Top

Published in:

01-10-2019 | Brachytherapy | Original Article

The impact of vaginal dilator use on vaginal stenosis and sexual quality of life in women treated with adjuvant radiotherapy for endometrial cancer

Authors: Dr. Sati Akbaba, MD, Dr. Jan T. Oelmann-Avendano, MD, Dr. David Krug, MD, Dr. Nathalie Arians, MD, Dr. Tilman Bostel, MD, PD Dr. Juliane Hoerner-Rieber, MD, PD Dr. Dr. Nils H. Nicolay, MD PhD, Prof. Dr. Dr. Juergen Debus, MD PhD, Prof. Dr. Katja Lindel, MD, PD Dr. Robert Foerster, MD

Published in: Strahlentherapie und Onkologie | Issue 10/2019

Abstract

Background

Despite a lack of evidence and low compliance, current guidelines recommend the use of a vaginal dilator (VD) after pelvic radiotherapy (RT). We analyzed the effect of VD on vaginal stenosis (VS) and its influence on sexual quality of life (QoL) in women treated with adjuvant RT for endometrial cancer (EC).

Methods

Between 2014 and 2015, 56 consecutive patients were instructed to use a VD after completion of treatment. The maximum diameter of the comfortably introducible VD was measured before and at 1 year after treatment. The degree of VS was evaluated clinically, and sexual QoL was assessed with the European Organisation for Research and Treatment of Cancer (EORTC) sexual functioning items before RT, during RT, at 6 weeks, and at 1 year after RT.

Results

One year after RT, mean VD diameter had decreased by 2.7 ± 3.2 mm (p < 0.001) and 36 patients (64.3%) had clinical VS (grade I–III). A larger decrease in VD diameter correlated with a higher degree of clinical VS (p < 0.001). VD use (p = 0.81), RT modality (p = 0.68), and adjuvant ChT (p = 0.87) had no influence on VD diameter. Sexual activity decreased during RT and increased beyond pre-RT values 1 year after RT (p < 0.001). Sexual enjoyment decreased continuously during and after completion of RT (p = 0.013) and was influenced negatively by a higher degree of clinical VS (p = 0.01).

Conclusion

Almost two thirds of patients developed clinical VS 1 year after adjuvant RT for EC, and sexual enjoyment was substantially reduced by VS. The use of a VD after RT may not serve to prevent sexual impairments and VS.

Group AES, Blake P, Swart AM, Orton J, Kitchener H, Whelan T, Lukka H, Eisenhauer E, Bacon M, Tu D et al (2009) Adjuvant external beam radiotherapy in the treatment of endometrial cancer (MRC ASTEC and NCIC CTG EN.5 randomised trials): pooled trial results, systematic review, and meta-analysis. Lancet 373(9658):137–146CrossRef

Creutzberg CL, van Putten WL, Koper PC, Lybeert ML, Jobsen JJ, Warlam-Rodenhuis CC, De Winter KA, Lutgens LC, van den Bergh AC, van der Steen-Banasik E et al (2001) The morbidity of treatment for patients with Stage I endometrial cancer: results from a randomized trial. Int J Radiat Oncol Biol Phys 51(5):1246–1255CrossRef

Foerster R, Schnetzke L, Bruckner T, Arians N, Rief H, Debus J, Lindel K (2016) Prognostic factors for long-term quality of life after adjuvant radiotherapy in women with endometrial cancer. Strahlenther Onkol 192(12):895–904CrossRef

Aerts L, Enzlin P, Verhaeghe J, Vergote I, Amant F (2009) Sexual and psychological functioning in women after pelvic surgery for gynaecological cancer. Eur J Gynaecol Oncol 30(6):652–656PubMed

Nout RA, Smit VT, Putter H, Jurgenliemk-Schulz IM, Jobsen JJ, Lutgens LC, van der Steen-Banasik EM, Mens JW, Slot A, Kroese MC et al (2010) Vaginal brachytherapy versus pelvic external beam radiotherapy for patients with endometrial cancer of high-intermediate risk (PORTEC-2): an open-label, non-inferiority, randomised trial. Lancet 375(9717):816–823CrossRef

Creutzberg CL, van Putten WL, Koper PC, Lybeert ML, Jobsen JJ, Warlam-Rodenhuis CC, De Winter KA, Lutgens LC, van den Bergh AC, van de Steen-Banasik E et al (2000) Surgery and postoperative radiotherapy versus surgery alone for patients with stage-1 endometrial carcinoma: multicentre randomised trial. PORTEC Study Group. Post Operative Radiation Therapy in Endometrial Carcinoma. Lancet 355(9213):1404–1411CrossRef

Keys HM, Roberts JA, Brunetto VL, Zaino RJ, Spirtos NM, Bloss JD, Pearlman A, Maiman MA, Bell JG, Gynecologic Oncology Group (2004) A phase III trial of surgery with or without adjunctive external pelvic radiation therapy in intermediate risk endometrial adenocarcinoma: a Gynecologic Oncology Group study. Gynecol Oncol 92(3):744–751CrossRef

Sorbe B, Horvath G, Andersson H, Boman K, Lundgren C, Pettersson B (2012) External pelvic and vaginal irradiation versus vaginal irradiation alone as postoperative therapy in medium-risk endometrial carcinoma—a prospective randomized study. Int J Radiat Oncol Biol Phys 82(3):1249–1255CrossRef

de Boer SM, Nout RA, Jurgenliemk-Schulz IM, Jobsen JJ, Lutgens LC, van der Steen-Banasik EM, Mens JW, Slot A, Stenfert Kroese MC, Oerlemans S et al (2015) Long-term impact of Endometrial cancer diagnosis and treatment on health-related quality of life and cancer survivorship: results from the randomized PORTEC-2 trial. Int J Radiat Oncol Biol Phys 93(4):797–809CrossRef

10.

Nout RA, van de Poll-Franse LV, Lybeert ML, Warlam-Rodenhuis CC, Jobsen JJ, Mens JW, Lutgens LC, Pras B, van Putten WL, Creutzberg CL (2011) Long-term outcome and quality of life of patients with endometrial carcinoma treated with or without pelvic radiotherapy in the post operative radiation therapy in endometrial carcinoma 1 (PORTEC-1) trial. J Clin Oncol 29(13):1692–1700CrossRef

11.

Nout RA, Putter H, Jurgenliemk-Schulz IM, Jobsen JJ, Lutgens LC, van der Steen-Banasik EM, Mens JW, Slot A, Stenfert Kroese MC, Nijman HW et al (2012) Five-year quality of life of endometrial cancer patients treated in the randomised Post Operative Radiation Therapy in Endometrial Cancer (PORTEC-2) trial and comparison with norm data. Eur J Cancer 48(11):1638–1648CrossRef

12.

Onujiogu N, Johnson T, Seo S, Mijal K, Rash J, Seaborne L, Rose S, Kushner DM (2011) Survivors of endometrial cancer: who is at risk for sexual dysfunction? Gynecol Oncol 123(2):356–359CrossRef

13.

Quick AM, Seamon LG, Abdel-Rasoul M, Salani R, Martin D (2012) Sexual function after intracavitary vaginal brachytherapy for early-stage endometrial carcinoma. Int J Gynecol Cancer 22(4):703–708CrossRef

14.

Hartman P, Diddle AW (1972) Vaginal stenosis following irradiation therapy for carcinoma of the cervix uteri. Cancer 30(2):426–429CrossRef

15.

Seibel M, Freeman MG, Graves WL (1982) Sexual function after surgical and radiation therapy for cervical carcinoma. South Med J 75(10):1195–1197CrossRef

16.

Miles T, Johnson N (2010) Vaginal dilator therapy for women receiving pelvic radiotherapy. Cochrane Database Syst Rev 9:CD7291

17.

Park HS, Ratner ES, Lucarelli L, Polizzi S, Higgins SA, Damast S (2015) Predictors of vaginal stenosis after intravaginal high-dose-rate brachytherapy for endometrial carcinoma. Brachytherapy 14(4):464–470CrossRef

18.

Bonner C, Nattress K, Anderson C, Carter J, Milross C, Philp S, Juraskova I (2012) Chore or priority? Barriers and facilitators affecting dilator use after pelvic radiotherapy for gynaecological cancer. Support Care Cancer 20(10):2305–2313CrossRef

19.

Cullen K, Fergus K, Dasgupta T, Fitch M, Doyle C, Adams L (2012) From “sex toy” to intrusive imposition: a qualitative examination of women’s experiences with vaginal dilator use following treatment for gynecological cancer. J Sex Med 9(4):1162–1173CrossRef

20.

Hinz A, Singer S, Brahler E (2014) European reference values for the quality of life questionnaire EORTC QLQ-C30: results of a German investigation and a summarizing analysis of six European general population normative studies. Acta Oncol 53(7):958–965CrossRef

21.

Fagotti A, Fanfani F, Ercoli A, Giordano MA, Sallustio G, Scambia G (2007) Postoperative ileus after para-aortic lymphadenectomy: a prospective study. Gynecol Oncol 104(1):46–51CrossRef

22.

van de Poll-Franse LV, Pijnenborg JM, Boll D, Vos MC, van den Berg H, Lybeert ML, de Winter K, Kruitwagen RF (2012) Health related quality of life and symptoms after pelvic lymphadenectomy or radiotherapy vs. no adjuvant regional treatment in early-stage endometrial carcinoma: a large population-based study. Gynecol Oncol 127(1):153–160CrossRef

23.

Todo Y, Yamamoto R, Minobe S, Suzuki Y, Takeshi U, Nakatani M, Aoyagi Y, Ohba Y, Okamoto K, Kato H (2010) Risk factors for postoperative lower-extremity lymphedema in endometrial cancer survivors who had treatment including lymphadenectomy. Gynecol Oncol 119(1):60–64CrossRef

24.

Tanaka H, Sato H, Miura H, Sato N, Fujimoto T, Konishi Y, Takahashi O, Tanaka T (2006) Can we omit para-aorta lymph node dissection in endometrial cancer? Jpn J Clin Oncol 36(9):578–581CrossRef

25.

Larson DM, Johnson K, Olson KA (1992) Pelvic and para-aortic lymphadenectomy for surgical staging of endometrial cancer: morbidity and mortality. Obstet Gynecol 79(6):998–1001PubMed

26.

Klee M, Machin D (2001) Health-related quality of life of patients with endometrial cancer who are disease-free following external irradiation. Acta Oncol 40(7):816–824CrossRef

27.

Becker M, Malafy T, Bossart M, Henne K, Gitsch G, Denschlag D (2011) Quality of life and sexual functioning in endometrial cancer survivors. Gynecol Oncol 121(1):169–173CrossRef

28.

Nout RA, Putter H, Jurgenliemk-Schulz IM, Jobsen JJ, Lutgens LC, van der Steen-Banasik EM, Mens JW, Slot A, Stenfert Kroese MC, van Bunningen BN et al (2009) Quality of life after pelvic radiotherapy or vaginal brachytherapy for endometrial cancer: first results of the randomized PORTEC-2 trial. J Clin Oncol 27(21):3547–3556CrossRef

29.

von Gruchalla B, Hahlweg-Widmoser B, Gugger B, Teschner A, Debus G (2003) Peri- and postmenopausal changes—body awareness, sexuality, and self-image of the middle-aged and older woman. Zentralbl Gynakol 125(6):202–208CrossRef

30.

Greimel E, Nordin A, Lanceley A, Creutzberg CL, van de Poll-Franse LV, Radisic VB, Galalae R, Schmalz C, Barlow E, Jensen PT et al (2011) Psychometric validation of the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-Endometrial Cancer Module (EORTC QLQ-EN24). Eur J Cancer 47(2):183–190CrossRef

31.

Cleary V, Hegarty J, McCarthy G (2011) Sexuality in Irish women with gynecologic cancer. Oncol Nurs Forum 38(2):E87–96CrossRef

32.

Miles T, Johnson N (2014) Vaginal dilator therapy for women receiving pelvic radiotherapy. Cochrane Database Syst Rev 9:CD7291

33.

Robinson JW, Faris PD, Scott CB (1999) Psychoeducational group increases vaginal dilation for younger women and reduces sexual fears for women of all ages with gynecological carcinoma treated with radiotherapy. Int J Radiat Oncol Biol Phys 44(3):497–506CrossRef

34.

Decruze SB, Guthrie D, Magnani R (1999) Prevention of vaginal stenosis in patients following vaginal brachytherapy. Clin Oncol (r Coll Radiol) 11(1):46–48CrossRef

35.

Gondi V, Bentzen SM, Sklenar KL, Dunn EF, Petereit DG, Tannehill SP, Straub M, Bradley KA (2012) Severe late toxicities following concomitant chemoradiotherapy compared to radiotherapy alone in cervical cancer: an inter-era analysis. Int J Radiat Oncol Biol Phys 84(4):973–982CrossRef

36.

Bahng AY, Dagan A, Bruner DW, Lin LL (2012) Determination of prognostic factors for vaginal mucosal toxicity associated with intravaginal high-dose rate brachytherapy in patients with endometrial cancer. Int J Radiat Oncol Biol Phys 82(2):667–673CrossRef

37.

Bruner DW, Lanciano R, Keegan M, Corn B, Martin E, Hanks GE (1993) Vaginal stenosis and sexual function following intracavitary radiation for the treatment of cervical and endometrial carcinoma. Int J Radiat Oncol Biol Phys 27(4):825–830CrossRef

38.

Sobotkowski J, Markowska J, Fijuth J, Pietraszek A (2006) Preliminary results of mitomycin C local application as post-treatment prevention of vaginal radiation-induced morbidity in women with cervical cancer. Eur J Gynaecol Oncol 27(4):356–358PubMed

39.

40.

Law E, Kelvin JF, Thom B, Riedel E, Tom A, Carter J, Alektiar KM, Goodman KA (2015) Prospective study of vaginal dilator use adherence and efficacy following radiotherapy. Radiother Oncol 116(1):149–155CrossRef

41.

Son CH, Law E, Oh JH, Apte AP, Yang TJ, Riedel E, Wu AJ, Deasy JO, Goodman KA (2015) Dosimetric predictors of radiation-induced vaginal stenosis after pelvic radiation therapy for rectal and anal cancer. Int J Radiat Oncol Biol Phys 92(3):548–554CrossRef

42.

Johnson N, Batchelor A, Lilford RJ (1991) Experience with tissue expansion vaginoplasty. Br J Obstet Gynaecol 98(6):564–568CrossRef

43.

Hoffman MS, Wakeley KE, Cardosi RJ (2003) Risks of rigid dilation for a radiated vaginal cuff: two related rectovaginal fistulas. Obstet Gynecol 101(5 Pt 2):1125–1126PubMed

Title: The impact of vaginal dilator use on vaginal stenosis and sexual quality of life in women treated with adjuvant radiotherapy for endometrial cancer
Authors: Dr. Sati Akbaba, MD
Dr. Jan T. Oelmann-Avendano, MD
Dr. David Krug, MD
Dr. Nathalie Arians, MD
Dr. Tilman Bostel, MD
PD Dr. Juliane Hoerner-Rieber, MD
PD Dr. Dr. Nils H. Nicolay, MD PhD
Prof. Dr. Dr. Juergen Debus, MD PhD
Prof. Dr. Katja Lindel, MD
PD Dr. Robert Foerster, MD
Publication date: 01-10-2019
Publisher: Springer Berlin Heidelberg
Keywords: Brachytherapy
Endometrial Cancer
Endometrial Cancer
Radiotherapy
Published in: Strahlentherapie und Onkologie / Issue 10/2019
Print ISSN: 0179-7158
Electronic ISSN: 1439-099X
DOI: https://doi.org/10.1007/s00066-019-01466-1

At a glance: The STEP trials

Springer Medicine

The impact of vaginal dilator use on vaginal stenosis and sexual quality of life in women treated with adjuvant radiotherapy for endometrial cancer

Abstract

Background

Methods

Results

Conclusion

At a glance: The STEP trials

Springer Medicine

Abstract

Background

Methods

Results

Conclusion

Please log in to get access to this content

Other articles of this Issue 10/2019

Rectal retractor application during image-guided dose-escalated prostate radiotherapy

Risk-adapted moderate hypofractionation of prostate cancer

Results of a multicenter intensity modulated radiation therapy treatment planning comparison study for a sample prostate cancer case

Treatment outcomes of prostate cancer patients with Gleason score 8–10 treated with definitive radiotherapy

Heart-sparing radiotherapy techniques in breast cancer patients: a recommendation of the breast cancer expert panel of the German society of radiation oncology (DEGRO)

Outcome of loco-regional radiotherapy in metastatic castration-resistant prostate cancer patients treated with abiraterone acetate