Jeanne Carter, PhD
Julia H. Rowland, PhD
AS REPORTED in the Journal of Clinical Oncology by Jeanne Carter, PhD, of Memorial Sloan Kettering Cancer Center, and colleagues, ASCO has issued a clinical practice guideline adaptation of the Cancer Care Ontario (CCO) guideline on interventions to address sexual problems in people with cancer.1 ASCO staff reviewed the CCO 2016 guideline and updated the relevant literature search. An ASCO expert panel reviewed guideline content and recommendations. The panel was co-chaired by Dr. Carter and Julia H. Rowland, PhD, of the National Cancer Institute.
Key recommendations are summarized below, with the ASCO panel’s modifications to CCO recommendations incorporated into the text. The full text of the guideline adaptation includes ASCO and CCO qualifying statements, excluded here for space considerations.
For All People With Cancer
RECOMMENDATION: It is recommended that there be a discussion with the patient, initiated by a member of the health-care team, regarding sexual health and dysfunction resulting from the cancer or its treatment. The conversation could include the patient’s partner, only if the patient so wishes.
This issue should be raised with the individual at the time of diagnosis and continue to be reassessed periodically throughout follow-up. The expert panel believes this is a vital recommendation, as the recommendations that follow cannot be used unless someone has taken the initiative to ask. It is recommended there be access to resources or referral information for the patient (and partner).
For Women With Cancer
SEXUAL RESPONSE: The expert panel believes psychosocial and/ or psychosexual counseling should be offered to women with cancer, aiming to improve elements of sexual response such as desire, arousal, or orgasm. Current evidence does not support one type of psychosocial or psychosexual counseling to be superior to another. Clinicians may offer flibanserin (Addyi) to premenopausal women who are experiencing hypoactive sexual desire disorder.
Body Image: It is recommended that psychosocial counseling be offered to women with cancer and body image issues. If a woman is partnered, evidence indicates couples-based interventions are effective when compared with usual care. No recommendation can be made for or against group therapy (with or without exercise) for women with body image issues.
Intimacy/Relationships: It is recommended that psychosocial counseling be offered to women with cancer aiming to improve intimacy and relationship issues. If a woman is partnered, evidence indicates that couples-based interventions are effective when compared with usual care.
“It is recommended that there be a discussion with the patient, initiated by a member of the health-care team, regarding sexual health and dysfunction resulting from the cancer or its treatment.”— Jeanne Carter, PhD, and colleagues
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Overall Sexual Functioning and Satisfaction: The expert panel recommends psychosocial counseling directed at the individual or couple or delivered in a group be offered to women with cancer who have problems with overall sexual functioning. Physical exercise or pelvic floor physiotherapy, in addition to psychosocial counseling, may also be of benefit. Current evidence does not support a specific psychosocial counseling intervention to improve sexual functioning and satisfaction.
Health-care providers should screen patients with cancer for overall sexual functioning and satisfaction, and a diagnosis should be established when there are physical issues playing a contributing role. All patients should be offered education and symptom management based on the patient’s diagnosis. For patients with persistent concerns, such as physical issues, a gynecologic examination would be ideal. For those continuing to have relationship issues and/or distress, mental health counseling should be an option.
Vasomotor Symptoms: For women with vasomotor symptoms, hormone therapy is the most effective intervention. For women unwilling or unable to use hormonal therapy, alternatives exist— for example, paroxetine, venlafaxine, gabapentin, or clonidine. Having a hormone-sensitive breast cancer is a contraindication to using systemic hormone therapy.
Psychosocial counseling (cognitive behavioral therapy) and/ or clinical hypnosis may provide a benefit and reduce vasomotor symptoms and should be offered.
When not contraindicated, estrogen therapy alone (oral, transdermal, or vaginal) is recommended for women who have had a hysterectomy, as it has a more beneficial risk/benefit profile.
Paroxetine and fluoxetine should not be offered to women with breast cancer taking tamoxifen. Adverse events of clonidine include hypotension, light-headedness, headache, dry mouth, dizziness, sedation, and constipation. Sudden cessation of treatment can lead to significant elevations in blood pressure.
Genital Symptoms: The expert panel believes that for women with symptoms of vaginal and/or vulvar atrophy, such as dryness, the following stepwise approach should be followed:
Lubricants for all sexual activity or touch, in addition to vaginal moisturizers to improve vulvovaginal tissue quality, may be tried first. It should be noted that moisturizers may need to be applied at a higher frequency (3–5 times per week) in the vagina, at the vaginal opening, and on the external folds of the vulva for symptom relief in female patients with cancer and survivors. For those who do not respond or whose symptoms are more severe at presentation, low-dose vaginal estrogen can be used.
For women with hormone receptor–positive breast cancer who are symptomatic and not responding to conservative measures, low-dose vaginal estrogen can be considered after a thorough discussion of risks and benefits. Lidocaine can also be offered for persistent introital pain and dyspareunia.
For women with current (or a history of) breast cancer who are on aromatase inhibitors and have not responded to previous treatment, clinicians may offer vaginal dehydroepiandrosterone. Finally, clinicians may offer the selective estrogen receptor modulator ospemifene (Osphena) to postmenopausal women without current (or a history of) breast cancer who are experiencing dyspareunia, vaginal atrophy, or other vaginal pain. Clinicians should offer pain relievers to women on aromatase inhibitors who are experiencing arthralgia that interferes with intimacy.
Clinicians may suggest the use of skin protectants/sealants applied to the external folds of the vulva in women using pads for leakage and/or discharge. Vaginal dilators may be of benefit in the management of vaginismus and/or vaginal stenosis and can be offered to anyone having pain with examinations and/or sexual activity. This is particularly important for women treated with pelvic (or vaginal) radiation therapy. Ideally, benefit is greatest when started early and should not be recommended based on sexual activity or sexual orientation but, rather, to all women at risk for vaginal changes to be proactive in their sexual and vulvovaginal health.
Cognitive behavioral therapy and pelvic floor (Kegel) exercises may be useful to decrease anxiety and discomfort and can decrease urinary tract symptoms. The expert panel believes that pelvic floor physiotherapy may be beneficial for patients experiencing symptoms of a potential pelvic floor dysfunction, including persistent pain and urinary and/or fecal leakage. Clinicians may refer patients to a urologist or urogynecologist for further evaluation and treatment of urinary incontinence or to a colorectal surgeon for fecal incontinence.
For Men With Cancer
SEXUAL RESPONSE: It is recommended that phosphodiesterase type 5 (PDE5) inhibitor medications be used to help men with erectile dysfunction. Men who do not respond to PDE5 inhibitors should consider alternate interventions, such as a vacuum erectile device, medicated urethral system for erection, or intracavernosal injection. There may be some benefit to initiating the use of any of the above interventions earlier after cancer treatment rather than later. Introduction prior to treatment initiation may be of benefit to some men.
Surgical interventions, including penile prosthesis implantation for erectile dysfunction, can be offered to patients who are not responding to conventional medical therapy or reporting adverse effects with such therapy. Clinicians may refer patients to a urologist for evaluation and treatment of stress urinary incontinence.
Men should be aware that it might take a long time for medications to work and that PDE5 inhibitors might not work for all men, especially in those with preexisting comorbidities. Clinicians should discuss with patients the appropriate duration of use and alternative options (eg, surgery) if the medications fail to work satisfactorily.
It is the opinion of the Expert Panel that any kind of regular stimulation (including masturbation) would likely be of benefit for improving sexual response, regardless of the stimulation used.
Contraindications include the use of nitrates in any form. Common acute adverse effects of PDE5 inhibitors include headaches, flushing, dizziness, upset stomach, nasal congestion, and dyspepsia.
Genital Changes: It is recommended that a vacuum erection device be used daily to prevent penis length loss. There may be some benefit to initiating the use of vacuum erection devices earlier after cancer treatment rather than later. Early treatment with PDE5 inhibitors may also be beneficial for this outcome.
Intimacy Relationships: The expert panel believes that individual or couples counseling should be offered for those wishing to improve relationship or intimacy issues. Current evidence does not support a particular intervention to improve intimacy or relationships.
Overall Sexual Functioning and Satisfaction: It is recommended that psychosocial counseling be offered to men with cancer (and their partners) to potentially improve sexual functioning and satisfaction. It is also recommended that the use of proerectile agents and devices be considered, recognizing that most of the benefit is specifically for erectile dysfunction. For men who have sex with men, additional education may need to be provided on the changes in erection and alternative ways to maintain sexual intimacy.
Body image, including such issues as weight changes, disfigurement, scarring, and hair loss, should be discussed and normalized in men. Clinicians should check testosterone levels, even if the patient has a cancer that is not typically associated with hormone changes. Options should be discussed when testosterone levels are within the normal range but the patient or clinician feels supplementation may have a clinical benefit and is not contraindicated.
Vasomotor Symptoms: Men with vasomotor symptoms should be offered medication for symptomatic improvements. Options would include venlafaxine, medroxyprogesterone acetate, cyproterone acetate, and gabapentin. Acupuncture may be a suitable alternative, as may other integrative medicine options, such as slow-breathing techniques and hypnosis, for which evidence demonstrates a clinical benefit in women. Psychosocial counseling (eg, cognitive behavioral therapy) may provide a benefit and reduce vasomotor symptoms and should be offered.
More information is available at www.asco.org/survivorship-guidelines and www.asco.org/guidelineswiki. A link to the CCO guideline can be found at www.cancercareontario.ca/en/content/interventions-address-sexual-problems-people-cancer. ■
DISCLOSURE: Drs. Carter and Rowland reported no conflicts of interest. For full disclosures of the expert panel, visit ascopubs.org.
1. Carter J, Lacchetti C, Andersen BL, et al: Interventions to address sexual problems in people with cancer: American Society of Clinical Oncology clinical practice guideline adaptation of Cancer Care Ontario guideline. J Clin Oncol 36:492-511, 2018.
Dr. Katz is a certified sexuality counselor at CancerCare Manitoba, Canada.
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