Quality of Life After Radical Prostatectomy

Transcription

1 Quality of Life After Radical Prostatectomy Bernard H. Bochner, MD FACS Attending Surgeon, Urology Service Vice Chairman, Department of Surgery Memorial Sloan-Kettering Cancer Center

2 Quality of Life After Radical Prostatectomy Individual series data available HOWEVER: Poor characterization of patient groups (case mix) Variation in reporting method Different definitions for outcomes The lack of high quality evidence makes comparative evaluations between different treatments difficult No QOL data from randomized trials available

3 Health-Related Quality of Life Patient-centered variable taken from the field of health services research Can be measured reliably Questionnaires (instruments) are pilot-tested the validated Domains can be general or disease-specific Responses to items are scored and can be used to calculate a summary score for each domain

4 Patients; N=1201; Spouses, N=625 Treatment Modalities Radical Prostatectomy, N=603 Brachytherapy, N=306 External Beam Radiotherapy, N=292

5 Sexual function caused moderate or severe distress after 2 years: in 43% of men after RP, 37% after XRT and 30% after brachy; ED caused distress in 44%, 22% and 13% of partners. Urinary function lead to moderate or severe distress after 1 yr: in 7% of patients after RP, 18% after brachy, and 11% after XRT, and in 4-5% of partners. GI symptoms caused moderate or severe distress in 9% of patients (and 4-5% of partners) a year after radiation (brachy or XRT).

6 Figure 1. Changes in Quality of Life after Primary Treatment for Prostate Cancer.

7 Surgeon Factor: Outcomes after Radical Prostatectomy To what degree are the outcomes of radical prostatectomy perioperative complications, urinary incontinence, erectile dysfunction, surgical margins and long term cancer control related to surgical technique in addition to the characteristics of the patient and the cancer?

8 Variability in 5-yr progression-free probabilities among experienced surgeons (>40 cases) adjusted for case mix p<0.0005

9 Heterogeneity in outcome among surgeons at MSKCC: full continence (no pads) Bianco et al J Urol 2010

10 Heterogeneity in outcome among surgeons at MSKCC: full potency (+/- oral agents) Bianco et al J Urol 2010

11 Effect of Surgeon and Hospital Volumes For Radical Cystectomy Adjusted Mortality operative mortality is largely mediated by surgeon volume. Patients can often improve their chances of survival substantially by selecting surgeons who perform the operation frequently. Birkmeyer et al, NEJM, 2003

12 Surgeon and Impact On Outcome After RRP: High Volume Surgeons Outcomes (%) Low Medium High Very high Surgeon Volume 0 Postoperative complications Late urinary complications Long-term incontinence Begg CB, Reidel ER, Bach PB, Kattan MW, Schrag D, WarrenJL, Scardino PT. Variations in morbidity after radical prostatectomy. NEJM 2002; 346:1142.

13 Surgeon and Impact On Outcome After RRP: Urinary Complications, High Volume Surgeons Expected (n=159) > 50 % Late Urinary Complications after RP (Bianco F et al. J Urol 2005)

14 Surgeon and Impact On Outcome After RRP: Urinary Complications, High Volume Surgeons Expected Observed p <.0001 % Late Urinary Complications after RP > 50

15 Achieving Optimal Outcomes after Radical Prostatectomy: The Trifecta Optimal outcome after RP is cancer control with full recovery of continence and potency. Individual studies report rates of ED, incontinence or cancer recurrence (rising PSA) in isolation. These rates do not adequately reflect the quality of the surgery nor fully inform patients of the probability of being cured of cancer and recovering normal urinary and sexual function ( Trifecta ). Saranchuk J, J Clin Oncol 2005; 23:4146

16 Cummulative Incidence Probabilities of Event Probability of recovering complete continence, normal erectile function and freedom from biochemical recurrence ( Trifecta ) after RP alone Trifecta Outcomes (Potent, Continent, PSA undetectable) Failure of RP to control prostate cancer N=647 Markov model Time (Months) from Radical Prostatectomy Cumulative probability of continence, potency and freedom from biochemical recurrence Probability of PSA recurrence

17 Variation among surgeons in achieving optimal results (TRIFECTA) Probability of being both potent and continent at 12 months

18 Cumulative Incidence of Recovery of Continence (No Pads or Leakage): Open vs. Lap RP Touijer A et al. J Urol 2008; 197:1811 Open Lap HR 0.56, p<.0005

19 QOL After Radical Prostatectomy Conclusion All treatments for prostate cancer adversely effect QOL Poor quality comparative data makes direct comparisons very difficult Surgical skill strongly associated with oncologic and functional outcomes after RRP Technology has not proven to provide major breakthrough in improved QOL over good open surgery.