Quality of life in T1–3N0 prostate cancer patients treated with radiation therapy with minimum 10-year follow-up

doi:10.1016/S0360-3016(99)00496-4

International Journal of Radiation OncologyBiologyPhysics

Volume 46, Issue 4, 1 March 2000, Pages 833-838

https://doi.org/10.1016/S0360-3016(99)00496-4 Get rights and content

Abstract

Purpose: To describe patient-reported quality of life using a validated survey in a cohort of patients who are long-term survivors of definitive radiotherapy for T1–3N0 prostate cancer.

Methods and Materials: Survivors of a previously reported cohort of prostate cancer patients treated with staging pelvic lymphadenectomy and definitive radiotherapy between November 1974 and August 1988 were queried using a questionnaire incorporating the RAND 36-Item Health Survey and the University of California, Los Angeles Prostate Cancer Index. Responses were reviewed and analyzed. Of the 146 N0 patients, 88 have survived for 10 years postdiagnosis. Fifty-six (64%) of these patients were still alive with valid addresses and were mailed copies of the questionnaires, of which 46 (82%) responded. Median potential follow-up from date of diagnosis was 13.9 years, with a median age of responders of 80 years.

Results: The mean sexual function score was 15.4, with a bother score of 42. The mean urinary function score was 65, with a bother score of 61. The mean bowel function score was 72.6, with a bother score of 64.8. The amount of patient bother reported in the sexual category is similar to that previously reported for cohorts of prostate cancer patients undergoing radiotherapy or observation. This is despite the fact that sexual function was similar to that previously reported for patients postprostatectomy. Patient-reported function and bother scores in urinary and bowel categories were somewhat more severe than a previously reported radiotherapy cohort with shorter follow-up.

Conclusions: With long follow-up, most patients who underwent radiotherapy for prostate cancer in the era described exhibit somewhat worse bladder, bowel, and erectile function than recently published controls without prostate cancer. In this cohort of older men with long follow-up, erectile function is similar to reported prostatectomy series. However, patient bother related to erectile function is similar to that of controls in earlier published radiotherapy series. Worse urinary and bowel function may be due to progressive symptoms with aging and longer follow-up, or to the radiotherapy techniques performed during the era in question.

Introduction

Quality of life (QOL) post-treatment is critically important in prostate cancer (CaP) patients because of the long life most patients enjoy after their diagnosis. In this review we discuss QOL in a cohort of surgically staged CaP patients with long follow-up. All patients were treated with definitive radiotherapy (XRT). This cohort of patients has been discussed in detail previously with respect to overall and disease-free survival (1), prostate-specific antigen (PSA) status of long-term survivors (2), and frequency of second primary malignancies (3).

Prior studies have emphasized QOL in patients with short follow-up postradiotherapy. Some studies have investigated complication rates a few years after XRT, but most focus on the time frame to 1 year post-therapy. Many studies report objective findings at time of follow-up; however, there is an emerging literature on patient-reported questionnaire data, which better describes the effect of the toxicity on the patient.

Our well-defined cohort of 146 patients receiving radiotherapy after negative pelvic lymph node dissection for T1–3 CaP represents a fertile group for analysis of QOL in radiotherapy patients with long follow-up. Specifically discussed are results in patients with minimum 10 years follow-up.

Section snippets

Methods and materials

At Naval Medical Center San Diego, between November 1, 1974 and August 1, 1988, 165 men with clinically organ-confined CaP were staged with open pelvic lymph node dissection prior to definitive radiotherapy. Nineteen men were found to have positive lymph nodes; the remaining 146 received definitive radiotherapy, generally treated with four-field, opposed anteroposterior, or arc technique to a median of 66.7 Gy (range 63–70.2 Gy). The average patient age at diagnosis was 66.7 years.

Techniques of

General health-related QOL

Comparison of our population was made with a control cohort of similar age men without prostate cancer (8). Results are summarized in Table 2. Our population is similar in terms of the SF-36 assessment tool, but appears to have more fatigue and greater physical role limitations.

Disease-specific QOL

Appendix I shows the survey results of the UCLA Prostate Cancer Index, and Table 3 shows comparison of these results with other series (4, 8). Sexual function scoring in our cohort was similar to postprostatectomy

Discussion

Quality of life has emerged as a critical endpoint in clinical cancer therapy (9). In a recent review of complications after XRT for T1–2 CaP, with a median follow-up of 6.1 years, frequencies of 5.1–5.4% were reported for genitourinary strictures, hematuria, and rectal bleeding (10). These are raw percentages, however, and do not reflect the effect that any toxicity had on the patient’s life. It is conceivable that a complication may severely impact one patient’s QOL, while another patient may

Conclusion

In a cohort of patients receiving definitive radiotherapy after negative pelvic lymphadenectomy, disease-specific QOL with long follow-up appears somewhat worse than in comparable recent patients reported with less follow-up. Since general health QOL is in keeping with similar age-matched controls, this discrepancy may be due to (a) progression of symptoms with longer follow-up, or (b) different radiotherapy techniques.

Acknowledgements

The kind assistance of Mark Litwin, M.D., in making the quality-of-life assessment tool available to us is acknowledged and gratefully appreciated.

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Cited by (26)

Bowel, Urinary, and Sexual Problems Among Long-Term Prostate Cancer Survivors: A Population-Based Study
2009, International Journal of Radiation Oncology Biology Physics
Citation Excerpt :
Knowledge of disease-specific complaints among long-term prostate cancer survivors is important because of the long life most patients experience after diagnosis. However, the number of relevant studies is small (17, 19–23). Most important, thus far no population-based study has been conducted that included both a large study population and a reference group and that also evaluated all available treatment options.
To obtain insight into the long-term (5- to 10-year) effects of prostate cancer and treatment on bowel, urinary, and sexual function, we performed a population-based study. Prostate-specific function was compared with an age-matched normative population without prostate cancer.
Through the population-based Eindhoven Cancer Registry, we selected all men diagnosed with prostate cancer between 1994 and 1998 in the southern Netherlands. In total, 964 patients, alive in November 2004, received questionnaire; 780 (81%) responded.
Urinary problems were most common after a prostatectomy; bowel problems were most common after radiotherapy. Compared with an age-matched normative population both urinary and bowel functioning and bother were significantly worse among survivors. Urinary incontinence was reported by 23–48% of survivors compared with 4% of the normative population. Bowel leakage occurred in 5–14% of patients compared with 2% of norms. Erection problems occurred in 40–74% of patients compared with 18% of norms.
These results form an important contribution to the limited information available on prostate-specific problems in the growing group of long-term prostate cancer survivors. Bowel, urinary, and sexual problems occur more often among long-term survivors compared with a reference group and cannot be explained merely by age. Because these problems persist for many years, urologists should provide patients with adequate information before treatment. After treatment, there should be an appropriate focus on these problems.
Salvage Radical Prostatectomy: Quality of Life Outcomes and Long-Term Oncological Control of Radiorecurrent Prostate Cancer
2006, Journal of Urology
Citation Excerpt :
This rate is nearly identical to those reported in other salvage series using a similar method of analysis.6,7 Because definitive RT is often associated with long-term erectile dysfunction,11,14–16 sexual function may be less of a concern for the cohort of men considering salvRP than for the population of men seeking standard, nonsalvage prostatectomy. Given the frequency of erectile dysfunction following RT, it is not surprising that after salvRP nearly all men will be unable to achieve an erection adequate for intercourse.
We review our 20-year experience with salvage radical prostatectomy to determine prognostic variables predictive of oncological control of radiorecurrent prostate cancer. Using a standardized questionnaire we also evaluate outcome data regarding the long-term sexual and urinary effects of salvage radical prostatectomy.
Between 1983 and 2002 salvage radical prostatectomy was performed in 51 patients with locally recurrent prostate cancer following definitive radiotherapy. Clinical information was obtained from a prospective database. Quality of life data were collected using the UCLA Prostate Cancer Index, a validated, patient administered instrument.
At 5 years 47% of patients were progression-free without androgen deprivation therapy. Among patients with pT2 disease 100% were progression-free at 5 years, compared with 35% of patients with pT3N0 disease or higher and 0% of patients with node positive (pTxN+) disease (p <0.001). Preoperative PSA 5.0 ng/ml or less was predictive of organ confined disease, and strongly associated with prolonged progression-free and overall survival (p <0.001 and 0.01, respectively). Mean urinary function scores for patients with or without an artificial urinary sphincter compared favorably with scores reported after standard, nonsalvage prostatectomy. Sexual dysfunction was nearly uniform in patients undergoing standard salvage radical prostatectomy but implantation of a penile prosthesis was associated with a clinically significant improvement in sexual function.
When initiated early in the course of recurrent disease, salvage radical prostatectomy provides excellent oncological control of radiorecurrent prostate cancer without the need for androgen ablation. Implantation of an artificial urinary sphincter and inflatable penile prosthesis devices in patients with postoperative urinary incontinence or erectile dysfunction results in significantly improved quality of life parameters.
Late rectal symptoms and quality of life after conformal radiation therapy for prostate cancer
2006, Radiotherapy and Oncology
This study was carried out in order to analyze the prevalence of late rectal and anal symptoms after conformal radiation therapy for prostate cancer and to assess their association with quality of life.
Two-hundred and forty nine patients were interviewed at 24–111 months after definitive conformal radiation therapy of localized prostate cancer with a median dose of 70 Gy. Rectal symptoms and fecal incontinence were evaluated with standardized questionnaires. Quality of life was assessed with the EORTC Quality of Life Questionnaire-C30 and the prostate cancer module PR25.
Rectal symptoms were mostly intermittent. Daily symptoms occurred in ≤5% of the patients. Incontinence was mostly mild with only 3% of the patients reporting daily incontinence episodes. Quality of life was comparable to that of the male German general population except that cognitive functioning and diarrhea were worse in the study population and pain was worse in the reference population. Global quality of life was associated with fecal incontinence, fecal urge, tenesmus, therapy for rectal symptoms and hormonal therapy for biochemical/clinical recurrence.
Rectal symptoms and fecal incontinence after conformal radiation therapy for prostate cancer are mostly intermittent. Fecal incontinence, fecal urge and tenesmus are associated with lower global quality of life levels.
Early prostate cancer: Prevention, treatment modalities, and quality of life issues
2003, European Urology
Our understanding of the screening, prevention and treatment of early prostate cancer is improving. This is a result of new data from clinical trials and the incorporation of efficacy measures based on risk assessment and quality of life (QoL). This review aims to examine completed and ongoing clinical trials that address issues in early prostate cancer, including screening, prevention, treatment, and QoL. Prostate-specific antigen (PSA) testing has a crucial and evolving role in detecting primary prostate cancer, evaluating prevention interventions and assessing the effectiveness of treatment. Questions remain about the optimal PSA parameters appropriate for primary screening and for diagnosing relapse. Emerging and established data provide evidence that early intervention with hormone therapy, either as immediate or adjuvant therapy, delays progression in prostate cancer patients with intermediate or poor prognosis. The impact of therapeutic modality on QoL has become better characterized, as QoL instruments have been developed, validated and applied.
Health related quality of life in men with prostate cancer
2003, Journal of Urology
Quality of life is of great concern to patients considering treatment options for prostate cancer. In the absence of clinical trial data clearly demonstrating that a particular treatment is superior to another for localized prostate cancer, in terms of cause specific survival, patients may value quality of life as much as quantity of life. The goal of this review is to familiarize the reader with the methodology of quality of life research and to review the recent literature on quality of life outcomes in prostate cancer.
A structured MEDLINE review of literature on health related quality of life in prostate cancer for the years 1995 to 2001 was performed, and was augmented with highly relevant articles from additional selected journals.
In the case of advanced or metastatic disease, where the goal of treatment is palliation and symptom-free survival, quality of life often becomes the primary desired outcome. In localized disease all treatments affect health related quality of life, although the impact of each therapy on sexual, urinary and bowel function is unique.
Although a highly personal and subjective entity, health related quality of life can be assessed using rigorous and scientifically stringent methods from the field of psychometric test theory. A substantial amount of literature exists regarding the use of established and validated instruments for assessing the impact of prostate cancer and its treatment on health related quality of life. This information is of critical importance when counseling men with newly diagnosed prostate cancer regarding treatment choices and is also helpful in setting appropriate expectations for men with metastatic disease.
Effect of age on biochemical disease-free outcome in patients with T1-T3 prostate cancer treated with definitive radiotherapy in an equal-access health care system: A radiation oncology report of the Department of Defense Center for Prostate Disease Research
2003, International Journal of Radiation Oncology Biology Physics
It has traditionally been a common perception that young age is a negative prognostic factor in prostate cancer (CaP). Furthermore, many urologists believe that younger patients are better suited to surgery rather than radiotherapy (RT) because of this perception. However, the data on the effect of age on outcome in patients with CaP are unclear. The records of the Department of Defense Center for Prostate Disease Research were queried for the biochemical disease-free results of patients after definitive RT and analyzed by age.
The records of 1018 patients with T1-T3 CaP treated with definitive RT between 1988 and 2000 were reviewed. The records of patients receiving adjuvant hormonal therapy or adjuvant or salvage RT postoperatively were excluded. Biochemical failure was calculated by the American Society for Therapeutic Radiology and Oncology criteria. The median potential follow-up was 85.3 months as of December 31, 2001.
Age did not affect biochemical disease-free survival significantly when considered as <60 vs. ≥60 years (p = 0.646), by decade (p = 0.329), or as a continuous variable (correlation coefficient r = 0.017, regression slope = 0.007, with p = 0.588 and R² < 0.001). Using multiple regression analysis, age was still not significant (p = 0.408). Other variables analyzed were pretreatment prostate-specific antigen level (p < 0.001), Gleason sum (p = 0.023), stage (p = 0.828), and RT dose (p = 0.033).
Age and biochemical disease-free survival after RT for CaP are not related. Age may not be a valid factor in choosing between primary treatment options for CaP.

View all citing articles on Scopus

^☆: The Chief, Bureau of Medicine and Surgery, Navy Department, Washington, DC, Clinical Investigation Program sponsored this report #S98-055, as required by HSETCINST 6000.41A. The opinions and assertions contained herein are those of the authors and are not to be construed as official or representing the views of the United States Navy or Department of Defense.

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Clinical InvestigationsQuality of life in T1–3N0 prostate cancer patients treated with radiation therapy with minimum 10-year follow-up☆

Abstract

Introduction

Section snippets

Methods and materials

General health-related QOL

Disease-specific QOL

Discussion

Conclusion

Acknowledgements

J Urol

J Urol

J Urol

J Urol

Urology

Urology

J Urol

J Urol

Urology

Lancet

The fate of clinically recurrence-free survivors after definitive radiotherapy for T1–3N0 prostate cancer

Radiat Oncol Investig

Clinical Investigations
Quality of life in T1–3N0 prostate cancer patients treated with radiation therapy with minimum 10-year follow-up☆