The results from a recent study showcase the disturbing prevalence of sexual dysfunction as a treatment side effect of cancer and gender disparity in how the problem is addressed by physicians.1 The study, conducted by James Taylor, MD, MPH, Chief Resident in the Department of Radiation Oncology at the Sidney Kimmel Medical College and Cancer Center at Thomas Jefferson University, and colleagues, surveyed 391 cancer survivors about their treatment, its effect on their sexual health, and whether they had been warned about the potential sexual ramifications prior to starting treatment. The survey was conducted through social media and in-clinic visits using an iPad.
The study’s findings showed that most survivors, 87%, reported that their cancer treatment affected their sexual function or desire, with 53.8% reporting body image distortion; 73.4% reporting dyspareunia; and 42.3% reporting an inability to achieve orgasm. Most of the respondents, 81%, were female; 30% were between the ages of 41 and 50. A total of 67% had received treatment for breast cancer; 16%, for prostate cancer; 6%, for endometrial cancer; 4%, for bladder cancer; and 2%, for rectal cancer. Overall, 47.4% of the respondents had received antihormone therapy; 78.1% had received chemotherapy; and 54.2% had received radiation therapy.
James Taylor, MD, MPH
Of these patients, less than half, 44%, were told their sexual health could be impacted before starting therapy. In addition, women were significantly less likely than men to have their sexual dysfunction addressed by their physician, 22% vs 53%, respectively, following their cancer treatment.1 Although previous studies have shown an overall reluctance by both clinicians and patients to discuss cancer- and treatment-related sexual difficulties,2 in Dr. Taylor’s study, more than half of respondents, 51%, said they would be comfortable with their physician initiating a conversation about sexual health.
The ASCO Post talked with Dr. Taylor about the results of his study; the importance of addressing the impact of cancer and its treatment on sexual health for both men and women; and evidence-based tools to assess patients’ sexual health following a cancer diagnosis to improve their quality of life.
Broadening the Definition of Sexual Health
There are many interesting findings from your study. What do you think was the most surprising result?
The result that stands out to me is how prevalent sexual toxicity is among cancer survivors. I have a couple of thoughts on why the percentage was so high, 87%, in our study. One reason is there was probably some responder bias in which people who experienced sexual toxicity from cancer treatment were more motivated to fill out the survey questionnaire. I also think many studies investigating sexual dysfunction after cancer use a pretty myopic definition of sexuality that focuses mainly on erectile dysfunction and vaginal dryness. We purposely focused on more generalized consequences of sexual changes following cancer therapy, including body and appearance changes, relationship challenges, and disappointment and sadness at the loss of sexual intimacy.
Differences Between Male and Female Patients
Another telling finding in your study is that men were more than twice as likely as women to be asked about their sexual health by their medical provider. Do you know why there was such a high gender disparity in physician discussions between their male and female patients?
The majority of the male respondents in our study were prostate cancer survivors. My theory is that, since there are multiple effective treatment options for that cancer, including surgery, radiation therapy, hormone therapy, and chemotherapy, which can affect sexual function in varying degrees, physicians are more likely to discuss the treatment options and their sexual impact with these patients. In fact, we often give these patients a standardized form to fill out before treatment begins that asks about sexual function, which we may then use when considering treatment options.
With other disease sites, for example, breast cancer, in which treatment is dictated by cancer stage, physician discussions are probably less focused on the potential sexual side effects, since there may not be a better treatment alternative to offer. However, regardless of the cancer type and whether the patient is female or male, we should be clear about all the possible side effects patients might experience from their treatment, including sexual dysfunction, and offer referrals to specialists to help patients manage these issues.
Making Sexual Health a Routine Part of Oncology Care
Sexual dysfunction is a well-known common long-term side effect of cancer and cancer-related treatment,3 so why isn’t sexual health a routine part of the initial discussion physicians have with their patients following a cancer diagnosis?
I do think sexual toxicity is likely discussed with many patients before treatment begins, and information on treatment side effects is also contained in patient consent forms. However, so many details are given at those early patient meetings, it may be glossed over because patients are focused on curing their cancer.
Patients with prostate cancer usually have time to weigh their different treatment options and consider their potential effects on sexuality before making a decision. Patients with a late-stage cancer do not have that same luxury and have to make treatment decisions quickly, so sexual health may not be at the forefront of those patient/provider discussions.
Also, physicians are often not adequately trained in sexual health and may not feel comfortable discussing the topic with patients. We have just completed a study querying physicians about their knowledge of cancer-related sexual side effects. We haven’t published the results yet, but we found that physicians who had sexual health education were more likely to raise these concerns with patients than providers who had not received this training.
What we have to do is address treatment side effects at the time of diagnosis; this way, patients will have time to digest the information, and then we can keep having these conversations as treatment progresses and ends. According to our study findings, one way to do this is to have an ongoing review of patients’ treatment side effects based on information they provide on a short form before each clinic visit.
Considering the Impact of Cancer Treatments on Sexuality
Which cancer therapies are likely to cause short-term vs long-term effects on sexual health?
We know that surgery, hormone therapies, and chemotherapies can have an acute, immediate effect on sexual function, and then these effects may wane over time. However, some forms of surgery, for example, the removal of the prostate, breast, or other body parts, can have long-lasting impacts on sexuality. As a radiation oncologist, I think a lot about the long-term consequences of radiation toxicity on sexual health, including radiation-induced vaginal stenosis, which can occur as long as a year after being treated for cervical and colorectal cancers. Radiotherapy can also cause breast fibrosis and breast shrinkage 1 to 2 years after treatment for breast cancer. So, I think of radiation therapy as causing more long-term sexual side effects, and other therapies as responsible for more short-term sexual side effects, although all cancer treatments have the potential to cause long-term and even permanent changes to sexual function.
Using Assessment Tools to Measure Cancer’s Impact on Sexuality
What are some evidence-based guidelines oncologists can use to assess patients’ sexual health following a cancer diagnosis?
ASCO has published a guideline that addresses sexual problems in people with cancer and provides recommendations to manage the issue. It includes information on how to initiate these conversations with patients and interventions to improve overall sexual functioning and satisfaction.4
Specifically for men, there are a couple of good assessment tools, including the International Prostate Symptom Score (https://qxmd.com/calculate/calculator_338/international-prostate-symptom-score-ipss), which can help physicians track the symptoms and management of benign prostatic hyperplasia, and the Sexual Health Inventory for Men (www.pfizerpro.com/sites/default/files/shim_vgu610709-01.pdf), which can help patients and providers determine the symptoms of erectile dysfunction.
More assessment tools are on their way, including one from the European Organisation for Research and Treatment of Cancer. It is now in development to capture survivors’ long-term physical, mental, and social health-related quality-of-life issues (https://qol.eortc.org/questionnaire/surv111/).
The really good news is that the number of cancer survivors is increasing. We have to become better educated about long-term survivorship care, including cancer’s impact on sexual health, so we can improve the quality of life for all patients.
DISCLOSURE: Dr. Taylor reported no conflicts of interest.
REFERENCES
1. Taylor J, Ruggiero M, Maity A, et al: Sexual health toxicity in cancer survivors: Is there a gender disparity in physician evaluation and intervention? Int J Radiat Oncol Biol Phys 108:S136, 2020.
2. Carter J, Lacchetti C, Rowland JH: Interventions to address sexual problems in people with cancer: American Society of Clinical Oncology Clinical Practice Guideline Adaptation Summary. J Oncol Pract 14:173-179; 2018.
3. Rajotte EJ, Baker KS, Heron L, et al: Sexual function in adult cancer survivors. J Clin Oncol 35:123, 2017.
4. 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.
