Sexual functioning after treatment for testicular cancer: comparison of treatment modalities

Testicular Cancer Treatments and Sexuality: A Narrative Review

The incidence of testicular cancer (TC) has been rapidly increasing over the past years. Diagnosis and early treatment have shown good oncological control, guaranteeing the patient different treatment approaches according to histology and tumor stage. Currently, physicians usually prioritize oncological outcomes over sexual outcomes and quality of life, considering as a first aim the overall survival of the patients; however, differently from other neoplasms, quality of life is still strongly affected among TC patients, and sexual outcomes are frequently compromised after each TC treatment. Several studies have suggested that each treatment approach may be associated with sexual dysfunctions, including erectile dysfunction, ejaculatory disorders, fertility issues, and hormonal changes. Since testicular cancer patients are more frequently young men, the subject of this work is substantial and should be analyzed in detail to help specialists in the management of this disease. The aim of the current narrative review is to generally describe every treatment for TC, including surgery, chemotherapy, radiotherapy, and retroperitoneal lymph node dissection, and to establish which sexual dysfunction may be specifically associated with each therapy.

Mitigating long-term and delayed adverse events associated with cancer treatment: implications for survivorship

Despite the importance of chemotherapy-associated adverse events in oncology practice and the broad range of interventions available to mitigate them, limited systematic efforts have been made to identify, critically appraise and summarize the totality of evidence on the effectiveness of these interventions. Herein, we review the most common long-term (continued beyond treatment) and late or delayed (following treatment) adverse events associated with chemotherapy and other anticancer treatments that pose major threats in terms of survival, quality of life and continuation of optimal therapy. These adverse effects often emerge during and continue beyond the course of therapy or arise among survivors in the months and years following treatment. For each of these adverse effects, we discuss and critically evaluate their underlying biological mechanisms, the most commonly used pharmacological and non-pharmacological treatment strategies, and evidence-based clinical practice guidelines for their appropriate management. Furthermore, we discuss risk factors and validated risk-assessment tools for identifying patients most likely to be harmed by chemotherapy and potentially benefit from effective interventions. Finally, we highlight promising emerging supportive-care opportunities for the ever-increasing number of cancer survivors at continuing risk of adverse treatment effects.

Patient-Reported Outcomes Associated with Treatments for Testicular Cancer: A Systematic Review

Background

Testicular cancer and its treatment can have major short- and long-term effects on the health-related quality of life of those affected. This systematic review aims to summarise patient-reported outcome (PRO) data concerning health-related quality of life, functional impacts and common side-effects of treatments for testicular cancer.

Methods

We systematically searched Medline OVID, CINAHL, PubMed, Embase and the Patient-Reported Outcomes Over Time In Oncology (PROMOTION) databases from inception to 25 March 2020, using "testicular cancer" and "PRO" search terms developed in conjunction with a medical librarian. Two authors screened abstracts and full-text articles for studies that reported primary PRO data related to the treatment of testicular cancer including at least 50 participants. We excluded psychosocial data as this was included in our companion review. Data were extracted by three reviewers, and quality was assessed by two reviewers using QUAL-SYST. Studies with a quality of score over 65% were included in our narrative synthesis.

Results

A total of 1831 records were identified via our database searches and 41 met inclusion criteria. Of these, 35 included participants who had chemotherapy. Twenty-eight different PRO measures were used across the 41 studies. Of the 41 studies, 29 had quality scores over 65% and were included in our narrative synthesis. We found that chemotherapy was generally associated with a higher side-effect burden than other treatments, and higher burden was associated with higher doses of chemotherapy. Hearing problems, peripheral neuropathy, and Raynaud's phenomena were particularly common side-effects. Problems with sexual functioning were associated with chemotherapy, radiotherapy and surgery.

Discussion

While many studies found that between-treatment differences resolved within the first 12 months since diagnosis, there were many long-term and dose-dependent impacts associated with chemotherapy and radiotherapy across PRO domains. Offering information about these aspects, and information about expected survival outcomes, will help inform, prepare, and empower patients to make decisions about treatment aligned with their preferences and personal situations.

Insertion of a testicular prosthesis at the time of radical orchiectomy for testicular cancer is safe in patients who will subsequently undergo chemotherapy or radiotherapy

We aimed to assess the incidence of prosthesis-related complications in patients who received a testicular prosthesis at the time of radical orchiectomy for testicular cancer and were then treated with chemotherapy (ChT) or radiotherapy (RT). We reviewed the records of the patients who underwent radical orchiectomy at our Institute since 1999; we also retrieved data from patients who underwent surgery elsewhere and then received ChT or RT at our Institution since 1999. We used the chi-square test to evaluate differences in the incidence of prosthesis-related complications between the groups. We retrieved the records of 587 patients; 393 had a testicular prosthesis implanted. Median follow-up was 57.7 months. One hundred thirty-eight patients (35.11%) received ChT, 129 RT (38.82%) and 10 (2.55%) both ChT and RT; of them, 6 (4.34%), 8 (6.20%) and 0 reported problems respectively. Seven (6.03%) of the 116 patients (29.52%) who had no further treatment had complications. The incidence of complications was not significantly different between patients who had no further treatment versus patients who underwent ChT (p = .75) or RT (p = .83). Testicular prosthesis insertion at the time of radical orchiectomy is safe even in patients subsequently undergoing ChT or RT.

Long-Term Follow Up of the Erectile Function of Testicular Cancer Survivors

The diagnosis of testicular cancer (TC) can have a considerable and persistent impact on a patient's sexuality, especially given its location. The high prevalence of TC in young adults, and the good prognosis, explain the great interest in sexual dysfunction and its influence on post-treatment quality of life. The aim of this study was to evaluate the impact of the diagnosis and treatments (inguinal orchiectomy and chemotherapy) on sex life. For this purpose, we recruited 241 TC patients attending the Laboratory of Seminology-Sperm Bank "Loredana Gandini" for sperm cryopreservation (mean age 31.3 ± 6.9 years) and 223 cancer-free healthy men who were undergoing andrological screening (mean age 32.0 ± 7.7 years). The IIEF-15 questionnaire was administered at the baseline (post-orchiectomy, pre-chemotherapy-T0) and at 6 (T1), 12 (T2), 18 (T3), 24 (T4), 48 months (T5) and >5 years (T6, median 96 months) after chemotherapy to all patients, to evaluate the following domains: erectile function (EF), orgasmic function (OF), sexual desire (SD), intercourse satisfaction (IS) and overall satisfaction (OS). A subgroup of patients also underwent blood sex hormone analysis for further correlations with IIEF scores. At the baseline, 37.7% of patients had erectile dysfunction (EF score <26) and all IIEF domains except OF showed significantly lower scores than in controls (p < 0.001). Long-term follow-up revealed persistently lower scores in TC survivors than in controls for EF, SD, IS, and OS. Furthermore, most IIEF domains did not improve significantly in TC patients during the duration of the follow-up, with the exception of EF, which showed a significant improvement from T2. Finally, no significant correlation was found between hormone levels (gonadotropin and testosterone) and IIEF-15 scores. In conclusion, TC and its treatment have a significant effect on sexuality. The absence of a clear correlation with biochemical hypogonadism suggests that this may to a large extent be due to the surgical procedure itself, or to the psychological impact of a cancer diagnosis.

Psychosocial Issues in Long-Term Survivors of Testicular Cancer

Testicular cancer is the most frequent tumor in young males aged 15-39 years. As cure rates are currently around 90%, the prevalence of survivors is increasing. However, a disease-free condition does not necessarily correspond to a life free of physical and psychosocial health problems. The aim of this review was to explore psychosocial morbidity among testicular cancer survivors. A literature search was conducted in three electronic databases (PubMed, Medline, and Embase). The results of the search on cancer survivors were then combined with those of the search on psychosocial concerns and work performance. Eighty-four publications met the inclusion criteria. Physical, psychological, work-related problems and changing perspectives about work and life in general influenced life and career decisions among testicular cancer survivors. Individual health, sexual relationships and work problems, affect several important aspects of survival and significantly influence the QoL of long-term survivors.

Sexual Function in a Nationwide Cohort of 2,260 Survivors of Testicular Cancer after 17 Years of Followup

PURPOSE

Evidence on the long-term impact of testicular cancer treatment on sexual function is not clear. Our aim was to estimate the effect of testicular cancer treatment on the risk of sexual dysfunction in long-term survivors of testicular cancer.

MATERIALS AND METHODS

We performed a cross-sectional study of 2,260 long-term survivors of testicular cancer with a median followup of 17 years (IQR 12-24), including 1,098 who underwent orchiectomy alone (surveillance), 788 treated with bleomycin, etoposide and cisplatin alone or post-chemotherapy retroperitoneal surgery, 300 treated with abdominal radiotherapy and 74 who received more than 1 line of treatment. Sexual function was evaluated by the IIEF-15 (International Index of Erectile Function-15) questionnaire. Results were compared between treatment groups using logistic regression analysis with the results on each of the 5 IIEF-15 dimensions as the outcome and treatment as exposure using surveillance as the referent.

RESULTS

The risk of erectile dysfunction was increased in all treatment groups compared to surveillance, including bleomycin, etoposide and cisplatin alone (OR 1.5, 95% CI 1.0-2.1, p <0.05), bleomycin, etoposide and cisplatin with post-chemotherapy surgery (OR 2.1, 95% CI 1.4-3.4, p <0.005), radiotherapy (OR 1.7, 95% CI 1.1-2.5, p <0.05) and more than 1 line of treatment (OR 3.2, 95% CI 1.6-6.3, p <0.005). Orgasmic dysfunction was associated with radiotherapy, bleomycin, etoposide and cisplatin with post-chemotherapy surgery and more than 1 line of treatment.

CONCLUSIONS

Treatment with bleomycin, etoposide and cisplatin, radiotherapy and more than 1 treatment line increased the risk of erectile dysfunction in long-term survivors of testicular cancer compared to surveillance. Patients should be informed about this as part of the information on treatment related late effects.

Sexual function and male cancer

Quality of life in general and sexual functioning in particular have become very important in cancer patients. Biological factors such as anatomic alterations, physiological changes and secondary effect of medical interventions may preclude normal sexual functioning even when sexual desire is intact. In spite of modern surgical techniques, improved chemotherapeutical drugs and sophisticated radiation techniques, still many patients complain of impaired sexual function after cancer treatment. A large number of instruments already exist to assess quality of life in cancer patients. It is important to standardize procedures and to use validated questionnaires. Collecting data on an ongoing basis before and long after treatment is mandatory, and control groups must be used. Patients should be offered sexual counselling and informed about the availability of therapies for sexual dysfunctions. In this paper we review the topic of sexual functioning after treatment (predominantly after radiotherapy) of the most common malignancies in men and give suggestions for treatment.

Pharmacologic and surgical therapies for sexual dysfunction in male cancer survivors

The recent recognition that many men experience sexual dysfunction following their diagnosis and treatment of genitourinary cancers, has led to the development multiple varied strategies that attempt to restore or preserve that function. In this manuscript we review the understanding of why it happens, highlight novel management strategies and discuss the concept of penile rehabilitation (PR) following prostate cancer (PCa) treatment, glans preserving strategies among men diagnosed with penile cancer and address the controversial issue of testosterone therapy in men with PCa.

Cost analysis of adjuvant management strategies in early stage (stage I) testicular seminoma

BACKGROUND

Acceptable post-orchiectomy adjuvant therapy strategies for stage I seminoma patients include surveillance, para-aortic radiation therapy (RT), dog-leg RT, and a single cycle of carboplatin. The required follow-up recommendations were amended by the National Comprehensive Cancer Network (NCCN) in 2012. Given a cause-specific survival of nearly 100%, a closer analysis of the reimbursement for each treatment strategy is warranted.

METHODS

NCCN guidelines were used to design treatment plans for each acceptable adjuvant treatment strategy. Follow-up charges were generated for 10 years based on 2012 (version 1.2012; unchanged in current version 1.2013) and 2011 NCCN (version 2.2011) surveillance recommendations. The 2012 Medicare reimbursement rates were used to calculate each treatment strategy and incremental cost-effectiveness ratios to compare the treatment options.

RESULTS

Under the current NCCN follow-up recommendations, the total reimbursements generated over 10 years of surveillance, para-aortic RT, dog-leg RT, and carboplatin were $10,643, $11,678, $9,662, and $10,405, respectively. This is compared with the reimbursements as per the 2011 NCCN recommendations: $20,986, $11,517, $9,394, and $20,365 respectively. Factoring the rates of relapse into a salvage model, observation was found to be more costly and less effective ($-1,831, $-7,318, $-7,010) in the adjuvant management of stage I seminoma patients.

CONCLUSION

Based on incremental cost-effectiveness ratios, para-aortic RT, dog-leg RT, and carboplatin are cost-effective options for the treatment of stage I seminoma when compared with observation; however, surveillance could potentially spare as many as 80%-85% of men diagnosed with stage I seminoma from additional therapy after radical inguinal orchiectomy. Such cost and reimbursement analyses are becoming increasingly relevant, but are not meant to usurp sound clinical judgment. Further studies are required to validate these findings.

Sexual functioning among testicular cancer survivors: a case-control study in the U.S

OBJECTIVE

Sexual function among testicular cancer survivors is a concern because affected men are of reproductive age when diagnosed. We conducted a case-control study among United States military men to examine whether testicular cancer survivors experienced impaired sexual function.

METHODS

A total of 246 testicular cancer cases and 236 ethnicity and age matched controls were enrolled in the study in 2008-2009. The Brief Male Sexual Function Inventory (BMSFI) was used to assess sexual function.

RESULTS

Compared to controls, cases scored significantly lower on sex drive (5.77 vs. 5.18), erection (9.40 vs. 8.63), ejaculation (10.83 vs. 9.90), and problem assessment (10.55 vs. 9.54). Cases were significantly more likely to have impaired erection (OR 1.72; 95% CI 1.11-2.64), ejaculation (OR 2.27; 95% CI 1.32-3.91), and problem assessment (OR 2.36; 95% CI 1.43-3.90). In histology and treatment analysis, nonseminoma, chemotherapy and radiation treated cases risk of erectile dysfunction, delayed ejaculation, and/or problem assessment were greater when compared to controls.

CONCLUSION

This study provides evidence that testicular cancer survivors are more likely to have impaired sexual functioning compared to demographically matched controls. The observed impaired sexual functioning appeared to vary by treatment regimen and histologic subtype.

Sexuality and body image in long-term survivors of testicular cancer

OBJECTIVE

This study explores sexual function and the influence of different treatment modalities on sexual function and body image among long-term survivors of testicular cancer (TCSs).

METHODS

A long-term follow-up assessment of all testicular cancer patients treated at Aarhus University Hospital, Denmark, from 1990 to 2000 was conducted. A total of 401 survivors (mean age: 46.6years; response rate: 66%) completed questionnaires concerning sexuality and changes in body image. Based on the treatment received, patients were categorised into one of four groups: surveillance, radiotherapy, chemotherapy, or chemotherapy supplemented with retroperitoneal lymph node dissection (RPLND).

RESULTS

Sexual dysfunctions were reported: 24% reduced sexual interest, 43% reduced sexual activity, 14% reduced sexual enjoyment, 18% erectile dysfunction, 7% ejaculatory problems and 3% increased sexual discomfort. Seventeen percent of the long-term TCSs reported changes in body image, and this was significantly associated with all six parameters of sexual dysfunction. When comparing treatments, only the RPLND procedure was associated with sexual dysfunction in the form of ejaculatory dysfunction.

CONCLUSION

Apart from RPLND, which was associated with ejaculatory dysfunction, treatment strategies for testicular cancer appeared not to influence sexual dysfunction. The level of erectile dysfunction seen in this sample of TCSs seemed to be higher than the level observed in the general male population and high levels of erectile dysfunction were associated with negative changes in body image. The results suggest that changes in body image are of importance when explaining the variation in sexual dysfunctions, but further prospective studies are needed to clarify this issue.

Sexual functioning of testicular cancer survivors and their partners - A review of literature

BACKGROUND

Testicular cancer (TC) is the most common cancer in the 25-40 age group, with peak morbidity at around 30 years of age. It is a period of highest productivity, when sexual sphere is an important aspect of life. The disease, invasive treatment and its consequences interfere with this sphere.

AIM

The aim of this paper was to review the most recent studies on the sexual functioning of patients treated for testicular cancer and their partners published in English language scientific journals in the period of 1989-2010.

RESULTS

Numerous studies report that men cured from testicular cancer are at risk of sexual disorders. Agents of psychological nature play an important role in the occurrence and persistence of sexual dysfunctions. Being in permanent relationship is a protective factor, while single persons are marked with particular predisposition to such dysfunctions. Sexual and marital satisfaction of TC survivors and their partners are mutually correlated.

CONCLUSION

With a growing number of TC survivors, a thorough investigation is required into their sexuality, both in an individual and dyadic dimension, so as to improve the quality of life of the affected young men, who take on their new social and professional roles in the period of highest reproductiveness.

Sequelae of treatment in long-term survivors of testis cancer

CONTEXT

Testicular cancer patients are often diagnosed at a young age, and because of the advances in the treatment of this disease, the vast majority have a normal life expectancy after therapy. Thus, recognition of the long-term sequelae of treatment (ie, surgery, radiation therapy, and chemotherapy) is particularly important in these patients.

OBJECTIVE

To review the adverse effects and the risk of secondary malignancy in long-term survivors of testicular cancer.

EVIDENCE ACQUISITION

We conducted a Medline search to identify original articles and reviews on the long-term effects of testicular cancer treatment. Although the search included articles from January 1948 to February 2011, the majority of the included articles were published in the last two decades.

EVIDENCE SYNTHESIS

All studies examining the long-term sequelae of treatment in testicular cancer are retrospective in nature, with most classified as cohort, case-control, and/or epidemiologic studies. Given that no standardized method of reporting long-term complications exists, evidence synthesis is limited.

CONCLUSIONS

Recent evidence suggests an increased risk of cardiovascular disease, neurotoxicity, and mild reductions in renal function in survivors of testicular cancer. Treatment of testicular malignancy can also negatively affect gonadal function and fertility and has been shown to result in an increased risk of solid malignancy and leukemia.

Sexual function, depressive symptoms and marital status in nonseminoma testicular cancer patients: a longitudinal study

GOAL

To longitudinally investigate sexual functioning in testicular cancer patients during the first year, and examine the effect of relationship status (with a partner or single) and depressive symptoms on sexual functioning.

PATIENTS AND METHODS

93 testicular cancer patients (39% single) treated in two large referral centers for testicular cancer filled in the International Index of Erectile Function (IIEF) and CES-D after orchiectomy (T1) and 3 (T2) and 12 (T3) months later.

RESULTS

Orgasmic functioning, overall satisfaction and total sexual functioning decreased between T1 and T2 and increased to an above T1 level at T3. Levels of erectile functioning and intercourse satisfaction were higher at T3 than at T1 and T2. Desire remained stable. Type of treatment did not affect sexual functioning. Singles reported worse sexual functioning at all measurement times than committed patients, and comparable desire. One year after surgery, singles also reported worse sexual functioning on three domains when compared with norms. Depressive symptoms were highest and significantly but weakly related to one domain of sexual functioning at T1, to three domains at T2, and to none at T3. Early depressive symptoms had small to moderate predictive power on sexual functioning at T2, but not at T3.

CONCLUSION

Sexual functioning, but not desire, fluctuates during the first year after testicular cancer. Type of treatment and depressive symptoms were no risk factors for sexual dysfunction in the longer term. Singles reported more sexual problems than patients in a relationship and norms, they may need more information and guidance concerning their sexuality.

Sexual function in men treated for testicular cancer

INTRODUCTION

Testicular germ cell cancer (TGCC) patients may be at risk of developing sexual dysfunction after treatment.

AIM

The aim of this study was to assess the prevalence of sexual dysfunctions in TGCC patients 3 to 5 years after treatment, and relate findings to biochemical hypogonadism, treatment intensity, and the expected prevalence in the Swedish male population.

METHODS

A questionnaire study on 129 consecutive TGCC patients 3 to 5 years post-treatment was performed. Comparators were an age-matched nationally representative group of men (N = 916) included in a study on sexual life in Sweden.

MAIN OUTCOME MEASURES

Sexual functions (including erectile dysfunctional distress), time since last intercourse, sexual satisfaction, and experience of sexological treatment seeking were assessed using the same questions used in the epidemiological study on sexual life in Sweden. The findings in TGCC patients were correlated to biochemical signs of hypogonadism and type of oncological treatment: Surveillance, adjuvant chemotherapy, adjuvant radiotherapy, or standard doses of chemotherapy.

RESULTS

A higher proportion of TGCC patients than comparators were likely to report low sexual desire (odds ratio [OR] 6.7 [95% confidence interval {CI} 2.1-21]) as well as erectile dysfunction (OR 3.8 [95% CI 1.4-10]). No significant differences were observed regarding erectile dysfunctional distress, change of desire over time, interest in sex, premature or delayed ejaculation, time since last intercourse, need for or receiving sexual advice, or sexual satisfaction. Hypogonadism did not predict erectile dysfunction (OR 1.1 [95% CI 0.26-4.5]) or low sexual desire (OR 1.2 [95% CI 0.11-14]). Treatment modality had no obvious impact on sexual function.

CONCLUSION

Men treated for testicular cancer had higher risk of having low sexual desire and erectile dysfunction 3 to 5 years after completion of therapy than comparators. These sexual dysfunctions were not significantly associated with treatment intensity or hypogonadism.

Influence of year of diagnosis, patient age, and sociodemographic status on recommending adjuvant radiation treatment for stage I testicular seminoma

PURPOSE

Adjuvant radiation therapy (ART) for stage I seminoma can cause adverse late effects and alternative postorchiectomy management strategies have been developed. This study evaluated ART trends in the United States and the impact of clinical and sociodemographic factors on ART recommendations.

METHODS

Of men diagnosed with stage I seminoma from 1990 through 2004, 3,125 were identified using the Surveillance, Epidemiology, and End Results cancer registry. A multivariable logistic regression analysis was performed to assess whether there was a significant association between diagnosis year, diagnosis age, race, county education level, region, tumor size, tumor category, and the recommendation for ART.

RESULTS

There was a significant association (P < .001) between later year of diagnosis and a decrease in ART recommendation. Compared with men diagnosed in 1990 to 1994, men diagnosed in 1995 to 1999, and 2000 to 2004 were less likely to have ART (adjusted odds ratio [OR], 0.63; 95% CI, 0.48 to 0.84; and OR, 0.49; 95% CI, 0.37 to 0.63, respectively). There also was a significant association (P < .001) between county education level and ART recommendation. Men residing in counties with the highest education level were more likely to receive ART than men residing in counties with the lowest education level (OR, 2.12; 95% CI, 1.59 to 2.82). Also, men older than 30 years were more likely to receive ART than men age 30 or younger (OR, 1.26; 95% CI, 1.03 to 1.55).

CONCLUSION

ART recommendations for stage I seminoma are declining. Men in less educated regions and the youngest men were less likely to receive a recommendation for ART.

Intimacy and sexuality after cancer: a critical review of the literature

Experiencing a diagnosis of cancer may dramatically alter the way a person feels about themselves, their body, and their significant relationships with others at sexual and intimate levels. The purpose of this article is to provide a critical analysis of the way patient sexuality and intimacy has been constructed throughout cancer and palliative care literature. A critique of 3 well-cited communication frameworks for health professionals: the PLISSIT, ALARM, and BETTER models, will be offered. In summary, a dominant emphasis throughout the literature explores the narrow relationship between cancer treatments and the impact of those treatments on patient sexual function or dysfunction, so that patient sexuality and intimacy are inextricably limited to fertility, contraception, menopausal, erectile functional, or capacity for intercourse. Few studies explore sexual or intimate issues that have arisen in the face of life-threatening illness, particularly when patients are older than 65 years. Despite being well cited during the past 30 years, the PLISSIT and ALARM counseling models are outdated in terms of more reflective, patient-centered, and negotiated forms of communication promoted throughout clinical practice guidelines and patient feedback in qualitative research. The BETTER communication model provides a significant step in assessing and documenting the patient's experience of sexuality after cancer.

A comprehensive systematic review of testicular germ cell tumor surveillance

BACKGROUND

Testicular cancer is the most common malignancy in men aged 15-34, and its incidence has been increasing over the past half-century. Survival for stage I testis cancer approaches 100% regardless of management strategy which is often dictated by other factors such as perceived morbidity. Advances in treatment have attempted to decrease morbidity and surveillance is thought to achieve this goal.

METHODS

An English language literature search of MEDLINE from 1966 to December 2005 and CINAHL from 1982 to December 2005 was conducted using a broad search strategy. Comparative and descriptive original articles on outcomes of seminoma or NSGCT surveillance would be deemed eligible and review articles containing no original data were omitted. One hundred and thirty-eight articles were selected for formal review, during which a database was compiled that documented the first author, publication year, tumor histologic type, study purpose or topic(s), methodology, sample size, median follow-up, and relevant results.

RESULTS

Most evidence for the efficacy of surveillance is from descriptive series or non-experimental comparative studies. Relapse occurs in approximately 28% and 17% of surveillance patients in NSGCT and seminoma, respectively, and cause-specific survival is approximately 98% and 100%, respectively. Compliance with surveillance ranges from poor to adequate, however there is no evidence that compliance impacts clinical outcome. Cost analyses have yielded inconsistent results when comparing treatment modalities. There is scant literature on quality of life and psychosocial issues and results are inconsistent. Active surveillance appears to be appropriate and perhaps optimal first line management of clinical stage I seminoma and non-seminomatous germ cell tumors. Further quantitative and qualitative research is warranted to deepen understanding of these issues that may impact treatment decision-making.

Issues of intimacy and sexuality in the face of cancer: the patient perspective

Experiencing a diagnosis of cancer has the potential to dramatically alter the way in which a person experiences intimate and sexual aspects of their lives. This article draws on data from a larger study into issues of intimacy and sexuality from the perspectives of patients and health professionals in cancer and palliative care. A 3-stage reflexive inquiry involved semistructured participant interviews (n = 82), textual analysis of national and international clinical practice guidelines (n = 33), and participant feedback at 15 patient and health professional educational forums. This article will present the analysis of 50 patient interviews, which showed 5 clusters of responses to a cancer diagnosis: "focus on survival," "trust in health professional," "desire for choices," "search for normality," and "need for negotiated communication." Most patients were searching for a reflexive, patient-centered and negotiated style of communication from the health professional of their choice, at a time and in a manner that suited their individual needs. Many patients were disappointed by the lack of information, support, and practical strategies provided by health professionals to assist them to live with the sexual and intimate changes they had experienced in the face of a life-limiting disease. Implications for nursing practice are discussed.

Quality of life in survivors of testicular cancer

The objective of this review was to give an overview of findings concerning quality of life (QOL) in general as well as its domains in survivors of testicular cancer. QOL on the group level was equal to that of men of the same age in the general population. Treatment strategies hardly influenced the QOL. The anxiety level, but not depression, was higher among survivors, while sexual functioning hardly differed from the male population norm. Patients to be treated for testicular cancer should be told about the outlook for good QOL, and the low risk of mental and physical long-term effects.

Sexual functions after high-dose chemotherapy in survivors of germ cell tumors

We investigated the changes in sexual function in male patients with germ cell tumor continuously disease free after one or two courses of high-dose chemotherapy with hematopoietic stem cell support. A questionnaire was mailed to 35 patients, and 30 patients sent it back. Sexuality was considered a problem by 10 patients (33%), but no patients considered sexuality a major problem. Erection was more difficult to achieve in seven patients (23%) and 10 patients (33%) experienced increased difficulty in maintaining an erection. Eight patients (27%) had the experience of less intensive and less frequent orgasm. In all, 13 patients (43%) thought that both the disease and treatment had worsened their sexual capacity, but 20 patients (67%) were satisfied with their sex life. Most of the patients (63%) considered that insufficient information and counselling had been given by their physicians about the sexual sequelae of therapy. However, the amount of information about the disease and treatment was considered good by 77 and 80% of the patients, respectively. This study shows that 27% of patients were not content with their ability to attain sexual satisfaction due to the illness or its treatment. Communication is an important issue and better information tools could lead to improved compliance in these patients.

Male sexuality after cancer treatment--needs for information and support: testicular cancer compared to malignant lymphoma

Testicular cancer (TC) as well as malignant lymphoma (ML), both have nowadays an excellent prognosis. However, both types of cancer may be diagnosed at young adulthood and patients may experience sexual concerns. In this article the need for information and support concerning sexuality will be explored, and the traumatic impact of cancer diagnosis with respect to this will be considered. A total of 264 patients with testicular cancer, median age 36 (S.D. 9.7) years, and 50 patients with malignant lymphoma, median age 42 (S.D. 11.7) years returned a questionnaire concerning sexual functioning; four items assessed the need for information or support concerning sexuality, at diagnosis and at follow-up. It appeared that more than half of the patients with testicular cancer reported a lack of information and support concerning sexuality during treatment; 67% of them still had a need for information at follow-up. These rates were significantly lower for patients with malignant lymphoma. Especially patients with testicular cancer who suffered sexual dysfunction reported extremely high needs for information and support. According to these findings it can be concluded that more attention should be paid to the doctor-patient communication with respect to sexual concerns in general, and especially where it concerns patients with testicular cancer.

Infertility rates following POMB/ACE chemotherapy for male and female germ cell tumours - a retrospective long-term follow-up study

The risk of chemotherapy-induced infertility in male and female germ cell tumour (GCT) survivors is unclear, but may correlate with cisplatin dose. Here, we examine a large series of GCT patients for the effect of chemotherapy on those attempting to have children. Our GCT database was screened for nonseminomatous GCT patients who had (1) received POMB/ACE chemotherapy (cisplatin, vincristine, methotrexate, bleomycin alternating with actinomycin D, cyclophosphamide and etoposide) and (2) stage I male GCT patients who were untreated between 1977 and 1996. Fertility was assessed by questionnaire and medical records. A total of 64 of 153 treated and 35 of 115 untreated men attempted to have children. In all, 28% (18 out of 64) receiving POMB/ACE were unsuccessful. Radiotherapy (six), atrophic remaining testis (one) or prior infertility (three) were implicated in 10 cases, so chemotherapy-induced infertility may have occurred in only 11% (eight out of 64). Strikingly, 26% (nine out of 35) of untreated stage I patients also failed to have children (three had radiotherapy, three prior infertility). Moreover, in treated men, no association was seen between cisplatin dose and infertility. In contrast, radiotherapy significantly increased male infertility (P=0.001). Of 28 treated women who attempted to have children, 25% (seven out of 28) were unsuccessful. One previously had infertility and one subsequently had successful IVF so chemotherapy-induced infertility potentially occurred in only 18% (five out of 28) and was not related to cisplatin dose. In conclusion, the risk of chemotherapy-induced infertility is low in both male and female GCT patients and does not clearly correlate with the cumulative cisplatin dose.

Fatigue, anxiety, and depression in long-term survivors of testicular cancer

PURPOSE

To investigate the prevalence of chronic fatigue (CF), the levels of anxiety and depression, and the correlation between these conditions in long-term survivors of testicular cancer (TCSs). Occurrence of CF in TCSs is compared with findings in male survivors of Hodgkin's disease (HDSs) and in males from the general population (GenPop).

METHODS

TCSs, HDSs, and two cohorts of the GenPop completed the Fatigue Questionnaire (FQ) and the Hospital Anxiety and Depression Scale (HADS) as part of a questionnaire survey. Cases of CF were identified according to published cut-offs, and the levels of anxiety (HADS-A) and depression (HADS-D) were calculated.

RESULTS

Among 791 TCSs, 16% displayed CF (HDSs, 24%; GenPop, 10%). In the age group younger than 30 years, the prevalence of CF was higher in TCSs than in the GenPop (P <.01). In TCSs, age, anxiety, depression, and comorbidity were independent predictors of CF. The mean HADS-A score in TCSs was significantly above the comparable figure of the GenPop and similar to that of HDSs. The mean HADS-D score in TCSs was below that of the GenPop. The highest and lowest mean scores of HADS-A and HADS-D were observed in the youngest TCSs.

CONCLUSION

The prevalence of CF is less in TCSs than in HDSs but exceeds that of the GenPop. Together with comorbidity and age, anxiety and depression predict CF in TCSs, warranting psychiatric intervention for cases of CF among TCSs. Anxiety is a larger problem in TCSs than depression, particularly among the youngest TCSs.

Quality of life in good prognosis patients with metastatic germ cell cancer: a prospective study of the European Organization for Research and Treatment of Cancer Genitourinary Group/Medical Research Council Testicular Cancer Study Group (30941/TE20)

PURPOSE

To describe global quality of life (GLQL) in patients with metastatic testicular cancer (TC) treated with four different schedules of bleomycin, etoposide, and cisplatin (BEP) chemotherapy (four v three cycles given over 5 v 3 days).

PATIENTS AND METHODS

Quality-of-life data were prospectively collected in 666 patients with metastatic TC entered into the European Organization for Research and Treatment of Cancer (EORTC) Trial 30941/United Kingdom Medical Research Council Trial TE20, using the EORTC Quality-of-Life Questionnaire C30 and a TC module. Data were analyzed by a mixed effects model and by evaluation of clinically relevant changes at 2 years.

RESULTS

The pattern of GLQL changes was similar in the four groups. Two years after chemotherapy, 36% of patients displayed improved GLQL as compared with baseline, whereas GLQL had deteriorated in 13%. At 3 months, patients receiving the 3-day regimen experienced increased gastrointestinal (GI) toxicity more than those receiving the 5-day regimen, with the difference reaching the level of clinical relevance (>or = 10-point change) if four cycles were given. The 3-day schedule increased the 2-year risk of tinnitus, with clinical relevance demonstrated after four cycles. Long-term peripheral neuropathy and Raynaud-like phenomena were not associated with the number of cycles or days per cycle. At 2 years, Raynaud-like phenomena, tinnitus, or reduced hearing were reported by 21% to 26% of the patients.

CONCLUSION

Because of the excess of acute GI toxicity and the increased risk of tinnitus after the 3-day regimen, we recommend the 5-day regimen if four cycles of BEP are planned. If only three cycles are to be given, then the 3-day regimen is acceptable, even given the increased risk of nausea/vomiting at 3 months.

Ejaculatory function in stage T1 nonseminomatous germ cell tumors: retroperitoneal lymph node dissection versus surveillance--a decision analysis

PURPOSE

Ejaculatory function remains a major concern for patients with low stage nonseminomatous germ cell tumors of the testis. Whereas, it has been extensively studied in patients undergoing retroperitoneal lymph node dissection, preservation of ejaculatory function on surveillance protocols has not been studied. To compare ejaculatory function for surveillance protocols to primary retroperitoneal lymph node dissection appropriately, we constructed a decision analysis model mimicking the standard treatment algorithm for stage 1 nonseminomatous germ cell tumor of the testis.

MATERIALS AND METHODS

The primary clinical payoff for this study is ejaculatory function. Based on this model, we established that a primary nerve sparing retroperitoneal dissection must be performed with a 96.8% ejaculatory function rate to be recommended as the appropriate therapy. However, if a highly skilled surgeon routinely performs post-chemotherapy dissection with an ejaculatory function rate of 69.2% or greater, surveillance should be offered as the primary treatment modality. This result simply demonstrates a high skill level to allow the surgeon to salvage ejaculatory function in post-chemotherapy retroperitoneal lymph node dissection settings. If this level cannot be achieved, primary retroperitoneal lymph node dissection is the best choice. If we account for a 10% loss of ejaculatory function from primary chemotherapy, the minimum ejaculatory function rate for primary retroperitoneal dissection decreases to 95.7%.

RESULTS

In the post-chemotherapy setting an 85.7% ejaculatory function rate must be achieved for surveillance to be considered the optimal choice. Clearly, less surgical rigor is needed with a primary retroperitoneal lymph node dissection when correcting for the effects of chemotherapy on ejaculatory function. Despite this fact, 1-way sensitivity analysis revealed that our model is insensitive to the ejaculatory function effects of chemotherapy. Furthermore, if the likelihood of recurrence on surveillance is greater than 16%, primary nerve sparing retroperitoneal lymph node dissection should again be recommended.

CONCLUSIONS

Thus, to maximize ejaculatory function for patients with stage 1 nonseminomatous germ cell tumor a nerve sparing primary retroperitoneal lymph node dissection should always be performed, unless the likelihood of recurrence on surveillance is low or the surgical skill level allows for a highly successful post chemotherapy nerve sparing dissection.

Treatment outcome, body image, and sexual functioning after orchiectomy and radiotherapy for Stage I-II testicular seminoma

PURPOSE

Orchiectomy followed by infradiaphragmatic irradiation is the standard treatment for Stage I-II testicular seminoma in The Netherlands. Because body image and sexual functioning can be affected by treatment, a retrospective study was carried out to assess treatment outcome, body image, and changes in sexuality after orchiectomy and radiotherapy.

METHODS AND MATERIALS

The medical charts of 166 patients with Stage I-II testicular seminoma were reviewed. A questionnaire on body image and current sexual functioning regarding the frequency and quality of erections, sexual activity, significance of sex, and changes in sexuality was sent to 157 patients (at a mean of 51 months after treatment).

RESULTS

Seventy-eight percent (n = 123, mean age 42 years) completed the questionnaire. During irradiation, almost half of patients experienced nausea and 19% nausea and vomiting. Only 3 patients had disease relapse. After treatment, about 20% reported less interest and pleasure in sex and less sexual activity. Interest in sex, erectile difficulties, and satisfaction with sexual life did not differ from age-matched healthy controls. At the time of the survey, 17% of patients had erectile difficulties, a figure that was significantly higher than before treatment, but which correlated also with age. Twenty percent expressed concerns about fertility, and 52% found their body had changed after treatment. Cancer treatment had negatively influenced sexual life in 32% of the patients.

CONCLUSIONS

Orchiectomy with radiotherapy is an effective and well-tolerated treatment for Stage I-II testicular seminoma. Treatment-induced changes in body image and concerns about fertility were detected, but the sexual problems encountered did not seem to differ from those of healthy controls, although baseline data are lacking.

Self-perceived physical, psychologic, and general symptoms in survivors of testicular cancer 3 to 13 years after treatment

Due to the large group of patients with advanced testicular cancer now being cured, it is important to identify the men who are at risk of deteriorated health. The purposes of this study were: (1) to delineate and compare frequency of self-perceived physical, psychologic, and general symptoms in men treated for testicular cancer with those of a general population sample and (2) to compare self-perceived physical, psychologic, and general symptoms in relation to secondary Raynaud phenomena, sexual dysfunction, infertility, and self-perceived attractiveness in different treatment modalities. The subjects were 277 survivors of testicular cancer (M = 42.2 years) who had completed a self-reported questionnaire (75.5% response rate). A population survey comprising 392 men was used as a comparison group (M = 45 years). The result demonstrated that although survivors of testicular cancer as a group reported significantly less frequency of backache, leg pain, cough, and eye problems than did the general population sample, they described that they significantly more often felt cold. Men reporting secondary Raynaud phenomena, infertility, and/or feeling less attractive had experienced significantly more self-perceived symptoms. Oncologist nurses could play an important role in psychologic counseling for those men.

Quality of life in long-term survivors of testicular cancer: a population-based case-control study

PURPOSE

To evaluate quality of life and social problems in long-term survivors of testicular cancer.

PATIENTS AND METHODS

In 1998, 71 testicular cancer survivors (cases) identified from the Calvados General Tumor Registry were enrolled onto a case-control study. One hundred nineteen healthy control subjects (controls), matched by age and location of residence, were selected at random from electoral rolls. Three self-administered questionnaires were used: two health-related quality-of-life questionnaires (Short Form-36 and European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-C30 core questionnaires) and one life situation questionnaire. Specific questions concerning sexuality were also added.

RESULTS

With a mean follow-up of 11 years, health-related quality-of-life scores did not differ significantly between cases and controls, nor did general symptom scores. Psychosocial problems were reported equally by cases and controls. Cases reported more modification of sexual life (P =.04) with decreased sexual enjoyment (P <.01), decreased desire (P =.02), and infertility (P <.01). Cases did not report more divorce than controls; they reported fewer changes in relationships with friends (P =.03). Although a similar proportion of cases and controls were at work, cases expressed less ambitious professional plans (P =.002). Cases had greater difficulty in borrowing from banks (P <.001).

CONCLUSION

French long-term survivors of testicular cancer do not express more impairment of health-related quality of life or familial or professional life in comparison with healthy men. They did have more sexual life problems and found difficulty in borrowing from banks. This information should be used by practitioners to help their patients cope with their disease and return to normal life.

Testicular implants and patient satisfaction: a questionnaire-based study of men after orchidectomy for testicular cancer

OBJECTIVES

To assess the satisfaction of men with their testicular implants after undergoing orchidectomy for testicular cancer, and to determine their reasons for accepting or declining a prosthesis.

PATIENTS AND METHODS

In all, 424 men who had undergone radical orchidectomy and were part of the testicular cancer follow-up programme were sent an anonymous questionnaire comprising 10 questions covering two main areas. First, the reasons for accepting or declining an implant and second (if they received an implant) their satisfaction with the size, position, feel, shape and overall comfort; 234 men (55%) responded.

RESULTS

About a third (71 men) accepted an implant, a third declined and a third were not offered the choice. Of the men who replied 91% felt that it was extremely important to be offered an implant at the time of surgery. Of the 71 who received an implant, 19 (27%) were dissatisfied and felt that they had an average or poor cosmetic result. The reasons for this dissatisfaction are presented and discussed.

CONCLUSIONS

All men undergoing orchidectomy should be offered a testicular implant, irrespective of age. Sample implants in all sizes should be available in the outpatient department. This will give men realistic expectations and allow them to choose a suitable size of implant. The dimensions of the available implants should be improved to create a more elliptical prosthesis, to avoid dissatisfaction with the shape. Adequate fixation to the base of the scrotum is important to avoid the 'high riding' implant.

The impact of chemotherapy on Leydig cell function in long term survivors of germ cell tumors

BACKGROUND

Because patients with germ cell tumors expect an additional life span of around 50 years after successful treatment, attention is now focused on potential long term toxicity. Limited data are available on Leydig cell function in long term survivors.

METHODS

The authors measured testosterone, sex hormone binding-globulin (SHBG), luteinizing hormone (LH), and follicle-stimulating hormone (FSH) levels in 244 patients with germ cell tumors. Patients were divided into three groups: Group 1 had received no chemotherapy (n = 58 patients), Group 2 had received cumulative doses of cisplatin < or = 400 mg/m(2) (n = 117 patients), and Group 3 had received cumulative doses of cisplatin > 400 mg/m(2) (n = 69 patients). The median times from chemotherapy were 74 months and 75 months in Groups 2 and 3, respectively.

RESULTS

Subnormal testosterone levels (< 10 nmol/L) were found in 5%, 11%, and 20% in Groups 1, 2, and 3, respectively (Group 1 vs. Group 3; P = 0.02). The mean testosterone level and the testosterone/SHBG ratio did not differ significantly between Groups 1 and 2; however, they did differ between Groups 1 and 3 (testosterone: 17.0 nmol/L vs. 14.9 nmol/L, respectively; P = 0.02; testosterone/SHBG ratio: 0.70 vs. 0.59; P < 0.05). There was a significant inverse correlation between the testosterone/SHBG ratio and LH (correlation coefficient [r] = -0.25; P = 0.0002). A significant positive correlation was found for LH and FSH (r = 0.78; P < 0.0001), indicating a strong association between Leydig cell dysfunction and germinal epithelial damage.

CONCLUSIONS

Standard doses of cisplatin-based chemotherapy do not lead to a significant deterioration of Leydig cell function in long term survivors of germ cell tumors. In contrast, high cumulative doses of chemotherapy cause a significant and persistent impairment of Leydig cell function. More data are needed regarding the clinical relevance of moderate testosterone deficiency. Further research is necessary to determine whether some patients may benefit from testosterone replacement.

Fertility and sexual function following orchiectomy and 2 cycles of chemotherapy for stage I high risk nonseminomatous germ cell cancer

PURPOSE

We investigate fertility and sexual function in patients following orchiectomy and adjuvant cisplatin based chemotherapy for high risk, stage I nonseminomatous germ cell tumor of the testis.

MATERIALS AND METHODS

Between 1985 and 1994, 59 patients with stage I nonseminomatous germ cell tumor and poor prognostic factors were treated with 2 cycles of cisplatin, vinblastine and bleomycin, or bleomycin, etoposide and cisplatin after orchiectomy. At least 32 months following treatment all patients were contacted and asked to complete a questionnaire regarding fertility and sexual activity, and to volunteer for a semen and hormonal analysis.

RESULTS

Of the 59 patients 49 (83%) completed the questionnaire. Before chemotherapy 18 (37%) patients had fathered children, 6 (12%) were involuntarily childless and none had a major sexual dysfunction. After treatment 11 (22%) patients fathered children, and 5 (10%) were involuntarily childless, with 4 involuntarily childless before chemotherapy. There were no significant alterations in sexual function. Semen analysis in 27 patients was normal in 23, and revealed mild oligospermia in 2 and azoospermia in 2. In 18 patients with hormone analysis median values for luteinizing hormone and free testosterone were normal but median value for follicle-stimulating hormone was slightly increased.

CONCLUSIONS

Two cycles of cisplatin based adjuvant chemotherapy do not seem to affect adversely fertility or sexual activity.

Objective and subjective effects of treatment for testicular cancer on sexual function

OBJECTIVE

To determine whether the treatment of patients with testicular cancer, using cisplatin combined with etoposide and bleomycin (BEP) after orchidectomy in those with disseminated disease, causes changes in sex hormones and penile vascularization, possibly related to sexual dysfunction.

PATIENTS AND METHODS

Ten patients treated with BEP were compared with 11 undergoing orchidectomy alone followed by surveillance. Sex hormone levels were analysed and cavernosal artery duplex ultrasonography performed before orchidectomy and at 6 and 12 months afterward. Patients were questioned about their sexual function. After 1 year, a visual erotic stimulation (VES) test was performed to assess penile rigidity.

RESULTS

In contrast to the surveillance group, BEP-treated patients had higher follicle-stimulating hormone (4.6 vs 26.5 U/L) and luteinizing hormone (1.4 vs 8.2 U/L) levels, and lower testosterone levels (21.1 vs 14.7 nmol/L) at 6 months than at baseline. At 1 year, most patients had compensated hypergonadotrophic eugonadism, but Leydig cell function had recovered. Changes in cavernosal artery peak flow velocities induced by local injection with papaverine/phentolamine showed no difference between the groups before and 6 months after orchidectomy. Loss of libido and erectile dysfunction were reported more frequently by BEP-treated patients. However, 1 year after treatment, most reported a satisfying sex life and VES resulted in a rigid erection in nearly all patients. The reported erectile dysfunction could not be explained by changes in plasma testosterone levels or diminished blood flow velocities.

CONCLUSIONS

After being diagnosed with testicular cancer, sexual morbidity is considerable, but within 1 year some improvement may be expected. BEP induces transient testicular dysfunction but this recovers. Although BEP is related to symptoms of angiopathy, cavernosal blood flow seems to be unaffected. These findings and the normal VES-evoked penile rigidity suggest that sexual dysfunction is more psychological than organically induced by BEP.

Health-related quality of life in patients treated for testicular cancer

Cross-sectional studies have shown that long-term health-related quality of life is satisfactory in the majority of testicular cancer patients, in spite of slight to moderate physical morbidity (sexual dysfunction, infertility) in at least a third of them. Modern risk-adapted treatment of testicular cancer patients will hopefully decrease the long-term sequelae furthermore. Prospective studies are needed to identify those patients at increased risk of developing major physical or psychosocial problems, and to study the role of medical and psychological intervention at an early phase of the clinical course in these patients. The long-term investigation and follow-up of testicular cancer survivors provide useful information on survivorship problems in cured cancer patients in general.

Long-term effects on sexual function and fertility after treatment of testicular cancer

This retrospective study evaluates the types and incidences of sexual disturbances and fertility distress in patients cured from testicular cancer and examines whether there is an effect resulting from different treatment modalities. A self-reported questionnaire was sent to 124 randomly selected patients who were treated at Hanover University Medical School between 1970 and 1993. Ninety-eight patients were included in the study, representing a response rate of 78%. All patients had been in complete remission (CR) for at least 24 months. The median age at diagnosis was 28 years (range 17-44). The median follow-up at the time of study was 12.0 years (range 2.8-25.6). Twenty patients (20%) had been treated for seminomatous and 78 patients (80%) for non-seminomatous germ cell tumours. Treatment included surveillance (7%), primary retroperitoneal lymph node dissection (RPLND) (13%), chemotherapy (CT) (33%), CT + secondary resection of residual retroperitoneal tumour mass (SRRTM) (43%) and infradiaphragmatic radiotherapy (4%). Patients receiving two treatment modalities (CT+SRRTM) reported more frequent an unfulfilled wish for children. Inability of ejaculation was clearly associated with RPLND and SRRTM. Subjective aspects of sexuality, like loss of sexual drive and reduced erectile potential, occurred only in a minority of patients after treatment. No abnormalities were observed concerning the course of pregnancies of partners. In conclusion, sexual dysfunction and infertility are common long-lasting sequelae in testicular cancer survivors affecting approximately 20% of patients. The relative risk for infertility appeared to be elevated for patients treated with the combination of CT+SRRTM. Twenty-one of 40 patients were able to fulfil their wish for children, and no congenital abnormalities were observed in these children.