With the advancements in science and technology, cancer survivors are increasing in number, despite its growing incidence globally. Quality of life (QOL) has thus become an important endpoint of any oncological maneuver. A well-preserved sexual functionality is an important component of QOL-defining parameter among these patients. According to the current working definition, sexual health is a state of physical, emotional, mental, and social well-being concerning sexuality, and not merely the absence of disease, dysfunction, or infirmity. Chemotherapy, radiotherapy, and surgery are the three modalities of treatment that are used for managing cancer patients and they have their individual side effects. Even though their effects on sexual health are well documented in the literature, it is less talked about while managing cancer patients. Thus, it becomes prudent to highlight this topic to provide a better sexual QOL to cancer patients. Also, since cancer survivors remain majorly in touch with their primary care physicians (PCPs) on their follow-up, it is important to make them aware of the issues that these patients might face and train them for symptomatic management and timely referral, if required.
The article thus aims to emphasize and bring forth an important unmet need of cancer patients and survivors, that is, sexual QOL. Further, it attempts to reinforce upon the various reasons for non-discussion of sexual health in onco-clinical practice, its need in routine practice, steps for improvement, and multidisciplinary approach to provide better sexual QOL for our patients.
Rationale and Review of Literature
In Radiation Oncology, although a majority of the studies depicting sexual side effects have been done in patients undergoing pelvic radiotherapy, a review by Rhoten et al. found the prevalence rates of sexual concerns to be ranging from 24% to 100% in head and neck cancer. Besides this, an estimated prevalence of up to 85% for sexual problems after breast cancer treatment has been found. Both men and women are prone to develop these side effects. Some of the concerns in women include decreased vaginal lubrication and nipple sensation, orgasmic difficulties or painful intercourse, and reduced sexual desire. Among men undergoing pelvic radiotherapy, premature ejaculation and erectile dysfunction are the main concerns. Besides the chemotherapy and radiotherapy treatment-induced side effects, changes in body image (post-surgery) might lead to thoughts of physical unattractiveness and can affect the sexual function, regardless of treatment. Thus, it is of paramount importance to understand various variables such as interpersonal relationships, including intimacy, communication, body image, and self-esteem, as these have also been identified as an important aspect of sexuality for cancer patients.
Reasons for Non-discussion
Although a lot many late side effects are seen in oncology patients undergoing treatment, there are several reasons for non-discussion between oncologists and patients with sexual health needs. Some of the reasons are as follows: 1. the generalized taboo of talking about sexuality, especially in less-developed countries; 2. lack of experience of the treating physician in dealing with sexual health topics; 3. assumption that if the patients have some issue, they will come forward with it themselves; and 4. presumption that it might go over the head of the patient. Further, in a survey done by Brautigam et al., it was seen that only up to 20% of doctors talk about sexual health issues and the main reason for non-communication by doctors with patients, about sexual problems, was the impression that the other issues of patients were of more concern. In another study done by Krouwel et al., it was docum ented that some of the other reasons for non-discussion were advanced age of the patient (in 50.6% of patients), the issue not being relevant for all types of cancers (in 43.8% of patients), lack of time (in 39.9% of patients), and no angle or motive for asking (in 35.2% of patients).
Assessment Tools and Models
Thus, to address the issues of sexual QOL in oncology patients, an adequate assessment of sexual concerns of both patients as well as their partners should be done. It gives them an opportunity and freedom to share their concerns, ask questions pertaining to their sexual health and intimacy, and also helps them to overcome their frustration. For this, open-ended questions in simple, understandable, local native language should be used by the treating oncologist. The oncologist can utilize the permission, limited information, specific suggestions, and intensive therapy (PLISSIT) model, as developed by Jack Annon in the year 1976, for assessing the level of assistance required for these patients. Oncosexology is a new discipline that primarily deals with the sexual health issues of cancer patients. The International Society of Sexuality and Cancer is the new multidisciplinary committee that has been formed to look into this area of cancer care.
Steps for Improvement
Looking at the current unmet need of oncology patients regarding their sexual health, it seems prudent to make the oncologists aware of the urgent need and steps to improvise on this important concern. Some of the steps that could be incorporated in the oncology practice are given in Figure 1 and are as follows: 1. It could be ensured that oncologists should openly discuss with their patients at the start of the therapy, the possible side effects that might affect their sexual QOL. It has been documented in the literature that doing so might help in providing better sexual QOL to these patients. 2. Besides open discussions, patient-reported outcomes measures are another way to discuss the QOL issues that are not always discussed during physician visits. 3. Upgradation of knowledge and skills in counseling these patients on such sensitive topics are required. 4. A multidisciplinary approach involving sexologists and health psychologists might help in bridging the gap in this regard and should be looked for. 5. A multidisciplinary outpatient clinic for oncosexology involving nurses and social workers for sexual counseling, a gynecologist, and a urologist having an experience of sex therapy can be created. 6. Also, PCPs, who are the first point of contact between the patients and the tertiary care health providers, should be adequately trained. Adequate training can help PCPs in (i) identifying the sexual health issues earlier and can guide the patients regarding appropriate tertiary care facilities; (ii) providing appropriate patient education, which can correct misconceptions regarding sexual hygiene, contraception, and transmission of sexually transmitted diseases (STDs); and (iii) identifying STD-associated malignancies earlier.
Overall, the viewpoint emphasizes the need for the incorporation of sexual health in oncology practice and the measures that might be incorporated for providing better sexual QOL. Future prospective studies on oncology patients’ sexual QOL are warranted for an in-depth understanding of the subject concerned.
- Sexual health-related QOL is less talked about while managing cancer patients.
- Sexual education, a multidisciplinary approach, and timely referral are some of the measures that might help in improving sexual QOL.
- Appropriate training of PCPs and paramedical staff should be emphasized upon.
- Sexual QOL is an important health-related parameter of cancer patients and survivors, which should be incorporated in routine practice.
- Appropriate training along with usage of questionnaires and tools might help in better approaching this issue.
New knowledge emerging from this manuscript
The article lays emphasis on a very important patient concern, that is, sexual QOL, which is less talked about in routine onco-clinical practice. Some of the measures that can be incorporated for improvement in this regard are also highlighted.
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Conflicts of interest
There are no conflicts of interest.
1. Edwards WM, Coleman E Defining sexual health
:A descriptive overview. Arch Sex Behav 2004;33:189–95.
2. Rhoten BA Head and Neck Cancer and Sexuality:A Review of the Literature. Cancer Nurs 2016;39:313–20.
3. Chang YC, Chang SR, Chiu SC Sexual problems of patients with breast cancer after treatment:A systematic review. Cancer Nurs 2019;42:418–25.
4. Panjari M, Bell RJ, Davis SR Sexual function after breast cancer. J Sex Med 2011;8:294–302.
5. Arraras JI, Manterola A, Illarramendi JJ, Asin G, de la Cruz S, Ibañez B, et al. Quality of life evolution in elderly survivors with localized breast cancer treated with radiotherapy over a three-year follow-up. Breast (Edinburgh, Scotland) 2018;41:74–81.
6. Biglia N, Moggio G, Peano E, Sgandurra P, Ponzone R, Nappi RE, et al. Effects of surgical and adjuvant therapies for breast cancer on sexuality, cognitive functions, and body weight. J Sex Med 2010;7:1891–900.
7. Boquiren VM, Esplen MJ, Wong J, Toner B, Warner E, Malik N Sexual functioning in breast cancer survivors experiencing body image disturbance. Psychooncology 2016;25:66–76.
8. Figueiredo MI, Cullen J, Hwang YT, Rowland JH, Mandelblatt JS Breast cancer treatment in older women:does getting what you want improve your long-term body image and mental health?. J Clin Oncol 2004;22:4002–9.
9. Brautigam E, Schratter-Sehn A, Kottmel A, Bitzer J, Teleky B, Ucsnik L Do radiation oncologists talk about sexual health
and dysfunction with their cancer patients?Results of the igls-vienna-sexmed-survey. Clin Transl Radiat Oncol 2020;21:120–6.
10. Krouwel EM, Hagen JH, Nicolai MP, Vahrmeijer AL, Putter H, Pelger RC, et al. Management of sexual side effects in the surgical oncology practice:A nationwide survey of Dutch surgical oncologists. Eur J Surg Oncol 2015;41:1179–87.
11. Enzlin P, Inge D The emerging field of 'oncosexology':Recognising the importance of addressing sexuality in oncology. Belgian J Med Oncol 2011;5:44–9.
12. Carr SV Talking about sex to oncologists and about cancer to oncologists. Sexologies 2007;16:267–72.