LET S TALK ABOUT CANCER AND SEX

Transcription

1 Teva Pharmaceuticals Europe BV, Piet Heinkade 107, 1019 GM Amsterdam, Netherlands Date of preparation: March HQ/ONCO/17/0001 LET S TALK ABOUT CANCER AND SEX Woet L. Gianotten Consultant in oncosexology Rehabilitation Centre De Trappenberg, Netherlands

2 TODAY S JOURNEY The taboo? The problem? Why are we not talking? Benefits of sex? Benefits of paying attention? How to have the conversation

3 LET S TALK ABOUT CANCER AND SEX The taboo? The problem? Why are we not talking? Benefits of sex? Benefits of paying attention? How to have the conversation

4 CANCER AND SEXUALITY: A TABOO? Society and the media Sex is for the young, the healthy, and the beautiful!

5 CANCER & SEXUALITY: A TABOO? Patient and partner Struggling in silence Taboo Oncology professionals In 62% of gynaecological oncology patients, sexuality had never been discussed! Sexology professionals Lindau ST, et al. Gynecol Oncol. 2007;106:413-8.

6 LET S TALK ABOUT CANCER AND SEX The taboo? The problem? Why are we not talking? Benefits of sex? Benefits of paying attention? How to have the conversation

7 Sexual function Sexual identity Sexual relationship

8 Sexual function Sexual identity Sexual relationship Gianotten WL, et al., editors. Seksualiteit bij ziekte en lichamelijke beperking. Uitgeverij van Gorcum; 2008.

9 DISTURBANCES Sexual function

10 DISTURBANCES Half of patients on SSRI or SNRI antidepressants no longer have an orgasm! 1 SNRI, serotonin-norepinephrine reuptake inhibitors; SSRI, selective serotonin re-uptake inhibitors. 1. Serretti A, Chiesa A. J Clin Psychopharmacol 2009;29:

11 DISTURBANCES Sexual function Sexual identity

12 DISTURBANCES Breast cancer + mastectomy: My husband doesn t want sex with me! Sexual function Sexual identity Sexual relationship Sexual relationship Androgen deprivation therapy for prostate cancer. In traditional relationship.

13 DISTURBANCES Sexual consequences Estimated percent with disruption to Cancer type intimacy or sexuality Breast 35 50% Head & neck 50% Blood & lymphatic system 50 70% Colon/rectum 40 85% Cervix 60 80% Ovary > 90% Bladder > 80% Prostate % All cancers > 50% Adapted from: Reisman Y, Gianotten WL, editors. Cancer, intimacy, and sexuality. Springer International Publishing; 2017.

14 UNMET NEEDS Modified from Opzij, 2006.

15 LET S TALK ABOUT CANCER AND SEX The taboo? The problem? Why are we not talking? Benefits of sex? Benefits of paying attention? How to have the conversation

16 WHY ARE WE NOT TALKING? No medical sexology in the medical curriculum (or no sexology at all) Gianotten WL, et al., editors. Seksualiteit bij ziekte en lichamelijke beperking. Uitgeverij van Gorcum; 2008.

17 They are too ill and depressed. All sexual desire has gone!

18 23% of men and 9% of women have more sexual desire when they are depressed Angst J. Int Clin Psychopharmacol.1998;13 Suppl 6:S1-4.

19 They are close to the end. It is not important any more!

20 An estimated 5% of patients continue to have sex (and sometimes even more than before) during the final phase of life! Gianotten, W. In: Mulhall J. et al. editors. Cancer and sexual health. Springer International Publishing; 2011;

21 Me, talking with my patients about sex? Imagine what they will think of me!

22 My oncologist never addressed sexuality. I think he is a poor lover!

23 Sex? You cannot discuss that. It is too private!

24 Sex? You can t discuss that. It s too private! Can you take off your pants? Open your legs a bit wider! Do you lose urine when sneezing? What colour is your stool? Too private?

25 "Don't think about your sex life. God gave you a second chance. You should be grateful!"

26 Yeah, but your treatment caused sexual damage, and you didn t tell me anything about that!

27 Isn t sex for the young, the healthy, and the beautiful?

28 I never liked sex that much! If I cannot have sex, I d rather die! I don t mind. But my husband really needs it! I don t worry about his lost erection. But now we have no more intimacy!

29 LET S TALK ABOUT CANCER AND SEX The taboo? The problem? Why are we not talking? Benefits of sex? Benefits of paying attention? How to have the conversation

30 WHY DO PEOPLE HAVE SEX? Relationship (love, intimacy, etc) Procreation Recreation (fun, adventure, lust, etc.)

31 MESTON & BUSS FOUND 237 DIFFERENT REASONS TO HAVE SEX 1. Stress reduction (physical subfactor) 2. Social status (goal-attainment subfactor) 3. Mate-guarding (insecurity subfactor) 4. Love (emotional subfactor) 5. Etc. Meston CM, Buss DM. Arch Sex Behav, 2007;36:

32 WE HAVE BEEN LOOKING FOR HEALTH BENEFITS OF SEXUAL EXPRESSION Emotionally Emotionally relaxing Decreases mutual tension Comforting & consoling A boost for male & female self-respect Diminishes/decreases depression Etc. Whipple B, et al. In: Tepper MS, et al. editors. Sexual health. Vol 1. Praeger; 2007: Gianotten W, et al. In: Tepper MS, et al. editors. Sexual health. Vol 1. Praeger; 2007:28-42.

33 WE HAVE BEEN LOOKING FOR HEALTH BENEFITS OF SEXUAL EXPRESSION Physically Distracts from pain Female genital stimulation increases endorphin levels and raises pain threshold Safe sleep medication Touch/massage and orgasm increase oxytocin level Enhanced mutual trust Sleep-inducing and muscle-relaxing Anxyolytic Whipple B, et al. In: Tepper MS, et al. editors. Sexual health. Vol 1. Praeger; 2007: Gianotten W, et al. In: Tepper MS, et al. editors. Sexual health. Vol 1. Praeger; 2007:28-42.

34 LONG TERM BENEFITS OF SEXUAL EXPRESSION Reduces development of vaginal atrophy Appears neuroprotective & neuroregenerative 1 Appears to slow down cognitive decline 2 Appears to benefit longevity 3,4 1. Spence RD, Voskuhl RR. Front Neuroendocrinol. 2012;33: Wright H, Jenks RA. Age Ageing. 2016;45: Palmore E. Gerontologist. 1982;22: Persson G. Acta Psychiatr Scand. 1981;64:

35 LET S TALK ABOUT CANCER AND SEX The taboo? The problem? Why are we not talking? Benefits of sex? Benefits of paying attention? How to have the conversation

36 DISCUSSING SEXUALITY WITHIN CANCER CARE Why is it important?

37 1 Because for many patients (and many partners) sexuality and intimacy are important aspects of QoL Be aware of the wide variety among patients and partners! QoL, quality of life.

38 2 Because our treatment interventions will cause, or have caused, so much harm!

39 3 Assuming that addressing sex could assist in regaining sexual expression: Sexual expression has CARE benefits (regarding sleep, pain, relaxation, etc.) And may have some CURE elements (regarding neuroprotection/neuroregeneration) 1 1. Spence RD, Voskuhl RR. Front Neuroendocrinol. 2012;33:

40 4 For some couples one may expect that continuing or regaining intimacy is a very relevant aspect in coping with all the cancer treatment hassles NB: divorce took place 1 After primary brain tumour 22% After non-cns cancer 7% CNS, central nervous system. 1. Glantz MJ, et al. Cancer 2009;115:

41 4 Female cancer patient with male carer Male cancer patient with female carer 84% 16% Glantz MJ, et al. Cancer 2009;115:

42 5 In a physical rehabilitation programme, HCP s were trained to address sexuality Some of the rehabilitation physicians proactively observed after this training that contact with the patients had improved ( more personal and intimate ) 1 We guess that this will also positively influence adherence to our treatment advice HCP, healthcare professional. Gianotten WL, et al. Sexual Relationship Ther. 2006;21:

43 6 Even in the terminal and palliative stage, attention for sexuality and intimacy was experienced as very rewarding de Vocht HM. Sexuality and intimacy in cancer and palliative care. Thesis. Netherlands 2011.

44 LET S TALK ABOUT CANCER AND SEX The taboo? The problem? Why are we not talking? Benefits of sex? Benefits of paying attention? How to have the conversation

45 Diagnosis Start of treatment End of treatment Follow-up Later The cancer care continuum Bondil P. In: Reisman Y, Gianotten WL, editors. Cancer, intimacy, and sexuality. Springer International Publishing; 2017:37-47.

46 Diagnosis Start of treatment End of treatment Follow-up Later Patient The cancer care continuum Bondil P. In: Reisman Y, Gianotten WL, editors. Cancer, intimacy, and sexuality. Springer International Publishing; 2017:37-47.

47 Diagnosis Start of treatment End of treatment Follow-up Later 1 Damaging effect of: Chemotherapy Surgery Anti-hormonal treatment Various medications Damaging effect of radiotherapy The cancer care continuum Bondil P. In: Reisman Y, Gianotten WL, editors. Cancer, intimacy, and sexuality. Springer International Publishing; 2017:37-47.

48 Example: Radical prostatectomy Don t worry! worry. You will not lose your erection! We are very good with with robot robot surgery! You will not lose your ability to have an erection! 1 It is possible that after the surgery you will not be able to have an erection. When that happens, there are several ways to deal with it. So don t forget to raise the subject! The cancer care continuum Bondil P. In: Reisman Y, Gianotten WL, editors. Cancer, intimacy, and sexuality. Springer International Publishing; 2017:37-47.

49 Diagnosis Start of treatment For many patients, sexuality is not very relevant End of treatment Follow-up later Survival mode Not at home Very tired Etc. The cancer care continuum Bondil P. In: Reisman Y, Gianotten WL, editors. Cancer, intimacy, and sexuality. Springer International Publishing; 2017:37-47.

50 Diagnosis Start of treatment Survival mode End of treatment Follow-up Later 2 Not at home Very tired Etc. The cancer care continuum Bondil P. In: Reisman Y, Gianotten WL, editors. Cancer, intimacy, and sexuality. Springer International Publishing; 2017:37-47.

51 Survival mode Not at home Very tired Etc. End of treatment 2 The cancer care continuum It is not uncommon for your treatment to have sexual consequences.... Your desire/erection/orgasm might be less good or disappear completely! Since we know that sexuality is important for most couples, we recommend that you invest in intimacy, even when sexuality doesn t function as before. Later, if sexuality does not return or develop satisfactorily, be aware that there are solutions for almost every sexual dysfunction. Bondil P. In: Reisman Y, Gianotten WL, editors. Cancer, intimacy, and sexuality. Springer International Publishing; 2017:37-47.

52 Diagnosis Start of treatment End of treatment Follow-up Later The cancer care continuum Bondil P. In: Reisman Y, Gianotten WL, editors. Cancer, intimacy, and sexuality. Springer International Publishing; 2017:37-47.

53 This is the situation most of you are in: Follow-up 3 I d like to discuss an area that we haven t addressed yet. We know that the treatment you have had can change intimacy and sexuality. Has your level of sexual desire changed since having chemotherapy? Has your erection/lubrication changed since the operation? Has your orgasm changed since starting on antidepressants? Or more general: In spite of the treatment, are you both satisfied with your current sexual life? It seems better not to ask about sexual problems because many people tend to connect sexual problems with relationship problems. ( And we love each other very much! ) The cancer care continuum

54 Oops!! There is a problem. What next??? Follow-up 3 Acknowledgement and explanation appear to be of sufficient help in 25% of problems! You will usually have the medical expertise to deal with the sexual side effects of your common interventions. If it gets too complex for you, it can t hurt to contact your colleagues in sexual medicine or sexology and ask for advice, or to refer the patient/couple. Your patients will not blame you for doing that! The cancer care continuum

55 Diagnosis Starting to Talk sex could be difficult. The only way to get used to it is by doing it! Start of treatment The cancer care continuum End of treatment Follow-up Later Once you have become used to it, when common oncology interventions cause a lot of sexual dysfunction: 4 It could help to include sexual function in history-taking. Because knowing the baseline can help. (and also to make clear that addressing sexuality is part of your approach). Bondil P. In: Reisman Y, Gianotten WL, editors. Cancer, intimacy, and sexuality. Springer International Publishing; 2017:37-47.

56 A next step when you are used to including sex: Diagnosis Start of treatment End of treatment Follow-up Later Which treatment modality? What kind of palliative care? Aspects of sexuality can become elements in the process of shared decision making The cancer care continuum Bondil P. In: Reisman Y, Gianotten WL, editors. Cancer, intimacy, and sexuality. Springer International Publishing; 2017:37-47.

57 TAKE HOME MESSAGE Sexuality can be very important. But people are all different!

58 TAKE HOME MESSAGE So, be aware of your own sexual frame of reference!

59 TAKE HOME MESSAGE No approach in medical care deserves the term holistic, as long as sexuality and intimacy have not been adequately addressed!