1. Sexuality and patients with advanced cancer
Pernille T. Jensen,
Subspecialist Consultant Gynecological Cancer, PhD
Dept. of Gynecology
Copenhagen University Hospital Herlev
Denmark

2. Agenda
Cancer and treatment related potential negative impact on the female and male sexual response in cancer patients
Gynecological cancer
Rectal/anal/bladder cancer
Prostate cancer
Surgery and radiotherapy
Practical issues in handling sexual problems
Future perspectives

3. Agenda
Cancer and treatment related potential negative impact on the female and male sexual response cancer patients
Gynecological cancer
Rectal/anal/bladder cancer
Prostate cancer
Surgery and radiotherapy
Practical issues in handling sexual problems
Future perspectives

4. Agenda
Cancer and treatment related potential negative impact on the female and male sexual response cancer patients
Gynecological cancer
Rectal/anal/bladder cancer
Prostate cancer
Surgery and radiotherapy
Practical issues in handling sexual problems
Future perspectives

5. Love, trust and intimacy
The sexual response
The Brain
Knowledge and fantasy
3. Break point
Distraction, spectator
Feelings
Love, trust and intimacy
2. Breakpoint
Anxiety, fear of failing,
anger and grief
The Body
Sexual enjoyment
1. Breakpoint
Pain, insufficient stimulation

6. Pelvic autonomic nerves and relation to central nerve system
Sensory input
Pudendal nerve
S2-S4
T10-T12
Brain
Visual input
Superior Hypo-gastric plexus
Inferior Hypo-gastric plexus
Splanchnic nn.
Rectum
Ureter, bladder and urethra
Penis, seminal vesicals
Uterus, vagina, clitoris

7. Male sexual function Visual input Brain
Sensory input
Pudendal nerve
S2-S4
T10-T12
Brain
Visual input
Superior Hypo-gastric plexus
Inferior Hypo-gastric plexus
Splanchnic nn.
Sympathetic outflow causes smooth muscle contraction leading to ejaculation
Parasympathetic activity maintain erection
Rectum
Ureter, bladder and urethra
Penis, seminal vesicals

8. Female sexual function
Sympathetic outflow maintain lubrication and causes smooth muscle contraction leading to orgasm
Sensory input
Pudendal nerve
S2-S4
T10-T12
Brain
Visual input
Superior Hypo-gastric plexus
Inferior Hypo-gastric plexus
Splanchnic nn.
Parasympathetic activity maintain vasocongestion
Rectum
Ureter, bladder and urethra
Vagina, clitoris and uterus

10. Important to remember..
Pelvic late effect of surgery and radiation will mimic those that we have data for!
Despite efforts to reduce the surgical trauma by using laparoscopic techniques, pelvic nerve injuries are very common
Individual differences in late effects after radiotherapy

11. Radiation effect on vulva/vagina
The rapid cell-turnover in vaginal mucosa makes it vulnerable to radiation effects
Submucosal bleeding
Confluent mucositis
Depridement
Fibrino-purulent exudation
Hypoxia og necrosis
Late complications
Thin and vulnerable vaginal mucosa and skin in vulva
Fibrosis
Narrow vaginal entrance
Narrow vagina with decreased elasticity
Different levels of vaginal stenosis

12. Female Sexual dysfunction (FSD)
Sexual desire disorders / reduced sexual interest
Sexual arousal disorders
Reduced/inhibited vaginal lubrication
Reduced subjective feeling of being aroused
Orgasmic disorders
Premature, delayed or absent orgasm following a normal excitement phase
Sexual pain disorders
Dyspareunia
Vaginismus

13. Male sexual dysfunction
Erectile dysfunction (ED)
Neurogenic
Vascular
Psychologic
Painful erection
Priapism
Orgasmic disorders
Delayed or absent orgasm
Premature ejaculation
Retrograd ejaculation
Sexual pain disorders
Sexual desire disorders

14. Gynecological cancer and sexual dysfunction Impaired sexual function
body image
Less attractive
Less feminine
Vaginal dryness
Vaginal shortening
Dys-pareunia
Impaired sexual function
Fatigue
Stage of disease
Meno-pause
Age
Fear of recurrence
Cancer treatment
Depression
Anxiety
Worries
Fear of dying

15. The impact of hypoactive sexual desire disorder on life

16. Sexuality in a palliative setting
Independent on age, gender, diagnosis, cultural background, and partner status:
Very reflective about their need to talk about sexuality
HCP’s ignored their need for staying intimate and sexual with their partner
Dismissed when they were seeking information, advice and emotional support about bodily and psychosexual changes
Horden AJ et al (2007) Soc. Scien Med 64:

17. Palliative HCP’s Lacking time.. Too private
The patient mainly want to discuss his cancer
Afraid of being misunderstood
Afraid of being condemned by other patients and the staff
Horden AJ et al (2007) Soc. Scien Med 64:

18. Two Danish multi-center studies
Herlev University hospital
Hvidovre Hospital
Næstved Hospital
Cph University hospital
Patients with advanced cervical cancer
Primary EBRT + brachytherapy
Radical hysterectomy + pelvic lymphadenectomy + EBRT
Patients with early stage cervical cancer
Radical hysterectomy + pelvic lymphadenectomy
Data from two Danish multi-center prospective questionnaire-based studies on HRQOL in patients with early stage cervical cancer treated by radical hysterectomy and pelvic lymphadenctomy only. Sexual functioning were assessed along with other measures prospectively.
Four different centers participated in the study. Patients with negative pelvic lymphnodes, no parametrial involvement and negative surgical margins were included in the first study while patients with positive lymphnodes, parametrial involvement or positive surgical margians who were referred for adjuvant radiotherapy were included in a second study of patients with advanced cervical cancer treated by radiotherapy.

19. Socio-demografic data Patients with persistent disease excluded
Design
ExtendedSVQ
Socio-demografic data 6 12 18 24 3 1
Mths
QLQ-30
UGQ
SVQ
As mentioned, the study design was prospective to evaluate the course of qol over time. The patients were sent all 3 questionnaires at …..
Patients with persistent disease excluded

20. Control group
Danish women randomly selected from the Danish Central Population Register
Born on the same date in odd years from 1913 til 1971
Age-matched
2 control women / patient

21. Advanced cervical cancer3m 1m 6m
12m
18m
24m
Sexual interest
Not at all–a little
Lack of lubrication
Quite a bit–very much
Dyspareunia
Orgasm
Never-occasionally
90%
RR 1.5
84%
RR 1.4
28%
RR 5.3
27%
RR 7.6
15%
RR 4.4
67%
RR 1.6
63%
Jensen PT et al IJROBP 2003

22. Advanced cervical cancer3m 1m 6m
12m
18m
24m
Size of vagina bothersome during intercourse – too small
Able to complete sexual intercourse
Never-occasionally
Not sexually active
Partner’s interest in sexual relations
Not at all-a little
Dissatisfied with sexlife
49%
RR 5.6
42%
RR 4.8
61%
RR 3.5
43%
RR 2.4
50%
RR 2.0
47%
The retrospective analysis revealed that despite considerable and persistent sexual dysfunction, 63% of those who were sexually active before their cancer, became sexually active again 12 mths. After radiotherapy, although with a decreased sexual activity frequency from median 1-2 times/week to 1-2 times/mth.
53%
RR 1.3
30%
RR 2.0
28%
RR 1.8

23. Retrospective comparison
Changes since cancer diagnosis
% scorings
Improved
No change
Deterioated p
Sexual interest
39.1
60.9
<0.001
Vaginal lubrication
4.2
33.3
62.5
Dyspareunia
16.7
27.8
55.6
0.05
Size of vagina
1 ”larger” ,”no change”, ”smaller”
4.01
48.0
48.01
0.002
Interest in intimacy
6.5
58.7
34.8
0.003
Partner’s sexual interest
86.8
13.2
0.03

24. Conclusion Risk of FSD after radiotherapy for cervical cancer
Patients who are disease free after radiotherapy for advanced cervical cancer are at high risk of experiencing persistent sexual and vaginal problems
Poor improvement over time
The results may underestimate the degree of sexual problems for the group of cervical cancer patients in general

25. Vulvectomi – partial or total +/- plastic surgery

26. Sexual rehabilitation after vulva cancer
Concern about continuation sexual relationship
Have to cope with husband’s poor coping
Insecure of anatomical changes
50% will become sexual inactive
Most pts will have severe FSD
Most pts have complaints re narrow vaginal entrance, impaired sensitivity, orgasmic and lubrication problems
Result of sexual rehabilitation presumably depends highly on pre-surgery information given to the couple
Weijmar Schultz et al. J psychosom obstet gynecol 1986
Green MS Gynecol Oncol 2000

27. Rectal cancer og FSD
Bruheim K Acta Oncologica 2010; 49:820-32

28. Rectal cancer og FSD Lack of sexual interest – 41%
Reduced arousal – 29%
Lack of lubrication – 56%
Orgasmic problems – 35%
Dyspareunia – 46%
53% rapported new sexual problems not present before the operation
61% rapported poorer sexual functioning than an age matched control group
61% was sexually active before the operation decreasing to 32% after the operation

29. After definitive treatment If further anti-androgen treatment is given
Prostate cancer og ED
After definitive treatment
Surgery +/- RT
If further anti-androgen treatment is given
At diagnosis
30-50% ED
60-80% ED
80-90% ED

30. Prostate cancer, Sexual dysfunction and the partner
High incidence of sexual dysfunction both in patients and their spouses; highly correlated
A higher prevalence of sexual dysfunction in couples with marietal problems.
A higher prevalence in couples that communicate poorly
A high correlation between the quality of the sexual relationship before and after the cancer
Of great importance for both spouses that their partner is sexually satisfied

31. Treatment Communication (therapy) with the patient and the partner
Pharmacological
Hormone replacement therapy (locally and/or systemically)
Phosphodiesterase inhibitors (e.g. Viagra)
Tibolone
Testosterone
Prostaglandine locally
Aids
Lubricants
Replens
Vaginal dilators
Vibrator
Penile transplants

32. Local Estrogen
Vaginal tablets
Vaginal ring
Vaginal creme

33. Cochrane review (2006) 19 randomised studies 4162 postmenopausal women
Prim. endpoint: vaginal atrophia / vaginitis
Significant effect of the creme, ring and tablets vs placebo
No difference in the effect of the 3 methods of application
More side effects of the creme
Women prefer the ring

34. Vaginal Estrogen to endometrial and breast cancer patients?
No evidence of endometrial proliferation with 6-24 mths use
No evidence to support yearly endometrial biopsy
No evidence to support additional progesterone
No studies have found increased risk of recurrence after vaginal estrogen in breast and endometrial cancer patients
All application methods reaches very quickly steady state serum level concentrations below that of menopausal women (< 50pmol/l)

35. Vaginal moisturizer

36. The effect of Replens
Replens is a polycarbofil which binds to the vaginal epithelium cells and maintains hydration leading to
Improvement in
vaginal fluid volume
moisture
elasticity

37. The effect of Replens The elasticity of the vagina improves
The natural pH og the vagina is restored
The physical discomfort disappears
Dyspareunia diminishes

38. HRT + / - Testosterone
No increased risk of cardio-vascular events or breast cancer of HRT when given to women with surgical premature menopause (up to the age of ~ 50)
No increased risk by adding testosterone (2 yrs. results)
A significant positive effect of HRT on sexuality in gynecological cancer patients (cervix and ovarian cancer)
A significant improvement in sexual desire in healthy menopausal women when testosterone is added to Estrogen preparations
Schufelt C et al Maturitas 2009, Al-Azzawi F et al Climacteric 2010, David S et al. NEJM 2008

39. HRT REMEMBER systemic HRT
After induced premature menopause with non-hormone dependent tumors
After pelvic radiation, especially for those with induced menopause
No increased risk of recurrence for non-hormone dependent tumors

40. Lubricants

41. Dilators

42. Vaginal dilation (hegar)
No international guidelines and a sparse evidence for the effect
One randomised controlled study on the use of hegar
Increased compliance with hegar use and reduced fear for having sex after cancer treatment, independent of age
The intervention included psychoeducational group counseling on vaginal dilatation and provided advice, proposals and information about sexual function and praxis
Robinson JW et al. IJROBP 1999

43. National forum of gyn.onc. Nurses (2005)
“Best practice guidelines on the use of vaginal dilators in women receiving pelvic radiotherapy”
Minimum 3 times/week
Water soluble lubricant
Supine or standing with one leg on a chair
A light pressure at insertion to the vagina
Each application should last 5-10 min
Move the dilator in different directions and rotate it if possible
Try different sizes, start with the smallest one
Rotate it again when removing

44. PDE5, prostate cancer and ED

45. Future directions
Sexuality is important for most cancer patients and cancer and its treatment may have a devastating effect on sexuality
HCP will have to improve re communication and handling of sexual complications after treatment
Sexuality has no age and no religion
HCP have to learn how to deal with patients’ sexual concerns and worries
The health care professionals decide what is on the agenda
HCP should be aware that they have an outstanding possibility to increase the QOL of cancer patients by communicating about sexual dysfunction following cancer treatment

46. One would certainly think that there could be no doubt about what is to be understood by the term ”sexual”. First and foremost, of course, it means the ”improper”, that which must not be mentioned..
Freud, 1943