Prostate cancer treatment and quality of life : a three level epidemiological approach

The decision whether or not to treat localized prostate cancer with curative intent is influenced by the expected beneficial and harmful effects in terms of patient survival and quality of life. In this thesis symptoms specifically related to prostate cancer treatment are investigated, including urinary and bowel symptoms and waning sexual functions. The prevalence of these symptoms and the extent to which they distress the men were assessed. Finally, the relationship between distress owing to these symptoms and psychological, physical and overall well-being was analyzed. Applying epidemiological methods, a total of 842 men were analyzed in seven studies. In four of the studies, 342 prostate cancer patients were compared to a reference group of 314 age matched men without prostate cancer and patients subjected to different treatment protocols were compared to each other and to patients not subjected to any initial treatment.

Urinary and bowel symptoms were more prevalent in the prostate cancer group than in the age-matched reference group but few men, with or without prostate cancer, reported severe symptoms. A small minority of patients (4%) reported high levels of distress owing to urinary or bowel symptoms and their feeling of well-being was impaired. The prevalence of impaired sexual function was much higher in the prostate cancer group than in the reference group. The majority of men with the disease that had experienced waning sexual function stated that this distressed them and distress owing to waning sexual function was more common than distress owing to urinary and bowel symptoms. Prostate cancer patients reporting moderate or high distress owing to waning sexual function (52%) reported an impaired feeling of well-being compared with other patients. Men treated for their prostate cancer were more likely to report waning sexual function compared with patients reporting no treatment. External beam radiation therapy was less likely than radical prostatectomy to be related to waning sexual function after treatment. The willingness to trade off an intact sexual capacity for the possibility of a prolonged life expectancy varied considerably among the men. This emphasizes the need to adapt treatment decisions to each individual, not only based on medical variables but also on the patient's emotional values and religious and ethical positions. It is possible that the question "How should localized prostate cancer be treated?" may newer be answered. We can only collect valid information about the basis for the trade-off and learn to communicate the data to the patient in a fruitful way.