Sexual Distress, Depression After Prostate Cancer Treatment

Ingrid Hein

May 20, 2020

Nearly one-third of men who have undergone treatment for prostate cancer report that a subsequent lack of sexual function has had the greatest impact on their quality of life, results from a new survey show.

"All the studies have been saying that sexual function is okay after treatment, but we know that's not true," said André Deschamps, MBA, who is chair of the European Prostate Cancer Coalition, known as Europa UOMO.

This issue has been neglected because people think older men aren't interested in sex, Deschamps told Medscape Medical News.

"It makes me mad when people say a man in his 70s doesn't have a sexual life." That's not the case, he said. "Our study shows you a real picture of quality of life after treatment. We know it is affected far more heavily than the medical world has been telling us."

The EUPROMS survey looked at quality of life in 2943 men, from 24 European countries, who had undergone some treatment for prostate cancer. Deschamps will present results at the European Association of Urology (EAU) 2020 Congress, which will be held online in July.

Participants were recruited to the study through their connection with Europa UOMO. The online survey, which took about 20 minutes to complete, collected data that were used to generate European Organisation for Research and Treatment of Cancer (EORTC) symptom scores and EQ-5D-5L and Expanded Prostate Cancer Index Composite (EPIC) quality-of-life scores. Data were collected by Cello Health UK. The survey was sponsored by Bayer, Ipsen, and Janssen Pharmaceutica, but they had no part in the research.

Men were eligible to complete the survey — which was available in 19 languages — if they were receiving or had received some form of treatment for prostate cancer, including active surveillance, surgery, external-beam radiation, prostate brachytherapy, chemotherapy, androgen-deprivation therapy, high-intensity focused ultrasound, and cryotherapy.

Mean age of the respondents was 70 years, and mean age at diagnosis was 64 years. Most of the men — 1937 — underwent one treatment, 636 underwent two, 300 underwent three, and 70 underwent at least four.

A preliminary analysis of scores on the EQ-5D-5L scale showed that 45% of respondents reported experiencing at least some anxiety or depression. And half of all men reported being affected by sexual dysfunction, with 28% considering it a "big problem" and 22% considering it a "moderate problem."

Men who reported fatigue and insomnia had the highest EORTC symptom scores; this was even more pronounced for men who had undergone two treatments and experienced a cancer recurrence.

And on the EPIC scale, scores for the sexual function domain indicate that this area had the greatest impact on quality of life. Scores for the urinary incontinence domain, the urinary obstructive domain, the bowel domain, and the hormonal domain indicated much smaller effects on quality of life.

"Most men hear the word cancer and they want it gone," Deschamps said. But this research shows that closely following the cancer using active surveillance results in longer patient quality of life, particularly as it relates to sexual function, but also as it relates to other complications.

"Prostate cancer can take a long time to grow and metastasize. It's not like breast cancer, which grows fast. It's better to follow and act only when the cancer is growing too fast," he explained.

Men need to know what the outcomes will be when they are discussing therapy for prostate cancer.

This research will help men make better decisions about treatment options. "This is a big sample and we can see that quality of life is an important issue. Given that 50% of men don't even know they have a prostate, we need to educate men, and talk about it, and increase testing to get early detection, like we do for breast cancer," he said.

Men tend to keep quiet when they are diagnosed. "It's a disease that's embarrassing because it has to do with your sexual life. It's a cancer that's linked to sexuality. Men don't talk about it," Deschamps pointed out.

And men are quiet about the impact of treatment on their sexuality. "There is a certain tendency to make it seem less bad when you are sitting opposite a nurse in a clinic," he said.

This lack of discussion around the disease is the crux of the problem, he added.

It's a disease that's embarrassing because it has to do with your sexual life. It's a cancer that's linked to sexuality. Men don't talk about it.

"This survey is a very important initiative," said Hein Van Poppel, MD, PhD, from University Hospitals Leuven in Belgium, who is adjunct secretary general of the EAU. "This has not been done before."

It has been a challenge to get a clear picture of how men do after treatment for prostate cancer.

"We offer treatment to a patient and they are grateful they are cured," Van Poppel told Medscape Medical News. The bar is low on quality-of-life issues immediately after treatment. "They say I'm fine, I'm cured, sexuality is not that important; they are very pleased with what we did for them."

But clearly, as studies like this show, all areas of sexuality take a hit after this cancer is treated, and more research is needed to pinpoint which treatments have the greatest impact.

Still, "this study is far from perfect," Van Poppel pointed out. The criteria of "some treatment" leaves a lot of questions unanswered. "Which ones had surgery, radiotherapy, radiotherapy with and without hormones, and triple treatments?"

Simply coming to the conclusion that 28% of men have experienced some impact on their sexual function does not offer a clear picture of who is being affected, he explained.

For example, men who have undergone surgical castration have no sexual function. "They have no libido and no interest; that's clear," he said. And "patients who undergo surgery, radiography can have erectile problems, but that's not always a parameter of sexual function."

Impotence after surgery does not preclude a sexual life. There are ways to achieve orgasm without ejaculation. "Some men come back and say 'I had an orgasm like I was ejaculating'," he explained. "It's not something between your legs, it happens in your brain."

Pelvic floor muscle training to improve climacturia in men with persistent erectile dysfunction after nerve-sparing radical prostatectomy was shown to have a significant effect in a study by Van Poppel and his colleagues.

But despite shortfalls in the research, the survey results are important, and he said he is looking forward to the presentation by Deschamps.

"The most important quality-of-life issues he mentions are sexuality, anxiety, and depression after treatment, and that's what we need to analyze; this has never been objectively assessed," Van Poppel pointed out.

European Association of Urology (EAU) 2020 Congress.

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