Sexuality and body image in long-term survivors of testicular cancer
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.
References (27)
- et al.
Is the sexual function compromised in long-term testicular cancer survivors?
Eur Urol
(2007) - et al.
Sexual function in men treated for testicular cancer
J Sex Med
(2009) - et al.
Treatment of testicular cancer: influence on pituitary-gonadal axis and sexual function
Urology
(2005) - et al.
Androgen deficiency symptoms in testicular cancer survivors are associated with sexual problems but not with serum testosterone or therapy
Urology
(2009) - et al.
Sexual dysfunction after treatment for testicular cancer: a systematic review
J Psychosom Res
(2001) - et al.
(Dis)embodying gender and sexuality in testicular cancer
Soc Sci Med
(2004) - et al.
Treatment outcome, body image, and sexual functioning after orchiectomy and radiotherapy for Stage I-II testicular seminoma
Int J Radiat Oncol Biol Phys
(2002) - et al.
Current concepts about testicular cancer
Eur J Surg Oncol
(1997) - et al.
Quality of life in survivors of testicular cancer
Urol Oncol
(2005) - et al.
Romantic and sexual relationships, body image, and fertility in adolescent and young adult testicular cancer survivors: a review of the literature
J Adolesc Health
(2010)