MGH Program Supports Sexual Health of Women Receiving Pelvic RT for Gastrointestinal and Gynecologic Malignancies

Cancer Network spoke with Lorraine Drapek, DNP, FNP-BC, AOCNP about her presentation, “A Multimodal Continuity of Care Program to Prevent or Minimize Vaginal Effects of Pelvic Radiation Therapy for Women with Lower Gastrointestinal and Gynecologic Cancers,” which she discussed at the 2018 Oncology Nursing Society Congress. Dr. Drapek is an Advanced Practice Nurse Practitioner in Radiation Oncology at Massachusetts General Hospital in Boston, where she specializes in curative and palliative care, symptom management, clinical trials, and survivorship care.

-Interviewed by Lori Smith, BSN, MSN, CRNP

Cancer Network: Can you briefly explain your presentation on minimizing the effects of pelvic radiation on women with lower GI and gynecologic malignancies?

Lorraine Drapek: This presentation involved my doctoral (DNP) work in establishing a sexual health clinic for women receiving pelvic radiation. Vaginal stenosis and worsening dryness can occur in up to 88% of women who receive pelvic radiation. There are international guidelines recommending the use of vaginal dilators for 2 years post treatment. However, adherence in North America, Europe, and Australia is poor. The specific aim of this program was to establish a [resource to help] women understand the importance of intervention and follow-up to minimize these symptoms.

Cancer Network: Can you elaborate on symptoms other than vaginal stenosis which may affect sexual function in this population?

Lorraine Drapek: Vaginal dryness, pain with sexual intercourse, and spasms with intercourse are all symptoms that can result. Vaginal dryness can occur with menopause. It can get worse with radiation, which causes scarring of the vaginal tissues. Pain with sexual intercourse (dyspareunia) and vaginal spasms (vaginismus) can result from both vaginal dryness and vaginal stenosis.

Cancer Network: In your presentation, you discuss low adherence rates to using vaginal dilators. Why do you think this is the case, and what can oncology nurses and advanced care providers do to increase adherence?

Lorraine Drapek: Patients do not always understand, or cannot focus on, vaginal health or sexual function before or during treatment. They are often worried about “staying alive” or getting through treatment. Vaginal dilators are often given and discussed at the end of treatment. At that time, women are [typically] very fatigued, have treatment-related pain, and experience bowel symptoms such as diarrhea. Some studies have shown that women often see a vaginal dilator as invasive, a reminder of cancer treatment, and “using a toy”-having a sexual meaning.

Cancer Network: Can you briefly describe the multimodal continuity-of-care program you evaluated, its various components, and your findings?

Lorraine Drapek: This program consists of a nurse-run clinic that provides a sexual/vaginal health assessment; patient education; vaginal dilators; and recommendations for vaginal moisturizers, including prescription agents. It also encompasses surveys about sexual/vaginal health, quality of life, and mood (depression/anxiety). The need for other services-such as social work, counseling, and pelvic floor therapy-is also evaluated.

Cancer Network: What is the most important takeaway for oncology nurses and other professionals those caring for women receiving pelvic radiation for GI and gynecologic malignancies?

Lorraine Drapek: Patient education about long-term vaginal effects should happen very early following treatment or prior to treatment. Patients want to be asked about their sexual health but are reluctant to initiate [the conversation with their healthcare] providers. In a 2015 sexual health needs assessment we conducted [Wo et al, Pract Radiat Oncol, 2017], we surveyed female and male patients, during the time they were receiving radiation and in the follow-up period.  Of 109 patients approached, 107 completed the survey. We found that patients are interested in a multidisciplinary approach and want providers to ask about sexual health, but were reluctant to bring up the topic themselves. The patients who were in follow-up surveillance had worse distress with respect to sexual health than those under treatment [through this program].