Long-term quality of life after definitive treatment for prostate cancer: patient-reported outcomes in the second posttreatment decade

Definitive treatment for prostate cancer includes radical prostatectomy (RP), external beam radiation therapy (EBRT), and brachytherapy (BT). The different side effect profiles of these options are crucial factors for patients and clinicians when deciding between treatments. This study reports long‐term health‐related quality of life (HRQOL) for patients in their second decade after treatment for prostate cancer. We used a validated survey to assess urinary, bowel, and sexual function and HRQOL in a prospective cohort of patients diagnosed with localized prostate cancer 14–18 years previously. We report and compare the outcomes of patients who were initially treated with RP, EBRT, or BT. Of 230 eligible patients, the response rate was 92% (n = 211) and median follow‐up was 14.6 years. Compared to baseline, RP patients had significantly worse urinary incontinence and sexual function, EBRT patients had worse scores in all domains, and BT patients had worse urinary incontinence, urinary irritation/obstruction, and sexual function. When comparing treatment groups, RP patients underwent larger declines in urinary continence than did BT patients, and EBRT and BT patients experienced larger changes in urinary irritation/obstruction. Baseline functional status was significantly associated with long‐term function for urinary obstruction and bowel function domains. This is one of the few prospective reports on quality of life for prostate cancer patients beyond 10 years, and adds information about the late consequences of treatment choices. These data may help patients make informed decisions regarding treatment choice based on symptoms they may experience in the decades ahead.

Data Pooling and Analysis to Build a Preliminary Item Bank

Assessing bowel function (BF) in prostate cancer can help determine therapeutic trade-offs. We determined the components of BF commonly assessed in prostate cancer studies as an initial step in creating an item bank for clinical and research application. We analyzed six archived data sets representing 4,246 men with prostate cancer. Thirty-one items from validated instruments were available for analysis. Items were classified into domains (diarrhea, rectal urgency, pain, bleeding, bother/distress, and other) then subjected to conventional psychometric and item response theory (IRT) analyses. Items fit the IRT model if the ratio between observed and expected item variance was between 0.60 and 1.40. Four of 31 items had inadequate fit in at least one analysis. Poorly fitting items included bleeding (2), rectal urgency (1), and bother/distress (1). A fifth item assessing hemorrhoids was poorly correlated with other items. Our analyses supported four related components of BF: diarrhea, rectal urgency, pain, and bother/distress.

The Health Effects of Masculine Self-Esteem Following Treatment for Localized Prostate Cancer Among Gay Men

PURPOSE

To identify factors associated with masculine self-esteem in gay men following treatment for localized prostate cancer (PCa) and to determine the association between masculine self-esteem, PCa-specific factors, and mental health factors in these patients.

METHODS

A national cross-sectional survey of gay PCa survivors was conducted in 2010-2011. To be eligible for the study, men needed to be age 50 or older, reside in the United States, self-identify as gay, able to read, write, and speak English, and to have been treated for PCa at least 1 year ago. One hundred eleven men returned surveys.

RESULTS

After simultaneously adjusting for the factors in our model, men aged 50-64 years and men aged 65-74 years reported lower masculine self-esteem scores than men aged 75 years or older. Lower scores were also reported by men who reported recent severe stigma. Men who reported feeling comfortable revealing their sexual orientation to their doctor reported higher masculine self-esteem scores than men who were not. The mental component score from the SF-12 was also positively correlated with masculine self-esteem.

CONCLUSION

PCa providers are in a position to reduce feelings of stigma and promote resiliency by being aware that they might have gay patients, creating a supportive environment where gay patients can discuss specific sexual concerns, and engaging patients in treatment decisions. These efforts could help not only in reducing stigma but also in increasing masculine self-esteem, thus greatly influencing gay patients' recovery, quality of life, and compliance with follow-up care.

Patient-reported outcomes after 3-dimensional conformal, intensity-modulated, or proton beam radiotherapy for localized prostate cancer

BACKGROUND

Recent studies have suggested differing toxicity patterns for patients with prostate cancer who receive treatment with 3-dimensional conformal radiotherapy (3DCRT), intensity-modulated radiotherapy (IMRT), or proton beam therapy (PBT).

METHODS

The authors reviewed patient-reported outcomes data collected prospectively using validated instruments that assessed bowel and urinary quality of life (QOL) for patients with localized prostate cancer who received 3DCRT (n = 123), IMRT (n = 153) or PBT (n = 95). Clinically meaningful differences in mean QOL scores were defined as those exceeding half the standard deviation of the baseline mean value. Changes from baseline were compared within groups at the first post-treatment follow-up (2-3 months from the start of treatment) and at 12 months and 24 months.

RESULTS

At the first post-treatment follow-up, patients who received 3DCRT and IMRT, but not those who received PBT, reported a clinically meaningful decrement in bowel QOL. At 12 months and 24 months, all 3 cohorts reported clinically meaningful decrements in bowel QOL. Patients who received IMRT reported clinically meaningful decrements in the domains of urinary irritation/obstruction and incontinence at the first post-treatment follow-up. At 12 months, patients who received PBT, but not those who received IMRT or 3DCRT, reported a clinically meaningful decrement in the urinary irritation/obstruction domain. At 24 months, none of the 3 cohorts reported clinically meaningful changes in urinary QOL.

CONCLUSIONS

Patients who received 3DCRT, IMRT, or PBT reported distinct patterns of treatment-related QOL. Although the timing of toxicity varied between the cohorts, patients reported similar modest QOL decrements in the bowel domain and minimal QOL decrements in the urinary domains at 24 months. Prospective randomized trials are needed to further examine these differences.

Ensuring comprehensive assessment of urinary problems in prostate cancer through patient-physician concordance

OBJECTIVES

To examine the concordance between clinicians and men diagnosed with prostate cancer on a clinician-derived pathophysiological classification of the following self-reported urinary complications: storage (irritative), voiding (obstructive), and leakage/incontinence.

MATERIALS AND METHODS

Fourteen urology experts classified 37 urinary function questionnaire items into 3 primary conceptual dimensions (e.g., storage [irritative], voiding [obstructive] and urinary leakage/incontinence) that would best reflect each item's content. In addition, 218 patient participants provided responses to the 37 items. Using classifications by experts to develop the conceptual framework, the structure was tested using confirmatory factor analyses with patient data.

RESULTS

Expert consensus was achieved in the classification of 31 out of 37 items. Using the 3-factor conceptual framework and patient data, the fit indices for the overall correlated factor model suggested an acceptable overall model fit. The analyses of the separate domains showed acceptable fit for the storage/irritative domain and the leaking/incontinence domain. The dimensionality of the voiding/obstructive domain was too difficult to estimate.

CONCLUSIONS

Our analysis found items that conceptually and psychometrically support 2 constructs (leaking/incontinence and storage/irritative). The consistency of this support between the groups suggests a clinical relevance that is useful in treating patients. We have conceptual support for a third hypothesis (voiding/obstructive), although there were too few items to assess this psychometrically. Relative motivating factors of bother and urinary complaints were not addressed and remain an unmet need in this field.

Safety of early discharge for low-risk patients with febrile neutropenia: a multicenter randomized controlled trial

PURPOSE

Febrile neutropenia commonly complicates cancer chemotherapy. Outpatient treatment may reduce costs and improve patient comfort but risk progression of undetected medical problems.

PATIENTS AND METHODS

By using our validated algorithm, we identified medically stable inpatients admitted for febrile neutropenia (neutrophils < 500/μL) after chemotherapy and randomly assigned them to continued inpatient antibiotic therapy or early discharge to receive identical antibiotic treatment at home. Our primary outcome was the occurrence of any serious medical complication, defined as evidence of medical instability requiring urgent medical attention.

RESULTS

We enrolled 117 patients with 121 febrile neutropenia episodes before study termination for poor accrual. We excluded five episodes as ineligible and three because of inadequate documentation of the study outcome. Treatment groups were clinically similar, but sociodemographic imbalances occurred because of block randomization. The median presenting absolute neutrophil count was 100/μL. Hematopoietic growth factors were used in 38% of episodes. The median neutropenia duration was 4 days (range, 1 to 15 days). Five outpatients were readmitted to the hospital. Major medical complications occurred in five episodes (8%) in the hospital arm and four (9%) in the home arm (95% CI for the difference, -10% to 13%; P = .56). No study patient died. Patient-reported quality of life was similar on both arms.

CONCLUSION

We found no evidence of adverse medical consequences from home care, despite a protocol designed to detect evidence of clinical deterioration. These results should reassure clinicians who elect to treat rigorously characterized low-risk patients with febrile neutropenia in suitable outpatient settings with appropriate surveillance for unexpected clinical deterioration.

Costs of home versus inpatient treatment for fever and neutropenia: analysis of a multicenter randomized trial

PURPOSE

For patients with cancer who have febrile neutropenia, relative costs of home versus hospital treatment, including unreimbursed costs borne by patients and families, are poorly characterized. We estimated costs from a randomized trial of patients with low-risk febrile neutropenia for whom outpatient care was feasible, comparing inpatient treatment with discharge to home care after inpatient observation.

METHODS

We collected direct medical and self-reported indirect costs for 57 inpatient and 35 outpatient treatment episodes of patients enrolled in a randomized trial from 1996 through 2000. Charges from hospital bills were converted to costs using Medicare cost-to-charge ratios. Patients kept daily logs of out-of-pocket payments and time spent by informal caregivers providing care. Dollar amounts were standardized to June 2008.

RESULTS

Mean total charges for the hospital arm were 49% higher than for the home treatment arm ($16,341 v $10,977; P < .01). Mean estimated total costs for the hospital arm were 30% higher ($10,143 v $7,830; P < .01). Inspection of sparse available data suggests that payments made were similar by treatment arm. Inpatients and their caregivers spent more out of pocket than their outpatient counterparts (mean, $201 v $74; P < .01). Informal caregivers for both treatment arms reported similar time caring and lost from work.

CONCLUSION

Home intravenous antibiotic treatment was less costly than continued inpatient care for carefully selected patients with cancer having febrile neutropenia without significantly increased indirect costs or caregiver burden.

Abstract PL04-02: Efficacy of PSA screening for prostate cancer: A case-control study of Caucasian and African American Medicare beneficiaries

Background: PSA screening has become standard practice in the US although mortality data from controlled trials is lacking to assess the efficacy of screening of African American men. We investigated whether PSA screening efficacy is similar among elderly Caucasian and African American men.

Methods: This case-control study compared PSA exposure history of Surveillance, Epidemiology, and End Results (SEER) dataset-derived cases deceased from prostate cancer to that of control subjects from a linked Medicare dataset. The prostate cancer cases include males diagnosed with prostate cancer between 1992 and 2005 that subsequently died from the disease (matched with 3:1 on race, age, and SEER region).

Results: We identified 8,846 cases deceased from prostate cancer, and 23,538 age-, race-, and SEER site-matched controls. African Americans comprised about 10% of both the cases (779) and controls (2,337). Conditional logistic regression analyses were used to calculate prostate cancer-specific mortality among African American (1.09 [95% CI 0.917–1.303]) and Caucasian subjects (1.14 [95% CI 1.076–1.201]) who were asymptomatic at the time of their PSA screening test.

Conclusions: The results of this large, claims-based, case-control study suggest that the efficacy of PSA screening among elderly African American men is not dissimilar to that of elderly Caucasian men, and that neither group benefitted from reduced mortality attributable to screening.

Citation Information: Cancer Epidemiol Biomarkers Prev 2011;20(10 Suppl):PL04-02.

Patient-reported long-term outcomes after conventional and high-dose combined proton and photon radiation for early prostate cancer

CONTEXT

Increased radiation doses improve prostate cancer control but also increase toxicity to adjacent normal tissue. Proton radiation may attenuate adverse effects.

OBJECTIVE

To determine long-term, patient-reported, dose-related toxicity.

DESIGN, SETTING, AND PATIENTS

We performed a post hoc cross-sectional survey of surviving participants in the Proton Radiation Oncology Group (PROG) 9509--a randomized trial comparing 70.2 Gy vs 79.2 Gy of combined photon and proton radiation for 393 men with clinically localized prostate cancer (stage T1b-T2b, prostate-specific antigen <15 ng/mL, and no radiographic evidence of metastasis). The estimated 10-year biochemical progression rate for patients receiving standard dose was 32% (95% confidence interval, 26%-39%) compared with 17% (95% confidence interval, 11%-23%) for patients receiving high dose (P < .001). We surveyed 280 of the surviving 337 patients (83%) from April 2007 to September 2008.

MAIN OUTCOME MEASURES

Prostate Cancer Symptom Indices, a validated measure of urinary incontinence, urinary obstruction and irritation, bowel problems, and sexual dysfunction, and related quality-of-life instruments.

RESULTS

At a median of 9.4 years after treatment (range, 7.4-12.1 years), participants' demographic and clinical characteristics were similar. Patient-reported outcomes were reported as mean (SD) scale score for standard dose vs high dose: urinary obstruction/irritation (23.3 [13.7] vs 24.6 [14.0]; P = .36), urinary incontinence (10.6 [17.7] vs 9.7 [15.8]; P = .99), bowel problems (7.7 [7.8] vs 7.9 [9.1]; P = .70), sexual dysfunction (68.2 [34.6] vs 65.9 [34.7]; P = .65), and most other outcomes were also similar, although patients receiving standard dose whose cancers had more often progressed expressed less confidence that their cancers were under control (mean [SD] scale score for standard dose, 76.0 [25.4] vs high dose, 86.2 [17.9]; P < .001). Many patients characterized their urinary and bowel function as normal despite reporting symptoms that, for other prostate cancer patients before and early after cancer treatment, caused substantial distress.

CONCLUSION

Among men with clinically localized prostate cancer, treatment with higher-dose radiation compared with standard dose was not associated with an increase in patient-reported prostate cancer symptoms after a median of 9.4 years.

Racial differences in trust and regular source of patient care and the implications for prostate cancer screening use

BACKGROUND

: Nonmedical factors may modify the biological risk of prostate cancer (PCa) and contribute to the differential use of early detection; curative care; and, ultimately, greater racial disparities in PCa mortality. In this study, the authors examined patients' usual source of care, continuity of care, and mistrust of physicians and their association with racial differences in PCa screening.

METHODS

: Study nurses conducted in-home interviews of 1031 African-American men and Caucasian-American men aged > or =50 years in North Carolina and Louisiana within weeks of their PCa diagnosis. Medical records were abstracted, and the data were used to conduct bivariate and multivariate analyses.

RESULTS

: Compared with African Americans, Caucasian Americans exhibited higher physician trust scores and a greater likelihood of reporting a physician office as their usual source of care, seeing the same physician at regular medical encounters, and historically using any PCa screening. Seeing the same physician for regular care was associated with greater trust and screening use. Men who reported their usual source of care as a physician office, hospital clinic, or Veterans Administration facility were more likely to report prior PCa screening than other men. In multivariate regression analysis, seeing the same provider remained associated with prior screening use, whereas both race and trust lost their association with prior screening.

CONCLUSIONS

: The current results indicated that systems factors, including those that differ among different sources of care and those associated with the continuity of care, may provide tangible targets to address disparities in the use of PCa early detection, may attenuate racial differences in PCa screening use, and may contribute to reduced racial disparities in PCa mortality. Cancer 2009. Published 2009 by the American Cancer Society.

Race, healthcare access and physician trust among prostate cancer patients

OBJECTIVE

To study the effect of healthcare access and other characteristics on physician trust among black and white prostate cancer patients.

METHODS

A three-timepoint follow-up telephone survey after cancer diagnosis was conducted. This study analyzed data on 474 patients and their 1,320 interviews over three time periods.

RESULTS

Among other subpopulations, black patients who delayed seeking care had physician trust levels that were far lower than that of both Caucasians as well as that of the black patients overall. Black patients had greater variability in their levels of physician trust compared to their white counterparts.

CONCLUSIONS

Both race and access are important in explaining overall lower levels and greater variability in physician trust among black prostate cancer patients. Access barriers among black patients may spill over to the clinical encounter in the form of less physician trust, potentially contributing to racial disparities in treatment received and subsequent outcomes. Policy efforts to address the racial disparities in prostate cancer should prioritize improving healthcare access among minority groups.

Individualizing quality-of-life outcomes reporting: how localized prostate cancer treatments affect patients with different levels of baseline urinary, bowel, and sexual function

PURPOSE

Although it is the most powerful predictor of early prostate cancer treatment-related complications and quality-of-life (QOL) outcomes, most studies do not stratify results by baseline function. Further, reporting functional outcomes as averaged numerical results may obscure informatively disparate courses. Using levels of treatment-related dysfunction, we address these problems and present the final QOL outcomes of our prospective cohort study of patients with early prostate cancer.

METHODS

We created categories for sexual, bowel, and urinary function, measured using numerical scores of the validated Prostate Cancer Symptom Indices and stratified into "normal," "intermediate" and "poor" levels of function by incorporating patient-reported symptom and distress information. We present QOL outcomes for 409 patients 36 months after radical prostatectomy, external-beam radiation therapy, and brachytherapy.

RESULTS

Different levels of baseline sexual, bowel, and urinary function produced distinctive treatment-related changes from baseline to 36 months. In general, the average scale increases in dysfunction were greatest among patients with normal baseline function, although patients with normal and intermediate baseline function had similar increases in sexual dysfunction. For patients whose baseline urinary obstruction/irritation was poor, both average scale scores and most patients' level of function improved after treatment, particularly after surgery.

CONCLUSION

The use of functional levels to stratify treatment-related outcomes by pretreatment functional status and to display the proportions of patients with improved, stable, or worsened function after treatment provides information that more specifically conveys the expected impact of treatment to patients choosing among localized prostate cancer treatments.

Perceived family history risk and symptomatic diagnosis of prostate cancer: the North Carolina Prostate Cancer Outcomes study

BACKGROUND

Prostate cancer (PrCA) is the most common cancer and the second leading cause of cancer death among US men. African American (AA) men remain at significantly greater risk of PrCA diagnosis and mortality than other men. Many factors contribute to the experienced disparities.

METHODS

Guided by the Health Belief Model, the authors surveyed a population of AA and Caucasian men newly diagnosed with PrCA to describe racial differences in perceived risk of PrCA and to examine whether 1) perceived high risk predicts greater personal responsibility for prostate care; and 2) greater personal responsibility for prostate care predicts earlier, presymptomatic diagnosis. Multivariate general linear modeling was performed.

RESULTS

The authors found that men with a PrCA family history appreciated their increased risk, but AA men with a family history were less likely to appreciate their increased risk. Nevertheless, neither reporting a PrCA family history nor perceived increased risk significantly predicted screening and preventive behaviors. Furthermore, higher physician trust predicted increased likelihood to have regular prostate exams and screening, indicating that the racial differences in seeking prostate care may be mediated through physician trust. Expressed personal responsibility for screening and more frequent preventive behaviors were associated with more frequent screening diagnoses, fewer symptomatic diagnoses, and less frequent advanced cancers.

CONCLUSIONS

Together, these results indicate that appreciating greater risk for PrCA is not sufficient to ensure that men will intend, or be able, to act. Increased trust in physicians may be a useful, central marker that efforts to reduce disparities in access to medical care are succeeding.

Outcomes and cost of outpatient or inpatient management of 712 patients with febrile neutropenia

PURPOSE

We retrospectively compared the outcomes and costs of outpatient and inpatient management of low-risk outpatients who presented to an emergency department with febrile neutropenia (FN).

PATIENTS AND METHODS

A single episode of FN was randomly chosen from each of 712 consecutive, low-risk solid tumor outpatients who had been treated prospectively on a clinical pathway (1997-2003). Their medical records were reviewed retrospectively for overall success (resolution of all signs and symptoms of infection without modification of antibiotics, major medical complications, or intensive care unit admission) and nine secondary outcomes. Outcomes were assessed by physician investigators who were blinded to management strategy. Outcomes and costs (payer's perspective) in 529 low-risk outpatients were compared with 123 low-risk patients who were psychosocially ineligible for outpatient management (no access to caregiver, telephone, or transportation; residence > 30 minutes from treating center; poor compliance with previous outpatient therapy) using univariate statistical tests.

RESULTS

Overall success was 80% among low-risk outpatients and 79% among low-risk inpatients. Response to initial antibiotics was 81% among outpatients and 80% among inpatients (P = .94); 21% of those initially treated as outpatients subsequently required hospitalization. All patients ultimately responded to antibiotics; there were no deaths. Serious complications were rare (1%) and equally frequent between the groups. The mean cost of therapy among inpatients was double that of outpatients ($15,231 v $7,772; P < .001).

CONCLUSION

Outpatient management of low-risk patients with FN is as safe and effective as inpatient management of low-risk patients and is significantly less costly.

Outcomes and cost of outpatient or inpatient management of 712 patients with febrile neutropenia

PURPOSE

We retrospectively compared the outcomes and costs of outpatient and inpatient management of low-risk outpatients who presented to an emergency department with febrile neutropenia (FN).

PATIENTS AND METHODS

A single episode of FN was randomly chosen from each of 712 consecutive, low-risk solid tumor outpatients who had been treated prospectively on a clinical pathway (1997-2003). Their medical records were reviewed retrospectively for overall success (resolution of all signs and symptoms of infection without modification of antibiotics, major medical complications, or intensive care unit admission) and nine secondary outcomes. Outcomes were assessed by physician investigators who were blinded to management strategy. Outcomes and costs (payer's perspective) in 529 low-risk outpatients were compared with 123 low-risk patients who were psychosocially ineligible for outpatient management (no access to caregiver, telephone, or transportation; residence > 30 minutes from treating center; poor compliance with previous outpatient therapy) using univariate statistical tests.

RESULTS

Overall success was 80% among low-risk outpatients and 79% among low-risk inpatients. Response to initial antibiotics was 81% among outpatients and 80% among inpatients (P = .94); 21% of those initially treated as outpatients subsequently required hospitalization. All patients ultimately responded to antibiotics; there were no deaths. Serious complications were rare (1%) and equally frequent between the groups. The mean cost of therapy among inpatients was double that of outpatients ($15,231 v $7,772; P < .001).

CONCLUSION

Outpatient management of low-risk patients with FN is as safe and effective as inpatient management of low-risk patients and is significantly less costly.

Measuring perceived effects of drinking an extract of basidiomycetes Agaricus blazei Murill: a survey of Japanese consumers with cancer

Background

To survey cancer patients who consume an extract of the Basidiomycetes Agaricus blazei Murill mushroom (Sen-Sei-Ro) to measure their self-assessment of its effects and to develop an instrument for use in future randomized trials.

Methods

We designed, translated and mailed a survey to 2,346 Japanese consumers of Sen-Sei-Ro self-designated as cancer patients. The survey assessed consumer demographics, cancer history, Sen-Sei-Ro consumption, and its perceived effects. We performed exploratory psychometric analyses to identify distinct, multi-item scales that could summarize perceptions of effects.

Results

We received completed questionnaires from 782 (33%) of the sampled Sen-Sei-Ro consumers with a cancer history. Respondents represented a broad range of cancer patients familiar with Sen-Sei-Ro. Nearly all had begun consumption after their cancer diagnosis. These consumers expressed consistently positive views, though not extremely so, with more benefit reported for more abstract benefits such as emotional and physical well-being than relief of specific symptoms. We identified two conceptually and empirically distinct and internally consistent summary scales measuring Sen-Sei-Ro consumers' perceptions of its effects, Relief of Symptoms and Functional Well-being (Cronbach's alpha: Relief of Symptoms, α = .74; Functional Well-Being, α = .91).

Conclusion

Respondents to our survey of Sen-Sei-Ro consumers with cancer reported favorable perceived effects from its use. Our instrument, when further validated, may be a useful outcome in trials assessing this and other complementary and alternative medicine (CAM) substances in cancer patients.

Hidden barriers between knowledge and behavior: the North Carolina prostate cancer screening and treatment experience

BACKGROUND

Prostate cancer (PC) mortality is much greater for African American than for Caucasian men. To identify patient factors that might account for some of this disparity, men within 6 months of diagnosis were surveyed about health attitudes and behavior.

METHODS

Using Rapid Identification in the North Carolina Cancer Registry, 207 African American and 348 Caucasian recently diagnosed PC patients were identified and surveyed.

RESULTS

African American men were younger and less often currently married, and had lesser education, job status, and income than Caucasian men (all P < .001). African American men were at no greater distance to medical care, but had less access: poorer medical insurance coverage, more use of public clinics and emergency wards, less continuity with a primary physician, and more often omitted physician visits they felt they needed. They also expressed less trust in physicians. African American men acknowledged their greater risk of PC, accepted greater responsibility for their health, and reported more personal failures that delayed diagnosis. African American men more often requested the tests that diagnosed their cancers, which resulted more often from routinely ordered screening tests for Caucasian men. African American men expressed less interest in nontraditional treatments.

CONCLUSIONS

Despite lesser education, African American men in North Carolina are aware of their increased risk of cancer, the importance of treatment, and their responsibility for their health. Obstacles to timely diagnosis and appropriate care, including greater physician distrust, appear more likely to arise from reduced access and continuity of medical care arising from their worse socioeconomic position.

Racial differences in clinical progression among Medicare recipients after treatment for localized prostate cancer (United States)

OBJECTIVE

Prostate cancer recurrence impacts patient quality of life and risk of prostate-cancer specific death following definitive treatment. We investigate differences in disease-free survival among white, black, Hispanic, and Asian patients in a large, population-based database.

METHODS

Merged Surveillance, Epidemiology, and End Results Program (SEER) and Medicare files provided data on 23,353 white patients, 2,814 black patients, 480 Hispanic patients, and 566 Asian patients diagnosed at age 65-84 years with clinically localized prostate cancer between 1986 and 1996 in five SEER sites. Patients were followed through 1998. Racial differences in disease-free survival were assessed using Kaplan-Meier survival curves and Cox regression models.

RESULTS

The 75th percentile disease-free survival time for black patients was 13 months less than that for white patients (95% confidence interval [CI]: 6.2-19.8 months), 29.7 months less than that for Hispanic patients (95% CI: 4.4-55.0 months), and 39.1 months less than that for Asian patients (95% CI: 12.1-66.1 months). In multivariate analysis, black race predicted shorter disease-free survival among surgery patients, but not among radiation patients.

CONCLUSIONS

Black patients experienced shorter disease-free survival compared to white, Hispanic, and Asian patients, and the disease-free survival of white, Hispanic, and Asian patients were not statistically different. Earlier recurrence of prostate cancer may help explain black patients' increased risk of mortality from prostate cancer.

Bringing prostate cancer quality of life research back to the bedside: translating numbers into a format that patients can understand

PURPOSE

Although measuring quality of life of patients with prostate cancer serves important research goals, its primary clinical purpose is informing patients. Sophisticated quality of life measures produce purely numerical results that patients have difficulty understanding. We present an approach that preserves the methodological strengths of validated multi-item measures but provides more accessible information for clinical use.

MATERIALS AND METHODS

Using validated indexes measuring urinary, bowel and sexual function we surveyed patients with clinically localized prostate cancer before treatment and at intervals thereafter. Based on patient responses to parallel distress measures we defined 3 levels of function, including normal-no abnormal symptom, intermediate-any abnormal symptom but none severely abnormal and poor-any severely abnormal symptom. We then translated patient survey results into these levels. To assess measurement properties we compared average symptom distress scores in patients at each symptom level.

RESULTS

Levels of function and patient distress scores correlated strongly. Large and approximately equal differences in distress scores separated patients at successive levels in all symptom indexes (effect size greater than 1.2, p < 0.0001). Using these categories we created tables showing 24-month outcomes in 417 previously reported patients by pretreatment symptom level and treatment, providing a tool for patients to determine posttreatment outcomes in similar patients.

CONCLUSIONS

Using symptom indexes to define levels of function produces a quality of life metric that is valid, defines quantitative intervals, is transparent and may be more useful to patients. This approach provides methodologically sound outcome information to patients attempting to choose a prostate cancer treatment.

Confidence and Uncertainty Long After Initial Treatment for Early Prostate Cancer: Survivors' Views of Cancer Control and the Treatment Decisions They Made

Purpose

The many years most men diagnosed with early prostate cancer live after diagnosis allow evolving assessments of their cancer control and their treatment choices, but little is known of these outcomes or the factors that influence them.

Patients and Methods

We surveyed an established, prospective cohort that had initiated treatment for early prostate cancer 4 to 8 years previously. We assessed perceived cancer control, quality of treatment decisions, and other domains of quality of life, along with treatment-related urinary, bowel, and sexual dysfunction.

Results

Most men reported high confidence in cancer control and their treatment decisions, but many reported misgivings about one or both. The diagnostic, treatment, and quality-of-life factors associated with these two outcomes were distinct. Perceived cancer control was lower among those with adverse medical factors: higher pretreatment Gleason scores, subsequent rises in prostate-specific antigen (PSA), and secondary androgen ablation therapy. Confidence in treatment decisions was unrelated to these factors and was higher in men who opted for radical prostatectomy or brachytherapy, reported close attention to current PSA, had high masculine self-esteem and little distress from sexual dysfunction, and were married.

Conclusion

Although perceptions of cancer control and the quality of their treatment decisions are linked, men can distinguish between these two outcomes. They incorporate objective indicators of high risk and adverse outcomes when assessing their cancer control; confidence in treatment decisions represents a more complex psychosocial adjustment to the persistent uncertainty that originates with their diagnosis.

Suspected spinal cord compression in cancer patients: a multidisciplinary risk assessment

Investigators involved in this study sought to identify independent clinical predictors of spinal cord compression (SCC) in cancer patients by analyzing a comprehensive set of potential risk factors based on the results of spine magnetic resonance imaging (MRI). In all, the investigators analyzed 136 episodes of suspected SCC among 134 cancer patients evaluated with spine MRI. Each subject was interviewed within 7 days of the spine MRI to collect accurate self-reported symptom data. Neurologic examination data were detailed by the physician examining the subject prior to the spine MRI; uniform demographic and clinical information regarding the subject's cancer history was abstracted from the medical record. Multivariable logistic regression analysis was used to identify independent predictors of SCC. Clinically significant SCC was defined as thecal sac compression (TSC), which occurred in 50 episodes (37%). Four independent predictors of TSC were identified and included information from the neurologic examination (abnormal neurologic examination), subject-reported symptoms (middle or upper back pain), and the oncologic history (known vertebral metastases and metastatic disease at initial diagnosis). These four predictors stratified patients experiencing episodes into subgroups with varying risks of TSC, ranging from 8% (no risk factors) to 81% (three or four risk factors). These results confirmed earlier retrospective studies indicating that the evaluation of cancer patients with suspected SCC should be based upon clinical information that includes cancer-related history, symptom data,and the presence of pertinent neurologic signs. These predictors may help clinicians to assess risk in this patient population.

Patient-reported acute gastrointestinal toxicity in men receiving 3-dimensional conformal radiation therapy for prostate cancer with or without neoadjuvant androgen suppression therapy

OBJECTIVE

To investigate the impact of 2 months of neoadjuvant and 2 months of concurrent hormonal therapy on the acute gastrointestinal (GI) toxicities associated with 3-dimensional conformal radiation therapy (3D-CRT) for prostate adenocarcinoma.

METHODS

The study cohort consisted of 80 men who underwent 3D-CRT with (n=40) or without (n=40) neoadjuvant and concurrent hormonal therapy. Computerized tomography-based planning occurred after neoadjuvant hormonal therapy. All patients completed a previously validated, quality-of-life self-assessment tool on 7 GI symptoms, including diarrhea, urgency, pain, rectal bleeding, cramping, mucus, and tenesmus, at baseline and weekly during radiation therapy.

RESULTS

Patients who received hormonal therapy were more likely to have T2b, T2c, T3a, or T3b (P<0.001) or Gleason score 7, 8, or 9 (P=0.02) disease compared to those that did not. The dose delivered to the planning target volume was 70 Gy for both groups. Median radiation treatment volume was numerically smaller for the hormone group but not to a statistically significant degree (949 vs. 1043 cc, P=0.30). Patients who received hormonal therapy had less rectal pain (P<0.01) and tenesmus (P=0.02) but more rectal mucus (P=0.03) compared to those who did not.

CONCLUSIONS

Prostate gland volume reduction after androgen suppression therapy may reduce patient-reported acute GI toxicities associated with 3D-CRT for prostate cancer.

Quality of life in prostate cancer

Little more than a decade ago, measurements of health-related quality of life (HRQOL) of prostate cancer patients began to enter the medical literature. Initially controversial and of little apparent relevance to clinical care, HRQOL has grown in importance in prostate cancer to the point that providing it in treatment discussions is now considered a core element of clinical care. The United States (US) Food and Drug Administration has used it to make approval decisions for prostate cancer drugs, and Europeans have endorsed its central role in prostate cancer as well [Altwein J, Ekman P, Barry M, et al. How is quality of life in prostate cancer patients influenced by modern treatment? The Wallenberg symposium. Urology 1997, 49(Suppl 4A), 66-76.]. We propose to characterise the treatment dilemmas facing patients with prostate cancer, the clinical relevance of HRQOL research, its central conceptual elements, the characteristics of some available instruments to measure it, the use of HRQOL in clinical studies, and some of the remaining challenges we have identified during our 13 years in the field.

American Society of Clinical Oncology recommendations for the initial hormonal management of androgen-sensitive metastatic, recurrent, or progressive prostate cancer

PURPOSE

To develop a clinical practice guideline for the management of men with metastatic, recurrent, or progressive carcinoma of the prostate. The focus of this document is on the use, combinations, and timing of various forms of androgen deprivation therapy (ADT) for the palliation of men with androgen-sensitive disease.

METHODS

An expert panel and writing committee were formed. The questions to be addressed by the guideline were determined, and a systematic review of the literature was performed, which included a search of online databases, bibliographic review, and consultation with content experts. A priori criteria were used to select studies for analysis and study authors were contacted when necessary.

RESULTS

There were 10 randomized controlled trials, six systematic reviews, and one Markov model available to inform the guidelines.

CONCLUSION

A full discussion between practitioner and patient should occur to determine which therapy is best for the patient. Bilateral orchiectomy or luteinizing hormone releasing hormone agonists are the recommended initial treatments. Nonsteroidal antiandrogen therapy may be discussed as an alternative, but steroidal antiandrogens should not be offered as monotherapy. Patients willing to accept the increased toxicity of combined androgen blockage for a small benefit in survival should be offered nonsteroidal antiandrogen in addition to castrate therapy. Until data from studies using modern medical diagnostic/biochemical tests and standardized follow-up schedules become available, no specific recommendations can be issued regarding the question of early versus deferred ADT. A discussion about the pros and cons of early versus deferred ADT should occur.

Assessing a Prostate Cancer Brachytherapy Technique Using Early Patient-Reported Symptoms: A Potential Early Indicator for Technology Assessment?

Brachytherapy for early prostate cancer can cause long-term urinary, bowel, and sexual dysfunction. Modifying technique may mitigate complications, but definitive outcome assessment requires long-term follow-up. Although radiation dose plausibly mediates all treatment-related toxicity, short-term symptoms may indicate long-term outcomes. We sought an early indication of whether a modified brachytherapy technique successfully decreased toxicity in the anticipated direction by assessing changes in symptoms and symptom distress 3 months after treatment. In a prospective study of clinically localized prostate cancer using a validated, patient-reported questionnaire, we assessed 85 men, whose primary treatment was brachytherapy alone, prior to treatment and 3 months after the procedure. Twenty-two men received standard ultrasound-guided brachytherapy (SB), and 63 men received magnetic resonance imaging-guided brachytherapy (MB), a technique intended to decrease urinary toxicity by reducing urethral irradiation. Patient age and other sociodemographic variables were similar in the 2 groups. The MB group experienced a greater increase in urinary obstruction/irritation symptoms (P = 0.02) and sexual function distress, but not sexual dysfunction (P = 0.22), whereas the SB group reported a smaller increase in bowel symptoms (P = 0.04) and bowel distress (P = 0.02). We found reduced short-term urinary obstruction/irritation and increased bowel problems after MB consistent with the hypothesized effects of the modified technique, although no obvious mechanism explains the decreased sexual function distress in MB patients. Whether these short-term changes predict long-term outcome differences will require much longer follow-up. However, these results suggest that measuring early symptoms may indicate whether an altered brachytherapy treatment technique has intended favorable consequences, potentially accelerating technology assessment.

Racial differences in mortality among Medicare recipients after treatment for localized prostate cancer

BACKGROUND

Prostate cancer mortality is higher among black American men than among white American men. We investigated whether racial disparities in outcomes of clinically localized prostate cancer vary by treatment (surgery, radiation therapy, or nonaggressive treatment).

METHODS

Merged Surveillance, Epidemiology, and End Results Program (SEER) and Medicare files provided data (on treatment modality, age, race, cancer stage, tumor grade, census tract socioeconomic status, and date of death) on 5747 black and 38 242 white patients diagnosed at age 65-84 years with clinically localized prostate cancer between 1986 and 1996 in five SEER sites. Patients were followed through 1998. Racial differences in survival outcomes were assessed using Kaplan-Meier survival curves and Cox regression models.

RESULTS

The median survival time for black patients was 1.7 years (95% confidence interval [CI] = 1.6 to 1.9 years) less than that for white patients. Median survival in black patients relative to white patients was 1.8 years (95% CI = 1.5 to 2.0 years) less among those who had surgery, 0.7 years (95% CI = 0.5 to 1.0 years) less among those who had radiation therapy, and 1.0 years (95% CI = 0.7 to 1.1 years) less among those who had nonaggressive treatment. Racial disparities were evident both in overall survival and in prostate cancer-specific survival, before and after statistical adjustment for covariates.

CONCLUSIONS

Black patients' poorer overall survival from localized prostate cancer varies by initial treatment, with the survival gap being largest among patients undergoing surgery. Investigating these treatment-specific differences may clarify the mechanisms underlying worse outcomes for black patients in the health care system.

Organ conservation in invasive bladder cancer by transurethral resection, chemotherapy and radiation: results of a urodynamic and quality of life study on long-term survivors

PURPOSE

Transurethral resection, chemotherapy and radiation with salvage cystectomy may be used as alternatives to immediate radical cystectomy in the management of invasive bladder cancer. Concern exists about the function of the retained bladder after such therapy.

MATERIALS AND METHODS

Of 221 patients with clinical T2-4a bladder cancer treated at Massachusetts General Hospital from 1986 to 2000 with trimodality therapy, 71 were alive with native bladders and disease-free in 2001. These patients were asked to undergo a urodynamic study and to complete a quality of life questionnaire. A total of 69% participated in some component of this study with a median time from trimodality therapy of 6.3 years (range 1.6 to 14.9).

RESULTS

Of 32 patients 24 had normally functioning bladders by urodynamic study. Decreased bladder compliance was seen in 7. Bladder hypersensitivity, involuntary detrusor contractions and incontinence were present in 2 women. The questionnaire showed that flow symptoms occurred in 6%, urgency in 15% and control problems in 19%. Of all women 11% wore pads. Distress from urinary symptoms was half as common as prevalence. Bowel symptoms occurred in 22% with 14% recording any level of distress. The majority of men retained sexual function. Global health related quality of life was high.

CONCLUSIONS

The majority of patients treated with trimodality therapy retain good bladder function. A fifth have evidence of bowel dysfunction.

Time course and predictors of symptoms after primary prostate cancer therapy

PURPOSE

Understanding the distinctive patterns of treatment-related dysfunction after alternative initial treatments for early prostate cancer (PC) may improve patients' choice of treatment and later help them adjust to its consequences. We characterized the time course of treatment complications while adjusting for potentially confounding pretreatment factors hindering other observational studies.

PATIENTS AND METHODS

In a prospective cohort study of 417 men we assessed urinary, bowel, and sexual function from before primary treatment to 24 months after. To control for potential confounding, we measured sociodemographic and PC prognostic factors, medical comorbidity, and pretreatment function commonly affected by PC and its treatment.

RESULTS

Patients who underwent external beam radiotherapy (EBRT), radical prostatectomy (RP), and brachytherapy (BT) differed significantly in sociodemographic factors, cancer prognostic factors, and pretreatment symptom status, especially sexual function. Urinary incontinence increased sharply after RP, while bowel problems and urinary irritation/obstruction rose after EBRT and BT. Sexual dysfunction increased in all patients, particularly after radical prostatectomy, and nerve-sparing surgical technique had little apparent benefit. There was no change in urinary function and little change in overall bowel function after 12 months, but the time course of sexual dysfunction varied by treatment and, for bowel function, by symptom. Multiple regression modeling confirmed that treatment influences all 24-month outcomes, but residual confounding persisted.

CONCLUSION

Pretreatment function and the primary treatment modality for early stage PC strongly predict the affected organ systems and time course of dysfunction. With this information, patients and their physicians may refine their choice of treatment and better anticipate its consequences.

Patients' perceptions of quality of life after treatment for early prostate cancer

PURPOSE

Treatment for early prostate cancer produces problematic physical side effects, but prior studies have found little influence on patients' perceived health status. We examined psychosocial outcomes of treatment for early prostate cancer.

PATIENTS AND METHODS

Patients with previously treated prostate cancer and a reference group of men with a normal prostate-specific antigen (PSA) level and no history of prostate cancer completed questionnaires. Innovative scales assessed behavioral consequences of urinary dysfunction, sexuality, health worry, PSA concern, perceived cancer control, treatment decision making, decision regret, and cancer-related outlook. Urinary, bowel, and sexual dysfunction were assessed with symptom indexes; health status was assessed by the Physical and Mental Summaries of the Short Form (SF-12) Health Survey.

RESULTS

Compared with men without prostate cancer, prostate cancer patients reported greater urinary, bowel, and sexual dysfunction, but similar health status. They reported worse problems of urinary control, sexual intimacy and confidence, and masculinity, and greater PSA concern. Perceptions of cancer control and treatment decisions were positive, but varied by treatment: prostatectomy patients indicated the highest and observation patients indicated the lowest cancer control. Bowel and sexual dysfunction were associated with poorer sexual intimacy, masculinity, and perceived cancer control; masculinity and PSA concern were associated with greater confidence in treatment choice; and diminished sexual intimacy and less interest in PSA were associated with greater regret.

CONCLUSION

The lack of change in global measures of health status after treatment for early prostate cancer obscures important influences in men's lives; cancer diagnosis and treatment complications may result in complex outcomes. Aggressive treatment may confer confidence in cancer control, yet be countered by diminished intimate relationships and masculinity, which accompany sexual dysfunction.

Patients' perceptions of quality of life after treatment for early prostate cancer

PURPOSE

Treatment for early prostate cancer produces problematic physical side effects, but prior studies have found little influence on patients' perceived health status. We examined psychosocial outcomes of treatment for early prostate cancer.

PATIENTS AND METHODS

Patients with previously treated prostate cancer and a reference group of men with a normal prostate-specific antigen (PSA) level and no history of prostate cancer completed questionnaires. Innovative scales assessed behavioral consequences of urinary dysfunction, sexuality, health worry, PSA concern, perceived cancer control, treatment decision making, decision regret, and cancer-related outlook. Urinary, bowel, and sexual dysfunction were assessed with symptom indexes; health status was assessed by the Physical and Mental Summaries of the Short Form (SF-12) Health Survey.

RESULTS

Compared with men without prostate cancer, prostate cancer patients reported greater urinary, bowel, and sexual dysfunction, but similar health status. They reported worse problems of urinary control, sexual intimacy and confidence, and masculinity, and greater PSA concern. Perceptions of cancer control and treatment decisions were positive, but varied by treatment: prostatectomy patients indicated the highest and observation patients indicated the lowest cancer control. Bowel and sexual dysfunction were associated with poorer sexual intimacy, masculinity, and perceived cancer control; masculinity and PSA concern were associated with greater confidence in treatment choice; and diminished sexual intimacy and less interest in PSA were associated with greater regret.

CONCLUSION

The lack of change in global measures of health status after treatment for early prostate cancer obscures important influences in men's lives; cancer diagnosis and treatment complications may result in complex outcomes. Aggressive treatment may confer confidence in cancer control, yet be countered by diminished intimate relationships and masculinity, which accompany sexual dysfunction.

Measuring patients' perceptions of the outcomes of treatment for early prostate cancer

BACKGROUND

Compared with careful attention to the physical (eg, urinary, bowel, sexual) dysfunction that may follow treatment, little attention has been given to the behavioral, emotional, and interpersonal changes that the diagnosis of early prostate cancer and subsequent physical dysfunction may bring.

OBJECTIVE

To construct patient-centered measures of the outcomes of treatment for early prostate cancer.

RESEARCH DESIGN

Qualitative study followed by survey of early prostate cancer patients and group of comparable patients with no history of prostate cancer. Analysis of focus groups identified relevant domains of quality of life, which were represented by Likert scale items included in survey questionnaires. Psychometric analyses of survey data defined scales evaluated with respect to internal consistency and validity.

RESULTS

Qualitative analysis identified three domains: urinary control, sexuality, and uncertainty about the cancer and its treatment. Psychometric analysis defined 11 scales. Seven were generically relevant to most older men: urinary control (eg, embarrassment with leakage), sexual intimacy (eg, anxiety about completing intercourse), sexual confidence (eg, comfort with sexuality), marital affection (eg, emotional distance from spouse/partner), masculine self esteem (eg, feeling oneself a whole man), health worry (eg, apprehensiveness about health changes), and PSA concern (eg, closely attending to one's PSA). Four scales were specific to the treatment experience: perceived cancer control, quality of treatment decision making, regret of treatment choice, and cancer-related outlook.

CONCLUSION

The scales provide definition and metrics for patient-centered research in this area. They complement measures of physical dysfunction and bring into resolution outcomes of treatment that have gone unnoticed in previous studies.