Health-related quality of life in men with prostate cancer undergoing active surveillance versus radical prostatectomy, external-beam radiotherapy, prostate brachytherapy and reference population: a cross-sectional study

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

BACKGROUND AND OBJECTIVE

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

METHODS

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

KEY FINDINGS AND LIMITATIONS

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

CONCLUSIONS AND CLINICAL IMPLICATIONS

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

PATIENT SUMMARY

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

Exploring Unmet Needs in Prostate Cancer Care: A Cross-sectional Descriptive Study

Background and objective

Prostate cancer, the most common cancer among men worldwide, has significant impact on quality of life. Supportive care needs for those affected by prostate cancer are not well understood. This study aims to describe patient-reported unmet needs and explore supportive care priorities of men treated for prostate cancer.

Methods

A cross-sectional survey was distributed to all men who had accessed prostate cancer services (including surgical, radiation, and medical oncology treatment modalities) at a tertiary hospital. The survey included qualitative questions exploring patient experience and a validated patient-reported outcome measure (Supportive Care Needs Survey Short Form 34). Clinical information was collected. Analyses included, descriptive statistics, multivariate logistic regression models and qualitative analyses using a framework method.

Key findings and limitations

A total of 162 participants provided survey data. Domains about information, self-management, and sexual function were the highest ranked items with unmet needs. A qualitative analysis also identified "relationships", "information", and "the value of hindsight" constructs. Participants who identified three or more unmet needs expressed treatment regret (odds ratio 5.92, 1.98-22.23, p = 0.01).

Conclusions and clinical implications

Understanding the unmet needs of patients may better inform supportive care interventions that address what is important to patients. Importantly, participants valued relationships. There may be opportunities to better meet the needs of patients by improving access to information and self-management resources, particularly around sexuality. Further research is warranted.

Patient summary

Prostate cancer and its treatment impacts are not well understood. Prioritisation of relationships and improving access to information and self-management resources are important. Further attention to prostate cancer supportive care in clinical practice is needed.

Quality of Life Longitudinal Evaluation in Prostate Cancer Patients from Radiotherapy Start to 5 Years after IMRT-IGRT

PURPOSE

The purpose of this study is to study the evolution of quality of life (QoL) in the first 5 years following Intensity-modulated radiation therapy (IMRT) for prostate cancer (PCa) and to determine possible associations with clinical/treatment data.

MATERIAL AND METHODS

Patients were enrolled in a prospective multicentre observational trial in 2010-2014 and treated with conventional (74-80 Gy, 1.8-2 Gy/fr) or moderately hypofractionated IMRT (65-75.2 Gy, 2.2-2.7 Gy/fr). QoL was evaluated by means of EORTC QLQ-C30 at baseline, at radiation therapy (RT) end, and every 6 months up to 5 years after IMRT end. Fourteen QoL dimensions were investigated separately. The longitudinal evaluation of QoL was analysed by means of Analysis of variances (ANOVA) for multiple measures.

RESULTS

A total of 391 patients with complete sets of questionnaires across 5 years were available. The longitudinal analysis showed a trend toward the significant worsening of QoL at RT end for global health, physical and role functioning, fatigue, appetite loss, diarrhoea, and pain. QoL worsening was recovered within 6 months from RT end, with the only exception being physical functioning. Based on ANOVA, the most impaired time point was RT end. QoL dimension analysis at this time indicated that acute Grade ≥ 2 gastrointestinal (GI) toxicity significantly impacted global health, physical and role functioning, fatigue, appetite loss, diarrhoea, and pain. Acute Grade ≥ 2 genitourinary (GU) toxicity resulted in lower role functioning and higher pain. Prophylactic lymph-nodal irradiation (WPRT) resulted in significantly lower QoL for global health, fatigue, appetite loss, and diarrhoea; lower pain with the use of neoadjuvant/concomitant hormonal therapy; and lower fatigue with the use of an anti-androgen.

CONCLUSIONS

In this prospective, longitudinal, observational study, high radiation IMRT doses delivered for PCa led to a temporary worsening of QoL, which tended to be completely resolved at six months. Such transient worsening was mostly associated with acute GI/GU toxicity, WPRT, and higher prescription doses.

Assessing health-related quality of life among cancer survivors during systemic and radiation therapy in Bangladesh: a cancer-specific exploration

BACKGROUND

Evaluating the effects of cancer diagnosis and treatment on a patient's overall well-being is crucial and health-related quality of life (HRQoL) is a reliable metric for assessing this impact. Little is known about HRQoL among cancer survivors across various stages and treatments. The study examined individual and clinical factors influencing HRQoL among cancer survivors.

METHODS

A cross-sectional study was conducted in two specialised cancer care hospitals in Dhaka, Bangladesh. Cancer-diagnosed adults receiving treatment at selected hospitals from January to May 2022 were enrolled. The 5-level EuroQol-5 Dimensions version (EQ-5D-5L) instrument was used to collect HRQoL data. HRQoL scores were derived using UK value sets. The investigation used a multivariable Tobit regression model to determine the association between independent variables and HRQoL scores.

RESULTS

A total of 607 adult patients were enrolled, with 55% being females and 66% aged 36 to 64 years. Reported health problems in five EQ-5D domains include mobility (11%), self-care (11%), usual daily activities (19%), pain/discomfort (21%), and anxiety/depression (46%). Patients with throat, brain, lung, blood, and liver cancer had lower utility scores. Advanced-stage cancer survivors had lower utility scores (β = -49 units, 95% codfidence interval [CI]: -0.75 to -0.22) compared to early-stage survivors. Physically inactive survivors had lower utility scores by 0.41 units (95% CI: -0.51 to -0.30) compared to their counterparts. Private hospital patients had higher utility scores, whereas patients belonged to poor socioeconomic groups scored worse than wealthier ones.

CONCLUSIONS

This study highlights the impact of clinical and individual characteristics on HRQoL among cancer survivors. These findings advocate for an enhanced Bangladeshi cancer patient care model through timely interventions or programs, early detection or diagnosis, tailored treatments, and the promotion of physical activity to bolster HRQoL outcomes.

Enzalutamide and Quality of Life in Biochemically Recurrent Prostate Cancer

BACKGROUND: EMBARK, a controlled trial reported elsewhere, showed enzalutamide plus leuprolide (combination) and enzalutamide monotherapy prolonged metastasis-free survival versus placebo plus leuprolide (alone) in patients with high-risk biochemically recurrent prostate cancer. Health-related quality of life was also analyzed but not reported. METHODS: In EMBARK, patients with biochemical recurrence (prostate-specific antigen doubling time of ≤9 months) were randomly assigned (1:1:1) to combination (n=355), leuprolide-alone (n=358), or enzalutamide monotherapy (n=355). In this article we provide the patient-reported outcomes (PROs) from EMBARK at baseline and every 12 weeks until metastasis or death. The key end point was time to first and confirmed clinically meaningful deterioration (TTFD/TTCD) in pain and health-related quality of life using four PRO measures and predefined thresholds. RESULTS: At baseline, all groups had high health-related quality of life. For worst pain, the median TTFD was 19.35 months with leuprolide alone, 13.93 months with combination (hazard ratio, 1.08; 95% confidence interval [CI], 0.89 to 1.30) and 16.59 months with monotherapy (hazard ratio, 1.09; 95% CI, 0.90 to 1.31). The median TTCD was 66.27 months with leuprolide alone, 80.00 months with combination (hazard ratio, 0.82; 95% CI, 0.65 to 1.04), and 60.91 months with monotherapy (hazard ratio, 1.02; 95% CI, 0.82 to 1.28). For Functional Assessment of Cancer Therapy–Prostate total score, the median TTFD was 11.10 months with leuprolide alone, 8.31 months with combination (hazard ratio, 1.14; 95% CI, 0.95 to 1.36), and 8.38 months with monotherapy (hazard ratio, 1.17; 95% CI, 0.98 to 1.39). The median TTCD was 36.53 months with leuprolide alone, 38.77 months with combination (hazard ratio, 1.04; 95% CI, 0.85 to 1.28), and 30.55 months with monotherapy (hazard ratio, 1.16; 95% CI, 0.95 to 1.41). CONCLUSIONS: The PROs from EMBARK show that both enzalutamide combination and monotherapy versus leuprolide alone, with oncologic benefits noted above, preserved high health-related quality of life in patients with high-risk biochemical recurrence of prostate cancer. (Funded by Pfizer and Astellas Pharma; ClinicalTrials.gov number, NCT02319837.)

Validating the total cancer location density metric for stratifying patients with low-risk localized prostate cancer at higher risk of grade group reclassification while on active surveillance

PURPOSE

To validate a previously proposed prognostic metric, Total Cancer Location (TCLo) density, in a contemporary cohort of men with grade group (GG) 1 prostate cancer (PCa) on active surveillance (AS).

METHODS

We evaluated 123 patients who entered AS with maximum GG1 PCa at diagnostic and/or confirmatory biopsy. TCLo was defined as the total number of PCa locations identified on both biopsy sessions. TCLo density was calculated as TCLo / prostate volume [ml]. Primary endpoint was progression-free survival (PFS), defined as time from confirmatory biopsy to grade group reclassification (GGR) on repeat biopsy or prostatectomy. Optimal cut-point for TCLo density was predefined in a previously reported cohort and applied to this contemporary cohort. Kaplan-Meier and multivariable Cox regression analysis were used to estimate the association of predictors with PFS.

RESULTS

During median follow-up of 7.8 years, (IQR 7.3-8.2) 34 men had GGR. Using previously defined cut-points, PFS at 5-years was 60% (95% CI: 44%-81%) vs. 89% (95% CI: 83%-96%) in men with high (≥0.06 ml^-1) vs. low (<0.06 ml^-1) TCLo density, and 63% (95% CI: 48%-82%) vs. 90% (95% CI: 83%-96%) in men with high (≥3) vs. low (≤2) TCLo (log-rank test: P < 0.0001, respectively). Adjusting for age, prostate volume, percent of positive cores and PSA, both higher TCLo density (HR [per 0.01 ml^-1 increase]: 1.18, 95% CI: 1.05-1.33, P = 0.005) and TCLo (HR: 1.69, 95% CI: 1.20-2.38, P = 0.002) were associated with shorter PFS.

CONCLUSION

The previously suggested prognostic value of TCLo density was confirmed in this validation cohort. TCLo alone performed similarly well. Patients with high TCLo density (≥0.06 ml^-1) or TCLo (>2) were at greater risk of GGR while on AS. With external validation, these metric may help guide risk-adapted surveillance protocols.

Patient-Factors Influencing the 2-Year Trajectory of Mental and Physical Health in Prostate Cancer Patients

This study aimed to examine the physical and mental Quality of Life (QoL) trajectories in prostate cancer (PCa) patients participating in the Pros-IT CNR study. QoL was assessed using the Physical (PCS) and Mental Component Score (MCS) of Short-Form Health Survey upon diagnosis and two years later. Growth mixture models were applied on 1158 patients and 3 trajectories over time were identified for MCS: 75% of patients had constantly high scores, 13% had permanently low scores and 12% starting with low scores had a recovery; the predictors that differentiated the trajectories were age, comorbidities, a family history of PCa, and the bowel, urinary and sexual functional scores at diagnosis. In the physical domain, 2 trajectories were defined: 85% of patients had constantly high scores, while 15% started with low scores and had a further slight decrease. Two years after diagnosis, the psychological and physical status was moderately compromised in more than 10% of PCa patients. For mental health, the trajectory analysis suggested that following the compromised patients at diagnosis until treatment could allow identification of those more vulnerable, for which a level 2 intervention with support from a non-oncology team supervised by a clinical psychologist could be of help.

The Effects of Multimodal Prehabilitation Interventions in Men Affected by Prostate Cancer on Physical, Clinical and Patient Reported Outcome Measures: A Systematic Review

OBJECTIVES

To synthesize existing evidence on the effects of multimodal prehabilitation interventions in men affected by prostate cancer on physical, clinical, and patient-reported outcome measures.

DATA SOURCES

A systematic review was conducted according to the PRISMA 2020 Statement Guidelines. Electronic databases (ie, Medline, Embase, CINAHL and Cochrane CENTRAL, and clinicaltrials.gov) were searched using key search terms. Articles were assessed according to prespecified eligibility criteria. Data extraction and quality appraisal was conducted. The findings were integrated in a narrative synthesis.

CONCLUSION

Of the 5863 publications screened, 118 articles were assessed in full text and 17 studies met the prescreening eligibility criteria. There were a range of study designs that included randomized controlled clinical trials (n = 11), quasi experimental (n = 4), cohort (n = 1), and case series (n = 1), covering a total of 1739 participants. The prehabilitation interventions included physical activity, peer support, pelvic floor muscle training, diet, nurse-led prehabilitation, psychological, and prehabilitation administration of phosphodiesterase-5 inhibitors.

IMPLICATIONS FOR NURSING PRACTICE

Significant heterogeneity existed in the prehabilitation intervention programs for men affected by prostate cancer in terms of the composition, duration, method of administration, and the outcomes measured to quantify their impact. This systematic review has identified that multimodal prehabilitation interventions are an emerging area for practice and research among men affected by prostate cancer. Importantly, there has been a lack of focus on the inclusion of partners as critical companions during this distressing phase of the cancer care continuum. For the moment, all members of the multidisciplinary team caring for people affected by prostate cancer are encouraged to use the findings in this review to inform holistic models of care.

The health-related quality of life in patients with prostate cancer managed with active surveillance using the Expanded Prostate Cancer Index Composite survey: Systematic review and meta-analysis

Objective

Methods

Results

Conclusion

THE ROLE OF THE APPARENT DIFFUSION COEFFICIENT OF THE BIPARAMETRIC MRI AS AN IMAGING MARKER OF PROSTATE CANCER

Prostate cancer (PCa) is the most common malignancy in men. The role of the apparent diffusion coefficient (ADC)of biparametric MRI (biMRI) which is a study without the use of dynamic contrast enhancement (DCE), in detectionof PCa is still not comprehensively investigated.

OBJECTIVE

The goal of the study was to assess the role of ADC of biMRI as an imaging marker of clinically significant PCaMaterials and methods. The study involved 78 men suspected of having PCa. All patients underwent a comprehensive clinical examination, which included multiparametric MRI of the prostate, a component of which was biMRI. TheMRI data was evaluated according to the PIRADS system version 2.1.

RESULTS

The distribution of patients according to the PIRADS system was as follows: 1 point - 9 (11.54 %)patients, 2 points - 12 (15.38 %) patients, 3 points - 25 (32.05 %) patients, 4 points - 19 (24.36 %) patients and5 points - 13 (16.67 %) patients. In a subgroup of patients with 5 points, clinically significant PCa was detected in 100 % of cases. In the subgroup of patients with tumors of 4 points clinically significant PCa was diagnosed in 16of 19 (84.21 %) cases, and in 3 (15.79 %) patients - clinically insignificant tumor. In the subgroup of patients with3 points, clinically significant PCa was diagnosed in 11 of 25 (44.0 %) cases, in 8 (32.0 %) patients - clinicallyinsignificant tumor and in 6 (24.0 %) patients - benign prostatic hyperplasia. PCa with a score of 7 on the Gleasonscale showed significantly lower mean values of ADC of the diffusion weighted MRI images compared to tumors witha score of < 7 on the Gleason scale: (0.86 ± 0.07) x 103 mm2/s vs (1.08 ± 0.04) x 103 mm2/s (р < 0.05).

CONCLUSIONS

The obtained results testify to the high informativeness of biMRI in the diagnosis of prostate cancer.The use of ADC allowed to differentiate clinically significant and insignificant variants of the tumor, as well asbenign changes in prostate tissues and can be considered as a potential imaging marker of PCa.

Health-related quality of life in men with localized prostate cancer treated with radiotherapy: validation of an abbreviated version of the Expanded Prostate Cancer Index Composite for Clinical Practice in Spain

Background

Health-related quality of life (HRQoL) is greatly affected by prostate cancer (PCa) and associated treatments. This study aimed to measure the impact of radiotherapy on HRQoL and to further validate the Spanish version of the 16-item Expanded Prostate Cancer Index Composite (EPIC-16) in routine clinical practice.

Methods

An observational, non-interventional, multicenter study was conducted in Spain with localized PCa patients initiating treatment with external beam radiotherapy (EBRT) or brachytherapy (BQT). Changes from baseline in EPIC-16, University of California-Los Angeles Prostate Cancer Index (UCLA-PCI), and patient-perceived health status were longitudinally assessed at end of radiotherapy (V2) and 90 days thereafter (V3). Psychometric evaluations of the Spanish EPIC-16 were conducted.

Results

Of 516 patients enrolled, 495 were included in the analysis (EBRT, n = 361; BQT, n = 134). At baseline, mean (standard deviation [SD]) EPIC-16 global scores were 11.9 (7.5) and 10.3 (7.7) for EBRT and BQT patients, respectively; scores increased, i.e., HRQoL worsened, from baseline, by mean (SD) of 6.8 (7.6) at V2 and 2.4 (7.4) at V3 for EBRT and 4.2 (7.6) and 3.9 (8.2) for BQT patients. Changes in Spanish EPIC-16 domains correlated well with urinary, bowel, and sexual UCLA-PCI domains. EPIC-16 showed good internal consistency (Cronbach’s alpha = .84), reliability, and construct validity.

Conclusion

The Spanish EPIC-16 questionnaire demonstrated sensitivity, strong discriminative properties and reliability, and validity for use in clinical practice. EPIC-16 scores worsened after radiotherapy in different HRQoL domains; however, a strong tendency towards recovery was seen at the 3-month follow-up visit.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12955-021-01856-z.

High-intensity interval training or resistance training versus usual care in men with prostate cancer on active surveillance: A three-arm feasibility randomized controlled trial

BACKGROUND

This study assessed the feasibility of a phase II randomized controlled trial of high-intensity interval training (HIIT), resistance training (RT), and usual care (UC) in men with prostate cancer (PCa) on active surveillance (AS) and evaluated changes in clinically relevant outcomes.

METHODS

Eighteen men undergoing AS for PCa were randomized to HIIT (n=5), RT (n=7), or UC (n=6). Exercise participants attended two supervised sessions weekly and were instructed to complete one home-based session weekly for 8 weeks. UC participants were provided with physical activity guidelines.

RESULTS

Feasibility was met for attendance, compliance, and retention, but not recruitment. HIIT increased leg press (mean: +8.2kg, 95%CI 1.1, 15.3) from baseline to 8 weeks. RT increased seated row (mean: +11.7kg, 95%CI 6.1, 17.3) and chest press (mean: +10.4kg, 95%CI 5.3, 15.5), leg press (mean: +13.1kg, 95%CI 5.9, 20.3), serum insulin-like binding protein-3 (IGFBP-3) (mean: +400.0ng/ml, 95%CI 94.5, 705.5), and decreased interferon-γ (mean: -3.1pg/ml, 95%CI -5.7, -0.4). No changes were observed in the UC group.

CONCLUSION

HIIT and RT may be effective strategies for improving muscle strength; however, only RT may increase serum IGFBP-3. Strategies that can enhance recruitment in men on AS are important prior to conducting a phase II trial.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov number NCT04266262 Novelty bullets • High-intensity interval training or resistance training are feasible during active surveillance for prostate cancer. • Resistance training may suppress the tumor-promoting effects of insulin-like growth factor-I (IGF-I) via increased expression of IGFBP-3.

Prostate Cancer Prehabilitation and the Importance of Multimodal Interventions for Person-centred Care and Recovery

BACKGROUND

Prostate cancer is the second most commonly diagnosed cancer globally. Cancer prehabilitation is defined as a process on the continuum of care that occurs between the time of a cancer diagnosis and the beginning of acute treatment. This article will discuss the importance of prostate cancer prehabilitation interventions in optimising physical and psychological recovery to enhance person-centred care.

DATA SOURCES

Electronic databases including CINAHL, MEDLINE, PsychINFO, Scopus, professional websites, and grey literature were searched using Google Scholar.

CONCLUSION

Prehabilitation in cancer care aims to enhance perioperative care and recovery. An emerging field of research suggests that the preoperative period may be physically and psychologically salient to introduce modifiable self-management behaviours to optimise overall recovery.

IMPLICATIONS FOR NURSING PRACTICE

Prostate cancer specialist nurses provide the hub of person-centred care across the entire cancer care continuum embedded within the multidisciplinary team. Individually tailored interventions such as exercise and pelvic floor muscle training programmes, nutritional advice, anxiety and depression reduction, and sexual well-being interventions should be considered in the prehabilitation phase of the cancer care continuum.

A novel predictor of clinical progression in patients on active surveillance for prostate cancer

INTRODUCTION

Active surveillance (AS) is standard of care in low-risk prostate cancer (PCa). This study describes a novel total cancer location (TCLo) density metric and aims to determine its performance in predicting clinical progression (CP) and grade progression (GP).

METHODS

This was a retrospective study of patients on AS after confirmatory biopsy (CBx). We excluded patients with Gleason ≥7 at CBx and <2 years followup. TCLo was the number of locations with positive cores at diagnosis (DBx) and CBx. TCLo density was TCLo/prostate volume (PV). CP was progression to any active treatment while GP occurred if Gleason ≥7 was identified on repeat biopsy or surgical pathology. Independent predictors of time to CP or GP were estimated with Cox regression. Kaplan-Meier analysis compared progression-free survival (PFS) curves between TCLo density groups. Test characteristics of TCLo density were explored with receiver operating characteristic (ROC) curves.

RESULTS

We included 181 patients who had CBx from 2012-2015 and met inclusion criteria. The mean age of patients was 62.58 years (standard deviation [SD] 7.13) and median followup was 60.9 months (interquartile range [IQR] 23.4). A high TCLo density score (>0.05) was independently associated with time to CP (hazard ratio [HR] 4.70; 95% confidence interval [CI] 2.62-8.42; p<0.001) and GP (HR 3.85; 95% CI 1.91-7.73; p<0.001). ROC curves showed TCLo density has greater area under the curve than number of positive cores at CBx in predicting progression.

CONCLUSIONS

TCLo density is able to stratify patients on AS for risk of CP and GP. With further validation, it could be added to the decision-making algorithm in AS for low-risk localized PCa.