Association between Regular Vaginal Dilation and/or Sexual Activity and Long-Term Vaginal Morbidity in Cervical Cancer Survivors

PURPOSE/OBJECTIVE(S)

To evaluate the association between regular vaginal dilation and/or sexual activity and vaginal morbidity in locally advanced cervical cancer patients after definitive radiochemotherapy and image-guided adaptive brachytherapy from the EMBRACE I study.

MATERIALS/METHODS

Physician-assessed vaginal morbidity (CTCAE v.3), vaginal dilation and patient-reported sexual activity (EORTC QLQ CX24) were assessed at baseline, every 3 months in the 1st year, every 6 months in the 2nd and 3rd year and yearly thereafter. For this longitudinal analysis, a subgroup of patients was selected with at least 3 follow-ups with information on vaginal dilation and/or sexual activity. Vaginal penetration summarized either the use of vaginal dilators or sexual activity or both. Regular vaginal penetration was defined if reported in ≥50%, infrequent if reported in <50% and absent if reported in 0% of follow-ups. Actuarial estimates of vaginal morbidity were calculated with Kaplan-Meier method and included the individual symptoms: vaginal dryness, stenosis, mucositis and bleeding. Group comparisons were evaluated with the log-rank test.

RESULTS

The EMBRACE I study included 1416 patients overall (2008-2015); the subgroup of patients for this longitudinal evaluation consists of 882 patients, with a median follow-up of 60 months (IQR 47-77). Of those, 565 (64%) reported regular, 205 (23%) infrequent and 112 (13%) no penetration. Reporting regular penetration was associated with a significantly lower risk of vaginal stenosis G≥2 of 23% at 5 years, compared to reporting of infrequent (37%) and no penetration (36%, p≤0.001). However, reporting regular penetration was associated with a significantly higher risk for vaginal dryness G≥1 (72% vs. 69% vs. 62%, respectively, p = 0.038) and bleeding G≥1 (61% vs. 40% vs. 25%, respectively, p≤0.001). No associations were seen for G≥1 vaginal stenosis, G≥2 dryness, G≥2 bleeding and G≥1/G≥2 mucositis.

CONCLUSION

Regular penetration (defined as vaginal dilation and/or sexual activity) was associated with lower risk for vaginal stenosis G≥2, but higher risk for vaginal dryness G≥1 and bleeding G≥1. Mild vaginal dryness seems to become apparent in particular for patients experiencing vaginal penetration. Minor vaginal blood loss during dilation and/or sexual activity is commonly reported by patients, resulting from atrophy of the vaginal mucosa and/or telangiectasia. While both of these G≥1 symptoms can be managed with lubricants, moisturizer and/or hormonal replacement therapy, G≥2 vaginal stenosis represents an irreversible fibrotic adverse event that can cause dyspareunia in many cancer patients. These long-term data support clinical recommendations for dilation and/or sexual activity after radiotherapy.

Clinical and imaging findings in cervical cancer and their impact on FIGO and TNM staging - An analysis from the EMBRACE study

OBJECTIVE

To investigate differences in local tumour staging between clinical examination and MRI and differences between FIGO 2009, FIGO 2018 and TNM in patients with primary cervical cancer undergoing definitive radio-chemotherapy.

METHODS

Patients from the prospective observational multi-centre study "EMBRACE" were considered for analysis. All patients had gynaecological examination and pelvic MRI before treatment. Nodal status was assessed by MRI, CT, PET-CT or lymphadenectomy. For this analysis, patients were restaged according to the FIGO 2009, FIGO 2018 and TNM staging system. The local tumour stage was evaluated for MRI and clinical examination separately. Descriptive statistics were used to compare local tumour stages and different staging systems.

RESULTS

Data was available from 1338 patients. For local tumour staging, differences between MRI and clinical examination were found in 364 patients (27.2%). Affected lymph nodes were detected in 52%. The two most frequent stages with FIGO 2009 are IIB (54%) and IIIB (16%), with FIGO 2018 IIIC1 (43%) and IIB (27%) and with TNM T2b N0 M0 (27%) and T2b N1 M0 (23%) in this cohort.

CONCLUSIONS

MRI and clinical examination resulted in a different local tumour staging in approximately one quarter of patients. Comprehensive knowledge of the differential value of clinical examination and MRI is necessary to define one final local stage, especially when a decision about treatment options is to be taken. The use of FIGO 2009, FIGO 2018 and TNM staging system leads to differences in stage distributions complicating comparability of treatment results. TNM provides the most differentiated stage allocation.