REFERENCES

EDITORIAL COMMENTS

The authors present a comparative analysis of longitudinal prostate cancer HRQOL outcomes for patients treated at a single institution with a variety of therapeutic modalities. Using the UCLAPCI the authors report higher urinary function and bother scores with BT and cryotherapy compared to ORP and RAP, and higher sexual function and bother scores with BT than with ORP, RAP or cryotherapy. The subject matter is timely and important, and the use of patient reported outcomes to compare results is to be commended. Nevertheless, the nonrandomized nature of the study design, whereby significant differences in baseline function and bother scores existed among patients undergoing different treatments, as well as the absence of an EBRT cohort and of data regarding patient satisfaction with treatment, argue for the continued prospective evaluation of HRQOL outcomes after prostate cancer treatment. Such studies are critical for appropriately interpreting our results and counseling our patients accordingly.

The authors performed a long-term longitudinal prospective study on QOL in patients undergoing treatments for prostate cancer. The article has some recognized limitations including the fact that oncological outcomes were not included, patients who received multimodal therapies were excluded from study and data on EBRT were absent. On the other hand, it is hard to argue that urologists and patients need more prospective data to provide realistic expectations in regard to long-term morbidity related to treatment. The authors reported significantly lower potency rates despite nerve sparing prostatectomy. Are we to think that most urologists perform as well as experts report or is this a more realistic view that patients should consider? Urology as a field has suffered from the absence of prospective randomized trials in prostate cancer that compare the main treatments with oncological and QOL outcomes. A patient who is diagnosed with clinically localized prostate cancer still faces a difficult task of comparing competing technologies on multiple levels (oncological outcomes, continence, potency). Furthermore, new technologies are not required to provide strong evidence of superiority or equivalence before adoption. If the standard for evaluating all treatments of prostate cancer were raised then patients and physicians would be able to use more objective criteria in determining the optimal treatment. It is possible that a new emphasis on cost-effectiveness and comparative analyses at a national level will force the issue.

Given that prostate cancer is one of the most common solid tumors, it is important to focus on the cancer, and how its various treatments affect the quantity and quality of life. Furthermore, since patients with localized prostate cancer now routinely live more than 10 to 15 years after diagnosis, it is critical that we obtain a better understanding of all the facts that could influence the short-term and long-term functional states and HRQOL in patients with prostate cancer.¹ This study evaluates HRQOL for ORP, RAP, cryotherapy and BT for 3 years using the UCLA-PCI questionnaire. While the study has limitations in the lack of randomization, EBRT data and several outcome measures such as comorbidities, marital status, education or income level, the ability to compare with baseline status helps minimize this bias.

These authors reported that BT and cryotherapy had a 3-fold higher rate of return to baseline urinary function compared to ORP and RAP. However, as they described the UCLA-PCI urinary function domain generally serves as a measure of continence, and the bother domain is not as reliable a measure of irritative or obstructive symptoms as other available metrics (eg American Urological Association Symptom Score, reference 10 in article). Subjects who underwent BT reported higher sexual HRQOL than other treatment groups. These results may guide decision making for treatment selection and the clinical management of HRQOL impairments after treatment for localized prostate cancer.

REFERENCE

1. Albertsen PC, Hanley JA, Penson DF et al: 13-Year outcomes following treatment for clinically localized prostate cancer in a population based cohort. J Urol 2007; 177: 932.

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