Quality of life after first-line treatment: a prospective, comparative study

Data to be published in the May 2010 issue of the Journal of Urology are going to make a lot of urologists rather less than happy about the implications for the use of radical prostatectomy as first-line treatment for prostate cancer.

Malcolm et al. have reported data on health-related quality of life (HRQOL) from a prospective, comparative, single-institution clinical series of prostate cancer patients treated with only one form of first-line therapy at Eastern Virginia Medical School, between February 2000 and December 2008. To be eligible for the analysis, patients had to complete a baseline questionnaire and at least one of seven possible follow-up questionnaires (given to patients at 3, 6, 12, 18, 24, 30, and 36 months after their initial treatment). Patients who received some form of combination or adjuvant therapy were excluded from the analysis to ensure that comparisons focused exclusively on the primary treatment.

The treatments that were included in the comparative study were:

  • Open radical prostatectomy (carried out by any one of four trained urologic oncologists) using either the retropubic or the perineal approach (ORP)
  • da Vinci robot-assisted laparoscopic prostatectomy (carried out by any one of three trained endourologic or oncologic surgeons) (RALP)
  • Brachytherapy using permanent palladium seeds (carried out by a single trained radiation oncologist in conjunction with one of three trained surgeons)
  • Cryotherapy, using a third-generation delivery system (carried out by a single trained urologist)

Now before we provide the results of this study, we should note what it did not include (which the authors are very careful to point out):

  • No data are available regarding actual oncologic outcomes for these patients (i.e., there are no biochemical failure or survival data).
  • The authors were “unable to fully account for the impact of comorbid conditions on HRQOL outcomes,” including things like obesity and smoking history.
  • Not all patients completed all questionnaires “despite concerted efforts to optimize followup.”
  • Patients were not randomized by treatment type but selected their own treatment (with appropriate clinical guidance).
  • The patients’ overall satisfaction with their treatment was not measured.

Clearly, these limitations have some impact on just how much can be read into the results, but the results are still striking:

  • 1,129 patients initially agreed to participate in this study.
  • 149 patient were excluded for insufficient follow-up and 195 patients were excluded because they had combination or subsequent salvage therapy.
  • 785 patients were eligible for data analysis.
    • 135 patients received an ORP.
    • 447 patients received a RALP.
    • 122 patients were treated with brachytherapy.
    • 81 patients were treated with cryotherapy.
  • A significant majority of the patients (607/785 or 77.3 percent) had a clinical stage of T1c or lower.
  • Most patients (490/785 or 62.4 percent) had a Gleason score of 6 or lower.
  • The median pretreatment PSA level for patients was between 5.2 and 6.2 ng/ml for all four treatment groups.
  • Median follow-up for the entire treatment group was 23.8 months (range, 3 to 36 months).
  • Compared to baseline levels, HRQOL was noticeably affected by all treatment types, but …
  • For urinary function and urinary bother
    • Men treated with brachytherapy and cryotherapy achieved significantly better outcomes than men treated with ORP or RALP.
    • Men treated with brachytherapy and cryotherapy reported a return to near-normal urinary tract status noticeably faster than men treated with ORP or RALP.
  • For sexual function and sexual bother
    • Men treated with brachytherapy had significantly better return of sexual function than men treated by any other method, and return of sexual function was poor for the other three forms of treatment.
    • Men treated with brachytherapy and cryotherapy reported significantly less sexual bother post-treatment than men treated with ORP or RALP.
    • There was minimal difference between sexual function outcomes after ORP and RALP.
  • For bowel function and bowel bother
    • There was minimal difference between the effect of the four treatments on bowel function and bowel bother over time.
    • Patients treated by all modalities had recovered nearly 100 percent of baseline bowel function and minimal bowel bother within 24 months.

Malcolm and his colleagues offer the following conclusions based on these data:

  • Brachytherapy and cryotherapy were associated with higher HRQOL scores than either surgery technique with respect to urinary outcome and bother.
  • Brachytherapy was associated with higher HRQOL scores than any of the other three treatments with respect to sexual outcome and bother
  • RALP showed no advantages compared to ORP in any HRQOL domain.

The Journal of Urology, unusually, published editorial comment on this paper from three different specialists. Their editorial comments tend to dwell on the study’s clearly documented limitations and the inevitable suggestion that more research will be needed. One editorialist does ask, however: “Are we to think that most urologists perform as well as experts report or is this a more realistic view that patients should consider?” It’s an important question.

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