Neglected Side Effects Predict Satisfaction With Prostate Cancer Treatment
By Daniel J. DeNoon
WebMD Medical News
Reviewed by Louise Chang, MD
March 19, 2008 -- Side effects men rarely think about before prostate cancer treatment have huge effects on their after-treatment quality of life.
The finding comes from a study of 1,201 men -- and 625 of their spouses or life partners -- before and after they received different treatments for prostate cancer at nine different high-quality hospitals. All the treatments were successful in that none of the men died from prostate cancer or from the treatment.
But not all of the men, or their life partners, were happy with the side effects they experienced after treatment. Some were disturbed by impotence or urinary/bowel incontinence, the symptoms on which pretreatment doctor-patient discussions tend to focus.
More neglected symptoms -- related to urinary obstruction or to "vitality" -- were equally disturbing, found Martin G. Sanda, MD, director of the Prostate Care Center at Beth Israel Deaconess Medical Center, and colleagues.
"The nice part of the prostate cancer story is that, by and large, the vast majority of patients are cured. Now the emphasis is on quality of survival," Sanda tells WebMD. "So we did a catchall study to see if there are things we can find out to make patients and doctors more accurately predict what the patient's outcomes will be, and to empower patients to make decisions based on what is right for them."
The study focused on the side effects men experience in the 24 months after various prostate cancer treatments:
* Radical prostatectomy, surgery to remove the prostate, using or not using nerve-sparing techniques.
* External-beam radiotherapy, using newer techniques, either with or without androgen-suppressing therapy.
* Brachytherapy, implantation of radioactive seeds, either with or without androgen-suppressing therapy.
Prostate Cancer Treatment Risks Differ
Every one of these prostate cancer treatments is linked to serious side effects. Each one has a different side-effect profile.
When discussing which treatment would be best for an individual patient, Sanda says doctors and patients tend to focus on three main side effects: sexual dysfunction, rectal incontinence, and urinary incontinence.
Those side effects have a huge impact on the lives of patients and their partners. But Sanda and colleagues find that other side effects have just as much impact. These fall into two main groups:
* Symptoms related to urinary irritation or obstruction, such as pain during urination, weak stream, and increased urination frequency.
* "Vitality" issues, including energy level, mood, perception of fitness, and weight.
"One thing that is new here is the entire notion that symptoms related to urinary obstruction are an important component of quality of life in these patients," Sanda says. "It is something that should be brought up to the same degree as issues of impotence or rectal incontinence problems."
Also new is the concept of "vitality" after prostate cancer treatment.
"Vitality is not a concrete physical symptom or something you can directly measure," Sanda says. "But the things in this area that patients reported being affected by treatment are things like energy level, mood, and perception of fitness, or weight. For some patients, especially those treated with hormone-suppressing therapy, this was at least as troublesome to them as impotence and bowel problems."
Hormonal therapy generally made the side effects of radiation therapy and brachytherapy worse. Nerve-sparing surgery generally lessened the side effects of prostatectomy.
Patients had worse side effects if, at the time of treatment, they were obese, had a large prostate, had high PSA scores, or were older.
African-American patients reported significantly less satisfaction with their prostate cancer treatment choice than did white patients. Because all patients in the study received the same quality of treatment, Sanda has two theories about this finding.
"Perhaps African-American patients weren't counseled as effectively about what they could expect after treatment," he says. "Or it may be the recognized reality that African-Americans tend to have somewhat worse prostate cancer than patients of other races."
Durado Brooks, MD, MPH, director for prostate and colorectal cancers at the American Cancer Society, agrees that the study raises questions about African-American men's expectations from prostate cancer treatment.
"Beyond communication issues is the question of whether African-American men have a different level of expectations based not on education but on culture," Brooks suggests.
Prostate Cancer Treatment: Don't Make Tough Decision Alone
Brooks says the Sanda study will be very helpful to patients -- as far as it goes. He notes that the two-year study overestimates the lifelong bother of side effects that may get better after two years, and underestimates the bother of side effects that take longer to appear.
"For example, after external-beam radiation, sexual dysfunction may take up to four years to appear," Brooks tells WebMD. "So it is very positive that, two years after external-beam radiation, men in the Sanda study maintained a high level of sexual function. But until we have four or five years of data, we won't know what the long-term outcomes will be."
He praises Sanda and colleagues for shedding light on the issue of including spouses or life partners in prostate cancer treatment decisions.
"Prostate cancer is very much a disease that impacts the entire family unit," Brooks says. "Men who in isolation make decisions according to what they think their spouse wants often turn out to be 180 degrees off from what their spouse really wants. Men and their spouses are going to live the rest of their lives with the consequences of this decision. It is best when both learn everything they can before making that decision."
Sanda notes that the first thing patients and their partners should focus on is which treatment is most likely to cure the cancer. After that, the question becomes which treatment has least impact on the life-quality factors that matter most to the patient and his partner.
"Our study suggests that the things to bring up are not just the issues of urinary incontinence and impotence and rectal side effects, but urinary obstruction, whether the patient has symptoms already, and the issue of vitality," Sanda says. "If hormonal treatment is part of the picture, ask about the side effects. We have long recognized that there can be breast tenderness and hot flashes, but we found these symptoms were relatively inconsequential compared to loss of energy and mood effects."
Last, but not least, Sanda advises patients and partners to have a frank talk with their doctor about how factors such as age, prostate size, and race affect what they can expect from prostate cancer treatment.
By Daniel J. DeNoon
WebMD Medical News
Reviewed by Louise Chang, MD
March 19, 2008 -- Side effects men rarely think about before prostate cancer treatment have huge effects on their after-treatment quality of life.
The finding comes from a study of 1,201 men -- and 625 of their spouses or life partners -- before and after they received different treatments for prostate cancer at nine different high-quality hospitals. All the treatments were successful in that none of the men died from prostate cancer or from the treatment.
But not all of the men, or their life partners, were happy with the side effects they experienced after treatment. Some were disturbed by impotence or urinary/bowel incontinence, the symptoms on which pretreatment doctor-patient discussions tend to focus.
More neglected symptoms -- related to urinary obstruction or to "vitality" -- were equally disturbing, found Martin G. Sanda, MD, director of the Prostate Care Center at Beth Israel Deaconess Medical Center, and colleagues.
"The nice part of the prostate cancer story is that, by and large, the vast majority of patients are cured. Now the emphasis is on quality of survival," Sanda tells WebMD. "So we did a catchall study to see if there are things we can find out to make patients and doctors more accurately predict what the patient's outcomes will be, and to empower patients to make decisions based on what is right for them."
The study focused on the side effects men experience in the 24 months after various prostate cancer treatments:
* Radical prostatectomy, surgery to remove the prostate, using or not using nerve-sparing techniques.
* External-beam radiotherapy, using newer techniques, either with or without androgen-suppressing therapy.
* Brachytherapy, implantation of radioactive seeds, either with or without androgen-suppressing therapy.
Prostate Cancer Treatment Risks Differ
Every one of these prostate cancer treatments is linked to serious side effects. Each one has a different side-effect profile.
When discussing which treatment would be best for an individual patient, Sanda says doctors and patients tend to focus on three main side effects: sexual dysfunction, rectal incontinence, and urinary incontinence.
Those side effects have a huge impact on the lives of patients and their partners. But Sanda and colleagues find that other side effects have just as much impact. These fall into two main groups:
* Symptoms related to urinary irritation or obstruction, such as pain during urination, weak stream, and increased urination frequency.
* "Vitality" issues, including energy level, mood, perception of fitness, and weight.
"One thing that is new here is the entire notion that symptoms related to urinary obstruction are an important component of quality of life in these patients," Sanda says. "It is something that should be brought up to the same degree as issues of impotence or rectal incontinence problems."
Also new is the concept of "vitality" after prostate cancer treatment.
"Vitality is not a concrete physical symptom or something you can directly measure," Sanda says. "But the things in this area that patients reported being affected by treatment are things like energy level, mood, and perception of fitness, or weight. For some patients, especially those treated with hormone-suppressing therapy, this was at least as troublesome to them as impotence and bowel problems."
Hormonal therapy generally made the side effects of radiation therapy and brachytherapy worse. Nerve-sparing surgery generally lessened the side effects of prostatectomy.
Patients had worse side effects if, at the time of treatment, they were obese, had a large prostate, had high PSA scores, or were older.
African-American patients reported significantly less satisfaction with their prostate cancer treatment choice than did white patients. Because all patients in the study received the same quality of treatment, Sanda has two theories about this finding.
"Perhaps African-American patients weren't counseled as effectively about what they could expect after treatment," he says. "Or it may be the recognized reality that African-Americans tend to have somewhat worse prostate cancer than patients of other races."
Durado Brooks, MD, MPH, director for prostate and colorectal cancers at the American Cancer Society, agrees that the study raises questions about African-American men's expectations from prostate cancer treatment.
"Beyond communication issues is the question of whether African-American men have a different level of expectations based not on education but on culture," Brooks suggests.
Prostate Cancer Treatment: Don't Make Tough Decision Alone
Brooks says the Sanda study will be very helpful to patients -- as far as it goes. He notes that the two-year study overestimates the lifelong bother of side effects that may get better after two years, and underestimates the bother of side effects that take longer to appear.
"For example, after external-beam radiation, sexual dysfunction may take up to four years to appear," Brooks tells WebMD. "So it is very positive that, two years after external-beam radiation, men in the Sanda study maintained a high level of sexual function. But until we have four or five years of data, we won't know what the long-term outcomes will be."
He praises Sanda and colleagues for shedding light on the issue of including spouses or life partners in prostate cancer treatment decisions.
"Prostate cancer is very much a disease that impacts the entire family unit," Brooks says. "Men who in isolation make decisions according to what they think their spouse wants often turn out to be 180 degrees off from what their spouse really wants. Men and their spouses are going to live the rest of their lives with the consequences of this decision. It is best when both learn everything they can before making that decision."
Sanda notes that the first thing patients and their partners should focus on is which treatment is most likely to cure the cancer. After that, the question becomes which treatment has least impact on the life-quality factors that matter most to the patient and his partner.
"Our study suggests that the things to bring up are not just the issues of urinary incontinence and impotence and rectal side effects, but urinary obstruction, whether the patient has symptoms already, and the issue of vitality," Sanda says. "If hormonal treatment is part of the picture, ask about the side effects. We have long recognized that there can be breast tenderness and hot flashes, but we found these symptoms were relatively inconsequential compared to loss of energy and mood effects."
Last, but not least, Sanda advises patients and partners to have a frank talk with their doctor about how factors such as age, prostate size, and race affect what they can expect from prostate cancer treatment.
Comments