Sexual morbidity associated with poorer psychological adjustment among gynecological cancer survivors

Sexual function of patients with endometrial cancer enrolled in the Gynecologic Oncology Group LAP2 Study

OBJECTIVES

To present responses to sexual function items contained within the quality of life (QOL) survey of the Gynecologic Oncology Group LAP2 study, to investigate associations between sexual function and other factors (such as relationship quality and body image), and to explore patterns of response in patients with endometrial cancer.

METHODS

Participants enrolled in the LAP2 QOL study arm completed a self-report QOL survey, which contained sexual function items, before surgery, and at 1, 3, and 6 weeks and 6 months after surgery. Responses to sexual function questions were classified into 3 patterns-responder, intermittent responder, and nonresponder-based on whether the sexual function items were answered when the QOL survey was completed.

RESULTS

Of 752 patients who completed the QOL survey, 225 completed the sexual function items within the QOL survey, 224 responded intermittently, and 303 did not respond at all. No significant differences of sexual function were found between the patients randomized to laparoscopy compared to laparotomy. Among those who responded completely or intermittently, sexual function scores declined after surgery and recovered to presurgery levels at 6 months. Sexual function was positively associated with better quality of relationship (P < 0.001), body image (P < 0.001), and QOL (P < 0.001), and negatively associated with fear of sex (P < 0.001).

CONCLUSION

Our findings suggest that younger patients, those who were married, and those who had quality relationships were more likely to answer the sexual function items and have better quality of sexual function. Factors such as age, relationship quality, body image, and pain may place women with endometrial cancer at risk for sexual difficulties in the immediate recovery period; however, sexual function improved by 6 months postoperatively in our cohort of patients with early-stage endometrial cancer.

Somatization and somatic symptom presentation in cancer: a neglected area

Abstract The recognition of somatization process in cancer patients is a challenging and neglected area, for the extreme difficulty in differentiating and assessing the psycho(patho)logical components from those biologically determined and related to cancer and cancer treatment, as well as for the scarce usefulness of rigid categorical DSM criteria. However, several dimensions of somatization (and the interconnected concept of abnormal illness behaviour) have been shown to be diagnosable in cancer patients and to negatively influence coping and quality of life outcomes. An integration of the formal DSM-ICD nosology with a system specifically taking into account the patients' emotional responses to cancer and cancer treatment, such as the Diagnostic Criteria for Psychosomatic Research (DCPR), is suggested. More data on some specific symptom dimensions, including pain, fatigue and sexual disorders, are needed to examine their possible psychological components. More research is also needed regarding the association of somatization with personality traits (e.g. type D distressed personality, alexithymia), developmental dimensions (e.g. attachment), and cultural issues (e.g. culturally mediated attributional styles to somatic symptoms). Also, the impact and effectiveness of specific therapeutic intervention in 'somatizing' cancer patients is necessary.

[Impact of cervical cancer treatment on micturition and sexual function]

CONTEXT

Cervical cancer is the second most common tumor in women worldwide and due to diagnostic and therapeutic advances, the overall survival rates at 5 years is approaching 70%. Disorders in micturition, defecation, sexuality and quality of life have been described, frequently caused by different treatments. Addressing these comorbidities in the medical follow-up is often limited or nonexistent.

METHODS

A systematic review of studies to identify the articles related with urogynecological sequels from cervical cancer treatment was carried out.

SUMMARY OF EVIDENCE

During radical hysterectomy, disruption of the autonomic nerve fibers which innervate the bladder appears to be the main cause of voiding dysfunction. Up to 36% of women report voiding dysfunction; from 10 to 80%, stress urinary incontinence (SUI), due to the decrease in urethral closure pressure. After radical hysterectomy and/or radiotherapy, vaginal shortening and stenosis after is often observed. Sexual function is altered in these women and those who are sexually active women after the surgery frequently report sexual dysfunction due to lack of lubrication and pain.

CONCLUSIONS

Voiding dysfunction and urinary incontinence are the most frequent urinary problems that occur in patients treated for cervical cancer. Systemic urogynecologic assessment of the symptoms suggestive of micturition dysfunctions during oncologic follow-up may be useful to detect the cases that can be evaluated and treated in an Urogynecology Unit.

Chinese women's sexuality concerns after gynecologic cancer

BACKGROUND

Sexuality has been recognized as an integral aspect of quality of life. Issues surrounding sexuality have also been acknowledged to have a great impact on the quality of life of gynecologic cancer patients.

OBJECTIVES

The objectives of this study were to describe sexual function and sexual activity among Chinese women after gynecologic cancer and to identify significant predicting factors of women's sexuality outcome changes.

METHODS

This is a descriptive correlational study that was performed in mainland China. A sexuality scale was used to assess women's sexuality outcomes.

RESULTS

A total of 156 Chinese women who had gynecologic cancer were included in this study. Study results revealed that sexual dysfunction was an important concern among these women (62.2%). The rate of sexual inactivity (70.5%) was relatively high. Reasons for sexual inactivity were related to worry about possibly weakening the potency of treatment (46.5%), fear of cancer recurrence (41.1%), and lack of sexual interest (31%). When looking at predictors of negative changes of women's sexuality after cancer, this study found that older age (>50 years old) was associated with the decrease of sexual desire/interest (odds ratio, 3.64; confidence interval, 1.19-11.16). Women who received radiation therapy had more severe vaginal dryness (odds ratio, 2.27; confidence interval, 1.10-4.72) and were less sexually active than those who did not have radiation therapy.

CONCLUSION

Chinese women after gynecologic cancer suffered from various sexuality concerns.

IMPLICATIONS FOR PRACTICE

Considering the high rates of sexual dysfunction and sexual inactivity, there is a need to integrate sexuality into routine nursing care.

Women's poorer satisfaction with their sex lives following gynecologic cancer treatment

Gynecologic cancer treatment can lead to anatomical changes in the genitalia that may impair sexual response. As a result, the authors aimed to assess women's self-perceptions of their sex lives following gynecologic cancer treatment and the impact of such treatment on sexual function. Thirty sexually active women were examined. At the first meeting with a physician sex therapist, women were asked about their satisfaction with their sexual activities prior to and after gynecologic cancer treatment, either with a partner or alone, and how many times per month they had sexual intercourse prior to the cancer diagnosis and after treatment. Women reported significantly worse sex lives and a significantly lower frequency of sexual relations following cancer treatment. All participants reported pain on vaginal penetration and feeling uncomfortable in discussing their sexual difficulties with the oncologist. The findings show that women experienced impaired sexual function, as well as poorer quality of sexual function, following gynecologic cancer treatment. Nurses should provide basic guidelines about sexual function to all patients who undergo treatment for gynecologic cancer.

Marriage and divorce among young adult cancer survivors

PURPOSE

We examined marital outcomes among cancer survivors diagnosed during early adulthood from the 2009 Behavioral Risk Factor Surveillance System dataset.

METHODS

Eligible participants were ages 20-39 years. Of the 74,433 eligible, N = 1,198 self-reported a cancer diagnosis between the ages of 18 and 37, were ≥2 years past diagnosis, and did not have non-melanoma skin cancer. The remaining N = 67,063 were controls. Using generalized linear models adjusted for age, gender, race, and education, we generated relative risks (RR) and 95 % confidence intervals (95 % CI) to examine survivor status on indicators of ever married, currently married, and divorced/separated.

RESULTS

Survivors were slightly older than controls [33.0 (SD = 3.8) vs. 30.0 (SD = 4.0); p < 0.001]. Average time since diagnosis was 7.4 years. Most common diagnoses were cervical (females; 45 %) and non-Hodgkin lymphoma (males; 20 %). Survivors were less likely to be currently married than controls (58 % vs. 64 %; RR = 0.92, 95 % CI 0.85-0.99). Among ever married participants, survivors were at an increased risk of divorce/separation than controls (18 % vs. 10 %; RR = 1.77, 95 % CI 1.43-2.19). Divorce/separation risk persisted for female survivors (RR 1.83, 95 % CI 1.49-2.25), survivors ages 20-29 (RR 2.57, 95 % CI 1.53-4.34), and survivors ages 30-39 (RR 1.62, 95 % CI 1.29-2.04).

CONCLUSIONS

The emotional and financial burdens of cancer may lead to marital stress for younger cancer survivors.

IMPLICATIONS FOR CANCER SURVIVORS

Young survivors may face a higher risk of divorce; support systems are needed to assist them in the years following diagnosis.

Effect of a pelvic floor muscle training program on gynecologic cancer survivors with pelvic floor dysfunction: a randomized controlled trial

OBJECTIVE

To investigate the effects of a pelvic floor rehabilitation program (PFRP) on pelvic floor function and quality of life (QoL) in gynecological cancer survivors in a prospective, randomized, controlled trial.

METHODS

Thirty-four patients with gynecological cancers recruited between July 2009 and December 2009 were randomly allocated into two groups: a PFRP group (n=17), who participated in a 4-week PFRP exercise program, and a non-PFRP group (n=17), who received the usual health care. The pelvic floor strength, the motor evoked potentials (MEPs) elicited by sacral and transcranial magnetic stimulation, the pelvic floor questionnaire, and the scores on two QoL questionnaires, (QLQ)-C30 and QLQ-CX 24, from the European Organization for Research and Treatment of Cancer (EORTC) were evaluated to assess changes in pelvic floor function and QoL before and after the exercise program.

RESULTS

Twenty four patients (12 from each group) completed the exercise program. The PFRP group improved in pelvic floor strength (mean difference (MD)=14.22, t(9)=2.389, P=0.036) and sexual functioning. The PFRP group also improved in physical and sexual function compared with the non-PFRP group.

CONCLUSIONS

The results suggest that the PFRP improved pelvic floor dysfunction and QoL of gynecological cancer patients. A larger randomized controlled trial is planned.

Psychometric validation of the Female Sexual Function Index (FSFI) in cancer survivors

BACKGROUND

The Female Sexual Function Index (FSFI) is the most commonly used self-report instrument to measure sexual functioning among women cancer survivors. Despite this, the validity and reliability of the FSFI for use in cancer populations has not been established.

METHODS

Data were combined from 3 separate institutional review board-approved studies of the psychosexual adjustment of women cancer survivors conducted at Memorial Sloan-Kettering Cancer Center. Psychometric analysis was applied to the FSFI responses from 181 women comprising 4 cohorts, including survivors of: gynecologic cancer (all types; 2 cohorts), malignancies requiring bone-marrow/stem cell transplantation, and early stage cervical cancer.

RESULTS

A factor analysis supported the subscale structure of the FSFI, yielding results nearly identical to those from the original FSFI validation study. Internal consistency reliability was 0.94 for the FSFI total score and ranged from 0.85 to 0.94 for the domain scores. Corrected item-total correlations ranged from 0.44 to 0.79 for the total score and from 0.62 to 0.88 for the domain scores. FSFI scores were correlated negatively with measures of depression, distress, and menopausal symptoms and were correlated positively with quality of life. FSFI scores exhibited a preliminary ability to discriminate between women based on whether or not they received chemotherapy and/or radiation.

CONCLUSIONS

The FSFI demonstrated strong psychometric properties in this study, supporting its continued use for monitoring sexual function and cancer-related dysfunction among sexually active women who are cancer survivors.

Contemporary quality of life issues affecting gynecologic cancer survivors

Regardless of cancer origin or age of onset, the disease and its treatment can produce short- and long-term sequelae (ie, sexual dysfunction, infertility, or lymphedema) that adversely affect quality of life (QOL). This article outlines the primary contemporary issues or concerns that may affect QOL and offers strategies to offset or mitigate QOL disruption. These contemporary issues are identified within the domains of sexual functioning, reproductive issues, lymphedema, and the contribution of health-related QOL in influential gynecologic cancer clinical trials.

Psycho-oncology: structure and profiles of European centers treating patients with gynecological cancer

OBJECTIVE

Psycho-oncological counseling should be an integrated part of modern cancer therapy. The aim of this study was to assess the structures and interests of psycho-oncology services within European Society of Gynecological Oncology (ESGO) centers.

METHODS

In 2010, a survey, which consisted of 15 questions regarding organization of psycho-oncological services and interests in training and research, was sent to all ESGO-accredited centers (n = 41).

RESULTS

The response rate was 65.8% (27 centers). 96.3% (n = 26) of the surveys came from universities, and 3.7% (n = 1) came from nonacademic institutions. Most of the institutions (92.6%, n = 25) offer psycho-oncological care, mainly by psychologists (64%, n = 16) or psycho-oncologists (48%, n = 12). Fifty-two percent of patients are evaluated for sexual dysfunction as sequelae of their disease or treatment-related adverse effects. Fifty-two percent (n = 14) of institutions offer psychological support for cancer care providers. Eighty-five percent (n = 23) of all centers are interested in psycho-oncological training, and the preferred teaching tools are educational workshops (87%). The main issues of interest are sexual problems in patients with cancer, communication and interpersonal skills, responses of patients and their families, anxiety and adjustment disorders, and palliative care. Eighty-five percent (n = 17) of the 20 institutions look for research in the field of psycho-oncology, and 55% (n = 11) of those are already involved in some kind of research.

CONCLUSIONS

Although psycho-oncological care is provided in most of the consulted ESGO accredited centers, almost 50% of women lack information about sexual problems. The results of the survey show the need for and interest in psycho-oncology training and research, including sexual dysfunction. Furthermore, psychological support should be offered to all cancer care providers.

Opinions and expectations of women in the treatment of cervical and uterine cancer in Spain

AIM

To know the experiences, needs and expectations of women in the treatment of cervical and uterine cancer in the Andalusian Health Service.

METHODS

Focus groups and in-depth interviews with women being treated for cervical-uterine cancer within the Andalusian Health Service. Analysis with Nudist Vivo 1.0 (QSR International Pty Ltd, Doncaster, Victoria, Australia).

RESULTS

The needs and expectations detected were: coherence in the promotion strategies and the presence of a proactive approach by health professionals, availability of comprehensive information and understanding, possibility of expressing to health professionals one's doubts and fears, and of participation in decision-making, technical quality, humane treatment and continuity of care and attention to psychosocial aspects.

CONCLUSION

The knowledge of women in the treatment of cancer of the cervix and uterus plays a crucial part in improving the delivery of these services.

Sexual adjustment following early stage cervical and endometrial cancer: prospective controlled multi-centre study

OBJECTIVE

The primary aim of this study was to investigate objective and subjective aspects of sexual adjustment for women with early stage cervical and endometrial cancer during the first 6 months post-treatment, compared to women with benign and pre-invasive gynaecological conditions. 'Objective' aspects of sexual function were operationalised as the frequency of sexual activity and 'subjective' aspects as the perceived quality of sexual interactions.

METHOD

This multi-centre controlled study compared sexual outcomes of women treated for early stage cervical and endometrial cancer (n = 53) with (i) benign gynaecological patients (n = 60), as a comparison group for the physical effects of major pelvic surgery, and (ii) pre-invasive cancer patients (n = 52), as a comparison group for the emotional effect of the perceived threat of cancer. All patients were assessed at baseline and at 6 months follow-up using standardised measures of objective and subjective aspects of sexual function, overall satisfaction with sexual life, relationship satisfaction and psychological distress.

RESULTS

Despite experiencing treatment-related physical changes, women with early stage cervical and endometrial cancer did not report more severe or longer-lasting sexual sequelae than the benign or pre-invasive groups. There were no significant differences between the three groups or changes over time for the objective, subjective or overall measures of sexual function, controlling for age, psychological distress and relationship satisfaction.

CONCLUSION

The current findings suggest that early stage cervical and endometrial cancer patients fare as well as benign and pre-invasive cancer groups in terms of sexual adjustment over the 6 months post-treatment.

Assessing gynecologic and breast cancer survivors' sexual health care needs

BACKGROUND

The objective of this study was to identify patterns of interest in receiving care for sexual concerns among women who were survivors of gynecologic and breast cancers.

METHODS

Survey and medical records data were collected from June 2008 to March 2009 from 261 gynecologic and breast cancer patients. Logistic regression was used to estimate the effect of age and months since treatment on interest in receiving sexual healthcare.

RESULTS

The mean participant age was 55 years (range, 21-88 years). Only 7% of women had recently sought medical help for sexual issues, yet 41.6% were interested in receiving care. Greater than 30% responded that they would be likely to see a physician to address sexual matters, and 35% of all women were willing to be contacted if a formal program was offered. Compared with older women (aged >65 years), younger women (ages 18-47 years) were significantly more likely to report interest in receiving care to address sexual issues (odds ratio [OR], 2.94; 95% confidence interval [CI], 1.14-7.54) and to see a physician to address sexual matters (OR, 4.51; 95% CI, 1.51-13.43), and they were more willing to be contacted for a formal program (adjusted OR [AOR], 5.00; 95% CI, 1.63-15.28). Compared with women who were currently in treatment, women who last received treatment >12 months previously were significantly more interested in receiving care (AOR, 2.02; 95% CI, 1.02-4.01) and were more willing to be contacted (AOR, 2.49; 95% CI, 1.18-5.26).

CONCLUSIONS

Greater than 40% of survivors expressed interest in receiving sexual healthcare, but few had ever sought such care. The current results indicated that there is an unmet need for attention to sexual concerns among women with gynecologic and breast cancers.