A newly-launched study aims to help men rediscover sexual intimacy after treatment for prostate cancer.
Before undergoing surgery for prostate cancer, Robert Kikkert did his homework, including reading “The Intelligent Patient’s Guide to Prostate Cancer,” written by his physician, Professor of Urologic Sciences Larry Goldenberg. So Kikkert was aware that erectile dysfunction was a common, and usually permanent, consequence of surgery.
That advance warning didn’t make the adjustment any easier.
“You always think you’re going to be on the best side of the statistics,” says Kikkert, a 70-year-old retired manager for BC Hydro. “You don’t appreciate the impact until it happens to you. I’ve talked to other guys who went through the same thing, and we all thought that way. Even if you advertised it a heck of a lot more, I’m not sure guys would really understand it until they’ve gone through it.”
To help men through that process, and even find ways of re-discovering sexual intimacy, UBC researchers are testing two different approaches – cognitive behavioral therapy and mindfulness.
It’s the first-ever clinical trial to evaluate strategies for helping men recovering from this side-effect of prostate cancer treatment. It’s also the first-ever collaboration between UBC’s Department of Obstetrics and Gynaecology and UBC’s Department of Urologic Sciences – even though they share the same floor, separated by a common waiting area, at Vancouver General Hospital.
“It’s as if there is a moat between us that we never cross,” says Professor of Obstetrics and Gynaecology Lori Brotto, leader of the project.
Crossing the gender gap
Dr. Brotto, Director of the UBC Sexual Health Laboratory, is well positioned to make that leap. Having spent nearly two decades studying female sexual dysfunction, she wants to know if the insights she has gained from women can be applied to men.
“Our approach will be focused on thinking about sexuality and sexual satisfaction in an entirely new way,” Dr. Brotto says. “That’s also why we’re including partners in the treatment. We will teach survivors and their partners together.”
The damage to genital nerves and blood vessels stemming from radiation or surgery for prostate cancer is severe enough that medications for erectile dysfunction (ED) often don’t work at all or with minimal effectiveness after many months of recovery. A 2006 Austrian study published in the World Journal of Urology found that 80 per cent of men who underwent surgery or radiation therapy for prostate cancer experienced moderate to severe erectile dysfunction, and a 2005 U.S. study published in the Journal of Urology found 71 per cent of men who underwent surgery for prostate cancer could not get erections firm enough for intercourse five years later.
But Dr. Brotto says urologists, perhaps through omission, convey an overly optimistic impression that the condition will be temporary.
“They say to patients, ‘Let’s get rid of the cancer, let’s get you back on your feet, and then we can get to work on restoring your sexual function,’ with the implication that it will be restored,” Dr. Brotto says. “Yet published literature consistently shows that erections can’t be restored with medication or injections for most of these survivors. Really, these guys have to learn to live with it. And they have a very hard time with that, because they’ve been led to believe they will be able to get back their sexual function.”
Dr. Brotto, who is also Executive Director of the Women’s Health Research Institute, has become one of the world’s few experts on women’s low sexual desire or arousal, inability to achieve orgasm, and sexual pain. She led the effort to revise the psychiatry profession’s classification of low sexual desire in the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders.
One of her most recent studies on female sexuality set the stage for her pivot to studying men: A five-year comparison of cognitive behavior therapy and mindfulness in helping women with Provoked Vestibulodynia (PVD), pain in the vulva or vagina caused by touch.
Both therapies focus on a person’s thoughts and belief system. But CBT aims to change a person’s irrational thoughts and improving their emotions. Mindfulness is geared toward acceptance and tuning in to the moment.
“With women who have sexual concerns, we find that both approaches lead to the same outcomes,” Dr. Brotto says. “Even though mindfulness is about not changing and being present, ultimately the women who practice it do change. They have improvements in sexual function, they’re happier, and less anxious. They also have less genital pain.”
The finding that two approaches are effective is good news. The fact that one of them, mindfulness, doesn’t require office visits to a therapist — and can even be done through online apps — is even better news, because that makes it a much more accessible treatment.
Group sessions and practice at home
Now, Dr. Brotto wants to see if the findings can be applied to survivors of prostate cancer.
Supported by a $190,000 Movember Discovery grant from Prostate Cancer Canada, it will involve as many as 240 men and their partners, divided among three arms – a CBT group, a mindfulness group, and a control group that will get basic education. Participants are now being recruited.
Participants in the treatment arms will attend weekly two-hour group sessions for a month, and will then complete questionnaires at the end of the treatment and six months later. Participants in the treatment groups will be encouraged to do CBT or mindfulness exercises between sessions, and to record them to track their experiences.
Dr. Brotto will be joined by the University of Washington’s Celestia Higano, the medical director of the Prostate Cancer Supportive Care Program of the Vancouver Prostate Centre who specializes in prostate cancer survivorship, Jennifer Bossio, a postdoctoral fellow in the Sexual Health Lab who wrote a mindfulness manual for erectile dysfunction induced by prostate cancer, and Phil Pollock, Program Manager for the Prostate Cancer Supportive Care Program.
Learning to live with it
“We don’t think these strategies will eliminate concerns about post-surgery sexual health,” Dr. Brotto says. “But if we show that there are ways to restore some measure of sexual intimacy and satisfaction, then men will be less hesitant to get the cancer treatment they need, and will have a better quality of life afterwards.”
Kikkert, one of several men who participated in a preliminary pilot study, went through four sessions of mindfulness training with his wife, Diane, and another couple. It was his first exposure to mindfulness, and he says it helped him accept that “an erection isn’t the only way to be intimate.”
“It lowered the pressure on that particular issue,” he said. “In a way, you’re grieving over a change in your life. So you might as well learn to live with it, and do the best you can with what you’ve got.”
Recruitment for this project has begun. For more details on how to enroll: