Changes in Sexuality, Body Image and Health Related Quality of Life in Patients Treated for Hematologic Malignancies: A Longitudinal Study

Sexual health in patients with malignant hematological disease: a Danish cross-sectional study

Background

Patients who undergo treatment for hematologic malignancies may experience a decline in sexual health, alterations in sexual functioning, and reproductive capacity during survivorship.

Aim

This study investigated the prevalence of sexual dysfunction and factors influencing sexual activity and functioning in patients with hematologic malignancies, to identify potential targets for interventions in clinical practice.

Methods

This nationwide cross-sectional study included adult patients diagnosed with a hematologic malignant disease in Denmark in the period from January 20, 2013, to August 20, 2022. Eligible participants received electronic questionnaires through their officially assigned digital mailbox.

Outcomes

Outcomes included the Female Sexual Function Index, International Index of Erectile Function, Female Sexual Distress Scale-Revised, European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Sexual Health, and European Organization for Research and Treatment of Cancer Quality of Life Questionnaire.

Results

A total of 362 patients, on average 5.7 ± 3.4 years postdiagnosis, completed the questionnaires. Of these, 52.5% women and 73.2% men reported sexual dysfunction, with more women (40.9%) than men (34.1%) being sexually inactive. Across gender, this was significantly more prevalent in patients >65 years of age and in those with a low quality of life. In addition, for women a significant association with fatigue and sleep difficulties was observed. In total, 40.3% reported sexual-related personal distress, with the highest proportion among patients 40 to 65 years of age. Most patients (98.7%) with sexual dysfunction had not discussed sexual issues with their healthcare professional.

Clinical implications

It is hoped that knowledge from this study will help healthcare professionals in clinical practice and encourage them to proactively address and discuss sexual health issues with their patients, irrespective of age.

Strengths and Limitations

Sexually inactive participants may reduce the overall score of sexual function in the scoring of both the Female Sexual Function Index and International Index of Erectile Function. We therefore analyzed sexual function in a subgroup analysis in only those being sexually active to emphasize that level of dysfunction persists in sexually active participants.

Conclusion

Patients report a high prevalence of sexual dysfunction, sexual distress, and gender-specific sexual symptoms following diagnosis and treatment of a malignant hematologic disease, impacting their quality of life.Sexual Health in Patients With Hematologic Malignancies; NCT05222282; https://clinicaltrials.gov/study/NCT05222282.

Disrupted biographies and gendered identities: A qualitative study exploring sexuality and blood cancer

PURPOSE

This study examines how blood cancer impacts patients' sexuality and sense of gendered identity.

METHODS

An interpretive epistemological framework necessitated a qualitative study design. Participants (6 male and 6 female), recruited from a hospital Haematology department in a large Northern English City, took part in semi-structured in-depth interviews to gather rich data about their subjective experiences.

RESULTS

A key theme from the qualitative data was a sense of disruption in relation to several aspects of their gendered identities and sexual life. Participants explained disruption to their sexual function and sexual sense of self. They narrated concerns about future imagined relationships. The emotional burden of sexuality related concerns was strongly articulated. A gendered perspective enabled the similarities and differences between men and women to be explored.

CONCLUSION

This study, drawing on rich qualitative data, documents the sexuality concerns of blood cancer patients; for some such concerns arise many years post treatment. The findings highlight the need for gender appropriate care around sexuality which should continue to be accessible well after diagnosis and treatment phases have ceased.

Sexual dysfunction is highly prevalent in male survivors of malignant lymphoma

Background

With improved survival in patients with lymphoma, long-term toxicity and quality of life (QoL), including sexual health, have become increasingly important.

Aim

We aimed to (1) determine the prevalence of erectile dysfunction (ED) in adult male lymphoma survivors; (2) determine whether testosterone deficiency, comorbidities, or lifestyle factors were associated; and (3) evaluate their impact on QoL.

Methods

A cross-sectional study including 172 male survivors of Hodgkin lymphoma or diffuse large B cell lymphoma diagnosed in adulthood between 2008 and 2018 was performed. Patients were in complete metabolic remission after first-line treatment and remained in remission at follow-up (3-13 years after diagnosis). Participants completed 3 questionnaires measuring sexual health and general QoL. Serum concentrations of total testosterone were measured and thorough medical history and sociodemographic factors were obtained. The Danish SEXUS Project, European Male Ageing Study, and European Organization of Research and Treatment of Cancer (EORTC) Reference Manual were used as reference values of the general population.

Outcomes

Patient reported outcome measures including the 5-item International Index of Erectile Function, EORTC C30, and EORTC 22-item Sexual Health Questionnaire.

Results

ED was reported by 55.2%, which was higher than in an age-matched Danish population cohort (17.5%). Erectile function score (5-item International Index of Erectile Function) was negatively associated with comorbidity, body mass index, smoking, and age and positively with the number of children conceived before treatment and serum concentration of total testosterone. Overt testosterone deficiency in combination with ED was detected in 10 (5.7%) of 176 survivors, including excluded survivors in hormonal treatment, which is higher than for the general population (0.1%-3.2% for men <70 years of age). Mean EORTC C30 global health score for survivors with ED was lower (67.7) than for survivors without ED (80.1) but was comparable to the general population (71.2). Furthermore, a positive association was seen between sexual function and both sexual and general QoL.

Clinical implications

Sexual health is important for QoL and related to comorbidities. The focus on improving QoL requires that both sexual health and comorbidities are addressed in the follow-up of lymphoma patients.

Strengths and limitations

Despite the relatively high number of included survivors, the cross-sectional design of this study warrants longitudinal studies to clarify the specific underlying causes of sexual dysfunction.

Conclusion

ED was highly prevalent and associated with comorbidity in lymphoma survivors, and more focus on sexual health and treatment related comorbidity is needed to improve sexual and general QoL.

Partnership, sexuality, and fertility-related communication: findings from a register-based study among long-term hematological cancer survivors

PURPOSE

Even though the number of hematological cancer survivors suffering from long-term and late consequences of their disease is growing, knowledge about their situation regarding partnership, sexuality, and fertility-related communication is sparse to date.

METHODS

We recruited survivors of hematological malignancies (≥ 3 years after diagnosis) from two cancer registries in Germany. We applied validated instruments and study-specific items on satisfaction with partnership, sexual functioning, and fertility-related communication with physicians. We provided descriptive statistics and conducted multiple regression analyses to identify associations of the outcomes with patient factors and well-being (anxiety, depression, and quality of life).

RESULTS

Of 2001 eligible survivors, 922 (46%) participated. Fifty-seven percent were male, and the mean age was 64 years. Ninety percent and 60% reported to be satisfied with their partnership and sexual life, respectively. However, 81% and 86% reported being sexually impaired by physical or mental symptoms, respectively. Seventy-four percent of those with incomplete family planning had a fertility-related conversation with a physician. Female gender (p < .05, Beta =  - .09), older age (p < .01, Beta = .10), and chemotherapy (p < .01, Beta = .10) were associated with less sexual pleasure caused by physical impairment. Satisfaction with partnership (p < .001, Beta = .22), satisfaction with sexual life (p < .001, Beta = .28), and conversation about fertility (p < .05, Beta = .26) were associated with better quality of life.

CONCLUSION

Even though long-term survivors seem to be generally satisfied with their partnership and sexual life, they may suffer from specific impairments. Our findings need to be verified in longitudinal studies.

Patterns of Concerns Among Hematological Cancer Survivors

BACKGROUND

Advances in treatment for hematological cancers warrant greater attention on survivorship concerns.

OBJECTIVE

The aims of this study were to describe survivorship concerns among hematological cancer survivors, identify subgroups of survivors with distinct classes of concerns, and examine sociodemographic and clinical differences across subgroups.

METHODS

We conducted a cross-sectional analysis of data from 1160 hematological cancer survivors, who rated their degree of concern regarding 20 physical, emotional, and practical changes. Clusters of concerns were identified using latent class analysis. Associations between respondent characteristics and cluster membership were calculated using multinomial logistic regression.

RESULTS

Survivors had a mean of 7.5 concerns (SD, 4.6; range, 0-19), the most frequent being fatigue/tiredness (85.4%); anxiety, stress, and worry about cancer returning (70.2%); and changes to concentration/memory (55.4%). Three distinct classes of concerns were identified: class 1 (low, 47.0%), characterized by low endorsement of most concerns, apart from fatigue; class 2 (moderate, 32.3%), characterized by high endorsement of a combination of concerns across domains; and class 3 (high, 20.7%), characterized by the highest number of concerns out of the 3 identified classes, including greater endorsement of concerns relating to sexual well-being. Class membership was differentiated by survivor age, sex, marital status, and diagnosis.

CONCLUSIONS

Three distinct patterns of concerns were detected in a large sample of hematological cancer survivors. Patterns of concerns could be differentiated by survivor characteristics.

IMPLICATIONS FOR PRACTICE

Our study highlights the concerns experienced by hematological cancer survivors and provides support for a tailored biopsychosocial approach to survivorship care in this context.

Patient-reported long-term quality of life after tisagenlecleucel in relapsed/refractory diffuse large B-cell lymphoma

The JULIET phase 2 trial evaluated a single infusion of tisagenlecleucel in adult patients with relapsed/refractory (r/r) diffuse large B-cell lymphoma (DLBCL). The objective of the current analysis was to evaluate patient-reported health-related quality of life (HRQoL) with a median follow-up of 19.3 months among patients infused with a single dose of tisagenlecleucel. Patients enrolled were ≥18 years of age with r/r DLBCL after ≥2 lines of therapy and had either undergone a failed autologous stem cell transplant or were ineligible for the procedure. Two validated HRQoL instruments, Functional Assessment of Cancer Therapy-Lymphoma (FACT-Lym) and Short Form-36 (SF-36) Health Survey, were used to measure HRQoL at baseline and months 3, 6, 12, and 18. At data cutoff (21 May 2018), 115 patients had received tisagenlecleucel infusion. Among the 99 patients evaluated, overall response rate was 54%, and 40% of patients achieved complete response (CR). Initially, 108 patients completed the HRQoL assessments at baseline, including 57 patients who eventually achieved CR or partial response (PR). Further, 30 and 21 patients in clinical response who completed assessments at baseline also completed assessments at months 12 and 18, respectively. Patients who achieved CR or PR sustained HRQoL improvement in all FACT scores at all time points. SF-36 instruments showed improvement above the minimal clinically important differences on 5 of 8 subscales. Long-term follow-up in the phase 2 JULIET study demonstrated that patients with r/r DLBCL who respond to tisagenlecleucel therapy had sustained, clinically meaningful improvements in HRQoL. This trial was registered at www.clinicaltrials.gov as #NCT02445248.

Development of a Conceptual Model of Chronic Lymphocytic Leukemia to Better Understand the Patient Experience

BACKGROUND AND OBJECTIVE

Understanding the patient experience is important for identifying the unmet need in chronic lymphocytic leukemia. The current study aimed to develop a comprehensive chronic lymphocytic leukemia conceptual model.

METHODS

The conceptual model was based on literature searches, review of chronic lymphocytic leukemia patient blogs/forums, and interviews with five expert clinicians, with 20 patients who received at most one treatment (first line) for their chronic lymphocytic leukemia, and with 20 patients with relapsed or refractory chronic lymphocytic leukemia. De-identified interviews were transcribed, coded, and evaluated using qualitative data analysis software.

RESULTS

Thirty-five prevalent chronic lymphocytic leukemia-related symptom and impact concepts were identified from literature searches, patient blogs/forums, and clinician interviews. Patient interviews confirmed the identified concepts and revealed five additional concepts. Fatigue-related sub-components were identified from how patients described their fatigue, covering symptoms (tiredness/need for sleep, lack of energy, weakness, cognitive fatigue), and impacts (decreased ability to maintain their social, familial, or professional role, decreased physical functioning, frustration). Three versions of the conceptual model were created: an overall model with all concepts; a model highlighting the most prominent concepts in first line; and a model highlighting the most prominent concepts in relapsed or refractory disease. Prominent concepts in both first line and relapsed or refractory disease were fatigue-related symptoms and impacts, muscle/joint aches, night sweats, bruising, fever, recurrent infections/illness, insomnia, decreased cognitive/emotional functioning, anxiety/worry, stress, depression, financial difficulty, and fear of death. Dyspnea and cough were prominent in first line only, and enlarged lymph nodes, headaches, pain/discomfort, weight loss, nausea/vomiting, and infusion reactions were prominent in relapsed or refractory disease only.

CONCLUSIONS

The results show that fatigue is a dominant issue affecting patients with chronic lymphocytic leukemia. The three versions of the conceptual model can help researchers to understand patients' unmet needs and guide the patient-reported outcome strategy for clinical trials.

Sexuality After Treatment of Diffuse Large B-cell Lymphoma: Patients' Experiences and Psychometric Testing of the Sexual Adjustment Questionnaire-Swedish Version II

Background

Sexuality is an important part of health-related quality of life. To ensure adequate supportive interventions, valid and reliable instruments specific to sexual changes and adjustments after cancer treatment are needed.

Objectives

The aims of this study were to test the psychometric properties of the Sexual Adjustment Questionnaire-Swedish version II (SAQ-SII) in patients treated for diffuse large B-cell lymphoma and to describe and explore patients' experiences of sexuality after treatment.

Methods

A cross-sectional study was conducted in 2019, using SAQ-SII and data from the National Quality Registry for Leukemia–subregistry for Lymphoma, which included 257 patients (25% response rate). An exploratory factor analysis was performed for psychometric evaluation. Internal consistency was assessed by Cronbach's α. Independent t tests, analysis of variance, and multiple regression were used to describe patients' experiences of sexuality.

Results

The exploratory factor analysis resulted in a 4-factor structure, explaining 65.7% of the total scale variance (SAQ-SII). The Cronbach's α for the SAQ-SII was 0.88 and varied between 0.70 and 0.89 across subscales. Sexuality was affected in various ways and extent. Sexual Interest was most affected, whereas Sexual Function was least affected. Being male, of younger age, without comorbidities, and in a relationship were associated to a higher Sexual Interest.

Conclusions

The SAQ-SII is a valid and reliable instrument to measure changes and adjustments in sexuality in patients treated for lymphoma.

Implications for Practice

Assessments of sexuality in a broad sense should be an integrated part of cancer care to ensure timely interventions for those who need and want support.

Longitudinal health-related quality of life in first-line treated patients with chronic lymphocytic leukemia: Results from the Connect® CLL Registry

Health-related quality of life (HRQoL) in patients with chronic lymphocytic leukemia (CLL) is important in guiding treatment decisions. However, the impact of CLL treatment initiation on HRQoL is unclear. We assessed HRQoL using the FACT-Leu and EQ-5D-3L questionnaires in the Connect ® CLL Registry, a large, US-based, multicenter, prospective observational study of CLL patients enrolled between 2010 and 2014, prior to the introduction of novel therapies. Among 889 patients initiating first-line therapy with chemoimmunotherapy or rituximab monotherapy, questionnaire completion rates were 95.7% and 95.8% at enrollment, and 70.8% and 69.4% at 12 months, for FACT-Leu Total and EQ-5D-3L, respectively. For 849 patients completing all five FACT-Leu components, average total scores were 135.7 at enrollment and 141.6 at 12 months. Among 526 patients with FACT-Leu Total scores at enrollment and 12 months, clinically meaningful (≥11-point) improvements or reductions were observed in 179 (34.0%) and 88 (16.7%) patients, respectively. Mean EQ-5D-3L index scores were 0.87 at enrollment and 12 months. Among 513 patients completing EQ-5D-3L at enrollment and 12 months, clinically meaningful (≥0.06-point) improvements or reductions were observed in 125 (24.4%) and 116 (22.6%) patients, respectively. In the Connect® CLL Registry, HRQoL remained stable or slightly improved after 12 months of follow-up.

Recommended patient information sheet on the impact of haematopoietic cell transplantation on sexual functioning and sexuality

Sexual concerns are common after haematopoietic cell transplantation (HCT). Exposure to total body irradiation (TBI), alkylating agent and graft versus host disease (GvHD) can all affect sexual function, leading to problems in sexual desire, arousal and the orgasm phase of the sexual response cycle. In high-risk haematological malignancies, such as acute leukaemia and myelodysplastic syndromes, HCT often offers the highest chance for long-term survival. In addition, these haematological diseases and HCT can have an impact on body image, self-esteem, (sexual) relationship and psychosocial factors, all of which are able to affect sexuality and sexual function. Five years post HCT, 80% of the female survivors and 46% of the male survivors report sexual dysfunction.

It has been shown that these patients cope better after having discussed sexual health. While healthcare providers (HCPs) have the responsibility to address sexual issues, it has been demonstrated that 48%–82% HCT recipients reported not having discussed sexual issues with their HCPs and that only one-third of the HCPs routinely discussed sexual issues with their patients. HCPs describe a lack of knowledge and being uncomfortable with the topic as the most important reasons for not addressing sexual functioning. Even so, it would help >90% HCPs if the patient initiated discussing sexual issues. However, to empower patients addressing sexual issues, adequate comprehensive patient information is needed. In an effort to better meet the patients’ need, a patient information sheet: ‘Information for patients undergoing Hematopoietic Cell Transplantation: the impact of the disease and treatment on sexual function and sexuality’, has been created.

In this review, we describe what is known about the impact of HCT on sexual function and briefly the management of sexual problems.

Assessment of Unmet Supportive Care Needs in Haematological Cancer Survivors

Background:

Health needs assessment is crucial for the provision of individualized nursing care. However, many patients report a significant number of unmet needs. The aim of the present study was the assessment of self-reported unmet supportive care needs among haematological cancer survivors in Greece.

Methods:

102 patients (mean age 66.2 years old) diagnosed with haematological cancer were included in a cross-sectional study, conducted in two major Greek public hospitals, between October and December 2016. Patients’ needs were assessed using the ‘Needs Evaluation Questionnaire’ (NEQ). Data analysis was conducted using the Statistical Package for Social Sciences software for Windows. Alfa-level (p-value) selected was 5%, bootstrap techniques were used for 95% CI estimation, χ² was used for differentiation control and Kuder-Richardson coefficient for reliability score assessment (ρ = 0.922).

Results:

Patients reported higher needs levels “to receive less commiseration from other people” (48%), “more information about my future condition” (44.1%) and “to feel more useful within my family” (42.2%). In contrast, patients reported lower levels to the needs “to speak with a spiritual advisor” (11.8%), “to have more help with eating, dressing and going to the bathroom” (13.7%) and “better attention from nurses” (18.6%). The mean score of satisfied patients (≥8/10) was 8.9 (SD 1.7). Associations between socio-demographic, hospitalization data and unmet needs groups were identified. The less satisfied patients (<8/10) reported more informational needs about their diagnosis and their future condition (p-value=0.002), about their exams and treatments (p-value=0.001), communicative (p-value <0.001), assistance and treatment (p-value<0.001) and hospital infrastructure (p-value <0.001).

Conclusion:

Various factors seem to be associated to the prevalent unmet care needs among haematological cancer patients. Establishing NEQ as a routine needs assessment tool could aid health professionals to early identify patients’ needs in a busy clinical setting and implement more individualized and patient-centered quality care.

Sexuality and cancer: The experience of adolescents and young adults

There are many components affecting the experience of sexuality for adolescents and young adults living with and beyond cancer. For patients, the interruption to normal socialization creates gaps in information and experience that potentially hinder development. In clinical practice, conversations relating to sexual consequences of illness or treatment are rare, as are age-appropriate assessment and intervention. In service design, the collaborative approach of oncofertility has yet to be replicated for sexuality. This paper considers how these obstacles can be overcome through local service development to address unmet need and promote sexual well-being for this group of patients.

Sexual health in patients with hematological malignancies: a neglected issue

Current evidence, although limited, outlines that sexual dysfunction may represent a prominent part of the symptom burden experienced by the patients with hematologic malignancies (HM). However, despite their presumed negative effects on quality of life (QoL), sexual health is not typically considered in the QoL assessment of HM patients. In addition, very few studies have been conducted in this area. Therefore, it would be important to further investigate how newer drugs developed in recent years for patients with HM, including targeted therapies and impact on sexual health, and how this influence overall patients' QoL outcomes.

Importance of and Satisfaction with Psychosocial Support among Cancer Patients and Survivors in Puerto Rico: Gender, Health Status, and Quality of Life Associations

OBJECTIVE

To assess needs perceptions regarding the importance of and satisfaction with psychosocial support among cancer patients and survivors in Puerto Rico.

METHODS

A cross-sectional study was conducted in 181 participants (70 men and 111 women) who were either undergoing cancer treatment (patients) or had completed cancer treatment (survivors). Participants completed a sociodemographic and clinical characteristics questionnaire, and the Psychosocial Needs Inventory (PNI).

RESULTS

The participants reported having or having had prostate (36%) or breast (32%) cancer or some other cancer type (32%). Of the 149 participants reporting cancer type, 130 were classified as having a high perceived level of health and quality of life, and 19 were classified as having a low perceived level of health and quality of life. In terms of perceived needs, the highest level of importance were assigned to the Support Network (e.g. family, friends, neighbors, care professionals; M = 2.88, SD = 0.43) and Health Professional (e.g., patient-health professional relationship, etc.; M = 2.80, SD = 0.50) categories, and the Emotional and Spiritual category was given the lowest importance (e.g., help managing negative emotions and spiritual counseling, etc.; M = 2.62, SD = 0.66). These perceptions varied by gender, perceived health status, and date of diagnosis. Women assigned more importance to the Health Professional and Information categories.

CONCLUSION

The results reflect the importance of considering psychosocial needs when providing psychosocial support to cancer patients and survivors. These findings are anticipated to inform services provided by psychosocial oncology support programs in Puerto Rico.