Urinary Continence and Sexual Potency Following Surgery and Adjuvant/Salvage Radiotherapy Versus Primary Radiotherapy: Is There A Winner?

Abstract

To compare prostate cancer specific quality of life (QOL) outcomes of post radical prostatectomy radiotherapy versus primary radiotherapy. Expanded Prostate cancer Index Composite (EPIC) surveys of patients with localized prostate cancer treated with either primary radiotherapy (RT) or surgery followed by adjuvant/salvage pelvic radiotherapy (S+RT) were extracted from an IRB approved clinical database. EPIC QOL summary scores for the urinary, sexual, bowel and hormonal domains were calculated and analyzed using descriptive and multivariate analysis using SPSS software (24th edition). Imperfect "bifecta” was defined as a score less than 40 in both incontinence and sexual domains. Perfect urinary function was defined as a score of 100. The clinically important difference was calculated using a distribution approach. 502 EPIC surveys at least 1 year after treatment were available for 372 RT and 130 S+RT patients. For RT vs. S+RT, mean age was 69.8 ±6.6 vs. 64±6.6 (P<0.001) respectively, Androgen deprivation therapy (ADT) was 58.7% vs 37.5%, p<0.001, ischemic heart disease (19.7% vs 11.8%. p = 0.042) and chronic renal disease (8.5% vs 3.1%, p = 0.042). Mean Urinary incontinence was 86.4 [CI-95 39.5-100] versus 68 [6.25 -100] for RT and S+RT respectively (p<0.001), confirming 6.5 points of clinically significant difference. The adjusted Odds ratio for perfect urinary function was 2.9 (1.8-4.4, p<0.001) for primary radiotherapy. The odds ratio of having both poor urinary and sexual performance (imperfect ” bifecta") was 3.4 in the S+RT arm (1.9-7.5, p<0.001) when adjusted to age and ADT use. There was no difference in bowel domain toxicity. Surgery with adjuvant/salvage RT was associated with significantly worse patient reported urinary continence outcomes at 1-year post treatment, lower odds of achieving perfect urinary continence and higher odds of both imperfect urinary and sexual performance. Patients referred for surgery with a high probability of requiring adjuvant or salvage radiotherapy should be informed regarding the impact on urinary and sexual performance.