Areej El-Jawahri, MD
- Improving cancer survivors’ sexual function may have a positive effect on their quality of life, physical and psychological health, and intimate relationships.
- Despite the prevalence of sexual dysfunction in cancer survivors, clinicians infrequently initiate or engage in discussions with their patients about their sexual health.
- Given the prevalence of sexual dysfunction in cancer survivors, innovative models of care, including web-based and mobile interventions, low-intensity interventions, and interventions integrated within the care infrastructure, have the highest potential to improve patients’ sexual health and function.
Cancer survivors experience a wide range of conditions that impact their sexual function.4,7-9,13,16-25 Figure 1 depicts an integrative bio-psycho-social approach to understanding and addressing sexual dysfunction in cancer survivors by Bober et al.9 Biologic, interpersonal, psychological, and social factors all contribute to sexual dysfunction in this population.
Biologic factors include decreased libido, decreased pleasure, vaginal alterations, erectile and ejaculatory dysfunction, delay or absence of orgasm/ejaculation, premature menopause, hormonal deficiency, dyspareunia, and infertility.7-9,13,16-20 Certain treatments such as radiation therapy can result in skin sensitivity, vaginal stenosis, and scarring.9,26
Patients also struggle with interpersonal problems including relationship disruptions, impaired communication, and intimacy concerns with their partner.9,22-25 Psychological factors that affect sexual function include depression, anxiety, fear of disease recurrence, lack of self-confidence, and body-image concerns.9,22-25 Lastly, personal values affect patient’s level of comfort in addressing their sexual health concerns.9 Thus, sexual dysfunction in cancer survivors is multifactorial and requires a multimodal approach to address patients’ specific health concerns.
Despite the prevalence of sexual dysfunction in cancer survivors, clinicians infrequently initiate or engage in discussions with their patients about their sexual health.5,19,27,28 Survivors often report having insufficient information about sexual function following treatment and little communication with their clinicians about their sexual health.5,19,27-30 Clinicians cite inadequate time, insufficient training, lack of systematic screening for sexual health concerns, and their own discomfort as barriers to addressing sexual dysfunction with their patients.26,31 Interestingly, patients who participate in a discussion with their clinician about sexuality report fewer sexual functioning problems compared to those who do not.5 Therefore, cancer survivors would greatly benefit from interventions to ensure they communicate with their clinicians about their sexual health concerns.
Ideally, anticipatory guidance regarding sexual health issues should be a key element of patient education before cancer treatment, but many cancer survivors who experience sexual dysfunction complain that they were not informed in advance.32 However, the focus on the cancer diagnosis and the need to initiate treatment often does not allow for proactively addressing post-treatment quality-of-life and sexual health concerns. Thus, the appropriate timing for these discussions cannot be easily standardized and will vary depending on the underlying disease and overall prognosis.
When discussing sexual health concerns after cancer treatment, clinicians should be direct, ask open-ended questions, and not make assumptions regarding patients’ sexual orientation or sexual practices.32,33 Open-ended questions may allow patients to feel comfortable sharing information regarding their sexual health and practice. In addition, it is important for clinicians to have additional resources locally for patients who wish to pursue further treatment.
Despite the well-documented burden of sexual dysfunction in cancer survivors, interventions to enhance sexual health and function are lacking.8,9,34 Given the multifaceted nature of sexual dysfunction in cancer survivors, interventions must include a comprehensive assessment and treatment plan to address their diverse sexual health needs.8,9 However, sexual health interventions typically have addressed either physical or psychological consequences of treatment.9,35-37
In a recent randomized clinical trial by Hummel et al, an internet-based cognitive behavioral therapy intervention was evaluated for breast cancer survivors with sexual dysfunction.38 The intervention entailed approximately 20 therapist-guided sessions delivered over a maximum of 24 weeks. The intervention led to improvement in overall sexual functioning, including desire, arousal, and vaginal lubrication.38 Additionally, the intervention group reported improvement in sexual pleasure, less discomfort during sex, and less sexual distress compared to the control group. There were no significant effects observed for orgasmic function, sexual satisfaction, intercourse frequency, relationship intimacy, marital functioning, psychological distress, or quality of life. Despite the intensity of this intervention, it yielded promising results in terms of improving sexual outcomes in breast cancer survivors.38
Sexual counseling interventions for cancer survivors have generally been extremely resource and time intensive, which may impact their dissemination potential.37,38 A personalized approach that addresses the biologic, interpersonal, psychological, and social aspects of sexual dysfunction in cancer survivors in a feasible, patient-centered, and scalable manner within the outpatient oncology setting is critically needed. In a recent study, Bober et al tested a brief psychoeducational intervention for managing sexual dysfunction for women who have undergone treatment for ovarian cancer in a pre-post pilot study.37 The intervention entailed a single half-day psychoeducational group session, take-home educational materials, and a single booster telephone call. This low-intensity behavioral intervention led to significant improvement in overall sexual function and psychological distress in ovarian cancer survivors.37
We recently completed a single-arm pilot study of a multimodal intervention to address sexual dysfunction in hematopoietic stem cell transplant survivors.39 Patients who screened positive for distress caused by sexual dysfunction attended monthly intervention visits with trained study transplant clinicians who performed an in-depth assessment of the causes of the patient’s sexual dysfunction; educated, normalized, and empowered patients to address their sexual health; and implemented therapeutic interventions targeting their specific sexual health needs. The median number of study visits was two (interquartile range was two to three) and the median duration of the first and second visits were 50 minutes and 30 minutes, respectively, demonstrating that the intervention was feasible and not labor intensive.39 The intervention led to statistically and clinically significant improvement in patients’ satisfaction and interest in sex, as well as sexual health and function, including orgasm, erectile function, lubrication, and vaginal discomfort. Patients also reported clinically significant improvement in their quality of life and depression and anxiety symptoms post-intervention.39
Both of these studies underscore that low-intensity multimodal interventions to address sexual dysfunction in cancer survivors are feasible, have promising preliminary efficacy, and should be tested in future trials. Because most comprehensive cancer centers do not have adequate access to sexual health specialists,6,21 these innovative models that are patient-centered and scalable have the potential for wide dissemination. Given the prevalence of sexual dysfunction in cancer survivors and the challenges of delivering survivorship care for many survivors in the community, innovative models of care, including web-based and mobile interventions, low-intensity interventions, and interventions integrated within the infrastructure of care, have the highest potential to improve patients’ sexual health and function.
About the Author: Dr. El-Jawahri is an assistant in medicine at Massachusetts General Hospital and an instructor of medicine at Harvard Medical School.