From: Frank Cromie <firstname.lastname@example.org>
To: email@example.com <firstname.lastname@example.org>
Date: Tuesday, March 09, 1999 6:29 PM
Subject: Re: [MOL] Sexuality, Sex and Cancer Series - 4Tell me Lillian,what about some guy like me?The only time I get excited,is when I TURN ON my computer.Frank-----Original Message-----
From: lillian <email@example.com>
To: firstname.lastname@example.org <email@example.com>
Date: Tuesday, March 09, 1999 11:52 AM
Subject: [MOL] Sexuality, Sex and Cancer Series - 4
As nurses, we cannot discuss the late effects of pelvic irradiation without considering the issues pertaining to quality of life. Advances in the field of cancer treatment have resulted in patients living longer with sequlae requiring care that will assure the development of each individual to their physical, psycho-social-sexual, vocational and educational potential. This is true with all cancers. From our first meeting at consultation and throughout the course of treatment, we should always take this into consideration while working with our patients. The late effects to be discussed, will be psychological, psycho-social/sexual dysfunctioning and, survivorship .
In the female the critical structures in the radiation fields are: cervix, vagina, ovaries, bladder and gastrointestinal tract. The late effects may include all or none of the following:
- Temporary or permanent sterility or infertility
- Chromosome damage
- Fibrosis and stenosis of the vaginal canal
- Premature menopause
- Late bladder /gastrointestinal problems
Temporary or Permanent Sterility or Infertility
If a patient is still in the childbearing years of her life, fertility may still be a concern for her and her partner. It is pertinent to know if they have any children, or if they wish to have any. If yes, alternate choices should be discussed such as; surrogate parenting, egg banking, etc. With temporary or permanent sterility or infertility; anovulation can occur with a radiation dose of 600 cGy for a woman over the age of 40. For the younger females (woman less then 40 years of age) it would take 2000 cGy over 5 to 6 weeks to cause approximately 90 % of the patients treated to experience sterility. If temporary sterility is an issue, the patient and her partner must be informed to utilize some form of medically approved form of birth control for at least two years after the radiation has been completed. This is the time necessary to allow the estrogen level to return to normal.
With chromosomal damage, if the ovary/ovaries are radiated; all ova present in the ovaries are exposed therefore, there is the potential for genetic mutation. Some interventions to be considered when working with your patient would be:
- Counseling with the patient and her partner. If sterility is an issue, you must allow the patient and/or her partner to express any grief and/or guilt to the loss of being able to bear a child.
- Referral to genetic counselors
- Instruction and options of birth control: use of condoms and/or diaphragm
- Utilizing other forms of lovemaking.
Fibrosis and Stenosis of the Vaginal Canal
The third late effect of pelvic irradiation is fibrosis and stenosis of the vaginal canal. The possibility of this occurring increases with the use if intracavitary implants, also known as brachytherapy. This is due to the radiation denuding the vaginal epithelium by direct effect on the basal layer of the mucosa, the endothelium of the small vessels, and on the fibroblasts of the connective tissue in the submucosa. Indirectly, the vaginal mucosa is further devitalized by the narrowing and the obliteration of the small vessels and circumferential fibrosis of the perivaginal tissues. The interventions for this late effect very important.
- If the patient has been sexually active; encouraging the patient to remain sexually active throughout treatment would be helpful.
- The use of the vaginal dilator is very important for followup. Giving the patient an explanation of how and why it should be used, along with a printed instruction sheet is very important. Being with patient the first time they insert the dilator is especially helpful to make sure the correct size dilator is given as well as observing patient technique. . Some patients may shy away from using the dilator. It is important to stress the importance of the use of the dilator for keeping the vagina open for future examinations as well as sexual reasons.
The fourth late effect on the list is premature menopause. Some of the psychological symptoms are: decreased libido, atrophy of the vaginal mucosa, decreased lubrication, depression and "hot flashes."
- For the symptom of decreased libido; helping a patient to adjust to the occurrence through education by explaining the physiological reason, which is, a decreased estrogen level. Counseling; with or without her partner can also be helpful.
- Atrophy of the vaginal canal can be caused by the cancer treatment, as well as the patients age. Use of Kegel exercises and encouraging the patient to utilize other forms of lovemaking maybe beneficial. This is especially helpful for those patients experiencing dyspareunia.
- Decreased vaginal lubrication can cause itchiness, burning and painful intercourse. It is helpful to explain what estrogen does and how the patient's estrogen has been decreased by the treatment. The most helpful intervention is the use of water based lubricants. Many of these are over the counter products and can be purchased at most pharmacies. Some of the most common products are Astroglide, Replens, K-Y Jelly and Gyno-Moist.
- Depression can also be a side effect of the treatment, which can be physiological or psychological. This can be related to hormonal changes or to the patient's cancer diagnosis.
- "Hot Flashes" can be also be related to hormonal changes.
Bladder /Gastrointestinal Tract
The bladder /gastrointestinal tract can also experience late effects. The bladder may receive anywhere between 4500 - 5000 cGy in 4 weeks to 7000 cGy in 7-9 weeks. Some of the side effects are hematuria, contracted bladder and urethra or bladder neck obstruction. Some interventions for bladder complications are:
- Force fluids, avoid spicy foods, avoid caffeine, and avoid alcohol
- For bladder neck obstruction, the patient may require having repeated dilations and possibly surgical interventions.
The major determinants for gastrointestinal tract late effects are the total radiation dose (the higher the dose, the greater the chance for complication), the daily dose fractionation and the volume of bowel irradiated. Some symptoms which may occur anywhere from 6 - 18 months after treatment are rectal bleeding, intestinal obstruction and necrosis, fistulas, proctitis , colitis, enteritis, ulceration of the mucosa and abcess. Fistulas are most common in women due to the close proximity of the vaginal canal and the rectum. These fistulas are not as common as in the past, due to the changes in technology and treatment planning used in planning the radiation treatment. Some of the predisposing factors which would increase the possibility of complications occurring are: prior abdominal and/or pelvic surgery, vascular changes due to other medical problems, and the use of radiation sensitizing drugs, combined modalities such as 5FU, methotrexate and adriamycin. The nurse should assess the patient for pain, changes in bowel habits and monitoring blood values.
There is a small (3-5%) incidence of secondary tumors with pelvic irradiation. Patients treated for cancer of the cervix have the very low risk of bladder, rectum, uterine corpus, connective tissue and bone cancer. Ovarian cancer patients have an increased risk of solid tumors after radiation treatment.
The sexual aspects involved with late effects of pelvic irradiation are often overlooked or just mentioned lightly. Patients and/or their partners may shy away from lovemaking thinking that: cancer may be contagious; radiated partners may be contaminated by the treatment or that they are "radioactive". Sometimes the partner may feel they will hurt the patient physically if they attempt intercourse. The nurse's role is to dispel these myths and any others the patient and/or partner may have.
Before the nurse can be helpful to the patient, he/she must examine her own attitudes, feelings and concerns related to sexuality. When should the subject of sexuality begin to be discussed? Sexuality should be discussed at the time of consultation as well as obtaining a pre-treatment sexual assessment. This assessment should consist of the patient's baseline sexual history; including;
- A sexual history prior to their diagnosis
- The importance of present sexual activity
- Any involvement of significant other
The practitioner should set up a trusting relationship with the patient; and if possible with the partner. Most patients will welcome the nurse discussing aspects of sexuality. Often times, the nurse will hear a sigh of relief from the patient and /or significant other. During the treatment evaluations it is important to assess the effects of radiation treatments on activities of daily living. Post treatment teaching should include the use of the vaginal dilator and the importance of follow-up. Many factors should be taken into consideration when addressing and discussing the subject of sexuality. Some important factors to consider when working with patients are the developmental capacity of the patient (age, lifestyle, and knowledge and education)the psychological, socio-cultural beliefs(values, religion) and the patient' s socio-economical status.
Quality of life issues must always be considered. The impact of late effects on self-esteem, intimacy and sexuality will directly effect how the patient deals with their disease and treatment. Always keep in mind, that the patient has cancer, which involves the organs that we all know deal with our self-image and our sexual performance. Through open discussions, common harmful myths about cancer can be dispelled. Patients especially females may feel they got cancer, because they are promiscuous; others may feel being "rough " during lovemaking, may have caused it. Do not assume, that if a patient is older, sex doesn't play a role in their life. We must also remember, survivorship is important to keep in mind from the time we meet the patient through their treatment and follow up visits
The impact of the disease can be devastating to all involved. A few of the fears they have may be; fear of the unknown, the uncertainty of the disease itself, fear of the loss of close relationships, fear of the loss of employment, fear of recurrence, and fear of risk of a second malignancy. This may be what the patient focuses on. We must stress the importance of all the qualities that make a person. Being a good friend, a loving mate, a valuable employee and a caring person are some of the important assets we must stress. All of these have not changed because they have survived cancer. The patient still has the same values, interests and concerns. Often, after going through the ordeal of cancer and its different modalities of treatment and surviving; the patient will re-focus their priorities and in some respects, have a greater appreciation of life. Hopefully, through our help the patient will achieve as normal and full a life as possible.