Sexuality _ Fertility Issues in Cancer Patients

Sexuality & Fertility Issues in Cancer Patients Carolyn Vachani, MSN, RN, AOCN 9/12/2006 OncoLink Copyright © Trustees of the University of Pennsylvania 1 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 9/12/2006 OncoLink Copyright © Trustees of the University of Pennsylvania 2 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 9/12/2006 OncoLink Copyright © Trustees of the University of Pennsylvania 3 Survey of Physician/Patient Communications If you wanted to talk to your doctor about a sexual problem, how concerned would you be that --- might happen? Your doctor would be uncomfortable talking about the problem because it was sexual in nature 45% 23% Your doctor would dismiss your concerns and say it was just in your head 51% 20% There would be no medical treatment for your problem 46% 30% Very Concerned 10 20 30 40 % % % % Somewhat concerned 0% 50 % 60 % 70 % 80 % 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 don’t know how to help or have time • I don’t agree with their lifestyle • They should be happy to be alive • They are too old, sick, young, etc. • I will offend them by asking 9/12/2006 OncoLink Copyright © Trustees of the University of Pennsylvania 5 Johnson’s 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 9/12/2006 OncoLink Copyright © Trustees of the University of Pennsylvania 6 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 9/12/2006 OncoLink Copyright © Trustees of the University of Pennsylvania 7 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 9/12/2006 OncoLink Copyright © Trustees of the University of Pennsylvania 8 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 9/12/2006 OncoLink Copyright © Trustees of the University of Pennsylvania 11 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 9/12/2006 OncoLink Copyright © Trustees of the University of Pennsylvania 13 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 9/12/2006 OncoLink Copyright © Trustees of the University of Pennsylvania 14 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”) 9/12/2006 OncoLink Copyright © Trustees of the University of Pennsylvania 15 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” 9/12/2006 OncoLink Copyright © Trustees of the University of Pennsylvania 16 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 9/12/2006 OncoLink Copyright © Trustees of the University of Pennsylvania 18 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 – Don’t confuse with Femring (a hormone replacement therapy)! 9/12/2006 OncoLink Copyright © Trustees of the University of Pennsylvania 19 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 • • 9/12/2006 OncoLink Copyright © Trustees of the University of Pennsylvania 20 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 9/12/2006 OncoLink Copyright © Trustees of the University of Pennsylvania 21 Resources • www.eyesontheprize.org (online community for gynecologic cancers) • Support groups (Gilda’s 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 • • • • • 9/12/2006 OncoLink Copyright © Trustees of the University of Pennsylvania 23 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) • • • • • • 9/12/2006 OncoLink Copyright © Trustees of the University of Pennsylvania 24 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 9/12/2006 OncoLink Copyright © Trustees of the University of Pennsylvania 25 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 (don’t 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 • • • • 9/12/2006 OncoLink Copyright © Trustees of the University of Pennsylvania 26 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) Prolonged or permanent azoospermia in 90% of men; platinum agents 50% Azoospermia in adulthood if treated before puberty Busulfan (600 mg/M2) Ifosfamide (42 g/m2) BCNU (300 mg/m2) Nitrogen mustard Actinomycin D 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) 9/12/2006 OncoLink Copyright © Trustees of the University of Pennsylvania 31 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) 9/12/2006 OncoLink Copyright © Trustees of the University of Pennsylvania 32 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 9/12/2006 OncoLink Copyright © Trustees of the University of Pennsylvania 33 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) 9/12/2006 OncoLink Copyright © Trustees of the University of Pennsylvania 34 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 ½ premature delivery, all need c-section – Recurrence rates equivalent to radical hysterectomy – Only for early stage disease (IA & IB) 9/12/2006 OncoLink Copyright © Trustees of the University of Pennsylvania 35 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 9/12/2006 OncoLink Copyright © Trustees of the University of Pennsylvania 36 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 9/12/2006 OncoLink Copyright © Trustees of the University of Pennsylvania 37 Local Sites for Sperm Banking • 3 National organizations (by mail) – www.cryolab.com – www.reprot.com – www.xytextissues.com • • • • • Women’s 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/) • Women’s Health Group of PA Bryn Mawr 9/12/2006 OncoLink Copyright © Trustees of the University of Pennsylvania 38 Local Sites for Women • Women’s 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) • Women’s Health Group of PA: Bryn Mawr (http://www.mainlinefertility.com) 9/12/2006 OncoLink Copyright © Trustees of the University of Pennsylvania 39 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 OncoLink Copyright © Trustees of the University of Pennsylvania 40 • • • • • 9/12/2006