Purpose

Patients treated for cervical cancer by irradiation (RT) are likely to experience radiation-induced injuries to the genitals and surrounding organs.  Additionally, these patients may be physically and psychologically affected by the general side effects and emotional distress after diagnosis and RT and are hence highly exposed to disruptions in their sexual function. Sexual dysfunction in cervical cancer patients has been described in several studies. The results are difficult to compare because of the different methods used to assess, analyze, and report sexual function. Most studies have focused on sexual outcomes after treatment of early-stage cervical cancer  and detailed knowledge concerning patients with locally advanced or recurrent cervical cancer is still very limited. As a group, patients with locally advanced cervical cancer have a median 5-year survival of about 50%.. Thus, many cervical cancer patients will live for years with the sequelae of their disease and need specific information about the consequences of the treatment they are offered.

In the few studies that have included advanced cervical cancer patients the data were often pooled with those of early-stage cervical cancer patients who were treated with surgery alone . Because of the larger tumor burden, more extensive treatment, and less favorable prognosis, the patient with locally advanced cervical cancer may be exposed to more sexual and vaginal problems than the early-stage cervical cancer patient cured after surgery alone. Therefore, when data from locally advanced and early-stage cervical cancer patients (treated by surgery alone) are pooled, the impact of disease and treatment on the sexual function is likely to be underestimated in patients with advanced disease. From an interventional perspective, it is of interest to map the consequences of treatment to develop relevant disease- and treatment-specific interventions that may alleviate side effects. In the case of unavoidable side effects, interventions directed toward information and sexual counseling may provide the patient with the knowledge enabling her to cope with the anticipated problems.

This paper is the third in a series describing the health-related quality of life in a sample of patients who were disease free after RT for locally advanced, recurrent, or persistent (after radical hysterectomy) cervical cancer (20, 21).To investigate the longitudinal course of self-reported sexual function and vaginal changes in patients disease free after radiotherapy (RT) for locally advanced, recurrent, or persistent cervical cancer.

Persistent sexual dysfunction and adverse vaginal changes were reported throughout the 2 years after RT, with small changes over time: approximately 85% had low or no sexual interest, 35% had moderate to severe lack of lubrication, 55% had mild to severe dyspareunia, and 30% were dissatisfied with their sexual life. A reduced vaginal dimension was reported by 50% of the patients, and 45% were never, or only occasionally, able to complete sexual intercourse. Despite sexual dysfunction and vaginal adverse effects, 63% of those sexually active before having cancer remained sexually active after treatment, although with a considerably decreased frequency.

Conclusion

Patients who are disease free after RT for locally advanced, recurrent, or persistent cervical cancer are at high risk of experiencing persistent sexual and vaginal problems compromising their sexual activity and satisfaction. The results of our study emphasize that patients treated by RT for cervical cancer should be informed about the potential risk of sexual and vaginal problems. We believe that this patient group has a seriously underestimated and neglected problem. Not only are the patients at high risk of experiencing sexual problems, they are also exposed to the taboo on communication about sexual problems among gynecologic oncologists. Vincent  found that 80% of the patients treated for cervical cancer wished for information on sexual issues from their physician and 56% of these did not feel sufficiently informed about sex. However, most of the patients would never themselves pose the question of sexual problems.

Different intervention strategies could be proposed. In a randomized study, Robinson   found increased compliance with the use of vaginal dilators and greater confidence in having sex in the intervention group given careful counseling about potential sexual difficulties and suggestions on alternative sexual practices in addition to careful instruction in the use of a vaginal dilator. After this study, verbal and written information on the use of a vaginal dilator was elaborated and given to all cervical cancer patients after intracavitary RT at both departments contributing patients to the present study. However, as pointed out in the study of Robinson  and confirmed by others, the practical instructions on the use of a vaginal dilator should be accompanied by specific counseling on sexual problems and vaginal changes anticipated or experienced .   The essential point of the  is that all health-care providers can provide counseling at the level at which they are confident. The most important issue is that questions regarding sexuality are encouraged and taken up by those who have the knowledge of potential consequences of the therapy given. The staff should be taught the basic knowledge of potential sexual problems and the management of the most pertinent ones. The clinician should be able to identify the couples who should be referred for professional sexual counseling. The present study provides detailed results useful for basic clinical information on sexual and vaginal problems after RT for cervical cancer.