Rarely do doctors talk about the impact of cancer on your intimacy and sexuality, a key part of quality of life. When the primary concern is with surviving and getting through the treatment, this is understandable. Thoughts about what life will be like after treatment are not top-of-mind. Staying alive is all that matters. But the fact is that the vast majority of patients will live a long time.
After decades of focusing on diagnosis, treatment, and cures, health care professionals are now more concerned than before with the phase called “survivorship.” Part of this is the totality we call “quality of life.” Quality of life is greatly affected by the choices made in treating the disease. When there are options, it is important that you know the quality-of-life consequences of each option. This chapter will outline various therapy choices for many different types of cancer, with special consideration given to the sexual side effects of various therapies.
Many side effects of various therapies have been well described. This is not the case for the effects on sexuality. The tables presented at the end of this chapter link therapies with their most common sexuality-related biological and psychological effects and the resulting emotions experienced by those in treatment and their partners. The tables only provide highlights, and are designed to be a general reference.
Table 1 lists some common treatment options for many cancers. They are listed here to provide a reference, not as a basis for deciding between treatments. As might be expected, each treatment has both advantages and undesirable side effects. Subsequent tables focus on their impact on sexuality.
Table 2 highlights the sexuality-related biological and psychological effects of different cancers and their treatments.
Table 3 shows the frequency of various sexual side effects.
Table 4 notes major emotions that the cancer patient and partner may experience.
Table 5 presents some common actions of women cancer sufferers and their partners. These actions can have a negative effect on the degree of success and the level of satisfaction that couples can achieve in renewing sexuality after cancer. Being alert to such negative behaviors may enable patients and their partners to conduct themselves differently and instead take the positive actions outlined in the remainder of this book.
Cancer therapies and physical side effects
Understanding how best to achieve the most satisfactory sexual experience after therapy can only occur when a woman and her partner know the effects of the therapy. Broadly speaking, the three major treatments for any cancer are surgery, radiation, and chemotherapy. Each individual being treated for cancer requires one or more of these treatment types (modalities) and may have a host of options to choose from within each modality, depending on the type of cancer and the stage at which the cancer is discovered. (Stage refers to the progression of the disease, from totally localized to diffuse or metastatic.)
Cancer and cancer therapy cause changes in the four Ps: an individual’s physical, physiological, and psychological makeup, and in the partner. The term physiological refers to the functioning of the body and its processes. For example, if a therapy affects an organ that produces a hormone, production of that hormone may increase or decrease, and various parts of the body will reflect such changes.
Table 1 shows the major modes of cancer therapy that may be discussed with a patient: surgery, radiation, or chemotherapy. The oncologist may recommend one or several in combination as being most appropriate, given the nature of the disease, its stage and other factors. The fourth column, Other, notes hormone therapy, as well as less widely used medically accepted therapies such as cryoablation and high-temperature ultrasound.
Surgery causes the most dramatic physical effects. Change in physical appearance is a major effect of breast surgery. Partial or total loss of sensation in the breast often also results. Surgery for gynecological and other pelvic cancers may cause changes in genital sensations, and may even make some types of sexual activity difficult or impossible. The majority of pelvic cancers concern the female organs - the uterus, ovaries, cervix, and vagina - but other pelvic cancers occur in the colon, small intestine, anal area and bladder. Treatment for abdominal and pelvic cancers affects nerves that go to the genital area, so that sensitivity in that area can be affected.
In addition to physical changes that are often observable, second-order effects include physiological and psychological changes. As shown in Table 1, surgery for breast cancer can be a mastectomy (the technical term for breast removal), which may or may not include surgically removing the lymph nodes on that side of the torso and under the arm, or a lumpectomy, in which only the cancerous tumor and some surrounding tissue is removed. Mastectomy (without immediate reconstruction) generally leaves a flat area with a scar where the surgeon sewed the skin together. Usually, the outcome of a lumpectomy is a scar much like a large dimple.
In both instances, nerves in the breast area must be cut to remove the diseased tissue. However, a mastectomy results in totally severing all nerves to the breast. The nerves cannot be replaced and will not regenerate to provide the previous extent of sensation. In the case of a lumpectomy, some of the nerves remain intact. The extent of the neural network that remains depends on the location and the size of the tumor.
The psychological impact of a mastectomy is due to the loss of a breast, the body’s resulting asymmetry, the scarring, and the loss of sensation in the area. Although the physical appearance of a lumpectomy may be merely a dimple-like depression, some women are psychologically affected.
Appearing symmetrical is a major reason why many women who have single-side mastectomies opt for reconstruction or an implant. However, reconstruction does not provide restoration of sensation, and will still leave scars that may at times cause discomfort. In addition, the scar capsule around the implant can contract, causing pain and hardening of the implant.
Given these facts and the numerous other possible complications of reconstructive surgery, it is scarcely surprising that many women, especially those who are older and/or in very secure, supportive relationships at the time of surgery, simply opt to wear external prostheses (breast forms) inside pocketed mastectomy bras to achieve a natural appearance when clothed. Good-quality mastectomy bras are both attractive and comfortable, and modern prostheses, especially those made of silicone, are comfortable to wear and quite similar to natural breasts in weight, size, and density. Just like real breasts, they come in a wide range of sizes. Their cost is often covered by insurance, including Medicare.
Some women with breast cancer may also be at increased risk for developing cancer in organs in the female reproductive tract. A prophylactic hysterectomy (removal of the uterus) or oophorectomy (removal of the ovaries) is sometimes performed when the woman has an altered gene related to breast cancer. Nerve damage, common during pelvic surgery, results in diminished genital sensitivity. The same is true for surgical treatment for colon and other abdominal and pelvic cancers. Surgery may be so extensive as to preclude intercourse. However, a woman may still have orgasms with stimulation of the clitoris.
Surgeries for gynecological and colon cancers usually affect nerves in the genital and rectal area. As a result, sensitivity may vary considerably, depending on the type of surgery, extent of disease, and skill of the surgeon. Women may experience a decrease in sensual responsiveness in some areas, and, by contrast, exhibit heightened responsiveness in other areas.
Radiation therapy, also known as radiotherapy, may be the primary or adjunct therapy (therapy to assist the primary, or first line, of therapy) to treat a cancer. The two main types of radiotherapy are external beam radiation and internal radiation therapy, also known as brachytherapy. Both are usually performed on an outpatient basis.
External beam radiation is provided by a machine that directs a beam of energy to the area of the