Jeanne Carter

Seeking meaning and hope: self‐reported spiritual and existential needs among an ethnically‐diverse cancer patient population

Spiritual beliefs and practices are believed to promote adjustment to cancer through their effect on existential concerns, including ones personal search for the meaning of life and death, and hope. This study sought to identify the nature, prevalence, and correlates of spiritual/existential needs among an ethnically‐diverse, urban sample of cancer patients (n=248). Patients indicated wanting help with: overcoming my fears (51%), finding hope (42%), finding meaning in life (40%), finding spiritual resources (39%); or someone to talk to about: finding peace of mind (43%), the meaning of life (28%), and dying and death (25%). Patients (n=71) reporting five or more spiritual/existential needs were more likely to be of Hispanic (61%) or African–American (41%) ethnicity (vs. 25% White; p<0.001), more recently diagnosed (mean=25.6 vs. 43.7 months; p<0.02), and unmarried (49% vs. 34%; p<0.05), compared with those (n=123) reporting two or fewer needs. Treatment status, cancer site, education, gender, age, and religion were not associated with level of needs endorsement. Discriminant analysis found minority status to be the best predictor of high needs endorsement, providing 65% correct classification, p<0.001. Implications for the development and delivery of spiritual/existential interventions in a multi‐ethnic oncology setting are discussed. Copyright

Psychometric validation of the female sexual function index (FSFI) in cancer survivors

The Female Sexual Function Index (FSFI) is the most commonly used self‐report instrument to measure sexual functioning among women cancer survivors. Despite this, the validity and reliability of the FSFI for use in cancer populations has not been established.

Society of Gynecologic Oncology recommendations for the prevention of ovarian cancer

Mortality from ovarian cancer may be dramatically reduced with the implementation of attainable prevention strategies. The new understanding of the cells of origin and the molecular etiology of ovarian cancer warrants a strong recommendation to the public and health care providers. This document discusses potential prevention strategies, which include 1) oral contraceptive use, 2) tubal sterilization, 3) risk‐reducing salpingo‐oophorectomy in women at high hereditary risk of breast and ovarian cancer, 4) genetic counseling and testing for women with ovarian cancer and other high‐risk families, and 5) salpingectomy after childbearing is complete (at the time of elective pelvic surgeries, at the time of hysterectomy, and as an alternative to tubal ligation). The Society of Gynecologic Oncology has determined that recent scientific breakthroughs warrant a new summary of the progress toward the prevention of ovarian cancer. This review is intended to emphasize the importance of the fallopian tubes as a potential source of high‐grade serous cancer in women with and without known genetic mutations in addition to the use of oral contraceptive pills to reduce the risk of ovarian cancer. Cancer 2015;121:2108–2120.

Simple Strategies for Vaginal Health Promotion in Cancer Survivors

INTRODUCTION With the population of cancer survivors nearing 12 million, an ever-increasing number of women will face vaginal health issues related to their disease and/or treatment. Abrupt menopause triggered by cancer treatment, for example, can cause intense and prolonged estrogen deprivation symptoms, including vaginal dryness and discomfort. Simple strategies to promote vaginal health are available. AIMS To provide a comprehensive overview of vaginal health issues caused by estrogen deprivation in female cancer patients/survivors and provide recommendations to identify, treat, and promote vaginal health. METHODS We describe a treatment algorithm, based on scientific literature and supported by clinical experience, found to be effective in treating these patients at two major cancer centers. We also provide examples of handouts for patient education on vaginal health promotion. MAIN OUTCOME MEASURES Evidence-based medicine and psychosocial literature, in addition to clinical experience at two major cancer centers. RESULTS Simple, non-hormonal interventions for sexual dysfunction are often overlooked. Several studies show that education on vaginal lubricants, moisturizers, and dilator use (as needed) can decrease the morbidity of vaginal atrophy. These studies also provide support for our clinical treatment recommendations. Our goal in this article is to increase awareness of these strategies and to provide assistance to general gynecologists and oncologists caring for cancer patients and survivors. CONCLUSIONS Dedicating a small amount of time to educate female cancer survivors about methods to promote vaginal health can result in the reduction or elimination of vaginal discomfort. Non-hormonal vaginal health strategies often appear sufficient to remedy these issues. However, large randomized trials are needed, varying the format and components of the treatment program and exploring efficacy in various groups of female cancer survivors.

Radical vaginal versus abdominal trachelectomy for stage IB1 cervical cancer: A comparison of surgical and pathologic outcomes

OBJECTIVES To compare the surgical and pathologic outcomes utilizing two surgical approaches for fertility-sparing radical trachelectomy in patients with stage IB1 cervical cancer. METHODS A prospectively maintained database of vaginal radical trachelectomy (VRT) and abdominal radical trachelectomy (ART) procedures was analyzed. All procedures were performed in a standardized manner by the same surgical group. Parametrial measurements were recorded from the final pathology report. Standard statistical tests were used. RESULTS Between 12/2001 and 7/2007, 43 adult patients with FIGO stage IB1 cervical cancer underwent surgery with the intent to perform a fertility-sparing radical trachelectomy. VRT was attempted in 28 patients (65%) and ART in 15 patients (35%). The median measured parametrial length in the VRT group was 1.45 cm compared to 3.97 cm in the ART group, P<0.0001. None of the parametrial specimens in the VRT group contained parametrial nodes. Parametrial nodes were detected in 8 (57.3%) of the ART specimens (P=0.0002). There was no difference in histologic subtypes, lymph vascular space invasion, or median total regional lymph nodes removed in the two groups. Median blood loss was greater but not clinically significant in the ART group, and median operating time was less in the ART group. The overall complication rate was not significantly different in the two groups. CONCLUSIONS Using standardized techniques, radical abdominal trachelectomy provides similar surgical and pathologic outcomes with possibly a wider parametrial resection, including contiguous parametrial nodes, as compared to the radical vaginal approach.

Reproductive outcomes of patients undergoing radical trachelectomy for early-stage cervical cancer

OBJECTIVE To report the reproductive outcomes of patients undergoing fertility-preserving radical trachelectomy (RT) for the treatment of early-stage cervical cancer. METHODS We analyzed data from our institutions first 105 patients who underwent attempted fertility-sparing surgery with radical trachelectomy, pelvic lymphadenectomy, and cerclage from November 2001 to October 2010. RESULTS Of the 105 patients who underwent attempted RT, 77 (73%) did not require a conversion to radical hysterectomy or postoperative treatment. The median age was 32 (range, 25-38 years). Most patients (75%) had stage IB1 disease. Sixty-six patients (63%) were nulliparous. Thirty-five women were actively attempting conception 6 months after surgery, and 23 (66%) women were successful in conceiving: there were 20 live births, 3 elective terminations, and 4 spontaneous miscarriages. Four patients had 2 pregnancies each; all delivered their second pregnancy between 32 and 36 weeks. Cerclage erosion through the vaginal wall occurred in 6 cases and was treated by transvaginal removal of protruding suture material. One of these patients experienced a second trimester miscarriage. CONCLUSIONS The majority of women who attempted to conceive after radical trachelectomy were successful, and most of their pregnancies resulted in full-term births. Assisted reproduction played an important role in select women. Cerclage likely contributed to a post-trachelectomy uterine ability to carry a pregnancy to the third trimester. The second post-trachelectomy pregnancy appears to be at higher risk for preterm delivery than the first pregnancy.

Radical trachelectomy for cervical cancer: Postoperative physical and emotional adjustment concerns

OBJECTIVE To investigate the incidence of cervical stenosis and related emotional and sexual adjustment concerns in women treated with radical trachelectomy. METHODS Prospective data of 30 stage I cervical cancer patients enrolled in an ongoing study were evaluated in combination with a medical chart review. RESULTS Eight patients (27%) did not have any stenosis of the neo-cervix postoperatively; 10 (33%) had clinically notable stenosis not requiring neo-cervical dilation to allow adequate sampling; moreover, 12 (40%) had sufficient stenosis requiring a neo-cervical dilation procedure, which proved to be safe and useful. The majority of the dilation procedures (n=8) were conducted under local anesthesia in the office. At preoperative baseline survey, women reported a high rate of sexual inactivity. Fear of intercourse and dyspareunia were reported prior to surgery; however, trends of adjustment and improvement were noted over time postoperatively. Overall, fear of sexual activity tended to lessen if the degree of dyspareunia decreased over time. Postoperative dyspareunia decreased over time, which could have been associated with the mechanical stretching due to vaginal dilator use or dilating benefit of intercourse. CONCLUSION Postoperative concerns associated with radical trachelectomy may be greater than what has been reported in the literature; however, several adjustment trends were noted with intermediate/long-term follow-up. Office cervical dilation is a simple procedure, which is helpful in the management of neo-cervical stenosis. We are currently investigating the value of a physician checklist as a clinical care model to remind medical professionals to monitor and address important survivorship issues.

Sexual Oncology: Sexual Health Issues in Women with Cancer

Sexual problems are widespread among female cancer patients and survivors. Dysfunction may result from various oncologic therapies such as surgery, radiation therapy, chemotherapy, hormonal manipulation, and cytostatic medication. Additionally, psychologic distress that the patient or her partner experiences during diagnosis and treatment of malignancy can impair a healthy female sexual response cycle. A sexual rehabilitation program in an oncology setting is necessary to provide comprehensive care to the cancer patient and her partner. A multidisciplinary treatment approach to sexual dysfunction includes psychological and psychiatric intervention, medical intervention, cognitive behavioral therapy, and recommended lifestyle adjustments. A holistic approach to assessing and treating sexual concerns should be individually tailored to the female patient in light of her disease stage and prognosis, age, marital status, fertility concerns, and social and professional environment.

A cross-sectional study of the psychosexual impact of cancer-related infertility in women: third-party reproductive assistance

IntroductionThis study empirically assessed emotional and sexual functioning, reproductive concerns, and quality of life (QOL) of cancer-related infertile women in comparison to those without a cancer history and explored awareness of third-party reproduction options in cancer survivors.MethodsOne hundred twenty-two cancer survivors (Gynecologic and Bone Marrow/Stem Cell Transplant) with cancer-related infertility and 50 non-cancer infertile women completed a self-report survey assessing: reproductive concerns (RCS), mood (CES D), distress (IES), sexual function (FSFI), menopause (SCL), QOL (SF 12), relationships (ADAS), and exploratory (reproductive options) items.ResultsCancer survivors exhibited greater sexual dysfunction and lower physical QOL than non-cancer infertile women (P < 0.001). No significant group differences were identified for mood (CES-D), mental health QOL (SF-12), reproductive concerns (RCS), and relationship satisfaction (ADAS). All groups scored in the FSFI range of sexual dysfunction, and with RCS scores above published means. Multivariate comparisons showed comparable depression and distress levels for all groups, but cancer survivors had poorer physical QOL [F(5,146)=4.22, P < 0.01]. A significant effect was also found for knowledge of third-party reproductive options on depression and distress levels [F(3,97)=4.62,P < 0.01]. Adjusted means demonstrated higher depression and distress scores for women with perceived unmet informational needs.ConclusionsOverall, loss of fertility was an emotionally challenging experience for women regardless of its cause. Cancer survivors were found to have lower scores of physical QOL and sexual function than non-cancer infertile women. Unmet informational needs about reproductive options appeared to be associated with negative mood and increased distress in cancer survivors.Implications for cancer survivorsTargeted interventions to increase knowledge about reproductive options could be of great assistance to women pursuing parenthood in cancer survivorship. Additionally, intervention studies to improve sexual functioning and QOL in women with cancer-related infertility should be a priority of future research.

The Physical Consequences of Gynecologic Cancer Surgery and Their Impact on Sexual, Emotional, and Quality of Life Issues

INTRODUCTION Surgical management of gynecologic cancer can cause short- and long-term effects on sexuality, reproductive function, and overall quality of life (QOL) (e.g., sexual dysfunction, infertility, lymphedema). However, innovative approaches developed over the past several decades have improved oncologic outcomes and reduced treatment sequelae. AIM To provide an overview of the standards of care and major advancements in gynecologic cancer surgery, with a focus on their direct physical impact, as well as emotional, sexual, and QOL issues. This overview will aid researchers and clinicians in the conceptualization of future clinical care strategies and interventions to improve sexual/vaginal/reproductive health and QOL in gynecologic cancer patients. MAIN OUTCOME MEASURES Comprehensive overview of the literature on gynecologic oncology surgery. METHODS Conceptual framework for this overview follows the current standards of care and recent surgical approaches to treat gynecologic cancer, with a brief overview describing primary management objectives and the physical, sexual, and emotional impact on patients. Extensive literature support is provided. RESULTS The type and radicality of surgical treatment for gynecologic cancer can influence sexual function and play a significant role in QOL. Psychological, sexual, and QOL outcomes improve as surgical procedures continue to evolve. Procedures for fertility preservation, laparoscopy, sentinel lymph node mapping, and robotic and risk-reducing surgery have advanced the field while reducing treatment sequelae. Nevertheless, interventions that address sexual and vaginal health issues are limited. CONCLUSIONS It is imperative to consider QOL and sexuality during the treatment decision-making process. New advances in detection and treatment exist; however, psycho-educational interventions and greater patient-physician communication to address sexual and vaginal health concerns are warranted. Large, prospective clinical trials including patient-reported outcomes are needed in gynecologic oncology populations to identify subgroups at risk. Future study designs need clearly defined samples to gain insight about sexual morbidity and foster the development of targeted interventions.