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Research has suggested that sexual dysfunction may be common among cancer patients and survivors. Studies have shown sexual dysfunction in up to 75% of patients with breast cancer, 77% of women with lung cancer, and up to 85% of patients with cervical cancer.1-3
“The most common sexual health issues reported by cancer patients include loss of sexual desire, vaginal dryness and pain, difficulty with arousal and orgasm, and difficulty accepting changes in the body by patient and partner,” explained Heather R. Macdonald, MD, of Hoag Health Center and the University of Southern California in Irvine.
Dr Macdonald noted that various cancer treatments have been shown to affect sexual health. Surgery, chemotherapy, hormone therapies, and radiation can negatively affect sexual health by impacting the patient’s general wellbeing or by changing the body’s function or appearance.
She added that “much of our sex drive is mental and emotional and is negatively impacted by fatigue, stress, anxiety, fear, and pain — all common to the cancer experience.”
Barriers to Addressing Sexual Health
Though studies have shown high rates of sexual dysfunction in cancer patients and survivors, research has also suggested that sexual health is often overlooked in the context of cancer.
In a study of 405 cancer survivors, 27.9% reported that their provider had inquired about their sexual health, and inquiries were more likely for male patients than for female patients (53% vs 22%; P <.001).4
In a survey of 120 medical oncologists, 81.5% said they discussed sexual function with fewer than half of their patients.5 And in a survey of 599 pediatric oncologists and advanced practice providers, 41.9% said they had no role or a small role in sexual health care.6
A literature review suggested that young adult cancer patients and survivors want more support and information about sexual health from their providers.7 The results also suggested that patients want oncology providers to initiate conversations about sexual health.
However, there are multiple reasons why oncology providers may fail to address sexual health, said Brooke Cherven, PhD, RN, CPON, of Emory University School of Medicine in Atlanta.
“Providers and patients are understandably focused on treating and curing cancer, and sexual health may not be prioritized in the presence of competing demands related to symptoms and treatment,” Dr Cherven said.
Another barrier to sexual health discussions is a lack of knowledge and training among providers. In the aforementioned survey of 120 medical oncologists, 64.6% said they lacked knowledge about sexual health, and 72.9% wanted additional training in sexual function counselling.5
Yet another barrier is discomfort related to talking about sexual health, which has been reported by patients and providers alike.6,7 Dr Macdonald said patients may be reluctant to raise concerns about their sexual health because they are picking up on providers’ discomfort in addressing personal issues.
“If clinicians signal that we are available to discuss sexual health side effects of treatments, patients are more likely to voice their questions,” she said.
How to Address Sexual Health
American Society of Clinical Oncology (ASCO) guidelines recommend that providers initiate discussions about disease-related and treatment-related effects on sexual health at each patient visit with the use of a simple screening measure, such as the Female Sexual Function Index (FSFI) or the Sexual Health Inventory for Men (SHIM).8
“Clinicians should discuss sexual health with their patients regularly from diagnosis through survivorship,” Dr Cherven advised. In the clinic where she practices, providers use evidence-based communication strategies to incorporate assessment of sexual function into discussions about reproductive health.
To increase their knowledge and ability to communicate about sexual health, providers can consult the aforementioned ASCO guidelines8 or access educational offerings from the American Society of Pediatric Hematology/Oncology9 and the Enriching Communication Skills for Health Professionals in Oncofertility (ECHO) program.10 Recent studies have shown promising results with clinician and patient training programs to improve communication about sexual health.11-13
Dr Cherven also suggested that oncology providers consider developing multidisciplinary referral networks that include urologists, gynecologists, psychologists, sex therapists, and peer support groups.
Dr Macdonald agreed that sexual health is best addressed with a combination of medical and psychological approaches, given the substantial influence of mental and emotional factors on sexual health. She emphasized the key role of mental health clinicians in helping to manage problems with sexual functioning, relationships, and body image.
“Knowing their local referral network will help clinicians feel more confident that they can find their patients the help they need,” Dr Macdonald added.
Room for Improvement
Dr Macdonald and Dr Cherven both noted ongoing needs to improve the understanding and treatment of sexual health issues in cancer patients and survivors.
“The Children’s Oncology Group Adolescent and Young Adult Sexual Health Task Force is focused on incorporating sexual health patient-reported outcomes within clinical trials and developing educational tools to support clinical providers in assessing sexual health with their patients,” Dr Cherven said.
“Research and clinical initiatives should address both physical and psychosocial sexual health needs, taking into account the developmental stage, sexual orientation, and gender identity of the survivor,” she added.
Dr Macdonald noted the dearth of research on female sexual responses, especially regarding the impact of hormone loss on sex drive.
“We need to shake off archaic attitudes regarding female sexuality,” she said. “We are doing our patients a disservice that our understanding and interventions for women are not as robust as those for men.”
Dr Macdonald also pointed out that many providers may still think of sexuality in terms of heterosexual couples, marriage, and sexual intercourse, and they may overlook the fact that sexual partnerships encompass all genders and can take different forms.14
“Clinicians need to be educated to use non-judgmental language and an unassuming manner so patients can be open about their intimate relationships, as these partnerships both affect and are affected by physical health,” Dr Macdonald said.
Disclosures: Dr Cherven is a consultant for the Enriching Communication Skills for Health Professionals in Oncofertility training program through NYU School of Medicine. Dr Macdonald reported no relevant disclosures.
References
1. Hernández-Blanquisett A, Quintero-Carreño V, Álvarez-Londoño A, Martínez-Ávila MC, Diaz-Cáceres R. Sexual dysfunction as a challenge in treated breast cancer: In-depth analysis and risk assessment to improve individual outcomes. Front Oncol. 2022;12:955057. doi:10.3389/fonc.2022.955057
2. Rodriguez T. Sexual dysfunction common but unique in women with lung cancer. Cancer Therapy Advisor. Published August 15, 2022.
3. Mishra N, Singh N, Sachdeva M, Ghatage P. Sexual dysfunction in cervical cancer survivors: A scoping review. Womens Health Rep (New Rochelle). 2021;2(1):594-607. doi:10.1089/whr.2021.0035
4. Taylor J, Ruggiero M, Maity A, et al. Sexual health toxicity in cancer survivors: Is there a gender disparity in physician evaluation and intervention? Int J Radiat Oncol Biol Phys. 2020;108(3):Suppl_S136. doi:10.1016/j.ijrobp.2020.07.872
5. Krouwel EM, Albers LF, Nicolai MPJ, et al. Discussing sexual health in the medical oncologist’s practice: Exploring current practice and challenges. J Cancer Educ. 2020; 35(6):1072–1088. doi:10.1007/s13187-019-01559-6
6. Frederick NN, Bingen K, Bober SL, et al. Pediatric oncology clinician communication about sexual health with adolescents and young adults: A report from the children’s oncology group. Cancer Med. 2021;10(15):5110-5119. doi:10.1002/cam4.4077
7. Lehmann V, Laan ETM, den Oudsten BL. Sexual health-related care needs among young adult cancer patients and survivors: A systematic literature review. J Cancer Surviv. 2022;16(4):913-924. doi:10.1007/s11764-021-01084-w
8. Carter J, Lacchetti C, Andersen BL, et al. Interventions to address sexual problems in people with cancer: American Society of Clinical Oncology Clinical Practice Guideline Adaptation of Cancer Care Ontario Guideline. J Clin Oncol. 2018;36(5):492-511. doi:10.1200/JCO.2017.75.8995
9. Addressing sexual health in adolescent and young patients with cancer and blood disorders. The American Society of Pediatric Hematology/Oncology. Published January 24, 2019. Accessed February 23, 2023.
10. The ECHO Program. ECHO-TORCH. NYU Langone Health. Accessed February 23, 2023.
11. Sopfe J, Pettigrew J, Afghahi A, Appiah LC, Coons HL. Interventions to improve sexual health in women living with and surviving cancer: Review and recommendations. Cancers (Basel). 2021;13(13):3153. doi:10.3390/cancers13133153
12. Reese JB, Lepore SJ, Daly MB, et al. A brief intervention to enhance breast cancer clinicians’ communication about sexual health: Feasibility, acceptability, and preliminary outcomes. Psychooncology. 2019;28(4):872-879. doi:10.1002/pon.5036
13. Reese JB, Sorice KA, Pollard W, et al. Efficacy of a multimedia intervention in facilitating breast cancer patients’ clinical communication about sexual health: Results of a randomized controlled trial. Psychooncology. 2021;30(5):681-690. doi:10.1002/pon.5613
14. Katz A, Agrawal LS, Sirohi B. Sexuality after cancer as an unmet need: Addressing disparities, achieving equality. Am Soc Clin Oncol Educ Book. 2022;42:1-7. doi:10.1200/EDBK_100032
