L. Klotz

Impact of Androgen-Deprivation Therapy on Physical Function and Quality of Life in Men With Nonmetastatic Prostate Cancer

PURPOSE This prospective longitudinal study evaluated the effect of androgen deprivation therapy (ADT) on objective and self-reported physical function. PATIENTS AND METHODS Men with nonmetastatic prostate cancer (PC) starting continuous ADT were enrolled in this matched cohort study. Physical function was assessed with the 6-minute walk test (6MWT), grip strength, and the timed-up-and-go (TUG) test, representing endurance and upper and lower extremity strength, respectively. Quality of life (QOL) was measured with the Medical Outcomes Study Short-Form 36 (SF-36) questionnaire. Subjects were assessed at baseline, 3, 6, and 12 months. Two control groups (PC without ADT; no PC), matched on age, education, and baseline function were enrolled. Mixed effects regression models were fitted, adjusting for baseline covariates. RESULTS We enrolled 87 patients on ADT, 86 PC controls, and 86 healthy controls; groups were similar in age (mean, 69.1 years; range, 50 to 87) and physical function. The 6MWT distance remained stable in the ADT group (P = .96) but improved in both control groups (P < .05). Grip strength declined in the ADT group (P = .04), remained stable in PC controls (P = .31), and improved in healthy controls (P = .008). TUG scores remained stable over time and across groups (P > .10). The SF-36 physical function summary score declined in the ADT group (P < .001), but increased in both control groups (P < .001). Negative effects on outcomes were observed within 3 months of starting ADT and were generally independent of age. CONCLUSION Endurance, upper extremity strength, and physical components of QOL are affected within 3 months of starting ADT. Up-front exercise interventions to counteract these losses are warranted.

PSA doubling time of prostate carcinoma managed with watchful observation alone

PURPOSE To study prostate-specific antigen (PSA) doubling time of untreated, favorable grade, prostate carcinoma. METHODS AND MATERIALS A prospective single-arm cohort study has been in progress to assess the feasibility of a watchful observation protocol with selective delayed intervention using clinical, histologic, or PSA progression as treatment indication in untreated, localized, favorable grade prostate adenocarcinoma (T1b-T2bN0 M0, Gleason Score < or = 7, and PSA < or = 15 ng/mL). Patients are conservatively managed with watchful observation alone, as long as they do not meet the arbitrarily defined disease progression criteria. Patients are followed regularly and undergo blood tests including PSA at each visit. PSA doubling time (Td) is estimated from a linear regression of ln(PSA) on time, assuming a simple exponential growth model. RESULTS As of March 2000, 134 patients have been on the study for a minimum of 12 months (median, 24; range, 12-52) and have a median frequency of PSA measurement of 7 times (range, 3-15). Median age is 70 years. Median PSA at enrollment is 6.3 (range, 0.5-14.6). The distribution of Td is as follows: <2 years, 19 patients; 2-5 years, 46; 5-10 years, 25; 10-20 years, 11; 20-50 years, 6; > 50 years, 27. The median Td is 5.1 years. In 44 patients (33%), Td is greater than 10 years. There was no correlation between Td and patient age, clinical T stage, Gleason score, or initial PSA level. CONCLUSION Td of untreated prostate cancer varies widely. In our cohort, 33% have Td > 10 years. Td may be a useful tool to guide treatment intervention for patients managed conservatively with watchful observation alone.

Permanent flank bulge is a consequence of flank incision for radical nephrectomy in one half of patients

The objective of the study was to determine the incidence and predictors of post operative pain and flank bulging in patients undergoing nephrectomy for a renal tumor through a flank or thoracoabdominal incision. Only one previous retrospective study (1974) has directly addressed this issue in urologic patients. This reported a 3% incidence of flank bulging. This was at variance with our own experience. To determine the incidence of pain and post-operative flank bulge after flank or thoraco-abdominal incision, a cross sectional survey among in 70 patients, who had a nephrectomy for a renal tumor between 1996 and 2000, was assessed by telephone interview. Four surgeons contributed patients to the study. Thirty-four of seventy (49%) patients complained of a flank bulge persisting more than 1 yr after surgery. Durable flank pain was experienced by 24%. This was severe in 3% of patients. Median pain magnitude was 5/10. There was no difference in bulge incidence between surgeons (P = 0.49). Flank bulging occurred more frequently in left sided nephrectomy (P = 0.054) than right. Other parameters including gender, age, and tumor size had no correlation with the rate of either complication. In all patients who described a flank bulge, the deformity was durable; there were no cases of spontaneous resolution. Patients described a significant impact on QOL, particularly in those under 60 yrs. The overall rate of postoperative flank bulging is considerably higher than has been previously reported. This deformity affects quality of life. The observation that almost 50% of patients experience a flank bulge following a flank incision supports the shift towards laparoscopic nephrectomy, and should be incorporated into decision making regarding the optimal surgical approach. This may be particularly relevant in the choice between open partial nephrectomy and laparoscopic radical nephrectomy in a patient with a normal contralateral kidney.

A re-assessment of the role of combined androgen blockade for advanced prostate cancer

Combined androgen blockade is a controversial topic, which has arguments both for and against. It is revisited by the authors of this mini‐review, with a full discussion on the benefits and cautions with this approach. A wide range of other issues is also addressed in this section: bilateral testicular cancer, male‐factor infertility, and buccal mucosa urethroplasty. All of these are of interest to general urologists, as well as to those with a more specific area of interest.

Cavernosal nerve mapping: current data and applications

There are four reviews in this months section, two relating to the technical aspects of treating prostate cancer, one to genetic instability and bladder cancer, and the final one about continence surgery in urogenital prolapse. The authors are from Canada, the USA, and the UK. The messages from all of the reviews are clear, and provide interesting reading. The contributions to this section continue to give considerable information, and there are many more to follow.

The role of serial free/total prostate-specific antigen ratios in a watchful observation protocol for men with localized prostate cancer.

Objective To examine the change in the free/total prostate specific antigen ratio (f/tPSA) with time and to assess the potential value of serial measurements of f/tPSA as a determinant of disease progression in untreated, low‐to‐intermediate grade prostate cancer (T1b‐T2b N0M0, Gleason score  7 and PSA  15 ng/mL).

Are serial bone scans useful for the follow-up of clinically localized, low to intermediate grade prostate cancer managed with watchful observation alone?

To assess the predictive value of serial bone scans as a surveillance tool for bone metastasis in men with clinically localized prostate cancer and managed with watchful observation.

The role of serial transrectal ultrasonography in a ‘watchful waiting’ protocol for men with localized prostate cancer

Objective To determine the value of serial 6‐monthly transrectal ultrasonography (TRUS) in a cohort of men with localized prostate cancer who consented to a programme of watchful waiting with selective delayed intervention.

Levels of sex hormones have limited effect on cognition in older men with or without prostate cancer

Androgen deprivation therapy is commonly used to treat prostate cancer, but by lowering testosterone levels it may affect cognitive function. However, the relationship between testosterone and cognition remains unclear. We examined the relationship between sex hormones (total testosterone, bioavailable testosterone, and estradiol) and cognition in a cross-sectional study of 198 older men (mean age 69.2 years, median education 16 years) with and without prostate cancer, none of who had started androgen deprivation therapy. We found relationships between total testosterone and two of four measures of working memory. Similar relationships were found in regression analyses adjusted for age and education with both total testosterone and estradiol. Neither hormone was related to other cognitive domains, nor was bioavailable testosterone level. Although cognitive function was not generally related to sex hormone levels in older men, there may be a weak association with working memory. These results may help guide future studies.