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Beyond survival: Bettering men’s quality of life following prostate cancer treatment

Few clinicians understand the consequences of prostate cancer treatment better than urological surgeon-scientist Martin Sanda, MD, director of the multidisciplinary prostate cancer clinic at BIDMC. As a surgeon, he performs nerve-sparing prostatectomies and works with radiation oncologists to treat patients using brachytherapy (implanted radioactive seeds) and radiotherapy. As a scientist, moreover, he has spearheaded numerous studies evaluating survivors’ quality of life following treatment. His most recent work, published in the New England Journal of Medicine, sheds new light on the side effect profile associated with each type of primary therapy and the impact of adjuvant androgen suppression, when combined with radiotherapy or brachytherapy.

The prospective study phone-surveyed 1,201 men and 625 spouses or partners about quality-of-life issues before treatment and at two months, six months, 12 months, and 24 months after the start of treatment; it also obtained a wealth of pre-treatment clinical data about patients—cancer stage and grade, prostate size, urinary symptoms associated with prostate disease (but not cancer), BMI, and a variety of other health factors—from the nine participating hospitals including DF/HCC institutional partners BIDMC, MGH, and BWH.

“We wanted to get beyond single-institution biases, do so in a prospective manner, and obtain accurate baseline data from patients and clinical records so that we could assess quality-of-life outcomes in patients with early-stage disease,” explains Sanda. The study uncovered two neglected side effects and correlated a distinct pattern of changes in quality of life with each treatment.

Neglected symptoms brought to light

Surprisingly, investigators discovered that urinary irritation or obstruction and vitality or hormonal concerns were as significant in determining quality of life and patient satisfaction with overall outcome after prostate cancer treatment as were urinary incontinence and bowel or rectal concerns. These findings, which represent under-appreciated factors not previously determined in a multicenter study, can facilitate treatment decisions, says Sanda. And while it was expected that men receiving adjuvant androgen suppression would experience precipitous effects on sexual function (the most commonly reported adverse effect of any treatment), effects on vitality—generally defined as energy level, mood, perception of fitness, and weight change—were also immediate. Although this symptom had been recognized as a potential problem with long-term hormone therapy, Sanda’s study showed that even when hormone therapy lasts for only a few months, its side effects can persist for years.

Predicting side effect profiles

Based on data from the first two years of the study, researchers uncovered side effects unique to each type of therapy. Among patients with benign prostatic hyperplasia (BPH), for example, who were troubled by urinary obstructive symptoms prior to treatment, prostatectomy actually improved urinary function whereas brachytherapy worsened BPH symptoms. Although prostatectomy had profound effects on erections, nerve-sparing surgery allowed “at least a reasonable prospect” of regaining sexual function, says Sanda, but recovery took from one to two years. Patients tended to recover urinary continence within several months to a year, and only about 10 percent continued having urinary problems.

Patients treated with radiation initially experienced less dramatic effects on erections, says Sanda, but by two years, the problem had become fairly common; the men who received radiation without adjuvant androgen suppression, however, fared better in this respect. “Even if hormone therapy is given for only six months, the effects seemed to linger one to two years out,” says Sanda, who now restricts hormone therapy to his highest-risk patients. The study also corroborated the effects of radiation on bowel/rectal function, but found that problems persisted in only about 5 to 10 percent of cases—“not as high as patients might fear,” assures Sanda.

In patients receiving brachytherapy, the study confirmed problems with urinary blockage and showed that they can linger up to two years in 10 to 20 percent of patients. Importantly, patients receiving brachytherapy without adjuvant androgen suppression experienced fewer urinary and sexual side effects.

Over the next year, Sanda and colleagues plan to integrate their research findings into a Web-based decision-analysis tool to help patients predict their side effect profile. “Our hope is that this tool will empower patients to make decisions based on what’s right for them.”

—Lonnie Christiansen