Health-related quality of life in patients with advanced prostate cancer: a multinational perspective

Virtual Surgical Guidance Improves Quality of Life Following Scapular Free-Flap Reconstruction of Maxillary Defects

BACKGROUND

The best approach to maxillary reconstruction with negative impact on the patient's quality of life (QOL) remains the subject of debate.

PURPOSE

This study was designed to evaluate the QOL outcomes following maxillary reconstruction using a scapular-free flap, with and without the computer-aided design and computer-aided manufacturing (CAD/CAM) technique.

STUDY DESIGN, SETTING, SAMPLE

A prospective randomized controlled clinical trial was performed following the CONSORT checklist. To be included, patients suffering from maxillary defects without previous surgery or lymph node involvement were selected. Patients with poor oncological prognosis, deficient performance status, preoperative chemotherapy, or radiotherapy, besides vascular contraindications, were excluded.

PREDICTOR VARIABLE

The predictor variable was the reconstruction technique, grouped into two equal categories. Patients were randomly assigned to reconstruction with a scapular-free flap, with the control group not utilizing a guide and the study group utilizing a CAD/CAM-customized guide.

MAIN OUTCOME VARIABLE

The primary outcome variable was the various domains of QOL, measured using the University of Washington Quality of Life score, 12 months after reconstruction.

COVARIATES

Age; sex; scapular flap side; and maxillary defect tumour type, histopathology, side, length, class, sagittal, and axial differential areas were considered.

ANALYSES

Shapiro-Wilk and Kolmogorov-Smirnov tests were performed for normality. For comparisons between the two groups, Student's t-test and Mann-Whitney test were used. The category variables were compared using the χ2 test. P ≤ .05 was considered statistically significant.

RESULTS

The sample was composed of twenty-two eligible patients, eleven in each group. The mean age of the control group was (50.09 ± 17.14) years, and 45.45% were male, while in the study group, the mean age was (48.36 ± 14.14) years, with 36.36% male. All the patients were evaluated, showing statistically significant differences between control and study groups in terms of pain, appearance, chewing, swallowing, speech, and shoulder (P ≤ .05), indicating that the scapular-free flap with a CAD/CAM osteotomy guide had improved the patient's QOL.

CONCLUSION AND RELEVANCE

The findings of this study indicate that virtual surgical planning with a CAD/CAM customized osteotomy guide using a scapular-free flap can improve QOL in maxillary reconstruction in terms of pain, appearance, chewing and swallowing food, pronouncing words, and shoulder QOL outcomes.

Intermittent versus continuous androgen deprivation therapy for advanced prostate cancer

Androgen deprivation therapy (ADT) is still a mainstay of treatment for advanced prostate cancer. Continuous ADT causes considerable patient morbidity including sexual dysfunction, poor mood and physical capacity, changes in body composition and health-care-related costs. Intermittent ADT has been used as an approach to ADT monotherapy to limit morbidity by enabling cyclical recovery of serum testosterone levels. To date, a number of well-performed randomized controlled trials and meta-analyses have demonstrated statistically insignificant differences in oncological outcomes between intermittent and continuous ADT monotherapy. Sexual outcomes, morbidity profiles and cost-savings favour intermittent therapy in most randomized trials, but the benefit for clinical practice is unclear. Despite the growing body of evidence, the optimal administration regime for ADT has not been clearly established and incorporation of adjunctive upfront treatments such as chemotherapy and novel anti-androgen agents has further hampered progress. Recommendations by authoritative urological and oncological societies regarding the use of intermittent ADT are limited. The potential benefits of reduced morbidity for a particular patient must be considered in light of the possible oncological outcomes. Although the oncological changes associated with intermittent ADT are controversial, intermittent ADT does seem to provide symptomatic benefit in patients compared with continuous ADT. However, careful selection of suitable patients is crucial.

Effects of Testosterone and Estradiol Deficiency on Vasomotor Symptoms in Hypogonadal Men

CONTEXT

The hormonal basis of vasomotor symptoms (VMS) in hypogonadal men is incompletely understood.

OBJECTIVE

To determine the contributions of testosterone and estradiol deficiency to VMS in hypogonadal men.

DESIGN

Two randomized trials were conducted sequentially between September 2004 and April 2011. Controls were recruited separately.

SETTING

A single-site academic medical center.

PARTICIPANTS

Healthy men ages 20-50, with normal serum testosterone levels.

INTERVENTION

Cohort 1 (n = 198, 81% completion) received goserelin acetate every 4 weeks to suppress gonadal steroids and were randomized to placebo or 1.25, 2.5, 5, or 10 g of testosterone gel daily for 16 weeks. Cohort 2 (n = 202, 78% completion) received the same regimen as cohort 1 plus anastrozole to block aromatization of testosterone. Controls (n = 37, 89% completion) received placebos for goserelin acetate and testosterone.

MAIN OUTCOME MEASURES

Incidence of visits with VMS. This was a preplanned secondary analysis.

RESULTS

VMS were reported at 26% of visits in cohort 1, and 35% of visits in cohort 2 (P = .02), demonstrating an effect of estradiol deficiency. When adjacent estradiol level groups in cohort 1 were compared, the largest difference in VMS incidence was observed between the 5-9.9 and 10-14.9 pg/mL groups (38% vs 16%, P < .001). In cohort 2, the 10-g testosterone group differed significantly from placebo (16% vs 43%, P = .048) after adjustment for small differences in estradiol levels, indicating that high testosterone levels may suppress VMS.

CONCLUSIONS

Estradiol deficiency is the key mediator of VMS in hypogonadal men. At high levels, testosterone may have a suppressive effect.

From QOL to QALYs: Comparing nononcologic outcomes in prostate cancer survivors across treatments

OBJECTIVE

We aim to highlight the progression from the early definition of nononcologic outcomes in prostate cancer (PC) to measurement and use of preferences to ensure appropriate treatment decisions in men with localized disease.

METHODS

We review the assessment of nononcologic outcomes after PC treatment and ways to use the outcomes to augment patient care.

RESULTS

PC treatments may have similar oncologic efficacy in men with certain clinical features, but they differ in their nononcologic outcomes. Tools to assess these outcomes have been developed and are useful in areas from treatment reimbursement to shared decision-making.

CONCLUSIONS

The ability to measure and make useful data on nononcologic outcomes evolved substantially over the past 20 years. Current work suggests that individual preference assessment for nononcologic outcomes is a promising means of matching patients with appropriate treatment.

Recommended patient-reported core set of symptoms to measure in prostate cancer treatment trials

The National Cancer Institute (NCI) Symptom Management and Health-Related Quality of Life Steering Committee convened four working groups to recommend core sets of patient-reported outcomes to be routinely incorporated in clinical trials. The Prostate Cancer Working Group included physicians, researchers, and a patient advocate. The group's process included 1) a systematic literature review to determine the prevalence and severity of symptoms, 2) a multistakeholder meeting sponsored by the NCI to review the evidence and build consensus, and 3) a postmeeting expert panel synthesis of findings to finalize recommendations. Five domains were recommended for localized prostate cancer: urinary incontinence, urinary obstruction and irritation, bowel-related symptoms, sexual dysfunction, and hormonal symptoms. Four domains were recommended for advanced prostate cancer: pain, fatigue, mental well-being, and physical well-being. Additional domains for consideration include decisional regret, satisfaction with care, and anxiety related to prostate cancer. These recommendations have been endorsed by the NCI for implementation.

Comparison of intermittent and continuous androgen deprivation and quality of life between patients with locally advanced and patients with metastatic prostate cancer: a post hoc analysis of the randomized FinnProstate Study VII

OBJECTIVE

The aim of the study was to compare intermittent (IAD) and continuous (CAD) androgen deprivation therapy (ADT) between locally advanced (M0) and metastatic (M1) prostate cancer, and the effect of ADT on the quality of life.

MATERIAL AND METHODS

In total, 852 men with advanced prostate cancer were enrolled to receive goserelin acetate for 24 weeks. Of these, 554 patients whose prostate-specific antigen (PSA) decreased to less than 10 ng/ml or by at least 50% (<20 ng/ml at baseline) were randomized to IAD or CAD. In the IAD arm, ADT was resumed for at least 24 weeks whenever PSA increased to greater than 20 ng/ml or above baseline.

RESULTS

Median follow-up time was 65 months. Median times from randomization to progression, death, prostate cancer death and treatment failure in M0 and M1 patients were 46.8 and 21.4, 57.6 and 40.3, 59.5 and 40.7, and 41.9 and 20.0 months, respectively (p < 0.001). No significant differences emerged between IAD and CAD. ADT showed a beneficial effect on pain, activity limitation and social functioning in M1 patients, and a deleterious effect on physical capacity in M0 patients and on sexual functioning in both groups. IAD offered extra benefit for activity limitation, social functioning and recovery of sexual functioning.

CONCLUSIONS

IAD is as efficient as CAD in treatment of locally advanced and metastatic prostate cancer. ADT improves quality of life in M1 patients, with IAD offering extra benefit.

Measuring health-related quality of life in men with prostate cancer: A systematic review of the most used questionnaires and their validity

OBJECTIVES

To identify and study the psychometric properties of the most used health-related quality-of-life (HRQoL) instruments in men with prostate cancer.

METHODS

We performed a literature search using PubMed and EMBASE to identify all studies on prostate cancer using a HRQoL instrument. The most often used HRQoL instruments were investigated in detail by 2 independent reviewers. Data were extracted regarding the characteristics and psychometric values of the instruments, i.e., content validity, internal consistency, criterion validity, construct validity, reproducibility, responsiveness, floor and ceiling effects, and interpretability. Good psychometric outcomes indicate a high methodological quality of the instrument.

RESULTS

Our systematic search revealed 13,812 potential relevant articles, of which 2,258 appeared relevant after screening the titles and reading the abstracts. We studied the psychometric properties of the 20 most often used HRQoL instruments, the first 3 of which were the Expanded Prostate Index Composite, University of California-Los Angeles Prostate Cancer Index, and Short Form-36 (SF-36). Content validity, internal consistency (α>0.70), criterion validity, construct validity, and reproducibility were good in 60%, 90%, 10%, 35%, and 65% of the 20 instruments, respectively. Responsiveness was not reported for 12 of 20 instruments (60%). Floor and ceiling effects and the interpretability of the questionnaires were only reported in 3 (15%) and 6 (30%) instruments.

CONCLUSIONS

Considering the psychometric properties, we advise to use the SF-12 as a generic instrument, the Cancer Rehabilitation Evaluation System-SF or the Functional Assessment of Cancer Therapy-General as cancer-specific HRQoL instruments, and the University of California-Los Angeles Prostate Cancer Index, the QUFW94, or the Functional Assessment of Cancer Therapy-Prostate as prostate cancer-specific instruments.

Gonadal steroids and body composition, strength, and sexual function in men

BACKGROUND

Current approaches to diagnosing testosterone deficiency do not consider the physiological consequences of various testosterone levels or whether deficiencies of testosterone, estradiol, or both account for clinical manifestations.

METHODS

We provided 198 healthy men 20 to 50 years of age with goserelin acetate (to suppress endogenous testosterone and estradiol) and randomly assigned them to receive a placebo gel or 1.25 g, 2.5 g, 5 g, or 10 g of testosterone gel daily for 16 weeks. Another 202 healthy men received goserelin acetate, placebo gel or testosterone gel, and anastrozole (to suppress the conversion of testosterone to estradiol). Changes in the percentage of body fat and in lean mass were the primary outcomes. Subcutaneous- and intraabdominal-fat areas, thigh-muscle area and strength, and sexual function were also assessed.

RESULTS

The percentage of body fat increased in groups receiving placebo or 1.25 g or 2.5 g of testosterone daily without anastrozole (mean testosterone level, 44±13 ng per deciliter, 191±78 ng per deciliter, and 337±173 ng per deciliter, respectively). Lean mass and thigh-muscle area decreased in men receiving placebo and in those receiving 1.25 g of testosterone daily without anastrozole. Leg-press strength fell only with placebo administration. In general, sexual desire declined as the testosterone dose was reduced.

CONCLUSIONS

The amount of testosterone required to maintain lean mass, fat mass, strength, and sexual function varied widely in men. Androgen deficiency accounted for decreases in lean mass, muscle size, and strength; estrogen deficiency primarily accounted for increases in body fat; and both contributed to the decline in sexual function. Our findings support changes in the approach to evaluation and management of hypogonadism in men. (Funded by the National Institutes of Health and others; ClinicalTrials.gov number, NCT00114114.).

Advanced prostate cancer treated with intermittent or continuous androgen deprivation in the randomised FinnProstate Study VII: quality of life and adverse effects

BACKGROUND

Intermittent dosing may reduce the adverse events (AEs) of androgen-deprivation therapy (ADT).

OBJECTIVE

To compare intermittent androgen deprivation (IAD) and continuous androgen deprivation (CAD) with regard to health-related quality of life (QoL).

DESIGN, SETTING, AND PARTICIPANTS

A total of 852 men with advanced prostate cancer (PCa) were enrolled to receive goserelin acetate 3.6 mg every 28 d for 24 wk. A total of 554 patients whose prostate-specific antigen (PSA) decreased to <10 ng/ml or by ≥50% (<20 ng/ml at baseline) were randomised to IAD or CAD.

INTERVENTION

In the IAD arm, ADT was resumed for at least 24 wk whenever PSA increased >20 ng/ml or above baseline.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

QoL was monitored with a validated Cleary 30-item questionnaire and analysed by the Mann-Whitney U test, 0.5 standard deviation rule, and repeated measures analysis of variance. AEs and adverse drug reactions (ADRs) were analysed by the chi-square test.

RESULTS AND LIMITATIONS

Median follow-up was 65 mo. Significant differences in QoL emerged in activity limitation, physical capacity, and sexual functioning, favouring IAD. No significant differences emerged in the prevalence of AEs: 87 patients in the IAD arm (31.8%) and 95 in the CAD arm (33.9%) had cardiovascular (CV) AEs (p=0.59), with 25 (9.1%) and 29 (10.4%) withdrawn (p=0.62), and 21 (7.7%) and 24 (8.6%) dying because of a CV event (p=0.70), respectively; bone fractures occurred in 19 (6.9%) and 15 (5.4%) patients (p=0.44), respectively. Hot flushes or night sweats were the most common ADRs (47.1% vs 50.4%; p=0.44). Erectile dysfunction (15.7% vs 7.9%; p=0.042) and depressed mood (2.2 vs 0%; p=0.032) were more common in the IAD arm.

CONCLUSIONS

IAD showed benefits in the treatment of advanced PCa with respect to QoL. The prevalence of AEs was not significantly lower with IAD.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT00293670.

General health related quality of life and associated factors among prostate cancer patients in two tertiary medical centers in Kuala Lumpur, Malaysia: a cross-sectional study

Measurement of quality of life among prostate cancer patients helps the health care providers to understand the impact of the disease in the patients' own perspective. The main aim of this study is to measure the quality of life among prostate cancer patients at University Malaya Medical Center (UMMC) and Universiti Kebangsaan Malaysia Medical Centre (UKMMC) and to ascertain the association factors for physical coefficient summary (PCS) and mental coefficient summary (MCS). A hospital based, cross sectional study using the Short Form-36 (SF-36) questionnaire was conducted over a period of 6 months. A total of 193 respondents were recruited. Their total quality of life score was 70.1± 14.7 and the PCS score was lower compared to MCS. The factors associated for PCS were: age, living partner, renal problem, urinary problem of intermittency, dysuria and hematuria. Factors associated for MCS were: age, living partner, renal problem, presenting prostatic specific antigen and urinary problem of intermittency and dysuria. Our prostate cancer patients had moderate quality of life in the physical health components but their mental health was less affected.

Comparing eccentric resistance exercise in prostate cancer survivors on and off hormone therapy: a pilot study

OBJECTIVES

To determine the feasibility of an eccentric resistance exercise training protocol in men with prostate cancer and to assess whether men with prostate cancer who are receiving androgen deprivation therapy (ADT) have a blunted effect from the training as compared with prostate cancer survivors not receiving ADT.

DESIGN

Prospective pilot study.

SETTING

Academic medical center.

PARTICIPANTS

Sixteen men with prostate cancer (Gleason scores 3+3 to 4+4) were initially enrolled. Ten men (mean age 66, range 48-86) completed the study, 5 were currently receiving ADT. Analysis was performed on these 10 men.

INTERVENTIONS

Subjects were evaluated at baseline. All men underwent a 12-week resistance exercise training protocol using a recumbent, high-force eccentric, leg cycle ergometer 3 times per week at a "somewhat hard" perceived exertion for 12 to 15 minutes. Preexercise and postexercise training changes were examined within and between groups.

MAIN OUTCOME MEASURES

Quadriceps muscle volume (magnetic resonance imaging), isometric knee extension strength, functional mobility (Timed Up and Go Test [TUG] and 6-minute walk [6MW]), health-related quality of life (FACT-P), and fatigue (FACIT-fatigue scale).

RESULTS

The ADT group demonstrated significant within-group improvements in the 6MW (P = .01) and isometric knee extension strength (P = .03). This group also demonstrated a clinically relevant change in the FACT-P; however, this did not meet statistical significance. The non-ADT group demonstrated significant within-group improvements in the physical subscale of the FACT-P (P = .03) and an increase in muscle volume (P = .04). Their improvements in the TUG approached significance (P = .08). No between-group differences existed.

CONCLUSIONS

Eccentric resistance exercise was well tolerated, and both groups derived some benefits in strength and functional mobility. Men receiving ADT did not appear to have a blunted response to the exercise as compared with prostate cancer survivors not receiving ADT.

Evaluation of health-related quality of life in patients with painful bladder syndrome/interstitial cystitis and the impact of four treatments on it

OBJECTIVE

Painful bladder syndrome/interstitial cystitis (PBS/IC) is an inflammatory bladder disease of unknown origin. Symptoms of PBS/IC compromise patients' quality of life (QoL). This study evaluated a health-related quality of life (HRQoL) questionnaire in PBS/IC.

MATERIAL AND METHODS

151 patients with PBS/IC filled in the HRQoL questionnaire before and after the treatment. Of these, 87 patients participated in a 3-month randomized study testing intravesical dimethyl sulfoxide (DMSO) and bacille Calmette-Guerin (BCG) and 64 patients took part in a 6-month randomized study evaluating oral cyclosporine A (CyA) and pentosan polysulfate sodium (PPS). The changes in HRQoL questionnaire were evaluated with respect to the changes in global response assessment (GRA).

RESULTS

The results of the HRQoL questionnaire reflected well the post-treatment GRA. Patients responding to their treatment had improved QoL. CyA treatment had more impact on emotional well-being, social functioning, activity limitation days, pain and physical capacity than PPS treatment (p<0.05). More patients responded to DMSO than BCG treatment according to GRA (p<0.01), but the results in HRQoL questionnaire were equal after DMSO and BCG treatments.

CONCLUSIONS

The HRQoL questionnaire can be used in evaluating QoL in PBS/IC patients. Treatment of PBS/IC had obvious effects on QoL.

Prostate cancer treatment and quality of life

Prostate cancer is detected today at earlier stages and in younger men than ever before. A lot of men are asymptomatic and also physically and sexually active at diagnosis, and most of them are being treated by curative procedures. These trends have led to increasing numbers of patients undergoing disease management for longer periods of time. For many patients quality of life (QoL) may be just as important as survival. Thus, QoL considerations may well be the critical factor in medical decision-making for most of them. Widespread interest in studying patient-centred outcomes has led to the development of methods for health-related QoL measurements. In fact, many questionnaires have been introduced in clinical practice to assess the impact of QoL in patients (SF-36, CARES, FACT, EORTC QLQ-C30, GRISS, UCLA PCI, PCOS). Herein we evaluate the impact of QoL on patients affected by prostate cancer and treated with watchful waiting, radical prostatectomy, radiotherapy and hormonal therapy; we have also considered the role of supportive care, including the administration of analgesics, antidepressants, corticosteroids, bisphosphonates, antiemetics and stool softeners, together with psychological support. The ultimate goal of QoL research should strongly improve medical care and concretely assist patients and physicians in treatment decision-making.

Pain assessment tools: is the content appropriate for use in palliative care?

Inadequate pain assessment prevents optimal treatment in palliative care. The content of pain assessment tools might limit their usefulness for proper pain assessment, but data on the content validity of the tools are scarce. The objective of this study was to examine the content of the existing pain assessment tools, and to evaluate the appropriateness of different dimensions and items for pain assessment in palliative care. A systematic search was performed to find pain assessment tools for patients with advanced cancer who were receiving palliative care. An ad hoc search with broader search criteria supplemented the systematic search. The items of the identified tools were allocated to appropriate dimensions. This was reviewed by an international panel of experts, who also evaluated the relevance of the different dimensions for pain assessment in palliative care. The systematic literature search generated 16 assessment tools while the ad hoc search generated 64. Ten pain dimensions containing 1,011 pain items were identified by the experts. The experts ranked intensity, temporal pattern, treatment and exacerbating/relieving factors, location, and interference with health-related quality of life as the most important dimensions. None of the assessment tools covered these dimensions satisfactorily. Most items were related to interference (231) and intensity (138). Temporal pattern (which includes breakthrough pain), ranked as the second most important dimension, was covered by 29 items only. Many tools include dimensions and items of limited relevance for patients with advanced cancer. This might reduce compliance and threaten the validity of the assessment. New tools should reflect the clinical relevance of different dimensions and be user-friendly.

The feasibility, reliability and validity of the McGill Quality of Life Questionnaire-Cardiff Short Form (MQOL-CSF) in palliative care population

In terminally-ill patients, effective measurement of health-related quality of life (HRQoL) needs to be done while imposing minimal burden. In an attempt to ensure that routine HRQoL assessment is simple but capable of eliciting adequate information, the McGill Quality of Life Questionnaire-Cardiff Short Form (MQOL-CSF: 8 items) was developed from its original version, the McGill Quality of Life Questionnaire (MQOL: 17 items). Psychometric properties of the MQOL-CSF were then tested in palliative care patients consisting of 55 out-patients, 48 hospice patients and 86 in-patients: The MQOL-CSF had little respondent burden (mean completion time = 3.3 min) and was evaluated as 'very clear' or 'clear' (98.2%), comprehensive (74.5%) and acceptable (96.4%). The internal consistency reliability was moderate to high (Cronbach's alpha = 0.462-0.858) and test-retest reliability (Spearman's r(s)) ranged from 0.512-0.861. Correlation was moderate to strong (0.478-0.725) between items in the short form and their analogous domains in the MQOL. Most MQOL-CSF items showed strong associations with their own domain (r(s) > or = 0.40). Scores from MQOL-CSF significantly differentiated between patients with differing haemoglobin levels (p < 0.05). Construct validity was overall supported by principal component analysis. It is concluded that the MQOL-CSF is a feasible tool with favourable psychometric properties for routine HRQoL assessment in the palliative care population.

Review of exercise intervention studies in cancer patients

PURPOSE

To present an overview of exercise interventions in cancer patients during and after treatment and evaluate dose-training response considering type, frequency, volume, and intensity of training along with expected physiological outcomes.

METHODS

The review is divided into studies that incorporated cardiovascular training, combination of cardiovascular, resistance, and flexibility training, and resistance training alone during and after cancer management. Criteria for inclusion were based on studies sourced from electronic and nonelectronic databases and that incorporated preintervention and postintervention assessment with statistical analysis of data.

RESULTS

Twenty-six published studies were summarized. The majority of the studies demonstrate physiological and psychological benefits. However, most of these studies suffer limitations because they are not randomized controlled trials and/or use small sample sizes. Predominantly, studies have been conducted with breast cancer patients using cardiovascular training rather than resistance exercise as the exercise modality. Recent evidence supports use of resistance exercise or "anabolic exercise" during cancer management as an exercise mode to counteract side effects of the disease and treatment.

CONCLUSION

Evidence underlines the preliminary positive physiological and psychological benefits from exercise when undertaken during or after traditional cancer treatment. As such, other cancer groups, in addition to those with breast cancer, should also be included in clinical trials to address more specifically dose-response training for this population. Contemporary resistance training designs that provide strong anabolic effects for muscle and bone may have an impact on counteracting some of the side effects of cancer management assisting patients to improve physical function and quality of life.

Questionnaires to measure sexual quality of life

CONTEXT

Sex is important to quality of life. There are a number of questionnaires to measure sexual-function, but many lack applicability and usefulness to certain groups.

OBJECTIVE

To identify questionnaires measuring sexual function, determine the domains most commonly assessed, and examine evidence for their usefulness in different populations.

DATA SOURCES

Computerized literature search using Medline, PubMed and PsychLit, reference lists, and unpublished reports, published in English between 1957 and 2001. MESH terms included sexual function, sexual dysfunction, sexual satisfaction, quality of life, and questionnaire. Articles were excluded if the questionnaire did not measure sexual function from the patient perspective.

DATA EXTRACTION

Questionnaires were grouped as general questionnaires that include a sexual function domain, and sexual-function-specific questionnaires. Questionnaires were evaluated for domains, applicability to different populations, and evidence for reliability, validity and responsiveness.

DATA SYNTHESIS

Literature search yielded 62 questionnaires, 57 which assessed sexual function from the patient perspective; 12 were general and 45 specific. Six domains were commonly represented, including interest and desire, satisfaction/quality of experience, excitement/arousal, performance, attitude/behavior, and relationship. Only 28% could be used in homosexual patients, and 52% were applicable to both genders; 57% were designed for use in chronic disease populations. Only nine questionnaires had evidence for both adequate reliability and validity.

CONCLUSIONS

Current measures of sexual functioning often exclude important domains, lack applicability to gender and sexual preference groups, or lack adequate testing of validity and testing in important populations. Future questionnaires should take into account these concerns.

Beyond the development of health-related quality-of-life (HRQOL) measures: a checklist for evaluating HRQOL outcomes in cancer clinical trials--does HRQOL evaluation in prostate cancer research inform clinical decision making?

PURPOSE

The aim of this study was to evaluate whether the inclusion of health-related quality of life (HRQOL), as a part of the trial design in a randomized controlled trial (RCT) setting, has supported clinical decision making for the planning of future medical treatments in prostate cancer.

MATERIALS AND METHODS

A minimum standard checklist for evaluating HRQOL outcomes in cancer clinical trials was devised to assess the quality of the HRQOL reporting and to classify the studies on the grounds of their robustness. It comprises 11 key HRQOL issues grouped into four broader sections: conceptual, measurement, methodology, and interpretation. Relevant studies were identified in a number of databases, including MEDLINE and the Cochrane Controlled Trials Register. Both their HRQOL and traditional clinical reported outcomes were systematically analyzed to evaluate their consistency and their relevance for supporting clinical decision making.

RESULTS

Although 54% of the identified studies did not show any differences in traditional clinical end points between treatment arms and 17% showed a difference in overall survival, 74% of the studies showed some difference in terms of HRQOL outcomes. One third of the RCTs provided a comprehensive picture of the whole treatment including HRQOL outcomes to support their conclusions.

CONCLUSION

A minimum set of criteria for assessing the reported outcomes in cancer clinical trials is necessary to make informed decisions in clinical practice. Using a checklist developed for this study, it was found that HRQOL is a valuable source of information in RCTs of treatment in metastatic prostate cancer.

Early prostate cancer: prevention, treatment modalities, and quality of life issues

Our understanding of the screening, prevention and treatment of early prostate cancer is improving. This is a result of new data from clinical trials and the incorporation of efficacy measures based on risk assessment and quality of life (QoL). This review aims to examine completed and ongoing clinical trials that address issues in early prostate cancer, including screening, prevention, treatment, and QoL. Prostate-specific antigen (PSA) testing has a crucial and evolving role in detecting primary prostate cancer, evaluating prevention interventions and assessing the effectiveness of treatment. Questions remain about the optimal PSA parameters appropriate for primary screening and for diagnosing relapse. Emerging and established data provide evidence that early intervention with hormone therapy, either as immediate or adjuvant therapy, delays progression in prostate cancer patients with intermediate or poor prognosis. The impact of therapeutic modality on QoL has become better characterized, as QoL instruments have been developed, validated and applied.

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.

Resistance exercise in men receiving androgen deprivation therapy for prostate cancer

PURPOSE

Androgen deprivation therapy is a common treatment in men with prostate cancer that may cause fatigue, functional decline, increased body fatness, and loss of lean body tissue. These physical changes can negatively affect health-related quality of life. Resistance exercise may help to counter some of these side effects by reducing fatigue, elevating mood, building muscle mass, and reducing body fat.

METHODS

In a two-site study, 155 men with prostate cancer who were scheduled to receive androgen deprivation therapy for at least 3 months after recruitment were randomly assigned to an intervention group that participated in a resistance exercise program three times per week for 12 weeks (82 men) or to a waiting list control group (73 men). The primary outcomes were fatigue and disease-specific quality of life as assessed by self-reported questionnaires after 12 weeks. Secondary outcomes were muscular fitness and body composition.

RESULTS

Men assigned to resistance exercise had less interference from fatigue on activities of daily living (P =.002) and higher quality of life (P =.001) than men in the control group. Men in the intervention group demonstrated higher levels of upper body (P =.009) and lower body (P <.001) muscular fitness than men in the control group. The 12-week resistance exercise intervention did not improve body composition as measured by changes in body weight, body mass index, waist circumference, or subcutaneous skinfolds.

CONCLUSION

Resistance exercise reduces fatigue and improves quality of life and muscular fitness in men with prostate cancer receiving androgen deprivation therapy. This form of exercise can be an important component of supportive care for these patients.

Health related quality of life in prostate carcinoma patients: a systematic review of randomized controlled trials

BACKGROUND

Health related quality of life (HRQOL) is increasingly reported as an important endpoint in cancer clinical trials. However, evidence suggests that HRQOL reporting is often inadequate. Given this, the authors undertook a systematic review to evaluate HRQOL assessment methodology and reported outcomes of randomized controlled clinical trials (RCTs) with prostate carcinoma patients.

METHODS

A comprehensive search of the literature from 1980 to 2001, mainly on the following databases, was undertaken: MedLine, Cancerlit, and the Cochrane Controlled Trials Register. Studies were identified according to a predefined coding scheme, including HRQOL measure, cultural validity, compliance data reported and the clinical significance of the results.

RESULTS

Twenty-five RCTs were identified, involving 8015 patients primarily with metastatic cancer. Bicalutamide was the medical treatment against which most treatment comparisons were made. Limitations identified included the fact that only 44% of the studies gave a rationale for selecting a specific HRQOL measure, 64% of the studies failed to report information about the administration of the HRQOL measure, and 56% failed to report compliance at baseline. The measure most often used was the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-Care 30 (EORTC QLQ-C30), although some studies used non-validated HRQOL tools.

CONCLUSIONS

The current study revealed a lack of a uniform approach to HRQOL assessment and several methodologic limitations. It is possible that such methodologic limitations have influenced trial findings for HRQOL outcomes.

Pain and health-related quality of life in a geographically defined population of men with prostate cancer

In order to provide baseline data on pain and health-related quality of life, to explore factors predicting pain and reduced quality of life, and to find potentially undertreated cases in men with prostate cancer, we undertook a population-based questionnaire study. The questionnaire, which included the EuroQo1 instrument, the Brief Pain Inventory form and 8 specially designed questions, was sent to all men with prostate cancer in the county of Ostergötland, Sweden. Of the 1442 men included in the study, 1243 responded to the questionnaire. Altogether 42% had perceived pain during the previous week and 26% stated their quality of life to be 50% or lower on a visual analogue scale. A high rating of health care availability and short time since diagnosis were found to significantly predict lower ratings of pain (P< 0.05). Pain was found to be a significant predictive factor for decreased quality of life together with high age, low rating of health care availability and palliative treatment (P< 0.05). In conclusion, assessment and treatment of pain is essential for a good quality of life in men with prostate cancer. The monitoring of prostate cancer patients should be individualized to fit the demands of the groups with the greatest need for support.

Single-therapy androgen suppression in men with advanced prostate cancer: a systematic review and meta-analysis

PURPOSE

To compare luteinizing hormone-releasing hormone (LHRH) agonists with orchiectomy or diethylstilbestrol, and to compare antiandrogens with any of these three alternatives.

DATA SOURCES

A search of the MEDLINE, Cancerlit, EMBASE, and Cochrane Library databases from 1966 to March 1998 and Current Contents to 24 August 1998 for articles comparing the outcomes of the specified treatments. The search was limited to studies on prostatic neoplasms in humans. Total yield was 1477 studies.

STUDY SELECTION

Reports of efficacy outcomes were limited to randomized, controlled trials. Twenty-four trials involving more than 6600 patients, phase II studies that reported on withdrawals from therapy (the most reliable indicator of adverse effects), and all studies reporting on quality of life were abstracted.

DATA EXTRACTION

Two independent reviewers abstracted each article by following a prospectively designed protocol. The meta-analysis combined data on 2-year overall survival by using a random-effects model and; reported results as a hazard ratio relative to orchiectomy.

DATA SYNTHESIS

Ten trials of LHRH agonists involving 1908 patients reported no significant difference in overall survival. The hazard ratio showed LHRH agonists to be essentially equivalent to orchiectomy (hazard ratio, 1.1262 [corrected] [95% CI, 0.915 to 1.386]). There was no evidence of difference in overall survival among the LHRH agonists, although CIs were wider for leuprolide (hazard ratio, 1.0994 [CI, 0.207 to 5.835]) and buserelin (hazard ratio, 1.1315 [CI, 0.533 to 2.404]) than for goserelin (hazard ratio, 1.1172 [CI, 0.898 to 1.390]). Evidence from 8 trials involving 2717 patients suggests that nonsteroidal antiandrogens were associated with lower overall survival. The CI for the hazard ratio approached statistical significance (hazard ratio, 1.2158 [CI, 0.988 to 1.496]). Treatment withdrawals were less frequent with LHRH agonists (0% to 4%) than with nonsteroidal antiandrogens (4% to 10%).

CONCLUSIONS

Survival after therapy with an LHRH agonist was equivalent to that after orchiectomy. No evidence shows a difference in effectiveness among the LHRH agonists. Survival rates may be somewhat lower if a nonsteroidal antiandrogen is used as monotherapy.

Convergent discriminitive, and predictive validity of the Prostate Cancer Specific Quality of Life Instrument (PROSQOLI) assessment and comparison with analogous scales from the EORTC QLQ-C30 and a trial-specific module. European Organisation for Research and Treatment of Cancer. Core Quality of Life Questionnaire

The Prostate Cancer Specific Quality of Life Instrument (PROSQOLI) is a measure of health-related quality of life (HRQL) that was designed to be an outcome measure for clinical trials in advanced hormone-resistant prostate cancer. The cross-sectional validity of the PROSQOLI was assessed using baseline data from a randomized trial in which HRQL was also assessed with the European Organisation for Research and Treatment of Cancer (EORTC) Core Quality of Life Questionnaire (QLQ-C30) and a trial-specific quality of life module (QLM-P14). Convergent validity was assessed with the multitrait-multimethod matrix approach; discriminative validity was assessed according to conventional clinical criteria; and predictive validity was assessed by the ability to predict survival duration. These assessments provided strong support for the validity of all PROSQOLI scales except those for family/marriage relationships and passing urine; modifications of these two scales are under evaluation. The strength, consistency, and independence of the prognostic information provided by the HRQL scales were striking. Differences between the instruments were generally subtle. These data support validity of the PROSQOLI and the analogous scales from the QLQ-C30 and QLM-P14 in symptomatic men with advanced hormone resistant prostate cancer. The PROSQOLI is a short, simple, and valid measure of HRQL in this setting.

Endocrine effects, efficacy and tolerability of a 10.8-mg depot formulation of goserelin acetate administered every 13 weeks to patients with advanced prostate cancer

OBJECTIVE

To determine the endocrine effects, efficacy and tolerability of a 10.8-mg depot formulation of Zoladextrade mark (goserelin acetate, Zeneca Pharmaceuticals, Wilmington, Delaware, USA), a luteinizing hormone-releasing hormone agonist analogue, when administration was extended from every 12 weeks to every 13 weeks in patients with advanced prostate cancer.

PATIENTS AND METHODS

Between July 1995 and May 1996, 59 patients with either locally advanced (T3 or T4) or metastatic prostate cancer were enrolled in an open-label, multicentre trial. Primary efficacy endpoints were testosterone measurements, and assessments of prostate specific antigen (PSA) response, subjective and objective response. Quality of life (QoL) was a secondary efficacy endpoint.

RESULTS

Mean testosterone concentrations decreased to < 0.3 microgram/L by week 4 and remained so for the duration of treatment. There were no statistically significant differences in mean testosterone levels between weeks 12 and 13, or weeks 25 and 26. Serum testosterone suppression was adequate in all 58 evaluable patients at week 13, and 51 of 52 (98%) patients at week 26. Of the 58 evaluable patients, 52 (90%) had a PSA response. A subjective response was recorded for six of 11 evaluable patients. Of 58 patients evaluable for objective response, 46 (79%) had a partial response, three (5%) had stable disease and nine (16%) had objective progression. Except for a significant (P=0.014) decrease in overall sexual interest, QoL was unchanged during therapy. The most common side-effects, regardless of causality, were hot flushes (67%), pain (31%) and pelvic pain (22%). Mild injection-site complaints occurred with only three of 221 (1.4%) depot injections.

CONCLUSIONS

Zoladextrade mark 10.8-mg depot, administered every 13 weeks to patients with advanced prostatic cancer, is well tolerated, provides adequate suppression of serum testosterone and produces PSA, subjective and objective responses.

Quality-of-life outcomes in long-term survivors of advanced prostate cancer

The authors evaluate the temporal progression of health-related quality of life (HRQOL) in men treated hormonally with surgical or medical castration, as well as to see if either treatment would be associated with a greater impact on patients' quality of life. The authors assessed general and prostate-targeted HRQOL with two self-administered, validated instruments (the RAND 36-Item Health Survey and the UCLA Prostate Cancer Index) in a longitudinal, observational study of 63 men newly diagnosed with metastatic prostate cancer and treated with bilateral orchiectomy or combined androgen blockade with leuprolide and flutamide. Patients completed the two HRQOL instruments by mail at baseline and at 3- and 6-month intervals after initiation of treatment. Significant improvements were demonstrated in 10 of 14 HRQOL domains for all men during the first 12 months. These include all eight of the general HRQOL domains and the disease-specific domains that address bowel function. The authors identified no differences in any of the general or prostate-targeted HRQOL domains when comparing men who underwent orchiectomy versus combined androgen blockade. Patients with metastatic prostate cancer can be informed that general and prostate-specific HRQOL will be similar, regardless of whether they choose medical or surgical castration, and that health status will likely remain stable or improve during the initial months of treatment. Physicians must make patients aware of both the quantity and quality of life they can expect with advanced prostate cancer, and must actively involve them in their treatment decisions.

The UCLA Prostate Cancer Index: development, reliability, and validity of a health-related quality of life measure

OBJECTIVES

The need for accurate measures of health-related quality of life (HRQOL) in men treated for prostate cancer is of paramount importance because patients may survive for many years after their diagnosis. Hence, interest has increased in choosing treatments that optimize both the quality and quantity of life in patients with this disease. This study sought to develop and evaluate a self-administered, multiitem, disease-specific instrument to capture the health concerns central to the quality of life of men treated for early stage prostate cancer.

METHODS

After focus group analysis and pilot testing, the instrument was tested with a large retrospective, cross-sectional survey. Exploratory factor analysis and multitrait scaling analysis were used to facilitate the formation of six scales containing 20 disease-targeted items that address impairment in the urinary, bowel, and sexual domains. The psychometric properties of the new scales were assessed by measuring test-retest reliability, internal consistency reliability, and construct validity. Performance on the new scales was compared with scores on other established cancer-related health-related quality of life instruments. Two hundred fifty-five long-term survivors of prostate cancer treatment and 273 age-matched and ZIP code-matched comparison subjects without prostate cancer from a large managed care population in California were studied. Mean age was 72.7 years. In addition to the new scales, the RAND 36-Item Health Survey (SF-36) was used as a generic core measure, and a cancer-related health-related quality of life instrument (the Cancer Rehabilitation System-Short Form) was used to provide construct validity.

RESULTS

For the new scales, test-retest reliability ranged from 0.66 to 0.93, and internal consistency ranged from 0.65 to 0.93. Disease-targeted measures of function and bother in the three domains correlated substantially with one another. Scale scores correlated well with related, established scales. Men undergoing prostatectomy or pelvic irradiation demonstrated the expected differences in performance on the disease-specific health-related quality of life scales when compared with each other or with comparison subjects. Age was inversely related to sexual and bowel function.

CONCLUSIONS

The UCLA Prostate Cancer Index performed well in this population of older men with and without prostate cancer. It demonstrated good psychometric properties and appeared to be well understood and easily completed. The high response among patients suggests that these men especially are interested in addressing both the general and disease-specific concerns that impact their daily quality of life.

Bicalutamide in advanced prostate cancer. A review

Bicalutamide is a nonsteroidal antiandrogen with a long elimination half-life (t1/2) that permits once-daily administration. When combined with a gonadorelin (gonadotrophin releasing hormone; GnRH) agonist in maximum androgen blockade (MAB) regimens, bicalutamide 50 mg once daily is at least as effective as flutamide 250 mg 3 times daily, as shown in a large randomised trial. Rate of treatment failure, the primary end-point, was significantly lower at 49 weeks with bicalutamide in this study, mainly because of a lower rate of withdrawal due to adverse events. Final results at a median follow-up of 160 weeks revealed longer median times to progression and death with bicalutamide than flutamide, but between-group differences were not significant overall. Although early trials demonstrated clinical benefits with bicalutamide 50 mg/day as monotherapy, the drug in this dosage is less effective than castration. Increasing the dosage to 150 mg/day has improved its efficacy in patients with non-metastatic disease: combined data from 2 trials demonstrate similar survival with bicalutamide in this dosage compared with castration. Accumulating evidence from these and other studies indicates that sexual interest appears to be better preserved with bicalutamide than with castration. The tolerability profile of bicalutamide is characteristic of antiandrogens, with breast pain and gynaecomastia occurring most often. Bicalutamide has not been causally associated with problems such as interstitial pneumonitis and difficulty with light/dark adaptation seen with nilutamide, and in a 50 mg/day dosage causes a lower incidence of diarrhoea than flutamide 750 mg/day. Changes in hepatic function are generally transient and resolve or improve during therapy or after bicalutamide treatment is withdrawn.

CONCLUSIONS

Bicalutamide, with its once-daily regimen and good tolerability, is an attractive option when combined with a GnRH agonist in patients with advanced prostate cancer who are suitable to receive MAB regimens. The role of bicalutamide as monotherapy in the management of this common malignancy is currently being assessed.

Impact of epilepsy on QOL in a Portuguese population: exploratory study

OBJECTIVES

To develop an outcome measure of QOL (quality of life) for the Portuguese population; describe QOL in epileptics; analyse how QOL is affected by epilepsy and analyse how QOL is affected by patients' characteristics.

PATIENTS AND METHODS

Study of a consecutive sample of 92 epileptics from an outpatient clinic, men and women, aged 15-65, having the basic education level. Firm diagnosis of epilepsy (with or without seizures) without other illness. A questionnaire based on ESI-55 and Health Insurance Experiment Short-Forms was used. Principal component analysis (orthogonal varimax) showed a solution explaining 55.6 of total variance. After the inspection, the 33 items were grouped into 5 sub-scales (dimensions).

RESULTS

Results showed that QOL was poor for people with partial seizures. The best scores were found on patients now free from seizures.

CONCLUSION

The QOL measure is sensitive to cultural differences, demographic and disease variables which could explain the results found.

Casodex (bicalutamide) 150-mg monotherapy compared with castration in patients with previously untreated nonmetastatic prostate cancer: results from two multicenter randomized trials at a median follow-up of 4 years

OBJECTIVES

To compare the efficacy, tolerability, and quality of life benefits of bicalutamide (Casodex) 150-mg/day monotherapy and castration in previously untreated nonmetastatic (M0) advanced prostate cancer.

METHODS

A total of 480 patients with Stage T3/T4 nonmetastatic disease randomly received oral bicalutamide 150 mg/day or castration (either bilateral orchiectomy or goserelin acetate [Zoladex] 3.6 mg every 28 days) in a 2:1 ratio in two open multicenter studies (studies 306 and 307). The design of these studies was similar to allow a pooled analysis.

RESULTS

In the combined survival analysis, at median follow-up of 202 and 205 weeks in studies 306 and 307, respectively, with 31% of the cases resulting in death, bicalutamide 150-mg monotherapy was statistically equivalent to castration; the risk of death from any cause was 7% less with bicalutamide than with castration (hazard ratio [HR] = 0.93). Data on time to treatment failure and objective progression could not be pooled, as results for these end points differed between the trials. In study 306, bicalutamide 150-mg monotherapy increased time to objective progression (HR = 0.58; P = 0.033) and treatment failure (HR = 0.66; P = 0.074), whereas in study 307, time to progression (HR = 1.35; P = 0.0471) and treatment failure (HR = 1.24; P = 0.097) favored castration. Bicalutamide therapy showed significant advantages over castration for both sexual interest (P = 0.029) and physical capacity (P = 0.046). Bicalutamide 150-mg monotherapy was well tolerated.

CONCLUSIONS

Bicalutamide 150-mg monotherapy provides a similar survival outcome to castration in previously untreated patients with nonmetastatic advanced prostate cancer and confers statistically significant benefits over castration with respect to sexual interest and physical capacity.

Measuring quality of life in men with prostate cancer using the functional assessment of cancer therapy-prostate instrument

OBJECTIVES

As the incidence of prostate cancer in the United States exceeds 330,000 in 1997, increasingly more men are faced with treatment choices for which there is no clear approach. At every stage of disease, these treatment choices may involve clinically equivalent modalities that differ in side effects and impact upon quality of life (QOL). Comprehensive, yet efficient, questionnaires are needed to measure QOL in patients with prostate cancer.

METHODS

Developed as a disease-specific adjunct to the Functional Assessment of Cancer Therapy (FACT) measurement system, a 12-item prostate cancer subscale (PCS) was developed and tested in three independent samples: a subscale development sample (n = 43), validity sample 1 (n = 34), and validity sample 2 (n = 96). The 12 items ask about symptoms and problems specific to prostate cancer. These questions are added to the general (FACT-G) instrument, thereby comprising a 47-item questionnaire.

RESULTS

Internal consistency of the PCS ranged from 0.65 to 0.69, with coefficients for FACT-G subscales and aggregated scores ranging from 0.61 to 0.90. Concurrent validity was confirmed by the ability to discriminate patients by disease stage, performance status, and baseline prostate-specific antigen (PSA) level. Sensitivity to change in performance status and PSA score over a 2-month period suggested that some subscales of the FACT-Prostate (P) (including the PCS) are sensitive to meaningful clinical change.

CONCLUSIONS

Our findings support use of the FACT-P as a meaningful component of QOL evaluation in men undergoing therapy for prostate cancer.

Single-agent therapy with bicalutamide: a comparison with medical or surgical castration in the treatment of advanced prostate carcinoma

OBJECTIVES

Single-agent therapy with bicalutamide, a nonsteroidal antiandrogen, was compared with castration, either surgical or medical, in patients with untreated Stage D2 prostate cancer.

METHODS

In an open, randomized, multicenter trial, patients were randomized to treatment with 50 mg bicalutamide (n = 243) once daily or to castration (n = 243), either orchiectomy or depot injection of goserelin acetate every 28 days. Primary efficacy endpoints were times to treatment failure and objective disease progression and survival. Assessments included review of measurable metastases, prostate dimensions, Eastern Cooperative Oncology Group performance status, pain, analgesic requirements, and quality of life responses.

RESULTS

The median duration of therapy was 39 weeks for bicalutamide-treated patients and 42 weeks for castrated patients; treatment failure occurred in 53% and 42% and disease progression in 43% and 33%, respectively. Treatment effects favored castration for both endpoints (P < or = 0.002), with hazard ratios (bicalutamide:castration) of 1.54 (95% confidence interval [CI], 1.18 to 2.00) for time to treatment failure and 1.6 (95% CI, 1.19 to 2.15) for time to disease progression. From the 1-year survival analysis, the hazard ratio for probability of death was 1.29 (95% CI, 0.96 to 1.72). Thus far, with a median follow-up of 86 weeks, median survival has not been reached in either group. Changes from baseline in several quality of life variables were significantly different (P < or = 0.01) between treatment groups periodically from months 1 to 6, and all favored bicalutamide. Overall, the antiandrogen was well tolerated compared with castration; with bicalutamide, hot flushes occurred less often and breast tenderness and gynecomastia more often.

CONCLUSIONS

Although a dosage of 50 mg of bicalutamide once daily was not as effective as castration, the favorable quality of life outcomes and the low incidence of nonhormonal adverse events provide reasons to evaluate bicalutamide, as a single therapeutic agent, at higher doses.