Addressing Sexual Dysfunction in Cancer Survivors: Updated NCCN Guideline

June 2016, Vol 6, No 6

The updated survivorship guideline (version 1.2016) from the National Comprehensive Cancer Network (NCCN) was presented at the 2016 NCCN annual conference and includes an extensive discussion on addressing sexual function in cancer survivors. The updated guideline recommends screening for sexual dysfunction in cancer survivors at regular intervals, followed by appropriate management based on the survivor’s readiness to discuss this sexual function.

Sexual Dysfunction in Female Survivors

Michelle E. Melisko, MD, Medical Director, University of California, San Francisco Breast Cancer Survivorship Program, discussed sexual dysfunction among female survivors, noting that this is likely to become more prevalent among young breast cancer survivors, with the increasing use of ovarian suppression.

In a recent study of 83 breast cancer survivors, 77% of participants and 60% of sexually active survivors qualified for a diagnosis of sexual dysfunction based on the Female Sexual Function Index.

“There is an increasing understanding of the safety and risks associated with hormonal interventions,” said Dr Melisko. With longer courses of aromatase inhibitors being recommended in women with breast cancer, “we will be seeing more vaginal dryness and sexual complaints,” she said.

For women with pain during sex­ual activity, the guideline adds the non–estrogen selective estrogen receptor modulator ospemifene (Osphena) to the list of treatment options, which also includes topical vaginal therapies (eg, moisturizers, gels, and lubricants), vaginal dilators, pelvic physical therapy, and topical anesthetics.

Ospemifene is contraindicated in cancer survivors with a history of estrogen-dependent cancers, but it can be useful for other survivors, said Dr Melisko. Menopausal hormone replacement therapy may be an option to manage sexual and menopausal symptoms in some patients.

For women with low sexual desire, the updated guideline mentions for the first time the use of flibanserin (Addyi), although a footnote states that there is a lack of data to support its use in cancer survivors.

A 2015 study found that 4% aqueous lidocaine applied to the vulva resulted in less pain during intercourse, a decrease in sexual distress, and an improvement in sexual function; of the 20 patients who completed the study and who had abstained from intercourse, 17 resumed comfortable penetration.

In another 2015 study, microablative CO2 laser improved scores on the Female Sexual Function Index at 12 weeks in 77 postmenopausal women with vaginal dryness, and was later approved by the FDA; however, no data with this method are available in patients with breast cancer.

Sexual Dysfunction in Male Survivors

Sexual dysfunction in male cancer survivors was presented by Joseph B. Narus, DNP, GNP-BC, ANP, Male Sexual and Reproductive Medicine Program, Memorial Sloan Kettering Cancer Center, New York, NY.

Hemoglobin A1c testing, lipid screening, and the evaluation of creatinine levels are now eliminated during the initial workup, because these routine laboratory tests are most likely completed by primary care physicians by the time male cancer survivors are referred to an oncologist, according to Dr Narus.

In addition, testosterone therapy may be indicated in men with erectile dysfunction (ED), ejaculatory problems, or orgasmic problems if the total testosterone level measured in the morning is <300 ng/dL. Furthermore, a low-dose oral phosphodiesterase-5 inhibitor is a treatment option for ED.

Referral to a specialist is now recommended for more complex ED issues, Dr Narus said. Previously, the guideline recommended intracavernosal injection therapy, penile vacuum devices, and intraurethral suppositories as second-line treatment options for ED, but these therapies are no longer mentioned.

Early evaluation of ED after recovery from cancer treatment is optimal; untreated ED may lead to long-lasting problems with erections because of fibrosis of the corporal cavernosa resulting in venous leak, said Dr Narus.

The patient’s comfort level with discussing sexual health should first be assessed, however, because men may initially be primarily concerned with their cancer.


  1. Goetsch MF, Lim JY, Caughey AB. A practical solution for dyspareunia in breast cancer survivors: a randomized controlled trial. J Clin Oncol. 2015;33:3394-3400.
  2. Salvatore S, Nappi RE, Parma M, et al. Sexual function after fractional microablative CO2 laser in women with vulvovaginal atrophy. Climacteric. 2015;18:219-225.

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