Health-related quality of life following radical prostatectomy: long-term outcomes.

PURPOSE: To identify the health-related quality of life (HRQoL) domains that radical prostatectomy (RP) impacts most negatively and to define the recovery of these domains over 30 months of observation. PATIENTS AND METHODS: A total of 1,200 RP patients completed the Patient-Oriented Prostate Utility Scale-Psychometric (PORPUS-P; range 0-100, higher is better), a prostate cancer-specific HRQoL measure, prior to RP and at 0-3 (T1), 3-9 (T2), 9-18 (T3) and 18-30 (T4) months post-RP. HRQoL changes were examined using paired t tests and a mixed-effect growth curve model. Multivariable analyses were performed to investigate demographic and treatment factors predicting the change in HRQoL. RESULTS: Mean baseline PORPUS-P score, 83.1, fell to 66.5 (p < 0.001) at T1. Over time HRQoL improved but did not return to baseline (T4 mean 76.4, p < 0.001). Domain analysis revealed that sexual function (p < 0.001), sexual drive (p < 0.001), energy (p = 0.001) and bladder control (p < 0.001) failed to return to baseline at T4. Sexual function demonstrated the greatest impairment overall. The multivariable model revealed Black men experienced greater losses in global HRQoL compared with White men (coefficient -2.77, 95% CI -5.00 to -0.54, p = 0.015). High baseline HRQoL, pro-erectile aid use and bilateral nerve-sparing were significantly associated with smaller reductions in HRQoL post-RP. CONCLUSION: Overall HRQoL, sexual drive, sexual function, energy and bladder control do not return to preoperative levels within 30 months post-RP. Black patients experience the greatest reductions in HRQoL. HRQoL losses may be ameliorated by use of pro-erectile aids. These findings help to identify at-risk patient populations and inform survivorship programs.

Concordance between transrectal ultrasound guided biopsy results and radical prostatectomy final pathology: Are we getting better at predicting final pathology?

INTRODUCTION: Inaccuracy in biopsy Gleason scoring poses a risk to men who may then receive inappropriate treatment. We assess whether there was a change in discordance rates between biopsy and radical prostatectomy at our institution in recent years, while considering the implementation of active surveillance and the shift in biopsy scores caused by the 2005 International Society of Urologic Pathology update to the Gleason scoring protocol. METHODS: We reviewed patients who underwent radical prostatectomy at our institution between May 2004 and April 2011. We analyzed clinical and pathological correlates of upgrading in 3 subgroups: Gleason sum (GS) 6/6, GS6/7 and GS7/7, where the sum preceding the dash was determined from biopsy and the subsequent sum was determined from the radical prostatectomy specimen. We applied the log-rank test and Cox model to a Kaplan Meier analysis of biochemical recurrence in the subgroups, and also mapped GS6/7 discordance over time. RESULTS: In total, 1717 patients met our inclusion criteria. The 3 subgroups had significantly different mean prostate-specific antigen, patient age, tumour volume, margin status, pathologic stage, prostate weight, transrectal ultrasound volume and rate of progression (p < 0.05). We noted a multiphasic trend with a fall in discordance after 2005. However, there was no sustained trend over the study period taken as a whole (p = 0.06). CONCLUSIONS: Although no sustained trend was observed, the falling discordance after 2005 may reflect the accommodation to the Gleason scoring update, while the gradual adoption of active surveillance may have led to the otherwise increasing trends. However, our observations may also be spurious biopsy sampling errors.

The effect of meeting physical activity guidelines for cancer survivors on quality of life following radical prostatectomy for prostate cancer.

PURPOSE: Recent literature has shown that preoperative physical activity (PA) can positively influence surgical outcomes. It is unknown whether the effect of meeting PA guidelines for cancer survivors can impact quality of life following radical prostatectomy for prostate cancer. METHODS: We reviewed our institutional database of prostate cancer outcomes and included patients that underwent radical prostatectomy and completed the Godin-Shephard Leisure Time Exercise Questionnaire (GLTEQ), the Patient-Oriented Prostate Utility Scale (PORPUS), the International Prostate Symptom Score (IPSS), and the five-item International Index of Erectile Function (IIEF). Participants were categorized as meeting or not meeting the American College of Sports Medicine physical activity guidelines for cancer survivors (150 min of moderate intensity or 75 min of vigorous intensity PA per week). Radical prostatectomy outcomes were measured preoperatively and at 6 and 26-weeks postoperatively. RESULTS: From June 2008 to August 2012, 509 men underwent curative, nerve-sparing radical prostatectomy for prostate cancer and completed the GLTEQ, of whom 46% met the PA guidelines. Prior to surgery, men that met the PA guidelines reported higher quality of life (p < 0.001) and erectile function (p = 0.049) than men that did not meet the guidelines. Quality of life at all postoperative timepoints was higher for men that met the PA guidelines after adjusting for age, preoperative body mass index, and surgical approach (p = 0.02). Men that met the PA guidelines were 19% less likely to be incontinent at 6 weeks postoperatively (p = 0.028). CONCLUSION: PA volume may be a useful marker at predicting postoperative recovery of quality of life and urinary incontinence following radical prostatectomy. IMPLICATIONS FOR CANCER SURVIVORS: Cancer survivors should be encouraged to meet PA guidelines prior to surgery in an effort to attenuate the decline in HRQOL and facilitate recovery.

Oncologic outcomes following radical prostatectomy in the active surveillance era.

OBJECTIVE: In this study, we examine the oncologic outcomes of men with low, intermediate and high preoperative risk for prostate cancer treated with radical prostatectomy prior to and during the active surveillance era. METHODS: We analyzed records from patients who underwent radical prostatectomy at our Canadian tertiary care facility from 2000 to 2012. Patients were stratified by D'Amico preoperative risk category and by year of treatment. Biochemical recurrence-free survival was estimated using the Kaplan-Meier method. RESULTS: We included 2643 consecutive patients in our analysis. The proportion of men with low-risk disease undergoing radical prostatectomy decreased from 2007 onwards coincident with the implementation of an active surveillance strategy in our institution. Men with low-risk and high-risk disease showed significantly worse biochemical outcomes from 2007 to 2012 compared to 2000 to 2006 (p < 0.05), while men with intermediate-risk prostate cancer showed no significant differences (p = 0.27). Within the low-risk cohort, the later treatment group displayed significantly lower age, pre-treatment prostate specific antigen and tumour volume and significantly higher testosterone and body mass index. CONCLUSIONS: The time period corresponding with the implementation of active surveillance at our institution corresponded with significant deterioration of biochemical outcomes in the low- and high-risk groups. This suggests that the men with most favourable disease deferred treatment, whereas men with worse preoperative disease characteristics were increasingly treated with radical prostatectomy in the past 6 years perhaps to their benefit.

Pathological, oncologic and functional outcomes of radical prostatectomy following active surveillance.

PURPOSE: We examined prostatectomy pathology, and oncologic and functional outcomes of men progressing from active surveillance to radical prostatectomy. MATERIALS AND METHODS: We identified patients on active surveillance treated with radical prostatectomy. We compared patients on active surveillance ultimately treated with radical prostatectomy to age and prostate specific antigen matched men undergoing immediate radical prostatectomy after a diagnosis of low risk disease who were candidates for active surveillance (group 1). We also compared patients on active surveillance with progression to Gleason 7 disease to men treated who had similar de novo disease (group 2) to determine whether patients on active surveillance have potentially adverse outcomes. RESULTS: Of 289 patients on active surveillance 41 (14.2%) underwent radical prostatectomy after a median of 35.2 months (IQR 22.8-46.6) on active surveillance. Compared to group 1, the radical prostatectomy after active surveillance group had expectedly worse pathological outcomes, whereas the pathological outcomes of patients undergoing radical prostatectomy after active surveillance with progression to Gleason 7 disease were similar to those of group 2. At a median of 3.5 years from radical prostatectomy (IQR 2.6-4.7), biochemical recurrence was low and comparable between the radical prostatectomy after active surveillance group and group 1 (2.6% vs 5.4%, p = 0.47), while erectile function was 29.0% and continence 89.7%, comparable to both groups. CONCLUSIONS: Radical prostatectomy after a period of active surveillance does not appear to result in adverse pathological outcomes compared to patients with a similar preoperative pathology.

Changes in health utilities and health-related quality of life over 12 months following radical prostatectomy.

INTRODUCTION: Although radical prostatectomy (RP) is an effective treatment for prostate cancer, it has potentially deleterious effects on health-related quality of life (HRQoL). Utility is an important global measure of HRQoL. This utility is also used in decision-making models and economic evaluations. There are no published prospective data characterizing men's utilities for health outcomes post-RP. METHODS: From July 2003 to June 2006, patients undergoing RP at the University Health Network in Toronto, Ontario, Canada, completed the Patient-Oriented Prostate Utility Scale (PORPUS), a disease-specific HRQoL and utility instrument. Men were included if they had clinically localized prostate cancer and had completed HRQoL measures prior to surgery and at least once within 9 to 18 months after the RP. Health-related quality of life was measured prior to surgery and at 4 stages after surgery: 0 to 3 months, 3 to 9 months, 9 to 18 months, and 18 to 30 months. Statistical analyses included pairwise t-tests and multivariable linear regression comparing changes in scores between baseline and the 9- to 18-month range. RESULTS: Two hundred and thirteen men (mean age 60.9, median Gleason score 7) met the inclusion criteria. At baseline, HRQoL was high (mean PORPUS-P [psychometric] = 83.8). Scores declined sharply by 3 months (65.5, p < 0.001) and improved but did not reach baseline by 9-18 months (75.1, p < 0.001). Utility scores (PORPUS-U[utility]) showed the same pattern: 0.94 at baseline; 0.81 at 3 months (p < 0.001); and 0.88 at 9 to 18 months (p < 0.001). Predictors of HRQoL, including baseline PORPUS score, nerve-sparing surgery and smoking status, decline after RP. CONCLUSION: Symptom scores are known to be affected up to 12 months after RP. Our study demonstrates that global health status also declines and remains affected 1 year after surgery.

The effect of nerve-sparing surgery on patient-reported continence post-radical prostatectomy.

INTRODUCTION: Urinary continence significantly affects quality of life after radical prostatectomy (RP). The impact of nerve-sparing surgery on continence is unclear from the current literature. METHODS: We identified men with prostate cancer from the University Health Network Prostate Centre database who underwent RP. Preoperatively and at each postoperative visit, patients completed the Patient-Oriented Prostate Utility Scale (PORPUS), a validated psychometric and health utility instrument. Incontinence was defined by a single questionnaire item. Patients with radiotherapy or less than 10 months follow-up were excluded. Chi-squared tests and ANOVA were used to compare groups. Multivariable logistic regression was used to control for effects of nerve-sparing and other covariates. RESULTS: Of the 253 eligible patients from 2003 to 2007, 159 patients had bilateral nerve-sparing, 32 had unilateral nerve-sparing and 62 had non-nerve-sparing surgery. Of these patients, 27%, 17% and 34%, respectively, were classified as incontinent at 1 year. These proportions were not significantly different between groups (p = 0.23). Multivariable logistic regression showed baseline urinary continence and urinary frequency to be significant predictors of patient-reported continence at 1 year postoperatively, with odds ratios of 1.7 (95% confidence interval [CI] 1.1-2.9) and 1.5 (95% CI 1.0-2.3), respectively. There was a significant difference in the proportion of PORPUS sexual function scores between nerve-sparing groups after excluding those with baseline sexual dysfunction (p = 0.003). Similarly, health-related utility scores were different across groups (p < 0.001). CONCLUSION: Our results do not suggest a difference in 1-year patient-reported continence based on the type of nerve-sparing RP. However, baseline continence and urinary frequency were significant predictors of continence at 1 year.

Personal digital assistant data capture: the future of quality of life measurement in prostate cancer treatment.

PURPOSE: This article examines the potential use of personal digital assistant (PDA) data capture systems for real-time linear monitoring of health-related quality of life (HRQOL) in prostate cancer research and clinical care. METHODS: We discuss the benefits and potential issues of using PDA data capture in the clinical health care setting. In addition, we describe the development and potential use of a PDA data capture system specific to managing HRQOL in prostate cancer treatment. CONCLUSION: Follow-up health care clinics require a practical and systematic process of HRQOL data capture and analysis. Traditional paper questionnaire data capture is problematic. Data manipulation required for clinical decision-making is impractical for patient feedback on same-day clinic visits. Furthermore, the process of transforming paper questionnaire data to analysis-quality data can compromise data integrity. In contrast, research findings confirm the acceptability, ease of use, and reliability of PDAs in capturing data across health care settings, including the collection of serial HRQOL data. The main concern for PDA capture systems is the ability to compare respondent's answers between the paper and PDA questionnaire. Other challenges included patients reporting a lack of computer literacy and/or poor eyesight, as well as initial start-up costs. If issues are successfully addressed, the use of a PDA data capture system, such as the PDA HRQOL system at Princess Margaret Hospital's Prostate Centre, allows for valid and economical data collection with the possibility of linear real-time measurement of changes in HRQOL. Accordingly, there appears to be significant potential for PDA data collection of serial HRQOL in prostate cancer clinic settings.