Life Quality After Prostate Cancer
Neglected Side Effects Predict Satisfaction With Prostate Cancer Treatment
By
Daniel J. DeNoon
WebMD Health News
Reviewed By
Louise Chang, MD
March 19, 2008 — Side effects men rarely think about before prostate cancer treatment have huge effects on their after-treatment quality of life.
The finding comes from a study of 1,201 men — and 625 of their spouses
or life partners — before and after they received different treatments for prostate cancer at nine different
high-quality hospitals. All the treatments were successful in that none of the
men died from prostate cancer or from the treatment.
But not all of the men, or their life partners, were happy with the side
effects they experienced after treatment. Some were disturbed by impotence or
urinary/bowel incontinence, the symptoms on
which pretreatment doctor-patient discussions tend to focus.
More neglected symptoms — related to urinary obstruction or to
"vitality" — were equally disturbing, found Martin G. Sanda, MD,
director of the Prostate Care Center at Beth Israel Deaconess Medical Center,
and colleagues.
"The nice part of the prostate cancer story is that, by and large, the
vast majority of patients are cured. Now the emphasis is on quality of
survival," Sanda tells WebMD. "So we did a catchall study to see if
there are things we can find out to make patients and doctors more accurately
predict what the patient's outcomes will be, and to empower patients to make
decisions based on what is right for them."
The study focused on the side effects men experience in the 24 months after
various prostate cancer treatments:
- Radical prostatectomy, surgery to remove the prostate, using or not using
nerve-sparing techniques.
- External-beam radiotherapy, using newer techniques, either with or without
androgen-suppressing therapy.
- Brachytherapy, implantation of radioactive seeds, either with or without
androgen-suppressing therapy.
Prostate Cancer Treatment Risks Differ
Every one of these prostate cancer treatments is linked to serious side
effects. Each one has a different side-effect profile.
When discussing which treatment would be best for an individual patient,
Sanda says doctors and patients tend to focus on three main side effects:
sexual dysfunction, rectal incontinence, and urinary incontinence.
Those side effects have a huge impact on the lives of patients and their
partners. But Sanda and colleagues find that other side effects have just as
much impact. These fall into two main groups:
- Symptoms related to urinary irritation or obstruction, such as pain during urination, weak
stream, and increased urination frequency.
- "Vitality" issues, including energy level, mood, perception of fitness, and weight.
"One thing that is new here is the entire notion that symptoms related
to urinary obstruction are an important component of quality of life in these
patients," Sanda says. "It is something that should be brought up to
the same degree as issues of impotence or rectal incontinence
problems."
Also new is the concept of "vitality" after prostate cancer
treatment.
"Vitality is not a concrete physical symptom or something you can
directly measure," Sanda says. "But the things in this area that
patients reported being affected by treatment are things like energy level,
mood, and perception of fitness, or weight. For some patients, especially those
treated with hormone-suppressing therapy, this was at least as troublesome to
them as impotence and bowel problems."
Hormonal therapy generally made the side effects of radiation therapy and
brachytherapy worse. Nerve-sparing surgery generally lessened the side effects
of prostatectomy.
Patients had worse side effects if, at the time of treatment, they were obese, had a large prostate,
had high PSA scores, or were older.
African-American patients reported significantly less satisfaction with
their prostate cancer treatment choice than did white patients. Because all
patients in the study received the same quality of treatment, Sanda has two
theories about this finding.
"Perhaps African-American patients weren't counseled as effectively
about what they could expect after treatment," he says. "Or it may be
the recognized reality that African-Americans tend to have somewhat worse
prostate cancer than patients of other races."
Durado Brooks, MD, MPH, director for prostate and colorectal cancers at the
American Cancer Society, agrees that the study raises questions about
African-American men's expectations from prostate cancer treatment.
"Beyond communication issues is the question of whether African-American
men have a different level of expectations based not on education but on
culture," Brooks suggests.
Prostate Cancer Treatment: Don't Make Tough Decision Alone
Brooks says the Sanda study will be very helpful to patients — as far as it
goes. He notes that the two-year study overestimates the lifelong bother of
side effects that may get better after two years, and underestimates the bother
of side effects that take longer to appear.
"For example, after external-beam radiation, sexual dysfunction may take
up to four years to appear," Brooks tells WebMD. "So it is very
positive that, two years after external-beam radiation, men in the Sanda study
maintained a high level of sexual function. But until we have four or five
years of data, we won't know what the long-term outcomes will be."
He praises Sanda and colleagues for shedding light on the issue of including
spouses or life partners in prostate cancer treatment decisions.
"Prostate cancer is very much a disease that impacts the entire family
unit," Brooks says. "Men who in isolation make decisions according to
what they think their spouse wants often turn out to be 180 degrees off from
what their spouse really wants. Men and their spouses are going to live the
rest of their lives with the consequences of this decision. It is best when
both learn everything they can before making that decision."
Sanda notes that the first thing patients and their partners should focus on
is which treatment is most likely to cure the cancer. After that, the question
becomes which treatment has least impact on the life-quality factors that
matter most to the patient and his partner.
"Our study suggests that the things to bring up are not just the issues
of urinary incontinence and impotence and rectal side effects, but urinary
obstruction, whether the patient has symptoms already, and the issue of
vitality," Sanda says. "If hormonal treatment is part of the picture,
ask about the side effects. We have long recognized that there can be breast
tenderness and hot flashes, but we found these
symptoms were relatively inconsequential compared to loss of energy and mood
effects."
Last, but not least, Sanda advises patients and partners to have a frank
talk with their doctor about how factors such as age, prostate size, and race
affect what they can expect from prostate cancer treatment.
SOURCES: Sanda, M.G. The New England Journal of Medicine, March 20, 2008; vol
358: pp 1250-1261. Martin G. Sanda, MD, director, Prostate Care Center, Beth Israel Deaconess
Medical Center; associate professor of surgery, Harvard Medical School,
Boston. Durado Brooks, MD, MPH, director, prostate and colorectal cancers, American
Cancer Society, Atlanta. News release, Beth Israel Deaconess Medical Center, Boston.
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