Oncology providers have ‘duty’ to address women’s sexual health during cancer therapy
Click Here to Manage Email Alerts
Most women with cancer experience some degree of sexual dysfunction, studies have shown, yet few are asked about sexual health before or during cancer treatment.
Many young women report a lack of desire and interest in sex, vaginal discomfort and dyspareunia, difficulties related to orgasm, and lower satisfaction with sex life in the first years after being diagnosed with cancer. Prevalence varies depending on the cancer type, and more intense treatment may increase risk for these issues, according to a population-based, cross-sectional study published last year in Acta Oncology.
Source: Sam Ogden / Dana-Farber
Once it occurs, sexual dysfunction can have a far-reaching impact on patients’ lives, according to Narjust Florez, MD, associate director of the cancer care equity program and thoracic medical oncologist at Lowe Center for Thoracic Oncology at Dana-Farber Cancer Institute, and member of the faculty at Harvard Medical School.
“Sexual health is often seen only as intercourse, and that is not the case,” Florez told Healio | HemOnc Today. “Sexual dysfunction has been directly associated with worse quality of life, depression, anxiety, early discontinuation of therapy even when there is curative intent, and increased need for pain medications and anxiolytics. These are among the many reasons why sexual health is so important to address.”
However, oncologists have not been trained to address sexual health, Florez added.
“There’s a big taboo and a lack of comfort level for oncology providers, but it is our duty to ask patients about their sexual health,” she said. “We don’t have to necessarily fix the sexual issues that patients have, but we must at least refer them to appropriate care.”
The lack of attention to sexual health appears to be more common when dealing with women vs. men with cancer, according to a study presented at last year’s American Society for Radiation Oncology Annual Meeting.
The retrospective analysis of adults evaluated for brachytherapy showed 89% of men with prostate cancer had been asked about sexual function at consult compared with only 13% of women with cervical cancer (P < .001). None of the women underwent sexual health assessment with a patient-reported outcomes tool; however, 81% of the men did (P < .001).
“Culturally, there are differences in how we talk about sexual dysfunction that affects men vs. women,” Jamie Takayesu, MD, radiation oncology resident physician at University of Michigan Rogel Cancer Center and lead author of the study, said in a press release. “We see ads on television about erectile dysfunction, for example, but there’s no equivalent to these for women. Physicians must become comfortable initiating these discussions with women.”
Healio | HemOnc Today spoke with oncologists about the effect of cancer treatments on women’s sexual health, ongoing research in this space and efforts to help clinicians broach the subject with their patients.
Lung cancer
Data are lacking on the impact of lung cancer treatment on women’s sexual health, but Florez and colleagues have been working to fill the knowledge gap.
In the ongoing, cross-sectional, international Sexual Health Assessment in Women with Lung Cancer (SHAWL) survey study, the researchers evaluated sexual activity among 249 women (median age, 59.6 years; 88% white) diagnosed with lung cancer between June 2020 and June 2021.
Results of the study showed more than half (53%) of women reported sexual activity with themselves or with someone else within the previous 30 days. Among them, 59% reported significant issues with vaginal dryness and 26% reported vaginal pain/discomfort during sexual activity.
Overall, 77% of women reported little to no interest in sexual activity and 67% reported rarely or never wanting to have sex. The most common reported factors that negatively impacted women’s satisfaction with their sex life included fatigue (40%), feeling sad/unhappy (28%), issues with their partners (22%) and shortness of breath (15%). Researchers additionally observed marked differences in decreased sexual desire/interest before vs. after a lung cancer diagnosis (15% vs. 31%; P < .001) as well as vaginal pain/discomfort (13% vs. 43%; P < .001).
Other issues that have not been studied extensively relate to body image, Florez said.
“Women experience changes to their bodies through cancer treatment, not only of the breasts with breast cancer but also with melanoma and large, disfigurative surgery. Patients with lung cancer have large surgical scars and patients with colorectal cancer do, as well,” she said. “All of that affects self-perception of the body and it affects sexual health. Body image, secondary to cancer care, affects women’s sexuality, starting with the love they have for themselves.”
Breast cancer
Other emerging research has focused on the sexual health of women who undergo treatment for breast cancer.
“One in eight women are diagnosed with breast cancer in their lifetime, which equates to more than 280,000 women per year in the U.S. alone diagnosed with breast cancer,” Sarah Tevis, MD, assistant professor of surgical oncology at University of Colorado School of Medicine, told Healio | HemOnc Today. “As our treatments continue to improve, we have a growing population of women living with the diagnosis and effects of treatment.”
Tevis and colleagues sought to characterize the education patients with breast cancer received about potential sexual health effects of treatment. They distributed questionnaires to 87 women (44.8% aged 45-65 years; 82.2% white) with stage zero to stage IV breast cancer who underwent treatment at an academic breast center in December 2020.
Sixteen women participated in additional semistructured individual interviews (n = 3) or a focus group discussion (n = 13) that included questions on sexual health education from the oncology care team and patient preferences for content, format and timing of education delivery.
“We started looking at how patients felt about the way their breasts looked after breast cancer surgery,” Tevis said. “We looked at physical well-being, psychosocial well-being and sexual health, and we quickly identified that patients had the lowest quality-of-life scores in the area of sexual health.”
Results of the study showed 93% of women had at least one sexual health symptom during treatment.
“More important than the symptoms themselves, women reported that those symptoms impacted not only their quality of life, but their relationships with their partners and their mental health.”
Among the 16 patients who participated in the additional interview process, few reported receiving information about potential sexual effects of treatment, but those who did indicated that it focused more on menopausal symptoms or fertility symptoms vs. sexual function.
“Other research has shown that women don’t want to bring the topic of sexual health up with their providers,” Tevis said. “Women want the discussion to be brought up by their medical team. Following the initial visit, we don’t have a specific timepoint or point person for following up about things such as sexual health, and we know from the literature that women are unlikely to raise the topic of sexual health themselves. Sexual health should absolutely be part of any survivorship plan, but it is important to bring it up early in treatment.”
MUSIC program
Cancer centers have begun to recognize the need to address women’s sexual health, according to Kristin E. Rojas, MD, FACS, FACOG, assistant professor of surgical oncology in the DeWitt Daughtry Family Department of Surgery in the division of surgical oncology at Sylvester Comprehensive Cancer Center at University of Miami Miller School of Medicine.
“Sexual health concerns of women with cancer and/or who are undergoing active treatment are severely underdiagnosed, but some of us are now dedicating a part of our practice to addressing these very common and important issues,” Rojas told Healio | HemOnc Today. “Because these topics have long been considered taboo, patients may be hesitant to bring it up with their providers. However, we know that patients who experience significant disruptions in their quality of life or sexual health concerns are significantly less likely to complete their cancer treatment, and these issues are extremely common.”
For this reason, Rojas created the Menopause Urogenital Sexual Health and Intimacy Clinic (MUSIC) program to address women’s sexual health after cancer treatment.
“I started my career as a board-certified gynecologist, but I am also a fellowship-trained breast cancer surgeon. Early on in my breast surgeon career, I noticed that many patients would bring up issues about sexual health in the clinic,” Rojas said. “However, we don’t always have the time to address these issues in the setting of the breast cancer clinic visit, so I started the MUSIC program dedicated to women who have a history of any type of cancer. I wanted to make these visits separate so that patients would have a visit where we just tackled these issues and left all of the treatment and diagnostic discussions for their regular visit.”
The one-on-one visits with specially trained nurse oncology practitioners from the MUSIC team are open to women with a history of any type of cancer, those who have been diagnosed with or currently undergoing treatment, or even women at high risk for cancer who have adopted risk-reduction strategies, Rojas continued.
“I started the program in New York but later brought it to South Florida, and it currently lives at Sylvester Comprehensive Cancer Center at University of Miami, with plans for expansion to other local sites,” she said. “The demand for this program has exploded. When we first started offering these services, we had a waitlist of more than 100 patients. Since then, we’ve been able to expand our team, and have treated between 200 and 300 female cancer survivors within the past 2.5 years.”
The MUSIC program also involves research into novel treatments for women’s sexual health concerns in the cancer setting. Rojas received funding for a pilot study to assess the use of platelet-rich plasma (PRP) injections into the vulva and vagina to treat pain during sex and vaginal dryness. The study is planned to enroll 20 women with a history of breast cancer who report experiencing these symptoms, according to a press release.
“The primary goal of the study is to standardize the way this treatment is given and then monitor the improvement of symptoms,” Rojas said in a press release.
Looking ahead
Work is needed to normalize the discussions about sexual health, according to experts with whom Healio | HemOnc Today spoke.
“We have to train medical students, residents and fellows to normalize sexual health — we need to normalize it and talk about it,” Florez said. “If we don’t talk about it, our patients will continue to think that this is just the price they must pay to live and undergo cancer treatment.”
During her initial conversation about sexual health with patients, Florez said many tell her they thought they couldn’t have sex because they have cancer and are undergoing chemotherapy.
“We know that isn’t true, but there’s a perception that this is the price they have to pay, and it is mostly among women,” Florez said. “Normalizing the talk of sexuality is what is needed. Opening the door to show patients that it is OK to talk about sexuality is key. Sexuality is human. None of us would be here without it. We need to normalize it.”
Rojas agreed and said more and more patients are going to bring up sexual health issues as these topics become more prominent.
“Social media has had a lot to do with that and how our culture has evolved, especially during the past 10 to 20 years,” she said. “I would encourage oncologists who may not be as comfortable discussing these issues to seek out resources online, or many times at major conferences there are sessions dedicated to addressing these topics specifically. It is not complicated. Oncologists need to be available to direct patients to the right resources even if feeling uncomfortable discussing the issue.”
In addition, providers should also speak with patients about these issues because they are not difficult to treat, Rojas continued.
“Oftentimes, we simply need to offer therapies that are safe and congruent with their cancer treatment, and even small interventions can have a significant impact,” she said. “This is important, because we have a lot of patients seeking information for alternative treatments that are outside of our standard of care. If we do not offer safe options for these very common problems, patients are going to seek treatment and specialists who may not be in line with our current guidelines and may potentially put them in danger. This is not only a call to action to help address sexual health problems for our patients, but it is also important that we have resources so that we don’t lose patients to potentially harmful fringe therapies.”
Tevis and colleagues are collaborating with patients on a series of educational videos to help address the issue of sexual health symptoms.
“Patients told us that we did a good job of addressing issues like fertility preservation or a specific side effect of surgery or treatment, such as their skin being numb after surgery or that treatments we prescribe may cause menopausal symptoms, but patients worked with us to come up with content they felt was lacking or that they wish they had known,” Tevis said.
Topics included mitigation strategies for sexual health symptoms and how to navigate relationships.
“This could involve intimacy with a current partner or, for patients who are single, how to start dating again and how to disclose this information to people they’re thinking about dating,” Tevis said. “Our ultimate hope is that we can better support our patients during treatment. We are hopeful that these videos will give them the tools to understand what to expect, how to better care for their sexual health during treatment and ultimately improve their quality of life.”
References:
- Florez N, et al. Abstract MA14. Presented at: International Association for the Study of Lung Cancer World Conference on Lung Cancer (hybrid meeting); Aug. 6-9, 2022; Vienna.
- Huynh V, et al. Ann Surg Oncol. 2022;doi:10.1245/s10434-022-12126-7.
- Sexual side effects of cancer treatment often unaddressed with female patients (press release). Published Oct. 21, 2022. Accessed Oct. 21, 2022.
- Sylvester’s sexual health after cancer program expands to meet needs of women with cancer (press release). Published Oct. 31, 2022. Accessed Jan. 26, 2023.
- Takayesu J, et al. Abstract 2306. Presented at: American Society for Radiation Oncology Annual Meeting; Oct. 23-26, 2022; San Antonio.
- Wettergren L, et al. Acta Oncol. 2022;doi:10.1080/0284186X.2022.2112283.
For more information:
Narjust Florez, MD, can be reached at narjust_florez@dfci.harvard.edu.
Kristin E. Rojas, MD, FACS, FACOG, can be reached at krojas@med.miami.edu.
Sarah Tevis, MD, can be reached at sarah.tevis@cuanschutz.edu.
Collapse
Florez N, et al. Abstract MA14. Presented at: International Association for the Study of Lung Cancer World Conference on Lung Cancer (hybrid meeting); Aug. 6-9, 2022; Vienna.
Click Here to Manage Email Alerts