Qualidade de vida e função sexual em mulheres com câncer do colo uterino = Quality of life and sexual function in women with cervical cancer

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REGINA CÉLIA GRION

QUALIDADE DE VIDA E FUNÇÃO SEXUAL EM

MULHERES COM CÂNCER DO COLO UTERINO

QUALITY OF LIFE AND SEXUAL FUNCTION IN

WOMEN WITH CERVICAL CANCER

CAMPINAS

2015

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UNIVERSIDADE ESTADUAL DE CAMPINAS Faculdade de Ciências Médicas

REGINA CÉLIA GRION

QUALIDADE DE VIDA E FUNÇÃO SEXUAL EM

MULHERES COM CÂNCER DO COLO DO ÚTERINO

QUALITY OF LIFE AND SEXUAL FUNCTION IN

WOMEN WITH CERVICAL CANCER

Dissertação de Mestrado apresentada à Pós-Graduação da Faculdade de Ciências Médicas da Universidade Estadual de Campinas para obtenção do Título de Mestre em Ciências da Saúde, área de concentração em Fisiopatologia Ginecológica.

Dissertation submitted to the Department of Post-Graduate Studies in Obstetrics and Gynecology, Faculty of Medical Sciences, University of Campinas to obtain the master degree on Health Sciences, area of Gynecology Pathophysiology

ORIENTADOR: PROF. DR. AARÃO MENDES PINTO-NETO

COORIENTADOR: PROF. DR. LUIZ FRANCISCO CINTRA BACCARO

ESTE EXEMPLAR CORRESPONDE À VERSÃO FINAL DA TESE DEFENDIDA PELO ALUNO REGINA CÉLIA GRION

E ORIENTADA PELO PROF. DR. AARÃO MENDES PINTO NETO

Assinatura do Orientador

CAMPINAS 2015

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BANCA EXAMINADORA DA DEFESA

REGINA CELIA GRION

ORIENTADOR: PROF. DR. AARÃO MENDES PINTO-NETO

COORIENTADOR: PROF. DR. LUIZ FRANCISCO CINTRA BACCARO

MEMBROS:

2. 3.

Programa de Pós-Graduação em Tocoginecologia da Faculdade de Ciências Médicas da Universidade Estadual de Campinas

Data: 18 / 08 / 2015

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RESUMO

brasileiras e a radioterapia pélvica é uma das principais modalidades terapêuticas disponíveis. Com a diminuição da mortalidade associada à doença, a avaliação da qualidade de vida e da função sexual ganha cada vez mais importância. Vários estudos descrevem estes aspectos após o tratamento do tumor, porém, há poucos relatos sobre os fatores que influenciam a qualidade de vida e a função sexual antes do início do tratamento radioterápico. Os objetivos do presente estudo foram avaliar os fatores associados à função sexual e à qualidade de vida em mulheres com câncer do colo uterino antes do início da radioterapia. Métodos: estudo de corte-transversal com 80 mulheres portadoras de câncer do colo do útero, com idade de 18 a 75 anos, encaminhadas para tratamento radioterápico no Hospital da Mulher Prof. Dr. José Aristodemo Pinotti (CAISM-UNICAMP) de janeiro/2013 a março/2014. As variáveis dependentes foram a função sexual, avaliada através do Índice de Função Sexual Feminino (IFSF), e a qualidade de vida, avaliada através da versão abreviada do questionário da Organização Mundial da Saúde (WHOQOL-bref). As variáveis independentes foram os dados sociodemográficos, os hábitos de saúde e as características da neoplasia. A análise estatística foi realizada através dos testes T de Student, Mann-Whitney, ANOVA e regressão linear múltipla. Resultados: A

média etária foi de 48,1 anos, 57,5% das mulheres se encontravam na pré-menopausa e 55% apresentavam estadio clínico IIIB. A maioria das mulheres (62%)

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relatou ter parceiro sexual e 30% se encontravam sexualmente ativas nos três meses prévios à radioterapia. Os principais sintomas durante as relações sexuais foram sangramento (41,7%), falta de prazer (33,3%), dispareunia (25%) e secura vaginal (16,7%). A avaliação pelo IFSF mostrou que as 18 mulheres que se encontravam sexualmente ativas no último mês, apresentavam disfunção sexual significativa (escore total médio = 25,6). Ter realizado cirurgia antes da radioterapia se associou negativamente com os domínios satisfação (p = 0,02) e excitação (p = 0,01) do IFSF. Mulheres com sangramento vaginal durante a relação sexual tiveram menores escores nos domínios orgasmo (p = 0,04) e satisfação (p = 0,03). Apresentar qualquer sintoma adverso durante a relação sexual se associou negativamente com o domínio dor (p = 0,02). Falta de prazer às relações se associou negativamente com o domínio orgasmo (p = 0,04) e fumar se associou positivamente com o escore total do IFSF (p = 0,04). Estadio clínico avançado, uso de medicação crônica e não ter realizado cirurgia correlacionaram-se negativamente com a qualidade de vida. Ter maior renda familiar, maior nível de escolaridade e não fumar correlacionaram-se positivamente com a qualidade de vida. Conclusão: um terço das mulheres com câncer de colo do útero mantinham relações sexuais três meses antes da radioterapia, porém apresentavam disfunção sexual significativa. Fatores relacionados à doença e ao seu tratamento foram os principais responsáveis pela deterioração da função sexual. A qualidade de vida sofre influência não apenas dos fatores relacionados à neoplasia, mas também de hábitos de vida, presença de comorbidades e características sociodemográficas como baixa renda familiar e escolaridade.

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Palavras-chave: Neoplasias do Colo do Útero; Sexualidade; Qualidade de Vida;

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SUMMARY

Brazilian women and pelvic radiotherapy is one of its major therapeutic methods. With the decreasing mortality associated with the disease, evaluation of quality of life and sexual function is becoming increasingly important. Several studies describe these aspects after the tumor treatment, however, there are few reports about the factors influencing quality of life and sexual function before the start of radiotherapy. The objectives of this study were to evaluate the factors associated with sexual function and quality of life in women with cervical cancer before the start of radiotherapy. Methods: a cross-sectional study was conducted with 80 women with cervical cancer, aged 18-75 years, referred for radiotherapy at the Women's Hospital Prof. Dr. José Aristodemo Pinotti (CAISM-UNICAMP), from January 2013 to March 2014. The outcome variables were sexual function, assessed using the Female Sexual Function Index (FSFI), and quality of life, assessed using the abbreviated version of the World Health Organization (WHOQOL-BREF) questionnaire. The independent variables were sociodemographic data, health related habits and the characteristics of the neoplasm. Statistical analysis was carried out using Student´s T test, Mann-Whitney test, ANOVA and multiple linear regression. Results: The mean age was 48.1 years, 57.5% were premenopausal and 55% had clinical stage IIIB. Thirty percent had been sexually active in the three months prior to their interviews. The majority of women (62%) reported having sexual partner and 30%

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had been sexually active in the three months prior to their interviews. The main adverse events during sexual intercourse were bleeding (41.7%), lack of pleasure (33.3%), dyspareunia (25%), and vaginal dryness (16.7%). The 18 women who had been sexually active in the previous month showed significant sexual dysfunction (total mean FSFI score = 25.6). Having undergone surgery before radiotherapy was negatively associated with arousal (p = 0.01) and satisfaction (p = 0.02) domains. Women with vaginal bleeding during intercourse had significantly lower scores in the orgasm (p = 0.04) and satisfaction (p = 0.03) domains. Women with any adverse symptoms during intercourse had lower scores in the pain domain (p = 0.02). Lack of pleasure during intercourse was negatively associated with the orgasm domain (p = 0.04) whereas smoking was positively associated with total FSFI score (p = 0.04). Advanced clinical stage, using any chronic medication and not having undergone surgery for cancer were negatively correlated with QOL. Higher family income, a longer duration of schooling and no smoking were positive correlated with QOL.

Conclusion: one third of women with cervical cancer were sexually active three

months prior to their interviews, but had concomitant significant sexual dysfunction. Factors related to the disease and its treatment were mainly responsible for the deterioration in sexual function. Quality of life is influenced not only by factors related to cancer, but also by lifestyle habits, comorbidities and sociodemographic characteristics such as low family income and schooling.

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SUMÁRIO

ABREVIATURAS E SIGLAS ... xxi

INTRODUÇÃO GERAL ... 1 OBJETIVOS ... 11 Objetivo Geral ... 11 Objetivos Específicos ... 11 CAPÍTULOS ... 13 CONCLUSÃO GERAL ... 37 REFERÊNCIAS ... 39 ANEXOS ... 47

Anexo 1 - Instrumento para coleta de dados ... 47

Anexo 2 - Índice da Função Sexual Feminina (IFSF) ... 54

Anexo 3 - Intrumento de Qualidade de vida... 59

Anexo 4 - Termo de Consentimento Livre e Esclarecido ... 63

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DEDICATÓRIA

Aos meus pais, Delamar e Edith Presentes em todos os meus caminhos escolhidos.

Pelo apoio e amor incondicional

Às minhas irmãs, Rôse e Raquel Pelo incentivo em todos os momentos deste estudo.

Aos meus sobrinhos, Felipe, Andréa, Nathália, Pedro e Flora Pelo carinho e alegria sempre presente. Inspiração infinita

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AGRADECIMENTOS

Ao meu orientador, Prof. Dr. Aarão Mendes Pinto Neto, pela oportunidade da realização deste trabalho.

Ao Prof. Dr. Luiz Francisco Cintra Baccaro, pela paciência, colaboração e valiosa dedicação na elaboração deste estudo.

À enfermeira e amiga Ana Francisca Vaz pela colaboração e oportunidade deste trabalho.

A todos os meus amigos constantes em todos os momentos da minha vida: Regina Tazinazzo, Maria Paula S. Araújo, Maria Ângela Bordin, Sandra Gomide. Obrigada.

A Jumara Martins, Kátia Regina de Jesus, Ana Paula Fortuna, pelos incentivos diários.

A todos os colaboradores do Ambulatório de Radioterapia do CAISM – Unicamp, que de alguma maneira auxiliaram na realização deste trabalho, em especial as técnicas de enfermagem Quézia, Shirley, Aparecida, Glória e Alice (in memoriam). À técnica de enfermagem Vanessa pelo auxílio na complementação deste estudo.

Em especial: às mulheres que participaram deste estudo, meu sincero agradecimento e respeito.

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Este estudo foi financiado pela

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP). Processo número 2012/09215-7.

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ABREVIATURAS E SIGLAS

Centro de Atenção Integral à Saúde da Mulher

EP – Estimated Parameter

FIGO – International Federation of Gynecology and Obstetrics FSFI – Female Sexual Function Index

IFSF – Índice de função sexual feminina IMC – Índice de Massa Corpórea

OMS – Organização Mundial da Saúde QOL – Quality of life

QV – Qualidade de vida

R² – Coefficient of Determination RT – Radiotherapy

SD – Standard Deviation

UNICAMP – Universidade Estadual de Campinas

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INTRODUÇÃO GERAL

O câncer do colo do útero é um importante problema de saúde pública. Estima-se que 87% das mortes pela doença ocorram em países em desenvolvimento. No Brasil, é a terceira neoplasia mais incidente em mulheres, com uma estimativa de 15590 casos novos no ano de 2014. Excetuando-se os tumores de pele não melanoma, o câncer do colo do útero é o mais incidente na região norte e o segundo mais incidente nas regiões centro-oeste e nordeste. A doença costuma manifestar-se a partir dos 30 anos e o risco aumenta com a idade, atingindo seu pico entre os 50 e 60 anos (1).

O exame citopatológico do colo do útero é o principal método de rastreamento do câncer cervical. No Brasil preconiza-se que o exame citopatológico seja oferecido às mulheres na faixa etária de 25 a 64 anos que já tenham tido atividade sexual (2). A Organização Mundial da Saúde (OMS) relata que há possibilidade de redução de 60 a 90% na incidência de câncer de colo uterino invasivo com realização de citologia oncótica em no mínimo 80% da população-alvo, associada a garantia de diagnóstico e tratamento adequados dos casos alterados (3). Para realizar-se uma estimativa da cobertura de exames citopatológicos de uma população pode-se utilizar a razão entre o total de exames realizados em determinado ano e o número total de indivíduos que constituem a população-alvo. Razões anuais de 0,3 a cada três anos sugerem cobertura de aproximadamente 100% da população neste período. Segundo os últimos dados do

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Instituto Nacional do Câncer, a razão entre exames citopatológicos e população-alvo (mulheres de 25 a 64 anos) considerando-se todo o país foi de 0,17 em 2010, 0,16 em 2011 e de 0,16 em 2012 (4).

Quando diagnosticado em fases iniciais as chances de cura do câncer de colo uterino são altas. Em estágios mais avançados, porém, a taxa geral de sobrevida em 5 anos após a realização concomitante de radioterapia e quimioterapia está em torno de 52% (5). Nas duas maiores cidades brasileiras, São Paulo e Rio de Janeiro, a taxa de mortalidade apresentou redução significativa entre 1980 e 2009, sobretudo para mulheres nascidas após a década de 1960 (6). As taxas de sobrevida em cinco anos no Brasil como um todo mantêm-se estáveis nas últimas duas décadas, sendo de 60,2% entre 1995 e 1999, 67,5% entre 2000 e 2004 e de 61,1% entre 2005 e 2009 (7). Em uma análise dos registros de neoplasias em 187 países entre 1980 e 2010 observou-se que a incidência cumulativa global do câncer do colo do útero diminuiu, porém, a variação foi menor nos países em desenvolvimento (8).

O câncer do colo do útero é uma doença de evolução lenta, frequentemente assintomática no seu desenvolvimento inicial. A primeira manifestação da progressão tumoral é o sangramento pós coito (sinusorragia), que pode evoluir com sangramento vaginal aumentado independente de relações sexuais e da fase do ciclo menstrual. Outros sinais e sintomas que podem estar presentes na progressão da doença são a dispareunia e a leucorreia de odor fétido. Em estágios avançados é comum as manifestações de fadiga devida à anemia provocada pelo sangramento crônico, além de dor abdomino-pélvica em decorrência da obstrução progressiva dos tratos urinário e gastrointestinal (9). Segundo a Federação Internacional de

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Ginecologia e Obstetrícia (FIGO), os estágios do câncer cervical são descritos utilizando numerais romanos de I a IV. Alguns estágios são subdivididos em sub-estágios indicados por letras e números. Resumidamente, carcinomas restritos à cervix são classificados dentro do estágio I; quando o carcinoma se estende para além do útero, porém não alcança a parede pélvica ou o terço inferior da vagina é classificado como estágio II; quando o tumor se estende ao terço inferior da vagina ou à parede lateral da pelve é classificado como estágio III e se o carcinoma se estende além da pelve verdadeira ou invade a mucosa da bexiga e/ou do reto é classificado como estágio IV (10). Recentemente, um estudo com 50 mulheres portadoras de câncer do colo uterino entre os estágios Ib e IVa evidenciou que os sintomas mais comuns antes do início do tratamento foram fadiga (36%), aumento da frequência urinária (32%), corrimento vaginal (22%), insônia (22%), cólicas abdominais (18%) e sangramento vaginal (16%) (11).

A cirurgia, a radioterapia e a quimioterapia são opções de tratamento para o câncer do colo uterino (12). A escolha do tipo de tratamento a ser utilizado leva em consideração o tamanho do tumor, o estadiamento, a idade da paciente e o desejo ou não de ter filhos (13). A histerectomia radical com linfadenectomia pélvica, associada ou não à quimioterapia e radioterapia, é a modalidade terapêutica mais frequentemente indicada para tumores do colo uterino em estágio inicial (12). Em casos mais avançados, a radioterapia associada a esquemas de quimioterapia aumenta a taxa de sobrevida e tempo livre de doença, além de diminuir as recidivas locais e metástases à distância (14,15).

Apesar dos avanços no rastremanto e controle da doença, ainda é comum o diagnóstico do câncer do colo do útero em estágio avançado (16) e a radioterapia

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pélvica é uma das principais modalidades terapêuticas nesses casos (17). Geralmente o tratamento radioterápico é ambulatorial, e pode ser realizado através de uma associação de teleterapia e braquiterapia, com uma duração de até oito semanas (12,15). Em algumas mulheres com tumores em estágios iniciais (IA1), se houver invasão tumoral do espaço linfovascular, a radioterapia pélvica pode ser indicada quando não há necessidade de preservação da fertilidade (15).

Os efeitos adversos agudos, que ocorrem durante o tratamento e em até 60 dias após a radioterapia (18), incluem alterações gastrointestinais (diarreia, dor abdominal, sangramento retal), geniturinárias (dispareunia, estenose vaginal, diminuição de lubrificação, disúria, urgência urinária), cutâneas (eritema, descamação, edema), hematológicas (anemia, leucopenia) e falência ovariana (19,20). De acordo com Kilic et al (21), eventos adversos agudos relacionados à radioterapia foram observados em 93% dos pacientes tratados por diferentes tipos de câncer, sendo que os sintomas mais frequentes foram gastrointestinais. Em mulheres portadoras de carcinoma de colo do útero localmente avançado observa-se toxicidade aguda após radioterapia em 77% dos casos, observa-sendo mais frequentes no retosigmóide (61%), bexiga (27%), pele (20%) e região genital (12%) (22). Sintomas geniturinários como incontinência, micção frequente e estenose vaginal ocorrem mais frequentemente após a radioterapia quando comparado a diferentes modalidades de tratamento como a cirurgia e a quimioterapia (23). Geralmente, os efeitos adversos agudos da radioterapia têm curta duração, sendo tratados com a administração de medicamentos sintomáticos (12). Por outro lado, as complicações tardias, podem levar a danos difíceis de serem revertidos, prejudicando a qualidade de vida (12). Durante e após a radioterapia as mulheres com câncer ginecológico

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reportam alterações sociais e psicológicas como angústia, alteração de autoimagem, alteração de humor, sintomas de depressão, raiva e confusão (24, 25, 26). Alguns estudos de prevalência reportam que ansiedade e depressão são mais frequentes em mulheres com câncer ginecológico em comparação com a população em geral (27, 28).

Em comparação com outros tipos de câncer ginecológico, o de colo uterino afeta mulheres mais jovens com maior frequência (29). Embora a radioterapia tenha efeitos benéficos, levando ao controle local da doença e a uma maior sobrevida, os efeitos adversos podem impactar de forma negativa a função sexual e reprodutiva, devido a alterações na anatomia vaginal, na função ovariana, perda de fertilidade e possível menopausa precoce (30, 31, 32, 33). Alguns estudos que descrevem a função sexual em mulheres com câncer do colo do útero após o tratamento com radioterapia relatam que entre 30% e 63% apresentam alterações relacionadas ao funcionamento sexual como principal causa de angústia a curto e longo prazo (20, 34).

A função sexual é um componente importante da qualidade de vida e pode estar comprometida nas mulheres tratadas com radioterapia (35). De maneira geral, a disfunção sexual pode ser definida como alteração de uma das etapas do ciclo de resposta sexual caracterizada por falta, excesso, desconforto e dor associada ao ato, que se manifesta de forma persistente ou recorrente (36). A disfunção sexual feminina tem etiologia multifatorial, envolvendo aspectos físicos, psicológicos e sociais. Mulheres com idade acima de 44 anos, aquelas na pós-menopausa, com antecedente de cirurgias vaginais e menor escolaridade parecem ter uma maior predisposição para disfunção sexual (37, 38). Na população brasileira, uma

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pesquisa avaliou a prevalência da disfunção sexual feminina em sete estados. O estudo incluiu 1219 mulheres, com idade média de 35,6 anos que responderam a um questionário sobre sexualidade. Alteração de ao menos uma das etapas do ciclo sexual foi referida por 49% das mulheres. Falta de desejo sexual foi relatado por 26,7% das participantes, alterações no orgasmo por 21% e dispareunia por 23,1%. A prevalência de queixas sexuais aumenta com a idade e o baixo nível educacional (39).

Os resultados dos estudos que avaliam a função sexual podem apresentar divergências quando diferentes instrumentos de análise são utilizados. Os questionários auto aplicados são mais adequados pois apresentam alto grau de confiabilidade, consistência e validade (36, 40). Dentre esses questionários destaca-se o “The Female Sexual Function Index” (FSFI) (41). O “The Female Sexual Function Index” é um questionário desenvolvido por Rosen et al (41), validado e traduzido para a língua portuguesa (42). No Brasil é denominado “Índice de Função Sexual Feminino” (IFSF). O questionário é composto por seis domínios e uma soma de escores que mede o grau de desejo (questões 1 e 2), excitação (questões 3-6), lubrificação (questões 7-10), orgasmo (questões 11-13), satisfação (questões 14-16) e dor (questões 17-19). Para obter-se os escores dos domínios, somam-se os escores individuais e multiplica-se pelo fator correspondente. Para obter o escore total da escala soma-se os escores de cada domínio, com o resultado variando de no mínimo 2 e no máximo 36. A pontuação zero em um domínio indica que a mulher não referiu atividade sexual nas últimas quatro semanas (34). A pontuação total pode indicar a presença de disfunção sexual quando o escore for menor ou igual a 26,55 (43).

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Alguns autores relatam que mulheres com câncer do colo do útero antes do início do tratamento radioterápico apresentam maior preocupação, maior comprometimento da imagem corporal e menor interesse e satisfação sexual em comparação às mulheres saudáveis (44,45). Antes do diagnóstico da neoplasia, a função sexual pode estar comprometida por sintomas como corrimento vaginal fétido, dor e sangramento genital (46). Após o diagnóstico, a preocupação com um possível agravamento da doença também é motivo para diminuição do desejo e satisfação sexual (47, 48). Em 2003, Jensen et al, em uma avaliação retrospectiva de mulheres com câncer do colo uterino onde a maioria apresentava tumores em estádio inicial (I/II), identificaram que 53% estavam sexualmente ativas antes da radioterapia (20). Estudo brasileiro com 95 mulheres, com idade entre 21 e 75 anos, encaminhadas para radioterapia por câncer cervical ou de endométrio, mostrou que 21,1% eram sexualmente ativas antes do início da radioterapia, sendo que a maioria não tinha parceiro sexual (50,5%). Após três anos do diagnóstico houve aumento significativo no número de mulheres sexualmente ativas em relação à avaliação inicial, sugerindo que o diagnóstico recente de câncer, além de sintomas como dor e sangramento vaginal prejudicam a função sexual (49). Mais recentemente, em 2014, um estudo prospectivo com 50 mulheres com câncer do colo do útero localmente avançado (IB-IVA) e média etária de 54 anos, identificou que 12% mantinham atividade sexual antes do início do tratamento radioterápico e 18% reportaram preocupações quanto a relações sexuais dolorosas (11).

A avaliação da qualidade de vida é um passo importante para uma abordagem mais humanista no tratamento do câncer, e vem sendo utilizada com o intuito de avaliar o impacto da doença e do tratamento na vida do paciente (50).

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Com o avanço dos métodos terapêuticos e a melhora da sobrevida, a avaliação dos aspectos relacionados não apenas à doença, mas também das condições de vida no geral ganha cada vez mais importância (51). A qualidade de vida foi definida pela Organização Mundial de Saúde (OMS) como “a percepção do indivíduo de sua posição na vida, no contexto da cultura e sistema de valores nos quais ele vive e em relação aos seus objetivos, expectativas, padrões e preocupações” (the WHOQOL GROUP, 1994). De acordo com essa definição o conceito de qualidade de vida é subjetivo e multidimensional, contemplando aspectos positivos e negativos (52).

Para avaliar a qualidade de vida, diversos questionários foram elaborados com a finalidade de transformar dados subjetivos em dados objetivos e mensuráveis, que possam comparar diversas populações (53). A OMS criou um instrumento de qualidade de vida genérico e autoexplicativo, dentro de uma perspectiva transcultural, denominado WHOQOL-100. É um instrumento com cem questões, dividido em seis domínios: físico, psicológico, nível de independência, relações sociais, meio ambiente e espiritualidade (54). Mais tarde, com a necessidade de um instrumento de avaliação mais curto, que demandasse pouco tempo para seu preenchimento, porém que mantivesse as mesmas características psicométricas, a OMS desenvolveu uma versão abreviada, o WHOQOL-bref (52). No Brasil foi traduzido e validado por Fleck e colaboradores e está disponível desde 1999 (55). Esse questionário contém 24 questões abrangendo quatro domínios: físico, psicológico, relacionamento social e meio ambiente; e duas questões sobre qualidade de vida e saúde geral.

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Alguns estudos avaliaram a qualidade de vida em mulheres com câncer ginecológico e sugeriram que ela sofre modificações ao longo do tempo (56, 57). Durante a fase de tratamento ativo a qualidade de vida piora, com tendência a melhorar com o passar dos anos (57). De acordo com Vaz et al, mulheres com câncer ginecológico em estádio avançado, baixo nível de escolaridade e na pós-menopausa apresentam pior escore na questão sobre saúde geral antes de iniciar a radioterapia. Provavelmente os sintomas relacionados com o câncer, como dor, anemia e sangramento vaginal, além das incertezas e expectativas sobre os resultados do tratamento, podem influenciar negativamente a qualidade de vida (47). Em 2008, Distefano et al, observaram que mulheres com idade entre 18 e 65 anos com câncer de colo do útero localmente avançado apresentavam piores escores de qualidade de vida no domínio físico em relação a mulheres com câncer cervical em estágios iniciais que seriam submetidas a cirurgia radical. Além disso, comorbidades, baixo nível de escolaridade e baixa renda familiar correlacionaram-se negativamente com a qualidade de vida dessas mulheres (58). Em estudo publicado em 2014, Azmawati et al, relataram que mulheres com câncer do colo do útero em estágio avançado, quando comparadas àquelas em estágio inicial, apresentam pior qualidade de vida em diversos domínios como estado de saúde global e funcionamento emocional (59). De acordo com alguns estudos, as características sociodemográficas têm pouca influência na qualidade de vida de pacientes com câncer quando outras variáveis são consideradas (60), não se associando com a qualidade de vida tanto antes (47) quanto após o tratamento (26).

Com a introdução de programas sociais mais abrangentes para prevenção do câncer do colo do útero, associado a avanços nos recursos terapêuticos,

espera-10

se que a mortalidade pela doença seja cada vez menor (6). Com isso, a forma como a doença afeta não apenas os aspectos físicos, como também os psicológicos, a qualidade de vida e a sexualidade ganham cada vez mais importância. Vários estudos descrevem a qualidade de vida e a função sexual de mulheres com longo tempo de sobrevida após o tratamento do câncer do colo uterino, porém, há poucos relatos sobre os fatores que influenciam a qualidade de vida e a função sexual antes do início do tratamento radioterápico (47,61,62). Conhecer esses fatores é importante para que se possa identificar precocemente mulheres mais suscetíveis aos efeitos adversos da radioterapia e instituir medidas multidisciplinares profiláticas em tempo oportuno. Com o objetivo de obter um melhor conhecimento dos aspectos relacionados à vida sexual e à qualidade de vida de mulheres portadoras de câncer do colo do útero em início de tratamento, foi conduzido estudo com mulheres encaminhadas para realização de radioterapia no Hospital da Mulher da Universidade Estadual de Campinas.

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OBJETIVOS

Avaliar a qualidade de vida e a função sexual de mulheres com câncer do colo do útero antes do início da radioterapia.

Objetivos Específicos

 Avaliar os fatores associados à qualidade de vida em mulheres com câncer do colo do útero antes do início da radioterapia

 Descrever a função sexual de mulheres com câncer do colo do útero antes do início da radioterapia.

 Avaliar os fatores associados à função sexual em mulheres com câncer do colo do útero antes do início da radioterapia.

13

14

Sexual function and quality of life in women with cervical cancer before radiotherapy: a pilot study

Regina Celia Grion, NP

Radiotherapy Division, Department of Gynecology, State University of Campinas (UNICAMP) Campinas-SP, Brazil

Luiz Francisco Baccaro, MD, PhD (corresponding author) (requests for reprints)

Department of Gynecology, State University of Campinas (UNICAMP) Rua Alexander Fleming, 101, Cidade Universitária Zeferino Vaz Postal Code: 13083-881

Campinas-SP, Brazil

Phone/fax: +55 19 3521 9306 E-mail: [email protected]

Ana Francisca Vaz, NP, PhD

Radiotherapy Division, Department of Gynecology, State University of Campinas (UNICAMP) Campinas-SP, Brazil

Lúcia Costa-Paiva, MD, PhD

Department of Gynecology, State University of Campinas (UNICAMP) Campinas-SP, Brazil

Délio Marques Conde, MD, PhD

Breast Clinic, Hospital for Maternal and Child Healthcare Goiânia-GO, Brazil

Aarão Mendes Pinto-Neto, MD, PhD

Department of Gynecology, State University of Campinas (UNICAMP) Campinas-SP, Brazil

Funding Organization: Fundação de Amparo à Pesquisa do Estado de São Paulo

(FAPESP) number 2012/09215-7

Regina Celia Grion, Luiz Francisco Baccaro, Ana Francisca Vaz, Lucia Costa-Paiva, Delio Marques Conde and Aarao Mendes Pinto-Neto declare that they have no conflict of interest.

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Abstract

Purpose: To achieve a better understanding of issues related to sexual function and quality

of life (QOL) of women with cervical cancer before radiotherapy treatment. Methods: A pilot study with 80 women with cervical cancer from Jan/2013 to Mar/2014. The outcome variables were sexual function assessed using the Female Sexual Function Index (FSFI) and QOL, assessed using the World Health Organization questionnaire. Independent variables were clinical and sociodemographic data. Statistical analysis was carried out using Student´s t-test, Mann–Whitney test, ANOVA and multiple linear regression. Results: The mean age was 48.1 years, 57.5% were premenopausal and 55% had clinical stage IIIB. Thirty percent had been sexually active in the three months prior to their interviews. The main adverse events during sexual intercourse were bleeding (41.7%), lack of pleasure (33.3%), dyspareunia (25%), and vaginal dryness (16.7%). The 18 women who had been sexually active in the previous month showed significant sexual dysfunction (total mean FSFI score = 25.6). Advanced clinical stage, using any chronic medication and not having undergone surgery for cancer were negatively correlated with QOL. Higher family income, a longer duration of schooling and no smoking were positive correlated with QOL. Conclusions: One third of women with cervical cancer were sexually active three months prior to their interviews, but have concomitant significant sexual dysfunction. Factors related to the disease are primarily responsible for the deterioration of sexual function. QOL is influenced not only by factors related to the cancer itself, but also by lifestyle habits, comorbidities and sociodemographic characteristics.

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Introduction

Cervical cancer remains the third most frequent cancer among Brazilian women, with an estimated 15,590 new cases in 2014 [1]. The mortality rate in the two largest cities of the country dropped significantly between 1980 and 2009 and a lower relative risk of death from cervical cancer after the year of 2000 has been documented in these cities, especially for women born after 1960 [2]. However, evaluation of data from throughout Brazil has shown that survival rates at five years have been stable over the last two decades, being 60.2% between 1995 and 1999, 67.5% between 2000 and 2004, and 61.1 % between 2005 and 2009 [3].

Pelvic radiotherapy is one of the main therapeutic modalities for locally advanced cervical cancer [4]. This is usually comprises a combination of teletherapy (external beam radiation therapy) and brachytherapy administered for up to eight weeks. Concomitant chemotherapy improves overall survival rate and disease-free interval and reduces local recurrence and distant metastases in selected patients [5,6]. When there is no need to preserve fertility, pelvic radiation therapy may be indicated even for women with early-stage tumors (from clinical stage IA1) if there is tumor invasion of the lymphovascular space [7].

With the introduction of increasingly widespread social programs for preventing cervical cancer and more effective therapeutic techniques, it is expected that the mortality of the disease will continue to fall [2]. Thus, not only the physical effects of the disease and its treatment, but also the psychological and sexual effects, that are components of QOL, have become increasingly important [8]. Some studies report that radiotherapy is the treatment modality most associated with worsening of quality of life and sexual function in survivors of cervical cancer [8-11] and another in particular have analyzed adverse effects associated with treatment [12-14]. Few studies, however, have described quality of life at start of therapy

17

[15,16] and even fewer have reported these women´s sexual function [17,18]. To achieve a better understanding of issues related to sexual function and quality of life of women with cervical cancer at initiation of radiotherapy, a pilot study was conducted on women referred for radiotherapy to the Women's Hospital of the State University of Campinas, Brazil.

Methods

A pilot study was conducted at the Women's Hospital of the State University of Campinas (Unicamp) from January 2013 to March 2014. The sample consisted of women with cervical cancer, aged 18–75 years, who had been invited to participate in a clinical trial on the effects of various treatments for vaginal stenosis after radiotherapy. Women who had already undergone pelvic radiotherapy treatment for cervical cancer, had used hormone therapy in the past six months, had any contraindication to the use of topical estrogen or had an intestinal disease such as ulcerative colitis or Crohn disease were excluded. During the first consultation before the start of radiotherapy treatment, interviews of average length forty minutes were conducted by the main investigator in an appropriate room in the hospital´s radiotherapy division. Data were acquired by using a questionnaire consisting of two sections: in the first section the women were asked questions concerning clinical and sociodemographic data; whereas in the second section, data were extracted from their medical records concerning the characteristics of their tumors. Questionnaires were also used to evaluate sexual function (Female Sexual Function Index) [19] and to assess quality of life (WHOQOL-bref) [20]. Ninety-four women were invited to participate; 14 refused, mainly because of lack of time to complete the survey. Thus, the final sample comprised 80 women, all of whom signed free and informed written consents before the interviews. The study was approved by the Research Ethics Committee of UNICAMP (Number 8933).

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Dependent variables

Sexual function

The “Female Sexual Function Index” [19] was used for sexual evaluation. This questionnaire had already been validated in Portuguese [21] and consists of nineteen questions grouped into six domains; namely desire, arousal, lubrication, orgasm, satisfaction and pain. All questions are multiple choice and each answer is assigned a value of zero to six. A zero score in a domain indicates that the woman reported no sexual activity in the previous month. A total score of less than or equal to 26.55 indicates the presence of sexual dysfunction. To obtain unambiguous total scores, the questionnaire was administered only to women who reported sexual activity in the previous month. The domain and total scores were analyzed as continuous variables [19,21].

Quality of life

The abbreviated version of the World Health Organization questionnaire (WHOQOL-BREF) was used to assess quality of life. WHOQOL-bref is a generic instrument for assessing quality of life that has previously been translated and validated in Portuguese [20]. It consists of 24 questions divided into four domains: physical, psychological, social relationships, and environment plus two additional questions that assess general quality of life and health. This instrument does not allow use of a total score. Higher scores in the various domains correspond to better quality of life in that domain. Scores for the various domains were analyzed as continuous variables.

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Independent variables

The independent variables assessed were: age (in years); race; clinical stage (IB1/IB2/IIB/IIIB); menopausal status (premenopausal/postmenopausal); marital status (single, married, living together, widowed, divorced); schooling (≤8 years/>8 years); body mass index (≤27.8/>27.8); smoker (yes/no); depression (yes/no); hypertension (yes/no); diabetes (yes/no); multimorbidity - two or more chronic illnesses (yes/no); family income (≤ US$750/>US$750); surgery (yes/no); employment (yes/no); sexual partner (yes/no); sexually active in the last three months (yes/no); number of episodes of sexual intercourse per week (0/1/>1); symptoms during sexual intercourse in the last three months (none/vaginal bleeding/lack of pleasure/dyspareunia/vaginal dryness); and reason for not having sexual intercourse (no partner/vaginal bleeding/pain/surgery/vaginal discharge/sexual partner with health problems).

Statistical analysis

Initially, a descriptive analysis of data using frequency distributions was performed. Variables were expressed as mean, median, standard deviation, maximum and minimum values. Next, bivariate analyzes were performed to assess associations between dependent and independent variables. The tests used for bivariate analysis were Student´s t-test, the Mann–Whitney test, ANOVA and ANOVA by Kruskal–Wallis depending on the normality distribution of data and the number of categories of independent variables. Finally, for the dependent variable of quality of life, multiple linear regression models were built for each domain of the WHOQOL-BREF [22]. The program used for the analysis was SAS, version 9.2 [23].

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Results

A total of 80 women with cervical cancer participated in the interviews. Their mean age was 48.1 ± 13.5 years (median, 48.0; range, 20.6–75.6), 56.3% of participants reported having studied eight years or fewer; 57.5% of women were premenopausal, and 51.3% reported family incomes below US$750. Most women had clinical stage IIIB (55%) cervical cancer. Some relevant clinical and sociodemographic characteristics are shown in Table 1. Most women (62%) reported having sexual partners and 30% had been sexually active in the three months prior to their interviews. Of these 41.7% reported having more than one episode of sexual intercourse per week. The main adverse events that had occurred during sexual intercourse were bleeding (41.7%), lack of pleasure (33.3%), dyspareunia (25%), and vaginal dryness (16.7%). Among women who had sexual partners, the main reason for not being sexually active was vaginal bleeding during intercourse (32.1%). Some of the clinical symptoms and aspects of sexual function are shown in Table 2.

FSFI and WHOQOL-BREF scores are shown in detail in Table 3. The Female Sexual Function Index (FSFI) questionnaire was administered only to women who had been sexually active in the previous month to avoid ambiguity in data analysis [19]. Women with cervical cancer who had been sexually active in the previous month showed significant sexual dysfunction (total mean FSFI score = 25.6). Analysis of the factors associated with worsening of sexual function revealed that having undergone surgery before radiotherapy was negatively associated with arousal (p = 0.01) and satisfaction (p = 0.02) domains, both associations being statistically significant. Women with vaginal bleeding during intercourse had significantly lower scores in the orgasm (p = 0.04) and satisfaction (p = 0.03) domains than those who did not. Women with any adverse symptoms during intercourse had lower scores in the pain domain than those who did not (p = 0.02). Lack of pleasure during

21

intercourse was negatively associated with the orgasm domain (p = 0.04) whereas smoking was positively associated with total FSFI score (p = 0.04). No factor was associated with the desire and lubricating domains (Table 4).

For the dependent variable of quality of life, multiple linear regression models were built for each WHOQOL-bref domain. In the physical domain, advanced clinical stage correlated negatively with quality of life (β = −2.19; p = 0.04) whereas higher family income was positively correlated (β = 0.0041, p = 0.03). As for the psychological domain, using any medication was negatively related to quality of life (β = −9.54; p = 0.02). In the environment domain, having a higher family income was positively related (β = 0.0044, p < 0.01), whereas having an advanced clinical stage was negatively related to quality of life (β = −1.31, p = 0.03). Non-smokers (β = 22.02; p < 0.01) and those with longer duration of schooling (β = 3.40, p = 0.03) had a positive association with overall quality of life. Not having undergone surgery for cancer (β = -16.03; p = 0.01) and having longer duration of schooling (β = -4.86, p < 0.01) were inversely associated with general health, whereas being a non-smoker was positively associated with general health (β = 16.35; p = 0.01). No factors were associated with the social relationships domain of the questionnaire (Figure 1).

Discussion

The aim of this pilot study was to gain information about aspects of sexuality and quality of life of women with cervical cancer at the beginning of treatment. Many studies have reported issues related to sexuality and quality of life of long time survivors of cervical cancer; however, there are few published studies on the sexual function of women who have recently begun treatment and the factors that influence their quality of life [15-17].

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Thirty percent of the women reported having had regular sex in the three months prior to their interviews. Of these, approximately 40% engaged in more than one episode of sexual intercourse per week. This frequency is higher than that previously reported. In 2011, Vaz et al. reported that 21,5% of women referred for radiotherapy for endometrial or cervical cancer were sexually active. It is noteworthy, however, that the mean age of these women was higher, most were postmenopausal, and a larger proportion of them had no sexual partner than in our cohort [24]. In 2014, Kirchheiner et al. reported that only 12% of women with locally advanced cervical cancer had been sexually active before the start of radiotherapy; however, the mean age was also higher than in our cohort [25].

Sexual function may be impaired by symptoms such as vaginal bleeding [24,26]. In this study, vaginal bleeding during intercourse was both the main reported adverse effect and the main reason for women not continuing to be sexually active. This association was expected: it occurred with women with locally advanced, large tumors, and thus a high risk of bleeding. Symptoms such as lack of pleasure during sexual intercourse, dyspareunia, and vaginal dryness were also common, and probably had similar origins. Women with a serious disease like cervical cancer face high levels of stress and concerns about health; these factors may inhibit their sexuality. Additionally, they may feel guilty in relation to sexual activity, because the virus that causes cervical neoplasia is transmitted by the venereal route. A combination of such factors may lead to a lower degree of desire and arousal, causing decrease in lubrication with consequent vaginal dryness, dyspareunia, and lack of pleasure. Women with gynecological cancer may experience decreased sexual desire from the moment of the diagnosis of malignancy [27]. Another possible inhibitor of sexuality is that approximately one third of women with cervical cancer believe that sexual relations can exacerbate disease [28.]

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The FSFI questionnaire was administered to women who had engaged in sexual activity in the 30 days prior to the interview. Although they had been sexually active in the previous month, these women had significant impairment of sexual functioning. Previous studies reported that sexual function in gynecologic [24,26] and cervical cancer [29] may be impaired by cancer diagnosis, cancer-related symptoms and surgery. The lowest scores were recorded in the desire and arousal domains, which is consistent with the reported symptoms of dyspareunia, lack of pleasure, and vaginal dryness. Analysis of the factors associated with worsening of sexual function in the assessed domains revealed a significant association between having undergone surgery before the start of radiotherapy and low scores in the arousal and satisfaction domains. Sexual arousal dysfunction was observed in women with cervical cancer before and after surgery when compared with healthy controls [29]. Most women whose initial form of treatment had been surgery had undergone radical hysterectomy plus pelvic lymphadenectomy (Wertheim–Meigs), a procedure with high morbidity that requires a long period of postoperative convalescence. This added to the stress of a cancer diagnosis may have contributed to lower levels of arousal and less satisfaction with sexual activity. Women with bleeding during intercourse were also less satisfied and experienced greater difficulty in achieving orgasm. In addition, the orgasm domain was compromised in women who reported lack of pleasure. In the pain domain, the only associated factor was having any adverse symptom(s) during intercourse. Thus, we found that sexual function in women with cervical cancer does not depend on sociodemographic characteristics, lifestyle habits, or comorbidities. Rather, postoperative convalescence and adverse symptoms related to the tumor are the main factors responsible for decreased sexual function. We believe that the positive association between smoking and higher total score on the questionnaire is

24

attributable to the small number of women who had been sexually active in the previous month and possible interference by other unidentified confounding variables.

WHOQOL-bref is a generic instrument that assesses four domains related to quality of life and has two questions about overall quality of life and general health [20]. More than half the women in this study had clinical stage IIIB cervical cancer and had worse scores in the physical and environmental domains of the questionnaire than women with earlier stages. In 2008, Distefano et al. found that women with locally advanced cervical cancer had worse quality of life scores in the physical domain than did women with earlier stages of cervical cancer [30]. Other recent studies have also shown that advanced cervical cancer affects the quality of life in various domains [31,32]. We found no association between multimorbidity (two or more chronic illnesses) and quality of life; however, users of chronic medications such as antihypertensive and oral antidiabetic drugs had worse scores in the psychological domain than those not taking such medications. It is probable that adding another health problem to subjects who already have health issues precipitates feelings of hopelessness, further affecting quality of life. Being a non-smoker had a beneficial effect on overall quality of life and general health. Frumovitz et al. reported an association between smoking and impaired emotional and mental well-being in women with cervical cancer. They postulated that smokers who are aware that smoking tobacco is associated with cancer have a more negative perception of their health status [9]. Women who had not undergone surgery prior to the start of radiation therapy had worse scores on the question regarding general health. A previous study using the same questionnaire (WHOQOL-BREF) reported a positive relationship between undergoing surgery and general health scores [16]. These women may have believed that surgery offers a greater possibility of curing cancer, leading to a positive effect on quality of life.

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Some sociodemographic characteristics were independently associated with quality of life of women with cervical cancer. It is noteworthy that this study was conducted in a public health service; most women attending such services have financial problems. Problems such as delay in diagnosis and treatment may have contributed to deterioration in quality of life. Have a higher family income was positively associated with the physical and environmental domains of the questionnaire. Indeed, a previous study showed that women with locally advanced cervical cancer who were unemployed had the lowest scores for quality of life in all domains investigated [30]. More recently, a study of US-American survivors of cervical cancer showed a strong independent association between low family income and poorer quality of life [33]. The association between schooling and quality of life was ambiguous in this study. Have attended school for longer was positively associated with overall quality of life; that is, women with higher education had better scores. However, the association between schooling and general health was the opposite: women with more education had lower scores for general health. An association between attending school for longer and better quality of life in women with locally advanced cervical cancer has been well documented [30,34]; the inverse association found in this study needs to be further researched.

This study has some limitations. The cross-sectional design, make it impossible to draw conclusions about cause and effect. Because this was a pilot study that was a component of an ongoing clinical trial, the sample comprised the women who were eligible for the clinical trial. We did not use a questionnaire that specifically assesses quality of life in women with cancer. To our knowledge, there is no such questionnaire validated for the Portuguese language spoken in Brazil. However, the generic questionnaire that we did use (WHOQOL-BREF) is able to identify various aspects of quality of life in women with cervical cancer.

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There were too few women who had been sexually active in the 30 days prior to the interview to allow multivariate analysis of the dependent variable "sexual function". It is recommended that FSFI questionnaire be administered only to women who have been sexually active in the previous month in order to avoid ambiguity in data analysis [19].

A significant proportion of women with cervical cancer in early treatment are frequently sexually active but have concomitant significant sexual dysfunction. Factors related to the disease and its treatment, such as adverse events and postoperative convalescence, are primarily responsible for the deterioration of sexuality. On the other hand, quality of life is influenced not only by factors related to the cancer itself, but also by lifestyle habits, comorbidities and sociodemographic characteristics such as low family income and education. This information is useful for identifying women who need more support and attention during the course of therapy for cervical cancer.

Author´s Contributions

RC Grion: Data collection / Manuscript writing

LF Baccaro: Data analysis / Manuscript writing / Manuscript editing AF Vaz: Data collection / Manuscript writing / Project development LC Paiva: Manuscript revision

DM Conde: Manuscript revision AM Pinto-Neto: Project development

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Table 1 - Sociodemographic characteristics in women with locally advanced cervical cancer (n=80)

n % Age ≤ 50 years 44 55.0 > 50 years 36 45.0 Clinical Stage IB1 15 18.8 IB2 04 5.0 IIB 17 21.2 IIIB 44 55.0 Menopausal Status Premenopausal 46 57.5 Postmenopausal 34 42.5 Marital Status Single 12 15.0 Married 22 26.2 Living togheter 17 21.2 Widowed 15 18.8 Divorced 14 17.5 Schooling ≤ 8 years 45 56.3 > 8 years 35 43.8 BMI ≤ 27.8 46 58.2 > 27.8 33 41.8 Smoker Yes 12 15.6 No 65 84.4 Multimorbidity Yes 24 30.0 No 56 70.0 Family Income ≤ US$ 750 41 51.3 > US$ 750 39 48.8 Surgery Yes 16 20.8 No 61 79.2 Employment Yes 35 43.8 No 45 56.3

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Table 2 - Clinical symptoms and aspects of sexual function in women with locally advanced cervical

cancer (n=80)

n %

Sexual partner

Yes 49 62.0

No 31 38.0

Sexually active in the last three months

Yes 24 30.0

No 56 70.0

Number of episodes of sexual intercourse per week

One 14 58.3

More than one 10 41.7

Symptoms during sexual intercourse

None 6 25.0

Vaginal bleeding 10 41.7

Lack of pleasure 8 33.3

Dyspareunia 6 25.0

Vaginal dryness 4 16.7

Reason for not having sexual intercourse *

No partner 31 55.4

Vaginal bleeding 18 32.1

Pain 7 12.5

Surgery 3 5.4

Vaginal discharge 2 3.6

Sexual partner with health problems 1 1.8

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Table 3 - Female Sexual Function Index (FSFI) and World Health Organization quality of life questionnaire – abbreviated version (WHOQOL-bref) scores in women with locally advanced cervical cancer

FSFIa _{Mean Standard}

deviation

Minimum value Maximum value Domains Desire Arousal Lubrication Orgasm Satisfaction Pain 3.3 1.2 1.8 5.4 3.7 1.3 1.2 5.4 4.8 1.0 3.0 6.0 4.1 1.4 1.6 6.0 4.7 1.2 2.4 6.0 5.0 1.0 3.2 6.0 Total score 25.6 5.3 16.6 33.6

WHOQOL – BREFb _{Mean Standard}

deviation

Minimum value Maximum value Domains

Physical 56.4 17.6 0.0 89.3

Psychological 59.6 16.6 16.7 95.8

Social relationships 65.9 15.8 25.0 100.0

Environment 57.2 11.4 28.1 87.5

Overall quality of life 59.7 22.0 0.0 100.0

General health 43.8 22.3 0.0 75.0

a_{18 women who reported sexual activity in the previous month}

34 Table 4 - Variables associated with the Female Sexual Function Index (n=18)

SD: standard deviation *Mann-Whitney test #Student´s T-test

Desire Arousal Lubrication Orgasm Satisfaction Pain Total

Mean (SD) p* value Mean (SD) p# value Mean (SD) p* value Mean (SD) p* value Mean (SD) p# value Mean (SD) p* value Mean (SD) p* value Surgery Yes 3.0(±1.1) 0.37 3.0(±1.3) 0.01 4.8(±1.2) 1.00 3.3(±1.5) 0.06 4.1(±1.2) 0.03 5.0(±1.0) 0.89 23.1(±5.9) 0.14 No 3.5(±1.3) 4.4(±0.9) 4.7(±1.0) 4.7(±0.9) 5.2(±0.9) 5.0(±1.0) 27.6(±3.8) Smoking Yes 4.5(±1.3) 0.16 5.3(±0.2) 0.07 6.0(±0.0) 0.07 6.0(±0.0) 0.06 6.0(±0.0) 0.10 5.4(±0.9) 0.62 33.2(±0.6) 0.04 No 3.2(±1.1) 3.5(±1.2) 4.6(±1.0) 3.8(±1.3) 4.6(±1.2) 5.0(±1.0) 24.6(±4.8) Lack of pleasure Yes 2.8(±1.2) 0.30 3.3(±1.5) 0.22 4.4(±1.2) 0.40 3.9(±1.5) 0.04 4.2(±1.6) 0.07 4.2(±1.2) 0.29 22.9(±5.7) 0.08 No 3.5(±1.1) 3.9(±1.2) 4.9(±1.0) 4.1(±1.4) 4.9(±1.0) 5.3(±0.7) 26.6(±4.9) Vaginal bleeding Yes 2.8(±1.2) 0.23 3.3(±1.6) 0.12 4.5(±0.9) 0.81 3.1(±1.1) 0.04 4.0(±1.2) 0.03 4.7(±0.8) 0.29 22.4(±4.6) 0.16 No 3.5(±1.1) 4.4(±1.1) 4.9(±1.1) 4.6(±1.3) 5.1(±1.0) 5.2(±1.0) 27.2(±5.0) Adverse symptom during intercourse Yes 3.4(±1.3) 0.69 3.6(±1.4) 0.57 4.6(±1.1) 0.19 4.0(±1.4) 0.56 4.5(±1.3) 0.29 4.7(±0.9) 0.02 24.8(±5.5) 0.30 No 3.0(±0.9) 4.0(±1.1) 5.3(±0.9) 4.3(±1.5) 5.2(±0.9) 5.9(±0.2) 27.7(±4.3)

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Figure 1 – Factors Associated with quality of life – multiple linear regression (n=80)

R²=0.274

Clinical Stage -2.19* p=0.04

Family Income 0.0041* p=0.03

R²=0.071

Chronic use of Medication -9.54* p=0.02

R²=0.241 Clinical Stage -1.31* p=0.03 Family Income 0.0044* p<0.01 R²=0.241 Non-smoking -22.02* p<0.01 Schooling 3.40* p=0.03 R²=0.235 No Surgery -16.03* p=0.01 Scholling -4.86* p<0.01 Non-smoking 16.35* p=0.01

*EStimated parameter; R²: Coefficient of determination.

Physical Psychological Enviroment Overall QOL General Health

37

CONCLUSÃO GERAL

 A qualidade de vida é influenciada não apenas por fatores relacionados ao câncer, mas também por hábitos de vida, comorbidades e características sociodemográficas, tais como baixa renda familiar e escolaridade.

 Um terço das mulheres com câncer cervical eram sexualmente ativas três meses antes do início do tratamento radioterápico, porém apresentavam disfunção sexual.

 Fatores relacionados à doença e ao seu tratamento, tais como eventos adversos e convalescença pós-cirúrgica, são os principais responsáveis pela deterioração da função sexual.

39

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