Sexual Difficulties after Pelvic Radiotherapy: Improving Clinical Management.

Modern multimodality cancer treatment has led to more than 2 million people living with and beyond cancer in the UK, an impressive survival statistic on which clinicians and services continue to build. However, what is less readily acknowledged by health professionals and patients alike are the 500,000 people whose daily lives are adversely affected by the longer term consequences of cancer treatment. Macmillan Cancer Support estimate as many as 350,000 people in the UK experience sexual consequences of cancer and its treatment, an aspect of survivorship and rehabilitation that receives relatively scant attention in service provision, policy development and research terms. This overview addresses the sexual impact of radical pelvic radiotherapy for the more common (prostate, ano-rectal, cervical and endometrial) adult malignancies. Through discussion of the clinical assessment and management of desire, arousal, orgasmic and sexual pain difficulties that arise after pelvic radiotherapy, this overview offers an integrated biopsychosocial model of practice that incorporates the physical, psychological and relationship elements of these treatment sequelae. It is important that clinicians raise the profile of the sexual consequences of cancer treatment as a legitimate aspect of survivorship and service provision. Only in this way can the identification and management of treatment-induced sexual difficulties, frequently experienced by patients and their partners, be better understood and managed. Increased focus on the sexual consequences of treatment and cancer survivorship more broadly may, in time, lead to greater clinical recognition, service development and, most importantly, increased research devoted to the effective management of what remains a neglected aspect of cancer care.

Development of UK guidance on the management of erectile dysfunction resulting from radical radiotherapy and androgen deprivation therapy for prostate cancer.

AIM: To develop a management strategy (rehabilitation programme) for erectile dysfunction (ED) after radiotherapy (RT) or androgen deprivation therapy (ADT) for prostate cancer that is suitable for use in a UK NHS healthcare context. METHODS: PubMed literature searches of ED management in this patient group together with a survey of 28 experts in the management of treatment-induced ED from across the UK were conducted. RESULTS: Data from 19 articles and completed questionnaires were collated. The findings discussed in this article confirm that RT/ADT for prostate cancer can significantly impair erectile function. While many men achieve erections through PDE5-I use, others need combined management incorporating exercise and lifestyle modifications, psychosexual counselling and other erectile aids. This article offers a comprehensive treatment algorithm to manage patients with ED associated with RT/ADT. CONCLUSION: Based on published research literature and survey analysis, recommendations are proposed for the standardisation of management strategies employed for ED after RT/ADT. In addition to implementing the algorithm, understanding the rationale for the type and timing of ED management strategies is crucial for clinicians, men and their partners.

Development of UK recommendations on treatment for post-surgical erectile dysfunction.

AIM: To develop a management strategy (rehabilitation programme) for postsurgical erectile dysfunction (ED) among men experiencing ED associated with treatment of prostate, bladder or rectal cancer that is suitable for use in a UK NHS healthcare context. METHODS: PubMed literature searches of ED management together with a survey of 13 experts in the management of ED from across the UK were conducted. RESULTS: Data from 37 articles and completed questionnaires were collated. The results discussed in this study demonstrate improved objective and subjective clinical outcomes for physical parameters, sexual satisfaction, and rates of both spontaneous erections and those associated with ED treatment strategies. CONCLUSION: Based on the literature and survey analysis, recommendations are proposed for the standardisation of management strategies employed for postsurgical ED.

The re-construction of women's sexual lives after pelvic radiotherapy: a critique of social constructionist and biomedical perspectives on the study of female sexuality after cancer treatment.

Pelvic radiotherapy creates physical effects and psychological responses that negatively affect the sexual health of women and couples, yet these sexual consequences are not frequently researched or clinically assessed. This focused ethnographic study explored factors that influence the clinical assessment of treatment-induced female sexual difficulties after pelvic radiotherapy within routine medical follow-up. Participant observation of follow-up clinics (n = 69) and in-depth interviews with 24 women, 5 partners and 20 health professionals were undertaken at two cancer centres in the South East of England from 2005 to 2006. Thematic analysis of interview transcripts resulted in five emergent themes, two of which are explored in detail within this paper. A social constructionist approach to human sexuality was used to explore representations of female sexuality in oncology follow-up constructed by clinicians, women and their partners. Yet neither social constructionist nor biomedical (the predominant model in medical follow-up) perspectives on human sexuality provided an adequate interpretation of these study findings. This paper argues that the comprehensive study and practice of sexual rehabilitation in oncology requires a synthesis of both biomedical and social constructionist perspectives in order to capture the complex, subjective and embodied nature of the female sexual response in both health and illness.

Assessment of treatment-induced female sexual morbidity in oncology: is this a part of routine medical follow-up after radical pelvic radiotherapy?

BACKGROUND: Oncology follow-up has traditionally prioritised disease surveillance and the assessment and management of symptoms associated with cancer and its treatment. Over the past decade, the focus on late effects of treatment has increased, particularly those that have an adverse effect on long-term function and quality of life. The aim of this research was to explore factors that influence the identification of treatment-induced female sexual difficulties in routine oncology follow-up after radical pelvic radiotherapy. METHODS: A structured observation schedule was used to systematically record topics discussed in 69 radiotherapy follow-up consultations observed over a 5-month period. RESULTS: Analysis suggests that physical toxicity assessment focused on bowel (81%) and bladder (70%) symptoms. Vaginal toxicity was discussed less frequently (42%) and sexual issues were explored in only 25% of consultations. Formal recording of radiation toxicity through assessment questionnaires was limited to patients participating in clinical trials. Surveillance activity and the management of active physical symptoms predominated and psychosocial issues were addressed in only 42% of consultations. INTERPRETATION: Female sexual morbidity after pelvic radiotherapy remains a neglected aspect of routine follow-up and cancer survivorship. Developments in both individual practice and service provision are necessary if the identification and management of treatment-induced female sexual difficulties is to be improved.

The assessment and management of sexual difficulties after treatment of cervical and endometrial malignancies.

As survival rates in the developed world for cervical and endometrial cancer continue to improve, both health practitioners and the women affected by these illnesses have begun to focus increasingly on quality of survival. Although survival has improved as a result of multimodal treatment regimens, this is not without an associated increase in both acute and late treatment-related toxicity. Treatment late effects in these women can affect bowel and bladder function and may also cause sexual difficulties. The systematic assessment and management of late effects lacks integration within current models of oncology follow-up. This lack of routine clinical assessment and availability of specialist referral pathways is particularly noticeable in relation to the management of female sexual difficulties. Sexual rehabilitation for women lags behind that provided for men with pelvic malignancy, particularly since the introduction of PDE5 inhibitor drugs in the 1990s and this inequity must be addressed.

Vaginal dilation associated with pelvic radiotherapy: a UK survey of current practice.

This paper presents results from the first UK national survey of patient information and interventions related to vaginal dilation in pelvic radiotherapy (RT). The aim was to elicit current practice with regard to the target population, content/process of patient education, and the evaluation of compliance in relation to this intervention. A 38-item questionnaire was sent to all RT departments (n= 65) and a convenience sample of specialist gynecological oncology nurses (n= 166), with response rates of 62% (n= 40) and 31% (n= 52), respectively. Data analysis (via SPSS v11) used both descriptive and inferential statistics. Divergence of opinion was evident regarding the specific target audience for dilator education, and only a limited number of elements of vaginal dilator technique achieved consensus. Sixty-seven percent of respondents stated they carried out a wider sexual health assessment associated with the provision of dilator information, although its content varied considerably. Results suggest the provision of vaginal dilation advice may benefit from being placed in the wider context of assessing treatment impact on women's sexual health, raising the profile of appropriate psychosexual assessment, and intervention in clinical oncology practice. Further research could determine the efficacy of vaginal dilation in preventing development of vaginal stenosis among women receiving pelvic RT.

Analgesics in cancer pain: current practice and beliefs.

Prescribing practices for patients with cancer pain among populations of doctors in the United Kingdom have been assessed by means of a postal questionnaire. The results indicate that amongst the sample of doctors completing the questionnaire the basic principles of pain control in cancer appear to be understood. Regular oral morphine or diamorphine are most often chosen with the dose being determined mainly by the severity of pain with no arbitrary upper limit. Fears of addiction and respiratory depression, and a relatively long prognosis no longer appear to be major deterrents to the use of strong opioid analgesics. These data indicate considerable shifts in opinion in the doctors responding to the questionnaire and these results and their implications for current and future teaching about the management of cancer pain are discussed.