Sexual Health Issues in Women with Cancer

The impact of curative cancer treatment on sexual health - clinical results from the EORTC QLQ-SH22 validation study

BACKGROUND

The European Organization of Research and Treatment of Cancer (EORTC) has recently developed and validated a patient-reported outcome measure (PROM) for sexual health (SH) in cancer patients. Here, we present results from a secondary analysis of the EORTC QLQ-SH22 validation study. The objective was to investigate the impact of cancer treatment on SH over the disease trajectory into survivorship in patients who underwent curative treatment.

METHODS

Participants completed the EORTC QLQ-SH22 and the EORTC QLQ-C30 assessing SH and Quality of Life. We analyzed differences in SH of patients on active cancer treatment compared to patients off-treatment (cross sectional group comparison) as well as changes in SH during the course of treatment (from pre-treatment to follow-up).

RESULTS

Our sample consisted of n = 394 (66.2% females) curatively treated cancer patients with 34% of patients being on-treatment and 66% of patients being in their follow-up after primary treatment (off-treatment group). Compared to patients off- treatment, patients on active cancer treatment experienced less sexual satisfaction (p = .021, Cohen's d = .36) and libido (p < .001, d = .60) and had higher levels of fatigue (p < .001, d = .50). Importance of sexual activity, masculinity and femininity did not differ between groups. Treatment effects on sexual activity decreased with treatment completion (p < .001, d = .50). Patients undergoing intensified treatment (chemotherapy, radiation, or endocrine treatment) reported more treatment effects (subscale EORTC QLQ-SH22) compared to patients undergoing surgery only.

CONCLUSION

Our results highlight the negative impact of oncological treatment on SH and how increasing treatment intensity further impair SH. Sexual satisfaction and libido improve after treatment completion while other aspects (e.g. masculinity/femininity) do not change during survivorship. We suggest monitoring of SH from the start of cancer treatment on and beyond into survivorship using PROMs as part of routine cancer care. Routine monitoring allows systematic identification of patient's SH problems and may improve awareness as well as target intervention for those in need of care.

Preclinical Female Model of Urogenital Dysfunction and Pathophysiological Changes After Pelvic Radiation Therapy

Introduction Radiation therapy (RT) is the gold standard for many pelvic cancers and improves overall patient survival. However, pelvic RT is associated with increased sexual dysfunction and urinary incontinence. Although the side effects of pelvic RT are well-documented, the pathological mechanisms leading to pelvic organ dysfunction are unknown, and a preclinical model has not been established. This study characterized the impact of pelvic RT at early and late timepoints on female rat bladder, vaginal, and urethral physiology and morphology. Methods Adult female Sprague-Dawley rats were divided into three groups (n = 8/group): (I) Sham, (II) four weeks RT (4wk RT), and (III) nine weeks RT (9wk RT). The RT groups received a single dose of 20 Gy external beam radiation, and experiments were conducted at 4wk and 9wk post-RT. Nerve-mediated vaginal blood flow was measured via laser Doppler. Tissue bath studies assessed vaginal contractility to electric field stimulation (EFS), adrenergic and cholinergic agonists, and relaxation to a nitric oxide donor. Bladder and urethral sphincters were evaluated for cholinergic, caffeine, and EFS-mediated contractility. Quantitative polymerase chain reaction (qPCR) measured gene expression of markers of oxidative stress. Vaginal, bladder, and urethral fibrosis were assessed with Masson's trichrome staining. Results At 4wk post-RT, total vaginal blood flow decreased, and at 9wk post-RT, returned to baseline levels. At 9wk post-RT, vaginal neurogenic and adrenergic-mediated contractile responses increased significantly. Vaginal epithelial thickness decreased post-RT and correlated with an acute rise in vaginal inflammatory gene expression. At 4wk post-RT, bladder neurogenic contractions decreased and remained lowered. Internal urethral contractions increased at 4wk post-RT and returned to Sham levels after 9wk post-RT. Pelvic RT increased external urethral neurogenic contractions, which remained elevated. Conclusion This novel preclinical model provides valuable insights into the temporal pathophysiology of pelvic RT-induced sexual and urinary dysfunction. The establishment of this model is crucial for understanding the underlying mechanisms involved in RT-induced pelvic injury. A reliable, clinically relevant model will allow for the testing of therapeutic strategies to prevent adverse effects with RT in pelvic cancer survivors.

Hyaluronic acid to manage radiotoxicities in gynecological cancer patients: a scoping review

PURPOSE

This study aimed to map the use of hyaluronic acid (HA) in preventing and controlling radiotoxicity in women with gynecological cancer undergoing radiotherapy.

METHODS

We conducted a scoping review of eight electronic databases: CINAHL, Cochrane CENTRAL, LILACS, PubMed, Scopus, Embase, LIVIVO, and the Web of Science Core Collection. In addition, a grey literature search was performed using Google Scholar and ProQuest Dissertations & Theses Global. A manual search was also identified additional references. The search was conducted on May 18, 2023. We included primary studies, reviews, and guidelines that discussed the use of HA to prevent and manage the toxicities resulting from gynecological radiotherapy.

RESULTS

Eighteen studies were included in this scoping review, published between 2009 and 2022. There was heterogeneity in the use of HA, particularly in the method of application (moisturizing gel, vaginal ovules, spacer gel, and bladder instillations). Furthermore, the radiotoxicities varied among studies, encompassing, among others, vaginal atrophy, dryness, dyspareunia, telangiectasis, adhesions, vaginal stenosis, bleeding, hematuria, and bladder issues. Most studies addressed the potential benefits of HA in managing the signs and symptoms resulting from radiotherapy.

CONCLUSION

HA has been utilized in clinical practice, in various formulations, for managing signs and symptoms in patients with gynecological cancer undergoing radiotherapy. However, further studies are necessary to thoroughly investigate the most effective method of HA application and its effectiveness in managing radiotoxicity.

Breast cancer survivorship and sexual dysfunction: a population-based cohort study

BACKGROUND

Breast cancer is the most common non-skin cancer in women and an increasing number of people are living as breast cancer survivors. While the prognosis of breast cancer continues to improve, the rates of sexual dysfunction and the risk related to cancer treatments have not been well characterized in a population-based study.

METHODS

We identified a cohort of 19,709 breast cancer survivors diagnosed between 1997 and 2017 from the Utah Cancer Registry, and 93,389 cancer-free women who were matched by age and birth state from the Utah Population Database. Sexual dysfunction diagnoses were identified through ICD-9 and ICD-10 codes from electronic medical records and statewide healthcare facilities data. Cox proportional hazard models were used to estimate hazard ratios for risk of sexual dysfunction.

RESULTS

Breast cancer survivors were at higher risk of sexual dysfunction diagnosis (9.1% versus 6.9%, HR 1.60, 95% CI 1.51-1.70) compared to the general population. This risk increased 2.05-fold within 1 to 5 years after cancer diagnosis (95% CI 1.89-2.22) and 3.05-fold in individuals diagnosed with cancer at < 50 years of age (95% CI 2.65-3.51). Cancer treatments including endocrine therapy, chemotherapy and radiation therapy were associated with an increased risk of sexual dysfunction among breast cancer survivors.

CONCLUSIONS

Risk of sexual dysfunction in breast cancer survivors is higher than in the general population, but may be underdiagnosed in the clinical setting. Health care professionals should be encouraged to address the topic of sexual health early on in the treatment of breast cancer, and routinely screen patients for symptoms of sexual dysfunction.

Pharmacotherapy for female sexual dysfunctions (FSDs): what is on the market and where is this field heading?

INTRODUCTION

Female sexual dysfunctions (FSDs) are common in women of any age and have a huge impact on quality of life and relationships. They have a multifaceted etiology limiting the development of pharmacotherapies with a high rate of effectiveness. Safety issues are also a concern.

AREAS COVERED

The authors report the most recent advances in pharmacotherapy for premenopausal and postmenopausal women with a main focus on hypoactive sexual desire disorders (HSDD) and associated sexual symptoms. Good levels of evidence have emerged for psychoactive agents, such as flibanserin and bremelanotide, as well as hormonal compounds (transdermal testosterone). The authors also report briefly on intravaginal DHEA (prasterone), local estrogen therapy (LET), and ospemifene to manage effectively vulvovaginal atrophy/genitourinary syndrome of menopause (VVA/GSM). In addition, they discuss promising therapeutic options highlighting the main reasons that hamper the availability of new labeled products. Finally, they include the importance of the multimodal approach to address FSDs.

EXPERT OPINION

Approved pharmacotherapies for FSD are limited. Validated multidimensional instruments and adequate objective measures of physical and mental responses to sexual external and internal incentives are mandatory to identify women suitable to chronic or on-demand treatments and to assess their pattern of response in research and practice.

Treatment of Urogenital Symptoms in Individuals With a History of Estrogen-dependent Breast Cancer: Clinical Consensus

SUMMARY

With an estimated 3.8 million breast cancer survivors in the United States, obstetrician-gynecologists often are on the front lines of addressing survivorship issues, including the hypoestrogenic-related adverse effects of cancer therapies or early menopause in survivors (1). Although systemic and vaginal estrogen are used widely for symptomatic relief of genitourinary syndrome of menopause in the general population, among individuals with a history of hormone-sensitive cancer, there is uncertainty about the safety of hormone-based therapy, leading many individuals with bothersome symptoms to remain untreated, with potential negative consequences on quality of life (2). An effective management strategy requires familiarity with a range of both hormonal and nonhormonal treatment options, knowledge about the pharmaceutical mechanisms of action, and the ability to tailor treatment based on individual risk factors. This clinical consensus document was developed using an a priori protocol in conjunction with two authors specializing in urogynecology and gynecologic oncology. This document has been updated to review the safety and efficacy of newer hormonal treatment options as well as nonhormonal modalities.

Clinical use and implications of sexual devices and sexually explicit media

Given that sexual pleasure is a core component of sexual health, devices that are designed to enhance and diversify sexual pleasure are particularly useful in clinical practice. Despite their growing popularity and widespread use in various biopsychosocial circumstances, many taboos still seem to exist, as indicated by the paucity of scientific literature on the prevalence, application and effectiveness of sexual devices for therapeutic use. However, sex toys and sexual devices are commonly used and have a variety of indications to expand individual and partnered sexuality and to treat sexual difficulties. Different devices are associated with specific advantages and potential risks, opportunities, barriers and ethical challenges when used in a clinical context. Increased knowledge about the aim and functional possibilities of sexual devices might help health-care professionals overcome potential embarrassment, preconceptions and other barriers, learn which patients might benefit from which products, consider their use in treatment programmes, educate about correct use and safety issues, and facilitate open communication about sexual pleasure with their patients.

A Prospective Single-Arm Study Evaluating the Effects of a Multimodal Physical Therapy Intervention on Psychosexual Outcomes in Women With Dyspareunia After Gynecologic Cancer

BACKGROUND

Dyspareunia affects most women after treatment for gynecologic malignancies. However, to date, evidence-based interventions remain limited and no study has examined the effects of multimodal physical therapy on psychosexual outcomes in these patients.

AIM

To assess the effects of multimodal physical therapy on psychosexual outcomes including sexual distress, body image concerns, pain anxiety, pain catastrophizing, pain self-efficacy and depressive symptoms in women with dyspareunia after treatment for gynecologic malignancies.

METHODS

Thirty-one gynecologic cancer survivors with dyspareunia enrolled in this prospective single-arm interventional study. The participants undertook 12 weekly sessions of physical therapy incorporating education, pelvic floor muscle exercises with biofeedback, manual therapy and home exercises. Outcome measures were evaluated pre- and post-treatment. Paired t-tests were conducted to investigate the changes from pre-treatment (P-value ˂ 0.05) while effect sizes (Cohen's d) were calculated to measure the magnitude of the change.

MAIN OUTCOME MEASURES

Sexual distress (Female Sexual Distress Scale-Revised), body image concerns (Body Image Scale), pain anxiety (Pain Anxiety Symptoms Scale), pain catastrophizing (Pain Catastrophizing Scale), pain self-efficacy (Painful Intercourse Self-Efficacy Scale) and depressive symptoms (Beck Depression Inventory-II).

RESULTS

Significant changes were found from pre- to post-treatment for all psychosexual outcomes. Women reported reductions in sexual distress (P ˂ 0.001, d = 1.108), body image concerns (P ˂ 0.001, d = 0.829), pain anxiety (P ˂ 0.001, d = 0.980), pain catastrophizing (P ˂ 0.001, d = 0.968) and depression symptoms (P = 0.002, d = 0.636) with an increase in pain self-efficacy (P ˂ 0.001, d ≥ 0.938) following the intervention.

CLINICAL IMPLICATIONS

The results suggest that multimodal physical therapy significantly improves sexual distress, body image concerns, pain anxiety, pain catastrophizing, pain self-efficacy and depressive symptoms in our sample of women with dyspareunia after treatment for gynecologic malignancies. The medium to large effect sizes obtained with the high proportion of women presenting meaningful changes according to the known minimal clinically important difference or clinical cut-off underlines the significance of these effects.

STRENGTHS & LIMITATIONS

The current study used validated questionnaires to assess the psychosexual outcomes of a well-designed physical therapy intervention using multiple modalities to address the multifaceted aspect of dyspareunia in cancer survivors. This study did not include a control group, which may limit drawing definitive conclusions.

CONCLUSION

Findings showed that multimodal physical therapy yielded significant improvements in psychosexual outcomes in gynecologic cancer survivors with dyspareunia. A randomized controlled trial is indicated to confirm these results. Cyr M-P, Dumoulin C, Bessette P, et al. A Prospective Single-Arm Study Evaluating the Effects of a Multimodal Physical Therapy Intervention on Psychosexual Outcomes in Women With Dyspareunia After Gynecologic Cancer. J Sex Med 2021;18:946-954.

Perceptions of Chinese Patients Treated for Gynaecological Cancer about Sexual Health and Sexual Information Provided by Healthcare Professionals: A Qualitative Study

Patients treated for gynaecological cancer (GC) generally experience impaired sexual function. Research on their sexual life experiences and perceptions on the sexuality care they receive is warranted. This study aimed to examine the perceptions of Chinese patients treated for GC regarding the effects of cancer treatment on their sexual function and femininity, their relationships with their partners, and the adequacy of the sexual information received from healthcare professionals during treatment. Individual, semi-structured interviews were conducted with 21 Chinese patients treated for GC, collecting data on their perceptions regarding the effects of cancer treatment on their sexual lives, femininity, and relationships with partners; and their views about the quality of sexuality care received. Data were analysed using content analysis. Participants experienced impaired sexual function, reduced sex drive, and expressed dissatisfaction with their sex lives. They perceived a loss of femininity and poor body image. They desired more information about how to address sexual problems and opted to receive this information from female healthcare professionals in individual counselling sessions during which the professionals could initiate such discussions. Overall, Chinese patients treated for GC have concerns about multiple sexual issues and a strong desire for information about strategies to address these issues. Nurse-led interventions should be implemented via a shared care approach to enhance patients' awareness about managing their sexual and psychological symptoms.

Effects of a nurse-led positive psychology intervention on sexual function, depression and subjective well-being in postoperative patients with early-stage cervical cancer: A randomized controlled trial

BACKGROUND

Sexual dysfunction is a common long-term complication of cervical cancer and its treatment. However, due to traditional Chinese culture, there are few studies on interventions to improve sexual function in China.

OBJECTIVES

To evaluate the effectiveness of a nurse-led positive psychology intervention on sexual function, depression and subjective well-being amongst postoperative patients with early-stage cervical cancer.

DESIGN

A randomized controlled trial.

SETTINGS AND METHODS

Patients who had undergone radical hysterectomy for early-stage cervical cancer and were followed up in gynaecological clinics were recruited via convenience sampling from three tertiary hospitals in Chongqing, China. Patients who met the inclusion criteria and agreed to participate (N = 91) were randomly assigned to a nurse-led positive psychology intervention (intervention group, n = 46) or usual care (control group, n = 45). The Female Sexual Function Index, Self-rating Depression Scale and Index of Well-being were used to assess sexual function, depression and subjective well-being, respectively, at baseline and 3 and 6 months after the intervention. Data were analysed by the chi-square test, Mann-Whitney U test, t-test and Pearson correlation analysis.

RESULTS

Compared with participants in the control group, participants in the intervention group showed significant improvements in sexual function (mean difference [MD]: -3.95, P = 0.005 at 3 months post-intervention; MD: -4.36, P = 0.001 at 6 months post-intervention). In addition, at 3 and 6 months after the intervention, the number of patients with improvements in their levels of depression and well-being in the intervention group was higher than that in the control group (P<0.05). The Pearson correlation analysis results showed that there was a negative correlation between sexual function and level of depression in patients (r =-0.612, P<0.001) and that sexual function was positively correlated with subjective well-being (r = 0.638, P<0.001).

CONCLUSION

The intervention group experienced significant improvements in sexual function, depression and subjective well-being. These findings suggest that a nurse-led positive psychology intervention should be implemented for postoperative patients with early-stage cervical cancer.

Quality of life in Mexican colorectal cancer patients: analysis with sociodemographic, medical, and psychological variables

In this study, we evaluated the influence of sex, age, clinical stage, and colostomy/ileostomy variables on the quality of life of Mexican patients with colorectal cancer. Using a descriptive cross-sectional design, 192 colorectal cancer patients were included in the study. Significant differences were observed in emotional functioning between patients with rectal cancer and those with colon cancer. Presence of colostomy/ileostomy was associated with significantly impaired social functioning. Body image was significantly different based on gender and diagnosis. Likewise, significant differences were observed with respect to symptoms of the general and specific quality of life modules for colorectal cancer: these included significant difference between male and female patients with respect to taste; significant difference between rectal and colon cancer with respect to presence of blood and mucous in stool, urinary incontinence, and buttock pain; and significant difference between patients with and without colostomy/ileostomy with respect to constipation, stool frequency, sore skin, and embarrassment. We observed significant correlation of dimensions of the quality of life with distress, post-traumatic stress, and optimism. Interventions for improving the quality of life of patients with colorectal cancer should be individualized based on the specific diagnosis and the presence/absence of colostomy/ileostomy.

Patterns of sexual health in patients with breast cancer in China: a latent class analysis

PURPOSE

This study aimed to identify unobserved distinct latent classes/subgroups of breast cancer (BC) patients in China with respect to various sexual health measures and examine the association of the latent membership with individual characteristics.

METHODS

In a cross-sectional study, 123 BC patients were analyzed. Their sexual health was measured using the Female Sexual Functioning Index (FSFI). Latent class analysis (LCA) was used to examine the patterns of sexual health in patients. Associations of the latent class membership with individual characteristics were examined using multinomial logistic regression.

RESULTS

Three a priori unknown distinct latent classes of patients were identified with respect to the 19 FSFI sexual health measures: 50 patients (41.6%) were classified in class 1 "No Impairment Group," 49 patients (39.4%) in class 2 "Organic Sexual Dysfunction Group," and 24 patients (19.1%) in class 3 "Poor Sexual Health Group." Income and anxiety were positively, whereas disease duration was negatively associated with the likelihood of being in class 2 than in class 1, patients with recurrence of cancer were likely to be in classes 2 and 3. Patients classified in class 3 were more likely to have better prior body image and have more severe menopausal symptoms, whereas less likely to have better post body image and have better partner relationships.

CONCLUSION

The findings revealed the heterogeneity of sexual health among BC patients in China and may guide to identify the high-risk patients and enable early intervention.

Sexual dysfunction in female cancer survivors: A narrative review

OBJECTIVES

Due to improvements in earlier detection and expansions in available treatments, the number of individuals surviving with cancer is steadily increasing. Sexual dysfunction is a common and often persistent complication for cancer survivors, affecting >60% of women diagnosed with cancer. Although highly prevalent, issues related to sexual health are often not addressed among survivors, with women reporting less discussion with providers compared to men.

METHODS

In this narrative review, we present a case series of three women seen in a psycho-oncology clinic who experienced sexual dysfunction following a cancer diagnosis. We then review existing literature on the presentation and management of sexual issues associated with cancer and its treatment.

RESULTS

The three cases highlight different mechanisms of sexual dysfunction after cancer, including anatomic changes, hormonal alterations, psychiatric conditions and medication side effects. The literature review includes discussion of the prevalence and course of sexual dysfunction in female cancer survivors. Tools for screening and assessment are then reviewed, as well as contributing factors and common presenting symptoms. We conclude with a discussion of both pharmacologic and non-pharmacologic approaches to management.

CONCLUSIONS

Despite its high prevalence and considerable impact on quality of life, the complication of sexual dysfunction after cancer diagnosis and treatment is still under recognized and undertreated. Improving awareness, communication, and screening, as well as appropriate referral to treatment, could have a profound impact on the ever growing number of women surviving with cancer with sexual health concerns.

A Systematic Review of Interventions for Sexual Well-Being in Women With Gynecologic, Anal, or Rectal Cancer

PROBLEM IDENTIFICATION

Treatments for cancer in the lower pelvis often cause lasting effects on women's sexual well-being. The purpose of this review is to describe interventions to improve sexual well-being in gynecologic, anal, or rectal cancer survivors.

LITERATURE SEARCH

This review follows the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) 2009 checklist and guidelines. A literature search was conducted using PubMed, CINAHL®, PsycINFO, and Cochrane Library.

DATA EVALUATION

Articles were original intervention research studies of women treated for gynecologic, anal, or rectal cancer and included sexual well-being outcomes. Study characteristics were extracted and compared in a table for analysis and synthesis.

SYNTHESIS

Of the 16 included studies, 1 focused on genitourinary rehabilitation, 12 focused on psychoeducational interventions, and 3 focused on combination interventions. Most interventions reported at least one positive sexual well-being outcome. Intervention format, delivery, dose, and outcome variables varied widely.

IMPLICATIONS FOR RESEARCH

Preliminary efficacy and feasibility of interventions are promising, but larger studies designed to discern optimal content, delivery format, dose, and timing are needed.

Nurses' attitudes towards support for and communication about sexual health-A qualitative study from the perspectives of oncological nurses

AIM AND OBJECTIVES

To explore nurses' articulations of support and communication regarding sexual health with patients.

BACKGROUND

Sexual health is adversely effected by cancer and various oncological treatments. Patients' often have the experience that healthcare professionals do not talk about sexual health.

METHOD

Semi-structured interviews were conducted with seven nurses in Southern Sweden. Content analyses were made, inspired by Foucault's concepts of power, discipline and normalisation. SRQR checklist was used.

RESULTS

Patients' sexual health had low priority in the oncological clinic from the perspective of nurses. The medical logic directed nurses' articulations about sexual health towards a physical view, understood as sex, and sexual problems, which could be treated pharmacologically. Further, nurses articulated a sexual norm that sex belongs to young people and younger persons in permanent, monogamous and heterosexual relationships. This norm-governed nurses' inclusion and exclusion of patients in communication about sexual health. According to nurses, most patients did not mention sex, but some patients challenged the clinic's norms. Assessing sexual health problems, nurses often engaged other professions and thereby became gatekeepers for patients' options for getting help.

CONCLUSIONS

From the perspective of nurses, nurses' support and communication regarding sexual health with patients with cancer diagnosis were relatively absent and had a low priority in an oncological clinic. Overall, the nurses had the power to set the agenda about patients' sexual health in the oncological clinic. The clinical gaze became a disciplinary technique that tacitly defined by whom, in what way and how sexual health could be articulated in an oncological clinic.

RELEVANCE TO CLINICAL PRACTICE

By illuminating nurses' preconceptions, thoughts and actions in relation to cancer patients' sexual health, the results invite practitioners to reflect upon and discuss the challenges, opportunities and limitations in providing inclusive and supportive sexual health care to cancer patients.

Screening for sexual health concerns in survivors of gynecological cancer

OBJECTIVE

To assess the impact of a screening tool, the Brief Sexual Symptom Checklist for Women, on referral rates to physiotherapists, sexual counselors, and psychologists for sexual issues among patients attending the practices of two gynecological oncologists.

METHODS

A prospective observational cohort study. A retrospective cohort of consecutive patients matched for age, diagnosis, and stage was used as a control group.

RESULTS

Seventy-eight women were recruited to the intervention group. Diagnoses were endometrial carcinoma (38%), ovarian carcinoma (33%), and cervical carcinoma (24%). Sixty percent had completed adjuvant treatment, and 89% were married or in a de facto relationship. More than half of participants reported at least one sexual difficulty and were not satisfied with their sexual function. The most commonly reported sexual issue was decreased sexual desire. Twelve of 77 (15%) women screened in the intervention group were referred to a sexual counselor and/or a physiotherapist for a sexual issue. Twelve percent of women in the intervention group were referred to a sexual counselor, compared with 5% in the control group (p = 0.072). There was no difference in the proportion of women referred to a pelvic floor physiotherapist between the two groups (8% of women in the intervention group vs. 8% in the control group; p = 1.000).

CONCLUSIONS

In the current study, the Brief Sexual Symptom Checklist for Women identified sexual health concerns in over half of gynecological cancer survivors and resulted in a non-significant trend to more referrals for sexual counseling.

Identifying distinct trajectories of change in young breast cancer survivors' sexual functioning

OBJECTIVES

To identify and characterize distinct trajectories of change in young women's sexual functioning over the first 5 years following breast cancer diagnosis.

METHODS

Group-based trajectory modeling was applied to the sexual functioning of 896 women diagnosed with stage I-IV breast cancer at age 40 or younger. The Cancer Rehabilitation Evaluation System was used to evaluate women's symptoms of sexual dysfunction annually for 5 years.

RESULTS

Five distinct trajectories of sexual functioning were identified: one asymptomatic, one minimally symptomatic, two moderately symptomatic, and one severely symptomatic trajectory. Twelve percent of women were asymptomatic throughout follow-up. The plurality of women experienced stable mild symptoms (42%). Among those with moderate symptoms, some experienced improvement over time (22%) while others experienced deterioration (13%); 11% experienced stable severe symptoms that did not remit over time. Independent predictors of experiencing a symptomatic rather than asymptomatic trajectory (P < 0.05, two-sided) included diagnosis with stage 2 versus 1 disease, ER positive disease treated with oophorectomy or ovarian suppression, being partnered, having anxiety, poorer body image, and greater musculoskeletal pain.

CONCLUSIONS

We identified distinct trajectories that describe the reported sexual symptoms in this cohort of young breast cancer survivors. The majority of women reported various degrees of sexual dysfunction that remained stable over the study period. There is, however, potential for improvement of moderate and severe symptoms of sexual dysfunction in early survivorship.

Sexual function and sex hormones in breast cancer patients

PURPOSE

Breast cancer patients (BCP) are at risk of female sexual dysfunction (FSD). Our aim was to clarify the effects of treatment strategies, and steroid hormones levels on FSD.

METHODS

We enrolled 136 BCP (46.9 ± 0.8 years), and 122 completed questionnaires. BCP were divided into four groups: 22 women with advanced breast cancer on neoadjuvant therapy (NAT), 48 on adjuvant therapy (AT), 30 taking hormonal therapy (HT) and 22 with metastatic cancer on first line chemotherapy (FLT). Fifty-eight healthy women (43 ± 2.8 years) were enrolled as controls. FSD was evaluated by FSFI, and sexual distress was assessed with FSDS-R. We have collected demographic data, laboratory values, and LH, FSH, total testosterone (T), and estradiol (E2) levels.

RESULTS

BCP showed a prevalence of FSD of 69%, total FSFI score was 17. FSDS-R was 8.3. FSD had a prevalence of 72 % in NAT, 65% in AT, 77% in metastatic BCP under FLT, 67% in HT, compared with a prevalence of 20% in controls. BCP showed lower E2 than normal values, as well as T. LH and FSH were significantly elevated than normal values. Total FSFI score was positively correlated with T in 122 BCP, no significant correlation was found between E2 and FSFI. Significant differences were found between NAT and HT in lubrication, pain domains and total FSDS-R score, AT and HT in pain domain, AT and NAT in lubrication domain.

CONCLUSIONS

BCP are at high risk of developing FSD both for treatment choice and hormonal status, but they have not sexually related personal distress.

Cancer Survivorship in Adults

With the favorable trend regarding survival of cancer in the Western world, there is an increasing focus among patients, clinicians, researchers, and politicians regarding cancer survivors' health and well-being. The number of survivors grows rapidly, and more than 3% of the adult populations in Western countries have survived cancer for 5 years or more. Cancer survivors are at increased risk for a variety of late effects after treatment, some life-threatening such as secondary cancer and cardiac diseases, while others mainly have negative impact on daily functioning and health-related quality of life (HRQOL). The latter factors include fatigue, anxiety disorders, sexual problems, insomnia, and reduced work ability, while depression does not seem to be more common among survivors than in the general population. Life style factors are highly relevant for cancer survivors concerning risk of relapse and somatic comorbidity. The field of cancer survivorship research has grown rapidly. How to best integrate the knowledge of the field into clinical practice with adequate follow-up of cancer survivors at risk for developing late effects, is still an unresolved question, although several models are under consideration.

The Relationship Between Body Mass Index and Sexual Function in Endometrial Cancer

OBJECTIVES

To explore the association between pretreatment body mass index (BMI) and post-treatment sexual function in women treated for endometrial cancer. 
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SAMPLE & SETTING

28 postmenopausal women treated with vaginal brachytherapy (VBT) took part in this multisite exploratory secondary analysis at the University of Pennsylvania and Northwestern University. 
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METHODS & VARIABLES

Secondary data analysis was used to determine if pretreatment BMI is associated with post-VBT sexual function in postmenopausal women treated for endometrial cancer at baseline and at six months post-treatment. Because of small sample size, participants were dichotomized according to enrollment BMI.

RESULTS

Both groups had poor sexual function at baseline. Although improved function was observed with time, neither group reached a score indicating healthy sexual function.
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IMPLICATIONS FOR NURSING

Understanding factors that influence sexual health in patients with gynecologic cancer can improve post-treatment quality of life. 
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Survivorship, Version 2.2017, NCCN Clinical Practice Guidelines in Oncology

Many cancer survivors experience menopausal symptoms, including female survivors taking aromatase inhibitors or with a history of oophorectomy or chemotherapy, and male survivors who received or are receiving androgen-ablative therapies. Sexual dysfunction is also common in cancer survivors. Sexual dysfunction and menopause-related symptoms can increase distress and have a significant negative impact on quality of life. This portion of the NCCN Guidelines for Survivorship provide recommendations for screening, evaluation, and treatment of sexual dysfunction and menopausal symptoms to help healthcare professionals who work with survivors of adult-onset cancer in the posttreatment period.

Sexual Health, Mental Health, and Beliefs About Cancer Treatments Among Women Attending a Gynecologic Oncology Clinic

Introduction

Sexual health is an important, yet overlooked, aspect of quality of life for gynecologic oncologic patients. Although patients with gynecologic cancer frequently report sexual health concerns, there are limited efforts to address these problems. A comprehensive understanding of the relationship between mental health and sexual health needs to be prioritized.

Aim

To examine multiple components of sexual health in patients with gynecologic cancer.

Methods

For the present study, sexual health concerns (ie, sexual frequency, desire, response, and satisfaction; orgasm; and pain during sex; independent variables), beliefs about cancer treatments affecting sexual health (dependent variable), and mental health (ie, anxiety and depressive symptoms; dependent variables) of patients at a US gynecologic oncology clinic were assessed.

Main Outcome Measures

Demographics; cancer diagnosis; positive screening results for cancer; sexual health histories including sexual frequency, desire, pain, orgasm, responsiveness, and satisfaction; and mental health including depression and anxiety symptoms.

Results

Most women reported experiencing at least one sexual health concern, and half the women screened positive for experiencing symptoms of depression and anxiety. Forty-nine percent of participants reported having no or very little sexual desire or interest in the past 6 months. Further, in mediation analyses, pain during sex was significantly and positively correlated with depressive symptoms (r = 0.42, P < .001), and this relationship was fully mediated by believing that cancer treatments affected one's sexual health (B = 0.16, 95% confidence interval = 0.01–0.48, P < .05).

Conclusion

Findings emphasize the need to further address and incorporate sexual and mental health into standard care for patients attending gynecologic oncology clinics. Screening women for whether and to what extent they perceive cancer treatments affecting their sexual health could provide a brief, easily administrable, screener for sexual health concerns and the need for further intervention. Intervention development for patients with gynecologic cancer must include mental health components and addressing perceptions of how cancer treatments affect sexual health functioning.

Eaton L, Kueck A, Maksut J, et al. Sexual Health, Mental Health, and Beliefs About Cancer Treatments Among Women Attending a Gynecologic Oncology Clinic. Sex Med 2017;5:e175–e183.

Sexual dysfunction in women with cancer: a systematic review with meta-analysis of studies using the Female Sexual Function Index

Cancer may impair sexual function in women. We provide an overview of studies that address Female Sexual Dysfunction (FSD) in women with cancer with a meta-analysis of observational studies that used a validated diagnostic tool. Searches included MEDLINE, Scopus, and Google Scholar for studies published from January 2000 to 31 December 2014. Every included study had to involve at least 30 cancer patients, to investigate FSD based on the Female Sexual Function Index (FSFI), and to have been published in peer-review journals. Duplicate independent data extraction and quality assessment were performed. Data were pooled using a random effects model if statistical heterogeneity was present. The main outcomes were FSFI total score and FSD prevalence. FSFI is a 19-item self-report instrument for assessing key dimensions of female sexual function. A value less than 26.55 is consistent with FSD. Thirty-five studies met the inclusion criteria. Among these, 27 reported FSFI scores, and 16 FSD prevalence. Most studies (56 %) had low to moderate quality. The mean value of FSFI was lower than 20 at all cancer sites: 16.25 (pooled random effect, 95 % CI 14.91-17.58, I ² = 14.5 %) for colorectal cancer, 18.11 (95 % CI 14.45-21.77, I ² = 97.8 %) for gynecological cancer, and 19.58 (95 % CI 17.64-21.53, I ² = 90.9 %) for breast cancer. FSD prevalence was higher than 60 % at all cancer sites, with the highest value for gynecological cancer (78.44 %, 95 % CI 68.36-88.52 %, I ² = 94.1 %). Women with cancer showed low FSFI scores with a high prevalence of FSD.

Desarrollo investigativo en salud sexual de mujeres con cáncer de mama: una revisión integrativa

<p>Objetivo: Caracterizar la producción científica relacionada con la salud sexual en mujeres con cáncer de mama.Metodología: Revisión integrativa. Se realizó una búsqueda en las bases de datos Scopus, Medline, LILACS y SciELO, así comobúsquedas secundarias en revistas científicas. Se encontraron 85artículos organizados y caracterizados por año, idioma y continente; edad promedio y tipos de tratamiento; metodología, perspectiva, enfoque, diseño, perspectiva disciplinar y tendenciatemática.Resultados: La temática reportó mayor producción de conocimiento en los últimos 10 años. La tendencia de investigación se orienta hacia tres categorías: Salud sexual y cáncer de mama; Salud sexual en la mujer y tratamientosdel cáncer de mama; y Salud sexual y relaciones de pareja.Conclusiones: La salud sexual en mujeres con cáncer de mamaes un aspecto importante en la calidad de vida, que continuamente se ve alterada como resultado de la enfermedad y los efectos adversos de los tratamientos. Esta condición no sólo aqueja a la persona enferma, sino también a su pareja, por lo que se requiere del desarrollo de líneas de acción que permitan dar una atención integral a las mujeres con esta enfermedad.</p>

Physical examination of the female cancer patient with sexual concerns: What oncologists and patients should expect from consultation with a specialist

Answer questions and earn CME/CNE Sexual concerns are prevalent in women with cancer or cancer history and are a factor in patient decision making about cancer treatment and risk-reduction options. Physical examination of the female cancer patient with sexual concerns, regardless of the type or site of her cancer, is an essential and early component of a comprehensive evaluation and effective treatment plan. Specialized practices are emerging that focus specifically on evaluation and treatment of women with cancer and sexual function problems. As part of a specialized evaluation, oncologists and their patients should expect a thorough physical examination to identify or rule out physical causes of sexual problems or dysfunction. This review provides oncology professionals with a description of the physical examination of the female cancer patient with sexual function concerns. This description aims to inform anticipatory guidance for the patient and to assist in interpreting specialists' findings and recommendations. In centers or regions where specialized care is not yet available, this review can also be used by oncology practices to educate and support health care providers interested in expanding their practices to treat women with cancer and sexual function concerns. CA Cancer J Clin 2016;66:241-263. © 2016 American Cancer Society.

Investigation of body image as a mediator of the effects of bowel and GI symptoms on psychological distress in female survivors of rectal and anal cancer

PURPOSE

Treatment for rectal and anal cancer (RACa) can result in persistent bowel and gastrointestinal (GI) dysfunction. Body image problems may develop over time and exacerbate symptom-related distress. RACa survivors are an understudied group, however, and factors contributing to post-treatment well-being are not well understood. This study examined whether poorer body image explained the relation between symptom severity and psychological distress.

METHODS

Participants (N = 70) completed the baseline assessment of a sexual health intervention study. Bootstrap methods tested body image as a mediator between bowel and GI symptom severity and two indicators of psychological distress (depressive and anxiety symptoms), controlling for relevant covariates. Measures included the European Organization for Research and Treatment of Cancer Core Quality of Life Questionnaire (EORTC-QLQ-CR38) Diarrhea, GI Symptoms, and Body Image subscales and Brief Symptom Index Depression and Anxiety subscales.

RESULTS

Women averaged 55 years old (SD = 11.6), White (79 %), and were 4 years post-treatment. Greater Depression was related to poorer Body Image (r = -.61) and worse Diarrhea (r = .35) and GI Symptoms (r = .48). Greater Anxiety was related to poorer Body Image (r = -.42) and worse GI Symptoms (r = .45), but not Diarrhea (r = .20). Body Image mediated the effects of bowel and GI symptoms on Depression, but not on Anxiety.

CONCLUSIONS

Long-term bowel and GI dysfunction are distressing and affect how women perceive and relate to their bodies, exacerbating survivorship difficulties. Interventions to improve adjustment post-treatment should address treatment side effects, but also target body image problems to alleviate depressive symptoms. Reducing anxiety may require other strategies. Body image may be a key modifiable factor to improve well-being in this understudied population. Longitudinal research is needed to confirm findings.

A manifesto on the preservation of sexual function in women and girls with cancer

Malignancies that affect females who survive cancer commonly originate in, invade, and/or metastasize to the sexual organs, including the ovaries, uterine corpus, uterine cervix, vagina, vulva, fallopian tubes, anus, rectum, breast(s), and brain. Females comprise most of the population (in number and proportion) with cancers that directly affect the sexual organs. Most females in the age groups most commonly affected by cancer are sexually active in the year before diagnosis, which includes most menopausal women who have a partner. Among female cancer survivors, the vast majority have cancers that are treated with local or systemic therapies that result in removal, compromise, or destruction of the sexual organs. Additionally, female cancer survivors often experience abrupt or premature onset of menopause, either directly with surgery, radiation, or other treatments or indirectly through disruption of female sex hormone or other neuroendocrine physiology. For many female patients, cancer treatment has short-term and long-lasting effects on other aspects of physical, psychological, and social functioning that can interfere with normal sexual function; these effects include pain, depression, and anxiety; fatigue and sleep disruption; changes in weight and body image; scars, loss of normal skin sensation, and other skin changes; changes in bodily odors; ostomies and loss of normal bowel and bladder function; lymphedema, and strained intimate partnerships and other changes in social roles. In spite of these facts, female patients who are treated for cancer receive insufficient counseling, support, or treatment to preserve or regain sexual function after cancer treatment.

Female Sexual Health Training for Oncology Providers: New Applications

Introduction

Sexual health care remains an unmet need for women with cancer. Many barriers are described, such as provider discomfort and lack of training; however, there is little evidence-based guidance regarding how to effectively address these obstacles.

Aim

This pilot study was performed to determine whether brief, targeted sexual health training for oncology providers results in improved provider comfort level and frequency of addressing female cancer-related sexual issues.

Methods

A brief (30–45 minute), targeted sexual health training program focused on improving comfort level, knowledge and communication skills when addressing breast cancer–related sexual issues was developed by the primary author. Using a pretest-posttest format, this educational program was provided to oncology providers (physicians and nurses/other allied health) from a suburban health-care system. Surveys based on 5-point Likert scales were provided before and 3–6 month post training.

Main Outcome Measures

Primary endpoints were changes in mean Likert scores for provider comfort level and self-reported frequency of addressing sexual issues. A secondary endpoint was change in mean Likert scores for perception of access to sexual health resources/referrals.

Results

Eligible respondents included 8 oncologists, 4 surgeons, and 62 nurses/other allied health. For total respondents, comparison of mean Likert scores for survey 1 (n = 71) and survey 2 (n = 36) demonstrated statistically significant increases for all parameters queried, including provider comfort level with bringing up (Pre mean Likert score = 3.4, Post = 4.3, P < 0.0001) and coordinating care (Pre = 3.5, Post = 4.6, P < 0.0001), and frequency of addressing sexual issues for both diagnosis/treatment and surveillance phase (Pre = 2.4, Post = 3.3, P ≤ 0.0052).

Conclusion

Brief, targeted sexual health training for oncology providers positively correlated with improved provider comfort level and frequency of addressing female cancer-related sexual issues.

Shyness and openness--common ground for dialogue between health personnel and women about sexual and intimate issues after gynecological cancer

In this article we explore shyness and openness related to sexuality and intimacy in long-term female survivors of gynecological cancer, and how these women experienced dialogue with health personnel on these issues. Further analysis on two core themes, based on empirical data presented elsewhere, inspired continued theoretical and philosophical thinking drawing on Løgstrup's expressions of life and unified opposites. The findings show that gynecological cancer survivors and health personnel share common ground as human beings because shyness and openness are basic human phenomena. Health personnel's own movement between these phenomena may represent a resource because it can help women to handle sexual and intimacy challenges following gynecological cancer.

Symptoms: Menopause, Infertility, and Sexual Health

By 2022, the number of survivors is expected to grow to nearly 18 million. Therefore, addressing acute and chronic negative sequelae of a cancer diagnosis and its treatments becomes a health imperative. For women with a history of breast cancer, one of the common goals of treatment and prevention of recurrence is to reduce circulating concentrations of estradiol, especially in women with hormone receptor positive breast cancer. Hormone deprivation after a diagnosis of breast cancer impacts physiological targets other than in the breast tissue and can result in unwanted side effects, all of which can negatively impact quality of life and function and cause distress. Symptoms that are most strongly linked by evidence to hormone changes after cancer diagnosis and treatment include hot flashes, night sweats, sleep changes, fatigue, mood changes, and diminishing sexual function, including vaginal atrophy (decreased arousal, dryness and dyspareunia), infertility, decreased desire and negative self-image. Weight gain and resulting body image changes are often concomitants of the abrupt onset of treatment-induced menopause. The purpose of this chapter is to briefly review what is known about the advent of premature menopause in women treated for breast cancer, menopausal symptoms that are exacerbated by endocrine treatments for breast cancer, and the associated concerns of hot flashes and related menopausal symptoms, sexual health and fertility issues. We will discuss limitations in the current research and propose strategies that address current limitations in order to move the science forward.

Qualitative accounts of patients' determinants of vaginal dilator use after pelvic radiotherapy

INTRODUCTION

Treatment with pelvic external beam radiotherapy with brachytherapy (EBRT/BT) for gynecological cancers may cause sexual dysfunction because of vaginal shortening and tightening. Regular vaginal dilator use is thought to reduce vaginal shortening and/or tightening, but compliance is poor.

AIMS

This study identified determinants of patients' adherence with dilator use after EBRT/BT.

METHODS

Semi-structured interviews were conducted with 30 women, aged 32-67 years, treated with EBRT/BT for gynecological cancers at two university medical centers in the past 36 months. Transcriptions were coded and analyzed with N-Vivo software.

MAIN OUTCOME MEASURES

Determinants of dilator use were clustered based on the Health Action Process Approach, which describes (i) motivation processes that lead to a behavioral intention and (ii) volition processes that lead to the initiation or maintenance of actual behavior.

RESULTS

Almost all women attempted to perform long-term regular vaginal dilator use. Intended dilator use was determined by the expectation that it would prevent the development of vaginal adhesions and stenosis. Planning dilator use and making it part of a routine, using it under the shower, using lubricants, a smaller dilator size, or vibrators helped women. Others reported a lack of time or privacy, forgetting, or feeling tired. Women self-regulated dilator use by rotating the dilator and timing dilator use. Influencing factors were negative emotions regarding dilator use or its hard plastic design, (being anxious for) pain or blood loss, and an association with EBRT/BT. Some women mentioned a lack of instrumental support, for example, lubricants. Others received reassurance through informational support or were supported socially.

CONCLUSION

Motivation and volition processes that determined dilator use were identified and used in the development of a sexual rehabilitation intervention. It is important to provide sufficient patient information and support, and enlarge patients' perceived self-efficacy.

Fertility issues in cancer survivorship

Breakthroughs in cancer diagnosis and treatment have led to dramatic improvements in survival and the need to focus on survivorship issues. Chemotherapy and radiotherapy can be gonadotoxic, resulting in impaired fertility. Techniques to help cancer survivors reproduce have been improving over the past decade. Discussion of the changes to a patient's reproductive health after cancer treatment is essential to providing comprehensive quality care. The purpose of this review is to aid in pre- and posttreatment counseling, focusing on fertility preservation and other strategies that may mitigate risks to the patient's reproductive, sexual, and overall health.

Diabetes and sexual dysfunction: current perspectives

Diabetes mellitus is one of the most common chronic diseases in nearly all countries. It has been associated with sexual dysfunction, both in males and in females. Diabetes is an established risk factor for sexual dysfunction in men, as a threefold increased risk of erectile dysfunction was documented in diabetic men, as compared with nondiabetic men. Among women, evidence regarding the association between diabetes and sexual dysfunction are less conclusive, although most studies have reported a higher prevalence of female sexual dysfunction in diabetic women as compared with nondiabetic women. Female sexual function appears to be more related to social and psychological components than to the physiological consequence of diabetes. Hyperglycemia, which is a main determinant of vascular and microvascular diabetic complications, may participate in the pathogenetic mechanisms of sexual dysfunction in diabetes. Moreover, diabetic people may present several clinical conditions, including hypertension, overweight and obesity, metabolic syndrome, cigarette smoking, and atherogenic dyslipidemia, which are themselves risk factors for sexual dysfunction, both in men and in women. The adoption of healthy lifestyles may reduce insulin resistance, endothelial dysfunction, and oxidative stress - all of which are desirable achievements in diabetic patients. Improved well-being may further contribute to reduce and prevent sexual dysfunction in both sexes.