Findings from new clinical studies continue to be reported on a daily basis, making it challenging for clinicians to stay up to date with the latest medical advancements. In this special edition article, we feature topics that may not be readily discussed in routine practice, as well as new screening recommendations for prostate cancer.

NO EXPIRATION DATE FOR SEX

A number of studies have shown the importance of sexuality in people's lives.^[1] In older adults, sexual health is a key aspect of general health and wellbeing.^[2] However, discussions around sex seldom occur among patients and providers.^[1] For health professionals, the thought that older adults don't have sex -- or didn't -- might be comforting. The reality is that for a significant proportion of older patients, sex has no use-by date, and humans are sexual beings throughout their lives.

According to some beliefs, the purpose of sex is to make children. According to others, sex is only for the young, the healthy, and the beautiful. For the medical profession, sex consists mainly of risks or dysfunctions. The results of these biases? Many middle-aged people fear their later sexual life. And medical professionals rarely ask about sexuality. That failing can be harmful. Sexuality and intimacy are essential elements for quality of life, with clear physical, emotional, and relational benefits.

Let's look at the data when researchers dared to ask seniors about their sexuality. We start with the 2015 UK national research on sexuality.^[3] The study found a link between age and a decline in various aspects of sexual activity -- but not a zeroing-out. For example, among men aged 70 to 79, 59% reported having had sex in the past year, with 19% having intercourse at least twice a month and 18% masturbating at least that often. Above age 80, those numbers dropped to 39%, 6%, and 5%, respectively. The reason behind the declines? A combination of taboo, fear of disease, use of medications or other interventions that disrupt sexual function or cause disfigurement, and a little bit of age itself.

What about women? Among women aged 70 to 79, 39% said they'd had sex in the past year, with 6% having intercourse at least twice per month and 5% masturbating 2 times or more monthly. Above age 80, those numbers were 10%, 4.5%, and 1%, respectively. Driving the fall-off in women were the same factors as for men, plus the sad reality that many heterosexual women become widowed because their older male partners die earlier.

The male-female difference also reflects lower levels of testosterone in women. And, because women say they value intimacy more than performance, we have 2 explanations for their lower frequency of masturbation. After all, a lot of intimacy occurs without either intercourse or masturbation.

Surprising and relevant is the amount of distress^[4] -- or rather, the relative lack thereof -- older patients report due to sexual problems. At ages 18 to 44, 11% of US women indicated sexual distress; at ages 45 to 64, the figure was 15%; and at age 65 and up, 9%.

For clinicians, those figures should prompt us to look more closely at alternative forms of sexual expression -- those not involving intercourse or masturbation -- in the aged, a field in which the general clinician typically does not consider.

Although dyspareunia or erectile problems affect many older adults in long-standing relationships, neither is a reason to abstain from sexual pleasure. Indeed, in many couples, oral sex will replace vaginal intercourse, and if urinary, fecal, or flatal incontinence intrude, couples often waive oral sex in favor of more cuddling, kissing, digital stimulation, and other forms of sexual pleasure.

What About the Expiry Date for Sex?

Fascinating research from Nils Beckman and colleagues found that the sex drive persists even as people (and men in particular) reach their 100th year.^[5] Beckman's group interviewed 269 Swedish seniors, all without dementia, at age 97. Sexual desire was affirmed by 27% of men and 5% of women in the survey. Among the men, 32% said they still had sexual thoughts, compared with 18% of women. Meanwhile, 26% of the men and 15% of the women said they missed sexual activity.

What should clinicians do with this information? First, we could start talking about sex with our older patients. According to the 97-year-old Swedes, most want clinicians to do so! More than 8 in 10 of both women and men in the survey expressed positive views about questions on sexuality. And please do not be scared to address the subject in the single senior.^[6] They, too, can have a sexual or relationship issue and are happy when raised with the subject. They're not scared to talk about masturbation, either.

When caring for adults with chronic diseases, cancer, in the course of physical rehabilitation, and even in the last phase of life,^[7] the clinical experience indicates that our patients are happy when we address sexuality and intimacy. Doing so can open the door to the admission of a problem and a corresponding solution, a lubricant or a phosphodiesterase type 5 (PDE5) inhibitor.

But sometimes the solution is the conversation itself: Roughly 25% of patients are sufficiently helped simply by talking about sex. Addressing the importance of sexual pleasure is nearly always valuable.

Here are a few ice-breakers clinicians may find helpful:

• Did taking this medication change aspects of sexuality? If so, does that bother you?
• Knowing that continuing intimacy is healthy, do you mind if I address that subject?
• We know that aspects of sexuality and intimacy are healthy. Without a partner, some people become sexually isolated. Would you like to talk about that?

If addressing sexuality has benefits, what about sex itself?

Clinicians are gradually learning more about the many short-, intermediate-, and long-term health benefits of solo and joint sexual activity.^[8] Short-term benefits include muscle relaxation, pain relief (even, perhaps ironically, for headaches), and better sleep -- all pretty valuable for older adults. Examples of intermediate-term benefits include stress relief and less depression. Research from the United States has found that hugging can reduce the concentrations of proinflammatory cytokines,^[9] and kissing positively influences cholesterol levels.^[10]

Finally, while the long-term benefits of sex might be less relevant for seniors, they do exist. Among them are delayed onset of dementia,^[11] and a substantial reduction in cardiovascular and cerebrovascular problems in men.^[12] More sex has been linked to longevity,^[13] with men benefitting a bit more than women from going through the entire process, including an orgasm, whereas women appear to gain from having a "satisfying" sex life, which does not always require an orgasm.

Clinicians must not forget that these benefits apply to both patients and clinicians alike. Addressing intimacy and sexuality can ease eventual sexual concerns and potentially create a stronger clinician-patient relationship.

STUDY SAYS CASUAL POT USE HARMFUL TO TEENS

An estimated 147 million people around the world, equating to 2% of the global population, consume cannabis. It has become closely related to youth culture, with uptake starting at a younger age compared with other drugs.^[14] Changes in legislation have legalized the recreational use of cannabis in some parts of the world and as a result, this drug is perceived to be less harmful than it was previously.^[15]

However, recreational marijuana use by teenagers is not as harmless as many people seem to think, even as it becomes increasingly legal in this country, authors of a new study say.^[16] Teenagers who use cannabis recreationally are 2 to 3 times more likely to have depression and suicidal thoughts than those who do not use it. And teens who have cannabis use disorder -- which means they cannot stop using it despite health and social problems -- are 4 times more likely to have those same thoughts and feelings.

The study was published in the Journal of the American Medical Association (JAMA). It looked at information from 68,000 teens in the National Survey on Drug Use and Health.^[16] Among the respondents, 2.5% reported cannabis use disorder and 10.2% reported subclinical cannabis use (nondisordered cannabis use). Compared with nonusers, those who reported nondisordered cannabis use had increased risk of major depression (adjusted odds ratio [AOR] 1.86), suicidal ideation (AOR 2.08), slower thoughts (AOR 1.76), difficulty concentrating (AOR 1.81), truancy (AOR 1.90), low grade point average (AOR 1.80), arrest (AOR 4.15), fighting (AOR 2.04), and aggression (AOR 2.16). Marijuana use was also linked to other issues, including not doing well in school, skipping school, and getting in trouble with the police. 

The prevalence of adverse psychosocial events was greatest in adolescents with cannabis use disorder (range of 12.6% to 41.9%), followed by those who reported subclinical cannabis use (range of 5.2% to 30.4%), and then nonusers (range of 0.8% to 17.3%). The study did not seek to explain the link between mental health problems and cannabis use.

LIMIT PSA SCREENING TO MEN WITH SYMPTOMS

Prostate cancer is the most prevalent form of cancer among men, and the third leading cause of cancer mortality in European men.^[17] Since the US Food and Drug Administration approved the first prostate-specific antigen (PSA) screen in 1986 as a means for monitoring disease progression in patients being treated for prostate cancer, the test has remained controversial, embraced by some for its presumed ability to spot early prostate cancer but scorned by others for its equivocal results in patients with benign prostate pathology and for its potential to lead to overdiagnosis and overtreatment of low-grade disease in men who would otherwise be likely to die of other causes.

A new strategy proposed by an international team of experts would limit the use of the PSA test in screening for prostate cancer to men who are younger than 70 years and who are at high risk or symptomatic. This would reduce potential harms from overdiagnosis and overtreatment, the risk for which is high with the on-demand screening that is the current standard of care in most wealthy nations.

In a paper published online on May 17 in the BMJ,^[17] the panel recommends instead a comprehensive nationwide program that would base PSA testing on individual patient risk and direct those with abnormal results to a managed system of imaging, targeted biopsy only if indicated, and subsequent active monitoring or treatment for those with more aggressive disease features.

Alternatively, government health programs could actively discourage widespread PSA testing and implement policies that would effectively limit PSA-based screening only to men with urologic symptoms warranting further exploration, say the authors, led by Andrew Vickers, PhD, a research epidemiologist at Memorial Sloan Kettering Cancer Center in New York, New York.

"Although we believe that early detection of prostate cancer should involve shared decision making, the current approach of determining testing by shared decision making has resulted in the worst possible practical outcome of high levels of PSA testing and medical harm, with minimal benefit and inequity," they comment. "To make better use of PSA testing, policy makers should choose between a comprehensive, risk-adapted approach that is specifically designed to reduce overdiagnosis and overtreatment, or restricting PSA testing to people referred to urologists with symptoms. That choice will need to take into account wider patient and public perspective, as well as health economic concerns," they continued.

Inappropriate Testing

Currently, only Lithuania and Kazakhstan have government-supported population-based screening programs for prostate cancer. In contrast, the United States, United Kingdom, and other high-income countries have opted not to implement nationwide prostate cancer screening but allow so-called "informed choice testing," in which men can receive PSA screening after discussion with a primary care physician, urologist, or other specialist.

The US Preventive Services Task Force recommends that for men aged 55 to 69 years, the decision to undergo PSA testing should be an individual one, based on an understanding of the risks and benefits.^[18] For men aged 70 or older, the task force flatly states, "Do not screen for prostate cancer."

But as Vickers and colleagues note, "high income countries that have made PSA testing available to men who request it after shared decision making with their physician now have a high prevalence of PSA testing with an inappropriate age distribution."

For example, they point out that in the UK, men in their 80s are twice as likely as men in their 50s to get a PSA test, even though men in the older age group are far less likely to have benefit and far more likely to experience harm from treatment. Similarly, in France, nearly one third of men over 40 get an annual PSA test, with the highest incidence of PSA testing in men over age 70. There are also high rates of PSA testing in men over 70 in Italy, Germany, and Ireland.

"A key problem is that, in current routine care -- and despite guidelines to the contrary -- most men with an abnormal PSA result have prostate biopsy, even though only a minority will have aggressive prostate cancer," Vickers and colleagues write. "Furthermore, most men with biopsy-detected cancers have either surgery or radiotherapy (with or without androgen deprivation therapy) even if they have low risk tumors that are unlikely to cause cancer-related morbidity or mortality." In addition, informed-choice PSA testing may lead to health inequities, the team comments, citing data from the United States, Canada, and Switzerland showing an inverse association between income and education and the likelihood of PSA testing. Also, in the United States and Canada, men from ethnic minority groups are less likely to have PSA testing.

Comprehensive Risk-Based Program

Vickers and colleagues propose that a "comprehensive, risk-based prostate cancer detection program based on best evidence on how to use PSA testing and manage subsequent diagnostic follow-up and treatment could reduce overdiagnosis and overtreatment."

"Such a program would restrict testing to men (and those not identifying as male but who have a prostate) aged 50-70, define testing intervals by PSA levels, stop testing early for those with lower PSA, offer biopsy only to those identified as at high risk of aggressive disease after a secondary test (such as magnetic resonance imaging [MRI] or blood markers), and limit treatment to those with high Gleason grade tumors," they write.

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