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- PATIENTS AND METHODS
- CONFLICT OF INTEREST
Prostate cancer is the most commonly diagnosed non-skin malignancy among men in North America. The choice of treatment for early-stage prostate cancer commonly involves radical prostatectomy (RP), prostate brachytherapy or occasionally external beam radiation therapy. Retrospective data indicate that overall survival rates and biochemical disease control are comparable for these three treatments [1,2], but nerve-sparing RP and brachytherapy are often the treatments of choice of younger, sexually active men. Future results from the American College of Surgeon's randomized clinical trial comparing RP and brachytherapy will be able to provide clinicians with answers about the efficacy of these two treatments in terms of survival and biochemical control of disease . Additionally, such a prospective randomized trial will be able to compare the two treatments in terms of quality of life and effects on sexual function. This is especially important as the early detection and success of treatment have resulted in men being diagnosed when younger and thus living longer with the consequences of treatment.
There is a perception that brachytherapy for early-stage prostate cancer is better for preserving potency; indeed, several investigators reported the 3-year potency preservation rate to be ≈ 70%[4–8] while others have reported rates of 40–95%[9–11]. Sildenafil is effective in assisting up to 80% of patients who have erectile dysfunction (ED) after brachytherapy to achieve an erection [9,12,13], and a recent meta-analysis by Robinson et al. reported brachytherapy as the treatment with the highest potency preservation rate.
The rate of reported ED after RP also varies; it is generally agreed that the potency preservation rate after RP tends to be better if erectile function is good beforehand, patients are younger, and the surgeon is successful in preserving the neurovascular bundles during surgery [15–18]. However, community results tend to be less encouraging, as reported in the Medicare survey of 739 men, where 39% were partly potent and 11% fully potent after RP . These differences in reported rate of ED might be associated with patient selection, and possibly the surgeon's skill. However, few radiation oncologists or urologists have actually used structured sexual-health assessments and validated questionnaires to prospectively evaluate sexual function before and after treatment, and thus any comparison between patients treated with RP or brachytherapy at various institutions is difficult .
At the time of diagnosis younger men in particular reportedly have a preference to be informed about how various treatments will affect their sexual function . Common problems influencing the reliability of data reported include: (i) the degree of sexual function has not been assessed before or after treatment; (ii) most reports include a retrospective chart review and there is a question of accuracy about the data collected; (iii) different definitions for erectile function have been used; and (iv) clinical follow-up times vary [14,20]. In addition, most studies have compared the degree of sexual dysfunction associated with various treatment options . Studies to identify the types of information resource that men have used or would like to access to meet their sexual health concerns after definitive treatment were identified as lacking. Thus the purpose of the present study was to identify preferences for sexual information resources in patients treated for early-stage prostate cancer with either RP or brachytherapy. The objectives were to identify: (i) the types of sexual information resource that men used before treatment; (ii) the types of resource men would have liked to have access to before and after treatment; (iii) the men's knowledge and use of treatments available to treat ED; (iv) the effect of sexual function on the treatment decision; and (v) the men's current level of sexual function after treatment.
PATIENTS AND METHODS
- Top of page
- PATIENTS AND METHODS
- CONFLICT OF INTEREST
Patients were recruited from The Prostate Centre at Vancouver General Hospital and the Radiation Department at the British Columbia Cancer Agency in Vancouver. The criteria for study participation included patients who had received either brachytherapy or RP as definitive treatment for early-stage prostate cancer within the last 3 years, and the ability to read and write English. These two treatments were chosen as most younger men were usually offered both of these treatment options.
Data collection commenced after obtaining ethical approval of the study protocol by the appropriate institutional review committees. A research assistant obtained informed consent from each participant and the survey was completed at that time. Men were asked to complete the survey themselves, but the research assistant was present to answer questions and ensure all forms were complete.
A two-part survey questionnaire was developed for the study based on a review of published work and previous clinical experience of investigators. Part 1 was used to record: (i) personal characteristics such as age, education and marital status; (ii) information resources used before treatment and that men would have liked to have access to before and after treatment, for sexual concerns; (iii) the level of sexual function and activity before treatment; and (iv) the types of treatments used or planned to use for sexual dysfunction if required. Part 2 was used to record: (i) disease characteristics (PSA, Gleason score, clinical stage); and (ii) treatment details (surgery, nerves spared; use of neoadjuvant hormone therapy, length of time).
Sexual function was assessed using the 15-item International Index of Erectile Function (IIEF) questionnaire . This measure includes five separate domains of sexual function: erectile function (six items), orgasmic function (two items), sexual desire (two items), intercourse satisfaction (three items), and overall satisfaction (two items). Scoring on the IIEF allows differentiation between different degrees of severity of sexual dysfunction, and has been used in several clinical trials to assess sexual function. The total possible score for the 15 items is 75. There is a high degree of internal consistency for each of the five domains (Cronbach's α of 0.73–0.91) . Cappelleri et al. recently established a scoring scale to assess the degree of ED using only the erectile function domain. The severity of ED in this domain was classified in five categories as no ED (26–30), mild (22–25), mild to moderate (17–21), moderate (11–16), and severe (6–10). The IIEF scale is very sensitive and specific for the effects of treatment but there are no published guidelines to identify the severity of ED using the total score from the 15 items. The IIEF was very reliable in the present 200 patients, as assessed by Cronbach's α (0.97).
Descriptive statistics, e.g. the mean (sd), were used to describe the participants. Chi-square statistics and t-tests were used to compare the personal and disease characteristics of the two treatment groups. Frequency tables were used to identify and describe types of information resources accessed before and after treatment, and therapies currently being used for ED. IIEF scores were considered as having interval levels of data; t-tests were used to assess any difference in mean IIEF scores between treatment groups.
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- PATIENTS AND METHODS
- CONFLICT OF INTEREST
In all, 212 patients were approached to participate in the study and 200 agreed to complete the survey. Overall, the mean (range) age of the participants was 64 (46–80) years. Most patients (85%) were married or living with a partner, had greater than a high school diploma (58%), were retired (49%), and had an urban address (81%). There were no patients who indicated they were in a same-sex relationship. Compared with patients in the RP group, patients in the brachytherapy group were significantly older, more had rural addresses and a higher proportion had less than a high school diploma (Table 1).
Table 1. The characteristics of the participants
|Mean (sd) age, years|| 61.3 (7.6)|| 66.9 (6.9)||<0.001|
|Education|| || ||<0.05|
|< High school|| 11|| 24|| |
|High School|| 23|| 26|| |
|> High school|| 66|| 50|| |
|Marital status|| || ||<0.05|
|Married/partner|| 88|| 81|| |
|Single/no partner|| 12|| 19|| |
|Employment status|| || ||0.14|
|Full-time|| 44|| 29|| |
|Part-time|| 13|| 13|| |
|Retired|| 41|| 56|| |
|Unemployed|| 2|| 2|| |
|Residence|| || ||<0.01|
|Urban|| 88|| 74|| |
|Rural|| 12|| 26|| |
|T1|| 44|| 46|| |
|T2|| 56|| 54|| |
|PSA, ng/mL|| 6.5 (3.07)|| 6.5 (2.87)|| |
|Gleason score|| 6.2 (0.64)|| 6.1 (0.62)|| |
Treatment groups did not differ in PSA level at the time of diagnosis, Gleason score, or stage of disease, as per study protocol. Significantly more men in the brachytherapy group received neoadjuvant hormone therapy (64) than in the RP group (37; P = 0.003). Ten men in the brachytherapy group and one in the RP group were receiving hormone therapy at the time of the interview.
Most patients (84%) reported that they had received or had access to some type of information on ED, but 68% of patients in the RP group and 54% in the brachytherapy group would have liked additional information on the effect of treatment on sexual function. Most (59%) patients reported urologists as the main source of sexual-related information (Table 2). Written information was identified as the source of information preferred most, both before (81%) and after treatment (55%). The Internet was also identified by 51% of patients as important before treatment. The preference to access these information resources was unaffected by whether the patient had received hormone therapy.
Table 2. Information resources used and preferred before and after treatment
|Information resources||Before, n (%)||After n (%)|
|Family physician|| 82 (41.0)||–|
|Internet|| 68 (34.0)||–|
|Prostate cancer patient|| 61 (30.5)||–|
|Pamphlet from doctor's office|| 57 (28.5)||–|
|Radiation oncologist|| 43 (21.5)||–|
|Prostate support group|| 31 (15.5)||–|
|Video on sexual function|| 26 (13.0)||–|
|Friend/relative|| 23 (11.5)||–|
|Written||162 (81.0)||109 (54.5)|
|Internet||102 (51.0)|| 61 (30.5)|
|Videos|| 98 (49.0)|| 63 (31.5)|
|Talk to other patients|| 69 (34.5)|| 57 (28.5)|
|Specific appointments with|
|Physician|| 48 (24.0)|| 40 (20.0)|
|Sexual health clinician|| 17 (8.5)|| 18 (9.0)|
|Physician or sexual health clinician|| 86 (43.0)|| 88 (44.0)|
|Access to sexual health clinician|
|As required/routine||138 (69.0)||141 (70.5)|
When asked if they would like a specific appointment to discuss sexual concerns about treatment, about a quarter of patients did not comment. Physicians were preferred as the providers of such information, but either the sexual health clinician or physician were identified as appropriate both before (43%) and after treatment (44%) (Table 2). About 70% of the patients would have liked access to a sexual-health clinician if needed, or as part of clinical practice before and after treatment. Compared with men who had partners in the RP group (57), a higher proportion of such men in the brachytherapy group (39) did not wish to include their partners in sexual counselling/discussions (P = 0.03).
The potential effect of treatment on future sexual function had no significant influence on the treatment chosen (P = 0.16). Most men who received either RP (74%) or brachytherapy (60%) reported that their initial treatment choice was ‘not at all’ (RP, 46; brachytherapy 34) or ‘a little’ (RP, 28; brachytherapy 26) influenced by the effect of treatment on sexual function.
The vast majority (>90%) of patients in both groups had some knowledge of oral medications, specifically sildenafil, as a treatment for sexual dysfunction. Compared with patients in the brachytherapy group, significantly more men in the RP group had used (RP 66; brachytherapy, 32; P < 0.001) or planned to use (RP, 61; brachytherapy, 33; P = 0.001) sildenafil in the future. There was a trend in the patients’ general lack of knowledge about the correct use of sildenafil with respect to expectations of results, correct use, adjustment of dosage, and times to use it after surgery.
Although most (60%) of patients in both groups knew about penile injections as a treatment for ED, 90% had not used this treatment and 87% did not plan to use it in the near future. Most (60%) of patients in both groups were aware of vacuum pumps, 96% had not used them, and 93% did not believe that they would use such a device in the future. Most patients (72%) were unaware of transurethral suppository medications and 96% did not plan to use this form of treatment in the future. Only half the patients were aware of surgical penile implants, 96% did not plan to have such a device implanted, but one patient had already had such a procedure.
For sexual function, compared with patients in the brachytherapy group, significantly more patients in the RP group reported being ‘quite a bit or very much’ interested (RP, 88; brachytherapy 68; P = 0.007), and ‘quite a bit/very much’ active (RP, 78; brachytherapy 54; P = 0.003) sexually before treatment. Most men in both the groups (RP 86; brachytherapy 79) reported they were able to have a full erection before treatment.
The mean overall IIEF scores were < 30 for men in both groups, with mean (sd) scores of 29.3 (19.59) and 26.97 (23.17) in the RP and brachytherapy groups, respectively. The mean erectile function domain scores for the entire sample indicated that they had a significant degree of ED (Table 3). Compared with the RP group, patients in the brachytherapy group had significantly lower mean scores on the sexual desire domain, at 6.05 (2.08) and 4.69 (2.35), respectively; the other domains were remarkably similar.
Table 3. The scores for the IIEF domains (200 men)
|IIEF||Mean (sd) score|
|Erectile function|| 9.74 (10.35)|
|Orgasmic function|| 3.75 (3.53)|
|Sexual desire|| 5.37 (2.22)|
|Intercourse satisfaction|| 4.12 (5.01)|
|Overall satisfaction|| 5.03 (2.72)|
- Top of page
- PATIENTS AND METHODS
- CONFLICT OF INTEREST
The aim of the present study was to identify the information resources required for sexual rehabilitation by men after treatment for early-stage prostate cancer. The types of information resources patients had accessed and that they would have preferred to access before and after treatment were identified. Urologists were the main source of information that patients used to obtain such information. This is not surprising, as all patients had been diagnosed and had their initial treatment consultation with one or more urologists. Most (84%) men reported that they had received or had access to information about ED, but 68% of men in the RP and 54% of men in the brachytherapy group still expressed a need for additional information on the effect of treatment on sexual function. Written information and the Internet were identified as the two preferred sources before treatment. However, only about a third of patients in the sample reported receiving written information or accessing information on the Internet. These results support those of Kirby et al., who reported that only 23% of men with prostate cancer in their sample had received written material related to sexuality. Although videos were also identified as being important, only 13% had actually watched a video about ED. This latter finding is attributed to the fact that most patients were not told that such resources were available.
Potential sexual dysfunction had no significant influence on treatment choice. One explanation for this is that immediate treatment for the cancer was the first priority and dealing with ED was an issue that could be addressed later. Unfortunately, most of the present patients reported having low levels of sexual function at the time of the interview. Lower levels of sexual desire were also evident especially among patients in the brachytherapy group. We consider that the high use of hormone therapy as part of institutional or clinical trial protocols affected these findings. About half of all the patients had received hormone therapy before and/or after treatment. However, patients reported that they did not fully understand how hormone therapy would affect their sexual function and desire, and most wanted to know how long the effect would last. Further research is necessary to study the effect of the duration of hormone therapy on sexual function.
Although there are various treatment options available for ED sildenafil was the most commonly prescribed treatment. The manufacturer provides physicians with a written brochure and video, and a free medication sample package, but most patients had not been provided with the complete patient-education package. Thus, many patients were not using the medication properly and had ‘given up’ after the free sample was used. Lack of detailed knowledge about other potential ED treatments was also identified.
Urologists and family physicians are usually the healthcare professionals who treat ED after definitive treatment for prostate cancer. However, physicians have been reported to underestimate the incidence of ED, because it is highly subjective . In addition, men may not feel comfortable initiating conversations about their sexual concerns within the context of a busy follow-up clinic appointment. Moore et al. reported that after surgery, men wanted to be treated and privately hoped that the urologist would raise the topic of ED. Based on our results, having specially trained sexual-health clinicians to provide this additional counselling may be one method of assisting physicians to address patients’ information needs both before and/or after treatment. However, most patients are not knowledgeable about the types of services such clinicians are capable of offering. As there are few specially trained sexual-health clinicians available to offer such services, this widens the gap of unmet needs even further.
Erectile function before treatment has been identified as one of the most important predictors of ED afterward [10,26]. Therefore, using validated questionnaires such as the IIEF, or even the erectile function domain of the IIEF, before and after treatment would be valuable to anticipate the outcome and effectiveness of treatment. Such assessments are particularly important, as early intervention with an intracavernosal injection of prostaglandin E shortly after RP reportedly results in a return of spontaneous erection with no medication by 1 year in 67% of the patients, vs only 20% with no intervention . Merrick et al. also reported that most (95%) men who are fully potent before brachytherapy but impotent afterward respond favourably to sildenafil. Therefore, it is conceivable that early intervention to promote erections, and dedicated time to address treatment-related sexual changes and relationship issues associated with treatment for early-stage prostate cancer, could be beneficial in terms of sexual rehabilitation.
Two factors to consider when interpreting the present results are recall bias and referral bias. First, we relied on the patient's self-reported level of sexual function before treatment and it is unknown if men overestimated their baseline function, based on their present level of sexual function. The general applicability of the results may also be compromised, given that patients are referred to the British Columbia Cancer Agency for brachytherapy from a variety of urologists’ practices throughout British Columbia, and comparisons were being made (in some instances) with a group of patients treated by urologists at a Prostate Centre of Excellence.
The intention of this survey was not to compare practices, but to provide an overall view of what is happening with these patients in the area of sexual health. Our results clearly show that about two-thirds of patients want more information on sexual health before and after treatment for early-stage prostate cancer. These patients and their partners also require information about how hormone therapy will affect their sexual relationship. Specifically they want access to written information, the Internet and videos. About three-quarters of men indicated that they would like to have a specific appointment to discuss sexual concerns with a healthcare professional either before or after treatment. One suggested approach is to offer these patients access to such sexual rehabilitation services at the time of the initial treatment decision and as part of routine care.