Providence Prostate Implant Quality of Life

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Therapy Side Effects             Long-Term Effects             Complications
Scoring Symptoms                Quality of Life Surveys
Dosimetry and Life Quality    Summary
For men with prostate cancer there are two major concerns. First, most want a treatment that provides a very high cure-rate. Second, they want to maintain their lifestyle and quality of life as close to normal as possible. Although there may be many different treatments with equivalent cure-rates, there are many differences among side effects, complications, and lifestyle changes during and following different treatments. One important misunderstanding regarding permanent prostate implants is that they are an "easy" form of treatment with fewer long-term side effects and complications. In fact, prostate implants are attractive to physicians because they provide a very high dose to the prostate and may ultimately improve the cure-rate. They are not, however, without side effects and potential complications, and in a small percent of men may cause greater side effects than other therapies.

Side Effects During Therapy
For most cancer treatments, there are side effects during and after therapy. Side effects are temporary symptoms associated with the treatment which are usually completely reversible following the completion of treatment. With external beam radiation, for example, an eight-week course of treatment is given and during those eight weeks, side effects may be experienced. By one month following the completion of treatment, those side effects have decreased dramatically for most men.

With permanent implants, the side effects may be more sustained because the implants deliver radiation continuously for many months. This varies from person-to-person, and the side effects are, in part, predicted by the symptoms the man has before the implant procedure. For most men, the side effects with implants are in the nuisance range.

The common side effects experienced with any form of radiation therapy for prostate cancer include: 1) rectal irritation causing frequent bowel movements and urgency (treated with medicine), and 2) bladder irritation causing frequent urination, nighttime urination, decreased stream, urgency, and burning with urination (also treated with medicine). Some men who have implants may experience greater side effects than they would have experienced with external beam therapy. By one year after radiation treatments, most men have returned close to their baseline function.

Long-Term Effects
Some prostate cancer treatments may produce long lasting effects and changes in a small percent of treated men. For example, some treatments may cause impotence, which may be permanent. Other treatments may cause incontinence or loss of bladder control. Such changes are not side effects because they are not as reversible, and they are not complications because they are an accepted possibility with each treatment. Long term effects can often be improved with treatment. Viagra , for example, may improve potency in men who experience radiation induced erectile dysfunction.

A few years ago, men considered implant therapies because they would cause less impotence, and less bladder and rectal irritation than other radiation treatment options. In fact, both implant and external beam radiation therapy may cause impotence. It is controversial whether implants are more sparing or more likely to leave a man potent than external beam options. Possible but not common long-term effects following external beam and implant radiation therapy include: impotence, bladder urgency, and rectal urgency. Bladder urgency means that "when you gotta go, you gotta go" and it is difficult to control the urine with such a strong signal. This usually responds well to medicationsAnother late change that is possible is minor rectal bleeding. The portion of the rectum right next to the prostate receives a high dose of radiation and as it heals the area may become fragile and prone to bleeding. In the past this was a difficult problem, but now two effective medications are available.

Complications
Complications are rare and less reversible. The chance of complications after any medical procedure is approximately 1 in 20 to 1 in 30. A complication does not mean that something has been done wrong. It reflects how the individual responds to a treatment. Two individuals with an identical dose of radiation to the prostate and rectum will experience different effects. For example, one may have no changes or complications and the other may develop a rectal ulcer.

Complications following external beam and implant radiation therapy include: rectal ulcers requiring a long, slow healing process, or a sphincter injury causing urinary leakage. For most complications, there are treatment approaches, but usually a long, slow process is necessary to improve or recover. In the Quality of Life Era, improved understanding of how and why some men experience these complications while others have little or none has made severe complications extremely rare.

Scoring of Symptoms
When men undergo treatment for prostate cancer, it is now common to score their side effects, late effects, and complications. Are they potent before treatment? Did they have rectal symptoms before treatment? Did they have bladder irritation and frequency before treatment? How does the radiation therapy change this and over what time span? As treatments are compared, it is important that baseline pre-treatment measurements and scores be done so that the time course of symptoms and recovery can be plotted. Men considering treatment options may want to know how many men become impotent, experience bladder problems, or develop rectal problems following treatment. Symptom scores allow this to be known.

Quality of Life Surveys
Another important measurement of treatment-related changes is a Quality of Life survey. In this type of survey, individuals list all of the symptoms they have that are related to the treatment, including urinary, rectal, and sexual change symptoms. What a Quality of Life survey provides, in addition to listing the symptoms and scoring them, is that it asks the person how he feels about these changes. Has this symptom affected their quality of life?

Someone may experience considerable irritation and difficulty with urination, but not be particularly bothered by it. They may tend to be the type that minimizes symptoms—they may "put up with a lot" as they describe themselves. Others with the same symptoms may be quite distressed, angry, frustrated, or bitter. Such people are not "complainers." They are not weak. Even though they are experiencing the same symptoms, the way their mind and brain interpret those symptoms is very different. Some people are not able to block out pain or unpleasant symptoms as well as others.

Although quality of life is a critical issue, it is sometimes difficult to compare quality of life between different treatments. For example, someone may choose a certain treatment with a full understanding that complications and side effects were possible (all effective treatments have potential side effects and complications). They are comfortable with the decision and if they develop a complication, they may not be bothered by it because they realize it was a possibility, a risk they were willing to take. On the other hand, someone might choose a treatment thinking it will cause fewer or no symptoms. If they experience symptoms they may be extremely upset. These two patients may have exactly the same symptoms, but very different quality of life scores.

One common example illustrating this difference is someone who is incontinent following surgery, but is not particularly bothered by it. His quality of life may be reported as excellent. On the other hand, the individual who has radiation and expected no symptoms may have a very poor quality of life, although their symptoms could be considered less drastic than the person with incontinence.

It is important to understand the need for both Symptom Scores and Quality of Life surveys. As men consider their treatment options, it is probably more important that they review the likely symptoms associated with a treatment before considering the quality of life studies, since quality of life is, in part, related to a person's reaction to the symptoms. Some men may find the idea of incontinence unbearable and know they would react to this side effect poorly. Others may be concerned about rectal injury or rectal ulcers, knowing they would have a difficult time adjusting to that outcome. Other men are most worried about the possibility of impotence and may choose a treatment with a better chance at maintaining potency.

The University of Michigan and Providence Hospital are involved in an extensive evaluation program under the leadership of Dr. Martin Sanda, M.D., a urologist at the University of Michigan. He has done research using symptom scores and quality of life surveys done before, during, and after treatment. These studies are critical to improving our understanding of treatments and will ultimately allow a fair comparison of treatments.

Measuring quality of life is key to Total Quality. Quality of life and symptom score studies allow physicians to better understand the mechanism of side effects. It is clear that placing seeds in certain parts of the prostate can cause profound side effects. As these sensitive areas are mapped out, it is possible to avoid them while still placing enough seeds around the critical area to achieve full dose.

This correlation of dose and symptoms has allowed improved understanding of bladder, rectal, and sexual changes, resulting in improved quality of life after implant therapy compared to earlier eras when full dose was the main priority.

Dosimetry and Quality of Life
Many advances in implant therapy have resulted from combining information from Quality of Life surveys and information from implant dosimetry. The use of MRI is especially useful in this regard, since the delicate structures in and around the prostate that are likely to cause symptoms are well defined on MRI.

It is therefore possible to calculate the dose to these structures and thus avoid direct implantation of seeds in and around these sensitive areas. This analysis has been extremely fruitful. Current seed placement techniques avoid the upper and lower urinary sphincters, bladder muscles, and erectile tissues. With these advances, it is far less common that disabling symptoms and complications occur.


 

Summary
Although one treatment may cause greater side effects than another, it does not mean that all men receiving that treatment will experience greater side effects. If in treatment A, 80 out of 100 men have acceptable side effects, and in treatment, B 70 out of 100 have acceptable side effects, treatment B would be said to cause greater side effects on average. Yet, in treatment B most of the men had acceptable side effects. It is incorrect to conclude that one treatment always causes more side effects than another. With implant therapy, we have learned to advise men with large prostates and numerous symptoms to pursue other options, thus decreasing the percentage of men with severe side effects. Changes in implant techniques have also reduced the number of men with severe side effects. Most men asked whether they would choose implant therapy if they had the choice to make over again say they would choose implant therapy.