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Researchers examine prevalence, quality of life, and treatment of men suffering from prostate problems

The Patient Outcomes Research Team for Prostatic Diseases, supported by the Agency for Healthcare Research and Quality (HS08397) and led by Michael J. Barry, M.D., of Massachusetts General Hospital, recently published four studies examining the prevalence of prostate problems and the quality of life and treatment of men who have prostate problems. The first study shows that prostatitis is a common condition among otherwise healthy men. The second study reveals that the lower urinary tract symptoms associated with benign prostatic hyperplasia (BPH) can significantly affect men's quality of life. A third study finds that educating primary care doctors and patients about prostate conditions has no impact on prostate-related primary care. The fourth study concludes that the use of radical prostatectomy (surgical removal of the prostate) to treat prostate cancer in men older than 70 years is now more selectively targeted to otherwise healthy men than it has been in the past. The articles are summarized here.

Collins, M.M., Meigs, J.B., Barry, M.J., and others. (2002, March). "Prevalence and correlates of prostatitis in the Health Professionals Follow-Up Study cohort." Journal of Urology 167, pp. 1363-1366.

Men who suffer from chronic prostatitis (inflammation of the prostate) typically experience lower urinary tract symptoms and pelvic pain, symptoms that overlap with BPH, a common condition affecting older men. Prostatitis and BPH are associated with lower urinary tract symptoms, and men can and do get both conditions. More than half (57 percent) of men with prostatitis in this study reported a history of BPH, and more than one-third (39 percent) with BPH reported a history of prostatitis. Whether there is a true association or just a confusion of symptoms is unknown, since there is no specific diagnostic test for either condition, explain these authors.

They examined a nationwide sample of 31,681 health professionals without prostate cancer for urological diagnoses, lower urinary tract symptoms, and demographic, clinical, and lifestyle factors. They then compared the characteristics of men with prostatitis to those with BPH. Men who had a history of BPH were nearly eight times more likely to have a history of prostatitis. Men with moderate or severe lower urinary tract symptoms, those with a history of sexually transmitted disease, and men who reported stress at home or work were more likely to have a history of prostatitis.

Men with prostatitis reported a higher burden of filling symptoms (frequency of urination, feelings of urgency to urinate, and excessive urination at night) relative to voiding symptoms (incomplete emptying, intermittent or weak stream, and straining). However, those with BPH had a similar mean void and fill score. The 2,163 men with prostatitis alone were younger and had less severe urinary tract symptoms (but a similar pattern of symptoms) than the 4,575 men with BPH alone. It may be that when men see physicians with similar lower urinary tract symptoms, younger men get diagnosed with prostatitis, while older men are diagnosed with BPH, conclude the researchers.

Welch, G., Weinger, K., and Barry, M.J. (2002). "Quality-of-life impact of lower urinary tract symptom severity: Results from the Health Professionals Follow-Up Study." Urology 59, pp. 245-250.

Lower urinary tract symptom (LUTS) severity suffered by men with BPH can have a significant impact on their physical and social functioning. High-moderate LUTS severity was associated with small to moderate increases in anxious and depressed mood and poorer role functioning related to emotional problems arising from illness. Severe LUTS was associated with additional problems of reduced vitality and diminished ability to work and carry out daily tasks as a result of illness. In fact, compared with individuals suffering from four other types of chronic illnesses (diabetes, angina, hypertension, and gout), men with BPH with severe LUTS had less vitality/energy. They also had poorer role functioning and more depressed and anxious feelings.

The detection and effective treatment of LUTS may substantially improve the quality of life of these men, conclude the researchers. They assessed symptom severity among 8,406 health professionals based on the American Urological Association Symptom Index (mild, 0 to 7; low moderate, 8 to 14; high moderate, 15 to 19; and severe, 20 to 35). They also analyzed their quality of life using a standard questionnaire. There was a clear symptom severity-related impact on all health-related quality of life dimensions.

The greatest disparities were found between the lowest and highest symptom severity groups for ability to physically carry out work or other usual activities (a 25 point difference on a 0 to 100 scale, with 100 being optimal functioning), vitality or energy level (16 points), role emotional (14), general health perceptions (14), physical functioning (11), bodily pain (10), social function (8), and mental health (7). These findings reinforce the notion that more aggressive medical treatment of patients with moderate to severe LUTS can produce substantial and specific benefits in health status for patients coping with these symptoms.

Hammond, C.S., Wasson, J.H., Walker-Corkery, E., and others. (2001). "A frequently used patient and physician-directed educational intervention does nothing to improve primary care of prostate conditions." Urology 58(6), pp. 875-881.

Primary care physicians (PCPs) are becoming more involved in diagnosing and managing prostatic diseases due to increased availability of effective medical treatments for BPH and the availability of the prostate-specific antigen (PSA) test for the early detection of prostate cancer. However, evidence suggests that PCPs are not always providing optimal care for prostate-related problems. Unfortunately, newsletters and other educational materials directed at PCPs and patients in two States did not have any noticeable impact on prostate-related primary care, according to this study.

The investigators randomized 33 rural primary care practices (including 50 PCPs) to either the educational intervention or no intervention (control group). They mailed two newsletters, conducted two face-to-face research staff visits, and provided educational manuals about management of prostate conditions to 17 intervention practices. In addition, they mailed educational pamphlets about prostate symptoms to patients at the intervention practices. After 18 months, 87 percent of patients and 92 percent of PCPs completed a final survey of prostate-related knowledge for patients and management of common prostate conditions for the physicians.

Before randomization, most men (59 percent) said they knew little or nothing about prostate problems that affect urination, and 63 percent reported little or no knowledge about PSA testing. Eighteen months later, there were no differences between intervention and control patients in measures of health status, urinary symptoms and bother, treatments received, and prostate-related knowledge. What's more, knowledge of intervention physicians and self-reported practices for managing common prostate conditions were no better than they were for the control physicians.

The researchers conclude that alternative educational approaches should be explored by urologists and PCPs who wish to improve understanding about and management of their patients' prostate-related problems.

Bubolz, T., Wasson, J.H., Lu-Yao, G., and Barry, M.J. (2001). "Treatments for prostate cancer in older men: 1984-1997." Urology 58, pp. 977-982.

After the introduction of PSA screening in the late 1980s, the rate of radical prostatectomy (RP) increased dramatically. However, after 1992, the use of RP decreased among older men. This study found that RP is now more selectively targeted for treatment of prostate cancer in men older than 70 years who have no other medical problems. The researchers examined the age-specific trends in RP, brachytherapy (BT, localized radiation therapy), and external beam radiotherapy (EBRT) use for the period 1984 to 1997 based on retrospective analysis of Medicare data on treatment for prostate cancer among Medicare beneficiaries.

The rate of RP peaked in 1992. From 1993 to 1997, its use decreased by 6 percent among men aged 65 to 69 years, 34 percent among men aged 70 to 74 years, and 50 percent for men 75 years of age and older. However, by 1997, the RP + BT treatment rate again approached the 1992 levels of RP alone. BT was used twice as often as RP in men aged 75 or older. By 1997, the RP + BT + EBRT rate exceeded the 1993 rate for men aged 65 to 69 years and was again approaching the 1993 rate for men aged 70 to 74 years. From 1984 to 1997, the proportion of men with coexisting medical conditions who underwent RP gradually declined and accounted for more than 60 percent of the decrease in the short-term mortality during this period. The remaining 40 percent reduction in short-term mortality was most likely due to improvements in surgical technique, anesthesia, and supportive care.

The increased use of BT and decreased use of RP, especially in men 70 and older, suggests that during this 5-year period, treatment was less aggressively pursued among the very old, for whom benefits are likely to be much less and the complications substantially higher. There were also trends toward lower rates for 30-day hospital readmissions during this period. Finally, variations in RP use by geographic region also decreased, suggesting that urologists might be reaching a consensus about what they consider appropriate for RP. This study did not address the use of androgen deprivation therapy.

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