Quality of life after treatment for prostate cancer

Quality of life is a major concern of patients when they are choosing treatment for prostate cancer. Health-related quality of life is a patient-centered variable from the field of health services research that can be measured in a valid and reliable manner. Using standardized questionnaires specifically developed to capture health-related quality of life data in men with prostate cancer, the effect of treatments on patients’ quality of life can be studied. Patients with localized disease who are undergoing radical prostatectomy tend to have more sexual and urinary dysfunction than men undergoing external beam radiation therapy, although both groups have more impairment in these areas than agematched controls. Men undergoing external beam radiation therapy have worse bowel function and more urinary distress from irritative voiding symptoms than men undergoing radical prostatectomy or age-matched controls. Recent studies of men undergoing interstitial brachytherapy indicate that these patients have less urinary leakage than those who undergo radical prostatectomy, but experience considerably more irritating voiding symptoms, which often profoundly affect their quality of life. Better information regarding the potential impact of prostate cancer treatment on quality of life will improve medical decision-making.     

Quality of life after external beam radiotherapy for localized prostate cancer: Comparison with other modalities

In external beam radiotherapy for localized prostate cancer, acute toxicities are typically transient and mild. These symptoms will disappear within 4–8 weeks after external beam radiotherapy. Some patients might suffer from proctitis with bloody stools as late rectal toxicity. Therefore, it has been shown that external beam radiotherapy has a more pronounced negative impact on bowel function compared with other treatment modalities. However, the recent development of modern beam delivery techniques, including intensity‐modulated radiotherapy, allows us not only to deliver higher doses to the prostate, but also to decrease the doses to the critical organs, resulting in the maintenance of patients’ quality of life within satisfactory levels. Patients’ quality of life after external beam radiotherapy is also strongly related to the total dose, fractionation regimens, dose parameters of the critical organs and treatment plan quality, with a trade‐off between the radicality of external beam radiotherapy and potentially increased toxicity. Radiation oncologists should choose treatment parameters carefully to achieve a reasonable balance between a good oncological outcome and the patient's quality of life.     

Urinary incontinence after treatment for localized prostate cancer

The incidence of incontinence after radical prostatectomy has ranged from 0 to 57% depending on the series and the type of incontinence considered. When total incontinence (not minimal stress incontinence) is reported, the average incidence is no more than 5%. This figure will increase with age, and in most series, approximately 10% of patients around the age of 70 will have total incontinence postoperatively. Preservation of continence after radical prostatectomy depends largely on the preservation of the distal urethral smooth-muscle sphincteric mechanism, which begins at the pelvic floor and ends at the prostatourethral junction. Newer techniques that attempt to increase postoperative continence include not cutting the puboprostatic ligaments and attempting to preserve as much striated muscle as possible along the length of the remaining urethra. Patients who are incontinent for 6 months after the surgery with no evidence of improvement will probably not become continent on their own. Therefore, some type of therapy should be considered. The options are periurethral injection of a bulking agent, implantation of an artificial sphincter, and, most recently, a bulbourethral sling procedure.     

Quality of life in patients with localized prostate cancer

To date, there are no studies conclusively documenting that one treatment for localized prostate cancer is superior to another in terms of overall survival. Therefore, patients must consider other outcomes when choosing primary therapy for localized disease. One of the most important factors patients consider when choosing their treatment is the effect of therapy on their quality of life (QOL). Over the past decade, there have been an increasing number of studies assessing health related QOL (HRQOL) outcomes in localized prostate cancer. The goal of this article is to review our current understanding of HRQOL in this disease. We will begin by examining the established HRQOL instruments for use in localized prostate cancer. We will then discuss the effect of various treatments on QOL and review the literature comparing HRQOL outcomes between therapies.     

Pretreatment depressive symptoms and treatment modality predict post-treatment disease-specific quality of life among patients with localized prostate cancer

PurposeThis study examines the prevalence of depressive symptoms before prostate cancer treatment and explores associations among pre-treatment depressive symptoms and post-treatment disease-specific QOL, controlling for treatment modality, and demographic and clinical covariates.Materials and methodsA case series of patients diagnosed with localized prostate cancer (T1-2N0M0) at a comprehensive cancer center was assessed. Of the 1,370 eligible patients, 869 (63.34%) completed questionnaires at diagnosis (baseline) and 6 months following treatment. Patients were treated with surgery (16.8%), brachytherapy (27.6%), or external beam radiation (EBRT; 55.6%). Depressive symptoms and disease-specific QOL were assessed with established measures (i.e., Center for Epidemiologic Studies Depression Scale (CES-D); sexual adjustment questionnaire (SAQ); and the American Urological Association symptom index).ResultsA fifth of the sample (19.7%) reported clinically elevated levels of depressive symptoms at baseline. The proportion of clinically elevated levels of baseline depressive symptoms was higher among surgery patients compared with patients treated with brachytherapy or external beam radiation. Depressive symptoms at baseline and treatment modality significantly predicted sexual and urinary dysfunction, related bother, activity limitation due to urinary dysfunction at 6 months, controlling for, age, PSA level, Gleason score, relevant baseline indicators of sexual and urinary dysfunction, related bother, and activity limitation (P < 0.05).ConclusionsPretreatment depressive symptoms and treatment modality predict QOL after PrCa treatment. Health care providers should be sensitive to the display of depressive symptoms before PrCa treatment and consider preventative interventions, including preparing patients for the changes in disease-specific QOL and related bother following prostate cancer treatment.     

The impact of cancer treatment on quality of life outcomes for patients with localized prostate cancer

PURPOSE: We evaluated the impact of localized prostate cancer treatment on general, cancer specific and symptom domains of quality of life for up to 5 years after diagnosis. MATERIALS AND METHODS: A total of 842 men from the Health Professionals Followup Study, diagnosed between 1993 and 1998, were included in cross-sectional analyses of quality of life associated with prostate cancer treatment. A subset of 146 men diagnosed after 1995 were followed prospectively. Quality of life was assessed with the Medical Outcomes Study Short-Form 36 Health Status Survey, Cancer Rehabilitation Evaluation System Short Form and University of California Los Angeles Prostate Cancer Index by mailed questionnaires. Primary treatment modality was taken from medical records and patient self-report. RESULTS: Significant treatment differences were observed in all quality of life measures, with the largest occurring in sexual, urinary and bowel symptoms. Bowel function was significantly worse in patients who received external radiation and brachytherapy compared with prostatectomy (p <0.05). Although they had better or equivalent urinary and sexual function (p <0.05), patients treated with external radiation, hormones or watchful waiting had lower generic quality of life scores in multiple domains compared with those who underwent prostatectomy. Patients who had brachytherapy had similar generic quality of life outcomes compared with prostatectomy in all domains. CONCLUSIONS: Our findings suggest that important differences in quality of life go beyond known physical symptoms associated with various prostate cancer treatment options, many of which involve making a trade-off. It is important for patients with prostate cancer and health care providers to consider these differences while making treatment decisions.     

Quality of life after high-dose-rate brachytherapy monotherapy for prostate cancer

Purpose

There is little information in the literature on health-related quality of life (HRQOL) changes due to high-dose-rate (HDR) brachytherapy monotherapy for prostate cancer.

Materials and Methods

We conducted a prospective study of HRQOL changes due to HDR brachytherapy monotherapy for low risk or favorable intermediate risk prostate cancer. Sixty-four of 84 (76%) patients who were treated between February 2011 and April 2013 completed 50 questions comprising the Expanded Prostate Cancer Index Composite (EPIC) before treatment and 6 and/or 12 months after treatment.

Results

Six months after treatment, there was a significant decrease (p<0.05) in EPIC urinary, bowel, and sexual scores, including urinary overall, urinary function, urinary bother, urinary irritative, bowel overall, bowel bother, sexual overall, and sexual bother scores. By one year after treatment, EPIC urinary, bowel, and sexual scores had increased and only the bowel overall and bowel bother scores remained significantly below baseline values.

Conclusions

HDR brachytherapy monotherapy is well-tolerated in patients with low and favorable intermediate risk prostate cancer. EPIC urinary and sexual domain scores returned to close to baseline 12 months after HDR brachytherapy.     

Impact of treatment modality on overall survival in localized ductal prostate adenocarcinoma: A national cancer database analysis

PurposeDuctal adenocarcinoma is considered a rare histological variant of prostate adenocarcinoma (PCa). Given the rarity of this subtype, optimal treatment strategies for men with nonmetastatic ductal PCa is largely unknown. We aimed to describe the impact of surgery, radiotherapy, systemic therapy, and observation on overall survival (OS) in men with nonmetastatic ductal PCa.Materials and methodsWe selected 1,656 cases of nonmetastatic ductal PCa, diagnosed between 2004 and 2015, within the National Cancer Database. Covariates included age, race, Charlson comorbidity score, clinical T stage, clinical lymph node stage, serum prostate specific antigen (PSA), income, hospital type, insurance status, year of diagnosis, and location of residence. Cox regression analysis tested the impact of treatment (surgery, radiotherapy, systemic therapy, and observation) on OS.ResultsIn men with nonmetastatic ductal PCa, median (interquartile range [IQR]) age and PSA were 67 (60–73) years and 6.2 (4.2–10.7) ng/ml, respectively. Advanced local stage (≥cT3a) was most frequently observed in patients initially treated with systemic therapy (34.8%), followed by those treated with radiotherapy (18.1%), surgery (7.1%) and observation (6.4%, P< 0.001). Serum PSA at presentation was highest in the systemic therapy cohort (median 16.0 ng/ml, IQR: 4.9–37.7), followed by the radiotherapy cohort (median 7.2 ng/ml, IQR: 4.1–12.2), observation cohort (median 7.0 ng/ml, IQR: 4.3–13.3) and surgery cohort (median 5.9 ng/ml, IQR: 4.3–9.2, P< 0.001). Multivariable analysis showed that in comparison to men treated surgically, OS was significantly lower for patients receiving radiotherapy (HR 2.2; 95% CI: 1.5–3.2), under observation (HR 4.6; 95% CI: 2.8–7.6) and receiving systemic therapy (HR 5.2; 95% CI: 3.0–9.1) as an initial course of treatment.ConclusionsWhile limited by its retrospective nature, our study shows that starting treatment with surgery is associated with more favorable long-term OS outcomes than radiotherapy, systemic therapy or observation.     

Methylglyoxal-induced apoptosis in human prostate carcinoma: potential modality for prostate cancer treatment

OBJECTIVE: To examine the cellular effects of methylglyoxal (MG), a toxic physiological metabolite, on human prostatic cancer PC-3 cells. METHODS: The effects of MG on cell growth and viability were evaluated first, and then its effects on the cell cycle and the glycolytic process were analyzed by Western blots and specific assays. Possible MG-induced apoptosis was also assessed by DNA analysis using agarose gel electrophoresis. RESULTS: MG > or =3 mM caused severe growth inhibition, resulting in nearly 100% cell death by 24h. The time course study revealed that expression of cyclin D(1), cdk2, and cdk4 was significantly (>50%) downregulated in 3 h of MG (3 mM) exposure, followed by the dephosphorylation of retinoblastoma protein by 6 h. Both the glyceraldehyde-3-phosphate dehydrogenase activity and the cellular lactate level were also reduced by approximately 50 and 80%, respectively, following 6-hour MG exposure. Induction of apoptosis by MG was indicated by partial degradation of poly(ADP-ribose) polymerase and further confirmed by discrete DNA fragmentation detected on an agarose gel. CONCLUSION: MG is capable of inducing apoptosis in prostatic cancer PC-3 cells, due primarily to a blocking of the cell cycle progression (G(1) arrest) and glycolytic pathway. Therefore, MG could be a potent apoptosis inducer, which may have a potential for prostate cancer treatment.     

Five year Expanded Prostate cancer Index Composite‐based quality of life outcomes after prostatectomy for localized prostate cancer

Study Type – Therapy (outcomes research) Level of Evidence 2c What’s known on the subject? and What does the study add? Previous studies typically assessed early outcomes (≤2 years) after prostatectomy often without individual pre‐operative scores for comparison. Our study followed patients and provides long term results, five years post‐operatively, and compared results to patients own baseline scores across all domains within EPIC.

OBJECTIVE

To document the Expanded Prostate cancer Index Composite (EPIC) results for men followed for 5 years after radical prostatectomy.

PATIENTS AND METHODS

EPIC and demographic information were prospectively obtained from 434 patients who received questionnaires preoperatively and 1, 4, 12, 24, 36, 48 and 60 months postoperatively. Paired t‐tests compared scores at individual time points. Percentage return to baseline was calculated at all postoperative time points and multivariate analyses evaluated postoperative trends.

RESULTS

The mean age of patients was 63.4 years. Mean urinary function and incontinence worsen after prostatectomy, with recovery stable 12 months after surgery. Mean urinary bother returned to baseline by 4 months post‐prostatectomy. Some 55.8% and 77.5% of patients return to their urinary function and bother baselines, respectively, 1 year after surgery. Mean sexual function and bother both declined after surgery, with new stable baselines achieved by 24 and 36 months post‐prostatectomy, respectively. Of the patients, 24.2% returned to their sexual function baseline by 24 months. No postoperative improvement was noted in mean sexual bother until the 12 months post‐prostatectomy. Of the patients, 36.8% returned to their sexual bother baseline by 36 months. Minimal change was noted in the bowel and hormonal domains.

CONCLUSIONS

Mean urinary function and incontinence did not recover to preoperative baseline after prostatectomy, although it did not add distress because mean urinary bother returned to pre‐prostatectomy levels. Mean sexual function declined post‐prostatectomy, with continued recovery up to 24 months. Sexual bother recovered later but, once it reached a new baseline, the distress does not lessen with time, probably indicating an inability to adjust to their functional loss.     

Quality of life following high‐intensity focused ultrasound for the treatment of localized prostate cancer: A prospective study

Objectives: To report our health‐related quality of life (QOL) and functional outcomes following high‐intensity focused ultrasound (HIFU) for localized prostate cancer. Methods: Data from prostate cancer patients undergoing HIFU at our institution between January 1999 and April 2007 were collected in our prospective database. Standard preoperative and surgical parameters, as well as baseline urinary function, QOL and sexual assessment were included. The Japanese version of the Functional Assessment of Cancer Therapy‐general (FACT‐G), the FACT‐prostate (P) and the International Index of Erectile Function‐5 (IIEF‐5) were used for the functional assessment. These self‐administered questionnaires were collected preoperatively and again at 6, 12 and 24 months postoperatively. Results: A total of 326 patients were included in the analysis. Maximum flow rate and residual urine volume were significantly impaired at 6 months (P = 0.010) after HIFU, even if they returned to baseline values at 12 or 24 months after HIFU. The total FACT‐G score significantly improved at 24 months (P = 0.027) after HIFU. At 6, 12 and 24 months after HIFU, 52%, 63% and 78%, respectively, of the patients, not receiving neoadjuvant hormonal therapy, were potent. Conclusions: In our experience, functional and QOL outcomes after HIFU therapy for localized prostate cancer are better than those after other treatment modalities.     

Quality of life outcomes after low dose‐rate brachytherapy for localized prostate cancer: Current status and future perspectives

The present review summarizes data from studies reporting on health‐related quality of life after brachytherapy and competing modalities. There are various therapeutic modalities for localized prostate cancer, including radical surgery, external beam radiotherapy and active surveillance. Advances in surgical and radiation treatment have entered clinical practice in the form of robot‐assisted surgery or intensity‐modulated radiotherapy. Brachytherapy remains the main treatment option for patients with localized prostate cancer, with 10‐year survival data showing favorable outcomes. Because each treatment modality has achieved favorable survival outcomes, focus in determining appropriate treatment has shifted toward health‐related quality of life, where each treatment has a different profile and/or adverse symptoms. The development of health‐related quality of life assessment tools has allowed the creation of a pool of specific health‐related quality of life data across many studies. The present article reviews the impact of brachytherapy and other modalities on quality of life, as well as future directions.     

The clinical impact of pathological review on selection the treatment modality for localized prostate cancer in candidates for brachytherapy monotherapy

Aim

To evaluate the impact of pathological review by pathologist with genitourinary expertise (PGU) on treatment modality of localized prostate cancer, we analyzed Gleason grade (GG) migration and the final treatment decision in a cohort of patients designated for permanent prostate brachytherapy (PPB).

Methods

From February 2005 to July 2010, a total of 247 patients with localized prostate cancer diagnosed by local community hospitals were referred to our hospital for PPB monotheray. All pathologic slides of prostate biopsies were reviewed by a single PGU. Patients ultimately selected their treatment modality from our recommendations based on the review. Indication for PPB monotherapy was the NCCN classification of patients as good or intermediate risk. In addition, patient with Primary GG 4 was regarded as unadapted case.

Results

Six cases were reinterpreted as no cancer (2.4%). GG change occurred in 94 cases (38.1%) of which 77 (81.9%) were upgraded and 17 (18.1%) downgraded. Of the total 247 patients, 86 (34.8%) changed therapies and 30 (12.1%) did so based on the pathologic slide review.

Conclusions

Pathological review of biopsy specimens is mandatory for the determination of treatment modality especially in candidates for monotherapy of permanent prostate brachytherapy.     

Quality of life outcomes after brachytherapy for early stage prostate cancer

PURPOSE: We compare general and disease specific health related quality of life in men undergoing brachytherapy for early stage prostate cancer to those undergoing radical prostatectomy and age matched healthy controls. MATERIALS AND METHODS: Cohorts consisted of 48 men treated with brachytherapy with and without pretreatment external beam radiation therapy (brachytherapy group), 74 who underwent radical prostatectomy (prostatectomy group) and age matched healthy controls from the literature. The RAND 36-item general health survey, University of California Los Angeles Prostate Cancer Index, American Urological Association symptom index, validated Cancer Interference with Life and Family Scales, and sociodemographic and co-morbidity questionnaires were completed 3 to 17 months after treatment. RESULTS: General health related quality of life did not differ greatly among the 3 groups. Urinary function (leakage) was worse in the brachytherapy group than in controls but better than in the prostatectomy group. Brachytherapy group patients had more irritative urinary symptoms and worse bowel function than controls. Sexual function and bother were worse in prostatectomy and brachytherapy groups than in healthy controls. Physical function, bodily pain, urinary function, and bother and American Urological Association symptom index scores improved with time after brachytherapy. Patients who underwent brachytherapy after external beam radiation performed worse in all general and disease specific health related quality of life domains compared to those who did not undergo pretreatment radiation therapy. CONCLUSIONS: At an average of 7.5 months after treatment the general health related quality of life of patients undergoing brachytherapy with and without pretreatment external beam radiation was similar to age matched controls, although urinary, bowel and sexual problems were reported. These problems appeared to improve during the first year after treatment. Much of the impairment in disease specific health related quality of life among patients undergoing brachytherapy may be attributed to pretreatment radiation.     

Salvage prostate cryoablation for recurrent localized prostate cancer after radiotherapy

Salvage prostate cryoablation (SCA) for recurrent localized prostate cancer after radiotherapy has been studied in Western countries for more than a decade. We present our experience of SCA in a Taiwanese medical center. We performed four cases of SCA for recurrent localized prostate cancer after radiotherapy. The data recorded included age, cancer stage, prostate-specific antigen (PSA) level, Gleason score, prostate volume and patient outcome. The median follow-up period was 17 months. All cases were biopsy-proven to have residual cancer before cryoablation. After SCA, 25% of the patients reached undetectable PSA levels, 50% showed response but did not reach undetectable levels, and 25% showed no decrease in PSA. The median recurrence-free duration after SCA was 18 months in the patients who experienced a decrease in PSA. ADT was initiated after SCA for the patient who did not show any response, and bone metastasis was later diagnosed in that patient. Most patients experienced obstructive voiding problems after SCA, which improved over time. SCA is a safe salvage option for prostate cancer patients with local recurrence after RT. The preliminary results are encouraging. More extensive imagery to exclude extra-glandular disease is warranted before SCA. A longer follow-up period and larger sample size are necessary to delineate the benefits more conclusively.