Treatment 'mismatch' in early prostate cancer - Do treatment choices take patient quality of life into account?

BACKGROUND. Pretreatment urinary, bowel, and sexual dysfunction may increase the toxicity of prostate cancer treatments or preclude potential benefits. Using patient-reported baseline dysfunction from a prospective cohort study, we determined the proportion of patients receiving relatively contraindicated ('mismatched') treatments. METHODS. Baseline obstructive uropathy and bowel dysfunction relatively contraindicate brachytherapy (BT) and external beam radiation therapy (EBRT), respectively, because they increase patients' Vulnerability to treatment-related toxicity. Baseline sexual dysfunction renders moot the intended benefit of nerve-sparing radical prostatectomy (NSRP), which is to preserve sexual function. We categorized patients' clinical circumstances by increasing complexity and counted the mismatches in each, expecting weaker or multiple contraindications to increase mismatched treatments. RESULTS. Of 438 eligible patients, 389 (89%) reported preexisting dysfunction, and more than one-third received mismatched treatments. Mismatches did not significantly increase with clinical complexity, and watchful waiting was very infrequent, even when all treatment options were contraindicated. Patient age and comorbidity, but not preexisting dysfunction, were associated with treatment choice. As expected, mismatched BT and EBRT led to worsened urinary and bowel symptoms, respectively, and NSRP did not improve outcomes after baseline sexual dysfunction. CONCLUSIONS. Pretreatment dysfunction does not appear to reliably influence treatment choices, and patients receiving mismatched treatments had worse outcomes. Further study is needed to determine why mismatched treatments were chosen, including the role of incomplete patient-physician communication of baseline dysfunction, and whether using a validated questionnaire before treatment decision-making would bypass this difficulty. Treatment mismatch may be a useful outcome indicator of the quality of patient-centered decisions.