Long-Term Side-Effects After Treatment for Anal Cancer
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1 Long-Term Side-Effects After Treatment for Anal Cancer Jeanne Carter, PhD Female Sexual Medicine & Women s Health Program Gynecology Service, Department of Surgery MSKCC 1
2 Survivorship U.S. population of cancer survivors is expected to grow to 18 million by 2020 Quality of life and managing issues of long-term and late effects of cancer treatment are a priority [ACS, 2013; NCI - Office of Survivorship] 2
3 Anal Cancer In 2013, it is estimated that 7,060 men and women will be diagnosed with anal cancer [SEER, 2013] Perspective of progress Standard of Care 1960s: Abdominoperineal excision with permanent colostomy Today: Nonsurgicaltreatment is highly effective with chemo/rt and allowing for anal function preservation [Aggarwal, Duke, and Glynn-Jones, 2013] 3
4 Long-Term HRQOL European study with a national cohort of 199 eligible survivors, with 129 respondents (64% participation rate) One of the largest studies of survivors after curative chemoradiotherapyfor anal cancer Results indicate that survivors have long-term impairment of HRQOL [Bentzen AG, Balteskard L, Wanderas EH et al., 2013] 4
5 Common Concerns In Anal Cancer Survivorship Significant Late-effects Reported After Treatment: Increased stool frequency* Buttock pain* Flatulence* Incontinence* In males - erectile difficulties* In females -dyspareuniaand reduced interest* * p<0.001 [Bentzen AG, Balteskard L, Wanderas EH et al., 2013] 5
6 Important Study Conclusion Increased attention and greater effort to identify and alleviate problems in survivorship of anal cancer are required 6
7 MSKCC Resources Female Sexual Medicine and Women s Health Program - Dyspareunia and decreased interest Male Sexual and Reproductive Medicine Program - Erectile difficulties Physical Medicine and Rehabilitation Services - Buttock pain - Incontinence 7
8 Male Sexual and Reproductive Medicine Program MSKCC Male Sexual Medicine Team John Mulhall, MD Head of Male Sexual Medicine Program Joseph Narus, NP Nurse Practitioner Christian Nelson, PhD Clinical Psychologist 8
9 Sexual Health For Men Treatments Medications to treat erectile and ejaculatory dysfunction Hormone replacement for low testosterone levels Post-treatment penile rehabilitation Dilators can be used to address anal/ rectal pain with intimacyor follow up examinations 9
10 Physical Medicine and Rehabilitative Services Physical Therapists with expertise in treating pelvic floor dysfunctions Silverman Center for Rehabilitation 515 Madison Avenue New York, NY
11 Female Sexual Medicine and Women s Health Program Jeanne Carter, PhD Head, Female Sexual Medicine Program Barbara Seidel, ANP-BC Sexual Medicine Nurse Practitioner Cara Stabile, BS Research Assistant Talea Burford, BA Physician Office Assistant 11
12 Female Sexual Medicine Program s Referral Patterns Reason for Referral (n=136) % (n) Vaginal Changes Pain/Dyspareunia Loss of Libido Sexuality/Intimacy Issues Post-Treatment 60% 82 39% 53 25% 34 24% 32 7% 9 The numbers may not add up to 100%, as more than one reason may have been provided in the referral 12
13 Sexual/Vaginal Health Concerns 32% (n=69) Problems existed before cancer and continued or worsened 42% (n=91) No problems before cancer, but had problems after cancer 16% (n=35) No problems before cancer and no problems after cancer 13
14 Level of Concern About Sexual Function/Vaginal Health How concerned are you about Sexual/ Vaginal Health? (0- not at all; 5-Somewhat; 10-Very Concerned) Female Cancer Patients/ Survivors Agreeing to Answer a Survey in the Waiting Room 77% (n=120) Somewhat to Very Concerned Female Cancer Patients/ Survivors Seeking Treatment Female Sexual Medicine and Women s Health 93% (n=425) Somewhat to Very Concerned 14
15 Anal Cancer Survivors Seeking Treatment At Female Sexual Medicine Program How concerned are you about Sexual/Vaginal Health? 100% - Somewhat to Very Concerned Do you feel confident about sexual activity in the future? 53% -Confident 37% - Not Confident 15
16 Anal Cancer Survivors Seeking Treatment At Female Sexual Medicine Program Characteristics % n Age Mean= 57.8 years, Range= years Race White 95% 18 Other 5% 1 Marital Status Married 58% 11 Single 21% 4 Separated/Divorced/Widow 21% 4 Disease Type Anal 100% 19 Anal & Other (Breast, GYN, Skin, Lymphoma) 32% 6 Engage in Sexual Activity 16% 3 Not Engaging in Sexual Activity 68% 13 16
17 Anal Cancer Survivors Seeking Treatment At Female Sexual Medicine Program Reason for Referral (n=19) % n Vaginal Changes 53% 10 Pain/Dyspareunia 53% 10 Sexuality/Intimacy Issues 11% 2 Pelvic Floor Dysfunction 5% 1 Pre-Operative Concerns 5% 1 The numbers may not add up to 100%, as more than one reason may have been provided in the referral 17
18 Solutions and Simple Strategies to Improve Vaginal/Sexual Health Vaginal Lubricants Mechanism: short-term benefit by decreasing vaginal irritation during sexual activity Administration - Both partners - Intercourse as well as with manual stimulation Water-based lubricants are recommended Examples -Over-the-counter products (KY, Astroglide, Eros for Women) - Natural Oils (almond oil, coconut oil, vitamin E) Silicone based lubricants can also be used 18
19 Solutions and Simple Strategies to Improve Vaginal/Sexual Health Vaginal Moisturizers Definition: preparation applied (at bedtime) vaginally to assist in hydrating the vaginal tissues suffering from hormonal deprivation Mechanism: longer lasting benefit by improving the balance of intracellular fluids in the vaginal epithelium and reducing vaginal dryness, itching, and irritation 19
20 Solutions and Simple Strategies to Improve Vaginal/Sexual Health Vaginal Moisturizers Examples: Non-hormonal -Replens [Nachtigallet al., 1994; van derlaaket al., 2002] - Liquidbeads, Aquabeads positive clinical feedback - Vitamin E vaginally Study with vaginal moisturizer made up of VitE, VitA and hyaluronic acid HyaloGyn available in the US [Costantion& Guaradli, 2008] Carlson KEY E -Vitamin E with coconut oil and palm oil * Important to apply externally to address dryness, and also beneficial to comfort if applied to the perianal area post-tx 20
![, 2002] - Liquidbeads, Aquabeads positive clinical feedback - Vitamin E vaginally Study with vaginal moisturizer made up of VitE, VitA and](/docs-images/52/12757243/images/page_20.jpg "hyaluronic acid HyaloGyn available in the US [Costantion& Guaradli, 2008] Carlson KEY E -Vitamin E with coconut oil and palm oil *")
21 Solutions and Simple Strategies to Improve Vaginal/Sexual Health Pelvic Floor Exercises Relaxation and control of the pelvic floor muscles can be extremely helpful in treating and preventing pain with intercourse and pelvic exams [Kizilkaya et al., 2003] It has been suggested that drawing blood flow to the pelvic floor may have possible restorative effects [Schroder et al., 2005] Research has noted poor pelvic floor strength to be associated with arousal dysfunction [Lowenstein et al., 2010] Based on clinical experience, it is recommended for pelvic floor exercises to be done daily and in conjunction with dilator therapy Research suggests possible benefits in rehabilitating anal sphincter control and QOL [Liu CH, Chen CH, and Lee JC, 2011] 21
22 Solutions and Simple Strategies to Improve Vaginal/Sexual Health Dilator Therapy Physical Benefits: -The process of mechanically stretching the tissues of the vagina to treat vaginal stenosis/adhesions Psychological Benefits: - Allows women to gain confidence and decrease anxiety/fear about pain Issues of Non-compliance: - Support and Information needed for success - Need to address any aversion (embarrassment) or fear at the beginning [Friedman et al., 2010; Jefferies et al., 2004; Decruze, 1999; Robinson, 1995; Pitkin, 1971] Need to broaden our perspective in the use of dilators 22
23 Sexual Rehabilitation For Both Men and Women Short-term Goals: Try to stay motivated & be consistent Remind yourself about importance and reason for the strategies Focus on the benefits you are feeling Have realistic expectations Don t feel pressured, flexibility is important Long-term Goals: Learn to troubleshoot or cope with potential problems Develop a plan for the long-term (maintenance) 23
24 Sexual Rehabilitation For Both Men and Women Dilators can be helpful in addressing pain with sex (vaginal or anal) and/ or pain with follow up examinations Vaginal dilators Anal dilation can be done with smaller vaginal/rectal dilators Amielle, Hegar, Soul source Lubricants are important for all sexual activity and for use with dilators Moisturizing externally is important post-rt for comfort, in particular the perianal area 24
25 Communication About Sexuality After Cancer Mismatched expectations between patients and providers Patients would like open communication on topics of intimacy & sexuality after cancer Medical professionals prefer to focus on combating the disease [Hordern& Street, 2007] 25
26 Tips For Enhancing Communication I have heard it is common to have sexual changes after cancer, do you have someone I could speak with about this? I am having some vaginal dryness (or discomfort) OR some erectile difficulties, do you have any information or suggestions? Could you give me some information about intimacy after cancer or refer me someone with expertise in this area? Sex has become painful (either vaginal or anal) do you have someone I could speak with? 26
27 27
28 Communication About Sexuality After Cancer Misperceptions Among Couples -Survivors report perception of greater vaginal changes and dryness than their partners -Highlights the importance of communication about changes in sexual function [Stafford & Judd, 2010] 28
29 Points To Remember It is not uncommon to experience changes in sexual function after cancer treatment Physical/Emotional Factors Transient and/or Chronic Conditions 29
30 Survivorship Resources MSKCC: Female Sexual Medicine and Women s Health Program Male Sexual and Reproductive Medicine Program Physical Medicine and Rehabilitation Services Most Cancer Centers: Specialists (ex. Gyn, Urology) Sexual Medicine Programs Physical Therapy 30
31 Organizations Survivorship Resources MSKCC Resources for Life After Cancer NCI Office of Cancer Survivorship - American Cancer Society (ACS) - Lance Armstrong Foundation Cancer Care The Wellness Community Gilda s Club 31
32 American Association of Sexuality Educators Counselors & Therapists (AASECT) -AASECT.org 32
33 Thank You 33
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