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Sexuality and patients with advanced cancer
Pernille T. Jensen, Subspecialist Consultant Gynecological Cancer, PhD Dept. of Gynecology Copenhagen University Hospital Herlev Denmark
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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The impact of hypoactive sexual desire disorder on life
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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:
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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:
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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.
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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
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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
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Advanced cervical cancer
3m 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
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Advanced cervical cancer
3m 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
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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
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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
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Vulvectomi – partial or total +/- plastic surgery
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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
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Rectal cancer og FSD Bruheim K Acta Oncologica 2010; 49:820-32
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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
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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
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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
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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
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Local Estrogen Vaginal tablets Vaginal ring Vaginal creme
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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
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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)
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Vaginal moisturizer
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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
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The effect of Replens The elasticity of the vagina improves
The natural pH og the vagina is restored The physical discomfort disappears Dyspareunia diminishes
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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
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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
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Lubricants
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Dilators
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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
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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
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PDE5, prostate cancer and ED
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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
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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
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