Sexual and marital relationships after radiotherapy for seminoma

The prevalence of sexual problems in the divorced population and the prevalence of separation in populations with sexual problems: a meta-analysis

The prevalence of divorce has significantly increased in the world, and scattered studies reveal that one of the main causes of divorce is sexual problems. The present study aimed to review the existing studies on the prevalence of sexual problems in separated people such as divorce applicants and people separated due to sexual problems. Another aim of this study was to find the prevalence of separation in patients with diseases affecting sexual function. A wide range of articles were searched in electronic databases until 21 April, 2023. The studies on both sexual problems and separation were included. From among 4110 studies, the data of 14 studies were reviewed and meta-analyzed. The prevalence of sexual problems was found to be 47% (CI: 29-64%) in separated people, 43% (CI: 18-68%) in women, and 52% (CI: 25-79%) in men and the prevalence of separation was 16% (CI: 6-26%) in people with sexual problems, 27% (CI: 21-33%) in women, and 11% (CI: -1-23%) in men. Moreover, the prevalence of separation in patients with diseases affecting sexual function was 4% (CI: 2-6%), 2% (CI: 0-3%) in women, and 5% (CI: 2-8%) in men. A considerably high rate of separations could be attributed to sexual problems.

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.

Clinical features and psychological aspects of the decision-making process in stage I testicular germ cell tumors

Testicular germ cell tumors (TGCTs) are the most prevalent malignancies in young Caucasian men. Clinical stage I (CSI) TGCTs present the highest cure rate and treatment options after orchiectomy depend on histology and risk factors. Nevertheless, the management of CSI TGCTs is controversial due to the availability of multiple treatments and the lack of randomized trials. An integrated multidisciplinary approach that includes clinicians (surgeons, radiotherapists and oncologists) and psychologists is crucial to maximize the patients' compliance and must be acknowledged with appropriate tools. The aim of our work is to review the oncological and psychological aspects of the decision-making process, discussing the fundamental role of the patient involvement in the personalized management of CSI TGCTs.

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.

Surveillance in stage I seminoma patients: a long-term assessment

BACKGROUND

Following orchidectomy patients with stage I seminoma of the testis may be managed by either surveillance or adjuvant treatment. In view of the very high cure rate, it is important to analyse long-term outcomes.

OBJECTIVE

To provide data to advise patients on treatment burden and risk of recurrence associated with surveillance.

DESIGN, SETTING, AND PARTICIPANTS

We audited the case records of 164 stage I seminoma patients registered at the Royal Marsden Hospital who were managed with a surveillance policy between 1980 and 2004 and followed for 1-20 yr (median: 13.5 yr).

MEASUREMENTS

All treatments and patterns of relapse were documented.

RESULTS AND LIMITATIONS

Twenty-two of 164 (13%) patients had relapsed at a median of 15.5 mo (range: 6-55 mo) from orchidectomy. Eighteen relapses appeared to be confined to the para-aortic nodes, but 6 of the 13 (46%) men treated with only para-aortic radiotherapy suffered a further relapse at another site. The disease-specific mortality was 1.3%. In the complete series of 164 patients, a total of 50 cycles of chemotherapy and 26 courses of radiotherapy was administered, representing an average of 0.46 "treatment units" per patient or an average of 3.45 treatment units per relapsing patient. The total number of treatment days was 390 d for radiotherapy and 133 d for chemotherapy, representing an average of 3.2 d per patient or 23.8 d per relapsing patient. This was a single-centre series extending back to the 1980s. Imaging and treatment protocols have advanced since then.

CONCLUSIONS

Surveillance postorchidectomy is a safe practice in the long term, and the majority of patients can avoid further treatment. There is the risk that those who do relapse face a higher burden of treatment than would be required if adjuvant treatment had been given.

Post-chemotherapy nerve-sparing retroperitoneal lymph node dissection for advanced germ cell tumor

OBJECTIVE

To report our experience with post-chemotherapy nerve-sparing retroperitoneal lymph node dissection (RPLND) for advanced germ cell tumor (GCT).

METHODS

Between 1994 and 2008, 92 patients with advanced GCT underwent RPLND after multiple treatments with systemic chemotherapy at our institution. A nerve-sparing RPLND was carried out in 78 patients (84.8%; median age 32 years). Of them, 19 had a seminoma and 59 had a non-seminoma.

RESULTS

Lumbar splanchnic nerves controlling ejaculatory function were macroscopically preserved during RPLND. Bilateral and unilateral lumbar splanchnic nerves were preserved in 40 patients and 38 patients, respectively. Sixty-five patients could be evaluated for ejaculation. Fifty-four patients (83.1%) achieved antegrade ejaculation with a median postoperative interval of 3 months (range: 1-10 months). Twenty-eight patients (28/30: 93.3%) and 26 patients (26/35: 74.3%) undergoing bilateral and unilateral nerve-sparing RPLND had antegrade ejaculation, respectively (P = 0.041). Only two patients (2.6%) had mediastinal and retroperitoneal recurrences during a median follow-up of 42 months (range: 1-138 months), respectively. However, these patients were cured by chemotherapy and surgery.

CONCLUSIONS

Post-chemotherapy nerve-sparing RPLND preserves ejaculatory function in the majority of patients with advanced GCT without increasing the risk of local recurrence.

Retroperitoneal lymph node dissection for high-risk stage I and stage IIA seminoma

INTRODUCTION

The clinical results of radiotherapy in low-stage seminoma are excellent with negligible early morbidity. However, in a long-term follow-up various complications may occur. On the other hand, experience in nonseminomas shows that surgical morbidity has decreased markedly after invention of a nerve-sparing technique. These issues served as a rationale for us to perform the primary retroperitoneal lymph node dissection (RPLND) in seminoma patients.

MATERIALS AND METHODS

Fourteen pure seminoma patients (10 high-risk stage I and four with clinical stage IIA) underwent nerve-sparing RPLND from September, 1997 to December, 2002.

RESULTS

Pathological evaluation revealed lymph node involvement in three out of 10 clinical stage I and in all four stage IIA cases. The patients' acceptance of the surgery was good. Minor intra- and early postoperative complications were observed in two cases. Antegrade ejaculation was preserved in all patients. No retroperitoneal or distant recurrences have been observed. All patients were free of disease with the mean follow-up period of 56 months.

CONCLUSION

The excellent results and minimum morbidity of nerve-sparing RPLND together with the increased concerns on late complications of radiotherapy may turn the preference of surgery in low-stage seminoma into the subject of future discussion.

Testicular cancer: a longitudinal pilot study on stress response symptoms and quality of life in couples before and after chemotherapy

Goals of work

The current study was designed to longitudinally examine stress response symptoms (SRS) and quality of life (QoL) in couples confronted with disseminated testicular cancer. The objectives were to examine couples’ patterns of adjustment over time and possible differences in adjustment between the patient and his partner.

Materials and methods

Couples completed the Impact of Event Scale and the QoL subscales physical functioning, social functioning, and mental health of the RAND-36 before chemotherapy (T1), after completion of chemotherapy (T2), and 1 year later (T3).

Results

Before chemotherapy 26% of the patients and 50% of partners reported clinically elevated levels of SRS. Patients reported lower physical and social functioning at T2 compared to T1 and T3. Partners reported an improvement in social functioning over the year and no changes in physical functioning or mental health. No relationships between patients and partners’ functioning were found. One year after diagnosis, QoL of patients and partners was similar to that of reference groups, and patients even reported better physical functioning than the reference group. SRS of patients and partners were negatively related at T1, and patients and partners’ social functioning were positively related at T2.

Conclusions

According to stress response levels, the period before the start of chemotherapy was most stressful for couples. Adjustment patterns differ between testicular cancer patients and their partners with patients reporting lowered QoL after completion of chemotherapy. QoL of couples returned to normal levels 1 year after diagnosis. The effect of disseminated testicular cancer on the QoL of patients and their partners seems to be temporary. A minority may need clinical attention for severe SRS.

How, why and when should urologists evaluate male sexual function?

Male sexual dysfunction-a term that is commonly used to refer to erectile dysfunction, premature ejaculation, decreased libido and impaired orgasm-is the primary complaint encountered by many urologists. Despite the high prevalence and bothersome nature of these complaints, they are frequently neglected in clinical practice. This paper highlights clinical situations in which urologists should systematically evaluate male sexual functioning. These include men who present with several common urologic disorders, such as pelvic trauma, malignancies, and lower urinary tract symptoms associated with benign prostatic hyperplasia, neurologic disorders and infertility. Studies have shown that erectile dysfunction might be a clinical marker of endothelial dysfunction, and consequently of undetected diabetes, hypertension, dyslipidemia, coronary artery disease and depression. We also address the question of whether urologists should adopt wide-ranging screening regimens for sexual dysfunction.

Marital and sexual satisfaction in testicular cancer survivors and their spouses

GOAL

To compare marital and sexual satisfaction of men who survived testicular cancer (TC) and their spouses to a reference group, and to compare marital and sexual satisfaction of couples who had a relationship at time of diagnosis (couples during TC) to couples who developed a relationship after completion of treatment (couples after TC).

PATIENTS AND METHODS

Two hundred and nineteen couples during TC and 40 couples after TC completed the Maudsley Marital Questionnaire, a validated instrument to measure marital and sexual satisfaction.

RESULTS

Survivors and spouses of both couple groups reported similar marital satisfaction as men and women of the reference group. Survivors (t=2.9, p<0.01) and spouses (t=2.9, p<0.01) of couples during TC and survivors of couples after TC (t=1.9, p=0.05) reported less sexual satisfaction than the reference groups. Survivors of couples after TC reported less sexual satisfaction than survivors of couples during TC (F=4.0, p<0.05). Correlations between sexual satisfaction of survivors and spouses in couples during TC (r=0.76, p<0.001) and couples after TC (r=0.77, p<0.001) were high.

CONCLUSION

Testicular cancer did not appear to have a negative effect on marital satisfaction in couples during TC, although TC survivors and their spouses reported less sexual satisfaction than men and women of the reference group. Survivors who developed a relationship after completion of treatment seemed to form a vulnerable group: their sexual satisfaction was lower than that of men in the reference group and of TC survivors with a longer relationship. Besides that, they more often reported marital problems than their spouses did.

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.

Having children after cancer. A pilot survey of survivors' attitudes and experiences

BACKGROUND

Although the prevalence of infertility after cancer treatment and the health of the offspring of survivors have been studied, little information has been available about survivors' attitudes, emotions, and choices with regard to having children.

METHODS

A questionnaire was received by 283 patients from the Cleveland Clinic Foundation tumor registry who were diagnosed before age 35 years, were age 18 years or older at the time of the survey, and were free of disease. The SF-36, a measure of health-related quality of life, was included, as well as questions about demographic and medical background, reproductive and fertility history, and a variety of concerns about having children after cancer.

RESULTS

The response rate to the survey was 47%, yielding a sample of 43 men and 89 women who had had cancer at various sites. Their mean age at diagnosis was 26 years and the mean time since diagnosis was 5 years. Before cancer, 35% had at least 1 child, compared with 46% currently. Of those currently childless, 76% want children in the future. Although about half of the entire sample view themselves as having impaired fertility, only 6% have undergone infertility treatment. Nineteen percent have significant anxiety that their cancer treatment could impact negatively on their children's future health. Of women, 18% fear that a pregnancy could trigger a cancer recurrence. Only 57% received information from their health care providers about infertility after cancer. Other reproductive concerns were discussed less often. Only 24% of childless men banked sperm before treatment. SF-36 scores were very similar to normative data for healthy Americans of similar age. About 80% of the sample viewed themselves positively as actual or potential parents. Feeling healthy enough to be a good parent after cancer was the strongest predictor (P < 0.001) of emotional well-being as measured by the Mental Component Score of the SF-36.

CONCLUSIONS

The great majority of younger cancer survivors see their cancer experience as potentially making them better parents. Those who are childless want to have children in the future. Many, however, are left with significant anxieties and insufficient information about reproductive issues.

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.

Evaluation of sexual life after orchidectomy followed by radiotherapy for early-stage seminoma of the testis

OBJECTIVE

To explore the changes perceived by patients in their sexual lives after orchidectomy and radiation therapy of the pelvic and para-aortic nodes for early-stage testicular seminoma (ST).

PATIENTS AND METHODS

A questionnaire mainly based on two self-completed instruments, previously used to assess the sexual life of patients affected by testicular cancer (the UCLA/RAND sexual module and the Groningen sexual questionnaire) was mailed to a consecutive series of 143 patients treated for ST between 1961 and 1995, and who showed no signs of disease after primary treatment.

RESULTS

Ninety-eight questionnaires (69%) were returned and were evaluable. The median age of the patients was 48 years (range 26-85) at the time they completed the questionnaire, with the median follow-up of 123 months (range 15-496). Most of the patients (86%) had been sexually active during the month before completing the questionnaire. Of these patients, 25% reported a low libido and 14% defined their sexual capacity as poor; 14% of the patients avoided sexual contact after treatment because of the disease and/or cancer therapies. After therapy, a minority of the patients found it more difficult to achieve and maintain an erection. Similarly, a few patients reached orgasm less intensely and less frequently. During the period after treatment, 24% reported a low semen volume, 14% premature ejaculation, 2% late ejaculation and 2% an absence of ejaculation. Most of the patients considered the information and counselling given by their physician about the sexual sequelae of therapy to be insufficient. However, the amount of information about the disease and treatment was considered to be good by, respectively, 64% and 61% of the patients. The only variable predictive of sexual adjustment was age at the time of the administration of the questionnaire.

CONCLUSION

The sexual adjustment of patients treated with orchidectomy and radiation therapy for early-stage ST is generally good, but a few have negative experiences. Although the main predictive factor is age, communication is an important issue and better information tools could lead to better adjustment.

Reproductive sequelae of cancer treatment

Remarkable advances have been made in the treatment of cancers that afflict patients of the reproductive age. Many survivors must now face the effects on gonadal function and have concerns about reproductive capacity. The sequelae of different modalities of cancer therapy specifically addressing surgery, chemotherapy, and radiotherapy on reproductive system are reviewed. Assisted reproductive technologies, prenatal diagnosis methods, and contraception counseling are briefly summarized in conclusion.

Nerve-sparing retroperitoneal lymph node dissection for metastatic testicular cancer

BACKGROUND

Nerve-sparing techniques are used during retroperitoneal lymph node dissection (RPLND) in patients with early stage testicular cancer to preserve postoperative ejaculatory function. Indications for the procedures have been extended to patients with a postchemotherapy retroperitoneal residual mass without compromising the efficacy of surgery. We report 6 cases diagnosed with metastatic testicular cancer who underwent nerve-sparing RPLND.

METHODS

Between January 1994 and March 1996, 6 patients with metastatic testicular cancer underwent nerve-sparing RPLND. Five of these patients received primary chemotherapy and a retroperitoneal residual mass. Four patients underwent complete bilateral RPLND and 2 underwent unilateral template surgery.

RESULTS

After a mean follow-up of 18.7 months (range, 8 to 34), there have been no local recurrences and 5 (83%) patients report antegrade ejaculation.

CONCLUSION

Nerve-sparing RPLND is applicable for selected patients with metastatic testicular cancer without increasing the risk of local recurrence. Ejaculatory function is preserved in the majority of patients, contributing to the improvement of the quality of life in men who require such surgery.

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

BACKGROUND

This retrospective study evaluates changes in sexual functioning after treatment for testicular cancer and investigates whether there is a relationship with different treatment modalities.

METHODS

A self-reported questionnaire was sent to 337 men who had been treated for testicular cancer at the University Hospital Groningen between 1977 and 1994. Medical information was obtained from the patient records.

RESULTS

A response was received from 287 men (85%); 264 patients were included in this study (78%). The mean patient age at follow-up was 37.7 years (range, 17-71 years). The mean follow-up period was 6.7 years (range, 0.25-18 years). Decrease in sexual functions was reported by 40% of patients (decrease in libido: 19%; arousal: 12% erection: 12.5%; orgasm: 19%; and ejaculation: 26%). Moreover, 23.5% of patients responding reported decreased sexual activity and 12.5% were dissatisfied with their sexual functioning. Patients with Stage II-IV nonseminoma who had been treated with polychemotherapy (PCT) with or without resection of residual retroperitoneal tumor mass (RRRTM) (PCT +/- RRRTM) reported a significantly sharper decrease in sexual functioning than patients who had been followed with a wait-and-see policy (W & S) (Stage I nonseminoma patients). It was noteworthy that patients treated by PCT alone reported more sharply decreased sexual functioning than patients treated by PCT + RRRTM. Patients treated by radiotherapy (Stage I-IIA seminoma) did not report findings significantly different from the W & S group.

CONCLUSIONS

Testicular cancer patients are at risk for reduced sexual functioning, especially when treated by chemotherapy, with or without resection of residual tumor. Although chemotherapy may influence somatic aspects of sexual functioning, it appears that psychologic factors arising from the confrontation with testicular cancer play a strongly mediating (if not determining) role.

Pre- and post-treatment sexual life in testicular cancer patients: a descriptive investigation

Aspects of sexuality were assessed by questionnaires in 76 testicular cancer patients after orchiectomy before further treatment and, respectively, 6, 12 and 36 months after therapy. Before treatment 11% of the patients reported dissatisfaction with sexual life. About 20% of the patients sometimes experienced reduced libido and erectile difficulties. Six months after therapy significantly more patients (27%) recorded an unsatisfactory sexual life as compared to the pretreatment situation. At the 36 months' evaluation 22 of 76 evaluable patients (18%) still stated that their sexual life was inferior to the pretreatment experience. Libido and erectile function decreased transiently during the first year after treatment in most patients. Twelve patients reported permanent 'dry ejaculation' after bilateral retroperitoneal lymph node dissection. Other sexual disturbances could not be related to specified treatment modalities. Increased age at the time of diagnosis and psychological distress tended to correlate with the incidence of sexual problems. For about 60% of the patients the discussion of expected and experienced sexual life problems was an important issue to be discussed before their treatment for testicular cancer and during follow-up. The high frequency of any kind of long-lasting sexual problems (30%), though often of minor degree, warrants an adequate counselling of these patients before and after treatment.

Sexual morbidity following radiotherapy for germ cell tumours of the testis

An anonymous questionnaire study was designed to assess sexual function after orchidectomy and radiotherapy for testicular cancer. Questionnaires were sent to: (1) 237 patients treated with orchidectomy and abdominal radiotherapy in Edinburgh from 1974 to 1988; (2) 32 patients under "surveillance" following orchidectomy alone; (3) 402 "normal" age-matched controls. All were asked questions concerning sexual function over the preceding 6 months. All the patients were also asked the same questions with reference to the first 6 months after completion of treatment. Completed questionnaires were returned from 137 (62%) radiotherapy patients, 18 (56%) surveillance patients and 121 (35%) controls. There was a significant difference between the radiotherapy patients and the controls in almost all the parameters looked at including erection, ejaculation and libido with the treated group performing less well. In addition, almost 24% of the radiotherapy patients felt disabled or disfigured by the treatment, most commonly because of the presence of only one testicle. A deterioration in sexual function was observed with increasing age. In the radiotherapy group of patients there was no difference in response between the two time periods or in any of the treatment variables. The clinical significance of these observations are unclear but together with the increasing information on other toxicities emerging following this therapy the role of radiation for early stage seminoma is being brought into question. This study also confirms the morbidity of orchidectomy. We suggest that testicular implants should be offered more widely.

Long-term psychosexual adjustment of acute leukemia survivors: impact of marrow transplantation versus conventional chemotherapy

Psychosexual sequelae associated with surviving acute leukemia treated with conventional chemotherapy or with chemotherapy followed by bone marrow transplantation (BMT) were investigated in 70 patients who were off treatment for at least 1 year. Assessment of psychosexual function included frequency of sexual activity, satisfaction, body image, gender role identity, and adjustment in sexual relations. No differences between BMT and conventional chemotherapy survivors were found on any of these measures, despite the high probability of gonadal impairment with BMT. Compared with physically healthy norms, women survivors generally reported decreased sexual frequency and satisfaction, whereas both men and women survivors reported poorer body image. Longer time since completing cancer treatment predicted greater frequency of sexual activity in women but poorer body image for both men and women. Those survivors who reported decreased sexual frequency, satisfaction, and poorer body image reported greater psychological distress and decreased energy. Results indicate that psychosexual sequelae in survivors of leukemia occur frequently and warrant intensive investigation, particularly to address the need for an intervention in those most distressed.

Paternity in patients with testicular germ cell cancer: pretreatment and post-treatment findings

Paternity before and after treatment was investigated in 177 patients with unilateral germ cell tumours of the testis. Before the cancer was diagnosed, 51% had fathered at least 1 child, 9% had a history of infertility and 40% had not wanted to have children. It was estimated that 72% of the patients would have fathered at least 1 child at the age of 40 years. After treatment 41 patients had wished to have children. Infertility was still a problem 5 years after the end of treatment in 53% of these men. No significant differences was observed between patients treated with orchiectomy alone and patients treated with cisplatin-based chemotherapy or subdiaphragmatic irradiation. In 8 patients, infertility was present in spite of an evident recovery of spermatogenesis. Congenital malformations were recorded in 3.8% of the live-born children conceived before the orchiectomy. This incidence did not exceed the Danish national rate, the relative risk being 2.5 (95% confidence limits, 0.9-5.5). No malformations were observed in the 22 children conceived after ending treatment.

Psychosocial well-being in testicular cancer patients

149 testicular cancer patients with no evidence of disease for 3 or more years filled in a questionnaire which covered the following subjects: psychosocial well-being, working ability and use of analgesics/tranquilisers. The questions were chosen to compare cancer patients' morbidity with that of age-matched controls. The patients had been treated with surgery (32 patients), radiotherapy (39 patients), cisplatin-based chemotherapy plus surgery (46 patients) or chemotherapy plus radiotherapy with or without surgery (32 patients). Since no systematic differences between the treatment groups were found, the analyses were undertaken with all patients combined. The patients felt significantly less exhausted after a working day, were more satisfied with life and felt stronger and more fit than the controls. On the other hand, the patients reported a significantly higher incidence of anxiety and depression than the normal population. The results indicate that patients treated for a malignant disease may have greater fluctuations in mood and affect than the general population.

Heterogeneity in responses to cancer. Part I: Psychiatric symptoms

Heterogeneity in psychiatric responses to disease specific diagnosis is demonstrated for two groups of cancer patients who are comparable in prognosis and treatment intensity. Implications of this heterogeneity are drawn for etiological study and for planning psychiatric interventions.

Serum levels of sex hormone binding globulin and oestradiol in patients with testicular cancer

Serum testosterone (T), oestradiol (E-2) and sex hormone binding globulin (SHBG) were measured in 84 orchiectomised testicular cancer patients before further treatment and 4 to 6 and 12 to 15 months after therapy. Patients were divided into 3 groups according to treatment: Group 1: cisplatin-based chemotherapy (27 patients); Group 2: abdominal radiotherapy (32 patients); Group 3: no antiproliferative treatment (chemotherapy/radiotherapy) (25 patients). Between 4 and 6 months after antiproliferative treatment, particularly after chemotherapy, a reversible significant increase in E-2 and SHBG was observed. Patients without antiproliferative treatment showed no significant changes in their comparable hormone levels; 15% of all normal T values were associated with elevated levels of SHBG and E-2. Although the aetiology of these hormonal changes remains unknown, they may be related to the clinical symptoms of hypogonadism displayed by 10 to 30% of patients undergoing treatment for testicular cancer.

Long-term effects of testicular cancer on marital relationships

Thirty-four long-term survivors of testicular cancer and their wives were interviewed individually almost four years past the end of treatment to measure psychological and relationship functioning. Factors identified as important for couple adjustment to cancer--good communication, spousal support, and marital satisfaction--all acted positively to facilitate functioning in this sample. Good psychological adjustment was reflected in scores on the POMS, CES-D, Sense of Coherence, and Relationship Dimension of the Family Environment Scales. Several couples demonstrated lasting impairment, but, overall, the great majority of relationships were strengthened and couples emerged more tightly bonded.

Long-term effects of testicular cancer on sexual functioning in married couples

Long-term sequelae of testicular cancer have not been reported from the perspective of patient and spouse. As part of a larger study, both members of 34 married couples were interviewed individually, almost 4 years after treatment ended. Spouse and patient responses were compared for concordance (agreement) regarding psychosexual functioning and fertility issues. Wives perceived fewer long-term problems than husbands and were extremely supportive throughout their husbands' illnesses. At interview, whereas 23.5% of patients still felt less attractive as a result of treatment, no spouses shared this perception. Patients were more likely to report decreased, and wives increased sexual satisfaction compared to before cancer. However, both patients and spouses were more likely to report decreased frequency of intercourse than increased. In other areas as well, concordance was generally high. Few couples reported that infertility would pose a problem, but 53% were parents; men who banked sperm were less likely to already have children.

Long-term morbidity after infradiaphragmatic radiotherapy in young men with testicular cancer

Long-term morbidity was evaluated in 357 patients with testicular cancer who were treated by infradiaphragmatic radiotherapy between 1970 and 1982. Myelopathy developed in four patients, radiation osteomyelitis in one, and radiation hepatitis in another after treatment. Posttreatment gastrointestinal symptoms were recorded in the medical records of 4% of patients but were mentioned by 41% of 199 who answered a questionnaire. The moderate gastrointestinal problems were recorded by 17% of the patients compared with 6% in a control group of healthy men. Postirradiation peptic ulcer occurred in 9%. A dose relationship existed, the risk of posttreatment gastrointestinal problems being less when the midplane dose was less than 40 Gy. Forty-one of 63 men who wished to do so fathered at least one child after their radiotherapy. The overall posttreatment quality of life was comparable to that of the control group. The authors conclude that the risk of major posttreatment morbidity is minimal for testicular cancer patients who undergo infradiaphragmatic radiotherapy after orchiectomy. Slight gastrointestinal symptoms are relatively common without major impact on quality of life. Gonadal toxicity is not a significant complication. Infradiaphragmatic radiotherapy is a safe, routine adjuvant treatment of seminoma in orchiectomized patients with Stage I seminoma. The midplane dose should not exceed 36 Gy in these patients.

Sexual dysfunction and treatment for early stage cervical cancer

Assessment of sexual frequency, function, and behavior, as well as martial happiness and psychological distress was performed for 61 women with early stage, invasive cervical cancer at the time of diagnosis. Cancer treatment was radical hysterectomy alone for 26 women and radiotherapy with or without surgery for 37. Followups took place at 6 and 12 months after cancer therapy. Women's sexual satisfaction, capacity for orgasm, and frequency of masturbation remained stable, whereas frequency of sexual activity with a partner and range of sexual practices decreased significantly by one year. Women who received irradiation with or without surgery resembled women who underwent radical hysterectomy alone at 6 months. By one year, however, the radiotherapy group had developed dyspareunia, which was reflected in gynecologist ratings at pelvic examination. The women receiving radiotherapy also had more problems with sexual desire and arousal, and were less likely to resume several daily life activities. Cancer treatment modality was not related to marital happiness or stability, however.

Sexuality and fertility in urologic cancer patients

With the advent of effective treatment for urologic cancer, the preservation of sexual function and fertility has become an important goal. Some cancer treatments damage the physiological systems involved in reproduction. All have a psychological impact on sexuality. For men with prostate cancer, current issues in sexual rehabilitation include the debate on nerve-sparing radical prostatectomy, the role of vascular damage in causing erectile dysfunction after radiotherapy, and the need for a better understanding of hormonal effects on central and peripheral mechanisms of sexual function. In the treatment of men and women with bladder cancer, the sexual function morbidity of radical cystectomy is described in data from prospective interview studies. Sexual desire and orgasm remain normal after surgery despite disruption of the genital vasocongestion accompanying sexual arousal. Long-term follow-up studies of testicular cancer patients suggest that some increase in sexual dysfunction does occur. Infertility remains a concern for a subgroup of younger, childless men. Attempts to modify or eliminate retroperitoneal lymphadenectomy are discussed, as is recovery of spermatogenesis after chemotherapy and radiotherapy. Sexual function in patients with penile, urethral, or renal cell carcinoma is briefly reviewed.