Sharon L. Bober

Sexuality in Adult Cancer Survivors: Challenges and Intervention

Sexual dysfunction is one of the most common and distressing consequences of cancer treatment. Although some treatment-related sexual adverse effects are short-term, many survivors face long-term effects such as treatment-induced menopause, altered gonadal function, and significant surgical disfigurement. Profound sexual dysfunction has been shown to have a significant negative effect on quality of life. Although these problems have been well documented and there are a range of intervention strategies that can help patients cope with treatment-related sexual problems, many survivors do not feel prepared for potential sexual changes and often do not receive adequate support to manage sexual dysfunction. Numerous barriers contribute to this underprovided aspect of survivorship care, including lack of provider training and access to readily available resources. In addition, psychological, relational, and cultural factors significantly influence sexuality but are often not taken into consideration in research and clinical practice. By taking an integrative approach and providing survivors with appropriate screening, information, and support, sexual dysfunction and accompanying distress can be significantly alleviated. In this article, we aim to provide a concise review of the most common sexual problems experienced by survivors and highlight some of the most promising evidence-based practices for assessment and intervention. We also address limitations encountered in research and practice and explore future directions, including suggestions for adopting an integrative treatment model to address sexual dysfunction in a cancer survivorship treatment setting.

Sexual Health Communication During Cancer Care Barriers and Recommendations

With improved cancer survival rates, it is becoming increasingly important to focus on quality of life issues throughout all stages of cancer treatment. Sexual problems often result from the physical and psychological side effects associated with cancer and cancer treatment regimens, yet few cancer patients recall discussing sexual risks before treatment or treatment options for sexual dysfunction after treatment. This review summarizes the literature, to date, on patient and clinician communication about sexual dysfunction. Patients’ views about the importance of these discussions and patient and clinician barriers to sexual dysfunction communication are presented. We adapted a behavioral health counseling model, the 5 A’s, and present it as a proposed framework for sexual health communication with cancer patients in a multidisciplinary setting.

Treatment-related amenorrhea and sexual functioning in young breast cancer survivors

Sexual dysfunction is a known complication of adjuvant therapy for breast cancer and an important determinant of quality of life. However, few studies have explored how treatment and other factors affect sexual functioning in young breast cancer survivors.

Sexual Function in Childhood Cancer Survivors: A Report from Project REACH

INTRODUCTION Of the approximately 12,000 children and adolescents that will be diagnosed with cancer in 2013, it is expected that over 80% of them will become long-term adult survivors of childhood cancer. Although it has been well established that cancer treatment often has profound negative impact on sexual functioning, sexual functioning in adult survivors of childhood cancer is not well understood. AIM The aim of the current study was to examine the report of sexual function in adult survivors of childhood cancer in relationship to both physical and emotional functioning. METHODS Two hundred ninety-one participants enrolled in Project REACH, a longitudinal study of childhood cancer survivors, completed questionnaires as part of an annual health survey. MAIN OUTCOME MEASURE Primary outcome measures included the sexual functioning subscale of the Swedish Health-Related Quality of Life Survey, the SF-12, and the BSI-18. RESULTS Results indicate that 29% of young adult survivors reported two or more discrete symptoms of sexual dysfunction. Females were twice as likely to report sexual problems. Sexual problems were not related to specific types of childhood cancer treatments such as type of chemotherapy or radiation. Young adults with sexual dysfunction did report poorer functioning across the range of SF-12 subscales including physical functioning, general health, fatigue, and mental health. CONCLUSIONS Significant sexual dysfunction is common in adult survivors of childhood cancer. A greater understanding of the particular relationship between sexual dysfunction and both physical and emotional well-being in this relatively young population is needed. Even when long-term cancer survivors are young adults and report generally good health, results underscore the need for clinicians to specifically assess sexual functioning.

General internist communication about sexual function with cancer survivors.

ABSTRACTBACKGROUNDSexual dysfunction is an important issue that affects many cancer survivors who are increasingly being cared for by internists.OBJECTIVETo examine the attitudes and reported practices of internists regarding survivorship care as it pertains to sexual dysfunction.DESIGNSurveys were sent to 406 physicians affiliated with the Department of Internal Medicine at the University of Colorado Denver School of Medicine. Of the 319 eligibles, 227 were returned (71% RR).MAIN RESULTSOf the 227 responders, 46% were “somewhat/very” likely to initiate a conversation about sexual dysfunction; 62% “never/rarely” addressed sexual dysfunction. Each additional weekly hour spent in patient care was associated with a 2% increase in the likelihood of sexual dysfunction being addressed or discussions about sexual dysfunction being initiated. Reported inadequate preparation/formal training around survivorship issues was associated with sexual dysfunction being addressed less often (odds ratio [OR] = 0.45). Perception of patient anxiety or fears about health was associated with sexual dysfunction being addressed more often (OR = 2.38). Perceived preparedness to evaluate long-term effects was associated with a greater likelihood of physicians initiating discussions about sexual functioning (OR = 2.49).CONCLUSIONSCancer survivors receive their long-term care from internists. Our results suggest that sexual dysfunction is often not addressed during their follow-up care. Additional training is needed to prepare physicians to negotiate this difficult issue.

Addressing Sexual Dysfunction After Risk-Reducing Salpingo-Oophorectomy: Effects of a Brief, Psychosexual Intervention

INTRODUCTION Women at high risk for ovarian cancer due to BRCA1 or BRCA2 mutation or family history are recommended to undergo risk-reducing salpingo-oophorectomy (RRSO) after age 35 or completion of childbearing. This potentially life-saving surgery leads to premature menopause, frequently resulting in distressing and unaddressed sexual dysfunction. AIM To pilot a novel sexual health intervention for women with BRCA1/2 mutations who previously underwent RRSO a using a single-arm trial. Feasibility and primary outcomes including sexual dysfunction and psychological distress were assessed. METHODS This single-arm trial included a one-time, half-day educational session comprised of targeted sexual health education, body awareness and relaxation training, and mindfulness-based cognitive therapy strategies, followed by two sessions of tailored telephone counseling. Assessments were completed at baseline and 2 months postintervention. MAIN OUTCOME MEASURE Study end points include feasibility and effectiveness as reported by the participant. RESULTS Thirty-seven women completed baseline and postintervention assessments. At baseline, participants had a mean age of 44.4 (standard deviation [SD] = 3.9) years and mean duration of 3.8 (SD = 2.7) years since RRSO. Overall sexual functioning (P = 0.018), as well as desire (P = 0.003), arousal (P = 0.003), satisfaction (P = 0.028), and pain (P = 0.018), improved significantly. There were significant reductions in somatization (P = 0.029) and anxiety scores (P < 0.001), and, overall, for the Global Severity Index (P < 0.001) of the Brief Symptom Inventory. Sexual self-efficacy and sexual knowledge also improved significantly from baseline to postintervention (both P < 0.001). Women were highly satisfied with the intervention content and reported utilizing new skills to manage sexual dysfunction. CONCLUSIONS This intervention integrates elements of cognitive behavioral therapy with sexual health education to address a much-neglected problem after RRSO. Results from this promising single-arm study provide preliminary data to move toward conducting a randomized, controlled trial.

Sexual functioning in long-term survivors of Hodgkin's lymphoma

Objective: Studies of Hodgkins lymphoma (HL) survivors have reported long‐term adjustment problems including sexual dysfunction, but the prevalence and persistence of sexual problems in HL survivors have not been well characterized. This study aimed to address these questions by comparing sexual health in a large cohort of long‐term HL survivors with a noncancer control group.

Can the distress thermometer (DT) identify significant psychological distress in long-term cancer survivors?: a comparison with the Brief Symptom Inventory-18 (BSI-18)

BackgroundAs the number of cancer survivors continues to grow, identification of brief, valid psychological screening measures is critical for providing these survivors with appropriate psychosocial care. The distress thermometer (DT) is a one-item distress screening recommended by the National Comprehensive Cancer Network (NCCN) for screening cancer patients during their treatment.MethodIn this study, the validity of the DT for identifying psychological distress in cancer survivors was evaluated by comparing results of the DT to the Brief Symptom Inventory-18 (BSI-18) in a sample of 120 survivors of adult onset cancer.ResultsResults indicated that when using the NCCN suggested cutoff score of 5, the DT only identified 10 of the 21 BSI-18 positive cases of psychological distress (sensitivity 47.6%; specificity 90.9%). Using an alternative DT cutoff score of 4, 12 of the 21 BSI-18 positive cases were identified (sensitivity 51.7%; specificity 89.9%).ConclusionsThe results do not support the validity of the DT in survivors of adult cancers.

Addressing female sexual function after cancer by internists and primary care providers.

INTRODUCTION There are now almost 14 million cancer survivors in the United States, and for the majority of survivors, the bulk of post-cancer medical care is provided by community primary care providers (PCPs). Sexual dysfunction is one of the most common and distressing quality of life issues facing female cancer survivors yet it has become increasingly evident that womens cancer-related sexual dysfunction often goes unaddressed, including in primary care treatment setting. AIM Building on a model that calls for an integrative approach to treatment, the aim is to concisely review barriers and challenges of managing cancer-related female sexual dysfunction for PCPs and to offer specific and effective strategies that PCPs may use to treat common sexual problems in their female cancer survivors. METHODS Literature was reviewed for relevant publications on the topic of treating cancer-related sexual dysfunction and primary care, and interviews were conducted with experts on state-of-the-art methods for treating cancer-related sexual dysfunction. MAIN OUTCOME MEASURE Clinical evidence that demonstrates the effectiveness of simple strategies to manage cancer-related female sexual dysfunction. RESULTS Cancer-related female sexual dysfunction does not seem to be appropriately acknowledged and addressed in primary care treatment settings. There is evidence to show that simple and effective strategies exist to ameliorate many of these problems. CONCLUSIONS PCPs provide the bulk of survivorship care and are therefore in a critical position to initiate assessment and treatment for female survivors with cancer-related sexual dysfunction. Although PCPs are in need of increased support and preparation to manage this aspect of survivorship care, simple and effective strategies are available for PCPs to offer women as part of their clinical practice.

Unraveling the Next Chapter : Sexual Development, Body Image, and Sexual Functioning in Female BRCA Carriers

Clinical genetic testing for BRCA1 and BRCA2 has become available in the past 15 years, and it has been established that female BRCA carriers have a high lifetime risk to develop both breast and ovarian cancer. Predisposition testing makes it possible to predict risk in families and to tailor medical management accordingly. In addition to close surveillance, prophylactic mastectomy and oophorectomy are primary risk reduction strategies offered to BRCA carriers. Although the emphasis of research thus far has been on the efficacy of surveillance and risk reduction strategies, it has become clear that genetic testing and the resulting medical decisions around risk reduction lead to a unique set of emotional, physical, and sexual issues for female BRCA carriers and their children. This article will focus on those issues in unaffected female BRCA carriers.