Many gynecologic and breast cancer survivors are sexually active, despite a high prevalence of sexual problems. 2–9,10,12–13
Several major cancer centers are exploring the creation of clinical programs to address these issues.14
However, physicians and institutions need data to demonstrate female cancer patients’ willingness to receive medical care for sexual concerns when considering investment in such clinical programs. This study, building on a small body of previous work by others, establishes not only need, but a substantial unmet need among women with breast and gynecologic cancer.
The current study finds that approximately 42% of all gynecologic and breast cancer patients seen in the gynecology oncology clinic at one urban academic medical center in Chicago were interested in seeking medical care for treatment of sexual problems, yet very few had done so. This corroborates findings by Huyghe and colleagues who found that, in a mail (26% response rate of a purposive sample) and clinic-based (17% response rate of a volunteer sample) survey of reproductive and fertility services needs among 124 female cancer survivors, that 39% of those with sexual problems would visit a medical doctor for help for a sexual problem if the visit were covered by insurance (this decreased by almost 50% if the patient had to pay out of pocket).15
Interestingly, in that study, patients with sexual problems were most likely to say that they would see a physician for sexual health care as compared to a mental health expert for personal counseling, couples therapy, or an all-female support group.15
Although the estimated prevalence of need for services to address sexuality issues in the current study is similar to Huyghe et al’s Houston-based study, that study included participants with a broader variety of cancer types including leukemia/lymphoma, colorectal cancer, breast and gynecologic cancers. Additionally, the prevalence estimate for seeing a physician for sexual health concerns was constrained to sexually active women,15
suggesting a lower overall interest than the 42% found in our study. This may be reflective of differences in response bias and/or the different populations surveyed; gynecologic and breast cancers and their treatments directly affect the female sexual organs and are known to have significant impact on psychosocial aspects of sexual functioning.2,12,16-18
The current study advances prior findings by documenting high interest in sexual health care in a larger, highly relevant sample of gynecologic and breast cancer survivors in the clinical setting, with a substantially higher response rate. In addition to establishing a high prevalence of need for services, our findings show how few women have independently sought this care and highlights a major discrepancy between need and solicitation of care in this patient group.
The current study also finds that reported need for sexual health care in women with gynecologic and breast cancer is independent of marital status, race, cancer type or cancer stage. Huyghe and colleagues also found that marital status and cancer type were not significant correlates of intended reproductive clinic usage, although they did not report which patients specifically desired care for sexual problems rather than for fertility concerns.15
Sexual problems in women with cervical or ovarian cancer have also been found to be independent of marital status.3–4
These findings provide evidence for physicians and others caring for women with cancer that marital status should not be used to profile which patients want or need help for sexual concerns. In our clinical experience at the Program for Integrative Sexual Medicine for Women and Girls with Cancer, we see married women, unmarried women with and without sexual partners, and lesbian women. The latter two groups are subject to stigma in health care encounters and may not disclose their sexual activity status to their physician, thus further isolating them from relevant care.19–21
Oncologists can easily and routinely assess need for sexual health services by ascertaining, for all patients, sexual concerns via a single or multi-item check-box on a self-completed form (the screening items used by our gynecology oncology group are shown in ) or via face-to-face review of systems during the physician visit. However, physician willingness to screen depends heavily on the availability of such services.10,22
If clinical services to address sexuality concerns among women with cancer are not locally available, patients may still benefit from the physician’s expression of empathy for the issue and direction to patient-oriented reading materials.5, 23–25
Sexual Health Screening Questions
In contrast to marital status, cancer type, and cancer stage, we did find that younger age was associated with somewhat greater interest in care to address sexual issues and willingness to be contacted by a formal sexual health program. However, we also found that more than one in five cancer survivors 65 years and older were interested in receiving sexual health care. Population and cancer registry studies demonstrate that the majority of older women 9
and cancer survivors2,3,5,14,26,27
value sexuality and think that sexual matters should be addressed by physicians. This highlights the fact that discussions of sexual side effects and outcomes with their physicians can help normalize these experiences for all patients, regardless of clinical and demographic characteristics.27
There is no evidence in the literature or clinical practice that patients are offended by physician attention to the topic of sexuality. To the contrary, asking about this aspect of a patient’s life signifies the physician’s concern for the patient’s and her partner’s overall well-being and openly acknowledges that cancers of the genital organs – and their treatment – often do impact women’s sexual life and functioning.2,26–28
In the current study, being more than 12 months from cancer treatment was significantly predictive of increased interest in care and willingness to be contacted for a sexual health program. To our knowledge prior studies do not specifically identify time since cancer treatment as a predictor of women’s interest in receiving sexual care. That women farther out from treatment were more interested in sexual health care is in contrast to prostate cancer care where the topic of sexuality is proactively addressed by oncologists and urologists as part of treatment planning and throughout the continuum of care.28,29
Our study did not survey women prior to treatment and no data exist to inform physicians about female cancer patients’ willingness to discuss sexuality issues as part of treatment planning or early in the course of treatment. We also do not address whether women would be willing to undergo interventions during the course of their treatment to address sexuality issues. Timing of patient interest in sexual care may also be dependent on the type of treatment, as undergoing prolonged interventions like chemotherapy or radiation may delay interest in care more than surgery alone. We did, however, find that as many as a third of patients currently in treatment for breast or gynecologic cancer responded positively to the needs assessment questions. We have also found, in a prior study of male and female lung cancer patients, that despite a very poor prognosis, sexuality was still a valued aspect of life that patients wanted addressed by their physicians.26
Although further research is needed, these findings suggest that even female cancer patients actively undergoing treatment or with uncertain prognoses are receptive to the topic of sexuality as part of their cancer care.
This study may be limited in its generalizability to populations in other care settings and with other cancer types, but complements the only other published study on the topic. The sample size in the current study limited subgroup analyses based on cancer type due to insufficient power. In addition, the survey questionnaire was created to inform clinical program development and was not initially intended for research purposes, thus limiting data collection to a very small number of items. While our study further establishes a need for sexual health care for cancer patients, there remains a lack of training and support for physicians in sexual health, evidenced by a paucity of sexual counseling services at comprehensive cancer centers in the US.15
In addition, there are few studies evaluating efficacy of interventions for sexual health morbidity in cancer survivors. 27,30
Future studies should focus not only on identifying those most likely to benefit from sexual health care but also in developing and evaluating specific types of interventions and their success at treating sexual dysfunction in this patient population. The Program in Integrative Sexual Medicine at the University of Chicago Medical Center was opened in October 2008 to specifically address sexuality issues among women and girls with cancer and is actively working with clinician-researchers at Memorial Sloan-Kettering Cancer Center and other U.S.-based cancer centers to build a network that will advance evidence-generating research and evidence-based practice in the field.31
Women with gynecologic and breast cancer have an unmet need for attention to sexual concerns. Women who have been treated for these cancers, regardless of marital status, age, cancer type or stage, should be informed by their physician of the sexual impact of their cancer and their cancer treatment. Identification of sexual concerns among this patient population requires physicians to incorporate screening into their clinical practice and throughout the continuum of cancer care. Further research is needed to expand the range of evidence-based options for treatment of sexual problems in women and girls with cancer.