Sometimes couples suffer in silence when their intimate relationship has been altered due to a cancer diagnosis and treatments. As a pastor at Cancer Treatment Centers of America^(R) in Philadelphia, I have been helping to facilitate a support group for men who either have cancer themselves or are the caregiver of someone with cancer. During one of our recent meetings I showed a film clip from a man who had a prostatectomy. He gave a helpful, transparent talk about rediscovering sexual intimacy after cancer treatment, and how it had altered his ability to have an erection. He was realistic but extremely hopeful. His honesty and the trust he instilled among the men created a safe space for great conversation about the side effects of cancer treatment-including altered sexuality. This conversation caused me to wonder: How many cancer patients are quietly struggling to maintain intimacy in their relationships? Patients often experience changes in libido, body image, physical strength, emotions, and self-confidence that can hurt intimate connection with their partners. From other patients I have worked with over the years, I have seen that it is not unusual for couples experiencing sexual dysfunction to begin to quietly withdraw from one another emotionally as well as physically.

The day after our men's support meeting I made an appointment with one of our hospital counselors to find out how our patients' sexuality was affected by cancer treatment. I discovered that all five hospitals within our hospital network assess the side effects experienced by our patients at each visit. We practice an integrated approach and along with cutting-edge clinical expertise also offer a whole range of complementary therapies that can counteract or reduce common treatment side effects. These therapies include acupuncture, naturopathy, massage, and nutritional care, as well as chaplains and counselors for emotional and spiritual counseling and support. The usual side effects that surface in our surveys are common for many cancer patients and include fatigue, nausea, and poor concentration. However, I was surprised to discover that in all five of our hospitals a chief complaint among cancer patients is difficulty with sexual intimacy. In fact, 48% of our patients who were surveyed reported distress related to sexual interest and function. This was equally reported among both men and women.

Soon after this discovery I was scheduled to conduct a training session with a church in New York that has a vibrant cancer care ministry. We had several cancer survivors speak on a panel to share their experiences dealing with cancer. One man on the panel was in his 30s and spoke about the many surgeries he had in his late teens and early 20s for cancer. He was a pastor and expressed deep gratitude to God for life, health, and his beloved and beautiful wife. Unexpectedly, in the middle of his story after mentioning his wife, he burst into tears in front of the whole room. He said that even though he had survived cancer and was grateful, he had also suffered sexually and was not able to give his wife what she deserved and desired. The room fell silent. Eventually others on the panel filled the silence with positive stories, but no one had anything to say about the elephant in the room, even though we were all deeply saddened by this young man's grief. After the meeting I was able to get a few minutes alone with him and asked if anyone had ever given him counseling about sexual function or intimacy. He looked me in the eye with a grateful expression and said, "NO ONE." Thanks to our hospital counselor I was able to offer him a variety of resources for support and hoped that would open up dialogue between this terrific young man and his wife.

Since that encounter I have been more sensitive in asking patients and caregivers about intimacy and connection with their partners. I continue to be surprised by the number of people who have had some of the best cancer care in the world and yet still have this major area of life unaddressed by "the system." Cancer, like many diseases, can be a frightening challenge. The stresses can even assault and stress the most resilient of relationships. As home healthcare clinicians, we are in a unique role of trust with cancer patients once they return home. We have a wonderful opportunity. Couples with established patterns of how they relate to one another sexually may need your help to redefine how they connect intimately. Like the young pastor who opened up about his struggles, many people affected by cancer have frustrations that run close to the surface of their heart. They are grateful to have resources to help them rebuild intimacy with the one they love. They are also grateful when we broach this sensitive topic. When we help keep partners connected with one another by providing information and a safe space to address their particular needs, then quality of life and wholeness will remain strong and fulfilling. Call your local cancer center and gather resources for your patients. Find out if there is a local support group. Urge your patients to seek counseling and support. And don't be afraid to bring up this sensitive subject-your patients will thank you.

Alcohol-Exposed Pregnancies-United States, 2011-2013

Alcohol is a teratogen. Prenatal alcohol exposure is associated with a range of adverse reproductive outcomes and can cause fetal alcohol spectrum disorders (FASDs) characterized by lifelong physical, behavioral, and intellectual disabilities. FASDs are completely preventable if a woman does not drink alcohol while pregnant. Centers for Disease Control and Prevention analyzed data from the 2011-2013 National Survey of Family Growth to generate U.S. prevalence estimates of risk for an alcohol-exposed pregnancy for 4,303 nonpregnant, nonsterile women aged 15 to 44 years, by selected demographic and behavioral factors. A woman was considered at risk for an alcohol-exposed pregnancy during the past month if she had sex with a male, drank any alcohol, and did not (and her partner did not with her) use contraception in the past month; was not sterile; and had a partner (or partners) not known to be sterile. The weighted prevalence of alcohol-exposed pregnancy risk among U.S. women aged 15 to 44 years was 7.3%. During a 1-month period, approximately 3.3 million women in the United States were at risk for an alcohol-exposed pregnancy. Alcohol use in pregnancy is associated with low birthweight, preterm birth, birth defects, and developmental disabilities. Women of reproductive age should be informed of the risks of alcohol use during pregnancy, and contraception should be recommended, as appropriate, for women who do not want to become pregnant. Women wanting a pregnancy should be advised to stop drinking at the same time contraception is discontinued. Healthcare providers should advise women not to drink at all if they are pregnant or there is any chance they might be pregnant. Alcohol misuse screening and behavioral counseling (also known as alcohol screening and brief intervention) are recommended for all adults in primary care, including reproductive-aged and pregnant women, as an evidenced-based approach to reducing alcohol consumption among persons who consume alcohol in excess of the recommended guidelines.

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