Systematic review: surveillance for breast cancer in women treated with chest radiation for childhood, adolescent, or young adult cancer.

BACKGROUND: Women treated with therapeutic chest radiation may develop breast cancer. PURPOSE: To summarize breast cancer risk and breast cancer surveillance in women after chest radiation for pediatric or young adult cancer. DATA SOURCES: Studies from MEDLINE, EMBASE, the Cochrane Library, and CINAHL (1966 to December 2008). STUDY SELECTION: Articles were selected to answer any of 3 questions: What is the incidence and excess risk for breast cancer in women after chest radiation for pediatric or young adult cancer? For these women, are the clinical characteristics of breast cancer and the outcomes after therapy different from those of women with sporadic breast cancer in the general population? What are the potential benefits and harms associated with breast cancer surveillance among women exposed to chest radiation? DATA EXTRACTION: Three investigators independently extracted data and assessed study quality. DATA SYNTHESIS: Standardized incidence ratios ranged from 13.3 to 55.5; cumulative incidence of breast cancer by age 40 to 45 years ranged from 13% to 20%. Risk for breast cancer increased linearly with chest radiation dose. Available limited evidence suggests that the characteristics of breast cancer in these women and the outcomes after diagnosis are similar to those of women in the general population; mammography can detect breast cancer, although sensitivity is limited. LIMITATION: The quality of evidence for key questions 2 and 3 is limited by substantial study heterogeneity, variation in study design, and small sample size. CONCLUSION: Women treated with chest radiation have a substantially elevated risk for breast cancer at a young age, which does not seem to plateau. In this high-risk population, there seems to be a benefit associated with early detection. Further research is required to better define the harms and benefits of lifelong surveillance.

Clitoral atrophy: a case series.

INTRODUCTION: Clitoral atrophy is often a neglected cause of female arousal complaints and warrants treatment with localized treatments. AIM: This is a case series of patients with clitoral atrophy in which localized estrogens were used to treat separate, distinct sexual complaints. METHODS: We report on three patients who were treated with localized estrogen tablets and cream for symptomatic clitoral atrophy despite a lack of data for use of these agents for the treatment of this diagnosis. The patients described here expressed understanding of the risks of vaginal hormonal therapy prior to treatment and at follow-up visits while on therapy. MAIN OUTCOME MEASURES: Patient reports, physical examination, and vaginal pH. RESULTS: All patients reported improvement or resolution of symptoms after the treatment with localized estrogen tablets and/or cream. CONCLUSIONS: Low-dose minimally absorbed local estrogen products can be used in combination with excellent tolerance and low side-effect profile to treat female sexual complaints.

Salvage chemotherapy for patients with advanced pure seminoma.

PURPOSE: We describe the response to conventional or high-dose salvage chemotherapy in patients with advanced seminoma who experience disease progression after receiving first-line platinum-based treatment. PATIENTS AND METHODS: Twenty-seven patients with progressive, advanced, pure seminoma were treated with salvage chemotherapy. Fifteen patients were treated with conventional-dose cisplatin-and-ifosfamide combination chemotherapy. Twelve patients were treated with high-dose chemotherapy followed by autologous stem-cell rescue. RESULTS: Fifteen patients (56%) achieved a complete response (CR), nine achieved CR with a conventional-dose cisplatin and ifosfamide program, and six experienced CR after high-dose chemotherapy. Fourteen patients (52%) are alive and disease-free, with 13 (48%) continuously disease-free at a median follow-up of 72 months. Twelve (57%) of 21 patients whose pretreatment tumors were studied morphologically were found to have seminoma with atypia. Eight patients underwent resection after salvage chemotherapy; six with histologic findings of necrotic debris/fibrosis alone are alive and disease-free at last follow-up. Both patients with viable seminoma found at surgery died of disease. CONCLUSION: Most patients with advanced seminoma are cured with standard first-line programs of cisplatin and etoposide with or without bleomycin. A small minority of patients with pure seminoma have resistant tumors and require salvage chemotherapy. In this setting, approximately 50% of patients with recurrent pure seminoma achieve durable CR with conventional or high-dose salvage chemotherapy. Identification of biologic markers to predict clinical outcome and an enhanced understanding of the basic biologic features of seminoma may lead to improvements in the management of this disease.

Impact of obesity on hospitalized patients.

Obesity is increasing at an alarming rate worldwide and is a risk factor for cardiac disease, diabetes, and stroke. This provides a challenge for the physicians caring for this patient population in the hospital. Skin integrity, medication dosing, testing, and nutrition are all altered by obesity. We summarize some of the current data on caring for the obese inpatient. Unfortunately, few data on this unique inpatient population exist.

Psychiatric illness presenting with a sexual complaint and management by psychotropic medications: a case report.

INTRODUCTION: Sexual medicine healthcare professionals, who do not normally examine men and women with psychiatric disorders, need to be aware that those with psychiatric disorders can and do present with sexual medicine problems. In particular, psychiatric individuals may present with a variety of delusions including those that have sexual content or sexual implications. The rare disorder of reverse delusional misidentification syndrome may be encountered in schizophrenic patients and may be best managed by the combined team effort of a sexual medicine specialist and psychiatrist. AIM: To report a case study that reiterates the assessment and sexual medicine management of a female with sexual dysfunction who believed she was transforming into a male. METHODS: Case report of a woman who attended an outpatient clinic in an academic medical center. RESULTS: A 60-year-old woman with a history of paranoid schizophrenia presented to a gynecologist for ovarian cancer screening. Evaluation revealed complaints that the patient's ovaries were testes that produced sperm and her clitoris was a penis capable of erection and ejaculation. Gynecological examination revealed only atrophic vaginitis. The patient was treated with local minimally absorbed vaginal estrogens and referred for psychological assessment and counseling. Psychotropic medication compliance was encouraged, weekly psychotherapy was continued, and delusional symptoms were minimized. CONCLUSION: Sexual medicine healthcare providers should be prepared to manage sex health concerns of men and women with psychiatric disorders, including delusional misidentification syndrome, in conjunction with a psychiatrist.

Sexual dysfunction in patients with gynecologic neoplasms: a retrospective pilot study.

INTRODUCTION: Little is known regarding the impact of a sexual health program on the sexual functioning of patients with a history of a gynecologic malignancy. AIM: To evaluate as a pilot study the prevalence of common sexual health symptoms and evaluate the effects and compliance with clinical recommendations in gynecologic oncology patients. METHODS: A retrospective cohort study of 259 female cancer patients who attended a survivorship program at an academic medical center from March 1, 2003 through December 31, 2004. Patients received symptomatic treatment recommendations including hormone therapy alternatives, psychosexual counseling, minimally absorbed vaginal estrogen suppositories, and vaginal dilators. MAIN OUTCOME MEASURES: Patient self-report of the severity of sexual symptomology at follow-up visit. RESULTS: Ninety-six patients (37%) had gynecologic neoplasms and the most common gynecologic malignancy seen was ovarian (27%). Median age at initial visit was 51 years (range 25-76) and 88 patients (92%) were postmenopausal. The most frequent presenting complaint encountered was dyspareunia (72%), atrophic vaginitis (65%), hypoactive desire (43%), and orgasmic dysfunction (17%). At a median of 6 months (range 0-20), 60 patients (63%) received follow-up, and of them 42 (70%) self-reported improvement in their symptoms. CONCLUSIONS: The establishment of a well-structured sexual health program in a cancer setting can result in a 63% compliance rate with a 70% subjective improvement in sexual health complaints. Further research with objective measures of sexual dysfunction is needed to better evaluate patients' progress in this setting.

Prevalence of psychiatric illness in women in an oncology sexual health population: a retrospective pilot study.

INTRODUCTION: Oncology patients often present to healthcare providers with a history of pre-existing psychiatric conditions. Associated treatments are well known to impact sexual functioning. The identification of these confounding conditions and medications is an integral part of the comprehensive management of sexual dysfunction in oncology patients. AIM: To report the prevalence of psychiatric diagnoses and agents in an oncology sexual health clinic. METHODS: A retrospective review was performed using 204 sequential charts of patients who attended the Sexual Health Program at Memorial Sloan-Kettering Cancer Center from March 2003 through August 2004. MAIN OUTCOME MEASURES: All patients were evaluated by a sexual medicine gynecologist and received an extensive medical history, psychosexual assessment, and a focused gynecologic examination. RESULTS: Fourteen patients (7%) did not have cancer and were excluded from further analysis. Of the remaining 190 patients, the median age at initial visit was 48 years (range 22-76) and the majority of patients were menopausal (87%). The most common diagnosis was breast cancer (44%). One hundred twenty-eight patients (67%) had prior pelvic surgery and 43 (23%) had prior pelvic radiation. The most frequently encountered sexual complaints were dyspareunia (65%), vaginal dryness (63%), hypoactive desire disorder (46%), and orgasmic dysfunction (7%). At initial presentation, 52 patients (27%) reported having a prior or concurrent psychiatric diagnosis and 72 (38%) were taking an anti-depressant and/or an anxiolytic. Treatment recommendations for sexual dysfunction consisted of psychosexual counseling, psychiatric referral, vaginal moisturizers and lubricants, hormonal therapy with minimally absorbed vaginal estrogen suppositories, vaginal dilators, and/or skilled exercise. CONCLUSION: Psychiatric conditions are commonly encountered in the oncology population as are the medications to treat them. Because it is well established that these medications are often implicated in sexual dysfunction, further research is needed to determine the mechanism of action within the desire pathway of the cancer patient and treatment of such disorders.

Sexual oncology: sexual health issues in women with cancer.

Sexual problems are widespread among female cancer patients and survivors. Dysfunction may result from various oncologic therapies such as surgery, radiation therapy, chemotherapy, hormonal manipulation, and cytostatic medication. Additionally, psychologic distress that the patient or her partner experiences during diagnosis and treatment of malignancy can impair a healthy female sexual response cycle. A sexual rehabilitation program in an oncology setting is necessary to provide comprehensive care to the cancer patient and her partner. A multidisciplinary treatment approach to sexual dysfunction includes psychological and psychiatric intervention, medical intervention, cognitive behavioral therapy, and recommended lifestyle adjustments. A holistic approach to assessing and treating sexual concerns should be individually tailored to the female patient in light of her disease stage and prognosis, age, marital status, fertility concerns, and social and professional environment.

Comparison of uterine malignancies that develop during and following tamoxifen therapy.

OBJECTIVES: There is a greater than 7-fold increased risk of uterine cancer in women with breast cancer exposed to tamoxifen. The objective of this study was to determine the percentage of women who developed uterine cancer more than 12 months after discontinuing tamoxifen (past users) and to compare their clinical and pathologic features with those of women who developed uterine cancer while on tamoxifen therapy or within 12 months of stopping therapy (recent users). METHODS: All women with a diagnosis of uterine cancer at Memorial Sloan-Kettering Cancer Center between 1980 and June 2004 with a past history of breast cancer treated with tamoxifen were identified. Clinical and pathologic data were obtained through retrospective chart review. RESULTS: There were 106 women identified with a history of breast cancer treated with tamoxifen preceding their diagnosis of uterine cancer. Thirty-nine (37%) developed uterine cancer more than 12 months after discontinuing tamoxifen. The median time until developing uterine cancer in past users was 33 months (range, 13-22). There were no significant differences in age at breast cancer diagnosis, body mass index, parity, stage of breast cancer, modality of breast cancer treatment, or duration of tamoxifen therapy between past and recent users of tamoxifen. Women who were past users of tamoxifen had significantly more FIGO (International Federation of Gynecology and Obstetrics) grade 3 and non-endometrioid histologic subtypes (P = 0.009; P = 0.007). CONCLUSIONS: More than one third of women treated with tamoxifen develop uterine cancer more than 12 months after discontinuing therapy. These women are at greater risk of developing moderately to poorly differentiated tumors, which is a known poor prognostic factor. Therefore, women with a past history of tamoxifen therapy should have continued surveillance after completion of tamoxifen to ensure early diagnosis of uterine cancer.

Celiac disease presenting as a paraneoplastic syndrome in a patient with synchronous endometrial and ovarian cancers.

OBJECTIVE: Celiac disease is characterized by gluten intolerance and commonly manifests with unexplained diarrhea, abdominal distention and weight loss. Infrequently, patients present with vague, non-specific symptoms which often delay diagnosis and treatment. CASE: A 52-year-old female with a history of synchronous endometrial and ovarian cancers, previously treated with surgical resection, staging and pelvic irradiation, presented with progressive paresthesias in her extremities. Extent of disease work-up was unremarkable. Neurologic evaluation suggested celiac disease which was later proven by duodenal biopsy. CONCLUSION: The development of new or worsening neurologic symptoms in the cancer patient requires a thorough evaluation especially to exclude metastatic disease and/or paraneoplastic syndromes. Once neoplastic processes are excluded, celiac disease should be considered in the differential diagnosis of patients with unexplained neurologic dysfunction.

Persistent sexual arousal syndrome associated with increased soy intake.

INTRODUCTION: Persistent sexual arousal syndrome is an uncommon sexual complaint. Patients with this disorder can be distressed by the escalation of tension in the pelvic region and the prevailing necessity to diminish the pressure by self-stimulation. Patients frequently suffer from guilt or shame and often do not seek medical care. There are many potential causes of this disorder; however, a definitive etiology has yet to be elucidated. CASE: The patient is a 44-year-old female who presented to her gynecologist for evaluation of dysmenorrhea and menometrorrhagia. During the review of systems, the patient reported 5-6 months of increased pelvic tension, not associated with an increase in desire that required her to self-stimulate to orgasm approximately 15 times daily. Upon further inquiry, the patient disclosed that her dietary regimen included soy intake in excess of 4 pounds per day that began approximately 1 month prior to the onset of symptoms. RESULTS: Treatment consisted of supportive counseling and dietary modification. At the 3-month follow-up visit, the patient's menstrual difficulties and sexual complaints resolved. CONCLUSIONS: Although no known cause or cure of persistent sexual arousal syndrome has been identified to date, the success of reducing dietary of phytoestrogens in this patient may provide insight into the etiology of the disorder and suggest potential treatments.

Brain cancer and sexual health: a case report.

OBJECTIVE: Cancer patients often encounter sexual concerns during the diagnosing, treatment, and recovery phase of their illness. However, the sexual concerns of these patients are often overlooked. Brain cancer patients are no exception to this oversight. METHODS: A case report of a 39-year-old patient with a history of high-grade anaplastic astrocytoma presented to the Sexual Health Program at the Memorial Sloan-Kettering Cancer Center complaining of vaginal discharge and several months of amenorrhea. Although the patient was administered extensive aggressive antineoplastic treatments, her disease rapidly progressed. RESULTS: Despite the patient's terminal illness she continued to have normal sexual thoughts, feelings, and desires; however, she had difficulty discussing these issues with her partner and caregiver, who was her mother. An examination by the sexual medicine gynecologist noted no clinical signs of genital infections; however, there was minimal vaginal atrophy. Her sexual health laboratory evaluation was extensively abnormal. Her treatment consisted of intravaginal non-hormonal moisturizers and vaginal lubricants, counseling, and sexual education. The patient successfully engaged in sexual contact with her partner by the third counseling session. SIGNIFICANCE OF RESULTS: Almost all oncology patients have sexual concerns during or following cancer treatment. These patients should be referred to comprehensive sexual health programs for treatment, if available.