Purpose To determine which health care provider and what timing is considered most suitable to discuss sexual and relational changes after prostate cancer treatment according to the point of view of men and their partners. Methods A cross-sectional survey was conducted among men diagnosed with prostate cancer or treated after active surveillance, who received laparoscopic radical prostatectomy, brachytherapy, intensity-modulated radiotherapy, and/ or hormonal therapy. If applicable, partners were included as well. Results In this survey, 253 men and 174 partners participated. Mean age of participating men was 69.3 years (SD 6.9, range 45–89). The majority (77.8%) was married and average length of relationship was 40.3 years (SD 14.1, range 2–64). Out of 250 men, 80.5% suffered from moderate to severe erectile dysfunction. Half of them (50.2%, n = 101) was treated for erectile dysfunction and great part was partially (30.7%, n = 31) up to not satisfied (25.7%, n = 26). Half of the partners (50.6%, n = 81) found it difficult to cope with sexual changes. A standard consultation with a urologist-sexologist to discuss altered sexuality is considered preferable by 74.7% (n = 183). Three months after treatment was the most suitable timing according to 47.6% (n =49). Conclusions During follow-up consultations, little attention is paid to the impact of treatment-induced sexual dys- function on the relationship of men with prostate cancer and their partners. A standard consultation with a urologist- sexologist 3 months after treatment to discuss sexual and relational issues is considered as most preferable. . . . . . Keywords Sexual dysfunction Erectile dysfunction Prostate cancer Partners Sexual health care Sexual counseling Background Prostate cancer (PCa) is the most common cancer among men in the Western world, with approximately 11.000 cases diag- * Lorena A. Grondhuis Palacios nosed in the Netherlands each year . Increased public L.A.Grondhuis_Palacios@lumc.nl awareness and prostate-specific antigen testing partially ex- plain the raise of PCa detection . Treatment method is pri- Department of Urology, Leiden University Medical Center, PO Box marily selected according to disease stage and where applica- 9600, 2300 WB Leiden, The Netherlands ble, to the patient’s preference. Early detection and improve- Department of Medical and Clinical Psychology, Tilburg University, ment of therapies have led to an increase in survival outcomes, PO Box 90153, 5000 LE Tilburg, The Netherlands meaning PCa therapy may be curative or life prolonging. Research Center of Nursing, Saxion University of Applied Sciences, Nevertheless, can PCa treatment affect quality of life (QoL) PO Box 70000, 7500 KB Enschede, The Netherlands majorly . Among other treatment-related side effects, such Department of Psychology, Education & Child Studies, Erasmus as incontinence of urine, sexual dysfunction (SD) is one of the University Rotterdam, PO Box 1738, 3000 most prevalent consequences of PCa treatment with erectile DR Rotterdam, The Netherlands dysfunction (ED) as primary complaint . Five years after Department of Medical Statistics, Leiden University Medical Center, PO Box 9600, 2300 WB Leiden, The Netherlands 4170 Support Care Cancer (2018) 26:4169–4176 diagnosis, 79% of men treated with radical prostatectomy 2015. Patients under active surveillance (AS) or treated (RP) experience ED and 64% of men treated with radiothera- (after AS) with laparoscopic radical prostatectomy py . Seventy-two percent of men treated with RP experi- (LRP), brachytherapy (BT), intensity-modulated radio- ence significant loss of QoL due to ED . At present, com- therapy (IMRT) and/or hormonal therapy (HT) were in- mon ED treatment options consist of PDE5 inhibitors, intra- cluded. Additional patient data obtained from the oncolo- urethral medications, intracavernous injections, vacuum ther- gy registration included age, PCa staging and type of ob- apy and penile protheses . Despite PDE5 inhibitors are tained treatment(s). Using the registration of the munici- considered as first-line treatment, alprostadil or tadalafil in pal personal records database, patients who deceased or comparison to placebo does not always show significant im- moved abroad were refined. This process led to a total of provement in RP-related ED [8, 9]. Accordingly, it is impor- 590 eligible men. In June 2015, an information letter and tant to initiate penile rehabilitation after PCa treatment as soon a consent form for patient and/or their partner were sent as possible in order to encounter which treatment suits best. by mail. Reason to not participate, could be indicated on Alterations in sexual health do not only affect men, but the consent form. With affirmative consent, questionnaires their partners as well. Partners report higher levels of anx- were sent in separate, post-paid envelopes to warranty iety, not only as a result of coping with the disease, but privacy of patients and their partners. also due to changes in their sexual relationship . Thirty-eight percent stated to be unsatisfied with the sex- Materials: questionnaire design ual relationship with their partner . Moreover, changes in a sexual relationship can negatively affect the overall The questionnaires were designed by the authors, based on the relationship . A study performed among couples fac- study aim and review of literature. The questionnaire devel- ing PCa showed that both men and partners suffered from oped for patients treated after diagnosis or after AS, consisted the impact of the treatment-related side effects on their of 47 items assessing topics such as socio-demographic fac- psychological wellbeing as well as on their romantic rela- tors, sexual function (SF) before and after treatment, experi- tionship . ence and satisfaction regarding current sexual health care and Nevertheless, limited research has been performed to in- desired sexual health management. A similar questionnaire vestigate adequate management of sexual side effects of PCa was developed for patients who were under AS where ques- treatment . There are limited opportunities for men and tions around received treatment were withdrawn. The ques- partners to address the impact of the treatment-related side tionnaire developed for partners consisted of 14 items includ- effects on their sexual health during follow-up consultations, ing socio-demographic factors, sexuality throughout their since priority is given to disease control . Consequently, partner’s treatment and whether counseling in sexuality and/ psychological wellbeing of men and their partners may be or relational matters would be appreciated. impaired, leading to a decrease in QoL . In February 2015, a pilot test was performed among five Hence, we aimed to evaluate the current situation of sexual members of the Dutch PCa Foundation to improve suitability health care and satisfaction of treatment options provided to and comprehensiveness of the questionnaire. Adjustments men experiencing treatment-related SD. Furthermore, we were made to the content, phrasing of questions and additions aimed to investigate which health care provider is preferred to answer possibilities were performed. Due to an incorrect and what timing is considered as most suitable for sexual question-answer combination with regard to the question what counseling after PCa treatment according to the point of view timing was found to be suitable for sexual counseling, part of of men and their partners. the answers lapsed. Responses from the participants who had interpreted the question correctly, were described in the results. Methods Statistical analysis Study population Quantitative data were analyzed using IBM SPSS Statistics, For this cross-sectional study, patients were recruited version 23.0. Descriptive statistics were used to analyze de- throughout the oncology registration of Leiden mographic and clinical variables. Numerical variables were University Medical Center. Based on the hospital’s decla- described with mean (SD), categorical variables with number ration code for PCa, a list was obtained with patients (%). Associations between preferred health care provider and diagnosed with or treated for PCa between 2013 and clinical data were analyzed using the Pearson’s Chi-Square 2015. Subsequently, the list also comprised patients who test. Associations in clinical data were calculated using the were diagnosed with or treated for PCa before 2013 and McNemar test. Two-sided p values < 0.05 were considered had received an (additional) treatment between 2013 and statistically significant. Support Care Cancer (2018) 26:4169–4176 4171 Table 1 Demographic and clinical characteristics of participating men Ethics n (%) The protocol for this study was approved by the Institutional Review Board at Leiden University Medical Center in June Age (years) 2015. Consent was essential, since it concerned a survey with Mean 69.3 (SD 6.9, range 45–89) 253 (100.0) sensitive questions and confidentiality of the participants had Occupation to be guaranteed. Employed 47 (18.6) Unemployed 7 (2.8) Retired, employed 69 (27.3) Retired, unemployed 129 (50.9) Results Unknown 1 (0.4) Education A total of 584 men were eligible to participate in this study (in No qualification/elementary school 16 (6.3) hindsight six men were considered ineligible to participate, Lower vocational education 65 (25.7) due to death after start of the study). Among men who did Intermediate vocational education 56 (22.1) not want to participate in the study (n = 168), most named Higher secondary education 33 (13.1) reasons were non-interest (n = 49), irrelevance regarding im- Higher education 81 (32.0) provement in this area (n = 33) and questions being too per- Unknown 2 (0.8) sonal (n = 29). A remaining group of 134 men who were Marital status approached, did not respond throughout the consent form. A Unmarried 18 (7.1) group of 29 men gave their consent, yet did not return the questionnaire. Consequently, a total of 253 men participated Married 196 (77.5) in our study. Common law 11 (4.3) Widowed 13 (5.1) Other 14 (5.5) Socio-demographic characteristics Unknown 1 (0.5) Duration of relationship (years) The average age of men was 69.3 years (SD 6.9, range 45– Mean 40.3 (SD 14.1, range 2–64) 217 (85.8) 89), the majority (78.6%, n = 198) was retired. Almost 78.0% Age at diagnosis (years) (n = 196) was married, with an average duration of the rela- Mean 66.2 years (SD 6.7, range 42–86) 253 (100) tionship of 40.3 years (SD 14.1, range 2–64). PCa was diag- TNM staging nosed at an average age of 66.2 years (SD 6.7, range 42–86) T—localized disease 232 (91.7) and most participants (91.7%, n = 232) had localized disease N—regional lymph node metastases 11 (4.3) at the time of diagnosis. IMRT combined with HT was the M—metastasized disease 8 (3.2) most common type of treatment received (28.1%, n = 71), TNM staging unknown 2 (0.8) followed by LRP (25.3%, n = 64) and IMRT (23.7%, n = Type of treatment 60). Further details on demographic and clinical characteris- Active surveillance (AS) 17 (6.7) tics are shown in Table 1. Laparoscopic radical prostatectomy (LRP) 64 (25.3) Brachytherapy (BT) 25 (9.9) Sexual function throughout treatment Intensity-modulated radiotherapy (IMRT) 60 (23.7) IMRT combined with HT 71 (28.1) Prior to treatment, 34.6% out of 250 participating men Hormonal therapy (HT) 15 (5.9) had moderate to severe ED. After treatment a significant 1 (0.4) Other difference in ED was found: 80.5% suffered from moder- ate to severe treatment-related ED (p < 0.001). Half of the Clinical diagnosis, no TNM staging available participants (50.0%, n = 124) was no longer sexually ac- Including LRP combined with IMRT (n = 5) and LRP combined with tive due to treatment and 78.2% (n = 190) reported dete- HT (n =1) riorated SF. Erectile complaints were experienced imme- Including BT combined with HT (n = 8) and IMRT combined with LRP diately after treatment mostly by men treated with LRP and HT (n =4) (93.8%, n = 60) followed by men treated with IMRT com- Pelvic lymph node dissection (n =1) bined with HT (77.9%, n =53). In Table 2,presenceof ED before and after treatment is displayed for the differ- treated with IMRT combined with HT by 62.5% (p < ent types of treatment, with the greatest increase of per- 0.001) and 53.3% (p < 0.001) respectively. centage points in men treated with LRP and in men 4172 Support Care Cancer (2018) 26:4169–4176 Table 2 Moderate to severe ED before and after treatment ED prior to treatment n (%) ED after treatment n (%) Percent difference (%) p value Type of treatment Active surveillance (AS) 5 (29.4) 6 (35.3) 5.9 NS (1.000) Laparoscopic radical prostatectomy (LRP) 20 (31.3) 60 (93.8) 62.5 < 0.001 Brachytherapy (BT) 14 (56.0) 22 (88.0) 32.0 0.021 Intensity-modulated radiotherapy (IMRT) 26 (43.3) 47 (81.0) 37.7 < 0.001 IMRT combined with HT 17 (24.6) 53 (77.9) 53.3 < 0.001 Hormonal therapy (HT) 5 (33.3) 11 (73.3) 40.0 NS (0.070) NS not significant Including LRP combined with IMRT (n = 5) and LRP combined with HT (n =1) Including BT combined with HT (n = 8) and IMRT combined with LRP and HT (n =4) McNemar test ED treatment options n = 115) mentioned these changes in intimacy have not influ- enced their romantic relationship. Participants were asked to report which types of ED treatment Regardless the fact that almost half of the partners reported options were offered by their health care provider. Out of difficulties around sexuality with their partner, 86.9% (n =93) available ED treatment options, PDE5 inhibitors were offered indicated to not be in need of additional support for sexual the most (50.0%, n = 94), followed by a single consultation to health and/or relational issues. A few partners (11.5%, n =6) discuss sexual health (12.8%, n =24), intra-urethral medica- indicated that a long-term relationship should be capable of tions (11.2%, n = 21), intracavernosal injections (6.9%, n = overcoming these kind of obstacles, and although a sexual 13), and vacuum therapy (5.4%, n = 10). One out of seven relationship is no longer existent, being intimate in another men (14.4%, n = 27) indicated their health provider never of- way is considered satisfactory as well. Several partners fered an ED treatment option. Out of 101 men, a third indi- (25.0%, n = 13) reported to have accepted the new situation cated Bpartial satisfaction^ (30.7%) up to Bno satisfaction^ around sexuality and experienced improved communication (25.7%) regarding treatment for their erectile complaints. within their relationship due to this alteration. Still, a greater Reasons for dissatisfaction consisted of limited results part of the partners (29.8%, n = 36), who did not feel the (54.8%, n = 17), discomfort (6.5%, n=2), andhighcosts necessity to obtain additional support, reported to have expe- (3.2%, n = 1). Six participants (19.4%) indicated to be unable rienced difficulties with their sexuality and relationship. Lack to report results concerning the effect of ED treatment, as they of intimacy (33.3%, n = 12), loss of their sexual relationship had not used the prescribed medication yet. Despite preceding (27.8%, n = 10), coping with frustrations of their partner, and results, only a third of men with ED (31.2%, n = 58) were coming from dealing with ED as well as the feeling of loss of offered the possibility to discuss sexuality with a specialized masculinity (25.0%, n = 9) and increased tension in their rela- health care provider, such as a sexologist. tionship (13.9%, n = 5) were the most named reasons. Partners Preferred sexual health care A total of 174 partners of men with PCa participated in this We asked the participants whether they would appreciate it to study, among them 171 women and 3 men. The average age discuss treatment-related SD and relational matters with cer- was 65.5 years (SD 7.6, range 45–86) and the majority tain health care providers. On the assumption this would take (65.6%, n = 114) was retired. Further details on demographic place with a urologist-sexologist, the majority (74.7%, n = and clinical characteristics are shown in Table 3. 183) answered positively. In case that would concern a sexol- Half of the partners (50.6%, n = 81) reported to have expe- ogist, 43.0% (n = 104) agreed and if these subjects would be rienced difficulties handling the altered situation regarding discussed with an oncology nurse, 40.5% (n = 98) conceded. sexuality. Fifty-one percent (n = 85) reported to have faced Around one fourth of participating men (24.4%, n = 60) indi- moderate to severe problems concerning sexuality subsequent cated such a consultation should only occur on patients’ ini- to treatment of their partner. As regards to other treatment- tiative. Two men preferred to discuss these personal matters related side effects, such as urinary incontinence, 61.6% with their general practitioner. (n = 101) mentioned to have not experienced difficulties deal- Preferences for certain health care providers depending ing with it. Nevertheless, the majority of the partners (69.3%, on received type of treatment were analyzed (see Fig. 1). Support Care Cancer (2018) 26:4169–4176 4173 Table 3 Demographic and clinical characteristics of the partners Urologist-sexologist 80 Sexologist n (%) Oncology nurse Age (years) Mean 65.5 (SD 7.5, range 45–86) 174 (100.0) Gender Female 171 (98.3) Male 3 (1.7) Occupation Employed 46 (26.4) Unemployed 14 (8.1) Retired, employed 19 (10.9) Retired, unemployed 95 (54.6) Type of treatment Education Fig. 1 Preferences for various health care providers per treatment No qualification/elementary school 12 (6.9) Lower vocational education 79 (45.4) suggested as a suited health care provider (27.3%, n = 19). Intermediate vocational education 33 (19.0) When comparing the group of men treated with IMRT com- Higher secondary education 17 (9.7) bined with HT with the LRP treatment group as well as with Higher education 33 (19.0) all other types of treatments, a significant difference in pref- Marital status erence as to the sexologist as most suited health care provider Unmarried 4 (2.3) was found (p <0.05 and p < 0.05). With regard to the prefer- Married 146 (83.9) ence for the oncology nurse, no significant difference was Common law 7 (4.0) found when the group of men who received IMRT was com- Widowed 1 (0.6) pared to the HT treatment group nor to all other types of Other 4 (2.3) treatments (p =0.38 and p =0.34). Unknown 12 (6.9) Subsequently, participants were inquired to determine the Comorbidities most suitable timing for sexual counseling. Almost half of the Hypertension 54 (18.4) participants (47.6%, n = 49) considered 3 months after treat- Hypercholesterolemia 45 (15.3) ment as best suited. A third (33.0%, n = 34) preferred as soon Rheumatic and joints disease 45 (15.3) as possible; meaning the first visit attending their urologist; Obesity 20 (6.8) around 4 weeks after treatment. A minority (11.6%, n =12) Chronic inflammatory lung disease 16 (5.4) mentioned a period of 6 to 9 months after treatment as conve- Diabetes mellitus 15 (5.1) nient, followed by a group who considered 1 year after treat- Psychological disease 13 (4.4) ment as most suited (7.8%, n =8). Heart and coronary artery disease 9 (3.1) As to which extent involvement of partners is important Thyroid disease 7 (2.4) when sexuality is discussed, 67.9% (n = 144) of participating Cerebrovascular accident 5 (1.7) men determined involvement of their partner as crucial. A Other 15 (5.1) small part (20.3%, n = 43) indicated to not feel concerned No comorbidities 50 (17.0) whether their partner is involved or not and 11.8% (n =25) preferred to discuss intimate issues without the presence of Data obtained by correlating partners with corresponding patients their partner. Partners of patients who did not participate Comorbidities are displayed in number of frequencies Discussion Out of all men who preferred the urologist-sexologist, this health care provider was named the most by men who had Key results undergone surgical treatment (84.4%, n =54). When compar- ing the group by whom the urologist-sexologist was named This study shows current sexual health care is not conclusive the least, namely men who received IMRT combined with HT according to men experiencing SD due to PCa treatment. (64.7%, n = 64), a significant difference was found (p =0.01). Significant loss of erectile function (EF) is experienced by Again, the group of men who received IMRT combined with the majority of men treated for PCa. Several ED treatment HT was in the minority as to when the sexologist was options are available, for what PDE5 inhibitors were LRP (n = 64) T (n = 25) IMRT (n = 60) IMRT with HT (n = 71) HT (n = 15) % 4174 Support Care Cancer (2018) 26:4169–4176 prescribed the most. However, more than half of the partici- especially in oncology treatments, considering its great impact pants were not satisfied with the ED treatment results. A stan- to psychological health and wellbeing . Nevertheless, psy- dard consultation with a urologist-sexologist 3 months after chosexual care is still found to be a great unmet need among treatment is preferred by the majority of the participants. The the majority of men treated for PCa, since psychosocial and same consultation performed by a sexologist or an oncology relational problems are unaddressed in comparison to physical nurse is considered preferable as well. Men who have received problems . Despite the fact sexual health issues may con- surgical treatment have a preference for a urologist-sexologist cern an important topic to them, they experience difficulties in compared to men who have received IMRT combined with disclosing their complaints with health care providers or their HT, whom prefer a urologist-sexologist the least. When it partners . Moreover, many tools are available to provide comes to a consultation with a sexologist, the group of men proper guidance to men experiencing SD; however, great part treated with IMRT combined with HT preferred the sexologist of them are hardly ever used . the least, whereas the group of men who were treated with Noteworthy to mention is the lack of need of the partners to IMRT preferred the sexologist the most. When the consulta- obtain supportive care around sexuality and/or relational is- tion would take place with an oncology nurse, among all types sues. Despite the imposing difference between the two gen- of treatments, no significant difference was found. Regarding ders, it has been described in the literature previously . the partners, half of them encountered issues concerning al- This study described a group of men and their partners where, tered sexuality. However, dealing with other treatment-related comparable to our study group, men were more interested to side effects, such as urinary incontinence, were not experi- obtain supportive care around altered sexuality whereas al- enced as a problem by a great number of partners. most half of the partners reported to not be interested in re- Moreover, the majority of the participating men indicated ceiving support for changes in their intimate relationship. presence of their partner as crucial during such consultations, Several types of reasons therefore were named by partners whilst a minority stated to prefer consultations in a private within our study group. Part of them considered these issues setting. as an obstacle apparent to overcome within their long-term relationship, whilst others accepted the altered situation and Comparison with literature even encountered improved communication with their partner. However, an important number of partners experienced sev- Although an overall high satisfaction is found concerning eral sexual issues, and are still not in need of additional sup- supportive care after treatment, men treated for PCa report- port. Wittmann et al. studied partners of men surgically treated ed that physical problems are addressed more often than for PCa and found that several partners did not attempt to psychosocial-related issues . SD as a result of PCa treat- initiate sexual activities in order to not pressure their partner ment comprises several components, including ED. to perform . Although partners may experience high un- Gandaglia et al. investigated whether penile rehabilitation met sexual needs, they tend to emphasize other elements of the is effective after nerve-sparing RP . Penile rehabilita- relationship rather than the sexual part to not let their partners tion was defined in this study as implementation of any feel insecure about their sexual performance . Thereupon, intervention in the context of obtaining erections sufficient men reported to be unaware of their partners’ sexual needs. So for sexual intercourse, and preferably to obtain EF back to despite the fact that partners report to not be in need of sexual its preoperative state. Clinical studies reported inconsistent support, they may not be neglected when sexual recovery for results as to long-term effects on EF. The authors conclud- men treated for PCa is considered, since they may disguise ed that an optimal recovery program for men treated with their own sexual needs to prevail upon their partner’sanxiety. RP is still a subject in need of further investigation. Regarding SF subsequent to RT, Incrocci performed a study to investigate post-radiation ED in men treated for Strengths and limitations PCa . The investigators stated post-radiation ED is a multi-factorial problem. Consequently, PDE5 inhibitors One of the strengths of this study consists of its large cohort of seem to be efficacious in only half of men treated with men obtained from an academical cancer registry center, em- radiation therapy. In consonance with our study, men who phasizing the use of accurate and reliable data. Throughout used PDE5 inhibitors reported dissatisfaction due to lack this study, we were able to identify the unmet needs of men of efficacy, high costs and side effects. treated for PCa and to determine their preference by means of their received treatment. Moreover, we were able to address Importance of psychosexual care the supportive care needs of their partners as well. Limitations include the cross-sectional research design, Current Western health care has gained more focus on improv- which implies participants presented their experiences retro- ing QoL throughout enhanced disease management, spectively. Longitudinal evaluation of intervention outcomes Support Care Cancer (2018) 26:4169–4176 4175 designed according to received treatment and the patient’s Compliance with ethical standards preference are key focus for future research. Conflict of interest The authors declare that they have no conflict of interest. Clinical implications Declaration Herewith I state to have full control of all primary data and I agree to allow the journal to review our data if requested. We were able to inventory to what extent ED treatment op- tions were offered within our department and to which degree Open Access This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License (http:// men were satisfied. Based on the study results, a patient- creativecommons.org/licenses/by-nc/4.0/), which permits any noncom- specific intervention can be developed and implemented. mercial use, distribution, and reproduction in any medium, provided The outcomes showed that men have the preference to discuss you give appropriate credit to the original author(s) and the source, pro- sexual health issues with a urologist-sexologist the most, vide a link to the Creative Commons license, and indicate if changes were made. followed by a sexologist and an oncology nurse. Within the groups of men who received various treatments, preferences concerning the adequate health care provider differed. Accordingly, the person who will discuss sexual matters with References men and their partners can be correlated throughout the re- ceived treatment. Content of these consultations can vary from 1. 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Supportive Care in Cancer – Springer Journals
Published: Jun 7, 2018
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