Effect of androgen deprivation therapy on sexual function and bother in men with prostate cancer: A controlled comparison

Ejaculatory function after radiotherapy for prostate cancer: a systematic review and meta-analysis

BACKGROUND

Scant data exists on the impacts of prostate radiation on ejaculatory function. We performed a systematic review and meta-analysis to assess ejaculatory outcomes in men after prostate radiation.

METHODS

We queried PubMed, Embase, and Web of Science to identify 17 articles assessing ejaculatory function post-radiation. The primary outcome was anejaculation rate and secondary outcomes included ejaculatory volume (EV), ejaculatory discomfort, and mean decline in ejaculatory function scores (EFS). We assessed study quality with the Newcastle-Ottawa scale. We calculated pooled proportions using inverse variance and random effects models.

RESULTS

We identified 17 observational studies with 2156 patients reporting ejaculatory profiles post-radiation. Seven studies utilized external beam radiation therapy, 7 brachytherapy, 1 stereotactic RT and 2 utilized either external or brachytherapy. Ten studies reported an anejaculation rate. Pooled proportion of patients having anejaculation, decreased EV and EjD were 18% (95% CI, 11-36%), 85% (95% CI, 81-89%) and 24% (95% CI, 16-35%), respectively. Five studies reported decline in EFS post-radiation.

CONCLUSIONS

Patients receiving radiation treatment may experience significant changes in their ejaculation, such as the absence of ejaculation, reduced EV, and EjD. It is important to counsel them about these potential side effects.

Effectiveness of educational and psychological survivorship interventions to improve health-related quality of life outcomes for men with prostate cancer on androgen deprivation therapy: a systematic review

OBJECTIVES

Androgen deprivation therapy (ADT), a common treatment for prostate cancer, has debilitating impacts on physical and psychological quality of life. While some interventions focus on managing the physical side effects of ADT, there is a paucity of interventions that also address psychosocial and educational needs. The objective of this systematic review was to identify psychological and educational survivorship interventions targeting health-related quality of life (HRQoL) outcomes in men on ADT.

DESIGN

A systematic review of randomised controlled trials.

DATA SOURCES

Web of Science, Cochrane, EBSCO Host, PubMed, SCOPUS from inception (1984) to 28 January 2023.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Psychological and/or educational survivorship interventions targeting HRQoL outcomes for men on ADT; minimum 80% of participants on ADT; used a validated HRQoL outcome measure; published in English in a peer-reviewed journal.

DATA EXTRACTION AND SYNTHESIS

Data extraction using pre-specified study criteria was conducted. Heterogeneity of eligible studies precluded a meta-analysis.

RESULTS

A total of 3381 publications were identified with eight meeting the criteria. Interventions were either psychological with a cognitive behavioural approach (n=4), or educational with (n=2) or without (n=2) psychoeducational components.Two studies reported a statistically significant improvement using a specific HRQoL measure. Most studies were not adequately powered and/or included small sample sizes limiting the conclusions that can be drawn on effectiveness. The most effective interventions were (i) individually based, (ii) educational with a psychoeducational component, (iii) supplemented with information packages and/or homework and (iv) included personalised needs assessments.

CONCLUSION

There is a paucity of literature reporting psychological and educational survivorship interventions targeting HRQoL outcomes for men on ADT. What is urgently needed are person-centred survivorship interventions that are flexible enough to identify and address individual needs, taking into account the impact ADT has on both physical and psychological quality of life.

PROSPERO REGISTRATION NUMBER

CRD4202230809.

Impact of neoadjuvant relugolix on patient-reported sexual function and bother

Introduction

Sexual function following local treatment for prostate cancer is an important quality of life concern. Relugolix is a novel oral GnRH receptor antagonist used in combination with radiation therapy in the treatment of unfavorable prostate cancer. It has been shown to achieve rapid and profound testosterone suppression. As a result, these very low testosterone levels may impact both sexual functioning and perceptions. This prospective study sought to assess neoadjuvant relugolix-induced sexual dysfunction prior to stereotactic body radiation therapy (SBRT).

Methods

Between March 2021 and September 2023, 87 patients with localized prostate cancer were treated with neoadjuvant relugolix followed by SBRT per an institutional protocol. Sexual function and bother were assessed via the sexual domain of the validated Expanded Prostate Index Composite (EPIC-26) survey. Responses were collected for each patient at pre-treatment baseline and after several months of relugolix. A Utilization of Sexual Medications/Devices questionnaire was administered at the same time points to assess erectile aid usage.

Results

The median age was 72 years and 43% of patients were non-white. The median baseline Sexual Health Inventory for Men (SHIM) score was 13 and 41.7% of patients utilized sexual aids prior to relugolix. Patients initiated relugolix at a median of 4.5 months (2-14 months) prior to SBRT. 95% and 87% of patients achieved effective castration (≤ 50 ng/dL) and profound castration (< 20 ng/dl) at SBRT initiation, respectively. Ability to have an erection, ability to reach orgasm, quality of erections, frequency of erections, and overall sexual function significantly declined following relugolix. There was a non- significant increase in sexual bother.

Discussion

In concordance with known side effects of androgen deprivation therapy (ADT), neoadjuvant relugolix was associated with a significant decline in self-reported sexual function. However, patients indicated only a minimal and non-significant increase in bother. Future investigations should compare outcomes while on relugolix directly to GnRH agonist-induced sexual dysfunction.

Enzalutamide and Quality of Life in Biochemically Recurrent Prostate Cancer

BACKGROUND: EMBARK, a controlled trial reported elsewhere, showed enzalutamide plus leuprolide (combination) and enzalutamide monotherapy prolonged metastasis-free survival versus placebo plus leuprolide (alone) in patients with high-risk biochemically recurrent prostate cancer. Health-related quality of life was also analyzed but not reported. METHODS: In EMBARK, patients with biochemical recurrence (prostate-specific antigen doubling time of ≤9 months) were randomly assigned (1:1:1) to combination (n=355), leuprolide-alone (n=358), or enzalutamide monotherapy (n=355). In this article we provide the patient-reported outcomes (PROs) from EMBARK at baseline and every 12 weeks until metastasis or death. The key end point was time to first and confirmed clinically meaningful deterioration (TTFD/TTCD) in pain and health-related quality of life using four PRO measures and predefined thresholds. RESULTS: At baseline, all groups had high health-related quality of life. For worst pain, the median TTFD was 19.35 months with leuprolide alone, 13.93 months with combination (hazard ratio, 1.08; 95% confidence interval [CI], 0.89 to 1.30) and 16.59 months with monotherapy (hazard ratio, 1.09; 95% CI, 0.90 to 1.31). The median TTCD was 66.27 months with leuprolide alone, 80.00 months with combination (hazard ratio, 0.82; 95% CI, 0.65 to 1.04), and 60.91 months with monotherapy (hazard ratio, 1.02; 95% CI, 0.82 to 1.28). For Functional Assessment of Cancer Therapy–Prostate total score, the median TTFD was 11.10 months with leuprolide alone, 8.31 months with combination (hazard ratio, 1.14; 95% CI, 0.95 to 1.36), and 8.38 months with monotherapy (hazard ratio, 1.17; 95% CI, 0.98 to 1.39). The median TTCD was 36.53 months with leuprolide alone, 38.77 months with combination (hazard ratio, 1.04; 95% CI, 0.85 to 1.28), and 30.55 months with monotherapy (hazard ratio, 1.16; 95% CI, 0.95 to 1.41). CONCLUSIONS: The PROs from EMBARK show that both enzalutamide combination and monotherapy versus leuprolide alone, with oncologic benefits noted above, preserved high health-related quality of life in patients with high-risk biochemical recurrence of prostate cancer. (Funded by Pfizer and Astellas Pharma; ClinicalTrials.gov number, NCT02319837.)

Testosterone and aging male, a perspective from a developing country

PURPOSE

Hypogonadism is associated with a wide range of physical and psychological symptoms that can affect the overall health of men. However, in a developing country, there are several imposing challenges in the diagnosis and treatment of hypogonadism, including a lack of awareness and understanding of the condition among healthcare providers and patients, limited resources and the high cost of treatment. This review aimed to examine the potential benefits and risks of testosterone replacement therapy (TRT) and provides a perspective of a developing country on the topic.

MATERIALS AND METHODS

A comprehensive literature review was conducted to gather relevant information on the impact of testosterone deficiency on ageing males and the effectiveness of TRT for treating hypogonadism. Published peer-reviewed articles were analyzed to evaluate the benefits and risks of TRT. Additionally, the unique challenges faced in the diagnosis and treatment of hypogonadism in a developing country were considered.

RESULTS

Testosterone replacement therapy has been shown to be an effective treatment for hypogonadism, particularly in symptomatic men with low testosterone levels. It offers potential benefits such as improvements in symptoms and overall quality of life. However, there are associated risks and side effects that need to be considered. In a developing country, challenges such as limited awareness and understanding of hypogonadism, resource constraints, and high treatment costs pose additional barriers to accessing TRT and comprehensive care.

CONCLUSION

In conclusion, TRT holds promise as a treatment for hypogonadism, but its implementation and accessibility face significant challenges in a developing country. Addressing these challenges, including raising awareness, allocating resources, and finding cost-effective solutions, is crucial for ensuring that men with hypogonadism in such settings receive appropriate diagnosis and treatment. Further research and efforts are needed to improve the management of hypogonadism in developing countries and optimize the potential benefits of TRT for affected individuals.

Marital status and perceived stress in men with advanced prostate cancer: A randomized-controlled trial of cognitive behavioral stress management

OBJECTIVE

Relationship status predicts numerous outcomes among medical populations. Few interventions evaluate the role of marital status on response to psychosocial treatment, and no such studies exist within advanced prostate cancer (APC). This study examined whether marital status modified the effect of a cognitive behavioral stress management (CBSM) intervention on perceived stress.

METHODS

Men with APC (N = 190) were randomized to 10-week CBSM or a health promotion (HP) intervention (#NCT03149185). The Perceived Stress Scale assessed perceived stress at baseline and 12-month follow-up. Medical status and sociodemographics were captured at enrollment.

RESULTS

Participants were mostly White (59.5%), non-Hispanic (97.4%), heterosexual (97.4%) men, 66.8% of whom were partnered. Neither condition nor marital status predicted perceived stress change at follow-up. However, a significant interaction was found between condition and marital status (p = 0.014; Cohen's f = 0.07), such that partnered men who received CBSM and unpartnered men who received HP reported greater reductions in perceived stress.

CONCLUSION

This is the first study to assess the impact of marital status on psychosocial intervention effects among men with APC. Partnered men derived greater benefit from a cognitive-behavioral intervention and unpartnered men equally benefitted from a HP intervention. Further research is necessary to understand the mechanisms underlying these relationships.

Pituitary-testis axis dysfunction following adjuvant androgen deprivation therapy

Men with high-risk, non-metastatic prostate cancer receive adjuvant androgen deprivation therapy (ADT) for at least 2 years according to Danish guidelines. It remains unclarified if patients regain the function of the pituitary-testis axis after cessation of ADT. Thus, we aimed to investigate the function of the pituitary-testis axis following adjuvant ADT. In this study, we included men who underwent external beam radiation therapy and ADT for high-risk prostate cancer. All patients underwent assessment of testosterone deficiency (TD) symptoms, full biochemical assessment of the pituitary-testis axis, and dynamic stimulatory tests of gonadotropin (gonadotropin-releasing hormone (GnRH) test) and testosterone production (human chorionic gonadotrophin (hCG) test). Patients were diagnosed with TD based on a combination of TD symptoms and testosterone below age-specific reference ranges. TD was characterized as primary, secondary, or mixed based on serum gonadotropins and stimulatory tests. We found that among the 51 patients included in the study, the median time on ADT was 3.2 years and median time since ADT cessation was 3.8 years. Twenty-eight patients were diagnosed with TD; 10 had primary TD (testicular dysfunction), 11 secondary TD (pituitary dysfunction), and 7 mixed TD (combined pituitary and testicular dysfunction). An inadequate testosterone response to hCG stimulation was shown in 42 patients, whereas only 11 patients had a subnormal gonadotropin response to GnRH. We conclude that persistent TD is a common long-term consequence of adjuvant ADT in prostate cancer survivors, equally distributed between pituitary and testicular dysfunction. The study emphasizes the necessity for systematic follow-up of full pituitary-testis axis function in patients receiving adjuvant ADT.

Symptom burden profiles in men with advanced prostate cancer undergoing androgen deprivation therapy

To identify symptom burden profiles among men with advanced prostate cancer undergoing androgen-deprivation therapy and examine their association with baseline sociodemographic and medical characteristics and psychosocial outcomes over time. Latent profile analysis was employed to identify distinct groups based on the Expanded Prostate Index Composite and the McGill Pain Questionnaire at baseline. Psychosocial outcomes were assessed at baseline, 6- and 12-month follow-ups. Three profiles emerged: "high symptom burden," "high sexual bother," and "low symptom burden." Men with "high symptom burden" were younger and exhibited higher baseline levels of depression, stress, cancer-specific distress, and anxiety than men in the other two groups. However, men with "high symptom burden" also demonstrated improvement in these psychosocial outcomes over time. Men with advanced prostate cancer who experience multiple co-occurring symptoms demonstrate worse psychosocial adjustment. Patients with substantial symptom burden, and specifically young men, may benefit from prompt referral to supportive care services.

Medical therapies causing iatrogenic male infertility

Primum non nocere. As physicians, our goal is to treat illnesses and alleviate suffering; however, in doing so, we can generate new problems in a game of medical whack-a-mole. For some patients, certain consequences or side effects are tolerable, while others may believe they have no alternative. For a male patient with infertility, a thorough history is imperative to elucidate whether the patient has been or is currently being exposed to medications that will harm libido, spermatogenesis, ejaculation, or the hypothalamic-pituitary-testosterone axis. This article will review the most common medications causing iatrogenic male infertility as well as options to minimize or even reverse their impact.

Hormone-Dependent Tumors and Sexuality in the Neuro-Oncology of Women (N.O.W.): Women's Brain Tumors, Gaps in Sexuality Considerations, and a Need for Evidence-Based Guidelines

PURPOSE OF REVIEW

While females make up almost 60% of all brain and spinal cord tumors in adults, guidelines that address women's issues in neuro-oncology are lacking. This review sheds light on two common women's issues in neuro-oncology.

RECENT FINDINGS

Neuro-oncology providers are often faced with patient questions about fertility and pregnancy maintenance or prevention and typically respond with generic cancer chemotherapy recommendations, based on the paucity of evidence on the use of common neuro-oncology chemotherapies and pregnancy. While these remain important gap issues, there are several other poorly researched issues in the Neuro-Oncology of Women (N.O.W.) including recommendations around endogenous and iatrogenic hormone exposure and female sexuality in cancer. As a significant percentage of cancers are hormone-dependent, it is important to understand how changes in hormone levels impact tumor biology over the course of a woman's lifespan. Furthermore, greater attention should be given to the impact of tumors and tumor treatments on female sexuality. This article is intended to serve as an introduction to these two specific subjects within the vast expanse of N.O.W. subject matter.

Patient-reported outcomes after Low-dose-rate versus High-dose-rate brachytherapy boost in combination with external beam radiation for intermediate and high risk prostate cancer

PURPOSE

Addition of a brachytherapy boost to external beam radiation therapy (EBRT) reduces prostate cancer (PCa) recurrence at the expense of genitourinary (GU) toxicity. Whether brachytherapy boost technique, specifically low-dose-rate (LDR-BT) versus high-dose-rate (HDR-BT), impacts treatment-related toxicity is unclear.

METHODS

Between 2012-2018, 106 men with intermediate/high risk PCa underwent EBRT (37.5-45 Gy in 1.8-2.5 Gy/fraction) plus brachytherapy boost, either with LDR-BT (110 Gy I-125 or 100 Gy Pd-103; n = 51) or HDR-BT (15 Gy x1 Ir-192; n = 55). Patient-reported outcomes (PRO) were assessed by International Prostate Symptom Score (IPSS) and Expanded Prostate Cancer Index Composite (EPIC-CP) surveys at 3-6-month intervals for up to three years following treatment, with higher scores indicating more severe toxicity. Provider-reported GU and gastrointestinal (GI) toxicity was graded per CTCAE v5.0 at each follow-up. Linear mixed models comparing PROs between LDR-BT versus HDR-BT were fitted. Stepwise multivariable analysis (MVA) was performed to account for age, gland size, androgen deprivation therapy use, and alpha-blocker medication use. Incidence rates of grade 2+ GU/GI toxicity was compared using Fisher's exact test.

RESULTS

Use of LDR-BT was associated with greater change in IPSS (p=0.003) and EPIC-CP urinary irritative score (p = 0.002) compared with HDR-BT, but effect size diminished over time (LDR-BT versus HDR-BT: baseline to 6-/24-month mean IPSS change, +6.4/+1.4 versus +2.7/-3.0, respectively; mean EPIC-CP irritative/obstructive change, +2.5/+0.1 versus +0.9/+0.1, respectively). Results remained significant on MVA. Post-treatment grade 2+ GU toxicity was significantly higher in the LDR-BT group (67.5% versus 42.9% for LDR-BT and HDR-BT, respectively; p <0.001). There were no differences between groups in incontinence, bowel function, and erectile function, or grade 2+ GI toxicity.

CONCLUSION

Compared with LDR-BT, HDR-BT was associated with lower acute patient- and provider-reported GU toxicity.

Prevalence of erectile dysfunction in male survivors of cancer: a systematic review and meta-analysis of cross-sectional studies

Background

Prevalence of erectile dysfunction (ED) in male survivors of cancer across cancer types has not been systematically analysed.

Aim

To estimate the prevalence of ED in all types of cancer and identify characteristics associated with ED in survivors of cancer.

Design and setting

Systematic review and meta-analysis (MA) of cross-sectional studies.

Method

MEDLINE, CINAHL, PsycINFO, and EMBASE were searched, targeting reports published from inception to 1 February 2020. All retrospective or prospective studies reporting prevalence of ED in male patients with cancer and using a validated tool for detection of ED were included. A random-effects MA model was used to pool prevalence of ED as absolute estimates at three different stages, that is, ‘healthy’, ‘at diagnosis’, and ‘after treatment’. A univariate MA regression including the three-level group variable as the only independent variable was used to assess the difference in ED prevalence across the three groups. Further MAs were conducted for studies involving patients at diagnosis and after treatment, and statistical inferences were made with setting for multiple testing controlling for a false discovery rate (FDR) <0.05.

Results

In total, 1301 studies were assessed for inclusion. Of these, 141 were potentially eligible and subsequently scrutinised in full text. Finally, 43 studies were included with a total of 13 148 participants. Overall, pooled data of the included studies showed an ED prevalence of 40.72% (95% confidence interval [CI] = 31.80 to 50.29) in patients with cancer, with prevalences of 28.60% (95% CI = 12.10 to 53.83) at time of diagnosis and 42.70% (95% CI = 32.97 to 53.03) after treatment, with significant difference between these two stages and across cancer locations, controlling for an FDR <0.05.

Conclusion

Erectile dysfunction was particularly high in male survivors of cancer and was associated with cancer treatment, cancer site, and age.

The management of sexual dysfunction resulting from radiotherapy and androgen deprivation therapy to treat prostate cancer: A comparison of uro-oncology practice according to disease stage

OBJECTIVES

To establish current uro-oncology practice in the management of sexual dysfunction (SD) following radiotherapy (RT) and/or androgen deprivation therapy (ADT) to treat prostate cancer. To identify differences in approach to the management of SD according to disease stage.

SUBJECTS AND METHODS

A 14-question mixed methods survey was designed to assess the current UK practice. Closed- and open-ended questions were used to quantify results while allowing participants to expand on answers. The survey was distributed to members of the British Uro-Oncology Group at the 2019 annual meeting.

RESULTS

Surveys were completed by 63 uro-oncologists attending the annual meeting of the British Uro-Oncology Group (response rate 66%). The major issue highlighted was a difference in approach to managing SD according to disease stage. More than half of the participants (56%) said 'advanced stage of disease' was a barrier to discussing SD. Clinicians were less likely to discuss SD, take baseline assessments, refer to a specialist clinic or offer rehabilitation when dealing with patients with advanced disease. Only a minority said that the management of SD was primarily their responsibility (11%). Nearly all clinicians (92%) had access to SD clinics; however, the majority of clinicians did not routinely refer patients.

CONCLUSIONS

This study shows that men with advanced prostate cancer need better support in managing SD. Patients receiving long-term ADT are less likely to be offered any kind of help or intervention. Specific guidance on managing SD in this cohort may result in improvements in sexual function, emotional well-being, quality of life, mental health and confidence.

Androgen receptors in areas of the spinal cord and brainstem: A study in adult male cats

Sex hormones, including androgens and estrogens, play an important role in autonomic, reproductive and sexual behavior. The areas that are important in these behaviors lie within the spinal cord and brainstem. Relevant dysfunctional behavior in patients with altered androgen availability or androgen receptor sensitivity might be explained by the distribution of androgens and their receptors in the central nervous system. We hypothesize that autonomic dysfunction is correlated with the androgen sensitivity of spinal cord and brainstem areas responsible for autonomic functions. In this study, androgen receptor immunoreactive (AR‐IR) nuclei in the spinal cord and brainstem were studied using the androgen receptor antibody PG21 in four uncastrated young adult male cats. A dense distribution of AR‐IR nuclei was detected in the superior layers of the dorsal horn, including lamina I. Intensely stained nuclei, but less densely distributed, were found in lamina X and preganglionic sympathetic and parasympathetic cells of the intermediolateral cell column. Areas in the caudal brainstem showing a high density of AR‐IR nuclei included the area postrema, the dorsal motor vagus nucleus and the retrotrapezoid nucleus. More cranially, the central linear nucleus in the pons contained a dense distribution of AR‐IR nuclei. The mesencephalic periaqueductal gray (PAG) showed a dense distribution of AR‐IR nuclei apart from the most central part of the PAG directly adjacent to the ependymal lining. Other areas in the mesencephalon with a dense distribution of AR‐IR nuclei were the dorsal raphe nucleus, the retrorubral nucleus, the substantia nigra and the ventral tegmental area of Tsai. It is concluded that AR‐IR nuclei are located in specific areas of the central nervous system that are involved in the control of sensory function and autonomic behavior. Furthermore, damage of these AR‐IR areas might explain related dysfunction in humans.

The Relative Impact of Urinary and Sexual Function vs Bother on Health Utility for Men With Prostate Cancer

Function and bother are related but distinct aspects of health-related quality of life. The objective of this study was to compare quantitatively the relative impacts of function and bother in urinary, sexual, and bowel outcomes on health utility as a reflection of health-related quality of life in men with prostate cancer. Our analysis included participants in the Cancer of the Prostate Strategic Urologic Research Endeavor utility supplementary study, with a final cohort of 1617 men. Linear regression on the patients’ function and bother summary scores (0-100) from the University of California, Los Angeles Prostate Cancer Index was performed to predict bias-corrected health utilities. Urinary and sexual bother were associated with each health utility, and their coefficients were 3.7 and 20.8 times greater, respectively, than those of the corresponding function. To our knowledge, our study provides the first quantitative and direct comparison of the impacts of function vs bother on health utility.

Men's sexual help-seeking and care needs after radical prostatectomy or other non-hormonal, active prostate cancer treatments

OBJECTIVE

To examine prostate cancer (PCa) survivors' sexual help-seeking intentions, behaviours, and unmet needs.

METHODS

In this prospective cohort study, men who underwent active, non-hormonal treatment completed baseline (N = 558) and 6-month follow-up (N = 387) questionnaires. Theory of planned behaviour (TPB) constructs (sexual help-seeking intention, perceived behavioural control (PBC), subjective norm, attitude), masculine values (e.g., sexual importance/priority, emotional self-reliance), sex life and functioning, sexual supportive care needs, distress (anxiety, depression), and sexual help-seeking behaviour were assessed.

RESULTS

Most men (M age = 64.6 years; M years post-diagnosis = 4.0) received prostatectomy (93%), reported severe erectile dysfunction (52%), ≥ 1 unmet sexual care need (66%), and sought help from a doctor (baseline 52%, follow-up 42%). Sexual care needs were significantly associated with poorer erectile function, reduced satisfaction with sex-life, valuing sex as important/integral to identity (masculine values), and increased depression (p ≤ 0.001). Sexual help-seeking intentions were significantly associated with valuing sex as important/integral to identity, recent help-seeking, greater confidence/control, perceiving support from important others, and positive attitudes, for sexual help-seeking (p < 0.001). Significant predictors of sexual help-seeking (follow-up) were baseline intentions, recent help-seeking (p < 0.001), and increased anxiety (p < 0.05).

CONCLUSIONS

Men's unmet sexual care needs, sexual help-seeking intentions, and behaviour appear driven by the importance/value attributed to sex, distress, positive feelings, support from others, and confidence for help-seeking. Psychosocial providers are well-placed to address men's concerns, yet few sought their assistance. Interventions to improve men's access to effective sexual care are needed, particularly focused on reframing masculine values about the importance of sex and leveraging TPB-based predictors of help-seeking.

Prostatic irradiation-induced sexual dysfunction: a review and multidisciplinary guide to management in the radical radiotherapy era (Part I defining the organ at risk for sexual toxicities)

Prostate cancer is the most common malignancy and the second leading cause of cancer-related death in men. Radiotherapy is a curative option that is administered via external beam radiation, brachytherapy, or in combination. Erectile, ejaculatory and orgasm dysfunction(s) is/are known potential and common toxicities associated with prostate radiotherapy. Our multidisciplinary team of physicians and/or scientists have written a three (3) part comprehensive review of the pathogenesis and management radiation-induced sexual dysfunction. Part I reviews pertinent anatomy associated with normal sexual function and then considers the pathogenesis of prostate radiation-induced sexual toxicities. Next, our team considers the associated radiobiological (including the effects of time, dose and fractionation) and physical (treatment planning and defining a novel Organ at Risk (OAR)) components that should be minded in the context of safe radiation treatment planning. The authors identify an OAR (i.e., the prostatic plexus) and provide suggestions on how to minimize injury to said OAR during the radiation treatment planning process.

Psychometric Validation of the Sexual Distress Scale in Men with Prostate Cancer

BACKGROUND

Different scales exist for the assessment of sexual distress in men with prostate cancer (PCa); however, these measures narrowly focus on distress associated with sexual function.

AIM

To validate and examine the psychometric properties of the Sexual Distress Scale (SDS) and Sexual Distress Scale-Revised (SDS-R), which were recently validated for use within men, in samples of sexually functional and sexually dysfunctional men with PCa.

METHODS

A sample of 538 men (with and without PCa and with and without sexual dysfunction) were used to examine the psychometric properties of the SDS. Confirmatory factor analysis followed by tests of measurement bias, calculations of reliability, and estimation of receiver operating characteristic (ROC) curves were used to examine the psychometric properties of the SDS and SDS-R. A subsample of 321 men completed the survey again 1 month later, and their responses were used to examine test-retest reliability.

OUTCOMES

Participants completed the SDS and SDS-R, as well as measures of sexual bother and sexual concerns, sexual function, sexual attitudes, and mood states.

RESULTS

The SDS and SDS-R assess 1 general domain of sexual distress; 1 violation of measurement invariance was found between men with and men without PCa, which limits the comparability of scores between these 2 groups. Internal consistency and test-retest reliabilities were above 0.93 and 0.82, respectively. Evidences of validity based on relations with other variables supported our predictions because sexual distress was associated with other measures of distress, sexual function, satisfaction, and mood and not correlated to sexual attitudes. Although the SDS and SDS-R discriminated between sexually functional and dysfunctional men, the accuracy of the cutoff scores was only moderate.

CLINICAL TRANSLATION

This instrument can be used by researchers and clinicians to examine sexual distress and can be used to elucidate how sexual distress relates to sexual function, well-being, and quality of life.

STRENGTHS AND LIMITATIONS

The SDS and SDS-R assess sexual distress independently of sexual function; however, with the current evidence, they should not be used to compare men with and men without PCa and to classify men with and men without sexual dysfunction.

CONCLUSION

This study provides a validation of the SDS and SDS-R that can be used in samples of men with PCa and with and without sexual dysfunction for the assessment of distress. Santos-Iglesias P, Walker LM. Psychometric Validation of the Sexual Distress Scale in Men with Prostate Cancer. J Sex Med 2018;15:1010-1020.

Preliminary exploration of clinical factors affecting acute toxicity and quality of life after carbon ion therapy for prostate cancer

Purpose

To assess toxicity and quality-of-life (QOL) after carbon ion radiotherapy (CIRT) at the Shanghai Proton and Heavy Ion Center (SPHIC) and identify clinical factors that correlate with urinary, bowel and sexual function.

Methods

Sixty-four patients with localized prostate cancer admitted from July 2015 to January 2018 underwent CIRT. At baseline and 5 time-points after radiotherapy, we assessed patients’ QOL using the 26-item edition of the Expanded Prostate Cancer Index-Composite (EPIC-26) Chinese version. Logistic regression was performed to identify clinical factors associated with acute genitourinary (GU) toxicity and relative QOL.

Results

By the end of CIRT, urinary irritation/obstruction temporarily declined (− 7.92 ± 1.76, p < .001). For urinary incontinence, bowel and sexual QOL, the scores remained stable at 2-year follow-up. The occurrences of acute Grade 1 and 2 GU toxicity were 20.3 and 10.9%, respectively, and of late Grade 1 and 2 GU toxicity were 3.1 and 1.6%, respectively. No acute or late gastrointestinal (GI) toxicity occurred. Transurethral resection of the prostate (TURP) was a risk factor that predicted a decline in urinary related QOL, and age made a difference to bowel-related QOL. For sexual QOL, castration status was a remarkable risk factor. An international prostate symptom score (IPSS) ≥8 increased the risk of Grade 1–2 acute GU toxicity 5.3-fold.

Conclusion

Patients with prostate cancer had favorable QOL after CIRT. IPSS ≥8 was a risk factor to acute GU toxicity, and TURP predicted a decline in urinary QOL. Age was related to bowel QOL, and castration status was associated with sexual QOL.

Trial registration

Carbon Ion Radiotherapy for the Treatment of Localized Prostate Cancer, NCT02739659. Registered April 15, 2016.

Patient-Reported Sexual Survivorship Following High-Dose Image-Guided Proton Therapy for Prostate Cancer

OBJECTIVE

To help guide individualized treatment, we sought to identify baseline predictive factors that impact long-term erectile function following high-dose image-guided radiotherapy (HD-IGRT).

METHODS

Potent men with localized prostate cancer treated with radiotherapy alone were enrolled in an institutional review board-approved prospective cohort study. Men received HD-IGRT as primary treatment of prostate cancer. Patient-reported inventories were used to assess erectile function at baseline, 6 months, 2 years, and 5 years after treatment. Long-term potency rates were compared to validated models, and baseline factors were used to create a novel, internally validated nomogram for predicting long-term function.

RESULTS

1,159 men were treated with HD-IGRT. Among 676 men who were potent at baseline and did not receive hormone therapy, the potency rates at 6 months, 2 years, and 5 years were 81%, 68%, and 61%. Recursive partitioning categorized patients into 3 groups based on two factors: baseline response to EPIC Q57 (ability to have an erection) and pre-existing heart disease. At 5 years, the most favorable group reported "very good" on Q57 and had an 80% potency rate (n = 137; p = 0.83); the intermediate group reported "good" on Q57 and had no baseline cardiac disease with a 62% potency rate (n = 145; p = 0.86); and the remaining poor risk group had a 37% potency rate (n = 117; p = 0.19).

CONCLUSIONS

Patient-reported pretreatment sexual function and comorbidities enables stratification and prediction of erectile function. EPIC subset questions with baseline comorbidities may potentially serve as a quick and practical clinical tool for predicting sexual survivorship.

Circulating Testosterone as the Hormonal Basis of Sex Differences in Athletic Performance

Elite athletic competitions have separate male and female events due to men's physical advantages in strength, speed, and endurance so that a protected female category with objective entry criteria is required. Prior to puberty, there is no sex difference in circulating testosterone concentrations or athletic performance, but from puberty onward a clear sex difference in athletic performance emerges as circulating testosterone concentrations rise in men because testes produce 30 times more testosterone than before puberty with circulating testosterone exceeding 15-fold that of women at any age. There is a wide sex difference in circulating testosterone concentrations and a reproducible dose-response relationship between circulating testosterone and muscle mass and strength as well as circulating hemoglobin in both men and women. These dichotomies largely account for the sex differences in muscle mass and strength and circulating hemoglobin levels that result in at least an 8% to 12% ergogenic advantage in men. Suppression of elevated circulating testosterone of hyperandrogenic athletes results in negative effects on performance, which are reversed when suppression ceases. Based on the nonoverlapping, bimodal distribution of circulating testosterone concentration (measured by liquid chromatography-mass spectrometry)-and making an allowance for women with mild hyperandrogenism, notably women with polycystic ovary syndrome (who are overrepresented in elite athletics)-the appropriate eligibility criterion for female athletic events should be a circulating testosterone of <5.0 nmol/L. This would include all women other than those with untreated hyperandrogenic disorders of sexual development and noncompliant male-to-female transgender as well as testosterone-treated female-to-male transgender or androgen dopers.

Scandinavian Prostate Cancer Patients' Sexual Problems and Satisfaction With Their Sex Life Following Anti-Cancer Treatment

INTRODUCTION

Active prostate cancer treatment is often associated with significant adverse physiological and psychological effects including significant sexual problems. Most studied among these sexual problems is erectile dysfunction while related sexual bothers such as overall sexual function and satisfaction with one's sex life are much less studied.

AIM

To investigate problems related to erectile functioning, orgasmic ability, sexual function, and satisfaction with one's sex life among a cohort of Scandinavian prostate cancer patients age 40 years and older who were sexually active prior to their diagnosis of prostatic cancer.

METHODS

The survey study used a cross-sectional design and a mixed recruitment procedure. Patients were recruited through the prostate cancer patient advocate organizations in Denmark, Norway, and Sweden (Scandinavia). The final sample included 1,707 prostate cancer patients. For analyses, participants were stratified into 4 groups according to their total treatment burden.

OUTCOMES

Outcomes included subjective reporting of erectile functioning, orgasm, and sexual functioning, and satisfaction with one's sex life.

RESULTS

The study found that the prevalence of erectile dysfunction and problems related to orgasm and overall sexual function ranged from 72-92% across prostatic cancer treatment groups. Conversely, this range was 61-69% among the respondents who had not undergone prostatic cancer treatment. Across treatment groups, a minority of patients (<15%) reported being satisfied with their sex lives. After socio-demographic variables were controlled for, patients who did not receive prostatic cancer treatment were 3.75 times more likely than those in the reference group to not report sexual function problems.

CONCLUSION

Among older prostate cancer patients, who at their time of diagnose were sexually active, sexual satisfaction is low and prevalence rates of sexual problems is high, thus underlining the strong clinical need to address sexual problems and satisfaction among this cohort of patients in order to promote sexual health and well-being following active cancer treatments. Martin Hald G, Dahl Pind M, Borre M, et al. Scandinavian Prostate Cancer Patients' Sexual Problems and Satisfaction With Their Sex Life Following Anti-Cancer Treatment. Sex Med 2018;6:210-216.

Mood, sexuality, and relational intimacy after starting androgen deprivation therapy: implications for couples

BACKGROUND

Patients on androgen deprivation therapy (ADT), a common treatment for prostate cancer, report significant declines in quality of life and detrimental impact on their intimate relationships. ADT depresses a man's testosterone to castrate levels, leading to declines in sexual function, and changes in mood. These changes can have profound impact on couples' intimate relationships.

METHOD

Patients undergoing ADT, and their consenting partners, were followed on a variety of outcomes relating to mood, sexual changes, and relational intimacy. Participants were assessed at baseline, 3 months, and 6 months. Changes in these three domains are documented. A dyadic analysis was conducted on the primary outcome of relational intimacy in order to assess the role of changes in mood and various aspects of sexuality on couples' intimate relationships.

RESULTS

Declines were observed in the first 6 months on ADT for sexual function, sexual frequency, and relational intimacy. Sexual bother increased within the first 3 months on ADT. No changes in mood were observed. Dyadic analysis revealed important effects on couples' reports of relational intimacy. (A) Patient and partner ratings of emotional intimacy were higher when partners better understood the patients' mood state. (B) Patient and partner ratings of sexual intimacy were higher when couples were more sexually active.

CONCLUSIONS

The current study confirms that patients experience reduced sexuality and relational intimacy during the first 6 months on ADT. Specific facets of relational intimacy are improved with increased sexual activity and also when partners recognize the emotional changes that patients are experiencing.

Sexual Recovery Following Prostate Cancer: Recommendations From 2 Established Canadian Sexual Rehabilitation Clinics

INTRODUCTION

Supportive sexual health care is much-needed adjuvant care to oncologic management for men with prostate cancer (PCa).

AIM

To inspire the initiation of biopsychosocial sexual health programming where it does not exist and to inform program enhancement in existing sexual rehabilitation clinics (SRCs).

METHODS

This article reviews the combined 30-year experience of 2 well-established Canadian SRCs for men and their partners after PCa treatments, interwoven with empirical evidence.

MAIN OUTCOME MEASURE

To comprehensively review the biopsychosocial approach to sexual health assessment of men with PCa and their partners to direct the practicalities of running a successful and sustainable SRC.

RESULTS

A full description of the biomedical and psychosocial approaches, inclusive of comprehensive sexual function, the penile rehabilitation controversy, and other medical and relationship issues affecting sexual adjustment, is provided to highlight the relevance of proper assessment and follow-through for sexual adaptation and adjustment. 10 recommendations for a successful SRC are discussed, including the principles behind developing a sustainable business plan, staff acquisition and training, budget, integration of treatment and research priorities, respectful and multidisciplinary approaches to care, and suggestions of visit formats, protocols, and questionnaires. We recommend a phased approach of an SRC into usual care with the option to provide accessible and equitable care to patients not within proximal access of treating institutions.

CONCLUSION

Sexual rehabilitation after treatment for PCa requires a complex treatment process. Providing sustainable sexual rehabilitation programming under the financially strained environment of the Canadian medical system is a challenge; therefore, to provide Canadian patients and their partners with comprehensive cancer care, they deserve a biopsychosocial approach combined with a creative and systematic implementation strategy. Elliott S, Matthew A. Sexual Recovery Following Prostate Cancer: Recommendations From 2 Established Canadian Sexual Rehabilitation Clinics. Sex Med Rev 2018;6:279-294.