Sexual dysfunction is widespread in prostate cancer patients and few treatments help

November 27, 2002

HOUSTON -- A much smaller percentage of men regain "normal" sexual function after treatment for prostate surgery than has been commonly believed, a survey has found.

Investigators at The University of Texas M. D. Anderson Cancer Center, working with researchers at the Cleveland Clinic, found that 85 percent of 1,236 prostate cancer patients surveyed reported having erectile dysfunction (ED) in the past six months.

Only 13 percent of the men said they had firm and reliable erections spontaneously, and while many patients tried such ED treatments as Viagra®, penile injections, vacuum devices and penile prostheses, only 8 percent regained near-normal erections with their use.

Some prostate cancer treatments such as nerve-sparing surgery and radioactive seed implants offer a somewhat better chance that a man can achieve an erection most of the time, but the overall picture is "generally dismal," said lead researcher Leslie Schover, Ph.D., a clinical psychologist in the Department of Behavioral Sciences at M. D. Anderson.

The investigation, funded by the American Cancer Society, was published in two parts. The first report, in the October 15 issue of the journal Cancer, examined the degree of sexual dysfunction in patients, and the second paper, published in the online edition of the Dec. 1 Cancer, looked at the ED treatments patients used, mostly in vain.

"Too often, prostate cancer patients are led by physicians and the popular media to believe they have a 50-50 chance, or better, to regain their erectile function, but, in fact, the great majority of survivors experience severe and lasting sexual problems and dissatisfaction in the years after treatment," said Schover, who has spent decades counseling men with ED. "Many men have been sold a bill of goods, and that's sobering."

To instill "more realistic expectations," patients, and their sexual partners, should receive counseling as a routine part of their oncology care, the researchers suggest.

Schover and six researchers from M. D. Anderson and the Cleveland Clinic sent surveys to 2,636 men in the Cleveland Clinic Foundation's Prostate Cancer Registry who were treated at that hospital with either radiotherapy or prostatectomy for localized prostate cancer. Among the questions asked were ones about the patient's past and current sexual functioning, their partner's sexual functioning, and current and intended use of medical treatments for ED.

Only 49 percent of patients returned the survey, and researchers say that the fact that men who filled out the questionnaire were younger and more likely to have had good erections before prostate cancer suggested up front that men who didn't respond to the survey had less interest in staying sexual active. Of the 1,236 men who did answer the survey, and thus expressed interest in the subject, 36 percent had ED when their cancer was initially diagnosed but by the time the survey was taken -- which was an average of 4.3 years after treatment - 85 percent reported having ED within the past six months. Also, 45 percent said their desire for sex was poor and 65 percent had trouble having satisfying orgasms.

"Men were as distressed about loss of desire and trouble having satisfying orgasms as about ED," the study reported. The survey also showed that younger age was strongly associated with better sexual outcome, as was the influence of following medical factors: not having neoadjuvant or current anti-androgen therapy, having bilateral nerve-sparing prostatectomy surgery or brachytherapy (implanted radiotherapy seeds), and having better mental and physical health. Sexual factors associated with better outcome included: having normal erections before cancer treatment; choosing a cancer treatment based on the hope that it would preserve sexual function, having more sexual partners in the past year, and having a partner who is free of sexual problems herself.

The second study looked at how effective the cornucopia of therapies designed to help ED were to patients surveyed. That report found that while 59 percent of patients tried at least one ED treatment to improve their sex lives, only 38 percent found a therapy that was at least somewhat helpful, and even fewer continued to use it. The survey also found that the treatments easiest to use, such as Viagra®, are the least effective in these patients, although many men continue to use them, hoping they will work.

For example, more than half of patients surveyed (549 men or 52 percent) tried Viagra®, but only 16 percent said it "greatly improved" sexually functioning. Yet 39 percent of these patients continue to use it.

By contrast, patients who use the most invasive ED therapy, a penile prosthesis, reported a 44 percent "greatly improved" functioning -- the highest rating obtained in the survey -- and 81 percent of these patients still use this method. But only 16 patients (2 percent) chose this option.

"Men wish Viagra would work, but we found that all current treatments excepthat implantation of a penile prosthesis have a drop-out rate exceeding 50 percent," Schover said.

The second-most-popular ED treatment was a vacuum device, used by 197 patients (19 percent). But only 19 percent reported "greatly improved" functioning although 41 percent reported that they still use the device. Penile injections, used by 179 men (18 percent), resulted in the second highest satisfaction result; 29 percent of patients who used it said it greatly improved sex, but just 34 percent of those patients still use the therapy.

Among other findings were that 79 percent of men who had bilateral nerve-sparing prostatectomy tried a therapy for ED, compared to only 50 percent of men who had brachytherapy, despite the fact that both of these treatments appeal to men who want to preserve their sex lives. Viagra® also works best in men who have both nerves spared in prostatectomy, or in men who have radiation therapy, the researchers found.

The negative impact of hormonal therapy on successful treatment for ED is also clear, said Schover. Few men with suppressed testosterone production found a successful treatment for their ED.

Finally, the researchers point out that a patient's relationship to a sexual partner is important in explaining successful use of a medical treatment for ED, especially if that partner has good sexual function. Yet most ED clinics make little effort to include the partner in treatment planning, said Schover. "Many men regard ED as their individual problem, but sex takes place in a relationship, and couples can be helped to make a mutual decision to pursue a treatment," she said.

Schover's co-authors are, from M. D. Anderson's Department of Behavioral Science: Rachel Fouladi, Ph.D., Carla Warneke and Leah Neese; and Eric Klein, M.D., and Craig Zippe, from the Cleveland Clinic's Department of Urology; as well as Patrick Kupelian, M.D., formerly of the Cleveland Clinic's Department of Radiation Oncology and now with M. D. Anderson Orlando.

University of Texas M. D. Anderson Cancer Center

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