Meta-analysis of rates of erectile function after treatment of localized prostate carcinoma

Sexual Structure Sparing for Prostate Cancer Radiotherapy: A Systematic Review

CONTEXT

Erectile dysfunction represents a major side effect of prostate cancer (PCa) treatment, negatively impacting men's quality of life. While radiation therapy (RT) advances have enabled the mitigation of both genitourinary and gastrointestinal toxicities, no significant improvement has been showed in sexual quality of life over time.

OBJECTIVE

The primary aim of this review was to assess sexual structures' dose-volume parameters associated with the onset of erectile dysfunction.

EVIDENCE ACQUISITION

We searched the PubMed database and ClinicalTrials.gov until January 4, 2023. Studies reporting the impact of the dose delivered to sexual structures on sexual function or the feasibility of innovative sexual structure-sparing approaches were deemed eligible.

EVIDENCE SYNTHESIS

Sexual-sparing strategies have involved four sexual organs. The mean penile bulb doses exceeding 20 Gy are predictive of erectile dysfunction in modern PCa RT trial. Maintaining a D100% of ≤36 Gy on the internal pudendal arteries showed preservation of erectile function in 88% of patients at 5 yr. Neurovascular bundle sparing appears feasible with magnetic resonance-guided radiation therapy, yet its clinical impact remains unanswered. Doses delivered to the testicles during PCa RT usually remain <2 Gy and generate a decrease in testosterone levels ranging from -4.6% to -17%, unlikely to have any clinical impact.

CONCLUSIONS

Current data highlight the technical feasibility of sexual sparing for PCa RT. The proportion of erectile dysfunction attributable to the dose delivered to sexual structures is still largely unknown. While the ability to maintain sexual function over time is impacted by factors such as age or comorbidities, only selected patients are likely to benefit from sexual-sparing RT.

PATIENT SUMMARY

Technical advances in radiation therapy (RT) made it possible to significantly lower the dose delivered to sexual structures. While sexual function is known to decline with age, the preservation of sexual structures for prostate cancer RT is likely to be beneficial only in selected patients.

Association Between Common Urologic Medications and Onset of Alzheimer's Disease and Related Dementias in Men With Prostate Cancer Managed by Different Primary Treatment Modalities

OBJECTIVE

To understand the relationship between common urologic medications phosphodiesterase-5 inhibitors (PDE5i) and anticholinergics (AC) and risk of dementia onset in men who underwent different primary treatments for prostate cancer.

MATERIALS AND METHODS

Patients (>50years) with prostate cancer (1998-2022) without Alzheimer's disease or related dementias were selected from Cancer of the Prostatic Strategic Urologic Research Endeavor Registry. Minimum medication use was 3months. Fine-Gray regression was performed to determine the association between medication exposure and dementia onset ≥12months after primary treatment in men matched on age, race, comorbid conditions, smoking, and type of clinical site, with competing risk of death.

RESULTS

Among 5937 men (53% PDE5i; 14% AC), PDE5i users were younger (63 vs 70, P < .01) with less CAD, CVA, DM (all P < .01); AC users were older (68 vs 66, P < .01) with higher incidence of comorbidities (P < .01). Median months of use was 24.3 (IQR 12.1, 48.7) for PDE5i and 12.2 (IQR 6.1, 24.3) for AC users. Cumulative incidence of Alzheimer's disease or related dementias was 6.5% at 15years. PDE5i (P = .07) and AC (P = .06) were not associated with dementia regardless of primary treatment modality.

CONCLUSION

In this retrospective cohort study, PDE5i and AC use do not appear independently associated with risk of dementia. Notably, our cohort was generally healthy and younger which may limit our ability to detect significance. We recommend prospective investigation into association between PDE5i and dementia and advise continued judicious stewardship of AC in older patient populations.

[Relationship between doses to anatomical structures and erectile dysfunction after radiotherapy for prostate cancer: A systematic review]

PURPOSE

During prostatic radiotherapy, damage to several anatomical structures could be the cause of erectile dysfunction: corpora cavernosa, internal pudendal arteries, penile bulb, and neurovascular bundles. Numerous studies have analysed the correlations between the dose received by these structures and erectile function. The objective of this article is to make a systematic review on current knowledge.

MATERIALS AND METHODS

A systematic review was performed in the Medline database using the search engine PubMed. Keywords for the search included: erectile dysfunction, penile bulb, corpora cavernosa, cavernosum, neurovascular bundles, radiation therapy, cancer, prostate cancer. The selected articles must study a correlation between erectile dysfunction and the dose received by anatomical structures. A total of 152 articles were identified. Of these 152 articles, 45 fulfilled the defined selection criteria.

RESULTS

For corpora cavernosa, seven studies were identified, only two studies demonstrated a significant correlation between the dose received by corpora cavernosa and the occurrence of erectile dysfunction. For penile bulb, only 15 of 23 studies showed a correlation. A mean dose on the penile bulb greater than 20Gy was found to be predictive of erectile dysfunction. None of the eight trials concerning neurovascular bundles succeeded to show a correlation between dose and erectile dysfunction. Only one study evaluated the relationship between the dose received by internal pudendal arteries and erectile dysfunction but was found to be negative. However, vessels-sparing studies showed good results on erectile function preservation without compromising the target volume.

CONCLUSION

We currently have little data to show a correlation between erectile dysfunction and sexual structures. It would be necessary to have additional prospective studies evaluating the impact of an optimization on these sexual structures on erectile dysfunction.

Sexual characteristics of patients with prostate cancer seen for radiation treatment

Background

Prostate cancer was estimated to be the second most diagnosed cancer and the fifth leading cause of cancer mortality among men, with an estimated 1.4 million new cases and 375,000 deaths globally in 2020. There are significant changes in sexual activities and subsequent changes in quality of life associated with the diagnosis and treatment of prostate cancer. Sexual problems experienced by prostate cancer patients include erectile dysfunction, reduced sexual desire, reduced sexual function, problems with ejaculation, as well as problems with orgasm, and these could occur before and/or after treatment. This study aims to highlight the sexual characteristics of prostate cancer patients, which would help identify altered sexuality that might require intervention by healthcare providers.

Method

All patients who presented with pathologically diagnosed, organ-confined prostate cancer referred for high-dose-rate brachytherapy were approached for participation in the study. An interviewer-administered questionnaire was administered to the consenting patients.

Results

A total of 56 patients gave consent for the study out of 60. All the patients were married, with 5 (8.9%) having multiple wives. Only ten respondents (17.9%) reported having other sexual partners besides their wives. More than half of the patients (34) (60.7%) started having sexual intercourse between the ages of 18 and 20. Many patients claimed that the diagnosis of prostate cancer had affected their sexual lives. About half of the respondents (44.6%) believed that their partners were less satisfied with their sexual performance, as evidenced by the loss of partners (5.4%), partners refusing sexual advances (14.3%), partners complaints (10.7%), and partners' reduced inclination to ask for sex (33.9%). One patient expressed fears of passing the disease to their partners.

Conclusion

The management of prostate cancer should include sex therapy and rehabilitation in couples from the point of diagnosis to maintain sexual function as close as possible to that in the general population in order to maintain an improved quality of life.

Efficacy and Safety of Udenafil Once Daily in Patients with Erectile Dysfunction after Bilateral Nerve-Sparing Robot-Assisted Laparoscopic Radical Prostatectomy: A Randomized, Double-Blind, Placebo-Controlled Study

PURPOSE

To evaluate the efficacy and safety of udenafil 75 mg once daily in patients with erectile dysfunction following bilateral nerve-sparing robot-assisted laparoscopic radical prostatectomy (BNS-RALP).

MATERIALS AND METHODS

A multi-center, prospective, randomized, controlled, double-blind study was conducted. Among patients with localized prostate cancer with international index of erectile function-erectile function domain (IIEF-EF) score of 18 or higher before BNS-RALP, those who developed postoperative erectile dysfunction (IIEF-EF score 14 or less at 4 weeks after BNS-RALP) were enrolled. Enrolled patients were randomly assigned to the udenafil 75 mg daily group or the placebo group in a 2:1 ratio. Each subject was followed up at 8 weeks (V2), 20 weeks (V3), and 32 weeks (V4) to evaluate the efficacy and safety of udenafil.

RESULTS

In all, 101 patients were screened, of whom 99 were enrolled. Of the 99 patients, 67 were assigned to the experimental group and 32 to the control group. Ten (14.93%) patients in the experimental group and 10 (31.25%) in the control group dropped out of the study. After 32 weeks of treatment, IIEF-EF score of 22 or higher was seen in 36.51% (23/63) of patients in the experimental group and 13.04% (3/23) patients in the control group (p=0.021). The proportion of patients with IIEF-EF improvement of 25% or more compared to the baseline was 82.54% (52/63) in the experimental group and 62.96% (17/27) in the control group (p=0.058).

CONCLUSIONS

Udenafil 75 mg once daily after BNS-RALP improved the erectile function without any severe adverse effects.

Analysis of Clinicopathological Factors Associated with Radiation-Induced Cystitis in Patients with Cervical Cancer

Objective

To analyze the clinicopathological characteristics associated with radiation-induced cystitis (RIC) in patients with cervical cancer treated with chemoradiotherapy (CRT) alone or postoperational (post-op) CRT.

Methods

107 patients with cervical cancer were retrospectively recruited into the study. The surgical status, FIGO staging, total and fractionated doses of radiotherapy (RT), and multiparameters including the dose, volume irradiated to the total bladder, and bladder wall were evaluated for RIC. The criteria on RIC were referred to CTCAE v5.0.

Results

Surgical operation and post-op CRT were delivered in 65 patients and CRT or RT alone in 42 patients. Among those with post-op CRT, 33/34 (97.06%), 22/43 (51.16%), and 10/30 (33.33%) patients were classified as FIGO stage I, II, and III/IV, respectively. The incidence of RIC was 30.84% for the whole group with 87.87% occurred in stage I and II patients. The incidence of CTCAE grade 2 and beyond was significantly higher in patients treated with post-op CRT than those with CRT alone (13.85% vs 2.38%, p = 0.043). Further analyses showed that the CTCAE level of RIC in the post-op CRT group was related to the relatively smaller average bladder volume (p = 0.029), whereas the difference in volume of bladder and bladder wall irradiated to 35.0 Gy or 40.0 Gy was not statistically significant between patients with or without RIC. Conclusion. The combination of surgery and post-op CRT may increase the incidence and severity of radiation-induced cystitis when compared to CRT alone, suggesting that bladder dysfunction associated with surgical procedure might increase the frequency and severity radiation related bladder toxicity. Further study is merited.

Canadian Urological Association guideline: Erectile dysfunction

Erectile dysfunction (ED) impacts the wellness and quality of life of millions of Canadians. An evaluation focused on the identification of reversible and irreversible underlying factors is recommended for patients presenting with ED. Through a shared decision-making model framework, the goal of ED treatment is to improve functional outcomes and enhance sexual satisfaction while minimizing adverse effects associated with treatment. Given that ED is assessed and treated by multiple different types of health practitioners, the purpose of this guideline is to provide the best available evidence to facilitate care delivery through a Canadian lens. After a narrative review of ED assessment and treatment for general readership, five key clinical questions relating to priority areas of ED are assessed using the GRADE and evidence-to-decision-making frameworks.

Simulation of an HDR "Boost" with Stereotactic Proton versus Photon Therapy in Prostate Cancer: A Dosimetric Feasibility Study

Purpose/Objectives

To compare the dose escalation potential of stereotactic body proton therapy (SBPT) versus stereotactic body photon therapy (SBXT) using high-dose rate prostate brachytherapy (HDR-B) dose-prescription metrics.

Patients and Methods

Twenty-five patients previously treated with radiation for prostate cancer were identified and stratified by prostate size (≤ 50cc; n = 13, > 50cc; n = 12). Initial CT simulation scans were re-planned using SBXT and SBPT modalities using a prescription dose of 19Gy in 2 fractions. Target coverage goals were designed to mimic the dose distributions of HDR-B and maximized to the upper limit constraint for the rectum and urethra. Dosimetric parameters between SBPT and SBXT were compared using the signed-rank test and again after stratification for prostate size (≤ 50cm³ and >50cm³) using the Wilcoxon rank test.

Results

Prostate volume receiving 100% of the dose (V100) was significantly greater for SBXT (99%) versus SBPT (96%) (P ≤ 0.01), whereas the median V125 (82% vs. 73%, P < 0.01) and V200 (12% vs. 2%, P < 0.01) was significantly greater for SBPT compared to SBXT. Median V150 was 49% for both cohorts (P = 0.92). V125 and V200 were significantly correlated with prostate size. For prostates > 50cm³, V200 was significantly greater with SBPT compared to SBXT (14.5% vs. 1%, P = 0.005), but not for prostates 50cm³ (9% vs 4%, P = 0.11). Median dose to 2cm³ of the bladder neck was significantly lower with SBPT versus SBXT (9.6 Gy vs. 14 Gy, P < 0.01).

Conclusion

SBPT and SBXT can be used to simulate an HDR-B boost for locally advanced prostate cancer. SBPT demonstrated greater dose escalation potential than SBXT. These results are relevant for future trial design, particularly in patients with high risk prostate cancer who are not amenable to brachytherapy.

Dosimetric feasibility of neurovascular bundle-sparing stereotactic body radiotherapy with periprostatic hydrogel spacer for localized prostate cancer to preserve erectile function

Objective:

We aim to test the hypothesis that neurovascular bundle (NVB) displacement by rectal hydrogel spacer combined with NVB delineation as an organ at risk (OAR) is a feasible method for NVB-sparing stereotactic body radiotherapy.

Methods:

Thirty-five men with low- and intermediate-risk prostate cancer who underwent rectal hydrogel spacer placement and pre-, post-spacer prostate MRI studies were treated with prostate SBRT (36.25 Gy in five fractions). A prostate radiologist contoured the NVB on both the pre- and post-spacer T2W MRI sequences that were then registered to the CT simulation scan for NVB-sparing radiation treatment planning. Three SBRT treatment plans were developed for each patient: (1) no NVB sparing, (2) NVB-sparing using pre-spacer MRI, and (3) NVB-sparing using post-spacer MRI. NVB dose constraints include maximum dose 36.25 Gy (100%), V34.4 Gy (95% of dose) <60%, V32Gy <70%, V28Gy <90%.

Results:

Rectal hydrogel spacer placement shifted NVB contours an average of 3.1 ± 3.4 mm away from the prostate, resulting in a 10% decrease in NVB V34.4 Gy in non-NVB-sparing plans (p < 0.01). NVB-sparing treatment planning reduced the NVB V34.4 by 16% without the spacer (p < 0.01) and 25% with spacer (p < 0.001). NVB-sparing did not compromise PTV coverage and OAR endpoints.

Conclusions:

NVB-sparing SBRT with rectal hydrogel spacer significantly reduces the volume of NVB treated with high-dose radiation. Rectal spacer contributes to this effect through a dosimetrically meaningful displacement of the NVB that may significantly reduce RiED. These results suggest that NVB-sparing SBRT warrants further clinical evaluation.

Advances in knowledge:

This is a feasibility study showing that the periprostatic NVBs can be spared high doses of radiation during prostate SBRT using a hydrogel spacer and nerve-sparing treatment planning.

Preliminary Development of a Mindfulness-Based Group Therapy to Expand Couples' Sexual Intimacy after Prostate Cancer: A Mixed Methods Approach

Introduction

Sexual health and intimacy are consistently reported among the top unmet supportive care needs of prostate cancer (PC) survivors. With an aging population and advances in PC detection and treatment, the need for better PC sexual health interventions is acute.

Aim

Examine the feasibility of a mindfulness-based therapy group aimed at improving sexual intimacy for couples following PC treatments.

Methods

A 4-session mindfulness-based group intervention was developed for PC survivors (mean age 65.6 yrs) and their partners (mean age 61.4 yrs). A mixed-methods approach was adopted to account for small sample sizes (N = 14 couples). Findings will guide future treatment refinement via participants’ lived experiences.

Main Outcome Measures

Quantitative outcomes assessed pretreatment, immediately after treatment, and 6 months later included relationship adjustment, sexual satisfaction, sexual function, depression, anxiety, and mindfulness. Qualitative outcomes used Grounded Theory Approach following posttreatment exit interviews.

Results

Effect sizes 6 months posttreatment indicated moderate improvements in overall sexual satisfaction and large increases in mindfulness in PC survivors, small decreases in sexual intimacy reported by partners, and small increases in anxiety in PC survivors and partners. Qualitative outcomes revealed 6 themes: (i) PC treatments must view PC as a couple’s disease; (ii) PC treatments must consider the impact of illness on individuals and the couple; (iii) Mindfulness was a valued treatment modality; (iv) Individual factors contribute to outcomes, and therefore, must be considered; (v) Multiple perceived mechanisms for change exist; (vi) Group format is a therapeutic element of the process.

Conclusion

An acceptance-based approach to sexual intimacy needs among PC survivors and their partners is feasible. While this small-scale preliminary study suggests that mindfulness may address some currently unmet needs among this population, randomized clinical trials are needed.

JA Bossio, CS Higano, LA Brotto. Preliminary Development of a Mindfulness-Based Group Therapy to Expand Couples’ Sexual Intimacy after Prostate Cancer: A Mixed Methods Approach. Sex Med 2021;9:100310.

Erectile dysfunction and cancer: current perspective

Erectile dysfunction (ED) is one of the major but underreported concerns in cancer patients and survivors. It can lead to depression, lack of intimacy between the couple, and impaired quality of life. The causes of erectile dysfunction are psychological distress and endocrinal dysfunction caused by cancer itself or side effect of anticancer treatment like surgery, radiotherapy, chemotherapy and hormonal therapy. The degree of ED depends on age, pre-cancer or pre-treatment potency level, comorbidities, type of cancer and its treatment. Treatment options available for ED are various pharmacotherapies, mechanical devices, penile implants, or reconstructive surgeries. A complete evaluation of sexual functioning should be done prior to starting anticancer therapy. Management should be individualized and couple counseling should be an integral part of the anticancer treatment.

Stereotactic body radiotherapy as a boost after external beam radiotherapy for high-risk prostate cancer patients

Background

The effect of high-dose-rate (HDR) brachytherapy after external radiation in high-risk prostate cancer patients has been proven. Stereotactic body radiotherapy as a less invasive method has similar dosimetric results with HDR brachytherapy. This study aims to evaluate the prostate-specific antigen (PSA) response, acute side effects, and quality of life of patients who underwent stereotactic body radiotherapy (SBRT) as a boost after pelvic radiotherapy (RT).

Methods

A total of 34 patients diagnosed with high-risk prostate cancer treated with SBRT boost (21 Gy in three fractions) combined with whole pelvic RT (50 Gy in 25 fractions) were evaluated. Biochemical control has been evaluated with PSA before, and after treatment, acute adverse events were evaluated with radiation therapy oncology group (RTOG) grading scale and quality of life with the Expanded Prostate Cancer Index Composite (EPIC) scoring system.

Results

The mean follow-up of 34 patients was 41.2 months (range 7-52). The mean initial PSA level was 22.4 ng/mL. None of the patients had experienced a biochemical or clinical relapse of the disease. Grade 2 and higher acute gastrointestinal (GI) was observed in 14%, and genitourinary (GU) toxicity was observed in 29%. None of the patients had grade 3-4 late toxicity.

Conclusions

SBRT boost treatment after pelvic irradiation has been used with a good biochemical control and acceptable toxicity in high-risk prostate cancer patients. More extensive randomized trial results are needed on the subject.

Relationship between radiation doses and erectile function deterioration in patients with localized prostate cancer treated with permanent prostate brachytherapy

OBJECTIVES

To investigate the relationship between radiation doses in prostate brachytherapy and deterioration of erectile function in patients with localized prostate cancer.

METHODS

A longitudinal survey study was carried out among 261 prostate cancer patients who received prostate brachytherapy. A total of 48 patients were potent at baseline and they did not receive any supplemental therapy preoperatively. Dosimetry parameters of the whole prostate gland, prostate apex, urethra and rectum were collected using the VariSeed 8.0 treatment planning system (Varian Medical Systems, Palo Alto, CA, USA). We carried out a logistic regression analysis to clarify the relationship between radiation doses and erectile function deterioration, which was assessed using the International Index of Erectile Function-15 questionnaire.

RESULTS

The median patient age was 66 years (range 53-70 years) with a median follow-up time of 44 months (36-71 months). The mean total International Index of Erectile Function-15 score decreased from 49.9 at baseline to 34.7 after 12 months (P < 0.001), but gradually plateaued within 36 months. Erectile function deterioration was noted in 32 (66.7%) patients 36 months after prostate brachytherapy. In an analysis of risk factors for erectile function deterioration after prostate brachytherapy, age ≥70 years (P = 0.029), prostate V100 ≥95% (P = 0.024), apex V100 ≥95% (P = 0.024), apex V150 ≥70% (P = 0.009) and apex D90 ≥150 Gy (P = 0.011) correlated with erectile function deterioration. A multivariate analysis identified an age of ≥70 years (odds ratio 7.91, P = 0.024) and apex V150 ≥70% (odds ratio 7.75, P = 0.007) as independent risk factors for erectile function deterioration after prostate brachytherapy.

CONCLUSIONS

An excessive radiation dose, particularly to the prostate apex area, and an advanced age might have a negative impact on the preservation of potency after prostate brachytherapy.

Risk of erectile dysfunction after modern radiotherapy for intact prostate cancer

BACKGROUND

Erectile dysfunction (ED) is a prevalent side effect of prostate cancer treatment. We hypothesized that the previously reported rates of ED may have improved with the advent of modern technology. The purpose of this project was to evaluate modern external beam radiotherapy and brachytherapy techniques to determine the incidence of radiotherapy (RT) induced ED.

METHODS

A systematic review of the literature published between January 2002 and December 2018 was performed to obtain patient reported rates of ED after definitive external beam radiotherapy, ultrafractionated stereotactic radiotherapy, and brachytherapy (BT) to the prostate in men who were potent prior to RT. Univariate and multivariate analyses of radiation dose, treatment strategy, and length of follow-up were analyzed to ascertain their relationship with RT-induced ED.

RESULTS

Of 890 articles reviewed, 24 met inclusion criteria, providing data from 2714 patients. Diminished erectile function status post RT was common and similar across all studies. The median increase in men reporting ED was 17%, 26%, 23%, and 23%, 3DCRT, IMRT, low dose rate BT, and SBRT, respectively, at 2-year median follow-up.

CONCLUSION

ED is a common side effect of RT. Risk of post-RT ED is similar for both LDR brachytherapy and external beam RT with advanced prostate targeting and penile-bulb sparing techniques utilized in modern RT techniques.

Dose to the penile bulb and individual patient anatomy are predictive of erectile dysfunction in men treated with 125I low dose rate brachytherapy for localized prostate cancer

Background: To evaluate the occurrence of erectile dysfunction at 3 years (3yED) after prostate brachytherapy (BT) and to predict 3yED after treatment based on patients and treatments characteristics. Material and methods: From September 2007 to July 2015, 117 men with mild or no ED [International Index of Erectile Function (IIEF-5) > 16] underwent ¹²⁵Iodine real-time ultrasound-guided low-dose rate BT to a total dose of 160 Gy for low-risk or favorable intermediate-risk prostate adenocarcinoma, and were followed prospectively during 3 years. Median age was 63 years (51-79). The post-implant dosimetric parameters on the postoperative computer tomography were derived from the dose-volume histogram of the prostate and the penile bulb (PB), crura, neurovascular bundles (NVBs) and internal pudendal arteries (IPAs). Potential clinical confounding factors were collected. Additionally, anatomical indexes reflecting the prostate anatomical location within the pelvis were studied. These variables were compared between patients with and without 3yED. 3yED was defined as an IIEF-5 score change to the lower category between baseline, with or without medication. Results: The 3yED rate was 59% (62% maintained an IIEF-5 > 16). On multivariate analysis, prostate D90% (p > .5) and pretreatment characteristics including age (p > .5), pre-implant potency (p > .5), diabetes (p = .08) and high cardiovascular risk rates (p = .1) did not influence the occurrence of 3yED. Only the PB dose especially the D10% > 51 Gy was associated with 3yED (p = .005). Conversely, dose to the crura, IPAs or NVBs did not seem to impact the erectile function. The prostate position, especially the apex location varied significantly between potent and impotent patients and 3yED was significantly associated with close position of the prostate apex to PB (p = .008). Conclusion: The most predictive factor of 3yED was the dose to the PB. This may be explained by variation in individual patients' anatomy and this could allow for the development of better strategies to prevent ED.

Comprehensive Evaluation of Focal Therapy Complications in Prostate Cancer: A Standardized Methodology

Purpose: Today, up to one-third of newly diagnosed prostate cancer (PCa) cases may be suitable for focal treatment. The lack of data about the toxicity profiles of lesion-targeting therapies, however, has made it difficult to compare treatment modalities. The aim of the present study was to evaluate comprehensively the incidence, severity, and timing of onset of complications for PCa patients undergoing focal high-intensity focused ultrasound (HIFU) and focal cryosurgical ablation of the prostate (CSAP). Materials and Methods: A total of 336 patients were included who underwent focal HIFU or focal CSAP as a primary treatment for PCa between January 2009 and December 2017. Mean follow-up was 11 months (standard deviation: 3.0). All complications were captured and graded according to severity, and classified by timing of onset. Univariate and multivariate analysis was performed to identify predictors of the most common side effects. Results: There were 98 complications in 79/210 patients (38%) undergoing focal HIFU and 34 complications in 27/126 patients (21%) undergoing focal CSAP. In terms of severity, 95% of the complications of focal HIFU and 91% of the complications of focal CSAP were minor. Most complications presented in the early postoperative period. On multivariate analysis, subtotal HIFU was associated with acute urinary retention (AUR), while a smaller prostate size and longer catheterization time with dysuria. In CSAP patients, longer catheterization time was associated with AUR and urethral sloughing. The main limitation is the nonrandomized and retrospective nature. Conclusions: Focal HIFU and focal CSAP provide a tolerable toxicity, with primarily minor complications presenting in the early postoperative period.

Sexual Health Recovery For Prostate Cancer Survivors: The Proposed Role Of Acceptance And Mindfulness-Based Interventions

INTRODUCTION

1 in every 7 Canadian men is affected by prostate cancer. Given impressive advances in detection, treatment, and survival rates, there is a considerable focus on survivors' supportive care needs. Among the top unmet supportive care needs for prostate cancer survivors are concerns related to sexual health and intimacy.

AIM

To provide a rationale for introducing mindfulness- and acceptance-based approaches into the role of psychosexual interventions aimed at improving sexual satisfaction among prostate cancer survivors (and their partners).

METHODS

A literature review was performed to examine the prevalence of sexual difficulties after prostate cancer treatment and the efficacy of current pharmacologic and psychological treatment approaches.

MAIN OUTCOME MEASURE

The main outcome measure was focused on sexual satisfaction in prostate cancer survivors.

RESULTS

Current pharmacologic interventions for sexual difficulties after prostate cancer treatment are not fully meeting the needs of prostate cancer survivors and their partners. Conclusions cannot be drawn from existing psychological interventions because of methodologic inconsistencies. Additionally, the focus on erectile function as a measure of treatment effectiveness is likely to instill a greater sense of hopelessness and loss for prostate cancer survivors, which may exacerbate issues around sexual intimacy and satisfaction. An impressive body of evidence supports the role of mindfulness in improving women's sexual functioning and there is preliminary evidence suggesting the efficacy of this approach for improving men's sexual functioning.

CONCLUSION

We propose that psychosexual interventions that prioritize mindfulness and acceptance-based frameworks may help men to tune into sensations while challenging the foci on performance and erections, thereby increasing the potential for improvement to sexual satisfaction among prostate cancer survivors. Bossio JA, Miller F, O'Loughlin JI, et al. Sexual Health Recovery for Prostate Cancer Survivors: The Proposed Role of Acceptance and Mindfulness-Based Interventions. Sex Med Rev 2019;7:627-635.

Development and usability testing of a multi-criteria value clarification methods for patients with localized prostate cancer

Current guidelines for the development of decision aids recommend that they have to include a process for helping patients clarify their personal values, for example, by using values clarification methods. In this article, we extensively described the development process of the web-based values clarification method for patients with localized low- to intermediate-risk prostate cancer based on the analytic hierarchy process. With analytic hierarchy process, the relative importance of different attributes of available treatments can be determined through series of pairwise comparisons of potential outcomes. Furthermore, analytic hierarchy process is able to use this information to present respondents with a quantitative overall treatment score and can therefore give actual treatment advice upon patients’ request. The addition of this values clarification method to an existing web-based treatment decision aid for patients with localized prostate cancer is thought to improve the support offered to patients in their decision-making process and their decision quality.

The incidence proportion of erectile dysfunction in patients treated with cryotherapy for prostate cancer: a meta-analysis

OBJECTIVES

With the maturity of cryotherapy for prostate cancer, the complications after operation are also decreasing, which can improve the prognosis of patients. However, erectile dysfunction (ED) is still one of the main complications after cryotherapy. Therefore, we performed a meta-analysis to evaluate the incidence of erectile dysfunction in patients after cryotherapy.

MATERIALS AND METHODS

A comprehensive literature search was performed in August 2018. PUBMED and EMBASE databases were searched to collect studies reporting the incidence rate of ED after cryotherapy from 2002 to 2018. Two reviewers independently screened the literatures, extracted data and assessed the risk of bias of included studies. Pooled ratio and its 95% confidence intervals (95% CIs) were performed by Stata 12.1.

RESULTS

Of the 157 articles identified on August 1st 2018, 23 studies which reported ED after cold ablative therapy were identified, however, only 12 used validated outcome measures and met inclusion criteria. A total of 12 studies were included in this meta-analysis. Overall, the results of this meta-analysis showed that the pooled incidence rate of ED was 0.27 (95% CI 0.26-0.28) which means that the incidence rate of ED after cryotherapy for prostate cancer was not high, but we still found that there are great heterogeneity between the 12 articles. By subgroup analysis, we found a statistically significant incidence rate of ED in primarily localized PCa which was 0.49 (95% CI 0.30-0.68), which is clearly lower than the incidence of recurrent prostate cancer after failed primary radiotherapy 0.61 (95% CI 0.43-0.79).

CONCLUSION

ED is one of the major complications after cryotherapy for PCa. Furthermore, subgroup analysis revealed a higher incidence rate in PCa undergoing radiotherapy. Significantly, with the development of cryotherapy technology, the incidence of ED after cryotherapy for prostate cancer is decreasing. While we still need further researches to advance knowledge in this field.

Canadian consensus algorithm for erectile rehabilitation following prostate cancer treatment

INTRODUCTION

The present descriptive analysis carried out by a pan-Canadian panel of expert healthcare practitioners (HCPs) summarizes best practices for erectile rehabilitation following prostate cancer (PCa) treatment. This algorithm was designed to support an online sexual health and rehabilitation e-clinic (SHARe-Clinic), which provides biomedical guidance and supportive care to Canadian men recovering from PCa treatment. The implications of the algorithm may be used inform clinical practice in community settings.

METHODS

Men's sexual health experts convened for the TrueNTH Sexual Health and Rehabilitation Initiative Consensus Meeting to address concerns regarding erectile dysfunction (ED) therapy and management following treatment for PCa. The meeting brought together experts from across Canada for a discussion of current practices, latest evidence-based literature review, and patient interviews.

RESULTS

An algorithm for ED treatment following PCa treatment is presented that accounts for treatment received (surgery or radiation), degree of nerve-sparing, and level of pro-erectile treatment invasiveness based on patient and partner values. This algorithm provides an approach from both a biomedical and psychosocial focus that is tailored to the patient/partner presentation. Regular sexual activity is recommended, and the importance of partner involvement in the treatment decision-making process is highlighted, including the management of partner sexual concerns.

CONCLUSIONS

The algorithm proposed by expert consensus considers important factors like the type of PCa treatment, the timeline of erectile recovery, and patient values, with the goal of becoming a nationwide standard for erectile rehabilitation following PCa treatment.

Analysis of Motion-dependent Clinical Outcome of Tumor Tracking Stereotactic Body Radiotherapy for Prostate Cancer

BACKGROUND

To analyze clinical outcome of CyberKnife (CK) tumor-tracking stereotactic body radiotherapy (SBRT) for prostate cancer (Pca) according to the magnitude of intra-fractional prostate motion.

METHODS

Medical records and daily treatment logs for 71 patients who received CK tumor-tracking SBRT were retrospectively analyzed. Statistical relationships between prostate motion and various outcome results, including local recurrence (LR), biochemical failure (BF), and treatment-related toxicity, were investigated in order to evaluate motion-dependent efficacy of tumor-tracking SBRT for Pca.

RESULTS

In a total 71 patients, 3 (4.2%) patients with LR, 12 (16.9%) patients with BF, and 22 (31%) patients with grade-II or worse toxicities to rectal or bladder (22 to rectal, 22 to bladder and 8 patients to both) were observed in a median follow-up of 47 months. Magnitudes of intra-fractional tumor motion along superior-inferior, right-left, and anterior-posterior (AP) axes were 0.15 ± 0.31, 0.12 ± 0.19, and 0.73 ± 0.32 mm, respectively. Radial magnitude was estimated to be 1.0 ± 0.35 mm. Intra-fractional movement was not significantly correlated with tumor control. However, it was significant correlated with the incidence of grade-II or worse toxicity to rectum or bladder particularly when tumor motion was in the AP axis.

CONCLUSION

Our quantitative results revealed that toxicity related to SBRT treatment was highly sensitive to intra-fractional prostate movements, although local-tumor control was not affected by such movements. Our results demonstrate that precise motion correction is essential in prostate SBRT, even if it seems to be small.

Does penile rehabilitation have a role in the treatment of erectile dysfunction following radical prostatectomy?

In men undergoing radical treatment for prostate cancer, erectile function is one of the most important health-related quality-of-life outcomes influencing patient choice in treatment. Penile rehabilitation has emerged as a therapeutic measure to prevent erectile dysfunction and expedite return of erectile function after radical prostatectomy. Penile rehabilitation involves a program designed to increase the likelihood of return to baseline-level erectile function, as opposed to treatment, which implies the therapeutic treatment of symptoms, a key component of post–radical prostatectomy management. Several pathological theories form the basis for rehabilitation, and a plethora of treatments are currently in widespread use. However, whilst there is some evidence supporting the concept of penile rehabilitation from animal studies, randomised controlled trials are contradictory in outcomes. Similarly, urological guidelines are conflicted in terms of recommendations. Furthermore, it is clear that in spite of the lack of evidence for the role of penile rehabilitation, many urologists continue to employ some form of rehabilitation in their patients after radical prostatectomy. This is a significant burden to health resources in public-funded health economies, and no effective cost-benefit analysis has been undertaken to support this practice. Thus, further research is warranted to provide both scientific and clinical evidence for this contemporary practice and the development of preventative strategies in treating erectile dysfunction after radical prostatectomy.

The Natural History of Erectile Dysfunction After Prostatic Radiotherapy: A Systematic Review and Meta-Analysis

BACKGROUND

Erectile dysfunction (ED) after treatment for prostate cancer with radiotherapy (RT) is well known, and pooled estimates of ED after RT will provide more accurate patient education.

AIM

To systematically evaluate the natural history of ED in men with previous erectile function after prostate RT and to determine clinical factors associated with ED.

METHODS

We performed a review of the PubMed and Medline, Embase, Cochrane Library, and Web of Science databases in April 2016 according to the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) statement. Identified reports included a measurement of ED before and after prostate RT. Two hundred seventy-eight abstracts were screened and 105 publications met the criteria for inclusion. Only men with known erectile function before RT were included in the analysis.

OUTCOME

ED after RT of the prostate.

RESULTS

In total, 17,057 men underwent brachytherapy (65%), 8,166 men underwent external-beam RT (31%), and 1,046 men underwent both (4%). Seven common instruments were used to measure ED, including 23 different cutoffs for ED. The Sexual Health Inventory for Men (SHIM) was used in 31 studies (30%). Pooled estimates of SHIM-confirmed ED (score <10-17) suggested the prevalence of ED after RT is 34% of men (95% CI = 0.29-0.39) at 1 year and 57% (95% CI = 0.53-0.61) at 5.5 years. Compared with brachytherapy, studies of the two types of radiation increased the proportion of new-onset ED found by 12.3% of studies (95% CI = 2.3-22.4). For every 10% who were lost to follow-up, the proportion of ED reported increased by 2.3% (95% CI = 0.03-4.7).

CLINICAL IMPLICATIONS

ED is common regardless of RT modality and increases during each year of follow-up. Using the SHIM, ED is found in approximately 50% patients at 5 years.

STRENGTHS AND LIMITATIONS

The strengths of this systematic review include strict inclusion criteria of studies that measured baseline erectile function, no evidence for large effect size bias, and a large number of studies, which allow for modeling techniques. However, all data included in this analysis were observational, which leaves the possibility that residual confounding factors increase the rates of ED.

CONCLUSION

Definitions and measurements of ED after RT vary considerably in published series and could account for variability in the prevalence of reported ED. Loss to follow-up in studies could bias the results to overestimate ED. Gaither TW, Awad MA, Osterberg EC, et al. The Natural History of Erectile Dysfunction After Prostatic Radiotherapy: A Systematic Review and Meta-Analysis. J Sex Med 2017;14:1071-1078.

Reproducibility in contouring the neurovascular bundle for prostate cancer radiation therapy

PURPOSE

Efforts to define the neurovascular bundle (NVB) for prostate radiation have varied. In this series, we sought to determine the reproducibility and reliability of contouring the classical posterolateral NVB on dedicated pelvic magnetic resonance imaging (MRI) scans.

METHODS AND MATERIALS

A total of 120 NVB structures were defined on 10 3-Tesla pelvic MRI scans in patients with prostate cancer but without extraprostatic extension. One pelvic radiologist served as the expert in contouring the right and left NVB for each case. Five radiation oncologists, with varying levels of experience, contoured the right and left NVBs on these same cases. The intraclass correlation coefficient across each rater and the expert, Pearson correlation coefficient between each rater and the expert, and the Dice similarity coefficient (DSC) between each rater and the expert were calculated to evaluate contour agreement and overlap.

RESULTS

The overall intraclass correlation coefficient was 0.89 (95% confidence interval [CI], 0.81-0.95). The Pearson correlation coefficient was 0.95 (95% CI, 0.86-0.98) for rater 1, 0.98 (95% CI, 0.95-0.99) for rater 2, 0.94 (95% CI, 0.86-0.98) for rater 3, 0.98 (95% CI, 0.95-0.99) for rater 4, and 0.84 (95% CI, 0.63-0.93) for rater 5. The mean DSC was 0.72 (standard deviation [SD], 0.07) for rater 1, 0.72 (SD, 0.06) for rater 2, 0.73 (SD, 0.09) for rater 3, 0.74 (SD, 0.09) for rater 4, and 0.68 (SD, 0.13) for rater 5. Overall, across all raters, the average DSC was 0.72 (SD, 0.09).

CONCLUSIONS

The classic posterolateral NVB can be accurately and reliably contoured on 3-Tesla pelvic MRI scans by radiation oncologists.

Prospective evaluation of a specific technique of sexual function preservation in external beam radiotherapy for prostate cancer

OBJECTIVE

Sexual preservation is an important issue in the treatment of localized prostate cancer. A technique of irradiation was developed to better preserve this function and has been evaluated.

METHODS

Eleven patients, with no erectile dysfunction (ED), were treated with daily IMRT-IGRT (total dose: 76-78 Gy). The pudendal arteries, penile bulb and cavernous body were delineated on the planning CT scan. The doses to these structures (with a 5 mm margin) were optimized to be as low as possible. The erectile function was documented using IIEF-5 scores at baseline, 6 months, 1 and 2 years. No ED was defined by an IIEF5 ≥ 20/25, a mild ED by an IIEF5 score of 17-19 and an important ED by a score <17.

RESULTS

The mean age was 68.4 years. At the median follow-up of 36 months, there was no biochemical relapse. Before RT, the mean IIEF5 score in all 11 patients was 23.4 (range, 20-25). At 6, 12, 18 and 24 months after RT, the mean IIEF scores were 21.2 (14-25), 21.3 (14-25), 21.8 (16-25) and 21.8 (16-25), respectively. At 2 years, 8 patients (72.7%) had no ED and 2 patients (18.2%) experienced a mild ED. The only patient with an important ED had a medical treatment and recovered a satisfactory IIEF score from 16 to 24.

CONCLUSION

The results of this technique of optimisation for sexual preservation are encouraging. Despite a mean age close to 70 years at the time of treatment, 90.9% of the patients had no to mild ED at 2 years. This rate increases at 100% with medical treatment. Advances in knowledge: Dose optimization on sexual organs is possible and could decrease the ED rates.

Factors associated with current and severe physical side-effects after prostate cancer treatment: What men report

We identified patient and disease characteristics associated with (1) "current" physical side-effects of any severity; and (2) "severe" physical side-effects "ever" experienced by 3,348 (54%) prostate cancer (PCa) survivors in Ireland diagnosed 2-18 years previously. Postal questionnaires collected symptoms at diagnosis, post-biopsy complications, comorbidities, primary treatments and physical side-effects post-treatment (urinary incontinence, erectile dysfunction, libido loss, bowel problems, breast changes, hot flushes, and fatigue, "ever" and "current" at time of questionnaire completion). Men were grouped by "early" (localised) and "late" (locally advanced/advanced) disease at diagnosis. Multivariable logistic regression analysis identified patient and disease-related factors associated with post-treatment side-effects. Complications post-biopsy were associated with higher risk of "current" libido loss and impotence. Radical prostatectomy was associated with higher risk of "current" and "severe" incontinence, libido loss and impotence in both early and late disease. In early disease, brachytherapy was associated with lower risk of "current" fatigue and "severe" impotence. Comorbidities were associated with higher risk of "current" experience of four side-effects (incontinence, libido loss, bowel problems, fatigue). Men on active surveillance/watchful-waiting reported lower risk of sexual dysfunction. These findings could inform development of tailored information on side-effects, which, in turn, could inform treatment decision-making and post-treatment monitoring.

Radiation safety of receptive anal intercourse with prostate cancer patients treated with low-dose-rate brachytherapy

PURPOSE

Prostate low-dose-rate (LDR) brachytherapy involves implantation of radioactive seeds permanently into the prostate gland. During receptive anal intercourse, the penis of the partner may come in close proximity to the implanted prostate gland. We estimate the potential intrarectal dose rates and suggest guidance on radiation precautions.

METHODS AND MATERIALS

One hundred two patients were included in the study. After implantation, with patients under anesthesia in the dorsal lithotomy position, a new set of ultrasound (US) images and a CT scan were obtained. The images were fused, radioactive seeds and US probe locations were determined on the CT, and prostate, bladder, and rectal contours were drawn on the US. Dose rates (cGy/h) were calculated for the portion of the US probe spanning the prostate for several dose-volume histogram parameters.

RESULTS

Twenty patients were treated with (125)I and 82 patients with (103)Pd. Average dose rates at Day 0 to the portion of the US probe spanning the prostate were 2.1 ± 1.3 cGy/h and 2.5 ± 0.8 cGy/h for patients treated with (125)I and (103)Pd, respectively. After 60 days, average calculated probe dose drops to 1.0 ± 0.6 cGy/h and 0.2 ± 0.1 cGy/h for (125)I and (103)Pd, respectively.

CONCLUSIONS

During the immediate weeks after prostate seed implant, the estimated intrarectal dose rates are higher in (103)Pd compared to (125)I. As (103)Pd decays faster than (125)I, 2 months after the implant, radiation exposure from (103)Pd becomes lower than (125)I. Receptive anal intercourse time should be kept as low as possible during 2 and 6 months after low-dose-rate brachytherapy of the prostate with (103)Pd and (125)I, respectively.

Changes in penile bulb dose when using the Clarity transperineal ultrasound probe: A planning study

PURPOSE

The Clarity system allows monitoring of intrafraction target organ movements in external beam radiation therapy of prostate cancer by using transperineal ultrasound. The probe positioning at the perineum could lead to a compression and shift of the penile bulb (PB) toward the high-dose region. Dose to the PB has been reported to be associated with the risk of posttreatment erectile dysfunction. This planning study reports on PB translations and changes in volume and dose when applying the transperineal ultrasound probe.

METHODS AND MATERIALS

For 10 patients treated with external beam radiation therapy for prostate cancer between 2013 and 2014, a planning computed tomography scan with and without the ultrasound probe in place was acquired. The planning target volume and organs at risk including the PB were contoured in the computed tomography scan with and without the probe. Radiation therapy plans for both scenarios were calculated. In a second step, for planning with the probe in position, an additional objective for improved sparing of the PB was introduced.

RESULTS

The median PB volume was 5.5 mL (range, 3.8-7.1 mL) without the probe and 3.5 mL (range, 2.0-5.8 mL) with the probe. The median shift of the PB was 1 mm in the posterior (range, 3 mm posterior-2 mm anterior) and 6 mm in the superior direction (range, 0-14 mm superior), with no relevant shift of the prostate. The median mean dose in 95% of the PB was 34.1 Gy (range, 6.0-50.4 Gy), 48.3 Gy (range, 7.2-56.8 Gy), and 39.4 Gy (range, 5.6-51.3 Gy) for plans without probe, with probe, and with probe and additional planning objective, respectively.

CONCLUSIONS

Dose to the PB increased when using the transperineal probe. After introducing an additional plan-optimization objective for PB sparing, dose-volume parameters were below Quantitative Analyses of Normal Tissue Effects in the Clinic thresholds for all but one patient.

Evaluation of tolerance and toxicity of high-dose-rate brachytherapy boost combined with interstitial hyperthermia for prostate cancer

Purpose The aim of this retrospective study was to evaluate the tolerance and early as well as late toxicity of high dose rate brachytherapy (HDRBT) boost combined with interstitial hyperthermia (IHT) in patients treated for prostate cancer. Material and methods Between January 2011 and June 2013 76 patients diagnosed with prostate cancer received treatment consisting of external beam radiotherapy (EBRT), followed by a HDRBT boost combined with IHT. IHT was performed before each brachytherapy fraction. Results The median follow-up time was 26.3 months (range 7-43 months). Early genitourinary (GU) grade 1 and 2 toxicities were common, but only two patients (2.6%) experienced acute urinary retention requiring temporary catheterisation (grade 2 toxicity). No grade 3 or 4 genitourinary or gastrointestinal toxicities were observed. In the group analysed, 59 of 76 patients had follow-up times longer than 18 months. The incidence of grade 2 late toxicity in the group studied did not exceed 23.7%. There were no late grade 2 or higher complications from the gastrointestinal tract. Conclusions The tolerance of HDRBT boost combined with IHT is good. The profile and the percentage of early and late complications are acceptable.

Focal cryotherapy of localized prostate cancer: a systematic review of the literature

Radical/whole gland treatment for prostate cancer has significant side-effects. Therefore focal treatments such as cryotherapy have been used to treat localized lesions whilst aiming to provide adequate cancer control with minimal side-effects. We performed a systematic review of Pubmed/Medline and Cochrane databases' to yield 9 papers for primary focal prostate cryotherapy and 2 papers for focal salvage treatment (radio-recurrent). The results of 1582 primary patients showed biochemical disease-free survival between 71-93% at 9-70 months follow-up. Incontinence rates were 0-3.6% and ED 0-42%. Recto-urethral fistula occurred in only 2 patients. Salvage focal cryotherapy had biochemical disease-free survival of 50-68% at 3 years. ED occurred in 60-71%. Focal cryotherapy appears to be an effective treatment for primary localized prostate cancer and compares favorably to radical/whole gland treatments in medium-term oncological outcomes and side-effects. Although more studies are needed it is also effective for radio-recurrent cancer with a low complications rates.

External beam radiotherapy for localized prostate cancer

Radiotherapy (XRT) is a curative treatment option for prostate cancer (PCa). Recent XRT technologies allow higher dose therapy that lead to increased local control with less adjacent tissue damage. Additionally, receiving neo-adjuvant or adjuvant hormonotherapy (HT) during radiation therapy increases the curative effect. The aim of this paper is to review the current literature and guidelines on external beam radiation therapy for PCa. However, brachytherapy and radiosurgery, a recently evolving relatively new technology for the radiotherapeutic management of localized PCa, are beyond the scope of this paper.

[Erectile dysfunction evaluation after brachytherapy for low risk prostate adenocarcinoma: prospective study of patients with a baseline IIEF5>16]

PURPOSE

To evaluate erectile function (EF) prospectively from 1 to 2 years post-brachytherapy in patients with a baseline IIEF5 score>16.

METHODS

Between 2007 and 2012, 179 patients underwent an exclusive brachytherapy for localised low risk prostate adenocarcinoma. Neo-adjuvant hormotherapy (15.6%) and post-brachytherapy intake phosphodiesterase inhibitors (PDE5i) were not considered as exclusion criteria. EF was evaluated via a scoring questionnaire IIEF5 before the surgical implantation, at month 12 and 24 post-operation. Only patients with an initial IIEF5 score>16 were included.

RESULTS

Of the 179 patients, 102 (57%) had a baseline IIEF5>16. At 12 months, 51.1% maintained an IIEF5>16 and 24.5% had a mild to moderate erectile dysfunction (ED), so that a total of 75.6% with IIEF5≥12. About 18% of patients had used PDE5i. At 24 months, 53.2% had an IIEF5>16 and 80.6% had an IIEF5≥12. Severe ED was reported in only 14.5% of the patients. The mean IIEF5 was 16.2 with an average decline of 5 points from the initial stage. All patients who were treated with PDE5i (27%) could have sexual intercourse. EF at baseline was reported as the only predictive factor of ED in multivariate analysis, 70% of patient without ED initially, had an IIEF5>16 at 1 and 2 years.

CONCLUSION

Severe ED was quite rare (14%) during the first 2 years post-brachytherapy and more than half of patients maintained an IIEF5>16. The main predictive factor was the erectile function at baseline.

LEVEL OF EVIDENCE

4.

Relationship between sexual function and prostate-specific antigen bounce after iodine-125 permanent implant brachytherapy for localized prostate cancer

OBJECTIVE

To analyze clinical and dosimetric factors involved in prostate-specific antigen bounce in patients who underwent permanent implant brachytherapy for localized prostate cancer, and to study the relationships among prostate-specific antigen bounce, age and sexual function.

METHODS

Between March 2007 and April 2012, 116 patients with localized prostate cancer underwent permanent implant, iodine-125 brachytherapy. Patients receiving external-beam radiotherapy or who used phosphodiesterase-5 inhibitor pre- or post-treatment were excluded. Prostate-specific antigen bounce was defined as an increase of ≥0.2 ng/mL and ≥0.4 ng/mL above an initial prostate-specific antigen nadir followed by a subsequent decline to or below the initial nadir without treatment. Clinical and dosimetric factors involved in prostate-specific antigen bounce were analyzed using multivariate logistic regression analysis with the forced entry method.

RESULTS

The median age was 66 years (range 51-80 years), and prostate-specific antigen bounce on a prostate-specific antigen rise of ≥0.2 ng/mL occurred in 47 of the 116 participants (40.5%). The median period before the prostate-specific antigen bounce was 17.5 months (range 8-36 months). Patients with prostate-specific antigen bounce were younger and had higher sexual function before treatment (P = 0.003) than those who not show prostate-specific antigen bounce. Regression analysis results showed that young age and a high level of pretreatment sexual function were significant predictive factors for prostate-specific antigen bounce (P = 0.028 and P = 0.048).

CONCLUSION

Sexual function seems to be associated with a prostate-specific antigen bounce in patients undergoing permanent implant brachytherapy for localized prostate cancer, and it can be preserved after treatment if it is well present before treatment. Highly maintained sexual function after treatment might influence prostate-specific antigen bounce.

Cryotherapy for primary treatment of prostate cancer: intermediate term results of a prospective study from a single institution

Purpose. Published data about cryotherapy for prostate cancer (PC) treatment are based on case series with a lack of clinical trials and the inexistence of a validated definition of biochemical failure. A prospective study with standardized followup protocol was conducted in our institution. Material and Methods. Prospective study of a series of cases including 108 patients diagnosed with localized PC at clinical stage T1c-T2c treated by primary cryoablation and median followup of 61 months. Criteria of biochemical recurrence were unified according to the American Society for Therapeutic Radiology and Oncology (ASTRO). End points were biochemical progression-free survival (BPFS), cancer-specific survival, and overall survival. Rate of complications was reported. Results. The BPFS for low-, medium-, and high-risk patients was 96.4%, 91.2%, and 62.2%, respectively. Cancer-specific survival was 98.1%. Overall survival reached 94.4%. Complications included incontinence in 5.6%, urinary tract obstruction in 1.9%, urethral sloughing in 5.6%, haematuria in 1.9%, perineal pain in 11.1%, and prostatorectal fistula in 0.9%. Erectile disfunction was found in 98.1%. Conclusions. Cryotherapy is an effective and minimally invasive treatment for primary PC in well-selected cases, with low surgical risk and good results in terms of BPFS, cancer-specific survival, and overall survival.

Localised prostate cancer: clinical and cost-effectiveness of new and emerging technologies

In contrast to pharmacological interventions that undergo rigorous clinical testing, recent technological advances in the treatment of prostate cancer (PCa) have particularly been introduced and driven by economic incentives rather than high-quality clinical evidence. In this review we summarise the clinical and cost-effectiveness of new and emerging technologies for localised PCa. We emphasise particularly on robotic prostatectomy, new developments in radiotherapy, novel technologies in focal therapy such as cryosurgery and high-intensity focused ultrasound (HIFU). Robotic-assisted laparoscopic radical prostatectomy (RALRP) has similar oncologic outcomes to open radical retropubic prostatectomy (RRP); however, patients who undergo RALRP are more likely to have improved short-term potency rates. Intensity-modulated radiotherapy (IMRT) and proton-beam therapy (PBT) have similar oncologic outcomes to external-beam radiotherapy (EBRT). IMRT has exhibited an improved gastrointestinal side effect profile compared to EBRT. PBT is not cost-effective compared to other radiotherapy modalities. Early studies of focal therapies in localised PCa have yielded positive results. Treatment decisions should be driven by cancer risk and patient preference rather than by financial incentives or availability of technology.

Patients' self-assessment versus investigators' evaluation in a phase III trial in non-castrate metastatic prostate cancer (GETUG-AFU 15)

BACKGROUND

Toxicity, which is a key parameter in the evaluation of cancer treatments, can be underestimated by clinicians. We investigated differences between patients and physicians in reporting adverse events of androgen deprivation therapy (ADT) with or without docetaxel in a multicentre phase III trial in non-castrate metastatic prostate cancer.

METHODS

The 385 patients included were invited to complete a 26-symptom questionnaire 3 and 6 months after the start of treatment, among which eighteen symptoms were also assessed by physicians, reported in medical records and graded using the Common Toxicity Criteria of the National Cancer Institute. Positive and negative agreements as well as Kappa concordance coefficients were computed.

FINDINGS

Data were available for 220 and 165 patients at 3 and 6 months respectively. Physicians systematically under-reported patients' symptoms. Positive agreement rates (at respectively 3 and 6 months) for the five most commonly reported symptoms were: 61.0% and 64.3% hot flushes, 50.0% and 43.6% fatigue, 29.4% and 31.1% sexual dysfunction, 24.4% and 14.4% weigh gain/loss, 16.7% and 19.3% for joint/muscle pain. For symptoms most frequently reported as disturbing or very disturbing by patients, the clinicians' failure to report them ranged from 50.8% (hot flushes) to 89.5% (joint/muscle pain) at 3 months, and from 48.2% (hot flushes) to 88.4% (joint/muscle pain) at 6 months.

INTERPRETATION

Physicians often failed to report treatment-related symptoms, even the most common and disturbing ones. Patients' self-evaluation of toxicity should be used in clinical trials to improve the process of drug assessment in oncology.

FUNDING

French Health Ministry and Institut National du Cancer (PHRC), Sanofi-Aventis, Astra-Zeneca, and Amgen.

Anxiety level of early- and late-stage prostate cancer patients

Purpose:

Anxiety can worsen prostate cancer patients’ decision making and quality of life. Early identification of anxiety disorders is thus very important for excellent prostate cancer treatment. This study aimed to determine the levels of anxiety in patients with early-stage prostate cancer compared with advanced-stage disease.

Methods:

This cross-sectional study was performed at the Department of Urology, ‘Cipto Mangunkusumo’ Hospital, Faculty of Medicine, University of Indonesia. The subjects were early-stage prostate cancer patients and advanced-stage prostate cancer patients with bone metastatic lesions proved by bone scan. Comparative analysis was done to analyze anxiety scores assessed by use of an 11-item modified Memorial Anxiety Scale for Prostate Cancer (MAX-PC) questionnaire. We also assessed the relationship of the MAX-PC score with age, prostate-specific antigen (PSA) value, number of bone metastases, and pain. Data were analyzed by using SPSS ver. 17 (SPSS Inc.).

Results:

There were 34 subjects with early-stage prostate cancer and 34 subjects with advanced-stage prostate cancer. We found that the mean anxiety score was significantly lower (P=0.0001) in the early-stage prostate cancer group (8.32±3.65) than in the advanced-stage prostate cancer group (12.61±4.56). Nine subjects had a pathological MAX-PC score (≥16), of whom 1 subject had early-stage disease and 8 subjects had advanced-stage disease. Furthermore, there were significant positive correlations (P<0.001) between MAX-PC score and visual analogue scale pain score (r=0.633), PSA value (r=0.263), and number of bone metastatic lesions (r=0.464). However, the correlation between age and anxiety score was not significant (P=0.170).

Conclusions:

The MAX-PC anxiety score was significantly associated with the stage of prostate cancer. Furthermore, visual analogue scale pain score, PSA value, and number of bone metastatic lesions can also affect the MAX-PC anxiety score.

Management of prostate cancer in Asia: resource-stratified guidelines from the Asian Oncology Summit 2013

Many local and systemic options for prostate cancer have emerged in recent years, but existing management guidelines do not account for diversity in health resources between different countries. We present recommendations for the management of prostate cancer, stratified according to the extent of resource availability-based on a four-tier system of basic, limited, enhanced, and maximum resources-to enable applicability to Asian countries with differing levels of health-care resources. This statement of recommendations was formulated by a multidisciplinary panel from Asia-Pacific countries, at a consensus session on prostate cancer that was held as part of the 2013 Asian Oncology Summit in Bangkok, Thailand.