Urinary incontinence following external-beam radiotherapy for clinically localized prostate cancer

Current Trends in Incidence and Management of T1a and T1b Prostate Cancer

Prostate cancer (PCa) identified incidentally (iPCa) after surgical treatment for symptomatic benign prostatic hyperplasia (BPH) causing lower urinary tract symptoms (LUTS) is considered low risk by the most current guidelines. Management protocols for iPCa are conservative and are identical to other prostate cancers classified as having favorable prognoses. The objectives of this paper are to discuss the incidence of iPCa stratified by BPH procedure, to highlight predictors of cancer progression, and to propose potential modifications to mainstream guidelines for the optimal management of iPCa. The correlation between the rate of iPCa detection and the method of BPH surgery is not clearly defined. Old age, small prostate volume, and high pre-operative prostate-specific antigen (PSA) are associated with an increased likelihood of detecting iPCa. PSA and tumor grade are strong predictors of cancer progression and can be used along with magnetic resonance imaging (MRI) and potential confirmatory biopsies to determine disease management. In instances that iPCa requires treatment, radical prostatectomy (RP), radiation therapy, and androgen deprivation therapy all have oncologic benefits but may be associated with increased risk after the BPH surgery. It is advised that patients with low to favorable intermediate-risk prostate cancer undergo post-operative PSA measurement and prostate MRI imaging before electing to choose between observation, surveillance without confirmatory biopsy, immediate confirmatory biopsy, or active treatment. Subdividing the binary T1a/b cancer staging into more categories with ranging percentages of malignant tissue would be a helpful first step in tailoring the management of iPCa.

Relationships between holmium laser enucleation of the prostate and prostate cancer

Holmium laser enucleation of the prostate (HoLEP) is a size-independent surgical option for treating benign prostatic hyperplasia (BPH) and lower urinary tract symptoms (LUTS) with excellent, durable functional outcomes. The prevalence of LUTS secondary to BPH and prostate cancer both increase with age, although the two diseases develop independently. Urologists often face a diagnostic dilemma, as men with LUTS secondary to BPH might also present with an elevated PSA and, therefore, need a diagnostic work-up to exclude prostate cancer. Nevertheless, ~15% of men with a negative elevated PSA work-up will undergo HoLEP and will be diagnosed with incidental prostate cancer at the time of HoLEP. Indeed, prostate cancer is often found in men undergoing HoLEP, and this situation can be challenging to manage. Variables associated with the detection of incidental prostate cancer, strategies to reduce incidental prostate cancer, as well as the natural history and management of this condition have been extensively studied, but further work in this area is still needed.

Management of men with lower urinary tract symptoms referred for prostate radiotherapy

Objective:

To report on the experience of the management of lower urinary tract symptoms (LUTS) in men referred for prostate radiotherapy (RT) in a large tertiary referral centre.

Methods:

Between February and November 2018, 156 men referred for radiotherapy were seen and assessed according to their LUTS history: International Prostate Symptom Score (IPSS), flow rate (FR) and post-void residual (PVR). Patients with LUTS were offered management options depending on severity including lifestyle advice, oral medication or surgery. A subset of patients ( n = 102) were reassessed post-RT, and univariate and multivariate logistic regression was performed to predict symptoms improvement.

Results:

Prior to referral for RT and assessment at our dedicated LUTS clinic, 65% of men had a documented history of LUTS, 14% had completed an IPSS questionnaire and only 13% had a urinary FR; 17% (27/156) had prior treatment in the form of medication or surgery. In our assessment, 77/156 (49%) had mild, 66/156 (42%) moderate and 13/156 (8%) severe LUTS determined by IPSS. Out of 156, 71 (46%) had a quality-of-life score >3. Of the men, 81% were offered lifestyle advice, 47 patients were started on alpha blockers and 20 (12.8%) went onto Transurethral Resection of the Prostate prior to RT; 6 weeks following RT, 61 (50%) patients had higher IPSS scores. Patients who were started on alpha blockers ( p = 0.022) or had TURP ( p = 0.015) were less likely to have an increase in IPSS score on multivariate analysis.

Conclusion:

Men undergoing RT for prostate cancer often have co-existing LUTS. Consideration and evaluation of their LUTS and offer of treatment either medication or surgery could improve urinary symptoms in men undergoing prostate radiotherapy in the short term. Longer term data are still needed to understand the full long-term impact on patient’s symptoms and quality of life. We recommend that patients have formal LUTS assessment pre-RT.

Level of evidence:

Not applicable.

Toxicity and outcomes after external beam irradiation for prostate cancer in patients with prior holmium laser enucleation of the prostate: Early experience

PURPOSE/OBJECTIVES

Holmium laser enucleation of the prostate (HoLEP) is commonly performed in patients with significant bladder outlet obstruction. However, there are few reports on the toxicity of external beam irradiation (RT) for prostate cancer in patients after prior HoLEP. In this study, we evaluate the side effects and treatment outcomes of RT after HoLEP.

MATERIALS/METHODS

Eighteen patients who had HoLEP and subsequently received RT for prostate cancer were included. Data collected included patient and disease characteristics, urinary function, and radiation dose. Acute and late urinary (GU) and gastrointestinal (GI) side effects were evaluated. Disease control and survival rates were calculated using Kaplan-Meier method.

RESULTS

Median follow-up was 18 months (range: 4-46 months). Median prostate volume was 107 ml before HoLEP and 24 ml after HoLEP. Median International Prostate Symptom Score (IPSS) was 17 (range: 5-32) before HoLEP. Median decline in IPSS score after HoLEP was 7 (range: -2-21). On uroflow study, peak flow rate, and post-void residual were significantly improved after HoLEP. After radiation, peak flow rate and average flow rate showed a decline but remained significantly improved compared to pre-HoLEP measurements. Maximum acute Common Terminology Criteria for Adverse Events (CTCAE) adverse events were 12 grade 1 and 3 grade 2 for GU, and 3 grade 1 for GI, respectively. Maximum late adverse events were 13 grade 1 and 2 grade 2 for GU, and all grade 0 for GI, respectively. At last follow-up, there were 8 grade 1 and 1 grade 2 late GU, and 3 grade 1 late GI adverse events, respectively. There was no significant increase in urinary incontinence after RT compared to before RT. The 18-month biochemical control, local control, distant control rates were 78%, 94%, and 80%, respectively.

CONCLUSIONS

Patients who received RT as definitive treatment for prostate cancer after prior HoLEP had low risk of serious acute and late side effects. HoLEP can be safely performed and should be considered in patients with significant bladder outlet obstruction and large prostate volume before RT.

The Management of Patients Diagnosed with Incidental Prostate Cancer: Narrative Review

5–14% of patients underwent surgery for benign prostate hyperplasia harboring prostate cancer (PCa) focus. The best management of incidental prostate cancer (iPCa) has been debated. The decision “treatment or no treatment” should be determined by predictors which accurately foretell PCa progression after transurethral resection of the prostate (TURP). The purpose of this study is to review the available data that can be useful in daily clinical judgment. Transrectal ultrasound prostate biopsy (TRUSBx) did not provide further Gleason score (GS) data in most patients diagnosed with iPCa. TRUSBX may be useful before active surveillance, but not in all following radical prostatectomy. The decision “treatment or no treatment” should be dependent on the expected chance of having residual cancer and clinical progression. Prostate-specific antigen (PSA) levels before and after TURP are good predictors of residual cancer after TURP. Pathological report of T0 is most likely seen in patients with low PSA density after TURP and indistinguishable lesion on multiparametric magnetic resonance imaging. The decision “treatment vs no treatment” is judged by life expectancy, tumor characteristic in the pathology report of TURP sample and PSA level following TURP. Active surveillance should be contemplated in patients with iPCa who have both prostate-specific antigen density ≤0.08 after TURP and indistinguishable cancer lesion on multiparametric magnetic resonance imaging. Patients who do not meet the criteria for active surveillance are candidates for radical prostatectomy or radiotherapy (RT). Radical prostatectomy could be peacefully done after TURP with somewhat greater morbidity. RT in patients who had a history of TURP could be safely done and is associated with acceptable quality of life.

Urinary function and quality of life after radiotherapy for prostate cancer in patients with prior history of surgical treatment for benign prostatic hyperplasia

BACKGROUND

To evaluate long-term IPSS score and urinary quality of life after radiotherapy for prostate cancer, in patients with prior history of surgical treatment for benign prostatic hyperplasia (BPH).

METHODS

In this retrospective study, we reviewed medical records of patients treated in our department, between 2007 and 2013 with surgery for BPH followed by radiotherapy for localized prostate cancer. Patients were contacted to fill in IPSS questionnaire and they were also asked for urinary quality of life. Predictive factors known to be associated with bad urinary function were also analysed.

RESULTS

Fifty-nine patients were included in our study. Median age was 70 years. Median follow-up was 4.6 years. Median radiotherapy dose was 78 Gy (5 × 2 Gy/week). Thirty patients (48.5%) received hormone therapy in combination with RT. Main surgery indications were urinary symptoms (65%) and urinary retention (20%). Five-year biochemical-disease free survival was 75% and 5-year clinical relapse free survival was 84%. At the time of the study, the IPSS after radiotherapy was as follows: 0-7: 77.6%; 8-19:20.7%; 20-35: 1.7%. Urinary quality of life was satisfactory for 74.2% of patients. After multivariate analysis, a high dose of RT and a medical history of hypertension were associated with a poorer quality of urinary life (p = 0.04).

CONCLUSION

External radiotherapy remains an appropriate treatment option without a major risk for deterioration in urinary function in patient with antecedent surgery for BPH. High dose of RT and a medical history of hypertension were associated with a poorer quality of urinary life.

Complications after artificial urinary sphincter implantation in patients with or without prior radiotherapy

OBJECTIVE

To compare complications after implantation of an artificial urinary sphincter (AUS) in patients with or without prior radiotherapy (RT).

PATIENTS AND METHODS

Between January 2000 and December 2011, 160 patients underwent AMS 800 AUS implantation in our institution. We excluded neurological and traumatic causes, implantation on ileal conduit diversion, penoscrotal urethral cuff position and those lost to follow-up. In all, 122 patients were included in the study, 61 with prior RT and 61 without prior RT. All patients underwent the same surgical technique by two different surgeons. All AUS were implanted with a bulbar urethral cuff position. The mean (range) follow-up was 37.25 (1-126) months.

RESULTS

In the patients without prior RT and those with prior RT, revision rates were 32.8% vs 29.5%, respectively (P = 0.59). The median time to first revision was 11.7 months. Early complications were similar in the two groups (4.9% vs 6.5%, P = 1). Erosion rates were not significantly different (4.9% vs 13.1%, P = 0.13). However, infection and explantation were more prevalent in patients with prior RT [two (3.2%) vs 10 (16.3%), P = 0.018 and three (4.9%) vs 12 (19.6%), P = 0.016, respectively]. Finally, continence rates were not significantly different [75.4% (without prior RT) vs 63.9% (with prior RT), P = 0.23].

CONCLUSION

AUS is the 'gold standard' treatment of male urinary incontinence after re-education failure in patients with or without prior RT. Our experience showed similar functional outcomes in both groups but a higher rate of major complications in the group with prior RT.

Contemporary issues in radiotherapy for clinically localized prostate cancer

Radiotherapy is a valid curative alternative to surgery for prostate cancer. However, patient selection is critical to ensure patients obtain benefits from therapy delivered with curative intent. Dose-escalated radiation has been shown to improve patient outcomes, facilitated by development of robust image guidance and better target delineation imaging technologies. These concepts have also rekindled interest in hypofractionated radiotherapy in the forms of stereotactic body radiotherapy and brachytherapy. Postprostatectomy radiotherapy also improves long-term biochemical outcome in men at high risk of local recurrence.

A report on major complications and biochemical recurrence after primary and salvage cryosurgery for prostate cancer in patients with prior resection for benign prostatic hyperplasia: a single-center experience

OBJECTIVE

To report on biochemical recurrence (BCR) and major complications in patients with prior prostate resection that underwent cryosurgery (CS) for prostate cancer.

METHODS

The Columbia University Urologic Oncology database identified patients that underwent CS after resection. Patient demographics, surgical details, prostate volume, prostate-specific antigen (PSA) levels, biopsy results, major complications, and BCR were recorded.

RESULTS

Prior resection for benign prostatic hyperplasia was identified in 32 patients who underwent CS. Median age was 70.7 years (range 54.9-83.1 years). Median prostate volume before and after resection was 40 (range 30-90) and 20 cm(3) (range 9-54), respectively. Median time from resection to CS was 50.4 months (range 0-178.1 months). Twenty-one (16 full and 5 focal gland ablations) and 11 patients underwent primary and salvage CS, respectively. Median prostate-specific antigen at CS was 5.9 ng/mL (range 0.1-18.4 ng/mL), with a median nadir post-CS of 0.1 ng/mL (range 0.04-12.2 ng/mL). Median follow-up was 41.2 months (range 8.9-154.2 months). According to Stuttgart and Phoenix definitions, 11 and 10 patients, respectively, experienced BCR. Three patients underwent further CS for disease recurrence. Overall complications were rare and minor. Patients with smaller glands postresection (<20 cc(3)) experienced a similar incidence of BCR as those with larger glands after CS in all the settings.

CONCLUSION

Although no patients experienced major complications after primary CS, 18% (2/11) had grade III or higher complications in the salvage setting. Postresection gland volume was not associated with BCR. Further research is needed to evaluate functional and oncological outcomes in postresection patients after CS because they are considered high-risk for major complications.

Late toxicity after conformal and intensity-modulated radiation therapy for prostate cancer: impact of previous surgery for benign prostatic hyperplasia

OBJECTIVES

To retrospectively compare late toxicity of conventional-dose three-dimensional conformal radiation therapy (3D-CRT) and high-dose intensity-modulated radiation therapy (IMRT) for prostate cancer.

METHODS

A total of 340 patients with T1-3 prostate cancer were treated with 3D-CRT (n = 228) and IMRT (n = 112). The median follow-up time was 5.9 years and 3.0 years, respectively. The prescription dose was 70 Gy for 3D-CRT and 78 Gy for IMRT. Late gastrointestinal (GI) and genitourinary (GU) toxicities were graded according to the Fox Chase modification of the Radiation Therapy Oncology Group and Late Effects Normal Tissue Task Force criteria.

RESULTS

There was no difference between 3D-CRT and IMRT in the incidence of GI and GU toxicity at 3 years. On multivariate analysis, transurethral resection of prostate/open transvesical prostatectomy (TURP/TVPE) for benign prostatic hyperplasia, carried out before radiotherapy, significantly increased the risk of Grade >or=2 GU toxicity (risk ratio 1.88). Among patients who experienced TURP/TVPE, the 5-year actuarial likelihood of Grade 2-3 urinary incontinence was 23%, compared with 9% for those without prostate surgery (P = 0.01).

CONCLUSIONS

Tolerance of 3D-CRT and IMRT was similar, despite the use of high radiation dose with IMRT. Previous TURP/TVPE increased the risk of GU toxicity.

Patterns of toxicity following high-dose-rate brachytherapy boost for prostate cancer: mature prospective phase I/II study results

BACKGROUND

To examine the long-term morbidity of high dose rate brachytherapy boost (HDRBB) in prostate cancer.

PATIENTS AND METHODS

A phase I/II HDRBB dose escalation protocol recruited 108 men up to November 1999. Treatment combined 46 Gy external beam radiation to the prostate with four fractions of HDR totalling 16 or 20 Gy. Morbidity data were collected prospectively regarding urological, bowel and erectile dysfunction (ED) symptoms using a validated clinician completed instrument. Actuarial incidence and prevalence of symptoms were estimated; the latter to account for potential recovery.

RESULTS

The median follow-up was 78 months, with 880 questionnaires completed. The respective actuarial cumulative incidence and point prevalence rates of any grade 2 or higher symptom score at 5 years were 24.9% (95% confidence intervals [CI] 16.8-33.5%) and 7.7% (95% CI 1.8-14.5%) for urinary toxicity; and 11.3% (95% CI 5.6-17.1%) and 3.0% (0-7.6%) for rectal toxicity, meaning that most symptom sub-domains showed substantial recovery with time. Corresponding erectile function toxicity figures for the subgroup of men (n=53) with normal erectile function prior to treatment and no androgen deprivation therapy were 77.0% (95% CI 64.9-88.1%) and 45.3% (95% CI 27.2-64.6%). Some late toxicity profiles developed after twelve months, typically with low grade bowel and urinary urgency. These peaked at 12-24 months and stayed relatively stable subsequently. Paradoxically, grade 1 or more nocturia symptoms settle with time, despite the accumulation of grade 2 or more toxicity beyond 24 months.

CONCLUSIONS

HDRBB as a means of dose escalation in prostate cancer is associated with low and relatively stable rates of long-term bowel and urinary morbidity, and compares favourably with external beam results. Actuarial incidence methods overstate the burden of toxicity with substantial recovery noted in most domains.

Risk factors of late rectal bleeding after carbon ion therapy for prostate cancer

PURPOSE

The aim of this study was to determine the risk factors for late gastrointestinal (GI) morbidity after hypofractionated carbon ion radiotherapy (C-ion RT) for prostate cancer.

METHODS AND MATERIALS

Between April 2000 and November 2003, a Phase II clinical trial of C-ion RT with a total dose of 66 GyE in 20 fractions was performed on 175 patients with prostate cancer, and the correlations of clinical and dosimetric parameters with the incidence of late GI toxicity in 172 patients who survived for more than 18 months were investigated.

RESULTS

Although no Grade 3-4 late morbidities of the rectum were observed, Grade 1 and 2 morbidities developed in 23 (13%) and 4 (2%) patients, respectively. Dose-volume histogram analysis revealed that the percentage of rectal volume receiving 50% of the prescribed dose (V50) was significantly higher in patients with rectal toxicity than without toxicity (13.2 +/- 5.6% with toxicity; 11.4 +/- 4.0% without toxicity, p = 0.046). Multivariate analysis demonstrated that the use of anticoagulation therapy (p = 0.010) and rectal V50 (p = 0.012) were significant risk factors for the occurrence of Grade 1-2 late GI toxicity.

CONCLUSIONS

Although C-ion RT with hypofractionation yielded favorable results regarding late GI complication, dosimetric parameter was a very important factor in the occurrence of rectal bleeding after C-ion RT as well as photon beam RT. Our results provide useful information for physicians applying charged particle RT in the treatment of prostate cancer.

Estimating the risk of long-term erectile, urinary and bowel symptoms resulting from prostate cancer treatment

Reports on long-term complications resulting from treatment for localized prostate cancer are very inconsistent. In order to estimate the risks of long-term erectile dysfunction, urine symptoms and bowel symptoms following prostatectomy (RP), external conventional or conformal beam radiation (ERT or CRT) and brachytherapy (BRT), 98 papers from the PubMed and Cochrane Clinical Trial databases were selected, reviewed and critically evaluated. The majority of papers were institution-based retrospective and prospective follow-up studies; only two of these studies measured the risk of developing more than one treatment complication. Due to differences in study designs and populations, it is difficult to directly compare studies and not meaningful to calculate summary estimates. In addition to focusing on randomized clinical trials and well-designed population based studies, future research should adopt standardized methodologies and should measure the risk of developing more than one treatment complication.

Functional anatomy of the prostate: implications for treatment planning

PURPOSE

To summarize the functional anatomy relevant to prostate cancer treatment planning.

METHODS AND MATERIALS

Coronal, axial, and sagittal T2 magnetic resonance imaging (MRI) and MRI angiography were fused by mutual information and registered with computed tomography (CT) scan data sets to improve definition of zonal anatomy of the prostate and critical adjacent structures.

RESULTS

The three major prostate zones (inner, outer, and anterior fibromuscular) are visible by T2 MRI imaging. The bladder, bladder neck, and internal (preprostatic) sphincter are a continuous muscular structure and clear definition of the preprostatic sphincter is difficult by MRI. Transition zone hypertrophy may efface the bladder neck and internal sphincter. The external "lower" sphincter is clearly visible by T2 MRI with wide variations in length. The critical erectile structures are the internal pudendal artery (defined by MRI angiogram or T2 MRI), corpus cavernosum, and neurovascular bundle. The neurovascular bundle is visible along the posterior lateral surface of the prostate on CT and MRI, but its terminal branches (cavernosal nerves) are not visible and must be defined by their relationship to the urethra within the genitourinary diaphragm. Visualization of the ejaculatory ducts within the prostate is possible on sagittal MRI. The anatomy of the prostate-rectum interface is clarified by MRI, as is the potentially important distinction of rectal muscle and rectal mucosa.

CONCLUSION

Improved understanding of functional anatomy and imaging of the prostate and critical adjacent structures will improve prostate radiation therapy by improvement of dose and toxicity correlation, limitation of dose to critical structures, and potential improvement in post therapy quality of life.

External beam radiotherapy as curative treatment of prostate cancer

External beam radiotherapy (RT) has been used as a curative treatment of prostate cancer for more than 5 decades, with the "modern" era emerging more than 3 decades ago. Its history is marked by gradual improvements punctuated by several quantum leaps that are increasingly driven by advancements in the computer and imaging sciences and by its integration with complementary forms of treatment. Consequently, the contemporary use of external beam RT barely resembles its earliest form, and this must be appreciated in the context of current patient care. The influence of predictive factors on the use and outcomes of external beam RT is presented, as is a selected review of the methods and outcomes of external beam RT as a single therapeutic intervention, in association with androgen suppression, or as a postoperative adjunct. Thus, the "state of the (radiotherapeutic) art" is presented to enhance the understanding of this treatment approach with the hope that this information will serve as a useful resource to physicians as they care for patients with prostate cancer.

Urinary incontinence in prostate cancer patients treated with external beam radiotherapy

BACKGROUND AND PURPOSE

To describe the incidence of urinary incontinence among prostate cancer patients treated with external beam radiotherapy (RT) and to investigate associated risk factors.

PATIENTS AND METHODS

One thousand and hundred ninety-two patients with >or=24 months follow-up were the subjects of this series. All patients received between 50 and 72 Gy in 20-37 fractions (median 66 Gy/33#). Post-RT urinary incontinence was scored by direct patient interviewing according to the modified RTOG/SOMA scale: Grade 1--occasional use of incontinence pads, Grade 2--intermittent use of incontinence pads, Grade 3--persistent use of incontinence pads, and Grade 4--permanent catheter. Risk-factors investigated were: age, diabetes, TURP prior to RT, elapsed time from TURP to RT, clinical stage, RT dose and presence of Grade >or=2 acute GU and GI toxicity. Non-parametric, actuarial univariated (Kaplan-Meier) and multivariated tests (MVA, Cox regression) were performed.

RESULTS

Median follow-up for the group is 52 months (24-109). Thirty-four patients (2.9%) had incontinence prior to RT, which was more common in TURP patients (7.8% vs 1.6% P<0.001). These are excluded from further analysis. Fifty-seven patients (4.9%) developed Grade 1 incontinence, 7 (0.6%) Grade 2, and 7 (0.6%) Grade 3. There was no Grade 4 incontinence. Actuarial rates for Grade >or=1 and >or=2 incontinence at 5 years are 7 and 1.7%, respectively. Risk factors on MVA associated with the development of Grade 1 or worse incontinence are pre-RT TURP (5-year rates 10% vs 6%, P=0.026), presence of Grade >or=2 acute GU toxicity (5-year rates 11% vs 5%, P=0.002). Age, diabetes, clinical stage, elapsed time from TURP to RT, RT dose or fraction size, acute GI toxicity were not significant. Patients who underwent post-RT TURP or dilatation for obstructive symptoms (4.3%), were more likely to develop Grade 2-3 incontinence (5-year rate 8 vs 1.5%, P=0.0015).

CONCLUSIONS

Grade 2 or greater urinary incontinence is rare among patients who have been treated with external beam radiotherapy. Associated risk factors are pre-RT TURP and the presence of increased acute GU toxicity. Post-radiaton TURP increases the risk of incontinence five-fold.

Urinary continence after salvage radiation therapy following radical prostatectomy, assessed by a self-administered questionnaire: a prospective study

OBJECTIVE

To evaluate urinary continence after salvage radiotherapy following radical prostatectomy (RP) for clinically localized prostate cancer.

PATIENTS AND METHODS

In all, 145 men had a retropubic RP in our department between 1992 and 2000. From this group, salvage radiotherapy with the dose of 65 Gy was given to 18 patients for a rising prostatic specific antigen (PSA) level. The mean (range) age at RP was 63 (50-72) years and the initial PSA level 14.95 (4.8-34) ng/mL. The radiotherapy was given at 46 (6-96) months after RP. A self-administered questionnaire about their urinary status was mailed to the patients before and 18 months after radiotherapy. The mean follow-up after radiotherapy was 34 (20-70) months.

RESULTS

Before radiotherapy, 17 patients were continent (defining continence as no regular use of pads). After salvage radiotherapy, 16 men had had no change in their urinary status, even for the one patient using pads. One patient with stress urinary incontinence showed a slight worsening of his urinary status after radiotherapy. Another patient who was continent before radiotherapy developed urgency with no urinary leakage. Fourteen men stated that they were very satisfied or satisfied about their urinary status after radiotherapy and four were mildly satisfied. Nine would undergo radiotherapy again even with their present continence status and nine probably would.

CONCLUSION

Using an anonymous self-administered questionnaire, salvage radiotherapy for a rising PSA level seems to be safe and does not worsen the continence achieved after RP in most patients.

Late toxicity following conventional radiotherapy for prostate cancer: analysis of the EORTC trial 22863

Late toxicity and other serious adverse events (SAE) were analysed in the European Organisation for Research and Treatment of Cancer (EORTC) trial 22863. The study evaluated the value of adjuvant endocrine treatment for locally advanced prostate cancer treated with radiotherapy. From 1987 to 1995, 415 patients were randomised. There was long-term toxicity information for 377 patients (91%). Median age was 70 years (range 50-80 years). Median follow-up for late toxicity was 42 months (range 3-136 months). Toxicity was graded according to a modified Radiotherapy and Oncology Group (RTOG) scale. Other late SAE, that was not classified as severe treatment toxicity, but were still life-threatening, were also assessed. There were 72 patients with grade 2, 10 patients with grade 3 and 4 patients with grade 4 toxicity. There were 20 patients with other late SAE, who were grouped according to their relationship to treatment; likely related (n = 1), unrelated (n = 7) and not assessable (n = 12). Although four treatment-related deaths (1%) occurred, grade 3 or 4 late complications were less than 5%.

Reducing the toxicity associated with the use of radiotherapy in men with localized prostate cancer

The risk for serious complications associated with modern radiotherapy is relatively low. Compared with conventional radiotherapy, 3DCRT and IMRT allow higher doses to be given more safely. The use of IMRT increases the time and effort required by physicians and physicists. Although there is a clear move toward IMRT, 3DCRT is considered standard. The quality assurance procedures for and fundamental questions regarding IMRT are evolving, including the radiobiologic consequences of altered time-dose fractionation and the greater dose heterogeneity in the target. Defining an accurate target volume and routinely correcting for set-up error and organ movement before each treatment promise to reduce the complications associated with EBRT in the next 5 years. Complications following prostate brachytherapy are better understood now than 10 years ago. Dosimetric or patient selection factors that correlate with a higher risk for complications, such as acute retention, strictures, severe prolonged urinary symptoms, fistulas, proctitis, and impotence, often can be accounted for or avoided. Finally, the role of radiation protectors is beginning to be addressed. It is hoped that these advances will eliminate toxicity associated with radiotherapy and increase cure rates.

Impact of neoadjuvant androgen ablation and other factors on late toxicity after external beam prostate radiotherapy

PURPOSE

To evaluate the late toxicity profile of prostate cancer patients treated with external beam radiotherapy, to investigate the possible risk factors for late toxicity, and to determine whether neoadjuvant androgen ablation (NAA) is a factor.

METHODS AND MATERIALS

The study population consisted of 1192 patients with > or =24 months' follow-up. Late GI and GU toxicities were scored with a modified Radiation Therapy Oncology Group/Subjective, Objective, Management, and Analytic scale. All patients were treated with external beam radiotherapy (52.5 Gy in 20 fractions to 72 Gy in 36 fractions), using either conventional or three-dimensional conformal techniques. Of the 1192 patients, 40% received NAA (median 5 months). Risk factors investigated on multivariate analysis were age, past medical history, use of pelvic fields, dose, fractionation, use and duration of neo- and adjuvant androgen ablation, and acute toxicity (Grade 2 or greater).

RESULTS

The median follow-up for the group was 49 months (range 24-105). The incidence of late Grade 2-3 GI or GU toxicity was 30% at 5 years (GI 12% and GU 20%). The incidence of late Grade 3 GI or GU toxicity was 8% at 5 years (GI 2.7% and GU 5.5%). No Grade 4 toxicity occurred. The risk factors of significance in relation to the development of late Grade 3 GU toxicity were coexisting GU disease (p = 0.02), prior transurethral resection of the prostate or transurethral resection of bladder tumor (p <0.0001), and presence of acute GU toxicity (p = 0.012). For late Grade 3 GI toxicity, short-term (< or =2 months) NAA (p = 0.0002) and coexisting GI disease (p = 0.017) were risk factors.

CONCLUSION

Short-term (< or =2 months) NAA, but not longer durations of NAA, increases the risk of developing Grade 3 GI late toxicity. The possible mechanism of this phenomenon is unclear.

Conformal photon-beam radiotherapy of prostate carcinoma

Three-dimensional conformal radiotherapy is the recommended radiation technique for localized or locally advanced prostate cancer. In the past decades, external beam irradiation procedures have evolved in the context of technical developments of radiation and imaging equipment. The article summarizes these developments and gives a definition of new techniques and their potential advantages over conventional irradiation. It is meant to provide urologists and medical and radiation oncologists with a better comprehension of modern radiation treatment of prostate cancer and its possible improvements in the future.

Urinary incontinence following treatment of localized prostate cancer

BACKGROUND

Urinary incontinence (UI) following treatment for localized prostate cancer is a significant adverse consequence most commonly seen after radical prostatectomy. UI can significantly impair the quality of life of patients who can otherwise expect a long survival.

METHODS

The authors review past and present literature on UI following treatment for localized prostate cancer. Special focus is placed on the rate of UI following different modes of therapy, the effect of posttreatment UI on patients' quality of life, and the success of different methods used to treat the incontinence.

RESULTS

Postprostatectomy UI has been reported in 25%-70% of cases, but few patients report being significantly bothered by the symptom. Postradiation adverse effects are mainly acute inflammatory, while late complications are rare but usually more serious. Comparative studies estimate UI following prostatectomy to be two times more common than following radiation, and surgical patients are three times more likely to continue to use pads. Watchful waiting carries a risk of incontinence related to prostate tumor progression. Several interventions can improve UI.

CONCLUSIONS

UI is the most common adverse consequence from treatment for localized prostate cancer. All of the possible treatment modalities carry some risk of UI. Providing accurate information to patients allows them to make informed decisions regarding treatment and can improve the quality of life in the posttreatment period.

Decision making and prostate cancer treatment selection: a review

OBJECTIVES

To review the issues surrounding decision making regarding prostate cancer treatment.

DATA SOURCES

Journal articles, abstracts, and selected findings from one prospective grounded theory research study.

CONCLUSIONS

Multiple factors are involved in the selection of prostate cancer treatment, such as individual disease-specific data, age, personal values, vicarious and personal cancer experiences, and the physician-patient relationship.

IMPLICATIONS FOR NURSING PRACTICE

Accurate information regarding each treatment option delivered by experts in their respective fields is necessary for informed decision making. A more multidisciplinary approach regarding discussion of treatment options is needed. Nurses play a pivotal role in facilitating discussion among family members and assisting patients to make a decision that balances their personal values with accurate information regarding treatment outcomes.

Health outcomes after external-beam radiation therapy for clinically localized prostate cancer: results from the Prostate Cancer Outcomes Study

PURPOSE

Studies reporting effects of radiotherapy for prostate cancer on sexual, bowel, and urinary function have been conducted primarily in referral centers or academic institutions. Effects of external-beam radiotherapy for prostate cancer among a population-based cohort were assessed.

PATIENTS AND METHODS

The study population included 497 white, Hispanic, and African-American men with localized prostate cancer from six US cancer registries who were diagnosed between October 1, 1994, and October 31, 1995, and treated initially with external-beam radiotherapy. They were interviewed at regular intervals, and medical records were reviewed. Distributions of responses for bowel-, urinary-, and sexual-related functions at 6, 12, and 24 months after diagnosis and adjusted mean composite change scores for each domain were analyzed.

RESULTS

Declines of 28.9% in the sexual function score and 5.4% in the bowel function score occurred by 24 months, whereas at this time, the urinary function score was relatively unchanged. A total of 43% of those who were potent before diagnosis became impotent after 24 months. More than two thirds of the men were satisfied with their treatment and would make the same decision again.

CONCLUSION

Sexual function was the most adversely affected quality-of-life domain, with problems continuing to increase between 12 and 24 months. Bowel function problems increased at 6 months, with partial resolution observed by 24 months. Despite the side effects, satisfaction with therapy was high. These results are representative of men in community practice settings and may be of assistance to men and to clinicians when making treatment decisions.

Long-term urinary toxicity after 3-dimensional conformal radiotherapy for prostate cancer in patients with prior history of transurethral resection

PURPOSE

To report on the long-term urinary morbidity among prostate cancer patients with a prior history of a transurethral resection of the prostate (TURP) treated with high-dose 3-dimensional conformal radiotherapy (3D-CRT).

METHODS AND MATERIALS

Between 1988 and 1997, 1100 patients with clinically localized prostate cancer were treated with 3D-CRT. Of these, 120 patients (8%) were identified as having had a prior TURP and are the subjects of this analysis. The median age was 71 years (range: 49-83 years). The clinical stages of the patients were T1c: 33 (28%); T2a: 38 (32%); T2b: 15 (13%); and T3: 34 (27%). Neoadjuvant androgen ablation therapy was given to 39 (33%). The median radiation dose prescribed to the planning target volume was 75.6 Gy (range: 64.8-81 Gy). The median elapsed time from TURP to initiation of 3D-CRT was 69 months (range: 4-360 months). The median follow-up time was 51 months (range: 18-109 months).

RESULTS

Five patients of the 120 with a prior history of TURP (4%) developed a urethral stricture after 3D-CRT which was corrected with dilatation. The 5-year actuarial likelihood of >/= Grade 2 late urinary toxicities was 9%. No Grade 4 urinary toxicities were observed in this group of patients. Among 110 patients who were completely continent of urine prior to 3D-CRT, 10 (9%) developed stress incontinence requiring 1 pad daily for protection or experienced occasional leakage (not requiring pad protection). The 5-year incidence of >/= Grade 1 stress incontinence was 18% in patients who developed acute >/= Grade 2 GU symptoms during the course of 3D-CRT compared to 7% for patients who experienced Grade 1 or no acute urinary symptoms (p = 0.05). The radiation dose (>/=75.6 Gy vs. <75.6 Gy), the number of prior TURP procedures, or the volume of resected tissue at the time of TURP had no significant impact on the long-term urinary morbidity outcome. A multivariate analysis demonstrated that the presence of Grade 2 acute urinary symptoms was the only predictor of >/= Grade 1 stress incontinence after 3D-CRT in this group of patients.

CONCLUSIONS

Despite prior TURP, the incidence of >/= Grade 3 urinary toxicities is low. Nevertheless, especially among patients with a prior history of TURP who experience Grade 2 acute urinary symptoms during radiation treatment, a higher risk of stress incontinence is observed.

Radiologic anatomy of the prostate gland: a clinical approach

Familiarity with normal anatomy is critical to interpretation of imaging of the prostate and peri-prostatic structures. This is especially true for MR imaging, which depicts these structures with exquisite detail due to high spatial resolution, superior contrast resolution, multiplanar capability, and large field of view. Anatomic understanding plays a key role in the assessment and management of prostatic disease, and allows evaluation of anatomic disturbances that may result from prostatic disease or therapy, and which may have functional consequences, particularly for continence and potency.

Urinary incontinence in patients who have a TURP/TUIP following prostate brachytherapy

PURPOSE

To determine urinary morbidity in patients who have transurethral resection of the prostate (TURP) after 125I brachytherapy.

MATERIALS AND METHODS

A total of 109 patients with Stage T1-T2 prostatic carcinoma were treated with 125I implantation from 1991 through 1995. Ten patients underwent TURP/transurethral incision of the prostate (TUIP) after brachytherapy to relieve urinary obstruction refractory to nonsurgical management.

RESULTS

Patients who developed refractory urinary retention had a slightly larger preimplant prostate volume than those who did not (62 vs. 54 ml; p = 0.16). Seven of the 10 patients developed some degree of permanent urinary incontinence following TURP/TUIP. Urinary incontinence was mild in three patients [Late Effects Normal Tissue Radiation Oncology Group (LENT) score = 1] and severe in four additional patients (LENT score = 3). There was no obvious relationship between the degree of incontinence and use of TURP vs. TUIP, amount of tissue resected, or time between brachytherapy and TURP/TUIP. In five patients for whom detailed urethral radiation dose information was available, the doses were higher than generally recommended.

CONCLUSION

Permanent urinary incontinence is common in patients who require a TURP or TUIP after prostate brachytherapy. Its cause is apparently multifactorial and may include the degree of physical damage to the urinary sphincters and the radiation dose to the urethral region.

Adjuvant radiation therapy does not cause urinary incontinence after radical prostatectomy: results of a prospective randomized study

PURPOSE

We analyzed the potential influence of adjuvant radiotherapy on urinary continence after radical prostatectomy.

MATERIALS AND METHODS

A total of 100 patients with N0M0 prostate cancer randomized in a prospective study on postoperative radiotherapy for locally advanced disease (positive surgical margin, capsular perforation and/or seminal vesicle infiltration) were studied. Objective pad weighing tests corroborated by direct personal interviews were used to evaluate urinary continence at regular postoperative intervals.

RESULTS

Of the patients 48 received 60 Gy. external radiotherapy with 18 MV photon beams between 12 and 16 weeks postoperatively, and 52 were followed expectantly. Risk factors were similar in both groups. With a mean followup of 24 months, no difference in complete urinary continence was observed. Of the irradiated group 77% and of the surveillance group 83% were totally dry. The fate of the bladder neck had no significant influence on final continence status, although there was a trend for faster recovery when the bladder neck was preserved.

CONCLUSIONS

In this prospective randomized study 60 Gy. external radiation therapy administered between 3 and 4 months after radical prostatectomy for pathologically locally advanced prostate cancer had no significant influence on urinary continence.