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Duchesne GM, Williams SG, Das R, Tai KH. Patterns of toxicity following high-dose-rate brachytherapy boost for prostate cancer: mature prospective phase I/II study results. Radiother Oncol 2007; 84:128-34. [PMID: 17561293 DOI: 10.1016/j.radonc.2007.05.019] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2006] [Revised: 05/01/2007] [Accepted: 05/21/2007] [Indexed: 11/29/2022]
Abstract
BACKGROUND To examine the long-term morbidity of high dose rate brachytherapy boost (HDRBB) in prostate cancer. PATIENTS AND METHODS A phase I/II HDRBB dose escalation protocol recruited 108 men up to November 1999. Treatment combined 46 Gy external beam radiation to the prostate with four fractions of HDR totalling 16 or 20 Gy. Morbidity data were collected prospectively regarding urological, bowel and erectile dysfunction (ED) symptoms using a validated clinician completed instrument. Actuarial incidence and prevalence of symptoms were estimated; the latter to account for potential recovery. RESULTS The median follow-up was 78 months, with 880 questionnaires completed. The respective actuarial cumulative incidence and point prevalence rates of any grade 2 or higher symptom score at 5 years were 24.9% (95% confidence intervals [CI] 16.8-33.5%) and 7.7% (95% CI 1.8-14.5%) for urinary toxicity; and 11.3% (95% CI 5.6-17.1%) and 3.0% (0-7.6%) for rectal toxicity, meaning that most symptom sub-domains showed substantial recovery with time. Corresponding erectile function toxicity figures for the subgroup of men (n=53) with normal erectile function prior to treatment and no androgen deprivation therapy were 77.0% (95% CI 64.9-88.1%) and 45.3% (95% CI 27.2-64.6%). Some late toxicity profiles developed after twelve months, typically with low grade bowel and urinary urgency. These peaked at 12-24 months and stayed relatively stable subsequently. Paradoxically, grade 1 or more nocturia symptoms settle with time, despite the accumulation of grade 2 or more toxicity beyond 24 months. CONCLUSIONS HDRBB as a means of dose escalation in prostate cancer is associated with low and relatively stable rates of long-term bowel and urinary morbidity, and compares favourably with external beam results. Actuarial incidence methods overstate the burden of toxicity with substantial recovery noted in most domains.
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Affiliation(s)
- Gillian Mary Duchesne
- Division of Radiation Oncology, Peter MacCallum Cancer Centre and University of Melbourne, Melbourne, Victoria, Australia.
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Incrocci L. Sexual function after external-beam radiotherapy for prostate cancer: What do we know? Crit Rev Oncol Hematol 2006; 57:165-73. [PMID: 16325413 DOI: 10.1016/j.critrevonc.2005.06.006] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2005] [Revised: 06/29/2005] [Accepted: 06/29/2005] [Indexed: 10/25/2022] Open
Abstract
Quality of life in general and sexual functioning in particular have become very important in cancer patients. Due to modern surgical techniques, improved quality of drugs for chemotherapy and very modern radiation techniques, more patients can be successfully treated without largely compromising sexual functioning. One can assume that because of the life-threatening nature of cancer, sexual activity is not important to patients and their partners, but this is not true. Prostate cancer has become the most common non-skin malignant neoplasm in older men in Western countries. In this paper, we discuss the various methods used to evaluate erectile and sexual dysfunction and the definition of potency. Data on the etiology of erectile dysfunction after external-beam radiotherapy for prostate cancer is reviewed, and the literature is been summarized. Patients should be offered sexual counseling and informed about the availability of effective treatments for erectile dysfunction, such as sildenafil, intracavernosal injection, and vacuum devices. Cancer affects quality of life and sexual function. The challenge for oncologists is to address this with compassion.
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Affiliation(s)
- Luca Incrocci
- Department of Radiation Oncology, Erasmus MC-Daniel den Hoed Cancer, P.O. Box 5201, 3008 AE Rotterdam, The Netherlands.
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Alibhai SMH, Naglie G, Nam R, Trachtenberg J, Krahn MD. Do older men benefit from curative therapy of localized prostate cancer? J Clin Oncol 2003; 21:3318-27. [PMID: 12947068 DOI: 10.1200/jco.2003.09.034] [Citation(s) in RCA: 139] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Prior decision-analytic models are based on outdated or suboptimal efficacy, patient preference, and comorbidity data. We estimated life expectancy (LE) and quality-adjusted life expectancy (QALE) associated with available treatments for localized prostate cancer in men aged >/= 65 years, adjusting for Gleason score, patient preferences, and comorbidity. METHODS We evaluated three treatments, using a decision-analytic Markov model: radical prostatectomy (RP), external beam radiotherapy (EBRT), and watchful waiting (WW). Rates of treatment complications and pretreatment incontinence and impotence were derived from published studies. We estimated treatment efficacy using three data sources: cancer registry cohort data, pooled case series, and modern radiotherapy studies. Utilities were obtained from 141 prostate cancer patients and from published studies. RESULTS For men with well-differentiated tumors and few comorbidities, potentially curative therapy (RP or EBRT) prolonged LE up to age 75 years but did not improve QALE at any age. For moderately differentiated cancers, potentially curative therapy resulted in LE and QALE gains up to age 75 years. For poorly differentiated disease, potentially curative therapy resulted in LE and QALE gains up to age 80 years. Benefits of potentially curative therapy were restricted to men with no worse than mild comorbidity. When cohort and pooled case series data were used, RP was preferred over EBRT in all groups but was comparable to modern radiotherapy. CONCLUSION Potentially curative therapy results in significantly improved LE and QALE for older men with few comorbidities and moderately or poorly differentiated localized prostate cancer. Age should not be a barrier to treatment in this group.
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Affiliation(s)
- Shabbir M H Alibhai
- University Health Network, Room ENG-233, 200 Elizabeth St, Toronto, Ontario, Canada M5G 2C4.
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Duchesne GM, Das R, Toye W, See A. Dose distribution and morbidity after high dose rate brachytherapy for prostate cancer: influence of V150 and V200 parameters. AUSTRALASIAN RADIOLOGY 2002; 46:384-9. [PMID: 12452909 DOI: 10.1046/j.1440-1673.2002.01091.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The purpose of this study is to identify factors predicting morbidity in patients undergoing high dose rate (HDR) brachytherapy boost with external beam irradiation for prostate cancer. Acute and late morbidity data were collected for 104 prostate cancer patients treated with an HDR boost together with external beam radiotherapy. Significant urinary and rectal morbidity were correlated with urethral and rectal point doses, and the proportions of the target volume receiving 100%, 150% and 200% (V200) or more of the prescribed dose. Rectal or urethral point doses did not predict morbidity. By contrast, the V200 was significantly higher for patients experiencing either acute or late urinary morbidity. The cut-off V200 was 15% of the target volume. Although theoretically beneficial for tumour cell kill, the treatment of significant proportions of the prostate to high dose might be associated with increased morbidity, and should preferably be avoided.
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Affiliation(s)
- Gillian M Duchesne
- Division of Radiation Oncology, Peter MacCallum Cancer Institute, Melbourne, Australia.
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Incrocci L, Slob AK. Incidence, etiology, and therapy for erectile dysfunction after external beam radiotherapy for prostate cancer. Urology 2002; 60:1-7. [PMID: 12100912 DOI: 10.1016/s0090-4295(02)01659-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Affiliation(s)
- Luca Incrocci
- Department of Radiation Oncology, Erasmus Medical Center, Daniel den Hoed Cancer Center, Rotterdam, The Netherlands
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Incrocci L, Slob AK, Levendag PC. Sexual (dys)function after radiotherapy for prostate cancer: a review. Int J Radiat Oncol Biol Phys 2002; 52:681-93. [PMID: 11849790 DOI: 10.1016/s0360-3016(01)02727-4] [Citation(s) in RCA: 114] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
PURPOSE Prostate cancer has become the most common nonskin malignant neoplasm in older men in Western countries. As treatment efficacy has improved, issues related to posttherapy quality of life and sexual functioning have become more important. METHODS AND MATERIALS We discuss the various methods used to evaluate erectile and sexual dysfunction and the definition of potency. The etiologies of erectile dysfunction after external beam radiotherapy and brachytherapy for prostate cancer are also reviewed. The literature is summarized, and comparative studies of radiation and surgery are surveyed briefly. RESULTS Rates of erectile dysfunction vary from 6 to 84% after external beam radiotherapy and from 0 to 51% after brachytherapy. In most of the studies, the analysis is retrospective, the definition of erectile dysfunction is not clear, only one question about sexual functioning is asked, and nonvalidated instruments are used. The etiology of erectile dysfunction after radiation for prostate cancer is not completely understood. CONCLUSIONS Because erectile function is only one component of sexual function, it is necessary to assess sexual desire, satisfaction, frequency of intercourse, and other such factors when evaluating the effects of therapy. Patients should be offered sexual counseling and informed about the availability of effective treatments for erectile dysfunction, such as sildenafil, intracavernosal injection, and vacuum devices.
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Affiliation(s)
- Luca Incrocci
- Department of Radiation Oncology, Erasmus University Medical Center Rotterdam (EMCR), The, Rotterdam, Netherlands.
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Helgason AR, Arver S, Adolfsson J, Dickman P, Granath F, Steineck G. 'Potency': the validation of information from a self-administered questionnaire using objective measurements of night-time erections and test-retest reliability. BRITISH JOURNAL OF UROLOGY 1998; 81:135-41. [PMID: 9467490 DOI: 10.1046/j.1464-410x.1998.00512.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To assess the validity and reliability of a questionnaire assessing 'physiological potency'. PATIENTS AND METHODS The study comprised 89 patients with prostate cancer and 43 men without; the latter were attending a consultation clinic because of problems with erection. All men answered three questions assessing erectile rigidity during sexual activity, morning and spontaneous erections. In the questionnaire, 'potency' was defined as erectile rigidity 'sufficient for intercourse most of the time' or better. 'Potency' in one or more of the three aspects of erection was defined as 'physiological potency'. The patients with prostate cancer answered the questionnaire twice with a 3-week interval. The men attending the consultation clinic underwent two nights of erectile monitoring (using the RigiScan device) and the minimum criterion for RigiScan potency was defined as 55% rigidity at both tip and base. RESULTS The test-retest assessment showed 93% conformity in the questionnaire diagnosis of 'physiological potency/impotence' between the tests. The sensitivity and specificity of the questionnaire assessment compared with the RigiScan method were 40% and 100%, respectively, when the question assessing sexually stimulated erectile rigidity was used alone. Using 'physiological potency', the sensitivity increased to about 60% without jeopardizing the specificity, and when men reporting depression were excluded from the analysis, the sensitivity increased to about 80%. CONCLUSIONS The test-retest reliability of the questionnaire was satisfactory. Using questions in a self-administered questionnaire, 'physiological impotence' can be diagnosed with complete and 'physiological potency' with 60-80% sensitivity. The sensitivity of the self-assessment for 'potency' depended on the number of questions asked and the proportion of men reporting depression.
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Affiliation(s)
- A R Helgason
- Southern Division of Community Medicine, Tobacco Prevention Center, Novum, Huddinge, Sweden
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Borghede G, Hedelin H. Radiotherapy of localised prostate cancer. Analysis of late treatment complications. A prospective study. Radiother Oncol 1997; 43:139-46. [PMID: 9192958 DOI: 10.1016/s0167-8140(96)01871-3] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE To describe the late side-effects of radical radiotherapy of prostatic carcinoma and to analyse how pretreatment and treatment-related factors contribute to the toxicity. MATERIALS AND METHODS 184 patients have regularly been followed after terminated radical external beam radiotherapy treatment (70 Gy) for a mean of 46 (range 24-96) months. For registration of toxicity a modified RTOG scale was used. The Cox regression model was used for multivariate analysis. RESULTS 37% of the patients had no late side-effects at all. Mild complications were reported by 53%, mainly gastrointestinal (42%) and urogenital (23%). A persistent improvement of the mild toxicity was seen in nearly half of the patients with gastrointestinal or nocturnal frequency side-effects. Only 16 (9%) patients had moderate or severe complications. The multivariate analysis revealed that the risk of posttreatment complications was strongly correlated to pretreatment presence of symptoms from the organs at risk. Posttreatment complications presenting first 3 years after irradiation were rare. CONCLUSIONS Radical external beam radiotherapy (70 Gy) can be given with a low risk of severe complications. It appears reasonable to assume that the risk can be further reduced by excluding patients with gastrointestinal and urinary tract disease or symptoms.
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Affiliation(s)
- G Borghede
- Department of Oncology, Sahlgrenska Hospital, Göteborg University, Sweden
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Fransson P, Widmark A. Self-assessed sexual function after pelvic irradiation for prostate carcinoma. Comparison with an age-matched control group. Cancer 1996; 78:1066-78. [PMID: 8780545 DOI: 10.1002/(sici)1097-0142(19960901)78:5<1066::aid-cncr17>3.0.co;2-0] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Treatment of localized prostate carcinoma is often accompanied by disturbances in sexual function. The patient's own opinion and experience with these problems can be of great importance for his quality of life. In men older than 50 years, disturbances in sexual function are common. Treatment such as radiotherapy (RT), which can induce sexual dysfunction, should be evaluated in relation to the problems in an age-matched population without prostate carcinoma. METHODS Sexual function was evaluated with a self-assessment questionnaire using linear-analogue scales. The questionnaire was sent to 199 patients with prostate carcinoma, median age 71 years (range, 51-86 years), who had received pelvic RT with curative intent and to 200 age-matched men in northern Sweden. Mean follow-up time after RT was 48 months (range, 24-56 months). RESULTS The response rate was high: 141 (71%) and 181 (91%) in the control and patient groups, respectively. Field reduction and treatment pause during RT was not associated with decreased problems in the patient groups. A failure to achieve erection was indicated in 12% of the control subjects, 56% of the patients who had received (RT only) and 87% of the RT + castration (RT + A) patients. In general, patients < 70 years treated with RT+A indicated more sexual problems than the RT only patients < 70 years. There was a strong negative correlation between age and sexual problems in the RT + A < 70 years group. However, in patients < 70 years, sexual activity after RT only, was not significantly different from the age-matched control population. CONCLUSIONS Patients with prostate carcinoma treated with RT only indicated higher levels of sexual dysfunction than age-matched controls. This was most obvious in patients younger than 70 years, although their sexual activity was comparable to age-matched controls. The addition of castration to RT tended to increase sexual problems, especially in patients < 70 years. In men between 70 and 74 years, the maintenance of sexual function seems to be very susceptible to disturbances. For patients older than 74 years, decreased sexual function was not perceived as such a significant problem, despite abolished desire and erection.
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Affiliation(s)
- P Fransson
- Department of Oncology, Umeå University, Sweden
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Abstract
The diagnosis of early-stage prostate cancer poses difficult management questions. Some clinicians recommend aggressive treatment strategies, whereas others suggest a more conservative approach. The controversy stems in part from the absence of randomized clinical trials that clearly document a net benefit of one treatment modality over another. From a clinician's perspective, the safest approach is to recommend an aggressive treatment such as surgery or radiation therapy. If it succeeds, the clinician claims a cure; if it fails, he has done everything possible. For patients, however, the choice of therapy should depend upon their assessment of the risks of disease progression versus the potential efficacy and risks associated with aggressive treatment options. Observation management appears to be most appropriate for older men who face minimal risk of disease progression. Men over age 65 with low-grade disease and/or minimal tumor volume, and men in their mid-seventies with low- to moderate-grade disease confined to the prostate, may decide that conservative management offers a low probability of prostate cancer-associated death without the potential for treatment-associated morbidity. Men who are at highest risk of disease progression may also wish to consider conservative management, because unfortunately neither radical surgery nor radiation therapy have been shown to be effective in controlling poorly differentiated disease. In these cases, some patients might feel that the morbidity associated with treatment is greater than the potential gain in longevity. Conservative management of younger patients with minimal comorbidities and relatively modest tumor volumes should be considered very cautiously. These patients are at significant risk of developing symptomatic disease and dying from prostate cancer, and they usually have the most to gain from either radical prostatectomy or radiation therapy.
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Affiliation(s)
- P C Albertsen
- Division of Urology, University of Connecticut Health Center, Farmington, USA
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Helgason AR, Fredrikson M, Adolfsson J, Steineck G. Decreased sexual capacity after external radiation therapy for prostate cancer impairs quality of life. Int J Radiat Oncol Biol Phys 1995; 32:33-9. [PMID: 7721637 DOI: 10.1016/0360-3016(95)00542-7] [Citation(s) in RCA: 102] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
PURPOSE The aim of this study was to assess to what extent patients treated with radiation therapy for prostate cancer experience change in sexual functioning and to what extent this effects quality of life. METHODS AND MATERIALS Information was provided by 53 men treated with radiation therapy for localized prostate cancer. Assessment was made with the "Radiumhemmets Scale of Sexual Functioning," which measures sexual desire, erectile capacity, orgasm, and to what extent a decrease in any of these aspects of sexual functioning affects quality of life. Function before treatment was assessed retrospectively. RESULTS Sexual desire diminished among 77% after treatment. The erection stiffness decreased in 77%. Before external radiation therapy, 66% had an erection usually sufficient for intercourse. Half of the men lost this ability after treatment. Of those retaining orgasm after treatment, 47% reported a decreased orgasmic pleasure and 91% a reduced ejaculation volume. Of all men, 50% reported that quality of life had decreased much or very much due to a decline in the erectile capacity following external radiation therapy. CONCLUSION The results of the present study indicate that external radiation therapy for prostate cancer is associated with a reduction in sexual desire, erectile capacity, and organism functions. In a majority of patients this reduces quality of life. Previously, we may have underestimated the importance an intact sexual function has for the quality of life in this patient category of elderly men.
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Affiliation(s)
- A R Helgason
- Department of Cancer Epidemiology, Karolinska Institutet, Stockholm, Sweden
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Mameghan H, Fisher R, Mameghan J, Brook S. Results of external beam radiotherapy in 448 patients with clinically localized adenocarcinoma of the prostate. THE AUSTRALIAN AND NEW ZEALAND JOURNAL OF SURGERY 1994; 64:389-94. [PMID: 8010899 DOI: 10.1111/j.1445-2197.1994.tb02236.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
The results of external beam radiotherapy for clinically localized adenocarcinoma of the prostate in 448 patients treated in the period 1980-90 were reviewed. The average follow up was 4.9 years. The patients were aged 44-87 years (median 69 years) and all had histopathological evidence of adenocarcinoma by needle biopsy or transurethral resection of prostate. The histopathological grading was: 127 G1; 154 G2; 127 G4; 28 Gx. Clinical staging according to TNM (American Urological Association) was: 29 T0 (A2); 4 T1 (B1); 173 T2 (B2); 176 T3 (C1); 63 T4 (C2); 3 Tx. Routine surgical pelvic lymph node staging was not performed but patients had radiological (computerized tomography scan or lymphogram) nodal staging: 350 N0; 22 N1; 12 N2; 64 Nx. High energy linear accelerator external beam radiotherapy was given by multiple fields to total doses of 50-70 Gy (median 60 Gy). The majority of patients (307, 69%) was treated by a uniform policy under the care of one radiation oncologist (HM). The rates of local and distant failure at 5 years were 10% (s.e. = 2%) and 42% (s.e. = 3%), respectively. The late complication rate at 5 years was 25% (s.e. = 2%), comprising mild 16%, moderate 7% and severe 1.3%. The 5 year overall survival rate was 64% (s.e. = 2%) and the cancer-specific survival rate was 74% (s.e. = 3%). Both histological grade and clinical stage were strongly predictive of overall survival and distant failure. Only histological grade was predictive of local failure.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- H Mameghan
- Department of Radiation Oncology, Prince of Wales Hospital, Randwick, New South Wales, Australia
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Abstract
Although there is little evidence that sexual behavior causes prostate cancer, men with prostate cancer often have sexual dysfunction before the cancer diagnosis is made. Each treatment for prostate cancer increases the prevalence of sexual problems. After nerve-sparing radical prostatectomy, the chance of recovering erections is better for men who are younger and in whom both neurovascular bundles can be spared. Definitions of "potency" after nerve-sparing surgery have not specified the rigidity of the erections achieved. Thus, some men classified as "potent" may wish additional sexual rehabilitation. The chance that definitive radiation therapy will cause erectile dysfunction probably has been overestimated. The prevalence rate may be closer to 25% of men with new problems compared with the 50% often cited in the literature. Men are more at risk to have erection problems after radiation therapy if the quality of erections before treatment was borderline. Hormonal therapy has an impact on the central mechanisms mediating sexual desire and arousability. Therefore, with most treatment methods, only approximately 20% of men remain sexually functional. Newer antiandrogenic drugs interfere less with sexual function, but their long-term ability to control prostate cancer is still under investigation. Sexual rehabilitation should be addressed by the primary care team. Sexual partners should be included in brief sexual counseling, even when a mechanical treatment for erectile dysfunction is prescribed.
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Affiliation(s)
- L R Schover
- Department of Urology, Cleveland Clinic Foundation, OH 44195-5041
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