By Narjust Duma, MD

The journey to making sexual health a focus of my thoracic oncology career started like many medical questions do: in the clinic. About 2 years ago, I was meeting with one of my patients, a woman with metastatic lung cancer who was receiving targeted therapy. During a routine physical examination, I noticed some skin abrasions in her armpits. I asked about the rash, as I thought it was secondary to her cancer treatment. My patient changed her physical posture and gave one-word answers to each question (something unusual for her). A few minutes later, she shared that she and her husband were exploring other ways to have intercourse due to the severe vaginal pain that she was experiencing. It was hard to learn that she has been experiencing these symptoms for months, and I was not aware of it. She was having vaginal bleeding after intercourse. In the first months after her cancer diagnosis, she was eager to re-start her sexual health, only to learn that lung cancer has also taken this away from her.

That day, I came to realize the consequences of lung cancer on my patients’ sexual health for the first time. After that patient encounter, I started asking senior oncologists about potential solutions for my patients' problems. I was surprised by the level of discomfort that my colleagues had while discussing the subject, the lack of awareness (like mine), and the invalidation of my patient's concerns. As with many problems in medicine, we need to turn to our literature. My first search revealed mostly information about sexual dysfunction in women with breast cancer or a history of pelvic malignancies. Data was limited mainly to the effects of anti-hormonal therapy and pelvic radiation. After a while, I started encountering articles about sexual dysfunction in patients with lung cancer, but sadly, they all dated back to the 1990s or early 2000s when most targeted therapies and immunotherapies were yet to be approved. After those first unsuccessful hours, I went back to the trials that led to the approval of the medication my patient was taking; after cruising through 10 articles, I could not find a mention of potential sexual adverse events.

Sexuality comprises psychological, relational, and cultural elements in addition to physiologic factors; it is critical to embrace an integrative bio-psycho-social approach to understanding and addressing this fundamental aspect of survivors' experience. In patients with lung cancer, sexual health can be affected by changes in body image after chemotherapy, shortness of breath secondary to lung surgery, or anxiety, since many of our patients are facing early mortality.

I was determined to find potential solutions to my patient's issue affecting her marital relationship and sense of well-being. Over the next few weeks, I consulted with several sexual counselors and gynecologists. Some shared that this was the first time they discussed a patient with lung cancer, but they believed many options were available for my patient.

After two simple interventions, my patient's sexual side effects significantly improved, and I saw for the first time how resuming a healthy sex life for a patient with lung cancer can improve their mood, symptom burden, and survivorship in general. Immediately, I started asking every patient about their sexual health. The initial conversations were uncomfortable, but now they have become part of our daily conversations. Over the last 2 years, I have asked all my patients about their sexual health during and after lung cancer treatment. Over 70% of my patients reported some degree of sexual dysfunction, from vaginal dryness to body image issues.

In many cases, I did not directly "fix" the issue affecting their sexual life; they received help from sexual counselors, surgeons, therapists, and many other specialists. However, every clinic day, I am reminded of the importance of sexual health in cancer care. I have seen patients' stress significantly decrease, feel more comfortable with their partners, and open about the possibility of having an active sexual life during cancer treatments.

To determine the real prevalence of sexual dysfunction in women with lung cancer, we designed the Sexual Health Assessment in Women with Lung Cancer (SHAWL) study in collaboration with the GO2 Foundation for Lung Cancer and two lung cancer activists, Ivy Elkins and Jill Feldman. The SHAWL study is the largest study to date evaluating the sexual health of women with lung cancer. The study is open to all women with a history of lung cancer or actively receiving treatment for the disease, regardless of cancer stage or treatment type. The survey is located in the GO2 Foundation Lung Cancer Registry; it is entirely confidential, and on average, it takes between 5 and 15 minutes to complete.

The SHAWL study aims to determine the real prevalence of sexual dysfunction in women with lung cancer, increase awareness about sexual health and lung cancer, and ultimately be the basis for future interventions in this study population.

It is time to bring awareness of sexual health in lung cancer.

Dr. Duma is a thoracic oncologist specializing in treating women with lung cancer at the University of Wisconsin. She studies the unique challenges of women with lung cancer and sex differences in lung cancer treatment tolerability and efficacy. Follow her on Twitter @NarjustDumaMD. Disclosure.