Study Results: The Effects of Sexual Dysfunction in Prostate Cancer Patients
Prostate cancer is the most common cancer in males, with more than 57,000 new cases each year. It accounts for around 26% of all male cancer cases. About one in six individuals with prostate cancer has advanced disease progression.
Treatment of Prostate Cancer
Radiotherapy (RT) and Androgen Deprivation Therapy (ADT)
RT and ADT are the primary treatments used in the management of prostate cancer. Radiotherapy is used to treat localized advanced prostate cancer. ADT is a form of hormone therapy that is used, as the name implies, to reduce levels of male hormones in the body that fuel the prostate cancer cells. ADT involves the luteinizing hormone-releasing hormone agonists (LHRHa) which reduce testosterone production in the testes.
When the hormones are lowered, cancer grows slowly and potentially shrinks. Reduction in testosterone also leads to loss of sexual interest and function. The main male hormones in the body are testosterone and dihydrotestosterone (DHT). The treatment period for ADT ranges from 6 to 36 months and is used in adjuvant and neoadjuvant settings. Hormone therapy is best used in combination with other treatments such as radiotherapy, chemotherapy, and androgen receptor-targeted agents.
An early diagnosis can help improve the survival rate of the patient for all stages of the disease. The current 5-year survival rate is 86.8% for men with all stages of the disease and 49% for men in stage IV disease.
Novel Androgen Receptor Antagonists
Modern treatments for prostate cancer also include the use of androgen receptor antagonists. Some of the most promising include abiraterone and enzalutamide. These are well known treatments in the metastatic castrate-resistant setting with growing evidence of effectiveness in hormone-sensitive cases. Antagonists work by blocking the effect of testosterone, which can have a negative effect on libido and function. However, their side effects are usually moderate in comparison to LHRHa.
The development of identifiable molecular biomarkers to better determine which patients are likely to benefit from a particular agent is essential, and is the subject of much current research. The utility of imaging techniques as predictive markers of efficacy will be crucial to minimizing the time patients are getting treatment for which their condition does not respond.
Since prostate cancer has a predominant genetic component, a family history of this type of cancer raises the risk of prostate cancer. Prostate cancer has also been linked to hereditary breast and ovarian cancer (HBOC) syndrome, due to germline mutations in homologous deoxyribonucleic acid (DNA) genes. Additionally, prostate cancer has been associated with Lynch syndrome, due to gene mutations involved with DNA mismatch repair. Thus, genetic testing is now recommended for patients with other risk factors for prostate cancer development. Future drug therapies will be aligned with the results of these genetic tests as specific targets will be more readily known.
Sexual Dysfunction in Prostate Cancer
Sexual dysfunction (SD) is a common side effect of the treatments RT and ADT. 80% of prostate cancer survivors describe their overall sexual function as ‘poor/very poor’ at 18 – 42 months after diagnosis.
ADT and Erectile Dysfunction
An estimated 94% of patients receiving ADT therapy experience related SD. Some of the most common sexual side effects linked to ADT; penis and testicle shrinkage, loss of libido, reduction in ejaculate, and infertility. Other indirect effects can also be caused by weight gain, breast enlargement, and fatigue.
Radiotherapy and Erectile Dysfunction
On average, 67-85% of patients receiving RT experience sexual dysfunction. Radiotherapy is believed to cause ED in various ways. First, it damages vascular structures which leads to luminal stenosis and insufficient blood supply to the arteries. Second, RT causes damage to the erection-inducing nerves which can result in loss of motor function. Corporal tissue fibrosis can also occur, which can lead to venous leak from the penis.
Combined RT and ADT treatments have been shown to have a larger negative impact on erectile function (EF). Patients who underwent RT for localized prostate cancer reported lower EF scores and poorer response to pharmaceutical interventions during the first 3 years after their treatment. In another study, researchers found that only 26% of men who received ADT and RT combined treatment regained their baseline EF just after 2 years; about 42% of patients who received RT alone regained function.
Management of Sexual Dysfunction
Early intervention is most recommended to minimize the impact of treatment and manage the reduction in libido. Patients are often presented with a myriad of treatment and support options. These include lifestyle changes such as diet, daily exercise, counseling, and psychosexual support.
Almost all men experience erectile dysfunction after prostate cancer treatments. The side effects are long-lasting and can persist a year or more before seeing any improvement. Unfortunately, only 25-50% of men who undergo radiation therapy see improvements after 2-3 years. Men with other diseases such as diabetes will also have trouble maintaining an erection post-treatment. There are several clinically recommended solutions to manage ED.
- Oral medications – These are drugs that are used to relax the muscles in the penis allowing blood to rapidly flow. On average, these drugs take about an hour to work and effects can last from 8 to 36 hours. Phosphodiesterase type 5 inhibitors are a commonly prescribed class of oral medications to treat ED.
- Injectable medications – These are medications that can induce an erection. Prostaglandins are one of the most commonly used groups of injectable drugs. They injected directly into the penis or into the urethra.
- Mechanical devices – Devices used to force blood into the penis using a vacuum seal. Around 80% of men who use mechanical devices find it successful.
Impact of Sexual Dysfunction
Sexual dysfunction has been shown to affect the quality of life, self-esteem, and relationships of men. Sexual performance has always been integral to man’s masculine identity and its loss can cause frustration. Survivors often live normal lives after treatment but reveal reduced intimacy with their partners.
ADT and Mental Health
Loss of sexual function often has a detrimental effect on mental health. Patients who have undergone ADT also have poor memory, attention span, and a decline in cognitive performance. Patients also report anxiety, fatigue, irritability after their diagnosis. This psychological distress is combined and even heightened by the hormonal impact of the cancer. Anxiety associated with poor sexual function is a common cause of reported anxiety. This can affect the quality of life of the patients.
- Radiotherapy and Androgen Deprivation Therapy for treating prostate cancer are known to increase risk of sexual dysfunction in patients.
- Sexual dysfunction can affect the patient’s quality of life. It can reduce self-esteem, sense of masculinity, and negatively affect relationships.
- The study shows differences in approach to the management of sexual dysfunction according to disease stage.
- Patients whose cancer has metastasized are less likely to receive help than those with locally advanced diseases.
- Clinicians who have special andrology support services don’t refer patients for help as they are worried about the side effects of these treatments.
Study Results on SD in Prostate Cancer Patients
Objective of the Study
This study aims to establish the current euro-oncology practice in the management of sexual dysfunction (SD) following radiotherapy (RT) and/or androgen deprivation therapy (ADT) to treat prostate cancer.
Subjects and Methods
Using a 14-question mixed-method survey, the participants were asked to assess the current UK practice. As published in Clinical Practice, the survey was distributed to members of the British Uro-Oncology Group in 2019.
- A major problem revealed is the difference in approach when managing sexual dysfunction according to disease stage in prostate cancer patients.
- 56% believed that advanced stage of disease as a barrier to discussing SD.
- Clinicians are shown to be less likely discuss SD in patients with advanced disease.
- Only a minority (11%) of patients believe that management of SD is their responsibility.
Study results show that men who suffer from advanced prostate cancer need better support. Patients who receive ADT should be offered help and intervention. Correct management of SD can improve the patient’s sexual function, mental health, confidence, and overall quality of life.