ATLANTA – One of the first large quality-of-life studies on today's prostate cancer treatments suggests that for some men, it's a matter of picking your poison and facing potential sexual, urinary or other problems.
Of the choices studied - surgery, standard radiation, hormone therapy or radioactive seeds - the seeds seemed to carry a lower risk of several of these side effects.
Hormone therapy - when combined with radiation - had a big effect on men's vitality and sexuality. The radioactive pellets sometimes led to sexual problems too, but more often involved discomfort in urinating.
The research, published in Thursday's New England Journal of Medicine, doesn't address the cure rates of different treatments. Moreover, not every treatment is an option for every man. For example, radioactive pellets are generally used only in men with early-stage cancer that is slow-growing.
Nor does the study speak to decisions about whether to treat at all a slow-growing form of cancer that can take 10 or 20 years to become life-threatening.
An 80-year-old man may choose to avoid all treatment and the assorted complications. But for a man of, say, 50, the study provides some insight into the side effects of different options, said Dr. William Oh, a Harvard University prostate cancer specialist.
"We've just never had the data that put patients side-by-side like this before," said Oh, who was not involved in the study.
The researchers surveyed about 1,200 patients, as well as 625 wives, who were enrolled at nine U.S. hospitals from March 2003 to March 2006. Telephone surveys were done before treatment began and at two, six, 12 and 24 months afterward.
Nearly 300 of the men in the study underwent brachytherapy, which involved the implant of radioactive pellets (often called "seeds") in the prostate to kill cancer cells.
About 300 got more conventional radiation treatments beamed at a tumor. And nearly 600 had their prostate tumors surgically removed, with most of them undergoing nerve-sparing procedures intended to minimize the operation's effect on sexual performance.
About 90 got hormone therapy in addition to conventional radiation, and some got it in addition to brachytherapy. Hormone therapy, which suppresses testosterone production, is used to enhance radiation treatment and improve survival.
Although life-threatening side effects were rare, men in all the groups experienced, to varying degrees, problems with urinating, achieving erections and moving their bowels.
No procedure was clearly best or worst across the board.
The wives of about 13 percent of men who had brachytherapy said they were distressed by problems with their partner's erections one year after treatment. The spouses of about 22 percent of the men in the traditional radiation group and 44 percent in the surgery group reported the same concern.
Incontinence was most common in the surgery group, with about 15 percent reporting the problem a year or two after treatment. For both standard radiation and brachytherapy, the figures were around 6 to 10 percent.
But when other urinary problems were counted, too - including pain and increased frequency - the brachytherapy group looked worse. About 18 percent of men who underwent brachytherapy said they had moderate or worse distress from urinary problems one year after treatment, compared with 11 percent of those who had traditional radiation and 7 percent of those who underwent surgery.
Among the most common problems in the brachytherapy group were a burning sensation or other pain, weak urinary stream and a sense of not being able to empty the bladder.
Bowel problems, such as rectal pain and frequency of having to go to the bathroom, were similar in the brachytherapy and radiation groups at one year, and lower in the surgery group.
Men who had radiation reported the least energy and most depression a year after treatment.
The researchers also found that men who had hormone treatments in addition to traditional radiation had worse recovery of sexual function.
Researchers said the study was not designed to provide a head-to-head comparison between treatments, because not each treatment group was the same.
Younger men, white men and college graduates tended to choose surgery more often. Black men tended to favor traditional radiation. Men with the earliest-stage tumors tended to go for radioactive seeds.
Each man must make his own decision, based on his condition and concerns. But as he weighs particular treatments, this study can give a helpful look at the experiences of men who chose the same option, said study co-author Dr. John Wei, a University of Michigan urologist.
Men should use the study to spark conversations with their physicians about the side effects of different treatments, said Dr. Otis Brawley, national chief medical officer of the American Cancer Society.
Among the men who say they made the right treatment choice is S. Jordan Perlman of Cleveland.
Perlman, 82, for years ran a women's clothing store in Cleveland. He was diagnosed in 1998 with early-stage prostate cancer and chose radioactive seeds, partly out of concern about the impact of surgery on sexual function. He had discomfort sitting down after the seeds were implanted, and a little trouble with incontinence initially.
But those problems quickly ended, and he said he has remained vigorous and continues to take daily power walks.
"I was very lucky," he said.