Good QOL, but Sexual Dysfunction Common After Prostate Cancer

Pam Harrison

February 05, 2019

Overall, men who have been treated for prostate cancer can expect quality of life equal to that as men in the general population, even those diagnosed with advanced disease, concludes the largest study of its kind.

However, the study also shows that sexual dysfunction is virtually ubiquitous among men treated for prostate cancer, regardless of age or disease stage.

In addition, men treated with androgen deprivation therapy (ADT) frequently report problems with hot flushes, low energy, and weight gain, the study shows.

"This study this study is the largest population based, patient-reported outcomes study of men with prostate cancer to date," say the authors, led by Amy Downing, PhD, University of Leeds, United Kingdom.

The study collected data on 35,823 men with prostate cancer, including 11,000 men living with locally advanced or metastatic disease (stage 3 or 4 disease), who are often excluded from quality-of-life studies, the authors note.

The study was published online January 31 in The Lancet Oncology.

The results are helpful to "those of us who treat prostate cancer to obtain a better understanding of how patients are coping with their disease and treatments," comments Fred Saad, MD, FRCSC, University of Montreal Hospital Center in Canada, in an accompanying editorial.

"Balancing the side-effects of treatment and the risks related to the cancer itself has become a priority in the field of prostate cancer," he observes. 

"For the time being, we can be reassured...that in terms of patient-perceived quality of life, we might be doing a better job than we previously thought," he adds.

Study Details

The participants in this British study were initially identified through cancer registration data, and were then mailed a health-related quality of life (HRQOL) survey. The questionnaire was completed at 18 to 24 months after diagnosis of prostate cancer. The median age was 71 years and the majority of participants  reported having at least one other long-term health problem.

Disease stage was known for 85.8% of the cohort out, of which 63.8% had stage I or II prostate cancer, 23.4% had stage III disease, and 12.8% had stage IV disease.

To assess functional outcomes, the EPIC-26 (Expanded Prostate Cancer Index Composite short form) was used to measure urinary incontinence; urinary irritation and obstruction; and bowel, sexual, vitality, and hormonal function, whereas the EuroQoL (EQ-5D-5L) questionnaire was used to assess measures of mobility; self-care; the ability to carry out usual activities of daily living; pain or discomfort; and anxiety or depression. The EQ-5D-5L was also used to rate a patient's self-assessed health based on how good he or she felt on the day the survey was completed.

"Mean adjusted EPIC-26 domain scores were high in all men, indicating good function, except for sexual function, for which scores were much lower," Downing and colleagues report.

Urinary and bowel function as assessed by the same questionnaire was similar across all stages of disease.

In contrast, men with stage 3 and 4 prostate cancer had significantly lower scores for vitality as well as hormonal and sexual function compared with men who had localized disease, study authors note.

Perhaps not surprisingly, more men who had their cancer removed surgically reported urinary incontinence than men who did not undergo prostatectomy, while men receiving ADT had worse hormonal and sexual function than men not treated with ADT, investigators add. 

Poor Urinary Function

Among men reporting poor urinary function, "the need to urinate frequently was the most common urinary symptom," the researchers note.

There was little difference in the incidence of this side-effect between different stages of the disease, but there was a difference between the different treatments that were administered.

Almost one third of men in the surgical group reported having to use pads one or more times per day, a higher rate than that reported by men treated with other modalities, the researchers observe.

Importantly, bowel dysfunction was a relatively infrequent complaint, and again differed little by disease stage.

However, of those men who did report bowel problems, more men who underwent external beam radiation therapy alone (or in combination with other modalities) were more affected by bowel urgency than men who were treated with surgery alone, the researchers point out.

Problems with low energy, hot flushes, and weight gain were, in contrast, more related to stage of disease than either urinary or bowel problems, but rates of these complaints varied considerably depending on how the prostate cancer had been treated.

For example, men who had received ADT — either alone or in combination with other therapies — were much more likely to report problems with hormonal function and fatigue than men who had not received ADT.

Specifically, over 30% of men receiving ADT reported experiencing significant hot flushes, and a similar percentage of men reported having low energy; these rates were much higher than in men who had not received ADT.

Men treated with ADT were also more likely to report weight gain compared with men who had not received ADT, the investigators also point out.

Poor Erections Extremely Common

Poor or very poor erections were, on the other hand, an extremely common complaint across the whole population, being reported by 81.5% of the group, with equal percentages reporting poor or very poor overall sexual function.

Sexual dysfunction rates were high even among men with localized disease, although they were higher still among men with later stages of prostate cancer.

Men who reported undergoing active surveillance were the least likely to report poor or very poor overall sexual function, yet even in this group, over half of patients registered this as a major complaint.

About 45% of men overall also indicated that they were bothered by their poor sexual function, although this complaint decreased slightly with age.

About 40% of men who reported poor or very poor sexual function noted that they were offered medications, devices, or counseling to help improve their sex lives.

However, this meant that close to 56% of the group were not offered any intervention for sexual dysfunction, and this percentage remained relatively high even in the youngest cohort.

Of those who were offered some sort of intervention, over 37% didn't bother with any of them and almost one quarter of recipients indicated that the intervention did not help.

Pain or discomfort were relatively common in the overall group, being reported by close to 42% of the men surveyed.

However, men with stage 4 prostate cancer were the most likely to report pain or discomfort, as well as difficulties carrying out activities of daily living.

That said, "the overall mean adjusted self-assessed health score was 76.3," Downing and colleagues report, which was only 5.7 points lower in men with stage 4 disease compared with men with stage 1 or 2 prostate cancer.

ADT and Quality of Life

As the authors note, most men with stage 3 or 4 prostate cancer in this particular cohort were on long-term or indefinite ADT.

Given the detrimental effects of ADT on both vitality and hormonal function, "results suggest that clinicians should pursue treatment approaches that preserve testosterone function when possible and minimize ADT use," the authors advise.

Steps to mitigate side effects associated with ADT include the use of intermittent rather than continuous ADT; avoidance of the unnecessary use of ADT; and a reduction in the duration of treatment from 3 years to 1 year. 

Predictive Markers

In the editorial, Saad expresses the hope that, eventually, the medical community will have predictive markers to help them discriminate between aggressive prostate cancer in need of early aggressive therapy and the more indolent forms of the disease.

Other biomarkers may also allow physicians to identify men who are most likely to suffer the ill effects from ADT.

"Until then, we must re-establish some reasonable equilibrium and return the focus to the fact that, first and foremost, we are treating a life-threatening disease for most of those diagnosed," Saad emphasizes.

In the recent past, aggressive screening for, and treatment of, prostate cancer probably did "more harm than good in many cases," Saad comments.

He admits that issues of quality of life, and this worry about doing more harm than good, has led him to "delay interventions in cancers [that] I underestimated," he writes, and he humbly regrets having delayed treatment decisions.

However, while aggressive screening and indiscriminate treatment is no longer acceptable, "the worry now is that the pendulum might have swung in the opposite direction and we fear that we might slowly creep back to the era in which most patients were treated at a late or incurable stage," he suggests.

"Clearly, continued intensive efforts in research are needed to achieve the aim of optimising and personalising care of patients with prostate cancer," he concludes.

The study was funded by the Movember Foundation in partnership with Prostate Cancer UK. Downing and Saad have disclosed no relevant financial relationships; Downing's study coauthors have disclosed relevant financial relationships, which are listed in the published manuscript.

The Lancet Oncol. Published online January 31, 2019. Full text, Editorial

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