Impact of Age and Race on Health-Related Quality of Life Outcomes in Patients Undergoing Radical Prostatectomy for Localized Prostate Cancer

OBJECTIVES

To investigate impact of age and race on health-related quality of life (HRQoL) in men undergoing radical prostatectomy (RP) using a prospectively maintained, racially diverse cohort.

METHODS

The Center for Prostate Disease Research Multicenter National Database was used to identify patients receiving RP from 2007-2017. The Expanded PCa Index Composite and 36 Item Short-Form Health Survey were completed at baseline and regular intervals. Groups were stratified based on age: <60, 60-70, >70. Longitudinal patterns in HRQoL were assessed using linear regression models, adjusting for baseline HRQoL, demographics, and clinical characteristics.

RESULTS

In 626 patients undergoing RP, 278 (44.4%) were <60, 291 (46.5%) were 60-70, 57 (9.1%) were >70. Older men had worse baseline urinary bother (P<.01) and sexual HRQoL (P<.01). Baseline urinary function was similar for older and younger men. Post-RP urinary and sexual HRQoL was significantly lower in men >70. However, when adjusting for baseline HRQoL, race, NCCN risk, and comorbidities, no difference was found between age groups in urinary function or bother, or sexual function. Sexual bother was worse in older men until 48 months post-operatively but subsequently improved to levels similar to younger patients. Race independently affected HRQoL outcomes with older African American men reporting worse urinary function and sexual bother.

CONCLUSIONS

When accounting for baseline HRQoL, age does not independently predict worse HRQoL outcomes. Older and younger men experience similar declines in urinary and sexual domain scores after RP. Our findings may be used to better inform patients regarding their expected post RP HRQoL and guide treatment decision-making.

Factors affecting health-related quality of life among prostate cancer patients: A systematic review

INTRODUCTION

Prostate cancer is recognized as the leading cause of malignancy-related incidence and mortality in the male population. The treatment regimens have long-term effects detrimental to the patient's quality of life. Hence, this review was aimed to determine the overall HRQOL and its associated among prostate cancer patients.

METHODS

The review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. The databases searched were PubMed, Embase, Google Scholar and Cumulative Index to the Nursing and Allied Literature (CINAHL), which provided articles that were critically examined, yielding 52 studies that met the inclusion criteria for the systematic review.

RESULTS

Out of 52 studies, 30 studies reported poor overall HRQOL in various domains after prostate cancer treatment. Contrastingly, 15 studies reported good overall quality of life after treatment. Among the various domains, sexual function was the most grossly affected functional score by the treatment modalities of prostate cancer. Nonetheless, seven studies showed that the absence of a significant change in the overall quality of life after treatment. According to the studies, older age, comorbidities, higher clinical stage, higher Gleason score, greater cancer severity, African American race, impaired mental health, neoadjuvant hormonal therapy and lower level of education were the major poor predictors of HRQOL among prostate cancer patients.

CONCLUSION

The overall HRQOL in prostate cancer patients was generally poor in various functional domains after treatment. Among the various domains, sexual function was the most grossly affected functional score by the treatment modalities of prostate cancer.

Cultural adaptation and validation of the Chinese version of the expanded prostate cancer index composite

AIM

The expanded prostate cancer index composite (EPIC) is a widely adopted instrument for the quality of life of patients with prostate cancer. We aimed to create a Chinese version of EPIC to further research in the Chinese-speaking population.

METHODS

A prototype was created by forward-backward translations and revisions. During cultural adaptation, 15 participants were interviewed after they had completed the prototype. A few issues highlighted included confusion related to the question format, subject non-familiarity with the Chinese term for "hot flashes," and the use of the Chinese term for "breast" as a strictly female body part. A pilot version was created based on the cultural adaptation findings. Validation of the pilot version was performed by having 50 participants complete the Chinese EPIC and EORTC QLQ-c30 twice within a 4-week period. Test-retest reliability (Pearson's correlations and difference distribution) and internal consistency (Cronbach's α) were measured using SAS version 9.4.

RESULTS

Test-retest reliability values for the urinary, bowel, sexual and hormone domains were 0.71, 0.51, 0.51 and 0.66, respectively; subscale test-retest reliability ranged between 0.29 and 0.82. Internal consistency for domains was good with Cronbach's α ranging from 0.76 to 0.78 for the initial test and 0.67 to 0.85 for the retest. The performance of this version of EPIC was comparable to the validated EORTC QLQ-C30.

CONCLUSION

The EPIC questionnaire was successfully translated into Chinese and was culturally adapted. The resultant Chinese version has high reliability and validity and will be an important tool for research on quality of life in the Chinese population.

Improvement in sexual function after robot-assisted radical prostatectomy: A rehabilitation program with involvement of a clinical sexologist

INTRODUCTION

To prospectively evaluate if the inclusion of a clinical sexologist in a penile and sexual rehabilitation program improves sexual function one year after prostate cancer surgery.

MATERIAL AND METHODS

Twelve months after da Vinci Radical Prostatectomy (dVRP) for prostate cancer, 28 fully potent (IIEF-5 >21) and sexually active men (ages 47-69 years, mean 61) who, in 2008, were enrolled in a prospectively monitored penile rehabilitation program (reference group) were compared with 79 fully potent (IIEF-5 >21) and sexually active men (ages 45-74 years, mean 61) enrolled in 2009 (study group); whose program differed by the inclusion of evaluation and treatment by a clinical sexologist.

RESULTS

Twelve months after dVRP, seventeen patients in the reference group (61%) were sexually active with regular penetrating sexual activity compared to sixty-six (84%) in the study group (p = 0.02). These findings were independent of whether they had undergone a nerve sparing or non-nerve sparing procedure. Almost 94% (74 patients) in the study group had at some time been able to perform penetrating sexual activity; 14 patients required additional visits to the clinical sexologist beyond the routine follow-up, 9 for short-term cognitive behavior therapy.

CONCLUSIONS

Inclusion of a clinical sexologist in a penile and sexual rehabilitation program appears to improve the ability to have regular sexual activity with penetrating sex one year after da Vinci Robotic Radical Prostatectomy.

Opportunities for targeted focal treatment in Japan

PURPOSE OF REVIEW

Widespread prostate-specific antigen screening has led to an increase in prostate cancer diagnoses in Asian populations, reflecting changes in socioeconomic status and epidemiological features in these countries. In this setting, the present review explores opportunities for target focal therapy in Japan.

RECENT FINDINGS

Our review examines several topics relating to focal therapy in Asia, and discusses the current status of prostate cancer diagnosis and treatment in that region. First, we summarize the prevalence of prostate cancer in Asian populations. Second, we examine prostate cancer diagnosis and treatment options such as mapping biopsy and MRI fusion biopsy in Japan. Third, we review treatment strategies for localized prostate cancer, especially robotic-assisted surgery, active surveillance, and high-intensity focused ultrasound. Lastly, we discuss the potential for focal therapy in Japan.

SUMMARY

The number of localized prostate cancer patients is expected to increase in Asia. Accordingly, the need for precise diagnosis in terms of localization of prostate cancer foci will also expand. MRI fusion target biopsies are being performed in Asia, particularly in some Japanese academic institutions, but as pilot studies. In recent years, an increase in robotic-assisted surgery in East Asia has yielded new options in prostate cancer treatment. Although active surveillance is a practical choice for low-risk prostate cancer in some Asian countries, focal therapy is expected to see increasing interest as another alternative in Japan.

Sexual dysfunction and infertility as late effects of cancer treatment

Sexual dysfunction is a common consequence of cancer treatment, affecting at least half of men and women treated for pelvic malignancies and over a quarter of people with other types of cancer. Problems are usually linked to damage to nerves, blood vessels, and hormones that underlie normal sexual function. Sexual dysfunction also may be associated with depression, anxiety, relationship conflict, and loss of self-esteem. Innovations in cancer treatment such as robotic surgery or more targeted radiation therapy have not had the anticipated result of reducing sexual dysfunction. Some new and effective cancer treatments, including aromatase inhibitors for breast cancer or chemoradiation for anal cancer also have very severe sexual morbidity. Cancer-related infertility is an issue for younger patients, who comprise a much smaller percentage of total cancer survivors. However, the long-term emotional impact of being unable to have a child after cancer can be extremely distressing. Advances in knowledge about how cancer treatments may damage fertility, as well as newer techniques to preserve fertility, offer hope to patients who have not completed their childbearing at cancer diagnosis. Unfortunately, surveys in industrialised nations confirm that many cancer patients are still not informed about potential changes to their sexual function or fertility, and all modalities of fertility preservation remain underutilised. After cancer treatment, many patients continue to have unmet needs for information about restoring sexual function or becoming a parent. Although more research is needed on optimal clinical practice, current studies suggest a multidisciplinary approach, including both medical and psychosocial treatment options.

Counseling the post-radical prostatectomy patients about functional recovery: high predictiveness of current status

OBJECTIVE

To develop prediction models to help counsel post-radical prostatectomy patients about functional recovery.

METHODS

The study included 2162 patients undergoing radical prostatectomy at a major cancer center, who reported urinary and erectile function at 1 year or at 2 years and at least 1 prior follow-up at 3, 6, 9, or 12 months. We created logistic regression models predicting function at one or 2 years on the basis of function at 3, 6, 9, and 12 months (2 years only), with the additional predictors of age, stage, grade, prostate-specific antigen levels, nerve-sparing status and baseline functional score.

RESULTS

No variable other than current functional score had a consistent statistically significant relationship with outcome. The area under the curves for predicting function at 2 years based on current function alone at 3, 6, 9, and 12 months were respectively 0.796, 0.831, 0.882, and 0.885 for erectile function and 0.789, 0.862, 0.869, and 0.876 for urinary function. Patients using 1 pad at 6 months had only a 50% probability of being pad free at 2 years; this dropped to 36% for patients using 2 pads. This suggests that there is an opportunity for early identification and possible referral of patients likely to have long-term urinary dysfunction.

CONCLUSION

Assessment of urinary and erectile function in the first postoperative year is strongly predictive of long-term outcome and can guide patient counseling and decisions about rehabilitative treatments.

Feeling well and talking about sex: psycho-social predictors of sexual functioning after cancer

BACKGROUND

Changes to sexual wellbeing are acknowledged to be a long-term negative consequence of cancer and cancer treatment. These changes can have a negative effect on psychological well-being, quality of life and couple relationships. Whilst previous conclusions are based on univariate analysis, multivariate research can facilitate examination of the complex interaction between sexual function and psycho-social variables such as psychological wellbeing, quality of life, and relationship satisfaction and communication in the context of cancer, the aim of the present study.

METHOD

Six hundred and fifty seven people with cancer (535 women, 122 men) and 148 partners (87 women, 61 men), across a range of sexual and non-sexual cancers, completed a survey consisting of standardized measures of sexual functioning, depression and anxiety, quality of life, relationship satisfaction, dyadic sexual communication, and self-silencing, as well as ratings of the importance of sex to life and relationships.

RESULTS

Men and women participants, reported reductions in sexual functioning after cancer across cancer type, for both people with cancer and partners. Multiple regression analysis examined psycho-social predictors of sexual functioning. Physical quality of life was a predictor for men and women with cancer, and for male partners. Dyadic sexual communication was a predictor for women with cancer, and for men and women partners. Mental quality of life and depression were also predictors for women with cancer, and the lower self-sacrifice subscale of self-silencing a predictor for men with cancer.

CONCLUSION

These results suggest that information and supportive interventions developed to alleviate sexual difficulties and facilitate sexual renegotiation should be offered to men and women with both sexual and non-sexual cancers, rather than primarily focused on individuals with sexual and reproductive cancers, as is the case currently. It is also important to include partners in supportive interventions. Interventions aimed at improving sexual functioning should include elements aimed at improving physical quality of life and sexual communication, with a focus on psychological wellbeing also being important for women with cancer.

Pilot study on quality of life and sexual function in men-who-have-sex-with-men treated for prostate cancer

INTRODUCTION

There is limited data on post-treatment quality of life (QoL) for men-who-have-sex-with-men (MSM) with prostate cancer (PCa). QoL in MSM may not be reflected by assessment tools designed for the heterosexual population.

AIMS

Our goals were to evaluate post-treatment QoL in PCa patients who are MSM, and to investigate the utility of current QoL assessment tool.

METHODS

PCa patients treated with surgery and/or radiation were recruited from the local MSM community. Each participant completed the Expanded Prostate Cancer Index Composite (EPIC) questionnaire, Male Sexual Health Questionnaire (MSHQ), and a questionnaire focused on insertive and receptive roles of anal intercourse.

MAIN OUTCOME MEASURES

Response scores were calculated based on questionnaire design and compared by treatment modality.

RESULTS

Seven participants treated with surgery (mean age 58) and eight participants treated with radiation (mean age 67) were recruited. No participant in the surgical group received androgen deprivation therapy (ADT) while two in radiation group were treated with ADT. The sample size of this study did not permit formal statistical analysis, although potential differences in Urinary and Bowel Domains from EPIC and Ejaculation Scale from MSHQ were observed. More participants from the radiation group seemed to be able to maintain both insertive and receptive anal intercourse roles after treatment compared to participants who received surgery.

CONCLUSIONS

While the two validated assessment tools suggested similar QoL scores including sexual function for both surgical and radiation groups, post-treatment sexual function related to anal intercourse may be better in the radiation group, as compared to the surgical group. Larger studies in PCa patients from MSM community are warranted to verify these data.

Sexual bother and function after radical prostatectomy: predictors of sexual bother recovery in men despite persistent post-operative sexual dysfunction

Changes in sexual bother (SB) following radical prostatectomy (RP) negatively affect health-related quality of life (HRQoL) of prostate cancer survivors. However, post-operative SB tends to be neglected whereas sexual function (SF) is thoroughly assessed in clinical practice and few studies have focused on and evaluated patients' SB. We retrospectively reviewed 2 345 consecutive patients who underwent RP between 2001 and 2009 at a single institution. SF and SB were assessed using Expanded Prostate Cancer Index Composite (EPIC) questionnaires. We stratified our cohort by SB recovery and post-operative SF status, including a subset of men who recovered SB despite persistent post-RP sexual dysfunction. Multivariable logistic regression analyses were conducted to identify factors for men who have SB recovery. Of 319 eligible patients, 133 (41.7%) recovered their SB at a mean of 20 months after RP. Among the 133 men who demonstrated SB recovery, 109 had post-operative sexual dysfunction. Patients with SB recovery despite post-RP sexual dysfunction were more likely to be old (p = 0.004), to have higher clinical T stage (p < 0.001), to have more non-nerve-sparing RP (p < 0.001), to have lower pre-operative EPIC-SF/SB scores (p < 0.001), to have more extracapsular extension (p = 0.031) and to be PDE5i non-users after surgery (p < 0.001). In multivariable analysis, predictors for this subset were lower comorbidity (OR 0.62, p = 0.043), higher clinical cancer stage (OR 2.35, p = 0.026), worse pre-operative SF (OR 0.98, p = 0.010), SB (OR 0.98, p < 0.010) and no PDE5i use (OR 0.37, p = 0.002); age was not related (OR 0.99, p = 0.555). As SB can influence patients' overall HRQoL, expectations of SB recovery should be provided to patients in the same way that SF recovery is presented. This study may help clinicians to discuss SB with patients and assess their potential for SB recovery following RP.

Loss of masculine identity, marital affection, and sexual bother in men with localized prostate cancer

INTRODUCTION

Erectile dysfunction (ED) is one of the most frequent sources of distress after treatment for prostate cancer (PCa), yet evidence suggests that men do not easily adjust to loss of sexual function over time. A hypothesized determinant of men's adaptation to ED is the degree to which they experience a loss of masculine identity in the aftermath of PCa treatment.

AIMS

The aims of this study were (i) to describe the prevalence of concerns related to diminished masculinity among men treated for localized PCa; (ii) to determine whether diminished masculinity is associated with sexual bother, after controlling for sexual functioning status; and (iii) to determine whether men's marital quality moderates the association between diminished masculinity and sexual bother.

METHODS

We analyzed cross-sectional data provided by 75 men with localized PCa who were treated at one of two cancer centers. Data for this study were provided at a baseline assessment as part of their enrollment in a pilot trial of a couple-based intervention.

MAIN OUTCOME MEASURES

The sexual bother subscale from the Prostate Health-Related Quality-of-Life Questionnaire and the Masculine Self-Esteem and Marital Affection subscales from Clark et al's PCa-related quality-of-life scale.

RESULTS

Approximately one-third of men felt they had lost a dimension of their masculinity following treatment. Diminished masculinity was the only significant, independent predictor of sexual bother, even after accounting for sexual functioning status. The association between diminished masculinity and sexual bother was strongest for men whose spouses perceived low marital affection.

CONCLUSIONS

Diminished masculinity is a prominent, yet understudied concern for PCa survivors. Regardless of functional status, men who perceive a loss of masculinity following treatment may be more likely to be distressed by their ED. Furthermore, its impact on adjustment in survivorship may rely on the quality of their intimate relationships.

A phase II, single-blind, randomized, crossover evaluation of the safety and efficacy of avanafil using visual sexual stimulation in patients with mild to moderate erectile dysfunction

OBJECTIVE

To evaluate the safety, efficacy and time course of three doses of avanafil (50 mg, 100 mg and 200 mg) compared with sildenafil 50 mg or placebo, given in conjunction with visual sexual stimulation (VSS) videos in men with mild to moderate erectile dysfunction (ED).

PATIENTS AND METHODS

Male patients, 35-70 years of age, with mild to moderate ED of ≥6 months duration, were included in the study. During the course of the study, each patient received placebo, active control (sildenafil 50 mg), and one dose of avanafil (50 mg, 100 mg or 200 mg), all administered in random order at least 72 h apart. RigiScan® (Dacomed Corp., Minneapolis, MN, USA) monitoring was used in conjunction with 20-min VSS videos (20, 60, and 100 min after dosing) to determine the duration of and time to ≥60% penile rigidity, maximum rigidity, tumescent activity units (TAUs), rigidity activity units (RAUs), and responses to the five-point Erection Assessment Scale. Safety assessments included adverse events (AEs), vital sign changes in response to dosing, laboratory results (complete blood counts, chemistry panel, prostate-specific antigen, serum testosterone, prothrombin time and urine analysis) and physical examination findings.

RESULTS

Eighty-three patients were randomized and received at least one dose of study medication; 82 patients completed the study. Peak response to avanafil occurred in the early interval (20-40 min after dosing), while peak response to sildenafil occurred either in the middle (60-80 min) or late (100-120 min) intervals after dosing. Results were qualitatively similar for all other efficacy endpoints. During the 20-40-min interval, the majority of values for TAUs and RAUs with the avanafil 50-mg, 100-mg and 200-mg treatments were significantly superior to placebo (P < 0.05). Avanafil treatment was generally well tolerated; facial flushing (7-15%) was the most commonly observed AE, and no visual disturbances were reported.

CONCLUSION

A favourable safety profile and improvement in sexual function, coupled with rapid onset of action and durability of effect, make avanafil an attractive option for males with ED, especially in the setting of on-demand treatment.

Increasing the dose of vardenafil on a daily basis does not improve erectile function after unilateral nerve-sparing radical prostatectomy

INTRODUCTION

Several treatment regimens for rehabilitation of erectile function (EF) after nerve-sparing radical prostatectomy (nsRP) are currently discussed. The optimal and most cost-effective therapy is still not found yet.

AIM

To evaluate the effect of vardenafil, a PDE5 inhibitor, dose escalation on recovery of EF after unilateral nsRP.

METHODS

Thirty-six sexually active patients received a unilateral nsRP. All patients completed an International Index of Erectile Function-5 items (IIEF-5) questionnaire concerning EF preoperatively. Group 1 (N = 12 patients) received vardenafil 5 mg/day vs. group 2 (N = 12) who received vardenafil 10 mg/day at night beginning the day of catheter removal. A control of 12 patients underwent follow-up without PDE5 inhibitors.

MAIN OUTCOME MEASURE

The IIEF-5 was the primary end point. IIEF-5 questionnaires were completed at baseline, 3, 6, and 12 months after nsRP.

RESULTS

In group 1 (5 mg/day vardenafil) the IIEF-5 score decreased from a preoperative 22.4 mean score to 4.2 at 3 months, 8.9 at 6 months, and 13.4 mean score at 12 months after nsRP vs. preoperative 22.8, 4.1 at 3 months, 7.9 at 6 months, and 12.8 mean score at 12 months in group 2 (10 mg/day vardenafil). In the control group the preoperative IIEF-5 mean score of 21.9 decreased to 3.8 at 3 months, 6.1 at 6 months, and 8.9 at 12 months. Statistical evaluation showed significant difference in IIEF-5 score and time to recovery of EF between groups 1 and 3 and between groups 2 and 3 (P < 0.01). No statistical differences were found between groups 1 and 2.

CONCLUSIONS

Daily low-dose vardenafil lead to significant improvement of recovery of EF. In this study doubling the dosage did not improve the recovery of EF further.

Robotic radical prostatectomy: The new gold standard

Objectives

Open radical prostatectomy (RP) has been the standard and primary treatment for focal prostate cancer. However, in recent years this view has changed, as robot-assisted laparoscopic RP has gained acceptance among urologists. In this review we evaluate the importance and place of robotics in laparoscopic urological surgery, discussing several techniques that are currently being used and potentially new techniques that might be used in the future.

Methods

We systematically reviewed papers published between 1998 and 2011 using the keywords ‘robotic prostatectomy’ ‘gold standard’ and the Medline database. In addition, after selecting relevant reports we searched ‘related citations’ of the documents to find further supporting published papers.

Results

In all, 50 original papers were identified using the search criteria; we also found 28 through ‘related citations’ browsing. Papers were selected according to their relevance to the current topic (i.e. RP, original articles) and incorporated into this review. These papers were used for their information on the advantages of using robotics, as well as innovative ideas being used in the field of robotic urological surgery.

Conclusion

Almost a decade after the first robotic RP many reports show the benefits and advantages of incorporating robotics into urological surgery. Robotic surgery decreases the learning curve necessary for surgeons when compared with laparoscopic techniques. In addition, patients prefer robotics, as the procedure is less invasive, diminishes the duration of hospitalisation and speeds the return to function.

Association between preoperative erectile dysfunction and prostate cancer features--an analysis from the Duke Prostate Center Database

INTRODUCTION

Erectile dysfunction (ED) is related to several co-morbidities including obesity, metabolic syndrome, cigarette smoking, and low testosterone, all of which have been reported to be associated with adverse prostate cancer features.

AIM

To examine whether preoperative ED has a relationship with adverse prostate cancer features in patients who underwent radical prostatectomy (RP).

METHODS

We analyzed data from our institution on 676 patients who underwent RP between 2001 and 2010. Crude and adjusted logistic regression models were used to investigate the association between preoperative ED and several pathological parameters. The log-rank test and multivariate proportional hazards model were conducted to determine the association of preoperative ED with biochemical recurrence (BCR).

MAIN OUTCOME MEASURES

The expanded prostate cancer index composite (EPIC) instrument was used to evaluate preoperative erectile function (EF). Preoperative normal EF was defined as EPIC-SF ≥ 60 points while ED was defined as preoperative EPIC-SF lower than 60 points.

RESULTS

Preoperatively, a total of 343 (50.7%) men had normal EF and 333 (49.3%) men had ED. After adjusting for covariates, preoperative ED was identified a risk factor for positive extracapsular extension (OR 1.57; P = 0.029) and high percentage of tumor involvement (OR 1.56; P = 0.047). In a Kaplan-Meier curve, a trend was identified that patients with ED had higher incidence of BCR than men with normal EF (P = 0.091). Moreover, using a multivariate Cox model, higher preoperative EF was negatively associated with BCR (HR 0.99; P = 0.014).

CONCLUSIONS

These results suggest that the likelihood for adverse pathological outcomes as well as BCR following prostatectomy is higher among men with preoperative ED, though these results require validation in larger datasets. The present study indicates that preoperative ED might be a surrogate for adverse prostate cancer outcomes following RP.