The management of patients with T1 adenocarcinoma of the low rectum: a decision analysis.

BACKGROUND: Decision making for patients with T1 adenocarcinoma of the low rectum, when treatment options are limited to a transanal local excision or abdominoperineal resection, is challenging. OBJECTIVES: The aim of this study was to develop a contemporary decision analysis to assist patients and clinicians in balancing the goals of maximizing life expectancy and quality of life in this situation. DESIGN: We constructed a Markov-type microsimulation in open-source software. Recurrence rates and quality-of-life parameters were elicited by systematic literature reviews. Sensitivity analyses were performed on key model parameters. PATIENTS AND SETTING: Our base case for analysis was a 65-year-old man with low-lying T1N0 rectal cancer. We determined the sensitivity of our model for sex, age up to 80, and T stage. MAIN OUTCOME MEASURES: The main outcome measured was quality-adjusted life-years. RESULTS: In the base case, selecting transanal local excision over abdominoperineal resection resulted in a loss of 0.53 years of life expectancy but a gain of 0.97 quality-adjusted life-years. One-way sensitivity analysis demonstrated a health state utility value threshold for permanent colostomy of 0.93. This value ranged from 0.88 to 1.0 based on tumor recurrence risk. There were no other model sensitivities. LIMITATIONS: Some model parameter estimates were based on weak data. CONCLUSIONS: In our model, transanal local excision was found to be the preferable approach for most patients. An abdominoperineal resection has a 3.5% longer life expectancy, but this advantage is lost when the quality-of-life reduction reported by stoma patients is weighed in. The minority group in whom abdominoperineal resection is preferred are those who are unwilling to sacrifice 7% of their life expectancy to avoid a permanent stoma. This is estimated to be approximately 25% of all patients. The threshold increases to 12% of life expectancy in high-risk tumors. No other factors are found to be relevant to the decision.

Impact of androgen-deprivation therapy on physical function and quality of life in men with nonmetastatic prostate cancer.

PURPOSE: This prospective longitudinal study evaluated the effect of androgen deprivation therapy (ADT) on objective and self-reported physical function. PATIENTS AND METHODS: Men with nonmetastatic prostate cancer (PC) starting continuous ADT were enrolled in this matched cohort study. Physical function was assessed with the 6-minute walk test (6MWT), grip strength, and the timed-up-and-go (TUG) test, representing endurance and upper and lower extremity strength, respectively. Quality of life (QOL) was measured with the Medical Outcomes Study Short-Form 36 (SF-36) questionnaire. Subjects were assessed at baseline, 3, 6, and 12 months. Two control groups (PC without ADT; no PC), matched on age, education, and baseline function were enrolled. Mixed effects regression models were fitted, adjusting for baseline covariates. RESULTS: We enrolled 87 patients on ADT, 86 PC controls, and 86 healthy controls; groups were similar in age (mean, 69.1 years; range, 50 to 87) and physical function. The 6MWT distance remained stable in the ADT group (P = .96) but improved in both control groups (P < .05). Grip strength declined in the ADT group (P = .04), remained stable in PC controls (P = .31), and improved in healthy controls (P = .008). TUG scores remained stable over time and across groups (P > .10). The SF-36 physical function summary score declined in the ADT group (P < .001), but increased in both control groups (P < .001). Negative effects on outcomes were observed within 3 months of starting ADT and were generally independent of age. CONCLUSION: Endurance, upper extremity strength, and physical components of QOL are affected within 3 months of starting ADT. Up-front exercise interventions to counteract these losses are warranted.