Toxicity and health-related quality of life during and after high dose rate brachytherapy followed by external beam radiotherapy for prostate cancer

Complications and side effects of high-dose-rate prostate brachytherapy

PURPOSE

To describe technical challenges and complications encountered during and after high-dose-rate prostate brachytherapy (HDR-BT) and review management of these complications.

METHODS AND MATERIALS

The authors performed a systematic review of the literature on toxicities encountered after prostate HDR-BT +/- external beam radiotherapy. A total of 397 studies were identified, of which 64 were included. A focused review of literature regarding the management of acute and late toxicities also performed.

RESULTS

Most acute toxicities include grade 0-2 genitourinary and gastrointestinal toxicity. Overall, Grade 3+ Common Terminology Criteria for Adverse Events toxicity after HDR-BT was low [genitourinary: 0-1%; gastrointestinal 0-3%]. Rates of fistula formation were <1%, and radiation cystitis/proctitis were <14% and more commonly reported in cohorts treated with HDR-BT boost and external beam radiotherapy.

CONCLUSIONS

HDR-BT both as monotherapy or combined with external beam radiotherapy for prostate cancer is well tolerated. Serious complications are rare.

Inverse planning in high-dose rate brachytherapy improves quality of life of prostate cancer patients compared with forward planning

OBJECTIVES

To understand differences in quality of life outcomes between cases with forward planning and cases with inverse planning, we examine patients undergoing high-dose rate brachytherapy combined with external beam radiotherapy for localized prostate cancer.

METHODS

We prospectively identified 283 patients with localized prostate cancer and divided them into forward planning and inverse planning groups. We extracted data on doses to the prostate, rectum and urethra that could potentially affect quality of life. We also evaluated quality of life using the Japanese version of Medical Outcome Study 8-Items Short Form Health Survey and Expanded Prostate Cancer Index Composite at pre-treatment and at 3, 6, 12 and 24 months after treatment. Wilcoxon signed rank test and Bonferroni correction were used to analyze the irradiation dose and any change in quality of life.

RESULTS

Doses to the prostate and rectum were not significantly different between the two groups. Notably, however, doses to the urethra were significantly lower in the inverse planning group than in the forward planning group. Patients in the forward planning group had significantly poorer physical component summary scores at 3 months according to survey results. In Expanded Prostate Cancer Index Composite, patients in the forward planning group had statistically significant poorer urinary, bowel and sexual scores than those in the inverse planning group. Quality of life related to decline in sexual function was significantly reduced in the inverse planning group.

CONCLUSIONS

Inverse planning in high-dose rate brachytherapy could significantly improve quality of life of patients with prostate cancer.

Impact of age on quality of life in patients with localized prostate cancer treated with high-dose rate brachytherapy combined with external beam radiotherapy

OBJECTIVES

To evaluate age-related quality of life changes in patients with localized prostate cancer treated by high-dose rate brachytherapy combined with external beam radiation therapy.

METHODS

A total of 172 patients with clinically localized prostate cancer were categorized to age groups <75 years and ≥75 years. Changes in their quality of life were evaluated using the Japanese version of Medical Outcome Study 8-Items Short Form Health Survey, Expanded Prostate Cancer Index Composite and International Index of Erectile Function-5 at baseline, and followed up to 24 months after treatment.

RESULTS

There were no significant differences in Medical Outcome Study 8-Items Short Form Health Survey scores, and urinary and bowel scores of the Expanded Prostate Cancer Index Composite for older men after treatment. International Index of Erectile Function-5 summary scores were significantly decreased in both groups. Although sexual function and sexual bother scores were decreased in patients aged <75 years, these scores were maintained in patients aged ≥75 years.

CONCLUSIONS

Quality of life of prostate cancer patients undergoing high-dose rate brachytherapy combined with external beam radiation therapy does not seem to be significantly affected by age.

Radiation dose to rectum in high-dose-rate brachytherapy with a single implant and two fractions for prostate cancer, and its prediction by prostate volume

We aimed to clarify the differences between the estimated rectal dose (ERD) and the first measured dose (FMD) and second measured dose (SMD) to the rectum during high-dose-rate (HDR) brachytherapy, and to predict FMD from the prostate volume (PV) or the rectal dose-volume parameters (RDVPs). ERD, FMD, and SMD were assessed with a rectal dosimeter during HDR brachytherapy of 18 Gy given in two fractions to 110 patients (48 hormone recipients, 62 hormone-naïve patients) with prostate cancer. The correlations between FMD and PV, and between FMD and RDVP (D 2ml-D 5ml) were investigated. ERD (mean ± SD) was 219 ± 44 cGy, FMD was 255 ± 52 cGy, and SMD was 298 ± 63 cGy, which differed significantly (p < 0.001). The correlation coefficients between ERD and FMD, and between FMD and SMD, were 0.82 and 0.78, respectively. SMD was equivalent to 118 ± 16 % FMD. The measured doses were significantly greater in the hormone recipients than in the hormone-naïve patients (p < 0.001). The increase in FMD correlated with the increases in PV and in RDVPs. The correlation coefficients between PV and FMD in all of the patients, in the hormone recipients, and in the hormone-naïve patients were 0.61, 0.64, and 0.64, respectively, whereas that between RDVPs and FMD was <0.53. In conclusion, the dose to the rectum increased with time and was correlated with the increases in PV and RDVPs. The correlation coefficient between FMD and PV was greater than that between FMD and RDVPs.

Catheter displacement prior to the delivery of high-dose-rate brachytherapy in the treatment of prostate cancer patients

Purpose

The purpose of this work was to report measured catheter displacement prior to the delivery of high-dose-rate brachytherapy (HDR) in the treatment of prostate cancer.

Material and methods

Data from 30 prostate cancer patients treated with HDR brachytherapy were analyzed retrospectively. Eighteen transperineal hollow catheters were inserted under transrectal ultrasound guidance. Gold marker seeds were also placed transperineally into the base and apex of the prostate gland. Five treatment fractions of 7.5 Gy each were administered over 3 days. The patient underwent CT scanning prior to each treatment fraction. Catheter displacement was measured from the pre-treatment CT dataset reconstructed at 1.25 mm slice thickness.

Results

Most of catheters were displaced in the caudal direction. Variations of 18 catheters for each patient were small (standard deviations < 1 mm for all but one patient). Mean displacements relative to the apex marker were 6 ± 4 mm, 12 ± 6 mm, 12 ± 6 mm, 12 ± 6 mm, and 12 ± 6 mm from plan to 1^st, 2^nd, 3^rd, 4^th, and 5^th fractions, respectively.

Conclusions

Our results indicate that catheter positions must be confirmed and if required, adjusted, prior to every treatment fraction for the precise treatment delivery of HDR brachytherapy, and to potentially reduce over-dosage to the bulbo-membranous urethra.

Predictive factors for acute and late urinary toxicity after permanent interstitial brachytherapy in Japanese patients

OBJECTIVES

To describe the frequency of and to determine predictive factors associated with Radiation Therapy Oncology Group urinary toxicity in prostate brachytherapy patients.

METHODS

From January 2004 to April 2011, 466 consecutive Japanese patients underwent permanent iodine-125-seed brachytherapy (median follow up 48 months). International Prostate Symptom Score and Radiation Therapy Oncology Group toxicity data were prospectively collected. Prostate volume, International Prostate Symptom Score before and after brachytherapy, and postimplant analysis were examined for an association with urinary toxicity, defined as Radiation Therapy Oncology Group urinary toxicity of Grade 1 or higher. Logistic regression analysis was used to examine the factors associated with urinary toxicity.

RESULTS

The rate of Radiation Therapy Oncology Group urinary toxicity grade 1 or higher at 1, 6, 12, 24, 36 and 48 months was 67%, 40%, 21%, 31%, 27% and 28%, respectively. Grade 2 or higher urinary toxicity was less than 1% at each time-point. International Prostate Symptom Score was highest at 3 months and returned to normal 12 months after brachytherapy. On univariate analysis, patients with a larger prostate size, greater baseline International Prostate Symptom Score, higher prostate V100, higher prostate V150, higher prostate D90 and a greater number of seeds had more acute urinary toxicities at 1 month and 12 months after brachytherapy. On multivariate analysis, significant predictors for urinary toxicity at 1 month and 12 months were a greater baseline International Prostate Symptom Score and prostate V100.

CONCLUSIONS

Most urinary symptoms are tolerated and resolved within 12 months after prostate brachytherapy. Acute and late urinary toxicity after brachytherapy is strongly related to the baseline International Prostate Symptom Score and prostate V100.

Early quality of life outcomes in patients with prostate cancer managed by high-dose-rate brachytherapy as monotherapy

OBJECTIVES

To evaluate the early quality of life outcomes in prostate cancer patients managed by high-dose-rate brachytherapy as monotherapy.

METHODS

A total of 51 patients with cT1c-T3aN0M0 prostate cancer treated between July 2007 and January 2010 were included in this study. The average age was 69 years, and the average initial serum prostate-specific antigen was 10.98 ng/mL. A total of 25, 18 and eight patients were considered to be low, intermediate and high risk, respectively. All patients received one implant of Ir-192 and seven fractions of 6.5 Gy within 3.5 days for a total prescribed dose of 45.5 Gy. For high-risk prostate cancer, neoadjuvant androgen deprivation therapy was carried out for at least 6 months, and continued after high-dose-rate brachytherapy. Quality of life outcomes were measured by using the International Prostate Symptom Score, the Functional Assessment of Cancer Therapy-Prostate and the International Index of Erectile Function Questionnaire. The oncological outcome was assessed by serum prostate-specific antigen and diagnostic imaging. Adverse events were also recorded.

RESULTS

The Functional Assessment of Cancer Therapy-Prostate scores decreased for a few months after high-dose-rate brachytherapy, and recovered to pretreatment condition thereafter. The International Prostate Symptom Score significantly increased 2 weeks after treatment for each of its items and their sum, and it returned to baseline after 12 weeks. Sexual function decreased at 2 and 4 weeks, and recovered after 12 weeks. Severe complications were rare. Within a median follow up of 17.2 months, two patients showed a prostate-specific antigen recurrence.

CONCLUSIONS

High-dose-rate brachytherapy for prostate cancer is a feasible treatment modality with acceptable toxicity and only a limited impact on the quality of life.

Reirradiation of prostate cancer with rectum preservation: eradicative high-dose-rate brachytherapy with natural type hyaluronate injection

INTRODUCTION

Reirradiation of locally recurrent prostate cancer after radiotherapy is limited because of its toxicity to the rectum that is closely adjacent to the prostate. To solve geometric anatomic constraints, including rectal size and distance from the prostate, we developed a technique that modifies the geometry by noninvasive direct intervention.

METHODS AND MATERIALS

In a patient with local recurrence of prostate cancer at 18 months after initial radiotherapy of 61.8 GyE(LQ2,3) (gray equivalent in 2 Gy/fraction at α/β=3 calculated with linear quadratic [LQ] model) to the prostate, we prescribed 16 Gy (60.8 GyE(LQ2,3) or 78.2 GyE(LQ2,1.6)) of reirradiation by high-dose-rate brachytherapy, using a bolus injection of native-type hyaluronate to create and maintain a distance between the prostate and the rectum and decrease rectal size during treatment.

RESULTS

The procedure was achieved in 10min, without complications. Rectal D(2cc) of the reirradiation was 5.58 Gy (9.58 GyE(LQ2,3)). Compared with the initial radiation, the gel injection resulted in an improved therapeutic ratio. The patient was regularly followed up at our clinic; at over 3.5 years after reirradiation, there was no evidence of recurrence or radiation-related toxicities greater than Grade 2, maintaining a nadir prostate-specific antigen level of 0.03 ng/mL without hormonal therapy.

CONCLUSION

We consider that this technique is useful for achieving safe and curative reirradiation of prostate cancer.

Combined curative radiotherapy including HDR brachytherapy and androgen deprivation in localized prostate cancer: a prospective assessment of acute and late treatment toxicity

Self-reported symptoms including urinary, bowel and sexual side effects were investigated prospectively at multiple assessment points before and after combined radiotherapy of prostate cancer including HDR brachytherapy and neoadjuvant androgen deprivation therapy. Between April 2000 and June 2003, patients with predominantly advanced localized prostate tumours subjected to this treatment were asked before treatment and on follow-up visits to complete a questionnaire covering urinary, bowel and sexual problems. The mainly descriptive analyses included 525 patients, responding to at least one questionnaire before or during the period 2-34 months after radiotherapy. Adding androgen deprivation before radiotherapy significantly worsened sexual function. During radiotherapy, urinary, bowel and sexual problems increased and were reported at higher levels up to 34 months, although there seemed to be a general tendency to less pronounced irritative bowel and urinary tract symptoms over time. No side effects requiring surgery were reported. Classic late irradiation effects such as mucosal bleeding were demonstrated mainly during the second year after therapy, but appear less pronounced in comparison with dose escalated EBRT series. In conclusion, despite the high radiation dose given, the toxicity seemed comparable with that of other series but long term (5-10 years) symptom outcome has to be determined.

3-D conformal treatment of prostate cancer to 74 Gy vs. high-dose-rate brachytherapy boost: a cross-sectional quality-of-life survey

The effects of two modalities of dose-escalated radiotherapy on health-related quality of life (HRQOL) were compared. Forty-one consecutive patients were treated with a 3-D conformal (3-DC) boost to 74 Gy, and 43 with high-dose rate (HDR) brachytherapy boost (2x9 Gy), following 3-D conformal treatment to 46 Gy. Median age was 70 years in both groups, median initial PSA was 7.9 microg/l in 3-DC boost patients and 8.1 microg/l in HDR boost patients. Stage was <or=T2 in 66% and 67% and Gleason score was >or=7 in 52% and 47%, respectively. HRQOL was assessed cross-sectionally using EORTC QLQ-C30 and organ-specific PR25 modules 3--32 (median 19) and 4--25 (median 14) months after treatment, respectively. Questionnaires were completed by 93% and 97% of patients, respectively. Diarrhea and insomnia scores were significantly increased in both groups. In the PR25 module, scores of 3-DC boost and HDR boost patients for urinary, bowel and treatment-related symptoms were similar. Among responders, 34% of 3-DC boost patients and 86% of HDR boost patients had severe erectile problems. Dose escalation in prostate cancer by either 3-DC boost to 74 Gy or HDR brachytherapy boost appears to result in similar HRQOL profiles.

Genitourinary toxicity after high-dose-rate (HDR) brachytherapy combined with Hypofractionated External beam radiotherapy for localized prostate cancer: an analysis to determine the correlation between dose-volume histogram parameters in HDR brachytherapy and severity of toxicity

PURPOSE

To evaluate the severity of genitourinary (GU) toxicity in high-dose-rate (HDR) brachytherapy combined with hypofractionated external beam radiotherapy (EBRT) for prostate cancer and to explore factors that might affect the severity of GU toxicity.

METHODS AND MATERIALS

A total of 100 Japanese men with prostate cancer underwent (192)Ir HDR brachytherapy combined with hypofractionated EBRT. Mean (SD) dose to 90% of the planning target volume was 6.3 (0.7) Gy per fraction of HDR. After 5 fractions of HDR treatment, EBRT with 10 fractions of 3 Gy was administrated. The urethral volume receiving 1-15 Gy per fraction in HDR brachytherapy (V1-V15) and the dose to at least 5-100% of urethral volume in HDR brachytherapy (D5-D100) were compared between patients with Grade 3 toxicity and those with Grade 0-2 toxicity. Prostate volume, patient age, and International Prostate Symptom Score were also compared between the two groups.

RESULTS

Of the 100 patients, 6 displayed Grade 3 acute GU toxicity, and 12 displayed Grade 3 late GU toxicity. Regarding acute GU toxicity, values of V1, V2, V3, and V4 were significantly higher in patients with Grade 3 toxicity than in those with Grade 0-2 toxicity. Regarding late GU toxicity, values of D70, D80, V12, and V13 were significantly higher in patients with Grade 3 toxicity than in those with Grade 0-2 toxicity.

CONCLUSIONS

The severity of GU toxicity in HDR brachytherapy combined with hypofractionated EBRT for prostate cancer was relatively high. The volume of prostatic urethra was associated with grade of acute GU toxicity, and urethral dose was associated with grade of late GU toxicity.

Clinical outcome in patients with prostate cancer treated with external beam radiotherapy and high dose-rate iridium 192 brachytherapy boost: a 6-year follow-up

To report the long-term results for treatment of localized carcinoma of the prostate using high dose rate (HDR) brachytherapy, conformal external beam radiotherapy (3D EBRT) and neo-adjuvant hormonal therapy (TAB). From 1998 through 1999, 154 patients with localized prostate cancer were entered in the trial. Biologically no evidence of disease (bNED) was defined at PSA levels < 2 microg/l. In order to compare the results of this treatment with other treatment modalities, the patient's pre-treatment data were used to calculate the estimated 5-year PSA relapse free survival using Kattan's nomograms for radical prostatectomy (RP) and 3D EBRT. After 6 years of follow-up, 129 patients remain alive. The actual 5-year relapse-free survival is 84%. None of the patients demonstrated clinical signs of local recurrence. The median PSA at follow-up among the relapse-free patients was 0.05 microg/l. Among the 80 patients who presented with clinical stage T3 tumours, 55 (68%) were relapse-free. The expected 5-year relapse-free survival using nomograms for RP and 3D EBRT was 54% and 70%, respectively. Late rectal toxicity RTOG grade 3 occurred in 1% of the patients. Late urinary tract toxicity RTOG grade 3 developed in 4% of the patients. Combined treatment, utilizing HDR, 3D EBRT and TAB, produces good clinical results. Rectal toxicity is acceptable. Urinary tract toxicity, most likely can be explained by the fact that during the first years of this treatment, no effort was made to localize the urethra, which was assumed to be in the middle of the prostate.

Prostate Cancer Survivors' and Partners' Self-Reports of Health-Related Quality of Life, Treatment Symptoms, and Marital Satisfaction 2.5-5.5 Years After Treatment

PURPOSE/OBJECTIVES

To describe health-related quality of life (QOL), health status, and marital satisfaction of couples as many as 5.5 years after treatment for prostate cancer.

DESIGN

Survey with longitudinal, comparative, and predictive elements.

SETTING

A tertiary care nonprofit medical center in the southwestern United States.

SAMPLE

Convenience sample of prostate cancer survivors (192 enrolled, 137 completed) and their partners (126 enrolled, 104 completed). Men averaged 70 years of age, women 66. Most men (86%) and women (89%) were white, and 71% had at least some college education.

METHODS

Questionnaires were mailed annually. Women were enrolled 3.5 years after their partners were treated. Study participants received separate questionnaire packets.

MAIN RESEARCH VARIABLES

Health-related QOL, health status including post-treatment symptoms, and marital satisfaction.

FINDINGS

Men's health-related QOL, general physical health, and vitality decreased; urinary and sexual post-treatment symptoms increased. Men were concerned about their sexual functioning although few sought treatment. Couples' health-related QOL and marital satisfaction were associated more closely than their health status.

CONCLUSIONS

Regardless of type of treatment, health-related QOL and general health tend to decrease for prostate cancer survivors; men in watchful waiting tended to have poorer health outcomes. Men are concerned about sexual functioning, yet few are taking steps to remedy problems. Couples' health-related QOL and marital satisfaction are linked; however, health status indicators are less associated.

IMPLICATIONS FOR NURSING

Nurses are in a key position to assess health-related QOL and sexual functioning concerns for prostate cancer survivors and their partners.

Prostate cancer treatment and quality of life

Prostate cancer is detected today at earlier stages and in younger men than ever before. A lot of men are asymptomatic and also physically and sexually active at diagnosis, and most of them are being treated by curative procedures. These trends have led to increasing numbers of patients undergoing disease management for longer periods of time. For many patients quality of life (QoL) may be just as important as survival. Thus, QoL considerations may well be the critical factor in medical decision-making for most of them. Widespread interest in studying patient-centred outcomes has led to the development of methods for health-related QoL measurements. In fact, many questionnaires have been introduced in clinical practice to assess the impact of QoL in patients (SF-36, CARES, FACT, EORTC QLQ-C30, GRISS, UCLA PCI, PCOS). Herein we evaluate the impact of QoL on patients affected by prostate cancer and treated with watchful waiting, radical prostatectomy, radiotherapy and hormonal therapy; we have also considered the role of supportive care, including the administration of analgesics, antidepressants, corticosteroids, bisphosphonates, antiemetics and stool softeners, together with psychological support. The ultimate goal of QoL research should strongly improve medical care and concretely assist patients and physicians in treatment decision-making.

Health-related quality of life in men receiving prostate brachytherapy on RTOG 98-05

PURPOSE

To prospectively assess health-related quality of life (HRQOL) during the first year after treatment with prostate brachytherapy (PB) alone for T1c-2a prostate cancer.

MATERIALS AND METHODS

Ninety-eight patients from 24 institutions were eligible and properly entered on this study. All patients were treated with PB alone using I-125 (Oncura Model 6711). The prescription dose was 145 Gy. Three separate health-related quality of life questionnaires (HRQOL) (Functional Assessment of Cancer Therapy-Prostate [FACT-P], Sexual Adjustment Questionnaire [SAQ], and International Prostate Symptom Score [IPSS]) were self-administered before and after PB (baseline; 3, 6, 9, and 12 months after PB). The standard error of the mean (SEM) was used to analyze changes in HRQOL scores over time. Patients who improved greater than the SEM were categorized as improved; patients that declined greater than the SEM were categorized as declined; patients were otherwise categorized as stable. All changes are measured using the pretreatment HRQOL score as baseline.

RESULTS

The percentage of men who reported the ability to have an erection decreased from 73% at baseline (65% unassisted, 8% assisted) to 57% at 1 year (36% unassisted, 21% assisted). The rate of urinary incontinence increased to 14% at 6 months but had decreased to 1% at the 12-month follow-up. At 1 year after PB, 80% of men reported decreased sexual functioning according to SAQ scores. More than 60% of men reported decreased urinary function at 12 months compared with baseline.

CONCLUSIONS

This article represents the first prospective, multi-institutional study of HRQOL in men treated with PB and demonstrates that patients undergoing PB have a very high overall HRQOL. The rate of incontinence by 1 year after PB is low, but many patients continue to have obstructive symptoms at 1 year. Although 78% of 1-year respondents state that they can achieve an erection with or without assistance, almost 50% report a decrease in sexual function.

First spinal axis segment irradiation with spot-scanning proton beam delivered in the treatment of a lumbar primitive neuroectodermal tumour. Case report and review of the literature

Primary intraspinal primitive neuroectodermal tumour (PNET) is a rare tumour entity. The optimal therapeutic management is unclear but, in general, this tumour is treated with surgery followed by radiotherapy and chemotherapy. Proton beam radiation therapy (PT) offers superior dose distributional qualities compared with X- or gamma rays, as the dose deposition occurs in a modulated narrow zone called the Bragg peak. As a result, organs at risk are optimally speared. Here, we present a patient treated with the first spinal axis segment irradiation using spot-scanning PT with a single field, combined with conventional cranio-spinal axis radiotherapy after surgery and chemotherapy, and an extensive review of the literature outlining the clinical features and treatment modality of spinal PNET.

Health-related quality of life in men after treatment of localized prostate cancer with external beam radiotherapy combined with 192ir brachytherapy: A prospective study of 93 cases using the EORTC questionnaires QLQ-C30 and QLQ-PR25

PURPOSE

To describe prospectively the long-term health-related quality of life (HRQOL) and treatment-related symptoms in patients with localized prostate cancer treated with neoadjuvant androgen deprivation therapy and radical radiotherapy (RT), including external beam RT and iridium high-dose-rate brachytherapy, and to compare them with age-matched normative data.

METHODS AND MATERIALS

A total of 93 patients with T1-T3a tumors consecutively treated with definitive RT at our institution completed the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (QLQ)-C30 and QLQ-prostate specific 25-item (PR25) module twice at an 18-month interval 0-18 months after RT. Subgroups were analyzed regarding acute and late effects on symptoms and quality of life.

RESULTS

The main analysis included 80 patients who were disease free at the final assessment. The levels of HRQOL were generally high, did not change over time, and were comparable to the normative data. Symptom development (urinary, bowel, and sexual) correlated well with the known acute and late effects of radical RT and neoadjuvant androgen deprivation therapy.

CONCLUSION

Combining external beam RT and HDR brachytherapy when treating prostate cancer did not appear to impair HRQOL and was comparable to that of other brachytherapy methods. The negative contribution from late neoadjuvant androgen deprivation therapy on symptom development seemed to be substantial but mostly transitory. Additional research is needed to determine the long-term HRQOL (3-5 years), and interventional randomized studies are suggested.

Quality of life following definitive therapy for localized prostate cancer: potential impact of multiple therapies

PURPOSE OF REVIEW

Patients with clinically localized prostate cancer often undergo multiple therapies during their disease trajectory, either as planned combinations or as salvage for recurrence. Most studies of health-related quality of life in men with prostate cancer have focused on those receiving one modality or another. This review summarizes the little that is known about health-related quality of life after multiple therapies.

RECENT FINDINGS

Twelve articles are reviewed. One is more of historical interest at this time and sets the stage for the great prevalence of combination therapy with androgen ablation in men undergoing pelvic irradiation. Six deal with brachytherapy combined with external beam radiation therapy, androgen ablation, or both. Three address androgen ablation or radiation for biochemical recurrence. One presents outcomes following salvage radiation, and one summarizes results from patients undergoing salvage radiation or prostatectomy following primary treatment with the other.

SUMMARY

Combination therapy for early stage prostate cancer confers many additional decrements in health-related quality of life that must be considered when making treatment decisions, especially given the minimal differences in survival between various approaches.