Fran Lowry

April 07, 2016

HOLLYWOOD, Florida — Sexual dysfunction is a common problem among cancer survivors and is likely to remain an important survivorship issue until data from evidence-based interventions emerge that can really help both men and women, experts said here at the National Comprehensive Cancer Network (NCCN) 21st Annual Conference.

For the first time, the NCCN guidelines mention two new agents: ospemifene (Osphena, Shionogi & Co, Inc) for vaginal dryness and flibanserin (Addyi, Sprout Pharmaceuticals) for lack of libido in women.

"But I can't use these drugs because they are not indicated for my cancer patients," Michelle Melisko, MD, from the University of California, San Francisco, Helen Diller Family Comprehensive Cancer Center, told Medscape Medical News.

Sexual dysfunction is likely to become more prevalent in young breast cancer survivors with increasing use of ovarian suppression, said Dr Melisko, whose practice focuses on breast cancer treatment and research.

She cited one study (Raggio GA et al, Psychol Health. 2014;29:632-650) that assessed 83 breast cancer survivors at a median of 7 years after their diagnosis.

The study assessed demographics; treatment information; sexual activity; sexual function, using the Female Sexual Function Index (FSFI); body image; and distress, using the Female Sexual Distress Scale–Revised.

The results showed that 77% of all women and 60% of the sample who were sexually active reported sexual dysfunction based on the FSFI.

"Their body satisfaction was worse than normal values, mastectomy was associated with worse sexual and body change distress, and posttreatment weight gain also predicted greater body dissatisfaction and body change stress," Dr Milesko said.

A greater number of younger women are being treated with longer courses of aromatase inhibitors, "so we will be seeing more vaginal dryness and sexual complaints," she said.

Some nonhormonal options to address vaginal dryness include coconut oil, olive oil, mineral oils, vaginal lubricants for sexual activity, and topical vitamins D and E. In one recent trial of 44 women, topical vitamin D reduced pain during intercourse and decreased vaginal pH compared with placebo after 8 weeks (Rad P, Iran J Nurs Midwifery Res. 2015;20:211-215).

Updated NCCN Guidelines for Male Sexual Health

"The 2016 guidelines are a simplified, user-friendly version of the past guidelines for sexual health issues in men after cancer treatment," Joseph B. Narus, DNP, Memorial Sloan Kettering Cancer Center, New York City, told Medscape Medical News.

Dr Joseph Narus

The guidelines have eliminated the use of hemoglobin A1C testing to rule out diabetes, as well as cholesterol and creatinine testing. They do continue to recommend testosterone testing, but now emphasize that this should be done in the morning, Dr Narus said.

The new guidelines also address orgasmic and ejaculatory problems, as well as low libido, he said.

"The discussion about erectile dysfunction management is now limited to trying an oral PDE5 inhibitor. Anything more complex should be referred to a specialist," Dr Narus said.

"The previous version of the guidelines spoke about second-line treatment options for erectile dysfunction, such as intracavernosal injection therapy, penile vacuum devices, and intraurethral suppositories, but these are not referenced in the current version," he said.

"I think one of the reasons is that these are more complex treatments and should be prescribed by an experienced clinician because of the potential side effects," Dr Narus said.

Clinicians are also advised to introduce a discussion about sexual health and concerns at the beginning of their evaluation.

"Start at the onset. Assess the patient's comfort level. Patients may not be open at their first visit because they are so focused on the cancer and therefore don't want to discuss it. However, as the patient gets to know the clinician and the clinician's team, he may feel that, as side effects come up with treatment, he will want to address those side effects," he said.

Erectile dysfunction that goes untreated can lead to permanent problems with erections, Dr Narus added.

"There are studies showing that erectile function should be evaluated and managed early in recovery in men who are not able to achieve erections after pelvic surgery, as poor oxygenation of the penile corporal bodies can lead to venous leak due to fibrosis of the tissue. It is important to be proactive," he said.

In his experience with patients undergoing cancer treatment and experiencing sexual problems, Dr Narus said he has learned to be "a very active listener."

"Patients will come in, and I basically ask them, what brings you in to see me today? I generally know the reason for their visit because they've checked it off on a box. It is important for them to tell me in their own words what is going on and not to disrupt the patient, particularly when it comes to issues of sexual health. A clinician should never try to get their agenda across or what they think the plan should be until the patient has had an opportunity to disclose their concerns and how they would like them addressed. Most of the patients have done their homework about interventions for erectile dysfunction. They have gone online and done research on cancer survivors, so they know what is out there," he said.

More Awareness Needed

"Sexual dysfunction as a result of cancer and its treatment, particularly in women with breast cancer and men with genitourinary cancers, remains an underdiscussed and underresearched problem," Lee Schwartzberg, MD, professor of medicine and chief of the Division of Hematology/Oncology at the University of Tennessee Health Science Center, Memphis, told Medscape Medical News.

"We need more awareness of the problem, more dialogue with our patients, and more evidence so we can help restore sexual function and improve survivorship," Dr Schwartzberg said.

Dr Melisko has financial relationships with Agendia BV, Eli Lilly and Company, Galena Biopharma, Genentech, Merrimack Pharmaceuticals, Nektar Therapeutics, and Pfizer. Dr Naros reports no relevant financial relationships. Dr Schwartzberg has financial relationships with Amgen Inc, Bristol-Myers Squibb, Caris Life Sciences, Genentech, Helsinn, Pfizer, and TESARO.

National Comprehensive Cancer Network (NCCN) 21st Annual Conference: Presented April 1, 2016.


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