Introduction
It is widely known that sexual dysfunction is a common side effect of oncological disease. All cancer therapies, including chemo-, hormonal- and immunotherapy, radiation and surgery can impair the sexual function. The prevalence of sexual side effects following therapy varies, depending on cancer and therapy type, but may even rise to 100% after treatment of genital cancers [
1‐
5]. Cancer patients often face sexual symptoms from the start of treatment and these are likely to continue or even increase in the long term [
6]. The consequences of cancer treatment can influence all aspects of sexuality, including desire, satisfaction and functioning. Sexuality is considered an extremely important quality-of-life concern by cancer survivors [
7‐
9]. Despite reporting concerns regarding their sexual function, patients are frequently not informed about how treatment may affect their sexual function [
1,
10,
11].
Given the high prevalence of sexual dysfunction and the complexity of the problems, an integrative approach to potential sexual problems is needed. Literature reveals a mismatch in expectations between the patient and healthcare providers regarding communication about sexuality [
12‐
14]. Patients reported unmet needs regarding discussing sexuality with their health care providers. While some patients wish to discuss this topic, they feel health care providers do not provide an opportunity to talk about sexual function or even ignore their sexual needs [
5,
11,
12,
15‐
17]. On the other hand, not all healthcare professionals consider it their task to discuss the subject [
18]. Moreover, they face several other barriers, such as uncomfortable feelings, insufficient knowledge, lack of training, lack of time and over involvement in aspects of patients’ personal lives. Oncology care providers do, however, consider sexual function to be an important topic [
18‐
21]. During cancer treatment, patients are treated by different professionals within a multidisciplinary team. It is not always clear which member of the team is responsible for addressing sexual function. Studies among different Dutch oncology care providers revealed that members of the oncology team, like radiation oncologists, oncology nurses and oncology surgeons, see some role for themselves in sexual function counselling, but all point to the medical oncologist to bring up the subject [
19‐
21].
Consequently, it is important to identify how medical oncologists report their own role in sexual counselling. An understanding of how medical oncologists acquire knowledge about sexual function counselling, how they apply sexual function counselling in practice, and which barriers they may encounter when bringing up the subject is needed to optimise management around sexual care for oncology patients. The aim of this study is to explore the attitude, practice patterns and education needs of medical oncologists regarding sexual function counselling.
Discussion
The present study provides insight into the practice patterns of Dutch medical oncologists with regard to discussing sexual function. It reveals the origins of several difficulties in discussing sexual function in current clinical practice. Medical oncologists do see sexual function counselling as part of their duty. Nevertheless, they do not routinely counsel sexual function due to several barriers, such as lack of training. A minority informs their patients about potential sexual side effects of planned cancer treatment. Whether oncologists counsel patients is related to the age of the patient, how they view the patient’s prognosis and to whether they stated they had more knowledge about sexual function.
The results of this study are in line with other self-reported surveys among oncology health care providers about communication regarding sexual concerns. To our knowledge, this is the first study to describe how medical oncologists see their role in sexual counselling, depicting the actual origin of difficulties in discussing sexual issues in current clinical practice.
According to our data, Dutch oncologists rarely bring up sexual side effects during the informed consent conversation before starting a treatment. Informed consent is seen as a crucial component of medical practice and authenticates patients’ autonomy. During informed consent, adverse effects that are common should be discussed [
26]. Given the high prevalence and additional burden of sexual dysfunction after cancer treatment, sexual side effects of treatment should be part of informed consent [
1‐
5,
26]. Lack of knowledge, lack of time and lack of clarity about sexual side effects in current guidelines may result in ambiguity regarding responsibility for discussing sexual side effects [
18]. An example of how to enhance communication about sexual side effects during informed consent is the use of an informed consent template, provided by the ASCO, where side effects, including sexual side effects are mentioned [
27]. Nevertheless, a form cannot replace direct patient-provider communication but could help the care provider to address the subject.
Since sexual problems can arise during early treatment, but may also arise after treatment and even extend long term, discussing sexual function during the whole cancer care process would seem to be important [
6]. However, the current survey revealed that Dutch oncologists do not routinely bring up the subject of sexuality during treatment and follow-up. According to the literature, other members of the multidisciplinary oncological team identified discussing sexual function as a responsibility of the oncologist [
19‐
21]. Members of the multidisciplinary oncological team seem to count on each other to tackle the conversation about sexual health. This highlights the importance of defining responsibilities within the oncology treatment team. According to this survey, only 12.8% of the respondents reported a clearly defined responsibility for addressing sexuality within their team. De Vocht et al. described a Stepped-Skills-model, which could be of help to define responsibilities [
18]. In this team-approach-model, there are team members who are ‘spotters’. These spotters, most likely the oncologist, discuss the sexual side effects of treatment, check whether patients need help and refer them where necessary. Other members, most probably the specialized nurses, are called ‘skilled companions’. They have the responsibility to support patients in their sexuality issues. Consequently, these members require training to improve their communication skills and their knowledge. Using such an integrated approach, sexual health may become part of daily clinical practice.
As already highlighted in the ‘
Introduction’ section, a mismatch in expectations regarding the discussion of sexual health between patient and providers does exist. The current study reveals some of the reasons why medical oncologists do not bring up sexuality, which may contribute to this mismatch. Of the respondents, almost 60% stated the ‘advanced age of the patient’ as a barrier to discussing sexual function, suggesting respondents may assume elderly patients are not sexually active. This may be an incorrect assumption. A study on the prevalence of sexual activity among 10,000 European adults showed that sexual desire and activity persist through old age, with 53% of the male respondents and 21% of the female respondents between 70 and 80 years of age being sexually active [
28].
Another barrier to discussing sexuality mentioned by almost half of the oncologists involved ‘the patient being too ill’. Also, frequency of bringing up sexual health declined when treatment had a palliative intent compared to a curative intent. A study reviewing sexual healthcare for cancer patients receiving palliative care confirmed a lack of sexual health care in this patient group, although the patients and their partners did feel the need for a conversation about the subject. Bringing up the subject of sexuality by a healthcare professional even improved quality of life and reduced stress of patients and partners [
29]. An interdisciplinary approach is required to recognise and manage symptoms in this palliative group.
In accordance with previous investigations, important reasons for the lack of frequency in discussing sexual health were a ‘lack of training’ and a ‘lack of knowledge’ [
15,
19‐
21]. These evidently recurrent barriers among different cancer care providers in different countries indicate that there is a role for education and practical training to improve the situation in practice. A pilot study involving 82 oncology providers showed that a brief (30–34 min) targeted sexual health training significantly enhanced the frequency of discussing sexual issues with cancer patients [
30]. In Iceland, a sexual health care educational intervention was implemented over a 2-year time period. Over 200 oncology nurses and physicians participated. The study showed that the perceived level of knowledge in providing sexual health care was higher after the intervention [
31]. Furthermore, communication tools, using standard patient questionnaires on sexuality resulted in improved communication between the patient and the health care provider regarding sexual function [
32]. However, with the increasing pressure on daily practice of physicians and nurses, and taking another major barrier—lack of time—into consideration, we are urged to look for additional ways of providing sexual health care. Possibilities for educating patient and partner regarding sexual function during and after cancer treatment, like e-health, using websites, videos and apps, have to be further investigated and evaluated.
Some limitations need to be considered. As no validated questionnaires were available, a non-validated questionnaire was administered. The use of a self-reported questionnaire may have led to under- or overestimation. Questionnaire-based studies are always subjected to response and selection bias. A sampling error may have occurred due to the low response rate, although this rate was comparable to that found by other questionnaire studies. There may be a difference between the oncologists who responded and those who did not respond to our questionnaire, possibly creating a bias. The fact that a postal survey was used may have resulted in incomplete responses. Internet questionnaires are known to have a higher degree of completeness since the researcher is able to compensate for errors among respondents who for example accidentally pass over a question [
24]. The subdivisions by area of specialization resulted in small numbers of medical oncologists in each group. For this reason, it was not possible to do proper sub-analyses per area. The area of specialisation of the majority of the responding oncologists was breast cancer. The questionnaire may, therefore, have been answered in the context of breast cancer, meaning the patients were slightly younger and were receiving (neo) adjuvant chemotherapy or hormonal therapy, with the accompanying effects on sexual functioning. A larger study among medical oncologists from different countries might be useful in defining differences between areas of specialisation.
The results of this study may improve the awareness of health care professionals in cancer treatment, especially medical oncologists, about the need to define the place of sexual health care in the course of the disease trajectory, to discuss if a specific team member is responsible for initiating the subject and, if necessary, provide additional training.
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.