Metastatic disease

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Metastatic prostate cancer includes a range of disease burden. For many men treated by curative surgery or radiation who subsequently experience PSA progression, quality of life is mostly affected by their primary treatment. As mentioned, the studies from Eastern Virginia Medical School and Michigan demonstrated satisfaction rate and QOL changes for patients with a rising PSA after definitive local therapy.5'66 As Pound et al.71 have demonstrated, men may persist with an elevated PSA for a median 8 years after radical prostatectomy before metastatic disease is documented and subsequently survive a median 5 more years.

For most men with metastatic lymph or bony disease, however, quality of life is primarily affected by androgen deprivation in the form of LHRH agonist or surgical castration (with or without complete androgen blockade with an oral non-steroidal antitestosterone agent such as flutamide or bicalutamide). Herr72 has reported a study of men with locally advanced or failed local therapy who elected immediate versus delayed hormonal therapy. Using the EORTC scale, they found that men on androgen therapy, as expected, experienced more fatigue, loss of energy, emotional distress and overall lower quality of life than men on deferred therapy. Combined androgen therapy showed greater adverse effects than androgen monotherapy. Thus, validated general QOL scales are sensitive to androgen deprivation therapies.

In a cross-sectional study of patients with metastatic disease using the SF-36, EORTC and a disease-specific module, patients in remission (hormone sensitive) showed similar scores to age-matched norms, whereas those with progressing disease showed lower scores for bodily pain, vitality, social function and mental health.73 However, no differences were seen in sexual function, sexual satisfaction, hot flashes or diarrhea.

A common dilemma for patients needing androgen deprivation therapy is whether to undergo surgical versus medical castration. While costs, trips to the doctor's office and body image are common features that direct the decision, two recent studies have looked at QOL issues. In the PCOS observational study,74 a large group of patients were identified who were treated with primary androgen ablation for localized, locally advanced and metastatic disease by either LHRH agonist or orchiectomy. This study was non-randomized and several baseline variables were different, making comparisons difficult. Nevertheless, significant declines in sexual function and interest were found with either therapy. Of interest, stage and other prognostic factors did not affect quality of life and satisfaction rates were 90% in each group. Litwin etal.75 performed a longitudinal study using the SF-36 and UCLA PCI. The study is small (47 combined androgen ablation vs. 16 orchiectomy) but achieved an impressive 84% response rate. They found no differences in SF-36 scores between the groups; social function, emotional well-being and pain were the highest scores, while energy/fatigue, and general health perceptions were the lowest. In the 12 months after diagnosis, they noted improvement in SF-36 scores. Sexual function was low in both groups, but sexual bother much less affected, indicating that patients adjust well to their diagnosis.

Finally, a critical difference between surgical and medical castration is the irreversible nature of the former. Do patients regret this choice? Clark et al.76 recently addressed this issue with selected SF-36 items, newly formulated questions and patient focus groups aimed at identifying regretful patients. As one may guess, regretful patients were more common in surgical patients (43% vs 36%, P=0.030), and regretful men scored poorer on several generic and prostate specific scales. Survey and comments from focus groups indicated that regretful men rated their communication with their physician as poor.

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