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Currently, the most common curative treatment options for men with localized (stage T1-2) prostate cancer are external beam radiotherapy (EBRT), interstitial permanent brachytherapy (BT) and radical prostatectomy. A number of series published equivalent outcomes concerning biochemical recurrence rates. Therefore, treatment decisions should particularly consider the specific risk and toxicity profile of a treatment method.
Several reports have already compared toxicities after EBRT and BT. However, methodical problems remain with often retrospective data, missing health-related quality of life (HRQOL) results and consistent differences concerning baseline patient characteristics. Generally, patients receiving BT are of younger ages. The patient age has a large impact both on the pre-treatment sexual function and a treatment-associated erectile dysfunction - well explaining better results after BT in comparison to EBRT. Furthermore, in accordance with treatment recommendations, patients receiving BT have smaller prostate volumes. A neoadjuvant hormonal therapy can additionally change the toxicity results in different HRQOL domains.
To further improve the knowledge in this field, thus the treatment decision for the involved physicians and patients, a matched pair analysis was performed. A group of 104 patients (52 in each group) has been surveyed prospectively before EBRT/BT (time A), at the last day of EBRT or one month after BT (time B), and a median time of 16 months after EBRT/BT (time C) using a validated questionnaire (Expanded Prostate Cancer Index Composite). The multi-item scale scores were transformed linearly to a 0-100 scale, with higher scores representing better HRQOL. All patients in the EBRT-group were treated with 1.8-2.0Gy fractions up to a total dose of 70.2-72.0Gy. BT was performed as monotherapy with a prescription dose of 145Gy. Only patients who answered all questionnaires have been included. Pairs were matched according to following criteria: age+5years, prostate volume+10cc, use of anti-androgens, and erectile function.
Patients scheduled for BT presented with significantly better urinary bother and urinary obstructive/irritative scores before treatment. Other scores did not differ >5 points. However, compared to baseline levels, both urinary function and urinary bother scores (obstructive/irritative scores in particular) decreased more after BT both at time B and time C. Comparing patients with baseline urinary bother scores <90 vs. >90, significantly lower scores - with a similar decrease - were found in both groups after BT. After EBRT, urinary bother scores improved significantly (+11 points) in the patient group with initial scores <90. Bowel function and bowel bother scores tended to be higher after BT, with a lower percentage of patients with painful bowel movements (BT: 12%/27%/15%; EBRT: 19%/52%/35% at time A/B/C, respectively; p<0.05 for differences at times B and C) and rectal bleeding (BT: 12%/12%/12%; EBRT: 8%/14%/17%). Sexual function and bother scores decreased significantly in both treatment groups, without any remarkable differences (81% vs. 84% with preserved ability to have an erection; 67% vs. 61% with preserved erections firm enough for intercourse after BT vs. EBRT).
Patients opting for a permanent I-125 brachytherapy need to consider a higher risk of urinary obstructive/irritative problems, but a lower risk of proctitis-associated problems compared to external beam radiotherapy. In view of a further deterioration of long-term mean urinary scores after permanent brachytherapy - in contrast to an improvement after external beam radiotherapy - patients with greater urinary problems before treatment should preferably be selected for external beam radiotherapy.
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