Introduction

There have been tremendous advances to increase the survival rates of women diagnosed with gynecological malignancies [1], leading to calls for a greater focus on survivorship care. This population is at high risk of developing sexual dysfunctions [2]. Painful sexual intercourse, or dyspareunia, is frequent, afflicting up to 67% of gynecological cancer survivors [3]. Women suffer from psychological distress and relationship issues, which undermine their quality of life [4]. Side effects of cancer treatments such as dyspareunia also tend to persist or worsen over time [5], and women have persistent unaddressed sexual difficulties [5,6,7].

Pelvic floor physical therapy (PFPT) has been proposed in survivorship guidelines to address dyspareunia [8,9,10]. This multimodal treatment may entail an educational module, manual therapy techniques, pelvic floor muscle exercises with biofeedback, and home exercises including insertion exercises with a dilator. A recent study has investigated a 12-week multimodal PFPT treatment in a cohort of gynecological cancer survivors with dyspareunia [11]. Results suggested a reduction in pain as well as an improvement in sexual function [11], pelvic floor muscle function [12], and psychosexual outcomes [13] immediately at post-treatment. Data collected at 12-month follow-up suggested that these improvements were maintained over time [14]. Overall, findings indicate that women with dyspareunia could benefit from multimodal PFPT. The evidence further suggests that multimodal PFPT should be considered in the cancer care continuum. However, data informing us whether it could be implemented in clinical settings are scarce.

Acceptability has become a key component in the development and implementation phases of complex treatments (e.g., multimodal treatment) in survivorship care [15, 16]. This multifaceted construct reflects the extent to which people consider a treatment avenue to be appropriate [17]. Appropriateness of treatment is based on cognitive and emotional responses of patients, which have been hypothesized to relate to satisfaction and participation behavior [17, 18]. For instance, if some aspects of a treatment are viewed as inappropriate, patients may not fully participate and may be dissatisfied, questioning whether the treatment could, or even should, be implemented. Accordingly, examining treatment acceptability would provide insight for implementation purposes and help avoid resource waste. To date, only quantitative data concerning the acceptability of multimodal PFPT in gynecological cancer survivors with dyspareunia are available. A mean adherence to home exercises of 88%, a mean attendance rate at treatment sessions of 93%, and an average satisfaction rate of 93% have been reported [11], providing an incomplete perspective of this treatment’s acceptability. Careful consideration of patients’ views and experiences provides the best opportunity to deepen our understanding of treatment acceptability, and their suggestions for improvements can be used to optimize treatment in clinical settings [17, 19].

Given that the development and implementation of effective treatments is a priority to help gynecological cancer survivors preserve or achieve a healthy sexual life [5,6,7], the aim of this qualitative study was to explore the views and experiences of gynecological cancer survivors with dyspareunia regarding the acceptability of multimodal PFPT treatment.

Materials and methods

Study design

This qualitative study was conducted in the Province of Quebec, Canada, and it followed a multicenter prospective interventional study investigating a multimodal PFPT treatment for gynecological cancer survivors with dyspareunia [11,12,13,14]. Individual semi-structured telephone interviews were carried out at 12-month follow-up, allowing participants to take a step back from the treatment. The study was approved by the institutional ethics committee, and the interventional study was registered on ClinicalTrials.gov (NCT03935698). Written informed consent was obtained from eligible women agreeing to participate.

Participants

Thirty-one women who received a diagnosis of endometrial or cervical cancer (stages I-IV) and had completed all cancer treatments for at least 3 months were recruited in the multicenter prospective interventional study. Gynecological cancer survivors had to have suffered regularly from moderate to severe vulvovaginal pain during sexual intercourse for at least 3 months. They also had to have a regular sexual partner and be willing to resume sexual activities with vaginal penetration. The main exclusion criteria were: (1) dyspareunia prior to cancer or pelvic pain unrelated to intercourse, (2) other pelvic conditions (e.g., urinary tract or vaginal infection, deep pelvic pain, chronic constipation, or severe pelvic organ descent) or pelvic surgery unrelated to cancer, (3) other primary pelvic cancer or breast cancer, (4) received PFPT in the last year, and (5) any coexisting significant medical conditions that were likely to interfere with the study procedures.

Treatment

The treatment was free of charge and consisted of 12 weekly individual sessions of multimodal PFPT that were delivered at a research center facility. Women were under the care of an experienced female physical therapist in pelvic health. Each week, the participants were invited to attend a 60-min in-person session in which the therapist used different modalities to reduce dyspareunia. Information on dyspareunia such as its pathophysiology and how the treatment may help in reducing the pain was provided. The physical therapist gave tips to alleviate and better manage dyspareunia, for instance by using vaginal lubricants, moisturizers, and relaxation and breathing techniques. Women were guided into resuming non-painful sexual activities with their partner. The latter was invited to take part in treatment to learn how to assist their partner in this process. Moreover, the physical therapist gave extensive explanations on how to prevent and treat pelvic floor disorders. Beside all the psychosexual-educational content that was given on hard copy and discussed with the therapist at each session, manual therapy techniques were performed externally and intravaginally on the pelvic floor muscles by the physical therapist. In addition, electromyography biofeedback with an intravaginal probe was used during the session under the supervision of the therapist. Furthermore, women were asked to complete a home exercise program regularly in which the exercises were similar to those carried out during the session. Home exercises entailed relaxation, coordination, strength, and endurance exercises five times per week as well as auto-insertion and desensitization exercises with a finger or vaginal dilator three times per week. It should be noted that all modalities gradually progressed in intensity (e.g., more pressure applied to stretch the tissues, longer duration of the technique or exercise, and greater dilator size), depending on each woman’s progress. The physical therapist also provided feedback on home exercises by means of a diary that was completed daily by the participants. Further details pertaining to the treatment protocol are provided elsewhere [11].

Data collection

The individual semi-structured telephone interviews lasted approximately 70 min. Prior to the interview, participants were informed about the topics to be discussed. They were also advised to read the documentation they were given during the study to refresh their memory and reflect on their experience. All interviews were conducted by the first author (MPC) who has an expertise in pelvic health, completed qualitative research training, and helped in designing the treatment but was not involved in the participants’ care. A nonjudgmental approach was used to create a genuine respectful relationship to ease the discussion about what could be perceived by women as intimate topics. The interviews were audio-recorded with the prior consent of the women. The interviewer used open-ended questions as well as probing questions addressing the following: (1) the women’s views and experiences of multimodal PFPT regarding its appropriateness, (2) the women’s participation, and (3) the women’s degree of satisfaction and suggestions for improvements. The interviews followed a semi-structured guide (Supplementary material), intersecting with the framework proposed by Sekhon et al. [17]. In addition, participants were asked if there were any changes in their health and if they had sought or undergone other treatments for dyspareunia or sexual dysfunction in the last 12 months.

Sample size

All women who participated in the treatment were invited to take part in the individual semi-structured telephone interview, regardless of their treatment response, to provide various views and experiences.

Data analysis

The first author (MPC) performed verbatim transcription of each interview and analyzed the transcripts using NVivo (version 12) software. To ensure data-driven analyses and interpretations, an inductive approach was adopted where the first author (MPC) applied codes to key ideas and then identified emerging themes [20]. Subsequently, the codes were reviewed (RD followed by MM and CC), and coding disagreements were discussed until a consensus was reached. Several meetings were convened to regroup codes into themes and subthemes. Relationships between themes and subthemes were explored by observing patterns across them. Field notes were used to explore researcher reflexivity and further support the interpretation of data. Quotations in English (n = 2) and quotations freely translated from French to English and revised by a certified translator (n = 26) were selected to illustrate the women’s input.

Results

Of the 31 gynecological cancer survivors with dyspareunia who participated in the multimodal PFPT treatment, 28 women took part in the interview (Fig. 1). One woman withdrew during treatment because of a serious illness in the family, one woman was lost to follow-up, and one was unavailable to take part in the interview because she was a healthcare provider required to work longer hours because of the coronavirus (COVID-19) pandemic; also, her partner had just been diagnosed with cancer (Fig. 1).

Fig. 1
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Flowchart

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At baseline, the participants’ mean age was 56 (SD 11) years. The women received different oncological treatments: 77% had surgery, 61% had brachytherapy, 48% had external beam radiation therapy, and 52% had chemotherapy. They completed all planned treatments for gynecological malignancies for a median time of 38 (Q1 9 to Q3 70) months before enrolling in the study. Eighteen (58%) women were married, seven (23%) were in a common-law relationship, and six (19%) were single but engaged in a relationship. Three (10%) women reported they had attended a few sessions of multimodal PFPT treatment more than 1 year before their enrollment. Additional details on baseline characteristics can be found elsewhere [11]. During the follow-up period, three women had a cancer recurrence or another cancer and one woman had a severe upper urinary tract infection. No woman stated that she had attempted other treatments for pain or sexual dysfunction after treatment, and only one reported being no longer with her partner. No significant difference in participant characteristics and treatment response was found between those who participated and those who did not participate in the interview.

Three themes emerged from the interview transcripts: (1) appropriateness of treatment characteristics; (2) balance between participation and treatment effectiveness; (3) satisfaction with the treatment and recommendations. The themes are described below, and participants’ quotes are presented sequentially according to themes in Tables 1, 2, and 3. Figure 2 illustrates the interactions between the themes and the subthemes.

Table 1 Quotes underlying Theme 1
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Table 2 Quotes underlying Theme 2
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Table 3 Quotes underlying Theme 3
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Fig. 2
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Acceptability of multimodal PFPT treatment

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Theme 1: Appropriateness of treatment characteristics

Subtheme 1.1: Modalities

Almost all participants did not know about multimodal PFPT at the beginning of the study, which led them to believe that this treatment would not alleviate dyspareunia or sexual dysfunction (quote 1). However, all of them acknowledged at some point that, while gaining knowledge, this treatment made sense and was suitable for improving sexual and pelvic health (quote 1). Our cohort did not express a preference regarding the modalities as all were perceived as helpful and complementary (i.e., the educational module, manual therapy techniques, pelvic floor muscle exercises with biofeedback, and home exercises including insertion exercises with a dilator), and women underlined that the treatment provided them with useful knowledge and tools that lasted over time (quotes 2 to 5).

Subtheme 1.2: Physical therapist

All women expressed their appreciation of their physical therapist (quotes 6 to 11). They described this appreciation by detailing their therapist’s great humane qualities (e.g., considerate, empathic, gentle, kind, and respectful), competency, and skills (quotes 6 to 10). These features were perceived as essential to help women confront, manage, and reduce their sexual problems (quotes 6 to 10). The physical therapist was viewed as an invaluable asset as the participants emphasized how she set the pace, led the treatment in a sequential and predictable manner, was available for women to discuss any issues, and adjusted the modalities from session to session (quotes 8 to 10). It should be noted that those who had more than one treating physical therapist reported they were comfortable because they did not feel their treatment was jeopardized (quote 10). While there was no treating male physical therapist in the current study, several participants stressed their preference for being treated by a woman (quote 11).

Subtheme 1.3: Care delivery

All participants reported that they appreciated the treatment being offered individually and in person (quotes 12 and 13). Several women specified that they would not have been comfortable to participate in a group intervention to discuss the intimate topic of pain and sexuality after cancer (quote 12). Participants felt that the physical contact with the physical therapist provided them with personalized advice and feedback (quotes 12 and 13). Participants concurred that it allowed them to benefit from the techniques performed by the therapist, which would have been difficult in a group or telehealth intervention (quotes 12 and 13).

Subtheme 1.4: Intensity

Treatment intensity was depicted in terms of number and frequency of sessions and home exercises. Most participants found the number of sessions (i.e., 12) and the frequency (i.e., one session per week and home exercises five times per week) appropriate for learning and for noticing important effects (quotes 14 and 15). A few women described the treatment as demanding at first (quote 16). Nonetheless, all of them acknowledged over time that this intensity was relevant (quotes 15 and 16).

Theme 2: Balance between participation and treatment effectiveness

According to the quotes of Subtheme 1.4, women designated the multimodal PFPT treatment as acceptable by weighing their efforts (i.e., participation) against the results they obtained (i.e., treatment effectiveness) (quote 17). As our cohort attributed importance to this ratio, participants described the enablers that overcame the barriers of women’s participation in the multimodal PFPT treatment. Participation was portrayed as the level to which they conformed to the treatment as prescribed (i.e., attendance at sessions and adherence to home exercises) and followed the advice given by the treating physical therapist. The enablers and barriers of participation related to treatment effects, treatment characteristics, and women’s beliefs and attitudes are presented below.

Subtheme 2.1: Participation and treatment effects

A large proportion of our cohort reported experiencing significant positive effects [11,12,13] after the multimodal PFPT treatment, some specifying that these began to appear as early as the third session (quote 18). As women were also able to observe their progress (e.g., increase in muscle control with biofeedback or upgrading the size of dilator) during the treatment (quotes 19 and 20), they explained that they were encouraged to pursue their efforts which, in turn, increased the treatment effectiveness (quote 18). It should be pointed out that the majority of our cohort reported that the treatment effects were maintained during the follow-up period while a few admitted that these were attenuated over time [14].

Subtheme 2.2: Participation and treatment characteristics

As deduced from quotes of Subtheme 1.4 and Subtheme 2.1, the high treatment intensity was cited as the most important factor that could discourage women from participating in the multimodal PFPT treatment (quote 21). Although these factors were not as prominent or relevant in the current study, the location, the cost, and the timing of the treatment were raised by some women to potentially impede participation (quotes 21 and 22). This led women to make a few suggestions to adjust the treatment. They suggested that initiating the treatment through other types of care delivery, giving first-hand information to manage sexual problems and subsequently offer more intensive care could be considered, particularly when environmental barriers prevent women from attending the treatment (i.e., women living in remote areas or when transportation is unsafe due to the weather) (quotes 21 and 22). As reflected in the quotes from Subtheme 1.3, participants implied that care delivery facilitated their participation in the multimodal PFPT treatment. Moreover, several of them reported that the structure and the supervision provided, with the back-and-forth with their therapist, motivated them to conform to the treatment (quotes 23 and 24). The physical therapist, through her positive and supportive attitude, was largely reported as a facilitator for women’s participation, and many women emphasized they enjoyed being with their therapist and how their relationship made them more committed to the treatment (quote 24).

Subtheme 2.3: Participation, women’s beliefs and attitudes

Although most of the participants did not know what multimodal PFPT entailed (Subtheme 1.1), the women stated that they were prepared and even determined to participate and complete the treatment (quotes 25 to 29). They explained how their needs and goals (i.e., willingness to improve their situation or attempt to reach the highest effectiveness), their beliefs regarding their sexual problems or engagement in treatment, their personality trait (i.e., highly committed person), and the research context (i.e., opportunity to help other women) played a role in their participation (quotes 25 to 29). Treatment expectations were diversified in our cohort (i.e., no expectations to high expectations) but were not perceived by women as a determinant of participation (quotes 26 and 28). Some women described how much their beliefs and attitudes changed during the treatment (quotes 25 and 29), and some said that their partner contributed to their participation (quote 30).

Theme 3: Satisfaction with the treatment and recommendations

Following the logical extension of Theme 1 and Theme 2, the participants said they were highly satisfied as they explained their positive experiences during the multimodal PFPT treatment and the balance between their participation and the treatment effectiveness they perceived (quotes 31 and 32). They particularly expressed their satisfaction when the treatment outcomes met their needs or reached, or even exceeded, their initial expectations (quote 32). To emphasize their satisfaction, some women compared their experience of multimodal PFPT with previous unsatisfactory treatment attempts (quote 33). Consequently, all participants recommended multimodal PFPT for women who have been treated for gynecological malignancies (quotes 31 to 34). Our cohort also stressed that multimodal PFPT should be automatically offered, free of charge, in the gynecological cancer care continuum, particularly considering that physical therapy services are supplied to treat other outpatient populations (e.g., after breast cancer treatment or orthopedic surgery and pain conditions) (quotes 31 to 34). Moreover, several participants highlighted the complementary role of physical therapists in multidisciplinary survivorship care (quotes 33 and 34).

Discussion

This is the first qualitative study to examine extensively the acceptability of multimodal PFPT. This treatment was found acceptable according to women who developed dyspareunia after gynecological malignancies. Our cohort described how the treatment was appropriate in terms of modalities, physical therapist, care delivery, and intensity. While the treatment intensity could be viewed as demanding, all participants stressed that it was relevant to see significant improvements. They explained that noticing the effects during the treatment encouraged them to pursue their participation. The physical therapist and the care delivery (i.e., treatment-related factors) as well as the women’s beliefs and attitudes (i.e., women-related factors) were also identified by women to facilitate their participation. Participants expressed their high satisfaction with the treatment as they detailed their positive experiences and the balance between their participation and the treatment effectiveness they perceived. All women recommended this multimodal PFPT treatment.

The multimodal PFPT treatment was found acceptable as our cohort described the modalities, the physical therapist, the care delivery, and the intensity as appropriate. Very few studies have examined the acceptability of multimodal PFPT in similar terms in gynecological cancer survivors [21,22,23]. The study of Lindgren et al. [23] described gynecological cancer survivors’ views and experiences (n = 13) of pelvic floor muscle training for treating incontinence. Although women had little or no experience with pelvic floor muscle training, they had a positive attitude toward this treatment [23], which is in line with the input of our cohort who did participate in a multimodal PFPT treatment. Women from the study of Lindgren et al. [23] also underlined the importance of being instructed by a competent professional [23], which further emphasizes the role of the physical therapist, as highlighted in our study. Data available also imply that the professional’s supportive role and dilator use are helpful for resuming sexual activity [21, 22], which is consistent with our study. In contrast to studies supporting internet- and group-based interventions for sexual and psychosocial problems [24, 25], our participants expressed that they preferred an individual and in-person treatment approach. Women explained how it allowed them to receive relevant information and benefit from manual therapy techniques and proper feedback (e.g., guidance). These results stress the importance of designing and offering treatments according to women’s condition (e.g., dyspareunia). Given that our cohort perceived the modalities as helpful and complementary and did not express preference for specific modalities, all of them can be made available to women.

The participants of the present study compared their participation and the treatment effectiveness they perceived and deemed the multimodal PFPT treatment as acceptable. While the intensity of the treatment could have burdened some women, it was reported as important to see significant improvements. This is the first qualitative study showing how treatment-related and women-related factors can counterbalance the burden of a treatment. Several participation barriers (e.g., financial constraints, perceived lack of utility, time constraints, and travel issues) and enablers (e.g., increased knowledge, gain in tools and skills, perceived improved well-being, sense of validation and support, and enhanced sense of empowerment) [26, 27] of PFPT treatments have been reported in women with dyspareunia but without a history of cancer, which are in line with those identified in the current study. Furthermore, women reported that participation is a key element to reaching the highest treatment effectiveness. Although no interventional study has examined the participation behavior of gynecological cancer survivors with sexual problems in treatments, studies conducted in women with no history of cancer presenting with pelvic floor disorders highlighted that participation is important in the context of PFPT [28, 29]. Given the attributed importance of participation behavior in treatment effectiveness, future studies should include measures of participation behavior. Further work should also compare the effects of different types of care delivery and level of supervision on participation behavior and treatment effectiveness to determine which should be emphasized.

Our participants described their high satisfaction according to their positive experiences with the multimodal PFPT treatment characteristics and the balance between participation and treatment effectiveness. Moreover, all participants recommended the treatment, and some even suggested slight adjustments to make it more accessible to women. Consequently, results support the implementation of the multimodal PFPT treatment in the gynecological cancer care continuum. Our findings also support and may refine the theoretical framework of acceptability [17]. It has been hypothesized that acceptability (i.e., appropriateness of treatment based on cognitive and emotional responses) likely influences participation behavior with the treatment [17], which has been shown in the current study. Our results also suggest that satisfaction is interlaced with the appropriateness of treatment in a dynamic framework of acceptability in which different factors influence participation behavior. For instance, women said that they were satisfied as they perceived beneficial effects because of their participation in the treatment. This further encouraged their participation and, ultimately, counterbalanced the burden induced by the regimen intensity. This reflects the interaction between the multiple facets of treatment acceptability [30], which should be considered comprehensively.

Some limitations should be considered when interpreting the findings of this study. The generalizability is limited by the sampling method. Our sample was composed of women who agreed to participate in the multimodal PFPT treatment. This sample, however, allowed us to understand treatment acceptability, including the dynamic interplay of factors influencing participation which is essential in the context of rehabilitation [28, 29]. The participants were mostly Caucasian (97%), had a stable sexual partner, and were willing to resume sexual activities with vaginal penetration. Our results can be generalized to women who have similar characteristics. Although women’s age, cancer stage diagnosis, cancer treatments, time elapsed since these treatments, level of education, and annual income varied in our cohort [11], these characteristics did not appear to significantly influence the acceptability of the multimodal PFPT treatment. Another strength of this study is the semi-structured guide, which was constructed based on a well-known framework of acceptability [17]. The in-depth qualitative interviewing also deepened our understanding of the treatment acceptability. The interviewer was not involved in the treatment of any participant, limiting the social desirability bias. Different methods were also used to reduce the researchers’ subjectivity in the data interpretation. Interviews were recorded, transcribed, and analyzed using an iterative and inductive approach. This allowed the emergence of innovative and contextual themes. Data saturation during data collection was reached, followed by inductive thematic saturation during analysis.

In conclusion, multimodal PFPT was found acceptable by gynecological cancer survivors. Findings provide a deeper understanding of this treatment’s acceptability which involves the appropriateness of its characteristics, the balance between participation and effectiveness, and satisfaction. Multimodal PFPT can be implemented in follow-up care in gynecological oncology. Selecting the most appropriate modalities, therapist, care delivery, and intensity is a critical step for implementation.