Sexual Dysfunction May Impair Quality of Life for Those With Cancer

During or after cancer treatment, patients may experience sexual dysfunction leading to a decrease in their quality of life.

The impact that cancer treatment has on a patient’s quality of life can be significant. Over time, acute and long-term effects of sexual dysfunction may occur. However, certain challenges such as sexual dysfunction are not typically brought up by patients or clinicians, which can cause significant problems for patients.

A poster presented at the 2023 American Society of Clinical Oncology (ASCO) Annual Meeting aimed to look at patients with cancer who experienced sexual dysfunction during or after treatment.¹ This study is part of the CLARIFY H2020 project—a European-funded project to help identify risk factors and quality of life decline at the end of cancer treatment in a cohort of Spanish patients.^2,3

While the CLARIFY H2020 project analyzed a small subset of patients, investigators intend to continue exploring this issue in a larger cohort. However, there is still an increased need for awareness of sexual dysfunction occurring in patients, especially for patients who have cancer located in the reproductive organs.

CancerNetwork^® spoke with lead study author Aylen Vanessa Ospina-Serrano, MD, MSc, a medical oncologist from the Puerta de Hierro Hospital in Madrid, Spain, who gave insight into the rationale behind this trial, the need for increased awareness of this subject, and what outcomes she hopes to see accomplished with future research.

“It’s not only 1 cancer [like breast or prostate cancer] that is [prone] to sexual dysfunction,” Serrano said. “Sexual dysfunction may [occur for patients with all types of cancer] and can differ depending on the oncologic treatment.”

CLARIFY H2020 Study Results

A total of 383 patients were included in the analysis, 68.1% of whom had breast cancer, 26.3% had lung cancer, and 5.0% had lymphoma. The median patient age was 56.5 years, and 80.4% of patients were women.

The study took place between October 2020 and May 2022, during which time investigators collected demographic and clinical variables in addition to measures of sexual dysfunction via a validated, Spanish language, gender targeted questionnaire.

Ospina-Serrano noted she began this review as part of her PhD.

“The purpose of the study was to define the available information on the characteristics of sexual dysfunction in patients with cancer, including differences by gender, [and type of cancer] because [clinicians] don’t know too much about this [disorder] in patients,” she said.

The results from the study indicated that patients with breast cancer, who made up the majority of the study’s population, were more likely to experience sexual dysfunction, specifically those with localized breast cancer. The absolute frequency of global sexual dissatisfaction occurred in 76% of women and 24% of men. Additionally, 31% of women reported engaging in sexual activity compared with 69% of men.

Moreover, 22.1% of women with metastatic breast cancer reported sexual dissatisfaction, as well as 35.9% of those with early-stage breast cancer and 15.4% of long-term survivors. For men with lung cancer, 8.8% reported dissatisfaction vs 2.8% of women. Additionally, 14.4% of men with lymphoma reported dissatisfaction vs 0.6% of women.

“The most common [sexual] long-term effects are those related to [induced] menopause, ablative surgeries, and gonad dysfunction, for example, in breast cancer gynecologic cancer, and prostate cancer,” Ospina-Serrano explained.

The study’s investigators concluded that most patients receiving treatment were affected by sexual dysfunction. Awareness of this disorder is needed across the multidisciplinary cancer team. However, when care teams hold discussions around quality of life, sexual function is not often prioritized, leaving the associated mental and emotional impact on patients and their partners unaddressed, Ospina-Serrano said.

The Mental Impact of Sexual Dysfunction

While sexual dysfunction impacts the body physically, the root cause could be something the patient is mentally or emotionally going through. It’s important that patients and clinicians consult a psychologist if an issue like sexual dysfunction is occurring in concordance with cancer treatment.

Jennifer A. Vencill, PhD, LP, a psychologist specializing in sexual health at the Mayo Clinic, also sat down with CancerNetwork^® to discuss the quality-of-life impact she has seen on patients with cancer.

“My specialty area within psychology is sexual health,” Vencill noted. “I’m working with [patients] on that psychosocial relational side of things to address changes in sexual behavior or sexual functioning. It’s often important, however, that they also have a sexual medicine exam with a physician or a medical provider, particularly if there have been changes in functioning, pain with sex, or genital pain.”

The American Cancer Society notably published information on the potential changes in sexual function that may occur during or after cancer treatment.⁴ The article focuses on how to adjust or adapt your sexuality after a cancer diagnosis or during treatment. Specifically, it highlights challenges like a change in sexual desire and body image and gives support on ways to adjust during the various stages of treatment.

Moreover, ASCO published guidelines focused on intervention to sexual problems among patients with cancer.⁵ The guidelines detailed that a care team member should initiate a discussion with the patient regarding sexual health and dysfunction. During this discussion, psychosocial or psychosexual counseling may be recommended where appropriate. Those with medical issues related to sexual dysfunction should be addressed prior to counseling.

Vencill highlighted the importance of being open with partners and recommends approaching different types of sexual experiences with a sense of flexibility, as during or after cancer treatment, what feels comfortable for the patient may change. She often recommends pelvic floor physical therapists if pain is a concern for the patient, citing that these physicians are a critical part of the care team in helping to alleviate sexual dysfunction.

When a patient’s quality of life comes into play, a multidisciplinary care team must be involved, according to Vencill.

“The medical side is important for sexual health,” she elaborated. “Many patients also struggle with the relational side, the psychological aspects, and body image changes. Pain has a psychological component as well. Libido concerns are often psychological and relational in nature. We want to make sure we’re addressing any of those domains, not just the medical part.”

Ospina-Serrano added that she wanted to study sexual dysfunction because it’s not something that is openly discussed and noted that there are very little data on how it impacts patients. Emerging therapies have increased survival lending to this disorder across various patient populations. Patients who have survived a cancer diagnosis will have a different life, with sexual dysfunction only further interrupting a patient’s lifestyle, she remarked.

Closing the Information Gap

A common theme among these experts and when reviewing various sources is the limited access to information or a lack of time dedicated to discussing these issues. As previously mentioned, this is due to a combination of patients waiting for these topics to be brought up during a visit and clinicians not addressing the potential challenge of sexual function.

“Sometimes this is not about a lack of knowledge, its logistics,” Vencill indicated. “If [clinicians] only have 15 minutes with a patient, they’re going to focus on cancer care. That’s what they’re there for. That’s their expertise. We want to make sure oncologists know even if you don’t feel qualified or able to have sexual health conversations with patients, we want to make sure they know where to send people for more information.”

Ospina-Serrano is happy that this subject is finally gaining traction among her colleagues. She noted that these conversations are a necessity, not only to help improve patients’ quality of life but also for clinicians.

Narjust Florez, MD, also studied sexual health in women with lung cancer through the Sexual Health Assessment in Women with Lung Cancer (SHAWL) study.⁶ Data from the study indicated that, women were most likely to have a reduction of interest in sexual activity compared with before their cancer diagnosis.

In a press release from Dana-Farber Cancer Institute, Florez, associate director of the Cancer Care Equity Program and thoracic oncologist at Dana-Farber Brigham Cancer Center said, “the SHAWL study is about bringing women’s sexuality to the forefront of scientific discussions because it has been significantly understudied. When comparing the information before lung cancer diagnosis and after lung cancer diagnosis, the difference is staggering. Lung cancer significantly affects the sexual health of these women.”⁷

The SHAWL study included 249 women, 67% of whom had stage IV lung cancer, 45% received targeted therapy. Moreover, a total of 33% of patients were receiving antidepressants and 14% were receiving beta blockers at the time of survey completion. Recent sexual activity was reported in 54% of patients, with 77% of patients having little or no interest in sexual activity, and 48% having minimal satisfaction with their sex life.

The press release concluded with Florez stating that sexual health includes related to quality of life. She also highlighted the need for sexual health to be integrated into thoracic oncology and that further research is needed.

Creating a More Accepting and Educated World

Moving forward, as this concept is discussed more in the oncology community, there are several factors that should be considered to bring sexual dysfunction to the forefront. Serrano noted that information should be better broken down for patients to understand and made more accessible so that clinicians are better informed on the topic. While studying different cancer drugs and their interactions is at the forefront of the medical oncology community, sexual health and dysfunction have largely not been a priority.

“The most important task is to [create a] team that can give the support to the patients and that oncologists can identify the problem and refer patients to care within that team,” Ospina-Serrano stated.

Further, the ASCO guidelines highlight the need for sexual dysfunction screening at the beginning of treatment and for a questionnaire to be given to see if any sexual health issues arise during treatment. Most importantly, patients who are at the highest risk for sexual dysfunction, such as those receiving therapy for breast, gynecologic, or prostate cancers, should be identified ahead of time.

The conditions are broken down between men and women and includede guidelines for those with body image issues, sexual response, intimacy and relationships, and overall sexual functioning satisfaction. Through each condition, a recommendation is made from the expert ASCO panel on how clinicians should approach these topics.

Vencill hopes that the social stigma surrounding sexual dysfunction will dissipate as more conversations around the topic take place. More educational resources need to be created because “education helps to get rid of shame and stigma around topics,” she said.

From a health care perspective, she is making a concerted effort to normalize these conversations and validate her patients’ experiences. Each patient she sees has common and legitimate concerns regarding their sexual health, but if these challenges aren’t discussed within the oncology space, it may make accessing treatment, therapy, and resources more difficult.

Sex after cancer treatment may look different, and Vencill wants clinicians and patients to know that it is okay.

“Sex after cancer might not look the way [patients] envision it; it might not look the way that it used to,” she said. “We often assume that that’s going to be a bad thing. The new sexual normal after cancer treatment might look very different from what they’re used to. Sometime’ that's a good thing.”

For Ospina-Serrano, next steps in identifying solutions to sexual dysfunction include evaluating a larger population of patients in Latin America and their access to health services, which in turn will enable better recommendations for each patient situation. Currently, the LUDICAS study is underway which aims to analyze each population of patients with sexual dysfunction and create a recommendation to accommodate their needs.

“The patients and my colleagues are enthusiastic [about this research] because this is a necessity. It’s an issue that we never have taken into account before. It’s important to incorporate this in the follow-up of the patients with cancer,” Ospina-Serrano concluded.

References

1. Ospina-Serrano AVO, Maximiano C, Sanchez de Ibarguren BC, et al. Sexual dysfunction in patients with cancer: results from the CLARIFY project. J Clin Oncol. 2023; 41(suppl 16):12094. doi:10.1200/JCO.2023.41.16_suppl.12094
2. Ospina-Serrano AV, Maximiano C, Cantos B, et al. Sexual dysfunction in patients with cancer, a challenge in oncology practice: results of the CLARIFY project. Clin Transl Oncol. Published online November 2, 2023. doi:10.1007/s12094-023-03332-0
3. CLARIFY. Accessed October 26, 2023. https://bit.ly/3v3yFoR
4. American Cancer Society. How cancer and cancer treatment can affect sexuality. Accessed October 26, 2023. https://rb.gy/ls2k6
5. Carter J, Lacchetti C, Anderson 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. 2017; 36(suppl 5):492-511. doi:10.1200/JCO.2017.75.8995
6. Florez N, Kiel L, Meza K, et al. Sexual health assessment in women with lung cancer study: sexual health assessment in women with lung cancer. Cancer. Published online October 16, 2023. doi:10.1002/cncr.35057
7. Sexual dysfunction high among women with lung cancer. News release. Dana-Farber Cancer Institute. August 9, 2022. Accessed October 26, 2023. https://rb.gy/kmxlb