Addressing Patients’ Sexual Dysfunction Throughout Survivorship

A Conversation With Patricia A. Ganz, MD


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Patricia A. Ganz, MD

Sexual health is an important issue for many patients—even those with advanced disease—and we have to acknowledge their concerns and provide solutions.

—Patricia A. Ganz, MD

Studies show that all cancers and related treatments have the potential to affect sexuality and sexual function. Surgery, chemotherapy, hormonal therapy, bone marrow transplantation, and radiation therapy can physically impact sexual health in myriad ways, including vaginal dryness, dyspareunia, and chemically induced menopause in women; erectile dysfunction in men; and reduced libido in both sexes. The psychological distress of a cancer diagnosis and treatment, caused by changes in body image, depression, and anxiety, can further conspire to tamp down sexual desire and patients’ ability to achieve arousal and orgasm.

Despite study findings1-3 showing that sexual dysfunction is an important quality-of-life issue for many patients throughout all phases of survivorship, including end of life, the subject remains a neglected component in palliative care. Because oncologists rarely broach the subject with their patients and patients are often hesitant to raise the issue themselves, fearing embarrassment and the possibility of interfering with their cancer treatment, sexual dysfunction remains largely undiagnosed and untreated.

The ASCO Post talked with Patricia A. Ganz, MD, Director of the Division of Cancer Prevention and Control Research at UCLA’s Jonsson Comprehensive Cancer Center and Director of the UCLA-LIVESTRONG Survivorship Center of Excellence, about how a cancer diagnosis and treatment affect the sexual health of men and women, and how oncologists can start a dialogue about sexual dysfunction with their patients.

Incidence and Causes

How prevalent is sexual dysfunction after a cancer diagnosis and treatment?

There are no exact data available, but sexual dysfunction is very common in both men and women following a cancer diagnosis. For women, the literature suggests that having good emotional well-being and being in a good-quality partnered relationship are very important in maintaining sexual health and function after a cancer diagnosis. For both men and women, changes in body image that are caused by surgery, radiation, and chemotherapy, such as alopecia, scars, and deformities, can affect the sense of sexual attractiveness and reduce interest in sexual activity and intimacy.

More prominent culprits are side effects of cancer and its treatment such as fatigue, pain, and physical impairment, all of which can interfere with arousal and interest in resuming normal sexual activity in both women and men. Low testosterone levels, especially in men, can also hinder sexual interest. Damage to the pelvic area from treatment for any type of cancer in that region—including testicular, prostate, rectal, colon, and bladder cancers—such as radical prostatectomy, radiation therapy, and orchiectomy, as well as stem cell or bone marrow transplant, can lead to erectile dysfunction.

For women, surgery for breast cancer can cause loss of nipple sensation, and removal of the whole breast can cause prolonged pain, discouraging the desire for physical contact. Systemic therapy, radiation therapy, and surgical treatment for gynecologic cancers can cause vaginal dryness and a narrowing of the vagina, causing intercourse to be painful and provoking anxiety, making it difficult for women to want to resume sexual activities. Hormonal therapies, such as aromatase inhibitors, can also cause severe vaginal dryness and pain with intercourse.

Raising the Issue

Why is so little medical attention paid to a health issue affecting virtually every cancer survivor?

Oncologists have a sort of “don’t ask, don’t tell” policy when it comes to sexual health. I usually raise the issue during adjuvant therapy and will ask patients, “How is your sex life?” And if patients want to talk about any problems they may be having, the question gives them an entrée and permission to respond. Some patients may not feel comfortable talking about these issues with their oncologist, but asking the question lets them know that the oncologist is aware that sexual dysfunction is a potential problem during and after cancer treatment and that it is okay to talk about it.

My experience is that most patients respond positively to that question and will give you information about their sexual health concerns if there is an issue for them.

Addressing the Problem

How should sexual health be addressed in the palliative care setting?

Any physical and psychosocial symptom, including pain, fatigue, sexual dysfunction, anxiety, and depression, should be managed throughout the continuum of oncology care. The mental and physical health of the whole person should be evaluated from the get-go, whether the patient has curable or advanced disease.

I see sexual health as a survivorship issue and our experience suggests the sooner you address the problem the more likely it is to be resolved. We conducted an intervention study4 for breast cancer several years ago. In that study, we initiated a group intervention for sexual dysfunction in women with breast cancer who were at least a year away from completing treatment. Although we saw some benefit, we found that many women had settled into a new routine of sexual inactivity and they were not always sure they wanted to try to resume intimacy.

In my opinion, interventions such as vaginal lubricants and moisturizers for vaginal dryness and pelvic muscle exercises for vaginal pain in women, and erectile dysfunction medications and penile rehabilitation for men, have to be introduced during or immediately at the end of treatment, because once people get set in a pattern of limited intimacy or find that they can’t do what they used to do, it is difficult to change that pattern.

Discussions and remedies for sexual health need to be included in the post-treatment care plan of every cancer
survivor.

For a long time, palliative care was more focused on end-of-life care and symptom management. But now oncologists and palliative care specialists are starting to address patients’ quality-of-life concerns from the moment of diagnosis.

I would advise clinicians to ask their patients, “What are the most important issues you need help with right now?” And if the patient raises sexual dysfunction as a big concern, it clearly has to be addressed.

Sexual health is an important issue for many patients—even those with advanced disease—and we have to acknowledge their concerns and provide solutions. ■

Disclosure: Dr. Ganz reported no potential conflicts of interest.

References

1. Howlett C, Swain M, Fitzmaurice N, et al: Sexuality: The neglected component in palliative care. Int J Palliat Nurs 3:218, 1997.

2. Katz A: The sounds of silence: Sexuality information for cancer patients. J Clin Oncol 23:238-241, 2005.

3. Redelman MJ: Is there a place for sexuality in the holistic care of patients in the palliative care phase of life? Am J Hosp Palliat Care 25:366-371, 2008.

4. Rowland JH, Meyerowitz BE, Crespi CM, et al: Addressing intimacy and partner communication after breast cancer: A randomized controlled group intervention. Breast Cancer Res Treat 118:99-111, 2009.

 

Addressing the evolving needs of cancer survivors at various stages of their illness and care, Palliative Care in Oncology is guest edited by Jamie H. Von Roenn, MD. Dr. Von Roenn is ASCO’s Senior Director of Education, Science and Professional Development Department.


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