Quality of Life: Impact of Prostate Cancer and its Treatment

Introduction

Prostate cancer is the leading solid organ malignancy diagnosed in men in USA, with an estimated 238,590 cases in 2013. The diagnosis of prostate cancer brings about a significant change in the health-related quality of life (HRQOL) of the patient, his sexual partner, and his family. Treatment effects and side effects present a significant socioeconomic burden, given the prevalence and incidence of prostate cancer. Options of treatment for clinically localized prostate cancer includes active surveillance, radical prostatectomy, and radiation therapy. Other measures that may be utilized in conjunction with the mentioned options or alone in the setting of locally advanced, recurrent, or metastatic diseases include hormonal therapy, chemotherapy, and cryotherapy. All of the aforementioned treatment options are associated with varying HRQOL. Prostate cancer thus presents a unique challenge to the physician and the patient when selecting a treatment modality.

The trifecta, the pentafecta

The goal of prostate cancer care and treatment includes oncological control, maintenance of good sexual function, and urinary control. The definitions of these outcome measures (the trifecta) in published literature are highly variable. Some authors have expanded this to include complication rates and margin status, termed the pentafecta. In this chapter, we will focus on HRQOL outcomes, namely, sexual potency and urinary continence, and as indicated, bowel dysfunction.

One of the major issues with research into quality of life (QOL) after prostate cancer treatment is that most studies do not utilize a standardized instrument in the assessment of outcome measures. Moreover, most of the studies evaluating QOL outcomes of prostate cancer management are retrospective in nature or prospective cohort studies at best. With the absence of randomization to different treatment options, recall and selection bias are huge issues compounding the interpretation of the results of these studies. Patients without pretreatment assessment of QOL may be more likely to report a greater decrease in HRQOL posttreatment. Furthermore, perception of QOL outcomes may be different between the doctor’s and the patient’s assessment.

Instruments for QOL research

Various validated instruments have been designed to standardize QOL assessment following the diagnosis of prostate cancer. Patients and/or their spouses typically complete these instruments as opposed to interviews conducted by physicians or other allied health professionals, since physician and patient estimates of QOL often disagree. The instruments typically assess physical functions, emotions, symptoms, and social functioning. The length of time required to complete any such survey should be reasonable, no more than 20 min. Herein, we will review some of the most commonly used QOL instruments.

Rand 36-Item Health Survey (SF-36)

The short-form health survey (SF-36) is a 36-item questionnaire focused on eight different domains: physical functioning, bodily pain, role limitations due to physical health problems, role limitations due to personal or emotional problems, general mental health, social functioning, energy/fatigue, and general health perceptions. Each domain is scored on a scale of 0–100, with higher scores indicating higher levels of function. When two groups are compared using SF-36, any difference of 6.5–8.3 points is considered to be clinically significant.

UCLA Prostate Cancer Index (UCLA-PCI)

The UCLA-PCI is a survey used to assess prostate-cancer-specific HRQOL, focused on six different domains: urinary function, urinary bother, bowel function, bowel bother, sexual function, and sexual bother. Each domain is scored on a scale of 0–100, with higher scores indicating higher levels of function or less bother. This tool has been shown to be reliable and differences of 10 points between two comparison groups is deemed clinically significant.

Expanded Prostate Cancer Index Composite

The Expanded Prostate Cancer Index Composite (EPIC) prostate cancer HRQOL survey was developed to include questions targeted at the urinary side effects of brachytherapy, which were not included in the UCLA-PCI. Although the AUA-SI (presented later) is routinely used in conjunction with UCLA-PCI, it was developed for benign prostatic hyperplasia (BPH) and thus, does not accurately assess treatment-related side effects of brachytherapy. Thus, the UCLA-PCI 20-item survey was expanded to the 50-item EPIC survey.

The EPIC survey also includes domain targeting hormone-related side effects, given that many patients undergoing radiation treatment are also on hormone therapy either in the short- or long-term. The EPIC survey utilizes the SF-12 to assess general QOL issues, instead of SF-36, in order to keep the survey short. Overall, EPIC measures outcomes related to urinary, bowel, sexual, and hormonal symptoms, a comprehensive assessment of HRQOL issues in the management of prostate cancer patients. The 50-item EPIC survey has subsequently been shortened to a 26-item survey while retaining its ability to discern the HRQOL domains, which the original form was designed to measure. A much shorter form containing 16-items, designed for use in clinical practice, was shown to be equally efficient and accurate.

AUA Symptom Index

The AUA Symptom Index (AUA-SI) was developed to assess obstructive and irritative urinary symptoms. This is a seven-item questionnaire focusing on frequency, nocturia, weak stream, hesitancy, intermittency, incomplete emptying, and urgency. Although it was developed to assess patients’ complaints related to BPH, the AUA-SI has been used to assess obstructive and irritating -voiding symptoms associated with prostate cancer treatment.

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