Sexual Function Issues

1
Sexual Function Issues
Among Men With Prostate Cancer Fiona Newton
2
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.
3
School of Psychology, Psychiatry and
Psychological Medicine Faculty of Medicine,
Nursing and Health Sciences, Department of
Psychology
4
Prostatic Carcinoma

• Spans spectrum from slow growing to aggressive
  forms
• Aggressive forms readily metastasise to the
  skeletal system
• No definitive way to ascertain which types
  prostate cancer will spread and which will remain
  indolent

5
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 (lt 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).

6
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).

7
Localised Prostate Cancer Treatment Modalities

• Radical Prostatectomy
• Surgical removal of prostate gland
• nerve sparing / non-nerve sparing
• Radiotherapy
• Used as single treatment or with 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

8
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)

9
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)

10
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).

12
Defining Health 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

13
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)

14
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 years
  after treatment
• Once the fear of cancer has diminished some men
  feel
• dissatisfied with residual decrements in their
  sexual
• functioning
• (Smith, 2003)

15
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.

18
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)

19
Potential Barriers to Seeking Help

• Common Male Attitudes Towards Their Health
• People who go to the doctor are all women and
  childrenand people who are really ill
• I dont go to the doctor because it cant be
  all that serious and Im just too busy
• The wife said I had to comereported to GP
• I would have been back at work sooner but the
  wife said I hadnt eaten for 24 hours and so
  shouldnt be driving
• Note Taken from Bruckenwell, P., Jackson, D.,
  Luck, M., Wallace, J., Watts, J. (1995). The
  crisis in mens health. Bath, UK Community
  Health UK.

20
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.)
21
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.

22
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

23
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
• N102 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
25
Classification of UCLA-PCI Scores

• 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)

26
88
54
n143
n102
27
63.8
29.3
n104
n36
28
Prostate Cancer Participants
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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.

30
A New Research Project Investigating Sexual
Function Problems
Among Men With and Without a Diagnosis of
Localised Prostate Cancer
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A Multi Site Monash University PhD Research
Project
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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

33
Study Design Foci

• Design
• A prospective longitudinal study to assess the
  relationship
• between male participants 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

34
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.

35
Participants

• Male Participants
• prostatectomy patients
• brachytherapy patients
• comparison group
• Spouses / Partners of Male Participants
• Prostate Cancer Specialists
• urologists
• radiation oncologists

36
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

37
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

38
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)

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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.

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References

• American Cancer Society. (2003). Cancer Facts
  Figures 2003. http//www.cancer.org/downloads/STT
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• American Psychiatric Association. (1994).
  Diagnostic and statistical manual for mental
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• Australian Institute of Health and Welfare AIHW
  Australasian Association of Cancer AACR.
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• http// ww.aihw.gov.au/publications/can/ca00/ca00-
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• Braslis, K., Snata-Cruz, C., Brickman, A.,
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  after radical prostatectomy. British Journal of
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• Bruckenwell, P., Jackson, D., Luck, M., Wallace,
  J., Watts, J. (1995). The crisis in mens
  health. Bath, UK Community Health UK.
• Brucker, P. S., Cella, D. (2003). Measuring
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• De Berardis, G., Franciosi, M., Belfiglio, M., Di
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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
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• Hall, J. D., Boyd, J. C., Lippert, M. C.,
  Theodorescu, D. (2003). Why patients choose
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  prostate cancer Results of a descriptive study.
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• Helgason, A. R., Adolfsoon, J., Dickman, P.,
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• Litwin, M. S., Flanders, S. C., Pasta, D. J.,
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