Active Surveillance Underused in Prostate Cancer Patients Who Want to Preserve Sexual Function

Ronald C. Chen, MD, MPH

Most men with low-risk prostate cancer said in a recent survey that preserving sexual function was important to them; however, researchers with the University of North Carolina Lineberger Comprehensive Cancer Center found that those with a preference for preserving sexual function were not necessarily more likely to receive active surveillance, the best strategy to preserve sexual function.

In results from the North Carolina Prostate Cancer Comparative Effectiveness and Survivorship Study of 1194 patients published in the Journal of the National Cancer Institute, 52.6% said that preserving sexual function was “very important,” but only 43.4% were assigned to active surveillance.

“Unfortunately, we found that men who had low-risk prostate cancer and wanted to preserve sexual function did not necessarily choose active surveillance,” lead investigator Ronald C. Chen, MD, an associate professor in the UNC School of Medicine Department of Radiation Oncology, said in a press release. “This indicates that many patients may not have known about active surveillance as an option.”

Investigators conducted a baseline survey prior to treatment for all enrolled patients. Demographic information was collected by patient report and included date of birth, race, marital status, educational attainment, and health insurance.

Baseline sexual function was assessed using the validated Prostate Cancer Symptom Indices (PCSI). The 5-question Sexual Dysfunction domain of the PCSI assesses patient erectile function, ejaculation, and orgasm. Answers to these questions are translated to an overall scale score from 0 (no dysfunction) to 100 (maximum dysfunction). In addition to a numerical score, the PCSI has also previously validated categorizing patients into 3 levels of function: normal, intermediate, or poor.

A total of 628 men (52.6%) indicated a strong preference for preserving sexual function and 566 patients (47.4%) indicated a lower preference. Older men were less likely to have a strong preference (adjusted risk ratio [aRR], 0.98 per year; 95% CI, 0.97-0.99). Men with normal sexual function, however, were more likely than men with poor function to rate the importance of sexual function highly (aRR, 1.59; 95% CI, 1.39-1.82).

Investigators found no evidence to suggest that patients with a strong preference to preserve sexual function were more likely to receive active surveillance.

Among men with normal baseline sexual function and a strong preference for preserving function, only 39.2% received active surveillance. Chen et al found that patients who had normal baseline sexual function but indicated lower preference to preserve function were actually more likely to receive active surveillance (49.2%). Patients who had poor baseline sexual function who indicated a lower preference to preserve sexual function were also more likely to receive active surveillance.

Among 568 men with low-risk cancer, there was no clear association between baseline sexual function or strong preference to preserve function with receipt of active surveillance. However, strong preference may differentially impact those with intermediate baseline function versus poor function (P_interaction = .02).

Chen said the results demonstrate that there is a disconnect between the treatment patients might prefer and the treatment they receive.

“The takeaway for prostate cancer patients is that they should always ask two important questions,” Chen said. “One, how aggressive is my cancer? Two, what are my options? After understanding this, it is important they communicate with their doctor what their priorities are in making a decision among the available options.”

He said it’s also important for physicians to counsel patients to reflect their preferences.

“Active surveillance is widely recognized to be an excellent option for patients diagnosed with low-risk prostate cancer, because it is the best option to preserve the patient's quality of life, including sexual function,” Chen said. “Some patients with prostate cancer may initially want aggressive treatment, and it is important for the physician, urologist, and radiation oncologist to fully counsel patients about the slow-growing nature of low-risk prostate cancer and that active surveillance is a safe option.”

Broughman JR, Basak R, Nielsen ME, et al. Prostate cancer patient characteristics associated with a strong preference to preserve sexual function and receipt of active surveillance [published online October 16, 2017]. J Natl Cancer Inst. doi: 10.1093/jnci/djx218.