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Table of Contents
Year : 2018  |  Volume : 1  |  Issue : 2  |  Page : 75-77

Love in the time of cancer

Department of Medical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India

Date of Web Publication17-May-2019

Correspondence Address:
Vikas Talreja
SFS Flat Number 886, Pocket GH 13, Paschim Vihar, New Delhi - 110 087
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/CRST.CRST_3_19

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How to cite this article:
Talreja V. Love in the time of cancer. Cancer Res Stat Treat 2018;1:75-7

How to cite this URL:
Talreja V. Love in the time of cancer. Cancer Res Stat Treat [serial online] 2018 [cited 2020 Jan 21];1:75-7. Available from: http://www.crstonline.com/text.asp?2018/1/2/75/258541

“Sir, uh…. things aren't working down there,” he said, looking straight at me. I was a third-year senior resident doing a rotation in the outpatient department flanked by hundreds of patients and was suddenly taking the sexual history of a man nearly twice my age. “Wow, I can't believe he's telling me this,” I thought. Then, I took a deep breath and started asking him about it: “When did this start?” It wasn't hard to ask questions that I had asked a thousand times already. Recent developments in cancer diagnostics and treatments have considerably improved long-term survival rates. Despite improvements in chemotherapy regimens and more focused radiotherapy and diverse surgical options, cancer treatments often have gonadotropic side effects that can manifest as loss of fertility or sexual dysfunction, particularly in young cancer survivors.

I had overheard a senior talking with a group of his peers about how he wanted to be a doctor who helped his patients with all aspects of their lives, including their sexuality. I liked what he was saying, but inside I cringed and thought, “Oh God, can't I just let someone else deal with the sex stuff?” If you should happen to have the same reaction, rest assured, you are not alone. Despite years of training in dealing with complex and difficult medical conditions, many physicians still have difficulty talking to patients about their sexual health. Expectations of patients from doctors are the bare minimum in terms of sexuality-associated quality of life issues.[1] Health professionals believe that patients will bring up the topic of sex if it is important, and although they deny being uncomfortable talking about sex, they insist that it is someone else's job.[2]

Several studies have shown that young patients frequently contemplate the long-term effects of their cancer treatment on childbearing potential. In one study, 81% of all adolescents with cancer were interested in fertility preservation options, even if they were experimental in nature.[3] Another survey reported that 50% of women who develop invasive breast cancer before the age of 40 years still desire conception after treatment.[4]

Although sexual dysfunction after cancer typically has a physiologic cause, sexual rehabilitation requires good sexual communication between partners, enough male self-esteem to pursue sexual activity, and willingness to view sexual pleasure as possible, even if the penis is not rigid enough for penetrative sex.

Yet sexual health and sexuality are areas of life that have myriad implications from reproduction to infectious disease to mental health. Sexual dysfunction can also be a clue to significant underlying medical problems, such as heart disease or hormonal deficiencies.[2] The potential implications for all areas of patient health reinforce the fact that it is worth getting comfortable taking a sexual history and addressing patients' concerns about sex and sexuality.[1] As a medical student, you may find that this is not emphasized in your training and you may need to be proactive in learning these skills.

I was unfortunate as a medical student not to have learned to take a sexual history and the related components of the physical examination, and none of my peers ever paid attention to this detail nor highlighted it in the discussion of various day-to-day topics of rare diagnosis and rarer treatment options. My seniors, however, taught me to approach these issues in as straightforward a way as possible and offered many useful suggestions. You can't assume anything. I also learned by reading books written by people with disabilities, such as “Mean Little Deaf Queer” and “Waist-High in the World.” In the book “Waist-High in the World,” the author Nancy Mairs is a writer who suffers from multiple sclerosis. She writes that that not one of her doctors ever asked about her sexual life, in spite of her having a very robust one. She writes beautifully and will challenge you as she did her own physicians to consider the sexual lives of patients with physical disabilities. The impact that life stage and lifestyle may have on the quality and type of support required could be further explored. For example, a young adult who has been established in a career for several years may be attracted to an online forum, rather than a face-to-face meeting held during work hours. It may also be a struggle to bridge the division between the different life experiences of younger teenagers and those of patients in their late twenties or thirties.[5],[6]

Unfortunately, only about 20% of men with cancer-related sexual problems ever consult a health professional.[7] I don't mean to imply that asking sensitive questions is ever easy, but it does get easier with practice, like all parts of the physical examination and history taking.

In active listening, through both words and nonverbal behavior, you convey the following messages to the patient:

  • I understand your problem
  • I know how you feel about it
  • I am interested in what you are saying
  • I am not judging you

A practicing oncologist likely uses just about every medium to communicate. They talk on the phone, send e-mail messages, converse one-on-one, participate in meetings, and give verbal and written orders. And, they communicate with many audiences – patients and their families, referring physicians, and office staff.

Hence, how do you learn to take a sexual history as a medical student? You must practice asking questions and you must practice tolerating the discomfort you might feel about asking these questions or listening to the answers. You may not be required to ask about sexual health as part of your social history, but it is a good idea to get into the habit of asking basic questions, such as, “Are you sexually active? With men, women, or both?” The more you practice, the more comfortable you will become in future.

According to the limited advice I received in my medical training, if you have only limited time, the best two questions to ask as part of a minimal “review of systems” are: (1) “Are you sexually active?” and (2) “Are you having any sexual difficulty such as pain or lack of sexual desire?”

As a medical student, you can also try asking questions in class. I once asked if Viagra ® works for women. I couldn't resist the temptation of asking the physician who was teaching us about erectile dysfunction in men, including treatment options, if Viagra had a role in treating female sexual disorders. The question generated a stunned silence. I wasn't the only one who wanted to hear his expert opinion that whether, in select situations, these drugs can help.

Ask the physician you are working with how she or he approached getting comfortable asking difficult questions. Ask the patients that you get to work with in medical school which qualities in a physician help them feel comfortable talking about sexual health and which ones make them uncomfortable. Medical school is a laboratory, and the patients you get to work with during school are a good source of information. They will teach you more than you can imagine, but first, you have to ask.

Seek out role models. If you can't find anyone at your school to work with, seek models elsewhere.

There are issues that cause us moral distress that we have all faced at one time or another: a patient's family member, a son or daughter, asks you not to tell their father or mother that he or she has cancer or is dying. We know how to explain and rationalize and resolve these issues because we have been trained to do so. But, where is the training when you are faced with distress about something that is not freely accepted in our society like liberty of sexuality all the time which disturbs you to the core of your being? How do you deal with this knowledge after meeting a patient's wife who cried in your office when she thought that her husband might die as a result of his prostate cancer? At times, I envy the straightforward approach to cancer – cut it out, burn it, and wrestle it into submission. For those of us who deal with the heads and the hearts of our patients, it is not always that simple. Reflect on your own biases and behaviors. Observe what makes you uncomfortable and try not to avoid that feeling. What makes you uncomfortable is often a signal to you of where you have room to grow. Approach your education as a social experiment. Remember that what in another context might be considered prurient curiosity is actually critical to your patients' health.

When the issue pertains to the opposite gender, the situation is more dismal, especially with limited studies done to explore female sexual dysfunction and among them, very few studies speak about management issues in India. Our treatments although effective have unyielding side effects on sexuality.[8],[9] I see many men in the aftermath of prostate cancer treatment, and their desire to maintain their erectile function provides me with an intimate look into the male psyche, which is tender and vulnerable. I see women who have survived breast cancer but struggle with the physical challenges of life without estrogen combined with their fear of recurrence if they do not eradicate every last microgram of that nourishing hormone. I see boys and men who have been given the gift of life from a stem-cell transplant and who have no libido and so badly want to be full players in the dance of life. As physicians, we have an obligation to be aware of what our patients are going through and how they are coping in order to give thoughtful advice. Sexual issues in young cancer survivors are often best addressed in the same way as we deal with their cancer management utilizing a multidisciplinary team consisting of physicians, nurses, social workers, psychiatrists, sex educators, counselors, or therapists.[10] Cancer does not create angels or devils out of any of us; it perhaps might make us more of what we essentially are – flawed, troubled, blessed, and inspired all at the same time.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Beach MC, Roter DL. Interpersonal expectations in the patient-physician relationship. J Gen Intern Med 2000;15:825-7.  Back to cited text no. 1
Schover LR, van der Kaaij M, van Dorst E, Creutzberg C, Huyghe E, Kiserud CE, et al. Sexual dysfunction and infertility as late effects of cancer treatment. EJC Suppl 2014;12:41-53.  Back to cited text no. 2
Burns KC, Boudreau C, Panepinto JA. Attitudes regarding fertility preservation in female adolescent cancer patients. J Pediatr Hematol Oncol 2006;28:350-4.  Back to cited text no. 3
de Pedro M, Otero B, Martín B. Fertility preservation and breast cancer: A review. Ecancermedicalscience 2015;9:503.  Back to cited text no. 4
Corey AL, Haase JE, Azzouz F, Monahan PO. Social support and symptom distress in adolescents/young adults with cancer. J Pediatr Oncol Nurs 2008;25:275-84.  Back to cited text no. 5
Evan EE, Zeltzer LK. Psychosocial dimensions of cancer in adolescents and young adults. Cancer 2006;107:1663-71.  Back to cited text no. 6
Huyghe E, Sui D, Odensky E, Schover LR. Needs assessment survey to justify establishing a reproductive health clinic at a comprehensive cancer center. J Sex Med 2009;6:149-63.  Back to cited text no. 7
Jensen JR, Morbeck DE, Coddington CC 3rd. Fertility preservation. Mayo Clin Proc 2011;86:45-9.  Back to cited text no. 8
Practice Committee of American Society for Reproductive Medicine. Fertility preservation in patients undergoing gontoxic therapy or gonadectomy: A committee opinion. Fertil Steril 2013;100:1214-23.  Back to cited text no. 9
Scott JL, Kayser K. A review of couple-based interventions for enhancing women's sexual adjustment and body image after cancer. Cancer J 2009;15:48-56.  Back to cited text no. 10


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