Prostate size and other neglected factors influence prostate cancer treatment satisfaction

BOSTON – Men with prostate cancer and their partners face difficult decisions regarding treatment, and accurate information regarding expected outcomes can be hard to find, according to results of a multi-center study published Wednesday in the New England Journal of Medicine.

Outcomes after prostate surgery, external radiation or brachytherapy (radioactive ‘seeds’) are highly individualized and depend not only on age, but also on factors that have been previously overlooked, such as the size of the prostate and whether a man has urinary symptoms due to prostate enlargement before treatment.

Previous studies focused mostly on problems with sexuality, bowel problems and problems with urinary incontinence after prostate cancer treatment, which the study confirmed as important concerns.

But the research team from nine hospitals, led by Martin G. Sanda, MD, Director of the Prostate Care Center at Beth Israel Deaconess Medical Center and Associate Professor of Surgery at Harvard Medical School, found that other symptoms, such as frequent or weak urination, are equally as important in determining overall patient satisfaction.

While many patients and doctors have assumed that prostate cancer treatment only causes side effects and does not reduce symptoms, the study found that some men with larger prostates benefit with improved urination after surgery. However, the study of 1,201 men and 625 spouses also found that overall satisfaction with treatment was lower among African-American men, despite their having received care at the same centers as their white counterparts.

The study examined the impact of the various forms of treatment on many facets of quality of life, including not only sexual function, bowel function and urinary incontinence – but also on concerns that are common yet have been previously neglected by researchers, including weak or frequent urination due to prostate enlargement as well as a man’s “vitality” or hormonal function.

“We didn’t presume whether one type of side effect or another is more important – instead, we measured a broad range of side effects, and asked how those mesh together and which ones actually matter in terms of either the patient’s or his partner’s satisfaction with the overall cancer treatment outcome,” says Sanda, adding the research found a greater level of importance than previously thought in a patient’s vitality, which includes concerns expressed by patients and their partners about the patient’s energy level, weight and mood.

“When the patient and doctor sit down, they need to be able to take factors like the patient’s age, prostate size, and treatment nuances into consideration and decide what’s right. The concept of assigning a general treatment or non-treatment based simply on someone’s age and cancer severity alone is no longer valid.”

Researchers found that hormonal therapy, when combined with brachytherapy or with external radiation, worsened multiple aspects of quality-of-life, and had particularly profound effects on men’s vitality and sexuality. Patients receiving radioactive seed treatment experienced problems with weak or frequent urination which lasted longer and had greater effect on overall satisfaction than previously appreciated.

Some men who had their prostates removed surgically reported problems with urinary incontinence, in contrast to those who experienced long-term improvement in urinary obstruction. Nerve-sparing techniques reduced the sexual side effects of that surgical procedure but did not eliminate them.

The study was the first multi-center effort to focus on satisfaction with overall outcome of cancer care and to include partners in the evaluation. And the results found that changes in quality of life played a significant role in determining whether patients and their partners were satisfied.

In particular, black patients were less satisfied with their treatment outcome, despite having received care and the same high-volume institutions as other patients.

“When I speak with black men who have undergone treatment for prostate cancer, many express dissatisfaction with their treatment-related side effects,” says J. Jacques Carter, MD, MPH, a primary care physician at BIDMC. “My sense is that they feel they were not given all of the options nor given a frank discussion about the adverse effects of the different treatment modalities.”

The study also confirmed a commonly held belief that treatment-related changes in quality of life among patients had a direct effect on their partners.

“The level of spousal distress arising from a patient’s symptoms after prostate cancer treatment was associated with the partner’s level of satisfaction with the treatment outcome,” the study declares.

“Partners matter, and satisfaction with overall outcome, from the perspective of the patient and partner, should be the bottom line in health care,” says Sanda. “It’s the simplest thing in the world to measure, but it’s something that hasn’t been done very well, particularly in cancer care.”