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Summary of main findings and contribution

This narrative review focuses on an important question: how psychosexual rehabilitation after cancer can be delivered at scale, rather than only describing how common sexual dysfunction is. The author organizes the available intervention evidence according to the intensity of care.

The low-intensity interventions, such as structured discussions, lubricants and moisturizers, topical lidocaine, and brief clinician training, appear to be relatively low-cost and have reasonable supporting evidence. However, two commonly recommended physical interventions seem to have weaker evidence than is often assumed: scheduled PDE5 inhibitors as part of “penile rehabilitation” and routine vaginal dilation during radiotherapy.

Psychological interventions showed small overall pooled effects, but some targeted trials reported moderate effects, particularly therapist-guided internet-based CBT among breast cancer survivors.

Based on this evidence, the author proposes a five-step stepped-care model (Steps 0–4), building on the extended PLISSIT approach, with suggested criteria for moving patients between levels of care. The paper also discusses possible adaptations for adolescents and young adults (AYA), men receiving androgen deprivation therapy (ADT), and sexual and gender minority (SGM) survivors.

Overall, the paper contributes by shifting the focus from simply identifying sexual dysfunction to considering how psychosexual rehabilitation could actually be delivered in routine oncology care. It also questions two commonly used practices and brings the available interventions together into a practical model that oncology teams, including nurses, could potentially adopt and evaluate.

Major issues

• The methods are not sufficiently reproducible. The review describes the use of “targeted searches,” but does not clearly report which databases were searched, the search dates, search terms, or how studies were selected. The evidence was also “appraised qualitatively,” without using a structured approach such as GRADE or a formal risk-of-bias assessment. Therefore, statements such as the claim that breast cancer has the “strongest trial evidence” may partly reflect the studies selected for the review.

• The stepped-care model has not been empirically validated. The model appears to have been developed by the author through mapping the available interventions to different levels of care. There is no clear evidence of a consensus process, stakeholder involvement, or implementation testing. In particular, the proposed 8–12 week threshold for stepping up care does not appear to have a cited empirical basis. The conclusion that the evidence supports “matching intensity to need” may therefore be stronger than what the available studies can demonstrate. None of the cited studies directly compared this stepped-care model with usual care or immediate referral.

• The evidence supporting Steps 0–2 is mainly clinician-level rather than patient-level. The cited clinician-training studies demonstrate that training can increase clinicians’ confidence or frequency of discussing sexuality, but this does not necessarily demonstrate improvement in patients’ sexual or psychological outcomes. Since these steps form the foundation of the proposed model, stronger evidence linking clinician-level changes to patient outcomes would strengthen the argument. The feasibility of nurse- or clinician-delivered interventions also appears to rely heavily on limited evidence, including one HSCT trial.

• Some important claims rely on weak or non-peer-reviewed evidence. The HSCT multimodal intervention [34] is presented as an important study for supporting the model, but it is based on a conference abstract. Other references [28, 47] also appear to be abstracts. In addition, the “medium-to-large” effects reported for couple-based interventions are based on very small pilot RCTs, including studies with only 23 and 29 couples. These findings should therefore be interpreted cautiously.

• The evidence standards are not applied consistently across interventions. The paper appropriately highlights the limited evidence for penile rehabilitation and vaginal dilation during radiotherapy. However, it then recommends supported dilation after radiotherapy based mainly on observational evidence and an uncontrolled cohort of 53 women, where the reported improvement increased from 11.5% to 60.9% pre- to post-intervention. A specific regimen is also supported by an abstract [28]. The strength of the recommendation should therefore be aligned more clearly with the strength and design of the evidence.

• The interpretation of pooled versus targeted psychological intervention effects may be too strong. The difference between the small pooled effect (SMD 0.24) and the larger effects reported in targeted studies (d 0.43–0.72) is interpreted as evidence that interventions may work better when targeted to patients with greater need. However, this difference could also be explained by heterogeneity between studies, differences in outcome measures, study quality, or small-study effects. The effect sizes also come from different statistical metrics and are discussed without providing confidence intervals, which makes direct comparison more difficult.

• There is no clear limitations section. The paper would benefit from explicitly discussing limitations such as potential search and selection bias, the strong focus on breast cancer, the limited evidence available for men, SGM survivors, and populations in LMIC settings, as well as the lack of evidence regarding cost-effectiveness, workforce requirements, and implementation feasibility.

Minor issues

• PLISSIT should be written in full when it is first introduced, as not all readers may be familiar with the model.

• AYA HOPE should also be defined at first use.

• The term “psychosexual rehabilitation” is described as a staged process, but throughout the paper it is also used broadly to include medical and physical interventions. A clearer operational definition would improve consistency.

• The labels in Table 2 are somewhat confusing, particularly the use of “Steps 0–2” and then “Step 2 (on-demand use)” when the intervention itself is described as scheduled.

• The HSCT row in Table 2 should include the sample size.

• Table 2 states that CBT improvements were maintained at 9 months, whereas the main text refers to outcomes at both 3 and 9 months. These descriptions should be checked for consistency.

• In Table 1, the “Rehabilitation targets” column sometimes describes interventions rather than actual rehabilitation targets. Separating these concepts would make the table clearer.

• In Table 3, the “criteria for stepping up” from Step 0 is not really presented as a clear criterion. More operational definitions would also be helpful for terms such as “relationship breakdown” and “complexity exceeding competence.”

• Figure 1 contains very small text and is difficult to read, particularly on a mobile screen. Increasing the font size or simplifying the figure would improve readability.

• The statement that sexual problems are “a leading unmet supportive care need” appears to rely on a review limited to men with genitourinary cancers [4]. The wording may therefore be broader than the population covered by the cited evidence.

• The sections addressing SGM and AYA survivors are useful but relatively brief and mainly descriptive. Including practical examples of inclusive sexual-health screening questions could make these adaptations more useful for clinical practice.

• I could not identify clear funding, conflict-of-interest, or data-availability statements. These should be included or clarified if they are not provided elsewhere in the manuscript.

Overall, the paper presents a useful and clinically relevant framework, but several of its conclusions and the proposed stepped-care structure appear to go beyond the strength of the currently cited evidence. Clarifying the review methodology, strengthening the distinction between evidence and author-derived recommendations, and expanding the limitations would make the manuscript more rigorous and easier to evaluate.

Competing interests

The author declares that they have no competing interests.

Use of Artificial Intelligence (AI)

The author declares that they used generative AI to come up with new ideas for their review.