Sex & Cancer: Conversations With Your Clinician

Recently, I gave a virtual talk to a large audience of primary care physicians. The topic was psychosocial issues for cancer patients and survivors, and a few slides and remarks were related to intimacy and sexual issues. When it came time for the Question & Answer segment, all but one question was related to sex. It was clear that the attendees knew this is important and felt uninformed and ill-prepared to talk with their patients about their concerns. It has always been my experience that oncologists feel similarly and are hampered by all the important worries that must be addressed in their too short visits with their patients.

Sexual health and possible sexual dysfunction resulting from cancer treatment are important topics on the clinician’s checklist.

A few years ago, the American Society of Clinical Oncology (ASCO) published guidelines for this conversation. This is a big deal as it recognizes that sexual health and possible sexual dysfunction resulting from cancer treatment are important topics on the clinician’s checklist. They recommend that all patients, regardless of age of diagnosis or treatment, should be offered psychosexual counseling, and any medical and potentially treatable factors should be addressed; these could include vaginal dryness or symptoms of vaginal atrophy in women and erectile dysfunction (ED) in men.

For a number of years, there have been recommendations like these. Clinicians are urged to raise the topic with their patients and to normalize their concerns. However, it seems that not a lot of progress has been made. In a 2020 survey administered by radiation oncologists, almost 400 patients with breast, endometrial, bladder, prostate, and rectal cancers were asked if their doctors had talked about sexual health with them. Not surprisingly, nine out of ten reported having sexual concerns or issues, but only 28% said that they had been asked about this by one of their providers.

An important goal is to somehow help oncology clinicians recognize the importance of these worries and to help them feel more comfortable raising the topic. There are few patients who can feel empowered to bring it up unless there is a real crisis brewing. It shouldn’t be impossible to take a few minutes to say something like: “Everyone who goes through cancer treatment experiences some problems with their intimate relationships. We can help with most of the concerns.”

Virtually all studies have also found a significant gender bias with many more men reporting conversations with their doctors than women. One reason for this may be the prevalence of prostate cancer and the strong likelihood of post-treatment (whether surgical or radiation therapy) sexual dysfunction. A 2020 study in Europe found that more than 75% of men who had been treated for prostate cancer said their sexual functioning was poor or very poor. Almost half also reported some degree of anxiety or depression and a lower than pre-cancer quality of life. The mean age of these men was 70, and that is an important reminder that sex remains important in our lives as we age.

In some ways, the physical issues are easier than the psychological ones. I have never met anyone who came through cancer feeling more sexy or virile than before the diagnosis. Our bodies have been battered and sometimes irrevocably changed. We may have lost body parts that were important in our intimate relationships, and our focus likely has been more on contending with chemotherapy side effects than on sex. Not all partners have been as comforting and supportive as we might have hoped, and even the most loving ones may have refrained from physical contact for fear of hurting us. Moving closer to one another can seem daunting.

There are a number of websites with helpful information; you can search online for “cancer and sex” to find some. A particularly imaginative one was launched in the United Kingdom last year: Sex with Cancer. In addition to products and advice, it offers training for medical professionals and a lot of resources for patients. The owners report that their best-selling items are lube and a button for healthcare providers that reads: Sex With Cancer Conversation Champion.