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Ten-year Mortality, Disease Progression, and Treatment-related Side Effects in Men with Localised Prostate Cancer from the ProtecT Randomised Controlled Trial According to Treatment Received

Lookup NU author(s): Professor David Neal, Vincent Gnanapragasam, Dr Owen Hughes, Dr Edgar Paez-Gueyraud

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This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License (CC BY-NC-ND).


Abstract

© 2019 The Author(s)Prostate cancer is very common, affecting about one in nine men during their lifetime, but most do not die or develop complications. The ProtecT trial randomised men with prostate-specific antigen-detected localised prostate cancer to active monitoring (AM), radical prostatectomy, or radiotherapy, and followed them up for 10 yr. We found that >90 out of every 100 men with localised prostate cancer do not die of prostate cancer within 10 yr, irrespective of whether treatment is by means of monitoring (AM), surgery, or radiotherapy. Side effects on sexual and bladder function are better after AM than after radical treatments, but the risks of spreading of prostate cancer are greater after AM.© 2019 The Author(s)Background: The ProtecT trial reported intention-to-treat analysis of men with localised prostate cancer randomly allocated to active monitoring (AM), radical prostatectomy, and external beam radiotherapy. Objective: To report outcomes according to treatment received in men in randomised and treatment choice cohorts. Design, setting, and participants: This study focuses on secondary care. Men with clinically localised prostate cancer at one of nine UK centres were invited to participate in the treatment trial comparing AM, radical prostatectomy, and radiotherapy. Intervention: Two cohorts included 1643 men who agreed to be randomised and 997 who declined randomisation and chose treatment. Outcome measurements and statistical analysis: Analysis was carried out to assess mortality, metastasis and progression and health-related quality of life impacts on urinary, bowel, and sexual function using patient-reported outcome measures. Analysis was based on comparisons between groups defined by treatment received for both randomised and treatment choice cohorts in turn, with pooled estimates of intervention effect obtained using meta-analysis. Differences were estimated with adjustment for known prognostic factors using propensity scores. Results and limitations: According to treatment received, more men receiving AM died of PCa (AM 1.85%, surgery 0.67%, radiotherapy 0.73%), whilst this difference remained consistent with chance in the randomised cohort (p = 0.08); stronger evidence was found in the exploratory analyses (randomised plus choice cohort) when AM was compared with the combined radical treatment group (p = 0.003). There was also strong evidence that metastasis (AM 5.6%, surgery 2.4%, radiotherapy 2.7%) and disease progression (AM 20.35%, surgery 5.87%, radiotherapy 6.62%) were more common in the AM group. Compared with AM, there were higher risks of sexual dysfunction (95% at 6 mo) and urinary incontinence (55% at 6 mo) after surgery, and of sexual dysfunction (88% at 6 mo) and bowel dysfunction (5% at 6 mo) after radiotherapy. The key limitations are the potential for bias when comparing groups defined by treatment received and changes in the protocol for AM during the lengthy follow-up required in trials of screen-detected PCa. Conclusions: Analyses according to treatment received showed increased rates of disease-related events and lower rates of patient-reported harms in men managed by AM compared with men managed by radical treatment, and stronger evidence of greater PCa mortality in the AM group. Patient summary: More than 95 out of every 100 men with low or intermediate risk localised prostate cancer do not die of prostate cancer within 10 yr, irrespective of whether treatment is by means of monitoring, surgery, or radiotherapy. Side effects on sexual and bladder function are better after active monitoring, but the risks of spreading of prostate cancer are more common.


Publication metadata

Author(s): Neal DE, Metcalfe C, Donovan JL, Lane JA, Davis M, Young GJ, Dutton SJ, Walsh EI, Martin RM, Peters TJ, Turner EL, Mason M, Bollina P, Catto J, Doherty A, Gillatt D, Gnanapragasam V, Holding P, Hughes O, Kockelbergh R, Kynaston H, Oxley J, Paul A, Paez E, Rosario DJ, Rowe E, Staffurth J, Altman DG, Hamdy FC

Publication type: Article

Publication status: Published

Journal: European Urology

Year: 2020

Volume: 77

Issue: 3

Pages: 320–330

Print publication date: 01/03/2020

Online publication date: 23/11/2019

Acceptance date: 30/10/2019

Date deposited: 15/07/2020

ISSN (print): 0302-2838

ISSN (electronic): 1873-7560

Publisher: Elsevier B.V.

URL: https://doi.org/10.1016/j.eururo.2019.10.030

DOI: 10.1016/j.eururo.2019.10.030

PubMed id: 31771797

Notes: Erratum at https://doi.org/10.1016/j.eururo.2020.05.030


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