The NCCN “Survival Guide” is the first time that sleep disorders are specifically discussed, reflecting the increased attention to comprehensive care for cancer survivors in recent years. It is easy to understand that good sleep is beneficial to the overall improvement of cancer survivors’ quality of life, as well as to fight and prevent tumor recurrence and metastasis. Tang Ligong, Department of General Surgery, Henan Cancer Hospital, said that the management of sleep disorders in the “Survival Guide” has certain guiding meaning and operability. The guideline emphasizes to clarify the diagnosis before treatment, so as to give appropriate treatment measures according to different conditions. The treatment measures include encouraging patients to increase physical activity and considering medication in certain cases; for refractory cases, multidisciplinary cooperation, including consultation with sleep specialists, is required. “Sleep disorders covered in the Survival Guide include insomnia, hypersomnia, sleep-related movement or breathing abnormalities, and ectopic sleep. 30% to 50% of cancer survivors suffer from sleep disorders, often combined with fatigue, anxiety, and depression. The “Survivorship Guidelines” for clinical practice regarding sleep disorders include screening for sleep disorders, evaluation of sleep disorder-related syndromes, and appropriate management based on the diagnosis. With regard to sleep disorder screening, the Survival Guide calls for patients to be asked about sleep problems on a regular basis, especially if their condition or treatment changes. Such questions include: ☆ Insomnia: Do you have trouble falling asleep and how often do you fall asleep? How many times do you wake up each night? How long has it been difficult to fall asleep? ☆ Excessive sleep: Have you fallen asleep while reading, watching TV, talking to friends, or driving? ☆ Respiratory arrest during sleep: Any snoring, shortness of breath or respiratory arrest during sleep? ☆ Restless legs syndrome: Have you ever wanted to move your legs very much while resting with uncomfortable feeling? ☆ Altered sleep: Is there sleepwalking, screaming on waking or violent movements during sleep? The “Survival Guide” calls for assessment of the following issues in individuals with sleep disorders: ☆ Comorbidities, including alcohol/other drug abuse, obesity, cardiac abnormalities, endocrine abnormalities (e.g., hypothyroidism), anemia, affective disorders, neurological abnormalities, and psychiatric abnormalities (depression and anxiety). ☆ Aspects of medication effects such as continued use of sleep aids, analgesics, antiemetics, stimulants, sedatives, sleeping pills, over-the-counter sleep aids, antihistamines ☆ Assessment of medication chemotherapy history, pain, fatigue, job changes, current coping regimen (relaxation, medication) The “Survival Guide” repeatedly emphasizes the importance of comprehensive management in the interventions proposed for sleep disorders, requiring frequent health education, consultation with sleep specialists when necessary, and timely consultation. Excessive sleep includes episodic sleep disorder, other sleep disorders, sleep apnea, restless legs syndrome, sleep arrhythmia, and ectopic sleep. ☆ For sleep deprivation syndrome related to insufficient sleep time, ensure more sleep or increase bedtime. ☆ For excessive sleep related to apnea and snoring, use polysomnography to check, and if sleep apnea is diagnosed, treat with continuous positive pressure ventilation, surgery, oral appliances, weight loss, and exercise. ☆ For sleep disorders related to discomfort sensation, ferritin below 45-50 ng/ml and diagnosis of restless legs syndrome, treatment with dopamine stimulants, benzodiazepines, gabapentin (extended-release tablets), and opioids is used. ☆ For prolonged nocturnal sleep (>9 h in adults), polysomnography or polysomnographic latency test detection is applied. If idiopathic hypersomnia is diagnosed, sleep hygiene education and stimulants should be given; if polysomnographic latency test is normal, prolonged sleep is diagnosed and no special treatment is needed. ☆ For excessive sleep associated with SIDS, frequent drowsiness, dreaming, sleep confusion or paralysis in sleep, polysomnography or polysomnographic latency test detection should be applied. For those diagnosed with episodic sleep disorder, arrange for short daytime sleep and consult a sleep specialist to give medication. ☆ For excessive daytime sleep without other syndromes, give medication (modafinil, methylphenidate, etc.) or consult a sleep specialist for other treatments and medications (e.g. sodium oxybate, amphetamine, methamphetamine, dextroamphetamine, etc.). Insomnia Sleep hygiene promotion for those with unexplained insomnia without treatment; active intervention for those with causative insomnia such as excessive daytime activities, decreased quality of life, aggravated comorbidities or depression. If insomnia is associated with co-morbidities (e.g., medical illness, neurological/psychiatric disorders, cancer recurrence, pain) or drug-induced insomnia, treatment includes treatment of co-morbidities, behavioral cognitive therapy, and, if safe, pharmacological interventions for difficulty falling asleep, unsustainable sleep, and failure to regain strength after sleep. ☆ Insomnia without comorbid diseases or without drug-induced insomnia, behavioral cognitive therapy, drug intervention and sleep hygiene education; if insomnia improves, no further treatment is necessary. The first time in the series of NCCN guidelines, the “Survival Guide” has addressed the issue of sexual function in cancer survivors in a more systematic and detailed manner. Various anti-cancer treatments, especially hormone therapy and direct pelvic treatment, may affect sexual function; depression and anxiety, which are common among cancer survivors, may also lead to sexual function problems, increasing patients’ pain and seriously affecting their quality of life. However, the lack of specialized training in sexual function for oncology professionals and the privacy issues involved make sexual dysfunction in cancer survivors a rare concern during medical visits. “The Survivorship Guide states that sexual dysfunction in cancer survivors should receive effective intervention and be an important part of cancer survivorship follow-up. The Survivorship Guide mentions that sexual dysfunction, including sexual need, arousal, orgasm, and painful intercourse, is more prevalent in female cancer survivors than in the healthy population. Female sexual dysfunction is related to tumor location and treatment modality. For example, cervical cancer survivors treated with radiation therapy have a higher incidence of sexual dysfunction than those treated with surgery; menopause due to endocrine therapy for breast cancer can cause sexual dysfunction; cancer survivors 5-10 years after successful hematopoietic stem cell transplantation may also experience severe sexual dysfunction, some associated with graft-versus-host disease, which can lead to vaginal fibrillation, stricture, and mucosal changes, causing vaginal pain, bleeding, and reduced painful intercourse. The lesions may cause vaginal pain, bleeding and reduced sensitivity of the genital tissues. In addition, high-dose corticosteroid use in chronic graft-versus-host disease can increase emotional instability and depression, affecting emotional attraction, sexual activity, and quality of life. The Survivorship Guidelines call for regular assessment of sexual function in female cancer survivors to understand changes in sexual function before and after tumor detection, the impact of current sexual activity and antitumor therapy on sexual function and behavior, the age of the cancer survivor, and the relationship between the cancer survivor and her partner. The physician may apply the Female Sexual Function Questionnaire for initial screening, and if the patient has a clear diagnosis of sexual dysfunction, further information about treatment-related issues. If a patient believes she is having problems with her sexual function, the Survivorship Guide recommends a thorough evaluation in the following areas: ☆ Understanding symptoms and psychological issues related to sexual dysfunction, such as anxiety, depression, and relationship with partner. ☆ Identify medications that may cause sexual dysfunction. ☆ Pay attention to the traditional factors that cause sexual dysfunction, such as cardiovascular disease, diabetes, obesity, smoking, and alcoholism. ☆ Understand the biological characteristics and treatment history of tumors. ☆ For patients with menopause due to antineoplastic treatment, the effect of menopause on sexual function should be carefully evaluated. ☆ Detailed physical examination and obstetrical and gynecological examination. Interventions The Survivorship Guidelines conclude that the current basis for interventions for sexual dysfunction in female oncology survivors is inadequate and needs to be confirmed by further research. Male sexual dysfunction Erectile dysfunction is highly prevalent in the general population and increases with age. One study showed that 33% of men over the age of 75 developed moderate to severe erectile dysfunction. “The Survival Guide notes that various treatments for cancer may reduce blood flow to the penis and/or damage the autonomic nervous system by damaging blood vessels, making erectile dysfunction more common. Epidemiological surveys have shown that the prevalence of erectile dysfunction in male survivors of colorectal cancer ranges from 45% to 75%, and up to 90% in prostate cancer survivors. Using the Erectile Dysfunction Management Guidelines published by the American College of Surgeons as a guide, the Survivorship Guidelines expert panel reached the following consensus: ☆ Adequate physician-patient communication is the basis for guiding the treatment of patients with erectile dysfunction. ☆ Psychological disorders are the main cause of erectile dysfunction and should be given more attention. Endocrine disorders are also important factors. The “Survival Guide” calls for regular evaluation to fully understand the changes in sexual function before and after cancer diagnosis and the impact of cancer treatment on sexual function. The Sexual Health Inventory for Men (SHIM) is useful in identifying patients who may benefit from treatment for erectile dysfunction. For patients with suspected sexual function problems, the Survival Guide recommends a thorough assessment of the following: ☆ Possible psychosocial issues such as anxiety, depression, and relationship problems. ☆ Identification of prescription and over-the-counter medications that may have an impact on sexual function. ☆ Physical examination and specialist genitourinary examination. ☆ Pay attention to possible cardiovascular risks, and for patients with erectile dysfunction, consult a cardiologist prior to treatment. For cancer survivors with erectile dysfunction, the Survival Guide recommends the following interventions: ☆ First, reduce risk factors, such as quitting smoking, losing weight, increasing physical activity, and avoiding excessive alcohol consumption. ☆ Appropriate psychosocial interventions for both spouses with the disease. ☆ Oral phosphodiesterase 5 inhibitors: Phosphodiesterase 5 inhibitors are contraindicated in patients using nitrates, as their combination can lead to a severe drop in blood pressure; monitor drug efficacy, adverse effects, and changes in the patient’s health status regularly during the course of drug administration. ☆ Patients who fail to respond to phosphodiesterase 5 inhibitor therapy may be seen in urology for consideration of other interventions, including intracavernous injection of vasoactive drugs into the penile corpus cavernosum, second-level intervention with the application of a vacuum compression device, and third-level intervention with penile prosthesis implantation.