Clinicians are not very good at talking about sexual and reproductive issues with cancer patients, according to Leslie Schover, PhD, a clinical psychologist and professor at the University of Texas MD Anderson Cancer Center in Houston.
“When they do surveys of unmet needs, in practically every survey that I've seen in recent years, cancer-related sexual problems rank pretty highly,” said Dr. Schover at the American Society of Clinical Oncology's 2013 annual meeting, held May 31 to June 3 in Chicago. About 50% of patients who have been treated for cancer have severe, long-term sexual problems, and they often go unaddressed, she noted.
One thing to keep in mind, Dr. Schover said, is the types of dysfunction that are likely in different patients, since counseling those at high risk can help them know what to expect. Vaginal dryness and pain with sex are extremely common in women taking aromatase inhibitors, while young breast cancer patients have a high risk for sexual problems if they become abruptly menopausal after chemotherapy, she said. Patients with pelvic cancer who have radiation therapy also are at increased risk of sexual dysfunction, while incontinence, a common side effect of some cancer treatments, can often cause patients to give up on sex entirely because of embarrassment, she said.
“Another unfortunate piece of news is that very few men have good sex lives after they get treated for prostate cancer,” Dr. Schover said. Studies have shown that fewer than 25% recover baseline erection quality after radical prostatectomy, and newer treatment methods have similar rates: “It doesn't matter if you do surgery with a robot or laparoscopically,” she said.
The National Comprehensive Cancer Network released new guidelines on cancer survivorship this year, but Dr. Schover described the section on sexuality as a great concept that was totally impractical.
For women, she said, the guideline first recommends an initial interview assessment, which would take at least five minutes to get through if you did discover any type of problem. The initial assessment for men involves a short self-report questionnaire, but there are problems with that too, she noted, because it only asks about erections and doesn't address other potential issues, such as decreased sexual desire, pain or changes in orgasm function.
“Then, if you find a problem, you're supposed to right then and there do a more complete sexual history, counsel the person on the impact of their cancer treatment on their sex life and their fertility, and do a physical exam,” Dr. Schover said. “My question is, who's going to spend 20 to 30 minutes on sexuality with literally half the patients in most oncology treatment settings?” Not only is there a lack of time and expertise in this area, she said, insurance coverage is also lacking.
As an alternative method that would achieve some of the same goals, Dr. Schover recommended following a model more like that used for psychological conditions in the U.K., which involves providing patients access to classes, written workbooks, or websites that can then be supplemented with phone counseling or email feedback, often by a peer or a trained nonprofessional coach. Individual therapy with a professional can be offered to patients who need it.
Dr. Schover said her research group, funded by small business grants from the National Cancer Institute, has developed websites on sexuality and fertility in cancer patients that also incorporate video vignettes and interviews, which she feels could be helpful given the very private nature of the topics. “Many people might not go to a support group but might be willing to use a website,” she said.
Blood test helps predict future fertility
For women considering becoming pregnant after cancer treatment concludes, a blood test for anti-Müllerian hormone (AMH) is increasingly being recognized as the best method available for determining ovarian reserve, she said.
“There are only I think two labs in the U.S. that do AMH, so it is a somewhat expensive test that has to be sent out of your institution,” she said. “But when you're talking to women and they're trying to make a decision about ‘How close am I to menopause? Is it important for me to preserve gametes before my cancer treatment or would I have success afterward if I try IVF?’, sometimes an AMH level may be helpful in making those decisions.”
There is a caveat, however, she said: The AMH test may currently be a better predictor for groups of women rather than for individual patients, “so you can't really rely on it like the gospel.”
Cryopreserving oocytes, Dr. Schover said, is no longer considered experimental and results in pregnancy rates almost as good as those from frozen embryos, according to data from the American Society of Reproductive Medicine. Patients trying to decide between freezing eggs or embryos should consider the strength of their relationship and whether they'll still be with their current partner in five to 10 years when they are trying to get pregnant, Dr. Schover recommended. “When you create an embryo, the man has control over whether you can use it later on, but your eggs belong to you,” she said.
The common wisdom about emergency fertility preservation has also changed, Dr. Schover noted. Until very recently, she said, it was thought that ovarian stimulation for egg harvesting couldn't be done until day 2 of the menstrual cycle. But now, she said, it's believed that the stimulation can take place whenever it's convenient, and eggs can be harvested within 14 days.
“It's also really important to remind patients that there are several studies now that suggest that women get a better yield by doing ovarian stimulation before their cancer treatment rather than waiting until later and hoping that they will continue to menstruate or regain their menstruation,” she said. “Stimulation after cancer treatment is often not very effective.”
Dr. Schover noted that treatment for most types of cancer can be delayed for two weeks to allow fertility preservation to take place. She also stressed that clinicians should remember to refer male patients for sperm banking. This technique continues to be underused, she said, and physician endorsement and referral are crucial, especially for younger patients.
Unfortunately, fertility preservation can be costly, an issue that Dr. Schover called “the elephant in the room.” Some insurers, however, will cover the procedures if an oncologist writes a letter stating they are necessary, she said. She also mentioned other potential resources, including Livestrong's Sharing Hope program, which helps with costs of sperm banking or ovarian stimulation for single patients with an annual income below $75,000 or couples with an annual income below $100,000, and H.E.A.R.T. Beat, a program that offers free medication for ovarian stimulation to women with a medical need for fertility preservation.
Don't forget contraception
Contraception is another area that's often overlooked in cancer patients, and one that's important to discuss during and after treatment, Dr. Schover said. Treatment can damage fertility, but there's no sure way to know if patients are fertile, so physicians need to remind them that contraception is still necessary, she stressed.
Because patients who become pregnant during cancer treatment can have a higher risk of having a child with birth defects, it's best to use highly reliable but reversible contraception, such as progesterone implants or IUDs, Dr. Schover said. Barrier contraceptives have the added benefit of protecting against sexually transmitted infections, which is especially important in immunosuppressed patients, she noted. She recommended counseling patients who want to have a child to wait at least six months after the end of cancer treatment, and possibly up to one to two years, before trying to conceive.
Dr. Schover also highlighted a few special cases regarding contraception. Gonadotropin-releasing hormone agonists or the levonorgestrel intrauterine system can be used in women with severe anemia, in whom it may be very important to reduce or even eliminate menstrual bleeding. The copper IUD is preferred, because it is reliable and does not involve hormones, for young breast cancer survivors or women at high risk for breast cancer due to chest irradiation, she said. Finally, because cancer increases risk for venous thromboembolism in many women, estrogen-containing oral contraceptives are not a good option.
“It's probably safer to use progestin-only oral contraceptives or injectable contraceptives, but they do decrease bone density, which is another issue for these young women, who often have premature ovarian failure in the end,” Dr. Schover said.