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The health-related quality of life in patients with prostate cancer managed with active surveillance using the Expanded Prostate Cancer Index Composite survey: Systematic review and meta-analysis The health-related quality of life in patients with prostate cancer managed with active...
Abdelhafez, Ahmed; Hosny, Khaled; El-Nahas, Ahmed R.; Liew, Matthew
2022-04-03 00:00:00
ARAB JOURNAL OF UROLOGY 2022, VOL. 20, NO. 2, 61–70 https://doi.org/10.1080/2090598X.2021.2024368 ORIGINAL ARTICLE The health-related quality of life in patients with prostate cancer managed with active surveillance using the Expanded Prostate Cancer Index Composite survey: Systematic review and meta-analysis a b c a Ahmed Abdelhafez , Khaled Hosny , Ahmed R. El-Nahas and Matthew Liew a b Wrightington Wigan and Leigh Teaching Hospitals NHS Foundation Trust, Wigan, UK; James Cook University Hospital, Middlesbrough, UK; Urology and Nephrology Centre, Mansoura University, Mansoura, Egypt ABSTRACT ARTICLE HISTORY Received 27 May 2021 Objective: To examine the health-related quality of life (HRQoL) of patients with prostate Accepted 10 October 2021 cancer managed with active surveillance (AS) compared with those who receive definitive treatment using the Expanded Prostate Cancer Index Composite (EPIC) Survey. KEYWORDS Methods: We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Prostate cancer; health- (PRISMA) guidelines and searched PubMed and ScienceDirect for articles published between related quality of life; April 2010 and April 2020. Eligible studies reported original data on the HRQoL of men under- Expanded Prostate Cancer going AS for prostate cancer, including studies comparing AS to curative methods particularly Index Composite radical prostatectomy, radiotherapy, and brachytherapy. Results: We identified nine eligible articles, all were non-experimental observational studies of which seven were longitudinal and two were cross-sectional studies. The EPIC questionnaire was the main instrument used in all studies to assess the HRQoL. AS was noted to show the highest calculated mean score among management groups in all comparative studies at study endpoints including cross-sectional studies (95% confidence interval 2.17–5.75, P < 0.001). The maximum score deterioration for patients who were managed with AS in all studies was only 7.5 points (12.2%) after 2 years follow-up. AS had the least mean score decline among all management groups. Patients with a normal testosterone level were found to have high HRQoL scores. The number of prostate biopsies did not correlate with the HRQoL score. Conclusion: Patients with prostate cancer managed with AS report less impacts on their HRQoL compared to patients who receive definitive treatments. However, further high- quality research with long-term data are required to help both the patient and the physician in making a well-informed management decision. Introduction addressed by recent National Institute for Health and Prostate cancer is the most common cancer among men Care Excellence (NICE) guidelines as an alternative in the UK in 2017 accounting for 26% of new cancer test [5,6]. cases in males. Prostate cancer was the second most Men eligible for AS have a low tumour volume, low common cause of cancer mortality in the same year. malignant potential, and low PSA level at the time of Between 2013 and 2017, the estimated survival rate of diagnosis. Eligibility criteria from different guidelines men diagnosed with prostate cancer was 77.6% in and institutions can be found in the Table 1. England. PSA testing helped to improve prostate cancer Health-related quality of life (HRQoL) in prostate survival in the UK by three folds in the last 40 years [1,2]. cancer aims to measure the physical and psychological Radical prostatectomy (RP), external beam radio- elements required to assess patient status including therapy (EBRT), and brachytherapy (BT) are the main- urinary function, sexual function, bowel function, hor- stay treatment of localised prostate cancer. However, monal function, and associated bother [7–9]. these modalities have detrimental effects on the The key principle of AS is to minimise the potential patient’s quality of life [3,4]. Active surveillance (AS) deterioration of the physical HRQoL in patients with was developed to allow patients with indolent prostate prostate cancer compared to others who received defi - cancer to avoid the side-effects of definitive treatment, nitive treatment. However, anxiety resulting from without losing the chance of having active manage- delayed therapy that affects the mental health of AS ment when indicated [4]. In AS patients, prostate biop- patients’ needs to be reduced as well to provide sies are routinely used as a confirmatory tool; however, balanced management. Therefore, lots of studies that multiparametric MRI (mpMRI) of the prostate has been examine short- and long-term HRQoL have been CONTACT Khaled Hosny khaled_hosny2@hotmail.com James Cook University Hospital, Middlesbrough, UK Systematic review registration: PROSPERO registration number CRD42020205895 This article has been republished with minor changes. These changes do not impact the academic content of the article. © 2022 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 62 A. ABDELHAFEZ ET AL. Table 1. Eligibility criteria for AS according to different guidelines and institutions. Clinical Serum PSA level, Biopsy PSA Maximum cancer extent Guideline/Institution Grade stage ng/mL Gleason density Positive cores per core NICE Low T1–T2a 10 ≤6 NA NA NA Intermediate T2b 10–20 7 Royal Marsden T1–2 ≤15 ≤3 + 4 – 50% of total - cores European Association of Urology T1c–T2 ≤10 ≤6 NA ≤2 ≤50% (EAU) National Comprehensive Cancer Very low T1c ≤10 ≤6 ≤0.15 50% NA Network (NCCN_ Low T1–T2a ≤10 ≤6 NA NA AUA Low T1–T2a ≥10 ≤6 NA NA NA Intermediate T2b 10–20 7 High T2c 20 8–10 Memorial Sloan-Kettering Cancer T1–T2a ≤10 ≤6 – ≤3 ≤50% Center (MSKCC) conducted to help patients weigh the benefits and offer a satisfactory survey instrument and an ade- hazards of AS compared to other treatment strate- quate test–retest reliability for urinary, bowel, sex- gies [10]. ual, and hormonal domain scores [13–21]. The Prostate Testing for Cancer and Treatment The aim of the present work was to provide (ProtecT) trial was the first randomised clinical trial to a systematic review and meta-analysis of the studies compare treatment methods for localised prostate can- that employed the EPIC survey to evaluate the impact cer in the PSA era [11]. It represents Level 1 evidence on of AS on the HRQoL of patients with prostate cancer. the disease-specific HRQoL of the concurrent manage- The EPIC instrument was chosen particularly in this ment options of prostate cancer. The study reported review (as the main tool to assess the physical element) that AS had the least impact on disease-specific HRQoL as it is comprehensive and widely used in the litera- of patients with prostate cancer at 6 years of follow-up. ture, therefore it would allow a meaningful comparison RP caused the highest negative impacts on urinary between different studies. continence and sexual function, while EBRT was asso- ciated with more bowel dysfunction [3]. Plenty of HRQoL instruments have been developed Methods to address the components of prostate cancer QoL Literature search based on the domains of urinary, bowel, and sexual function. The Expanded Prostate Cancer Index The electronic databases of PubMed and ScienceDirect Composite (EPIC) survey is a QoL instrument that was were selected to examine the literature. Systematic developed from the original University of California- searches were done according to the Preferred Los Angeles Prostate Cancer Index (UCLA-PCI) by Reporting Items for Systematic Reviews (PRISMA) stan- a panel of experts of Urology oncologists, Radiation dards. Search of the databases used the keywords oncologists, survey researchers and prostate cancer ‘prostate cancer’, ‘cancer’, ‘active surveillance’, ‘health- nurses [3]. The original UCLA-PCI was enhanced by related quality of life’, and ‘quality of life’. The key- adding more items to assess extra urinary and bowel words were typed in each database in different com- symptoms, haematuria, and hormonal symptoms. binations that were chosen by the reviewers. The Symptom-specific bother items were added to the reviewers followed the same pattern in searching the questionnaire in order to address a bother scale. The databases to ensure the consistency of the data search. total score is calculated based on scores derived from A search of the databases took place during April 2020 each item from 0–100, with higher scores representing to capture relevant articles for the review. better QoL [12]. The other validated disease-specific instruments Eligibility criteria developed for HRQoL in patients with prostate can- cer, e.g. the Functional Assessment of Cancer The inclusion criteria of this review were articles pub- Therapy-Prostate (FACT-P) and European lished between April 2010 and March 2020, written in Organisation for Research and Treatment of Cancer English language, and focussed only on the HRQoL of quality of life questionnaire prostate specific 25-item men undergoing AS. Types of studies included were (EORTC QLQ PR-25), are limited in evaluating randomised and non-randomised, comparative, and obstructive and irritative voiding symptoms. They non-comparative, where data were collected either might be also lacking the assessment of both func- prospectively or retrospectively following the start of tions related bother and scores evaluating the primary intervention for prostate cancer or patient effects of hormonal therapy. The EPIC is thought to enrolment in an AS protocol. They should have ARAB JOURNAL OF UROLOGY 63 a sample size of ≥20 patients in each arm, reported Results HRQoL outcome measured using the EPIC survey with As shown in Figure 1, the search of the selected elec- a minimal 12-month follow-up. tronic databases yielded 429 articles. After exclusion of The population included adult men diagnosed with all ineligible articles, a thorough review of the remain- clinically localised prostate cancer, who had been man- ing articles yielded a final nine articles that met all the aged with either AS or active treatment including inclusion criteria for the present review. Five studies EBRT, BT, or RP. Patients without cancer were involved were included in the pooled analysis. Risks of bias are in some studies as a reference. The exclusion criteria shown in Figure 7. included commentaries, dissertations, theses, editor- All studies were non-experimental observational stu- ials, letters to the editor, books, and review articles. dies with seven longitudinal and two cross-sectional The results of the search were used to identify the studies. Six articles included comparative groups and articles that met the inclusion criteria then further the other three articles focussed only on AS patients. analysis was conducted to meet the objectives of the Two studies involved non-cancer groups as references. review. RevMan software version 5.4 [22] was used to The sample size in the studies ranged from 163 to 879. for a pooled analysis for five studies comparing AS to The racial distribution of the studies mostly consisted of definitive treatment. Figure 1 represents a flow chart of White men and revealed a significant lack of minority the process followed in the article’s selection. populations. For example, the racial distribution for the The primary outcome of the present review was study conducted by Parker et al. [23] was 86.1% White, specified as the HRQoL score in patients with low-risk 6.7% Black, 6.1% Hispanic, and 1.1% Asian, while the prostate cancer who were managed either by AS or race was not reported in three articles. active treatment measured using the EPIC survey. The main questionnaire utilised in those studies was Secondary outcomes were the domains of prostate the EPIC, either the complete version (EPIC-50) or the cancer-specific HRQoL such as urinary, sexual, and short version (EPIC-26); however, other additional bowel function. questionnaires were used such as Short-Form 36 Figure 1. Data flow chart of article selection process. 64 A. ABDELHAFEZ ET AL. Health Survey Questionnaire (SF-36) and SF-12 in group but was not clinically significant. There was no seven studies. Other questionnaires were used such difference in the mental score in all groups. as the State-Trait Anxiety Inventory (STAI) and Mishel Interestingly, the reported level of generic anxiety Uncertainty Illness Scale (MUIS). Five of the nine arti- was similar in the four groups. cles focussed on the combination of the HRQoL factors The third study by Egger et al. [26], aimed at asses- of sexual, bladder, and bowel function, and anxiety sing the long-term psychological impact of conserva- and depression. Two of the remaining four articles tive treatment of prostate cancer on patient’s HRQoL. focussed on sexual dysfunction and testosterone They underwent a 10-year follow-up of low-risk pros- levels, and the other two articles discussed HRQoL tate cancer patients who were managed with AS/ related anxiety and psychological well-being. watchful waiting (WW) in comparison to other groups managed initially with either RP, RT/high-dose rate (HDR) BT or low-dose-rate (LDR) BT. Comparative studies (Figures 3 and 4) In this study, AS/WW patients had equivalent long- term urinary bother and sexual health scores to AS vs RP vs EBRT vs BT patients who received immediate active treatment A cross sectional study by Sureda et al. [24] randomly but with less bowel bother than RT/HDR BT patients matched two different groups of patients according to and better urinary incontinence than RP patients. risk group, age, and time from start of treatment until Initially, AS/WW patients had higher levels of distress completion of the survey. A group of 99 patients on AS than other groups. However, in general, AS/WW for low-/intermediate-risk prostate cancer diagnosed patients have similar long-term psychological QoL as between January 2008 and June 2015 was matched the active treatment group. In this study, it was noted to an equal group from the Spanish Multicentric Study that a high percentage of patients under AS/WW (43%) of Clinically Localised prostate cancer who underwent received treatment during follow-up. active treatment between 2003 and 2005. The AS group reported lower physical and mental health score especially in bodily pain and vitality on AS vs EBRT short-term follow-up, which was explained by repeated Benarji et al. [27] recruited 60 patients treated with prostate biopsies. The AS group reported better urine EBRT and 103 patients managed with AS. This control scores compared to RP. The AS group at longitudinal study had a mean follow-up of ≤2.5 years had better sexual function scores compared 44 months for EBRT and 32 months for AS using to all other groups but significantly better than RP. Other the EPIC and SF-36 questionnaires administered at urinary and bowel function domains were equal in all baseline, every 3 months in the first year, then groups. every 6 months. The RP group reported better physical health dimen- They reported significantly worse bowel function sions than AS for <2.5 years but no difference at at year 1 and 2 in the EBRT group. Both groups had similar >2.5 years. While in the mental dimensions, the only bowel function and bother scores at 3 years. The EBRT difference was in the vitality score that was worse in the group had a significant decline in the physical health AS group who are aged ≤70 years or monitored for score in the first 2 years after treatment. While the sexual ≤2.5 years. function score showed an insignificant decline at the 2- In another cross-sectional study by Venderbos et al. and 3-year follow-up. It was noted that AS patients had [25], they used an age-matched reference group of a remarkable decline in urinary function at year 3. men without prostate cancer. Participants in the study were recruited from the European Randomized AS versus RP Study of Screening for Prostate Cancer (ERSPC) trial Jeldres et al. [9] recruited 228 patients who underwent and from clinical practice with low-risk prostate cancer. RP and 77 patients managed with AS. Patients were Questionnaires were mailed to the patients and all aged ≤75 years with low-risk prostate cancer. The EPIC patients had a minimum follow-up of ≥4 years. and SF-36 questionnaires were used at baseline and at The AS and RT groups reported better urinary func- different intervals up to 3 years. tions than the RP group. The AS and reference groups The RP group had lower urinary function scores up reported less urinary incontinence than the RT and RP to 3 years, with worse urinary bother scores in the first groups. The RT patients reported less urinary inconti- 18 months, but equivalent to AS at 2 and 3 years. nence than the RP patients. Urinary bother and bowel Bowel function and bother scores became equal to function were similar in the four groups. The reference AS at 2 years. There was no difference in hormonal group reported no statistically significant difference in functions. The AS group had better sexual function comparison to AS group for urinary continence and than the RP group at all times despite some improve- sexual functioning. Sexual function was highest in the ment in the RP group at 6 months and 2 years but AS group and lowest in the RP group. The AS group remained lower than AS at 3 years. reported better physical summary scores than the RT ARAB JOURNAL OF UROLOGY 65 The SF-36 questionnaire outcome reported lower They reported that older age and obesity were physical component score for RP at 3 months but associated with lower scores. Testosterone level is sig- equivalent to AS at 1 and 2 years, with no significant nificantly correlated to patient satisfaction at 6 months, difference at 6 months. However, mental scores did and increased testosterone level might be correlated not show any significant difference between the two to improved HRQoL in AS patients for at least 2 years. groups. Patients’ stratification by testosterone level at enrol- ment helps to identify patients at risk of low HRQoL. In addition, they reported lower scores for urinary incon- AS negative prostate biopsy tinence, urinary irritation, sexual and hormonal func- Pham et al. [28] compared 89 patients diagnosed with tions with lower testosterone levels; however, only low-risk prostate cancer and managed with AS to incontinence was statistically significant. another group of 420 patients who had negative pros- tate biopsies. The EPIC and SF-36 surveys were con- AS and psychological function ducted at baseline (before or after biopsy) then at 12, Parker et al. [23] studied the impact of illness uncer- 24 and 36 months after biopsy. tainty, anxiety, fear of progression on HRQoL in patients Bowel functions were better in the AS group at with prostate cancer under AS. Different questionnaires 1 year but no significant difference afterwards. The were used in this study to evaluate the psychological AS group also showed a slight decline in urinary func- well-being of the patients including STAI, MUIS, SF-12, tion and mental health, but it was insignificant and did and Memorial Anxiety Scale for Prostate Cancer. Patients not show meaningful clinical difference at 3 years. were asked to complete questionnaires at the time of enrolment and every 6 months up to 30 months. They reported that AS patients can maintain high Non-comparative studies (Figures 5 and 6) HRQoL with minimal decline except for sexual function AS and sexual function that decreased over time, but not clinically significant. Pearce et al. [29] did a prospective study of 195 Older age was associated with lower Physical patients with low-risk prostate cancer on AS aiming Component Scale (PCS), sexual satisfaction scores, at evaluating the relationship between repeat prostate while higher BMI was associated with poorer hormo- biopsies and sexual dysfunction to predict the predis- nal, satisfaction, Physical Component Scale and Mental posing factors for sexual dysfunction. Patients did not Component Scale scores. The number of prostate biop- receive any prior treatment for prostate cancer or sies did not affect the sexual functioning score. Illness prostate medications other than finasteride or dutaste- uncertainty decreased over time in AS starting from ride. Participants completed questionnaires at enrol- 12 months after study enrolment. Anxiety was higher ment followed by a confirmatory biopsy, PSA and DRE at 12 and 24 months and lower at 18 and 30 months and this was repeated every 6 months for 2 years with subsequent biopsies done every 2 years unless indi- Quantitative assessment and main analysis cated by abnormal PSA or DRE. They reported a decline in sexual score over the first We conducted a limited meta-analysis only on the five 24 months. It was noted that length of time on AS, comparative studies that compared AS to the defini - older age at enrolment, and diabetes, were indepen- tive treatment options including RP, EBRT, and BT. The dent risk factors for sexual dysfunction. While anxiety, studies included 2599 participants with different com- body mass index (BMI), and number of biopsies did not parisons of active treatments to AS. RevMan software predict sexual dysfunction. Interestingly, higher base- version 5.4 [22] was used for the pooled analysis of the line PSA was associated with a more rapid decline in five studies. An index I between 0% and 40% was sexual function. defined as not important heterogeneity, I between Cohen et al. [30] prospectively evaluated the impact of 30% and 60% was defined as moderate heterogeneity, low testosterone levels on HRQoL of patients with pros- I between 50% and 90% was defined as substantial tate cancer on AS. They interviewed 223 patients with heterogeneity, and I between 75% to 100% is defined a mean age of 66.8 years who had low-risk/favourable- as considerable heterogeneity. Heterogeneity was intermediate-risk prostate cancer. Questionnaires were measured using the chi-squared statistics (P = 0.05). answered at enrolment and every 6 months during the The AS group was noted to show the highest calcu- first 2 years of AS and annually thereafter. They defined lated mean score among management groups in all low testosterone level as <300 ng/dL, low–normal 300– comparative studies at study endpoints (95% CI 2.17– 400 ng/dL, and normal ≥400 ng/dL according to the 5.75; P < 0.001). There was no heterogeneity I = 0%, Endocrine Society Clinical Practice Guidelines that con- P = 0.89. sider that a testosterone level of ˂300 ng/dL represents A completed summary of the pooled analysis table deficiency if accompanied by signs and symptoms of and forest plot of the comparative studies can be hypogonadism. found in Figure 2. 66 A. ABDELHAFEZ ET AL. Figure 2. Pooled analysis table and Forest plot of the comparative studies. Assessment of risk of bias and confounding factors of information or uncertainty over the potential for Two review authors independently assessed the risk of bias. Disagreements between the reviewers were bias of each included study against key criteria: ran- resolved by discussion and consensus. dom sequence generation, allocation concealment, blinding of participants, personnel, and outcome; incomplete outcome data, selective outcome report- Discussion ing and other sources of bias in accordance with meth- Urinary function scores were generally worse in the ods recommended by The Cochrane Collaboration [8]. surgically treated groups among all other groups in all Additional items were added to assess the risk of con- studies and that was probably related to the highest founders. Those confounders were developed by prevalence of urinary incontinence. Urinary bother experts from the European Association of Urology scores were not as low as urinary function. Urinary Prostate Cancer Guideline Panel. The selected con- bother was even better in the surgical group than AS/ founding factors consisted of age, baseline QoL score, WW in the Egger et al. [26] study, which is explained by baseline Gleason score, and comorbidities. The older age in the WW group who are more bothered by author’s judgements were categorised as either high other urinary symptoms. In patients under AS, urinary risk, low risk, or unclear, which might be related to lack Baseline EPIC score 86.7 86.5 84.2 84.2 83.2 81.6 81.5 80.6 78.4 72.8 Benarji et al Egger et al Pham et al Jelders at al AS RP EBRT/RT LDR non-cancer Figure 3. The mean HRQoL scores at baselines of the comparative studies. Follow up EPIC scores 83.4 81.6 82.6 80.5 80.5 81.3 80.2 78.1 77.8 78.3 76.5 76.1 74.5 75.2 72.1 68.9 67.2 61.9 Bnarji et al Egger et al Pham et al Jelders et al Surenda et al Vanderbos et al AS RP RT/HDR LDR/BT Non-cancer Figure 4. The mean HRQoL scores at the comparative studies end-points. ARAB JOURNAL OF UROLOGY 67 up in all studies even in the non-cancer group of Pham et al. [28]. This was accompanied with a similar drop in Baseline scores the sexual bother. Parker et al. [23] reported that older age has a negative influence on sexual function and satisfaction. Conversely, Korfage et al. [31] did not find a significant reduction in sexual bother among older- 82.6 aged patients. This is explained by ‘response shift’, which means that those men underwent cognitive 61.4 adaptation and accepted changes in their sexual func- tioning being an inevitable consequence of prostate cancer [31–33], which also explained the unexpected result of the Pham et al. [28] study. The correlation between prostate biopsy and sexual dysfunction is controversial, as some studies reported no adverse effects of prostate biopsy on erectile func- tion, while other studies indicate long- and short-term sexual dysfunction as a result of repeated prostate biopsies [34–36]. Pearce et al. [29] did not notice a correlation between the number of biopsies, the Pearce et Parker et total Gleason score, and sexual dysfunction. However, their study was limited by the relatively small number al al of biopsies due to the short follow-up; as ~60% of patients had only one biopsy, therefore the impact of multiple biopsies could not be evaluated properly. The most significant drop in the HRQoL score AS among all management groups was in the EBRT Figure 5. The mean HRQoL scores during AS at baselines of group. Egger et al. [26] reported that the mean score the non-comparative studies. dropped by 16.5 points (21%) in the 10-year follow-up. Whilst Pearce et al. [29], reported that the maximum score deterioration for patients managed with AS was functions scores are equivalent to those of non-cancer only 7.5 points (12.2%) after a 2-year follow-up. AS had groups and better than patients scores in the curative the least mean score decline among all groups. groups. Patients with normal testosterone levels are found to Patients undergoing treatment with RT had the have better scores than others with low or low–normal highest prevalence of bowel dysfunction and as levels. a result the worst scores in comparison to other treat- AS showed the best mean total score in all com- ment groups or non-cancer patients. The only excep- parative studies except in in the Egger et al. [26] study tion was the LDR BT group in the Egger et al. [26] study where LDR/BT had a better mean score. However, LDR/ who recorded the highest score, which suggests that BT also showed a significant deterioration of the score LDR BT has the least long-term impact on bowel with 14.4-point drop (16.6%) from the baseline score. function. The AS baseline score in the same study was lower Patients managed with AS had the best sexual func- than LDR/BT by 13.7 points and it dropped at the study tion scores in comparison to patients receiving active end-point with only 3.9 points (5.3%). The LDR/BT high treatment. However, the score dropped during follow- End point scores 100 87.7 85.2 83.8 53.9 Pearce et al Parker et al Cohen et al* AS low low normal normal Figure 6. The mean HRQoL scores during AS at the non-comparative studies endpoints. 68 A. ABDELHAFEZ ET AL. Figure 7. Risk of bias and confounding assessment. Red colour indicates high ROB, yellow uncertain ROB, and green low ROB. ROB, risk of bias. score at the study end-point might be explained by the expected. The level of anxiety and uncertainty seems to small sample size (32 patients), therefore this should be easing off as time passes on AS. The impact on be interpreted cautiously. sexual function during AS is clearly caused by some In general, it can be observed that patients on AS factors that are unrelated to prostate cancer such as perform well in most of HRQoL aspects, especially urin- old age, diabetes mellitus, obesity, and testosterone ary and bowel functions. The physical and mental func- level. tions of AS patients can be affected by repeated The available evidence has shown that the use of prostate biopsies during follow-up; however, with the HRQoL questionnaires before and during AS is extre- emergence of mpMRI in the new guidelines for mon- mely useful in the clinical evaluation of the patients itoring as an alternative to repeat prostate biopsies, the and understanding their needs and expectations. It impact will be reduced significantly. It does not seem would be good practice to discuss the impact of AS that AS patients are suffering from more anxiety than on the patient HRQoL in comparison to the curative other patients receiving curative treatment as would be treatment options during the counselling process ARAB JOURNAL OF UROLOGY 69 before starting the patients on AS. The authors recom- ORCID mend the use of HRQoL questionnaires, such as the Ahmed R. El-Nahas http://orcid.org/0000-0001-7366-7306 EPIC, before and after the start of AS. Some limitations of the present study should be noted. First, only five of the nine studies included in References this systematic review were comparative studies; [1] Moher D, Liberati A, Tetzlaff J, et al. Preferred reporting therefore, we had to make a limited meta-analysis on items for systematic reviews and meta-analyses: the the comparative studies. Another limitation is the rela- PRISMA statement. PLoS Med. 2009;6:e1000097. tively small number of cases in the included studies [2] Cancer Research UK. Prostate cancer statistics. https:// and the relatively short follow-up of patients, which www.cancerresearchuk.org/health-professional/can did not exceed 36 months in most of the studies. Our cer-statistics/statistics-by-cancer-type/prostate- future recommendation is to use other electronic data- cancer#heading-Zero [3] Donovan JL, Hamdy FC, Lane JA, et al. Patient-reported bases not used in this systematic review to look at outcomes after monitoring, surgery or radiotherapy more results from different studies in literature. for prostate cancer. N Engl J Med. 2016;375:1425–1437. [4] Sanda MG, Dunn RL, Michalski J, et al. Quality of life Conclusion and satisfaction with outcome among prostate-cancer survivors. N Engl J Med. 2008;358:1250–1261. The evidence provided in this review shows that AS [5] Dasgupta P, Davis J, Hughes S. NICE guidelines on patients have the highest HRQoL EPIC scores in con- prostate cancer 2019. BJU Int. 2019;124:1. trast to other patients treated with active treatment [6] Walton Diaz A, Shakir NA, George AK, et al. Use of serial multiparametric magnetic resonance imaging in the modalities. Patients with prostate cancer managed management of patients with prostate cancer on with AS reported less impacts on their HRQoL com- active surveillance. Urol Oncol. 2015;33(5):202-e1– pared to patients who received definitive treatments. 202.e7. Further high-quality research with long-term data is [7] Acar C, Schoffelmeer C, Tillier C, et al. Quality of life in required to help both the patient and the physician in patients with low-risk prostate cancer. A comparative making a well-informed management decision. retrospective study: brachytherapy versus robot assisted laparoscopic prostatectomy versus active surveillance. J Endourol. 2014;28:117–124. [8] Cooperberg MR, Carroll PR. 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