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Am Fam Physician. 1998;58(9):1972-1978

to the editor: I am writing to express my deep concern and disagreement in relation to the article on prostate cancer written by Dr. Naitoh and colleagues.1 This article was obviously written with a strong urologist bias and does not accurately describe the diagnosis and treatment of prostate cancer from the aspects that should be delivered by a family physician practicing in the United States.

I feel that Dr. Naitoh's article is grossly biased toward radical prostatectomy. An article on the complications of external beam radiotherapy is cited in Table 5.2 This article was published in 1994; since then, major advancements in brachytherapy have changed this management extensively. A highly respected meta-analysis by Coley and colleagues3,4 points to the questionable outcomes of radical prostatectomy. The results of this analysis indicate that, as with using favorable assumptions, earlier studies show an increase in life expectancy of only two weeks after radical prostatectomy. This information is not brought out in Dr. Naitoh's article, and it is inappropriate for this article to be published today with what is known about the advancements in the management of prostate cancer.

The information that is cited in Tables 3 and 4 on complications after radical prostatectomy is also extremely misleading.1 Table 3 states that rates of urinary incontinence are low with the procedure. Rates vary with the institution and the surgeon who performs the procedure. The most misleading part of the article is Table 4, which states that, after radical prostatectomy, patients 40 to 50 years of age have potency rates of 100 percent and patients 61 to 70 years of age have potency rates that are 43 percent higher than preoperative rates of sexual function. I think these rates vastly underestimate the actual occurrence of impotency as a complication of radical prostatectomy. I am disappointed that a more balanced discussion was not presented on this extremely important topic.

in reply: We appreciate Dr. Epperson's comments, and we want to make it clear that we did not intend to write a review article that was weighted toward radical prostatectomy. Recent evidence suggests that radical prostatectomy offers a slight long-term advantage over radiotherapy in terms of cancer control, although one must also remember that radical prostatectomy is associated with a higher complication rate.1

While Dr. Epperson criticized our article because we referenced data on the complications of radiotherapy published in 1994, more recent studies have not reported complication rates that are markedly different.2 Countless variations in the delivery of external beam radiotherapy (such as 2-D or 3-D conformal techniques, blocking, neoadjuvant prostate downsizing using antiandrogens, dose escalation and proton-based regimens) have made radiotherapy a “moving target.” Because of this, the data on complications of radiotherapy are difficult to interpret and compare.3 Furthermore, since many of the complications related to radiation (impotence, radiation cystitis) can take a few years to become evident, and since validated survey instruments that measure complications and outcomes have rarely been used in the radiotherapy literature, the true impact of modern external beam radiotherapy on patient quality of life remains undefined.

While Dr. Epperson commented on our failure to discuss the “major advances in brachytherapy,” we felt that more study was needed before we could recommend brachytherapy for the average patient who has a tumor confined to the prostate. While we agree that brachytherapy represents a potential advancement in the treatment of localized prostate cancer, we deliberately avoided discussion of this modality even though we perform this technique in our own practice.

We chose to avoid discussion of brachytherapy (as well as discussion of other novel techniques for the treatment of prostate cancer, which include cryosurgery, proton beam therapy and thermotherapy), because (1) the data on the recurrence of prostate-specific antigen are not mature enough to make any long-term conclusions about the ability of this modality to cure prostate cancer; (2) to date, the long-term complication rates (such as impotence) have not been adequately studied using validated survey instruments in a prospective manner; and (3) the quality of implant placement, the use of post-treatment dosimetry, the use of palladium versus the use of iodine seeds, the use of seeds in combination with androgen ablation or external beam radiotherapy and the role of high-dose-rate brachytherapy make the subject much more complex and controversial than what could be covered in the limited scope of our review article. We do, however, feel that brachytherapy should be explored as a treatment for low-stage, low-volume, low-grade prostate cancer.

Finally, Dr. Epperson criticized the complication rates that we reported, especially since rates reported in the literature vary widely. However, the existence of variation in reported complication rates should not be a reason to dismiss the value of a therapy; it is simply an indication that more studies are needed to determine why there is variation and how complication rates can be minimized. At this time, the reasons for variation of continence and potency rates among different institutions are unknown. While the variation could be attributed to differences in the “institution and surgeon,” the other factors that must be considered include (1) the definitions of incontinence and impotence that were used, (2) the methods that were used to measure incontinence and impotence, and (3) the case-mix adjusters such as age, comorbidity, baseline functioning and factors related to the tumors.

While studies are currently ongoing to determine which quality measures are important following the treatment of prostate cancer, it cannot be said with certainty that the skill of the surgeon alone determines the outcome, just as it cannot be said that variations in the delivery of radiotherapy alone result in the variation of the bladder irritation and impotence rates that have been reported in the radiotherapy literature.4

In summary, we believe that the following statements reflect state-of-the-art treatment of localized prostate cancer: (1) over the long term (more than 10 to 15 years), surgery provides a slight advantage over radiotherapy in terms of disease-free survival; (2) there is a low, but real, risk of severe incontinence following radical prostatectomy; (3) external beam radiotherapy does not cause incontinence; (4) both treatments may result in impotence; (5) brachytherapy appears to work well in the treatment of low-stage, low-grade tumors, although there is not enough long-term data to make any definitive statements regarding its efficacy or side effects; and (6) watchful waiting is best applied in older men who have low-grade cancers (Gleason <6), and who have a life expectancy of fewer than 10 years.

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This series is coordinated by Kenny Lin, MD, MPH, deputy editor.

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