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Predicting the Return of Erectile Function Following Prostate Cancer Treatment In Clinical Practice Using EPIC-CP
Andrew Wagner, MD1, Jonathan Chipman, MS2, Meredith Regan, ScD3, Catrina Crociani, MPH1, Martin Sanda, MD4, Peter Chang, MD, MPH1.
1Beth Israel Deaconess Medical Center, Boston, MA, USA, 2Vanderbilt University, Memphis, TN, USA, 3Dana-Farber Cancer Institute, Boston, MA, USA, 4Emory University, Atlanta, GA, USA.

Background: While models predicting survival after prostate cancer (PC) treatment are prevalent, few predict post-treatment quality of life outcomes. We previously developed and externally validated models predictive of functional erections sufficient for intercourse two years following radical prostatectomy (RP), external beam radiation (EBRT) or brachytherapy (BT) using EPIC-26 (Alemozaffar et al, JAMA 2011). However, challenges with using EPIC-26 in clinical practice may preclude realistic use of these models. EPIC for Clinical Practice (EPIC-CP) is a one-page, 16-item questionnaire validated to measure health related quality of life in PC patients in the clinical setting (Chang et al J Urol 2011). We aimed to recalibrate these models for use with EPIC-CP to better enable point of care prognostication of sexual function in clinical practice.
Methods: Using a previously described multicenter longitudinal cohort, we identified 493 men treated with RP, 217 with EBRT and 230 with BT with complete sexual domain and model covariate information. We used the established covariates in the EPIC-26-based models to recalibrate the multivariable logistic regression models for use with EPIC-CP. We examined Pearson residuals to determine goodness of fit and compared the individual predictions based on the revised models with those generated by the EPIC-26-based models.
Results: The recalibrated EPIC-CP-based models are presented in Tables 1, 2, and 3 for RP, EBRT, and BT, respectively. The models demonstrated excellent discrimination (AUC 0.76 for RP, 0.81 for EBRT, and 0.87 for BT). Odds ratio estimates for the EPIC-CP models changed by no more than 0.2 from their EPIC-26 counterparts, and remained significant. EPIC-CP and EPIC-26-based predictions had good concordance: the mean ± SD difference in predicted probability between EPIC-26 and EPIC-CP models was 0.0 ± 0.08 in each
treatment group. Predicted probabilities were within 10%, 15.4%, and 15.8% for 95% of the RP, EBRT and BT subjects, respectively.
Conclusions: EPIC-CP-based nomograms predicting erectile function two years after RP, EBRT, and BT are in good agreement with established EPIC-26-based tools and offer an easily applied and accurate prediction regarding a common and impactful side effect of PC treatment. Their use in clinical practice may help adjust patient expectations for different treatment options and facilitate patient-centered care.
Table 1: Model Predicting the Likelihood of Erections Sufficient For Intercourse after Radical Prostatectomy
Age 50-59
PSA ≤ 10675034
PSA > 10463018
Age 60-69
PSA ≤ 10533622
PSA > 10321911
Age 70+
PSA ≤ 10392414
PSA > 1021126
Non-nerve sparing
Age 50-59
PSA ≤ 10352112
PSA > 1019106
Age 60-69
PSA ≤ 1023137
PSA > 101163
Age 70
PSA ≤ 101584
PSA > 10732

Table 2: Model Predicting the Likelihood of Erections Sufficient For Intercourse after External Beam Radiotherapy
Without neoadjuvant hormone therapy
PSA < 4 ng/mL907858
PSA ≥ 4 ng/mL755432
With neoadjuvant hormone therapy
PSA < 4 ng/mL755431
PSA ≥ 4 ng/mL492813

Table 3: Model Predicting the Likelihood of Erections Sufficient For Intercourse after Brachytherapy
Age 60
BMI < 25968868
BMI ≥ 25, < 35927647
BMI ≥ 35734318
Age 65
BMI < 25958460
BMI ≥ 25, < 35896939
BMI ≥ 35653513
Age 70
BMI < 25937952
BMI ≥ 25, < 35856131
BMI ≥ 35572810
Age 60
BMI < 25917445
BMI ≥ 25, < 35815526
BMI ≥ 3551238
Age 65
BMI < 25886737
BMI ≥ 25, < 35754620
BMI ≥ 3542176
Age 70
BMI < 25835929
BMI ≥ 25, < 35683815
BMI ≥ 3534134

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