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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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slide1

Sexual Function Issues

Among Men With Prostate Cancer

Fiona Newton

slide2

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.

slide3

School of Psychology, Psychiatry and Psychological Medicine

Faculty of Medicine, Nursing and Health Sciences,

Department of Psychology

slide4

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
slide5

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).
slide6

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).

slide7

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
slide8

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)

slide9

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)

slide10

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)

slide11

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).

slide12

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
slide13

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)

slide14

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)

slide15

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)

slide16

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

slide17

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.

slide18

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)

slide19

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.

slide20

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.)

slide21

Aim

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.

slide22

Methodology

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

slide23

Participants

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)
slide25

Classification of UCLA-PCIScores

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)

slide26

88%

54%

n=143

n=102

slide27

63.8%

29.3%

n=104

n=36

slide29

Utilisation of Erectile Function Aids

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.

slide30

A New Research Project Investigating

Sexual Function Problems

Among Men With and Without a Diagnosis of

Localised Prostate Cancer

slide32

Study Rationale

  • 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

slide33

Study Design & Foci

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
slide34

Study Objectives

  • 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.

slide35

Participants

Male Participants

  • prostatectomy patients
  • brachytherapy patients
  • comparison group

Spouses / Partners of Male Participants

Prostate Cancer Specialists:

  • urologists
  • radiation oncologists
slide36

Data Collection Points

  • 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
slide37

Male Participant Measures

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
slide38

Other Participant Measures

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)

slide39

Implications of 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.

slide40

References

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.

slide41
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.

slide42
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.

slide43
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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