Efficacy and Safety of Treatments to Improve Dyspareunia in Breast Cancer Survivors: A Systematic Review

From diagnosis to survivorship addressing the sexuality of women during cancer

For women diagnosed with cancer, side effects affecting their sexuality are extremely common and can be distressing and life-changing; however, most women are left in the dark without any guidance from their oncology teams regarding possible side effects and treatment options. American Society of Clinical Oncology clinical guidelines provide guidance on the recommended assessments related to the domains of sexual function and their respective interventions. Despite the existence of these guidelines, the reality is that only a few women with cancer are asked about sexual concerns that result from cancer treatments. Common barriers to sexuality discussion reported by oncology providers include a lack of qualification and knowledge, not having a place to refer patients, and not knowing how to start the conversation. Social media remains a widely untapped resource regarding sexuality and cancer interventions, as people are increasingly turning to social media for health information and advice. This may be especially relevant for sexuality, as oncologists may not feel comfortable or well-trained to discuss the topic, and patients may be reluctant to bring up sexual concerns during their visits. Social media can play a critical role in studying sexual health and in sexuality interventions, particularly in adolescent and young adult patients with cancer. Here, we discuss the lack of inclusion regarding sexuality in oncology, the rates of sexual dysfunction in patients with cancer, treatment options for common sexual concerns, how to utilize the reach of various social media channels, and provide patient and provider resources.

Clinical Practice Strategies to Address Sexual Health in Female Cancer Survivors

PURPOSE

The objectives of this narrative review are to describe (1) the evidence for interventions addressing four key issues affecting female sexual health in cancer populations (ie, low sexual desire, vulvovaginal symptoms, negative body image, and sexual partner relationships) that are ready or nearly ready for integration into practice and (2) the current state of patient-provider sexual health communication related to female sexual health as these findings could have implications for integrating sexual health into practice.

METHODS

A narrative review of recent intervention evidence for female cancer survivors' sexual health was conducted.

RESULTS

Strong evidence was found for behavioral interventions, such as psychosexual counseling and psychoeducation to treat concerns related to sexual health, including desire, body image, and sexual partner relationships. For partnered female survivors, couple-based psychosexual interventions have been found to be effective. There are no proven pharmacologic treatments for sexual-related concerns other than for vulvovaginal atrophy in female cancer survivors. Vaginal nonhormonal and low-dose hormonal agents are effective remedies for vulvovaginal symptoms. Laser treatment has not yet been fully evaluated. Sexual partners are a critical context for sexual health. Despite much need, discussions around this topic continue to be relatively infrequent. Recent technology-based interventions show promise in improving discussions around sexual health.

CONCLUSION

Effective interventions exist for many sexual health challenges for female survivors although more high-quality intervention research, particularly multimodal interventions, is needed. Many of the effective interventions are nonpharmacologic, and thus, evaluation of the use of digital delivery to improve access to these interventions is needed. Cancer care delivery research is urgently needed to translate existing effective interventions into practice, including strategies to improve patient-provider communication around this topic.

Unrecognized sexual dysfunction in gay and bisexual men after prostate cancer treatment: the antecedents and impact of anodyspareunia

BACKGROUND

Anodyspareunia may be an adverse outcome of prostate cancer (PCa) treatment for gay, bisexual, and other men who have sex with men (GBM).

AIM

The aims of this study were to (1) describe the clinical symptoms of painful receptive anal intercourse (RAI) in GBM following PCa treatment, (2) estimate the prevalence of anodyspareunia, and (3) identify clinical and psychosocial correlates.

METHODS

This was a secondary analysis of baseline and 24-month follow-up data from the Restore-2 randomized clinical trial of 401 GBM treated for PCa. The analytic sample included only those participants who attempted RAI during or since their PCa treatment (N = 195).

OUTCOMES

Anodyspareunia was operationalized as moderate to severe pain during RAI for ≥6 months that resulted in mild to severe distress. Additional quality-of-life outcomes included the Expanded Prostate Cancer Index Composite (bowel function and bother subscales), the Brief Symptom Inventory-18, and the Functional Assessment of Cancer Therapy-Prostate.

RESULTS

Overall 82 (42.1%) participants reported pain during RAI since completing PCa treatment. Of these, 45.1% experienced painful RAI sometimes or frequently, and 63.0% indicated that the pain was persistent. The pain at its worst was moderate to very severe for 79.0%. The experience of pain was at least mildly distressing for 63.5%. Painful RAI worsened for a third (33.4%) of participants after completing PCa treatment. Of the 82 GBM, 15.4% were classified as meeting criteria for anodyspareunia. Antecedents of anodyspareunia included a lifelong history of painful RAI and bowel dysfunction following PCa treatment. Those reporting symptoms of anodyspareunia were more likely to avoid RAI due to pain (adjusted odds ratio, 4.37), which was negatively associated with sexual satisfaction (mean difference, -2.77) and self-esteem (mean difference, -3.33). The model explained 37.2% of the variance in overall quality of life.

CLINICAL IMPLICATIONS

Culturally responsive PCa care should include the assessment of anodyspareunia among GBM and explore treatment options.

STRENGTHS AND LIMITATIONS

This is the largest study to date focused on anodyspareunia among GBM treated for PCa. Anodyspareunia was assessed with multiple items characterizing the intensity, duration, and distress related to painful RAI. The external validity of the findings is limited by the nonprobability sample. Furthermore, the cause-and-effect relationships between the reported associations cannot be established by the research design.

CONCLUSIONS

Anodyspareunia should be considered a sexual dysfunction in GBM and investigated as an adverse outcome of PCa treatment.

Sexual Perception in Spanish Female Breast Cancer Survivors. Cross-Sectional Survey

BACKGROUND

The aim was to assess sexual perception in female breast cancer survivors and establish if women presenting with sexual dysfunctions symptoms receive pelvic floor physiotherapy or request information on treatment.

METHODS

Cross-sectional survey carried out between January and March 2021. An online survey designed by the authors was structured in 3 dimensions: demographic and anthropometric data, medical data and sexual perception data. An open format survey with 23 questions available to any website visitor. The survey followed the CHERRIES guidelines. The study included 130 women who fulfilled the inclusion criteria.

RESULTS

The presence of pain during sexual activity was reported in 56.92% of cases. Specifically, 40.8% reported superficial dyspareunia, which is most commonly expressed by women as a "stinging pain." Surprisingly, only 4.6% of the women had received any type of pelvic floor physiotherapy treatment or had sought information.

CONCLUSIONS

Women breast cancer survivors have a negative perception of their sexuality. In addition, there is a lack of knowledge about the role of physiotherapy in sexual dysfunction, and only a small percentage of women received pelvic floor treatment or information to address their sexual dysfunction.

Sexual Dysfunction in Postmenopausal Women with Breast Cancer on Adjuvant Aromatase Inhibitor Therapy

Introduction

The aim of this study was to investigate whether postmenopausal women with breast cancer (BC) on adjuvant aromatase inhibitor (AI) therapy have a higher prevalence of female sexual dysfunction (FSD). Second, the aim was to determine the quality of life (QoL) and level of anxiety depending on whether or not they are AI users.

Methods

A prospective cross-sectional study involving 168 patients was performed. Three questionnaires were carried out: sexual functioning was evaluated with the Female Sexual Function Index (FSFI), while the EORTC QLQ-BR23 measures to study QoL in patients with BC and the State-Trait Anxiety Inventory (STAI) questionnaire (trait and status) were used to assess anxiety status in patients under treatment with AIs or not.

Results

47.6% (80/168) of the postmenopausal BC survivors were not sexually active (mean time after surgery: 48.6 months) despite a relatively low mean age (56.43 years). Postmenopausal AI-treated women had significantly worse sexual function as measured by the FSFI (23.40 ± 5.26 vs. 30.16 ± 2.24; p = 0.000). There were significant differences between both groups in all domains, except orgasm. The QoL score was 37.67 ± 7.38 in AI users versus 39.00 ± 1.44 among nonusers (p = 0.053). Patients under endocrine treatment also presented STAI scores significantly higher (25.83 ± 4.99 vs. 19.00 ± 7.12; p = 0.000). Trait anxiety was high in both groups, but this was not statistically significant.

Conclusions

We observed a high prevalence of sexual inactivity among BC survivors regardless of AI use. Patients with AI use presented significantly higher prevalence of FSD, worse QoL, and greater anxiety.