ADT, Sex Top QOL Problems in Prostate Cancer

Men treated for advanced prostate cancer had quality of life similar to that of men with early-stage disease, except for sexual dysfunction and effects of hormone therapy, a large British study showed.

Overall, across all disease stages, the QOL scores reflected good functional status, with the exception of sexual dysfunction. Men treated with androgen deprivation therapy (ADT) reported significantly more “moderate to big problems” with hot flushes, low energy, and weight gain.

Despite a high prevalence of sexual problems, fewer than half the men surveyed said their healthcare providers offered no interventions, as reported online in The Lancet Oncology.

“Overall, our findings show that most men living 18 to 42 months after diagnosis of prostate cancer can expect to have similar HR (Health Related) QOL to men in the general population,” concluded Amy Downing, PhD, of the University of Leeds, and coauthors. “Those diagnosed with locally advanced and metastatic prostate cancer do not report substantially different HRQOL outcomes to those diagnosed with localized disease.”

“Sexual dysfunction is common across all disease stages, with notably poor provision of sexual support in the U.K.,” they added. “Our results suggest that there are subgroups of men who would benefit from service improvements around sexual rehabilitation and measures to reduce the effects of ADT.”

The author of an accompanying editorial said the study offered a measure of reassurance about the care received by patients with prostate cancer, given widespread concern about overdiagnosis and overtreatment.

“I, for one, admit that issues of quality of life and the worry of doing more harm than good, have sometimes made me delay interventions in cancers I underestimated,” wrote Fred Saad, MD, of the University of Montreal. “I have humbly regretted some of the decisions I made with the best possible intentions.

“The work presented by Downing and colleagues does help to put these issues into better perspective and is a step in the right direction in helping those of us who treat prostate cancer to obtain a better understanding of how patients are coping with their disease and treatments.”

As the authors and Saad noted, the study was one of the largest of its type, including data for almost 37,000 men who responded to a national survey. Historically, few studies accumulated comprehensive data on HRQOL of men living with advanced prostate cancer, in particular.

Investigators mailed a survey to 58,930 men alive 18 to 42 months after diagnosis of prostate cancer. The survey elicited information about urinary, bowel, sexual, and hormonal function, as well as vitality (functional outcomes, measured by the Expanded Prostate Cancer Index Composite short form, EPIC-26). Other questions focused on generic HRQOL, comprising mobility, self-care, usual activity, pain/discomfort, and anxiety/depression, plus a self-assessment of health (assessed by the EuroQol instrument).

The survey attracted 35,823 responses, and disease stage could be determined for 30,733 respondents. Almost two thirds (19,599) of the study participants had stage I or II disease, about a fourth (7,209) had stage III, and about 13% (3,925) had stage IV.

Men who submitted completed questionnaires had a median age of 71 and almost half (16,638) were ages 65-74. Overall, 7,488 (20.9%) reported treatment with external beam radiotherapy plus ADT. A majority of the men with stage IV disease received ADT alone or in combination with radiotherapy or other systemic treatment.

In general, the men had good functional status, with mean scores on urinary, bowel, and hormonal function ranging from 80 to 89. The mean score for sexual function dropped to 24. By disease stage, scores for urinary and bowel function were similar. Scores for hormonal function decreased with increasing disease stage at diagnosis (83.6 for stage I-II, 75.3 for stage III, 68.0 for stage IV), as did sexual function scores (28.5, 16.4, 11.9).

With regard to general health status, 33.8% reported problems with mobility, 11.5% with self-care, 36.5% with usual activities, and 41.7% with pain/discomfort. Scores for all four outcomes increased with disease stage. The overall mean score for self-assessed health status was 76.3 for men with stages I-III prostate cancer, declining to 70.6 for men with stage IV disease.

Subgroup analysis of the adverse effects of ADT showed that 30.7% of men treated with ADT reported problems with hot flushes as compared with 5.4% of men whose treatment did not include ADT. Reported rates of low energy and weight gain were 29.4% vs 14.7% and 22.5% vs 6.9%, respectively.

Across all disease stages, sexual dysfunction was common, including:

• Poor/very poor erections: 81.5%
• Poor/very poor orgasm: 76.6%
• Poor/very poor overall sexual function: 81.0%

The frequency of self-reported poor/very poor sexual function increased from 75.0% of men with stage I-II disease to 90.4% of men with stage III prostate cancer to 96.0% of men with stage IV disease. Rates of sexual dysfunction increased from 51.1% of men on active surveillance to 83.7% of those treated with surgery alone to 93.6% of men who received only ADT.

Overall, 41.4% of the respondents said they were offered medication or other aids for sexual dysfunction. The proportion increased with patient age and disease stage at diagnosis but many younger men and those with early-stage disease were not offered aids for sexual dysfunction, the authors reported.