Vance Garrison Fowler, MD

• Professor of Medicine
• Florence McAlister Distinguished Professor of Medicine
• Professor in Molecular Genetics and Microbiology
• Member in the Duke Clinical Research Institute

https://medicine.duke.edu/faculty/vance-garrison-fowler-md

Community health professionals work with the patient at home bacteria animation effective 150mg roxithromycin, and the team is available to the patient antimicrobial irrigation buy cheap roxithromycin 150mg online, family infection 13 lyrics cheap 150mg roxithromycin with mastercard, and community health workers on a 24-hour-a-day basis antibiotic resistance data cheap roxithromycin 150mg line. It attempts to integrate assessment techniques, drug therapy, behavioral approaches, and anesthetic and neurosurgical approaches and stresses continuity of care. Treatment begins with a diagnostic evaluation that addresses the medical, psychological, and social components of pain. If the anticancer treatment is effective, pain relief usually occurs and the drugs used for analgesia can be discontinued without difficulty. Pain treatment begins with the use of analgesic drugs, starting with nonopioid drugs alone or in combination. If severe persistent pain does not respond to analgesic drugs or if the side effects of the drugs are not tolerated, the physician should consider switching analgesics. A trial of an adjuvant drug together with the opioid and nonopioid drug would also be appropriate. Alternatively, epidural or intrathecal opioids may be considered if systemic analgesics produce excessive side effects such as confusion or sedation. Cognitive-behavioral approaches must be integrated from the onset of treatment and should be used along with the medical and surgical approaches. There is a critical need to expand both the research and educational efforts in cancer pain to improve the control of pain in these patients. Information on the basic mechanisms of pain modulation can be culled only from a careful study of these clinical pain problems. These patients can teach us the physiologic and psychological differences between acute and chronic pain problems, the importance of the evolution of psychological factors, the difference between pain and suffering, the clinical pharmacology of analgesic drugs, and the behavioral mechanisms humans use to suppress pain. The use of innovative approaches based on sound scientific principles and advanced on research technology offers the opportunity to understand the complex phenomenon of pain. Pain in ambulatory patients with lung or cancer: prevalence, characteristics and impact. Documentation of severe pain, opioid doses, opioid related side effect with patients with cancer: a retrospective study. A controlled trial to improve care for seriously ill hospitalized patients: the study to understand prognosis and preferences for outcomes and risks of treatments. Character of terminal illness in the advanced cancer patient: pain and other symptoms during the last 4 weeks of life. Validation of World Health Organization guidelines for cancer pain relief: a 10 year prospective study. Temporal presentation of chronic cancer pain: transitory pains on admission to a multidisciplinary pain clinic. Report of a subcommittee on assessment and methodologic issues in the management of childhood cancer. The development of the Wisconsin Brief Pain Questionnaire to assess pain in cancer and other diseases. Use of the McGill Pain Questionnaire in the management of cancer pain-replicability and consistency. The Memorial Pain Assessment Card: a valid instrument for the assessment of cancer pain. Symptom and quality of life survey of medical oncology patients at a Veterans Affairs Medical Center. Implementation of guidelines for cancer pain management: results of a randomized controlled clinical trial. The relationship of pain and symptom management to patient requests for physician-assisted suicide. Principles of analgesic use in the treatment of acute pain and cancer pain, 3rd ed. A retrospective comparison of dose ratios between methadone, hydromorphone, and morphine. Morphine versus methadone in the pain treatment of advanced cancer patients followed up at home. Rapid switching from morphine to methadone in cancer patients with poor response to morphine. The nature of opioid responsiveness and its implications for neuropathic pain: new hypotheses derived from studies of opioid infusions. Efficacy and safety of nonsteroidal antiinflammatory drugs for cancer pain: a meta-analysis. Non steroidal anti-inflammatory drugs as the first step in cancer pain therapy; double-blind, within-patient study comparing nine drugs. Cost issues related to pain management: report from the cancer pain panel of the Agency for Health Care Policy and Research. Availability of opioids for cancer pain relief: recent trends, assessment of symptom barriers, New York health organization guidelines, and the risk of diversion. Pharmacological characterization of morphine-6-glucuronide, a very potent morphine metabolite. Metabolite, morphine-6-glucuronide, contributes to the analgesia produced by morphine infusion in pain patients with normal renal function. Plasma morphine and morphine-6-glucuronide during chronic morphine therapy for cancer pain: plasma profiles, steady-state concentrations and the consequences of renal failure. Morphine-6-glucuronide concentrations and opioid-related side effects: a survey in cancer patients. Comparison of continuous subcutaneous and intravenous hydromorphine infusions for management of cancer pain. Comparison of continuous subcutaneous and intravenous hydromorphone infusions for management of cancer pain. Long-term intraventricular infusion of morphine for intractable pain in cancer of the head and neck. Comparison of analgesic effects of morphine sulfate, hydroxyzine and other combinations in patients with postoperative pain. Methylnaltrexone for reversal of constipation due to chronic methadone use: a randomized controlled trial. Amitriptyline relieves diabetic neuropathy pain in patients with normal or depressed mood. Association of pain relief with drug side effects in postherpetic neuralgia: a single dose study of clonidine, codeine, ibuprofen, and placebo. The selective serotonin reuptake inhibitor paroxetine is effective in the treatment of diabetic neuropathy symptoms. Gabapentin for the symptomatic treatment of painful neuropathy in diabetes mellitus, a randomized controlled trial. Treatment of metastatic prostate cancer with low-dose prednisoneevaluation of pain and quality of life as prognostic indices of response. Glucocorticoid treatment for brain metastases and epidural spinal cord compressions review. Analgesic effect of alprazolam in patients with chronic, organic pain of malignant origin. A comparison of the analgesic effects of methotrimeprazine and morphine in patients with cancer. Beneficial effects of ketamine in a chronic pain state with allodynia, possibly due to central sensitization. Dextromethorphan for the treatment of neuropathic pain: a double-blind, randomised controlled crossover trial with integral n-of-1 design. A double-blind, crossover trial of intravenous clodronate in metastatic bone pain. Intravenous pamidronate disodium treatment: bone metastases in patients with breast cancer. Analgesic activity of calcitonin in patient with painful osteolytic metastases of breast cancer: results of a controlled randomized study. Low-dose gallium nitrate for prevention of osteolysis in myeloma: results of a pilot randomized study. Bone pain palliation with strontium 89 in breast cancer patients with bone metastases with refractory bone pain. Psychosocial and behavioral management of cancer pain: the social work contribution. Thoracic epidural morphine in the palliation of chest wall pain secondary to relapsing polychondritis.

Treatment with oral melphalan and prednisone was introduced 30 years ago and has remained the standard of therapy antibiotic xidox generic 150 mg roxithromycin otc, providing symptomatic relief as well as tumor mass reduction antibiotic 7146 150 mg roxithromycin with amex. The absorption of oral melphalan is unpredictable antimicrobial 8536 cheap roxithromycin 150 mg overnight delivery, requiring its ingestion on empty stomach and increase in dose if the patient does not develop cytopenia antibiotic resistant bacteria deaths roxithromycin 150 mg lowest price. In patients receiving melphalan and prednisone, a prompt response was associated with a poor survival, reflecting possibly a highly proliferative tumor. The median response duration was 18 months and overall survival was 24 to 36 months. One of the frequent complications of melphalan and prednisone therapy was the development of cytopenia and eventually myelodysplastic changes in the marrow. With successful treatment with high-dose therapy, melphalan and prednisone are not being used as induction therapy because the ability to mobilize adequate numbers of stem cells decreases with prolonged use of this combination; the incidence of treatment-related myelodysplastic syndrome and acute myeloid leukemia increases and partial resistance even to high-dose chemotherapy develops. Results from large studies evaluating standard-dose chemotherapy regimens are listed in Table 46. In the majority of the studies, there was no benefit of any of these combinations over melphalan and prednisone, and the toxicity problems, including bone marrow stem cell damage, remained the same. A metaanalysis of 18 published studies with 3814 patients randomized to receive melphalan and prednisone or various other chemotherapeutic combinations showed that melphalan and prednisone and other chemotherapeutic combinations are equivalent. The role of high-dose corticosteroids was initially investigated in the late 1960s with an observation of therapeutic benefit in small numbers of patients. High-dose dexamethasone was evaluated in combination with vincristine and Adriamycin. The advantages of this combination include quick response, effectiveness in hypercalcemia, quick relief of bone pain, applicability in patients with renal failure, and no cumulative bone marrow stem cell damage, allowing subsequent successful mobilization of stem cells. In a study evaluating glucocorticosteroid dose intensity, chemotherapy regimens with higher glucocorticosteroid dose intensity yielded higher response rates and improved survival (P =. The role and efficacy of interferon in the management of myeloma remains controversial. Its mode of action remains multifactorial; direct growth inhibitory action as well as its antiangiogenic and immunomodulatory activity may contribute to its overall action. However, in combination with other chemotherapeutic regimens, it has failed to demonstrate beneficial effect. Its role in maintenance therapy after standard-dose therapy has generally been more positive, with demonstration in some of the studies of significant prolongation of survival for groups receiving interferon-a. A metaanalysis of eight trials involving 929 patients randomized to interferon versus no treatment showed prolongation of relapse-free survival by 7 months and overall survival by 5 months. However, in younger patients and those with lower tumor burden interferon was more effective. Radiation Therapy Radiation therapy was considered the mainstay of the treatment for myeloma before availability of chemotherapeutic options. However, with more effective chemotherapy, especially high-dose chemotherapy, the role of radiation has now been limited. In this setting, it provides excellent local control, and in a subset of patients it provides long-term disease-free survival when a solitary lesion is confirmed through extensive radiographic workup. Patients with solitary bone plasmacytoma following definitive radiation therapy (4000 to 5000 cGy) have progression-free survival of 30% compared with extramedullary plasmacytoma in which progression-free survival is around 70%. In patients with bone pains or symptomatic soft tissue masses, radiation is only considered when patients have failed chemotherapeutic options. The dose for palliative radiation therapy has been substantially lower, in the range of 1500 to 2500 cGy. Studies to date have failed to show any benefit of hemibody radiation in multiple myeloma. However, total body radiation has been used in relation with allogeneic transplantation as well as autologous transplantation. More recent studies have demonstrated that total body irradiation does not provide additional cytoreductive potential and it actually increases treatment-related morbidity and mortality and delays immune recovery following high-dose therapy possibly affecting disease control. Total body irradiation as part of conditioning for allogeneic transplantation is especially important in the optimal regimen for achieving engraftment; however, its role in cytoreduction in this setting also remains questionable. Newer studies are evaluating low-dose radiation therapy with or without chemotherapy in nonmyeloablative conditioning regimens that may be associated with lower morbidity and still achieve tumor control through graft versus myeloma effect. High-Dose Therapy with Peripheral Blood Stem Cell Support the low incidence of complete response with standard induction chemotherapy, even in newly diagnosed patients, suggests a marked drug resistance that is possibly acquired during a prolonged subclinical course of the disease evidenced by the presence of complex karyotypic aberrations and multiple molecular changes. This observation led to a pilot study by the late Tim McElwain and his colleagues at the Royal Marsden Hospital where they evaluated role of melphalan dose escalation (140 mg/m2). Bone marrow support in the subsequent studies improved the treatment-related mortality 22 and further dose escalation of melphalan to 200 mg/m 2 and by added total body irradiation provided further improvement in response. Initial demonstration of activity of high-dose melphalan therapy has lead to series of evaluations by various institutions of this treatment with stem cell support to avoid prolonged cytopenia (Table 46. A total of 231 newly diagnosed multiple myeloma patients aged 70 years or younger were treated on this protocol. The partial remission and complete remission rates after induction therapy were 69% and 14%; after the first high-dose melphalan dose they were 82% and 30%, and after the second transplant, 95% and 48%, respectively. With a median follow-up of 37 months, event-free and overall survival were 43 and 62 months, respectively. The median duration of neutropenia less than 500/mL and platelets less than 50,000/mL was 6 and 7 days, respectively. The projected 5-year event-free survival is 28% and overall survival is 52% with high-dose therapy compared with 10% and 12%, respectively, for the standard therapy arm. With total therapy, complete response was obtained in 40% and both event-free and overall survivals were markedly extended. C: Randomized study of early high-dose therapy with melphalan, 140 mg/m2, plus total body irradiation (800 cGy) versus initial standard dose therapy followed by high-dose therapy at relapse. With early high-dose therapy a superior complete response rate and event-free survival was observed with superior quality of life; however, overall survival was similar between the two arms. The superiority of high-dose therapy was also confirmed in a pair-mate analysis comparing 116 patients treated on the tandem transplant arm with a similar number of patients selected from 1123 patients treated with standard therapy on various Southwest Oncology Group studies and selected for important prognostic factors. Using an intent-to-treat-approach, compared with standard therapy, patients undergoing tandem transplant as part of the total therapy regimen had a superior partial response rate (86% vs. With a short follow-up, no differences in response, complete remission (32% and 33%), or event-free (54% and 57%) and overall survival (71% and 67%) were observed in the whole group. However, a subgroup of patients with low b 2m showed a significant survival benefit with tandem transplant. Longer follow-up will determine if all or a subset of patients may benefit from such an approach. Other institutions have studied high-dose chemotherapy with stem cell support in myeloma. Various investigators have studied high-dose therapy in previously treated patients showing its effectiveness in achieving complete responses. Molecular complete responses have been observed in myeloma after high-dose therapy. These factors include source of stem cell, conditioning regimen, timing of transplant, and tumor-cell purging. To obtain high-quality hematopoietic stem cells, ideal timing for stem cell collection is early in the course of the induction treatment. Overall survival was similar in both arms after early and late transplant (median, 64. Median event-free survival was 39 months after high-dose therapy, whereas median time to transplant after randomization to conventional chemotherapy was only 13 months. However, patients randomized to early high-dose therapy had a longer time without symptoms, treatment, and treatment-related toxicity, thus providing a rationale for early high-dose therapy. An ongoing Intergroup trial in the United States randomizing patients to up-front high-dose therapy or standard therapy with high-dose therapy as a salvage treatment should also further define the role of high-dose therapy. High-dose melphalan (140 to 200 mg/m) with or without total body irradiation is the most common conditioning regimen used in 2 myeloma. Melphalan seems to be superior to thiotepa when given with total body irradiation, with patients achieving longer relapse-free and overall survival duration. The addition of total body irradiation has not been shown to improve cytoreduction, and in fact it increases morbidity and treatment-related mortality. A poor outcome in one study using total body irradiation was considered to be related to delayed immune recovery. Myeloma cell contamination as evaluated by polymerase chain reaction or sensitive immunofluorescence is universally observed in stem cell products.

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The incidence antibiotics for uti in humans order roxithromycin 150mg free shipping, severity antibiotics effects on body cheap 150 mg roxithromycin visa, and onset of radiation-induced emesis appear to be related to the size of the radiation field antibiotic mouthwash prescription generic 150 mg roxithromycin with amex, the dose per fraction antibiotics for uti child cheap 150 mg roxithromycin amex, and the site of irradiation. Radiation-induced emesis occurs acutely in more than 90% of patients who receive total body irradiation for bone marrow transplantation, within 30 to 60 minutes in more than 80% of patients who receive single high-dose or large-field hemibody irradiation (>500 cGy), and within 2 to 3 weeks in approximately 50% of patients who receive conventional fractionated radiotherapy (200 cGy per fraction) to the upper abdomen. This mechanism is most likely involved when radiation is applied to the upper abdomen, hemibody, or total body. A randomized, double-blind, placebo-controlled evaluation revealed oral ondansetron to be an effective therapy for the prevention of emesis induced by total body irradiation. In a study involving patients undergoing fractionated upper abdominal radiation, patients who received oral granisetron had a significantly longer median time to first emesis than did those who received placebo (35 days vs. Because the mechanism of the nausea and vomiting secondary to comorbid conditions is not usually well understood, it is difficult to know which antiemetics may be helpful. Future studies must be conducted to determine the optimal doses of metoclopramide as well as other antiemetics that may be used in drug combinations. With the increased use of expensive antiemetics and with managed care dictating the length of hospital stays, the emphasis is shifting to primary outpatient management of patient treatment courses. The challenge for physicians becomes one of providing a treatment plan in which patients are offered state-of-the-art and cost-effective therapy. Single-dose regimens given in combination with a corticosteroid provide an effective and convenient alternative in antiemetic therapy. Regimens that take advantage of a completely oral route of administration are easy and convenient for patients and are likely to reduce nursing and pharmacy costs; however, prolonged use of oral serotonin antagonists should be avoided, as there appears to be little or no value in this setting. In addition to these recommendations, adherence by physicians and nurses to established doses and schedules of antiemetics and their appropriate use can be cost-effective measures for patients and institutions. The guidelines were modified in 1994 to include granisetron, 10 mg/kg, for moderately or highly emetogenic chemotherapy. Additional cost savings were realized while the quality of life of the patients was unaffected. Some studies did not use "no nausea" as one of the criteria for a complete response. Because nausea was ranked as the most severe chemotherapy-related symptom according to a relatively recent survey, the effect of the agents on nausea should also be evaluated. Economic considerations for the selection of antiemetic regimens should answer the following questions: Will the use of the regimens likely result in a reduced hospitalization While receiving therapy, will patients be able to maintain their usual level of activity Are there mandated restrictions on the use of an agent in hospital formularies and in clinical settings Extensive basic and clinical research has made it possible to control treatment-induced nausea and vomiting. With recognition and anticipation of nausea and vomiting, counseling of the patient and family, prophylactic intervention, flexibility in the therapeutic approach, and constant reassessment of the treatment plan, chemotherapy- and radiotherapy-induced nausea and vomiting can be managed effectively in 80% to 90% of patients. Incidence of nausea and vomiting with cytotoxic chemotherapy: a prospective randomized trial of antiemetics. Anxiety as a predictor of behavioral therapy outcome for cancer chemotherapy patients. Predicting development of anticipatory nausea in cancer patients: prospective examination of eight clinical characteristics. Preventing chemotherapy-induced nausea and vomiting: an update and review of emesis. On the receiving end: patient perceptions of the side effects of cancer chemotherapy. Neurotransmitter receptor binding studies predict antiemetic efficacy and side effects. Synthetic enkephalin analog in the treatment of cancer chemotherapy-induced vomiting. Inhibition of cisplatin-induced vomiting by selective 5-hydroxytryptamine M-receptor antagonism. Antagonism of serotonin S3 receptors with ondansetron prevents nausea and emesis induced by cyclophosphamide-containing chemotherapy regimens. Prevention of cyclophosphamide/cytarabine emesis with ondansetron in children with leukemia. A randomized double-blind comparison of ondansetron and metoclopramide in the prophylaxis of emesis induced by cyclophosphamide, fluorouracil, and doxorubicin or epirubicin chemotherapy. Reduction of cisplatin-induced emesis by a selective neurokinin-1-receptor antagonist. Effect of chemotherapy on taste sensation in patients with disseminated malignant melanoma. Combination antiemetic therapy in the control of chemotherapy-induced drug emetogenic potential emesis. Therapeutic guidelines on the pharmacologic management of nausea and vomiting in adult and pediatric patients receiving chemotherapy or radiation therapy or undergoing surgery. Metoclopramide dose-related toxicity and preliminary antiemetic studies in children receiving cancer chemotherapy. Nonpharmacologic factors in the development of posttreatment nausea with adjuvant chemotherapy for breast cancer. The effect of a susceptibility to motion sickness on the side effects of cancer chemotherapy. Previous history of emesis during pregnancy and motion sickness as risk factors for chemotherapy-induced emesis. Therapeutic guidelines on the pharmacological management of nausea and vomiting in adult and pediatric patients receiving chemotherapy or radiation therapy or undergoing surgery. Recommendations for the use of antiemetics: evidence-based clinical practice guidelines. Prevention of chemotherapy and radiotherapy-induced emesis: results of the Perugia consensus conference. Dose-response trial across 4 oral doses of dolasetron for emesis prevention after moderately emetogenic chemotherapy. A double-blind comparison of the efficacy and safety of oral granisetron with oral prochlorperazine in preventing nausea and emesis in patients receiving moderately emetogenic chemotherapy. A unique all-oral, single-dose, combination antiemetic regimen with high efficacy and marked cost saving potential. Antiemetic effect of oral versus intravenous metoclopramide in patients receiving cisplatin: a randomized double-blind trial. Efficacy of oral ondansetron and dexamethasone in prevention of nausea and vomiting associated with moderately high and highly emetogenic chemotherapy. Comparison of the anti-emetic efficacy of different doses of ondansetron given as either a continuous infusion or a single intravenous dose, in acute cisplatin-induced emesis. Ondansetron compared with granisetron in the prophylaxis of cisplatin-induced acute emesis: a multicenter double-blind, randomized, parallel group study. Stratified, randomized, double-blind comparison of intravenous dose regimens in the prevention of cisplatin-induced nausea and vomiting. The clinical role of granisetron (Kytril) in the prevention of chemotherapy-induced emesis. Comparative clinical trial of granisetron and ondansetron in the prophylaxis of cisplatin-induced emesis. A double-blind, randomized, comparison intravenous study of single dose dolasetron versus ondansetron in preventing cisplatin-related emesis. Antiemetic efficacy of high-dose metoclopramide: randomized trials with placebo and prochlorperazine in patients with chemotherapy-induced nausea and vomiting. Antiemetic activity of high-dose metoclopramide combined with methylprednisolone versus metoclopramide alone in dacarbazine-treated cancer patients. A randomized double-blind study of the Italian Oncology Group for Clinical Research. Ondansetron compared with high-dose metoclopramide in prophylaxis of acute and delayed cisplatin-induced nausea and vomiting. Controlling delayed vomiting: a double-blind, randomized trial comparing placebo, dexamethasone alone, and metoclopramide plus dexamethasone in patients receiving cisplatin. Improved control of cisplatin-induced emesis with high dose metoclopramide and with combinations of metoclopramide, dexamethasone, and diphenhydramine. New approaches in preventing delayed emesis: altering the time of regimen initiation and use of combination therapy in a 109 patient trial.

Other predictors varied somewhat between men and women infection nursing diagnosis discount 150mg roxithromycin free shipping, with poor health being particularly salient for men and falling household income and low sexual activity being important for women bacteria eating flesh order roxithromycin 150mg amex. Despite these difficulties infection 3 months after miscarriage roxithromycin 150mg line, most respondents indicated that sex was emotionally satisfying and was associated with very positive feelings can antibiotics cure acne for good proven 150 mg roxithromycin. Although specific prevalence rates vary somewhat in other studies, 11,12,13,14,15,16 and 17 depending on study sample and methodology, the general conclusions are similar. Sexual dysfunction is a common experience, with most individuals experiencing difficulty at some points in their lives. However, sexual dysfunction need not result in dissatisfaction with sexuality or loss of intimacy. More intense and direct tactile stimulation typically is required for arousal and orgasm than is needed in younger men and women. As most men age, erections are less rigid, ejaculation is less forceful, and the refractory period lasts longer (often for many hours). In addition to the anatomic changes associated with menopause, women experience decreased lubrication and, in some cases, reduced intensity of orgasm. Chronic medical conditions and general ill-health can exacerbate the natural slowing of sexual response. Sexual desire and the frequency of sexual thoughts appear to decline with age, particularly for men, although sexual interest does remain present. For women, the prevalence of arousal disorders, as indicated by difficulty lubricating, increases with age. The menopausal transition is characterized by a decreased responsiveness of the ovaries to luteinizing hormone and follicle-stimulating hormone. Gradually, over time, the estradiol levels fall as the ovarian follicles are depleted and there is no further response to the pituitary gonadotropins luteinizing hormone and follicle-stimulating hormone. It is with these changes that the clinical symptoms of estrogen deficiency begin to occur. Lowered levels of estradiol affect various target tissues, including the vagina, skin, bone, vascular endothelium, and smooth muscle, as well as the hypothalamic temperature-regulating centers. Many women who become menopausal experience symptoms associated with estrogen deficiency, including vasomotor symptoms (hot flashes, sweats, palpitations), urinary incontinence, and vaginal dryness. Vasomotor symptoms are most frequent (up to 75% of menopausal women experience these at some point) and are among the earliest symptoms of menopause, with urinary incontinence and vaginal dryness increasing slowly during the later postmenopausal years. Several population-based studies of perimenopausal and menopausal women have documented that most women who have partners are sexually active 13; however, changes can occur in sexual functioning (desire, arousal, orgasm) that are age related 23,27 and to which menopause may contribute. The relation between menopause, sex steroids, and sexual motivation ("libido") remain controversial. With chronic or untreated symptoms of vaginal dryness, postmenopausal women may choose to avoid sexual intercourse completely. In a volunteer sample of healthy postmenopausal women who were not on hormone replacement therapy, vaginal dryness was reported by 37% of women 45 to 64 years of age. If one adds to this the variety of physical, psychosocial, and treatment-related factors associated with cancer treatment, a menopausal woman may certainly experience sexual dysfunction. Although these changes do not occur as precipitously as in menopause, a steady, age-related diminution is noted in most men. This can result in declining libido, which in turn tends to decrease erectile function. A notable variation in this pattern exists, and it is not uncommon for men to remain libidinous and potent well into advanced years. Peripheral circulatory problems and degenerative neuromuscular conditions also become more common, both increasing the incidence of vasculogenic and neurogenic erectile dysfunction (see Table 56. The literature suggests that patients with higher levels of psychological distress experience more sexual dysfunction. Sexual problems that were increased included not being interested in having sex, difficulty in being sexually aroused, and difficulty reaching orgasm. In a study of patients with early-stage cervical cancer, psychological as well as physical problems were highly correlated with sexual outcome. The changes associated with cancer and its treatment are often dramatic, ranging from surgical defects and deformities. In one study, more favorable body image was a significant predictor of sexual interest in breast cancer survivors. More research is needed to determine the mechanisms through which body image disruption affects sexual functioning. For some patients, weight gain is an important consequence of treatment that can interfere with body image. This effect has been particularly noted for women receiving adjuvant chemotherapy for breast cancer. In a multivariate analysis, onset of menopause and chemotherapy administration were each independent predictors of weight gain. Weight gain was not explained by increased caloric intake or decreased physical activity. In a cross-sectional evaluation of 779 patients with colorectal, lung, and prostate cancers at all phases of disease. Treatment of the underlying causes of the fatigue, whether medically or psychologically, may have important benefits in terms of psychological functioning. Uncontrolled pain is associated with psychological distress, poor appetite, and lack of sleep, all of which can decrease sexual interest. However, one study demonstrated the association of pain with decreased sexual functioning after high dose chemotherapy and autologous bone marrow support. Not only can spouses provide much needed emotional support, but they may also contribute to the clinical decision-making process. Physicians must be aware that the spouse often does not agree with the patient when assessing the relative value of sexual function versus survival. In fact, studies comparing husbands and wives suggest that the latter are much more willing to give up sexual function for a chance at longer survival. In addressing the partner relationship, it is also important never to assume that the patient is heterosexual, especially when the patient is alone for tests, consultations, and follow-up visits. Gay and lesbian couples enjoy long-term relationships that are emotionally equivalent to heterosexual marriage, yet given the degree of societal homophobia, they may fear being honest, even with their physicians. A few words of candid support may go a long way in allowing patients to feel better about involving their same-gender partner. The literature does suggest that survivors of childhood and adolescent cancers are at increased risk for marital difficulties. In a large study of long-term survivors of childhood cancers compared with sibling controls, Byrne and colleagues 63 noted that both male and female survivors were less likely to marry than sibling controls and that the marriage deficit was particularly pronounced for survivors of brain and central nervous system tumors. In addition, the average length of first marriages was shorter for survivors than controls. These findings may have important long-term implications for the sexual functioning of these long-term survivors, warranting more detailed inquiry. Postoperative pain and fatigue are important factors that limit recovery of sexual functioning for several weeks after surgery. Surgical treatments with the most significant impact on sexual functioning are those involving the pelvis, such as radical prostatectomy, radical cystectomy, abdominal-perineal resection for rectal cancer, and radical hysterectomy for gynecologic cancers. When radiation is added to surgical treatments, additional nerve and tissue injury may occur, with fibrosis and occasional pelvic pain syndromes. Changes in body image may occur as a result of surgery, especially when it is disfiguring and visible to others, but even hidden body scars may present a difficulty for some patients. In men, pelvic surgery for prostate, bladder, or rectal cancer can easily damage the parasympathetic sacral fibers that are responsible for penile erection. These nerves course posterolateral to the prostate and anterolateral to the rectum and are intimately associated with both structures, especially at the apex of the prostate just anterior to the rectal wall. Although techniques have been developed for identification and preservation of these neurovascular bundles during radical prostatectomy,66 such preservation is much more difficult during abdominal-perineal resection of the rectum. The mere trauma of dissection to separate them from the prostate or rectum may also lead to their permanent failure. The effect is immediate, and neuronal recovery is slow, often lasting months or years. Pelvic surgery for bladder or rectal cancer may also result in female sexual dysfunction, largely due to scarring, shortening, and stenosis of the vagina. The primary landing site for lymphatic spread from the testes is located in the interaortocaval region for right-sided tumors and in the paraaortic region for left-sided tumors.