What Women Need to Know About Sex and Cancer Treatment

Amid the onslaught of questions and worries that can be prompted by a bladder or kidney cancer diagnosis, most women are not immediately concerned with how the disease and its treatment might affect their sex life. Though sex may not be as top-of-mind as issues like survival itself or caring for a family, it is still a significant aspect of quality of life that is worth preserving and nurturing.

Maintaining a healthy sex life while dealing with cancer requires open and honest discussion both between partners as well as with a cancer care provider, but it may be difficult to know exactly what to discuss. We spoke with Dr. Tanaka Dune, a urogynecologist within the Weill Cornell Medicine and NewYork-Presbyterian Hospital (WCM/NYP) Center for Female Pelvic Health, and our Genitourinary (GU) Oncology Program’s own Dr. Ana Molina to find out how to guide the conversation.

Recognize Changes

Fighting cancer can be physically and mentally exhausting, leaving many women without much energy or desire to engage in sexual activity. Additionally, the potential aesthetic changes to the body caused by treatment, such as scarring, hair loss and weight fluctuation may hamper confidence or lead to feelings of unattractiveness. Yet, if all parties are consenting and communicative, it is safe to have sex during and after cancer treatment.

Women should be aware, however, that certain types of chemotherapy can damage the ovaries and lead to vaginal dryness, irritation and/or atrophy (thinning and shrinking of vaginal tissue due to lack of estrogen), which may cause discomfort during sex and otherwise.

Dune“You should never be aware of your vagina,” says Dr. Dune. “If you become aware, that’s when you need to start talking about it.”

Ask Questions

Healthcare providers work with the best interest of the whole person in mind, so women do not need to be afraid to ask questions or feel embarrassed about how much they do or do not know about sexuality. Clinician assistance often leads to better patient health outcomes, faster. For example, it can be difficult for women to discern between pain in the vagina and pain in the pelvic floor, the network of muscles that supports the vagina and other pelvic organs, and a doctor can ask clarifying questions to determine the appropriate next steps to treat the issue and suppress the pain.

Evaluate Options

As with most elements of cancer care, there is no one-size-fits-all approach to navigating sex during and after treatment.

To combat chemo-induced vaginal dryness, for example, lubrication options are abundant, granting patients the ability to customize based on individual needs and preferences. Certain compounds found in lubricants can trigger yeast infection, irritate the vulva and/or dry out vaginal and anal tissues, so women should avoid using petroleum-based lubricants like mineral oil or Vaseline, as well as those that contain nonoxynol-9, glycerin, glycols or parabens. Instead, they can opt for silicone- or water-based lubricants, or natural oil lubricants like vegetable, olive, peanut, avocado or coconut oil. To reduce vaginal tightness, doctors may recommend use of pelvic floor physical therapists, who teach exercises that involve contracting and relaxing vaginal and pelvic floor muscles. This type of therapy can be achieved manually and/or with the use of vaginal dilators.

For issues of insecurity and anxiety that may disturb some women’s sex lives, possible remedies include psycho-social and/or psycho-sexual support services. The WCM/NYP Genitourinary Oncology Program connects patients and spouses/partners with support groups and counseling and can even offer hair-preserving cold cap therapy or a wig prescription to combat chemotherapy-induced hair loss that may contribute to a lack of confidence.

Molina“Addressing psycho-social issues together with your partner via counseling or support groups can have a positive impact on your life and intimate relationships,” says Dr. Ana Molina.

Since most forms of cancer treatment weaken the immune system, it is especially important that women use barrier protection during oral, anal and vaginal sex to prevent exchange of bodily fluids that can lead to sexually transmitted disease.

Patients should note that while the Internet is a fantastic tool for resources and self-education – often preferred because of the ability to search for information within the comfort of one’s own home – it is best to check with a healthcare team before acting on health advice found online.

Prevalence and Clinical Outcomes of Advanced Prostate Cancer Patients with Inherited DNA-Repair Mutations

DNA Helix_NCICollaborative work has shown that approximately 12% of men with advanced prostate cancer have inherited, or germline, DNA-repair mutations that disrupt the normal function of the genes involved in repairing damaged DNA. Somatic alterations in DNA-repair pathways are also common in prostate cancer, particularly in late-stage disease. Somatic alterations affect only tumor cells, but are not inherited or passed on. Inherited mutations in DNA-repair genes – such as BRCA2, ATM, and CHEK2 – are associated with an increased risk of several other cancers as well as prostate cancer, including breast, ovarian, and pancreatic cancer. In particular, mutations in BRCA2, associated with 1.8% of overall prostate cancer cases, have been associated with more aggressive prostate cancer characteristics and worse outcomes, including increased risk of recurrence and poorer overall survival rates.

As a result of the increasing number of men with these types of mutations, the National Comprehensive Cancer Network (NCCN) guidelines have recently changed, now recommending genetic testing for all men with metastatic prostate cancer.

Weill Cornell Medicine

“Genetic testing for inherited mutations may provide some men with prognostic information about their prostate cancer risk,” says Dr. Scott Tagawa, Director of the Weill Cornell Medicine and NewYork-Presbyterian Genitourinary (GU) Oncology Program. “Even more importantly, genetic testing can also be used to inform screening of family members and may increasingly inform precision-medicine based approaches to manage the disease using specific molecular features such as DNA-repair genes,” says Dr. Tagawa.

How do Inherited Mutations Impact Treatment?

Clinical research studies are continually being conducted to investigate new ways to treat advanced prostate cancer patients with germline DNA-repair mutations since these patients comprise a unique subset of patients. Currently, little has been known about whether DNA-repair mutation status impacts benefit from standard therapies for the disease and this is just one area that needs to be researched in order to specifically tailor treatment options for this subset of patients.

Weill Cornell Medicine and NewYork-Presbyterian’s Drs. Himisha Beltran, Scott Tagawa and David Nanus, along with collaborators from around the globe, address this in research published today in the high impact factor journal European Urology and simultaneously presented at the American Society of Oncology (ASCO) 2018 Genitourinary (GU) Cancers Symposium by Dr. Misha Beltran. The researchers reviewed 390 medical records of patients who previously participated in a New England Journal of Medicine (NEJM) study examining men with advanced prostate cancer with known germline DNA-repair mutations and those without these mutations. The goal of the research was to determine whether germline mutations in DNA-repair genes impact the benefit of standard therapies for metastatic prostate cancer, such as docetaxel chemotherapy and androgen receptor signaling inhibitors abiraterone acetate and enzalutamide. Results showed that all patients appeared to benefit from standard therapies similarly to other metastatic prostate cancer patients, regardless of germline mutation status.

“The data suggest that metastatic prostate cancer patients with inherited mutations in DNA damage repair genes, including those with BRCA2 mutation, derive similar benefit from standard of care therapies in terms of both response rate and progression-free survival,” says Dr. Scott Tagawa. “While we continue to investigate additional agents thought to preferentially benefit those with DNA repair alterations, current evidence indicates that detection of any of these mutations should not prevent metastatic prostate cancer patients from receiving standard therapies including taxanes, abiraterone and enzalutamide, as standard of care treatment.”

Additionally, sophisticated genetic analysis and testing may be performed by genetic counselors and widely-available commercial testing is also available to physicians and patients. Dr. Panagiotis Vlachostergios, fellow and medical oncologist at Weill Cornell Medicine and NewYork-Presbyterian, presented research at ASCO Genitourinary (GU) Cancers Symposium focused on using a commercial 30-gene panel to test men with localized prostate cancer and advanced prostate cancer for the presence of inherited gene mutations. Out of the 17 men with localized disease and 35 men with metastatic prostate cancer, eight of 52 (15%) were found to have a germline alteration. A higher percentage of men with an inherited mutation had localized (23.5%) versus advanced disease (11.4%), though testing might have been biased towards those with family history of cancer or those diagnosed with high-grade cancer at earlier age.

Both the results published in European Urology and research presented at the 2018 ASCO GU Cancer Symposium underscore the importance of genetic testing to determine what, if any, mutations may be present in prostate cancer in order to determine the best possible treatment options. While the published data supports the use of standard therapies in those with metastatic prostate cancer who have germline DNA-repair mutations, not all patients respond to these types of treatment, demonstrating the need for alternate treatment options for this patient population. Weill Cornell Medicine and NewYork-Presbyterian are in the process of opening several clinical trials to include men with prostate cancer in need of different lines of therapy. Clinical trials testing PARP inhibitors, a drug target for cancer therapy that appears to be more effective in prostate cancer patients with DNA-repair mutations, are ongoing and may offer additional therapy options for this group of patients in the near future.

Bladder Cancer – From the Basics to State-of-the-Art

One of the many ways Weill Cornell Medicine and NewYork-Presbyterian provide supportive resources to the community is by offering physician-led presentations and Q&A sessions in the Myra Mahon Patient Resource Center.

Two weeks ago, Dr. Scott Tagawa, medical oncologist and Director of the Weill Cornell Medicine Genitourinary (GU) Oncology Program, presented to and educated people in the local community about bladder cancer. His presentation was titled, “Bladder Cancer: From the Basics to State-of-the-Art.” Following the presentation, all attendees were invited to ask Dr. Tagawa questions.

Key topics from Dr. Tagawa’s presentation included the most common risk factors for bladder cancer, different types of bladder cancer (also known as clinical phases), and corresponding treatment options, research, as well as the benefits of utilizing an individualized approach to treatment, also known as precision medicine.

Highlights from Dr. Tagawa’s presentation are outlined below.

Bladder Cancer Risk FactorsScreen Shot 2017-12-14 at 9.22.30 AM

Dr. Tagawa noted that anyone can be diagnosed with bladder cancer, however, factors such as age and exposure to cigarette smoke may increase the risk of bladder cancer from developing. Most people who are diagnosed with bladder cancer are older in age. In fact, the average age at diagnosis is 73. In addition, bladder cancer is twice as common among Caucasians as African Americans.

Clinical Phases of Bladder Cancer and Corresponding Treatment Options

BladderCancer_5Dr. Tagawa highlighted the importance of using a uniform method for developing and testing biomarkers in bladder cancer, a disease with a high incidence of recurrence and expensive clinical surveillance. He also pointed out that most bladder cancers are of a type called transitional cell, affecting the same kinds of cells (transitional cells) that are usually the cancerous cells responsible for renal pelvis, ureter as well as kidney cancers. Dr. Tagawa described the four main phases of bladder cancer.

Pre-Cancer Diagnosis

The first phase is to assess symptoms in high-risk individuals, which defines those who are likely to develop bladder cancer. The most common symptom of bladder cancer is blood in the urine and testing to include assessment for the possibility of cancer would be beneficial for a high-risk population. Risk factors include, those who are aged 65 years or older, have used tobacco and has family history of cancer.

Often, the first test in the assessment of a patient with the symptom of blood in urine (or reddish urine) is a urinalysis, which is a test to assess for the presence of blood versus other elements that may appear like blood in the urine.  Other tests may include the assessment of other urine or blood factors, including assessment for infection. One test that is more specific for bladder cancer is a urine cytology, which looks at the urine under a microscope to detect abnormal appearing cells. If these cells are seen, a cancer diagnosis may be made, as the bladder has “shed” these cells into the urine. However, this test does not detect all cases of bladder cancer. Physicians may also want to perform blood tests or scans including, CT scan, MRI and ultrasounds.

“Superficial” Non-Muscle Invasive Disease

Non-muscle invasive disease means the cancer is confined to the inner lining of the bladder with no evidence that it has spread to another part of the pelvis or other organs. It used to be referred to as “superficial” bladder cancer, but this term is confusing since this stage of cancer often does invade into the first lining of the bladder. This type of bladder cancer comprises about 70% of all cases of newly-diagnosed bladder cancer. These patients are typically managed with resection (surgical removal of the cancerous parts of the bladder using a scope/camera), sometimes followed by intravesical therapy (usually immunotherapy with bacillus calmette-guerin), a process where the physician inserts a liquid drug directly into the bladder through a catheter. The drug can affect the cells lining the bladder without having major effects in other parts of the body.

Muscle Invasive Disease

In patients with muscle invasive disease, the cancer has spread into the muscle wall of the bladder. Those with this type of bladder cancer, which comprise of approximately 40% of all bladder cancer patients, are preferentially treated with systemic neoadjuvant chemotherapy followed by surgery to remove the bladder. Dr. Tagawa explained the different types of surgery patients may undergo if they are diagnosed with muscle invasive disease. The first is transurethral bladder tumor resection (TURBT), in which the surgeon removes the tumor using a tool with a small wire loop. Another form of surgery is a radical cystectomy, the removal of the whole bladder and possibly nearby tissues and organs. In addition, lymph nodes in the pelvis area are removed for both men and women, also known as a pelvic lymph node dissection. A selected subgroup of patients may have similar outcomes with a combination of initial TURBT surgery followed by chemotherapy and radiation.

Metastatic Disease

Patients with metastatic bladder cancer, accounting for approximately 15% of bladder cancer patients, have cancer that has extended through the bladder wall and invaded the pelvic and/or abdominal wall. Dr. Tagawa noted that while the other clinical states are treatable, if someone is going to pass away from bladder cancer, they would most likely be at the metastatic disease state. Dr. Tagawa highlighted that chemotherapy with platinum-based regimens remains the mainstay of first-line treatment for metastatic disease. He explained that if physicians combine platinum-based chemotherapy (e.g. cisplatin) with other treatments, patients will most likely benefit from positive clinical outcomes, resulting in tumor shrinkage and longer overall survival rates.

Systemic immunotherapy (administered into veins as opposed to only instillation in the bladder) is another treatment approach and one in which bladder cancer patients tend to have positive responses. The type of immunotherapy drugs given to patients with bladder cancer are known as immune checkpoint inhibitors, as they “release the brakes” on the immune system and allow immune cells to attack tumors. The first Food and Drug Administration (FDA)- approved immunotherapy drugs is tecentriq, also known as atezolizumab, which is an immune checkpoint inhibitor that selectively binds to cancer cells based on the presence of PD-L1, a protein on the tumor’s surface.  There are now five such drugs approved for bladder cancer – more than for any other cancer type.

Treatment Approaches in the Pipeline

Dr. Tagawa noted that we’ve come a long way in recent years with the most available treatment options than ever before for bladder cancer patients. He emphasized, though, that there is still room for improvement with the development of more treatments and additional treatment combinations to increase survival rates for patients. One of the ways physicians are able to do this is by utilizing precision medicine, treating each patient as an individual based on his or her own genetic makeup. For bladder cancer patients, physicians look at the different genes and whether the genetic mutations are within the tumor, or germline, to determine the best treatment options. Some of the most promising drugs for bladder cancer work best in the presence of certain altered genes. Another way clinicians are able to continue utilizing precision medicine is through clinical trials, which pave the way toward further scientific advances that could potentially find a cure for bladder cancer, in addition to other cancers. Weill Cornell Medicine and NewYork-Presbyterian offer many bladder cancer-specific trials that you can search for here.

Overall, Dr. Tagawa reinforced the benefit of working with a multidisciplinary team, which should include at least a surgeon, radiation oncologist and medical oncologist. He concluded his talk by emphasizing how clinical research has progressed over the years and what it has taught us – “we have seen translational therapy lead to real clinically relevant improvement for patients.”

Watch Dr. Tagawa’s full presentation below.