In 2014 prostate cancer survivors roughly numbered 2 percent of the male U.S. population, and while use of active surveillance has increased, the majority of men diagnosed with prostate cancer eventually initiate treatment. Outcomes are excellent, with 10 year cancer mortality of approximately 5 percent. Therefore, oncologists and other care providers for these patients must not only provide initial treatment, but also manage late and ongoing treatment effects as part of care continuity. Currently, we do not do as well as we can; comparing post-surgical routine care with that of a prostate survivorship clinic, patient satisfaction and indicators of individual functional assessments were improved in the survivor-focused setting (Cancer 2015;121(9):1484-91).
Quality of Life Improvements
Many patients do not have access to specialized survivor clinics, and both patient and provider enjoy the ongoing relationship of follow-up care. What then, can we do to improve the quality of life of our prostate cancer survivors? The key is paying attention to the main functional systems that are affected by treatment: urinary tract, lower bowel, sexual, and hormonal. While some effects are strictly related to one type of treatment (i.e., rectal injury from radiation), many cross treatment disciplines and all deserve evaluation and management as needed.
Urinary bother can vary dramatically depending on patient characteristics and treatment modality. Age, co-morbidities, and use of surgery, radiation, or both all increase likelihood of urinary symptoms and treatment can vary from medication to physical therapy to surgical procedures. The degree of bother the patient experiences has been linked to emotional distress and treatment-decision regret (Cancer 2015;121(12):2029-35). Treatment varies depending on whether patient notes obstructive symptoms (alpha-reductase inhibitors, evaluation for urethral stricture) or incontinence (pelvic floor therapy, surgical intervention). While pelvic floor physical therapy appears primarily to speed recovery to new post-surgical baseline, its role after radiation has not been evaluated. In fact, the common wisdom that recovery of urinary control halts after post-operative radiotherapy is disproven by recent data (Eur Urol 2014; 65(3):546-51).
Bowel symptoms are predominantly an issue for those who underwent radiotherapy. With the highly conformal treatments currently used, radiation proctitis is somewhat less common than in the past, but remains quite frustrating for the individual suffering from it. I generally recommend management through radiation oncology, initially with topical anti-inflammatories and escalating as necessary. However, what every provider can do to prevent post-radiation rectal problems is to treat constipation and to remind patients and their gastroenterologists to exhibit caution in biopsy during sigmoidoscopy/colonoscopy. Instrumentation of mild radiation proctitis is the most common cause of high grade rectal complications (Brachytherapy 2015;14(2):148-59).
Open, Honest Conversations
Sexual toxicity from surgery, radiation, or hormonal manipulation is perhaps the greatest driver of quality of life in a prostate cancer survivor. Patients consistently rate relationship change due to cancer treatment as having a negative impact on life after cancer. It is important to ask about satisfaction with sexual function, as many men do not feel comfortable raising the issue themselves. Standard pharmacologic or device options are available. Researchers are finding a couples approach to sexual dysfunction is more effective, as partner's interest and ability to engage impacts the survivor's sexual experience (Supportive Care in Cancer 2014;22(9):2509-2515).
Sexual dysfunction is one of the main symptoms of androgen deprivation, but other toxicities (fatigue, weight gain, and muscle loss) and the silent but impactful metabolic and bone changes can become major concerns of men after treatment. Even short-term ADT injections can lead to prolonged hypogonadism. Both pharmacologic and behavioral modifications can reduce the impact of ADT on men's health and quality of life. For example, exercise improves both general and disease-specific patient reported quality of life (Endocr Relat Cancer 2016;23(2):101-12).
Team Approach
Monitoring for recurrence is often shared by the multi-disciplinary team. Consideration of treatment effects can be done in the same manner, with screening for symptoms in routine follow-up initiating management either through the oncology clinic or by engaging the various support/referral services available to maximize our patients' quality of life as prostate cancer survivors.