The Prevalence and Types of Sexual Dysfunction in People With Cancer

Sexuality is a complex, multidimensional phenomenon that incorporates biologic, psychologic, interpersonal, and behavioral dimensions. It is important to recognize that a wide range of normal sexual functioning exists. Ultimately, sexuality is defined by each patient and his/her partner within a context of factors such as gender, age, personal attitudes, and religious and cultural values.

Many types of cancer and cancer therapies are frequently associated with sexual dysfunction. Across sites, estimates of sexual dysfunction after various cancer treatments have ranged from 40% to 100%.[1] Most of the information relates to women who have breast or gynecologic cancer and men who have prostate cancer. Less is known about how other types of cancers—in particular, other solid tumors—affect sexuality. Research suggests that about 50% of women who have had breast cancer experience long-term sexual dysfunction,[2,3] as do a similar proportion of women who have had gynecologic cancer.[4] For men with prostate cancer, erectile dysfunction (erections inadequate for intercourse) has been the primary form of sexual dysfunction investigated. Prevalence rates of erectile dysfunction have varied. In general, those studies that have used patients’ self-reports have found higher rates of erectile dysfunction ranging from 60% to 90% after radical prostatectomy and between 67% and 85% following external-beam radiation therapy.[5-8] Erectile dysfunction appears to be least prevalent with brachytherapy and most prevalent when cryotherapy is used to treat localized prostate cancer.[9] For Hodgkin lymphoma and testicular cancer, 25% of people who have had these cancers are left with long-term sexual problems.[3,10]

Several summary articles on sexuality and cancer give particular emphasis on cancer sites that have a direct impact on sexual functioning.[11-13] An individual’s sexual response can be affected in a number of ways, and the causes of sexual dysfunction are often both physiological and psychological. The most common sexual problems for people with cancer are loss of desire for sexual activity in men and women, erectile dysfunction in men, and dyspareunia (pain with intercourse) in women.[3] Men may also experience anejaculation (absence of ejaculation), retrograde ejaculation (ejaculation going backward to the bladder), or the inability to reach orgasm. Women may experience changes in genital sensations due to pain or a loss of sensation and numbness, as well as a decreased ability to reach orgasm. Loss of sensation can be as distressing as painful sensation for some individuals.[14] In women, premature ovarian failure as a result of chemotherapy or pelvic radiation therapy is a frequent antecedent to sexual dysfunction, particularly when hormone replacement is contraindicated because the malignancy is hormonally sensitive.[2]

Unlike many other physiological side effects of cancer treatment, sexual problems do not tend to resolve within the first year or two of disease-free survival;[2,7,15-19] rather, they may remain constant and fairly severe or even continue to increase. Although it is unclear how much sexual problems influence a survivor’s rating of overall health-related quality of life, these problems are clearly bothersome to many patients and interfere with a return to normal posttreatment life. Assessment, referral, intervention, and follow-up are important for maximizing quality of life and survival.[2,17]

In this summary, unless otherwise stated, evidence and practice issues as they relate to adults are discussed. The evidence and application to practice related to children may differ significantly from information related to adults. When specific information about the care of children is available, it is summarized under its own heading.

In a qualitative study of 48 men (130 approached) with erectile dysfunction after treatment for early prostate cancer,[20] quality of life was significantly affected in areas such as the following:

• The quality of sexual intimacy.
• Everyday interactions with women.
• Sexual fantasy life.
• Perceptions of their masculinity.

Patients who participated in a randomized trial that compared radical prostatectomy with watchful waiting were asked to complete a questionnaire regarding symptoms, psychological functioning, and quality of life.[21] Although the frequency of sexual thoughts was similar in both groups, the prevalence of erectile dysfunction (changes in voluntary erection in sexual situations, erection on awakening, and spontaneous erections) was higher in the radical prostatectomy group (80%) than in the watchful-waiting group (45%). Among men who underwent radical prostatectomy, 56% were moderately or greatly distressed by the decline in sexual function, as compared with 40% of men in the watchful-waiting group.[21]

In a different population—that of male lymphoma survivors—a cross-sectional study of 15-year survivors of both Hodgkin and non-Hodgkin lymphoma compared sexual function and hormone levels with those of age-matched controls.[22] Overall, the authors concluded that sexual function (as measured by the Brief Sexual Function Inventory [BSFI]) was significantly worse in the lymphoma survivors than in controls. In univariate analysis, lower functioning was attributed to the following:

• Increased age.
• Lower testosterone.
• Higher luteinizing hormone.
• Greater fatigue and emotional distress.
• At least one comorbidity.

There are several cautions in interpreting these results:

• The types of comorbidities are not listed; hence, it is not known whether cardiovascular disease was prevalent.

• Multivariate analyses to look at the relative impact of the various contributing factors to lower functioning were not performed.

• Considering the overall mean scores, the BSFI subscale scores were neither that low nor that different from the scores of controls (a difference of <0.5) even though they were statistically significantly different, likely because of the large sample size.

Although the authors concluded that sexual function was worse, it was only slightly worse; however, it reached statistical significance. Therefore, it is not clear from this study how much sexual functioning contributed to distress or decreased quality of life.[22]

References

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22. Kiserud CE, Schover LR, Dahl AA, et al.: Do male lymphoma survivors have impaired sexual function? J Clin Oncol 27 (35): 6019-26, 2009.  [PUBMED Abstract]