Cervical Cancer: Issues of Sexuality and Fertility

The importance of quality of life during and after treatment for cervical cancer has been ignored for too long. The pervasive attitude that focuses on cure, with morbidity an afterthought, is still paramount in many patients' and oncologists' minds. However, at the insistence of patients and families, many clinicians have recognized and started to address these issues over the past 2 decades. Despite the best intentions, quantification of quality of life is complex and difficult. Evaluation of the tools used to measure and assess quality of life is essential. A study comparing patients' evaluations of the European Organization for Research and Treatment of Cancer (EORTC) quality of life questionnaire (QLQ)-C30 with their own quality of life suggested that our methodology warrants improvement.[ 1] Dr. Carter and colleagues are to be congratulated on their efforts. As noted in their review, most patients hesitate to bring up issues of sexuality and fertility, and their needs go unmet. Patients will frequently tell nonmedical health professionals about their quality-of-life concerns but will not mention a word to their treating physicians. Perhaps this reflects the patient's perception of the physician's discomfort in dealing with the subject or the length of time afforded each visit. An important point that the authors may have overlooked is the well-documented fact that sexual dysfunction in many patients starts with symptoms that eventually lead to the diagnosis of cervical cancer, such as abnormal bleeding or pain.[2] It thus becomes easy to conceptualize how similar symptoms associated with intercourse and due to noncancerous causes can lead to further dysfunction. Furthermore, a significant proportion of patients develop the irrational belief that sexual intercourse may predispose them to recurrence. This may be rooted in their readings that cervical cancer (due to its relationship with human papillomavirus) is a sexually transmitted disease.[3] If sex caused the cancer, it is reasonable for laypersons to surmise that it may predispose to a recurrence. Early-Stage Cervical Cancer
Although no direct comparisons of sexuality in patients treated with surgery vs radiation are available, indirect evidence suggests that posttreatment sexual functioning is disrupted less with surgery.[4,5] Possible explanations for this include the fact that ovarian function can be preserved, and the caliber, distensibility, and ability of the vagina to lubricate (through transudation) are maintained. Furthermore, most patients prefer the idea of removing the cancer, rather than irradiating it in situ. However, all of the above must be interpreted in light of the fact that, in general, patients treated with radiation therapy are not comparable to patients treated with surgery; they tend to have larger tumors, be older in age, and have more comorbidities. Fertility Preservation
Fertility (in the natural sense) can be preserved surgically with the use of a radical trachelectomy. However, intracavitary irradiation in the absence of external-beam irradiation has also been used as a method of preserving fertility.[6] New reproductive technologies have expanded the definition of maintaining fertility. Surgical removal of the ovaries or radiation-induced ovarian failure does not necessarily signify the inability to procreate. Cryopreservation of embryos, mature oocytes, and even ovarian tissue is now being performed.[7] Should radical trachelectomy be offered to women with no desire to preserve fertility, solely to preserve the uterus? Presently, most clinicians do not feel that the small incremental risks theoretically associated with this surgery over radical hysterectomy justify its use. However, patients may feel differently. In our series after 2 years of follow-up, approximately 33% of women who underwent radical trachelectomy had not attempted conception. On detailed questioning, many of these women had little prospect or interest in pregnancy, yet took comfort in the fact that they had done all they could to preserve their fertility. Recurrent Cervical Cancer
Treatment of recurrence presents a somewhat different scenario. At diagnosis, stage I cervical cancers are associated with an 85% to 90% probability of cure. With this in mind, it is not difficult to look beyond treatment and address issues of sexuality and fertility. However, in the setting of recurrent disease, with cure rates varying from 40% to 60%, survival is very much threatened. Patients previously treated with surgery alone tend to receive radiation therapy, and conversely, patients previously treated with radiation therapy alone tend to be candidates for pelvic exenteration. The latter procedure represents the ultimate in surgical aggressiveness, producing obvious changes in body function. In the 1970s and 1980s, surgeons addressed the issue of sexuality by offering construction of a neovagina (using muscle or skin) at the time of surgery. Sexuality was interpreted as intercourse, and success was measured by the length and size of the resulting vagina, not its functional status or the patient's satisfaction. The naivety associated with such rudimentary interpretation and evaluation is readily evident. Not unexpectedly, pelvic exenteration has been well documented to be associated with profound effects on quality of life, body image, and sexual functioning.[8,9] The Future
What then is the best management? Despite the suggestion in the literature that most patients benefit from brief psychosexual interventions such as counseling and support, the needs of most patients are unmet.[10] Dr. Carter and colleagues have touched upon methods to meet those needs within a sexual-health program. Such a comprehensive approach should not be limited to cervical cancer. Many other malignancies, such as breast cancer and hematologic malignancies, interfere with sexuality and fertility. In an ideal setting, trained professionals interested in the preservation of sexuality and fertility should evaluate all new cancer patients, preferably as part of tumor site groups or teams in a cancer center. Patients identified as being at risk would then be offered assistance in whatever domain required. Although the above services could be offered off-site, the presence of such expertise within the cancer center has the advantage of access to the treating physician and the patient chart, including medical history, therapy, and medications. Inclusion of such a program within one of these facilities would truly justify the use of the term "comprehensive cancer center."