NCCN Survivorship Guidelines Update Management of Sexual Dysfunction

TON July 2016 Vol 9 No 4 - Guidelines
Wayne Kuznar

Hollywood, FL—An updated survivorship guideline from the National Comprehensive Cancer Network (NCCN) includes an extensive revision on addressing sexual function in cancer survivors. Version 1.2016 of the survivorship guidelines recommends screening for sexual dysfunction in cancer survivors at regular intervals and offering appropriate assessments, referrals, and interventions based on whether the survivor is ready to have a conversation about sexual function.1

The updated guidance was presented at the NCCN 21st Annual Conference, with presentations focusing on the guidelines for women and for men.2

Female Sexual Health

Michelle Melisko, MD, presented the guideline for women, noting that sexual dysfunction is likely to become more prevalent in young breast cancer survivors with increasing use of ovarian suppression.

A recent study of 83 breast cancer survivors revealed that 77% of all study participants and 60% of sexually active ones qualified for a diagnosis of sexual dysfunction based on the Female Sexual Function Index (FSFI).3

"There is an increasing understanding of the safety and risks associated with hormonal interventions," said Dr Melisko, Associate Professor of Hematology/Oncology, University of California San Francisco, Helen Diller Family Comprehensive Cancer Center.

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 symptoms of pain with sexual activity, the guideline adds ospemifene, a nonestrogen selective estrogen receptor modulator, to the list of treatment options, which also includes topical vaginal therapies (moisturizers, gels, and lubricants), vaginal dilators, pelvic floor physical therapy, and topical anesthetics. Ospemifene is currently contraindicated in survivors with a history of estrogen-dependent cancers, said Dr Melisko, but can be useful for other cancer survivors. Menopausal hormone replacement therapy may be an option to manage sexual and menopausal symptoms in some patients.

For women with low libido, for the first time the updated guideline mentions the option of using flibanserin, although a footnote declares the lack of data to support its use in cancer survivors.

Recently, a study found that 4% aqueous lidocaine applied to the vulva reduced pain during intercourse, decreased sexual distress, and improved sexual function,4 said Dr Melisko. Seventeen of 20 patients who completed the study and who had abstained from intercourse resumed comfortable penetration. Micro ablative CO2 laser improved scores on the FSFI at 12 weeks in 77 postmenopausal women with vaginal dryness, and was later approved by the US Food and Drug Administration, but no data with this method are available in breast cancer patients.

Male Sexual Health

An update on sexual function in male cancer survivors was presented by Joseph B. Narus, DNP, GNP-BC, ANP, Nurse Practitioner, Sexual and Reproduction Program, Memorial Sloan Kettering Cancer Center, New York City.

Eliminated in the workup in the new guideline is hemoglobin A1C testing, lipid screening, and evaluation of creatinine. Testosterone therapy may be indicated in men with erectile dysfunction, ejaculatory problems, or orgasmic problems if total testosterone measured in the morning is <300 ng/dL.

A low-dose oral phosphodiesterase-5 inhibitor is a treatment option for erectile dysfunction. Referral to a specialist is now recommended for more complex erectile dysfunction, he said. Second-line treatment options mentioned in the guideline include intracavernosal injection therapy, penile vacuum devices, and intraurethral suppositories.

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

The patient's comfort level with a discussion of sexual health should first be assessed, however, because men may initially be concerned primarily with their cancer.


1. National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®): Survivorship. Version 1.2016. Fort Washington, PA: NCCN; 2016. cian_gls/pdf/survivorship.pdf. Accessed April 25, 2016.
2. Melisko M, Narus J. Sexual function in cancer survivors: updates to the NCCN Guidelines® for survivorship. Presented at: National Comprehensive Cancer Network 21st Annual Conference; March 31-April 2, 2016; Hollywood, FL.
3. Raggio GA, Butryn ML, Arigo D, et al. Prevalence and correlates of sexual morbidity in long-term breast cancer survivors. Psychol Health. 2014;29:632-650.
4. 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.

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Last modified: July 26, 2016