calculated radiation dose to the penile
bulb was associated with erectile dys-
function at 2 years after treatment but
not to the assigned treatment dose.
trial of a hypofractionated schedule
compared with a standard schedule
found similar 5-year urinary and bowel
symptoms, but efficacy was also iden-
A further problem in assessing out-
comes after proton beam or more
widely available radiation modalities is
that, despite their frequent use, little
long-term patient-reported data are
available. Most reports have at most
but occasionally ex-
tend to 3 years.
However, at a me-
dian of 5.5 years (range, 4-8 years),
patients in a contemporaneous multi-
center prospective cohort study
had undergone external beam photon
radiation reported roughly compa-
rable outcomes (T
Some data support the explanation
that symptoms become less noticeable
over time. Korfage et al
found that pa-
tients trivialized dysfunction, espe-
cially sexual dysfunction, associating it
with old age, and assigned adverse ef-
fects to treatment—not disease. In their
studies, disease-specific instruments de-
tected dysfunction, but they also de-
tected response shift as patients adapted
to changed health. Yu et al
strong correlation between optimism
and eating ability in Chinese patients
treated for nasopharyngeal carci-
noma, indicating that psychological sta-
tus influenced reported function.
These data challenge the assumption
that the quality-of-life impact of persist-
ing dysfunction is stable and can be ex-
trapolated from naive expectations or
early treatment experience. Any metric
that assumes a stable relationship be-
tween symptoms and quality of life over
time, such as quality-adjusted life-year,
requires empirical validation of the as-
sumption of stability over time, whether
or not the analysis discounts benefits over
To the extent that patients adapt
to treatment-related dysfunction, the as-
sumption that the impact of treatment-
related dysfunction is stable underesti-
mates the net benefit of treatment.
Prostate cancer is now being de-
tected and treated at earlier ages and
cured patients may live for decades with
treatment adverse effects. Long-term
outcomes have thus become a central
factor in patient treatment decisions,
but to date, long-term patient-
reported data are lacking for both sur-
gery and radiation. The experimental
higher dose in PROG 9509 is now com-
mon in clinical practice. Among men
with clinically localized prostate can-
cer, treatment with higher-dose radia-
tion compared with standard dose was
not associated with an increase in pa-
tient-reported prostate cancer symp-
toms after a median of 9.4 years.
Author Contributions: Dr Talcott had full access to all
of the data in the study and takes responsibility for
the integrity of the data and the accuracy of the data
Study concept and design: Talcott, Shipley, Slater,
Acquisition of data: Talcott, Rossi, Zietman.
Analysis and interpretation of data: Talcott, Clark,
Drafting of the manuscript: Talcott, Clark, Slater,
Critical revision of the manuscript for important in-
tellectual content: Talcott, Rossi, Shipley, Clark, Slater,
Statistical analysis: Talcott, Clark, Niemierko.
Obtained funding: Talcott, Shipley, Zietman.
Administrative, technical, or material support: Rossi,
Study supervision: Talcott, Slater, Zietman.
Financial Disclosures: Dr Slater reported that his
brother is an employee of Optivus Technology, a com-
pany that builds proton radiation facilities. The other
authors reported no disclosures.
Funding/Support: This research was supported by the
Bertucci Genitourinary Cancer Research Fund, Mas-
sachusetts General Hospital, Boston, MA.
Role of the Sponsor: The Bertucci Genitourinary Can-
cer Research Fund had no role in the design and con-
duct of the study; collection, management, analysis,
and interpretation of the data; and preparation, re-
view, or approval of the manuscript.
Additional Contributions: We would like to acknowl-
edge Anita E. Rodrigues, BA, Center for Outcomes Re-
search, Massachusetts General Hospital, Boston; and
Catherine Reyes, BS, Center for Outcomes Research,
Massachusetts General Hospital, Boston, MA, and cur-
rently MD candidate, Harvard Medical School, for con-
tacting eligible patients, enrolling patients, and car-
rying out data collection; and Mary M. Lunt, BSN, Loma
Linda University Medical Center, Loma Linda, CA, for
contacting potential study participants. Ms Rod-
rigues and Ms Reyes were compensated for their roles
in the study. Ms Lunt, an employeee at LLUMC, was
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LONG-TERM OUTCOMES AFTER RADIATION FOR PROSTATE CANCER
1052 JAMA, March 17, 2010—Vol 303, No. 11 (Reprinted with Corrections) ©2010 American Medical Association. All rights reserved.
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