Real-world data: High rates of complications and unplanned hospital admissions in mHSPC

Seventy percent of patients with metastatic hormone-sensitive prostate cancer (mHSPC) experience disease-related complications, while 59 percent require ≥1 unplanned hospital admission during the course of disease, a study by the Chinese University of Hong Kong (CUHK) has shown.

Given the reverse stage migration observed in prostate cancer (PCa) diagnosis in the US following a decrease in prostate-specific antigen (PSA)–based screening in the past decade, the researchers said their findings indicate a need for reconsidering the role of PSA-based PCa screening in terms of preventing disease-related morbidity and mortality. [Nat Rev Urol 2017;14:26-37; Urol Oncol 2016;34:335.e21-e28; J Natl Cancer Inst 2021;113:64-71; JAMA Oncol 2017;3:705-707; Hong Kong Med J 2023;doi:10.12809/hkmj219523]

The CUHK study included 100 consecutive patients (median age, 74 years; median serum PSA level at diagnosis, 202.5 ng/mL) diagnosed with mHSPC between January 2016 and August 2017 at five hospitals (Alice Ho Miu Ling Nethersole Hospital, North District Hospital, Pok Oi Hospital, Prince of Wales Hospital, and Tuen Mun Hospital) that formed the Hong Kong Prostate Cancer (HK-CaP) study group. Ninety-nine patients received androgen deprivation therapy, while 17 also received chemotherapy. The patients’ data were analyzed to investigate the incidence and types of complications that occur during the course of mHSPC.

Over a median follow-up of 32.9 months, disease-related complications occurred in 70 percent of the patients. Skeletal-related events were the most common, with bone pain reported in 41 percent of patients. Among patients with bone pain, 85 percent (n=35) required regular analgesics, 29 percent (n=12) required opioid analgesics, 49 percent (n=20) required palliative radiotherapy for bony metastases, 51 percent (n=21) developed pathologic fractures, and 20 percent (n=8) had cord compression.

The second most common complication was retention of urine secondary to prostatic obstruction, reported in 28 percent of patients. Of these patients, only 25 percent (n=7) were able to discontinue urethral catheter use, 36 percent (n=10) required endoscopic prostatic surgery, and 39 percent (n=11) required long-term urethral catheter use.

Among 15 patients who developed ureteral obstruction, 27 percent (n=4) required ureteral stenting, while 27 percent (n=4) required long-term nephrostomy drainage.

Other complications included anaemia (41 percent), deep vein thrombosis (4 percent), and psychiatric problems (4 percent).

In addition, 59 percent of patients had ≥1 unplanned hospital admission during the course of disease (1–5 unplanned admission[s], 43 percent; 6–10 unplanned admissions, 10 percent; >10 unplanned admissions, 6 percent) – much higher than the 6.5 percent readmission rate among patients with localized PCa observed for >5 years in Hong Kong. [Hong Kong Med J 2020;26:95-101]

The most common indications for unplanned hospital admissions were skeletal-related events (bone pain, fracture, and fall; 19 percent), urinary complications (haematuria, ureteric obstruction, and bladder outcome obstruction; 16 percent), and sepsis (urosepsis, pneumonia, and infection of other origin; 28 percent).

According to the researchers, these real-world data suggest a need to reconsider management approaches for patients with mHSPC. “The role of PSA-based screening in PCa should [also] be reconsidered,” they added.

Previous discussions of PSA-based screening mainly focused on survival benefits as well as harms associated with screening procedures and overtreatment of low-risk disease. [Cochrane Database Syst Rev 2013;1:CD004720]

“There has been minimal consideration of the potential advantages of screening in terms of preventing disease-related complications, the negative effects of advanced disease on quality of life … [and] the potential financial implications of managing advanced PCa and its complications,” the researchers pointed out. “Earlier diagnosis of PCa may help patients avoid progression to advanced or metastatic disease, thereby reducing suffering … and its treatment-related complications.”