Quality of life at 12 months post-surgery for localized prostate cancer

There is an interesting new report in the Journal of Urology that addresses perceptions of and actual quality of life of a cohort of German patients for up to 12 months after they were treated with radical prostatectomy for clinically localized prostate cancer.

Treiyer et al. carried out a prospective study on a cohort of 236 men, all of whom  received an open radical retropubic prostatectomy (carried out by one of four experienced urologic surgeons) between January 2005 and October 2007.  The majority of the patients were between 61 and 69 years of age and had excellent or very good health status prior to their surgery. The primary objective of the study was to establish the relative importance of patient and tumor characteristics to predict continence, potency, and physical and mental health 1 year after radical prostatectomy.

It is important to understand exactly how the authors went about measuring patients’ perceptions of their outcomes and their quality of life, so here are the basic facts about how the study was conducted:

  • All patients had to complete a preoperative questionnaire within 1 month before radical prostatectomy and a 1-year postoperative follow-up questionnaire.
  • Patients also received questionnaires at 3 and 6 months post-surgery.
  • The questionnaires were largely based on validated formats (e.g., the Short Form General Health Survey, the International Index of Erectile Function and the International Consultation of Incontinence Questionnaire), to evaluate postoperative health-related quality of life, erectile function, and continence.
  • The questionnaires also included non-validated questions related to patient satisfaction after surgery.
  • The authors were careful to define their quality of life endpoints for certain key criteria.
    • Potency was defined as the ability to have an “erection sufficient for intercourse upon most attempts with or without a phosphodiesterase type 5 inhibitor.”
    • Continence was defined as “wearing no pads.”
    • Return to baseline quality of life was defined as the achievement of 90 percent of both baseline physical and baseline mental quality of life as experienced pre-surgery.

So given these important factors, here are the key findings of the study:

  • At 1-year of follow-up
    • 75 percent of patients had returned to baseline physical health.
    • 73 percent of patients had returned to baseline mental health.
    • 75 percent of patients were continent.
    • 26 percent of patients were potent.
  • Mental health recovered more slowly than physical health.
  • Preoperative PSA levels < 20 ng/ml, nerve-sparing technique, no intraoperative or postoperative complications, no adjuvant treatment, and attendance at a postoperative rehabilitation program were all significant factors that positively influenced outcomes in regard to post-surgical health-related quality of life, potency, and continence.

The full text of the paper by Treiyer and his colleagues contains a significant level of additional information related to all of the factors that affect outcome — far more than we could go into here. This is certainly a paper than many support group leaders will want to read in detail.

What appears to be particularly important about this study to The “New” Prostate Cancer InfoLink is the emphasis the authors place on the combination of mental and physical counseling of patients (and perhaps spouses/partners) both before and after radical retropubic prostatectomy. In their conclusions, the authors are very clear about the importance and the value of such counseling:

Finally, our data highlight the mental impact of this surgery on patient health. We propose that men should undergo a combined mental and physical counseling program before and after surgery to predict and optimize [health-related quality of life], potency and continence after [radical retropubic prostatectomy].

It is our perception that far too many men are completely unprepared for the potential physical and mental effects of both surgical and other forms of treatment for prostate cancer. They are unaware of the high probability of loss of potency. They are unaware of the short- and the long-term risks for even minor loss of complete continence. And these two factors alone have profound impact on their mental health.

When one adds to that some of the other relatively common problems associated with radical surgery for prostate cancer (e.g., risk for Peyronie’s disease, loss of penile length due to re-attachment of the urethra to the bladder, pathological upgrading post-surgery, time to recover even normal levels of continence), it is hardly surprising than many men go into withdrawal and deep levels of depression once they start to realize the consequences of their treatment.

We would note, however, that pre- and post-treatment counseling is equally appropriate for men deciding on other forms of treatment. Brachytherapy, external beam radiation therapy, proton beam radiation therapy, cryotherapy, and high-intensity focused ultrasound are all associated with a significant risk for some side effects that (all too often) are not fully appreciated by patients at the time they make their decisions about treatment. It is high time that careful pre- and post-treatment counseling became an obligatory component of the management of prostate cancer. Patients should have the right to opt out of such counseling if they wish to, but all providers should be required to give or narrange for such counseling (probably carried out by appropriately trained nurses or nurse practitioners) unless the patient actually does opt out (with a clear understanding that he does so at his own risk).

4 Responses

  1. I concur that pre-op guidance is crucial if patients are to cope more effectively with adverse treatment effects after RP. This is particularly true in reference to clarifying potential and likely sexuality and intimacy outcomes. If properly acquainted with these adverse outcomes of prostate surgery — whether open or robotic, patients may be less likely to deny the reality of very real concerns leading to withdrawal for months on end after a prostate cancer procedure is over. By the same token, nurses or PAs assigned to clarify these issues in advance of treatment need to go beyond describing potential problems; they should offer ways to counter adverse effects and guide patients in redefining what intimacy and masculine identity is all about. As a healthcare educator and intimacy coach I’m happy to share my thoughts on that elsewhere, due to limited space here.

  2. I am very much in agreement with the conclusions posted by “Sitemaster” at the end of the summary of this article. Also comments added by Rabbi Weinsberg.

    I had RP (DaVinci) at a world-reknowned clinic/hospital and I would have welcomed more counseling on the likely effects. I knew my tumor was such that nerve-sparing techniques were almost certainly out of the question. And that’s my point — although they were clear as to what the limitations of my recovery might be, there was very little offered in the way of advice as to what could be done to cope, emotionally, mentally, and physically.

    Unfortunately, the link to Rabbi Weinsberg’s additional comments did not work… can that be fixed?

    Thanks for all you do here at the The “New” Prostate Cancer InfoLink!

  3. The link to Rabbi Ed’s web site is fixed.

  4. Prostate cancer surgery is very different from surgery for most other cancers. Whereas the removal of the tumor is the end of the process for most cancers, it is only the beginning for prostate cancer. As I tell my patients, prostatectomy is a start of a journey. It really leads to a different life because of the various side effects like impotence and incontinence. As such, I really try to stress to my patients that certain aspects of their lives will be different. I stress that most men will have some incontinence immediately after surgery and that sex, while achievable, will take more work and will feel different due to a dry ejaculate. By spending a lot of time on expectations before surgery through honest counseling, I feel that patients enjoy a much better quality of life after surgery. By knowing what to expect, they are prepared for the inevitable setbacks and life changes that are to come. I find that many patients undergoing surgery for prostate cancer are not adequately prepared. Many go to top insitutions where the expectation is that everything will go perfectly. As a result, when complications occur, these men are often devastated. It never ceases to amaze me that despite all of the new technology available in medicine, the most important tools for physicians are still patience, empathy, and honesty.

    Prostate Doc

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