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Related and Disease-Specific Quality of Life in Patients with Nonmetastatic Prostate Cancer Treated with Radical Prostatectomy Or External Beam Radiotherapy

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Related and Disease-Specific Quality of Life in Patients with Nonmetastatic Prostate Cancer Treated with Radical Prostatectomy Or External Beam Radiotherapy Prostate Cancer and Prostatic Diseases (2004) 7, 144–151 & 2004 Nature Publishing Group All rights reserved 1365-7852/04 $30.00 www.nature.com/pcan A 3-y prospective study of health- related and disease-specific quality of life in patients with nonmetastatic prostate cancer treated with radical prostatectomy or external beam radiotherapy K Yoshimura1, Y Arai2*, K Ichioka1, Y Matsui1, K Ogura3 & A Terai1 1Department of Urology, Kurashiki Central Hospital, Sendai, Japan; 2Department of Urology, Tohoku University Graduate School of Medicine, Sendai, Japan; and 3Department of Urology, Otsu Red Cross Hospital, Sendai, Japan We assessed the longitudinal alteration of the quality of life (QOL) of patients with localized prostate cancer after radical prostatectomy or hormonoradiotherapy during 3-y follow-up. In addition, we examined the impact on QOL of initiation of second treatment after failure of primary treatment. In all, 135 patients with localized prostate cancer who underwent radical retropubic prostatectomy (RP) (N ¼ 84) or external beam radiotherapy with neoadjuvant hormone (XRT) (N ¼ 51) at our institute and who had a minimum follow-up of 3 y were included in this study. Data were collected prospectively, at baseline, at 3 months after treatment, at 1 y, and annually thereafter. QOL, generic and disease-targeted was evaluated using the European Organization for Research and Treatment of Cancer Prostate Cancer QOL Questionnaire, the Sapporo Medical University Sexual Function Questionnaire, the International Prostate Symptom Index Quality of Life Score and similar questions regarding bowel function. Repeated-measures ANOVA revealed significantly different patterns of alteration in the domains of QOL, with the exception of several domains, between the RP and XRT groups. Rapid decline of sexual function and increase in sexual bothersomeness were followed by slight amelioration throughout follow-up in the RP group, and did not change thereafter in the XRT group. Overall satisfaction with urinary condition significantly improved after treatment and that with bowel condition was stable during follow- up in both of the groups. Failure of primary treatment and initiation of salvage treatment had no impact on QOL. This prospective study revealed longitudinal alteration of QOL status of patients undergoing treatment for localized prostate cancer, but did not yield any conclusions regarding effect of treatment failure and second treatment on QOL due to small sample size. It should be noted that different instruments for assessment of QOL can generate different outcomes. Prostate Cancer and Prostatic Diseases (2004) 7, 144–151. doi:10.1038/sj.pcan.4500714 Published online 27 April 2004 Keywords: quality of life; prospective study; radical retropubic prostatectomy; external beam radiation therapy Introduction *Correspondence: Y Arai, Department of Urology, Tohoku University In recent years, screening for prostate cancer has Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai 980-8574, Japan. E-mail: [email protected] promoted detection of disease at an earlier stage. Since Received 12 January 2004; revised 10 February 2004; accepted 25 locally confined prostate carcinoma rarely exhibits rapid February 2004; published online 27 April 2004 progression, it is likely that patients with localized Quality of life in patients with prostate cancer K Yoshimura et al prostate cancer can live long lives. Thus, health-related the patient was older than 75 y and/or had a tumor with 145 quality-of-life effects may play a crucial role in determin- clinical stage of cT3a or higher. However, final determi- ing choice of treatment. nation of treatment modality was made by the patient The standard treatment options for localized prostate after thorough discussion of options including watchful cancer in Japan include radical prostatectomy and waiting. external-beam radiation. It is known that prostatectomy Of 84 patients in the RP group, 10 received neoadju- can induce urinary incontinence and erectile dysfunction vant hormone therapy 3–6 months prior to RP. Of 10 due to damage to the urinary sphincter and cavernous patients receiving preoperative hormone therapy, seven nerve.1,2 Irradiation therapy is associated with bladder had clinical T3 disease. One of the remaining three irritability, rectal irritability, and erectile dysfunction.3 patients had clinical T2 and the other two had clinical While these treatment options directly influence quality T1c disease with high serum PSA level of 31–97 ng/ml. of life (QOL), especially several disease-specific domains Although usefulness of neoadjuvant hormone therapy is including urinary, bowel, and sexual conditions, long- questionable at present, it was considered a permissible term follow-up may reveal impacts of other factors such option for locally advanced prostate cancer during this as salvage therapy for initial treatment failure and entry period. The procedure of RP was essentially the initiation of second treatment. same as that originally described by Walsh. The Many studies published in the past decade examined cavernous nerve was spared bilaterally in 26 patients, the QOL of patients with localized prostate cancer, and and unilaterally in 39. Pelvic lymph node dissection was we also previously reported short-term changes of QOL routinely performed. Three of us (YA,KY,KO) performed of patients undergoing radical prostatectomy.4 However, all operations. Of 51 patients in the XRT group, all most of these studies were retrospective, cross-sectional, received neoadjuvant hormone therapy using leuprolide or short-term prospective ones. Further, most of the or goserelin. Median duration from hormone therapy to studies reported previously used the Medical Outcome radiation was 6.7 months. All of these patients under- Study Short Form-36 (SF-36)5 and the University of went external beam radiation to a total of 66 Gy with the California at Los Angeles Prostate Cancer Quality of Life conventional method. Index (UCLA PCI)6 as modalities for evaluation of QOL. Our definition of PSA failure was as follows: (1) in the These questionnaires are well-constructed and utilized RP group, PSA nadir above 0.1 ng/ml, or three con- widely throughout the world. However, there is no secutive PSA increases from nadir below 0.1 ng/ml, (2) in single perfect questionnaire and each validated ques- the XRT group, three consecutive PSA increases after 1- tionnaire has different characteristics. year from termination of radiation therapy. In this long-term prospective study with a minimum follow-up of 3 y, we attempted despite the small size of the study population to examine the following two QOL methodology issues: first, longitudinal alteration of QOL after treat- ment, and second, the impact of initiation of second The primary health-related QOL measure used was the treatment on QOL after failure of primary treatment. Japanese version of the European Organization for Since we conducted this study using the European Research and Treatment of Cancer Prostate Cancer Organization for Research and Treatment of Cancer Quality-of-Life Questionnaire (EORTC-P), which was Prostate Cancer QOL Questionnaire (EORTC-P)7 and validated by Isaka et al.9 The questionnaire consists of the Sapporo Medical University Sexual Function Ques- 32 items grouped into the following scales: physical tionnaire (SMUSFQ),8 our study may yield findings other functioning (PF, eight items); physical symptoms (PS, than studies performed with the SF-36 and UCLA PCI. nine items); fatigue/malaise (FM, five items); sexual problems (SP, three items); psychological distress (PD, five items); and impact of the disease on family/social life (ID, two items). Subscale scores were the sum of the Materials and methods items in each domain. In addition to the 32-item scale, the Face Scale, prepared with some modification from Between April 1996 and October 2000, a total of 167 men the original form reported by Lorish and Maisiak,10 with localized prostate cancer received treatment with contains five drawings of a single face arranged in radical retropubic prostatectomy (RP) or external radia- decreasing order of mood and numbered from 1 to 5, tion therapy (XRT) at our institute. After informed with 1 representing the most positive mood and 5 consent, 135 patients (81%) participated in this study. representing the most negative mood. Of the 135 patients, 84 underwent RP and 51 underwent Disease-targeted measures were used to address the XRT. The questionnaires mentioned below were an- level of function or amount of bothersomeness of sexual, swered by the participants before treatment, 3 months urinary, and bowel functions. To evaluate sexual func- and 1 y after treatment, and annually thereafter. They tion, we used the questionnaire developed by researchers were staged with digital rectal examination, transrectal at the Sapporo Medical University School of Medicine ultrasound (TRUS), abdominal computed tomography, (SMUSM), which has been validated in more than 5000 and bone scan, according to the 1992 UICC staging adult Japanese men.8 It concerns sexual desire, ability to system. All patients underwent prostate-specific antigen have an erection, and quality of sexual activity, as we (PSA) determination before prostate biopsy. previously described. To evaluate amount of compre- Basically, we recommended retropubic radical prosta- hensive bothersomeness of urinary function, we used the tectomy if the patient was 75 y of age or younger and had International
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