EFFECT OF EXTERNAL BEAM RADIATION VERSUS RADICAL PROSTATECTOMY

EFFECT OF EXTERNAL BEAM RADIATION VERSUS RADICAL PROSTATECTOMY ON PATIENT MORTALITY AND QUALITY OF LIFE CAPSTONE PROJECT, MPAS 218 SPRING 2019 JORDAN JEPSON APRIL 12, 2019

DISCLOSURES Jordan Jepson, PA-S • No financial interests or other relationships with manufacturers of commercial products, suppliers of commercial services, or commercial supporters, if any, are presented in this course content. • No commercial support was received for this activity. • I do have a prostate Adapted from R. Sunseri

PICOT QUESTION • IN AMERICAN PATIENTS OVER 60 YEARS OLD WITH LOCALIZED PROSTATE CANCER, WHAT IS THE EFFECT OF EXTERNAL BEAM RADIATION ON QUALITY OF LIFE AND MORTALITY COMPARED TO RADICAL PROSTATECTOMY?

KEY ISSUES • IDENTIFY CURRENT TREATMENTS OF PROSTATE CANCER • DISCUSSING SIDE EFFECTS/MORTALITY AFTER TREATMENT • POSSIBLY ESTABLISHING A FIRST-LINE TREATMENT • NEED FOR MORE RESEARCH INTO DEVELOPING TREATMENTS • IMPORTANCE OF PATIENT EDUCATION

BACKGROUND – STATISTICS • 2 ND MOST PREVALENT CA IN AMERICAN MEN (ACS-2019) • 2 ND LEADING CAUSE OF CA RELATED DEATHS • 184, 000 NEW CASES OF PROSTATE CA DX’D IN THE US (ACS-2018) • 32, 000 DEATHS • OCCURS IN 99 PER 100, 000 (ENTIRE MALE POPULATION OF US) • OCCURS IN 580 PER 100, 000 FOR AGE 65 -75 • RATES DOUBLE EVERY 5 YEARS AFTER AGE 50 • 2. 9 MILLION MEN CURRENTLY LIVING WITH PROSTATE CA

BACKGROUND – TREATMENTS • RADICAL PROSTATECTOMY • SURGICAL REMOVAL OF PART OR ALL OF THE PROSTATE • EXTERNAL BEAM RADIATION THERAPY • FOCUSED MULTI-BEAM RADIATION ON THE PROSTATE • BRACHYTHERAPY • PLACEMENT OF RADIOACTIVE SEEDS DIRECTLY INTO THE GLAND

Radical Prostatectomy BACKGROU ND – SIDE EFFECTS OF TREATMENT • External Beam Radiation Therapy Surgical complications (anesthesia • Erectile dysfunction reaction, infection, bleeding) • Urinary Incontinence • Erectile Dysfunction • Skin Reaction • Urinary Incontinence • Bowel Dysfunction – radiation • Loss of fertility • Lymphedema • Difficulty urinating/dysuria • Possible decrease in penis length • Secondary malignancies • Rectal leakage proctitis

WHICH TREATMENT IS BETTER?

EXAMINING THE EVIDENCE • OVER 15 ARTICLES WERE EVALUATED • ASSESSED MORTALITY OUTCOMES AND AFFECTS ON QOL • STUDIES: • RETROSPECTIVE COHORT STUDIES • OBSERVATIONAL STUDIES • SURVEYS

EXAMINING THE EVIDENCE – MORTALITY • 10 -YEAR SURVIVAL RATES OF PATIENTS TX’D WITH EBRT VS RP: • JELDRES ET AL. , 2009 • 75. 3% AFTER RP VS. 36. 7% AFTER EBRT • KIBEL ET AL. , 2012 • 88. 9% AFTER RP VS. 82. 6% AFTER EBRT • PROSTATE CANCER SPECIFIC MORTALITY FOR RP AND EBRT WAS 1. 8% AND 2. 9%, RESPECTIVELY • BOORJIAN ET AL. , 2011 • 92% AFTER RP VS. 88% AFTER EBRT

EXAMINING THE EVIDENCE – MORTALITY CONT’D • 10 -YEAR CANCER SPECIFIC MORTALITY • ABDOLLAH ET AL. , 2012 • 1. 4% AFTER RP AND 3. 9% AFTER EBRT (P<0. 001) • SUN ET AL. , 2011 • IN RP, EBRT, AND OBSERVATION PATIENTS, CSM RATES WERE 3. 6%, 6. 5%, AND 10. 8%

EXAMINING THE EVIDENCE – QOL AFTER TREATMENT • QOL OUTCOMES 48 MONTHS AFTER PROSTATE CA TREATMENT: • GORE ET AL. , 2009 • URINARY INCONTINENCE: 307 S/P RP AND 78 S/P EBRT • SEXUAL DYSFUNCTION AFFECTED ALL GROUPS • BOWEL DYSFUNCTION MORE COMMONLY REPORTED AFTER EBRT • QOL OUTCOMES REPORTED AMONG PROSTATE CA SURVIVORS: • SANDA ET AL. , 2008 • EBRT: LONG-LASTING URINARY IRRITATION, BOWEL DYSFUNCTION, SEXUAL DYSFUNCTION • RP: URINARY INCONTINENCE , SEXUAL DYSFUNCTION - IMPROVED • ABDULLAH ET AL. , 2017 • URINARY INCONTINENCE: 34% S/P RP AND 18% S/P EBRT • DECISIONAL REGRET: 34% OF PATIENTS

SUMMARY OF THE EVIDENCE • RADICAL PROSTATECTOMY IS ASSOCIATED WITH HIGHER 10 -YEAR SURVIVAL OUTCOMES AND LOWER CANCER-SPECIFIC MORTALITY COMPARED TO EBRT • FINDINGS WERE CONSISTENT WITH 11 STUDIES. • SIDE EFFECTS ARE COMMON WITH BOTH TREATMENT MODALITIES • NERVE-SPARING RP IS ASSOCIATED WITH FASTER UI/SD IMPROVEMENT • EBRT IS ASSOCIATED WITH BOWEL DYSFUNCTION • EBRT HAS LESS REPORTED UI SYMPTOMS • DECISIONAL REGRET WAS SHARED BY BOTH GROUPS

CONCLUSION • RADICAL PROSTATECTOMY HAS BETTER MORTALITY OUTCOMES THAN EBRT • EBRT AND RP BOTH DEMONSTRATE UI AND ED SYMPTOMS AFTER TREATMENT • NERVE SPARING RP HAS IMPROVED OUTCOMES • MORE DATA IS NEEDED ON IMPROVED RADIATION THERAPIES

IMPLICATIONS FOR PRACTICE • CAN RECOMMEND RP FIRST BASED ON MORTALITY RATES • FOR LOCALIZED PROSTATE CANCERS • CURTAIL TREATMENT MODALITY BASED OFF SIDE EFFECT PROFILE • COMORBIDITIES • PROVIDE APPROPRIATE PATIENT EDUCATION ON SIDE EFFECTS • THE PATIENT ULTIMATELY DECIDES THE TREATMENT

KNOWLEDGE GAPS • UNKNOWN THE EFFICACY OF NEWER RADIATION THERAPIES • TRIALS AND PROSPECTIVE STUDIES ARE BEING DONE, AND IMPROVED TECHNIQUES ARE PROMISING • IMPROVED TECHNIQUES FOR RP

NEXT STEPS • ASSESS SURVIVAL OUTCOMES/MORTALITY RATES OF NEW RADIATION THERAPIES • CONFORMAL EBRT, IMAGE GUIDED RADIATION THERAPY, PROTON BEAM THERAPY • ASSESS SIDE EFFECT PROFILE OF NEW RADIATION THERAPIES • EDUCATE PROVIDERS ON NERVE-SPARING RADICAL PROSTATECTOMY • NOVEMBER 2018, ASCO PUT FORTH GUIDELINES FOR HYPOFRACTIONATION EBRT TREATMENT FOR EARLY-STAGE PROSTATE CA

TAKE-HOME POINTS • RP HAS STATISTICALLY SIGNIFICANT BETTER MORTALITY OUTCOMES THAN EBRT • RP HAS HIGHER INCIDENCE OF GU SIDE EFFECTS • EBRT HAS HIGHER INCIDENCE OF GI SIDE EFFECTS AND SECONDARY MALIGNANCY • PATIENT EDUCATION IS CRUCIAL

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QUESTIONS?