Identifying and Addressing the Overlooked Need of Patient Sexual Health

During the whirlwind of emotions and newfound obligations brought on by a cancer diagnosis, the sexual health needs of patients are often overlooked by clinicians. Thus, this area of cancer care has often not received the proper amount of attention, and this lack of focused attention trickles down to the training of hematology and oncology fellows.

“After facing a cancer diagnosis and going through treatment, many patients are completely blindsided by the devastating impact to their sexual health,” Laila S. Agrawal, MD, a hematologist/ oncologist in the Department of Breast Medical Oncology at Norton Healthcare in Louisville, Kentucky, explained in a statement to Oncology Fellows. “As oncologists, it is our responsibility to counsel and prepare our patients for the adverse effects [AEs] of cancer treatment and address ways to help treat these AEs. Sadly, when it comes to sexuality, and especially so for women, there is often zero discussion about the impact of cancer treatment on sexual function. For the minority [of] women who do bring it up to their oncologists, many are made to feel as if there isn’t anything to be done about it, it is the price to pay for surviving cancer, or they should just be grateful to be alive. They may conclude that if their oncologist hasn’t brought it up, there is nothing that can be done to help. The truth is that sexual AEs are very common [and] can be very distressing, and there are multiple treatment options that can make things better.”

In a survey of hematology and oncology fellowship program directors, findings from which were presented during the 2023 American Society of Clinical Oncology Annual Meeting and subsequently published in JCO Oncology Practice, Jennifer Barsky Reese, PhD, FSBM, and coauthors sought to better characterize the current state of training of fellows regarding the sexual health of patients with cancer. Survey respondents (n = 114) indicated that less than half (49.1%) of programs offered some formal instruction on patient sexual health and only 36.8% offered formal instruction on safe sex practices, although 75.4% did so concerning patient fertility. Additionally, most program directors reported that a lack of experts was a significant barrier to instructing fellows of the topics of patient sexual health (74.3%), safe sex practices (67.9%), and fertility (53.5%; FIGURE).

“It seems like reproductive health and fertility do tend to appear more often in clinical discussions with patients with cancer as opposed to sexual functioning,” Reese, an associate professor in the Cancer Prevention and Control Program at Fox Chase Cancer Center in Philadelphia, Pennsylvania, said in an interview with Oncology Fellows. “We know that these issues are not necessarily coming up as often as we’d like them to, even though they’re included in clinical guidelines for care. We’ve also known for many years [that the reason they are not properly integrated] is because of a lack of training in how to discuss these issues. I’ve tested provider interventions, [but] after discussing this issue with my colleagues, we thought, why don’t we start with the fellowship level? This is the moment in time in an oncologist’s training when they’re really steeped in learning about how to treat patients with various kinds of cancers and [should be] getting the whole experience of how to deal with all these issues.”

Reese and coauthors sent a survey to all hematology/oncology fellowship program directors in the US (n = 176); directors were identified via a search of the American Medical Association Residency and Fellowship Database website. The median number of fellows per program was 12 (range, 2-50).

The survey consisted of 14 items concerning fertility, sexual health, and safe sex practices. For each domain, program directors were asked about the coverage of topics via formal training, the use of informal training methods such as case studies or webinars, the barriers to providing instruction, and the amount of time dedicated to formal instruction relative to the overall academic year. The objectives of the study were to examine the provision of training in sexual and reproductive health topics during fellowship in terms of formal and informal instruction and to identify and interrogate the primary barriers to offering this instruction.

Additional findings from the survey revealed that most hematology/ oncology fellowship programs did not offer formal training in terms of the impact of cancer treatment on female sexual health (70.8%), male sexual health (71.7%), or body changes/ image (73.5%); a vast majority of programs also did not address patient distress related to sexual health/body image changes (75.2%) or dating and sexual relationships after cancer (85.8%). In terms of safe sex practices following cancer treatment, most programs did not cover the use of contraception/birth control (68.1%), sexually transmitted diseases/infections (85.8%), or safe sex practices during a patient’s treatment (69.0%).

In terms of barriers to providing formal training for oncology fellows around patient sexual health, program directors indicated that difficulty finding space in the curriculum and the lack of requirement or expectation that these issues were part of the program played a role. Specifically for sexual health, safe sex practices, and fertility, program directors cited difficulty in finding space in the curriculum as a significant barrier at rates of 49.6%, 54.0%, and 43.0%, respectively. A lack of requirement or expectation for patient sexual health, safe sex practices, and fertility to be included in a fellowship program was listed as a significant barrier at a rate of 56.6%, 60.2%, and 34.5%, respectively.

Outside of formal training, most program directors listed direct clinical experience as a training method regarding patient sexual health (78.1%), safe sex practices (72.8%), and fertility (77.2%). Case-based learning (38.6% vs 28.9% vs 42.1%, respectively), webinars or other online modules (21.9% vs 18.4% vs 16.7%), grand rounds (18.4% vs 12.3% vs 25.4%), and journal club (11.4% vs 7.0% vs 20.2%) were lesser-utilized additional training methods for fellows in the respective areas.

“If you’re training with an attending [clinician] who never brings up sexual issues with the patients, then that’s obviously going to limit what you’re learning,” Reese explained. “The problem with direct clinical experience being used as a primary method for training fellows in these areas is that practicing clinicians’ practice patterns are going to be very divergent from one to the next. Some may bring it up with every patient, some may bring it up with no patients, and some may bring it up at different times. It’s idiosyncratic, and we know that because most oncologists themselves “If you’re training with an attending [clinician] who never brings up sexual issues with the patients, then that’s obviously going to limit what you’re learning,” Reese explained. “The problem with direct clinical experience being used as a primary method for training fellows in these areas is that practicing clinicians’ practice patterns are going to be very divergent from one to the next. Some may bring it up with every patient, some may bring it up with no patients, and some may bring it up at different times. It’s idiosyncratic, and we know that because most oncologists themselves haven’t received training in these issues, the idea of learning from clinicians who themselves haven’t received training is potentially problematic.”

“If we could develop some kind of program or training that could be inserted within fellowship, it could potentially have a great impact on the field. These are future clinicians who are developing their practice patterns and their habits. We want them to go off into their own individual practice with the knowledge and skills to be able to address sexual issues and reproductive concerns,” she added.

To address the fellowship training shortcomings described in the survey, Reese and her colleagues are developing a National Cancer Institute– funded program to provide a series of skills-based training workshops aimed at providing oncology fellows with the tools to properly address the issue of patient sexual health. Ideally, she said, the fellowship programs themselves would bring in experts in this area to offer training to fellows, either in person or via virtual training sessions, and appoint a designated expert in this area within a given institution. Reese noted that many of the fellowship directors included in the survey wrote in and indicated that although patient sexual health training was not explicitly in their program, they recognized it as an important issue and would consider methods to emphasize it in the training of fellows in the future.

“Having formal instruction about management of sexual health concerns after cancer treatment, making opportunities for fellows to rotate through sexual health clinics, and providing access to more in-depth educational opportunities can help fellows be better prepared to meet this need,” Agrawal stated in conclusion. “Interested fellows can join professional societies like the International Society for the Study of Women’s Sexual Health, which hosts an in-person course and an annual meeting, and the Scientific Network on Female Sexual Health and Cancer, which has a scientific meeting as well as webinars. Fellows can become involved in these organizations to learn, find research mentors, and present research.”

Reference

Reese JB, Bauman JR, Sorice KA, Frederick N, Bober SL. Hematology and oncology fellow education about sexual and reproductive health: a survey of program directors in the United States. JCO Oncol Pract. Published online February 6, 2024. doi:10.1200/OP.23.00499