Marieke van Son

114 CHAPTER 6 dose to the urethra (≥16 Gy). Higher level of baseline sexual functioning was predictive of better sexual HR-QoL. A comparison with our previous work on ultrafocal salvage HDR-BT shows similar trends in terms of treatment-related toxicity. Our first report (n=17, median follow-up 10 months) described physician-graded toxicity following the Common Terminology Criteria for Adverse Events version 4.0 (CTCAE). There was minor grade 1 rectal toxicity (mild or asymptomatic) and urinary toxicity was limited to approximately 25% grade 2 (moderate) and 5% grade 3 (severe) toxicity. Grade 3 new-onset erectile dysfunction occurred in 1/6 patients with full erectile function at baseline and 1/7 patients with moderate erectile dysfunction at baseline(13). In a more recent update (n=50, median follow-up 31 months), 4% had new-onset grade 2 rectal toxicity. While severe urinary toxicity was still limited (2%), more patients had developed grade 2 toxicity (52%). Grade 3 new-onset erectile dysfunction was seen in 22%. Regarding patient-reported toxicity, the IPSS revealed a temporary increase of urinary symptoms in the first month after treatment (maximummedian score 11.5). The International Index of Erectile Function (IIEF) showed a downward trend of erectile func- tion over time, frommedian score 11 at baseline to median 3 after 3 years follow-up(14). Within the current literature on salvage treatments for radiorecurrent prostate cancer, there is limited data of patient-reported HR-QoL. Reports of HR-QoL that have been published are heterogeneous, using a variety of different questionnaires. Two studies reported IPSS and IIEF scores after whole-gland salvage treatments, namely whole- gland salvage LDR-BT (n=19) and whole-gland salvage HIFU (n=81). The questionnaires revealed a peak to moderate urinary symptoms (mean IPSS ±15) and a deterioration to severe ED (mean IIEF ±6) in the first year(15, 16). Another study on whole-gland salvage HIFU in 61 patients used the University of California Los Angeles Prostate Cancer Index (UCLA-PCI) as patient-reported outcome measurement. They reported clinically signif- icant urinary and sexual function deterioration after 1.5 years follow-up. At a scoring range of 0-100, mean urinary function decreased with 12 points (p<0.01) and mean sexual function decreased with 15 points (p<0.01). Bowel function was not affected(17). Regarding targeted salvage treatments, only two studies described HR-QoL. A study on ultrafocal salvage LDR-BT (20 patients) used the EORTC QLQ-PR25, reporting a clinically significant increase of median 12 points in urinary symptoms after 3 years (p<0.01)(18). A study on focal salvage HDR-BT to a quadrant of the prostate (15 patients) used the Expanded Prostate Cancer Index Composite (EPIC). They reported a significant deterioration of sexual function after 3.5 years (approximately -20 points on a 0-100 scale, p<0.01), whereas the urinary and bowel domains were not significantly affected. The median IPSS never exceeded a score of 10(19). To have a better understanding of what factors predict HR-QoL, we explored the as- sociation between several predictors and HR-QoL change. The apparent predictors for the urinary domain confirmed our expectations. We already screen for baseline urinary symptoms using the IPSS questionnaire, with scores >15 being a contra-indication for treatment. Although severe urinary toxicity has been low, we are strict in adhering