About 500,000 women develop invasive carcinoma of the cervix per year around the world. Nearly 80% of the cases occur in developing countries.1 In Brazil, cervical cancer is the second among the most common malignant neoplasms in women, breast cancer being the first. It is estimated that 19 of 100,000 Brazilian women will develop carcinoma of the cervix. About 49% of treated women for invasive cervical tumors will survive 5 years.2
The age-adjusted 5-year relative survival rate for women who were treated for invasive carcinoma of the cervix is 71.2%.3 The quality of life (QOL) of gynecologic cancer survivors is a matter of controversy. Some studies point to deterioration, others to stability, and still others to an improvement of the QOL over time.4,5 Little is known about the impact of different modalities of treatment, diagnoses, disease stages, age, and other risk factors on the QOL of this population.4,6
Each treatment modality for invasive carcinoma of the cervix may present different complication rates, such as infertility, premature menopause, lymphedema, and sexual, intestinal, and urinary dysfunction.1,4,7,8 Moreover, patients need to readjust their familiar life and workplace and societal role and duties, concerning the possibility of disease recurrence.6
Some studies seem to indicate that QOL levels tend to be negatively affected during the period between the diagnosis of cancer and the completion of treatment, with a tendency to improve in about 6 to 12 months and to stabilize 1 to 2 years following treatment, matching the levels of QOL of healthy women.4 However, the time necessary for a complete recovery of pretreatment QOL status remains debatable. A study involving women who have survived invasive carcinoma of the cervix suggested that QOL levels may only catch up with those of the general population 5 to 7 years after cancer treatment.6
The standardized assessment of the QOL and mental health (MH) in women who were treated for invasive carcinoma of the cervix taking into consideration anxiety levels, modality of treatment, age, post-treatment time span, and levels of education, among other factors, might be useful to clarify some contradictory data about the impact of the disease and its treatment on this population. For example, some believe the adverse effects of treatment do not worse the general QOL.9 Others have found difference in QOL in women treated of invasive cervical carcinoma by radiotherapy (RT).10,11 The influence of type of treatment, RT, or surgery on the QOL is still a matter of controversy. The evaluation of the same parameters in a matched group of women with no history of malignancy would thus contribute for detection of possible differences in QOL between treatment modalities.
The aim of this study was to compare the QOL and MH of women surviving at least 2 years after treatment for invasive carcinoma of the cervix by radical hysterectomy (RH), chemotherapy (CT)/RT, or by surgery followed by adjuvant therapy (RH + CT/RT). The QOL/MH of a control group of women with no history of malignancy was also assessed for comparison with the treated groups.
One hundred fourteen women who met the criteria for inclusion in this study were interviewed between April and September 2008. Among these interviewees, 57 had been treated for invasive carcinoma of the cervix between March 1996 and March 2006 with RH (n = 11), CT/RT (n = 26), or RH + CT/RT (n = 20). Women (n = 57) without malignancy history from the Outpatient Gynecologic Clinic, Hospital das Clínicas, Federal University of Minas Gerais, constituted the control group. This group, despite being formed by women at a slightly lower age, matched the study groups in terms of family income, education, and social position as they all are users of the public health system in Brazil, with presumed similar social condition and no possibility to pay for the private medical attention. All patients came from families with an income of up to 2 minimum wage salaries. The reasons for the women in this control group search for medical advice were either routine gynecologic consultation without specific complaints or cancer prevention. If a serious medical condition or clinical cancer suspicion was raised, the patient was withdrawn from the group.
The inclusion criteria were (1) history of treatment for invasive carcinoma of the cervix between March 1996 and March 2006 with no evidence of other malignant neoplasms and no past hysterectomy for any reason and (2) agreement to participate in the study signing an informed consent.
Women with residence outside the municipality of Belo Horizonte, recurrence of primary neoplasm, previous treatment for other malignant disease, severe mental illness or mental deficiency, and unwillingness to participate in the study were ineligible.
From 421 women treated for cervical carcinoma and initially eligible to participate in the study, 65 had died, and 278 were not localized because their home addresses and telephone numbers had changed and their new contact information was not available at any accessible database. The remaining 78 women were invited, although only 60 agreed to participate in the study. Three of these 60 patients were excluded because of either distress during the survey or exclusion criteria. Final data on 57 women treated for invasive carcinoma of the cervix were obtained and analyzed. The recruitment of the control group was conducted through convenience sampling, by order of arrival of the women at the clinical center, considering inclusion and exclusion criteria trying, as much as possible, to match this group with the study groups. However, as stated above, the main criteria were social status matching and no serious illness.
A pilot project was carried out with 20 women who approached the general profile of this population in Brazil. Based on the pilot project, corrections were made before the application of the questionnaires, and the utilization of the auxiliary visual scales was decided based on the educational level. The visual scales were then developed under the guidance of Prof E. Nascimento, from the Department of Psychology at the Federal University of Minas Gerais, an expert in the field of psychological tool adaptation and construction. Simple visual numerical rating scales were applied to the noneducated women to help in the understanding of the interviewees. These rating auxiliary numerical scales consist of a numerical line that graduates and follows the correct and specific answers to State-Trait Anxiety Inventory (STAI), GHQ-12, and 36-item Medical Outcomes Study Short-Form Health Survey (SF-36) tests, helping the test comprehension. The pilot project was important to point out to the need of use of complementary numerical scale to increase the original answers’ reliability. Numerical scales are increasingly being used to evaluate pain in cancer patients.12
Clinical information was collected by application of a questionnaire containing general items, to evaluate descriptive and intervenient variables. The entire protocol for this study was approved by the institutional review boards of all the institutions involved. The questionnaires were translated to Portuguese, but no construct validity was done before application.
The SF-36 Questionnaire
The SF-36 survey is one of the most worldwide generic instruments used for assessing the QOL of women with gynecologic cancer and control groups. The original version of the generic questionnaire validated for life evaluation based on SF-3613 was used. This version has been translated and validated for Brazilian population and assesses through the interviewee’s self-perception the functional capacity, physical aspects, pain, general state of health, vitality, social and emotional aspects, and MH.13–15 Even considering the SF-36 limitations, this instrument was used instead of WHO QOL-100 (World Health Organization Quality of Life Assessment) questionnaire as the latter is less commonly used by many authors in this situation.
The 12-Item General Health Questionnaire
The General Health Questionnaire is a recognized instrument for assessing psychological well-being. Twelve-item General Health Questionnaire (GHQ-12) is a reduced version of the General Health Questionnaire,16 built to assess MH is capable to identify the severity of nonpsychotic psychiatric disorders, being useful in assessing a general score for psychological well-being.17
Sexuality was evaluated by the inclusion of just 1 question about the satisfaction with actual sexual life.
The STAI Inventory
To assess the anxiety levels, the STAI (Original Form X), developed by Spielberger et al,18 translated and adapted to Brazilian context was used because it was the only validated version for Portuguese language available. This inventory assesses 2 distinct concepts of anxiety: state-anxiety (the momentary state of anxiety the subjects find themselves in during the test) and trait-anxiety (the individual trait of the subject: their latent disposition to become more anxious when faced with stressful situations).18
The Life Events Inventory
Stressful events can also impact people’s levels of well-being, stress, MH, and QOL. They can therefore work as intervening factors in these studies. The Life Events Inventory19 assesses the occurrence of relatively unexpected stressful events possibly involved with the current psychic state of the individual, such as changes related to work, loss of social support, family, changes in the occupational environment, personal difficulties, and finances.19 The evaluated events were only those concerning the last year period for all patients.
Chronological variables had normal distribution and therefore are expressed as mean ± SD and compared by 1-way analysis of variance, followed by Newman-Keuls test for multiple comparisons. Quantitative scores (SF-36, STAI, and life events) deviated from normal distribution and therefore are reported as medians and quartiles and compared by Kruskal-Wallis analysis of variance, followed by Dunn test for multiple comparisons. Qualitative variables are reported as frequency and percentage and analyzed with likelihood ratio χ2 test. In all cases, P < 0.05 was considered statistically significant. The sample size was calculated to allow a minimal detectable difference of 6 units in the SF-36 scores, 6 units in the STAI scores, and 1.8 units in the Life Events Inventory, with 80% statistical power at 95% significance level.
No significant differences were found between groups regarding the following variables: satisfaction with sexual life, literacy, family income, being a smoker or former smoker, menopausal hormone therapy, diabetes, other illnesses, religious beliefs, and thinking life has improved in the last 10 years. The control group and the 3 treatment subgroups were, however, different in some aspects: age, current partner, educational level, lack of menstruation, arterial hypertension, and cardiovascular disease (P < 0.05, Table 1).
Of the 57 women treated for invasive carcinoma of the cervix, 23 (40.3%) were in stage I, 27 (47.4%) in stage II, and 7 (12.3%) in stage III. Significant differences were found among treatment subgroups, in terms of age at the time of treatment, staging, and tumor histological type (P < 0.05, Table 2). Women subjected to surgical treatment alone (RH) presented lower average age at the time of treatment and a predominance of stage I (90.90%).
Overall, the general QOL and the MH levels among women treated for invasive carcinoma of the cervix at least 2 years before this study were similar to the QOL among women with no history of malignant neoplasm. In addition, no significant differences were observed in term of levels of general QOL and MH among the 3 treated groups (Table 3).
In a reanalysis pooling all 57 women from the study group, the state-anxiety score of STAI inventory was paradoxically lower among women treated for invasive carcinoma of the cervix (median, 34; interquartile range, 27–39) than in women with no history of malignant neoplasm (median, 37; interquartile range, 32–45; P = 0.035), indicating higher anxiety levels at the moment of the interview in control subjects.
Several factors have been associated with the QOL among women treated for invasive carcinoma of the cervix, such as RT, multimodal treatment, long treatment periods, younger ages, avoidance coping, lower educational attainment, lack of spiritual beliefs, and lack of support at home, all of which are known as risk factors for poor adjustment and a low QOL. Staging and location of the tumor have not been correlated to QOL.4,10 The diversity of these factors is due not only to the complex interaction of clinical and psychosocial variables, but also to the use of many different assessment methods, which are not always standardized or validated.20 Thus, we have prioritized greater precision in the epidemiological and methodological designs of our study with true standardization of the tests applied and a detailed division of the treatment groups.
Unlike some other published studies, no statistically significant differences in QOL and MH of women in relation to the type of cancer treatment were detected. Women who survived invasive carcinoma of the cervix treated by RT had lower scores for general QOL when compared with the control group over a period of 24 months.10 Irradiated women treated more than 5 years earlier reported higher levels of anxiety than those subjected to surgery, but presented no difference from the control group.11 Women treated exclusively with RT also presented greater levels of somatization of depressive symptoms, greater frequency of menopause symptoms, and worse sexual function, even after adjustment of the confusion variables.11 Despite a tendency in the scientific literature to point out to a greater occurrence of psychosocial and sexual problems among survivors treated with RT than among women treated with surgery, it is still too early to draw such conclusions.20
Our findings on the general QOL of the interviewees are similar to those of a study with 46 women treated for invasive carcinoma, showing a satisfactory QOL of women who survived the disease when compared with a control group.21 The physical well-being summaries of women treated for cervix and vaginal cancer approached the scores of the control group 18 months after treatment, even though the majority of the women presented acute and chronic adverse effects of the treatments.10 It might well be possible that the differences between cervical cancer survivors’ levels of QOL can be more properly explained by factors such as adaptation to the disease, types of coping behaviors, MH levels, or changes in personal values than by factors related to the type of treatment. Women might consider the lasting symptomatic adverse effects of the treatments as inevitable, so that they are not taken into consideration when recording general QOL scores.9 The internal changes in values experienced by women over time can lead to general QOL scores similar to those found in the normal population, despite the fact that they present various posttreatment stress symptoms.20 It is important to remember that although QOL is a multidimensional construct, there is evidence that MH, or the psychological domain, might be the dimension of greatest predictive power for the general QOL scores.22
The evaluation of sexual behavior is difficult to assess. A few international pretested tools are available to assess sexual function in women who were treated for invasive carcinoma of the cervix.20 At the time the study was done, no questionnaire to evaluate sexuality satisfaction was available for Brazilian population. For this reason, it was decided to study if there was a relationship between QOL and satisfaction with sexual life, independent of specific sexual function alterations. Further studies seem to be necessary to establish a pattern for sexual function evaluation.
Although some limitations regarding SF-36 questionnaire application might exist, mainly in women older than 65 years in whom a low rate of responses is expected this is a matter for discussion. In the present study, we have not observed a low response rate of patients older than 65 years in accordance with the demonstration that this tool is reliable for the aged.13,23 Other questionnaires, such as EORTC QLQ-C30 (European Organization for the Research and Treatment of Cancer Core Quality of Life Questionnaire) and EORTC QLQ-CX24 (European Organization for Research and Treatment of Cervical Cancer Quality of Life Questionnaire 24), specific for evaluation of QOL of cancer patients, were neither validated nor translated to Portuguese by the time the study was done and could not have been applied.
Unexpectedly, we observed lower scores of state-anxiety in the cancer patients compared with the control group. The women in the control group were interviewed in an outpatient environment, just before gynecologic examination, which is a situation that might be stressing. Because the state-anxiety scale of the STAI assesses the momentary anxiety present at the time of the test, the residential environment of the interviews may have positively influenced the state of anxiety among the cancer surviving patients, affording them a greater degree of relaxation during the interview. Nevertheless, the patients had already completed the cancer treatment at least 2 years before, which might explain their low anxiety state by the time of the survey.
Our results are limited by the absence of a QOL assessment specifically tailored for women surviving cervical cancer and by the nonideal pairing of the control group by age and interview place. Another limitation of this study was the high proportion of eligible patients who were not localized and therefore could not be included. Without finding these patients for a prospective data collection, an accurate analysis of their epidemiological characteristics was not possible. This could cause a selection bias, through inclusion of women with more stable residence and perhaps higher socioeconomic status than typical real-life patients. However, the final study sample had very similar age, literacy, relationship status, income, and proportion of patients at stage 0-I as compared with a nationwide population survey of more than 77,000 cases of cervical cancer diagnosed between 2000 and 2009.24 The only difference was in the proportion of patients at stage II (47% in our sample vs 24% in the national survey) and stage III (12% vs 29%), but this likely reflects regional differences, with the study sample approaching the characteristics of the local population rather than the national average. Because the study was not designed to compare disease stages but only treatment modalities, our findings should not be extrapolated to high-stage disease, which is underrepresented in the study sample.
In conclusion, even if the variations among the tools for assessing QOL in women with gynecologic cancer are too broad, our findings suggest that the general QOL and the MH in women treated for invasive cervical carcinoma are similar to those of women who never had the disease. In addition, there are no differences in general QOL and MH levels among women treated for invasive carcinoma of the cervix in relation to the modality of treatment used.
1. Waggoner SE. Cervical cancer. Lancet
. 2003; 361: 2217–2225.
2. BRASIL. Ministério da Saúde. Secretaria de Vigilância em Saúde. Secretaria de atenção à Saúde. Instituto Nacional de Câncer. Coordenação de Prevenção e Vigilância. Inquérito domiciliar sobre comportamentos de risco e morbidade de doenças e agravos não transmissíveis: Brasil, 15 capitais e Distrito Federal, 2002–2003. INCA, Rio de Janeiro, Brazil: 2003. Available at: http://www.inca.gov.br/
. Accessed 30 November 30, 2008.
4. Pearman T. Quality of life
and psychosocial adjustment in gynecologic cancer survivors. Health Qual Life Outcomes
. 2003; 20: 1–33.
5. Greimel E, Thiel I, Peintinger F, et al. Prospective assessment of quality of life
of female cancer patients. Gynecol Oncol
. 2002; 85: 140–147.
6. Bradley S, Rose S, Lutgendorf S, et al. Quality of life
and mental health in cervical and endometrial cancer survivors. Gynecol Oncol
. 2006; 100: 479–486.
7. Wenzel L, DeAlba I, Habbal R, et al. Quality of life
in long-term cervical cancer survivors. Gynecol Oncol
. 2005; 97: 310–317.
8. Holland CM, Shafi MI. Radical hysterectomy
. Best Pract Res Clin Obstet Gynaecol
. 2005; 19: 387–401.
9. Korfage IJ, Essink-Bot ML, Mols F, et al. Health-related quality of life
in cervical cancer survivors: a population-based survey. Int J Radiat Oncol Biol Phys
. 2009; 73: 1501–1509.
10. Klee M, Thranov I, Machin D. The patients’ perspective on physical symptoms after radiotherapy
for cervical cancer. Gynecol Oncol
. 2000; 76: 14–23.
11. Frumovitz M, Sun CC, Schover LR, et al. Quality of life
and sexual functioning in cervical cancer survivors. J Clin Oncol
. 2005; 23: 7428–7436.
12. 12. Brunelli C, Zecca E, Martini C, et al. Comparison of numerical and verbal rating scales to measure pain exacerbations in patients with chronic cancer pain. Health and Quality Of Life
Outcomes, V.2010;8:42. Available at: http//www.hqlo.com/content/8/1/42
13. Ciconelli RM, Ferraz MB, Santos W, et al. Tradução para a língua portuguesa e validação do Questionário Genérico de Avaliação de Qualidade de Vida SF-36 (Brasil SF-36). Rev Bras Reumatol
. 1999; 39: 143–150.
14. Conde DM. Câncer de Mama, Menopausa e Qualidade de Vida
. Campinas, São Paulo, Brazil: Faculdade de Ciências Médicas da Universidade Estadual de Campinas; 2005.
15. Silva CHD, Derchain SFM. Qualidade de vida em mulheres com câncer ginecológico: uma revisão da literatura. Rev bras Cancerol
. 2006; 52: 33–47.
16. Goldberg D, Pasquali L, Gouveia VV, et al. Questionário de Saúde Geral de Goldberg: Manual Técnico QSG
. São Paulo, Brazil: Casa do psicólogo; 1996
17. Gouveia VV, Chaves SSS, Oliveira ICP, et al. A utilização do QSG-12 na população geral: estudo de sua validade de construto. Psic Teor e Pesq
. 2003; 19: 241–248.
18. Spielberger CD, Gorsuch RL, Lushene RE. Manual for the State-Trait Anxiety Inventory
. Palo Alto, CA: Consulting Psychologist Press; 1970
19. Savoia MG. Escalas de eventos vitais e de estratégias de enfrentamento (coping). Rev Psiquiatr Clín
. 1999; 26: 57–67.
20. Vistad I, Fossa SD, Dahl AA. A critical review of patient-rated quality of life
studies of long-term survivors of cervical cancer. Gynecol oncol
. 2006; 102: 563–572.
21. Li C, Samsioe G, Iosif C. Quality of life
in long-term survivors of cervical cancer. Maturitas
. 1999; 32: 95–102.
22. Smith K, Avis N, Assmann S. Distinguishing between quality of life
and health status in quality of life
research: a meta-analysis. Qual Life Res
. 1999; 8: 447–459.
23. Walters SJ, Munro JF, Brazier JE. Using the SF-36 with older adults: a cross-sectional community-based survey. Age Ageing
. 2001; 30: 337–343.
24. Thuler LCS, Bergmann A, Casado L. Profile of the patients with cervical cancer in Brazil, 2000–2009: secondary base study. Rev Bras Cancerol
. 2012; 58: 351–357.