Article

Andropause Syndrome in Men Treated for Metastatic Prostate Cancer A Qualitative Study of the Impact of Symptoms

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Abstract

Androgen deprivation therapy (ADT) has become the cornerstone of treatment for men with metastatic prostate cancer. However, treatments are associated with a number of adverse effects that collectively are referred to as andropause syndrome, or the male menopause. This study explored the experience and impact of andropause symptoms, particularly hot flashes, among men undergoing ADT for metastatic prostate cancer. Twenty-one men receiving ADT for metastatic prostate cancer underwent a qualitative interview focusing on the adverse effects of ADT and the impact of these symptoms on daily living and coping strategies. The most frequently mentioned adverse effects were hot flashes and night sweats, gynecomastia, cognitive decline, and changes in sexual function. Hot flashes did impact on everyday functioning, and night sweats regularly disturbed sleep patterns and led to participants feeling tired and irritable. Participants reported a lack of control over their hot flashes and night sweats. There was reluctance among our sample to disclose the type of symptoms experienced to others. The occurrence of andropause symptoms, including hot flashes and night sweats, was common among this sample. Participants reported a range of cognitive and behavioral responses to these symptoms. There was some reluctance about discussing a prostate cancer diagnosis or the occurrence of symptoms with others. The findings have implications for a range of individual and couple interventions to manage the impact of this constellation of symptoms.

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... Of the 573 articles identified, 15 studies with a total of 1491 participants met the prespecified eligibility for inclusion in this systematic review, as outlined in the PRISMA-P flow diagram ( Fig. 1) [27][28][29][30][31][32][33][34][35][36][37][38][39][40][41]. The mean number of participants per study was 99 (standard deviation [SD] 117.14). ...
... Qualitative studies A summary of the demographics and study design of the qualitative studies is presented in Table 1 [32][33][34][35][36][37][38][39][40][41]. A complete list of all findings by study is available in Supplementary Table 7. Thematic analysis revealed the following key themes: cancer progression and/or survival; pain; fatigue; and other symptoms (sexual dysfunction, bothersome lower urinary tract symptoms [LUTS]; Table 3) [26]. ...
... A complete list of all findings by study is available in Supplementary Table 7. Thematic analysis revealed the following key themes: cancer progression and/or survival; pain; fatigue; and other symptoms (sexual dysfunction, bothersome lower urinary tract symptoms [LUTS]; Table 3) [26]. Cancer progression and/or OS benefits related to treatment were a key theme extracted from five of the studies [35][36][37][38][39]. Dearden et al [37] undertook semistructured interviews with 38 patients with mCRPC who were receiving a novel antiandrogen therapy (abiraterone acetate or enzalutamide). ...
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Context Advances in systemic agents have increased overall survival for men diagnosed with metastatic prostate cancer. Additional cytoreductive prostate treatments and metastasis-directed therapies are under evaluation. These confer toxicity but may offer incremental survival benefits. Thus, an understanding of patients’ values and treatment preferences is important for counselling, decision-making, and guideline development. Objective To perform a systematic review of patients’ values, preferences, and expectations regarding treatment of metastatic prostate cancer. Evidence acquisition The MEDLINE, Embase, and CINAHL databases were systematically searched for qualitative and preference elucidation studies reporting on patients’ preferences for treatment of metastatic prostate cancer. Certainty of evidence was assessed using Grading of Recommendation, Assessment, Development and Evaluation (GRADE) or GRADE Confidence in the Evidence from Reviews of Qualitative Research (CERQual). The protocol was registered on PROSPERO as CRD42020201420. Evidence synthesis A total of 1491 participants from 15 studies met the prespecified eligibility for inclusion. The study designs included were discrete choice experiments (n = 5), mixed methods (n = 3), and qualitative methods (n = 7). Disease states reported per study were: metastatic castration-resistant prostate cancer in nine studies (60.0%), metastatic hormone-sensitive prostate cancer in two studies (13.3%), and a mixed cohort in four studies (26.6%). In quantitative preference elicitation studies, patients consistently valued treatment effectiveness and delay in time to symptoms as the two top-ranked treatment attributes (low or very low certainty). Patients were willing to trade off treatment-related toxicity for potential oncological benefits (low certainty). In qualitative studies, thematic analysis revealed cancer progression and/or survival, pain, and fatigue as key components in treatment decisions (low or very low certainty). Patients continue to value oncological benefits in making decisions on treatments under qualitative assessment. Conclusions There is limited understanding of how patients make treatment and trade-off decisions following a diagnosis of metastatic prostate cancer. For appropriate investment in emerging cytoreductive local tumour and metastasis-directed therapies, we should seek to better understand how this cohort weighs the oncological benefits against the risks. Patient summary We looked at how men with advanced (metastatic) prostate cancer make treatment decisions. We found that little is known about patients’ preferences for current and proposed new treatments. Further studies are required to understand how patients make decisions to help guide the integration of new treatments into the standard of care.
... While the 5-year survival rate in the UK is generally good, PCa survivors face unwanted treatment side effects, which are particularly troublesome following androgen deprivation therapy (ADT) and which can continue for up to 5-8 years [2]. These include hot flushes and night sweats (HFNS), gynecomastia, cognitive function, and changes in sexual function [3]. HFNS are estimated to affect up to 80% of PCa patients [4], and are associated with distress and reduced quality of life -particularly affecting sleep and physical well-being [5]. ...
... Little research has been carried out on appraisals and reactions to HFNS in men with PCa, but one qualitative study of men having ADT [3] found that men reported a lack of control over their HFNS and there was reluctance to disclose the type of symptoms that they experienced to others. In a qualitative study aimed to specifically examine cognitions and behaviours relating to HFNS in men undergoing ADT for PCa [21], five main cognitive appraisals relating to HFNS were identified: changes in oneself, impact on masculinity, embarrassment/social-evaluative concerns, perceived control and acceptance/adjustment. ...
... Their concern about their illness being exposed to others by their HFNS might reflect difficulty in dealing with their illness in general, possibly stigma about a cancer diagnosis or not knowing how to answer questions from other people [21]. Concerns about masculinity are common amongst men with PCa, for whom sexual problems and gynecomastia are treatment side effects [3,[32][33][34], and there is evidence suggesting that this is particularly the case for younger men following radical prostatectomy [35]. For both the current sample and for women with HFNS, embarrassment and concern about hot flushes in social situations is associated with 'having to leave or avoid social situations because of hot flushes'. ...
... However it remains debatable whether this small advantage can be meaningful when applied to everyday clinical practice. In respect of individualised patient care, it has to be recognised that patients on MAB experience a significant impairment of quality of life in the areas of sexuality (including loss of libido and erectile dysfunction), cognitive function and body temperature regulation (Cruz Guerra, 2009;Grunfeld et al, 2012 ). Therefore, when nurses are discussing when nurses are discussing MAB with patients, as with ADT, raising the effect on quality of life is of paramount importance. ...
... Patients may be anxious about the effect of the condition and its treatment on body image and sexuality and its effect on relationships (Grunfeld et al, 2012). Psychological support is key when providing holistic care, because metastatic patients report great levels of distress and high levels of bone pain (Langford et al, 2011). ...
Article
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Advances in diagnosis mean that prostate cancer can be detected in the early stages, when options such as surgery and radiotherapy offer curative approaches and active surveillance is appropriate. However, advanced or metastatic disease continues to challenge medical management, which offers only palliative approaches. With such a prognosis, effective treatment of metastatic and metastatic castrate-resistant prostate cancer (mCRPC) is an important element of the management of these patients. The second article of this two-part series focuses on the main management approaches, emerging therapies and nursing roles.
... ADT has many deleterious side effects, including potential deficits in cognitive function (reviewed in [2][3][4]). Furthermore, ADT can also result in suboptimal sleep, fatigue, and depression [5][6][7][8][9][10][11][12], all of which may contribute to cognitive decline. ...
... In addition, what needs to be explored in future studies is other factors known to be linked to cognition, such as sleep function. Based on self-reports from PCa patients, ADT results in sleep disturbance [5][6][7][8]. Using actigraphy, Hanisch et al. [109] found that, on average, PCa patients on ADT required more than 30 minutes to fall asleep, slept for only about 6 hours, and woke up 2.7 times per night. ...
Article
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Background: Many prostate cancer (PCa) patients are on androgen deprivation therapy (ADT) as part of their cancer treatments but ADT may cause cognitive impairments. ADT depletes men of both androgen and estrogen. Whether estradiol supplementation can improve cognitive impairments in patients on ADT is understudied. Objective: To summarize data on the effects of estradiol treatment on cognitive function of androgen-deprived genetic male populations (PCa patients and male-to-female transsexuals) and castrated male animals. Method: Publications were identified by a literature search on PubMed and Google Scholar. Results: While some studies showed that estradiol improves cognitive function (most notably, spatial ability) for castrated rats, what remain uninvestigated are: 1) whether estradiol can improve cognition after long-term androgen deprivation, 2) how estradiol affects memory retention, and 3) how early vs. delayed estradiol treatment after castration influence cognition. For androgen-deprived genetic males, estradiol treatment may improve some cognitive functions (e.g., verbal and visual memory), but the findings are not consistent due to large variability in the study design between studies. Conclusion: Future studies are required to determine what the best estradiol treatment protocol is to maximize cognitive benefits for androgen-deprived genetic males. Tests that assess comparable cognitive domains in human and rodents are needed. What particularly under-investigated is how the effects of estradiol on cognitive ability intersect with other parameters; sleep, depression and physical fatigue. Such studies have clinical implications to improving the quality of life for both PCa patients on ADT as well as for male-to-female transsexuals.
... The management of CRPC has been transformed with the introduction of these new agents but questions regarding their optimum timing, combination therapy and toxicity profile still need to be answered. [168,[188][189][190][191][192][193]. The constellation of ADT induced serious toxicities is labelled as 'castration syndrome' or 'androgen deprivation syndrome', and it has a huge negative impact upon the quality of life (QoL) of the patients [168,194,195]. ...
... Vasomotor symptoms including hot flushes and night sweats are frequently reported by patients undergoing ADT for PC [188,192,193,265]. Sharp decline in circulating sex hormone levels brought about by ADT is thought to induce re-setting of the thermostat in pre-optic area of hypothalamus to a lower point, which causes hyperactivation of peripheral thermoregulatory mechanisms resulting in development of hot flushes and night sweats [168]. ...
... Hot flashes and nocturia were the factors most commonly reported by the patients as contributing to their awakenings. Interestingly, a qualitative study of 21 men receiving ADT for metastatic prostate cancer suggested the existence of an interaction between climacteric symptoms, urinary incontinence , and sleep impairments [15]. More precisely, some participants reported that when awakened at night because of night sweats, they would then feel a sense of urgency to urinate that would require them to get up, thereby lengthening their time awake and possibly diminishing their ability to go back to sleep. ...
... Unexpectedly, the increase in excessive urinary frequency persisted throughout the duration of the study in ADT–RTH patients, whereas it was only transient in RTH patients. This finding raises the possibility of an additive effect of ADT over the negative impact already documented for RTH, which is consistent with the findings of Grunfeld et al. [15] already discussed and which indicate that night sweats induced by ADT could lead to increased urinary symptoms at night when associated with awakenings. Finally, this study provided some evidence that the impact of ADT and RTH for prostate cancer on insomnia symptoms is not a direct one but is mediated by levels of climacteric and urinary symptoms. ...
... Sexual activity has been shown to decline considerably in PC patients on ADT with up to 85 % of the patients reporting sexual side effects. 12,31,41,42 This sexual inactivity is a consequence of diminished libido, physical changes (decreased strength, adiposity, genital shrinkage), and erectile dysfunction. 12,43 Loss of masculine traits in PC patients negatively impacts their psychosocial and sexual life. ...
... *The primary cardiovascular analysis was based on a modified intention-to-treat approach: patients were included in the estrogen patch group if they had been treated with patches at any point, and were included in the luteinizing hormone-releasing hormone agonist (LHRHa) group if they had received LHRH but not patches at any point. Median follow-up was 19 months (interquartile range[12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31]. The analysis was not powered to compare treatment groups. ...
Article
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Androgen deprivation therapy (ADT) resulting in testosterone suppression is central to the management of prostate cancer (PC). As PC incidence increases, ADT is more frequently prescribed, and for longer periods of time as survival improves. Initial approaches to ADT included orchiectomy or oral estrogen (diethylstilbestrol [DES]). DES reduces PC-specific mortality, but causes substantial cardiovascular (CV) toxicity. Currently, luteinizing hormone-releasing hormone agonists (LHRHa) are mainly used; they produce low levels of both testosterone and estrogen (as estrogen in men results from the aromatization of testosterone), and many toxicities including osteoporosis, fractures, hot flashes, erectile dysfunction, muscle weakness, increased risk for diabetes, changes in body composition, and CV toxicity. An alternative approach is parenteral estrogen, it suppresses testosterone, appears to mitigate the CV complications of oral estrogen by avoiding first-pass hepatic metabolism, and avoids complications caused by estrogen deprivation. Recent research on the toxicity of ADT and the rationale for revisiting parenteral estrogen is discussed.
... Prostate cancer (PC) is the second most common cancer among men worldwide [1]. The most common symptoms are difficulty in urinating, erectile dysfunction and problems during sexual intercourse [2,3]. Genetic background contributes to PC risk, as suggested by associations with race, family and specific gene variants [4,5]. ...
Article
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Background Prostate cancer (PC) is the second most common cancer among men in the United States, and it imposes a considerable threat to human health. A deep understanding of its underlying molecular mechanisms is the premise for developing effective targeted therapies. Recently, deep transcriptional sequencing has been used as an effective genomic assay to obtain insights into diseases and may be helpful in the study of PC.Methods In present study, ChIP-Seq data for PC and normal samples were compared, and differential peaks identified, based upon fold changes (with P-values calculated with t-tests). Annotations of these peaks were performed. Protein¿protein interaction (PPI) network analysis was performed with BioGRID and constructed with Cytoscape, following which the highly connected genes were screened.ResultsWe obtained a total of 5,570 differential peaks, including 3,726 differentially enriched peaks in tumor samples and 1,844 differentially enriched peaks in normal samples. There were eight significant regions of the peaks. The intergenic region possessed the highest score (51%), followed by intronic (31%) and exonic (11%) regions. The analysis revealed the top 35 highly connected genes, which comprised 33 differential genes (such as YWHAQ, tyrosine 3-monooxygenase/tryptophan 5-monooxygenase activation protein and ¿ polypeptide) from ChIP-Seq data and 2 differential genes retrieved from the PPI network: UBA52 (ubiquitin A-52 residue ribosomal protein fusion product 1) and SUMO2 (SMT3 suppressor of mif two 3 homolog 2) .Conclusions Our findings regarding potential PC-related genes increase the understanding of PC and provides direction for future research.
... 안면홍조는 인종, 문화, 식이, 기후, 생활습관에 따라 정도 의 차이가 다양한 것으로 알려져 있다. 유럽과 미국여성이 아 시아 여성에 비해 안면홍조를 경험하는 비율이 높으며 (Freeman & Sherif, 2007;Gold et al., 2000), 체질량 지수 (Kim & Sunwoo, 2007), 흡연 (Cochran, Gallicchio, Miller, Zacur, & Flaws, 2008), 불규칙한 식습관 (Dormire & Reame, 2003), 카페인 섭취 (Lee, Kang, Kim, Park, & Song, 2011), 부정적인 감정 (Gold et al., 2006) (Engstrom, 2008;Frisk, 2010;Grunfeld et al., 2012;Kaplan et al., 2011), 국내에서는 Kim 등(2009) ...
Article
Purpose: This research investigated the degree and predictors of hot flashes and hypogonadism symptoms in patients with prostate cancer receiving hormone replacement therapy. Methods: The subjects were 111 patients with prostate cancer receiving hormone replacement therapy in two university hospitals located in D city. The measurement tools included Hot Flash Diary and AMS (Aging Male's Symptoms rating scales). The data were analyzed using t-test, ANOVA, and binary logistic regression analysis. Results: The percentage of patients who experienced hot flashes among the participants was 14.4%. The predictors for hot flashes were eating irregularly, having coffee frequently and the types of hormone. The average score of hypogonadism symptom was 2.16 out of five-point scale and the highest score of hypogonadism symptom was the sexual symptoms (2.77 out of five-point scale). The predictors for hypogonadism symptom were eating habits and years of having the illness. Conclusion: These findings provide the information that irregularly eating habit was an important factor in hot flashes and hypogonadism symptoms of the participants. Therefore the development of a nutritional education encouraging regular meals is necessary for the given population.
... Prostate cancer is the most common cancer among men in the United Kingdom and the second leading cause of cancer related death in men in the Western world [1]. Androgen deprivation therapy (ADT) is prescribed to inhibit cancer progression [2] but is associated with debilitating side effects, including hot flushes and night sweats (HFNS), that affect up to 80% of men having ADT [3,4]. HFNS are not well understood; reductions in androgen levels are believed to alter the function of brain neurotransmitters, leading to disruption of the thermoregulatory system in the hypothalamus [4,5]. ...
Article
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Objective Hot flushes and night sweats (HFNS) are experienced by up to 80% of prostate cancer patients undergoing androgen deprivation therapy (ADT). This study evaluates the effects of a guided self-help cognitive behavioural therapy (CBT) intervention on HFNS problem-rating (primary outcome), HFNS frequency, mood and health-related quality of life (secondary outcomes) in patients undergoing ADT. Methods Patients reporting treatment-induced HFNS were randomly assigned to CBT (n=33) or treatment as usual (TAU) (n=35), stratified for cancer type. The CBT intervention included a booklet, CD plus telephone contact during a 4-week period. Validated self-report questionnaires were completed at baseline, 6weeks and 32weeks after randomisation. The primary outcome was HFNS problem rating (perceived burden of HFNS) at 6weeks after randomisation. Potential moderators and mediators were examined. Data analysis was conducted on a modified intention-to-treat basis. ResultsCompared with TAU, CBT significantly reduced HFNS problem rating (adjusted mean difference: -1.33, 95% CI -2.07 to -0.58; p=0.001) and HFNS frequency (-12.12, 95% CI -22.39 to -1.84; p=0.02) at 6weeks. Improvements were maintained at 32weeks, but group differences did not reach significance. There were significant reductions in negative HFNS Beliefs and Behaviours following CBT, but not in mood or quality of life. Conclusions Guided self-help CBT appears to be a safe and effective brief treatment for men who have problematic HFNS following prostate cancer treatments. Further research might test the efficacy of the intervention in a multicentre trial. (c) 2015 The Authors. Psycho-Oncology published by John Wiley & Sons Ltd.
... A number of studies suggest that testosterone is linked to a worsening of obstructive sleep apnoea in men [71,[73][74][75]; however, blocking androgen action, via flutamide administration, does not affect sleep architecture or breathing parameters in men with sleep apnoea [76]. Interestingly, androgen deprivation therapy (ADT) for prostate cancer is highly associated with insomnia, potentially as a consequence of an increased occurrence of hot flushes and night sweats [77,78]. Although rare, oestrogen therapy is an effective therapeutic for ADT-induced hot flushes [79][80][81]. ...
Article
Full-text available
Men and women sleep differently. While much is known about the mechanisms that drive sleep, the reason for these sex differences in sleep behaviour is unknown and understudied. Historically, women and female animals are underrepresented in studies of sleep and its disorders. Nevertheless, there is a growing recognition of sex disparities in sleep and rhythm disorders. Women typically report poorer quality and more disrupted sleep across various stages of life. Findings from clinical and basic research studies strongly implicate a role for sex steroids in sleep modulation. Understanding how neuroendocrine mediators and sex differences influence sleep is central to advancing our understanding of sleep-related disorders. The investigation into sex differences and sex steroid modulation of sleep is in its infancy. Identifying the mechanisms underlying sex and gender differences in sleep will provide valuable insights leading to tailored therapeutics that benefit each sex. The goal of this review is to discuss our current understanding of how biological sex and sex steroids influence sleep behaviour from both the clinical and pre-clinical perspective.
... Not all men are aware that hot flushes are a side effect of ADT leading to confusion and anxiety (Grunfeld, Halliday, Martin, & Drudge-Coates, 2012). In addition, embarrassment and perceptions of altered masculinity may result from hot flushes and men may report feelings of powerlessness and difficulties adjusting to bodily changes associated with treatment (Eziefula, Grunfeld, & Hunter, 2013). ...
Article
Up to 80% of men who receive androgen deprivation therapy report hot flushes and for many these are associated with reduced quality of life. However it is recognised that there are a number of barriers to men’s engagement with support to manage symptoms and improve quality of life. This qualitative study was embedded within a larger randomised controlled trial (MANCAN) of a guided self-help cognitive behavioural intervention to manage hot flushes resulting among men receiving androgen deprivation therapy. The study aimed to explore the engagement and experiences with the guided self-help intervention. Twenty men recruited from the treatment arm of the MANCAN trial participated in a semi-structured interview exploring acceptability of the intervention, factors affecting engagement and perceived usefulness of the intervention. Interviews were audio-recorded, transcribed verbatim and analysed using a Framework approach. Over two thirds of respondents (69%) reported reading the intervention booklet in full and over 90% reporting practising the relaxation CD at least once a week. Analysis of the interviews identified three super-ordinate themes and these related to changes in hot flush symptomatology (learned to cope with hot flushes in new ways), the skills that participants had derived from the intervention (promoting relaxation and reducing stressors), and to a broader usefulness of the intervention (broader impact of the intervention and skills). The present study identified positive engagement with a guided self-help intervention and that men applied the skills developed through the intervention to help them undertake general lifestyle changes. Psycho-educational interventions (e.g. cognitive behaviour therapy, relaxation, and positive lifestyle elements) offer the potential to be both effective and well received by male cancer survivors.
... ADT has been linked to anxiety and depression in patients [2][3][4]. Conspicuous to patients are not just physical changes (e.g., hot flashes, gynecomastia, loss of body hair, and weight gain), but sexual (lost libido and erection dysfunction), and emotional changes (depression, tearfulness, and fatigue), all of which negatively impact on patients' quality of life of and indirectly on their partners [5][6][7][8]. Men on intermittent ADT report lower physical and psychological quality of life when on ADT compared to off periods [9]. ...
Article
Objective: Prostate cancer and its treatments, particularly androgen deprivation therapy (ADT), affect both patients and partners. This study assessed how prostate cancer treatment type, patient mood, and sexual function related to dyadic adjustment from patient and partner perspectives. Methods: Men with prostate cancer (n = 206) and partners of men with prostate cancer (n = 66) completed an online survey assessing the patients' mood (profile of mood states short form), their dyadic adjustment (dyadic adjustment scale), and sexual function (expanded prostate cancer index composite). Results: Analyses of covariance found that men on ADT reported better dyadic adjustment compared with men not on ADT. Erectile dysfunction was high for all patients, but a multivariate analysis of variance found that those on ADT experienced greater bother at loss of sexual function than patients not on ADT, suggesting that loss of libido when on ADT does not mitigate the psychological distress associated with loss of erections. In a multiple linear regression, patients' mood predicted their dyadic adjustment, such that worse mood was related to worse dyadic adjustment. However, more bother with patients' overall sexual function predicted lower relationship scores for the patients, while the patients' lack of sexual desire predicted lower dyadic adjustment for partners. Conclusions: Both patients and partners are impacted by the prostate cancer treatment effects on patients' psychological and sexual function. Our data help clarify the way that prostate cancer treatments can affect relationships and that loss of libido on ADT does not attenuate distress about erectile dysfunction. Understanding these changes may help patients and partners maintain a co-supportive relationship. Copyright © 2015 John Wiley & Sons, Ltd.
... The consequences of TD are the same whether or not a man has a history of PCa. Symptoms include sexual dysfunction, depressed mood, cognitive decline, hot flashes, fatigue, loss of muscle mass and strength, and irritability [7]. TD also reduces bone mineral density, increases the risk for development of obesity [8], type 2 diabetes [9] and cardiovascular events [10], and is associated with increased all-cause and CVD mortality [11][12][13]. ...
Article
Introduction: The use of testosterone therapy (TTh) in men with prostate cancer (PCa) is relatively new, and controversial, due to the longstanding maxim that TTh is contraindicated in men with PCa. Scientific advances have prompted a reevaluation of the potential role for TTh in men with PCa, particularly as TTh has been shown to provide important symptomatic and general health benefits to men with testosterone deficiency (TD), including many men with PCa who may expect to live 30-50 years after diagnosis. Areas covered: This review outlines the historical underpinnings of the historical belief that TTh “fuels” PCa and the experimental and clinical studies that have radically altered this view, including description of the saturation model. The authors review studies of TTh in men with PCa following radical prostatectomy and radiation therapy, in men on active surveillance, and in men with advanced or metastatic PCa. Expert opinion: TTh provides important symptomatic and overall health benefits for men with PCa who have TD. Although more safety studies are needed, TTh is a reasonable therapeutic option for men with low-risk PCa after surgery or radiation. Data in men on active surveillance are limited, but initial reports are reassuring.
... 5,7,8) 남성호르몬차단요법의 치료기간에 따른 각 신체증상에 대해 서구, 유럽국가들에서는 많은 연구들이 진행되고 있다. 2,4,7,9) ...
... Gynecomastia and hot flashestwo of the four posttreatment symptoms related to the symptom clusterare side-effects of androgen deprivation therapy. Studies have previously indicated that these are associated with stigma, shame, loss of masculinity and psychological distress [36,37]. As regards urinary incontinence, men who experience this may fear smelling or leakage of urine and find using incontinence pads embarrassing [38]; this may lead to social isolation and increased risk of depression [39]. ...
Article
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Purpose: Pain, fatigue and depression are common sequelae of a cancer diagnosis. The extent to which these occur together in prostate cancer survivors is unknown. We (i) investigated prevalence of the pain-fatigue-depression symptom cluster and (ii) identified factors associated with experiencing the symptom cluster among prostate cancer survivors. Methods: Men in Ireland diagnosed with prostate cancer 2-18 years previously were identified from population-based cancer registries and sent postal questionnaires. Cancer-related pain and fatigue were measured using the EORTC QLQ-C30 and depression using the DASS-21. Cut-offs to define 'caseness' were pain ≥ 25, fatigue ≥ 39 and depression ≥ 10. Associations between survivor-related factors, clinical variables and specific prostate cancer physical symptoms and the symptom cluster were assessed using multivariate logistic regression. Results: A total of 3348 men participated (response rate = 54%). Twenty-four percent had clinically significant pain, 19.7% had clinically significant fatigue, and 14.4% had depression; 7.3% had all three symptoms. In multivariate analysis, factors significantly associated with the symptom cluster were living in Northern Ireland, experiencing back pain at diagnosis and being affected by incontinence, loss of sexual desire, bowel problems, gynecomastia and hot flashes post-treatment. There was a strong association between the cluster and health-related quality of life. Conclusions: The pain-fatigue-depression symptom cluster is present in 1 in 13 prostate cancer survivors. Physical after-effects of prostate cancer treatment are associated with this cluster. More attention should be paid to identifying and supporting survivors who experience multiple symptoms; this may help health-related quality of life improve among the growing population of prostate cancer survivors.
... In a sample of 12 Canadian men interviewed about perceived effects of their ADT, several themes emerged such as contrasts between expectations and reality of treatment in addition to impacts on sexual function and relationships [20]. In a sample of 21 men with metastatic prostate cancer interviewed at a London teaching hospital, the primary adverse effects of ADT reported by patients were hot flashes, gynecomastia, cognitive decline, and diminished sexual function [21]. Three Canadian men interviewed about their ADT experience and exercise drew connections to music and routines [22]. ...
Article
Objective: We undertake qualitative research with men treated in a Pretoria, South Africa Oncology clinic to address men’s self-reported experiences on androgen deprivation therapy (ADT). Methods: Analyses rely upon 22 men’s responses to open-ended questions during interviews. These men were 63–78 years of age, and almost all married (three widowed), had children and were no longer engaged in paid work. Results: In addressing questions about the anticipated and experienced positive and broader side effects of ADT, men referred to its treatment for prostate cancer, with several generally specifying health or life. Patients also referred to a variety of more specific effects such as pain, nausea, difficulties urinating, gaining weight, low energy and sleep disruptions that appeared to reflect a mixture of influences of prostate cancer, ADT and oncological treatment. In addressing a question about the effects of ADT on romantic/sex life, 16 of 19 married men referred to deleterious impacts on their sex lives. With respect to perceived family, work or broader social life impacts, some men noted others’ worries and social support. Conclusion: Findings are situated within discussions of existing research on ADT largely from North American or European samples, and broader views of testosterone and male social behavior.
... Our previous metasyntheses of qualitative literature illustrated that men with advanced PCa can experience uncertainty, loss and isolation; feel physically restricted; and lament altered career plans and a disrupted future [10][11][12][13][14]. However, previous qualitative research on men with advanced PCa is either focused specifically on symptoms [10,15,16], spirituality [17] or decision-making [12] or conducted with men 'close to death' [18] or with castrate-refractory PCa [10,19,20]. Few studies [11,21] have explored men's coping or adjustment strategies to living with advanced PCa and particularly the impact of disease and treatment-related challenges. ...
Article
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PurposeDue to recent treatment advances, men are increasingly living longer with advanced prostate cancer (PCa). This study sought to understand men’s experiences of living with and adjusting to advanced hormone-responsive PCa and how this influenced their quality of life (QoL), in order to highlight how support could be optimized.Methods Participants were recruited through a UK wide survey—the ‘Life After Prostate Cancer Diagnosis’ study. In-depth telephone interviews were conducted with 24 men (aged 46–77 years) with advanced (stage IV) hormone-responsive PCa diagnosed 18–42 months previously. Thematic analysis was undertaken using a framework approach.ResultsMost participants perceived their QoL to be relatively good, which was influenced by the following factors (enablers to ‘living well’ with PCa): a sense of connectedness to others, engagement in meaningful activities, resources (social, cognitive, financial), ability to manage uncertainty, utilization of adjustment strategies and support, communication and information from health professionals. Barriers to ‘living well’ with PCa were often the converse of these factors. These also included more troublesome PCa-related symptoms and stronger perceptions of loss and restriction.Conclusions In our study, men living with advanced hormone-responsive PCa often reported a good QoL. Exploring the influences on QoL in men with advanced PCa indicates how future interventions might improve the QoL of men who are struggling. Further research is required to develop and test interventions that enhance QoL for these men.
... Sleep problems are common for PCa patients, 1-3 e.g., urinary symptoms after prostatectomy can disrupt sleep at night. 1 Furthermore PCa patients on androgen deprivation therapy (ADT) often have nocturnal hot flashes that lead to frequent awakening. 2,4,5 Sleep disruption can often lead to other side effects such as daytime fatigue that can further reduce patients' quality of life. ...
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Introduction Many men with prostate cancer (PCa) experience insomnia symptoms post-treatment. We explore here PCa patients’ preference for strategies to manage their sleep. Patients and Methods A brief online survey was launched on Facebook and promoted by Prostate Cancer Foundation New Zealand. The survey contained validated questionnaires on various sleep-related parameters, as well as questions about sleep management strategies. Results We recruited 82 PCa patients (67.9 ± 6.3 years old). Participants with high insomnia severity index (ISI) scores reported significantly worse daytime sleepiness, more severe fatigue, being less of a “morning person”, and more frequent dreaming. Most participants (71–95%) were open to trying behavioural strategies for improving sleep hygiene, especially by improving their sleeping conditions and having a consistent sleep-wake schedule. Insomnia severity and past use of androgen deprivation therapy were significant predictors for the number of sleep treatments used. Participants with a high ISI were more likely to have used medication, CBT, and herbal remedies or supplements for treating sleep issues than those with low ISI. Furthermore, in patients who had not used these treatments options, those with a high ISI were more willing to try CBT and hypnosis compared to those with a low ISI. Reasons for not willing to try various sleep treatments were documented. Conclusion Most PCa patients are willing to adjust their behavior or lifestyle to improve their sleep habits/behaviours. Patients with severe insomnia are more likely to have both used and express willingness to try, interventions to improve sleep, with preferences for CBT and hypnosis.
... For example, urinary symptoms after a prostatectomy may wake up patients multiple times a night [1]. Furthermore, androgen deprivation therapy (ADT) in men with systemic PCa, often causes nocturnal hot flashes that lead to frequent awakening [2,4,5]. Sleep disruption can lead to other outcomes such as daytime fatigue, sleepiness, and cognitive changes that affect patients' quality of life. ...
Article
Introduction: Insomnia symptoms are common among prostate cancer (PCa) patients. We explore here whether education level is associated with sleep-related outcomes, and preference for sleep management strategies. Methods: A short online survey was posted on Facebook with the help of Prostate Cancer Foundation New Zealand. The survey consisted of scales on sleep-related parameters, as well as questions about sleep management strategies. Results: Demographic data were similar between participants with (n = 49) and without (n = 32) university education. Participants with no university education were more likely to receive external beam radiation (P = 0.035) than participants without university education. In addition, those without university education also had significantly more comorbidities (P = 0.046), higher body mass index (P = 0.048), and more severe fatigue (P = 0.031) but similar levels of insomnia symptoms (P = 0.50), sleepiness (P = 0.36) and morningness-eveningness (P = 0.07) than those with university education. After controlling for age, number of comorbidities, and insomnia severity, lower education was associated with lower likelihood of having used herbal remedies or supplements for improving sleep (OR = 0.208, P = 0.041). Education level is not related to the use of sleep medication, cognitive behaviour therapy, mindfulness, acupuncture, hypnosis for sleep management in PCa patients. Conclusion: Education level is not associated with insomnia symptoms, but with fatigue level and the use of herbal remedies or supplements for sleep management in PCa patients.
... Grunfield et al. examined sleep quality and duration in patients with metastatic PCa undergoing ADT with focus groups. 87 Participants reported having nocturia and hot flashes or night sweats that negatively impacted sleep quality and duration. Some participants reported behavioral responses (e.g., changing pillows and room temperature). ...
Article
Objective/Background To examine the impact of prostate cancer (PCa) on sleep health for patients and caregivers. We hypothesized that sleep disturbances and poor sleep quality would be prevalent among patients with PCa and their caregivers. Patients/Methods A systematic literature search was conducted according to the Preferred Reporting Items for a Systematic Review and Meta-analysis guidelines. To be eligible for this systematic review, studies had to include: (1) patients diagnosed with PCa and/or their caregivers; and (2) objective or subjective data on sleep. 2,431 articles were identified from the search. After duplicates were removed, 1,577 abstracts were screened for eligibility, and 315 underwent full-text review. Results and Conclusions Overall, 83 articles met inclusion criteria and were included in the qualitative synthesis. The majority of papers included patients with PCa (98%), who varied widely in their treatment stage. Only 3 studies reported on sleep among caregivers of patients with PCa. Most studies were designed to address a different issue and examined sleep as a secondary endpoint. Commonly used instruments included the Insomnia Severity Index and European Organization for Research and Treatment of Cancer Core Quality of Life Questionnaires (EORTC-QLQ). Overall, patients with PCa reported a variety of sleep issues, including insomnia and general sleep difficulties. Both physical and psychological barriers to sleep are reported in this population. There was common use of hypnotic medications, yet few studies of behavioral interventions to improve sleep for patients with PCa or their caregivers. Many different sleep issues are reported by patients with PCa and caregivers with diverse sleep measurement methods and surveys. Future research may develop consensus on validated sleep assessment tools for use in PCa clinical care and research to promote facilitate comparison of sleep across PCa treatment stages. Also, future research is needed on behavioral interventions to improve sleep among this population.
... Gynaecomastia poses a potential downside to the psychological health of men on ADT and needs to be considered when balancing the costs and benefits of ADT options. Although only one-third of men who develop gynaecomastia show symptoms, it can negatively affect self-image and consequently reduce overall quality of life [10,11]. ...
Article
The impact of oncologic treatments on fertility and menopausal symptoms is often significant for patients with cancer. Surgery, radiation, and chemotherapy can all damage the reproductive organs or the hypothalamic pituitary axis that controls them, impairing fertility and causing hormonally mediated symptoms such as hot flashes. Understanding these risks and strategies to mitigate them may substantially improve cancer survivorship care. For both female and male patients who desire a future biologic child, there are a variety of fertility preservation techniques that should be considered. For cancer survivors who experience menopausal symptoms, lifestyle changes may be beneficial, and hormonal and nonhormonal pharmacologic agents are well proven to reduce symptom burden.
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Objective: For many survivors of prostate cancer, returning to work posttreatment is a realistic goal. However, little research to date has explored work among prostate cancer survivors. The focus of this study was to explore the meaning of work among prostate cancer survivors and to describe the linkages between masculinity and work following prostate cancer treatment. Method: Fifty prostate cancer survivors who were in paid employment prior to their diagnosis completed a semistructured interview following completion of their treatment and of these, 41 also completed a 12-month follow-up interview. Framework analysis of the 91 transcripts was undertaken. Results: The majority of the men had returned to work at the 12-month interview. Four themes were identified, and these were labeled "Work and self-identity," "Work-related implications of treatment side effects," "Disclosure of cancer," and "Perceptions of future as a cancer survivor." A degree of embarrassment and concern about residual side effects and whether these would present a challenge within the workplace was apparent among our sample and was compounded by a reluctance to disclose these. Conclusions: The descriptions provided by the men in this study reveal that the experience of prostate cancer can lead to challenges for both social and work-related roles. The influence of prostate cancer on men's reports of masculinity was variable, and recognition of these differences is required. In addition, some survivors of prostate cancer may require specific interventions aimed at helping them to manage disclosure of their illness, particularly within a work environment.
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Abstract This study sought to explore the lived experiences of physically active prostate cancer survivors on androgen deprivation therapy (ADT), who exercise individually. Three older men (74-88 years old) with prostate cancer, using ADT continuously for at least 12 months and regularly exercising for at least 6 months, participated in this qualitative pilot study, informed by interpretive phenomenology. Data were gathered using individual semi-structured interviews, audio recorded and transcribed verbatim. Coherent stories were drawn from each transcript and analyzed using iterative and interpretive methods. van Manen's lifeworld existentials provided a framework for interpreting across the research text. Three notions emerged: Getting started, Having a routine and Being with music. Together they reveal what drew the participants to exercising regularly despite the challenges associated with their cancer and treatments. This study provides insights into the benefits of, and what it means for, older men with prostate cancer to regularly exercise individually. These findings may assist cancer clinicians and other allied health professionals to be more attuned to prostate cancer survivors' lived experiences when undergoing ADT, allowing clinicians to better promote regular exercise to their patients as a foundational component of living well.
Article
Background/purpose: Modern men have changed their beauty and grooming habits, which has resulted in an increasing demand for cosmetics for men. However, very little information is available about the dermatological needs of male skin. Therefore, the aim of this present clinical study was to conduct the first systematic assessment of the skin physiology of men with special attention to lifetime changes. Methods: A total of 150 healthy male subjects (aged 20-70 years) were selected following strict criteria, including age, sun behavior and smoking habits. Transepidermal water loss (TEWL), hydration level, sebum production and pH values were measured with worldwide-acknowledged biophysical measuring methods at the forehead, cheek, neck, volar forearm and dorsum of hand. Results: TEWL and sebum production vary by localization, but generally not with increasing age, whereas stratum corneum (SC) hydration decreases significantly at the face and neck. The greatest decrease was assessed at the forehead. Skin surface pH significantly increases with aging in the face. Conclusion: The present study assigns for the first time systematic reference values for standardized biophysical measuring methods and localizations reflecting the skin physiology of men in relation to age. The results show that the physiology of male skin partly changes with aging. While SC hydration and skin surface pH are affected by the subject's age, TEWL and sebum production show only minor variations.
Article
Men with prostate cancer (PCa) frequently undergo androgen deprivation therapy (ADT), typically in the form of a depot injection of luteinizing hormone-releasing hormone agonists (LHRHa). LHRHa are associated with many adverse effects (eg, hot flashes, sexual dysfunction, loss of muscle mass, osteopenia, metabolic syndrome), which drastically impact patient quality of life. This literature review, which includes a comprehensive table documenting prevalence rates, provides a quick reference for health care professionals involved in the care of men undergoing ADT with LHRHa. Primary sources were acquired from PubMed using the search terms "androgen deprivation therapy" and each potentially adverse effect (eg, "androgen deprivation therapy and hot flashes"). Commonly cited review articles were also examined for citations of original studies containing prevalence rates. More than 270 articles were reviewed. In contrast to many existing reviews, rates are cited exclusively from original sources. The prevalence rates, obtained from original sources, suggest that more than half of documented adverse effects are experienced by as many as 40% or more of patients. A critique of the literature is also provided. Although there is a vast literature of both original and review articles on specific adverse effects of LHRHa, the quality of research on prevalence rates for some adverse effects is subpar. Many review articles contain inaccuracies and do not cite original sources. The table of prevalence rates will serve as a quick reference for health care providers when counseling patients and will aid in the development of evidence-based patient education materials.
Article
Hot flushes and night sweats are common amongst menopausal women, and psychological interventions for managing these symptoms have recently been developed for women. However, flushes in men with prostate cancer, which commonly occur following androgen deprivation therapy (ADT), remain under-researched. This study is a qualitative exploration of flush-related cognitive appraisals and behavioural reactions reported by a sample of these men. Semi-structured, in-depth interviews were conducted with 19 men who were experiencing flushes after receiving ADT for prostate cancer. Framework analysis was used to generate and categorise emergent themes and explore associations between themes. Five main cognitive appraisals included the following: changes in oneself, impact on masculinity, embarrassment/social-evaluative concerns, perceived control and acceptance/adjustment. There were men who held beliefs about the impact of flushes on their perceptions of traditional gender roles, who experienced shame and embarrassment due to concerns about the salience of flushes and perceptions by others and who experienced feelings of powerlessness over flushes. Powerlessness was associated with beliefs about the potentially fatal consequences of discontinuing treatment. Two other dominant themes included awareness/knowledge about flushes and management strategies. Experiences of flushes appeared to be influenced by upbringing and general experiences of prostate cancer and ADT. The range of men's appraisals of, and reactions to, flushes generated from this qualitative exploration were broadly similar to those of menopausal women but differed in terms of the influence of masculinity beliefs. These findings could be used to inform future research and psychological interventions in this under-researched field. Copyright © 2013 John Wiley & Sons, Ltd.
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Andropause is a condition of decreasing testosterone in men that usually begins to occur at about 40 years of age. Many men find it difficult to acknowledge there may be a problem by refusing to even talk about the symptoms. The study was conducted to the standards of MASSQ (2012) within male older adults to introduce a relevant criterion. About 382 men with age range of 50-80 and with the mean age of 65.3 ± 2.32 were sampled with the cluster-ratio sampling method from the eight cities of Khuzestan province in southwestern Iran. The aged samples replied to the 25 items of MASSQ. Coefficients of Cronbach's alpha (α = 0.89), split-half (0.91), convergent validity (0.72), divergent validity (-0.32), and criterion validity (0.67) were estimated, which were significant at P < 0.01. The exploratory factor analysis demonstrated that the 25-items of MASSQ for aged samples are organized into four factors (sexual, somatic, psychic, and behavioral) which clarify 79% of the scale's variance. Second-order confirmatory factor analysis pointed out that the factors are well-matched up onto a principal factor. Consequently, the four-factor model was well appropriate for the data by the fit index techniques for adjusting the scale [adjusted goodness of fit index = 0.92, goodness-of-fit statistic = 0.91, root mean square error of approximation = 0.006, incremental fit index = 0.94, normed fit index = 0.91, comparative fit index = 0.97]. The results pointed to the well-adjusted reliability and validity of MASSQ and its usefulness for the relevant studies as well.
Article
(1) Background: Studies examining the psychosocial impact of living long term on systemic treatment in advanced cancer patients are scarce. This scoping review aimed to answer the research question “What has been reported about psychosocial factors among patients living with advanced cancer receiving life-long systemic treatment?”, by synthesizing psychosocial data, and evaluating the terminology used to address these patients; (2) Methods: This scoping review was conducted following the five stages of the framework of Arksey and O’Malley (2005); (3) Results: 141 articles published between 2000 and 2021 (69% after 2015) were included. A large variety of terms referring to the patient group was observed. Synthesizing qualitative studies identified ongoing uncertainty, anxiety and fear of disease progression or death, hope in treatment results and new treatment options, loss in several aspects of life, and worries about the impact of disease on loved ones and changes in social life to be prominent psychosocial themes. Of 82 quantitative studies included in the review, 76% examined quality of life, 46% fear of disease progression or death, 26% distress or depression, and 4% hope, while few studies reported on adaptation or cognitive aspects. No quantitative studies focused on uncertainty, loss, or social impact; (4) Conclusion and clinical implications: Prominent psychosocial themes reported in qualitative studies were not included in quantitative research using specific validated questionnaires. More robust studies using quantitative research designs should be conducted to further understand these psychological constructs. Furthermore, the diversity of terminology found in the literature calls for a uniform definition to better address this specific patient group in research and in practice.
Article
Objective Prostate cancer is one of the mostly commonly diagnosed cancers in men. Unfortunately, the treatment for this cancer can have a number of negative side effects, both for the man himself and his partner. This study investigated the support needs of both men and partners throughout the prostate cancer journey and how this journey may be optimally managed. Methods Thirty-one men who had undergone prostate cancer treatment within the last 6 years and 31 partners answered a questionnaire, which explored support care issues as identified in the literature and from focus groups. ResultsMen and partners were moderately satisfied with information given regarding diagnosis, treatment and side effects, but partners were more satisfied with information relating to the particular chosen treatment. Men's understanding of their chosen treatment's potential side effects was significantly different from their understanding of diagnosis, cancer outcome, treatment options and selected treatment. Timing of information delivery was preferred by men at diagnosis, whereas partners preferred after the diagnosis. Men wanted more time to think about the diagnosis and treatment, whereas partners wanted an opportunity to discuss the diagnosis. The management of common side effects such as emotional changes, incontinence and erectile dysfunction was rated as somewhat' satisfactory. Conclusion Men and partners may have different educational and supportive needs throughout the prostate cancer journey that require attention and tailored management. Copyright (c) 2014 John Wiley & Sons, Ltd.
Article
Prostate cancer impacts on the daily lives of men, particularly their physical and emotional health, relationships and social life. This paper highlights how men cope with disease and treatment and the strategies they employ to manage their diagnosis alongside daily life. Twenty-seven men were interviewed at different stages in their disease pathway: nine men prior to radiotherapy, eight men at 6–8 months post radiotherapy and 10 men at 12–18 months post radiotherapy. A grounded theory approach was used to collect and analyse the data. Regardless of the point at which they were interviewed four areas emerged as important to the men: the pathway to diagnosis; the diagnosis; the impact of prostate cancer and its treatment on daily life; and living with prostate cancer. Prostate cancer was diagnosed using the prostate-specific antigen (PSA) test, rectal examination and biopsy. Many men did not understand the consequences of a high PSA reading before they undertook the test. Painful investigative biopsies were viewed as the worst part of the disease experience. Radiotherapy was considered less invasive than other treatments, although preparatory regimes were associated with stress and inconvenience. Men used various strategies to deal with treatment-induced threats to their masculinity in the long term.
Article
Patients with metastatic prostate cancer (PC) live longer than patients with metastatic tumours of other sites. Consequently, their social network can influence their quality of life (QoL) during a remarkable life span. The aim of this article is to present the findings of a systematic review of the studies that focused on social network supporting the quality of life of these patients. A systematic review for studies meeting specific criteria was undertaken on three databases. Some level of unmet psychological needs was present in 54 % of the patients. Depression and fatigue are highly prevalent, and the dyads, patient and partner, are at higher risk for distress symptoms. The efforts of individuals to cope with metastatic PC appear influenced by adaptative skills and specific types of family support. Psychological and relational problems predominate in the hormone-sensitive stage and are increasingly replaced by physical symptoms, social and spiritual needs in the later stages. In the early castration-resistant stage, patients will discuss with their doctors information about drugs, control of side effects and treatment strategies. In metastatic PC patients, needs change during the course of the disease. Social support plays a major role in maintaining or disrupting QoL and in the efficacy of psychosocial treatments. The trajectory of disease and its effect on the reduced QoL over the entire life expectancy should be kept in mind by health system providers and social workers.
Article
To assess the relationship between of androgen deprivation therapy (ADT) and the mood of prostate cancer (PCa) patients and partners of PCa patients. PCa patients (n = 295) and partners of patients (n = 84) completed an online survey assessing the patients' current mood and mood prior to treatment, relationship adjustment, and sexual function. We compared men on ADT to men who received non-hormonal treatments for their PCa. Patients currently treated with ADT (n = 82) reported worsened mood as measured by the Profile of Mood States compared to those not on ADT (n = 213). The negative impact of ADT on mood, however, was reduced in older patients. Partners of patients on ADT (n = 42) reported similar declines in the patient's mood that patients reported, but to a greater degree than patient-reported levels. Our data support ADT's impact on PCa patients' mood and verify that partners concurrently see the effects. The psychological changes related to ADT can impact relationships and affect the quality of life of both PCa patients and partners. Patients and their partners are likely to benefit from being well informed about the psychological effects of androgen deprivation on men beginning ADT. Copyright © 2015 John Wiley & Sons, Ltd. Copyright © 2015 John Wiley & Sons, Ltd.
Article
Androgen deprivation therapy (ADT) is a hormone treatment for prostate cancer and is linked to altered cognition, including memory changes, which can have detrimental effects on quality of life (QOL). The aim of this research was to develop an intervention to support men with memory changes associated with ADT. The Intervention Mapping framework guided intervention development through a series of rigorous steps. A self-management booklet called MEMORY MANager was developed, which incorporated education, self-assessment, compensatory strategies and techniques to improve mood. It was found to be an acceptable means of supporting men. This booklet could be valuable to healthcare professionals and patients as a means of improving QOL among men who undergo ADT. This is the first reported self-management intervention developed for managing cognitive changes in men who undergo ADT. Although preliminary, findings appear promising. More research is needed to evaluate effectiveness of the intervention and its implementation.
Article
Background: Cancer is the leading cause of death in Taiwan. Because the causes of cancer are often difficult to identify, a diagnosis of cancer is occasionally attributed to karma and the concept of stigma. These feelings lead to a life predicament, and stigma influences these perceptions. Objective: This study intended to understand how stigma is formed in the disease-related experiences of women with cancer. Methods: Ten participants were interviewed at the time of a confirmed diagnosis of advanced cancer and completed cancer treatment with regular follow-up after treatment, and all subjects underwent 2-3 interviews. The number of interviews conducted was determined by data saturation. A content analysis method was used. Results: The stigma of cancer includes the concepts of "cancer equals death", including the feeling of death approaching and an awareness of disease severity. "Cancer equals menace to social life" suggests that social life is affected and includes other individuals' uncomfortable attitudes toward cancer (shame, sympathy, pity, suffering, and over-cautiousness) and external physical changes. "Cancer equals cancer-ridden life" includes being sensitive to the topics of death and calculating the number of remaining survival days. Conclusions: The process from early diagnosis to the decision to receive treatment is complicated for patients with cancer. After the diagnosis is confirmed, the stigma of diagnosis significantly affects patients. Regarding social stereotypes, educating the public to resolve individuals' negative responses to cancer and further convey social and public information to women in society is necessary.
Article
Objective: Hot flushes and night sweats (HFNS) are common but under-researched in prostate cancer survivors undergoing androgen-deprivation therapy (ADT). We aimed to examine subjective reports and physiological measures of HFNS, and the influence of sociodemographic, clinical and psychological factors on HFNS in men undergoing ADT. Methods: Sixty-eight men undergoing ADT for prostate cancer attended an assessment interview, completed questionnaires (assessing HFNS frequency and problem-rating, mood, stress, optimism, somatosensory amplification, HFNS beliefs/behaviors) and wore an ambulatory sternal skin conductance (SSC) monitor for 48 h. Results: The sample had a mean age of 69.76 (standard deviation, SD = 8.04) years, were on average 27.24 (SD = 28.53) months since cancer diagnosis and had been on their current ADT regime for 16 months (range 2-74 months). The men reported frequent (weekly mean 51.04, SD = 33.21) and moderately problematic HFNS. Overall, 294 (20%) of the SSC-defined HFNS were concordant with prospective frequency (event marker), while 63% were under-reported and 17% were over-reported, under-reporting being more common than over-reporting. There were no significant predictors of HFNS frequency (subjective or physiological measures), but psychological variables (HFNS beliefs and behaviors (β = 0.56, p < 0.03), anxiety (β = 0.24, p < 0.01) and somatic amplification (β = 0.76, p < 0.04) were the main predictors of problematic HFNS, i.e. troublesome symptoms. Conclusions: These results are consistent with those of studies of women during menopause and breast cancer survivors, i.e. subjective and physiological measures appear to identify different HFNS dimensions. Psychological variables (HFNS beliefs and behaviors, anxiety and somatic amplification) can be targeted, using cognitive behavior therapy, for symptom relief.
Article
Prostate cancer (PCa) can negatively impact on men's sexual, urinary and emotional functioning, affecting quality of life. Most men with PCa are older (≥65 years), married and heterosexual and little is known about the impact on men who are younger, unpartnered or gay. We aimed to synthesise existing qualitative research on these three groups of men. A systematic metasynthesis was undertaken that included data on the unique impacts of PCa on younger (<65 years) (n = 7 papers), unpartnered (n = 17 papers) or gay or bisexual men (n = 11 papers) using a modified meta-ethnographic approach. The three overarching constructs illustrated the magnified disruption to men's biographies, that included: marginalisation, isolation and stigma-relating to men's sense of being "out of sync"; the burden of emotional and embodied vulnerabilities and the assault on identity-illustrating the multiple threats to men's work, sexual and social identities; shifting into different communities of practice-such as the shift from being part of a sexually active community to celibacy. These findings suggest that PCa can have a particular impact on the quality of life of younger, unpartnered and gay men. This has implications for the provision of tailored support and information to these potentially marginalised groups.
Article
Objective: Between 25% and 40% of prostate cancer patients report insomnia symptoms. Although a possible role of androgen deprivation therapy (ADT) and radiation therapy (RTH) and some of their side effects have been postulated, this issue has rarely been investigated. This study aimed to (1) compare the evolution of insomnia symptoms and somatic symptoms, which may affect sleep quality (i.e., hot flashes, night sweats, and urinary symptoms), in patients receiving combined ADT and RTH with that in patients receiving RTH only and (2) assess the mediating role of somatic symptoms in the relationship of ADT and RTH with insomnia symptoms. Methods: Sixty men scheduled to receive RTH for prostate cancer, with (n = 28) or without (n = 32) ADT, were assessed prior to receiving any treatment (baseline) and at seven additional times over 16 months (1, 2, 4, 6, 8, 12, and 16 months) using the Insomnia Severity Index and the Physical Symptoms Questionnaire. Results: A significant interaction effect was found indicating an increase in insomnia scores in ADT-RTH patients at 2, 4, and 6 months, as compared with baseline, and stable scores in RTH patients. A significant mediating role of hot flashes and night sweats was found in the relationship between ADT and insomnia symptoms. The relationship with RTH was also significantly mediated by these two symptoms albeit more strongly by excessive urinary frequency. Conclusions: Androgen deprivation therapy is associated with an increased risk for insomnia, and side effects of ADT and RTH appear to play a role in the development of insomnia in this population.
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The use of reliability and validity are common in quantitative research and now it is reconsidered in the qualitative research paradigm. Since reliability and validity are rooted in positivist perspective then they should be redefined for their use in a naturalistic approach. Like reliability and validity as used in quantitative research are providing springboard to examine what these two terms mean in the qualitative research paradigm, triangulation as used in quantitative research to test the reliability and validity can also illuminate some ways to test or maximize the validity and reliability of a qualitative study. Therefore, reliability, validity and triangulation, if they are relevant research concepts, particularly from a qualitative point of view, have to be redefined in order to reflect the multiple ways of establishing truth. This article discusses the use of reliability and validity in the qualitative research paradigm. First, the meanings of quantitative and qualitative research are discussed. Secondly, reliability and validity as used in quantitative research are discussed as a way of providing a springboard to examining what these two terms mean and how they can be tested in the qualitative research paradigm. This paper concludes by drawing upon the use of triangulation in the two paradigms (quantitative and qualitative) to show how the changes have influenced our understanding of reliability, validity and triangulation in qualitative studies.
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The risks of testosterone therapy in men remain poorly understood. The aim of this study was to conduct a systematic review and meta-analyses of testosterone trials to evaluate the adverse effects of testosterone treatment in men. We searched MEDLINE, EMBASE, and Cochrane CENTRAL from 2003 through August 2008. Review of reference lists and contact with experts further identified candidate studies. Eligible studies were comparative, randomized, and nonrandomized and reported the effects of testosterone on outcomes of interest (death, cardiovascular events and risk factors, prostate outcomes, and erythrocytosis). Reviewers, working independently and in duplicate, determined study eligibility. Reviewers working independently and in duplicate determined the methodological quality of studies and collected descriptive, quality, and outcome data. The methodological quality of the 51 included studies varied from low to medium, and follow-up duration ranged from 3 months to 3 yr. Testosterone treatment was associated with a significant increase in hemoglobin [weighted mean difference (WMD), 0.80 g/dl; 95% confidence interval (CI), 0.45 to 1.14] and hematocrit (WMD, 3.18%; 95% CI, 1.35 to 5.01), and a decrease in high-density lipoprotein cholesterol (WMD, -0.49 mg/dl; 95% CI, -0.85 to -0.13). There was no significant effect on mortality, prostate, or cardiovascular outcomes. The adverse effects of testosterone therapy include an increase in hemoglobin and hematocrit and a small decrease in high-density lipoprotein cholesterol. These findings are of unknown clinical significance. Current evidence about the safety of testosterone treatment in men in terms of patient-important outcomes is of low quality and is hampered by the brief study follow-up.
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Background: The National Health Service (NHS) cancer plan for England was published in 2000, with the aim of improving the survival of patients with cancer. By contrast, a formal cancer strategy was not implemented in Wales until late 2006. National data on cancer patient survival in England and Wales up to 2007 thus offer the opportunity for a first formal assessment of the cancer plan in England, by comparing survival trends in England with those in Wales before, during, and after the implementation of the plan. Methods: We analysed population-based survival in 2.2 million adults diagnosed with one of 21 common cancers in England and Wales during 1996-2006 and followed up to Dec 31, 2007. We defined three calendar periods: 1996-2000 (before the cancer plan), 2001-03 (initialisation), and 2004-06 (implementation). We estimated year-on-year trends in 1-year relative survival for patients diagnosed during each period, and changes in those trends between successive periods in England and separately in Wales. Changes between successive periods in mean survival up to 5 years after diagnosis were analysed by country and by government office region of England. Life tables for single year of age, sex, calendar year, deprivation category, and government office region were used to control for background mortality in all analyses. Findings: 1-year survival in England and Wales improved for most cancers in men and women diagnosed during 1996-2006 and followed until 2007, although not all trends were significant. Annual trends were generally higher in Wales than in England during 1996-2000 and 2001-03, but higher in England than in Wales during 2004-06. 1-year survival for patients diagnosed in 2006 was over 60% for 12 of 17 cancers in men and 13 of 18 cancers in women. Differences in 3-year survival trends between England and Wales were less marked than the differences in 1-year survival. North-South differences in survival trends for the four most common cancers were not striking, but the North West region and Wales showed the smallest improvements during 2001-03 and 2004-06. Interpretation: The findings indicate slightly faster improvement in 1-year survival in England than in Wales during 2004-06, whereas the opposite was true during 2001-03. This reversal of survival trends in 2001-03 and 2004-06 between England and Wales is much less obvious for 3-year survival. These different patterns of survival suggest some beneficial effect of the NHS cancer plan for England, although the data do not so far provide a definitive assessment of the effectiveness of the plan.
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Prostate cancer affects one in six American men. Erectile and sexual dysfunctions are long-term side effects of prostate cancer treatment. PubMed database was searched for papers on prostate cancer-related sexual recovery for men and couples. The search yielded articles on (1) the treatment of erectile dysfunction, (2) men's psychological and culturally diverse adaptation to the sexual side effects; (3) the impact of prostate cancer on couples' relationships; and (4) interventions to promote sexual function. Erectile dysfunction after prostate cancer treatment has been widely studied. Research on the sexual recovery of men and couples or understanding it in a cultural context is scarce. Greater focus on the impact of sexual sequelae of prostate cancer treatment on men as well as couples in diverse groups is needed. Clinical implications for treating sexual dysfunction and promoting sexual recovery for prostate cancer survivors and their partners are discussed. Recommendations for future research are provided.
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Prostate cancer is the most common male cancer in the Western world. The most substantial long term morbidity from this cancer is sexual dysfunction with consequent adverse changes in couple and intimate relationships. Research to date has not identified an effective way to improve sexual and psychosocial adjustment for both men with prostate cancer and their partners. As well, the efficacy and cost effectiveness of peer counselling as opposed to professional models of service delivery has not yet been empirically tested. This paper presents the design of a three arm randomised controlled trial (peer vs. nurse counselling vs. usual care) that will evaluate the efficacy of two couples-based sexuality interventions (ProsCan for Couples: Peer support vs. nurse counselling) on men's and women's sexual and psychosocial adjustment after surgical treatment for localised prostate cancer; in addition to cost-effectiveness. Seventy couples per condition (210 couples in total) will be recruited after diagnosis and before treatment through urology private practices and hospital outpatient clinics and randomised to (1) usual care; (2) eight sessions of peer-delivered telephone support with DVD education; and (3) eight sessions of oncology nurse-delivered telephone counselling with DVD education. Two intervention sessions will be delivered before surgery and six over the six months post-surgery. The intervention will utilise a cognitive behavioural approach along with couple relationship education focussed on relationship enhancement and helping the couple to conjointly manage the stresses of cancer diagnosis and treatment. Participants will be assessed at baseline (before surgery) and 3, 6 and 12 months post-surgery. Outcome measures include: sexual adjustment; unmet sexuality supportive care needs; attitudes to sexual help seeking; psychological adjustment; benefit finding and quality of life. The study will provide recommendations about the efficacy of peer support vs. nurse counselling to facilitate better sexual and couple adjustment after prostate cancer as well as recommendations on whether the interventions represent efficient health service delivery. ACTRN12608000358347.
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Because the optimal timing of the institution of antiandrogen therapy for prostate cancer is controversial, we compared immediate and delayed treatment in patients who had minimal residual disease after radical prostatectomy. Ninety-eight men who underwent radical prostatectomy and pelvic lymphadenectomy and who were found to have nodal metastases were randomly assigned to receive immediate antiandrogen therapy, with either goserelin, a synthetic agonist of gonadotropin-releasing hormone, or bilateral orchiectomy, or to be followed until disease progression. The patients were assessed quarterly during the first year and then semiannually. After a median of 7.1 years of follow-up, 7 of 47 men who received immediate antiandrogen treatment had died, as compared with 18 of 51 men in the observation group (P=0.02). The cause of death was prostate cancer in 3 men in the immediate-treatment group and in 16 men in the observation group (P<0.01). At the time of the last follow-up, 36 men in the immediate-treatment group (77 percent) and 9 men in the observation group (18 percent) were alive and had no evidence of recurrent disease, including undetectable serum prostate-specific antigen levels (P<0.001). In the observation group, the disease recurred in 42 men; 13 of the 36 who were treated had a complete response to local treatment or hormonal therapy (or both), 16 died of prostate cancer, and 1 died of another disease. The remaining men in this group were alive with progressive disease at the time of the last follow-up or had had a recent relapse. Except for the treatment group (immediate therapy or observation), no clinical or histologic characteristic significantly influenced the outcome. Immediate antiandrogen therapy after radical prostatectomy and pelvic lymphadenectomy improves survival and reduces the risk of recurrence in patients with node-positive prostate cancer.
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Non-steroidal antiandrogen monotherapy offers potential quality of life benefits over other treatment modalities in patients with prostate cancer. Nevertheless, gynecomastia and breast pain still represent the most bothersome side effects during this treatment. In this update article, recent advances in the management options for gynecomastia/breast pain caused by hormonal manipulation are reviewed and critically analyzed.
Article
This paper draws on the results of a longitudinal, qualitative study of men with prostate cancer (treated with prostatectomy) and their spouses. Interviews were conducted separately and simultaneously with men and their spouses, at three points in time (pre‐surgery, 8–10 weeks post‐surgery and 11–13 months post‐surgery). The primary focus in the paper is on men's responses to questions about their decisions to share information (or not) with others about their diagnosis and ongoing medical situation. Most men with prostate cancer avoided disclosure about their illness where possible, and placed great importance on sustaining a normal life. Factors related to limiting disclosure included men's low perceived need for support, fear of stigmatization, the need to minimize the threat of illness to aid coping, practical necessities in the workplace, and the desire to avoid burdening others. This study contributes to an understanding of disclosure issues related to prostate cancer, and raises issues about how best to be helpful to men, given their tendency to minimize the impact of illness, and the need for support. Copyright © 2000 John Wiley & Sons, Ltd.
Article
PURPOSE: Hot flashes can be a prominent problem in women with a history of breast cancer. Given concerns regarding the use of hormonal therapies in such patients, other nonhormonal means for treating hot flashes are required. Based on anecdotal information regarding the efficacy of fluoxetine and other newer antidepressants for treating hot flashes, the present trial was developed. PATIENTS AND METHODS: This trial used a double-blinded, randomized, two-period (4 weeks per period), cross-over methodology to study the efficacy of fluoxetine (20 mg/d) for treating hot flashes in women with a history of breast cancer or a concern regarding the use of estrogen (because of breast cancer risk). Eligible patients had to have reported that they averaged at least 14 hot flashes per week; they could have received tamoxifen or raloxifene as long as they were on a stable dose. The major outcome measure was a bivariate construct representing hot flash frequency and hot flash score, analyzed by a classic sums and differences cross-over analysis. RESULTS: Eighty-one randomized women began protocol therapy. By the end of the first treatment period, hot flash scores (frequency × average severity) decreased 50% in the fluoxetine arm versus 36% in the placebo arm. Cross-over analysis demonstrated a significantly greater marked hot flash score improvement with fluoxetine than placebo (P = .02). The results were not adjusted for potential confounding influences, including age and tamoxifen use. The fluoxetine was well tolerated. CONCLUSION: This dose of fluoxetine resulted in a modest improvement in hot flashes.
Article
Andropause, or the age-related decline in serum testosterone, has become a popular topic in the medical literature over the past several years. Andropause includes a constellation of symptoms related to lack of androgens, including diminished libido, decreased generalized feeling of well-being, osteoporosis, and a host of other symptoms. The andropause syndrome is very prominent in men undergoing hormonal ablation therapy for prostate cancer. Most significant in this population are the side effects of hot flashes, anemia, gynecomastia, depression, cognitive decline, sarcopenia, a decreased overall quality of life, sexual dysfunction, and osteoporosis with subsequent bone fractures. The concept of andropause in prostate cancer patients is poorly represented in the literature. In this article, we review the current literature on the symptoms, signs, and possible therapies available to men who cannot take replacement testosterone.
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Qualitative researchers rely — implicitly or explicitly — on a variety of understandings and corresponding types of validity in the process of describing, interpreting, and explaining phenomena of interest. In this article, Joseph Maxwell makes explicit this process by defining five types of understanding and validity commonly used in qualitative research. After discussing the nature of validity in qualitative research, the author details the philosophical and practical dimensions of: descriptive validity, interpretive validity, theoretical validity, generalizability, and evaluative validity. In each case, he addresses corresponding issues of understanding. In conclusion, Maxwell discusses the implications of the proposed typology as a useful checklist of the kinds of threats to validity that one needs to consider and as a framework for thinking about the nature of these threats and the possible ways that specific threats might be addressed.
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In the management of prostate cancer, gynaecomastia and breast pain can be a significant problem for men treated with hormonal therapy, affecting not just their physical but also their psychological and sexual well-being. Prompt recognition, evaluation and management are therefore essential. Urology nurses involved in the assessment, treatment and follow-up of this patient group across the patient pathway can play a key part in identifying the problem and addressing the issue of gynaecomastia, which may positively affect subsequent patients outcomes. This paper examines the causes, evaluation and current management of gynaecomastia culminating in a case study review.
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Androgen deprivation therapy (ADT) in the management of prostate cancer poses a considerable risk to bone health in prostate cancer patients, throughout their continuum of care. Associated decreases in bone mineral density and an increased risk of fracture can lead to major quality-of-life concerns and an adverse impact on morbidity and mortality, in an often already overburdened patient. Urology nurses in their administration and monitoring of the effects of ADT are essential for identifying at-risk patients and ensure timely and effective assessment and treatment. As health educators, they are ideally situated to promote and influence patients to adopt essential lifestyle changes in a multidisciplinary arena, to reduce risk factors. Supportive treatments are available to significantly reduce both bone loss and fracture risk that can easily be adopted by urology nurses in their existing clinical working environments to further strengthen positive management strategies for bone health.
Article
We report preliminary results for the first 164 patients enrolled in a multicenter studycomparing the endocrine effects, efficacy, and safety of 3.6 mg of goserelin acetate (Zoladex) and orchiectomy in patients with Stage D2 prostate cancer. Eighty-one patients were randomly allocated to receive Zoladex and 83 to orchiectomy. The median follow-up time for all patients was two hundred ten days. Median serum levels of testosterone were reduced to castrate levels (< 50 ng/dL) within four weeks in both groups and remained suppressed for up to sixty weeks. An objective response according to modified criteria of the National Prostatic Cancer Project was observed in 81 percent and 78 percent of patients in the Zoladex and orchiectomy groups, respectively. There were no statistically significant differences between treatment groups in the distributions of time to treatment failure or time to disease progression. The most commonly reported adverse events in both treatment groups were hot flashes, cancer-related pain, unspecified pain, and urinary symptoms. These results suggest that Zoladex may offer an alternative to orchiectomy in the treatment of advanced prostate cancer.
Article
To evaluate a group cognitive behavioural intervention to alleviate menopausal symptoms in women who have had treatment for breast cancer. A single group design was used with pre- and post-treatment assessment and a 3-months follow-up. Seventeen women who had completed active breast cancer treatment were treated. Following a 2-week daily diary assessment they were offered 6 (90 min) weekly sessions of Group cognitive behaviour therapy (CBT). The CBT included information and discussion, relaxation and paced breathing and CBT to reduce stress and manage hot flushes (HF), night sweats (NS) and sleep. The primary outcome measure was Hot Flush Frequency and Hot Flush Problem Rating; secondary outcomes included the Women's Health Questionnaire (WHQ) and health-related quality of life (SF 36). Beliefs about HF were monitored in order to examine the effects of cognitive therapy. HF and NS reduced significantly following treatment (38% reduction in frequency and 49% in problem rating) and improvements were maintained at 3 months follow-up (49% reduction in frequency and 59% in problem rating). Depressed mood, anxiety and sleep (WHQ) significantly improved, as did aspects of quality of life (SF 36) (emotional role limitation, energy/vitality and mental health). There was a significant reduction in negative beliefs about HF, NS and sleep following CBT. These results suggest that CBT delivered in groups might offer a viable option for women with troublesome menopausal symptoms following breast cancer treatment, but further controlled trials are needed.
Article
Hot flushes and night sweats (HF/NS) are commonly experienced by mid-aged women during the menopause transition. They affect approximately 70% of women but are regarded as problematic for 15-20% largely due to physical discomfort, distress, social embarrassment, and sleep disturbance. There is a need for effective and acceptable nonmedical treatments for menopausal symptoms due to the declining use of hormone therapy (HT) following publication of the Women's Health Initiative and other prospective studies which associated HT use with increased risk of stroke and breast cancer. HF/NS are an example of a physiological process embedded within, and moderated by, psychological processes, as evidenced by discrepancies between subjective experiences and physiologically measured symptoms. We describe a cognitive model of menopausal hot flushes that can explain symptom perception, cognitive appraisal, and behavioral reactions to symptoms. Theoretically, the model draws on symptom perception theory, self-regulation theory, and cognitive behavioral theories. The model can be used to identify the variables to target in psychological interventions for HF/NS and to aid understanding of possible mediating factors. As part of Phase II intervention development, we describe a cognitive behavioral treatment which links the bio-psycho-social processes specified in the model to components of the intervention.
Article
Menopausal symptoms - hot flushes and night sweats (HF/NS) - are particularly troublesome for women who have undergone breast cancer treatment. Non-medical treatments, such as cognitive behaviour therapy, are being developed but there is a lack of information about cognitive and behavioural reactions to HF/NS in breast cancer patients. Thirty-five women who had completed active breast cancer treatment with at least 10 HF/NS per week completed questionnaires assessing HF/NS, mood and beliefs, and took part in interviews to elicit cognitive and behavioural reactions and a thematic content analysis used to analyse the data. The mean weekly frequency of HF/NS was 76 (SD=46) (57 HF and 19 NS). Smokers reported significantly more night sweats, but BMI and mood were not associated with HF/NS frequency. Cognitive and behavioural responses were varied but broadly similar to those of well women. The main cognitive themes were: embarrassment/social anxiety, loss of control, beliefs about NS, sleep and tiredness, and the main behaviours were: carry on and ignore them, cool down, avoidance, communication with others. The results are discussed within a cognitive behavioural framework and might inform the development of psychological interventions for these treatment related symptoms.
Article
Knowledge of the molecular and cellular changes that occur during the transition of hormone-naïve to castration-resistant prostate cancer (CRPC) is increasing rapidly. This might provide a window of opportunity for (future) drug development, and for treating patients with these potential devastating states of disease. The objective of this review is to provide an understanding of the mechanisms that prostate cancer cells use to bypass androgen-deprived conditions. We searched PubMed for experimental and clinical studies that describe the molecular changes that lead to CRPC. CRPC remains dependent on a functional androgen receptor (AR), AR-mediated processes, and on the availability of intraprostatic intracellular androgens. CRPCs might acquire different (molecular) mechanisms that enable them to use intracellular androgens more efficiently (AR amplification, AR protein overexpression, AR hypersensitivity), use alternative splice variants of the AR protein to mediate androgen-independent AR functioning, and have altered co-activator and co-repressor gene and protein expression. Furthermore, CRPCs might have the ability to synthesise androgens de novo from available precursors through a renewed and up-regulated synthesis of steroid-hormone converting enzymes. Blocking of enzymes key to de novo androgen synthesis could be an alternative means to treat patients with advanced and/or metastatic disease. In CRPC, prostate cancer cells still rely on intracellular androgens and on an active AR for growth and survival. CRPCs have gained mechanisms that enable them to use steroids from the circulation more efficiently through altered gene expression, and through a renewed and up-regulated synthesis of steroid hormone-converting enzymes. Additionally, CRPCs might synthesise AR isoforms that enable AR mediated processes independent from available androgens.
Article
Patients with prostate cancer (PCa) are presented with multiple therapeutic options. However, the evidence supporting a survival benefit with current PCa therapies is often limited and data directly comparing the available options are lacking. Although dramatic improvements have been made in the treatment methods available for PCa and there has been a decline in death rates for the disease, each active intervention has potential side effects and long-term complications that can adversely affect quality of life (QOL). The cancer diagnosis and management strategies can also negatively affect the QOL of patients and their families. The healthcare costs associated with cancer treatment are another factor to consider. When determining treatment options, patients and physicians should consider the efficacy of the therapy, as well as the safety, effect on QOL, and cost. As a part of a risk reduction strategy, effective screening programs, along with possible therapeutic agents, could have a positive effect on QOL and offer a preemptive benefit to patients at increased risk of PCa.
Article
We longitudinally followed serum prostate specific antigen (PSA) levels in 48 patients who were treated with either orchiectomy, monthly luteinizing hormone-releasing hormone injection or continuous diethylstilbestrol for stage D2 prostate adenocarcinoma and achieved an objective response. Of the patients 34 had clinical evidence of disease progression (median remission duration 19 months). Median length of followup for the 14 patients who remained in remission was 42 months. Pretreatment performance status, pretreatment extent of metastases as measured by a bone scan and post-treatment nadir PSA level were univariately correlated with remission duration. After adjustment for the 2 former pretreatment variables, a highly significant independent effect of the nadir PSA level on remission duration persisted. Patients whose post-treatment nadir PSA level decreased below 4 ng./ml. had a significantly longer remission duration than those whose nadir PSA remained elevated (median 42 versus 10 months, p less than 0.0001). No cases were observed to progress (as defined by our criteria independent of PSA level) while the serial post-treatment PSA levels continued to decrease or remained at a plateau after reaching the nadir. The time at which the PSA began to increase once the nadir was reached predated objective evidence of progression in all patients except 2 in whom the 2 events occurred simultaneously (mean lead time 7.3 +/- 5.0 months). We conclude that following serial PSA levels in patients treated with androgen ablation for metastatic prostate cancer can aid in distinguishing favorable from nonfavorable responders early in the course of therapy and greatly assist in monitoring for progression.
Article
We report preliminary results for the first 164 patients enrolled in a multicenter study comparing the endocrine effects, efficacy, and safety of 3.6 mg of goserelin acetate (Zoladex) and orchiectomy in patients with Stage D2 prostate cancer. Eighty-one patients were randomly allocated to receive Zoladex and 83 to orchiectomy. The median follow-up time for all patients was two hundred ten days. Median serum levels of testosterone were reduced to castrate levels (less than 50 ng/dL) within four weeks in both groups and remained suppressed for up to sixty weeks. An objective response according to modified criteria of the National Prostatic Cancer Project was observed in 81 percent and 78 percent of patients in the Zoladex and orchiectomy groups, respectively. There were no statistically significant differences between treatment groups in the distributions of time to treatment failure or time to disease progression. The most commonly reported adverse events in both treatment groups were hot flashes, cancer-related pain, unspecified pain, and urinary symptoms. These results suggest that Zoladex may offer an alternative to orchiectomy in the treatment of advanced prostate cancer.
Article
To compare the efficacy and safety of goserelin and orchiectomy in patients with stage D2 prostate cancer. A randomized, open, multicenter study was conducted in 283 patients. Patients were allocated to goserelin, 3.6 mg every 28 days or to orchiectomy. Study end points were endocrine response, objective response, time to treatment failure, survival, and tolerability. Objective response was based on modified criteria of the National Prostate Cancer Project. Serum testosterone decreased from baseline to castrate levels by week 4 in each group and remained below castrate levels thereafter. Acid phosphatase and alkaline phosphatase concentrations also decreased in each group. The goserelin and orchiectomy groups had similar results for objective response (82% versus 77%) and had similar medial times to treatment failure (52 versus 53 weeks) and survival (119 versus 136 weeks). No significant interactions between treatments and prognostic factors were observed. Adjusting for baseline testosterone concentration had no effect on survival outcome. Race had no influence on outcome or efficacy end points. Common adverse events in both groups were pain, hot flushes, and lower urinary tract symptoms. Goserelin is well tolerated and as effective as orchiectomy in patients with Stage D2 prostate cancer.
Article
A total of 77 men with prostatic carcinoma treated with orchiectomy or a gonadotropin releasing hormone analogue before September 1987 underwent evaluation by a questionnaire regarding vasomotor symptoms. Answers were received from 84% of the patients. Of 63 patients 43 (68%) reported hot flushes during treatment, while 30 (48%) still had flushes 5 years after treatment. Of the latter 30 patients 28 (median 7.6 years after treatment) had vasomotor symptoms at the time of the study. Only 13 of 43 men with vasomotor symptoms after the start of treatment had relief 5 years later. At the time of the study 13 of 30 patients (more than 40%) still had flushes 8 years after castration. Most men reported that the flushes presently had the same frequency and duration as when they started therapy. Contrary to the general belief that the symptoms disappear with time, our study highlighted a long persistence of hot flushes after castration.
Article
Hot flashes are often a troublesome symptom in breast carcinoma survivors and men with prostate carcinoma who have undergone androgen deprivation therapy. A previous clinical study demonstrated that, on a short term basis, low dose megestrol acetate markedly reduced hot flashes and was well tolerated. Little information has been available regarding the long term use of low dose megestrol acetate for hot flashes. Patients previously enrolled on a randomized placebo-controlled trial that evaluated the short term use of megestrol acetate for hot flashes were contacted and interviewed by telephone. A total of 132 persons were contacted. Nine percent of the patients discontinued megestrol acetate after resolution of their hot flashes. Forty-five percent of the patients contacted were continuing to utilize megestrol acetate approximately 3 years beyond the conclusion of the 1992 study. Three-quarters of these patients were utilizing < or =20 mg of megestrol acetate per day. Potential toxicities attributed to megestrol acetate included episodes of chills, appetite stimulation/weight gain, vaginal bleeding, and carpal tunnel syndrome symptoms. A substantial proportion of patients continue to use megestrol acetate for periods of up to 3 years or longer with continued control of hot flashes. This treatment appears to be relatively well tolerated.
Article
Menopause is an expected event in a woman's life. Treatment for breast cancer can impact the onset of menopause and precipitate symptoms such as hot flashes. Yet this sequelae of events is not well measured, defined or assimilated into quality of life assessments for cancer survivors. Though not life threatening, hot flashes can greatly impact a woman's quality of life or functional ability. It is important for health care professionals to more fully understand the nature of the experience of hot flashes so as not to underestimate their disruptive potential. As part of a larger clinical trial to look at the effectiveness of vitamin E for hot flashes, breast cancer survivors kept a log of both the frequency and intensity of their hot flashes. These women then wrote descriptions to define the severity of those hot flashes. The purpose of this paper is to provide insight into the experience of hot flashes in breast cancer survivors and to describe the severity of hot flashes with narratives given by the women experiencing them.
Article
This paper draws on the results of a longitudinal, qualitative study of men with prostate cancer (treated with prostatectomy) and their spouses. Interviews were conducted separately and simultaneously with men and their spouses, at three points in time (pre-surgery, 8-10 weeks post-surgery and 11-13 months post-surgery). The primary focus in the paper is on men's responses to questions about their decisions to share information (or not) with others about their diagnosis and ongoing medical situation. Most men with prostate cancer avoided disclosure about their illness where possible, and placed great importance on sustaining a normal life. Factors related to limiting disclosure included men's low perceived need for support, fear of stigmatization, the need to minimize the threat of illness to aid coping, practical necessities in the workplace, and the desire to avoid burdening others. This study contributes to an understanding of disclosure issues related to prostate cancer, and raises issues about how best to be helpful to men, given their tendency to minimize the impact of illness, and the need for support.
Article
To examine variation in men's long-term regret of treatment decisions, ie, surgical versus chemical castration, for metastatic prostate cancer and its associations with quality of life. Survey of previously treated patients to assess treatment decisions and quality of life, supplemented with focus groups. Two items addressing whether a patient wished he could change his mind and the belief that he would have been better off with the treatment not chosen were combined in classifying survey respondents as either satisfied or regretful. Chi(2) and t tests were used to test associations between regret and treatment history, complications, and quality of life. Survey respondents included 201 men aged 45 to 93 years (median, 71 years), who had begun treatment (71% chemical castration, 29% orchiectomy) a median of 2 years previously. Most reported complications: hot flashes (70%), nausea (34%), and erectile dysfunction (81%). Most were satisfied with the treatment decision, but 23% expressed regret. Regretful men more frequently reported surgical (43%) versus chemical (36%) castration (P: = .030) and nausea in the past week (54% v 32%; P: = .010) but less frequently reported erectile dysfunction (56% v 72%; P: = .048). Regretful men indicated poorer scores on every measure of generic and prostate cancer-related quality of life. Qualitative analyses revealed substantial uncertainty about the progress of their disease and the quality of the decisions in which patients participated. Regret was substantial and associated with treatment choice and quality of life. It may derive from underlying psychosocial distress and problematic communication with physicians when decisions are being reached and over subsequent years.
Article
Hot flashes can be troublesome, especially when hormonal therapy is contraindicated. Preliminary data have suggested that newer antidepressants, such as venlafaxine, can diminish hot flashes. We undertook a double-blind, placebo-controlled, randomised trial to assess the efficacy of venlafaxine in women with a history of breast cancer or reluctance to take hormonal treatment because of fear of breast cancer. Participants were assigned placebo (n=56) or venlafaxine 37.5 mg daily (n=56), 75 mg daily (n=55), or 150 mg daily (n=54). After a baseline assessment week, patients took the study medication for 4 weeks. All venlafaxine treatment started at 37.5 mg daily and gradually increased in the 75 mg and 150 mg groups. Patients completed daily hot-flash questionnaire diaries. The primary endpoint was average daily hot-flash activity (number of flashes and a score combining number and severity). Analyses were based on the women who provided data throughout the baseline and study weeks. 191 patients had evaluable data for the whole study period (50 placebo, 49 venlafaxine 37.5 mg, 43 venlafaxine 75 mg, 49 venlafaxine 150 mg). After week 4 of treatment, median hot flash scores were reduced from baseline by 27% (95% CI 11-34), 37% (26-54), 61% (50-68), and 61% (48-75) in the four groups. Frequencies of some side-effects (mouth dryness, decreased appetite, nausea, and constipation) were significantly higher in the venlafaxine 75 mg and 150 mg groups than in the placebo group. Venlafaxine is an effective non-hormonal treatment for hot flashes, though the efficacy must be balanced against the drug's side-effects. Confirmation of the results of this 4-week study awaits the completion of three ongoing randomised studies to assess the effects of other related antidepressants for the treatment of hot flashes.
Article
We evaluated the incidence and frequency of, and distress due to hot flashes after castration therapy with polyestradiol phosphate and complete androgen ablation. A total of 915 men with metastatic prostate carcinoma enrolled in the Scandinavian Prostatic Cancer Group-5 trial study were randomized to intramuscular injections of 240 mg. Polyestradiol phosphate every 2 weeks for 8 weeks followed by monthly subcutaneous injections or complete androgen ablation, that is bilateral orchiectomy or 3.75 mg. of the gonadotropin-releasing hormone analog triptorelin monthly combined with 250 mg. of the antiandrogen flutamide 3 times daily. The incidence and frequency of, and distress due to hot flashes were recorded at regular intervals using a questionnaire. Of the 915 men 901 were evaluated at a median followup of 18.5 months. The incidence of hot flashes was 30.1% and 74.3% in the polyestradiol phosphate and complete androgen ablation groups, respectively (p <0.001). In the polyestradiol phosphate group the frequency of and distress due to hot flashes were significantly lower than in the androgen ablation group. There was complete relief from hot flashes in 50% of the men on polyestradiol phosphate during followup compared with none on androgen ablation. The incidence of hot flashes did not differ in men with and without tumor progression. Endocrine treatment with polyestradiol phosphate induced fewer and less distressing hot flashes than complete androgen ablation. Flashes also disappeared to a greater extent during polyestradiol phosphate than during androgen ablation. The data in this study enable us to provide thorough individual information to patients on the risk and grade of expected distress and duration of hot flashes during polyestradiol phosphate or complete androgen ablation treatment.
Article
Hot flashes can be a prominent problem in women with a history of breast cancer. Given concerns regarding the use of hormonal therapies in such patients, other nonhormonal means for treating hot flashes are required. Based on anecdotal information regarding the efficacy of fluoxetine and other newer antidepressants for treating hot flashes, the present trial was developed. This trial used a double-blinded, randomized, two-period (4 weeks per period), cross-over methodology to study the efficacy of fluoxetine (20 mg/d) for treating hot flashes in women with a history of breast cancer or a concern regarding the use of estrogen (because of breast cancer risk). Eligible patients had to have reported that they averaged at least 14 hot flashes per week; they could have received tamoxifen or raloxifene as long as they were on a stable dose. The major outcome measure was a bivariate construct representing hot flash frequency and hot flash score, analyzed by a classic sums and differences cross-over analysis. Eighty-one randomized women began protocol therapy. By the end of the first treatment period, hot flash scores (frequency x average severity) decreased 50% in the fluoxetine arm versus 36% in the placebo arm. Cross-over analysis demonstrated a significantly greater marked hot flash score improvement with fluoxetine than placebo (P =.02). The results were not adjusted for potential confounding influences, including age and tamoxifen use. The fluoxetine was well tolerated. This dose of fluoxetine resulted in a modest improvement in hot flashes.
Article
We did a randomised phase III trial comparing external irradiation alone and external irradiation combined with an analogue of luteinising-hormone releasing hormone (LHRH) to investigate the added value of long-term androgen suppression in locally advanced prostate cancer. Between 1987 and 1995, 415 patients were randomly assigned radiotherapy alone or radiotherapy plus immediate androgen suppression. Eligible patients had T1-2 tumours of WHO grade 3 or T3-4 N0-1 M0 tumours; the median age of participants was 71 years (range 51-80). In both treatment groups, 50 Gy radiation was delivered to the pelvis over 5 weeks, and 20 Gy over 2 weeks as a prostatic boost. Goserelin (3.6 mg subcutaneously every 4 weeks) was started on the first day of irradiation and continued for 3 years; cyproterone acetate (150 mg orally) was given for 1 month starting 1 week before the first goserelin injection. The primary endpoint was clinical disease-free survival. Analyses were by intention to treat. 412 patients had evaluable data, with median follow-up of 66 months (range 1-126). 5-year clinical disease-free survival was 40% (95% CI 32-48) in the radiotherapy-alone group and 74% (67-81) in the combined-treatment group (p=0.0001). 5-year overall survival was 62% (52-72) and 78% (72-84), respectively (p=0.0002) and 5-year specific survival 79% (72-86) and 94% (90-98). Immediate androgen suppression with an LHRH analogue given during and for 3 years after external irradiation improves disease-free and overall survival of patients with locally advanced prostate cancer.
Article
Andropause, or the age-related decline in serum testosterone, has become a popular topic in the medical literature over the past several years. Andropause includes a constellation of symptoms related to lack of androgens, including diminished libido, decreased generalized feeling of well-being, osteoporosis, and a host of other symptoms. The andropause syndrome is very prominent in men undergoing hormonal ablation therapy for prostate cancer. Most significant in this population are the side effects of hot flashes, anemia, gynecomastia, depression, cognitive decline, sarcopenia, a decreased overall quality of life, sexual dysfunction, and osteoporosis with subsequent bone fractures. The concept of andropause in prostate cancer patients is poorly represented in the literature. In this article, we review the current literature on the symptoms, signs, and possible therapies available to men who cannot take replacement testosterone.
Article
Hot flashes are as common in men who have been castrated due to prostate cancer as hot flashes are in women after menopause. The symptom can cause significant discomfort for a considerable length of time. The hot flashes are most likely caused by a reduction in sex-hormone levels, which, in turn, causes an instability in the hypothalamic thermoregulatory center. Calcitonin gene-related peptide is involved in menopausal hot flashes in women and possibly also in castrated men. The mainstays of treatment for castrated men with hot flashes remain estrogens, progesterone, and cyproterone acetate, each of which has different side effects. Other treatments for hot flashes include clonidine and antidepressants and, according to one uncontrolled study, electrostimulated acupuncture. Nonetheless, there is a need for more effective and less toxic treatments. In this review, we will discuss the prevalence, duration, distress, physiology, and treatment options of hot flashes in men subjected to castration therapy due to prostate cancer.
Article
We surveyed patients with prostate cancer treated with androgen deprivation therapy to examine the influence of hot flashes on quality of life (QOL). Fifty-five outpatients with prostate cancer (M0, 39; M1, 16) treated with androgen deprivation therapy (castration, 15; castration and antiandrogen, 40) were enrolled in this study. Mean duration of androgen deprivation therapy was 21 months (2-91 months). The patients were still being treated with androgen deprivation therapy at the time of the survey. The functional assessment of cancer therapy (FACT) was used as a QOL questionnaire for outpatients with prostate cancer treated with androgen deprivation therapy. Hot flash assessments were used to document the number and severity (mild, moderate, and severe) of daily hot flashes. The patients prescribed fluvoxamine maleate were reassessed for hot flashes 2 weeks after the prescription. Thirty-two of the 55 patients (58.2%) suffered from hot flashes. Hot flashes deteriorated the physical well-being subscale of QOL in patients with prostate cancer treated with androgen deprivation therapy (P = 0.043). There was a significant relationship between the desire to be treated for hot flashes and the hot flash assessments (P = 0.038). Fluvoxamine maleate was significantly effective in reducing hot flashes (P = 0.001). Hot flashes had adverse effects on the patients' physical status and deteriorated the patients' QOL. New treatment options such as fluvoxamine maleate might help simplify the often difficult management of hot flashes in patients with prostate cancer treated with androgen deprivation therapy.
Article
Large numbers of Australian men are diagnosed and treated for prostate cancer each year. The incidence is exceeding mortality, and men are living longer with prostate cancer and the common treatment[s] side effect of impotence. Despite these epidemiological trends there is little research about men's experiences of impotence following treatment. An ethnographic study of Anglo-Australian men with localized prostate cancer explored participants' experiences of impotence following prostatectomy. In-depth semi-structured interviews with 15 men were analyzed using a social constructionist gendered framework. In particular, the effect of impotence on participants' masculinity, sexuality and intimate relationships was explored. The findings show that participants rationalized forgoing potency prior to surgery as a way of living longer. However, diverse complex reactions accompanied impotence. Whilst most participants redefined masculine ideals of phallocentric sex, the way in which this occurred varied greatly. The findings disrupt essentialist constructions of male sexuality and impotence, and provide valuable insight for clinical practice.
Article
Men, culture and hegemonic masculinity: understanding the experience of prostate cancer Following a diagnosis of, and treatment for prostate cancer, there is an expectation that men will cope with, adjust to and accept the psychosocial impact on their lives and relationships. Yet, there is a limited qualitative world literature investigating the psychosocial experience of prostate cancer, and almost no literature exploring how masculinity mediates in such an experience. This paper will suggest that the experience of prostate cancer, the process by which it is investigated, and the way in which it is understood has been shaped by an essentialist interpretation of gender, exemplified by hegemonic masculinity as the archetypal mechanism of male adaptation. In response to this static and limiting view of masculinity, this paper will offer a reframe of hegemonic masculinity. This reframe, being more aligned with common experience, will portray masculinity as a dynamic and contextual construct, better understood as one of a number of cultural reference points around which each man organises and adopts behaviour. It will be suggested that the extant literature, in being organised around hegemonic masculinity, obfuscates the experience of prostate cancer and acts to render covert any collateral masculinities, public or private, that may also be operating.
Article
Hot flushes, the most common health problem reported by menopausal-age women, can lead to significant morbidity and affect the social life, ability to work and sleep pattern of the sufferer. Women treated for breast cancer and men receiving androgen ablation for prostate cancer experience hot flushes that are more frequent, severe and longer lasting than those experienced by the general menopausal population. In women with breast cancer, hot flushes can result from chemotherapy-induced menopause, hormonal therapy, or ovarian suppression. In men with prostate cancer, hot flushes occur after surgical or medical castration. Hormone replacement therapy with oestrogen-based compounds has been a mainstay of treatment for hot flushes during the perimenopausal period. However, recent studies have shown that, in healthy menopausal women, hormone replacement therapy is associated with an increased risk of breast cancer, myocardial infarction, thrombo-embolic events and stroke. Thus, identifying nonhormonal agents that can control hot-flush symptoms is essential to the quality of life of a growing population of cancer survivors. The most promising agents act on the CNS and include selective serotonin reuptake inhibitors, as well as venlafaxine and gabapentin.
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First, to examine the experience of menopause and quality of life in a migrated Asian population from the Indian subcontinent living in Birmingham, UK, and, second, to compare their experience with a matched sample of Caucasian women living in the same geographical area and also with a sample of Asian women with similar socioeconomic background living in Delhi, India. In this cross-sectional study of 153 peri- and postmenopausal women aged 45-55 years, 52 Asian women originating from the Indian subcontinent living in Birmingham (UKA, mean age 51.4 years), 51 Caucasian women (UKC, mean age 52.3 years) and 50 Asian women living in Delhi, India (DEL, mean age 49.72 years) were interviewed to collect information about their lifestyle, general health, menopause experience and help-seeking behavior. The Women's Health Questionnaire and the Menopause Representation Questionnaire (both translated and linguistically validated in Hindi) were used to examine the prevalence of physical and emotional symptoms and the extent to which these were attributed to the menopause. The two Asian groups (UKA, DEL) reported poorer health and generally more physical and emotional symptoms than the UKC group. However, for menopausal symptoms (hot flushes and night sweats) there was a different pattern; the DEL group reported significantly fewer symptoms compared to the UKA and UKC groups (hot flushes: UKC 60.8%, UKA 75%, DEL 32% (p < 0.001); night sweats: UKC 50%, UKA 56.9%, DEL 24% (p = 0.002)). The prevalence of vaginal dryness was highest in the UKA group and lowest in the DEL group (UKC 21.6%, UKA 38.2%, DEL 7.3% (p = 0.005)). The number of symptoms attributed to menopause was significantly lower in the DEL group (9.3 +/- 7.8) compared to the two UK groups (UKC 18.9 +/- 7.4, UKA 19.8 +/- 10.7), but the UKA women tended to attribute some physical symptoms to the menopause such as breathlessness, weight gain and stiff joints that might have other causes. The UK Asian women's experience of the menopause is more similar to the Caucasian women in the UK than that of the women in Delhi. However, Asian women living in the UK and the Indian subcontinent shared the experience of poor health and reports of more physical and emotional symptoms in general. The possible reasons for these differences are discussed.
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This paper describes the findings from an ethnographic study of 16 Anglo-Australian men treated with androgen deprivation therapy (ADT) for advanced prostate cancer. Utilising a social constructionist gendered analysis, participants' experiences, particularly in relation to embodied masculinity, are described in the context of reduced testosterone that accompany ADT. The findings indicated that participants reformulated many ideals of hegemonic masculinity in response to functional body changes. However, hegemonic masculinity strongly influenced participants' philosophical resolve to "fight" prostate cancer. The findings are considered in broader ongoing debates about essentialist sex and the social construction of gender.
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Primary prostate cancer treatment often results in suboptimal urinary, bowel and/or sexual function. These effects are not inevitable. After treatment patients typically report high health related quality of life (QoL) scores. This discrepancy between disease-specific and generic results raises the question which meaning side effects actually have to patients. In a qualitative study we explored two mechanisms which could possibly explain the discrepancy: insensitivity of generic QoL measures to these specific symptoms and adaptation to changed health (response shift). In semi-structured interviews with 33 prostate cancer patients in the Netherlands we collected data on their opinions regarding health and QoL, we observed how respondents behaved when completing health status and QoL questionnaires, and solicited comments on a QoL questionnaire, its items, and its content validity. We observed that patients trivialized sexual (dys) function referring to old age. We found that while they might consider sexual, urinary, and bowel dysfunctions as problems, they did not take such dysfunctions into account when completing QoL measures because they did not view these dysfunctions as aspects of health. This finding reveals a so far unidentified cause of the insensitivity of generic measures of health status. Furthermore, response shift appeared to be present: many patients accepted the side effects as inevitable consequences of having been treated for prostate cancer, a condition they perceived as life threatening. We conclude that generic QoL measures cannot reveal the impact of sexual, urinary and bowel dysfunctions on patients because such dysfunctions are not perceived as health problems. By presenting these findings we want to draw attention to issues that complicate QoL assessments in general and in prostate cancer patients in particular.
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Updates on hormonal therapy in the treatment of prostate cancer are presented. The most common therapy is to reduce testosterone to castrate levels. A dosage of 1 mg diethylstilbestrol daily prolonged survival in patients with advanced prostate cancer. The leuteinizing hormone-releasing hormone agonists have essentially replaced surgical orchiectomy in the vast majority of clinical settings; however, a major problem with the leuteinizing hormone- releasing hormone agonists has been the surge and flare of testosterone levels. If hormonal therapy is initiated early, the risk of major complications is significantly decreased. Combined androgen blockade is better than monotherapy, although there is only a small clinical benefit. When androgen deprivation is used for a short time and the normal androgen milieu is re-established, the side effects and toxicity of androgen deprivation are decreased. The major complications of androgen deprivation include hot flushes, reduction of bone mineral density, osteoporosis, and anemia. Intermittent androgen blockade might have the same benefits of total androgen suppression with fewer side effects, increased duration of androgen dependence, and less cost. The 10 steps to take when advising patients about initiation of androgen deprivation therapy are reviewed.