Sexuality, sexual function important aspects of survivorship care

I read with interest the Oncology Brief by Dr Anna Wilkinson in the July/August 2024 edition of Canadian Family Physician that provided a road map for family physicians caring for cancer survivors.¹

I was disappointed to see that an important aspect of survivorship care was omitted; sexuality and sexual function have been identified as unmet needs for cancer survivors.²

Treatments for the 4 cancers with road maps in the article (breast, colon, lung, and prostate) result in substantial sexual problems. One meta-analysis of women treated for breast cancer indicated 73% met the diagnostic criteria for female sexual dysfunction.³ Loss of libido causing distress is one of the most common sexual problems, with 57% of women taking aromatase inhibitors reporting this in 1 study.⁴ Vulvovaginal atrophy associated with this class of drugs is the cause of dyspareunia in 93% of women.⁵ Seventy-one percent of women treated with mastectomy and reconstruction report loss of breast sensuality, an important aspect of sexual arousal for many.⁶

In men treated for prostate cancer with surgery, 95% report profound erectile dysfunction at 6 months after treatment⁷ and only 43% of younger men report a return to baseline erectile function at 3 years after surgery.⁸ Older men, who are usually treated with radiation therapy, fare slightly better with 88% experiencing loss of erections 6 months after treatment.⁷ When androgen deprivation therapy is added to the radiation therapy regimen, additional sexual side effects are experienced including genital shrinkage (42%), pain with orgasm (15%), and decreased skin sensation.⁹ Twenty-five percent of men who have surgery for rectal cancer experience erectile dysfunction¹⁰ and 93% of men who had multimodal treatment for rectal cancer reported negative impacts on erections.¹¹

Family physicians see cancer survivors at all stages of the disease and, due to their longitudinal relationships with these survivors, should be addressing all short- and long-term consequences of cancer treatment. Ignoring challenges related to sexuality and sexual function, as well as the distress and changes in intimate relationships that result, is a missed opportunity for patient-centred care. Most survivors want validation and normalization of their sexual concerns at a minimum, but some will want interventions for these. It behooves family physicians to be aware of these sexual challenges and inclusion of them in any road maps for cancer survivorship is essential.

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