Sexual Dysfunction Common for Women With Metastatic Breast Cancer

“We know that sexual dysfunction is common in breast cancer patients for multiple reasons, but previous studies have primarily focused on survivors of early-stage breast cancer and have included very small numbers of patients with MBC,” said lead author Nusrat Jahan, MD, now an assistant professor of medicine in hematology/oncology at the University of Alabama at Birmingham.

“The few small studies that did look at MBC patients are at least 20 years old, from a time when the prognosis for this disease was extremely poor. But today, some MBC patients, especially those who are hormone receptor–positive or HER2-positive, can live quite long lives after their diagnosis—five to seven years or more.

“Sexuality is an important quality of life. If someone is very ill, it does not get priority, but for women who are doing well on their treatment program, they may feel like they are missing out on that aspect of life,” Dr. Jahan explained.

“This is an issue we are dealing with more and more,” agreed Allison Butts, PharmD, an assistant professor of family practice at the University of Kentucky College of Pharmacy, in Lexington, who practices in the Comprehensive Breast Care Center, and who was not involved with the study. “Initially there is the shock of the life-threatening diagnosis, and things like sexuality don’t seem to matter. But as time passes, and they get back to living a normal life, it can become more of a priority.”

Dr. Jahan and colleagues administered a questionnaire to 103 patients from the Mayo Clinic Breast Disease Registry (MCBDR) who had a diagnosis of de novo MBC and responded to a question about sexual dysfunction at the baseline MCBDR survey. Participants reported their sexual dysfunction on a scale of 0 (no dysfunction) to 10 (severe dysfunction) at baseline, and then annually for four years. Participants answered additional sexual symptom questions in years 2 and 4.

At baseline, the prevalence of any sexual dysfunction (score of 1-10) was 56.3%. That increased to 57.1% at year 1, 80.4% at year 2, 65.8% at year 3 and 85% at year 4. Vaginal dryness was reported by approximately 49% and 39% of patients in years 2 and 4, respectively, and was associated with higher severity of sexual dysfunction.

“We found that sexual dysfunction was fairly common and increased over time,” Dr. Jahan said. “This is understandable; most of the known treatments for MBC have a negative impact on sexual quality. One of the most common problems was vaginal dryness, which is very treatable. By year 2 of the study, decreased interest in sex overall was also common, and became more prevalent as time went on. Only about 15% of patients did not express, at any of the time points, that they had any sexual concerns.”

Patients often feel uncomfortable bringing up questions about sexual dysfunction with their healthcare providers, Dr. Jahan said. “One of the most important things we can do is to ask them about it and let them know there are options. While there have been few studies of interventions for vaginal dryness in this population, we can extrapolate data from the early-stage breast cancer setting. Nonhormonal moisturizers, and to a limited extent, even certain hormone-containing vaginal tablets and rings which have less systemic absorption, can be used on an as-needed basis.” (Systemic estrogen therapy is contraindicated in breast cancer survivors.)

There can be gender and generational barriers to discussing sexual dysfunction in the clinic, Dr. Butts said. ““In my experience, some women may be less comfortable talking to a male provider about their sexual health and be more forthcoming with a female provider. Younger patients are also more apt to bring up the topic; older patients can be more reluctant, particularly if there are grown children in the visit with them. I always tell patients, ‘If something like this does happen, here’s what we can do about it.’ It’s important to open those doors.”

Although vaginal dryness is the main treatable sexual issue for women with MBC, Dr. Butts noted that sexual dysfunction can also involve a general lack of sex drive, which may be related to feeling unwell due to cancer treatments or to associated depression and fatigue. “These are aspects that we aren’t as good at dealing with, but we still need to talk about them,” she said.

Dr. Jahan is now developing a follow-up study that will address multiple additional questions. “This study did not use a standardized scale for sexual dysfunction, but rather a customized instrument we designed for ease of administration,” she explained.

“The follow-up study will use the validated Patient-Reported Outcomes Measurement Information System (PROMIS) Sexual Function and Satisfaction measures, developed by the National Institutes of Health, which will give us a better idea of what types of problems these patients face. We also plan to assess the correlation between the presence of sexual dysfunction and perceived quality of life. And as groundwork for a future study on interventions, we will also be asking women about their experience talking to healthcare providers about sexual dysfunction, and how they feel it could be improved.”