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

Einfluss der Anwendung eines Vaginaldilatators auf Vaginalstenose und sexuelle Lebensqualität nach adjuvanter Radiotherapie bei Frauen mit Endometriumkarzinom

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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.

Zusammenfassung

Hintergrund

Trotz fehlender Evidenzlage und geringer Compliance empfehlen die aktuellen Leitlinien die Anwendung eines Vaginaldilatators (VD) nach pelviner Radiotherapie (RT). Wir analysierten den Effekt eines Vaginaldilatators auf die Vaginalstenose (VS) und auf die sexuelle Lebensqualität (QoL) bei Frauen mit Endometriumkarzinom (EC) nach erfolgter adjuvanter RT.

Methoden

Zwischen 2014 und 2015 wurden 56 Patientinnen instruiert, einen VD nach Beendigung der RT zu benutzen. Der maximale Durchmesser des am angenehmsten einführbaren VD wurde vor und 1 Jahr nach Therapie gemessen. Die Ausprägung der VS wurde 1 Jahr nach Therapie klinisch erfasst und die sexuelle QoL anhand der von der European Organisation for Research and Treatment of Cancer (EORTC) vorgegebenen sexuellen Funktionsfragen vor, während, 6 Wochen und 1 Jahr nach RT bestimmt.

Ergebnisse

Der mittlere VD-Durchmesser nahm 1 Jahr nach RT um 2,7 ± 3,2 mm ab (p < 0,001). Bei 36 Patientinnen (64,3%) konnten wir klinisch eine VS (Grad I–III) feststellen. Hierbei nahm der VD-Durchmesser mit höherer klinischer Ausprägung der VS ab. Die Anwendung des VD (p = 0,81), die RT-Modalität (p = 0,68) und eine adjuvante Chemotherapie (p = 0,87) hatten keinen Einfluss auf den VD-Durchmesser. Zudem nahm die sexuelle Aktivität während RT ab und stieg nach RT über den Ausgangswert hinaus (p < 0,001). Das sexuelle Vergnügen nahm kontinuierlich während und nach Beendigung der RT ab (p = 0,013) und korrelierte negativ mit einem höheren Grad an klinischer VS (p = 0,01).

Schlussfolgerung

Nahezu ein Drittel der Patientinnen entwickelten 1 Jahr nach adjuvanter RT eine VS und die sexuelle Lebensqualität zeigte sich aufgrund der VS beträchtlich reduziert. Durch Anwendung des VD nach RT können eine VS und die Verschlechterung der sexuellen Funktionalität möglicherweise nicht vermieden werden.

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References

  1. 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):137–146

    Article  Google Scholar 

  2. 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):1246–1255

    Article  CAS  Google Scholar 

  3. 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):895–904

    Article  Google Scholar 

  4. 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):652–656

    CAS  PubMed  Google Scholar 

  5. 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):816–823

    Article  CAS  Google Scholar 

  6. 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):1404–1411

    Article  CAS  Google Scholar 

  7. 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):744–751

    Article  Google Scholar 

  8. 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):1249–1255

    Article  Google Scholar 

  9. 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):797–809

    Article  Google Scholar 

  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):1692–1700

    Article  Google Scholar 

  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):1638–1648

    Article  Google Scholar 

  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):356–359

    Article  Google Scholar 

  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):703–708

    Article  Google Scholar 

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

    Article  CAS  Google Scholar 

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

    Article  CAS  Google Scholar 

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

    Google Scholar 

  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):464–470

    Article  Google Scholar 

  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):2305–2313

    Article  Google Scholar 

  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):1162–1173

    Article  Google Scholar 

  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):958–965

    Article  Google Scholar 

  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):46–51

    Article  CAS  Google Scholar 

  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):153–160

    Article  Google Scholar 

  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):60–64

    Article  Google Scholar 

  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):578–581

    Article  Google Scholar 

  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):998–1001

    CAS  PubMed  Google Scholar 

  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):816–824

    Article  CAS  Google Scholar 

  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):169–173

    Article  Google Scholar 

  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):3547–3556

    Article  Google Scholar 

  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):202–208

    Article  Google Scholar 

  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):183–190

    Article  Google Scholar 

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

    Article  Google Scholar 

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

    Google Scholar 

  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):497–506

    Article  CAS  Google Scholar 

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

    Article  CAS  Google Scholar 

  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):973–982

    Article  Google Scholar 

  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):667–673

    Article  Google Scholar 

  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):825–830

    Article  CAS  Google Scholar 

  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):356–358

    CAS  PubMed  Google Scholar 

  39. 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):464–470

    Article  Google Scholar 

  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):149–155

    Article  Google Scholar 

  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):548–554

    Article  Google Scholar 

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

    Article  CAS  Google Scholar 

  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):1125–1126

    PubMed  Google Scholar 

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Acknowledgements

We thank our Gynecologic Research Group members for their great effort.

Author information

Authors and Affiliations

  1. Department of Radiation Oncology, University Hospital Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany

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

  2. Heidelberg Institute for Radiation Oncology (HIRO), National Center for Radiation Research in Oncology (NCRO), Heidelberg, Germany

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

  3. Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120, Heidelberg, Germany

    Nils H. Nicolay MD PhD &  Juergen Debus MD PhD

  4. Department of Radiation Oncology, University Hospital Schleswig-Holstein, Arnold-Heller-Strasse 3, 24105, Kiel, Germany

    David Krug MD

  5. Department of Radiation Oncology, University Hospital Mainz, Langenbeckstrasse 1, 55131, Mainz, Germany

    Tilman Bostel MD

  6. Department of Radiation Oncology, Freiburg University Medical Center, Robert-Koch-Strasse 3, 79106, Freiburg, Germany

    Nils H. Nicolay MD PhD

  7. Department of Radiation Oncology, Staedtisches Klinikum Karlsruhe, Moltkestrasse 90, 76133, Karlsruhe, Germany

    Katja Lindel MD

  8. Department of Radiation Oncology, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland

    Robert Foerster MD

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  1. Sati Akbaba MD
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  2. Jan T. Oelmann-Avendano MD
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  3. David Krug MD
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  5. Tilman Bostel MD
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  6. Juliane Hoerner-Rieber MD
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  7. Nils H. Nicolay MD PhD
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  9. Katja Lindel MD
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  10. Robert Foerster MD
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Corresponding author

Correspondence to Robert Foerster MD.

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Conflict of interest

S. Akbaba, J.T. Oelmann-Avendano, D. Krug, N. Arians, T. Bostel, J. Hoerner-Rieber, N.H. Nicolay, J. Debus, K. Lindel, and R. Foerster declare that they have no competing interests.

Ethical standards

This study was approved by the independent ethical committee of the University of Heidelberg, Germany, on 21st of June 2016 (#S-269/2016) and was conducted with the Helsinki Declaration of 1975 in its most recently amended version. The requirement of informed consent was waived by the ethical committee due to the retrospective nature of this study.

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The data used in this analysis is from publications available in the public domain.

The first author and the corresponding author developed and planned the retrospective analysis. All authors read and approved the final manuscript.

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Akbaba, S., Oelmann-Avendano, J.T., Krug, D. et al. The impact of vaginal dilator use on vaginal stenosis and sexual quality of life in women treated with adjuvant radiotherapy for endometrial cancer. Strahlenther Onkol 195, 902–912 (2019). https://doi.org/10.1007/s00066-019-01466-1

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