Just as having a baby renders you forever different; managing any chronic illness or even a divorce leaves you knowing ‘you will never be the same again.’ It is called ‘Survivorship’ and has become incorporated into the terminology and management of cancer care. We refer to it as ‘Survivorship Medicine’. We know more cancer patients become ‘survivors’ as treatment expands their lives. Thus, as health care providers, the areas of care have extended from only addressing the disease to include maintaining or restoring Quality of Life (QoL). Sexuality is one domain of QoL that is frequently ignored by cancer specialists and health care providers.
‘The success or failure of cancer treatment is not judged solely on the basis of cure but also on how it affects quality of life (QoL) for patients, their partners and their families.’ (Katz A, Woman Cancer Sex, 2009). Also there are organisations, volunteers and media campaigns which in a multitude of ways support, educate and care for patients partners, families and communities.
What about sexuality in cancer survivors? Who is ensuring this domain of QoL is being attended to? Sexuality is not a conversation easily embraced by HCPs – Nor by patients, partners, families or communities. I am yet to see a billboard, advert or media campaign for an adapted prosthetic swimsuit or a vaginal moisturiser that boldly targets women with cancer. Even in the subtle advertising of PDE5I’s (Viagra, Levitra , Cialais) nowhere is it specifically marketed to men with prostate cancer or other forms of pelvic non-gynecological cancer. Quite silly actually since this is a ‘done deal’ target group ‘ if considered good candidates, these drugs are recommended first line therapies for men who will in all likelihood have erectile dysfunction.
For a person to enjoy healthy sexuality they need four major body systems that function well, namely psychological, vascular, neurological and hormonal. Cancer brings stigmitisation, anxiety, body image disruption, fear of the present and the future and that’s before any treatment has begun. It is no wonder that cancer survivors will have sexual difficulties, even dysfunctions. It is that clear. It is that true. In most cancers at least one of these four systems will be negatively impacted. You can always count on the psychological system being negatively affected. And then we have to take into consideration the impact of treatments as well as maintenance therapies on the physiological, anatomical and hormonal systems of cancer survivors.
I am getting ahead of myself. In my role of Sexual Medicine Clinician, Educator and Activist I am delighted to be writing this column. As HCPs I wish for you to consume the evidence based scientific information I will be sharing with you; to begin to put them into practice with your patients and even if some of the ideas I bring you may provoke you to discomfort (as all new ideas will do), I urge you to consider the needs, rights and QoL your patients and their partners deserve.
It is only since the early 1980’s that the range and frequency of sexual concerns after cancer treatment have been the object of empirical study. In the 1990’s research on the prevalence of cancer ‘related sexual dysfunction began to link sexual difficulties with the pathophysiology of cancer and its surgery, radiation, chemotherapy, hormonal manipulation and cytostatic medication. Current research focuses on the development of interventions to ameliorate the sexual side effects of cancer treatment. These include medications, physical aids and psychosocial treatments. (Brotto, L & Kingsberg, S. in Levine S et al Handbook of Clinical Sexuality for Mental Health Professionals, 2010)
The three foundational principles of Sexual Medicine for clinical evaluation and management are a good beginning for HCPs to understand how to approach working with cancer patients. These are:
- adoption of a patient-centered framework , with emphasis on cultural competence in clinical practice
- application of evidence- based medicine in diagnostic and treatment planning
- use of a management approach in evaluating and treating sexual problems in both men and women. ( Hatzichristou D et al in Journal of Sexual Medicine 2010;7;337-348)
What these principles mean is that the psychological, physiological and social aspects of cancer care, as in all chronic illnesses, are deeply intertwined. The cancer management team needs to continuously address, counsel and educate about sexual function throughout the course of the cancer patient’s life. Research indicates that interventions appear to be most effective when started near the time of diagnosis and initiation of treatment. Information should be offered to people with cancer as well as their partners at regular stages after diagnosis and during treatment and chronic management. (Sadovsky R et al in Journal of Sexual Medicine 2010:7: 349-373)
As HCPs we know that our patients have a responsibility to own their illness, to take responsibility for their illness at multiple levels. The ‘New Normal’ approach’s underlying premise is ‘illness brings a change in quality of life, including sexuality.’ To transition into the ‘New Normal’ sexuality we want our patients to embrace these three steps:
Step 1: Acknowledge this illness with concomitant sexual problems is happening to you
Step 2: Talk to your partner about what you are feeling and thinking
Step 3: Get help/facts , i.e. talk to your HCP about your sexuality.
In the months ahead I look forward to bringing you evidence based scientific information on specific aspects of cancer and sexuality. Case studies will form a part of each article. I most welcome your comments, queries and case studies so that this becomes a vital interactive learning forum.
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