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Prostate Cancer: The Price of Early Detection

Jonsson Comprehensive Cancer Center, University of California Los Angeles Schools of Medicine and Public Health, Los Angeles, CA

Cancer mortality rates in the United States have declined significantly during the past 5 years.¹ There are several potential explanations for this decline, including, but not limited to, a decrease in the use of tobacco products, the effective use of screening and early detection strategies in the general population (specifically for breast and cervical cancer), and the more widespread application of treatment strategies that are known to be effective (eg, adjuvant therapy for breast cancer). When screening strategies for cancer are implemented, they first downstage the cancers that are diagnosed, eg, the rapid stage shift in prostate cancer cases associated with the introduction of the prostate-specific antigen test in 1991,² or they vastly decrease the number of new invasive cancers that are diagnosed, eg, the steep decline in the number of invasive cervical cancer cases after the widespread introduction of the Pap smear. However, the principal goal of a cancer screening program has traditionally been to reduce mortality. For if there is no mortality reduction from cancer screening, then individuals who are detected early with cancer live with the diagnosis of cancer for a longer time (lead time bias) and do not ultimately benefit in terms of survival gains. This has been nicely demonstrated in the recent reanalysis of the Mayo Lung Project, in which the harms of screening are amply discussed and the problem of overdiagnosis is raised.^3,4

Another potential benefit of cancer screening could be a quality-of-life advantage that could result from earlier diagnosis and a smaller tumor, especially if different treatment strategies for smaller and larger organ-confined cancers exist. Cancers for which there are organ preservation strategies (eg, breast, cervix, larynx, bladder) provide some examples of how with smaller tumors patients may have more limited procedures yet expect the same survival as with more radical treatments. Conservation of the breast preserves body image,⁵ and laryngeal conservation treatment preserves the voice.⁶ Although overall quality of life may or may not be affected by these specific end points, for some patients the unique benefits of organ preservation will be very important and enhance the value of early detection.

In this issue of the Journal of Clinical Oncology, Madalinska et al⁷ report the results of a study of the health-related quality-of-life outcomes in patients with localized prostate cancer diagnosed by either screening or clinical detection. They sought to determine whether the quality-of-life outcomes in men who chose either radical prostatectomy or primary radiotherapy differed by the mode of detection. Further, because this was an elegantly designed prospective study, they could examine the changes in health-related quality of life that occurred as a result of either treatment in both patient populations. The authors used state-of-the-art quality-of-life instruments for their study, and all patients were assessed at baseline shortly after diagnosis and before a decision was made about the type of treatment that would be used. Subsequent assessments occurred 6 months and 12 months later. Finally, the investigators had nearly complete participation of all eligible patients diagnosed as having localized prostate cancer during the study period, thereby eliminating possible selection bias in the final study samples.

The main findings from this study are as follows: (1) Over the 12 months of follow-up, there were some differences in quality-of-life outcome by treatment, with radiotherapy patients experiencing more short-term increases in bodily pain and decreases in general health perceptions compared with patients who underwent prostatectomy, as well as significantly more limitations due to physical and emotional health at the 12-month assessment. (2) Bowel functioning problems were significantly associated with radiotherapy and persisted at 1 year after diagnosis. (3) Sexual functioning problems were common before treatment in all men, and erectile problems occurred at an increased rate in both treatment groups at the 6- and 12-month assessments, with significantly more problems in the prostatectomy group. (4) One year after the diagnosis of prostate cancer, patients who received prostatectomy had quality-of-life scores above those of the general Dutch population, and radiotherapy patients were similar to the general population. (5) Pretreatment urinary problems were rare in both treatment groups and increased as a result of either radiotherapy or prostatectomy, with poorer levels of functioning in the prostatectomy group. (6) Patients whose cancers were detected by screening did not differ demographically from those whose cancers were detected clinically; however, tumor stage and grade were significantly more favorable in the screen-detected group. (7) Patients who selected radiotherapy instead of radical prostatectomy were significantly older. (8) Baseline quality of life as measured by a generic health-related quality-of-life instrument differed according to treatment group, with prostatectomy patients scoring higher on most scales and notably a half SD higher on the physical component scale. (9) Screen-detected and clinically detected patients reported comparable levels of quality of life, although the screen-detected group tended to score higher on the health perceptions scale, with scores that were higher than the sex- and age-adjusted population norms. (10) For urinary, bowel, and sexual functioning assessments, the screen-detected patients did not differ in outcomes after treatment from the clinically detected patients.

This prospective study of the impact of prostate cancer treatments on quality of life adds to the developing body of literature on this topic.^8-15 As noted by the authors, these patients selected their therapy, and thus there could be unmeasured biases associated with treatment choice that could also be reflected in the quality-of-life assessments. Furthermore, the study methodology did not control for patient comorbidity, which could have affected quality of life. Nevertheless, the data from this study provide accurate assessments of outcomes that are meaningful to men as they consider with their health care providers which treatment options are best for their individual situation. For example, in the case of a man who is no longer sexually active, a prostatectomy might be preferred, since there will be fewer problems with bowel function and somewhat better general quality of life than would occur with radiotherapy.

However, the most important new finding from this carefully conducted study is that screen-detected patients share equally in the changes in quality of life and increased symptoms after either prostatectomy or radiotherapy. That is, despite smaller and more favorable tumors, they underwent the same treatments as clinically detected patients and suffered the same outcomes after treatment. For men whose cancers are detected by screening, these decrements in quality of life should only be justified if and when screening is shown to decrease mortality. Unfortunately, we must await the results of the ongoing trials in Europe and the United States’ Prostate, Lung, Colorectal, and Ovary Screening Trial before such conclusions can be made. Any screening-related survival gains must then be adjusted to reflect the quality-of-life changes induced by curative treatment; these should include not only the impairments in urinary, sexual, and bowel function but also the relief and decreased anxiety experienced after being cured of prostate cancer. Ultimately, it is not survival but quality-adjusted survival that must be improved if prostate cancer screening is to be judged as effective. In addition, treatment strategies for early-stage prostate cancer must continue to be improved and refined, so that the very-early-stage, screen-detected patients need not be subjected to the same quality-of-life impairments as are patients with more advanced local cancers. Only then might we see an advantage for men with screen-detected prostate cancers.

REFERENCES

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14. Litwin MS, Pasta DJ, Yu J, et al: Urinary function and bother after radical prostatectomy or radiation for prostate cancer: A longitudinal, multivariate quality of life analysis from the cancer of the prostate strategic urologic research endeavor. J Urol 164: 1973-1977, 2000[Medline]

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This Article Full Text (PDF) Purchase Article View Shopping Cart Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Save to my personal folders Download to citation manager Rights & Permissions Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Ganz, P. A. Articles by Litwin, M. S. Search for Related Content PubMed PubMed Citation Articles by Ganz, P. A. Articles by Litwin, M. S. Social Bookmarking                            What's this?