8. Rehabilitation – Prostate Cancer

Background information

Re: Recommendation 8.1 and Statement 8.2

In Germany, the IXth Book of the Social Code (SGB IX) legally prescribes the right to rehabilitation benefits. There is a legal entitlement to benefits for participation (§ 4) with the aim of averting, eliminating, reducing, preventing aggravation, mitigating consequences, avoiding/mitigating other social benefits, securing or facilitating participation in working life and life in society, holistically promoting personal development and enabling as independent and self-determined a lifestyle as possible.

The effectiveness of a differentiated multimodal therapy concept has been proven for inpatient specialist uro-oncological rehabilitation by a prospective study. Overall, all parameters of physical performance, all psychosocial scales of the quality of life measurement instrument QLQ-C30 of the EORTC, all incontinence parameters, and the impairment due to erectile dysfunction are significantly improved by inpatient follow-up treatment [985]. This efficacy has not yet been demonstrated with outpatient approaches. A randomized comparison of inpatient and outpatient rehabilitation is pending.

 

Re: Recommendation 8.3

The working group Rehabilitation of Urological and Nephrological Diseases of the Academy of German Urologists has formulated necessary structural requirements (personnel, spatial and technical equipment) and characteristics of process quality for the implementation of urological rehabilitation measures to ensure the quality of outcomes [986]. Urological expertise is required with regard to therapeutic options and follow-up treatment concepts, since post-interventional functional disorders and treatment-specific complications require immediate specialist treatment. Since primary information on cancer and therapeutic options often occurs while the patient is still in the "acute shock stage", it is often only partially absorbed. In inpatient rehabilitation, lectures, discussion groups, one-on-one meetings with doctors, psychologists and social workers also have the task of reworking and processing the information in the sense of consolidation, classification, evaluation, processing of experiences, and gaining perspectives. Health education and psychoeducational aspects are not integrated with a "raised forefinger", but as an attractive option to become an acting subject again. In the context of encouraging participation, contacts with self-help groups can also be facilitated, with which there is often good cooperation. The information needs of rehabilitation patients in the follow-up treatment procedure after radical prostatectomy are significantly reduced from 3.03 to 0.10 on a Goal Attainment Scale (from 0 = no information needs to 6 = very strong information needs) by the concerted measures within three to four weeks [985].

 

Re: Recommendation 8.4

Postoperative urinary incontinence initially reduces the patient's quality of life in a decisive way. Thus, the basis of the rehabilitation process is a functional and psychosocial diagnosis in order to achieve a reliable reproducible quantification of the functional disturbances and impairments of participation subjectively and objectively. Rehabilitation-specific questions must be taken into account: To what extent do ability impairments result in everyday life and occupation, what are the effects on performance [987]? A sensible therapy concept for the elimination of postoperative urinary incontinence integrates the current state of knowledge on anatomy, physiology, and pathophysiology of the lower urinary tract in men [988], [989]. Specific physiotherapy continence training should be provided in group and individual exercises, taking into account comorbidities and pain conditions. A Cochrane review identifies moderate-quality evidence for the benefit of postoperative pelvic floor muscle training compared with a control intervention without the same at one year (incontinence rates 10% vs. 32%, RR 0.32, 95%CI 0.20 – 0.51) [979]. Another meta-analysis (2017 update search) pooled studies that also used pelvic floor training primarily designed for women, which is not translatable to male anatomy, and finds no efficacy of preoperative pelvic floor training as an adjunct to postoperative training [980]. In higher grade postoperative incontinence, bladder function stabilizing medication in addition to continence training shows significant benefits [990]. Preferably for third-degree urinary incontinence, electrostimulation therapy is also given [991]. A meta-analysis (update search 2017) failed to find any benefit of electrical stimulation in addition to pelvic floor muscle training [981]. A Cochrane review analyzed several conservative interventions, including those mentioned above, and also failed to find a benefit in terms of incontinence rates – regardless of treatment, symptoms improved over time. The review identified data from small studies suggesting that electrostimulation or external magnetic innervation or combinations thereof may be effective [979]. If there is insufficient improvement in urinary incontinence, endoscopic video biofeedback sphincter training is used to provide optimal training [992]. A randomized three-arm prospective study in third-degree incontinent patients impressively confirmed the significant efficacy of electrical stimulation as an adjunct to continence training depending on actual device use, with perineal stimulation with surface electrodes showing significant advantages over a rectally applied probe [993]. The effectiveness of a differentiated multimodal therapy concept has been proven for inpatient specialist uro-oncological rehabilitation. Overall, multimodal continence training in the context of inpatient rehabilitation significantly improves all incontinence parameters [985].

 

Re: Recommendation 8.5

One year postoperatively, after increasing recovery of continence and quality of life, erectile dysfunction is the primary problem reducing quality of life, especially with regard to self-image and partnership. In Germany, there is a discrepancy in the assessment of the care of patients with erectile dysfunction after radical prostatectomy by urologists versus patient surveys. Patients see a greater need for education and therapy here [994], [995]. During inpatient specialist urological rehabilitation, there is a high need for counseling and treatment for erectile dysfunction, independent of age and various morbidity factors. In a study by Otto and Dombo, almost all patients (95%) took advantage of initial counseling in the form of a specialized lecture. Individual sexual health counseling occurred in 68% of patients, 71% of whom tested an aid. Again, 69% of these patients achieved successful rehabilitation regarding their erectile dysfunction [985]. Research by Otto and associates showed a desire for therapy in 53% of patients. In terms of therapy, 11% preferred vacuum erection therapy, 21% preferred erectile tissue autoinjection therapy, and 74% preferred therapy with a phosphodiesterase-5 inhibitor. An inadequate effect was documented in 36% of patients, and a good effect was documented in 54% of our own patient population [985].

Since the introduction of anatomic radical nerve-sparing prostatectomy, a decisive change in the current radical surgical technique has been initiated. This surgical procedure has reduced the incidence of therapy-related impotence in specialized centers from previously nearly 100% to approximately 19% to 40%. The introduction of selective PDE-5 inhibitors has resulted in a paradigm shift in the treatment of erectile dysfunction. With bilateral preservation of the cavernous nerve bundles, 56% of preoperatively potent men were able to have intercourse without an aid. Adding men who respond positively to phosphodiesterase-5 inhibitors, success is achieved in up to 90% [717], [996], [997], [998], [999], [1000].

Results from two small randomized trials (n=33 and n=52) suggest improvement in several endpoints including regaining potency with specific physiotherapy training plus electrostimulation or biofeedback [982], [983]. Based on this evidence, the author group also makes a weak recommendation for these or other combinations. The decision on which aid to use is individual and also depends on concomitant internal diseases (CHD, hypertension, and CAD) and their drug therapy, which calls for close interdisciplinarity in rehabilitation.

Practical testing of the procedure under urological supervision during inpatient rehabilitation is important. Furthermore, there is a preference for drug therapy for recovery of erectile function and interim preservation of erectile tissue elasticity [985]. Previous studies favored a low, every-evening dose of a phosphodiesterase-5 inhibitor for rehabilitation of erectile dysfunction [1001], [1002]. According to recent studies, as-needed use of the phosphodiesterase-5 inhibitor vardenafil appears to be at least equivalent in effectiveness [1003], [1004].

In addition to comprehensive information about the existing treatment option, the possibility of being able to practically test this procedure until it is safely mastered, in order to prevent the psychological stress reaction that clearly occurs in long-term observation, is decisive for the choice of the most suitable treatment procedure for the individual [985], [1005].

 

Re: Recommendation 8.6

Psychosocial care of cancer patients (and their relatives) is considered an important component of comprehensive oncological treatment. In addition to survival, maintaining or restoring the quality of life of patients, some of whom have to cope with severe impairments due to disease and treatment, is a focus of oncological treatment [1006], [1007]. Impairments primarily affect the following areas: physical problems (symptoms, pain, loss of physical integrity), functional disorders (restriction of performance, questioning of social roles), emotional well-being, sexuality/intimacy, social participation [1008], [1009].

The nature and extent of the individual burden are not only dependent on disease factors, but also on personal and environmental factors such as individual resources, disease management strategies, and the extent of social support [1010]. Early diagnosis of mental disorders resulting from illness and therapy or occurring simultaneously and their treatment is essential [1011] (see also background text to Recommendation 10.6). Recommendations for determining the need for psycho-oncological care and information about suitable instruments can be found in the S3 guideline on psycho-oncological diagnosis, counseling and treatment of adult cancer patients ([1012], http://www.leitlinien-programm-onkologie.de/leitlinien/psychoonkologie/).

Particularly critical phases in the course of the disease include the end of primary treatment, and the subsequent period of waiting for long-term therapeutic success [1013]. During this time, rehabilitation offers support for prostate cancer patients. Anxiety, especially fear of progression, depressiveness, and adjustment disorders are common psychological symptoms accompanying cancer. The subjective psychological burden is independent of the objective findings [1014].

The early recognition of psychological disorders in oncological care and the provision of a broad and low-threshold psychosocial support offer is of particular importance, because co-morbid psychological disorders in cancer patients not only complicate their treatment, but also have a detrimental effect on compliance and lead to poorer medical treatment outcomes [1015]. Such an offer can be facilitated during rehabilitation [1016] and may represent a low-threshold social support for affected patients that is less threatening to the masculine role and therefore easier to accept, due to the remoteness from home and the thus lower experienced control within the social environment. For prostate cancer patients, such psychosocial support linked to sex therapy counseling can be an essential aid to coping with the disease [1017], [1018].

A meta-analysis of psycho-oncological studies shows that psycho-oncological interventions reduce psychological distress and have positive effects on anxiety, depression, helplessness, pain, occupational impairment, physical and social activities, and quality of life, among others (see [1011]). In addition, a study by Küchler et al. demonstrates a survival benefit for cancer patients from a psychotherapeutic support program during their acute treatment [1019].

Inpatient rehabilitation enables early provision of psycho-oncological support for prostate cancer patients, which is rarely guaranteed in the outpatient setting close to home due to lack of capacity and long waiting times [1020].

Re: Statement 8.7 and Recommendation 8.8

Rehabilitation measures may also be indicated during hormone deprivation treatment. The objectives for these patients are essentially the same as those after prostatectomy and radiotherapy, and also include the targeted treatment of the specific side effects of tumor treatment by means of androgen deprivation (see Table 20).

Here, the goals of medical training/exercise therapy are avoiding or reducing fatigue, improving body composition (fat, muscle, bone mass), psychological stabilization, and thus an improvement in the quality of life, while taking into account the respective existing limitations and tumor-related lesions of the patients.

The evidence on the effectiveness of a function-oriented exercise program on the physical and psychological performance of patients after and during androgen deprivation, after radiotherapy, and in the presence of existing metastatic disease in prostate cancer is currently weak (heterogeneous studies, small sample sizes). Nevertheless, it has been proven in other contexts that physical activity in any form has a positive influence on both physical and psychological condition and thus on the known consequences of hormone deprivation treatment as well as on quality of life. The three most recent reviews based on randomized trials consistently show significant improvements in the endpoints of fatigue and quality of life, despite limited methodological quality of the included studies [1021], [1022], [1023].

Re: Recommendation 8.9

The explanations to the previous recommendations suggest that rehabilitative measures not only help to restore performance before the disease, but can also be helpful for dealing with a non-curable disease. Although there is no evidence to date on the benefit of rehabilitative measures in the palliative care situation, appropriate procedures should also be recommended to these patients, while taking into account their individual symptoms.