Objective
The purpose of this study was to assess the prevalence of pelvic floor disorders and sexual function in survivors of gynecologic cancer.
Study Design
We surveyed survivors of gynecologic cancer (survivors) and women seeking gynecologic care (control patients) who were >30 years old. All survivors were disease- and treatment-free for ≥1 year. Validated questionnaires were used to evaluate pelvic floor disorders.
Results
One hundred eight control patient and 260 survivor questionnaires were completed. A high prevalence of pelvic floor disorders was observed in both groups; 56% of control subjects and 70% of survivors reported moderate to severe urinary incontinence ( P > .05). Survivors were more likely to experience fecal incontinence (42% vs 32%; P = .02). Survivors reported less sexual desire ( P = .04) and less ability to climax ( P = .04), despite no difference in dyspareunia.
Conclusion
Fecal incontinence and sexual dysfunction are significant problems in survivors of gynecologic cancer.
Survivors of cancer number approximately 10 million in the United States. With an increasing aged population, this number will continue to grow. As cancer treatment improves, cancer survivor’s quality of life and long-term health outcomes have gained increasing importance with health care providers. Cancer survivorship crosses all aspects of patient health, which includes a patient’s physical, emotional, occupational, and social well-being. In 2007, approximately 78,000 women were diagnosed with gynecologic cancer, which included uterine, cervical, ovarian and vulvar malignancies.
Many therapeutic advances for gynecologic cancer have evolved within the last 20 years and have led to improved quality of life during and immediately after either surgical or medical treatments. Some advances, such as the introduction of chemoradiation for lower genital tract cancers and improvements in radiation technique for a variety of gynecologic malignancies, have also improved survival rates for women with gynecologic malignancies. Minimally invasive surgical approaches for both cervical and endometrial cancer have enhanced the patient’s perioperative quality of life and decreased operative morbidity. Introduction of less radical vulvar cancer surgery has likewise decreased perioperative morbidity with improved long-term outcomes. Nonetheless, often the same treatment that offers a cure for the cancer leads to long-term side-effects that can diminish a survivor’s quality of life. The growing number of survivors of cancer presents a challenge for providers of women’s healthcare to think beyond cancer treatment and start considering the needs and issues that will enhance the quality of life for those women who live beyond cancer.
One important aspect of quality of life that is directly impacted by gynecologic cancer and treatment is pelvic floor function. Common pelvic floor disorders include pelvic organ prolapse, urinary incontinence (UI), anal incontinence, and sexual dysfunction. These disorders are known to affect quality of life negatively and, despite high prevalence, are under assessed in survivors of gynecologic cancer. Our knowledge of how prevalent pelvic floor disorders are in survivors of gynecologic cancer and how the cancer treatment influences these problems is limited. Our study objectives are to assess the prevalence of pelvic floor disorders and sexual dysfunction in survivors of gynecologic cancer compared with women at a general gynecology clinic who had no history of a gynecologic cancer.
Materials and Methods
This study was performed at the University of New Mexico Health Sciences Center through the Department of Obstetrics and Gynecology. Institutional review board approval was obtained. Our control patients were women at a general gynecology clinic who were ≥30 years old without a diagnosis of cancer. Our survivors of gynecologic cancer were women who attended the gynecologic oncology clinics for routine surveillance visits who were ≥30 years old and had a history of uterine, cervical, ovarian, or vulvar cancer. No women attending the urogynecology clinic were enrolled into either study group. All survivors had been disease- and treatment-free for at least 1 year.
Written consent was not required because this was an anonymous survey. All eligible patients were offered participation in the survey during clinic visits. The study was conducted over a 10-month time period. Clinic schedules were screened for eligible patients, and every attempt was made to offer the survey to all eligible patients. Eligible women were asked to complete the survey at the time of their doctor’s visit. The survey included demographic information and medical/surgical information. Survivors of cancer provided recall data regarding their cancer diagnosis and treatment. Validated questionnaires measured UI severity with the Sandvik Incontinence Severity Index, anal incontinence with the Wexner Fecal Incontinence scale, pelvic organ prolapse with question #35 from the Epidemiology of Prolapse and Incontinence Questionnaire, and sexual function with the Pelvic Organ Prolapse/Urinary Incontinence Sexual questionnaire (PISQ-12).
The Sandvik Incontinence Severity Index is a 2-question symptom severity scale that measures the presence and amount of urinary leakage. The Sandvik Incontinence Severity Index has been validated against pad weights and urinary diaries of incontinent women. Presence of any UI is defined as a score of >0. Moderate-to-severe UI is defined as a score of ≥3.
The Wexner Fecal Incontinence Scale measures the presence and severity of anal incontinence symptoms. The scale records both the type (gas, mucus, liquid, solid stool) and frequency of anal incontinence symptoms. Presence of anal incontinence is defined as a score of >0. Fecal incontinence in our study is specific to leakage of liquid or solid stool and not gas incontinence.
The presence of prolapse was defined as an affirmative answer to question #35 from the Epidemiology of Prolapse and Incontinence Questionnaire. This question was also used by Lukacz et al and Nygaard et al in assessments of pelvic floor disorders and was found to indicate severe symptoms.
Finally, the Pelvic Organ Prolapse/Urinary Incontinence Sexual questionnaire (PISQ-12) was used to assess sexual function in our study. The questionnaire consists of 12 questions, 9 of which are not specific to women with pelvic floor disorders. Use of the 9 general questions allows for comparison of function in women with and without pelvic floor disorders. We also included a question in the survey to evaluate how often providers ask patients about pelvic floor disorders during their care.
Two hundred fifty survivors of gynecologic cancer and 100 gynecologic patients were required to detect a 20% difference in the rates of UI between groups, with an alpha error of .05 and a beta of 80%. UI is the most common pelvic floor disorder and has been reported previously in the literature, although rates of anal incontinence, prolapse, and sexual dysfunction have been studied more poorly among survivors of cancer. Statistical analysis included descriptive statistics, Student t tests, and Fisher’s exact tests, as appropriate to compare the groups. PISQ scores were adjusted for possible differences in baseline values with the use analysis of covariance. Multivariable logistic regression analysis was used to verify whether variables that differed between groups were covariates. Data analysis was performed with SAS/STAT software (SAS Institute Inc, Cary, NC).
Results
One hundred eight gynecologic patients and 260 cancer survivor questionnaires were completed. Demographic data are summarized in Table 1 . Survivors of cancer were older (57 ± 12 vs 47 ± 10 years; P < .001) and were more likely to be in a committed relationship (46% vs 34 %; P = .04) but did not differ from control patients with respect to race, except there were more Native American women in the cancer survivor group (16 vs 8%; P = .03), which demonstrated the referral pattern for cancer care in New Mexico. Survivors of cancer were also more likely to have undergone hysterectomy (87 vs 26%; P < .001) and bilateral oophorectomy (82% vs 14%; P < .001). Parity was similar between the control and the survivor groups, with a mean number of children (n = 2) in both groups. Given the known effects of age, hysterectomy, and menopausal status on pelvic floor disorders, all differences described later were controlled for in multivariate analyses.
| Variable | Gynecologic patients (n = 108) | Survivors of gynecologic cancer (n = 260) | P value |
|---|---|---|---|
| Age, y a | 47 ±10 | 57 ± 12 | < .001 |
| High school education, % | 72 | 61 | .05 |
| Partner, % | 34 | 46 | .04 |
| Native American, % | 8 | 16 | .03 |
| Household income >$10,000, % | 55 | 50 | NS |
| Parity, n b | 2.2 (0–9) | 2.2 (0–12) | NS |
| Nulliparous, % | 22 | 25 | NS |
| Menopause, % | 36 | 83 | < .001 |
| Hysterectomy, % | 26 | 87 | < .001 |
| Bilateral oophorectomy, % | 14 | 82 | < .001 |
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