Sexuality and patients with advanced cancer

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

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

8. Sympathetic outflow maintain lubrication and causes smooth muscle contraction leading to orgasm Visual input Brain Superior Hypo-gastric plexus T10-T12 Inferior Hypo-gastric plexus Splanchnic nn. S2-S4 Pudendal nerve Parasympathetic activity maintain vasocongestion Sensory input Female sexual function • 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. 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 Male sexual dysfunction

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

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 64:1704-1718

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 64:1704-1718

18. 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 Two Danish multi-center studies

19. ExtendedSVQ Socio-demografic data 3 0 24 6 12 18 Mths 1 Patients with persistent disease excluded QLQ-30 UGQ SVQ Design

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. 84% RR 1.4 90% RR 1.5 28% RR 5.3 28% RR 5.3 3m 1m 6m 12m 18m 24m 27% RR 7.6 15% RR 4.4 67% RR 1.6 63% RR 1.6 Advanced cervical cancer Jensen PT et al IJROBP 2003

22. 49% RR 5.6 42% RR 4.8 3m 1m 6m 12m 18m 24m 61% RR 3.5 43% RR 2.4 50% RR 2.0 47% RR 2.0 53% RR 1.3 30% RR 2.0 28% RR 1.8 Advanced cervical cancer

23. Retrospective comparison

24. ConclusionRisk 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. 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. Freud, 1943 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..