Abstract
This survey study evaluates the presence of erectile dysfunction in men who had experienced cancer during childhood.
Male sexual dysfunction and its association with psychological and physical well-being have been underreported in childhood cancer survivors (CCSs). To our knowledge, this study provides the first data on a large population of systematically and clinically assessed CCSs, enumerating the prevalence and consequences of erectile dysfunction (ED) and identifying potential targets for intervention.
Methods
This cross-sectional, single-institution study included male CCSs, 18 years or older, 10 years or more from diagnosis of childhood cancer who completed questionnaires on sexual health.1 In sexually active participants, mild to severe ED was defined by scores of 25 or less, using the validated, 6-item version of the International Index of Erectile Function.2 In non–sexually active participants, responses to items that queried problems achieving or sustaining an erection were used to characterize ED. Low total testosterone level was defined as morning serum concentrations less than 250 ng/dL (to convert to nanomoles per liter, multiply by 0.0347). Psychological distress, body image dissatisfaction, and health-related quality of life were measured using the Brief Symptom Inventory, the Body Image Scale, and the 36-Item Short-Form Health Survey, respectively. Physical health outcomes included lean muscle mass, vitality, physical activity, slowness, weakness, and exercise tolerance.3 This study was approved by the institutional review board at St Jude Children's Research Hospital; written informed consent was obtained from all participants.
To limit false-positive results, elastic net regression was used to select variables for multivariable analyses. Associations between demographic and treatment-related risk factors, psychological distress, physical health, and ED were evaluated (relative risk [RR], 95% CI). Statistical significance was set at α = .05 (2-sided).
Results
The survey participant rate was 62.6% (1021 of 1631 eligible patients). A total of 1021 participants (median age, 31.3 years; range, 18.8-61.5 years) were included. ED scores were available for 956. Erectile dysfunction was reported by 277 (29.0%; 95% CI, 26.1%-32.0%) of the participants. In sexually active participants (n = 873 [85.5%]), independent risk factors for ED included Hispanic or other race/ethnicity (RR, 1.94; 95% CI, 1.05-3.61), age at the time of the study (RR, 0.98; 95% CI, 0.96-1.00), and low testosterone levels (RR, 1.70; 95% CI, 1.20-2.41) (Table). When data of both sexually and non–sexually active participants were combined, black race (RR, 1.51; 95% CI, 1.14-2.02) was also a risk factor for ED. Individuals with greater body image dissatisfaction and low lean muscle mass were more likely to report ED in both the sexually active and combined groups (Table).
Table. Multivariable Analysis of Factors and Markers Associated With ED Among Study Participants.
| Characteristic | Sexually Active Participants (n = 873)a | All Participants (n = 1021)b | ||||||
|---|---|---|---|---|---|---|---|---|
| Model 1 (n = 238)c | Model 2 (n = 277)d | |||||||
| No. | No. (Row %) | RR (95% CI) | P Value | No. | No. (Row %) | RR (95% CI) | P Value | |
| Demographic-Related Factors | ||||||||
| Race/ethnicity | ||||||||
| Non-Hispanic white | 725 | 198 (27.3) | 1 [Reference] | 837 | 229 (27.4) | 1 [Reference] | ||
| Non-Hispanic black | 77 | 29 (37.7) | 1.46 (0.98-2.17) | .06 | 92 | 35 (38.0) | 1.51 (1.14-2.02) | .005 |
| Hispanic/other | 22 | 11 (50.0) | 1.94 (1.05-3.61) | .04 | 27 | 13 (48.2) | 1.78 (1.19-2.66) | .005 |
| Age at diagnosis, mean (SD), y | ||||||||
| Mean (SD) | 873 | 8.6 (5.6) | 0.99 (0.97-1.02) | .56 | 1021 | 8.4 (5.5) | NS | |
| Age at questionnaire, mean (SD), y | ||||||||
| Mean (SD) | 873 | 32.7 (8.2) | 0.98 (0.96-1.00) | .05 | 1021 | 32.1 (8.4) | 0.98 (0.97-1.00) | .03 |
| Treatment-Related Factors | ||||||||
| Illicit drug use | ||||||||
| No | 688 | 206 (29.9) | 1 [Reference] | 802 | 240 (29.9) | 1 [Reference] | ||
| Yes | 125 | 30 (24.0) | 0.80 (0.54-1.18) | .26 | 138 | 33 (23.9) | 0.80 (0.59-1.08) | .15 |
| Testicular radiation dose | ||||||||
| None | 786 | 223 (28.4) | NS | 911 | 257 (28.2) | 1 [Reference] | ||
| Yes | 38 | 15 (39.5) | NS | 45 | 20 (44.4) | 1.23 (0.87-1.74) | .25 | |
| Cranial radiation dose | ||||||||
| None | 588 | 154 (26.2) | 1 [Reference] | 678 | 182 (26.8) | 1 [Reference] | ||
| 1-29 Gy | 180 | 59 (32.8) | 1.27 (0.91-1.78) | .16 | 201 | 66 (32.8) | 1.25 (0.98-1.60) | .07 |
| ≥30 Gy | 56 | 25 (44.6) | 1.48 (0.93-2.37) | .10 | 77 | 29 (37.7) | 1.27 (0.91-1.78) | .17 |
| Surgery affecting ED | ||||||||
| No | 761 | 214 (28.1) | 1 [Reference] | 884 | 252 (28.5) | 1 [Reference] | ||
| Yes | 63 | 24 (38.1) | 1.30 (0.84-2.00) | .24 | 72 | 25 (34.7) | 1.17 (0.85-1.61) | .34 |
| Low testosterone level | ||||||||
| No | 626 | 157 (25.1) | 1 [Reference] | 716 | 181 (25.3) | 1 [Reference] | ||
| Yes | 198 | 81 (40.9) | 1.70 (1.20-2.41) | .003 | 240 | 96 (40.0) | 1.53 (1.18-1.99) | .001 |
| Markers of Physical Condition | ||||||||
| Hand grip strength (weakness) | ||||||||
| No | 788 | 225 (28.6) | 1 [Reference] | 912 | 260 (28.5) | 1 [Reference] | ||
| Yes | 31 | 13 (41.9) | 1.28 (0.71-2.28) | .41 | 37 | 16 (43.2) | 1.26 (0.73-2.15) | .41 |
| Poor physical activity | ||||||||
| No | 525 | 136 (25.9) | 1 [Reference] | 607 | 156 (25.7) | 1 [Reference] | ||
| Yes | 291 | 100 (34.4) | 1.16 (0.88-1.54) | .30 | 337 | 118 (35.0) | 1.20 (0.92-1.56) | .18 |
| Low lean muscle mass | ||||||||
| No | 645 | 174 (27.0) | 1 [Reference] | 745 | 201 (27.0) | 1 [Reference] | ||
| Yes | 128 | 48 (37.5) | 1.44 (1.04-2.00) | .03 | 147 | 53 (36.1) | 1.36 (1.00-1.86) | .05 |
| Markers of Psychological Distress | ||||||||
| Depression | ||||||||
| No | 683 | 175 (25.6) | 1 [Reference] | 792 | 202 (25.5) | 1 [Reference] | ||
| Yes | 125 | 56 (44.8) | 1.41 (0.94-2.12) | .09 | 144 | 67 (46.5) | 1.42 (0.98-2.07) | .07 |
| Anxiety | ||||||||
| No | 721 | 194 (26.9) | 1 [Reference] | 833 | 226 (27.1) | 1 [Reference] | ||
| Yes | 87 | 37 (42.5) | 1.22 (0.78-1.90) | .38 | 103 | 43 (41.8) | 1.09 (0.72-1.64) | .69 |
| Body image dissatisfaction, mean (SD) | ||||||||
| ED | 235 | 1.6 (0.6) | 1.28 (1.03-1.60) | .02 | 274 | 1.6 (0.7) | 1.32 (1.08-1.63) | .01 |
| No ED | 581 | 1.4 (0.5) | 1 [Reference] | 674 | 1.4 (0.5) | 1 [Reference] | ||
Abbreviations: ED, erectile dysfunction; NS, not selected for the model by the elastic net regression method; RR, relative risk.
Reported sexual activity during the 4 weeks prior to study participation.
Reported sexual activity or no sexual activity during the 4 weeks prior to study participation.
Analysis with International Index of Erectile Function (IIEF) scale (scores ≤25 are consistent with mild to severe ED).
Analysis with IIEF scale or questionnaire response consistent with ED.
Discussion
The prevalence of ED in our study was considerably higher compared with other CCS cohorts or the general population.4,5 Hypogonadism, a condition often undiagnosed in CCSs, could explain the associations between low testosterone levels, low lean muscle mass, and ED.6 We also found an association between nonwhite race/ethnicity and ED. The reasons for this association are not clear and need further exploration in populations enriched for racial/ethnic minorities. The finding that younger age at assessment was associated with a higher risk for ED is likely a reflection of the differential age distributions between tumor types in our population: protocols to treat patients with brain tumors were introduced at our institution in the mid-1980s. Therefore, this association is likely driven by including younger survivors treated for brain tumors, which is a population at risk for hypogonadism.6
The association between ED and greater body image dissatisfaction may be bidirectional and emphasizes that ED requires multidisciplinary treatment that combines psychological counseling and medical treatment. The lack of validated questionnaires has limited the reliable assessment of ED in non–sexually active CCSs; further diagnostic research is warranted. Furthermore, potential selection bias and misclassification may have overestimated the prevalence of ED in our cohort. Although the results from these analyses are hypothesis generating and need validation in an independent cohort, our data support the hypothesis that ED may be a modifiable condition in CCSs. Clinicians should be aware that appropriate management of hypogonadism may improve impaired sexual functioning in CCSs.
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