contQOL

"Focused on the Prostate since 1996"

QOL Abstracts

Patient-Reported Symptoms After Primary Therapy for Early Prostate
Cancer: Results of a Prospective Cohort Study (Talcott)

Results of hospital cancer registry surveys by the American College of
Surgeons: outcomes of prostate cancer treatment by radical prostatectomy.(Mettlin)

Follow-up Prostate Cancer Treatments After Radical Prostatectomy: a Population-Based Study (Lu-Yao)

Prostate Carcinoma Patients' Perspectives after Prostatectomy or
Radiation Therapy (Shrader-Bogen)

Patient-reported impotence and incontinence after nerve-sparing radical prostatectomy (Talcott)

Erectile Functioning of Men Treated for Prostate Carcinoma (Robinson)

Patient-Reported Symptoms After Primary Therapy for Early Prostate
Cancer: Results of a Prospective Cohort Study

By James A. Talcott, Patricia Rieker, Jack A. Clark, Kathleen J. Propert, Jane C. Weeks, Clair J. Beard, Kenneth I.
Wishnow, Irving Kaplan, Kevin R. Loughlin, Jerome P. Richie, and Philip W. Kantoff

Purpose: To assess complications of therapy for early (nonmetastatic) prostate cancer.

Patients and Methods: A prospective study of a cohort of 279 men who sought treatment advice and completed required
pretreatment forms. The measures were self-reported patient symptoms and other measures of quality of life before therapy
and at 3 and 12 months afterward.

Results: Bowel and bladder symptoms were uncommon pretreatment. Patients frequently reported irritative bowel and
bladder symptoms at 3 months after radiotherapy, although these subsided somewhat at 12 months. Substantial ("a lot")
urinary incontinence and wearing of absorptive pads were reported by 11% and 35% at 12 months after surgery and varied
little by age. Incontinence occurred after radiotherapy infrequently, and only in men more than 65 years old. Inadequate
erections, present in one third of men pretreatment, were nearly universal at 3 months after surgery, although some
improvement, primarily in men under 65 years of age, was evident at 12 months. Sexual dysfunction after radiotherapy
increased less but continually through 12 months, suggesting that observed treatment-related differences would decline with
further follow-up.

Conclusion: External-beam radiotherapy of early prostate cancer is followed by bowel and bladder irritability, by increasingly
severe sexual dysfunction and, in men aged more than 65 years, occasional urinary incontinence. Greater sexual dysfunction
and urinary incontinence occur in the year following radical prostatectomy. These postsurgical complication rates from patient
questionnaires are greater than have been reported in other treatment series and confirm the results of two retrospective studies
of patient-reported complications.

J Clin Oncol 16:275-283.

Address reprint requests to James A. Talcott, MD, SM, Center for Outcomes Research, Massachusetts General Hospital,
B75 230, Boston, MA 02114; Email james_talcott@dfci.harvard.edu.

© 1998 by American Society of Clinical Oncology.

Results of hospital cancer registry surveys by the American College of
Surgeons: outcomes of prostate cancer treatment by radical prostatectomy.
Mettlin CJ; Murphy GP; Sylvester J; McKee RF; Morrow M; Winchester DP
Cancer Control and Epidemiology, Roswell Park Cancer Institute, Buffalo,
New York, USA.
AB - BACKGROUND: The number of prostate cancer patients treated by radical
prostatectomy has increased. Different data sources have yielded
various estimates of the outcomes of this treatment and the need for
additional therapy. To provide additional perspective on these
issues, the American College of Surgeons conducted surveys of cancer
registries and reviewed related data. METHODS: In 1993, in the first
phase of the study, hospital cancer registries and programs were sent
survey forms and instructions requesting data on up to 5 patients
treated by radical prostatectomy at their institutions in 1990. In
1996, in the second phase of the study, additional data were
requested on treatment administered to the 1990 patients up to 5
years after surgery, and hospitals were also invited to submit new
data on patients diagnosed in 1993. Responses were received from 482
hospitals concerning 2122 patients for 1990, and 265 hospitals
provided data on 1304 patients diagnosed in 1993. Follow-up data on
1076 of the 1990 patients were provided by 258 hospitals. Kaplan-
Meier survival curves were calculated to determine the probability of
additional treatment after radical prostatectomy. RESULTS: Similar
surgical pathology outcomes were reported for the 1990 and 1993
patients. For 1990 and 1993, respectively, it was reported that 27.5%
and 29.7% of patients maintained erectile function adequate for
intercourse after surgery. For 1990 and 1993, respectively, complete
control or only occasional urinary incontinence requiring no pads was
reported for 81.3% and 79.8% of patients. The surgical mortality
rates were less than 1% for both the 1990 and the 1993 patients. The
5-year cumulative probability of any additional treatment after
radical prostatectomy was 10.5%. Seminal vesicle involvement,
positive surgical margins, lymph node involvement, capsular
penetration, high Gleason score, and high prostate specific antigen
were significantly associated with greater probability of additional
treatment. CONCLUSIONS: Hospital cancer registries are valuable
sources of data on patterns of care and outcome for prostate cancer
patients. Continuing evaluation of the outcomes of prostate cancer
treatments is needed to reconcile the differences in outcomes
reported from different data sources.

Follow-up Prostate Cancer Treatments After Radical Prostatectomy: a Population-Based Study

Grace L. Lu-Yao, Arnold L. Potosky, Peter C. Albertsen, John H. Wasson, Michael J. Barry, John E. Wennberg

J Natl Cancer Inst 1996;88:166-73

Background: Radical prostatectomy is one of the most commonly used curative procedures for the treatment of localized prostate cancer. The probability that a patient will undergo additional cancer therapy after this procedure is largely unknown.

Purpose: The objective was to determine the likelihood of additional cancer therapy after radical prostatectomy.

Methods: Data for this study were derived from a linked dataset that combined information from the Surveillance, Epidemiology, and End Results Program and Medicare hospital and physician claims. Records were included in this study if patient histories met the following criteria: (a) residing in Connecticut, Washington (Seattle- Puget Sound), or Georgia (Metropolitan Atlanta); (b) having been diagnosed with prostate cancer during the period from January 1, 1985, through December 31, 1991; (c) undergoing radical prostatectomy by December 31, 1992; and (d) having no evidence of other types of cancer. Patients were considered to have had additional cancer therapy if they had had radiation therapy, orchiectomy, and/or androgen-deprivation therapy by injection after radical prostatectomy. The interval between the initial treatment and any follow-up treatment was calculated from the date of radical prostatectomy to the 1st day of the follow-up cancer therapy. All presented probabilities are based on Kaplan-Meier estimates. Results: The study population consisted of 3494 Medicare patients, 3173 of whom underwent radical prostatectomy within 3 months of prostate cancer diagnosis. Although radical prostatectomy is often reserved for localized cancer, less than 60% (1934) of patients whose records were included in this study had organ-confined disease, according to final surgical pathology. Overall, the 5-year cumulative incidence of having any additional cancer treatment after radical prostatectomy reached 34.9% (95% confidence interval [CI] = 31.5%-38.5%). For patients with pathologically organ-confined cancer, the 5-year cumulative incidence was 24.3% (95% CI = 20.0%-29.3%) overall and ranged from 15.6% (95% CI = 9.7%-24.5%) for well-differentiated cancer (Gleason scores 2-4) to 41.5% (95% CI = 27.9%-58.4%) for poorly differentiated cancer (Gleason scores 8-10). The corresponding figures for pathologically regional cancer were 22.7% (95% CI = 12.0%-40.5%) and 68.1% (95% CI = 58.7%-77.1%).

Conclusion: Further treatment of prostate cancer was done in about one third of patients who had had a radical prostatectomy with curative intent and in about one quarter of patients who were found to have organ-confined disease. Implications: Given the common requirement for follow-up cancer treatments after radical prostatectomy and the uncertainties about the effectiveness of the various follow-up treatment strategies, further investigation of these treatments is warranted.

[J Natl Cancer Inst 1996;88:166-73]

Quality of Life and Treatment Outcomes

Prostate Carcinoma Patients' Perspectives after Prostatectomy or
Radiation Therapy

Cheryl L. Shrader-Bogen, R.N.1, Janice L. Kjellberg, R.N.1, Carol P. McPherson,
M.S.W., M.P.H.1, Charles L. Murray, M.D., F.A.C.P.1,2

Cancer 79:1977-86, 1997

1 Oncology Research, Institute for Research and Education, Methodist Hospital
Cancer Center, HealthSystem Minnesota, Minneapolis, Minnesota. 2 Department of
Medical Oncology, University of Minnesota Medical School, Minneapolis, Minnesota.

BACKGROUND. Of the estimated 317,000 men in the United States diagnosed with prostate carcinoma in 1996, 57% will have localized disease, and their 5-year relative survival rate will be 98%. Limited information exists on patient-reported quality of life (QOL) and the incidence and severity of treatment-related side effects. The purpose of this study was to identify and compare patients' self-reported QOL and treatment side effects 1-5 years after radical prostatectomy or radiotherapy.

METHODS. Data collection for this cross-sectional study included a mailed, self-administered survey with three parts: a demographic survey, the Functional Assessment of Cancer Therapy-General (FACT-G), and a newly developed Prostate Cancer Treatment Outcome Questionnaire (PCTO-Q). The FACT-G measured the effect of prostate carcinoma on overall QOL in the two treatment groups. The PCTO-Q assessed the patients' perceptions of the incidence and severity of specific changes in bowel, urinary, and sexual functions. The test-retest reliability of the PCTO-Q in a pilot study was 91.2%.

RESULTS. Two hundred seventy-four eligible men completed the questionnaires; 132 (48%) reported having undergone prostatectomy and 142 (52%) reported having undergone radiotherapy. After age adjustment, the radiotherapy group reported more bowel dysfunction (P = 0.001), whereas the prostatectomy group reported more urinary problems (P = 0.03) and more sexual dysfunction (P = 0.001). Scores for the FACT-G were similar in the two treatment groups.

CONCLUSIONS. Men undergoing treatment for clinically localized prostate carcinoma continue to experience difficulty long after treatment. In this study, the prostatectomy group fared worse in regard to sexual and urinary functions, whereas the radiotherapy group experienced more bowel dysfunction. Survivor-reported QOL and treatment outcomes can assist physicians in counseling patients in the selection of the preferred course of treatment.

Cancer 79:1977-86, 1997
Copyright © 1997 American Cancer Society.

Patient-reported impotence and incontinence after nerve-sparing radical prostatectomy

JA Talcott1, P Rieker1, KJ Propert2, JA Clark1, KI Wishnow3, KR Loughlin4, JP Richie4 and PW Kantoff1

Journal of the National Cancer Institute, Volume 89, Issue 15: August 6 1997.

1Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA, USA, 2Dana-Farber Cancer Institute and Harvard
School of Public Health, Boston, MA, USA, 3New England Deaconess Hospital and Harvard Medical School, Boston, MA,
USA, 4Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA

The age-adjusted rate of radical prostatectomy, the most common treatment of early (nonmetastatic) prostate cancer, increased almost sixfold between 1984 and 1990. This increase was due in part to reported improvements in postoperative sexual potency after the use of newly developed 'nerve-sparing' procedures. However, published estimates from physicians of impotence following various types of radical prostatectomy may be low, since not all patients may report treatment-related complications accurately and completely to their doctors. In contrast, direct surveys of patients indicate much higher rates of postoperative sexual and urinary dysfunction. One problem with most physician and patient surveys is that they have been performed retrospectively, and pretreatment impotence and incontinence prevalent in older men cannot be assessed accurately in retrospective studies. Purpose: This study was initiated in a cohort of men before they underwent radical prostatectomy to assess treatment-related effects on impotence and incontinence.

Methods: The study population consisted of 94 men enrolled in a cohort study of treatment for early prostate cancer. The patients completed questionnaires about sexual and urinary functions before surgery and at 3 and 12 months after surgery and had adequate information to assess the type of surgical technique used (non-nerve-sparing, unilateral nerve-sparing, or bilateral nerve-sparing). Because items assessing sexual function were inadvertently omitted from the questionnaire in the initial months of the study, information on sexual function for all time periods was available for only 49 men.

Results: Compared with men who had not been treated with a nerve-sparing procedure, men who underwent nerve-sparing radical prostatectomy, particularly of the bilateral type, were younger and had better prognostic features, indicating less advanced cancers. Before surgery, nine (75%) of 12 men not treated with a nerve-sparing procedure reported erections that were usually inadequate for sexual intercourse compared with six (33%) of 18 men and one (5%) of 19 men who underwent unilateral and bilateral nerve-sparing prostatectomies, respectively. At 12 months after surgery, most men reported inadequate erections, including 15 (79%) of the 19 men who had bilateral nerve-sparing surgery; unilateral nerve preservation provided no apparent benefit. In general, nerve-sparing surgery was associated with more use of absorbent pads at 3 and 12 months following treatment, and this approach was associated with substantial urinary incontinence at 3 months but not at 12 months following surgery.

Conclusions: Nerve-sparing prostatectomy, particularly when performed unilaterally, improves postoperative function to a lesser extent than previously reported. Because men with preoperative impotence and more advanced cancers receive nerve-sparing surgery less often, some of the previously reported benefit of nerve preservation may be the result of patient selection and not of the technique per se

Cancer 79:538-44, 1997
Copyright © 1997 American Cancer Society. All rights reserved.
Published by John Wiley & Sons, Inc.

Erectile Functioning of Men Treated for Prostate Carcinoma
Cancer 79:538-44, 1997

John W. Robinson, Ph.D., C. Psych.1, Marie S. Dufour, B.A.2, Tak S. Fung, Ph.D.3

1 Department of Oncology and Programme in Clinical Psychology, The University of
Calgary, and Department of Psychosocial Resources, Tom Baker Cancer Centre,
Calgary, Alberta, Canada. 2 Department of Psychosocial Resources, Tom Baker
Cancer Centre, Calgary, Alberta, Canada. 3 Academic Computing Services, The
University of Calgary, Calgary, Alberta, Canada.

Received June 4, 1996, revision received October 7, 1996; accepted October 7, 1996.

BACKGROUND. Published reports of complication rates, such as erectile associated with treatments for prostate carcinoma are often used to guide decision-making and develop clinical guidelines. Unfortunately, the published data are largely combining findings from several studies to produce a better result.

METHODS. A comprehensive literature review and subsequent meta-analysis of the r of erectile dysfunction associated with external beam radiotherapy and radical prostatectomy the data from 40 articles that met selection criteria.

RESULTS. The probability of maintaining erectile functioning after radiotherapy is The probability after surgery is 0.42. This difference is significant. Analysis of the effects of variables such as patient age and stage of disease on erectile functioning could not be performed due to inconsistencies across studies and the limited number of studies reporting such variables.

CONCLUSIONS. The published data indicate that men with normal erectile functioning more likely to retain this function after radiotherapy than after surgery. Attention is drawn to treatments, such as cryotherapy, brachytherapy, three-dimensional conformal radiotherapy, and neoadjuvant hormones can be strengthened to reflect more accurately the rate of treatment-associated erectile dysfunction.