Marjan J. Traa

Sexual (dys)function and the quality of sexual life in patients with colorectal cancer: a systematic review

BACKGROUND To determine (i) the prevalence of sexual (dys)function in patients with colorectal cancer and (ii) treatment-related and sociodemographic aspects in relation to sexual (dys)function and the quality of sexual life. Recommendations for future studies are provided. METHODS A systematic search was conducted during the period 1990 to July 2010 that used the databases PubMed, PsychINFO, The Cochrane Library, EMBASE, and OVID Medline. RESULTS Eighty-two studies were included. The mean quality score was 7.2. The percentage of preoperatively potent men that experienced sexual dysfunction postoperatively varied from 5% to 88%. Approximately half of the women reported sexual dysfunction. Preoperative radiotherapy, a stoma, complications during or after surgery, and a higher age predicted more sexual dysfunction with a strong level of evidence. Type of surgery and a lower tumor location predicted more sexual dysfunction with a moderate level of evidence. Insufficient evidence existed for predictors of the quality of sexual life. Current studies mainly focus on biological aspects of sexual (dys)function. Furthermore, existing studies suffer from methodological shortcomings such as a cross-sectional design, a small sample size, and the use of nonstandardized measurements. CONCLUSIONS Sexuality should be investigated prospectively from a biopsychosocial model, hereby including the quality of sexual life.BACKGROUND To determine (i) the prevalence of sexual (dys)function in patients with colorectal cancer and (ii) treatment-related and sociodemographic aspects in relation to sexual (dys)function and the quality of sexual life. Recommendations for future studies are provided. METHODS A systematic search was conducted during the period 1990 to July 2010 that used the databases PubMed, PsychINFO, The Cochrane Library, EMBASE, and OVID Medline. RESULTS Eighty-two studies were included. The mean quality score was 7.2. The percentage of preoperatively potent men that experienced sexual dysfunction postoperatively varied from 5% to 88%. Approximately half of the women reported sexual dysfunction. Preoperative radiotherapy, a stoma, complications during or after surgery, and a higher age predicted more sexual dysfunction with a strong level of evidence. Type of surgery and a lower tumor location predicted more sexual dysfunction with a moderate level of evidence. Insufficient evidence existed for predictors of the quality of sexual life. Current studies mainly focus on biological aspects of sexual (dys)function. Furthermore, existing studies suffer from methodological shortcomings such as a cross-sectional design, a small sample size, and the use of nonstandardized measurements. CONCLUSION Sexuality should be investigated prospectively from a biopsychosocial model, hereby including the quality of sexual life.

Higher prevalence of sexual dysfunction in colon and rectal cancer survivors compared with the normative population: A population-based study

BACKGROUND To compare colorectal cancer survivors with a normative population regarding erectile dysfunction, ejaculation problems, dyspareunia, dry vagina, sexual functioning (SF) and enjoyment (SE). In addition, the sociodemographic, clinical and psychological correlates of (dys)function in survivors are examined. PATIENTS AND METHODS The European Organisation for Research and Treatment of Cancer (EORTC) QLQ-CR38 sexuality subscales were completed by survivors (n=1371; response rate 82%), of which 1359 received surgical treatment and were included in the analysis. The normative population consisted of 400 participants (response rate 78%). RESULTS Erectile problems were more often present in rectal cancer (54%) than colon cancer survivors (25%) and the normative population (27%; p<.0001). They also had more ejaculation problems (68%) than colon cancer survivors (47%; p<.001). Dry vagina was common in colon (28%) and rectal cancer survivors (35%), while the normative population scored lower (5%; p=.003). In addition, colon (9%) and rectal cancer survivors (30%) experienced more pain during intercourse than the normative population (0%; p=.001). SE for men was similar across groups, while women with colorectal cancer reported lower scores than the normative population. Higher age, being a woman, not having a partner, a low educational level, rectal cancer, depressive symptoms and fatigue were associated with lower SF. Lower SE was associated with higher age and being a woman, depressive symptoms and cardiovascular disease. CONCLUSION SF was deteriorated in both sexes after cancer, which affected womens SE negatively. Attention towards sexual (dys)function in colorectal cancer survivors is needed.

The sexual health care needs after colorectal cancer: the view of patients, partners, and health care professionals

PurposeSexual dysfunction among patients with colorectal cancer is frequently reported. Studies examining patients’ sexual health care needs are rare. We examined the sexual health care needs after colorectal cancer treatment according to patients, partners, and health care professionals (HCPs). Factors that impede or facilitate the quality of this care were identified.MethodParticipants were recruited from three Dutch hospitals: St. Elisabeth, TweeSteden, and Catharina hospitals. Patients (n = 21), partners (n = 9), and 10 HCPs participated in eight focus groups.ResultsIt is important to regularly evaluate and manage sexual issues. This does not always occur. Almost all participants reported a lack of knowledge and feelings of embarrassment or inappropriateness as barriers to discuss sexuality. HCPs reported stereotypical assumptions regarding the need for care based on age, sex, and partner status. The HCPs debated on whose responsibility it is that sexuality is discussed with patients. Factors within the organization, such as insufficient re-discussion of sexuality during (long-term) follow-up and unsatisfactory (knowledge of the) referral system impeded sexual health care. The HCPs could facilitate adequate sexual health care by providing patient-tailored information and permission to discuss sex, normalizing sexual issues, and establishing an adequate referral system. It is up to the patients and partners to demarcate the extent of sexual health care needed.ConclusionsOur findings illustrate the need for patient-tailored sexual health care and the complexity of providing/receiving this care. An adequate referral system and training are needed to help HCPs engage in providing satisfactory sexual health care.

Measuring the health-related quality of life and sexual functioning of patients with rectal cancer : Does type of treatment matter?

The literature on the health‐related quality of life (HRQOL) after rectal cancer is growing, however, a comparison between patients with nonadvanced disease (NAD), locally advanced rectal cancer (LARC), locally recurrent rectal cancer (LRRC) and a normative population has not been made. Data on the sexual functioning of patient groups is also scarce. We compared (i) the HRQOL of patients with NAD, LARC, or LRRC, with a special focus on sexual functioning and (ii) the HRQOL of the three treatment groups with a normative population. The EORTC QLQ‐C30 and QLQ‐CR38 were completed by 80 patients with NAD, 292 LARC patients and 67 LRRC patients. The normative population (n = 350) completed the EORTC QLQ‐C30 and the Sexual Functioning and Sexual Enjoyment scales of the CR38. LRRC patients reported a lower Physical Function, Social Function, Future Perspective, Sexual Functioning and more Pain compared with LARC and NAD patients. Also, LRRC patients had a worse Body image than NAD patients and a lower Male Sexual Functioning than LARC patients. More than 75% of men and 50% of women were sexually active preoperative, compared with less than 50% and less than 35% postoperative. Male LRRC patients had more problems with erectile or ejaculatory functioning and felt less masculine than NAD or LARC patients. Women did not differ on Lubrication, Dyspareunia and Body Image. About 10% of patients used aids in order to improve erectile functioning (men) or lubrication (women). The treatment groups reported a lower HRQOL and sexual functioning compared with the normative population.

The Preoperative Sexual Functioning and Quality of Sexual Life in Colorectal Cancer: A Study among Patients and Their Partners

INTRODUCTION Even though the body of literature on sexual functioning is growing, information on the preoperative sexual functioning and the quality of sexual life after colorectal cancer is lacking. Research focusing on female patients and on partners is also rather scarce. AIM This cross-sectional study aimed to describe the preoperative sexual functioning, quality of sexual life, and relationship functioning for male and female colorectal cancer patients and their partners. In addition, the mean scores of the patients and partners were compared with mean norm scores. METHODS Patients diagnosed with colorectal cancer (N = 136) and their partners (N = 106) were recruited before surgical treatment in six Dutch hospitals. MAIN OUTCOME MEASURES Men completed the International Index of Erectile Functioning, while women completed the Female Sexual Function Index. All partnered participants completed the Golombok-Rust Inventory of Sexual Satisfaction and the Maudsley Marital Questionnaire. The mean scores were compared with mean norm scores derived from the manuals of the questionnaires. RESULTS All participants were in a heterosexual relationship. Female patients reported a lower quality of sexual life compared with male patients. Male partners reported a lower sexual functioning and a lower quality of sexual life compared with male patients. Colorectal cancer patients and partners (both sexes) reported a lower sexual functioning and a lower quality of sexual life compared with norm populations but scored similar on relationship functioning. CONCLUSION A lower sexual functioning and a lower quality of sexual life are already reported preoperatively; however, relationship functioning was comparable with a norm population. Therefore, all the impairment seen after treatment should not be solely attributed to the effects of treatment.

Dynamic Article: Vaginal and Perineal Reconstruction Using Rectus Abdominis Myocutaneous Flap in Surgery for Locally Advanced Rectum Carcinoma and Locally Recurrent Rectum Carcinoma

BACKGROUND: Surgery for locally advanced and recurrent rectal carcinoma sometimes requires partial resection of the perineum and/or vagina necessitating subsequent reconstruction. OBJECTIVE: The aim of this study was to describe the surgical and functional outcomes of reconstructing the vagina and/or the perineum by using the vertical rectus abdominis myocutaneous flap and to evaluate the health status of patients who received reconstruction. DESIGN: This is a retrospective cohort study. SETTINGS: This study was conducted at a tertiary referral hospital for locally advanced and recurrent rectal cancer. PATIENTS: Patients receiving multimodality treatment for primary or recurrent locally advanced rectal carcinomas were included. MAIN OUTCOME MEASURES: First, the surgical outcome was assessed. Second, 10 female patients who received vaginal reconstruction underwent a gynecological examination including biopsies. Finally, quality of life was assessed and compared with patients who underwent treatment for rectal carcinoma without a reconstruction. RESULTS: Fifty-one patients underwent reconstruction of the dorsal vagina and/or the perineum with the use of a vertical rectus abdominis myocutaneous flap. In 13 patients, the flap was used to close a perineal defect; in 26 patients, to close a vaginal defect; and in 12 patients, to close both. In 3 patients, partial necrosis of the flap occurred that was treated conservatively. In 4 patients, stenosis of the introitus occurred, as found in the gynecological examination. Biopsies confirmed epithelialization of the vaginal wall. All groups reported good functioning and low symptom burden. After vaginal reconstruction, women reported equal or higher scores on global health status, emotional functioning, and body image. LIMITATIONS: The lack of information on the health status of the patients before the start of treatment prohibits making causal inferences in health status over time. DISCUSSION: Reconstruction of the perineum and/or dorsal vagina was successful in all patients. Surgeons and gynecologists who use the vertical rectus abdominis myocutaneous flap should be aware of stenosis of the vaginal introitus. Gynecological consultation at an early stage should be standard.

Biopsychosocial predictors of sexual function and quality of sexual life: a study among patients with colorectal cancer

Objective A low sexual function (SF) has been reported in patients with colorectal cancer. However, research often focusses on clinical predictors of SF, hereby omitting patients’ subjective evaluation of SF [i.e., the quality of sexual life (QoSL)] and psychosocial predictors of SF and QoSL. In addition, research incorporating a biopsychosocial approach to SF and QoSL is scarce. Therefore, this study aimed to evaluate (I) relatedness between SF and the QoSL, (II) the course of SF and QoSL, and (III) biopsychosocial predictors of SF and QoSL. Methods Patients completed questionnaires assessing sociodemographic factors (i.e., age, sex) and personality characteristics (i.e., neuroticism, trait anxiety) before surgery. Questionnaires assessing psychological (i.e., anxious and depressive symptoms, body image, fatigue) and social (i.e., sexual activity, SF, non-sensuality, avoidance of sexual activity, non-communication, relationship function) aspects were measured preoperative and 3, 6, and 12 months after surgery. Clinical characteristics were obtained from the Eindhoven Cancer Registry (ECR). Bivariate correlations evaluated relatedness between SF and QoSL. Linear mixed-effects models examined biopsychosocial predictors of SF and QoSL. Results SF and QoSL are related constructs (r=0.206 to 0.642). Compared to preoperative scores, SF did not change over time (P>0.05). Overall, patients’ QoSL decreased postoperatively (P=0.001). A higher age (β=−0.02, P=0.006), fatigue (β=−0.02, P=0.034), not being sexually active (β=−0.081, P<0.001), and having a stoma (β=0.37, P=0.035) contributed to a lower SF. Having rectal cancer (β=−1.64, P=0.003), depressive symptoms (β=−0.09, P=0.001), lower SF (β=1.05, P<0.001), and more relationship maladjustment (β=−0.05, P=0.027) contributed to a lower QoSL (P<0.05). In addition, partners’ SF (β=0.24, P<0.001) and QoSL (β=0.30, P<0.001) were predictive for patients’ SF and QoSL, respectively. A significant interaction between time and gender was reported for both outcomes (P’s=0.002). Conclusions SF and QoSL are related but distinctive constructs. The course of SF and QoSL differed. Different biopsychosocial predictors were found for SF and QoSL. The contribution of partner-related variables to patients’ outcomes suggests interdependence between patients and partners. Men and women showed different SF and QoSL trajectories. We recommend that health care professionals, when discussing sexuality, realize that SF and QoSL are no interchangeable terms and should, therefore, be discussed as two separate entities. In addition, it is favored that clinicians focus not only on biological predictors of SF and QoSL, but obtain a broader perspective in which they also pay attention to psychosocial factors that may impair SF and QoSL. More in depth research on interdependence between patients and partners, biopsychosocial predictors of partners’ SF and QoSL, and gender effects is needed.

Sexual, marital, and general life functioning in couples coping with colorectal cancer: a dyadic study across time

This study evaluated the following: (a) levels of sexual, marital, and general life functioning for both patients and partners; (b) interdependence between both members of the couple; and (c) longitudinal change in sexual, marital, and general life functioning and longitudinal stress‐spillover effects in these three domains from a dyadic perspective.

Psychosocial consequences of diagnosis and treatment of lung cancer and evaluation of the need for a lung cancer specific instrument using focus group methodology

ObjectivesPatients with lung cancer (LC) have high rates of psychosocial symptoms and international guidelines recommend regular psychosocial screening during treatment. This study evaluates psychosocial consequences of diagnosis and treatment of LC in a qualitative way and evaluates the need for a LC specific screening instrument.MethodsFocus group meetings with LC patients were divided by treatment type. Patients discussed psychological and social consequences of diagnosis and treatment. Major themes were identified using content analysis. Themes were re-evaluated in a subsequent focus group, in accordance with the European Organization for Research and Treatment of Cancer (EORTC) guidelines.ResultsPatients reported a range of psychosocial consequences, such as frustration due to physical limitations, fear of recurrence, sadness of leaving behind partner and children, and disappointing social support. Patients treated with palliative intent specifically indicated insecurities about the future. Patients from all treatment modalities indicated a need for family support during treatment. No themes specific to LC arose.ConclusionsPatients with LC are coping with a range of psychosocial consequences, independent of the type of treatment they receive. Fear of recurrence/metastasis and insecurity about the future were more prominent in patients receiving palliative chemotherapy. Themes were not specific to LC; therefore, a screening instrument specific for the LC population does not seem required. However, the current standard for screening is considered insufficiently sensitive and a stepped screening approach with specific screening tools and a clinical interview is suggested as usual care.

The Sexual Consequences of Cancer Surgery

Sexual problems can be present before being diagnosed with cancer but can also develop or aggravate after diagnosis (see Chap. 9), during treatment (see Chaps. 10, 11, 12 and 13), or after treatment. Sexual problems can develop even if the reproductive organs are not involved in treatment. For most cancer types or stages, surgery is an important part of the multidisciplinary treatment. In order to increase the probability that a radical resection can be performed, and sometimes even allow more limited surgery, radiotherapy and/or chemotherapy can precede surgery. After surgery, some patients require additional chemotherapy in order to reduce the risk of developing a local occurrence or metastatic disease. This chapter provides a general overview of the sexual consequences of cancer surgery across time. Some examples are shown in Table 12.1, though a more detailed description of cancer-type-specific consequences are presented in Chaps. 15, 16, 17, 18, 19, 20, 21, 22 and 23.