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Introduction

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Prevalence rates of sexual difficulties associated with cancer and its treatment vary widely depending on the primary diagnosis, treatment modality, method(s) of assessment and threshold criteria for severity and type of sexual dysfunction. Rates generally exceed those found in the general UK adult population of 14.1% (in the 16-24 year age group) to 27.8% (in the 55-64 year age group).1 This national population survey of sexual lifestyles and attitudes also found a strong association between low sexual function and age >55 years, menopause, depression, poor self-assessed general health and relationship satisfaction; these are also relevant factors for those affected by cancer.1

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Sexual consequences following cancer treatment are common, particularly among people treated for pelvic malignancies or breast cancer, with over 50% experiencing severe and persistent disruption to their sexual well-being.2 Given the biopsychosocial aetiology of many sexual difficulties, the increased use of nerve-sparing surgery and targeted pelvic radiotherapy techniques may not directly translate into reduced rates of sexual dysfunction. Furthermore, primary chemoradiotherapy for gynaecological or anal cancer and extended endocrine therapy (especially aromatase inhibitors) for breast cancer also contribute significantly to the high rates and severity of sexual disruption seen in oncology.3 Common treatment-associated sexual difficulties include loss of sexual interest, arousal and sexual pain difficulties, orgasmic or ejaculatory difficulties, and reduced sexual confidence and satisfaction.

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In women, sexual consequences may arise from premature menopause with reduced vaginal lubrication and dyspareunia (sexual pain), orgasmic difficulties and reduced sexual satisfaction. Pelvic surgery, radiotherapy and vaginal graft versus host disease after stem cell transplantation can lead to vaginal dryness, adhesions, fibrosis, stenosis and vaginal shortening, resulting in pain and an inability to have penetrative sex. Breast surgery may cause altered appearance and breast sensation, while vulval surgery can result in introital stenosis or reduced clitoral sensitivity that leads to sexual pain or orgasmic changes.

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In men, erectile dysfunction may result from hormonal changes secondary to androgen deprivation therapy, or result from nerve damage and vascular changes following pelvic surgery or radiotherapy. Reduced orgasmic intensity, dry or retrograde ejaculation and climacturia after pelvic surgery or radiotherapy also have a negative impact on men's sexual expression following cancer treatment.3

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Anxiety and depression, body image adjustment, altered femininity or masculinity, infertility concerns, relationship strain and broader social difficulties are also common precipitating and maintaining factors for sexual difficulties associated with cancer.

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Clinical assessment

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In the oncology follow-up clinic, discussion of disease surveillance and acute side effects is generally prioritized over the assessment and management of late effects of treatment. Discussing the sexual consequences of cancer remains a challenging aspect of communication for health professionals and patients alike:4 such conversations are more likely to be reported by male (68%) than by female (43%) cancer patients,5 perhaps reflecting the greater number of biomedical treatments available for the management of erectile dysfunction.6

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