Prostate cancer survivorship in modern times - insights into management of erectile dysfunction and urinary incontinence for clinically localized prostate cancer survivors in the United States.

PURPOSE: Determine factors associated with receiving erectile dysfunction (ED) and urinary incontinence (UI) treatment following therapy for clinically localized prostate cancer (PCa).

METHODS

Patients diagnosed with PCa (cT1-3N0M0) between 2015 and 2024 who were treated with radical prostatectomy (RP) and/or radiation therapy (RT) were identified in EPIC Cosmos. Patients receiving hormone monotherapy (HT), < 1 year follow-up, or incomplete data were excluded. ED and UI diagnoses and treatments were captured via CPT and ICD-10 codes. Cox multivariable regression adjusted for clinical and socioeconomic factors to identify treatment predictors, with sensitivity analyses among patients with baseline ED or UI.

RESULTS

Among 90,161 men, 39.29% developed ED, 33.35% received medical ED treatment (EDMT), and 0.99% underwent prosthesis (ST). UI occurred in 20.68% of patients, with 1.4% undergoing surgery (UIT). Black race (HR 1.50, p < 0.001) and prior ED (HR 1.41, p < 0.001) increased EDMT, while older age (HR 0.66, p < 0.001), higher social vulnerability (HR 0.85, p < 0.001), and RT-based therapy (RP + RT HR 0.75; RT + HT HR 0.39; RT HR 0.36; all p < 0.001) decreased EDMT. Prosthesis use was more likely among Black men (HR 2.03, p < 0.001), socially vulnerable patients (HR 1.86, p < 0.001), and those with prior ED (HR 2.06, p < 0.001), but less likely with older age (HR 0.61, p < 0.001) and RT-based therapy (RP + RT HR 0.63; RT + HT HR 0.18; RT HR 0.14; all p < 0.001). Prior UI (HR 2.08, p < 0.001) and social vulnerability (HR 1.25, p = 0.003) increased UIT, whereas RT (HR 0.08, p < 0.001) and RT + HT (HR 0.15, p < 0.001) reduced utilization. These disparities persisted among patients with baseline ED and UI.

CONCLUSIONS

Despite a high prevalence of ED and UI following PCa treatment, surgical intervention remains uncommon (1%). Socioeconomic and clinical factors are significantly associated with treatment patterns, highlighting the need for improved pretreatment counseling and survivorship care.

IMPLICATIONS OF CANCER SURVIVORS: Medical and surgical interventions for ED and UI are infrequently utilized. The differences in treatment frequency likely reflect not only variations in the underlying frequency, severity and patient preference, but also systemic, racial, and socioeconomic barriers. Prostate cancer survivors should actively advocate for their quality of life by initiating early discussions with their providers regarding all available functional recovery options. Furthermore, establishing equitable, culturally informed, and patient-centered survivorship pathways is vital to ensure all survivors receive the comprehensive care necessary to maximize their long-term outcomes.