Sexual problems after treatment, interventions that help 1 tokyo

 Over 50% of survivors of breast, gynecology, prostate, testicular, rectal cancer have enduring problems with sexual functioning reducing for many their quality of life.. “There may be

Sexual Problems after

Treatment and Interventions that Help

Juntendo Hospital, Oct 22, 2010

Patricia Fobair, LCSW, MPH Stanford University Hospital

 In 2006, we published an article in the

journal, Psycho-Oncology 15: 579-594

(2006) on the subject

of  “Body Image and Sexual Problems in Young Women w/ Breast Cancer,”

 The Body Image article was # 1 on the top Psycho-Oncology article, Jan 2006 & Nov

2007 Why was it so popular?

* Pat Fobair, Susan L Stewart, Subo Chang, Carol D’Onofrio, Priscilla J Banks and Joan Bloom.

 Over 50% of survivors of breast, gynecology, prostate,

testicular, rectal cancer have enduring problems with

sexual functioning reducing for many their quality of life.

 Effective interventions have been elusive for survivors and their partners.

 Pharmaceutical solutions,

 Internet interventions,

 Couples counseling, and all of the above

 There is a need for more -attention.

 1) What are the key sexual

problems found among cancer

survivors by diagnosis.

improve sexual functioning? What helps?

 Literature search of English language abstracts and databases, 1980-2006.

 International studies, using standardized measures, re: psychosocial problems that trouble cancer

survivors following diagnosis and treatment.

 Intervention research re: physical exercise, group supports, journal writing, yoga, meditation and

imagery.

 Personal experience.

(25- Sexual satisfaction (36-67%)

 Sexual problems (45-88%)

In our study in the San Francisco Bay

area-50% of the 546 women reported 2 or more problems with body image Body image improved at five years (Bloom, et al 2004)

52% of 360 Brca pts, all stages, 0-7 months post diagnosis, reported problems w/sex functioning ( Fobair et al 2006,

Psychooncology)

56% of 185 of the same Brca pts 5 years post treatment

continued to have a lack of sexual desire ( Bloom et al 2004, Psychooncology)

**Result: Sexual functioning remained a problem over time.

 36% of 187 Brca pts w/benign tumors = deterioration

in sexual life Bukovic et al 2004, Coll Antropol Croatia.

 50% of 98 Brca w/br conserv surgery = dissatisfied

w/sex life after treatment vs 27% before Bukovic et al 2005, Onkologie Croatia.

 56% of 108 Brca pts w/mastectomy & adjuv treatment

= dissatisfied w/sex life after treatment vs 30%

before Bukovic et al 2005, Onkologie, Croatia.

 19% or 6/39 pts w/rectal ca recovered normal ejaculatory

function 1st year postop Hojo et al 1991, Dis Colon Rectum Japan

 31% or 12/39 pts w/ rectal ca recovered erectile function 1st

year postop Hojo et al 1991, Dis Colon Rectum Japan

 32% of 81 women w/ rectal ca were sexually active after

surgery vs 61% active before Hendren et al 2005, Ann Surg.Canada

 50% of 99 men w/rectal ca were sexually active after surgery vs 91% before Hendren et al 2005, Ann Surg.Canada

Effects of Sexual Problems on

Intimate Relationships

 Interpersonal relationships are vulnerable

after a cancer diagnosis; continuity in life is challenged (Mages et al 1979, 1981)

 Couples facing breast cancer reported greater decreases in marital functioning, & more

adjustment problems compared with couples adjusting to benign breast disease (Northouse

et al 1998)

 Patient’s ability to be open in communication with partner predicted outcome in 2 studies (Walker, 1997; Wimberly et al 2005)

Involving husbands helped -

Husbands report more

problems than their wives

Physicians and Patients have

Trouble Starting the Conversation

about Sex

had 1 or more problems with sexual

activity, but less than 19% attempted to ask for help Only 9% of physicians asked the

men and women about their sexual health (Moreira et al 2005)

discussed sexual issues with ovarian

patients (Stead et al 2003)

with their physicians about sexual issues (Takahashi et al 2006)

How to start the conversation

with your patient about

sexual issues

 Before the end of treatment,

physicians can give the patient

permission to talk about sexual

issues with questions, like:

 “Is there anything you would like to talk about?”

 “How has this affected you, sexually?”

 “Tell me about any sexual changes

you’ve noticed?

Dialogue between Physician

and Cancer Survivors

 1 “There may be changes in the way your

body responds to sexual encounters after

treatment which may affect your intimate

relationship.”

 2.” It is important to keep open

communication with your partner about

possible sexual changes.”

 3.” Look after your health, pay attention to your diet, sleep, exercise and emotional

health.”

 4 “Use vaginal creams to cope with dryness, and maintain sexually active as much as

possible.”

 5 Refer your patient for brief counseling or

and Spiegel, 2009)

Problems with libido

Counseling & support groups

Improve couple’s communication

Regular exercise

Schedule sexual encounters

Testosterone supplement

Estrogen supplements (Estring)

Testosterone patch (if approved)

L-arginine, esp for women who can’t take estrogen

 Sexual arousal disorder

Take more time with sexual activities

Sensory music, erotic movies

Vaginal lubricants and moisturizers,

Getting comfortable with each other’s bodies

in non sexual cuddling, and massage,

 Orgasmic disorder

Allow more time for sexual activities

Change antidepressants, re: Wellbutrin

Vibrators

Sensate focusing, nonsexual touch and massage Self stimulation

Positional change

Refer to sexual therapist

Learning again how to “let go”

 Physical exercise improved mortality risk, physical

energy, mood, vigor, and sexual functioning.

 Group support helped survivors decrease stress, anxiety, depression, loneliness, emotional well-being and vigor.

 Journal writing was helpful in decreasing survivor’s pain, self-blame, physical symptoms, and emotional

expression

 Yoga, Meditation and Imagery were helpful with quality

of sleep, mood, and quality of life.

 Exercise

 111 ca pts randomized to 14 week training or to controls The

fatigue score decreased x 17 pts in control group and 5.8 in active group

Thorsen et al 2005 JCO Norway

 111 w/ prostate ca & radiotherapy,(18 mo’s) found that higher level physical activity = better sexual functioning Dahn et al 2005, Urology USA

 91 ca pts on chemo & 54 hour exercise program Improvements in fitness were correlated w/improvements in depression but not w.anxiety Midtgaard et al 2005, Palliat Support Care Denmark.

 82 ca pts on chemo trained 54 hours Muscular strength, physical fitness, activity levels, treatment related symptoms, physical & role functioning Adamsen et al 2006 Support Care Cancer Denmark

 66 men w/Prostate ca randomized to walking (33) or control (33) Control pts Exercise group increased their distance walked (13.2%, P = 0.0003) Controls improved their fatigue scores, exercisers did not Windsor et al 2004, Cancer Scotland, UK.

 52 women w/ca were measured at baseline, midtreatment and end of

treatment Women who walked 90 minutes 3x’s week had less fatigue,

emotional.distress and better QOL than those who were less active Mock

et al 2001 Cancer Practice USA

 40 women w/brca who exercised were compared w/79 sedentary brca pts Regular exercisers reported more positive attitudes re: physical condition, vigor, sexual attractiveness, less confusion, fatigue, depression and better mood Pinto & Trunzo 2004 Mayo Clin Proc USA

 Brief sexual counseling interventions have been

helpful 4 sessions (Schover et al 1987; Schover &

 Partner support using psycho-educational group

program improved marital satisfaction (Bultz et al 2000)

Types of Counseling

 Emotionally focused marital therapy helps

patients suffering isolation or post-traumatic stress or recurrent anxiety from diagnosis

(Johnson & Talitman 1997)

 Support groups are most available source of assistance (Fobair 1997a,1997b; Antoni et al 2006)

 Weekly physical activity is helpful in

improving fatigue, mood, cardiopulmonary, and quality of life, comparing patients with control groups (Holick et al 2008; Irwin et al 2008; Courneya et al 2003; Aiello et al 2004; Pinto & Trunzo

2004)

 Emotionally focused marital therapy has been helpful to couples dealing with posttraumatic stress Johnson SM, Talitman E J Marital Fam Ther 1997; 23(2):135

 Therapy concentrates on the creation of

secure attachment. Johnson SM, Williams-Keeler L J Marital Fam Ther 1998; 24(1): 25-40

 An attachment injury occurs when one

partner violates the expectation that the

other will offer comfort and caring in times of danger or distress Johnson SM, Makinen JA, Millikin JW

 J Marital Fam Ther 2001; 27(2): 145-155Joh

 Disappointments occur with spouses who fail to

communicate their concern or withdraw from the

patient following diagnosis or treatment Johnson SM, et al J Marital Fam Ther 2001;27(2):145-.

 Among the couples dealing with trauma, the female

partner’s trust, her faith in her husband predicted the couples’ satisfaction at follow-up Johnson SM, Talitman E J Marital Fam Ther 1997;23

 When wives showed trust in their husbands, husbands were more comfortable with physical intimacy in

relationship As above, 23(2):135

 Meta-Analysis of 116 studies found benefits for adults w/ cancer in relation to anxiety, depression mood, nausea,

vomiting, pain and knowledge Devine & Westlake 1995, Oncol Nurs Forum USA

 303 Brca pts, in 3 yr study found trend (p=0.05) w/

intervention group having reduced anxiety vs.controls Kissane et

al 2003, Psychooncology Australia

 181 Brca pts.were assigned to support group (SG) or

complementary/alternative interventions (CAM) 91% SG & 80% CAM improved symptoms of PTSD; only support group had significant

decreases in overall stress. Levine et al 2005, Psychooncology USA

 154 Brca pts assessed for emotion regulation and adjustment over 4 pts time 12 week Interv 54 group, 56 decliners, 44 control At 4 mo’s

Interv.pts.+ better emotional well-being & at 12 mo’s + decrease in emotional suppression = showing delayed impact Cameron et al 2006,

Psychooncology, New Zealand.

problems with mood and +higher scores vigor vs controls Fukui et al

2000, Cancer Japan.

scores for loneliness, and higher scores number of confidants vs controls Fukui et al 2003, Oncol Nurs Forum, Japan.

 134 Ca pts offered 10 weekly 2 hour groups in 10 cities

in Switzerland QL assessed x 3 QL improved anxiety (p=0.0005), depression (p<0.0001) Van Wegberg et al 2000 Schweiz Med Wochenschr Switzerland

 125 Brca pts w/ mets disease 64 interv group w/ 1 year interv.vs 61 controls 102 completed Group members showed decline in trauma vs controls. Classen et al 2001, Arch Gen Psychiatry USA

 118 Brca partners 36 participated 3 months after group partners reported greater marital satisfaction

Bultz et al 2000, Psychooncology Canada

Support groups

help - 9 studies found improvements in sleep quality, mood, stress,

cancer-related symptoms, and overall quality of life Bower et al, 2005, Cancer Control USA.

 38 cancer survivors randomly assigned (20/18) to a 7-week yoga program had better quality of life, better emotional function, and fewer physical

symptoms Culos-Reed et al, 2006, PsychoOncology Canada.

 20 studies on meditation (397 intervention/561controls) found benefit for

cancer patients in better mood, less anxiety, better autoimmune

function, and less emotional disturbance Arias et al 2006, J Altern Complement Med USA

 154 breast cancer patients w/12 week intervention with relaxation, guided

imagery, meditation, emotional expression, behavior modification reported

increase in relaxation techniques, sense of control, emotional well-being, coping, and less cancer worry Cameron et al 2006, PsychoOncology, NZ.

 Physical exercise improved mortality risk, physical

energy, mood, vigor, and sexual functioning.

and depression, and loneliness while improving

emotional well-being and vigor.

pain, self-blame, and physical symptoms, and improved emotional affect.

well-being, coping and reduce worry Yoga helped with sleep, mood, & quality of life

Improving hot flashes

1 Effexor for depression & hot

flashes.

2 Paxil for depression, obsessive compulsive, post-traumatic

stress, hot flashes.

3 Neurontin prevents migraine

headaches, pain after shingles

and hot flashes.

4 Clinidine Catapres-TTS

(transdermal patch) helps with

migraine, hot flashes

Improving Sexual Comfort in

Lovemaking

sexual arousal and satisfaction (Derzko et

al 2007)

sensation, ability to achieve orgasm

(Berman & Berman 2004) May help some

women.

vasocongestion & sexual arousal, now in

clinical studies (Kielbasa & Daniel 2006)

ginkgo, damiana, multivitamins and

minerals increases sexual desire (Ito et al 2006)

Management of Vaginal

Dryness

times weekly has proven safe and effective

in increasing vaginal moisture Estradiol

and total estrone serum levels remained in the normal postmenopausal range The

women’s urogenital health component

improved (Belisle et al, 2006)

100-600 ieu’s increases vaginal lubrication, reduces dryness (Fugh-Berman, 2003)

 KY Jelly with vitamin E (Fugh-Berman, 2003)

 Sexual Problems frequently over 50% of survivors

of Cancer

 Pharmaceuticals can add quality of life.

 Marital therapy, physical exercise, group support and journal writing have demonstrated

effectiveness in helping patients improve physical, emotional health and sexual health.

 These intervention are relatively easy to initiate in medical or community settings.

 Cancer survivors are grateful when provided

services that help them recover.

Improving quality of life=goal