Sexual bother in men with advanced prostate cancer undergoing androgen deprivation therapy

Impact of neoadjuvant relugolix on patient-reported sexual function and bother

Introduction

Sexual function following local treatment for prostate cancer is an important quality of life concern. Relugolix is a novel oral GnRH receptor antagonist used in combination with radiation therapy in the treatment of unfavorable prostate cancer. It has been shown to achieve rapid and profound testosterone suppression. As a result, these very low testosterone levels may impact both sexual functioning and perceptions. This prospective study sought to assess neoadjuvant relugolix-induced sexual dysfunction prior to stereotactic body radiation therapy (SBRT).

Methods

Between March 2021 and September 2023, 87 patients with localized prostate cancer were treated with neoadjuvant relugolix followed by SBRT per an institutional protocol. Sexual function and bother were assessed via the sexual domain of the validated Expanded Prostate Index Composite (EPIC-26) survey. Responses were collected for each patient at pre-treatment baseline and after several months of relugolix. A Utilization of Sexual Medications/Devices questionnaire was administered at the same time points to assess erectile aid usage.

Results

The median age was 72 years and 43% of patients were non-white. The median baseline Sexual Health Inventory for Men (SHIM) score was 13 and 41.7% of patients utilized sexual aids prior to relugolix. Patients initiated relugolix at a median of 4.5 months (2-14 months) prior to SBRT. 95% and 87% of patients achieved effective castration (≤ 50 ng/dL) and profound castration (< 20 ng/dl) at SBRT initiation, respectively. Ability to have an erection, ability to reach orgasm, quality of erections, frequency of erections, and overall sexual function significantly declined following relugolix. There was a non- significant increase in sexual bother.

Discussion

In concordance with known side effects of androgen deprivation therapy (ADT), neoadjuvant relugolix was associated with a significant decline in self-reported sexual function. However, patients indicated only a minimal and non-significant increase in bother. Future investigations should compare outcomes while on relugolix directly to GnRH agonist-induced sexual dysfunction.

Sexual characteristics of patients with prostate cancer seen for radiation treatment

Background

Prostate cancer was estimated to be the second most diagnosed cancer and the fifth leading cause of cancer mortality among men, with an estimated 1.4 million new cases and 375,000 deaths globally in 2020. There are significant changes in sexual activities and subsequent changes in quality of life associated with the diagnosis and treatment of prostate cancer. Sexual problems experienced by prostate cancer patients include erectile dysfunction, reduced sexual desire, reduced sexual function, problems with ejaculation, as well as problems with orgasm, and these could occur before and/or after treatment. This study aims to highlight the sexual characteristics of prostate cancer patients, which would help identify altered sexuality that might require intervention by healthcare providers.

Method

All patients who presented with pathologically diagnosed, organ-confined prostate cancer referred for high-dose-rate brachytherapy were approached for participation in the study. An interviewer-administered questionnaire was administered to the consenting patients.

Results

A total of 56 patients gave consent for the study out of 60. All the patients were married, with 5 (8.9%) having multiple wives. Only ten respondents (17.9%) reported having other sexual partners besides their wives. More than half of the patients (34) (60.7%) started having sexual intercourse between the ages of 18 and 20. Many patients claimed that the diagnosis of prostate cancer had affected their sexual lives. About half of the respondents (44.6%) believed that their partners were less satisfied with their sexual performance, as evidenced by the loss of partners (5.4%), partners refusing sexual advances (14.3%), partners complaints (10.7%), and partners' reduced inclination to ask for sex (33.9%). One patient expressed fears of passing the disease to their partners.

Conclusion

The management of prostate cancer should include sex therapy and rehabilitation in couples from the point of diagnosis to maintain sexual function as close as possible to that in the general population in order to maintain an improved quality of life.

The impact of hegemonic masculine ideals on self-esteem in prostate cancer patients undergoing androgen deprivation therapy (ADT) compared to ADT-naïve patients

PURPOSE

Androgen deprivation therapy (ADT) for Prostate Cancer (PCa) is associated with side effects that could lead to negative body image and low masculine self-esteem of survivors. We compared a group of PCa survivors following ADT with ADT-naïve patients, expecting the ADT group to show lower masculine self-esteem. We also expected patients with hegemonic masculinity ideals to show poorer masculine self-esteem and we hypothesized that ADT would moderate this relationship, expecting PCa patients on ADT with stronger hegemonic ideals to show the worst masculine self-esteem scores among study participants.

METHODS

We compared 57 PCa survivors on ADT (M_age  = 64.16 (7.11)) to 59 ADT-naïve patients (M_age  = 65.25 (5.50)), on the Masculine Self-Esteem Scale (MSES), Body Image Scale (BIS), and Hegemonic Masculinity Ideals Scale (HMIS).

RESULTS

While the two groups did not significantly differ on masculine self-esteem (F [1, 115] = 3.46, p = 0.065, η_p ²  = 0.029) and body image (F [1, 115] = 3.46, p = 0.065, η_p ²  = 0.029), younger age was significantly associated with higher body image issues (F [1, 115] = 8.63, p < 0.01, η_p ²  = 0.071, β = -0.30). Hegemonic masculinity significantly predicted more masculine self-esteem related issues (t (2, 114) = 2.31, β = 0.375, p < 0.05). ADT did not moderate this relationship.

CONCLUSIONS

The results suggest that endorsing hegemonic masculinity could represent a risk factor for low masculine self-esteem regardless of ADT status and that younger age is associated with negative body image among PCa survivors.

IMPLICATIONS

These results suggest the importance of inclusion of topics related to hegemonic masculinity when providing support to PCa survivors, both when discussing treatment side effects, as well as in the later phases of survivorship. This pilot also suggests that younger PCa survivors might benefit from body-image focused support regardless of treatment plan.

Psychosocial Aspects of Living Long Term with Advanced Cancer and Ongoing Systemic Treatment: A Scoping Review

(1) Background: Studies examining the psychosocial impact of living long term on systemic treatment in advanced cancer patients are scarce. This scoping review aimed to answer the research question “What has been reported about psychosocial factors among patients living with advanced cancer receiving life-long systemic treatment?”, by synthesizing psychosocial data, and evaluating the terminology used to address these patients; (2) Methods: This scoping review was conducted following the five stages of the framework of Arksey and O’Malley (2005); (3) Results: 141 articles published between 2000 and 2021 (69% after 2015) were included. A large variety of terms referring to the patient group was observed. Synthesizing qualitative studies identified ongoing uncertainty, anxiety and fear of disease progression or death, hope in treatment results and new treatment options, loss in several aspects of life, and worries about the impact of disease on loved ones and changes in social life to be prominent psychosocial themes. Of 82 quantitative studies included in the review, 76% examined quality of life, 46% fear of disease progression or death, 26% distress or depression, and 4% hope, while few studies reported on adaptation or cognitive aspects. No quantitative studies focused on uncertainty, loss, or social impact; (4) Conclusion and clinical implications: Prominent psychosocial themes reported in qualitative studies were not included in quantitative research using specific validated questionnaires. More robust studies using quantitative research designs should be conducted to further understand these psychological constructs. Furthermore, the diversity of terminology found in the literature calls for a uniform definition to better address this specific patient group in research and in practice.

Symptom burden profiles in men with advanced prostate cancer undergoing androgen deprivation therapy

To identify symptom burden profiles among men with advanced prostate cancer undergoing androgen-deprivation therapy and examine their association with baseline sociodemographic and medical characteristics and psychosocial outcomes over time. Latent profile analysis was employed to identify distinct groups based on the Expanded Prostate Index Composite and the McGill Pain Questionnaire at baseline. Psychosocial outcomes were assessed at baseline, 6- and 12-month follow-ups. Three profiles emerged: "high symptom burden," "high sexual bother," and "low symptom burden." Men with "high symptom burden" were younger and exhibited higher baseline levels of depression, stress, cancer-specific distress, and anxiety than men in the other two groups. However, men with "high symptom burden" also demonstrated improvement in these psychosocial outcomes over time. Men with advanced prostate cancer who experience multiple co-occurring symptoms demonstrate worse psychosocial adjustment. Patients with substantial symptom burden, and specifically young men, may benefit from prompt referral to supportive care services.

Sexual function in men undergoing androgen deprivation therapy

Androgen deprivation therapy (ADT) has a deleterious effect on sexual functions and general well-being in men. Despite this evidence, however, patient and couple knowledge about ADT side effects as well as their management is poor. Similar considerations can be made for physician endorsement of management strategies. In this paper, we summarize and critically discuss available evidence regarding the possible associations between ADT and sexual dysfunction as well as the best therapeutical options. Preclinical data show that ADT is associated with penile contractility impairment as well as lower response to phosphodiesterase type 5 inhibitors (PDE5i). Available data indicate that ADT resulted in a five to sixfold increased risk of reduced libido and in a threefold increased risk of ED confirming the main role of testosterone in regulating sexual desire. Despite this evidence, sexuality remains an important aspect of health and well-being for men and their partner. The best therapeutical options depend on patient and couple desires and needs. When nonpenetrative erections are still possible, nonpenetrative activities should be encouraged to maintain sexual intimacy. A combined and personal educational program including the collaboration of different professional figures (including general physicians, oncologists, andrologists, sexologists, and psychologists) trained in sexual medicine is advisable in order to provide the best support to subjects undergoing ADT.

An Educational Program to Help Patients Manage Androgen Deprivation Therapy Side Effects: Feasibility, Acceptability, and Preliminary Outcomes

Androgen deprivation therapy (ADT), a common treatment for prostate cancer, is associated with physical, psychological, and sexual side effects that reduce patients' quality of life. The authors designed an educational program to prepare patients for managing these side effects. This paper describes an implementation model for national dissemination of the program, testing its feasibility and acceptability at the institutional and patient level. Postprogram changes in patients' self-efficacy to manage side effects and side effect bother are also explored. Patients on or anticipating ADT enrolled in the educational program. Pre and post intervention questionnaires measured patient satisfaction with the program, side effect bother, and self-efficacy to manage ADT side effects. The ADT Educational Program was deemed feasible and acceptable. Five of six targeted sites successfully launched the program with sufficient patient enrolment. Patient attendees were highly satisfied. Self-efficacy, bother, and use of management strategies were interrelated. Lower bother was associated with increased self-efficacy and more use of management strategies, and increased bother was associated with lower self-efficacy and less use of management strategies. Based on pre-post scores, improvements in patients' self-efficacy to manage ADT side effects were also observed. Results demonstrate that this brief educational program is feasible and acceptable to patients and cancer care institutions. The program appears to promote self-efficacy and the uptake of ADT management strategies for ADT side effects. The results of this study support the program implementation and suggest that improvements in self-efficacy after program participation may help patients adapt to ADT side effects.

Transdermal oestradiol for androgen suppression in prostate cancer: long-term cardiovascular outcomes from the randomised Prostate Adenocarcinoma Transcutaneous Hormone (PATCH) trial programme

BACKGROUND

Androgen suppression is a central component of prostate cancer management but causes substantial long-term toxicity. Transdermal administration of oestradiol (tE2) circumvents first-pass hepatic metabolism and, therefore, should avoid the cardiovascular toxicity seen with oral oestrogen and the oestrogen-depletion effects seen with luteinising hormone releasing hormone agonists (LHRHa). We present long-term cardiovascular follow-up data from the Prostate Adenocarcinoma Transcutaneous Hormone (PATCH) trial programme.

METHODS

PATCH is a seamless phase 2/3, randomised, multicentre trial programme at 52 study sites in the UK. Men with locally advanced or metastatic prostate cancer were randomly allocated (1:2 from August, 2007 then 1:1 from February, 2011) to either LHRHa according to local practice or tE2 patches (four 100 μg patches per 24 h, changed twice weekly, reducing to three patches twice weekly if castrate at 4 weeks [defined as testosterone ≤1·7 nmol/L]). Randomisation was done using a computer-based minimisation algorithm and was stratified by several factors, including disease stage, age, smoking status, and family history of cardiac disease. The primary outcome of this analysis was cardiovascular morbidity and mortality. Cardiovascular events, including heart failure, acute coronary syndrome, thromboembolic stroke, and other thromboembolic events, were confirmed using predefined criteria and source data. Sudden or unexpected deaths were attributed to a cardiovascular category if a confirmatory post-mortem report was available and as other relevant events if no post-mortem report was available. PATCH is registered with the ISRCTN registry, ISRCTN70406718; the study is ongoing and adaptive.

FINDINGS

Between Aug 14, 2007, and July 30, 2019, 1694 men were randomly allocated either LHRHa (n=790) or tE2 patches (n=904). Overall, median follow-up was 3·9 (IQR 2·4-7·0) years. Respective castration rates at 1 month and 3 months were 65% and 93% among patients assigned LHRHa and 83% and 93% among those allocated tE2. 157 events from 145 men met predefined cardiovascular criteria, with a further ten sudden deaths with no post-mortem report (total 167 events in 153 men). 26 (2%) of 1694 patients had fatal cardiovascular events, 15 (2%) of 790 assigned LHRHa and 11 (1%) of 904 allocated tE2. The time to first cardiovascular event did not differ between treatments (hazard ratio 1·11, 95% CI 0·80-1·53; p=0·54 [including sudden deaths without post-mortem report]; 1·20, 0·86-1·68; p=0·29 [confirmed group only]). 30 (34%) of 89 cardiovascular events in patients assigned tE2 occurred more than 3 months after tE2 was stopped or changed to LHRHa. The most frequent adverse events were gynaecomastia (all grades), with 279 (38%) events in 730 patients who received LHRHa versus 690 (86%) in 807 patients who received tE2 (p<0·0001) and hot flushes (all grades) in 628 (86%) of those who received LHRHa versus 280 (35%) who received tE2 (p<0·0001).

INTERPRETATION

Long-term data comparing tE2 patches with LHRHa show no evidence of a difference between treatments in cardiovascular mortality or morbidity. Oestrogens administered transdermally should be reconsidered for androgen suppression in the management of prostate cancer.

FUNDING

Cancer Research UK, and Medical Research Council Clinical Trials Unit at University College London.

On the Relationship Between Erectile Function and Sexual Distress in Men with Prostate Cancer

Erectile difficulties are common after prostate cancer (PCa) treatment and are associated with sexual distress. However, the relationship between erectile function and sexual distress has yet to be carefully examined. This study had three goals: (1) examine the relationship between erectile function and sexual distress; (2) determine groups of men based on erectile function and sexual distress; and (3) examine the psychosexual characteristics of these groups. A cross section of 233 sexually active men after PCa treatment (age M = 64.90 years, SD = 7.50) completed an online survey containing demographic, health, and sexuality and relationship questionnaires. The relationship between erectile function and sexual distress was curvilinear. Four groups of men were found: good erectile function and low sexual distress, poor erectile function and high sexual distress, but also good erectile function yet high sexual distress, and poor erectile function and low sexual distress. Regardless of erectile function, men with greater sexual distress were more depressed, reported additional sexual concerns, placed less value on sex, were less sexually satisfied, and used protective buffering communication more frequently. They were also less likely to be satisfied with their adaptation to sexual changes and less likely to have found a solution to those changes. The relationship between erectile function and sexual distress is complex, characterized by a wide array of responses to erectile function (high and low distress) and multiple correlates of sexual distress. These results broaden the concept of sexual recovery after PCa treatment, which may assist clinicians and researchers to better address sexual problems after PCa treatment.

Phase II open-label study investigating apalutamide in patients with biochemical progression after radical prostatectomy

Apalutamide, a competent inhibitor of the androgen receptor, has shown promising clinical efficacy results for patients with advanced prostate cancer. Here, we describe the rationale and design for the SAVE trial, a multi-center, Phase II study, wherein 202 men with biochemical progression after radical prostatectomy are randomly assigned 1:1 to apalutamide plus salvage radiotherapy (SRT) or androgen-deprivation therapy with an luteinizing hormone-releasing hormone agonist or antagonist plus SRT. The primary objective is to compare sexual function between the two treatment arms based on the expanded prostate cancer index-26 sexual domain score at nine months after start of hormonal treatment. The key secondary objectives are to assess quality of life, to evaluate the safety profile and the short-term efficacy of apalutamide in combination with SRT. ClinicalTrials.gov identifier: NCT03899077.

Prostatic irradiation-induced sexual dysfunction: a review and multidisciplinary guide to management in the radical radiotherapy era (Part I defining the organ at risk for sexual toxicities)

Prostate cancer is the most common malignancy and the second leading cause of cancer-related death in men. Radiotherapy is a curative option that is administered via external beam radiation, brachytherapy, or in combination. Erectile, ejaculatory and orgasm dysfunction(s) is/are known potential and common toxicities associated with prostate radiotherapy. Our multidisciplinary team of physicians and/or scientists have written a three (3) part comprehensive review of the pathogenesis and management radiation-induced sexual dysfunction. Part I reviews pertinent anatomy associated with normal sexual function and then considers the pathogenesis of prostate radiation-induced sexual toxicities. Next, our team considers the associated radiobiological (including the effects of time, dose and fractionation) and physical (treatment planning and defining a novel Organ at Risk (OAR)) components that should be minded in the context of safe radiation treatment planning. The authors identify an OAR (i.e., the prostatic plexus) and provide suggestions on how to minimize injury to said OAR during the radiation treatment planning process.

Estimating utilities/disutilities for high-risk metastatic hormone-sensitive prostate cancer (mHSPC) and treatment-related adverse events

PURPOSE

To capture UK societal health utility values for high-risk metastatic hormone-sensitive prostate cancer (mHSPC) and the disutility associated with treatment-related adverse events (AEs) to inform future cost-utility analyses.

METHODS

A literature review, and patient and clinical expert interviews informed the development of health states characterising mHSPC symptoms and the impact of treatment-related AEs on health-related quality of life (HRQL). Three base health states were developed describing a typical patient with high-risk mHSPC: receiving androgen deprivation therapy (ADT) [Base State 1]; receiving docetaxel plus ADT [Base State 2]; completed docetaxel and still receiving ADT whose disease has not yet progressed [Base State 3]. Six additional health states described treatment-related AEs. The health states were validated with experts and piloted with general public participants. Health state utilities were obtained using the time trade-off (TTO) method with 200 members of the UK general population. A generalised estimating equation (GEE) model was used to estimate disutility weights.

RESULTS

Mean TTO scores for Base State 1 to 3 were 0.71 (SD = 0.26), 0.64 (SD = 0.27), and 0.68 (SD = 0.26), respectively, indicating that receiving docetaxel plus ADT was most impactful on HRQL. The GEE model indicated when compared to Base State 2 that the nausea and vomiting AE had the most impact on HRQL (- 0.21), while alopecia was least burdensome (- 0.04).

CONCLUSIONS

The study highlights the differences in utility between base health states and the significant impact of treatment-related AEs on the HRQL of patients with mHSPC. These findings underline the importance of accounting for impaired HRQL when assessing treatments for mHSPC.

Quality of life worsened the most severely in patients immediately after intensity-modulated radiotherapy for prostate cancer

Purpose

The aim of this study was to evaluate the chronological changes in lower urinary tract symptoms (LUTSs), disease-related quality of life (QOL), and health-related QOL (HR-QOL) of patients who received intensity-modulated radiotherapy (IMRT).

Patients and methods

In 121 patients who had received IMRT and were followed up for >2 years, the International Prostate Symptom Score (IPSS), Overactive Bladder Symptom Score (OABSS), Expanded Prostate Cancer Index Composite (EPIC), and 8-Item Short-Form Health Survey (SF-8) were used before IMRT, at the halfway point in IMRT, immediately after IMRT, and 1–24 months after the completion of IMRT.

Results

The IPSS and OABSS and the urinary and bowel domains of the EPIC indicated that QOL worsened at the halfway point in IMRT, further worsened more severely immediately after IMRT, and then improved. The sexual domain of the EPIC significantly decreased at the halfway point in IMRT, which significantly lowered until 24 months. The scores of physical functioning, role physical, bodily pain, vitality, social functioning, and role emotional domains in the SF-8 significantly decreased and reached their lowest points immediately after IMRT.

Conclusion

QOL worsened the most severely in patients immediately after IMRT for prostate cancer. This knowledge can influence treatment recommendations and enable patients to make better informed decisions.

Mood, sexuality, and relational intimacy after starting androgen deprivation therapy: implications for couples

BACKGROUND

Patients on androgen deprivation therapy (ADT), a common treatment for prostate cancer, report significant declines in quality of life and detrimental impact on their intimate relationships. ADT depresses a man's testosterone to castrate levels, leading to declines in sexual function, and changes in mood. These changes can have profound impact on couples' intimate relationships.

METHOD

Patients undergoing ADT, and their consenting partners, were followed on a variety of outcomes relating to mood, sexual changes, and relational intimacy. Participants were assessed at baseline, 3 months, and 6 months. Changes in these three domains are documented. A dyadic analysis was conducted on the primary outcome of relational intimacy in order to assess the role of changes in mood and various aspects of sexuality on couples' intimate relationships.

RESULTS

Declines were observed in the first 6 months on ADT for sexual function, sexual frequency, and relational intimacy. Sexual bother increased within the first 3 months on ADT. No changes in mood were observed. Dyadic analysis revealed important effects on couples' reports of relational intimacy. (A) Patient and partner ratings of emotional intimacy were higher when partners better understood the patients' mood state. (B) Patient and partner ratings of sexual intimacy were higher when couples were more sexually active.

CONCLUSIONS

The current study confirms that patients experience reduced sexuality and relational intimacy during the first 6 months on ADT. Specific facets of relational intimacy are improved with increased sexual activity and also when partners recognize the emotional changes that patients are experiencing.

Influence of symptoms of depression on the quality of life of men diagnosed with prostate cancer

Abstract Objective: to evaluate the prevalence of symptoms of depression among men diagnosed with prostate cancer and their association with quality of life and treatment-related factors. Methods: a cross-sectional study of 85 men with a mean age of 66±8 years who were diagnosed with prostate cancer was performed. The survey was based on a questionnaire with previously validated instruments which investigated social, demographic and economic characteristics, the history of the disease, quality of life (European Organization for Research and Treatment of Cancer Questionnaire C30 - EORTC QLQ-C30 / QLQ-PR25) and symptoms of depression (Beck Depression Inventory). The presence of symptoms of depression was considered an outcome, and statistical analyzes were performed using the Chi-square test, Fisher's exact test, Mann Whitney U test and Poisson regression (p<0.05). Results: significant results were found for quality of life in relation to symptoms of depression in the functional, global and symptomatic health scale (p<0.001). This demonstrates that the presence of symptoms of depression is related to a negative quality of life. Conclusions: for a greater understanding of prostate cancer and its consequences on the quality of life of patients it is important to consider possible disorders in psychological aspects caused by the illness, as symptoms of depression are frequent in patients undergoing treatment for prostate cancer.

The Effect of Targeted Therapy for Genitourinary Malignancies on Sexual Function and Fertility

PURPOSE OF REVIEW

Targeted therapy for genitourinary cancer is being used at an increasing rate. These medications show great survival benefit but are relatively lacking in long-term adverse effect data. With increasing survivability, measures to improve quality of life must be considered for GU cancer and a large proponent of this is sexual function.

RECENT FINDINGS

mTOR inhibitors have shown an effect on testosterone levels and may have a link to abnormal semen parameters. Tyrosine kinase inhibitors (TKIs) have shown no adverse sexual outcomes in the literature. There are laboratory links to tyrosine kinases having a beneficial effect on erectile and sexual function. Possible sexual side effects must be discussed with patients receiving a diagnosis of cancer. Further research is required to determine the exact mechanisms and outcomes of sexual function with new and emerging targeted therapy.

Effect of androgen deprivation therapy on sexual function and bother in men with prostate cancer: A controlled comparison

OBJECTIVES

The adverse sexual effects of androgen deprivation therapy (ADT) on men with prostate cancer have been well described. Less well known is the relative degree of sexual dysfunction and bother associated with ADT compared to other primary treatment modalities such as radical prostatectomy. We sought to describe the trajectory and relative magnitude of changes in sexual function and bother in men on ADT and to examine demographic and clinical predictors of ADT's adverse sexual effects.

METHODS

Prostate cancer patients treated with ADT (n = 60) completed assessments of sexual function and sexual bother 3 times during a 1-year period after the initiation of ADT. Prostate cancer patients treated with radical prostatectomy only and not receiving ADT (n = 85) and men with no history of cancer (n = 86) matched on age and education completed assessments at similar intervals.

RESULTS

Androgen deprivation therapy recipients reported worsening sexual function and increasing bother over time compared to controls. Effect sizes for the differences in sexual function were large to very large, and for bother were small to very large. Age younger than 83 years predicted relatively poorer sexual function, and age younger than 78 years predicted greater sexual bother at 12 months in men on ADT compared to men not on ADT.

CONCLUSIONS

Most men on ADT for prostate cancer will never return to baseline levels of sexual function. Interventions focused on sexual bother over function and designed to help couples build and maintain satisfying relationship intimacy are likely to more positively affect men's psychological well-being while on ADT than medical or sexual aids targeting sexual dysfunction.

The influence of stigma on the quality of life for prostate cancer survivors

The purpose of the present study was to investigate the influence of stigma on prostate cancer (PCa) survivors' quality of life. Stigma for lung cancer survivors has been the focus of considerable research (Else-Quest & Jackson, 2014); however, gaps remain in understanding the experience of PCa stigma. A cross-sectional correlational study was designed to assess the incidence of PCa stigma and its influence on the quality of life of survivors. Eighty-five PCa survivors were administered survey packets consisting of a stigma measure, a PCa-specific quality of life measure, and a demographic survey during treatment of their disease. A linear regression analysis was conducted with the data received from PCa survivors. Results indicated that PCa stigma has a significant, negative influence on the quality of life for survivors (R² = 0.33, F(4, 80) = 11.53, p < 0.001). There were no statistically significant differences in PCa stigma based on demographic variables (e.g., race and age). Implications for physical and mental health practitioners and researchers are discussed.

Infertility, impotence, and emasculation--psychosocial contexts for abandoning reproduction

From a Darwinian perspective we live to reproduce, but in various situations genetic males elect not to reproduce by choosing medical treatments leading to infertility, impotence, and, in the extreme, emasculation. For many men, infertility can be psychologically distressing. However, for certain genetic males, being infertile may improve their quality of life. Examples include (1) men who seek vasectomy, (2) individuals with Gender Dysphoria (e.g., transwomen, and modern day voluntary eunuchs), (3) most gay men, and (4) men treated for testicular and prostate cancer. Men who desire vasectomy typically have a Darwinian fitness W >1 at the time of their vasectomies; i.e., after they have their desired number of offspring or consider themselves past an age for parenting newborns. In contrast, prostate and testicular cancer patients, along with individuals with extreme Gender Dysphoria, do not necessarily seek to be sterile, but accept it as an unavoidable consequence of the treatment for their condition undertaken for survival (in case of cancer patients) or to achieve a better quality of life (for those with Gender Dysphoria). Most gay men do not father children, but they may play an avuncular role, providing for their siblings’ offspring's welfare, thus improving their inclusive fitness through kin selection. In a strictly Darwinian model, the primary motivation for all individuals is to reproduce, but there are many situations for men to remove themselves from the breeding populations because they have achieved a fitness W ≥1, or have stronger medical or psychological needs that preclude remaining fertile.

Quality-of-life outcomes from the Prostate Adenocarcinoma: TransCutaneous Hormones (PATCH) trial evaluating luteinising hormone-releasing hormone agonists versus transdermal oestradiol for androgen suppression in advanced prostate cancer

OBJECTIVES

To compare quality-of-life (QoL) outcomes at 6 months between men with advanced prostate cancer receiving either transdermal oestradiol (tE2) or luteinising hormone-releasing hormone agonists (LHRHa) for androgen-deprivation therapy (ADT).

PATIENTS AND METHODS

Men with locally advanced or metastatic prostate cancer participating in an ongoing randomised, multicentre UK trial comparing tE2 versus LHRHa for ADT were enrolled into a QoL sub-study. tE2 was delivered via three or four transcutaneous patches containing oestradiol 100 μg/24 h. LHRHa was administered as per local practice. Patients completed questionnaires based on the European Organisation for Research and Treatment of Cancer quality of life questionnaire 30-item core (EORTC QLQ-C30) with prostate-specific module QLQ PR25. The primary outcome measure was global QoL score at 6 months, compared between randomised arms.

RESULTS

In all, 727 men were enrolled between August 2007 and October 2015 (412 tE2, 315 LHRHa) with QoL questionnaires completed at both baseline and 6 months. Baseline clinical characteristics were similar between arms: median (interquartile range) age of 74 (68-79) years and PSA level of 44 (19-119) ng/mL, and 40% (294/727) had metastatic disease. At 6 months, patients on tE2 reported higher global QoL than those on LHRHa (mean difference +4.2, 95% confidence interval 1.2-7.1; P = 0.006), less fatigue, and improved physical function. Men in the tE2 arm were less likely to experience hot flushes (8% vs 46%), and report a lack of sexual interest (59% vs 74%) and sexual activity, but had higher rates of significant gynaecomastia (37% vs 5%). The higher incidence of hot flushes among LHRHa patients appear to account for both the reduced global QoL and increased fatigue in the LHRHa arm compared to the tE2 arm.

CONCLUSION

Patients receiving tE2 for ADT had better 6-month self-reported QoL outcomes compared to those on LHRHa, but increased likelihood of gynaecomastia. The ongoing trial will evaluate clinical efficacy and longer term QoL. These findings are also potentially relevant for short-term neoadjuvant ADT.

Maintaining intimacy for prostate cancer patients on androgen deprivation therapy

PURPOSE OF REVIEW

Androgen deprivation therapy (ADT) causes erectile dysfunction and increases patients' emotionality while diminishing their sexual interest. ADT has been linked to erosion of spousal bonds; however, this is not an invariant outcome. Understanding the factors that lead to these various outcomes may help couples deal with ADT.

RECENT FINDINGS

A subset of couples report that they became closer as a result of the patients going on ADT. Recent data suggest that what helps couples most is preemptive awareness of ADT's side-effects and congruence in how patients and their partners understand and accept the psychosexual impact of ADT. Sex therapy for prostate cancer patients divides along gendered lines, with distinctly 'male' (recovery of erections) and 'female' (promoting sexual practices that are not erection dependent) approaches. Unfortunately, neither is very effective for couples when the patient is on ADT. Options beyond the standard gendered framework, such as use of an external penile prosthesis, may be worth offering to ADT patients trying to find a 'new normal' that is sexually rewarding for them.

SUMMARY

Intimacy is sharing something with someone that one shares with no one else. Exploring novel sexual practices can help couples stay intimate, even when the patient is on ADT.

Sexual healing in patients with prostate cancer on hormone therapy

Since prostate cancer becomes more common with age, at least one-third of men have sexual problems at diagnosis. All localized treatments for prostate cancer greatly increase the prevalence of sexual dysfunction, which include loss of desire, erectile dysfunction, and changes in orgasm. Even men on active surveillance have a higher rate of problems than matched peers without prostate cancer. However, men given androgen deprivation therapy (ADT) have the worst rates of sexual dysfunction. Even after 3 to 4 months of ADT, men's desire for sex is decreased and irreversible damage may occur to the erectile tissue in the penis. Erections do not recover in about one-half of men, even if ADT is discontinued. Although intermittent ADT allows some recovery of sexual function, serum testosterone requires 9 to 12 months off ADT to recover. Again, one-half of men have permanent erectile dysfunction. If ADT causes atrophy of the erectile tissue, blood leaks out of the venous system during erection. This syndrome is difficult to treat except with surgery to implant a penile prosthesis. Despite the high rate of sexual problems in men on ADT, a small group stays sexually active and is able to have reliable erections. To improve men's sexual satisfaction on ADT, it may be important to educate them about getting extra mental and physical sexual stimulation, as well as using penile rehabilitation during hormone therapy. Information on reaching orgasm and coping with problems such as dry orgasm, pain with orgasm, and urinary incontinence during sex also should be provided.

The primary health care physician and the cancer patient: tips and strategies for managing sexual health

There is a large and growing population of long-term cancer survivors. Primary care physicians (PCPs) are playing an increasingly greater role in the care of these patients across the continuum of cancer survivorship. In this role, PCPs are faced with the responsibility of managing a range of medical and psychosocial late effects of cancer treatment. In particular, the sexual side effects of treatment which are common and have significant impact on quality of life for the cancer survivor, often go unaddressed. This is an area of clinical care and research that has received increasing attention, highlighted by the presentation of this special issue on Cancer and Sexual Health. The aims of this review are 3-fold. First, we seek to overview common presentations of sexual dysfunction related to major cancer diagnoses in order to give the PCP a sense of the medical issues that the survivor may present with. Barriers to communication about sexual health issues between patient/PCPs in order are also described in order to emphasize the importance of PCPs initiating this important conversation. Next, we provide strategies and resources to help guide the PCP in the management of sexual dysfunction in cancer survivors. Finally, we discuss case examples of survivorship sexual health issues and highlight the role that a PCP can play in each of these case examples.

Omissions in Urology Residency Training Regarding Sexual Dysfunction Subsequent to Prostate Cancer Treatment: Identifying a Need

OBJECTIVE

To assess urology residents' current knowledge, practice, previous training, barriers, and training needs regarding prostate cancer treatment-related sexual dysfunction.

MATERIALS AND METHODS

A cross-sectional questionnaire study inventoried the practice patterns and training need of urology residents attending a national training course in June 2015.

RESULTS

Of 101 urology residents throughout the Netherlands, 87 attended the training (response rate 100%). Median age was 32 years (range 28-38); 55.2% were woman. Regardless of the residency level, most trainees had never received education about sexual dysfunction (58.6%), reported a limited level of knowledge (48.3%), and indicated an evident need for training (69.4%). The majority did not feel competent to advise prostate cancer patients regarding the treatment of sexual dysfunction (55.2%). Almost all participants inquired about preoperative erectile dysfunction (89.7%), and always informed about treatment-related sexual dysfunction (88.5%). At follow-up, 63.9% of the residents routinely addressed sexual complaints again. More than half of the participants indicated that urology residency training does not provide sufficient education on sexual dysfunction (54.8%).Time constraint (67.1%) and lack of training (35.3%) were the most frequently mentioned barriers.

CONCLUSION

Current urology residency does not pay sufficient attention to sexual communication skills and sexual dysfunction. The residents require more knowledge about and more practical training in sexual counseling. Findings support efforts to enhance the education of urology residents regarding prostate cancer treatment-related sexual dysfunction.

The perspective of prostate cancer patients and patients' partners on the psychological burden of androgen deprivation and the dyadic adjustment of prostate cancer couples

OBJECTIVE

Prostate cancer and its treatments, particularly androgen deprivation therapy (ADT), affect both patients and partners. This study assessed how prostate cancer treatment type, patient mood, and sexual function related to dyadic adjustment from patient and partner perspectives.

METHODS

Men with prostate cancer (n = 206) and partners of men with prostate cancer (n = 66) completed an online survey assessing the patients' mood (profile of mood states short form), their dyadic adjustment (dyadic adjustment scale), and sexual function (expanded prostate cancer index composite).

RESULTS

Analyses of covariance found that men on ADT reported better dyadic adjustment compared with men not on ADT. Erectile dysfunction was high for all patients, but a multivariate analysis of variance found that those on ADT experienced greater bother at loss of sexual function than patients not on ADT, suggesting that loss of libido when on ADT does not mitigate the psychological distress associated with loss of erections. In a multiple linear regression, patients' mood predicted their dyadic adjustment, such that worse mood was related to worse dyadic adjustment. However, more bother with patients' overall sexual function predicted lower relationship scores for the patients, while the patients' lack of sexual desire predicted lower dyadic adjustment for partners.

CONCLUSIONS

Both patients and partners are impacted by the prostate cancer treatment effects on patients' psychological and sexual function. Our data help clarify the way that prostate cancer treatments can affect relationships and that loss of libido on ADT does not attenuate distress about erectile dysfunction. Understanding these changes may help patients and partners maintain a co-supportive relationship. Copyright © 2015 John Wiley & Sons, Ltd. Copyright © 2015 John Wiley & Sons, Ltd.

Psychological effects of androgen-deprivation therapy on men with prostate cancer and their partners

The clinical benefits of androgen-deprivation therapy (ADT) for men with prostate cancer (PC) have been well documented and include living free from the symptoms of metastases for longer periods and improved quality of life. However, ADT comes with a host of its own serious side effects. There is considerable evidence of the adverse cardiovascular, metabolic, and musculoskeletal effects of ADT. Far less has been written about the psychological effects of ADT. This review highlights several adverse psychological effects of ADT. The authors provide evidence for the effect of ADT on men's sexual function, their partner, and their sexual relationship. Evidence of increased emotional lability and depressed mood in men who receive ADT is also presented, and the risk of depression in the patient's partner is discussed. The evidence for adverse cognitive effects with ADT is still emerging but suggests that ADT is associated with impairment in multiple cognitive domains. Finally, the available literature is reviewed on interventions to mitigate the psychological effects of ADT. Across the array of adverse effects, physical exercise appears to have the greatest potential to address the psychological effects of ADT both in men who are receiving ADT and in their partners.

The effects of resistance exercise on physical performance and health-related quality of life in prostate cancer patients: a systematic review

PURPOSE

Physical exercise has been shown to be an effective, safe, and quite inexpensive method to reduce cardiovascular and metabolic risk factors and is currently in the process of establishing its relevance for cancer specific morbidity and mortality. The aim of this systematic review was to focus on specific effects of resistance exercise (RE) in the adjuvant therapy and rehabilitation of prostate cancer patients (PCaPs) receiving or having received androgen deprivation therapy (ADT).

METHODS

A systematic literature search focusing on relevant and peer-reviewed studies published between 1966 and September 2014, using PubMed, EMBASE, MEDLINE, SCOPUS, and Cochrane Library databases, was conducted.

RESULTS

The majority of studies demonstrated RE as an effective and safe intervention to improve muscular strength and performance, fatigue and quality of life (QoL) in PCaPs, while there is inconclusive evidence concerning cardiovascular performance, body composition, blood lipids, bone mineral density (BMD), and immune response.

CONCLUSION

Existing evidence leads to the conclusion that RE seems to be a safe intervention in PCaPs with beneficial effects on physical performance capacity and QoL. Nevertheless, further research in this field is urgently needed to increase understanding of exercise interventions in PCaPs.