MD Anderson Cancer Center
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Lisa Garvin: Welcome to Cancer Newsline, a weekly Podcast series from the University of Texas, MD Anderson Cancer Center. Cancer Newsline helps you stay current with the news on cancer research, diagnosis, treatment, and prevention, providing the latest information on reducing your family's cancer risk. I'm your host, Lisa Garvin. Today, our guest is Dr. Leslie Schover, she is a professor of Behavioral Science here at MD Anderson, and a cancer in sexuality guru. We are going to talk about the CAREss study. Dr. Schover what is CAREss?
Dr. Leslie Schover: Well, CAREss is the cute acronym we've made for the study. It stands for Counseling about Regaining Erections and Sexual Satisfaction. And the "care" part is capitalized because it's a couple study, and one of the things that's very important is that couple show their caring and affection to each other.
Lisa Garvin: So this is for men who are prostate cancer patients and their partners.
Dr. Leslie Schover: Yes, it actually was for men who had finished their treatment. They needed to be, I think, a year out from the end of their treatment and they were treated for localized prostate cancer. So they were men who either got surgery or radiation therapy and who weren't currently taking hormone therapy.
Lisa Garvin: And what do we know about erectile dysfunction vis-a-vis radical prostatectomy and radiation. I understand that the outcomes might be slightly better for men who undergo radiation.
Dr. Leslie Schover: Well, it depends on who you talk to it and how they measure it. My personal point of view for my 30 plus years in the field is that there is no free lunch when it comes to prostate cancer and erections. No matter what kind of treatment you have unless you are quite young for prostate cancer like under 60 and you had excellent erections when you were diagnosed. And you have one of the treatments that best sparing erections like either bilateral nerves sparing with surgery or brachytherapy, the seed implants with radiation therapy, you are highly unlikely to end up with erections that are anywhere near what they were like before your cancer.
Lisa Garvin: And typically with men, they are probably less likely to seek help for sexual dysfunction as opposed to women.
Dr. Leslie Schover: Actually surprisingly, it's about equal, but it's not very high. I mean global studies around the world about 20 percent of men or women who have sexual problem seek help. Now, men who have surgery for prostate cancer have a higher rate of help seeking. It's more like 50 to 60 percent. But that's probably because their urologist often tell them that if they wanna have the best chance that regaining erections they should do something right away after surgery to keep blood flow going so they put them on pills or penile injections, or a vacuum pump during those early months after surgery.
Lisa Garvin: So what's the hope with CAREss? There are two arms there's the group that just getting printed information and then there is an internet component.
Dr. Leslie Schover: Well, actually it was a comparison of more traditional face-to-face sexual counseling done in three sessions with both partners present or the same content provided on website where each partner have their own homepage and their own password to access the website and they were assigned a counselor and they actually communicated with their counselor via email. So it was comparing internet versus face-to-face treatment.
Lisa Garvin: What were the preliminary results?
Dr. Leslie Schover: Well, actually the final results 'cause, you know, we are, you know, have just published the final paper were what I'd hope which was that either format of treatment was equally effective. And, you know, although we had about of third of the couples drop out of either treatment it was kind of equal no matter which arm they were assigned to. Those--Of those that stayed in, significant, you know, number of the couples had improvements in their sexual function and satisfaction. And the other thing that was very gratifying to me was that the improvements tended to stay significant at a year followup and I'll tell you very few studies of what call cognitive behavioral therapy the kind of the brief coping therapies we used a lot with cancer patients, do that long followup, and most of them just do a posttreatment from pretreatment comparison or maybe a six-month followup. So to see results that are lasting is very--is very nice.
Lisa Garvin: The typical pattern with men with respect to their sexual function, are they likely to go it alone and maybe they go to a counselor alone or try to deal with it themselves rather than involve their partner in the conversation?
Dr. Leslie Schover: A lot of them will go alone, but they don't go to a counselor typically. They go to a urologist or sexual medicine specialist and they say, "Fix my erection. If my erection was hard again, everything would be perfect." And that's a problem because our research preparatory to the study over a number of years showed us that of all the men who have treatment for localize prostate cancer maybe 20 percent of them end up really happy and satisfied with their sexual function in the long term. And what we found is that it's really important to include the partner to have a partner who's motivated to make sex better and to find a treatment for erections that's effective. And a lot of men go in and they try the newer pills. And unfortunately those pills aren't strong enough to really make a difference for many of these men. And so when the pill doesn't work they say, "Oh, why aren't I like the guy on the commercial, you know, where's my two bathtubs, where is the tango?" And they just give up at that point.
Lisa Garvin: Now I guess its good news that--because I would think that some men would be more likely to do something on the internet because they don't have to go to somebody's office and talk about their problems with the real person, so that's must be a hopeful signal to you?
Dr. Leslie Schover: It is, and that's not the only barrier. For one thing insurance coverage for the mental health part of this kind of multidisciplinary treatment where you want the couples to seek out a treatment that's gonna work for the erections, but you also want them to work together on their sexual communication and integrating the treatment into their sex lives. And the insurance coverage typically it's not bad for the urologist services but it's terrible for the mental health services. So providing something like this on the internet could be much more cause effective. And the other barrier is there aren't that many mental health professionals that have both sex therapy and oncology experience. And most of us, you know, are located in major cancer centers in big cities. So this a way where we could potentially reach out to, you know, more people and where maybe less experience therapies if they have the website to work with could do a better job.
Lisa Garvin: I can remember 10 years ago when I started at MD Anderson sexuality and cancer was--if not taboo, not talked about very much. So we've really come a long way in just 10 years.
Dr. Leslie Schover: Do you realize that I was here from 1981 to '85? Actually I started my career with cancer and sexuality at MD Anderson then and I had my primary appointment neurology but I also work with gynecology and breast. So we actually have a lot of interest then and I was doing clinical work and now I have a hundred percent research appointment. And when I left I had a lot of people saying "Oh, gosh, you know, we have nobody to replace you." But part of the problem is it's not a big revenue earner and it's also considered often kind of a frail, you know, not the most important thing. And so it is difficult to get these services integrated into a cancer center.
Lisa Garvin: And of course with a man, sexual function is the most important thing or a very important thing, so.
Dr. Leslie Schover: Well, it's very variable, you know, but it's very variable for men and women it depends on their age and their relationship situation, and how important sex was to them to begin with.
Lisa Garvin: In your study group did you--because often cancer--prostate cancer strikes men over 50, some of them may not have a sex life at all or reduced sex life, or no interest in sex. What sort of range did you have in your participants as far as age and abilities?
Dr. Leslie Schover: I think our average age was 64. And in order to be in the study they had to have, you know, a problem with sex that they wanted to fixed. And so, you know, that--but that encompasses a lot of prostate cancer survivors. And, you know, now with PSA testing, you know, the average age of diagnoses has dropped some although with the controversy about whether that's worthwhile. It may not always stay in that lower range, but yes, it's certainly, prostate cancer becomes much more common with aging.
Lisa Garvin: What do you hope to do with CAREss?
Dr. Leslie Schover: Well, actually what I'm working is probably kind of the next iteration of CAREss. I have a grant from the National Cancer Institute, that's what they call a small business grant, which means you're actually suppose to create a commercial product because that help small businesses. So we've been working on a prototype for a website that would actually cover all cancer sites for men. And would have includes, you know, all the exercises and things that were helpful in CAREss but goes beyond that is well. And, you know, has more bells and whistles and will have videos of actual survivors talking about their experiences. And maybe vignettes illustrating things like good sexual communication or how to talk to your doctor about sex and things like that because my kind of dream has been to have things like that available for any cancer patient or survivor around the country who's making decision about what kind of treatment they should have or is recovering from their treatment or maybe four years out and has had the sexual problem that they've done nothing about and something makes them say, you know, I don't really wanna live this way anymore with this. And, you know, to have accurate information and some self-help strategies and advice on how to get high quality medical care. You know, that's what I've really been aiming for.
Lisa Garvin: But it sounds like the first step for prostate cancer survivors is to seek help and to not wait two or three or four years.
Dr. Leslie Schover: Yes, that's true. And, you know, the timing is also different. You mentioned at the beginning that maybe radiation therapy is less destructive. But the issue is that if you have radical prostatectomy your erections are worst right after surgery and then if you're going to recover, there is maybe up to two years or so during which time your erections make it better. But with radiation therapy you may be fine when you stop radiation but over the next six months, two years, three years, five years things gradually deteriorate from the long term impact of the radiation on the circulation to the pelvis and penis. So, you know, by the time you look at five years out there is not that much difference between the two groups.
Lisa Garvin: Do you think that maybe some men may attribute their erectile dysfunction to age and maybe not connected to their cancer if there more than a few years out from treatment?
Dr. Leslie Schover: Possibly. I mean they may not realize that for example having radiation therapy to the pelvis could accelerate some of those changes that actually are you know pretty common with aging and cardiovascular disease factors as well.
Lisa Garvin: What would be your message to men who have undergone prostate--'cause it seems to me they should address the sexuality issue before they have any problems. What would be your advice to men who are undergoing prostate cancer treatment or have just finished treatment?
Dr. Leslie Schover: Well, I think that it's true that the best advice is to talk to either your own oncologist and, you know, since urologists are so familiar with these problems many of them are pretty good at talking about them and know latest things to do certainly here at MD Anderson I would expect they would. But also some sexual medicine specialist believe that for example if men take the pills like sildenafil or vardenafil a couple of weeks before radical prostatectomy that it may help the nerves actually be somewhat protected during surgery. And certainly there is, you know, some evidence although it's still controversial that if you do something to try to, you know, maintain your erections even in those early, you know, months after surgery that that may give you a better chance of recovering more function, you know, as the months go on. And with radiation therapy there's also some evidence that that actually doing some of the same things during and after your radiation therapy may help protect your erections.
Lisa Garvin: So how does the partner benefit from CAREss?
Dr. Leslie Schover: Well, actually CAREss is a very equal opportunity intervention and, you know, one of the things we often see is about a third of men with prostate cancer have already had erection problems. But also in that age group many of the women are over age 51, the average age of menopause. And over the years many women developed vaginal dryness related to their menopause and don't do anything to seek help or get treatment and then sex becomes painful and the vagina actually may not be able to expand as much as it normally did before. And also with many of these older couples, sex may have gotten pretty routine, and once the men has an erection problem for awhile it can become pretty emotionally draining, you know, you try and it's a failure experience and the next day everyday is unhappy. So we really focus in CAREss also on the woman's right to have sexual pleasure and that, you know, it's important for the partner to understand her body and what kinds of touch please her and we have a lot of information about using vaginal moisturizers and lubricants to overcome some these problems with vaginal dryness and pain.
Lisa Garvin: When do you hope to offer this internet-based intervention?
Dr. Leslie Schover: Well, we hope to start our randomized trial in our Sexual Medicine Clinic here at MD Anderson maybe around February of we stay on target. And, you know, after that it might be a year or year an a half I would think before it might be available to the general public. So it's still gonna be awhile.
Lisa Garvin: So prostate cancer survivors and their partners will need to stay tune because it sounds like good things around the horizon.
Dr. Leslie Schover: Thank you.
Lisa Garvin:Thank you Dr. Schover. If you have questions about anything you've heard today on Cancer Newsline, contact askMDAnderson at 1-877-MDA-6789 or online at www.mdanderson.org/ask. Thank you for listening to this episode of Cancer Newsline. [Background music] Tune in next week for the next podcast in our series.
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