 cancer were alive and free of disease at five years.4

Another large series5 followed 2,091 patients (average age, 58.1 ± 6.6 years) with clinically localized prostate cancer who had a radical prostatectomy between 1982 and 1999. The majority of patients had Gleason 5 to 6 cancer, and 40 percent of these patients were diagnosed as a result of PSA screening. Biochemical failure (i.e., a PSA level higher than 0.2 ng per mL) was one indicator of recurrence. The five-, 10-, and 15-year probabilities of biochemical recurrence-free survival were 84, 72, and 63 percent, respectively. The corresponding metastases-free survival probabilities were 96, 89, and 81 percent.5 Another related study18 found that the median time to biochemical failure was about eight years, and the median time to metastases after biochemical failure was about five years.

Observations from these two studies suggest that patients have good disease-free survival rates following radical prostatectomy for clinically localized disease. However, to draw inferences about the efficacy of surgery, these results would have to be compared with older studies that followed men during conservative management in the pre-PSA era. This comparison may be biased in favor of surgery because some of the patients in the more recent surgical studies were diagnosed by PSA screening; thus, more recent studies have a greater proportion of patients with localized disease (a downward stage migration or lead-time bias). It also is not clear whether the type of cancer detected early or by screening is the same as cancer detected based on clinical symptoms (length-time bias). Finally, these surgical studies have included only patients who have had a radical prostatectomy and are from tertiary care institutions, and may not be applicable to patients in the community setting (selection bias). Therefore, management outcomes in the post-PSA era based on large community databases (i.e., Surveillance, Epidemiology, and End Results), may be more applicable to the average patient.8 However, these databases are just beginning to mature because of the long natural history of prostate cancer and the time required for updating these databases.19

RADIATION TREATMENT

Another treatment for patients with localized prostate cancer is external or interstitial radiation. Conformal external beam radiation generally has replaced conventional external radiation because higher doses of radiation can be directed to the prostate with less radiation to the surrounding tissues.20 Interstitial radiation or brachytherapy involves the placement of radioactive pellets (i.e., iodine-125 or palladium-103) into the prostate gland.

No large trials comparing radiation with other forms of treatment in the post-PSA era have been conducted. Some outcomes that are not specific to prostate cancer, such as overall survival, may be worse after radiation because patients who choose radiation tend to be older and have more comorbid illnesses than patients who choose radical prostatectomy (selection bias). To compare treatment outcomes, it is preferable to compare studies with similar clinical stages and grade distributions to minimize lead and length-time biases. A recent retrospective cohort study21 found similar biochemical failure (a rising PSA after treatment) rates after radical prostatectomy and higher-dose radiation (≥ 72 Gy). Differences between radiation and radical prostatectomy were attributable to pretreatment PSA and T-stage (lead time) and biopsy Gleason score (length time).21 Several case series also have shown that disease-free survival following radiation is comparable with radical prostatectomy.67 The efficacy of brachytherapy is comparable with external radiation.2223

Long-Term Side Effects

Radical prostatectomy has the highest risk of immediate serious complications, including a low risk of death.24 Although all of these management options have long-term side effects, patients are more likely to experience symptoms as a result of cancer progression (i.e., urinary obstruction and bone pain) during conservative management.25 Because approximately twice as many patients develop metastatic disease under conservative management, these patients are probably more likely to require hormone ablation therapy, which causes side effects such as fatigue and hot flashes.1726

Erectile dysfunction and urinary side effects are the most common complications following radical prostatectomy and radiation (Table 2).20,2747 The risk of developing these symptoms after treatment increases with patient age and comorbid illnesses.4849 Lower complication rates occur in hospitals that perform a large number of prostatectomies. Fewer men will have postsurgical erectile dysfunction after unilateral or bilateral nervesparing surgery.4250 Urinary side effects may be lower with sparing of the bladder neck51 and muscles of the distal urethral sphincter.49 Estimates for the risks of post-treatment complications also depend on how side effects are described in a study and tend to be higher if patients, instead of physicians, report the symptoms.4243

TABLE 2

Side Effects of Prostate Cancer Treatment

Side effectEstimated risk after radical prostatectomy (%)Estimated risk after external radiation therapy (%)Estimated risk after brachytherapy (%)

Bowel dysfunction

2 to 17

0 to 30

1 to 10

Erectile dysfunction

50 to 90

30 to 85

∼ 20 at 2 to 3 years,

∼ 50 at 5 to 6 years

Urinary dysfunction

15 to 60

2 to 30

12 to 30


Information from references 20 and 27 through 47.

TABLE 2   Side Effects of Prostate Cancer Treatment

View Table

TABLE 2

Side Effects of Prostate Cancer Treatment

Side effectEstimated risk after radical prostatectomy (%)Estimated risk after external radiation therapy (%)Estimated risk after brachytherapy (%)

Bowel dysfunction

2 to 17

0 to 30

1 to 10

Erectile dysfunction

50 to 90

30 to 85

∼ 20 at 2 to 3 years,

∼ 50 at 5 to 6 years

Urinary dysfunction

15 to 60

2 to 30

12 to 30


Information from references 20 and 27 through 47.

In general, more than 50 percent of patients are expected to have erectile dysfunction as a result of radical prostatectomy.27,28,37,38 Generally, the risk is less following conformal radiation and brachytherapy.35 The risk of frank urinary incontinence is low, but milder urinary symptoms (i.e., urine leakage) are common after radical prostatectomy and external radiation.27,32,49 More patients will have irritative urinary symptoms after brachytherapy than after external radiation.35 The risk of long-term bowel symptoms (i.e., tenesmus and stool leakage) is highest following external radiation.2729 The risk of long-term bowel symptoms following brachytherapy is low.3652

Patient Recommendations

Until the completion of randomized trials in the post-PSA era, it is difficult to recommend a best management option for localized prostate cancer with certainty.10 Because of long-term side effects, the integration of survival outcomes with quality of life is important. One recent study13 used decision modeling to estimate quality-adjusted life years (QALYs) for patients with clinically localized prostate cancer. Patients with Gleason 2 to 4 cancer had a decreased number of QALYs following treatment; conversely, patients with Gleason 7 to 10 cancer had an increased number of QALYs following treatment. Outcomes for patients with Gleason 5 to 6 cancer were less clear; treatment was marginally beneficial depending on the underlying assumptions used in the model.13

This review focuses on management options for localized prostate cancer; patients with advanced disease (i.e., extracapsular or nodal involvement) generally are not candidates for curative management. Based on the recent literature, the following suggestions can be made for patients with clinically localized prostate cancer. Conservative management is reasonable for patients with Gleason 2 to 4 cancer because these patients do not have a shortened life expectancy, and treatment is associated with long-term side effects. In contrast, patients with Gleason 7 to 10 cancer should consider treatment (i.e., radical prostatectomy or radiation). These patients have a high risk of dying from prostate cancer, and disease-free survival appears to be better after treatment. The majority of patients have moderately differentiated (Gleason score of 5 to 6) cancer. Because there is no convincing evidence for or against treatment, younger patients who are tolerant of long-term treatment side effects should consider radical prostatectomy or radiation therapy.13 However, older patients and patients with a life expectancy of less than 10 years with moderately differentiated cancer probably will not benefit from more aggressive management of their disease.

The Authors

VIBHA BHATNAGAR, M.D., M.P.H, is assistant clinical professor in the Department of Family and Preventive Medicine at the University of California, San Diego (UCSD), School of Medicine. She has a part-time appointment in Health Services Research and Development, Veterans Affairs San Diego Healthcare System. Dr. Bhatnagar graduated from the University of Ottawa School of Medicine, Ontario, Canada, and completed a family medicine residency at Montefiore Medical Center, Bronx, N.Y. She has a master’s degree in public health from the Harvard School of Public Health in Boston.

ROBERT M. KAPLAN, PH.D., is chair of health services at the University of California, Los Angeles, School of Public Health and RAND Corporation. He is former professor and chair of the Department of Family and Preventive Medicine and director of the Health Outcomes and Assessment Program at the UCSD School of Medicine. He graduated from UCSD with a doctoral degree in cognitive psychology.

Address correspondence to Vibha Bhatnagar, M.D., M.P.H., Veterans Affairs San Diego Healthcare System, 3350 La Jolla Village Dr., 111N-1, San Diego, CA 92161 (e-mail:vbhatnagar@ucsd.edu). Reprints are not available from the authors.

The authors indicate that they do not have any conflicts of interest. Sources of funding: Centers for Disease Control and Prevention grant no. U57-CCU–920–678–01.

REFERENCES

1. National Cancer Institute. Incidence and mortality. Accessed online April 5, 2005, at: http://seer.cancer.gov/publications/prostate/inc_mort.pdf.

2. Cancer facts & figures 2003. Accessed online April 5, 2005, at: http://www.cancer.org/downloads/STT/CAFF2003pwsecured.pdf.

3. Albertsen PC. Who needs to be treated?. Mol Urol. 1999;3:183–90.

4. Blute ML, Bergstralh EJ, Iocca A, Scherer B, Zincke H. Use of Gleason score, prostate specific antigen, seminal vesicle and margin status to predict biochemical failure after radical prostatectomy. J Urol. 2001;165:119–25.

5. Han M, Partin AW, Zahurak M, Piantadosi S, Epstein JI, Walsh PC. Biochemical (prostate specific antigen) recurrence probability following radical prostatectomy for clinically localized prostate cancer. J Urol. 2003;169:517–23.

6. Shipley WU, Thames HD, Sandler HM, Hanks GE, Zietman AL, Perez CA, et al. Radiation therapy for clinically localized prostate cancer: a multi-institutional pooled analysis. JAMA. 1999;281:1598–604.

7. Sandler HM, Dunn RL, McLaughlin PW, Hayman JA, Sullivan MA, Taylor JM. Overall survival after prostate-specific-antigen-detected recurrence following conformal radiation therapy. Int J Radiat Oncol Biol Phys. 2000;48:629–33.

8. National Cancer Institute. Surveillance, Epidemiology, and End Results. Probability of developing or dying of cancer: prostate cancer. Accessed online April 5, 2005, at: http://seer.cancer.gov/faststats/html/dev_prost.html.

9. Gann PH, Hennekens CH, Stampfer MJ. A prospective evaluation of plasma prostate-specific antigen for detection of prostatic cancer. JAMA. 1995;273:289–94.

10. Wilt TJ, Brawer MK. The Prostate Cancer Intervention Versus Observation Trial: a randomized trial comparing radical prostatectomy versus expectant management for the treatment of clinically localized prostate cancer. J Urol. 1994;152(5 pt 2):1910–4.

11. Black WC, Welch HG. Advances in diagnostic imaging and overestimations of disease prevalence and the benefits of therapy. N Engl J Med. 1993;328:1237–43.

12. Albertsen PC, Hanley JA, Gleason DF, Barry MJ. Competing risk analysis of men aged 55 to 74 years at diagnosis managed conservatively for clinically localized prostate cancer. JAMA. 1998;280:975–80.

13. Bhatnagar V, Stewart ST, Bonney WW, Kaplan RM. Treatment options for localized prostate cancer: quality-adjusted life years and the effects of lead-time. Urology. 2004;63:103–9.

14. Begg CB, Riedel ER, Bach PB, Kattan MW, Schrag D, Warren JL, et al. Variations in morbidity after radical prostatectomy. N Engl J Med. 2002;346:1138–44.

15. LuYao GL, Yao SL. Population-based study of long-term survival in patients with clinically localised prostate cancer. Lancet. 1997;349:906–10.

16. Albertsen PC, Fryback DG, Storrer BE, Kolon TF, Fine J. Long-term survival among men with conservatively treated localized prostate cancer. JAMA. 1995;274:626–31.

17. Holmberg L, Bill-Axelson A, Helgesen F, Salo JO, Folmerz P, Haggman M, et al. A randomized trial comparing radical prostatectomy with watchful waiting in early prostate cancer. N Engl J Med. 2002;347:781–9.

18. Pound CR, Partin AW, Eisenberger MA, Chan DW, Pearson JD, Walsh PC. Natural history of progression after PSA elevation following radical prostatectomy. JAMA. 1999;281:1591–7.

19. Clegg LX, Feuer EJ, Midthune DN, Fay MP, Hankey BF. Impact of reporting delay and reporting error on cancer incidence rates and trends. J Natl Cancer Inst. 2002;94:1537–45.

20. Dearnaley DP, Khoo VS, Norman AR, Meyer L, Nahum A, Tait D, et al. Comparison of radiation side-effects of conformal and conventional radiotherapy in prostate cancer: a randomised trial. Lancet. 1999;353:267–72.

21. Kupelian PA, Elshaikh M, Reddy CA, Zippe C, Klein EA. Comparison of the efficacy of local therapies for localized prostate cancer in the prostate-specific antigen era: a large single-institution experience with radical prostatectomy and external-beam radiotherapy. J Clin Oncol. 2002;20:3376–85.

22. Grimm PD, Blasko JC, Sylvester JE, Meier RM, Cavanagh W. 10-year biochemical (prostate-specific antigen) control of prostate cancer with (125) I brachytherapy. Int J Radiat Oncol Biol Phys. 2001;51:31–40.

23. Beyer DC, Brachman DG. Failure free survival following brachytherapy alone for prostate cancer: comparison with external beam radiotherapy. Radiother Oncol. 2000;57:263–7.

24. Arai Y. Radical prostatectomy: time trends, morbidity and quality of life. Int J Urol. 2001;8:S15–8.

25. Steineck G, Helgesen F, Adolfsson J, Dickman PW, Johansson JE, Norlen BM, et al. Quality of life after radical prostatectomy or watchful waiting. N Engl J Med. 2002;347:790–6.

26. Albertsen PC, Aaronson NK, Muller MJ, Keller SD, Ware JE Jr. Health-related quality of life among patients with metastatic prostate cancer. Urology. 1997;49:207–16.

27. Potosky AL, Legler J, Albertsen PC, Stanford JL, Gilliland FD, Hamilton AS, et al. Health outcomes after prostatectomy or radiotherapy for prostate cancer: results from the Prostate Cancer Outcomes Study. J Natl Cancer Inst. 2000;92:1582–92.

28. Litwin MS, Melmed GY, Nakazon T. Life after radical prostatectomy: a longitudinal study. J Urol. 2001;166:587–92.

29. Fowler FJ Jr, Barry MJ, Lu-Yao G, Wasson JH, Bin L. Outcomes of external-beam radiation therapy for prostate cancer: a study of Medicare beneficiaries in three surveillance, epidemiology, and end results areas. J Clin Oncol. 1996;14:2258–65.

30. Madalinska JB, Essink-Bot ML, de Koning HJ, Kirkels WJ, van der Maas PJ, Schroder FH. Health-related quality-of-life effects of radical prostatectomy and primary radiotherapy for screen-detected or clinically diagnosed localized prostate cancer. J Clin Oncol. 2001;19:1619–28.

31. Lim AJ, Brandon AH, Fiedler J, Brickman AL, Boyer CI, Raub WA Jr, et al. Quality of life: radical prostatectomy versus radiation therapy for prostate cancer. J Urol. 1995;154:1420–5.

32. Hamilton AS, Stanford JL, Gilliland FD, Albertsen PC, Stephenson RA, Hoffman RM, et al. Health outcomes after external-beam radiation therapy for clinically localized prostate cancer: results from the Prostate Cancer Outcomes Study. J Clin Oncol. 2001;19:2517–26.

33. Storey MR, Pollack A, Zagars G, Smith L, Antolak J, Rosen I. Complications from radiotherapy dose escalation in prostate cancer: preliminary results of a randomized trial. Int J Radiat Oncol Biol Phys. 2000;48:635–42.

34. Fransson P, Damber JE, Tomic R, Modig H, Nyberg G, Widmark A. Quality of life and symptoms in a randomized trial of radiotherapy versus deferred treatment of localized prostate carcinoma. Cancer. 2001;92:3111–9.

35. Zelefsky MJ, Cown D, Fuks Z, Shike M, Burman C, Jackson A, et al. Long term tolerance of high dose three-dimensional conformal radiotherapy in patients with localized prostate carcinoma. Cancer. 1999;85:2460–8.

36. Gelblum DY, Potters L. Rectal complications associated with transperineal interstitial brachytherapy for prostate cancer. Int J Radiat Oncol Biol Phys. 2000;48:119–24.

37. Fowler FJ Jr, Barry MJ, Lu-Yao G, Wasson J, Roman A, Wennberg J. Effect of radical prostatectomy for prostate cancer on patient quality of life: results from a Medicare survey. Urology. 1995;45:1007–13.

38. Fowler FJ Jr, Barry MJ, Lu-Yao G, Wasson J, Roman A, Wennberg J. Patient-reported complications and follow-up treatment after radical prostatectomy. The National Medicare Experience: 1988–1990 (updated June 1993). Urology. 1993;42:622–9.

39. Litwin MS, Hays RD, Fink A, Ganz PA, Leake B, Leach GE, et al. Quality-of-life outcomes in men treated for localized prostate cancer. JAMA. 1995;273:129–35.

40. Smith DS, Carvalhal GF, Schneider K, Krygiel J, Yan Y, Catalona WJ. Quality-of-life outcomes for men with prostate carcinoma detected by screening. Cancer. 2000;88:1454–63.

41. Stock RG, Kao J, Stone NN. Penile erectile function after permanent radioactive seed implantation for treatment of prostate cancer. J Urol. 2001;165:436–9.

42. McCammon KA, Kolm P, Main B, Schellhammer PF. Comparative quality-of-life analysis after radical prostatectomy or external beam radiation for localized prostate cancer. Urology. 1999;54:509–16.

43. Shrader-Bogen CL, Kjellberg JL, McPherson CP, Murray CL. Quality of life and treatment outcomes: prostate carcinoma patients’ perspectives after prostatectomy or radiation therapy. Cancer. 1997;79:1977–86.

44. Stanford JL, Feng Z, Hamilton AS, Gilliland FD, Stephenson RA, Eley JW, et al. Urinary and sexual function after radical prostatectomy for clinically localized prostate cancer: the Prostate Cancer Outcomes Study. JAMA. 2000;283:354–60.

45. Jonler M, Madsen FA, Rhodes PR, Sall M, Messing EM, Bruskewitz RC. A prospective study of quantification of urinary incontinence and quality of life in patients undergoing radical retropubic prostatectomy. Urology. 1996;48:433–40.

46. Gray M, Petroni GR, Theodorescu D. Urinary function after radical prostatectomy: a comparison of the retropubic and perineal approaches. Urology. 1999;53:881–90.

47. Madalinska JB, Essink-Bot ML, de Koning HJ, Kirkels WJ, van der Maas PJ, Schroder FH. Health-related quality of life in patients with screen-detected versus clinically diagnosed prostate cancer preceding primary treatment. Prostate. 2001;46:87–97.

48. Althof SE. Quality of life and erectile dysfunction. Urology. 2002;59:803–10.

49. Krane RJ. Urinary incontinence after treatment for localized prostate cancer. Mol Urol. 2000;4:279–86.

50. Rabbani F, Stapleton AM, Kattan MW, Wheeler TM, Scardino PT. Factors predicting recovery of erections after radical prostatectomy. J Urol. 2000;164:1929–34.

51. Gaker DL, Gaker LB, Stewart JF, Gillenwater JY. Radical prostatectomy with preservation of urinary continence. J Urol. 1996;156(2 pt 1):445–9.

52. Benoit RM, Naslund MJ, Cohen JK. Complications after prostate brachytherapy in the Medicare population. Urology. 2000;55:91–6.

Members of various family medicine departments develop articles for “Practical Therapeutics.” This article is one in a series coordinated by the Department of Family and Preventive Medicine at the University of California, San Diego, School of Medicine. Guest editor of the series is Tyson Ikeda, M.D.


Copyright © 2005 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact afpserv@aafp.org for copyright questions and/or permission requests.

Want to use this article elsewhere? Get Permissions


Article Tools

  • Download PDF
  • Print page
  • Share this page
  • AFP CME Quiz

Information From Industry

More in Pubmed

Navigate this Article