Androgen Deprivation Therapy for Prostate Cancer: Recommendations to Improve Patient and Partner Quality of Life

Abstract

Introduction Because of improved prostate cancer detection, more patients begin androgen deprivation therapy (ADT) earlier and remain on it longer than before. Patients now may be androgen deprived for over a decade, even when they are otherwise free of cancer symptoms. Aim An ADT Survivorship Working Group was formed to develop and evaluate interventions to limit the physiological and emotional trauma patients and their partners experience from this treatment. Methods The multidisciplinary Working Group met for 2 days to define the challenges couples face when patients commence ADT. A writing sub-group was formed. It compiled the meeting’s proceedings, reviewed the literature and, in consultation with the other members of the working group, wrote the manuscript. Main Outcome Measures Expert opinion of the side effects of ADT that affect the quality of life (QOL) of patients and their partners and the recommendations for managing ADT to optimize QOL were based on the best available literature, clinical experience, and widespread internal discussions among Working Group members. Results Side effects identified as particularly challenging include: (i) body feminization; (ii) changes in sexual performance; (iii) relationship changes; (iv) cognitive and affective symptoms; and (v) fatigue, sleep disturbance, and depression. Recommendations for managing ADT include providing information about ADT side effects before administration of ADT, and, where appropriate, providing referrals for psychosocial support. Sexual rehabilitation principles for persons with chronic illness may prove useful. Psychological interventions for sexual sequelae need to be offered and individualized to patients, regardless of their age or partnership. Support should also be offered to partners. Conclusions Our hope is that this plan will serve as a guide for optimizing how ADT is carried out and improve the lives of androgen-deprived men and their intimate partners.

Management of erectile dysfunction in men treated with androgen deprivation therapy

“…9 While it may be intuitive that the maintenance of erections throughout ADT should slow the rate of penile atrophy and preserve the ability for spontaneous erections, much of the research in penile rehabilitation has been done in the radical prostatectomy group where a degree of nerve damage is to be expected. 10 Use of phosphodiesterase-5 inhibitors (PDE5i), for example, has been shown to preserve penile smooth muscle content post radical prostatectomy.…”

Quality of life issues in men undergoing androgen deprivation therapy: a review

“…This has been confirmed in two studies including a recent meta-analysis. 21,22 In this review, these QoL issues are adapted from a Canadian ADT survivorship working group 23 and categorized into the following six areas:…”

“…Increased abdominal girth and thickening of pre-penile fat pad can further reduce visibility of the penis. It has been suggested by an expert working group 23 that this inability to see the penis results in many ADT patients electing to sit while voiding, thus further diminishing their sense of masculinity. Penile length and girth can be maintained to some degree by penile rehabilitation methods to encourage erections, which, in turn, increase tissue oxygenation, cavernosal circulation and thus a normalized elastin/fibrinogen ratio.…”

“…Despite this reduced libido, some men remain troubled by the loss of erections, 41 while others are relieved that the loss of erections is associated with the loss of libido. 42 The ADT survivorship group 23 has recognized that patients' lack of preparation for such sexual changes results in regret, anger or depression. Patients care about this disconnection with libido, ED and reduced orgasmic ability due to its importance to sense of self, masculinity, QoL and loss of intimate relationships.…”

“…79 The ADT survivor groups noted that many couples stop sharing a bed when a patient commences ADT leading to isolation of the partners from each other. 23 The linkage between depression and low levels of serum testosterone remains unclear, and indeed may be related to patient age and comorbidities as it is more common in men over age 65 years. 80 Regardless of whether it is attributable to the treatment side effects or surgery or radiation 81 or testosterone deficiency itself, patients do experienced expression as such appropriate treatment should begin as early as possible.…”