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Sexual Function Issues. Among Men With Prostate Cancer Fiona Newton. Research Team . PhD Candidate Fiona Newton, BSc. Hons. Research Supervisors Dr. Sue Burney, Ph.D., MAPS. Registered Psychologist. Director, External Programs and Lecturer, Department of Psychology School of

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Sexual Function Issues

Among Men With Prostate Cancer

Fiona Newton


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Research Team

PhD Candidate

Fiona Newton, BSc. Hons.

Research Supervisors

Dr. Sue Burney, Ph.D., MAPS. Registered Psychologist.

Director, External Programs and Lecturer, Department of Psychology School of

Psychology, Psychiatry and Psychological Medicine, Faculty of Medicine,

Nursing and Health Sciences Monash University.

Associate Professor Mark Frydenberg, MBBS, FRACS.

Clinical Associate Professor, Department of Surgery, Monash University;

Chairman, Department of Urology, Monash Medical Centre.

Dr. Jeremy Millar, FRANZCR, FAChPM.

Radiation Oncologist, The William Buckland Radiotherapy Clinic.

Statistical Consultant

Professor Kim Ng, Ph.D.

Head, School of Psychology, Psychiatry and Psychological Medicine, Faculty of

Medicine, Nursing and Health Sciences, Monash University.


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School of Psychology, Psychiatry and Psychological Medicine

Faculty of Medicine, Nursing and Health Sciences,

Department of Psychology


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Prostatic Carcinoma

  • Spans spectrum from slow growing to aggressive forms

  • Aggressive forms readily metastasise to the skeletal system

  • No definitive way to ascertainwhich types prostate cancer will spread and which will remain indolent


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Age Standardised Incidence Rates

  • With exception of basal and squamous skin cancers, prostate cancer is the leading site of new cancer diagnoses in Australian men.

  • Australian Incidence Data

  • 124.9 per 100 000 males

  • Lifetime risk (< 74 years): 1 in 11*

  • *This risk rate is similar to that of females contracting breast

  • cancer.

  • (Australian Institute of Health and Welfare, [AIHW] & Australasian Association

  • of Cancer [AACR], 2003).


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Age Standardised Mortality Rates

Australian Mortality Data

  • 2,665 deaths reported during the year 2000*

    *Second only to lung cancer related deaths

    (Australian Institute of Health and Welfare, [AIHW] & Australasian

    Association of Cancer [AACR], 2003).

    Impact of Age

  • Risk positively correlated with age

    e.g. American males between 40 – 59 years: 1 in 45

    (American Cancer Society [ACS], 2003).


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Localised Prostate Cancer Treatment Modalities

Radical Prostatectomy

  • Surgical removal of prostate gland

    nerve sparing / non-nerve sparing

    Radiotherapy

  • Used as single treatment orwith adjunctive hormonal therapy

    EBRT / Brachytherapy

    Watchful Waiting

  • Clinical monitoring of the cancer

    PSA and DRE

  • Treatment is initiated when there is evidence of disease progression


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Male Sexual Function

  • A biopsychosocial process

  • Comprised of four overlapping phases

    Sexual Drive

    Sexual Arousal + Erect Penis in potent males

    Orgasm and Ejaculation

    Refractory period

    (Seidman & Roose, 2000)


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Male Sexual Dysfunction

Male Sexual Dysfunction

  • A multidimensional construct

  • Encapsulates physical + psychological issues.

    (Brucker & Cella, 2003; National Institute of Health [NIH], 1993)

    Construct includes

  • Erectile dysfunction

  • Ejaculatory problems

  • Inability to achieve orgasm

  • Dissatisfaction with their sex life

  • Loss of interest in sex life

  • Lowered sexual desire

    (American Psychiatric Association, 1994; Incrocci et al., 2002; Schover, Friedman,

    Weiler, Heiman, & LoPiccolo, 1982)


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Definition of Impotence

Impotence

An inability to attain and sustain a penile erection that is

adequate for ‘satisfactory’ sexual intercourse.

(1993 National Institutes of Health consensus on erectile dysfunction)

Limitations of Definition

Fails to address the issue of erectile function problems

among men without a willing sexual partner

Need a broader definition that encapsulates the quality of the

erection outside the context of sexual intercourse.

(Incrocci et al., 2002)


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Definition of Erectile Dysfunction

Erectile Dysfunction

The inability of the male to obtain and maintain a rigid penis

long enough for sexual performance

  • within parameters of penetrative sex

  • outside the parameters of penetrative sex

    (Incrocci et al., 2002; Katz et al., 2002).


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DefiningHealth Related Quality of Life (HRQOL)

  • Encapsulates

  • Physical Wellbeing

  • Psychological Wellbeing

  • Social Wellbeing

  • Clinical Efficacy in Prostate Cancer Research

  • HRQOL is an essential component in the selection process of treatment modality

  • HRQOL is a more immediate endpoint than added years of survival


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Sexual Function & HRQOL

  • Sexual Function is one of the major HRQOL domains

    affected across all treatment intervention in both the short and

    longer-term.

    (Brucker & Cella, 2003; Litwin, Flanders, Pasta, Stoddard, et al.,1999)

  • Sexual dysfunction can negatively impinge on

    • self-image

    • intimate relationships with partner

    • social relationships

    • general mental health

      (De Berardis et al., 2002; Feldman, Goldstein, Hatzichriou, Krane, & McKinlay,

      1994; Huges, 2000; Ofman, 1995)


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Onset & Duration of Sexual Function Problems

  • Problems with sexual functioning often continue long after

    many of the physiological side-effects of cancer treatment

    (e.g. nausea, fatigue, and bodily pain) have resolved.

    (Braslis et al., 1995, Helgason, Adolfsoon, et al., 1997; Litwin, Hays, et al., 1995)

  • The onset and intensity of side effects differ across

    treatment modality during the first two yearsafter treatment

  • Once the fear of cancer has diminished some men feel

    dissatisfied with residual decrements in their sexual

    functioning

    (Smith, 2003)


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Sexual Function & Treatment Decisions

  • Fear of post-treatment sexual dysfunction can influence

    men in deciding which therapeutic intervention to undertake.

    (Hall, Boyd, Lippert, & Theodorescu, 2003; Schover et al., 2002; Porterfield, 1997;

    Singer et al., 1991)


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Schover et al. (2002) Retrospective Study

Background Information

N = 1,236 men treated for localised prostate cancer

Treatments: definitive radiation therapy or prostatectomy

Average time since treatment: 4.3 years

Findings Pertaining to Treatment Choice

  • 51% reported that the issue of preserving sexual function

    had influenced their choice of treatment to some degree

  • 24% stated that the desire to maintain erectile function

    was a major issue in treatment choice

  • 27% reported that the desire to maintain erectile function

    was a minor consideration


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Schover et al. (2002) Study (Cont.)

Findings Pertaining to Sexual Function

The greater majority of patients who underwent either

radiation therapy or prostatectomy still suffered from sexual

dysfunction and remained dissatisfied with their sexual

functioning more than four years after treatment.


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Key Message

  • Special attention should be given to the sexual function needs of patients throughout all phases of the management of prostate cancer

    (Incrocci et al. 2002)


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Potential Barriers to Seeking Help

Common Male Attitudes Towards Their Health

  • “People who go to the doctor are all women and children…and people who are really ill”

  • “I don’t go to the doctor because it can’t be all that serious and I’m just too busy”

  • “The wife said I had to come…[reported to GP]”

  • “I would have been back at work sooner but the wife said I hadn’t eaten for 24 hours and so shouldn’t be driving”

    Note: Taken from Bruckenwell, P., Jackson, D., Luck, M., Wallace, J., & Watts, J. (1995). The crisis in men’s health. Bath, UK: Community Health UK.


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Sexual Function among Men Treated for Localised Prostatic Cancer: A Retrospective Australian Pilot Study

(Newton, F., Burney, S., Frydenberg, M., Millar, J., & Ng, K. T.)


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Aim Cancer: A Retrospective Australian Pilot Study

To investigate whether sexual, urinary, and bowel dysfunction

influenced the HRQOL of men treated for localised prostate

cancer two or more years prior to the study.

Note: Only the descriptive data pertaining to sexual function is

presented in this seminar.


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Methodology Cancer: A Retrospective Australian Pilot Study

Study Design

  • A retrospective study

  • Convenience sampling

    HRQOL Measures Used

  • RAND 36-Item Health Survey (SF-36 v2)

  • UCLA Prostate Cancer Index (UCLA PCI)

  • Derogatis Affects Balance Scale (DABS)

    Participants also completed a study specific ‘Demographic &

    Brief Medical’ questionnaire


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Participants Cancer: A Retrospective Australian Pilot Study

Prostate Cancer Participants

  • N= 163 men treated for localised prostatic cancer at least

    two years previously

  • Age 51-80 years (M = 65.84, SD = 5.85)

    Non-Prostate Cancer Participants

  • N=102 men without a diagnosis of prostate cancer

  • Within the two years prior to study:

    -ve Prostate Specific Antigen blood test

    -ve Digital Rectal Exam

  • Age 45-77 years (M = 61.03, SD = 7.86)


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Prostate Cancer Participants Cancer: A Retrospective Australian Pilot Study


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Classification of UCLA-PCI Cancer: A Retrospective Australian Pilot StudyScores

Participant scores on the UCLA-PCI sexual and bother scales

were categorised using clinical criteria such that:

  • 75-100 denoted a better outcome

    (i.e. high levels of sexual function or low level of sexual bother)

  • 0-74 a poorer outcome

    (i.e. low levels of sexual function or high level of sexual bother)


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88% Cancer: A Retrospective Australian Pilot Study

54%

n=143

n=102


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63.8% Cancer: A Retrospective Australian Pilot Study

29.3%

n=104

n=36


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Prostate Cancer Participants Cancer: A Retrospective Australian Pilot Study


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Utilisation of Erectile Function Aids Cancer: A Retrospective Australian Pilot Study

Only 25.7% (n = 48) of prostate cancer patients reported

using erectile aids.

This finding seems counter-intuitive given the high levels of

sexual dysfunction noted among the same patient cohort.

We are investigating this issue in a prospective study that is

currently underway in Melbourne.

Unfortunately, data pertaining to the usage of sexual function

aids were not collected from participants in the comparison

group.


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A New Research Project Investigating Cancer: A Retrospective Australian Pilot Study

Sexual Function Problems

Among Men With and Without a Diagnosis of

Localised Prostate Cancer


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A Multi Site Monash University Cancer: A Retrospective Australian Pilot Study

PhD Research Project


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Study Rationale Cancer: A Retrospective Australian Pilot Study

  • Little information exists about the psychosocial impact of

    erectile dysfunction on men undergoing brachytherapy or a

    prostatectomy for localised prostate cancer.

  • Little is also known about the attitudes of the spouses /

    partners of patients toward erectile dysfunction and the use

    of erectile aids


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Study Design & Foci Cancer: A Retrospective Australian Pilot Study

Design

A prospective longitudinal study to assess the relationship

between male participant’s sexual functioning ability and

selected dimensions of their HRQOL.

Foci

  • Psychosocial impact of erectile dysfunction on men undergoing brachytherapy or a prostatectomy for localised prostate cancer.

  • Potential psychosocial problems experienced by patients with erectile dysfunction

  • Attitudes of the spouses / partners of patients toward erectile dysfunction

  • Attitudes of the spouses / partners toward the use of erectile aids


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Study Objectives Cancer: A Retrospective Australian Pilot Study

  • To examine the relationship between the sexual

    functioning of brachytherapy and prostatectomy patients and

    specific dimensions of their health-related quality of life.

  • To provide insights into the potential psychosocial

    problems experienced by patients with erectile dysfunction.


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Participants Cancer: A Retrospective Australian Pilot Study

Male Participants

  • prostatectomy patients

  • brachytherapy patients

  • comparison group

    Spouses / Partners of Male Participants

    Prostate Cancer Specialists:

  • urologists

  • radiation oncologists


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Data Collection Points Cancer: A Retrospective Australian Pilot Study

  • A maximum of 5 data collection periods

  • Male Participants

  • Data collected pre-treatment/baseline

  • then 4 ½ monthly for 18 months

  • Spouses / Partners

  • Information sought at the 9 and 18 month data collection points

  • Tools

  • Self-report questionnaires

  • Structured telephone interviews


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Male Participant Measures Cancer: A Retrospective Australian Pilot Study

Validated Measures

  • International Index Erectile Function (IIEF)

  • Sexual Bother Domain of the University California Los Angeles-Prostate Cancer Index (UCLA-PCI)

  • Psychological Index Erectile Dysfunction (PIED)

  • Sexual Self-Efficacy in Erectile Functioning (SSES-E)

  • Profile of Mood States (POMS)

    Study Specific Measures

  • Baseline demographic & medical questionnaire

  • Post-treatment medical questionnaire


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Other Participant Measures Cancer: A Retrospective Australian Pilot Study

Spouse / Partner Measures

  • Structured telephone interview (9 m and 18 m periods)

  • Study specific questionnaire (18 m period)

    Prostate Cancer Specialist Measure

  • Pencil and paper version of the structured telephone

    interview (administered once)


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Implications of Study Cancer: A Retrospective Australian Pilot Study

It is anticipated that the findings will:

  • assist medical personnel in providing psychological

    support for patients during the treatment selection and the

    post-treatment recovery phases.

  • provide information to patients and their spouses/partners

    about the possible psychosocial sequale associated with

    erectile dysfunction.


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References Cancer: A Retrospective Australian Pilot Study

American Cancer Society. (2003). Cancer Facts & Figures 2003. http://www.cancer.org/downloads/STT/CAFF2003PWSecured. pdf. Accessed January 15, 2004.

American Psychiatric Association. (1994). Diagnostic and statistical manual for mental disorders (4th ed.). Washington, DC: Author.

Australian Institute of Health and Welfare [AIHW] & Australasian Association of Cancer [AACR]. (2003). Cancer in Australia 2000.

http:// ww.aihw.gov.au/publications/can/ca00/ca00-x03.pdf. Accessed 15th January, 2004.

Braslis, K., Snata-Cruz, C., Brickman, A., Soloway, M. S. (1995). Quality of life 12 months after radical prostatectomy. British Journal of Urology, 75, 48-53.

Bruckenwell, P., Jackson, D., Luck, M., Wallace, J., & Watts, J. (1995). The crisis in men’s health. Bath, UK: Community Health UK.

Brucker, P. S., & Cella, D. (2003). Measuring self-reported sexual function in men with prostate cancer. Urology, 62, 596-606.

De Berardis, G., Franciosi, M., Belfiglio, M., Di Nardo, B., Greenfield, S., Kaplan, S., Valentini, M., & Nicolucci, A. (2002). Erectile dysfunction and quality of life in type 2 diabetic patients: A serious problem too often overlooked. Diabetics Care, 25(2), 284-291.


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Feldman, H. A., Goldstein, I., Hatzichristou, D. G., Krane, R. J., & McKinlay, J. B. (1994). Impotence and its medical and psychological correlates: Results of the Massachusetts male aging study. Journal of Urology, 151, 54-61.

Hall, J. D., Boyd, J. C., Lippert, M. C., & Theodorescu, D. (2003). Why patients choose prostatectomy or brachytherapy for localized prostate cancer: Results of a descriptive study. Urology, 61, 402-407.

Helgason, A. R., Adolfsoon, J., Dickman, P., Arver, S., Fredrikson, M., & Steinbeck, G. (1997). Factors associated with waning sexual function among elderly men and prostate cancer patients. Journal of Urology, 158, 155-159.

Huges, M. K. (2000). Sexuality and the cancer survivor: A silent coexistence. Cancer Nursing, 23(6), 477-482.

Incrocci, L., Slob, A. K., & Levendag, P. C. (2002). Sexual (dys)function after radiotherapy for prostate cancer: A review. Int. J. Radiation Oncology Biol. Phys, 52(3), 681-693.

Katz, R., Salomon, L., Hoznek, A., De La Taille, A., Vordos, D., Cicco, A., Chopin, D., & Abbou, C. C. (2002). Patient reported sexual function following laparoscopic radical prostatectomy. Journal of Urology, 168, 2078-2082.


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Litwin, M. S., Flanders, S. C., Pasta, D. J., Stoddard, M. L., Lubeck, D. P., & Henning, J. M. (1999). Sexual function and bother after radical prostatectomy or radiation for prostate cancer: Multivariate quality-of-life analysis from CaPSURE-Cancer of the Prostate Strategic Urologic Research Endeavor. Urology, 54, 503-508. Retrieved January 7, 2002 from Science Direct database.

Litwin, M. S., Hays, R. D., Fink, A., Ganz, P. A., Leake, B., Leach, G. E., & Brook, R. H. (1995). Quality-of-life outcomes in men treated for localized prostate cancer. JAMA, 273(2), 129-135.

National Institute of Health [NIH]. (1993). National Institute of Health consensus conference. Impotence. JAMA, 270(1), 83-90.

Ofman, U. S. (1995). Sexual quality of life in men with prostate cancer. Cancer, 75, 1949-1953. Retrieved July 20, 2002 from Wiley Interscience database.

Porterfield, H.A. (1997). Perspectives on prostate cancer treatment: Awareness, attitudes, and relationships. Urology, 49(supplement 3A), 102-103.

Schover, L. R., Fouladi, R. T., Warneke, C. L., Neese, L., Klein, E. A., Zippe, C., & Kupelian, P. A. (2002). Defining sexual outcomes after treatment for localized prostate carcinoma. Cancer, 95, 1773-1785.


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Schover, L. R., Friedman, J. M., Weiler, S. J., Heiman, J. R., & LoPiccolo, J. (1982). Multiaxial problem-orientated system for sexual dysfunctions: An alternative to DSM III. Archives of General Psychiatry, 39, 614-619.

Seidman, S. N., & Roose, S. P. (2000). The relationship between depression and erectile dysfunction. Current Psychiatry Reports, 2, 201-205.

Singer, P. A., Tasch, E. S., Stocking, C., Rubin, S., Siegler, M., & Weichselbaum, R. (1991). Sex or survival: Trade-offs between quality and quantity of life. Journal of Clinical Oncology, 9(2), 328-334.

Smith, J. A. (2003). Editorial. Sexual function after radical prostatectomy. Journal of Urology, 169, 1465.


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