Advanced Practice Providers' Role in Intimacy in Advanced Cancer Patients

Abstract

The primary objectives of early phase clinical trials are to determine the safety, tolerability, and recommended doses of an investigational agent for patients with advanced cancer. Although these advances in cancer treatment have resulted in patients living longer, patients often experience psychological side effects that may affect sexual health and intimacy. It is estimated that cancer and its subsequent treatments affect the sexual health and intimacy of 40% to 100% of this patient population. Patients with advanced cancer who have undergone numerous treatments may be impacted negatively, not only physically (such as being disfigured by surgical resection) but also emotionally in relationship aspects with their intimate partners. Health-care providers who treat patients with advanced cancer enrolled in early phase clinical trials tend to focus primarily on treatment, physical side effects, and symptom management. Advanced practice providers (APPs) are accustomed to performing comprehensive physical examinations on patients; however, research indicates that intimacy and sexuality are most often excluded in discussions with patients with advanced cancer. The purpose of the article is to increase awareness of the need to address intimacy and sexuality in this patient population and to encourage APPs to make this a part of their everyday practice.

The primary objectives of early phase clinical trials are to determine the safety and tolerability of investigational agents and to determine the recommended doses for patients with advanced cancer (Sikic et al., 2019). The advances made in the treatment of cancer have contributed to patients with advanced cancer living longer. This patient population has significant disease burden usually with corresponding symptoms, affecting physiological, social, physical, and emotional relationships. Many patients with advanced cancer continue to value intimate relationships as a significant part of their quality of life, just as much as their physical, emotional, spiritual, and psychosocial well-being (Wang et al., 2018). Intimate relationships may reduce stress and provide social support for some patients with advanced cancer. Advanced practice providers (APPs) must consider how these symptoms affect intimacy in this patient population.

INTIMACY AND SEXUALITY

Intimacy is broadly defined as emotional and physical closeness (with or without sex), which includes communication, touching, love, or social relationships (Kelemen et al., 2019). Sexuality is defined as a continuum of thoughts and behaviors, fantasies, or acts that may or may not be associated with procreation and pleasure (Ventriglio & Bhugra, 2019). Many consider sexuality as a vital component of life, and it may impact mental health (Ventriglio & Bhugra, 2019). It is estimated that cancer and its subsequent treatment affects the sexual health and intimacy of 40% to 100% of this patient population (van Roij et al., 2022).

Research shows that intimacy needs and sexuality are excluded in a comprehensive assessment. Approximately 90% of nurses report that this subject is most often excluded in discussions with advanced cancer patients (Kelemen et al., 2019). Patients with advanced cancer who have undergone numerous treatments may be impacted negatively, not only physically (such as being disfigured by surgical resection) but also emotionally in relationships with their intimate partners (Jonsdottir et al., 2021). Providers who treat these patients primarily focus on treatment, side effects, and symptom management. Intimacy can provide social support and reduce stress for patients undergoing cancer treatment (Jonsdottir et al., 2021). Coping with advanced cancer has a huge impact on this patient population and often goes unaddressed by many health-care providers.

Kelemen and colleagues (2019) reported that the World Health Organization defined sexuality as a central or fundamental aspect of a human being throughout life that encompasses sex and intimacy. Sexual dysfunction secondary to cancer treatment or disease can adversely affect body image, thereby affecting cognitive, physical, and emotional aspects of patients with advanced cancer. This may affect femininity in women and masculinity in men. Feelings of closeness and intimacy are affected and may in turn affect quality of life for this patient population. Many health-care providers fear being intrusive and misconceive the importance of sexuality and intimacy in this patient population (Kelemen et al., 2019). The primary focus for providers is to treat the disease and control the symptoms. Intimacy, sexual health, and sexual dysfunction discussion in advanced cancer patients remain as unspoken topics (van Roij et al., 2022). The APP has an opportunity to explore and address the needs of these patients.

ROLE OF APPs

Advanced cancer patients and their significant others can experience fluctuations in relationships, such as changes in their roles and responsibilities as the disease progresses (Reese et al., 2022). Open communication between patients and their health-care providers can proactively address concerns about intimacy at this stage of life. Often, health-care providers assume that cancer treatments have a major impact on a patient's desire to have an intimate relationship or they no longer desire intimacy. Misconceptions on the part of the clinician about the importance of this topic in this patient population and the lack of training on the subject matter may interfere with the management of intimacy and sexuality. Other times, patients themselves do not know how to approach the topic, causing these challenges to be overlooked (Mares & Rábago-Olivares, 2021). The APP can explore this area with the patient and provide appropriate interventions.

A detailed discussion with the patient and/or significant other may be important in addressing concerns with intimacy in patients with advanced cancer. Research indicates that positive communication, such as self-disclosure, partner responsiveness, and engagement will facilitate positive psychological outcomes in couples coping with cancer (Bober, 2021). Consultation with the appropriate specialty can provide hormonal therapies such as testosterone or estrogen replacement if so desired by the patient. A thorough review of medication with modifications of those that contribute to sexual dysfunction, encouraging psychosocial and/or psychosexual counseling, and a multidisciplinary team approach can aim to improve intimacy in patients with advanced cancer (Bober, 2021).

Intimacy can be an emotionally loaded topic, and the APP may struggle with addressing this area of concern. Barriers can include issues with time, embarrassment, and lack of adequate training (Bober, 2021). Advanced practice providers in the phase I clinic are accustomed to performing a comprehensive physical examination and toxicity checks from clinical trial treatment; therefore, a great start could be initiating a conversation especially emphasizing intimacy during this time. Straightforward screening questions or having an intimacy conversation guide can help with APPs' discomfort. Careful history taking that includes a review of patients' medications is essential, along with evaluating their fatigue, dyspnea, and depression levels (Bober, 2021). Referrals to the appropriate specialty such as gynecology, urology, and psychosocial and/or psychosexual counseling should be provided as needed.

Advances in cancer treatment have resulted in patients living longer. Cancer and its subsequent treatments can affect sexuality and intimacy. Patients enrolled in clinical trials are monitored closely for safety and efficacy. Although an area of concern, intimacy in patients with advanced cancer is relatively unaddressed (Lopresti, 2018). Advanced practice providers should initiate the most important step, which is asking whether patients are experiencing intimacy issues, discuss those problems further, and whether they would like information or a referral for help. With improvements in emphasizing this topic and empowering patients with information about potential therapeutics and open communication, APPs can help patients reclaim intimacy and ensure optimal care in these patient populations.