Survivorship, late effects and cancer of the cervix

Targeting Siglec-15 mediates mitochondrial retrograde regulation of cervical cancer development

Cervical cancer (CCA) is the predominant cause of fatalities from gynecologic malignancies, with metastasis responsible for 80 % of cancer-related mortalities. This study preliminarily examined the involvement of Sialic Acid Binding Ig Like Lectin 15 (Siglec-15) in the development of CCA and its probable mechanisms. We assessed the capacity of Siglec-15 to modulate CCA progression by establishing knockdown and overexpression Siglec-15 cell lines, supplemented with animal models, using both in vivo and in vitro dual investigations. Our findings indicate that Siglec-15 is significantly expressed in CCA cell lines and is intimately associated with the proliferation, migration, and invasion capabilities of CCA cells, as well as mitochondrial ROS homeostasis. The suppression of Siglec-15 expression markedly reduced tumor growth in mice, potentially due to Siglec-15's role in regulating the Mitogen-Activated Protein Kinase (MAPK) signaling pathway, which mediates the retrograde regulation of mitochondrial ROS homeostasis. Siglec-15 may emerge as a novel therapeutic target and prognostic marker for patients with CCA.

The Role of Traditional Chinese Medicine in the Management of Cervical Cancer

Globally, cervical cancer poses a substantial public health challenge, with low and middle-income countries bearing the highest burden [Rajkhowa, P., D.S. Patil, S.M. Dsouza, P. Narayanan and H. Brand. Evidence on factors influencing HPV vaccine implementation in South Asia: a scoping review. Glob. Public Health 18: 2288269, 2023]. The incidence rate ranks second highest among female malignant tumors in China, following only breast cancer. The prognosis of advanced cervical cancer is extremely poor, with a 5-year progression-free survival (PFS) rate of only 15%, and the treatment of advanced recurrent or metastatic cervical cancer remains a huge challenge. An increasing amount of evidence suggests that traditional Chinese medicine (TCM) can significantly enhance sensitivity to chemotherapeutic drugs, strengthen antitumor effects, and notably improve adverse reactions associated with cancer such as fatigue and bone marrow suppression. In recent years, the therapeutic effects and mechanisms of Chinese herbal medicines, such as the Guizhi-Fuling-decoction, the compound Yangshe granule, Huangqi, and Ginseng, herbal monomers (e.g., Ginsenoside Rh2, Tanshinone IIA, and Tetrandrine), and the related extracts and compound formulations, have received extensive attention for the treatment of cervical cancer. This paper reviews the research progress of TCM in cervical cancer. In addition, we reported a case of an advanced cervical cancer patient with multiple abdominal and pelvic metastasis who initially received chemotherapy, was then treated with TCM alone, and subsequently survived for 22 years. The model of whole-process management with TCM can enable more cancer patients to obtain longer survival periods.

A Randomized Controlled Trial on Pranayama and Yoga Nidra for Anxiety and Depression in Patients With Cervical Cancer Undergoing Standard of Care

Introduction Cervical cancer might intensify the psychological distress among patients with cervical cancer and the distress caused by the diagnosis and treatment. So, depression and anxiety are at higher levels in patients with cervical cancer. Yoga Nidra and Pranayama are thought to reduce the aftereffects of chemotherapy and radiotherapy potentially. So, in this study, we used the techniques of Yoga Nidra and Pranayama to evaluate their effect on patients with cervical cancer undergoing standard care. Methodology Seventy women with cervical cancer were randomized into experimental and control groups. The experimental group of patients with cervical cancer received 30 minutes of yoga intervention twice daily five days a week, for six weeks. The control group was given only the standard of care. The outcome measures were assessed using the Hospital Anxiety and Depression Scale (HADS) questionnaire. The assessment was done at baseline, second, fourth, and sixth weeks. Results The results of within‑group comparisons in both groups showed that there was a significant improvement in depression and anxiety scores, with P ≤ 0.05 being considered statistically significant. Between groups, analysis shows that in the preintervention, there was no difference between the yoga and control group as P > 0.05. After the yoga intervention, there was an enhancement in depression and anxiety scores.  Conclusions The results of the study concluded that the Yoga Nidra and Pranayama module can be given as adjuvant therapy to the standard of care in patients with cervical cancer for treating the disease and treatment-related anxiety and depression.

The burden of cervical cancer survivorship: Understanding morbidity and survivorship needs through hospital admissions

Objective

To describe disease- and treatment-related survivorship burden amongst survivors of cervical cancer and identify risk factors for hospital admissions after initial treatment.

Methods

Retrospective chart review including patients treated for cervical cancer from 2014 to 2020 at a single urban academic institution. Clinical, demographic, and hospital admission characteristics were summarized. Associations between patient characteristics and likelihood of admission were examined using univariate and multivariate regression.

Results

Of 366 patients undergoing surveillance following completion of primary treatment, 156 (43 %) were hospitalized for cancer or treatment-related sequela in the median follow-up of 3.6 years (IQR 1.4-6.4), with a median of 2 admissions (IQR 1-4.5) per patient and 570 unique admissions. While 65 (35 %) of admitted patients had multiple reasons for admission, the most common reasons for admission were: gastrointestinal complications (43 %), infection (38 %), genitourinary complications (33 %), and pain control (23 %). A substantial proportion of admitted patients underwent interventions including surgical procedures (57 %), transfusion of blood products (40 %), and interventional radiology procedures (28 %) and utilized supportive care services including case management (53 %), physical therapy (40 %), and occupational therapy (36 %). On multivariate analysis, odds of admission were higher among Black patients (aOR 2.4, p <.01), uninsured patients (aOR 2.7, p <.05), those with lower performance status (aOR 1.4, p <.05), and those with recurrence (aOR 5.5, p <.001).

Conclusion

Survivors of cervical cancer represent a high-risk population frequently hospitalized after initial treatment. Black patients, uninsured patients, those with recurrence, and those with lower performance status faced higher odds of admission. Comprehensive, team-based care is necessary to address complex survivorship needs.

The Experiences of Cervical Cancer Patients During Follow-Up Care in Ethiopia: A Qualitative Study

Purpose

The purpose of the study was to explore the experiences among cervical cancer patients during follow-up care.

Patients and Methods

A qualitative study was conducted with purposively selected cervical cancer patients receiving follow-up treatment at Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia. Data were collected using semi-structured interviews and analyzed via thematic analysis.

Results

The results obtained in this study indicated that women experienced a variety of physical and psychosocial difficulties in the context of cervical cancer care. The data analysis resulted in five themes. Women have undergone difficulties indicated as lack of satisfaction with the health care experience, dealing with treatment side effects, struggle in work and daily life, having stress, disruption in social relationships, and financial difficulties incurred because of their illness and treatment.

Conclusion

This study highlights that cervical cancer patient’s experience is the outcome of a complex interplay by personal, clinical, psychological, and social spheres. Thus, interdisciplinary approach between health and psychosocial professionals is needed during follow-up care in order to help women experience better psychosocial adjustment.

Sexual Dysfunction in Cervical Cancer Survivors: A Scoping Review

Sexual function in cervical cancer survivors declines significantly after treatments irrespective of the modality used. Only a few studies have looked at their psychosexual needs, perception, and acceptance of psychosexual support. This review summarizes findings of current qualitative as well as quantitative studies to understand the plight of cervical cancer survivors regarding sexual dysfunction and the management issues. The effect of gynecologic cancers on sexuality depends on multiple factors such as psychosexual factors, biologic factors, and age. Younger patients have poorer outcomes with a more pronounced impact on sexual well-being. Radicality of surgery has direct correlation with sexual dysfunction. Low or no sexual interest, lack of lubrication, dyspareunia, and reduced vaginal caliber are frequently found. For too long, researchers have focused on defining the prevalence and types of sexual problems after various cancer treatments. The area that continues to be neglected is the evaluation of effective interventions to prevent or treat cancer-related sexual dysfunction. In particular, mental health and medical specialists need to collaborate to create cost-effective treatment programs. Collaborative intervention with gynecologists, sexologists, radiotherapists, and nursing staff would be beneficial to optimize the sexual wellness of cancer survivors and their spouses.

Integrative meta-analysis of gene expression profiles identifies FEN1 and ENDOU as potential diagnostic biomarkers for cervical squamous cell carcinoma

Cervical carcinoma is a global public health burden. Given that it is usually asymptomatic at potentially curative stages, the development of clinically accurate tests is critical for early detection and individual risk stratification. The present study performed an integrative meta-analysis of the transcriptomes from 10 cervical carcinoma cohorts, with the aim of identifying biomarkers that are associated with malignant transformation of cervical epithelium, and establish their clinical applicability. From among the top ranked differentially expressed genes, flap structure-specific endonuclease 1 (FEN1) and poly (U)-specific endoribonuclease (ENDOU) were selected for further validation, and their clinical applicability was assessed using immunohistochemically stained microarrays comprising 110 tissue cores, using p16 and Ki67 staining as the comparator tests. The results demonstrated that FEN1 expression was significantly upregulated in 65% of tumor specimens (P=0.0001), with no detectable expression in the non-tumor tissues. Furthermore, its expression was significantly associated with Ki67 staining in tumor samples (P<0.0001), but no association was observed with p16 expression or the presence of human papilloma virus types 16/18, patient age, tumor grade or stage. FEN1 staining demonstrated lower sensitivity than p16 (69.3 vs. 96.8%) and Ki67 (69.3 vs. 76.3%); however, the specificity was identical to p16 and higher than that of Ki67 (100 vs. 71.4%).ENDOU staining was consistent with the microarray results, demonstrating 1% positivity in tumors and 40% positivity in non-tumor tissues. Gene set enrichment analysis of cervical tumors overexpressing FEN1 revealed its association with enhanced growth factor signaling, immune response inhibition and extracellular matrix remodeling, whereas tumors with low ENDOU expression exhibited inhibition of epithelial development and differentiation processes. Taken together, the results of the present study demonstrate the feasibility of the integrative meta-analysis approach to identify relevant biomarkers associated with cervical carcinogenesis. Thus, FEN1 and ENDOU may be useful diagnostic biomarkers for squamous cervical carcinoma. However, further studies are required to determine their diagnostic performance in larger patient cohorts and validate the results presented here.

Healthy-related quality of life in patients with cervical cancer in Southwest China: a cross-sectional study

Background

Cervical cancer is the second most common female malignant tumor in the world. According to a study in 2018, the incidence of cervical cancer in Yunnan Province of China was 11.42 per 100,000, the mortality rate was 3.77 per 100,000, and higher than the national average. Health-related quality of life (HRQoL) can be used not only in the selection and effect evaluation of clinical treatment plans of cervical cancer, but also in the evaluation of prognosis and long-term survival status. In this study, 288 cervical cancer patients admitted to the Yunnan Cancer Hospital in Southwest China from 2018 to 2020 were used as the survey objects to understand the HRQoL of cervical cancer patients and explore the related factors that affect HRQoL.

Methods

The Chinese version of the functional assessment of cancer therapy-cervix (functional assessment of cancer therapy-cervix v4.0, FACT-Cx V4) was used to investigate 288 patients with cervical cancer in Yunnan Province. Statistical analysis was performed using t-test, analysis of variance, multiple linear regression and other methods.

Results

The total FACT-Cx score of cervical cancer patients was (130.16 ± 14.20), the physical well-being (PWB) score was (22.02 ± 4.47), the social/family well-being (SWB) score was (25.66 ± 3.59), the emotional well-being (EWB) score was (19.75 ± 3.54), the functional well-being (FWB) score was (16.91 ± 5.01) and the additional focus area (cervical cancer subscale, CxS) score was (45.78 ± 4.61). From the multi-factor analysis results, the scores of PWB, FWB, Cxs and the total FACT-Cx were related to the choice of different treatment methods, the PWB scores of patients with concurrent chemoradiotherapy was low(β = − 1.67, P = 0.003), the FWB scores of patients with concurrent chemoradiotherapy was low(β = − 2.02, P = 0.001), the CxS scores of patients with concurrent chemoradiotherapy was low(β = − 1.61, P = 0.006), the total score of FACT-Cx of patients with concurrent chemoradiotherapy was low(β = − 5.91, P = 0.001). SWB score was affected by marital status, married patients had high PWB scores(β = 5.44, P = 0.006). The patients with heavy disease expenditures as aproportion of family disposable income(β = − 3.82, P = 0.002) and aged 60 and above(β = − 3.29, P = 0.003) had lower FWB scores. The total score FACT-Cx of patients participating in cervical cancer screening was higher(β = 7.61, P = 0.001).

Conclusion

The choice of treatment method is the common influencing factor of PWB, FWB, Cxs and the total FACT-Cx. Disease expenditures as a proportion of family disposable income, the treatment method, the marital status and whether to participate in cervical cancer screening affect the patient’s evaluation of their own HRQoL. Medical staff should pay special attention to the choice of different treatment methods, popularize vaccination knowledge and cervical cancer screening, give more humanistic care and health education to cervical cancer patients who have low education level, poor economic conditions, divorced or separated, and encourage patients to participate in active treatment to improve the health-related quality of life.

Sexual Morbidity Assessment in Gyne-Oncology Follow-Up: Development of the Sexual Well-Being After Cervical or Endometrial Cancer (SWELL-CE) Patient-Reported Outcome Measure

BACKGROUND

Clinical assessment and management of sexual difficulties after gynecological cancer remain a neglected aspect of women's rehabilitation.

AIM

To develop and validate a patient-reported outcome measure of sexual well-being for women experiencing sexual consequences of cervical and endometrial cancer treatment for use in routine follow-up.

METHODS

This is a sequential mixed method study comprising (i) in-depth qualitative interviews (n=21 of 118) to generate items regarding sexual consequences of cervical or endometrial cancer and treatment; (ii) questionnaire construction with 51 core items (all respondents) and 4 subsections (18-58 items), depending on the relationship status and whether or not participants were sexually active (SA/NSA); (iii) item refinement following cognitive debriefing (n=13 of 21); (iv) validation of resultant items via postal survey (n=788 women) and Rasch analysis; and (v) creation of brief (14-item) clinical screener. Women attending routine follow-up (3 months to 5 years) at 6 English cancer centers and members of 3 UK cancer patient websites, who met the study inclusion criteria, were invited to participate.

OUTCOMES

The primary outcome of this study was the construction and initial psychometric testing of SWELL-CE short and long form versions.

RESULTS

21 women participated in interviews and 250 of 788 (32%) returned the postal survey (T1). 110 draft items were evaluated using cognitive testing (n=13) to refine instrument design and test face validity, comprehension, and acceptability. Exploratory factor analysis of survey data (n=250) produced an initial 6 domain structure as a guidance for the Rasch analysis. Subsequent Rasch analysis yielded a 3 domain structure: physical sexual function, sexual and relationship concerns, and sexual desire and sexual self-esteem, each satisfying Rasch model requirements within their respective SA (item pool =59) and NSA (item pool =53) categories, including the absence of local response dependency and all showing strict unidimensionality. The 3 subscales demonstrated good psychometric properties, external validity, and test-retest reliability. A valid Rasch short form of 14 items was created from the larger item pool.

CLINICAL IMPLICATIONS

This PROM may assist clinicians to improve identification, discussion, and management of women who could benefit from sexual rehabilitation.

STRENGTHS & LIMITATIONS

Initial evaluation supports psychometric validity and reliability in the assessment of physical sexual function, sexual interest and sexual self-esteem, and sexual and relationship concerns in this study sample. However, given this study's modest response rate (32%, n=250), findings should be interpreted with caution. This PROM identifies sexual concerns in women who are sexually active or sexually non-active due to illness or treatment-associated sexual difficulties.

CONCLUSION

Sexual Well-being after Cervical or Endometrial Cancer is a novel and psychometrically valid sexual well-being measure for clinical assessment of female sexual difficulties after cervical or endometrial cancer treatment. White ID, Tennant A, Taylor C, Sexual Morbidity Assessment in Gyne-Oncology Follow-Up: Development of the Sexual Well-Being After Cervical or Endometrial Cancer (SWELL-CE) Patient-Reported Outcome Measure. J Sex Med 2020;17:2005-2015.

A comparative analysis of quality of life after postoperative intensity-modulated radiotherapy or three-dimensional conformal radiotherapy for cervical cancer

AIMS

The aim of this study is to compare the quality of life (QOL) between adjuvant three-dimensional conformal radiotherapy (3DCRT) or intensity-modulated radiotherapy (IMRT) for cervical cancer.

MATERIALS AND METHODS

QOL assessment was done at the baseline and then longitudinally after completing (chemo) radiation. All patients completed EORTC QLQ-C30 and EORTC QLQ Cx-24 modules. Independent-sample t-test was used to compare the mean scores between the two groups. Analysis of variance was used to compare differences in QOL measures over the six time points (baseline, post-RT, 3, 6, 9, and 12 months after treatment) and between treatment groups (3DCRT vs. IMRT). Linear mixed model was also performed to account for attrition.

RESULTS

Overall, 64 patients (image-guided IMRT, n = 40 and 3DCRT, n = 24) completed QOL assessment. The median age and follow-up period were 48 years and 15.5 months, respectively. General QOL domains such as emotional (at 12 months, P = 0.04) and social (at 3 months, P = 0.02 and 12 months, P = 0.03) were better with IMRT. Pain (12 months, P = 0.03); fatigue (12 months, P = 0.05); nausea and vomiting (12 months, P = 0.03); insomnia (post-RT, P = 0.05 and 12 months, P = 0.03); appetite loss (post-RT and 12 months, P = 0.04); and diarrhea (6 months, P = 0.02 and 12 months, P = 0.003) scores were significantly better with IMRT. On linear mixed model analysis, there was a significant interaction between treatment cohort and assessment intervals for physical, emotional, and social functioning, appetite loss, diarrhea, lymphedema, and menopausal symptom scores were significantly better with IMRT.

CONCLUSIONS

Treatment technique (IMRT vs. 3DCRT) impacts early QOL in undergoing adjuvant radiation for cervical cancer.

Sexuality of Moroccan Survivors of Cervical Cancer: A Prospective Data

Introduction:

This is a prospective study aiming to describe how cervical cancer and its treatment can affect the sexuality of a specific population of Moroccan women survivors of this disease.

Materiels and Methods:

It is a comparison of clinical features and Female Sexual Function Index (FSFI) of 3 balanced groups of women, made up of 100 survivors of cervical cancer, 100 survivors of non-gynecological cancer and a group of 100 healthy women.

Results:

97% of the patients stopped their full sexual activity at the time of treatment; the time interval between treatment and regular sexual activity was 8 months for the cervical cancer group, and 5.8 months for non-gynecologic cancer (P =0.001). Vaginal length assessed by pelvic examination during follow up visits was estimated at about 6.2 cm, 9.2 cm and 9.5 cm respectively for the cervical cancer group, non-gynecologic cancer group and the control group (p=0.04). On the basis of the FSFI questionnaire, the analysis of the 6 main sexuality parameter scores did attest worse results for the variables related to sexual function for cervical cancer group, but not in a statistically significant way.

Conclusion:

In order to preserve an optimal quality of life after cervical cancer, the sexual dimension is a crucial parameter to take into consideration throughout treatment phases, especially radiation (by encouraging sexual intercourses, and using vaginal dilators during the treatment). Moroccan survivors of this disease must be treated according to a multidisciplinary approach, that includs the psychological component.

Socioeconomic status as an independent risk factor for severe late bowel toxicity after primary radiotherapy for cervical cancer

OBJECTIVE

To evaluate the frequency of and risk factors for severe late bowel toxicity after curative radiotherapy in women treated for locally advanced cervical cancer.

METHODS

Included were 515 women treated for locally advanced cervical cancer with primary radiotherapy with curative intent from 1992 to 2013. Bowel toxicity was graded according to the Common Terminology Criteria for Adverse Events. Associations between risk factors and severe late bowel toxicity were assessed using Cox proportional hazards regression models.

RESULTS

Median follow-up was 78months. Fifty-nine patients developed severe late bowel toxicity. The actuarial 3-year and 5-year severe late bowel toxicity rates were both 13%. In the multivariable analysis, factors significantly associated with severe late bowel toxicity were: smoking (HR 2.59 [1.48-4.55]), severe acute bowel toxicity (HR 2.46 [1.24-4.49]), previous major abdominal surgery (HR 2.35 [1.20-4.60]), hypertension (HR 2.33 [1.23-4.40]), parametrial boost (HR 2.18 [1.10-4.33]), low socioeconomic status (HR 2.05 [1.17-3.59]) and low BMI (HR 0.93 [0.88-0.99]). First symptoms of severe late bowel toxicity were reported after a median follow-up of 9months, but occurred up to 10years after end of treatment. Only one third of the patients with severe late bowel toxicity were referred to a gastroenterologist.

CONCLUSIONS

Severe late bowel toxicity is a frequent complication of definitive radiotherapy for cervical cancer. Several independent risk factors were found which warrant further research. A standardized and structured approach in the early diagnostics and management of bowel toxicity is needed.

Impact of Ospemifene on Quality of Life and Sexual Function in Young Survivors of Cervical Cancer: A Prospective Study

Background

Cervical cancer (CC) treatments impact quality of life (QoL) and sexual function (SF) of survivors. Treatment options to reduce sexual dysfunction are limited. The aim of this study was to assess the effectiveness of ospemifene in CC survivors with clinical signs and symptoms of vulvovaginal atrophy (VVA) focusing on their QoL and SF.

Materials and Methods

Fifty-two patients with previous diagnosis of stage I-IIa CC suffering from VVA and treated with ospemifene were enrolled into a single arm prospective study. Patient underwent 6 months of therapy. At baseline and after 6 months all subjects performed Vaginal Health Index (VHI). The SF and QoL were measured by The European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire (QLQ) and the Cervical Cancer Module (CXC-24).

Results

After treatment a significant improvement of each parameter of VHI has been demonstrated. Global health status and emotional and social functioning scores improved significantly. On the contrary, general symptoms scales did not show significant difference from baseline data. Sexual activity, sexual vaginal functioning, body image, and sexual enjoyment scores increased significantly.

Conclusion

Ospemifene seems to be effective in decreasing the VVA symptoms in CC survivors.

Measuring health-related quality of life in cervical cancer patients: a systematic review of the most used questionnaires and their validity

Background

Data on health-related quality of life (HRQoL) is paramount for shared and evidence based decision-making. Since an overview of cervical cancer HRQoL tools and their validity appears to be lacking, we performed a systematic review on usage of disease specific HRQoL instruments in cervical cancer patients and their psychometric properties to identify the most suitable cervical cancer specific HRQoL tool.

Methods

We searched Pubmed, EMBASE and PsycINFO from inception up to 18 October 2016 for studies on quality of life in cervical cancer patients. Data extraction and HRQoL identification was performed by two independent reviewers. Validation studies of the identified cervical cancer specific HRQoL tools were retrieved and assessed on psychometric properties using the COSMIN checklist. All used cervical cancer specific HRQoL instruments were scored and ranked according to their psychometric properties.

Results

We included 156 studies (20,690 patients) and identified 31 HRQoL tools. The EORTC QLQ-CX24 (35 studies; 5,556 patients) and FACT-Cx (22 studies; 4,224 patients) were the only cervical cancer specific tools.

The EORTC QLQ-CX24 had 4 out of 9 positive rated psychometric properties; internal consistency, content and construct validity, and agreement. Criterion validity, reliability, and interpretability scored doubtful. Responsiveness and floor- and ceiling effects were not reported. The FACT-Cx had 2 out of 9 positive rated psychometric properties; internal consistency and agreement. Content validity, reliability, and interpretability scored doubtful while criterion and construct validity scored negative. Responsiveness and floor- and ceiling effects were not reported.

Conclusion

The validity of the often used EORTC QLQ-CX24 questionnaire for cervical cancer patients remains uncertain as 5 out of 9 psychometric properties were doubtful or not reported in current literature. Cervical cancer specific HRQoL tools should therefore always be used in conjunction with validated generic cancer HRQoL tools until proper validity has been proven, or a more valid tool has been developed.

Electronic supplementary material

The online version of this article (doi:10.1186/s12874-016-0289-x) contains supplementary material, which is available to authorized users.

Needs and priorities of women with endometrial and cervical cancer

INTRODUCTION

Rehabilitation after cancer is important, and efficient rehabilitation requires knowledge of patient's needs. This study aimed to identify short-term rehabilitation needs of women with endometrial and cervical cancer.

METHODS

Ninety-six women (82.6%) were included in an exploratory questionnaire study from Odense University Hospital from September 2011 to March 2012. Needs were assessed pre-treatment and 3 months later using the three-levels-of-needs questionnaire. Furthermore, 16 women participated in focus group interviews following the treatment. The interviews were audio-recorded, transcribed verbatim and analyzed thematically.

RESULTS

Forty-four of the included women were diagnosed with cervical cancer (median age 45 years). Of these, 22 had FIGO-stage 1 disease (50%) and 23 received radiation therapy (52.3%). The remaining 52 women (median age 66.5 years) were diagnosed with endometrial cancer. Of these, 38 had FIGO-stage 1 disease (73.1%) and 25 were treated with laparoscopic surgery (48.1%). Emotional functioning was significantly worse prior to treatment in both the cancers (p < 0.001 cervical and p = 0.002 endometrial) and worry constituted an unmet need in 70.7% of cervical and 34.7% of endometrial cancer patients. Both the patient groups experienced significant lymphedema post-treatment [endometrial cancer (p = 0.006) and cervical cancer (p = 0.002)]. Further, urological problems were more prevalent post-treatment in endometrial cancer patients (p = 0.018), while sexual problems were of specific concern for cervical cancer patients (p = 0.029). However, in both cancer groups, the mean problem intensity scores were comparable to normative data, suggesting that the majority of patients will not require extensive rehabilitation. Qualitative analysis indicated that treatment modality and marital status severely impacted on coping, suggesting that irradiated and single women are at higher risk of developing rehabilitation needs. Additionally, women younger than 55 years more often requested help dealing with sexual and psychological complications.

DISCUSSION

Women with endometrial and cervical cancer experience emotional problems prior to therapy and lymphedema, and urological and sexual problems following treatment. An awareness of these problems may facilitate early identification of women with unmet needs and enable individualized follow-up adjusted for such patient's needs. Interventions aimed at improving sexual and psychological functioning should be available.

Patient preferences for side effects associated with cervical cancer treatment

OBJECTIVES

The aim of this study was to assess patient preferences regarding side effects associated with cervical cancer treatment.

METHODS/MATERIALS

The visual analog scale (VAS) and modified standard gamble (SG) were used to elicit preferences of women with no evidence of disease after primary treatment of cervical cancer. Higher scores on VAS and SG indicated more favorable ratings for a given health state. Health states (HS) included vaginal shortening, diarrhea, dietary changes, menopause, moderate nausea/vomiting, rectal bleeding, sexual dysfunction, and urinary self-catheterization. Descriptive statistics, Kruskal-Wallis, Mann-Whitney U, and Wilcoxon signed-ranks tests and correlation coefficients were used for statistical analysis.

RESULTS

Seventy-eight patients participated in the study. Median age was 44.1 years (range, 24.9-67.8 years). Median time since treatment completion was 31.2 months (range, 1.0-113.3 months). The HSs rated as most favorable by VAS were also rated as most favorable by SG. Increasing age was associated with higher VAS scores for menopause and vaginal shortening (P = 0.04 and 0.036). African Americans had higher VAS scores for dietary changes (P = 0.05), sexual dysfunction (P = 0.028), and diarrhea (P = 0.05) when compared with Hispanic and non-Hispanic white patients. Women receiving radiation had more favorable VAS scores for menopause compared with women undergoing radical hysterectomy (P = 0.05). Women receiving chemotherapy rated urinary self-catheterization less favorably by VAS score compared with those not receiving chemotherapy (P = 0.045).

CONCLUSIONS

Multiple demographic and clinical factors influence the severity of treatment-related adverse effects perceived by women surviving cervical cancer. A better understanding of factors influencing patient preferences regarding treatment side effects will allow providers to formulate care better tailored to the individual desires of each patient.

Risk of colorectal cancer among long-term cervical cancer survivors

Because advances in therapy have increased long-term survival for women with cervical cancer, it is important to study the risk of secondary primary malignancies in high-dose organ areas. From the 1973-2009 National Cancer Institute Surveillance, Epidemiology, and End Results (SEER) program, we studied the risk of developing cancer of the colon and rectum in 64,507 cervical cancer patients over 35 years after initial radiation treatment. We also assessed change in risk over time. Kaplan-Meier estimator for survival curve and Cox proportional hazards models was used. More than half (52.6%) of the cervical cancer patients received radiation treatment. In the analyses adjusted for race/ethnicity, age, marital status, surgery status, stage and grade, the risk of colon cancer between those both with and without XRT diverged beginning at approximately 8 years. After 8 years, the hazard ratio for developing colon cancer was 2.00 (95% CI 1.43-2.80) for women with radiation versus those without radiation treatment. The risk of rectal cancer diverged after 15 years of follow-up (HR 4.04, 95% CI 2.08-7.86). After 35 years of follow-up, the absolute risk of developing colon cancer was 6.5% for those who received radiation versus 2.5% for those without, and 3.7 versus 0.8% for rectum. The risk of colon and rectum cancer over 20 years of follow-up after radiation remained the same across three eras (1973-1980, 1981-1990, and 1991-2000). Radiation-induced second cancers of the colon and rectum may occur 8 years after radiation treatment for cervical cancer.

Bladder and bowel symptoms in cervical and endometrial cancer survivors

BACKGROUND

Previous studies likely underestimate the prevalence of bowel and bladder symptoms in gynecologic cancer survivors. We sought to estimate the prevalence of these symptoms in cervical and endometrial cancer survivors who had completed treatment 1 year previously compared with non-cancer controls, and to examine factors associated with more severe symptoms in survivors.

METHODS

As part of a larger quality of life study, survivors who were 1-year posttreatment for cervical or endometrial cancer (n = 104) completed measures of bladder and bowel symptoms. An age-matched and race/ethnicity-matched sample of women with no history of cancer was recruited for comparison purposes.

RESULTS

Survivors reported a higher prevalence of bladder symptoms, specifically storage and incontinence symptoms, than non-cancer controls. Prevalence rates for bowel symptoms in survivors were higher than those reported in previous studies. Greater symptom severity was associated with younger age, lower annual incomes, and less education. Other correlates included higher body mass index and history of smoking. As hypothesized, more severe symptoms were associated with radical hysterectomy and pelvic radiation.

CONCLUSIONS

Bladder and bowel symptoms are more prevalent in cervical and endometrial cancer survivors than non-cancer controls. Future research should replicate these findings in a larger, prospective study.

A study to evaluate the cause of bone demineralization in gynecological cancer survivors

BACKGROUND

An association between treatment for gynecological cancers and risk of osteoporosis has never been formally evaluated. Women treated for these cancers are now living longer than ever before, and prevention of treatment-induced morbidities is important. We aimed to distinguish, in gynecological cancer survivors, whether cancer therapy has additional detrimental effects on bone health above those attributable to hormone withdrawal.

METHODS

We performed a retrospective cross-sectional analysis of dual energy x-ray absorptiometry (DEXA) scan results from 105 women; 64 had undergone bilateral salpingo-oophorectomy (BSO) followed by chemotherapy or radiotherapy for gynecological malignancies, and 41 age-matched women had undergone BSO for benign etiologies. All were premenopausal prior to surgery.

RESULTS

The median age at DEXA scan for the cancer group was 42 years, and 66% had received hormonal replacement therapy (HRT) following their cancer treatment. For the benign group, the median age was 40 years, and 87% had received HRT. Thirty-nine percent of cancer survivors had abnormal DEXA scan results compared to 15% of the control group, with the majority demonstrating osteopenia. The mean lumbar spine and femoral neck bone mineral densities (BMDs) were significantly lower in cancer patients. A history of gynecological cancer treatment was associated with significantly lower BMD in a multivariate logistic regression.

CONCLUSIONS

Women treated for gynecological malignancies with surgery and adjuvant chemotherapy have significantly lower BMDs than age-matched women who have undergone oophorectomy for noncancer indications. Prospective evaluation of BMD in gynecological cancer patients is recommended to facilitate interventions that will reduce the risk of subsequent fragility fractures.

Prevalence of secondary lymphedema in patients with head and neck cancer

CONTEXT

Because surgery, radiation, and/or chemotherapy disrupt lymphatic structures, damage soft tissue leading to scar tissue formation and fibrosis, and further affect lymphatic function, patients with head and neck cancer may be at high risk for developing secondary lymphedema. Yet, no published data are available regarding the prevalence of secondary lymphedema after head and neck cancer treatment.

OBJECTIVES

The aim of this study was to examine prevalence of secondary lymphedema in patients with head and neck cancer.

METHODS

The study included 81 patients with head and neck cancer who were three months or more post-treatment. External lymphedema was staged using Foldi's lymphedema scale. Internal lymphedema was identified through a flexible fiber-optic endoscopic or mirror examination. Patterson's scale was used to grade degrees of internal lymphedema.

RESULTS

Of the 81 patients, 75.3% (61 of 81) had some form of late-effect lymphedema. Of those, 9.8% (6 of 61) only had external, 39.4% (24 of 61) only had internal, and 50.8% (31 of 61) had both types.

CONCLUSION

Lymphedema is a common late effect in patients with head and neck cancer, and it develops in multiple external and internal anatomical locations. During physical examination and endoscopic procedures, clinicians should assess patients with head and neck cancer for late-effect lymphedema. Referral for treatment should be considered when lymphedema is noted. Research is needed to examine risk factors of lymphedema in patients with head and neck cancer and its effects on patients' symptoms, function, and quality of life.

Assessment of treatment-induced female sexual morbidity in oncology: is this a part of routine medical follow-up after radical pelvic radiotherapy?

BACKGROUND

Oncology follow-up has traditionally prioritised disease surveillance and the assessment and management of symptoms associated with cancer and its treatment. Over the past decade, the focus on late effects of treatment has increased, particularly those that have an adverse effect on long-term function and quality of life. The aim of this research was to explore factors that influence the identification of treatment-induced female sexual difficulties in routine oncology follow-up after radical pelvic radiotherapy.

METHODS

A structured observation schedule was used to systematically record topics discussed in 69 radiotherapy follow-up consultations observed over a 5-month period.

RESULTS

Analysis suggests that physical toxicity assessment focused on bowel (81%) and bladder (70%) symptoms. Vaginal toxicity was discussed less frequently (42%) and sexual issues were explored in only 25% of consultations. Formal recording of radiation toxicity through assessment questionnaires was limited to patients participating in clinical trials. Surveillance activity and the management of active physical symptoms predominated and psychosocial issues were addressed in only 42% of consultations.

INTERPRETATION

Female sexual morbidity after pelvic radiotherapy remains a neglected aspect of routine follow-up and cancer survivorship. Developments in both individual practice and service provision are necessary if the identification and management of treatment-induced female sexual difficulties is to be improved.

Quality of life and adverse events after radiotherapy in gynecologic cancer survivors: a cohort study

PURPOSE

To evaluate quality of life (QOL) in gynecologic cancer survivors after radiotherapy (RT), investigate the frequency of adverse events and demonstrate an association between these symptoms and QOL.

METHODS

A prospective cohort study of 95 women aged 21-75 years undergoing RT for gynecologic cancer was carried out. QOL was assessed by the WHOQOL-BREF before, at 4 months, 1 year and 3 years after RT and adverse events were evaluated following RT by the (CTCAE) v 3.0 scale. QOL scores were assessed by the Wilcoxon signed rank test over time. Multiple linear regression analysis was used to identify predictors of QOL.

RESULTS

The most frequent adverse events were pain (64.2%) and dyspareunia (45.9%). A significant increase in QOL scores was observed in the psychological domain, general health and overall QOL. Pain was negatively associated with the physical, psychological and social relationship domains (p < 0.01); dyspareunia with the physical and social relationship (p < 0.01); decreased sexual interest with the psychological (p < 0.01). Higher family income was positively associated with the psychological domain and general health (p < 0.01).

CONCLUSIONS

Results suggested that QOL improved after RT in women with gynecologic cancer. Adverse events, such as pain, dyspareunia and decreased sexual interest had a negative impact on QOL.

MRI and PET scans for primary staging and detection of cervical cancer recurrence

Worldwide, cervical cancer is the second most common malignancy in women, and is a major cause of morbidity and mortality. Accurate tumor staging is essential for optimal treatment planning and prognosis. Cervical cancer is staged by clinical examination according to the International Federation of Gynecology and Obstetrics staging system. However, clinical staging has inherent deficiencies in evaluating several parameters that are critical for treatment planning. It is now widely accepted that cross-sectional imaging, and in particular MRI, has an important role to play in the staging of these tumors. MRI is an excellent modality for depicting invasive cervical cancer: it can provide objective measurement of tumor size and provides a high negative predictive value for parametrial invasion and stage IVA disease. MRI and positron emission tomography (PET)/computed tomography (CT) play key roles in identifying recurrent disease. PET/CT is also useful in detecting nodal and distant metastases and in radiotherapy planning. Diffusion-weighted MRI is an emerging imaging technique that is currently being evaluated for the detection of primary and recurrent disease and in the assessment of treatment response.

Outcomes of a cancer-related fatigue clinic in a comprehensive cancer center

Cancer-related fatigue (CRF) is a significant issue for cancer patients and frequently precipitates increased stress and anxiety for patients and caregivers alike. CRF may present well after the initial phase of cancer diagnosis and treatment, regardless of whether the cancer is in remission, widely metastatic, or somewhere in between. Determining whether the etiology of fatigue is potentially reversible and whether it is an effect of treatment or another unrelated cause is often perplexing. Because of the significant impact of CRF on patients at our institution, we organized a CRF clinic and began evaluating patients for fatigue in 1998. Our goal has been to initiate a more focused and, at the same time, more comprehensive effort in educating, evaluating, and treating CRF. The purpose of this report was to present a retrospective review of patients treated in our CRF clinic between 1998 and 2005, to examine the outcomes of our patients, and to briefly describe some of the challenges encountered in treating these patients. This information may help reassess and improve approaches in addressing CRF and subsequently improve fatigue in these patients.

The impact of radiotherapy late effects on quality of life in gynaecological cancer patients

The aims of this study were to assess changes in quality of life (QoL) scores in relation to radical radiotherapy for gynaecological cancer (before and after treatment up to 3 years), and to identify the effect that late treatment effects have on QoL. This was a prospective study involving 225 gynaecological cancer patients. A QoL instrument (European Organisation for the Research and Treatment of Cancer QLQ-C30) and late treatment effect questionnaire (Late Effects Normal Tissues - Subjective Objective Management Analysis) were completed before and after treatment (immediately after radiotherapy, 6 weeks, 12, 24 and 36 months after treatment). Most patients had acute physical symptoms and impaired functioning immediately after treatment. Levels of fatigue and diarrhoea only returned to those at pre-treatment assessment after 6 weeks. Patients with high treatment toxicity scores had lower global QoL scores. In conclusion, treatment with radiotherapy for gynaecological cancer has a negative effect on QoL, most apparent immediately after treatment. Certain late treatment effects have a negative effect on QoL for at least 2 years after radiotherapy. These treatment effects are centred on symptoms relating to the rectum and bowel, for example, diarrhoea, tenesmus and urgency. Future research will identify specific symptoms resulting from late treatment toxicity that have the greatest effect on QoL; therefore allowing effective management plans to be developed to reduce these symptoms and improve QoL in gynaecological cancer patients.