Psychosocial adjustment to pelvic exenteration

Clinician attitude towards sexual counseling in women with gynecologic malignancies: European Network of Young Gynaecological Oncologists (ENYGO) survey

OBJECTIVE

Both the location of primary disease and treatment side effects may have an impact on sexual function in oncogynecological patients. The aim of this study was to examine the prevalence, strategies, difficulties, and ideas for improvement in sexual counseling among specialists managing patients with gynecologic malignancies.

METHODS

This was a cross-sectional survey study performed among healthcare professionals treating patients with gynecologic malignancies. A self-prepared questionnaire included 61 questions concerning general demographic information and different aspects of sexual counseling in the gynecologic oncology practice. Analysis included attitudes, behaviors, management strategies, difficulties, and ideas for possible systemic improvements. Statistical analysis involved descriptive statistics, two-sided chi-square test, and Fisher's exact test.

RESULTS

A total of 150 respondents from 46 countries answered the survey. The majority of survey participants stated that sexual counseling of oncological patients is very important (n=73, 49%) or important (n=46, 31%). One hundred and two (68%) respondents agreed that sexual counseling of gynecologic oncology patients should be routinely provided by the specialist managing the primary disease. However, collecting information concerning sexual function is performed often or always by only 21% of respondents and 19% discuss the topic rarely or never. The most frequently indicated barriers leading to difficulties in sexual counseling include lack of time (74%), lack of specialist knowledge (55%), and patient embarrassment (48%). One hundred and seven (71%) respondents expressed interest in participating in sexual counseling workshops organized by the European Society of Gynaecological Oncology (ESGO)/European Network of Young Gynaecological Oncologists (ENYGO), 74 (49%) would like to access webinars on the topic, and 120 (80%) would be interested in materials in the ESGO online educational resources.

CONCLUSION

One of the proposed solutions to insufficient access to sexual care for women with gynecologic malignancies is providing access to specialist educational programs for both patients and healthcare specialists.

Prospective assessment of patient-reported outcomes in gynecologic cancer patients before and after pelvic exenteration

OBJECTIVE

Pelvic exenteration (PE) is a surgical procedure associated with significant morbidity offered to select women with locally advanced or recurrent gynecologic cancers. This ongoing study examines an array of patient-reported outcomes and satisfaction with PE.

METHODS

Since February 2009, prospectively enrolled participants completed questionnaires evaluating body image (BIS), depression (CESD), social support (DUFSS), symptoms (MDASI), sexual function (SAQ), functional status (SF-12), quality of life (The Stoma-QOL), satisfaction with decision (SWD) and an investigator-designed survey at baseline, 6, and 12months after PE. Mann-Whitney and Wilcoxon signed-rank tests were used to evaluate the data.

RESULTS

Fifty-four women enrolled. Median age was 56years (31, 85). Median BMI was 30.7kg/m² (16.8, 54.4). The majority of patients (78%) were white. Cancer diagnoses included 41% cervix, 22% uterus, 19% vagina, 17% vulva and 2% ovary. Most surgeries were total PEs (76%). Patients were satisfied with their decision to undergo PE at 6 and 12months. One year after exenteration, 79% of women stated they would have a PE again. Sexual pleasure decreased from baseline to 12months after PE (p=0.02), while sexual discomfort remained unchanged (p=0.42). Body image worsened over time (p=0.003). Physical functioning (SF-12) declined (p=0.001), while mental functioning remained stable (p=0.46). There were no significant changes in stoma-related QOL, social support, or depression scores.

CONCLUSIONS

Despite a decrease in physical functioning, persistent low body image and sexual pleasure, most women were satisfied with their decision and would undergo pelvic exenteration again. This study identifies survivorship issues that should be addressed after PE.

The Paradox of Pelvic Exenteration: The Interaction of Clinical and Psychological Variables

OBJECTIVES

To text the feasibility of a psychological intervention package administered to 49 pelvic exenteration candidates, aimed at evaluating the preoperative prevalence of psychological distress and assessing the presence of any correlation between preoperative psychological distress and clinical variables such as pain and hospitalization length.

METHODS

Patients were referred to the psychology unit from the very beginning of their clinical pathway and were administered the Psychological Distress Inventory (PDI) and the Mini-Mental Adjustment to Cancer (Mini-MAC) questionnaire at prehospital admission. Patients presenting with a significant level of distress received nonstandardized psychological support. Statistical analyses were performed to detect the presence of any correlation between psychological variables at prehospital admission and clinical outcomes.

RESULTS

The 40% of patients had significant levels of distress at prehospital admission (PDI ≥ 30). As regards Mini-MAC, the mean value of fighting spirit attitude and fatalism was higher in our sample than in the normative sample of the Mini-MAC validation study in the Italian cancer population. Their anxious preoccupation attitude was lower. There were no correlations between clinical and psychological variables: level of postsurgery pain was higher (3.7) in the subgroup of patients with presurgery PDI < 30 compared with those with PDI ≥ 30 (3.5). However, this difference was not statistically significant (P = 1.00). Considering hospitalization length, the above described trend was similar.

CONCLUSIONS

Although highly distressed, pelvic exenteration candidates show an adaptive range of coping mechanisms. This calls for a greater effort in studying the complexity of their psychoemotional status to provide them with the best multidisciplinary care. Extensive study of the real effectiveness of psychological intervention is warranted: randomized clinical trials could help in detecting the presence of any correlation between clinical and psychological variables in a multidisciplinary approach.

Health-related quality of life and the transformation of symptoms

This paper traces the development of health-related Quality of Life instruments over the last half century. It identifies the emergence of key components of quality of life measurement in other health status questionnaires between about 1950 and 1980 and their formalization in Quality of Life instruments in the mid 1980s. The common developmental thread that linked these Quality of Life instruments and their precursors was the identification of 'distal symptoms' that represented the impact of illness beyond its immediate bodily manifestations. The measurement of distal symptoms through Quality of Life instruments also served to detach symptoms from their customary patho-physiological referent. Other contemporary examples of these free-floating symptoms reinforce the argument that the nature and meaning of symptoms has been transformed over recent decades.

Sexual rehabilitation medicine in a female oncology setting

Comprehensive oncological care has recently expanded not only to include diagnosis and treatment but survivorship medicine as well. Tertiary health care facilities are now developing multidisciplinary survivorship programs that focus on helping cancer patients live active, fulfilled lives while dealing with the potentially damaging and longstanding sexual ramifications of cancer and cancer therapy. As part of a growing trend, health care institutions are establishing specialized sexual health programs to address cancer patients' sexual needs using functionalized survivorship curricula. Such programs provide individual or couples management to men and women who suffer from sexual dysfunction as a result of a cancer diagnosis and/or treatment. Using the Sexual Health Program at the Memorial Sloan-Kettering Cancer Center as a prototype for the development of future sexual health programs, this article will discuss the specific components and benefits of such programs. An effective program focuses on 4 key issues-clinical care, patient education and support, medical and scientific research, and medical education and training for health care professionals and providers. This article will discuss how sexual health programs benefit the female cancer patient (it should be noted, however, that these programs, such as the one at our institution, are usually available for either sex).

Psychosocial issues: pelvic exenterative surgery

This review of the literature describes the psychosocial consequences of all the elements associated with Pelvis Exenterative Surgery (PES): a diagnosis of cancer and/or its recurrence, impact of procedures such as simple or radical hysterectomy, prostatectomy, or colostomy. All studies report a high incidence of anxiety, depression, self-image insult, sexual dysfunction, social isolation, and dysfunction. There are few studies of the consequences of PES itself. Their consensus is that its psychosocial impact is not as catastrophic as one would expect. However, their methodological drawbacks do not yet permit a definitive conclusion. The interaction of the patients with their surgeon and treatment team during the preoperative period is examined with special attention to potential pitfalls. Acute psychiatric syndromes that may occur during the postoperative period (delirium, anxiety, depression, brief reactive psychosis) and their management is discussed. So are sexual dysfunctions. General principles of intervention in preparing patients for invasive procedures and facilitating favorable outcomes are described. J. Surg. Oncol. 2001;76:224-236.

Pelvic exenteration: effects of surgery on quality of life and body image--a prospective longitudinal study

OBJECTIVES

The goal of this study was to evaluate the impact of reconstructive and nonreconstructive surgical procedures on quality of life and body image for women who undergo pelvic exenteration.

METHODS

Twenty-eight patients were assessed in a prospective study with a preoperative semistructured interview and an objective assessment (T1). Interviews and questionnaires were repeated 4 (T2) and 12 (T3) months postoperatively. The women were divided into groups with two, one, or no ostomies. A separate comparison was made of women with and without vaginal capacity. Quality of life was defined in terms of five categories according to the definition of health proposed by the World Health Organization: physical and psychosocial health; marital and sexual status; medical interactions.

RESULTS

At all points in time, the patients' quality of life was affected most significantly by worries about the progression of the tumor. Twelve months postoperatively, patients with two ostomies reported a significantly lower quality of life (P = 0.008) and poorer body image (P = 0.002) than patients with no ostomy. At T3, patients with vaginal capacity reported fewer problems in all categories related to quality of life and significantly (P = 0.015) fewer sexual problems.

CONCLUSION

An evaluation of quality of life and body image demonstrates the benefits of newer techniques for organ reconstruction. Thus, organ reconstruction should be performed whenever possible in patients with pelvic exenteration.

Psychosexual dysfunction in women with gynaecological cancer following radical pelvic surgery

OBJECTIVE

To assess the prevalence and severity of psychosexual dysfunction in women treated for cancer of the cervix and vulva by radical vulvectomy, Wertheim's hysterectomy and pelvic exenteration; and to identify the risk factors for sexual morbidity and ways in which it might be reduced.

DESIGN

Retrospective study of patients by questionnaire and semistructured interview, 6 months to 5 years following surgery.

SETTING

Gynaecology-Oncology Unit of a general hospital.

PATIENTS

105 English speaking women with gynaecological cancer.

RESULTS

90% of the women in relationships had been sexually active prior to surgery. Of this group, 24% had no sexual difficulties post-operatively; 66% of the latter still had problems more than 6 months later, and 15% of the latter never resumed intercourse (excluding those with a colpectomy). 82% of those aged less than 50 years who had had radiotherapy suffered sexual dysfunction. Lack of desire was the commonest problem, and half the women felt that their sexual relationship had deteriorated, yet only 16% felt that their marriage had worsened. Younger women were more likely to attribute personal and marital distress to their sexual problems. More information on sexual matters would have been liked by 28% of the women.

CONCLUSIONS

Sexual dysfunction is common following radical pelvic surgery and tends to remain a chronic problem. As well as organic causes there is a strong psychogenic element brought about by loss of fertility, disfigurement, depression and anxiety about one's desirability as a sexual partner. The presence of a stable relationship before the diagnosis of cancer helps women cope better, and young single women are a very vulnerable group. Patients want more information on sexual matters and the provision of sexual counselling may improve outcome in the future.

Social relations, social support and survival among patients with cancer

This study examined the relationship between social relationships and social support and survival following a first diagnosis of breast, colorectal, or lung cancer. Findings showed different factors related to survival for those with breast vs lung or colorectal cancer and for those with localized vs non-localized cancers. Results provide important evidence that social relations and social support may operate differently depending on cancer site and extent of disease.

Psychosocial adjustment following major gynaecological surgery for carcinoma of the cervix and vulva

One-hundred and five women had undergone major gynaecological surgery for carcinoma of the cervix and vulva were interviewed retrospectively to elicit post-operative psychosocial and psychosexual problems. This interview took place between 6 months and 5 yr after surgery. Responses to the Hospital Anxiety and Depression Scale indicated that 20% of the women were 'probable' cases of anxiety and 21% were 'definite' cases. On the depression scale, 18% were 'doubtful' cases and 14% were 'definite' cases. Scores on the scales were not associated with age of the woman, the type of operation or the time period between being interviewed and the operation. Two-thirds of the women who were sexually active prior to the operation indicated ongoing sexual problems when interviewed and the presence of these problems was found to be significantly associated with the woman's level of anxiety.

Psychosexual issues: the woman with gynecologic cancer

Psychosexual concerns often confront women with a diagnosis of gynecologic cancer. These concerns can be physiologic or psychological in origin. Oncology nurses are in a key position to assess these potential or actual sexual problems. Interventions can be designed to prevent or minimize the adverse sexual sequelae often associated with this group of diseases. A strong knowledge base and comfort with the topic of sexuality are of utmost importance.

Three conflicts as a result of causal attributions

There is a difference between the causal attributions of cancer (Ca)-patients and those of myocardial infarction (MI)-patients. MI-patients go through and check their autobiographies looking for the possible causes suggested by the medical world. Ca-patients on the contrary search for possible explanations. This is probably due to the lack of medical knowledge on the cause and course of their disease. They search through their autobiographies and the result is idiosyncratic, very personal attributions with which they create an explanation which is often not in accordance with the physicians' view. These attributions of Ca-patients are a source of conflicts, both within themselves (doubt), with their physicians and with their partners or other close relatives. Nevertheless they stick to their own explanations, although often secretly and with ambivalence, and despite the conflicts which they produce.

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

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

Surgery of intraepithelial neoplasia, CIN, VAIN, and VIN

The various surgical treatments of CIN, VAIN, and VIN have been discussed. The necessity for careful pretreatment, histological diagnosis and colposcopic mapping of the various conditions has been stressed. The relative risks of malignant progression of the various conditions have been discussed along with the various modes and methods of surgical therapy. The facts emerging are that traditional surgical therapy is giving ground to more modern techniques of ablation, particularly that of carbon dioxide laser photoevaporation therapy. Particularly in treatment of CIN and VIN, laser therapy has begun to show many advantages. Traditional surgical techniques for treatment of intraepithelial neoplasia of the lower genital tract in the female have, in response, become more conservative in their application with an emphasis on preservation and reconstruction. However, in some cases confirmation of early results by long-term follow-up will be necessary. The general tendency of close surveillance and conservative treatment befits the management of non-invasive genital tract intraepithelial neoplasia.

Quality of life variables in surgical trials

Clinical trials are commonly performed in surgery to assess the efficacy of one or more treatments. Many therapies result in only partial or temporary improvement, rather than cure. Others sharply affect the quality of patients' lives or of their deaths. For most interventions, it is important to document effects on quality of life as well as morbidity and mortality rates. yet, a review of the literature reveals that very few surgical trials consider quality of life variables as outcome measures. Surgical investigators in areas like cancer, inflammatory bowel disease, end stage renal disease, and cardiac disease have examined quality of life issues extensively using a variety of scales and indices. However, most studies on quality of life are hampered by poor design and inadequate methods of assessment. Failure to evaluate quality of life variables prevents the recognition and full use of potentially beneficial therapies and the rejection of potentially harmful ones.

Sexual dysfunction and signs of gynecologic cancer

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

Sexual functioning morbidity among cancer survivors. Current status and future research directions

The current article reviews available data and considers methodologic issues for future research in which sexual functioning among adult cancer patients is an endpoint variable. Circumstances that may cause sexual disruption for any cancer patient are suggested, including mood disturbance, changed health status, somatization, and reprioritization of life concerns. Data on the incidence and magnitude of sexual functioning morbidity following the diagnosis and treatment of cancer at major organ sites, including breast, genital, colon, rectum, and bladder, are reviewed. Finally, strategies for continuing descriptive study of the sexual problems of cancer patients are suggested. Such data are necessary to eventually target preventive or therapeutic resources to patients in greatest need.

Sexual and Psychological Implications of Gynecologic Malignancy

The sexual implications of gynecologic malignancy are best understood by asking, and answering, the following three questions. What is the psychological effect on the woman? What is the physiological effect on the woman? What is the psychological effect on the partner? The psychological effect of the cancer on the woman is primarily determined by whether the malignancy is primary, recurrent, or terminal; the primary physiological determinants are whether the treatment is with surgery, radiation, or chemotherapy. The partner can be affected psychologically by all six of the variables. Preoperative knowledge of the woman's sexual history may influence subsequent treatments.

A medical chart review for information about sexual functioning in cervical carcinoma

Fifty medical charts from two departments of radiotherapy, one in France and the other in the United States, were reviewed to determine their utility in contributing to information about sexual functioning after treatment for cervical cancer. For both settings, useful information about the disease, its treatment and the post-treatment complications was readily available. Significant differences were found between the settings in the documentation of data about sexual function, vaginal dilator use and dilator compliance. The utility of medical records for the purpose of gathering information about sexual functioning after radiotherapy for cervical cancer was found to be significantly higher in one of the settings for several variables. Possible reasons for these findings are given along with medical charts for the promotion and study of sexual rehabilitation for patients with cervical carcinoma.

Treatment for Gynecologic Cancer: A Review of the Effects on Female Sexuality

Approximately 75,000 new cases of gynecologic cancer are diagnosed in the United States each year. Since few women can be treated by chemotherapy alone, most undergo extensive treatments that directly alter their sexuality either by causing specific anatomic changes or by generating concerns about continued responsiveness or activity. The major treatments for gynecologic malignancies including radiation therapy or radical hysterectomy for cervical carcinoma, radical vulvectomy for vulvar carcinoma, and pelvic exenteration for recurrent disease, are outlined. Research relating to their effects on female sexuality is critically reviewed. Also discussed are the relevant domains of treatment and patient characteristics that need assessment and investigation in this new and important research area.

Pelvic exenteration for vulvovaginal carcinoma

Between 1964 and 1978, 16 pelvic exenterations were performed for advanced and recurrent vulvovaginal carcinoma. Eight patients had Stage III carcinoma and four had recurrent vulvar carcinoma. Ten patients had involvement of the anus/sphincter, and two had involvement of the proximal half of the urethra. There were four patients with vaginal carcinoma. Two patients with recurrent vaginal carcinoma had bladder/urethral involvement; one patient each with primary vaginal carcinoma had rectovaginal and vesicovaginal septal disease. Seven patients are alive and free of disease--six for more than 5 years and one for 4 years and 4 months. Three patients died, free of disease, one each of cerebrovascular accident, traumatic subdural hematoma, and pulmonary embolus. One patient died on the ninth postoperative day of aspiration pneumonitis. The absolute 5-year survival rate is 54%.