Early quality of life in patients with localized prostate carcinoma: an examination of treatment-related, demographic, and psychosocial factors.

Prostate carcinoma is the most common solid tumor malignancy in American men. The American Cancer Society estimates that, in 2001, approximately 198,100 men will be diagnosed with prostate carcinoma in the United States.1 Nevertheless, fewer than 20% of these men are expected to die from the disease, and 93% will survive for at least 5 years postdiagnosis, making quality of life (QoL) issues paramount in this population. The man who is diagnosed with localized prostate carcinoma has several therapeutic options. These include radical prostatectomy (RP), or surgical removal of the prostate gland; external beam radiotherapy (EBR), or focusing radiation on the malignancy from outside of the body; and brachytherapy (BT), or implanting radioactive seeds into the prostate gland. Patients also may elect not to be treated. There is no consensus on which of these therapeutic approaches is best, and results from nonrandomized studies show similar survival rates.2–4 Thus, selection of the appropriate treatment for patients with clinically localized prostate carcinoma frequently is based on factors other than survival advantage. Both medical and nonmedical factors will determine treatment choice. Stage and grade of disease, age, number and type of comorbid conditions, and access to a given treatment all are important factors in treatment selection. Some men have fewer choices than others. For example, an elderly man with low-grade, early-stage prostate carcinoma and heart disease is not a good candidate for RP. Consequently, he may be encouraged by his physician to select a less risky treatment, such as EBR. However, for many others, the appropriate treatment is less obvious. It is in these situations that information about QoL outcomes becomes critical to decision making. Several studies have compared health-related QoL (HRQoL) outcomes across treatments.5–11 Most have compared RP with EBR. In general, men who undergo RP report more urinary dysfunction (i.e., greater incontinence and greater use of absorptive pads) and more sexual dysfunction (i.e., reduced erectile capacity and low level of sexual desire) compared with men who are treated with EBR.5,7–11 Bowel dysfunction (i.e., urgency and diarrhea) is reported more often by men who are treated with EBR compared with men who undergo RP.8,10 In one study, men who underwent RP or men who were treated with EBR evidenced short-term reductions in energy level and role limitations due to physical function.7 By 1 year post-treatment, both groups showed significant and clinically meaningful increases in role functioning, whereas only the group of men who underwent RP showed substantial improvements in energy level. Recently, comparisons have been made between BT and other treatments. Zelefsky et al.12 compared men who were treated with EBR with men who were treated with BT. In the short term, those who received BT showed slightly higher urinary toxicity (e.g., urethral stricture) compared with those who were treated with EBR. Brandeis et al.13 compared men who were treated with BT (both with and without pretreatment EBR) with men who underwent RP.13 Although the RP group reported greater urinary leakage than the BT group, the BT group reported more obstructive and irritative urinary symptoms (i.e., increased frequency and urgency, nocturia, and weak urine stream). Those studies showed that prostate-specific complications, such as urinary, sexual, and bowel dysfunction, will vary by treatment. However, there appear to be few differences across treatment groups in other domains of HRQoL. Apart from some role limitations and decreased energy levels, functioning in most other domains appears to be unaffected by treatment. Nonetheless, concluding that treatments for localized prostate carcinoma have little effect on general HRQoL may be premature. With one notable exception,7 many studies have assessed HRQoL anywhere from several months to several years after treatment. At these later time points, men may have regained most of their general functioning. Undoubtedly, attending to the long-term sequelae of localized prostate carcinoma is important, but men also may have concerns about the effects of different treatments in the short term.14 To address these issues, we investigated prostate specific HRQoL and general HRQoL shortly after men had undergone treatment with RP, EBR, or BT. A second focus of this analysis was to examine the relation of demographic and psychosocial factors to HRQoL in men who are treated for localized prostate carcinoma. Demographic factors, such as age, ethnicity, and marital status, appear to be important predictors of recovery.6,15,16 Psychosocial factors, such as stress, optimism, and social support, also have been implicated in men's recovery from prostate carcinoma and its treatments.17–19