Sexuality After Cancer as an Unmet Need: Addressing Disparities, Achieving Equality

Caring for sexual and gender minority patients with genitourinary cancer: A primer for inclusive practices

Recognizing sexual orientation and gender identity (SOGI) is paramount in the management of genitourinary cancers, as sexual and gender minority (SGM) individuals encounter unique healthcare challenges leading to disparities. SGM patients often confront systemic barriers, provider biases, and scarcity of tailored resources, resulting in diminished satisfaction and adverse health outcomes. The evaluation and treatment of genitourinary cancers in SGM patients demand a nuanced, multidisciplinary approach that focuses on the unique health determinants often overlooked by the healthcare system. This review highlights recommendations for the inclusivity of SGM patients within the clinic, from inclusive signage to gender inclusive language. For the evaluation and treatment of SGM patients with genitourinary cancers, it is recommended to employ organ-based language, to utilize validated questionnaires encompassing mental health, sexual behavior, and patient-reported outcomes, and to provide timely referrals to social work and onco-fertility when appropriate. Ultimately, approaching inclusivity through education targeted at both SGM patients and healthcare providers is pivotal for centering care around the patient, improving the quality of life and outcomes for SGM patients facing genitourinary cancers.

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.

Sexual dysfunction after surgery for primary sporadic cranial meningiomas: prevalence and risk factors

BACKGROUND

Although postoperative quality of life (QoL) has been studied in relation to a variety of aspects following meningioma resection, the impact of meningiomas on sexual life has not been investigated. The aim of this study is to determine the impact of cranial meningioma surgery on patients' postoperative sexual life.

METHODS

A standardized questionnaire, anonymous and based on the Arizona Sexual Experiences Scale (ASEX), was sent to 87 patients who had been selected for participation in the study based on the following criteria: a postoperative Karnofsky performance of ≥ 80 and below 60 years of age at diagnosis.

RESULTS

53 patients (53/87; 61%) responded to the survey. The study identified eleven patients (20.8%) who reported sexual dysfunction (SD) according to ASEX criteria. Six of these patients were women (55%) and five were men (45%). Univariable analysis revealed that SD was observed with greater frequency in patients with non-skull base tumors (p = 0.006) and in those with a left-hemispheric meningioma (p = 0.046). Multivariable analysis revealed that non-skull base tumor location is the only independent factor being associated with SD (OR = 5.71, 95% CI = 1.02-31.81, p = 0.047).

CONCLUSION

This first investigation of sexual functioning post-surgery for cranial meningiomas indicates that SD is a prevalent issue among non-skull base meningioma patients. Consequently, we recommend that pre- and postoperative sexual health should be further addressed in future QoL investigations of cranial meningioma patients.

Impact of a Cancer Survivorship Continuing Medical Education Course on Learners' Attitudes and Intention to Change Practice

An innovative, case-based continuing medical education course, Health After Cancer: Cancer Survivorship for Primary Care, was developed to engage clinicians in cancer survivorship care. A post-course survey measured the educational impact of the course on learners' intentions to change practice and changes in attitudes related to interprofessional collaborative practice. Qualitative analysis of free text responses was performed using the immersion-crystallization method. Learners earning continuing education credit (N = 1202) completed the post-course evaluation survey: 17.4% physicians, 8.0% advanced practice providers, 56.7% nurses, 2.2% pharmacists, 15.7% other health professionals. Learners' intended practice changes included improving communication (N = 438), incorporating knowledge into practice (N = 282), prioritizing survivorship clinical care (N = 167), and increasing oncology-primary care collaboration for patients (N = 53). Responses frequently involved more than one theme. Specific actions or knowledge that learners intended to incorporate into practice included improving their assessment of cancer survivor's risk and concerns (N = 128), incorporating knowledge of late effects of cancer treatment into practice (N = 122), educating patients about survivorship topics (N = 117), increasing empathy and understanding of survivors' experiences (N = 94), improving listening skills (N = 70), and dedicating more time to survivorship care (N = 63). Learners' changes in attitudes reflected an increased appreciation for collaboration, especially between oncology and primary care clinicians. A continuing medical education course designed to drive interest in engaging with cancer survivorship topics was effective at shaping learners' attitudes and intent to change practice, and has the potential to improve communication, care coordination, and healthcare experiences of cancer survivors.

"Just for pregnant women, not for you": a qualitative evaluation of the sexual and reproductive healthcare experiences of transgender and gender diverse cancer survivors

PURPOSE

To identify opportunities to improve sexual and reproductive health (SRH) care for transgender and gender diverse (TGD) cancer survivors by describing (1) challenges experienced when navigating SRH care and (2) strategies to help overcome these challenges.

METHODS

We enrolled a purposive sample of 17 adult TGD cancer survivors and 5 co-survivors. We aimed for a diverse sample across cancer experience, age, racial/ethnic background, sexual orientation, and gender identity. We conducted 90-min individual interviews via videoconference and used reflexive thematic analysis, guided by a focus on three social determinants of health.

RESULTS

Themes describing challenges were as follows: (1) Cancer treatment's impact on sexual health was insufficiently addressed by cancer care providers; (2) fertility-related information and conversations were complicated by gendered expectations and ultimately did not meet survivors' needs; (3) feeling excluded and uncared-for in healthcare settings due to gendered language and lack of supportive services that met their needs; and (4) TGD survivors commonly reported high financial burden, negatively impacting their access to care. Strategies to overcome these challenges were (1) a solid social support network that can be integrated into the care team to meet the unique SRH needs of TGD survivors and (2) gender-affirming healthcare providers and environments to address SRH care needs and concerns.

CONCLUSIONS

TGD survivors and co-survivors desire improved access to gender-affirming SRH care in cancer survivorship.

IMPLICATIONS FOR CANCER SURVIVORS

Key opportunities to improve gender-affirming SRH care in cancer survivorship include fostering and engaging TGD survivors' support networks and implementing system-level changes in cancer care settings.

Fear of cancer progression and the quality of sexual life of female cancer patients in Romania

Introduction

As cancer survival rates increase, it has become crucial to pay attention to the long-term quality of life of survivors, including sexual functioning. The quality of sexual life and fear of cancer progression are often unmet needs, significantly impacting cancer patients' overall quality of life. In this study, we investigate these factors in Romanian female cancer patients and highlight their relationship with mental health and demographic variables.

Methods

This study included 242 Romanian female cancer patients who completed questionnaires assessing sexual functioning (EORTC QLQ-SHQ22), fear of cancer progression (FoP-Q), depression (PHQ-9), and anxiety (GAD-7). We examined these relationships using descriptive, exploratory, and regression analyses.

Results

Around 50% of patients reported impairments in sexual satisfaction and pain during sex. Lower sexual satisfaction increased sexual dysfunction, and heightened fear of cancer progression (FCP) were associated with depression, anxiety, younger age, lower education, rural residence, and unmarried status.

Discussion

This study reveals a complex interplay between sexual health, fear of cancer progression, and psychological well-being among female cancer survivors in Romania. Addressing sexual concerns, providing psychoeducation, promoting coping with the fear of progression, and utilizing interdisciplinary interventions are essential to improving these patients' overall quality of life. These findings underscore the need for integrated care approaches that consider both physical and psychological dimensions of cancer survivorship.

Beyond Survival: A Scoping Review on the Sexual Health of Sexual and Gender Minority Women Following Curative Cancer Treatment

INTRODUCTION

To explore the existing research on sexual health experiences of sexual and gender minority women (SGMW) post-curative cancer treatment.

METHODOLOGY

This scoping review was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews. Four articles that focused on sexual health experiences of SGMW post-curative cancer treatment were included.

RESULTS

Four themes were identified: (a) sexual function; (b) sexual orientation and gender identity, including disclosure and health care provider reactions; (c) relationship dynamics, such as relationship status and the quality of romantic relationships; and (d) body image.

DISCUSSIONS

The findings underscore substantial challenges faced by SGMW cancer survivors in achieving optimal sexual well-being, impacting their access to post-treatment care. This study advocates for more expansive research efforts involving diverse participant cohorts, extending beyond breast cancer, to gain deeper insights into these critical issues.

Investigating sexual health after breast cancer by longitudinal assessment of patient-reported outcomes

BACKGROUND

Sexual concerns are a major unaddressed need among survivors of breast cancer (BC) with significant negative effects on quality of life. We longitudinally analyzed sexual health over time, using patient-reported outcomes.

METHODS

Patients with stage I-III BC prospectively included from the CANcer TOxicity cohort (CANTO) provided data at diagnosis, then 1, 2, and 4 years afterward. Sexual concerns outcomes included poor body image (score ≤91/100), poor sexual functioning (≤16/100), poor sexual enjoyment (≤66/100), and sexual inactivity (EORTC QLQ-B23). Multivariate generalized estimating equation models assessed associations with sexual concerns after diagnosis, adjusting for age, sociodemographic, tumor, treatment, and clinical characteristics.

RESULTS

Nearly 78.1% among 7895 patients reported at least one sexual concern between diagnosis and 4 years' follow-up. Over time, the proportion of patients reporting sexual concerns either increased or remained constant with diagnosis. Less than half (46%, range 11.4-57) of the patients with sexual concerns reported the use of supportive care strategies, including gynecological or psychological consultations (range 11.4-57.4). Factors consistently associated with sexual concerns up to 4 years after diagnosis included already reporting the same concern at diagnosis [odds ratio (OR)poor body image 3.48 [95% confidence interval (CI) 3.11-3.89]; ORsexual inactivity 9.94 (95% CI 8.84-11.18), ORpoor sexual function 9.75 (95% CI 8.67-10.95), ORpoorsexual enjoyment 3.96 (95% CI 3.34-4.69)], endocrine therapy use [ORpoor body image 1.15 (95% CI 1.01-1.31); ORsexual inactivity 1.19 (95% CI 1.02-1.39), ORpoor sexual function 1.17 (95% CI 1.01-1.37), ORpoor sexual enjoyment 1.23 (95% CI 1.00-1.53)], and depression [ORpoor body image 2.00 (95% CI 1.72-2.34); ORsexual inactivity 1.66 (95% CI 1.40-1.97), ORpoor sexual function 1.69 (95% CI 1.43-2.00), ORpoor sexual enjoyment 1.94 (95% CI 1.50-2.51)]. Outcome-specific associations were also identified.

CONCLUSIONS

Sexual concerns seem frequent, persistent, and insufficiently addressed. Pretreatment concerns, endocrine therapy, and emotional distress are commonly associated factors. A proactive evaluation of sexual health across the care continuum is needed, to promptly identify patients suitable for multidisciplinary counseling, referral, and supportive interventions.

Optimizing sexuality of young women with breast cancer: how can the breast clinic help?

BACKGROUND

Breast cancer treatment can lead to sexual dysfunction which, in general, impacts younger women more. Being well informed and having good social support are important elements in dealing with this dysfunction.

AIMS

This study aims to explore how specialized breast clinics can help young women with questions or problems regarding their sexual health by fulfilling their information and social support needs.

METHOD

A thematic analysis was used for 16 interviews with young women (18-45 years) diagnosed with breast cancer, in Belgium.

RESULTS

Participants report a lack of information on sexual issues and find the information insufficiently tailored to young women. The empathy of healthcare providers and their communication skills play an important role in whether sexual issues can be discussed. Finally, they indicate that more attention should be paid to their partner (relationship).

CONCLUSION

The breast clinic might help young women by giving more specific advice on what is sexually allowed (or not) during treatment, by informing them about lubricants and sex toys, by adapting brochures and information sessions to young women, by investing in the partner's well-being and their relationship, and by training healthcare providers better.

Point-of-care assessment of sexual concerns among young adult oncology active patients and survivors

PURPOSE

Adolescent and young adult (AYA) oncology populations have unique sexual health concerns that deserve more attention. Our study aimed to describe sexual health and related concerns in young adults (YAs) to move toward integrating sexual health into routine care.

METHODS

A total of 127 YAs (ages 19-39) in active treatment and survivorship from three outpatient oncology clinics provided demographic and clinical information. They completed versions of the NCCN Distress Thermometer and Problem List (AYA-POST; AYA-SPOST) developed specifically for AYAs as part of an ongoing needs assessment study.

RESULTS

Over one quarter (27.6%) of the total sample (Mage = 31.96, SD = 5.33) - 31.9% in active treatment (n = 72) and 21.8% in survivorship (n = 55) - reported at least one sexual health concern (i.e., sexual concern, loss of libido (desire for sex), pain with sex, and unprotected sex). Those undergoing active treatment with sexual concerns had significantly higher distress than those without sexual concerns, whereas this pattern was nonsignificant for those in survivorship. Both genders often endorsed general sexual concerns and loss of libido.

CONCLUSION

The current study adds to the important and burgeoning literature on sexual health concerns of YAs oncology populations. The prevalence of sexual concerns, differences between treatment status and between those with and without sexual concerns highlight the utility and need to embed screening that includes sexual health items at point of care. This can facilitate discussion of these sensitive and multifaceted needs throughout the cancer continuum.

Point of Care Assessment of Sexual Concerns among AYA Oncology Active Patients and Survivors

Purpose Adolescent and young adults (AYAs) oncology populations have unique sexual health concerns that deserve more attention. The current study aimed to describe the prevalence and characteristics of sexual health and related concerns in AYAs in active treatment and survivorship to move toward integrating sexual health in routine care. Methods A total of 127 AYAs (ages 19-39) in active treatment and survivorship were recruited from three outpatient oncology clinics. In addition to providing demographic and clinical information, they completed an adapted version of the NCCN Distress Thermometer and Problem List (AYA-POST; AYA-SPOST) as part of an ongoing needs assessment study. Results Over one quarter (27.6%) of the total sample ( M age = 31.96, SD  = 5.33) - 31.9% of active treatment, and 21.8% in survivorship - reported at least one sexual health concern (i.e., sexual concern, loss of libido, pain with sex, and unprotected sex). The most frequently endorsed concerns differed between active treatments and survivorship. Both genders often endorsed general sexual concerns and loss of libido. Conclusion The literature on sexual concerns in the AYA population is sparse and inconclusive, especially accounting for gender and other types of concerns. The current study highlights the need for further examination between treatment status, psychosexual concerns, emotional distress, and demographic and clinical factors. Given the prevalence of sexual concerns in AYAs in active treatment and survivorship, providers should consider integrating assessment and discussion of these needs at onset of diagnosis and as part of monitoring.

The Anatomy of a Hybrid In-Person and Virtual Sexual Health Clinic in Oncology

Sexual health is compromised by the diagnosis and treatment of virtually all cancer types. Despite the prevalence and negative impact of sexual dysfunction, sexual health clinics are the exception in cancer centers. Consequently, there is a need for effective, efficient, and inclusive sexual health programming in oncology. This paper describes the development of the innovative Sexual Health Clinic (SHC) utilizing a hybrid model of integrated in-person and virtual care. The SHC evolved from a fusion of the in-person and virtual prostate cancer clinics at Princess Margaret. This hybrid care model was adapted to include six additional cancer sites (cervical, ovarian, testicular, bladder, kidney, and head and neck). The SHC is theoretically founded in a biopsychosocial framework and emphasizes interdisciplinary intervention teams, participation by the partner, and a medical, psychological, and interpersonal approach. Virtual visits are tailored to patients based on biological sex, cancer type, and treatment type. Highly trained sexual health counselors facilitate the virtual clinic and provide an additional layer of personalization and a "human touch". The in-person visits complement virtual care by providing comprehensive sexual health assessment and sexual medicine prescription. The SHC is an innovative care model which has the potential to close the gap in sexual healthcare. The SHC is designed as a transferable, stand-alone clinic which can be shared with cancer centers.