Management of sexual dysfunction in breast cancer survivors: a systematic review editorial---looking back to move ahead.

This comprehensive review of sexual dysfunction in breast cancer survivors (BCS’s) by Su et al., is a must read for all clinicians who care for not only midlife women who have had breast cancer, but for all women who have had a breast cancer diagnosis, regardless of their age. From these data, although the authors are able to offer useful management strategies, it is clear that there are many opportunities for evaluating current options and exploring future ones for BCS’s with sexual dysfunction. As the authors note, there is still a ‘clinical trials’ road ahead of us that remains to be tread if we are toidentify effective interventions supported by high quality evidence that ultimately will assist BCS’s with their sexual issues and improve their sexual interest, maintain their orgasmic ability and ameliorate or eliminate their genitopelvic pain. What was particularly striking about this extensive literature review was the authors’ recommendation that educational and counseling interventions be included in both the clinical management of the BCS with sexual dysfunction and in clinical trials evaluating prescription and OTC pharmacologic interventions aimed to improve or eliminate sexual dysfunction. The recommendation of face-time with the patient reinforces much of the ground breaking work done by pioneers in the field of sexual medicine—namely, that sexual dysfunction is multidimensional in origin and that each woman will present with unique circumstances and needs that will demand different approaches and at times multifaceted treatment strategies. Let’s take a short journey back over the past few decades with some examples that reinforce what this review by Su et. al suggest—that education and counseling strategies be provided to the BCS and be included in clinical trials. The reason one-on-one/ group education/counseling interventions with patients is critical in patient care and in the evaluation of the safety and efficacy of management strategies in the research setting can be attributed to the psychological, social, cultural, financial and inter- and intrapersonal relationship issues that impact sexual health and wellness. Focusing on BCS’s, the major areas that will adversely impact their sexual function and should be addressed include the woman’ sr eaction (and her clinician’s) to the diagnosis of the cancer itself, the body alterations that are necessitated by the breast cancer treatment and the new role of ‘patient’ that the otherwise healthy women is suddenly catapulted into. First, the diagnosis of breast cancer and its overall meaning to the woman (and, when there is one, her sexual partner) and her clinician must be addressed when dealing with the patient and in studying a particular pharmacologic intervention. Early sexual health thought leaders clearly spelled out that the management of sexual dysfunction, especially in BCS’s must encompass the impact of the cancer on both the patient/couple and, not surprisingly, her treating clinician. Over 30 years ago, the textbook, Sexual Problems in Medical Practice ,( edited by Harold Lief, MD) contains many of the elements critical to addressing sexual issues in patients, including the patient’s and clinician’s reaction to the cancer diagnosis [1]. As stated in this text, the physician has to keep the woman’s sexual health a priority throughout the breast cancer treatment as well as afterwards and not dismiss this aspect of the patient’s life as unimportant. Levay, Sharpe and Kagle, as referenced in this text, further noted, that cancer in general “…is associated with disfigurement after surgery, long and painful illness and high probability of death. It is not surprising that physicians often give the patient’s sexual life low priority” [2]. Therefore, this aspect of cancer’s meaning to the woman and her clinician should be addressed as a part of any intervention being prescribed or studied for management of sexual dysfunctions. That both the clinician and the BCS have to embrace the same outlook about the BCS’s