Health Disparities of Sexual Minority Patients Following Prostate Cancer Treatment: Results From the Restore-2 Study

Clinical considerations for sexual and gender minorities with prostate cancer

At every stage of the cancer continuum, the management of sexual and gender minorities with prostate cancer requires a thoughtful and multidisciplinary approach. For example, it is important to recognize that receptive anal intercourse, common among sexual minority men-i.e. gay and bisexual men-can potentially elevate prostate-specific antigen (PSA) leading to overdiagnosis and overtreatment. Additionally, it is important to understand that sexual minority men with prostate cancer might engage in insertive and/or receptive anal intercourse, as opposed to insertive vaginal intercourse, requiring a treatment conversation that expands beyond the usual discussion of sexual health in prostate cancer patients. For gender minorities-i.e. transgender women or trans feminine individuals (those recorded male at birth with feminine gender identities)-it is important to consider gender affirming hormones and pelvic surgeries as they can cause diagnostic and treatment challenges, including PSA suppression, more aggressive disease, and anatomical changes. Furthermore, it is essential to recognize that gender minorities are a diverse cohort and may or may not be on gender affirming hormone therapy and may or may not have received or intend to receive pelvic affirming surgery. In this seminar article, we highlight considerations for personalized management of prostate cancer in sexual and gender minorities to improve care for this understudied cohort and enhance health equity.

Does sexual rehabilitation work for gay and bisexual prostate cancer patients? Acceptability, feasibility, and efficacy results from the Restore-2 randomized controlled trial

PURPOSE

Sexual minority prostate cancer patients have worse health-related quality of life outcomes than heterosexual patients. We conducted the first study to test whether sexual and urinary rehabilitation tailored for sexual minority patients was acceptable, feasible, and efficacious at improving their sexual and urinary function.

METHODS

Restore-2 was a 24-month randomized controlled trial of an online biopsychobehavioral rehabilitation study for sexual minority men treated for prostate cancer experiencing sexual and/or urinary problems. Participants were 401 US sexual minority men treated for prostate cancer and experiencing sexual and/or urinary problems at baseline. Intervention components included phosphodiesterase-5 inhibitors, sexual aids, a pelvic floor exercise regimen and video, a guide to good gay sex following treatment, and coaching. Quality of life assessments were completed at baseline, 3, 6, 12, 18, and 24 months.

RESULTS

We confirmed good acceptability and feasibility, but only minimal improvement was observed over time and no differences were found between treatment and control arms.

CONCLUSIONS

We found no evidence that the intervention improved sexual or urinary outcomes for participants. However, we confirmed excellent acceptability and feasibility for a sexual rehabilitation program tailored to sexual minority participants. In addition, participants reported enduring usage and acceptability of sexual aids (including vacuum pump, anal dilators, and penile constriction rings) as well as masturbation and pelvic floor exercises to accommodate their sexual challenges.

IMPLICATIONS FOR CANCER SURVIVORS

Sexual "accommodation," rather than "rehabilitation," may be a more accurate and realistic goal for this population. Patients should be provided sexual aids to help accommodate their sexual and urinary challenges.

TRIAL REGISTRATION

This study was retrospectively registered with ClinicalTrials.gov, study number: NCT03923582; date: 22/04/2019.

Military service and health-related quality of life among gay and bisexual prostate cancer survivors: Results from the -2 study

INTRODUCTION

There are notable disparities in health-related quality of life (HRQOL) between gay and bisexual men (GBM) and heterosexual patients with prostate cancer (PCa); however, the role of past military service is unclear. This study examines HRQOL differences in GBM PCa survivors based on reported military service history.

METHODS

We used data from the 24-month follow-up survey of the Restore-2 study, a clinical trial which evaluated a rehabilitation programme for GBM PCa survivors. PCa HRQOL was assessed using the Expanded Prostate Cancer Index Composite (EPIC-50) and the Functional Assessment of Cancer Treatment-Prostate (FACT-P). Mental health quality of life was assessed using the Brief Symptom Inventory-18 (BSI-18) scale, while sexual functioning was measured using the Sexual Minorities and Prostate Cancer Scale (SMACS). Multivariable linear regression was used to estimate unadjusted and adjusted mean differences in HRQOL between GBM with and without a reported history of military service.

RESULTS

In this cross-sectional study of 351 GBM PCa survivors, 47 (13.4%) reported a history of US military service. After adjusting for covariates, participants who reported a history of military service (compared with those with no military service) had clinically better scores on the FACT-P physical, social and emotional well-being domains, as well as higher total FACT-General, EPIC urinary bother and hormonal function scores. Additionally, men with a history of military service reported significantly fewer sexual problems, more sexual confidence and less urinary incontinence in sex.

CONCLUSION

This exploratory study provides the first evidence that GBM PCa survivors with a military background may have clinically better outcomes than those without military service. Potential reasons may include the structured support and healthcare access associated with military service, fostering resilience and well-being. These findings underscore the need for further research to elucidate how military service influences PCa HRQOL.

Preliminary Psychometric Evaluation of Novel Measures of Therapist Practice Related to LGBTQ+ Clients

BACKGROUND

Culturally competent and equitable mental healthcare for LGBTQ+ people is critical for addressing mental health inequities for this population. Tools to assess therapists' practice with LGBTQ+ clients are needed for research and clinical efforts related to mental healthcare equity goals.

METHODS

We conducted a preliminary assessment of the reliability and validity of a novel 28-item self-report measure assessing therapist practice with LGBTQ+ clients. We examined the construct validity using factor analyses, the convergent and criterion validity using intercorrelations with LGBTQ-affirming knowledge, self-efficacy, and attitudes, and the internal consistency using Cronbach alpha.

RESULTS

Our overall total LGBTQ+ practice measure demonstrated excellent internal consistency (Cronbach's alpha = 0.91) and was strongly associated with LGBTQ+ knowledge (rho = 0.377), self-efficacy (rho = 0.633), and LGBTQ+ attitudes (rho = 0.305). We also identified two subscales: "Commitment to Continued Learning" and "Affirmative Practices", which demonstrated similarly strong internal consistency and tests of validity.

CONCLUSIONS

Our novel measure of overall LGBTQ+ practice, including two subscales, demonstrated strong reliability and validity. These findings have important implications for practice and research in mental healthcare for LGBTQ+ clients. Future research exploring these measures in relationship to mental healthcare outcomes is recommended.

Sexual health and treatment-related sexual dysfunction in sexual and gender minorities with prostate cancer

Prostate cancer treatment has substantial effects on sexual health and function. Sexual function is a vital aspect of human health and a critical component of cancer survivorship, and understanding the potential effects of different treatment modalities on sexual health is crucial. Existing research has extensively described the effects of treatment on male erectile tissues necessary for heterosexual intercourse; however, evidence regarding their effects on sexual health and function in sexual and gender minority populations is minimal. These groups include sexual minority - gay and bisexual - men, and transgender women or trans feminine people in general. Such unique effects in these groups might include altered sexual function in relation to receptive anal and neovaginal intercourse and changes to patients' role-in-sex. Sexual dysfunctions following prostate cancer treatment affecting quality of life in sexual minority men include climacturia, anejaculation, decreased penile length, erectile dysfunction, and problematic receptive anal intercourse, including anodyspareunia and altered pleasurable sensation. Notably, clinical trials investigating sexual outcomes after prostate cancer treatment do not collect sexual orientation and gender identity demographic data or outcomes specific to members of these populations, which perpetuates the uncertainty regarding optimal management. Providing clinicians with a solid evidence base is essential to communicate recommendations and tailor interventions for sexual and gender minority patients with prostate cancer.

"Ultimately, You Realize You're on Your Own": The Impact of Prostate Cancer on Gay and Bisexual Men Couples

An estimated one in three gay and bisexual (GB) male couples receive a prostate cancer (PCa) diagnosis over their life course with limited understanding of the impacts on their relationships. Psychological distress related to PCa diagnosis and treatment-related side effects have been shown to disrupt established GB partnership dynamics. Communication barriers often develop within GB relationships affected by PCa, further exacerbating couple tensions, isolating partners, and lowering quality of life for both patients and partners. In order to elaborate on these phenomena following a PCa diagnosis, we conducted focus group discussions with GB men in relationships. Men were recruited nationally through PCa support groups, and after completing consent procedures, they were invited to one of two focus group discussions conducted through video conference. Topics discussed included the diagnosis and medical decision making pertaining to PCa; healthcare provider experiences; the emotional, physical, and sexual impact of PCa diagnosis and treatment; sources of support and appraisal of resources; and partner involvement and communication. There were twelve GB men who participated in focus group discussions that were audio-recorded and transcribed, and analyzed using a thematic approach. GB couple experiences with PCa during and after treatment choice and recovery identified common patient-provider communication barriers. In particular, GB men reported difficulties in disclosing their sexuality and relationship to their providers, limiting conversations about treatment choice and partner engagement in care. Both patients and partners experienced times of being alone after treatment, either by choice or to give space to their partner. However, partners often did not explicitly discuss their preferences for being alone or together, which resulted in partners' disengagement in their relationship and the prostate cancer healthcare process. This disengagement could blunt the notable PCa survival benefits of partnership for GB men.

Prostate Cancer in Sexual Minorities: Epidemiology, Screening and Diagnosis, Treatment, and Quality of Life

Prostate cancer has the highest incidence among all cancers in men. Sexual minorities, including gay and bisexual men, as well as transgender, were previously a "hidden population" that experienced prostate cancer. Although there continues to remain a paucity of data in this population, analyses from studies do not reveal whether this population is more likely to endure prostate cancer. Nonetheless, several qualitative and quantitative studies have established worse quality-of-life outcomes for sexual minorities following prostate cancer treatment. Increased awareness of this previously "hidden population" among healthcare workers, as well as more research, is warranted to gain further understanding on potential disparities faced by this growing population.

LGBTQI cancer patients' quality of life and distress: A comparison by gender, sexuality, age, cancer type and geographical remoteness

Background

There is growing acknowledgement of the psycho-social vulnerability of lesbian, gay, bisexual, transgender, queer and/or intersex (LGBTQI) people with cancer. The majority of research to date has focused on cisgender adults with breast or prostate cancer.

Study Aim

This study examined psycho-social factors associated with distress and quality of life for LGBTQI cancer patients and survivors, across a range of sexualities and gender identities, intersex status, tumor types, ages and urban/rural/remote location using an intersectional theoretical framework.

Method

430 LGBTQI people with cancer completed an online survey, measuring distress, quality of life (QOL), and a range of psycho-social variables. Participants included 216 (50.2%) cisgender women, 145 (33.7%) cisgender men, and 63 (14.7%) transgender and gender diverse (TGD) people. Thirty-one (7.2%) participants reported intersex variation and 90 (20%) were adolescents or young adults (AYA), aged 15-39. The majority lived in urban areas (54.4%) and identified as lesbian, gay or bisexual (73.7%), with 10.9% identifying as bisexual, and 10.5% as queer, including reproductive (32.4%) and non-reproductive (67.6%) cancers.

Results

Forty-one percent of participants reported high or very high distress levels, 3-6 times higher than previous non-LGBTQI cancer studies. Higher rates of distress and lower QOL were identified in TGD compared to cisgender people, AYAs compared to older people, those who identify as bisexual or queer, compared to those who identify as lesbian, gay or homosexual, and those who live in rural or regional areas, compared to urban areas. Elevated distress and lower QOL was associated with greater minority stress (discrimination in life and in cancer care, discomfort being LGBTQI, lower outness) and lower social support, in these subgroups. There were no differences between reproductive and non-reproductive cancers. For the whole sample, distress and poor QOL were associated with physical and sexual concerns, the impact of cancer on gender and LGBTQI identities, minority stress, and lack of social support.

Conclusion

LGBTQI people with cancer are at high risk of distress and impaired QOL. Research and oncology healthcare practice needs to recognize the diversity of LGBTQI communities, and the ways in which minority stress and lack of social support may affect wellbeing.