A Non-Randomized Comparison of Online and In-Person Formats of the Canadian Androgen Deprivation Therapy Educational Program: Impacts on Side Effects, Bother, and Self-Efficacy

Although Androgen Deprivation Therapy (ADT) is effective in controlling prostate cancer (PCa) and increasing survival, it is associated with a myriad of side effects that cause significant morbidity. Previous research has shown that PCa patients starting on ADT are neither fully informed nor well-equipped to manage the breadth of ADT's side effects. The ADT Educational Program (a 1.5 h interactive class plus a book) was developed as an evidence-based resource for patients dealing with ADT. Our aim here was to compare the efficacy of an online version of the class with a previously assessed in-person version of the class. Using mixed MANOVAs within a non-randomized comparison design, we assessed: (1) changes in patients' experiences of self-efficacy to manage and bother associated with side effects approximately 10 weeks after attending a class, and (2) potential differences in these variables between online and in-person class formats. Side effect bother decreased from pre- to post-class but did not differ between in-person (n = 94) and online (n = 137) class cohorts. While self-efficacy to manage side effects was slightly higher post-class in both cohorts, the increase was not statistically significant. Average self-efficacy ratings were significantly higher among in-person versus online class participants (p < 0.05; ηp2 = 0.128). Both online and in-person classes are associated with a significant reduction in the severity of side effect bother reported by PCa patients, suggesting non-inferiority of online versus in-person formats. Online classes offer greater accessibility to the program for patients outside the reach of in-person classes, increasing the availability of the program to more PCa patients and family members across Canada.

Hormones and visual attention to sexual stimuli in older men: an exploratory investigation

BACKGROUND

Testosterone is associated with sexual desire and performance in men, but little is known about cognitive mechanisms underlying this relationship. Even less is known about the influence of estradiol, despite its production from testosterone, and high receptor density in brain regions related to male sexual behavior.

METHOD

We used eye-tracking to compare men's visual attention to images of fully clothed (i.e. neutral) and minimally clothed (i.e. sexy) models in three groups: androgen-deprived (n = 6) and not androgen-deprived with prostate cancer (n = 11), and healthy controls (n = 7). We also assessed effects of serum testosterone, estradiol, and sex hormone-binding globulin levels.

RESULTS

We found no group effect for fixations to sexy compared to neutral images, and no influence of testosterone on either total fixations, or proportion of fixations to sexy images. In contrast, we found that sex hormone binding globulin positively predicted total fixations, and estradiol positively predicted proportion of total fixations on sexy images--regardless of androgen treatment status.

CONCLUSION

Our results suggest that visual attention to sexual stimuli in men may be significantly affected by hormones. This has potential implications for clinical populations that experience sexual side effects, such as prostate cancer patients on androgen deprivation therapy.

How Are Patients With Prostate Cancer Managing Androgen Deprivation Therapy Side Effects?

BACKGROUND

Androgen deprivation therapy (ADT) for prostate cancer has numerous side effects. Clinical guidelines for side effect management exist; however, these are not always integrated into routine practice. What remains undocumented and therefore the objective of this study, is to describe patients' willingness to employ established strategies.

PATIENTS AND METHODS

Study participants were 91 men who had attended an educational program (ie, attend a class plus read a book), designed to prepare patients for managing ADT side effects. Three months later, patients completed the ADT Management Strategies Inventory, to determine use of strategies. Descriptive analyses were conducted.

RESULTS

At the time of class attendance, the average ADT duration was 133 days. Patient preferences for a variety of strategies for each side effect are presented. Highlights include: a high degree (> 65%) of patients using or willing to use exercise to manage medical risks and physical side effects. Forty percent of patients continued to engage in non-penetrative sexual activities, despite reduced sexual desire and erectile dysfunction.

CONCLUSIONS

When educated about options, patients are willing to use a wide array of ADT management strategies. Consequently, health care providers should ensure that patients know about side effects and how to manage them. Exercise appears to be the single best strategy to encourage, because it is helpful in managing many side effects (eg, weight gain, muscle weakening, fatigue) and reducing medical risks of ADT (eg, cardiovascular disease, type II diabetes, and osteoporosis). A general trend was patient's preference for behavioral and lifestyle strategies over pharmacologic interventions.

The Prostate Cancer Rehabilitation Clinic: a biopsychosocial clinic for sexual dysfunction after radical prostatectomy

Purpose

The most prevalent intervention for localized prostate cancer (pca) is radical prostatectomy (rp), which has a 10-year relative survival rate of more than 90%. The improved survival rate has led to a focus on reducing the burden of treatment-related morbidity and improving the patient and partner survivorship experience. Post-rp sexual dysfunction (sdf) has received significant attention, given its substantial effect on patient and partner health-related quality of life. Accordingly, there is a need for sdf treatment to be a fundamental component of pca survivorship programming.

Methods

Most research about the treatment of post-rp sdf involves biomedical interventions for erectile dysfunction (ed). Although findings support the effectiveness of pro-erectile agents and devices, most patients discontinue use of such aids within 1 year after their rp. Because side effects of pro-erectile treatment have proved to be inadequate in explaining the gap between efficacy and ongoing use, current research focuses on a biopsychosocial perspective of ed. Unfortunately, there is a dearth of literature describing the components of a biopsychosocial program designed for the post-rp population and their partners.

Results

In this paper, we detail the development of the Prostate Cancer Rehabilitation Clinic (pcrc), which emphasizes multidisciplinary intervention teams, active participation by the partner, and a broad-spectrum medical, psychological, and interpersonal approach.

Conclusions

The goal of the pcrc is to help patients and their partners achieve optimal sexual health and couple intimacy after rp, and to help design cost-effective and beneficial rehabilitation programs.

Effect of Increasing Levels of Web-Based Behavioral Support on Changes in Physical Activity, Diet, and Symptoms in Men With Prostate Cancer: Protocol for a Randomized Controlled Trial

Background

More than 3.1 million men in the United States are prostate cancer survivors. These men may improve their physical function, quality of life, and potentially their prognosis by adopting healthier lifestyle habits. The internet provides a scalable mechanism to deliver advice and support about improving physical activity and dietary habits, but the feasibility and acceptability of a Web-based lifestyle intervention and the dose of support necessary to improve health behaviors are not yet known.

Objectives

The Community of Wellness is a Web-based intervention focused on supporting exercise and healthy dietary practices for men with prostate cancer. The objectives of this study were to determine the feasibility, acceptability, and preliminary efficacy of the Community of Wellness Web portal among prostate cancer survivors by conducting a randomized controlled trial (RCT) comparing 4 levels of additive Web-based content and interaction with participants: Level 1 (Teaching; Control), Level 2 (Teaching + Tailoring), Level 3 (Teaching + Tailoring + Technology), and Level 4 (Teaching + Tailoring + Technology + Touch).

Methods

This is a single-blinded RCT comparing 3 levels of behavioral support within the Community of Wellness Web portal intervention (Levels 2 to 4) with each other and with the control condition (Level 1). The control condition receives general static Web-based educational information only on physical activity and dietary habits, self-efficacy for behavior change, motivation for physical activity, and changes in anxiety and treatment-related side effects. We will enroll and randomize 200 men with prostate cancer equally to 4 levels of the Community of Wellness Web-based intervention for 3 months (50 men per level). Surveys will be completed by self-report at baseline, 3 months (immediately postintervention), and 6 months (3 months postintervention). Feasibility and acceptability will be assessed by enrollment statistics, Web-based usage metrics, and surveys at the 3-month time point. We will also conduct focus groups after the postintervention follow-up assessment in a sample of enrolled participants to evaluate elements of usability and acceptability that cannot be obtained via surveys.

Results

Enrollment is ongoing, with 124 enrolled. Study completion (6-month follow-up) is expected by July 2019.

Conclusions

The goal of the study is to identify the level of support that is feasible, acceptable, promotes behavior change, and improves health in men with prostate cancer to inform future efforts to scale the program for broader reach.

Trial Registration

ClinicalTrials.gov NCT03406013; https://clinicaltrials.gov/ct2/show/NCT03406013 (Archived by WebCite at http://www.webcitation.org/73YpDIoTX).

International Registered Report Identifier (IRRID)

PRR1-10.2196/11257

Focal MRI-Guided Salvage High-Dose-Rate Brachytherapy in Patients With Radiorecurrent Prostate Cancer

Introduction:

Whole-gland salvage treatment of radiorecurrent prostate cancer has a high rate of severe toxicity. The standard of care in case of a biochemical recurrence is androgen deprivation treatment, which is associated with morbidity and negative effects on quality of life. A salvage treatment with acceptable toxicity might postpone the start of androgen deprivation treatment, might have a positive influence on the patients’ quality of life, and might even be curative. Here, toxicity and biochemical outcome are described after magnetic resonance imaging–guided focal salvage high-dose-rate brachytherapy in patients with radiorecurrent prostate cancer.

Materials and Methods:

Seventeen patients with pathologically proven locally recurrent prostate cancer were treated with focal high-dose-rate brachytherapy in a single 19-Gy fraction using magnetic resonance imaging for treatment guidance. Primary radiotherapy consisted of external beam radiotherapy or low-dose-rate brachytherapy. Tumors were delineated with Ga-68–prostate-specific membrane antigen or F18-choline positron emission tomography in combination with multiparametric magnetic resonance imaging. All patients had a prostate-specific antigen level of less than 10 ng/mL at the time of recurrence and a prostate-specific antigen doubling time of ≥12 months. Toxicity was measured by using the Common Terminology Criteria for Adverse Events version 4.

Results:

Eight of 17 patients had follow-up interval of at least 1 year. At a median follow-up interval of 10 months (range 3-40 months), 1 patient experienced a biochemical recurrence according to the Phoenix criteria, and prostate-specific membrane antigen testing revealed that this was due to a distant nodal metastasis. One patient had a grade 3 urethral stricture at 2 years after treatment.

Conclusion:

Focal salvage high-dose-rate brachytherapy in patients with radiorecurrent prostate cancer showed grade 3 toxicity in 1 of 17 patients and a distant nodal metastasis in another patient. Whether this treatment option leads to cure in a subset of patients or whether it can successfully postpone androgen deprivation treatment needs further investigation.

Androgen Deprivation Alters Attention to Sexually Provocative Visual Stimuli in Elderly Men

INTRODUCTION

Testosterone is known to regulate male sexual interest, but the exact way that androgens influence men's sexual cognition remains unclear.

AIM

To investigate the influence of androgen deprivation (AD) on visual responses to sexually suggestive stimuli in men treated for prostate cancer with AD therapy.

METHODS

Patients with AD-treated prostate cancer, patients with prostate cancer not on AD therapy, and age-matched healthy control participants were exposed to images of male and female runway models fully or minimally clothed. Eye tracking was used to compare looking behavior among groups.

MAIN OUTCOME MEASURES

Proportion of fixations on fully clothed vs minimally clothed models and proportion of fixations on target areas of interest (ie, legs, chest, pelvis, and face) of fully clothed and minimally clothed models were analyzed and compared among groups.

RESULTS

Although men not on AD exhibited a larger proportion of fixations on the minimally clothed compared with the fully clothed images, there was no difference between the 2 image types for men on AD. This was true regardless of whether the images depicted male or female models. Groups did not differ in their fixations to target areas of interest.

CONCLUSION

These results suggest that testosterone can influence men's visual attention to sexual stimuli; specifically, AD can attenuate the time spent fixated on sexualized targets. Palmer-Hague JL, Tsang V, Skead C, et al. Androgen Deprivation Alters Attention to Sexually Provocative Visual Stimuli in Elderly Men. Sex Med 2017;5:e245-e254.

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.

What do urologists think patients need to know when starting on androgen deprivation therapy? The perspective from Canada versus countries with lower gross domestic product

Background

Androgen deprivation therapy (ADT) side effects are numerous and negatively impact prostate cancer patients’ quality of life. There is considerable discrepancy though among Canadian urologists regarding what ADT side effects and side effect management strategies. Little is known about global differences in ADT patient education.

Methods

International respondents were recruited via online posting and at an international urology conference. Hypotheses suggest that economic and cultural differences influence patient education practices; therefore, international respondents were divided into 3 categories (high, medium, and low gross domestic product).

Results

No differences were found between responses from Canadian urologists and high GDP countries. Compared to responses from low GDP countries, Canadian urologists are more likely to endorse informing patients about: osteoporosis, loss of muscle mass, weight gain, fatigue/sleep disturbance, relationship changes, cognitive changes, and loss of body hair. Infertility was the only side effect more often disclosed by urologists in low GDP counties. Recommended management strategies for hot flashes are more likely to be pharmaceutical in Canada, and behavioral in low GDP countries. Management strategies for gynecomastia are emphasized more in low GDP countries. Physical exercise is endorsed consistently more often by Canadian urologists.

Conclusions

ADT educational practices vary greatly between Canada and lower GDP countries. Factors that could contribute to differences include economics (e.g., ADT drug costs), differences in side effect presentation due to different ADT drugs used, racial differences in perceived side effect burden, disease status at ADT commencement, and cultural differences in patient-physician shared-decision making.