Quality of life following definitive therapy for localized prostate cancer: potential impact of multiple therapies

Association of Metformin Treatment with Risk for Death in Diabetic Patients with Concomitant Gastric Cancer

IMPORTANCE

Despite the existing guideline's recommendation of metformin therapy as the initial approach for managing diabetes mellitus (DM), there remains a scarcity of comprehensive documentation regarding metformin's impact on outcomes that are important for patients.

OBJECTIVES

The objective of this study was to assess the potential impact of metformin treatment on the risk of death in individuals diagnosed with both gastric cancer and pre-existing diabetes mellitus (DM); Design, Setting, and Participants: The study made use of a dataset encompassing nationwide health insurance claims, allowing for a retrospective analysis of all patients with a history of gastric cancer diagnosis (classified under International Classification of Diseases 10th Revision code: C16.X) spanning from 1 January 2002 to 31 December 2012. The primary objective was to observe death within a 5-year follow-up period. The study population comprised 63,664 individuals who fell into two categories: those treated with metformin (n = 29,548) and those who did not receive metformin treatment (n = 34,116). This classification was based on the initial treatment allocation following the diagnosis of gastric cancer.

EXPOSURES

Metformin treatment, comorbidities, concurrent medication, and procedural information.

OUTCOMES

All-cause death, disease-specific death, cardiovascular death.

RESULTS

During the 5-year follow-up period, the metformin treatment group exhibited a lower cumulative incidence of all-cause death (27.5%) in comparison to the group not receiving metformin treatment (32.8%). Furthermore, the relative hazards for all-cause death were significantly reduced in the metformin treatment group (HR: 0.80, 95% CI 0.78-0.82), indicating a lower risk of death when compared to the non-metformin group. In addition, metformin treatment was associated with lower occurrences of disease-specific death (related to gastric cancer) and cardiovascular death when compared to the group not undergoing metformin treatment.

CONCLUSIONS

The findings demonstrated that the use of metformin was effective at improving prognosis among gastric cancer patients documented with prior DM. In this population-based cohort study, metformin treatment was associated with reduced risk of mortality.

Integration of Patient Reported Outcomes in Drug Development in Genitourinary Cancers

PURPOSE OF REVIEW

Patient reported outcomes (PROs) are increasingly utilized in cancer drug development, and are of particular importance in genitourinary cancers due to symptom burden, multiple treatment options with similar efficacy, and often prolonged duration of disease. Here we review current data and perspectives related to use of PROs in drug development for genitourinary cancers, including insights on the regulatory process for drug approval.

RECENT FINDINGS

The FDA is committed to incorporating PRO data into the regulatory process for development and approval of new cancer drugs, but challenges exist due to lack of standardization of PRO instrument choice and analytic approach, missing data, and difficulty isolating treatment effect from disease-related effects. We review guidance for standardization of PRO methodology that is nonetheless tailored to disease state and anticipated effects of treatment. PRO and efficacy data should be simultaneously analyzed and reported for best clinical practice. Multiple disease-specific PRO instruments exist for genitourinary cancers. While clinicians, researchers, and regulatory bodies alike recognize the importance of PROs in cancer drug development, challenges remain regarding implementation of best practices.

Psychosocial screening for patients with prostate cancer: The development and validation of the psychosocial distress questionnaire-prostate cancer

We describe the psychosocial distress questionnaire-prostate cancer (PDQ-PC), a psychosocial screening list developed and validated specifically for prostate cancer patients. An existing screening list, the psychosocial distress questionnaire-breast cancer (PDQ-BC), was used as a starting point. Two focus groups were then implemented to investigate which items of the PDQ-BC were relevant for the PDQ-PC and which new items were needed. Validity and reliability of the questionnaire were assessed on 278 prostate cancer patients. Factor analysis showed that the 36-item PDQ-PC comprises eight subscales, for which the internal consistency ranged from α = 0.48-0.88. Moreover, moderate to high convergent validity was found.

Prostate cancer and sexual function

Prostate cancer is now ranked fifth in incidence among cancers in Korean adult males. This is attributable to the more Westernized dietary style which increases the morbidity of prostate cancer and the development of cancer diagnostic technologies, such as prostate-specific antigen and advanced medical systems, increasing the rate of prostate cancer diagnosis. Prostate cancer effects include not only erectile dysfunction caused by the disease itself, but also by psychiatric disorders caused by prostate cancer or its treatments. Prostate cancer by itself reduces sexual desire and the frequency of sexual intercourse. Additionally, surgery or hormonal therapy to block testosterone further increases the frequency of erectile dysfunction. Erectile dysfunction following radical prostatectomy is primarily attributable to nerve injury caused by intraoperative nerve traction, thermal injury, ischemic injury, and local inflammatory reactions. Additionally, the absence of nocturnal penile tumescence causes persistent hypoxia of the corpus cavernosum, which, secondarily, causes anatomical and functional changes in the corpus cavernosum. Preservation of erectile function is one of the most significant issues for patients with local prostate cancer. Erectile dysfunction following radical prostatectomy is known to have various prognoses, depending on preservation of the neurovascular bundle, patient age, and preoperative erectile status. Intracavernosal injections, PDE5 inhibitors, and penile rehabilitation therapy using a vacuum constriction device after radical prostatectomy are known to improve the recovery of erectile function. Recently, testosterone replacement therapy has also drawn attention as a treatment method.

What men say about surviving prostate cancer: complexities represented in a decade of comments

The experience of men who have completed cancer treatment and transitioned into survivorship is not well understood; therefore, a qualitative, descriptive, narrative analysis was conducted with open-ended questions that participants responded to annually during the course of a 10-year period. The participants expressed that the experience was complex and three themes were identified: "symptoms," "can't go back," and "needs." Time also emerged as an important concern. Participants indicated that sexual and physical symptoms impacted their entire life and that acknowledgment, information, and help from others were important to their recovery. Returning to baseline functioning was no longer possible; rather, a new normal now existed. The findings will help oncology nurses better understand the experience of being a prostate cancer survivor. The need for long-term interventions with information delivered prior to, during, and beyond the treatment process was identified. Clinical interventions should move toward a more integrated approach that helps men develop their new normal.

Medical expenditures of adult cancer survivors aged <65 years in the United States

BACKGROUND

To the authors' knowledge, this is the first study to provide national estimates of medical expenditures for all adult cancer survivors aged <65 years. Most studies of expenditures for cancer survivors in this age group have been based on the Medical Expenditure Panel Survey (MEPS) and were limited to "affected survivors."

METHODS

MEPS expenditure data for 2001 to 2007 were linked to data identifying all survivors from the National Health Interview Survey (NHIS), which is the MEPS sampling frame. The sample was comprised of adults ages 25 to 64 years. Propensity-score matching was used to estimate the effects of cancer on average total and out-of-pocket expenditures for all services and separately for prescriptions. Probit models were used to estimate effects on the probability of exceeding different expenditure thresholds.

RESULTS

Mean annual expenditures on all services in 2007 were $16,910 ± $3911 for survivors who were newly diagnosed with cancer, $7992 ± $972 for survivors who had been diagnosed in previous years, and $3303 ± $103 for other adults. Fifty-three percent of survivors were not identified in MEPS but only by linking to NHIS. Expenditures for all survivors averaged approximately $9300 compared with $13,600 for "affected survivors." For previously diagnosed survivors, the increase in mean expenditures attributable to cancer was approximately $4000 to $5000 annually. On average, relatively little of the increase was paid out of pocket, but cancer nearly doubled the risk of high out-of-pocket expenditures.

CONCLUSIONS

Previous MEPS analyses overstated average expenditures for all survivors. Nevertheless, the current results indicated that the increase in expenditures attributable to cancer is substantial, even for longer term survivors, and that cancer increases the relative risk of high out-of-pocket expenditures.

Psychosocial interventions to improve quality of life in prostate cancer survivors and their intimate or family partners

PURPOSE

The primary purpose was to test the effectiveness of two telephone-delivered psychosocial interventions for maintaining and improving quality of life (QOL) (psychological, physical, social, and spiritual well-being) among 71 prostate cancer survivors and the 70 intimate or family partners who were supporting them in their recovery.

METHODS

This study used a three-wave repeated measures experimental design. Both the interpersonal counseling intervention (TIP-C) and health education attention condition (HEAC) were delivered using the telephone.

RESULTS

Improvements in depression, negative affect, stress, fatigue, and spiritual well-being were significantly higher for survivors in the HEAC than for those in the TIP-C condition. Partners in the HEAC condition showed significantly greater improvements in depression, fatigue, social support from family members, social well-being, and spiritual well-being compared to partners in the TIP-C condition. The results revealed superior outcomes for those assigned to the HEAC intervention.

CONCLUSIONS

The psychosocial interventions in this study were effective in maintaining or improving the QOL for prostate cancer survivors and their partners. Both the survivor and their intimate partner or family member benefitted from the interventions. Future research is needed to determine the optimal timing and client characteristics for each intervention.

Survival benefit for early hormone ablation in biochemically recurrent prostate cancer

PURPOSE

To determine whether early initiation of androgen ablation in patients with biochemically recurrent prostate cancer, but without clinically evident metastases, is associated with improved overall or disease-specific survival. To describe subgroups, based on PSA kinetics, which are most likely to benefit from early androgen ablation.

MATERIALS AND METHODS

A retrospective cohort of 124 patients, who were definitively treated by external beam radiotherapy between 1988 and 1999, and subsequently received androgen ablation for biochemical (92 patients) or clinically metastatic (32 patients) failure, was reviewed. Median follow-up time was 6.2 years. Overall survival, disease-specific survival, and hormonal control were examined and compared for patients whose hormone ablation was started early (prostate-specific antigen [PSA] <or=15 ng/ml or PSA doubling time >7 months) or late in the course of their biochemical failure.

RESULTS

All patients had biochemical response to hormone initiation, with a median PSA nadir of 0.05 ng/ml. Early initiation of hormone ablation resulted in statistically significant improvement in all outcome measures. Multivariate analysis indicated that PSA doubling time at hormone initiation was the most consistent predictor of outcome. The 5-year overall survival was 78% for patients whose androgen ablation was initiated at doubling time <or=7 months and 93% for patients when initiated at doubling time >7 months. Mean survival improved from 84.9 +/- 4.6 (doubling time <or=7) to 115.3 +/- 8.4 months (doubling time >7). Survival for patients started on hormones with doubling time <5 months was similar to that of patients with clinical metastases.

CONCLUSIONS

This survival benefit justifies the use of androgen ablation in patients whose doubling time approaches 7 months. A randomized trial is needed to confirm these findings, investigate potential benefit for patients with longer doubling times, and gather data on the morbidity of early hormone ablation, including quality of life issues.

Prostate Cancer Survivors' and Partners' Self-Reports of Health-Related Quality of Life, Treatment Symptoms, and Marital Satisfaction 2.5-5.5 Years After Treatment

PURPOSE/OBJECTIVES

To describe health-related quality of life (QOL), health status, and marital satisfaction of couples as many as 5.5 years after treatment for prostate cancer.

DESIGN

Survey with longitudinal, comparative, and predictive elements.

SETTING

A tertiary care nonprofit medical center in the southwestern United States.

SAMPLE

Convenience sample of prostate cancer survivors (192 enrolled, 137 completed) and their partners (126 enrolled, 104 completed). Men averaged 70 years of age, women 66. Most men (86%) and women (89%) were white, and 71% had at least some college education.

METHODS

Questionnaires were mailed annually. Women were enrolled 3.5 years after their partners were treated. Study participants received separate questionnaire packets.

MAIN RESEARCH VARIABLES

Health-related QOL, health status including post-treatment symptoms, and marital satisfaction.

FINDINGS

Men's health-related QOL, general physical health, and vitality decreased; urinary and sexual post-treatment symptoms increased. Men were concerned about their sexual functioning although few sought treatment. Couples' health-related QOL and marital satisfaction were associated more closely than their health status.

CONCLUSIONS

Regardless of type of treatment, health-related QOL and general health tend to decrease for prostate cancer survivors; men in watchful waiting tended to have poorer health outcomes. Men are concerned about sexual functioning, yet few are taking steps to remedy problems. Couples' health-related QOL and marital satisfaction are linked; however, health status indicators are less associated.

IMPLICATIONS FOR NURSING

Nurses are in a key position to assess health-related QOL and sexual functioning concerns for prostate cancer survivors and their partners.

Quality of life for men receiving a second treatment for prostate cancer

PURPOSE

We assessed the impact of second treatment on health related quality of life for men with prostate cancer. This issue is important because second treatment resulting from prostate specific antigen recurrence has the potential to further negatively impact health related quality of life and affect the overall value of treatment. We compared differences in health related quality of life before and after second treatment for men who had asymptomatic prostate specific antigen recurrence with those who did not have biochemical failure.

MATERIALS AND METHODS

Men in this analysis (897) had localized disease, initially underwent radical prostatectomy monotherapy, and completed at least 1 health related quality of life questionnaire before and after radical prostatectomy. In this cohort 175 men underwent second treatment (nonadjuvant). The Medical Outcomes Survey Short Form-36 and UCLA Prostate Cancer Index were used to measure health related quality of life. Associations between patient groups and time on health related quality of life were analyzed using repeated measures.

RESULTS

Men who received a second treatment presented with more severe disease before radical prostatectomy and had worse general health related quality of life. Although health related quality of life differed significantly with time for the 2 groups, most domains for the second treatment group improved or remained stable until 15 months before second treatment, at which point they declined. Scores in the sexual functioning and role-physical domains showed clinically and statistically significant patterns of decreasing with time.

CONCLUSIONS

Health related quality of life is affected following second treatment but starts to decline approximately 1 year before second treatment. Not all aspects of health related quality of life decreased at the same rate, so patients should be counseled that certain domains may be affected more by additional treatment.

Targeted-cryosurgical ablation of the prostate with androgen deprivation therapy: quality of life in high-risk prostate cancer patients

AIM

To present preliminary results on health-related quality of life (QoL), prostate-associated symptoms and therapeutic effects of targeted-cryosurgical ablation of the prostate (TCSAP) with androgen deprivation therapy (ADT) in high-risk prostate cancer (PCa) patients.

METHODS

Thirty-four men with high-risk PCa features underwent TCSAP, and ADT was added to improve the treatment outcomes. High-risk parameters were defined as either prostate-specific antigen (PSA) = or > 100ng/mL, or Gleason score = or > 8, or both. The Genito-Urinary Group of the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30 (EORTC QLQ-C30) with prostate-cancer-specific module (QLQ-PR25) was used for evaluating morbidities and PSA levels were recorded every 3 months. PSA failure was defined as the inability to reach a nadir of 0.4 ng/mL or less.

RESULTS

Although it was not statistically significant, the global health status scores increased after TCSAP with ADT. The scores for five functional scales also became higher after treatment. The most prominent symptom after treatment was sexual dysfunction, followed by treatment-related and irritative voiding symptoms.

CONCLUSION

TCSAP with ADT appears to be minimally invasive with high QoL except for sexual dysfunction. Long-term follow-up of PSA data and survival is necessary before any conclusions can be made on the efficacy of this promising new therapeutic modality in the treatment of PCa.

Effect of combined treatment with salvage radiotherapy plus androgen suppression on quality of life in patients with recurrent prostate cancer after radical prostatectomy

PURPOSE

To examine the effect of salvage radiotherapy (RT) plus 2-year androgen suppression (AS) on quality of life (QOL).

METHODS AND MATERIALS

A total of 74 patients with biopsy-proven local recurrence or PSA relapse after radical prostatectomy were treated with salvage RT plus 2-year AS, as per a phase II study. Quality of life was prospectively assessed with the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire 30-Item Version 3.0 with the added prostate cancer-specific module at baseline and predefined follow-up visits.

RESULTS

Patients experienced a significant increase in bowel dysfunction (23%) by the end of RT (p < 0.0001). This bowel dysfunction improved after RT but remained slightly elevated (5-10%) throughout the 2-year AS period. This extent of residual bowel dysfunction would be considered of minimal clinical importance. A similar, but less pronounced, pattern of change did occur for urinary dysfunction. Erectile function showed no change during RT, but had an abrupt decline (10%) with initiation of AS that was of moderate clinical significance (p < 0.01). None of the other QOL domains demonstrated a persistent, significant change from baseline that would be considered of major clinical significance.

CONCLUSION

The combined treatment with salvage RT plus 2-year AS had relatively minor long-term effects on QOL.

Laparoscopic radical prostatectomy: Conventional and robotic

By 2015, prostate cancer will become the most commonly diagnosed cancer in men. Radical prostatectomy reduces disease-specific mortality in patients with localized prostate cancer; however, the invasiveness of surgery and its resultant side effects cause many men to seek other treatments. In 2000, laparoscopic radical prostatectomy emerged as a minimally invasive alternative to open surgery; it has been refined recently by the addition of robotic technology. To examine the outcomes of robotic radical prostatectomy and compare them with those from open and conventional laparoscopic radical prostatectomy, we prospectively collected baseline demographic data on all patients undergoing surgery for prostate cancer over a 4-year period at our center. Urinary function and sexual function were evaluated using standardized criteria as well as a questionnaire preoperatively and at 1, 3, 6, 12, and 18 months after their procedure. Operative and postoperative outcomes were compared using values for open radical prostatectomy as the reference standard. A total of 100 men underwent open radical prostatectomy with conventional laparoscopic radical prostatectomy (n = 50) and robotic radical prostatectomy (n = 500). The odds ratios for operative times, blood loss, postoperative pain, complications, and median times to urinary continence and resumption of sexual activity all were lower for robotic than for open or laparoscopic radical prostatectomy. It appears safe to conclude that conventional laparoscopic radical prostatectomy is a reasonable alternative to open radical prostatectomy in the surgical treatment of patients with clinically localized prostate cancer. The incorporation of robotics may result in even better surgical outcomes than conventional laparoscopy. However, the surgical robot is expensive; few centers have access to the technology and even fewer have expertise in the technique. For robotic radical prostatectomy to become the standard of care for the treatment of localized prostate cancer will require economies of cost, dissemination of surgical expertise, and data from randomized trials.

Psychological functioning associated with prostate cancer: cross-sectional comparison of patients treated with radiotherapy, brachytherapy, or surgery

This study compared the prevalence of psychological difficulties (i.e., anxiety and depression), psychophysiological problems (i.e., insomnia and fatigue), and sexual difficulties across three modalities of treatment for prostate cancer (radiotherapy, brachytherapy, and radical prostatectomy). A total of 861 men completed a battery of questionnaires assessing anxiety, depression, fatigue, insomnia, and quality of life. Patients who initially received radiotherapy had higher levels of depression, anxiety, and fatigue and a lower quality of life, and were more likely to report clinical levels of depression and fatigue. Patients who initially received surgery were more likely to report clinical levels of sexual difficulties but less likely to report clinical levels of depression and fatigue, while patients who received brachytherapy were less likely to report sexual difficulties. Although cross-sectional, these findings raise the possibility of a differential influence of treatments for prostate cancer on some aspects of psychological functioning.

Cognitive-behavioral stress management improves stress-management skills and quality of life in men recovering from treatment of prostate carcinoma

BACKGROUND

The current study evaluated the efficacy of a 10-week, group-based, cognitive-behavioral stress management (CBSM) intervention relative to a half-day seminar in improving quality of life (QoL) among men who were treated for localized prostate carcinoma (PC) with either radical prostatectomy (RP) or radiation therapy.

METHODS

Ninety-two men were assigned randomly to either the 10-week CBSM group intervention or a 1-day seminar (control group). The intervention was designed to improve QoL by helping participants to identify and effectively manage stressful experiences and was focused on the treatment-related sequelae of PC.

RESULTS

A hierarchical regression model was used to predict postintervention QoL. The final model, including all predictors and relevant covariates (i.e., income, baseline QoL, ethnicity, and group condition), explained 62.1% of the variance in QoL scores. Group assignment was a significant predictor (beta = - 0.14; P = 0.03) of QoL after the 10-week intervention period, even after controlling for ethnicity, income, and baseline QoL. Post-hoc analyses revealed that individuals in the CBSM intervention condition showed significant improvements in QoL relative to men in the 1-day control seminar. Improved QoL was mediated by greater perceived stress-management skill.

CONCLUSIONS

A 10-week cognitive-behavioral group intervention was effective in improving the QoL in men treated for PC, and these changes were associated significantly with intervention-associated increases in perceived stress-management skills.

Why and how to study the fate of cancer survivors

This paper provides a rationale for the importance of studying health outcomes in cancer survivors, including their growing numbers, the need for detailed information on the short and long-term effects of treatment, and the interactions of cancer with other comorbid conditions. However, there are a number of challenges associated with this research. Identification and recruitment of cancer survivors is not always easy, and linking their current health status to details of medical treatment is important, but not always feasible. National surveys and databases are a potential source of information on survivors, but may not provide sufficient details for this type of research. Strategies need to be developed to plan for long-term outcome studies in cancer patients from the very beginning of treatment to obtain the most comprehensive data on the outcomes of survivors.

Quality of life and economic considerations in the management of prostate cancer

The purpose of this article was to provide an overview of the morbidity and mortality of prostate cancer, QOL issues and the economic impact of the disease. We searched Medline (from 1990 onwards) for all studies dealing with prostate cancer epidemiology, treatment, screening and staging, and critically reviewed the most relevant articles, focusing on pharmacoeconomic issues. Prostate cancer is the most common cancer in men. In the US, new estimated cases of prostate cancer represented 14.8% of all new cancer cases for 2000, with estimated deaths from prostate cancer comprising 5.8% of all deaths from cancer. Current options for prostate cancer management include radical prostatectomy, cryosurgery, radiotherapy, hormone therapy and watchful waiting. Many of the long-term effects of treatment, such as urinary incontinence, impotence and radiation-induced proctitis, have a large impact on patients' quality of life and, in some patients, may offset the clinical benefits. Regulatory bodies and managed care organisations are assigning increasing importance to the evaluation of QOL benefits as an independent clinical endpoint and a measure of patient satisfaction. Several screening programmes for early detection of prostate cancer, mostly based on prostate-specific antigen (PSA) measurement or digital rectal examination, have been proposed, but their routine implementation in all asymptomatic elderly men has been questioned. There is still no definite proof that patient outcomes are improved by extensive PSA screening. Furthermore, the total cost of a screening programme is difficult to define since it extends well beyond the initial test. Several instruments are used for QOL assessment in prostate cancer, some of which have been specifically developed for, or adapted to, patients with this disease, such as the Functional Assessment Cancer Therapy (FACT) tool, Prostate Cancer Treatment Outcome Questionnaire (PCTO-Q) and Prostate Cancer Specific Quality of Life Instrument (PROSQOLI). More than 50% of treatment costs for prostate cancer are accrued during the patient's last year of life, and total initial care costs decrease with increasing age. In the US, initial average inpatient costs were estimated at $US 2253, in 1995, for men aged > or =80 years, compared with $US 4540 for men aged 35-64 years. In recent years, treatments based on combined modalities (i.e. radiotherapy/prostatectomy plus hormonal therapies) have emerged. Although cost-effectiveness analyses of various treatment options have been attempted, the strength of their conclusions appears to be limited by the lack of homogeneous literature data on the effects of such interventions on survival and morbidity.