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Originally published as JCO Early Release 10.1200/JCO.2009.22.0491 on July 20 2009 © 2009 American Society of Clinical Oncology.
Improving the Utility of Quality-of-Life Data From Men With Prostate CancerUrology and Health Services, David Geffen School of Medicine, School of Public Health, Jonsson Comprehensive Cancer Center, University of California, Los Angeles, CA Dostoevsky's central conceit in his 19th-century existentialist writings on human suffering is that man can ultimately accommodate to almost any tribulation. Contemporary psychosocial research in health-related quality-of-life outcomes in men with prostate cancer bears out this truth.1–3 This thesis notwithstanding, the medical literature is replete with studies documenting the poignant impact of quality-of-life impairments on men treated for early-stage prostate cancer. Radiation or surgery can lead to significant dysfunction or distress in the urinary, sexual, or bowel domains. Hence, the simultaneous consideration of both quality and quantity of life improves medical decision making for these men. Against this backdrop, Chen et al4 set out improve the clinical utility of quality-of-life assessments for men with prostate cancer. They begin with the premise that numerical-summary valuations of these inherently qualitative phenomena mask patients' actual experience. This motivates them to enhance and customize the tracking of quality-of-life outcomes. They further posit that a man's sexual, urinary, and bowel outcomes after prostate cancer treatment hew closely to his premorbid quality of life. This is reminiscent of the carpal-tunnel patient's preoperative entreaty, "Doctor, will I be able to play Rachmaninov after my surgery?" to which the hand surgeon unctuously replies, "It depends on how well can you play Rachmaninov before your surgery." But the truism applies to the penis as well as the pianist—the turgor of youth wanes with advancing age. Building on their prior elegant work,5 the authors dis-sever quality-of-life results from the commonly used (but user unfriendly) continuous scales into three discrete categories: normal, intermediate, and poor. This trichotomization of scores provides a clearer illustration of changes in dysfunction over time. Indeed, their online figures that track scores longitudinally belie the more useful picture presented in their stacked-bar charts and, to a less visually engaging degree, in their summary tables. This pragmatic device (of recasting the scores as normal, intermediate, or poor) allows quality of life to be shown as proportions, which are intrinsically easier than domain scores to understand. Of course, the critical methodological ingredient, largely undefended by the authors, lies in where the lines are drawn to separate normal, intermediate, and poor, and in whether they are drawn arbitrarily, empirically, or meaningfully. But the work offers several notable findings. Severe obstructive and irritative voiding symptoms improve most dramatically and durably after radical prostatectomy and worsen most markedly after brachytherapy or external-beam radiation. Urinary incontinence, although most pronounced after surgery, rarely translates into severe dysfunction. Severe bowel dysfunction occurs in up to one in five men treated with either form of radiation but is rare in those undergoing prostatectomy. Most of the quality-of-life decline from prostate cancer treatment rests in sexual dysfunction. This last observation is shown most potently with the stacked-bar charts—baseline impairment portends later decrepitude. Happily, men with normal sexual function before treatment are more likely to maintain at least intermediate function, especially after brachytherapy. These findings corroborate much previous work,6–10 but their novel presentation provides appeal for the quality-of-life abecedarian. The line graphs show that for every outcome in every treatment group, better baseline function predicts better function during the 3 subsequent years. Yet the stacked-bar charts transform the abstruse underlying data into its most valuable primordial components. Currently available quality-of-life instruments for men with prostate cancer are imbued with reliability, validity, and responsiveness drawn from the field's sound foundational history. They depict the myriad impacts of treatment in such high definition that improving the quality of the signal seems nearly impossible. Yet with their simplistic approach, Chen et al4 have harnessed the key constituents of quality of life in a manner that is at once elemental and plenary. The unresolved question is whether this black-and-white version of the truth is as comprehensive as the rich color format to which we have grown accustomed. Either way, this study ratifies the paramount importance of quality of life during the long arc of prostate cancer survivorship. AUTHOR'S DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST The author(s) indicated no potential conflicts of interest. REFERENCES 1. Sprangers MA, Schwartz CE: Integrating response shift into health-related quality of life research: A theoretical model. Soc Sci Med 48:1507–1515, 1999.[CrossRef][Medline] 2. Hagedoorn M, Sneeuw KC, Aaronson NK: Changes in physical functioning and quality of life in patients with cancer: Response shift and relative evaluation of one's condition. J Clin Epidemiol 55:176–183, 2002.[CrossRef][Medline] 3. Korfage IJ, de Koning HJ, Essink-Bot ML: Response shift due to diagnosis and primary treatment of localized prostate cancer: A then-test and a vignette study. Qual Life Res 16:1627–1634, 2007.[CrossRef][Medline] 4. Chen RC, Clark JA, Talcott JA: Individualizing quality-of-life outcomes reporting: How localized prostate cancer treatments affect patients with different levels of baseline urinary, bowel, and sexual function. J Clin Oncol 27:3916–3922, 2009. 5. Chen RC, Clark JA, Manola J, et al: Treatment ‘mismatch’ in early prostate cancer: Do treatment choices take patient quality of life into account? Cancer 112:61–68, 2008.[CrossRef][Medline] 6. Talcott JA, Rieker P, Clark JA, et al: Patient-reported symptoms after primary therapy for early prostate cancer: Results of a prospective cohort study. J Clin Oncol 16:275–283, 1998. 7. Potosky AL, Harlan LC, Stanford JL, et al: Prostate cancer practice patterns and quality of life: The Prostate Cancer Outcomes Study. J Natl Cancer Inst 91:1719–1724, 1999. 8. Lepor H, Kaci L: The impact of open radical retropubic prostatectomy on continence and lower urinary tract symptoms: A prospective assessment using validated self-administered outcome instruments. J Urol 171:1216–1219, 2004.[CrossRef][Medline] 9. Litwin MS, Gore JL, Kwan L, et al: Quality of life after surgery, external beam irradiation, or brachytherapy for early-stage prostate cancer. Cancer 109:2239–2247, 2007.[CrossRef][Medline] 10. Sanda MG, Dunn RL, Michalski J, et al: Quality of life and satisfaction with outcome among prostate-cancer survivors. N Engl J Med Mar 20 358:1250–1261, 2008.[CrossRef]
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Copyright © 2009 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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