Prospective Quality of Life Study of South African Women Undergoing Treatment for Advanced-stage Cervical Cancer

doi:10.1016/j.clinthera.2015.08.018

Clinical Therapeutics

Volume 37, Issue 10, 1 October 2015, Pages 2324-2331

https://doi.org/10.1016/j.clinthera.2015.08.018 Get rights and content

Abstract

Purpose

The majority of South African cervical cancer patients present with advanced-stage disease. Chemoradiation therapy, in comparison with radiation therapy, results in marginally improved survival in women with advanced cervical cancer. The impact on the quality of life due to the addition of a chemosensitizer in a situation of limited survival benefits warrants objective assessment. This prospective study compares the quality of life for women with cervical cancer and treated with radiation or chemoradiation therapy at Tygerberg Hospital, South Africa.

Methods

A prospective study was done in a population with a high incidence of advanced cervical cancer. Quality of life measurements were done at pretreatment, post treatment, and follow-up. The European Organisation for Research and Treatment of Cancer Quality of Life Core Questionnaire and the Cervix Cancer Module were used.

Findings

The study included 219 women. Forty-four women were treated with primary surgery. A total of 102 women completed primary radiation therapy and 73 women completed primary chemoradiation therapy. The demographic characteristics of the last 2 treatment groups were different. Women receiving chemoradiation therapy had a higher educational level (P < 0.01) and had less advanced stage (III or IV) cervical cancer (P < 0.01). Radiation therapy was used significantly more in HIV-positive women. The presiding clinicians chose treatment options based on clinical factors unrelated to quality of life. Chemoradiation therapy resulted in statistically more improvement in the pain (P < 0.05), fatigue (P < 0.05), appetite loss (P < 0.01), and nausea and vomiting (P < 0.05) quality of life domains. In these domains, pretreatment quality of life scores were significantly higher in the radiation therapy group, implying a poorer quality of life status at the initiation of treatment. In post hoc analysis, the global health domain was significantly more improved (P = 0.03) by chemoradiation. Peripheral neuropathy was not increased by chemoradiation.

Implications

Chemoradiation therapy improved quality of life more than radiation therapy in certain domains. This allows for selection of chemoradiation as a treatment option in situations where quality of life is the end point of treatment.

Introduction

Cervical cancer remains common in developing countries, where the majority of cases occur.¹ In these developing countries, a high incidence of advanced-stage cervical cancer is found. The advanced stage is not amenable to surgery, and radiation therapy has been the treatment of choice.² In 1995, on the basis of 5 randomized controlled trials, the National Cancer Institute recommended that chemoradiation therapy be the preferred treatment for advanced-stage cervical cancer.³ A meta-analysis by Green et al⁴ of available studies showed a 5-year survival benefit of 29% in all stages of cervical cancer for chemoradiation therapy compared with radiation therapy. In a separate meta-analysis, Lukka et al⁵ calculated a 26% survival benefit, but subsequent limitations—for example, omission of unpublished studies—challenged this finding.5, 6 A Cochrane review calculated a survival benefit of 13% across all stages of cervical cancer treated with chemoradiation therapy.⁷ Limitations in all of these meta-analyses were differences in study designs, accrual rates, and treatment schedules. Additional limitations included heterogeneity of the control arms of the studies, including the use of previously conducted studies as controls. These limitations were addressed by performing an individual patient data analysis. This individual patient data analysis found there was a 9% survival benefit with chemoradiation therapy in all stages of cervical cancer. The effect of chemoradiation therapy on survival decreased with increasing tumor stage, with estimated absolute survival benefits of 10% (stage IA−IIA), 7% (stage IIB), and 3% (stage III−IVA) at 5 years.⁸

Despite increased toxicity, chemoradiation therapy is still widely accepted.⁹ The increased toxicity relates to specifically increased grade 3 and 4 hematologic toxicity (2-fold increases) and gastrointestinal (3-fold increases) events in the chemoradiation therapy group.¹⁰ The presence of physician-recorded toxicity correlates poorly with patient-reported quality of life.¹¹ A meta-analysis of chemoradiation therapy toxicity suggests that although the acute toxicity was acceptable, additional studies on the toxicity-related impact on quality of life are needed.¹⁰ The present study aims to describe the impact on quality of life of radiation therapy or chemoradiation therapy for women with cervical cancer treated at Tygerberg Hospital, South Africa.

Section snippets

Inclusion Criteria

Newly diagnosed cervical cancer patients referred to the Unit of Gynaecologic Oncology, Tygerberg Hospital were approached to participate in the study. The unit is 1 of the 2 tertiary referral units for public-sector patients of the Western Cape Province. The Western Cape Province has a population of 5.8 million. The majority of the population (85%) does not have private insurance and are dependent on the public facilities provided by the 2 tertiary hospitals (Tygerberg Hospital and Grootte

Demographic Data

A total of 219 women completed pretreatment questionnaires, 134 post treatment, and 96 at 3-month follow-up visit. The total study group had an incidence of 22% positive HIV status. There was a significant difference in loss to follow-up between HIV-positive and HIV-negative patients (Figure 1). The women undergoing radiation therapy or chemoradiation therapy were further analyzed. Mean ages of the 2 treatment groups were similar. The radiation therapy group had significantly more pensioners

Discussion

The study on women treated for cervical cancer at Tygerberg Hospital found demographic differences between women treated with radiation therapy and chemoradiation therapy. Monthly incomes were similar, but there were more women with incomes below the poverty line in the radiation therapy group. Black pensioners underwent radiation therapy more than chemoradiation therapy. The stage distribution was significantly different among the treatment groups, and radiation therapy was used more in stage

Conclusions

Chemoradiation therapy is an appropriate treatment in selected patients. The enhancement of quality of life of women with cervical cancer treated with radiation therapy and chemoradiation therapy is of a similar magnitude in the majority of quality of life domains. In selected domains, chemoradiation therapy is associated with better improvement in quality of life than radiation therapy. Selection bias exists in the initial selection of patients to receive either therapy. This bias is related

Conflicts of Interest

The authors have indicated that they have no conflicts of interest regarding the content of this article.

Acknowledgments

This research is part of a PhD thesis (G. C. Du Toit) with promotor Prof. T. F. Kruger, Department of Obstetrics and Gynaecology, Stellenbosch University. The members of the Unit of Gynaecological Oncology, Tygerberg Hospital, and the head of the unit, Prof. M. H. Botha, are acknowledged for their assistance. G. C. Du Toit planned the study protocol, collected the data, and wrote the article. M. Kidd performed the statistical analysis.

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The purpose of this study was to assess the sexuality of cervical cancer patients undergoing radiotherapy at a major cancer treatment center in Ghana. This is an area of interest as globally; cervical cancer kills approximately 342,000 people per annum with an estimated number of 604,000 new cases in 2020. Acknowledging the World Health Organization's definition of sexual health as a state of physical, mental and social well-being in relation to sexuality, this paper sheds light on how these dimensions affect the quality of life of cervical cancer patients.
This was a longitudinal study, which assessed the impact of radiotherapy on the sexuality of both premenopausal and postmenopausal cervical cancer patients presenting for primary treatment with chemoradiation from April to July, 2021 at a major cancer treatment centre in Ghana. The Female Sexual Function Index and Body Image Scale questionnaires were respectively used to evaluate the sexual functions scores among the cervical cancer patients, and to assess the impact of the treatment on their body image. MATLAB software was used for data analysis.
Most of the cervical cancer patients sampled were postmenopausal (57 %). About 79 % premenopausal and 96 % postmenopausal cervical cancer patients were sexually inactive during radiotherapy (day 15). Also, 48 % premenopausal and 24 % postmenopausal patients were very dissatisfied with their bodies at the onset of treatment. The frequency of orgasm in cervical cancer patients declined after treatment causing a deterioration in their sexual function. The patients' sexuality was influenced by age and menopausal status. The decreased sexual desire of the patients resulted in emotional distancing from their partners, which invariably induced changes in their partners’ level of sexual interest. This study established significant differences between premenopausal and postmenopausal cervical cancer patients who were generally very dissatisfied with their sexual relationships with their partners on day 1 (p = 0.02) and on day 15 (p = 0.00) of treatment.
The majority of patients who presented for treatment for cervical cancer in this study were postmenopausal. Their interest in sexual activity was more influenced by their menopausal status than their antineoplastic treatment. This study indicates that cervical cancer patients are more likely to develop sexual health problems which could substantially worsen over the course of their treatment and beyond.
The study will contribute within the oncology team by assisting personnel in putting in place measures that will guide the treatment of cervical cancer patients and improve quality of care.
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It was observed that most of the participants were single, followed by cohabitating, divorced, and once married, contrary to previous findings in which the predominant marital statuses were married and single (Parra and Carrillo, 2011), and others that have found married to be the most common marital status of participants in a sample from Cartagena, Colombia (Castillo et al., 2015). On the other hand, Campbell et al. (2015) found in a sample from South Africa that the most common marital status was single, followed by married. All of the above denote that having support from one partner grants emotional stability and courage in facing the disease.
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However, the mean age of our sample (45.7 years) was younger than the mean age of 50 found by both Snyman and Herbst (2013) and Du Toit and Kidd (2015) and the age of 53 described in the study of Kaila and Maree (2018). Similar to our study, most of the women in the studies conducted in Gauteng Province (Snyman & Herbst, 2013; Kaila & Maree, 2018) were single, which is in contrast with the study conducted in the Western Cape (Du Toit & Kidd, 2015) where a larger percentage of women were married and widowed. The literacy level of our respondents was comparable to the study of Kaila and Maree (2018) and higher than the participants in the study of Snyman and Herbst (2013).
Cervical cancer is the second most common cancer in South African women, but the most common cancer in Black women. Despite cervical cancer screening being available, most women present with late stage disease requiring the standard curative treatment of radiotherapy, with or without chemotherapy. Cervical cancer and its treatment have various side effects, which have a negative influence on sexual function. Our study aimed at describing the sexual function of women treated for cervical cancer at an academic hospital, in the third (M3), sixth (M6) and twelfth months (M12) after completing treatment. A cross sectional design, convenience sampling and calculated sample size (n = 147) were used. Structured interviews were conducted to collect the data, and the Female Sexual Function Index (FSFI) served as data collection instrument. Kruskal Wallis H and Chi-square tests were used to determine the relationships between the variables. The data were collected between July and August 2015. The majority of the women (94.6%; n = 139) experienced sexual dysfunction, which persisted over time. The most affected domain was arousal, whilst satisfaction was the least affected. Pain experienced during sexual activity persisted as time progressed. Age, educational level, the type of treatment received and having had sexual counselling before treatment commenced did not influence sexual function. Our study provided evidence that the majority of women treated for cervical cancer live with long lasting sexual dysfunction affecting all sexual function domains. Although sexual dysfunction reached the highest level in the third month after treatment, there was little improvement over time.
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The QOL of cervical cancer patients is affected by general health status and good relationships between the patients and healthcare professionals13. Cervical cancer patients receiving chemotherapy may experience a number of side effects, such as pain, fatigue, nausea, vomiting, and poor appetite, and they affect the QOL of these patients14. Poor management of the treatment's side effects and inadequate self-care negatively affect the QOL of patients6,15.
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Prospective Quality of Life Study of South African Women Undergoing Treatment for Advanced-stage Cervical Cancer

Abstract

Purpose

Methods

Findings

Implications

Introduction

Section snippets

Inclusion Criteria

Demographic Data

Discussion

Conclusions

Conflicts of Interest

Acknowledgments

Ann Oncol

Lancet

Clin Oncol (R Coll Radiol)

Clin Oncol (R Coll Radiol)

Clin Oncol

Radiother Oncol

Int J Radiat Oncol Biol Phys

Clinical prognostic parameters in Stage III cervical carcinoma

S Afr Med J