Beyond Survival: A Cross-Sectional Analysis of Guideline Recommendations for Cognitive, Sexual, and Psychological Problems in Cancer Survivors

Beyond Survival: A Cross-Sectional Analysis of Guideline Recommendations for Cognitive, Sexual, and Psychological Problems in Cancer Survivors | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Beyond Survival: A Cross-Sectional Analysis of Guideline Recommendations for Cognitive, Sexual, and Psychological Problems in Cancer Survivors Joshua Ayoson, Nadine Schneider, Brian Casanova, Lina Kleijkers, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7235753/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 13 You are reading this latest preprint version Abstract Background/Objective: As the number of cancer survivors increases globally, so does the spotlight on life after cancer. Beneath the surface of remission lies a cluster of silent struggles: cognitive impairments, fractured sexual health, and unspoken psychological wounds. The aim was to summarize current recommendations for adult cancer survivors suffering from cognitive impairment, sexual health, and psychological problems. Methods: A systematic search of PubMed, the Cochrane Library, and major professional society websites was conducted in January 2025. Guidelines published in English from 2000 to 2024 were included if they addressed cognitive, sexual, or psychological issues in adult cancer survivors. Two reviewers independently appraised guideline quality using AGREE II and extracted recommendations, which were then standardized using the GRADE framework. Results Of 524 guidelines screened, 13 guidelines from 7 professional societies met inclusion criteria. Thirteen (92.2%) were of moderate quality; one (7.8%) was low quality. Guidelines strongly emphasized addressing long-term survivorship as a different set of challenges, requiring recognition of psychosocial needs. Strong recommendations supported the use of validated tools for assessing cognitive, sexual, and psychological issues. Non-pharmacologic interventions such as education, physical activity, coping strategies, cognitive rehabilitation, and cognitive behavioral therapy were universally endorsed. Multidisciplinary approaches were recommended for survivors with conditions affecting daily life and quality of life (Qol). Pharmacologic options included PDE5 inhibitors, vaginal estrogens, and osteoporosis treatment for high-risk patients. Conclusion : Cognitive, sexual, and psychological concerns should be proactively screened and managed in cancer survivors. Non-pharmacologic, patient-centered interventions should be prioritized, with individualized care and shared decision-making. Biological sciences/Cancer Health sciences/Health care Health sciences/Oncology Biological sciences/Psychology Social science/Psychology Figures Figure 1 Introduction The modern cancer narrative is evolving from a battle for survival to a pursuit of a meaningful, healthy life after treatment. With the number of cancer survivors continuing to rise globally [1], survivorship care has emerged as a critical domain in oncology. However, beyond the obvious side effects of therapy lie less visible, yet profoundly life-altering challenges: persistent cognitive impairment [2], disrupted sexual health [3,4], and psychological distress [5,6]. Cognitive impairment, often described as “chemo brain”, can linger long after treatment, affecting memory, attention, and executive function [7]. Sexual dysfunction, frequently overlooked in follow-up care, can impair intimacy and self-esteem [3,4,8]. Psychological problems, including depression, anxiety, and fear of recurrence, often remain unspoken, yet severely impact QoL [5]. Evidence suggests that approximately 46% of cancer survivors perceive cognitive deficits [9]. More than 40% of female cancer patients experience sexual dysfunction following cancer treatment, which has been linked to body image concerns [10,11]. Additionally, 45% to 75% of male colorectal cancer survivors report erectile dysfunction [12,13], with up to 90% of prostate cancer survivors affected [14]. Further, approximately 25% of cancer survivors experience psychological distress, which can manifest as depression, anxiety, panic attacks, posttraumatic stress disorder, cancer worry, or anger [15,16]. Although complaints may improve over time, a substantial proportion of survivors report persistent long-term effects that can reshape a survivor’s identity, interpersonal relationships, and ability to reintegrate into everyday life [17]. Cancer survivors face unique post-treatment challenges due to the combined effects of disease, intensive therapies, and psychological strain [18]. Treatment-related neurotoxicity, inflammation, and brain changes may result in cognitive issues [19, 20]. Hormonal fluctuations, psychological stress, and concerns about body image can all affect sexual health, while additional factors such as fear, isolation, and financial pressure may exacerbate psychological distress. [5]. Despite the growing awareness of these survivorship issues, a consistent, evidence-based approach to their identification and management remains elusive [21]. While professional societies have issued survivorship guidelines over the years, it remains unclear how comprehensively they address these critical areas or whether they provide actionable recommendations supported by strong evidence [22]. This systematic review aims to identify, compare, and critically evaluate current recommendations of guidelines that address cognitive impairment, sexual health, and psychological problems in adult cancer survivors. The goal was to assess the level of evidence for recommendations and expose gaps in current evidence-based survivorship care. Cancer survivorship is a process that begins at the moment of diagnosis and continues through the balance of life [23]. The needs of cancer survivors differ throughout the trajectory and late follow-up care (typically 3 to 5 years after their diagnosis) differs compared to earlier phases. Given that different health care providers will care for survivors once they completed their treatment and cancer related follow-up, we focused in this analysis on survivorship care that starts after completion of the cancer related treatment. This cross-sectional analysis of guidelines would also assess and compare the recommendations across different cancer types and healthcare professional disciplines. The strength of this approach lies in its ability to integrate evidence and expert perspectives from multiple fields. By combining systematic review methodology with a cross-sectional design, it provide a broad yet detailed overview of current clinical recommendations. These recommendations draw not only from high-quality evidence but also from multidisciplinary expert consensus, allowing for a well-rounded synthesis of perspectives across clinical specialties. By analysing the quality, consistency, and gaps in these guidelines, this review seeks to identify best practices and provide actionable insights for clinicians and policymakers Study design: In this cross-sectional analysis of guidelines, we conducted a systematic literature search adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [24] to identify all relevant guidelines. Results will be reported following the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist [25] for cross-sectional studies and the PRISMA statement for systematic reviews. Systematic search of guidelines We systematically searched PubMed and the Cochrane Library using relevant MeSH terms and keywords such as “cancer survivors”, “cancer survivorship”, “post-cancer care”, “follow-up”, and “after therapy”, were used in combination with “guideline”, “clinical practice guideline”, and “recommendation”. The full search is depicted in supplemental table S1 . In addition, we searched the webpages of relevant professional societies, reviews, and relevant literature on the topic through external sources, and discussion with experts in the field. Eligibility criteria Survivorship was defined as the period starting after the completion of cancer treatment and follow-up, typically ranging from 3 to 5 years post-diagnosis, in line with existing survivorship care models. For this review, we included guidelines that provided recommendations for the management of cognitive, sexual, and psychological problems during the long term follow up phase. When multiple guidelines from the same society and/or several publications were available, we included the most recent ones. We excluded guidelines without recommendations for cognitive, sexual, and psychosocial problems, reviews, protocols, commentaries, and editorials. We also excluded guidelines and recommendations for cancer survivors of childhood cancers, as their long-term health risks, follow-up care, and late effects differ significantly from those of adult cancer survivors. Survivorship care in childhood cancer requires specialized guidance that addresses developmental, organ-specific, and psychosocial considerations which may not be directly applicable to the broader adult survivor population [26]. Study procedure The study process involved two independent reviewers (J.A. and N.S.) for each of the following steps: title and abstract screening, full-text screening, data extraction, and quality assessment of the guidelines. First, titles and abstracts of all identified references were screened for eligibility. Subsequently, the full texts of potentially relevant references were reviewed for in- or exclusion. Finally, data on recommendations were extracted using a predefined spreadsheet, covering areas such as authors, society, clinical problem, intervention, effect of intervention, level of evidence, and strength of recommendation. In case a guideline used other methods to grade the level of evidence (LOE) and strength of recommendations (SOR), the grading was standardized according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework [27] . See supplemental table S3 and S4 . Disagreements between the two reviewers’ assessments were discussed and resolved by consensus. If consensus could not be achieved, third-party arbitration was done by a third reviewer (E.H. or M.W.). Quality of guidelines In compliance with the Appraisal of Guidelines for Research and Evaluation II (AGREE II) criteria [18], two reviewers (J.A and N.S) independently assessed the quality of the guidelines (Table S2). Given that the manual recommends up to four assessors, we discussed all discrepancies between and resolved them through consensus discussions by two other authors (E. H-L and M.W). This assessment provided an overall evaluation as well as a detailed analysis across six domains, comprising 23 individual items: scope and purpose (3 items), stakeholder involvement (3 items), rigor of development (8 items), clarity of presentation (3 items), applicability (4 items), and editorial independence (2 items). Each item was scored on a 3 star (***) scale, with 1 star indicating "not adhered to", 2 star “moderately adhered” to and 3 indicating "fully adhered." To summarize overall quality, we applied the following classification criteria: High quality: Guidelines receiving 3 stars in at least 5 of the 6 domains (i.e., >15 total stars). Moderate quality: Guidelines receiving an average of 2 stars across domains (i.e., ~12–15 total stars), including occasional domains rated as 1 star. Low quality: Guidelines with <12 total stars or multiple domains rated as 1 star. See supplementary file for detailed assessment of each domain. Given our focus on cognitive, sexual, or psychological specific content, providing a general recommendation for the entire guideline would have been potentially misleading and outside our study scope. Instead, we evaluated (1) the overall methodological quality of each guideline using AGREE II, and (2) the strength and evidence base of related recommendations to the clinical problems in this study. Statistical analyses We summarized continuous and categorical variables with numbers and percentages. Given the simplicity of the data, no statistical software was used. Results Systematic literature review After the exclusion of 105 duplicate references, 418 references were included for screening (Figure 1). During the title and abstract screening, 272 references were excluded and 146 references read in full-text. Of these, 133 guidelines were excluded: 79 (59.4%) of the guidelines addressed primarily surveillance strategies for recurrence or progression and 54 (40.6%) addressed other late effects (e.g., cardiovascular or endocrine complications) but not cognitive, sexual, or psychological problems. Finally, thirteen (13) guidelines from seven (7) professional societies met the predefined inclusion criteria and were included in the final analysis. Guidelines Eleven (84.6%) were cancer type-specific, addressing survivorship issues related to particular cancers such as breast, colorectal, prostate, head and neck, small cell lung, and testicular cancer ( Table 1 ). Two guidelines (15.4%, the National Comprehensive Cancer Network (NCCN 2024) [34] and the American College of Sports Medicine (ACSM 2019) [36]) offered broad recommendations applicable to survivors of all cancer types. The guidelines were issued by both national and international organizations in Europe and the USA. Quality of Guidelines According to the AGREE II Criteria The overall quality of the guidelines varied from moderate (twelve guidelines [92.3%], to low (one guideline [7.7%], the Association of Coloproctology of Great Britain & Ireland (ACPGBI) 2017 guideline [29]), see supplemental Table S2 for the detailed assessment). In particular, the lower score of the ACPGBI guideline reflects evolving standards in guideline development rather than poor quality at the time of publication. Quality of most guidelines was low in particular for missing details on stakeholder involvement, rigor of development, and applicability. Most guidelines did not grade their strength of recommendations (SOR), mainly due to limited evidence supporting the recommendations. Recommendations for Cognitive Impairment Assessment Although most guidelines acknowledged cognitive dysfunction as a potential consequence of treatment, there was no framework for the assessment. The most comprehensive and detailed approach was recommended in the NCCN 2024 Survivorship Guideline [34] ( Table 2 ). A patient-centered approach to cognitive dysfunction includes reassurance and validation of survivors by emphasizing that symptoms often improve over time and do not typically progress (SOR: not classified, LOE: moderate). The guideline recommended a neuropsychological evaluation in survivors whose QoL or work function is impacted, in particular due to its value for the treatment and disability assessments progress (SOR: not classified, LOE: moderate). In patients with cognitive dysfunction, the ACS 2015 guideline [31] suggested screening for depression or anxiety that may worsen and referring for treatment (SOR: not classified, LOE: expert opinion). In breast cancer survivors with cognitive dysfunction, a neurological assessment (SEOM 2018 [32], (SOR: not classified, LOE: not classified)), and a prompt evaluation for reversible causes of cognitive impairment like fatigue, insomnia, and depression (ASCO/ACS 2015 [33], (SOR: not classified, LOE: expert opinion)) was recommended. In patients with small cell lung cancer undergoing prophylactic cranial irradiation, it is recommended to monitor cognitive function and thoroughly evaluate for other potentially treatable causes of cognitive impairment (ESMO 2021 guideline [35] (SOR: strong for, LOE: moderate)). Non-Pharmacological Treatment Most guidelines recommend non-pharmacological approaches as the first choice. According to the NCCN guideline [34], pharmacologic interventions should be the last line of therapy in survivors for whom other interventions have been insufficient (SOR: strong for, not classified: moderate). Treatment options include cognitive stimulating activities (e.g., reading and visual memory exercises, (SEOM 2018 guideline [32], (SOR: not classified, LOE: not classified))), and referral for rehabilitation and group cognitive training (ASCO/ACS 2015 [33], (SOR: not classified, LOE: expert opinion)). Cognitive behavioral therapy (CBT) was recommended based on a moderate level of evidence (NCCN 2024). Two small studies showed benefits in breast cancer survivors with cognitive dysfunction [38,39]. In 40 survivors, CBT improved verbal memory without significant impact on self-reported cognitive complaints [38], and in 47 survivors, video CBT improved self-reported cognitive impairment and neuropsychological processing speed compared with supportive therapy [39]. In survivors with cognitive impairment that interferes with QoL or work functioning, cognitive rehabilitation through speech-language pathologists, occupational therapists, or neuropsychologists was recommended (NCCN 2024 guideline [34], (SOR: not classified, LOE: moderate)). Two guidelines recommended physical activity (ACSM 2019 [36], NCCN 2024 [34]). According to the ACSM 2019 guideline [36], aerobic training may mitigate treatment-related cognitive decline (SOR: not classified, LOE: low). The NCCN 2024 [34] recommended routine physical activity (SOR: not classified, LOE: moderate) based on a study that showed that exercise intervention significantly improved processing speed and by referring to the growing evidence from general geriatric and cancer-specific populations [37]. The NCCN guideline further recommended meditation, yoga (two studies showed improved patient-reported cognitive dysfunction [42,43]), and mindfulness-based stress reduction (two studies showed improved symptoms [40,41], (SOR: not classified, LOE: moderate)). Pharmacological Treatment Although pharmacologic agents such as methylphenidate, modafinil, and donepezil are discussed, these agents should only be used in selected, carefully monitored cases (NCCN 2024 [34] (low evidence)). For example, donepezil improved objective memory performance in one trial but did not affect self-reported cognitive function. Recommendations for Psychological Problems in Cancer Survivors. Assessment All guidelines recommended to assess the presence of psychological problems during consultations (expert consensus to moderate level of evidence) and the use of validated tools to assess psychological problems (expert consensus) such as distress (Distress Thermometer (DT)), depression (Patient Health Questionnaire-9 (PHQ-9), Hospital Anxiety and Depression Scale (HADS)), anxiety (HADS and Generalized Anxiety Disorder-7(GAD-7)), and trauma (PC-PTSD-5). The most comprehensive and clinically actionable recommendations were published by the NCCN 2024 guideline [34]. The guideline recommended routine screening during follow-up visits, including inquiries about feelings of nervousness, anxiety, sadness or depression, and their impact on QoL. Furthermore, contributing factors such as pain, fatigue, endocrine dysfunction, and sleep disturbances should also be identified (SOR: not classified, LOE: moderate). For breast cancer survivors, routine assessment of psychological symptoms, including body image concerns, was specifically recommended. Further, the use of wigs and prostheses was recommended (ACS 2016 guideline [33], (SOR: not classified, LOE: moderate)). In prostate cancer survivors, additional annual screening for prostate-specific antigen (PSA) anxiety and fear of recurrence was recommended (ASC 2014 guideline [45], (SOR: not classified, LOE: moderate)). The guideline recommended timely referrals of survivors with PSA anxiety and/or fear of recurrence, which has been shown to improve outcomes (expert opinion and observations). For colorectal cancer survivors, patients with permanent stomas may experience isolation, altered body image, and reduced QoL. Thus, their sexual dysfunction, distress, depression, anxiety, and QoL should be assessed (ACS 2015 guideline [31], (SOR: not classified, LOE: moderate)). For head and neck cancer survivors, routine screening for depression, distress, and body image issues at baseline, mid-treatment, and follow-up was recommended (ACS 2016 [49] and EHNS 2022 [30], expert opinion). Non-Pharmacological Treatment All guidelines recommended that cancer survivors should have access to psychological care throughout follow-up care and be referred to psychologists when needed (level of evidence: expert consensus). Further, not only psychological problems need to be addressed but also needs related to finances, work, and family (ACS 2014 [45], , NCCN 2024 [34], ACS 2016 [49], and EHNS 2022 [30] (LOE: expert opinion)). Two guidelines recommended physical activity (ACSM 2019 [36] and NCCN 2024 [34], (SOR: strong for)). Whereas the 2024 NCCN guideline [34] recommended regular physical activity based on moderate level of evidence, the 2019 ACSM guideline [36] was more specific with a high level of evidence. The guideline supports moderate-intensity aerobic exercise three times per week for 12 weeks, or twice-weekly combined aerobic and resistance training for 6 to 12 weeks, to reduce anxiety and depressive symptoms in cancer survivors. The NCCN guideline [34] also recommends that cancer survivors consider other alternative treatments (e.g., yoga, tai chi, mindfulness), which may also be helpful to relieve distress (limited evidence). In survivors experiencing grief, trauma, or existential distress, referral to psycho-oncology providers, spiritual care teams, or palliative specialists was recommended. Family and caregiver support are also prioritized, recognizing the broader emotional impact of cancer on the household (LOR: moderate). The ASC 2014 guideline [45] recommends to managing distress or depression with in-office counseling or pharmacotherapy. However, survivors with moderate to severe symptoms should be referred to mental health professionals if initial treatment is insufficient (expert opinion). Pharmacological treatment In moderate to severe depression, generalized anxiety, or PTSD, the use of selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) was recommended (NCCN 2024 guideline [34], (level of evidence: moderate)). The use of the drugs should include counselling about the delayed effects and the need to try different drugs until the best option is identified. SNRIs should be used with caution in survivors taking tamoxifen as they inhibit CYP2D6, which has to convert tamoxifen to its active form (endoxifen) [50]. The use of benzodiazepines should be restricted to short-term or acute management. Tricyclic antidepressants and monoamine oxidase inhibitors (MAOIs) were not recommended as first-line agents due to their unfavorable side effect profiles. Recommendations for Sexual Health in Cancer Survivors Assessment Most guidelines recommend routine screening for sexual health problems using validated questionnaires and open-ended questions ((Table 3), ASCO/ACS 2015 [33], NCCN guideline [34], ASC 2014 [45]). Further, the NCCN guideline [34] recommended an assessment of contributing factors such as mental health, medication side effects, and comorbidities (e.g., cardiovascular disease, diabetes, and substance use). Specific recommendations addressed prostate cancer survivors (the use of Sexual Health Inventory for Men (SHIM) to screen for erectile function, ACS 2014 guideline [45] (SOR: not classified, LOE: expert consensus)), colorectal cancer survivors (sexual dysfunction and fertility; ACS 2015 [31] (SOR: not classified, LOE: expert consensus)), and breast cancer survivors (sexual function; ACS 2016 [33] (SOR: not classified, LOE: expert consensus), premature menopause and infertility; ESMO 2024 [46] (SOR: strong for, LOE: low)). The ESMO 2024 [46] and 2022 [47] guidelines emphasize anticipatory guidance and risk monitoring. The NCCN 2024 guideline [34] further recommended shared decision-making, particularly when hormonal therapies are being considered, to ensure that survivors are informed of both the potential benefits and oncologic risks (SOR: not classified, LOE: moderate). Non-Pharmacological Treatment Non-pharmacological therapies were recommended as first line, such as lubricants, moisturizers, and pelvic floor physical therapy. CBT, yoga, and mindfulness for both female and male survivors were recommended by most guidelines, especially when emotional or relational dynamics play a key role. The NCCN 2024 guideline [34] also addressed orgasmic dysfunction and climacturia, recommending interventions such as pelvic floor muscle training, patient education (e.g., on sexual positioning), and referral to sexual health specialists (Level of evidence: moderate). For breast cancer survivors, psychological support and non-pharmacologic interventions (e.g., vaginal lubricants) were recommended (SEOM 2018 [32], expert opinion). In prostate cancer survivors, penile rehabilitation, partner involvement in management of intimacy concerns and referral to urology or sexual therapy for persistent dysfunction, were recommended (ACS 2014 [45], expert opinion). Pharmacological Treatment In general, there is limited evidence for pharmacological interventions, and the NCCN 2024 guideline [34] cautions against the use of unapproved and unregulated regenerative or restorative therapies marketed for sexual dysfunction. Similarly, the ACS 2019 guideline [36] does not specifically recommend exercise to improve sexual function in cancer survivors. While exercise is known to benefit sexual function in the general population, its effects in cancer survivors, particularly those treated for prostate cancer, remain unclear due to treatment-related anatomical changes (e.g., nerve-sparing vs. non-nerve-sparing surgery) (Level of evidence: insufficient). Recommendations for Men For male rectal cancer survivors, the use of phosphodiesterase type 5 (PDE5) inhibitors (such as sildenafil, vardenafil, tadalafil) was recommended by guidelines (ASC 2014, LOR: expert opinion; NCCN 2024 guideline, LOR: moderate). The ACS 2015 guideline [31] recommended the use of udenafil (50 mg) for 12 weeks based on one RCT showing benefits in 80 patients [48] (Level of evidence: high). In case PDE5 inhibitors are not sufficient for the treatment of erectile dysfunction, penile injections or vacuum devices were recommended (NCCN 2024 guideline [34], LOR: moderate). Testosterone replacement may be considered in men with confirmed symptomatic hypogonadism but is contraindicated in those with hormone-sensitive malignancies (ESMO 2022 guideline [47] (LOR: conditional for, LOE: moderate)). Patients with prostate cancer who will undergo long-term androgen deprivation therapy are at high risk for osteoporosis: therefore the ESMO 2020 guideline [44] recommends initiating oral bisphosphonate therapy or monitor Dual-energy X-ray Absorptiometry (DEXA) scans during treatment (SOR: conditional for, LOE: high). Recommendations for Women Hormonal treatments remain controversial in hormone-sensitive cancers, and no guideline offers a strength of recommendation. The use of dehydroepiandrosterone (DHEA) can be considered for vaginal dryness or pain with sexual activity (NCCN 2024 [34], LOE: moderate). However, the guideline warns that DHEA should be used with caution in survivors with a history of estrogen-dependent cancers. Ospifemene was recommended for dyspareunia in women without hormone-sensitive cancers (NCCN 2024, (LOE: moderate)). Further, flibanserin may be used for premenopausal survivors with low or lack of desire, libido, or intimacy (NCCN 2024, LOE: limited). For other substances (bremelanotide, bupropion, or buspirone), the use may be considered. However, robust data in cancer populations are lacking (LOE: insufficient). Discussion In this systematic analysis of thirteen guidelines, we summarized recommendations for cognitive, sexual, or psychological problems in cancer survivors. Given the high prevalence and burden of disease, the current evidence supporting recommendations was limited. Many recommendations were based on expert consensus. Additionally, actionable recommendations were limited. Long-term survivorship needs to be addressed as a different set of challenges, to encompass the psychosocial needs of patients once treatment ends (strong recommendation, expert opinion). Strong recommendations were identified for routine assessment of cognitive, psychological, and sexual health problems throughout follow-up care using validated questionnaires. Survivors should have access to psychological care and/or be referred to in case of depression, anxiety, or distress. Counselling and early referral to cognitive behavioral therapy should be initiated in survivors with psychological problems that affect the ability to work or impact their QoL. Also strongly recommended was physical activity to reduce depressive symptoms, stress, anxiety, and improve cognitive function (LOE: moderate (NCCN 2024 [34]) to high (ACSM 2019 [36]). According to the ACSM 2019, moderate intensity aerobic training three times per week for 12 weeks or twice weekly combined aerobic plus resistance training for 6–12 weeks reduced anxiety and depressive symptoms in cancer survivors during and after treatment significantly. For sexual health, topical non-pharmacological options (e.g., lubricants, pelvic floor therapy) were recommended. Strong recommendations were also found for the discussion of premature menopause, infertility, and potential sexual dysfunction in each patient before the start of adjuvant therapy. Early education and guidance on sexual health concerns and infertility, with appropriate referral to CBT, psychoeducational support, sexual therapy, and mindfulness training, was recommended. Pharmacologic (e.g., vaginal estrogen, DHEA, PDE5 inhibitors) options were discussed including the cautious use in hormone-sensitive tumors. Due to the increased risk for osteoporosis in men undergoing long-term androgen deprivation therapy, prostate cancer survivors should be screened and treated if indicated. Also, postmenopausal breast cancer survivors should be referred for a baseline DEXA scan to assess bone health. Findings in light of the literature The burden of cognitive deficits, psychological problems, and sexual health issues among cancer survivors is substantial. Depending on cancer type and the treatments, between 20% and 75% of cancer survivors report persisting cognitive deficits - often long after completion of active treatment – including impaired memory, executive function, and attention [51,52]. This translates into challenges in returning to work, maintaining productivity, managing complex tasks, and sustaining social relationships. For instance, studies show that up to 30-40% of breast cancer survivors report being unable to return to their pre-cancer level of occupational functioning even several years post-treatment, with cognitive complaints cited as a major contributing factor [53,54]. Beyond occupational challenges, cognitive deficits often co-occur with psychological distress, such as anxiety, depression, and reduced self-esteem [55]. These issues can place strains on personal relationships and diminish the overall QoL. Psychological issues - including anxiety, depression, fear of recurrence, PTSD, and existential crises - are among the most prevalent and disruptive issues faced by cancer survivors, with pooled estimates indicating that 25-40% experience clinically significant symptoms [56]. Thus, effective follow-up care needs to identify and address cognitive and psychological issues of cancer survivors. There is a critical need for effective interventions targeting both the biological underpinnings (e.g., neuroinflammation, endocrine dysregulation) and the psychosocial consequences of cancer-related cognitive impairment. Functional MRI and biomarker studies support that cognitive impairment is biologically grounded, involving disrupted neural networks, inflammation, neuroendocrine dysregulation, and oxidative stress [58]. Yet, most guidelines still approach cognitive dysfunction as a subsidiary psychosocial issue, failing to provide structured treatment algorithms [59]. Over the past years, more evidence based on high-quality randomized trials has been published demonstrating the importance of exercise. There is compelling evidence that exercise improves cognitive function in older adults and other clinical populations [60]. In cancer survivors, randomized trials showed an improvement of cancer related fatigue [61]. Randomized clinical studies should assess the impact of exercise and nutrition on cognitive function as the primary outcome. Sexual dysfunction is another major concern, often linked to cognitive changes, treatment-induced hormonal imbalance, body image disturbances, and emotional distress [57]. These sexual problems can adversely affect intimacy, relationship satisfaction, and overall mental health. Sexual dysfunction has been reported in up to 90% of men with prostate cancer and 70% of women with breast or pelvic cancer. The underlying causes range from nerve injury, adverse effects of treatments, hormonal disruption, body image disturbance and trauma-related avoidance [62,63]. Although most guidelines recommend screening and addressing sexual health, survivors frequently report that sexual concerns are unaddressed or dismissed in routine follow-up, leading to avoidable declines in intimacy, self-esteem, and relationship satisfaction [64]. Given that most guidelines did not offer actionable recommendations, clinicians are left without evidence-based interventions. Treatments, such as vaginal estrogen, DHEA, pelvic floor therapy, and PDE5 inhibitors are well supported in the literature [4,65,66,67]. Psychosexual therapy, CBT, and mindfulness-based strategies show promising benefits for cancer survivors [68], however most guidelines refer to these approaches as alternative treatments without specifying on duration and intensity.. Psychological distress extends beyond being a mere side effect; it is strongly associated with increased mortality, poor treatment adherence, impaired immune function, and higher healthcare costs [69-70]. Additionally, it correlates with reduced QoL, alongside negative long-term outcomes, such as social isolation, impaired interpersonal relationships, and increased risk of substance abuse, particularly alcohol [71-74]. Thus, it is important in effective follow-up care to identify affected survivors or survivors at risk for psychological problems. Validated screening instruments such as the Distress Thermometer, PHQ-9, HADS, and GAD-7 have been used for over a decade [75], and their routine use may improve clinical care. Although meta-analyses support non-pharmacologic interventions including CBT, psychoeducation, mindfulness, and supportive-expressive therapy[76], these approaches remain underutilized, often due to insufficient implementation guidance. For instance, studies have shown that despite CBT's well-established effectiveness for a range of mental health conditions, many patients do not receive it due to limited availability, high cost, and a shortage of trained providers [77]. To address these barriers, digital and internet-based CBT (iCBT) platforms have emerged as accessible and cost-effective alternatives. Evidence suggests that iCBT can be as effective as face-to-face therapy for certain populations [78]. However, concerns persist about the potential for such tools, particularly AI-powered chatbots, to replace meaningful human interaction, possibly exacerbatingsocial isolation or reducing therapeutic alliance [79]. Limitations Several limitations need to be discussed. Although we used an extended search strategy, and consulted all websites of professional societies, we may have missed guidelines with recommendations for cognitive impairments, sexual health and psychological problems in cancer survivors. Only English-language publications were reviewed, which may introduce language bias and limit international applicability. Further, more evidence on specific interventions may have been published since the publication of the guidelines and thus, not be included in this study. Given that newer evidence is also not included in the guidelines, clinicians are also not likely to use them for their patients. In addition, some of the included guidelines span more than a decade, during which both the strength of the evidence base and the methodological standards for guideline development have evolved. As a result, some variability in recommendations may be due to publication date. Older guidelines may not reflect current best evidence and should therefore be interpreted with caution. Importantly, our analysis was restricted to recommendations for post-treatment survivorship care. We did not evaluate interventions specific to patients undergoing active cancer treatment, nor those living with advanced disease or receiving end-of-life care. Thus, this study provides the most comprehensive overview of current recommendations and their evidence in the survivorship phase. Implications for Research Given the low level of evidence for most recommendations, there is an urgent need to assess the efficacy of assessments and interventions for cognitive, sexual, and psychological care in cancer survivors. High-quality clinical studies should assess the efficacy of aerobic and resistance training on cognitive function and psychological problems. Further, future research should focus on uncovering the biological underpinnings of post-treatment neurocognitive dysfunction. Investigations into neuro-inflammation, blood-brain barrier disruption, oxidative stress, HPA axis dysregulation, and altered neurotransmitter signaling are crucial to identify actionable therapeutic targets [58]. Longitudinal studies incorporating neuroimaging, circulating biomarkers (e.g., IL-6, TNF-α, BDNF), and objective cognitive assessments (e.g., MoCA, FACT-Cog, PROMIS-CF) are needed to elucidate symptom trajectories [59,80]. Interventional research should test multimodal strategies, combining cognitive rehabilitation, physical activity, and CBT, delivered either in person or digitally, carefully considering timing, intensity, and personalization. In the area of sexual health, research remains disproportionately underdeveloped despite high prevalence rates and its profound effect on QoL. This may be due to different causal pathways, including vascular injury, neurotoxicity, endocrine disruption, treatment-induced inflammation, and body image issues [65]. High-quality randomized controlled trials should compare multimodal treatment of first-line non-pharmacologic interventions (e.g., pelvic floor therapy, lubricants, psychosexual education) with pharmacologic agents (e.g., PDE5 inhibitors, topical estrogen, DHEA, testosterone therapy) stratify by sex, cancer type, hormonal receptor status, and treatment exposure to optimize intervention targeting. Additionally, the role of CBT and sex therapy should be further investigated. While psychosocial interventions such as CBT, MBSR, and psychoeducation have demonstrated efficacy in controlled settings, there remains a need to expand their reach, cultural relevance, and scalability, particularly through digital mental health platforms. Long-term studies are needed to assess the durability of effects and cost-effectiveness across diverse survivor populations. In all areas, survivorship research must evolve to reflect the interconnected nature of post-treatment sequelae. Studies should adopt integrated, symptom cluster frameworks that evaluate interventions for co-occurring cognitive, sexual, and emotional symptoms. Further, the establishment of core outcome sets and standardized criteria for treatment response is critical for harmonizing data and advancing meta-analytic synthesis. Implementation science must be embedded within future research to evaluate feasibility, health system integration, and patient-centeredness of interventions [22,28]. Finally, emerging technologies, including wearable biosensors, symptom tracking, and AI-assisted clinical decision tools, offer scalable solutions but remain under-evaluated. In particular, virtual reality (VR) interventions and mirror therapy are gaining attention as novel approaches to address body image disturbances among cancer survivors. Early studies have demonstrated that VR-based exposure therapy can help reduce body-related anxiety and improve body satisfaction by allowing patients to interact with modified virtual representations of their bodies [81]. Similarly, mirror therapy, traditionally used in stroke rehabilitation, has been adapted for cancer populations and shows promise in improving physical function and reducing body dissatisfaction following breast cancer surgery [82]. Despite these encouraging preliminary results, larger, methodologically rigorous trials are needed to confirm the efficacy of these interventions and to guide their integration into routine cancer survivorship care. By aligning mechanistic insights, personalized intervention models, and implementation pathways, future research can bridge the gap between evidence and practice, ensuring that survivorship care evolves beyond surveillance into proactive, precision survivorship. Implications for clinical practice In cancer survivors, effective follow-up care includes the screening for and treatment of cognitive impairment, sexual dysfunction, and psychological problems. The use of validated questionnaires may help to identify affected persons. Non-pharmacological interventions are the main cornerstone in the treatment. Counselling before, during, and after the cancer therapy should encompass life-changing issues such as fertility, libido, fatigue, cognitive impairment, and psychological issues. Given the increasing body of evidence that suggests physical activity positively influences various adverse effects during and after cancer therapy, all patients should be encouraged to engage in physical activities. Multidisciplinary collaboration and early identification across all three domains can significantly improve survivorship outcomes and QoL. Conclusion In cancer survivors, cognitive impairment, sexual dysfunction, and psychological problems should be screened and identified during clinical encounters. For cognitive impairment, education and physical activity are recommended. For psychological problems, early non-pharmacologic interventions such as exercise, CBT, coping strategies, mindfulness, and symptom-specific therapies have been recommended. In survivors suffering from sexual dysfunction, shared decision-making and counselling are recommended. Abbreviations ACGBI: Association of Coloproctology of Great Britain and Ireland ACS: American Cancer Society ACSM: American College of Sports Medicine AGREE II: Appraisal of Guidelines for Research and Evaluation II ASCO: American Society of Clinical Oncology ADT: Androgen Deprivation Therapy BDNF: Brain-Derived Neurotrophic Factor CBT: Cognitive Behavioral Therapy CRC: Colorectal Cancer CTIBL: Cancer Treatment-Induced Bone Loss DHEA: Dehydroepiandrosterone DEXA: Dual-Energy X-ray Absorptiometry EHNS: European Head and Neck Society ESMO: European Society of Medical Oncology FACT-Cog: Functional Assessment of Cancer Therapy – Cognitive Function FSFI: Female Sexual Function Index GAD-7: Generalized Anxiety Disorder-7 GCT: Germ Cell Tumor GRADE: Grading of Recommendations Assessment, Development, and Evaluation HADS: Hospital Anxiety and Depression Scale HPA: Hypothalamic–Pituitary–Adrenal (Axis) IL-6: Interleukin-6 IRB: Institutional Review Board MAOI: Monoamine Oxidase Inhibitor MDASI-HN: MD Anderson Symptom Inventory – Head and Neck module MBSR: Mindfulness-Based Stress Reduction MoCA: Montreal Cognitive Assessment NCCN: National Comprehensive Cancer Network NS: Not Stated PCI: Prophylactic Cranial Irradiation PHQ-9: Patient Health Questionnaire-9 PDE5 inhibitors: Phosphodiesterase Type 5 Inhibitors PROMIS-CF: Patient-Reported Outcomes Measurement Information System – Cognitive Function PTSD: Post-Traumatic Stress Disorder QoL: Quality of Life SEOM: Spanish Society of Medical Oncology (Sociedad Española de Oncología Médica) SHIM: Sexual Health Inventory for Men SNRI: Serotonin-Norepinephrine Reuptake Inhibitor SSMO: Spanish Society of Medical Oncology SSRI: Selective Serotonin Reuptake Inhibitor TCA: Tricyclic Antidepressant TNF-α: Tumor Necrosis Factor Alpha Declarations Competing interests J.A declare no competing interest. N.S declare no competing interest. B.C declare no competing interest. L.K declare no competing interest. L.S declare no competing interest. S.R declare competing interest; Research support from other organizations: Roche, AstraZeneca, Swiss National Foundation and Amgen. K.G-F declare competing interest; Grant from the Kanton Aargau, Switzerland. Funding a pilot project for consultation of cancer survivors. E.H-L declare competing interest; Grant from the Kanton Aargau, Switzerland. Funding a pilot project for consultation of cancer survivors. M.M.W declare competing interest; Grant from the Kanton Aargau, Switzerland. Funding a pilot project for consultation of cancer survivors and a Grant from the Stiftung Cardio.” Funding Information This work was supported by the Canton of Aargau, Switzerland. References K. D. Miller, L. Nogueira, T. Devasia, A. B. Mariotto, K. Yabroff, A. Jemal, J. Kramer und R. L. 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Description of Guidelines on cognitive, sexual, and psychological problems in Survivorship Care Guideline Country/Region Issuing Organization Scope Cancer Type-Specific Overall quality ACGBI 2017 [29] Great Britain Association of Coloproctology of Great Britain & Ireland Cancer type-specific Colon, Rectal and Anal Cancer Poor ASCO/ACS 2016 [33] USA American Society of Clinical Oncology (ASCO) Cancer type-specific Breast Cancer Moderate EHNS 2022 [30] Europe European Head and Neck Society (EHNS) Cancer type-specific Head and Neck Cancer Moderate NCCN 2024 [34] USA National Comprehensive Cancer Network (NCCN) Broad No Moderate ACSM 2019 [36] USA American College of Sports Medicine (ACSM) Broad No Moderate ESMO 2024 [46] Europe European Society of Medical Oncology (ESMO) Cancer type-specific Breast Cancer Moderate ESMO 2020 [44] Europe European Society of Medical Oncology (ESMO) Cancer type-specific Prostate Cancer Moderate ACS 2014 [45] USA American Cancer Society (ACS) Cancer type-specific Prostate Cancer Moderate ACS 2015 [31] USA American Cancer Society (ACS) Cancer type-specific Colorectal Cancer Moderate ACS 2016 [49] USA American Cancer Society (ACS) Cancer type-specific Head and Neck Cancer Moderate ESMO 2021 [35] Europe European Society of Medical Oncology (ESMO) Cancer type-specific Small Cell Lung Carcinoma Moderate SOEM, 2018 [32] Europe Spanish Society of Medical Oncology. Cancer type-specific Breast Cancer Moderate ESMO 2022 [47] Europe European Society of Medical Oncology (ESMO) Cancer type-specific Testicular Cancer Moderate Table 2 To 4 are available in the Supplementary Files section. Additional Declarations Competing interest reported. “J.A declare no competing interest. N.S declare no competing interest. B.C declare no competing interest. L.K declare no competing interest. L.S declare no competing interest. S.R declare competing interest; Research support from other organizations: Roche, AstraZeneca, Swiss National Foundation and Amgen. K.G-F declare competing interest; Grant from the Kanton Aargau, Switzerland. Funding a pilot project for consultation of cancer survivors. E.H-L declare competing interest; Grant from the Kanton Aargau, Switzerland. Funding a pilot project for consultation of cancer survivors. M.M.W declare competing interest; Grant from the Kanton Aargau, Switzerland. Funding a pilot project for consultation of cancer survivors and a Grant from the Stiftung Cardio.” Supplementary Files PRISMA2020checklistformanuscriptoncognitiveimpairmentsexualhealthandpsychologicalproblems.docx EvaluationbasedonAGREEIIcriteriaof13guidelines.docx Supplementarytable.docx Table2To4.docx Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 20 Apr, 2026 Reviews received at journal 14 Apr, 2026 Reviews received at journal 09 Apr, 2026 Reviewers agreed at journal 19 Mar, 2026 Reviewers agreed at journal 19 Mar, 2026 Reviews received at journal 19 Mar, 2026 Reviewers agreed at journal 19 Mar, 2026 Reviewers agreed at journal 21 Aug, 2025 Reviewers invited by journal 19 Aug, 2025 Editor assigned by journal 19 Aug, 2025 Editor invited by journal 08 Aug, 2025 Submission checks completed at journal 07 Aug, 2025 First submitted to journal 07 Aug, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7235753","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":503710222,"identity":"9d6aa5fd-f346-49b7-b1b4-248a2649916a","order_by":0,"name":"Joshua Ayoson","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA4ElEQVRIiWNgGAWjYBAC9gYGNiRuRQKDAQOKCCZgRNVyhmQtjG3EaGlvf/aYp4ZB3uB4+8PHhfPS7M0ZmJ89wKul54y5Mc8xBsMNZ84YG8/clpO4s4HN3ACvlhk5bNI8bAyMG24AGbzbKhIMDvCwSeDXkv5Mmucfg/2GG0AG75wKe4JaBGckmEnztjEkbrgBYjTkMG4gpEWa54yZ5Nw+ieSZIL/wHEtL3NnMZoZXCx97+zOJN99sbPtAIcZTk2xvzt78DK8WKJBgUDgAYzMToR4M5BuIVTkKRsEoGAUjDgAAq19DZjAj5b8AAAAASUVORK5CYII=","orcid":"","institution":"Cantonal Hospital of Baden","correspondingAuthor":true,"prefix":"","firstName":"Joshua","middleName":"","lastName":"Ayoson","suffix":""},{"id":503710223,"identity":"72e6bfbf-f974-475a-a595-3d9437ab9e4c","order_by":1,"name":"Nadine Schneider","email":"","orcid":"","institution":"Cantonal Hospital of Baden","correspondingAuthor":false,"prefix":"","firstName":"Nadine","middleName":"","lastName":"Schneider","suffix":""},{"id":503710224,"identity":"e1acefc9-62c7-4519-9bd8-3994a1a096db","order_by":2,"name":"Brian Casanova","email":"","orcid":"","institution":"Cantonal Hospital of Baden","correspondingAuthor":false,"prefix":"","firstName":"Brian","middleName":"","lastName":"Casanova","suffix":""},{"id":503710227,"identity":"c4c73970-f65e-4f73-a996-f4dcaaed4393","order_by":3,"name":"Lina Kleijkers","email":"","orcid":"","institution":"Cantonal Hospital of Baden","correspondingAuthor":false,"prefix":"","firstName":"Lina","middleName":"","lastName":"Kleijkers","suffix":""},{"id":503710228,"identity":"eebf3f08-1fdb-421e-a424-f96fe246f9e0","order_by":4,"name":"Luca Siragusa","email":"","orcid":"","institution":"Cantonal Hospital of Baden","correspondingAuthor":false,"prefix":"","firstName":"Luca","middleName":"","lastName":"Siragusa","suffix":""},{"id":503710229,"identity":"e0326c56-c4d3-4592-9ae8-71ebc3e2770e","order_by":5,"name":"Sacha I Rothschild","email":"","orcid":"","institution":"Cantonal Hospital of Baden","correspondingAuthor":false,"prefix":"","firstName":"Sacha","middleName":"I","lastName":"Rothschild","suffix":""},{"id":503710230,"identity":"f9865c1f-b1cf-4c76-a022-5e5f78ec2faf","order_by":6,"name":"Katharina Gut-Fischer","email":"","orcid":"","institution":"Cantonal Hospital of Baden","correspondingAuthor":false,"prefix":"","firstName":"Katharina","middleName":"","lastName":"Gut-Fischer","suffix":""},{"id":503710231,"identity":"d9e6f0d1-3001-4dbb-8515-929a9f048616","order_by":7,"name":"Eva Haegler-Laube","email":"","orcid":"","institution":"Cantonal Hospital of Baden","correspondingAuthor":false,"prefix":"","firstName":"Eva","middleName":"","lastName":"Haegler-Laube","suffix":""},{"id":503710234,"identity":"74a17a49-b346-4f5e-a903-974446bddbab","order_by":8,"name":"Maria M. 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N.S declare no competing interest. B.C declare no competing interest. L.K declare no competing interest. L.S declare no competing interest. S.R declare competing interest; Research support from other organizations: Roche, AstraZeneca, Swiss National Foundation and Amgen. K.G-F declare competing interest; Grant from the Kanton Aargau, Switzerland. Funding a pilot project for consultation of cancer survivors. E.H-L declare competing interest; Grant from the Kanton Aargau, Switzerland. Funding a pilot project for consultation of cancer survivors. M.M.W declare competing interest; Grant from the Kanton Aargau, Switzerland. Funding a pilot project for consultation of cancer survivors and a Grant from the Stiftung Cardio.”","formattedTitle":"Beyond Survival: A Cross-Sectional Analysis of Guideline Recommendations for Cognitive, Sexual, and Psychological Problems in Cancer Survivors","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe modern cancer narrative is evolving from a battle for survival to a pursuit of a meaningful, healthy life after treatment. With the number of cancer survivors continuing to rise globally [1], survivorship care has emerged as a critical domain in oncology. However, beyond the obvious side effects of therapy lie less visible, yet profoundly life-altering challenges: persistent cognitive impairment [2], disrupted sexual health [3,4], and psychological distress [5,6]. Cognitive impairment, often described as \u0026ldquo;chemo brain\u0026rdquo;, can linger long after treatment, affecting memory, attention, and executive function [7]. Sexual dysfunction, frequently overlooked in follow-up care, can impair intimacy and self-esteem [3,4,8]. Psychological problems, including depression, anxiety, and fear of recurrence, often remain unspoken, yet severely impact QoL [5]. \u003c/p\u003e\n\u003cp\u003eEvidence suggests that approximately 46% of cancer survivors perceive cognitive deficits [9]. More than 40% of female cancer patients experience sexual dysfunction following cancer treatment, which has been linked to body image concerns [10,11]. Additionally, 45% to 75% of male colorectal cancer survivors report erectile dysfunction [12,13], with up to 90% of prostate cancer survivors affected [14]. Further, approximately 25% of cancer survivors experience psychological distress, which can manifest as depression, anxiety, panic attacks, posttraumatic stress disorder, cancer worry, or anger [15,16]. Although complaints may improve over time, a substantial proportion of survivors report persistent long-term effects that can reshape a survivor\u0026rsquo;s identity, interpersonal relationships, and ability to reintegrate into everyday life [17]. Cancer survivors face unique post-treatment challenges due to the combined effects of disease, intensive therapies, and psychological strain [18]. Treatment-related neurotoxicity, inflammation, and brain changes may result in cognitive issues [19, 20]. Hormonal fluctuations, psychological stress, and concerns about body image can all affect sexual health, while additional factors such as fear, isolation, and financial pressure may exacerbate psychological distress. [5]. \u003c/p\u003e\n\u003cp\u003eDespite the growing awareness of these survivorship issues, a consistent, evidence-based approach to their identification and management remains elusive [21]. While professional societies have issued survivorship guidelines over the years, it remains unclear how comprehensively they address these critical areas or whether they provide actionable recommendations supported by strong evidence [22]. This systematic review aims to identify, compare, and critically evaluate current recommendations of guidelines that address cognitive impairment, sexual health, and psychological problems in adult cancer survivors. The goal was to assess the level of evidence for recommendations and expose gaps in current evidence-based survivorship care. Cancer survivorship is a process that begins at the moment of diagnosis and continues through the balance of life [23]. The needs of cancer survivors differ throughout the trajectory and late follow-up care (typically 3 to 5 years after their diagnosis) differs compared to earlier phases. Given that different health care providers will care for survivors once they completed their treatment and cancer related follow-up, we focused in this analysis on survivorship care that starts after completion of the cancer related treatment. This cross-sectional analysis of guidelines would also assess and compare the recommendations across different cancer types and healthcare professional disciplines. The strength of this approach lies in its ability to integrate evidence and expert perspectives from multiple fields. By combining systematic review methodology with a cross-sectional design, it provide a broad yet detailed overview of current clinical recommendations. These recommendations draw not only from high-quality evidence but also from multidisciplinary expert consensus, allowing for a well-rounded synthesis of perspectives across clinical specialties. By analysing the quality, consistency, and gaps in these guidelines, this review seeks to identify best practices and provide actionable insights for clinicians and policymakers\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eStudy design: \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn this cross-sectional analysis of guidelines, we conducted a systematic literature search adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [24] to identify all relevant guidelines. Results will be reported following the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist [25] for cross-sectional studies and the PRISMA statement for systematic reviews.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eSystematic search of guidelines \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe systematically searched PubMed and the Cochrane Library using relevant MeSH terms and keywords such as \u0026ldquo;cancer survivors\u0026rdquo;, \u0026ldquo;cancer survivorship\u0026rdquo;, \u0026ldquo;post-cancer care\u0026rdquo;, \u0026ldquo;follow-up\u0026rdquo;, and \u0026ldquo;after therapy\u0026rdquo;, were used in combination with \u0026ldquo;guideline\u0026rdquo;, \u0026ldquo;clinical practice guideline\u0026rdquo;, and \u0026ldquo;recommendation\u0026rdquo;. The full search is depicted in \u003cstrong\u003esupplemental table S1\u003c/strong\u003e. In addition, we searched the webpages of relevant professional societies, reviews, and relevant literature on the topic through external sources, and discussion with experts in the field.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eEligibility criteria\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSurvivorship was defined as the period starting after the completion of cancer treatment and follow-up, typically ranging from 3 to 5 years post-diagnosis, in line with existing survivorship care models. For this review, we included guidelines that provided recommendations for the management of cognitive, sexual, and psychological problems during the long term follow up phase. When multiple guidelines from the same society and/or several publications were available, we included the most recent ones. We excluded guidelines without recommendations for cognitive, sexual, and psychosocial problems, reviews, protocols, commentaries, and editorials. We also excluded guidelines and recommendations for cancer survivors of childhood cancers, as their long-term health risks, follow-up care, and late effects differ significantly from those of adult cancer survivors. Survivorship care in childhood cancer requires specialized guidance that addresses developmental, organ-specific, and psychosocial considerations which may not be directly applicable to the broader adult survivor population [26].\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eStudy procedure\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study process involved two independent reviewers (J.A. and N.S.) for each of the following steps: title and abstract screening, full-text screening, data extraction, and quality assessment of the guidelines. First, titles and abstracts of all identified references were screened for eligibility. Subsequently, the full texts of potentially relevant references were reviewed for in- or exclusion. Finally, data on recommendations were extracted using a predefined spreadsheet, covering areas such as authors, society, clinical problem, intervention, effect of intervention, level of evidence, and strength of recommendation. In case a guideline used other methods to grade the level of evidence (LOE) and strength of recommendations (SOR), the grading was standardized according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework [27]\u003cstrong\u003e. \u003c/strong\u003eSee\u003cstrong\u003e supplemental table S3 and S4\u003c/strong\u003e. Disagreements between the two reviewers\u0026rsquo; assessments were discussed and resolved by consensus. If consensus could not be achieved, third-party arbitration was done by a third reviewer (E.H. or M.W.).\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eQuality of guidelines\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn compliance with the Appraisal of Guidelines for Research and Evaluation II (AGREE II) criteria [18], two reviewers (J.A and N.S) independently assessed the quality of the guidelines (Table S2). Given that the manual recommends up to four assessors, we discussed all discrepancies between and resolved them through consensus discussions by two other authors (E. H-L and M.W). This assessment provided an overall evaluation as well as a detailed analysis across six domains, comprising 23 individual items: scope and purpose (3 items), stakeholder involvement (3 items), rigor of development (8 items), clarity of presentation (3 items), applicability (4 items), and editorial independence (2 items). Each item was scored on a 3 star (***) scale, with 1 star indicating \u0026quot;not adhered to\u0026quot;, 2 star \u0026ldquo;moderately adhered\u0026rdquo; to and 3 indicating \u0026quot;fully adhered.\u0026quot; To summarize overall quality, we applied the following classification criteria: High quality: Guidelines receiving 3 stars in at least 5 of the 6 domains (i.e., \u0026gt;15 total stars). Moderate quality: Guidelines receiving an average of 2 stars across domains (i.e., ~12\u0026ndash;15 total stars), including occasional domains rated as 1 star. Low quality: Guidelines with \u0026lt;12 total stars or multiple domains rated as 1 star. See supplementary file for detailed assessment of each domain. Given our focus on cognitive, sexual, or psychological specific content, providing a general recommendation for the entire guideline would have been potentially misleading and outside our study scope. Instead, we evaluated (1) the overall methodological quality of each guideline using AGREE II, and (2) the strength and evidence base of related recommendations to the clinical problems in this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical analyses\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe summarized continuous and categorical variables with numbers and percentages. Given the simplicity of the data, no statistical software was used.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eSystematic literature review\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAfter the exclusion of 105 duplicate references, 418 references were included for screening (Figure 1). During the title and abstract screening, 272 references were excluded and 146 references read in full-text. Of these, 133 guidelines were excluded: 79 (59.4%) of the guidelines addressed primarily surveillance strategies for recurrence or progression and 54 (40.6%) addressed other late effects (e.g., cardiovascular or endocrine complications) but not cognitive, sexual, or psychological problems. Finally, thirteen (13) guidelines from seven (7) professional societies met the predefined inclusion criteria and were included in the final analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eGuidelines\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEleven (84.6%) were cancer type-specific, addressing survivorship issues related to particular cancers such as breast, colorectal, prostate, head and neck, small cell lung, and testicular cancer (\u003cstrong\u003eTable 1\u003c/strong\u003e). Two guidelines (15.4%, the National Comprehensive Cancer Network (NCCN 2024) [34] and the American College of Sports Medicine (ACSM 2019) [36]) offered broad recommendations applicable to survivors of all cancer types. The guidelines were issued by both national and international organizations in Europe and the USA.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eQuality of Guidelines According to the AGREE II Criteria\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe overall quality of the guidelines varied from moderate (twelve guidelines [92.3%], to low (one guideline [7.7%], the Association of Coloproctology of Great Britain \u0026amp; Ireland (ACPGBI) 2017 guideline [29]), see supplemental Table S2 for the detailed assessment). In particular, the lower score of the ACPGBI guideline reflects evolving standards in guideline development rather than poor quality at the time of publication. Quality of most guidelines was low in particular for missing details on stakeholder involvement, rigor of development, and applicability. Most guidelines did not grade their strength of recommendations (SOR), mainly due to limited evidence supporting the recommendations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRecommendations for Cognitive Impairment\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAssessment\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAlthough most guidelines acknowledged cognitive dysfunction as a potential consequence of treatment, there was no framework for the assessment. The most comprehensive and detailed approach was recommended in the NCCN 2024 Survivorship Guideline [34] (\u003cstrong\u003eTable 2\u003c/strong\u003e). A patient-centered approach to cognitive dysfunction includes reassurance and validation of survivors by emphasizing that symptoms often improve over time and do not typically progress (SOR: not classified, LOE: moderate). The guideline recommended a neuropsychological evaluation in survivors whose QoL or work function is impacted, in particular due to its value for the treatment and disability assessments progress (SOR: not classified, LOE: moderate). In patients with cognitive dysfunction, the ACS 2015 guideline [31] suggested screening for depression or anxiety that may worsen and referring for treatment (SOR: not classified, LOE: expert opinion). In breast cancer survivors with cognitive dysfunction, a neurological assessment (SEOM 2018 [32], (SOR: not classified, LOE: not classified)), and a prompt evaluation for reversible causes of cognitive impairment like fatigue, insomnia, and depression (ASCO/ACS 2015 [33], (SOR: not classified, LOE: expert opinion)) was recommended. In patients with small cell lung cancer undergoing prophylactic cranial irradiation, it is recommended to monitor cognitive function and thoroughly evaluate for other potentially treatable causes of cognitive impairment (ESMO 2021 guideline [35] (SOR: strong for, LOE: moderate)).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eNon-Pharmacological Treatment\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eMost guidelines recommend non-pharmacological approaches as the first choice. According to the NCCN guideline [34], pharmacologic interventions should be the last line of therapy in survivors for whom other interventions have been insufficient (SOR: strong for, not classified: moderate). Treatment options include cognitive stimulating activities (e.g., reading and visual memory exercises, (SEOM 2018 guideline [32], (SOR: not classified, LOE: not classified))), and referral for rehabilitation and group cognitive training (ASCO/ACS 2015 [33], (SOR: not classified, LOE: expert opinion)). Cognitive behavioral therapy (CBT) was recommended based on a moderate level of evidence (NCCN 2024). Two small studies showed benefits in breast cancer survivors with cognitive dysfunction [38,39]. In 40 survivors, CBT improved verbal memory without significant impact on self-reported cognitive complaints [38], and in 47 survivors, video CBT improved self-reported cognitive impairment and neuropsychological processing speed compared with supportive therapy [39]. In survivors with cognitive impairment that interferes with QoL or work functioning, cognitive rehabilitation through speech-language pathologists, occupational therapists, or neuropsychologists was recommended (NCCN 2024 guideline [34], (SOR: not classified, LOE: moderate)). Two guidelines recommended physical activity (ACSM 2019 [36], NCCN 2024 [34]). According to the ACSM 2019 guideline [36], aerobic training may mitigate treatment-related cognitive decline (SOR: not classified, LOE: low). The NCCN 2024 [34] recommended routine physical activity (SOR: not classified, LOE: moderate) based on a study that showed that exercise intervention significantly improved processing speed and by referring to the growing evidence from general geriatric and cancer-specific populations [37]. The NCCN guideline further recommended meditation, yoga (two studies showed improved patient-reported cognitive dysfunction [42,43]), and mindfulness-based stress reduction (two studies showed improved symptoms [40,41], (SOR: not classified, LOE: moderate)).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePharmacological Treatment\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAlthough pharmacologic agents such as methylphenidate, modafinil, and donepezil are discussed, these agents should only be used in selected, carefully monitored cases (NCCN 2024 [34] (low evidence)). For example, donepezil improved objective memory performance in one trial but did not affect self-reported cognitive function.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRecommendations for Psychological Problems in Cancer Survivors.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAssessment\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAll guidelines recommended to assess the presence of psychological problems during consultations (expert consensus to moderate level of evidence) and the use of validated tools to assess psychological problems (expert consensus) such as distress (Distress Thermometer (DT)), depression (Patient Health Questionnaire-9 (PHQ-9), Hospital Anxiety and Depression Scale (HADS)), anxiety (HADS and Generalized Anxiety Disorder-7(GAD-7)), and trauma (PC-PTSD-5). The most comprehensive and clinically actionable recommendations were published by the NCCN 2024 guideline [34]. The guideline recommended routine screening during follow-up visits, including inquiries about feelings of nervousness, anxiety, sadness or depression, and their impact on QoL. Furthermore, contributing factors such as pain, fatigue, endocrine dysfunction, and sleep disturbances should also be identified (SOR: not classified, LOE: moderate). For breast cancer survivors, routine assessment of psychological symptoms, including body image concerns, was specifically recommended. Further, the use of wigs and prostheses was recommended (ACS 2016 guideline [33], (SOR: not classified, LOE: moderate)). In prostate cancer survivors, additional annual screening for prostate-specific antigen (PSA) anxiety and fear of recurrence was recommended (ASC 2014 guideline [45], (SOR: not classified, LOE: moderate)). The guideline recommended timely referrals of survivors with PSA anxiety and/or fear of recurrence, which has been shown to improve outcomes (expert opinion and observations). For colorectal cancer survivors, patients with permanent stomas may experience isolation, altered body image, and reduced QoL. Thus, their sexual dysfunction, distress, depression, anxiety, and QoL should be assessed (ACS 2015 guideline [31], (SOR: not classified, LOE: moderate)). For head and neck cancer survivors, routine screening for depression, distress, and body image issues at baseline, mid-treatment, and follow-up was recommended (ACS 2016 [49] and EHNS 2022 [30], expert opinion).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eNon-Pharmacological Treatment\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAll guidelines recommended that cancer survivors should have access to psychological care throughout follow-up care and be referred to psychologists when needed (level of evidence: expert consensus). Further, not only psychological problems need to be addressed but also needs related to finances, work, and family (ACS 2014 [45], , NCCN 2024 [34], ACS 2016 [49], and EHNS 2022 [30] (LOE: expert opinion)). Two guidelines recommended physical activity (ACSM 2019 [36] and NCCN 2024 [34], (SOR: strong for)). Whereas the 2024 NCCN guideline [34] recommended regular physical activity based on moderate level of evidence, the 2019 ACSM guideline [36] was more specific with a high level of evidence. The guideline supports moderate-intensity aerobic exercise three times per week for 12 weeks, or twice-weekly combined aerobic and resistance training for 6 to 12 weeks, to reduce anxiety and depressive symptoms in cancer survivors. The NCCN guideline [34] also recommends that cancer survivors consider other alternative treatments (e.g., yoga, tai chi, mindfulness), which may also be helpful to relieve distress (limited evidence). In survivors experiencing grief, trauma, or existential distress, referral to psycho-oncology providers, spiritual care teams, or palliative specialists was recommended. Family and caregiver support are also prioritized, recognizing the broader emotional impact of cancer on the household (LOR: moderate). The ASC 2014 guideline [45] recommends to managing distress or depression with in-office counseling or pharmacotherapy. However, survivors with moderate to severe symptoms should be referred to mental health professionals if initial treatment is insufficient (expert opinion).\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePharmacological treatment\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eIn moderate to severe depression, generalized anxiety, or PTSD, the use of selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) was recommended (NCCN 2024 guideline [34], (level of evidence: moderate)). The use of the drugs should include counselling about the delayed effects and the need to try different drugs until the best option is identified. SNRIs should be used with caution in survivors taking tamoxifen as they inhibit CYP2D6, which has to convert tamoxifen to its active form (endoxifen) [50]. The use of benzodiazepines should be restricted to short-term or acute management. Tricyclic antidepressants and monoamine oxidase inhibitors (MAOIs) were not recommended as first-line agents due to their unfavorable side effect profiles.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRecommendations for Sexual Health in Cancer Survivors\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAssessment\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eMost guidelines recommend routine screening for sexual health problems using validated questionnaires and open-ended questions ((Table 3), ASCO/ACS 2015 [33], NCCN guideline [34], ASC 2014 [45]). Further, the NCCN guideline [34] recommended an assessment of contributing factors such as mental health, medication side effects, and comorbidities (e.g., cardiovascular disease, diabetes, and substance use). Specific recommendations addressed prostate cancer survivors (the use of Sexual Health Inventory for Men (SHIM) to screen for erectile function, ACS 2014 guideline [45] (SOR: not classified, LOE: expert consensus)), colorectal cancer survivors (sexual dysfunction and fertility; ACS 2015 [31] (SOR: not classified, LOE: expert consensus)), and breast cancer survivors (sexual function; ACS 2016 [33] (SOR: not classified, LOE: expert consensus), premature menopause and infertility; ESMO 2024 [46] (SOR: strong for, LOE: low)). The ESMO 2024 [46] and 2022 [47] guidelines emphasize anticipatory guidance and risk monitoring. The NCCN 2024 guideline [34] further recommended shared decision-making, particularly when hormonal therapies are being considered, to ensure that survivors are informed of both the potential benefits and oncologic risks (SOR: not classified, LOE: moderate).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eNon-Pharmacological Treatment\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eNon-pharmacological therapies were recommended as first line, such as lubricants, moisturizers, and pelvic floor physical therapy. CBT, yoga, and mindfulness for both female and male survivors were recommended by most guidelines, especially when emotional or relational dynamics play a key role. The NCCN 2024 guideline [34] also addressed orgasmic dysfunction and climacturia, recommending interventions such as pelvic floor muscle training, patient education (e.g., on sexual positioning), and referral to sexual health specialists (Level of evidence: moderate). For breast cancer survivors, psychological support and non-pharmacologic interventions (e.g., vaginal lubricants) were recommended (SEOM 2018 [32], expert opinion). In prostate cancer survivors, penile rehabilitation, partner involvement in management of intimacy concerns and referral to urology or sexual therapy for persistent dysfunction, were recommended (ACS 2014 [45], expert opinion).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePharmacological Treatment\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eIn general, there is limited evidence for pharmacological interventions, and the NCCN 2024 guideline [34] cautions against the use of unapproved and unregulated regenerative or restorative therapies marketed for sexual dysfunction. Similarly, the ACS 2019 guideline [36] does not specifically recommend exercise to improve sexual function in cancer survivors. While exercise is known to benefit sexual function in the general population, its effects in cancer survivors, particularly those treated for prostate cancer, remain unclear due to treatment-related anatomical changes (e.g., nerve-sparing vs. non-nerve-sparing surgery) (Level of evidence: insufficient).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eRecommendations for Men\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFor male rectal cancer survivors, the use of phosphodiesterase type 5 (PDE5) inhibitors (such as sildenafil, vardenafil, tadalafil) was recommended by guidelines (ASC 2014, LOR: expert opinion; NCCN 2024 guideline, LOR: moderate). The ACS 2015 guideline [31] recommended the use of udenafil (50 mg) for 12 weeks based on one RCT showing benefits in 80 patients [48] (Level of evidence: high). In case PDE5 inhibitors are not sufficient for the treatment of erectile dysfunction, penile injections or vacuum devices were recommended (NCCN 2024 guideline [34], LOR: moderate). Testosterone replacement may be considered in men with confirmed symptomatic hypogonadism but is contraindicated in those with hormone-sensitive malignancies (ESMO 2022 guideline [47] (LOR: conditional for, LOE: moderate)). Patients with prostate cancer who will undergo long-term androgen deprivation therapy are at high risk for osteoporosis: therefore the ESMO 2020 guideline [44] recommends initiating oral bisphosphonate therapy or monitor Dual-energy X-ray Absorptiometry (DEXA) scans during treatment (SOR: conditional for, LOE: high).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eRecommendations for Women\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eHormonal treatments remain controversial in hormone-sensitive cancers, and no guideline offers a strength of recommendation. The use of dehydroepiandrosterone (DHEA) can be considered for vaginal dryness or pain with sexual activity (NCCN 2024 [34], LOE: moderate). However, the guideline warns that DHEA should be used with caution in survivors with a history of estrogen-dependent cancers. Ospifemene was recommended for dyspareunia in women without hormone-sensitive cancers (NCCN 2024, (LOE: moderate)). Further, flibanserin may be used for premenopausal survivors with low or lack of desire, libido, or intimacy (NCCN 2024, LOE: limited). For other substances (bremelanotide, bupropion, or buspirone), the use may be considered. However, robust data in cancer populations are lacking (LOE: insufficient).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this systematic analysis of thirteen guidelines, we summarized recommendations for cognitive, sexual, or psychological problems in cancer survivors. Given the high prevalence and burden of disease, the current evidence supporting recommendations was limited. Many recommendations were based on expert consensus. Additionally, actionable recommendations were limited. \u003c/p\u003e\n\u003cp\u003eLong-term survivorship needs to be addressed as a different set of challenges, to encompass the psychosocial needs of patients once treatment ends (strong recommendation, expert opinion). Strong recommendations were identified for routine assessment of cognitive, psychological, and sexual health problems throughout follow-up care using validated questionnaires. Survivors should have access to psychological care and/or be referred to in case of depression, anxiety, or distress. Counselling and early referral to cognitive behavioral therapy should be initiated in survivors with psychological problems that affect the ability to work or impact their QoL. Also strongly recommended was physical activity to reduce depressive symptoms, stress, anxiety, and improve cognitive function (LOE: moderate (NCCN 2024 [34]) to high (ACSM 2019 [36]). According to the ACSM 2019, moderate intensity aerobic training three times per week for 12 weeks or twice weekly combined aerobic plus resistance training for 6\u0026ndash;12 weeks reduced anxiety and depressive symptoms in cancer survivors during and after treatment significantly. For sexual health, topical non-pharmacological options (e.g., lubricants, pelvic floor therapy) were recommended. Strong recommendations were also found for the discussion of premature menopause, infertility, and potential sexual dysfunction in each patient before the start of adjuvant therapy. Early education and guidance on sexual health concerns and infertility, with appropriate referral to CBT, psychoeducational support, sexual therapy, and mindfulness training, was recommended. Pharmacologic (e.g., vaginal estrogen, DHEA, PDE5 inhibitors) options were discussed including the cautious use in hormone-sensitive tumors. Due to the increased risk for osteoporosis in men undergoing long-term androgen deprivation therapy, prostate cancer survivors should be screened and treated if indicated. Also, postmenopausal breast cancer survivors should be referred for a baseline DEXA scan to assess bone health.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFindings in light of the literature\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe burden of cognitive deficits, psychological problems, and sexual health issues among cancer survivors is substantial. Depending on cancer type and the treatments, between 20% and 75% of cancer survivors report persisting cognitive deficits - often long after completion of active treatment \u0026ndash; including impaired memory, executive function, and attention [51,52]. This translates into challenges in returning to work, maintaining productivity, managing complex tasks, and sustaining social relationships. For instance, studies show that up to 30-40% of breast cancer survivors report being unable to return to their pre-cancer level of occupational functioning even several years post-treatment, with cognitive complaints cited as a major contributing factor [53,54]. Beyond occupational challenges, cognitive deficits often co-occur with psychological distress, such as anxiety, depression, and reduced self-esteem [55]. These issues can place strains on personal relationships and diminish the overall QoL. Psychological issues - including anxiety, depression, fear of recurrence, PTSD, and existential crises - are among the most prevalent and disruptive issues faced by cancer survivors, with pooled estimates indicating that 25-40% experience clinically significant symptoms [56]. Thus, effective follow-up care needs to identify and address cognitive and psychological issues of cancer survivors. There is a critical need for effective interventions targeting both the biological underpinnings (e.g., neuroinflammation, endocrine dysregulation) and the psychosocial consequences of cancer-related cognitive impairment. Functional MRI and biomarker studies support that cognitive impairment is biologically grounded, involving disrupted neural networks, inflammation, neuroendocrine dysregulation, and oxidative stress [58]. Yet, most guidelines still approach cognitive dysfunction as a subsidiary psychosocial issue, failing to provide structured treatment algorithms [59]. \u003c/p\u003e\n\u003cp\u003eOver the past years, more evidence based on high-quality randomized trials has been published demonstrating the importance of exercise. There is compelling evidence that exercise improves cognitive function in older adults and other clinical populations [60]. In cancer survivors, randomized trials showed an improvement of cancer related fatigue [61]. Randomized clinical studies should assess the impact of exercise and nutrition on cognitive function as the primary outcome. \u003c/p\u003e\n\u003cp\u003eSexual dysfunction is another major concern, often linked to cognitive changes, treatment-induced hormonal imbalance, body image disturbances, and emotional distress [57]. These sexual problems can adversely affect intimacy, relationship satisfaction, and overall mental health. Sexual dysfunction has been reported in up to 90% of men with prostate cancer and 70% of women with breast or pelvic cancer. The underlying causes range from nerve injury, adverse effects of treatments, hormonal disruption, body image disturbance and trauma-related avoidance [62,63]. Although most guidelines recommend screening and addressing sexual health, survivors frequently report that sexual concerns are unaddressed or dismissed in routine follow-up, leading to avoidable declines in intimacy, self-esteem, and relationship satisfaction [64]. Given that most guidelines did not offer actionable recommendations, clinicians are left without evidence-based interventions. Treatments, such as vaginal estrogen, DHEA, pelvic floor therapy, and PDE5 inhibitors are well supported in the literature [4,65,66,67]. Psychosexual therapy, CBT, and mindfulness-based strategies show promising benefits for cancer survivors [68], however most guidelines refer to these approaches as alternative treatments without specifying on duration and intensity.. \u003c/p\u003e\n\u003cp\u003ePsychological distress extends beyond being a mere side effect; it is strongly associated with increased mortality, poor treatment adherence, impaired immune function, and higher healthcare costs [69-70]. Additionally, it correlates with reduced QoL, alongside negative long-term outcomes, such as social isolation, impaired interpersonal relationships, and increased risk of substance abuse, particularly alcohol [71-74]. Thus, it is important in effective follow-up care to identify affected survivors or survivors at risk for psychological problems. Validated screening instruments such as the Distress Thermometer, PHQ-9, HADS, and GAD-7 have been used for over a decade [75], and their routine use may improve clinical care. Although meta-analyses support non-pharmacologic interventions including CBT, psychoeducation, mindfulness, and supportive-expressive therapy[76], these approaches remain underutilized, often due to insufficient implementation guidance. For instance, studies have shown that despite CBT\u0026apos;s well-established effectiveness for a range of mental health conditions, many patients do not receive it due to limited availability, high cost, and a shortage of trained providers [77]. To address these barriers, digital and internet-based CBT (iCBT) platforms have emerged as accessible and cost-effective alternatives. Evidence suggests that iCBT can be as effective as face-to-face therapy for certain populations [78]. However, concerns persist about the potential for such tools, particularly AI-powered chatbots, to replace meaningful human interaction, possibly exacerbatingsocial isolation or reducing therapeutic alliance [79].\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eLimitations\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSeveral limitations need to be discussed. Although we used an extended search strategy, and consulted all websites of professional societies, we may have missed guidelines with recommendations for cognitive impairments, sexual health and psychological problems in cancer survivors. Only English-language publications were reviewed, which may introduce language bias and limit international applicability. Further, more evidence on specific interventions may have been published since the publication of the guidelines and thus, not be included in this study. Given that newer evidence is also not included in the guidelines, clinicians are also not likely to use them for their patients. In addition, some of the included guidelines span more than a decade, during which both the strength of the evidence base and the methodological standards for guideline development have evolved. As a result, some variability in recommendations may be due to publication date. Older guidelines may not reflect current best evidence and should therefore be interpreted with caution. Importantly, our analysis was restricted to recommendations for post-treatment survivorship care. We did not evaluate interventions specific to patients undergoing active cancer treatment, nor those living with advanced disease or receiving end-of-life care. Thus, this study provides the most comprehensive overview of current recommendations and their evidence in the survivorship phase. \u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eImplications for Research\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eGiven the low level of evidence for most recommendations, there is an urgent need to assess the efficacy of assessments and interventions for cognitive, sexual, and psychological care in cancer survivors. High-quality clinical studies should assess the efficacy of aerobic and resistance training on cognitive function and psychological problems. Further, future research should focus on uncovering the biological underpinnings of post-treatment neurocognitive dysfunction. Investigations into neuro-inflammation, blood-brain barrier disruption, oxidative stress, HPA axis dysregulation, and altered neurotransmitter signaling are crucial to identify actionable therapeutic targets [58]. Longitudinal studies incorporating neuroimaging, circulating biomarkers (e.g., IL-6, TNF-\u0026alpha;, BDNF), and objective cognitive assessments (e.g., MoCA, FACT-Cog, PROMIS-CF) are needed to elucidate symptom trajectories [59,80]. Interventional research should test multimodal strategies, combining cognitive rehabilitation, physical activity, and CBT, delivered either in person or digitally, carefully considering timing, intensity, and personalization.\u003c/p\u003e\n\u003cp\u003eIn the area of sexual health, research remains disproportionately underdeveloped despite high prevalence rates and its profound effect on QoL. This may be due to different causal pathways, including vascular injury, neurotoxicity, endocrine disruption, treatment-induced inflammation, and body image issues [65]. High-quality randomized controlled trials should compare multimodal treatment of first-line non-pharmacologic interventions (e.g., pelvic floor therapy, lubricants, psychosexual education) with pharmacologic agents (e.g., PDE5 inhibitors, topical estrogen, DHEA, testosterone therapy) stratify by sex, cancer type, hormonal receptor status, and treatment exposure to optimize intervention targeting. Additionally, the role of CBT and sex therapy should be further investigated. While psychosocial interventions such as CBT, MBSR, and psychoeducation have demonstrated efficacy in controlled settings, there remains a need to expand their reach, cultural relevance, and scalability, particularly through digital mental health platforms. Long-term studies are needed to assess the durability of effects and cost-effectiveness across diverse survivor populations. In all areas, survivorship research must evolve to reflect the interconnected nature of post-treatment sequelae. Studies should adopt integrated, symptom cluster frameworks that evaluate interventions for co-occurring cognitive, sexual, and emotional symptoms. Further, the establishment of core outcome sets and standardized criteria for treatment response is critical for harmonizing data and advancing meta-analytic synthesis. Implementation science must be embedded within future research to evaluate feasibility, health system integration, and patient-centeredness of interventions [22,28]. \u003c/p\u003e\n\u003cp\u003eFinally, emerging technologies, including wearable biosensors, symptom tracking, and AI-assisted clinical decision tools, offer scalable solutions but remain under-evaluated. In particular, virtual reality (VR) interventions and mirror therapy are gaining attention as novel approaches to address body image disturbances among cancer survivors. Early studies have demonstrated that VR-based exposure therapy can help reduce body-related anxiety and improve body satisfaction by allowing patients to interact with modified virtual representations of their bodies [81]. Similarly, mirror therapy, traditionally used in stroke rehabilitation, has been adapted for cancer populations and shows promise in improving physical function and reducing body dissatisfaction following breast cancer surgery [82]. Despite these encouraging preliminary results, larger, methodologically rigorous trials are needed to confirm the efficacy of these interventions and to guide their integration into routine cancer survivorship care. By aligning mechanistic insights, personalized intervention models, and implementation pathways, future research can bridge the gap between evidence and practice, ensuring that survivorship care evolves beyond surveillance into proactive, precision survivorship.\u003c/p\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eImplications for clinical practice\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn cancer survivors, effective follow-up care includes the screening for and treatment of cognitive impairment, sexual dysfunction, and psychological problems. The use of validated questionnaires may help to identify affected persons. Non-pharmacological interventions are the main cornerstone in the treatment. Counselling before, during, and after the cancer therapy should encompass life-changing issues such as fertility, libido, fatigue, cognitive impairment, and psychological issues. Given the increasing body of evidence that suggests physical activity positively influences various adverse effects during and after cancer therapy, all patients should be encouraged to engage in physical activities. Multidisciplinary collaboration and early identification across all three domains can significantly improve survivorship outcomes and QoL.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn cancer survivors, cognitive impairment, sexual dysfunction, and psychological problems should be screened and identified during clinical encounters. For cognitive impairment, education and physical activity are recommended. For psychological problems, early non-pharmacologic interventions such as exercise, CBT, coping strategies, mindfulness, and symptom-specific therapies have been recommended. In survivors suffering from sexual dysfunction, shared decision-making and counselling are recommended.\u0026nbsp;\u003c/p\u003e\n"},{"header":"Abbreviations","content":"\u003cp\u003eACGBI: Association of Coloproctology of Great Britain and Ireland\u003c/p\u003e\n\n\u003cp\u003eACS: American Cancer Society\u003c/p\u003e\n\n\u003cp\u003eACSM: American College of Sports Medicine\u003c/p\u003e\n\n\u003cp\u003eAGREE II: Appraisal of Guidelines for Research and Evaluation II\u003c/p\u003e\n\n\u003cp\u003eASCO: American Society of Clinical Oncology\u003c/p\u003e\n\n\u003cp\u003eADT: Androgen Deprivation Therapy\u003c/p\u003e\n\n\u003cp\u003eBDNF: Brain-Derived Neurotrophic Factor\u003c/p\u003e\n\n\u003cp\u003eCBT: Cognitive Behavioral Therapy\u003c/p\u003e\n\n\u003cp\u003eCRC: Colorectal Cancer\u003c/p\u003e\n\n\u003cp\u003eCTIBL: Cancer Treatment-Induced Bone Loss\u003c/p\u003e\n\n\u003cp\u003eDHEA: Dehydroepiandrosterone\u003c/p\u003e\n\n\u003cp\u003eDEXA: Dual-Energy X-ray Absorptiometry\u003c/p\u003e\n\n\u003cp\u003eEHNS: European Head and Neck Society\u003c/p\u003e\n\n\u003cp\u003eESMO: European Society of Medical Oncology\u003c/p\u003e\n\n\u003cp\u003eFACT-Cog: Functional Assessment of Cancer Therapy \u0026ndash; Cognitive Function\u003c/p\u003e\n\n\u003cp\u003eFSFI: Female Sexual Function Index\u003c/p\u003e\n\n\u003cp\u003eGAD-7: Generalized Anxiety Disorder-7\u003c/p\u003e\n\n\u003cp\u003eGCT: Germ Cell Tumor\u003c/p\u003e\n\n\u003cp\u003eGRADE: Grading of Recommendations Assessment, Development, and Evaluation\u003c/p\u003e\n\n\u003cp\u003eHADS: Hospital Anxiety and Depression Scale\u003c/p\u003e\n\n\u003cp\u003eHPA: Hypothalamic\u0026ndash;Pituitary\u0026ndash;Adrenal (Axis)\u003c/p\u003e\n\n\u003cp\u003eIL-6: Interleukin-6\u003c/p\u003e\n\n\u003cp\u003eIRB: Institutional Review Board\u003c/p\u003e\n\n\u003cp\u003eMAOI: Monoamine Oxidase Inhibitor\u003c/p\u003e\n\n\u003cp\u003eMDASI-HN: MD Anderson Symptom Inventory \u0026ndash; Head and Neck module\u003c/p\u003e\n\n\u003cp\u003eMBSR: Mindfulness-Based Stress Reduction\u003c/p\u003e\n\n\u003cp\u003eMoCA: Montreal Cognitive Assessment\u003c/p\u003e\n\n\u003cp\u003eNCCN: National Comprehensive Cancer Network\u003c/p\u003e\n\n\u003cp\u003eNS: Not Stated\u003c/p\u003e\n\n\u003cp\u003ePCI: Prophylactic Cranial Irradiation\u003c/p\u003e\n\n\u003cp\u003ePHQ-9: Patient Health Questionnaire-9\u003c/p\u003e\n\n\u003cp\u003ePDE5 inhibitors: Phosphodiesterase Type 5 Inhibitors\u003c/p\u003e\n\n\u003cp\u003ePROMIS-CF: Patient-Reported Outcomes Measurement Information System \u0026ndash; Cognitive Function\u003c/p\u003e\n\n\u003cp\u003ePTSD: Post-Traumatic Stress Disorder\u003c/p\u003e\n\n\u003cp\u003eQoL: Quality of Life\u003c/p\u003e\n\n\u003cp\u003eSEOM: Spanish Society of Medical Oncology (Sociedad Espa\u0026ntilde;ola de Oncolog\u0026iacute;a M\u0026eacute;dica)\u003c/p\u003e\n\n\u003cp\u003eSHIM: Sexual Health Inventory for Men\u003c/p\u003e\n\n\u003cp\u003eSNRI: Serotonin-Norepinephrine Reuptake Inhibitor\u003c/p\u003e\n\n\u003cp\u003eSSMO: Spanish Society of Medical Oncology\u003c/p\u003e\n\n\u003cp\u003eSSRI: Selective Serotonin Reuptake Inhibitor\u003c/p\u003e\n\n\u003cp\u003eTCA: Tricyclic Antidepressant\u003c/p\u003e\n\n\u003cp\u003eTNF-\u0026alpha;: Tumor Necrosis Factor Alpha\u003c/p\u003e\n\n"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eJ.A declare no competing interest. N.S declare no competing interest. B.C declare no competing interest. L.K declare no competing interest. L.S declare no competing interest. S.R declare competing interest; Research support from other organizations: Roche, AstraZeneca, Swiss National Foundation and Amgen. K.G-F declare competing interest; Grant from the Kanton Aargau, Switzerland. Funding a pilot project for consultation of cancer survivors. E.H-L declare competing interest; Grant from the Kanton Aargau, Switzerland. Funding a pilot project for consultation of cancer survivors. M.M.W declare competing interest; Grant from the Kanton Aargau, Switzerland. Funding a pilot project for consultation of cancer survivors and a Grant from the Stiftung Cardio.\u0026rdquo;\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding Information\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by the Canton of Aargau, Switzerland.\u0026nbsp;\u003c/p\u003e\n"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eK. D. Miller, L. Nogueira, T. Devasia, A. B. Mariotto, K. Yabroff, A. Jemal, J. Kramer und R. L. 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Front Psychol. 2018 Apr 27;9:509\u003c/li\u003e\n\u003cli\u003eAyoson J, Schneider N, Rothschild S, Gut-Fischer K, H\u0026auml;gler E, Wertli MM, \u0026bdquo;Recommendations for Cancer-Related Fatigue in Survivorship Care: A Cross-Sectional Analysis of Guidelines,\u0026ldquo; Manuscript submitted for publication, 2025.\u003c/li\u003e\n\u003cli\u003eTierney DK, \u0026bdquo;Sexuality: a quality-of-life issue for cancer survivors.,\u0026ldquo; Semin Oncol Nurs, Bd. 24, Nr. 2, pp. 71-9, 2008. \u003c/li\u003e\n\u003cli\u003eHill EK, Sandbo S, Abramsohn E, Makelarski J, Wroblewski K, Wenrich ER, McCoy S, Temkin SM, Yamada SD und Lindau ST, \u0026bdquo;Assessing gynecologic and breast cancer survivors\u0026apos; sexual health care needs.,\u0026ldquo; Cancer, Bd. 117, Nr. 12, pp. 2643-51, 2011. \u003c/li\u003e\n\u003cli\u003eCarter J, Lacchetti C, Andersen BL, Barton DL, Bolte S, Damast S, Diefenbach MA, DuHamel K, Florendo J, Ganz PA, Goldfarb S, Hallmeyer S, Kushner DM und Rowland JH, \u0026bdquo;Interventions to Address Sexual Problems in People With Cancer: American Society of Clinical Oncology Clinical Practice Guideline Adaptation of Cancer Care Ontario Guideline.,\u0026ldquo; J Clin Oncol, Bd. 36, Nr. 5, pp. 492-511, 2018. \u003c/li\u003e\n\u003cli\u003eMcVicker L, Labeit AM, Coupland CAC, Hicks B, Hughes C, McMenamin \u0026Uacute;, McIntosh SA, Murchie P und Cardwell CR., \u0026bdquo;Vaginal Estrogen Therapy Use and Survival in Females With Breast Cancer.,\u0026ldquo; JAMA Oncol, Bd. 10, Nr. 1, pp. 103-108, 2024. \u003c/li\u003e\n\u003cli\u003eCucciniello L, Miglietta F, Guarneri V und Puglisi F, \u0026bdquo;Managing sexual health challenges in breast cancer survivors: A comprehensive review.,\u0026ldquo; Breast., Bd. 76, 2024. \u003c/li\u003e\n\u003cli\u003eBarton DL, Sloan JA, Shuster LT, Gill P, Griffin P, Flynn K, Terstriep SA, Rana FN, Dockter T, Atherton PJ, Tsai M, Sturtz K, Lafky JM, Riepl M, Thielen J und Loprinzi CL, \u0026bdquo;Evaluating the efficacy of vaginal dehydroepiandosterone for vaginal symptoms in postmenopausal cancer survivors: NCCTG N10C1 (Alliance),\u0026ldquo; Support Care Cancer, Bd. 26, Nr. 2, pp. 643-650, 2018. \u003c/li\u003e\n\u003cli\u003ePieramico S, Castro R, Aguiar S, Bismarck F, Ferreira D, Carvalho J, Quinta Gomes AL und Nobre P, \u0026bdquo;A systematic review on the efficacy of CBT interventions for the mental and sexual health of survivors of prostate cancer.,\u0026ldquo; Sex Med Rev, Bd. 12, Nr. 1, pp. 48-58, 2023. \u003c/li\u003e\n\u003cli\u003eMitchell AJ, Ferguson DW, Gill J, Paul J und Symonds P, \u0026bdquo;Mitchell AJ, Ferguson DW, Gill J, Paul J, Symonds P. Depression and anxiety in long-term cancer survivors compared with spouses and healthy controls: a systematic review and meta-analysis.,\u0026ldquo; Lancet Oncol, Bd. 14, Nr. 8, pp. 721-32, 2013. \u003c/li\u003e\n\u003cli\u003ePinquart M und Duberstein PR, \u0026bdquo;Depression and cancer mortality: a meta-analysis.,\u0026ldquo; Psychol Med., Bd. 40, Nr. 11, pp. 1797-810, 2010. \u003c/li\u003e\n\u003cli\u003eKittel JA, Seplaki CL, van Wijngaarden E, Richman J, Magnuson A, Conwell Y. Fatigue, impaired physical function and mental health in cancer survivors: the role of social isolation. Support Care Cancer. 2024 Dec 11;33(1):16\u003c/li\u003e\n\u003cli\u003eHoffman KE, McCarthy EP, Recklitis CJ, Ng AK. Psychological distress in long-term survivors of adult-onset cancer: results from a national survey. Arch Intern Med. 2009 Jul 27;169(14):1274-81\u003c/li\u003e\n\u003cli\u003eKim J, Keegan TH. Characterizing risky alcohol use, cigarette smoking, e-cigarette use, and physical inactivity among cancer survivors in the USA-a cross-sectional study. J Cancer Surviv. 2023 Dec;17(6):1799-1812\u003c/li\u003e\n\u003cli\u003eNalbant B, Karger A, Zimmermann T. Cancer and Relationship Dissolution: Perspective of Partners of Cancer Patients. Front Psychol. 2021 May 21;12:624902\u003c/li\u003e\n\u003cli\u003eKroenke K, Wu J, Yu Z, Bair MJ, Kean J, Stump T und Monahan PO, \u0026bdquo;Patient Health Questionnaire Anxiety and Depression Scale: Initial Validation in Three Clinical Trials.,\u0026ldquo; Psychosom Med, Bd. 78, Nr. 6, pp. 716-27, 2016. \u003c/li\u003e\n\u003cli\u003eFaller H, Schuler M, Richard M, Heckl U, Weis J und K\u0026uuml;ffner R, \u0026bdquo;Effects of psycho-oncologic interventions on emotional distress and quality of life in adult patients with cancer: systematic review and meta-analysis,\u0026ldquo; J Clin Oncol, Bd. 31, Nr. 6, pp. 782-93, 2013. \u003c/li\u003e\n\u003cli\u003eShafran R, Clark DM, Fairburn CG, Arntz A, Barlow DH, Ehlers A, Freeston M, Garety PA, Hollon SD, Ost LG, Salkovskis PM, Williams JM, Wilson GT. Mind the gap: Improving the dissemination of CBT. Behav Res Ther. 2009 Nov;47(11):902-9\u003c/li\u003e\n\u003cli\u003eAndersson G, Cuijpers P, Carlbring P, Riper H, Hedman E. Guided Internet-based vs. face-to-face cognitive behavior therapy for psychiatric and somatic disorders: a systematic review and meta-analysis. World Psychiatry. 2014 Oct;13(3):288-95.\u003c/li\u003e\n\u003cli\u003eAdam D. Supportive? Addictive? Abusive? How AI companions affect our mental health. Nature. 2025 May;641(8062):296-298.\u003c/li\u003e\n\u003cli\u003eMyers JS, Parks AC, Mahnken JD, Young KJ, Pathak HB, Puri RV, Unrein A, Switzer P, Abdulateef Y, Sullivan S, Walker JF, Streeter D und Burns JM, \u0026bdquo;First-Line Immunotherapy with Check-Point Inhibitors: Prospective Assessment of Cognitive Function.,\u0026ldquo; Cancers (Basel), Bd. 15, Nr. 5, p. 1615, 2023. \u003c/li\u003e\n\u003cli\u003ePorras-Garcia B, Serrano-Troncoso E, Carulla-Roig M, Soto-Usera P, Ferrer-Garcia M, Figueras-Puigderrajols N, Yilmaz L, Onur Sen Y, Shojaeian N, Guti\u0026eacute;rrez-Maldonado J. Virtual Reality Body Exposure Therapy for Anorexia Nervosa. A Case Report With Follow-Up Results. Front Psychol. 2020 May 15;11:956\u003c/li\u003e\n\u003cli\u003eYuan R, Wei X, Ye Y, Wang M, Jiang J, Li K, Zhu W, Zheng W, Wu C. The effects of the mirror therapy on shoulder function in patients with breast cancer following surgery: a randomized controlled trial. J Cancer Surviv. 2024 Oct;18(5):1574-1589\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1. Description of Guidelines on\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003ecognitive, sexual, and psychological problems in Survivorship Care\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"1025\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGuideline\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCountry/Region\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 302px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIssuing Organization\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eScope\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCancer Type-Specific\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOverall quality\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eACGBI 2017\u003c/strong\u003e[29]\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eGreat Britain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 302px;\"\u003e\n \u003cp\u003eAssociation of Coloproctology of Great Britain \u0026amp; Ireland\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003eCancer type-specific\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003eColon, Rectal and Anal Cancer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003ePoor\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eASCO/ACS 2016\u003c/strong\u003e[33]\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eUSA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 302px;\"\u003e\n \u003cp\u003eAmerican Society of Clinical Oncology (ASCO)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003eCancer type-specific\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003eBreast Cancer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEHNS 2022\u003c/strong\u003e[30]\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eEurope\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 302px;\"\u003e\n \u003cp\u003eEuropean Head and Neck Society (EHNS)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003eCancer type-specific\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003eHead and Neck Cancer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNCCN 2024\u003c/strong\u003e[34]\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eUSA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 302px;\"\u003e\n \u003cp\u003eNational Comprehensive Cancer Network (NCCN)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003eBroad\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eACSM 2019\u003c/strong\u003e[36]\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eUSA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 302px;\"\u003e\n \u003cp\u003eAmerican College of Sports Medicine (ACSM)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003eBroad\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eESMO 2024\u0026nbsp;\u003c/strong\u003e[46]\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eEurope\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 302px;\"\u003e\n \u003cp\u003eEuropean Society of Medical Oncology (ESMO)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003eCancer type-specific\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003eBreast Cancer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eESMO 2020\u003c/strong\u003e[44]\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eEurope\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 302px;\"\u003e\n \u003cp\u003eEuropean Society of Medical Oncology (ESMO)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003eCancer type-specific\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003eProstate Cancer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eACS 2014\u003c/strong\u003e[45]\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eUSA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 302px;\"\u003e\n \u003cp\u003eAmerican Cancer Society (ACS)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003eCancer type-specific\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003eProstate Cancer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eACS 2015\u003c/strong\u003e[31]\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eUSA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 302px;\"\u003e\n \u003cp\u003eAmerican Cancer Society (ACS)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003eCancer type-specific\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003eColorectal Cancer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eACS 2016\u003c/strong\u003e[49]\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eUSA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 302px;\"\u003e\n \u003cp\u003eAmerican Cancer Society (ACS)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003eCancer type-specific\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003eHead and Neck Cancer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eESMO 2021\u003c/strong\u003e[35]\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eEurope\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 302px;\"\u003e\n \u003cp\u003eEuropean Society of Medical Oncology (ESMO)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003eCancer type-specific\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003eSmall Cell Lung Carcinoma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSOEM, 2018\u003c/strong\u003e[32]\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eEurope\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 302px;\"\u003e\n \u003cp\u003eSpanish Society of Medical Oncology.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003eCancer type-specific\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003eBreast Cancer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eESMO 2022\u003c/strong\u003e[47]\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eEurope\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 302px;\"\u003e\n \u003cp\u003eEuropean Society of Medical Oncology (ESMO)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003eCancer type-specific\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003eTesticular Cancer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTable 2 To 4 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-7235753/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7235753/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground/Objective:\u003c/strong\u003e As the number of cancer survivors increases globally, so does the spotlight on life after cancer. Beneath the surface of remission lies a cluster of silent struggles: cognitive impairments, fractured sexual health, and unspoken psychological wounds. The aim was to summarize current recommendations for adult cancer survivors suffering from cognitive impairment, sexual health, and psychological problems.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e A systematic search of PubMed, the Cochrane Library, and major professional society websites was conducted in January 2025. Guidelines published in English from 2000 to 2024 were included if they addressed cognitive, sexual, or psychological issues in adult cancer survivors. Two reviewers independently appraised guideline quality using AGREE II and extracted recommendations, which were then standardized using the GRADE framework.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOf 524 guidelines screened, 13 guidelines from 7 professional societies met inclusion criteria. Thirteen (92.2%) were of moderate quality; one (7.8%) was low quality. Guidelines strongly emphasized addressing long-term survivorship as a different set of challenges, requiring recognition of psychosocial needs. Strong recommendations supported the use of validated tools for assessing cognitive, sexual, and psychological issues. Non-pharmacologic interventions such as education, physical activity, coping strategies, cognitive rehabilitation, and cognitive behavioral therapy were universally endorsed. Multidisciplinary approaches were recommended for survivors with conditions affecting daily life and quality of life (Qol). Pharmacologic options included PDE5 inhibitors, vaginal estrogens, and osteoporosis treatment for high-risk patients.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e:\u003c/p\u003e\n\u003cp\u003eCognitive, sexual, and psychological concerns should be proactively screened and managed in cancer survivors. Non-pharmacologic, patient-centered interventions should be prioritized, with individualized care and shared decision-making.\u003c/p\u003e","manuscriptTitle":"Beyond Survival: A Cross-Sectional Analysis of Guideline Recommendations for Cognitive, Sexual, and Psychological Problems in Cancer Survivors","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-01 08:51:20","doi":"10.21203/rs.3.rs-7235753/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-04-20T20:43:36+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-14T16:44:04+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-09T15:14:48+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"76360461425127854703487522019299830427","date":"2026-03-19T16:50:27+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"76144874947843001682305839953729381756","date":"2026-03-19T15:12:00+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-19T08:12:50+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"225062740043994239606356066284622297852","date":"2026-03-19T08:10:43+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"95669822794999286148852078353407169321","date":"2025-08-21T13:48:18+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-19T11:41:20+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-08-19T11:38:11+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-08-08T20:15:11+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-07T12:55:47+00:00","index":"","fulltext":""},{"type":"submitted","content":"Scientific Reports","date":"2025-08-07T12:48:04+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"fa4fa05a-aeff-4476-af05-9e78c3063f86","owner":[],"postedDate":"September 1st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[{"id":53514841,"name":"Biological sciences/Cancer"},{"id":53514842,"name":"Health sciences/Health care"},{"id":53514843,"name":"Health sciences/Oncology"},{"id":53514844,"name":"Biological sciences/Psychology"},{"id":53514845,"name":"Social science/Psychology"}],"tags":[],"updatedAt":"2026-05-20T18:08:38+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-01 08:51:20","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7235753","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7235753","identity":"rs-7235753","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}