Dr. Katz is a certified sexuality counselor at CancerCare Manitoba, Canada.
SEXUALITY AND SEXUAL functioning are important to cancer survivors, and considering the significant number of survivors, this is an issue that should not be ignored. In a survey of cancer survivors who had completed treatment, 43% reported sexual problems; however, just 13% stated that they had received treatment for these problems.1
One of the barriers cited by oncology care providers to discussing sexual side effects of treatment is lack of knowledge, including not knowing about interventions that may help alleviate problems. The publication of the ASCO guideline by Carter and colleagues,2 reviewed in this issue of The ASCO Post, on interventions to address sexual problems in individuals with cancer should go a long way in providing information to oncology care providers that is helpful to their patients.
“The ASCO guideline adaptation provides the best available evidence for interventions…that can be provided by a multidisciplinary team to address the psychosexual needs of the patient and partner.”— Anne Katz, PhD, RN, FAAN
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This guideline, adapted from the Cancer Care Ontario (CCO) guidelines,3 details the interventions available to address sexual problems in adults with cancer in a comprehensive manner, including, where evidence exists, pharmaceutical, psychosocial, and psychosexual interventions. The guideline updates many of the recommendations from the original, including medications that are not available in Canada (eg, ospemifene [Osphena] and flibanserin [Addyi]) and makes suggestions for referrals to other health-care providers based on the symptoms or problems the patient is experiencing. The additions to the recommendations are clearly highlighted in the article in four pages (“The Bottom Line”), which should be required reading for all oncology care providers.
That said, perhaps the most important takeaway from the guideline is found in the first line of the recommendations section of the abstract. It reads: “It is recommended that there be a discussion with the patient, initiated by a member of the health-care team, regarding sexual health and dysfunction resulting from cancer or its treatment.” Two messages in this one sentence are of vital importance: The first is that there is a discussion with the patient, and the second, that it is initiated by a member of the health-care team.
The Discussion
STARTING A DISCUSSION with the patient is the first step in addressing this issue. Assessment of sexual functioning or the presence of sexual problems is a neglected area of oncology care4 despite patient reports that it is important.5
Women are especially disadvantaged, with less than one-third reporting information; men are twice as likely to receive information about sexual changes after cancer.4 This may be because of the assumption that in the absence of medication for women to treat sexual problems, there is nothing to be done, whereas there are medications for men, although they treat just one symptom. However, this assumption is a restrictive one that negates the benefits of psychosocial and psychosexual interventions better suited to the multifactorial nature of sexuality and sexual difficulties that affect not just the patient but the partner as well.
The discussion should be initiated by the health-care provider, just as we initiate a discussion about all potential side effects of treatment. Would any of us omit a discussion about nausea as a side effect of chemotherapy or the risk of febrile neutropenia? To do so would be regarded as incompetence at best and constitutes negligence.
Why then is it acceptable to leave out important anticipatory guidance about the effects of aromatase inhibitors on the vulvovaginal mucosa? A significant barrier cited by some is the lack of time to have long and detailed discussions about this issue.6 In practice, however, what patients most often want is validation that they are not alone in their experience of altered sexuality and that resources are available to help. This does not take a lot of time to provide, and not all patients will require intensive sex therapy. Many will be helped by referral to a urologist, gynecologist, or sexual medicine specialist, as well as a pelvic floor physiotherapist or psychosocial counselor.
It is not sufficient to talk about this just once and then consider our responsibility over. The patient may be reluctant to initiate the conversation7 or may assume that if it is important, the health-care provider will raise the topic.
Subsequent Assessment
ASSESSING SEXUAL health concerns should occur repeatedly along the treatment and survivorship trajectory because patients will have differing needs for information and/or support at different times. Anticipatory guidance at the time of diagnosis may be forgotten or ignored in the gravity of learning about a life-changing and life-threatening disease. During active treatment, patients may feel too ill to be sexually active. This does not negate the need to talk about body image changes that are not necessarily directly related to sexual activity but do have an impact on sexual self-image and concerns about future functioning.
The ASCO guideline adaptation provides the best available evidence for interventions—both including and beyond the purely pharmaceutical—that can be provided by a multidisciplinary team to address the psychosexual needs of the patient and partner. The inclusion of this information should encourage us all to establish referral partners to address the concerns of the patient where necessary. But without the initiation of the discussion by the health-care provider, an important aspect of quality of life will be neglected.■
DISCLOSURE: Dr. Katz reported no conflicts of interest.
REFERENCES
1. Rechis R, Reynolds KA, Beckjord EB, et al: ‘I learned to live with it’ is not good enough: Challenges reported by post-treatment cancer survivors in the Livestrong surveys: A Livestrong report, 2010. May, 2011. Available at https:// d1un1nybq8gi3x.cloudfront.net/sites/default/files/what-we-do/reports/LSSurvivorSurveyReport_final_0.pdf. Accessed February 15, 2018.
2. Carter J, Lacchetti C, Andersen BL, et al: Interventions to address sexual problems in people with cancer: American Society of Clinical Oncology clinical practice guideline adaptation of Cancer Care Ontario guideline. J Clin Oncol 36:492-511, 2018.
3. Barbera L, Zwaal D, Elterman K, et al: Interventions to address sexual problems in people with cancer. A quality initiative of the Program in Evidence-Based Care, Cancer Care Ontario, April 28, 2016. Available at https:// www.cancercareontario.ca/en/content/interventions-address-sexual-problems-people-cancer. Accessed February 15, 2018.
4. Reese JB, Bober SL, Daly MB: Talking about women’s sexual health after cancer: Why is it so hard to move the needle? Cancer 123:4757-4763, 2017.
5. Kent EE, Arora NK, Rowland JH, et al: Health information needs and health-related quality of life in a diverse population of long-term cancer survivors. Patient Educ Couns 89:345-352, 2012.
6. Park ER, Bober SL, Campbell EG, et al: General internist communication about sexual function with cancer survivors. J Gen Intern Med 24(suppl 2):S407-S411, 2009.
7. Hordern AJ, Street AF: Constructions of sexuality and intimacy after cancer: Patient and health professional perspectives. Soc Sci Med 64:1704-1718, 2007.
