Prostate cancer is a major public health issue in all Western countries, including Australia. It is now the most commonly diagnosed cancer in men, and second only to lung cancer as the leading cause of cancer death in men. The age-standardised incidence of prostate cancer remained steady at 40 per 100 000 men until 1990, when there was a dramatic increase, associated with the introduction of early detection and screening programs based on measurement of prostate-specific antigen (PSA) levels (Anti-Cancer Council of Victoria Epidemiology Centre, personal communication). The incidence peaked by 1994 and has subsequently fallen to about 120 per 100 000 men. In the United States the incidence peak occurred several years earlier, in 1990-1991, and has fallen 1% per year since then.1
The decision by a patient, in consultation with his treating physician, to undergo active therapy for localised prostate cancer is complex and severely hampered by a lack of randomised controlled trials comparing different treatment methods with each other and with an untreated control group. Trials that may clarify the situation are under way in both the United States and Europe, but definitive results are many years away because of the relatively slow growth and progression of many prostate cancers. In the meantime, many variables need to be considered when making a treatment decision; these include the patient's age, associated co-morbid illnesses, stage and grade of the disease, and pretreatment PSA levels. Data from the Surveillance, Epidemiology, and End Results (SEER) program in the United States have demonstrated that for some men prostate cancer may be well managed with close surveillance ("watchful waiting") over a 10-year period.2 However, the data provide little security for healthy men in the age group 50-60 years who are diagnosed with the disease -- especially if diagnosed with cancer of higher histological grades, for which radical prostatectomy was shown to provide a survival benefit at 10 years.2 Thus, younger men diagnosed with localised prostate cancer have a strong desire to eradicate the disease and to maximise their chances of improved long term survival.
Unfortunately, therapy of localised prostate cancer is associated with side effects that may alter quality of life. Watchful waiting, on the other hand, has no adverse effects until progression occurs, and the patient is placed on androgen ablative therapy, with its attendant side effects, such as hot flushes and impotence.
Owing to the incidence of postoperative impotence and incontinence, most of the scrutiny of side effects of therapy has focused on radical prostatectomy. Early studies from single institutions in the United States reported very low complication rates. Catalona et al, in 1993, reported a 94% continence rate, and that, depending on whether a bilateral or unilateral nerve-sparing procedure was performed, 41%-63% of men regained potency after the operation.3 Another group reported a 92% continence rate and a 68% potency rate.4,5 However, these analyses were based on review of patient records and direct physician interview of the patient. This method may not accurately reflect the true morbidity because of patients' reluctance to directly report adverse events to their surgeon.
In this issue of the Journal, Heathcote et al present the results of an independently administered questionnaire to determine patients' perception of the incidence and significance of side effects following surgery.6 The authors are to be commended for the study, which provides local results, experiences and attitudes. They found that postoperative urinary incontinence occurred in 20% of patients, with 11% of patients requiring pads at least once a week, 8% requiring one pad daily, and only 1% requiring two or more pads daily. Only 12% of men were truly potent after prostatectomy, but, despite this, 75% were happy or coping with the situation. Nevertheless, impotence was the treatment-related problem most affecting quality of life. Although the authors did not use a formal validated instrument to measure quality of life (eg, CaPSURE7), an appropriate modification specifically assessing continence and potency issues was used. This study is consistent with other international studies in which independent questionnaires were used.
It is clear that the early publications may have under-reported the incidence of complications (see Box, below). Independent questionnaires, including that of Heathcote et al, have detected a higher incidence of complications. Despite this, patients reported that they were generally happy with treatment and would choose to have surgery again. Only eight of the 112 patients surveyed by Heathcote et al were not satisfied with treatment, and only 14 were reluctant to have the same treatment again. The results suggest that, in almost all patients, the desire to be cured of the disease may outweigh any adverse effects of radical prostatectomy.
It is important for surgeons to know that patients can successfully adapt to these side effects, but this adaptation does not mean that the side effects are unimportant to patients. In most studies of quality of life with prostate cancer, less than 10% of patients required pads on a daily basis (although up to 30% may leak on occasions but not require pads). Most required only one pad per day and found this of minimal concern. The 1%-2% who required two or more pads each day generally found the side effect troublesome. Impotence was a larger concern in most series, including that of Heathcote et al, but, surprisingly, only 10%-30% of patients found it to be a serious problem, and usually not enough of an issue that they would not choose surgery again. It is crucial that patients understand and agree to these compromises, having been fully informed of the controversies regarding the benefits of aggressive treatment of localised prostate cancer.
Mark Frydenberg
Clinical Associate Professor, Department of Surgery, and Chairman
Department of Urology, Monash Medical Centre, Melbourne, VIC
- Wingo PA, Riel LAG, Rosenberg HM, et al. Cancer incidence and mortality, 1973-1995: a report card for the US. Cancer 1998; 82: 1197-1207.
- Lu-Yao GL, Yao S-L. Population based study of long term survival in patients with clinically localised prostate cancer. Lancet 1997; 349: 906-910.
- Catalona WJ, Basler JW. Return of erections and urinary continence following nerve sparing radical retropubic prostatectomy. J Urol 1993; 150: 905-907.
- Steiner MS, Morton RA, Walsh PC. Impact of anatomical radical prostatectomy on urinary continence. J Urol 1991; 145: 512-515.
- Quinlan DM, Epstein JI, Carter BS, Walsh PC. Sexual function following radical prostatectomy: influence of preservation of neurovascular bundles. J Urol 1991; 145: 998-1002.
- Heathcote PS, Mactaggart P, Boston RJ, et al. Health-related quality of life in Australian men remaining disease-free after radical prostatectomy. Med J Aust 1998; 168: 483-486.
- Lubeck DP, Litwin MS, Henning JM, Carroll PR. Measurement of health-related quality of life in men with prostate cancer: the CaPSURE database. Qual Life Res 1997; 6: 385-392.
- Bates TS, Wright MPJ, Gillatt DA. Prevalence and impact of incontinence and impotence following total prostatectomy assessed anonymously by the ICS-Male questionnaire. Eur Urol 1998; 33: 165-169.
- Fowler FJ Jr, Barry MJ, Lu-Yao G, et al. Effect of radical prostatectomy for prostate cancer on patient quality of life: results from a Medicare survey. Urology 1995; 45: 1007-1015.
- Kaye KW, Creed KE, Wilson GJ, et al. Urinary continence after radical retropubic prostatectomy. Analysis and synthesis of contributing factors: a unified concept. Br J Urol 1997; 80: 444-451.