Purpose

While androgen deprivation therapy can delay cancer progression and reduce tumor burden, its use can be limited by adverse side effects. We evaluated the effect of androgen deprivation therapy on mental and emotional well-being in men with nonmetastatic prostate cancer.

Materials and methods

Participants were enrolled in the national CaPSURE (Cancer of the Prostate Strategic Urologic Research Endeavor) registry, and treated with radical prostatectomy, external beam radiation therapy or brachytherapy with no androgen deprivation therapy (local); local with androgen deprivation therapy (combination); or primary androgen deprivation therapy. Emotional quality of life was evaluated by SF-36® social function, role emotional, vitality and mental health subscales before and up to 24 months after treatment. Subscales were assessed as continuous scores and as clinically meaningful declines of at least half a standard deviation since pretreatment. Associations between treatment and quality of life changes over time were evaluated with mixed modeling. Quality of life declines were evaluated with logistic regression.

Results

Among 3,068 men the combination and primary androgen deprivation therapy groups were older, single, with less education and higher clinical CAPRA (Cancer of the Prostate Risk Assessment) score risk than the local group (all values p <0.01). Androgen deprivation therapy exposure was associated with significant changes with time in adjusted role emotional (-8.4 points, p = 0.01) and vitality (-9.2 points, p = 0.02) scores. Treatment group was not associated with any clinically meaningful quality of life declines. A potential limitation is the observational nature of the study.

Conclusions

Use of androgen deprivation therapy was associated with changes in mental and emotional well-being but did not result in clinically meaningful declines at 24 months. Patients must be counseled on possible quality of life changes related to androgen deprivation therapy as well as interventions to attenuate these effects before receiving treatment for prostate cancer.

Background

Men aged >65 yr are less likely to receive local therapy for prostate cancer (PCa), perhaps because of concerns about quality-of-life (QOL) outcomes.

Objective

To describe QOL before and after PCa treatment in men of varying ages.

Design, setting, and participants

Participants enrolled in CaPSURE who underwent radical prostatectomy, brachytherapy, external beam radiation, androgen deprivation therapy, or active surveillance for localized PCa.

Outcome measurements and statistical analysis

QOL changes over time were assessed among age groups using repeated-measures mixed models adjusted for race, year, clinical risk, treatment, comorbidities, and an age-time interaction term. Differences are reported as adjusted least-square means and percentage decline. Secondary analyses evaluated age and QOL for local (prostatectomy, radiation) compared to nonlocal treatment (hormonal, surveillance).

Results and limitations

Older men had lower mean unadjusted pre- and post-treatment QOL scores for nearly all domains. Of the domains evaluated, adjusted mean sexual function, sexual bother, and urinary function showed greater declines from baseline to 2 yr. At 2 yr, more men <60 yr than those >70 yr experienced declines in urinary function (14% vs 9%) and sexual bother (39% vs 17%). Declines in these domains were also greater for local than for nonlocal treatment.

Conclusions

Definitive treatment for localized disease should not be deferred for older men because of fears regarding QOL declines. Younger men should be counseled about potential post-treatment declines in QOL despite higher absolute QOL scores. Communicating these differences to patients will facilitate more appropriate treatment decision-making in men of all ages.

Patient summary

In this study we evaluated quality of life before and after treatment for localized prostate cancer in a diverse patient population. Declines in quality of life after treatment varied according to age and treatment. We conclude that counseling about quality of life will help patients of all ages to make more appropriate treatment decisions.

Objective

To compare rates of lymph node dissection (LND) and nodal yields between patients treated with open radical retropubic prostatectomy (ORRP) and robot-assisted RRP (RARP) in a contemporary single-institution series.

Patients and methods

Data from 1278 consecutive patients (716 ORRP and 562 RARP) from one institution were accrued prospectively in an institutional database, and the data analysed retrospectively. Disease risk was assessed using the Cancer of the Prostate Risk Assessment (CAPRA) score. The likelihood of LND, nodal yield, and likelihood of node positivity were compared between ORRP and RARP.

Results

Of patients treated with ORRP and RARP, 47.8% and 31.8% had LND, respectively, with more receiving LND over time in both surgical approaches. Men undergoing LND had a higher disease risk than those not undergoing LND (mean CAPRA score 4.3 vs 2.1, P < 0.01), and there was no difference in risk between those undergoing ORRP or RARP (mean CAPRA score 3.0 vs 2.9, P = 0.29). The mean (sd) nodal yield was 14.4 (8.7) for ORRP and 9.3 (5.4) for RARP (P < 0.01). Among patients undergoing LND, 5.8% of ORRP and 4.1% of RARP patients had positive nodes (P < 0.01).

Conclusions

The indications for LND and template dissection should be the same regardless of surgical approach. The nodal yield was adequate using both approaches; the yield was higher among ORRP than RARP patients, but the difference was not large, and is less remarkable than the wide variation in yield within each approach. Several factors might explain this variation.

Background

Biopsy progression on active surveillance (AS) for prostate cancer (PCa) often reflects failure of the initial biopsy to detect cancer present at enrollment. The risks for delayed treatment among men who progress on AS are not well defined.

Objective

To report outcomes for men who underwent surgery after AS compared to men who underwent immediate surgery and the influence of selection bias on this outcome.

Design, setting, and participants

AS-eligible (ASE) men who underwent radical prostatectomy (RP) after a median of 20 mo of AS were compared to ASE men who underwent RP within 6 mo of diagnosis. A subset of men on AS who underwent RP after upgrade to Gleason 3+4 was compared to matched controls with similar pretreatment biopsy features who underwent immediate RP.

Outcome measurement and statistical analysis

Rates of adverse pathology (upstaging, positive surgical margin, or Gleason upgrading) were examined. Logistic regression was used to determine associations between treatment subgroup and adverse pathology.

Results and limitations

Of 157 ASE men who underwent delayed RP after AS, 54 were upgraded to Gleason 3+4 before surgery. ASE men who underwent immediate RP had lower probability of adverse pathology than ASE men who underwent delayed RP (hazard ratio [HR] 0.34, 95% confidence interval [CI] 0.21-0.55). The rate of adverse pathology did not differ between immediate and delayed RP patients matched for pretreatment characteristics (HR 0.79, 95% CI 0.27-2.28). The observational design of this study is its main limitation.

Conclusions

When compared to men with similar pretreatment biopsy features, those who underwent delayed RP were not at higher risk of adverse pathology.

Patient summary

The oncologic safety of delayed treatment when indicated for men enrolled in active surveillance for prostate cancer is important. We found that men who underwent delayed surgery had similar outcomes to men who underwent immediate prostatectomy.

Background

African American (AA) men suffer a higher prostate cancer (PCa) burden than other groups.

Objective

We aim to determine the impact of race on the risk of upgrading, upstaging, and positive surgical margins (PSM) at radical prostatectomy (RP) among men eligible for active surveillance.

Design, setting, and participants

We studied men with low-risk PCa treated with RP at two centers. Low clinical risk was defined by National Comprehensive Cancer Network criteria. Outcome variables were upgrading, upstaging, and PSMs at surgery. Associations between race and the outcomes were evaluated with logistic regression adjusted for age, relationship status, diagnostic prostate-specific antigen level, percentage of positive biopsy cores, surgical approach, year of diagnosis, and clinical site.

Results and limitations

Of 9304 men diagnosed with PCa, 4231 were low risk and underwent RP within 1 yr. Men were categorized as AA (n=273; 6.5%), Caucasian (n=3771; 89.1%), or other racial/ethnic group (Other; n=187; 4.4%). AA men had a significantly younger mean age (58.7 yr; standard deviation: ±7.06), and fewer (85%) were married or had a partner. Upgrading (34%) and upstaging (13%) rates did not significantly differ among the groups. The PSM rate was significantly higher in AA men (31%) than in the Caucasian (21%) and Other (20%) groups (p<0.01). We found an association between race group and PSM rate (p<0.03), with higher odds of PSMs in AA men versus Caucasian men (odds ratio [OR]: 1.64; 95% confidence interval [CI], 1.08-2.47). No statistically significant associations between race and rates of upgrading and upstaging were found. This study was limited by the relatively low proportion of AA men in the cohort.

Conclusions

Among clinically low-risk men who underwent RP, AA men had a higher likelihood of PSMs compared with Caucasian men. We did not find statistically significantly different rates of upgrading and upstaging between the race groups.

Patient summary

We analyzed two large groups of men with what appeared to be low-risk prostate cancer based on the initial biopsy findings. The likelihood of finding worse disease (higher grade or stage) at the time of surgery was similar across different racial groups.

Purpose

NCCN Guidelines® recommend annual prostate biopsies for men with low risk prostate cancer on active surveillance. We determined whether erectile function decreases with the number of biopsies experienced.

Materials and methods

During a median 3.2-year followup after prostate cancer diagnosis in 2003 to 2010 at our institution 427 men on active surveillance underwent a total of 1,197 biopsies and provided 1,398 erectile function evaluations via the Sexual Health Inventory for Men questionnaire. For analysis we decomposed the 25-point questionnaire responses into a 5-point erectile function score and a 3-level sexual activity status. We used separate models adjusted for patient characteristics to determine whether either outcome varied with biopsy exposure.

Results

At diagnosis the median age was 61 years and median prostate specific antigen was 5.3 ng/ml. Of the cases 70% were clinical stage cT1 and 93% were Gleason score less than 7. Of biopsies followed by evaluations 40% were the first undergone by the patient and 9% were the fifth to ninth. At the first erectile function evaluation 15% of men were inactive, 8% engage in stimulation and 77% engaged in intercourse. Sexual activity level changed in greater than 20% of respondents between evaluations. Adjusted erectile function scores were not associated with biopsy exposure cross-sectionally or longitudinally but they corresponded with the 50th, 63rd and 80th percentiles of erectile function by increasing sexual activity level. Similarly, sexual activity was not associated with biopsy exposure. Separated outcomes were more accurate and informative than Sexual Health Inventory for Men scores.

Conclusions

Our study had high power to detect erectile function-biopsy associations but it estimated that the effects were negligible. We recommend erectile function scores over Sexual Health Inventory for Men scores to avoid biased assessment of erectile function.

Background

Few studies have reported on late declines and long-term health-related quality of life (HRQOL) after prostate cancer (PCa) treatment.

Objective

We assessed long-term HRQOL following various treatments for localized PCa.

Design, setting, and participants

This cohort study of HRQOL up to 10 yr after treatment used a prospectively accrued, nationwide PCa registry that collects longitudinal patient-reported HRQOL.

Intervention

Various primary treatments for localized PCa.

Outcome measurements and statistical analysis

The Medical Outcomes Studies 36-item Short Form and the University of California, Los Angeles, Prostate Cancer Index characterized physical function, mental health, and sexual, urinary, and bowel function and bother. Repeated measures mixed-model analysis assessed change in HRQOL by treatment over time, and logistic regression was used to measure the likelihood of a clinically significant decline in HRQOL.

Results and limitations

Among 3294 men, 1139 (34%) underwent nerve-sparing radical prostatectomy (NSRP), 860 (26%) underwent non-NSRP, 684 (21%) underwent brachytherapy, 386 (12%) underwent external beam radiotherapy, 161 (5%) underwent primary androgen deprivation therapy, and 64 (2%) pursued watchful waiting/active surveillance. Median follow-up was 74 mo (interquartile range: 50-102). Most treatments resulted in early declines in HRQOL, with some recovery over the next 1-2 yr and a plateau in scores thereafter. Surgery had the largest impact on sexual function and bother and on urinary function, radiation had the strongest effect on bowel function, and androgen deprivation therapy had the strongest effect on physical function. The main limitation was attrition among the cohort.

Conclusions

Although most men experience initial declines in HRQOL in the first 2 yr after treatment, there is little change from 3 to 10 yr and most differences between treatments attenuated over time.

Patient summary

Various treatments for prostate cancer result in a distinct constellation of adverse effects on health-related quality of life, which may have a long-term impact. These findings are helpful regarding shared decision making over choice of primary treatment.

Background

The prognostic meaning of an undetectable ultrasensitive prostate-specific antigen (USPSA) level after prostatectomy remains unclear.

Objective

To determine whether an undetectable USPSA level obtained after surgery is a predictor of biochemical recurrence (BCR)-free survival.

Design, setting, and participants

From the Urologic Oncology Database at the University of California San Francisco, 525 men were identified who had a USPSA measurement 1-3 mo postoperatively with at least 2 yr of follow-up. All preoperative and pathologic criteria were recorded.

Measurements

Patients were stratified based on their initial USPSA level. We defined an undetectable USPSA level at ≤0.05 ng/ml. Recurrence was defined as two consecutive prostate-specific antigen (PSA) levels ≥0.2 ng/ml or secondary treatment.

Results and limitations

We found that 456 patients (87%) had undetectable USPSA and 69 patients (13%) had detectable USPSA immediately postprostatectomy. A 5-yr recurrence-free rate of 86% was found in the undetectable USPSA group compared with 67% in the detectable USPSA group (p<0.01). For patients with pT3 disease, men with an undetectable USPSA had a 5-yr BCR-free survival rate of 78% compared with 40% for men with a detectable USPSA (p<0.01). A multivariable analysis confirmed that patients with an undetectable USPSA were 67% less likely to recur (hazard ratio: 0.33; 95% confidence interval: 0.20-0.55). As the detection level of PSA is lowered, the false-positive rate of BCR necessarily increases. A limitation of the study is its retrospective nature.

Conclusions

An undetectable USPSA after radical prostatectomy is a prognostic indicator of BCR-free survival at 5 yr and may aid in predicting outcome in higher risk patients.