Role of decision aids in orthopaedic surgery

Medical treatment of patients inherently entails the risk of undesired complication or side effects. It is essential to inform the patient about the expected outcomes, but also the possible undesired outcomes. The patients preference and values regarding the potential outcomes should be involved in the decision making process. Even though many orthopaedic surgeons are positive towards shared decision-making, it is minimally introduced in the orthopaedic daily practice and decision-making is still mostly physician based. Decision aids are designed to support the physician and patient in the shared- decision-making process. By using decision aids, patients can learn more about their condition and treatment options in advance to the decision-making. This will reduce decisional conflict and improve participation and satisfaction.     

Making decisions about treatment for localized prostate cancer

OBJECTIVE: To describe the decision-making processes used by men diagnosed with localized prostate cancer who were considering treatment. PATIENTS AND METHODS: Men newly diagnosed with localized prostate cancer from outpatient urology clinics and urologists' private practices were approached before treatment. Their decision-making processes and information-seeking behaviour was assessed; demographic information was also obtained. RESULTS: Of 119 men approached, 108 (90%) were interviewed; 91% reported non-systematic decision processes, with deferral to the doctor, positive and negative recollections of others' cancer experiences, and the pre-existing belief that surgery is a better cancer treatment being most common. For systematic information processing the mean (sd, range) number of items considered was 4.19 (2.28, 0-11), with 57% of men considering four or fewer treatment/medical aspects of prostate cancer. Men most commonly considered cancer stage (59%), urinary incontinence (55%) and impotence (51%) after surgery, and low overall mortality (45%). Uncertainty about probabilities for cure was reported by 43% of men and fear of cancer spread by 37%. Men also described uncertainty about the probabilities of side-effects (27%), decisional uncertainty (25%) and anticipated decisional regret (18%). Overall, 73% of men sought information about prostate cancer from external sources, most commonly the Internet, followed by family and friends. CONCLUSIONS: In general, men did not use information about medical treatments comprehensively or systematically when making treatment decisions, and their processing of medical information was biased by their previous beliefs about cancer and health. These findings have implications for the provision of informational and decisional support to men considering prostate cancer treatment.     

Mental health implications in bladder cancer patients: A review

Although the majority of bladder cancer literature has been dedicated to optimizing oncological outcomes and focuses on physical prognostic criteria such as nutritional and performance status, emerging data has suggested that both pre- and post-treatment mental health may play as important a role in patient outcomes as physical health. In this review, we summarize the literature regarding the prognostic implications of mental illness on bladder cancer patients and review how both the diagnosis and treatment of bladder cancer can affect mental health across various disease states. Literature review via a modified, nonsystematic analysis was performed from 2000 to 2018 in PubMed, Web of Science, EMBASE, SCOPUS, and OVID. Search terms included “bladder cancer,” “non–muscle-invasive bladder cancer,” “muscle-invasive bladder cancer,” “mental health,” “psychological distress,” “depression,” and “suicide.” Articles were limited to English-language, peer-reviewed, original research. A total of 87 publications were reviewed that met our initial inclusion criteria, and 19 relevant publications were incorporated in our review. Eleven studies were prospective and 8 were retrospective. Two articles included non–muscle-invasive bladder cancer patients, 11 included muscle-invasive bladder cancer patients, and 6 incorporated bladder cancer patients across all disease stages. Mental health issues, such as depression and anxiety, often coexist with a diagnosis of bladder cancer with a worse prognosis associated with greater psychological burden. Bladder cancer patients also have an increased risk of suicide especially in older, unmarried, male patients with more advanced disease states. Poor mental health can impact treatment outcomes such as postsurgical complication rates as well as survival-related outcomes similar to physical health. While awareness of the importance of mental health in bladder cancer patients is growing, further studies are needed to assess the role of interventions such as cognitive behavioral therapy or pharmacotherapy in order to optimize treatment.     

A systematic review of decision aids for patients making a decision about treatment for early breast cancer

Several complex treatment decisions may be offered to women with early stage breast cancer, about a range of treatments from different modalities including surgery, radiotherapy, and endocrine and chemotherapy. Decision aids can facilitate shared decision-making and improve decision-related outcomes. We aimed to systematically identify, describe and appraise the literature on treatment decision aids for women with early breast cancer, synthesise the data and identify breast cancer decisions that lack a decision aid.A prospectively developed search strategy was applied to MEDLINE, the Cochrane databases, EMBASE, PsycINFO, Web of Science and abstract databases from major conferences. Data were extracted into a pre-piloted form. Quality and risk of bias were measured using Qualsyst criteria. Results were synthesised into narrative format.Thirty-three eligible articles were identified, evaluating 23 individual treatment decision aids, comprising 13 randomised controlled trial reports, seven non-randomised comparative studies, eight single-arm pre-post studies and five cross-sectional studies. The decisions addressed by these decision aids were: breast conserving surgery versus mastectomy (+/− reconstruction); use of chemotherapy and/or endocrine therapy; radiotherapy; and fertility preservation. Outcome measures were heterogeneous, precluding meta-analysis. Decisional conflict decreased, and knowledge and satisfaction increased, without any change in anxiety or depression, in most studies. No studies were identified that evaluated decision aids for neoadjuvant systemic therapy, or contralateral prophylactic mastectomy.Decision aids are available and improved decision-related outcomes for many breast cancer treatment decisions including surgery, radiotherapy, and endocrine and chemotherapy. Decision aids for neoadjuvant systemic therapy and contralateral prophylactic mastectomy could not be found, and may be warranted.     

The Personal Patient Profile-Prostate decision support for men with localized prostate cancer: A multi-center randomized trial

ObjectiveThe purpose of this trial was to compare usual patient education plus the Internet-based Personal Patient Profile-Prostate, vs. usual education alone, on conflict associated with decision making, plus explore time-to-treatment, and treatment choice.MethodsA randomized, multi-center clinical trial was conducted with measures at baseline, 1-, and 6 months. Men with newly diagnosed localized prostate cancer (CaP) who sought consultation at urology, radiation oncology, or multi-disciplinary clinics in 4 geographically-distinct American cities were recruited. Intervention group participants used the Personal Patient Profile-Prostate, a decision support system comprised of customized text and video coaching regarding potential outcomes, influential factors, and communication with care providers. The primary outcome, patient-reported decisional conflict, was evaluated over time using generalized estimating equations to fit generalized linear models. Additional outcomes, time-to-treatment, treatment choice, and program acceptability/usefulness, were explored.ResultsA total of 494 eligible men were randomized (266 intervention; 228 control). The intervention reduced adjusted decisional conflict over time compared with the control group, for the uncertainty score (estimate ?3.61; (confidence interval, ?7.01, 0.22), and values clarity (estimate ?3.57; confidence interval (?5.85,?1.30). Borderline effect was seen for the total decisional conflict score (estimate ?1.75; confidence interval (?3.61,0.11). Time-to-treatment was comparable between groups, while undecided men in the intervention group chose brachytherapy more often than in the control group. Acceptability and usefulness were highly rated.ConclusionThe Personal Patient Profile-Prostate is the first intervention to significantly reduce decisional conflict in a multi-center trial of American men with newly diagnosed localized CaP. Our findings support efficacy of P3P for addressing decision uncertainty and facilitating patient selection of a CaP treatment that is consistent with the patient values and preferences.     

The impact of age and comorbidity on survival outcomes and treatment patterns in prostate cancer

The management of localized prostate cancer is based on stage, grade, PSA, and subjective assessment of comorbidity and life expectancy. Over the last 15 y, stage migration and the improved use of Gleason sum, PSA and TNM staging have led to many treatment options for patients with newly diagnosed localized prostate cancer. At the same time, advances in treatment techniques have helped decrease the long-term complications of surgery and radiotherapy. However, the importance of age and comorbidity, in survival outcomes and treatment decision-making has been largely overlooked. Currently, stage, grade, and PSA are the only quantifiable variables consistently used in research and treatment decision-making. Comorbidity and life expectancy have remained largely subjective variables. Increasing longevity and a rapidly aging population have made age and comorbidity increasingly important factors in clinical research and treatment decision-making. This article reviews the importance of age and comorbidity on treatment decisions and survival outcomes in prostate cancer, as well as their use as objectively quantifiable variables. Examples from the general oncology literature are given. The overview also examines validated comorbidity indices and advocates the use of the Charlson Comorbidity Index (CCI) in research outcomes and treatment decision-making in prostate cancer. Several clinical vignettes are provided to demonstrate the potential clinical utility of the CCI as applied to prostate cancer.     

Management of radiation failure for localized prostate cancer

Due to the historically large number of patients with localized prostate cancer (CAP) treated by radiation therapy, an increasing number of patients are presenting local failure. The currently available concepts regarding its definition as well as management options are reviewed. The literature regarding radiation failure for localized prostate cancer was reviewed. Emphasis was made on articles concerning definition of radiation failure, patient evaluation and restaging and definitive as well as palliative management options. There is definitely a subset of patients with locally recurrent prostate cancer without evidence of metastasis that could potentially benefit from aggressive local therapy. A treatment algorithm is proposed but it should be emphasized that treatment options should be individualized to suit the need of a particular patient.     

Patient decision aids in joint replacement surgery: a literature review and an opinion survey of consultant orthopaedic surgeons

INTRODUCTION

Patient decision aids could facilitate shared decision-making in joint replacement surgery. However, patient decision aids are not routinely used in this setting.

METHODS

With a view to developing a patient decision aid for UK hip/knee joint replacement practice, we undertook a systematic search of the literature for evidence on the use of shared decision-making and patient decision aids in orthopaedics, and a national survey of consultant orthopaedic surgeons on the potential acceptability and feasibility of patient decision aids.

RESULTS

We found little published evidence regarding shared decision-making or patient decision aids in orthopaedics. In the survey, 362 of 639 (57%) randomly selected consultant orthopaedic surgeons responded. Respondents appear representative of consultant orthopaedic surgeons in the UK. Of 272 valid responses, 79% (95% CI, 73–85%) thought patient decision aids a good or excellent idea. There was consensus on the potential helpfulness of patient decision aids and core content. A booklet to take home was the preferred medium/practice model.

CONCLUSIONS

Despite the increased emphasis on patient involvement in decision-making, there is little evidence in the medical literature relating to shared decision-making or the use of patient decision aids in orthopaedic surgery. Further research in this area of clinical practice is required. Our survey shows that consultant orthopaedic surgeons in the UK are generally positive about the use of patient decision aids for joint replacement surgery. Survey results could inform future development of patient decision aids for joint replacement practice in the UK.     

The ‘CaP Calculator’: an online decision support tool for clinically localized prostate cancer

Study Type – Prognosis (risk model)
Level of Evidence 2a

OBJECTIVE

To design a decision‐support tool to facilitate evidence‐based treatment decisions in clinically localized prostate cancer, as individualized risk assessment and shared decision‐making can decrease distress and decisional regret in patients with prostate cancer, but current individual models vary or only predict one outcome of interest.

METHODS

We searched Medline for previous reports and identified peer‐reviewed articles providing pretreatment predictive models that estimated pathological stage and treatment outcomes in men with biopsy‐confirmed, clinical T1‐3 prostate cancer. Each model was entered into a spreadsheet to provide calculated estimates of extracapsular extension (ECE), seminal vesicle invasion (SVI), and lymph node involvement (LNI). Estimates of the prostate‐specific antigen (PSA) outcome after radical prostatectomy (RP) or radiotherapy (RT), and clinical outcomes after RT, were also entered. The data are available at http://www.capcalculator.org .

RESULTS

Entering a patient’s 2002 clinical T stage, Gleason score and pretreatment PSA level, and details from core biopsy findings, into the CaP Calculator provides estimates from predictive models of pathological extent of disease, four models for ECE, four for SVI and eight for LNI. The 5‐year estimates of PSA relapse‐free survival after RT and 10‐year estimates after RP were available. A printout can be generated with individualized results for clinicians to review with each patient.

CONCLUSIONS

The CaP Calculator is a free, online ‘clearing house’ of several predictive models for prostate cancer, available in an accessible, user‐friendly format. With further development and testing with patients, the CaP Calculator might be a useful decision‐support tool to help doctors promote evidence‐based shared decision‐making in prostate cancer.     

Low conflict and high satisfaction: Decisional outcomes after attending a combined clinic to choose between robotic prostatectomy and radiotherapy for prostate cancer

BackgroundDecisional conflict and post-treatment decisional regret have been documented in men with localised prostate cancer (LPC). However, there is limited evidence regarding decisional outcomes associated with the choice between robotic-assisted radical prostatectomy (RARP) and radiotherapy, when both treatment options are available in the public health system. There is increasing support for multidisciplinary approaches to guide men with LPC in their decision-making process. This study assessed decisional outcomes in men deciding between RARP or radiotherapy treatment before and after attending a LPC combined clinic (CC).MethodsQuantitative longitudinal data were collected from 52 men who attended a LPC CC, where they saw both a urologist and radiation oncologist. Patients completed questionnaires assessing involvement in decision-making, decisional conflict, satisfaction and regret before and after the CC, three months, six months and 12 months post-treatment. Urologists and radiation oncologists also reported their perceptions regarding patients' suitability for, openness to, perceived preferences and appropriateness for each treatment. Data was analysed using paired/independent samples t-tests and McNemar's tests.ResultsMost participants (n = 37, 71%) opted for RARP over radiotherapy (n = 14, 27%); one participant deferred treatment (2%). Urologists and radiation oncologists reported low agreement (κ = 0.26) regarding the most appropriate treatment for each patient. Participants reported a desire for high levels of control over their decision-making process (77.5% patient-led, 22.5% shared) and high levels of decisional satisfaction (M = 4.4, SD = 0.47) after the CC. Decisional conflict levels were significantly reduced (baseline: M = 29.3, SD = 16.9, post-CC: M = 16.3, SD = 11.5; t = 5.37, P < 0.001) after the CC. Mean decisional regret scores were ‘mild’ at three-months (M = 16.0, SD = 17.5), six-months (M = 18.8, SD = 18.7) and 12-months (M = 18.2, SD = 15.1) post-treatment completion.ConclusionThis is the first Australian study to assess decisional outcomes when patients are offered the choice between RARP and radiotherapy in the public health system. A CC seems to support decision-making in men with LPC and positively impact some decisional outcomes. However, larger-scale controlled studies are needed to confirm these findings.     

Decisional regret and quality of life after participating in medical decision-making for early-stage prostate cancer

OBJECTIVE: To determine the effect of men's reported levels of involvement in medical decision-making and quality of life (QoL) on their levels of decisional regret after definitive treatment. PATIENTS AND METHODS: Men referred to a hospital-based resource centre completed QoL and decisional-regret measures after definitive treatment for localized prostate cancer. Data from these questionnaires were linked with a previous study conducted to determine if providing individualized information to men newly diagnosed with prostate cancer would lower their levels of psychological distress and enable them to become more active participants in treatment decision-making. The preferred role in medical decision-making and QoL had previously been measured at the time of diagnosis and the assumed role at 4 months after the definitive treatment decision. This postal survey was conducted approximately 18 months after diagnosis. RESULTS: Of 74 men, 67 (91%) responded; the mean (sd) time since definitive treatment was 10.3 (4.7) months and the mean age of the men 62.5 (6.9) years. Radical prostatectomy was the most frequent treatment (72%). Most (94%) patients participated in medical decision-making either actively or collaboratively and did not regret their treatment choice. The type of definitive treatment received had no effect on decisional regret; patients' QoL scores were similar to the levels before treatment. Levels of sexual function were significantly lower after definitive treatment, but urinary incontinence was not significantly affected. Men who had neoadjuvant hormone therapy reported having significantly more treatment-related symptoms. CONCLUSIONS: There is no evidence that providing information to facilitate participation in medical decision-making causes decisional regret or psychological distress within the first year after definitive treatment. A longitudinal follow-up of these patients is required to adequately assess the long-term effects of treatment on QoL and decisional regret.     

Survey of factors underlying treatment choice for patients with localized prostate cancer (radical prostatectomy vs extrabeam radiotherapy)

PURPOSE: Little is known regarding factors for decision-making on treatment by localized prostate cancer patients. We therefore conducted a survey series of cases for influence on treatment decision making, and also satisfaction after therapy. MATERIALS AND METHODS: A total of 51 patients with localized prostate cancer treated with radical prostatectomy (RP) or external beam radiation therapy (EBRT) were mailed original questionnaires about their treatment decision-making factors and satisfaction and the results compared between the two groups. RESULT: Some 48 (94.1%) patients responded to the questionnaire, 38 (79.2%) and 10 (20.8%) after RP and EBRT, respectively. The major factor determining the decision as to treatment approach was the physician in both groups (more than 90%). Excluding physicians, family or others were more important in the RP group than the EBRT group (p = 0.023). RP group patients desired removal of their prostate for cancer control, while, EBRT group patients favored the less invasive approach in consideration of side effects. Over 80% patients indicated they would definitely or probably choose the same treatment again, although some of the RP group would switch to watchful-waiting because of sexual dysfunction, urinary incontinence and the invasive nature of the procedure. CONCLUSION: Physicians are in a most important position to help patients understand prostate cancer and treatment, outcomes, and need to help them make their best choice, with appropriate follow up including mental care.     

Therapie des nichtmetastasierten Prostatakarzinoms

Background

Patients with nonmetastatic prostate cancer face a complex treatment decision. To support them with personalized information, a variety of interactive computerized decision aids have been developed in Anglo-Saxon countries. Our goal was to identify relevant decision aids and investigate their didactic strengths and limitations.

Materials and methods

We included decision aids that derived individualized content from personal and clinical data provided by the patient. By conducting a systematic literature and internet research through November 2013 supplemented by expert interviews, we identified 10 decision aids of which 6 had been investigated scientifically. We compared their individual characteristics as well as the design and results of the evaluation studies.

Results

The decision aids present two to seven therapy choices, whereby radical prostatectomy and percutaneous radiotherapy are always included. Number and type of parameters provided by the patient also vary considerably. Two decision aids derive a therapeutic recommendation from the patient’s input. Evaluation studies showed higher disease-related knowledge and greater confidence in the treatment decision after using one of six decision aids. Satisfaction with the decision aid was predominantly high.

Conclusions

Currently personalized patient decision aids for treatment of nonmetastatic prostate cancer are only available in English. These tools can facilitate the shared decision making process for patients and physicians. Therefore, comparable decision aids should be developed in German.     

Comorbidity and primary treatment for localized prostate cancer: data from CaPSURE

PURPOSE: The optimal approach for treating localized prostate cancer remains controversial, leading to a multifactorial decision making process. We characterized the extent to which the presence and number of comorbidities affects treatment for localized prostate cancer. MATERIALS AND METHODS: Data were abstracted from a longitudinal observational database of men with prostate cancer. A total of 5,149 men diagnosed with localized prostate cancer between 1995 and 2001 were included in this analysis if they had been treated with RP, external beam radiation, brachytherapy, hormonal therapy or surveillance. Comorbidity was assessed through a patient reported checklist of conditions. Multinomial logistic regression was used to determine the OR of the likelihood of receiving each type of therapy. The number of comorbidities and specific comorbidities in patients receiving RP were compared with comorbidities in patients receiving other treatment. RESULTS: The adjusted OR showed a dose response between the number of comorbidities and an increasing probability of any nonRP treatment. In addition, heart disease, stroke or another urinary condition were found to be associated with treatment. CONCLUSIONS: Patient comorbidities affect decision making regarding treatment for localized prostate cancer. Urologists and other physicians treating this disease appear to evaluate patient comorbidities when selecting treatment options.     

The patient's dilemma: prostate cancer treatment choices

PURPOSE: We summarize the literature addressing factors that influence treatment decisions made by men with prostate cancer. MATERIALS AND METHODS: A MEDLINE search of the English language literature published between 1969 and 2000, using the combined MESH key words "prostatic neoplasms," "patient participation," "Internet" and "decision making," generated 181 abstracts. Only 23 of these publications addressed factors influencing treatment decisions made by men with prostate cancer. Nine additional relevant studies were identified from references in the original 23 articles. Subsequently a search for the term "prostate cancer" using several popular Internet search engines yielded more than 1 million hits. A further search was performed using the key words "prostate cancer" and "prostate" within on-line archives of the United Kingdom television channels BBC, ITV, and channels 4 and 5, and newspapers The Sun, The Daily Mail, The Observer, The Guardian and The Times. RESULTS: When there is poor quality evidence or little professional consensus to support a particular treatment over another, no clinical guidelines regarding treatment are possible. Patients are faced with a series of options, and the data reveal that the process of choosing between these options is based on input from a large number of sources. These sources differ in the way that benefits of treatment are emphasized over harms and vice versa. We identified little evidence regarding which type of input exerts the greatest influence on patients. It may be that the sources associated with the most bias have the greatest influence. CONCLUSIONS: There is a paucity of information on how patients with prostate cancer use different types of input in the treatment decision making process. The physician, as principal caregiver, still appears to have the most direct influence on patient choice. Just how long this status will continue is uncertain.     

Barriers to sexual recovery in men with prostate,bladder and colorectal cancer

BackgroundSurvivors of prostate, bladder, and colorectal cancer endure many sexual side-effects of treatment that negatively impact their relationships and diminish their quality of life. Multiple barriers exist in addressing men's sexual concerns in oncological care.ObjectiveTo describe barriers of sexual recovery in men with prostate, bladder, and colorectal cancer.MethodsWe searched PubMed for peer-reviewed, English-language articles published from 1999 to 2019 using the following search terms: “prostate cancer,” or “bladder cancer,” or “colorectal cancer,” and “male,” and “sexual function,” or “sexual barrier” or “sexual dysfunction.” Criteria for inclusion consisted of peer-reviewed articles (review, cross-sectional, longitudinal, interventional, or pilot studies) addressing sexual issues in men with a history of prostate, bladder, or colorectal cancer.ResultsBarriers to sexual recovery in men with prostate, bladder, and colorectal cancer include psychosocial barriers such as the feeling of loss, grief, depression and anxiety, the poor utilization, and excessive cost of pro-erectile aids, a diminished sense of masculinity and reluctance to seek help for sexual problems, as well as poor couple coping. Barriers in healthcare also exist, as healthcare providers often do not effectively address sexual issues due to poor communication, lack of comfort in discussing sexual issues, time constraints, and patients’ hesitation to initiate discussions on sexual dysfunction. Patients with stomas and gay, bisexual, and queer men face additional challenges in their recovery of sexual intimacy. Barriers to sexual recovery are present in men during all stages of cancer and all modalities of treatment including surgery, radiation, or androgen deprivation therapy.ConclusionThere are multiple overlapping psychosocial and healthcare system barriers to sexual recovery after prostate, bladder, and colorectal cancer treatment. Oncological providers must be cognizant of these complex barriers so they can facilitate patients’ access to resources needed for successful sexual recovery after genitourinary cancer treatment. Evidence based interventions, such as couple psychosexual counseling and peer support should be implemented via multidisciplinary care.     

Characteristics,Treatments, and Outcomes of Tibial Plateau Nonunions: A Systematic Review

BackgroundDue to the rare incidence of tibial plateau nonunions, current studies are limited to small sample sizes and patient demographics. The aim of this systematic review is to quantify and report patient and fracture traits, possible risk factors, and treatment outcomes of tibial plateau nonunions.MethodsPubMed, Clinical Key, and MEDLINE were searched for articles published prior to August 2020 in accordance to the preferred reporting items for systematic reviews and meta-analyses (PRISMA). The authors used varying combinations of the following terms to identify relevant articles: “tibial,” “plateau,” “nonunion,” “non-union.” Studies were assessed for patient demographics, pre-revision nonunion characteristics, treatment, and post-revision outcomes.ResultsEight studies were included, yielding 31 tibial plateau nonunions (21 males, 10 females). The majority of nonunions were associated with high energy trauma (52.2%) and were Schatzker class VI (54.8%). Schatzker class I and II nonunions were not attributed to neglect, contradicting previous suggestions. Time to union was 4.0 months, the most common treatments being autologous bone grafting (76.7%) and revision plating (63.3%).ConclusionThis study demonstrates the effectiveness of autologous bone grafts and revision plating for tibial plateau nonunions. Physicians may use these findings to guide decision making in the event of high energy plateau nonunions. Lastly, various limitations exist within the current literature, emphasizing the need for standardized reporting measures.     

Testosterone replacement therapy (TRT) and prostate cancer: An updated systematic review with a focus on previous or active localized prostate cancer

Often contraindicated because of the theoretical risk of progression based on the dogma of hormone dependent prostate cancer (CaP), testosterone replacement therapy (TRT) is increasingly discussed and proposed for hypogonadal patients with localized CaP. To perform a systematic literature review to determine the relationship between TRT and the risk of CaP with a focus on the impact of TRT in the setting of previous or active localized CaP. As of October 15, 2019, systematic review was performed via Medline Embase and Cochrane databases in accordance with the PRISMA guidelines. All full text articles in English published from January 1994 to February 2018 were included. Articles were considered if they reported about the relationship between total testosterone or bioavailable testosterone and CaP. Emphasis was given to prospective studies, series with observational data and randomized controlled trials. Articles about the safety of the testosterone therapy were categorized by type of CaP management (active surveillance or curative treatment by radical prostatectomy, external radiotherapy or brachytherapy). Until more definitive data becomes available, clinicians wishing to treat their hypogonadal patients with localized CaP with TRT should inform them of the lack of evidence regarding the safety of long-term treatment for the risk of CaP progression. However, in patients without known CaP, the evidence seems sufficient to think that androgen therapy does not increase the risk of subsequent discovery of CaP.     

Health related quality of life in men with prostate cancer

PURPOSE: Quality of life is of great concern to patients considering treatment options for prostate cancer. In the absence of clinical trial data clearly demonstrating that a particular treatment is superior to another for localized prostate cancer, in terms of cause specific survival, patients may value quality of life as much as quantity of life. The goal of this review is to familiarize the reader with the methodology of quality of life research and to review the recent literature on quality of life outcomes in prostate cancer. MATERIALS AND METHODS: A structured MEDLINE review of literature on health related quality of life in prostate cancer for the years 1995 to 2001 was performed, and was augmented with highly relevant articles from additional selected journals. RESULTS: In the case of advanced or metastatic disease, where the goal of treatment is palliation and symptom-free survival, quality of life often becomes the primary desired outcome. In localized disease all treatments affect health related quality of life, although the impact of each therapy on sexual, urinary and bowel function is unique. CONCLUSIONS: Although a highly personal and subjective entity, health related quality of life can be assessed using rigorous and scientifically stringent methods from the field of psychometric test theory. A substantial amount of literature exists regarding the use of established and validated instruments for assessing the impact of prostate cancer and its treatment on health related quality of life. This information is of critical importance when counseling men with newly diagnosed prostate cancer regarding treatment choices and is also helpful in setting appropriate expectations for men with metastatic disease.