All over the world, men live shorter than women and suffer more from heart disease and cancer. When the administrators of Indian Government admit that for decades India has been struggling to achieve the National Health Program target related to women, children and communicable and non-communicable diseases, men’s health was inadvertently ignored. Indian and International Faculty from Men’s Health Society of India (MHSI) and International Society of Men’s Health (ISMH) will meet and exchange their thoughts. Take a look at the Scientific Program of the First Indian Conference on Men’s Health 2012 (MHSI Scientific Program) and register now (First Indian Conference on Men’s Health 2012)!

Zauber AG, et al. Colonoscopic Polypectomy and Long-Term Prevention of Colorectal-Cancer Deaths. N Engl J Med 2012;366:687-96.  

Bretthauer M, Kalager M.  Colonoscopy as a triage screening test. N Engl J Med 2012;366:759-60.

In a recent study, Dowswell and colleagues assessed 28 men aged 34 to 80 years who had been treated for colorectal cancer. Despite some limitations (e.g., small group, descriptive approach), the study provides several interesting pieces of information. In survivors of colorectal cancer, ED is frequent. However, many patients do not seek help for ED for various reasons (e.g., unawareness of the association between experienced symptoms and colorectal cancer or cancer therapy, lack of knowledge about the possible treatment for ED, embarrassment, lack of confidence, perception of ED as a subject which is inappropriate for the medical office).

Even more importantly, among those who sought help for ED, almost none were receiving adequate, effective and affordable care. The patients emphasized lack or inadequacy of information about the risk of ED, inability or unwillingness of health care providers to speak about sexual function or even unintentionally offensive remarks, especially in regard to older men. In some cases, patients did not obtain any help from professional healthcare providers and sought medication on the internet.

Thus, from the practical point of view, three points are important. First, neither information about ED nor treatment for ED are incorporated into routine care of men with colorectal cancer.  Second, in these men, it may be necessary to explore problem of sexual function sensitively but routinely. Third, in case of older men, making assumptions about their sexual behavior or motivation (in particular, about lack thereof) may be inadvertently offensive.

Dowswell G, Ismail T, Greenfield S, Clifford S, Hancock B, Wilson S. Men’s experience of erectile dysfunction after treatment for colorectal cancer: qualitative interview study. BMJ. 2011 Oct 18;343:d5824. doi: 10.1136/bmj.d5824.

Pre-treatment prediction of post-intervention erectile function would be useful in patient counseling. The Prostate Cancer Outcomes and Satisfaction with Treatment Quality Assessment (PROSTQA) is a prospective, multicenter study that in 2003, began enrolling men with localized prostate cancer scheduled for definitive therapy with radical prostatectomy, external beam radiotherapy or brachytherapy.  Apart from baseline patient data, the investigators recorded details of the treatment planned including nerve sparing surgery, hormonal therapy and radiation protocols. Post-intervention patient reported outcomes were recorded by third-party interviews using validated questionnaires.

In a recent trial by Alemozaffar and colleagues published in JAMA, the study investigators reported patient assessed erectile function in 1027 men who had completed 24 months after intervention. A significant increase in erectile dysfunction was reported in all 3 intervention groups: 63% vs 28% in radical prostatectomy, 63% vs 47% in the external radiotherapy group and 57% vs 33% in the brachytherapy group. Among men who were potent prior to intervention, 52% had ED after intervention; 60% in the prostatectomy group, 42% in the external radiotherapy group and 37% in the brachytherapy group. The authors were able to generate models that accurately predicted the occurrence of erectile dysfunction in the three treatment strategies.  Models such as this one suggest that stratification by pretreatment patient characteristics and treatment details enables prediction of erectile function 2 years after prostatectomy, external radiotherapy, or brachytherapy for prostate cancer.  While such a model cannot be used to judge superiority of one treatment strategy over another, it does aid in counseling patients about their individual outcome probabilities.

Alemozaffar M, Regan MM, Cooperberg MR, Wei JT, et al. Prediction of erectile function following treatment for prostate cancer.  JAMA 2011;306:1205-14.

Why does the ISMH run a campaign about hypogonadism?

There are three main topics in the field of men´s health: prostate health, erectile dysfunction and hypogonadism/TDS. The ISMH choose hypogonadism/TDS for the campaign as it is often correlated with other severe disease as diabetes, obesity, atherosclerosis or cardiovascular disease. Furthermore men with hypogonadism do have a lower life expectancy than men with normal testosterone level (Khaw K-T et al., Circulation 2007;116: 2694-2701, Shores MM, Matsumoto AM, Sloan KL, Kivlahan DR, Arch Intern Med. 2006;166:1660-1665).

 What is the purpose of the campaign?

Many men have testosterone deficiency without knowing it. They are suffering from non-specific symptoms and most have no idea that apathy, irritability, lethargy and loss of libido may be due to hypogonadism caused by low levels of testosterone. Almost nobody knows that testosterone production is decreasing with increasing visceral fat while, at the same time, testosterone is needed to metabolize visceral fat. It is a vicious circle. More informed men can make better decision in regard to their health when they are aware of the consequences.

The aim of the campaign is to help men and their partners recognize that certain changes they may be experiencing might not be due just to aging, make them ask a doctor about it and help to prevent long-term effects like the metabolic syndrome.

Men are not likely to talk or read about their health problems and go to the doctor. This is why the campaign is being displayed in daily newspapers, finance and sport magazines. With the football a key visual was chosen that grabs the attention of many men in a more humorous way trying to channel their interest towards the important taboo afflicted health topic of hypogonadism.

What are GPs interested in/aware of when it comes to TDS?

Hypogonadism/TDS awareness amongst health care professional is usually low, treatment rates in Europe are about ¼ compared to the US. However, interest and knowledge of GPs are increasing along with the growing scientific understanding that hypogonadism is no life style issue and not part of the normal aging process. Hypogonadism caused by low levels of testosterone is often associated with serious health issues in men (Muller M et al, European Journal of Endocrinology 2003; 149 583–589; Mulligan T et al, Int J Clin Pract 2006; 60, 7, 762–769). This is the reason why the ISMH is requesting more international studies on testosterone and related medical conditions. The call for more research was one of the results of the ISMH consensus conference 2010 in New York. The ISMH runs a number of educational initiatives and more efforts are planned in the next future.

Who came up with the idea to start this campaign?

The concept was formed during the ISMH consensus conference on hypogonadism and testosterone replacement therapy (TRT) in New York in 2010 (Traish A et al, Am J Med 2011; 124: 578-587; Wang C et al, Diab Care 2011; 34: 1669-1675). This scientific meeting of 25 international experts was also attended by many pharmaceutical companies including Bayer. The current campaign about symptoms of hypogonadism caused by low levels of testosterone in Sweden is a logical result of this conference and the publications resulting from this meeting. It is part of the ISMH’s mission to improve the health of men and empower them to pursue healthier lives. Bayer is named as the sponsor for this campaign, but the ISMH is responsible for content and the wording of the campaign. Additionally, the campaign is not related to any product but suggests to men with symptoms to consult their doctors. Other industry partners would be very welcome as these would help to increase the impact of this awareness campaign on the TDS/hypogonadism.

You can contact us through our website (http://www.ismh.org/en/contact/) or our bureau in Vienna:

Lazarettgasse 9/5
1090 Vienna, Austria
Tel +43/ (0)1 / 904 78 12
Fax +43/ (0)1 / 409 60 11
E-Mail office@ismh.org

In this trial, sex hormones exhibited direct relationships with all-cause mortality, as the relationship between low free T, elevated sex hormone binding globulin (SHBG), and elevated LH were statistically significant in association with cardiovascular mortality.  While there was a noticeable relationship between total T and increased mortality, this relationship did not reach statistical significance.  Overall, men with both low free T and high LH were at greatest risk of cardiovascular mortality.  Higher T levels were associated with lung cancer, and elevated SHBG levels were associated with non-CVD mortality.

The study concluded that low serum free T may predict mortality from CVD, yet a true cause-and-effect relationship cannot be exclusively determined.  The authors postulate that prevention and early treatment of androgen deficiency syndrome may improve CV outcomes, but not necessarily mortality from other outcomes.

This study can be contrasted with a previous trial published in 2010 with men who received T supplementation (Basaria S, et al.  NEJM 2010).  This trial examined 209 men at mean 74 years of age, all of whom had a high prevalence of hypertension, diabetes mellitus, hyperlipidemia, and obesity.  The conclusions stated that use of T gel in these men was associated with increased risk of adverse CV events, questioning the safety of T supplementation.  Additional and more rigorous trials are needed to better elucidate more clear relationships between T and cardiovascular mortality risks.

Hyde Z, Norman PE, Flicker L, et al.  Low free testosterone predicts mortality from cardiovascular disease but not other causes: The Health in Men Study.  J Clin Endocrinol Metab published ahead of print as doi:10.1210/jc.2011-1617.

 This statement has received significant media attention in the United States and in Europe, and is felt to be very controversial.  The American Urological Association (AUA) responded immediately to the USPSTF’s statement, citing “the task force’s recommendations will ultimately do more harm than good to the many men at risk for prostate cancer, both here in the US and around the world.  Until there is a better widespread test for this potentially devastating disease, the USPSTF — by disparaging the test — is doing a great disservice to the men worldwide who may benefit from the PSA test” (AUA Daily Scope, October 13, 2011)./

Following the initial trial, observation continued, with each group having greater than 13,000 person-years of follow-up.  There were 521 additional cases of prostate cancer detected since the original study was published.  The hazard ratio in the group of men given vitamin E who developed prostate cancer was 1.17; that for the selenium group was 1.09; that for the group who received vitamin E plus selenium was 1.05.  The authors concluded absolute increased risks of prostate cancer per 1000 person-years of 1.6 for the vitamin E group; 0.8 for the selenium group; and 0.4 for the group who received both vitamin E and selenium.

Detection and prevention of prostate cancer remains an important public health goal on the worldwide level.  The authors noted that these results differ from previous studies on the relationship between vitamin E supplementation and prostate cancer risk.  The ATBC (Alpha-Tocopherol, Beta Carotene) trial reported a 35% risk reduction in men who took 50mg/day of vitamin E over an average period of 6.1 years.  The reported 17% increased risk of prostate cancer in the SELECT trial follow-up suggests not only the potential for harm through vitamin E supplementation, but as the authors also claim, there is a great need for consumers to be surveillant of the potential health benefit claims of unregulated over-the-counter products that may claim to be beneficial to overall health and cancer prevention.

Klein EA, Thompson IM, Tangen CM, et al.  Vitamin E and the risk of prostate cancer.  JAMA 2011;306(14):1549-56.

Professor Siegfried Meryn, General Secretary of the International Society of Men’s Health, explains:

“Male attitudes towards urinary symptoms have been neglected in medical research and this is one of the very few surveys that asks ‘how do men feel?’ and ‘why don’t men seek help?’ This survey will provide a unique insight about men and their health and it is vital that we, as healthcare  professionals, understand the attitudes and behaviours of the men we are treating.”

The BPH survey: a male perspective was developed by an expert steering group of urologists and GPs, and explores:

• What discourages men from seeking medical attention
• What prompts men to seek help
• Who men consult about their bothersome urinary symptoms

It is hoped that the insights will help healthcare professionals have more meaningful conversations with men about their prostate problems so that their condition can be rapidly diagnosed and managed. Findings from the survey should also help men to understand that bothersome urinary symptoms are not an inevitable part of ageing.

First findings from the survey will be released online during the Men’s Health World Congress 2011 in Vienna, Austria.

GlaxoSmithKline (GSK) is committed to supporting research to help educate and increase understanding of Benign Prostatic Hyperplasia (BPH), a common prostate disorder. As part of this commitment GSK has developed and funded this project – “The BPH survey: a male perspective” through the creation of a steering group of healthcare professionals – urologists and GPs – to advise on the content of the survey, as well as the implementation of the project across the largest European markets (UK, France, Italy, Germany and Spain).  GSK has supported and paid the International Society of Men´s Health (ISMH) for the opportunity to launch the results of this project in the press contact section of their website during their annual Men´s Health World Congress, taking place in Vienna in 2011. All rights relating to the project and the data published are property of GSK.

References

1. Garraway WM, Collins GN, Lee RJ. High prevalence of benign prostatic hypertrophy in the community. Lancet. 1991; 338: 469-71.

2. Banks I, Mayor S, Meryn S. Talking prostates. Journal of Men’s Health. 2010; 7: 221-226.

Date of preparation: September 2011 , Job bag code: URCE/BPH/0022a/11

Hypogonadotropic hypogonadism occurs in up to 33% of men with type 2 diabetes. The Massachusetts Male Aging Study found that low levels of testosterone and sex hormone binding globulin (SHBG) are independent risk factors for the development of type 2 diabetes. In addition, this study demonstrated that low serum testosterone predicts the development of metabolic syndrome.

Declining serum testosterone levels throughout a man’s life are associated with an increase in all-cause mortality and an increase in atherosclerosis, visceral obesity, insulin resistance, dyslipidemia, and hypertension, the key components of the metabolic syndrome. Prospective clinical trials in men with prostate cancer who have undergone androgen deprivation therapy have found increased cardiovascular risk by increasing body weight, reducing insulin sensitivity, and/or resulting in dyslipidemia.

Reference: Ullah MI, Washington T, Kazi M, et al. Testosterone deficiency as a risk factor for cardiovascular disease. Horm Met Res 2001;43:153-164.