Hematology and oncology fellowship programs devote very little time to learning how to properly address patients’ sexual and reproductive health concerns, according to a recent survey of program directors.
Jennifer Barsky Reese, PhD, the survey’s lead author and associate professor in the Cancer Prevention and Control Program at Fox Chase Cancer Center in Philadelphia, said that the lack of training is a significant oversight, especially because many cancer treatments cause sexual dysfunction and infertility. Patients also experience emotional and interpersonal distress as a result of the cancer itself and from oncologic therapies, the authors explain in JCO Oncology Practice.
Dr. Reese told OBR that years of her own research have shown that discussions about sexual health and function are frequently absent from clinical encounters in cancer care, even though those issues are “common and distressing, and also persistent for many patients.”
Less Than an Hour of Training Common
The survey was undertaken to help identify barriers preventing the addition of such training in the fellowship curriculum and to inform what an ideal training program might look like, Dr. Reese explained.
She and her colleagues sent the survey to all 176 hematology-oncology fellowship programs in the United States. Of the 114 program directors who responded, one did not fully complete the survey. The authors thus ultimately analyzed responses from 113 programs.
Most programs (86; 75%) offered some formal training about fertility over the course of the three-year fellowship, although it was usually less than one hour. Although 30 programs reported having zero hours of fertility-related training in year one, another 30 programs offered more than one hour, 17 offered more than an hour of such training in year two, and 14 had more than an hour in year three. The most-discussed topic was the effect of ongoing cancer treatment on women’s fertility. Fertility after treatment was the least commonly included topic.
More than half (53%) of program directors reported having zero hours of formal training in sexual health in year one. That number increased to 58% (66 programs) in year two and 65% (73 programs) in year three.
Almost half of programs (56; 49%) offered training on topics such as the effect of cancer treatment on male and female sexual health, but usually for less than an hour. Fewer programs offered any training on body image and distress or dating and sexual relationships.
Slightly more than a third (42 programs; 37%) offered training on safe sex practices, again generally less than an hour in a given year. The most common topics were use of contraception while receiving treatment and education about sexually transmitted infections.
Finding Space for Sexual Health Training
Dr. Reese said that she was not surprised by the lack of formal training. Neither was Gerald Hsu, MD, associate clinical professor of medicine and director of the Hematology/Oncology Fellowship Program at the University of California San Francisco.
“I think I was one of the program directors who said that we do provide some training on fertility counseling, but not in the other aspects of sexual and reproductive health,” Dr. Hsu said.
Despite the findings, Dr. Hsu is not convinced that sexual and reproductive health should be a formal part of fellowship training in the specialty. “I think we’re wrong to assume that all the education, everything that you need to be a competent oncologist, has to happen during fellowship,” he said. “What we really want to develop in fellowship are habits, a desire to learn what you don’t know, and the skills to adapt to a changing landscape.”
The survey found that the biggest barrier to including training was a lack of experts to teach the topic. Program directors also cited a lack of requirement or expectation for including the content. Dr. Reese pointed out that the American Society for Clinical Oncology and the National Comprehensive Cancer Network recommend that oncologists address patients’ sexual health concerns.
“There is a consensus now that it’s up to providers, oncologists specifically, who are treating patients, that they need to discuss potential sexual side effects of the treatments that they are prescribing to their patients,” said Dr. Reese.
“No one expects oncologists to become experts in sexual health or in sex therapy,” she said. The idea is to give patients permission to discuss the topic and open the door to referrals.
Addressing the issue may be challenging. “Because time is so valuable in fellowship training, whatever we’re putting into that curriculum, I really want to know is going to be high yield,” said Dr. Hsu. It would be important to first assess patients’ needs and desires and then design an educational intervention that might help fellows develop skills, he explained.
Still, reliance on clinical encounters for training about sexual health may be problematic, Dr. Reese suggested. “Many attendings themselves don’t bring up the topic of sexual health with their patients,” she said. “So it’s idiosyncratic at best and at worst there’s the real potential that fellows leave without ever having discussed sexual health with their patients.”
Dr. Hsu disagreed. “Clinical encounters drive a lot of our meaningful learning,” he said, adding that it lets fellows connect to what they’ve been reading or hearing in lectures. He also suggested that fellows will study topics of interest on their own and that “self-directed, unstructured learning is perhaps just, or even more, important than structured didactic teaching.”
Dr. Reese has applied for a National Cancer Institute grant to develop and pilot a training module on sexual and reproductive health for hematology-oncology fellows. Her application received a perfect score, which she said is an indicator of how the agency views the importance of the topic.
“I think there are still big taboos with discussing sex in a candid and open manner in this society,” said Dr. Reese. “We’d like to intervene early in the professional careers of these young clinicians so that they can start their practices with this being just another aspect of health they talk about.”
Dr. Reese and Dr. Hsu reported no relevant financial relationships.
