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 ascertainwhich 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 (< 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 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

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)

11. 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. 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

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 yearsafter 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)

16. 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

17. 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 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.

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 • 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)

24. Prostate Cancer Participants

25. 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)

26. 88% 54% n=143 n=102

27. 63.8% 29.3% n=104 n=36

28. Prostate Cancer Participants

29. 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

31. A Multi Site Monash University PhD Research Project

32. 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 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

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)

39. 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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