UroToday.com – In this ever-evolving health care environment, comprehensive clinical outcomes evaluation is increasingly important. While measurement of morbidity, mortality, and survival data is important, they cannot be considered the only results of consequence. Measurement of quality of life is a modern day benchmark. For many patients and their families, quality of life trumps quantity.

Individuals diagnosed and seeking treatment for cancer want to know how their life will be after disease intervention. Oftentimes when counseling a patient before treatment, the full perspective on how life will be in the aftermath is incompletely or imprecisely explored. Also regrettably, oftentimes quality of life analyses are performed more for research purposes than to benefit the patient.

Quality of life, though difficult to define, has become an increasingly important therapeutic goal. Much of the research examining the burden of cystectomy on HRQOL is retrospective, methodologically flawed, or uses non-validated instruments. Recent endeavors such as the Bladder Cancer Index (BCI) and FACT-VCI(Vanderbilt Cystectomy Index) have sought to provide effective validated means to measure QOL in bladder cancer patients [1-2]. These authors should be commended for their work.

Radical cystectomy remains the surgical standard for locally invasive bladder cancer and increasing numbers of robotic cystectomies are being performed worldwide. This analysis represents the first study to examine quality of life after robotic cystectomy and urinary diversion. The short-term data using the FACT-BL questionnaire revealed recovery of quality of life metrics three months after surgery with continued improvement at a six-month evaluation.

After robotic cystectomy, patients often described an ability to rapidly regain functional capacity and perform physical activity. Objectively this was reflected in the return to baseline in the Functional and Physical FACT domains three months after surgery. Reference to open cystectomy series by Kuzaksizoglu and Karvinen illustrates how quality of life recovery can be boosted through functional enhancement [3-4]. Kuzaksizoglu determined that quality of life measures return only after 12 months, as a result of delay in functional improvement. Karvinen reported an association between exercise and quality of life. The potential for robotics to assist with the recovery period thus lies in allowing quicker return to baseline levels of functioning and exercise.

In an open series with the same questionnaire, Mansson et al’s Swedish cohort had similar preoperative FACT-G scores, 86 vs. 84 from the current study [5]. Those scores declined following surgery even after one year. The trend in our study is reversed after one month with recovery in quality of life scores. Further controlled comparative studies to the open standard are needed to ascertain a statistical and clinical difference. Longer term follow-up will determine whether improvement is sustained. Also, quantification of exercise can be useful for determining a cause-effect relationship.

References:

1. Gilbert SM, Wood DP, Dunn RL, Weizer AZ, Lee CT, Montie JE, Wei JT. Measuring health-related quality of life outcomes in bladder cancer patients using the Bladder Cancer Index (BCI). Cancer. 2007 May 1;109(9):1756-62.
2. Cookson MS, Dutta SC, Chang SS, Clark T, Smith JA Jr, Wells N. Health related quality of life in patients treated with radical cystectomy and urinary diversion for urothelial carcinoma of the bladder: development and validation of a new disease specific questionnaire. J Urol. 2003 Nov;170(5):1926-30.
3. Karvinen KH, Courneya KS, North S, Venner P. Associations between exercise and quality of life in bladder cancer survivors: a population-based study. Cancer Epidemiol Biomarkers Prev. 2007 May;16(5):984.
4. Kulaksizoglu H, Toktas G, Kulaksizoglu IB, Aglamis E, Unlüer E. When should quality of life be measured after radical cystectomy? Eur Urol. 2002 Oct;42(4):350.
5. Månsson A, Al Amin M, Malmström PU, Wijkström H, Abol Enein H, Månsson W. Patient-assessed outcomes in Swedish and Egyptian men undergoing radical cystectomy and orthotopic bladder substitution–a prospective comparative study. Urology. 2007 Dec;70(6):1086-90.

Written by Bertram Yuh, MD as part of Beyond the Abstract on UroToday.com

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