Surprising Data From Prostate Cancer Quality of Life Study

LOS ANGELES--A survey of men with and without prostate cancerused four different instruments (see below) to get a clear pictureof how treatment decisions affect quality of life, and found somesurprising results, Mark S. Litwin, MD, MPH, told Oncology NewsInternational.

Quality of life should be considered an important medical outcome,on a par with quantity of life, when making treatment decisionsin prostate cancer, said Dr. Litwin, of the UCLA School of Medicine.Yet in most studies, outcome measures of various treatments areno more sensitive than "alive versus dead."

Researchers from UCLA and the RAND Corporation measured qualityof life in 214 men treated for clinically localized prostate cancerand 273 age-matched controls who had never had prostate cancerdiagnosed. The patients were treated with either radical prosta-tectomy(98 patients), external-beam irradiation (56), or observationalone (60). Patients completed a questionnaire at home, withoutassistance.

Surprisingly, responses to the parts of the survey reflectinggeneral health and well-being showed no differences between patientsand controls, Dr. Litwin said (JAMA 273:129-135, 1995). One exceptionwas that observation patients reported greater role limitationsdue to emotional problems, which may be caused by anxiety anduncertainty concerning the future course of their prostate cancer.

Day-to-Day Life Not Compromised

A cancer-specific questionnaire also showed no differences ingeneral health (excluding sexual function), "implying thatthe major activities in patients' day-to-day lives are not compromisedafter prostate cancer therapy, regardless of which treatment ischosen," he said.

However, a prostate-specific instrument revealed significant differencesbetween patients and controls in bowel symptoms, urinary incontinence,and sexual dysfunction. Surgery and radiation patients were worseoff functionally than observation or comparison patients. Thesurprising finding was that many were not very bothered by theirdysfunctions.

Impotence for example, bothered 78% of men a great deal, but 22%were able to adjust and reported little or no bother from it.Only a few men (8%) reported diarrhea as an important bother.

The concept of "bother" is becoming increasingly important,as it reflects the realization that each individual reacts differentlyto disease-related dysfunction, Dr. Litwin said.

He pointed out that findings in the control group underline theimportance of comparing prostate cancer patients to a group thatis truly comparable, rather than to some ideal of perfect function.

"We expected the so-called healthy controls to have near-perfectcontinence--but they didn't," Dr. Litwin said. On a 0 to100 scale, urinary function was rated as 83 among controls, comparedto 68 in radical prostatectomy patients.

The high level of sexual dysfunction in all groups was striking:Patients who did not have prostate cancer scored only 47 of 100on the sexual function scale, while patients receiving observation,radiation, and surgery, scored 41, 35, and 19, respectively.

A comparison of the 23 men who had nerve-sparing surgery withthe 75 men who had standard prostatectomy showed no statisticallysignificant group difference in any of the health-related qualityof life scores, but the nerve-sparing surgery patients had a higher,though not statistically significant, sexual function score thanthe standard surgery patients.

"With so few men in the nerve-sparing group, we had limitedstatistical power to demonstrate a difference that may be present,"he said, adding that this would be an interesting area for futurestudies.

The findings underscore the importance of making individualizedtreatment decisions, because patients will weigh the importanceof different outcomes differently, Dr. Litwin said.

"The traditional Western medical perspective of maximizingsurvival at all cost is inadequate," Dr. Litwin commented.Indeed, the most rational approach to treating men with localizedprostate cancer needs to include not only adding years to life,but also adding life to years."

Based on these results, physicians can advise patients newly diagnosedwith localized prostate cancer that treatment is unlikely to affectgeneral quality of life but may be associated with clinicallysignificant changes in sexual, urinary, or bowel function.

Dr. Litwin's colleagues in the project were Drs. Ron Hays, ArleneFink, Patricia Ganz, Barbara Leake, Gary Leach, and Robert Brook.

Quality of Life Instruments

Consensus is emerging on common terms and on various outcomesthat together constitute quality of life, Dr. Mark Litwin toldOncology News International (see story above). In the UCLA study,four different assessment tools were used:

1. General health-related quality of life (HRQOL) was measuredwith the RAND 36-item Health Survey 1.0, which addresses eighthealth concepts: physical and social function, bodily pain, emotionalwell-being, energy/fatigue, general health perceptions, and rolelimitations due to physical or emotional problems.

2. Cancer-specific HRQOL was measured with the CAncer RehabilitationEvaluation System-Short Form (CARES-SF), abridged to 45 items,which addresses five areas: physical, psychosocial and sexualfunction; medical interaction; and marital interaction.

3. The 28-item Functional Assessment of Cancer Therapy-Generalform (FACT-G) was also used to look at cancer-specific measuresof well-being, including physical, social/family, relationshipwith physician, emotional, and functional.

4. Disease-targeted quality of life was measured with a new 20-iteminstrument developed by the UCLA researchers and available fromthem by request (write: UCLA Division of Urology, Box 173817,Los Angeles, CA 90095). The instrument assesses function and bother(the impact of dysfunction on daily life) in three organ systems:sexual, urinary, and bowel. The scales are then converted to a0 to 100 range, with higher scores representing better outcomes.