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% posttreatment.[1] 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’s lymphoma and testicular cancer, 25% of people who have had these cancers are left with long-term sexual problems.[3,10] Several articles summarize the literature on sexuality and cancer, with a 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.[14,15] 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] Most often, orgasm remains intact for men and women, although it may be delayed secondary to medications and/or anxiety.

Unlike many other physiological side effects of cancer treatment, sexual problems do not tend to resolve within the first year or 2 of disease-free survival.[2,7,16-19] Rather, they may remain constant and fairly severe. Although it is unclear the extent that 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. In a qualitative study of 48 men (130 approached) with erectile dysfunction after treatment for prostate cancer, quality of life was significantly affected, including areas such as the quality of sexual intimacy, everyday interactions with women, sexual fantasy life, and perceptions of their masculinity. Patients who participated in a randomized trial that compared radical prostatectomy to watchful waiting were asked to complete a questionnaire regarding symptoms, psychological functioning, and quality of life. 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 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.[20,21] Assessment, referral, intervention, and follow-up are important for maximizing quality of life and survival.[2,18]

References

1. Derogatis LR, Kourlesis SM: An approach to evaluation of sexual problems in the cancer patient. CA Cancer J Clin 31 (1): 46-50, 1981 Jan-Feb.  [PUBMED Abstract]
   
   
2. Ganz PA, Rowland JH, Desmond K, et al.: Life after breast cancer: understanding women's health-related quality of life and sexual functioning. J Clin Oncol 16 (2): 501-14, 1998.  [PUBMED Abstract]
   
   
3. Schover LR, Montague DK, Lakin MM: Sexual problems. In: DeVita VT Jr, Hellman S, Rosenberg SA, eds.: Cancer: Principles and Practice of Oncology. 5th ed. Philadelphia, Pa: Lippincott-Raven Publishers, 1997, pp 2857-2872. 
   
   
4. Andersen BL: Quality of life for women with gynecologic cancer. Curr Opin Obstet Gynecol 7 (1): 69-76, 1995.  [PUBMED Abstract]
   
   
5. Walsh PC, Epstein JI, Lowe FC: Potency following radical prostatectomy with wide unilateral excision of the neurovascular bundle. J Urol 138 (4): 823-7, 1987.  [PUBMED Abstract]
   
   
6. Talcott JA, Rieker P, Clark JA, et al.: Patient-reported symptoms after primary therapy for early prostate cancer: results of a prospective cohort study. J Clin Oncol 16 (1): 275-83, 1998.  [PUBMED Abstract]
   
   
7. Smith DS, Carvalhal GF, Schneider K, et al.: Quality-of-life outcomes for men with prostate carcinoma detected by screening. Cancer 88 (6): 1454-63, 2000.  [PUBMED Abstract]
   
   
8. Stanford JL, Feng Z, Hamilton AS, et al.: Urinary and sexual function after radical prostatectomy for clinically localized prostate cancer: the Prostate Cancer Outcomes Study. JAMA 283 (3): 354-60, 2000.  [PUBMED Abstract]
   
   
9. Robinson JW, Moritz S, Fung T: Meta-analysis of rates of erectile function after treatment of localized prostate carcinoma. Int J Radiat Oncol Biol Phys 54 (4): 1063-8, 2002.  [PUBMED Abstract]
   
   
10. Arai Y, Kawakita M, Okada Y, et al.: Sexuality and fertility in long-term survivors of testicular cancer. J Clin Oncol 15 (4): 1444-8, 1997.  [PUBMED Abstract]
    
    
11. Auchincloss SS: Sexual dysfunction in cancer patients: issues in evaluation and treatment. In: Holland JC, Rowland JH, eds.: Handbook of Psychooncology: Psychological Care of the Patient With Cancer. New York, NY: Oxford University Press, 1989, pp 383-413. 
    
    
12. Lamb MA: Sexuality and Sexual Functioning. In: McCorkle R, Grant M, Frank-Stromborg M, et al., eds.: Cancer Nursing: A Comprehensive Textbook. 2nd ed. Philadelphia, Pa: WB Saunders Co, 1996, pp 1105-1127. 
    
    
13. Ofman US, Auchincloss SS: Sexual dysfunction in cancer patients. Curr Opin Oncol 4 (4): 605-13, 1992.  [PUBMED Abstract]
    
    
14. Havenga K, Maas CP, DeRuiter MC, et al.: Avoiding long-term disturbance to bladder and sexual function in pelvic surgery, particularly with rectal cancer. Semin Surg Oncol 18 (3): 235-43, 2000 Apr-May.  [PUBMED Abstract]
    
    
15. Weijmar Schultz WC, Van de Wiel HB, Hahn DE, et al.: Sexuality and Cancer in Women. Annu Rev Sex Res 3: 151-200, 1992. 
    
    
16. Fosså SD, Woehre H, Kurth KH, et al.: Influence of urological morbidity on quality of life in patients with prostate cancer. Eur Urol 31 (Suppl 3): 3-8, 1997.  [PUBMED Abstract]
    
    
17. Helgason AR, Adolfsson J, Dickman P, et al.: Factors associated with waning sexual function among elderly men and prostate cancer patients. J Urol 158 (1): 155-9, 1997.  [PUBMED Abstract]
    
    
18. Litwin MS, Hays RD, Fink A, et al.: Quality-of-life outcomes in men treated for localized prostate cancer. JAMA 273 (2): 129-35, 1995.  [PUBMED Abstract]
    
    
19. Relander T, Cavallin-Ståhl E, Garwicz S, et al.: Gonadal and sexual function in men treated for childhood cancer. Med Pediatr Oncol 35 (1): 52-63, 2000.  [PUBMED Abstract]
    
    
20. Steineck G, Helgesen F, Adolfsson J, et al.: Quality of life after radical prostatectomy or watchful waiting. N Engl J Med 347 (11): 790-6, 2002.  [PUBMED Abstract]
    
    
21. Bokhour BG, Clark JA, Inui TS, et al.: Sexuality after treatment for early prostate cancer: exploring the meanings of "erectile dysfunction". J Gen Intern Med 16 (10): 649-55, 2001.  [PUBMED Abstract]
    
    

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