Comparison of Health Related Quality of Life (HRQOL) in Men Treated With Radical Prostatectomy or External Beam Radiotherapy for Localized Prostate Cancer

Reviewer: Charles B. Simone, II, MD
Abramson Cancer Center of the University of Pennsylvania
Last Modified: October 30, 2007

Presenter: Varagur M. Venkatesan, MD
Presenter's Affiliation: London Regional Cancer Program, London Health Sciences Centre
Type of Session: Scientific

Background

Although no large, randomized trials have directly compared outcomes between the two leading treatment modalities for patients with low-risk prostate cancer, historical comparisons have found no difference in overall survival between patients undergoing radical prostatectomy (RP) and external beam radiation therapy (EBRT).
Therefore, treatment decisions are often based on treatment morbidity and patient quality of life. Quality of life is subjective and multidimensional, and accounts for expectations, satisfactions, value systems, and various facets of personal life that patients experience.
This study compares the long-term health-related quality of life outcomes among patients treated with RP and EBRT for localized prostate cancer using a validated questionnaire.

Materials and Methods

Investigators mailed consent forms and questionnaire to all patients with prostate cancer treated with RP or EBRT at their institution from 1998 to 2004 to compare health-related quality of life (HRQOL) following the different treatment modalities.
The Expanded Prostate Cancer Index Composite (EPIC) was used to measure quality of life pertaining to their disease, as EPIC has previously been shown to be a validated, reliable, and comprehensive instrument from which data can be obtained. EPIC was supplemented with mental health queries from SF-12, another validated research tool.
Questionnaires were self-administered and provided patient-reported outcomes.

Results

Questionnaires were mailed out to all 1,775 patients who underwent RP or ERBT as primary treatment for prostate cancer at the investigative institution.
Questionnaire response rate was 72% (633/883) for RP and 66% (592/892) for EBRT.
Among respondents, patients who underwent EBRT were on average more likely to be older (73 years vs. 67 years) and retired (89% vs. 66%) than patients who underwent RP, but fewer earned greater than $30,000 per year (55% vs. 70%). Respondents were equally likely to be Caucasian (96.5% in both groups), and there was no significant difference between groups in the time from treatment.
Rates of comorbidities among patients who underwent EBRT were uniformly higher for all disease queries, including diabetes mellitus (18% vs. 12%), myocardial infarction (27% vs. 14%), and stroke (9% vs. 3%).
Hormone therapy was also higher among patients who received definitive irradiation. This was seen among patients who received neoadjuvant hormonal therapy (56% vs. 27%) and adjuvant hormonal therapy (22% vs. 8%). Patients who underwent EBRT were also more likely to be receiving current hormonal injections (32% vs. 19%) and oral hormonal administration (26% vs. 16%) at the time of survey completion.
When compared with those who received EBRT, patients who underwent RP had a small but statistically significant improvement in long-term HRQOL outcome for urinary irritative and bowel queries (p<0.0001 for both), but significantly lower scores for queries pertaining to urinary incontinence (p<0.0001).
Patients receiving either treatment modality showed poor sexual domain scores, although reported scores among surgery patients were higher (p=0.0001).
Equal scores were seen among the mental component of SF-12 domain.
Multivariate analysis was performed to examine the impact of patient- and treatment-related factors on morbidity and quality of life
Age and the number of comorbidities were significant variables in determining sexual quality of life (p < 0.0001).
Urinary quality of life was significantly influenced by comorbidities and current hormone treatment for recurrence (p < 0.0001).
Patients had significantly worse bowel quality of life with increasing number of comorbidities and treatment with EBRT (p < 0.0001).

Author's Conclusions

The majority of prostate cancers are diagnosed at an early stage, with either RP or EBRT resulting in good biochemical control and survival rates.
In comparison to those who received EBRT, patients who underwent RP in this study population had better bowel and sexual quality of life, but worse self-reported urinary morbidity.
Results from this study may provide patients with early stage prostate cancer a view of the HRQOL following EBRT or RP that might help them when deciding which treatment modality to pursue.

Clinical/Scientific Implications

With relatively similar long-term survival outcomes between patients undergoing EBRT or RP for early stage prostate cancer, treatment decisions are often based on treatment morbidity and patient quality of life. By quantifying subjective health-related outcomes through the use of validated surveys, this study provides patients with data regarding patient-reported treatment morbidities that can help aid them in deciding which definitive treatment to pursue. Patients can weight the self-importance of such treatment toxicities as urinary incontinence, rectal bleeding and bowel incontinence, and sexual dysfunction. However, it is important to realize that this study is nonrandomized and is instead a cross-sectional analysis. Patients were not matched for age or comorbidities, both of which have been shown to influence treatment toxicities. Although investigator biases have been limited through the use of a survey, recollection and selection biases could still have influenced results. Future randomized trials with matched patient populations should examine this important topic of quality of life following treatment for early stage prostate cancer.

Partially funded by an unrestricted educational grant from Bristol-Myers Squibb.