ORLANDO, FL, USA (UroToday.com) - Treatment of localized prostate cancer has side effects, which can be variable in how they impact patient health-related quality of life (HRQOL). Dr. John L. Gore from the University of Washington discussed the utility of clinical tools that provide individualized treatment decisions and their potential impact on quality of life outcomes.
Current patient-reported outcome (PRO) measures include the Prostate Cancer Index (PCI), Expanded Prostate Cancer Index Composite (EPIC), Functional Assessment of Cancer Therapy (FACT-P), and Patient-oriented Prostate Utility Scale (POrPUS). These scales measure function versus bother, and include generic, disease-specific domains.
PRO registries include CaPSURE, Prostate Cancer Outcomes Study (PCOS), CEASAR, and PROST-QA. CaPSURE is based in community, academic, and VA hospitals, and has data on over 15 000 patients with prostate cancer from 1995 to present. Punnen, et al. performed an analysis of CaPSURE data on 3 294 patients treated with nerve-sparing and non nerve-sparing radical prostatectomy, brachytherapy, external beam radiation, primary androgen deprivation, and active surveillance to identify long-term HRQOL changes. They found that surgery had the largest impact on sexual function and bother as well as urinary incontinence compared to radiation or conservative management. Radiation had the strongest impact on bowel function and was severe regardless of type. Most men had initial declines in HRQOL in the first 2 years of treatment, but there was little change between years 3 and 10. Differences between treatments attenuated over time.
Dr. Resnick and colleagues published the Prostate Cancer Outcomes Study, which enrolled 3 500 men to identify long-term outcomes of treatment for localized disease. Propensity-scoring analysis of functional outcomes at baseline through 15 years demonstrated that surgical patients were more likely to have urinary incontinence at 2 and 5 years post treatment vs radiation patients, but not at 15 years. The same trend was identified for erectile dysfunction with differences in both groups attenuated at 15 years. Bowel urgency was higher among men receiving radiation at 2 and 5 years, while there was no difference in the adjusted odds of bowel urgency at 15 years. Long-term changes may have been associated with age-related decline.
Dr. Gore reported his group’s study on intermediate to long-term quality of life outcomes after treatment for localized prostate cancer. He found that urinary incontinence was more common after prostatectomy than after brachytherapy or external beam radiation, while voiding and storage symptoms were more prevalent after brachytherapy. The percentage of patients with severe urinary bother decreased over time. Sexual dysfunction affected all groups, but prostatectomy patients had a lower likelihood of regaining baseline function. Consistent with the other reported studies, bowel dysfunction was more common in the radiation groups.
There are a number of decision aids that have been found to reduce decisional conflict, provide increased knowledge, provide increased satisfaction and decreased uncertainty, and there are at least 7 ongoing clinical trials focused on analysis of decision aids for improvement of HRQOL.
One caveat in the application of HRQOL tools is the heterogeneity that exists within the sample to which these tools are applied. For example, Izard and colleagues found in their analysis of urinary control scores within 2 months that patients in the bottom quartile of urinary control have significant heterogeneity in variation of control compared to those in the top quartile.
This highlights the need for more personalized HRQOL scoring systems through patient-centered outcomes research. Medical informatics may be the next important resource to facilitate such personalized approaches to decision-making and survivorship care.
Presented by John L. Gore, MD at the 2015 Genitourinary Cancers Symposium - "Integrating Biology Into Patient-Centric Care" - February 26 - 28, 2015 - Rosen Shingle Creek - Orlando, Florida USA
University of Washington
Reported by Nikhil Waingankar, MD, medical writer for UroToday.com