For the past six years, Dr. Bruce L. Dalkin, MD, has been performing a high-quality, well-designed outcomes study to measure changes in quality of life (QoL) after surgery for prostate cancer. The driving force behind the study was to be able to honestly and accurately counsel newly diagnosed men on expectations of surgical treatment under his care.
Men in the study complete the UCLA Prostate Cancer Index prior to surgery and then annually thereafter. All surveys are done anonymously and are collected at a third-party data center. The capture rate of men who complete the surveys after surgery is around 90 percent, the highest published in medical literature. The data manager reviews the results each year with Dr. Dalkin, and changes in technique or methods of patient education are initiated based on any adverse outcomes.
Using these surveys, Dr. Dalkin’s results were as follows:
- In the general health domains of the survey, there was rarely any change after surgery.
- In bowel function and other domains, there was no significant change after surgery.
- In urinary health, by two years after surgery 89 percent of men were pad-free and returned to baseline in their domain score. Seven percent wore a safety-liner in their under shorts (a mini-pad that could remain all week), and 4 percent of men needed a pad. Overall in the United States, the percentage of men needing pads after surgery is around 30 to 40 percent, and those with severe urinary leakage who then have further surgery is around 8 percent. In Dr. Dalkin’s patients, the rate of surgery for severe urinary leakage is 0.6 percent. “Other surgeons have published similar results to those I have found, none truly better,” Dr. Dalkin says, “but many far worse. There are clear differences in the rates of urinary incontinence after surgery between surgeons, due primarily to their technical skills.”
In sexual health, all treatments—surgery, radiation and others—have a negative impact. Aside from simply the loss of an erection, men may note a change in the nature of the sensation of orgasm, decreased penile rigidity even if able to have intercourse, or the loss of urine with orgasm (climacturia). In Dr. Dalkin’s surveys, among men under the age of 60 with good pre-operative sexual health who underwent bilateral nerve-sparing surgery, at two years 72 percent are able to have erections adequate for intercourse without the need for any pills or treatments. In those having only one nerve spared for concern regarding cancer control, 52 percent are able to have erections adequate for intercourse without pills or treatments.
The national rates of potency after surgery, including with the use of pills, in men under the age of 60 with good pre-operative function are 20 to 25 percent for bilateral nerve-sparing surgery, and less than 10 percent for unilateral nerve-sparing surgery. The results are lower for older men or those with pre-treatment sexual health problems. For urologic cancer surgeons in the United States these results are quite poor, and they vary between surgeons based on their technical skill. Importantly, in men who return erections adequate for intercourse, only 40 percent actually have the same sexual health score as they did prior to surgery. Whether this is due to a change in the rigidity of the erection, orgasm sensation or other issues is unknown and demands further study.
“At present, we do not have the necessary research tools to answer this question,” Dr. Dalkin says. “But hopefully we will be able to in the near future. There is a newly developed, ongoing sexual health–outcomes research project for men undergoing treatment for localized prostate cancer at Memorial Sloan-Kettering Cancer Center in New York City that will likely be addressing these issues.”
Radiation Therapy QoL Outcome Studies
In the field of radiation therapy, there are few well-designed outcomes studies. Those that exist use 3-D conformal therapy or seed implantation. There have been no well-designed outcomes studies with proton therapy, intensity modulated radiation therapy (IMRT) or intensity-gated radiation therapy (IGRT). Although it’s commonly stated that IMRT or IGRT has fewer side effects, there is no accurate data to support this statement. In the well-designed studies to date, the results are as follows:
- In bowel health, between 10 to 18 percent of men will have a long-term negative impact on their bowel health with symptoms such as loose stools, soiling their underpants and blood in the stool.
- In urinary health, 12 to 20 percent of men note a significant change in their urinary habits with symptoms such as urinary frequency, urgency, nighttime wakening to urinate or blood in the urine. These rates are higher for men with pre-treatment urinary trouble, larger prostates or prior prostate surgery. The type of urinary incontinence seen after radiation is termed urgency incontinence, and it requires 8 to 12 percent of men to wear a pad after treatment. Only about half of these, or 4 to 5 percent truly need a pad or they would have to change their underwear/pants. This rate is higher in men with prior prostate surgery.
- In sexual health, for men with good pre-treatment sexual health, at three years after radiation, only 15 to 25 percent are still able to have erections adequate for intercourse without the use of pills. Although erectile dysfunction pills will help some men after radiation, we do not know what percentage of men benefit.
None of the survey studies in radiation patients extend past three to four years, and there is significant concern that side effects from radiation can increase as men get older, as we saw with cervical cancer in women in the past. As with surgery, there are likely differences in side effects simply between radiation centers or physicians, but this has not been well studied either.
Interpreting Post-treatment QoL Study Results
“In reviewing this information on treatment impact on quality of life, I believe the most accurate statement we can make in counseling men in the decision-making process of treatment for their localized cancer, is the following: Well-done surgery should result in less negative impact on quality of life than well-done radiation,” says Dr. Dalkin.
“Surgery does not result in any long-term changes in bowel health or urinary symptoms, as does radiation; the rates of urinary incontinence are similar between the two treatments; and if a man can have nerve-sparing surgery done correctly, his chances of maintaining good sexual health are likely better with surgery than radiation.
Unfortunately, a lot of the surgical and radiation treatments for prostate cancer in the United States may not be done well, so this statement may not be true for the country as a whole. In order to honestly counsel patients on quality-of-life changes due to treatment, each surgeon and radiation oncologist should perform a well-designed outcomes project to learn their own results. At present, there are less than 20 urologic surgeons or radiation oncologists in the United States who know their own results.”