Ask About Sexual Function in Breast Cancer Patients on Endocrine Tx

Roxanne Nelson, RN, BSN

October 31, 2019

SAN FRANCISCO — Breast cancer patients taking endocrine therapy to prevent a relapse have long reported adverse effects on sexual function, but a new study suggests that this issue affects nearly all of these women.

Just about all (99%) of the postmenopausal women who took part in the study scored low on the Female Sexual Function Index (FSFI), indicating a high degree of sexual dysfunction, including vulvovaginal dryness and severe dyspareunia (painful intercourse).

The problem appeared to be most pronounced in postmenopausal women who began with tamoxifen and then transitioned to aromatase inhibitors (AI), as they had lower scores on the FSFI than postmenopausal women on tamoxifen, noted lead author Jeanne Carter, PhD, head of the Department of Sexual Health and Women's Health at Memorial Sloan Kettering Cancer Center in New York City.

The average FSFI score was lowest in those postmenopausal women who took endocrine therapy for the longest time, "so it really speaks to the cumulative effect of these therapies," she added.

Carter reported the new results here at the Supportive Care in Oncology Symposium 2019.

In a discussion of the study, Charles Loprinzi, MD, a medical oncologist at the Mayo Clinic, Rochester, Minnesota, emphasized that there are important clinical applications to be drawn from this study.

First is to "believe patients when they say that they do have symptoms," and "secondly, even if they don't bring it up, ask patients."

Loprinzi also emphasized that it is important to "provide advice and refer to appropriate experts if you don't feel like you have as much advice to give."

Basically, sexual function is not discussed very much, he commented. "And part of the reason [is] we are busy with lots of other things, and patients have other things on their mind."

High Symptom Burden

The study involved 446 women who were seen at the Female Sexual Medicine & Women’s Health Program (FSMWHP) at Memorial Sloan Kettering Cancer Center. Of this group, 77% were postmenopausal; 7% were actively on ovarian suppression, and 16% were peri- and premenopausal patients with breast cancer.

The women were on several different therapeutic regimens: postmenopausal women on AIs alone (30%); on tamoxifen followed by AI (22%); tamoxifen alone (16%) or no therapy (16%); and pre/perimenopausal women who received tamoxifen alone (9%) or no therapy (5%).

The postmenopausal women on tamoxifen tended to be less sexually active as compared with the other groups, Carter noted. There was also a shorter time since treatment completion in the endocrine suppressed group and the pre- and perimenopausal women vs the postmenopausal women.

On average, postmenopausal women were 13.25 years older than the women who were suppressed or receiving tamoxifen, and the average time since initial diagnosis was 6.25 years in the postmenopausal group, 4 years in the suppressed group, and 2.5 years in the pre- and perimenopausal group.

The initial consult took place an average of 3.3 years posttreatment in postmenopausal women and 1.8 years in the younger groups.

When looking at vaginal outcomes, severe pH was highest among postmenopausal women or those receiving their first treatment with tamoxifen and then put on ovarian suppression. Vaginal tissues overall were thin with endocrine use in all age groups (63%), and Carter noted that long term endocrine therapy use may contribute to stenosis in some women.

For vulvar outcomes, atrophy was high in postmenopausal women and those with ovarian suppression (50%) as compared to the pre- and perimenopausal group (18%). Vulvar irritation without atrophy was higher among pre- and perimenopausal women who were on tamoxifen (44%) as compared with that age group not on endocrine therapy (19%).

"We should be intervening early, since it's necessary to address vulvar atrophy in postmenopausal women, as well as women being suppressed," said Carter. "And vestibular irritation was present in all groups from 53% to 70%, which I think is an issue that people are not aware of. Vestibular irritation can contribute to insertional pain or pain with exams."

When the women were asked how concerned or worried they were about their sexual function and vulvovaginal health, the majority expressed a high degree of concern. This concern was most pronounced among the pre- and perimenopausal women, whether or not they were on tamoxifen.

"We also asked them about how confident they felt about future sexual activity, and 46% to 76% of the population did not feel confident about future sexual activity, which can be connected with these symptoms," Carter said.

Finally, women were queried about vulvovaginal tissue quality, which is a patient-reported assessment of a woman's view of her tissue quality, such as if she’s having vaginal dryness, vulvar dryness, pain with vaginal penetration, or any discomfort with external stimulation. "All cohorts were more symptomatic in the vulva than in the vagina, so it's an area of concern that's not being addressed," said Carter. "Vulvar symptoms of dryness and painfulness to the touch were highest in our active ovarian suppressed group, which may be because the young group is more sexually active."

Carter has disclosed no relevant financial relationships. Coauthor Shari Beth Goldfarb has disclosed relationships with Intrarosa, Sermonix Pharmaceuticals, Paxman, and Valeant Pharmaceuticals International. Loprinzi reports relationships with Asahi Kasei, DISARM Pharmaceuticals, Metys Pharmaceuticals, PledPharma, Bristol-Myers Squibb, Janssen and Hologic/Cynosure.

Supportive Care in Oncology Symposium (SCOS) 2019: Abstract 8. Presented October 26, 2019.

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