Larry Hembroff

Quality of Life and Satisfaction with Outcome among Prostate-Cancer Survivors

BACKGROUND We sought to identify determinants of health-related quality of life after primary treatment of prostate cancer and to measure the effects of such determinants on satisfaction with the outcome of treatment in patients and their spouses or partners. METHODS We prospectively measured outcomes reported by 1201 patients and 625 spouses or partners at multiple centers before and after radical prostatectomy, brachytherapy, or external-beam radiotherapy. We evaluated factors that were associated with changes in quality of life within study groups and determined the effects on satisfaction with the treatment outcome. RESULTS Adjuvant hormone therapy was associated with worse outcomes across multiple quality-of-life domains among patients receiving brachytherapy or radiotherapy. Patients in the brachytherapy group reported having long-lasting urinary irritation, bowel and sexual symptoms, and transient problems with vitality or hormonal function. Adverse effects of prostatectomy on sexual function were mitigated by nerve-sparing procedures. After prostatectomy, urinary incontinence was observed, but urinary irritation and obstruction improved, particularly in patients with large prostates. No treatment-related deaths occurred; serious adverse events were rare. Treatment-related symptoms were exacerbated by obesity, a large prostate size, a high prostate-specific antigen score, and older age. Black patients reported lower satisfaction with the degree of overall treatment outcomes. Changes in quality of life were significantly associated with the degree of outcome satisfaction among patients and their spouses or partners. CONCLUSIONS Each prostate-cancer treatment was associated with a distinct pattern of change in quality-of-life domains related to urinary, sexual, bowel, and hormonal function. These changes influenced satisfaction with treatment outcomes among patients and their spouses or partners.

Patient-reported quality of life after stereotactic body radiotherapy (SBRT), intensity modulated radiotherapy (IMRT), and brachytherapy

BACKGROUND AND PURPOSE Stereotactic body radiotherapy (SBRT) is being used for prostate cancer, but concerns persist about toxicity compared to other radiotherapy options. MATERIALS AND METHODS We conducted a multi-institutional pooled cohort analysis of patient-reported quality of life (QOL) [EPIC-26] before and after intensity-modulated radiotherapy (IMRT), brachytherapy, or SBRT for localized prostate cancer. Data were analyzed by mean domain score, minimal clinically detectable difference (MCD) in domain score, and multivariate analyses to determine factors associated with domain scores at 2-years. RESULTS Data were analyzed from 803 patients at baseline and 645 at 2-years. Mean declines at 2-years across all patients were -1.9, -4.8, -4.9, and -13.3 points for urinary obstructive, urinary incontinence, bowel, and sexual symptom domains, respectively, corresponding to MCD in 29%, 20%, and 28% of patients. On multivariate analysis (vs. IMRT), brachytherapy had worse urinary irritation at 2-years (-6.8 points, p<0.0001) but no differences in other domains (p>0.15). QOL after SBRT was similar for urinary (p>0.5) and sexual domains (p=0.57), but was associated with better bowel score (+6.7 points, p<0.0002). CONCLUSIONS QOL 2-years after brachytherapy, IMRT, or SBRT is very good and largely similar, with small differences in urinary and bowel QOL that are likely minimized by modern techniques.

Evaluation results of a 21st birthday card program targeting high-risk drinking

The B.R.A.D. Birthday Card initiative was started on the campus of Michigan State University (MSU) in April 1999. MSU administrators send the safe-drinking 21st birthday card (B.R.A.D.) and laminated wallet card to students shortly before their 21st birthday. Objective: To evaluate the effectiveness of the 21st birthday card, MSU and B.R.A.D., Inc, applied for and were awarded a 2-year US Department of Education grant in 2001. Participants: The authors surveyed 1,731 students within 2 weeks of their 21st birthday. Methods: Of all students turning 21 years old during the study, the authors randomly selected students for each group. A control group received no card. All others received the standard B.R.A.D. card or a gender-tailored message card. Results: Key findings include: 74% of students saved part of the card, 65% shared the card with family or friends, 22% reported thinking about the card during their celebration, 12% reported drinking less because of the card, 15% reported learning something new about alcohol poisoning, and 98% believed that MSU and B.R.A.D. should continue sending cards to students. Conclusions: Receiving, reading, and recalling the content of the B.R.A.D. card appears to reduce the total number of drinks a celebrant consumes.

Partners' long-term appraisal of their caregiving experience, marital satisfaction, sexual satisfaction, and quality of life 2 years after prostate cancer treatment.

Background: Partners of men treated for prostate cancer report more emotional distress associated with a diagnosis of prostate cancer than the men report; the duration of distress for partners is seldom examined. Objectives: The purpose of this study was to determine the long-term effects of prostate cancer treatment on partners’ appraisal of their caregiving experience, marital satisfaction, sexual satisfaction, and quality of life (QOL) and factors related to these variables. Methods: This exploratory study evaluated QOL among spouses of prostate cancer survivors at 24 months after treatment. Partners completed a battery of self-report questionnaires in a computer-assisted telephone interview. Results: The sample consisted of 121 partners with average age of 60 years. There was a significant relationship between partners’ perceptions of bother about the man’s treatment outcomes and negative appraisal of their caregiving experience and poorer QOL. Younger partners who had a more negative appraisal of caregiving also had significantly worse QOL. Conclusions: Men’s treatment outcomes continued to bother the partner and resulted in more negative appraisal and lower QOL 2 years after initial prostate cancer treatment. Younger partners may be at greater risk of poorer QOL outcomes especially if they have a more negative view of their caregiving experience. Implications for Practice: Findings support prior research indicating that prostate cancer affects not only the person diagnosed with the disease but also his partner. Partners may benefit from tailored interventions designed to decrease negative appraisal and improve symptom management and QOL during the survivorship period.

Neoadjuvant androgen deprivation therapy leads to immediate impairment of vitality/hormonal and sexual quality of life: results of a multicenter prospective study.

OBJECTIVE To evaluate the immediate effects of neoadjuvant androgen deprivation therapy (NADT) on health-related quality of life (HRQOL) among patients undergoing radiation therapy (RT) for newly diagnosed prostate cancer. METHODS The Prostate Cancer Outcomes and Satisfaction with Treatment Quality Assessment Consortium is a prospective multi-institutional study. HRQOL is measured with the Expanded Prostate Cancer Index Composite-26 questionnaire. Differences in patient-reported HRQOL were observed between pretreatment and 2 months after NADT start (and before definitive RT) with significant differences evaluated by paired t test. RESULTS From among 450 patients who completed the Expanded Prostate Cancer Index Composite-26 before and 2 months after NADT start, 71 received NADT before proceeding with definitive RT. Patients receiving NADT experienced significant impairment in vitality/hormonal (P <.0001) and sexual (P <.0001) HRQOL after NADT initiation. The mean ± standard deviation vitality/hormonal score fell from an average of 94.1 ± 9.7 before NADT to 78.7 ± 16.3 two months after NADT initiation; and sexual HRQOL fell from a mean of 51.7 ± 31.1 pretreatment to 32.3 ± 26.1 after NADT initiation. Both these HRQOL domain changes exceeded the thresholds for clinical significance. Patients receiving NADT also experienced a significant impairment in urinary continence (P = .024), although this difference did not meet the criteria for clinical significance. CONCLUSION In this analysis, patients receiving NADT experience significant impairment in sexual and vitality/hormonal HRQOL even before starting definitive RT. The significant effect of this therapy on HRQOL needs to be considered before initiating NADT in men where there is no clear evidence of clinical benefit.

Uncertainty and perception of danger among patients undergoing treatment for prostate cancer

Study Type – Therapy (attitude prevalence)

Satisfaction with Information Used to Choose Prostate Cancer Treatment

PURPOSE After being diagnosed with prostate cancer men must assimilate information regarding the cancer. Satisfaction with information reflects the evaluation of information sources used before treatment to select a therapy. We describe the use and helpfulness of several information sources available to prostate cancer survivors. We also identified factors associated with satisfaction with information. MATERIALS AND METHODS A total of 1,204 men with newly diagnosed prostate cancer were enrolled in the prospective, multicenter Prostate Cancer Outcomes and Satisfaction with Therapy Quality Assessment study. The validated satisfaction with information domain of the Service Satisfaction Scale-Cancer was administered to subjects 2 months after treatment. The relationship between several factors, such as demographics, socioeconomic factors, cancer severity and types of information sources, and satisfaction with information were evaluated using multiple regression. RESULTS Sources of information endorsed by subjects varied by race, education and study site. The most helpful sources were treatment description by the treating physician (33.1%), Internet sites (18.9%) and books (18.1%). In multiple variable models patient age (p = 0.005) and information provided by the physician regarding outcomes in their patients (p = 0.01) were independently associated with patient satisfaction with the information provided. CONCLUSIONS Various information sources were used and endorsed as helpful by subjects, although results for physician patients was the only source independently associated with satisfaction with information. Providing patients with information about possible or expected courses of care and outcomes may improve satisfaction.

Relief of Urinary Symptom Burden after Primary Prostate Cancer Treatment

Purpose: Harms of prostate cancer treatment on urinary health related quality of life have been thoroughly studied. In this study we evaluated not only the harms but also the potential benefits of prostate cancer treatment in relieving the pretreatment urinary symptom burden. Materials and Methods: In American (1,021) and Spanish (539) multicenter prospective cohorts of men with localized prostate cancer we evaluated the effects of radical prostatectomy, external radiotherapy or brachytherapy in relieving pretreatment urinary symptoms and in inducing urinary symptoms de novo, measured by changes in urinary medication use and patient reported urinary bother. Results: Urinary symptom burden improved in 23% and worsened in 28% of subjects after prostate cancer treatment in the American cohort. Urinary medication use rates before treatment and 2 years after treatment were 15% and 6% with radical prostatectomy, 22% and 26% with external radiotherapy, and 19% and 46% with brachytherapy, respectively. Pretreatment urinary medication use (OR 1.4, 95% CI 1.0–2.0, p = 0.04) and pretreatment moderate lower urinary tract symptoms (OR 2.8, 95% CI 2.2–3.6) predicted prostate cancer treatment associated relief of baseline urinary symptom burden. Subjects with pretreatment lower urinary tract symptoms who underwent radical prostatectomy experienced the greatest relief of pretreatment symptoms (OR 4.3, 95% CI 3.0–6.1), despite the development of deleterious de novo urinary incontinence in some men. The magnitude of pretreatment urinary symptom burden and beneficial effect of cancer treatment on those symptoms were verified in the Spanish cohort. Conclusions: Men with pretreatment lower urinary tract symptoms may experience benefit rather than harm in overall urinary outcome from primary prostate cancer treatment. Practitioners should consider the full spectrum of urinary symptom burden evident before prostate cancer treatment in treatment decisions.

When (not if) evaluation flexibility is desirable. Examples from the CPHPE initiative.

The evaluation literature often debates whether evaluators should be flexible in evaluation design and activities in order to collaborate with program directors and be responsive to programming needs. Two conditions are specified under which evaluation flexibility is not only desirable but essential. Two examples from the cluster evaluation of the W. K. Kellogg Foundation’s Community Partnerships for Health Professions Education initiative are provided to illustrate why flexibility under these conditions proved to be essential. One of the examples, related to the “community” involvement in the initiative, illustrates the need for flexibility as programs experience goals clarification. The other example, related to the coincidental national health care reform efforts, illustrates the need for flexibility both to capture programs’efforts to protect their integrity and to ensure against spurious conclusions as a result of external turbulence in policy environments. How the cluster evaluation team addressed these issues is also described.

PD18-08 PROSPECTIVE MULTICENTER COMPARISON OF OPEN AND ROBOTIC RADICAL PROSTATECTOMY: THE PROST-QA/RP2 CONSORTIUM

distance (intermediate [12.5-49.9miles] and long [49.9-249.9miles] vs. short [<12.5miles]) and the effect of distance on OM were calculated using multivariate regression analyses. Additional analyses evaluated the distance effect on OM in all patients and in selected subgroups. RESULTS: Overall, 54.5%, 33.4%, and 12.1% traveled short, intermediate, and long distances, respectively. Residency in rural area, and receiving treatment at academic/high-volume centers independently predicted long travel distance. Non-Hispanic blacks and Medicaid-insured were less likely to travel long distances (all P<0.001). At multivariate analysis, traveling intermediate distance (hazard ratio [HR]1⁄40.97; 95% confidence interval (CI)1⁄40.95-0.99; P<0.001) and long distance (HR1⁄40.87; 95% CI1⁄40.83-0.92; P<0.001) were associated with lower OM risk, as compared to short distance (Figure 1). In subgroup analyses, long travel distance was associated with decreased OM in non-Hispanic whites, privately-insured, Medicare-insured, and patients treated at academic or high-volume centers (P<0.001), but not in non-Hispanic blacks (P1⁄40.3). Long travel distance was associated with an increased OM in Medicaidinsured patients (P<0.001; Figure 2). CONCLUSIONS: Our results suggest that interestingly not only patients traveling longer distances live longer, but that even if they are going the extra mile, their OM outcomes are likely to be influenced by baseline socioeconomic and facility specific factors. Specifically, we observed concerning socioeconomic disparities in the access to care regarding a higher travel burden, which translated into less favorable OM outcomes for non-Hispanic blacks and non-privately insured patients.