Commentary on Watchful Waiting and Health Related Quality of Life for Patients With Localized Prostate Cancer
Article Outline
Health related quality of life (HRQOL) is an important consideration among men diagnosed with prostate cancer. With 5-year recurrence-free survival in excess of 80% regardless of therapy,1, 2 the consequences of therapy are of paramount concern. With the specter of over treatment looming,3, 4 active surveillance has been advocated to minimize the population that is burdened by the morbidity of treatment.5 Indeed, these considerations often guide therapy choices. The study by Arredondo et al provides insight into the relationship between an initial choice of watchful waiting and HRQOL. The question is highly relevant as most men choosing this more passive treatment option probably expect minimal declines in health status beyond those related to aging.
The authors used the CaPSURE® database to longitudinally follow the HRQOL of 310 men who initially chose watchful waiting for prostate cancer. Patient reported HRQOL was determined using the validated RAND 36-Item Health Survey (SF-36) for measuring general health status and the UCLA Prostate Cancer Index for ascertaining constructs more specific to the prostate. The authors noted statistically significant declines in multiple health domains over time but the majority of these changes were of questionable clinical significance.
Nonetheless, the findings of the study are provocative. Are there potential unanticipated tradeoffs in HRQOL associated with watchful waiting? Most will agree that the downstream consequences of prostate cancer treatment on HRQOL influence patient decision making. For this reason, it is important to understand the implications of watchful waiting on health status. There are several plausible mechanisms by which treatment choice may have a deleterious impact on health status, including the psychosocial effects of labeling, morbidity related to repeated invasive testing (eg prostate biopsy) and psychological harms resulting from a more passive approach to treating a theoretically lethal disease, among others. The current study raises the possibility that there are indeed measurable consequences to this treatment choice.
The increasing advocacy for watchful waiting is predicated on the assumption that deferring or even eliminating definitive therapy in select patients will minimize the aggregate morbidity in the population at large. However, if watchful waiting were ultimately found to adversely impact health status, at least one impetus for encouraging this approach would be lost.
References
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- . Androgen suppression and radiation vs radiation alone for prostate cancer: a randomized trial. JAMA. 2008;299:289
- . Early stage prostate cancer—do we have a problem with over detection, over treatment or both?. J Urol. 2005;173:1061
- . Incidence of initial local therapy among men with lower-risk prostate cancer in the United States. J Natl Cancer Inst. 2006;98:1134
- Expectant management of prostate cancer with curative intent: an update of the Johns Hopkins experience. J Urol. 2007;178:2359
PII: S0022-5347(08)00547-8
doi:10.1016/j.juro.2008.03.005
© 2008 American Urological Association. Published by Elsevier Inc. All rights reserved.