Although surviving cancer should be a happy event, there are reports that people living with the effects of cancer and its treatment face challenges that make it difficult to regain the health and quality of life they had before they became ill. One area, often described as affecting a person's quality of life, is patients' sexual health, that is, experiencing how the illness and treatment have affected their sexuality. For patients, issues related to their sexual health can often seem less important during diagnosis and active treatment. At the same time, there are matters related to patients' sexuality, such as preserving fertility, that need to be addressed early in the course of the disease. When patients have completed treatment and have "returned to life," part of that return is their sexual health, which includes intimacy, closeness, and communication with partners, as well as, but not for all, sexual interest (desire), sexual satisfaction, and the person's ability and desire to be sexually active. The ever-increasing number of cancer survivors living with the effects of cancer means that they require both specialized and primary care; such healthcare providers can face major challenges in providing support to survivors regarding issues of sexuality. Sexual healthcare should be an integral part of holistic, person-centered cancer care, as has been recognized in recent decades. However, historically, implementing nurse-led sexual healthcare in cancer settings has been a challenge. Because nursing care is based on a holistic approach, giving emphasis to the role of the nurse in supporting patients living with and after cancer that includes care for the sexual health of survivors is important.

The challenges for nurses to address sexual health of survivors are at societal, organizational, and individual levels. The care is often fragmented between specialists and primary care generalists, with the latter lacking nurses with specific competences in the consequences of cancer treatment in general and specifically the impact of treatment on sexuality. At the same time, specialized cancer services may not have the capacity to support all survivors who have completed acute treatment. There are several possible solutions to achieve seamless cancer care and for nurses to become comfortable supporting survivors on issues related to sexuality. Solutions begin at the stages of handing over responsibility to the next healthcare provider. This handoff is most effective when done together with survivors to further ensure person-centered care, including the focus on the survivors' sexual health. This will require that nurses are competent in both the sexuality of cancer patients and how to address their sexual health, although such topics are often perceived as sensitive and somewhat taboo. Specialty and primary care organizations need to support this kind of care focus.

Sexual health cancer care remains suboptimal and challenging, in part due to nurses' uncertainty regarding their role and comfortableness with the topic, inexperience and lack of sufficient training in dealing with the topic, and, as described previously, an inhibiting healthcare environment.1,2 In the review by Papadopoulou and colleagues,2 the paucity of sexual health interventions is noted; these authors proposed a competency framework to promote the development of basic competence for nurses on sexuality in persons with cancer (entry level) and advancement to a more specialized, autonomous role (mastery level). This framework, together with models such as the neo-theoretical framework of sexuality3 and the integrative biopsychosocial model for intervention,4 provides an education foundation regarding sexual health. As part of the topic competency, nurses also need training in how to initiate a dialogue about sexuality. In an ongoing research project SexCanWebEdNurse, we are evaluating an education intervention available online 24/7, using films and literature, and step-by-step weekly challenges to achieve competency with sexual healthcare for patients with cancer or in survivorship. The intervention is built around the BETTER training5 composed of 5 steps: bring it up, explain, tell, timing, and educate. The entry process is to practice BETTER first with a friend or a colleague and thereafter with patients and, where present, their partners.

We as researchers, leaders, and clinical nurses in cancer care, and in collaboration with patient organizations, need to emphasize that sexual healthcare must provide patients and survivors with access to a nurse who is competent and skilled in sexual health. A way to begin such access is to introduce sexual health competency in primary cancer care centers. There, persons receiving treatment for cancer could receive care from nurses with expertise in all areas of cancer rehabilitation to support them to "return to life."

Cecilia Olsson, PhD, RN, OCN

Associate Professor in Nursing, Department of Health Sciences, Karlstad University, Sweden; Department of Bachelor'

Education in Nursing, Lovisenberg Diaconal University College, Oslo, Norway; and Member of the Editorial Board for

CANCER NURSING and Cancer Care Research Online

References