Transcript Addressing the psychological aspects of gynecologic cancer

Psychological Aspects of GYN
Cancer Survivorship
Sharon L. Bober, Ph.D.
Director, Sexual Health Program
Dana-Farber Cancer Institute
Assistant Professor, Dept. of Psychiatry
Harvard Medical School
Boston, MA
November 4, 2016
No Disclosures

I, Sharon Bober, have been asked to disclose any
significant relationships with commercial entities that
are either providing financial support for this program
or whose products or services are mentioned during my
presentations.

I have no relationships to disclose (or disclose
relationships).

I may discuss the use of vaccines in a manner not
approved by the U.S. Food and Drug Administration,
but in accordance with ACIP recommendations.
Survivorship- What do we mean?
• Survivorship has different definitions; typically thought
about as living with, through and beyond cancer.
• “Survival…begins at the point of diagnosis, because that is
the time when patients are forced to confront their own
mortality and begin to make adjustments that will be part of
their immediate and to some extent, long-term future.”
-
F. Mullan, 1985, New Eng J Med
• Good news: majority of GYN cancer patients will become
long-term cancer survivors; currently close to 250,000
cervical CA survivors in US.
After Treatment…Quality of Life
•
However, “survivorship” is a complicated phase of care.
When treatment ends, survivors face mix of feelings
including joy, concern, relief, uncertainty, guilt and fear.
•
Unfortunately, impact of treatment for cervical cancer can
negatively impact quality of life for years after treatment (Park
•
et al, Cancer, 2007, Wenzel, Cancer 2008)
•
On-going concerns after treatment ends can include:
Physical changes/Loss of Fertility
Emotional/psychological changes
Difficulty re-establishing social/family roles
Financial/occupational changes & burdens
Unique Burdens after Cervical CA

Cervical cancer survivors face loss of fertility, sexual
dysfunction and changes in body image and self-esteem.

Survivors also may struggle with guilt/blame/stigma
because:

Cervical cancer is largely thought of as “preventable”

There is effective screening/ “should” have been caught earlier

The associations with sexually transmitted virus
Hobbs, CA Forum, 2008
Psychosexual Distress after Cervical CA
Young survivors are often left with distressing changes
related to:
 Self-concept
◦ Loss of self-confidence, perceived loss of femininity

Body image
◦ Experience of accelerated aging, perceived loss of attractiveness

Sexuality/Sexual function
◦ Pain, Diminished arousal and desire

Reproductive capacity
◦ Loss of fertility
The majority of GYN cancer survivors are never asked
about these experiences and do not receive
education/support to address these issues (Pfaendler et al,
Clin Ther, 2015)
Sexual Health and Cervical Cancer
•
Sexual dysfunction is one of most common, enduring and
distressing consequence of cervical cancer treatment
•
Sexual health is often one of the first aspects of“normal”life to
be disrupted
•
Majority of survivors say they were not fully prepared for dealing
with changes in sexual function (Matloff & Bober 2009, Elit et al, 2001)
•
74-95% of women after GYN cancers have severe, long-lasting
sexual problems (Ganz, 1998, 1999).
Treatment-Induced Menopause…
•
Tx-induced menopause can be dramatic; symptoms often
more severe, less predictable and longer-lasting than
natural menopause.
•
Hot flashes, Night flushes, Sleep changes, Fatigue
•
Vaginal dryness, burning, itching, chafing → Pain
•
Decreased Arousal/Difficulty Reaching Orgasm
•
Decreased androgen levels/decreases in desire
(Schover, 2000, Partridge 2004, 2008)
Common Sexual Dysfunction Related to
Treatment
•
Narrowing of the vagina from radiation therapy  Pain
with sexual activity
•
Decreased physical response, arousal
•
Difficulty reaching orgasm
•
Decreased interest & low desire
•
Bladder and bowel dysfunction  body image/self-esteem
•
Relationship issues related to changes in sexual function,
changes in desire and decreased communication.
Risk Factors to Keep in Mind
Risk factors associated with negative psychological outcomes:
Radiotherapy or multi-modal therapies for treatment
• Increased duration of treatment
• Young age
• Relationship status: single women and women in unstable
relationships
• History of depression
• Sub-optimal coping styles (disengaged, avoidant, denial)
(Pearman, Health Qual Life, 2003;
•
Wentzel, JCO, 2005)
Support and Treatment
Psychological distress and tx-related sexual dysfunction can
be treated!

Survivors need to be asked if they are experiencing any
bothersome changes in sexual health or sexual function
◦ “Many women who have gone through this treatment notice changes in
sexual function, has that happened to you?”
◦ “Changes in sexual function and body image are common after GYN
cancer, is that something you have experienced?”

Need for inquiry as to whether women are experiencing any
kind of distress that is bothersome or getting in the way of
normal function and ask if they want some support.
‘This is the price I had to pay…”

Women often do not know that sexual dysfunction such
can be treated/improved!
◦ Women need instructions/coaching for how to use
vaginal dilators, vaginal moisturizers, pelvic floor
exercises and personal products.

Psychological distress needs to be addressed!

Critical to empower patients & provide
education/information as needed

Our responsibility as clinicians to have
resources/referral sources available for women
◦ Counseling, group support, written resources, appropriate referrals
Resources are available!

http://www.macmillan.org.uk/information-andsupport/coping/relationships/your-sex-life-and-sexuality

http://www.cancer.org/treatment/treatmentsandsideeffects/phy
sicalsideeffects/sexualsideeffectsinwomen/sexualityforthewoman
/sexuality-for-the-woman-with-cancer-toc

https://www.livestrong.org/we-can-help/finishingtreatment/female-sexual-health-after-cancer
DFCI Sexual Health Program
Mission: To help patients restore healthy sexual functioning as
an integral part of overall survivorship care.
The SHP is a multi-disciplinary clinic that incorporates
medical and behavioral approaches to successfully treat
sexual dysfunction after cancer. The SHP aims to develop,
evaluate and disseminate practical programs of sexual
rehabilitation for a wide range of cancer survivors.
[email protected]