UK doctors and surgeons have formulated what is probably the world’s first clinical guidance on anal sex before, during, and after diagnosis and treatment for prostate cancer. This consensus guideline, which is aimed at clinicians as well as gay and bisexual men with prostate cancer, recommends that men should abstain from receiving anal sex for a period of time before, during, and after certain tests and cancer treatments.

It also warns of possible risks to sexual partners from exposure to radiation. The guidance is being presented at the UK Imaging and Oncology congress in Liverpool, and funded by Health Education England (HEE) in partnership with The National Institute for Health Research (NIHR).

Guideline coordinator, Sean Ralph* (The Clatterbridge Cancer Centre, Wirral) said:
“Men are normally advised to resume sexual activity soon after prostate cancer treatments in order to help preserve their erectile function. However, the increased likelihood of participating in anal sex means that some groups of patients – gay and bisexual men in particular – have different risks, such as the possibility of anal sex causing physical damage after a prostate operation or radiotherapy. We found that most oncologists and surgeons don’t ask patients about their sexual orientation or sexual practices, which means some men won’t get the appropriate advice and support they need to continue having a safe and fulfilling sex life. This new guidance represents the first time** that health professionals have developed clinical advice in relation to anal sex before, during, and after tests and treatments for prostate cancer”.

The guidance is based on the consensus opinion of 15 clinical oncologists and 11 urological surgeons, recruited with help from The Royal college of Radiologists, The British Association of Urological Surgeons, the British Uro-oncology Group, Prostate Cancer UK and the Gay and Lesbian Association of Doctors and Dentists.

Recommendations
Panel members were asked to give opinions on when it was safe to receive anal sex before and after prostate cancer tests and treatments. The consensus agreed was:
Before a PSA blood test – 1 week (may lead to an inaccurate result)
Following a transrectal biopsy (TRUS)- 2 weeks (may cause bleeding, pain or increase the risk of infection)
Following a transperineal biopsy -1 week (to allow bruising to settle, and reduce painful intercourse)
Following a radical prostatectomy (surgical removal of prostate)- 6 weeks (may cause bleeding, pain, and increase the risk of urinary incontinence)
During external beam radiotherapy and 2 months afterwards (could make acute side effects worse, be painful, or result in long term complications such as rectal bleeding)
The clinical oncologists were unable to agree on how long men should abstain from receiving anal sex after permanent seed brachytherapy, where radioactive seeds are inserted into the prostate to kill the cancer. Following additional consultation with medical physicists, it was agreed that men should abstain from receiving anal sex for 6 months, in order to minimise radiation exposure to sexual partners. This was based on review of existing evidence which included guidance produced for an individual patient based at a UK hospital. Patients receiving high dose-rate brachytherapy should avoid anal sex for 2 months.

Sean Ralph added “It is important to note that there was a range of opinions on how long men should abstain from receiving anal sex, so the figures we quote are based on the most common answers provided. There is a lack of concrete clinical evidence on this subject. What we have done is take the opinions of some of the top clinicians working within prostate cancer in order to produce guidance where none previously existed. It’s the first real step in informing both doctors and patients about best practice advice based on expert clinical experience and judgement.”

Prostate Cancer UK has already incorporated these findings into their patient advice.

Although all panel members agreed that it is important for men to abstain from receiving anal sex before, during, and after investigations and treatments for prostate cancer, only 3 out of the 26 panel members (12%) always ask prostate cancer patients about their sexual orientation, and only 2 of the 26 (8%) always ask about anal sex if they are aware that their patient is gay or bisexual.

“Prostate cancer should be viewed as a disease which affects sexual health, wellbeing, and relationships. Health professionals should therefore be asking men questions about their sexual orientation and sexual practices in order to ensure that they have the right information to make informed treatments decisions and to manage their side effects appropriately”, said Sean Ralph. “Patients should be cared for in a manner that takes account of their needs as an individual, including their sexual orientation. Patient-centred care needs to be truly incorporated into the training of health professionals and the culture of the NHS and not just used as the latest buzzword as part of some target driven, box ticking exercise.”

Commenting, Dr John Burton (Edinburgh Cancer Centre, and UKIO Vice-President, Oncology) said:

“This guidance will be invaluable to clinicians and people receiving treatment for prostate cancer.
It is long overdue, and addresses an inequality in the level of information available to patients.

This will not just benefit patient care in the UK, but as the first guidance of its kind in the world, it will inevitably have an impact across the cancer community globally. More generally, this work is about not making assumptions but instead listening to the patient and providing them with advice appropriate to their situation; this is something we need to remember with every patient”.

Dr Burton was not involved in this work, this is an independent comment.

Catherine Winsor, Deputy Director of Support & Influencing at Prostate Cancer UK said:

“Our Specialist Nurses often get asked how long men should abstain from having sex before, during and after different tests and treatments for prostate cancer, from both patients and the professionals who support them. This important and much-needed research has addressed an important gap in our ability to support gay and bisexual men.

We’ve used this to update our written patient information for this group to include these more specific timeframes on when they should abstain. We hope that health professionals will use these findings to provide more consistent, evidence-based guidance to men who have anal sex.”

* Researcher Sean Ralph is a therapeutic radiographer and co-founder of Out with Prostate Cancer, the UK’s first prostate cancer support group for gay and bisexual men. In November 2018 he was awarded Radiographer of the Year for the North West Region by The Society and College of Radiographers.?

**There has been a previous US study on anal sex after permanent seed brachytherapy for prostate cancer; the present guidance takes this US guidance into account.
Source: UK Imaging and Oncology Congress