Quality of life after standard therapies for localized prostate cancer


Assessment of patient quality of life (QoL) after standard forms of treatment for localized prostate cancer is difficult for many reasons — not least because there is no real agreement among members of the research community about the best ways to measure QoL or patient satisfaction after treatment.

What is very clear, however, is that relatively few patients are “satisfied” with their erectile/sexual function after standard forms of treatment — and this is a key driver behind the development of newer forms of treatment (such a the various forms of high-intensity focused ultrasound [HIFU] and focal forms of therapy).

A recent paper by Nicholaisen et al. (in the Journal of Clinical Nursing) looked, in considerable detail, at patient quality of life and satisfaction with information provided to a cohort of Norwegian patients at 3 to 4 years after three types of standard treatment: radical prostatectomy, radical external beam radiotherapy, and post-surgical radiotherapy.

The results of this study can be summarized as follows (and there are no real surprises associated with these results):

  • The study cohort included 143 men, all treated at a single Norwegian hospital between January 2008 and December 2008 (and still alive in the autumn of 2011).
  • QoL among these men at 3 to 4 years post-treatment is best described as “fair”.
  • QoL scores were generally very low with regard to sexual factors (regardless of treatment type).
  • As a whole, the study population reported a lower overall QoL than similar men in the normal, healthy population.
  • QoL factors affecting mental and physical summary domains appear to have an important impact on overall QoL regardless of treatment type.
  • Patients receiving more information and detail about treatment and post-treatment effects before their treatment reported higher levels of satisfaction with the information provided and also reported high QoL scores.

The study confirms what many prostate cancer advocates have argued for many years … which is that many patients are under-informed about the potential consequences of prostate cancer treatment when they make the decision to have specific types of treatment. Regardless of what the treating physician may think that he (or she) has communicated to the patient, the fact is that all too often patients either haven’t been given that information in a neutral manner, with full disclosure of the risks of treatment as compared to the benefits, or haven’t really heard and absorbed that information.

The sexual function factor is a particularly important part of this equation because so many men define their quality of life (at least in part, and rightly or wrongly) by their personal perception of their own sexual potency and abilities. Failure on the part of the medical community to fully acknowledge this male trait, and therefore to avoid dealing honestly and accurately with the impact of prostate cancer treatment on erectile and sexual function can be devastating to many men and their families once the realities start to “sink in”.

The “New” Prostate Cancer InfoLink is well aware that there are many physicians who do make considerable efforts to ensure that their patients understand the potential consequences of standard forms of treatment on erectile and sexual function. However, it is also all too clear that there are many physicians who make little to no efforts to do this. … Worse still, there can be a tendency to brush the whole thing off and under-acknowledge the risks with statements like, “I expect most of my patients to be capable of intercourse within a few months post-surgery.” The problem here is that whatever a physician may think he or she means by that, it certainly doesn’t reflect reality.

Post-treatment quality of life for the vast majority of prostate cancer patients is going to be lower than it is for their otherwise healthy peers. How much lower may depend to a very large extent on: (a) the individual patient’s ability to simply handle this type of adversity and (b) the expectations of the patient about quality of life post-treatment based on what he knows pre-treatment.

The “New” Prostate Cancer InfoLink would point out — yet again — that there is a moral and ethical obligation on the provider community to make the risks of prostate cancer treatment (of all types) very clear to patients. Failure to do this is one of the prime drivers of over-treatment. And while hoping for good, high-quality outcomes is certainly wise, acknowledging the reality that this only happens some of the time is probably even wiser.

9 Responses

  1. I take exception to this statement: “The sexual function factor is a particularly important part of this equation because so many men define their quality of life (at least in part, and rightly or wrongly) by their personal perception of their own sexual potency and abilities. Failure on the part of the medical community to fully acknowledge this male trait, and therefore to avoid dealing honestly and accurately with the impact of prostate cancer treatment on erectile and sexual function can be devastating to many men and their families once the realities start to “sink in”.”

    I feel like by claiming that is a “male trait” it really underestimates the importance of a healthy sexual relationship for men, and their partners. As a (now separated) wife of a prostate cancer patient I can say that the sexual complications took our marriage to a place we just couldn’t survive…and it wrecked both of our lives in the end. It wasn’t about my husband’s perception of his potency … it was so, so much more.

    Thank you for this forum. It’s so important.

  2. Dear Clara:

    My prior statement does not apply to all men, all couples, or all situations. However, even though it was not a factor in your and your husband’s case, it is certainly a factor in many, many cases that I have seen over and over and over again over the past 25 years. And the consequences can be terrible … as you correctly point out … regardless of the precise causes.

    I do not dispute for one instant your statement about “the importance of a healthy sexual relationship for men, and their partners”. The problem is that all too often the sexual relationships between couples are, in fact, not based on a healthy mutual respect for the importance of both partners in the relationship, and so when things start to go wrong the women get blamed for something that is not in any way their fault.

  3. Excellent post, sir. This is the driving factor in my decision to remain on AS!! As long as I keep drawing a Gleason 6 in the biopsy lottery, I am in this for the long run.

    Great post. Thank you.

  4. Walt,I wish you luck with the biopsy lottery. One biopsy was plenty enough for me, and the blood in the semen I had for some time following the biopsy was itself something of a turn-off.

    I went down the radical prostatectomy route, and was quite explicitly told I had only perhaps a 20% chance of retaining “adequate” erectile function(one-sided nerve sparing in my case)

    Despite the poor odds being spelled out, and to the point of the article, I do not in fact think the psychological consequences of poor potency were described to me. As it happens I also find the absence of ejaculate quite distressing too, although I don’t think everyone else takes the same view.

    With a lot of work, patience, and the invaluable help of a very understanding wife we have managed to retain a very satisfying sexual element in our relationship. My erectile function is not what it was when I was 18, but neither was it just before the prostatectomy. Two and a half years out from the operation there is still a slow improvement.

  5. I was disappointed about my ED post-RP, but now that I’m on ADT and SRT and have no libido I don’t care about sex. At least one QoL issue resolved! LOL

  6. JamesL, hang in there. Sounds like you have a great wife. Cherish that! :-)

    Robert, sorry to hear that.

  7. I was well-informed about ED, but not at all about ADT. When I first asked a friendly doctor about side effects of my treatment, he said “probable impotence within four years.” I laughed and said, “Ach, I will be 71 by then and won’t think about sex very much anyway.” My prediction was correct, and seminal for my present state.

  8. About 6 months ago I had a procedure call ProstRcision, due to a PSA of 4.7 and a subsequent biopsy that resulted in a few 3 + 3 = 6 and 3 + 4 = 7 Gleason scores. Now my PSA is at 1.3 on the way to 0.2 ng/ml. It has not minimized or prohibited my sexual relationship with my wife; to be frank that has increased. I would recommend anyone that has been diagnosed with prostate cancer to please do your research before doing anything radical.

  9. Dear Willie:

    We agree, any wise patient should do careful research before committing to any form of treatment for his prostate cancer.

    Having said that, you should be aware that radiation therapy in general is rarely associated with a significant, short-term loss of sexual or erectile function. The above study refers to quality of life 3-4 years post treatment, not at just 6 months. Of course, I hope that your PSA level does indeed drop down below 0.2 ng/ml and stay there and that you will still have a high sexual quality of life 3-4 years from now.

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