Date of Graduation
Master of Science in Physician Assistant Studies
Mary Von PA-C
Context: Prostate cancer is the second leading cause of cancer in men, second to skin cancer and the second leading cause of cancer related deaths second only to lung cancer. With the development of the PSA test prostate cancer is getting detected in its early stages, thought to be 7 years earlier than before PSA. The treatments for Prostate CA vary, but for those patients with low grade and early stage cancer one treatment option is that of Brachytherapy. These patients tend to suffer fewer complications than those who have had a radical or partial prostatectomy; however they can still develop significant urinary, erectile and rectal symptoms. Objective: The goal of this study is to look at the symptoms of patient's pre and then 5 years post brachytherapy and compare the symptoms. My hope is that majority of patients will worsen their symptom scores by only a small margin, This research will also allow the surgens at The Urology Clinic to better assess their patients outcomes. Setting: Data was collected at the Urology Clinic in' Portland through a patient survey and from the brachytherapy database at the advanced urology center in Emanuel Hospital in Portland, OR. Method: A retrospective chart review and brief survey sent to patients who have had Brachytherapy. The review included those patients who received treatment for prostate cancer from 8/1996 through 5100, and Dr. McCoy was the Urologist on the case. These dates were chosen to give the best chance' of obtaining 5 year follow-up data. The Brachytherapy Database in the Advanced Urology Department of Emanuel was utilized to obtain the majority of data. The remaining information was obtained through a brief follow-up survey that was sent out to the 138 patients of Dr. McCoy's. The five year data was then compiled and pretreatment and post-treatment symptom comparisons were made based on patients risk factors (PSA, Gleason Score, Age) and whether or not the patients failed the treatment (30r > successive rises in PSA). Results: General Outcomes The resuits of the five year post PSA values were addressed (see table 2 and figure 9). Due to patients being lost to follow-up or death, we were only able to obtain the five year post-treatment PSA values for 63.8% (n=88) of our patients. Of the 88 , patients, only one experienced an increase in PSA from pre-treatment (5.2ng/ml) to a five year post-treatment PSA C14.1ng/ml). Majority of patients experienced an increase in their AUA scores, the mean pre-treatment AUA score was 7.04 and the mean post-treatment AUA score was 11.52, a difference of 4.48 (see table 3). Graph B and C depict the urinary and sexual outcomes. About a 40% decrease in sexual potency was seen post':treatment (table 3). There was a 30% increase in rectal symptoms from pre- vs. post-treatment (table 3), L~w vs. High Risk The low risk PSA population comprised 81.8% of the study population. "In terms of PSA reduction, the low risk group did not experience as large of a decrease in PSA values that those of the High risk group experienced in the first 3 years; however, both groups managed to experience significant PSA reductions over the 5 year term. When risk was categorized based on pre-PSA, Gleason score and extra-prostatic extension probability, there were no real differences between the low and high risk groups of AUA scores (low risk mean pre/post AUA= 6.88/11.49 ±1, high risk mean pre/post AUA=7.73/l1.63 ±1) (see table 4). Significant improvement in SHIM scores of patients in both the low and high risk groups, but due to the difference in population size it is difficult to determine. The rectal symptoms in the low risk group, due to the larger population, were more varied. The post-rectal symptom data supported the development of bleeding in 1-2% of the low risk g~oup and about 6% in the high risk group. The development of proctitis was insignificant. It was difficult to determine from the results whether PSA or Gleason score was a better determinate for how patients would tolerate the treatment. (Low vs. High PSA: Chi-square=3.145, df=1, p=0.076; Gleason: Chi square= 0.006, df=1, p=0.936). To depict extra-prostatic extension vs. SHIM a nonparametric analyses (Mann-Whitney V) was used, (1iee figure 12) and the results appeared to be significant (Mann-Whitney V = 1120.50, p=O.017). The data for extension and ADA again showed a similar increase in ADA post-treatment. There was no difference between the low and high risk groups in terms of the rectal symptoms. Mono- vs. Multi-therapy The addition of other therapies did not yield an obvious benefit over mono-therapy (see table 5). The use of a two-sample t-test, found no significant difference between the two groups of patients (t=0.007, df=75, p==0.995). PSA was affected in the two groups and this showed a significant difference. Patients in the multi-therapy group experienced a greater decrease in PSA values compared to the monotherapy group. (t=2.783, df=85, p=0.007). Mann-Whitney U test p=0.006. Sexual function was affected by the type of therapy. Those who received multi-therapy experienced more improvement than those with mono-therapy (Chi-square=4.420, df==1, p=0.036). - Erectile Dysfunction Medications In- this study, 20% (n=18) of the study population was admittedly taking -one of these medications. There were no significant _ differences in outcomes between patients who took ED medications and those who -aid -not (chi-square=2.156, df=1, p=0.142). Conclusions: The treatment of prostate cancer with the use of brachytherapy, in this study has been shown to yield minimal risk in regards to patients developing urinary, sexual and rectal symptoms. The general outcome of this study population resulted in 98.9% of the 88 study patients to have a decrease in their PSA, 20-40% increase in AVA scores, about a 20% improvement in SHIM scores and about 25% of the patients developed rectal symptoms with 11-12% of those as proctitis. From this we can conclude that patients are more likely to develop urinary symptoms post brachytherapy than ED, or rectal symptoms. When the patients were divided into Low and High Risk groups by PSA, Gleason score, and then by probability of developing extra-prostatic extension, calculated from the Partin Table, there was no significant difference between the PSA and Gleason score however there does tend to be a trend for the high risk groups to improve more than expected by random error. The use of extra-prostatic extension does prove to be an indicator of potency. Along these same lines; there did not appear to be any real advantage to those patients who received external beam, hormone therapy or a combination of the two along with brachytherapy versus those who just received brachytherapy as a mono therapy. There are many alternative studies that could be applied to this topic.
McMillan, Ian, "An assessment of patient symptoms pre- and postbrachytherapy for prostate cancer, focusing on those patients who are 5 years post-treatment." (2005). School of Physician Assistant Studies. 82.