Patient age has a strong impact on HRQOL for prostate cancer patients before a primary curative treatment. Increasing urinary incontinence, urinary bother, and above all a strongly age-related decreasing sexual function has to be considered. Comparability of studies analyzing incontinence and impotence is often limited by different definitions. Urinary continence can be defined by wearing pads, dripping urine when coughing, any involuntary loss of urine or other definitions [23–25]. In the RTOG/EORTC (Radiation Therapy Oncology Group/European Organization for Research and Treatment of Cancer) grading system, urinary incontinence does not occur at all . LENT SOMA (Late Effects Normal Tissues with Subjective, Objective, Management and Analytic categories) tables consider incontinence in some detail (e.g. grade 1 = < weekly episodes/occasional use of pads) . HRQOL questionnaires allow an assessment with a higher accuracy from the patient's perspective.
Remarkable differences result between the percentage of patients who retain some ability to have an erection with increasing age and the percentage with erections firm enough for intercourse. Probably the best definition of potency (if only a single definition is used) is the ability to have an erection sufficient for penetration. This ability was found to decline particularly comparing the age groups ≤65, 66-70 and 71-75 years. Sexual function scores decreased remarkably between all age groups (mean decrease of 18 points between the age groups ≤65 and >75 years). Older patients accept a missing potency easier, so that changes of sexual bother scores were found to be less impressive (mean decrease of only 8 points between the age groups ≤65 and >75 years). Improving bother scores for patients with low scores before external beam radiotherapy have been shown in a recently published analysis , indicating some adaptation to the sexual problems.
Rectal domain scores have not been found to be age-dependent. However, some symptoms differed between the age groups. Older patients tend to have less frequent bowel movements - a consequence of declining metabolism and physical activity. Furthermore, the percentage of patients who observed bloody stools is decreasing. It is unclear, if bloody stools are actually not occurring or simply not noticed. An occasional bleeding rate of 12% in the patient group up to 65 years is remarkable. As rectal bleeding is considered an important sign of proctitis following radiotherapy, this high frequency stresses the importance of recording the presence of bleeding already before treatment. For example, a higher bleeding rate in a patient group with a lower dose to the rectum volume could only be explained by a higher bleeding rate already before treatment in a group of patients after post-prostatectomy radiotherapy . Late rectal bleeding is a key dose-limiting end point in prostate radiotherapy with increasing incidence above a dose of 60 Gy . In a study by Goldner et al. , 52 patients were reported with grade 2-3 EORTC/RTOG late rectal side effects - the reason was rectal bleeding for 50 patients (96%).
Hormonal function, as defined in the EPIC questionnaire, improved with higher patient ages. Testosterone levels are known to decline with age. Manifestations of testosterone deficiency include depression, irritability, weakness, diminished libido, reduced muscle and bone mass . The results of this study suggest some adaptation to changing hormone levels. As both comorbidities and age (contrary effects on hormonal scores) are considered in the calculation of CCI, no effect of CCI differences was found on hormonal scores.
As recently reported by Bhojani et al. , select comorbidities have a very strong effect on urinary function and sexual function. In comparison to the younger patients (≤65 years), the incidence of comorbidities was higher with increasing age in our study. Comorbidities have an additional, independent impact on HRQOL. Focusing on specific comorbidities, hypertension - the most frequent comorbidity in this population - has not been found to influence any of the HRQOL domains. Diabetes mellitus, a disease known to ensue microvascular complications and neuropathy, had the strongest influence on urinary symptoms and, above all, sexuality. Both sexual function and sexual bother scores were affected with a mean decrease of 16 and 18 points, respectively. Diabetes is very well known as a predictor of late radiation morbidity [32, 33]. In contrast to studies using only various toxicity grading scales [32, 33], prospective HRQOL studies help to consider more accurately pre-existing symptoms. Coronary heart disease and independently, chronic obstructive pulmonary disease, were associated with decreased hormonal domain scores. These diagnoses are very well known to reduce normal physical activities. No correlation of comorbidities, similar to the patient age, was found with the rectal domain scores.