- Email: [email protected]
Quality of life in prostate cancer patients taking androgen deprivation therapy
458
D.F. Penson / Urologic Oncology: Seminars and Original Investigations 24 (2006) 457– 464
Pilot intervention to enhance sexual rehabilitation for couples after treatment for localized prostate carcinoma. Canada AL, Neese LE, Sui D, Schover LR, Department of Behavioral Science, The University of Texas MD Anderson Cancer Center, Houston, TX. Cancer 2005;104:2689 –700 Background: The majority of prostate carcinoma survivors experience enduring sexual difficulties and associated distress in the years after definitive treatment. A counseling intervention aimed at improving levels of sexual satisfaction and increasing successful utilization of medical treatment for erectile dysfunction (ED) was developed and pilot-tested for both the survivor of prostate carcinoma and his partner. Methods: All male participants were 3-month to 5-year survivors of localized prostate carcinoma who had been treated with radical prostatectomy or radiation therapy, and were married or in a committed relationship. Couples were randomized to attend four sessions of counseling together or to have the man attend alone. In both groups, partners completed behavioral homework. The sessions included education on prostate carcinoma and sexual function and options to treat ED as well as sexual communication and stimulation skills. Standardized questionnaires at baseline, posttreatment, and at 3-month and 6-month follow-up assessed sexual function, marital adjustment, psychologic distress, and utilization of treatments for ED. Results: Fifty-one of 84 couples randomized to treatment completed the intervention (61%). Attendance by the partner did not affect outcomes. Participants completing the intervention demonstrated improvement in male overall distress (P ⬍ 0.01), male global sexual function (P ⬍ 0.0001), and female global sexual function (P ⬍ 0.05) at 3-month follow-up, but regression toward baseline was noted at 6-month follow-up. However, utilization of ED treatments increased from 31% at the time of study entry to 49% at the 6-month follow-up (P ⫽ 0.003). Conclusions: The results of this brief pilot counseling intervention demonstrated significant gains in sexual function and satisfaction and increased utilization of treatments for ED. However, modifications are needed in future randomized trials to reduce the rate of premature termination and to improve long-term maintenance of gains.
Commentary The report describes the results of a randomized trial comparing patient-reported outcomes among subjects with localized prostate cancer and ED who were currently married to or living with a female partner for at least a year. All patients had undergone surgery or received radiation for prostate cancer 3 months to 5 years before randomization and were having sexual dysfunction at entry into the study. Subjects were randomized to receive psychologic counseling alone or with their partner. It is noteworthy that of the 84 subjects and their partners who were randomized, only 51 completed the assigned interventions and were included in the analysis. The analysis did not show any differences in patient-reported outcomes between the 2 groups at baseline, posttreatment, or 3 or 6 months after treatment. Therefore, the researchers grouped the 51 subjects into a single cohort and examined longitudinal outcomes. Subjects who completed the intervention had significant improvement in male overall distress and global sexual function. In addition, these subjects report greater satisfaction and higher usage of ED treatments. The authors conclude that a counseling intervention may improve patient-reported sexual outcomes in localized prostate cancer, although further research is needed. There is little doubt that some survivors of prostate cancer benefit from psychosocial counseling after treatment for localized disease. As urologic oncologists, we tend to focus on physiologic ED, and lose sight of the fact that changes in body image and perceived masculinity associated with surgery or radiation often place a heavy psychologic burden on patients. Not surprisingly, this often does not respond to phosphodiesterase inhibition alone. The key is determining which patients will benefit from a psychosocial intervention. This study shows that patients will address this problem themselves and self-select for treatment. Of the original 84 subjects, 33 (39%) “voted with their feet” and chose not to complete the counseling. However, the remaining 61% did complete the therapy and appeared to derive some benefit. Therefore, by at least offering psychosocial counseling to survivors of prostate cancer, we may improve outcomes. When it comes to sexuality in localized prostate cancer, it is time for us to start thinking of the entire patient, as opposed to just his penis. doi:10.1016/j.urolonc.2006.07.012 David F. Penson, M.D., M.P.H. Quality of life in prostate cancer patients taking androgen deprivation therapy. Dacal K, Sereika SM, Greenspan SL, School of Medicine, University of Pittsburgh, Pittsburgh, PA. J Am Geriatr Soc 2006;54:85–90 Objectives: To examine the effect of androgen deprivation therapy (ADT) on health-related quality of life (HRQOL), self-reported HRQOL was compared in prostate cancer patients receiving short- (⬍ 6 months) or long-term (⬎ or ⫽ 6 months) ADT and healthy controls. Design: Cross-sectional study. Setting: Academic medical center in Pittsburgh, Pennsylvania. Participants: Ninety-six men, including those with prostate cancer receiving short-term, long-term, and no ADT and healthy controls. Men taking medications or having diseases known to affect bone mineral metabolism were excluded. Measurements: The 36-item Short Form Medical Outcomes Study Health Survey (an HRQOL assessment) and a comorbidity index were administered to each participant. Characteristics, including body composition (assessed using dual-energy x-ray absorptiometry) and gonadal status (serum total and free testosterone) were measured approximately 3 months or less before the HRQOL assessment.
D.F. Penson / Urologic Oncology: Seminars and Original Investigations 24 (2006) 457– 464
459
Results: As expected, men receiving ADT had significantly lower levels of testosterone, free testosterone, and lean body mass, as well as greater body fat and comorbidity index (all P⬍.01) than men not receiving ADT (i.e., men with prostate cancer and healthy controls). Participants receiving ADT reported significantly poorer QOL in the areas of physical function (P⬍.001), general health (P⬍.001), and physical health component summary (P⬍.001) than men not receiving ADT. There were no significant differences in HRQOL outcomes between participants receiving short- or long-term ADT. Comorbidity and testosterone levels were associated with several QOL scales. After controlling for the significant joint predictors of comorbidity and total testosterone using hierarchical regression analysis, ADT was no longer a significant predictor, and only comorbidity and total testosterone contributed to the explanation of the variance of the physical health component summary. Comorbidity alone contributed to the explanation of the variance in physical function, bodily pain, general health, and vitality. Conclusion: Patients with prostate cancer who were receiving ADT experience worse HRQOL than those not receiving ADT, but duration of ADT was not a contributing factor. After controlling for comorbidity, total testosterone level rather than ADT accounted for a small yet statistically significant percentage of the total variance of the physical health component summary. These findings have important clinical implications regarding the decision to treat prostate cancer patients with ADT. Commentary This article describes a small cross-sectional study comparing health-related quality of life among 4 groups: survivors of prostate cancer on short-term ADT, those on long-term ADT, survivors of prostate cancer who had not received ADT, and healthy controls. All subjects completed the 36-item Short Form Medical Outcomes Study Health Survey, a general HRQOL instrument, and a comorbidity index. In addition, subjects had dual energy x-ray absorptiometry and serum testosterone measurement. A total of 96 subjects participated in the study. There were no differences noted in general HRQOL among men receiving long or short-term ADT therapy, and, therefore, these patients were grouped together. Subjects receiving ADT reported significantly lower physical functioning, role limitations caused by physical problems, and general health than those who had not received ADT. The authors then performed a multivariate regression analysis in which receipt of ADT no longer explained any of the variance in HRQOL. Rather, the only 2 factors that predicted HRQOL were comorbidity and total testosterone levels. The authors conclude that testosterone level and comorbidity, rather than receipt of ADT, are more important factors to consider when deciding when to treat patients with prostate cancer with ADT. It is well known that ADT can negatively impact quality of life. Patients report hot flashes, sexual dysfunction, and fatigue, just to name a few of the possible side effects that can affect HRQOL. The problem is that general HRQOL instruments, such as the 36-item Short Form Medical Outcomes Study Health Survey, may not be sensitive enough to pick up these problems. However, in the current study, the instrument did find significantly worse physical quality of life in men on ADT in the univariate analysis. The fact that this finding was not noted in the multivariate analysis has more to do with the limitations of the statistical analyses, specifically that the model violated the assumption of colinearity, and small sample size than did the fact that comorbidity or total testosterone has more impact on HRQOL than ADT. After all, what lowered the testosterone in these men in the first place? doi:10.1016/j.urolonc.2006.07.013 David F. Penson, M.D., M.P.H. Quality of life in long-term survivors of bladder cancer. Allareddy V, Kennedy J, West MM, Konety BR, Department of Urology, University of Iowa, Iowa City, IA. Cancer 2006;106:2355– 62 Background: The quality of life (QOL) of long-term survivors of bladder cancer in a population-based registry was assessed. Methods: The Functional Assessment of Cancer Therapy (FACT-BL) instrument was used to evaluate QOL in a population-based sample of bladder cancer patients. QOL scores were compared between those undergoing radical cystectomy (RC) or those with an intact bladder (BI) and between continent and conduit urinary diversion groups. The influence of current age and time since diagnosis of cancer on QOL were also examined. Multivariate regression analyses were performed to examine the influence of age, time since diagnosis, current condition, treatment, stage of cancer, and comorbid conditions on QOL. Results: A total of 259 patients participated in the study who had undergone RC (n⫽82) or other therapy (BI) (n⫽177). There were no differences in general QOL scores between RC and BI groups and between the 2 urinary diversion groups, but patients undergoing RC had worse sexual function scores. QOL scores for BI patients tended to decrease with increasing age (P⫽.01). Presence of comorbid conditions lowered QOL (P⬍.05). Conclusions: General QOL does not vary among long-term bladder cancer survivors regardless of treatment, but sexual functioning can be adversely affected in those undergoing cystectomy. Long-term QOL declines even in those with intact bladders, particularly in those with comorbidities. Commentary This article describes a cross-sectional study of long-term health-related QOL (HRQOL) outcomes in a population-based cohort of survivors of bladder cancer. The authors sent the FACT-BL instrument to all patients diagnosed with bladder cancer in the state of Iowa from 1990 to 1999. A total of 840 living subjects were identified, of which 259 (31%) completed the questionnaire.
D.F. Penson / Urologic Oncology: Seminars and Original Investigations 24 (2006) 457– 464
Pilot intervention to enhance sexual rehabilitation for couples after treatment for localized prostate carcinoma. Canada AL, Neese LE, Sui D, Schover LR, Department of Behavioral Science, The University of Texas MD Anderson Cancer Center, Houston, TX. Cancer 2005;104:2689 –700 Background: The majority of prostate carcinoma survivors experience enduring sexual difficulties and associated distress in the years after definitive treatment. A counseling intervention aimed at improving levels of sexual satisfaction and increasing successful utilization of medical treatment for erectile dysfunction (ED) was developed and pilot-tested for both the survivor of prostate carcinoma and his partner. Methods: All male participants were 3-month to 5-year survivors of localized prostate carcinoma who had been treated with radical prostatectomy or radiation therapy, and were married or in a committed relationship. Couples were randomized to attend four sessions of counseling together or to have the man attend alone. In both groups, partners completed behavioral homework. The sessions included education on prostate carcinoma and sexual function and options to treat ED as well as sexual communication and stimulation skills. Standardized questionnaires at baseline, posttreatment, and at 3-month and 6-month follow-up assessed sexual function, marital adjustment, psychologic distress, and utilization of treatments for ED. Results: Fifty-one of 84 couples randomized to treatment completed the intervention (61%). Attendance by the partner did not affect outcomes. Participants completing the intervention demonstrated improvement in male overall distress (P ⬍ 0.01), male global sexual function (P ⬍ 0.0001), and female global sexual function (P ⬍ 0.05) at 3-month follow-up, but regression toward baseline was noted at 6-month follow-up. However, utilization of ED treatments increased from 31% at the time of study entry to 49% at the 6-month follow-up (P ⫽ 0.003). Conclusions: The results of this brief pilot counseling intervention demonstrated significant gains in sexual function and satisfaction and increased utilization of treatments for ED. However, modifications are needed in future randomized trials to reduce the rate of premature termination and to improve long-term maintenance of gains.
Commentary The report describes the results of a randomized trial comparing patient-reported outcomes among subjects with localized prostate cancer and ED who were currently married to or living with a female partner for at least a year. All patients had undergone surgery or received radiation for prostate cancer 3 months to 5 years before randomization and were having sexual dysfunction at entry into the study. Subjects were randomized to receive psychologic counseling alone or with their partner. It is noteworthy that of the 84 subjects and their partners who were randomized, only 51 completed the assigned interventions and were included in the analysis. The analysis did not show any differences in patient-reported outcomes between the 2 groups at baseline, posttreatment, or 3 or 6 months after treatment. Therefore, the researchers grouped the 51 subjects into a single cohort and examined longitudinal outcomes. Subjects who completed the intervention had significant improvement in male overall distress and global sexual function. In addition, these subjects report greater satisfaction and higher usage of ED treatments. The authors conclude that a counseling intervention may improve patient-reported sexual outcomes in localized prostate cancer, although further research is needed. There is little doubt that some survivors of prostate cancer benefit from psychosocial counseling after treatment for localized disease. As urologic oncologists, we tend to focus on physiologic ED, and lose sight of the fact that changes in body image and perceived masculinity associated with surgery or radiation often place a heavy psychologic burden on patients. Not surprisingly, this often does not respond to phosphodiesterase inhibition alone. The key is determining which patients will benefit from a psychosocial intervention. This study shows that patients will address this problem themselves and self-select for treatment. Of the original 84 subjects, 33 (39%) “voted with their feet” and chose not to complete the counseling. However, the remaining 61% did complete the therapy and appeared to derive some benefit. Therefore, by at least offering psychosocial counseling to survivors of prostate cancer, we may improve outcomes. When it comes to sexuality in localized prostate cancer, it is time for us to start thinking of the entire patient, as opposed to just his penis. doi:10.1016/j.urolonc.2006.07.012 David F. Penson, M.D., M.P.H. Quality of life in prostate cancer patients taking androgen deprivation therapy. Dacal K, Sereika SM, Greenspan SL, School of Medicine, University of Pittsburgh, Pittsburgh, PA. J Am Geriatr Soc 2006;54:85–90 Objectives: To examine the effect of androgen deprivation therapy (ADT) on health-related quality of life (HRQOL), self-reported HRQOL was compared in prostate cancer patients receiving short- (⬍ 6 months) or long-term (⬎ or ⫽ 6 months) ADT and healthy controls. Design: Cross-sectional study. Setting: Academic medical center in Pittsburgh, Pennsylvania. Participants: Ninety-six men, including those with prostate cancer receiving short-term, long-term, and no ADT and healthy controls. Men taking medications or having diseases known to affect bone mineral metabolism were excluded. Measurements: The 36-item Short Form Medical Outcomes Study Health Survey (an HRQOL assessment) and a comorbidity index were administered to each participant. Characteristics, including body composition (assessed using dual-energy x-ray absorptiometry) and gonadal status (serum total and free testosterone) were measured approximately 3 months or less before the HRQOL assessment.
D.F. Penson / Urologic Oncology: Seminars and Original Investigations 24 (2006) 457– 464
459
Results: As expected, men receiving ADT had significantly lower levels of testosterone, free testosterone, and lean body mass, as well as greater body fat and comorbidity index (all P⬍.01) than men not receiving ADT (i.e., men with prostate cancer and healthy controls). Participants receiving ADT reported significantly poorer QOL in the areas of physical function (P⬍.001), general health (P⬍.001), and physical health component summary (P⬍.001) than men not receiving ADT. There were no significant differences in HRQOL outcomes between participants receiving short- or long-term ADT. Comorbidity and testosterone levels were associated with several QOL scales. After controlling for the significant joint predictors of comorbidity and total testosterone using hierarchical regression analysis, ADT was no longer a significant predictor, and only comorbidity and total testosterone contributed to the explanation of the variance of the physical health component summary. Comorbidity alone contributed to the explanation of the variance in physical function, bodily pain, general health, and vitality. Conclusion: Patients with prostate cancer who were receiving ADT experience worse HRQOL than those not receiving ADT, but duration of ADT was not a contributing factor. After controlling for comorbidity, total testosterone level rather than ADT accounted for a small yet statistically significant percentage of the total variance of the physical health component summary. These findings have important clinical implications regarding the decision to treat prostate cancer patients with ADT. Commentary This article describes a small cross-sectional study comparing health-related quality of life among 4 groups: survivors of prostate cancer on short-term ADT, those on long-term ADT, survivors of prostate cancer who had not received ADT, and healthy controls. All subjects completed the 36-item Short Form Medical Outcomes Study Health Survey, a general HRQOL instrument, and a comorbidity index. In addition, subjects had dual energy x-ray absorptiometry and serum testosterone measurement. A total of 96 subjects participated in the study. There were no differences noted in general HRQOL among men receiving long or short-term ADT therapy, and, therefore, these patients were grouped together. Subjects receiving ADT reported significantly lower physical functioning, role limitations caused by physical problems, and general health than those who had not received ADT. The authors then performed a multivariate regression analysis in which receipt of ADT no longer explained any of the variance in HRQOL. Rather, the only 2 factors that predicted HRQOL were comorbidity and total testosterone levels. The authors conclude that testosterone level and comorbidity, rather than receipt of ADT, are more important factors to consider when deciding when to treat patients with prostate cancer with ADT. It is well known that ADT can negatively impact quality of life. Patients report hot flashes, sexual dysfunction, and fatigue, just to name a few of the possible side effects that can affect HRQOL. The problem is that general HRQOL instruments, such as the 36-item Short Form Medical Outcomes Study Health Survey, may not be sensitive enough to pick up these problems. However, in the current study, the instrument did find significantly worse physical quality of life in men on ADT in the univariate analysis. The fact that this finding was not noted in the multivariate analysis has more to do with the limitations of the statistical analyses, specifically that the model violated the assumption of colinearity, and small sample size than did the fact that comorbidity or total testosterone has more impact on HRQOL than ADT. After all, what lowered the testosterone in these men in the first place? doi:10.1016/j.urolonc.2006.07.013 David F. Penson, M.D., M.P.H. Quality of life in long-term survivors of bladder cancer. Allareddy V, Kennedy J, West MM, Konety BR, Department of Urology, University of Iowa, Iowa City, IA. Cancer 2006;106:2355– 62 Background: The quality of life (QOL) of long-term survivors of bladder cancer in a population-based registry was assessed. Methods: The Functional Assessment of Cancer Therapy (FACT-BL) instrument was used to evaluate QOL in a population-based sample of bladder cancer patients. QOL scores were compared between those undergoing radical cystectomy (RC) or those with an intact bladder (BI) and between continent and conduit urinary diversion groups. The influence of current age and time since diagnosis of cancer on QOL were also examined. Multivariate regression analyses were performed to examine the influence of age, time since diagnosis, current condition, treatment, stage of cancer, and comorbid conditions on QOL. Results: A total of 259 patients participated in the study who had undergone RC (n⫽82) or other therapy (BI) (n⫽177). There were no differences in general QOL scores between RC and BI groups and between the 2 urinary diversion groups, but patients undergoing RC had worse sexual function scores. QOL scores for BI patients tended to decrease with increasing age (P⫽.01). Presence of comorbid conditions lowered QOL (P⬍.05). Conclusions: General QOL does not vary among long-term bladder cancer survivors regardless of treatment, but sexual functioning can be adversely affected in those undergoing cystectomy. Long-term QOL declines even in those with intact bladders, particularly in those with comorbidities. Commentary This article describes a cross-sectional study of long-term health-related QOL (HRQOL) outcomes in a population-based cohort of survivors of bladder cancer. The authors sent the FACT-BL instrument to all patients diagnosed with bladder cancer in the state of Iowa from 1990 to 1999. A total of 840 living subjects were identified, of which 259 (31%) completed the questionnaire.