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

Pelvic floor rehabilitation in cancer survivorship: an umbrella review

PURPOSE

This umbrella review aimed to identify, critically appraise, and summarize current systematic reviews with meta-analyses on the role of pelvic floor rehabilitation in cancer survivorship.

METHODS

Four bibliographic databases were searched from inception to August 1, 2024. Two independent reviewers screened the titles and abstracts of 379 records and retrieved 24 full-text systematic reviews. Assessing the Methodological Quality of Systematic Reviews-2 was used for quality assessment. Qualitative syntheses were performed to compile the effects of pelvic floor rehabilitation on bladder function, bowel function, quality of life, and other outcomes. Measures of effect sizes of these outcomes in each meta-analysis were extracted and summarized.

RESULTS

Seventeen systematic reviews with meta-analyses published between 2012 and 2024 were included in this umbrella review, containing a total of 92 primary studies. For quality assessment, four studies were evaluated as moderate quality, five as low, and eight as critically low. Populations with prostate, colorectal, and gynecological cancer were studied. Effects of pelvic floor rehabilitation on bladder, bowel, sexual function, and quality of life were reported and synthesized.

CONCLUSIONS

Pelvic floor rehabilitation is an essential component of cancer survivorship, including following prostate, colorectal, and gynecological cancer surgery. Further high-quality primary studies with adequate sample sizes are needed to inform clinical practice and research endeavors.

IMPLICATIONS FOR CANCER SURVIVORS

This umbrella review highlights the therapeutic potential of pelvic floor rehabilitation, underscores the need for its broader implementation in survivorship care, and guides future research directions to optimize outcomes for cancer survivors.

Non-gastrointestinal symptom burden following colorectal cancer treatment-a systematic review

BACKGROUND

Colorectal cancer is one of the most common malignancies worldwide. Improvements in screening and treatment have allowed for earlier detection and longer survival. However, treatments, which may involve surgery, radiotherapy and/or chemotherapy, often lead to patients developing both gastrointestinal and non-gastrointestinal symptoms that can persist long term. This systematic review aims to understand better the non-gastrointestinal symptoms that patients develop after colorectal cancer treatment and how these are identified and assessed through the use of questionnaires.

METHOD

The review was conducted according to PRISMA guidelines. Scopus, PubMed, Web of Science, PsycINFO and Cochrane Library were searched. Eligible studies evaluated the non-gastrointestinal symptoms that patients had developed and continued to have at 12 months or longer after treatment. Studies that were performed on patients who were within 12 months of treatment, who had a recurrent or a secondary cancer, had stage 4 cancer/were palliative or that looked solely at gastro-intestinal symptoms were excluded. Articles were limited to studies on human subjects written in English published between February 2012 and July 2024.

RESULTS

The searches identified 3491 articles. Thirty-seven articles met the inclusion criteria, of which, 33 were quantitative, 2 were qualitative and 2 were mixed methods study designs. Nearly two-thirds (n = 22) were cross-sectional studies, whereas 14 were longitudinal. One study had both a cross-sectional and longitudinal component to it. Most studies were of medium to high quality based on the Newcastle Ottawa Scale (n = 23) and were conducted in 14 countries, the majority of which were performed in the Netherlands (n = 14). The majority of participants in the included studies (n = 30/37) were men. There were also three studies that were performed with only female participants and one study that was performed with male participants only. The age range of research participants across all the studies was 29 to 89 years. Forty-five different validated questionnaires containing 5-125 question items were used to collect information on the side effects and impact of colorectal cancer treatment. Completion rate for questionnaires varied from 30 to 100% (median 63.5%). These determined effects on quality of life, emotional/psychological distress, sexual and urinary dysfunction, neuropathy, fatigue and hip pain.

CONCLUSION

This systematic review highlighted a wide range of longer-term non-gastrointestinal symptoms that frequently adversely affect QoL following treatment. These studies included highlighting the importance of nutrition/diet, physical activity, spirituality and communication in managing these long-term side effects.

Multi-Disciplinary Management in Rectal Cancer Survivorship: A Clinical Practice Review

Colorectal cancer (CRC) is the third most common cancer in the USA and worldwide. In the USA, nearly one-third of CRC cases are anatomically classified as rectal cancer. Over the past few decades, continued refinement of multimodality treatment and the introduction of new therapeutic agents have enhanced curative treatment rates and quality of life outcomes. As treatments improve and the incidence of young onset rectal cancer rises, the number of rectal cancer survivors grows each year. This trend highlights the growing importance of rectal cancer survivorship. Multimodality therapy with systemic chemotherapy, chemoradiation, and surgery can result in chronic toxicities in multiple organ systems, requiring a multi-disciplinary care model with services ranging from appropriate cancer surveillance to management of long-term toxicities and optimization of modifiable risk factors. Here, we review the evidence on these long-term toxicities and provide management considerations from consensus guidelines. Specific topics include bowel dysfunction from radiation and surgery, oxaliplatin-induced neuropathy, accelerated bone degeneration, the impact of fluoropyrimidines on long-term cardiovascular health, urinary incontinence, sexual dysfunction, and psychosocial distress. Additionally, we review modifiable risk factors to inform providers and rectal cancer survivors of various lifestyle and behavioral changes that can be made to improve their long-term health outcomes.

Body Image Issues in Patients With Colorectal Cancer: A Scoping Review

BACKGROUND

Stomas in colorectal cancer (CRC) survivors lead to body image problems. Advances in treatment help reduce the rate of stoma formation, but body image distress is still frequently experienced in CRC survivors.

OBJECTIVES

This review is aimed toward mapping and describing the state of knowledge regarding body image in patients with CRC.

METHODS

A systematic literature search complying with the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines was conducted. Screening and data extraction were performed by 2 reviewers independently for all potentially eligible studies.

RESULTS

A total of 56 eligible articles were selected. The majority of these studies were quantitative studies (85%). The eligible studies were classified into 4 broad categories: instruments used to assess body image, prevalence of body image distress, factors related to body image, and impact of body image distress. The European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-CR38) colorectal questionnaire was the most common measurement tool found among the reviewed studies (70%), and body image distress was reported by 25.5% to 86% of participants. Excluding gender, age, type of surgery, adjuvant therapy, time from diagnosis, social support, and stoma status, changes in bowel habits was identified as affecting the body image of patients with CRC.

CONCLUSION

Changing bowel habits emerged as a significant factor causing body image distress for CRC survivors.

IMPLICATIONS FOR PRACTICE

Clinicians should raise awareness about body image distress in patients with CRC, focus on finding effective measures and interventions intended to help alleviate symptoms of bowel dysfunction, and prepare patients to adapt to altered bowel functions.

Sexual function remains persistently low in women after treatment for colorectal cancer and anal squamous cell carcinoma

BACKGROUND

Women diagnosed with colorectal cancer (CRC) or anal squamous cell carcinoma (ASCC) are at high risk of sexual dysfunction after treatment, yet little is known about recovery and risk factors for chronic dysfunction.

AIM

We aimed to describe sexual function and sexual activity among women who underwent definitive treatment for CRC or ASCC, examine relationships between time since treatment completion and sexual function, and explore factors associated with desire and changes in sexual desire over time.

METHODS

As part of a prospective cohort study of patients with gastrointestinal cancer at the University of California San Francisco, female-identifying participants who finished definitive treatment for CRC or ASCC completed the Female Sexual Function Index (FSFI) at 6- to 12-month intervals. We used multivariable linear mixed models to explore factors associated with the FSFI desire subscale.

OUTCOMES

Outcomes were rates of sexual activity, proportion at risk for sexual dysfunction (FSFI score <26.55), total FSFI score, and FSFI desire subscale.

RESULTS

Among the 97 cancer survivors who completed at least 1 FSFI, the median age was 59 years, the median time since treatment end was 14 months, and 87% were menopausal. Fifty-five women (57%) had a history of colon cancer; 21 (22%), rectal cancer; and 21 (22%), ASCC. An additional 13 (13%) had a current ostomy. Approximately half the women were sexually active (n = 48, 49%). Among these 48 sexually active women, 34 (71%) had FSFI scores indicating risk for sexual dysfunction. Among the 10 sexually active women who completed a FSFI ≥2 years since end of treatment, the median total score was 22.6 (IQR, 15.6-27.3). None of the evaluated characteristics were associated with desire (age, tumor site, treatment, menopause status, or ostomy status).

CLINICAL IMPLICATIONS

Consistent with prior studies, we found low desire scores after treatment for CRC or ASCC, with little recovery over time, suggesting that patients should not expect an eventual rebound of sexual function.

STRENGTHS AND LIMITATIONS

Strengths of our study include longitudinal data and use of the validated FSFI. Women with ASCC composed 22% of our cohort, allowing for insight into this rare disease group. Limitations of this study include the small sample size, particularly for longitudinal analyses, and the enrollment of patients at variable times since treatment end.

CONCLUSION

We observed a high prevalence of sexual health concerns, including low desire, after the treatment of CRC and ASCC that persisted for years after treatment was completed.

Management of treatment-related sequelae following colorectal cancer

AIM

Colorectal cancer survivors are one of the most rapidly growing groups of patients living with and beyond cancer. In a national multidisciplinary setting, we have examined the extent of late treatment-related sequelae in colorectal cancer survivors and present the scientific evidence for management of these conditions in this patient category with the aim of facilitating identification and treatment.

METHOD

A systematic search for existing guidelines and relevant studies was performed across 16 and 4 databases, respectively, from inception to 2021. This yielded 13 guidelines and 886 abstracts, of which 188 were included in the finalized guideline (231 included for full text review). Secondarily, bibliographies were cross-referenced and 53 additional articles were included.

RESULTS

Symptoms have been divided into overall categories including psychosocial, bowel-related, urinary, sexual (male and female), pain/neuropathy and fatigue symptoms or complaints that are examined individually. Merging and grading of data resulted in 22 recommendations and 42 management strategies across categories. Recommendations are of a more general character, whereas management strategies provide more practical advice suited for initiation on site before referral to specialized units.

CONCLUSION

Treatment-related sequelae in colorectal cancer survivors are common and attention needs to be focused on identifying patients with unmet treatment needs and the development of evidence-based treatment algorithms.

Sexual dysfunction in female patients with anal cancer treated with curative intent: A systematic review of the literature

BACKGROUND AND PURPOSE

Patients with anal squamous cell carcinoma (SCC) are treated with sphincter-preserving radiation therapy and concurrent chemotherapy, achieving excellent oncologic outcomes. Patients, however, may experience treatment-related morbidity including sexual dysfunction. The objective of this systematic review was to review the literature on sexual dysfunction in female patients treated for anal cancer and to identify knowledge gaps.

MATERIALS AND METHODS

This systematic review was registered in PROSPERO prior to initiation. Databases searched included MEDLINE, Embase, PubMed, Cochrane, and Google Scholar. There were no restrictions on the study time period. Studies were limited to English. All study designs were included except review articles, letters to the editor, and case reports with less than ten patients.

RESULTS

In total, 1801 studies were retrieved and 19 met the inclusion criteria, including: 13 cross-sectional surveys, 3 prospective studies, 1 longitudinal intervention study, 1 retrospective chart review, 1 case control study. Sexual function was assessed using the female sexual functioning index (FSFI), EORTC-QLQ-CR30 and -CR38; response rates were low (<50 % in most studies). Sexual dysfunction was reported by up to 85 % of women; the most common symptoms being dyspareunia (17-65 %), vaginal dryness (22-88 %), and loss of libido (38-95 %). Gastrointestinal issues, such as bowel problems, and body image concerns additionally affected sexual function and quality of life.

CONCLUSION

Sexual dysfunction is a common issue affecting most female patients treated for anal cancer and there is a paucity of evidence on the management of this important survivorship issue. There is additionally a lack of ethnic, economic, and educational diversity and there are no studies addressing the unique needs of LGBTQ individuals - future studies should make a concerted effort to include a diverse patient population.

Management of late adverse effects after chemoradiation for anal cancer

BACKGROUND AND PURPOSE

Significant improvements in the treatment of anal cancer have produced a growing population of anal cancer survivors. These patients often experience late adverse effects related to their treatment. Research has revealed substantial unmet needs because of long-term symptoms and functional impairments after treatment that may negatively affect health-related quality of life. The purpose of the present guidelines is to review the scientific evidence for the management of late adverse effects after (chemo)radiotherapy ([C]RT) for anal cancer and to extrapolate knowledge from other pelvic malignancies treated with pelvic (C)RT so that they may guide the clinical management of late adverse effects.

MATERIALS AND METHODS

Relevant studies were systematically searched in four databases from their inception to June 2020 (no language limitation) and guidelines were searched in 16 databases, focussing on bowel dysfunction, psychosocial aspects, pain, and sexual and urinary dysfunction. The guidelines were developed by a panel of experts using the Oxford Centre for Evidence-based Medicine, levels of evidence, and grades of recommendations.

SCIENTIFIC EVIDENCE

Late adverse effects after (C)RT for anal cancer are associated with a low overall quality of life among survivors. The most pronounced late adverse effects are bowel dysfunction (present in up to 78%), urinary dysfunction (present in up to 45%), and sexual dysfunction (present in up to 90% of men and up to 100% of women). Only indirect data on adequate treatment options of these late adverse effects for anal cancer are available.

CONCLUSION

Quality of life and late adverse effects should be monitored systematically following treatment for anal cancer to identify patients who require further specialist evaluation or support. Increased awareness of the extent of the problem may serve to stimulate and facilitate multidisciplinary collaboration, which is often required.

The Long-Term Effects of Cancer Treatment on Sexuality and Couple Relationships

Breast cancer and its pharmacological treatment often induce an impairment in women's sexual functioning and couple relationships, as a consequence of physiological changes and psychosocial issues that may arise and persist long after treatment. This study aims to evaluate the sexual functioning, the quality of the couple relationship, and the overall health status of breast cancer survivors. A further objective is to determine the predictive role of specific clinical and sociodemographic variables for sexual functioning and the couple relationship. Sixty-four breast cancer survivors completed the following questionnaires: the Female Sexual Function Index (FSFI), the Dyadic Adjustment Scale (DAS), the Short Form Health Survey-12 (SF-12), and a self-report questionnaire to collect sociodemographic characteristics. Clinical information was retrieved from medical records. Compared to normative data, our sample reported significantly (p < .01) lower mean scores in the FSFI, DAS, and Physical Component (PCS) and Mental Component Summary (MCS) of the SF-12. Multiple regression analyses show a significant effect of age, hormonal therapy, and psychological well-being on sexual functioning and a significant effect of physical and mental well-being on the quality of the couple relationship. Additionally, 75% of patients qualified for sexual dysfunction as measured by the FSFI global scale, and 71.9% declared they were not adequately informed about the side effects of treatments on sexuality. The high prevalence of sexual dysfunction in breast cancer survivors underlines the need for specific attention to this problem, starting from a complete and targeted communication between patients and health providers regarding these side effects.

Body Image Related to Sexual Health: Development of the Concept

INTRODUCTION

Disturbances in body image can have an impact on sexual health and are prevalent in women of reproductive age. Although body image is important, the definition of this concept is inconsistent across the disciplines of nursing, medicine, and psychology. Use of a consistent definition in clinical practice and research could lead to a more comprehensive understanding of disturbances in body image, thereby advancing research-based knowledge and clinical practice. The purpose of this concept development was to advance the concept of body image as it relates to sexual health among women of reproductive age from the perspectives of 3 disciplines with a strong focus on body image: nursing, medicine, and psychology.

METHODS

Strategies for concept development as described by Rodgers provided the basis for this work. The process includes a search, review, and synthesis of the literature surrounding the concept of interest.

RESULTS

Seventy-one articles, mostly qualitative and quantitative descriptive, were included and used to develop the concept. Body image related to sexual health in women of reproductive age is a multifaceted concept that is composed of an emotional and behavioral response to one's perceived appearance, sexuality, and degree of femininity. An individual's body image is influenced by sociocultural identities, race, ethnicity, and health status. It has both physical and psychological impact on health outcomes.

DISCUSSION

This interprofessional and comprehensive definition of body image should enhance understanding, assessment, and management of body image disturbances, thus bridging disciplines and enhancing interprofessional research and practice.

Strategies to Minimize Late Effects From Pelvic Radiotherapy

During the past 30 years, radiation treatment techniques have significantly improved, from conventional external-beam radiation therapy, to three-dimensional conformal radiation therapy, to current intensity-modulated radiation therapy, benefiting patients who undergo treatment of pelvic malignancies. Modern treatment options also include proton beam irradiation as well as low and high dose rate brachytherapy. Although the acute adverse effects of these modalities are well documented in clinical trials, less well known are the true incidence and optimal management of those late adverse effects that can occur months to years later. In a population of survivors of cancer that is steadily increasing, with many such patients receiving radiotherapy at some time during their disease course, these late effects can become a considerable management and quality-of-life issue. This review will examine the range of late toxicities that can occur from pelvic radiotherapy and explore strategies to prevent and mitigate them.

Patient interest in the Lowdown on Down There: attendance at a vulvovaginal and sexual health workshop post-cancer treatment

PURPOSE

Sexual difficulties and vulvovaginal changes are common for women undergoing, and following, cancer treatments. These changes have significant impacts on quality of life and significant relationships. The current study aimed to (1) evaluate women's interest and attendance in a group-based educational workshop to address changes in vulvovaginal health and sexuality after cancer, and (2) describe participant characteristics and presenting concerns.

METHODS

Two hundred eighteen women with a history of cancer expressed interest in receiving information about the workshop and completed phone screening. Interested women (n = 156) completed an online questionnaire package examining vulvovaginal health and sexual function prior to attending the workshop.

RESULTS

Approximately 75% of the women who completed screening attended the workshop. Clinically significant sexual distress was reported by 91% of participants, and 97% of sexually active participants exceeded the threshold for sexual dysfunction (per FSFI). Women within 1-2 years of diagnosis tended to report less sexual distress, less severe vulvovaginal symptoms, and less impact from these symptoms compared to women farther out from diagnosis. While the majority of women reported vaginal dryness and pain during intercourse, only a minority reported engaging in health promotion strategies sufficient to expect symptom improvement.

CONCLUSIONS

The current study suggests that group-based educational workshops for vulvovaginal and sexual concerns are utilized by patients and should be offered to women well into disease survivorship. Workshops targeting vulvovaginal symptoms and sexual concerns may be a cost-effective method of reducing sexual distress and improving patients' sexual function and quality of life.

Sexual Function in Women with Colorectal/Anal Cancer

BACKGROUND

Treatments for colorectal and anal cancers can have a detrimental impact on sexual function. Type of treatment, which may include surgery, radiation, and/or chemotherapy, varies by disease site and severity. Treatment and long-term side effects can impact sexual function and intimacy for patients and their partners.

AIM

To review the literature regarding treatment for colorectal/anal cancer and its impact on female sexual function, and to provide an assessment of medical outcomes and patient-reported outcomes (PROs) of women with a history of colon, rectal, or anal cancer seeking sexual health treatment.

METHODS

We performed a PubMed search to identify peer-reviewed, English-language articles published between 2008 to 2018, using the following search terms: "colorectal cancer," or "rectal cancer," or "anal cancer" and "sexual function," or "sexual dysfunction." We also assessed the medical outcomes and PROs from our recent cross-sectional cohort study of 99 women with a history of colon, rectal, or anal cancer seeking sexual health treatment.

MAIN OUTCOME MEASURES

Sexual function, quality of life, and PROs after colorectal/anal cancer.

RESULTS

A total of 23 studies were identified. Study designs included 15 cross-sectional survey studies, 5 longitudinal studies, 2 psychoeducational interventions, and 1 pilot study. 10 studies included only women, and 13 included both men and women. The literature and our cohort confirmed that women with colorectal/anal cancer experience changes in sexual function after diagnosis and throughout the continuum of care; however, the scarcity of data in this area indicates a need for additional intervention trials and longitudinal studies.

CONCLUSIONS

Research studies with large sample sizes and long study durations are needed to help us better understand the needs of female survivors of colorectal/anal cancer. Women with colorectal/anal cancer need simple strategies and resources to address concerns of sexual function after cancer treatment. Such interventions have been shown to enhance survivorship and quality of life. Canty J, Stabile C, Milli L, et al. Sexual Function in Women with Colorectal/Anal Cancer. Sex Med Rev 2019;7:202-222.

Depressive Symptoms and Quality of Life Among Adolescent and Young Adult Cancer Survivors: Impact of Gender and Latino Culture

Ethnic and sex variations in depressive symptoms and quality of life (QOL) among adolescent and young adult (AYA) childhood cancer survivors were explored among a sample of Latino and non-Latino childhood cancer survivors (CCSs) (n = 194) treated at hospitals in Los Angeles County. Latinos scored higher in depressive symptoms and lower in QOL when compared with non-Latinos. Males had higher depressive symptoms. Among Latinos, higher levels of acculturation were associated with depression and a poorer QOL, and we found that more acculturated Latino males were more likely to have meaningful levels of depression than less acculturated males or females. Interventions addressing depressive symptoms may be most needed for Hispanic male CCSs.

Sexual quality of life, body image distress, and psychosocial outcomes in colorectal cancer: a longitudinal study

PURPOSE

The objectives were to assess changes in sexual QOL and body image distress over time and to examine longitudinal associations between sexual QOL and body image variables with psychosocial outcomes in a sample of colorectal cancer patients.

METHODS

Participants (N = 141) completed a mail-based survey assessing sexual QOL [sexual distress (ISS), treatment impact on sexual function (SFQ), sexual function (FSFI; IIEF)], body image distress (BIS), and psychosocial outcomes [relationship quality (DAS-4), depressive symptoms (CESD-SF), and health-related QOL (HRQOL; FACT-C)]; 88 patients completed 6-month follow-up surveys (62%). Gender and cancer subgroups (male vs. female; rectal vs. colon cancer) were compared and longitudinal models examined associations between sexual QOL and body image variables with psychosocial outcomes over time and by subgroup.

RESULTS

Impairments in sexual QOL and body image distress were common. Women and patients with rectal cancer reported worse body image distress compared to men (p = .005) and those with colon cancer (p = .03), respectively; compared to patients with colon cancer, those with rectal cancer reported worse treatment impact (p < .001) and marginally worse sexual function and HRQOL (p's = .05). At 6-month follow-up, body image distress decreased (p = .02), while sexual QOL was stable (e.g., 58% classified as dysfunctional at both time points, p = .13). For most sexual and body image predictors, worse impairment was associated with worse psychosocial outcomes over time. Several significant gender and cancer subgroup effects were found.

CONCLUSIONS

Sexual QOL and body image are compromised after colorectal cancer and tend to remain impaired if unaddressed. Sexual concerns should be addressed early to limit broader-reaching psychosocial effects.

Sexual Function and Health-Related Quality of Life in Long-Term Rectal Cancer Survivors

INTRODUCTION

Sexual dysfunction is a treatment sequela in survivors of rectal cancer (RC). Differences in health-related quality of life (HRQOL) can occur based on ostomy status (permanent ostomy vs anastomosis).

AIM

To describe alterations in sexual function and HRQOL based on ostomy status in long-term (≥5 years) survivors of RC.

METHODS

Survivors of RC with an ostomy (n = 181) or anastomosis (n = 394) were surveyed using validated HRQOL and functional status tools. We compared sexuality outcomes between the ostomy and anastomosis groups and reported differences adjusted for clinical and demographic characteristics. Qualitative data from one open-ended question on survivors' greatest challenges since their surgery were analyzed to explore sexuality, symptoms, and relationships.

MAIN OUTCOME MEASURES

Whether sexually active, satisfaction with sexual activity, and select sexual dysfunction items from the Modified City of Hope Quality of Life-Colorectal.

RESULTS

Survivors with a permanent ostomy were more likely to have been sexually inactive after surgery if it occurred before 2000 and experience dissatisfaction with appearance, interference with personal relationships and intimacy, and lower overall HRQOL. Female survivors of RC with an ostomy were more likely to have problems with vaginal strictures and vaginal pain after surgery that persisted at the time of the survey (≥5 years later). Radiation treatment, tumor stage, soilage of garments in bed, and higher Charlson-Deyo comorbidity scores were negatively associated with outcomes. Six qualitative themes emerged: loss of and decreased sexual activity, psychological issues with sexual activity, physical issues with sexual activity, partner rejection, ostomy interference with sexual activity, and positive experiences with sexuality.

CONCLUSION

Sexual dysfunction is a common long-term sequela of RC treatment, with more problems observed in survivors with a permanent ostomy. This warrants widespread implementation of targeted interventions to manage sexual dysfunction and improve HRQOL for these survivors.

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.

Pelvic radiotherapy and sexual function in women

BACKGROUND

During the past decade there has been considerable progress in developing new radiation methods for cancer treatment. Pelvic radiotherapy constitutes the primary or (neo) adjuvant treatment of many pelvic cancers e.g., locally advanced cervical and rectal cancer. There is an increasing focus on late effects and an increasing awareness that patient reported outcomes (PROs) i.e., patient assessment of physical, social, psychological, and sexual functioning provides the most valid information on the effects of cancer treatment. Following cure of cancer allow survivors focus on quality of life (QOL) issues; sexual functioning has proved to be one of the most important aspects of concern in long-term survivors.

METHODS

An updated literature search in PubMed was performed on pelvic radiotherapy and female sexual functioning/dysfunction. Studies on gynaecological, urological and gastrointestinal cancers were included. The focus was on the period from 2010 to 2014, on studies using PROs, on potential randomized controlled trials (RCTs) where female sexual dysfunction (FSD) at least constituted a secondary outcome, and on studies reporting from modern radiotherapy modalities.

RESULTS

The literature search revealed a few RCTs with FSD evaluated as a PRO and being a secondary outcome measure in endometrial and in rectal cancer patients. Very limited information could be extracted regarding FSD in bladder, vulva, and anal cancer patients. The literature before and after 2010 confirms that pelvic radiotherapy, independent on modality, increases the risk significantly for FSD both compared to data from age-matched healthy control women and compared to data on patients treated by surgery only. There was only very limited data available on modern radiotherapy modalities. These are awaited during the next five years. Several newer studies confirm that health care professionals are still reluctant to discuss treatment induced sexual dysfunction with patients.

CONCLUSIONS

Pelvic radiotherapy has a persistent deteriorating effect on the vaginal mucosa impacting negatively on the sexual functioning in female cancer patients. Hopefully, modern radiotherapy modalities will cause less vaginal morbidity but results are awaited to confirm this assumption. Health care professionals are encouraged to address potential sexual dysfunction both before and after radiotherapy and to focus more on quality than on quantity.

Facilitating psychosexual adjustment for women undergoing pelvic radiotherapy: pilot of a novel patient psycho-educational resource

Purpose

This pilot study aimed to obtain feedback on the feasibility, safety and acceptability of a psychosexual rehabilitation booklet developed for women undergoing pelvic radiation therapy (PRT) and to explore women's sexual, informational and supportive care needs post‐PRT rehabilitation.

Methods

Twenty women treated with PRT for gynaecological or anorectal cancer within the last 5 years, who had received vaginal dilators, provided feedback on the format, content and utility of the booklet and discussed their post‐treatment information needs, via a semi‐structured phone interview. Women completed standardized (HADS, IES‐R) and study‐specific scales to characterize psychological status of the sample and to assess participants' booklet knowledge and feedback, respectively.

Results

The booklet was perceived as very helpful, informative and not distressing, providing additional information to that discussed with clinicians. After reading the booklet, women had good understanding of strategies to reduce the sexual impact of PRT. Many women reported that discussion of sexuality was often avoided during consultations, despite them experiencing distressing sexual experiences and difficulties post‐PRT.

Conclusions

This novel resource which addresses an important component of post‐pelvic radiation care appears acceptable and highly valued. Findings have highlighted a need for sexual health communication training for clinicians who treat this population so that they can initiate conversations about vaginal health and sexual health in an informed and comfortable manner. The impact of the revised booklet on psychosexual and clinical outcomes is being evaluated in a multicentre RCT.

American Cancer Society Colorectal Cancer Survivorship Care Guidelines

Colorectal cancer (CRC) is the third most common cancer and third leading cause of cancer death in both men and women and second leading cause of cancer death when men and women are combined in the United States (US). Almost two-thirds of CRC survivors are living 5 years after diagnosis. Considering the recent decline in both incidence and mortality, the prevalence of CRC survivors is likely to increase dramatically over the coming decades with the increase in rates of CRC screening, further advances in early detection and treatment and the aging and growth of the US population. Survivors are at risk for a CRC recurrence, a new primary CRC, other cancers, as well as both short-term and long-term adverse effects of the CRC and the modalities used to treat it. CRC survivors may also have psychological, reproductive, genetic, social, and employment concerns after treatment. Communication and coordination of care between the treating oncologist and the primary care clinician is critical to effectively and efficiently manage the long-term care of CRC survivors. The guidelines in this article are intended to assist primary care clinicians in delivering risk-based health care for CRC survivors who have completed active therapy.

Investigation of body image as a mediator of the effects of bowel and GI symptoms on psychological distress in female survivors of rectal and anal cancer

PURPOSE

Treatment for rectal and anal cancer (RACa) can result in persistent bowel and gastrointestinal (GI) dysfunction. Body image problems may develop over time and exacerbate symptom-related distress. RACa survivors are an understudied group, however, and factors contributing to post-treatment well-being are not well understood. This study examined whether poorer body image explained the relation between symptom severity and psychological distress.

METHODS

Participants (N = 70) completed the baseline assessment of a sexual health intervention study. Bootstrap methods tested body image as a mediator between bowel and GI symptom severity and two indicators of psychological distress (depressive and anxiety symptoms), controlling for relevant covariates. Measures included the European Organization for Research and Treatment of Cancer Core Quality of Life Questionnaire (EORTC-QLQ-CR38) Diarrhea, GI Symptoms, and Body Image subscales and Brief Symptom Index Depression and Anxiety subscales.

RESULTS

Women averaged 55 years old (SD = 11.6), White (79 %), and were 4 years post-treatment. Greater Depression was related to poorer Body Image (r = -.61) and worse Diarrhea (r = .35) and GI Symptoms (r = .48). Greater Anxiety was related to poorer Body Image (r = -.42) and worse GI Symptoms (r = .45), but not Diarrhea (r = .20). Body Image mediated the effects of bowel and GI symptoms on Depression, but not on Anxiety.

CONCLUSIONS

Long-term bowel and GI dysfunction are distressing and affect how women perceive and relate to their bodies, exacerbating survivorship difficulties. Interventions to improve adjustment post-treatment should address treatment side effects, but also target body image problems to alleviate depressive symptoms. Reducing anxiety may require other strategies. Body image may be a key modifiable factor to improve well-being in this understudied population. Longitudinal research is needed to confirm findings.

Comparison of the Effects of Elaeagnus angustifolia Flower Capsule and Sildenafil Citrate Tablet on Anxiety Resulting From Sexual Dysfunction in Women Referring to the Selected Clinics of Shiraz University of Medical Sciences

Dissatisfaction from sexual relationships can result in deprivation as well as problems, such as depression, anxiety, and destruction of family’s mental health. One hundred twenty-five women (18 to 40 years) who suffered from hypoactive sexual desire disorder were divided into Elaeagnus angustifolia flower (4.5 g g daily for 35 days), sildenafil citrate tablet (50 mg for 4 weeks), and control groups. The study data were collected using the Female Sexual Function Index and Spielberger’s questionnaire and measurement of thyroid-stimulating hormone and prolactin hormone. In the Elaeagnus angustifolia group, the mean score of state and trait anxiety decreased after the intervention. In the sildenafil citrate group also, the mean score of state anxiety decreased from 22.15 ± 4.98 to 20.1 ± 5.15 ( P = .001) and that of trait anxiety decreased from 23.07 ± 4.44 to 21.55 ± 4.82 ( P = .002) after the intervention. Consumption of sildenafil citrate tablet was effective in reduction of the mean score of anxiety resulting from sexual dysfunction.

Body image and sexual function in women after treatment for anal and rectal cancer

OBJECTIVE

Treatment for anal and rectal cancer (ARCa) often results in side effects that directly impact sexual functioning; however, ARCa survivors are an understudied group, and factors contributing to the sexual sequelae are not well understood. Body image problems are distressing and may further exacerbate sexual difficulties, particularly for women. This preliminary study sought to (1) describe body image problems, including sociodemographic and disease/treatment correlates, and (2) examine relations between body image and sexual function.

METHODS

For the baseline assessment of a larger study, 70 women completed the European Organization for Research and Treatment of Cancer Core Quality of Life Questionnaire and Colorectal Cancer-specific Module, including the Body Image subscale, and Female Sexual Function Index. Pearson's correlation and multiple regression evaluated correlates of body image. Among sexually active women (n = 41), hierarchical regression examined relations between body image and sexual function domains.

RESULTS

Women were on average 55 years old (standard deviation = 11.6), non-Hispanic White (79%), married (57%), and employed (47%). The majority (86%) reported at least one body image problem. Younger age, lower global health status, and greater severity of symptoms related to poorer body image (p's < 0.05). Poor body image was inversely related to all aspects of sexual function (β range 0.50-0.70, p's < 0.05), except pain. The strongest association was with Female Sexual Function Index Sexual/Relationship Satisfaction.

CONCLUSION

These preliminary findings suggest the importance of assessing body image as a potentially modifiable target to address sexual difficulties in this understudied group. Further longitudinal research is needed to inform the development and implementation of effective interventions to improve the sexual health and well-being of female ARCa survivors.

Baseline characteristics and concerns of female cancer patients/survivors seeking treatment at a Female Sexual Medicine Program

PURPOSE

The purpose of this study is to characterize patients seeking treatment at a Female Sexual Medicine and Women's Health Program and examine their sexual/vaginal health issues.

METHODS

Data from clinical assessment forms were extracted from 509 women referred to the Female Sexual Medicine and Women's Health Program during/after cancer treatment. The form consists of a Vaginal Assessment Scale (VAS), vaginal health items, patient-reported outcomes (PROs) (Sexual Activity Questionnaire [SAQ], Sexual Self-Schema Scale [SSS], Female Sexual Function Index [FSFI]), and exploratory items.

RESULTS

Of 509 patients, 493 (97 %) completed PROs; 253 (50 %) received a pelvic examination. The majority had a history of breast (n = 260, 51 %), gynecologic (n = 184, 36 %), or colorectal/anal (n = 35, 7 %) cancer. Mean age was 51.2 years; 313 (62 %) were married/partnered. Approximately two thirds had elevated vaginal pH scores (5-6.5 [35 %] or 6.5+ [33 %]) and minimal (62 %) or no (5 %) vaginal moisture. Eighty-seven patients (44 %) experienced pain during their exam (23 % mild, 11 % moderate, 1.5 % severe, and 8.5 % not indicated). Fifty-three percent engaged in sexual activity with a partner; only 43 % felt confident about future sexual activity. Ninety-three percent were somewhat to very concerned/worried about sexual function/vaginal health. Approximately half had moderate/severe dryness (n = 133, 51 %) and dyspareunia (n = 120, 46 %). The mean SSS score was 60.7, indicating a slightly positive sexual self-view. However, 93.5 % (n = 429) had an FSFI score <26.55, suggesting sexual dysfunction.

CONCLUSIONS

At initial consult, women reported vaginal dryness, pain, and sexual dysfunction. For many women, pelvic exams showed elevated vaginal pH, lack of moisture, and discomfort with the exam itself. Future analyses will examine changes over time.

Factors affecting sexual function: A comparison between women with gynecological or rectal cancer and healthy controls

This study had two purposes: (i) to explore differences in sexual function between women with gynecological or rectal cancer after related pelvic-area treatments and women without cancer; and (ii) to investigate the relationships among body image, anxiety and depression, sexual relationship power, sexual self-schema, and female sexual function. The participants (n = 139) were recruited through Internet cancer support groups and women's health organizations in the USA. Six structured questionnaires were mailed, and the data were analyzed using descriptive and inferential statistics. The results showed that women with gynecological or rectal cancer had significantly worse sexual function than women without cancer. Having gynecological/rectal cancer and a negative sexual self-schema were significantly related to poor sexual function. Furthermore, sexual self-schema moderated the relationship between sexual relationship power and female sexual function. Healthcare providers could give more attention to sexual issues in women who have undergone treatment for gynecological or rectal cancer, especially for those with a negative sexual self-schema and high sexual relationship power, which might improve these women's quality of life.

Mind the gaps: what's missing from current economic evaluations of universal HPV vaccination?

BACKGROUND

Since the original licensing of human papilloma virus (HPV) vaccination for women, evidence is accumulating of its effectiveness in preventing HPV-related conditions in men, and universal vaccination (vaccinating men and women) is now recommended in some countries. Several models of the cost-effectiveness of universal HPV vaccination have been published, but results have been mixed. This article assesses the extent to which economic studies have captured the range of values associated with universal HPV vaccination, and how this influences estimates of its cost-effectiveness.

METHODS

Eight published economic evaluations of universal HPV vaccination were reviewed to identify which of the values associated with universal HPV vaccination were included in each analysis.

RESULTS

Studies of the cost-effectiveness of universal HPV vaccination capture only a fraction of the values generated. Most studies focused on impacts on health and health system cost, and only captured these partially. A range of values is excluded from most studies, including impacts on productivity, patient time and costs, carers and family costs, and broader social values such as the right to access treatment. Further, those studies that attempted to capture these values only did so partially.

DISCUSSION

Decisions to invest in universal HPV vaccination need to be based on a complete assessment of the value that it generates. This is not provided by existing economic evaluations. Further work is required to understand this value. First, research is required to understand how HPV-related health outcomes impact on society including, for instance, their impact on productivity. Second, consideration should be given to alternative approaches to capture this broader set of values in a manner useful to decisions-makers, such as multi-criteria decision analysis.

Sexual and reproductive health in cancer survivors

As patients live longer after cancer diagnosis and treatment, attention to symptoms and quality of life (QoL) are of increasing importance both during treatment and throughout survivorship. Two complications of multi-modal cancer treatment that can profoundly affect both men and women are sexual dysfunction and infertility. Survivors at highest risk for treatment-related sexual dysfunction are those with tumors that involve the sexual or pelvic organs and those whose treatment affects the hormonal systems mediating sexual function. Sexual dysfunction may not abate without appropriate intervention. Therefore, early identification and treatment strategies are essential. Likewise, multiple factors contribute to the risk of infertility from cancer treatment and many cancer patients of reproductive age would prefer to maintain their fertility, if possible. Fortunately, advances in reproductive technology have created options for young newly diagnosed patients to preserve their ability to have a biologic child. This paper will focus on the sexual and reproductive problems encountered by cancer survivors and discuss some treatment options.