Sexual health is an important aspect of quality of life that requires a positive and respectful approach to sexuality and sexual relationships.³ Often, sexuality in cancer management suffers thus affecting the quality of life in these patients.

Reduced sexual function is a common distressful consequence of lung cancer diagnosis and treatment. The estimated prevalence of sexual dysfunction in cancer patients ranges from 40% to 100% depending on the type of cancer, treatment modality, and methods of assessment.⁴ In lung cancer patients, the prevalence has not been well documented, however studies show that sexual function progressively worsens over the lifetime of the patients.⁵ Lung cancer patients and their partners suffer significant physical and psychological distress as a result of cancer diagnosis and management. Data suggests that substantial disruptions in the psychological well-being impacts patient’s sexual functioning, social well-being, and quality of life.⁶ In addition to the effects of cancer diagnosis and treatment, older age and comorbidities such as diabetes, arthritis, congestive heart failure worsen and increase concerns on sexuality.⁷

Lung cancer management has often minimized sexual health and remained focused on the short-term quality of life improvement and palliative care. Conversations surrounding sexual health in cancer patients have been largely reserved.⁸ A research study that examined the effects of lung cancer treatment in sexuality reported that 51.7% of patients had self-reported sexual concerns and of these patients, 24.7% had moderate to severe sexual concerns.⁹ Despite these numbers, cancer care providers and patients express that sexual health issues are not well addressed or adequately treated in the course of cancer management.^10-12 Poor patient-provider communication is a major barrier to sexual health management in oncology as patients may feel unsupported and uncomfortable discussing their sexuality concerns openly.^13-14 Patient’s interactions with health care providers during cancer management and follow-up are great opportunities to discuss quality of life issues including sexuality and sexual health. An interactive cancer management approach ensures the patient feels supported at all times during care.

Intimacy in Cancer Patients

According to the American Psychological Association (APA), intimacy is defined as an interpersonal state of emotional closeness and characterizes familiar, close, and usually affectionate or loving personal relationships that require parties to have detailed knowledge or deep understanding of each other.¹⁵ Intimate relationships are vital to human beings but often suffer when partners suffer from significant or chronic illnesses such as cancer.

Cancer diagnosis and treatment is stressful and causes significant distress on the physical and psychological well-being of cancer patients and their partners and as a result, a significant strain on the intimate relationships between cancer patients and their partners. Fatigue, pain, body image concerns, self-esteem and worth, depression, anxiety are some of the reasons why intimacy in relationships can be affected.¹⁶

Patients and partners have unique experiences and valid concerns in the course of cancer diagnosis and management. Communication, assessment, and evaluation by the cancer care team can help tailor interventions best suited to the patient and their partner. Briefly, some of the ways to manage intimacy issues and concerns include; patients and partners seeking professional help from their cancer care team, establish open communication with each other, make necessary adjustments to accommodate for physical and emotional symptoms such as fatigue, pain, shortness of breath, low energy or moods, validating each other’s feelings, and setting time when appropriate for closeness and reacquaintance with each other.¹⁶

Reproductive Health Concerns in Lung Cancer Patients

Cancer diagnosis and treatment are often a threat to fertility to reproductive-aged patients. Although statistically majority of patients with lung cancer are past childbearing age, a few patients are diagnosed with lung cancer during the reproductive age group.

Infertility is defined as failure to conceive after 1 year of intercourse without contraception and may be permanent or transient. Causes of compromised fertility vary and include; side effects of cancer treatment (chemotherapy, radiation therapy), age, psychological effects of the disease, and treatment.¹⁷

Depending on the patient, different methods to restore/preserve fertility exist and should be discussed by the primary care and cancer care team at diagnosis or before treatment starts such as chemotherapy and radiation therapy. There are evidence-based guidelines on fertility preservation options for men and women and guidance regarding these options from oncologists and cancer care providers.

The patient’s ability for intimacy and sexuality can be affected by a variety of factors that directly or indirectly stem from the disease. Symptoms of lung cancer independently contribute to a decrease in sexual function among patients and include pain, fatigue, and shortness of breath. The functional status of lung cancer patients correlates to sexual concerns in these patients.¹⁰ Factors that contribute indirectly include psychological stressors and adverse effects of cancer treatment (surgery, chemotherapy, radiation therapy).¹⁸ A summary of the causes of sexual dysfunction is shown in Figure 2.

Figure 2: Causes of sexual dysfunction in cancer patients

Psychological distress

Depression and anxiety are prevalent among cancer patients with studies reporting rates of up to 43.4% in lung cancer patients.¹⁹ Anxiety and depression are associated with a decline in sexuality. As a result of the high rates of psychological distress in cancer patients, reduced sexuality is prevalent in this population.²⁰

Anticancer therapies

Chemotherapy and surgery are significantly associated with decreased sexual function in lung cancer patients.

Surgery for lung cancer can decrease the sexual functioning of patients due to its invasive nature and increased physiological demands. Increased fear and anxiety post-operatively also contributes to the decreased sexual functioning among patients undergoing surgery for lung cancer. Depression and anxiety are especially prevalent in patients with lung cancer post-operatively.²¹

Chemotherapy for lung cancer is associated with fatigue, psychosocial and physical symptoms, and increased distress, all of which can reduce sexual function in these patients.²²

The first step towards the management of the concerns in intimacy and sexuality is holding discussions on the same throughout treatment and follow-up. Issues with intimacy and sexuality are important medical conditions just as any other medical conditions that need to be addressed. Health care providers are not bothered or too busy to handle such issues and according to the American Society of Clinical Oncology (ASCO) should initiate discussions on sexual health and dysfunction to the patients.⁴ We encourage patients to have a discussion openly with their health care provider at any time during cancer management. The choice to include the partner in the conversation should be made if the patient so wishes. Sometimes patients may feel uncomfortable bringing up sexual concerns with the cancer care team and in that case, should bring them up to the primary care physicians. Below are some phrases that can be used to bring up discussions on sexuality.²³

Management and Evaluation of Sexual Health

Pre-treatment counseling and routine assessment
It is important to understand before and during cancer treatment that reduced sexual function is among the adverse effects encountered during treatment. This varies from patient to patient and the degree of dysfunction also varies throughout cancer management. Providers having baseline information on your pre-treatment/pre-diagnosis sexuality allows for easier follow-up and addressing any sexual concerns as soon as they arise. As discussed earlier, the causes of declining sexual function are varied and include; psychological stressors (anxiety, depression), physical stressors (fatigue, shortness of breath, pain), and psychosocial stressors (financial, familial, occupational, marital). They all affect individuals differently and addressing these causes with your health care provider is important in management.¹⁸

Communication and involving the partner
Patients and their partners both undergo distressful phases that may cause intimacy concerns in the duration of cancer management. Communication with health care providers is important to establish goals and treatment outcomes for sexuality function. Including partners in these discussions when the patients are willing and comfortable may offer better perspectives on expected course and outcomes during cancer management.²⁴

Specific management
Information on the management of sexual problems and concern below has been sourced from the ASCO recommendations. Access to sexual health resources and referral information for the patient and partner is available from the health care providers. (Figure 3)

Psychosocial/psychosexual counseling should be offered to all cancer patients to improve sexual functioning.  Current evidence does not support any type of counseling over the other. Counseling is especially helpful for cancer patients who are experiencing body image issues, patients looking to improve intimacy and sexuality issues, and also to improve overall sexual functioning and satisfaction.⁴ Regular stimulation may also be helpful for patients experiencing sexual difficulties.

Specific medications can also be used to reduce symptoms and improve sexual function. These medications are tailored to men and women depending on their symptoms and after careful evaluation. For women, these include: lubricants, vaginal moisturizers used as the first option for vaginal dryness and used at higher frequency as needed, low dose vaginal estrogen are a second option for those who do not respond to lubricants, lidocaine used for introital pain and dyspareunia, and dehydroepiandrosterone for women with vaginal/vulval atrophy.

For men; phosphodiesterase type 5 inhibitors may be beneficial for erectile dysfunction. Men who do not respond to these may consider alternative interventions such as erectile devices, medicated urethral system, or intracavernosal injections.

Behavioral therapy such as cognitive behavioral therapy, hypnosis, and medications such as Serotonin Reuptake Inhibitors (SNRI) such as venlafaxine are other options that are considered for the treatment of sexual dysfunction.⁴

Figure 3: Summary of the management of sexual dysfunction

1. Sexual and Reproductive Health and Research (SRH), including the Human Reproduction Programme (HRP). https://www.who.int/teams/sexual-and-reproductive-health-and-research/key-areas-of-work/sexual-health/defining-sexual-health
2. Albers LF, van Belzen MA, van Batenburg C, et al. Discussing sexuality in cancer care: towards personalized information for cancer patients and survivors. Support Care Cancer. 2020;28(9):4227-4233. doi:10.1007/s00520-019-05257-3
3. Sexual Health | CDC. Accessed May 19, 2021. https://www.cdc.gov/sexualhealth/Default.html
4. Carter J, Lacchetti C, Andersen BL, et al. Interventions to address sexual problems in people with cancer: American society of clinical oncology clinical practice guideline adaptation of cancer care. Ontario guideline. J Clin Oncol. 2018;36(5):492-511. doi:10.1200/JCO.2017.75.8995
5. Shell JA, Carolan M, Zhang Y, Meneses KD. The longitudinal effects of cancer treatment on sexuality in individuals with lung cancer. Oncol Nurs Forum. 2008;35(1):73-79. doi:10.1188/08.ONF.73-79
6. Sarna L, Brown JK, Cooley ME, et al. Quality of life and meaning of illness of women with lung cancer. Oncol Nurs Forum. 2005;32(1). doi:10.1188/05.onf.e9-e19
7. Williams, RN, MSNc, PHN AC, Reckamp, MD K, reeman, MSN, RN, ANP-BC, CHPN B, Sidhu, MSW, LCSW R, Grant, RN, DNSc, FAAN M. Sexuality, Lung Cancer, and the Older Adult: An Unlikely Trio? J Adv Pract Oncol. 2013;4(5):331. doi:10.6004/jadpro.2013.4.5.5
8. Experts Call for More Awareness of Sexual Dysfunction in Lung Cancer Patients – The ASCO Post. Accessed May 17, 2021. https://ascopost.com/News/15070
9. Reese JB, Shelby RA, Abernethy AP. Sexual concerns in lung cancer patients: An examination of predictors and moderating effects of age and gender. Support Care Cancer. 2011;19(1):161-165. doi:10.1007/s00520-010-1000-0
10. Jennifer RB, Shelby RA, Abernethy Pickar Amy. Sexual concerns in lung cancer patients: an examination of predictors and m…: EBSCOhost. Supportive Care in Cancer. doi:10.1007/s00520-010-1000-0
11. Lindau ST, Surawska H, Paice J, Baron SR. Communication about sexuality and intimacy in couples affected by lung cancer and their clinical-care providers. 2011;20(2):179-185. doi:10.1002/pon.1787
12. Southard NZ, Keller J. The importance of assessing sexuality: A patient perspective. Clin J Oncol Nurs. 2009;13(2):213-217. doi:10.1188/09.CJON.213-217
13. Bober SL, Sanchez Varela V. Sexuality in adult cancer survivors: Challenges and intervention. J Clin Oncol. 2012;30(30):3712-3719. doi:10.1200/JCO.2012.41.7915
14. Flynn KE, Reese JB, Jeffery DD, et al. Patient experiences with communication about sex during and after treatment for cancer. 2012;21(6):594-601. doi:10.1002/pon.1947I
15. Intimacy – APA Dictionary of Psychology. https://dictionary.apa.org/intimacy
16. Sexual Intimacy During Cancer Treatment | CTCA. https://www.cancercenter.com/community/for-caregivers/intimacy-during-cancer
17. Lee SJ, Schover LR, Partridge AH, et al. American Society of Clinical Oncology recommendations on fertility preservation in cancer patients. J Clin Oncol. 2006;24(18):2917-2931. doi:10.1200/JCO.2006.06.5888
18. Ntekim A. Sexual Dysfunction Among Cancer Survivors. In: Sexual Dysfunctions – Special Issues. InTech; 2011. doi:10.5772/26008
19. Zabora J, BrintzenhofeSzoc K, Curbow B, Hooker C, Piantadosi S. The prevalence of psychological distress by cancer site – PubMed. 2001;10(1):19-28. Accessed May 26, 2021. https://pubmed.ncbi.nlm.nih.gov/11180574/
20. Lu Y, Fan S, Cui J, et al. The decline in sexual function, psychological disorders (anxiety and depression) and life satisfaction in older men: A cross-sectional study in a hospital-based population. 2020;52(5):e13559. doi:10.1111/and.13559
21. Huang X, Zhang TZ, Li GH, Liu L, Xu GQ. Prevalence and correlation of anxiety and depression on the prognosis of postoperative non-small-cell lung cancer patients in North China. Medicine (Baltimore). 2020;99(11):e19087. doi:10.1097/MD.0000000000019087
22. Wong ML, Paul SM, Cooper BA, et al. Predictors of the multidimensional symptom experience of lung cancer patients receiving chemotherapy. Support Care Cancer. 2017;25(6):1931-1939. doi:10.1007/s00520-017-3593-z
23. Duma N. How to Maintain Your Sexual Health During and After Lung Cancer | Cancer.Net. https://www.cancer.net/blog/2020-11/how-maintain-your-sexual-health-during-and-after-lung-cancer
24. Hordern AJ, Currow DC. A patient-centred approach to sexuality in the face of life-limiting illness. Med J Aust. 2003;179(6 SUPPL.):S8-S11. doi:10.5694/j.1326-5377.2003.tb05567.x
25. Bolat MS, Celik B, Celik HK, Akdeniz E. The impact of thoracotomy on psychological and sexual function in men with lung cancer. Rev Int Androl. 2019;17(3):94-100. doi:10.1016/j.androl.2018.05.002