Sexual Health in Women Following Cancer: There Is No “I” in Team

Don S. Dizon, MD^a and Anne Katz, RN, PhD^b

^a Founder and Director, The Oncology Sexual Health Clinic, Clinical Co-Director, Gynecologic Oncology,  Massachusetts General Hospital Cancer Center; Associate Professor of Medicine, Harvard Medical School

^b AASECT Certified Sexuality Counselor, Clinical Nurse Specialist, CancerCare Manitoba, Winnipeg, Canada

Sexual health is a major concern of patients who have been treated for cancer–both those in remission and those with advanced or metastatic disease. It is widely recognized that the cancer experience can impact one’s relationships and can be associated with other sequelae, including depression and anxiety. As such, attention to the sexual lives of our patients is an important part of ongoing care.

A recent paper by Lindau et al. [1] reported on the findings of a group of professionals within the Scientific Network on Female Sexual  Health and Cancer (the “Network”).  They have written a guide to what they consider to be the standard examination of women with cancer and sexual concerns. However, the reader should be aware that  this paper has significant shortcomings.

First, these findings are based on a survey of a small group of practitioners (n = 34), mostly from the specialties of gynecology and psychology. We would argue that this limited number of  providers does not reflect the community of clinicians involved in the care of women living with cancer, nor does it include the insights of the very women whose concerns it seeks to address. The writing group on this important topic is notably absent of medical oncologists, with only one gynecologic oncologist and two radiation oncology providers included. It also ignores the voice of nurses and other psychosocial clinicians who are often among the first to inquire about and identify sexual health concerns in cancer patients.  

Sexual health cannot and should not be viewed in isolation, but is rather part of the entire experience of cancer patients and survivors. Women value their sexual health, but it is important to recognize and balance this with other concerns, whether it be the management (or avoidance) of acute or delayed treatment-related toxicities, or  an understanding of her own individual goals (e.g., achieving remission, disease stability, or palliation). Without an understanding of the more global picture of the cancer experience, the sexual health evaluation becomes a “niche” examination, rather than a part of comprehensive cancer care.

In regard to this paper from the Network, perhaps the biggest concern is the heavily weighted emphasis on the physical nature of sexual concerns. The bulk of this paper is devoted to the physical examination of the patient, which we propose is excessively comprehensive.  While it is important to understand the female pelvic anatomy, such a comprehensive evaluation is often unnecessary. Instead, we would argue that the physical examination should be tailored to the patient’s concerns.  Indeed, the take-home point should not be that any specific formulaic examination is  required for all women. The proposed examination also ignores the reality that it is often impractical to perform in most cancer outpatient clinics,  and as such, may not elicit broader participation by cancer centers (or general gynecologists). Most importantly, this emphasis on the physical examination ignores the more subtle, but equally important expressions of sexual problems including changes in body image, loss of libido, diminished or absent sensations of arousal, changes to the sensation and experience of orgasm, and global alterations in sexual self-image and sexual confidence.

Assessment and intervention for complex sexual concerns rely on a collaborative approach, which includes a deeper understanding of the physical, psychological, and social domains, and is best accomplished with the oncology team, not as a stand-alone assessment. When it comes to cancer, we would argue that the voice of the oncology care provider is equally critical. Approaching sexual health with such a singular emphasis as is presented in this paper neglects this construct and does little to advance or encourage the participation of the oncology care provider, including medical oncologists and oncology nurses.

This review does not provide an assessment that can be achieved by many providers, especially those without training in the field of obstetrics and gynecology.  As such, it is an unfortunate and missed opportunity to recognize the important input of  the oncology team, including  oncologists, advanced care providers, and patients as participants in the evaluation of sexual health.

Reference

1. Lindau ST, Abramsohn EM, Baron SR, et al. Physical examination of the female cancer patient with sexual concerns: What oncologists and patients should expect from consultation with a specialist. CA Cancer J Clin. 2016 Jan 19.