|Year : 2016 | Volume
| Issue : 2 | Page : 938-944
Survey of cervical cancer survivors regarding quality of life and sexual function
Wenjuan Zhou1, Xiangcheng Yang2, Yunyun Dai3, Qihui Wu4, Guoping He5, Gang Yin4
1 Department of Humanistic Nursing, Xiangya School of Nursing, Central South University; Department of Pathology, School of Basic Medicine, Central South University, Changsha, Hunan 410013, P. R. China
2 Department of Orthopedics, Zhuzhou Central Hospital, The Affiliated Zhuzhou Hospital Xiangya School of Medicine, Central South University, Zhuzhou, Hunan 412007, P. R. China
3 Department of Basic Nursing, School of Nursing, Guilin Medical University, Guilin, Guangxi 541004, P. R. China
4 Department of Pathology, School of Basic Medicine, Central South University, Changsha, Hunan 410013, P. R. China
5 Department of Humanistic Nursing, Xiangya School of Nursing, Central South University, Changsha, Hunan 410013, P. R. China
|Date of Web Publication||25-Jul-2016|
172, Tongzipo Road, Changsha City, Hunan Province
P. R. China
Source of Support: None, Conflict of Interest: None
Objective: To investigate the quality of life (QOL) of cervical cancer survivors in China.
Methods: Cervical cancer survivors were selected from 4 Tertiary Provincial Hospitals in Changsha, Hunan Province. Enrolled were 140 patients who received cancer treatments in these hospitals from 2007 to 2010. The Functional Assessment of Cancer Therapy-Cervix (FACT-Cx) Questionnaire was used to assess the QOL of the participants. Spiritual well-being was evaluated with the Functional Assessment of Chronic Illness Therapy-Spiritual Well-being (FACIT-Sp). Sexual function was measured with the Female Sexual Functioning Index.
Results: The average total FACT-Cx score was 124.45 (70–157). The average FACT-general score was 112.39 (49–150), and the average FACIT-Sp score was 13.9 (2–33.6). The prevalence of sexual dysfunction in our participants was 78%. Factors that were associated with QOL in cervical cancer survivors included gastrointestinal symptoms, health insurance, age, sleep disorders, and the number of complications. Sexual function was affected by radiotherapy, age, type of surgery, sleep disorders, and occupation.
Conclusion: The QOL and sexual function of cervical cancer survivors were lower than the general population. Treatment-related complications and sexual dysfunction significantly affected patients' QOL. Having health insurance was associated with better QOL. Sexual function was adversely affected by radiotherapy and radical hysterectomy.
Keywords: Cervical cancer, cervical cancer survivors, health insurance, hysterectomy, quality of life, radiotherapy, sexual function
|How to cite this article:|
Zhou W, Yang X, Dai Y, Wu Q, He G, Yin G. Survey of cervical cancer survivors regarding quality of life and sexual function. J Can Res Ther 2016;12:938-44
| > Introduction|| |
Cervical cancer remains a major cancer-related cause of death of women in undeveloped countries. More than 470,000 new cases of cervical cancer are diagnosed annually, and worldwide more than 200,000 died of this disease; 80% in the developing countries. In China, approximately 130,000 new cases of cervical cancer are diagnosed annually, and more than 53,000 women die from it. In 2009, the Chinese Ministry of Health implemented the Cervical Cancer Prevention Plan, a free program that encourages early detection and treatment.
Treatment options for cervical cancer include hysterectomy combined with radiotherapy and chemotherapy, or hysterectomy alone. With these treatments, ~80–90% of cervical cancer patients with Stage I–II can be cured, and 60% of patients with Stage III. As for other cancers, treatments for cervical cancer often cause unwanted side effects  including physical changes, mental stress, digestive and urinary dysfunctions, menopausal symptoms, infertility, and sexual dysfunction.,, Some side effects are chronic and significantly affect patients' normal life, including small bowel obstruction, stress urinary incontinence, vaginal atrophy, and limb swelling due to lymphatic blockage.,,
An assessment of the quality of life (QOL) of cancer patients is important for personalizing treatment and providing auxiliary care. Ferrell et al. suggested that the QOL of cancer patients can be assessed in terms of their physical, psychological, social, and spiritual well-being. Specifically, physical well-being and symptoms are represented by degrees of functional activity, strength and fatigue, sleep and rest, overall physical health, fertility, and pain.,,, Factors that influence psychological well-being includes feelings of being in control, anxiety, depression, enjoyment and leisure, fear of recurrence, levels of cognition and attention, distress regarding the diagnosis, and control over treatment.,,, Social well-being can be affected by distress in the family, roles and relationships, affection and sexual function, appearance, enjoyment, isolation, finances, and factors related to work.,,, Spiritual well-being can be influenced by the meaning given to the illness, religion, hope, uncertainty, and inner strength.,,,
Sexual relations are an important determinant of human QOL. Cervical cancer survivors suffer from pain and psychological distress that often affects their sexual relationships. In addition, studies have shown that within 5 years of a radical hysterectomy, 25% of cervical cancer survivors experience symptoms of vaginal shortening. In those who receive radiotherapy, vaginal atrophy, vaginal stenosis, and structural changes in the vaginal tissue are common. It has been reported that cervical cancer survivors had sexual problems associated with radiotherapy. In general, sexual function in cervical cancer survivors declined significantly after treatments.,, Subsequently, research attention has been given to the QOL of cervical cancer survivors, with regard to the quality of sexual relations.,,, However, in China, while the number of women who have survived cervical cancer has increased due to the free screening program begun in 2009, the quality of their lives after treatment has been largely neglected.
The present study surveyed the status of QOL of cervical cancer survivors in China in order to understand the factors affecting QOL and sexual functions.
| > Methods|| |
The Institutional Review Boards of the university and the four hospitals approved this study. The necessary sample size was estimated by multiple regression analysis, with R2 = 0.216, α = 0.05, and a 90% power to detect a difference. The minimum estimated number of patients was 134. Thus, 140 survivors of cervical cancer were recruited in the study [Figure 1].
|Figure 1: Process of selecting cervical cancer survivors for participation in the study|
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The patients enrolled in the study had been previously treated for cervical cancer in the Gynecological Oncology Departments of 4 tertiary level hospitals in Hunan Province. For inclusion, all the patients satisfied the following criteria: Older than 18 years; had received a diagnosis of cervical cancer at Stages I, II, or III; cervical cancer treatments had ended; had normal abilities to read, write, and speak Chinese; and able and willing to sign the informed consent form. Patients were excluded whose tumor had recurred; had mental illness or cognitive impairment.
All participants were voluntary and anonymous and could quit the study at any time. All the patients filled out a self-reported questionnaire. Participants' names were replaced by numbers in the questionnaires. All data were secured and accessed only by the researchers.
Functional Assessment Cancer Therapy-Cervix
The Functional Assessment of Cancer Therapy-Cervix (FACT-Cx) Questionnaire is specifically designed for evaluating the QOL of cervical cancer survivors. It comprises the FACT-general (FACT-G) Questionnaire (27 items) and the Cx-specific subscale (15 items). The FACT-G Questionnaire consists of 4 subscales, specifically the physical, social/family, emotional, and functional well-being subscales (with 7, 7, 6, and 7 items, respectively). The Cx-specific subscale concerns the symptoms of cervical cancer, with responses given on a Likert scale from 0 (not at all) to 4 (very much). Cronbach's alpha coefficients for each subscale of FACT-Cx were physical well-being (0.82), social/family well-being (0.69), emotional well-being (0.74), functional well-being (0.80), and overall FACT-Cx (0.89)., Each subscale produced a score, and there was a QOL score for the FACT-G portion and a total cervical cancer QOL score for the FACT-Cx. The sum of the scores for the physical well-being, functional well-being, and Cx-specific subscales, termed the trial outcome index (TOI), were taken to reflect the effects of cervical cancer treatments on the physical and functional symptoms of the survivors.
Functional Assessment of Chronic Illness Therapy-Spiritual Well-being scale
The Functional Assessment of Chronic Illness Therapy-Spiritual Well-being (FACIT-Sp) scale is a means to evaluate aspects of spiritual well-being such as a sense of meaning, peace, inner strength, and spiritual comfort. It includes eight items related to the meaning of life and four items regarding the role of faith in adjusting to a change in life. The FACIT-Sp scale was previously validated in 1617 patients with cancer (breast, colon, lung, or head and neck cancers) or HIV; Cronbach's α coefficients were 0.81 for a sense of meaning/peace, 0.88 for belief, and 0.87 for the overall FACIT-Sp. The scoring system of the FACIT-Sp is similar to that of the FACT-G, and, therefore, the sum of scores each can be considered to reflect QOL.
| > Female Sexual Functioning Index|| |
The Female Sexual Functioning Index (FSFI) is a self-reported measurement of sexual function. The FSFI contains 19 items covering 6 domains of sexual function, specifically sexual desire, sexual arousal, lubrication, orgasm, sexual satisfaction, and pain of intercourse (2, 4, 4, 3, 3, and 3 items, respectively). The FSFI can differentiate patients with female sexual arousal disorder (FSAD) from patients with normal sexual function, who served as control patients, in each of the 6 domains, as well as by the full-scale score. The cut-off point score of the FSFI to identify FSAD is 26.55; a score <26.55 is considered indicative of FSAD. Cronbach's α coefficients were reported to be from 0.760 to 0.874.
Data were analyzed with the SPSS version 16.0 (SPSS Inc., 233 South Wacker Drive, 11th Floor, Chicago, IL 60606-6412) statistical package. Univariate statistics and scatter plots were used to examine outliers and data distribution. Pearson's correlation coefficients were used for associations among demographic variables, cancer treatment, QOL, specific QOL domains (physical, functional, emotional, social, and spiritual), and domains of sexual function. Multiple linear regression analysis was used to assess the predictors for overall and scale-specific QOL and sexual function.
| > Results|| |
The average age of the patients was 45.61 ± 7.81 years, with a range from 27 to 68 years [Table 1]. More than 60% of the participants were farmers or homemakers. The highest educational level of 72.2% of the participants was below high school. More than 30% had no health insurance. Approximately, 57% (80/140) of the patients had undergone chemotherapy, and 108 of the 140 (77%) had radiotherapy. Participants with 3 or more complications accounted for 41.5% of the study population.
Functional Assessment Cancer Therapy-Cervix score
The average FACT-Cx scores for the physical, social/family, emotional, and functional well-being subscales were 22.22, 21.96, 18.35, and 18.43, respectively. The average overall score was 81.01 [Table 2]. The Cx-specific subscale score was 43.10, and the TOI was 84.16. The total FACT-Cx score was 124.45.
|Table 2: Functional Assessment Cancer Therapy-Cervix Questionnaire results|
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Assessment of sexual function
The sexual function of patients with cervical cancer was evaluated by the FSFI. The average score for sexual desire was 2.58, 1.81 for arousal, 2.80 for sexual satisfaction, and 2.47 for pain during intercourse. With an FSFI score <26.55 considered diagnostic for FSAD, the proportion of patients with FSAD was 78% [Table 3].
The scores of the FSAD patients on the Cx-specific subscale and the TOI were significantly lower than that of the control group (who had normal sexual functions), 41.97 ± 8.02 vs. 47.54 ± 5.43 (P = 0.002), and 82.76 ± 14.92 vs. 89.49 ± 12.06 (P = 0.04), respectively.
Regression analysis of factors that related to quality of life
The regression analysis showed that a variety of factors was significantly associated with the FACT-G and FACIT-Sp scores in cervical cancer survivors, including age, possession of health insurance, number of complications, gastrointestinal symptoms, and sleep disorders (R2 = 0.330, P < 0.05) [Table 4]. Factors that were significantly associated with the total FSFI score were age, radiotherapy, sleep disorders, radical hysterectomy, and white-collar occupation (R2 = 0.445, P < 0.05) [Table 5].
|Table 4: Regression analysis of total score of Functional Assessment Cancer Therapy-general and Functional Assessment of Chronic Illness Therapy-Spiritual Well-being|
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|Table 5: Regression analysis of total score of female sexual functioning index|
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| > Discussion|| |
The present study found that the QOL and sexual function of Chinese cervical cancer survivors were low, and affected by multiple factors such as treatment-related complications and the possession of health insurance.
QOL scores varied in different study populations. Compared to a study using the same scales for QOL, our participants received lower scores in physical, psychological, functional well-being, and overall QOL. In contrast, the cervical cancer survivors in the present study achieved higher scores in physical and social/family well-being, but lower scores in the rest of the domains compared with another report. The score of the spiritual well-being of our participants was lower than another report. The higher proportion of participants complaining of gastrointestinal symptoms and sleep disorders in the present study may partially explain the discrepancy between our findings and the others.,,
In the present study, we found that having health insurance coverage was related to the QOL of cervical cancer survivors. This is the first report of a direct link between health insurance and QOL of cervical cancer survivors in China. Patients who are not covered by health insurance are expected to pay all their medical expenses themselves. This can prevent them from seeking medical care when they need it, and as a result their QOL suffers. It was found previously that in survivors of other cancers, patients without health insurance chose to get medical treatment at later, more advanced stages of their cancer, often waiting until they could no longer perform normal life activities., For those who had health insurance in China, the choice of treatment was greatly influenced by the type of health insurance. Therefore, cervical cancer survivors with better health insurance might be treated aggressively and consequently have more treatment-related complications, which would also damage their QOL. The Chinese government provided a new cooperative health insurance for rural residents, and it was reported that the coverage rate reached to 99%. However, the present study found that 30.7% patients still needed to pay the medical costs by themselves, implying that the health insurance coverage needs to be improved. Meanwhile, the new cooperative health insurance can only cover about 30% of medical costs, and many cancer therapy costs are not covered by any medical insurance, which could influence cancer patients' QOL as well.
Many of the postsurgical symptoms of cervical cancer survivors are related to declining sexual function., In our study, we found that patients who experienced vaginal atrophy had declined in sexual function, as shown by significantly lower Cx-specific subscale scores and trial outcome indices compared with those without vaginal atrophy. In addition, more than 70% of our participants were identified as having sexual dysfunction, based on their FSFI scores. This is similar to a previous report in which 73% of cervical cancer survivors had sexual dysfunction. Therefore, sexual dysfunction is a common side effect caused by cervical cancer treatment. The main treatments responsible for sexual dysfunction in the present study were radiotherapy or radical hysterectomy. Approximately, 57.1% of our participants accepted radiotherapy and 60% of them accepted radical hysterectomy.
To the best of our knowledge, the present study found, for the 1st time, that occupation was associated with sexual function in cervical cancer survivors. White-collar cervical cancer survivors had better sexual function than those in other occupations, which was probably related to their higher education level and lower proportion of radiotherapy found in the study. It was reported previously that women's psychological and cognitive changes strongly affected the experience and quality of their sexual lives. The major reasons given by our participants for avoiding sex were concerns of cancer recurrence (63.8%) and fear of pain and bleeding due to sex (31.9%). This finding suggested the role of psychological factors in sexual activities. Therefore, adequate education and good communication with physicians about sexual activities seem to be important factors for the quality of sexual life in cervical cancer survivors.
The participants in the present study voluntarily joined the survey. It is possible that some patients whose QOL was seriously affected by cancer treatments might have refused to participate in the study. However, this would not affect our findings that cervical cancer survivors have low QOL because those who refused to attend would have lower QOL than the participants. Another limit of this cross-sectional study was that we were unable to study changes in the QOL of the cancer survivors over the long-term. The QOL of some cancer survivors may improve with time, while for others it may be the opposite. A prospective cohort study could monitor changes in cancer survivors' QOL.
Sexuality is an important concern of cervical cancer survivors. Due to traditional culture, cervical cancer survivors in China usually avoid discussing issues of sexuality with physicians. A model Gynecological Advice Clinic has shown positive outcomes in British cancer patients who face sexuality issues. Therefore, a similar strategy could be adopted to improve cervical cancer survivors' sexual function and QOL in China.
| > Conclusion|| |
The QOL of cervical cancer survivors was found to be low, as well as sexual functions, and a variety of complications was related to declining QOL. Medical care providers should take corresponding measures to improve cervical cancer survivors' QOL and sexual functions such as educating patients and actively treating complications related to cancer treatments.
Financial support and sponsorship
This study was supported by Science Foundation for the Youth Scholars of Central South University (No. 124917), National Natural Science Foundation of China (NSFC, no. 81201675) and Hunan Province Philosophy and Social Science Fund (No. 14YBA396).
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]