Prostate-specific symptoms of prostate cancer in a German general population

Abstract

Predominant symptoms in prostate cancer patients are erectile dysfunctions and urinary problems. As decreases of these functions can be attributed to disease and treatment but also to age-related decreases, we conducted a study on a German reference population measuring general quality of life (QoL) as well as prostate-specific symptoms. In cooperation with a German health insurance company, 3000 questionnaires were mailed to a randomly selected sample of men aged 45-75 years. Questionnaires used were the EORTC QLQ-C30 and a prostate-specific module (PSM). One thousand one hundred and fifty questionnaires were returned (response rate: 37.6%). QoL data from this reference population were compared to QoL data from a historical cohort study of prostate cancer patients following either prostatectomy or radiotherapy. In terms of general QoL, the reference population showed similar QoL scores as prostatectomy patients, but better scores than radiotherapy patients. On the PSM, the reference sample showed better overall QoL, but a surprisingly high extent of erectile dysfunction, urinary problems and psychic strain. Taking into account the sensitive topic of this study (sexuality and urinary problems), the response rate is more than satisfying. Older men in our randomly selected, population-based sample do not show perfect erectile and urinary function. These findings should be considered when interpreting QoL data of prostate cancer patients.

Full text

ORIGINAL ARTICLE
Prostate-specific symptoms of prostate cancer in a German
general population
B Bestmann
1,3
, C Loetters
2
, T Diemer
2
, W Weidner
2
,TKu
¨
chler
1
and V Rohde
2,3
1
Department of General and Thoracic Surgery, Reference Center Quality of Life in Oncology, University Hospital of
Schleswig-Holstein, Kiel, Germany and
2
Department of Urology and Pediatric Urology, University Hospital, Giessen, Germany
Predominant symptoms in prostate cancer patients are erectile dysfunctions and urinary problems.
As decreases of these functions can be attributed to disease and treatment but also to age-related
decreases, we conducted a study on a German reference population measuring general quality of
life (QoL) as well as prostate-specific symptoms. In cooperation with a German health insurance
company, 3000 questionnaires were mailed to a randomly selected sample of men aged 45–75 years.
Questionnaires used were the EORTC QLQ-C30 and a prostate-specific module (PSM). One
thousand one hundred and fifty questionnaires were returned (response rate: 37.6%). QoL data
from this reference population were compared to QoL data from a historical cohort study of prostate
cancer patients following either prostatectomy or radiotherapy. In terms of general QoL, the
reference population showed similar QoL scores as prostatectomy patients, but better scores than
radiotherapy patients. On the PSM, the reference sample showed better overall QoL, but a
surprisingly high extent of erectile dysfunction, urinary problems and psychic strain. Taking into
account the sensitive topic of this study (sexuality and urinary problems), the response rate is more
than satisfying. Older men in our randomly selected, population-based sample do not show perfect
erectile and urinary function. These findings should be considered when interpreting QoL data of
prostate cancer patients.
Prostate Cancer and Prostatic Diseases (2007) 10, 52–59. doi:10.1038/sj.pcan.4500921; published online 14 November 2006
Keywords: healthy controls; prostate-specific symptoms; quality of life; reference population
Introduction
Prostate cancer is one of the most common forms of
cancer in males in Europe and in the USA. About 48 650
men in Germany are newly diagnosed with prostate
cancer every year.
1
As the two major treatment options
for patients with clinically localized prostate cancer (e.g.
radical prostatectomy and radiotherapy) are considered
to be comparable in terms of survival,
2
other therapy-
specific health outcomes such as quality of life (QoL)
may be important for treatment decisions. Furthermore,
the great majority of patients receiving treatment for
clinically localized prostate cancer ultimately die with,
rather than of, their carcinoma. Therefore, the patients
will have to live many years with the long-term effects of
their treatment,
3
which may have adverse impact on the
patients’ QoL.
At present, a great number of questionnaires have
been developed to measure general but also disease-
and/or treatment-specific QoL in patients with prostate
cancer. In Europe, the most commonly used instrument
for assessment of health-related QoL (HRQoL) in cancer
patients is the EORTC QLQ-C30.
4
It is designed to be
modular with the core questionnaire and additionally
disease- and/or treatment-specific modules to measure
disease-related symptoms or aspects of morbidity that
are consequences of the supplied therapy or tumor site.
Beginning in 1996, Kuechler and co-workers developed a
prostate-specific module (PSM) in a process similar to
the guidelines for the development of tumour- and
therapy-specific modules established by the EORTC
Study Group on QoL.
5
The prostate cancer module
consists of 36 items addressing therapy and prostate
cancer-specific issues such as change of sexual problems,
urinary problems or treatment strain leading to the scales
‘urinary problems’, ‘incontinence’, ‘erectile dysfunction’,
’sexual problems’, ‘problems with partner’, ‘pain’, ‘heat’,
‘nutrition’ and ‘psychic strain’.
6
Predominant symptoms in prostate cancer patients are
erectile dysfunction and urinary problems. Within
Europe and especially Germany, there is an ongoing
debate on what symptoms are prostate cancer associated
and what amount of symptoms is normal in men with
Received 22 June 2006; revised 19 September 2006; accepted 25
September 2006; published online 14 November 2006
Correspondence: Dr B Bestmann, Department of General and
Thoracic Surgery, Reference Center Quality of Life in Oncology,
University Hospital of Schleswig-Holstein, Kiel, Arnold-Heller-Str. 7,
Kiel 24105, Germany.
E-mail: bbestmann@chirurgie-sh.de
3
These authors contributed equally to this work.
Prostate Cancer and Prostatic Diseases (2007) 10, 52–59
&
2007 Nature Publishing Group All rights reserved 1365-7852/07
$30.00
www.nature.com/pcan

increasing age. As decreases of these functions can be
attributed to disease and treatment but might also be age
related, we conducted a study on a German reference
population measuring as well general QoL as prostate-
specific symptoms using the EORTC QLQ-C30 and the
PSM. A few studies have been performed to obtain QoL
data from reference populations,
7
but this is the first trial
measuring disease-specific QoL in a German reference
population targeting prostate-specific QoL. The data
from this study can be used as comparison group in
studies with older men treated for prostate cancer.
Patients and methods
Subjects
A population-based sample of N ¼ 3000 men aged 45–75
years (selected according to prostate cancer incidence)
was randomly selected from the computer records of a
German general health insurance company (‘Sancura
BKK’). As we intended to investigate health-related QoL
in the general population, no medical inclusion or
exclusion criteria were defined. A letter of introduction
was mailed to all selected subjects from the health
insurance company. Two weeks later, each patient was
mailed the questionnaires together with a pre-stamped
return envelope. In order to provide a high level of
anonymity, the mailing was carried out by a neutral
private company. All patients who returned their
questionnaires within 4 weeks were included in the
analysis; a non-responder analysis was not possible due
to strict anonymization.
As a comparison group, five historic cohorts of
prostate cancer patients completing the same set of
questionnaires were used. This sample consists of
N ¼ 950 patients following either radical prostatectomy
or radiation therapy.
6
The patients following radio-
therapy were a little older than the prostatectomy
patients; furthermore, they tend to have higher tumor
stages. Therefore, in order to reduce this bias and to keep
the groups (radiotherapy vs prostatectomy) comparable,
the sample was restricted solely to a subsample of
N ¼ 375 patients with low or intermediate risk according
to international classification standards.
8
QoL assess-
ment was restricted up to 2 years after primary
treatment. Altogether, 39 patients following radiotherapy
and 436 patients following prostatectomy were included
in the statistical analysis.
Statistical analysis
The scoring of the EORTC QLQ-C30 core questionnaire
and the PSM was performed according to the EORTC
QLQ-C30 Scoring Manual:
5
scales were calculated when
at least half of the items were completed by the patients.
Internal consistency of the PSM was assessed by
calculating Cronbach’s alpha. Results are presented as
total numbers (%) or mean7s.d. All distribution and
frequencies were compared by w
2
test. QoL analyses were
performed parametrically using unpaired t-tests and
analyses of variance.
A P-value less than 0.05 was considered to be
statistically significant (corrected for multiple tests),
whereas a mean difference of 10 points and more on
the QoL scales represents a clinically significant/relevant
difference.
9
Instrumentation
HRQoL was assessed using the EORTC QLQ-C30 Core
Questionnaire (Version 2.0) and the PSM. The EORTC
QLQ-C30 is a cancer specific 30-item questionnaire.
4
It
includes five functional scales (physical, role, cognitive,
emotional and social), four symptom scales (fatigue,
pain, nausea and vomiting) and a global health scale.
There are also a number of single items addressing
additional symptoms commonly reported by cancer
patients (dyspnea, loss of appetite, insomnia, constipa-
tion and diarrhea) and perceived financial effect of the
disease. In the QLQ-C30, all items have response
categories with four levels, from ‘not at all’ to ‘very
much’, except the two items of the global health scale
(overall physical condition and for overall QoL), that use
seven-point items ranging from ‘very poor’ to ‘excellent’.
High scale scores present a high response level, with
high functional scale scores representing high/healthy
levels of functioning, and high scores for symptoms
scales/items representing high levels of symptomato-
logy/problems.
5
The PSM consists of 36 items addressing therapy and
prostate cancer-specific issues such as change of sexual
problems, urinary problems or treatment strain leading
to the theoretical scales ‘sexuality’, ‘pain’, ‘micturition’,
‘partnership’, ‘heat’, ‘general symptoms’ and ‘inconti-
nence’. The PSM was used in several (mainly historical
cohort) studies in Germany and has been psychometri-
cally tested using data from an empirical meta-analysis.
6
The PSM scales are scored according to the EORTC QLQ-
C30 symptom scales ranging from 0 to 100, with high
values representing a high level of symptomatology/
poor QoL.
Results
Sample description
The mailing was conducted from 1st of March until 15th
of April 2004. Within this time frame, 1150 out of the 3000
mailed questionnaires were returned by the patients
(response rate: 38.3%). Mean age of all respondents was
56.8 years (s.d. 7.7). Sociodemographic data are dis-
played in Table 1.
Even though the respondents in this sample are
somewhat younger than ‘the average prostate cancer
patient’, these data indicate that this sample of male
‘non-patients’ can be assumed to be comparable to
prostate cancer patients.
Psychometric properties of the PSM
As this disease-specific module was used the first time in
a ‘healthy’ population, the first step of analysis was an
evaluation of the module’s psychometric properties. The
PSM indicates good to sufficient internal consistency
with a total Cronbach’s alpha of 0.74. For the module
scales, Cronbach’s alpha ranges from 0.49 to 0.94.
Only the scales ‘(prostate-specific) pain’ and ‘nutrition’
show poor internal consistency (Cronbach’s alphao0.7);
Symptoms of prostate cancer in a German general population
B Bestmann et al
53
Prostate Cancer and Prostatic Diseases

similar findings for ‘nutrition’ and ‘(prostate-specific)
pain’ were shown in the validation study of the PSM.
6
These scales are currently revised by the authors (Table 2).
As the psychometric properties do not differ signi-
ficantly from the reliability coefficients reported in the
original validation study, we therefore assume the
module can be used for assessment of HRQoL in men
without prostate cancer too.
QoL data
The EORTC QLQ-C30 Functional Scales are shown in
Figure 1. Overall, subjects performed well on all
functional scales. Apart from ‘emotional functioning’,
all functional scales decrease with increasing age.
Especially on the scale ‘physical functioning’, a remark-
able age-related deterioration was found. Young patients
(aged 45–50 years) reported statistically and clinically
significant better QoL than older patients (aged 71–75
years), with a mean difference of at least 10 points on all
EORTC QLQ-C30 Functional Scales but ‘emotional
functioning’.
Figure 2 shows the EORTC QLQ-C30 Symptom Scales.
With increasing age, the symptom levels for ‘fatigue’,
‘pain’, ‘dyspnea’, ‘insomnia’ and ‘financial difficulties’
increase too. Especially men aged 71–75 years show
high levels of symptomatology. For ‘nausea/vomiting’,
‘appetite loss’ and ‘diarrhea’, no clear age-related trend
was found.
Figure 3 shows that similar to the findings for the
EORTC QLQ-C30 Symptom Scales, increasing age also is
associated with increasing levels of symptomatology
on the PSM Scales. On all PSM Scales, patients aged
71–75 years show a significantly poorer QoL than
younger patients. The mean values for ‘erectile dysfunc-
tion’, ‘sexual problems’ and ‘psychic strain’ increase
remarkably with increasing age.
Men aged 45–50 years and men aged 51–55 years show
similar erectile dysfunction scores. The mean difference
on the erectile dysfunction scales between young (aged
45–50) and old men (aged 71–75) is about 30 points,
which is not only statistically but also clinically of high
significance (Figure 4).
More than one-third of all respondents report some
degree of urinary dysfunction; 42.3% suffer from post-
void dribbling. Like on the other scales, all urinary
symptoms increase with increasing age, that is, younger
patients report better urinary function.
When compared to prostate cancer patients,
the healthy reference population shows similar
QoL scores as prostatectomy patients on the EORTC
QLQ-C30 Functional and Symptom Scales. Only on
the ‘social functioning’ scale the reference popu-
lation scored significantly better than prostatectomy
patients. Comparing the reference population to radio-
therapy patients, we found statistically and clinically
significant differences for ‘physical functioning’,
‘role functioning’, ‘social functioning’, ‘pain’ and
‘diarrhea’, with radiotherapy patients showing poorer
QoL (Figure 5).
Table 1 Sociodemographic characteristics of the sample
Reference sample (N ¼ 1150) Prostatectomy patients (N ¼ 436) Radiotherapy patients (N ¼ 39)
N (%) N (%) N (%)
Age categories (years)
45–50 347 (30.2) 7 (2.1) 1 (2.6)
51–55 236 (20.5) 38 (11.3) 0
56–60 179 (15.6) 61 (18.2) 4 (10.3)
61–65 201 (17.5) 90 (26.8) 3 (7.7)
66–70 140 (12.2) 109 (32.4) 15 (38.5)
71–75 31 (2.7) 31 (9.2) 16 (41.0)
Missing 16 (1.4) 0 0
Marital status
Unmarried 50 (4.4) 1 (0.3) 1 (2.6)
Married 956 (83.1) 262 (78.0) 32 (82.1)
Divorced 104 (9.0) 3 (0.9) 0
Widowed 26 (2.3) 8 (2.4) 4 (10.3)
Missing 14 (1.2) 62 (18.5) 2 (5.1)
Employment status
Full-time employed 648 (56.4) 59 (17.6) 3 (7.7)
Part-time employed 13 (1.1) 0 0
Housewife/-husband 2 (0.2) 0 0
Unemployed 125 (10.9) 6 (1.8) 1 (2.6)
Early retired 33 (2.9) 25 (7.4) 0
Retired 327 (28.4) 204 (60.7) 35 (89.7)
Missing 2 (0.2) 42 (12.5) 0
Table 2 Cronbach’s alpha for the PSM Scales
Cronbach’s alpha N Number of items
Erectile dysfunctions 0.761 858 2
Sexual problems 0.938 1060 5
Psychic strain 0.760 841 3
(Prostate-specific) pain 0.630 1004 5
Problems with partner 0.840 935 2
Nutrition 0.487 1140 2
Heat 0.770 1140 2
Urinary problems 0.706 1141 3
Mean 0.737 1015 3
Abbreviation: PSM, prostate-specific module.
Symptoms of prostate cancer in a German general population
B Bestmann et al
54
Prostate Cancer and Prostatic Diseases

On the PSM, we found similar QoL scores for
prostatectomy patients and the (healthy) reference
population in terms of ‘urinary problems’, ‘(prostate-
specific) pain’, ‘nutrition’ and ‘psychic strain’. Even
though the healthy reference population does not reach
the level of prostate cancer patients (prostatectomy as
well as radiotherapy patients), they show remarkably
high scores for ‘erectile dysfunction’ and ‘sexual
problems’ (Figure 6).
In summary, prostate cancer patients differ clinically
significant (Owing to the large sample size, almost all
differences are statistically significant, but certainly not
clinically relevant.) from the reference group of ‘non-
patients’ in four out of eight scales from the PSM.
As this study was designed to provide reference
values for QoL assessment in prostate cancer patients,
the mean scores and s.d. for all QoL scales are displayed
in Table 3.
Discussion
In this cross-sectional study, we have analyzed HRQoL
in a German reference population. The questionnaires
0
20
40
60
80
100
Physical functioning
(PF)
Role functioning
(RF)
Emotional
functionin
g
(EF)
Cognitive
functionin
g
(CF)
Social functioning
(SF)
Global Health
Status (QoL)
45 to 50 years
51 to 55 years
56 to 60 years
61 to 65 years
66 to 70 years
71 to 75 years
Figure 1 EORTC QLQ-C30 Functional Scales.
0
20
40
60
80
100
Fatigue (FA) Nausea/Vomiting
(NV)
Pain (PA ) Dyspnoea (DY) Insomnia (SL) Appetite loss (AP) Constipation (CO) Diarrhoea (DI) Financial difficulties
(FI)
45 to 50 years
51 to 55 years
56 to 60 years
61 to 65 years
66 to 70 years
71 to 75 years
Figure 2 EORTC QLQ-C30 Symptom Scales.
Symptoms of prostate cancer in a German general population
B Bestmann et al
55
Prostate Cancer and Prostatic Diseases

were mailed to a randomly selected sample of
N ¼ 3000 male insurants of a German health insurance
company.
Taking into account not only the sensitive topic but
also the facts that the questionnaire is comparatively long
and – due to strict anonymization – the use of incentives
was not possible, a response rate of 38.3% is really
satisfying. In a comparable study of older men without
prostate cancer in the USA, where cash incentives and
telephone reminders were used, a response rate of 44.8%
was achieved.
10
The questionnaires analyzed for this paper were the
EORTC QLQ-C30 core questionnaire
4
and a newly
validated PSM developed by Ku
¨
chler et al.
6
A psycho-
metric analysis of this healthy sample showed that the
PSM showed highly satisfactory internal consistency
with a mean Cronbach’s alpha of 0.73. We therefore
assume that this disease-specific instrument can be used
for the assessment of HRQoL in this German general
population.
In terms of general QoL (QLQ-C30), the reference
population showed similar QoL scores as prostatectomy
patients, but better scores than radiotherapy patients. On
the PSM, the reference sample showed better QoL, but a
high extent of erectile dysfunction, urinary problems and
psychic strain. Many studies compared HRQoL out-
comes after between treatments and at various times of
assessment. The findings of these studies are hetero-
geneous and many of them have methodological limita-
tions. One possible reason for the differences between
prostatectomy and radiotherapy patients in this study
could be that the radiotherapy patients are a generally
more ‘unhealthy’ subset of patients, that is, that patients
in a poorer general condition are more likely to receive
radiotherapy. Therefore, we tried to minimize this bias
by restricting the sample solely to patients with low to
intermediate risk.
Not only the EORTC QLQ-C30 functional and symp-
tom scales but also the scales from the PSM showed
significant dependencies on age. On all EORTC QLQ-C30
0
20
40
60
80
100
urinary
problems
erectile
dysfunction
sexual
problems
problems
with partner
(prostate
specific) pain
heat nutrition psychic
strain
45 to 50 years
51 to 55 years
56 to 60 years
61 to 65 years
66 to 70 years
71 to 75 years
Figure 3 PSM Scales.
99,0 02,06,
93,5
5,10,3
86,6 10,5 0,7
86,5 10,6 0,3
57,3 35,4 0,7
26,7 15,4 20,2 37,7
0% 20% 40% 60% 80% 100%
blood in urine or semen
pain while passing urine
urgency
hesitancy initiating
urination
post-void dribbling
dysuria
not at all a little quite a bit very much
Figure 4 Urinary problems of ‘non-patients’, all age groups.
Symptoms of prostate cancer in a German general population
B Bestmann et al
56
Prostate Cancer and Prostatic Diseases

Functional Scales, but ‘emotional functioning’ and
‘cognitive functioning’, a remarkable age-related de-
crease was found. For the EORTC QLQ-C30 Symptom
Scales, we found that increasing age is associated with
increasing levels of symptomatology. On the PSM scales,
it was shown that increasing age also corresponds with
higher levels of prostate-specific symptoms. For most
PSM scales, a linear relationship between age and scale
score was found. The increase of symptoms is most
pronounced in the oldest age group. Similar findings
were reported for the EORTC QLQ-C30 scales by
Hjermstad et al.
11
and Schwarz and Hinz.
7
This under-
lines the necessity to account for age differences when
populations with different age distributions are com-
pared. However, it should be kept in mind that these
data were obtained from a cross-sectional design and not
from a prospective sample. Another limitation of this
study is the respondents’ age. With a mean age of 57
years, this sample is clearly younger than the median age
at diagnosis of prostate cancer patients (B70 years). As
the participants of this study were randomly selected
from the records of a health insurance company, this fact
indicates a response bias (younger patients are more
likely to answer the questionnaires than older ones). It
would have been interesting to get more information
about this bias, but due to strict anonymization, a non-
0
20
40
60
80
100
Physical
Functioning
Role
Functioning
Emotional
Functioning
Cognitive
Functioning
Social
Functioning
Global
Health
Fatigue
Nausea/ Vomiting
Pain
Dyspnoea
Insomnia
Appetite Loss
Constipation
Diarrhoea
Financial
Difficulties
reference values radiation therapy
prostatectomy
EORTC QLQ-C30 Scales
Figure 5 Comparison between reference values and prostate cancer patients following either prostatectomy or radiotherapy.
0
10
20
30
40
50
60
70
80
90
100
Erectile
Dysfunctions
Sexual Problems Psychic Strain Pain Problems with
Partner
Nutrition Heat Urinary Problems
healthy controls
radio therapy prostatectomy
Figure 6 Comparison between reference values and prostate cancer patients following either prostatectomy or radiotherapy.
Symptoms of prostate cancer in a German general population
B Bestmann et al
57
Prostate Cancer and Prostatic Diseases

responder analysis was not feasible. Nevertheless, as the
data of this study is not analyzed and presented as a
whole, but in a age-stratified way, this reference data
allow future comparisons with different samples of
prostate cancer patients obtained from clinical studies.
Comparing the reference sample to the historic cohort
of prostate cancer patients on the EORTC QLQ-C30
scales, it was shown that the healthy sample showed
similar QoL scores as prostatectomy patients, but
significantly better QoL than radiotherapy patients on
the PSM; the reference sample showed better QoL than
prostate cancer patients (prostatectomy patients as well
as radiotherapy patients), but also a remarkably high
degree of ‘erectile dysfunction’ and ‘sexual problems’.
Interpreting these differences, it has to be kept in mind
that the reference population studied in this paper is no
completely healthy but rather a ‘normal’ sample. Patients
with a history of prostate or other sites of cancer were not
excluded from this survey. We assume that the incidence
rate for prostate cancer in this randomly selected sample
is comparable to the incidence rate in Germany in
general.
Conclusions
Comparisons with reference populations facilitate to
interpret the significance of differences in QoL scores of
different patient groups (e.g. patients with high and low
tumor stage) and score changes over time.
The male ‘non-patients’ in our randomly selected,
population-based sample do not show perfect erectile
and urinary function. The data showed decreases in
sexual functions not only for prostate cancer patients but
also to some extent for the age-matched reference
population. The increase of symptoms and decreases of
sexual and urinary function in prostate cancer patients
should therefore not only be attributed to radical
treatment for prostate cancer but also to the normal
aging process as well. These findings should be kept in
mind when interpreting QoL data of prostate cancer
patients.
Acknowledgements
This study was supported by grants from Takeda
Pharma Inc. (Japan) and Sancura BKK (Germany).
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Table 3 Mean scores and s.d. for all QoL scales (EORTC QLQ-C30 Functional and Symptom Scales, scales of the PSM)
All respondents 45–50 years 51–55 years 56–60 years 61–65 years 66–70 years 71–75 years Age not specified
N ¼ 1150 N ¼ 347 N ¼ 236 N ¼ 179 N ¼ 201 N ¼ 140 N ¼ 31 N ¼ 16
PF 90.0 (15.2) 93.8 (11.3) 92.2 (14.2) 89.1 (14.4) 87.4 (16.1) 85.79 (18.8) 76.9 (21.0) 78.2 (21.9)
RF 87.7 (22.0) 92.7 (17.4) 90.0 (20.5) 84.0 (24.6) 84.9 (22.8) 83.2 (25.2) 78.5 (26.2) 74.2 (25.1)
EF 73.6 (23.1) 73.6 (22.7) 71.0 (24.3) 72.9 (22.6) 74.8 (23.0) 78.7 (22.5) 73.1 (23.4) 63.3 (22.2)
CF 83.2 (20.1) 86.4 (18.1) 84.0 (20.4) 82.0 (21.6) 81.5 (19.9) 82.4 (18.5) 66.7 (27.2) 72.2 (23.3)
SF 85.5 (23.5) 89.7 (19.3) 86.0 (22.2) 84.9 (26.1) 82.0 (25.2) 83.1 (25.6) 72.0 (29.6) 81.1 (21.7)
Global health status (QoL) 69.0 (19.5) 72.0 (18.3) 69.6 (19.2) 67.7 (19.7) 66.3 (20.0) 68.5 (20.5) 62.4 (21.0) 61.1 (18.8)
FA 21.5 (22.6) 17.9 (21.4) 20.7 (23.0) 22.5 (21.5) 23.6 (22.6) 22.5 (22.4) 37.1 (28.2) 36.4 (28.1)
NV 2.2 (8.6) 2.0 (7.6) 3.0 (10.4) 2.3 (10.6) 2.1 (6.4) 1.8 (8.6) 0.5 (3.0) 3.0 (6.7)
PA 23.1 (28.2) 17.0 (24.2) 22.4 (27.2) 28.2 (32.7) 24.7 (28.4) 24.9 (26.7) 33.3 (31.9) 55.6 (31.3)
DY 11.5 (22.7) 6.7 (18.3) 8.8 (20.0) 15.6 (22.8) 13.9 (25.4) 15.6 (25.8) 22.2 (29.5) 33.3 (36.5)
SL 22.4 (28.2) 16.3 (24.3) 21.2 (29.8) 23.1 (27.8) 26.2 (27.9) 29.1 (30.4) 33.3 (34.4) 46.7 (32.2)
AP 3.9 (12.9) 2.5 (9.5) 5.2 (15.6) 5.1 (14.0) 4.5 (13.6) 2.6 (12.0) 3.2 (10.0) 9.1 (21.6)
CO 4.4 (14.1) 3.1 (12.6) 3.1 (12.3) 4.1 (13.6) 5.7 (14.3) 6.0 (17.1) 9.7 (21.4) 13.3 (21.3)
DI 8.1 (18.1) 6.3 (15.4) 8.6 (20.1) 10.1 (19.0) 7.8 (16.4) 8.7 (19.6) 9.7 (19.6) 17.8 (27.8)
FI 16.3 (28.8) 8.7 (21.5) 14.3 (29.2) 18.6 (28.7) 21.2 (30.8) 20.5 (31.1) 34.4 (37.0) 48.9 (39.6)
Urinary problems 1.8 (7.4) 0.8 (5.5) 1.0 (4.6) 1.5 (5.2) 2.7 (8.6) 2.9 (9.6) 8.8 (19.1) 5.2 (10.2)
Erectile dysfunction 51.1 (29.2) 42.7 (25.9) 42.9 (25.1) 53.2 (29.9) 60.0 (29.4) 66.2 (31.0) 72.2 (29.6) 48.7 (26.8)
Sexual problems 26.9 (29.3) 14.3 (20.8) 20.6 (25.4) 28.1 (28.0) 40.6 (31.9) 45.1 (32.4) 47.2 (34.2) 23.2 (22.3)
Problems with partner 9.5 (20.0) 6.0 (15.9) 7.1 (16.7) 11.8 (23.7) 13.0 (21.0) 11.9 (23.6) 14.7 (27.4) 12.8 (18.2)
(Prostate-specific) pain 16.2 (19.9) 12.1 (16.2) 15.9 (19.8) 20.7 (24.1) 16.8 (20.3) 17.3 (19.6) 23.7 (18.1) 28.9 (25.1)
Heat 7.5 (17.3) 5.1 (12.1) 9.0 (19.9) 9.8 (19.4) 8.2 (18.4) 5.1 (15.1) 11.3 (23.3) 18.9 (25.1)
Nutrition 8.2 (16.1) 5.8 (11.8) 9.5 (19.4) 8.4 (15.8) 7.5 (14.7) 9.5 (18.0) 19.9 (20.8) 15.6 (21.3)
Psychic strain 25.4 (22.3) 20.1 (19.7) 24.3 (22.4) 27.6 (23.8) 28.5 (21.7) 29.4 (22.8) 37.7 (26.6) 38.0 (26.2)
Abbreviations: AP, appetite loss; CF, cognitive functioning; CO, constipation; DI, diarrhea; DY, dyspnea; EF, emotional functioning; FA, fatigue; FI, financial
difficulties; NV, nausea/vomiting; PA, pain; PF, physical functioning; PSM, prostate-specific module; QoL, quality of life; RF, role functioning; SF, social
functioning; SL, insomnia.
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