Health-related QOL after salvage HIFU for recurrent, localized prostate cancer

Men with locally recurrent prostate cancer after first-line external beam radiation therapy (EBRT) have historically had three options for second-line treatment: salvage radical prostatectomy, salvage cryoablation, and salvage brachytherapy. Salvage high-intensity focused ultrasound (HIFU) is now being tested in the USA and is already being performed with some regularity in other countries.

Berge et al. have just reported data on the quality of life (QOL) of 61 Norwegian men with a rising PSA and supposedly localized prostate cancer recurrence after first-line EBRT. As far as we know, this is the first report of long-term follow-up of health-related QOL in men treated with salvage HIFU after EBRT. These men were all treated using the Ablatherm device. It should be noted that in all 61 of these patients, a bladder neck incision (BNI) with or without a transurethral resection of the prostate (TURP) was carried out just prior to HIFU to reduce the postoperative catheterization period and to avoid bladder outlet obstruction.

The 61 patients were all asked to complete appropriate questionnaires at baseline and again at follow-up post-salvage HIFU.

The core results of their study are as follows:

  • 57/61 men (93 percent) had evaluable data at baseline (prior to HIFU).
  • 46/61 men (75 percent) had evaluable data after salvage HIFU.
  • The average (mean) time between HIFU treatment and follow-up questionnaire response was 17.5 months (range, 6 to 29 months).
  • The average (mean) urinary function score decreased from 79.7 ± 12.1 before HIFU to 67.4 ± 17.8 after HIFU (P < 0.001).
  • The average (mean) sexual function score decreased from 32.1 ± 24.1 before HIFU to 17.2 ± 17.0 after HIFU (P < 0.001).
  • There were no significant effects on bowel function.
  • There was a significant reduction in the mean score for physical health-related QOL between baseline and follow-up.
  • There was no significant change in the mean score for mental health-related QOL between baseline and follow-up.

The wide range in the time from treatment to follow-up questionnaire is perhaps problematic in assessing the results of this study. The data might have been more meaningful if the follow-up questionnaires had all been given at (say) 12 and 24 months post-HIFU so that the time from treatment to assessment of health-related QOL was better standardized.

In an associated editorial comment on this paper, Uchida notes that complications have previously been shown to be higher after salvage HIFU compared with primary HIFU. Such complications can include urethral stricture, incontinence, and/or rectourethral fistula. He also points out that the need to carry out a BNI and a TURP prior to HIFU may result in an increased rate of incontinence after HIFU and so a decreased urinary function score.

Uchida states that, in his opinion, prospective, randomized, controlled trials, with long-term follow-up, are needed if we are to be able to accurately assess the relative merits of the various types of salvage therapy that are now available for the treatment of men with localized recurrence following first-line EBRT.

It is also important to note that there may be significant differences in the outcomes achievable with the two differing types of HIFU equipment now in increasingly widespread use — the Ablatherm technology (which is most commonly found in Europe) and the Sonablate technology (which appears to be favored by many US-based physicians offering this form of treatment in the Caribbean and Mexico).

Note: We had asked the authors for a copy of the full text of this paper for careful review; as of today’s date, we have not yet received a sop of the full text of this paper.

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