A national network to advance the field of cancer and female sexuality

Hematology and Oncology Fellow Education About Sexual and Reproductive Health: A Survey of Program Directors in the United States

PURPOSE

Clinical oncology guidelines recommend addressing sexual and reproductive health (SRH) concerns in routine cancer care. However, limited training often hinders clinicians' ability to do so effectively. The objective of this study was to understand the state of current fellowship education on SRH (ie, sexual health, safe sex practices, and fertility) through conducting a national survey of US hematology/oncology fellowship program directors (PDs).

METHODS

A survey was sent to all PDs of adult hematology/oncology fellowship programs in the United States via online link. PDs who did not complete the survey were sent up to four follow-up emails and a paper mailing. Descriptive statistics and McNemar tests were conducted.

RESULTS

One hundred-fourteen PDs responded (65%). Fewer programs offered formal instruction on sexual health (49%) and safe sex practices (37%) compared with fertility (75%). Informal training in SRH relied heavily on direct clinical experience (73%-78% of programs), with other methods (eg, case-based approaches, webinars, and journal clubs) being less common. Lack of experts to provide instruction was the most commonly cited barrier to offering training in SRH, endorsed by 74% for sexual health, 68% for safe sex practices, and 54% for fertility; difficulty finding space within the curriculum (50%; 54%; and 43%, respectively) and a lack of training requirements were also commonly endorsed (57%; 60%; and 35%, respectively). Barriers were endorsed more commonly for sexual health topics than fertility.

CONCLUSION

The results highlight the scarcity of training in SRH, particularly in sexual health, within hematology/oncology fellowship programs. The heavy reliance on informal instruction methods may lead to inconsistent and inadequate education. Efforts to integrate comprehensive training in SRH into fellowship programs are crucial to ensuring that such concerns are included in routine cancer care.

Investigating the impact of the COVID-19 pandemic on breast cancer clinicians’ communication about sexual health

Purpose

We assessed breast cancer clinicians’ perspectives on how the COVID-19 pandemic and increased use of telehealth affected their clinical communication about sexual heath.

Methods

Breast cancer clinicians participating in a sexual health communication intervention study (N = 29; 76% female; 66% oncologists; 34% advanced practice clinicians) completed an online survey. Data analysis consisted of descriptive statistics and thematic analysis.

Results

All clinicians were using telehealth, with most (66%) using it for up to half of their clinic appointments. Although only 14% of clinicians reported having shorter clinic visits, 28% reported having less time to discuss sexual health; 69% reported no change; and 3% said they had more time. Forty-one percent reported sexual health was less of a priority; 55% reported no change; and 3% said it was more of a priority. Thirty-five percent reported telehealth was less conducive to discussing sexual health; 59% reported no change; and 7% reported more conducive. Qualitative analysis revealed key issues underlying the perceived impact of the pandemic on discussions of sexual health including heightened clinician discomfort discussing such issues via telehealth, the less personal nature and privacy issues in telehealth visits, increased concerns about risk of COVID-19 infection and other health concerns (e.g., missing recurrence, mental health) taking priority, and clinician-perceived patient factors (e.g., discomfort, decreased priority) in discussing sexual concerns.

Conclusion

Pandemic-related changes in breast cancer clinicians’ practice could be exacerbating challenges to discussing sexual health. Methods for integrating sexual health into cancer care are needed, regardless of the mode of delivery.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00520-022-07003-8.

Finding sexual health aids after cancer: are cancer centers supporting survivors' needs?

PURPOSE

Sexual dysfunction is one of the most prevalent and distressing treatment-related side effects for both male and female cancer survivors. Survivorship care guidelines recommend therapeutic sexual aids to help improve sexual problems. However, little is known about the availability of sexual aids and resources at cancer centers.

METHODS

Twenty-five comprehensive cancer centers affiliated with both the National Cancer Institute and the National Comprehensive Care Network were surveyed using the "mystery shopper" method to determine whether various types of sexual aids were available at the centers. Staffs from cancer center staff retail stores and patient boutiques were queried in separate telephone calls regarding the availability of these aids for and women.

RESULTS

Of the 25 centers contacted, 23 (92%) responded about aids for men, and 22 (88%) responded about aids for women. Eighty-seven percent of the centers reported having no sexual aids available for men, and 72% of centers reported having no aids available for women. The most common advice given to mystery shoppers was a suggestion to use the internet. Only one center had numerous aids/resources for both men and women.

CONCLUSIONS

The large majority of cancer centers reported having no sexual aids or other sexual health resources available for men or women.

IMPLICATIONS FOR CANCER SURVIVORS

Results underscore the widespread lack of resources to promote sexual health rehabilitation at major cancer centers, both for male and female survivors.

Sexual functioning among early post-treatment breast cancer survivors

PURPOSE

This study aims (1) to estimate percentages of partnered women who are sexually active over the first 2 years post-breast cancer diagnosis; (2) to identify factors related to sexual inactivity; and (3) to evaluate separately, among both sexually active and inactive survivors, the relation between sexual problems and treatment-related variables, symptoms, and psychosocial factors.

METHODS

Longitudinal observational study of breast cancer survivors recruited within 8 months of cancer diagnosis and followed for 18 months. The main outcome measures were (1) being sexually active/inactive in the past month and (2) sexual problems assessed with the four-item sexual problem domain of the Quality of Life in Adult Cancer Survivors (QLACS) scale.

RESULTS

At baseline, 52.4% of women reported being sexually active in the past month. This percentage increased to 60.7% 18 months later. In multivariable repeated-measures analyses, age, past chemotherapy, depressive symptoms, and lower perceived attractiveness were related to inactivity. Sexually inactive women reported more problems on the QLACS than sexually active women. In stratified multivariable analyses, depressive symptoms were related to greater sexual problems for both sexually active and inactive women, as was vaginal dryness. Among the sexually active women, younger age at diagnosis, less illness intrusiveness, and lower perceived attractiveness were related to more problems.

CONCLUSIONS

Research has shown that sexual functioning/sexual health are key aspects of quality of life for many cancer survivors, and are often not addressed by health care providers. Future studies should examine how such topics are handled by clinicians in their interactions with survivors.

Abuse, cancer and sexual dysfunction in women: A potentially vicious cycle

More than 30% of women have a history of abuse. Women with cancer may be at substantially increased risk for abuse, but this issue is rarely discussed in the course of oncology care. Women with a history of abuse who present for cancer care commonly have a high prevalence of co-morbid illness. Sexual dysfunction, a highly prevalent but under-recognized condition among women of all ages, is also more common among both women with a history of abuse and women with cancer. Although common after cancer, sexual dysfunction, like abuse, can be stigmatizing and often goes undiagnosed and untreated. This review first examines the literature for evidence of a relationship between any history of abuse and cancer among women, addressing two questions: 1) How does abuse promote or create risk for developing cancer? 2) How does cancer increase a woman's susceptibility to abuse? We then examine evidence for a relationship between abuse and female sexual dysfunction, followed by an investigation of the complex relationship between all three factors: abuse, sexual dysfunction and cancer. The literature is limited by a lack of harmonization of measures across studies, retrospective designs, and small and idiosyncratic samples. Despite these limitations, it is imperative that providers integrate the knowledge of this complex relationship into the care of women with cancer.

Talking about women's sexual health after cancer: Why is it so hard to move the needle?

Despite increasing calls to integrate sexual health into routine cancer care, the majority of women diagnosed with cancer do not receive information about how their cancer treatments will affect their sexual health. With the significant challenges that exist to clinical discussion of sexual health, efforts on multiple fronts are needed to close the gap in the care of women diagnosed with cancer.

How to ask and what to do: a guide for clinical inquiry and intervention regarding female sexual health after cancer

PURPOSE OF REVIEW

As the number of female cancer survivors continues to grow, there is a growing need to bridge the gap between the high rate of women's cancer-related sexual dysfunction and the lack of attention and intervention available to the majority of survivors who suffer from sexual problems. Previously identified barriers that hinder communication for providers include limited time, lack of preparation, and a lack of patient resources and access to appropriate referral sources.

RECENT FINDINGS

This study brings together a recently developed model for approaching clinical inquiry about sexual health with a brief problem checklist that has been adapted for use for female cancer survivors, as well as practical evidence-based strategies on how to address concerns identified on the checklist. Examples of patient education sheets are provided as well as strategies for building a referral network.

SUMMARY

By providing access to a concise and efficient tool for clinical inquiry, as well as targeted material resources and practical health-promoting strategies based on recent evidence-based findings, we hope to begin eliminating the barriers that hamper oncology providers from addressing the topic of sexual/vaginal health after cancer.

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.

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.

Beyond barriers: fundamental 'disconnects' underlying the treatment of breast cancer patients' sexual health

Sexual health concerns represent one of the most frequently experienced and longest-lasting effects of breast cancer treatment, but research suggests that service providers rarely discuss sexual health with their patients. Existing research examining barriers to addressing patients' sexual health concerns has focused on discrete characteristics of the provider-patient interaction without considering the broader context in which these interactions occur. Drawing on the experiences of 21 breast cancer survivors, this paper explores three ways in which fundamental cultural and structural characteristics of the cancer care system in the USA may prevent breast cancer survivors from addressing their sexual health concerns, including: (1) when patients discussed sexual health with their providers, their providers approached sexuality as primarily physical, while participants experienced complex, multidimensional sexual health concerns; (2) specialisation within cancer care services made it difficult for patients to identify the appropriate provider to address their concerns; and (3) the structure of cancer care literally disconnects patients from the healthcare system at the time when sexual side effects commonly emerged. These data suggest that addressing breast cancer survivors' sexual health concerns requires a multifaceted approach to health systems change.

Vaginal Dryness and Beyond: The Sexual Health Needs of Women Diagnosed With Metastatic Breast Cancer

While research on the sexual health of women with early stage cancer has grown extensively over the past decade, markedly less information is available to support the sexual health needs of women diagnosed with advanced breast cancer. Semistructured interviews were conducted with 32 women diagnosed with metastatic breast cancer (ages 35 to 77) about questions they had concerning their sexual health and intimate relationships. All participants were recruited from a comprehensive cancer center at a large Midwestern university. Three themes were examined: the role of sexual activity and intimate touch in participants' lives, unmet information needs about sexual health, and communication with medical providers about sexual concerns. Findings indicated that sexual activities with partners were important; however, participants worried about their own physical limitations and reported frequent physical (e.g., bone pains) and vaginal pain associated with intercourse. When women raised concerns about these issues in clinical settings, medical providers often focused exclusively on vaginal lubricants, which did not address the entirety of women's problems or concerns. In addition, women diagnosed with metastatic breast cancer reported needing additional resources about specialized vaginal lubricants, nonpenetrative and nongenitally focused sex, and sexual positions that did not compromise their physical health yet still provided pleasure.

Efficacy trial of an Internet-based intervention for cancer-related female sexual dysfunction

The recent NCCN Guidelines for Survivorship recommend systematic evaluation and multidisciplinary treatment of cancer-related sexual dysfunctions. However, most oncology professionals fail to routinely assess sexual problems and lack expertise to treat them. An Internet-based intervention was designed to educate female patients and their partners about cancer-related sexual problems, describe medical treatment options and how to find expert care, and provide self-help strategies. A randomized trial assessed efficacy of the intervention when used as self-help versus the same Web access and 3 supplemental counseling sessions. Survivors of localized breast or gynecologic cancers completed online questionnaires at baseline, posttreatment, and 3- and 6-month follow-up, including the Female Sexual Function Index (FSFI), the Menopausal Sexual Interest Questionnaire (MSIQ), the Brief Symptom Inventory-18 (BSI-18) to assess emotional distress, and the Quality of Life in Adult Cancer Survivors (QLACS) scale. Program evaluation ratings were completed posttreatment. Fifty-eight women completed baseline questionnaires (mean age, 53 ± 9 years). Drop-out rates were 22% during treatment and 34% at 6-month follow-up. Linear mixed models for each outcome across time showed improvement in total scores on the FSFI, MSIQ, and QLACS (P<.001) and BSI-18 (P=.001). The counseled group improved significantly more on sexuality measures, but changes in emotional distress and quality of life did not differ between groups. Program content and ease of use were rated positively. Research is needed on how best to integrate this intervention into routine clinical practice, and particularly how to improve uptake and adherence.