Impact of a novel neoadjuvant and adjuvant hormone-deprivation approach on quality of life, voiding function, and sexual function after prostate brachytherapy

Short- and long-term HRQOL issues following brachytherapy for prostate cancer

Given the lack of evidence from randomized controlled trials and large prospective studies, controversy exists regarding the optimal treatment strategy for early stage prostate cancer. The impact of various treatments on health-related quality of life has become an increasingly important but controversial issue. The literature on health-related quality of life following brachytherapy, an increasingly used treatment option that can have short- and long-term side effects influencing patient health-related quality of life is reviewed. Urinary, bowel and sexual health-related quality of life issues related to this treatment are addressed. The authors findings suggest that brachytherapy with or without external beam radiotherapy and/or hormonal treatment has a considerable impact on short-term health-related quality of life but this impact diminishes in the long-term. However, in certain subgroups of patients, brachytherapy has long-term effects on bowel, bladder and sexual function. Clinicians should ensure that patients are aware of these consequences on long-term health-related quality of life.

Influence of serum testosterone on urinary continence and sexual activity in patients undergoing radical prostatectomy for clinically localized prostate cancer

The aim of the present study was to evaluate how serum testosterone level (T) can affect urinary continence and erectile function in patients undergoing radical prostatectomy (RP). We included 257 patients with clinically localized prostate cancer, those who had filled out preoperative quality of life questionnaires (University of California, Los Angeles Prostate Cancer Index, International Index of Erectile Function (IIEF)), and those who had T and total PSA sampled the day before surgery. We calculated correlations between T and age, body mass index (BMI), PSA, urinary function or bother (UF, UB) and sexual function or bother (SF, SB) and IIEF-5 in the whole population and in sub-populations with normal (⩾10.4 nmol l⁻¹) and low (<10.4 ng ml⁻¹) T using Pearson's and Spearman's correlation coefficients. We evaluated differences in these parameters between patients with low and normal T using the unpaired samples t-test and Mann–Whitney test, and finally the correlation between UF and SF, UB and SB, and between PSA and T in the overall population, and separately in patients with low and normal T using the Pearson's correlation coefficient. Mean preoperative T was 13.5 nmol l⁻¹ and 23.7% of patients presented a low T. Mean age, mean BMI and mean preoperative total PSA at RP were 64.3 years, 25.9 kg m⁻² and 9.0 ng ml⁻¹, respectively. BMI was negatively correlated with T in the overall population (r=−0.266; P=0.02); moreover, patients with normal T presented lower BMI compared with patients with low T (25.7 vs 27.6: P=0.02). We found a significant correlation between SF scores and T in patients with normal T (r=0.1777: P=0.05). SF was significantly higher in patients with normal T compared with those with low T (74.8 vs 64.8: P=0.05). Furthermore, UF and UB were significantly correlated with SF (r=0.2544: P<0.01) and SB (r=0.2512: P=0.01), respectively, in men with normal T. Serum T was significantly correlated with PSA in men with low T (r=0.3874: P=0.0029), whereas this correlation was missed in the whole population and in men with normal T. The correlation between preoperative PSA and T in men with low T is in agreement with the ‘saturation' model proposed by Morgentaler. The correlation between basal T and preoperative erectile function and urinary continence underlines the importance of assessing T before RP.

Cancer-related pain and quality of life in prostate cancer patients: assessment using the Functional Assessment of Prostate Cancer Therapy

The objective of this study was to assess disease-associated pain and quality of life (QOL) in patients with prostate cancer (PC). A total of 102 PC patients (clinical stage B, C: 20, D2: 82) patients were enrolled. QOL was assessed using the Functional Assessment of Cancer Therapy, General and Prostate (FACT-G/P). Disease-specific pain response was assessed using the visual analog scale and the face rating scale. In patients with stage D2 PC, mean age, serum prostate-specific antigen level, and performance status were 72.5 +/- 7.1 years (range, 55-88), 217 +/- 467 ng/mL (range, 0.1-2600), and 1.4 (0-4), respectively. The score of physical well-being and FACT-P was significantly lower in stage D2 patients, compared with those of stage B/C (P = 0.02, 0.0088, respectively). Performance status, extent of disease, and the visual analog scale were related with a poor QOL score (P = 0.0054, 0.01, <0.0001, respectively). Thirty-two patients (39%) had disease-specific pain, and 25 patients received a related treatment. Ten patients under morphine analgesics maintained better QOL in almost all domains, compared with the seven patients without any painkillers. Combined use of FACT and pain scales enhances the objective assessment of QOL and pain status in PC patients. Control of disease-associated pain is crucial to improving QOL in stage D2 PC patients.

Preliminary results of radiation therapy for prostate cancer in human immunodeficiency virus-positive patients

OBJECTIVES

The purpose of this study was to report on the clinical outcomes of patients treated at our institution for prostate cancer (PCa) who had been previously diagnosed as Human immunodeficiency virus (HIV) positive.

METHODS

The authors conducted a retrospective study of 14 PCa/HIV patients who were being treated for PCa with external beam radiotherapy, brachytherapy, or a combination of the two. Each patient's prostate-specific antigen (PSA) level, CD4 count, and viral load were obtained before the initial radiation treatment and at the time of their most recent follow-up. In addition, 13 of 14 patients completed a quality of life survey with a social worker on staff and were examined by their radiation oncologist to assess the complications after treatment.

RESULTS

Comparing pretreatment data with the data at last follow-up, only 1 patient's PSA level remained above 1.1 ng/mL. The average CD4 count remained stable, increasing from 523 to 577 cells/mm(3), with the lowest final count at 200 cells/mm(3). Viral load increased in only 2 of 14 patients. There were no unusual rectal, urinary, or sexual complications, and no infections related to treatment.

CONCLUSIONS

Based on changes in viral load and CD4 count, radiotherapy does not appear to have a long-term negative effect on the immune system. Treatment complications are consistent with HIV-negative patients, giving no evidence that the subset of PCa/HIV patients should be treated differently from PCa patients without HIV when considering radiation therapy. More investigation will be necessary before reliable mortality and morbidity data can be assessed.

Efficacy of neoadjuvant bicalutamide and dutasteride as a cytoreductive regimen before prostate brachytherapy

OBJECTIVES

To evaluate the cytoreductive effectiveness of combined neoadjuvant bicalutamide and dutasteride before prostate brachytherapy for clinically localized prostate cancer.

METHODS

From April 2003 to May 2005, 31 patients opted for cytoreduction with bicalutamide (50 mg daily) and dutasteride (0.5 mg daily). Before, and at 3 months (90 +/- 5 days) after, the initiation of medical therapy, all patients underwent a transrectal ultrasound volumetric study of the prostate gland, with ellipsoid volume determination of the prostate gland and transition zone. The variables analyzed included pretreatment and posttreatment prostate and transition zone volumes and changes in width, height, and length of the prostate gland and transition zone. A multivariate analysis was performed to identify predictors for prostate gland and transition zone volume reduction.

RESULTS

Before the initiation of bicalutamide and dutasteride, the mean prostate volume was 54.3 cm3 by planimetric summation and 49.7 cm3 by ellipsoid volume calculation. After a 3-month course of combination medical therapy, the average prostate volume was 36.1 cm3 (33.6% reduction) and 32.5 cm3 (34.6% reduction) using the volumetric and ellipsoid volume determinations, respectively. Bicalutamide and dutasteride resulted in a 39.8% reduction in transition zone volume (20.8 cm3 versus 12.4 cm3). The prostate gland and transition zone dimensions (width, height, and length) decreased about 11.4% to 19.9%.

CONCLUSIONS

The prostate gland and transition zone volume reductions after a 3-month course of neoadjuvant bicalutamide and dutasteride are comparable to previous reports of volume reduction using a luteinizing hormone-releasing hormone agonist with or without an antiandrogen.

Impact of hormonal therapy prior to radical prostatectomy on the recovery of quality of life

BACKGROUND

We investigated the changes in health-related quality of life (HRQOL) in patients who underwent prostatectomy (RP) with or without neoadjuvant hormonal therapy (NHT).

METHODS

A total of 72 patients undergoing direct RP (DRP group) and 26 patients receiving neoadjuvant hormonal therapy (NHT group) were enrolled in the present study. The baseline interview was conducted before RP (not initiation of therapy). Follow-up interviews were conducted in person at scheduled study visits of 3, 6, and 12 months after surgery. We measured general and disease specific HRQOL with the Medical Outcomes Study 36-Item Short Form and University of California, Los Angeles Prostate Cancer Index, respectively.

RESULTS

At baseline, the NHT group scored statistically lower for not only sexual function (P < 0.001), but also the general HRQOL, such as role limitations due to physical problems (P = 0.007), social function (P = 0.045) and mental health (P = 0.034), than the DRP group. The NHT group reported lower scores in social function and mental health at 3 months (P = 0.040 and 0.006, respectively). Patients who received NHT for more than 3 months continued to show significantly lower scores for some HRQOL domains 12 months later.

CONCLUSION

Neoadjuvant hormonal therapy may decrease not only sexual function, but also general HRQOL before surgery. The recovery of HRQOL appeared to be further prolonged in patients who received long-term NHT.

Brachytherapy for prostate cancer

The use of prostate brachytherapy for the treatment of early-stage, low-grade, low-volume carcinoma of the prostate continues to rise. Given the prolonged natural history of these early lesions, treatment failures may take many years or even a decade or more before becoming clinically evident. It is therefore likely that as the brachytherapy data mature, clinicians will be asked to help manage a potentially large cohort of men who have failed this local therapy--a scenario that will provide a number of unique challenges for the treatment of the disease and the management of the lower urinary tract. This article offers a contemporary review and suggestions with regard to the follow-up of patients who have undergone prostate brachytherapy, including low-dose rate permanent implants and high-dose rate temporary implants for the management of localized prostate cancer. In addition, current controversies in defining biochemical failure following radioactive implantation--including important data regarding the "prostate-specific antigen bounce" phenomenon--are discussed. Finally, a comprehensive review of the management of local recurrence following brachytherapy is offered.