NCCN Categories of Evidence and Consensus
Category 1: Based upon high-level evidence, there is uniform NCCN consensus that the intervention is appropriate.
Category 2A: Based upon lower-level evidence, there is uniform NCCN consensus that the intervention is appropriate.
Category 2B: Based upon lower-level evidence, there is NCCN consensus that the intervention is appropriate.
Category 3: Based upon any level of evidence, there is major NCCN disagreement that the intervention is appropriate.
All recommendations are category 2A unless otherwise noted.
Clinical trials: NCCN believes that the best management for any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.
Overview
Cancer treatment, especially hormonal therapy and therapy directed toward the pelvis, can often impair sexual function. In addition, depression and anxiety, which are common in survivors, can contribute to sexual problems. Thus, sexual dysfunction is common in survivors and can cause increased distress and have a significant negative impact on quality of life.1-5 Nonetheless, sexual function is often not discussed with survivors.6,7 Reasons for this include a lack of training of health care professionals, discomfort of providers with the topic, and insufficient time during visits for discussion.1 However, effective strategies for treating both female and male sexual dysfunction exist,8-11 making these discussions a critical part of survivorship care.
Male Aspects of Sexual Dysfunction
The NIH Consensus Conference on Impotence defined impotence, or male erectile dysfunction (ED), as the inability to achieve or maintain an erection sufficient for satisfactory sexual performance.”12 In fact, impotence and ED are not synonymous. Impotence can involve problems of sexual desire, orgasm, or ejaculation, which are not necessarily linked with achieving or maintaining an erection.13
ED occurs frequently in the general population and increases with age.14 In one community-based study, 33% of men aged at least 75 years reported moderate or worse ED.15 ED is also very common in male cancer survivors. Anticancer treatment modalities used in a variety of cancers have the potential to damage blood vessels, leading to a reduction in blood circulation to the penis, and/or damage to the autonomic nervous system. Thus, higher rates of ED are seen in cancer survivors than in the general population. The prevalence of ED in male survivors of colorectal cancer has been reported to range from 45% to 75%,2,16,17 and it has been reported in up to 90% of prostate cancer survivors.18-22
NCCN Clinical Practice Guidelines in Oncology: Survivorship: Sexual Dysfunction (Male), Version 1.2013
Version 1.2013, 03-08-13 ©2014 National Comprehensive Cancer Network, Inc. All rights reserved. The NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN®.
Citation: Journal of the National Comprehensive Cancer Network J Natl Compr Canc Netw 12, 3; 10.6004/jnccn.2014.0037
NCCN Clinical Practice Guidelines in Oncology: Survivorship: Sexual Dysfunction (Male), Version 1.2013
Version 1.2013, 03-08-13 ©2014 National Comprehensive Cancer Network, Inc. All rights reserved. The NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN®.
Citation: Journal of the National Comprehensive Cancer Network J Natl Compr Canc Netw 12, 3; 10.6004/jnccn.2014.0037
In 2005, the American Urological Association (AUA) published a guideline on the management of ED; it was reviewed and confirmed as still valid by the AUA in 2011.13 Using a consensus-based approach with the AUA guideline as a guide, the NCCN Survivorship Panel concluded that (1) informed patient and physician decision-making is the standard for guiding treatment decisions for ED treatment; and (2) a psychological overlay frequently exists in patients with ED and may be even more pronounced in the face of cancer survivorship. Endocrine disorders are also an important consideration in the cause of ED. Although sex therapy and the diagnosis and treatment of endocrine disorders are important management issues, these are beyond the scope of these guidelines and are therefore not addressed in depth.
Evaluation and Assessment for Male Sexual Function
Male cancer survivors should be asked about their sexual function at regular intervals. Patients should be asked about their sexual functioning before they received the cancer diagnosis, and their perceptions regarding the impact of cancer treatment on their sexual functioning and intimacy. A quantitative questionnaire such as the Sexual Health Inventory for Men can be considered to help identify patients who might benefit from treatment of ED.14
Patients with concerns about their sexual function should undergo a more thorough evaluation, including screening for possible psychosocial problems (ie, anxiety, depression, relationship issues, drug or alcohol use) that can contribute to sexual dysfunction. Identifying prescription and over-the-counter medications (especially hormone therapy or opioids) that could be a contributing factor is also important. A focused physical examination can also be helpful and should include examination of the chest (for gynecomastia), abdomen, phallus, scrotum/testicles, and cord structures.
Importantly, cardiovascular risk should be estimated for all men with ED, especially those with cardiovascular disease. Cardiovascular disease and ED share risk factors and often coexist.23 Sexual activity is considered equivalent to walking 1 mile in 20 minutes on a flat surface or to climbing 2 flights of stairs in 20 seconds.23 Men who cannot perform these exercises without symptoms are considered to be at high risk for experiencing adverse events associated with sexual activity and should be referred to a cardiologist before treatment for ED.23
Interventions for Male Sexual Dysfunction
Treatment for ED begins with modification of risk factors, such as smoking cessation, weight loss, increasing physical activity, and avoiding excess alcohol consumption. In addition, treatment of psychosocial problems, with referral to sex and couples therapy as appropriate, can often alleviate symptoms of ED.
Oral phosphodiesterase type 5 inhibitors (PDE5is) have been shown to improve the symptoms of ED and be well tolerated.8,10 Many studies have also shown the efficacy and tolerability of PDE5i for treating ED in patients with cancer and survivors.24,25 Importantly, PDE5is are contraindicated in patients taking oral nitrates, because together they can lead to a dangerous decrease in blood pressure.26,27
The timing and dose of PDE5i should be started conservatively, and it should be titrated to maximum dose if needed.13 The patient should be monitored periodically for efficacy, side effects, and any significant change in health status. An adequate trial of PDE5i is defined as at least 5 separate occasions at the maximum dose before reporting it as noneffective, unless the reason for fewer trials is an unacceptable side effect. A different PDE5i can be tried after failure of first-line PDE5i therapy.
If the second PDE5i fails, additional interventions can be considered, with referral to a urologist. These options include second-level interventions, such as intraurethral alprostadil suppositories, intracavernous vasoactive drug injection therapy, and vacuum constriction. A third-level and definitive type of intervention, penile prosthesis implantation, can be considered.13
Individual Disclosures for the NCCN Survivorship Panel
References
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