Patient-Reported Outcomes after Monitoring, Surgery, or Radiotherapy for Prostate Cancer

Theorising masculinity, ageing, and the lived body: the case of prostate cancer

This article conceptualises how masculinity and masculine ideals are played out in relation to prostate cancer treatment and its side-effects, offering a heuristic and theoretical perspective with which to make sense of the complex interrelationship between lived gendered bodies and social structures. With the support of three case studies of older men treated for prostate cancer, the article explores how the concept of hegemonic masculinity can be used to analyse the ill and ageing body. A phenomenologically informed approach to the body, which illustrates how masculinity is lived and experienced through certain body schemas, is used. The three case studies show variation in how masculinity is enacted and embodied, illustrating actions to (1) restore and maintain masculinity through phallic experience; (2) reconstruct masculinity by connecting bodily experience to notions of the ageing and a less potent body; and (3) to counter narrowly defined notions of masculinity by dissociating or decoupling masculinity from ideals of potency and performance. With the help of the case studies, the strategies identified, and the fluidity and dynamism of the concept of hegemonic masculinity, findings reveal how inequalities between men and women are produced and maintained, in and through bodily experience, and diverse body schemas.

Perioperative outcomes, environmental impact and economic implications of pelvic drain discontinuation in prostate cancer patients undergoing robot-assisted radical prostatectomy

PURPOSE

The utility of a pelvic drain (PD) after robot-assisted radical prostatectomy (RARP) has been recently questioned. We investigated the impact of discontinuing PD placement after RARP on complications, pain, environmental benefits, and cost savings.

METHODS

We identified 1,199 patients who underwent RARP with or without extended pelvic lymph node dissection from 2016 to 2023 at a referral center. Starting in 2018, PD placement was discontinued in uncomplicated RARPs. Complications were collected following the European Association of Urology (EAU) recommendations on reporting and grading. Multivariable logistic regression models (MLR) evaluated the impact of PD use on perioperative outcomes and opioid usage. The PD life cycle-associated Carbon Dioxide Equivalent Emissions (CO2e) and its economic impact were estimated.

RESULTS

A PD was placed in a total of 555 (46%) patients, with a decreasing rate from 94% to 18% between 2016 and 2023. The rates of any and high-grade (HG) complications were similar between patients with and without PD (29 vs. 28% and 5% vs. 6%, respectively; all P ≥ 0.2). At MLR, the PD placement was not associated with the risk of any (OR:1.09, 95%CI:0.79-1.5) or HG complications (OR 1.45, 95%CI 0.80-2.63). PD placement was associated with greater postoperative opioid usage (OR:1.58, 95%CI:1.01-2.51, P = 0.045). The CO2e spared rose from 220 in 2016 to 2,180 in 2022 and cost savings per year increased from 1,855€ in 2016 to 18,506€ in 2022.

CONCLUSION

Unnecessary PD placement should be avoided in uncomplicated RARPs to obtain environmental benefits, reduce health-related costs, and improve patients' outcomes.

Comparing post-treatment urinary and colorectal procedures in prostate cancer patients using population-based linked data

PURPOSE

To investigate urinary and colorectal procedures among men who underwent radical prostatectomy (RP) and external beam radiotherapy (EBRT).

METHODS

We studied 16,271 (RP = 8516 and EBRT = 7755) South Australian men diagnosed with prostate cancer between 2001 and 2021. Colorectal and urinary procedures were extracted from hospital admission procedure codes and Medical Benefits Schedule item codes. Rates were estimated at 30-days, 90-days, 6-months, 1-year, 2-years and 5-years post-treatment. We estimated the average treatment effect of RP (compared with EBRT) by applying propensity-matched analyses, accounting for sociodemographic and clinical characteristics. Subgroup analyses were undertaken for different treatment periods (2001-2010 vs. 2011-2021).

RESULTS

At 1-year post-treatment, the crude rates of colorectal procedures were 43 and 70/1000 person-years among RP and EBRT patients, respectively, while crude rates for urinary procedures were 258 and 74/1000 person-years, respectively. Propensity matched analyses indicated that patients undergoing RP underwent more post-treatment urinary procedures, being 21.2% higher at 6-months and 16.3% higher at 5-years than men who received EBRT. Colorectal procedures were slightly more frequent among RP than EBRT patients during the first 90-days but less frequent from 1-year onwards (5.9% lower at 5-years among RP group). Between 2011 and 2021, there were considerably fewer urinary procedures for men who underwent RP than those treated between 2001 and 2010.

CONCLUSION

There is a statistically significant difference in the frequency of post-treatment procedures between patients who underwent RP and those who had EBRT, which likely indicates a difference in adverse treatment effects. These findings may lead to more informed treatment decision-making.

Whole-gland or Subtotal High-intensity Focused Ultrasound Versus Radical Prostatectomy: The Prospective, Noninferiority, Nonrandomized HIFI Trial

BACKGROUND AND OBJECTIVE

High-intensity focused ultrasound (HIFU) has emerged as an interesting ablative alternative to radical prostatectomy (RP) and radiation therapy (RT) for localized prostate cancer (PC). However, no prospective comparative data have been published for HIFU.

METHODS

We performed a prospective nonrandomized nationwide trial in 46 centers in France comparing RP versus HIFU. The main inclusion criterion was low- to intermediate-risk PC. The primary endpoint was salvage therapy-free survival (STFS). Secondary endpoints were metastasis-free survival, PC-specific survival, overall survival, and functional outcomes.

KEY FINDINGS AND LIMITATIONS

From 2015 to 2019, 3328 patients were included (1967 HIFU and 1361 RP). Median age was 74.7 versus 65.1 yr (p < 0.001) and median PSA was 7.1 versus 6.9 ng/ml (p = 0.5) in the HIFU and RP groups, respectively. Intermediate-risk PC was diagnosed in 61% of patients in the HIFU group and 64% in the RP group (p = 0.10). The 30-mo STFS was not inferior in the HIFU group (hazard ratio 0.71, 95% confidence interval 0.52-0.97; p = 0.008). Some 10% of patients experienced urinary retention after HIFU. Grade >IIIa complications occurred in 54/1967 cases in the HIFU group and 29/1361 cases in the RP group (p = 0.3). In the HIFU group, fewer patients experienced a deterioration in 12-mo urinary continence (29% vs 44%) and the decrease in median International Index of Erectile Function-5 score was lower (difference -7 vs -13) in comparison to RP. Internal Prostate Symptom Scores and quality-of-life scores were comparable in the two groups. The main limitations are the lack of randomization and the age difference between the groups.

CONCLUSIONS AND CLINICAL IMPLICATIONS

This large prospective trial demonstrates that whole-gland or subtotal HIFU provides comparable medium-term STFS outcomes to RP. Urinary continence and erectile function were less impaired after HIFU. These results should be interpreted with caution owing to the lack of randomization and the age difference between the groups. Future research should consider longer follow-up and evaluate focal treatments. This trial is registered on ClinicalTrials.gov as NCT04307056.

Influential Factors Impacting Treatment Decision-making and Decision Regret in Patients with Localized or Locally Advanced Prostate Cancer: A Systematic Literature Review

CONTEXT

Treatment decision-making (TDM) for patients with localized (LPC) or locally advanced (LAPC) prostate cancer is complex, and post-treatment decision regret (DR) is common. The factors driving TDM or predicting DR remain understudied.

OBJECTIVE

Two systematic literature reviews were conducted to explore the factors associated with TDM and DR.

EVIDENCE ACQUISITION

Three online databases, select congress proceedings, and gray literature were searched (September 2022). Publications on TDM and DR in LPC/LAPC were prioritized based on the following: 2012 onward, ≥100 patients, journal article, and quantitative data. The Preferred Reporting Items Reviews and Meta-analyses guidelines were followed. Influential factors were those with p < 0.05; for TDM, factors described as "a decision driver", "associated", "influential", or "significant" were also included. The key factors were determined by number of studies, consistency of evidence, and study quality.

EVIDENCE SYNTHESIS

Seventy-five publications (68 studies) reported TDM. Patient participation in TDM was reported in 34 publications; overall, patients preferred an active/shared role. Of 39 influential TDM factors, age, ethnicity, external factors (physician recommendation most common), and treatment characteristics/toxicity were key. Forty-nine publications reported DR. The proportion of patients experiencing DR varied by treatment type: 7-43% (active surveillance), 12-57% (radical prostatectomy), 1-49% (radiotherapy), 28-49% (androgen-deprivation therapy), and 21-47% (combination therapy). Of 42 significant DR factors, treatment toxicity (sexual/urinary/bowel dysfunction), patient role in TDM, and treatment type were key.

CONCLUSIONS

The key factors impacting TDM were physician recommendation, age, ethnicity, and treatment characteristics. Treatment toxicity and TDM approach were the key factors influencing DR. To help patients navigate factors influencing TDM and to limit DR, a shared, consensual TDM approach between patients, caregivers, and physicians is needed.

PATIENT SUMMARY

We looked at factors influencing treatment decision-making (TDM) and decision regret (DR) in patients with localized or locally advanced prostate cancer. The key factors influencing TDM were doctor's recommendation, patient age/ethnicity, and treatment side effects. A shared, consensual TDM approach between patients and doctors was found to limit DR.

Patient-reported Outcome Measures and Experience Measures After Active Surveillance Versus Radiation Therapy Versus Radical Prostatectomy for Prostate Cancer: A Systematic Review of Prospective Comparative Studies

BACKGROUND AND OBJECTIVE

Current management options for localized prostate cancer (PCa) include radical prostatectomy (RP), radiotherapy (RT), and active surveillance (AS). Despite comparable oncological outcomes, there is still lack of evidence on their comparative effectiveness in terms of patient-reported outcome measures (PROMs) and patient-reported experience measures (PREMs). We conducted a systematic review of studies comparing PROMs and PREMs after all recommended management options for localized PCa (RP, RT, AS).

METHODS

A literature search was performed in the MEDLINE, EMBASE, and Cochrane CENTRAL databases in accordance with recommendations from the European Association of Urology Guidelines Office and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. All prospective clinical trials reporting PROMs and/or PREMs for comparisons of RP versus RT versus AS were included. A narrative synthesis was used to summarize the review findings. No quantitative synthesis was performed because of the heterogeneity and limitations of the studies available.

KEY FINDINGS AND LIMITATIONS

Our findings reveal that RP mostly affects urinary continence and sexual function, with better results for voiding symptoms in comparison to other treatments. RT was associated with greater impairment of bowel function and voiding symptoms. None of the treatments had a significant impact on mental or physical quality of life. Only a few studies reported PREMs, with a high rate of decision regret for all modalities (up to 23%).

CONCLUSIONS AND CLINICAL IMPLICATIONS

All recommended treatments for localized PCa have an impact on PROMs and PREMs, but for different domains and with differing severity. We found significant heterogeneity in PROM collection, so standardization in real-world practice and clinical trials is warranted. Only a few studies have reported PREMs, highlighting an unmet need that should be explored in future studies.

PATIENT SUMMARY

We reviewed differences in patient reports of their outcomes and experiences after surgical prostate removal, radiotherapy, or active surveillance for prostate cancer. We found differences in the effects on urinary, bowel, and sexual functions among the treatments, but no difference for mental or physical quality of life. Our results can help doctors and prostate cancer patients in shared decision-making.

Radical Prostatectomy Versus Stereotactic Radiotherapy for Clinically Localised Prostate Cancer: Results of the PACE-A Randomised Trial

BACKGROUND AND OBJECTIVE

Randomised data on patient-reported outcomes (PROs) for stereotactic body radiotherapy (SBRT) and prostatectomy in localised prostate cancer are lacking. PACE-A compared patient-reported health-related quality of life after SBRT with that after prostatectomy.

METHODS

PACE is a phase 3 open-label, randomised controlled trial. PACE-A randomised men with low- to intermediate-risk localised prostate cancer to SBRT or prostatectomy (1:1). Androgen deprivation therapy (ADT) was not permitted. The coprimary outcomes were the Expanded Prostate Index Composite (EPIC-26) number of absorbent urinary pads required daily and bowel domain score at 2 yr. The secondary endpoints were clinician-reported toxicity, sexual functioning, and other PROs.

KEY FINDINGS AND LIMITATIONS

In total, 123 men were randomised (60 undergoing prostatectomy and 63 SBRT) from August 2012 to February 2022. The median follow-up time was 60.7 mo. The median age was 65.5 yr and the median prostate-specific antigen (PSA) value 7.9 ng/ml; 92% had National Comprehensive Cancer Network (NCCN) intermediate-risk disease. Fifty participants received prostatectomy and 60 received SBRT. At 2 yr, 16/32 (50%) prostatectomy and three of 46 (6.5%) SBRT participants used one or more urinary pads daily (p < 0.001; 15 and two, respectively, used one pad daily); the estimated difference was 43% (95% confidence interval [CI]: 25%, 62%). At 2 yr, bowel scores were better for prostatectomy (median [interquartile range] 100 [100-100]) than for SBRT (87.5 [79.2-100]; p < 0.001), with an estimated mean difference of 8.9 between these (95% CI: 4.2, 13.7); sexual scores were worse for prostatectomy (18 [13.8-40.3]) than for SBRT (62.5 [32.0-87.5]). The limitations were slow recruitment and incomplete 2-yr PRO response rates.

CONCLUSIONS AND CLINICAL IMPLICATIONS

SBRT was associated with less patient-reported urinary incontinence and sexual dysfunction, and slightly more bowel bother than prostatectomy. These randomised data should inform treatment decision-making for patients with localised, intermediate-risk prostate cancer.

Nerve graft for erectile dysfunction after radical prostatectomy: animal study and clinical data-a narrative review

Introduced in the late 1990s, nerve grafting, particularly with sural and genitofemoral nerves, aims to enhance erectile function recovery when neurovascular bundles cannot be preserved following radical prostatectomy. Over the past three decades, researchers have conducted numerous animal and clinical studies to explore the application and clinical effectiveness of this method, with the hope of benefiting patients suffering from erectile dysfunction after radical prostatectomy. Animal studies have demonstrated the potential of various grafting materials, including autologous nerve and vein grafts, and bioengineered grafts, in promoting nerve regeneration and erectile function recovery. Clinical studies, especially those focusing on sural and genitofemoral nerve grafts, have shown mixed results with varied success rates due to methodological weaknesses and small sample sizes. This review thoroughly incorporates current data, explores emerging nerve grafting methods, demonstrates the complexity of nerve grafting outcomes, and emphasizes the necessity for continuous research, including multi-institutional randomized controlled trials, to establish standardized protocols and optimize patient selection for nerve grafting in the management of erectile dysfunction after radical prostatectomy.

Advances in localized prostate cancer: A special focus on photothermal therapy

Prostate cancer (PCa) is a high prevalence disease, per 10000 habitants, that tends to increase with age. This pathology is difficult to detect at an early stage due to the absence of symptoms, hence the importance of monitoring signs for early detection. This disease can be detected by various methods, including plasmatic levels of prostate-specific antigen (PSA) and rectal touch, with biopsy being necessary to confirm the diagnosis. Patients affected by prostate cancer can have localized or advanced disease. There are conventional approaches that have been used as a reference in localized cancer, such as active surveillance, surgery, or radiotherapy. However, the adverse effects might vary and, sometimes, they can be permanent. An overview about the innovative therapeutic approaches to improve outcomes in terms of both tumor remission and side effects for localized PCa is presented. In case of emerging light-based treatment strategies, they aimed at ablating tumor tissue by inducing an external light are non-invasive, localized and, considerably, they are able to reduce lesions in peripheral tissues. One is photodynamic therapy (PDT) and it involves the photooxidation of molecules culminating in the formation of reactive oxygen species (ROS), inducing cell death. On the other hand, photothermal therapy (PTT) is based on inducing hyperthermia in cancer cells by irradiating them with beams of light at a specific wavelength. To improve the heat generated, gold nanoparticles (AuNPs) have those desirable characteristics that have drawn attention to PTT. Various studies point to AuNPs as efficient nanomaterials in PTT for the treatment of tumors, including prostate cancer. This review includes the most representative advances in this research field, dated from 1998 to 2023. It is noticed that several advances have been made and the way to find the effective treatment without impacting adverse side effects is shorter.

Trends of prostate cancer treatment in Ehime Prefecture, Japan: analysis of a hospital-based cancer registry

BACKGROUND

We previously conducted a retrospective Japanese cohort study of patients who underwent radical prostatectomy (RP) between January 2010 and December 2020 in Ehime Prefecture. This study revealed an increase in the number of RP, but other treatment trends remained unclear. In the current study, we examined prostate cancer treatment in Ehime Prefecture using the hospital-based cancer registry of all designated cancer care hospitals and community cancer care hospitals belonging to the Council of Ehime Cancer Care Hospitals.

METHODS

Trends of prostate cancer were compared by year according to stage and treatment using data from the hospital-based cancer registry between 2011 and 2020.

RESULTS

The number of patients with stage 1 disease increased over time, but the proportion of patients with stage 1 disease among all patients decreased from 65.2% in 2012 to 56.9% in 2020. The number of patients with stage 2 disease also increased, but the proportion of such patients among all patients remained constant. Meanwhile, the proportions of patients with stage 3 or 4 disease increased significantly over time, while that of patients undergoing RP increased from 29.2% in 2011 to 45.7% in 2020 (P < 0.001). The proportion of patients receiving radiotherapy (RT) decreased from 25.8% in 2011 to 17.2% in 2020. The use of hormone therapy (HT) remained unchanged, and the proportion of patients undergoing observation fell from 11.0% in 2011 to 7.0% in 2020. A higher proportion of patients with stage 3 cancer received HT, and RT was more frequently used in stage 3 cancer than in stage 1-2 cancer. The use of HT increased with age.

CONCLUSIONS

The data highlighted differences in prostate cancer stages and treatment over time. This information could be shared with both urologists and radiologists to improve treatment.

French AFU Cancer Committee Guidelines - Update 2024-2026: Prostate cancer - Diagnosis and management of localised disease

OBJECTIVE

The aim of the Oncology Committee of the French Urology Association is to propose updated recommendations for the diagnosis and management of localized prostate cancer (PCa).

METHODS

A systematic review of the literature from 2022 to 2024 was conducted by the CCAFU on the elements of diagnosis and therapeutic management of localized PCa, evaluating references with their level of evidence.

RESULTS

The recommendations set out the genetics, epidemiology and diagnostic methods of PCa, as well as the concepts of screening and early detection. MRI, the reference imaging test for localized cancer, is recommended before prostate biopsies are performed. Molecular imaging is an option for disease staging. Performing biopsies via the transperineal route reduces the risk of infection. Active surveillance is the standard treatment for tumours with a low risk of progression. Therapeutic methods are described in detail, and recommended according to the clinical situation.

CONCLUSION

This update of French recommendations should help to improve the management of localized PCa.

Oncological Outcomes of Partial Gland Ablation Using High-Intensity Focused Ultrasound After Additional Confirmatory Transperineal Mapping Biopsy in Men with Prostate Cancer

BACKGROUND/OBJECTIVES

To evaluate whether additional confirmatory transperineal mapping biopsy (TPMB) in men with localized prostate cancer (PCa) alters the treatment plan and outcome of partial gland ablation (PGA) using high-intensity focused ultrasound (HIFU).

METHODS

We retrospectively reviewed data from 96 patients who underwent PGA using HIFU between January 2020 and June 2022. After multiparametric magnetic resonance imaging (mpMRI), all men underwent transrectal ultrasound (TRUS)-guided, cognitive-targeted biopsy and systematic biopsy. Men eligible for PGA using HIFU first underwent confirmatory TPMB. Any changes in the treatment plan after TPMB were analyzed. Follow-up TRUS-guided biopsy was performed 1 year post-operatively to evaluate oncological outcomes. Clinically significant PCa (csPCa) was defined as Gleason grade (GG) ≥ 2.

RESULTS

Among all subjects, the median age (IQR) was 65.0 (60.0-72.0) years and the prostate-specific antigen level was 5.20 (3.71-7.81) ng/mL. The results of both TRUS-guided biopsy and TPMB led to a change in the treatment plan (from unilateral to bilateral PGA) for 13 (13.5%) patients. The 1-year follow-up TRUS-guided biopsy identified PCa in 13 (13.5%) patients, and csPCa in 7 (7.3%) patients. The infield- and outfield-positive rates were 8.3% (8/96) and 3.1% (3/96), respectively, for any PCa, and 3.1% (3/96) and 2.1% (2/96), respectively, for csPCa.

CONCLUSIONS

Confirmatory TPMB results in better disease identification and localization, thereby affecting the treatment plan and improving oncological outcomes. Therefore, confirmatory TPMB should be considered to establish an appropriate strategy for patients with localized PCa eligible for PGA using HIFU.

The hidden costs: a qualitative analysis exploring the experience of prostate cancer treatment-related side effects on sexual function and urinary incontinence among Black survivors and their caregivers

PURPOSE

Prostate cancer (PCa) disproportionately affects Black men in the U.S., leading to high incidence and mortality rates. Post-treatment challenges, such as sexual dysfunction and urinary incontinence, significantly impact quality of life yet are frequently overlooked. The purpose of this study was to characterize the experience of treatment-related side effects around sexual function and urinary incontinence among Black survivors of PCa and their caregivers.

METHODS

We conducted semi-structured virtual interviews with 11 Black survivors of PCa and 11 caregivers (22 total participants). Survivors were eligible if they were diagnosed and treated for PCa within the last decade and caregivers were eligible if they self-identified as a caregiver for a Black survivor. Interviews were transcribed verbatim and analyzed using a qualitative descriptive approach.

RESULTS

During interviews, participants spontaneously discussed topics covering sexual dysfunction and urinary incontinence. Key themes identified from interview discussions included the physical experience of PCa treatment, knowledge of the impact of PCa treatment on life quality, and the process of navigating survivorship care. Although they received peer and familial support, survivors expressed a desire for clinicians to initiate discussions on sexual dysfunction and urinary incontinence. Caregivers recounted their experiences while providing support to the survivor.

CONCLUSIONS

The findings underscore the need for clinicians to prioritize discussions on sexual dysfunction and urinary incontinence with patients, and for enhancement of care pathways and resources for these issues in survivorship care.

IMPLICATIONS FOR CANCER SURVIVORS

Trained professionals, such as occupational and physical therapists, social workers, genetic counselors, and psychologists, have the potential to fill this survivorship care gap.

A Systematic Review of Clinical Trials Comparing Radiation Therapy Versus Radical Prostatectomy in Prostate Cancer

The treatment landscape for localized and regional prostate cancer includes active surveillance, radiation therapy (RT), and radical prostatectomy (RP). Population-based studies comparing RP to radiation reveal conflicting results due to methodological flaws. This systematic review and pooled analysis of studies aim to compare cause-specific survival (CSS), overall survival (OS), disease-free survival (DFS) and toxicity outcomes, comparing RP to RT in the management of prostate cancer. This systematic review search included the PubMed, Embase, and Cochrane libraries according to the PRISMA statement with the inception of each database up to June 24, 2023. Randomized phase 2 or 3 clinical trials that compared RP to RT in prostate cancer were included. The forest plot for the Odds ratio (OR) was plotted using the Mantel-Haenszel method, and the Z test was used to assess significance. A fixed effects model was used for meta-analysis. The search yielded seven completed randomized clinical trials and four ongoing trials. The majority of complete trials had low to intermediate-risk patient populations. OR for OS was 1.00 with 95% CI, 0.71-1.41 (P-value: 0.98), CSS OR was 0.99 with 95% CI, 0.45-2.18 (P-value 0.11), OR for DFS was 1.26 with 95% CI, 0.89-1.78 (P-value 0.19) when comparing RP to RT. The rate of distant metastatic disease was 2.3% in the RP versus 2.9% in the RT at 10 years. The rate of second malignant neoplasms was 4.5% in the RP compared to 4.2% in the RT arm at 10 years. RP caused more urinary symptoms, with a predominance of the need for urinary pads and a higher incidence of sexual dysfunction, and RT caused a higher incidence of bowel symptoms, such as blood in stools and fecal incontinence. This study provides evidence that the treatment-related outcomes are similar in patients with low to intermediate-risk prostate cancer when comparing RP to RT. Multidisciplinary treatment approaches and factoring patients' values and preferences should form the cornerstone of the ideal treatment option for each patient with localized prostate cancer. Patients with prostate cancer have an equal chance of being cancer-free and alive at 10 years with either RP or RT. In terms of side effects, RP causes more urine leakage and loss of erections, whereas RT tends to cause more bowel side effects, such as blood in stools and fecal leakage.

MRI software and cognitive fusion biopsies in people with suspected prostate cancer: a systematic review, network meta-analysis and cost-effectiveness analysis

Background

Magnetic resonance imaging localises cancer in the prostate, allowing for a targeted biopsy with or without transrectal ultrasound-guided systematic biopsy. Targeted biopsy methods include cognitive fusion, where prostate lesions suspicious on magnetic resonance imaging are targeted visually during live ultrasound, and software fusion, where computer software overlays the magnetic resonance imaging image onto the ultrasound in real time. The effectiveness and cost-effectiveness of software fusion technologies compared with cognitive fusion biopsy are uncertain.

Objectives

To assess the clinical and cost-effectiveness of software fusion biopsy technologies in people with suspected localised and locally advanced prostate cancer. A systematic review was conducted to evaluate the diagnostic accuracy, clinical efficacy and practical implementation of nine software fusion devices compared to cognitive fusion biopsies, and with each other, in people with suspected prostate cancer. Comprehensive searches including MEDLINE, and Embase were conducted up to August 2022 to identify studies which compared software fusion and cognitive fusion biopsies in people with suspected prostate cancer. Risk of bias was assessed with quality assessment of diagnostic accuracy studies-comparative tool. A network meta-analysis comparing software and cognitive fusion with or without concomitant systematic biopsy, and systematic biopsy alone was conducted. Additional outcomes, including safety and usability, were synthesised narratively. A de novo decision model was developed to estimate the cost-effectiveness of targeted software fusion biopsy relative to cognitive fusion biopsy with or without concomitant systematic biopsy for prostate cancer identification in biopsy-naive people. Scenario analyses were undertaken to explore the robustness of the results to variation in the model data sources and alternative assumptions.

Results

Twenty-three studies (3773 patients with software fusion, 2154 cognitive fusion) were included, of which 13 informed the main meta-analyses. Evidence was available for seven of the nine fusion devices specified in the protocol and at high risk of bias. The meta-analyses show that patients undergoing software fusion biopsy may have: (1) a lower probability of being classified as not having cancer, (2) similar probability of being classified as having non-clinically significant cancer (International Society of Urological Pathology grade 1) and (3) higher probability of being classified at higher International Society of Urological Pathology grades, particularly International Society of Urological Pathology 2. Similar results were obtained when comparing between same biopsy methods where both were combined with systematic biopsy. Evidence was insufficient to conclude whether any individual devices were superior to cognitive fusion, or whether some software fusion technologies were superior to others. Uncertainty in the relative diagnostic accuracy of software fusion versus cognitive fusion reduce the strength of any statements on its cost-effectiveness. The economic analysis suggests incremental cost-effectiveness ratios for software fusion biopsy versus cognitive fusion are within the bounds of cost-effectiveness (£1826 and £5623 per additional quality-adjusted life-year with or with concomitant systematic biopsy, respectively), but this finding needs cautious interpretation.

Limitations

There was insufficient evidence to explore the impact of effect modifiers.

Conclusions

Software fusion biopsies may be associated with increased cancer detection in relation to cognitive fusion biopsies, but the evidence is at high risk of bias. Sufficiently powered, high-quality studies are required. Cost-effectiveness results should be interpreted with caution given the limitations of the diagnostic accuracy evidence.

Study registration

This trial is registered as PROSPERO CRD42022329259.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Evidence Synthesis programme (NIHR award ref: 135477) and is published in full in Health Technology Assessment; Vol. 28, No. 61. See the NIHR Funding and Awards website for further information.

Communicating prostate cancer outcomes data to consumers A brief communication

OBJECTIVE

To translate and communicate outcomes data for prostate cancer from a clinical registry data into a consumer-friendly resource.

METHODS

First, we analyzed real-world data from the South Australian Prostate Cancer Clinical Outcomes Collaborative (SA-PCCOC) registry for men diagnosed from 2008 to 2018 including clinical and functional outcomes following surgery, external beam radiotherapy, brachytherapy, hormone therapy, active surveillance and watchful waiting. These outcomes included overall survival, cancer specific survival, biochemical recurrence, decline in functional outcomes, and transition to active treatment following active surveillance. Second, we translated outcomes into a summary text and pictographic format and present in one document that consumers found easy to understand and interpret. This "Prostate Cancer Outcomes Report Card" was developed in consultation with a consumer advisory group and further improved through exploratory interviews with people affected by prostate cancer, an online survey among the general public, and clinician feedback.

RESULTS

The 5-year prostate cancer-specific survival rate was 97%. There is a reasonably high chance of cancer returning within 5 years (17% after surgery and 14% after radiotherapy) while 1 in 3 men on active surveillance transitioned to other treatments within 5 years. Sexual function was negatively affected following all treatment types. Men with higher risk disease had a worse prognosis, a higher chance of recurrence and greater decline in physical function. Consumers required trustworthy, comprehensive, simple and up-to-date information collated in one place, and valued having access to this resource. Data on high survival rates were considered reassuring. There were high levels of unmet psychosocial and supportive care needs, especially in relation to mental health and sexual function. The report card was well received by patients and health care workers.

CONCLUSIONS

This relatively simple and easily understandable consumer-oriented outcome report serves to better inform men with prostate cancer and facilitate patient-provider communication and shared decision-making.

Transperineal biopsy devices in people with suspected prostate cancer - a systematic review and economic evaluation

Background

People with suspected prostate cancer are usually offered either a local anaesthetic transrectal ultrasound-guided prostate biopsy or a general anaesthetic transperineal prostate biopsy. Transperineal prostate biopsy is often carried out under general anaesthetic due to pain caused by the procedure. However, recent studies suggest that performing local anaesthetic transperineal prostate biopsy may better identify cancer in particular regions of the prostate and reduce infection rates, while being carried out in an outpatient setting. Devices to assist with freehand methods of local anaesthetic transperineal prostate may also help practitioners performing prostate biopsies.

Objectives

To evaluate the clinical effectiveness and cost-effectiveness of local anaesthetic transperineal prostate compared to local anaesthetic transrectal ultrasound-guided prostate and general anaesthetic transperineal prostate biopsy for people with suspected prostate cancer, and local anaesthetic transperineal prostate with specific freehand devices in comparison with local anaesthetic transrectal ultrasound-guided prostate and transperineal prostate biopsy conducted with a grid and stepping device conducted under local or general anaesthetic.

Data sources and methods

We conducted a systematic review of studies comparing the diagnostic yield and clinical effectiveness of different methods for performing prostate biopsies. We used pairwise and network meta-analyses to pool evidence on cancer detection rates and structured narrative synthesis for other outcomes. For the economic evaluation, we reviewed published and submitted evidence and developed a model to assess the cost-effectiveness of the different biopsy methods.

Results

We included 19 comparative studies (6 randomised controlled trials and 13 observational comparative studies) and 4 single-arm studies of freehand devices. There were no statistically significant differences in cancer detection rates for local anaesthetic transperineal prostate (any method) compared to local anaesthetic transrectal ultrasound-guided prostate (relative risk 1.00, 95% confidence interval 0.85 to 1.18) (n = 5 randomised controlled trials), as was the case for local anaesthetic transperineal prostate with a freehand device compared to local anaesthetic transrectal ultrasound-guided prostate (relative risk 1.40, 95% confidence interval 0.96 to 2.04) (n = 1 randomised controlled trial). Results of meta-analyses of observational studies were similar. The economic analysis indicated that local anaesthetic transperineal prostate is likely to be cost-effective compared with local anaesthetic transrectal ultrasound-guided prostate (incremental cost below £20,000 per quality-adjusted life-year gained) and less costly and no less effective than general anaesthetic transperineal prostate. local anaesthetic transperineal prostate with a freehand device is likely to be the most cost-effective strategy: incremental cost versus local anaesthetic transrectal ultrasound-guided prostate of £743 per quality-adjusted life-year for people with magnetic resonance imaging Likert score of 3 or more at first biopsy.

Limitations

There is limited evidence for efficacy in detecting clinically significant prostate cancer. There is comparative evidence for the PrecisionPoint™ Transperineal Access System (BXTAccelyon Ltd, Burnham, UK) but limited or no evidence for the other freehand devices. Evidence for other outcomes is sparse. The cost-effectiveness results are sensitive to uncertainty over cancer detection rates, complication rates and the numbers of core samples taken with the different biopsy methods and the costs of processing them.

Conclusions

Transperineal prostate biopsy under local anaesthetic is equally efficient at detecting prostate cancer as transrectal ultrasound-guided prostate biopsy under local anaesthetic but it may be better with a freehand device. local anaesthetic transperineal prostate is associated with urinary retention type complications, whereas local anaesthetic transrectal ultrasound-guided prostate has a higher infection rate. local anaesthetic transperineal prostate biopsy with a freehand device appears to meet conventional levels of costeffectiveness compared with local anaesthetic transrectal ultrasound-guided prostate.

Study registration

This study is registered as PROSPERO CRD42021266443.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Evidence Synthesis programme (NIHR award ref: NIHR134220) and is published in full in Health Technology Assessment Vol. 28, No. 60. See the NIHR Funding and Awards website for further award information.

Impact of oral antithrombotic agents on urinary continence recovery following robot-assisted radical prostatectomy: a retrospective cohort study

BACKGROUND

Robot-assisted radical prostatectomy (RARP) is a preferred minimally invasive surgical treatment for prostate cancer. The number of elderly patients and those with cardiovascular and/or cerebrovascular issues undergoing surgery is increasing, and many of them are taking antithrombotic (AT) agents. However, the effect of AT agents on postoperative urinary recovery has not been adequately studied. In this study, we analyzed the differences in the postoperative recovery of urinary continence and oncological outcomes in patients undergoing RARP for localized prostate cancer between AT agent adherents and non-adherents.

METHODS

A total of 394 patients who underwent conventional anterior RARP between February 2015 and February 2021 were categorized into two groups: those taking oral AT agents (AT group) and the control group. Urinary continence recovery, complications, and oncological outcomes were compared between the groups. A Cox proportional hazards analysis was performed to identify clinical factors that affect urinary continence recovery.

RESULTS

The background data and bleeding complications did not differ significantly between the groups. The recovery of continence was significantly poorer in the AT group in terms of complete pad free (HR: 0.53 [95% CI: 0.39-0.71]) and use of ≤ 1 safety pad (HR: 0.74 [95% CI: 0.59-0.94]). The rate of anastomotic leakage on cystography was significantly higher in the AT group (20.9% vs. 6.7%). A univariate analysis revealed that taking antithrombotic agents, higher prostate-specific antigen levels, and a more advanced clinical stage were associated with a poor urinary continence recovery; a multivariate analysis showed that taking AT agents was an independent factor negatively associated with urinary continence recovery. There was no significant difference between the groups in the positive surgical margin rate (19.0% vs. 23.8%) or the biochemical-recurrence-free rate.

CONCLUSION

Taking oral AT agents may be associated with poor urinary continence recovery after RARP.

Prostate cancer focal therapy: surgeon experience influences oncological results

INTRODUCTION

Characterization of the index lesion of prostate cancer (PCa) has facilitated the development of focal therapy to reduce complications caused by radical treatments. In the present study, we sought to identify factors associated with the oncological results of focal therapy for PCa.

METHODS

Between April 2017 and February 2020, 123 PCa patients received focal therapy performed with high-intensity focused ultrasound (HIFU). The patients presented unilateral localized disease, PSA < 20 ng/dl, clinical stage T1-T2, ISUP grade 1-3, and more than 10 years of life expectancy. Five certified surgeons with different levels of experience performed the procedures and were divided into groups #1 and #2 (>30 HIFUs performed) and #3 (10-15 HIFUs performed each). All patients were prospectively followed and underwent surveillance biopsy 1 year post-treatment. The primary endpoint was radical treatment, and secondary endpoints included focal therapy failure and in-field recurrence. Univariate and multivariate logistic regression were used to detect associations between clinical and procedure variables and the endpoints.

RESULTS

The median follow-up was 54.3 months, with a mean age of 64.4 years. The mean PSA was 6.6 ng/dl; 59.3% of patients had intermediate-risk disease, and the remaining had low-risk. During follow-up, 29 (23.6%) patients required radical treatment (external beam radiation therapy), 37 (30.1%) experienced treatment failure, and 26 (21.1%) had an in-field recurrence with an ISUP grade of ≥2. Radical treatment in the follow-up was associated with patients treated by surgeons in group #3 and with elevated post-HIFU PSA concentrations. Baseline PSA concentrations, group #3 surgeons, and post-HIFU PSA concentrations were associated with treatment failure. In-field positive biopsies were associated with baseline and post-HIFU PSA concentrations. Furthermore, patients treated by surgeons in group #3 were independently associated with radical treatment and focal therapy failure.

CONCLUSION

Focal therapy with HIFU has acceptable oncological outcomes in the medium term, and the surgeon's experience and technique are independently associated with the need for subsequent radical treatment and focal therapy failure.

Concurrent occurrence of adenocarcinoma and urothelial carcinoma of the prostate gland: A case report

BACKGROUND

Adenocarcinoma is the most common subtype of prostate cancer. Prostatic urothelial carcinoma (UC) typically originates from the prostatic urethra. The concurrent occurrence of adenocarcinoma and UC of the prostate gland is uncommon.

CASE SUMMARY

We present the case of an 82-year-old male patient with simultaneous adenocarcinoma and UC of the prostate gland. The patient underwent a transrectal ultrasound-guided biopsy, and the pathology test revealed UC. Subsequently, transurethral laser prostatectomy was performed, and the pathology test indicated adenocarcinoma of the prostate with a Gleason score of 3 + 4 and high-grade UC. Therefore, the patient was treated with androgen deprivation therapy, systemic chemotherapy, and immunotherapy. Magnetic resonance imaging performed during follow-up revealed a prostate tumor classified as cT2cN1M0, stage IVA. Therefore, the patient underwent robotic-assisted radical prostatectomy and bilateral pelvic lymph node dissection. The final pathology test of the prostate gland revealed acinar-type adenocarcinoma, Gleason pattern 4 + 3, pT2N0M0, and high-grade UC. The patient regularly presented to the clinic for postoperative follow-up evaluations. He did not experience any urinary discomfort.

CONCLUSION

According to our literature review, this is the first reported case of coexisting adenocarcinoma and UC of the prostate gland.

Does sexual rehabilitation work for gay and bisexual prostate cancer patients? Acceptability, feasibility, and efficacy results from the Restore-2 randomized controlled trial

PURPOSE

Sexual minority prostate cancer patients have worse health-related quality of life outcomes than heterosexual patients. We conducted the first study to test whether sexual and urinary rehabilitation tailored for sexual minority patients was acceptable, feasible, and efficacious at improving their sexual and urinary function.

METHODS

Restore-2 was a 24-month randomized controlled trial of an online biopsychobehavioral rehabilitation study for sexual minority men treated for prostate cancer experiencing sexual and/or urinary problems. Participants were 401 US sexual minority men treated for prostate cancer and experiencing sexual and/or urinary problems at baseline. Intervention components included phosphodiesterase-5 inhibitors, sexual aids, a pelvic floor exercise regimen and video, a guide to good gay sex following treatment, and coaching. Quality of life assessments were completed at baseline, 3, 6, 12, 18, and 24 months.

RESULTS

We confirmed good acceptability and feasibility, but only minimal improvement was observed over time and no differences were found between treatment and control arms.

CONCLUSIONS

We found no evidence that the intervention improved sexual or urinary outcomes for participants. However, we confirmed excellent acceptability and feasibility for a sexual rehabilitation program tailored to sexual minority participants. In addition, participants reported enduring usage and acceptability of sexual aids (including vacuum pump, anal dilators, and penile constriction rings) as well as masturbation and pelvic floor exercises to accommodate their sexual challenges.

IMPLICATIONS FOR CANCER SURVIVORS

Sexual "accommodation," rather than "rehabilitation," may be a more accurate and realistic goal for this population. Patients should be provided sexual aids to help accommodate their sexual and urinary challenges.

TRIAL REGISTRATION

This study was retrospectively registered with ClinicalTrials.gov, study number: NCT03923582; date: 22/04/2019.

Impact of comorbidities on prostate cancer-specific mortality: A population-based cohort study

AIM

To assess the impact of comorbidities on prostate cancer mortality.

METHODS

We studied 15,695 South Australian men diagnosed with prostate cancer between 2003 and 2019 from state-wide administrative linked data sets. Comorbidity was measured 1-year before prostate cancer diagnosis using Rx-Risk, a medication-based comorbidity index. Flexible parametric competing risk regression was used to estimate the independent association between comorbidities and prostate cancer-specific mortality. Specific common comorbidities within Rx-Risk (cardiac disorders, diabetes, chronic airway diseases, depression and anxiety, thrombosis, and pain) were also assessed to determine their association with mortality. All models were adjusted for sociodemographic variables, tumor characteristics, and treatment type.

RESULTS

Prostate cancer-specific mortality was higher for patients with a Rx-Risk score ≥3 versus 0 (adjusted sub-hazard ratio (sHR) 1.34, 95% CI: 1.15-1.56). Lower comorbidity scores (Rx-Risk score 2 vs. 0 and Rx-Risk score 1 vs. 0) were not significantly associated with prostate cancer-specific mortality. Men who were using medications for cardiac disorders (sHR 1.31, 95% CI: 1.13-1.52), chronic airway disease (sHR 1.20, 95% CI: 1.01-1.44), depression and anxiety (sHR 1.17, 95% CI: 1.02-1.35), and thrombosis (sHR 1.21, 95% CI: 1.04-1.42) were at increased risk of dying from prostate cancer compared with men not on those medications. Use of medications for diabetes and chronic pain were not associated with prostate cancer-specific mortality. All Rx-Risk score categories and the specific comorbidities were also associated with increased risk of all-cause mortality.

CONCLUSION

The findings showed that ≥3 comorbid conditions and specific comorbidities including cardiac disease, chronic airway disease, depression and anxiety, and thrombosis were associated with poor prostate cancer-specific survival. Appropriate management of these comorbidities may help to improve survival in prostate cancer patients.

Stereotactic Magnetic Resonance-Guided Daily Adaptive Radiation Therapy for Localized Prostate Cancer: Acute and Late Patient-Reported Toxicity Outcomes

Purpose

To report acute and late bowel, urinary, and sexual dysfunction patient-reported outcome measures, among patients with localized prostate cancer who underwent stereotactic magnetic resonance-guided daily adaptive radiation therapy (SMART).

Methods and Materials

All patients who completed a baseline 12-item Patient-Reported Outcomes Version of the Common Terminology Criteria for Adverse Events questionnaire, before undergoing SMART with 36.25 Gy in 5 fractions, were subsequently followed up with the same graded questionnaire at set time points. Latest prostate-specific antigen levels were recorded. The percentage of patients who reported no change from their baseline adverse event (AE) or reported a new ≥ "frequent or almost constant" or "severe grade or higher" AE grade during follow-up was calculated. The maximum 12-item Patient-Reported Outcomes Version of the Common Terminology Criteria for Adverse Events grade for each item was recorded for each patient. The percentage of toxicity levels for each separate AE item at set time points was calculated.

Results

The total number of patients was 69 with a median follow-up of 27 months. Median age of the cohort was 73 years (range, 54-85 years). The median pretreatment prostate-specific antigen level, T stage, and Gleason score were 7.5 mmol/L (range, 4.5-32 mmol/L), T2b (range, T2-T3b), and 7 (3 + 4; range, 6-9), respectively. No patient had biochemical failure during follow-up. Regarding bowel symptoms, >80% of men reported no change from baseline toxicity during follow-up. New ≥ frequent or almost constant diarrhea was reported in 9% of patients. "Almost constant" diarrhea peaked at 1 month but was absent at >33 months. Regarding urinary symptoms, increased urinary urgency was the most common complaint (39%). Twenty percent of men reported new ≥ frequent or almost constant urinary urgency incidence peaking at 1 month but absent at >33 months. New "severe" sexual dysfunction was seen in 26% of patients and was persistent at >33 months.

Conclusions

Our study is one the largest patient-reported outcomes study after prostate SMART. It shows acceptable levels of toxicity even up to 2 years after treatment.

Perioperative infection prevention during inflatable penile prosthesis surgery: a narrative review

Background and Objective

Penile prostheses are an option for the management of erectile dysfunction (ED). Over the years penile prosthesis surgery has become increasingly safe owing to improvements such as antibiotic usage, coated devices, and surgical techniques. However, infection remains a dreaded complication during prosthesis surgery. Efforts to minimize risk of infection in the perioperative period have been extensively studied. Herein, we performed a narrative review on preoperative, intraoperative, and postoperative strategies for infection prevention during placement of a penile prosthesis with a comparison of infection prevention strategies to other surgical fields.

Methods

A literature review was performed using PubMed and Google Scholar. Studies evaluating perioperative management of penile prosthesis infection were included. The following search terms were used to for our literature search: penile prosthesis, inflatable penile prosthesis, infection, prevention, perioperative management. Articles were graded based on the 2011 Oxford Centre for Evidence Based Medicine (OCEBM) guidelines and a table was generated with each intervention discussed and its level of evidence based on current literature.

Key Content and Findings

Optimization of patient's comorbid conditions can help reduce risk during prosthesis operations. Monitoring and optimizing a patient's glycemic control has been investigated, but the current literature does not necessarily support a strict hemoglobin A1c (HbA1c) or pre-operative blood glucose level. Surgical field preparation using chlorhexidine-based solutions has been shown to be superior to iodine-based solutions. Appropriately selected peri-operative antibiotics have also been shown to reduce infection risk. Intraoperatively, the use of coated devices in addition to a 'no touch' technique have been shown to significantly reduce the risk of inflatable penile prosthesis (IPP) infection. Post operatively, available evidence of antibiotic use has not been demonstrated to be effective in reducing infection rates.

Conclusions

Surgical infection following placement of an IPP is a devastating and morbid complication with infection rate up as high as 1-3% in virgin cases and 7-18% in revision cases. While perioperative techniques exist and have reduced risk of infection, more prospective data is needed to evaluate the clinical significance of these different approaches. More research in these areas, along with future options such as nanoparticles, antibiotic coated suture, and next generation sequencing (NGS) for bacterial pathogens, may shed light on further ways to optimize infection reduction strategies for prosthesis surgery.

Impact of the diagnostic label for a low-risk prostate lesion: protocol for two online factorial randomised experiments

INTRODUCTION

Many types of prostate cancer present minimal risk to a man's lifespan or well-being, but existing terminology makes it difficult for men to distinguish these from high-risk prostate cancers. This study aims to explore whether using an alternative label for low-risk prostate cancer influences management choice and anxiety levels among Australian men and their partners.

METHODS AND ANALYSIS

We will run two separate studies for Australian men and Australian women with a male partner. Both studies are between-subjects factorial (3×2) randomised online hypothetical experiments. Following consent, eligible participants will be randomised 1:1:1 to three labels: 'low-risk prostate cancer, Gleason Group 1', 'low-risk prostate neoplasm' or 'low-risk prostate lesion'. Participants will then undergo a second randomisation step with 1:1 allocation to the provision of detailed information on the benefits and harms of different management choices versus the provision of less detailed information about management choices. The required sample sizes are 1290 men and 1410 women. The primary outcome is the participant choice of their preferred management strategy: no immediate treatment (prostate-specific antigen (PSA)-based monitoring or active surveillance using PSA, MRI, biopsy with delayed treatment for disease progression) versus immediate treatment (prostatectomy or radiation therapy). Secondary outcomes include preferred management choice (from the four options listed above), diagnosis anxiety, management choice anxiety and management choice at a later time point (for participants who initially choose a monitoring strategy).

ETHICS AND DISSEMINATION

Ethics approval has been received from The University of Sydney Human Research Ethics Committee (2023/572). The results of the study will be published in a peer-reviewed medical journal and a plain language summary of the findings will be shared on the Wiser Healthcare publications page http://www.wiserhealthcare.org.au/category/publications/ TRIAL REGISTRATION NUMBERS: Australian New Zealand Clinical Trials Registry (ID 386701 and 386889).

Targeted microwave ablation for prostate cancer (FOSTINE1b): a prospective 'ablate-and-resect' study

OBJECTIVE

To assess histopathological outcomes, as well as feasibility and safety of targeted microwave ablation (TMA) via the Trinity® system (KOELIS, La Tronche, France).

PATIENTS AND METHODS

Prospective, single-institution, interventional Phase IIa study with an 'ablate-and-resect' design. In all, 11 patients diagnosed with localised prostate cancer (PCa) underwent TMA via the Trinity system under conscious sedation in an outpatient setting using a single transrectal TATO® 18-G antenna with different treatment regimens. Magnetic resonance imaging (MRI) and robot-assisted radical prostatectomy (RARP) were conducted at 7 days and 1 month after TMA, respectively. Nine patients received RARP, and two patients chose to withdraw their consent following TMA. These men chose an active surveillance protocol upon confirmation of a low-risk prostate cancer diagnosis. Functional outcomes and adverse events were evaluated at baseline and follow-up visits using validated questionnaires. Prostate volumetry and confirmation of necrosis were carried out through MRI and whole-mount histopathological examination.

RESULTS

The TMA was successfully executed, and all patients were discharged on the same day. No severe adverse events (Common Terminology Criteria for Adverse Events Grade ≥3) were reported at the 7-day and 1-month follow-up visits. Additionally, no declines were observed in urinary, sexual and ejaculation functional outcomes. T1-weighted MRI revealed clear and well-defined ablation zones. The RARP was executed without difficulty, particularly during the dissection of the posterior plane. As a result, no intraoperative complications were encountered. Histopathological assessment on surgical specimens confirmed the absence of viable cells, indicating complete necrosis of the ablative zone if a power intensity >10 W was used during TMA. Ablation zone volumetry revealed no notable distinctions between the three-dimensional segmentation of the virtual ablation zone at TMA (median volume: 2 mL) and MRI (median volume: 1.923 mL). Conversely, a significant reduction was noted in the surgical specimen (median volume: 0.221 mL).

CONCLUSIONS

Targeted microwave ablation via the Trinity system for localised PCa treatment proves to be a secure and feasible procedure, with complete necrosis evidence within the ablation zone on surgical specimens.

Six-year outcomes of robot-assisted radical prostatectomy versus volumetric modulated arc therapy for localized prostate cancer: A propensity score-matched analysis

BACKGROUND

Although robot-assisted radical prostatectomy (RARP) and intensity-modulated radiotherapy are the leading respective techniques of prostatectomy and radiotherapy for localized prostate cancer, almost no study has directly compared their outcomes; none have compared mortality outcomes.

METHODS

We compared 6‑year outcomes of RARP (n = 500) and volumetric modulated arc therapy (VMAT, a rotational intensity-modulated radiotherapy, n = 360) in patients with cT1-4N0M0 prostate cancer. We assessed oncological outcomes, namely overall survival (OS), cancer-specific survival (CSS), radiological recurrence-free survival (rRFS), and biochemical recurrence-free survival (bRFS), using propensity score matching (PSM). We also assessed treatment-related complication outcomes of prostatectomy and radiotherapy.

RESULTS

The median follow-up duration was 79 months (> 6 years). PSM generated a matched cohort of 260 patients (130 per treatment group). In the matched cohort, RARP and VMAT showed equivalent results for OS, CSS, and rRFS: both achieved excellent 6‑year outcomes for OS (> 96%), CSS (> 98%), and rRFS (> 91%). VMAT had significantly longer bRFS than RARP, albeit based on different definitions of biochemical recurrence. Regarding complication outcomes, patients who underwent RARP had minimal (2.6%) severe perioperative complications and achieved excellent continence recovery (91.6 and 68.8% of the patients achieved ≤ 1 pad/day and pad-free, respectively). Patients who underwent VMAT had an acceptable rate (20.0%) of grade ≥ 2 genitourinary complications and a very low rate (4.4%) of grade ≥ 2 gastrointestinal complications.

CONCLUSION

On the basis of PSM after a 6-year follow-up, RARP and VMAT showed equivalent and excellent oncological outcomes, as well as acceptable complication profiles.

Management of Patients With a Negative Multiparametric Prostate MRI Examination: AJR Expert Panel Narrative Review

Multiparametric MRI (mpMRI) of the prostate aids risk stratification of patients with elevated PSA levels. Although most clinically significant prostate cancers are detected by mpMRI, insignificant cancers are less evident. Thus, multiple international prostate cancer guidelines now endorse routine use of prostate MRI as a secondary screening test before prostate biopsy. Nonetheless, management of patients with negative mpMRI results (defined as PI-RADS category 1 or 2) remains unclear. This AJR Expert Panel Narrative Review summarizes the available literature on patients with an elevated screening PSA level and a negative prostate mpMRI result and provides guidance for these patients' management. Systematic biopsy should not be routinely performed after a negative mpMRI examination in patients at average risk but should be considered in patients at high risk. In patients who undergo PSA screening rather than systematic biopsy after negative mpMRI, clear triggers should be established for when to perform a repeat MRI examination. Patients with a negative MRI result followed by negative biopsy should follow their health care practitioners' preferred guidelines concerning subsequent PSA screening for the patient's risk level. Insufficient high-level data exist to support routine use of adjunctive serum or urine biomarkers, artificial intelligence, or PSMA PET to determine the need for prostate biopsy after a negative mpMRI examination.

Overview of Radiation Therapy in the Management of Localized and Metastatic Prostate Cancer

PURPOSE OF REVIEW

The goal is to describe the evolution of radiation therapy (RT) utilization in the management of localized and metastatic prostate cancer.

RECENT FINDINGS

Long term data for a variety of hypofractionated definitive RT dose-fractionation schemes has matured, allowing patients and providers many standard-of-care options to choose from. Post-prostatectomy, adjuvant RT has largely been replaced by an early salvage approach. Multiparametric MRI and PSMA PET have enabled increasingly targeted RT delivery to the prostate and oligometastatic tumors. Areas of active investigation include determining the value of proton beam therapy and perirectal spacers, and optimally incorporate genomic tumor profiling and next generation hormonal therapies with RT in the curative setting. The use of radiation therapy to treat prostate cancer is rapidly evolving. In the coming years, there will be continued improvements in a variety of areas to enhance the value of RT in multidisciplinary prostate cancer management.

From Screening to Mortality Reduction: An Overview of Empirical Data on the Patient Journey in European Randomized Study of Screening for Prostate Cancer Rotterdam After 21 Years of Follow-up and a Reflection on Quality of Life

BACKGROUND

Previous research quantified the effect of prostate-specific antigen (PSA)-based prostate cancer (PCa) screening on quality-adjusted life years using 11-yr follow-up data from the European Randomized Study of Screening for Prostate Cancer (ERSPC) extrapolated by the Microsimulation Screening Analysis (MISCAN). ERSPC data now matured to 21 yr of follow-up.

OBJECTIVE

To provide an overview of the effect of PSA-based screening on tumour characteristics and PCa treatment using long-term, detailed, empirical ERSPC data.

DESIGN, SETTING, AND PARTICIPANTS

Men were included from the ERSPC Rotterdam who were randomised to a PSA-based screening (S) or control (C) arm.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

We assessed the effects of PSA-based screening on the number of PCa diagnoses, tumour characteristics, treatments, and cumulative incidence of disease progression. We also evaluated the changes in tumour characteristics and treatments over time for both study arms.

RESULTS AND LIMITATIONS

Among PCa patients in the S-arm, fewer patients were diagnosed with advanced tumour stages (T3/T4: 12% vs 23%; relative risk [RR] = 0.50; 95% confidence interval [CI] 0.44-0.57), less disease progression was observed, and less secondary treatment (30% vs 48%; RR = 0.61; 95% CI 0.57-0.66; p < 0.001) and less palliative treatment were needed (21% vs 55%; RR = 0.38; 95% CI 0.35-0.42) than among those in the C-arm. This was at the cost of overdiagnosis and increased local treatments (eg, radical prostatectomy: 32% vs 14%; RR = 2.18; 95% CI 1.92-2.48). Over time, the number of local treatments decreased, whereas expectant management strategies increased. The RRs of treatments were slightly different from those of the MISCAN.

CONCLUSIONS

After 21 yr of follow-up, empirical data of the ERSPC showed that PSA-based screening reduces advanced PCa stages, disease progression, and extensive treatments at the cost of more overdiagnosis and probably more overtreatment. Our data showed reduced local treatments and increased expectant management strategies over time.

PATIENT SUMMARY

Prostate-specific antigen-based screening reduces the number of invasive prostate cancer treatments needed, however, at the cost of more overdiagnosis and probably more overtreatment. Limiting these costs remains crucial to benefit optimally from prostate cancer screening.

The lived experience of prostate cancer: 10-year survivor perspectives following contemporary treatment of localized prostate cancer

PURPOSE

Studies relying on standardized instruments to measure patient-centered harms and benefits of cancer treatment may fail to capture important elements of the lived experience of cancer patients. Further, qualitative studies on the survivorship experience of men with localized prostate cancer (PCa) are limited. We sought to explore the early experience, long-term experience, and advice provided for others among long-term survivors of localized PCa.

METHODS

Semi-structured qualitative interviews with a subset (n = 66) of respondents to a survey of 10-year PCa survivors who underwent active surveillance, radical prostatectomy, or radiotherapy. Topics included early and long-term experiences and advice to other men and physicians.

RESULTS

Immediately after treatment, men were mostly satisfied with radiation and active surveillance due to remaining whole and avoiding surgical removal of the prostate. Meanwhile, men treated with surgery felt relieved by the removal of cancer. Some early negative perception was related to short-term anxiety, particularly among men who underwent active surveillance. Long-term experiences included accepting the trade-offs of urinary and sexual side effects with survival. Most men fared well financially, some had strengthened relationships, and many reported greater appreciation and compassion. Men provided essential advice to other men and physicians on the importance of gathering detailed information on treatments and establishing a strong relationship with physicians.

CONCLUSIONS

Long-term survivors of localized PCa generally do well by accepting the long-term effects of contemporary treatments, experiencing strengthened relationships, and developing a better overall life approach.

IMPLICATIONS FOR CANCER SURVIVORS

We provide useful perspectives and insights for men opting to use current-day treatments for localized PCa.

Estimating the Effect of Radical Prostatectomy: Combining Data From the SPCG4 and PIVOT Randomized Trials With Contemporary Cohorts

PURPOSE

Two randomized trials (SPCG4 and PIVOT) have compared surgery to conservative management for localized prostate cancer. The applicability of these trials to contemporary practice remains uncertain. We aimed to develop an individualized prediction model for prostate cancer mortality comparing immediate surgery at a high-volume center to active surveillance.

MATERIALS AND METHODS

We determined whether the relative risk of prostate cancer mortality with surgery vs observation varied by baseline risk. We then used various estimates of relative risk to estimate 15-year mortality with and without surgery using, as a predictor, risk of biochemical recurrence calculated from a model.

RESULTS

We saw no evidence that relative risk varied by baseline risk, supporting the use of a constant relative risk. Compared with observation, surgery was associated with negligible benefit for patients with Grade Group (GG) 1 disease (0.2% mortality reduction at 15 years) and small benefit for patients with GG2 with lower PSA and stage (≤5% mortality reduction). Benefit was greater (6%-9%) for patients with GG3 or GG4 though still modest, but effect estimates varied widely depending on choice of hazard ratio for surgery (6%-36% absolute risk reduction).

CONCLUSIONS

Surgery should be avoided for men with low-risk (GG1) prostate cancer and for many men with GG2 disease. Surgical benefits are greater in men with higher-risk disease. Integration of findings with a life expectancy model will allow patients to make informed treatment decisions given their oncologic risk, risk of death from other causes, and estimated effects of surgery.

Prostate-Specific Antigen Screening and Prostate Cancer Mortality: An Emulation of Target Trials in US Medicare

PURPOSE

No consensus about the effectiveness of prostate-specific antigen (PSA) screening exists among clinical guidelines, especially for the elderly. Randomized trials of PSA screening have yielded different results, partly because of variations in adherence, and it is unlikely that new trials will be conducted. Our objective was to estimate the effect of annual PSA screening on prostate cancer (PC) mortality in Medicare beneficiaries age 67-84 years.

METHODS

This is a large-scale, population-based, observational study of two screening strategies: annual PSA screening and no screening. We used data from 537,599 US Medicare (2001-2008) beneficiaries age 67-84 years who had a good life expectancy, no previous PC, and no PSA test in the 2 years before baseline. We estimated the 8-year PC mortality and incidence, treatments for PC, and treatment complications of PSA screening.

RESULTS

In men age 67-74 years, the estimated difference in 8-year risk of PC death between PSA screening and no screening was -2.3 (95% CI, -4.1 to -1.1) deaths per 1,000 men (a negative risk difference favors screening). Treatment complications were more frequent under PSA screening than under no screening. In men age 75-84 years, risk difference estimates were closer to zero.

CONCLUSION

Our estimates suggest that under conventional statistical criteria, annual PSA screening for 8 years is highly compatible with reductions of PC mortality from four to one fewer PC deaths per 1,000 screened men age 67-74 years. As with any study using real-world data, the estimates could be affected by residual confounding.

In Silico Comparison of Three Different Beam Arrangements for Intensity-Modulated Proton Therapy for Postoperative Whole Pelvic Irradiation of Prostate Cancer

Background and purpose: Proton therapy has been shown to provide dosimetric benefits in comparison with IMRT when treating prostate cancer with whole pelvis radiation; however, the optimal proton beam arrangement has yet to be established. The aim of this study was to evaluate three different intensity-modulated proton therapy (IMPT) beam arrangements when treating the prostate bed and pelvis in the postoperative setting. Materials and Methods: Twenty-three post-prostatectomy patients were planned using three different beam arrangements: two-field (IMPT2B) (opposed laterals), three-field (IMPT3B) (opposed laterals inferiorly matched to a posterior-anterior beam superiorly), and four-field (IMPT4B) (opposed laterals inferiorly matched to two posterior oblique beams superiorly) arrangements. The prescription was 50 Gy radiobiological equivalent (GyE) to the pelvis and 70 GyE to the prostate bed. Comparisons were made using paired two-sided Wilcoxon signed-rank tests. Results: CTV coverages were met for all IMPT plans, with 99% of CTVs receiving ≥ 100% of prescription doses. All organ at risk (OAR) objectives were met with IMPT3B and IMPT4B plans, while several rectum objectives were exceeded by IMPT2B plans. IMPT4B provided the lowest doses to OARs for the majority of analyzed outcomes, with significantly lower doses than IMPT2B +/- IMPT3B for bladder V30-V50 and mean dose; bowel V15-V45 and mean dose; sigmoid maximum dose; rectum V40-V72.1, maximum dose, and mean dose; femoral head V37-40 and maximum dose; bone V40 and mean dose; penile bulb mean dose; and skin maximum dose. Conclusion: This study is the first to compare proton beam arrangements when treating the prostate bed and pelvis. four-field plans provided better sparing of the bladder, bowel, and rectum than 2- and three-field plans. The data presented herein may help inform the future delivery of whole pelvis IMPT for prostate cancer.

Analysis of Oncology and Radiation Therapy Representation on the National Board of Medical Examiners Official Practice Material for the United States National Standardized Medical Board Examinations

Radiation therapy (RT) is a critical component of multidisciplinary cancer care, but has inconsistent curricular exposure. We characterize the radiation oncology (RO) content on the standardized undergraduate medical examinations by comparing its context and prevalence with other domains in oncology. National Board of Medical Examiners (NBME) self-assessments and sample questions for the United States Medical Licensing Exam (USMLE) Steps 1-3 and NBME clinical science shelf examinations were accessed (n = 3878). Questions were inductively analyzed for content pertaining to oncology and treatment modalities of RT, systemic therapy (ST), and surgical intervention (SI). Questions were coded using USMLE Physician Tasks/Competencies and thematic analysis. Descriptive statistics and analyses using the Kruskal-Wallis test are reported. A total of 337 questions (8.6%) within the USMLE and shelf exams included oncology content, with 101 questions (2.6%) referencing at least one cancer treatment modality (n = 35 RT, 45 ST, 57 SI). Treatment questions were more common on USMLE Step 2 CK (n = 35/101, 32%) compared to Step 1 (n = 23/101, 23%) and Step 3 (n = 8/101, 8%) (p < 0.001). RT was significantly less likely to be the correct answer (2/35, 6%) compared to ST (4/45, 9%) and SI (18/57, 32%) (p = 0.003). Therapeutic oncology questions are uncommon on the examination material, with an under-representation of radiation-related content, and contextual bias favoring surgical approaches. We advocate for greater RO involvement in the content creation of such examinations to help trainees better understand multidisciplinary cancer care.

Outcomes after precision prostatectomy: safety, efficacy and transference of skills

PURPOSE

Precision Prostatectomy (PP) is a viable treatment option for men with unilateral dominant cancer who are interested in preserving functional outcomes. To date, the data published about the outcomes of this technique has come from a single center only (Henry Ford - HF). We present the surgical, functional, and oncological outcomes of the first series of patients to undergo PP outside of HF, to demonstrate the safety and reproducibility of the technique.

METHODS

Between 2022 and 2023, PP was offered to select patients who were interested in preserving their functional status. Men who underwent PP were followed at 3 monthly intervals; information regarding their functional status was simultaneously obtained. Men who had biochemical recurrence were advised to undergo remnant biopsy. If residual cancer was detected, then remnant removal was performed.

RESULTS

The median age and median PSA of the study group was 63 years and 6.89 ng/ml respectively. The median operative and console times were 196.5 and 154 minutes. No intra-operative complications were noted. Three patients had a total of three post-operative complications. Three patients had biochemical recurrence; cancer was not detected in any of these patients on postoperative biopsies of the prostatic remnant. At 12 months, 91% of patients reported using 0 pads/day and 90.9% of pre-operatively potent patients were potent at 12 months.

CONCLUSION

PP is a safe and reproducible technique that can ensure cancer control and preservation of functional status in select patients. Further studies with large sample sizes and longer follow-up are required to ascertain the long-term outcomes of this surgical technique.

Perceptions of prostate cancer patients undergoing definitive radiotherapy on the impact of prostate cancer and radiation therapy on male sexuality

Introduction

Male sexual function is an important aspect of the life of prostate cancer patients and plays a significant role in the long-term quality of life of prostate cancer survivors. However, there is a paucity of published literature on the perceived impact of prostate cancer and its treatment on the sexual function of patients in Ghana and West Africa in general. The purpose of this study was to explore the perceptions of prostate cancer patients on the effects of the disease and radiation therapy on male sexual function. The study also examined the changes in sexuality experienced by men with prostate cancer.

Methods

This research was a descriptive longitudinal study conducted at the third largest hospital in Africa. The study included Ghanaian prostate cancer patients of all ages who were treated with definitive radiotherapy at the study site between October 2021 and May 2022. Quantitative data were collected and analysed using the Statistical Package for Social Sciences version 26.0 and Microsoft Excel 2019. Descriptive statistics were used to determine frequencies and percentages of the demographic characteristics.

Results

The mean age of the participants was 65.7 years (SD 6.7) ranging from 50 to 81 years. Patients had different ideas about the potential adverse effects of prostate cancer (86%) and radiotherapy (70%) on male sexual function. A decrease in sexual desire (54%) was the commonest perceived effect of prostate cancer on male sexual function followed by premature ejaculation (49%) and a decrease in sexual activity (48%). On the other hand, erectile dysfunction (49%) was the commonest perceived effect of radiotherapy for prostate cancer on male sexual function followed by a decrease in sexual desire (38%) and premature ejaculation (37%). Health professionals were the major source of information regarding the perceptions of the patients on the effects of both prostate cancer (46%) and radiation therapy (43%) on male sexual function.

Conclusion

There should be enhancement of awareness measures to educate Ghanaian cancer patients on the side effects and implications of treatment on their sexuality. Comprehensive sexual health assessment should be incorporated in the routine care of patients with cancers that have the potential to impact the sexual function of patients.

Systemic therapy and radiotherapy related complications and subsequent hospitalisation rates: a systematic review

BACKGROUND

Hospitalisation  resulting from complications of systemic therapy and radiotherapy places a substantial burden on the patient, society, and healthcare system. To formulate preventive strategies and enhance patient care, it is crucial to understand the connection between complications and the need for subsequent hospitalisation. This review aimed to assess the existing literature on complications related to systemic and radiotherapy treatments for cancer, and their impact on hospitalisation rates.

METHODS

Data was obtained via electronic searches of the PubMed, Scopus, Embase and Google Scholar online databases to select relevant peer-reviewed papers for studies published between January 1, 2000, and August 30, 2023. We searched for a combination of keywords in electronic databases and used a standard form to extract data from each article. The initial specific interest was to categorise the articles based on the aspects explored, especially complications due to systemic and radiotherapy and their impact on hospitalisation. The second interest was to examine the methodological quality of studies to accommodate the inherent heterogeneity. The study protocol was registered with PROSPERO (CRD42023462532).

FINDINGS

Of 3289 potential articles 25 were selected for inclusion with ~ 34 million patients. Among the selected articles 21 were cohort studies, three were randomised control trials (RCTs) and one study was cross-sectional design. Out of the 25 studies, 6 studies reported ≥ 10 complications, while 7 studies reported complications ranging from 6 to 10. Three studies reported on a single complication, 5 studies reported at least two complications but fewer than six, and 3 studies reported higher numbers of complications (≥ 15) compared with other selected studies. Among the reported complications, neutropenia, cardiac complications, vomiting, fever, and kidney/renal injury were the top-most. The severity of post-therapy complications varied depending on the type of therapy. Studies indicated that patients treated with combination therapy had a higher number of post-therapy complications across the selected studies. Twenty studies (80%) reported the overall rate of hospitalisation among patients. Seven studies revealed a hospitalisation rate of over 50% among cancer patients who had at least one complication. Furthermore, two studies reported a high hospitalisation rate (> 90%) attributed to therapy-repeated complications.

CONCLUSION

The burden of post-therapy complications is emerging across treatment modalities. Combination therapy is particularly associated with a higher number of post-therapy complications. Ongoing research and treatment strategies are imperative for mitigating the complications of cancer therapies and treatment procedures. Concurrently, healthcare reforms and enhancement are essential to address the elevated hospitalisation rates resulting from treatment-related complications in cancer patients.

Localized prostate cancer in older patients: Radical prostatectomy or radiotherapy versus observation

INTRODUCTION

This study evaluates the effects of radical prostatectomy (RP) or irradiation on overall survival (OS) and prostate cancer-specific mortality (PCSM) in older patients with localized prostate cancer (PC).

MATERIALS AND METHODS

We conducted a comprehensive literature review across PubMed, EMBASE, and the Cochrane Library from inception up to December 2023 to identify studies comparing the outcomes of surgery or radiotherapy (RT) versus observation in patients aged 65 and older with localized PC. We pooled hazard ratios (HRs) for OS and PCSM using random-effects models.

RESULTS

Thirteen studies involving 284,066 patients were analyzed. Three were large randomized trials (RCTs) and 10 were retrospective studies. Overall survival with surgery was greater in observational studies (HR = 0.52, 95% confidence interval [CI] 0.47-0.59; P < 0.001) than in RCTs (HR = 0.84, 95%CI 0.72-0.98; P = 0.03). Data on PCSM from seven studies also indicated a significant benefit for RP in RCTs (HR = 0.47; 95% CI: 0.3-0.73; P < 0.001) and observational studies (HR = 0.41, 95%CI 0.27-0.62; P < 0.001). Both analyses presented high heterogeneity (I2 = 90%, P < 0.001 and I2 = 65%, P = 0.01). An analysis of patients receiving RT indicated a significant, albeit smaller, OS (n = 7 studies) and PCSM (n = 5 studies) advantage (HR = 0.69; 95% CI: 0.59-0.79; P < 0.001; and HR = 0.60; 95% CI 0.44-0.82; P = 0.001) compared to observation (1 RCT and 8 observational studies).

DISCUSSION

The evidence suggests that patients with PC might consider opting for surgery as the main treatment option or, alternatively, for RT, as an alternative to observation, based on their individual medical history, life expectancy, and preferences.

Temporal trends in medication and service use patterns for mental health issues among men with prostate cancer

OBJECTIVE

Prostate cancer can significantly impact mental wellbeing, creating uncertainty and morbidity. This study described patterns of psychotropic medication and mental health service use, as a proxy measure for mental health problems, 5 years before and 5 years after prostate cancer diagnosis.

METHODS

Population-based registry data were linked with Pharmaceutical Benefits Scheme and Medicare Benefits Schedule data for all prostate cancer patients diagnosed in South Australia between 2012 and 2020 (n = 13,693). We estimated the proportion and rates of psychotropic medication and mental health service use before and after diagnosis. Multivariable adjusted interrupted time series analyses (ITSA) were conducted to uncover temporal patterns.

RESULTS

Fifteen percent of men commenced psychotropic medications and 6.4% sought out mental health services for the first time after diagnosis. Psychotropic medication use rose from 34.5% 5 years before to 40.3% 5 years after diagnosis, including an increase in use of antidepressants (from 20.7% to 26.0%) and anxiolytics (from 11.3% to 12.8%). Mental health service use increased from 10.2% to 12.1%, with the increase mostly being general practice mental health visits (from 7.8% to 10.6%). Multivariable ITSA indicated a significant rise in medication and service utilisation immediately before and in the first 2 years following prostate cancer diagnosis.

CONCLUSION

There is a clear increase in psychotropic medication use and mental health service use around the time of prostate cancer diagnosis. Mental health outcomes of men with prostate cancer may be improved with early mental health screening, particularly during the diagnosis process, to enable early intervention.

Demographic and Clinical Factors Associated With Health-Related Quality-of-Life Profiles Among Prostate Cancer Survivors

PURPOSE

Our purpose was to describe the prevalence and predictors of symptom and function clusters related to physical, emotional, and social components of general health-related quality of life (HRQOL) in a population-based sample of prostate cancer (PCa) survivors.

METHODS

Participants (N = 1,162) completed a baseline survey at a median of 9 months after diagnosis to ascertain the co-occurrence of eight symptom and functional domains that are common across all cancers and not treatment-specific. We used latent profile analysis (LPA) to identify subgroup profiles of survivors with low, moderate, or high HRQOL levels. Multinomial logistic regression models were used to identify clinical and sociodemographic factors associated with survivors' membership in the low versus moderate or high HRQOL profile.

RESULTS

The LPA identified 16% of survivors who were categorized in the low HRQOL profile at baseline, indicative of the highest symptom burden and lowest functioning. Factors related to survivors' membership in the low versus higher HRQOL profile groups included less than age 65 years at diagnosis, identifying as non-Hispanic Black race, not working, being a former versus never smoker, systemic therapy, less companionship, more comorbidities, lower health care financial well-being, or less spirituality. Several factors remained associated with remaining in the low versus higher HRQOL profiles on the follow-up survey (n = 699), including younger age, Black race, comorbidity, and lower financial and spiritual well-being.

CONCLUSION

About one of six PCa survivors experienced elevated physical and psychosocial symptoms that were independent of local curative therapy, but with younger age, race, comorbidity, and lower financial and spiritual well-being as stable risk factors for poor HRQOL over time.

Mediating Effects of Self-Efficacy and Illness Perceptions on Mental Health in Men with Localized Prostate Cancer: A Secondary Analysis of the Prostate Cancer Patient Empowerment Program (PC-PEP) Randomized Controlled Trial

Understanding how interventions reduce psychological distress in patients with prostate cancer is crucial for improving patient care. This study examined the roles of self-efficacy, illness perceptions, and heart rhythm coherence in mediating the effects of the Prostate Cancer Patient Empowerment Program (PC-PEP) on psychological distress compared to standard care. In a randomized controlled trial, 128 patients were assigned to either the PC-PEP intervention or standard care. The PC-PEP, a six-month program emphasizing daily healthy living habits, included relaxation and stress management, diet, exercise, pelvic floor muscle exercises, and strategies to improve relationships and intimacy, with daily activities supported by online resources and live sessions. Participants in the intervention group showed significant improvements in self-efficacy and specific illness perceptions, such as personal control and emotional response, compared to the control group. These factors mediated the relationship between the intervention and its psychological benefits, with self-efficacy accounting for 52% of the reduction in psychological distress. No significant differences in heart rhythm coherence were observed. This study highlights the critical role of self-efficacy and illness perceptions in enhancing psychological health in prostate cancer patients through the PC-PEP. The results underscore this program's effectiveness and the key mechanisms through which it operates. Given the high rates of distress among men undergoing prostate cancer treatments, these findings emphasize the importance of integrating the PC-PEP into clinical practice. The implementation of the PC-PEP in clinical settings can provide a structured approach to reducing psychological distress and improving overall patient well-being.

Salvage High-Intensity Focused Ultrasound for Prostate Cancer after Radiation Failure: A Narrative Review

For patients diagnosed with localized prostate cancer, there are multiple treatment options available. The traditional treatment modalities include radical prostatectomy and radiotherapy. Nevertheless, focal therapy, including high-intensity focused ultrasound (HIFU) and cryotherapy, has emerged as a less-invasive method in this setting. Some patients undergoing primary radiation therapy experience recurrence, but there is currently no consensus on the optimal approach for salvage treatment in such cases. The lack of robust data and randomized controlled trials comparing different whole-gland and focal salvage therapies presents a challenge in determining the ideal treatment strategy. This narrative review examines the prospective and retrospective data available on salvage HIFU following radiation therapy. Based on the literature, salvage HIFU for radio-recurrent prostate cancer has promising oncological outcomes, with an overall 5-year survival rate of around 85%, as well as incontinence rates of about 30% based on the patient's risk group, follow-up times, definitions used, and other aspects of the study. Salvage HIFU for prostate cancer proves to be an effective treatment modality for select patients with biochemical recurrence following radiotherapy.

Impact of postoperative sexual function on health-related quality of life after robot-assisted radical prostatectomy

Background

We investigated potential disparities in health-related quality of life, particularly concerning urinary function, between patients with preserved and those with impaired sexual function after robot-assisted radical prostatectomy (RARP).

Materials and methods

Between December 2012 and April 2020, 704 men underwent RARP in our hospital. This study included 155 patients with a preoperative 5-item International Index of Erectile Function (IIEF-5) of ≥12 points and an assessable IIEF-5 at 12 months postoperatively. Health-related quality of life was assessed using the 8-item Short-Form Health Survey and Expanded Prostate Cancer Index Composite (EPIC) preoperatively and at 3, 6, and 12 months postoperatively. A logistic regression analysis and Wilcoxon rank sum tests were performed.

Results

Patients were grouped according to the median IIEF-5 score 12 months after surgery: those with preserved sexual function (n = 71) and those with impaired sexual function (n = 84). The mental component summary of the 8-item Short-Form Health Survey was better in the group with preserved sexual function at 6 months postoperatively than in the group with impaired sexual function (p < 0.01). In the EPIC, the group with preserved sexual function performed better not only in the sexual domain but also in the urinary domain at all time points compared with the group with impaired sexual function (p < 0.01). In the comparison of the urinary subdomains of the EPIC, there were no significant differences in urinary function or incontinence, but there were significant differences in urinary distress and irritative/obstructive scores (p < 0.01).

Conclusions

Patients with preserved postoperative sexual function after RARP showed better urinary function than those with impaired sexual function. Hence, preserved sexual function is closely associated with urinary function.

Patient-reported Side Effects 1 Year After Radical Prostatectomy or Radiotherapy for Prostate Cancer: A Register-based Nationwide Study

BACKGROUND

Data on functional and psychological side effects following curative treatment for prostate cancer are lacking from large, contemporary, unselected, population-based cohorts.

OBJECTIVE

To assess urinary symptoms, bowel disturbances, erectile dysfunction (ED), and quality of life (QoL) 12 mo after robot-assisted radical prostatectomy (RARP) and radiotherapy (RT) using patient-reported outcome measures in the Swedish prostate cancer database.

DESIGN, SETTING, AND PARTICIPANTS

This was a nationwide, population-based, cohort study in Sweden of men who underwent primary RARP or RT between January 1, 2018 and December 31, 2020.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Absolute proportions and odds ratios (ORs) were calculated using multivariable logistic regression, with adjustment for clinical characteristics.

RESULTS AND LIMITATIONS

A total of 2557 men underwent RARP and 1741 received RT. Men who underwent RT were older (69 vs 65 yr) and had more comorbidities at baseline. After RARP, 13% of men experienced incontinence, compared to 6% after RT. The frequency of urinary bother was similar, at 18% after RARP and 18% after RT. Urgency to defecate was reported by 14% of men after RARP and 34% after RT. At 1 yr, 73% of men had ED after RARP, and 77% after RT. High QoL was reported by 85% of men after RARP and 78% of men after RT. On multivariable regression analysis, RT was associated with lower risks of urinary incontinence (OR 0.25, 95% confidence interval [CI] 0.19-0.33), urinary bother (OR 0.79, 95% CI 0.66-0.95), and ED (OR 0.54, 95% CI 0.46-0.65), but higher risk of bowel symptoms (OR 2.86, 95% CI 2.42-3.39). QoL was higher after RARP than after RT (OR 1.34, 95% CI 1.12-1.61).

CONCLUSIONS

Short-term specific side effects after curative treatment for prostate cancer significantly differed between RARP and RT in this large and unselected cohort. Nevertheless, the risk of urinary bother was lower after RT, while higher QoL was common after RARP.

PATIENT SUMMARY

In our study of patients treated for prostate cancer, urinary bother and overall quality of life are comparable at 1 year after surgical removal of the prostate in comparison to radiotherapy, despite substantial differences in other side effects.

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.

Enhancing care: evaluating the impact of True North Sexual Health and Rehabilitation eTraining for healthcare providers working with prostate cancer patients and partners

Background

Educational programs that enhance healthcare providers' competence in managing the care of patients with sexual dysfunction following prostate cancer treatments are needed to facilitate comprehensive sexual health treatments for patients and their partners.

Aim

In this study we evaluated the impact of a real-world online sexual health educational intervention called the True North Sexual Health and Rehabilitation eTraining Program. This program is designed to increase healthcare providers' knowledge and self-efficacy in providing sexual healthcare to prostate cancer patients and their partners.

Methods

Healthcare providers were invited to join a 12-week virtual training program. Participants completed precourse surveys (n = 89), retrospective prepost surveys (n = 58), and a 3-month follow-up survey (subset n = 18) to assess retention of relevant outcomes. Additionally, a course satisfaction survey was administered to participants (n = 57) at the end of the course.

Outcomes

The main outcomes focused on participants' perceived knowledge and self-efficacy in conducting assessments and providing interventions for various relevant physical, functional, psychological, and relational domains of sexual dysfunction in prostate cancer patients and their partners.

Results

According to the retrospective analysis of post-then-pre-survey results, graduates perceived that their knowledge of and self-efficacy in providing sexual health counseling improved after completing the course. The 3-month follow-up survey indicated that the course graduate self-efficacy remained high 3 months after the course. Furthermore, the satisfaction survey indicated that a vast majority (98.2%) of participants were satisfied with the educational intervention.

Clinical Implications

This real-world sexual health educational intervention can increase self-efficacy and knowledge in healthcare providers who are supporting prostate cancer patients dealing with sexual dysfunction.

Strengths and Limitations

The use of a retrospective post-then-pre-survey helped to mitigate response shift bias while minimizing data gaps. However, it is important to note that this investigation was not a traditional research study and lacked a control group, thus limiting causal attributions.

Conclusion

The True North Sexual Health and Rehabilitation eTraining program acts as an accessible and effective resource for healthcare providers seeking specialized training in providing sexual healthcare for prostate cancer patients and their partners.