Sexual Health in Women With Cancer and Those in Survivorship Care

Sexual Health in Women With Cancer and Those in Survivorship Care
The Network + GEMSTONE Educational Module Last Update: February 20, 2019 The Scientific Network on Female Sexual Health and Cancer collaborated with GEMSTONE, a group of experts in gynecologic oncology, to provide direction and approval of the material in this educational resource. TESARO, Inc. provided writing and organizational support to the GEMSTONE Committee in the generation of this material.

Module Objectives Raise awareness about sexual health in female cancer patients/survivors Review common sexual health problems and strategies for screening patients Educate on how to perform physical examination on female cancer patients/survivors with sexual health problems Consider interventions that can be used to improve sexual health in female cancer patients/survivors This module will highlight issues of particular relevance for gynecologic cancer patients and survivors

Module Outline Effects of Cancer and Its Treatment on Female Sexual Health Physical Examination in Female Cancer Patients/Survivors With Sexual Health Problems Female Sexual Health and Interventions for Addressing Sexual Problems in Women With Cancer Facilitating Conversations About Sexual Health Tools for Assessing Sexual Health in Female Cancer Patients/Survivors Resources for More Information Implications for Clinical Practice Summary and Unresolved Questions

Effects of Cancer and Its Treatment on Female Sexual Health

Female Sexual Response Cycle2,3
Sexual Health, Sexual Dysfunction, and the Female Sexual Response Cycle Sexual Health1 Female Sexual Response Cycle2,3 A state of physical, emotional, mental, and social well-being in relation to sexuality Sexual stimuli Sexual arousal Arousal and sexual desire Emotional and physical satisfaction Emotional intimacy Sexual Dysfunction1 Problems during any phase of the sexual response cycle Emotional intimacy motivates sexually neutral women to be responsive to sexual stimuli Psychological and biological factors control arousability 1. Huffman LB, et al. Gynecol Oncol. 2016;140(2): Basson R. J Sex Marital Ther ;26(1): Basson R. Obstet Gynecol. 2001;98(2):350-3.

Sexual Dysfunction Is Prevalent Among Survivors of Gynecologic Cancers
A survey of 1,029 survivors of gynecologic malignancies identified sexual dysfunction as one of the most common health-related issues Most common cancers in these women were cervical (29%), endometrial (26%), and ovarian/primary peritoneal/fallopian tube (26%) Before, During, and After Treatmenta During and After Treatmenta Rank Health Issue % 1 Fatigue 60.6 2 Sleep disturbance 54.9 3 Urinary dysfunction 50.9 4 Sexual dysfunction 48.4 5 Neurologic symptoms 45.4 Rank Health Issue % 1 Fatigue 44.3 2 Sexual dysfunction 35.7 3 Sleep disturbance 35.3 4 Neurologic symptoms 35.2 5 Urinary dysfunction 33.0 a Top 5 health issues reported in study. Westin SN, et al. J Cancer Surviv. 2016;10(2):

Many Women With Cancer Express Concern About Sexual Health
In 2 recent studies, female cancer patients/survivors (including women with gynecologic cancers) were surveyed regarding their concern or worry about sexual function and vaginal health: Women With History of Gynecologic or Breast Cancer Seeking Treatment at MSKCC Outpatient Clinics (N=218)1 Women With a History of Cancer Seeking Treatment at MSKCC FSMWHP (N=459)2 Percent of Patients Percent of Patients “Moderately” to “very dissatisfied” with sexual function/ vaginal health “Somewhat” to “very concerned” with sexual function/ vaginal health “Not at all” to “a little concerned” with sexual function/ vaginal health “Somewhat” to “very concerned” with sexual function/ vaginal health FSMWHP, Female Sexual Medicine and Women’s Health Program; MSKCC, Memorial Sloan Kettering Cancer Center. 1. Stabile C, et al. Breast Cancer Res Treat. 2017;165(1): Carter J, et al. Support Care Cancer. 2015;23(8):

Women With Cancer Often Report Vaginal Dryness, Pain, and Sexual Dysfunction
Sexual health problems were assessed among 509 women seeking treatment at the FSMWHP at MSKCC Many participants had a history of breast cancer (51%), gynecologic cancer (36%), or colorectal/anal cancer (7%) 48% of patients had completed cancer treatment, and 52% were on active treatment Sexual health problems may result in reduced confidence for sexual activity: Common sexual/vaginal health problems: 44% reported pain during examination 51% had moderate/severe vaginal dryness 46% experienced moderate/severe dyspareunia 93.5% had an FSFI score <26.55, indicating sexual dysfunction “Engaged in sexual activity with a partner” “Felt confident about future sexual activity” 53% 43% FSFI, female sexual function index; FSMWHP, Female Sexual Medicine and Women’s Health Program; MSKCC, Memorial Sloan Kettering Cancer Center. Carter J, et al. Support Care Cancer. 2015;23(8):

Sexual Dysfunction in Women With Ovarian Cancer2-5
Most Women With Ovarian Cancer Experience Negative Effects on Sexual Function In a survey of patients with ovarian cancer, 57% of respondents reported that their sex life was adversely affected by cancer and its treatment1 Sexual discomfort is associated with reduced physical and social well-being2,3 Sexual Dysfunction in Women With Ovarian Cancer2-5 Decreased Arousal Increased Vaginal Dryness Less Sexual Activity Decreased Libido Problems With Orgasm More Dyspareunia 1. Stewart DE, et al. Gynecol Oncol. 2001;83(3): Huffman LB, et al. Gynecol Oncol ;140(2): Wenzel LB, et al. Psychooncology. 2002;11(2): Stead ML, et al. Best Pract Res Clin Obstet Gynaecol. 2007;21(2): Stead ML, et al. Br J Cancer. 2003;88(5):

Sexual Dysfunction Among Sexually Active Womena
Lack of Desire and Physical Problems Impair Sexual Activity in Patients With Ovarian Cancer Women with ovarian cancer (N=232) were surveyed about sexual activity and sexual functioning: 50% of these women were sexually activea Sexual Dysfunction Among Sexually Active Womena Reported Issue Percent Patients Problems with vaginal dryness 80% Discomfort with vaginal penetration 62% Problems reaching orgasm 75% Reasons for Sexual Inactivity Among Women Who Were Not Sexually Activeb Reason Percent Patients No partner 44% Lack of interest 38% Physical problems making sex difficult 23% Fatigue 10% a Had engaged in sexual activity at least once in the past month. b Had not engaged in sexual activity at least once in the past month. Carmack Taylor CL, et al. J Clin Oncol. 2004;22(5):881-9.

Patients With Endometrial and Cervical Cancer Experience Sexual Health Problems
Sexual dysfunction is prevalent among women with a history of endometrial and cervical cancer1,2 Standard treatment for endometrial and cervical cancers includes radical hysterectomy, which has been associated with3 Decreased sexual interest (25%-57%) Loss of sensation in the labia (71%) Vaginal dryness (10%-26%) Vaginal shortening (25%-26%) Dyspareunia (18%) An estimated 89% of endometrial cancer survivors have sexual dysfunction1 Sexual dysfunction ranked as the top health concern of cervical cancer survivors, affecting 45.2% of patients2 1. Onujiogu N, et al. Gynecol Oncol. 2011;123(2): Westin SN, et al. J Cancer Surviv ;10(2): Stabile C, et al. Transl Androl Urol 2015;4(2)

Effects of Pelvic Radiation Therapy1,4
Radiation Therapy Affects Vaginal Health in Patients with Gynecologic Cancer Endometrial and cervical cancer are often treated with pelvic radiation1,2 Both external beam radiation therapy and vaginal brachytherapy negatively affect sexual function Radiation therapy is significantly associated with sexual dysfunction in patients with endometrial and cervical cancer2,3 Effects of Pelvic Radiation Therapy1,4 Pelvic pain and irritation Loss of vaginal elasticity Thinning of the vaginal lining Increased vaginal dryness and bleeding Vaginal stenosis Dyspareunia 1. Jensen PT, et al. Transl Androl Urol. 2015;4(2): Onujiogu N, et al. Gynecol Oncol. 2011;123(2): Westin SN, et al. J Cancer Surviv. 2016;10(2): American Cancer Society. Pelvic Radiation Can Affect a Woman’s Sex Life. treatment/treatments-and-side-effects/physical-side-effects/fertility- and-sexual-side-effects/sexuality-for-women-with-cancer/pelvic-radiation.html. Updated January 12, Accessed February 8, 2019.

Sexual Dysfunction Disrupts Quality of Life in Women With Gynecologic Cancer
Sexual dysfunction is associated with poor psychosocial adjustment and decreased quality of life in women with a history of gynecologic cancer1-4 This sexual morbidity affects women during treatment and long-term survivorship2,3,5 Women with gynecologic cancer report an array of mental health effects,including4,6,7: Perceived loss of femininity Depression Anxiety Sexual dysfunction is one of the most profoundly affected quality-of-life issues in women with gynecologic cancers4 1. Levin AO, et al. Int J Gynecol Cancer. 2010;20(3): Flay LD, et al. Int J Radiat Oncol Biol Phys. 1995;31(2): Carter J, et al. Gynecol Oncol ;119(2): Carmack Taylor CL, et al. J Clin Oncol. 2004;22(5): Lindau ST, et al. Gynecol Oncol. 2007;106(2): Kornblith AB, et al. Gynecol Oncol ;59(2): Bodurka-Bevers D, et al. Gynecol Oncol. 2000;78(3):302-8.

Patients Are Unlikely to Initiate Discussion of Sexual Health Problems With HCPs
Sexual health is important to female cancer patients/survivors; however, they are unlikely to initiate a discussion of sexual health1,2 From the patient’s point of view, barriers to this conversation include1: Wanting to avoid making the HCP uncomfortable Believing that it is the HCP’s job to ask about sexual health Worrying that the HCP will not see sexual dysfunction as a valid problem Survivors may feel a loss of confidence in sexual activity1,3 Lack of HCP–patient communication about sexual health leads to unmet patient needs1 HCP, healthcare provider. 1. Bober SL, et al. Curr Opin Support Palliat Care. 2016;10(1): Coady D, et al. Obstet Gynecol. 2016;128(4): Gilbert E, et al. Psychol Health. 2013;28(6):

Physical Examination in Female Cancer Patients/ Survivors With Sexual Health Problems

Physical Examination Can Identify Physical Issues That May Cause Sexual Problems
Physical examination of female cancer patients/survivors who report sexual function problems is an essential part of a comprehensive evaluation Goals of physical examination include: Identifying normal and abnormal findings, and informing patient of these findings Determining whether these findings are related to the patient’s symptoms Ideally, comprehensive physical examination is performed by an HCP who is: Able to collaborate with the patient’s oncologist Proficient in genito-pelvic examination skills Knowledgeable about cancer pathophysiology Evaluation of patients without a physical examination may lead to misdiagnosis and failed treatment HCP, healthcare provider. Lindau ST, et al. CA Cancer J Clin. 2016;66(3):

Patients in Active Cancer Treatment Patients in Survivorship Care
Guidelines for Physical Examination in Patients in Active Treatment vs Survivorship Care Patients in Active Cancer Treatment Inform patients about possible short- and long-term side effects of treatment, including potential problems related to sexual function It is recommended that patients be in the care of an oncologist, including an HCP specialized in hospice or palliative care who is able to consult with the oncologist and participate in care coordination Inform patients about possible impairment of vaginal capacity for penetration and sexual function if being treated with pelvic radiation Patients in Survivorship Care It is recommended that patients be in the care of an HCP with knowledge of cancer survivorship guidelines Potential underlying causes of sexual problems to be addressed before conducting a specialized sexual health evaluation. These may include: Untreated, chronic medical conditions and late effects of cancer treatment Gynecologic conditions (eg, abnormal uterine bleeding or pelvic mass) HCP, healthcare provider. Lindau ST, et al. CA Cancer J Clin. 2016;66(3):

Physical Examination Includes Numerous Core Components
Physical examination is performed after obtaining patient consent and in a private setting Findings should be discussed directly with the patient and communicated to the treating oncology care provider Components of a Physical Examination Can Include: External genital examination Pelvic floor function examination Vaginal speculum examination Vaginal capacity assessment Vaginal bimanual examination Anal and rectovaginal examination Abdominal examination Breast examination Vital signs Weight Mental status Lindau ST, et al. CA Cancer J Clin. 2016;66(3):

Female Sexual Health and Interventions for Addressing Sexual Problems in Women With Cancer

Sexual Health Is Influenced by Physical, Psychological, and Social Factors
Sexual health of cancer patients/survivors is affected by interplay among multiple factors1-3: Physical effects of cancer Psychological and social effects of cancer Symptoms of menopause Physical effects of cancer treatment Sexual Health1-3 1. Eaton L, et al. Sex Med. 2017;5(3):e Simon JA, et al. Menopause ;25(7): Huffman LB, et al. Gynecol Oncol. 2016;140(2):

Changes to Vulvovaginal Tissue Can Occur in Cancer Patients/Survivors
Vulvovaginal atrophy (VVA) is a chronic and progressive condition that often occurs in postmenopausal women as a result of decreased estrogen levels1,2 Symptoms of VVA include1: Vaginal dryness, irritation, soreness, postcoital bleeding, and pain Urinary frequency, urgency, and incontinence Patients report adverse effects on intimacy, enjoyment of sexual intercourse, and sexual spontaneity2 Symptoms of VVA tend to be more severe in female cancer patients/survivors than in the general population2 VVA, vulvovaginal atrophy. 1. Mac Bride MB, et al. Mayo Clin Proc. 2010;85(1): Eaton AA, et al. J Sex Med ;14(1):

Vaginal Anatomy Before and After Menopause2
Genitourinary Syndrome of Menopause (GSM) Affects Many Women as They Age GSM is inclusive of symptomatic VVA and lower urinary tract symptoms related to decreased levels of estrogens and androgens1 Constellation of signs and symptoms involve labia majora or minora, vestibule/introitus, clitoris, vagina, urethra, and bladder Presentation is highly variable Vaginal Anatomy Before and After Menopause2 More than 50% of midlife and older women have symptoms of GSM1 Symptoms of GSM may negatively affect1: Sexual function Activities of daily living Emotional health Body image Relationships Prior to menopause After menopause Reduced blood flow Vaginal fornix Vaginal fornix loss Cervix Vaginal wall Thinned vaginal wall Rugal fold loss Rugal folds Reduced vaginal length Labia minora Labia atrophy Labia majora Vaginal narrowing GSM, genitourinary syndrome of menopause; VVA, vulvovaginal atrophy. 1. Simon JA, et al. Menopause. 2018;25(7): Jin J. JAMA. 2017;317(13):1388.

Some Cancer Treatment Strategies May Trigger Menopause
Cancer treatment may induce menopause or symptoms of menopause1 Potential Causes of Menopause in Women Undergoing Cancer Treatment1 Menopause Symptoms1 Hot flashes/night sweats Irregular or no menstrual periods Problems sleeping Vaginal dryness, itching, irritation, or discharge Loss of interest in sex Painful intercourse Bladder or vaginal infections Mood swings or irritability Weight gain Depression Hormone therapy Radiation therapy to the pelvis Chemotherapy Surgical removal of the ovaries In women who are already menopausal, stopping HRT upon cancer diagnosis/treatment may lead to an increase in menopause symptoms2 HRT, hormone replacement therapy. 1. Canadian Cancer Society. Treatment-Induced Menopause. information/diagnosis-and-treatment/managing-side-effects/treatment-induced-menopause/. Accessed November 19, BreastCancer.org. Stopping Hormone Replacement Therapy: “Cold Turkey” Menopause. turkey. Updated January 27, Accessed February 1, 2019.

Common Sexual Health Problems Summary of Potential Interventions
Interventions Are Available for Treating Sexual Problems in Women With Cancer Numerous strategies are available for treating sexual health problems in women with cancer, including gynecologic cancer patients/survivors1 Common Sexual Health Problems Summary of Potential Interventions Genital symptoms Including symptoms of VVA (vaginal dryness, irritation, soreness, and pain, as well as urinary frequency, urgency, and incontinence) Vaginal moisturizers and lubricants Skin sealants and protectants Hormone therapies (low-dose vaginal estrogen, DHEA, ospemifene) Lidocaine and pain relievers Dilator therapy Pelvic floor therapy Cognitive behavioral therapy Vaginal laser therapy2,a Vasomotor symptoms Hot flashes and night sweats Hormone therapy Nonhormonal options (paroxetine, venlafaxine, gabapentin, clonidine, fluoxetine) Psychosocial counseling and/or clinical hypnosis Decreased sexual response Psychosocial counseling Regular stimulation Flibanserin Reduced overall sexual functioning and satisfaction Physical exercises or pelvic floor therapy Intimacy or relationship concerns Body image issues a Laser therapy an investigational treatment for women with genitourinary syndrome of menopause, and several studies have shown promising results with this treatment modality. DHEA, dehydroepiandrosterone; VVA, vulvovaginal atrophy. 1. Carter J, et al. J Clin Oncol. 2018;36(5): Rabley A, et al. Curr Urol Rep ;19(10):83.

Vaginal Moisturizers and Lubricants Are Effective for Treating Genital Symptoms
A stepwise approach is recommended for treating genital symptoms, including vaginal and/or vulvar atrophy, dryness, pain, and dyspareunia1 Nonhormonal strategies are recommended as initial treatment1,2 Vaginal moisturizers to improve vulvovaginal tissue quality Moisturizers may be hydrating or soothing (natural oil) Lubricants for sexual activity/touch Lubricants may be water-based, silicon-based, or natural oils Vaginal moisturizers and lubricants are available without a prescription Considerations for successful use of vaginal moisturizers1,2: Apply moisturizer in vagina, at vaginal opening, and on external folds of the vulva Cancer patients/survivors may require frequent application (ie, 3–5 times per week) Moisturizer can be used regardless of sexual activity Apply moisturizer at bedtime for best absorption 1. Carter J, et al. J Clin Oncol. 2018;36(5): Memorial Sloan Kettering Cancer Center. Improving Your Vulvovaginal Health. education/vaginal-health. Updated July 25, Accessed December 7, 2018.

Hormonal Strategies May Be Appropriate When Initial Treatment Fails
Low-dose vaginal estrogen may be recommended to treat genital symptoms for patients without hormone-positive breast cancer or other hormone-sensitive malignancies whose symptoms do not respond to initial (nonhormonal) interventions1,a Low-dose vaginal estrogen may also be considered for patients with hormone-positive breast cancer or other hormone-sensitive malignancies after a discussion of risk/benefit1 Risk of cancer recurrence is not thought to be increased in women with current or history of breast cancer who use vaginal estrogen to treat urogenital symptoms2 Concerns remain regarding risk of recurrence for women with breast cancer who are being treated with aromatase inhibitors Alternative hormonal treatment options may be considered in other situations1: Vaginal DHEA for women with breast cancer who are taking aromatase inhibitors Ospemifene for postmenopausal women without current or history of breast cancer Risk/benefit associated with vaginal DHEA or ospemifene is unknown in women with a history of cancer or those on endocrine therapy1 Thorough discussion of this uncertainty should be had with the patient before initiating therapy a May also be considered as initial treatment for patients who present with severe symptoms. DHEA, dehydroepiandrosterone. 1. Carter J, et al. J Clin Oncol. 2018;36(5): American College of Obstetricians and Gynecologists. Committee Opinion: The Use of Vaginal Estrogen in Women With a History of Estrogen-Dependent Breast Cancer. Committee-Opinions/Committee-on-Gynecologic-Practice/The-Use-of-Vaginal-Estrogen-in- Women-With-a-History-of-Estrogen-Dependent-Breast-Cancer. Reaffirmed Accessed December 7, 2018.

Vasomotor Symptoms May Be Treated With Hormone Therapy or Nonhormonal Options
Hormone therapy is the most effective intervention for vasomotor symptoms1 Alternatives exist for women unwilling/unable to use hormone therapy1: Paroxetine (SSRI), venlafaxine (SNRI), gabapentin (GABA analog), and clonidine (alpha- adrenergic-agonist)1-4 Paroxetine/fluoxetine may not be appropriate for women with breast cancer taking tamoxifen1 Estrogen therapy alone (oral, transdermal, or vaginal) is recommended for women with hysterectomy when not contraindicated1 Psychosocial counselinga and/or clinical hypnosis may also be offered1 Systemic hormone therapy is safe for many women with hormone-sensitive cancers (eg, ovarian or endometrial) as well as for women with genetic risk for such cancers1,b a Cognitive behavioral therapy. b Only after individualized risk/benefit discussions occur with the patient’s primary oncology provider. GABA, gamma-aminobutyric acid; SNRI, serotonin and norepinephrine reuptake inhibitor; SSRI, selective serotonin reuptake inhibitor. 1. Carter J, et al. J Clin Oncol. 2018;36(5): Carroll DG. Am Fam Physician ;73(3): Rose MA, et al. Anaesthesia. 2002;57(5): Giovannitti JA, et al. Anesth Prog. 2015;62(1):31-9.

Skin Sealants and Protectants May Be Helpful for Women Who Wear Pads
Many cancer patients/survivors wear panty liners or pads to control urine leakage or discharge1,2 Pad use can lead to drying out of the vulva Skin protectants and sealants are recommended for these women, as the agents may prevent drying out of tissue when applied to external folds of the vagina1,2 Patients with urinary incontinence may be referred to a urologist or urogynecologist for further evaluation and treatment Among female cancer patients/survivors seeking treatment at a female sexual medicine health program, ~30% reported wearing pads at their baseline visit3 32% 1. Carter J, et al. J Clin Oncol. 2018;36(5): Memorial Sloan Kettering Cancer Center. Improving Your Vulvovaginal Health. education/vaginal-health. Updated July 25, Accessed December 7, Carter J, et al. J Cancer Surviv. 2017;11(2):

Vaginal Dilators Can Help Manage Vaginal Stenosis/Vaginismus and Dyspareunia
Vaginal dilators may be effective for prevention/management of vaginal stenosis or vaginismus and can be offered to women who experience pain during examination and/or sexual activity1 Benefit of dilator therapy is greatest if started early Dilators should be offered to all women at risk of vaginal changes Lidocaine may used to treat persistent introital pain or dyspareunia1 Pain relievers may be given to patients taking aromatase inhibitors who experience arthralgia that interferes with intimacy1 Dilator therapy is particularly important for women treated with pelvic or vaginal radiation therapy1 Dilators are most effective if used regularly after radiation or surgery to keep the vagina from shrinking/tightening due to scarring2 1. Carter J, et al. J Clin Oncol. 2018;36(5): American Cancer Society. Treating Sexual Problems for Women With Cancer. side-effects/physical-side-effects/fertility-and-sexual-side-effects/sexuality-for-women-with- cancer/problems.html. Revised January 12, Accessed February 8, 2019.

Pelvic Floor Therapy May Be Effective for Addressing Genital Symptoms
Cognitive behavioral therapy and pelvic floor exercises may decrease anxiety and discomfort Pelvic floor physiotherapy may be recommended for women with symptoms of pelvic floor dysfunction Refer to urologist, urogynecologist, or colorectal surgeon for further evaluation or treatment of urinary or fecal incontinence Carter J, et al. J Clin Oncol. 2018;36(5):

Counseling and Regular Stimulation May Improve Sexual Response
Psychosocial and/or psychosexual counseling may help enhance components of the sexual response including1: Current evidence does not support the use one form of counseling or education (psychosocial vs psychosexual) over the other Regular stimulation (including masturbation) may also be recommended to help increase sexual response1 Arousal Desire Orgasm Carter J, et al. J Clin Oncol. 2018;36(5):

Flibanserin Is an Option for Premenopausal Women With Impaired Sexual Response
Flibanserin may be appropriate for premenopausal women with hypoactive sexual desire disorder (HSDD)1,2 Flibanserin is a multimodal serotonergic agent, and its MOA is not well understood In 2015, flibanserin was approved for treatment of premenopausal women with acquired, generalized HSDD3,a However, flibanserin has not been studied in women with a history of cancer or taking endocrine therapy; risk/benefit profile is unclear in these patients1 a Characterized by low sexual desire that causes marked distress or interpersonal difficulty and is not due to a coexisting medical or psychiatric condition, problems with the relationship, or effects of a medication or other drug substance. MOA, mechanism of action. 1. Carter J, et al. J Clin Oncol. 2018;36(5): English C, et al. PT. 2017;42(4): Flibanserin package insert. Sprout Pharmaceuticals, Inc; May 2018.

Psychosocial Counseling and Pelvic Floor Therapy May Improve Sexual Function
Psychosocial counseling (in individual, couple, or group setting) may be beneficial for patients with problems related to sexual function and satisfaction For patients with continuing relationship issues and/or distress, mental health counseling may be recommended Physical exercises or pelvic floor physiotherapy may also be offered Education and symptom management is also recommended to help improve sexual function and satisfaction Gynecologic examination is suggested for patients with persistent problems Carter J, et al. J Clin Oncol. 2018;36(5):

Counseling May Be Helpful for Women With Intimacy or Body Image Concerns
Psychosocial counseling may be recommended for women with issues related to intimacy/relationships or body image For patients who are partnered, couples-based interventions may be suggested Patients with preexisting depression or body image issues may be at high risk Body image issues can be evaluated early and often, taking into account cultural or religious factors Cultural factors Body Image Religious factors Carter J, et al. J Clin Oncol. 2018;36(5):

Patient Adherence to Vaginal and Sexual Health Interventions Is High
Patient adherence and response to vaginal and sexual health interventions were examined among patients with cancer receiving treatment at the FSMWHP at MSKCC (N=175) 53% had a history of breast cancer, and 32% had a history of gynecologic cancer Adherence to Sexual and Vaginal Health Interventions Patient adherence to recommended vaginal/sexual health interventions was generally high Percent of Patients Regular use of vaginal lubricant with sexual activity or dilator use Consistent administration of vaginal moisturizer Regular performance of pelvic floor exercises Compliance with dilator therapy FSMWHP, Female Sexual Medicine and Women’s Health Program; MSKCC, Memorial Sloan Kettering Cancer Center. Carter J, et al. J Cancer Surviv. 2017;11(2):

First Assessment, Mean (SD) Last Assessment, Mean (SD)
Simple Interventions Can Improve Sexual/ Vaginal Health in Women With Cancer Significant positive changes were observed in response to simple interventions aimed at addressing sexual health problems Interventions included rationale and instructions for using vaginal moisturizers, lubricants, pelvic floor exercise, and vaginal dilator therapy Patients were also given psychosexual education about sexual changes that are associated with cancer and its treatment Variable n First Assessment, Mean (SD) Last Assessment, Mean (SD) P Value VAS composite 173 1.09 (0.65) 0.55 (0.50) <0.001 VuAS composite 168 0.79 (0.67) 0.59 (0.55) FSFI total score 141 12.53 (7.68) 16.18 (9.30) Use of interventions were associated with improved vulvovaginal symptoms, decreased pain with examination, improved sexual function, a decrease in elevated vaginal pH, and greater intimacy confidence FSFI, female sexual function index; SD, standard deviation; VAS, vaginal assessment scale; VuAS, vulvar assessment scale. Carter J, et al. J Cancer Surviv. 2017;11(2):

Facilitating Conversations About Sexual Health

Women With Gynecologic Cancer Report Barriers to Discussion of Sexual Health
Gynecologic cancers have profound effects on female sexual health, but HCPs infrequently discuss sexual health with their patients Rationale for lack of communication by HCPs include: Lack of a sense of personal responsibility Limited time Lack of knowledge and experience Feelings of embarrassment Lack of resources to provide support A survey of 16 physicians and 27 nurses that treat women with ovarian cancer found that only 25% of physicians and 19% of nurses discuss sexual function with patients Physicians Nurses 25% 19% HCP, healthcare provider. Stead ML, et al. Br J Cancer. 2003;88(5):

… but only 7% raised this issue with their HCP2
There Is a Disconnect Between Patients and HCPs Regarding Sexual Health 74% of long-term survivors of gynecologic cancer thought that physicians should routinely inquire about sexual health1 However, 62% of these women reported never discussing sexual health with their physician1 A survey of 261 breast and gynecologic cancer survivors revealed that 42% were interested receiving sexual healthcare … … but only 7% raised this issue with their HCP2 HCP, healthcare provider. 1. Lindau ST, et al. Gynecol Oncol. 2007;106(2): Hill EK, et al. Cancer. 2011;117(12):

Women With Cancer Are Interested in Receiving Information About Sexual Health
Despite this lack of attention, many gynecologic cancer patients/survivors are interested in receiving education and counseling about sexual health1,2 Preference for Receiving Information About Sexual Health in Women With a History of Gynecologic or Breast Cancer3 Percent Patients Speak with medical team/other medical professionals Written information followed by discussion with medical team Group setting 1. Green MS, et al. Gynecol Oncol. 2000;77(1): Hill EK, et al. Cancer ;117(12): Stabile C, et al. Breast Cancer Res Treat. 2017;165(1):77-84.

Sexual Health Discussion Topics for Physicians and Their Patients
Vaginal or vulvar pain (not during sex) Decreased lubrication or dryness Pain with sexual touch/vaginal insertion Anxiety about sex Decreased sensation Difficulty reaching orgasm Bober SL, et al. Curr Opin Support Palliat Care. 2016;10(1):44-54.

Tools for Assessing Sexual Health in Female Cancer Patients/Survivors

Overview of Tools for Assessing Sexual Health in Female Cancer Patients/Survivors
Brief and informative tools are available to help HCPs facilitate conversations about vaginal/sexual health in the setting of a busy oncology practice1,2 These tools are validated for use in cancer patients/survivors Instruments are also available to assess vaginal/sexual health in clinical research studies1,2 However, many of these tools are too lengthy and time-intensive for day-to-day use Tools Designed for Use in Routine Clinical Practice1-3 Sexual symptom checklist Single-item screener VAS and VuAS Tools Designed for Use in Clinical Research Studies4,5 PROMIS SexFS FSFI FSFI, female sexual function index; HCP, healthcare provider; PROMIS, Patient-Reported Outcomes Measurement Information System; SexFS, sexual function and satisfaction measure; VAS, vaginal assessment scale; VuAS, vulvar assessment scale. 1. Bober SL, et al. Curr Opin Support Palliat Care. 2016;10(1): Flynn KE, et al. J Gen Intern Med. 2015;30(10): Eaton AA, et al. J Sex Med. 2017;14(1): Weinfurt KP, et al. J Sex Med. 2015;12(9): Rosen R, et al. J Sex Marital Ther ;26(2):

Sexual Symptom Checklist2
Tools for Clinical Practice: Checklist May Be Used to Assess Sexual Function Sexual health may be evaluated serially1,2 Assess before treatment, throughout treatment, and continuing into survivorship This approach allows for the determination of treatment/intervention effects on sexual functioning Sexual symptom checklist was developed for use with female cancer patients/survivors2 This tool may be used regardless of age, partner status, sexual orientation, or level of sexual activity Sexual Symptom Checklist2 Please answer the following questions about your overall sexual function: Are you satisfied with your sexual function?  Yes  No Do you have any concerns about vaginal health?  Yes  No If not satisfied with sexual function AND/OR concerns about vaginal health, please continue. Do you experience any of the following sexual problems or concerns? Little or no interest in sex Decreased sensation (or loss of sensation) Decreased vaginal lubrication (dryness) Difficulty reaching orgasm Pain during sex Vaginal or vulva pain or discomfort (not during sex) Anxiety about having sex Other problem or concerns: ____________________ [TIP: Some patients will respond that they are not having these problems or concerns because they stopped having sex altogether. The provider should reassure the patient; let her know that she is not alone, and ask if she can recall what kinds of problems or concerns she was having that led her to stop having sex.] Would you like more information, resources, and/or would you like to speak with someone about these issues?  Yes  No The checklist reminds HCPs to reassure women who are no longer sexually active as a result of treatment-related problems, and it prompts HCPs to make patients aware that they are not alone and that help is available2 HCP, healthcare provider. 1. Coady D, et al. Obstet Gynecol. 2016;128(4): Bober SL, et al. Curr Opin Support Palliat Care. 2016;10(1):44-54.

Single-Item Clinical Screener
Tools for Clinical Practice: Single-Item Screener Captures Sexual Health Problems A single-item, self-report screener was developed and validated for capturing common sexual health problems in US adults, including those with cancer This screener is effective at identifying sexual problems associated with decreased sexual function in both men and women In the past 12 months, has there ever been a period of 3 months or more when you had any of the following problems or concerns? Check all that apply. You wanted to feel more interest in sexual activity Your vagina felt too dry You had pain during or after sexual activity You had difficulty having an orgasm You felt anxious about sexual activity You did not enjoy sexual activity Some other sexual problem or concern No sexual problems or concerns Single-Item Clinical Screener Patient responses on the screener may facilitate conversation and help guide treatment decisions Flynn KE, et al. J Gen Intern Med. 2015;30(10):

Tools for Clinical Practice: VAS and VuAS Assess Vaginal and Vulvar Symptoms
VAS and VuAS are simple, 4-item measures that have been validated to assess tissue quality and function in women with cancer, including gynecologic cancers An HCP may administer the VAS or VuAS to assess a patient’s perception of dryness, soreness, irritation, and pain in the vaginal and vulvar areas Items 1–3: Vaginal and vulvar dryness, soreness, and irritation during routine activities Item 4: Discomfort/pain that occurs during sexual activity (vaginal intercourse or external manual stimulation of the vulva alone or with a partner) Items are scored from 0 (none) to 3 (severe) Composite scores are calculated as the mean of item scores when ≥2 of 4 items are present Lower scores indicate better function Shaft of clitoris Clitoris Outer lip Urethra opening Inner lip Vagina opening A diagram may be used to educate patients about their symptoms and help identify areas of concern Vestibule Anus HCP, healthcare provider; VAS, vaginal assessment scale; VuAS, vulvar assessment scale. Eaton AA, et al. J Sex Med. 2017;14(1):

Tools for Clinical Research: PROMIS® SexFS Evaluates Sexual Function and Satisfaction
PROMIS SexFS is a set of self-reported measures that may be used to assess sexual function and satisfaction1 This instrument was developed for use in patients with cancer; it has also been validated in US adults without cancer2 Sexual Function: Gender-Neutral Domains2 Interest in sexual activity Orgasm: ability Orgasm: pleasure Oral discomfort with sexual activity Oral dryness with sexual activity Anal discomfort with sexual activity Sexual activities Therapeutic aids for sexual activity Factors interfering with sexual satisfaction Bother regarding sexual function Sexual Function: Female-Specific Domains2a Vaginal lubrication for sexual activity Vaginal discomfort with sexual activity Vulvar discomfort with sexual activity: labia Vulvar discomfort with sexual activity: clitoris Sexual Satisfaction2 Satisfaction with sex life a Male-specific domains not included on slide. PROMIS, Patient-Reported Outcomes Measurement Information System; SexFS, sexual function and satisfaction measure. 1. Flynn KE, et al. J Sex Med. 2013;10(1): Weinfurt KP, et al. J Sex Med ;12(9):

Tools for Clinical Research: FSFI Evaluates Sexual Functioning
FSFI is a brief self-report measurement of female sexual function that has been validated for use in cancer survivors1,2 Questionnaire consists of 19 questions This instrument was designed for use in clinical trials3 Domains and Domain Items on FSFI Questionnaire3 Domain Domain Items Desire Frequency Level Arousal Confidence Satisfaction Lubrication Difficulty Frequency of maintaining Difficulty in maintaining Domain Domain Items Orgasm Frequency Difficulty Satisfaction With closeness to partner With sexual relationship With overall sex life Pain Frequency during vaginal penetration Frequency after vaginal penetration Level during or after vaginal penetration FSFI, female sexual function index. 1. Baser RE, et al. Cancer. 2012;118(18): Eaton AA, et al. J Sex Med ;14(1): Rosen R, et al. J Sex Marital Ther. 2000;26(2):

Resources for More Information

Links to Other Resources and Tools of Interest
The Scientific Network on Female Sexual Health and Cancer National Cancer Institute – Sexual Health Issues in Women With Cancer American Cancer Society – Sex and the Woman With Cancer and-sexual-side-effects/sexuality-for-women-with-cancer.html Memorial Sloan Kettering Cancer Center – Sexual Health health-fertility/health The University of Chicago Medicine – Program in Integrative Sexual Medicine for Women & Girls With Cancer (PRISM)

Implications for Clinical Practice

Implications for Clinical Practice
Sexual health problems may differ for patients in active treatment or in survivorship1 Patients are interested in sexual health information/counseling, and prefer to receive this information through discussions with their HCPs2 Query patients about sexual health, and validate/normalize their sexual health concerns3 Discuss sexual health with patients multiple times throughout the continuum of care; it is not a “one-time” discussion4 Key topics to cover when discussing sexual health with cancer patients/survivors include the following3 Difficulty reaching orgasm, pain with sexual touch/vaginal insertion, vaginal or vulvar pain (not during sex), anxiety about sex, decreased sensation, and decreased lubrication (dryness) Cancer patients/survivors may need to use a combination of multiple sexual health promotion strategies5,6 HCP, healthcare provider. 1. Carmack Taylor CL, et al. J Clin Oncol. 2004;22(5): Stabile C, et al. Breast Cancer Res Treat. 2017;165(1): Bober SL, et al. Curr Opin Support Palliat Care. 2016; 10(1): Carter J, et al. J Clin Oncol ;36(5): Carter J, et al. J Sex Med. 2011;8(2):549– Faubion SS, et al. J Womens Health (Larchmt). 2015;24(11):

Implications for Clinical Practice (continued)
Cancer patients/survivors may require more frequent application (likely 3–5 times per week) of vaginal moisturizer compared with the general population1 If a woman continues to have insertional pain, inquire if she is using moisturizers externally on the vaginal, including the vaginal opening2 If the patient continues to report vulvar discomfort, screen for possible pad usage2 If patients are using moisturizers, lubricants, and dilators and have persistent pain, consider a physical therapy referral to evaluate for pelvic floor dysfunction, especially in the setting of incontinence2 Screen patients for pain with gynecologic examination each time examination is performed3 Provide patients with information about underlying issues (eg, chronic conditions) unrelated to cancer that may be contributing to their sexual health problems3 Remind patients that sexual health promotion strategies take time, and help patients stay motivated to routinely use these strategies4,5 1. Carter J, et al. J Clin Oncol. 2018;36(5): Personal Communication from Dr. Jeanne Carter, Memorial Sloan Kettering Cancer Center. January Lindau ST, et al. CA Cancer J Clin. 2016;66(3): American Cancer Society. Treating Sexual Problems for Women With Cancer. treatments-and-side-effects/physical-side-effects/fertility-and-sexual-side-effects/sexuality-for- women-with-cancer/problems.html. Updated January 12, Accessed February 11, Carter J, et al. J Cancer Surviv. 2017;11(2):

Summary and Unresolved Questions

Module Summary Sexual dysfunction is very common among women with gynecologic cancers, and it is associated with poor psychosocial adjustment and diminished quality of life1,2 Women with cancer are not likely to initiate a discussion regarding their sexual health, and HCPs infrequently discuss sexual function with their patients3,4 Patients want information regarding the effects of cancer treatment on sexual health and are interested in sexual health interventions5,6 Systematic physical examination is essential for patients with sexual health problems, and the absence of a comprehensive approach may result in misdiagnosis and failed treatment7 HCP, healthcare provider. 1. Westin SN, et al. J Cancer Surviv. 2016;10(2): Levin AO, et al. Int J Gynecol Cancer. 2010;20(3): Bober SL, et al. Curr Opin Support Palliat Care ;10(1): Stead ML, et al. Br J Cancer. 2003;88(5): Green MS, et al. Gynecol Oncol. 2000;77(1): Hill EK, et al. Cancer. 2011;117(12): Lindau ST, et al. CA Cancer J Clin. 2016;66(3):

Unresolved Questions All cancer patients/survivors are at risk for sexual health problems, but how can we best identify vulnerable patients? What is the best way to promote open communication about sexual health between HCPs and their patients? How can HCPs support patient uptake and long-term adherence to sexual health interventions? How can HCPs ensure that healthy, high-risk women also receive information about sexual health, including potential side effects of cancer risk-reducing surgeries? What is the best method for ensuring that patients have access to sexual healthcare and sexual health interventions? HCP, healthcare provider.

The Network + GEMSTONE The Scientific Network on Female Sexual Health and Cancer collaborated with GEMSTONE, a group of experts in gynecologic oncology, to provide direction and approval of the material in this educational resource. TESARO, Inc. provided writing and organizational support to the Network and GEMSTONE in the generation of this material. TESARO, Inc. | Winter Street | Waltham, MA 02451 ©2019 TESARO, Inc. All rights reserved. NP-DS-US /19

Sexual Health in Women With Cancer and Those in Survivorship Care

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Sexual Health in Women With Cancer and Those in Survivorship Care

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