Fatigue, sexual function and mood following treatment for haematological malignancy: the impact of mild Leydig cell dysfunction

Sexual Health in Adolescents and Young Adults With Cancer

Sexual health (SH), an integral aspect of overall health and quality of life, can be negatively affected by cancer and cancer treatment. SH is influenced by biological, psychological, social, and cultural factors, and, for adolescents and young adults (AYAs), developmental factors. The AYA population (age 15-39 years) is diverse in terms of psychosexual development, interpersonal relationships, and varying levels of independence, resulting in unique SH needs for this population. AYAs with cancer are particularly vulnerable to unmet SH needs related to contraception and infection prevention, sexual function, body image, and romantic/sexual relationships. Sexual dysfunction during and after cancer treatment is reported by 30%-100% of AYA cancer survivors. Clinical guidelines recommend discussing SH and screening for dysfunction but currently lack specifics regarding psychosexual interventions and strategies for incorporating screening into clinical care. Research and clinical priorities include improved provider-AYA communication regarding SH, standardization of SH measures and screening tools, infrastructure to support the SH needs of AYAs across pediatric and adult clinical environments, and engagement of sexual and gender minority AYAs in research. As the field of SH in cancer evolves, interventions need to be tailored to the developmental needs that are unique to AYAs and address the multidimensional aspects of SH.

Epigenome editing based on CRISPR/dCas9p300 facilitates transdifferentiation of human fibroblasts into Leydig-like cells

Recently, Leydig cell (LCs) transplantation has a promising potential to treat male hypogonadism. However, the scarcity of seed cells is the actual barrier impeding the application of LCs transplantation. Utilizing the cutting-edge CRISPR/dCas9^VP64 technology, human foreskin fibroblasts (HFFs) were transdifferentiated into Leydig-like cells（iLCs） in previous study, but the efficiency of transdifferentiation is not very satisfactory. Therefore, this study was conducted to further optimize the CRISPR/dCas9 system for obtaining sufficient iLCs. First, the stable CYP11A1-Promoter-GFP-HFFs cell line was established by infecting HFFs with CYP11A1-Promoter-GFP lentiviral vectors, and then co-infected with dCas9^p300 and the combination of sgRNAs targeted to NR5A1, GATA4 and DMRT1. Next, this study adopted quantitative reverse transcription polymerase chain reaction (qRT-PCR), Western blot, and immunofluorescence to determine the efficiency of transdifferentiation, the generation of testosterone, the expression levels of steroidogenic biomarkers. Moreover, we utilized chromatin immuno-precipitation (ChIP) followed by quantitative polymerase chain reaction (ChIP-qPCR) to measure the levels of acetylation of targeted H3K27. The results revealed that advanced dCas9^p300 facilitated generation of iLCs. Moreover, the dCas9^p300-mediated iLCs significantly expressed the steroidogenic biomarkers and produced more testosterone with or without LH treatment than the dCas9^VP64-mediated. Additionally, preferred enrichment in H3K27ac at the promoters was detected only with dCas9^p300 treatment. The data provided here imply that the improved version of dCas9 can aid in the harvesting of iLCs, and will provide sufficient seed cells for cell transplantation treatment of androgen deficiency in the future.

Nandrolone Supplementation Promotes AMPK Activation and Divergent 18[FDG] PET Brain Connectivity in Adult and Aged Mice

Decreased anabolic androgen levels are followed by impaired brain energy support and sensing with loss of neural connectivity during physiological aging, providing a neurobiological basis for hormone supplementation. Here, we investigated whether nandrolone decanoate (ND) administration mediates hypothalamic AMPK activation and glucose metabolism, thus affecting metabolic connectivity in brain areas of adult and aged mice. Metabolic interconnected brain areas of rodents can be detected by positron emission tomography using ¹⁸FDG-mPET. Albino CF1 mice at 3 and 18 months of age were separated into 4 groups that received daily subcutaneous injections of either ND (15 mg/kg) or vehicle for 15 days. At the in vivo baseline and on the 14th day, brain ¹⁸FDG-microPET scans were performed. Hypothalamic pAMPK^T172/AMPK protein levels were assessed, and basal mitochondrial respiratory states were evaluated in synaptosomes. A metabolic connectivity network between brain areas was estimated based on ¹⁸FDG uptake. We found that ND increased the pAMPK^T172/AMPK ratio in both adult and aged mice but increased ¹⁸FDG uptake and mitochondrial basal respiration only in adult mice. Furthermore, ND triggered rearrangement in the metabolic connectivity of adult mice and aged mice compared to age-matched controls. Altogether, our findings suggest that ND promotes hypothalamic AMPK activation, and distinct glucose metabolism and metabolic connectivity rearrangements in the brains of adult and aged mice.

Rapid Differentiation of Human Embryonic Stem Cells into Testosterone-Producing Leydig Cell-Like Cells In vitro

Background:

Leydig cells (LCs) are testicular somatic cells that are the major producers of testosterone in males. Testosterone is essential for male physiology and reproduction. Reduced testosterone levels lead to hypogonadism and are associated with diverse pathologies, such as neuronal dysfunction, cardiovascular disease, and metabolic syndrome. LC transplantation is a promising therapy for hypogonadism; however, the number of LCs in the testis is very rare and they do not proliferate in vitro. Therefore, there is a need for an alternative source of LCs.

Methods:

To develop a safer, simple, and rapid strategy to generate human LC-like cells (LLCs) from stem cells, we first performed preliminary tests under different conditions for the induction of LLCs from human CD34/CD73 double positive-testis-derived stem cells (HTSCs). Based on the embryological sequence of events, we suggested a 3-step strategy for the differentiation of human ESCs into LLCs. We generated the mesendoderm in the first stage and intermediate mesoderm (IM) in the second stage and optimized the conditions for differentiation of IM into LLCs by comparing the secreted testosterone levels of each group.

Results:

HTSCs and human embryonic stem cells can be directly differentiated into LLCs by defined molecular compounds within a short period. Human ESC-derived LLCs can secrete testosterone and express steroidogenic markers.

Conclusion:

We developed a rapid and efficient protocol for the production of LLCs from stem cells using defined molecular compounds. These findings provide a new therapeutic cell source for male hypogonadism.

Small Molecule Epigenetic Modulators in Pure Chemical Cell Fate Conversion

Although innovative technologies for somatic cell reprogramming and transdifferentiation provide new strategies for the research of translational medicine, including disease modeling, drug screening, artificial organ development, and cell therapy, recipient safety remains a concern due to the use of exogenous transcription factors during induction. To resolve this problem, new induction approaches containing clinically applicable small molecules have been explored. Small molecule epigenetic modulators such as DNA methylation writer inhibitors, histone methylation writer inhibitors, histone acylation reader inhibitors, and histone acetylation eraser inhibitors could overcome epigenetic barriers during cell fate conversion. In the past few years, significant progress has been made in reprogramming and transdifferentiation of somatic cells with small molecule approaches. In the present review, we systematically discuss recent achievements of pure chemical reprogramming and transdifferentiation.

Conversion of Fibroblast into Functional Leydig-like Cell Using Defined Small Molecules

Recent studies have demonstrated that fibroblasts can be directly converted into functional Leydig cells by transcription factors. However, the transgenic approach used in these studies raises safety concerns for its future application. Here, we report that fibroblasts can be directly reprogrammed into Leydig-like cells by exposure to a combination of forskolin, 20α-hydroxycholesterol, luteinizing hormone, and SB431542. These chemical compound-induced Leydig-like cells (CiLCs) express steroidogenic genes and have a global gene expression profile similar to that of progenitor Leydig cells, although not identical. In addition, these cells can survive in testis and produce testosterone in a circadian rhythm. This induction strategy is applicable to reprogramming human periodontal ligament fibroblasts toward Leydig-like cells. These findings demonstrated fibroblasts can be directly converted into Leydig-like cells by pure chemical compounds. This strategy overcomes the limitations of conventional transgenic-based reprogramming and provides a simple, effective approach for Leydig cell-based therapy while simultaneously preserving the hypothalamic-pituitary-gonadal axis.

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Direct induction of fibroblasts into Leydig-like cells (CiLCs) by chemicals

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CiLCs were modulated by HPG axis and produced testosterone in a diurnal rhythm

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Conversion process toward CiLCs did not pass through an intermediate state

Sexual Dysfunction in Adolescent and Young Adult Survivors of Childhood Cancer: Presentation, Risk Factors, and Evaluation of an Underdiagnosed Late Effect: A Narrative Review

An area of concern affecting the quality of life of childhood cancer survivors (CCS) is that of sexual dysfunction (SD), which may be a result of both physical and psychosexual challenges associated with cancer and its treatment. This is especially pertinent as CCS are known to experience diminished quality of life compared to peers. Relevant to SD, cancer and its associated treatment are associated with negative effects on body image and romantic relationships, as well as overall physical and mental health. Although CCS have been shown to have SD at higher rates than the general population, this is often under-recognized and CCS commonly report that it is not addressed by their health care providers. To guide future research and improve clinical screening and treatment practices for SD, we performed a narrative review of this understudied topic to summarize existing knowledge of the incidence, risk factors, pathophysiology, and rates of screening for SD in CCS. We also outline current gaps in knowledge and directions for future research.

CRISPR/dCas9-mediated activation of multiple endogenous target genes directly converts human foreskin fibroblasts into Leydig-like cells

Recently, Leydig cell (LC) transplantation has been revealed as a promising strategy for treating male hypogonadism; however, the key problem restricting the application of LC transplantation is a severe lack of seed cells. It seems that targeted activation of endogenous genes may provide a potential alternative. Therefore, the aim of this study was to determine whether targeted activation of Nr5a1, Gata4 and Dmrt1 (NGD) via the CRISPR/dCas9 synergistic activation mediator system could convert human foreskin fibroblasts (HFFs) into functional Leydig-like cells. We first constructed the stable Hsd3b-dCas9-MPH-HFF cell line using the Hsd3b-EGFP, dCas9-VP64 and MS2-P65-HSF1 lentiviral vectors and then infected it with single guide RNAs. Next, we evaluated the reprogrammed cells for their reprogramming efficiency, testosterone production characteristics and expression levels of Leydig steroidogenic markers by quantitative real-time polymerase chain reaction or Western blotting. Our results showed that the reprogramming efficiency was close to 10% and that the reprogrammed Leydig-like cells secreted testosterone rapidly and, more importantly, responded effectively to stimulation with human chorionic gonadotropin and expressed Leydig steroidogenic markers. Our findings demonstrate that simultaneous targeted activation of the endogenous NGD genes directly reprograms HFFs into functional Leydig-like cells, providing an innovative technology that may have promising potential for the treatment of male androgen deficiency diseases.

Quality of Life in Long-Term Testicular Cancer Survivors With Compensated Leydig Cell Dysfunction

BACKGROUND

Compensated Leydig cell (LC) dysfunction, defined by elevated serum levels of luteinizing hormone (LH) in combination with normal total testosterone levels, is common in testicular cancer (TC) survivors. The association between this condition and quality of life is unknown. We aimed to clarify if TC survivors with compensated LC dysfunction have impaired quality of life.

PATIENTS AND METHODS

In total, 147 long-term TC survivors were included. On the basis of a single measurement of testosterone and LH, compensated LC dysfunction was defined by age-adjusted levels of LH above normal range combined with testosterone levels within the normal range. Quality-of-life outcomes including sexual function, anxiety and depression, fatigue, and overall self-evaluated quality of life were compared between patients with and without compensated LC dysfunction with adjustment for age.

RESULTS

In total, 60 TC survivors had compensated LC dysfunction and 87 TC survivors had normal LC function. TC survivors with compensated LC dysfunction had lower serum levels of total testosterone (11 vs. 13 nmol/L, P = .016). There were no significant differences in the investigated quality-of-life outcomes (anxiety, depression, sexual function, fatigue) between the 2 groups.

CONCLUSION

Compensated LC dysfunction in TC survivors was not associated with symptoms of depression, anxiety, sexual dysfunction, fatigue, or impaired overall self-evaluated quality of life. Limitations include the few cases of symptoms of depression (n = 7). Our findings do not suggest that testosterone substitution is indicated in TC survivors with compensated LC dysfunction.

Induced pluripotent stem cell-derived conditional medium promotes Leydig cell anti-apoptosis and proliferation via autophagy and Wnt/β-catenin pathway

Leydig cell transplantation is a better alternative in the treatment of androgen-deficient males. The main purpose of this study was to investigate the effects of induced pluripotent stem cell-derived conditioned medium (iPS-CM) on the anti-apoptosis, proliferation and function of immature Leydig cells (ILCs), and illuminate the underlying mechanisms. ILCs were exposed to 200 μmol/L hydrogen peroxide (H2 O2 ) for 24 hours with or without iPS-CM treatments. Cell apoptosis was detected by flow cytometric analysis. Cell proliferation was assessed using cell cycle assays and EdU staining. The steroidogenic enzyme expressions were quantified with Western blotting. The results showed that iPS-CM significantly reduced H2 O2 -induced ILC apoptosis through down-regulation of autophagic and apoptotic proteins LC3-I/II, Beclin-1, P62, P53 and BAX as well as up-regulation of BCL-2, which could be inhibited by LY294002 (25 μmol/L). iPS-CM could also promote ILC proliferation through up-regulation of β-catenin and its target proteins cyclin D1, c-Myc and survivin, but was inhibited by XAV939 (10 μmol/L). The level of bFGF in iPS-CM was higher than that of DMEM-LG. Exogenous bFGF (20 ng/mL) or Wnt signalling agonist lithium chloride (LiCl) (20 mmol/L) added into DMEM-LG could achieve the similar effects of iPS-CM. Meanwhile, iPS-CM could improve the medium testosterone levels and up-regulation of LHCGR, SCARB1, STAR, CYP11A1, HSD3B1, CYP17A1, HSD17B3 and SF-1 in H2 O2 -induced ILCs. In conclusion, iPS-CM could reduce H2 O2 -induced ILC apoptosis through the activation of autophagy, promote proliferation through up-regulation of Wnt/β-catenin pathway and enhance testosterone production through increasing steroidogenic enzyme expressions, which might be used in regenerative medicine for future.

The antineoplastic busulphan impairs peritubular and Leydig cells, and vitamin B12 stimulates spermatogonia proliferation and prevents busulphan-induced germ cell death

Busulphan (Bu), an alkylating agent used for bone marrow and spermatogonial stem cell transplantation (SSCT), impairs Sertoli (SC) cells, which are necessary for the spermatogonial stem cell (SSC) homing during transplantation. As Leydig (LC) and peritubular myoid (PMC) cells are essential for SC support and maintenance of spermatogonial niche, we evaluated the impact of Bu on the LC and PMC structural integrity. Vitamin B₁₂ (B₁₂) has demonstrated beneficial effects against drug-induced testicular changes; thus, we also examined whether this vitamin is able to stimulate spermatogonia mitotic activity and prevent Bu-induced germ cell death. Rats received 10mg/kg of Bu in the 1st and 4th days, and daily B₁₂ supplementation during Bu treatment and for 6days after the last injection of Bu (Bu-6d), totaling 10days of treatment. Other animals received the same treatment as Bu-6d, and B₁₂ supplementation (Bu+7dB₁₂) or saline (Bu+7dS) for 7 more days, totaling 17days of treatment. Serum testosterone levels were measured. In the historesin-embedded testis sections, the seminiferous tubule and epithelial areas were measured, and the number of spermatogonia and PMC was quantified. Actin and 17β-HSD6 immunofluorescence was detected, and the number of TUNEL-positive LC and germ cells was computed. In Bu-6d, PMC number reduced, and a weak actin immunoexpression and death in these cells was observed. The testosterone levels reduced, and the interstitial tissue showed a weak 17β-HSD6 immunoexpression and increased number of TUNEL-positive LC. In Bu+7dB₁₂, the number of spermatogonia was higher than in Bu-6d and Bu+7dS, and the number of TUNEL-positive germ cells was significantly lower than in Bu+7dS. Bu exerts a harmful impact on PMC and LC, reducing the testosterone levels. Vitamin B₁₂ prevents significantly Bu-induced germ cell death and stimulates spermatogonia proliferation, being a useful strategy for the enrichment of SSC in vitro and an adjuvant therapy for spermatogenesis recovery in oncologic patients.

Do male esophageal cancer patients have impaired sexual function after esophagectomy? A self-reported outcomes study

PURPOSE

Sexual function is a significant part of patients' quality of life, which is another important aspect of cancer. This study assessed and compared the sexual function of male esophageal cancer patients to that of age-matched normal controls through postoperative follow-up surveys.

METHODS

The study included 105 male esophageal cancer patients aged 38-81 years who underwent a curative-intent esophagectomy between April 2012 and May 2014. This observational study included sociodemographic and clinicopathological characteristics and responses to sexual function questionnaires International Index of Erectile Function (IIEF) at 6 and 12 months after surgery. An age-matched normal control group was recruited. Non-parametric tests were used when appropriate.

RESULTS

The median patient age was 59 years. The factors significantly associated with sexual dysfunction on the 6-month survey included older age, and postoperative complications. At 12 months after surgery, older age was significantly associated with poorer sexual function. The sexual function scores significantly increased from 6 to 12 months after surgery (P < 0.05); there was no difference in the patients' 12-month sexual function scores and those of the normal controls (P > 0.05). Notably, compared to older patients (age ≥60 years), the younger (age <60 years) patients reported a significantly better sexual function scores (P < 0.05).

CONCLUSIONS

Age, and postoperative complications were the factors significantly associated with sexual function. Impaired sexual function after primary treatment can be recovered in male esophageal cancer patients; younger patients may regain sexual function better than their older counterparts.

Direct Reprogramming of Mouse Fibroblasts toward Leydig-like Cells by Defined Factors

Leydig cells (LCs) play crucial roles in producing testosterone, and their dysfunction leads to male hypogonadism. LC transplantation is a promising alternative therapy for male hypogonadism. However, the source of LCs limits this strategy for clinical applications. Here, we report our success in reprogramming mice fibroblasts into LCs by expressing three transcriptional factors, Dmrt1, Gata4, and Nr5a1. The induced Leydig-like cells (iLCs) expressed steroidogenic genes, had a global gene expression profile similar to that of adult LCs, and acquired androgen synthesis capabilities. When iLCs were transplanted into rats or mice testes that were selectively depleted of endogenous LCs, the transplanted cells could survive and function in the interstitium of testis, resulting in the restoration of normal levels of serum testosterone. These findings demonstrate that the fibroblasts were able to be directly converted into iLCs by few defined factors, which may facilitate future applications in regenerative medicine.

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Direct reprogramming of fibroblasts into Leydig cell fate by defined factors

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Induced Leydig-like cells (iLCs) exhibit adult Leydig cell characterizations

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Conversion process toward iLCs did not pass through a mitotic cell state

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Transplantation of iLCs could survive and function in the interstitium of testis

A Pound of Cure Requires An Ounce (or More) of Prevention: Survivorship and Complications of Therapy for Hematologic Malignancies

Patients treated for a hematologic malignancy are at risk for treatment-related complications. As the goal of therapy is frequently curative, treatments are especially intensive and long-term toxicity is common. Chemotherapy and radiation are associated with increased risk for cardiac and pulmonary disease, endocrine disorders, infertility, sexual dysfunction, second cancers, and psychosocial distress. The risk for each complication is dictated by patient characteristics including age, co-morbidities, and genetic predispositions, as well as the specifics of therapy. Survivors of pediatric cancers and allogeneic hematopoietic stem cell transplantation have unique risks due to vulnerable age at time of toxic exposure and ongoing immune dysfunction, respectively.

Fatigue in male lymphoma survivors differs between diagnostic groups and is associated with latent hypothyroidism

BACKGROUND

Few studies have explored fatigue in different groups of lymphoma survivors and the association with hormonal dysfunctions. The aims were to analyze associations between fatigue and thyroid and gonadal function in male lymphoma survivors. In addition, the impact of chronic fatigue on work situation and daily functioning were explored.

PATIENTS AND METHODS

This cross-sectional study included male lymphoma survivors diagnosed in 1980-2002, aged ≤ 50 years at diagnosis and > 18 years at survey in 2007. The participants (n = 233, median age at survey: 48 years, median observation time: 15 years) completed questionnaires assessing levels of fatigue, chronic fatigue (duration ≥ 6 months), mental distress, daily functioning and work situation. Levels of thyroid and gonadal hormones were assessed. The participants were grouped according to diagnosis: Hodgkin lymphoma (HL, n = 131), aggressive/very aggressive non-Hodgkin lymphoma (NHL) (n = 67) and indolent NHL (n = 35). Thyroid hormones were categorized as normal (n = 174) or latent hypothyroidism (elevated thyroid stimulating hormone, n = 59). Gonadal hormones were categorized as normal (n = 111), elevated follicle stimulating hormone only (n = 45), primary (n = 35) or secondary hypogonadism (n = 42). Uni- and multivariate regression analyses were performed. A p value < 0.05 indicated the level of significance.

RESULTS

The survivors of HL and aggressive/very aggressive NHL had similar fatigue levels and similar prevalence of chronic fatigue (HL: 31%, aggressive/very aggressive; NHL: 27%). Survivors of indolent NHL had lower fatigue levels and prevalence of chronic fatigue (11%). Latent hypothyroidism was associated with increased fatigue levels (p = 0.042). Gonadal function was not associated with levels of fatigue or chronic fatigue. Mental distress was associated with increasing fatigue levels and chronic fatigue (p < 0.001). We found negative associations between chronic fatigue, daily functioning and work status.

CONCLUSIONS

Fatigued lymphoma survivors should be investigated for thyroid function. The negative impact of chronic fatigue on daily functioning and work status emphasizes the importance of maintaining the effort in understanding the mechanisms behind fatigue.

Directed mouse embryonic stem cells into leydig-like cells rescue testosterone-deficient male rats in vivo

The primary function of Leydig cells is to secrete testosterone, which is critical in the regulation of male reproduction and development. Low levels of testosterone will lead to male hypogonadism. Stem cell-derived Leydig cell transplantation may be a promising alternative therapy for male hypogonadism. Thus far, others have reported that Leydig-like cells can be derived from mesenchymal stem cells, embryonic stem cells (ESCs), and induced pluripotent stem cells. However, the efficiency of the differentiating Leydig cells remains low, and progress toward generating functional adult Leydig cells (ALCs) is limited. Herein, we describe a robust method of directing differentiation of mouse embryonic stem cells (mESCs) into Leydig-like cells in vitro by overexpression of the transcription factor steroidogenic factor-1 (SF-1) and treatment with a combination of 8-Bromoadenosine-3',5'-cyclic monophosphate and forskolin. These differentiated cells express mRNA encoding the steroidogenic enzymes and produce progesterone and testosterone. Importantly, when transplanted into male rats that had their original Leydig cells selectively eliminated by ethylene dimethanesulfonate, these in vitro-derived Leydig-like cells further developed into functional ALCs that rescued serum testosterone levels. These data provide evidence that mESCs can be induced to differentiate into Leydig-like cells in vitro, which can develop in the in vivo microenvironment.

Effects of bleomycin, etoposide and cisplatin treatment on Leydig cell structure and transcription of steroidogenic enzymes in rat testis

Cytotoxic anticancer chemotherapy affects pituitary-testicular hormonal axis in humans and in animals. This study investigated the effects on Leydig cells of three cycles of bleomycin, etoposide and cisplatin (0.75, 7.5, and 1.5mg/kg, respectively; BEP) chemotherapy in rat testis. The chemotherapy has induced hyperplasia of and degenerative changes in Leydig cells at the end of BEP exposure, which remained so even after a recovery time of 63 days. The increased testicular oxidative stress at the end of the chemotherapy returned to normal level after the recovery time. The chemotherapy has stimulated the transcription of scavenger receptor class type-B1 (SCARB1), steroidogenic acute-regulatory protein (StAR), cytochrome P450 cholesterol side-chain cleavage (CYP11A1), CYP17A1, and inhibited that of 17β-hydroxysteroid dehydrogenase (HSD17B6) and CYP19A1 in association with increased cholesterol and decreased testosterone levels. Even after the recovery time, the chemotherapy still had inhibitory effects on the transcription of all of the above genes in addition to luteinizing hormone receptor and HSD3B1, but not on the StAR gene. The cholesterol and testosterone levels also did not show any significant differences with the control group. The decreased testosterone level at the end of chemotherapy was probably due to inhibition of HSD3B1 and HSD17B6 genes. In conclusion, clinically relevant dose-levels and treatment protocols of BEP chemotherapy adversely affect Leydig cell function. The BEP chemotherapy inhibits the transcription of steroidogenic enzymes and that these effects sustain over an extended period of time without returning to normal levels.

Biomarkers of chemotherapy-induced testicular damage

Increasing numbers of men are having or wanting children after chemotherapy treatment. This can be attributed to improvements in cancer therapies that increase survival. However, a side effect of most chemotherapy drugs is disruption of spermatogenesis and a drastic reduction in sperm count and quality. Although many men eventually recover reproductive function, as indicated by normal semen analyses, there is no clinical test that can assess sperm quality at a high level of sensitivity. Sperm fluorescent in situ hybridization (i.e., FISH) and several different tests for deoxyribonucleic acid (DNA) fragmentation have been used infrequently in clinical assessment. Animal models of chemotherapy-induced testicular damage are currently being used to identify potential molecular biomarkers that may be translatable to humans-these include sperm messenger RNAs, microRNAs, histone modifications, and DNA methylation patterns. Changes in these molecular measurements are quantitative and sensitive, potentially making them important clinical biomarkers of testicular function after chemotherapy treatment.

Sexual quality of life in Hodgkin Lymphoma: a longitudinal analysis by the German Hodgkin Study Group

Background:

Health-related quality of life (HRQoL) comprises different domains of physical, mental, and social well-being. In this analysis, we focus on sexual quality of life in Hodgkin Lymphoma (HL) patients.

Methods:

Four-thousand one-hundred and sixty patients enroled in the HD10–HD12 trials underwent HRQoL assessment. Instruments included the Quality of Life Questionnaire for survivors (QLQ-S), combining the European Organisation for Research and Treatment of Cancer QLQ-C30, Multidimensional fatigue (FA) inventory (MFI-20) and an additional sexual functioning (SX) scale. We describe SX up to 27 months after therapy and analyse relationship to stage, age, gender, FA, social functioning, and therapy. Statistical methods range from descriptive statistics to a classification of SX courses, and a longitudinal structural equations model with full information maximum likelihood estimation of missing data. In the analysis, a score below 50 was used to describe severe sexual dysfunction.

Results:

Three-thousand two-hundred and eight patients provided data on SX. Patients in advanced stages reported lower SX than patients in early stages both, before and after the treatment. During follow-up, an improvement of SX compared with baseline was detected, except for those ⩾50 years. Patients in early stages reached normal SX, whereas advanced-stage patients remained below the reference value for healthy controls. Sexual functioning during follow-up was significantly and strongly related to previous SX, other HRQoL measures, age, and stage, and to lesser degree with gender and chemotherapy.

Conclusion:

Overall, HL patients have a decreased sexual quality of life at baseline, which improves after therapy and normalises in early-stage patients. Importantly, long-term SX is more closely related to patient characteristics and SX at baseline than to the intensity of treatment.

Differences in fatigue experiences among patients with advanced cancer, cancer survivors, and the general population

CONTEXT

Fatigue is a multidimensional symptom experienced physically, cognitively, and emotionally. Research on fatigue experiences in various stages of cancer might help to elucidate the nature of cancer-related fatigue.

OBJECTIVES

To compare fatigue experiences in advanced cancer patients (ACPs), cancer survivors (CSs), and controls from the general population (GenPop).

METHODS

Sixty-three ACPs (no antitumor therapy in the last month and no options for future therapy) were matched for age, sex and diagnosis with 63 CSs (last treatment one to five years ago) and 315 controls. Fatigue was measured unidimensionally with the Numeric Rating Scale and multidimensionally with the Multidimensional Fatigue Inventory.

RESULTS

All fatigue levels (general fatigue, physical fatigue, reduced activity, reduced motivation, and mental fatigue) were higher in ACPs than in CSs and controls (P<0.01), whereas fatigue levels were not different between CSs and controls. NRS scores in ACPs and CSs were significantly predicted by the fatigue dimensions physical fatigue and mental fatigue only. Although physical fatigue and mental fatigue were strongly related in the GenPop, the relation was weaker in CSs and not significant in ACPs. In multivariate analyses, only physical fatigue differentiated ACPs from CSs and controls (P<0.01).

CONCLUSION

ACPs experience fatigue more intensely than CSs and controls when fatigue is measured multidimensionally. Although mental and physical dimensions of fatigue contribute to the overall experience of fatigue in both groups of cancer patients, physical fatigue best differentiated ACPs from both CSs and controls.

Mindfulness-based cognitive therapy reduces chronic cancer-related fatigue: a treatment study

INTRODUCTION

About one-third of cancer survivors suffer from severe chronic fatigue. Aim of this study was to evaluate the efficacy of mindfulness-based cognitive group therapy in reducing severe chronic fatigue in cancer survivors with mixed diagnoses.

PATIENTS AND METHODS

Participants (n = 100) were randomly selected from a cohort and allocated to an intervention and a waiting list condition. Analyses were based on 59 participants in the intervention condition and 24 in the waiting-list condition. Fatigue severity (Checklist Individual Strength), functional impairment (Sickness Impact Profile) and well being (Health and Disease-Inventory) were assessed before and after the 9-week intervention. The intervention group had a follow-up 6 months following the intervention.

RESULTS

At post-treatment measurement the proportion of clinically improved participants was 30%, versus 4% in the waiting list condition (χ(2) (1) = 6.71; p = 0.007). The mean fatigue score at post-measurement was significantly lower in the intervention group than in the waiting list group corrected for pre-treatment level of fatigue. The mean well-being score at post-measurement was significantly higher in the intervention group than in the waiting list group corrected for pre-treatment level of well-being. The treatment effect was maintained at 6-month follow-up. No difference between the two conditions was found in functional impairment.

DISCUSSION

Mindfulness-based cognitive therapy is an effective treatment for chronic cancer-related fatigue.

Quality of life, self-esteem, fatigue, and sexual function in young men after cancer: a controlled cross-sectional study

BACKGROUND

Androgen deficiency is increasingly recognized in young male cancer survivors; however, its impact on quality of life (QOL) is not established. The authors investigated the relationship between androgen levels, QOL, self-esteem, fatigue, and sexual function in young male cancer survivors compared with control subjects.

METHODS

A cross-sectional, observational study of 176 male cancer survivors and 213 male controls aged 25 to 45 years was performed. Subjects completed 3 QOL scales (Medical Outcomes Study 36-Item Short-Form Health Survey version 2, the 12-item General Health Questionnaire [GHQ-12], and Aging Male Scale), and measures of self-esteem (Rosenberg Self-Esteem Scale), fatigue (Functional Assessment of Chronic Illness Therapy-Fatigue), and sexual function (Derogatis Interview for Sexual Functioning-II Self-Report-Male).

RESULTS

Cancer survivors had lower scores for all components of the Short-Form Health Survey, Aging Male Scale, and Functional Assessment of Chronic Illness Therapy-Fatigue, and for 4 of 5 subsections of the Derogatis Interview for Sexual Functioning than controls. The majority of these differences remained after adjusting by linear regression analysis. Levels of psychiatric disorder or self-esteem did not differ between the 2 groups. In cancer survivors, those with androgen deficiency (serum testosterone < or = 10 nmol/L) had lower scores than those without for all components of the Short-Form Health Survey, the General Health Questionnaire, Functional Assessment of Chronic Illness Therapy-Fatigue, and the Derogatis Interview for Sexual Functioning. Serum testosterone only weakly correlated with health measures.

CONCLUSIONS

Young male cancer survivors self-report a marked impairment in QOL, energy levels, and quality of sexual functioning, and this was exacerbated in those with androgen deficiency. However, psychological distress was not elevated, self-esteem was normal, and sexual relationships were not impaired. The relationship with testosterone is complex, and appears dependent on a threshold level rather than direct correlation. Interventional trials are needed to determine whether testosterone replacement would improve QOL in young male cancer survivors.

Fatigue in gynecological cancer patients during and after anticancer treatment

CONTEXT

Research has indicated that individuals with gynecological cancer experience severe fatigue.

OBJECTIVES

This longitudinal survey aimed to analyze the fatigue experienced over the course of one year by a gynecological cancer population, to determine if the fatigue was more severe than that reported by females without cancer, and to identify variables associated with cancer-related fatigue (CRF).

METHODS

Data were collected over a 12-month period before, during, and after anticancer treatment. Fatigue was assessed using the Multidimensional Fatigue Symptom Inventory-Short Form. Participants with cancer also completed the Rotterdam Symptom Checklist.

RESULTS

Sixty-five cancer patients (mean age = 57.4 years, standard deviation [SD] = 13.9) and 60 control subjects (mean age = 55.4 years, SD = 13.6) participated. Descriptive analysis and repeated measurements modeling indicated that the cancer participants reported worse fatigue than the noncancer individuals before, during, and after anticancer treatment (P < 0.001) and that the level of fatigue in persons with cancer changed with time (P = 0.02). A forward stepwise regression demonstrated that psychological distress level was the only independent predictor of CRF during anticancer treatment (P < 0.00), explaining 44% of the variance in fatigue. After treatment, both psychological distress level (P < 0.00) and physical symptom distress (P = 0.03) were independent predictors of fatigue, accounting for 81% of the variance.

CONCLUSION

Psychological distress level is an important indicator of CRF in gynecological cancer. Interventions focused on the reduction of psychological distress may help alleviate CRF.

Do male lymphoma survivors have impaired sexual function?

PURPOSE

Sexual function in male lymphoma survivors was examined and compared with that of age-matched controls.

PATIENTS AND METHODS

This cross-sectional study included serum gonadal hormone levels (testosterone, sex hormone-binding globulin, luteinizing hormone [LH], and follicle-stimulating hormone) and responses to questionnaires assessing sexual function (Brief Sexual Function Inventory [BSFI]), socioeconomic factors, quality of life, emotional distress, and fatigue. The lymphoma group included 246 men < or = 50 years old at diagnosis who were diagnosed from 1980 to 2002 and treated at the Norwegian Radium Hospital. For each lymphoma survivor, two age-matched controls (n = 492) were drawn from a normative sample with BSFI scores.

RESULTS

The lymphoma survivors had a mean age at survey of 47.4 years, the mean duration of follow-up was 14.8 years, and 79% lived in committed relationships. All BSFI domain scores decreased significantly with age. Lymphoma survivors having low testosterone and/or elevated LH had lower BSFI scores than survivors with normal gonadal hormones. Multivariate analyses showed that increasing age, more emotional distress, poor physical health, and low testosterone and/or elevated LH were significantly associated with reduced sexual function within the lymphoma group. Lymphoma survivors had significantly lower BSFI domain scores than did controls on erection, ejaculation, and sexual satisfaction.

CONCLUSION

Lymphoma survivors had significantly poorer sexual function than normative controls. It is unclear whether the abnormal hormone levels directly cause the reduced sexual function within the lymphoma group or if a mediating factor is involved, such as aging, emotional distress, or perceived health status.

Sexuality after hematopoietic stem cell transplantation

Severe sexual dysfunction and absence of sexual activity are common for long-term survivors of high-dose chemotherapy with or without total body irradiation and hematopoietic stem cell transplantation (HSCT). These treatments have known effects on gonadal function. Males and females develop abnormal hormone levels and in turn this affects sexual desire and genital organs. The sexual functioning questionnaire (SFQ), designed and tested with this population, has allowed improved understanding of the problems, quality of sexual response, and sexual behaviors in the HSCT population. Male and female HSCT survivors report more problems than age- and gender-matched healthy controls and these problems persist over time if not caught and treated early. Sexual dysfunction is a more striking problem for female survivors than males. Almost no high quality evidence supports the efficacy of interventions to treat sexual dysfunction in this population. However, promising medical and behavioral treatments are discussed for men and women.

Subcutaneous autologous testicle transplantation in Wistar rats

OBJECTIVE

To assess the hormone secretion and viability of subcutaneous autotransplanted testicles in Wistar rats.

STUDY DESIGN

Wistar rats were randomly divided into four groups: sham (group I, n = 4), bilateral orchiectomy (group II, n = 4), sliced autotransplantation group (group III, n = 4), and whole-testicle autotransplantation group (group IV, n = 4). Sexual behavior (genital sniffing, thrusting intromissions, mounts with pelvic thrusting frequency), serum testosterone levels, and body weight were measured eight weeks after the procedure.

RESULTS

Subcutaneous autotransplantation elicited an increased number of mounts (P < 0.007) and intromissions (P < 0.009) and a significant reduction in the latency of these two behaviors (P < 0.034) compared with castrated animals. The frequency of sniffing of the bodies of sexually receptive females was not affected by castration (P = 0.326). Serum testosterone in whole autotransplantation group (219.23; 184.02-229.23) was higher than for the sliced autotransplantation group (0.74; 0.54-0.91) and bilateral orchiectomy group (0.59; 0.4-0.82; P < 0.05). We demonstrated that testicles transplanted without vascular anastomosis maintain their hormone secretion and exert neuroendocrine function on sexual behavior in rats. Autotransplantation could be an important alternative means of gonadal preservation for oncological patients considered for oncological therapies.

Sexual function changes during the 5 years after high-dose treatment and hematopoietic cell transplantation for malignancy, with case-matched controls at 5 years

This prospective study evaluated sexual function through 5 years after myeloablative allogeneic hematopoietic cell transplantation (HCT) for cancer to determine sexual function recovery and residual problems. Adults completed measures before HCT (N = 161), with survivors followed at 6 months and at 1, 2, 3, and 5 years. At 5 years case-matched controls also completed assessments. Analyses indicated that men and women differed in rates of being sexually active across time (P < .001) and in overall sexual function (P < .001). Both sexes declined in sexual activity rates and sexual function from before HCT to 6 months afterward (P < or = .05). Activity rates recovered for men by 1 year (74%) and for women by 2 years (55%). Men improved from their 6-month nadir in sexual function by 2 years (P = .02), whereas women did not improve by 5 years (P = .17). Both male and female survivors were below controls in rates of sexual activity and sexual function at 5 years. Most women reported sexual problems (80% of survivors vs 61% of controls, P = .11); in contrast for men 46% of survivors versus 21% of controls (P = .05) reported problems. Thus, despite some recovery, sexual dysfunction remained a major problem for men and women after HCT. Aggressive efforts are needed to treat these deficits.

Prevalence and consequences of androgen deficiency in young male cancer survivors in a controlled cross-sectional study

BACKGROUND

Testosterone replacement in hypogonadal males improves body composition, sexual function, and health-related quality of life. Male cancer survivors are at risk of androgen deficiency; however, when and in whom testosterone should be replaced remain unanswered questions.

OBJECTIVE

The aim of our study was to define the prevalence of androgen deficiency in this patient group through assessment of testosterone levels and related measures.

DESIGN

This was a cross-sectional, observational study of cases and controls. We recruited 176 cancer survivors and 213 controls, aged 25-45 yr.

RESULTS

Of cancer survivors, 97% had received chemotherapy and 40% radiotherapy. Cancer survivors had lower total testosterone (tT) levels than controls (mean difference 2.67 nmol/liter; 95% confidence interval 1.58-3.76; P = 0.003), and 24 of 176 (13.6%; 95% confidence interval 9.3-19.5) had a tT less than 10 nmol/liter, which was less than 2.5% centile for controls. Cancer survivors had a greater fat mass, higher fasting insulin and glucose levels, increased fatigue, and reduced sexual function and health-related quality of life. In both cohorts, the tT correlated negatively with insulin levels and negatively with body fat mass; however, the difference in tT between them was independent of fat mass. We measured tT and SHBG and calculated bioavailable testosterone. The changes in calculated bioavailable testosterone were similar to tT.

CONCLUSIONS

A significant proportion of young male cancer survivors had a frankly low tT associated with an increased fat mass and insulin level compared with controls. These factors would be predicted to improve in response to testosterone replacement therapy and provide a powerful argument for an interventional study of testosterone therapy in young male cancer survivors.

Assessment of cancer-related fatigue: implications for clinical diagnosis and treatment

Cancer-related fatigue (CRF) is a highly prevalent and debilitating symptom experienced by most cancer patients during, and often for considerable periods after, treatment. The recognition of the importance of CRF to patients' psychosocial and cognitive functioning, as well as to their quality of life, has driven the development of a wide range of assessment tools for screening and diagnosis of CRF. Over 20 different measures have been used to assess CRF from either a unidimensional or multi-dimensional perspective. Unidimensional measures are often single-question scales that generally focus on identifying the occurrence and severity of CRF, whereas multidimensional measures may also examine the effect of CRF across several domains of physical, socio-emotional, and cognitive functioning. This paper provides an overview and critique of measures commonly used to assess CRF. Single-question assessment is the most commonly used and the most useful methodology. Strategies to facilitate reliable assessment of CRF are also discussed. Disclosure of potential conflicts of interest is found at the end of this article.

Children with sickle cell disease: growth and gonadal function after hematopoietic stem cell transplantation

The aim of this study is to describe the growth, pubertal development, and gonadal function of a cohort of 30 sickle cell disease children who underwent bone marrow transplantation. They all received the standard pretransplant conditioning regimen of busulfan (14 or 16 mg/kg) and cyclophosphamide (200 mg/kg). Growth was normal both before and after transplant. Seven out of 10 girls had severe ovarian failure and requirement for estrogen replacement. Three out of 10 girls recovered some ovarian function posttransplant, with spontaneous pubertal development, menses, and 1 successful normal pregnancy. Follicle-stimulating hormone (FSH) serum levels were very high during spontaneous puberty and slowly normalized thereafter in these 3 patients. The 3 girls with ovarian function recovery differed from the 7 others by the lower busulphan dose of the conditioning regimen they received (14 rather than 16 mg/kg). All boys showed spontaneous pubertal development. However, most of them had small testis and elevated serum FSH levels, reflecting germinal epithelium damage. Testosterone level was low normal and luteinizing hormone elevated, reflecting Leydig cell insufficiency. In conclusion, 7/10 girls had complete gonadal failure and most of the boys had spontaneous puberty but germinal epithelial failure. Serum FSH levels showed important variations over time in the same patient.

The Experience of Fatigue in Turkish Patients Receiving Chemotherapy

PURPOSE/OBJECTIVES

To determine the experience of fatigue in Turkish patients receiving chemotherapy.

DESIGN

Descriptive.

SETTING

Outpatient unit in a large university hospital in Ankara, Turkey.

SAMPLE

100 patients randomly chosen from those who were undergoing chemotherapy at the outpatient unit.

METHODS

Data were collected using a personal information form developed by the investigator and a visual analog scale for fatigue.

MAIN RESEARCH VARIABLES

Measures taken by patients to cope with fatigue, fatigue experienced by individuals affecting their daily activities, age and gender, disease and treatment factors, and symptoms related to the chemotherapy.

FINDINGS

The majority of patients (86%) experienced fatigue, and 73% stated that they coped with fatigue by decreasing their activities and resting more. Age was not a statistically significant factor affecting the level of fatigue, but gender was found to have an effect. Length of illness, number of chemotherapy courses, and the patients' symptoms affected level of fatigue.

CONCLUSIONS

The majority of patients experienced fatigue, and most of the measures used to cope with fatigue were not effective. Fatigue affected patients' daily activities.

IMPLICATIONS FOR NURSING

A need exists for more and better interventions to help patients cope with chemotherapy-related fatigue.

The radiation-induced block in spermatogonial differentiation is due to damage to the somatic environment, not the germ cells

Radiation and chemotherapeutic drugs cause permanent sterility in male rats, not by killing most of the spermatogonial stem cells, but by blocking their differentiation in a testosterone-dependent manner. However, it is not known whether radiation induces this block by altering the germ or the somatic cells. To address this question, we transplanted populations of rat testicular cells containing stem spermatogonia and expressing the green fluorescent protein (GFP) transgene into various hosts. Transplantation of the stem spermatogonia from irradiated adult rats into the testes of irradiated nude mice, which do not show the differentiation block of their own spermatogonia, permitted differentiation of the rat spermatogonia into spermatozoa. Conversely transplantation of spermatogonial stem cells from untreated prepubertal rats into irradiated rat testes showed that the donor spermatogonia were able to colonize along the basement membrane of the seminiferous tubules but could not differentiate. Finally, suppression of testosterone in the recipient irradiated rats allowed the differentiation of the transplanted spermatogonia. These results conclusively show that the defect caused by radiation in the rat testes that results in the block of spermatogonial differentiation is due to injury to the somatic compartment. We also observed colonization of tubules by transplanted Sertoli cells from immature rats. The present results suggest that transplantation of spermatogonia, harvested from prepubertal testes to adult testes that have been exposed to cytotoxic therapy might be limited by the somatic damage and may require hormonal treatments or transplantation of somatic elements to restore the ability of the tissue to support spermatogenesis.

Management of fatigue in cancer patients

Cancer-related fatigue (CRF) is either a symptom or a syndrome depending on criteria for diagnosis. CRF is present in 20% to 30% of long-term cancer survivors and 80% to 90% during treatment and at the end of life. Assessment requires determining the presence, severity, and interference with daily activities. Different descriptors for fatigue (eg, tiredness, lack of vigor) measure different patient experiences. Associated factors such as depression, pain, insomnia, dyspnea, anemia, and deconditioning worsen CRF and should be treated if present. Associated factors that contribute to the severity of fatigue differ depending on the stage of cancer. Pharmacologic interventions include recombinant erythropoietin, psychostimulants, corticosteroid, anti-inflammatory drugs other than steroids, and L-carnitine. Advances in the management of CRF will require an understanding of the underlying mechanism before target-specific therapies can be developed.

Context moderates illness-induced lifestyle disruptions across life domains: a test of the illness intrusiveness theoretical framework in six common cancers

The illness intrusiveness theoretical framework maintains that illness-induced lifestyle disruptions compromise quality of life in chronic life-threatening conditions and that this effect is moderated by social, psychological, and contextual factors. Considerable evidence indicates that lifestyle disruptions compromise quality of life in cancer and other diseases and that the effects differ across life domains. The hypothesis that contextual factors (e.g. age, education, income, stressful life events) moderate these effects has not been tested extensively. We investigated whether age, income, education, and/or recent stressful life events modify the experience of illness intrusiveness across three central life domains (Relationships and Personal Development, Intimacy, and Instrumental life) in six common cancers. A sample of 656 cancer outpatients with one of six common cancers (breast, prostate, lymphoma, lung, head and neck, and gastrointestinal, all n's>100) completed the Illness Intrusiveness Ratings Scale while awaiting follow-up appointments with an oncologist. Results indicated statistically significant (all p's<0.05) interactions involving each of the hypothesized moderator variables and the Life Domain factor. In each case, greatest divergence was evident when illness intrusiveness involved instrumental life domains (e.g. work, finances, health, and active recreation). The findings substantiate the illness intrusiveness theoretical framework and support its relevance for people with cancer. The psychosocial impact of chronic life-threatening disease differs across life domains and depends on the context in which it is experienced.

Cancer-related fatigue: A critical appraisal

This aim of this systematic review was to determine the prevalence and pattern of cancer-related fatigue (CRF), and identify factors associated with its development. Relevant literature was identified through an electronic database search using specified keywords. Included studies investigated CRF in adult cancer patients using a multidimensional fatigue measure. The methodological quality was assessed using six published standards. CRF is apparent both during and after anti-cancer therapy, however, the prevalence of CRF varied between studies. The variables associated with the development and persistence of CRF remain to be identified. Inconsistencies were evident in the pattern of CRF and its associated factors. This is likely to have arisen from the inherent difficulties in the measurement of a subjective sensation, further complicated by the myriad of outcome measures used. More methodologically sound research; assessing CRF from the commencement of therapy, considering all pertinent variables is needed.

The prevalence and moderators of fatigue in people who have been successfully treated for cancer

OBJECTIVE

The aims of this study were to estimate the prevalence of severe fatigue in disease-free breast cancer patients according to draft International Classification of Disease, Tenth Edition (ICD-10) criteria for cancer-related fatigue (CRF) and to obtain further information on the validity of these criteria. Furthermore, hypotheses derived from psychosocial theories of fatigue regarding the association of fatigue with activity level, psychological distress, and cognitive constructs were also tested.

METHODS

Sixty-nine disease-free breast cancer patients were assessed at least 6 months posttreatment, using self-report questionnaires and a structured interview.

RESULTS

Nineteen percent of the sample met criteria for CRF. This subgroup differed significantly from the rest of the sample on multiple measures of fatigue and interference. Self-reported activity level bore no relationship to fatigue. Fear of recurrence (FOR) contributed to fatigue indirectly, whilst psychological distress and beliefs about activity appeared to predict fatigue directly.

CONCLUSION

The validity of the draft ICD-10 criteria for CRF was supported. Further research is required into the relationship between fatigue, emotional distress, and cognitive-behavioural factors.

Prevalence and Correlates of Fatigue in Long-Term Survivors of Childhood Leukemia

Purpose

To estimate the prevalence of fatigue, identify the factors associated with fatigue, and to explore the relationship between fatigue and quality of life (QOL) in long-term survivors of childhood acute lymphoblastic leukemia (ALL).

Methods

One hundred sixty-one ALL survivors diagnosed at Childrens Hospital Los Angeles (Los Angeles, CA) before age 18 years and between January 1, 1975 and December 31, 1995, participated in a structured telephone interview. Participants were aged 18 to 41 years and off treatment for an average of 14 years. Four measures of fatigue, including the Revised–Piper Fatigue Scale, were used to assess fatigue; depression was assessed using the Center for Epidemiological Studies Depression Scale. Multivariate logistic regression models were developed to identify factors associated with fatigue and depression.

Results

Prevalence of fatigue (30%) fell within the general population normal limits. Fatigue and depression were highly correlated (Pearson r = 0.75). Fatigue was associated with marriage (OR = 0.11; 95% CI, 0.02 to 0.50), having children (OR = 5.80; 95% CI, 1.30 to 25.82), sleep disturbances (OR = 6.15; 95% CI, 2.33 to 16.22), pain (OR = 5.56; 95% CI, 2.13 to 14.48), obesity (OR = 3.80; 95% CI, 1.41 to 10.26), cognitive impairment (OR = 2.56; 95% CI, 1.02 to 6.38), and exercise-induced symptoms (OR = 2.98; 95% CI, 1.11 to 8.02). Four factors associated with fatigue were also associated with depression: sleep disturbances, pain, obesity, and cognitive impairment. Fatigue was inversely related to QOL.

Conclusion

Some survivors of childhood ALL experience fatigue many years after treatment. Fatigued survivors represent a high-risk subgroup as they report more depression and poorer QOL than nonfatigued survivors and their peers.

Fertility, gonadal and sexual function in survivors of testicular cancer

Modern treatments cure most testicular cancer patients, so an important goal is to minimise toxicity. Fertility and sexual functioning are key issues for patients. We have evaluated these outcomes in a cross-sectional study of long-term survivors of testicular cancer. In total, 680 patients treated between 1982 and 1992 completed the EORTC Qly-C-30(qc30) questionnaire, the associated testicular cancer specific module and a general health and fertility questionnaire. Patients have been subdivided according to treatment received: orchidectomy either alone (surveillance, S n=169), with chemotherapy (C, n=272), radiotherapy (R, n=158), or both chemotherapy and radiotherapy (C/RT n=81). In the surveillance group, 6% of patients had an elevated LH, 41% an elevated FSH and 11% a low (<10 nmol l⁻¹) testosterone. Hormonal function deteriorated with additional treatment, but the effect in general was small. Low testosterone was more common in the C/RT group (37% P=0.006), FSH abnormalities were more common after chemotherapy (C 49%, C/RT 71% both P<0.005) and LH abnormalities after radiotherapy (11% P<0.01) and chemotherapy (10%, P<0.001). Baseline hormone data were available for 367 patients. After treatment, compared to baseline, patients receiving chemotherapy had significantly greater elevations of FSH (median rise of 6 (IQR 3–9.25) iu l⁻¹ compared to 3 (IQR 1–5) iu l⁻¹ for S; P<0.001) and a fall (compared to a rise in the surveillance group) in median testosterone levels (−2 (IQR −8.0 to −1.5) vs 1.0. (IQR −4.0–4.0) P<0.001). Patients with low testosterone (but not elevated FSH) had lower quality of life scores related to sexual functioning on the testicular cancer specific module and lower physical, social and role functioning on the EORTC Qly C-30. Patients with a low testosterone also had higher body mass index and blood pressure. Treatment was associated with reduction in sexual activity and patients receiving chemotherapy had more concerns about fathering children. In total, 207 (30%) patients reported attempting conception of whom 159 (77%) were successful and a further 10 patients were successful after infertility treatment with an overall success rate of 82%. There was a lower overall success rate after chemotherapy (C 71%; CRT 67% compared to S 85% (P=0.028)). Elevated FSH levels were associated with reduced fertility (normal FSH 91% vs elevated 68% P<0.001). In summary, gonadal dysfunction is common in patients with a history of testicular cancer even when managed by orchidectomy alone. Treatment with chemotherapy in particular can result in additional impairment. Gonadal dysfunction reduces quality of life and has an adverse effect on patient health. Most patients retain their fertility, but the risk of infertility is likely to be increased by chemotherapy. Screening for gonadal dysfunction should be considered in the follow-up of testicular cancer survivors.

Testosterone administration attenuates regional brain hypometabolism in women with anorexia nervosa

Abnormalities in brain metabolism have not been consistently well localized in anorexia nervosa (AN), and effects of specific therapies on these functional abnormalities have not been studied. Androgen replacement therapy improves mood, well-being and cognitive function in men with androgen deficiency. We therefore hypothesized that women with AN and relative androgen deficiency would exhibit regional brain hypometabolism compared with healthy controls, and that low-dose physiologic androgen replacement would attenuate the hypometabolism in some of these brain loci. We used FDG PET and statistical parametric mapping methods to investigate regional brain glucose metabolism in (1) 14 women with AN and 20 healthy control subjects of similar mean age and (2) women with AN after randomization to low-dose replacement testosterone therapy or placebo. Cerebral metabolism was decreased in the posterior cingulate, pregenual anterior cingulate, left middle temporal, right superior temporal, and left dorsolateral prefrontal cortex in the AN group compared with controls. In AN patients receiving testosterone, cerebral metabolism increased in the posterior cingulate, subgenual anterior cingulate, premotor cortex, right caudate and right parietal lobes. In conclusion, our data demonstrate distinct loci of regional brain hypometabolism in women with AN compared with controls. Moreover, abnormalities in one of these regions-the posterior cingulate cortex-were attenuated towards normal with low-dose testosterone replacement therapy. Further study is warranted to replicate these findings, as well as to determine their physiological and clinical significance.

Physical performance, depression, immune status and fatigue in patients with hematological malignancies after treatment

BACKGROUND

Fatigue is a frequent and severe problem after treatment of patients with hematological malignancies. This symptom has been associated with anemia, reduced physical performance, mood, endocrine disorders and impaired nutritional status. Recently, it has been suggested that fatigue can be related to a persistent activation of the immune system with increased production of proinflammatory cytokines. However, there is no conclusive evidence regarding the role of the immune system in the origin of fatigue in cancer patients.

PATIENTS AND METHODS

We evaluated the correlation of fatigue with thyroid function, markers of immune activity [interleukin (IL)-1alpha, IL-1 soluble receptor, IL-6, C-reactive protein and neopterin], liver and kidney function, mood and physical ability in 71 patients with hematological malignancies. All patients had been free of relapse and not received treatment (chemotherapy, radiotherapy or immune modulators) for at least 3 months.

RESULTS

Fatigue was related to depression (r=0.84; P<0.0001) and reduced performance status (r=-0.61; P<0.0001). However, there was no correlation between fatigue and thyroid, liver and kidney function, anemia, albumin concentration or markers of immune activity (all r-values <0.20; P>0.05).

CONCLUSIONS

We conclude that fatigue in relapse-free patients with hematological malignancies is associated with depressive mood and reduced physical performance, but not with impairment of thyroid function, anemia or persistent activation of the immune system.

Fatigue and aging

Fatigue is the most common chronic symptom of cancer and the symptom most likely to disrupt the patient's activity and to cause disability.Fatigue affects older cancer patients to the same order of magnitude as younger ones and appears to be related to different factors such as anemia, depression, and reduced neuromuscular energy production. Interestingly, some studies have suggested that the duration of fatigue may be age-related. In the elderly, fatigue may cause functional dependence; functional dependence may lead to interruption of treatment, decline in quality of life and expensive home care. Available interventions include reduction of centrally acting drugs, management of anemia and metabolic abnormalities, and management of depression, treatment of sleep disorders, correction of endocrine abnormalities and realistic exercise programmes.

Fatigue, anxiety, and depression in long-term survivors of testicular cancer

PURPOSE

To investigate the prevalence of chronic fatigue (CF), the levels of anxiety and depression, and the correlation between these conditions in long-term survivors of testicular cancer (TCSs). Occurrence of CF in TCSs is compared with findings in male survivors of Hodgkin's disease (HDSs) and in males from the general population (GenPop).

METHODS

TCSs, HDSs, and two cohorts of the GenPop completed the Fatigue Questionnaire (FQ) and the Hospital Anxiety and Depression Scale (HADS) as part of a questionnaire survey. Cases of CF were identified according to published cut-offs, and the levels of anxiety (HADS-A) and depression (HADS-D) were calculated.

RESULTS

Among 791 TCSs, 16% displayed CF (HDSs, 24%; GenPop, 10%). In the age group younger than 30 years, the prevalence of CF was higher in TCSs than in the GenPop (P <.01). In TCSs, age, anxiety, depression, and comorbidity were independent predictors of CF. The mean HADS-A score in TCSs was significantly above the comparable figure of the GenPop and similar to that of HDSs. The mean HADS-D score in TCSs was below that of the GenPop. The highest and lowest mean scores of HADS-A and HADS-D were observed in the youngest TCSs.

CONCLUSION

The prevalence of CF is less in TCSs than in HDSs but exceeds that of the GenPop. Together with comorbidity and age, anxiety and depression predict CF in TCSs, warranting psychiatric intervention for cases of CF among TCSs. Anxiety is a larger problem in TCSs than depression, particularly among the youngest TCSs.