Cancer and Sexual Problems

Cancer and Sexual Problemsjsm_1620 349..373

Richard Sadovsky, MD,* Rosemary Basson, MD,† Michael Krychman, MD,‡§¶

Antonio Martin Morales, MD,** Leslie Schover, PhD,†† Run Wang, MD,‡‡ and Luca Incrocci, MD, PhD§§

*Family Practice, SUNY-Downstate Medical Center, Brooklyn, NY, USA; †Psychiatry, University of British Columbia,Vancouver, British Columbia, Canada; ‡Sexual Medicine, Hoag Hospital, Newport Beach, CA, USA; §Southern CaliforniaCenter for Sexual Health and Survivorship Medicine, Newport Beach, CA, USA; ¶Obstetrics and Gynecology, Universityof Southern California, Los Angeles, CA, USA; **Urology, Hospital Carlos Haya, Malaga, Spain; ††Behavioral Science,University of Texas M. D. Anderson Cancer Center, Houston, TX, USA; ‡‡Urology, University of Texas Medical School atHouston and MD Anderson Cancer Center, Houston, TX, USA; §§Erasmus MC, Daniel den Hoed Cancer Center,Rotterdam, Netherlands

DOI: 10.1111/j.1743-6109.2009.01620.x

A B S T R A C T

Introduction. There are many data on sexual problems subsequent to cancer and its treatment, although thelikelihood of problems in specific individuals depends on multiple variables.Aims. To gain knowledge about the risks of sexual problems among persons with cancer and to provide recom-mendations concerning their prevention and optimal treatment.Methods. A committee of multidisciplinary specialists was formed as part of a larger International Consultationworking with urologic and sexual medicine societies over a 2-year period to review the result of chronic illnessmanagement on sexual function and satisfaction. The aims, goals, data collection techniques, and report format weredefined by a central committee.Main Outcomes Measures. Expert consensus was based on evidence-based medical and psychosocial literaturereview, extensive group discussion, and an open presentation with a substantial discussion period.Results. Cancer and cancer treatments have both direct and indirect effects on physiologic, psychological, andinterpersonal factors that can all impact negatively on sexual function and satisfaction. Data on the likelihood of specificsexual problems occurring with cancer and its management vary depending on prediagnosis function, patient response,support from the treatment team, specific treatments used, proactive counseling, and efforts to mitigate potentialproblems. This summary details available literature concerning the pathophysiologic and psychological impacts ofcancer diagnosis and treatment on sexual function, plus recommendations for their prevention and management.Conclusions. Cancer and its management have a significant negative impact on sexual function and satisfaction.These negative effects can be somewhat mitigated by understanding prediagnosis sexual functioning level, counsel-ing, careful treatment choices, and, when indicated, therapy post-treatment using educational, psychological, phar-macologic, and mechanical modalities. Sadovsky R, Basson R, Krychman M, Morales AM, Schover L, Wang R,and Incrocci L. Cancer and sexual problems. J Sex Med 2010;7:349–373.

Key Words. Sexual Problems; Cancer and Sexual Problems; Cancer Treatment and Sexual Problems; Chemotherapyand Sexual Problems; Radiation and Sexual Problems

Introduction

C ancer impacts patients, partners, families,and entire social environments [1]. While

coping with issues of stigmatization, withdrawal,guilt, anxiety about the future, and both dread ofpotential treatment side effects as well as real treat-ment adverse effects, it is not surprising that

persons with cancer suffer from sexual difficulties[2,3]. Modalities used to treat cancer includingsurgery, chemotherapy, radiation therapy, andhormone treatment all have direct and indirectimpact on body functions and image related tosexual function.

Sexuality and intimacy can reduce emotionaldistress and improve psychosocial response to a

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cancer diagnosis [4,5]. There are many treatmentsand treatment modifications that can minimize thenegative sexual effects of cancer. Conversationswith patients about sex are needed to determinewhen and which of these treatments would beappropriate. Pretreatment sexual assessments maybe particularly useful as some experts note thatvarying baseline sexual function among patientscan produce distinctive treatment-related changes[6]. Stratifying treatment-related outcomes bypretreatment functional status can provide betterinformation about expected impacts to specificpatients. Unfortunately, limited outcomes studiesinclude these pretreatment data.

In this manuscript, we will identify the preva-lence and underlying pathophysiology of sexualdysfunction associated with cancer and its treat-ment. We will address psychosocial factors con-tributing to sexual problems. Particularly inwomen, mood and relationship issues may be morecrucial determinants than medical or surgicalinterruption of the sexual response. Currentlyaccepted treatments, as well as emerging treat-ments, will be summarized. Potential preventionof dysfunction will be included.

Cancer in Men

ProstateWatchful WaitingThe diagnosis of prostate cancer has increaseddramatically following widespread introduction ofprostate-specific antigen testing [7]. Watchfulwaiting (WW) is still a viable treatment option forclinically localized disease with low grade and lowvolume of prostate cancer, particularly for olderpatients with a life expectancy of less than 10 years.One of the major considerations for WW is topreserve or maintain the patients’ quality of life(QoL) including their sexual function. Patientswith prostate cancer on WW should have the samerisk factors (such as cardiovascular diseases, meta-bolic syndromes) for developing sexual dysfunc-tion when compared with age-matched men in thegeneral population. However, patients on WWmay have psychological distress because of theuncertainty regarding the disease course and thepossibility of regret for not receiving curativetreatment [8]. This distress may be associated withincreased sexual dysfunction. Patients on WW forprostate cancer also have worse lower urinary tractsymptoms (LUTS) (mostly obstructive symptoms)compared with patients after RP [9]. It is wellknown that LUTS is associated with male sexual

dysfunction [10]. However, few randomized, con-trolled trials are available to compare the QoLand sexual function for men who select WW, withage- and cofactor-matched men without prostatecancer, and to men with prostate cancer whoreceived active treatment.

Limited publications suggest that men on WWfor prostate cancer have increased risk for erectiledysfunction (ED) and more generalized sexualdysfunction compared with men without prostatecancer [11,12].

Recent comparison studies of WW to activetreatment modalities on sexual function with rela-tively large numbers of patients confirm that WWhas less impact on sexual function compared withactive treatment modalities [10,11,13–17]. Man-agement of sexual dysfunction includes addressingthe psychological distress associated with knowingthe diagnoses as well as standard medical options.Healthy spousal communication and couples’sexual rehabilitation may help reduce the negativeimpact of prostate cancer diagnosis and/or treat-ment [18]. Included also is treatment of any asso-ciated LUTS. At present, prevention consists ofeducating men about common risk factors forsexual dysfunction, counseling patients about thedisease course of the prostate cancer, and earlytreatment of any LUTS.

Surgical TreatmentDifferent surgical options are available for treatinglocalized prostate cancer, with disease-free survivalrates nearly equivalent, hence current majorefforts to optimize treatment outcomes are aimedto reduce the morbidity of these procedures [19].Today, the majority of men usually achieveresumption of all physical activities, recovery ofurinary control, and normalization of bowel func-tion within a few months of surgery. However, EDconfronts all men as a long-term and sometimespermanent complication following this treatmenteven when maximal cavernous nerve sparing tech-niques are applied. Sexual function is reportedlymore commonly influenced after prostate cancertherapy than other domains of health-relatedquality of life [20–22].

Breakthrough modifications to the surgicaltechnique [23] have decreased the complicationrate of total and stress-induced incontinence toless than 10% and significantly reduced EDwithout compromising oncological principles,leading radical prostatectomy (RP) to become thegold standard treatment for organ-confined pros-tate cancer for several decades [24–27]. Other

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additional anatomic, technologic, and pharmaco-logic advances to minimize morbidity have beendeveloped [9]. Within the past decade, a majordevelopment has been the introduction of laparo-scopic RP (LRP) and robotic-assisted LRP(RALRP) [28,29].

The postoperative incidence of ED has beenstudied in various circumstances. Among men whowere preoperatively potent and whose postopera-tive erectile function (EF) was assessed withouterectile aids, the incidence of ED over varyingperiods of time ranged from 24% to 82% [30–35].Among men who were preoperatively potent andwhose postoperative EF was assessed with orwithout erectile aids, the incidence of erectile dys-function over varying periods of time ranged from14% to 78% [36–49]. As anticipated, results werebetter when patients had undergone bilateralnerve-sparing RP, were younger age, had an expe-rienced surgeon, and used postoperative pharma-cologic and/or mechanical erectile aids. Thoseinterested in a wider scope of sexual dysfunctionsafter RP are encouraged to read the mentionedexcellent reviews by Stanford et al. [36], Trabulsiet al. [50], Menon et al. [42], Penson et al. [45],Zippe et al. [51], Miranda-Sousa et al. [52],Burnett et al. [53], and Mulhall et al. [54].

Although the main and well-accepted patho-physiological issue is the neurological damage, therole of Accesory Pudendal Arteries [54] is underdebate as a major precipitator of cavernoushypoxia in those patients in whom the cavernousnerves has been preserved. The cascade of eventsending in cavernous fibrosis can start not only as aconsequence of neural but of vascular damage aswell.

The following issues should be taken intoaccount, when evaluating EF recovery: (i) age andcomorbidities [53]; (ii) preoperative EF [37,50];(iii) preservation of the neurovascular bundles[37,45,53]; and (iv) surgical technique of excel-lence, not necessarily referring to surgicalapproach, i.e., open vs. laparoscopic or robot-assisted, but to refinement on the procedure itselfwhich is related to the surgeon’s experience(volume) [55].

Currently, no standard treatment or prophylaxisexists for post-RP ED. Neuro-protective andregenerative therapies, including inmunophillinligands, hold promise to reduce the morbidity oflocalized prostate cancer therapy [56]. Good sur-gical technique includes: maximal nerve preserva-tion, avoidance of vascular damage (minimizingcavernous ischemia), and voidance of thermal and

electrical energy sources [57]. In the meantime,several treatment modalities are available tomanage sexual dysfunction following RP. Neuraldamage takes time to recover even when thenerves are preserved; up to 4 years [38,58,59], sopenile rehabilitation must be considered in allpatients aiming to resume spontaneous sexualactivity after an RP. Additional treatment optionsare [52]: (i) patient education, lifestyle modifica-tion, psychotherapy, oral therapy, and the use of avacuum device; (ii) intraurethral alprostadil andintracavernous injection therapy; and (iii) penileprosthesis implantation.

Other distressing effects of surgical treatmentinclude: penile shortening (68%), loss of sexualdesire (60–80%), less satisfying orgasms (64–87%), overall sexual dissatisfaction (61–91%)[60,61]. Climacturia, or orgasm-associated urinaryincontinence, is a known complication of RP. Theexact rate of this problem is not well establishedand varies from 45% to 93% [62–64]. Literature isscant, providing information on the managementof these problems. Some report on penile lengthpreservation by means of vacuum devices begins toappear [65].

RadiotherapyA study by Zelefsky and Eid concluded that thepredominant etiology of radiation-induced impo-tence was arteriogenic [66]. Several more recentclinical studies investigated the relationshipbetween the radiation dose to the neurovascularbundles, the penile bulb and the penile bodies, andpost-radiation ED presenting contradicting results[67–82]. Most studies have only analyzed fewpatients and the statistical power can be ques-tioned. Post-radiation ED has more likely a mul-tifactorial etiology, and is not only based on theradiation dose to one single anatomical structure.If this is the case, it is much harder to find acorrelation between ED and the dose to a specificstructure. To date, no final conclusions can bedrawn whether or not the radiation dose to thepenile structures correlates with post-radiationED [83]. Even in a prospective, randomized trial,such correlation was not found [81].

An extensive review of the adverse sexual effectsof external-beam radiotherapy (EBRT) has beenpublished [84]. Only studies that prospectivelyevaluated erectile functioning using validatedquestionnaires and using a proper definition ofpotency are useful to draw conclusions on the inci-dence of post-radiation ED [85–91]. In general,this reaches about 60–70% in prospective studies.

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Two recent prospective trials have shown an inci-dence of ED in 30–40% of the patients treated byEBRT [85,86]. Prospective studies show anincrease of ED between 1 and 2 years after radio-therapy, but it does not seem to change after 3years [85,86].

Brachytherapy was originally introduced notonly to limit the detrimental effects of EBRT onbowel and urinary function, but also to help pre-serve sexual function. In general, after permanentseed implantations, ED rates range from 5% to51%, with the highest percentages found after thecombination brachytherapy and EBRT [92–101].The highest ED rates, ranging from 29% to 89%,have been reported combining the temporaryIridium-192 implants with EBRT.

Deterioration of sexual activity has been associ-ated with the severity of ejaculatory dysfunction(EjD), particularly a decrease in volume or anabsence of semen [102]. After radiotherapy, ejacu-latory disturbances varied from a reduction orabsence of ejaculate volume (2–56%) to discom-fort during ejaculation (3–26%) and hemospermia(5–15%). Dissatisfaction with sex life was reportedin 25–60%, and decreased sexual desire in12–58%. One study reported a decreased intensityof orgasm, decreased frequency and rigidity oferections, and decreased importance of sex[66,67,100,101].

Prevention is a difficult matter with little infor-mation available. Possibly, reduction of treatmentmargins, the use of fiducials to visualize the pros-tate, and more sophisticated radiation techniquessuch as the intensity modulated radiotherapy,might reduce post-radiation ED. More research isneeded.

Treatment of post-radiation ED with intracav-ernosal injections was highly effective in one smallstudy [103]. Dubocq et al. reported a high satisfac-tion rate and low morbidity in 34 patients with apenile implant [104]. The efficacy of sildenafilafter radiotherapy in open-label studies has beenreported to be up to 90% of the patients [105–108]. In the only randomized, double-blind trialperformed so far, sildenafil improved erections sig-nificantly as compared with placebo with 55% ofthe patients reporting successful intercourse com-pared with 18% on placebo [109,110]. Similarresults have been reported in one randomized,double-blind trial using tadalafil [111,112].

Androgen Deprivation TherapyTestosterone plays an important role in maintain-ing male sexual desire and modulates many aspects

of the neurogenic vascular dilatation integral to theerectile response. Decreasing serum testosteroneby medical or surgical means can have a significantnegative impact on QoL for patients because ofadverse effects including decreased libido, osteo-porosis, vasomotor flushing, fatigue, anemia, dia-betes mellitus, metabolic syndrome, and alteredbody composition [113–118]. Men who undergoandrogen deprivation therapy (ADT) have afurther decline in ability for sexual intercourse anda decrease in sexual desire compared with men whoare not treated with ADT [119]. Men receivingluteinizing hormone-releasing hormone (LHRH)agonists reported more worry and discomfort andsomewhat poorer overall health and were less likelyto believe they are free of cancer compared withorchiectomy patients [120]. However, despite theinduction of castrate testosterone levels with ADTand the potential for loss of libido and resultingED, there is a subset of patients in clinical practicewho maintain erectile and sexual function [120].Heterogeneity in collecting data and defining out-comes makes the scant data on sexual dysfunctionafter ADT difficult to interpret and sometimessurprising. Most studies showed a decrease insexual function; notably interest in sex and EF withboth medical and surgical ADT [119–122]. Thedevelopment of other side effects of low testoster-one, including hot flashes, can cause significantnegative effect on QoL.

Among other actions, gonadal steroids act onbrain regions involved in the control of sexualbehavior and neuroendocrine regulation, modu-lating release of neurotransmitters includingdopamine which is thought to modulate sexualdesire. Available data from preclinical and clinicalstudies suggest that androgens regulate the mul-tiple signaling pathways and the structure of thecorpus cavernosum. Androgen reduction causeschanges in tissue response to endogenous vasodi-lators causing reduced blood inflow (failure tofill); changes in the fibroelastic properties andexpandability with poor compliance of the corpuscavernosum (failure to accumulate blood underpressure) and dysfunctional veno-occlusivemechanism (resulting in increased blood outflow),all contributing to ED [123].

ED secondary to androgen deprivation mayrespond to most standard treatments for ED. Inthe study by DiBlasio et al. addressing treatmentresponsiveness, response rates were 33–80% withmedical therapy, including 44% receiving phos-phodiesterase type 5 inhibitors monotherapy[120]. Other forms of ADT, specifically antiandro-

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gen monotherapy and intermittent androgen dep-rivation (IAD), have also been shown to beassociated with significantly better sexual functionoutcomes. The low desire as a consequence ofADT can improve during the “off treatmentphases” when on IAD therapy [124]. No specificdata have been found on absent or delayed ejacu-lation. The multiple potential benefits of IAD arean improvement in the ADT adverse event profilenormally associated with therapy, an increase inthe patient’s overall QoL, and a prolongation ofthe time taken for the tumor to become androgenindependent [124].

Testicular CancerTesticular cancers are mainly germ cell tumors thatare classified histopathologically into seminoma,nonseminoma, and combined tumors. Theyaccount for about 1% of all male cancers [125].Excellent cure rates have been achieved withgreater than a 99% cure rate in the early stages bythe standardization of treatment with surgery,radiation, and platinum-based chemotherapy[126]. As testicular cancer affects mostly youngmen aged 20–40 years, and these patients willsurvive many decades after successful treatment,the negative impact of the illness and its treatmenton their sexual lives should be addressed.

There are numerous studies reporting sexualdysfunction in patients with testicular cancer andafter the cancer treatment. Systematic review andmeta-analysis in 2001 [127,128] yielded high ratesof EjDs (some 50%) and more modest increases inED. However, recent studies provide controversialresults regarding the sexual function after the tes-ticular cancer treatment finding a lower incidenceof posttreatment problems or even none[126,129,130].

The mechanisms of sexual dysfunction associ-ated with testicular cancer and its treatment arecomplex [125–135]. Nerve damage during retro-peritoneal lymph node dissection (RPLND)surgery is proven to be the responsible, yet pre-ventable etiology in most cases for EjD. Hormonaldisturbance may be considered as a correctablecause for sexual dysfunction in some patients.Changes in body image are statistically signifi-cantly associated with a negative impact onpatients’ sexual life.

Treatment of sexual dysfunction for testicularcancer survivors should follow the same principlesas the treatment for patients without a history oftesticular cancer. However, it is important to iden-tify the psychological distress of testicular cancer

and its treatment on patients and to includepsychological therapy. Hormonal abnormalitiesshould be identified and corrected unless there is acontraindication. All men undergoing orchiec-tomy should be offered the option of testicularimplantation and the realistic expectations of thetesticular implantation should be discussed withthe patients [135]. Because the fertility outcome intesticular cancer patients varies so much betweenindividuals, and because ultimate treatments arenot always predictable at diagnosis, routine spermbanking is recommended before beginning che-motherapy or pelvic radiotherapy [136].

RPLND with nerve sparing surgery has provedto be and will continue, if indicated, to be the mosteffective preventive strategy to avoid EjD. Studyhas shown that patients with testicular cancer whosuffered sexual dysfunction reported extremelyhigh needs for information and support [137].Adequate information and support may prevent orreduce sexual anxiety and suffering.

Penile CancerOf all urogenital cancers, the one that most obvi-ously jeopardizes sexual function is penile cancer(PC). It is an especially distressing disease becauseof its serious physical and psychosexual conse-quences. Factors implicated in its etiology andsuitable for intervention are: circumcision andpoor genital hygiene. The conventional treatmentfor this cancer is partial or total penile amputation,radiation- or laser therapy. It appears that mostpatients can still enjoy a sexual life if laser treat-ment is used [138,139]. More invasive proceduresreduce this likelihood [140]. If the lesion is earlyand noninvasive, conservative treatment with localresection, Mohs micrographic surgery, topicalchemotherapy, external beam radiotherapy, bra-chytherapy, cryosurgery, or laser therapy can beused, with only marginal compromise of sexualfunction and satisfaction [141–145].

In partial penectomy, in spite of a reduction inthe penile length, vaginal penetration is frequentlypossible as is the ability to reach orgasm and ejacu-lation. The main reason for not resuming sexualintercourse appeared to be related to feelings ofshame owing to the small penile size and absenceof glans penis found in 50% of sexually abstinentpatients [140]. Studies of sexual function afterpartial penectomy have some conflicting resultsfor partial penectomy and largely unaltered sexualfunction domains for localized laser treatment[140,141,146]. Given that PC most frequentlyappears later in life, some patients may develop


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ED after definitive treatment. This can bemanaged with current therapies, regardless of thetherapeutic method used for the malignancy. Ahigh percentage of patients with partial penectomymaintain sexual function. This suggests thatadequate follow-up possibly with a multidisci-plinary team may improve sexual desire, function,and satisfaction after partial penectomy, althoughthis remains to be demonstrated [140].

If total penectomy is necessary, the reason fornot resuming sexual intercourse or masturbation isobvious [146]; however, no studies have beenfound addressing sexual function outcomes withregard to other sexual activities and satisfaction inthese patients. Surgical complications may alsocompromise resumption of sexual activity afteramputation. Conservative treatment, when fea-sible, should be aimed to preserve as much of thepenis, hence sexual identity and activity. Meatalstricture is the most frequent complication afterpartial penectomy. Excessive penile shaft skin hasnot been described as a complication; keeping itmay give the post-penectomy phallus an appear-ance of a short uncircumcised, but normal, penis.However, the excessive skin may interfere withfunction and require excision.

Pelvic Nongynecologic Cancer in Men and Women

BladderIntravesical TreatmentSuperficial cancer is removed during cystoscopy,typically followed by chemotherapy or immuno-therapy with Bacille Calmette-Guërin instilled intothe bladder [147]. There is little research on theimpact of treatment for superficial cancer on sexualfunction in men or women. Intravesical therapy istypically followed by a week of pelvic pain [148] andsometimes temporary ED [149]. One small, cross-sectional comparative study suggested that menand women receiving intravesical chemotherapyhave similar sexual function as those receiving onlycystoscopic tumor removal [150].

Pelvic RadiotherapyDefinitive radiotherapy is rarely used becauselong-term survival is much poorer than afterradical cystectomy [151]. Radiation also typicallydecreases bladder capacity, causing problems withurinary frequency, urgency, and incontinence.However, some small retrospective studies foundmale sexual function to be less impaired afterdefinitive radiotherapy than after radical cystec-tomy [152–154].

Radical Cystectomy and Nerve Sparing toPreserve EFStandard radical cystectomy also removes theprostate, seminal vesicles, and pelvic lymph nodes.When cancer is multifocal, especially when it ispresent in the bladder neck or urethra, the entireurethra may be removed, but this has recentlybecome more controversial [155]. Althoughorgasm is preserved, it is different because of theloss of ejaculate after radical cystectomy. ED isusual.

Schover et al. [156] found that sexual inactivityfollowing surgery increased from 20% before cys-tectomy to 50% at follow-up. Preoperatively, 35%had ED vs. 94% at follow-up. Surgical modifica-tions have included removing the whole prostate;attempting to avoid the neurovascular bundleslateral to its surface; and sparing the prostate,seminal vesicles, and vasa deferentia so that bothEF and ejaculation and fertility can be preserved[157–159]. Although nerve sparing appears toreduce the risk of ED, particularly if the entireprostate is spared, the risk of local recurrence isalso elevated. A recent review of 252 cancerpatients who had some form of prostate-sparingcystectomy also found a suspiciously high rate ofdistant metastases [160]. The risk of ED followingsurgery varied in different series depending on theextent of surgery [157–159,161–163].

Recovery of EF may be enhanced after nerve-sparing prostatectomy during radical cystectomyby the use of penile injection therapy or the oralphosphodiesterase inhibitors within a few weeksof surgery. This sexual rehabilitation may alsoinclude a counseling component, which was shownto improve patient satisfaction with treatmentoutcome [164].

Types of Urinary DiversionIt is presumed that having urinary continence willincrease the likelihood of remaining sexuallyactive. Unfortunately, it is impossible to conduct arandomized trial comparing ileal conduits with thetwo major competing diversions: (i) continentcutaneous diversion often called the Kock orIndiana pouch; and (ii) neobladder. A major draw-back of the neobladder is that many patients havesome stress incontinence during the day and moresevere lack of urinary control during sleep [151].As surgery to create a neobladder is longer andmore complex than that to make an ileal conduit,reconstruction is significantly more common inpatients who are younger and in better health[165].

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A recent review of the literature found no clearevidence for superiority of one method overanother in terms of general QoL [166] agreeingwith our independent review of the evidence ofimpact of varying urinary diversions on sexualfunction or activity [150,161,167–171].

Modifications to Female Radical CystectomyRadical cystectomy has typically included remov-ing the uterus, ovaries, and front part of the vaginaalong with node dissection. Because bladdercancer becomes more common with age, manywomen may not be sexually active at diagnosis.One older study [172] identified only nine sexuallyactive women out of 39 who had received radicalcystectomy during a 38-month period. In thesewomen, the vagina had been repaired without anytissue grafting, resulting in a narrowed or shal-lower vagina. Nevertheless, therapy includinglubricants, topical estrogen, dilators, counseling,and pelvic muscle relaxation helped seven toresume intercourse with no or only mild discom-fort. Orgasmic response remains intact afterradical cystectomy.

For women with cancer at the bladder, neckurethrectomy is usually necessary and preventsconstruction of a neobladder [160]. Direct sexualconsequences of urethrectomy have not beenstudied in women.

Surgeons have also tried to use more limitedresection and nerve sparing to improve women’sQoL after radical cystectomy. One concern hasbeen that traditional cystectomy may cause clitoralnumbness [173]. A study of sensory thresholds in16 women after radical pelvic surgery showed,however, that sensation was only be reduced in thearea of the proximal urethra, whereas sensation inthe distal urethra was intact [174]. The pelvicnerve plexus that mediates sensation in the upperurethra is often damaged in surgery, but thepudendal nerve, which innervates the lowerurethra, clitoris, and outer third of the vagina, isnot in the surgical field. As in men, type of urinarydiversion appears to have little impact on women’ssexual function after radical cystectomy [149,173].The Cleveland Clinic group [175,176] havedescribed a technique to preserve the neurovascu-lar bundles on the anterior vaginal wall by usingcareful sharp dissection. It is unclear whethersparing the neurovascular bundles can help evenpostmenopausal women to have better blood flowinto the vaginal walls with sexual arousal, andtherefore more normal vaginal lubrication, or ifthe benefit is a result of sparing more of the ante-

rior wall so that vaginal size remains optimal. It isalso important to acknowledge a selection bias, inthat women more interested in maintaining sexualactivity may opt for nerve-sparing cystectomy.Retrospective comparisons of women who chooseone procedure vs. another may not be veryenlightening [173,175,177]. Operations that spareneurovascular bundles and vaginal tissue may helppreserve sexual function.

Colorectal and Anal CancerTreatment for colorectal cancer has the potentialto interfere with sexuality in a variety of ways.Despite surveys indicating intact QoL after col-orectal cancer, specific assessment of sexuality con-sistently reveals high percentages of men andwomen discontinuing sexual activity or experienc-ing sexual dysfunction [178–181]. Furthermore, inprospective cohorts, other psychosocial and physi-cal symptoms improve over time while sexualfunction remains impaired [178,182–184]. If thetumor is in the rectum, cancer treatments are morelikely to impair sexual function. In a recent com-parison, 86% of survivors of rectal tumors hadsexual dysfunction compared with 39% of coloncancer survivors [185].

In a retrospective survey of 476 cancer survivorswho had lived a mean of 10 years with a colostomy,complaints about interference with sex werecommon. Fifteen percent of these cancer survivorshad become sexually inactive. ED was present in79% of men [185]. Interestingly, 71% of thoseremaining active were satisfied with their sex lives.Unfortunately, surgery that reconnects the colonand rectum typically leaves survivors with bowelfrequency and some incontinence offering noimprovement in QoL [186].

Two major QoL inventories have been validatedfor patients with colorectal cancer, the EORTCQLQ-CR38 [187] and the FACT-C [188], eachwith a few items assessing sexual function. Itremains difficult to compare rates and types ofdysfunction across studies, however, because someresearchers use idiosyncratic questionnaires andsome use the more detailed International Indexof Erectile Function [179,189,190] and FemaleSexual Function Index [179,191] scales, whichmeasure sexual function in any adult population.Although a number of surveys have concluded thatmen are more likely to have sexual dysfunctionthan women after treatment for rectal cancer[192–195], few data are available for women. Manyelderly women are not sexually active at the time ofcancer diagnosis [179,192,193,196]. Typically they


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lack a partner or their partner is ill or has ED.Women also appear more likely than men to giveup sexual activity after cancer treatment [179,192].For those women who remain sexually active,prevalence and types of problems appear similar tothose in women treated for other pelvic tumors,such as cancer of the bladder, ovaries, or uterus[172]. For further reading, multiple studies havelooked at sexual function after treatment for coloncancer among men [179,181,189,192,197–199]and among women [179,192,197].

Unfortunately, researchers have focused on thephysiological impact of cancer treatment withoutexploring the relationship between sexual functionor satisfaction and other indices of mood andcoping [178,179,183,192,193,200]. It is probablethat emotional variables, including premorbid psy-chosocial adjustment, social support, and socio-economic status interact with physiologicalimpairment in determining sexual outcomes.Because many men in the age group at high riskfor colorectal cancer already have erection prob-lems, some surveys have found older age to be abetter predictor of sexual function than a specifictype of colorectal cancer treatment [193,200].Finally, a greater proportion of women in thecohorts refuse to complete questionnaires that askabout their sexuality. In six recent surveys thatprovided information on participation from menvs. women in completing sexual items, responserates for men ranged from 52% to 100% com-pared with 27% to 70% for women[179,192,197,200–202].

Anal cancer, unlike colorectal cancer, is a type ofskin cancer that is strongly related to the humanpapilloma virus. Research has not yet examined theimpact of anal cancer on sexual behavior or satis-faction. As treatment usually involves simulta-neous local radiation therapy and chemotherapy[203], receptive anal intercourse would probablybecome painful and alternative types of sexualstimulation might need to be substituted.Radiation-induced vaginal stenosis is alsolikely.

Hematopoietic Cancers and Cell Transplantation

Over the past 20 years, survival after hematopoi-etic cell transplantation has increased dramatically,making QoL more salient [204]. Transplant mate-rial may be gathered before preparation from thepatient (autologous transplantation) or is obtainedfrom a donor matched to the recipient on humanleucocytic antigens, proteins on the surface of

blood cells (allogeneic transplantation). Increas-ingly, less intensive regimens are used, followed byinfusing blood stem cells and using growth stimu-lating factors (usually granulocyte colony-stimulating factor) to increase stem cellproduction [204]. New techniques allow stem cellsto be purified from the patient’s own blood, reduc-ing the chance that a transplant will contain cancercells [205]. Cord blood is used most often for chil-dren, as it contains a limited number of stem cells[205].

Multiple physiological impacts of hematopoi-etic transplantation affect sexual function [206–225]. Most studies have small numbers ofparticipants with few including baseline measure-ments and/or comparison groups that have notbeen transplanted. Limited conclusions can bedrawn. Sexual function is affected more severelyfor women than for men.

The most common adverse effects found inmost studies among men are ED and decreasedorgasm and among women are decreased desireand vaginal dryness. Primary hypogonadismresulting from chemotherapy, especially alkylatingagents, can cause decreased desire, ED, anddecreased semen volume in men, while prematureovarian failure can result in loss of sexual desire,vaginal dryness, and dyspareunia in women.Failure to begin puberty in children, mostcommon during chemotherapy with busulfan, ismore common among girls. Autonomic nervedamage that may result from chemotherapy withvincristine or platinum-based drugs can result indecreased erection and/or ejaculation. Damage tothe vascular bed resulting from total body irradia-tion can result in ED or decreased vaginal secre-tions. Graft vs. host disease can cause penilecurvature, pain, and ED in men, and vaginalinflammation and scarring and vestibulodynia inwomen.

Although some recovery of sexual activity andpleasure occurs in the first 2 years after transplan-tation, survivors remain more likely than controlsto experience sexual dysfunction even 5–10 yearsafter their cancer treatment. The presence of sig-nificant sexual problems after conditioning andbefore transplant suggests that the long-termsexual dysfunction has complex causes. Not onlymay prior cancer treatment have damaged pelvicnerves and vasculature or reduced hormone pro-duction, but the intensive conditioning to preparefor hematologic transplantation, as well as theongoing psychological stress exacerbate sexualproblems.

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Cancer in Children and Teens

Research on the QoL of survivors of cancer inchildhood and adolescence has rarely investigatedsexual function. The past 10 years have brought averitable explosion of research on the impact ofpediatric and adolescent cancer on fertility[226,227]. Yet, almost no empirical data are avail-able about sexual development in young survivors.Some will not even go through natural pubertywithout hormonal support [228], and a largergroup bears visible signs of their cancer history,such as very short stature, obesity, loss of a limb, orfacial deformities. Most have little idea that theymay be at risk not only for infertility, but for sexualproblems as well. A survey of 217 cancer survivorsaged 18–40 at approximately 3–5 year follow-upfrom treatment found that about half desiredcounseling on sexuality, just as many as wantedassessment of infertility or counseling on adoptionservices [229]. Unmet needs were particularlyacute in the group aged 18–29, whose age at diag-nosis put them in the Adolescent and Young Adultpopulation that is now a focus of attention [230].

Even once these young people reach adulthood,research on sexual function seems to be off limits.In the past 10 years, only two surveys of small,selected groups have been published. Men treatedfor low testosterone resulting from several typesof childhood cancer treatments rarely reported“normal” sex lives [231]. Eugonadal survivors weremore likely to meet criteria for being sexuallyfunctional, but the rate of problems was higherthan expected among young men. A more recentDutch study of childhood cancer survivors [232]over age 25 years found that experience with sexualintercourse was significantly lower than agenorms. Being diagnosed during adolescence led todelays in sexual development in terms of dating,experimenting with intimate touch, intercourse,and for women, with masturbation. Sexual prob-lems were common: 41% reported low sexualdesire, 45% sexual dissatisfaction, 44% feelingunattractive, and 14% feeling their cancer historyinterfered with their chance to have a futureromantic relationship. Of note, these two surveyswere conducted in Northern Europe, where ado-lescent sexuality is not stigmatized as it is in theUnited States [233].

Psychoeducational models used to counsel ado-lescents about reproductive health issues haveshown some short-term increases in knowledge,decreased general emotional distress, more posi-tive body image, and less anxiety about sexuality

and dating [234]. In the future, it might be moreacceptable to teens to use an Internet-based orpeer counseling model along with the material inthe workbook.

Cancer in Women

Gynecological CancersSurgical removal remains the mainstay of treat-ment for many gynecological cancers, especiallyovarian in origin. Pelvic radiation is often theprimary or main adjunctive treatment for cervicaland some endometrial cancers: external beam ifoften followed by intravaginal or brachytherapy.The sudden loss of ovarian hormones fromsurgery or chemotherapy also contributes to sexualdysfunction.

Women with these diagnoses consider theirsexual health to be one of the three most importantaspects of quality health care [235] and while 74%in one study believed their physicians shoulddiscuss sex [236], such discussions did not occur in62% of the time. Moreover, sexual dysfunction canbe the primary source of distress from symptomsrelated to cervical cancer treatment [237]. Theprevalence studies [236–251] of sexual dysfunctionafter specific gynecological cancers are often diffi-cult to compare as sample size, oncological stages,and follow up times are variable. Recent studiesdemonstrate that between 30% and 63% ofwomen who undergo treatment for cervical cancerexperience some sexual complaint [238]. Themajority of women (62–88%) are at high risk fordeveloping vaginal agglutination, stenosis withinthe first 3 months after radiotherapy [252].According to the National Cancer Institute,research shows that approximately one-half ofwomen who have been treated for breast andgynecologic cancers experience long-term sexualdysfunction. Qualitative study highlights theimportance of lost femininity and fertility and thefear of dyspareunia in women with endometrialand cervical cancer [239].

The sexual side effects of treatment for gyneco-logic cancer are of multifactorial etiology andinclude direct and indirect mechanisms [253–255].Cancer treatment modalities including chemo-therapy, surgery, and radiation as well as patientand partner psychosocial issues can all influencesexual function. Chemotherapy can cause prema-ture ovarian failure resulting in adverse effects ofhormone deficiency. Surgical procedures and tech-nique have a significant impact of sexual function.Radical hysterectomy for cervical cancer is noted


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to have persistent negative ramifications on sexualdesire whereas lubrication and other vaginal con-cerns may dissipate over time, as noted in onestudy where the autonomic nerves in the cardinaland uterosacral ligaments were likely spared [238].Nerve-sparing radical hysterectomy is in itsinfancy [256] but early data suggest neurovascularpreservation leads to improved sexual function[51,241].

Ovarian removal signifies both reproductiveloss and the advent of menopause [257]. Bowelresections and anterior/posterior exenterations foradvanced gynecologic malignancy can result instomas, colostomies, and ileoconduits impactingon self-image. Radiation can cause skin fibrosis,and vaginal narrowing and shortening.

Some surgical techniques are becoming lessaggressive without impact on survival as oncologi-cal surgeons consider sexual health concerns: cli-toral preservation surgery for vulvar cancer offersselected women decreased morbidity with preser-vation of sexual function [258]. There are ongoingstudies of radical tracelectomy (which preservesfertility) for early cervical disease and subsequentsexual function. The emerging trend is to provideadequate cancer treatment, but with minimal sur-gical removal of tissue and to minimize long-termnegative sexual consequences [259]. In all cases,adequate preparation and information may facili-tate sexual adjustment after surgical intervention[260].

Sexual self-schema may account for variance inpredicting current sexual behavior in cancer survi-vors; those with positive self-sexual concept mayadapt more positively [239]. Recently, studies havenoted the success of brief psychosexual interven-tions and of addressing the informational andsexual needs of cancer patients [261–263]. Mind-fulness training that has been incorporated into apsychoeducational program for women witharousal disorder subsequent to gynecologicalcancer has been effective in preliminary studies[264,265]. An effective method of treatment forsexual difficulties in cancer patients is through thecoordinated provision of information, support,and symptom management [262]. Limited studyhas shown increased compliance with therapy andsubjective improvement in sexual symptoms [266].

Areas identified for future study to reducesexual dysfunctions following pelvic surgery inwomen include: (i) vaginal dilator use to increasecompliance and gain optimal comfort and pleasurewith intercourse; (ii) which of the minimallyabsorbed local vaginal estrogen products (ring,

tablet, or cream) best restores vaginal integrity andsexual satisfaction; and (iii) the safety of intravagi-nal dehydroepiandrosterone (DHEA) to providelocal tissue synthesis of estrogen and testosteronemay be explored in this population [267].

Breast CancerSexual concerns are distressing complications forwomen during their diagnostic, treatment, andsurvivorship phases of breast cancer. Etiologicalfactors include premature menopause, premorbidsexual dysfunction, and negative self-concept[268,269] relationship discord and depression[270]. Women of Asian [271] or African American[272] descent may be less communicative aboutsexual health concerns and possibly more prone tosexual dysfunction after breast cancer, but this hasyet to be determined. There is limited study onbreast cancer survivors who are lesbian, bisexual,or single.

Sexual complaints after the diagnosis of breastcancer, occurring alone or in combination, arerelatively common including all sexual complaints30–100%, desire disorder 23–64%, arousal orlubrication concerns 20–48%, orgasmicconcerns 16–36%, and dyspareunia 35–38%[261,270,272,273]. Treatment-related effects[253,274,275] occurring with chemotherapyand/or hormonal manipulation are similar to thosenoted for gynecologic cancers in the previoussection. The probability that a woman will entermenopause as a result of chemotherapy increasesdramatically at the age of 35. More than 40% ofwomen receiving chemotherapy at the age of 40become amenorrheic [276]. Weight gain with che-motherapy and hormonal manipulation has beenlinked to women’s feelings of lost attractiveness[277]. Goodwin et al. [278] noted a mean overallweight gain of 1.6 kg, with an average gain of2.5 kg, in newly diagnosed breast cancer patientsreceiving chemotherapy, and a 1.3-kg gain in thosetaking tamoxifen. Tamoxifen, a first generationselective estrogen receptor modulator, is pre-scribed to block estrogen receptors in the breast,but it also acts as a weak estrogen agonist on theuterine lining requiring monitoring for adverseendometrial effects. It is probably neither agonistnor antagonist in the vagina. Studies that havelooked at the impact of tamoxifen on sexual func-tion have proven inconclusive [279]. Aromataseinhibitors (Anastrozole, Letrozole, and Exemes-tane) are rapidly becoming the mainstay of treat-ment for various stages of breast cancer. Thesedrugs prevent the production of any estrogen and

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many women complain of vaginal dryness, moder-ate and severe dypareunia, exacerbated meno-pausal symptoms, and loss of sexual desire [280].Scientific data are limited. Management mayinclude encouragement of nonpenetrative sex ifnonestrogen vaginal products to ease dyspareuniaare insufficient.

Breast surgery can result in loss of sexual self-image, loss of nipple sensitivity, scarring that canbe disfiguring and painful, lymph node dissectioncausing swelling, and possibly painful lymphe-dema. Radiation can result in skin fibrosis, loss ofsexual sensitivity of the skin, cardiac and respira-tory damage, fatigue alopecia, diarrhea, andgeneral malaise negatively impacting sexual desireand response. Studies are lacking with respect toMammoSite (Hologic Corp. Bedford, MA, USA),a novel minimally invasive intramammary place-ment of radiation at the time of surgical interven-tion and its implications on female sexual function.

Up to 10% of women with breast cancer mayhave a genetic predisposition for the developmentof ovarian cancer because of breast cancer suscep-tibility gene (BRCA) mutations and some of thesewomen may choose to undergo a risk-reducingbilateral salpingo-oophorectomy (RRBSO). In arecent study [281], women who underwent aRRBSO were negatively impacted, experiencingdyspareunia and reduced body image [282]. Inaddition, many women choose to undergo prophy-lactic mastectomy of the breast unaffected bycancer, fearing bilateral involvement or anotherprimary breast cancer. Study of subsequent sexualfunction is scant but cosmetic results are notalways favorable and may negatively impact sexualself-esteem. Sexual problems may be more signifi-cant immediately after surgery and some graduallydecrease with time, but there is still a need toaddress sexual issues, especially in younger breastcancer survivors.

The literature confirms that many women adaptwell after they learn of their diagnosis but there isa subset of women who report continued anxiety,depression, and concerns regarding body image,fear of recurrence, post-traumatic stress disorder,and sexual problems well after treatment comple-tion [276]. Other emotional concerns may includehesitancy to start a new relationship with need todisclose medical details, and fear of rejection by apartner coupled with the stress and sadness of pos-sible changed fertility, life plans, and finances.Spouses can also have mood changes and developdepression. Sometimes, women link prior negativesexual experiences, past sexual behavior (promis-

cuity, extramarital affairs, or acquisition of sexuallytransmitted diseases) to their cancer diagnosis.Younger and distant recurrence patients may havethe greatest risk for sexual dysfunction [283]. Boththe frequency of intercourse and kissing declinesignificantly.

Survivors’ levels of relationship distress, depres-sion, and age rather than hormonal levels haveproved the most significant variables affectingarousal, orgasm, lubrication, satisfaction, andsexual pain [5,275]. One study of women receivingongoing anti-estrogen therapy noted that relation-ship factors predicted desire and a history ofchemotherapy predicted problematic arousal,lubrication, orgasm, and pain. However, there wasno relationship between sexual function and hor-monal levels including androgen metabolites[284]. The experience of chemotherapy ratherthan the resulting low hormones appeared to behighly detrimental to sexual function.

It is imperative to counsel patients concerningpossible sexual remedies including treatments forvaginal dryness [273]. As breast cancer is oftenhormonally sensitive and tumor cells possessestrogen and progesterone receptors, treatment ofmenopausal sequelae with systemic replacementhormones is almost always contraindicated. Theuse of alternative medications, including serotoninreuptake inhibitors, antihypertensive medications,and environmental modifications (rhythmicbreathing, acupuncture, vitamins, avoiding spicyfoods and alcohol, dressing in layers) is becomingmore widely accepted to help decrease the inten-sity and severity of menopausal symptoms, thoughevidence of efficacy with these modalities islimited. Sexual health resources to enhance bodyimage (wigs, special lingere, attachable nipples,etc.) should be widely available to help the survivorreclaim her sexual self-esteem. The use of mini-mally absorbed local vaginal estrogen productsremains an individual decision that requiresinformed consent and consultation with the oncol-ogy team [253,285]. Several small reports [286]noted increased estradiol levels in women whotake aromatase inhibitors and vaginal estrogentablets. New lower dose tablets need further inves-tigation and safety in breast cancer populations islacking. Preliminary studies suggest that 0.5 g ofPremarin vaginal cream applied twice weekly hasno endometrial effects and is not systemicallyabsorbed; however, it remains officially contrain-dicated in hormonally sensitive cancer survivors[267]. Long-term safety data are lacking such thatthe use of local estrogens for the treatment of


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vaginal atrophy after breast cancer women remainsexperimental: the amount of escape into the sys-temic circulation has the potential to interfere witharomatase inhibition. Nonhormonal water-basedlubricants and moisturizers remain the primarytreatment. Delivery of DHEA to the vaginal tissuemay allow strictly local androgen action and, withan aromatase inhibitor preventing the accumula-tion of any local estrogen, be a preferable choice inthe future for women who must be strictly sys-temically estrogen deplete [287]. A phase III RCTof 216 postmenopausal women without breastcancer given DHEA, has confirmed maturation ofepithelial cells and decrease in pH without signifi-cantly increasing serum estrogen or testosteronelevels, with all steroid values remaining in therange seen in postmenopausal women. Alldomains of sexual function improved [288,289].

The safety of androgen replacement in thebreast cancer population has not been adequatelystudied. The use of androgen replacement inestrogen-deficient breast cancer patients was noteffective for lowered libido in a recent randomizedplacebo-controlled crossover clinical trial [290].Future studies are needed to examine the safetyand efficacy of androgens in this population.

Psychosexual counseling and possible psycho-logical therapies for sexual dysfunction should beoffered to all breast cancer survivors with sexualcomplaints specifically addressing possible anxiety,

stress, unpleasant symptoms including hot flashes,sexual comfort in lovemaking, and mood changesfrom the imposed infertility. Taken together, thetrio of counseling, over-the-counter remedies, andpharmacologic treatments can do much to amelio-rate the sexual issues caused by breast cancer andits management [291,292].

Recommendations for Reducing Cancer Impact onSexual Activity

Recommendations for physiologic management ofcancer that may mitigate the impact of cancer onsexual function and satisfaction are described inTable 1. More studies are needed in every cancercategory. General recommendations that areappropriate for all types of cancer include: (i)manage pretreatment sexual problems the same asin persons without cancer; (ii) use treatment tech-niques least likely to damage nerve, vascular, orother local structures; (iii) manage any hormonalresults of treatment; and (iv) make use of appro-priate posttreatment psychological, pharmaco-logic, and mechanical sexual aids

The psychosocial aspects of a cancer diagnosisare myriad and complex. Every stage of manage-ment, from initial diagnosis to treatment to thesurvivor stage, has a variety of psychosocial stres-sors for the patient, partner, and other loved ones.The cancer management team needs to continu-

Table 1 Some recommendations for physiologic management of cancer and treatment to reduce incidence of sexualproblems

Type of cancer/treatment Recommendation Grade

Prostate watchful waiting Treat LUTS CSurgical treatment Perform anatomical nerve-sparing RP B

Refine techniques including avoiding cauterization and preserving accessory pudendal artery CRadiation treatment The likely multifactorial etiology should guide therapy CAndrogen deprivation therapy Discuss sexual sequelae of medical vs. surgical ADT CTesticular cancer Avoid nerve damage during RPLND surgery C

Offer testicular implant CPenile cancer Preserve maximal penile shaft CBladder cancer Sparing anterior vaginal wall and/or neurovascular bundles may help women preserve

sexual functionC

Colorectal cancer Avoid abdominoperineal resection CAvoid adjuvant radiotherapy if possible BLaparoscopic total mesenteral resection may enable nerve sparing C

Hematopoietic cancers andtransplantation

Use topical treatment for genital graft vs. host disease CTreat ovarian failure and dyspareunia with local or systemic estrogen C

Cancer in children and teens Strong recommendation for research of sexual health in this population CGynecologic cancers Nerve-sparing technique has better outcome C

Vaginal dilators are useful to maintain vaginal patency CMinimally absorbed local vaginal is helpful for most survivors C

Breast cancer Tamoxifen is likely neutral on sexual function CLocal vaginal DHEA may be useful, more research is needed CNonhormonal water-based lubricants and moisturizers improve dypareunia C

DHEA = dehydroepiandrosterone; ADT = androgen deprivation therapy; LUTS = lower urinary tract symptoms; RP = radical prostatectomy;RPLND = retroperitoneal lymph node dissection.

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ously address, counsel, and educate about sexualfunction throughout the course of the cancerpatient’s life. Discussions of precancer sexual func-tion, sexual dysfunctions caused by disease manage-ment, and disease natural history should beundertaken when a cancer diagnosis is made [2,6].Patients with cancer desire to have the opportunityto discuss sexual concerns with their medical teamsalthough most of these studies look at specificallywomen with gynecologic tumors [293,294]. Rec-ommendations for the content of this discussion areincluded in Table 2 (adapted from [2,3]). Thesediscussions can occur intermittently during man-agement and need to be brought up by the clinicalteam. Couple-based interventions are beginning toshow some improvement in women’s sexual adjust-ment and body image after cancer. A meta-analysisstudying women with cancer showed that the stron-gest positive effects were couple focused andincluded: (i) educating both partners about thewoman’s diagnosis and treatment; (ii) promotingcouples’ mutual coping and support processes; and(iii) including specific therapies to address sexualand body image concerns [295]. Interventionsappeared to be most effective when started near thetime of diagnosis and initiation of treatment. Thereis little information about how men respond tocounseling, but information should be offered topeople with cancer at regular stages after diagnosisand during treatment and chronic management.

Conclusion

Sexual dysfunction and dissatisfaction is fairlycommon following a cancer diagnosis and is often

exacerbated by treatments. More studies areneeded to clarify which patient and caregiverfactors as well as which treatment choices offer thebest chance of maintaining sexual functioning.Pretreatment counseling should include both pre-diagnosis sexual activity assessment, as well aspatient and partner education and inclusion intreatment decisions. Posttreatment managementshould include additional sexual health discussionsand the offering of psychological, pharmacologic,and/or mechanical aids that can mitigate resultingsexual problems.

Corresponding Author: Luca Incrocci, MD, PhD,Erasmus MC-Daniel den Hoed Cancer Center, P.O.Box 5201, 3008 AE Rotterdam, The Netherlands.Tel: 31 10 70 41 507; Fax: 31 10 70 41 013; E-mail:[email protected]

Conflict of Interest: Dr. Krychman is a speaker for WarnerChilcott and Wyeth Pharmaceuticals and a consultantto Boehringer Ingelheim, Johnson & Johnson, AstraZenica. No conflict of interest to declare for Drs.Basson, Incrocci, Martin Morales, Sadovsky, Schover,and Wang.

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