Sexual Health Considerations in Cancer Treatment and Survivorship

Michael Krychman, MD

Cancer impacts the lives of patients in many different ways, but one way in which adults facing a cancer diagnosis may be affected is the impact that the disease and its subsequent treatment can have on sexual function.

Estimates on just how many cancer patients are impacted vary, depending on the tumor type. However, since general treatment options such as chemotherapy and radiation are similar across tumor types, assessing the sexual needs of a cancer patient may benefit in part from a universal approach, still keeping in mind the individual needs of each patient.

That was the message passed along at NCONN 2012 by Michael Krychman, MD, medical director of sexual medicine at Hoag Hospital and executive director of The Southern California Center for Sexual Health and Survivorship, both in Newport Beach, California.

“There are treatments that we do as healthcare professionals like chemotherapy and radiation that can have far-reaching implications on sexual function, as well as medications that we put our patients on that may be for an extended period of time—that all can have an impact on the sexual response cycle,” Krychman said.

For example, women treated with radiation for their tumors often experience a range of similar side effects that impact sexual function across tumor types, including vaginal changes, erythema and ulcerations, superficial or deep dyspareunia, and local effects due to placement. For patients treated with chemotherapy, sexual side effects can include premature ovarian failure, amenorrhea, menopausal syndrome, and vaginal mucosal erythrodysesthesia.

Some types of cancer have their own impact on sexual healt h beyond these side effects, however. Lung cancer patients of - ten have difficulty breathing, so Krychman recommended that intimacy be scheduled during optimal breathing times and avoided after consuming a heavy meal or alcohol because of the impact that fatigue may have on breathing; in addition, bronchodilators and oxygen therapy should be used prior t o intimacy, if prescribed. Anot her example is Hodgkin’s lymphoma, where intensive treatments such as bone marrow transplants and high-dose chemotherapy can lead to sexual problems and fertility issues.

Therapies for a “New Normal”

Krychman said that when it comes to sexual health, patients with cancer may need to establish a “new normal,” which may include the use of various therapies to address sexual complaints. Krychman said that there are more options than ever before when it comes to safely and effectively improving sexual function.

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It’s very important to normalize the experience and create a safe environment where sexuality can be discussed. ”

—Michael Krychman, MD

He reviewed a number of therapies at the conference, including ones that are currently under clinical investigation. One such product is ospemifene, a selective estrogen receptor modulator that is under review by the FDA to treat vulvar and vaginal atrophy in patients who have gone through menopause in order to treat moderate to severe dyspareunia, or painful sexual intercourse. If approved, it would be the first oral alternative to vaginal estrogens. Additionally, intravaginal dehydroepiandrosterone (DHEA) suppositories, which have been shown to restore and revive the vaginal epithelium without affecting estradiol levels, are under clinical investigation as well.

While DHEA suppositories are being studied in cancer survivors, ospemifene is not being explored specifically in cancer patients with sexual health concerns. However, Krychman believes that cancer patients could benefit from these new therapies if studies back up their clinical efficacy.

“We’re waiting to see what will happen in terms of the FDA with ospemifene, and then maybe they would consider further postmarketing studies in the oncologic patient,” Krychman said. “But it’s a very exciting time for sexual medicine in general, particularly when there is some concern for the cancer patient.”

A continually expanding assortment of viable treatment options is available, but Krychman said the only way that a patient is going to benefit from these options is if the channels of communication remain open. Krychman said that the nurse navigator is an essential part of establishing a safe environment for the patient so that he or she feels comfortable enough in discussing sexual health issues, and even then, only when the time is appropriate.

Open Lines of Communication

“We need to individualize and prioritize with our patients who come in,” Krychman said. “Some may not benefit from early discussion. Others may benefit during therapy, and others may benefit in their survivorship phase. There’s really no one hard, fast rule, but I think it’s very important to normalize the experience and create a safe environment where sexuality can be discussed and resources can be accessed as well.”

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Dr. Michael Krychman on the Awareness of Sexual Health Concerns

If a patient is not ready to talk to a nurse navigator or a treating oncologist in person about sexual health concerns, Krychman suggested a number of online resources that could be of some assistance and lend themselves to eventual discussion in person. One website he suggested was the International Society for the Study of Women’s Sexual Health (ISSWSH), where patients can find providers in their region who address sexual health concerns.

“I think it’s important for patients to become educated and mark down their questions so they’re prepared for their visit,” Krychman said.