For many patients, one of the most challenging aspects of cancer is the adverse effects that follow disease treatment. They come in dif&shy;ferent forms, such as nausea, vomiting, diarrhea, hair loss, anemia, and chemo brain. Another unfortunate, and often underreported, adverse effect involves sexual health and fertility.

Although sexual and fertility concerns during and after cancer affect men and women differently, both genders have the same desire for intimacy.

In this issue’s cover story, Jeffrey Albaugh, PhD, APRN, CUCNS, direc&shy;tor of sexual health at NorthShore University HealthSystem in Evanston, Illinois, walks through the specific issues related to sex that men and women who are cancer survivors face, offering many ways in which oncology nurses can help patients address their concerns.

Albaugh’s most crucial piece of advice is to have conversations with patients to let them know they are not alone. A study, discussed by Albaugh in the cover story, found that 62% of internists working with patients with cancer never or rarely address sexual issues. Albaugh understands that sexuality is crucial to being human. Through his nursing experience, he found that empowering patients with information about sexual dysfunction and fertility can lead to bet&shy;ter decision making.

® also discusses improving the accuracy of patient identification. Whether it be human or computer error, these mistakes are still happening in cancer care centers across the country despite efforts by the Joint Commission, the American Society of Clinical Oncology, and the Oncology Nursing Society. Our editor in chief dissects a lawsuit that was a result of a wrong-patient error that led to the patient receiving che&shy;motherapy intended for someone else. In these pages, we examine how this could have been avoided and discuss further actions to reduce patient identi&shy;fication mistakes.

Retirement is often dreamed about, but rarely feels like it’s within reach. A new book, 

Redefining Retirement For Nurses: Finding Meaning After Retirement

, tells the stories of 26 nurses and their journeys to the next phases of life. 

® speaks with one of the authors, who after 45 years of nursing, sold her home and pur&shy;chased an RV to travel the country. Much like the nurses whose stories she shares, Joanne Evans found it most challenging to not overcommit herself, whether it be for speaking engagements or volunteer work, again in the chapter she likes to call “rewiring” rather than “retiring.”

Also in this issue, a new drug to help reduce oral mucositis in patients with head and neck cancer, promoting 

awareness, and the impact that nurse case managers have on clinical outcomes.

We hope you find these articles in-formative, and as always, thank you for reading.

Articles

From the Chairman

This letter from the Chairman and CEO of Oncology Nursing News® gives an overview of the contents of the March 2018 print issue of the magazine. 

Sex After Cancer: Let Patients Know They Are Not Alone

Cancer care starts at prediagnosis. The initial conversa&shy;tion between a patient and the healthcare team helps establish trust. However, many patients and their loved ones report receiv&shy;ing inadequate information about diagnosis, treatment, and prognosis from the beginning.

In a study by Figg et al, 44% of the 437 patients who completed a survey reported that the initial conversation about their cancer diagnosis lasted 10 minutes or less. That can leave a patient feeling confused, angry, and unsupported. However, oncology nurse case man&shy;agers can help bridge the gap between fear of the unknown and confidence in the healthcare team.

THE MAKING OF AN ONCOLOGY NURSE CASE MANAGER

Oncology nurse case managers optimize quality and cost-ef&shy;fective care in both hospital and community settings. These highly skilled nurses possess specialized training and certifi&shy;cation in case management and/or oncology. Case managers may work face-to-face or via telephone with patients.

Nurse case management has been recognized as a success&shy;ful method for optimizing cancer care pathways, increasing quality of care and achieving cost-effectiveness. These health&shy;care professionals possess not only an extensive clinical back&shy;ground but also a vast understanding of the healthcare indus&shy;try, payer sources, and psychosocial care.

Many nurse case managers become certified. The Commission for Case Manager Certification (CCMC) is the larg&shy;est accrediting body and considered the gold standard in the field. An estimated 50% of employers require the certifica&shy;tion for nurse case managers, and 63% of employers offer reimbursement for the exam, according to CCMC. Experience coupled with certification prepares nurse case managers to deliver care in a patient-centric model.

Nurse case managers and nurse navigators are often confused and the terms interchanged. Although they may have com&shy;mon responsibilities, such as timely access to care and mini&shy;mizing healthcare barriers, they are not the same.

Navigation is defined as individualized assistance that helps patients, families, and caregivers overcome healthcare system barriers and facilitates timely access to quality health and psychosocial care, from prediagnosis through all phases of the cancer experience.

Case management involves a collaborative process of assess&shy;ment, planning, facilitation, care coordination, evaluation, and advocacy for options and services to meet the individ&shy;ual needs of the patient, according to the Case Management Society of America. Through communication, resource man&shy;agement, education, and patient advocacy, the case manager coordinates a patient-centered plan of care.

The case manager is tasked with finding the delicate balance between treatment, resource use, evi&shy;denced-based medicine, and the patient’s ability to make informed decisions. Through education, resource allocation, and support, the case manager advocates for the patient. Further, a case manager advocates for multidisci&shy;plinary team members, the hospital, and the payer source. This role of advocacy for the common good and for the patient requires careful balance.

Case managers are highly skilled in inter&shy;viewing, reflection, critical thinking, and collaboration. They use techniques such as motivational interviewing to help empower the patient to make individualized decisions and accomplish goals. This approach helps the case man&shy;ager ensure that all oncology treatment is patient-centered.

Case managers are familiar with available local, state, and national resources. They work with the patient to find the support they need in their own community. For instance, a patient may require transportation, meals, or financial assistance.A case manager is in a unique role that involves both assist&shy;ing with the patient’s clinical needs and examining inter&shy;personal and psychosocial needs. One of the most challeng&shy;ing aspects of this position involves considering the cost of treatment. Some patients have a realistic outlook on their prognosis; others do not. It is the case manager’s job to help the patient find the right resources and treatment that are not only clinically focused but financially sound. This may be the difference between another round of chemotherapy or pursuing palliative or hospice care. These conversations take a great amount of skill, empathy, and compassion.

Nurses educate, and oncology nurse case man&shy;agers use education as a pillar of their practice. By educat&shy;ing the patient in an open, honest manner, case managers increase adherence to treatment pathways. The case man&shy;ager ensures that the patient understands the treatment plan, diagnosis, and prognosis. It is the case manager’s job to provide the patient with the information needed to make informed self-care decisions.

Case managers are committed to helping patients navigate the highly specialized and fragmented healthcare system. Using the 4 case management philosophies, they ensure that the patient experiences a coherent and individually focused care pathway that is delivered at the right time using the right resources.

 is a freelance healthcare writer and owner of 

. She has been a Registered Nurse for 20 years and is passionate about case management, nursing leadership, and finding the right care for patients in every setting. 

Fast Facts for the Frontline

Applying 4 philosophies to the nurse case manager role can assist with patient decision making.

Oncology Case Management: Optimizing Care Pathways

Joanne Evans’ new beginning—as she likes to call it&mdash;began after she retired from her 45-year nursing career. Evans, who holds a string of credentials&mdash;MEd, RN, PMHCNS-BC&mdash; sold her house, bought an RV, and put 9000 miles on it in 7 months. Besides traveling throughout the United States, she continues to write and speak at nursing conferences on plant-based nutrition&mdash; another one of her passions.

But for some retired nurses, as Evans learned, figuring out what to do with their newfound free time isn’t as easy as they anticipated. So, along with Patricia A. Tabloski, PhD, GNP-BC, FGSA, FAAN, she wrote a book to help. 

Redefining Retirement for Nurses: Finding Meaning in Retirement

delves into re-creating life after leaving a career. In an interview with 

, Evans discussed what they learned from their interviews with 26 nurses.

Most of us grew up with 1 concept of retirement, and nowadays it’s really different. There are so many more opportunities. Retirement is almost like a whole new phase of life, because you most likely have another 20 years. The book looks at how 26 nurses continued to bring meaning to their lives after leaving a full-time nursing position. These nurses have spent their whole careers tak&shy;ing care of other people and making decisions— whether in research, education, management, or clinical areas&mdash;and now, how can they take all this knowledge and continue to bring meaning to their lives in this next phase? Do they do it in nursing or another area?

The book explores areas such as healthy aging, being active, eating healthy food, finan&shy;cial management, spending time with family and friends, getting adequate sleep, and reducing stress. It also discusses how to decide on a good time to retire, whether to move or stay put, and about volunteer activities, as well as how to deal with the unexpected life challenges.

What inspired you to write on this subject? 

For me, I was 65, and when I enter new begin&shy;nings, I tend to talk with other people. Pat and I were sitting at her beach house on Cape Cod, and I said, “Pat, what do people really do in their next phase? And, what do nurses do?”

We started talking, and then I began to speak with other nurses. I lived in the Washington, DC, area for 42 years, and I didn’t know if I wanted to stay there or if I wanted to move. I didn’t know if I wanted to keep my house or rent it out. I wanted to travel and buy an RV, but I had never traveled in an RV. I met with a financial adviser, so I knew where I was financially. That’s when I realized how broad retirement was and how many oppor&shy;tunities I might consider.

I learned upon doing these interviews that most people weren’t even calling it retirement. They preferred “rewiring,” “repurposing,” “new begin&shy;ning,” or “transitioning.”

Of the 26 personal stories, did any related to oncology stand out to you? 

One nurse had spent a lot of time focused on plan&shy;ning retirement, but then she retired and received a cancer diagnosis. Her whole plan went out the window. The book examines how she dealt with it, replanned, and regrouped. Other nurses have experienced health challenges, and they also shared how they navigated the unexpected.

A section of the book is titled “The New Realities of Retirement.” What are those realities? 

Many people underestimate the number of oppor&shy;tunities available. Retirement is a time to focus on yourself, as well as family, friends, and the community. As nurses, we don’t do this.

Nurses should take a look at their health. Do they have chronic or genetic health problems now or that may be coming down the road?

As far as money, all the nurses interviewed said it’s crucial to talk with a financial adviser or someone knowledgeable in this area.

Regarding family, some nurses spent their retire&shy;ment taking care of their grandchildren or even a parent or friend who had health problems.

Where did the nurses you spoke with end up? 

Some continued in nursing but moved to part-time positions or taught classes and workshops. Some started new businesses. Other people decided they didn’t want to do anything related to nursing but wanted to volunteer. One nurse recommended that nurses “speed date” the orga&shy;nizations they are interested in. Once organiza&shy;tions know that nurses are willing to volunteer, everybody wants them.

If nurses want to do volunteer work, it’s best to figure out how much time they actually have available. Do they want to do ongoing work or specific projects? 

All the nurses agreed that they wanted to declutter, have less stress, and not overcommit themselves again. They all said that they have no concept of boredom and loved having the option to say no.

What nursing-related roles can be taken on in retirement? 

I have done medical missions in the Dominican Republic and Ecuador. There are a lot of inter&shy;national volunteering opportunities. Nurses also can stay local and participate on boards, mentor new graduates, talk with high school students about nursing, or speak at community colleges. In oncology, they can teach about healthcare and prevention, as well as lead workshops with dif&shy;ferent community organizations that focus on their expertise. They may also be interested in writing that could eventually be published in a local newspaper.

You mentioned earlier that nurses are used to putting others’ needs ahead of their own. Do you feel this makes the retirement transition more difficult? 

It’s more of a challenge that you don’t get over&shy;committed. All of us have been in positions where we easily put in 40, 60 hours a week. You can also do that in retirement with not much trouble.

Everyone said they love having choices. They can pick and choose what they want to do. Additionally, nurses we interviewed said they looked forward to sleeping in, no longer dealing with morning or night meetings, and not having to worry about shifts on holidays or weekends or even bad weather and staffing patterns.

We live in a world that is very fast-paced, so 1 of the challenges is learning to slow down. Retirement is the time to practice this.

What retirement advice would you offer a new nurse, and what would you tell one who is nearing the end of a career? 

When just starting out, the biggest item is finances. It’s good to meet with a financial adviser or someone who is astute about finance, so they can look at long-term goals. Those close to retirement should figure out how much money they will need 5, 10, 20 years out. It’s important to be knowledgeable about that.

Is there anything else that you would like to add?

The only thing that holds you back is your health, time, creativity, and money—otherwise, opportunities are wide open.

 Rdefining Retirement for Nurses: Finding Meaning in Retirement

Feature Story

A new book delves into re-creating life after leaving a traditional nursing job.

Nurses Find Meaning and Purpose After Retirement

Family caregiver satisfaction with end-of-life (EOL) care is key to better understanding patient EOL expe&shy;riences.

 In measuring family caregiver satisfaction, it is important to conceptualize what is considered a “good death” or “good dying process.”2 Understanding the bereaved family caregiver’s satisfaction can help lead to improved EOL care for patients.

 In particular, families of patients who die in their preferred location are more likely to be satisfied with EOL care provided.

Most people can identify the elements of their loved one’s experience of dying that were “satisfactory.” Often, these cen&shy;ter around using less-aggressive medical care and earlier hos&shy;pice referrals.

A longitudinal National Institutes of Health—funded study (NRO14856) conducted at the Frances Payne Bolton School of Nursing by Sara L. Douglas, PhD, RN, is examining aggres&shy;siveness of EOL care in advanced cancer among patients, fam&shy;ily caregivers, nurses, and physicians.

Approximately 2 months following the death of a loved one with advanced cancer, a phone interview is conducted with the bereaved family caregiver. The 13-item version of the Family Satisfaction with End-of-Life Care (FAMCARE-P13) scale asks the caregiver to rate responses to questions on symptom management, inclusion of family in treatment decisions, prognosis, healthcare provider (doctor and nurse) availability to the family, coordination of care, and overall satisfaction with care in the week preceding death.6 Family caregivers rate their level of satisfaction from “very satisfied” to “very dissatisfied.”

Additionally, 2 open-ended questions ask family caregivers to discuss (1) aspects of care that may have caused them to think it was time to stop cancer therapy and focus on com&shy;fort and (2) if the care and treatment received was consistent with their loved one’s wishes. An advantage of assessing fam&shy;ily caregiver satisfaction with EOL care both qualitatively and quantitatively is the ability to compare and relate both sets of data to gain a more accurate understanding of the caregiv&shy;er’s perspective,

 including grief and bereavement outcomes among family caregivers following death. Bereaved family caregivers openly share their thoughts, lending insight that can inform future oncologic EOL research to provide clini&shy;cal practice guidelines toward improving EOL experiences for patients and families.

Oncology nurses are well positioned to make significant impacts in EOL satisfaction in advanced cancer. Preparation is key to improving EOL care experiences for these patients and their families. Oncology nurses can encourage patients and families to have conversations about EOL wishes early on, including discussions about patient and family values,

 which are often shared and can influence EOL decision making.

Oncology nurses can answer EOL-related questions and refer patients and families to appropriate resources such as chaplaincy, social work, or counseling services as needs are identified at any point on the disease trajectory—and even after death for the bereaved family. In doing this, nurses can help empower patients and families to initiate such conversa&shy;tions with each other and with healthcare providers, as well as reduce anxiety. Research shows that patients who engage in EOL conversations with their physicians are more likely to receive care that is consistent with their wishes, which can reduce suffering near the EOL.

Encouraging patients and families to become comfortable with speaking about death can reduce psychological distress and bereavement and increase the likelihood that the med&shy;ical care provided will be consistent with the patient’s per&shy;sonal preferences.

Realizing one’s own mortality and how it can change outlook, perhaps even for the better, may also affect how caregivers plan for the end of their own lives.

In summary, the death of a loved one with cancer creates a void in the lives of family and friends left behind. One of the most salient memories in the minds of family caregivers involves the EOL experience of their loved one, followed by its impact on the grieving process. Future research should use oncology nurses, nurse researchers, and an interdisci&shy;plinary team to examine family caregiver satisfaction with EOL care provided, with bereavement outcomes measured over time. This will help identify specific areas that require more focus, with a goal of improving the EOL experiences for patients with advanced cancer and subsequently out&shy;comes with their families.  

is a postdoctoral fellow, Frances Payne Bolton School of Nursing Case Western Reserve University, in Cleveland, Ohio. 

is Arline H. & Curtis F. Garvin Professor and assistant dean for research, Frances Payne Bolton School of Nursing at Case Western Reserve University, Cleveland, Ohio.

Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life

. Washington, DC: The National Academies Press; 2015.

2. Miyashita M, Morita T, Sato K, et al. Good death inventory: a mea&shy;sure for evaluating good death from the bereaved family member’s per&shy;spective. 

. 2008;35(5):486-498. doi: 10.1016/ j.jpainsymman.2007.07.009.

3. Sadler E, Hales B, Henry B, et al. Factors affecting family satisfac&shy;tion with inpatient end-of-life care. 

. 2014;9(11):e110860. doi: 10.1371/journal.pone.0110860.

4. Wright AA, Zhang B, Ray A, et al. Associations between end-of-life dis&shy;cussions, patient mental health, medical care near death, and caregiver bereavement adjustment. 

. 2008;300(14):1665-1673. doi: 10. 1001/jama.300.14.1665.

5. Lipson AR, Douglas SL. Factors influencing care decisions for patients with advanced cancer. 

6. Beaumont C, Nekolaichuk C. FAMCARE and FAMCARE-2 guide&shy;lines. Edmonton Zone Palliative Care Program website. palliative.org/ NewPC/_pdfs/tools/FAMCARE%20Guidelines-15Aug12.pdf. Updated August 15, 2012. Accessed September 28, 2017.

Nursing Research: Generating and Assessing Evidence for Nursing Practice

. 9th ed. New York, NY: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2012.

8. Winter L. Patient values and preferences for end-of-life treatments: are values better predictors than a living will? 

. 2013;16(4):362- 368. doi: 10.1089/jpm.2012.0303.

9. Mack JW, Weeks JC, Wright AA, et al. End-of-life discussions, goal attainment, and distress at the end of life: predictors and out&shy;comes of receipt of care consistent with preferences. 

. 2010;28(7):1203-1208. doi: 10.1200/JCO.2009.25.4672.

10. National Cancer Institute. Planning the transition to end-of-life care in advanced cancer (PDQ)—health professional version. National Cancer Institute at the National Institutes of Health website. cancer.gov/ about-cancer/advanced-cancer/planning/end-of-life-hp-pdq. Updated March 1, 2017. Accessed September 28, 2017.

Partner Perspectives

Family caregiver satisfaction with end-of-life care is key to better understanding patient experiences.

Family Caregiver Satisfaction With End-of-Life Care Following Advanced Cancer

Playing favorites occurs in many aspects of life. Children often accuse their parents of it; in the workforce, a boss might be perceived as giving a better assignment to a certain worker over another. Favoritism, which is defined as favoring 1 person or group over others with equal claim, also exists in the medical field, with healthcare providers having favorite patients.

Favoritism can be conscious or unconscious behavior. It can breed resentment and negative feelings among patients and colleagues, and it may even be a form of discrimination.

The National Council of State Boards of Nursing identifies favoritism as an early warning sign of a boundary crossing. The concern is that some patients may be treated differently or better than others. Favoritism can be a sign of overinvolve&shy;ment and straying outside the “zone of helpfulness” of a thera&shy;peutic relationship.

Amanda, a 38-year-old onocology nurse,reflected back on her early years as an oncology research nurse and her favorite patient. Jane, a Baptist missionary, had metastatic melanoma and was participating in a phase I/II clinical trial. Her husband, Ron, had just finished treatment for renal cell carcinoma when she learned of her diagnosis. They had 5 adult children who lived all over the United States but nowhere near the treatment center.

“I instantly bonded with her,” Amanda recalled. “I could relate to her values and beliefs; in fact, we discovered we knew some of the same people at my church. I felt terrible that she had not recovered from her husband’s cancer only to find out she had cancer."

Although their children were supportive, this couple’s life was now in the Philippines as missionaries.

“I spent hours just sitting with her during stem cell collection for a research trial,” Amanda continued. “I found myself wanting to solve all her problems and continued to help her via email, even after she left the cancer center. I know I gave her preferential treatment and went outside my boundaries as a nurse."

Why nurses may like or dislike some patients, as well as how those feelings affect nursing care, has not received great atten&shy;tion in nursing literature. But a qualitative study conducted by researchers from the Johns Hopkins Bloomberg School of Public Health in Baltimore, Maryland, examined the physician—patient relationship. Many primary care physicians stated that although they try to treat all patients equally, favorites often receive extra or more timely care. One physician admitted that favorite patients “probably hear back more rapidly than less favorite patients.” That mind-set can be picked up by a patient who then tries to become a “favorite” to get better treatment.

Long before I learned about professional boundaries, I fell prey to this thinking, too. For instance, when my family members were in the hospital, I always made sure they had a bowl full of candy to offer staff.

What factors may cause us to favor—or want to avoid&mdash;some patients more than others? Below are some that I explored:

First, nurses must acknowledge that they are simply going to like and dislike some patients. It’s human nature. Patients who have an engaging, captivating person&shy;ality or hold similar values or beliefs may be easier to like or relate to.

When nurses see a need, they try to meet it. Often, nurses act without thinking about downstream effects.

Nurses can feel close to patients, especially those who are very sick or whom they have known for a long time. That patient often becomes one of the favorites.

This psychological term describes how past feelings, conflicts, and attitudes can affect present relation&shy;ships, situations, and circumstances. For example, a patient who sees a nurse more as a nurturing mother or father figure can become less independent or even childlike. This may cause a nurse to treat that patient differently or do more for them.

 With this form of transference, the nurse’s reaction to a patient may affect care. A patient may remind the nurse of a favorite uncle or crit&shy;ical father, which can positively or nega&shy;tively affect the care a patient receives.

This label often describes a patient who is considered challenging or high maintenance—someone who is angry, nonadherent, demanding, never satisfied, or highly critical. Difficult patients may cause nurses to feel ineffective or incompe&shy;tent, frustrated, or even exasperated. Nurses may start to distance them&shy;selves or become underinvolved, which is also considered a boundary crossing because it is outside the “zone of helpfulness.”

A patient who is considered easy (eg, is especially nice, has good veins, requires simple treatment, or expresses gratitude) tends to become a favorite. Nurses may find themselves wanting to be associated with those kinds of patients, spending more time with them or doing favors for them.

Some nurses may at some point err on the side of being overly invested with certain patients, perhaps early on in their career (like Amanda). It is important to remember that this naturally occurs in human bonding. Anne Devine, MA, BSN, a nurse turned writer, wrote about this subject, stating, “Sometimes nurses sense a connection with a patient that we don’t fully understand in the moment.” Although she tried to make every patient feel special, she said, some became her favorites.

Oncology nurses should realize that they are not alone in their quest for the perfect balance of nurturing/caring and professionalism. They have a responsibility to ensure that all patients with cancer receive the same quality of care. With an emphasis on cancer disparity, it is even more important to be aware of favoritism and its impact. Nurses who do so will be better equipped to stay inside the boundary lines.

Professionally Speaking

Patient favoritism crosses boundaries. Why do nurses often breach this professional barrier?

Raising a Red Flag: Patient Favoritism

I recall asking my mother’s oncologist in 1997, when 

gene testing was still in its infancy, about the possibility of testing her blood for this genetic mutation or freezing and storing her blood for future analysis. My mother was dying from recurrent metastatic breast cancer and, 5 years ear&shy;lier, had been treated for primary ovarian cancer. As a fam&shy;ily nurse practitioner, I was not only interested in this new testing for the sake of science but also personally concerned that my older sister, brother, and I might have inherited an increased risk of cancer associated with this genetic anomaly. My inquiry was dismissed with the nonchalant response that 

testing was just “too new to worry about right now.” In retrospect, a definitive result for my mother back then would have guided future healthcare recommendations for us.

After recently viewing the 2015 documentary 

, I began to question why I had not sought genetic testing for the last 20 years. 

gene mutations but also powerfully highlights the personal stories of both women and men with positive mutations, depicting their subse&shy;quent journeys, including treatment, restoration, remission, or death. The documentary advocates that “knowledge is power” and speaks passionately about the need for increased awareness of genetic testing and breast cancer prevention.

is to raise awareness of male breast cancer. Despite the overwhelming “pinkness” of the breast cancer world, men inherit 

mutations as fre&shy;quently as women do. Regardless of gender, a parent with an inherited mutation has a 50% chance of passing it on to each of their offspring, whether the baby is a girl or boy.1 It struck me that if I were 

-positive, even my son could have a genetic mutation that might be transmitted to his children someday.

Up to 10% of all breast cancers may be linked to genetic mutations, with 

genetic anomaly may have up to an 80% lifetime risk of developing breast cancer, as well as ovarian, colon, skin, and pancreatic cancers. Although breast cancer is rare in men, the American Cancer Society estimated that about 2470 new cases of male invasive breast cancer were diagnosed in 2017 and that about 460 men would die from the disease.

 The average lifetime risk of breast cancer in men is about 1 in 1000 (0.1%) compared with 1 in 8 (about 12%) for women. A man with an abnormal 

2 gene has a life&shy;time breast cancer risk of about 8%, 80 times greater than that of the average man without a genetic mutation, and is 7 times more likely to develop prostate cancer than men without an abnormal gene.

 Although survival rates are simi&shy;lar for men and women with the same stage of breast cancer, men are often diagnosed at a later stage. This is often because men did not report early symptoms and/or the cancer spread to adjacent structures due to less breast tissue.

 Healthcare providers routinely document medical histories and cancer risk of their patients, but many do not always refer high-risk patients, including men, for genetic counseling or testing.

Genetic counseling and subsequent testing require serious consideration. Some individuals may not wish to have addi&shy;tional medical testing or recommended prophylactic sur&shy;gery if faced with the knowledge of a positive result. Because genetic mutations affect all biological relatives, there may be emotional tension and fear within the family, factoring into decisions regarding marriage, childbearing, and career choices. Fear, hesitation, and doubt abound in the areas of employment discrimination; potentially higher health, life, and mortgage insurance rates; test reliability; and financial coverage for genetic testing. Individuals who may have posi&shy;tive genetic mutations might also experience feelings of guilt and loss of control. However, the federal Genetic Information Nondiscrimination Act of 2008, along with many state laws, prohibits discrimination based on genetic information in rela&shy;tion to health insurance and employment, although it does not cover life insurance, disability insurance, or long-term care insurance.

, many online resources address cancer risk. A risk calculator on Bright Pink, a national nonprofit organization (BrightPink.org), quickly pro&shy;vides information regarding the user’s chances of developing breast or ovarian cancer. The Male Breast Cancer Coalition, a nonprofit organization, reminds the public that “men have breasts, too” and offers a related series (HISbreastcancer.org). Both organizations add blue to the traditional pink ribbon to recognize breast cancer in both genders.

Today, I am bold enough to pursue genetic counseling and testing for not only 

but also the comprehensive 34-gene panel that may identify my risk of as many as 8 dif&shy;ferent cancers. My decision was based on neither my own 25 years’ experience and medical knowledge as a nurse prac&shy;titioner nor my healthcare providers’ prompting. It was made after I viewed 

and heard the powerful stories of people whose lives were positively changed by knowledge of their genetics. By taking the nonthreatening approach of consulting a genetic counselor, plus the simple act of sending out a freshly collected 1-cc sample of saliva, I will affect not only my health but also the well-being of my daughters, son, and grandchildren.

Some high-risk individuals might also be stirred to action by modalities such as film, social media, websites, and blogs. But why is it that we as healthcare providers do not consistently promote awareness of breast cancer risk to both women and men, as well as genetic counseling referral (when indicated) to our patients? When taking the family medical history, we all can address breast cancer risk, symptom recognition, and pre&shy;vention. A caring, sensitive attitude is crucial to dispel myths and alleviate fears, especially those of a man who may feel emasculated by talk of self-breast exam, areolar masses, and nipple discharge. When indicated, providers must encourage patients with multiple breast cancer risk factors, regardless of gender, to consider genetic counseling and/or 

testing. For those who opt for testing, the results, whether negative or positive, not only deliver the power of knowledge but also afford healthcare providers the ability to make better manage&shy;ment and treatment decisions.

 DNP, RN, CRNP, FNP-BC, is the director of graduate clinical faculty and clinical affairs at Duquesne University School of Nursing in Pittsburgh, PA.

1. Senapathy K. “Pink & Blue” documentary challenges female only myths about breast cancer and BRCA mutations. Genetic Literacy Project website. geneticliteracyproject.org/2015/06/08/pink-blue-documentary-challenges-female-only-myths-about-breast-cancer-and-brca-mutations. Published June 8, 2015. September 17, 2017.

2. U.S. Breast Cancer Statistics. BreastCancer.org website. breastcancer.org/symptoms/understand_bc/statistics. Modified January 9, 2018. Accessed September 15, 2017.

3. Siegel RL, Miller KD, Jemal A. Cancer statistics, 2017. 

. 2017;67(1):7-30. doi: 10.3322/caac.21387.

5. Can breast cancer in men be found early? ACS website. 

cancer.org/cancer/breast-cancer-in-men/detection-diagnosis-staging/detection.html

: cancer risk and genetic testing. National Cancer Institute website. 

cancer.gov/about-cancer/causes-prevention/genetics/brca-fact-sheet

. Updated April 1, 2015. Accessed September 20, 2017.

By taking the nonthreatening approach of consulting a genetic counselor, plus the simple act of sending out a freshly collected 1-cc sample of saliva, I will affect not only my health but also the well-being of my daughters, son, and grandchildren.

Promoting BRCA Awareness

In the United States, 38.5% of men and women will receive a cancer diagnosis at some point.

 Many of these patients will suffer in silence with sexual and fertility problems because of the stigma associated with them. Patients wait for their trusted healthcare professionals to bring up the subject, which often doesn’t happen. A study by Park et al found that 62% of internists working with patients with cancer never or rarely address sexual issues.

Patients need to know that it is OK to ask about and address sexual health issues. 

Findings from several studies show that sexual issues are common among many patients. For instance, in a Livestrong Foundation study, investigators determined that sexual dysfunction was among the top 3 physical concerns reported by 43% of the men and women with cancer.

Cancer treatment can affect sex and intimacy in terms of functional changes, physical disfigurement, and/or alterations in relationship dynamics with partners. Sexual dysfunction can involve loss of sexual desire, lack of arousal, and/or orgasm problems in both genders. For women, it could also involve pain with sex, lack of lubrication and vaginal dryness, atrophy, and/or stenosis. Specific issues for men include erectile dysfunction (ED), ejaculatory dysfunction, and/or hypogonadism (low testosterone accompanied by symptoms).

Treatments involving surgery, chemotherapy, and radiation can affect reproductive organs, leading to sexual dysfunction or infertility. Chemotherapy, specifically, can alter hormones such as estrogen and testosterone, leading to a multitude of sexual problems, including decreased desire, dryness, pain with penetration, or ED.

Although fertility may not be a concern for all patients, assumptions should be put aside and fertility information should be addressed and offered to anyone who might be interested in childbearing. In a study of 3129 patients with cancer, fertility was a concern for about 60%, of whom 70% said they did not receive information about options for preserving fertility.

 Cancers, such as prostate, colon, testicular, ovarian, uterine, and cervical, often occur in the pelvic area, which contains the reproductive organs—ovaries, uterus, fallopian tubes, testicles, and prostate. Surgical excision of or radiation therapy to these organs can lead to infertility.

			The American Cancer Society resource discusses sexual feelings and attitudes during cancer, as well as fertility. Within this page, additional online resources are listed for specific needs of men and women.

			Targeted to women with breast cancer, MiddlesexMD provides sexual health information and products that can help women of any age

			The National Cancer Institute gives an overview of treatments and the sexual health issues they may cause, as well as ways to manage them.

			The free online book is a guide for men and their partners following a cancer diagnosis. It is written by Jeffrey Albaugh, PhD, APRN, CUCNS.

As patients perceive sexual dysfunction as a problem—a bother&mdash;they often feel embarrassment and shame that negatively affect quality of life.

 However, healthcare professionals can help prevent that by taking immediate actions following a patient’s cancer diagnosis. For instance, patients should receive pamphlets and other educational materials about sexual health and fertility issues—they all will need this information. Most important, let patients know that sexual issues are not uncommon, and resources are available to help them understand and address the problems. Simply normalizing the situation opens the door for further discussion or information seeking.

Treatment of fertility and sexual problems is directed and driven by the patient’s goals and desires. Because sexual dysfunction is multifactorial, assessment and treatment can be time intensive and complex. Referral to an appropriate trained expert, such as through the 

American Society of Sexual Educators, Counselors and Therapists

, is significant, but the most critical step is to let patients know that they are not alone and there are treatment options.

For many women with cancer, vaginal dryness occurs. Treatment may include local intravaginal estrogen therapy, nonhormonal moisturizers used regularly, hyaluronic acid, ospemifene, and/or lubricants to reduce friction during sex.

 Penetrative pain also can be related to pelvic floor muscle hypertonicity or stenosis. This can be treated with pelvic floor physical therapy, vaginal dilators, and intravaginal muscle relaxants.

ED is an adverse effect seen in men following cancer treatment but can be treated with phosphodiesterase type 5 inhibitors—eg, sildenafil (Viagra), vardenafil (Levitra), and tadalafil (Cialis)&mdash;a vacuum constriction device, intraurethral suppository, intracavernosal injections, or a penile implant.

 Premature ejaculation can be treated with cognitive behavioral therapies (eg, stop/start, positioning, and squeeze technique), layered condoms to decrease sensation, desensitizing sprays or gels, and/or off-label use of antidepressants.

 Hypogonadism in men involves a low testosterone blood level combined with symptoms such as decreased sex drive, energy, or mood; fatty weight gain; and decreased ability to concentrate. The syndrome is typically treated with testosterone (eg, transdermal or buccal patch, injection, pellets, or nasal spray). Because testosterone is a steroid, proceeding with such therapy after cancer diagnosis and treatment may be controversial and even contraindicated—specifically in the case of prostate cancer, because steroids may increase or contribute to cancer growth. Experts in replacement therapy should handle this with care and caution, collaborating with the oncology team.

Diminished ability to climax affects both men and women. Identifying and resolving the underlying cause, such as use of antidepressants and/or pain medications, can improve the ability to orgasm. In some cases, consulting a sex therapist and/or adding vibration to stimulation may help a patient orgasm.

Sexual issues often involve a psychogenic component, which can negatively affect intimacy and sexual encounters. Concerns about ED or pain during penetration, for example, can affect self-confidence, self-esteem, and quality of life. It may be beneficial for men and women to address body image issues, function loss, or relationship problems through sex or relationship therapy.

In terms of fertility, it is critical that patients are offered the option of retrieving and preserving gametes prior to cancer treatment that may permanently compromise their ability to produce their own sperm or oocytes (eggs). Some treatments, such as chemotherapy and radiation, may temporarily halt sperm or egg production. Removal of the sex organs, which produce gametes, may permanently impair a patient’s ability to bear children. Although cancers of the reproductive system would more likely lead to infertility issues, chemotherapy for other types of cancers may also affect the hormonal system and possibly lead to infertility. All these factors must be considered.

One option is cryopreservation of sperm or oocytes, which requires planning on the patient’s part. Men who have reached puberty can donate sperm (ideally, several samples, not just 1) prior to cancer treatment. Assistive methods for ejaculation can also be engaged when needed for sperm extraction. If sperm donation is not an option or a male has not reached puberty, testicular gonadal tissue can be cryopreserved. Women can preserve oocytes or embryos, which requires 10 days of ovarian stimulation with gonadotropins, followed by transvaginal needle aspiration of mature oocytes while under sedation. The challenging thing about preserving embryos is that women must choose a sperm donor to fertilize the egg before cryopreservation. Ovarian tissue also can be cryopreserved. Assistive reproductive methods can also be helpful, including insemination and in vitro fertilization; other, more advanced implantation options continue to become available.

Sexuality is a vital part of the human experience. Therefore, identifying and helping patients address fertility and sexual issues is an essential part of cancer care. Oncology nurses can be on the front line of providing information about sexual dysfunction, which should be available to patients before, during, and after treatment. Empowering patients with information about fertility and sexual dysfunction treatment options allows men and women to make their own informed decisions about treatment. As cancer survival rates increase and patients live longer, addressing long-term adverse effects such as sexual dysfunction becomes increasingly paramount. That can be as simple as providing a list of some of the excellent resources available or letting the patient know that sexual issues are common after cancer.

1. Howlader N, Noone AM, Krapcho M, et al, eds. SEER cancer statistics review (CSR) 1975-2014. Surveillance, Epidemiology, and End Results Program website. 

. Published April 2017. Updated June 28, 2017. December 23, 2017.

2. Park ER, Bober SL, Campbell EG, Recklitis CJ, Kutner JS, Diller L. General internist communication about sexual function with cancer survivors. 

 2009;24(suppl 2):S407-411. doi: 10.1007/s11606-009-1026-5.

3. Rechis R, Reynolds KA, Beckjord EB, Nutt S. “I learned to live with it” is not good enough: challenges reported by post-treatment cancer survivors in the LIVESTRONG surveys. LIVESTRONG website. d1un1nybq8gi3x.cloudfront.net/sites/default/files/what-we-do/reports/LSSurvivorSurveyReport_final_0.pdf. Published May 2011. December 28, 2017.

4. Penson DF, Feng Z, Kuniyuki, et al. General quality of life 2 years following treatment for prostate cancer: what influences outcomes? Results from the prostate cancer outcomes study. 

 2003;21(6):1147-1154. doi: 10.1200/JCO.2003.07.139.

5. Carter J, Stabile C, Gunn A, Sonoda Y. The physical consequences of gynecologic cancer surgery and their impact on sexual, emotional, and quality of life issues. 

 2013;10(suppl 1):24-34. doi: 10.1111/jsm.12002.

6. Ye S, Yang J, Cao D, Lang J, Shen K. A systematic review of quality of life and sexual function of patients with cervical cancer after treatment. 

2014;24(7):1146-1157. doi: 10.1097/IGC.0000000000000207.

A sexual health expert and oncology nurse hopes to empower patients to make informed decisions.

March 2018