Sexual dysfunction and other distressful symptoms in cervical cancer survivors

Background: The majority of cervical cancer survivors are young or middle-aged women who will live many years with their treatment-induced sequelae. The effects of preoperative brachytherapy are unclear and treatment traditions vary - in Sweden and internationally. The relative occurrence of long-term distressful symptoms related to different treatments and the extent to which the women want to trade off optimal survival chances are not known.

Methods: The effects of radical hysterectomy were studied in a comparison with population controls, and the effects of additional brachytherapy could be studied due to various treatment policies at different centres. We used an anonymous postal questionnaire, studying the nature, occurrence and intensity of the symptoms and, separately, the corresponding symptom-induced distress.

Results: We obtained information from 256 of 332 (77%) cervical cancer survivors and 350 of 495 (72%) population controls. Radical hysterectomy alone caused insufficient lubrication (relative risk [RR] 2.8 as compared to controls), reduced genital swelling at arousal (RR 1.5), reduced vaginal length (RR 6.1) and vaginal elasticity (RR 7.1), dyspareunia (RR 4.4), straining to void (RR 21.8), lymphoedema (RR 8.1) and distress from vaginal changes (RR 3.0). The addition of preoperative brachytherapy yielded RR 3.1 for defecation urgency, RR 8.5 for frequent nocturia and RR 1.6 for moderate and severe anxiety, but no excess risk concerning vaginal changes. The addition of external radiotherapy yielded, e.g., RR 13.1 for frequent nocturia and RR 4.8 for frequent defecation. A history of sexual abuse and cervical cancer gave RR 30.0 for superficial dyspareunia as compared to population controls with no history of sexual abuse. The majority of women were not prepared to forgo brachytherapy (even at a possible risk of 1% decreased survival) to avoid its long-term side effects.

Conclusion: Sexual dysfunction is the most distressful symptom in cervical cancer survivors, thus emphasising efforts to avoid it and interventions to relieve it. The excess risk of distressful treatment- induced symptoms from preoperative brachytherapy is low, if any, and the majority of women prioritise optimal survival over freedom from treatment-induced symptoms. To meet the needs of women with early cervical cancer, a valid (randomised) study of the effects of preoperative brachytherapy is warranted. The long-term situation for cervical cancer survivors can be improved by clinical application of the data from this and other studies, and a number of areas for future research that may better the situation even more have been specified.

List of scientific papers

I. Bergmark K, Avall-Lundqvist E, Dickman PW, Henningsohn L, Steineck G (1999). Vaginal changes and sexuality in women with a history of cervical cancer. N Engl J Med. 340(18): 1383-9.
https://pubmed.ncbi.nlm.nih.gov/10228188

II. Bergmark K, Avall Lundqvist E, Dickman PW, Henningsohn L, Steineck G (2002). Patient-rating of distressful symptoms after treatment for early cervical cancer. Acta Obstetrica et Gynecologica Scandinavica. [Accepted]

III. Bergmark K, Avall Lundqvist E, Dickman PW, Henningsohn L, Steineck G (2002). Long-term symptom prevalence after radical hysterectomy for early cervical cancer and among population controls. [Submitted]

IV. Bergmark K, Avall Lundqvist E, Dickman PW, Henningsohn L, Steineck G (2002). Distressful symptoms in cervical cancer survivors after radical hysterectomy with or without preoperative brachytherapy. [Submitted]

V. Bergmark K, Avall Lundqvist E, Dickman PW, Henningsohn L, Steineck G (2002). Sexual abuse: Long-term effect on sexuality and well-being, and relation to cervical cancer. [Submitted]

VI. Steineck G, Bergmark K, Henningsohn L, al-Abany M, Dickman PW, Helgason A (2002). Symptom documentation in cancer survivors as a basis for therapy modifications. Acta Oncologica. [Accepted]