NPWH 2006 - Concerns About Sex and Pregnancy in Cancer Survivors

|

Sex and Pregnancy in Cancer SurvivorsChris Knutson, ANP, MN

"Survivorship medicine" is becoming a more frequent challenge for practitioners of all specialties. Women cancer survivors who make their way back into "routine" care following cancer treatment have questions and concerns that could hardly be considered routine. Some will ultimately be cured. Some will deal with cancer's chronicity. All of them find their lives forever changed by cancer.

Michael Krychman, MD, Co-Director of the Sexual Medicine Program at Memorial Sloan-Kettering Cancer Center, New York, recently spoke of the reproductive and sexual concerns of women with cancer. He reminds his patients that "you may survive this illness but your life will never, ever be the same." Helping patients come to grips with that concept and making accommodations to enhance or preserve sexual functioning and fertility are increasingly frequent and critical components of cancer care.

Thanks to earlier diagnosis and more effective treatments, more and more individuals are surviving cancer, and surviving it at earlier ages. As women trend toward later childbearing, the 2 issues will eventually intersect. Frank and open discussions between practitioner and patient can help women overcome fears of infertility, disfigurement, and loss of function or pleasure at a time when intimacy and comfort may be especially necessary as components of recovery.

Evaluation of the cancer patient must include a sensitive inquiry into sexual status and history, with a focus on the disease process, impact of surgical interventions, and sequelae of adjunctive therapies such as radiation or chemotherapy. Special physical concerns of cancer patients are similar to those of anyone with a chronic disease: fatigue, pain, limits in range of motion, or shortness of breath. In addition, the cancer survivor may sometimes need to deal with the issue of an ostomy.

Partners may draw back out of concern or fear of causing pain and wait for the woman to signal her need for physical comfort and intimacy. The woman patient, on the other hand, may be reticent to initiate sexual contact for fear of rejection, loss of a feeling of physical appeal, loss of sensation, and uncertainty of her body's capacity to express and feel pleasure. Structured "safe" intimate tasks and gradually escalating exercises, providing advice for positioning, vaginal stretching, and self-stimulation, can be helpful in moving the woman or couple toward exploring sexual relationships in new dimensions.

Dr. Krychman spoke of some tantalizing new research suggesting that oxytocin and DHEA released during orgasm may have an inhibitory effect on cancer or reduce odds of developing cancer, so the successful return to sexual activity may also have therapeutic advantages beyond physical comfort, intimacy, and pleasure.

Many gynecologic cancer treatments can produce a premature menopausal status, resulting in infertility and reduced sexual desire. Nonhormonal treatment regimens for hot flushes and sleeping or mood problems include administration of selective serotonin reuptake inhibitors and serotonin and norepinephrine reuptake inhibitors, sometimes in off-label applications. These include citalopram, fluoxetine, paroxetine, sertraline, and venlafaxine.[2-4] Off-label use of gabapentin is also showing promise in reduction of hot flushes.[5]

Use of botanicals and vitamin E have not been shown to be reliably effective, and the plant estrogens (as advertised in soy, red clover, or black cohosh products) may not be safe for breast cancer survivors. The vaginal dryness associated with menopause can be addressed with nonhormonal moisturizers, some of which mimic native vaginal secretions.[6] Low-dose estrogen-containing products that produce a predominantly local effect such as a vaginal estrogen ring or estrogen pellet may be considered for brief and periodic use.[7]

When Disease Is Complicated by Pregnancy

Malignancy of any kind is generally treated as if the patient were not pregnant.[8] Malignancies of the upper abdomen, lung, or extremities should be treated as usual. A pregnancy diagnosis and odds of infant survival must be considered in relation to the stage of cancer and weeks of pregnancy. Therapeutic doses of radiation are lethal to a 1- to 10-day-old embryo and can cause gross malformations up through the eighth week. From 8 weeks to term, intrauterine growth retardation, malformations, and permanent growth retardation can result.

Chemotherapy should be delayed until after the first trimester, if possible. In the second and third trimesters, spontaneous abortion, intrauterine growth retardation, low birth weight, and prematurity may result,[1] but data are limited and longer-term effects have not been firmly established.[9]

Breast cancer in particular may be masked during pregnancy due to breast engorgement, delaying the diagnosis. However, any solid mass should be investigated promptly, including the performance of diagnostic mammography as the danger of fetal damage from exposure to a small amount of radiation is less than the imminent danger of undetected disease.[9]

Reproductive Health Concerns of Young Women With Cancer

Young women diagnosed with cancer may have a desire to preserve fertility, and pregnancy after cancer raises concerns the practitioner can help address. For example, women may worry that they may not survive long enough to raise a child to adulthood or they may have residual physical limitations that will interfere with parenting. Patients may be especially concerned with the possibility of passing on family traits, as with the breast cancer gene.

Breastfeeding may be perceived as a challenge by women having had mastectomy, lumpectomy, or radiation, but studies show breastfeeding is usually unaffected in the untreated breast. While uncommon, breastfeeding may even be possible in the treated breast, depending on the extent of undamaged glandular tissue remaining after surgery and radiation. Studies show that the milk produced from the treated breast is safe for the infant.[9,10]

There have been significant advances in fertility-sparing and parenting options for the woman having cervical, uterine, or ovarian cancer. Cervical treatment can sometimes be put off until the pregnancy is advanced to viability. "There is no evidence that pregnancy per se adversely affects the outcome of cervical carcinoma."[8] Radical trachelectomy, dissection of the cervix while leaving the uterine body intact, is becoming more prevalent, even though it is not yet considered the standard of care. However, this method is the most promising and has high success rates. Trachelectomy may be indicated for women with disease staged at IB1 or earlier who wish to preserve fertility.[11]

Studies indicate trachelectomy preserves fertility, although assistance may be needed to achieve pregnancy and cerclage required to maintain the pregnancy. Complications requiring hospitalization may include premature rupture of membranes resulting in premature birth; hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome; and placenta previa.[12]

Another option for fertility includes embryo cryopreservation, which is now widespread and successful. This method requires delay of treatment in order to stimulate ovulation and undergo in vitro fertilization. The necessity of a male partner or acceptance of donor sperm is another issue when considering this option. Oocyte cryopreservation, while not requiring a male sperm donor or partner, still delays treatment while the woman undergoes ovarian stimulation, and is less successful than other assisted reproductive technologies. Other options include: ovarian tissue cryopreservation of primordial follicles and ovarian tissue transplantation (excision of entire ovary or harvesting ovarian tissue strips for cryopreservation and later reanastomosis), both experimental; shielding from radiation; and assisted conception following treatment. In addition, donor eggs and embryos, surrogacy, adoption, and acceptance of child-free living are all options to be explored.

In summary, clinicians can help women who are pregnant or are still wishing to achieve pregnancy to cope with cancer diagnoses and survivorship issues. Research and resources are growing within an emerging body of research evidence.

References

  1. Krychman ML. Sex and pregnancy after cancer. Program and abstracts of the National Association of Nurse Practitioners in Women's Health 9th Annual Meeting; September 27-30, 2006; Las Vegas Nevada.
  2. Hoffman RF, Viera AJ, Stone KJ. Off-label uses for selective serotonin inhibitors. Am Fam Physician. 2005;71:43.
  3. Longo DL. Venlafaxine, a nonestrogenic antidepressant with efficacy against hot flashes? Update: Harrison's Internal Medicine, 1/24/01. Available at: http://www.accessmedicine.com/updatesContent.aspx?aid=396472 (Fee required.) Accessed October 10, 2006.
  4. French L. SSRIs ineffective for the management of hot flashes. Am Fam Physician. 2005;71:2361.
  5. Walling AD. Gabapentin reduces hot flashes in breast cancer survivors. Am Fam Physician. 2006;73:1073.
  6. The Susan G. Komen Breast Cancer Foundation. After Treatment: Alternatives to Postmenopausal Hormones. Available at: http://www.komen.org/intradoc-cgi/idc_cgi_isapi.dll?IdcService=SS_GET_PAGE&ssDocName=3-6-6. Accessed November 15, 2006.
  7. The Susan G. Komen Breast Cancer Foundation. After Treatment: Sex and Sexuality. Available at: http://www.komen.org/intradoc-cgi/idc_cgi_isapi.dll?IdcService=SS_GET_PAGE&ssDocName=3-6-4. Accessed November 15, 2006.
  8. Cancer in pregnancy. The Merck Manual of Diagnosis and Therapy. Available at: http://www.merck.com/mmpe/sec18/ch261/ch261e.html. Accessed November 15, 2006.
  9. Cunningham FG, Leveno KJ, Bloom, SL, et al. Williams Obstetrics. 22nd edition. New York: McGraw-Hill Medical Publishing Division; 2005.
  10. The Susan G. Komen Breast Cancer Foundation. After Treatment: Having Children After Breast Cancer. Available at: http://www.komen.org/intradoc-cgi/idc_cgi_isapi.dll?IdcService=SS_GET_PAGE&ssDocName=3-6-5. Accessed November 15, 2006.
  11. Bansal N, Herzog T. Fertility options in women with gynecologic malignancies. Womens Oncol Rev. 2005;5:185-191.
  12. Worchester S. Post-radical trachelectomy pregnancy appears safe. Ob Gyn News. 2003;38:10.

Source: Medscape

Info

Previous entry: Test Predicts Breast Cancer Recurrence

Next entry: Experimental cancer drug attacks tumors in novel way

Find recent content on the main index or look in the archives to find all content.