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Authors Bellardita L, Rancati T, Alvisi MF, Villani D, Magnani T, Marenghi C, Nicolai N, Procopio G, Villa S, Salvioni R and Valdagni R.
Review Date March 2013
Citation Eur Urol 2013 : http://dx.doi.org/10.1016/j.eururo.2013.01.009
A diagnosis of prostate cancer is often a stressful experience for men and their families but responses will differ depending on a range of factors. Treatment options are offered to patients in the context of their individual feelings about the diagnosis and the threat posed by cancer. As overtreatment is one of the issues associated with PSA testing for prostate cancer, active surveillance (AS) is emerging as an alternative approach to limit the risk of overtreatment and associated impairment of quality of life (QoL) in patients with low-risk localised prostate cancer. Although most patients on AS come to terms with the uncertainties of this approach, some men are distressed by living with untreated cancer and in most reported series of patients, 5-10% elect to have active treatment rather than continuing on AS without a clear clinical reason. The factors that predict a poorer QoL or higher anxiety in men on AS are not well described but are helpful to know when providing support for men who are either making decisions about, or undergoing AS for low risk prostate cancer.
To identify factors associated with poor quality of life during AS
Between September 2007 and March 2012, 103 Italian patients participated in the Prostate Cancer Research International Active Surveillance (PRIAS) QoL study. Mental health (Symptom Checklist-90), demographic, clinical, and decisional data were assessed at the beginning of AS. Health-related QoL (HRQoL) was assessed using the Functional Assessment of Cancer Therapy – prostate version (FACT-P), and style of coping with cancer was measured using the Mini-Mental Adjustment to Cancer (Mini-MAC). Outcomes were assessed after 10 months of AS.
Multivariable logistic regression models were used to identify predictors of low (<25th percentile) HRQoL, adjustment to cancer, and a global QoL index (combination of 2 sub-scales of the FACT-P with the Mini-MAC) 10 months after enrolment.
Mean age of patients was 67 years (standard deviation: ±7 years). Having a partner was protective for (odds ratio [OR]: 0.08; p = 0.009,) and impaired mental health (OR: 1.2, p = 0.1) was associated with (p = 0.006; area under the curve [AUC]: 0.72), low HRQoL. The maladaptive adjustment to cancer (p = 0.047; AUC: 0.60) was associated with recent diagnosis of cancer (OR: 3.3; p = 0.072). Poor global QoL (overall p = 0.02; AUC: 0.85) was predicted by impaired mental health (OR: 1.16; p = 0.070) and time from diagnosis to enrolment in AS <5 months (OR: 5.52; p = 0.009). The influence of several different physicians on the choice of AS (OR: 0.17; p = 0.044), the presence of a partner (OR: 0.22; p = 0.065), and diagnostic biopsy with >18 core specimens (OR: 0.89; p = 0.029) were inversely associated with low QoL and thus were predictors of better QoL. Limitations of this study were the small sample size, the lack of a control group and short follow up time.
Factors predicting poor QoL were lack of a partner, impaired mental health, recent diagnosis, influence of fewer clinicians and lower number of core samples taken at diagnostic biopsy. Educational and emotional support programs based on findings from this and other studies identifying risk factors for poor QoL could help to alleviate anxiety and consequent effects on QoL of men on AS.
Points to Note
- This study has identified several factors that potentially impact on QoL and could be addressed by physicians and others in multidisciplinary teams working with men on active surveillance: lack of support from a partner, a short time from diagnosis to treatment decision, a prior history of mental health problems, consultation with fewer physicians prior to starting AS, and fewer cores taken at biopsy.
- Although most studies suggest men on AS adjust well to living with the threat of cancer, those prone to anxiety or with certain other psychological and demographic characteristics may not fare well and need extra support.
- The study included only 103 patients, strength of evidence based on statistical significance was not very high and there was no control group so findings need to be interpreted with caution.
- The finding of an association with number of cores taken at biopsy was interpreted by the authors as reflecting a perception by patients that the more cores taken, the greater the chance that all cancer cells were found. This could then act to reduce anxiety during AS.
- Research on the psychological effects of AS is important given that AS is an effective way to reduce over-treatment in men diagnosed with low risk prostate cancer using PSA testing.
- Studies on QoL and psychological outcomes, combined with studies on functional outcomes of the various treatment pathways after prostate cancer diagnosis all make important contributions to assessing the benefits and risks of PSA testing or screening.