Life vs. quality of life: A delicate balance

Prostate cancer management continues to challenge us in many ways. The U.S. Preventive Services Task Force has modified its recommendations and now suggests that men ages 55 to 70 discuss the potential impact of screening before deciding to pursue PSA testing (JAMA 2017; 317:1949-50). Unfortunately, these abstract concepts only become real for many men after they undergo biopsy and are confronted with a new diagnosis of prostate cancer.

Our job as professionals is not to “sell” our favorite therapy, but rather to counsel men on the risks and benefits associated with various treatment strategies. To begin, men must have a good understanding of the threat posed by their disease. Results from the recently published ProtecT trial and the PIVOT trial update suggest that men with low-grade disease have minimal benefit during the 10 to 15 years immediately following diagnosis (N Eng J Med 2016; 375:1415-24; N Eng J Med 2017; 377:132-42). Clinically significant disease progression may take 15 to 20 years or longer. These men must balance these outcomes against the potential harms of intervention.

Data reported by Barocas et al and reviewed in this issue of Urology Times suggest that both radical prostatectomy and radiation therapy carry real clinical consequences. Despite promised advances in external beam radiation therapy technology and robotic surgery, these procedures still have the potential to compromise bowel, bladder, and sexual function. Patients should be made aware of these facts as they try to balance the threat posed by disease against the potential impact on quality of life.

Young men with high-grade disease face a significant risk of disease progression and are probably best served by surgery and additional radiation should PSA recurrence occur. Older men with low-grade disease are probably best served by surveillance. They risk significant immediate problems with bowel, bladder, and sexual function with little likely long-term benefit.

Between these extremes are many men who face a real dilemma. Our job is to provide them with accurate data such as those provided by Barocas et al to help them balance the probability of extending life against the potential of compromising quality of life.

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