Research in context
Evidence before this study
We searched Ovid databases (MEDLINE, Embase, and PsychINFO) for articles relating to health-related quality of life (HRQOL) using the terms “health-related quality of life”, “localised”, “advanced”, “metastatic”, “stage” and “prostate cancer” or “prostatic neoplasms” published between June 1, 1996, and June 1, 2018. Studies were excluded if they had no measure of HRQOL and were included if they included men with either early, late, or combined stages of prostate cancer. Most articles were about men with localised disease, with good quality evidence collected in clinical trials and observational studies of specific cohorts. Few studies have focused on those men with locally advanced or metastatic prostate cancer. In the few studies separating results by stage, poorer HRQOL has been associated with later stages of disease. However, sample sizes tend to be small. Therefore, little is known about the effects of metastatic prostate cancer in men living with and after a diagnosis of advanced disease, especially compared with men with non-metastatic disease.
Added value of the study
To our knowledge, this is first study to compare, at scale, the HRQOL and functional outcomes of men living with localised and advanced metastatic prostate cancer. Data were collected for 35 823 men, with diagnostic stage information available for 30 733, of whom 23·4% had stage III disease and 12·8% stage IV disease. The population-based approach can be used to investigate the quality of survival of the increasingly prevalent group of men living with and beyond a diagnosis of prostate cancer. We identified that men with stage III and IV disease reported more problems, including those generic to health and those related to treatment, particularly androgen deprivation therapy (ADT) than did those with early stage disease. Poor sexual function was reported by most men, regardless of stage, and more than half of men reported not being offered any intervention or support for this problem. Despite specific functional morbidities, many men with prostate cancer self-reported their overall health to be similar to men in general population studies and a substantial proportion of men with stage IV disease (23·5%) reported no problems on any dimension of the EuroQol five dimensions (EQ-5D) questionnaire. These results highlight areas of unmet need and will be crucial in helping men make informed decisions about their treatment.
Implications of all the available evidence
Most men living 18–42 months after a diagnosis of prostate cancer can expect to experience similar HRQOL to men in the general population, including those with stage III disease and many of those with stage IV disease. Although sexual morbidity is common, most men are not offered helpful interventions or support. The evidence suggests that there are subgroups of men who would benefit from service improvements around sexual rehabilitation and measures to minimise the use of ADT. These measures could include wider use of intermittent ADT (rather than continuous use), the avoidance of unnecessary ADT (ie, for non-metastatic disease), and the use of shorter courses of neoadjuvant treatment (reduced from 3 years to 1 year). We collected data from men living up to 42 months after diagnosis. Men with stage IV disease are likely to experience deterioration in their HRQOL at some point following this period. Further evidence is needed to inform appropriate service provision for such patients in these later years.