- Email: [email protected]
Re: Prediction of Erectile Function Following Treatment for Prostate Cancer
622
EUROPEAN UROLOGY 61 (2012) 621–626
Re: Prediction of Erectile Function Following Treatment for Prostate Cancer Alemozaffar M, Regan MM, Cooperberg MR, et al. JAMA 2011;306:1205–14 Expert’s summary: The authors conducted a prospective analysis of 1027 patients from nine US university-affiliated hospitals to assess the impact on sexual function as measured by response to the Expanded Prostate Cancer Index Composite (EPIC-26) validated questionnaire through 24 mo after therapy. The patients had localized prostate cancer and were undergoing treatment by radical prostatectomy (RP; n = 524), external beam radiation therapy (EBRT; n = 241), and brachytherapy (n = 262). A predictive model for sexual function was developed and validated using a cohort of 1655 patients from the CaPSure registry who had 24-mo sexual function recorded by the University of California Los Angeles Prostate Cancer Index. Using multivariable analysis, adequacy of posttreatment sexual function was directly related to young age and pretreatment sexual function for each of the treatment modalities. Erectile function was affected adversely and most frequently after RP. Erectile dysfunction was reported by 55–65% of men after RP, by 33–51% after EBRT, and by 30–45% after brachytherapy. At the 2-yr follow-up interval, half of all patients were using medications or devices to maintain erectile function. Models were more accurate in predicting sexual function after radiation therapy when compared to RP, perhaps secondary to a greater potential for variability in the expertise and volume experience of surgeons with the nerve-sparing procedure.
Certain observations in the study by Alemozaffar et al are notable. Age, prostate-specific antigen level <10 (favorable), and pretreatment sexual function were common factors predicting return of erectile function for all treatment modalities. Unique factors were performance of nerve sparing (favorable) for surgery and the coadministration of androgen deprivation (unfavorable) for EBRT. The trend for better preservation of erectile function among patients receiving brachytherapy has been reported in other series [2]. As a reflection of our incomplete understanding of the multiple factors involved in recovery of erectile function, fully 40% of 50-yr-old men with excellent preoperative sexual function maintained this level of function when nonnerve-sparing surgery was performed. Nerve sparing was successful in raising the percentage of function another 30– 70%. This 30% boost of nerve-sparing function over nonsparing held true for the 60- and 70-yr-old patient as well. The dominant determinant of sexual function is the preoperative status of function. The study did not include a comparative analysis of an active surveillance cohort. Although active surveillance patients may ultimately come to treatment and suffer the impact on QoL, they gain the advantage of postponing these side effects. The editorialist (the founder of a patient-centered outcomes research institute) advocates that patients are routinely informed about and invited to participate in their health care decisions and to adopt the position of ‘‘no decision about me, without me.’’ Conflicts of interest: The author has nothing to disclose.
References Expert’s comments: A frequently voiced statement from physicians delivering treatment for localized prostate cancer is that cancer control is quite similar between the primary options of surgery or radiation, and therefore, treatment decisions are based largely on patient awareness, perception, and acceptance of quality of life (QoL) outcomes associated with these therapies. QoL, specifically sexual function is very subjective, and thus its measurement difficult to quantify. Pretreatment discussions can deliver vague and sometimes confusing information to patients whose compromised attention may lead to further misinterpretation of the facts [1]—a situation destined to lead to post-treatment disappointment, dissatisfaction, and dismay.
Re: Role of Magnetic Resonance Imaging Before Initial Biopsy: Comparison of Magnetic Resonance Imaging– Targeted and Systematic Biopsy for Significant Prostate Cancer Detection Haffner J, Lemaitre L, Puech P, et al BJU Int 2011;108:E171–8. Experts’ summary: The authors compared magnetic resonance imaging (MRI)– targeted biopsies with extended systematic biopsies for the
[1] Beydoun HA, Mohan R, Beydoun MA, Davis J, Lance R, Schellhammer P. Development of a scale to assess patient misperceptions about treatment choices for localized prostate cancer. BJU Int 2010;106: 334–41. [2] Malcolm JB, Fabrizio MD, Barone BB, et al. Quality of life after open or robotic prostatectomy, cryoablation or brachytherapy for localized prostate cancer. J Urol 2010;183:1822–8. Paul Schellhammer Department of Urology, Eastern Virginia Medical School, 6333 Center Drive, Bldg 16, Norfolk, VA 23502, USA E-mail address: [email protected] DOI: 10.1016/j.eururo.2011.12.037
detection of significant prostate cancer (PCa). A total of 555 consecutive patients with suspicion of PCa had prebiopsy MRI, 10–12 transrectal ultrasound–guided systematic biopsies, plus two targeted biopsies at any MRI area suspicious for malignancy. Significant PCa was defined as >5 mm total cancer length, any Gleason pattern >3, or both. The median prostatespecific antigen (PSA) level was 6.75 ng/ml (range: 0.18–100). MRI was positive in 351 patients (63%), and overall, 302 patients (54%) had cancer detected at extended systematic biopsies, targeted biopsies, or both. Of 302 cancers detected,
EUROPEAN UROLOGY 61 (2012) 621–626
Re: Prediction of Erectile Function Following Treatment for Prostate Cancer Alemozaffar M, Regan MM, Cooperberg MR, et al. JAMA 2011;306:1205–14 Expert’s summary: The authors conducted a prospective analysis of 1027 patients from nine US university-affiliated hospitals to assess the impact on sexual function as measured by response to the Expanded Prostate Cancer Index Composite (EPIC-26) validated questionnaire through 24 mo after therapy. The patients had localized prostate cancer and were undergoing treatment by radical prostatectomy (RP; n = 524), external beam radiation therapy (EBRT; n = 241), and brachytherapy (n = 262). A predictive model for sexual function was developed and validated using a cohort of 1655 patients from the CaPSure registry who had 24-mo sexual function recorded by the University of California Los Angeles Prostate Cancer Index. Using multivariable analysis, adequacy of posttreatment sexual function was directly related to young age and pretreatment sexual function for each of the treatment modalities. Erectile function was affected adversely and most frequently after RP. Erectile dysfunction was reported by 55–65% of men after RP, by 33–51% after EBRT, and by 30–45% after brachytherapy. At the 2-yr follow-up interval, half of all patients were using medications or devices to maintain erectile function. Models were more accurate in predicting sexual function after radiation therapy when compared to RP, perhaps secondary to a greater potential for variability in the expertise and volume experience of surgeons with the nerve-sparing procedure.
Certain observations in the study by Alemozaffar et al are notable. Age, prostate-specific antigen level <10 (favorable), and pretreatment sexual function were common factors predicting return of erectile function for all treatment modalities. Unique factors were performance of nerve sparing (favorable) for surgery and the coadministration of androgen deprivation (unfavorable) for EBRT. The trend for better preservation of erectile function among patients receiving brachytherapy has been reported in other series [2]. As a reflection of our incomplete understanding of the multiple factors involved in recovery of erectile function, fully 40% of 50-yr-old men with excellent preoperative sexual function maintained this level of function when nonnerve-sparing surgery was performed. Nerve sparing was successful in raising the percentage of function another 30– 70%. This 30% boost of nerve-sparing function over nonsparing held true for the 60- and 70-yr-old patient as well. The dominant determinant of sexual function is the preoperative status of function. The study did not include a comparative analysis of an active surveillance cohort. Although active surveillance patients may ultimately come to treatment and suffer the impact on QoL, they gain the advantage of postponing these side effects. The editorialist (the founder of a patient-centered outcomes research institute) advocates that patients are routinely informed about and invited to participate in their health care decisions and to adopt the position of ‘‘no decision about me, without me.’’ Conflicts of interest: The author has nothing to disclose.
References Expert’s comments: A frequently voiced statement from physicians delivering treatment for localized prostate cancer is that cancer control is quite similar between the primary options of surgery or radiation, and therefore, treatment decisions are based largely on patient awareness, perception, and acceptance of quality of life (QoL) outcomes associated with these therapies. QoL, specifically sexual function is very subjective, and thus its measurement difficult to quantify. Pretreatment discussions can deliver vague and sometimes confusing information to patients whose compromised attention may lead to further misinterpretation of the facts [1]—a situation destined to lead to post-treatment disappointment, dissatisfaction, and dismay.
Re: Role of Magnetic Resonance Imaging Before Initial Biopsy: Comparison of Magnetic Resonance Imaging– Targeted and Systematic Biopsy for Significant Prostate Cancer Detection Haffner J, Lemaitre L, Puech P, et al BJU Int 2011;108:E171–8. Experts’ summary: The authors compared magnetic resonance imaging (MRI)– targeted biopsies with extended systematic biopsies for the
[1] Beydoun HA, Mohan R, Beydoun MA, Davis J, Lance R, Schellhammer P. Development of a scale to assess patient misperceptions about treatment choices for localized prostate cancer. BJU Int 2010;106: 334–41. [2] Malcolm JB, Fabrizio MD, Barone BB, et al. Quality of life after open or robotic prostatectomy, cryoablation or brachytherapy for localized prostate cancer. J Urol 2010;183:1822–8. Paul Schellhammer Department of Urology, Eastern Virginia Medical School, 6333 Center Drive, Bldg 16, Norfolk, VA 23502, USA E-mail address: [email protected] DOI: 10.1016/j.eururo.2011.12.037
detection of significant prostate cancer (PCa). A total of 555 consecutive patients with suspicion of PCa had prebiopsy MRI, 10–12 transrectal ultrasound–guided systematic biopsies, plus two targeted biopsies at any MRI area suspicious for malignancy. Significant PCa was defined as >5 mm total cancer length, any Gleason pattern >3, or both. The median prostatespecific antigen (PSA) level was 6.75 ng/ml (range: 0.18–100). MRI was positive in 351 patients (63%), and overall, 302 patients (54%) had cancer detected at extended systematic biopsies, targeted biopsies, or both. Of 302 cancers detected,