Approximately 22 million cancer survivors are expected by 2030: cancer diagnoses are increasing but significant advances in treatments lead to a significant survival rate for breast cancer.
At the same time, attention to quality of life and sexual health without distinction of gender is increasing. These data* emerge from a recent review of the literature made by the specialists of the IRCCS Istituto Nazionale Regina Elena (IRE) who today met with colleagues from other healthcare institutions and with citizens and patients. “Sexual health is a fundamental issue – underlines Patrizia Vici, oncologist in charge of the IRE phase IV study structure and promoter of the event – but largely underestimated, especially by women with breast cancer while there is little data on men with breast disease.”
Both sexes have a high rate of sexual dysfunction. There can be many therapeutic approaches and there are many in-depth studies to be carried out with a view to personalized care and gender medicine.
It is necessary to deepen the phenomenon of dysfunctions related to therapies and the related treatment options. The lack of data in male breast cancer patients may be of extraordinary relevance in BRCA1/2 mutation carriers as the odds of developing breast and prostate cancer, as well as sexual dysfunction, are particularly high.
“Recently done overhaul – underlines Patrizia Vici– collected evidence from numerous studies reporting a high percentage of female sexual dysfunctions: decreased sexual interest 49.3%, dyspareunia 35%-38%, concerns about body image and sexual desire 10%-14% , arousal drop 5%), and orgasm 5% the most common complaints. Studies on dysfunctions in male cancer patients were also included, but studies and data on male patients with breast cancer were completely missing.”
Most of the data collected concerns the dysfunctions resulting from prostate cancer. However, hormone treatments commonly used in the treatment of breast cancer, including tamoxifen, aromatase inhibitors, LHRH analogs, and chemotherapy drugs, can also cause sexual dysfunction in men. Studies show that these treatments can affect the production of testosterone and other hormones, leading to decreased libido, erectile dysfunction and other sexual problems.
Male patients are usually more proactive in raising sexual issues and more inclined to openly ask for information and solutions, in contrast to female patients who tend to be more reticent in asking for information related to sex. The embarrassment is not one-sided, and often the issue is not addressed appropriately by healthcare professionals. Male and female sexuality has many physiological, anatomical, psychological and cultural differences highlighted the specialists who attended.
There is a lack of knowledge and experience in managing the tools available to oncologists to appropriately address this issue, which can result in a significant underestimation of sexual health and a considerable underestimation of sexual disorders. The tools for managing malfunctions are there and experts have talked about them extensively, but there is a need to carry out large-scale studies to evaluate the most promising solutions more carefully.
Treatment of breast cancer is increasingly personalized according to the characteristics of the tumor and the needs of the patient and can combine surgery, chemotherapy and radiotherapy, as well as immunological, biological and endocrine therapies. Each of these treatments can negatively affect sexual function: surgery impacts body image and in fact conservative interventions and breast reconstructions lead women to greater satisfaction in their sexual life than mastectomised patients. Chemotherapy and endocrine treatment or other adjuvant therapies are no less. Long-lasting side effects affect and tend to affect adherence and overall compliance with treatment.
For example, the incidence rate of vulvovaginal atrophy, a syndrome characterized by a dramatic reduction in the thickness of the vaginal epithelium and a marked reduction in blood flow, is much lower in those taking tamoxifen than in those taking aromatase inhibitors. Tamoxifen is indicated as adjuvant therapy in male patients with ER-positive breast cancer and is often associated with decreased libido and documented erectile dysfunction since the early 20s. Aromatase inhibitors in male patients must be administered with LHRH analogues, they determine, similarly to what occurs in prostate cancer, a complete block of hormone production, with obvious consequences on sexuality.
There are many therapies for women: local ones consisting of water-based or silicone-based vaginal lubricants; vaginal moisturizers that guarantee elasticity and lubrication and can be based on hyaluronic acid. Low-dose vaginal estrogens (estradiol and estriol, etc.) were also tested, scrupulously agreed with the oncologist for safety issues in the use of hormonal treatments, but they are to be reserved for selected cases not responsive to other therapeutic strategies and under close surveillance. Of more recent use, the vaginal CO2 laser which significantly improves dyspareunia.
Finally, for both sexes, there are psycho-oncological consultations and psychotherapy, which are more effective if carried out as a couple. If for women psychological therapies reduce anxiety, increase knowledge of the sexual sphere and generally improve the quality of life, it has been found that in men they only increase adherence to therapies for erectile dysfunction; the combination of some drugs with shock waves, and finally, intra cavernous injections, can be strategies to combat erectile dysfunction.
There are various opportunities but also some limitations concerning the therapies mentioned: the fractional laser is not a service offered by public hospitals and the long-term benefits need to be investigated; moreover, the cost-effectiveness aspects of the various options should be investigated and the sexual disorders in male patients affected by breast cancer, of which there is almost no trace in the literature, should be studied in detail.
*Sexual dysfunctions in breast cancer patients: evidence in context.
Vizza R, Capomolla EM, Tosetto L, Corrado G, Bruno V, Chiofalo B, Di Lisa FS, Filomeno L, Pizzuti L, Krasniqi E, Sanguineti G, Villa A, Giannini A, Kayal R, Stranges V, Tomao S, Botti C, Tomao F, Barba M, Vizza E, Ciliberto G, Vici P.Sex Med Rev. 2023 Apr 18: qaad006. doi: 10.1093/sxmrev/qead006.