Radiotherapy and Oncology, 25 (1992) 207-212 © 1992 Elsevier Science Publishers B.V. All rights reserved. 0167-8140/92/$05.00
207
RADION 01044
Short Communication
Sexual morbidity following radiotherapy for germ cell tumours of the testis Sandra D. Tinkler, Grahame C. W. Howard and Gillian R. Kerr Department of Clinical Oncology, Western General Hospital, Edinburgh, UK (Received 6 February 1992, revision received 12 May 1992, accepted 4 June 1992)
Key words: Testicular cancer; Radiotherapy; Sexual function
Summary An anonymous questionnaire study was designed to assess sexual function after orchidectomy and radiotherapy for testicular cancer. Questionnaires were sent to: (1)237 patients treated with orchidectomy and abdominal radiotherapy in Edinburgh from 1974 to 1988; (2) 32 patients under "surveillance" following orchidectomy alone; (3) 402 "normal" age-matched controls. All were asked questions concerning sexual function over the preceding 6 months. All the patients were also asked the same questions with reference to the first 6 months after completion of treatment. Completed questionnaires were returned from 137 (62%) radiotherapy patients, 18 (56%) surveillance patients and 121 (35%) controls. There was a significant difference between the radiotherapy patients and the controls in almost all the parameters looked at including erection, ejaculation and libido with the treated group performing less well. In addition, almost 24 % of the radiotherapy patients felt disabled or disfigured by the treatment, most commonly because of the presence of only one testicle. A deterioration in sexual function was observed with increasing age. In the radiotherapy group of patients there was no difference in response between the two time periods or in any of the treatment variables. The clinical significance of these observations are unclear but together with the increasing information on other toxicities emerging following this therapy the role of radiation for early stage seminoma is being brought into question. This study also confirms the morbidity of orchidectomy. We suggest that testicular implants should be offered more widely.
Introduction
Germ cell tumours of the testis are relatively rare accounting for about 1% of all male cancers but the incidence is rising [ 1-3]. They are now one of the most curable solid tumours of adults with a long-term survival for early disease approaching 100% [4]. It is standard practice in Britain to give adjuvant radiotherapy to the ipsilateral pelvic and retroperitoneal lymph nodes to patients with stage 1 seminoma, where a relatively low dose of radiation (30-35 Gy in 15-20 daily fractions or its equivalent) will reduce the relapse rate from 20% to about 2 ~ [4-6]. It is generally assumed that the longterm sequelae from this treatment are minimal. Recent studies how-
ever have shown an increased incidence in gastrointestinal side effects, e.g. peptic ulceration [7,8] and data are emerging suggesting that there might be an effect on sexual function in patients treated with radiotherapy [9-14]. The side effects of retroperitoneal lymph node dissection (RPLND) are better documented with dry ejaculation occurring in the majority of patients [15,16] although nerve sparing techniques may preserve normal ejaculation in 45-100% of cases [17]. Libido, erection and orgasm after RPLND are reported to be normal [16]. There is however some evidence that the addition of radiotherapy to the iliac and para-aortic regions following RPLND may result in erectile dysfunction in about 20% of cases [16]. It has been assumed that radiotherapy has less of an effect on sexual function than RPLND but reports have been conflicting. A deterioration in sexual function has been reported in 10-50% of patients after treatment for testicular cancer [9-14]. These studies have found a reduction in libido [ 9,11 ], erectile dysfunction [ 9,1113], ejaculatory dysfunction [9] and alteration in body image [ 13]. Increasing sexual dysfunction has also been found with increasing age [9]. Other studies however have reported no adverse effect on sexual function [ 18-21 ]. The interpretation of published data is often difficult in view of their lack of appropriate controls, small sample sizes and multiplicity of therapies used. Materials and methods
The questionnaire This was designed specifically for the study as there were no appropriate well validated brief sexual function questionnaires in existence. It was not possible to validate the questionnaire, e.g. by test-retest as the study was anonymous. It was however piloted on a small number of normal men and patients ineligible for the study. Six main areas of sexual function were explored: (1) Presence of a regular sexual partner. (2) Satisfaction with sex life. (3) Libido: specifically the frequency of sexual activity (intercourse or masturbation) and how often sex was thought about. (4) Erectile function: if erections occurred, how often these erections were sustained long enough for sexual intercourse, and how often they woke with an erection. (5) Ejaculatory function: if ejaculation occurred and any perceived
Address for correspondence." Sandra D. Tinkler, Department of Clinical Oncology, Western General Hospital, Crewe Road, Edinburgh EH4 2XU, UK.
208 change in the amount of semen or in the quality of orgasm. (6) Any perceived disability or disfigurement resulting from the treatment. Questionnaires were sent to the following groups of men: (1) 237 patients aged 25-64 years who were alive and disease-free 2-17 years after orchidectomy and radiotherapy to the abdomen for a germ cell turnout of the testis. All had received radiotherapy in Edinburgh from 1974 to 1988. Patients who had also received chemotherapy were excluded. (2) 32 patients currently under regular "surveillance" follow-up in Edinburgh after orchidectomy alone for good prognosis stage 1 teratoma. (3) 402 "normal controls" aged 25-64 years obtained at random from the lists of five local General Practitioners. All the men were asked the questions with reference to recent sexual function as defined over the previous 6 months. The radiotherapy and surveillance patients were also asked the same questions as relevant to the first 6 months after completion of their treatment. Anonymity was ensured by including all the treatment details at the end of the questionnaire. The whole document was then returned by the patients.
Statistical analysis Several tests of significance were employed in the analysis of the results. A simple comparison of means was used to assess the age distribution of the study groups. When the data was divided into two responses, e.g. yes/no then the chi-squared test was used. Comparison of the two time periods studied in the treated group of patients was analysed using the Wilcoxon test. The Mann-Whitney U test was
a)
used for the rest of the data. In all cases a two-tailed significant level is quoted. Results
Response rates to the questionnaire were 62% (137) for the radiotherapy treated patients, 56% (18) for the surveillance patients and 35% (121) for the controls. Although the lower response rate for the control group was expected it may introduce a bias into the results as the attitudes of the respondents may differ from that of the nonrespondents. The number of respondents in the radiotherapy and control groups were similar. They were also well matched for age with a mean age of 44 and 44.3 years for the radiotherapy and control groups respectively. In addition, the groups were well matched for the presence of a regular sexual partner (95, 94 and 92% for the radiotherapy, surveillance and control groups respectively). The mean age of the surveillance group was 36.8 years and was significantly different from the radiotherapy group (p
207
RADION 01044
Short Communication
Sexual morbidity following radiotherapy for germ cell tumours of the testis Sandra D. Tinkler, Grahame C. W. Howard and Gillian R. Kerr Department of Clinical Oncology, Western General Hospital, Edinburgh, UK (Received 6 February 1992, revision received 12 May 1992, accepted 4 June 1992)
Key words: Testicular cancer; Radiotherapy; Sexual function
Summary An anonymous questionnaire study was designed to assess sexual function after orchidectomy and radiotherapy for testicular cancer. Questionnaires were sent to: (1)237 patients treated with orchidectomy and abdominal radiotherapy in Edinburgh from 1974 to 1988; (2) 32 patients under "surveillance" following orchidectomy alone; (3) 402 "normal" age-matched controls. All were asked questions concerning sexual function over the preceding 6 months. All the patients were also asked the same questions with reference to the first 6 months after completion of treatment. Completed questionnaires were returned from 137 (62%) radiotherapy patients, 18 (56%) surveillance patients and 121 (35%) controls. There was a significant difference between the radiotherapy patients and the controls in almost all the parameters looked at including erection, ejaculation and libido with the treated group performing less well. In addition, almost 24 % of the radiotherapy patients felt disabled or disfigured by the treatment, most commonly because of the presence of only one testicle. A deterioration in sexual function was observed with increasing age. In the radiotherapy group of patients there was no difference in response between the two time periods or in any of the treatment variables. The clinical significance of these observations are unclear but together with the increasing information on other toxicities emerging following this therapy the role of radiation for early stage seminoma is being brought into question. This study also confirms the morbidity of orchidectomy. We suggest that testicular implants should be offered more widely.
Introduction
Germ cell tumours of the testis are relatively rare accounting for about 1% of all male cancers but the incidence is rising [ 1-3]. They are now one of the most curable solid tumours of adults with a long-term survival for early disease approaching 100% [4]. It is standard practice in Britain to give adjuvant radiotherapy to the ipsilateral pelvic and retroperitoneal lymph nodes to patients with stage 1 seminoma, where a relatively low dose of radiation (30-35 Gy in 15-20 daily fractions or its equivalent) will reduce the relapse rate from 20% to about 2 ~ [4-6]. It is generally assumed that the longterm sequelae from this treatment are minimal. Recent studies how-
ever have shown an increased incidence in gastrointestinal side effects, e.g. peptic ulceration [7,8] and data are emerging suggesting that there might be an effect on sexual function in patients treated with radiotherapy [9-14]. The side effects of retroperitoneal lymph node dissection (RPLND) are better documented with dry ejaculation occurring in the majority of patients [15,16] although nerve sparing techniques may preserve normal ejaculation in 45-100% of cases [17]. Libido, erection and orgasm after RPLND are reported to be normal [16]. There is however some evidence that the addition of radiotherapy to the iliac and para-aortic regions following RPLND may result in erectile dysfunction in about 20% of cases [16]. It has been assumed that radiotherapy has less of an effect on sexual function than RPLND but reports have been conflicting. A deterioration in sexual function has been reported in 10-50% of patients after treatment for testicular cancer [9-14]. These studies have found a reduction in libido [ 9,11 ], erectile dysfunction [ 9,1113], ejaculatory dysfunction [9] and alteration in body image [ 13]. Increasing sexual dysfunction has also been found with increasing age [9]. Other studies however have reported no adverse effect on sexual function [ 18-21 ]. The interpretation of published data is often difficult in view of their lack of appropriate controls, small sample sizes and multiplicity of therapies used. Materials and methods
The questionnaire This was designed specifically for the study as there were no appropriate well validated brief sexual function questionnaires in existence. It was not possible to validate the questionnaire, e.g. by test-retest as the study was anonymous. It was however piloted on a small number of normal men and patients ineligible for the study. Six main areas of sexual function were explored: (1) Presence of a regular sexual partner. (2) Satisfaction with sex life. (3) Libido: specifically the frequency of sexual activity (intercourse or masturbation) and how often sex was thought about. (4) Erectile function: if erections occurred, how often these erections were sustained long enough for sexual intercourse, and how often they woke with an erection. (5) Ejaculatory function: if ejaculation occurred and any perceived
Address for correspondence." Sandra D. Tinkler, Department of Clinical Oncology, Western General Hospital, Crewe Road, Edinburgh EH4 2XU, UK.
208 change in the amount of semen or in the quality of orgasm. (6) Any perceived disability or disfigurement resulting from the treatment. Questionnaires were sent to the following groups of men: (1) 237 patients aged 25-64 years who were alive and disease-free 2-17 years after orchidectomy and radiotherapy to the abdomen for a germ cell turnout of the testis. All had received radiotherapy in Edinburgh from 1974 to 1988. Patients who had also received chemotherapy were excluded. (2) 32 patients currently under regular "surveillance" follow-up in Edinburgh after orchidectomy alone for good prognosis stage 1 teratoma. (3) 402 "normal controls" aged 25-64 years obtained at random from the lists of five local General Practitioners. All the men were asked the questions with reference to recent sexual function as defined over the previous 6 months. The radiotherapy and surveillance patients were also asked the same questions as relevant to the first 6 months after completion of their treatment. Anonymity was ensured by including all the treatment details at the end of the questionnaire. The whole document was then returned by the patients.
Statistical analysis Several tests of significance were employed in the analysis of the results. A simple comparison of means was used to assess the age distribution of the study groups. When the data was divided into two responses, e.g. yes/no then the chi-squared test was used. Comparison of the two time periods studied in the treated group of patients was analysed using the Wilcoxon test. The Mann-Whitney U test was
a)
used for the rest of the data. In all cases a two-tailed significant level is quoted. Results
Response rates to the questionnaire were 62% (137) for the radiotherapy treated patients, 56% (18) for the surveillance patients and 35% (121) for the controls. Although the lower response rate for the control group was expected it may introduce a bias into the results as the attitudes of the respondents may differ from that of the nonrespondents. The number of respondents in the radiotherapy and control groups were similar. They were also well matched for age with a mean age of 44 and 44.3 years for the radiotherapy and control groups respectively. In addition, the groups were well matched for the presence of a regular sexual partner (95, 94 and 92% for the radiotherapy, surveillance and control groups respectively). The mean age of the surveillance group was 36.8 years and was significantly different from the radiotherapy group (p
