Factorial Trial to Optimize an Internet-Delivered Intervention for Sexual Health After Breast Cancer: Protocol for the WF-2202 Sexual Health and Intimacy Enhancement (SHINE) Trial.

BACKGROUND: Although most survivors of breast cancer report substantial sexual concerns following treatment, few receive support for these concerns. Delivering sexual health care to survivors of breast cancer via the internet could overcome many of the barriers to in-person treatment. Even when delivered remotely, survivor time constraints remain a leading barrier to sexual health intervention uptake. OBJECTIVE: Guided by the multiphase optimization strategy methodological framework, the primary objective of this study is to identify the most efficient internet-delivered sexual health intervention package that is expected to provide survivors of breast cancer the greatest benefit with the fewest (and least-intensive) intervention components. This study aims to determine how intervention components work (mediators) and for whom they work best (moderators). METHODS: Partnered, posttreatment adult female survivors of breast cancer (N=320) experiencing at least 1 bothersome sexual symptom (ie, pain with sex, vaginal dryness, low sexual desire, and difficulty with orgasm) related to their breast cancer treatment will be enrolled. Clinic-based recruitment will be conducted via the Wake Forest National Cancer Institute Community Oncology Research Program (NCORP) Research Base. Participants will be randomly assigned to 1 of 16 combinations of four intervention components with two levels each in this factorial trial: (1) psychoeducation about cancer-related sexual morbidity (receive either enhanced vs standard versions); (2) communication skills training for discussing concerns with health care providers (received vs not received); (3) communication skills training for discussing concerns with a partner (received vs not received); and (4) intimacy promotion skills training (received vs not received). Cores will be fully automated and implemented using a robust internet intervention platform with highly engaging elements such as animation, video, and automated email prompts. Survivors will complete web-based assessments at baseline (prerandomization time point) and again at 12 and 24 weeks later. The primary study aim will be achieved through a decision-making process based on systematically evaluating the main and interaction effects of components on sexual distress (Female Sexual Distress Scale-Desire, Arousal, Orgasm) and sexual functioning (Female Sexual Function Index) using a generalized linear model approach to ANOVA with effect coding. Mediation analyses will be conducted through a structural equation modeling approach, and moderation analyses will be conducted by extending the generalized linear model to include interaction effects. RESULTS: This protocol has been reviewed and approved by the National Cancer Institute Central Institutional Review Board. Data collection is planned to begin in March 2024 and conclude in 2027. CONCLUSIONS: By identifying the combination of the fewest and least-intensive intervention components likely to provide survivors of breast cancer the greatest sexual health benefit, this study will result in the first internet intervention that is optimized for maximum impact on the undertreated, prevalent, and distressing problem of breast cancer-related sexual morbidity. TRIAL REGISTRATION: ClinicalTrials.gov NCT06216574; https://clinicaltrials.gov/study/NCT06216574. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/57781.

Hematology and Oncology Fellow Education About Sexual and Reproductive Health: A Survey of Program Directors in the United States.

PURPOSE: Clinical oncology guidelines recommend addressing sexual and reproductive health (SRH) concerns in routine cancer care. However, limited training often hinders clinicians' ability to do so effectively. The objective of this study was to understand the state of current fellowship education on SRH (ie, sexual health, safe sex practices, and fertility) through conducting a national survey of US hematology/oncology fellowship program directors (PDs). METHODS: A survey was sent to all PDs of adult hematology/oncology fellowship programs in the United States via online link. PDs who did not complete the survey were sent up to four follow-up emails and a paper mailing. Descriptive statistics and McNemar tests were conducted. RESULTS: One hundred-fourteen PDs responded (65%). Fewer programs offered formal instruction on sexual health (49%) and safe sex practices (37%) compared with fertility (75%). Informal training in SRH relied heavily on direct clinical experience (73%-78% of programs), with other methods (eg, case-based approaches, webinars, and journal clubs) being less common. Lack of experts to provide instruction was the most commonly cited barrier to offering training in SRH, endorsed by 74% for sexual health, 68% for safe sex practices, and 54% for fertility; difficulty finding space within the curriculum (50%; 54%; and 43%, respectively) and a lack of training requirements were also commonly endorsed (57%; 60%; and 35%, respectively). Barriers were endorsed more commonly for sexual health topics than fertility. CONCLUSION: The results highlight the scarcity of training in SRH, particularly in sexual health, within hematology/oncology fellowship programs. The heavy reliance on informal instruction methods may lead to inconsistent and inadequate education. Efforts to integrate comprehensive training in SRH into fellowship programs are crucial to ensuring that such concerns are included in routine cancer care.

Starting the Conversation: randomized pilot trial of an intervention to promote effective clinical communication about sexual health for gynecologic cancer survivors.

PURPOSE: Gynecologic cancer survivors often hesitate to raise sexual health concerns with their clinicians. We pilot tested Starting the Conversation (STC), a theory-guided intervention aimed at facilitating survivors' clinical communication about sexual health. METHODS: Survivors (N = 32) were randomized 2:1 to STC (23-min video and accompanying workbook grounded in social cognitive theory that provides information and skills training for communicating with providers about sexual concerns, and resource guide) or control (resource guide only). Feasibility was assessed through enrollment, retention, and intervention completion rates (benchmarks: 60%, 80%, 70%); acceptability was assessed through post-intervention program evaluations (benchmark: 75%). Preliminary effects were assessed for sexual health communication (self-reported after next clinic encounter), self-efficacy for clinical communication about sexual health (post-intervention and 2-month follow-up), and sexual activity and anxiety/depressive symptoms (2-month follow-up). RESULTS: All feasibility/acceptability benchmarks were surpassed; 76% enrolled, 97% retained, ≥ 95% used intervention materials, and 100% endorsed STC as acceptable. Positive STC effects were seen for increases in self-efficacy (Cohen's d's = 0.45 at post-intervention; 0.55 at follow-up). In STC, 35% and 45% of women raised or asked about sexual health concerns during the post-intervention clinic visit, respectively, versus 0 and 27% in the control arm. Other measures showed little change. CONCLUSIONS: Data support the STC intervention as feasible and acceptable, with promising effects for gynecologic cancer survivors' communication about sexual health concerns. Because sexual health communication is relevant across the treatment trajectory, we included both on-treatment and post-treatment survivors. While this may be a limitation, it could also enhance sample generalizability. A larger trial is needed to determine efficacy. IMPLICATIONS FOR CANCER SURVIVORS: Communication about sexual health is important yet lacking for cancer survivors. Patient-focused interventions may help address concerns and improve survivors' health outcomes.

Profiles of women's adjustment after cancer based on sexual and psychosocial wellbeing: results of a cluster analysis.

BACKGROUND: Sexual wellbeing is a critical yet often overlooked aspect of overall wellbeing for women across cancer diagnoses. OBJECTIVE: We identified profiles of women cancer survivors by sexual and psychosocial outcomes and compared groups for differences in relevant outcomes and individual characteristics. METHODS: Partnered women treated for cancer (n = 226; M age = 51.1 (12.6); 54% breast cancer; 86% White) completed a cross-sectional survey assessing sexual and psychosocial wellbeing. K-means cluster analysis modeled subgroups (clusters) with similar response patterns on measures of sexual wellbeing (sexual function, distress, sexual communication, and self-efficacy for communication), psychosocial wellbeing (quality of life (QOL), anxiety and depressive symptoms), and time since treatment. ANOVAs with Tukey post-hoc analyses and chi-square analyses tested cluster mean differences. RESULTS: Three distinct clusters of women differed by levels of adjustment in sexual and psychosocial wellbeing: higher-adjustment (32.7%), intermediate (37.6%), and lower-adjustment (29.6%). Significant differences among the clusters were found for all outcomes, with largest effect sizes for sexual distress (η2p = 0.66), sexual communication (η2p = 0.51), sexual satisfaction (η2p = 0.44), and anxiety and self-efficacy for communication (η2p = 0.32). The intermediate adjustment group was characterized by lower adjustment on measures of sexual and relationship function, and better adjustment on measures of QOL and mood. CONCLUSIONS: Findings suggest that for women cancer survivors, measures of sexual and psychosocial wellbeing can model distinct profiles to inform targeted interventions to meet women's needs. Evidence-based targeted interventions could lead to better sexual function, and ultimately to better QOL and overall wellbeing. IMPLICATIONS FOR PRACTICE: A stepped intervention approach to sexual health care for women with cancer, where content and format depend on degree of sexual and psychosocial adjustment after cancer, may be most appropriate. Interdisciplinary teams may address sexual, emotional, and relationship functioning.

Coping With Changes to Sex and Intimacy After a Diagnosis of Metastatic Breast Cancer: Results From a Qualitative Investigation With Patients and Partners.

Objective: Prior research examining sexual and intimacy concerns among metastatic breast cancer (MBC) patients and their intimate partners is limited. In this qualitative study, we explored MBC patients' and partners' experiences of sexual and intimacy-related changes and concerns, coping efforts, and information needs and intervention preferences, with a focus on identifying how the context of MBC shapes these experiences. Methods: We conducted 3 focus groups with partnered patients with MBC [N = 12; M age = 50.2; 92% White; 8% Black] and 6 interviews with intimate partners [M age = 47.3; 83% White; 17% Black]. Participants were recruited through the Fox Chase Cancer Center Tumor Registry and the Cancer Support Community. Qualitative data were analyzed using the Framework Method and Dedoose software. Results: Qualitative analyses revealed several key themes reflecting ways in which MBC shapes experiences of sex/intimacy: (1) the heavy disease/treatment burden leads to significant, long-term sexual concerns (e.g., loss of interest and vaginal dryness/discomfort) and consequent heightened emotional distress for both patients (e.g., guilt around not being able to engage in intercourse) and partners (e.g., guilt around pressuring the patient to engage in sexual activity despite pain/discomfort); (2) viewing the relationship as having "an expiration date" (due to expected earlier mortality) influences patients' and partners' concerns related to sex/intimacy and complicates coping efforts; and (3) information needs extend beyond managing sexual side effects to include emotional aspects of intimacy and the added strain of the life-limiting nature of the disease on the relationship. The heightened severity of sexual concerns faced by patients with MBC, compounded by the terminal nature of the disease, may place patients and partners at risk for significant adverse emotional and interpersonal consequences. Conclusion: Findings suggest unique ways in which sex and intimate relationships change after a diagnosis of metastatic breast cancer from both patients' and partners' perspectives. Consideration of the substantial physical and emotional burden of MBC and the broader context of the relationship and intimacy overall is important when developing a sexuality-focused intervention in this population. Addressing sexual concerns is a critical part of cancer care with important implications for patients' health and quality of life.

Investigating the impact of the COVID-19 pandemic on breast cancer clinicians' communication about sexual health.

PURPOSE: We assessed breast cancer clinicians' perspectives on how the COVID-19 pandemic and increased use of telehealth affected their clinical communication about sexual heath. METHODS: Breast cancer clinicians participating in a sexual health communication intervention study (N = 29; 76% female; 66% oncologists; 34% advanced practice clinicians) completed an online survey. Data analysis consisted of descriptive statistics and thematic analysis. RESULTS: All clinicians were using telehealth, with most (66%) using it for up to half of their clinic appointments. Although only 14% of clinicians reported having shorter clinic visits, 28% reported having less time to discuss sexual health; 69% reported no change; and 3% said they had more time. Forty-one percent reported sexual health was less of a priority; 55% reported no change; and 3% said it was more of a priority. Thirty-five percent reported telehealth was less conducive to discussing sexual health; 59% reported no change; and 7% reported more conducive. Qualitative analysis revealed key issues underlying the perceived impact of the pandemic on discussions of sexual health including heightened clinician discomfort discussing such issues via telehealth, the less personal nature and privacy issues in telehealth visits, increased concerns about risk of COVID-19 infection and other health concerns (e.g., missing recurrence, mental health) taking priority, and clinician-perceived patient factors (e.g., discomfort, decreased priority) in discussing sexual concerns. CONCLUSION: Pandemic-related changes in breast cancer clinicians' practice could be exacerbating challenges to discussing sexual health. Methods for integrating sexual health into cancer care are needed, regardless of the mode of delivery.

Adapting a Theory-Informed Intervention to Help Young Adult Couples Cope With Reproductive and Sexual Concerns After Cancer.

OBJECTIVE: Most young adults diagnosed with breast or gynecologic cancers experience adverse reproductive or sexual health (RSH) outcomes due to cancer and its treatment. However, evidence-based interventions that specifically address the RSH concerns of young adult and/or LGBTQ+ survivor couples are lacking. Our goal is to develop a feasible and acceptable couple-based intervention to reduce reproductive and sexual distress experience by young adult breast and gynecologic cancer survivor couples with diverse backgrounds. METHODS: We systematically adapted an empirically supported, theoretically grounded couple-based intervention to address the RSH concerns of young couples coping with breast or gynecologic cancer through integration of stakeholder perspectives. We interviewed 11 couples (22 individuals) with a history of breast or gynecologic cancer to review and pretest intervention materials. Three of these couples were invited to review and comment on intervention modifications. Content experts in RSH and dyadic coping, clinicians, and community advisors (one heterosexual couple and one LGBTQ+ couple, both with cancer history) participated throughout the adaptation process. RESULTS: Findings confirmed the need for an online, couple-based intervention to support young couples experiencing RSH concerns after breast or gynecologic cancer. Qualitative themes suggested intervention preferences for: (1) A highly flexible intervention that can be tailored to couples' specific RSH concerns; (2) Active steps to help members of a dyad "get on the same page" in their relationship and family building plans; (3) A specific focus on raising partners' awareness about how cancer can affect body image and physical intimacy; and (4) Accessible, evidence-based information about RSH for both partners. These results, along with feedback from stakeholders, informed adaptation and finalization of the intervention content and format. The resulting virtual intervention, Opening the Conversation, includes five weekly sessions offering training to couples in communication and dyadic coping skills for addressing RSH concerns. CONCLUSION: The systematic adaptation process yielded a theory-informed intervention for young adult couples facing breast and gynecological cancers, which will be evaluated in a randomized controlled trial. The long-term goal is to implement and disseminate Opening the Conversation broadly to reach young adult couples with diverse backgrounds who are experiencing RSH concerns in cancer survivorship.

Including partners in discussions of sexual side effects from breast cancer: a qualitative study of survivors, partners, and providers.

PURPOSE: Ensuring there are clear standards for addressing cancer-related sexual side effects is important. Currently, there are differences in two leading sets of clinical guidelines regarding the inclusion of survivors' romantic partners into clinical discussions between survivors and their providers about this issue. To help refine guidelines, we examine breast cancer survivor, partner, and oncology provider perspectives about including partners in discussions about cancer-related sexual side effects in a secondary analysis of a broader qualitative study. METHODS: Partnered female breast cancer survivors (N = 29) completed online surveys, and intimate partners of breast cancer survivors (N = 12) and breast oncology providers (N = 8) completed semi-structured interviews. Themes were derived from thematic content analysis. RESULTS: Among survivors who reported a discussion with their provider, fewer than half indicated their partner had been present, despite most survivors expressing it was - or would have been - helpful to include their partner. Partners also largely indicated being included was or would have been helpful, when welcomed by the survivor. Providers similarly emphasized the importance of survivors' autonomy in deciding whether to discuss sexual concerns in the presence of a partner. CONCLUSIONS: Partners were infrequently included in conversations about cancer-related sexual side effects, even though survivors, partners, and providers alike expressed value in these discussions occurring with the couple together - when that is the survivor's preference. Findings suggest future clinical guidelines should emphasize that incorporating partners into clinical discussions about sexual concerns is important for many breast cancer patients. Soliciting and enacting patients' preferences is essential for truly patient-centered care.

Psychological and sexual distress in rectal cancer patients and partners.

BACKGROUND: Rectal cancer (RC) patients experience unique sources of distress, including sexual dysfunction and body image concerns, which can also cause distress among partners. This preliminary study investigated patterns of psychological distress, sexual functioning, sexual distress, and relationship satisfaction among RC patient-partner couples at pivotal points during cancer treatment. METHODS: Twenty couples participated (N = 40). Patients and partners completed a series of validated measures of psychological distress (ET), sexual functioning (FSFI; IIEF), sexual distress (GMSEX; Sexual Distress Scale) and relationship satisfaction (GMREL) at time of diagnosis, 3 weeks after radiation, 4 weeks post-surgery, and after chemotherapy and surgery for ostomy closure. Descriptive statistics, t-tests, and repeated-measures ANOVA were used to analyze scores over time, first for patients and partners, and then by sex. RESULTS: Relationship satisfaction remained elevated over time. In this sample, 55% of patients and 78.9% of partners reported clinically significant rates of psychological distress at diagnosis, which decreased to 23% and 46% respectively at the last assessment. Sexual satisfaction and distress worsened for patients and partners between baseline and surgery for ostomy closure. Both male and female participants reported statistically significant declines in sexual function from baseline to end of treatment (p < 0.05). DISCUSSION: Relative to relationship satisfaction, psychological and sexual health outcomes seem more vulnerable to the effects of RC treatment during the first year after diagnosis, both for patients and partners and for men and women. Results support the need for psychosocial care and sexual education/counseling for couples coping with RC.

Mobile Technology-Based (mLearning) Intervention to Enhance Breast Cancer Clinicians' Communication About Sexual Health: A Pilot Trial.

BACKGROUND: Most breast cancer clinicians lack training to counsel patients about sexual concerns. The purpose of this study was to assess the feasibility, acceptability, and preliminary effects of a mobile learning (mLearning) intervention (improving Sexual Health and Augmenting Relationships through Education [iSHARE]) aimed at enhancing breast cancer clinicians' knowledge of, beliefs about, and comfort with discussing patients' sexual health concerns. METHODS: Clinicians listened to a 2-part educational podcast series offering information on breast cancer-related sexual health concerns and effective communication on the topic, which consisted of interviews with expert guests. Intervention feasibility was assessed through rates of enrollment, retention, and intervention completion, with benchmarks of 40%, 70%, and 60%, respectively. Acceptability was assessed through program evaluations, with 75% of clinicians rating the intervention favorably (eg, relevance, satisfaction) signifying acceptability. Clinicians self-reported their knowledge about breast cancer-related sexual health concerns, beliefs (ie, self-efficacy for discussing sexual health concerns), and comfort with discussing sexual concerns measured at preintervention and postintervention. Qualitative analysis examined clinicians' perceptions of lessons learned from the intervention. RESULTS: A total of 32 breast cancer clinicians enrolled (46% of those invited; 97% of those who responded and screened eligible), 30 (94%) completed both the intervention and study surveys, and 80% rated the intervention favorably, demonstrating feasibility and acceptability. Results showed positive trends for improvement in clinician knowledge, beliefs, and comfort with discussing sexual health concerns. Clinicians reported key lessons learned, including taking a proactive approach to discussing sexual health concerns, normalizing the topic, addressing vaginal health, sending the message that help is available, and assessing sexual health concerns with patients from different backgrounds. CONCLUSIONS: Breast cancer clinicians were amenable to participating in the iSHARE intervention and found it useful. iSHARE showed promise for improving clinician's knowledge and comfort discussing patients' sexual health concerns. A larger trial is required to demonstrate efficacy. Future studies should also examine whether iSHARE can improve patient-clinician communication and address patients' sexual concerns.

Understanding Sexual Help-Seeking for Women With Breast Cancer: What Distinguishes Women Who Seek Help From Those Who Do Not?

BACKGROUND: Sexual problems are extremely common for women after breast cancer (BC). AIM: To determine, in a sample of BC outpatients, how commonly women sought help for sexual concerns, from a health care provider (HCP), from other individuals, or from alternate sources; and to examine whether help-seeking was associated with women's sexual function/activity, self-efficacy for clinical communication about sexual health, or sociodemographic/medical characteristics. METHODS: BC patients participating in a sexual/menopausal health communication intervention trial completed web-based baseline self-report surveys. One-way analysis of variances compared effects of the level of sexual help-seeking (none; 1 outlet; 2-3 outlets) on sexual function domains. Chi-square or t-tests compared women seeking help with those not seeking help on other study variables. MAIN OUTCOME MEASURES: Patient-reported outcome instruments assessed sexual help-seeking (past month), sexual function and activity (PROMIS Sexual Function and Satisfaction Brief Profile Version 2.0), and self-efficacy (confidence) for communicating with their BC clinician about sexual health. RESULTS: 144 women (mean age = 56.0 years; 62% partnered; 67% white; 27% black/African American; 4% Hispanic/Latina; 15% stage IV) participated in this study. 49% of women sought help for sexual concerns, most often from intimate partners, family and/or friends (42%), followed by HCPs (24%), or online/print materials (19%); very few women (n = 4; 3%) sought help only from a HCP. Women seeking help were younger and more likely to be partnered and sexually active than those not seeking help. Sexual function was impaired for all domains but was most impaired for sexual interest. Among sexually active women, those seeking help from 2 to 3 sources reported worse sexual function in certain domains (sexual interest, lubrication, vaginal discomfort, vulvar discomfort-labial, satisfaction). Women seeking help from outlets other than HCPs had significantly lower self-efficacy than those who did not. CLINICAL IMPLICATIONS: BC patients with access to a partner and who are sexually active but find sex unsatisfying, uncomfortable, or lack interest may be in particular need of sexual help. Further, women may turn to outlets other than HCPs for sexual help partly because they lack the confidence to do so with a HCP. Sexual health information should be made available to women's partners, family, and friends, so they may effectively discuss such issues if needed. STRENGTHS & LIMITATIONS: Strengths of the study included examination of a range of sexual function domains and a theoretical construct in relation to BC patients' sexual help-seeking and a medically diverse sample. Limitations include a cross-sectional design. CONCLUSION: Women treated for BC should receive accurate and timely sexual health information. Reese JB, Sorice KA, Pollard W, et al. Understanding Sexual Help-Seeking for Women With Breast Cancer: What Distinguishes Women Who Seek Help From Those Who Do Not? J Sex Med 2020;17:1729-1739.

Communication about Sexual Health in Breast Cancer: What Can We Learn from Patients' Self-Report and Clinic Dialogue?

OBJECTIVE: Research assessing clinical communication about sexual health is limited. We compared clinical communication about sexual health across patients' self-reports and coded dialogue in breast cancer outpatients. METHODS: 134 patients had clinic visits audio-recorded and coded for sexual health communication and completed self-report questionnaires immediately after the visit. Associations between the self-report and dialogue were assessed using Phi coefficient. Agreements (present/absent) and discrepancies (omissions, commissions) about discussed topics were classified and discrepancies analyzed for themes. RESULTS: Sexual health was discussed in 61 of 134 patient visits (46%). Associations were significant (p < .01) but differed by topic (φ = .27-.76). 37 women (23%) had ≥ 1 self-report error. Discrepancies were common (19 omissions, 29 commissions). Patients often omitted communication about sexual concerns when such concerns were not problematic, and interpreted non-specific discussions as including specific topics of concern, even when not explicitly stated. Omissions were more common for women with lower education. CONCLUSIONS: Patients' reports of whether sexual health communication occurs does not always align with observed dialogue, and may vary by personal relevance of the topic. PRACTICE IMPLICATIONS: There are limitations in determining the prevalence of clinical communication about sexual health through patient self-report. Explaining sexual health terms might enhance shared understanding.

Evaluating a couple-based intervention addressing sexual concerns for breast cancer survivors: study protocol for a randomized controlled trial.

BACKGROUND: Sexual concerns are distressing for breast cancer survivors and interfere with their intimate relationships. This study evaluates the efficacy of a four-session couple-based intervention delivered via telephone, called Intimacy Enhancement (IE). The IE intervention is grounded in social cognitive theory and integrates evidence-based techniques from cognitive behavioral couple therapy and sex therapy to address survivors' sexual concerns and enhance their and their partners' sexual, relationship, and psychological outcomes. METHODS: This trial is designed to evaluate the efficacy of the IE intervention in improving survivors' sexual function, the primary study outcome. Secondary outcomes include survivors' sexual distress, partners' sexual function, and survivors' and partners' relationship intimacy and quality as well as psychological distress (depressive symptoms and anxiety symptoms). Additional aims are to examine whether treatment effects on patient sexual function are mediated by sexual communication and self-efficacy for coping with sexual concerns and to explore whether survivor age and race/ethnicity moderate intervention effects on survivors' sexual function. Eligible adult female breast cancer survivors reporting sexual concerns and their intimate partners are recruited from two academic sites in the USA and are randomized to either the IE intervention or to a control condition of equal length offering education and support around breast cancer-related health topics (Living Healthy Together). The target sample size is 120 couples. Self-report outcome measures are administered to participants in both conditions at baseline (T1), post-treatment (T2), 3 months post-treatment (T3), and 6 months post-treatment (T4). DISCUSSION: Evidence-based interventions are needed to address sexual concerns for breast cancer survivors and to enhance their and their intimate partners' sexual, relationship, and psychological well-being. This randomized controlled trial will allow us to examine the efficacy of a novel couple-based intervention delivered via telephone for breast cancer survivors experiencing sexual concerns and their intimate partners, in comparison with an attention control. Findings of this study could influence clinical care for women with breast cancer and inform theory guiding cancer-related sexual rehabilitation. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03930797. Registered on 24 April 2019.

Why do breast cancer survivors decline a couple-based intimacy enhancement intervention trial?

Recruitment challenges hinder behavioral intervention research in cancer survivors. The purpose was to examine the reasons for declining and intervention preferences of study-eligible breast cancer survivors declining a trial of a four-session couple-based Intimacy Enhancement intervention (refusers) and explore whether refusers differed from participants on key characteristics. Partnered, post-treatment breast cancer survivors reporting sexual concerns who were eligible for but declined participation in the intervention trial were approached to complete a standardized 5-min telephone survey assessing reasons for declining and support preferences. Demographic, clinical, and sexual concerns information were collected during screening. Trial participants and refusers were compared on key variables of age, race, hormone therapy use, time since treatment, level of sexual concerns, and recruitment method using t-tests or chi-square tests. Among the 31 women who declined the trial and completed the survey, the most common reasons for declining were time commitment (74%) and partner noninterest (32%). Most (61%) reported that the telephone format played little to no role in their refusal. Eighty-one percent wanted their partners involved in a program addressing sexual concerns. The two most preferred resources were informational websites (45%) and meeting with a professional (26%). Trial participants and refusers did not differ on any key factors examined. Developing intimacy interventions that are very brief, partner-optional, or that use stepped care may bolster uptake. The methods used to examine study-eligible candidates' needs and preferences could be employed in other health populations, thus having broader implications for research design.

A brief intervention to enhance breast cancer clinicians' communication about sexual health: Feasibility, acceptability, and preliminary outcomes.

OBJECTIVE: Sexual concerns are often unaddressed for breast cancer patients; one reason is inadequate clinician training. We examined the feasibility, acceptability, and potential benefits of a novel intervention, improving Sexual Health and Augmenting Relationships through Education (iSHARE) for breast cancer clinicians. METHODS: Clinicians received training in communicating about sexual concerns with breast cancer patients. Intervention feasibility and acceptability were measured through enrollment/participation and postintervention program evaluations, respectively. Intervention effects were assessed through (1) clinician self-reported beliefs about sexual health communication, assessed at baseline, post-intervention, and 1- or 6-month follow-up, (2) clinical communication coded from audio recorded, transcribed clinic encounters at preintervention or postintervention, and (3) patient satisfaction with clinical care, reported immediately after the clinic visit. Patients also reported sociodemographic characteristics and level of sexual concerns. RESULTS: Seven breast cancer clinicians enrolled (88% participation), completed the intervention, and were audio recorded in clinic encounters with 134 breast cancer outpatients (67 each at preintervention or postintervention). Program evaluations supported intervention acceptability. Effect sizes suggest iSHARE increased clinicians' self-efficacy (d = 0.27) and outcome expectancies for communicating about sexual concerns (d = 0.69) and reduced communication barriers (d = -0.14). Clinicians' sexual health communication behaviors increased from baseline to postintervention, including for raising the topic (28% vs 48%), asking questions (33% vs 45%), and offering information (18% vs 24%). Neither patient satisfaction nor duration of sexual health communication changed (mean duration less than 1 minute at both time points). CONCLUSIONS: The iSHARE intervention was feasible and well received by clinicians and may change breast cancer clinicians' beliefs and communication behaviors regarding sexual health.

A randomized pilot trial of a couple-based intervention addressing sexual concerns for breast cancer survivors.

The purpose was to test the feasibility, acceptability, and preliminary efficacy of a 4-session couple-based Intimacy Enhancement (IE) intervention addressing breast cancer survivors' sexual concerns delivered via telephone. Twenty-nine post-treatment breast cancer survivors reporting sexual concerns and their intimate partners were randomized (2:1) to the IE intervention or to an educational control condition, both of which were delivered by trained psychosocial providers. Feasibility and acceptability were measured through recruitment, retention, session completion, and post-intervention program evaluations. Couples completed validated sexual, relationship, and psychosocial outcome measures at pre- and post-intervention. Between-group effect sizes and 95% confidence intervals were calculated using the Hedges g. Data supported intervention feasibility and acceptability. For survivors, the IE intervention had medium to large positive effects on all sexual outcomes and most psychosocial outcomes. Effects were less visible for relationship outcomes and were similar but somewhat smaller for partners. The IE intervention demonstrated feasibility, acceptability, and promise in addressing breast cancer survivors' sexual concerns and enhancing their and their partners' intimate relationships and psychosocial well-being. Implications for Psychosocial Oncology Practice The IE intervention demonstrated feasibility and acceptability, suggesting it could be well-received by breast cancer survivors with sexual concerns and their partners. Effects of the IE intervention on breast cancer survivors' sexual concerns and on their and their partners' intimate relationships and psychosocial well-being could not be attributed to therapist time and attention. Interventions that psychosocial providers can use to address breast cancer survivors' sexual concerns are important to the growing number of breast cancer survivors living for many years after their diagnosis.

Patient-clinician communication about sexual health in breast cancer: A mixed-methods analysis of clinic dialogue.

OBJECTIVES: Breast cancer patients' sexual health needs are frequently unmet. We examined the prevalence and content of communication about sexual health between breast cancer patients and clinicians. METHODS: Female breast cancer patients being seen in oncology clinic follow-up had a clinic visit audio recorded and self-reported sexual problems after the visit. Transcripts were coded for sexual health communication; data were analyzed descriptively or using Chi-square tests. RESULTS: We recorded 67 patients (81% participation rate) interacting with one of 7 cancer clinicians (5 physicians; 2 advanced practice clinicians). Approximately 1/3 of women (n = 22) reported sexual problems; sexual health communication occurred with 10/22 of those women (45%). Across all 67 patients, 27 (40%) visits contained communication about sexual health. Seventy-percent of sexual health communication was clinician-initiated. When in-depth sexual health discussions occurred, the most common topics discussed were sexual inactivity (6), body image (5), vaginal dryness (4), and safety of sexual activity (2). CONCLUSION: Communication about sexual health was uncommon even for women reporting sexual problems and was largely initiated by clinicians. PRACTICE IMPLICATIONS: Because women with breast cancer often do not raise sexual concerns during clinic visits, breast cancer clinicians should raise the topic of sexual health for all patients.

Sexual quality of life, body image distress, and psychosocial outcomes in colorectal cancer: a longitudinal study.

PURPOSE: The objectives were to assess changes in sexual QOL and body image distress over time and to examine longitudinal associations between sexual QOL and body image variables with psychosocial outcomes in a sample of colorectal cancer patients. METHODS: Participants (N = 141) completed a mail-based survey assessing sexual QOL [sexual distress (ISS), treatment impact on sexual function (SFQ), sexual function (FSFI; IIEF)], body image distress (BIS), and psychosocial outcomes [relationship quality (DAS-4), depressive symptoms (CESD-SF), and health-related QOL (HRQOL; FACT-C)]; 88 patients completed 6-month follow-up surveys (62%). Gender and cancer subgroups (male vs. female; rectal vs. colon cancer) were compared and longitudinal models examined associations between sexual QOL and body image variables with psychosocial outcomes over time and by subgroup. RESULTS: Impairments in sexual QOL and body image distress were common. Women and patients with rectal cancer reported worse body image distress compared to men (p = .005) and those with colon cancer (p = .03), respectively; compared to patients with colon cancer, those with rectal cancer reported worse treatment impact (p < .001) and marginally worse sexual function and HRQOL (p's = .05). At 6-month follow-up, body image distress decreased (p = .02), while sexual QOL was stable (e.g., 58% classified as dysfunctional at both time points, p = .13). For most sexual and body image predictors, worse impairment was associated with worse psychosocial outcomes over time. Several significant gender and cancer subgroup effects were found. CONCLUSIONS: Sexual QOL and body image are compromised after colorectal cancer and tend to remain impaired if unaddressed. Sexual concerns should be addressed early to limit broader-reaching psychosocial effects.

A systematic review of dyadic studies examining relationship quality in couples facing colorectal cancer together.

BACKGROUND: Despite the adverse effects that treatment for colorectal cancer can have on patients' quality of life and, in particular, their intimate relationships, very little research has been conducted on the psychosocial adjustment for both patients and their partners/spouses. OBJECTIVES: The aim of this systematic review was to examine dyadic studies of adjustment in couples in which one partner has been diagnosed with colorectal cancer. METHODS: Pub Med, PsychINFO, MEDLINE, Social Sciences Abstracts (EBSCO), and the Cochrane Library were systematically searched for studies reporting quality of life outcomes for colorectal cancer patients and their partners/spouses. Only studies that included dyads in the sample were eligible for inclusion. The Quality Assessment Tool for Quantitative Studies was used to evaluate each study. RESULTS: A total of 277 studies were identified, of which 9 studies met the inclusion criteria (N = 388 couples). The methodological quality of the studies was high in that they used standardized instruments validated with their samples, conducted dyadic data analyses (when appropriate), and used longitudinal designs. A synthesis of the studies revealed that (1) relationship factors (eg, support, communication, dyadic coping, and relationship satisfaction) affect adjustment to cancer; (2) cancer-related distress impacts each partner's adjustment or the relationship; and (3) gender, role (patient/caregiver), and clinical characteristics (treatment, mental health) can mediate adjustment to cancer. CONCLUSION: The quality of the relationship can influence patients' and their partners' adjustment to colorectal cancer. Psychosocial interventions that address relationship issues may be beneficial to couples facing the challenges of colorectal cancer.