A review of quality-of-life evaluations in prostate cancer

Key issues affecting quality of life and patient-reported outcomes in prostate cancer: an analysis conducted in 2128 patients with initial psychometric assessment of the prostate cancer symptom scale (PCSS)

OBJECTIVE

Evidence-based quality of life (QL) questionnaires require the identification of issues of importance to patients. The primary aim of this study was to inform providers on patient-expressed issues while enhancing the content validity of instruments assessing QL and patient-reported outcomes (PROs) in prostate cancer. The study provided additional psychometric properties for the new PRO and QL instrument, the Prostate Cancer Symptom Scale (PCSS).

METHODS

An anonymous web-based survey of 2128 patients with prostate cancer was conducted with patients rating 18 QL items on a five-point scale.

RESULTS

Most respondents (74%) were aged 55-74 years, had early stage disease at diagnosis (81%) and were diagnosed within 2 years of the survey (81%). The top five-rated issues were: overall QL, ability to perform normal activities, maintaining independence, ability to sleep and not being a burden. These items were ranked as either 'very important' or 'important' by at least 88% of patients. None of the most highly ranked issues were symptoms. Instead, the highest ranked items were global issues reflecting the impact of symptoms on patients. In addition to the enhanced content validity findings, good reliability results and initial support for construct validity are reported for the PCSS.

CONCLUSIONS

This is the largest survey providing patient-expressed background for content validity for QL and PRO measures. The findings of this study should aid development of newer practical questionnaires, such as the PCSS, which can be adapted to electronic platforms enhancing rapid and accurate PRO and QL evaluation.

The internal and external responsiveness of Functional Assessment of Cancer Therapy-Prostate (FACT-P) and Short Form-12 Health Survey version 2 (SF-12 v2) in patients with prostate cancer

PURPOSE

To examine the responsiveness of Functional Assessment of Cancer Therapy-Prostate (FACT-P) and Short Form-12 Health Survey version 2 (SF-12 v2) in prostate cancer patients because there is a lack of evidence to support their responsiveness in this patient population.

METHODS

One hundred sixty-eight subjects with prostate cancer were surveyed at baseline and at 6 months using the SF-12 v2 and FACT-P version 4. Internal responsiveness was assessed using paired t test and generalized estimating equation. External responsiveness was evaluated using receiver operating characteristic curve analysis.

RESULTS

The internal responsiveness of the FACT-P and SF-12 v2 to detect positive change was satisfactory. The FACT-P and SF-12 v2 could not detect negative change. The FACT-P and the SF-12 v2 performed the best in distinguishing between improved general health and worsened general health. The FACT-P performed better in distinguishing between unchanged general health and worsened general health. The SF-12 v2 performed better in distinguishing between unchanged general health and improved general health.

CONCLUSIONS

Positive change detected by these measures should be interpreted with caution as they might be too responsive to detect "noise," which is not clinically significant. The ability of the FACT-P and the SF-12 v2 to detect negative change was disappointing. The internal and external responsiveness of the social well-being of the FACT-P cannot be supported, suggesting that it is not suitable to longitudinally monitor the social component of HRQOL in prostate cancer patients. The study suggested that generic and disease-specific measures should be used together to complement each other.

Association between single-nucleotide polymorphisms in growth factor genes and quality of life in men with prostate cancer and the general population

PURPOSE

Improved survival for men with prostate cancer has led to increased attention to factors influencing quality of life (QOL). As protein levels of vascular endothelial growth factor (VEGF) and insulin-like growth factor 1 (IGF-1) have been reported to be associated with QOL in people with cancer, we sought to identify whether single-nucleotide polymorphisms (SNPs) of these genes were associated with QOL in men with prostate cancer.

METHODS

Multiple linear regression of two data sets (including approximately 750 men newly diagnosed with prostate cancer and 550 men from the general population) was used to investigate SNPs of VEGF and IGF-1 (10 SNPs in total) for associations with QOL (measured by the SF-36v2 health survey).

RESULTS

Men with prostate cancer who carried the minor 'T' allele for IGF-1 SNP rs35767 had higher mean Role-Physical scale scores (≥0.3 SD) compared to non-carriers (p < 0.05). While this association was not identified in men from the general population, one IGF-1 SNP rs7965399 was associated with higher mean Bodily Pain scale scores in men from the general population that was not found in men with prostate cancer. Men from the general population who carried the rare 'C' allele had higher mean Bodily Pain scale scores (≥0.3 SD) than non-carriers (p < 0.05).

CONCLUSIONS

Through identifying SNPs that are associated with QOL in men with prostate cancer and men from the general population, this study adds to the mapping of complex interrelationships that influence QOL and suggests a role for IGF-I in physical QOL outcomes. Future research may identify biomarkers associated with increased risk of poor QOL that could assist in the provision of pre-emptive support for those identified at risk.

Reference values for the CAVIPRES-30 questionnaire, a global questionnaire on the health-related quality of life of patients with prostate cancer

OBJECTIVE

Define and establish the reference values of the CAVIPRES-30 Questionnaire, a health related quality of life questionnaire specific for prostate cancer patients.

MATERIAL AND METHODS

The CAVIPRES-30 was administered to 2,630 males with prostate cancer included by 238 Urologist belonging to the Spanish National Healthcare System. Descriptive analysis on socio-demographic and clinical data were performed, and multivariate analyses were used to corroborate that stratification variables were statistically significantly and independently associated to the overall score of the questionnaire.

RESULTS

The variables Time since diagnosis of the illness, whether the patient had a Stable partner or not, if he was, or not, undergoing Symptomatic treatment were statistically significantly and independently associated (P < .001) to the overall score of the questionnaire. The reference values table of the CAVIPRES-30 questionnaire is made up of different kinds of information of each patient profile: sample size, descriptive statistics with regard to the overall score, Cronbach's alpha value (between .791 and .875) and the questionnaire's values are reported by deciles.

CONCLUSIONS

The results of this study contribute new proof as to the suitability and usefulness of the CAVIPRES-30 questionnaire as an instrument for assessing individually the quality of life of prostate cancer.

Assessing quality of life in patients with prostate cancer: a systematic and standardized comparison of available instruments

Purpose

The objective was to obtain a standardized evaluation of available prostate cancer-specific quality of life instruments used in patients with early-stage disease.

Methods

We carried out systematic literature reviews in the PubMed database to identify manuscripts which contained information regarding either the development process or metric properties of prostate cancer-specific quality of life instruments. Each instrument was evaluated by two experts, independently, using the Evaluating Measures of Patient-Reported Outcomes (EMPRO) tool. An overall and seven attribute-specific EMPRO scores were calculated (range 0–100, worst to best): measurement model, reliability, validity, responsiveness, interpretability, burden and alternative forms.

Results

Eight instruments and 57 manuscripts (2–15 per instrument) were identified. The Expanded Prostate Cancer Index Composite (EPIC) was the best rated (overall EMPRO score 83.1 points). Good results were also obtained by University of California Los Angeles-Prostate Cancer Index (UCLA-PCI), Patient-Oriented Prostate Utility Scale (PORPUS) and Prostate Cancer Quality of Life Instrument (PC-QoL) with 77.3, 70.5 and 64.8 points, respectively. These four instruments passed with distinction the validity and responsiveness evaluation. Insufficient reliability results were observed for UCLA-PCI and PORPUS.

Conclusions

Current evidence supports the choice of EPIC, PORPUS or PC-QoL. Attribute-specific EMPRO results facilitate selecting the adequate instrument for every purpose. For longitudinal studies or clinical trials, where responsiveness is the priority, EPIC or PC-QoL should be considered. We recommend the PORPUS for economic evaluations because it allows cost-utility analysis, and EPIC short versions to minimize administration burden.

Electronic supplementary material

The online version of this article (doi:10.1007/s11136-014-0678-8) contains supplementary material, which is available to authorized users.

Measuring health-related quality of life in men with prostate cancer: A systematic review of the most used questionnaires and their validity

OBJECTIVES

To identify and study the psychometric properties of the most used health-related quality-of-life (HRQoL) instruments in men with prostate cancer.

METHODS

We performed a literature search using PubMed and EMBASE to identify all studies on prostate cancer using a HRQoL instrument. The most often used HRQoL instruments were investigated in detail by 2 independent reviewers. Data were extracted regarding the characteristics and psychometric values of the instruments, i.e., content validity, internal consistency, criterion validity, construct validity, reproducibility, responsiveness, floor and ceiling effects, and interpretability. Good psychometric outcomes indicate a high methodological quality of the instrument.

RESULTS

Our systematic search revealed 13,812 potential relevant articles, of which 2,258 appeared relevant after screening the titles and reading the abstracts. We studied the psychometric properties of the 20 most often used HRQoL instruments, the first 3 of which were the Expanded Prostate Index Composite, University of California-Los Angeles Prostate Cancer Index, and Short Form-36 (SF-36). Content validity, internal consistency (α>0.70), criterion validity, construct validity, and reproducibility were good in 60%, 90%, 10%, 35%, and 65% of the 20 instruments, respectively. Responsiveness was not reported for 12 of 20 instruments (60%). Floor and ceiling effects and the interpretability of the questionnaires were only reported in 3 (15%) and 6 (30%) instruments.

CONCLUSIONS

Considering the psychometric properties, we advise to use the SF-12 as a generic instrument, the Cancer Rehabilitation Evaluation System-SF or the Functional Assessment of Cancer Therapy-General as cancer-specific HRQoL instruments, and the University of California-Los Angeles Prostate Cancer Index, the QUFW94, or the Functional Assessment of Cancer Therapy-Prostate as prostate cancer-specific instruments.

Measuring symptoms in localized prostate cancer: a systematic review of assessment instruments

It is critical for prostate cancer researchers and clinicians to have access to comprehensive, sensitive and simple-to-use symptom measures that allow them to understand and quantify the subjective patient experience. The purpose of the current review is to provide a comprehensive review, detailed tool descriptions and objectively defined quality criteria to facilitate tool choices for patients with localized prostate cancer. Using a systematic web-based literature search, we found n=29 prostate symptom measures described in n=35 validation studies. To be recommended, tools needed to meet four criteria: broad domain coverage, ability to differentiate objective and subjective experience, good internal consistency and validation in at least two populations and/or having achieved two types of validations. Of the 29 tools reviewed, n=7 meet our criteria for recommendation, and three in particular (the EPIC-26 (Expanded Prostate Cancer Index Composite)-26, PC-QOL (Prostate Cancer-Quality of Life) and the UCLA-PCI (UCLA Prostate Cancer Index)) showed the strongest psychometrics. There is a reasonable number of measures to choose from that meet criteria for good psychometrics.

Radical prostatectomy versus watchful waiting for prostate cancer

BACKGROUND

The lack of evidence regarding the effectiveness of treatment options for clinically localised prostate cancer continues to impact on clinical decision-making. Two such options are radical prostatectomy (RP) and watchful waiting (WW). WW involves providing no initial treatment and monitoring the patient with the intention of providing palliative treatment if there is evidence of disease progression.

OBJECTIVES

To compare the beneficial and harmful effects of RP versus WW for the treatment of localised prostate cancer.

SEARCH STRATEGY

MEDLINE, EMBASE, The Cochrane Library, ISI Science Citation Index, DARE and LILACS were searched through 30 July 2010.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials comparing the effects of RP versus WW for clinically localised prostate cancer.

DATA COLLECTION AND ANALYSIS

Data extraction and quality assessment were carried out independently by two authors.

MAIN RESULTS

Two trials met the inclusion criteria. Both trials commenced prior to the widespread availability of prostate-specific antigen (PSA) screening; hence the results may not be applicable to men with PSA-detected disease.One trial (N = 142), conducted in the US, was judged to be of poor quality. All cause (overall) mortality was not significantly different between RP and WW groups after fifteen years of follow up (Hazard Ratio (HR) 0.9 (95% Confidence Interval (CI) 0.56 to 1.43).The second trial (N = 695), conducted in Scandinavia, was judged to be of good quality. After 12 years of follow up, the trial results were compatible with a beneficial effect of RP on the risks of overall mortality, prostate cancer mortality and distant metastases compared with WW but the precise magnitude of the effect is uncertain as indicated by the width of the confidence intervals for all estimates (risk difference (RD) -7.1% (95% CI -14.7 to 0.5); RD -5.4% (95% CI -11.1 to 0.2); RD -6.7% (95% CI -13.2 to -0.2), respectively).        Compared to WW, RP increased the absolute risks of erectile dysfunction (RD 35% (95% CI 25 to 45)) and urinary leakage (RD 27% (95% CI 17 to 37)). These estimates must be interpreted cautiously as they are derived from data obtained from a self-administered questionnaire survey of a sample of the trial participants (N = 326), no baseline quality of life data were obtained and nerve-sparing surgery was not routinely performed on trial participants undergoing RP.

AUTHORS' CONCLUSIONS

The existing trials provide insufficient evidence to allow confident statements to be made about the relative beneficial and harmful effects of RP and WW for patients with localised prostate cancer. The results of ongoing trials should help to inform treatment decisions for men with screen-detected localised prostate cancer.

Short- and long-term HRQOL issues following brachytherapy for prostate cancer

Given the lack of evidence from randomized controlled trials and large prospective studies, controversy exists regarding the optimal treatment strategy for early stage prostate cancer. The impact of various treatments on health-related quality of life has become an increasingly important but controversial issue. The literature on health-related quality of life following brachytherapy, an increasingly used treatment option that can have short- and long-term side effects influencing patient health-related quality of life is reviewed. Urinary, bowel and sexual health-related quality of life issues related to this treatment are addressed. The authors findings suggest that brachytherapy with or without external beam radiotherapy and/or hormonal treatment has a considerable impact on short-term health-related quality of life but this impact diminishes in the long-term. However, in certain subgroups of patients, brachytherapy has long-term effects on bowel, bladder and sexual function. Clinicians should ensure that patients are aware of these consequences on long-term health-related quality of life.

External beam radiotherapy in prostate cancer patients: short- and long-term health-related quality of life issues

Health-related quality of life is an increasingly important issue in the treatment of prostate cancer. External beam radiotherapy is a frequently-used treatment option which can have short- and long-term side effects influencing the patients' quality of life. In this review the urinary, intestinal and sexual health-related quality of life issues related to treatment with external beam radiotherapy are addressed. Recent research reports allow us to provide an overview on both the short- and long-term of a patient's cancer experience. External beam radiotherapy has different effects on bowel, bladder and sexual function. This review suggests that external beam radiotherapy has a considerable short-term effect on bowel and sexual functioning, and that urinary function is rarely affected. In the long-term there is still a small, but non-negligible, effect on bowel functioning. Sexual function is greatly affected by external beam radiotherapy in the long-term. Recent radiotherapy treatment techniques, such as conformal external beam radiotherapy, tend to give better health-related quality of life outcomes. However, this needs confirmation by more studies in the short- and long-term including health-related quality of life measurements.

Patient-reported outcomes after cytotoxic chemotherapy in metastatic castration-resistant prostate cancer: a systematic review

BACKGROUND

In the clinical setting of metastatic castration-resistant prostate cancer the aim of treatment is palliation. Palliation can refer to symptom management or non-curative treatments. Patient-reported outcome is any outcome based on data provided by patients. The aim of this paper is to perform a systematic review of clinical trials including a patient-reported outcome assessment in patients treated with cytotoxic chemotherapy, and to compare their results by traditional medical and patient-reported outcomes assessment.

METHODS

In November 2009 a literature search for published studies was undertaken. Selected phase-3 studies were primarily evaluated on the quality of patient-reported outcomes reporting and assessment methodology.

FINDINGS

Health-related quality of life assessment was the most common endpoint, pain control the second one. Results of patient-reported and traditional endpoints analysis are resumed, as well as methodology assessment and quality of patient-reported outcomes reporting. Frequently, methodologic limitations affect patient-reported outcomes assessment in clinical trials, either data analysis, particularly not reporting individual scores of health-related quality of life questionnaires, statistical corrections, limited efforts to avoid missing data, or lacking report of duration of palliative response.

CONCLUSIONS

Results of trials can differ if different outcomes, medical or patient-reported, are considered in the analysis. Cytotoxic chemotherapy of metastatic castration-resistant prostate cancer is a challenging issue. A survival benefit is reported only for docetaxel, but this treatment is not always feasible. In all patients, initiation of chemotherapy should be based on patient's preferences within discussion of individual risk and benefit, particularly in patients with extensive asymptomatic and symptomatic metastases.

The Canadian Uro-Oncology Group multicentre phase II study of docetaxel administered every 3 weeks with prednisone in men with metastatic hormone-refractory prostate cancer progressing after mitoxantrone/prednisone

OBJECTIVE

To investigate the use of docetaxel 75 mg/m(2) intravenously every 3 weeks plus prednisone 5 mg orally twice daily in men with metastatic hormone-refractory prostate cancer (HRPC) progressing after first-line mitoxantrone/prednisone (MP), the primary outcome being progression-free survival with prostatic-specific antigen (PSA) and pain response, toxicity and quality of life (QoL) also assessed.

PATIENTS AND METHODS

Thirty patients from four centres were enrolled in the study; all had had previous MP for symptomatic, metastatic HRPC and all had castrate levels of testosterone maintained during therapy.

RESULTS

At enrolment, the median age was 69 years, the mean PSA level was 324 ng/dL, and 86% of patients reported pain. There was a PSA response in 57% of the men and a reduction in pain in >60%; the overall QoL was maintained. There were four cases of febrile neutropenia and two treatment-related deaths. The median progression-free and overall survival were 5 and 15 months, respectively.

CONCLUSION

Docetaxel was associated with high rates of PSA and pain response in this study. Non-haematological toxicity was similar to that during first-line treatment, but rates of febrile neutropenia and toxic death appeared to be slightly higher. In selected patients with progressive metastatic HRPC previously treated with mitoxantrone, docetaxel appears to be a beneficial therapeutic option.

On the Importance of Race, Socioeconomic Status and Comorbidity When Evaluating Quality of Life in Men With Prostate Cancer

PURPOSE

Clear and accurate information about health related quality of life outcomes for men diagnosed with prostate cancer is essential for men and their physicians to make appropriate care decisions. To determine the completeness and quality of available health related quality of life information we performed a review of health related quality of life studies, assessing what information was and was not reported.

MATERIALS AND METHODS

A structured literature search identified 184 relevant health related quality of life studies representing 40,931 subjects.

RESULTS

More than 95% of health related quality of life studies did not provide key information about factors known to influence outcomes. The most common omissions included information about treatments received, followup, socioeconomic status or demographic characteristics. Most data were obtained from well educated, high income socioeconomic groups, who are generally quite healthy. More than 60% of subjects were college graduates, 85% were currently married and 43% were currently employed. While black Americans comprised 15% of men studied in the 80% of studies reporting race, little information is available on Hispanic or Asian men.

CONCLUSIONS

Most of the available prostate cancer health related quality of life literature does not describe or does not account for factors known to influence health outcomes. These omissions limit their interpretability for patients trying to make decisions about treatment. More attention should be given to fully characterizing all dimensions of care that may influence quality of life outcomes and evaluating health related quality of life in Asian and Hispanic populations. Men and physicians should exercise caution when interpreting results that do not fully account for multiple factors that influence health related quality of life.

Quality of life findings from a multicenter, multinational, observational study of patients with metastatic hormone-refractory prostate cancer

BACKGROUND

The assessment of health-related quality of life (HRQL) for patients with hormone-refractory prostate cancer (HRPC) is of paramount importance because new treatments have a modest impact on survival but side effects of treatment and disease symptoms can significantly impact HRQL.

METHODS

This was an observational, non-interventional, multi-center, multi-national cohort study of patients with metastatic HRPC. Health-related quality of life was assessed using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ C30), the Functional Assessment of Cancer Therapy-Prostate (FACT-P) and the EQ-5D index. Mean changes from baseline to month 3, 6, and 9 were computed and tested using paired t-tests.

RESULTS

FACT-P PCS, EQ-5D index and 10 of 14 EORTC domains were statistically significantly lower (P < 0.05) than the baseline scores at the 3, 6 and 9 month visits. The domains that did not reach statistical significance were cognitive functioning, insomnia, diarrhea and financial difficulties.

CONCLUSIONS

These data demonstrate that patients with metastatic HRPC experience rapid, significant deterioration in HRQL, highlighting the need for effective palliative therapy for men with HRPC.

Prostatectomie périnéale

There is a lack of prospective randomised trials comparing the efficacy of the different techniques for treating localised prostate cancer. Consequently, selecting one rather than the other appears very difficult. Even radical prostatectomy is controversial regarding its best approach--perineal, retropubic or laparoscopic. The perineal route was the first to be undertaken, and it was dropped out due to the need of performing obturator lymphadenectomy by a separate approach. Widespread use of prostate-specific antigen as a screening method has enabled to diagnose prostate cancer at its early stages, when the potential for lymphatic dissemination is low, which enables to obviate Lymphadenectomy in most patients. This was a promoting circumstance to use the perineal route in radical prostatectomies. In this article we discuss the perineal radical prostatectomy surgical technique, its indications, and its advantages and disadvantages as compared to other approaches.

Quality of life as a potential predictor for morbidity and mortality in patients with metastatic hormone-refractory prostate cancer

BACKGROUND

The association between HRQL measures with outcomes in patients with metastatic hormone-refractory prostate cancer (HRPC) is unclear.

METHODS

Baseline and 12-week HRQL was collected using the European Organization for Research and Treatment of Cancer (EORTC QLQ-C30) and the Functional Assessment of Cancer Therapy - Prostate (FACT-P). Outcomes included: (1) survival; (2) time to disease progression and (3) time to bone pain. Cox proportional hazards regression models were used. The relative predictive performance of each HRQL instrument and domain was compared.

RESULTS

Baseline HRQL scores and 12-week change scores > the median were significant predictors of all clinical outcomes but varied by domain. For example, the hazard of death for a change in FACT-P Grand Total Score > median was 49% of the hazard for a change < or = the median. Including baseline or 12-week change in HRQL resulted in improvement in prediction performance.

CONCLUSIONS

Patients with better baseline HRQL have better predicted survival, time to disease progression and pain prognosis than those with worse HRQL. In addition, the 12-week change in HRQL appears to improve predictive accuracy for most clinical outcomes. It appears that greater deterioration in HRQL is prognostic for rapid disease progression.

Reclaiming Wellness-Living With Bodily Problems, As Narrated by Men With Advanced Prostate Cancer

Having advanced prostate cancer means living with considerable bodily problems, a living we know little about. Thus, the aim of this study was to illuminate meanings of living with bodily problems, as narrated by men with advanced metastasized hormone refractory prostate cancer. Eighteen participants were interviewed, and the text was analyzed using a phenomenological-hermeneutic approach. Findings show that meanings of living with bodily problems are to live in cyclical movements between experiencing wellness and experiencing illness. New, or changed, bodily problems mean losing wellness and experiences of being ill. Understanding and, to some extent, being in control of bodily problems, make it possible to reclaim wellness and to experience oneself as being well. Findings also show that pain and fatigue are the most prominent problems and that they have different meanings. Pain being a threat of dying in agony, whereas fatigue is more of an emissary of death. Reclaiming wellness versus adaptation and enduring versus suffering deriving from 2 different perspectives, the inside or life world perspective and the outside or professional perspective, are questions discussed in the article. One clinical implication for nursing is the risk of obstructing the patients' possibility of reclaiming wellness by focusing on symptoms and disease.

Liminality as biographical disruption: unclassifiability following hormonal therapy for advanced prostate cancer

The hormonal treatment of advanced prostate cancer involves life disruptive side-effects, such as impotence, libido loss and bodily feminisation. Conflicting views on the weight of the disruption they cause as against the therapy's survival benefits currently underlie debates over its appropriate mode of administration and its optimal timing in cases that do not necessitate immediate intervention. On the basis of a study of the disruptions caused to various life domains of 15 Israeli patients receiving such treatment, the present paper illustrates an integrated approach to their analysis that sheds new light on their intensity. The study was conducted by means of in-depth interviews and its data were processed according to the constant comparative analysis method. Its findings indicate that the therapy allowed the patients to regain their strength, to retain their need of love, basic masculine self-identification and spousal ties, and to renew their past social contacts. On the other hand they could no longer define themselves as healthy, sexually competent and 'male' in all respects, and their pre-treatment relationships with partners and friends lost the sense of closeness. Further psychosocial costs that were detected include patients' deprivation of their sense of continuity, excitements, hopes and coping capabilities. An integrated analysis of the concurrent normalisation and deviantisation processes undergone by them yielded the conclusion that the therapy subjects them to a liminal state, that is, the inability to classify themselves into culturally available categories. The difficulties entailed in this state highlight the need to take them into consideration when patients' condition allows a choice between alternative forms of hormonal therapy and between its early or deferred commencement. The interpretation of the disruption to their lives in terms of liminality also clarifies former studies' confusing reference to this subject and points to issues that still await investigation.

Advanced prostate cancer patients' ways of coping with the hormonal therapy's effect on body, sexuality, and spousal ties

The authors examine the coping strategies employed by advanced prostate cancer patients receiving hormonal therapy to learn from their experience about potential solutions to their nonmedical needs. The study was based on in-depth interviews with 15 such patients and data analysis by the constant comparative method. The main psychosocial difficulties detected were patients' bodily feminization, sexual dysfunction, and disruption of spousal intimacy. Participants contended with these difficulties through disguise, diversion, and avoidance strategies applied in social interactions, and through self-redefining, self-distancing, and self-solacing cognitive tactics. The analysis of these coping techniques clarifies the motives behind their adoption by the participants, their changing patterns over time, their advantages and disadvantages, and the potential that understanding these issues possesses for improving interventions aimed at alleviating patients' difficulties.

Beyond the development of health-related quality-of-life (HRQOL) measures: a checklist for evaluating HRQOL outcomes in cancer clinical trials--does HRQOL evaluation in prostate cancer research inform clinical decision making?

PURPOSE

The aim of this study was to evaluate whether the inclusion of health-related quality of life (HRQOL), as a part of the trial design in a randomized controlled trial (RCT) setting, has supported clinical decision making for the planning of future medical treatments in prostate cancer.

MATERIALS AND METHODS

A minimum standard checklist for evaluating HRQOL outcomes in cancer clinical trials was devised to assess the quality of the HRQOL reporting and to classify the studies on the grounds of their robustness. It comprises 11 key HRQOL issues grouped into four broader sections: conceptual, measurement, methodology, and interpretation. Relevant studies were identified in a number of databases, including MEDLINE and the Cochrane Controlled Trials Register. Both their HRQOL and traditional clinical reported outcomes were systematically analyzed to evaluate their consistency and their relevance for supporting clinical decision making.

RESULTS

Although 54% of the identified studies did not show any differences in traditional clinical end points between treatment arms and 17% showed a difference in overall survival, 74% of the studies showed some difference in terms of HRQOL outcomes. One third of the RCTs provided a comprehensive picture of the whole treatment including HRQOL outcomes to support their conclusions.

CONCLUSION

A minimum set of criteria for assessing the reported outcomes in cancer clinical trials is necessary to make informed decisions in clinical practice. Using a checklist developed for this study, it was found that HRQOL is a valuable source of information in RCTs of treatment in metastatic prostate cancer.

Costs of prostate cancer, metastatic to the bone, in the Netherlands

OBJECTIVE

To quantify medical costs associated with bone metastases in patients with prostate cancer. Bone metastases in patients with prostate cancer are associated with considerable morbidity, negatively impact quality of life, and can add substantially to medical costs, given a median survival of 30-35 months from diagnosis of bone metastases.

METHODS

A retrospective cost analysis from both a community and university hospital in The Netherlands was conducted. Twenty-eight patient records (14 from each hospital) were investigated to assess the impact of skeletal-related events (SREs), including fractures, spinal cord compression, and radiotherapy, on total direct medical costs and cost of hospitalization. Costs are given in EUROS (Euros).

RESULTS

The average total cost of treatment was Euros 13,051 per patient over the 24-month follow-up period, which includes an average cost of Euros 6973 per patient to treat SREs. Treatment of SREs more than doubled total treatment costs. Patients in this analysis experienced, on average, one SRE per year, and the cost of SREs varied from Euros 1187 to Euros 40,948.

CONCLUSIONS

Occurrence of SREs contributes significantly to the cost of care for patients with advanced prostate cancer. These data suggest that bisphosphonates, which can reduce pain and SREs, may reduce healthcare costs.

Health related quality of life in prostate carcinoma patients: a systematic review of randomized controlled trials

BACKGROUND

Health related quality of life (HRQOL) is increasingly reported as an important endpoint in cancer clinical trials. However, evidence suggests that HRQOL reporting is often inadequate. Given this, the authors undertook a systematic review to evaluate HRQOL assessment methodology and reported outcomes of randomized controlled clinical trials (RCTs) with prostate carcinoma patients.

METHODS

A comprehensive search of the literature from 1980 to 2001, mainly on the following databases, was undertaken: MedLine, Cancerlit, and the Cochrane Controlled Trials Register. Studies were identified according to a predefined coding scheme, including HRQOL measure, cultural validity, compliance data reported and the clinical significance of the results.

RESULTS

Twenty-five RCTs were identified, involving 8015 patients primarily with metastatic cancer. Bicalutamide was the medical treatment against which most treatment comparisons were made. Limitations identified included the fact that only 44% of the studies gave a rationale for selecting a specific HRQOL measure, 64% of the studies failed to report information about the administration of the HRQOL measure, and 56% failed to report compliance at baseline. The measure most often used was the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-Care 30 (EORTC QLQ-C30), although some studies used non-validated HRQOL tools.

CONCLUSIONS

The current study revealed a lack of a uniform approach to HRQOL assessment and several methodologic limitations. It is possible that such methodologic limitations have influenced trial findings for HRQOL outcomes.

Helping patients with localized prostate carcinoma manage uncertainty and treatment side effects: nurse-delivered psychoeducational intervention over the telephone

BACKGROUND

The objective of this study was to test the efficacy of an individualized uncertainty management intervention delivered by telephone to Caucasian and African-American men with localized prostate carcinoma and directed at managing the uncertainties of their disease and treatment.

METHODS

The authors delivered a psychoeducational intervention by phone to men with prostate carcinoma, with or without supplemented delivery to a close family member, that was directed at managing uncertainty and improving symptom control. One hundred thirty-four Caucasian men and 105 African-American men were assigned randomly to one of two approaches to delivering the intervention or to the control condition. Men entered the study immediately after surgical treatment or in the first 3 weeks of radiation therapy. Trained nurses delivered the intervention through weekly phone calls for 8 weeks.

RESULTS

The authors found that the majority of intervention effects were from baseline to 4 months postbaseline, when treatment side effects are most intense. Both Caucasian men and African-American men who received either one of the two approaches for delivering the intervention improved in the two uncertainty management methods of cognitive reframing and problem solving. Similarly, when the intervention groups were combined, men who received the intervention also improved significantly in control of incontinence by 4 months postbaseline. Decreases in the number of treatment side effects differed by time and treatment/ ethnic group interactions as did satisfaction with sexual functioning.

CONCLUSIONS

This is one of the first tests of a psychoeducational intervention among men with prostate carcinoma and was the first test that included a sufficient number of African-American men to test by ethnic group. Therefore, replication of these findings is advised.

Efficacy of epoetin beta on hemoglobin, quality of life, and transfusion needs in patients with anemia due to hormone-refractory prostate cancer--a randomized study

OBJECTIVE

Erythropoietin is shown to be an effective treatment for anemia in various types of cancers, however only limited studies have evaluated its benefits in advanced hormone-refractory prostate cancer (HRPC). This multi-center study investigated the influence of 2 different doses of epoetin beta on quality of life, hemoglobin level, need for blood transfusion, and safety, in the treatment of anemia in patients with metastatic HRPC.

MATERIALS AND METHODS

This study randomized 180 patients to receive either epoetin beta 1000 IU or 5000 IU subcutaneously 3 times per week for 12 weeks. Hemoglobin was evaluated at study start and 6 time-points during the study. Quality of life (QoL) was assessed by the European Organization for Research and Treatment of Cancer questionnaire, QLC-C30, before treatment start and after 6 and 12 weeks of treatment. Best supportive care and blood transfusions were given, if clinically indicated. Additional laboratory values and adverse events were followed for safety.

RESULTS

Hemoglobin increased significantly (>20 g/l) in 43% in the high dose (HD) group and 25% in the low dose (LD) group in response to treatment. Levels were significantly higher in the HD group than the LD group (p < 0.001) after 8 and 12 weeks. QoL improved significantly if the increase in hemoglobin was >20 g/l. Significantly more patients in the LD group received blood transfusions than the HD group (p < 0.005). There were no differences between the groups regarding overall quality of life and fatigue. The treatment was well tolerated in both groups.

CONCLUSIONS

Epoetin beta is shown to be safe and effective for the treatment of anemia in many patients with HRPC. It is found to improve QoL and physical functioning, and relieve fatigue symptoms, in many of these critically ill patients.