Cervical Cancer: Issues of Sexuality and Fertility
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.[
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
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. 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. 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. 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. 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. 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."
2. Andersen BL, Lachenbruch PA, Anderson B, et al: Sexual dysfunction and signs of gynecologic cancer. Cancer 57:1880-1886, 1986.
3. Schiffman M, Castle PE: Human papillomavirus: Epidemiology and public health. Arch Pathol Lab Med 127:930-934, 2003.
4. Grumann M, Robertson R, Hacker NF, et al: Sexual functioning in patients following radical hysterectomy for stage Ib cancer of the cervix. Int J Gynecol Cancer 11:372-380, 2001. 5. Jensen PT, Groenvold M, Klee MC, et al: Longitudinal study of sexual function and vaginal changes after radiotherapy for cervical cancer. Int J Radiat Oncol Biol Phys 56:937- 949, 2003.
6. Covens AL, van der Putten HW, Fyles AW, et al: Laparoscopic ovarian transposition. Eur J Gynecol Oncol 17:177-182, 1996.
7. Posada MN, Kolp L, Garcia JE: Fertility options for female cancer patients: Facts and fiction. Fertil Steril 75:647-653, 2001.
8. Andersen BL, Hacker NF: Psychosexual adjustment following pelvic exenteration. Obstet Gynecol 61:331-338, 1983.
9. Dempsey GM, Buchsbaum HJ, Morrison J: Psychosocial adjustment to pelvic exenteration. Gynecol Oncol 3:325-334, 1975.
10. Robinson JW, Faris PD, Scott CB: Psychoeducational group increases vaginal dilation for younger women and reduces sexual fears for women of all ages with gynecological carcinoma treated with radiotherapy. Int J Radiat Oncol Biol Phys 44:497-506, 1999.