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M PINKAWA ET AL.
Editorial Comment Editorial Comment to Transurethral resection of the prostate after radiotherapy for prostate cancer: Impact on quality of life Prostate cancer is the most common form of non-cutaneous malignancy in North America, and the third by incidence worldwide in males. As surgical, radiotherapeutic and systemic therapies continue to improve, the chance of a cure, and consequently long-term survival, has increased in patients with prostate cancer. The 5-year disease-specific survival rate of patients diagnosed with prostate-confined cancer well exceeded 95%. Additionally, in the prostate-specific antigen screening era, more patients present with asymptomatic cancer and no genitourinary deficits at all. Consequently, maximizing and preserving the quality of life (QOL) in these patients after treatment has become important, as a significant portion of them will reach their expected life expectancy. The impact of a patient’s prior genitourinary procedures, such as transurethral resection of the prostate (TURP) for benign prostatic hyperplasia, is a significant QOL contributor in this group of patients. Patients receiving prostatectomy or external beam radiotherapy (EBRT) might show different long-term QOL profiles.1 Historically, prior TURP is a relative contraindication for low-doserate brachytherapy (a permanent, radioactive seed implant technique), but not for radical prostatectomy. In prostate cancer patients with a history of prior TURP, newer evidence has suggested that the adverse event rates of high-dose-rate brachytherapy, a temporary implant with improved dosimetric flexibilities intraoperatively, are low and could be acceptable.2 However, the short-term and long-term QOL impacts of TURP on EBRT outcome in prostate cancer patients are largely unknown, because of a lack of prospective evaluation on this topic. In this issue of International Journal of Urology, Pinkawa et al. published a retrospective, matched-pairs study titled “Transurethral resection of the prostate after radiotherapy for prostate cancer: Impact on quality of life”.3 A group of 49 patients with prior TURP who successfully completed EBRT was retrospectively compared with 487 patients without TURP; they were all treated in the same era at the authors’ institution in Germany. Their use of higher EBRT doses (70.2–80 Gy per course) was modern, with incorporation of 3-D conformal, intensity-modulated (IMRT) and image-guided radiation therapies in the majority of their patient cases. The use of androgen deprivation therapy was equal in both arms (35% each). In balancing the heterogenous factors in their population, the authors additionally carried out a one-to-one matching for their cohort of 49 patients with TURP. The QOL survey tool was given over multiple time-points including baseline. The authors reported significantly fewer short-term symptoms (lower drops in QOL compared with baseline, across multiple domains) in patients who had prior TURP compared with those without a TURP history. Their long-term outcome showed that QOL was
904
acceptable in this group of patients with TURP, except for those patients who underwent the procedure more than 2.5 years before EBRT (poorer incontinence score). It is important to note that both groups of patients, with or without EBRT, had similar baseline QOL scores at initiation of EBRT. Previously, there have been concerns regarding the use of brachytherapy or EBRT in patients with a prior TURP history. Regarding EBRT, a number of studies, including a detailed 38-article systematic review have been reported.4 However, the use of QOL surveys was not common. In another case–control 71-patient series, the authors observed that patients with prior TURP had a higher risk of severe acute genitourinary toxicities; however, the rates remained low and their symptoms were usually short-lived.5 To evaluate whether modern EBRT, such as IMRT, should be an acceptable or even more suitable therapeutic modality for patients who have had a significant surgical history with TURP, patient-reported QOL measures must be incorporated along with traditional physician-assessed adverse effect end-points in future studies.6 Terence T Sio M.D., M.S. Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, USA [email protected] DOI: 10.1111/iju.12579
Conflict of interest None declared.
References 1 Sanda MG, Dunn RL, Michalski J et al. Quality of life and satisfaction with outcome among prostate-cancer survivors. N. Engl. J. Med. 2008; 358: 1250–61. 2 Luo HL, Fang FM, Chuang YC, Chiang PH. Previous transurethral resection of the prostate is not a contraindication to high-dose rate brachytherapy for prostate cancer. BJU Int. 2009; 104: 1620–3. 3 Pinkawa M, Klotz J, Djukic V, Petz D, Holy R, Eble MJ. Transurethral resection of the prostate after radiotherapy for prostate cancer: impact on quality of life. Int. J. Urol. 2014; 21: 899–903. 4 Ishiyama H, Hirayama T, Jhaveri P et al. Is there an increase in genitourinary toxicity in patients treated with transurethral resection of the prostate and radiotherapy?: a systematic review. Am. J. Clin. Oncol. 2014; 37: 297–304. 5 Devisetty K, Zorn KC, Katz MH, Jani AB, Liauw SL. External beam radiation therapy after transurethral resection of the prostate: a report on acute and late genitourinary toxicity. Int. J. Radiat. Oncol. Biol. Phys. 2010; 77: 1060–5. 6 Basch E, Bennett A, Pietanza MC. Use of patient-reported outcomes to improve the predictive accuracy of clinician-reported adverse events. J. Natl. Cancer Inst. 2011; 103: 1808–10.
© 2014 The Japanese Urological Association
M PINKAWA ET AL.
Editorial Comment Editorial Comment to Transurethral resection of the prostate after radiotherapy for prostate cancer: Impact on quality of life Prostate cancer is the most common form of non-cutaneous malignancy in North America, and the third by incidence worldwide in males. As surgical, radiotherapeutic and systemic therapies continue to improve, the chance of a cure, and consequently long-term survival, has increased in patients with prostate cancer. The 5-year disease-specific survival rate of patients diagnosed with prostate-confined cancer well exceeded 95%. Additionally, in the prostate-specific antigen screening era, more patients present with asymptomatic cancer and no genitourinary deficits at all. Consequently, maximizing and preserving the quality of life (QOL) in these patients after treatment has become important, as a significant portion of them will reach their expected life expectancy. The impact of a patient’s prior genitourinary procedures, such as transurethral resection of the prostate (TURP) for benign prostatic hyperplasia, is a significant QOL contributor in this group of patients. Patients receiving prostatectomy or external beam radiotherapy (EBRT) might show different long-term QOL profiles.1 Historically, prior TURP is a relative contraindication for low-doserate brachytherapy (a permanent, radioactive seed implant technique), but not for radical prostatectomy. In prostate cancer patients with a history of prior TURP, newer evidence has suggested that the adverse event rates of high-dose-rate brachytherapy, a temporary implant with improved dosimetric flexibilities intraoperatively, are low and could be acceptable.2 However, the short-term and long-term QOL impacts of TURP on EBRT outcome in prostate cancer patients are largely unknown, because of a lack of prospective evaluation on this topic. In this issue of International Journal of Urology, Pinkawa et al. published a retrospective, matched-pairs study titled “Transurethral resection of the prostate after radiotherapy for prostate cancer: Impact on quality of life”.3 A group of 49 patients with prior TURP who successfully completed EBRT was retrospectively compared with 487 patients without TURP; they were all treated in the same era at the authors’ institution in Germany. Their use of higher EBRT doses (70.2–80 Gy per course) was modern, with incorporation of 3-D conformal, intensity-modulated (IMRT) and image-guided radiation therapies in the majority of their patient cases. The use of androgen deprivation therapy was equal in both arms (35% each). In balancing the heterogenous factors in their population, the authors additionally carried out a one-to-one matching for their cohort of 49 patients with TURP. The QOL survey tool was given over multiple time-points including baseline. The authors reported significantly fewer short-term symptoms (lower drops in QOL compared with baseline, across multiple domains) in patients who had prior TURP compared with those without a TURP history. Their long-term outcome showed that QOL was
904
acceptable in this group of patients with TURP, except for those patients who underwent the procedure more than 2.5 years before EBRT (poorer incontinence score). It is important to note that both groups of patients, with or without EBRT, had similar baseline QOL scores at initiation of EBRT. Previously, there have been concerns regarding the use of brachytherapy or EBRT in patients with a prior TURP history. Regarding EBRT, a number of studies, including a detailed 38-article systematic review have been reported.4 However, the use of QOL surveys was not common. In another case–control 71-patient series, the authors observed that patients with prior TURP had a higher risk of severe acute genitourinary toxicities; however, the rates remained low and their symptoms were usually short-lived.5 To evaluate whether modern EBRT, such as IMRT, should be an acceptable or even more suitable therapeutic modality for patients who have had a significant surgical history with TURP, patient-reported QOL measures must be incorporated along with traditional physician-assessed adverse effect end-points in future studies.6 Terence T Sio M.D., M.S. Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, USA [email protected] DOI: 10.1111/iju.12579
Conflict of interest None declared.
References 1 Sanda MG, Dunn RL, Michalski J et al. Quality of life and satisfaction with outcome among prostate-cancer survivors. N. Engl. J. Med. 2008; 358: 1250–61. 2 Luo HL, Fang FM, Chuang YC, Chiang PH. Previous transurethral resection of the prostate is not a contraindication to high-dose rate brachytherapy for prostate cancer. BJU Int. 2009; 104: 1620–3. 3 Pinkawa M, Klotz J, Djukic V, Petz D, Holy R, Eble MJ. Transurethral resection of the prostate after radiotherapy for prostate cancer: impact on quality of life. Int. J. Urol. 2014; 21: 899–903. 4 Ishiyama H, Hirayama T, Jhaveri P et al. Is there an increase in genitourinary toxicity in patients treated with transurethral resection of the prostate and radiotherapy?: a systematic review. Am. J. Clin. Oncol. 2014; 37: 297–304. 5 Devisetty K, Zorn KC, Katz MH, Jani AB, Liauw SL. External beam radiation therapy after transurethral resection of the prostate: a report on acute and late genitourinary toxicity. Int. J. Radiat. Oncol. Biol. Phys. 2010; 77: 1060–5. 6 Basch E, Bennett A, Pietanza MC. Use of patient-reported outcomes to improve the predictive accuracy of clinician-reported adverse events. J. Natl. Cancer Inst. 2011; 103: 1808–10.
© 2014 The Japanese Urological Association
