Reproductive and sexual function after platinum-based chemotherapy in long-term ovarian germ cell tumor survivors: a gynecologic oncology group study
Commentary by Ms Kim Hobbs
The article:
Gershenson DM, Miller AM, Champion VL, et al. Reproductive and Sexual Function After Platinum-Based Chemotherapy in Long-Term Ovarian Germ Cell Tumor Survivors: A Gynecologic Oncology Group Study. J Clin Oncol 2007;25:2792–7.
The reviewer:
Kim Hobbs is a social worker at the Department of Gynaecological Cancer, Westmead Hospital in Sydney.
Summary
Abbreviations
Dyadic Adjustment Scale (DAS); Gynecological Symptom Scale (GSS); Reproductive Concerns Scale (RCS); Sexual Activity Questionnaire (SAQ); Sexual Self Schema Scale (SSSS)
Study Design
This case-control study compared menstrual and reproductive outcomes, sexual functioning and dyadic adjustment (quality of relationships) in 132 ovarian germ cell tumour survivors to a control group of 137 female acquaintances, matched for age, race and education. Patients had a history of either early or advanced malignant ovarian germ cell tumour, had been treated with surgery along with platinum-based chemotherapy, and were continuously disease-free, with a minimum follow-up of two years. The participants were mailed an informed consent and background questionnaire (with cancer- related questions deleted for controls). A 60-minute computer-assisted telephone interview was conducted with both subjects and controls. Quality of life was measured using reliable and validated scales (SAQ, Gynaecological Symptom Scale, 14-item Reproductive Concerns Scale, 26-item Sexual Self Schema and the Dyadic Adjustment Scale).
Findings
Physical Parameters of Survivors
Seventy-one survivors (53.8%) had fertility sparing surgery. Of these, 62 (87.3%) reported that they were still having menstrual periods compared with 83.2% of controls.
Pregnancy
Twenty-four survivors (18.2%) reported they had 37 children after cancer treatment compared to 92 controls (67.2%) reporting having 186 children. Of the 24 survivors to have children, 20 (83%) had a live birth from the first pregnancy after cancer treatment. Spontaneous abortions were reported by 19 (14%) survivors (5.3% after cancer treatment, 9.1% before cancer) compared with 35 (25.5%) by controls. Induced abortions were reported by 10 (7.5%) survivors (3% after cancer treatment, 4.5% before cancer treatment) compared with 11 (8%) by controls.
Sexual functioning and dyadic adjustment
Survivors had significantly greater reproductive concerns (p=<0.0001), less sexual pleasure (p=0.017) and lower scores on the total Sexual Activity Scale Score (p=0.007) compared to controls. Survivors had better dyadic consensus (p=0.001), dyadic satisfaction (p=0.002), dyadic cohesion (p=0.004) and a higher total DAS score (p=0.01) than controls.
Fertile and infertile survivors
Infertile survivors reported significantly greater reproductive concerns (p<0.0001) and sexual discomfort (p=0.036) compared to fertile survivors.
Conclusion
The authors concluded that women who had fertility-sparing surgery were likely to retain menstrual function and fertility after chemotherapy. Survivors had an increase in gynaecologic symptoms and diminished sexual pleasure, however they tended to have stronger, more positive relationships with significant others compared to controls.
Commentary
What does this article add to existing clinical evidence in this area?
This prospective case-control study has the potential to add significantly to knowledge about the important areas of sexual function, reproductive outcomes and dyadic relationship satisfaction for a small group of predominantly young women with a rare cancer from which most can expect to be cured.
The literature to date reports very little on this combination of topics. Whilst there are articles on sexual function following treatment for gynaecological cancers generally, there is virtually nothing reported exclusively on this sub-group of patients. Other studies which seek to investigate fertility following chemotherapy treatment for all types of cancer, report their findings in terms of numbers of pregnancies and births. The potential strength of this study is that it sets out to evaluate the qualitative, not just quantitative outcomes of treatment.
How adequate was the methodology used in addressing the aims of this study?
The study recruited an impressive sample of 132 germ cell tumour survivors (defined as more than 2 years disease-free), and 137 matched controls. The authors note that this “is the largest and most comprehensive survey of survivors of malignant ovarian germ cell tumors”. All patients had been diagnosed with early or advanced ovarian germ cell tumours, and had been treated with surgery plus platinum-based chemotherapy. An interesting method of recruiting control subjects, involved the patient participants recommending acquaintances who had not had a cancer diagnosis, matched for age, race and education. All participants needed to be fluent in English to complete the mailed questionnaire and telephone interview.
A battery of scales with established statistical validity and reliability was used to measure quality of life outcomes: the SAQ (to assess sexual functioning); the GSS (for specific gynaecological concerns); the RCS (to assess reproductive problems or worries of survivors diagnosed and treated in their childbearing years); the SSSS (to measure a cognitive self-view of both positive and negative aspects of sexual functioning); and the DAS (to assess the quality of marital or other dyadic relationships).
What are the implications of this study for clinical practice in Australia?
Given the relatively large sample size and the comprehensive qualitative assessment of the study sample, the analysis of results in this article is quite superficial and focuses primarily on quantitative outcomes, such as the number of births. For example, it is reported that 24 of the 132 survivors had produced children since their cancer treatment, but there is no discussion of how many of the other survivors may have wished to have children, or conversely not wished to have children. The age range of the cancer survivors was 19 to 64 years (median 35.5 years). Clearly, many at the older end of the range would neither wish nor expect to have children. Further, 23 of the survivors were taking the oral contraceptive pill, thus precluding pregnancy. Some patients (it is not specified how many), had been treated many years prior to the study and had undergone hysterectomy and salpingo-oophorectomy, making reproduction impossible. In fact, only 71 of the 132 survivors (a little more than half) had been treated with fertility-sparing surgery. Whilst it is encouraging to know that women can maintain fertility after appropriate surgery and chemotherapy, there is scant analysis in this article on the impact for the substantial number of women who have not retained reproductive function.
There are some potentially interesting findings on sexual satisfaction and dyadic relationship satisfaction, but again these are summarily reported in this article. Possible reasons are briefly canvassed as to why cancer survivors may expend more effort in maintaining healthy dyadic relationships, and why those with fertility problems following treatment report greater reproductive concerns and sexual discomfort, but these themes are not explored and expanded.
The authors promise future publications from this large study, and it is to be hoped that more thorough qualitative analysis of the potentially rich pool of data, may elucidate findings which will inform clinical practice in the management of women with germ cell tumours.
Editor: Ms Jane Francis, Program Manager/Ovarian Cancer, National Breast Cancer Centre.
Editorial Committee: Prof Michael Friedlander – Medical Oncologist, Prof Neville Hacker – Gynaecological Oncologist, Dr Gillian Mitchell – Medical Oncologist, Dr Deborah Neesham – Gynaecological Oncologist, Ms Georgie Richter – Gynaecological Nurse.
Disclaimer
Clinical Update - Ovarian Cancer is produced by the National Breast Cancer Centre (NBCC) and is intended to provide health professionals with timely expert commentary on new research in ovarian cancer. Commentaries included in Clinical Update - Ovarian Cancer do not replace recommendations included in NBCC clinical practice guidelines.
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