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Multicenter Study
. 2011 Sep 21;306(11):1205-14.
doi: 10.1001/jama.2011.1333.

Prediction of erectile function following treatment for prostate cancer

Mehrdad Alemozaffar  1 , Meredith M Regan, Matthew R Cooperberg, John T Wei, Jeff M Michalski, Howard M Sandler, Larry Hembroff, Natalia Sadetsky, Christopher S Saigal, Mark S Litwin, Eric Klein, Adam S Kibel, Daniel A Hamstra, Louis L Pisters, Deborah A Kuban, Irving D Kaplan, David P Wood, Jay Ciezki, Rodney L Dunn, Peter R Carroll, Martin G Sanda
Affiliations
Multicenter Study

Prediction of erectile function following treatment for prostate cancer

Mehrdad Alemozaffar et al. JAMA. .

Abstract

Context: Sexual function is the health-related quality of life (HRQOL) domain most commonly impaired after prostate cancer treatment; however, validated tools to enable personalized prediction of erectile dysfunction after prostate cancer treatment are lacking.

Objective: To predict long-term erectile function following prostate cancer treatment based on individual patient and treatment characteristics.

Design: Pretreatment patient characteristics, sexual HRQOL, and treatment details measured in a longitudinal academic multicenter cohort (Prostate Cancer Outcomes and Satisfaction With Treatment Quality Assessment; enrolled from 2003 through 2006), were used to develop models predicting erectile function 2 years after treatment. A community-based cohort (community-based Cancer of the Prostate Strategic Urologic Research Endeavor [CaPSURE]; enrolled 1995 through 2007) externally validated model performance. Patients in US academic and community-based practices whose HRQOL was measured pretreatment (N = 1201) underwent follow-up after prostatectomy, external radiotherapy, or brachytherapy for prostate cancer. Sexual outcomes among men completing 2 years' follow-up (n = 1027) were used to develop models predicting erectile function that were externally validated among 1913 patients in a community-based cohort.

Main outcome measures: Patient-reported functional erections suitable for intercourse 2 years following prostate cancer treatment.

Results: Two years after prostate cancer treatment, 368 (37% [95% CI, 34%-40%]) of all patients and 335 (48% [95% CI, 45%-52%]) of those with functional erections prior to treatment reported functional erections; 531 (53% [95% CI, 50%-56%]) of patients without penile prostheses reported use of medications or other devices for erectile dysfunction. Pretreatment sexual HRQOL score, age, serum prostate-specific antigen level, race/ethnicity, body mass index, and intended treatment details were associated with functional erections 2 years after treatment. Multivariable logistic regression models predicting erectile function estimated 2-year function probabilities from as low as 10% or less to as high as 70% or greater depending on the individual's pretreatment patient characteristics and treatment details. The models performed well in predicting erections in external validation among CaPSURE cohort patients (areas under the receiver operating characteristic curve, 0.77 [95% CI, 0.74-0.80] for prostatectomy; 0.87 [95% CI, 0.80-0.94] for external radiotherapy; and 0.90 [95% CI, 0.85-0.95] for brachytherapy).

Conclusion: Stratification by pretreatment patient characteristics and treatment details enables prediction of erectile function 2 years after prostatectomy, external radiotherapy, or brachytherapy for prostate cancer.

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Conflict of interest statement

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. None of the coauthors have been compensated specifically for work related to this manuscript other than having received research support from the National Institutes of Health (NIH) to cover costs of conducting the study. Dr Cooperberg reported serving as a consultant for Denreon and Ortho-Centocor and receiving payment for lectures from Takeda, Abbott, and Amgen. Dr Wei reported serving as a consultant for Envisioneering Inc and sanofi-aventis; serving as an expert witness for Genprobe; serving as a proctor for American Medical Systems; and receiving research funding from sanofiaventis. Dr Michaliski reported making donations to charity in lieu of honoraria for his role as a board member for Elekta Inc, Augmenix Inc, and Viewray. Dr Sandler reported serving as a consultant for Varian, Calypso Medical, Millennium-Takeda, and Centocor-Ortho Biotech. Dr Kibel reported serving as a consultant for Myraid, Caris, Dendreon, sanofi-aventis, Cougar, and Ferring; receiving payment for lectures from Dendreon; and holding stock in Myriad. Dr Kuban serving as a consultant for Ferring Pharmaceuticals and bioTheranostics and as a lecturer supported by the Radiation Oncology Institute. Dr Wood reported serving as a consultant for Intuitive Surgical and holding stock in that company. Dr Carroll reported receiving an institutional research grant from Abbott. Dr Sanda reported receiving a lecture honnorarium from Eli Lily. No other authors reported financial disclosures.

Figures

Figure 1
Figure 1
Model-Predicted Probability of Functional Erections Suitable for Intercourse 2 Years After Radical Prostatectomy Model-predicted probabilities based on pretreatment Expanded Prostate Cancer Index Composite sexual function score stratified by age, pretreatment prostate-specific antigen (PSA) level, and planned nerve sparing. Higher sexual function score denotes better sexual function. N=524 (66 [13%] with PSA level >10 ng/mL and 43 [8%] undergoing non–nerve-sparing surgery); median age, 60 years.
Figure 2
Figure 2
Model-Predicted Probability of Functional Erections Suitable for Intercourse 2 Years After External Radiotherapy for Prostate Cancera Model-predicted probabilities based on pretreatment Expanded Prostate Cancer Index Composite sexual function score stratified by pretreatment prostate-specific antigen (PSA) level and planned use of neoadjuvant hormone therapy. Higher sexual function score denotes better sexual function. N=241 (39 [16%] with PSA level <4 ng/mL and 74 [31%] receiving neoadjuvant hormone therapy. aNote that curves for no use of neoadjuvant hormone therapy/PSA ≥4 ng/mL and use of neoadjuvant hormone therapy/PSA <4 ng/mL overlap.
Figure 3
Figure 3
Model-Predicted Probability of Functional Erections Suitable for Intercourse 2 Years After Brachytherapy for Prostate Cancer Model-predicted probabilities based on pretreatment Expanded Prostate Cancer Index Composite sexual function score stratified by age, body mass index (BMI; calculated as weight in kilograms divided by height in meters squared), and race. Higher sexual function score denotes better sexual function. N = 262 (28 [11%] African American; 57 [22%] with BMI <25, 187 [71%] with BMI 25–35, and 18 [7%] with BMI ≥35); median age, 66 years.
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