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

Reliability of maximal cardiopulmonary exercise testing in men with prostate cancer

PURPOSE

To accurately assess exercise interventions and to evaluate acute and chronic cardiovascular effects in patients with early-stage cancer, consistently reliable functional outcome measures must be obtained. An incremental cardiopulmonary exercise test (CPET) with gas exchange measurement to assess peak oxygen consumption (V˙O2peak) provides the gold standard outcome of cardiorespiratory fitness.

METHODS

In the context of a randomized controlled trial, 40 patients with prostate cancer (mean age, 59 ± 7 yr) after radical prostatectomy performed two maximal CPET within 5.6 ± 5.5 d of each other. Incremental treadmill tests were performed in the morning under identical laboratory conditions. Reliability and within-subject variability from test 1 to test 2 for peak and submaximal variables were assessed by correlation coefficients, intraclass correlations (ICC), Bland-Altman plots, coefficient of variation, and paired t-tests.

RESULTS

There was high reliability between CPET for V˙O2peak (r = 0.92; P < 0.001; ICC, 0.900), ventilatory threshold (r = 0.88; P < 0.001; ICC, 0.927), minute ventilation-carbon dioxide production relation (V˙E/V˙CO2) (r = 0.86; P < 0.001; ICC, 0.850), and peak heart rate (r = 0.95; P < 0.001; ICC, 0.944). However, high within-subject variability was observed for all CPET parameters (mean coefficient of variation, 4.7%). Compared with those for test 1, significantly higher mean values were observed for V˙O2peak (27.0 ± 5.6 vs 28.1 ± 5.3 mL·kg·min, P < 0.05), ventilatory threshold (1.91 ± 0.5 vs 1.97 ± 0.4 L·min, P < 0.05), and V˙E/V˙CO2 (31.3 ± 5.8 vs 32.8 ± 3.4, P < 0.05) in test 2.

CONCLUSIONS

These findings indicate the presence of significant, and potentially clinically important, variability in CPET procedures in men with clinically localized prostate cancer and have important implications for the application and use of CPET to evaluate the efficacy of interventions to improve aerobic capacity in the oncology setting.

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.

Low-dose rate brachytherapy for patients with low- or intermediate-risk prostate cancer: A systematic review

INTRODUCTION

We review the current evidence for the role of low-dose rate brachytherapy (PB) in patients with low- or intermediate-risk prostate cancer using a systematic review of the literature.

METHODS

We searched MEDLINE and EMBASE (from January 1996 to October 2011), the Cochrane Library, relevant guideline web-sites, and websites for meetings specific for genitourinary diseases.

RESULTS

Ten systematic reviews and 55 single-study papers met the pre-planned study selection criteria. In the end, 36 articles were abstracted and analyzed for this systematic review. There is no evidence for a difference in efficacy between PB and external beam radiation therapy (EBRT), or between PB and radical prostatectomy (RP). During the 6 months to 3 years after treatment, PB was associated with less urinary incontinence and sexual impotency than RP, and RP was associated with less urinary irritation and rectal morbidity than PB. However, these differences diminished over time. PB conferred less risk of impotency and rectal morbidity in the three years after treatment than EBRT. Iodine-125 and alladium-103 did not differ with respect to biochemical relapse-free survival and patient-reported outcomes.

CONCLUSIONS

PB alone is a treatment option with equal efficacy to EBRT or RP alone in patients with newly diagnosed low- or intermediate-risk prostate cancer who require or choose active treatment.

Evidence-based guideline recommendations on low-dose rate brachytherapy in patients with low- or intermediate-risk prostate cancer

OBJECTIVE

The Genitourinary Cancer Disease Site Group (GU DSG) and Cancer Care Ontario's Program in Evidence-Based Care (PEBC) in Ontario, Canada developed a guideline on low-dose rate brachytherapy (LDR-BT) in patients with early-stage low-grade prostate cancer in 2001. The current updated guideline focuses on the research questions regarding the effect of LDR-BT alone, the effect of LDR-BT with external beam radiation therapy (EBRT) and the selection of an isotope.

METHODS

This guideline was developed by using the methods of the Practice Guidelines Development Cycle and the core methodology was a systematic review. MEDLINE and EMBASE (from January 1996 to October 2011), the Cochrane Library, main guideline websites, and main annual meeting abstract websites specific for genitourinary diseases were searched. Internal and external reviews of the draft guideline were conducted.

RESULTS

The draft guideline was developed according to a total of 10 systematic reviews and 55 full text articles that met the pre-planned study selection criteria. The quality of evidence was low to moderate. The final report reflects integration of the feedback obtained through the internal review (two oncologists and a methodologist) and external review (five target reviewers and 48 professional consultation reviewers) process, with final approval given by the GU DSG and the PEBC.

CONCLUSION

THE MAIN RECOMMENDATIONS ARE: (1) For patients with newly diagnosed low-risk or intermediate-risk prostate cancer who require or choose active treatment, LDR-BT alone is a treatment option as an alternative to EBRT alone or RP alone; and (2) I-125 and Pd-103 are each reasonable isotope options.

The contribution of the cone beam Kv CT (CBKvCT) to the reduction in toxicity of prostate cancer treatment with external 3D radiotherapy

OBJECTIVE

Show that verification through cone beam Kv CT (CBKvCT) in a series of patients treated with 3D external radiotherapy (3DRT) for prostate cancer (PC) is related to a reduction in acute and late toxicity levels.

MATERIALS AND METHOD

A retrospective, non-randomized study of two homogeneous groups of patients treated between 2005 and 2008, 46 were verified using electronic portal devices (EPIDs) and 48 through CBKvCT. They received 3DRT for localized PC (T1-T3N0M0) and were prescribed the same doses. Treatment was simulated and planned with the same criteria with the same equipment with a median follow-up time of 24 months (12-54 months). Urinary and gastrointestinal toxicity was determined using Common Toxicity Criteria scale, version 4 and RTOG scales. Statistical analysis of data was performed where p < 0.005 being significative.

RESULTS AND DISCUSSION

With an overall median follow-up time of 24 months, the levels of proctitis were, respectively, 19.56, 15.21 and 15.2 % in the first group, compared with 4.17, 2.08 and 8.33 % in the second. Statistically, less total and late proctitis, late rectal bleeding, anal fissure, total and acute haematuria, total and acute urinary frequency and total urinary incontinence was observed. No statistically significant evidence of a lowering in toxicity neither in terms of acute and late dysuria nor of a relationship to the TNM, Gleason or PSA or in the grade of stability.

CONCLUSION

Verification through CBKvCT in this series is associated with a statistically significant lowering toxicity. This justifies its use. Greater monitoring would be necessary to assess the impact of verification at the level of biochemical control.

A national study of adverse effects and global quality of life among candidates for curative treatment for prostate cancer

OBJECTIVES

To provide population-based estimates of typical adverse effects (AEs), e.g. urinary, bowel and sexual dysfunction, in patients with non-metastatic recurrence-free prostate cancer (PCa) by curative treatment method, including no treatment. To describe associations between typical AEs and global quality of life (QoL) and to study patients' use of medication for erectile dysfunction (EDmed) and the relationship between such use and global QoL.

PATIENTS AND METHODS

In October 2006 a national population-based sample of PCa survivors diagnosed in 2004 was invited to a postal survey focusing on treatment-related AEs and global QoL, 12-32 months after treatment start. All had completed their initial treatment. In the present study, 771 compliers were categorized into four groups of localized or locally advanced PCa related to the treatment they completed: (i) no treatment; (ii) radical prostatectomy (RP); (iii) radiotherapy (RAD) without hormones; and (iv) RAD with hormone therapy of 3-24 months duration. Measurement of AEs was restricted to function, using selected items from the 50-item Expanded Prostate Cancer Index Composite and the Brief Sexual Function Inventory among others, whereas global QoL was measured with the 12-item short-form health survey. National prescription data enabled assessment of adjuvant hormone application and EDmed use.

RESULTS

Men who had undergone RP reported more urinary incontinence (24%) than the other treatment groups, but had the lowest level of moderate/severe urinary irritative-obstructive symptoms. Men from the 'no treatment' group had the highest level of moderate/severe irritative-obstructive urinary symptoms. Men who had undergone RAD reported higher levels of irritative intestinal symptoms and faecal leakage compared with the RP group and the no treatment group. In all treatment groups, poor sexual drive and poor erectile function were common AEs, with men treated with RP reporting the highest prevalence of poor erectile function (89%). Presence of irritative-obstructive urinary symptoms and poor sexual drive were independently associated with low global QoL in multivariate analyses. Fifty percent of the study group had used EDmed after treatment start, but only 47% of them were still using EDmed at the time of the survey. Use of EDmed was not significantly associated with global QoL.

CONCLUSIONS

PCa survivors after curative treatment, but also patients without any anticancer therapy, report high levels of urinary and sexual AEs. Irritative-obstructive urinary symptoms and poor sexual drive were significantly associated with low global QoL, whereas erectile function and use of EDmed were not.

High perceived stress is linked to afternoon cortisol levels and greater symptom distress in patients with localized prostate cancer

BACKGROUND

Patients treated with radical prostatectomy (RP) or radiation therapy (RT) for prostate cancer can experience stress and symptoms that impact quality of life.

OBJECTIVE

The objectives of this study were to describe cortisol levels, perceived stress, symptoms, and symptom distress; compare differences in variables measured between RP and RT; and identify associations among cortisol levels, perceived stress, symptoms, and symptom distress in patients treated for localized prostate cancer.

METHODS

A descriptive, cross-sectional study was conducted with 53 patients (RP n = 24, RT n = 29). Data from saliva, questionnaires, and interviews were collected within 3 months of treatment. Saliva samples were collected at 4 times over 2 consecutive days. Data were analyzed using descriptive statistics, correlations, and regressions.

RESULTS

A robust diurnal rhythm of cortisol secretion with heightened levels in the early morning and lowered levels late in the day was found. On average, the entire sample had moderate symptoms and symptom distress for urinary, bowel, and sexual dysfunction. The RP group reported significantly more urinary and sexual dysfunction symptoms and fewer bowel symptoms than did the RT group. Perceived stress was positively correlated with higher afternoon cortisol levels and greater symptom distress.

CONCLUSION

Moderate symptoms and symptom distress found in our sample indicate the need for interventions to address these outcomes in men treated for prostate cancer. Self-reported perceived stress can be used to assess the stress level and symptom distress in clinic setting.

IMPLICATIONS FOR PRACTICE

Patients treated for prostate cancer with RP or RT should be assessed for symptoms and symptom distress and targeted for early symptom management interventions.

Cost effectiveness of chemoprevention for prostate cancer with dutasteride in a high-risk population based on results from the REDUCE clinical trial

BACKGROUND

The REDUCE trial examined whether chemoprevention with the dual 5-alpha reductase inhibitor, dutasteride, reduced risk of prostate cancer (PCa) detection on biopsy.

OBJECTIVE

We examined the cost effectiveness of dutasteride compared with placebo in preventing PCa in men at increased risk as seen in REDUCE, from a US payer perspective.

METHODS

A Markov model was developed to compare costs and outcomes of chemoprevention with dutasteride 0.5 mg/day or placebo with usual care in men aged 50-75 years, with serum prostate-specific antigen (PSA) of 2.5-10 ng/mL (men aged <60 years) or 3.0-10 ng/mL (men aged ≥60 years), and with a single negative prostate biopsy in the prior 6 months. The model simulated the REDUCE cohort annually through different health states over 4-, 10-year and lifetime time horizons. Risks of PCa for men receiving placebo and dutasteride were obtained from REDUCE. Rates of acute urinary retention events and benign prostate hyperplasia-related surgeries also came from REDUCE. Costs and utilities were obtained from published literature. All costs are reported in $US, year 2009 values.

RESULTS

The model indicated that, over 10 years, dutasteride patients would experience fewer PCas (251 vs 312 per 1000 patients) at increased cost ($US15 341 vs $US12 316) than placebo patients. Although life-years were not substantially affected, the model calculated an increase in QALYs of 0.14 for dutasteride patients. Chemoprevention with dutasteride appeared to be cost effective, with an incremental cost per QALY of $US21 781 and cost per PCa avoided of $US50 254. The 4-year and lifetime incremental costs per QALY were $US18 409 and $US22 498, respectively.

CONCLUSIONS

Despite increased cost due to taking a drug for prevention, dutasteride 0.5 mg/day may be cost effective in men at increased risk for PCa.

Cost effectiveness of 5-alpha reductase inhibitors for the prevention of prostate cancer in multiple patient populations

BACKGROUND

Although 5-alpha reductase inhibitors (5ARIs) have demonstrated that they reduce the risk of prostate cancer (PCa), they have not demonstrated cost effectiveness in the patient populations in which they have been examined.

OBJECTIVE

A decision-analytic model was created to explore economic benefits from a third-party payer perspective of the use of 5ARIs in preventing PCa in men with different risk factors for developing the disease.

METHODS

A Markov model was developed to simulate a cohort of men annually through health states (e.g. healthy male, benign prostatic hyperplasia [BPH], PCa, PCa recurrence) over a man's lifetime. Men with risk factors were treated with a 5ARI and compared with patients given no chemoprevention. Men from the general population were examined along with higher-risk men who had been referred to a PCa centre. Baseline risk was estimated via published risk data, risk factor analyses and risk equations. Clinical efficacy, morality, costs and utilities were obtained from published literature. Outcomes of the model included number of prostate cancers, incremental costs, incremental QALYs, incremental cost per QALY and number needed to treat. Along with sensitivity and scenario analyses, a validation of outcomes was performed. All costs were valued in $US, year 2009 values. Costs were discounted at 3% per annum.

RESULTS

Men receiving 5ARIs benefited through a reduction in the number of PCas. Assuming a cost-effectiveness threshold of $US50 000 per QALY, chemoprevention with 5ARIs was cost effective ($US37 900 per QALY) in men from the general population who were aged 50 years with elevated prostate-specific antigen (PSA), and who were aged 50 years with PCa family history and elevated PSA ($US31 065 per QALY). Chemoprevention with 5ARIs was not cost effective in men aged 50 years with no additional risk factors, men aged 50 years with abnormal digital rectal examinations (DREs), and men aged 50 years with a family history ($US86 511, $US85 577 and $US84 950 per QALY, respectively). In higher-risk men, chemoprevention could be expected to be cost effective ($US18 490 to $US11 816 per QALY, depending on risk scenario). Results were sensitive to changes in utilities, assumed PCa risk reduction with 5ARIs, and patient age.

CONCLUSION

When considering common risk factors associated with PCa, prevention with 5ARIs is expected to be cost effective in 50-year-old men with elevated PSA. As a man's risk increases, the cost effectiveness of 5ARI chemoprevention improves.

Reduction in the risk of prostate cancer: future directions after the Prostate Cancer Prevention Trial

The landmark Prostate Cancer Prevention Trial (PCPT) generated interest in the potential health benefits and cost of reducing prostate cancer risk--specifically, the potential role of 5alpha-reductase inhibitors. However, the PCPT raised several unanswered questions, including the cause and significance of the increased incidence of high-grade tumors associated with finasteride. In the present study, we review the PCPT findings and unanswered questions, next steps in this field, and ongoing prostate cancer prevention trials addressing these unanswered questions. Particular emphasis is placed on the design of the second large-scale trial of a 5alpha-reductase inhibitor, the REduction by DUtasteride of prostate Cancer Events (REDUCE) trial.

Exercise therapy across the prostate cancer continuum

Exercise has been increasingly investigated as an adjunct therapy for cancer patients. The purpose of this paper is to comprehensively review the literature regarding exercise as a therapeutic adjunct for prostate cancer (PC). Several studies in patients with PC have shown quality of life improvements associated with exercise. Although no study has established the effect of exercise as a monotherapy for PC, the molecular mechanisms responsible for the potential association between exercise and PC are being elucidated. Given the low-risk, high-reward nature of these studies, further investigations are needed to better define the function of exercise along the PC continuum.

Evaluation of an internet-based disease trajectory decision tool for prostate cancer screening

OBJECTIVE

To evaluate the application of a chronic disease model (CDM) for prostate cancer to visual analog scale (VAS) and time trade-off (TTO) decision tools.

METHODS

A total of 138 men (mean age 58 years) viewed a CDM module for prostate cancer with and without prostate specific antigen (PSA) screening. Participants rated their hypothetical quality of life with potential prostate cancer treatment complications using a CDM-based VAS decision tool. They were then asked to estimate how many years they would be willing to trade to be free of treatment complications using a CDM-based TTO decision tool. The consistency between VAS and TTO scores and the relationship between scores and preferences for PSA screening test and hypothetical treatment choice for prostate cancer were then evaluated.

RESULTS

There was a significant relationship between the VAS and TTO ratings (regression P < 0.001). The TTO tool was sensitive to age. Mean scores with standard deviations for those less than 58 years compared to those 58 years and more were 7.78 (1.75) and 8.41 (1.52), respectively (P = 0.04). Using the VAS tool, men who chose PSA screening had higher quality of life ratings compared to men who did not choose PSA screening: 7.73 (1.78) and 6.59 (2.39), respectively (P = 0.01). Similar results were found with the TTO decision tool: 8.33 (1.45) and 7.04 (2.00), respectively (P = 0.005). Men who would hypothetically prefer treatment for moderately differentiated prostate cancer also had higher TTO scores compared to men who preferred watchful waiting: 8.54 (1.39) and 7.85 (1.73), respectively (P = 0.04).

CONCLUSION

CDM-based for prostate cancer, VAS and TTO ratings were consistent and were concordant with patient preferences for screening; TTO ratings were also concordant with treatment choice. The use of the CDM-based TTO ratings to adjust for quality of life in decision analytic modeling needs to be explored.

Quality of life for members of Swedish Prostate Cancer Patient Associations

Prostate Cancer Patient Associations (PCPAs) have become common. The aim of this study was to evaluate the quality of life of patients belonging to PCPAs. Members of 10 PCPAs in Sweden with prostate cancer completed 2 quality of life questionnaires (Quality-of-Life Questionnaire [QLQ-C30] and Prostate Cancer Symptom Scale). Of 2,028 members, 1,301 (64%) responded to the survey. Sixty percent of the members felt "healthy," and 38% were "free from the cancer." Ninety-five percent scored >80 on the physical function scale compared with 44% on the overall quality of life/health scale. The most severe symptom was sleeping disturbances (mean = 29). Seventeen percent scored "Quite a bit/Much" tiredness. More than 50% did not report any bladder or bowel problems. Fifty percent had "Much" sexual problems, and almost 80% did not have sufficient erection. Those reported as being "disease free" scored higher on the functioning scales than those with "metastatic disease." Those with an experience of a "metastatic disease" had more symptoms than those with less advanced disease. This is the first descriptive study of quality of life in members of Swedish PCPAs with prostate cancer. These findings show that it is possible to gain valid data to further study the situation of patients living with prostate cancer by collecting data from PCPAs.

Preliminary results of radiation therapy for prostate cancer in human immunodeficiency virus-positive patients

OBJECTIVES

The purpose of this study was to report on the clinical outcomes of patients treated at our institution for prostate cancer (PCa) who had been previously diagnosed as Human immunodeficiency virus (HIV) positive.

METHODS

The authors conducted a retrospective study of 14 PCa/HIV patients who were being treated for PCa with external beam radiotherapy, brachytherapy, or a combination of the two. Each patient's prostate-specific antigen (PSA) level, CD4 count, and viral load were obtained before the initial radiation treatment and at the time of their most recent follow-up. In addition, 13 of 14 patients completed a quality of life survey with a social worker on staff and were examined by their radiation oncologist to assess the complications after treatment.

RESULTS

Comparing pretreatment data with the data at last follow-up, only 1 patient's PSA level remained above 1.1 ng/mL. The average CD4 count remained stable, increasing from 523 to 577 cells/mm(3), with the lowest final count at 200 cells/mm(3). Viral load increased in only 2 of 14 patients. There were no unusual rectal, urinary, or sexual complications, and no infections related to treatment.

CONCLUSIONS

Based on changes in viral load and CD4 count, radiotherapy does not appear to have a long-term negative effect on the immune system. Treatment complications are consistent with HIV-negative patients, giving no evidence that the subset of PCa/HIV patients should be treated differently from PCa patients without HIV when considering radiation therapy. More investigation will be necessary before reliable mortality and morbidity data can be assessed.

Preoperative prediction of multifocal prostate cancer and application of focal therapy: review 2007

Prostate cancer is a leading malignancy among men. Early prostate cancer is most commonly treated with radical surgery and radiotherapy. In the era of prostate-specific antigen and newly emerging highly specific screening tests, a greater number of men are given a diagnosis earlier in life, and disease is more often confined. Less-invasive treatments, such as focal therapy, are becoming increasingly popular, yielding shorter hospital stays, faster recovery, and fewer complications. Potential drawbacks to focal therapy include the risk of incomplete treatment, which may result from missed cancer foci and inadequate ablation to target tissues. Furthermore, this approach is not universally applicable to all patients--for example, those who have periurethral and extraprostatic extension of the tumor may not benefit from focal treatment. This article reviews the importance of multifocal prostate cancer and the application of focal treatment.

Physical and emotional predictors of depression after radical prostatectomy

Radical prostatectomy commonly results in urinary, sexual, and bowel dysfunction that bothers men and may lead to depressive symptomatology (hereafter depression) that occurs at a rate 4 times greater for men with prostate cancer than healthy counterparts. The purpose of this study was to assess depressive symptoms in men shortly after radical prostatectomy and to identify associated risk factors. Seventy-two men were interviewed 6 weeks after surgery. Measured were depression (Geriatric Depression Scale), self-efficacy (Stanford Inventory of Cancer Patient Adjustment), social support (Modified Inventory of Socially Supportive Behaviors), physical and emotional factors (UCLA Prostate Cancer Index), and social function (SF-36 subscale). Results indicate that men with high self-efficacy and less sexual bother were 45% and 55% less likely to have depressive symptoms, respectively. Findings from this study add to the limited amount of information on the complex relationship between prostate cancer treatment and depression in men.

10-Year Survival and Quality of Life in Patients With High-Risk PN0 Prostate Cancer Following Definitive Radiotherapy

PURPOSE

To evaluate long-term overall survival (OS), cancer-specific survival (CSS), clinical progression-free survival (cPFS), and health-related quality of life (HRQoL) following definitive radiotherapy (RT) given to T(1-4p)N(0)M(0) prostate cancer patients provided by a single institution between 1989 and 1996.

METHODS AND MATERIALS

We assessed outcome among 203 patients who had completed three-dimensional conformal RT (66 Gy) without hormone treatment and in whom staging by lymphadenectomy had been performed. OS was compared with an age-matched control group from the general population. A cross-sectional, self-report survey of HRQoL was performed among surviving patients.

RESULTS

Median observation time was 10 years (range, 1-16 years). Eighty-one percent had high-risk tumors defined as T(3-4) or Gleason score (GS) > or =7B (4+3). Among these, 10-year OS, CSS, and cPFS rates were 52%, 66%, and 39%, respectively. The corresponding fractions in low-risk patients (T(1-2) and GS < or =7A [3+4]) were 79%, 95%, and 73%, respectively. Both CSS and cPFS were predicted by GS and T-classification; OS was associated with GS only. High-risk, but not low-risk, patients had reduced OS compared with the general population (p < 0.0005). When pelvis-related side effects were included in multivariate analyzes together with physical function and pain, sexual, urinary, and bowel function were not independently associated with self-reported global quality of life.

CONCLUSIONS

Despite surgically proven (p)N(0), RT with dosage <70 Gy as monotherapy does not give satisfactory CSS rates after 10 years in patients with T(3-4) or GS > or =7B.

Patient-Assessed Late Toxicity Rates and Principal Component Analysis After Image-Guided Radiation Therapy for Prostate Cancer

PURPOSE

The aims of this study were to determine the incidence of patient-assessed late toxicity after high-dose, image-guided radiation therapy in a cohort of men with prostate cancer; and to correlate toxicity with conventional dosimetric parameters and rectal and bladder dose-volume histograms (DVH) reduced using principal component analysis.

METHODS AND MATERIALS

Toxicity questionnaires were sent to 690 men treated for localized prostate cancer to 75.6 Gy or 79.8 Gy using three-dimensional conformal radiation therapy (3DCRT) or intensity-modulated radiation therapy (IMRT) between 1997 and 2003 at the Princess Margaret Hospital. Toxicity was graded according to the modified Radiation Therapy Oncology Group (RTOG)-late effects normal tissue (LENT) scoring system. Late rectal and bladder toxicity scores were dichotomized as < Grade 2 and > or = Grade 2, and correlated with dosimetric parameters and with the first three principal components of rectal and bladder DVHs.

RESULTS

In all, 63% of the patients completed the questionnaire. At a median follow-up of 37 months, the incidence of late rectal toxicity RTOG Grades 1, 2, and 3 was 25.2%, 2.5%, and 0.7% respectively. The incidence of late urinary toxicity RTOG Grade 1, 2, and 3 was 16.5%, 8.8%, and 0.9% respectively. Maintenance of erectile function sufficient for intercourse was reported in 68%. No dosimetric parameter analyzed, including principal component analysis reduction of DVHs, correlated with late toxicity.

CONCLUSIONS

Postal questionnaire was effective for collection of patient-assessed late toxicity data. The incidence of late toxicity was low, with a lack of correlation to dosimetric parameters. We attribute this to the use of conformal techniques and daily image guidance.

The prognostic significance of perineural invasion in prostatic cancer biopsies: a systematic review

Men with clinically localized prostate cancer are faced with a wide range of treatment options, and only Gleason grading is universally used as a histopathological prognostic factor for this disease. The significance of perineural invasion in diagnostic biopsies is controversial. Opinion about whether or not it should influence treatment decisions is currently almost equally divided. To address this, the authors performed a systematic review of studies that examine the association between perineural invasion and prostate cancer recurrence. MEDLINE, Embase, and the Web of Knowledge were searched from January 1990 to December 2005. Outcomes analyzed were the development of biochemical or clinical recurrence. Twenty-one articles on the association of perineural invasion in biopsies and prostate cancer recurrence after radical prostatectomy (n = 10) or radiotherapy (n = 11) were found but none on its significance in the context of watchful waiting. Structured data extraction was performed to allow comparisons between articles and to identify sources of heterogeneity to explain discrepancies in results. The considerable variation in study design, execution, and reporting precluded meta-analysis and quantitative risk estimation, but the weight of evidence suggested that perineural invasion in biopsies was a significant prognostic indicator, particularly in specific patient groups defined by presenting serum prostate-specific antigen levels and biopsy Gleason scores. Immediate treatment rather than watchful waiting may be more appropriate for patients with localized prostatic cancer and perineural invasion. However, the data are limited, and well-designed studies that use predefined stringent protocols are required to provide robust estimates of risk to aid in treatment planning.

An analysis of erectile function after intensity modulated radiation therapy for localized prostate carcinoma

Radiation therapy for prostate cancer can cause erectile dysfunction (ED). Intensity Modulated Radiation Therapy (IMRT) can reduce the amount of radiation to surrounding tissues associated with ED. We characterize the incidence of and factors associated with ED in prostate cancer patients after IMRT at the National Naval Medical Center (NNMC). Patients potent by definition of the Sexual Health Inventory for Men (SHIM) before treatment completed the specific erectile questions of the SHIM after IMRT. Statistical analyses were performed to examine the relationships between several factors and ED. Thirty-two of 45 patients with mean age of 68.2 years (50-86 years) completed the SHIM. The median follow-up was 36.8 months (16-63.6 months) as defined by the time from completion of therapy to reassessment with the SHIM. Eight of 32 patients (25%) had no post-treatment ED (SHIM score 22-25), three of 32 (9%) had mild post-treatment ED (SHIM score 17-21), five of 32 (16%) had mild to moderate ED (SHIM score 12-16), five of 32 (16%) had moderate ED (SHIM score 8-11) and 11 of 32 (34%) had severe post-treatment ED (SHIM score<8). Post-treatment potency was significantly associated with the pre-treatment SHIM score (P=0.001) and history of hypertension (P=0.03). The mean radiation dose to the penile bulb and volume of penile bulb treated were not associated with post-treatment potency (P=0.38, 0.76, respectively). IMRT maintains potency in the majority of patients. This analysis compares favorably in preserving erectile function to previously reported series using conventional external beam radiation therapy techniques. The dose of radiation received by the penile bulb and volume of penile bulb were not associated with post-treatment ED in this analysis.