Hypothesis / aims of study
Pelvic floor dysfunction covers a large series of different conditions and abnormalities of the pelvic floor that adversely affect the quality of life in women. The number of cancer survivors is increasing worldwide, thanks to advancements in early detection and treatment as well as the global population's aging. In 2018, 43.8 million cancer survivors had been diagnosed during the previous five years.1 The quality of life of cancer survivors is becoming increasingly important to healthcare providers as the number of cancer survivors grows. Cancers of the ovaries, uterus, cervix, vulva, and vagina are referred to as gynecological cancers. After breast cancer, they are the second most common cancer in women.2 Major advancements in existing radiotherapy, chemotherapy, and surgical procedures provide hope for these women's long-term survival. With such gains in survival, the morbidity of therapy and its effect on quality of life must be factored into care decisions more frequently. Gynecologic cancer care also requires various treatment modalities that, alone or in combination, have the ability to damage the pelvic organs and contribute to pelvic floor disorders. The incidence of pelvic floor dysfunctions (PFDs) in women who have been treated for gynecological malignancies has not been well described.
The aim of our study is to compare the incidence of PDFs in women before and after different types of treatment for gynecological malignancies. We hypothesized that the prevalence of PFDs in the gynecologic cancer population would be higher after the treatment.
Study design, materials and methods
We searched the following electronic bibliographic databases: MEDLINE, EMBASE, Global Health, The Cochrane Library and Web of Science through April 2021. The search strategy includes only terms relating to or describing the intervention. The key words were pelvic floor disorders (pelvic organ prolapse, urinary incontinence, stress incontinence, overactive bladder, frequency, nocturia), gynecological cancer, vulva-cervix-vaginal-ovary-endometrium cancer, treatment, surgery, chemotherapy, hormonal treatment, radiotherapy. The combined searches produced 56 distinct citations. All studies of any design except Case reports, Case Series, Letters, Editorials, and Reviews were included. The inclusion criteria were as follows: women with any histological proved gynecologic cancer (uterine, ovarian, cervical, vulvar, and/or vaginal) with valid data on prevalence of PFDs both before and after any oncologic treatment. Our primary goal was to determine the prevalence of PFDs in those who underwent some form of gynecologic malignancy intervention. As secondary outcome, will aimed to determine the deterioration of PFDs in women after therapy for gynecological cancer. Following the screening of abstracts, two reviewers reviewed the full text of 56 papers, of which 11 were included in the study.
Results
Of the 550 studies retrieved, 11 met the criteria for systematic review. The prevalence of PFDs in 663 survivors of cervical cancer was evaluated in 9 studies and in 37 vulva cancer survivors in 2 studies. There were no studies dealing with patient with endometrial cancer or ovarian cancer that met the criteria of this systematic review, therefore this study does not include any results for the prevalence of PFDs in women who had interventions for endometrial and ovarian cancer.
Treatment for cervical cancer led a rise in the rate of Stress Urinary Incontinence (SUI), pre-treatment SUI was 14.2% (75/529) and post-treatment SUI was 33.7% (171/507), p:<0.0001. Also, there was an increase of Overactive Bladder (OAB) and Mixed Urinary Incontinence (MUI) prevalence in cancer survivors after oncological therapy (pre-treatment OAB: 5.50% (24/436) vs post-treatment OAB: 19.95% (87/436), p:<0.0001 and pre-treatment MUI: 0.0% (0/333) vs post-treatment MUI: 5.40% (18/333), p:<0.0001). The overall prevalence of urinary incontinence (UI) in cervical cancer survivor was significantly increased after treatment [Pre-treatment Total UI 17.46% (106/607) vs Post-treatment Total UI 54,54% (302/564), p:0.0001]. There was only one study that evaluate the Fetal Incontinence (FI) before and after therapy for cervical cancer. Although there was a minor increase of FI after treatment in cervical cancer survivors (0/58 vs 3/58), this was not statistically significant (p=0.25).
There were only two studies that examine the prevalence of PFDs before and after therapy in vulvar cancer survivors and more specifically only the total Urinary Incontinence. In total, 37 women with vulvar cancer participate in both studies, 4 of them diagnosed with UI before oncological therapy and 9 after treatment. This slight increase was not statistically significant (p=0.063) (Figure 1).
Interpretation of results
The prevalence of urinary incontinence increases exponentially after any intervention for the treatment of cervical cancer. The more likely is that this might be a common trend among women who undergo any intervention for the treatment of gynecological cancer, as it is indicated in already published reviews [3]. However, the quality of data regarding this field is suboptimal. The main concerns are (a) the poor design of the studies – most of them report of only post-operative symptoms, (b) the infrequent use of validated instruments to quantify the PFDs as appropriately, and (c) the inclusion of multiple cancers in many of the studies that do not discriminate type of disease and type of interventions. The last issue is very significant as the surgical approach is different between the various types of gynecological cancer.