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Counseling Cancer Patients About Changes in Sexual Function

Counseling Cancer Patients About Changes in Sexual Function

ABSTRACT: Cancer treatments often cause sexual dysfunctions that remain severe long after therapy is over. Nevertheless, sexual counseling is not routinely provided in most oncology treatment settings. Most patients and their partners can benefit from brief counseling that includes education on the impact of cancer treatment on sexual functioning; suggestions on resuming sex comfortably and improving sexual communication; advice on how to mitigate the effects of physical handicaps, such as having an ostomy, on sexuality; and self-help strategies to overcome specific sexual problems, such as pain with intercourse or loss of sexual desire. Brief counseling can be provided by one of the allied health professionals on the oncology treatment team. A minority of patients will need specialized, intensive medical or psychological treatment for a sexual dysfunction. In a large cancer center, such treatment could be provided as part of a reproductive health clinic serving the special needs of cancer patients. In smaller settings, the oncologist should build a referral network of specialists. Not all managed care organizations reimburse for these services, however. [ONCCOLOGY 13(11):1585-1591, 1999]

Introduction

Sexual dysfunction is one of the more common,
enduring consequences of cancer treatment. About half of women who
survive breast or gynecologic cancer report severe, long-lasting
sexual problems.[1-3] Probably as many as 70% of men who are
undergoing active treatment for localized prostate cancer will
experience sexual impairment.[4-8] Although disease-free breast or
prostate cancer survivors typically report that their overall
health-related quality of life is normal, their sexual problems
remain bothersome exceptions to this general good functioning.[1,6]
For other cancers, such as testicular cancer, leukemia, or
Hodgkin’s disease, at least one-quarter of patients are left
with sexual dysfunction.[9-11]

Recent research has also highlighted that sexual dysfunction is
highly prevalent among the general population of US men and women 18
to 59 years old, and that these problems are associated with both
poor physical health and emotional distress.[12] Sexual problems
become progressively more common with aging in men,[12,13] whereas
menopausal women in the community are more likely to maintain good
sexual function if they still have a partner.[14] Because sexual
problems can contribute to poor self-esteem and interfere with
relationships, it is worth some effort to try to remediate them.

Barriers to Providing Sexual Counseling in
Oncology Settings

For a variety of reasons, sexual counseling has not become a routine
part of oncology care in most settings.

Time Constraints

One important barrier is the time required for such counseling. A
recent study found that the average duration of an outpatient visit
to a family physician is now 10 minutes, including all
patient-physician communication and the physical examination.[15]
When a patient reported being emotionally distressed, the duration of
the visit only increased to an average of 12.8 minutes.[16]

In busy oncology clinics, where outpatient visits must include
educating patients about their disease, prognosis, and treatment,
physicians and nurses often do not have the luxury of assessing
quality-of-life issues. They may hesitate to bring up a topic such as
sexuality because discussing it will take too much time and is not
high enough on the list of priorities. Even when a patient returns
for periodic follow-up visits, time is short and the focus is on the
results of diagnostic tests.

Under managed care, more patients are being followed after the
completion of cancer treatment by family physicians rather than
oncologists. Nonspecialist physicians may not be as familiar with the
long-term side effects of cancer treatment, including the risks of
sexual dysfunction.

Physicians may also be working within systems that discourage
referrals for specialty care. Furthermore, even in traditional
indemnity plans, many private insurers exclude mental health
treatment of sexual dysfunction from their list of reimbursed services.

Discomfort About Discussing Sexual Issues

Another barrier is the discomfort health care providers and patients
may feel about discussing sexuality. Despite the ubiquity of sexual
topics in the media, our society still considers sexuality
“dirty” and titillating. A young physician may fear that an
older cancer patient will regard a question about sexual function as
disrespectful or even flirtatious. When the physician and patient are
of different religious or ethnic backgrounds, fears of being
insensitive or intrusive may be exacerbated. Yet, hidden sexual
issues may interfere with patients’ compliance with cancer
treatment, as the following vignette illustrates:

A female medical oncology fellow who had spent her life in the
Midwest was puzzled when one of her first patients in Texas, an
80-year-old Mexican-American widower, refused his third shot of
hormonal therapy for metastatic prostate cancer. The elderly man, who
spoke fluent English, said that he understood when the doctor
stressed that stopping the hormones would allow his bone metastases
to spread. The man offered no explanation for his refusal. However,
after a few minutes, the patient’s son, who was also present
during the visit, explained: “My father feels that if he
can’t still be a man, it is time to die.”

“You mean he’s worried about his sex life? But your father
is a widower and he told me he had no girlfriends!” the fellow exclaimed.

“That’s true,” the son agreed, “but he still
expects to be able to have erections, even if they just happen in the
morning or in the shower. Without that ability, he doesn’t want
to go on.”

Structure for Providing Basic Sexual Counseling

Oncology health care providers can easily become more comfortable and
knowledgeable about sexual counseling, if they are willing to invest
the time to do so. The American Medical Association, recognizing the
limited training that physicians are given in this area, has designed
a special workshop on this topic for continuing medical
education.[17] For oncologists who want to gain more knowledge about
understanding, assessing, and treating sexual problems related to
cancer, comprehensive reviews of the literature are available.[2,18]

Routine Quality-of-Life Screening

The most practical way to include sexual counseling routinely in
oncology clinics is to provide routine screening and counseling for
quality-of-life issues related to cancer treatment. When treatment
teams are organized by disease site (for example, in a breast cancer
clinic) or by treatment modality (such as on a bone marrow transplant
unit or in radiation oncology), each treatment team should designate
an allied health professional, usually an oncology nurse specialist,
physician’s assistant, or social worker, to assess and triage
patients for quality-of-life problems. Even in a smaller oncology
setting, such an allied health professional is often available.

In a brief, 30- to 45-minute interview, it is possible to assess the
patient’s social support network, reaction to cancer, past and
current mood or anxiety disorders, past and current substance abuse,
current major life stresses, quality of the patient’s intimate
relationship, and any sexual problems or concerns. Although
conducting such an interview with each new patient requires an
investment of time on the part of the health care provider, it can
save valuable physician-hours by identifying patients who need more
intensive mental health or social work services.

When adequate support is provided in the medical setting, a
distressed patient or chaotic family is less likely to demand an
inappropriate amount of time and energy from the physician actually
treating the cancer.[19] Patients also feel that they have an
advocate on the treatment team who knows them as individuals—a
factor that can greatly enhance patient satisfaction and possibly
even compliance with treatment.

Perhaps an even more efficient way to screen patients for
quality-of-life problems is to ask all new patients to fill out a
questionnaire designed to measure quality-of-life concerns for cancer
patients. Several of these are available that include subscales to
measure sexual function and satisfaction. Patients who indicate
specific sources of distress on the questionnaire can then be
evaluated further and referred for needed services.

The most thorough, most detailed of these quality-of-life
questionnaires is the Cancer Rehabilitation and Evaluation System
(CARES).[20] It includes several questions about sexual function and
satisfaction, as well as providing information on concerns about
marital or dating relationships. The Functional Assessment of Cancer
Therapy (FACT) has the advantage of brevity and is available in both
a general version and several site-specific versions that assess
sexual symptoms more extensively.[21]

At follow-up visits during or after cancer treatment, a brief
questionnaire or face-to-face assessment of quality of life,
including sexuality, should also be routine. Sexual problems, in
particular, often become more apparent, or at least more distressing,
during the first months after a patient finishes active treatment.

Extent of Counseling

Once patients with sexual problems or concerns have been identified,
most do not require extensive medical or psychological treatment.
Rather, they need information about the impact of cancer treatment on
sexuality and suggestions for getting their sex life back to normal.

In a review of close to 400 patients who consulted a psychologist in
a cancer center for sexual rehabilitation, 73% were seen only once or
twice.[22] For a subset of patients who provided follow-up data,
about 64% reported some improvement in their sexual problems. Thus, a
large majority of patients can benefit from brief counseling.

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