Predicting sexual and psychologic morbidity and improving the quality of life for women with gynecologic cancer

The research progress made in the 1980s on understanding psychologic outcomes after gynecologic cancer has continued since the 1986 conference. To facilitate future intervention research, a model for predicting the risk for psychologic and behavioral morbidity is provided. This model clarifies psychologic, behavioral, and medical routes leading to a reduced quality of life. Although few intervention studies have been conducted with gynecologic patients, studies in other patients with cancer suggest that psychologic interventions can reduce emotional distress, enhance coping, and improve general adjustment and sexual functioning, in particular. The final section of this article discusses future research directions and challenges institutions and study groups to support quality-of-life research for women with gynecologic cancer.

Psychological interventions for cancer patients to enhance the quality of life

Although the thrust of the nation's cancer objectives for the year 2000 is prevention and screening, each year approximately 1 million Americans are diagnosed and must cope with the disease and treatments. They do so with the aid of family, friends, and the health care system, but accumulating data suggest that psychological interventions may be important for reducing emotional distress, enhancing coping, and improving "adjustment." Experimental and quasi-experimental studies of psychological interventions are reviewed, and discussion of treatment components and mechanism is offered. A final section discusses future research directions and challenges to scientific advance.

Psychological interventions for cancer patients to enhance the quality of life

Although the thrust of the nation's cancer objectives for the year 2000 is prevention and screening, each year approximately 1 million Americans are diagnosed and must cope with the disease and treatments. They do so with the aid of family, friends, and the health care system, but accumulating data suggest that psychological interventions may be important for reducing emotional distress, enhancing coping, and improving "adjustment." Experimental and quasi-experimental studies of psychological interventions are reviewed, and discussion of treatment components and mechanism is offered. A final section discusses future research directions and challenges to scientific advance.

Physiologic and psychobehavioral research in oncology

A major thrust in research in psychosocial oncology is the study of the interaction of psychologic and physiologic variables. This discussion reviews the current status and future directions of such research. Areas addressed include pain, nausea and vomiting with chemotherapy, sexuality, effects of cancer on psychologic and neuropsychologic function, impact of psychologic factors on cancer and its treatment, and psychoneuroimmunology. In addition, specific recommendations for strategies to facilitate research in these areas of psychosocial oncology are proposed.

Body Image for Women: Conceptualization, Assessment, and a Test of its Importance to Sexual Dysfunction and Medical Illness

The content and valence of women's body image attitudes, general and enduring positive or negative feelings about the body, are studied with psychometric analyses of measures and contrasted groups. Data from two frequently used measures (Body Image Scale, Derogatis & Melisaratos, 1979; Body Satisfaction Scale, Berscheid, Walster & Bohrnstedt, 1973) provided an evaluation of the construct and the assessment of body image. Two studies are provided. The construct analyses suggest two contents for body attitude measures: a general factor of body, facial, and sexual (genital and breast) items, and a second factor assessing weight and/or its body correlates-the hips, thighs, and buttocks. Also, a method factor, a response style of negativity, may be important. Body image attitudes are correlated with some conceptually relevant criteria, such as interest in engaging in sexual activity; however, these relationships do not appear sufficiently strong to predict behavior, such as the occurrence or resolution of sexual dysfunction. Generalized body image disturbance as currently conceptualized and assessed may be difficult to document, particularly when item content and response styles are considered.

How cancer affects sexual functioning

Significant sexual morbidity occurs in the majority of cancer patients. In the assessment of sexual functioning, the health-care provider needs to survey sexual behavior, sexual desire, excitement, orgasm, and resolution (i.e., the sexual response cycle), and the occurrence of sexual dysfunction(s). Data are available documenting sexual disruption for the major sites of disease, including breast, colorectal, bladder, and the genitals, as well as for those with Hodgkin's disease. The author includes a brief model (ALARM) to assist the health professional in assessing sexual functioning in cancer patients.

Controlled prospective longitudinal study of women with cancer: I. Sexual functioning outcomes

The incidence and etiology of sexual difficulties for women with survivable cancer were studied. Women with early stage gynecologic cancer (n = 47) were assessed after their diagnosis but prior to treatment and then reassessed at 4, 8, and 12 months posttreatment. Sexual and medical outcomes were compared with data from members of two matched comparison groups who were also assessed longitudinally: women diagnosed and treated for benign gynecologic disease (n = 18) and gynecologically healthy women (n = 57). Global sexual behavior disruption did not occur, but the frequency of intercourse declined for women treated for disease, whether malignant or benign. In relation to the sexual response cycle, diminution of sexual excitement is pronounced for women with disease; however, this difficulty is more severe and distressing for women with cancer, possibly due to significant coital and postcoital pain, premature menopause, treatment side effects, or a combination. Changes in desire, orgasm, and resolution phases of the sexual response cycle may also occur, but they are of lesser magnitude or duration or both. Approximately 30% of the women treated for cancer were diagnosed with a sexual dysfunction. The nature, early timing, and maintenance of sexual functioning morbidity suggest the instrumental role that cancer and cancer treatments play in these deficits (particularly arousal problems) and suggest that preventive therapies are necessary.

Controlled prospective longitudinal study of women with cancer: II. Psychological outcomes

The incidence and etiology of major life difficulties for women with survivable cancer were studied. Women with early stage cancer (n = 65) were assessed after their diagnosis but prior to treatment and then reassessed at 4, 8, and 12 months posttreatment. Two matched comparison groups, women diagnosed and treated for benign disease (n = 22) and healthy women (n = 60), were also assessed longitudinally. Results for four life areas are reported: (a) The emotional response to the life-threatening diagnosis and anticipation of treatment was characterized by depressed, anxious, and confused moods, whereas the response for women with benign disease was anxious only. In both cases, these responses were transitory and resolved posttreatment. (b) There was no evidence for a higher incidence of relationship dissolution of poorer marital adjustment; however, 30% of the women treated for disease reported that their sexual partners may have had some difficulty in reaching orgasm (i.e., delayed ejaculation) after the subjects' treatment. (c) There was no evidence for impaired social adjustment. (d) Women treated for cancer retained their employment and their occupations; however, their involvement (e.g., hours worked per week) was significantly reduced during recovery. These data and those in a companion report (Andersen, Anderson, & deProsse, 1989) suggest "islands" of significant life disruption following cancer; however, these difficulties do not appear to portend global adjustment vulnerability.

A psychometric analysis of the sexual arousability index

The Sexual Arousability Index (SAI) assesses self-reported sexual arousal in women and was administered on four occasions to a group of normal sexually active women (n = 57) and to another group undergoing surgical gynecologic treatment (n = 66) that resulted in a predictable and clinical level of sexual dysfunction. These data were used for a psychometric analysis of the SAI. In terms of reliability, internal consistency estimates were in the .92-.96 range, and 4-month test-retest reliabilities ranged from .74 to .90. An evaluation of validity revealed both strengths and limitations of the SAI. The content analysis indicated that at least six domains are sampled, including seduction activities, body caressing, oral-genital and genital stimulation, intercourse, masturbation, and erotic media. To examine construct validity, we conducted a factor analysis that revealed a five-factor solution accounting for 85% of the variance. Furthermore, the factor solution was stable across groups and time, and the factors were sensitive to the occurrence of important behavior changes. The SAI, like other psychological measures, was poor in predicting a criterion (i.e., the occurrence of inhibited sexual excitement) concurrently or at the time of follow-up.

A psychometric analysis of the Sexual Arousability Index

The Sexual Arousability Index (SAI) assesses self-reported sexual arousal in women and was administered on four occasions to a group of normal sexually active women (n = 57) and to another group undergoing surgical gynecologic treatment (n = 66) that resulted in a predictable and clinical level of sexual dysfunction. These data were used for a psychometric analysis of the SAI. In terms of reliability, internal consistency estimates were in the .92-.96 range, and 4-month test-retest reliabilities ranged from .74 to .90. An evaluation of validity revealed both strengths and limitations of the SAI. The content analysis indicated that at least six domains are sampled, including seduction activities, body caressing, oral-genital and genital stimulation, intercourse, masturbation, and erotic media. To examine construct validity, we conducted a factor analysis that revealed a five-factor solution accounting for 85% of the variance. Furthermore, the factor solution was stable across groups and time, and the factors were sensitive to the occurrence of important behavior changes. The SAI, like other psychological measures, was poor in predicting a criterion (i.e., the occurrence of inhibited sexual excitement) concurrently or at the time of follow-up.

Controlled prospective longitudinal study of women with cancer: I. Sexual functioning outcomes

The incidence and etiology of sexual difficulties for women with survivable cancer were studied. Women with early stage gynecologic cancer (n = 47) were assessed after their diagnosis but prior to treatment and then reassessed at 4, 8, and 12 months posttreatment. Sexual and medical outcomes were compared with data from members of two matched comparison groups who were also assessed longitudinally: women diagnosed and treated for benign gynecologic disease (n = 18) and gynecologically healthy women (n = 57). Global sexual behavior disruption did not occur, but the frequency of intercourse declined for women treated for disease, whether malignant or benign. In relation to the sexual response cycle, diminution of sexual excitement is pronounced for women with disease; however, this difficulty is more severe and distressing for women with cancer, possibly due to significant coital and postcoital pain, premature menopause, treatment side effects, or a combination. Changes in desire, orgasm, and resolution phases of the sexual response cycle may also occur, but they are of lesser magnitude or duration or both. Approximately 30% of the women treated for cancer were diagnosed with a sexual dysfunction. The nature, early timing, and maintenance of sexual functioning morbidity suggest the instrumental role that cancer and cancer treatments play in these deficits (particularly arousal problems) and suggest that preventive therapies are necessary.

Controlled prospective longitudinal study of women with cancer: II. Psychological outcomes

The incidence and etiology of major life difficulties for women with survivable cancer were studied. Women with early stage cancer (n = 65) were assessed after their diagnosis but prior to treatment and then reassessed at 4, 8, and 12 months posttreatment. Two matched comparison groups, women diagnosed and treated for benign disease (n = 22) and healthy women (n = 60), were also assessed longitudinally. Results for four life areas are reported: (a) The emotional response to the life-threatening diagnosis and anticipation of treatment was characterized by depressed, anxious, and confused moods, whereas the response for women with benign disease was anxious only. In both cases, these responses were transitory and resolved posttreatment. (b) There was no evidence for a higher incidence of relationship dissolution of poorer marital adjustment; however, 30% of the women treated for disease reported that their sexual partners may have had some difficulty in reaching orgasm (i.e., delayed ejaculation) after the subjects' treatment. (c) There was no evidence for impaired social adjustment. (d) Women treated for cancer retained their employment and their occupations; however, their involvement (e.g., hours worked per week) was significantly reduced during recovery. These data and those in a companion report (Andersen, Anderson, & deProsse, 1989) suggest "islands" of significant life disruption following cancer; however, these difficulties do not appear to portend global adjustment vulnerability.

Attributions and adjustment to life-threatening illness

An analysis of the role of attribution in major illness and serious injury is presented. Evidence reviewed includes the impact of illness variables on attributions, the association between attributions and adjustment to illness, and the proposed mechanisms of this association. Illness and injury characteristics such as severity and time since diagnosis appear to relate to attributional activity and content, but the association between attributions and psychological or physical adjustment is weak. Overall, it would appear that the attribution construct can describe individuals' reactions to life-threatening illness or injury. However, the utility of attribution in understanding the processes involved in adjustment to illness has not yet been demonstrated.

Sexual functioning after treatment of in situ vulvar cancer: preliminary report

Forty-two patients treated for in situ vulvar cancer at two institutions participated in structured assessment interviews and completed questionnaires to examine postoperative sexual, marital, and psychological adjustment. Patient responses were compared with a matched sample of gynecologically healthy women. The results indicated a specific pattern of sexual disruption for the women treated for preinvasive disease. Sexual behavior patterns appeared to be maintained, as was the desire phase of the sexual response cycle. However, there was specific disruption of the phases of excitement and resolution and, to a lesser extent, orgasm. In addition to a two- to threefold increase in the frequency of sexual dysfunction, 30% of the sample was sexually inactive at follow-up. Although replication of these findings is necessary, this investigation suggests that sexual functioning correlates with the magnitude of treatment.

Sexual functioning complications in women with gynecologic cancer. Outcomes and directions for prevention

Since the 1980 conference on gynecologic cancer, there has been an energetic focus on the psychological and behavioral outcomes following gynecologic cancer diagnosis and treatment. Extensive descriptive data on the sexual outcomes following cervix cancer are available. Much less is known about the sexual outcomes for women with other disease sites such as the ovary or vulva or women receiving radical or combination treatments. New directions for research and the design of preventive treatments to reduce sexual complications are discussed.

Psychosomatic Aspects of Gynecologic Oncology: Present Status and Future Directions

Among women genital malignancies are second in frequency only to breast cancer. Primary disease sites include the endometrium, cervix, ovary, and vulva. With early diagnosis and aggressive therapy, two-thirds of these women will survive for at least 5 years. This encouraging prognosis is in contrast to the distress that may be experienced by women during diagnosis, treatment, and recovery periods. A brief review of major avenues of current research and clinical work is provided, including; psychological responses to gynecologic cancer symptomatology; affective distress; sexual problems; and treatment-related distress. Areas for future investigation are highlighted, including difficulties occurring with disease recurrence; disruption of close relationships; and problems of the elderly woman with cancer.

Sexual dysfunction and signs of gynecologic cancer

Forty-one women recently diagnosed with early-stage cervical or endometrial cancer and a matched group of healthy women in no gynecologic distress, participated in a detailed assessment of their sexual functioning. Data included the range and frequency of sexual behavior, level of sexual responsiveness, and the presence of sexual dysfunction. Multivariate analyses of variance indicated that prior to the onset of cancer signs/symptoms the gynecologic cancer patients reported similar patterns of sexual activity and responsiveness as the healthy sample. With the appearance of disease signs, however, the gynecologic cancer patients reported experiencing significant sexual dysfunction symptoms. While sexual morbidity is typically conceptualized as occurring after the diagnosis and treatment of cancer, these data indicate that such changes are a major source of variation in describing the prediagnosis sexual status of the gynecologic cancer patient.

Radiation Therapy and Psychological Distress in Gynecologic Oncology Patients: Outcomes and Recommendations for Enhancing Adjustment

Radiotherapy is used commonly in the treatment of gynecologic malignancies. Many patients experience emotional distress prior to the initiation of radiotherapy, during the course of treatment, or after the completion of treatment. This paper describes treatment experiences from the patients' perspective, reviews the empirical data concerning patients' emotional responses to these treatments, and overviews strategies for reducing patient distress.

Anxiety and cancer treatment: response to stressful radiotherapy

Previous research with individuals undergoing surgery or diagnostic procedures provided a conceptual framework for analysis of radiation therapy, a common form of cancer treatment. The present investigation was designed to document the magnitude of anxiety patients experience in response to one particularly stressful form of radiation treatment. In addition, the change in anxiety responses with repeated exposures and individual differences among patients that may affect their adjustment were explored. In Part 1, gynecologic cancer patients receiving their first internal radiotherapy application were studied. As the time for treatment neared, subjective and physiologic indicants of anxiety and distress among the patients significantly increased. By 24 hours post-treatment, anxiety for all patients remained elevated. These post-treatment data are convergent with other investigations of post-treatment distress among cancer patients, but contrast with data obtained from those receiving treatment for benign conditions. A subset of the women who required two applications of radiotherapy participated in Part 2. These patients continued to respond negatively during the second treatment. Data on individual differences in anxiety responses (i.e., low vs. high anxiety) were obtained in both investigations and suggest that those with low levels of pre-treatment anxiety experience considerable disruption post-treatment.