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1.
Introduction
Since the introduction of prostate-specific antigen testing,
there has been a substantial shift to a more favourable stage
in newly diagnosed prostate cancer (PCa), with approxi-
mately 81% of cases being diagnosed as clinically localised
[1] .Currently, evidence-based management for clinically
localised PCa includes active surveillance (AS), surgery,
external beam radiotherapy (EBRT), and brachytherapy (BT)
[2] .Knowledge of the adverse events of different manage-
ment options is critical for making informed treatment
decisions, considering that the survival benefit is uncertain,
especially in men with favourable-risk PCa
[3] .The adverse effects of primary treatments for localised
disease can negatively impact disease-specific quality of life
(QoL)
[4]. The concept of QoL is subjective; however, in
cancer cohorts, specific tools or patient-reported outcome
measures (PROMs) have been developed and validated.
These questionnaires assess common issues that affect men
after PCa diagnosis and treatment and generate scores,
which reflect the impact on perceptions of health-related
quality of life (HRQoL). It is currently unclear which primary
treatment for localised disease offers superior disease-
specific QoL outcomes. The primary objective of this
systematic review was to compare cancer-specific QoL data
as measured by PROMs for intermediate (1–10 yr) to long-
term (
>
10 yr) follow-up, among competing treatments.
2.
Evidence acquisition
2.1.
Search strategy
The review was performed according to the Preferred
Reporting Items for Systematic Reviews and Meta-analyses
(PRISMA) guidelines
[5]and Cochrane review principles
[6] .An experienced research librarian performed the search
strategy in consultation with a multidisciplinary panel of
expert clinicians and patient representative (European
Association of Urology [EAU] Prostate Cancer Guideline
Panel). The database searched were EMBASE, MEDLINE,
AMED, PsycINFO, Cochrane Database of Systematic Reviews,
and Cochrane Central Register of Controlled Trials. Searches
were limited to studies published from the year 2000 on-
wards. No language restrictions were imposed. Full details of
the search strategies used are described in Appendix A.
All abstracts and full-text articles were screened by two
independent reviewers (M.I.L. and M.A.L.). Disagreement
was resolved by discussion; if no agreement was reached, a
third independent party acted as an arbiter (L.B.).
2.2.
Types of study design included
Randomised and nonrandomised comparative studies
where outcome data were collected prospectively after
primary intervention for PCa was initiated (see section
2.4 for included interventions) with a sample size of at least
10 patients per arm, reporting cancer-specific QoL out-
comes measured by validated PROMs
[7]with at least 12mo
of follow-up, were eligible for inclusion.
2.3.
Types of participants included
The study population was adult men ( 18 yr of age)
diagnosed with clinically localised PCa (T1–T2c), who had
not undergone any previous treatment prior to their
primary treatment for PCa (with the exception of neoadju-
vant androgen deprivation therapy [ADT] preceding radio-
therapy).
2.4.
Types of interventions included
The following interventions were eligible for inclusion:
1. AS/monitoring (as defined by primary authors)
2. Radical prostatectomy (RP; open or laparoscopic or robot
assisted)
3. Radiotherapy (3D conformal or intensity-modulated
[IMRT] or stereotactic [SBRT] radiotherapy) BT boost
low risk of bias. The quality of evidence from observational studies was low to moderate.
For a follow-up of up to 6 yr, active surveillance was found to have the lowest impact on
cancer-specific QoL, surgery had a negative impact on urinary and sexual function when
compared with active surveillance and EBRT, and EBRT had a negative impact on bowel
function when compared with active surveillance and surgery. Data from one small RCT
reported that brachytherapy has a negative impact on urinary function 1 yr post-treatment,
but no significant urinary toxicity was reported at 5 yr.
Conclusions:
This is the first systematic review comparing the impact of different primary
treatments on cancer-specific QoL for men with clinically localised prostate cancer, using
validated cancer-specific patient-reported outcome measures only. There is robust evi-
dence that choice of primary treatment for localised prostate cancer has distinct impacts on
patients’ QoL. This should be discussed in detail with patients during pretreatment
counselling.
Patient summary:
Our review of the current evidence suggests that for a period of up to 6 yr
after treatment, men with localised prostate cancer who were managed with active
surveillance reported high levels of quality of life (QoL). Men treated with surgery reported
mainly urinary and sexual problems, while those treated with external beam radiotherapy
reported mainly bowel problems. Men eligible for brachytherapy reported urinary pro-
blems up to a year after therapy, but then their QoL returned gradually to as it was before
treatment.
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2017 European Association of Urology. Published by Elsevier B.V. All rights reserved.
Radiotherapy
Active surveillance
Brachytherapy
Systematic review
E U R O P E A N U R O L O G Y 7 2 ( 2 0 1 7 ) 8 6 9 – 8 8 5
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