ESMO 2021: Quality of Life and Long-Term Comorbidities

( The Earlier Treatment in Prostate Cancer “How can we maximize the therapeutic index?” educational session at the European Society for Medical Oncology (ESMO) 2021 congress included a presentation by Dr. Heather Payne discussing quality of life and long-term comorbidities. Dr. Payne started by highlighting what quality of life means for our patients. Indeed, quality of life has multiple definitions, including the patient’s subjective report of their health status, their overall enjoyment of life, a measure of an individual’s sense of well-being and ability to carry out various activities, and the extent to which hopes and ambitions are matched by experience. Quality of life also has multiple domains, including physical, emotional/psychological, social functioning, level of independence, environmental (ie. financial resources, home, freedom), spirituality/religion, and others.

A common tool for measuring quality of life is The Functional Assessment of Cancer Therapy-Prostate (FACT-P) Questionnaire. The FACT-G scale assesses physical, functional, social/family, and emotional well-being, whereas the FACT-P questionnaire includes all of the components of the FACT-G scale plus the prostate cancer subscale. Higher scores (range 0 to 108) represent better quality of life, and increases of >=5 points are suggested to be related to a clinically meaningful improvement in quality of life (and a reduction of >=5 points associated with a clinically meaningful worsening of quality of life). The components of FACT-P are as follows. 


The Brief Pain Inventory is commonly used to evaluate pain. BPI-SF consists of 11 questions that assess (i) pain severity at its worst, least, average, and now, and (ii) pain interference with daily functions. Patients are asked to rate pain severity and interference using an 11-point numerical rating scale:


Dr. Payne notes that there is significant patient heterogeneity and it is difficult to ascertain which patient characteristics we should take into account. Individual life expectancy, health status, and comorbidities, not age, should be central in clinical decision-making and treatment. Important to consider is PFS/MFS, as progression of prostate cancer has an impact on the physical and emotional quality of life. Therapy choices need to consider comorbidities and known potential toxicities of different therapies, especially if efficacy is similar. The International Society of Geriatric Oncology recommends that treatment for older men with prostate cancer should be based on health status (mainly driven by comorbidities) and patient preferences, not chronological age. Treatment adapted to health status may utilize the following algorithm for delineating appropriate assessment/treatment:


Dr. Payne emphasized that ADT has several adverse effects, including bone loss with increased risk of fracture, increased risk of diabetes, and increased risk of fatal cardiac events. As such, it is important to assess baseline bone density, prevent risks of osteoporosis, and proceed with caution in patients with a history of stroke, chronic heart failure, and myocardial infarction. The EORTC 133/PEACE III trial has specifically highlighted the risk of bone fractures and the lack of bone protective agent use. In men that did not use a bone protective agent that was randomized to ADT + enzalutamide, the cumulative incidence of bone fracture at 12 months was 12.4% compared to 37.4% for ADT + enzalutamide + Radium-223. This risk was essentially nullified among patients that were also taking a bone protective agent. ADT is also associated with worsening body image perception and resultant negative impact on quality of life. There is also evidence on a negative impact on body image regardless of treatment, since the loss of masculinity is common across all disease stages. Thus, exercise can help alleviate some of the psychological effects of self-image. Furthermore, depression and anxiety are prevalent across treatment groups, and anxiety is significantly associated with prostate cancer stage and can be affected by the number of bone lesions, pain, and PSA level. Patients with urological cancers are five times more likely than the general population to die of suicide.

Long-term follow-up of the SPARTAN trial assessed health-related quality of life (using FACT-P and QD-5D-3L) finding that apalutamide + ADT improved MFS and OS in patients with nmCRPC while preserving quality of life, whereas quality of life among patients receiving placebo + ADT declined after one year.

Regarding management of comorbidities, Dr. Payne notes that for these patients with advanced prostate cancer, this is an opportunity to treat co-existing conditions. Additionally, we must be aware of the toxicities of treatment, especially where this is a choice in treatment, assessing contraindications to therapies and exacerbation of pre-existing conditions. Polypharmacy may also be an issue for these patients, defined as >5 medications, and can lead to poor compliance, increased risk of drug interactions, and unwanted side effects. Patients prescribed medication from various clinics are not always coordinated between primary and secondary care. We must be aware of over-the-counter medications and supplements, as patients are not always aware of the reasons why they have been prescribed different medicines. In advanced disease, the use of medications for symptom relief may also increase pill burden and confusion about prescribed medications.

Dr. Payne concluded her presentation of quality of life and long-term comorbidities among prostate cancer patients with the following concluding statements:

  • Quality of life and comorbidities can be measured with scales and charts and are essential for trial outcome data
  • We see these patients in the clinic all the time and we need to ask the right questions
  • We need to treat prostate cancer effectively and early to maximize quality of life
  • We need a holistic approach and extended multidisciplinary prostate cancer care. Prostate cancer may be only one factor in their health/quality of life and we must be aware of comorbidities and polypharmacy which may influence choice of therapy
  • Each and every patient needs an individualized treatment plan

Presented by: Heather A. Payne, Oncology Department, University College London Hospital, London, UK

Written by: Zachary Klaassen, MD, MSc – Urologic Oncologist, Assistant Professor of Urology, Georgia Cancer Center, Augusta University/Medical College of Georgia, @zklaassen_md on Twitter during the 2021 European Society for Medical Oncology (ESMO) Annual Congress 2021, Thursday, Sep 16, 2021 – Tuesday, Sep 21, 2021.

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