Radiation therapy versus radical prostatectomy in the PSA era: a urologist's view

Comparison of quality of life after stereotactic body radiotherapy and surgery for early-stage prostate cancer

Background

As the long-term efficacy of stereotactic body radiation therapy (SBRT) becomes established and other prostate cancer treatment approaches are refined and improved, examination of quality of life (QOL) following prostate cancer treatment is critical in driving both patient and clinical treatment decisions. We present the first study to compare QOL after SBRT and radical prostatectomy, with QOL assessed at approximately the same times pre- and post-treatment and using the same validated QOL instrument.

Methods

Patients with clinically localized prostate cancer were treated with either radical prostatectomy (n = 123 Spanish patients) or SBRT (n = 216 American patients). QOL was assessed using the Expanded Prostate Cancer Index Composite (EPIC) grouped into urinary, sexual, and bowel domains. For comparison purposes, SBRT EPIC data at baseline, 3 weeks, 5, 11, 24, and 36 months were compared to surgery data at baseline, 1, 6, 12, 24, and 36 months. Differences in patient characteristics between the two groups were assessed using Chi-squared tests for categorical variables and t-tests for continuous variables. Generalized estimating equation (GEE) models were constructed for each EPIC scale to account for correlation among repeated measures and used to assess the effect of treatment on QOL.

Results

The largest differences in QOL occurred in the first 1–6 months after treatment, with larger declines following surgery in urinary and sexual QOL as compared to SBRT, and a larger decline in bowel QOL following SBRT as compared to surgery. Long-term urinary and sexual QOL declines remained clinically significantly lower for surgery patients but not for SBRT patients.

Conclusions

Overall, these results may have implications for patient and physician clinical decision making which are often influenced by QOL. These differences in sexual, urinary and bowel QOL should be closely considered in selecting the right treatment, especially in evaluating the value of non-invasive treatments, such as SBRT.

Quality of life after therapy for localized prostate cancer

Given the lack of unequivocal survival data clearly favoring one treatment over another for localized prostate cancer, patients strongly consider quality-of-life effects when choosing treatment for this common malignancy. In the past 15 years, a sizeable body of literature assessing health-related quality-of-life (HRQOL) outcomes in localized prostate cancer has emerged. The goal of this article is to review the quality-of-life experience after treatment for localized prostate cancer. Specifically, I will briefly discuss how quality of life is measured and then review the quality of life effects of each of the commonly used treatment strategies in localized prostate cancer. Finally, I attempt to directly compare the quality-of-life effects of the various treatments to assist clinicians in advising patients with newly diagnosed localized prostate cancer.

Use of different definitions of biochemical failure after external beam radiotherapy changes conclusions about relative treatment efficacy for localized prostate cancer

OBJECTIVES

To report biochemical relapse-free survival (bRFS) after radiotherapy (RT) for localized prostate cancer with two separate failure definitions and compare the results with those after radical prostatectomy (RP).

METHODS

The study sample comprised 2516 patients with a median follow-up of 78 months. Biochemical relapse after RT was defined as either the American Society for Therapeutic Radiology Oncology definition (definition A [DefA]) or a prostate-specific antigen elevation of more than 2 ng/mL greater than the nadir prostate-specific antigen level (definition N [DefN]). Failure after RP was defined as a prostate-specific antigen level greater than 0.2 ng/mL.

RESULTS

Compared with DefA, DefN resulted in a 13% greater bRFS rate at 5 years and a 12% lower bRFS rate at 10 years. On multivariate analysis, the treatment modality (RP versus RT) was a significant predictor of bRFS using DefA in favor of RP (P <0.001), but was not with DefN (P = 0.87). Higher radiation doses were independently associated with a better outcome with either definition.

CONCLUSIONS

Compared with DefA, DefN resulted in better outcomes for up to 7 years after RT, but worse outcomes thereafter. The use of DefA versus DefN resulted in opposite conclusions about the relative efficacies of RT and RP, with DefN suggesting RT is equivalent to RP and DefA that it is worse than RP. Different definitions of biochemical failure after RT can result in differences in the conclusions about treatment efficacy in men with localized prostate cancer, thereby potentially affecting clinical decisions.

An update on randomized clinical trials in localized and locoregional prostate cancer

It is important that treatment decisions be based upon scientific data, as opposed to anecdotal experience and expert opinion. The goal of this article is to provide an update on phase III clinical trials in localized and locoregional prostate cancer. Studies comparing surgery and observation for localized disease are reviewed, as are studies comparing various forms of radiotherapy. The effectiveness of certain neoadjuvant and adjuvant therapies is also addressed. Although there are numerous phase III studies ongoing in these areas, there are still large gaps in our understanding of the treatment of localized disease, and additional clinical trials are needed.

The efficacy of conventional external beam, three-dimensional conformal, intensity-modulated, particle beam radiation, and brachytherapy for localized prostate cancer

Technologic advances in radiation treatment planning and delivery have generated popular interest in the different radiation therapy techniques used in treating patients with localized prostate cancer. Throughout the past decade, high-energy (> 4 MV) linear accelerators have largely replaced Cobalt machines in external beam radiation therapy (EBRT) delivery. Conventional EBRT has been used to treat prostate cancer successfully since the 1950s. By switching to computed tomography-based planning, three-dimensional conformal radiation therapy provides better relative conformality of dose than does conventional EBRT. Intensity-modulated radiation therapy (IMRT) has further refined dose conformality by spreading the low-dose region to a larger volume. However, the potential long-term risks of larger volumes of normal tissues receiving low doses of radiation in IMRT are unknown. Particle-beam radiation therapy offers unique dose distributions and characteristics with higher relative biologic effect and linear energy transfer. Transperineal prostate brachytherapy offers the shortest treatment time with equivalent efficacy without significant risk of radiation exposure. The addition of hormonal therapy to radiation therapy has been shown to improve the outcome of radiation therapy.

Quality of life in patients with localized prostate cancer

To date, there are no studies conclusively documenting that one treatment for localized prostate cancer is superior to another in terms of overall survival. Therefore, patients must consider other outcomes when choosing primary therapy for localized disease. One of the most important factors patients consider when choosing their treatment is the effect of therapy on their quality of life (QOL). Over the past decade, there have been an increasing number of studies assessing health related QOL (HRQOL) outcomes in localized prostate cancer. The goal of this article is to review our current understanding of HRQOL in this disease. We will begin by examining the established HRQOL instruments for use in localized prostate cancer. We will then discuss the effect of various treatments on QOL and review the literature comparing HRQOL outcomes between therapies.

Quality of life after treatment for prostate cancer

Quality of life is a major concern of patients when they are choosing treatment for prostate cancer. Health-related quality of life is a patient-centered variable from the field of health services research that can be measured in a valid and reliable manner. Using standardized questionnaires specifically developed to capture health-related quality of life data in men with prostate cancer, the effect of treatments on patients' quality of life can be studied. Patients with localized disease who are undergoing radical prostatectomy tend to have more sexual and urinary dysfunction than men undergoing external beam radiation therapy, although both groups have more impairment in these areas than age-matched controls. Men undergoing external beam radiation therapy have worse bowel function and more urinary distress from irritative voiding symptoms than men undergoing radical prostatectomy or age-matched controls. Recent studies of men undergoing interstitial brachytherapy indicate that these patients have less urinary leakage than those who undergo radical prostatectomy, but experience considerably more irritating voiding symptoms, which often profoundly affect their quality of life. Better information regarding the potential impact of prostate cancer treatment on quality of life will improve medical decision-making.

General quality of life 2 years following treatment for prostate cancer: what influences outcomes? Results from the prostate cancer outcomes study

PURPOSE

The goal of this study was to determine the relationship between primary treatment, urinary dysfunction, sexual dysfunction, and general health-related quality of life (HRQOL) in prostate cancer.

METHODS

A sample of men with newly diagnosed prostate cancer between 1994 and 1995 was randomly selected from six population-based Surveillance, Epidemiology, and End Results registries. A baseline survey was completed by 2,306 men within 6 to 12 months of diagnosis, and these men also completed a follow-up HRQOL survey 2 years after diagnosis. Logistic regression models were used to determine whether primary treatment, urinary dysfunction, and sexual dysfunction were independently associated with general HRQOL outcomes approximately 2 years after diagnosis as measured by the Medical Outcomes Study 36-item Short Form Health Survey. The magnitude of this effect was estimated using least square means models.

RESULTS

After adjustment for potential confounders, primary treatment was not associated with 2-year general HRQOL outcomes in men with prostate cancer. Urinary function and bother were independently associated with worse general HRQOL in all domains. Sexual function and bother were also independently associated with worse general HRQOL, although the relationship was not as strong as in the urinary domains.

CONCLUSION

Primary treatment is not associated with 2-year general HRQOL outcomes in prostate cancer. Although both sexual and urinary function and bother are associated with quality of life, men who are more bothered by their urination or impotence are more likely to report worse quality of life. This implies that future research should be directed toward finding ways to improve treatment-related outcomes or help patients better cope with their posttreatment urinary or sexual dysfunction.

Helping patients with localized prostate carcinoma manage uncertainty and treatment side effects: nurse-delivered psychoeducational intervention over the telephone

BACKGROUND

The objective of this study was to test the efficacy of an individualized uncertainty management intervention delivered by telephone to Caucasian and African-American men with localized prostate carcinoma and directed at managing the uncertainties of their disease and treatment.

METHODS

The authors delivered a psychoeducational intervention by phone to men with prostate carcinoma, with or without supplemented delivery to a close family member, that was directed at managing uncertainty and improving symptom control. One hundred thirty-four Caucasian men and 105 African-American men were assigned randomly to one of two approaches to delivering the intervention or to the control condition. Men entered the study immediately after surgical treatment or in the first 3 weeks of radiation therapy. Trained nurses delivered the intervention through weekly phone calls for 8 weeks.

RESULTS

The authors found that the majority of intervention effects were from baseline to 4 months postbaseline, when treatment side effects are most intense. Both Caucasian men and African-American men who received either one of the two approaches for delivering the intervention improved in the two uncertainty management methods of cognitive reframing and problem solving. Similarly, when the intervention groups were combined, men who received the intervention also improved significantly in control of incontinence by 4 months postbaseline. Decreases in the number of treatment side effects differed by time and treatment/ ethnic group interactions as did satisfaction with sexual functioning.

CONCLUSIONS

This is one of the first tests of a psychoeducational intervention among men with prostate carcinoma and was the first test that included a sufficient number of African-American men to test by ethnic group. Therefore, replication of these findings is advised.

[Conformal radiotherapy of prostatic cancer: a general review]

Recent progress in radiotherapeutic management of localized prostate cancer is reviewed. Clinical aspects--including dose-effect beyond 70 Gy, relative role of conformal radiation therapy techniques and of early hormonal treatment--are discussed as well as technical components--including patient immobilization, organ motion, prostate contouring, beam arrangement, 3-D treatment planning and portal imaging. The local control and biological relapse-free survival rates appear to be improved by high dose conformal radiotherapy from 20 to 30% for patients with intermediate and high risk of relapse. A benefit of overall survival is expected but not yet demonstrated. Late reactions, especially the rectal toxicity, remain moderate despite the dose escalation. However, conformal radiotherapy demands a high precision at all steps of the procedure.