Side-effects of treatment for localized prostate cancer: are they valued differently by patients and healthy controls?

A Systematic Review and Meta-Analysis of Prostate Cancer Utility Values of Patients and Partners Between 2007 and 2016

Background. There is widespread agreement that both the length and quality of life matter when assessing new technologies and/or models of care in the treatment for cancer patients. Quality of life for partners/carers also matters, particularly for prostate cancer. Purpose. This systematic review aims to provide up-to-date utility values along the prostate cancer care continuum (i.e., from prescreening through to palliative care) for use where future trial-based or modelled economic evaluations cannot collect primary data from men and/or partners. Data Sources. A protocol was developed and registered on the international register of systematic reviews—PROSPERO. Databases searched included EBSCO Information Services (CINAHL, EconLit, Global Health, HEED, MEDLINE Complete, PsycINFO), Cochrane Database of Systematic Reviews, Web of Science, and Embase. Study Selection. Study selection terms included health-related quality of life, prostate cancer, and partners or carers. Data Extraction. The authors identified articles published between 2007 and 2016 that provided health state utility values, with statistical uncertainty, for men with or at risk of prostate cancer and/or their partner/carers. Data Synthesis and Results. Study quality and generalizability of utilities was evaluated and meta-analysis conducted against prespecified criteria. From 906 original articles, 29 recent primary studies met the inclusion/exclusion criteria. We tabulate all the utility values with uncertainty, along with considerable methodological detail and patient population characteristics. Limitations. Utility values pertaining to carers/partners were limited to one study. Conclusions. Studies varied in design, measurement instruments utilized, quality, and generalizability. There is sufficient qualitative and quantitative detail for the reported utility values to be readily incorporated into economic evaluations. More research is needed with carers/partners and with newly developing prostate cancer-specific quality of life tools.

Utility after robot-assisted radical prostatectomy compared to conventional approaches for localized prostate cancer [socioeconomic perspective study]

BACKGROUND

This study presented the utility across approaches (robotic-assisted radical prostatectomy (RARP) and laparoscopic radical prostatectomy (LRP) or open radical prostatectomy (ORP)), across disease states after surgery, and also across functional outcomes for localized prostate cancers. The utility was measured using the time trade-off method.

METHODS

This survey was based on a scenario that describes the state of health in detail and considers surgical methods, short-term adverse effects following RP, disease-specific conditions, and additional treatments 1 year following RP.

RESULTS

This study analyzed 393 men; the utility values are as follows: first, health status postoperatively showed that the utility value decreased in patients who underwent ORP versus those who underwent LRP. The utility value for ORP and LRP versus RARP was reduced by ~0.028 (10 days per year) and 0.008 (3 days per year), respectively. Second, the utility value based on adverse effects after RP indicated that erectile dysfunction caused a greater reduction in efficacy than urinary incontinence. Regarding erectile dysfunction and urinary incontinence, the efficacy was reduced to ~0.137 (50 days per year) and 0.111 (41 days per year), respectively, as compared to a health state without adverse effects based on no evidence of disease status.

CONCLUSIONS

In conclusion, the disutility was much greater due to the side effects than the disutility due to the difference in the surgical method. In particular, the disutility of erectile dysfunction was bigger than that of the urinary incontinence.

Patient and oncologist preferences for attributes of treatments in advanced melanoma: a discrete choice experiment

PURPOSE

To examine and compare patient and oncologist preferences for advanced melanoma treatment attributes and to document their trade-offs for benefits with risks.

MATERIALS AND METHODS

A discrete choice experiment (DCE) was conducted among advanced melanoma patients and oncologists. Qualitative pilot testing was used to inform the DCE design. A series of scenarios asked stakeholders to choose between two hypothetical medications, each with seven attributes: mode of administration (MoA), dosing schedule (DS), median duration of therapy (MDT), objective response rate (ORR), progression-free survival (PFS), overall survival (OS), and grade 3-4 adverse events (AEs). Hierarchical Bayesian logistic regression models were used to determine patients' and oncologists' choice-based preferences, analysis of variance models were used to estimate the relative importance of attributes, and independent t-tests were used to compare relative importance estimates between stakeholders.

RESULTS

In total, 200 patients and 226 oncologists completed the study. OS was most important to patients (33%), followed by AEs (29%) and ORR (25%). For oncologists, AEs were most important (49%), followed by OS (34%) and ORR (12%). An improvement from 55% to 75% in 1-year OS was valued similar in magnitude to a 23% decrease (from 55% to 32%) in likelihood of AEs for oncologists.

CONCLUSION

Patients valued OS, AEs, and ORR sequentially as the most important attributes in making a treatment decision, whereas oncologists valued AEs most, followed by OS and ORR. In comparison, patients differed significantly from oncologists on the importance of ORR, AEs, and PFS, but were consistent in OS and the rest of attributes.

Is the EQ-5D suitable for use in oncology? An overview of the literature and recent developments

The European Quality of Life-5 Dimensions (EQ-5D) questionnaire is widely used in oncology to generate quality of life weights (utilities). The typical purpose is to inform health economic evaluation studies. The EQ-5D is generally suitable for this purpose; it has shown a reasonable degree of reliability, content validity, construct validity and responsiveness in the majority of the available studies. In situations of doubt, combination with other quality-of-life instruments may be an option. The authors expect that the five-level version of the EQ-5D will gradually replace the three-level version, due to reduced ceiling effects and more appropriate responsiveness. Further research should address the benefits achievable through additional dimensions or patient-based valuation, and the validity of EQ-5D versions for proxy respondents.

Regulation of crosstalk between epithelial to mesenchymal transition molecules and MMP-9 mediates the antimetastatic activity of anethole in DU145 prostate cancer cells

The underlying antimetastatic mechanism of anethole (1) still remains unclear in association with the molecules of the epithelial to mesenchymal transition (EMT). Herein, the role of the EMT molecules was elucidated in terms of the antimetastatic activity of 1 using DU145 cells. Anethole significantly inhibited the adhesion of DU145 cells to vitronectin-coated plates, as well as migration in a wound-healing assay and invasion using a Boyden chamber. Also, anethole suppressed the expression of MMP-9 in DU145 cells by zymography, ELISA, and RT-PCR. Consistently, the silencing of MMP-9 enhanced the activity of 1 to upregulate the expression of E-cadherin and to attenuate the expression of Vimentin in DU145 cells. Compound 1 enhanced E-cadherin, which is an epithelial marker and attenuated the expression of Vimentin, Twist, and Snail as mesenchymal molecules at the mRNA level. Consistently, anethole upregulated E-cadherin and downregulated the expression of Vimentin, Twist and PI3K, and AKT at the protein level in DU145 cells. Conversely, the antimetastatic effects of 1 to inhibit invasion and the expression of MMP-9 and upregulate E-cadherin were reversed by the EMT inducer TGF-β in DU145 cells. Overall, the present findings suggest that anethole exerts antimetastatic activity via regulation of crosstalk between EMT molecules and MMP-9 on the basis of the in vitro data obtained.

Anticipated adaptation or scale recalibration?

BACKGROUND

The aim of our study was to investigate anticipated adaptation among patients in the subacute phase of Spinal Cord Injury (SCI).

METHODS

We used an observational longitudinal design. Patients with SCI (N = 44) rated their actual, previous and expected future Quality of Life (QoL) at three time points: within two weeks of admission to the rehabilitation center (RC), a few weeks before discharge from the RC, and at least three months after discharge. We compared the expected future rating at the second time point with the actual ratings at the third time point, using student's t-tests. To gain insight into scale recalibration we also compared actual and previous ratings.

RESULTS

At the group level, patients overpredicted their improvement on the VAS. Actual health at T3(M = 0.65, sd =0.20)) was significantly lower than the predicted health at T1 of T3 (M = 0.76, sd = 0.1; t(43) = 3.24, p < 0.01), and at T2 of T3(M = 0.75,sd = 0.13; t(43) = 3.44, p < 0.001). Similarly the recalled health at T3 of T2 (M = 0.59, sd = 0.18) was significantly lower than the actual health at T2 (M = 0.67, sd = 0.15; t(43) = 3.26, p <0.01). Patients rated their future and past health inaccurately compared to their actual ratings on the VAS. In contrast, on the TTO patients gave accurate estimates of their future and previous health, and they also accurately valued their previous health. Looking at individual ratings, the number of respondents with accurate estimates of their future and previous health were similar between the VAS and TTO. However, the Bland-Altman plots show that the deviation of the accuracy is larger for the TTO then the VAS. That is the accuracy of 95% of the respondents was lower in the TTO then in the VAS.

CONCLUSIONS

Patients at the onset of a disability were able to anticipate adaptation. Valuations given on the VAS seem to be biased by scale recalibration.

[Temporal changes in quality of life after prostate carcinoma]

INTRODUCTION

Each year more than 60,000 German men are diagnosed with prostate cancer. The incidence nearly doubled in the last 10 years due to intensified use of PSA testing for early detection. To date, either radical prostatectomy or radiotherapy is recommended for treatment of localized prostate cancer. Both strategies have similar survival chances (83-94%), but show different side effects. In view of the good prognosis implications for health-related quality of life (QoL) may play an important role in the therapy decision-making process and should be discussed with patients.

MATERIALS AND METHODS

Prostate cancer patients were asked twice about oncological health care and QoL (EORTC QLQ-C30, Version 2) as part of the OVIS study conducted in Schleswig-Holstein. The first questioning took place 16 months after the initial diagnosis and the second one at month 42. QoL was compared with German reference data. Logistic regression identified predictors for (a) low QoL at baseline (as indicated by global health status/QoL below the group median) and (b) clinically relevant detriments, defined as a difference of ≥10 points, in the chronological sequence.

RESULTS

Prostate cancer patients (n=1,345; median age at diagnosis 66 years) report a mean global QoL score that is higher than that of a healthy German reference sample (difference 6.3). In the temporal course, 56% of patients did not experience a clinically relevant change in QoL (<10 points difference). However, 20% reported a clinically relevant decrease and 24% a clinically relevant increase (≥ 10 points difference) regarding global health status/QoL. Higher age, lower social class, chemotherapy, undesired side effects and long-term complications as well as rehabilitative care predict low QoL at baseline, while progression of the disease and living in an urban surrounding as well as young age at diagnosis predict a decrease of QoL in the chronological sequence.

CONCLUSIONS

Self-reported QoL of prostate cancer patients depends on various personal and medical factors. Physicians should be aware of these factors and include them in the discussion about the appropriate therapy method with their patients. In general, therapists and family members have problems describing the QoL of their patients and relatives. Assessing the QoL and QoL-influencing factors with a short questionnaire seems to be feasible and may be helpful in the therapy decision-making process.

Dyadic concordance among prostate cancer patients and their partners and health-related quality of life: does it matter?

Serious and chronic illnesses occur within a family context, affecting not only the patient but also the spouse/partner, children and extended family network. Spouses/partners are likely to experience the greatest personal impact, and may influence patient adjustment. Also, the intimate relationship may be affected by the illness experience. This study examined whether dyadic concordance on the characteristics of prostate cancer (PC) was related to health-related quality of life (HRQOL), psychological distress and marital adjustment in PC patients and their female partners. Couples (N=164) completed questionnaires on the appraisals of PC, and individual and dyadic adjustment. Patient and partner PC appraisal ratings were positively correlated. There was a general pattern of patients and partners in concordant dyads, versus those in dyads in which spouses maximised or minimised PC characteristics, reporting significantly better individual HRQOL outcomes, although there were several exceptions. Patient-partner appraisal (dis)agreement generally did not significantly predict dyadic adjustment. Overall, results suggest that dyadic disagreement is associated with worse HRQOL in couples facing PC.

To what extent can response shift theory explain the variation in prostate cancer patients' reactions to treatment side-effects? A review

BACKGROUND

There appears to be a conflict between published literature and in vitro evidence concerning the effects of treatment-induced side-effects on prostate cancer patients. There is an existing body of research which indicates evidence for a phenomenon whereby quality-of-life scores of patients' post-treatment reflect no difference to healthy controls and are perhaps even higher than before treatment, despite the substantial side-effects such as sexual and urinary dysfunction. However, when observing clinical patients at Good Hope Hospital urology clinic, it appears that whilst patients are seemingly unaffected by the threat of sexual and urinary side-effects of treatment at diagnosis, they become increasingly concerned about these consequences following treatment, indicating evidence for a response shift in the opposite direction. This phenomenon is investigated here.

METHODS

Thirteen papers were selected for review and considered in terms of their contribution to research into response shift as a coping process and in particular, response shift in prostate cancer.

RESULTS AND CONCLUSIONS

Based on the existing literature, an underlying model is formulated for the moderation of the extent and direction of prostate cancer patients' response shift, incorporating the function of external influences such as perceived social support.

Screening and prostate-cancer mortality in a randomized European study

BACKGROUND

The European Randomized Study of Screening for Prostate Cancer was initiated in the early 1990s to evaluate the effect of screening with prostate-specific-antigen (PSA) testing on death rates from prostate cancer.

METHODS

We identified 182,000 men between the ages of 50 and 74 years through registries in seven European countries for inclusion in our study. The men were randomly assigned to a group that was offered PSA screening at an average of once every 4 years or to a control group that did not receive such screening. The predefined core age group for this study included 162,243 men between the ages of 55 and 69 years. The primary outcome was the rate of death from prostate cancer. Mortality follow-up was identical for the two study groups and ended on December 31, 2006.

RESULTS

In the screening group, 82% of men accepted at least one offer of screening. During a median follow-up of 9 years, the cumulative incidence of prostate cancer was 8.2% in the screening group and 4.8% in the control group. The rate ratio for death from prostate cancer in the screening group, as compared with the control group, was 0.80 (95% confidence interval [CI], 0.65 to 0.98; adjusted P=0.04). The absolute risk difference was 0.71 death per 1000 men. This means that 1410 men would need to be screened and 48 additional cases of prostate cancer would need to be treated to prevent one death from prostate cancer. The analysis of men who were actually screened during the first round (excluding subjects with noncompliance) provided a rate ratio for death from prostate cancer of 0.73 (95% CI, 0.56 to 0.90).

CONCLUSIONS

PSA-based screening reduced the rate of death from prostate cancer by 20% but was associated with a high risk of overdiagnosis. (Current Controlled Trials number, ISRCTN49127736.)

Valuing health: does enriching a scenario lead to higher utilities?

OBJECTIVES

Patients have been found to value their own experienced health state higher than an investigator-constructed scenario of that health state. The aim of this study was to investigate if patients value their own experienced health state higher than a standard EQ-5D scenario of their health state and if "enriching'' this scenario by adding individualized attributes reduces the differences between experienced health and the scenario.

METHODS

Face-to-face interviews were held with 129 patients with rheumatoid arthritis. Patients were asked to value in a time tradeoff their own experienced health; 6 standard EQ-5D scenarios, of which the 5th (untold to them) represented their own health state; and a standard EQ-5D scenario of their health state (identified as such) enriched with individual attributes.

RESULTS

The own experienced health state was not valued differently from the own standard EQ-5D state and was lower compared to the own enriched EQ-5D state of that same health state. An interaction effect was found for health status. Patients with better health did not report different values for their own experienced health compared with their own standard EQ-5D description; their own experienced state was rated lower than their own enriched EQ-5D description. Patients with poor health valued all 3 health states similarly. Surprisingly, utilities for scenarios enriched with exclusively negative individual attributes were not lower than those for the own standard EQ-5D description.

CONCLUSION

The hypothesis that disparities in valuation can be attributed to EQ-5D description being too sparse was not confirmed.

A graphical device to represent the outcomes of a logistic regression analysis

BACKGROUND

Ongoing research on the best way to diagnose prostate cancer has yielded and will continue to yield vast amounts of information. Based on, for example, information from prostate cancer screening trials models have been made that enable urologists to predict which man has prostate cancer on the basis of pre-biopsy data. In patients with screen detected prostate cancer, the presence of indolent disease can now be identified with reasonable certainty by a different model. For these men active surveillance may be a better option than aggressive treatment with its possible side effects as impotence, incontinence and bowel damage. Both models mentioned above are logistic regression models. Nomograms enable their use in daily clinical practice.

METHODS

Nomograms require the memorization and addition of intermediate results. We aimed to design a device that has the same function as a nomogram without this draw back.

RESULTS

A new device that resembles a circular slide rule was developed and is currently being tested in prostate cancer diagnosis and in prostate cancer patient counseling.

CONCLUSIONS

The new device has identical functionality to the nomogram without the drawback of the latter. The application of the device is not limited to the field of prostate cancer research.

Primary combined androgen blockade in localized disease and its mechanism

In spite of clinical practice guidelines such as NCI-PDQ - in which primary androgen deprivation therapy (PADT) is not recommended as the primary treatment for localized prostate cancer - many patients have been treated with PADT. One of the reasons is that urologists themselves permit patients' desire because they know the effectiveness of PADT for some patients in their experiences. In this review we demonstrate basic mechanisms and the clinical efficacy of primary combined androgen blockade (PCAB) for localized or locally advanced prostate cancer. Then we discuss which patients are candidates for PCAB, and show that more than 30% of low- or intermediate-risk localized prostate cancers could be controlled in the long term with only PCAB. Short-term or intermittent PADT could not be recommended because of the possibilities of changing the character of the cancer cells by incomplete androgen ablation. We propose algorithms for the treatment of localized prostate cancer not only in low- and intermediate-risk groups but also in the high-risk group.

Individual differences in the use of the response scale determine valuations of hypothetical health states: an empirical study

Background

The effects of socio-demographic characteristics of the respondent, including age, on valuation scores of hypothetical health states remain inconclusive. Therefore, we analyzed data from a study designed to discriminate between the effects of respondents' age and time preference on valuations of health states to gain insight in the contribution of individual response patterns to the variance in valuation scores.

Methods

A total of 212 respondents from three age groups valued the same six hypothetical health states using three different methods: a Visual Analogue Scale (VAS) and two variants of the Time trade-off (TTO). Analyses included a generalizability study, principal components analysis, and cluster analysis.

Results

Valuation scores differed significantly, but not systematically, between valuation methods. A total of 36.8% of variance was explained by health states, 1.6% by the elicitation method, and 0.2% by age group. Individual differences in the use of the response scales (e.g. a tendency to give either high or low TTO scores, or a high or low scoring tendency on the VAS) were the main source of remaining variance. These response patterns were not related to age or other identifiable respondent characteristics.

Conclusion

Individual response patterns in this study were more important determinants of TTO or VAS valuations of health states than age or other respondent characteristics measured. Further valuation research should focus on explaining individual response patterns as a possible key to understanding the determinants of health state valuations.