Defining an international research agenda for quality of life in men with prostate cancer

Setting an Agenda for Assessment of Health-related Quality of Life Among Men with Prostate Cancer on Active Surveillance: A Consensus Paper from a European School of Oncology Task Force

BACKGROUND

Literature on the health-related quality of life (HRQoL) for men with localized prostate cancer (PCa) on active surveillance (AS) shows a need for methodological guidance regarding HRQoL issues and how to address them.

OBJECTIVE

The European School of Oncology Task Force (ESO TF) aimed to identify a core set of research questions and related measures to include in AS HRQoL studies.

DESIGN, SETTING, AND PARTICIPANTS

A modified Delphi study was used to reach consensus on AS HRQoL research topics and tools between 2014 and 2015. Data were collected by engaging a multidisciplinary team of 15 experts.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

An open-ended questionnaire was used to collect information from ESO TF members regarding issues in AS HRQoL research. Then a structured questionnaire was used to collect ratings on the usefulness/importance of different AS HRQoL aspects. Items that ≥80% of ESO TF members rated as useful/important were retained. Items with a 50-80% rating were discussed to reach final agreement.

RESULTS AND LIMITATIONS

Six main research questions concerning the selection of outcome measures, measurement tools, and comparison groups were identified as relevant. The core set of measures identified were related to individual characteristics, psychological dimensions; decision-making-related issues, and physical functioning. The multidisciplinary expertise of ESO TF members was a significant asset, even if bringing different backgrounds to the discussion table represented a challenge.

CONCLUSIONS

HRQoL measures have to be sensitive to the specific needs of men on AS. The definition of HRQoL outcomes will enhance a broader understanding of the HRQoL of men on AS and sustain patient-centered medicine.

PATIENT SUMMARY

An international panel agreed on a set of health-related quality-of-life aspects to be assessed among men on active surveillance for prostate cancer. Valid relevant questionnaires were identified. The experts' indications lay a foundation for future research and clinical practice.

Single blind randomized phase III trial to investigate the benefit of a focal lesion ablative microboost in prostate cancer (FLAME-trial): study protocol for a randomized controlled trial

Background

The treatment results of external beam radiotherapy for intermediate and high risk prostate cancer patients are insufficient with five-year biochemical relapse rates of approximately 35%. Several randomized trials have shown that dose escalation to the entire prostate improves biochemical disease free survival. However, further dose escalation to the whole gland is limited due to an unacceptable high risk of acute and late toxicity. Moreover, local recurrences often originate at the location of the macroscopic tumor, so boosting the radiation dose at the macroscopic tumor within the prostate might increase local control. A reduction of distant metastases and improved survival can be expected by reducing local failure. The aim of this study is to investigate the benefit of an ablative microboost to the macroscopic tumor within the prostate in patients treated with external beam radiotherapy for prostate cancer.

Methods/Design

The FLAME-trial (Focal Lesion Ablative Microboost in prostatE cancer) is a single blind randomized controlled phase III trial. We aim to include 566 patients (283 per treatment arm) with intermediate or high risk adenocarcinoma of the prostate who are scheduled for external beam radiotherapy using fiducial markers for position verification. With this number of patients, the expected increase in five-year freedom from biochemical failure rate of 10% can be detected with a power of 80%. Patients allocated to the standard arm receive a dose of 77 Gy in 35 fractions to the entire prostate and patients in the experimental arm receive 77 Gy to the entire prostate and an additional integrated microboost to the macroscopic tumor of 95 Gy in 35 fractions. The secondary outcome measures include treatment-related toxicity, quality of life and disease-specific survival. Furthermore, by localizing the recurrent tumors within the prostate during follow-up and correlating this with the delivered dose, we can obtain accurate dose-effect information for both the macroscopic tumor and subclinical disease in prostate cancer. The rationale, study design and the first 50 patients included are described.

Trial registration

This study is registered at ClinicalTrials.gov: NCT01168479

Sexual quality of life for localized prostate cancer: a cross-cultural study between Japanese and American men

Introduction

Race and ethnicity are important factors in health-related quality of life (QOL) because of racial differences in preferences for, and trust in, health systems. Such factors are likely to affect QOL and patient satisfaction with care.

Results

Using a self-reported questionnaire, Japanese men with prostate cancer reported lower sexual function scores at baseline. In detail, Japanese men were more likely than American men to report poor sexual desire, poor erection ability, poor overall ability to function sexually, poor ability to attain orgasm, poor quality of erections, infrequency of erections, infrequency of morning erections, and intercourse in the previous 4 weeks. However, Japanese men were less likely than American men to be concerned about their sexual function. Two years after surgery, American patients were more likely than Japanese patients to regain their baseline sexual function. The use of phosphodiesterase-5 (PDE-5) inhibitors has been widely publicized as the solution to erectile dysfunction after prostate cancer treatment. Although PDE-5 inhibitors have been available in Japan since 1999, it is striking that Japanese men with localized prostate cancer are much less likely (only 10%) to use PDE-5 inhibitors than American men.

Conclusion

Japanese patients with localized prostate cancer report worse sexual function but are less concerned about their reduced function. In the absence of a biological explanation for such differences, however, we suspect that cultural differences may explain the differences between QOL survey results from Japanese or American men with prostate cancer.

The relationship of quality of life and distress in prostate cancer patients compared to the general population

Background: The aim of this study is two-fold. The first part compares quality of life (QoL) data of prostate cancer patients with those of a representative and age-specific sample of the general population and analyzes the influence of cancer related as well as socio-demographic parameters on QoL. Secondly, differences in QoL depending on the experienced psychological distress will be shown both in prostate cancer patients and in the general population.

Material and Methods: A sample of 265 prostate cancer patients completed both the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30) and the Hospital Anxiety and Depression Scale (HADS) during their stay in the hospital. A total HADS cut off score of 15 was used to indicate psychological distress and significant emotional concerns in patients and men of the general population. The results of the patients were compared with those of the general population (N=444).

Results: Prostate cancer patients reported significantly worse levels of social and emotional functioning as well as more symptoms like insomnia, constipation and diarrhea compared to the general population. Patients and men of the general population with a total HADS score ≥15 reported lower QoL in all sub-scales except for diarrhea in comparison to people without distress.

Discussion: Psychological distress is accompanied by lower QoL and therefore should be taken into consideration when QoL is assessed. Furthermore, clinicians should be trained by professionals to detect distress in their patients and to pay more attention to their emotional concerns, which are strongly associated with the patients’ well-being and QoL during their stay in hospital.

Five-year follow-up of health-related quality of life after intensity-modulated radiation therapy for prostate cancer

OBJECTIVE

We evaluated health-related quality of life (HRQOL) in patients with localized prostate cancer who underwent intensity-modulated radiation therapy (IMRT) or three-field conformal radiotherapy (3DCRT).

METHODS

A total of 97 patients underwent 3DCRT and 36 underwent IMRT for localized prostate cancer between 2002 and 2004. We measured the general and disease-specific HRQOL with the Medical Outcomes Study 36-Item Health Survey and University of California, Los Angeles Prostate Cancer Index, respectively.

RESULTS

There were no significant differences in the pre-operative characteristics of the two groups. The patients in the 3DCRT group were more likely to receive hormonal therapy compared with the IMRT group before and after radiation therapy (P < 0.001 and P = 0.011, respectively). With regard to general HRQOL domains, both the 3DCRT and IMRT group scores showed no significant difference between baseline and any of the observation periods. At 60 months after treatment, the 3DCRT group had significantly worse bowel function and bother scores than baseline (both P < 0.001). On the other hand, there were no significant differences between the baseline and any of the post-treatment time periods in the IMRT group. In the 3DCRT group, sexual function remained substantially lower than the baseline level (P = 0.023). The IMRT group tended to show a decrease in sexual function, which was not statistically significant (P = 0.11).

CONCLUSIONS

IMRT can provide the possibility to deliver a high irradiation dose to the prostate with satisfactory functional outcomes for long-term periods.

Qualitative analysis of cancer patients' experiences using donated human milk

This represents the first published account from the patient's perspective of the use of human milk as cancer therapy. Purposive sampling was used to select a sample of 10 participants. Five were patients and 5 were family proxies. Individual interviews were conducted using confirmatory interviewing technique to obtain individual perspectives on the motivation for cancer patients to take donated human milk. Human milk therapy improved the quality of life (QOL) measures in the physical, psychological, and spiritual domains for most patients interviewed. The patients continued their use of human milk despite cost, taste, and discouragement from the conventional medical community. The study results support the theory that QOL may be more important to cancer patients than cancer outcomes and may improve patient medical care overall. These interviews offer information to cancer patients, their practitioners, and donor milk banks on outcomes and symptom relief from this therapy.

Health-related quality of life 3 years after high-dose intensity-modulated radiotherapy with gold fiducial marker-based position verification

OBJECTIVE

To evaluate the change in quality of life (QoL) 3 years after high-dose intensity-modulated radiotherapy (IMRT) using gold fiducial marker-based position verification in patients with locally advanced prostate cancer.

PATIENTS AND METHODS

Between October 2003 and November 2004, 95 patients with locally advanced prostate cancer were treated with 76 Gy IMRT with gold-fiducial marker-based position verification. Before treatment (baseline) and 1, 6 and 36 months after RT the QoL was measured using the RAND-36, the European Organization for Research and Treatment of Cancer (EORTC) core questionnaire (QLQ-C30(+3)) and the prostate tumour-specific module (EORTC QLQ-PR25). Changes in QoL with time of > or =10 points were considered clinically relevant.

RESULTS

After 3 years there was a statistically significant improvement in QoL for emotional role restriction and functioning, change in health, mental health and insomnia, compared with baseline. Emotional role restriction increased by >10 points and was therefore clinically relevant, while all other differences were of <10 points. There was a statistically significant deterioration of QoL after 3 years in physical and cognitive functioning, bowel symptoms/function and sexual activity. Only the sexual activity QoL score changed by 12 points and was therefore the only meaningful deterioration in QoL at 3 years after treatment.

CONCLUSION

IMRT and accurate position verification provide the possibility to deliver a high irradiation dose to the prostate without clinically relevant deterioration in long-term QoL, except for a persistent decrease in sexual activity score.

Quality of life after therapy for localized prostate cancer

Given the lack of unequivocal survival data clearly favoring one treatment over another for localized prostate cancer, patients strongly consider quality-of-life effects when choosing treatment for this common malignancy. In the past 15 years, a sizeable body of literature assessing health-related quality-of-life (HRQOL) outcomes in localized prostate cancer has emerged. The goal of this article is to review the quality-of-life experience after treatment for localized prostate cancer. Specifically, I will briefly discuss how quality of life is measured and then review the quality of life effects of each of the commonly used treatment strategies in localized prostate cancer. Finally, I attempt to directly compare the quality-of-life effects of the various treatments to assist clinicians in advising patients with newly diagnosed localized prostate cancer.

Health-related quality of life in patients with locally advanced prostate cancer after 76 Gy intensity-modulated radiotherapy vs. 70 Gy conformal radiotherapy in a prospective and longitudinal study

PURPOSE

To compare quality of life (QoL) after 70 Gy conformal radiotherapy with QoL after 76 Gy intensity-modulated radiotherapy (IMRT) in patients with locally advanced prostate carcinoma.

METHODS AND MATERIALS

Seventy-eight patients with locally advanced prostate cancer were treated with 70 Gy three-field conformal radiotherapy, and 92 patients received 76 Gy IMRT with fiducial markers for position verification. Quality of life was measured by RAND-36, the European Organization for Research and Treatment of Cancer core questionnaire (EORTC QLQ-C30(+3)), and the prostate-specific EORTC QLQ-PR25, before radiotherapy (baseline) and 1 month and 6 months after treatment. Quality of life changes in time (baseline vs. 1 month and baseline vs. 6 months) of > or =10 points were considered clinically relevant.

RESULTS

Differences between the treatment groups for QoL changes over time occurred in several QoL domains. The 76-Gy group revealed no significant deterioration in QoL compared with the 70-Gy group. The IMRT 76-Gy group even demonstrated a significantly better change in QoL from baseline to 1 month in several domains. The conformal 70-Gy group revealed temporary deterioration in pain, role functioning, and urinary symptoms; for the IMRT 76-Gy group a better QoL in terms of change in health existed after 1 month, which persisted after 6 months. For both treatment groups temporary deterioration in physical role restriction occurred after 1 month, and an improvement in emotional role restriction occurred after 6 months. Sexual activity was reduced after treatment for both groups and remained decreased after 6 months.

CONCLUSIONS

Intensity-modulated radiotherapy and accurate position verification seem to provide a possibility to increase the radiation dose for prostate cancer without deterioration in QoL.

Effect of androgen deprivation therapy on quality of life in Japanese men with prostate cancer

OBJECTIVE

We evaluated health-related quality of life (HRQOL) in Japanese men receiving androgen deprivation therapy (ADT) for prostate cancer.

METHODS

Fifty-six men were enrolled in this study. HRQOL was prospectively measured before ADT, and at 3, 6 and 12 months after treatment began, using a general (36-item Short-Form Health Survey) and disease-specific (the University of California, Los Angeles Prostate Cancer Index) HRQOL questionnaire.

RESULTS

In the general HRQOL questionnaire, patients with stage B (n = 22) or C (n = 17) disease showed a decline in vitality at 6 and 12 months (P < 0.05 for both). Stage D patients (n = 17) had improvements in bodily pain at 3 and 12 months (P < 0.05 for both), vitality at 12 months (P < 0.05), role-emotional at 6 months (P < 0.05), and mental health at 3 months (P < 0.05). When clinical stages were not considered, there were no significant changes in the 36-item Short-Form Health Survey. As for the disease-specific HRQOL, urinary function improved after ADT at 6 and 12 months (P < 0.05 for both), and urinary bother decreased at 3 (P < 0.05), 6 (P < 0.005) and 12 months (P < 0.05). Sexual function decreased at 3 (P < 0.05), 6 (P < 0.005) and 12 months (P < 0.005) but sexual bother improved at 6 and 12 months (P < 0.05 for both). If patients were stratified by clinical stages, similar findings were observed.

CONCLUSIONS

General HRQOL was mostly unaffected by ADT in Japanese men. Disease-specific questions indicated an increase in urinary function. Although deterioration of sexual function was marked, most patients did not report sexual bother. Our results shed new light on the impact of ADT on HRQOL and could provide useful information about patient-centered outcome evaluations.

Health-related quality of life in Dutch men with prostate cancer

Prostate cancer is the most prevalent solid malignancy in men in the Netherlands. With regard to treatment, the focus of attention has shifted in the last decade from pure survival rates to health-related quality of life. HRQOL is affected differently by different treatments. The objective of this study is to assess the HRQOL related to treatment regime and time since diagnosis in Dutch men with prostate cancer. We conducted a cross-sectional study among 238 men with prostate cancer in a heterogeneous sample who filled in a general health-related quality-of-life measure (EORTC-QLQ-C30) and a prostate cancer specific quality-of-life instrument (the EORTC-QLQ-PR25) and a Joy-of-Life questionnaire. Men on hormonal treatment are doing worse compared with other treatments with respect to physical functioning, role functioning, fatigue, pain and sexual functioning. No differences were found between radical prostatectomy and radiation therapy on any of the HRQOL dimensions nor for time since diagnosis. In hormonal therapy, men who are diagnosed longer than two years ago report a worse cognitive functioning and more burdens from urinary problems.

A prospective longitudinal study comparing the impact of external radiation therapy with radical prostatectomy on health related quality of life (HRQOL) in prostate cancer patients

BACKGROUND

The objective of the present study is to compare the impact on the general and disease-specific health related quality of life (HRQOL) of external radiation therapy (ERT) with radical prostatectomy (RP) in patients with localized prostate cancer, and to explore which factors, and to what extent, contribute to the assessed changes in HRQOL.

METHODS

One hundred and thirty eight patients participated in this prospective longitudinal study. They completed before treatment (T0) and after 12 months (T1) a questionnaire constructed of validated instruments, measuring HRQOL and several psychosocial factors (PF). Among other things, multiple regression analyses including all baseline characteristics, HRQOL and PF were executed in order to meet the objectives.

RESULTS

RP patients showed significantly more improvement in their emotional function, while they reported more incontinence and a worse sexual function. There was significantly more improvement in the overall HRQOL of ERT patients, while the changes in the gastrointestinal function of these patients were significantly worse. Only the differences with respect to incontinence can be attributed to the treatment itself. Almost all HRQOL change scores are primarily influenced by their own baseline score. The influence of other factors, like age, socioeconomic status, and several PF, is limited.

CONCLUSIONS

The impact on HRQOL of ERT is similar to that of RP, except for incontinence. RP patients suffer more from incontinence than ERT patients. Changes in the assessed HRQOL are mainly influenced by the pre-treatment HRQOL scores.

Andropause: Symptom Management for Prostate Cancer Patients Treated With Hormonal Ablation

Andropause, or the age-related decline in serum testosterone, has become a popular topic in the medical literature over the past several years. Andropause includes a constellation of symptoms related to lack of androgens, including diminished libido, decreased generalized feeling of well-being, osteoporosis, and a host of other symptoms. The andropause syndrome is very prominent in men undergoing hormonal ablation therapy for prostate cancer. Most significant in this population are the side effects of hot flashes, anemia, gynecomastia, depression, cognitive decline, sarcopenia, a decreased overall quality of life, sexual dysfunction, and osteoporosis with subsequent bone fractures. The concept of andropause in prostate cancer patients is poorly represented in the literature. In this article, we review the current literature on the symptoms, signs, and possible therapies available to men who cannot take replacement testosterone.

A randomized study comparing epirubicin in a 4-weekly versus a weekly intravenous regimen in patients with metastatic, hormone resistant, prostatic carcinoma: effects on health related quality of life

The treatment of hormone resistant prostate cancer) with epirubicin 25 mg/m(2)(Epi25) on a weekly intravenous regimen may be better in terms of health related quality of life (HRQOL) than with 100 mg/m(2)(Epi100) on a 4-weekly regimen. A total of 79 patients who filled out the EORTC-QLQ-C30 questionnaire for the assessment of HRQOL could be evaluated. Compared with the baseline, no changes in HRQOL function scales or significant changes in the following HRQOL symptom scales were found. The Epi25 group reported less pain during the first 3 months and the Epi100 group more dyspnoea after 4 weeks and less pain and less insomnia but more loss of appetite after 8 weeks. In both groups, toxicity was comparable, except for World Health Organisation grade II-III alopecia occurring in 82% in the Epi100 versus 31% in the Epi25 group. There were no significant differences between groups in response rates and survival. In this study, HRQOL was not improved which is in line with other studies using only epirubicine. Epirubicin as single agent therapy should not be used in future treatment of patients with HRPC.

Health-related quality of life and psychosocial factors in patients with prostate cancer scheduled for radical prostatectomy or external radiation therapy

OBJECTIVE

To assess whether baseline health-related quality of life (HRQOL) and psychosocial profiles differ in patients with prostate cancer scheduled for radical prostatectomy (RP) or external radiation therapy (ERT), as there is evidence that HRQOL is influenced by psychosocial factors (PFs), so that any variation at baseline should be considered when comparing the effect of therapy on HRQOL.

PATIENTS AND METHODS

Before receiving therapy, HRQOL and PFs were assessed in 65 patients scheduled for RP and in 73 scheduled for ERT. To measure HRQOL (generic and disease-specific) and PFs, an extended questionnaire was constructed, using validated and standardized instruments. Clinical data were collected from patients' medical records. Comparisons adjusted for age and socio-economic status (SES) were analysed using Student's t-test and univariate analyses of variance and covariance.

RESULTS

Patients scheduled for ERT were 7.9 years older and had a lower SES (both P < 0.001), more often had stage T3 and T4 disease, had poorer histopathological differentiation and higher levels of prostate-specific antigen (all P < 0.01). They also reported a worse physical, role, cognitive and social function, more fatigue, more pain, a lower overall HRQOL and worse sexual function than patients scheduled for RP. There were no differences in urinary and bowel function, nor in the PFs assessed.

CONCLUSION

The baseline HRQOL profile of patients scheduled for RP is better than in those scheduled for ERT. These results are in line with those from the few other studies on this subject. Knowing the impact of RP and ERT on HRQOL should therefore be based mainly on longitudinal studies including baseline measures, the analyses of which should be adjusted for age and SES. In the present small study, baseline PFs did not differ between the treatments.

The impact of androgen deprivation therapy on health related quality of life in asymptomatic men with lymph node positive prostate cancer

PURPOSE

To evaluate the impact of androgen deprivation on health related quality of life (HRQOL) in patients with asymptomatic lymph node positive prostatic carcinoma (LPPC).

MATERIALS AND METHODS

HRQOL domains were measured, using standard instruments in 91 patients with histologically proven LPPC. Most patients were randomized for immediate or deferred hormonal treatment until progression was observed. For analyses concerning the time to progression and survival the Kaplan-Meier method was used.

RESULTS

Patients treated with androgen deprivation showed a significantly worse sexual, emotional, and physical function, experienced more hot flushes and a worse overall HRQOL, compared with patients receiving no therapy. Time to progression was significantly shorter in the deferred treated patients in comparison with the immediately treated patients (33 vs. 62 months, p<0.001). No significant differences were found with respect to the duration of survival.

CONCLUSION

Hormonally treated patients with asymptomatic LPPC have a worse HRQOL compared with patients receiving no therapy. The duration of survival was similar, whether patients received immediate or deferred hormonal treatment. Nowadays, with patients' preferences playing an increasingly important role in therapeutic decision making, physicians should be aware of this negative impact and ought to inform the patients on this.

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.

Ethnic differences in quality of life among early breast and prostate cancer survivors

This study assessed quality of life (QOL) in recently diagnosed breast and prostate cancer patients of European American and Asian Pacific Islanders (specifically, individuals of Filipino, Japanese, and Native Hawaiian ancestry) to investigate whether QOL varied according to ethnicity and the relative importance of ethnicity as a predictor of QOL. Participants were identified through consecutive registrations on the Hawaii Tumor Registry, based on a diagnosis of breast or prostate cancer 4-6 months previously. QOL was measured by the QLQ-C30, a standardized questionnaire widely used in cancer patient populations. Two hundred and twenty-seven individuals participated (101 prostate and 126 breast cancer patients). QOL was similar across ethnic groups in most areas of QOL. However, differences were found in several areas, all in the direction of Filipino patients reporting worse outcomes. Hierarchical stepwise regressions supported the importance of ethnicity, controlling for clinical and demographic predictors. We conclude that additional research is needed to understand the relationship between ethnicity and QOL in cancer survivors.

Prostate cancer: natural history and surgical treatment of localised disease

In summary, there is increasing and convincing evidence that radical prostatectomy is effective in locally confined, poorly differentiated prostate cancer. Diagnostic efforts, therefore, should be targeted toward this disease and probably also, based on the natural history evidence, toward moderately differentiated disease, mainly Gleason score 7. It is unclear, at present, how this can be achieved. Further improvement of our diagnostic capabilities is urgently needed. Hopefully ongoing randomised studies comparing radical prostatectomy to surveillance and studies comparing radical prostatectomy to radiotherapy are urgently desired. The randomised screening studies, which are ongoing, will provide important information with respect to the effect of treatment. If prostate cancer mortality in those men who are randomised to screening turns out to be better than in those randomised to control, this will also be an indication of the effectiveness of treatment. Also, the screening studies and associated natural history studies based on serum repositories and follow-up in non-screened patients will provide important information with respect to the natural history of prostate cancer in relation to PSA and changes of PSA over time. Finally, quality of life with and without treatment will have to be evaluated, in a prospective manner, in multicentre settings according to validated criteria such as those presented by Litwin. The outcomes of such studies will have to be added as utilities to data relating to traditional endpoints such as cancer-specific and overall survival. In the meantime, clinical practice will be determined by the fact that the only way to cure prostate cancer is early diagnosis and aggressive management. Encouragement comes from the increasing volume of evidence showing that poorly differentiated disease can be eradicated as long as it is locally confined.

Living with treatment decisions: regrets and quality of life among men treated for metastatic prostate cancer

PURPOSE

To examine variation in men's long-term regret of treatment decisions, ie, surgical versus chemical castration, for metastatic prostate cancer and its associations with quality of life.

METHODS

Survey of previously treated patients to assess treatment decisions and quality of life, supplemented with focus groups. Two items addressing whether a patient wished he could change his mind and the belief that he would have been better off with the treatment not chosen were combined in classifying survey respondents as either satisfied or regretful. Chi(2) and t tests were used to test associations between regret and treatment history, complications, and quality of life.

RESULTS

Survey respondents included 201 men aged 45 to 93 years (median, 71 years), who had begun treatment (71% chemical castration, 29% orchiectomy) a median of 2 years previously. Most reported complications: hot flashes (70%), nausea (34%), and erectile dysfunction (81%). Most were satisfied with the treatment decision, but 23% expressed regret. Regretful men more frequently reported surgical (43%) versus chemical (36%) castration (P: = .030) and nausea in the past week (54% v 32%; P: = .010) but less frequently reported erectile dysfunction (56% v 72%; P: = .048). Regretful men indicated poorer scores on every measure of generic and prostate cancer-related quality of life. Qualitative analyses revealed substantial uncertainty about the progress of their disease and the quality of the decisions in which patients participated.

CONCLUSION

Regret was substantial and associated with treatment choice and quality of life. It may derive from underlying psychosocial distress and problematic communication with physicians when decisions are being reached and over subsequent years.