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

Sexuality and cancer in adolescents and young adults - a comparison between reproductive cancer patients and patients with non-reproductive cancer

BACKGROUND

Sexuality is an important aspect of quality of life for adolescent and young adults that remains understudied in cancer patients. Most current knowledge about how cancer and cancer treatments can affect patients' sexuality pertains to reproductive cancer patients (breast, gynecological, male reproductive organs), whereas only little is known about how the disease affects the sex lives of patients with other types of cancer. This study examined sexual satisfaction and sexual supportive care needs among adolescent and young adult cancer patients, with a particular focus on how the type of cancer a person has is associated with these issues differently.

METHODS

Five hundred seventy-seven (n = 424 females, 73.5%) patients between 18 and 39 years of age at diagnosis and representing all major tumor entities completed the standardized questionnaire. The analysis addressed the following topics: sexual satisfaction (Life Satisfaction Questionnaire), sexual supportive care needs (Supportive Care Needs Survey), and changes in sexuality (Questions on Life Satisfaction Modules). These topics were tested by mean differences between reproductive and non-reproductive cancer, equivalence testing and regression analyses.

RESULTS

About one third of the patients reported being dissatisfied with their sexuality and having supportive care needs in this area. Changes in sexuality were significantly more common in women with reproductive cancers than in those who had other types of cancer (t = - 2.693, p = .007), while both groups had equivalence in scores for sexual satisfaction and sexual supportive care needs. Reproductive cancers are not more associated with deterioration of sexual satisfaction (R2 = .002, p = .243), changes in sexuality (R2 = .006, p = .070) or increased sexual supportive care needs than non-reproductive cancers (R2 = .004, p = .131).

CONCLUSIONS

The results indicate that about a third of adolescents and young adults with both reproductive but also with non-reproductive cancer experience sexual dissatisfaction in similar measure. An equal percentage of these patients also express a desire to receive supportive care in this area. Consequently, health care professionals should address issues of sexuality and cancer as a matter of routine when caring for young adults even when patients have a non-reproductive cancer.

[Sexual dysfunctions of patients treated with orchidectmoy, chemotherapy and retroperitoneal lymphadenectomy, need for systematic andrological care?]

GOAL

Long-term evaluation of the incidence of sexual dysfunction from patients who were treated by orchidectomy, chemotherapy, and retroperitoneal lymphadenectomy for testicular cancer.

METHODS

In 2018, patients who were treated in two academic hospitals by orchiectomy, chemotherapy, and retroperitoneal lymphadenectomy, and were in complete remission, were included. The patients included in this study filled the survey, which covered aspects of their sexuality (the Male Sexual Health Questionnaire) and answered additional questions, which evaluated psychological impact and modification of their sexuality since the management of their cancer.

RESULTS

Twenty patients have been included, 70% of the patients treated for non-seminomatous germ cell tumor. Mean age was 36.4years±12.1 and the average duration of follow-up was 59months±34. Sexual dysfunction was found in 50% of the patients. Only 10% of the patients could preserve satisfying sexual activity during their treatment. Since the end of their treatment, 16%, 21% and 37% of patients respectively declared high libido loss, lower tumescent erections and persistence of anejaculation. In the end, nearly 70% of these patients wished a dedicated consultation with an urologist with subspecialty in andrology, in order to obtain further information during their care course.

DISCUSSION

These patients have shown multicomponent sexual dysfunction. They could benefit from a new healthcare pathway implying early involvement of andrologist network.

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

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

A systematic review of quantitative observational studies investigating psychological distress in testicular cancer survivors

OBJECTIVE

Testicular cancer (TC) affects young men and may cause psychological distress despite a good prognosis. This systematic review evaluated the prevalence, severity, and correlates of anxiety, depression, fear of cancer recurrence (FCR), and distress in TC survivors.

METHODS

A systematic search of literature published 1977 to 2017 was conducted to find quantitative studies including TC survivor-reported outcomes relevant to review objectives. The quality of included articles was assessed, and a narrative synthesis conducted.

RESULTS

Of 6717 articles identified, 66 (39 good, 20 fair, and 7 poor quality) reporting results from 36 studies were included. Testicular cancer survivors' mean anxiety levels were higher than in the general population, while mean depression and distress were no different. Clinically significant anxiety (≈1 in 5) and to a lesser extent distress (≈1 in 7), but not depression, were more prevalent in TC survivors than the general population. Approximately 1 in 3 TC survivors experienced elevated FCR. Poorer psychological outcomes were more common among TC survivors who were single, unemployed/low socio-economic status, suffering from co-morbidities, experiencing worse symptoms/side effects, and using passive coping strategies.

CONCLUSIONS

Many TC survivors do not experience significant psychological morbidity, but anxiety and FCR are prevalent. Inadequate coping resources (eg, low socio-economic status and social support) and strategies (eg, avoidance) and greater symptoms/side effects were associated with poorer outcomes. Theoretically driven prospective studies would aid understanding of how outcomes change over time and how to screen for risk. Age and gender appropriate interventions that prevent and manage issues specific to TC survivors are also needed.

The Evolution and Technique of Nerve-Sparing Retroperitoneal Lymphadenectomy

The evolution of retroperitoneal lymph node dissection technique and associated template modifications for nonseminomatous germ cell tumors have resulted in significant improvement in the long-term morbidity. Through the preservation of sympathetic nerves via exclusion from or prospective identification within the boundaries of resection, maintenance and recovery of antegrade ejaculation are achieved. Nerve-sparing strategies in early-stage disease are feasible in most patients. Postchemotherapy, select patients can be considered for nerve preservation. This article describes the anatomic and physiologic basis for, indications and technical aspects of, and functional and oncologic outcomes reported after nerve-sparing retroperitoneal lymphadenectomy in testicular cancer.

How has early testicular cancer affected your life? A study of sexual function in men attending active surveillance for stage one testicular cancer

PURPOSE

Testicular cancer is the most common cancer in young men, it is frequently diagnosed at key times in relationship formation. In early stage disease the vast majority of tumours will be cured by surgery alone with patients being offered active surveillance rather than adjuvant therapies. To date, research has not evaluated how surveillance alone impacts on sexual function.

METHODS

The aim of this quantitative longitudinal study was to ascertain the sexual function of men with stage one disease at 3 and 12 months post diagnosis and to compare with normative data. Additional data was collected on the information men sought regarding sexual function and media they used to access this.

RESULTS

This study shows that men's sexual function is altered at diagnosis and improves by 3 months. At 12 months, whilst not statistically significant, sexual function improves but not to the same level as normative data comparison. Men appear to find verbal information useful at 3 months, however men appear to be seeking written and online information at 12 months.

CONCLUSION

The intricacies of sexual function together with the low number of participants may have been best met with a qualitative approach. However, the information data indicates the importance of further research into the effects of early stage testicular cancer on sexual function. Therefore, further qualitative research is recommended to explore the effects of early stage testicular cancer in relation to sexual function.

Side Effects of Adjuvant Radiotherapy in Men with Testicular Seminoma Stage I

In this study we followed up the side effects of adjuvant radiotherapy in patients with testicular seminoma stage I over a period from 13 to 84 months (median 28 months). The most frequent side effects during radiotherapy were gastrointestinal (nausea/vomiting), psychological, cognitive, and minor sexual problems.

The reported side effects were treated by antiemetics and anxiolytics. After radiotherapy, the side effects persisted in 6 % of patients, but only a few of them required additional treatment. Healthy children were born to 76 % of patients in the 18 to 39 years age group. This study shows that adjuvant radiotherapy of the para-aortic lymph nodes with the total dosage of 24 Gy in 16 daily fractions administered to testicular seminoma patients causes acceptable side effects, does not adversely affect quality of life and fertility, if the approach to treatment is individual and family consulting is provided. This makes adjuvant radiotherapy of the para-aortic lymph nodes an acceptable treatment for testicular seminoma stage I patients.

Sequelae of treatment in long-term survivors of testis cancer

CONTEXT

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

OBJECTIVE

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

EVIDENCE ACQUISITION

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

EVIDENCE SYNTHESIS

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

CONCLUSIONS

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

Sexual function in men treated for testicular cancer

INTRODUCTION

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

AIM

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

METHODS

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

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSION

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

The Quality of Life and Hormonal Disturbances in Testicular Cancer Survivors in Cisplatin Era

OBJECTIVES

To assess the degree of hormonal abnormalities in testicular cancer survivors and the effect of these changes on patients' quality of life.

METHODS

Men with complete remission of testicular cancer for over 2 yr were eligible. Patients completed the State-Trait Anxiety Inventory (STAI), the Hospital Anxiety and Depression Scale (HADS), Beck Depression Inventory (BDI), the International Index of Erectile Function (IIEF), and the Sexual Functioning Questionnaire (SFQ), and rated their physical and psychological well-being, quality of life, and relationship with their partner. Levels of the hormones testosterone, estradiol, thyreotropin, follicle-stimulating hormone (FSH), luteinizing hormone (LH), and prolactin were determined. Relationships between hormone levels and questionnaire results were assessed.

RESULTS

A total of 326 men were tested, of whom 269 were treated with platinum-based chemotherapy. The most common endocrine abnormalities were above-normal gonadotropin levels (LH, 55%, and FSH, 49% of cases) and lowered testosterone (15%). Twenty-seven percent (STAI) and 28% (HADS) of the patients had abnormal anxiety levels, while the depression rate was 15% (BDI) and 18% (HADS); 40% of patients had erectile dysfunction. Linear regression analysis excluding the influence of age showed higher depression levels in the BDI among patients with elevated LH (p=0.010) or FSH (p=0.017). Patients with above-normal LH showed increased sexual problems in the SFQ (p=0.030). Elevated gonadotropins correlated with deteriorated physical well-being (p=0.028). Men with abnormal estradiol were more prone to erectile dysfunction (p=0.009).

CONCLUSIONS

Hormonal abnormalities have a negative impact on the quality of life of testicular cancer survivors.

Quality of life in survivors of testicular cancer

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

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

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

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.

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

PURPOSE

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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

Sexual dysfunction after treatment for testicular cancer: a systematic review

OBJECTIVES

We aimed to assess the nature and risk of sexual dysfunction in men after treatment for testicular cancer.

METHOD

Systematic review of sexual dysfunction in men treated for testicular cancer. The odds ratio or proportions of subjects with reduced sexual drive, erectile dysfunction or orgasmic/ejaculatory dysfunction was calculated.

RESULTS

A detailed review of 79 of the 227 citations was conducted. The highest level of evidence found, were controlled studies. Six controlled studies examined sexual function in 709 patients after they had received treatment. Seven uncontrolled studies examined sexual function in 337 subjects before and after treatment for testicular cancer. Most studies were limited by low response rates, use of unvalidated questionnaires and inclusion of a variety of treatment modalities. Few assessed psychological function and none examined its possible interaction with sexual dysfunction. Meta-analysis of the controlled studies indicated significantly reduced or absent orgasm (OR=4.62, 95% CI=2.47-8.63) together with erectile (OR=2.47, 95% CI=1.54-3.96) and ejaculatory dysfunction (OR=28.57, 95% CI=1.75-464.78) up to 2 years after treatment. Effects on sexual function were less consistent in the uncontrolled studies.

CONCLUSIONS

The controlled studies indicate that sexual dysfunction persists for up to 2 years after treatment. However, better evidence is needed in studies that control for the impact of the testicular cancer, the treatment modality and psychological reactions to both.

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.

Assessment and treatment of depression in the cancer patient

The prevalence, diagnosis, and treatment of depression in the cancer patient are reviewed. Although frequently encountered in the cancer patient population, depression often remains undiagnosed and untreated. This carries grave consequences in that depressed cancer patients experience a poorer quality of life, are less compliant with medical care, have longer hospital stays, and have higher mortality rates. Diagnostic assessment of depression in the cancer patient raises difficulties both upon phenomenological and etiological grounds. In particular, the presence of neurovegetative symptoms which may be secondary to either cancer or depression may cloud the diagnostic picture. Due to the serious consequences of unrecognized depression, a more sensitive inclusive approach to diagnosis is recommended in the clinical setting. Finally, the limited data regarding treatment of depression in patients with cancer is reviewed. This includes a discussion of both psychosocial and pharmacological interventions which are shown to alleviate depression, improve quality of life measures, improve immune function, and lengthen survival time.

Retroperitoneal lymphadenectomy in staging and treatment. The development of nerve-sparing techniques

Currently, where available and widely practiced, nerve-sparing RPLND offers the least toxic and safest alternative in management of clinical stage I nerve-sparing germ cell tumor. Twenty-six percent to 30% of such cases are found to be node positive and, if no adjuvant chemotherapy is elected, two thirds do not relapse; those who do are uniformly rescued by chemotherapy. The 70% who are node negative have no long-term toxicity and do better in quality of life studies than their surveillance counterparts. Also, risk-benefit and cost-benefit studies support the competitive position, of RPLND vis-à-vis the other options. Nonetheless, it is fair to say there are several options for management of clinical stage I nonseminomatous germ cell tumors that, when well applied, work well. Their choice depends on regional factors related to availability and experience.

Psychosocial adjustment after testicular cancer treatment

PURPOSE

The high cure rate in testicular cancer has provoked investigations relating to the quality of life in long-term survivors. We determine the psychosocial consequences of the disease especially in regard to sexual and professional performance.

MATERIALS AND METHODS

Among the testicular cancer patients treated with various treatment modalities 140 rendered free of disease for at least a year were included in this study. General Health Questionnaire 28 and a general survey were used to determine quality of life issues.

RESULTS

Regarding the sexual life of these patients, problems related to libido, erection and ejaculation increased significantly during treatment and subsequently recovered but did not return to baseline after treatment. During treatment the frequency of sexual intercourse and/or masturbation decreased significantly in all patients. Of the single patients 35% thought that medical history would be a concern for the potential spouse. Regarding professional lives, 22.4% thought that they had better performance after treatment compared to before therapy, whereas only 6.1% reported it to be worse. When professional performance was analyzed according to the treatment modalities those who had received radiotherapy did worse. General Health Questionnaire scores indicated that patients with this disease had a positive view of life compared to that of the normal population.

CONCLUSIONS

Although we observed a substantial recovery in sexual life after treatment, it was evident that therapy did have a negative effect on sexual functions. There was no effect on occupational performance and perspective of life, which may be related to the fact of having overcome a life threatening disease.

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.

Cost- and risk-benefit considerations in the management of clinical stage I nonseminomatous testicular tumors

BACKGROUND

The high curability of clinical stage I nonseminomatous germ cell tumors (NSGCTs) and the availability of equally effective management options (retroperitoneal lymph node dissection [RPLND] and surveillance) allows for treatment decisions based on secondary end points, including sort- and long-term toxicity and cost relative to benefit. The purpose of this study was to perform cost-benefit and risk-benefit analyses of management options in clinical stage I NSGCT using data from the literature and Indiana University.

METHODS

The overall costs for 100 patients undergoing a primary RPLND were compared with the total costs of 100 patients managed by surveillance for clinical stage I disease. These two options were then analyzed in terms of survival, late relapse, acute and chronic toxicity (including fertility), and perioperative morbidity.

RESULTS

The overall costs of these two approaches were essentially identical. The two options were similar in terms of survival, although RPLND demonstrated superiority in terms of fertility, toxicity, and late relapse.

CONCLUSIONS

The choice of nerve-sparing RPLND or surveillance in clinical stage I NSGCT patient cannot be made on the basis of cost as a discriminator. Instead, the decision should be made based on patient desires, physician expertise, biological predictors, and short- and long-term toxicity.

Preservation of function in genitourinary cancers: psychosexual and psychosocial issues

GU cancers are commonly associated with treatment-related sexual dysfunction, varying from mild to severe. For the clinical oncologist, it is important to be aware that sexual problems or sexual dysfunction may occur as a result of any aspect of cancer and cancer treatment. Sexual function is sensitive to the effects of trauma, both physical and emotional. This is particularly the case for patients whose cancer affects their genitals. Despite some commonalities of psychosocial and psychosexual issues in GU patients across diagnostic categories, GU patients do not present as one distinct, homogeneous group. GU neoplasms, with the exception of bladder cancer, affect mostly men. Men and women tend to differ in their ways of dealing with emotional distress and physical illness. While the man may typically do well using denial as a defense and may not want to discuss his feelings about his diagnosis and treatment, his partner may suffer if her way of coping is oriented toward communicating thoughts and feelings about the situation. Another important difference in this population is related to age and developmental differences. Testicular cancer typically is diagnosed in young men between the ages of 15 and 34 (46). The patients often still live with their parents or have just formed families of their own. In contrast, prostate cancer is diagnosed in older men, who are at a completely different stage in their lives when they have to deal with this challenge. Developmental stage at the time of diagnosis and treatment is an important variable in adaptation to cancer (47). Since GU malignancies and their treatments directly or indirectly affect sexual organs and sexual functioning, issues of sexual body image and identity as men or women are frequent concerns for GU patients. This is most obviously the case for men facing penectomy or orchiectomy. Similarly, women undergoing cystectomy with its simultaneous removal of uterus, ovaries, and parts of the vaginal wall face issues regarding their femininity as well as doubts about future sexual functioning. However, body image concerns are not limited to these two groups but may affect any cancer patient. The experience of having lost all hair due to chemotherapy, bearing of surgical scars, lost or altered functioning, and just the realization of having had cancer may change the way a patient feels about his/her body permanently.(ABSTRACT TRUNCATED AT 250 WORDS)

Quality of life in patients treated for penile cancer. A follow-up study

OBJECTIVES

To study the long-term psychosocial well-being of patients following successful physical treatment for cancer of the penis.

PATIENTS AND METHODS

Thirty patients (median age at follow-up 57 years, range 28-75) were followed up for a median of 80 months after treatment for penile cancer (local excision/laser beam treatment, 5; radiotherapy, 12; partial penectomy, 9; total penectomy, 4). They underwent a semi-structured interview and completed the Impact of Events Scale, General Health Questionnaire and the EORTC QLQ C-30 questionnaire. Global scales for measuring sexual function, subjective well-being and social activity were constructed and found reliable and valid.

RESULTS

There was a strong correlation between the well-being scale and the EORTC scales for overall quality of life and psychological distress. Patients treated with partial or total penectomy had a worse outcome with regard to sexual function than patients treated conservatively, but there was no difference in the other domains of quality of life, indicating that even the more radically treated patients usually adapted adequately. Half of the individuals had mental symptoms at follow-up, and these patients were less satisfied and showed less social activity. Seven men reported that, if asked again, they would choose treatment with lower long-term survival to increase the chance of remaining sexually potent, but the majority gave priority to higher long-term survival.

CONCLUSION

Before treatment of penile cancer, physicians should thoroughly discuss the expected outcome and consequences of the different treatment options with the patient. Psychosocial treatment might be helpful for patients with mental symptoms.

Sexuality in patients treated for penile cancer: patients' experience and doctors' judgement

OBJECTIVE

To evaluate sexuality after successful treatment of penile cancer.

PATIENTS AND METHODS

Post-therapy sexuality was evaluated in 30 men (median age 57 years; range 28-75) treated for cancer of the penis 80 months previously (median; range: 11-225 months). Treatment regimes were: local excision/laser beam treatment, 5; definitive radio-therapy, 12; partial penectomy, 9; total penectomy, 4. Patients underwent a semi-structured interview and completed three self-administered questionnaires (psychosocial adjustment to severe illness [PAIS], mental symptoms [GHQ], quality of life [EORTC QLQ C-30]). A global score of overall sexual functioning was constructed consisting of sexual interest, sexual ability, sexual satisfaction, sexual identity, partner relationship and frequency of coitus.

RESULTS

In 10 of 12 patients treated by irradiation the sexual global score was not or only slightly reduced compared with two of nine patients after partial penectomy and one of five patients with local surgery/laser beam treatment. All four patients who had undergone total penectomy recorded a severely reduced sexual global score. Of the six single domains, sexual identity and partner relationship did not change with increasing age, whereas the other scores of sexual life deteriorated as the patient became older. In the patients treated by irradiation doctors evaluated the patients' post-treatment sexuality to be more impaired than that experienced by the patients.

CONCLUSION

Within the limitations due to the small number of patients studied, radiotherapy seems to be the treatment of choice in limited cancer of the penis if preservation of sexuality is a major therapeutic aim. Physicians counselling patients with this rare malignancy need more information about treatment-related problems of sexuality after different therapeutic modalities.