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In Reply:

Fred Hutchinson Cancer Research Center, Seattle, WA

Drs Vordermark and Koelbl raise three points regarding our study¹ and conclude that they are not convinced that health-related quality of life (HRQOL) is similar following surgery or radiotherapy for localized prostate cancer. In their first remark, they note that we do not present raw data (summary scores in each of the six general HRQOL domains examined), but rather only present global means for the entire cohort. These raw data were summarized in the original manuscript, as no significant differences were noted and no obvious trends were observed. We now specifically present the raw data for the two most common forms of therapies (radical prostatectomy and external beam radiotherapy) in Table 1 to support our claim that no statistically or clinically meaningful differences in general HRQOL were noted between treatments.

Finally, Drs Vordermark and Koelbl suggest that our finding that urinary dysfunction is associated with worse general HRQOL and the higher incidence of urinary leakage following radical prostatectomy would lead them to suspect that there would at least be a trend toward better general HRQOL in men undergoing radiotherapy. The data in Table 1 demonstrate that this is not the case and beg the question "why not?" There are a number of reasons why we may not have observed differences in general HRQOL given the well-known differences in functional outcomes following the various treatments for localized prostate cancer.⁵ First, urinary dysfunction (defined as frequent leakage or no control), although more common after surgery, still occurs in the minority of patients, regardless of treatment (8% overall and 21.5% of surgical patients). It may be that frequency of occurrence is low enough in the surgical group that it does not influence mean scores enough to result in significant differences between treatment groups. Another possibility is that other forms of urinary dysfunction that can occur after radiotherapy may affect general HRQOL but are not captured using the narrow definition of urinary dysfunction as "frequent leakage or no control." In this case, we are referring to irritative voiding symptoms, such as frequency, urgency, and dysuria, that have been documented to occur more commonly in men undergoing radiotherapy.^6,7 In fact, in an analysis from the Prostate Cancer Outcomes Study, 36% of men undergoing radiotherapy for localized prostate cancer reported urinary frequency more than half the time 2 years following treatment.⁴ It is possible that these irritative voiding symptoms that can occur following radiotherapy may have had a deleterious effect on general HRQOL similar to that of urinary incontinence following surgery, resulting in 2-year general HRQOL outcomes being equivalent between the two treatments.

In summary, our data clearly demonstrate that, while there may be differences in functional outcomes and disease-specific HRQOL 2 years following treatment for localized prostate cancer, there are no differences between radical prostatectomy and radiotherapy in general HRQOL outcomes. The fact that men who experience urinary and sexual dysfunction have worse general HRQOL underscores the need for us to develop ways to improve the survivorship experience for all men with localized prostate cancer. While it may be true that advances in both surgical and radiotherapeutic techniques in the mid-1990s have decreased organ toxicity,^8,9 it is equally true that the incidence of treatment-related side effects is still high for all therapies.^6,10,11 Only when we recognize that these complications affect general HRQOL, and start to develop therapeutic interventions that improve both function and bother, will we best serve our patients.

AUTHORS’ DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

The authors indicated no potential conflicts of interest.

REFERENCES

1. Penson DF, Feng Z, Kuniyuki A, et al: General quality of life 2 years following treatment for prostate cancer: What influences outcomes? Results from the prostate cancer outcomes study. J Clin Oncol 21:1147–1154, 2003[Abstract/Free Full Text]

2. Potosky AL, Legler J, Albertsen PC, et al: Health outcomes after prostatectomy or radiotherapy for prostate cancer: results from the Prostate Cancer Outcomes Study. J Natl Cancer Inst 92:1582–1592, 2000[Abstract/Free Full Text]

3. Stanford JL, Feng Z, Hamilton AS, et al: Urinary and sexual function after radical prostatectomy for clinically localized prostate cancer: the Prostate Cancer Outcomes Study. JAMA 283:354–360, 2000[Abstract/Free Full Text]

4. Hamilton AS, Stanford JL, Gilliland FD, et al: Health outcomes after external-beam radiation therapy for clinically localized prostate cancer: Results from the Prostate Cancer Outcomes Study. J Clin Oncol 19:2517–2526, 2001[Abstract/Free Full Text]

5. Penson DF, Litwin MS, Aaronson NK: Health related quality of life in men with prostate caner. J Urol 169:1653–1661, 2003[CrossRef][Medline]

6. Wei JT, Dunn RL, Sandler HM, et al: Comprehensive comparison of health-related quality of life after contemporary therapies for localized prostate cancer. J Clin Oncol 20:557–566, 2002[Abstract/Free Full Text]

7. Fowler FJ Jr, Barry MJ, Lu-Yao G, et al: Outcomes of external-beam radiation therapy for prostate cancer: A study of Medicare beneficiaries in three surveillance, epidemiology, and end results areas. J Clin Oncol 14:2258–2265, 1996[Abstract]

8. Gralnek D, Wessells H, Cui H, et al: Differences in sexual function and quality of life after nerve sparing and nonnerve sparing radical retropubic prostatectomy. J Urol 163:1166–1170, 2000[CrossRef][Medline]

9. Dearnaley DP, Khoo VS, Norman AR, et al: Comparison of radiation side-effects of conformal and conventional radiotherapy in prostate cancer: a randomized trial. Lancet 353:267–272, 1999[CrossRef][Medline]

10. Bacon CG, Kawachi I: Quality-of-life differences among various populations of localized prostate cancer patients: 2001. Curr Urol Rep 3:239–243, 2002[Medline]

11. Davis JW, Kuban DA, Lynch DF, et al: Quality of life after treatment for localized prostate cancer: differences based on treatment modality. J Urol 166:947–952, 2001[CrossRef][Medline]

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