Abstract
There is growing awareness of the importance of sexual health in the quality of life
of cancer patients and survivors. Brachytherapy, a vital component for the curative
treatment of cervical cancer, leads to both direct and indirect sequelae that result
in vaginal and sexual morbidity. The emergence of 3D image-guided adaptive brachytherapy
has led to a better understanding of dose-and-effect relationships for critical organs-at-risk
and there are new recommendations for vaginal dose reporting in the ongoing EMBRACE
II study. An understanding of the vagina as an organ-at-risk and its dose-and-effect
relationships can help brachytherapists limit dose to the vagina and improve sexual
morbidity. Brachytherapists play a critical role in the primary and secondary prevention
of vaginal and sexual sequelae resulting from treatment. Through close surveillance
and recognition of common symptoms, brachytherapists can intervene with effective
strategies to prevent and treat vaginal and sexual symptoms. This review summarizes
the current literature on dosimetric factors that may predict for vaginal morbidity.
It will focus on quantitative and qualitative reports of brachytherapy-related vaginal
toxicity and sexual dysfunction. Lastly, it will review the available evidence supporting
clinical interventions to mitigate the development and progression of vaginal and
sexual sequelae to improve functional quality post-treatment.
Keywords
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References
- Interventions to Address Sexual Problems in People with Cancer: American Society of Clinical Oncology Clinical Practice Guideline Adaptation of Cancer Care Ontario Guideline.J Clin Oncol. 2018; 36: 492-511
- Contemporary quality of life issues affecting gynecologic cancer survivors.Hematol Oncol Clin North Am. 2012; 26: 169-194
- Sexual dysfunction in women with cancer.Fertil Steril. 2013; 100: 916-921
Candy B, Jones L, Vickerstaff V, et al. Interventions for sexual dysfunction following treatments for cancer in women (Cochrane Review). 2016.
- Sexuality and sexual function in long-term survivors of cervical cancer.J Womens Health. 2008; 17: 955-963
- A 2-year prospective study assessing the emotional, sexual, and quality of life concerns of women undergoing radical trachelectomy versus radical hysterectomy for treatment of early-stage cervical cancer.Gynecol Oncol. 2010; 119: 358-365
- Defining and measuring reproductive concerns of female cancer survivors.J Natl Cancer Inst Monogr. 2005; : 94-98
- The physical consequences of gynecologic cancer surgery and their impact on sexual, emotional, and quality of life issues.J Sex Med. 2013; 10: 21-34
- Sexual morbidity following radical hysterectomy for cervical cancer.Espert Rev. Anticancer Ther. 2010; 10: 1037-1042
- Objective assessment of sexual arousal in women with a history of hysterectomy.BJOG. 2004; 111: 456-462
- Pelvic dysfunctions and quality of life after nerve-sparing radical hysterectomy: a multicenter comparative study.Anticancer Res. 2012; 32: 581-588
- Vulvar cancer patients’ quality of life: a qualitative assessment.Int J Gynecol Cancer. 2004; 14: 875-881
- Radiation-induced vaginal stenosis: current perspectives.Int J Womens Health. 2017; 9: 273-279
- Review: sexuality in adult cancer survivors: challenges and intervention.J Clin Oncol. 2012; 30: 3712-3719
- Postradiotherapy morbidity in long-term survivors after locally advanced cervical cancer: how well do physicians’ assessments agree with those of their patients?.Int J Radiat Oncology Biol Phys. 2008; 71: 1335-1342
- Radiation-induced morphological changes in the vagina.Strahlenther Onkol. 2012; 188: 1010-1019
- Manifestation pattern of early-late vaginal morbidity after definitive radiation (Chemo)Therapy and image-guided adaptive brachytherapy for locally advanced cervical cancer: an analysis from the EMBRACE study.Int J Radiation Oncol Biol Phys. 2014; 89: 88-95
- Late injury of cancer therapy on the female reproductive tract.Int J Radiat Oncol Biol Phys. 1995; 31: 1282-1299
- Preventing vaginal stenosis after brachytherapy for gynaecological cancer: an overview of Australian practices.Eur J Oncol Nursing. 2004; 8: 30-39
- Literature review of vaginal stenosis and dilator use in radiation.Pract Radiat Oncol. 2019; 9: 479-491
- Radiotherapy-induced vaginal fibrosis in cervical cancer survivors.Acta Oncol (Madr). 2017; 56: 661-666
- Early development of vaginal shortening during radiation therapy for endometrial or cervical cancer.Int J Gynecol Cancer. 2001; 11: 234-235
- The effect of pelvic radiotherapy on vaginal brachytherapy cylinder diameter: implications for optimal treatment order.Brachytherapy. 2016; 15: 549-553
- Severe late toxicities following concomitant chemoradiotherapy compared to radiotherapy alone in cervical cancer: an inter-era analysis.Int J Radiat Oncol Biol Phys. 2012; 84: 973-982
- Vaginal necrosis: a rare late toxicity after radiation therapy.Gynecol Oncol. 2021; 160: 602-609
- The irradiation tolerance dose of the proximal vagina.Radiother Oncol. 2003; 67: 77-85
- Radiation tolerance of the vaginal mucosa.Int J Radiat Oncol Biol Phys. 1980; 6: 711-716
- Vaginal dose de-escalation in image guided adaptive brachytherapy for locally advanced cervical cancer.Radiother Oncol. 2016; 120: 480-485
International commission on radiation units and measurements. Prescribing, Recording, and Reporting Brachytherapy for Cancer of the Cervix (ICRU report 89). Bethesda: 2013.
- The EMBRACE II study: the outcome and prospect of two decades of evolution within the GEC-ESTRO GYN working group and the EMBRACE studies.Clin Transl Radiat Oncol. 2018; 9: 48-60
- Dose volume parameter D2cc does not correlate with vaginal side effects in individual patients with cervical cancer treated within a defined treatment protocol with very high brachytherapy doses.Radiother Oncol. 2010; 97 (76-69)
- Vaginal dose, toxicity and sexual outcomes in patients of cervical cancer undergoing image based brachytherapy.Asian Pac J Cancer Prev. 2014; 15: 3619-3623
- Vaginal tolerance of CT based image-guided high-dose rate interstitial brachytherapy for gynecological malignancies.Radiat Oncol. 2014; 9
- Vaginal dose is associated with toxicity in image guided tandem ring or ovoid-based brachytherapy.Int J Radiat Oncol Biol Phys. 2016; 94: 1099-1105
- Dose-effect relationship and risk factors for vaginal stenosis after definitive radio(chemo)therapy with image-guided brachytherapy for locally advanced cervical cancer in the EMBRACE study.Radiother Oncol. 2016; 118: 160-166
- Multicentre evaluation of a novel vaginal dose reporting method in 153 cervical cancer patients.Radiother Oncol. 2016; 120: 420-427
- Vaginal dose point reporting in cervical cancer patients treated with combined 2D/3D external beam radiotherapy and 2D/3D brachytherapy.Radiother Oncol. 2013; 107: 99-105
- Dose-effect relationship between vaginal dose points and vaginal stenosis in cervical cancer: an EMBRACE-I sub-study.Radiother Oncol. 2022; 168: 8-15
- Using new vaginal doses evaluation system to assess the dose-effects relationship for vaginal stenosis after definitive radio(Chemo) therapy for cervical cancer.Front Oncol. 2022; 12840144
- The association of vagina equivalent dose in 2Gy fraction (EQD2) to late vagina toxicity in patients of cervical cancer treated with WPRT plsu IGABT.Brachytherapy. 2022; 21: 658-667
- Vaginal 11-point and volumetric dose related to late vaginal complications in patients with cervical cancer treated with external beam radiotherapy and image-guided adaptive brachytherapy.Radiot Oncol. 2022; (In press)https://doi.org/10.1016/j.radonc.2022.07.009
- Dose-volume correlation of cumulative vaginal doses and late toxicity after adjuvant external radiation and brachytherapy for cervical cancer.Brachytherapy. 2017; 16: 855-861
- Vaginal dose-surface maps in cervical cancer brachytherapy: methodology and preliminary results on correlation with morbidity.Brachytherapy. 2021; 20: 565-575
- The EMBRACE II study: the outcome and prospect of two decades of evolution within the GEC-ESTRO GYN working group and the EMBRACE studies.Clin Transl Radiat Oncol. 2018; 9: 48-60
- Inter-observer and intra-observer variability in reporting vaginal dose points for cervical cancer in high-dose rate brachytherapy.J Contemp Brachyther. 2020; 12: 139-146
- Evidence-based dose planning aims and dose prescription in image-guided brachytherapy combined with radiochemotherapy in locally advanced cervical cancer.Semin Radiat Oncol. 2020; 30: 311-327
- The patients’ perspective on physical symptoms after radiotherapy for cervical cancer.Gynecol Oncol. 2000; 76: 14-23
- A critical review of patient-rated quality of life studies of long-term survivors of cervical cancer.Gynecol Oncol. 2006; 102: 563-572
- Vaginal changes and sexuality in women with a history of cervical cancer.N Engl J Med. 1999; 340: 1383-1389
- Vaginal stenosis and sexual function following intracavitary radiation for the treatment of cervical and endometrial carcinoma.Int J Radiat Oncol Biol Phys. 1993; 27: 825-830
- Patient-reported sexual adjustment after definitive chemoradiation and MR-guided brachytherapy for cervical cancer.Brachytherapy. 2019; 18: 133-140
- Longitudinal study of sexual function and vaginal changes after radiotherapy for cervical cancer.Int J Radiat Oncol Biol. 2003; 56: 937-949
- Health-related quality of life in locally advanced cervical cancer patients after definitive chemoradiation therapy including image guided adaptive brachytherapy: an analysis from the EMBRACE study.Int J Radiat Oncol Biol Phys. 2016; 94: 1088-1098
- Impact of Vaginal symptoms and hormonal replacement therapy on sexual outcomes after definitive chemoradiotherapy in patients with locally advanced cervical cancer: results from the EMBRACE-I study.Int J Radiat Oncol Biol Phys. 2022; 112: 400-413
- Sexual difficulties after pelvic radiotherapy: improving clinical management.Clin Oncol. 2015; 27: 647-655
- Sexual health and wellbeing after pelvic radiotherapy among women with and without a reported history of sexual abuse: important issues in cancer survivorship care.Support Care Cancer. 2021; 29: 6851-6861
- Posttraumatic stress disorder after high-dose-rate brachytherapy for cervical cancer with application under spinal/epidural anesthesia and risk factors.Int J Radiat Oncol Biol Phys. 2014; 89: 260-267
- How to ask and what to do: a guide for clinical inquiry and intervention regarding female sexual health after cancer.Curr Opin Supp Palliat Care. 2016; 10: 44-54
- Assessment of treatment-induced female sexual morbidity in oncology: is this a part of routine medical follow-up after radical pelvic radiotherapy?.Br J Cancer. 2011; 105: 903-910
- Development and validation of a single-item screener for self-reporting problems in U.S. adults.J Gen Intern Med. 2015; 30: 1468-1475
NCCN Clinical practice guidelines in oncology: survivorship. Version 1. 2022, March 30, 2022. Available at: https://www.nccn.org/professionals/physician_gls/pdf/survivorship.pdf. Accessed July 17, 2022.
- Validation of clinical tools for vaginal and vulvar symptom assessment in cancer patients and survivors.J Sex Med. 2017; 14: 144-151
Cancer Therapy Evaluation Program. Common Terminology Criteria for Adverse Events (CTCAE). Version 4.0, DCTD, NCI, NIH, DHHS. 2009. Available at: https://evs.nci.nih.gov/ftp1/CTCAE/CTCAE_4.03/Archive/CTCAE_4.0_2009-05-29_QuickReference_8.5×11.pdf. Accessed July 17, 2022.
- LENT SOMA scales for all anatomic sites.Int J Radiat Oncol Biol Phys. 1995; 31: 1049-1091
- Assessment of an onco-sexology support and follow-up program in cervical or vaginal cancer patients undergoing brachytherapy.Support Care Cancer. 2021; 29: 4311-4318
- Benefits of a multidisciplinary women's sexual health clinic in the management of sexual and menopausal symptoms after pelvic radiotherapy.Am J Clin Oncol. 2021; 44: 143-149
- Prospective study of vaginal dilator use adherence and efficacy following radiotherapy.Radiother Oncol. 2015; 116: 149-155
- A Retrospective study of vaginal stenosis following treatment of cervical cancers and the effectiveness of rehabilitation interventions.Med Health Sci. 2017; 11 (94-88)
- Vaginal dilator therapy for women receiving pelvic radiotherapy.Cochrane Database Syst Rev. 2014; 2014CD007291
- Vaginal dilator use to promote sexual wellbeing after radiotherapy in gynecological cancer survivors.Medicine(Baltimore). 2022; 101: e28705
- Consensus for vaginal stenosis prevention in patients submitted to pelvic radiotherapy.PLoS One. 2019; 14e0221054
Sydney Gynaecological Oncology Group. Vaginal dilator therapy: guidelines for the use of vaginal dilators receiving pelvic radiotherapy and brachytherapy treatments. Sydney local health district. Available at: https://www.slhd.nsw.gov.au/services/sgog/Patient-Information-VD_Therapy.html. Access date July 17, 2022.
International guidelines on vaginal dilation after pelvic radiotherapy. Produced by the International Clinical Guideline Group, chaired by Dr Tracie Miles, President, National Forum of Gynaecological Oncology Nurses, UK. Available at: https://www.pocd.com.au/core/media/media.nl/id.47537/c.3923593/.f?h=f2e5bc493442741b7e6c Access date July 17, 2022.
- Sexual rehabilitation after pelvic radiotherapy and vaginal dilator use: consensus using the Delphi method.Int J Gynecol Cancer. 2014; 24: 1499-1506
- Topical estrogen, testosterone, and vaginal dilator in the prevention of vaginal stenosis after radiotherapy in women with cervical cancer: a randomized clinical trial.BMC Cancer. 2021; 21: 682
- Perceptions and practices regarding women's vaginal health following radiation therapy: a survey of radiation oncologists practicing in the United States.Pract Radiat Oncol. 2017; 7: 356-363
- 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. 2012; 9: 1162-1173
- A single-arm, prospective trial investigating the effectiveness of a non-hormonal vaginal moisturizer containing hyaluronic acid in postmenopausal cancer survivors.Support Care Cancer. 2021; 29: 311-322
- Local -Tocopherol for acute and short-term vaginal toxicity prevention in patients treated with radiotherapy for gynecologic tumors.Int J Gynecol Cancer. 2011; 21: 1708-1711
- Secondary prevention, not secondary importance: embracing survivorship concerns and HRT after cervical cancer radiation therapy.Int J Radiat Oncol Biol Phys. 2022; 112: 414-416
- Hormone therapy (HT) in women with gynecologic cancers and in women at high risk for developing a gynecologic cancer: a Society of Gynecologic Oncology (SGO) clinical practice statement: this practice statement has been endorsed by The North American Menopause Society.Gynecol Oncol. 2020; 157: 303-306
- Menopause: hormone, lifestyle, and optimizing aging.Obstet Gynecol Clin North Am. 2019; 46: 501-514
- Postirradiation vaginitis. An evaluation of prophylaxis with topical estrogen.Radiology. 1971; 99: 417-421
- Hormonal replacement therapy in patients after cervical cancer treatment.Gynecol Oncol. 1987; 26: 169-177
- Hormone replacement therapy after treatment for cervical cancer: are we adhering to standard of care?.Gynecol Oncol. 2017; 147: 597-600
- Hormone therapy after uterine cervical cancer treatment: a Swedish population-based study.Menopause. 2015; 22: 633-639
- Long-term cervical cancer survivors suffer from pelvic floor symptoms: a cross-sectional matched cohort study.Gynecol Oncol. 2010; 117: 281-286
- Can stronger pelvic muscle floor improve sexual function?.Int Urogynecol J. 2010; 21: 553-556
- Pelvic radiation therapy induced vaginal stenosis: a review of current modalities and recent treatment advances.Medicina (Mex). 2021; 57: 336
- Vulvo-vaginal atrophy: a new treatment modality using thermo-ablative fractional CO2 laser.Maturitas. 2015; 80: 296-301
- Results of a phase I-II study on laser therapy for vaginal side effects after radiotherapy for cancer of uterine cervix or endometrium.Cancers (Basel). 2020; 12: 1639
- Pilot study of fractional CO2 laser therapy for genitourinary syndrome of menopause in gynecologic cancer survivors.Maturitas. 2021; 144: 37-44
- A study protocol of vaginal laser therapy in gynecological cancer survivors.Climacteric. 2020; 23: 53-58
- Comparison of vaginal microbiota in gynecologic cancer patients pre- and post- radiation therapy and healthy women.Cancer Med. 2020; 9: 3714-3724
- Changes in the cervical microbiota of cervical cancer patients after primary radio-chemotherapy.Int J Gynecol Cancer. 2020; 30: 1326-1330
- Gynecologic cancer treatment toxicities and relationships with the vaginal microbiome.Gynecol Oncol. 2021; 162: S165-S166
- Changes in the vaginal microbiome and associated toxicities following radiation therapy for gynecologic cancers.Front Cell Infect Microbiol. 2021; 11680038
- A first radiotherapy application of functional bulboclitoris anatomy, a novel female sexual organ-at-risk, and organ-sparing feasibility study.Br J Radiol. 2021; 9420201139
- A review of psycho educational interventions to improve sexual functioning, quality of life, and psychological outcomes in gynecological cancer patients.Cancer Nurs. 2016; 39: 20-31
- A brief mindfulness-based cognitive behavioral intervention improves sexual functioning versus wait-list control in women treated for gynecologic cancer.Gyncol Oncol. 2012; 125: 320-325
- Clitoral therapy device for treatment of sexual dysfunction in irradiated cervical cancer patients.Int J Radiat Oncology Biol Phys. 2005; 61: 1078-1086
- Impact of ospemifene on quality of life and sexual function in young survivors of cervical cancer: a prospective study.Biomed Res Int. 2017; 7513610
- Flibanserin in postmenopausal women with hypoactive sexual desire disorder: results of the PLUMERIA study.J Sex Med. 2017; 14: 834-842
Article info
Publication history
Published online: December 23, 2022
Accepted:
October 27,
2022
Received in revised form:
October 17,
2022
Received:
August 2,
2022
Identification
Copyright
© 2022 American Brachytherapy Society. Published by Elsevier Inc. All rights reserved.
