[Understanding lower gynaecological cancer consultation delay and help-seeking behavior in patients over 65]. / Compréhension du délai de consultation pour les cancers gynécologiques bas chez les patientes âgées de plus de 65 ans.

INTRODUCTION: Delays for consultation of more than six months exist for uterine cancer. Delays in diagnosis of more than five years exist for vulvar cancer. The peak incidence of these neoplasms appear after the age of 65 years. Patient's symptoms are characteristically swelling, vaginal bleeding or itching. This study aims to understand what is happening during this period for women over 65 years old. It also tries to identify triggers during the help-seeking period. METHODS: Qualitative studies using semi-structured interviews with dual analyses (semio-pragmatic and psychodynamic) have been conducted on a population of older (65+) gynaecologic cancer patients, recruited from a French oncology centre. RESULTS: Twelve patients were interviewed. Patients' courses of action were determined by the characteristics of their symptoms, their feelings and their emotions. Representations, subjective beliefs and past experiences were employed to make sense of their symptoms. The patient's friend and family circle had an important role in incentivizing the patient to seek consultation. Multiple factors affected the path towards consulting the doctor. The initial medical contact included several challenges. The patient would consult a doctor earlier if he had more information about his illness and if his relationship with the doctor was better. CONCLUSION: Our findings are similar to those of other cancers. The peculiarity for this population appears to be the different representations of age-related changes in the reproductive system, and the taboo associated with this issue when facing friends and family.

Assessing the Quality of Life in Patients With Endometrial Cancer Treated With Adjuvant Radiotherapy.

OBJECTIVE: The current study evaluates long-term quality of life (QOL) and sexual function of patients with endometrial cancer who received adjuvant pelvic external beam radiotherapy (EBRT) and/or vaginal brachytherapy (BRT). MATERIALS AND METHODS: One hundred forty-four endometrial cancer survivors who were treated between January 2000 and December 2009 in our department were included in this study. Median follow-up was 79 months (range, 31-138 months). Fifty-two patients were treated with 45 to 50.4 Gy EBRT, 76 were with BRT, and 16 were with both EBRT and BRT. Brachytherapy was in the form of vaginal cuff BRT with 5 × 550 cGy high dose rate BRT, prescribed to the first 4 cm and whole wall thickness of vagina. Quality of life was assessed using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 and subscales from the supplemental 24-item Cervical Cancer Module. RESULTS: Vaginal BRT patients reported better physical functioning (P = 0.01), role functioning (P = 0.03), and sexual enjoyment (P = 0.01) compared to EBRT group. Symptom score (P = 0.01), lymphedema (P = 0.03), pain (P = 0.02), and diarrhea (P = 0.009) scores were also higher with EBRT. Vaginal BRT did not worsen symptom scores or sexual functions when added to EBRT. Obese patients experienced higher rates of lymphedema (P = 0.008). Cognitive and role functioning scores were significantly higher in patients with normal body mass index. CONCLUSIONS: External beam radiotherapy negatively affects long-term QOL and sexual functions in endometrial cancer survivors. Vaginal BRT provides higher QOL. Patients with body mass index within normal limits have improved QOL.

Quality of life valuations of HPV-associated cancer health states by the general population.

OBJECTIVES: To obtain health-related quality of life valuations (ie, utilities) for human papillomavirus (HPV)-related cancer health states of vulval, vaginal, penile, anal and oropharyngeal cancers for use in modelling cost-effectiveness of prophylactic HPV vaccination. METHODS: Written case descriptions of each HPV-associated cancer describing the 'average' patient surviving after the initial cancer diagnosis and treatment were developed in consultation with oncology clinicians. A general overview, standard gamble questionnaire for each health state and a quiz was conducted in 120 participants recruited from the general population. RESULTS: In the included population sample (n=99), the average age was 43 years (range = 18-70 years) with 54% men, 44% never married/43% married, 76% education beyond year 12 and 39% employed full-time. The utility values for the five health states were 0.57 (95% CI 0.52 to 0.62) for anal cancer, 0.58 (0.53 to 0.63) for oropharyngeal cancer, 0.59 (0.54 to 0.64) for vaginal cancer, 0.65 (0.60 to 0.70) for vulval cancer and 0.79 (0.74 to 0.84) for penile cancer. Participants demonstrated a very good understanding of the symptoms, diagnosis and treatment of these cancers with a mean score of 9 (SD=1.1) on a 10-item quiz. CONCLUSIONS: This study provides utility estimates for the specific HPV-related cancers of vulval, vaginal, penile, anal and oropharyngeal cancers valued by a general population sample using standard gamble. The results demonstrate considerable quality of life impact associated with surviving these cancers that will be important to incorporate into modelling cost-effectiveness of prophylactic HPV vaccination in different populations.

Sexual morbidity in very long term survivors of vaginal and cervical cancer: a comparison to national norms.

OBJECTIVES: To compare sexuality among very long term survivors of vaginal and cervical cancer to national norms and assess quality of care for sexual problems. METHODS: A survey of survivors in a cancer registry (n=221) provided data comparable to the 1992 National Health and Social Life Survey (NHSLS). The NHSLS sample was individually matched on age and race to survivors at a 2:1 ratio. Responses were compared using conditional logistic regression and two-sample t-tests. Correlates of sexual problems among survivors were analyzed using multivariate logistic regression. RESULTS: Survivors' mean age was 49 years (SD=6.0); median survivorship was 26.8 years (range 5.5-39.7). Survivors and controls reported similar levels of sexual partnership and activity, but sexual problems were significantly more prevalent among survivors (mean number of problems 2.6 versus 1.1, P<0.001). Satisfaction with care for sexual problems was lower than with cancer care overall (5.5 versus 8.0/10, P<0.001). While 74% believed that physicians should discuss sex, 62% reported never discussing the effect of genital tract cancer on sexuality. In adjusted analysis, survivors reporting no such discussion were significantly more likely to exhibit current complex sexual morbidity (> or =3 concurrent sexual problems) (OR 2.74, 95% CI 1.14-6.58). CONCLUSIONS: Despite profoundly more sexual problems, survivors' rate of sexual partnership and activity was similar to population controls. Satisfaction with care relating to sexuality was significantly lower than with cancer care overall. Conversation with a physician about the sexual effects of cancer is associated with significantly lower likelihood of complex sexual morbidity among very long term survivors.

Knowledge of tumor markers and the psychological consequences of tumor marker sampling in patients with gynecologic cancers.

BACKGROUND: The aim of this study was to investigate the extent of knowledge about serum tumor markers in patients suffering from gynecologic cancer. MATERIALS AND METHODS: 360 women with a median age of 60 years (range: 26-88 years) visiting the oncological outpatient clinic of the Department of Gynecology and Obstetrics of the University of Vienna, between February and July 1998, were asked to complete a self-report questionnaire. RESULTS: The majority of patients (85.2%) believed it was important to know about tumor markers and felt safe when they knew the recent level of the tumor marker (71.6%). On the other hand, many patients felt they were insufficiently informed (43%). 88.9% of the patients did not know the recent serum level of the tumor marker. The patients who had been informed by a physician were significantly better informed about tumor markers than women relying on other sources such as nurses, relatives or other patients (p < 0.001). Patients with an age of more than 65 years significantly less frequently knew the meaning of tumor markers (p < 0.001). Fewer women suffering from ovarian cancer were uninformed about tumor markers as compared to women suffering from other malignancies (p < 0.001). CONCLUSION: We conclude that the majority of patients in oncological follow-up are interested in tumor markers and want to be informed about these substances. Periodical serum tumor marker sampling is regarded as a safety measure by patients, but information about tumor markers should be improved.

Life after radiotherapy: the psychological and social effects experienced by women treated for advanced stages of cervical cancer.

PURPOSE: The aim of this study was to describe the psychological and social reactions of women with advanced stages of cancer of the cervix during and after radiotherapy. METHODS: A questionnaire about health-related quality of life was used, which consisted of the EORTC QLQ-C30 and additional specific questions. One-hundred eighteen patients filled out the questionnaire at the end of treatment and 1, 3, 6, 12, 18, and 24 months later. The scores from the disease-free patients were compared to those from 236 healthy controls. RESULTS: Many patients experience psychological and social consequences at the end of treatment and 1 to 3 months later. Patients continue to think about their illness and treatment throughout the 24-month study period, but find it increasingly hard to share their worries with others. Their score on overall quality of life never reaches that of the controls. CONCLUSION: Disease-free patients treated for cancer of the cervix with radiotherapy have psychological reactions. The interpretation of the results should take into consideration that the patients change their personal frame of reference over the course of time. Professionals should be aware of patients' needs to talk about their disease long after treatment. Patients should be informed about the risk of psychological reactions. The more information about possible symptoms they receive the better their ability to cope with them should they arise.

The patients' perspective on physical symptoms after radiotherapy for cervical cancer.

PURPOSE: The aim of this study was to describe the physical symptoms experienced by patients with advanced stages of cervical cancer during the first 2 years after radiotherapy. METHODS: A questionnaire about health-related quality of life was used. It consisted of the EORTC QLQ-C30 and additional specific questions. The patients were assessed at the end of treatment and 1, 3, 6, 12, 18, and 24 months later. The scores from the 118 patients were compared to those from 236 healthy controls. RESULTS: Most patients had acute physical symptoms at the end of treatment and up to 3 months later. Local symptoms such as frequent voiding and diarrhea may become chronic symptoms. CONCLUSION: Assessment of health-related quality of life includes information about milder side effects that is not usually included in physician scoring of morbidity. Information about possible side effects improves the patient's ability to cope with the symptoms should they occur.

The role of the clinical psychologist in gynecological cancer.

Gynecological cancers, which account for a substantial proportion of cancer cases in women, can precipitate a wide range of psychological difficulties including affective disturbances, sexual problems, certain somatic symptoms, and family issues. The clinical psychologist has a unique contribution to make in the assessment and treatment of the psychological needs of gynecological cancer patients, while also conducting research and providing training for health professionals regarding the psychological issues associated with gynecological cancer. Although the gynecological cancer setting affords the clinical psychologist multiple personal benefits, strategies must usually be implemented to minimize any negative impact arising from working in an area of considerable psychological stress.

Primary vaginal cancer.

Vaginal cancer, 2% of all female genital malignancies, has a worse prognosis than cervical cancer. Squamos cell carcinoma, the most common histologic subtype, may be associated partly with human papillomavirus. Most patients present with vaginal bleeding and discharge. Radiation or surgery are the main treatment modalities, but the physical and psychosexual morbidity can be significant.

Factor analysis of medical data of patients with primary and metastatic vaginal cancer.

This study adds up to the series of studies on application of factorial designs to analysis of cancer patients medical data. Namely, besides the information regarding his/her disease, each hospitalized cancer patient also provides the variety of data regarding his/her psychological, cultural, social, economical, genetic, constitutional and medical background. The aim of this particular study was to analyze clinical data in patients with primary and metastatic vaginal cancer and to compare them with the results of factor analytic approach in some other gynecological cancers, namely vulvar and cervical cancer. In this particular study the authors have processed the data regarding 25 characteristics of 200 consecutive patients with primary vaginal cancer and 300 consecutive patients with metastatic vaginal cancer treated between 1980 and 1994 at the Department for Gynecological Oncology of the University Hospital for Gynecology and Obstetrics, Zagreb, Croatia. The results revealed numerous repeating clusters of variable correlations across all four factor analyses in patients with cervical, vulvar, primary and metastatic vaginal cancers.

[Psychoanalysis and cancer. A case report and a hypothesis]. / Psychoanalyse und Krebs. Ein Fallbericht und eine Hypothese.

The psychoanalytic treatment of a 39 year old female cancer patient demonstrates a close connection between psychic factors (cumulative separation trauma, conflict-laden relationship to the mother, oedipal conflicts etc.) and the onset and course of the cancer. After eight years of analytic therapy the cancer symptoms disappeared. The authors formulate the hypothesis that cancer may occur on a primarily somatic or psychic basis.

The detection of depression by patient self-report in women with gynecologic cancer.

We examined the utility of patient self-report forms in identifying those gynecologic oncology patients who would be diagnosed by an experienced consultation-liaison psychiatrist as suffering from major depression. Sixty-five women with gynecologic tumors were evaluated by a consultation-liaison psychiatrist, using standardized (DSM-III) criteria. Each patient also completed a Carroll Rating Scale for Depression (CRS). The CRS demonstrated sensitivity and specificity of 87 percent and 58 percent, respectively. Used as a screening instrument to rule out depression, the CRS yielded a negative predictive value of 94 percent. We identified a priori forty items from the CRS which should not be influenced by the non-psychiatric biologic effects of gynecologic tumors, and compared the performance of this non-cancer related symptoms subscale (NCSG) to that of the CRS. The NCSG did not significantly outperform the CRS; its sensitivity and specificity were 87 percent and 62 percent, respectively. Because our study population was relatively homogeneous (i.e., non-ovarian gynecologic oncology patients without severe debilitation who were not receiving chemotherapy, radiation therapy, or other invasive procedures), the findings should not be generalized to other oncologic populations at this time. Our results suggest that patient self-report forms can be effective screening devices for identifying those non-ovarian, gynecologic oncology patients who should then be carefully evaluated for coexisting clinical depression.

[Cultural identification of patients with sexually transmitted diseases]. / Identificazione culturale dell'affetto da M.S.T.

The authors considered psychological problems concerning the communication to patients about a diagnosis of Sexual Transmitted Disease and particularly of HPV disease. In the past this sort of affection was related to some well identified social groups, but with the recent changes in sexual behavior, cultural and moral principles, the reference models are changed too. Consequently today it is difficult to recognize a rigid identification. However it is still possible that during the communication of the diagnosis the physician unconsciously transfers to the patient "his" classification with a given model among the groups of STD affected. This is particularly true for the gynecologist that is reporting on HPV infection or disease. Therefore the physician has to pay a great attention to the way he communicates, because in addition to the clinical concept there are psychological effects on the patient and on her relationships that could result iatrogenic.