Elsevier

Sexual Medicine Reviews

Volume 7, Issue 2, April 2019, Pages 202-222
Sexual Medicine Reviews

Review
Sexual Function in Women with Colorectal/Anal Cancer

https://doi.org/10.1016/j.sxmr.2018.12.001Get rights and content

Abstract

Background

Treatments for colorectal and anal cancers can have a detrimental impact on sexual function. Type of treatment, which may include surgery, radiation, and/or chemotherapy, varies by disease site and severity. Treatment and long-term side effects can impact sexual function and intimacy for patients and their partners.

Aim

To review the literature regarding treatment for colorectal/anal cancer and its impact on female sexual function, and to provide an assessment of medical outcomes and patient-reported outcomes (PROs) of women with a history of colon, rectal, or anal cancer seeking sexual health treatment.

Methods

We performed a PubMed search to identify peer-reviewed, English-language articles published between 2008 to 2018, using the following search terms: “colorectal cancer,” or “rectal cancer,” or “anal cancer” and “sexual function,” or “sexual dysfunction.” We also assessed the medical outcomes and PROs from our recent cross-sectional cohort study of 99 women with a history of colon, rectal, or anal cancer seeking sexual health treatment.

Main Outcome Measures

Sexual function, quality of life, and PROs after colorectal/anal cancer.

Results

A total of 23 studies were identified. Study designs included 15 cross-sectional survey studies, 5 longitudinal studies, 2 psychoeducational interventions, and 1 pilot study. 10 studies included only women, and 13 included both men and women. The literature and our cohort confirmed that women with colorectal/anal cancer experience changes in sexual function after diagnosis and throughout the continuum of care; however, the scarcity of data in this area indicates a need for additional intervention trials and longitudinal studies.

Conclusions

Research studies with large sample sizes and long study durations are needed to help us better understand the needs of female survivors of colorectal/anal cancer. Women with colorectal/anal cancer need simple strategies and resources to address concerns of sexual function after cancer treatment. Such interventions have been shown to enhance survivorship and quality of life.

Canty J, Stabile C, Milli L, et al. Sexual Function in Women with Colorectal/Anal Cancer. Sex Med Rev 2019;7:202–222.

Introduction

The U.S. population of cancer survivors is expected to grow to 20 million by 2026.1 Despite early screening/detection and cancer prevention strategies, colorectal cancer is a common malignancy among both men and women.2 Anal cancer is less common; however, the number of newly diagnosed anal cancer cases has been rising every year.3 The incidence and mortality rates of colorectal cancer are higher in men than in women, and rates of anal cancer are slightly higher in women.3 In 2018, there will be an estimated 47,530 newly diagnosed cases of colon cancer, 17,100 new cases of rectal cancer, and 5,620 new cases of anal cancer among women.4

Treatment for colorectal/anal cancers varies by disease site and severity. Standard treatment typically includes a combination of surgery, chemotherapy, and/or radiation therapy. Management of colorectal cancer relies primarily on surgical resection of the bowel with the adjacent draining lymph nodes. The use of neoadjuvant or adjuvant chemotherapy (with or without radiation) to treat colorectal cancer depends on tumor location and disease stage. Treatment for colorectal/anal cancer may require a temporary or permanent stoma (an artificial opening on the abdomen through which the bowel or bladder diverts). The stoma opening allows for the attachment of a changeable bag through which feces can be eliminated.5 For anal cancer, primary radical radiotherapy and concomitant chemotherapy improve survival while also preserving the anal sphincter.6 The 5-year survival rates for colorectal/anal cancer have improved in recent years with screening advancements, an increase in the removal of colonic polyps (precursors to cancer), novel surgical techniques and therapies (adjuvant therapy), better preoperative staging, and targeted therapies.7 The use of adjuvant chemotherapy for colon cancer and neoadjuvant chemoradiation for rectal cancer also has improved survival rates.8

Female survivors of colorectal/anal cancer are typically older adults, with an average age of 72 years for colon, 63 years for rectal, and early 60s for anal cancer.1 Common issues of aging, such as comorbid illnesses and vulvovaginal tissue quality, can be exacerbated by cancer therapy.7 As these women live longer, understanding the long-term side effects of treatment are a priority.

Common physical side effects of treatment include autonomic nerve injury, bowel function issues (eg, incontinence, increased stool frequency, flatulence), buttock pain, and vulvovaginal health issues (eg, dryness, fibrosis, adhesions, shortening),9, 10, 11 all of which can adversely impact quality of life (QOL). Colorectal/anal cancer can have adverse and persistent effects on sexual function and psychological well-being. It should be noted that urologic issues, such as erectile dysfunction, are common among male cancer survivors and can result in significant difficulties in survivorship12; however, in this review, we explore the limited recent literature on the sexual health of women diagnosed and treated for colorectal/anal cancer, and also offer insights from our recent cohort of women who sought treatment to address vulvovaginal sexual health concerns.

Section snippets

Literature Review

We searched PubMed for peer-reviewed, English-language articles published between 2008 and 2018 using the following search terms: “colorectal cancer,” or “rectal cancer,” or “anal cancer” and “female,” and “sexual function,” or “sexual dysfunction.” Because most of the studies that we identified were not exclusively female-focused, we included studies that had both men and women. The criteria for inclusion consisted of peer-reviewed articles (cross-sectional, longitudinal, interventional, or

Overview of the Literature

Of 65 initially identified studies, 23 met our inclusion criteria (Table 1).13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35 Of these 23 studies, 10 included women only13, 14, 15, 16, 17, 18, 23, 25, 30, 34 and 13 included both men and women.19, 20, 21, 22, 24, 26, 27, 28, 29, 31, 32, 33, 35 There were 15 cross-sectional survey studies,13, 14, 15, 17, 19, 20, 21, 24, 25, 26, 30, 31, 32, 33, 34 2 psychoeducational interventions,23, 27 5 longitudinal

Future directions of research and clinical care

Studies that have examined the sexual function of women with colorectal/anal cancer have identified sexual dysfunction as a prevalent issue after cancer treatment. Although the rates of sexual dysfunction vary by study design and treatment modality, the research supports including the management of sexual function in patients with colorectal/anal cancer as part of standard care. Furthermore, sexual function concerns should be reassessed throughout treatment and into survivorship.

Future research

Conclusions

Our review of the existing literature shows that more research is needed to explore the sexual health concerns of women treated for colorectal/anal cancer regarding long-term follow-up, pretreatment assessments, and interventions. Future trials including more women and younger patients are needed. Addressing the sexual health concerns of women with cancer is imperative for maximizing QOL into long-term survivorship. During the shared decision making process, healthcare providers should prepare

Statement of authorship

Category 1

  1. (a)

    Conception and Design

    • Jocelyn Canty; Cara Stabile; Jeanne Carter

  2. (b)

    Acquisition of Data

    • Jocelyn Canty; Lisania Milli; Barbara Seidel; Deborah Goldfrank; Jeanne Carter

  3. (c)

    Analysis and Interpretation of Data

    • Jocelyn Canty; Cara Stabile; Lisania Milli; Barbara Seidel; Jeanne Carter

Category 2
  1. (a)

    Drafting the Article

    • Jocelyn Canty; Cara Stabile; Jeanne Carter

  2. (b)

    Revising It for Intellectual Content

    • Jocelyn Canty; Cara Stabile; Lisania Milli; Barbara Seidel; Deborah Goldfrank; Jeanne Carter

Category 3
  1. (a)

    Final Approval of the Completed Article

Acknowledgments

The authors thank Sally Saban and George Monemvasitis for their careful review and valuable feedback.

References (55)

  • L. Manderson

    Boundary breaches: The body, sex and sexuality after stoma surgery

    Soc Sci Med

    (2005)
  • S.O. Breukink et al.

    Psychophysiological assessment of sexual function in women after radiotherapy and total mesorectal excision for rectal cancer: A pilot study on four patients

    J Sex Med

    (2009)
  • S.J. Falk et al.

    Sexual dysfunction in women with cancer

    Fertil Steril

    (2013)
  • S.S. Faubion et al.

    Recognition and management of nonrelaxing pelvic floor dysfunction

    Mayo Clin Proc

    (2012)
  • Cancer treatment and survivorship: Facts and figures (2016-2017)

  • K. Simon

    Colorectal cancer development and advances in screening

    Clin Interv Aging

    (2016)
  • A.B. Moscicki et al.

    Screening for anal cancer in women

    J Low Genit Tract Dis

    (2015)
  • R.L. Siegel et al.

    Cancer statistics, 2018

    CA Cancer J Clin

    (2018)
  • J.A. Albaugh et al.

    Sexual dysfunction and intimacy for ostomates

    Clin Colon Rectal Surg

    (2017)
  • D.A. Haggstrom et al.

    Approach to the long-term survivor of colorectal cancer

  • S.R. Alberts et al.

    Colon, rectal, and anal cancers

  • S.K. Hendren et al.

    Prevalence of male and female sexual dysfunction is high following surgery for rectal cancer

    Ann Surg

    (2005)
  • C. Benedict et al.

    Body image and sexual function in women after treatment for anal and rectal cancer

    Psychooncology

    (2016)
  • C. Benedict et al.

    Investigation of body image as a mediator of the effects of bowel and GI symptoms on psychological distress in female survivors of rectal and anal cancer

    Support Care Cancer

    (2016)
  • G. Bohm et al.

    Anorectal, bladder, and sexual function in females following colorectal surgery for carcinoma

    Int J Colorectal Dis

    (2008)
  • J. Carter et al.

    Vaginal and sexual health treatment strategies within a female sexual medicine program for cancer patients and survivors

    J Cancer Surviv

    (2017)
  • H. Corte et al.

    Female sexual function after abdominoperineal resection for squamous cell carcinoma of the anus and the specific influence of colpectomy and vertical rectus abdominis myocutaneous flap

    Colorectal Dis

    (2011)
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    Conflicts of interest: None to report.

    Funding: Funded in part through National Institutes of Health/National Cancer Institute Memorial Sloan Kettering Cancer Center Support Grant P30 CA008748.

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