Sexual Health Tool Kit for Breast and Gynecologic Oncology Providers

Cancer impacts quality of life during and after treatment, and sexual dysfunction is a common, often untreated, side-effect for women diagnosed with breast and gynecologic cancer. Many women are not aware of sexual side effects until after treatment and into survivorship, have unfulfilled sexual health needs, and would prefer their provider initiate conversations. The goal of this quality improvement (QI) project was to increase provider and staff comfortability surrounding sexual health discussions with cancer patients and to create a beneficial toolkit to facilitate discussions surrounding sexual health changes. A local women's health outpatient oncology clinic in Salt Lake City, Utah, lacked adequate resources to facilitate conversations about sexual health changes between patients, providers and staff, and the clinic was not providing adequate sexual health education to patients. A pre-implementation survey and short discussion were used to gather and evaluate participants demographics, baseline knowledge, behaviors, and comfort regarding sexual health discussions. A sexual health toolkit was created from evidence-based resources and pre- survey/discussion results. A short educational session introduced the participants to the sexual health toolkit, and implementation was reviewed weekly, allowing for rapid change. A post- implementation survey, which evaluated the feasibility, usability, and satisfaction of the toolkit, was distributed. Descriptive statistics were used to analyze qualitative and quantitative data, paired T tests were used to compare continuous data, and ordinal data was compared using the Wilcoxon matched paired test. A two-sided p-value <0.05 was considered significant. A sexual health toolkit, based on pre-survey results, was created and implemented. The toolkit was adapted from evidence-based online resources, which addressed IMPLEMENTATION OF SEXUAL HEALTH TOOLKIT the most frequently asked questions, and was created for staff to facilitate discussions in clinic with patients. The survey was sent to thirty-two participants. Eleven (34.4%) participants completed the pre-survey, and 12 (37.5%) participants took the post-survey, of which eight (25.0%) completed both. Comfortability improved post-toolkit implementation, and participants indicated high usability and satisfaction with the implementation of a sexual health toolkit. One hundred percent of participants (n=12) strongly agreed or agreed that the toolkit improved female sexual health knowledge and felt it was a useful tool. Eleven participants (91.7%) strongly agree or agree that they would continue to use the sexual health toolkit with their patients. Participants reported adequate knowledge regarding sexual health for breast and gynecologic cancer patients both pre- and post-implementation but did not always discuss these topics with patients. Though not statistically significant, there was an improvement in participant comfort discussing sexual health topics with patients. Almost all participants found the toolkit a useful patient education tool, and all stated they will continue to use the toolkit. Overall, the sexual health toolkit was beneficial for healthcare staff in discussing sexual health changes with patients.

IMPLEMENTATION OF SEXUAL HEALTH TOOLKIT Implementation of a Sexual Health Toolkit for Breast and Gynecologic Oncology Providers: A Quality Improvement Project Kristianna B. Kundrat and Diane Chapman College of Nursing: The University of Utah NURS 7703: DNP Scholarly Project III April 14th, 2024 1 IMPLEMENTATION OF SEXUAL HEALTH TOOLKIT 2 Abstract Background: Cancer impacts quality of life during and after treatment, and sexual dysfunction is a common, often untreated, side-effect for women diagnosed with breast and gynecologic cancer. Many women are not aware of sexual side effects until after treatment and into survivorship, have unfulfilled sexual health needs, and would prefer their provider initiate conversations. The goal of this quality improvement (QI) project was to increase provider and staff comfortability surrounding sexual health discussions with cancer patients and to create a beneficial toolkit to facilitate discussions surrounding sexual health changes. Local Problem: A local women’s health outpatient oncology clinic in Salt Lake City, Utah, lacked adequate resources to facilitate conversations about sexual health changes between patients, providers and staff, and the clinic was not providing adequate sexual health education to patients. Methods: A pre-implementation survey and short discussion were used to gather and evaluate participants demographics, baseline knowledge, behaviors, and comfort regarding sexual health discussions. A sexual health toolkit was created from evidence-based resources and presurvey/discussion results. A short educational session introduced the participants to the sexual health toolkit, and implementation was reviewed weekly, allowing for rapid change. A postimplementation survey, which evaluated the feasibility, usability, and satisfaction of the toolkit, was distributed. Descriptive statistics were used to analyze qualitative and quantitative data, paired T tests were used to compare continuous data, and ordinal data was compared using the Wilcoxon matched paired test. A two-sided p-value <0.05 was considered significant. Interventions: A sexual health toolkit, based on pre-survey results, was created and implemented. The toolkit was adapted from evidence-based online resources, which addressed IMPLEMENTATION OF SEXUAL HEALTH TOOLKIT 3 the most frequently asked questions, and was created for staff to facilitate discussions in clinic with patients. Results: The survey was sent to thirty-two participants. Eleven (34.4%) participants completed the pre-survey, and 12 (37.5%) participants took the post-survey, of which eight (25.0%) completed both. Comfortability improved post-toolkit implementation, and participants indicated high usability and satisfaction with the implementation of a sexual health toolkit. One hundred percent of participants (n=12) strongly agreed or agreed that the toolkit improved female sexual health knowledge and felt it was a useful tool. Eleven participants (91.7%) strongly agree or agree that they would continue to use the sexual health toolkit with their patients. Conclusion: Participants reported adequate knowledge regarding sexual health for breast and gynecologic cancer patients both pre- and post-implementation but did not always discuss these topics with patients. Though not statistically significant, there was an improvement in participant comfort discussing sexual health topics with patients. Almost all participants found the toolkit a useful patient education tool, and all stated they will continue to use the toolkit. Overall, the sexual health toolkit was beneficial for healthcare staff in discussing sexual health changes with patients. Keywords: breast cancer, gynecologic cancer, sexual health education, sexual health toolkit IMPLEMENTATION OF SEXUAL HEALTH TOOLKIT 4 Introduction Problem Description Cancer has been shown to affect quality of life during treatment and into survivorship (Albers et al., 2020; Chang et al., 2023; Huynh et al., 2022; Pup et al., 2019). In women diagnosed with breast and gynecologic cancer, sexual dysfunction is a common effect of cancer, but is underdiagnosed and undertreated (Pup et al., 2019). Patients can experience low libido, lack of interest in sexual activity, vaginal dryness, pain during intercourse, and vaginal stenosis (Huynh et al.,2022; Pizetta et al., 2022). Many women are not aware that these side effects are related to their cancer until after treatment and feel embarrassed broaching these topics if providers do not acknowledge or inquire about sexual dysfunction (Chen et al., 2021; Reese et al., 2023). With increasing cancer survival rates, quality of life is an important clinical issue for women diagnosed with cancer, especially gynecological or breast cancer (Seaborne et al., 2021). Providers are aware of sexual health concerns and have a desire to discuss these with patients but face several barriers, such as cultural differences, discomfort, lack of knowledge/training, burnout, lack of time, patient age, and patient prognosis (Gong et al., 2021; Krouwel et al., 2020; Rath et al., 2015; Wazqar, 2020). Female cancer patients in Utah have access to advanced therapies and collaborative treatment teams, with many skilled providers and resources throughout Salt Lake City. A cohort study was performed in Utah looking at breast cancer survivors diagnosed between 1997 and 2017 through the Utah Cancer Registry and found that there were 19,709 breast cancer survivors compared with 93,389 cancer-free women (Chang et al., 2023). Sexual dysfunction was identified through International Classification of Diseases (ICD) codes from electronic health records. It was observed that breast cancer survivors were at 1.60-fold higher risk of sexual IMPLEMENTATION OF SEXUAL HEALTH TOOLKIT 5 dysfunction compared to the general population (Chang et al., 2023). This risk increased 2.05fold one to five years after cancer diagnosis and 3.05-fold in individuals with a cancer diagnosis younger than 50 years old (Chang et al., 2023). Despite being such a common issue, research found that it was rarely discussed. In fact, sexual health in cancer patients and survivors was discussed less than 25% of the time and few patients received help on sexual health topics from a health professional (Chang et al., 2023). Providers often believe that patients will bring this topic up if there are issues; however, this is a misconception, as patients fear their concerns will be dismissed, providers will have a lack of comfort with the topic, or there will be limited treatment options (Chen et al., 2021; Reese et al., 2023; Chang et al., 2023). In order to understand this problem at the local site, the project lead had informal discussions with staff and patients at the clinic regarding the lack of resources available to both providers and patients. Prior to this quality improvement (QI) project, there was only one webpage and two relevant patient information handouts available at the outpatient site for this project. The first handout focused on different lubrication methods, and the second was on birth control methods and when to resume intercourse post-treatment. None of the available information directly focused on sexual health as a cancer patient or survivor. The general lack of sexual health resources available to the patients at this clinic, combined with a clear body of evidence that supports the provision of sexual health education to breast and gynecologic cancer patients, reinforced the need for a sexual health toolkit for providers and staff at this practice. Available Knowledge Many patients believe providers should initiate a conversation regarding sexual health. One study found that 74% of patients and survivors felt sexual health was essential, but only 29% received such education (Flynn et al., 2012; Stabile et al., 2017). Due to time constraints, IMPLEMENTATION OF SEXUAL HEALTH TOOLKIT 6 busy clinic days, lack of knowledge or resources, and embarrassment, sexual and vaginal health are often disregarded (Flynn et al., 2012; Gong et al., 2021; Krouwel et al., 2020; Rath et al., 2015; Stabile et al., 2017; Wazqar, 2020). A cross-sectional study surveyed 150 providers from a teaching hospital that provided cancer and palliative care and found that only 32.7% (n = 49) of the participants had received sexual health education, and most of the education was through self-study (Wazqar, 2020). Wang et. al (2015) demonstrated that a brief, targeted sexual health training can improve provider comfort and frequency of addressing female-cancer-related sexual health issues. Targeted sexual health training led to 85% of participants acknowledging that women with cancer were interested in sexual health education (Wang et al. 2015; Winterling et al., 2020). Some sexual health interventions and programs have received positive reviews from participants. For example, 95% of women who participated in the Women's Integrative Sexual Health (WISH) program in Wisconsin recommended the program to other cancer survivors experiencing quality of life issues related to sexual health dysfunction (Seaborne et al., 2021). Rationale The Institute for Healthcare Improvement (IHI) Model guided this QI project. The IHI model looks at processes and is used to help accelerate and improve progress. The IHI model incorporates three questions and the Plan-Do-Study-Act (PDSA) cycle, and gathers feedback throughout the intervention, allowing for rapid changes throughout the implementation phase. The first step in the IHI Model is creating a team, and the team for this project included the breast and gynecologic oncology providers, clinic managers, registered nurses, medical assistants, patient coordinators, content expert, and the clinic sponsor who served as a liaison to clinic management. The aim was to improve breast and gynecologic oncology providers' knowledge and comfort in discussing sexual health topics with patients within three months of IMPLEMENTATION OF SEXUAL HEALTH TOOLKIT 7 implementing a sexual health toolkit. This project used the PDSA cycle, and included planning, trying, adjusting, and data analysis throughout the project. The project lead evaluated the project for changes, missed opportunities, and recommendations for improvement. The information gleaned from this QI project might help expand implementation on a larger scale throughout the cancer hospital associated with this outpatient clinic. Specific Aims The purpose of this Doctor of Nursing Practice (DNP) QI project was to assess the feasibility, usability, and satisfaction of an evidence-based Sexual Health Toolkit for providers who were caring for female cancer patients and survivors over the age of 18. Methods Context This QI project was implemented at an outpatient women's health cancer clinic within a local urban cancer hospital in Salt Lake City, Utah, which is also a teaching and research hospital. The clinic primarily cares for a female patient population older than 18 years with a diagnosis of breast or gynecologic cancer and also sees patients for genetics and plastic surgery. The study participants included physicians, physician assistants, nurse practitioners, registered nurses, medical assistants, patient coordinators, and licensed clinical social workers who worked with the breast and gynecologic cancer teams. Interventions Phase 1 of this QI project included discussions regarding the need for a sexual health toolkit and provider education on best practices for using the toolkit. A pre-intervention survey assessed baseline knowledge, practices, barriers, preferred resources, and comfort in discussing sexual health topics. IMPLEMENTATION OF SEXUAL HEALTH TOOLKIT 8 Phase 2 focused on developing the sexual health toolkit, which was based on information from the pre-survey, and included a sexual health brochure and an in-service education session to support adoption of the toolkit. The brochure was used as a resource for patients as well as a tool to facilitate provider communication. It was designed in a question-and-answer format, and addressed common patient concerns regarding sexual health changes. The main topics covered in the brochure included vaginal dryness, menopause symptoms, painful intercourse, side effects from radiation or chemotherapy, fertility, and body changes. Phase 3 assessed the toolkit's feasibility, usability, and satisfaction. Throughout implementation, the project lead met with participants weekly to collect feedback and determine if any rapid changes were necessary to the toolkit or implementation practice. A postintervention survey, which assessed provider satisfaction with the toolkit, was developed and distributed to participants, and data was analyzed using pre-and-post implementation survey results and feedback from participants. Study of the Intervention(s) The approach chosen for assessing the impact of the intervention was comparing the comfort and knowledge between pre- and post-intervention surveys. The pre-intervention data in phase 1 was used to aid in the development of an evidence-based toolkit, as well as assess baseline knowledge and comfort of participants. Phase 1 pre-intervention data was compared with phase 3 post-intervention survey results to determine if the sexual health toolkit led to an increase in provider comfort in discussing sexual health with patients. Additionally, charts were reviewed weekly for 11 weeks after implementation to monitor the frequency of toolkit use and need for any rapid changes. The pre-survey (Appendix A) was administered after a short learning session via zoom and was sent by e-mail to participants of the zoom educational session. IMPLEMENTATION OF SEXUAL HEALTH TOOLKIT 9 Additionally, there were monthly informal meetings with key stakeholders to evaluate the feasibility, usability, and satisfaction of the toolkit and address any suggestions for improvement. Content analysis was used to analyze informal qualitative data collected frequently and identify common barriers and suggestions for improvement while using the toolkit. Changes were made to the toolkit after informal input from participants (e.g. adding additional lubricant options, changing the text color to improve readability, changing the format of the toolkit to a sheet rather than a brochure, and providing additional copies of the toolkit due to frequency of use). While some questions on the pre-and-post surveys were the same, the pre-survey had questions that addressed baseline knowledge, and the post-survey had questions that addressed feasibility, usability, and satisfaction of the sexual health toolkit. Change in comfort was also assessed in the post-intervention survey (Appendix B). The expected outcomes included increased discussions around sexual health changes, improved comfortability surrounding these discussions with participants, and overall improved patient outcomes and quality of life. The key stakeholders received an executive summary that included an overview of the project and recommendations for sustaining sexual health toolkit use. Measures Pre-and post-implementation surveys were created by the QI lead and content expert. Surveys were distributed via email and then managed through REDCap, an online survey management tool available through the University of Utah. As there were no validated survey tools available, the QI lead and content expert created pre and post intervention surveys to satisfy the project’s needs. The project chair evaluated and approved survey content prior to distribution. IMPLEMENTATION OF SEXUAL HEALTH TOOLKIT 10 The pre-survey included 16 Likert style, yes/no, and short answer questions to gather data on demographics, knowledge, behaviors, and comfort regarding sexual health discussions (Tables 1-3,Appendix A). A smart phrase was created in the electronic health record (EHR) for participants to document use of the toolkit, and chart reviews were conducted to determine the frequency of use of the toolkit. The post-implementation survey (Appendix B) consisted of 19 questions, 12 of which were used in the pre-survey as well, and seven new Likert-style questions which addressed the feasibility, usability, and satisfaction of the toolkit (Table 4). Analysis Descriptive statistics were used to present demographic data and study outcomes. Continuous data were presented as mean and standard deviation, while Likert-style questions were interpreted as ordinal data and presented using frequencies and percentages. Qualitative data was collected from informal weekly discussions with participants. For the paired questions on the pre-and post-surveys, continuous data was compared using a paired t-test, while ordinal data was compared using the Wilcoxon matched paired test. A two-sided p-value <0.05 was considered significant. Ethical Considerations It was determined by the University of Utah Institutional Review Board (IRB) that this was a QI project and was exempt from IRB oversight. No protected health information was collected during this project. There were no conflicts of interest. IMPLEMENTATION OF SEXUAL HEALTH TOOLKIT 11 Results Thirty-two individuals received the pre and post survey via e-mail. Pre-surveys were distributed after a short informal discussion that shared the purpose of the toolkit in clinic. Eleven (34.4%) individuals completed the pre-survey, while 12 (37.5%) completed the postsurvey, eight (25%) of whom completed both. Demographic data of all participants are reported in Table 1. The pre-survey included four (36.4%) physicians, one (9.1%) advanced practice provider, five (45.5%) nurses, and one (9.1%) patient coordinator. The post-survey included five (41.7%) physicians, one (8.3%) advanced practice provider, three (25.0%) nurses, two (16.7%) patient coordinators, and one (8.3%) medical assistant. Three (27.3%) respondents on the presurvey specialized in both breast and gynecologic cancer, while eleven (100%) of respondents specialized in gynecologic cancers. Post-survey, one (8.3%) respondent specialized in breast cancer while eleven (91.7%) specialized in gynecologic cancer. Eleven (100%) respondents on the pre-survey were female while ten (83.3%) respondents on the post-survey were female. Five (45.5%) respondents on the pre-survey and five (41.7%) on the post-survey had been practicing in oncology care for less than three years. Two (18.2%) pre-survey participants and two (16.7%) post-survey participants had nine or more years of oncological experience. As seen in Table 2, participants reported that providers and patients bring up topics of sexual health changes more often than partners during office visits. Participants indicated that the most common areas of interest from patients were vaginal dryness (90.9%, n=10), vaginal pain (72.7%, n=8), dyspareunia (63.6%, n=7), decreased libido (45.5%, n=5), and body dysmorphia (18.2%, n=2). Prior to the intervention, eight (72.7%) participants were recommending pelvic floor therapy, 6 (54.5%) were referring patients to the Midlife Women’s Health and Menopause program, and 7 (63.6%) were using the lubrication list that had previously been created by this IMPLEMENTATION OF SEXUAL HEALTH TOOLKIT 12 cancer clinic. When designing the sexual toolkit, information from the pre-survey indicated that the resource should include information on sexual health changes, treatment options for these changes, and information on additional resources that were available on post-cancer sexual health. All participants in the pre-survey agreed that additional resources would be helpful in supporting the clinic to have conversations on sexual health with their patients (Table 2). Postintervention, the toolkit designed for this project was used by 83.3% (n=10) of participants (Table 2). Many participants indicated that discussing sexual health with their patients was important, (mean 93.8/100 ± 5.4), however, they also indicated that they were not having these conversations regularly (mean 36.5/100 ± 9.9). Eight (72.7%) participants stated the main barriers to discussing sexual health were time constraints due to short appointments, and nine (81.8%) participants said that there were higher priority topics to discuss during appointments with their cancer patients. Seven (63.6% pre-survey, 58.3% post-survey) participants agreed or strongly agreed that they had sufficient knowledge regarding sexual health changes associated with cancer treatment (Table 3). Prior to the implementation of the toolkit, one participant felt that they did not have adequate knowledge regarding sexual health changes, but after implementation, no respondents reported a lack of knowledge on the topic. After the intervention, there was a 10.6% increase in comfort in discussing sexual health with patients, which was a noted improvement but was not found to be statistically significant. Throughout implementation, data was collected to assess toolkit use. During the 11-week implementation, 1,178 patients were seen. Eighty toolkits were printed and distributed during this timeframe but only the use of 22 was documented in the EHR. IMPLEMENTATION OF SEXUAL HEALTH TOOLKIT 13 Feasibility, usability, and satisfaction were evaluated after the implementation of the toolkit (Table 4). All participants agreed or strongly agreed that the sexual health toolkit improved their knowledge of female sexual health. Additionally, all participants agreed or strongly agreed that they were satisfied with the toolkit, that it was a valuable educational tool, and that they planned to continue using it. Nine (75%) participants agreed or strongly agreed that the EHR dot phrase used for documenting usage was easy and something that could be used in the future. Discussion Summary Sexual health discussion and education should be an integral part of breast and gynecologic oncology healthcare. This QI project aimed to develop a sexual health toolkit that was easy and feasible for respondents to use and had high provider satisfaction ratings. This QI project took place over three months, with the goal that over that time period, there would be an increase in the number of sexual health conversations and in the comfort level of the provider to have these conversations. The results from the pre-implementation survey suggested that participants had adequate knowledge regarding sexual health changes in cancer patients but were not initiating conversations on sexual health due to a number of barriers. After the toolkit was implemented, participants reported improved comfort with sexual health discussions, though this result was not statistically significant. Data from the post-intervention survey indicated that the toolkit was feasible, usable, and associated with provider satisfaction, and all participants (n=12) indicated a plan to continue using the toolkit, even after the intervention period ended. The toolkit was restocked weekly, which was an indicator that it was being used frequently. In the post survey, 75% (n=9) were IMPLEMENTATION OF SEXUAL HEALTH TOOLKIT 14 satisfied with the ease of electronically documenting the use of the toolkit through a dot phrase, which is a simple process, but does add steps to the daily workload of the participant. The satisfaction, high frequency of use, and ease of the dot phrase, as well as the low cost of the project (printing the toolkit) are notable strengths of this QI project. Due to the satisfaction, usability, and feasibility of this toolkit, and the buy-in from the project sponsor and education department at the cancer clinic, this toolkit will continue to be utilized. The QI project was led by motivated project sponsors who are excited to continue the use of the toolkit and ensure that the evidence-based information in the toolkit is kept up-to-date. As of March 2024, the toolkit is under review to ensure the most accurate information is included before continued usage. Interpretation Based on the data from this project, we have concluded that it is essential to discuss sexual health changes with cancer patients, but there are unfortunate barriers that prevent this discussion, the most common of which were time constraints and the need to discuss other topics (Figure 1). These findings were consistent with barriers that have been reported in other studies (Gong et al., 2021; Krouwel et al., 2020; Rath et al., 2015; Wazqar, 2020) and are challenging to address in practice. The pre-implementation phase revealed that 63.6% (n=7) of participants felt they had adequate knowledge regarding sexual health changes. Though knowledge was adequate, discussing sexual health ranked much lower with a pre survey mean of 36.5/100 ± 9.9. Many expressed the need for additional resources in clinic to effectively implement more discussion surrounding sexual health (Table 2). There were 32 participants who were sent the survey, and response rate was 34.4% completing the pre-survey and 37.5% completing the post-survey. The response rates were affected by the level of involvement of participants within the clinic, as identified through IMPLEMENTATION OF SEXUAL HEALTH TOOLKIT 15 informal discussions with staff. This was anticipated due to concerns regarding time constraints and the time required to add a new process into clinic workflow. During this time period, the clinic also experienced staff turn-over, with several staff leaving and new staff joining the breast and gynecologic teams, which may have influenced rates of involvement. During implementation, it was noted that toolkits were used during visits, but documentation of use was not performed. As the project moved further along in the implementation phase and after informal meetings and education, there was more of an understanding of the role of the toolkit, which led to further implementation and increase in documentation in the EHR. The post-implementation phase identified an improvement in comfortability, feasibility, usage, and satisfaction with the toolkit. Clinic staff were open to the project, agreed that the EHR dot phrase was an easy way to document use of the toolkit, and all participants indicated that they would continue to use the toolkit and found it to be a beneficial resource. Based on those responses, it can be understood that there is intent for sustainability for this QI project, and despite the lack of statistical significance on improvement measures, descriptive statistics indicated that this was a valuable toolkit that improved the sexual health discussions in the clinic. Results were consistent with previously published reports (Wang et al., 2015). Costs of the QI project were negligible, with the only associated cost being the printing of the brochure. Limitations The QI project had several limitations which should be acknowledged when evaluating the data. The respondents all came from a single outpatient oncology clinic, only 11-12 participated in the surveys, and 87.5% of the respondents were female, which limits the generalizability of the data to other settings. Additionally, all of the participants had the same specialties, so this data cannot be generalized to participants outside of breast and gynecological IMPLEMENTATION OF SEXUAL HEALTH TOOLKIT 16 expertise. Despite several reminders about survey completion, there was a low response rate for both the pre-and-post survey, which might indicate an inaccurate understanding of the toolkit usage or dissatisfaction on a larger scale among participants who did not complete the surveys. The small sample size also limited the depth of the data analysis, and future studies should be conducted employing a larger, more diverse sample size. An additional limitation was the lack of consistent charting of the sexual health toolkit usage. Many participants used the toolkit without documenting usage in the EHR. However, the frequency at which the toolkit needed to be restocked suggested that providers were using it more frequently than documented, which further supports the finding of satisfaction and usability of the toolkit. These limitations may have impacted the project’s outcomes and are important for interpreting results. Conclusions Overall, the sexual health toolkit was a beneficial resource that encouraged clinic staff to initiate sexual health discussions with their patients. The results demonstrated that all participants felt that the sexual health toolkit was worthwhile and valuable for both staff and patients and was easy to use. The toolkit, which had high satisfaction ratings, can be easily modified for specific needs of different clinics or other patient populations who are experiencing sexual health changes related to cancer treatments. The toolkit is currently being modified to address male sexual health dysfunction in cancer patients and will be extended to that patient population shortly. The minimal financial costs, positive participant satisfaction, and frequency of use make this project sustainable, and the adaptability makes it easy to use system-wide. The QI project was led by motivated project sponsors, who are excited to continue the use of the toolkit and keep the evidence-based information within the toolkit up-to-date, as well as edit the IMPLEMENTATION OF SEXUAL HEALTH TOOLKIT 17 toolkit for more generalized use in cancer clinics. The education department at the cancer clinic is reviewing the toolkit and will continue to do quarterly reviews to ensure that the toolkit shares up-to-date information with the patients and staff. IMPLEMENTATION OF SEXUAL HEALTH TOOLKIT 18 Acknowledgments I would like to acknowledge and express gratitude to my project chair, Diane Chapman, DNP, APRN, FNP-C. Diane spent countless hours working with me and guiding me throughout this project for the past three semesters. I am so thankful for all her help and time. I would like to acknowledge and thank my content expert, Dr. Katherine Harris, a gynecologic oncologist, for her insight and passion regarding sexual health in cancer patients. I would also like to thank my project sponsors, Molly Duane, RN, and Ashley Burke, RN, who made this project possible within Huntsman Cancer Institute. This project would not have been possible without the amazing participants and the gynecology oncology and breast oncology teams at Huntsman Cancer Institute. I especially want to thank the medical doctors, advanced practice providers, registered nurses, medical assistants, and patient coordinators who participated in the implementation of my project. IMPLEMENTATION OF SEXUAL HEALTH TOOLKIT 19 References Albers, L. F., Palacios, L. A. G., Pelger, R. C. M., & Elzevier, H. W. (2020). 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Discussing sexual health in the medical oncologist's practice: Exploring current practice and challenges. Journal of Cancer Education, 35(6), 1072– 1088. https://doi.org/10.1007/s13187-019-01559-6 Pizetta, L. M., Reis, A. D. C., Méxas, M. P., Guimarães, V. D. A., & De Paula, C. L. (2022). Management strategies for sexuality complaints after gynecologic cancer: A systematic review. Revista Brasileira de Ginecologia e Obstetrícia / RBGO Gynecology and Obstetrics, 44(10), 962–971. https://doi.org/10.1055/s-0042-1756312 Pup, L. D., Villa, P., Amar, I. D., Bottoni, C., & Scambia, G. (2019). Approach to sexual dysfunction in women with cancer. International Journal of Gynecologic Cancer, 29(3). https://doi.org/10.1136/ijgc-2018-000096 Rath, K. S., Huffman, L. B., Phillips, G. S., Carpenter, K. M., & Fowler, J. M. (2015). Burnout and associated factors among members of the Society of Gynecologic Oncology. American Journal of Obstetrics and Gynecology, 213(6), 824.e1-824.e9. https://doi.org/10.1016/j.ajog.2015.07.036 Reese, J. B., Bober, S. L., Sorice, K. A., Handorf, E., Chu, C. S., Middleton, D., McIlhenny, S., & El-Jawahri, A. (2023). Starting the conversation: Randomized pilot trial of an intervention to promote effective clinical communication about sexual health for gynecologic cancer survivors. Journal of Cancer Survivorship, (9)103, 1821-1829. https://doi.org/10.1007/s11764-022-01327-4 IMPLEMENTATION OF SEXUAL HEALTH TOOLKIT 21 Seaborne, L. A., Peterson, M., Kushner, D. M., Sobecki, J., & Rash, J. K. (2021). Development, implementation, and patient perspectives of the Women's Integrative Sexual Health program: A program designed to address the sexual side effects of cancer treatment. Journal of the Advanced Practitioner in Oncology, 12(1). https://doi.org/10.6004/jadpro.2021.12.1.3 Wang, L. Y., Pierdomenico, A., Lefkowitz, A., & Brandt, R. (2015). Female sexual health training for oncology providers: New applications. Sexual Medicine, 3(3), 189–197. https://doi.org/10.1002/sm2.66 Wazqar, D. Y. (2020). Sexual health care in cancer patients: A survey of healthcare providers’ knowledge, attitudes, and barriers. Journal of Clinical Nursing, 29(21–22), 4239–4247. https://doi.org/10.1111/jocn.15459 Winterling, J., Lampic, C., & Wettergren, L. (2020). Fex-Talk: A short educational intervention intended to enhance nurses’ readiness to discuss fertility and sexuality with cancer patients. Journal of Cancer Education, 35(3), 538–544. https://doi.org/10.1007/s13187019-01493-7 IMPLEMENTATION OF SEXUAL HEALTH TOOLKIT 22 Tables and Figures Table 1 Survey Demographics Characteristics Job Title MD NP/PA RN MA Patient Coordinator Biological Sex Female Male Experience in Oncology Care 0-3 years 3-6 years 6-9 years 9+ years Pre-Survey(N=11) n (%) Post-Survey (N=12) n (%) 4 (36.4) 1 (9.1) 5 (45.5) 1 (9.1) 5 (41.7) 1 (8.3) 3 (25.0) 1 (8.3) 2 (16.7) 10 (91.0) 1 (9.1) 10 (91.0) 2 (16.7) 5 (45.5) 2 (18.2) 2 (18.2) 2 (18.2) 5 (41.7) 3 (25.0) 2 (16.7) 2 (16.7) IMPLEMENTATION OF SEXUAL HEALTH TOOLKIT 23 Table 2 Assessment of Current Practices, Barriers & Desired Resources Question Pre- Survey (N=11) n (%) Post-Survey (N=12) n (%) During an office visit, who typically initiates a conversation about sexual health? Patient Partner Provider 7 (63.6) 1 (9.1) 5 (45.5) 9 (75.0) 0 (0.0) 7 (58.3) Which of the following topics have your patients asked you about? Vaginal dryness Dyspareunia Body dysmorphia Decreased libido Vaginal pain Loss of sensation 10 (90.9) 7 (63.6) 2 (18.2) 5 (45.5) 8 (72.7) 1 (9.1) 12 (100.0) 7 (58.3) 3 (25.0) 10 (83.3) 9 (75.0) 5 (46.7) 8 (72.7) 11 (91.7) 7 (63.6) 6 (54.5) - 8 (66.7) 6 (50.0) - 2 (18.2) 1 (9.1) 2 (16.7) 10 (83.3) - What resources are you aware of / do you refer or give your patients who are experiencing sexual health difficulties during cancer treatment/care? Referral to pelvic floor physical therapy Lube list paper Referral to Dr. Moreno Midlife Women's Health and Menopause Program Referral to a sex therapist Kristi's Sexual Health Tool Kit Other What barriers prevent you from discussing sexual health changes with cancer patients? Time constraint Patient’s age Patient's prognosis 8 (72.7) 3 (27.3) IMPLEMENTATION OF SEXUAL HEALTH TOOLKIT Patient's emotions during appointment Other family/friends in the appointment Provider comfortability in the moment Other important topics to discuss 'Additional resources would be helpful in clinic to support providers and patients in discussing sexual health topics.' Strongly agree Agree Neutral Disagree Strongly Disagree If additional resources would be beneficial in clinic regarding sexual health knowledge and education for breast and gynecologic cancer providers and patients, which resources would be the most helpful for you and your patients? A video regarding sexual health changes related to cancer care and treatment A resource sheet with available knowledge of sexual health changes and ways to overcome/deal with these changes Pamphlet with education and resources offered through Huntsman and the University Support group information A list of websites available A combination of resources 4 (36.4) 5 (45.5) 2 (18.2) 9 (81.8) 9 (81.8) 2 (18.2) - 4 (36.4) 8 (72.7) 8 (72.7) 6 (54.5) 4 (36.4) 8 (72.7) 24 IMPLEMENTATION OF SEXUAL HEALTH TOOLKIT 25 Table 3 Measurement of Change Regarding Sexual Health Discussions and Practices Question pvalue Test Mean ± Standard Deviation Post Survey (N=8) Mean ± Standard Deviation How important do you believe it is to discuss sexual health changes during cancer treatment with breast and gynecologic cancer patients? (0-10) 8.0 ± 1.9 8.0 ± 1.1 1.00 Paired ttest How important do you believe it is to discuss sexual health changes into survivorship with breast and gynecologic cancer patients? (0-100) 93.8 ± 5.4 88.4 ± 6.7 0.12 Paired ttest How often do you discuss sexual health changes with oncology patients? (0-100) 36.5 ± 9.9 34.0 ± 4.9 0.57 Paired ttest How comfortable are you when it comes to discussing sexual health with breast and gynecological cancer patients? (0-100) 63.6 ± 19.2 74.2 ± 7.4 0.19 Paired ttest Pre-Survey Post-Survey pvalue Test n (%) n (%) 0.52 Wilcoxon matchedpair test 2 (25.0) 5 (62.5) 1 (12.5) - 3 (37.5) 4 (50.0) 1 (12.5) - 'I have adequate knowledge regarding sexual health changes that occur during cancer treatment and into survivorship.' Strongly agree Agree Neutral Disagree Strongly disagree Missing Pre-Survey (N=8) IMPLEMENTATION OF SEXUAL HEALTH TOOLKIT Table 4 Post-Intervention Questions Assessing Feasibility, Usability and, Satisfaction Question Post Survey (N=12) n (%) 'I feel that the educational intervention improved my female sexual health knowledge.' Strongly agree Agree Neutral Disagree Strongly Disagree 8 (66.7) 4 (33.3) - 'I think that the sexual health education intervention improved my comfort level in initiating a conversation with patients about sexual health.' Strongly agree Agree Neutral Disagree Strongly Disagree 7 (58.3) 5 (41.7) - 'I think that the sexual health education intervention improved my comfort level in counseling patients about sexual health concerns.' Strongly agree Agree Neutral Missing Disagree Strongly Disagree 6 (50.0) 4 (33.3) 1 (8.3) 1 (8.3) - 'I think that the sexual health patient brochure is a useful patient education tool.' Strongly agree Agree Neutral Disagree Strongly Disagree 11 (91.7) 1 (8.3) - 26 IMPLEMENTATION OF SEXUAL HEALTH TOOLKIT 'I plan to continue to provide the sexual health brochure to my patients.' Strongly agree Agree Neutral Disagree Strongly Disagree 9 (75.0) 2 (16.7) 1 (8.3) - 'I think the Epic dot phrase (.kksexualhealthtoolkit) was easy to use for documenting use of the sexual health toolkit.' Strongly agree Agree Neutral Disagree Strongly Disagree 6 (50.0) 3 (25.0) 3 (25.0) - 27 IMPLEMENTATION OF SEXUAL HEALTH TOOLKIT 28 Figure 1 Barriers to Discussing Sexual Health Changes with Oncology Patients Barriers to Discussing Sexual Health Changes with Oncology Patients N=8 8 7 6 7 6 5 4 3 3 2 2 1 2 0 1 0 Other Provider Other family/friends comfortability important in the in the moment topics to dicuss appointment No barriers identified 0 Time constraint Patient's age Patients prognosis Patient's emotions during appointment Participants IMPLEMENTATION OF SEXUAL HEALTH TOOLKIT 29 Appendix A Pre-Implementation Survey The purpose of this Doctor of Nursing Practice (DNP) Quality Improvement (QI) project is to assess the usability, feasibility, and acceptability of an evidence-based Sexual Health Toolkit for providers caring for female cancer patients over the age of 18 and into survivorship. Thank you for taking the time to take my survey! Kristi Kundrat Please provide the last four digits of your phone number. This will be used to compare data preand post-intervention. Please be on the lookout for a follow-up survey in a couple of weeks. This survey will be distributed after the implementation of a sexual health tool kit. This information will not be used for anything else. Thank you! **** Specialty: • Breast Cancer • Gynecologic Cancer • Other Job title: • MD • NP/PA • RN • MA • LCSW • Other Biological sex: • Male • Female • Other • Prefer not to answer Years of Experience in Oncology Care: • 0-3 years • 3-6 years • 6-9 years • 9+ years IMPLEMENTATION OF SEXUAL HEALTH TOOLKIT 30 How important do you believe it is to discuss sexual health changes during cancer treatment with breast and gynecologic cancer patients? • Not important • Somewhat important • Very important How important do you believe it is to discuss sexual health changes into survivorship with breast and gynecologic cancer patients? • Not important • Somewhat important • Very important How often do you discuss sexual health changes with oncology patients? • Never • Sometimes • Often How comfortable are you when it comes to discussing sexual health with breast and gynecological cancer patients? Please select the response that best describes your comfort level. • Uncomfortable • Comfortable • Very Comfortable "I have adequate knowledge regarding sexual health changes that occur during cancer treatment and into survivorship." • Strongly agree • Agree • Neutral • Disagree • Strongly disagree During an office visit, who typically initiates a conversation about sexual health? • Patient • Partner • Provider • Other Which of the following topics have your patients asked you about? • Vaginal dryness • Dyspareunia • Body dysmorphia • Decreased libido • Vaginal pain IMPLEMENTATION OF SEXUAL HEALTH TOOLKIT • • 31 Loss of sensation Other What resources are you aware of / do you refer or give your patients who are experiencing sexual health difficulties during cancer treatment/care? • Referral to pelvic floor physical therapy • Lube list paper. • Referral to Dr. Moreno Midlife Women's Health and Menopause Program • Referral to a sex therapist • Other IMPLEMENTATION OF SEXUAL HEALTH TOOLKIT 32 Appendix B Post-Implementation Survey The purpose of this Doctor of Nursing Practice (DNP) Quality Improvement (QI) project is to assess the usability, feasibility, and acceptability of an evidence-based Sexual Health Toolkit for providers caring for female cancer patients over the age of 18 and into survivorship. Thank you for taking the time to take my survey! Kristi Kundrat Please provide the last four digits of your phone number. This will be used for comparing data pre and post intervention. Please be on the lookout for a follow up survey in a couple of weeks. This survey will be distributed after the implementation of a sexual health tool kit. This information will not be used for anything else. Thank you! **** Specialty: • Breast Cancer • Gynecologic Cancer • Other Job title: • MD • NP/PA • RN • MA • LCSW • Other Biological sex: • Male • Female • Other • Prefer not to answer Years of Experience in Oncology Care: • 0-3 years • 3-6 years • 6-9 years IMPLEMENTATION OF SEXUAL HEALTH TOOLKIT • 33 9+ years How important do you believe it is to discuss sexual health changes during cancer treatment with breast and gynecologic cancer patients? • Not important • Somewhat important • Very important How important do you believe it is to discuss sexual health changes into survivorship with breast and gynecologic cancer patients? • Not important • Somewhat important • Very important How often do you discuss sexual health changes with oncology patients? • Never • Sometimes • Often How comfortable are you when it comes to discussing sexual health with breast and gynecological cancer patients? Please select the response that best describes your comfort level. • Uncomfortable • Comfortable • Very Comfortable "I have adequate knowledge regarding sexual health changes that occur during cancer treatment and into survivorship." • Strongly agree • Agree • Neutral • Disagree • Strongly disagree During an office visit, who typically initiates a conversation about sexual health? • Patient • Partner • Provider • Other Which of the following topics have your patients asked you about? Vaginal dryness • Dyspareunia • Body dysmorphia • Decreased libido IMPLEMENTATION OF SEXUAL HEALTH TOOLKIT • • • 34 Vaginal pain Loss of sensation Other What resources are you aware of / do you refer or give your patients who are experiencing sexual health difficulties during cancer treatment/care? • Referral to pelvic floor physical therapy • Lube list paper • Referral to Dr. Moreno Midlife Women's Health and Menopause Program • Referral to a sex therapist • Kristi's Sexual Health Tool Kit • Other Evaluation of Educational Intervention and Sexual Health Toolkit I feel that the educational intervention improved my female sexual health knowledge. • Strongly Agree • Agree • Neutral • Disagree • Strongly Disagree I think that the sexual health education intervention improved my comfort level in initiating a conversation with patients about sexual health. • Strongly Agree • Agree • Neutral • Disagree • Strongly Disagree I think that the sexual health education intervention improved my comfort level in counseling patients about sexual health concerns. • Strongly Agree • Agree • Neutral • Disagree • Strongly Disagree I think that the sexual health patient brochure is a useful patient education tool. • Strongly Agree • Agree • Neutral IMPLEMENTATION OF SEXUAL HEALTH TOOLKIT • • 35 Disagree Strongly Disagree I plan to provide the sexual health brochure to my patients. • Strongly Agree • Agree • Neutral • Disagree • Strongly Disagree I think the Epic dot phrase (.kksexualhealthtoolkit) for sexual health is useful in evaluating and documenting a patient's sexual health. • Strongly Agree • Agree • Neutral • Disagree • Strongly Disagree Additional resources would be helpful to have in clinic to support providers and patients in discussing sexual health? • Strongly Agree • Agree • Neutral • Disagree • Strongly Disagree IMPLEMENTATION OF SEXUAL HEALTH TOOLKIT 36 Appendix C Sexual Health Toolkit (Word Document Format) Sexual Health and Cancer Understanding Sexual Health Changes During Cancer Treatment and Into Survivorship for Breast and Gynecologic Patients There are a variety of sexual changes that women may face after a gynecologic/breast cancer diagnosis and treatment. Surgery, radiation, chemotherapy, and other treatments can cause sexual side effects. Frequently asked questions: How do I discuss sexual health changes with the healthcare team? - Be open and honest with the side effects that you are experiencing and the questions you have prior to surgery or treatment. Some examples of questions to ask your provider include: ▪ How will treatment affect intercourse? ▪ Is it safe to have intercourse during treatment? If not, when will it be, okay? ▪ Are there any types of intercourse I should not partake in? ▪ Do I need to use birth control or other protection during treatment? ▪ Can my treatment or medications be passed to my partner during intercourse? (Cancer, Sex, and the Female Body, 2020) I am experiencing vaginal dryness. What can I do? - Moisturizers and lubrications are great options for women who experience vaginal dryness. - Moisturizers help with vaginal pain, itching, and irritation due to everyday dryness. Dryness can be associated with a lack of estrogen, which can be due to the removal of the ovaries or other treatments such as pelvic radiation or endocrine therapy. - Moisturizers: Coconut oil (yes! The kind you cook with!), Replens, Hyaluronic acid. - Lubrication: Water-based lube is better if condoms are used for protection. Silicone lube can provide better lubrication but can break down condoms. - Recommended lubrications: PJUR, Platinum Wet, Sliquid, Albolene, Uberlube, Astroglide, Slippery Stuff - If these do not help, please contact your healthcare provider for further options/treatment. What are the menopause symptoms I may experience due to surgery and chemotherapy? - Vaginal dryness, night sweats/ hot flashes, mood swings, lower sexual desire, decrease in energy, emotional lability, and irregular or no menstrual periods are all symptoms that an individual might experience due to menopause. o Tips for hot flashes! ▪ Avoid spicy foods, alcohol, and smoking IMPLEMENTATION OF SEXUAL HEALTH TOOLKIT ▪ ▪ ▪ ▪ ▪ ▪ 37 Avoid hot baths, showers, and saunas Wear layers so you can remove one if you become hot Acupuncture Estrogen (speak with your provider. estrogen cannot be used with certain types of cancer) Medications Fans Communication! - It is crucial for patients to have open communication with partners and providers. - This is VERY important for sexual well-being; supportive intimate partners lead to a better quality of life. - Talk to your partner about how you are feeling. - There are other ways to experience intimacy than intercourse. - Planning dates and times for intimacy can help bring partners closer together. - There are ways to improve communication in relationships, including working on routines, talk therapy, stress management, and sex therapy. - You are not alone if you are experiencing changes in sexual and intimate relationships throughout oncology treatment. - Everyone should be able to enjoy being intimate alone or with a partner, and many women struggle with this after cancer diagnosis and treatment. (Intimacy, Sex and Fertility Issues, 2023) I am experiencing painful intercourse. - As women age, the vagina naturally loses elasticity and moisture, but cancer treatments and surgeries can speed up this process (Managing Female Sexual Problems Related to Cancer, 2020) - After surgeries and radiation, the vagina can become shorter and narrower, but there are ways to improve this! o Use a dilator or vibrator to gently stretch the vagina and help keep it open. • Make sure you and your partner take enough time to lead up to sex. Foreplay is an integral part of intercourse to expand the vagina and increase natural lubrication. • Use different positions that feel more comfortable. Try positions where you can control the movement, as well as lots of lubrication. • Our bodies remember the pain that is experienced during intercourse and tend to tense up after that. It is essential to pay attention to this and focus on pelvic floor muscle relaxation. • Consider pelvic floor physical therapy, as this is often helpful for anyone with painful intercourse. - Lubricants with no coloring, spermicides, perfume, or flavoring are best, as they are less likely to irritate vaginal tissue. Coconut oil is also a great option. - There is never too much lube! (Managing Female Sexual Problems Related to Cancer, 2020) What side effects related to sexual health can radiation cause? IMPLEMENTATION OF SEXUAL HEALTH TOOLKIT - - 38 Radiation can cause scarring of the vagina, which can contribute to painful intercourse and a shorter vaginal canal. After radiation, most women benefit from using vaginal dilators to keep the vagina from scarring. This allows for continued sexual intercourse and medical examinations in the future. If you have not been taught how to use vaginal dilators, please speak to your provider. You can also use a vibrator instead of the medical vaginal dilators. Generally, it is recommended to use the dilator or vibrator at least three times a week for 5-10 minutes each time. (Managing Female Sexual Problems Related to Cancer, 2020) Will cancer treatment affect my fertility? - If you desire future fertility, it is important to discuss with your provider prior to starting treatment. - There are many fertility resources through the University of Utah. - Fertility may be affected even after completion of cancer treatment. (How Cancer and Cancer Treatment Can Affect Fertility in Females, 2020) Will I have any sexual health changes after surgery for my breast cancer? - Breast surgeries include lumpectomies (removal of a small portion of the breast) and mastectomies (removal of all the breast tissue either on one side or both). Reconstruction (plastic surgery to recreate breasts after breast cancer surgery) is an option if desired by a patient. - Surgery associated with breast cancer does not typically have direct impacts on sexual intercourse. However, this surgery can have a significant impact on body image as well as changes in sensation affecting the breast or nipple tissue. - It is important to manage the psychological and physical changes associated with breast surgery. - Nipple reconstruction, tattooing, and breast reconstruction are options that women may choose after having breast cancer surgery. Some of these options require multiple surgical operations. - It is important that women feel comfortable and have options to achieve their goals regarding self-image related to the changes associated with breast cancer. (Managing Female Sexual Problems Related to Cancer, 2020) References: Cancer, Sex, and the Female Body. (2020, February 6). American Cancer Society. https://www.cancer.org/cancer/managing-cancer/side-effects/fertility-and-sexual-sideeffects/sexuality-for-women-with-cancer/cancer-sex-sexuality.html How Cancer and Cancer Treatment Can Affect Fertility in Females. (2020, February 6). American Cancer Society. https://www.cancer.org/cancer/managing-cancer/side-effects/fertility-andsexual-side-effects/fertility-and-women-with-cancer/how-cancer-treatments-affect-fertility.html Intimacy, Sex and Fertility Issues. (2023). Cancer Support Community. https://www.cancersupportcommunity.org/article/intimacy-sex-and-fertility-issues IMPLEMENTATION OF SEXUAL HEALTH TOOLKIT 39 Managing Female Sexual Problems Related to Cancer. (2020, February 5). American Cancer Society. https://www.cancer.org/cancer/managing-cancer/side-effects/fertility-and-sexual-sideeffects/sexuality-for-women-with-cancer/problems.html IMPLEMENTATION OF SEXUAL HEALTH TOOLKIT Appendix D Sexual Health Toolkit for Breast Cancer Patients (PDF/Brochure format) 40 IMPLEMENTATION OF SEXUAL HEALTH TOOLKIT Appendix E Sexual Health Toolkit for Ovarian Cancer Patients (PDF/Brochure format) 41 IMPLEMENTATION OF SEXUAL HEALTH TOOLKIT 42 Appendix F Provider Presentation 3/24/24 BACKGROUND OF MY PROJECT • Cancer causes a myriad of problems (Pup et al., 2019) • Quality of life is an important clinical issue for cancer patients (Seaborne et al., 2021) SEXUAL HEALTH TOOL KIT FOR BREAST AND GYNECOLOGIC ONCOLOGY PROVIDERS • Sexual dysfunction is under diagnosed and under treated (Pup et al., 2019) KRISTI KUNDRAT, WHNP, DNP STUDENT UNIVERSITY OF UTAH COLLEGE OF NURSING IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DOCTOR OF NURSING PRACTICE © U N IV E R S IT Y O F U T A H • Imperative to include sexual health education in cancer care à simple tools can improve management (Pup et al., 2019) H E A L T H , 2 0 1 8 1 © U N IV E R S IT Y O F U T A H H E A L T H , 2 0 1 8 2 PROBLEM OBJECTIVES • Female cancer patients and survivors have unfulfilled sexual health needs (Stabile et al., 2017) • Survival rates for gynecologic and breast cancers are increasing (Stabile et al., 2017) • Sexual function, body dysmorphia and vaginal health are topics often not discussed by providers (Stabile et al., 2017) • Barriers include: cultural differences, discomfort, lack of education, lack of time, age of patient, patient prognosis Objective 1: Assess current processes for delivering sexual health education to breast and gynecologic cancer patients receiving treatment and into survivorship. Objective 2: Adapt a sexual health tool kit for providers. Objective 3: Implement a sexual health tool kit for provider use Objective 4: Evaluate the feasibility, useability and satisfaction of a sexual health tool kit for providers. (Krouwel et al., 2020) © U N IV E R S IT Y O F U T A H H E A L T H , 2 0 1 8 3 © U N IV E R S IT Y O F U T A H H E A L T H , 2 0 1 8 4 REFERENCES IMPLEMENTATION OF A SEXUAL HEALTH TOOL KIT • Pre-intervention survey this week Seaborne, MPAS, PA-C, L., Peterson, DNP, M., M. Kushner, MD, D., Sobecki MD, MA, J., & K. Rash, MPAS, PA-C, J. (2021). Development, Implementation, and Patient Perspectives of the Women’s Integrative Sexual Health Program: A Program Designed to Address the Sexual Side Effects of Cancer Treatment. Journal of the Advanced Practitioner in Oncology, 12(1). https://doi.org/10.6004/jadpro.2021.12.1.3 • Please provide feedback! Pup, L. D., Villa, P., Amar, I. D., Bottoni, C., & Scambia, G. (2019). Approach to sexual dysfunction in women with cancer. International Journal of Gynecologic Cancer, 29(3). https://doi.org/10.1136/ijgc-2018-000096 • Educational session and implementation of sexual health tool kit Smith, T., Kingsberg, S. A., & Faubion, S. (2022). Sexual dysfunction in female cancer survivors: Addressing the problems and the remedies. Maturitas, 165, 52–57. Retrieved May 28, 2023, from https://doi.org/10.1016/j.maturitas.2022.07.010 Stabile, C., Goldfarb, S., Baser, R. E., Goldfrank, D. J., Abu-Rustum, N. R., Barakat, R. R., Dickler, M. N., & Carter, J. (2017). Sexual health needs and educational intervention preferences for women with cancer. Breast Cancer Research and Treatment, 165(1), 77–84. Retrieved May 28, 2023, from https://doi.org/https://doi-org.ezproxy.lib.utah.edu/10.1007/s10549-017-4305-6 • TPC once a month with a sexual health topic and feedback from providers Krouwel, E. M., Albers, L. F., Nicolai, M. P. J., Putter, H., Osanto, S., Pelger, R. C. M., & Elzevier, H. W. (2020). Discussing Sexual Health in the Medical Oncologist’s Practice: Exploring Current Practice and Challenges. Journal of Cancer Education, 35(6), 1072–1088. https://doi.org/10.1007/s13187-019-01559-6 Pizetta, L. M., Reis, A. D. C., Méxas, M. P., Guimarães, V. D. A., & De Paula, C. L. (2022). Management Strategies for Sexuality Complaints after Gynecologic Cancer: A Systematic Review. Revista Brasileira de Ginecologia e Obstetrícia / RBGO Gynecology and Obstetrics, 44(10), 962–971. https://doi.org/10.1055/s-0042-1756312 • Questions, Comments, Concerns, Feedback? © U N IV E R S IT Y 5 O F U T A H H E A L T H , 2 0 1 8 © U N IV E R S IT Y O F U T A H H E A L T H , 2 0 1 8 6 1 IMPLEMENTATION OF SEXUAL HEALTH TOOLKIT 43 Appendix G Executive Summary Implementation of a Sexual Health Toolkit for Breast and Gynecologic Oncology Providers A Quality Improvement Project Introduction: Sexual health dysfunction is often an issue for breast and gynecologic oncology patients during treatment and into survivorship, and many patients do not receive adequate education regarding these changes that may occur. This Doctor of Nursing Practice (DNP) Quality Improvement (QI) project aimed to assess the feasibility, usability, and satisfaction of an evidence-based Sexual Health Toolkit for providers caring for female cancer patients over 18 and into survivorship. Background: Breast and gynecologic oncology patients often face challenges related to sexual health during and after treatment. These challenges can significantly impact their quality of life and overall well-being. A cohort study was performed in Utah looking at breast cancer survivors diagnosed between 1997 and 2017 through the Utah Cancer Registry. There were 19,709 breast cancer survivors compared with 93,389 cancer-free women. Sexual dysfunction was identified through ICD codes from electronic health records. It was observed that breast cancer survivors were at higher risk of sexual dysfunction compared to the general population. Despite being a common issue, the topic of sexual health with cancer patients and survivors is under-addressed in the clinical setting, and less than 25% of patients with sexual problems receive help from a health professional. Recognizing this, there is a need to provide comprehensive support and resources to healthcare providers and oncology teams. Deliverables: A comprehensive assessment, with a pre-implementation survey and discussion of current practices and provider needs, revealed a gap in resources and appropriate sexual health resources in breast and gynecologic oncology care. Providers expressed a desire for an accessible tool and guidelines to facilitate discussions about sexual health with their patients and address related concerns effectively. The project aimed to improve provider discussions and comfortability regarding sexual health changes with patients with the use of a sexual health toolkit. Results: The survey was sent to thirty-two participants and eleven (34.4%) completed the presurvey, and 12 (37.5%) took the post-survey, of which eight (25.0%) took both. All paired participants reported adequate knowledge regarding sexual health both pre- and post- sexual health toolkit implementation with 63.6% (n=7) of participants pre-survey and 58.3% (n=7) post, stating they strongly agree or agree they had sufficient knowledge at both timepoints. Comfortability improved post-toolkit implementation, and participants indicated high usability and satisfaction with the implementation of a sexual health toolkit. A hundred percent of participants (n=12) strongly agreed or agreed that the toolkit improved female sexual health knowledge, and felt it was a useful tool. There were no statistically significant differences in data collected pre-and post-intervention. IMPLEMENTATION OF SEXUAL HEALTH TOOLKIT 44 Recommendations: It is recommended to continue implementing the Sexual Health Toolkit for Breast and Gynecologic Oncology Providers as a quality improvement project. The toolkit can be easily applied to other settings and is currently being modified to address male sexual health dysfunction in cancer patients. It is sustainable due to the ease of use and low costs associated with the toolkit. It can be modified and used in other clinics for women who are experiencing sexual health changes related to other cancer treatments. Due to participant feedback and great patient comments, the project will continue to be used and carried out within the Salt Lake City, Utah, oncology clinic. By implementing the Sexual Health Toolkit, breast and gynecologic oncology providers will be better equipped to support their patients' sexual health needs, leading to improved quality of life, patient satisfaction, and overall cancer care outcomes.