Sexuality and body image in long-term survivors of testicular cancer

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Abstract

Objective

This study explores sexual function and the influence of different treatment modalities on sexual function and body image among long-term survivors of testicular cancer (TCSs).

Methods

A long-term follow-up assessment of all testicular cancer patients treated at Aarhus University Hospital, Denmark, from 1990 to 2000 was conducted. A total of 401 survivors (mean age: 46.6 years; response rate: 66%) completed questionnaires concerning sexuality and changes in body image. Based on the treatment received, patients were categorised into one of four groups: surveillance, radiotherapy, chemotherapy, or chemotherapy supplemented with retroperitoneal lymph node dissection (RPLND).

Results

Sexual dysfunctions were reported: 24% reduced sexual interest, 43% reduced sexual activity, 14% reduced sexual enjoyment, 18% erectile dysfunction, 7% ejaculatory problems and 3% increased sexual discomfort. Seventeen percent of the long-term TCSs reported changes in body image, and this was significantly associated with all six parameters of sexual dysfunction. When comparing treatments, only the RPLND procedure was associated with sexual dysfunction in the form of ejaculatory dysfunction.

Conclusion

Apart from RPLND, which was associated with ejaculatory dysfunction, treatment strategies for testicular cancer appeared not to influence sexual dysfunction. The level of erectile dysfunction seen in this sample of TCSs seemed to be higher than the level observed in the general male population and high levels of erectile dysfunction were associated with negative changes in body image. The results suggest that changes in body image are of importance when explaining the variation in sexual dysfunctions, but further prospective studies are needed to clarify this issue.

Introduction

Testicular cancer (TC) is the most common form of cancer in men between 20 and 35 years of age.1, 2 Major improvements in treatment have been achieved with the introduction of cisplatin-based chemotherapy, which has yielded cure rates of 70–85% in patients with metastatic disease.3 The effectiveness of treatment has resulted in a progressively larger number of young men who have become long-term survivors and who have to cope with possible long-term effects of the disease and cancer treatment on sexuality and body image. The results of studies comparing testicular cancer survivors (TCSs) to a norm population have suggested that TCSs generally have higher levels of sexual dysfunction, primarily erectile and ejaculatory dysfunction.4, 5 Studies examining the influence of various treatment regimens on sexual function in TCSs have shown mixed results. For instance, while some studies have not found evidence that levels of erectile and ejaculatory dysfunctions and libido are influenced by treatment regimens,6, 7, 8 others have shown reduced sexual interest and sexual activity in patients who had received chemotherapy with or without radiotherapy compared to men who have received surgery only.9, 10, 11 When investigating the consequences of retroperitoneal lymph node dissection (RPLND), there seems to be fairly consistent evidence that this procedure is associated with increased risk of ejaculatory dysfunction.10, 12, 13 Definitive conclusions based on the available studies are difficult to obtain since the field has been characterised by patient populations receiving a variety of different treatment regimens, variations in lengths of follow-ups and the use of different instruments for assessing sexual dysfunction. Moreover, validated norm material concerning sexual function is often lacking.

There is often no obvious explanation of the sexual morbidity reported in studies of sexual function among TCSs, suggesting that sexual dysfunction could have both biological and psychological causes. Only a small number of studies have considered psychological function and the possible interactions between psychological distress and sexual dysfunction.13, 14 Patients diagnosed with TC are treated with orchiectomy, and removal of a testicle might be seen as a disembodying procedure in a time of heightened fixation on the ‘perfect body’ and a striving for physical fitness.15 The results of one study have shown negative changes in body image approximately 4 years following treatment for TC,16 and it appears relevant to investigate whether changes in body image following treatment for TC are associated with sexual dysfunction.

On this background, the purpose of this study was to examine sexual morbidity in TCSs who had received surveillance, radiotherapy, chemotherapy or chemotherapy followed by RPLND. Furthermore, the purpose was to examine whether sexual morbidity was associated with perceived changes in body image. In many of the studies investigating the sexual dysfunction in TCSs, the group of surveillance patients has constituted a minority (approximately 10–20%). In the present study, the vast majority of patients with stage I disease were consistently assigned to surveillance during the entire study period. This treatment strategy increased the number of surveillance-only-patients, and the proportion of surveillance patients in the present study was generally higher than in other studies of sexual dysfunction (approximately 50%). Hence, the statistical power when comparing surveillance with other treatment modalities is increased compared to previous studies.

Section snippets

Study design

A long-term follow-up assessment was conducted on all TC patients treated at the Department of Oncology, Aarhus University Hospital, Denmark from 1st January 1990 to 31st December 1999. All patients with a diagnosis of germ cell tumour, including bilateral TC, were included into a Germinative Tumour Database (GTD). A total of 695 patients were included in the GTD. The medical record for each patient was reviewed, and information concerning age at diagnosis, histopathology, disease stage at

Statistics

Differences in age, histopathology, disease stage at diagnosis and type of treatment between respondents and non-respondents were explored with chi-square tests (categorical data) and Student’s t-tests for independent variables (continuous data). Differences in age between treatment groups were explored with one-way analyses of variance (ANOVAs) using the Bonferroni procedure to adjust for multiple comparisons. Differences in marital status, parenthood, employment status, educational level,

Results

Eligibility criteria for participation were met by 611 patients. Of these, 401 returned questionnaires corresponding to a response rate of 66%. Respondents were younger than non-respondents (t = −4.63, p < .0001), but did not differ with respect to any of the disease-related factors including histopathology (chi2 = 4.86, p = 0.09), disease stage at diagnosis (chi2 = 4.45, p = 0.22), and type of treatment (chi2 = 1.04, p = 0.60). Patients were classified into four groups according to the treatment received:

Discussion

Although several studies have examined the influence of treatment on sexuality of TCSs,9, 11, 12, 14 due to the mixed results, the question remains as to whether and to what degree TCSs are at risk for sexual morbidity, and which factors are associated with sexual dysfunction. Problems with sexual function were prevalent among the TCSs included in this study. Twenty-five percent of the survivors reported reduced sexual interest and 43% reduced sexual activity. These findings are in accordance

Conclusion

In summary, sexual dysfunctions were present to a relatively high degree: 18% of the TCSs reported erectile dysfunction, 7% reported ejaculatory problems and 24% reported reduced sexual interest. Furthermore, 17% of the long-term TCSs reported changes in body image. Ejaculatory dysfunction was related to RPLND, but apart from this, no significant associations were found between treatment modalities and sexual dysfunction. The level of erectile dysfunction in this sample appeared higher compared

Conflict of interest statement

None declared.

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