Although medical experts put the proportion of female survivors facing some form of sexual dysfunction following a cancer diagnosis and treatment at nearly 100%, very few women raise sexual health concerns with their oncologist. In a study of 261 patients with gynecologic or breast cancer published last year in the journal Cancer,1 about 42% of respondents said they were interested in receiving medical care for sexual problems they were experiencing following their treatment, but only 7% asked for help. The study results showcase the extent of the unmet need for attention to the sexual health concerns of cancer survivors.
Barriers to Discussion
Patients are not the only ones who are reluctant to broach the subject of sexual health. According to the study findings, 62% of vaginal and cervical cancer survivors reported that no doctor ever asked them about the sexual effects of their cancer or treatment.
There are many reasons why both patients and doctors are hesitant to discuss sexual health. “Patients don’t want to embarrass their doctor or make anyone uncomfortable. They also understand that time is limited and that the primary job of their physician is to focus on saving lives. Although patients desperately want help, it is not clear where they can turn,” said Sharon L. Bober, PhD, Assistant Professor, Department of Psychiatry at Harvard Medical School, and Director of the Sexual Health Program, Department of Psychosocial Oncology and Palliative Care at Dana-Farber Cancer Institute.
“Despite the fact that we live in such a highly sexualized culture, genuine conversation about sexual function is still quite taboo, even—or especially—in the physician consulting room,” Dr. Bober continued. “We also know from physician surveys we’ve conducted that most doctors feel they do not have the adequate preparation to address this issue with their patients.”
Physicians may also be too embarrassed to initiate the conversation. “Oncologists may not be comfortable talking about sex. We are taught to treat and cure cancer, and the feeling may be that some of these problems are the inevitable side effects of treatment and part of the price patients pay for surviving their disease,” said Lidia Schapira, MD, Staff Oncologist, Gillette Center for Breast Oncology at Massachusetts General Hospital; Assistant Professor of Medicine at Harvard Medical School; and Associate Editor of ASCO’s patient information website, Cancer.net. Also, physicians may feel that there are no sexual medical experts—or they may not know any—to refer patients to for treatment, said Dr. Schapira.
Components of Sexual Dysfunction
Surgery, chemotherapy, hormonal therapy, and radiation therapy all contribute to sexual dysfunction in women. Problems may include both physical factors such as fatigue, the onset of chemically induced menopause—which can be more severe and less predictable than naturally occurring menopause—vaginal dryness, and dyspareunia, and psychological factors, including fear, changes in body image, depression, anxiety, reduced libido, and the inability to achieve arousal and orgasm. And while breast and gynecologic cancers tend to get the most attention for causing long-term sexual problems, all cancers have the potential to shutdown sexual health.
“We assume that [only] cancers involving breasts, ovaries, and the prostate have a major negative impact [on sexual function], but a wide range of treatments for other cancers, such as bone marrow transplant for blood cancers, also often result in profound changes,” said Dr. Bober. “Vaginal graft-vs-host disease, which can cause vaginal discomfort and painful intercourse, is very common in these patients, and often doctors don’t relate the sexual side effects to the transplant and graft-vs-host disease.”
Radiation therapy for colorectal and bladder cancers can also affect sexual health because it can cause fibrosis of the vaginal tissue, making sexual activity painful. Not only are problems with sexual functioning ubiquitous following cancer therapy, but they are also less likely to get resolved quickly, crippling the long-term quality of life for many cancer survivors, said Dr. Bober.
Sexual Health Is Part of Quality of Life
With nearly 14 million cancer survivors today, according to the latest figures from the American Cancer Society, and projections of more than 18 million by 2022, the need to include sexual health as part of the overall survivorship quality-of-life clinical assessment is crucial, said Dr. Schapira.
“Questions about sexual function should become part of the routine questions we ask patients about their health, in the same way we ask about problems with shortness of breath, tolerance to medication, or ability to eat,” she commented. “Just asking if a patient has any concerns about her sexual activity or whether she is sexually active can be a conversation starter. Even if the oncologist can’t fix the problem, showing a willingness to listen and making a referral to a sexual health specialist [or a gynecologist who specializes in menopause issues] would help us make progress.”
Having patient education material on the effects of cancer on female sexual health on hand to give patients or to have on display in office waiting rooms can help jump-start the conversation. They can also provide survivors with information on potential solutions, which can range from simple remedies such as vaginal moisturizers and lubricants to combat vaginal dryness to learning pelvic muscle awareness techniques to reduce vaginal pain during sexual activity (see sidebar on resources).
“It is not reasonable to expect that oncologists are going to become sexual medicine experts,” said Dr. Bober. “However, it’s not only reasonable, but actually imperative for doctors to identify useful resources available either in their hospital or in the community. Many of the sexual problems that women struggle with, whether it is dyspareunia, menopausal symptoms, or low libido, can be made much better if not managed completely with some intervention. Now that so many patients live long after diagnosis and treatment, it is crucial that we start attending to this problem.” ■
Disclosure: Drs. Bober and Schapira reported no potential conflicts of interest.
1. Hill EK, Sandbo S, Abramsohn E, et al: Assessing gynecologic and breast cancer survivors’ sexual health care needs. Cancer 117:2643-2651, 2011.
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