Treatment decision regret in long-term survivors after radical prostatectomy: a longitudinal study

Patient-Reported Outcome Measures and Decision Regret After Salvage Radical Prostatectomy for Recurrent Prostate Cancer Following Radiotherapy or Focal Therapy

BACKGROUND/OBJECTIVES

Radical prostatectomy (RP) may be considered for recurrent prostate cancer (PCa) following primary curative-intended local therapy. The effect of different prior therapies on patient-reported outcome measures (PROMs) after RP is not well defined.

METHODS

Validated PROMs (SF-12, EPIC-26, Decision Regret Scale) were used to compare health-related quality of life (HRQOL) and functional status changes following salvage RP after radiotherapy (RT-sRP) or focal therapy (FT-sRP), relative to primary RP.

RESULTS

Among 26,515 RP patients who underwent RP between 2014 and 2024, 107 (0.4%) previously received radiotherapy (RT-sRP) and 98 (0.4%) previously received focal therapy (FT-sRP). Compared with primary patients before RP, only the sexual function of RT-sRP patients was lower (EPIC score, 51 vs. 75, p < 0.001). One year after RP, RT-sRP patients exhibited lower functional status in all EPIC-26 domains compared to primary RP patients, whereas FT-sRP patients did not differ significantly. For instance, the median 1 yr EPIC-26 urinary incontinence scores were 46 (RT-sRP), 86 (FT-sRP), and 92 (primary RP). In adjusted mixed model analyses, the detrimental effects of RT-sRP vs. primary RP were further validated. In contrast, no such association was observed for FT-sRP. Decision regret and severe complications were low.

CONCLUSIONS

Prior FT had only a marginal effect on HRQOL and functional status following RP, while urinary continence and sexual function were lower for RT-sRP patients as compared to primary RP patients. However, from an overall PROM perspective, prior therapies did not exert a prohibitive effect that would preclude RP as a treatment option in those patients.

Decision regret after curative treatment and its association with the decision-making process and quality of life for prostate cancer patients

OBJECTIVES

To determine how the treatment decision-making process and posttreatment health-related quality of life (HRQOL) are related to regret about treatment choice for prostate cancer patients in Japan.

METHODS

We invited a total of 614 patients who were treated with radiation therapy (RT), radical prostatectomy (RP), or active surveillance/watchful waiting (AS/WW) from April 2007 to March 2021. Posttreatment regret was evaluated by the Decision Regret Scale. HRQOL was evaluated by the Expanded Prostate Cancer Index Composite and the 12-item Short Form Survey. The decision-making process was assessed by patient evaluation of the decision-making process. We compared the decision regret scale scores across treatment types, HRQOL, and decision-making processes.

RESULTS

Data from 371 patients were analyzed (RT: 202, RP: 149, AS/WW: 20). The median length of time since treatment was 64 (IQR: 43-93) months. The decision regret scale scores were not significantly different among the treatment groups but were significantly greater (strong regret) in patients with poor urinary summary scores, bowel summary scores, and hormonal summary scores. The decision regret scale scores were significantly lower (less regret) for patients who reported being adequately informed at the time of the treatment decision and who had adequately communicated their questions and concerns to physicians than for patients who reported less adequate communication. This result was also observed among patients who reported low HRQOL scores.

CONCLUSIONS

These findings underline the important influence of posttreatment HRQOL and decision-making as an interactive process between physicians and their patients on posttreatment regret in prostate cancer patients.

Urinary continence outcomes, surgical margin status, and complications after radical prostatectomy in 2,141 German patients treated in one high-volume inpatient rehabilitation clinic in 2022

PURPOSE

To identify independent predictors of urinary continence and report early complications after radical prostatectomy (RP) in a large, contemporary German cohort.

METHODS

Urinary incontinence data of patients undergoing 3-week inpatient rehabilitation (IR) after RP were prospectively assessed by 24-hr pad test and uroflowmetry at the beginning and the end of IR, respectively. Lymphoceles were assessed prospectively by ultrasound. Tumor and patient characteristics, and information on urinary leakage on initial cystography were retrospectively extracted from discharge letters and surgical reports. Regression analyses were performed to identify predictors of urinary continence at the beginning of IR.

RESULTS

Overall, 2,141 patients were included in the final analyses. Anastomotic leakage on the initial cystography and lymphoceles were found in 11.4% and 30.8% of patients, respectively. Intervention for a symptomatic lymphocele was required in 4.2% of patients. At the end of IR, 54.2% of patients were continent, while the median urine loss decreased to 73 g (interquartile range 15-321). Multivariable logistic regression analysis identified age and diabetes mellitus as independent negative predictors, but nerve-sparing surgery as an independent positive predictor of urinary continence (each p < 0.001). Multivariable linear regression analysis showed that 24-hr urine loss increased by 7 g with each year of life (p < 0.001), was 79 g higher in patients with diabetes mellitus (p = 0.007), and 175 g lower in patients with NS (p < 0.001).

CONCLUSION

Age, diabetes mellitus, and NS are significantly associated with continence outcomes in the early period after RP. Our analyses may help clinicians to pre-operatively counsel patients on potential surgical outcomes.

Do all prostate cancer patients want, and experience shared decision making prior to curative treatment?

OBJECTIVE

In comparable men with non-metastatic prostate cancer, radical prostatectomy (RP), radiotherapy (RAD) and active surveillance (AS) are treatment options with similar survival rates, but different side-effects. Healthcare professionals consider pretreatment shared decision making (SDM) to be an essential part of medical care, though the patients' view about SDM is less known. In this article, we explore prostate cancer (PCa) patients' SDM wish (SDMwish), and experiences (SDMexp).  Material and methods: This is a registry-based survey performed by the Cancer Registry of Norway (2017-2019). One year after diagnosis, 5,063 curatively treated PCa patients responded to questions about their pre-treatment wish and experience regarding SDM. Multivariable analyses identified factors associated with SDM. Statistical significance level: p < 0.05.  Results: Overall, 78% of the patients wished to be involved in SDM and 83% of these had experienced SDM. SDMwish and SDMexp was significantly associated with decreasing age, increasing education, and living with a partner. Compared with the RP group, the probability of SDMwish and SDMexp was reduced by about 40% in the RAD and the AS groups.  Conclusion: Three of four curatively treated PCa wanted to participate in SDM, and this wish was met in four of five men. Younger PCa patients with higher education in a relationship, and opting for RP, wanted an active role in SDM, and experienced being involved. Effective SDM requires the responsible physicians' attention to the individual patients' characteristics and needs.

Patient's Desire and Real Availability Concerning Supportive Measures Accompanying Radical Prostatectomy: Differences between Certified Prostate Cancer Centers and Non-Certified Centers Based on Patient-Reported Outcomes within the Cross-Sectional Study Improve

Certification as a prostate cancer center requires the offer of several supportive measures to patients undergoing radical prostatectomy (RP). However, it remains unclear how patients estimate the relevance of these measures and whether the availability of these measures differs between certified prostate cancer centers (CERTs) and non-certified centers (NCERTs). In 20 German urologic centers, a survey comprising questions on the relevance of 15 supportive measures was sent to 1000 patients at a median of 15 months after RP. Additionally, patients were asked to rate the availability of these measures using a four-item Likert scale. The aim of this study was to compare these ratings between CERTs and NCERTs. The response rate was 75.0%. In total, 480 patients underwent surgery in CERTs, and 270 in NCERTs. Patients rated 6/15 supportive measures as very relevant: preoperative medical counselling concerning treatment options, a preoperative briefing answering last questions, preoperative pelvic floor exercises (PFEs), postoperative PFEs, postoperative social support, and postoperative rehabilitation addressing physical fitness recovery. These ratings showed no significant difference between CERTs and NCERTs (p = 0.133-0.676). In addition, 4/9 of the remaining criteria were rated as more detailed by patients in CERTs. IMPROVE represents the first study worldwide to evaluate a patient-reported assessment of the supportive measures accompanying RP. Pertinent offers vary marginally between CERTs and NCERTs.

Trajectory of Depression among Prostate Cancer Patients: A Secondary Analysis of a Randomized Controlled Trial

Background: While psychological difficulties, such as depression, among prostate cancer patients are known, their longitudinal burden remains understudied. We assessed the burden of depression across low-, intermediate- and high-risk prostate cancer groups, and the association between regret and long-term depression. Methods: Secondary analysis of data from a multi-centered randomized controlled study among localized prostate cancer patients was carried out. Assessments were performed at baseline, and at 3-, 6-, 12- and 24-month follow-up. Depression was assessed using the Center for Epidemiologic Studies Depression (CES-D) scale. A CES-D score ≥ 16 indicates high depression. Regret was measured using the regret scale of the Memorial Anxiety Scale for Prostate Cancer (MAX-PC). The proportion of patients with high depression was compared over time, for each risk category. Logistic regression was used to assess the association between regret, and long-term depression after adjusting for age, race, insurance, smoking status, marital status, income, education, employment, treatment, number of people in the household and study site. Results: The study had 743 localized prostate cancer patients. Median depression scores at 6, 12 and 24 months were significantly larger than the baseline median score, overall and for the three prostate cancer risk groups. The proportion of participants with high depression increased over time for all risk groups. Higher regret at 24-month follow-up was significantly associated with high depression at 24-month follow-up, after adjusting for covariates. Conclusions: A substantial proportion of localized prostate cancer patients continued to experience long-term depression. Patient-centered survivorship care strategies can help reduce depression and regret, and improve outcomes in prostate cancer care.