A qualitative metasynthesis exploring the impact of prostate cancer and its management on younger, unpartnered and gay men

What can patient-reported experience measures tell us about the variation in patients' experience of prostate cancer care? A cross-sectional study using survey data from the National Prostate Cancer Audit in England

OBJECTIVES

A national survey aimed to measure how men with prostate cancer perceived their involvement in and decisions around their care immediately after diagnosis. This study aimed to describe any differences found by socio-demographic groups.

DESIGN

Cross-sectional study of men who were diagnosed with and treated for prostate cancer.

SETTING

The National Prostate Cancer Audit patient-reported experience measures (PREMs) survey in England.

PARTICIPANTS

Men diagnosed in 2014-2016, with non-metastatic prostate cancer, were surveyed. Responses from 32 796 men were individually linked to records from a national clinical audit and to administrative hospital data. Age, ethnicity, deprivation and disease risk classification were used to explore variation in responses to selected questions.

PRIMARY AND SECONDARY OUTCOME MEASURES

Responses to five questions from the PREMs survey: the proportion responding to the highest positive category was compared across the socio-demographic characteristics above.

RESULTS

When adjusted for other factors, older men were less likely than men under the age of 60 to feel side effects had been explained in a way they could understand (men 80+: relative risk (RR)=0.92, 95% CI 0.84 to 1.00), that their views were considered (RR=0.79, 95% CI 0.73 to 0.87) or that they were involved in decisions (RR=0.92, 95% CI 0.85 to 1.00). The latter was also apparent for men who were not white (black men: RR=0.89, 95% CI 0.82 to 0.98; Asian men: RR=0.85, 95% CI 0.75 to 0.96) and, to a lesser extent, for more deprived men.

CONCLUSIONS

The observed discrepancies highlight the need for more focus on initiatives to improve the experience of ethnic minority patients and those older than 60 years. The findings also argue for further validation of discriminatory instruments to help cancer care providers fully understand the variation in the experience of their patients.

Heteronormative biases and distinctive experiences with prostate cancer among men who have sex with men: a qualitative focus group study

BACKGROUND

Men who have sex with men (MSM) face many challenges and biases in healthcare. Within urology there is a need to better understand how prostate cancer impacts MSM given the unique ways in which side effects that accompany treatment may affect this population. The goal of this study is to explore the experience of MSM with prostate cancer to advance the existing literature in this area and inform implementation and delivery of clinical practice and policy guidelines.

METHODS

Four focus groups were conducted with a semi-structured interview guide. Using a phenomenological qualitative approach consistent with grounded theory [1] and naturalistic inquiry principles we sought to better understand the direct experiences of MSM with prostate cancer. Audio transcriptions were thematically analyzed to identify themes that impact MSM throughout their prostate cancer journey. An iterative, team-wide classification process was used to identify, organize, and group common codes into higher-order categories and themes.

RESULTS

Patient's choice of provider and their interactions with the healthcare system were strongly impacted by their sexual identities. Participants commented on navigating the heteronormative healthcare environment and the impact of assumptions they encountered. MSM experienced the sexual side effects of prostate cancer treatment in unique ways. Issues with erectile dysfunction and ejaculatory dysfunction had significant impacts on patient's sexual experience, with some describing being forced to explore new modes of sexual expression. Anejaculation was a theme that was distressing for many participants. The emotional impact of a prostate cancer diagnosis was significant in the men interviewed. Common themes included loss of identity and fear for future relationships.

CONCLUSIONS

MSM have unique concerns after prostate cancer treatment that differ from men who don't identify as MSM. It is critical that providers familiarize themselves with the concerns of this patient population regarding prostate cancer treatment. An important step toward reducing heteronormative bias in prostate cancer care is to better understand the goals, identity, and sexual practices of MSM and to provide informed anticipatory guidance.

Prostate cancer disclosure and sexual orientation: Understanding outness to healthcare providers as a situational or consistent phenomenon

OBJECTIVE

In this study, we investigated if outness is more a situational or a consistent characteristic in gay, bisexual, and other men who have sex with men (GBM) treated for prostate cancer and how the disclosure of sexual orientation impacts provider discussions of sexual side effects.

METHODS

Data came from Restore, an online cross-sectional survey of 193 GBM prostate cancer survivors living in North America and were analyzed using various statistical models.

RESULTS

Disclosure of sexual orientation and of living with prostate cancer were not significantly correlated. Participants who were out regarding sexual orientation were more likely to report that their surgeons and urologists discussed the sexual side effects of treatment.

CONCLUSION

Outness appears to be a situational phenomenon. GBM prostate cancer survivors who were out regarding sexual orientation received more discussion surrounding sexual side effects of prostate cancer treatment from their providers.

PRACTICE IMPLICATIONS

It is important for healthcare providers to inquire about patient's sexual orientation to provide holistic care to these patients to address health disparities within this group.

Sexual Dysfunction in Gay and Bisexual Prostate Cancer Survivors: A Concept Analysis

Sexual dysfunction is a common side effect of prostate cancer (PCa) treatment, yet it remains poorly defined in the literature. Current definitions are based on heteronormative assumptions which do not consider the unique experiences of gay and bisexual (GBM) PCa survivors. The purpose of this paper is to use Walker and Avant's method to conduct a concept analysis of sexual dysfunction among GBM in the context of PCa survivorship. The review included 46 articles published between 2002-2019. The following attributes were identified: (1) erectile dysfunction, (2) ejaculatory change (anhedonia/anejaculation), (3) urinary incontinence/climacturia, and (4) anodyspareunia. For GBM PCa survivors, sexual dysfunction involves reduced or abnormal functioning of four core elements of a sexual encounter, which inhibit GBM from engaging in and being satisfied with sexual activity.

Addressing urologic health disparities in sexual and gender minority communities through patient-centered outcomes research

Sexual and gender minority (SGM) communities face stigma and discrimination that impact all aspects of health. To better understand and improve their urologic health outcomes, we must study SGM patients as a distinct population and pursue research on outcomes identified as priorities to SGM communities. Patient-centered outcomes research (PCOR) is a methodology which is increasingly familiar to urologists and is crucial to adequately addressing SGM health in future urological research. We review existing literature focused on urologic outcomes of SGM populations and highlight specific PCOR initiatives built on SGM community engagement.

Redefining masculinity - Men's repair work in the aftermath of prostate cancer treatment

Treatments for prostate cancer have many potential side effects such as a loss of erection, weaker orgasms, and incontinence. These are all bodily changes that may challenge dominant masculine ideals. In this article, I use Persson's repair work to describe how men tackle these side effects, and I describe the trouble their repair work elicits in terms of masculinity. I analyse interviews with eleven Swedish men, all treated for prostate cancer, and show that such work is done in three ways. Bodily repair work elicits the work men do to restore bodily functions, often through medical technologies. Relational repair work describes how relations with (potential) others shape men's bodily and sexual concerns, and the ways relations redefine such concerns. Age marking as repair emphasises how age is used in the redefinitions of norms about masculinities and aging bodies, both in relation to oneself and others. The analysis highlights how men's repair work is multifaceted, and is performed against the backdrop of dominant discourses on masculinity, medicine and old age. The analysis of such repair work is valuable to research on how masculinity is constructed in the light of treatment side effects and older age.

A Qualitative Exploration of Prostate Cancer Survivors Experiencing Psychological Distress: Loss of Self, Function, Connection, and Control

PURPOSE

To explore the experiences of men with prostate cancer identified as having psychological distress and to identify factors influencing distress.

PARTICIPANTS & SETTING

28 men with prostate cancer diagnosed 18-42 months earlier, identified as having psychological distress on survey measures.

METHODOLOGIC APPROACH

Semistructured telephone interviews were conducted. Thematic analysis using a framework approach was used.

FINDINGS

Men with psychological distress had strong perceptions of loss toward self (identity, sexuality/masculinity, self-confidence), function (physical activities), connection (relational, social, community), and control (future, emotional). Psychological vulnerability appeared heightened in particular groups of men. Maladaptive strategies of emotional concealment, help-seeking avoidance, and withdrawal appeared to contribute to distress.

IMPLICATIONS FOR NURSING

Distress in men with prostate cancer is multifaceted. Men with distress should be identified and offered support. Nurse- or peer-led interventions are required.

Experiences of Support for Sexual Dysfunction in Men With Prostate Cancer: Findings From a U.K.-Wide Mixed Methods Study

BACKGROUND

Men with prostate cancer (PCa) often experience sexual dysfunction following diagnosis and treatment, yet little is known about the support they receive to deal with this.

AIM

To explore men's experiences of support for sexual dysfunction following PCa diagnosis.

METHODS

This study included a U.K.-wide survey of men 18-42 months post-diagnosis of PCa, identified through cancer registries. The survey measured sexual function and the extent to which men perceived sexual dysfunction to be a problem (Expanded Prostate Cancer Index Composite-26), access to and experience of medications, devices, and specialist services for sexual dysfunction, and included a free-text question for further comments. Analysis focussed on men who reported poor sexual function, which they considered a moderate or big problem. Descriptive statistics explored the characteristics of men offered intervention and those that found this helpful. Free-text responses were analyzed using thematic analysis.

OUTCOME

The main outcome of this study was to assess access to and experience of medications, devices, and specialist services for sexual dysfunction.

RESULTS

39.0% of all survey respondents (13,978/35,823) reported poor sexual function, which they considered a moderate or big problem. 51.7% of these men were not offered any intervention to aid sexual functioning. 71.9% of those offered an intervention reported trying it, of whom 48.7% found the intervention helpful. Men treated with surgery or brachytherapy were most likely to be offered an intervention. Medication was the most commonly offered intervention and 39.3% of those who tried medication found this helpful. Although offered less often, approximately half of the men who tried devices or attended specialist services found the intervention helpful. Free-text responses indicated that barriers to accessing support included inadequate information and support from healthcare professionals, embarrassment, negative views about treatment options, concerns about side effects and safety, and inconsistencies between secondary and primary care. Barriers to continuing use included limited effectiveness of treatments, inadequate ongoing support, and funding constraints. Drivers of sexual recovery included patient proactivity and persistence with trying different treatment options and ongoing support from health professionals.

CLINICAL IMPLICATIONS

There is an urgent need to ensure that all men are offered, and have equal access to, sexual care support, with referral to specialist services when required.

STRENGTHS & LIMITATIONS

This study presents data from a large, U.K.-wide, population-based study of men with PCa and includes quantitative and qualitative findings. The possibility of non-response bias should, however, be considered.

CONCLUSION

There are significant shortcomings in the support offered to U.K. men with sexual dysfunction following diagnosis and treatment for PCa which need to be addressed. Watson E, Wilding S, Matheson L, et al. Experiences of Support for Sexual Dysfunction in Men With Prostate Cancer: Findings From a U.K.-Wide Mixed Methods Study. J Sex Med 2021;18:515-525.

An Examination of the Role of Socioeconomic Status in the Relationship between Depression and Prostate Cancer Survivorship in a Population-Based Sample of Men from Atlantic Canada

OBJECTIVE

Prostate and skin cancer are among the most prevalent forms of cancer among men and have favorable survival rates compared to other, more aggressive forms of cancers. Recent studies have shown that the odds of depression among men with a lifetime history of prostate cancer are higher compared to men without a lifetime history of prostate cancer. Here we extend previous findings and examine the role of socioeconomic status in the relationship between depression and cancer survivorship status in a population-based sample of men from Atlantic Canada.

METHODS

A cross-sectional analysis was conducted on a subsample of 6,585 male participants aged 49-69 years from the 2009-2015 survey cycle of the Atlantic PATH study. The primary outcome was screening positive for mild, moderate or severe depression using the Patient Health Questionnaire (PHQ-9). The main predictor variable was cancer survivorship status (the presence of a lifetime history of prostate cancer, skin cancer, forms of cancer other than prostate or skin cancer, or absence of a lifetime cancer diagnosis). Covariates included age, education, marital status, household income, province, ethnicity, comorbidity, and survivorship time.

RESULTS

An estimated 14.7% of men in this sample screened positive for mild, moderate or severe depression. Men with a history of prostate cancer were 2.60 (95% CI: 1.02, 6.65) times more likely to screen positive for depression than men with a history of any other form of cancer. The odds ratios were 10.23 (95% CI: 2.82, 37.49) or 4.00 (95% CI: 1.20, 13.34) times higher for survivors of prostate or skin cancer who reported a low household income to screen positive for depression compared to men with a history of any other form of cancer and high household income.

CONCLUSIONS

These results extend current evidence of the association between prostate cancer survivorship and depression compared with men who never had a history of cancer diagnosis by indicating that this association still stands when the survivors of prostate cancer are compared to survivors of any other form of cancer, and further indicates that this association is moderated by household income. The findings highlight the importance of delivering mental health screening and support to prostate cancer survivors during the cancer journey, especially those with low household incomes.

The Politics of LGBT+ Health Inequality: Conclusions from a UK Scoping Review

This scoping review of UK evidence aimed to describe what is known about Lesbian, Gay, Bisexual, and Trans (LGBT+) health inequalities in relation to cancer, mental health, and palliative care to inform research, policy and public health interventions. Using a scoping review methodology, we identified studies from database searches, citation tracking, and expert consultation. The in/exclusion criteria was based on the PICOS framework. The data were charted and then summarised to map the theoretical approaches and the main types of evidence and identify knowledge gaps. In total, 279 articles were screened and 83 were included in the final review. We found that there is limited UK research examining LGBT+ health inequality in cancer, mental health and palliative care. We would argue that this thin evidence base is partly due to national policy discussions of LGBT+ health inequality that are framed within a depoliticised ‘it’s getting better’ narrative, and an unwillingness to adequately acknowledge the unjust social and economic relations that produce LGBT+ health inequality. In addition, LGBT+ health inequality is depoliticised by existing public health explanatory theories, models and frameworks that exclude sexual orientation and gender diversity as dimensions of power that interlock with those of socio-economic, race and ethnicity. This is a barrier to developing public health interventions that can successfully tackle LGBT+ health inequality

Promoting Sexual Well-being for Men and Their Partners Affected by Prostate Cancer

OBJECTIVE

To present an overview of the issues related to the sexual well-being of people affected by prostate cancer and their partners, and propose ways to manage and address these by oncology nurses and the wider multi-disciplinary team.

DATA SOURCES

Electronic databases such as PubMed and Cinahl were used to retrieve relevant literature published between 2010 and 2020.

CONCLUSION

Sexual well-being in patients with prostate cancer and their partners is multifaceted, comprising physical, emotional, social, and cultural aspects.

IMPLICATIONS FOR NURSING PRACTICE

A combination of pharmacologic and non-pharmacologic interventions, together with enhanced communication, can be successful in providing culturally competent, person-centered care by oncology nurses and the wider multi-disciplinary team.

Strategies for living well with hormone-responsive advanced prostate cancer-a qualitative exploration

PURPOSE

Due 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.

RESULTS

Most 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.

Prostate cancer in sexual minorities and the influence of HIV status

Prostate cancer is the second most common cause of cancer-related death in men in the USA, but the effect of prostate cancer diagnosis and treatment on men in a sexual minority group, including men who have sex with men and transgender women, is poorly understood. Efforts to study this population are complicated, as cancer registries do not routinely collect information on sexual orientation. As a result, epidemiological data regarding this population have come from small studies that have included disparate rates of prostate cancer screening, diagnosis and treatment. Qualitative studies indicate that prostate cancer is experienced differently by sexual minorities, with distinct health-care needs that arise owing to differences in sexual practices, social support systems and relationships with the medical community. Notably, sexual minorities have been reported to experience poorer health-related quality of life outcomes than heterosexual men, and tend to have less robust social support systems, experience increased psychological distress caused by sexual dysfunction (areas of which are unmeasured after treatment), experience isolation within the health-care system and express increased levels of dissatisfaction with treatment. The incidence of prostate cancer actually seems to be decreased in men from sexual minorities living with HIV, despite there being no differences in screening and treatment, with poor cancer-specific mortality. Although the literature on patients with prostate cancer in men from sexual minority groups has historically been sparse, peer-reviewed research in this area has grown considerably during the past decade and has become an important field of study.

Long-Term Endocrine and Metabolic Consequences of Cancer Treatment: A Systematic Review

The number of patients surviving ≥5 years after initial cancer diagnosis has significantly increased during the last decades due to considerable improvements in the treatment of many cancer entities. A negative consequence of this is that the emergence of long-term sequelae and endocrine disorders account for a high proportion of these. These late effects can occur decades after cancer treatment and affect up to 50% of childhood cancer survivors. Multiple predisposing factors for endocrine late effects have been identified, including radiation, sex, and age at the time of diagnosis. A systematic literature search has been conducted using the PubMed database to offer a detailed overview of the spectrum of late endocrine disorders following oncological treatment. Most data are based on late effects of treatment in former childhood cancer patients for whom specific guidelines and recommendations already exist, whereas current knowledge concerning late effects in adult-onset cancer survivors is much less clear. Endocrine sequelae of cancer therapy include functional alterations in hypothalamic-pituitary, thyroid, parathyroid, adrenal, and gonadal regulation as well as bone and metabolic complications. Surgery, radiotherapy, chemotherapy, and immunotherapy all contribute to these sequelae. Following irradiation, endocrine organs such as the thyroid are also at risk for subsequent malignancies. Although diagnosis and management of functional and neoplastic long-term consequences of cancer therapy are comparable to other causes of endocrine disorders, cancer survivors need individually structured follow-up care in specialized surveillance centers to improve care for this rapidly growing group of patients.

Gay men's experiences of sexual changes after prostate cancer treatment-a qualitative study in Sweden

Background: The needs of gay men after prostate cancer treatment are becoming visible. This patient group reports a more negative impact of treatment than heterosexual men. Yet, gay men's experiences of post-treatment sexual changes are still little explored. This study aims to determine specific concerns of gay men's post-treatment sexual practices. Methods: A qualitative study design was deployed using semi-structured interviews as data. Participants were purposefully sampled through advertisements and the snowball method. Eleven self-identifying gay men aged 58-81 years and treated for prostate cancer participated in interviews during 2016-2017. The interviews were transcribed, coded and thematically analysed. Results: The analysis highlights sexual changes in relation to the physical body, identity and relations. Problematic physical changes included loss of ejaculate and erectile dysfunction. Some respondents reported continued pleasure from anal stimulation and were uncertain about the role of the prostate. These physical changes prompted reflections on age and (dis)ability. Relationship status also impacted perception of physical changes, with temporary sexual contacts demanding more of the men in terms of erection and ejaculations. Conclusions: Gay prostate cancer survivors' narratives about sexual changes circle around similar bodily changes as heterosexual men's, such as erectile problems and weaker orgasms. The loss of ejaculate was experienced as more debilitating for gay men. Men who had anal sex were concerned about penetration difficulties as well as sensations of anal stimulation. Additional studies are required to better understand the role of the prostate among a diversity of men, regardless of sexuality.

Social Support and Health-Related Quality of Life Among Gay and Bisexual Men With Prostate Cancer

OBJECTIVES

To describe social support patterns of gay and bisexual men with prostate cancer (GBMPCa) and how social support is associated with prostate cancer outcomes.

SAMPLE & SETTING

A cross-sectional online survey with 186 GBMPCa recruited from a national cancer support group network.

METHODS & VARIABLES

Descriptive statistics of social support and linear regression of social support on general and prostate cancer-specific quality of life (QOL). Social support and health-related QOL were assessed generally and specific to prostate cancer.

RESULTS

Participants primarily relied on partners or husbands, gay and bisexual friends, chosen family, and men from support groups for support. The most common types of support received were informational and emotional social support. Low general social support was significantly associated with worse prostate cancer symptom bother and general mental QOL. Wanting more social support was significantly associated with worse prostate cancer-specific and general QOL.

IMPLICATIONS FOR NURSING

Clinicians should be aware of the different social support networks and needs of GBMPCa and refer them to relevant support groups to improve QOL.

Prostate cancer and the impact on couples: a qualitative metasynthesis

PURPOSE

To review and interpret existing qualitative literature on the experiences of couples affected by prostate cancer (PCa).

METHODS

A metasynthesis was carried out which included a systematic search of seven databases between 2000 and 2016. A modified version of Noblit and Hare's meta-ethnographic approach was used to synthesise qualitative study findings and inform overarching interpretations.

RESULTS

Thirty-seven studies focusing on the experiences of men with PCa and their partner dyad were included producing seven interconnected constructs. The construct accepting change vs seeking continuity reflects the range of ways individuals within the dyad and couples adjust to the diagnosis. Cultivating connection vs disengaging illustrates how couples seek to manage the impact of PCa and its treatment on their relationship, which may lead to a threatened identity, including sexual insecurities. Shielding me, you and us reflects the ways in which couples strive to protect themselves as individuals and/or each other from the impact of PCa. Being a partner and its challenges highlights the responsibilities partners assume and the impact of their supporting role. Yet, partners sometimes report feeling unsupported and side-lined both by the man they are caring for and by healthcare professionals. Couples often recognise the value of facing PCa together.

CONCLUSIONS

PCa affects both members of the dyad as individuals, as well as the couple's relationship. How best to support couples and how to overcome difficulties in expressing their concerns to one another requires further consideration. Healthcare professionals should endeavour to employ a couple-focused approach where appropriate.