Sexual effects of cancer: men and people born with male reproductive organs

Study Reveals Lasting Side Effects Of Prostate Cancer Therapy

LONG-TERM complications following treatment for prostate cancer (PCA) are a significant concern, as evidenced by a recent cohort study involving 3,946 patients with PCA. This study leveraged a unique data linkage between two major prostate cancer prevention trials and Medicare claims, examining the health outcomes of men treated for PCA compared with a broader population of older men. It found that, even 12 years post-treatment, PCA patients experience markedly higher complication rates, underscoring the long-lasting impact of treatment decisions.

The study revealed that patients treated for PCA, particularly with radiotherapy, have an elevated risk of developing several severe complications compared to the general population. Notably, those who underwent radiotherapy had a threefold increased risk of developing bladder cancer. The risks were even more pronounced for radiation-specific conditions, with a 100-fold increase in conditions such as radiation cystitis and proctitis. These complications highlight the profound effects of radiotherapy on surrounding tissues, long after the initial cancer treatment.

Moreover, complications extended beyond those associated with radiotherapy alone. Patients who underwent prostatectomy also showed significantly increased risks of urinary and sexual complications, with a hazard rate 7.23 times higher than in untreated older men. For those who received radiotherapy, this risk was nearly 2.76 times greater than in the untreated group. Such findings underline the physical costs associated with both primary treatment approaches for PCA.

The results of this study underscore the importance of patient counselling in the treatment decision process. Given the often slow-growing nature of PCA, treatment approaches need to carefully consider the balance between cancer control and potential adverse effects. For many patients, the potential for age-related health issues may be compounded by the added burden of treatment-related complications. Therefore, the study calls for a focus on PCA prevention and highlights a need for open, informed discussions between patients and healthcare providers regarding the potential long-term impact of PCA treatments. By doing so, patients can make treatment choices that reflect both their cancer status and overall quality of life in the long term.

Reference

Unger JM et al. Long-term adverse effects and complications after prostate cancer treatment. JAMA Oncol. 2024;DOI:10.1001/jamaoncol.2024.4397.

MRI-guided Radiation Therapy Reduces Long-term Side Effects For Patients With Prostate Cancer

After a comprehensive two-year follow-up, researchers at the UCLA Health Jonsson Comprehensive Cancer Center found that MRI-guided stereotactic body radiotherapy (SBRT) for prostate cancer significantly reduced long-term side effects and improved quality of life, particularly in bowel and sexual health, compared to conventional CT-guided treatment.

"The MIRAGE trial is the only randomized trial to date comparing these state-of-the-art technologies in radiation oncology. It was designed to see whether MRI-guided SBRT led to less toxicity than CT-guided SBRT," said Dr. Michael Steinberg, professor and chair of Radiation Oncology at the David Geffen School of Medicine at UCLA, director of Clinical Affairs at the UCLA Health Jonsson Comprehensive Cancer Center and senior author of the study.

The research team conducted a secondary analysis of the phase 3 clinical trial, called MIRAGE, to evaluate the impact of using MRI guidance to deliver high-precision radiation therapy for prostate cancer. Radiation therapy is a standard treatment option, especially for those with localized prostate cancer. However, the side effects of treatment can be severe and long-lasting, affecting a patient's urinary, bowel, and sexual function. MRI guidance allows for more targeted treatment with reduced planning margins around the prostate, meaning less exposure to surrounding healthy tissue. This approach was compared with the standard CT-guided SBRT, which typically requires larger treatment margins.

The team found that patients receiving MRI-guided SBRT experienced significantly fewer urinary and bowel side effects. Specifically, 27% of MRI-guided patients reported moderate or severe urinary issues -- such as urinary incontinence and irritation -- compared to 51% of those receiving CT guidance. Additionally, gastrointestinal toxicity -- such as bowel issues -- were reported by only 1.4% of MRI-guided patients, a notable reduction compared to 9.5% in the CT-guided group. MRI guidance also correlated with improved scores on specific quality-of-life measures, including bowel function and sexual health.

The findings highlight a promising shift in prostate cancer treatment practices, highlighting the potential of MRI-guided radiation therapy to improve patient outcomes.

"This study adds strong evidence that the enhanced precision and accuracy afforded by MRI-guided SBRT leads to significantly fewer urinary, bowel, and sexual side effects for men receiving prostate SBRT," noted Dr. Amar Kishan, executive vice chair of radiation oncology at the David Geffen School of Medicine at UCLA and first author of the study. "The MRI-guided approach, which includes real-time tracking of the prostate itself and the use of a built-in MRI to help deliver the radiation, allows us to use significantly narrower planning margins when delivering radiation, leading to less radiation to normal tissues. This in turn reduces the risk of enduring side effects that can impact a patient's quality of life."

Urinary And Sexual Side Effects Less Likely After Advanced Radiotherapy Than Surgery For Advanced Prostate Cancer Patients

Men with prostate cancer are less likely to experience urinary and sexual side effects two years after treatment with an advanced type of radiotherapy than surgery, according to researchers from The Royal Marsden NHS Foundation Trust and The Institute of Cancer Research, London.

The PACE-A study is the world's first randomised trial to compare the long-term side effects of stereotactic body radiotherapy (SBRT) versus surgery in patients with early-stage prostate cancer. Results from the trial are being presented at the 2023 ASCO Genitourinary Cancers Symposium today.

123 men from 10 UK centres were enrolled in the trial, with 59 ultimately treated with SBRT and 50 with surgery. After two years, significantly fewer patients (4.5 per cent) treated with SBRT reported needing to use urinary pads, which manage urinary incontinence, compared with surgery (47 per cent). Patients treated with SBRT also reported better sexual function after two years than those treated with surgery.

However, although moderate or serious bowel problems were not reported by many men in the study, those treated with SBRT were more likely (16 per cent) than surgical patients to report minor problems (0 per cent).

Sub-millimetre precision

SBRT, which can be carried out on a CyberKnife or a modern linear accelerator, allows clinicians to target tumours to sub-millimetre precision. It delivers five high doses of radiation to patients over one to two weeks, compared with standard radiotherapy, which delivers more moderate doses through approximately 20 sessions over four weeks. The Royal Marsden has two Cyberknife machines, which were funded by The Royal Marsden Cancer Charity.

Chief Investigator Professor Nicholas van As, Medical Director and Consultant Clinical Oncologist at The Royal Marsden NHS Foundation Trust, and Professor in Precision Prostate Radiotherapy at The Institute of Cancer Research, London, said: 

"This world-first study reveals that SBRT, an advanced form of radiotherapy now widely available across the UK, is often kinder and can mean less long-term side effects than surgery for prostate cancer patients. 

"One of the biggest concerns for men I see in clinic ahead of treatment for prostate cancer is whether it will make them incontinent, and many worry about the impact on their sexual function too. While there is a risk both SBRT and surgery will cause problems, these results suggest SBRT is less likely to.

"Going forwards, these results should support clinicians in facilitating important discussions with prostate cancer patients about whether to opt for SBRT or surgery, helping them make an informed decision based on their individual needs and concerns." 

Patient experience

Professor Emma Hall, Co-Director of the Clinical Trials and Statistics Unit at The Institute of Cancer Research, London which is managing the PACE trial said:

"Understanding how cancer treatments affect patients' lives should be at the heart of research. This important trial uses patient-reported outcomes to understand how various treatments for prostate cancer affect patients following recovery.

"It's great to see that using SBRT for early-stage prostate cancer can help people avoid sexual and urinary side effects that are commonly associated with surgery, and I hope these findings will help men decide, with their clinician, the best course of treatment for them."

'Side effects have been minimal'

Alexander Szczerbiuk, 73 from Morden, was diagnosed with prostate cancer in November 2017 at his local hospital following a blood test which revealed his prostate-specific antigen (PSA) levels were raised. Alexander was referred to The Royal Marsden and, after being recruited to the PACE-A trial, was treated with SBRT via CyberKnife. He said:

"In terms of treatment, you couldn't wish for anything better. It was only two months from my diagnosis to the last of my five CyberKnife sessions, and I was pleased as punch everything happened so quickly.

"Before the treatment, my biggest concern was incontinence, as I really couldn't bear the thought of having to use urinary pads. This meant I was delighted to be selected for CyberKnife which, as a minimally invasive option, was a no-brainer. Fortunately, the side effects have been minimal and, while I experience rectal bleeding very occasionally, I urinate normally and have never needed to use a pad."

The PACE-A trial was funded by Accuray and Varian, a Siemens Healthineers company, sponsored by The Royal Marsden, and managed by the Clinical Trials and Statistics Unit at The Institute of Cancer Research (ICR).

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