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Sexual dysfunction common among patients with myeloproliferative neoplasms

More than two-thirds of patients with myeloproliferative neoplasms reported experiencing some degree of sexual dysfunction, according to prospective study results from the Myeloproliferative Neoplasms Quality of Life International Study Group.

The researchers observed the most severe sexual dysfunction symptoms in older patients, those with cytopenias and transfusion requirements, and patients receiving steroids or immunomodulators.

“The impact of having a chronic hematological malignancy on important quality of life issues, such as sexuality, have been poorly studied and appreciated,” Ruben A. Mesa, MD, FACP, professor of medicine and chair of the division of hematology and medical oncology at Mayo Clinic in Phoenix, as well as a HemOnc Today Editorial Board member, told HemOnc Today. “After fatigue, challenges with intimacy are the most prevalent symptom patients with myeloproliferative neoplasms [MPN] complain of.”

Mesa and colleagues sought to determine the degree to which patients with MPN — a diverse group of hematologic malignancies that include polycythemia vera, essential thrombocytopenia and myelofibrosis — experience sexual dysfunction, as well as its relation to quality of life, patient characteristics, disease features, treatment and symptom burden.

The researchers prospectively evaluated a multinational cohort of 1,971 patients with MPN (essential thrombocytopenia, n = 827; polycythemia vera, n = 682; myelofibrosis, n = 456; other, n = 6). Fifty-two percent of patients (n = 1,024) were aged 60 years or older (median age, 59.2 years), and 53.2% (n = 1,060) were female.

The researchers analyzed responses to the Myeloproliferative Neoplasm Symptom Assessment Form (MPN-SAF) and the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30, as well as individual disease characteristics and laboratory data. They compared sexuality scores with an age-matched, healthy control population from Sweden (n = 401).

Overall, 64% (n = 1,259) of patients with MPN reported experiencing some degree of sexual dysfunction, with 43% (n = 839) experiencing severe symptoms (MPN-SAF item score 4). Patients with MPN had a significantly higher rate of sexual dysfunction than the healthy population (MPN-SAF score, 3.6 vs. 2; P < .001).

Patients with myelofibrosis experienced the most problematic MPN-SAF sexuality scores (4.38), followed by patients with polycythemia vera (3.61) and essential thrombocytopenia (3.12; P < .0001).

Univariate analysis showed patients with laboratory abnormalities had more problematic sexuality symptom scores than patients without (4.34 vs. 3.27; P < .0001). This included patients with anemia (4.86 vs. 3.38; P < .0001), leukopenia (4.1 vs. 3.44; P = .035) and thrombocytopenia (4.42 vs. 3.39; P = .0004).

Further, patients requiring red blood cell transfusions had more problematic sexuality scores (5.03 vs. 3.49; P < .0001).

A final multivariate analysis showed that age older than 60 years correlated with severe sexuality symptoms (P < .0001).

A multivariate analysis evaluating patient language groups showed Chinese language was most closely associated with sexuality-related symptoms (P < .0001). Conversely, patients with MPN who spoke Swedish did not have a significant difference in sexuality scores compared with controls who spoke Swedish (2.4 vs. 2).

Patients who experienced sexuality symptoms also had impairments in physical functioning, social functioning, role functioning, cognitive functioning, emotional functioning and overall global health (P < .001 for all), as well as an increased incidence of financial problems (P < .01).

Sexuality scores correlated highly with sad mood (Pearson correlation, 0.38), inactivity (Pearson correlation, 0.34), correlation problems (Pearson correlation, 0.33), dizziness (Pearson correlation, 0.32) and insomnia (Pearson correlation, 0.31).

Sexual dysfunction symptoms correlated with impaired quality of life (P < .0001).

The researchers also drew correlations between sexual dysfunction and modes of treatment, with more problematic sexuality scores observed among patients currently receiving interferon (4.06 vs. 3.47; P = .009), immunomodulators (5.31 vs. 3.45; P < .0001) and steroids (5.36 vs. 3.49; P < .0001) compared with patients not receiving those treatments.

The researchers acknowledged limitations of their study. The MPN-SAF sexuality question did not specify any singular aspect of the term, which could potentially produce broad interpretations. Further, they could not determine whether the similarity in scores between patients and controls from Sweden were due to the small sample size or other factors.

“Our study identifies the significant prevalence of challenges with intimacy that can include not only physical limitations, such as impotence, but the loss of sexual desire and the impact of other symptoms on feelings of intimacy,” Mesa said.

The frequency of sexual dysfunction among patients with MPN may be due in part to clinicians who feel uncomfortable broaching the subject during treatment, Aaron T. Gerds, MD, MS, assistant professor of medicine at Cleveland Clinic Taussig Cancer Center, wrote in a related editorial.

“Physicians may have a fear of causing patient distress, a feeling that it is not their responsibility, a lack of time or training, the perception that sexuality is not important to address at the time of the initial oncology visit, or the belief that patients will or should raise the issues if they have concerns,” Gerds wrote.

More awareness of the importance of sexual functioning may alleviate this issue, Gerds concluded.

“One potential solution is incorporating questions regarding sexuality-related concerns on a clinic intake form completed by the patient at the time of the consultation,” Gerds wrote. “Because it already includes a question regarding ‘problems with sexual desire or function,’ routine symptom assessment with the MPN-SAF could be used as a simple tool to prompt a physician–patient discussion of sexuality-related symptoms.” – by Cameron Kelsall

For more information:

Ruben A. Mesa, MD, FACP, can be reached at mesa.ruben@mayo.edu.

Disclosure: Mesa reports grants from CTI Biopharma, Gilead and Incyte, as well as a consultant role with Novartis, for work performed outside of the current study. Please see the full study for a list of all other researchers’ relevant financial disclosures. Gerds reports advisory board positions with AstraZeneca, CTI Biopharma, Incyte and Roche.

More than two-thirds of patients with myeloproliferative neoplasms reported experiencing some degree of sexual dysfunction, according to prospective study results from the Myeloproliferative Neoplasms Quality of Life International Study Group.

The researchers observed the most severe sexual dysfunction symptoms in older patients, those with cytopenias and transfusion requirements, and patients receiving steroids or immunomodulators.

“The impact of having a chronic hematological malignancy on important quality of life issues, such as sexuality, have been poorly studied and appreciated,” Ruben A. Mesa, MD, FACP, professor of medicine and chair of the division of hematology and medical oncology at Mayo Clinic in Phoenix, as well as a HemOnc Today Editorial Board member, told HemOnc Today. “After fatigue, challenges with intimacy are the most prevalent symptom patients with myeloproliferative neoplasms [MPN] complain of.”

Mesa and colleagues sought to determine the degree to which patients with MPN — a diverse group of hematologic malignancies that include polycythemia vera, essential thrombocytopenia and myelofibrosis — experience sexual dysfunction, as well as its relation to quality of life, patient characteristics, disease features, treatment and symptom burden.

The researchers prospectively evaluated a multinational cohort of 1,971 patients with MPN (essential thrombocytopenia, n = 827; polycythemia vera, n = 682; myelofibrosis, n = 456; other, n = 6). Fifty-two percent of patients (n = 1,024) were aged 60 years or older (median age, 59.2 years), and 53.2% (n = 1,060) were female.

The researchers analyzed responses to the Myeloproliferative Neoplasm Symptom Assessment Form (MPN-SAF) and the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30, as well as individual disease characteristics and laboratory data. They compared sexuality scores with an age-matched, healthy control population from Sweden (n = 401).

Overall, 64% (n = 1,259) of patients with MPN reported experiencing some degree of sexual dysfunction, with 43% (n = 839) experiencing severe symptoms (MPN-SAF item score 4). Patients with MPN had a significantly higher rate of sexual dysfunction than the healthy population (MPN-SAF score, 3.6 vs. 2; P < .001).

Patients with myelofibrosis experienced the most problematic MPN-SAF sexuality scores (4.38), followed by patients with polycythemia vera (3.61) and essential thrombocytopenia (3.12; P < .0001).

Univariate analysis showed patients with laboratory abnormalities had more problematic sexuality symptom scores than patients without (4.34 vs. 3.27; P < .0001). This included patients with anemia (4.86 vs. 3.38; P < .0001), leukopenia (4.1 vs. 3.44; P = .035) and thrombocytopenia (4.42 vs. 3.39; P = .0004).

Further, patients requiring red blood cell transfusions had more problematic sexuality scores (5.03 vs. 3.49; P < .0001).

A final multivariate analysis showed that age older than 60 years correlated with severe sexuality symptoms (P < .0001).

A multivariate analysis evaluating patient language groups showed Chinese language was most closely associated with sexuality-related symptoms (P < .0001). Conversely, patients with MPN who spoke Swedish did not have a significant difference in sexuality scores compared with controls who spoke Swedish (2.4 vs. 2).

Patients who experienced sexuality symptoms also had impairments in physical functioning, social functioning, role functioning, cognitive functioning, emotional functioning and overall global health (P < .001 for all), as well as an increased incidence of financial problems (P < .01).

Sexuality scores correlated highly with sad mood (Pearson correlation, 0.38), inactivity (Pearson correlation, 0.34), correlation problems (Pearson correlation, 0.33), dizziness (Pearson correlation, 0.32) and insomnia (Pearson correlation, 0.31).

Sexual dysfunction symptoms correlated with impaired quality of life (P < .0001).

The researchers also drew correlations between sexual dysfunction and modes of treatment, with more problematic sexuality scores observed among patients currently receiving interferon (4.06 vs. 3.47; P = .009), immunomodulators (5.31 vs. 3.45; P < .0001) and steroids (5.36 vs. 3.49; P < .0001) compared with patients not receiving those treatments.

The researchers acknowledged limitations of their study. The MPN-SAF sexuality question did not specify any singular aspect of the term, which could potentially produce broad interpretations. Further, they could not determine whether the similarity in scores between patients and controls from Sweden were due to the small sample size or other factors.

“Our study identifies the significant prevalence of challenges with intimacy that can include not only physical limitations, such as impotence, but the loss of sexual desire and the impact of other symptoms on feelings of intimacy,” Mesa said.

The frequency of sexual dysfunction among patients with MPN may be due in part to clinicians who feel uncomfortable broaching the subject during treatment, Aaron T. Gerds, MD, MS, assistant professor of medicine at Cleveland Clinic Taussig Cancer Center, wrote in a related editorial.

“Physicians may have a fear of causing patient distress, a feeling that it is not their responsibility, a lack of time or training, the perception that sexuality is not important to address at the time of the initial oncology visit, or the belief that patients will or should raise the issues if they have concerns,” Gerds wrote.

More awareness of the importance of sexual functioning may alleviate this issue, Gerds concluded.

“One potential solution is incorporating questions regarding sexuality-related concerns on a clinic intake form completed by the patient at the time of the consultation,” Gerds wrote. “Because it already includes a question regarding ‘problems with sexual desire or function,’ routine symptom assessment with the MPN-SAF could be used as a simple tool to prompt a physician–patient discussion of sexuality-related symptoms.” – by Cameron Kelsall

For more information:

Ruben A. Mesa, MD, FACP, can be reached at mesa.ruben@mayo.edu.

Disclosure: Mesa reports grants from CTI Biopharma, Gilead and Incyte, as well as a consultant role with Novartis, for work performed outside of the current study. Please see the full study for a list of all other researchers’ relevant financial disclosures. Gerds reports advisory board positions with AstraZeneca, CTI Biopharma, Incyte and Roche.

    Perspective

    The prevalence of patients living with chronic hematologic malignancies is increasing; this is a direct result of our aging population, heightened recognition, refined treatment and better outcomes. Living with a chronic hematologic malignancy, such as a myeloproliferative neoplasm (MPN), may impact a patients quality of life in a variety of ways. The National Comprehensive Cancer Network identifies sexual dysfunction as a major issue facing patients with cancer and survivors that negatively impacts their quality of life and mood; however, this has not been well studied in patients with MPN.

    Sexual health is an important part of our identity as adults, and directly impacts our self-esteem and happiness. It also is becoming clear that cancer and its treatment can impact sexual health and function to a larger degree than age-matched patients without a history of cancer. In addition, multiple studies have shown that sexual dysfunction causes distress and negatively impacts quality of life for cancer survivors.

    Don Dizon

    Don S. Dizon

    Moreover, sexual function is associated with fatigue, emotional well-being, relationship satisfaction, anxiety and depression. Patients living with or after cancer can experience a spectrum of symptoms, both physical and emotional, that may impact sexual health.

    We currently understand that sexual dysfunction includes problems with sexual desire and pleasure; hormonal deficiencies; changes in vaginal tissue; delayed or absent orgasm; ejaculatory problems; and psychological problems, such as anxiety, depression, and changes in body image all of which may be attributed not only to burden of the underlying disease, but also to toxicities of therapy.

    The data on patients with MPN and their sexual health concerns has received little study until now. Geyer and colleagues performed a population-based cohort study examining 1,971 multinational patients with MPN compared with an age-matched, healthy control group. Researchers found that a substantial proportion of patients living with MPNs experience severe sexual symptoms and associated impairments in quality of life. Further, researchers report that more severe sexual symptoms directly correlate with specific treatment modalities and disease burden including anemia, fatigue and transfusion dependence all of which also can impact patients cognition and emotional and physical functioning. Despite that there were only two general questions about sexual symptoms in this study, these questions were sufficient to unveil the extent of this problem for this vulnerable population.

    Although multiple studies have shown that a substantial proportion of patients living with and beyond cancer (now including MPN) struggle with sexual dysfunction, clinicians rarely and infrequently address this issue. Beyond general lack of awareness, clinicians site time constraints, lack of proper training, uncertainty on how to initiate conversations and ignorance on interventions as significant obstacles to discussions with patients. The study by Geyer and colleagues is helpful in educating clinicians regarding awareness, and we as a community need to encourage clinicians and patients alike to have open and honest conversations about sexual health.

    Nevertheless, sexual dysfunction is not one symptom and identification of the etiology of dysfunction in an individual patient requires more specific tools such as the PROMIS Sexual Function and Satisfaction Tool for men and women, the Brief Sexual Function Inventory for men and the Female Sexual Function Index for women. Familiarizing ourselves with such screening tools and understanding if we can adapt these into our routine clinical practice is the first step toward improving our patients symptoms.

    If clinicians are unsure or unable to identify the actual symptoms of sexual dysfunction, they should consider referral to sexual health specialists, obstetrics and gynecology, or urology colleagues. Future studies should focus on developing and testing interventions that can be integrated into clinical practice to screen for and address sexual dysfunction.

    In conclusion, the study by Geyer and colleagues is useful in illuminating the burden of sexual dysfunction in a large population of patients with MPN. We are hopeful that the oncology community at large will invest the time and effort to improve such symptoms.

    References:

    Dizon DS, et al. Oncologist. 2014;doi:10.1634/theoncologist.2013-0302.

    Donovan KA, et al. Cancer Control. 2010 Jan;17(1):44-51.

    Laumann EO, et al. JAMA. 1999;doi:10.1001/jama.281.6.537.

    Morreale MK. Adv Psychosom Med. 2011;doi:10.1159/000328809.

    Syrjala KL, et al. Blood. 2008;doi:10.1182/blood-2007-06-096594.

    • Julie Vanderklish, NP; Don S. Dizon, MD, FACP; and Areej R. El-Jawahri, MD
    • Massachusetts General Hospital

    Disclosures: Dizon, Vanderklish and El-Jawahri report no relevant financial disclosures.