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

Men's experiences of surviving testicular cancer: an integrated literature review

PURPOSE

To synthesise literature in order to elucidate the experiences of men who have survived testicular cancer and determine their quality of life following treatment.

METHODS

An integrated review sought appropriate literature by utilising a keyword search across seven databases. Retrieved studies were appraised for quality, with 2 qualitative, 12 quantitative and 2 mixed method studies deemed appropriate for this review. The data were extracted and aggregated into categories by way of a thematic analysis. The themes were personal challenges and impact on health, psychological and emotive challenges, perception of reproduction and sexual changes and outlook and support.

RESULTS

Men experienced physical, emotional and sexual difficulties. Some men believed they were infertile, despite evidence that fertility is not compromised in the long term. Psychological conditions can be exacerbated by cultural pressures to conceive and cultural expressions about male identity. Men who had undergone orchidectomy reported minimal impact on their mental health than the men who had chemotherapy or radiotherapy as part of their treatment modality. Sexual dysfunction caused by chemotherapy-associated side effects was detrimental to men's quality of life. In addition, men who had a partner, who were employed, and who had children were able to adjust better after treatment than those who did not. Provision of clear and honest information post-treatment helped testicular cancer survivors return to their normal lives.

CONCLUSIONS

The evidence from the review suggests that the burden of disease for testicular cancer survivors is overall low. Men who had surgical intervention and were treated for testicular cancer experienced minimal impact on their mental health status than the men who had chemotherapy or radiotherapy as part of their treatment modality.

IMPLICATIONS FOR CANCER SURVIVORS

There is a need to provide appropriate referrals to the relevant services, including psychosocial support, and the development of more adequate communication resources for men following treatment for testicular cancer.

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.

131I-tositumomab myeloablative radioimmunotherapy for non-Hodgkin's lymphoma: radiation dose to the testes

PURPOSE

To investigate radiation doses to the testes delivered by a radiolabeled anti-CD20 antibody and its effects on male sex hormone levels.

MATERIALS AND METHODS

Testicular uptake and retention of (131)I-tositumomab were measured, and testicular absorbed doses were calculated for 67 male patients (54 ± 11 years of age) with non-Hodgkin's lymphoma who had undergone myeloablative radioimmunotherapy (RIT) using (131)I-tositumomab. Time-activity curves for the major organs, testes, and whole body were generated from planar imaging studies. In a subset of patients, male sex hormones were measured before and 1 year after the therapy.

RESULTS

The absorbed dose to the testes showed considerable variability (range = 4.4-70.2 Gy). Pretherapy levels of total testosterone were below the lower limit of the reference range, and post-therapy evaluation demonstrated further reduction [4.6 ± 1.8 nmol/l (pre-RIT) vs. 3.8 ± 2.9 nmol/l (post-RIT), P<0.05]. Patients receiving higher radiation doses to the testes (≥ 25 Gy) showed a greater reduction [4.7 ± 1.6 nmol/l (pre-RIT) vs. 3.3 ± 2.7 nmol/l (post-RIT), P<0.05] compared with patients receiving lower doses (<25 Gy), who showed no significant change in total testosterone levels.

CONCLUSION

The testicular radiation absorbed dose varied highly among individual patients. Patients receiving higher doses to the testes were more likely to show post-RIT suppression of testosterone levels.

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.

Romantic and sexual relationships, body image, and fertility in adolescent and young adult testicular cancer survivors: a review of the literature

This review presents a summary of existing knowledge regarding the effect of testicular cancer along four broad domains, including romantic and sexual relationships, body image, and fertility. A total of 37 studies were reviewed. Of note, most research consists of older adult testicular cancer survivors, with very little research attention afforded to adolescent and young adult survivorship. Relationship status (i.e., partnered versus unpartnered) appears to play an important role as it relates to adjustment outcomes in testicular cancer survivors. In addition, sexual function (and thereby fertility) and body image are also frequently compromised. Implications regarding a lack of developmentally focused research on adolescent and young adult testicular cancer survivorship are discussed, along with recommendations for new research.

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.

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.

A patient-centred approach to sexuality in the face of life-limiting illness

Sexuality is intrinsic to a person's sense of self and can be an intimate form of communication that helps relieve suffering and lessens the threat to personhood in the face of life-limiting illness. Health professionals struggle to accept that people with life-limiting illness, especially older people, continue to be sexual beings. People facing life-limiting illness may appreciate the opportunity to discuss issues of sexuality and intimacy with a trusted health professional. Practical strategies to assist health professionals to communicate effectively about sexuality and intimacy include creating a conducive atmosphere, initiating the topic, using open-ended questions and a non-judgmental approach, and avoiding medical jargon.

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.

The use of preferences to measure the benefit of adjuvant radiation therapy for stage I seminoma

PURPOSE

In Stage I seminoma, treatment with radiation therapy (RT) after radical inguinal orchiectomy reduces the likelihood of relapse by 15%, but does not improve survival, thus making quality of life an important outcome measure. The purpose of this study was to use utilities to assess the quality of life benefits associated with adjuvant RT in this setting.

MATERIALS AND METHODS

One hundred healthy men were interviewed using a utility assessment tool. Utilities for five health states were measured using the standard gamble technique: (A) adjuvant RT with 5% recurrence risk; (B) recurrence after RT, salvaged with chemotherapy; (C) orchiectomy alone with 20% recurrence risk; (D) recurrence after orchiectomy alone, salvaged with RT; and (E) recurrence after orchiectomy alone, salvaged with chemotherapy.

RESULTS

The median age was 25. Utilities were highest for nonrecurrent health states, and lowest for recurrence salvaged with chemotherapy. All differences in utilities between health states were significant, except between states A and C and B and E. Variability in utilities was not explained by the sociodemographic factors examined.

CONCLUSIONS

Our results suggest that healthy males do not value the 15% reduction in recurrence risk achievable with adjuvant RT. However, they do predict that an actual recurrence, especially one requiring salvage chemotherapy, will lead to significant decline in quality of life. We intend to use these utilities to further evaluate the cost-effectiveness of RT in this setting.

Castration increases pulsatile luteinizing hormone release, but fails to diminish mounting behavior in sexually experienced bulls

We tested the hypothesis that mounting and chemoinvestigatory behaviors are testosterone-dependent in bulls. Eighteen bulls were divided into three treatment groups: intact (I), castrated (C) and castrated+testosterone (T). Sexual behaviors of all bulls were tested with an unrestrained receptive female 1 week prior to and weekly for 4 weeks after castration. Mounts with intromissions, aborted mounts and flehmen responses were quantified for each test period. In addition, patterns of LH and testosterone secretion were assessed at these times. Neither mounts with intromissions nor aborted mounts were affected by treatment. In contrast, numbers of flehmen responses were lower in C bulls than in the other groups following castration. Before castration, concentrations of LH were not different among groups and LH pulse frequency was approximately one pulse per hour. Castration resulted in a 2-fold increase in mean concentrations of LH and a 6-fold increase in LH pulse frequency. Neither mean concentration of LH nor LH pulse frequency changed in I or T bulls. The data fail to support the hypothesis that mounting behavior is T-dependent, but supports the hypothesis that this steroid hormone regulates flehmen behavior in sexually experienced bulls.

Quality of life studies and genito-urinary tumors

BACKGROUND

Genitourinary (GU) tumors represent a large proportion of solid cancers (1 of 4) and a wide variety of natural histories, based on various prognostic factors and resulting in different treatment options and end points. In some cases, for the same stage of disease, different treatment strategies do not impact differently on overall survival (OS): surgery vs. radiation, or radical vs. conservative multidisciplinary approach, adjuvant or neoadjuvant, chemotherapy vs. BSC. Quality of life (QoL) is considered a reasonable end point when differences in OS do not seem to be striking.

DESIGN

A review of the literature on different disease stages was undertaken to show where and when QoL was used as the end point of treatment efficacy.

RESULTS

Very few studies have been performed in prostate, bladder and testicular cancer to show the impact of different treatment approaches on QoL. Although these studies might be considered as non-conclusive, some data may allow a better choice for the patients.

CONCLUSIONS

QoL as the principal end point has not been used in clinical trials of GU tumors comparing different treatment approaches. This makes the choice between treatments offering similar survival but different toxicity patterns, body and behavioral consequences more difficult. We suggest that future prospective randomized studies should be planned taking into account the QoL as the main end point.

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.

Quality of life after radiotherapy for early-stage testicular seminoma

BACKGROUND AND PURPOSE

Standard therapy in early-stage testicular seminoma (TS) includes inguinal orchiectomy followed by irradiation (XRT) of the pelvic and para-aortic nodes. Since this treatment is highly effective in controlling the disease and leads to many long survivors, the quality of life (QL) may be impaired by treatment-induced side-effects. The aim of this study was to provide a QL evaluation of patients treated with XRT after orchiectomy for TS.

MATERIALS AND METHODS

We used a validated self-completed questionnaire based on a series of 44 items covering all QL fields. The items were grouped into six subscales with standardized scores. The questionnaire was mailed to a consecutive series of 143 patients treated between 1961 and 1995 for TS with no evidence of disease after primary treatment.

RESULTS

Ninety-eight questionnaires (68.5%) were returned and are assessable. The median age of the patients was 48 years (range, 26-85 years) at the time of completing the questionnaire, with a median follow-up after completion of treatment of 123 months (range, 15-432 months). The physical and autonomy subscale standardized scores were > or =1 in 83 and 95% of the cases, respectively. Psychological problems were reported by a small percentage of patients, ranging from 13, who reported a depressive condition, to 16%, who declared feeling tense. Of the patients, 86 and 89% have regularly met relatives and friends. The urinary score was above the central point in 99% of the patients. Only 6% of the patients perceived their body image as worsened by treatment. The patients who were more informed about the disease and therapy had a better physical and psychological adjustment.

CONCLUSIONS

The QL in our patients resulted as satisfactory, with a maintained body image and few side-effects. The information given to the patients about their disease and its treatment influenced the post-treatment QL adjustment.

Sexual function and fertility after treatment of testicular cancer

As a result of the introduction of effective cisplatin-based chemotherapeutic regimens into the clinical routine, even patients with metastatic testicular cancer at initial diagnosis can be cured of their disease. Sexual dysfunction and infertility are common long-lasting sequelae in testicular cancer survivors, affecting approximately 20% of patients after the application of the different treatment modalities currently available for the treatment of early and advanced clinical stages, including retroperitoneal surgery and systemic chemotherapy. Accordingly, it has been demonstrated that fertility distress and sexual disturbances, the latter occurring in only a minority of patients after surgical or chemotherapeutic treatment of testicular germ cell tumours, substantially alter the patients' quality of life. It is even worse because testicular cancer mostly affects men in the prime of their physical, sexual and reproductive function. Although semen quality is frequently poor at initial diagnosis and further deteriorates after orchiectomy, probably because of structural abnormalities in the remaining contralateral testicle, the advent of intracytoplasmatic sperm injection promises a fertile future to most patients, even if only a few sperms are present in the ejaculate. Further long-term investigations should be initiated to clarify the impact of the different treatment modalities on fertility and sexual life. The main objective should be the identification of patients who are at increased risk of developing therapy-related physical and psychological problems.