Sexuality and sexual function in long-term survivors of cervical cancer

Brachytherapy impacts on sexual function: An integrative review of the literature focusing on cervical cancer

There is growing awareness of the importance of sexual health in the quality of life of cancer patients and survivors. Brachytherapy, a vital component for the curative treatment of cervical cancer, leads to both direct and indirect sequelae that result in vaginal and sexual morbidity. The emergence of 3D image-guided adaptive brachytherapy has led to a better understanding of dose-and-effect relationships for critical organs-at-risk and there are new recommendations for vaginal dose reporting in the ongoing EMBRACE II study. An understanding of the vagina as an organ-at-risk and its dose-and-effect relationships can help brachytherapists limit dose to the vagina and improve sexual morbidity. Brachytherapists play a critical role in the primary and secondary prevention of vaginal and sexual sequelae resulting from treatment. Through close surveillance and recognition of common symptoms, brachytherapists can intervene with effective strategies to prevent and treat vaginal and sexual symptoms. This review summarizes the current literature on dosimetric factors that may predict for vaginal morbidity. It will focus on quantitative and qualitative reports of brachytherapy-related vaginal toxicity and sexual dysfunction. Lastly, it will review the available evidence supporting clinical interventions to mitigate the development and progression of vaginal and sexual sequelae to improve functional quality post-treatment.

Quality of life among cervical cancer patients following completion of chemoradiotherapy at Ocean Road Cancer Institute (ORCI) in Tanzania

OBJECTIVE

Effective cancer treatment involves aggressive chemo-radiotherapy protocols that alter survivors' quality of life (QOL). This has recently aroused the attention not only to focus on clinical care but rather to be holistic and client-centered, looking beyond morbidity and mortality. The study assessed the QOL and associated factors among patients with cervical cancer (CC) after the completion of chemoradiotherapy.

METHODS

A cross-sectional analytical study was conducted at Ocean Road Cancer Institute (ORCI) from September to November 2020. A total of 323 CC patients were interviewed with a structured questionnaire of QOL, the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30), and its cervical cancer module (EORTC QLQ-CX24). The QOL domains, socio-demographic and clinical variables were analyzed with Mann-Whitney and Kruskal-Wallis on SPSS version 23, and a P < 0.05 was considered significant.

RESULTS

More than half (54.8%) of the CC patients had a good overall QOL. Overall, QOL was affected by education (P = 0.019), smoking (0.044), sexual partner (P = 0.000), treatment modality (P = 0.018), and time since completion of treatment (P = 0.021). Patients who underwent external beam radiation suffered from significant side effect symptoms (P < 0.05) while those who underwent combined external beam radiation and brachytherapy had higher functioning in most domains (P < 0.05).

CONCLUSIONS

A significant improvement in QOL was observed after chemoradiotherapy and was affected by socio-demographic and clinical variables. Thus, calls for individualized care in addressing these distressing symptoms.

Climacteric symptoms in postoperative patients among endometrial cancer, cervical cancer, and ovarian cancer: a cross-sectional study

Purpose

To date, no studies have assessed climacteric symptoms after hystero-adnexectomy for endometrial, cervical, or ovarian cancer. Thus, this study aimed to compare climacteric symptoms among patients who underwent surgery for these three cancer types.

Methods

In this cross-sectional study, we interviewed patients who were registered at a menopausal outpatient clinic between January 1999 and July 2016 after undergoing total hysterectomy, intrapelvic only or intrapelvic plus para-aortic lymph node dissection, and bilateral adnexectomy performed via laparotomy as a cancer treatment. Climacteric symptoms were assessed using a patient-reported questionnaire covering core domains with five symptoms only at the initial consultation. Each symptom was graded from 0 (no symptoms) to 3 (severe symptoms). We evaluated the frequency of symptom severity according to the time elapsed since surgery and the cancer type.

Results

The numbers of patients with endometrial, ovarian, and cervical cancer were 328, 90, and 107, respectively. Overall, climacteric symptoms were more severe in patients with cervical cancer than in those with endometrial or ovarian cancer; symptom severity decreased with increasing time since surgery. However, symptom severity did not decrease significantly over time in patients with cervical cancer even after > 5 years had elapsed since surgery.

Conclusion

The climacteric symptoms were less severe in patients with endometrial or ovarian cancer with longer time elapsed since surgery but not in those with cervical cancer. Patients with cervical cancer may require more prompt interventions, including symptomatic treatment and longer follow-up period, than those with endometrial or ovarian cancer.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00520-022-07117-z.

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.

Sexual Function and the Role of Sexual Communication in Women Diagnosed with Cervical Cancer: A Systematic Review

The objective of this systematic review was to summarize the changes in sexual function in cervical cancer survivors. The additional objective was to exhibit the role of sexual communication in adapting to these changes. A systematic search was performed across four electronic databases. Eighteen studies met the inclusion criteria. The most common sexual dysfunction was pain during sexual intercourse, vaginal dryness, decreased level of satisfaction and sexual interest. Some changes in vaginal anatomy and effects on psychosocial functioning were described. We confirmed that sexual communication with healthcare professionals and partners may be essential to help improve sexuality in CC survivors.

Impact of cervical cancer on the sexual and physical health of women diagnosed with cervical cancer in Ghana: A qualitative phenomenological study

INTRODUCTION

Although cervical cancer is preventable, it is a major gynecological disorder among women currently. More than 500,000 new cases of cervical cancer are being diagnosed across the globe, with one woman dying of cervical cancer every 2 min. In addition, about half of cervical cancer survivors have challenges with their sexual function. Despite these findings, literature regarding the sexual function of women with cervical cancer is scanty. The study aims to assess cervical cancer's impact on the sexual and physical health of women diagnosed with cervical cancer in Ghana.

METHODS

The researchers of this study employed a qualitative approach with phenomenological design. A purposive sampling technique was used to select 30 participants engaged in face-to-face in-depth interviews that were audio-recorded. The content of the transcripts was analyzed using content analysis.

RESULTS

This study revealed that cervical cancer patients experienced low libido due to the cervical cancer symptoms and the side effects of chemotherapy. This low libido made them divert their sexual gratification from the vagina to other centers of the body. Findings further revealed that some participants showed apathy toward their partners' sexual feelings. Some physical problems experienced by the participants were also unraveled.

CONCLUSION

Cervical cancer affects all aspects of a woman's health, including sexual function and physical well-being. Therefore, there is the need for more to help address challenges faced by cervical cancer women about their sexual and physical health.

Quality of life in long term survivors of cervical cancer: A cross sectional study

Background

Quality of life (QOL) is an important parameter to evaluate and modify in patients treated for cervical cancer as long-term survival is excellent in early-stage and reasonably good in locally advanced stage compared to other solid cancers. The aim of the study was the cross sectional evaluation of the quality of life in survivors completing at least 3 years of follow-up after curative therapy for cervical cancer at a tertiary cancer institute.

Methods

All patients, following primary curative treatment with no evidence of recurrence and completing at least 3 years follow-up, were assessed for QOL using the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire (QLQ)-30 and its cervical cancer module (Cx24). Patients were subdivided based on the modality of treatment. Analysis was done using Kruskal-Wallis and Mann-Whitney U test.

Results

One hundred seven patients were analyzed out of the 113 patients initially included. Treated patients showed good global QOL (mean value: 84.07) and functional scores (covering all domains). In the cervical cancer module, sexual activity, sexual enjoyment, and sexual function were low in the majority of the respondents. Chronic lymphedema, symptom experience, and sexual worry were significant across all the treatment arms.

Conclusion

Cervical cancer survivors have an overall good QOL. However, certain concerns related to the sexual quality of life, symptom experience, and chronic lymphedema need to be addressed appropriately.

Sexuality of Women after Gynecological Surgeries

(1) Background: Disorders of sexual life negatively impact self-esteem and social relationships. This problem affects patients after gynecological surgery. Providing access to specialist sexologist care constitutes an important aspect of support for this patient group. (2) Objective: The aim of the study was to assess the sexual life of women depending on the time since surgery, extent of gynecological surgery and postoperative chemotherapy and/or radiotherapy. (3) Methods: The study included 136 patients from gynecological outpatient clinics in Szczecin, Poland. The women answered questions from a special three-part questionnaire. Participation was anonymous and voluntary. The data obtained in the survey were subject to statistical analysis. (4) Results: Among patients with a sparing of the cervix, most have never or almost never experienced discomfort or pain during intercourse, and believe that the quality of their sex life has not deteriorated after surgery. It was found that cervical removal, despite the existence of other conditions, increases the chance of pain during sexual activity 11 times. We found that the removal of adnexa did not increase the risk of changing sexual activity. In patients who had not undergone postoperative chemo- and/or radiotherapy, sexual activity did not change after surgery, and they never or almost never experienced discomfort or pain during intercourse. On the other hand, it was shown, despite the smaller study group, that patients treated with postoperative chemo- and/or radiotherapy did not initiate sexual intercourse. (5) Conclusion: The more extended the gynecological surgery of the uterus, the greater the limitation of sexual life.

Body Image, Sexuality, and Sexual Functioning in Women With Gynecologic Cancer: An Integrative Review of the Literature and Implications for Research

BACKGROUND

Cervical and uterine cancers are common in women. Diagnosis and treatment of these cancers can lead to significant issues with body image, sexuality, and sexual functioning. A comprehensive review can improve understanding of these 3 concepts, in turn enhancing identification and management.

OBJECTIVES

To (1) present the qualitative, descriptive, and correlational research literature surrounding body image, sexuality, and sexual functioning in women with uterine and cervical cancer; (2) identify gaps in the literature; and (3) explore the implications of the findings for future research.

METHODS

A comprehensive search of the literature was undertaken by searching PubMed, CINAHL, and PsycINFO using predetermined subject headings, keywords, and exploded topics. After a comprehensive evaluation using specific criteria, 121 articles were reviewed.

RESULTS

Qualitative studies provided information about women's issues with body image, sexuality, and sexual functioning, whereas quantitative studies focused primarily on sexual functioning. The literature lacks correlational studies examining body image and sexuality. Significant issues regarding communication and quality of life were noted, and few studies were based on clear conceptual models.

CONCLUSION

The state of the science gleaned from this review reveals that while much is known about sexual functioning, little is known about body image and sexuality.

IMPLICATIONS FOR PRACTICE

Further work is warranted to develop conceptual models and research on body image, sexuality, and sexual functioning as a foundation for interventions to improve quality of life.

Overview of Centers for Disease Control and Prevention's Case Investigation of Cervical Cancer Study

Background: Despite advances in cervical cancer screening, a significant number of women in the United States have not received adequate screening. Studies have suggested that approximately half of the women who developed cervical cancer were not adequately screened. The Centers for Disease Control and Prevention (CDC) Case Investigation of Cervical Cancer (CICC) Study took a unique approach to reconstruct the time before a woman's cervical cancer diagnosis and understand the facilitators and barriers to screening and care. This article provides an overview of the study. Methods: This study included all cervical cancer survivors diagnosed with invasive cervical cancer aged 21 years and older in three U.S. states from 2014-2016. The study design consisted of three different data collection methods, including comprehensive registry data, a mailed survey, and medical chart abstraction. This overview compares the characteristics of cervical cancer survivors in the three states by study participation and eligibility status. Results: Registries identified 2,748 women diagnosed with invasive cervical cancer. Of these, 1,730 participants were eligible for participation, 28% (n = 481) enrolled in the study and 23% (n = 400) consented to the medical chart abstraction. Conclusion: The CICC Study is unique in that it addresses, with medical record verification, the medical history of woman 5 years before their cervical cancer diagnosis as well as provides information from the woman on her health care behaviors. This study provides data on a general population of cervical cancer survivors in three states that could be used to guide interventions to increase cervical cancer screening.

A Systematic Review of Sexuality and Depression of Cervical Cancer Patients

Objectives: The goal of this article is to investigate the correlation between sexuality and depression of cervical cancer (CC) patients. Methods: A bibliographical search was carried out in the databases CINAHL, PubMed, and Cochrane Library with the following terms in English for the years 2006 to 2017: sexuality, sexual function, sexual dysfunction, sexual problems, mood, depression, emotional distress, cervical cancer. Results: Fourteen studies were included. They present heterogeneity in the stage of the disease, the selected treatments, and their sample. From the studies, only 7 are evaluated as good methodologically. Sexual dysfunction and depression of CC patients persist for many years after treatments. The younger women, those who underwent radiotherapy, and those who had chronic fatigue, as an aftereffect of treatments, had increased depression. Women that underwent surgery and adjuvant therapy experienced the highest rates of depressive symptoms. There is a positive relationship between sexuality and depression in patients with CC. Conclusions: Sexuality and depression οf women with CC are affected by their therapies to a significant extent. There is a positive correlation between the two variables. The existing methodologically good studies are scarce, and for this reason the results cannot be generalized in all CC patients.

A systematic review on the prevalence of symptoms of depression, anxiety and distress in long-term cancer survivors: Implications for primary care

Introduction

Symptoms of depression, anxiety and distress are common in the first years after a cancer diagnosis, but little is known about the prevalence of these symptoms at the long term. The aim of this review was to describe the prevalence of symptoms of depression, anxiety and distress in long‐term cancer survivors, five or more years after diagnosis, and to provide implications for primary care.

Methods

We performed a systematic literature search in the PubMed, PsycINFO and CINAHL databases. Studies were eligible when reporting on the prevalence of symptoms of depression, anxiety and/or distress in long‐term cancer survivors (≥5 years after diagnosis), treated with curative intent.

Results

A total of 20 studies were included. The reported prevalence of depressive symptoms (N = 18) varied from 5.4% to 49.0% (pooled prevalence: 21.0%). For anxiety (N = 7), the prevalence ranged from 3.4% to 43.0% (pooled prevalence: 21.0%). For distress (N = 4), the prevalence ranged from 4.3% to 11.6% (pooled prevalence: 7.0%).

Conclusion

Prevalences of symptoms of depression, anxiety and distress among long‐term survivors of cancer do not fundamentally differ from the general population. This is reassuring for primary care physicians, as they frequently act as the primary physician for long‐term survivors whose follow‐up schedules in the hospital have been completed.

A correlation study of fear of cancer recurrence, illness representation, self-regulation, and quality of life among gynecologic cancer survivors in Taiwan

OBJECTIVE

The purpose of this study was to examine the correlations among fear of cancer recurrence (FCR), illness representation (IR), self-regulation (SR), and quality of life (QOL) in gynecologic cancer survivors.

MATERIALS AND METHODS

A cross-sectional study was conducted with 287 participants recruited from a medical center in northern Taiwan. Four questionnaires, the Assessment of Survivor Concerns (ASC), the Brief Illness Perception Questionnaire (BIPQ), the Self-Regulation Questionnaire (SRQ), and the European Organization for Research and Treatment of Cancer's Quality-of-Life Questionnaire-Core 30-item (EORTC QLQ-C30), were used to assess FCR, IR, SR, and QOL respectively. Data pertaining to socio-demographic characteristics and self-reported medical status was also collected from the participants. Stepwise regression analysis was performed to identify predictors of QOL.

RESULTS

The results showed that FCR (r = -.21, P < .01) and IR (r = -.44, P < .01) was negatively correlated with global QOL subscale of the EORTC QLQ-C30. SR, IR, and health status in the self-reported medical status explained 39% of the variance in global QOL, with SR of the largest.

CONCLUSIONS

Our findings provided valuable information to healthcare professionals about the ability of SR to affect QOL and negative impacts of FCR and IR on gynecologic cancer survivors.

Exploring Iranian women's perceptions and experiences regarding cervical cancer-preventive behaviors

BACKGROUND

Preventive behaviors regarding cervical cancer are essential for women's health. Even though many studies have addressed women's knowledge and attitudes toward cervical cancer, little information is available about their experiences of cervical cancer-preventive behaviors. Thus, the aim of this study is to explore the perceptions and experiences of Iranian women regarding cervical cancer-preventive behaviors.

METHODS

This study used a qualitative approach and was conducted in Zanjan, Iran. Participants included 27 women, aged 20-60 years, with no previous history of cervical cancer symptoms or diagnosis. Data were obtained through semi-structured in-depth interviews and focus group discussions. Inductive qualitative content analysis was employed to converge and compare themes through participant data.

RESULTS

The following six main themes emerged from the analysis: attitudes toward cervical cancer and preventive behaviors, preventive behaviors' concept, self-care, religion and culture, perceived social support, and awareness about cervical cancer and preventive behavior. The findings revealed that several women had misconceptions about cervical cancer and were even superstitious about the causes of it. Fear, shame, and embarrassment were reasons for not undertaking cervical cancer screening. Cervical cancer was also linked to worries about decreased marital satisfaction, sexuality, and femininity. However, religion was considered a positive factor to conducting cancer-preventive behaviors.

CONCLUSIONS

This study showed that improving knowledge about the causes of cervical cancer, increasing awareness of the potential consequences of it, and creating positive attitudes toward screening behavior might encourage Iranian women to perform cervical cancer-preventive behaviors.

Interventions for sexual dysfunction following treatments for cancer in women

BACKGROUND

The proportion of people living with and surviving cancer is growing. This has led to increased awareness of the importance of quality of life, including sexual function, in those affected by cancer. Sexual dysfunction is a potential long-term complication of many cancer treatments. This includes treatments that have a direct impact on the pelvic area and genitals, and also treatments that have a more generalised (systemic) impact on sexual function.This is an update of the original Cochrane review published in Issue 4, 2007, on interventions for treating sexual dysfunction following treatments for cancer for men and women. Since publication in 2007, there has been an increase in the number of trials for both men and women and this current review critiques only those for women. A review in press will present those for men.

OBJECTIVES

To evaluate the effectiveness of interventions for treating sexual dysfunction in women following treatments for cancer. To assess adverse events associated with interventions.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL 2015, Issue 9), MEDLINE, EMBASE, PsycINFO, AMED, CINAHL, Dissertation Abstracts and the NHS Research Register. The searches were originally run in January 2007 and we updated these to September 2015.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that assessed the effectiveness of a treatment for sexual dysfunction. The trial participants were women who had developed sexual dysfunction as a consequence of a cancer treatment. We sought evaluations of interventions that were pharmaceutical, mechanical, psychotherapeutic, complementary or that involved physical exercise.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted the data and assessed trial quality. We considered meta-analysis for trials with comparable key characteristics.

MAIN RESULTS

Since the original version of this review we have identified 11 new studies in women. The one study identified in the earlier version of this review was excluded in this update as it did not meet our narrower inclusion criteria to include only interventions for the treatment, not prevention, of sexual dysfunction.In total 1509 female participants were randomised across 11 trials. All trials explored interventions following treatment either for gynaecological or breast cancer. Eight trials evaluated a psychotherapeutic or psycho-educational intervention. Two trials evaluated a pharmaceutical intervention and one pelvic floor exercises. All involved heterosexual women. Eight studies were at a high risk of bias as they involved a sample of fewer than 50 participants per trial arm. The trials varied not only in intervention content but in outcome measurements, thereby restricting combined analysis. In the trials evaluating a psychotherapeutic intervention the effect on sexual dysfunction was mixed; in three trials benefit was found for some measures of sexual function and in five trials no benefit was found. Evidence from the other three trials, two on different pharmaceutical applications and one on exercise, differed and was limited by small sample sizes. Only the trial of a pH-balanced vaginal gel found significant improvements in sexual function. The trials of pharmaceutical interventions measured harm: neither reported any. Only one psychological intervention trial reported that no harm occurred because of the intervention; the other trials of psychological support did not measure harm.

AUTHORS' CONCLUSIONS

Since the last version of this review, the new studies do not provide clear information on the impact of interventions for sexual dysfunction following treatments for cancer in women. The sexual dysfunction interventions in this review are not representative of the range that is available for women, or of the wider range of cancers in which treatments are known to increase the risk of sexual problems. Further evaluations are needed.

The primary health care physician and the cancer patient: tips and strategies for managing sexual health

There is a large and growing population of long-term cancer survivors. Primary care physicians (PCPs) are playing an increasingly greater role in the care of these patients across the continuum of cancer survivorship. In this role, PCPs are faced with the responsibility of managing a range of medical and psychosocial late effects of cancer treatment. In particular, the sexual side effects of treatment which are common and have significant impact on quality of life for the cancer survivor, often go unaddressed. This is an area of clinical care and research that has received increasing attention, highlighted by the presentation of this special issue on Cancer and Sexual Health. The aims of this review are 3-fold. First, we seek to overview common presentations of sexual dysfunction related to major cancer diagnoses in order to give the PCP a sense of the medical issues that the survivor may present with. Barriers to communication about sexual health issues between patient/PCPs in order are also described in order to emphasize the importance of PCPs initiating this important conversation. Next, we provide strategies and resources to help guide the PCP in the management of sexual dysfunction in cancer survivors. Finally, we discuss case examples of survivorship sexual health issues and highlight the role that a PCP can play in each of these case examples.

Self-Reported Sexual Function Measures Administered to Female Cancer Patients: A Systematic Review, 2008-2014

A systematic review was conducted to identify and characterize self-reported sexual function (SF) measures administered to women with a history of cancer. Using 2009 PRISMA guidelines, we searched electronic bibliographic databases for quantitative studies published January 2008-September 2014 that used a self-reported measure of SF, or a quality of life (QOL) measure that contained at least 1 item pertaining to SF. Of 1,487 articles initially identified, 171 were retained. The studies originated in 36 different countries with 23% from US-based authors. Most studies focused on women treated for breast, gynecologic, or colorectal cancer. About 70% of the articles examined SF as the primary focus; the remaining examined QOL, menopausal symptoms, or compared treatment modalities. We identified 37 measures that assessed at least one domain of SF, eight of which were dedicated SF measures developed with cancer patients. Almost one third of the studies used EORTC QLQ modules to assess SF, and another third used the Female Sexual Function Inventory. There were few commonalities among studies, though nearly all demonstrated worse SF after cancer treatment or compared to healthy controls. QOL measures are better suited to screening while dedicated SF questionnaires provide data for more in depth assessment. This systematic review will assist oncology clinicians and researchers in their selection of measures of SF and encourage integration of this quality of life domain in patient care.

The vaginal and gastrointestinal microbiomes in gynecologic cancers: a review of applications in etiology, symptoms and treatment

The human microbiome is the collection of microorganisms in the body that exist in a mutualistic relationship with the host. Recent studies indicate that perturbations in the microbiome may be implicated in a number of diseases, including cancer. More specifically, changes in the gut and vaginal microbiomes may be associated with a variety of gynecologic cancers, including cervical cancer, uterine cancer, and ovarian cancer. Current research and gaps in knowledge regarding the association between the gut and vaginal microbiomes and the development, progression, and treatment of gynecologic cancers are reviewed here. In addition, the potential use of probiotics to manage symptoms of these gynecologic cancers is discussed. A better understanding of how the microbiome composition is altered at these sites and its interaction with the host may aid in prevention, optimization of current therapies, development of new therapeutic agents and/or dosing regimens, and possibly limit the side effects associated with cancer treatment.

Health disparities and the cancer survivor

Disparities on the basis of race and ethnicity have been described in a variety of survivorship outcomes, including late and long-term effects of treatment, surveillance and health maintenance, and psychosocial outcomes. However, the current body of literature is limited in scope and additional research is needed to better define and address disparities among cancer survivors.

Sexuality and chronic illness

Sexual function is often affected in individuals living with chronic illness and their partners, and multiple comorbidities increase the likelihood of sexual dysfunction. This review focuses on the areas of cardiovascular disease, respiratory conditions, and cancer, all areas for which there are practical, evidence-based strategies to guide sexual counseling. Although nurses have been reluctant to address the topic of sexuality in practice, a growing number of studies suggest that patients want nurses to address their concerns and provide resources to them. Thus, nurses must be proactive in initiating conversations on sexual issues to fill this gap in practice.

The physical consequences of gynecologic cancer surgery and their impact on sexual, emotional, and quality of life issues

INTRODUCTION

Surgical management of gynecologic cancer can cause short- and long-term effects on sexuality, reproductive function, and overall quality of life (QOL) (e.g., sexual dysfunction, infertility, lymphedema). However, innovative approaches developed over the past several decades have improved oncologic outcomes and reduced treatment sequelae.

AIM

To provide an overview of the standards of care and major advancements in gynecologic cancer surgery, with a focus on their direct physical impact, as well as emotional, sexual, and QOL issues. This overview will aid researchers and clinicians in the conceptualization of future clinical care strategies and interventions to improve sexual/vaginal/reproductive health and QOL in gynecologic cancer patients.

MAIN OUTCOME MEASURES

Comprehensive overview of the literature on gynecologic oncology surgery.

METHODS

Conceptual framework for this overview follows the current standards of care and recent surgical approaches to treat gynecologic cancer, with a brief overview describing primary management objectives and the physical, sexual, and emotional impact on patients. Extensive literature support is provided.

RESULTS

The type and radicality of surgical treatment for gynecologic cancer can influence sexual function and play a significant role in QOL. Psychological, sexual, and QOL outcomes improve as surgical procedures continue to evolve. Procedures for fertility preservation, laparoscopy, sentinel lymph node mapping, and robotic and risk-reducing surgery have advanced the field while reducing treatment sequelae. Nevertheless, interventions that address sexual and vaginal health issues are limited.

CONCLUSIONS

It is imperative to consider QOL and sexuality during the treatment decision-making process. New advances in detection and treatment exist; however, psycho-educational interventions and greater patient-physician communication to address sexual and vaginal health concerns are warranted. Large, prospective clinical trials including patient-reported outcomes are needed in gynecologic oncology populations to identify subgroups at risk. Future study designs need clearly defined samples to gain insight about sexual morbidity and foster the development of targeted interventions.

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.

[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.

Sexual functioning of cervical cancer survivors: a review with a female perspective

OBJECTIVE

Sex is an important, often deteriorated, dimension of quality of life after cancer treatment. We conducted a systematic review on sexual functioning of cervical cancer survivors.

METHODS

Studies between January 1988 and April 2010 were rated on their internal validity. Results were analyzed focusing on four major categories of sexual functioning: desire, arousal, orgasm, pain. Comparisons were made between healthy controls versus cervical cancer survivors, survivors before versus after treatment and between different treatment modalities.

RESULTS

Twenty studies were included. Most studies showed no differences in the ability to achieve an orgasm. Cervical cancer survivors reported more dyspareunia than healthy controls and dyspareunia was more frequent and lasted longer after radiotherapy. Lack of lubrication was more frequent in cervical cancer survivors and a significant decrease in sexual interest and activity after treatment was found.

CONCLUSION

Cervical cancer survivors are at risk for sexual pain disorders, while sexual satisfaction (orgasm) is not impaired and radiotherapy negatively influenced sexual pain disorders. Health care providers should inform cervical cancer survivors about the possible risk of developing sexual pain disorders after cervical cancer treatment, especially after radiotherapy. As sexual satisfaction per se is not impaired, we suggest that prevention and treatment of sexual dysfunction should focus on painless and satisfactory sex instead of on resuming intercourse.

Sexuality after treatment of head and neck cancer: findings based on modification of sexual adjustment questionnaire

OBJECTIVES/HYPOTHESIS

Evaluate sexual dysfunction in patients after treatment for head and neck cancer.

STUDY DESIGN

Single-institution cross-sectional study.

METHODS

Our modified Sexual Adjustment Questionnaire was administered to 42 patients (mean age, 55.1 years) and included seven questions (total score, 7-35). Based on sexual satisfaction ratings, we categorized three groups as unsatisfied (7-16), satisfied (17-25), and very satisfied (26-35). Clinical information was obtained by reviewing medical records. Bivariate analysis tested associations between sexual satisfaction and patient-related factors (e.g., sex, age, site/cancer stage, treatment, time between treatment and survey, partner, alcohol/tobacco consumption). Pearson correlation was used to analyze two continuous variables, and multivariate logistic regression analysis was used to evaluate the independent impact of each factor.

RESULTS

All 42 patients rated that head and neck cancer negatively impacted their sexual relationships, including 21 (50%) rating effects as negative or extremely negative. Men reported higher satisfaction scores with sexual function (mean ± standard deviation) than women (19.9 ± 5.0 vs. 16.3 ± 6.5, respectively; P = .06). Respondents with partners reported higher scores than those without partners (19.9 ± 5.3 vs. 14.1 ± 4.4, respectively; P = .01). When the survey was administered (median, 12 months; range, 4-33 months) after the first treatment, mean score was 19; 57% of respondents were sexually satisfied, 31% were unsatisfied, and 12% were very satisfied. Instrument reliability was .82 (Cronbach alpha).

CONCLUSIONS

Patients who are male and ≤ 60 years have a higher probability of sexual satisfaction during recovery. Our sexual dysfunction questionnaire will be administered in further prospective studies in patients with head and neck cancer.

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.

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.

Cancer-related infertility in survivorship

INTRODUCTION

To empirically assess and describe the emotional, sexual, and physical impact of cancer-related infertility on gynecologic cancer survivors.

METHODS

The study was composed of 88 survivors of cervical, endometrial/uterine, ovarian cancer, and gestational trophoblastic disease who experienced impaired or loss of fertility as a result of treatment. Patient age ranged from 21 to 49 years. Participants completed a 1-time self-report survey, including medical and demographic information and empirical measures of mood (Center for Epidemiologic Studies Depression Scale), distress (Impact of Event Scale), sexual function (Female Sexual Function Index), and menopause (Menopausal Symptom Checklist).

RESULTS

Eighty-four (96%) of the 88 enrolled patients had undergone a surgical intervention as part of their cancer treatment. Sixty-three patients (77%) reported clinically significant levels of distress in relation to loss of fertility or impaired fertility. Survivors' levels of distress (P < 0.0001) and depression (P < 0.0001) were associated with the severity and number of menopausal symptoms reported. Patients who retained functioning ovaries (partial fertility) (41%, n = 36) reported being less bothered by menopausal symptoms (P = 0.01) and having higher sexual functioning than those with ovarian failure (P < 0.0001).

CONCLUSIONS

The emotional and physical impact of impaired or loss of fertility can be complex and long lasting, with women experiencing high levels of distress, menopausal symptoms, and changes in sexual function persisting into survivorship. Future research should focus on the development of strategies to identify, monitor, and address, in a clinical care setting, the issues these cancer survivors face. Alternate family-building strategies should also be explored before treatment and/or upon treatment completion when feasible.

Long-term quality of life in gynecological cancer survivors

PURPOSE OF REVIEW

This review addresses current knowledge about long-term quality of life (QOL) in survivors of gynecological cancer.

RECENT FINDINGS

Survivors of gynecological cancer have generally good long-term QOL, equivalent to healthy controls; however, specific deficits are more prevalent than in women without cancer. Ovarian cancer survivors have good QOL, with few physical symptoms. Psychological distress and sexual impairments exist. No differences in QOL occur between survivors of early and advanced stage disease. Cervical cancer survivors treated with radiotherapy reported more QOL impairments than survivors treated with other approaches. There were no differences on sexuality and sexual function among survival time periods. In general, cervical cancer survivors seem to have a positive attitude towards sexuality. Self-esteem is an important psychological variable in the study of long-term QOL.

SUMMARY

When considering specific diseases, ovarian and cervical cancers were the most researched. Endometrial cancer was underreported in recent literature. Studies addressing vulvar and vaginal cancers are lacking. Physical, psychosocial and sexuality were the most investigated QOL domains. Advances are observed in current research; however, more rigorous and larger studies are required to further understand long-term QOL. Available findings are crucial to develop interventions to support those at risk for QOL impairments.

Health status and adaptation among long-term cervical cancer survivors

OBJECTIVES

This study assesses health and adaptation among long-term survivors of cervical cancer. Little research has been published on women who have survived over ten years after diagnosis of this disease. Both clinicians and patients can benefit from increased information on the likelihood of chronic and late effects of cervical cancer across the life course of survivors.

MATERIALS AND METHODS

The investigators interviewed 208 individuals six years or more post-invasive cervical cancer diagnosis from the Connecticut Tumor Registry. Cervical cancer survivors were compared with women from the general population interviewed in the Connecticut Behavioral Risk Factor Survey (BRFS). Measures of health status and adaptation were compared across successive categories of survival time, including self-assessment of general health according to an item from the MOS-36, days of ill health in past month, and days in past month in which activity was limited by physical or mental health.

RESULTS

No differences were detected in self-reported general health status between cervical cancer survivors and BRFS controls. But cervical cancer survivors more often reported days of illness and days in which their activities were limited by illness during the month prior to interview. No differences were detected in employment, marital status, or health insurance coverage. No statistically significant differences were detected across survival time categories.

CONCLUSIONS

A high level of adaptation appears to prevail among cervical cancer survivors. Late effects on health status are not evident. However, the possibility that specific subgroups may experience particularly severe challenges should not be ignored and future research should help identify these subgroups.