As physicians, we occasionally treat both life-threatening and quality-of-life-threatening conditions. Many times there is overlap between these two categories, and this is aptly illustrated with the overlap between cancer and subsequent changes in sexual function. The excellent review of this subject by Drs. Tal and Mulhall addresses issues in which cancer in men affects sexual health, but, conversely, sexual health probably also affects patient psychological adjustment and coping with the stages of cancer.
Lack of Discussion
Historically, medical education has done little to address sexual health during training.[1] Consequently, most medical school graduates are ill-equipped to deal with this area of their patients’ lives.[2] This translates into physicians that are often uncomfortable with broaching the topic during patient visits. Most patients also fail to bring up this discussion with their physicians despite willingness to talk about their concerns.[3] While sexual activity is a normal bodily function, the social and cultural connotations associated with it make discussion of specifics seem violations of privacy. However, we know that sexual dysfunction contributes to depression and other forms of mental illness.[4,5]
Patients’ concomitant physical, mental, emotional, and social condition plays a role in their adjustment when faced with the diagnosis of cancer. Patients with a satisfactory sex life have an advantage over those with an unsatisfactory one. While poorly studied, this advantage is most likely helpful in the adjustment to cancer. Often, when patients hear they have cancer, discussion is rightly focused on the prognosis and potential treatment options. Nonetheless, the cancer diagnosis affects all aspects of the patient’s life, including sexual health. This area is often not evaluated and not treated.Causes of Dysfunction
Sexual dysfunction is common in the general population.[6] Its causes are often multifactorial and include both physical and psychological factors. Misconceptions about what can or cannot be done to treat problems may also influence conversations between patient and caregiver. Physicians’ perceptions often underestimate quality-of-life issues plaguing patients.[7,8] By remembering that cancer patients may have baseline sexual dysfunction, physicians and support staff should recognize that the addition of cancer may magnify an already stressful situation.
Medical providers must also remember that male sexual function is not exclusively dependent on erectile function. In a time of oral therapy and prominent advertising regarding erectile dysfunction, many tend to equate sexual health with the ability to obtain and maintain erections. As pointed out in the article, disorders of libido, problems with ejaculation and/or orgasm, and anatomic deformity can also contribute to male sexual dysfunction. Partner response and support is especially overlooked in many discussions.Comprehensive Treatment
All stages of cancer, from diagnosis to treatment, affect sexual health. Any malignancy-not only those that affect the genital organs-can disrupt normal sexual patterns. Concerns of one’s own mortality and body image can certainly interfere with desire or ability to engage in meaningful sexual relations. Depression over diagnosis, fatigue from treatment, and physical alterations from surgery are just some examples of how cancer impacts sexual activity. Physicians treating cancer should discuss these issues with their patients as means of a comprehensive treatment plan.[9]
As we move into the era of multidisciplinary team treatment for oncology patients, we should include discussions of sexual health. Oncologists, urologists, and mental health teams can assist each other in identifying and treating men with both cancer and sexual dysfunction. We are better equipped today than ever to evaluate and treat this combination, and patients want to talk about their sexual concerns. Moreover, addressing this issue early makes it much easier to discuss later during the treatment course. At a time when patients are looking for any type of normalcy in their lives, maintaining and/or restoring sexual health is important. Perhaps, it even affects the body’s response to malignancy and subsequent therapy.—Chad W.M. Ritenour, MD
