Hard Choices

Better understanding of the quality of life for men following prostate cancer therapy may help others make better treatment decisions.

By Alicia Di Rado

A diagnosis of prostate cancer not only might be shocking—it can be downright confusing.

Suddenly, a man with prostate cancer must decide between a variety of possible treatments: surgery, radiation, hormone therapy—or even no therapy at all, just careful monitoring from a physician.

Within each treatment choice, there may be yet more options: Should a man undergo traditional radiation, or opt for brachytherapy, the use of implanted radioactive seeds, for example?

Each type of treatment carries its own benefits and advantages, its own risks and downsides. But today, for a man with early stage prostate cancer, no single treatment stands above the others as the clear-cut, best choice.

That is why Keck School of Medicine of USC researchers want to dig deeper into what life is like for men after treatment for prostate cancer. By better understanding the many short- and long-term effects of prostate cancer therapy, these researchers hope to give physicians, patients and family members the information they need to make the best possible treatment decisions.

Potential changes

Prostate cancer is the most common cancer, excluding skin cancers, in American men, and it ranks second, behind lung cancer, as a cause of cancer death. Simply surviving cancer might be the foremost issue in the minds of men diagnosed with prostate cancer.

But routine prostate-specific antigen (PSA) testing of men now means that many cancers are caught early, when they are most curable. Treatments also have improved, so men can and do live long lives after diagnosis. While about one man in every six will be diagnosed with prostate cancer during his lifetime, only one man in 33 actually will die of this disease.

Put another way, in comparison to men their same age, men diagnosed with prostate cancer have a 98 percent survival rate at five years, an 84 percent survival rate at 10 years, and a 56 percent survival rate at 15 years past diagnosis, according to the American Cancer Society. These are “relative” survival percentages, which describe the survival of men with prostate cancer in comparison to other men in the same age groups without prostate cancer. While men may die of other causes, these figures can be used to determine the effect of prostate cancer alone on survival.

With that in mind, men who face treatment for the cancer also are faced with contemplating life after cancer, and all its potential changes. That means choosing treatment often comes down to choosing which potential side effects are more palatable.

The Prostate Cancer Outcomes Study, or PCOS, may help.

Reading results

USC epidemiologists and physicians are members of the research team for PCOS, a study of nearly 3,500 diverse prostate cancer patients at six institutions across the nation, including USC/Norris Comprehensive Cancer Center. Sponsored by the National Cancer Institute, PCOS is one of the nation’s largest and most representative studies on life after prostate cancer.

PCOS researchers have followed prostate cancer survivors for five years, and recently began issuing results from this follow-up. They also released results showing some differences in quality of life linked to the type of treatment patients chose.

Five years after diagnosis, men with localized cancer treated through surgery struggled more with urinary incontinence than did men treated with traditional radiotherapy. More than 15 percent of surgery patients had no urinary control or frequently leaked urine, compared to about 4 percent of radiotherapy patients. However, men who had radiotherapy were more likely to be irritated by slow or difficult urination and the urgent need to urinate than were surgically treated men.

When it comes to sexual function, by two years after treatment, many men treated surgically had significant trouble with impotence, but then gradually improved over the next three years. In contrast, potency in men treated through radiotherapy gradually declined in all years after treatment. By the five-year mark, about 79 percent of the surgically treated men and nearly 64 percent of the men who had undergone radiotherapy did not have sufficient sexual function for intercourse.

According to David Penson, M.D., M.P.H., associate professor of urology and preventive medicine at the Keck School and a PCOS investigator, the growing body of research on treatment’s effects on quality of life will guide patients as they face tough decisions. It also reminds physicians that each patient has different concerns and perceptions of the effects of treatment.

Says Penson: “The bottom line is that urologists need to remember that they can’t use that same follow-up approach with every prostate cancer patient. One man’s success may be another man’s failure.”

Ethnicity’s role

The more researchers have delved into life after prostate cancer, the more Penson’s words ring true.

Keck School investigators have been looking at differences in quality of life after prostate cancer among men of different races and ethnicities in the PCOS, making them the first to look at outcome within these groups. Their findings are intriguing.

In a recent study, the researchers found that five years after surgery, African-American men reported less sexual and urinary trouble than non-Latino white men—yet, in a seeming paradox, they were also more dissatisfied with their sexual functioning.

In this part of the study, researchers focused on 1,475 non-Latino white, 321 African-American and 279 Latino prostate cancer patients who were treated with surgery or radiotherapy. They asked the men about changes in their urinary, bowel and sexual function in the years after diagnosis; they also asked how much of a problem such changes in function posed in the men’s lives.

“We found that African-American men had significantly better sexual and urinary function five years after prostatectomy than non-Latino white men did,” says Ann S. Hamilton, Ph.D., assistant professor of preventive medicine at the Keck School and senior author of the PCOS-based study. However, when researchers asked how much patients’ change in sexual function bothered them, Hamilton says, “The African-American men indicated slightly more dissatisfaction. We couldn’t really explain why that might be.”

Because African-American men have tended to have worse outcomes after prostate cancer treatment, researchers suspected they might have poorer function, as well. Results were surprising.

Researchers found that five years after surgery, nearly 40 percent of African-American men had erectile function adequate for sexual intercourse; only about 23 percent of their non-Latino white counterparts could say the same. However, nearly 51 percent of African-American men reported that their sexual function was a moderate-to-big problem, compared to only 44 percent of non-Latino white men.

The researchers controlled for an exhaustive list of factors that might affect results, including income level, age and additional treatments such as hormone therapy, but differences among ethnic groups remained.

“There may be differences among ethnic groups in their perceptions of function,” Hamilton proposes.

The researchers also found that while about 34 percent of Latino men who underwent prostatectomy reported having erectile function adequate for sexual intercourse, about 49 percent of the same group reported sexual function as a moderate-to-big problem.

Researchers say results point out that significant side effects continue to affect men’s lives long after prostate cancer treatment. “In the end, what is important is actually how the therapy affects each man,” Hamilton says.

“In terms of counseling men for side effects, perhaps there may be additional care that could be taken in discussing sexual side effects,” she adds.

Interestingly, men from different ethnic and racial groups who were treated through radiation therapy experienced no significant differences in their recovery of sexual, urinary or bowel function after treatment, Hamilton says. The radiation therapy group included those who had received external beam radiation therapy, as well as those who underwent brachytherapy—the use of radioactive “seeds”. Researchers caution, though, that the number of patients included might not have been large enough to recognize differences among ethnic groups in those receiving radiotherapy.

Members of the USC research team included Penson, Frank Gilliland, M.D., Ph.D., and Dennis Deapen, Dr.P.H., both of preventive medicine, and Terri Kang Johnson, a doctoral student in biostatistics.

The research team plans to next address how treatment choices affect other measures of quality of life, such as vitality, physical pain and mental health.

 

Informed Decisions

To make his treatment choice, a man with prostate cancer needs information. But how do men get their facts and make their decisions? And once they have finished treatment, are they happy with the decisions they have made?

Ann S. Hamilton, Ph.D., assistant professor of preventive medicine at the Keck School of Medicine of USC, will lead a new study examining this process of decision-making that men go through when choosing prostate cancer treatment. David Penson, M.D., M.P.H., associate professor of urology and preventive medicine at the Keck School, is co-principal investigator on the project, which is sponsored by the National Cancer Institute.

The project will involve newly diagnosed patients from three sites: Los Angeles, northern California (Kaiser Permanente Health System) and Seattle (Fred Hutchinson Cancer Research Center). In Los Angeles, about 150 ethnically and economically diverse patients will come from two USC-affiliated locations—USC/Norris Cancer Hospital and LAC+USC Medical Center—as well as the West Los Angeles Veterans Administration Hospital.

Unlike the longstanding Prostate Cancer Outcomes Study (PCOS), which began following patients six months after diagnosis, this new study will enroll patients as soon as they discuss therapy with their physicians.

“We’d like to identify the important and consistent factors that influence the choice of therapy near the time of treatment for men with localized prostate cancer, specifically looking at less-studied influences, including the spouse or partner, friends and relatives, trust in the health-care system and physicians’ second opinions,” says Hamilton.

The researchers will analyze whether the influence of each factor varies according to the patients’ race.

Six months after diagnosis, the researchers will again speak with patients. This time, they will identify factors that patients either did not anticipate or had discounted at the time they made their treatment decision. They hope to understand the influence of the men’s relationship with their partners, their desire and ability to work and their productivity at work, and out-of-pocket costs for cancer-related treatments—as well as side effects.

“Because it’s unclear which therapy results in the longest life-expectancy benefit, patients often make decisions based upon how they feel a particular therapy will affect their quality of life,” Penson says. “The problem is that we don’t know if patients are making good and informed decisions.

“Patients are gathering their information from many sources, some reliable and perhaps some not so reliable. This study will help us to understand not only how treatment affects quality of life, but how patients decide on treatment. Hopefully, the study will allow us to identify ways to improve communication between providers and patients, providing our patients with a clearer understanding of their situation and resulting in better decision-making and improved quality of life for these men.”