Sexual, psychological, and relational functioning in women after surgical treatment for vulvar malignancy: a literature review

Somatic and autonomic nerve density and distribution within the clitoris: an immunohistochemical study in adult female cadavers

INTRODUCTION AND HYPOTHESIS

Knowledge of clitoral neuroanatomy is critical to vulvar surgery. We sought to characterize the density and distribution of autonomic and somatic nerves supplying the clitoris.

METHODS

Pelvic tissue harvested from female cadavers was sectioned axially at three anatomic levels: the proximal aspect of the clitoral body (CB), the distal CB, and the glans. The CB, glans, and the surrounding connective tissue (dorsal, lateral, and ventral) were outlined microscopically. An area containing large nerve bundles dorsal to the CB, referred to as the dorsal nerve subregion, was analyzed separately. Double-immunofluorescent staining for beta III tubulin (βIIIT), a global axonal marker, and myelin basic protein (MBP), a myelinated nerve marker, was performed. Threshold-based automatic image-segmentation distinguished stained areas. Autonomic and somatic density were calculated as percentage of tissue stained with βIIIT alone, and βIIIT and MBP respectively. Comparisons were made using nonparametric Friedman tests.

RESULTS

Seven cadavers, aged 22-81, were examined. Somatic (mean 4.42%, SD ± 1.97) and autonomic (2.14% ± 2.42) nerve density was highest in the dorsal nerve subregion and dorsal region at the distal CB level. Compared with the CB, somatic density was higher in proximal (0.05% ± 0.03 vs 1.27% ± 0.69, p = 0.03) and distal (0.29% ± 0.25 vs 1.09% ± 0.41, p = 0.05) dorsal regions. Somatic density was greater in the glans than in the surrounding lateral (0.78% ± 0.47 vs 0.43% ± 0.23, p = 0.03) and ventral (0.78% ± 0.47 vs 0.52% ± 0.2, p = 0.03) regions. Autonomic density was greater than somatic in all areas, except for the dorsal nerve subregion.

CONCLUSIONS

Somatic and autonomic nerve density were greatest in a well-defined region dorsal to the CB. Surgical preservation of this region is critical for maintaining nerve supply to the clitoris.

Anatomic Subtype Differences in Extramammary Paget Disease: A Meta-Analysis

Importance

Extramammary Paget disease (EMPD) is a rare, highly recurrent cutaneous malignant neoplasm of unclear origin. EMPD arises most commonly on the vulvar and penoscrotal skin. It is not presently known how anatomic subtype of EMPD affects disease presentation and management.

Objective

To compare demographic and tumor characteristics and treatment approaches for different EMPD subtypes. Recommendations for diagnosis and treatment are presented.

Data Sources

MEDLINE, Embase, Web of Science Core Collection, and Cochrane Reviews CENTRAL from December 1, 1990, to October 24, 2022.

Study Selection

Articles were excluded if they were not in English, reported fewer than 3 patients, did not specify information by anatomic subtype, or contained no case-level data. Metastatic cases on presentation were also excluded.

Data Extraction and Synthesis

Abstracts of 1295 eligible articles were independently reviewed by 5 coauthors, and 135 articles retained. Reporting was in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guidelines. The analysis was cunducted in August 2019 and updated in November 2022.

Findings

Most vulvar EMPD cases were asymptomatic, and diagnosis was relatively delayed (mean, 25.1 months). Although most vulvar EMPD cases were intraepidermal (1247/1773 [70.3%]), radical surgeries were still performed in almost one-third of cases. Despite this aggressive surgical approach, 481 of 1423 (34%) recurred, commonly confined to the skin and mucosa (177/198 [89.4%]). By contrast, 152 of 1101 penoscrotal EMPD cases (14%) recurred, but more than one-third of these recurrences were regional or associated with distant metastases (54 of 152 [35.5%]). Perianal EMPD cases recurred in one-third of cases (74/218 [33.9%]), with one-third of these recurrences being regional or associated with distant metastasis (20 of 74 [27.0%]). Perianal EMPD also had the highest rate of invasive disease (50% of cases).

Conclusions and Relevance

The diagnosis and treatment of EMPD should differ based on anatomic subtypes. Considerations for updated practice may include less morbid treatments for vulvar EMPD, which is primarily epidermal, and close surveillance for local recurrence in vulvar EMPD and metastatic recurrence in perianal EMPD. Recurrences in penoscrotal subtype were less common, and selective surveillance in this subtype may be considered. Limitations of this study include the lack of replication cohorts and the exclusion of studies that did not stratify outcomes by anatomic subtype.

A review of functional and surgical outcomes of gynaecological reconstruction in the context of pelvic exenteration

BACKGROUND

Radical surgical excision may be the only curative option for patients with advanced pelvic malignancy, but concerns surrounding the functional outcomes and survivorship of patients undergoing exenterative surgery remain. This is especially important in the context of vulvovaginal resection, where patients are often younger and surgery can have a profoundly negative impact on quality of life, body image and overall wellbeing. Reconstructive procedures are an important means of mitigating these adverse effects but outcomes are poorly described.

AIM

To define the outcomes associated with gynaecological reconstructive procedures following pelvic exenterative surgery and to compare them with the outcomes of those patients who did not undergo reconstruction.

METHODS

An international, multicentre retrospective investigation comparing the outcomes of reconstruction with no reconstruction. The protocol was prospectively registered (NCT05074069).

RESULTS

334 patients were included. 77 patients had a neovagina reconstructed, 139 patients underwent flap reconstruction and 118 were not reconstructed. Patients who underwent reconstruction had a longer operative time and hospital stay with an increased risk of minor perineal complications. Reconstruction did not confer an increased risk of surgical reintervention, and overall complication rates were equivalent. Procedure-specific major morbidity was 5.2 % and 11.5 % for neovaginal and flap reconstruction, respectively. 66 % of patients undergoing neovaginal reconstruction experienced no long term morbidity. 7 % developed neovaginal stenosis and 12 % suffered disease recurrence.

CONCLUSION

Neovaginal reconstruction is safe in carefully selected patients and offers specific advantages over alternative techniques, with few patients requiring reoperation. Primary closure does not increase perineal morbidity.

Betapapillomaviruses in p16-Negative Vulvar Intraepithelial Lesions Associated with Squamous Cell Carcinoma

Approximately 40% of vulvar squamous cell carcinoma (vSCC) cases are etiologically associated with high-risk human papillomaviruses (HPVs) of the alpha genera (α-HPV) that cause other anogenital cancers; however, the etiology of α-HPV-negative vSCC is poorly understood. HPVs of the beta genera (β-HPV) are risk factors for cutaneous squamous cell carcinoma (cSCC) and may be related to carcinomas originating in other cutaneous sites such as the vulva. In this study, we investigate the presence of β-HPVs, with an emphasis on p16-negative squamous lesions adjacent to vSCC. We subjected 28 vulvar squamous intraepithelial lesions adjacent to vSCC for comprehensive HPV genotyping, p16 and p53 immunohistochemistry, and consensus morphology review. Selected cases were subjected to qPCR and RNA in situ hybridization. Clinical data were obtained from medical records. β-HPV DNA was detected in eight of ten p16-negative lesions and three of fourteen p16-positive high-grade squamous intraepithelial lesions. The HPV DNA loads in vulvar squamous intraepithelial lesions ranged between less than 1 HPV DNA copy per cell to more than 100 HPV DNA copies per cell. This is, to the best of our knowledge, the first report of the association of p16-negative vulvar intraepithelial squamous lesions with detection of β-HPVs. These findings expand possible etiologic mechanisms that may contribute to p16-negative lesions of the vulva.

Effectiveness of psychoeducation intervention among women with gynecological cancer: a systematic review and meta-analysis of randomized controlled trials

Psychoeducation interventions have been suggested to improve sexual functioning and quality of life. The aim of this study was to examine the effects of the psychoeducation intervention on quality of life, sexual function, and psychological outcomes; and to identify the critical components of psychoeducation intervention for women with gynecological cancer. This study was a systematic review and meta-analysis. Psychoeducation interventions were searched using six English databases, eligible studies were extracted, and the risk of bias was evaluated by two authors independently. A random effects model was used to examine the intervention effects. We conducted subgroup analysis and meta-regression to assess the variables underlying the heterogeneity. In total, eight trials were identified, and 1128 participants were included. Women who received the psychoeducation intervention had better quality of life (standardized mean difference (SMD) = 0.59, 95% confidence interval (CI): 0.22, 0.97), sexual functioning (SMD = 0.63, 95% CI: 0.27, 0.99), and psychological outcomes (i.e., anxiety and depression (SMD =  - 0.27, 95% CI: - 0.09, - 0.44)). Interventions that combined lecture-based, skill practical, discussion, and counseling were conducted using an online format and were delivered by a team of health professionals that had higher scores of qualities of life. Additionally, involving significant others in the intervention improved sexual functioning. Psychoeducation interventions effectively improve quality of life, sexual functioning, anxiety, and depression. Incorporating lecture-based, practical skills, discussion, and counseling through an online format and involving significant others are beneficial for improving the quality of life and sexual functioning among women with gynecological cancer.

Squamous Cell Carcinoma of the Vulva: A Survival and Epidemiologic Study with Focus on Surgery and Radiotherapy

Vulvar squamous cell carcinoma (SCC) is the most frequent vulvar neoplasia. While the primary role of surgery is widely accepted, large population studies are needed to compare survival between diverse treatment modalities and to identify independent prognostic factors to help council patients and guide oncological treatment. The U.S. National Cancer Index, Surveillance, Epidemiology and End Results (SEER) program data between 2000 and 2018 was screened for all squamous cell carcinoma affecting the vulva. Raw data was processed with IBM SPSS. Demographic, clinical-pathological and treatment data were studied. Overall survival (OS) was calculated using the Kaplan–Meier method and subgroups were compared using the log rank test. A multivariate cox regression was conducted to identify independent prognostic factors. A total of 11,360 patients were identified with a median age of 65. Median overall survival was 101 months. Surgery as a primary treatment is the therapeutic sequence associated with the best overall survival. Multivariate cox-regression did not meet proportional hazard assumption. Age, pathological grade, stage at diagnosis, treatment sequence and the use of chemotherapy were identified as independent prognostic factor. Surgery alone is the treatment sequence offering the best overall survival. Surgery should be offered to all eligible patients.

Vulval extra-mammary Paget's disease: the master of disguise revealed

Extra-mammary Paget's disease is a rare cancer affecting the anogenital region and can present with a myriad of symptoms. In women, the diagnosis of Paget's disease can be challenging as it mimics several other vulval conditions. It is important to promptly recognise this disease because of its potential association with synchronous tumours, such as colorectal adenocarcinoma. The mainstay of treatment is with immunomodulating therapies or surgery, but unfortunately the risk of recurrence is high and appears to be independent of treatment choice and tissue margin status. There is growing evidence to move away from traditional surgical excision to using topical therapy, such as imiquimod, as surgery can often be extensive and disfiguring with a prolonged recovery time. There is considerable psychosexual and physical morbidity associated with Paget's disease, largely owing to multiple surgical recurrences. As recurrences can occur several years after the initial presentation, long-term follow up of patients is recommended.

The Impact of Vulvar Cancer on Psychosocial and Sexual Functioning: A Literature Review

Simple Summary

The diagnostic and therapeutic pathway of vulvar cancer impacts severely on the psychosocial and psychosexual equilibrium of women affected by it. The current literature shows the presence of depressive and anxious symptoms in association with physical, psychological and behavioural alterations in sexuality as well as deterioration of partner relationship. The aim of this article is to highlight the difficulties and challenges faced by women diagnosed and treated for vulvar cancer to provide early recognition and appropriate assistance. By implementing an integrated care model, it should be possible to detect unmet needs and improve the quality of life of these women.

Abstract

Women who are diagnosed and treated for vulvar cancer are at higher risk of psychological distress, sexual dysfunction and dissatisfaction with partner relationships. The aim of this article is to provide a review of the psychological, relational and sexual issues experienced by women with vulvar cancer in order to highlight the importance of this issue and improve the quality of care offered to these patients. A review of the literature was performed using PubMed, CINAHL, PsycINFO, and the Cochrane Library. The results are presented as a narrative synthesis and highlight the massive impact of vulvar cancer: depressive and anxiety symptoms were more frequent in these women, and vulvar cancer may have a negative effect on sexuality from a physical, psychological and behavioural point of view. Factors that may negatively affect these women’s lives are shame, insecurity or difficulties in self-care and daily activities. This review highlights the psychosocial and psychosexual issues faced by women diagnosed and treated for vulvar cancer, although more studies are needed to better investigate this field of interest and to identify strategies to relieve their psychological distress. Care providers should implement an integrated care model to help women with vulvar cancer recognise and address their unmet needs.

Association Between Vulvar Squamous Intraepithelial Lesions and Psychiatric Illness

OBJECTIVES

The aims of the study were to describe and to compare demographics and the prevalence of psychiatric disorders among patients with low- and high-grade vulvar squamous intraepithelial lesions.

METHODS

A retrospective chart review was performed for patients presenting to a vulvar diseases clinic between 1996 and 2019 (N = 2,462). Intake questionnaire data were entered into a deidentified database. Results were compared between 80 patients with biopsy-confirmed high-grade squamous intraepithelial lesions (HSILs) and 48 patients with biopsy-confirmed low-grade squamous intraepithelial lesions (LSILs). Bivariate analysis was performed to compare demographics and psychiatric treatment and outcomes across HSIL and LSIL groups.

RESULTS

Among 128 patients with vulvar disease, 80 (62.5%) had HSILs and 48 (37.5%) had LSILs. Patients with HSILs were significantly older (HSIL median [interquartile range] = 49.0 (39.0-61.0) vs LSIL = 36.0 [29.0-53.0], p = .006). There were no significant differences between groups across race/ethnicity, education, marital status, or self-reported household income categories. Forty percent of HSIL patients reported depression compared with 20.8% of LSIL patients (p = .03), whereas 31.3% of HSIL patients and 8.3% of LSIL patients reported anxiety (p = .002). Bipolar disorder was reported in 3.8% of HSIL patients and no LSIL patients (p = .29). There were no differences in the proportion of patients receiving psychiatric counseling, medications, or hospitalizations between groups.

CONCLUSIONS

Squamous intraepithelial lesions of the vulva are associated with psychiatric disorders above age-matched national averages; these disorders are more prominent in the HSIL group. Combining mental health services with ongoing disease treatment seem to be part of a comprehensive approach to caring for this patient population.

Stepped approach to improving sexual function after gynaecological cancer: the SAFFRON feasibility RCT

BACKGROUND

Women affected by gynaecological cancer are often unaware of the sexual consequences of both the cancer and its treatment. Most do not receive appropriate advice or help to recover sexual function, and the effect on their sexuality may be profound, both physically and emotionally. However, several potential therapies can be effective in helping recover some sexual engagement and change self-perception around sex. A major initial challenge is informing and involving patients in an appropriate and sensitive manner, and a further issue is delivering therapies in busy gynaelogical oncology clinics. This study was conceived in response to a National Institute for Health Research (NIHR) Health Technology Assessment (HTA) call asking for proposals to improve sexual functioning in women treated for gynaecological cancer while taking into account associated issues of mood. Existing evidence-based therapies for improving sexual function after cancer treatment were adapted and placed within a 'stepped care' model for delivering these in the NHS setting. An assessment and treatment stepping algorithm was developed in parallel, both to assign women to a treatment level at assessment and to follow their progress session by session to advise on changing intervention level. The assessment tool was applied to all participants on the principle that the problem was sexual difficulty, not the cancer of origin.

PARTICIPANTS

Women aged > 18 years (with partners at their choice) treated for any gynaecological malignancy with surgery and/or chemotherapy and/or radiation at University College London Hospital or Bristol Gynaecological cancer centres, minimally 3 months post end of treatment, of any sexual orientation, with sexual function difficulties identified by three initial screening questions.

DESIGN

A feasibility two-arm, parallel-group randomised controlled pilot trial.

SETTING

Two NHS gynaecological cancer centres, one in London and one in Bristol.

INTERVENTIONS

A three-level stepped care intervention.

OBJECTIVE

To assess the feasibility of conducting a full-scale investigation of stepped therapy and indicate the potential benefits to patients and to the NHS generally.

PRIMARY OUTCOME MEASURES

Recruitment to study, proportion of women stepping up, number of usable data points of all measures and time points over length of trial, and retention of participants to end of trial.

RESULTS

Development of the intervention and accompanying algorithm was completed. The study was stopped before the recruitment stage and, hence, no randomisation, recruitment, numbers analysed, outcomes or harms were recorded.

LIMITATIONS

As the study did not proceed, the intervention and its accompanying algorithm have not been evaluated in practice, and the capacity of the NHS system to deliver it has not been examined.

CONCLUSIONS

None, as the study was halted.

FUTURE WORK

The intervention could be studied within a clinical setting; however, the experience of the study group points to the need for psychosocial studies in medical settings to establish pragmatic and innovative mechanisms to ensure adequate resource when extending staff clinical skills and time to deliver any new intervention for the duration of the trial.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN12010952 and ClinicalTrials.gov NCT02458001.

FUNDING

This project was funded by the NIHR HTA programme and will be published in full in Health Technology Assessment; Vol. 23, No. 5. See the NIHR Journals Library website for further project information.

Quality of Life, Sexual Functioning, and Physical Functioning Following Perineal Reconstruction with the Lotus Petal Flap

BACKGROUND

Lotus petal flaps (LPF) may be used for the reconstruction of extralevator abdominoperineal defects that cannot be closed primarily. Limited data are available on how perineal reconstruction with the LPF impacts on patients' quality of life (QoL), sexual functioning, and physical functioning.

METHODS

A cross-sectional study was performed following perineal reconstruction with the LPF. The QoL of patients having undergone LPF reconstruction was compared with a control group in which perineal defects were closed without flaps. Sexual and physical functioning (presence of perineal herniation and range of motion [ROM] of the hip joints) could only be evaluated in the LPF group. Psychometrically sound questionnaires were used. Physical functioning was evaluated subjectively with binary questions and objectively by physical examination.

RESULTS

Of the 23 patients asked to participate, 15 (65%) completed the questionnaires and 11 (47%) underwent physical examination. In the control group, 16 patients were included. There were no significant differences in QoL between the LPF and control groups. Within the LPF group, 33% of patients were sexually active postoperatively compared with 87% preoperatively. No perineal herniation was found. The ROM of the hip joints was bilaterally smaller compared with the generally accepted values.

CONCLUSIONS

Conclusions should be made with care given the small sample size. Despite a supposedly larger resection area in the LPF group, QoL was comparable in both groups. Nonetheless, reconstruction seemed to affect sexual function and physical function, not hampering overall satisfaction.

Quality of life and associated factors after surgical treatment of vulvar cancer by vulvar field resection (VFR)

Purpose

To investigate patient-reported quality of life (QoL) and associated factors in vulvar cancer patients treated surgically by vulvar field resection (VFR) without adjuvant radiation.

Methods

We retrospectively evaluated patient-reported QoL as part of the prospective monocentric VFR trial using the 30-item European Organization for Research and Treatment of Cancer quality-of-life questionnaire (EORTC QLQ-C30) supplemented by a question assessing sexual activity. All patients had been treated by VFR and no participant had received adjuvant radiotherapy. The gynecologic cancer lymphedema questionnaire (GCLQ) was used to determine the presence of lymphedema. Structured telephone interviews were conducted to assess postoperative sequelae and long-term complications.

Results

Forty-three VFR patients (median age 63 years) were available for QoL assessment. Thirty-eight (88%) had received inguinal lymph-node dissection in addition to VFR. Mean global QoL (global health status) rating among all patients was 66.1 (± 25.5) on a scale from 0 to 100 with higher scores indicating better QoL. Higher GCLQ scores were significantly associated with lower global QoL scores (Spearman's rank correlation ρ =− 0.7, p < 0.0001). The presence of preoperative co-morbidities and postoperative wound-healing complications were also linked to reduced QoL (p < 0.01 for both). In a multivariable regression model, there was a significant interaction between preoperative co-morbidities and wound-healing complications with regard to global QoL (p < 0.05).

Conclusion

Overall, VFR patients exhibit good quality of life postoperatively. The presence of lymphedema, wound-healing complications, and preoperative morbidities were associated with reduced QoL. Prospective longitudinal studies have to confirm our findings in the future.

Electronic supplementary material

The online version of this article (10.1007/s00404-020-05584-5) contains supplementary material, which is available to authorized users.

Cancer-Related Distress: Revisiting the Utility of the National Comprehensive Cancer Network Distress Thermometer Problem List in Women With Gynecologic Cancers

PURPOSE

The Distress Thermometer (DT) includes a measure of cancer-related distress and a list of self-reported problems. This study evaluated the utility of the DT problem list in identifying concerns most associated with distress and poorer quality of life (QOL) in survivors of gynecologic cancer.

METHODS

Demographic, clinical, psychosocial functioning, and DT data were described among 355 women participating in a gynecologic cancer cohort. Problems from the DT list were ranked by prevalence, distress, and QOL. Logistic regression models explored factors associated with problems that were common (≥ 25% prevalence) and associated with distress and QOL.

RESULTS

The average age of participants was 59.9 years (standard deviation [SD], 10.8 years). Most participants were non-Hispanic white (97%) and had ovarian (44%) or uterine (42%) cancer. The mean DT score was 2.7 (SD, 2.7); participants reported a mean of 7.3 problems (SD, 5.9 problems). The most common problems were fatigue (53.6%), worry (49.9%), and tingling (46.3%); least common problems were childcare (2.1%), fevers (2.1%), and substance abuse (1.1%). Report of some common problems, including tingling, sleep, memory, skin issues, and appearance, was not associated with large differences in distress or QOL. In contrast, some rarer problems such as childcare, treatment decisions, eating, housing, nausea, and bathing/dressing were associated with worse distress or QOL. Younger age, lower income, and chemotherapy were risk factors across common problems that were associated with worse distress or QOL (fatigue, nervousness, sadness, fears, and pain).

CONCLUSION

The DT problem list did not easily identify concerns most associated with distress and low QOL in patients with gynecologic cancer. Adaptations that enable patients to report their most distressing concerns would enhance clinical utility of this commonly used tool.

Quality of Life and Sexual Functioning After Vulvar Reconstruction With the Lotus Petal Flap

OBJECTIVE

Resection of (pre) malignant lesions in the vulvoperineal area may result in large defects that cannot be closed primarily. The lotus petal flap technique is widely used for reconstruction. The aim of this study was to evaluate both quality of life (QoL) and sexual functioning of patients who underwent the lotus petal flap procedure, because no data are available on this topic.

METHODS

A cross-sectional study was performed on all eligible patients (N = 38) who underwent the lotus petal flap procedure between 2005 and 2016. The European Organization for Research and Treatment of Cancer Quality of Life Questionnaire C30, Female Sexual Function Index, and Body Image Scale were used to evaluate QoL and sexual functioning. The European Organization for Research and Treatment of Cancer Quality of Life Questionnaire C30 and Female Sexual Function Index scores were compared with scores of age-matched healthy women.

RESULTS

Twenty-six patients (68%) responded. The mean (SD) age was 65.5 (16.3) years, and the median follow-up time was 38.5 months (range 16-141 months). Quality of life scores were lower compared with healthy women in the domains physical, role, and social functioning. Sexual activity rates were comparable with healthy women; however, sexual functioning was worse. Although patients were satisfied about their sexual life, pain was reported.

CONCLUSIONS

Patients who underwent vulvar reconstructive surgery with lotus petal flaps seem to have a lower QoL compared with healthy women. Patients report more pain during sexual activity but are satisfied about their sexual functioning. These results should be included in preoperative counseling and follow-up of future patients eligible for vulvar reconstruction with a lotus petal flap.

A Systematic Review of Interventions for Sexual Well-Being in Women With Gynecologic, Anal, or Rectal Cancer

PROBLEM IDENTIFICATION

Treatments for cancer in the lower pelvis often cause lasting effects on women's sexual well-being. The purpose of this review is to describe interventions to improve sexual well-being in gynecologic, anal, or rectal cancer survivors.

LITERATURE SEARCH

This review follows the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) 2009 checklist and guidelines. A literature search was conducted using PubMed, CINAHL®, PsycINFO, and Cochrane Library.

DATA EVALUATION

Articles were original intervention research studies of women treated for gynecologic, anal, or rectal cancer and included sexual well-being outcomes. Study characteristics were extracted and compared in a table for analysis and synthesis.

SYNTHESIS

Of the 16 included studies, 1 focused on genitourinary rehabilitation, 12 focused on psychoeducational interventions, and 3 focused on combination interventions. Most interventions reported at least one positive sexual well-being outcome. Intervention format, delivery, dose, and outcome variables varied widely.

IMPLICATIONS FOR RESEARCH

Preliminary efficacy and feasibility of interventions are promising, but larger studies designed to discern optimal content, delivery format, dose, and timing are needed.

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.

Screening for sexual health concerns in survivors of gynecological cancer

OBJECTIVE

To assess the impact of a screening tool, the Brief Sexual Symptom Checklist for Women, on referral rates to physiotherapists, sexual counselors, and psychologists for sexual issues among patients attending the practices of two gynecological oncologists.

METHODS

A prospective observational cohort study. A retrospective cohort of consecutive patients matched for age, diagnosis, and stage was used as a control group.

RESULTS

Seventy-eight women were recruited to the intervention group. Diagnoses were endometrial carcinoma (38%), ovarian carcinoma (33%), and cervical carcinoma (24%). Sixty percent had completed adjuvant treatment, and 89% were married or in a de facto relationship. More than half of participants reported at least one sexual difficulty and were not satisfied with their sexual function. The most commonly reported sexual issue was decreased sexual desire. Twelve of 77 (15%) women screened in the intervention group were referred to a sexual counselor and/or a physiotherapist for a sexual issue. Twelve percent of women in the intervention group were referred to a sexual counselor, compared with 5% in the control group (p = 0.072). There was no difference in the proportion of women referred to a pelvic floor physiotherapist between the two groups (8% of women in the intervention group vs. 8% in the control group; p = 1.000).

CONCLUSIONS

In the current study, the Brief Sexual Symptom Checklist for Women identified sexual health concerns in over half of gynecological cancer survivors and resulted in a non-significant trend to more referrals for sexual counseling.

The psychosocial issues of women with cancer of the vulva

Background

Cancer of the vulva is rare, it is a disease commonly diagnosed in elderly women, however, the incidence in younger women is rising. Many patients diagnosed and treated for vulval cancer face physical, social, sexual and psychological challenges. It is essential that therapy radiographers and members of the wider multidisciplinary team understand such challenges in order to provide patient centred care.

Aim

This review aims to highlight the key psycho-social issues experienced by patients with cancer of the vulva, identifying implications for practice in order to improve the holistic care for this patient group.

Method

A search of English literature was performed using Medline, Pubmed, CINAHL and PsycINFO. Search terms included, vulva or vulval cancer, psychosocial, psychosexual impact and quality of life. Articles were excluded if they focussed on cancers other than gynaecological and vulval cancers.

Results and Conclusions

Although there are numerous reports on the psychological and psychosocial problems faced by gynaecological cancer patients; there was a paucity of literature pertaining to patients with cancer of the vulva, this is consistent with previous research. Studies show a significant negative, psychosocial impact experienced by these women. Common themes being isolation, loneliness, stigmatisation and lack of information for patients and their carers, themes spanning over three decades. Nevertheless, it is important to be aware of the findings from recent studies consistent with patient’s needs, highlighting that listening to women’s narratives on living with cancer of the vulva is essential if we are to help with the psychosocial issues experienced by these women. They underline a necessity to raise awareness among healthcare professionals and the general public, to improve holistic support for this particular group of women. This is particularly important in the radiotherapy setting as many of these women undergo lengthy courses of treatment and the appropriately trained therapeutic radiographer can play a vital role in addressing the physical and psychosocial problems.

Approach to sexual dysfunction in women with cancer

Sexual dysfunction in female cancer patients remains under-diagnosed and under-treated. As sexual dysfunction is becoming an increasingly common side effect of cancer treatments, it is imperative for healthcare providers and especially gynecologic oncologists to include a comprehensive evaluation of sexual health as a routine part of the workup of such patients. Although most oncologists are not experienced in treating sexual dysfunctions, simple tools can be incorporated into clinical practice to improve the management of these conditions. In this review, we propose a practical approach to selecting proper treatment for sexual dysfunctions in female cancer patients. This includes three main steps: knowledge, diagnosis, and sexual counseling. Knowledge can be acquired through a specific updating about sexual issues in female cancers, and with a medical training in female sexual dysfunctions. Diagnosis requires a comprehensive history and physical examination. Sexual counseling is one of the most important interventions to consider and, in some cases, it may be the only intervention needed to help cancer patients tolerate their symptoms. Sexual counseling should be addressed by oncologists; however, select patients should be referred for qualified psychological or sexological interventions where appropriate. Finally, a multidisciplinary team approach may be the best way to address this challenging issue.

MRI evaluation of vulvar squamous-cell carcinoma in fresh radical local excision specimens for cancer localization and prediction of surgical tumor-free margins

In the surgical treatment of vulvar squamous-cell carcinoma (VSCC), tumor-free margins of 8 mm or more are considered adequate. However, limited perioperative information on the tumor-free margins other than the surgeon's own estimation is available. The purpose of this study was therefore to investigate the feasibility of ex vivo MRI in localizing VSCC and to assess the surgical tumor-free margins in fresh radical local excision (RLE) specimens to guide the surgeon during resections. Nine patients with biopsy-proven VSCC scheduled for RLE were prospectively included. Intact fresh specimens were scanned using a 7 T preclinical MR-scanner. Whole mount H&E-stained slides were obtained every 3 mm and correlated with ex vivo MRI. A pathologist annotated VSCC and minimal tumor-free margins (3 o'clock, 9 o'clock, basal) on the digitalized histological slides. An observer with knowledge of histology (the non-blinded annotation) and a radiologist blinded to histology (the blinded annotation) separately performed annotation of the same features on ex vivo MRI. Linear correlation and agreement of the ex vivo MRI measurements with histology were assessed. Diagnostic performance for VSCC localization and identification of margins less than 8 mm was expressed as positive and negative predictive values (PPV, NPV). In 153 matched ex vivo MRI slices, the observer correctly identified 79/91 margins as less than 8 mm (PPV 87%) and 110/124 margins as 8 mm or greater (NPV 89%). The radiologist correctly annotated absence of VSCC in 73/81 (NPV 90%) and presence in 65/72 (PPV 90%) slices. Sixty-four of 90 margins were correctly identified as less than 8 mm (PPV 71%) and 83/102 margins as 8 mm or greater (NPV 81%). Both non-blinded and blinded annotations were linearly correlated and demonstrated good agreement with histology. Accurate localization of VSCC and measurements of the surgical tumor-free margins in fresh RLE specimens using ex vivo MRI seems feasible. High diagnostic performance in VSCC localization and identification of margins less than 8 mm suggest ex vivo MRI to be clinically applicable.

Assessing Patient-reported Quality of Life Outcomes in Vulva Cancer Patients: A Systematic Literature Review

Objectives

Vulva cancer (VC) treatment carries a high risk of severe late effects that may have a negative impact on quality of life (QoL). Patient-reported outcome measures (PROMs) are increasingly used when evaluating disease- and treatment-specific effects. However, the adequacy of measures used to assess sequelae and QoL in VC remains unclear. The aims of the present study were to evaluate disease- and treatment-related effects as measured by PROMs in VC patients and to identify available VC-specific PROMs.

Methods/Materials

A systematic literature search from 1990 to 2016 was performed. The inclusion criterion was report of disease- and treatment-related effects in VC patients using PROMs in the assessment. Methodological and reporting quality was in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. This systematic review was performed as part of phase 1 of the development of a European Organisation for Research and Treatment of Cancer QoL questionnaire for VC patients.

Results

The search revealed 2299 relevant hits, with 11 articles extracted including a total of 535 women with VC; no randomized controlled trials were identified. The selected studies exhibited great heterogeneity in terms of PROMs use. Twenty-one different instruments assessed QoL. Most of the questionnaires were generic. Different issues (sexuality, lymphedema, body image, urinary and bowel function, vulva-specific symptoms) were reported as potentially important, but the results were not systematically collected. Only one VC-specific questionnaire was identified but did not allow for assessment and reporting on a scale level.

Conclusions

Vulva cancer treatment is associated with considerable morbidity deteriorating QoL. To date, there is no validated PROM available that provides adequate coverage of VC-related issues. The study confirms the need for a VC-specific QoL instrument with sensitive scales that allows for broad cross-cultural application for use in clinical trials.

["Alone with the taboo" - The social support experienced by women with vulvar neoplasia: a qualitative study]

"Alone with the taboo" - The social support experienced by women with vulvar neoplasia: a qualitative study Abstract.

BACKGROUND

Cancer of the vulva is a gynaecological disease often with relevant impact for these women's daily life. On top of the medical complications, psychological problems might arise as well, due to the impaired quality of life and the withdrawal from social life. We do not know whether and what type of support is given to these patients.

AIM

The qualitative study aimed at describing how the affected women experience the support they receive from their social environment from the time of the diagnosis to six months postoperatively.

METHODS

A qualitative design was used. In a secondary analysis, 20 transcribed interviews from the WOMN-PRO study were analysed by qualitative content analysis according to Mayring.

RESULTS

The findings from the study resulted in four main categories: having a serious disease shows how the patients experience the diagnosis as a shock and are confronted with questions of guilt and taboos. The category feel alone was strongly represented with features of not-speaking out, not looking at it and not-acting. Do it on your own features descriptions of the strategies the women use to get out of their loneliness. In experience help, it is shown that women who try to get in touch with their social environment usually receive support.

CONCLUSIONS

Patients have a high demand for information concerning the disease and its possible impacts on their daily life as well as emotional and practical support from their families / partners and especially from health professionals. We recommend designating someone who acts throughout the whole treatment process as a mediator and a person of trust.

Treatment of Inoperable Vulvar Cancer: Where We Come From and Where Are We Going

Abstract

Vulvar cancer is a rare disease affecting elderly women that is commonly treated with surgery, radiation, and chemotherapy. When tumors compromise the urethra and the anus, or when it is in the groin lymph nodes, radiotherapy, chemotherapy, or both are necessary after surgery.

The treatment of locally advanced vulvar cancer has suffered significant changes though the recent decades. So far, the best sequence of treatment is not known: surgery, chemotherapy, or radiotherapy. The radical surgeries usually need a long recovery term both in the region of the vulva and in the area of the groin lymph nodes. When it is performed, convalescence can delay other treatments, such as radiotherapy and chemotherapy. On the other hand, the use of radiotherapy and chemotherapy as a first step treatment can result in a complete elimination of the disease in at least 30% of the cases or substantial reduction of its size, allowing less extensive surgery. Therefore, the historical evolution of locally advanced vulvar cancer is reviewed.

Consequences of gynecological cancer in patients and their partners from the sexual and psychological perspective

The diagnosis of gynecological cancer and the following consequences of the treatment radically change the lives of cancer patients and their partners. Women experience negative consequences in terms of sexual, psychological and social functioning. Surgical treatment may result in a decrease in sexual pleasure and pain during intercourse. Chemotherapy and radiotherapy can cause a loss of libido and negatively affect the capacity to experience pleasure or orgasm.

Treatment-related changes may include the occurrence of body image disorders, decreased quality of life as well as depressive and anxiety disorders among patients. Furthermore, a negative influence on the relationship between the affected women and their partners, as well as an adverse effect on the social activity, can be observed. Cancer is not an individual experience. It also affects partners of the sick women in terms of psychological and sexual functioning.

This article depicts possible problems encountered by cancer patients and their partners from the psychological and sexual perspective. The emphasis is put on understanding sexuality not only in the context of sexual performance, but also in a wider perspective.

The sexual health of female rectal and anal cancer survivors: results of a pilot randomized psycho-educational intervention trial

BACKGROUND

Sexual dysfunction is a frequently reported consequence of rectal/anal cancer treatment for female patients.

PURPOSE

The purpose of this study was to conduct a small randomized controlled trial to assess the efficacy of a telephone-based, four-session Cancer Survivorship Intervention-Sexual Health (CSI-SH).

METHODS

Participants (N = 70) were stratified by chemotherapy, stoma, and menopause statuses before randomization to CSI-SH or assessment only (AO). Participants were assessed at baseline, 4 months (follow-up 1), and 8 months (follow-up 2).

RESULTS

The intervention had medium effect sizes from baseline to follow-up 1, which decreased by follow-up 2. Effect sizes were larger among the 41 sexually active women. Unadjusted means at the follow-ups were not significantly different between the treatment arms. Adjusting for baseline scores, demographics, and medical variables, the intervention arm had significantly better emotional functioning at follow-ups 1 and 2 and less cancer-specific stress at follow-up 1 compared to the AO arm.

CONCLUSION

The data supported the hypothesized effects on improved sexual and psychological functioning and quality of life in CSI-SH female rectal/anal cancer survivors compared to the AO condition. This pilot study (N = 70) of CSI-SH supported the impact of this intervention on sexual and psychological functioning and quality of life on rectal and anal cancer survivors compared with an AO condition. However, intervention effects were stronger at follow-up 1 as compared to follow-up 2 and were stronger for sexually active women.

IMPLICATIONS FOR CANCER SURVIVORS

Women may benefit from a brief, four-session, sexual health intervention after treatment from rectal and anal cancer.

Care of survivors of gynecologic cancers

The number of cancer survivors is increasing and most healthcare providers will manage patients who have completed therapy for malignancy at some point. The care of survivors of gynecologic malignancies may seem daunting in a busy general gynecology practice. This paper intends to review the literature and suggest management of these women for the general gynecologist.

Medical and surgical interventions for the treatment of usual-type vulval intraepithelial neoplasia

BACKGROUND

Usual-type vulval intraepithelial neoplasia (uVIN) is a pre-cancerous condition of the vulval skin. Also known as high-grade VIN, VIN 2/3 or high-grade vulval squamous intraepithelial lesion (HSIL), uVIN is associated with high-risk subtype human papilloma virus (HPV) infection. The condition causes distressing vulval symptoms in the majority of affected women and may progress to vulval cancer, therefore is usually actively managed. There is no consensus on the optimal management of uVIN. High morbidity and recurrence rates associated with surgical treatments make less invasive treatments highly desirable.

OBJECTIVES

To determine which interventions are the most effective, safe and tolerable for treating women with uVIN.

SEARCH METHODS

We searched the Cochrane Gynaecological Cancer Group Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL), Issue 8 2015, MEDLINE and EMBASE (up to 1 September 2015). We also searched registers of clinical trials, abstracts of scientific meetings, reference lists of included studies and contacted experts in the field.

SELECTION CRITERIA

Randomised controlled trials (RCTs) that assessed medical and surgical interventions in women with uVIN. If no RCTs were available, we included non-randomised studies (NRSs) with concurrent comparison groups that controlled for baseline case mix in multivariate analysis.

DATA COLLECTION AND ANALYSIS

We used Cochrane methodology with two review authors independently extracting data and assessing risk of bias. Where possible, we synthesised data in meta-analyses using random-effects methods. Network meta-analysis was not possible due to insufficient data.

MAIN RESULTS

We included six RCTs involving 327 women and five NRSs involving 648 women. The condition was variously named by investigators as uVIN, VIN2/3 or high-grade VIN. Five RCTs evaluated medical treatments (imiquimod, cidofovir, indole-3 carbinol), and six studies (one RCT and five NRSs) evaluated surgical treatments or photodynamic therapy. We judged two RCTs and four NRSs to be at a high or unclear risk of bias; we considered the others at relatively low risk of bias. Types of outcome measures reported in NRSs varied and we were unable to pool NRS data. Medical interventions: Topical imiquimod was more effective than placebo in achieving a response (complete or partial) to treatment at five to six months post-randomisation (three RCTs, 104 women; risk ratio (RR) 11.95, 95% confidence interval (CI) 3.21 to 44.51; high-quality evidence). At five to six months, a complete response occurred in 36/62 (58%) and 0/42 (0%) women in the imiquimod and placebo groups, respectively (RR 14.40, 95% CI 2.97 to 69.80). Moderate-quality evidence suggested that the complete response was sustained at one year (one RCT, nine complete responses out of 52 women (38%)) and beyond, particularly in women with smaller VIN lesions. Histologically confirmed complete response rates with imiquimod versus cidofovir at six months were 45% (41/91) and 46% (41/89), respectively (one RCT, 180 women; RR 1.00, 95% CI 0.73 to 1.37; moderate-quality evidence). Twelve-month data from this trial are awaited; however, interim findings suggested that complete responses were sustained at 12 months. Only one trial reported vulval cancer at one year (1/24 and 2/23 in imiquimod and placebo groups, respectively). Adverse events were more common with imiquimod than placebo and dose reductions occurred more frequently in the imiquimod group than in the placebo group (two RCTs, 83 women; RR 7.77, 95% CI 1.61 to 37.36; high-quality evidence). Headache, fatigue and discontinuation were slightly more common with imiquimod than cidofovir (moderate-quality evidence). Quality of life scores reported in one trial (52 women) were not significantly different for imiquimod and placebo. The evidence of effectiveness of topical treatments in immunosuppressed women was scant. There was insufficient evidence on other medical interventions. Surgical and other interventions: Low-quality evidence from the best included NRS indicated, when data were adjusted for confounders, that there was little difference in the risk of VIN recurrence between surgical excision and laser vaporisation. Recurrence occurred in 51% (37/70) of women overall, at a median of 14 months, and was more common in multifocal than unifocal lesions (66% versus 34%). Vulval cancer occurred in 11 women (15.1%) overall at a median of 71.5 months (9 to 259 months). The risk of vulval cancer did not differ significantly between excision and laser vaporisation in any of the NRSs; however, events were too few for robust findings. Alternative surgical procedures that might be as effective include Cavitron ultrasonic surgical aspiration (CUSA) and loop electrosurgical excision (LEEP) procedures, based on low- to very low-quality evidence, respectively. Very low-quality evidence also suggested that photodynamic therapy may be a useful treatment option.We found one ongoing RCT of medical treatment (imiquimod) compared with surgical treatment.

AUTHORS' CONCLUSIONS

Topical treatment (imiquimod or cidofovir) may effectively treat about half of uVIN cases after a 16-week course of treatment, but the evidence on whether this effect is sustained is limited. Factors predicting response to treatment are not clear, but small lesions may be more likely to respond. The relative risk of progression to vulval cancer is uncertain. However, imiquimod and cidofovir appear to be relatively well tolerated and may be favoured by some women over primary surgical treatment.There is currently no evidence on how medical treatment compares with surgical treatment. Women who undergo surgical treatment for uVIN have about a 50% chance of the condition recurring one year later, irrespective of whether treatment is by surgical excision or laser vaporisation. Multifocal uVIN lesions are at a higher risk of recurrence and progression, and pose greater therapeutic dilemmas than unifocal lesions. If occult cancer is suspected despite a biopsy diagnosis of uVIN, surgical excision remains the treatment of choice. If occult cancer is not a concern, treatment needs to be individualised to take into account the site and extent of disease, and a woman's preferences. Combined modalities may hold the key to optimal treatment of this complex disease.

The impact of surgery for vulval cancer upon health-related quality of life and pelvic floor outcomes during the first year of treatment: a longitudinal, mixed methods study

OBJECTIVE

To measure the long-term impact of surgical treatment for vulval cancer upon health-related quality of life and pelvic floor outcomes during the first year of therapy.

METHODS

Prospective, longitudinal, mixed-methods study. Twenty-three women aged >18 years with a new diagnosis of vulval cancer were recruited. The EORTC QLQ C30, SF-36 and an electronic pelvic floor assessment questionnaire (ePAQ-PF) were administered at baseline (pre-treatment) and 3, 6, 9 and 12 months post-treatment. Mixed effects repeated measures models (all adjusted for age and BMI) were used to investigate changes over time and differences between cancer stage. Qualitative interviews were carried out with 11 of the women and analysed using a thematic approach.

RESULTS

Mean age was 59.9 years (SD = 15.3; range = 23.8-86.6 yrs). Mean BMI was 30.0 (SD = 4.5; range = 24.4-38.2). Sixteen women had early (Stage 1 to 2B), and seven women had advanced stage disease (Stage 3 to 4B). Questionnaire scores revealed that physical and social functioning, fatigue, pain and general sex life were significantly worse at 12 months than pre-treatment (p = < 0.05). Qualitative analysis revealed multiple treatment side effects which were perceived as severe and enduring. Women with advanced vulval cancer had significantly worse SF-36 mental health scores at 12 months compared to women with early stage disease (p = 0.037).

CONCLUSIONS

Surgery for vulval cancer has long-term implications which can be persistent 12 months post-treatment. High rates of morbidity relating to lymphoedema and sexual function re-enforce the need for specialist clinics to support women who suffer these complications. © 2015 The Authors. Psycho-Oncology published by John Wiley & Sons Ltd.

Sexual well-being in patients with vulvar disease: results from a preliminary prospective matched case-control study

INTRODUCTION

Only a few studies have focused on the description of sexual well-being in patients with vulvar disease (VD). The aim of this study was to test the hypothesis that VD patients have an overall impaired sexual well-being that varies depending on the type of VD.

STUDY DESIGN

An observational, prospective, single center and 1:1 matched case-control study was conducted in Nantes University Hospital (France). All new patients attending the specific consultation for VD between June 2011 and January 2013 were included. A control group was randomly selected from women who had a scheduled consultation for gynecologic follow-up. A validated French version of the Female Sexual Function Index (FSFI) was used. This self-administered questionnaire was distributed to all case and control women. VD was classified into 4 groups: inflammatory, (pre)malignant, infectious, and other VD. Descriptive statistics and multivariate mixed analyses were performed.

RESULTS

Seventy-two VD patients and seventy-two control women completed the FSFI questionnaire. The median FSFI score was 21.1 in the VD patients versus 28.1 in the control patients. In the multivariate analysis, the FSFI score was significantly decreased by an average of 4.5 points (p=0.003) in the VD patients. On the FSFI subscores, VD had significant impacts on items related to "arousal", "pain", "lubrication", "satisfaction", and "desire". When comparing the VD groups, the total FSFI score seemed lower for (pre)malignant VD.

CONCLUSION

This preliminary study showed that VD patients had an impaired sexual well-being.

Medical interventions for high-grade vulval intraepithelial neoplasia

BACKGROUND

This is an updated version of a review first published in theCochrane Database of Systematic Reviews, Issue 4, in 2011. Vulval intraepithelial neoplasia (VIN) is a pre-cancerous condition of the vulval skin and its incidence is increasing in women under 50 years. High-grade VIN (also called usual-type VIN (uVIN) or VIN 2/3 or high-grade vulval intraepithelial lesion) is associated with human papilloma virus (HPV) infection and may progress to vulval cancer, therefore is usually actively managed. There is no consensus on the optimal management of high-grade VIN; and the high morbidity and relapse rates associated with surgical interventions make less invasive interventions highly desirable.

OBJECTIVES

To evaluate the effectiveness and safety of medical (non-surgical) interventions for high-grade VIN.

SEARCH METHODS

We searched the Cochrane Gynaecological Cancer Group Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2015, Issue 3), MEDLINE and EMBASE (up to 30 March 2015). We also searched registers of clinical trials, abstracts of scientific meetings, reference lists of included studies and contacted experts in the field.

SELECTION CRITERIA

Randomised controlled trials (RCTs) that assessed non-surgical interventions in women diagnosed with high-grade VIN.

DATA COLLECTION AND ANALYSIS

We used Cochrane methodology with two review authors independently abstracting data and assessing risk of bias. Where possible, we synthesised data in meta-analyses using random effects methods.

MAIN RESULTS

Five trials involving 297 women with high-grade VIN (defined by trial investigators as VIN 2/3 or VIN 3 or 'high-grade' lesions) met our inclusion criteria: three trials assessed the effectiveness of topical imiquimod versus placebo; one assessed topical cidofovir versus topical imiquimod; and one assessed low- versus high-dose indole-3-carbinol in similar types of participants. Three trials were at a moderate to low risk of bias, two were at a potentially high risk of bias.Meta-analysis of the three trials comparing topical imiquimod 5% cream to placebo found that women in the active treatment group were more likely to show an overall response (complete and partial response) to treatment at five to six months compared with the placebo group (Risk Ratio (RR) 11.95, 95% confidence interval (CI) 3.21 to 44.51; participants = 104; studies = 3; I(2) = 0%; high-quality evidence). A complete response at five to six months occurred in 36/62 (58%) and 0/42 (0%) participants in the active and placebo groups, respectively (RR 14.40, 95% CI 2.97 to 69.80; participants = 104; studies = 3; I(2) = 0%). A single trial reported 12-month follow-up, which revealed a sustained effect in overall response in favour of the active treatment arm at 12 months (RR 9.10, 95% CI 2.38 to 34.77; moderate-quality evidence), with 9/24 (38%) and 0/23 (0%) complete responses recorded in the active and placebo groups respectively. Progression to vulval cancer was also documented in this trial (one versus two participants in the active and placebo groups, respectively) and we assessed this evidence as low-quality. Only one trial reported adverse events, including erythema, erosion, pain and pruritis at the site of the lesion, which were more common in the imiquimod group. Dose reductions occurred more frequently in the active treatment group compared with the placebo group (19/47 versus 1/36 participants; RR 7.77, 95% CI 1.61 to 37.36; participants = 83; studies = 2; I(2) = 0%; high-quality evidence). Only one trial reported quality of life (QoL) and there were no significant differences between the imiquimod and placebo groups.For the imiquimod versus cidofovir trial, 180 women contributed data. The overall response at six months was similar for the imiquimod and cidofovir treatment groups with 52/91 (57%) versus 55/89 (62%) participants responding, respectively (RR 0.92, 95% CI 0.73 to 1.18). A complete response occurred in 41 women in each group (45% and 46%, respectively; RR 1.00, 95% CI 0.73 to 1.37). Although not statistically different, total adverse events were slightly more common in the imiquimod group of this trial with slightly more discontinuations occurring in this group. Longer term response data from this trial are expected.The small trial comparing two doses of indole-3-carbinol contributed limited data. We identified five ongoing randomised trials of various interventions for VIN.

AUTHORS' CONCLUSIONS

Topical imiquimod appears to be a safe and effective treatment for high-grade VIN (uVIN), even though local side-effects may necessitate dose reductions. However, longer term follow-up data are needed to corroborate the limited evidence that response to treatment is sustained, and to assess any effect on progression to vulval cancer. Available evidence suggests that topical cidofovir may be a good alternative to imiquimod; however, more evidence is needed, particularly regarding the relative effectiveness on longer term response and progression. We await the longer-term response data and the results of the five ongoing trials.

Sexual Activity and Function in Patients With Gynecological Malignancies After Completed Treatment

Objective

Sexual activity (SA) and sexual function (SF) after completion of treatment are central for quality of life (QoL) in women affected by gynecological cancer (GC). The aim of this study was to analyze the sexual outcome and overall QoL of women after treatment for primary GC compared with a healthy control group (CG).

Methods

In a multicenter cross-sectional study, 77 women aged 28 to 67 years were surveyed at least 12 months after completion of primary therapy for cervical, endometrial, or vulvar cancer [gynecological cancer group (GCG)]. Data were collected through validated questionnaires (Female Sexual Function Index-d, EORTC Quality of Life Questionnaire-C30, and Sexual Activity Questionnaire) and compared to a control of 60 healthy women (CG).

Results

In the GCG, 41.3% were sexually active compared to 78.0% in the CG. Twelve women of the CG and 42 women of the GCG indicated the reasons for their sexual inactivity. The most common reason for sexual inactivity in the GCG was “the-presence-of-a-physical-problem” [18/42 (42.9%) vs 2/12 (16.7%) in the CG], whereas in the CG, “because-I-do-not-have-a-partner” was most common [6/12 (50.0%) vs 11/42 (26.2%) in the GCG]. Sexually active patients in the GCG had an SF comparable to the CG. In multivariate analysis of the total cohort (n = 137), relationship status [solid partnership vs living alone; odds ratio (OR), 33.82; 95% confidence interval (CI), 4.83–236.70], smoking (OR, 0.25; 95% CI, 0.06–1.03), and age (OR, 0.87; 95% CI, 0.79–0.94) influenced SA significantly. The probability of SA thereby decreased with increasing age. Quality of life and subjective general health status were not significantly different between the GCG and the CG (EORTC Quality of Life Questionnaire-C30 score 68.25 vs 69.67).

Conclusions

A high number of patients with GC remain sexually inactive after treatment, indicating that women experience persistent functional problems. However, women who regain SA after completed treatment have a good overall SF and vice versa.

Endoscopic groin lymphadenectomy with a thigh approach to gynecologic malignancies: a retrospective study with 5-year experience

OBJECTIVES

The objective of this study was to report a safe and feasible technique with endoscopic groin lymphadenectomy (EGL) through thigh approach in the treatment of different gynecologic malignancies.

STUDY DESIGN

Consecutive gynecological malignant patients proceeded to groin lymphadenectomy were treated by this technique over a 5-year period (2005 to 2010). Data regarding the surgical perioperative complications were recorded.

RESULTS

Eleven patients with 21 EGL were performed. Procedures included bilateral groin lymphadenectomy (n = 10) and left groin lymphadenectomy (n = 1). The median patient age and body mass index were 61 years and 25.2, respectively. The median operational time, which includes the dissection of both groins and the other procedures, was 210 minutes. The median blood loss was 200 mL. The median number of retrieved lymph nodes was 13 (range, 8-26), and all of these are histologically negative. No intraoperative complications occurred. One patient was noted in cutaneous cellulitis on the right side of the patient with clinical resolution 15 days after surgery. There were no perioperative mortalities. All the cutaneous scars were healed without wound breakdown. There were no perioperative mortalities. At the latest follow-up, all patients were completely satisfied with the cosmetic results.

CONCLUSIONS

In this study, we first report EGL with a thigh approach in gynecologic malignancies; it is a safe and feasible technique, for groin nodal dissection, with low risks of morbidity of the skin and legs. A larger prospective study with long-term and survival analyses is warranted.

Sexual functioning in women after surgical treatment for endometrial cancer: a prospective controlled study

INTRODUCTION

Endometrial cancer (EC) can affect sexual functioning based on anatomical, physiological, psychological, and relational mechanisms.

AIM

The aim of this study was to prospectively investigate sexual adjustment of women with EC during a follow-up period of 2 years after surgical treatment and to compare the results with women who underwent a hysterectomy for a benign gynecological condition and healthy control women.

METHODS/MAIN OUTCOME MEASURES

In this prospective controlled study, participants completed the Short Sexual Functioning Scale, Specific Sexual Problems Questionnaire, Beck Depression Inventory Scale, World Health Organization-5 Well-being Scale, and Dyadic Adjustment Scale to assess various aspects of sexual and psychosocial functioning before undergoing a hysterectomy and 6 months, 1 year, and 2 years after surgery.

RESULTS

Eighty-four women with EC, 84 women with a benign gynecological condition, and 84 healthy controls completed the survey. In EC survivors, no differences were found in sexual functioning during prospective analyses. In comparison with women with a benign gynecological condition, significantly more EC patients reported entry dyspareunia 1 year after surgical treatment. Moreover, compared with healthy women, pre- and postoperatively, significantly more EC patients reported sexual dysfunctions, including sexual desire dysfunction, arousal dysfunction, entry dyspareunia, and a reduced intensity of orgasm. Furthermore, compared with healthy controls, EC patients reported significantly lower overall well-being 1 year after surgical treatment. Nevertheless, consensus in the partner relationship was significantly higher in EC patients compared with healthy controls. Moreover, before treatment, quality of partner relationship was negatively associated with sexual arousal dysfunction and orgasm dysfunction.

CONCLUSIONS

In EC patients, no differences were found in sexual functioning when prospectively comparing the situation before surgery with the situation after surgery. However, when compared with healthy controls, EC patients are at high risk for sexual dysfunctions, both before and after surgical treatment.

Psychologic, relational, and sexual functioning in women after surgical treatment of vulvar malignancy: a prospective controlled study

OBJECTIVE

Vulvectomy for vulvar malignancy can affect sexual functioning based on anatomic, physiologic, psychologic, and relational mechanisms. The aims of this study were to prospectively investigate sexual adjustment of women with vulvar malignancy during a follow-up period of 1 year after vulvectomy and to compare the results with healthy control women.

METHODS

In this prospective controlled study, participants completed the Beck Depression Inventory scale, World Health Organization-5 Well-being scale, Dyadic Adjustment Scale, Short Sexual Functioning Scale, and Specific Sexual Problems Questionnaire to assess various aspects of psychosocial and sexual functioning just before surgery, 6 months, and 1 year after treatment.

RESULTS

Twenty-nine women with vulvar malignancy and 29 healthy controls completed the survey. Compared with the presurgery status, no significant differences were found in psychologic, relational, and sexual functioning in women after surgery for vulvar malignancy. Compared with healthy control women, women with vulvar malignancy reported significantly lower psychologic well-being and quality of partner relationship, both before and after treatment. Moreover, significantly more patients with vulvar malignancy reported preoperative and postoperatively sexual dysfunctions than healthy controls, including entry and deep dyspareunia, abdominal pain during intercourse, reduced ability to achieve orgasm, and reduced intensity of orgasm.

CONCLUSIONS

This prospective study yielded no differences in psychosocial and sexual functioning for women with vulvar malignancy before and after vulvectomy. However, when compared with healthy controls, patients with vulvar malignancy are at high risk for sexual dysfunctions, both before and after surgical treatment.

Feeling well and talking about sex: psycho-social predictors of sexual functioning after cancer

BACKGROUND

Changes to sexual wellbeing are acknowledged to be a long-term negative consequence of cancer and cancer treatment. These changes can have a negative effect on psychological well-being, quality of life and couple relationships. Whilst previous conclusions are based on univariate analysis, multivariate research can facilitate examination of the complex interaction between sexual function and psycho-social variables such as psychological wellbeing, quality of life, and relationship satisfaction and communication in the context of cancer, the aim of the present study.

METHOD

Six hundred and fifty seven people with cancer (535 women, 122 men) and 148 partners (87 women, 61 men), across a range of sexual and non-sexual cancers, completed a survey consisting of standardized measures of sexual functioning, depression and anxiety, quality of life, relationship satisfaction, dyadic sexual communication, and self-silencing, as well as ratings of the importance of sex to life and relationships.

RESULTS

Men and women participants, reported reductions in sexual functioning after cancer across cancer type, for both people with cancer and partners. Multiple regression analysis examined psycho-social predictors of sexual functioning. Physical quality of life was a predictor for men and women with cancer, and for male partners. Dyadic sexual communication was a predictor for women with cancer, and for men and women partners. Mental quality of life and depression were also predictors for women with cancer, and the lower self-sacrifice subscale of self-silencing a predictor for men with cancer.

CONCLUSION

These results suggest that information and supportive interventions developed to alleviate sexual difficulties and facilitate sexual renegotiation should be offered to men and women with both sexual and non-sexual cancers, rather than primarily focused on individuals with sexual and reproductive cancers, as is the case currently. It is also important to include partners in supportive interventions. Interventions aimed at improving sexual functioning should include elements aimed at improving physical quality of life and sexual communication, with a focus on psychological wellbeing also being important for women with cancer.

Informal caregiving for cancer patients

According to the recent worldwide estimation by the GLOBOCAN project, in total, 12.7 million new cancer cases and 7.6 million cancer deaths occurred in 2008. The worldwide number of cancer survivors within 5 years of diagnosis has been estimated at be almost 28.8 million. Informal caregivers, such as family members and close friends, provide essential support to cancer patients. The authors of this report provide an overview of issues in the study of informal caregivers for cancer patients and long-term survivors in the United States and Europe, characterizing the caregivers commonly studied; the resources currently available to them; and their unmet needs, their psychosocial outcomes, and the psychosocial interventions tailored to their special circumstances. A broad overview of the state of research and knowledge, both in Europe and the United States, and observations on the directions for future research are provided.

A review of complications associated with the surgical treatment of vulvar cancer

OBJECTIVE

The mainstay of treatment for most vulvar malignancies is surgery to the vulva with lymphadenectomy to the inguino-femoral areas, plus radiotherapy or/and chemotherapy for locally advanced, or recurrent disease. Treatment is associated with significant physical, sexual, and psychological morbidity. The high morbidity rate has resulted in a continuing shift in treatment paradigms that focus on treatments that reduce morbidity without compromising cure rates. This paper reviews the complications associated with contemporary surgical treatment for vulva cancer and discusses preventative strategies.

METHODS

A review of the English literature was undertaken for articles published between 1965 and August 31, 2012 to identify articles that assessed complications resulting from surgery to the vulva or groins in patients with vulva cancer. Two independent researchers selected and qualitatively analyzed the articles using a predetermined protocol.

RESULTS

The heterogeneity of articles and differences in definitions and outcomes made this unsuitable for meta-analysis. Most studies advocated for change in surgical technique to reduce complications associated with inguino-femoral lymphadenectomy and surgery to the vulva, with varying success. The most effective means of preventing complications is by omitting systematic lymph node dissection. This can be achieved safely through sentinel lymph node biopsy. Saphenous vein sparing, VTE prophylaxis, the use of flaps and grafts, and preoperative counseling are additional ways to decrease morbidity.

CONCLUSION

Despite technical advances, complications following surgical treatment for vulva cancer remain high. More research, particularly multi centered randomized controlled trials to improve the quality of evidence and studies that focus on complications as an outcome measure and analyze individual surgeon complication rates, are needed. Measures also need to be standardized throughout the gynecologic oncology community to allow for better comparison between studies.

Psychological correlates of sexual dysfunction in female rectal and anal cancer survivors: analysis of baseline intervention data

INTRODUCTION

Sexual dysfunction represents a complex and multifactorial construct that can affect both men and women and has been noted to often deteriorate significantly after treatment for rectal and anal cancer. Despite this, it remains an understudied, underreported, and undertreated issue in the field of cancer survivorship.

AIM

This study examined the characteristics of women enrolled in an intervention trial to treat sexual dysfunction, and explored the relationship between sexual functioning and psychological well-being.

METHODS

There were 70 female posttreatment anal or rectal cancer survivors assessed as part of the current study. Participants were enrolled in a randomized intervention trial to treat sexual dysfunction and completed outcome measures prior to randomization.

MAIN OUTCOMES MEASURES

The main outcome measures are quality of life (QOL) (European Organization for Research and Treatment of Cancer Core Quality of Life Questionnaire [EORTC-QLQ-C30] and Colorectal Cancer-Specific Module [QLQ-CR38]), sexual functioning (Female Sexual Functioning Index), and psychological well-being (Brief Symptom Inventory Depression/Anxiety, Impact of Events Scale-Revised, CR-38 Body Image).

RESULTS

Women enrolled in the study intervention were on average 55 years old, predominantly Caucasian (79%), married (57%), and a median of 4 years postprimary treatment. For those reporting sexual activity at baseline (N=41), sexual dysfunction was associated with a range of specific measures of psychological well-being, all in the hypothesized direction. The Sexual/Relationship Satisfaction subscale was associated with all measures of psychological well-being (r=-0.45 to -0.70, all P<0.01). Body image, anxiety, and cancer-specific posttraumatic distress were notable in their association with subscales of sexual functioning, while a global QOL measure was largely unrelated.

CONCLUSIONS

For sexually active female rectal and anal cancer survivors enrolled in a sexual health intervention, sexual dysfunction was significantly and consistently associated with specific measures of psychological well-being, most notably Sexual/Relationship Satisfaction. These results suggest that sexual functioning may require focused assessment by providers, beyond broad QOL assessments, and that attention to Sexual/Relationship Satisfaction may be critical in the development and implementation of interventions for this cohort of patients.

Safety and efficacy of topical cidofovir to treat high-grade perianal and vulvar intraepithelial neoplasia in HIV-positive men and women

OBJECTIVE

To evaluate the safety and efficacy of topical cidofovir for treatment of high-grade squamous perianal intraepithelial neoplasia (PAIN) and vulvar intraepithelial neoplasia (VIN) lesions in HIV-positive individuals.

DESIGN

Phase IIa prospective multicenter trial conducted at eight clinical sites through the AIDS Malignancy Consortium.

METHODS

: HIV-positive patients with biopsy-proven high-grade PAIN that was at least 3 cm were enrolled. PAIN biopsy specimens were assessed for human papillomavirus (HPV) using PCR and type-specific HPV probing. Participants applied 1% topical cidofovir to PAIN and VIN (if present) for six 2-week cycles. Results were designated as complete response (CR), partial response (PR) (>50% reduction in size), stable disease, or progressive disease (PD).

RESULTS

Twenty-four men and nine women (eight with high-grade VIN as well) were enrolled. Mean age was 44 years and mean CD4 cell count was 412 cells/μl. HPV DNA (most commonly HPV16) was detected in all pretreatment study specimens. Twenty six (79%) participants completed treatment per protocol: CR, five (15%); PR, 12 (36%), stable disease, seven (21%); PD, two (6%) (one with a superficially invasive cancer and one with new area of high-grade PAIN). Treatment was well tolerated with most common adverse events being mild to moderate affecting lesional skin: pain/burning/irritation (25 patients) and ulceration (13 patients).

CONCLUSION

Topical cidofovir had 51% efficacy in the short-term treatment of high-grade PAIN and VIN with acceptable toxicity in HIV-positive individuals. Randomized control studies with more prolonged treatment courses and longer follow-up to assess the durability of the response are needed.

Treatment failure in patients with HPV 16-induced vulvar intraepithelial neoplasia: understanding different clinical responses to immunotherapy

Failure of the immune system to launch a strong and effective immune response to high-risk HPV is related to viral persistence and the development of anogenital (pre)malignant lesions such as vulvar intraepithelial neoplasia (VIN). Different forms of immunotherapy, aimed at overcoming the inertia of the immune system, have been developed and met with clinical success. Unfortunately these, in principal successful, therapeutic approaches also fail to induce clinical responses in a substantial number of cases. In this review, the authors summarize the traits of the immune response to HPV in healthy individuals and in patients with HPV-induced neoplasia. The potential mechanisms involved in the escape of HPV-induced lesions from the immune system indicate gaps in our knowledge. Finally, the interaction between the immune system and VIN is discussed with a special focus on the different forms of immunotherapy applied to treat VIN and the potential causes of therapy failure. The authors conclude that there are a number of pre-existing conditions that determine the patients' responsiveness to immunotherapy. An immunotherapeutic strategy in which different aspects of immune failure are attacked by complementary approaches, will improve the clinical response rate.

Quality of life in women with vulvar cancer submitted to surgical treatment: a comparative study

OBJECTIVES

To investigate the occurrence and severity of lymphoedema of the lower extremities (LLE), quality of life (QoL), and urinary and sexual dysfunction in women with vulvar cancer submitted to surgical treatment.

STUDY DESIGN

Twenty-eight patients with vulvar cancer submitted to vulvectomy and inguinofemoral lymphadenectomy and 28 healthy, age-matched women (control group) were evaluated. The occurrence and severity of LLE were determined by Miller's Clinical Evaluation. QoL, urinary function and sexual function were assessed by the EORTC QLQ-C30, SF-ICIQ and FSFI questionnaires, respectively. The differences between groups and correlations were assessed using Student's t-test, Chi-squared test, Mann-Whitney U-test and Spearman's rho test.

RESULTS

The groups were similar in terms of marital status, educational status, menopausal status, hormone therapy and height. The occurrence and severity of LLE were higher in women with vulvar cancer compared with the control group (p<0.001 and p = 0.003, respectively). A significant association was found between the severity of LLE and advanced age (p = 0.04), and the severity of LLE and higher body mass index (BMI; p = 0.04) in patients with vulvar cancer. In the patients with vulvar cancer, there was a significant correlation between the severity of LLE and worse QoL in the following domains: physical, cognitive, emotional, social, fatigue, pain, sleep and financial questions (p < 0.05). There was no difference in urinary function between the two groups (p = 0.113). Age and number of deliveries were the only variables associated with the occurrence of urinary incontinence (p = 0.01). Urinary incontinence was present in women with a mean age of 74.9 ± 4.6 years and a mean of 7.3 ± 1.3 normal deliveries. There was no difference between the groups in terms of the sexual function. Multivariate analysis showed an association between sexual function and age (p = 0.01), and sexual function and being in a stable relationship (p=0.02).

CONCLUSION

Patients submitted to vulvectomy or inguinofemoral lymphadenectomy for vulvar cancer are at higher risk of developing LLE compared with healthy, age-matched women. This has a negative effect on QoL, but does not interfere with urinary or sexual function.