Dr. Julia H. Rowland
Dr. Jeanne Carter
“It’s a conspiracy of silence,” Julia H. Rowland, PhD, Office of Cancer Survivorship, National Cancer Institute, National Institutes of Health, said. “Sexual well-being is an important issue for anyone, regardless of where they are in their life course. Negative effects on this valued aspect of human function is a complication of cancer and its treatment that we need to tackle.”
Addressing the topic is “a huge task, and those of us who worked on the ASCO clinical practice guidelines want to acknowledge and appreciate the Cancer Care Ontario (CCO) panel for creating the original guideline,1” Jeanne Carter, PhD, Female Sexual Medicine and Women’s Health Program, Memorial Sloan Kettering Cancer Center, said. The Canadian guidelines “are excellent and emphasize the emotional and psychosocial, as well as the physical, ramifications of treatment,” she said. ASCO took those guidelines one step further to concentrate on the timing of the discussion, symptom management, and educational resources.
What the ASCO Guidelines Recommend
The ASCO clinical practice guideline stresses that health care providers need to initiate the discussion about sexual function with their patients as early as possible in the treatment paradigm.2
“At diagnosis, both the patient and provider are focused on how to get control of this cancer, and how to eradicate it. As such, discussing sexual function may not occur or even be desirable in the first conversation with a patient,” Dr. Rowland said.
As clinicians begin to develop a treatment plan for their patients, eliciting information about what aspects of their lives patients consider important—including sexual function and intimacy—is crucial.
“It is up to the clinicians to open that door,” Dr. Rowland said.
ASCO recommends that clinicians let the patient determine when to have an in-depth conversation about the topic but to address it before treatment, “because some of the treatments may be altered [depending on] how important sexual function is for an individual, or how you’re going to care for them in the course of active therapy,” Dr. Rowland said.
This discussion needs to be built into clinician practices, she said. “If clinicians are uncomfortable with the topic, they should find someone on their health care team who can address it with patients. Patients should also decide if their partners should be part of the conversation,” she said.
There are two issues for clinical oncologists. First, patients of child-bearing age may have questions about or issues with fertility, which ASCO has previously addressed.3 Fertility issues may be “even bigger” when they loom in the presence of losing the capacity for intimacy, Dr. Rowland said. Second, as the ASCO guidelines emphasize, sexual function and intimacy are not just physical components of quality of life for patients but also psychological and social components.
Continuing to reassess sexual well-being throughout care and follow-up is important. If patients are not ready to have the discussion initially, “ask about symptoms to get the conversation going,” Dr. Carter said. “Patients will appreciate the information; you’d be surprised how many times in our program women have thought they were the only ones experiencing issues with sexual function and intimacy.”
Addressing Sexual Concerns
The ASCO guidelines note that “medical and treatable contributing factors should be identified and addressed first.”2 Common sexual problems for cancer survivors include decreased desire, arousal disorders, pain (largely in women), and erectile dysfunction in men.2
Treatment may include moisturizers and lubricants or low-dose hormones for women; in men, treatment is likely to include medication, such as phosphodiesterase type 5 inhibitors (PDE5i) for erectile dysfunction. Both women and men who experience vasomotor symptoms should be offered interventions for symptomatic improvement, “including behavioral options, such as cognitive behavioral therapy; slow breathing and hypnosis; and medications, such as venlafaxine and gabapentin,” according to the ASCO guidelines.2 ASCO has suggested a stepwise approach that involves several options not included in the original CCO guidelines.1
The ASCO guidelines add that flibanserin has not been evaluated in women with a history of cancer or those who are treated with endocrine therapy; as such, the risk-benefit ratio for that particular medication type is uncertain. ASCO noted that a thorough discussion with patients to outline the uncertainty of risks versus benefits of the use of vaginal dehydroepiandrosterone and ospemifene should occur.
CCO also suggests that patients receive counseling about hormone therapy. ASCO qualifies the statement to add that clinicians should discuss all options (including integrative approaches) with their patients.
CCO and ASCO both suggest that men are best served by a combination of psychosocial counseling toward long-term use and PDE5i medication adherence, together with PDE5i treatment. Men have more strategies and medications available to help overcome some of the sexual function issues, Dr. Carter said, but the issue is more complex for women because both hormonal and nonhormonal strategies are involved.
The guidelines specify that counseling should be provided to all patients, even if specialized therapists are not available. ASCO recommends that clinicians assess patients for body image issues early and often within the cancer care continuum; patients with pre-existing depression and/or body image issues may be at a higher risk of susceptibility for problems.
Powerful Mind-Body Connection
“The best way that we can help men and women recover from their cancer experience and embrace their sexuality in a positive way is to make sure that we’re giving the physical capacity to do that while supporting them as they’re trying to make sense of this emotionally and reconnect with their body,” Dr. Carter said. “The mind-body connection is powerful in the field of sexuality.”
“Clinicians need to think broadly,” Dr. Rowland said. “Know who the clinicians in your community are who can provide appropriate interventions.”
Clinicians should also take a step back and ask themselves how often the topic is broached.
“Modifying the question to ask, ‘How are things at home?’ instead of ‘How are you?’ allows the patient to share concerns about social interactions, relationships, or other stressors,” Dr. Rowland said. For some clinicians, opening the topic may be as simple as having materials about cancer and intimacy in waiting rooms and as part of the pack of educational materials provided to patients.
“Unlike emotional distress, where most patients pull together what they need over time, sexual dysfunction doesn’t get better. It gets worse. That’s a wake-up call for our clinicians. If we do not intervene, the issue does not resolve,” Dr. Rowland said.
“We have to be nonjudgmental and help patients get the information that they need, so patients/survivors can move beyond their cancer experience and have sexuality in their life in whatever way is meaningful to them,” Dr. Carter said.
–Michelle Dalton, ELS