Dr. Schover’s review of counseling strategies for cancer patients regarding changing sexual function reflects her many years as a clinical therapist and researcher in this area. Her article describes the common failure of clinicians to address the sexual health concerns of cancer patients, and provides a comprehensive approach to this problem for use in the oncology clinical setting. In particular, the author points out how seldom assessments of sexual functioning are performed by health professionals. Such assessments may be more routine among gynecological and genitourinary cancer specialists, who must directly address the sexual consequences of their surgical treatments in women. However, a healthy sex life is important to most women, and the effects of cancer treatments are wide ranging and go beyond surgical treatment of the pelvic organs. Specifically, cancer treatments often affect body image, can precipitate premature menopause with attendant vasomotor symptoms, and may directly influence the partner relationship.[1] Therefore, the sexual impact of cancer treatment should be considered in all women with a cancer diagnosis.
Sexual Health and Functioning
Whenever one considers sexual health and functioning in women, it is important to determine where the woman is in her reproductive life cycle. For example, the impact of chemotherapy treatments will vary considerably in relationship to the age and menopausal status of the woman, with those closest to natural menopause likely to experience the greatest disruption from
chemotherapeutic agents, especially alkylating drugs.[2] The onset of premature menopause, added to the burden of the cancer diagnosis, can contribute to changes in body image, mood, libido, sleep, and vaginal lubrication, beyond the other physical and emotional effects of cancer treatment. Permanent loss of fertility may be another blow to sexual health.
Women with a variety of cancer diagnoses will face these problems, but they are most difficult for women with hormone-dependent cancers (eg, breast and endometrial cancers), where hormone supplementation is usually contraindicated. Increasingly, physicians have become more proactive in describing this potential complication of treatment (eg, loss of fertility, premature menopause). Perhaps prechemotherapy counseling is one of the best times to assess a woman’s current sexual health and functioning, and to accurately prepare her for the potential effects of cancer treatment on this aspect of her health.
Factors Affecting Sexual Health
Similarly, the woman’s partner status (single, widowed, partnered) and the quality of the relationship are important pieces of information that may also influence sexual health. Women who are unpartnered and dating often have substantial concerns about how to tell a new partner about the cancer, especially its potential impact on her future health and fertility. Changes in body image as a result of surgery or other treatments can contribute to modesty or embarrassment when considering a new sexual relationship. Again, information about these aspects of the woman’s social support and partner relationship can be conveniently assessed early in the consultation process.
For breast cancer patients in particular, new information is available on the impact of cancer treatment on sexual health.[1-5] In a recently completed study, we found that sexual functioning declines with age in breast cancer survivors, but in a fashion similar to age- matched women without cancer.[3] The type of surgical treatment (breast conservation vs mastectomy) plays little role in sexual health outcomes,[1] but adjuvant chemotherapy has a significant impact on sexual functioning, both in older and younger women.[1,3,4] Vaginal dryness, a symptom that can be managed with either nonestrogen vaginal lubricants or topical estrogen, seems to be the major contributor to sexual dysfunction.[1]
Interestingly, in these breast cancer survivors, tamoxifen(Drug information on tamoxifen) (Nolvadex) therapy did not seem to play a significant role in sexual dysfunction,[1] a finding supported in large part by the recently completed Breast Cancer Prevention Trial.[6] Additional factors that were found to contribute to sexual interest were body image and emotional well-being, whereas the quality of the partnered relationship and the partner’s sexual problems influenced sexual satisfaction.[1] Although specific to breast cancer, the results of these studies are likely to have relevance to women with other types of cancer.
Clinical Interventions
A number of the factors associated with sexual dysfunction can be addressed with specific interventions.[1] For example, in a recently completed randomized trial of 72 breast cancer survivors, we evaluated the efficacy of a nurse practitioner–delivered clinical intervention for management of menopausal symptoms (hot flashes, vaginal dryness, urinary incontinence). As suggested by Dr. Schover, we used the Cancer Rehabilitation Evaluation System (CARES)[7,8] to screen for rehabilitation problems, including sexual interest and dysfunction.
The nurse practitioner used the results of the patient-completed CARES questionnaire to identify women who were having severe problems (including emotional, marital, and sexual) and referred patients for counseling as appropriate. In addition, the medical component of the intervention focused on providing educational, behavioral, and pharmacologic interventions for the target menopausal symptoms. The intervention succeeded in significantly reducing menopausal symptoms, with a secondary finding of improved sexual functioning.[Ganz PA, Greendale GA, Peterson L, et al, unpublished data] Thus, it appears clinically feasible to address many of the factors that may be contributing to sexual dysfunction in breast cancer survivors.
Discussion
Because patients will seldom directly express sexual concerns to their health care provider, either prior to or after cancer treatment, it is essential that these issues be discussed with patients in a routine, matter-of-fact way. Dr. Schover’s suggestions for making this work are reasonable and comprehensive, but will probably not be feasible in most practice settings.
Instead, the treating oncologist should find a comfortable way to ask “How is your sex life going?” in a nonjudgmental, straightforward way. Often, a good time for the clinician to ask this is somewhere either in the middle or toward the end of a treatment course, to let the patient know that the practitioner is willing to talk about these issues. If the woman has no problems or is not interested in talking, the conversation will end there. However, she will know that she can bring up the topic in the future if she wishes. Similarly, a patient who is very anxious to share her concerns will appreciate the opportunity to discuss her problems. Often the health care professional can provide information, reassurance, referrals, and specific remedies (eg, treatment for vaginal dryness).
With the recent media attention given to sexual health in the general population, patients now expect their physicians to be well informed and receptive to discussing these issues. The very privileged relationship that the oncologist has with the woman with cancer (guiding her through treatment decisions for a life-threatening condition) should permit him or her to assist the woman with this aspect of her health and recovery. We are fortunate that there is now a growing body of research on sexual health after cancer that can inform and guide those discussions.
A 70-year-old man with a history of localized prostate cancer treated with whole-pelvis radiation therapy with a boost to the prostate, in conjunction with androgen deprivation therapy 7 years prior, presented with lower back pain. A bone scan revealed an area of activity in the sacrum. What is the most likely diagnosis?
