Affirming Care for Sexual and Gender Minority Prostate Cancer Survivors: Results from an Online Training.

Sexual and gender minority people have unique, unaddressed healthcare needs following prostate cancer. The research team along with a group of established subject matter experts developed a training and companion materials for healthcare professionals to address this need. Post-assessment evaluation was reported in frequencies and percentages by combining results from learners who attended an original, live web-based training and learners who completed the same training on-demand via a Learning Management System. Learners from both the live and archived training reported that the training increased their knowledge to effectively work with sexual and gender minority prostate cancer survivors. Learners also reported gaining new resources and strategies they could apply to their work. Results indicate the training fills an educational gap for healthcare professionals and supports the need for additional training of healthcare professionals focused on the healthcare needs of SGM cancer survivors.

Sexual Violence and Chemsex among Substance-Using Sexual and Gender Minorities in Texas.

Chemsex is the use of methamphetamine or other substances to enhance sexual experiences, and is most often associated with sexual minority men. Within the chemsex literature, questions of sexual violence emerge due, in part, to ambiguity about what constitutes consent within sexualized environments with co-occurring substance use.To understand the context in which sexual violence occurs, data from an online survey of sexual and gender minority Texans were analyzed using bivariate and logistic regression (N = 1273), and qualitative interviews with substance-using sexual minority men from a separate sample were thematically analyzed (N = 22).Among survey participants, 12.8% experienced a form of sexual violence (10.1% experienced intimate partner violence and 7.6% experienced sexual assault). When participants were categorized based on past year substance use and sex party attendance, 48.0% of participants who used drugs and attended sex parties (a proxy for chemsex) experienced sexual violence (41.6% experienced intimate partner violence and 41.0% experienced sexual assault). When variables statistically significant at the bivariate-level were entered into logistic regression models, participants in the chemsex category were 12.5 [95% CI: 6.9, 22.8] times more likely to experience sexual violence. Substance-using sexual minority men experiencing sexual violence describe situations in which consent is difficult to revoke and sexual exploitation is likely to occur.Studies which more deeply explore the relationship between sexual and relationship violence and chemsex among sexual and gender minorities are needed. Particularly, the notion of consent needs further conceptualization in the context of drug use and sex parties. HIGHLIGHTS: Measures of recent substance use and sex party attendance were combined to create a proxy measure for chemsex, which is the use of substances to enhance sexual experiences.Substance-using sexual and gender minorities engaging in chemsex were at increased risk of sexual violence.In addition to engaging in chemsex, variables associated with an increased odds of sexual violence among sexual and gender minorities were younger age, having a non-monosexual sexual identity, and receiving a mental health diagnoses.Studies on sexual and gender minorities engaging in chemsex should be developed to further explore sexual exploitation.

Development and evaluation of a bladder Cancer specific survivorship care plan by patients and clinical care providers: a multi-methods approach.

BACKGROUND, CONTEXT AND PURPOSE: In spite of the mixed evidence for their impact, survivorship Care Plans (SCPs) are recommended to enhance quality of care for cancer survivors. Data on the feasibility of SCPs in bladder cancer (BC) is sparse. Using a mixed-methods approach, this study describes the iterative development, acceptability and feasibility of BC specific SCP (BC-SCP) in clinical settings. METHODS: In Phase I, we developed the BC-SCP. In Phase II, we conducted four focus groups with 19 patients and 15 providers to examine its acceptability and usability challenges. Data analyses using the Atlas.ti program, informed refinement of the BC-SCP. In Phase III, we conducted feasibility testing of the refined BC-SCP with 18 providers from 12 health-centers. An encounter survey was completed after each assessment to examine the feasibility of the BC-SCP. Chi-square and Fisher Exact tests were used for comparative analyses. RESULTS: During phase I, we observed high patient and provider acceptability of the BC-SCP and substantial engagement in improving its content, design, and structure. In Phase II, providers completed 59 BC-SCPs. Mean time for BC-SCP completion was 12.3 min. Providers reported that BC-SCP content was clear, did not hamper clinic flow and was readily completed with easy-to-access information. Comparative analyses to examine differences in SCP completion time by patient clinico-demographic characteristics and provider type revealed no significant differences. CONCLUSIONS: Our BC-SCP has clinical relevance, and can be used in an active practice setting. However, considerable progress will be necessary to achieve implementation of and sharing the BC-SCP with patients and care providers, particularly within the electronic medical record. In summary, BC-SCPs are essential to improve the follow up care of BC survivors. Clinical resources are required to ensure appropriate implementation of BC-SCPs. TRIAL REGISTRATION: Study HUM00056082.

Mental Health Differences Between Older and Younger Lesbian, Gay, Bisexual, and Transgender Veterans: Evidence of Resilience.

OBJECTIVE: To examine health and identity differences between older (50+) and younger (< 50) lesbian, gay, bisexual, and transgender (LGBT) veterans. METHODS: Participants (N = 254) completed an internet survey assessing depression, anxiety, alcohol use, identity, minority stress, and outness. T tests and logistic regression were used to analyze results. RESULTS: Older LGBT veterans reported less alcohol use (p < .01) than younger counterparts. No age differences in depression or anxiety were reported. Older participants reported LGBT identity as more central to their overall identity (p < .01) and having less minority stress (p < .05), than younger participants. CONCLUSIONS: Compared to younger LGBT veterans, older LGBT veterans appeared more resilient over stressors that can impact mental health. Overall older LGBT veterans experienced less alcohol use and reported less minority stress than younger veterans. LGBT identity was more central to older veterans' overall identity than younger Veterans. CLINICAL IMPLICATIONS: LGBT veterans may experience stressors that can impact mental health, although older LGBT veterans show remarkable resilience. Clinicians should assess sexual orientation and gender identity, as well as veteran status, of patients in order to best evaluate their health risks and strengths.

The effects of attachment and outness on illness adjustment among gay men with prostate cancer.

OBJECTIVE: Previous research has suggested that gay men facing prostate cancer may be particularly vulnerable to poor illness adjustment. Moreover, although attachment and greater disclosure of sexual orientation have been associated with health outcomes, their associations in this population have been largely unexamined. The purpose of the present study was to investigate whether greater outness about one's sexual orientation significantly mediated the associations between anxious and avoidant attachment and illness intrusiveness among gay men with prostate cancer. METHODS: Ninety-two gay and bisexual men who had received a diagnosis of prostate cancer in the past 4 years were recruited for the present study. Self-report questionnaires assessed demographic and medical variables, attachment, outness level and comfort, and illness intrusiveness. Bootstrapping procedures were used to assess for mediation. RESULTS: Results suggested significant associations between anxious attachment, outness comfort, and illness intrusiveness. Less comfort with outness significantly mediated the association between greater anxious attachment and more illness intrusiveness. Avoidant attachment was not significantly associated with illness intrusiveness. CONCLUSIONS: Findings support the mediating role of the subjective experience of being an out gay man in the association between anxious attachment and illness intrusiveness. These results suggest that facilitating greater comfort with outness would be beneficial for illness adjustment among gay men with prostate cancer whom have more anxious attachment styles. Copyright © 2015 John Wiley & Sons, Ltd.

Threat of Sexual Disqualification: The Consequences of Erectile Dysfunction and Other Sexual Changes for Gay and Bisexual Men With Prostate Cancer.

Gay and bisexual (GB) men with prostate cancer (PCa) have been described as an "invisible diversity" in PCa research due to their lack of visibility, and absence of identification of their needs. This study examined the meaning and consequences of erectile dysfunction (ED) and other sexual changes in 124 GB men with PCa and 21 male partners, through an on-line survey. A sub-sample of 46 men with PCa and seven partners also took part in a one-to-one interview. ED was reported by 72 % of survey respondents, associated with reports of emotional distress, negative impact on gay identities, and feelings of sexual disqualification. Other sexual concerns included loss of libido, climacturia, loss of sensitivity or pain during anal sex, non-ejaculatory orgasms, and reduced penis size. Many of these changes have particular significance in the context of gay sex and gay identities, and can result in feelings of exclusion from a sexual community central to GB men's lives. However, a number of men were reconciled to sexual changes, did not experience a challenge to identity, and engaged in sexual re-negotiation. The nature of GB relationships, wherein many men are single, engage in casual sex, or have concurrent partners, influenced experiences of distress, identity, and renegotiation. It is concluded that researchers and clinicians need to be aware of the meaning and consequences of sexual changes for GB men when designing studies to examine the impact of PCa on men's sexuality, advising GB men of the sexual consequences of PCa, and providing information and support to ameliorate sexual changes.

Relationship between illness uncertainty, anxiety, fear of progression and quality of life in men with favourable-risk prostate cancer undergoing active surveillance.

OBJECTIVES: To evaluate prospectively the associations between illness uncertainty, anxiety, fear of progression and general and disease-specific quality of life (QoL) in men with favourable-risk prostate cancer undergoing active surveillance (AS). PATIENTS AND METHODS: After meeting stringent enrollment criteria for an AS cohort study at a single tertiary care cancer centre, 180 men with favourable-risk prostate cancer completed questionnaires at the time of enrollment and every 6 months for up to 30 months. Questionnaires assessed illness uncertainty, anxiety, prostate-specific QoL (using the Expanded Prostate Cancer Index Composite [EPIC] scale) and general QoL (using the 12-time short-form health survey [SF-12]) and fear of progression. We used linear mixed-model analyses and multilevel mediation analyses. RESULTS: Sexual scores on the EPIC scale significantly declined over time (P < 0.05). Illness uncertainty was a significant predictor of all EPIC summary scores, SF-12 physical component summary (PCS) scores, mental component summary (MCS) scores and fear of progression scores (all P < 0.05), after controlling for demographic and clinicopathological factors. Anxiety predicted all EPIC summary, MCS and fear of progression scores (all P < 0.05) but not PCS scores (P = 0.08). Scores on PCS, MCS, EPIC summary scales (except sexual scale), and fear of progression did not change significantly over the study period (all P > 0.10). CONCLUSION: Over the 2.5-year follow-up, QoL remained stable; only sexual function scores significantly declined. Illness uncertainty and anxiety were significant predictors of general and prostate-specific QoL and fear of progression. Interventions to reduce uncertainty and anxiety may enhance QoL for men with prostate cancer on AS.

Health-Related Quality of Life, Psychological Distress, and Sexual Changes Following Prostate Cancer: A Comparison of Gay and Bisexual Men with Heterosexual Men.

INTRODUCTION: Decrements in health-related quality of life (HRQOL) and sexual difficulties are a recognized consequence of prostate cancer (PCa) treatment. However little is known about the experience of gay and bisexual (GB) men. AIM: HRQOL and psychosexual predictors of HRQOL were examined in GB and heterosexual men with PCa to inform targeted health information and support. METHOD: One hundred twenty-four GB and 225 heterosexual men with PCa completed a range of validated psychosexual instruments. MAIN OUTCOME MEASURE: Functional Assessment of Cancer Therapy-Prostate (FACT-P) was used to measure HRQOL, with validated psychosexual measures, and demographic and treatment variables used as predictors. RESULTS: GB men were significantly younger (64.25 years) than heterosexual men (71.54 years), less likely to be in an ongoing relationship, and more likely to have casual sexual partners. Compared with age-matched population norms, participants in both groups reported significantly lower sexual functioning and HRQOL, increased psychological distress, disruptions to dyadic sexual communication, and lower masculine self-esteem, sexual confidence, and sexual intimacy. In comparison with heterosexual men, GB men reported significantly lower HRQOL (P = .046), masculine self-esteem (P < .001), and satisfaction with treatment (P = .013); higher psychological distress (P = .005), cancer related distress (P < .001) and ejaculatory concern (P < .001); and higher sexual functioning (P < .001) and sexual confidence (P = .001). In regression analysis, psychological distress, cancer-related distress, masculine self-esteem, and satisfaction with treatment were predictors of HRQOL for GB men (R2Adj = .804); psychological distress and sexual confidence were predictors for heterosexual men (R2Adj = .690). CONCLUSION: These findings confirm differences between GB and heterosexual men in the impact of PCa on HRQOL across a range of domains, suggesting there is a need for GB targeted PCa information and support, to address the concerns of this "hidden population" in PCa care.

Fear of recurrence: the importance of self-efficacy and satisfaction with care in gay men with prostate cancer.

OBJECTIVE: Limited research has investigated the psychosocial processes that underpin the effect of physical symptoms on fear of cancer recurrence. Additionally, despite evidence of increased vulnerability of marginalized populations to negative outcomes, few studies have examined the unique experience of gay men coping with the cancer process. The goals of this study were to determine whether disease-related self-efficacy and satisfaction with medical care mediated the relationship between greater physical symptoms and worse fear of recurrence among gay or bisexual prostate cancer survivors. METHODS: Participants were composed of 92 self-identified gay or bisexual men, who had received a diagnosis of prostate cancer in the past 4 years. Participants provided demographic information and completed self-report questionnaires that assessed symptom function, self-efficacy for prostate cancer symptoms, satisfaction with healthcare, and fear of recurrence. Bootstrapping procedures were used to assess for significant mediation. RESULTS: Results suggested significant mediation of the relationship between each of bowel, hormonal, and sexual function with fear of recurrence by self-efficacy and satisfaction with healthcare. Mediation was not significantly supported for the association between urinary function and fear of recurrence. CONCLUSIONS: Findings support the explanatory effects of self-efficacy for symptom management and satisfaction with healthcare on the relationship between symptom function and fear of recurrence. These results indicate that psychological processes, specifically psychological factors that hold particular relevance to gay or bisexual men, reflect a potential avenue for intervention to decrease fear of cancer recurrence.

Preparing Trainees to Deliver Patient-Centered Care in an Ambulatory Cancer Clinic.

The purpose of this paper is to describe how an interprofessional cancer care clinic at the Cleveland Veteran's Affairs Medical Center (VAMC) is training health care professionals in patient-centered care. Teaching strategies included patient huddle discussions pre- and post-clinic, role-play, noon "lunch and learn" conferences, and, most importantly, patient interactions, which were evaluated with the patient perception of patient centeredness (PPPC) instrument. This instrument is designed to capture patient and provider perceptions of the provider's patient centeredness. Early findings demonstrated that patient responses were overwhelmingly positive and lacked variability. In response to the lack of variability, the educator in the clinic participated in the evaluation and patient, provider, and trainer responses were compared. Discussion of the weekly evaluations provided helpful formative feedback on patient centeredness to the trainees rotating through this specialty care clinic.

Changes in sexual roles and quality of life for gay men after prostate cancer: challenges for sexual health providers.

INTRODUCTION: Gay men with prostate cancer (GMPCa) may have differential health-related quality of life (HRQOL) and sexual health outcomes than heterosexual men with prostate cancer (PCa), but existing information is based on clinical experience and small studies. AIMS: Our goals were to: (i) describe HRQOL and examine changes in sexual functioning and bother; (ii) explore the psychosocial aspects of sexual health after PCa; and (iii) examine whether there were significant differences on HRQOL and sexual behavior between GMPCa and published norms. METHODS: A convenience sample of GMPCa completed validated disease-specific and general measures of HRQOL, ejaculatory function and bother, fear of cancer recurrence, and satisfaction with prostate cancer care. Measures of self-efficacy for PCa management, illness intrusiveness, and disclosure of sexual orientation were also completed. Where possible, scores were compared against published norms. MAIN OUTCOME MEASURES: Main outcome measures were self-reported sexual functioning and bother on the Expanded Prostate Cancer Index. RESULTS: Compared with norms, GMPCa reported significantly worse functioning and more severe bother scores on urinary, bowel, hormonal symptom scales (Ps < 0.015-0.0001), worse mental health functioning (P < 0.0001), greater fear of cancer recurrence (P < 0.0001), and were more dissatisfied with their PCa medical care. However, GMPCa reported better sexual functioning scores (P < 0.002) compared with norms. Many of the observed differences met criteria for clinical significance. Physical functioning HRQOL and sexual bother scores were similar to that of published samples. GMPCa tended to be more "out" about their sexual orientation than other samples of gay men. CONCLUSIONS: GMPCa reported substantial changes in sexual functioning after PCa treatment. They also reported significantly worse disease-specific and general HRQOL, fear of recurrence, and were less satisfied with their medical care than other published PCa samples. Sexual health providers must have an awareness of the unique functional and HRQOL differences between gay and heterosexual men with PCa.

Educational opportunities in bladder cancer: increasing cystoscopic adherence and the availability of smoking-cessation programs.

Cancer survivors who continue to smoke following diagnosis are at increased risk for recurrence. Yet, smoking prevalence among survivors is similar to the general population. Adherence to cystoscopic surveillance is an important disease-management strategy for non-muscle-invasive bladder cancer (NMIBC) survivors, but data from Surveillance, Epidemiology, and End Results program (SEER) suggest current adherence levels are insufficient to identify recurrences at critically early stages. This study was conducted to identify actionable targets for educational intervention to increase adherence to cystoscopic monitoring for disease recurrence or progression. NMIBC survivors (n = 109) completed telephone-based surveys. Adherence was determined by measuring time from diagnosis to interview date; cystoscopies received were then compared to American Urological Association (AUA) guidelines. Data were analyzed using non-parametric tests for univariate and logistic regression for multivariable analyses. Participants averaged 65 years (SD = 9.3) and were primarily white (95 %), male (75 %), married (75 %), and non-smokers (84 %). Eighty-three percent reported either Ta- or T1-stage bladder tumors. Forty-five percent met AUA guidelines for adherence. Compared to non-smokers, current smokers reported increased fear of recurrence and psychological distress (p < 0.05). In regression analyses, non-adherence was associated with smoking (OR = 33.91, p < 0.01), providing a behavioral marker to describe a survivor group with unmet needs that may contribute to low cystoscopic adherence. Research assessing survivorship needs and designing and evaluating educational programs for NMIBC survivors should be a high priority. Identifying unmet needs among NMIBC survivors and developing programs to address these needs may increase compliance with cystoscopic monitoring, improve outcomes, and enhance quality of life.

Sexual dysfunction among male veterans returning from Iraq and Afghanistan: prevalence and correlates.

INTRODUCTION: Sexual dysfunction (SD) is not well described in the Iraq/Afghanistan veteran population despite high prevalence of multiple risk factors for this issue. AIM: To estimate the prevalence and examine the association of various sociodemographic, mental health, comorbid conditions and life style factors with sexual dysfunction in Iraq/Afghanistan veterans. METHODS: This exploratory cross-sectional study was conducted using data from the VA administrative database. A total of 4,755 Iraq/Afghanistan veterans were identified who sought treatment from the Michael E. DeBakey Veterans Affairs Medical Center inpatient and outpatient clinic between September 2007 and August 2009. MAIN OUTCOME MEASURES: Sexual dysfunction was determined by ICD9-CM codes related to sexual health issues and/or by specific medications, primarily phosphodiesterase-5 inhibitors (PDE5i), prescribed for erectile dysfunction. RESULTS: The overall prevalence of sexual dysfunction was 5.5% (N = 265). By age category, it was 3.6% (N = 145) for Iraq/Afghanistan veterans aged 18-40 years and 15.7% (N = 120) for Iraq/Afghanistan veterans aged > 40 years, respectively. A multivariate logistic-regression model revealed that annual income, marital status, post-traumatic stress disorder, and hypertension were significant risk factors of SD (all P < 0.05) among younger Iraq/Afghanistan veterans, whereas among the older Iraq/Afghanistan veterans, being African American and having PTSD and hypertension were significant risk factors of SD (all P < 0.05). There was marked discrepancy between documented erectile dysfunction and prescription of a PDE5i. CONCLUSIONS: These data demonstrate that a significant proportion of Iraq/Afghanistan veterans have SD and that the risk factors differ between younger and older veterans. Our findings also suggest that SD is likely under-coded. To better identify the scope of the problem, systematic screening for sexual dysfunction may be appropriate perhaps as part of an initial post-deployment health evaluation.

Assessment and documentation of sexual health issues of recent combat veterans seeking VHA care.

INTRODUCTION: Sexual health is an important aspect of human existence associated with disease and overall health. Despite these associations and the existence of medical treatments to improve sexual function, sexual health is often overlooked in health care. Recent combat veterans may be particularly vulnerable to sexual health issues due to their deployment-related health issues such as mental health conditions, prescription medications use, and psychosocial challenges. AIM: This study assesses the sexual health issues of recent combat veterans seeking care at a Veterans Affairs Medical Center (VAMC) documented in the primary care and mental health notes from the first 6 months of care. MAIN OUTCOME MEASURES: Documentation of sexual health issues in the progress notes (coded into categories), primary care vs. mental health care visit note, initial vs. follow-up visit notes, and templated vs. non-templated text. METHODS: This is a retrospective chart review of the first 158 consecutive patients seen for an initial assessment in the VAMC post-deployment clinic. Medical records were reviewed and text of sexual health issues and relevant patient and care characteristics were abstracted and coded into variables. RESULTS: Almost 25% of patients had documented sexual health issues in the first 6 months of care. We coded 52 separate sexual health issues into 13 distinct categories. Overall, most sexual health issues were documented in mental health care notes, in non-templated text, and at follow-up visits. The use of templated text appeared to drive the documentation of low libido (the most common sexual health issue) in mental health care notes. CONCLUSIONS: Sexual health issues are prevalent in recent combat veterans seeking care at a VAMC, but patterns of documentation suggest that they may be under-reported or incompletely addressed. A more systematic and provider-initiated approach to assessment of sexual health may promote fuller discussion of sexual health issues and optimize management.

Psychosocial aspects of active surveillance.

PURPOSE OF REVIEW: To summarize the literature on psychosocial responses to active surveillance as well as educational and support strategies to promote adherence. RECENT FINDINGS: There are two prevalent responses among men undergoing active surveillance; anxiety and uncertainty. The education of a patient about low-risk prostate cancer as well as the inquiry by the physician into patient's priorities and goals with respect to their prostate cancer diagnosis provide opportunities to facilitate a collaborative relationship between the physician and the patient. Supplemental support services for men undergoing active surveillance, including support groups and Internet-based interventions continue to be researched in relation to their role in promoting adherence to active surveillance. SUMMARY: Active surveillance continues to remain a highly valued management approach for men with early stage prostate cancer. However, it is suggested that the psychosocial burden of living with prostate cancer plays a substantial role in adherence to active surveillance and outcomes of men with the disease. Effective clinician education and counseling, as well as the referral for supplemental support services must be implemented and documented in future research studies and clinical practice.

Symptom management strategies for men with early-stage prostate cancer: results from the Prostate Cancer Patient Education Program (PC PEP).

While the literature on prostate cancer health-related quality of life has grown extensively, little is known about symptom management strategies used by men to manage treatment-related side effects and the effectiveness of those strategies. We collected 628 symptom management reports from 98 men treated for localized prostate cancer. Participants were recruited from email lists and a prostate cancer clinic in Northern California. Data were collected using the Critical Incident Technique. Symptom management reports were assigned to categories of urinary, sexual, bowel, mental health, systemic, or "other." We calculated descriptive statistics by symptom type and management strategy effectiveness. The most common symptoms were urinary (26 %) and sexual (23 %). Participants' symptom management strategies varied widely, from medical and surgical interventions (20 %) to behavioral strategies (11 %) to diet and lifestyle interventions (12 %). The effectiveness of symptom management strategies varied, with sexual symptoms being managed effectively only 47 % of the time to mental health symptom management strategies considered effective 89 % of the time. Doing nothing was a commonly reported (15 %) response to symptoms and was effective only 14 % of the time. Men report the least effectiveness in symptom management for sexual dysfunction after prostate cancer treatment. Including men's experience with managing treatment side effects may be an important way to improve survivorship programs and make them more acceptable to men. More work is needed to find out why men frequently do nothing in response to symptoms when effective solutions exist and how providers can successfully engage such men.

Perception of cancer and inconsistency in medical information are associated with decisional conflict: a pilot study of men with prostate cancer who undergo active surveillance.

UNLABELLED: Men with prostate cancer who choose active surveillance may experience anxiety and depression. Higher anxiety related to uncertainty surrounding cancer has been shown to increase the likelihood of choosing active treatment in the absence of a clinical indication. Certain characteristics, including physician influence and a neurotic personality, may also increase the risk of psychological distress. Our study identified particular areas that may affect the degree of satisfaction or uncertainty experienced by men choosing active surveillance. We showed that men with a positive outlook who perceived that they were receiving consistent medical information had improved ability to manage uncertainty and felt more in control of their decision-making. Men who were confident in their ability to manage prostate-related symptoms also had less insecurity with their decision. OBJECTIVE: To understand the factors associated with decision-making, we conducted a telephone-based survey as part of a pilot study to develop a psychoeducational intervention for men with prostate cancer who undergo active surveillance. PATIENTS AND METHODS: From 2007 to 2008, we conducted a cross-sectional study of 34 individuals on active surveillance for prostate cancer. We examined how specific mental health, quality of life and sociodemographic characteristics relate to decision-making. Five validated decision-making scales were used as primary outcomes reflecting the amount of satisfaction, regret and conflict a participant experienced about his decision to undergo active surveillance. A multivariate regression model was developed to identify specific psychosocial factors related to the decision-making outcomes. RESULTS: Primary analyses focused on the decisional satisfaction and conflict measures, as the decisional regret measure showed poor reliability (α < 0.70) in this sample. Four psychosocial measures showed strong associations across the decision-making subscales, including the Fife Constructed Meaning Scale (Pearson r > 0.26), Mishel Uncertainty in Illness Scale - Inconsistency (r > 0.32), Mental Health Index-5 (r > 0.33), and Lepore self-efficacy for prostate symptom management scale (r > 0.33). Individuals with higher self-efficacy for prostate cancer symptom management (P = 0.02) and higher positive meaning for cancer (P = 0.03) were less likely to express decision-making conflict as the result of uncertainty. Individuals reporting higher positive meaning for cancer (P = 0.01) and less uncertainty in illness attributed to inconsistency (P = 0.02) were less likely to exhibit decision-making conflict related to the perceived effectiveness of treatment. CONCLUSIONS: Men choosing active surveillance represent a patient group with unique vulnerabilities that require new psychoeducational interventions to provide information and support that will maintain and improve quality of life. We describe specific characteristics that may put patients at higher risk during the decision-making process and indicate their increased need for such interventions.

A pilot study of HIV/STI risk among men having sex with men using erectile dysfunction medications: challenges and opportunities for sexual medicine physicians.

INTRODUCTION: A growing literature suggests relationships between erectile dysfunction medications (EDM) and riskier sexual behavior among men who have sex with men (MSM). Questions remain concerning EDM use and related HIV/sexually transmitted infections (STI) risk among older MSM, particularly those 40 years and over, for whom EDM may be medically warranted. AIM: This exploratory pilot study explores the relationship between EDM and risky sexual behavior in a convenience sample of MSM using EDM and attending historic sex-on-premises venues. METHODS: We examined anonymous surveys from 139 MSM. Bivariate relationships were examined. We then fit a multiple logistic regression model to determine predictors of engaging in unprotected anal intercourse (UAI) at last EDM, using variables identified as being significantly related to UAI in the bivariate analyses. Potential predictors entered the model in a stepwise fashion. MAIN OUTCOME MEASURES: The primary outcome measure was engaging in UAI at last EDM use. RESULTS: MSM participating in the study ranged from 27 to 77 years and averaged 52.0 years (standard deviation = 10.73 years). These participants were primarily older MSM; fewer were younger MSM (12.12%), under age 40. Participants reporting UAI at last EDM use (N = 41) were significantly younger (P < 0.01). Men visiting bars within the last 6 months reported less UAI (P < 0.01). Both variables were independent predictors of UAI in the logistic regression model (P < 0.01). CONCLUSIONS: Similar to reports from younger MSM, our findings suggest older MSM using EDM and reporting UAI are also recreational drug users. We include recommendations for urologists and other sexual medicine physicians treating MSM who may be at elevated risk for HIV/STI infection because of joint EDM and club drug use.

Racial/ethnic differences in upper-tract urothelial cancer.

OBJECTIVES: Information on clinical characteristics, pattern of initial treatment and survival in patient with upper-tract urothelial carcinomas (UTUC) is scarce. Our study examined the racial/ethnic differences in patients diagnosed with incident UTUC. DESIGN: Observational study. The data analyses included: proportion and ANOVA for categorical and continuous variables, respectively; Kaplan-Meier method for calculating overall survival; and Cox-proportional hazards models for obtaining adjusted hazard-ratios. SETTING: Regions of the Surveillance, Epidemiology and End Results (SEER). PATIENTS OR PARTICIPANTS: 16,702 incident UTUC patients identified from the SEER dataset 1988-2007 (14,192 White, 967 Hispanic, 718 African American and 825 Asian). INTERVENTIONS: None. MAIN OUTCOME MEASURES: Race/ethnicity-specific distributions of demographics, tumor characteristics, patterns of initial treatment, and survival. RESULTS: African American and Hispanic patients were diagnosed at a younger age than Whites and Asians (P = .001). Hispanics were more likely to be diagnosed with larger tumor size than Whites and Asians (P < .0001). Asians were more likely to be diagnosed with advanced stage and higher tumor grade. Cox-regression revealed that Whites and Asians were significantly less likely to die after UTUC diagnosis than African Americans (HR = .78, 95% Cl = .67-.91 and HR = .75, 95% CI = .61-.91, respectively; all P = < .01). CONCLUSIONS: Our study found that Asians had worse tumor characteristics at the initial presentation than the other groups in this study, but that their risk of dying was lower. Further research is needed to include a larger number of Asian patients to examine subgroup differences and to confirm the paradoxical finding of higher survival with poor clinical characteristics.

Measuring illness uncertainty in men undergoing active surveillance for prostate cancer.

BACKGROUND AND PURPOSE: Uncertainty is an aversive experience and plays an important role in the lives of men undergoing active surveillance (AS; earlier referred to as watchful waiting) for early-stage prostate cancer. Yet reliable and valid measures of uncertainty have not been fully tested in this population. This secondary analysis therefore tested the reliability of the Mishel Uncertainty in Illness Scale Community Form (MUIS-C; M.H. Mishel, 1997b) for use with men undergoing AS for prostate cancer. METHODS: Item-Total correlations were conducted on the 23 items of the MUIS-C with four samples of men undergoing AS. RESULTS: Cronbach's alpha for the full MUIS-C was .908; 22 of 23 items showed significant positive correlations with the total score. Removing the item without a significant correlation from the reliability analysis increased Cronbach's alpha to .913. CONCLUSIONS: The Mishel Uncertainty in Illness Scale-Community Form for Active Surveillance is a reliable and valid tool for measuring uncertainty with men undergoing AS for prostate cancer.