# Patient‐reported outcomes: active surveillance vs radical therapies in low‐risk prostate cancer

## TL;DR

This study compares quality of life outcomes for low-risk prostate cancer patients undergoing active surveillance versus treatments like surgery or radiation.

## Contribution

The study provides the first large-scale prospective comparison of functional outcomes across active surveillance and radical therapies for low-risk prostate cancer.

## Key findings

- Active surveillance preserved urinary and sexual function without decline over 12 months.
- Radical prostatectomy caused significant declines in urinary continence and sexual function, exceeding clinical thresholds.
- Radiotherapy led to clinically relevant declines in multiple domains, including bowel and hormonal function.

## Abstract

To prospectively evaluate functional patient‐reported outcomes (PROs) in patients with low‐risk prostate cancer (PCa) managed with active surveillance (AS), nerve‐sparing radical prostatectomy (NS‐RP), non‐NS‐RP, or radiotherapy (RT).

This multicentre prospective cohort study used data from the Prostate Cancer Outcomes (PCO) study in Germany, Austria and Switzerland, including 6265 patients with low‐risk PCa enrolled between 2016 and 2023. PROs were assessed at baseline and 12 months after treatment/enrolment using the 26‐item Expanded Prostate Cancer Index Composite Short Form (EPIC‐26), measuring urinary continence, bowel, sexual, hormonal, and irritative/obstructive symptoms. Mean score changes were compared with minimal important differences (MIDs) to determine clinical significance.

In all, 475, 4352, 813, and 625 patients received AS, NS‐RP, non‐NS‐RP, and RT, respectively. At 12 months, AS was associated with stable function across all EPIC‐26 domains. In contrast, both RP groups experienced significant declines in urinary continence (NS‐RP: −18 points; non‐NS‐RP: −26 points) and sexual function (NS‐RP: −35 points; non‐NS‐RP: −30 points), exceeding MID thresholds. Urinary continence did not decline after RT but clinically relevant declines occurred in irritative/obstructive urinary (−5 points), bowel (−7 points), hormonal (−5 points), and sexual function (−12 points). Age‐stratified analysis showed clinically significant declines in urinary and sexual function after NS‐RP across all age groups, with the greatest loss in sexual function among younger patients and the most pronounced continence impairment in the 70–79 years age group. In contrast, functional outcomes under AS remained stable in all age cohorts.

Active surveillance is underutilised in the observed cohort. Prospective PCO data demonstrates that AS preserves urinary continence and sexual function compared to active treatment, supporting its role as the first‐line strategy for suitable candidates. Despite advancements including NS techniques, RP, and to a lesser extent RT, remain associated with substantial functional impairment even in younger men.