Validation of a questionnaire for self-rating of urological and gynaecological morbidity after treatment of gynaecological cancer

Taraxerol Induces Cell Apoptosis through A Mitochondria-Mediated Pathway in HeLa Cells

Objective

Taraxerol acetate has potent anti-cancer effects via the induction of apoptosis, autophagy, cell cycle arrest, and inhibition of cell migration. However, whether taraxerol induced apoptosis and its underlying mechanisms of action is not clear. In the present study, we assess the effects of taraxerol on the mitochondrial apoptotic pathway and determine the release of cytochrome c to the cytosol and activation of caspases.

Materials and Methods

In this experimental study, we mainly investigated the effect of taraxerol on HeLa cells. We tested cell viability by the MTT assay and morphologic changes, analyzed apoptosis by DAPI staining and flow cytometry. We also determined reactive oxygen species (ROS) and mitochondrial membrane potential (MMP) using a Microplate Reader. In addition, the apoptotic proteins were tested by Western blot.

Results

Taraxerol enhanced ROS levels and attenuated the MMP (Δψm) in HeLa cells. Taraxerol induced apoptosis mainly via the mitochondrial pathway including the release of cytochrome c to the cytosol and activation of caspases 9 and 3, and anti-poly (ADP- ribose) polymerase (PARP). Taraxerol could induce the down-regulation of the anti-apoptotic protein Bcl-2 and up-regulation of pro-apoptotic protein Bax. It suppressed the PI3K/ Akt signaling pathway.

Conclusion

These results demonstrated that taraxerol induced cell apoptosis through a mitochondria-mediated pathway in HeLa cells. Thus, taraxerol might be a potential anticervical cancer candidate.

Quality of life, urogynecological morbidity, and lymphedema after radical vaginal trachelectomy for early-stage cervical cancer

OBJECTIVE

Radical vaginal trachelectomy (RVT) offers a possibility for future childbearing for young women with early-stage cervical cancer. However, the literature on quality of life and self-reported morbidity in patients undergoing RVT is scarce. The aim of this study was to prospectively assess quality of life after RVT with focus on urogynecological morbidity and lymphedema. Furthermore, the aim of this study was to compare results with those in women treated with radical abdominal hysterectomy (RAH) and with age-matched control women from the general population.

METHODS AND MATERIALS

Eighteen patients with early-stage cervical cancer operated with RVT were prospectively included and assessed preoperatively, 3, 6, and 12 months postoperatively using validated questionnaires. Thirty-two patients treated with RAH were included consecutively and assessed once at 12 months postsurgery, whereas an age-matched control group of 30 healthy women was assessed once.

RESULTS

Fifty percent of the RVT group and 41% of the RAH reported any grade of incomplete bladder emptying problems at 1 year postsurgery assessment. Eleven percent of the RVT patients and 12.5% of the RAH patients reported severe lymphedema of the legs as assessed by the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Cervical Cancer Module. The Global Health Status scores of the RVT patients improved over time but were significantly lower than in the healthy controls during the entire observation time (P = 0.029).

CONCLUSIONS

Patients treated with RVT for early-stage cervical cancer had persistent bladder emptying problems and lymphedema comparable to those experienced by patients treated with RAH and significantly higher than those reported by healthy control women.

Quality of life and sexual function in patients with borderline tumors of the ovary. A substudy of the Arbeitsgemeinschaft Gynaekologische Onkologie (AGO) study group ROBOT study

PURPOSE

Borderline tumors of the ovary (BOT) represent an entity of ovarian neoplasms with low malignant potential and excellent prognosis. Mainstay of therapy is surgery including adequate staging and complete tumor resection, possibly inducing long-term side effects, especially in premenopausal women. The aim of this study was to evaluate quality of life (QoL) and sexual function in patients treated for BOT, also with respect to treatment modalities.

METHODS

This prospective study was part of an ambidirectional multicentric cohort study in patients with BOT in Germany. Patients from seven centers completed three questionnaires after completion of therapy. QoL and sexual function data were correlated with treatment characteristics: surgical approach, lymphadenectomy, and fertility sparing surgery.

RESULTS

One hundred ten patients returned the questionnaires. Median follow-up was 4.0 years. The majority lived in a relationship (n = 85, 77%, missing n = 4), and 49% (n = 54, missing n = 6) were sexually active. The main reason for sexual inactivity was "no partner" (38%). The women had a mean global health status of 69.8 (SD 22.7; min 0, max 100), with 100 implying perfect health. Mean QoL score was 73.7 (SD 23.3, range 0 to 100). Both scores showed no difference regarding fertility preserving surgery, surgical approach, and lymphadenectomy. Sexually active women had a significantly higher QoL (78.7 vs. 67.4, p = 0.0156) and global health status (75.9 vs. 60.9, p = 0.0013) than inactive patients.

CONCLUSIONS

In this prospective study, patients who had been diagnosed with BOT had a very good quality of life and global health status. Sexually inactive women stated lack of a partner as the main reason and had an inferior HRQoL compared to sexually active women.

Adjuvant chemotherapy, a valuable alternative option in selected patients with cervical cancer

Radiotherapy is the standard treatment for cervical cancer, but causes radiotherapy-induced complications. Recently, chemotherapy has been more extensively utilized. Here, we perform a large-scale comparison of chemotherapy and radiotherapy. From 2002 to 2008, 2,268 patients were grouped according to adjuvant radiotherapy or chemotherapy before and/or after surgery, and we compared the 5-year overall survival (OS) and disease-free survival (DFS) rates, recurrence rates, side effects, quality of life (QoL), and sexual activity. There were no significant differences between the treatment groups for the 5-year OS and DFS rates (OS: p = 0.053, DFS: p = 0.095), although marginally improved outcomes were observed in the chemotherapy group (OS: 86.5% vs. 82.8%; DFS: 84.5% vs. 81.4%). However, patients with early-stage disease, clinical response, and younger age had increased 5-year OS and DFS rates following chemotherapy compared to radiotherapy (p<0.05). The chemotherapy group exhibited significantly lower 5-year recurrence and distant failure rates compared to the radiotherapy group (p<0.001 and p = 0.007, respectively). Nausea and vomiting were the most frequent short-term complications of chemotherapy, whereas bowel and urinary complications were more frequent in the radiotherapy group. Compared to the chemotherapy group, patients who received radiotherapy reported a lower QoL, less frequent sexual activity, and more severe menopausal symptoms (p<0.05). Cervical cancer patients treated with chemotherapy, especially those with early-stage disease, clinical responses, and younger ages, have more positive outcomes, fewer complications, better QoL and sexual activity, suggesting that chemotherapy may be a valuable alternative option for selected patients.

[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.

Development and initial validation of the Three-Levels-of-Needs Questionnaire for self-assessment of palliative needs in patients with cancer

CONTEXT

To improve palliative care, it is important that questionnaires accurately assess the needs of the patients. No questionnaire existed that combined three different and important approaches to needs assessment. We developed such a questionnaire, called the Three-Levels-of-Needs Questionnaire (3LNQ), based on literature searches. The 3LNQ measures 12 important needs with three different approaches when used as a supplement to the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30): problem intensity, problem burden, and felt need.

OBJECTIVES

To investigate the initial validity of the 3LNQ.

METHODS

We used a relatively new method that investigates whether the questionnaire has the same meaning for the patients as for the researchers. To do this, 74 patients with advanced cancer filled out the questionnaire and participated in an open-ended interview. The patients' responses to the questionnaire before the interview were compared against the researchers' responses based on the interviews. Items showing substantial agreement were accepted as valid without further analysis. For the remaining items, reasons for disagreements were analyzed qualitatively.

RESULTS

All items on problem intensity, eight of 12 items on problem burden, and three of 12 items on felt need were accepted as valid because of high agreement. Analysis of the qualitative data concerning the remaining items showed that most disagreements did not indicate problems with the patients' self-assessment. Instead, different causes for disagreements were elucidated, but these did not interfere with validity.

CONCLUSION

The 3LNQ appears to measure palliative needs comprehensively, and this initial validation showed satisfactory results. The analysis gave important insights into the patients' perceptions of their own situations, into their expectations of the health care system, and into the complexity of needs assessment.

Sexual Oncology: Sexual Health Issues in Women with Cancer

Sexual problems are widespread among female cancer patients and survivors. Dysfunction may result from various oncologic therapies such as surgery, radiation therapy, chemotherapy, hormonal manipulation, and cytostatic medication. Additionally, psychologic distress that the patient or her partner experiences during diagnosis and treatment of malignancy can impair a healthy female sexual response cycle. A sexual rehabilitation program in an oncology setting is necessary to provide comprehensive care to the cancer patient and her partner. A multidisciplinary treatment approach to sexual dysfunction includes psychological and psychiatric intervention, medical intervention, cognitive behavioral therapy, and recommended lifestyle adjustments. A holistic approach to assessing and treating sexual concerns should be individually tailored to the female patient in light of her disease stage and prognosis, age, marital status, fertility concerns, and social and professional environment.

Errors in Symptom Intensity Self-Assessment by Patients Receiving Outpatient Palliative Care

BACKGROUND

Patient-based symptom scores are the standard method for assessment in palliative care. There has been limited research on the frequency of errors upon using this approach. The Edmonton Symptom Assessment Scale (ESAS) is a reliable and valid assessment tool routinely used for symptom intensity assessment in our cancer center.

OBJECTIVE

To determine if patients were scoring the symptoms on the ESAS in the way it was supposed to be scored.

SETTINGS

The study was carried out at the outpatient palliative care center.

DESIGN AND SUBJECTS

Retrospective review of 60 consecutive patient charts was done where the patient had initially scored the ESAS. The physician looked at this scoring on the ESAS and went back to the patient to do the scoring again to see if the patient had scored it in the way it was intended to be scored. The same physician did the assessment on all of the patients.

OUTCOME MEASURES

Level of agreement (weighted kappa) before versus after the physician visit; Screening performance of patient completed ESAS for mild and moderate symptom intensity.

RESULTS

Complete agreement ranged from 58% (sleep) to 82% (well-being); the weighted kappa ranged from 0.49 (drowsiness) to 0.78 (well-being). There was more agreement for symptoms such as dyspnea, nausea, anxiety, and depression and less agreement for symptoms such as lack of sleep and lack of appetite. The screening performance of the initial patient self assessment showed less sensitivity for nausea, drowsiness if the intensity was mild and less sensitivity for pain, nausea, anxiety, and drowsiness if the intensity was moderate.

CONCLUSIONS

Vigilance needs to be maintained about the ESAS scores done by the patients particularly for symptoms of sleep, appetite, and pain. There is a likelihood of error if doctors or nurses do not routinely check the way patients have completed the assessment form. More research is needed to determine the best way to teach patients how to minimize errors in self-reporting of symptoms.

A randomized crossover trial to examine administration techniques related to the Bristol female lower urinary tract symptom (BFLUTS) questionnaire

AIMS

To investigate whether two methods of assessing lower urinary tract symptoms, interview-assisted standardized questionnaires, and self-completed standardized questionnaires, were comparable.

METHODS

Women referred to a tertiary urogynecology urodynamic clinic with lower urinary tract symptoms were recruited. The psychometrically robust Bristol Female Lower Urinary Tract Symptoms (BFLUTS) questionnaire was used to assess urinary symptoms. A randomized crossover design for questionnaire completion was used: Group A-an initial interview-assisted questionnaire at the urodynamic clinic with a follow-up postal questionnaire; or Group B-an initial pre-out-patient postal questionnaire followed up by a second interview-assisted questionnaire whilst attending a scheduled urodynamic clinic.

RESULTS

A total of 114 women were randomized for initial questionnaire administration method to achieve 72 completed sets (63%). Total scores were higher on self-completion compared to interview, this difference was not significant [t = -1.951, P > 0.05]. No item had perfect agreement between postal and interview methods and generally, interview-assisted questions had lower scores, indicating better health status. The items with the worst agreement (slight or moderate) were those concerned with sexual health, with women giving lower scores, exaggerating health on interview. For example bother of vaginal discomfort (kappa(w) = 0.09), compared to question assessing frequency (kappa(w) = 0.65).

CONCLUSIONS

This data suggests women respond differently to the BFLUTS questionnaire when data is collected by self-completion in the woman's home compared to interviews. No individual question item had perfect agreement between the two methods of administration. Overall, individual question items were scored higher on self-completion than interview.

Longitudinal study of sexual function and vaginal changes after radiotherapy for cervical cancer

PURPOSE

To investigate the longitudinal course of self-reported sexual function and vaginal changes in patients disease free after radiotherapy (RT) for locally advanced, recurrent, or persistent cervical cancer.

MATERIALS AND METHODS

A total of 118 patients referred for RT were included. The patients were assessed, using a validated self-assessment questionnaire, at the termination of RT and 1, 3, 6, 12, 18, and 24 months later. The results were compared with an age-matched control group from the general population.

RESULTS

Persistent sexual dysfunction and adverse vaginal changes were reported throughout the 2 years after RT, with small changes over time: approximately 85% had low or no sexual interest, 35% had moderate to severe lack of lubrication, 55% had mild to severe dyspareunia, and 30% were dissatisfied with their sexual life. A reduced vaginal dimension was reported by 50% of the patients, and 45% were never, or only occasionally, able to complete sexual intercourse. Despite sexual dysfunction and vaginal adverse effects, 63% of those sexually active before having cancer remained sexually active after treatment, although with a considerably decreased frequency.

CONCLUSIONS

Patients who are disease free after RT for locally advanced, recurrent, or persistent cervical cancer are at high risk of experiencing persistent sexual and vaginal problems compromising their sexual activity and satisfaction.