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Objective: The Radiumhemmets Scale of Disease-Specific Symptom Assessment-Prostate Cancer has been used in several studies. However, no test-retest reliability study of it has been conducted concerning the assessment of urinary, anal sphincter or large bowel function. The aim of this study was to evaluate the reliability of items assessing these functions., Material and Methods: We investigated 89 prostate cancer patients randomly selected from a group of patients diagnosed in Stockholm. The patients answered 24 questions assessing anal sphincter, large bowel and urinary function twice, with a 3-week interval in-between, to assess reliability., Results: Most of the questions assessing bowel and urinary symptoms showed substantial or near-perfect agreement. The kappa value for bowel symptom items was > or = 0.60 for all items, except for defecation urgency (0.40-0.55). The kappa value for urinary symptom items varied between 0.43 and 1.0, except for urinary urgency (0.30-0.39)., Conclusions: When comparing the impact of different symptoms of anal sphincter, large bowel or urinary tract dysfunction, it may be important to consider that defecation urgency and urinary urgency have the highest measuring error (low reliability). This error dilutes assessed associations with, for example, decreased quality of life. Nevertheless, the test-retest reliability for anal sphincter, large bowel and urinary symptoms indicates that surveys yield meaningful information.

Background: The estimation of the parameters that describe the dose-response relations of anal sphincter regarding the clinical endpoints of fecal leakage and blood or phlegm in stools is important in the optimization of prostate cancer radiotherapy. Also, the validity of the relative seriality model for this clinical case needs to be examined by associating the clinical follow-up results with the predicted complication rates., Patients and Methods: In this study, 65 patients who received radiation therapy for clinically localized prostate adenocarcinoma are analyzed. The clinical treatment outcome and the three-dimensional dose distribution delivered to anal sphincter were available for each patient. A questionnaire was used for assessing the clinical bowel and urinary symptoms. A maximum likelihood fitting was performed to calculate the best estimates of the parameters used by the relative seriality model. The clinical utilization of the calculated parameters in predicting anal sphincter complication probabilities was illustrated by applying the best estimate of the parameters to a subset of the patient population., Results: The estimated values of the parameters for the two clinical endpoints are D (50) = 70.2 Gy, gamma = 1.22, s = 0.35 for fecal leakage and D (50) = 74.0 Gy, gamma = 0.75, s approximately 0 for blood or phlegm in stools. The standard deviations of the parameters were also calculated together with the confidence intervals of the dose-response curves. The analysis proved that the treatment outcome pattern of the patient material can suitably be reproduced by the relative seriality model (probability of finding a worse fit = 60.2%, the area under the receiver operating characteristic curve = 0.72 and 0.69 and chi(2)-test = 0.97 and 0.86, respectively)., Conclusion: Fecal leakage is characterized by a medium relative seriality whereas blood or phlegm in stools was found to have strong volume dependence (low relative seriality). Diminishing the biologically effective uniform dose to anal sphincter < 40-45 Gy may significantly reduce the risk of fecal leakage or blood or phlegm in stools for patients irradiated for prostate cancer.

Purpose: To investigate dysfunction caused by unwanted radiation to the anal-sphincter region and the rectum., Methods and Materials: A questionnaire assessing bowel symptoms, sexual function, and urinary symptoms was sent to 72 patients with clinically localized prostatic adenocarcinoma treated by external beam radiation therapy at the Radiumhemmet, Karolinska Hospital, in Stockholm, Sweden, 2-4 years after treatment. The mean percentage dose-volume histograms for patients with and without the specific symptom were calculated., Results: Of the 65 patients providing information, 9 reported fecal leakage, 10 blood and mucus in stools, 10 defecation urgency, and 7 diarrhea or loose stools. None of the 19 and 13 patients who received, respectively, a dose of > or =35 Gy to < or =60% or > or =40 Gy to < or =40% of the anal-sphincter region volume reported fecal leakage (p < 0.05). In dose-volume histograms, a statistically significant correlation was found between radiation to the anal-sphincter region and the risk of fecal leakage in the interval 45-55 Gy. There was also a statistically significant correlation between radiation to the rectum and the risk of defecation urgency and diarrhea or loose stools in the interval 25-42 Gy. No relationship was found between anatomic rectal wall volume and the investigated late effects., Conclusions: Although the limited data in this study prevent the definition of a conclusive threshold regarding volume and dose to the anal-sphincter region and untoward morbidity, it seems that careful monitoring of unnecessary irradiation to this area should be done because it can potentially help reduce the risk of adverse effects, such as fecal leakage. Future studies should pay more attention to the anal-sphincter region and help to more rigorously define its radiotherapeutic tolerance.

Aims: The authors investigated whether becoming a widow after the death of a husband from cancer results in long-term psychological or physical morbidity., Method: In April and May 1999, an attempt was made to contact all of the 506 women who were living with men dying of prostate cancer in 1996 or of urinary bladder cancer in 1995 or 1996, as well as 287 population controls., Results: Completed questionnaires were received from 379 of the widows and 220 of the controls. Widowhood was associated with a low or moderate subjective quality of life (relative risk [RR] = 1.4, 95% confidence interval 1.2-1.7), low or moderate psychological well-being (RR = 1.8, 1.4-2.3), anxiety (RR = 1.9, 1.3-2.7), depression (RR = 2.2, 1.6-2.9), sleep disturbances (RR = 1.9, 1.5-2.4), diabetes (RR = 3.5, 1.2-7.9), and economic dissatisfaction (RR = 1.6, 1.3-2.0)., Conclusion: An excess risk of psychological morbidity, diabetes mellitus and dissatisfaction with the economic situation was found in the widowed population.

The aim of this study was to investigate whether external beam radiation treatment with three or four fields affects the risk of long-term distressful symptoms. The study included 145 patients who had been treated in Stockholm from 1993 to 1996 for localized prostate cancer. Bowel, urinary and sexual function as well as symptom-induced distress were assessed by means of a postal questionnaire 29-59 months after therapy. Among patients treated with a multileaf collimator, defecation urgency, diarrhoea and loose stools were more common after four fields than after three fields, but faecal leakage necessitating the use of pads and distress from the gastrointestinal tract were less common (although not statistically significantly so). Among bowel symptoms, the strongest association with gastrointestinal distress was found for faecal leakage. Three fields without a multileaf collimator entailed a higher risk of defecation urgency than three fields with a multileaf collimator. We conclude that the choice of three or four fields may imply a contrasting risk scenario for defecation urgency or diarrhoea in comparison with faecal leakage.

Objective: To investigate to what extent prostate cancer patients confide their emotional concerns, and whether having no one to confide in affects well-being., Material and Methods: A population-based study using epidemiological methods. A questionnaire was mailed to all 431 living prostate cancer patients aged 50-80 at the time of selection, diagnosed 1.5-2 years previously in Stockholm County, and 435 randomly selected men in the same age group. The questionnaire was completed anonymously. The main outcome measures included questions assessing the extent to which the men could share emotionally taxing feelings with their partner or others and questions assessing well-being., Results: The questionnaire was returned by 79% of the patients and by 73% of the randomly selected men. Approximately one in five patients had no one to confide in. Of patients living with a partner, only one in 10 confided in someone other than their partner. Three out of 10 patients living in a relationship could not confide in their partner. Men having no one to confide in were less content with their life and reported poorer psychological and overall well-being compared with other men. The prostate cancer patients were not more likely to have someone to confide in than men in general., Conclusions: The results indicate that a lack of emotional support may be a problem for many prostate cancer patients and that the traditional psychosocial support offered to most cancer patients in Sweden may not reach male patients. There may be a need for a gender-adapted approach to emotional support.

Background and Purpose: To investigate whether the type of collimation technique, target dose and treated volume influence the prevalence of intact erectile function after external beam radiation therapy for localized prostate cancer., Patients and Methods: A prospective study was conducted to assess erection stiffness before treatment and after follow-ups of 9-18 months and 4-5.5 years. Information was collected using the Radiumhemmet Scale of Sexual Function., Results: Thirty-one men were 'potent' before the radiation. Fourteen of them were treated with a conventional collimator and 17 were given three-dimensional conformal therapy with the aid of a multileaf collimator. Preserved erectile function at 9-18 months was found in 17 of the 31 men (55%) and at the 4-5-year follow-up in five of 22 (23%). Preservation of potency was related to the treatment procedure but not to the treatment volume., Conclusions: Conformal therapy may increase the percentage of men preserving erectile function during radiotherapy for localized prostate cancer; it is possible that the differences to conventional therapy do not depend on treated volume.

Objectives: To investigate the prevalence of urinary and bowel symptoms in population-based groups of men with and without prostate cancer., Methods: A self-administered questionnaire, assessing 5 urinary and 3 bowel symptoms, was sent to the 431 men diagnosed as having prostate cancer in the Stockholm area in 1992 who were still alive in October 1993 and to 435 randomly selected control subjects with an age distribution matching men with newly diagnosed prostate cancer in the same area. The results were evaluated as ratios of proportions., Results: Among the prostate cancer patients, all urinary and bowel symptoms assessed were more common and the risk of having the various symptoms was 1.3-4.5 times that of the controls. The risks of having leakage of urine after radical prostatectomy and bowel urgency after external beam radiation therapy were fourfold when compared with the control group. We noted an increased risk ratio of proportions of leakage of faeces after radical prostatectomy and this risk was significantly increased when men with any of 11 specified diseases were excluded from the analysis to reduce confounding., Conclusions: Prostate cancer and its treatment affects urinary and bowel functions. The increased risk of having leakage of faeces after radical prostatectomy may be a chance phenomenon due to few patients subjected to surgery, but warrants further investigation.

Purpose: We identified factors that affect sexual function in men 50 to 80 years old and, therefore, may confound the comparison among groups of elderly men. In particular, we identified factors that may influence a comparison between prostate cancer patients and the general population, or confound the relationship when comparing subgroups of patients in nonrandomized studies., Materials and Methods: A questionnaire, including the Radiumhemmet Scale of Sexual Function and modules assessing potential risk factors for waning sexual function, was sent to 431 patients 50 to 80 years old with prostate cancer diagnosed 1.5 to 2 years previously in the Stockholm area (Sweden) and a reference group of 435 age matched randomly selected men., Results: Factors associated with physiological impotence included prostate cancer (relative risk 1.9), diabetes mellitus (relative risk 2.3), myocardial infarction (relative risk 1.5), medication with diuretics (relative risk 1.5), hydrogen blockers (relative risk 2.3) and warfarin type anticoagulants (relative risk 1.7). Patients treated for prostate cancer were more likely to be physiologically impotent compared to those with no initial treatment, and this was true for all treatment protocols after adjustment for confounding factors. Men treated with radical prostatectomy were more likely to be physiologically impotent than men treated with external beam radiation therapy (relative risk 1.5)., Conclusions: Waning sexual function in the prostate cancer patients was largely due to side effects of the treatment and this could not be explained by confounding factors. In particular, confounding could not explain the greater risk of impotence after radical prostatectomy compared to external beam radiation therapy.

The objective was to investigate how prostate cancer and its treatment affects sexual, urinary and bowel functions and to what extent eventual complications cause distress. A questionnaire was sent to 431 men aged 50-80 years with prostate cancer diagnosed in 1992 in the Stockholm area (Sweden) and 435 randomly selected men with a similar age distribution. Sexual function, as compared with their youth, was diminished in a majority of all men. The prostate cancer patients were, however, more likely to report low frequency and/or intensity in all aspects of sexual function. A majority of the men were distressed by a waning sexual capacity. The proportion of men with prostate cancer who were severely distressed owing to a decline in sexual function was larger than in the reference group. The willingness to trade off an intact sexual function for long-term survival varied considerably among the men in the reference group. Urinary and bowel symptoms were less common than a waning sexual function in both groups, and few appeared to be severely distressed by urinary or bowel symptoms. A decline in sexual functions was the most common cause of disease-specific distress in men with prostate cancer.

Purpose: The aim of this study was to assess to what extent patients treated with radiation therapy for prostate cancer experience change in sexual functioning and to what extent this effects quality of life., Methods and Materials: Information was provided by 53 men treated with radiation therapy for localized prostate cancer. Assessment was made with the "Radiumhemmets Scale of Sexual Functioning," which measures sexual desire, erectile capacity, orgasm, and to what extent a decrease in any of these aspects of sexual functioning affects quality of life. Function before treatment was assessed retrospectively., Results: Sexual desire diminished among 77% after treatment. The erection stiffness decreased in 77%. Before external radiation therapy, 66% had an erection usually sufficient for intercourse. Half of the men lost this ability after treatment. Of those retaining orgasm after treatment, 47% reported a decreased orgasmic pleasure and 91% a reduced ejaculation volume. Of all men, 50% reported that quality of life had decreased much or very much due to a decline in the erectile capacity following external radiation therapy., Conclusion: The results of the present study indicate that external radiation therapy for prostate cancer is associated with a reduction in sexual desire, erectile capacity, and organism functions. In a majority of patients this reduces quality of life. Previously, we may have underestimated the importance an intact sexual function has for the quality of life in this patient category of elderly men.