Self-assessed health-related quality of life in men being treated for prostate cancer with radiotherapy: instrument validation and its relation to patient-assessed bother of symptoms

Conformal Radiotherapy of Clinically Localized Prostate Cancer: Analysis of Rectal and Urinary Toxicity and Correlation with Dose-Volume Parameters

Aims and background

Rectal and urinary toxicities are the principal limiting factors in delivering a high target dose to patients affected by prostate cancer. The verification of such toxicity is an important step before starting a dose-escalation program. The present observational study reports on the acute and late rectal and urinary toxicity in relation with dose-volume parameters in 104 patients with localized prostate cancer treated with 3-dimensional conformal radiation therapy.

Methods and study design

One hundred and four patients with stage T1b-T3b prostate cancer were treated with three-dimensional conformal radiation therapy to a total dose of 74 Gy, 2 Gy per fraction. Rigid dose constraints were applied for rectum and bladder. Acute and late rectal and urinary toxicities were analyzed also in relation to dose-volume histograms. Biochemical relapse-free survival was defined according to the American Society of Therapeutic Radiation Oncology (ASTRO) criteria and to the RTOG-ASTRO Phoenix Consensus Conference Recommendations using the Kaplan-Meier method.

Results

No grade 3 toxicity was observed. Acute and late grade 2 toxicity rates were 5.8% and 9.0% for rectum and 12.5% and 2.0% for bladder, respectively. Rectal V70 influenced the occurrence of late grade 2 toxicity. A relationship between acute and late urinary toxicity was also found. After a median follow-up of 30 months (range, 20–50), the actuarial overall and biochemical relapse-free survival rates were 84% and 77%, respectively, with a significant difference between low-intermediate and high-risk patients.

Conclusions

Conformal radiotherapy to the dose of 74 Gy was administered with good compliance. The incidence of acute and late toxicity was relatively low in accord with our dose constraints. Rectal V70 proved to be a reliable prognosticator of late toxicity. Overall survival and biochemical relapse-free survival rates were more favorable for low and intermediate-risk and significantly less favorable for high-risk patients.

Data Pooling and Analysis to Build a Preliminary Item Bank

Assessing bowel function (BF) in prostate cancer can help determine therapeutic trade-offs. We determined the components of BF commonly assessed in prostate cancer studies as an initial step in creating an item bank for clinical and research application. We analyzed six archived data sets representing 4,246 men with prostate cancer. Thirty-one items from validated instruments were available for analysis. Items were classified into domains (diarrhea, rectal urgency, pain, bleeding, bother/distress, and other) then subjected to conventional psychometric and item response theory (IRT) analyses. Items fit the IRT model if the ratio between observed and expected item variance was between 0.60 and 1.40. Four of 31 items had inadequate fit in at least one analysis. Poorly fitting items included bleeding (2), rectal urgency (1), and bother/distress (1). A fifth item assessing hemorrhoids was poorly correlated with other items. Our analyses supported four related components of BF: diarrhea, rectal urgency, pain, and bother/distress.

Fatalism, medical mistrust, and pretreatment health-related quality of life in ethnically diverse prostate cancer patients

OBJECTIVE

Few studies have examined the impact of cultural processes prevalent in minority ethnic groups such as cancer fatalism and medical mistrust on health-related quality of life (HRQoL) following a cancer diagnosis. The present study examined relationships among ethnicity, HRQoL, and two possible cultural vulnerability factors-fatalistic attitudes and medical mistrust-among an ethnically diverse sample of men with prostate cancer (PC) prior to undergoing active treatment.

METHODS

A total of 268 men with localized PC (30% African American, 29% Hispanic, and 41% non-Hispanic White) were assessed cross-sectionally prior to active treatment. Path analyses examined relationships among ethnicity, vulnerability factors, and HRQoL.

RESULTS

Ethnicity was not related to HRQoL after controlling for relevant covariates. Hispanic men reported greater cancer fatalism compared with non-Hispanic White men (β = 0.15, p = 0.03), and both Hispanics (β = 0.19, p < 0.01) and African Americans (β = 0.20, p < 0.01) reported greater medical mistrust than non-Hispanic Whites. Fatalism demonstrated a trend toward negatively impacting physical well-being (β = -0.12, p = 0.06), but was not significantly related to emotional well-being (β = -0.10, p = 0.11). Greater medical mistrust was associated with poorer physical (β = -0.14, p = 0.03) and emotional well-being (β = -0.13, p = 0.04).

CONCLUSIONS

Results indicate that fatalistic attitudes and medical system mistrust were more prevalent among minority men. Less trust in the medical system was associated with poorer physical and emotional well-being. Attention to perceptions of the healthcare system and its relation to HRQoL may have implications for targeting culturally driven attitudes that may compromise adjustment to a PC diagnosis.Copyright © 2015 John Wiley & Sons, Ltd.

African American men significantly underestimate their risk of having prostate cancer at the time of biopsy

BACKGROUND

Guidelines for prostate cancer (PCa) screening recommend physicians to have an informational discussion with patients. At the time of biopsy, patients should be informed of their heightened PCa risk, particularly African Americans (AA) who have significantly higher diagnostic and mortality risk. We tested predictors of patients' estimation of their likelihood of having PCa at the time of biopsy.

METHODS

A convenience sample of AA (n = 207) and white (n = 271) biopsy patients was surveyed at the time of prostate biopsy. Participants gave likelihood estimations of having PCa and data on their socio-demographics, health, clinical status, and general and PCa-specific anxiety. Binary logistic regressions tested for predictors of the patients' estimations and biopsy results.

RESULTS

Fifty-one percent of AA men answered that they had a '0%' likelihood of having PCa versus 19% of whites, whereas 57% of AA men had abnormal biopsies compared with 42% of whites. In logistic regressions, predictors of patient answers of 0% chance of PCa were AA ethnicity (OR = 4.50; p < 0.001), lower cancer-specific anxiety (OR = 0.93; p < 0.01), less education (OR = 2.38; p < 0.05), and less urinary disturbance (OR = 0.70; p < .05). In a second regression, AA patients trended towards higher positive biopsy rates (OR = 1.43; p = 0.17).

CONCLUSIONS

At biopsy, AA more often estimated their likelihood of PCa as 0%, despite higher risks. Reasons for these low estimates and their potential contribution to poor treatment outcomes of AA patients require further investigation.

The evolution of rectal and urinary toxicity and immune response in prostate cancer patients treated with two three-dimensional conformal radiotherapy techniques

Background

Our research compared whole pelvic (WP) and prostate-only (PO) 3-dimensional conformal radiotherapy (3DCRT) techniques in terms of the incidence and evolution of acute and late toxicity of the rectum and urinary bladder, and identified the PTV-parameters influencing these damages and changes in antitumor immune response.

Methods

We analyzed 197 prostate cancer patients undergoing 3DCRT for gastrointestinal (GI) and genitourinary (GU) toxicities, and conducted a pilot immunological study including flow cytometry and an NK cell cytotoxicity assay. Acute and late toxicities were recorded according to the RTOG and the LENT-SOMA scales, respectively. Univariate and multivariate analyses were conducted for factors associated with toxicity.

Results

In the WP group, an increase of acute rectal toxicity was observed. A higher incidence of late GI/GU toxicity appeared in the PO group. Only 18 patients (WP-7.76% and PO-11.11%) suffered severe late GI toxicity, and 26 patients (WP-11.21% and PO-16.05%) severe late GU toxicity. In the majority of acute toxicity suffering patients, the diminution of late GI/GU toxicity to grade 1 or to no toxicity after radiotherapy was observed. The 3DCRT technique itself, patient age, T stage of TNM classification, surgical intervention, and some dose-volume parameters emerged as important factors in the probability of developing acute and late GI/GU toxicity. The proportion and differentiation of NK cells positively correlated during 3DCRT and negatively so after its completion with dose-volumes of the rectum and urinary bladder. T and NKT cells were down-regulated throughout the whole period. We found a negative correlation between leukocyte numbers and bone marrow irradiated by 44-54 Gy and a positive one for NK cell proportion and doses of 5-25 Gy. The acute GU, late GU, and GI toxicities up-regulated the T cell (CTL) numbers and NK cytotoxicity.

Conclusion

Our study demonstrates the association of acute and late damage of the urinary bladder and rectum, with clinical and treatment related factors. The 3DCRT itself does not induce the late GI or GU toxicity and rather reduces the risk of transition from acute to late toxicity. We have described for the first time the correlation between organs at risk, dose-volume parameters, and the immunological profile.

A systematic review of the use and validation of health-related quality of life instruments in older cancer patients

AIM

The aim of this paper is to systematically review the use and validation of HRQOL instruments in older cancer patients.

METHOD

A systematic review of 5 databases and 3 research registers identified studies reporting the use and validation of HRQOL instruments in cancer patients aged over 65 years from 1995 to mid 2007.

RESULTS

Thirty-one studies reported the use of HRQOL measures in older people, using a range of generic and disease-specific instruments. Little work was reported in patients aged over 80 years. All studies exhibited methodological limitations. Fourteen studies were identified with variable evidence on the psychometric properties and clinical usefulness of identified instruments.

CONCLUSION

Our review identified that the development, validation and use of HRQOL instruments often ignore the specific needs of older people. This review highlights the need for a HRQOL instrument specifically designed to capture the issues and concerns most relevant to older cancer patients.

Predictors for rectal and intestinal acute toxicities during prostate cancer high-dose 3D-CRT: results of a prospective multicenter study

PURPOSE

To find predictors for rectal and intestinal acute toxicity in patients with prostate cancer treated with > or =70 Gy conformal radiotherapy.

METHODS AND MATERIALS

Between July 2002 and March 2004, 1,132 patients were entered into a cooperative study (AIROPROS01-02). Toxicity was scored using the Radiation Therapy Oncology Group/European Organization for Research and Treatment of Cancer scale and by considering the changes (before and after treatment) of the scores of a self-administered questionnaire on rectal/intestinal toxicity. The correlation with a number of parameters was assessed by univariate and multivariate analyses. Concerning the questionnaire, only moderate/severe complications were considered.

RESULTS

Of 1,132 patients, 1,123 were evaluable. Of these patients, 375, 265, and 28 had Grade 1, 2, and 3 Radiation Therapy Oncology Group/European Organization for Research and Treatment of Cancer toxicity, respectively. The mean rectal dose was the most predictive parameter (p = 0.0004; odds ratio, 1.035) for Grade 2 or worse toxicity, and the use of anticoagulants/antiaggregants (p = 0.02; odds ratio, 0.63) and hormonal therapy (p = 0.04, odds ratio, 0.65) were protective. The questionnaire-based scoring revealed that a greater mean rectal dose was associated with a greater risk of bleeding; larger irradiated volumes were associated with frequency, tenesmus, incontinence, and bleeding; hormonal therapy was protective against frequency and tenesmus; hemorrhoids were associated with a greater risk of tenesmus and bleeding; and diabetes associated highly with diarrhea.

CONCLUSION

The mean rectal dose correlated with acute rectal/intestinal toxicity in three-dimensional conformal radiotherapy for prostate cancer, and hormonal therapy and the use of anticoagulants/antiaggregants were protective. According to the moderate/severe injury scores on the self-assessed questionnaire, several clinical and dose-volume parameters were independently predictive for particular symptoms.

A measure of health-related quality of life among patients with localized prostate cancer: results from ongoing scale development

BACKGROUND

We revised our prostate cancer-specific measure to better address the physiologic complications of the 3 major therapies for clinically localized prostate cancer and to assess the impact of symptoms on broader aspects of patient functioning. The study used a cross-sectional design, and participants completed the measure in a clinical setting.

PATIENTS AND METHODS

Participants underwent radical prostatectomy (n = 130), external beam radiation therapy (n = 120), or brachytherapy (n = 129). Their mean age was 66 years (standard deviation [SD], 8.2 years), and the median time since treatment was 12.36 months (mean, 21.7; SD, 25.4). Items were derived from previously validated instruments or developed based on the clinical experience of a multidisciplinary group of health professionals.

RESULTS

The revised instrument included 46 items that formed 8 physiologic scales (2 urinary, 3 sexual, and 3 bowel function); 3 associated bother scales; and cancer worry, treatment regret, and treatment satisfaction scales. Correlations among scales provided evidence of convergent/divergent validity. Significant group differences were found using analysis of covariance (with time since treatment and age as covariates) on 6 of the 8 physiologic scales and on bowel bother and treatment satisfaction.

CONCLUSION

The instrument provides a sensitive measure of physiologic differences across the 3 primary treatment groups and indicates that there are few differences across treatment groups on broader aspects of health-related quality of life. Further development of the measure is recommended.

Knowledge of colon cancer screening in a national probability sample in the United States

This study examined colon cancer screening knowledge and potential covariates (demographic, health, health care, and cancer information seeking) among adults of at least 45 years of age. Data were analyzed from the 2003 National Cancer Institute's (NCI's) Health Information National Trends Survey (HINTS 2003), a U.S. random-digit dial study. Our sample consisted of 3,131 adults (53.6% female, 77.9% White). The colon cancer screening knowledge questions assessed whether participants had heard of the fecal occult blood test (FOBT; 73.7%), knew the recommended start age (26.1%), knew the frequency of FOBT (39.5%), had heard of flexible sigmoidoscopy or colonoscopy (84.3%), knew the start age (39.6%), and knew the frequency with which to test (12.8%). Factors associated with lower knowledge (all equal to p < .05 in a multivariate analysis) included being younger (45 to 49 years old) or older (70 years old or more), African American or non-Hispanic other, unmarried; had lower educational attainment; had not visited a health care provider in the past year; had not previously undergone FOBT; and had never looked for cancer information. This study documents low rates of colon cancer screening knowledge in the general population, and identifies subgroups where health communication interventions are most warranted.

Comparing measures of acute bowel toxicity in patients with prostate cancer treated with external beam radiation therapy

PURPOSE

This study strives to compare early measures of bowel toxicity in patients with prostate cancer receiving definitive or adjuvant 3D conformal external beam radiation therapy and concurrent daily endorectal application of amifostine.

METHODS

Eighteen patients were enrolled in the clinical study with a median follow-up of 12 months. Prescription doses ranged from 66 Gy to 76 Gy with a daily fractionation of 2 Gy. Acute bowel toxicity was measured at baseline, at Weeks 5 and 7 of radiotherapy, and at 1 and 3 months after the completion of therapy. Measures of acute bowel toxicity included the Radiation Therapy Oncology Group (RTOG) acute radiation morbidity scoring criteria, Expanded Prostate Cancer Index Composite (EPIC) self-assessment questionnaires, and proctoscopic examinations.

RESULTS

The mean EPIC bowel scores changed significantly through the course of therapy and follow-up (p < 0.0001), with a progressive decrease in scores at Weeks 5 and 7 of treatment, a partial recovery at 3 months, and a correlation to the gold standard RTOG grade (p = 0.004). Proctoscopic toxicity scores were low, did not vary over time, and did not correlate with either EPIC or RTOG scores.

CONCLUSION

The EPIC questionnaire measurements are most sensitive to changes in acute bowel toxicity through a course of radiotherapy and correlate with RTOG acute toxicity scores. Endoscopic examination of the rectal mucosa at the end and immediate follow-up of a course of therapy does not seem to be informative or reproducible between observers in the acute setting.

Quality of life in prostate cancer

Little more than a decade ago, measurements of health-related quality of life (HRQOL) of prostate cancer patients began to enter the medical literature. Initially controversial and of little apparent relevance to clinical care, HRQOL has grown in importance in prostate cancer to the point that providing it in treatment discussions is now considered a core element of clinical care. The United States (US) Food and Drug Administration has used it to make approval decisions for prostate cancer drugs, and Europeans have endorsed its central role in prostate cancer as well [Altwein J, Ekman P, Barry M, et al. How is quality of life in prostate cancer patients influenced by modern treatment? The Wallenberg symposium. Urology 1997, 49(Suppl 4A), 66-76.]. We propose to characterise the treatment dilemmas facing patients with prostate cancer, the clinical relevance of HRQOL research, its central conceptual elements, the characteristics of some available instruments to measure it, the use of HRQOL in clinical studies, and some of the remaining challenges we have identified during our 13 years in the field.

Racial/Ethnic differences in functional outcomes in the 5 years after diagnosis of localized prostate cancer

PURPOSE

We investigated racial/ethnic differences in functional outcomes up to 5 years after diagnosis among men with aggressively treated localized prostate cancer.

PATIENTS AND METHODS

Patients were from the Prostate Cancer Outcomes Study, a population-based cohort study that surveyed patients at 6, 12, 24, and 60 months after diagnosis. Analyses were stratified by primary treatment. Racial/ethnic differences at each time point were assessed using Generalized Estimating Equations, adjusting for pretreatment function, age at diagnosis, secondary treatment, and other confounders. An adjusted summary score for each functional domain was calculated for each time period.

RESULTS

Patients included 1,475 non-Hispanic white, 321 African-American, and 279 Hispanic prostate cancer patients. After 60 months, among prostatectomy patients, African-Americans had significantly higher sexual function scores than non-Hispanic whites (43.9 v 36.1; P = .02), but were more likely to have a moderate to big problem with sexual function (50.6% v 44.4%; P = .04). African-Americans also had higher urinary function scores at 5 years than non-Hispanic whites (78.5 v 72.4; P = .04) and were less likely to have problems with incontinence. Changes in sexual and bowel function after radiotherapy showed no significant racial/ethnic differences.

CONCLUSION

This long-term cohort study found that, among prostatectomy patients, African-Americans had better recovery of sexual and urinary function at 60 months after diagnosis that was likely to be of mild clinical significance, despite reporting more problems with sexual function than non-Hispanic whites. More study is necessary to understand reasons for these differences. In contrast, no racial/ethnic differences in recovery from radiotherapy were found.

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.

A Randomised Trial of Cranberry Versus Apple Juice in the Management of Urinary Symptoms During External Beam Radiation Therapy for Prostate Cancer

AIMS

The aim of the study was to assess whether the oral intake of cranberry juice cocktail compared with apple juice was associated with a significant difference in urinary symptoms experienced during radical external beam radiation therapy (EBRT) for prostate carcinoma.

MATERIALS AND METHODS

One hundred and twelve men with prostate cancer were randomised to either 354 ml cranberry juice or apple juice a day. Stratification was based on a history of a previous transurethral resection of prostate (TURP yes/no) and baseline International Prostate Symptom Score (IPSS < 6 or > or = 6) of urinary symptoms.

RESULTS

The maximum IPSS (MRT) and the maximum change in IPSS from baseline (DRT) are used to report the results. We analysed the effects of juice allocation on DRT and MRT using analysis of covariates (ANCOVA). We observed no significant difference for DRT (P = 0.39) or MRT (P = 0.76) related to the consumption of cranberry compared with apple juice. However, we found a significant relationship between the history of a previous TURP and both DRT (P = 0.01) and MRT (P = 0.01). The history of a previous TURP was associated with lower values for both end points. Baseline IPSS was significant for DRT (P = 0.004) and MRT (P < or = 0.001). We found a significant relationship between the baseline IPSS < 6 or > or = 6 cut point on MRT (P < or = 0.001) but not on DRT (P = 0.43). The use of neoadjuvant hormones had no significant effect on DRT (P = 0.64) or MRT (P = 0.76). The use of additional symptomatic medication during the study was not significantly different between the two arms.

CONCLUSIONS

This study shows no significant difference in the urinary symptoms experienced during EBRT related to the consumption of cranberry juice compared with apple juice.

Measuring patients' perceptions of the outcomes of treatment for early prostate cancer

BACKGROUND

Compared with careful attention to the physical (eg, urinary, bowel, sexual) dysfunction that may follow treatment, little attention has been given to the behavioral, emotional, and interpersonal changes that the diagnosis of early prostate cancer and subsequent physical dysfunction may bring.

OBJECTIVE

To construct patient-centered measures of the outcomes of treatment for early prostate cancer.

RESEARCH DESIGN

Qualitative study followed by survey of early prostate cancer patients and group of comparable patients with no history of prostate cancer. Analysis of focus groups identified relevant domains of quality of life, which were represented by Likert scale items included in survey questionnaires. Psychometric analyses of survey data defined scales evaluated with respect to internal consistency and validity.

RESULTS

Qualitative analysis identified three domains: urinary control, sexuality, and uncertainty about the cancer and its treatment. Psychometric analysis defined 11 scales. Seven were generically relevant to most older men: urinary control (eg, embarrassment with leakage), sexual intimacy (eg, anxiety about completing intercourse), sexual confidence (eg, comfort with sexuality), marital affection (eg, emotional distance from spouse/partner), masculine self esteem (eg, feeling oneself a whole man), health worry (eg, apprehensiveness about health changes), and PSA concern (eg, closely attending to one's PSA). Four scales were specific to the treatment experience: perceived cancer control, quality of treatment decision making, regret of treatment choice, and cancer-related outlook.

CONCLUSION

The scales provide definition and metrics for patient-centered research in this area. They complement measures of physical dysfunction and bring into resolution outcomes of treatment that have gone unnoticed in previous studies.

Quality of life after treatment for prostate cancer

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

An Internet-ready database for prospective randomized clinical trials of high-dose-rate brachytherapy for adenocarcinoma of the prostate

PURPOSE

To demonstrate a new interactive Internet-ready database for prospective clinical trials in high-dose-rate (HDR) brachytherapy for prostate cancer.

METHODS AND MATERIALS

An Internet-ready database was created that allows common data acquisition and statistical analysis. Patient anonymity and confidentiality are preserved. These data forms include all common elements found from a survey of the databases. The forms allow the user to view patient data in a view-only or edit mode. Eight linked forms document patient data before and after receiving HDR therapy. The pretreatment forms are divided into four categories: staging, comorbid diseases, external beam radiotherapy data, and signs and symptoms. The posttreatment forms separate data by HDR implant information, HDR medications, posttreatment signs and symptoms, and follow-up data. The forms were tested for clinical usefulness.

CONCLUSION

This Internet-based database enables the user to record and later analyze all relevant medical data and may become a reliable instrument for the follow-up of patients and evaluation of treatment results.

Contemporary measures for the assessment of health-related quality of life in prostate cancer

Over the past decade, increasing attention has been paid to the proper assessment and evaluation of health-related quality of life in men with prostate cancer. A major motivation for this work is the lack of strong evidence that survival end-points differ among the various therapies in the setting of documented differences in morbidities. This review summarizes the current literature regarding the evaluation of health-related quality of life for prostate cancer. The use of validated measures and other issues relevant for prostate cancer-specific assessments will be discussed.

A randomized trial of the choice of treatment in prostate cancer: design and baseline characteristics

OBJECTIVE

To assess the effects of different approaches to decision-making on the treatment chosen for prostate cancer and on the patients' quality of life in prostate cancer.

PATIENTS AND METHODS

A multicentre randomized trial was conducted, including all histologically confirmed cases of prostate cancer diagnosed between September 1993 and November 1994 in four Finnish hospitals. In the intervention group, the role of the patient in the choice of treatment was actively emphasized. In the control group, the treatment was chosen using standardized treatment protocols. The first intermediate endpoint was the patient's participation in decision-making and the next will be the treatment chosen in the intervention and control groups. The main outcome will be the quality of life. Clinical data on prognostic factors including age, tumour grade, stage, functional status and serum prostate-specific antigen (PSA) concentration was collected for comparison between the arms, and between those enrolled or not.

RESULTS

In all, 210 of 251 eligible patients were randomized into the two arms. Patients were randomized before obtaining informed consent, which led to four patients already randomized refusing to participate. The 41 patients not enrolled were of similar age and grade distribution, but more frequently had extensive disease than had those enrolled in the trial. Three patients were unable to participate because of rapid deterioration in their general condition after randomization. There were no clear differences in baseline characteristics (including age, functional status, tumour grade and stage) of the patients between the arms. The distribution of PSA level differed slightly between the arms, which may require adjustment in the analyses. Patients in the intervention arm participated in decision-making more actively than those in the control arm.

CONCLUSION

Randomized studies on ethical issues such as the patient's role in choosing treatment are feasible and likely to provide important information.

Symptom indexes to assess outcomes of treatment for early prostate cancer

BACKGROUND

Patients' perceptions of treatment outcomes are important in the management of early prostate cancer, but few studies have offered reliable and responsive measures to assess the likely side effects of the most common treatments.

OBJECTIVE

To develop indexes of urinary, bowel, and sexual function, and related distress.

RESEARCH DESIGN

Prospective cohort study of the outcomes of treatment for early prostate cancer, with self-administered questionnaires completed before treatment, and 3 and 12 months afterward. Hypothesized indexes, based on a clinical model of pathophysiological side effects of treatment, were defined and evaluated with respect to reliability and validity.

SUBJECTS

Patients (n = 184) undergoing radical prostatectomy or external beam radiotherapy for early prostate cancer.

MEASURES

Urinary and bowel items pertained to frequency or intensity of symptoms of dysfunction; parallel items assessed symptom-related distress. Sexual dysfunction items assessed the quality of erections, orgasm, and ejaculation; distress was assessed by 2 items adapted from the MOS Sexual Problems (MOS-SP) scale. HRQoL was assessed by the SF-36 and Profile of Mood States.

RESULTS

Symptom and symptom-related distress indexes for urinary incontinence, urinary obstruction/irritation, bowel dysfunction, and sexual dysfunction were defined. Symptom and distress indexes in each domain were highly correlated. Responsiveness was substantial and varied by treatment in ways consistent with clinical experience. The indexes accounted for significant proportions of the variance in HRQoL measures.

CONCLUSIONS

These indexes may be used in monitoring outcomes of treatment for early prostate cancer.

Prospective assessment of voiding and sexual function after treatment for localized prostate carcinoma: comparison of radical prostatectomy to hormonobrachytherapy with and without external beam radiotherapy

BACKGROUND

Voiding and sexual function after treatment are major determinants of quality of life in prostate carcinoma patients. Erectile dysfunction, incontinence, and urinary symptoms, both obstructive and irritative, have a significant negative impact on patient quality of life. This prospective study was undertaken to evaluate voiding, sexual function, and their impact on patients with localized prostate carcinoma who were treated with radical retropubic prostatectomy (RP) and to compare these patients with patients who were undergoing hormonobrachytherapy with external bean radiotherapy (HBTC) and patients who were undergoing hormonobrachytherapy without external beam radiotherapy (HBT).

METHODS

Patients treated for localized prostate carcinoma with either RP or interstitial palladium-103 (103Pd) HBTC or HBT were prospectively administered a voiding and sexual function questionnaire before any treatment was initiated and at posttreatment visits. Questionnaire components included the American Urological Association Symptom Score (AUASS) and specific items that addressed urinary control and sexual function from the University of California at Los Angeles Prostate Cancer Index. Questionnaire results were compiled, and differences among treatment groups were assessed over time.

RESULTS

From January 1997 to November 1999, 127 consecutive patients were treated with either unilateral or bilateral nerve-sparing RP (42 patients), HBTC (40 patients) or HBT (45 patients) by 2 surgeons proficient in all procedures. Using the overall score and the obstructive subscale (OAUA) of the AUASS, the RP group showed a posttreatment decrease in scores compared with both HBTC and HBT groups. OAUA scores of HBTC and HBT groups were significantly greater than scores in RP patients over the course of the study. HBTC patients had increased irritative symptoms initially when compared with RP patients, and, although not statistically significant, the magnitude of the difference persisted over the course of the study. Total AUASS and subscale scores for the RP group returned to near baseline levels within 12 months. The use of incontinence pads was a criterion for urinary incontinence, and the proportion of patients returning to baseline continence was lower in RP patients over the course of the study. No notable differences in Voiding Bother (VB) scores were found. Initially RP patients experienced worse Sexual Function (SF) scores; however, scores for RP patients changed over time and approached the levels seen in HBTC patients at 18 months. The Sexual Function Bother (SFB) scores also were higher initially in the RP group but then decreased to similar levels observed for HBTC patients by 18 months. None of the treatment groups returned to near baseline SF or SFB scores during the course of this study.

CONCLUSIONS

Comparison of voiding function indicated that HBTC and HBT patients initially have more obstructive voiding symptoms, whereas urinary incon- tinence is initially worse in RP patients. Initially RP patients demonstrated worse SF and SFB scores, but RP patients returned to HBTC levels within 18 months.

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.

Self-assessed health-related quality of life in men who have completed radiotherapy for prostate cancer: instrument validation and its relation to patient-assessed bother of symptoms

The purpose of this study was to develop a psychometrically reliable and valid questionnaire to assess the disease-specific dimensions of health-related quality of life (HRQOL) in the urinary function (UF), bowel function (BF), and sexual function (SF) domains of prostate cancer (PCa) patients treated with radiation therapy. Patients were given a six-page questionnaire using Likert-type questions assessing three HRQOL dimensions during their follow-up visits after completing radiotherapy. Scales created from an earlier study were utilized and tested for reliability and validity. In addition, we assessed the relationship between these dimensions and the degree to which a decreased HRQOL increases the degree to which patients feel bothered about their symptoms. There are two scales within each dimension: BF, Urgency and Daily Living; UF, Urgency and Weakness of Stream; SF, Interest/Satisfaction and Impotence. Internal-consistency reliability coefficients (Cronbach's alpha) for the proposed scales range from 0.48 to 0.92, and all item-scale correlations and divergence correlations validate the use of the scales, ranging from 0.49 to 0.89. The validity of these scales is also confirmed by the rising median scores with rising reported levels of patient-perceived "bother." The different dimensions have differing quantitative influences on patients. We have developed a prostate-specific HRQOL instrument that is an adequate and suitable tool for measuring HRQOL along three distinct dimensions for patients who have completed radiotherapy for PCa. Psychometric standards for reliability and validity were met for the proposed scales. Moreover, positive correlations were found between these dimensions and how bothered patients were by their symptoms, suggesting important relationships that should be followed in PCa patients after radiotherapy. Certain scales have strong influences on patient-perceived "bothersomeness" of symptoms, such as loss of control of BF, urgency of BF, urgency of urination, and level of interest/satisfaction in sex. Compared to our earlier study on patients being treated with radiotherapy for PCa, this study produced very similar results. With some modification, the same questionnaire could be used for both groups of patients. Int. J. Cancer (Radiat. Oncol. Invest.) 90, 163-172 (2000).

Quality of life following prostate cancer treatments

Quality of life is of major concern to patients when choosing a treatment for prostate cancer. Health-related quality of life (HRQOL) is a patient-centered variable from the field of health services research that can be assessed in a valid and reliable manner. Using standardized questionnaires specifically designed to measure HRQOL in men with prostate cancer, we can now study the effect of various treatments on patients' quality of life. Treatments for metastatic prostate cancer can have significant effects in all areas of patients' quality of life. Patients with localized disease undergoing radical prostatectomy (RP) tend to have more sexual and urinary dysfunction than do men undergoing external beam radiation therapy (EBRT), although both groups have worse quality of life in these areas than age-matched controls. Men undergoing EBRT have worse bowel function than age-matched controls or men undergoing RP. Recent studies of men undergoing interstitial brachytherapy indicate that these patients have less urinary leakage than those who undergo RP, but experience considerably more irritative voiding symptoms, which can profoundly affect quality of life. Patients need to be informed of the possible impact of therapy on quality of life when choosing treatment.

In the radiotherapy of prostate cancer, technique determines the doses to the penile structures

For 11 consecutive prostate cancer patients undergoing three-dimensional conformal radiotherapy (3DCRT) in our institution, penile structures (PNS) were outlined in CT images obtained for treatment planning purposes. Dose-volume histograms (DVHs) were compared in order to study dose-volume relations for three techniques: 4FLD, an axial coplanar, four-field box technique; 6FLD, a six-field coplanar technique; and 4NAX, a coplanar but non-axial, four-field technique. All three techniques delivered equal doses to the planning target volumes (PTV). Our statistical analyses strongly indicate that the three techniques can be ranked as 6FLD better than 4FLD (and 4FLD better than 4NAX) as far as irradiating PNS volume during treatment of prostate cancer (PC) is concerned. For each technique, there is a "spread" owing to differences in patient anatomy and/or target size, position, and extent, but each technique has a similar "profile" or "shape" distinct from other techniques. Whether irradiating smaller volumes of PNS will influence the sexual potency outcome remains to be demonstrated. However, PNS should be considered as another critical structure in addition to rectum, bladder and femoral heads in the radiotherapy (RT) of PC, especially in 3DCRT dose escalation studies. Sexual potency outcomes can be correlated to dose-volume relations in the future and this will help refine radiotherapy techniques further.