Sexuality & Fertility Issues in Cancer Patients

Carolyn Vachani, MSN, RN, AOCN

9/12/2006

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Scope of Sexuality Issues 40-100% of cancer patients experience some form of sexual dysfunction Issues do not always resolve after therapy Almost all cancer treatments have the potential to alter sexual function (surgery, chemotherapy, radiation, hormones) Represents major quality of life (QOL) issue With intervention, up to 70% of patients can have improved functioning
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To Optimize QOL, Nurses Can: Learn evidence-based information on how diagnosis/treatment affects sexual function Conduct assessments before/during therapy Inform patients of possible changes Educate clients & partners Provide guidance & suggestions for adapting to changes Know resources & refer when needed

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Survey of Physician/Patient Communications

If you w anted to talk to your doctor about a sexual problem howconcerned w , ould you be that --- m ight happen?
You do r w uld be u m rta r cto o nco fo ble ta lking ab u th p ble b u it w s o t e ro m eca se a se l in n xua ature

4% 4

4% 4

Yo d cto w uld dism yo r co ce s ur o r o iss u n rn an sa it w just in yo r he d d y as u a

4% 4

4% 4

T ere w ld be n m dica tre tm nt fo h ou o e l a e r yo r p b m u ro le 4 %

4% 4

4% 4

Ve C ncern ry o ed

4 4 4 4 4 4 4 4 % % % % Som h t conce d ew a rne

4 4 4 4 % %

4 4 4 4 % %

Marwick, C Survey says patients expect little physician help on sex. JAMA 1999;281:2173-2174.

Nurses Beliefs
Someone else will do it Patients never ask about it, so they must not care I dont know how to help or have time I dont agree with their lifestyle They should be happy to be alive They are too old, sick, young, etc. I will offend them by asking
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Johnsons Behavioral Model

All of the patterned, repetitive, purposeful ways of behaving that characterize each person's life make up an organized and integrated whole, a system Categorizes all human behavior into seven subsystems: Attachment, Achievement, Aggressive, Dependence, Sexual, Ingestive, and Eliminative Disturbance in one subsystem affects the other subsystems Can be applied to sexual dysfunction

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PLISSIT Model for Communication Permission (Assessment) Limited Information (Education) Specific Suggestion (Counseling) Intensive Therapy (Referral) Developed in 1976 by Robinson & Annon based on the four levels of intervention Applied to sexuality by Estes in 2002 70% can be managed by first 3 levels
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Sexual Dysfunction in Men

Chemo/hormonal therapy: Erectile dysfunction, decreased
libido, ejaculatory dysfunction, gynecomastia, penile/ testicular atrophy, and infertility

Radiation/ brachytherapy: Urinary issues, impotence, bowel

dysfunction, penile/ testicular atrophy

Surgery: Urinary issues, impotence, body image, pain, retrograde

ejaculation

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Sexual Dysfunction in Women Chemo/Hormone therapy: Irregular menses, early

menopause, hot flashes, insomnia, irritability, depression, vaginal dryness, painful intercourse, infertility, and decreased libido

Radiation/ brachytherapy: Pelvic fibrosis, vaginal

atrophy/stenosis, scarring, decreased lubrication, urinary effects, erythema, edema, ulceration, decreased elasticity, shortening, and increased irritation of vagina

Surgery: Body image, bowel changes, ROM issues,

menopause, pain, changes in vaginal size/sensitivity, loss of nipple

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General Nursing Interventions Ask the question! Educational resources

ACS booklets for men & women

Suggestions for energy conservation, alternatives to intercourse, position changes, resting Set the right mood with relaxation, candles, music, wine Sense of humor
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General Nursing Interventions

Suggest open communication with partner Use of pillows to alleviate pain with positioning, use of pain meds Kegel exercises to relax pelvic muscles Treat depression Neutropenic pts - no intercourse / tampons Referral to therapist relationship & sexual issues Look for AASECT (American Association of Sex Educators, Counselors, Therapists) credentials and/or a marriage and family therapist who has experience with people with cancer

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Ostomy Surgery: Interventions

Address issues of Body Image Concerns about odor
Tight appliance Avoid foods that cause flatulence or urinary odor (asparagus)

Appliance cover, lingerie Ostomy accessories (search for ostomates)

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Interventions for Male Issues

Surgical Nerve-Sparing Techniques
Results depend on surgeon skill, pt age (better if <50yo, worse if >70yo), comorbidities Both nerve bundles spared: 50-90% success One bundle spared: 25-50% success No nerves spared: >84% with impotence More likely to have initial impotence, but regain function within 6 mos 3 yrs Early intervention with meds to prevent atrophy Without prostate, can have orgasm / normal sensation, but no ejaculate/semen dry orgasm

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Interventions for Female Issues

Vaginal lubricants
Use before/during sexual activity Water soluble, water- or silicone-based Petroleum-based can damage condoms and encourage vaginal infection

Vaginal Moisturizer
Replens: 3x a week, for a minimum of 3 months Vaginal tissue regains moisture & elasticity Use with lubricants, can also use Replens before intercourse

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Interventions for Female Issues

Vaginal Estrogens
Creams: use 2-3x week Causes elevated systemic estrogen (highest in first 3-4 mos), not good for breast cancer pts E-string: silicone ring, slow release of local estrogen over three months Vagifem: tablet inserted at night, QD for 2 weeks, then biweekly Risk is thought to be low for breast cancer pts. With ring & tablets, but long term studies not done yet Dont confuse with Femring (a hormone replacement therapy)!

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Radiation-Induced Vaginal Stenosis

Radiation for cervical and endometrial cancers, or to the pelvic region: risk for fibrosis / stenosis Risk increases with brachytherapy Decreased blood supply leads to dry, tender, less elastic tissue that may close off vagina Women who are sexually active should be encouraged to remain active Vaginal dilator with or without estrogen cream used 3 times a week for life (can substitute with intercourse). Start when radiation starts. Educate on use and cleaning of dilator, give written instructions also important for exam comfort (not just sexual activity), can start small and increase size of dilator

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Other Interventions for Women

Eros device to increase blood flow to clitoris, use 3-4x a week. Increases sensitivity & lubrication with gentle vacuum Sensua & Viagel creams containing L-arginine (dilates blood vessels) & menthol applied to clitoris to increase blood flow Viagra being tested in women

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Resources
www.eyesontheprize.org (online community for gynecologic cancers) Support groups (Gildas Club, Wellness Community) www.oncolink.org www.ustoo.org (prostate cancer website) www.fertilehope.org www.resolve.org (fertility) ACS Sexuality booklets (available on ACS website)

Pregnancy & Treatment

~4% (50,000) of people diagnosed with cancer are under age 35 Discuss importance of birth control use - for both sexes - during hormones, chemo, xrt Condoms for 48 hrs after chemo (excreted in semen) IUD, sponge, diaphragm risk of infection if neutropenic, foams can irritate vaginal tissue Should not conceive after treatment for ~1 yr for women, ~2 yrs for men Data on risk for fetus exposed to chemo is limited and related to trimester (1st is greatest risk) Drug choice, does it enter fetal circulation? Delay radiation until after birth or use shielding Use non-radiation tests (US, MRI), choose safe anesthesia

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Risk of Infertility: Radiation

Small dose can = big damage Temporary or permanent, can take up to 4 yrs to resume fertility: monitor FSH & sperm counts if desire pregnancy Permanent sperm damage at 4 Gy, but Leydig cells need higher dose (20-30 Gy), so sexual characteristics can be unaffected Oocytes related to pre-treatment pool size >40 yrs old: 5-6 Gy; <40 yrs old: 20 Gy for permanent ovarian failure <35 yrs old more likely to resume menstruation, but can still have premature menopause TBI causes sterility in 80% men, 90% women Cranial XRT affecting pituitary - may require supplemental hormones (testosterone, FSH)

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Radiation Risk to Future Pregnancy Pelvic/ Uterine radiation XRT in childhood results in changes in uterine musculature & blood flow, decrease in size (40% of normal size) Spontaneous abortion: 38% vs. 12% (in the general public) Preterm labor: 62% vs. 9% Low birth weight: 62% vs. 6% No increase in birth defects seen after XRT or chemo in men or women

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Risk of Infertility: Chemo

Drug(s), dose, duration, and age of patient Higher dose, longer duration, and older age pose highest risk Alkalating agents most likely to cause infertility (dont require cell proliferation to cause damage) Stem cell / BMT (without TBI): infertility extremely likely in women, 50% of men Women can regain menses and still have premature menopause (42% by age 31 vs. 5% of normal population) Resumption of menses is no guarantee of fertility Men can develop low/no sperm count with no damage to Leydig cells

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Chemotherapy (dose to cause effect)

Known Effect on Sperm Count

Chlorambucil (1.4 g/m2) Cyclophosphamide (19 g/m2) Procarbazine (4 g/m2) Melphalan (140 mg/m2) Cisplatin (500 mg/m2) BCNU (1 g/m2) CCNU (500 mg/m2) Busulfan (600 mg/M2) Ifosfamide (42 g/m2) BCNU (300 mg/m2) Nitrogen mustard Actinomycin D

Prolonged or permanent azoospermia in 90% of men; platinum agents 50%

Azoospermia in adulthood if treated before puberty Azoospermia likely, and are often given with other highly sterilizing agents, adding to the effect

Risk for Infertility: Surgery Orchiectomy (bilateral) Penectomy Prostate or bladder surgery damage Prostatectomy Hysterectomy Oopherectomy (bilateral)

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Options for fertility preservation in men

Sperm banking only after puberty
$700-1500 for 1-3 donations/ 1-5 yrs storage Although many men have poor quality sperm at diagnosis, new techniques can use it anyway (even just 1-2 samples) No sex for 5 days prior, 24-48 hours between samples; Testicular aspirate if no semen

Intracytoplasmic sperm injection (ICSI)

Newer technique for fertilization, very successful

GnRH agonist/antagonists
Turn off gonads (only tested in mice, no births)

Cryopreservation of testicular tissue, then transplant or grow in vivo (+ births in mice)

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Options for Fertility Preservation in Women Embryo freezing cycle 12-14 days, 10-25% chance of
pregnancy per embryo stored, cost $8-12,000, then cost of storage, thaw & implanting

Ovarian transposition (oophoropexy) move ovaries

from XRT field, can be laparoscopic, cost ?, been done for 30yrs, 16-90% success rate

Egg cryopreservation cycle 12-14 days, 2% chance

of live birth per thawed egg, cost ~$8,000, then cost of storage, thaw, fertilizing & implanting

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Options for Fertility Preservation in Women

GnRH agonist/antagonist : theory is to stop proliferation
Suppress ovarian function via hypothalamic-pituitary access (some studies use birth control pills for same effect) Experimental, studies +/-, large randomized study by SWOG ongoing

Ovarian tissue freezing: 60% follicles lost to freezing, have been 2 live births*
5 laparoscopic biopsies can yield 3500 follicles Transplant: auto* (orthotopic/heterotopic), xeno (mice), In Vitro Maturation (success in mice, cows)

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Options for Fertility Preservation in Women

Radical trachelectomy: for cervical cancer, experimental?
Remove cervix, leave uterus intact, permanent cerclage (stitch closed uterus) Started in 1987, >100 live births, 53% chance of pregnancy over 5 years High risk births (premature rupture of membranes) about premature delivery, all need c-section Recurrence rates equivalent to radical hysterectomy Only for early stage disease (IA & IB)

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Assessing Ovarian Function in Survivors

FSH & Estradiol
Check on 3rd day of menses FSH >12mIU or E2 > 75pg/ml =severely impaired fertility (or poor ovarian reserve) Levels effected by tamoxifen

Anti-Mullerian hormone (AMH)

Produced by early follicles, good predictor of reserve

Antral follicle count

Via ultrasound on 3rd day menses, not affected by tamoxifen Count # developing follicles, is proportionate to # remaining

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Financial Assistance
11 states require insurance companies to cover infertility dx & tx (unless self-insured) (NJ, NY & MD) www.resolve.org (has info for all states) Check on extent of benefits, talk to HR representatives Sharing Hope program thru Fertile Hope sperm bank for $150 (1yr storage) (must meet requirements) www.fertilehope.org has many financial assistance links/tips Rates vary greatly!! Shop around

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Local Sites for Sperm Banking

3 National organizations (by mail)
www.cryolab.com www.reprot.com www.xytextissues.com

Womens Institute; 815 Locust / Plymouth Meeting Penn Fertility 3701 Market Fairfax Cryobank 3401 Market (http://www.fairfaxcryobank.com/) Drexel Fertility Bala Cynwyd / Center City Reproductive Science Institute Jenkintown
(http://www.rsiinfertility.com/)

Womens Health Group of PA Bryn Mawr

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Local Sites for Women

Womens Institute: 815 Locust / Plymouth Meeting (http://www.womensinstitute.org/) Penn Fertility: 3701 Market (http://www.pennhealth.com/fertility) Drexel Fertility: Bala Cynwyd / Center City (http://www.drexelfertility.medem.com) Womens Health Group of PA: Bryn Mawr (http://www.mainlinefertility.com)

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References
Devita, VT, Hellman, S & Rosenberg, SA. Cancer: Principles & Practice of Oncology (7th edition). Lippincott Williams & Wilkins, Philadelphia, PA 2005. Itano, JK & Taika, KN. Core Curriculum for Oncology Nursing (4th edition). Oncology Nursing Society 2005. Krebs, L. & Marrs, JA. What Should I Say? Talking With Patients About Sexuality Issues. Clinical Journal of Oncology Nursing. 10 (3)313-315, 2006. Lee SJ, Schover LR, Partridge AH, et al: American Society of Clinical Oncology recommendations on fertility preservation in cancer patients. Journal of Clinical Oncology 24:2917-31, 2006 Nieman CL, Kazer R, Brannigan RE, et al: Cancer survivors and infertility: a review of a new problem and novel answers. Journal of Supportive Oncology 4:171-8, 2006 Simon B, Lee SJ, Partridge AH, et al: Preserving fertility after cancer. CA: A Cancer Journal for Clinicians 55:211-28; quiz 263-4, 2005
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