Chapter
Biopsychosocial Factors in Gynaecological
20 Cancer
Laura E. Simonelli and Amy K. Otto
Gynaecological Cancer Statistics
Global statistics on the prevalence of gynaecological
cancers as a group are limited. In the United States,
gynaecological cancers – which include cancers of the
cervix, ovary, uterus, vagina and vulva – account for
11% of all cancers diagnosed in women, affecting
approximately 90,000 women each year [1]. Cervical
cancer is the most common type of gynaecological
cancer worldwide and is the fourth most common
cancer in women, affecting over half a million women
each year [2]. Cervical cancer alone represents approxi-
mately 7.9% of all cancers in women [2]. Endometrial
cancer and ovarian cancer are the next most common
types of gynaecological cancer, accounting for 4.8%
and 3.6% of all cancers in women, respectively [2].
Survival rates for gynaecological cancer vary
greatly by country, as well as site and stage of cancer.
About 7.5% of female cancer deaths worldwide are
due to cervical cancer, with the vast majority of cervi-
cal cancer cases and deaths occurring in less-
developed countries [2]. The five-year survival rate
for cervical cancer is around 60–70% worldwide, but
ranges from as low as 46% in India to as high as 77% in
South Korea [2,3]. Globally, the five-year survival
rates for endometrial and ovarian cancer are approxi-
mately 69% and 30–50%, respectively [2]. Worldwide
survival rates for less-common gynaecological cancers
are limited, but in the United States the five-year
relative survival rate is about 50% for vaginal cancers
and 16–86% for vulvar cancers, although these figures
depend largely on cancer stage [3].
Treatments for Gynaecological Cancer
Treatment for gynaecological cancers will vary
depending on the site and stage of the disease, but
most commonly involve surgery, chemotherapy and
radiation therapy. Surgery often includes total
abdominal hysterectomy (including removal of the
uterus and cervix), bilateral salpingo-oophorectomy
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(removal of both ovaries and fallopian tubes) and
potentially resection of additional organs and lymph
nodes [4]. Chemotherapies including platinum drugs
(e.g. cisplatin) and taxanes (e.g. paclitaxel) are often
used in the treatment of gynaecological cancers [5].
Finally, radiation therapy is used in the treatment of
approximately 40% of gynaecological cancers as an
adjunct to surgery [5].
Quality of Life
The gynaecological cancer patient’s physical and emo-
tional symptom burden negatively impacts health-
related and overall quality of life [4,6]. Quality of life
concerns in gynaecological cancer vary by disease site
and can include issues related to physical functioning
(e.g. urinary and faecal incontinence, sexual dysfunc-
tion, lymphoedema) and psychosocial functioning (e.g.
body image concerns, role changes, anxiety, depression,
sexual dysfunction), which are reviewed in greater detail
subsequently in this chapter. Among women treated
with radiation therapy for gynaecological cancers,
nearly all report some negative change in quality of
life, specifically physical, sexual and/or social function-
ing [7]. Within this population, pain, dyspareunia and
decreased interest in sex specifically have been asso-
ciated with decreased quality of life in physical, psycho-
logical or social domains [8]. Among gynaecological
cancer patients treated with chemotherapy, nausea and
vomiting have been negatively associated with quality of
life [9]. More broadly, urinary incontinence [10] and
sexual morbidity [4,11] in particular have been found to
predict poorer short-term and long-term quality of life
and are associated with anxiety and depression.
Biological Factors
Physical Sequelae
The physical sequelae of gynaecological cancers include
both acute side effects (e.g. fatigue, gastrointestinal
169
 Section 2 Gynaecology
problems, alopecia) and long-term/late effects of
disease and treatment. Late effects of treatment can
appear months to years after cancer treatment comple-
tion. Common, late effects of gynaecologic cancer
include cognitive changes, sexual side effects, changes
in bowel patterns, peripheral neuropathy and skin
changes [12].
Neurological Effects
Neurological and central nervous system effects may
include pain, neuropathy, cognitive changes, fatigue
and sleep disturbance. Both acute and chronic pain
are common in cancer patients. Gynaecological can-
cer pain may include both neuropathic pain, as dis-
cussed next, and nociceptive pain, which results from
tissue damage and is described as sharp, aching or
throbbing [6]. Unfortunately, there are no evidence-
based guidelines for treating pain in gynaecological
cancer specifically, and pain is often inadequately
managed. Treatment for pain related to gynaecologi-
cal cancer typically follows guidelines established for
cancer pain or general pain management; analgesics
are traditionally used, ranging from non-opioid
analgesics (e.g. nonsteroidal anti-inflammatory
drugs [NSAIDs]) for milder pain to full opioid ago-
nists (e.g. fentanyl) for more severe pain [6].
Peripheral neuropathy occurs in 5–38% of patients
treated with chemotherapy, and the co-
administration of platinum and taxane chemothera-
pies increases the likelihood of neurotoxic sequelae
sevenfold [5]. Some patients will experience
a reduction in neuropathy post treatment, while
others will deal with it as a long-term effect.
Pharmacotherapy including NSAIDs, tricyclic antide-
pressants and GABA agonists such as pregabalin and
gabapentin may be used to target neuropathy, though
with varying success and undesirable secondary side
effects [5]. Physical therapy including gait training
and lower body strengthening to improve balance
[13] and alternative therapies including acupuncture
may also offer some relief [5].
Cognitive changes such as memory loss, short-
term memory impairment and difficulty concentrat-
ing or learning new skills are common following
treatment for gynaecological cancers [12]. Though
there is limited research on the occurrence of ‘chemo-
brain’ specifically within a gynaecological cancer
population, there is evidence to support changes in
brain function following chemotherapy in other can-
cers [14,15]. There is evidence that cognitive skills
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such as attention, processing speed and reaction
time decline during the course of chemotherapy for
ovarian cancer [16]. There is also evidence that other
factors such as fatigue, sleep disturbance, anxiety and
depression may also contribute to cognitive changes,
as some cognitive changes have been noted before the
initiation of chemotherapy treatment [17].
Treatments may target the multifactorial nature of
cognitive changes after cancer through use of cogni-
tive behavioural therapy, exercise, brain-training and
pharmacological interventions including antidepres-
sants or central nervous system stimulants (e.g.
Provigil, Ritalin).
Fatigue is almost ubiquitous among cancer
patients, with prevalence rates of up to 96% [6].
Fatigue often persists and is a top survivorship con-
cern with up to 30% of survivors reporting fatigue
one year post treatment [6]. An interplay of multiple
factors including cancer disease and treatment
directly, nutrition, anaemia, anxiety, depression and
sleep disturbance exacerbate this common concern.
Multidisciplinary approaches to managing fatigue
include pharmacotherapy, nutrition, treating sleep
disturbance and psychological comorbidities, and
exercise, though optimal type, timing and intensity
of the latter have not been determined [6]. One small
study investigated the use of a psychostimulant
(methylphenidate) twice per day in women treated
for recurrent gynaecological cancer and found signif-
icant improvement in fatigue, mood and quality of life
[18].
Most of the research on sleep disturbance in
gynaecological cancer has been conducted in women
with ovarian cancer. Sleep disturbance or poor sleep
quality was endorsed by almost 70% of patients with
ovarian cancer both during and after treatment, and
almost half used sleep medication during the month
prior to responding [19]. Additionally, poor sleep
quality is associated with reduction in all quality-of-
life domains and increased depression [19]. Sleep dis-
turbance also appears to persist at least a year after
treatment, and factors such as depression, use of pain
medication and premenopausal status may contribute
to this [20]. Cognitive behavioural therapy, including
sleep hygiene, stimulus control, cognitive restructur-
ing and relaxation training, is effective in treating
sleep disturbance [11]. Pharmacological agents (e.g.
benzodiazepines, antidepressants, hypnotic medica-
tions or melatonin), though often prescribed, do not
appear to adequately help with this issue [20].

Lymphatic System Effects
Lymphoedema – a condition where fluid is blocked
from properly draining in the lymphatic system and
builds up in body tissue – is caused by surgery, radia-
tion or metastases in women with gynaecological
cancer. It is most common in vulvar cancer patients
(35–47%), followed by cervical cancer (12–17%), uter-
ine (8–17%) and ovarian cancer (4–7%) [6].
Lymphoedema can result in considerable fluid accu-
mulation and impacts on patients’ appearance, body
image and mobility. Lymphoedema is a chronic con-
dition requiring lifelong, consistent management.
Treatment for lymphoedema includes use of com-
pression garments, lymphatic drainage massage and
physical therapy [6].
Gastrointestinal and Genitourinary Effects
Acute effects of radiation therapy may include
damage to intestinal mucosa resulting in diarrhoea,
nausea, and stomach cramps, while long-term and
late effects may include enteritis, bowel obstruction
or fistula formation, often leading to the need for
additional surgeries and related comorbidities [5].
Faecal incontinence is also a significant concern for
survivors of gynaecologic cancer [21]. Additionally,
there is a high prevalence of intestinal obstruction
symptoms near the end of life [6].
Pelvic floor dysfunction includes bladder storage
and voiding problems, urinary and faecal inconti-
nence and sexual dysfunction. Survivors of gynaeco-
logic cancer are significantly more likely than non-
cancer controls to have urinary storage issues,
including nocturia, urinary urgency, urinary leakage
and bladder pain [22]. They are also significantly
more likely than controls to have urinary inconti-
nence issues, including urge, stress, mixed and noc-
turnal enuresis [22]. Approximately two out of three
women with gynaecologic cancer will suffer from pre-
existing urinary incontinence, pelvic organ prolapse
or both before cancer treatment, though it may be
possible to surgically address these concerns in the
course of cancer treatment [23]. Physical therapy in
the form of pelvic floor training may benefit gynaeco-
logic cancer survivors with pelvic floor dysfunction by
strengthening the pelvic floor muscles and in turn
reducing incontinence and improving sexual func-
tioning [24]. The combination of pelvic floor therapy
and behavioural therapy including urinary inconti-
nence management advice (e.g. avoiding bladder irri-
tants, optimal balance of fluid intake) may also hold
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Biopsychosocial Factors in Gynaecological Cancer
promise as demonstrated in gynaecologic cancer sur-
vivors [25].
Endocrine and Sexual Functioning Effects
Surgery, chemotherapy and radiation therapy contri-
bute to sexual morbidity. Surgery for vaginal, vulvar
and cervical cancers may alter anatomy, including loss
of clitoral tissue. Surgery and radiation therapy also
contribute to vaginal stenosis and related dryness, loss
of elasticity and resilience, and scar tissue [26].
Chemotherapy can contribute to menopause and the
resulting loss of oestrogen leading to vaginal atrophy,
dryness and dyspareunia [26]. Additionally, cytotoxic
effects of chemotherapy, including fatigue, nausea,
pain, and early menopause, may affect a woman’s
libido [26]. Abbott-Anderson and Kwekkeboom [27]
categorized quality-of-life concerns related to sexual
function into three main dimensions: physical
(including dyspareunia, changes in the vagina, and
decreased sexual activity), psychological (including
‘decreased libido, alterations in body image, anxiety
related to sexual performance’) and social (‘difficulty
maintaining previous sexual roles, emotional distan-
cing from partners, perceived change in partner’s level
of sexual interest’) [p. 477].
In order to help address sexual dysfunction among
cancer survivors, an open dialogue between patients
and their providers is helpful. Providers can assess
sexual health history and include sexual health in
routine review of systems [26]. Assessment measures
are also available; the Female Sexual Functioning
Index demonstrates sound psychometric properties
for measuring sexual functioning in cancer survivors
[28]. Once concerns are identified, multidisciplinary
treatment approaches including medical, physical
therapy and psychological management may help
with sexual functioning changes. For example, non-
hormonal lubricating agents such as Replens can
relieve vaginal dryness and reduce pain during sexual
activity, and vaginal dilators may help with stenosis
[26]. While using hormones to address sexual con-
cerns among gynaecological cancer survivors is still of
some debate, vaginal oestrogen may be an option for
some women to relieve dryness and thinning of
the vaginal area. There is also some evidence that
hormone replacement therapy to treat menopausal
symptoms does not increase risk of recurrence for
women with endometrial, epithelial ovarian, cervical,
vaginal and vulvar cancers [29]. Physical therapy
including pelvic floor therapy can address sexual
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 Section 2 Gynaecology

dysfunction related to weak pelvic floor muscles [24]. Depression

Psychotherapy can target body image concerns, com-
Although about a quarter of all cancer patients experi-
munication, arousal problems and depression and
ence depression, few are offered treatment for their
anxiety symptoms leading to sexual dysfunction by
depressive symptoms [6]. A limited amount of research
using education and cognitive behavioural interven-
has specifically examined depression among gynaeco-
tions [30].
logical cancer patients. In a sample of low-income,
Treatment for gynaecologic cancers can impact
ethnic-minority women in the United States who
fertility in women of childbearing age. Surgical resec-
were being treated for gynaecological or breast cancer,
tion of cancer or disease staging typically involves the
approximately 17% reported at least moderate levels of
removal of organs necessary for reproduction, includ-
depressive symptoms, yet only a minority received
ing the uterus, ovaries, fallopian tubes and cervix.
treatment for their depression in the form of antide-
Fertility-sparing procedures, though not always pos-
pressant medication (12%) or counselling/support
sible, may include trachelectomy for early-stage cer-
groups (5%) [36]. Among these women, those who
vical cancer, and uterine and contralateral ovarian
reported greater economic stress experienced even
preservation for good-prognosis ovarian tumours
greater rates of depression and poorer quality of life
and the latter early-stage uterine and cervical cancers
[37]. The substantial number of untreated depression
[31]. Progestational agents might also be used for
cases among gynaecological cancer patients is thought
treatment of early-stage uterine cancer, though more
to be due to the underestimation of depressive symp-
research is needed. If ovarian- or cervical-sparing
toms on the part of providers [36] as well as the expec-
treatments are not an option, oocyte or embryo cryo-
tation among both patients and providers that
preservation may still allow for future childbearing if
depression is a normal part of the cancer experience
the uterus is maintained [32]. Chemotherapy can
[6]. Unmet survivorship needs (e.g. need for help redu-
contribute to infertility via damage to oocytes; this
cing overall stress in life) among gynaecological cancer
impact is variable depending on the chemotherapeu-
survivors have been associated with increased symp-
tic agent and dosage, patient age and ovarian func-
toms of depression [38].
tioning. Similarly, radiation therapy may damage
Increased physical sequelae of treatment, espe-
oocytes, in addition to the effects in the uterus and
cially menopausal symptoms and sexual dysfunction,
hypothalamic-pituitary axis. Ovarian transposition is
have also been linked to increased depressive symp-
one option for protecting the ovaries from radiation
toms [39]. Side effects of treatment like fatigue may
in treating cervical, vaginal and uterine cancers [32].
inhibit participation in usual activities and mirror
Nonetheless, fertility-sparing options are not always
somatic symptoms of depression, which may also
possible, and the resulting psychosocial impact can be
make the identification of depression in cancer
enormous.
patients more challenging [6]. However, the relation-
ship between physical sequelae of treatment and dis-
Psychological Factors tress has been found to be moderated by social
The physical sequelae of gynaecological cancer often support such that patients with greater support
contribute to symptoms of depression and anxiety experience fewer depressive symptoms and traumatic
[33,34]. Interestingly, women who receive more exten- stress [40].
sive treatments consistently report higher distressed
mood and anxiety and lower quality of life but do not
report higher levels of depression overall when com- Anxiety
pared to women who received less extensive treatment Anxiety is another common issue among cancer
[35]. Among survivors who have undergone more patients, with approximately one-fifth of all cancer
extensive treatment, those who use more avoidant cop- patients reporting significant anxiety symptoms [6]
ing strategies (e.g. denial) tend to report higher levels of and up to about 60% wanting help with management
depression and distressed mood and lower quality of [41]. As with depression, little research has focussed
life than those who use more engagement-based coping on anxiety among gynaecologic cancer patients and
strategies like positive reframing [35]; this relationship survivors specifically. One study found that
was not found, though, among women who received nearly one-third of survivors endorse clinically signif-
shorter, less extensive treatments. icant levels of anxiety, and these survivors are

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three times more likely to report anxiety symptoms
than the general population [38]. Some side effects of
treatment like lymphoedema have also been suggested
to trigger increased anxiety, as some patients wrongly
attribute these symptoms to disease recurrence or
progression [4]. As with depression, anxiety often
goes undiagnosed and untreated among cancer
patients due to incorrect beliefs that anxiety is normal
in the context of cancer, or that anxiety symptoms
stem directly from the cancer or its treatment [6].
For many cancer patients, anxiety is often
focussed around fear of cancer recurrence; in fact, it
is often comorbid with anxiety disorders like general-
ized anxiety disorder, although it is a distinct con-
struct from generalized anxiety [42]. Fear of cancer
recurrence has been found to be the most common
need for supportive care among women with gynae-
cological cancers, endorsed by about one-quarter of
survivors [38]; however, comparatively little work has
examined this construct among survivors. More
advanced disease, as may be the case among many
ovarian cancer survivors, is associated with greater
and more persistent levels of fear of cancer recurrence
over time [43]. Unfortunately, this is a realistic fear for
many survivors, as many gynaecological cancers, par-
ticularly ovarian cancer, have very high recurrence
rates (70–90% over five years) [44]. Psychosocial fac-
tors, such as exaggerated perception of disease sever-
ity, are also strong predictors of fear of cancer
recurrence [43]. Recently, an increasing amount of
research has investigated potential interventions spe-
cifically for fear of cancer recurrence such as cogni-
tive-existential group therapy, which has shown
promising results in breast and ovarian cancer survi-
vors [45].
Aside from fear of cancer recurrence, the presence
of other unmet survivorship needs has been signifi-
cantly correlated with anxiety, depression and post-
traumatic stress symptoms, and those with advanced
disease reported more unmet needs [38,46].
Concerns about Death/Dying
Many gynaecologic cancer patients experience worry
and concerns related to death and dying at diagnosis
and throughout treatment [47], although some
research has suggested that death anxiety may
decrease with time following diagnosis [48]. Many
women respond to worries about death with avoid-
ance strategies like distraction; others take a more
task-oriented approach, making lists and getting
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Biopsychosocial Factors in Gynaecological Cancer
legal documentation in order, or an emotion-
oriented approach, using positive self-talk and relying
on ‘inner psychological strength’ to cope [47].
Along with worry about death itself, another com-
mon fear among gynaecological and other cancer
survivors is becoming physically/mentally incapaci-
tated and dependent on others towards the end of
life [47]. Utilization of palliative and hospice care
earlier in the illness trajectory has been encouraged,
which can improve symptom management and
patient and family satisfaction [49], as the value that
patients place on survival is generally tempered by the
desire for good quality of life [50].
General Loss and Grief
Infertility is often an unfortunate outcome associated
with treatment of cancer among women of reproduc-
tive age. It is often associated with increased feelings
of grief and sadness, and decreased quality of life, even
beyond a year after completing treatment [31].
In some women, the loss of childbearing ability com-
pounds the stress of the cancer diagnosis and effec-
tively creates a ‘double trauma’, which can lead to
poorer long-term outcomes such as prolonged grief
and poor coping strategies [31]. However, research
has suggested that receipt of support and information
about reproductive issues may help reduce levels of
anxiety and emotional distress among cancer survi-
vors [31].
For women dealing with the many and varied
physical problems of gynaecologic cancer and result-
ing physical or functional losses (e.g. disability, infer-
tility, loss of energy, loss of role functioning), one’s
sense of meaning or purpose in life may change [51].
Survivors may have difficulty making sense of their
cancer experience, and this loss of meaning can
exacerbate depressive symptoms in survivorship [51].
Body Image Issues
Appearance and functional changes are common
among gynaecological cancer survivors. Body image
concerns including hair loss, weight change, loss of
female organs, changes to vaginal and vulvar areas,
functional urinary and bowel changes, and ostomies
may also contribute to changes in a woman’s sexual
self-schema and libido [52], especially among younger
patients [53]. Swelling caused by lymphoedema may
also contribute to changes in body image and often
necessitates changes to the patient’s usual clothing
choices [4].
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 Section 2 Gynaecology
Social Factors
Role Changes and Social Isolation
Impaired social functioning is associated with increased
distress and decreased quality of life. Survivors with
more social contacts and social support have been
found to be less negatively affected by their cancer,
reporting fewer symptoms of anxiety and depression,
better role functioning, more energy and better health
than those who are more socially isolated [40].
Patients often experience significant interference
to their social activities and family life. Many of the
physical sequelae of treatment can impact daily activ-
ities, ability to work and body image. For example,
urinary incontinence [10], lymphoedema [54] or cog-
nitive impairment [5] can create feelings of embar-
rassment or decreased self-confidence and are
associated with social withdrawal. Fertility issues, sex-
ual dysfunction and menopausal symptoms stemming
from cancer treatment leave some patients feeling like
‘damaged goods’, which may also contribute to social
isolation [31]. Reducing or stopping work may result
in disconnection from social contacts as well.
Although cancer survivors in general are at an ele-
vated risk of unemployment compared to healthy
individuals, gynaecologic (and breast) cancer survi-
vors are even more likely to choose to stop working or
reduce their work hours than other cancer survivors
[53]. Younger survivors in particular appear to report
greater interference in their social and family lives;
however, they report better role functioning than
older survivors, as measured by limitations on work,
daily activities and pursuing hobbies [53].
Changes in Sexual Relationships
Partners of women with gynaecological cancer are
also affected by loss of sexuality and intimacy.
Resentment, withdrawal and relationship conflict
can develop due to partner’s mixed responses, includ-
ing worrying about the patient’s health, and desiring
sexual activity but feeling guilty [30]. Conversely,
some research has suggested that patients’ feelings of
intimacy during sexual activity may actually increase
following their diagnosis [28].
Health Disparities
Additional social factors such as income and racial
disparities can impact cancer outcomes. As already
mentioned, gynaecological cancer rates and mortality
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are higher in less-developed regions of the world [2].
In the United States, low-income and minority women
are less likely to receive adjuvant treatment, less likely
to adhere to treatment and more likely to die from
gynaecologic cancers [37]. Low-income women with
gynaecologic cancer report greater unmet supportive
care needs related to physical/daily living and practical
concerns, and African-American women report
greater unmet sexuality and psychological needs com-
pared to their Caucasian counterparts [55]. Patient
navigation [37] and multidisciplinary care, including
psychology, physical therapy, and social work [55], to
target unmet needs may improve adherence and sub-
sequent outcomes.
Summary
The biopsychosocial and quality-of-life impairment
of gynaecological cancer is extensive, from multi-
system physical sequelae, to depression and anxiety,
to role and relationship changes and social isolation.
As summarized, some of these issues can be
addressed with multidisciplinary approaches includ-
ing medical, physical therapy and psychological
treatments, whilst others have fewer approaches
available. Research has been less devoted to gynae-
cological cancers compared to other cancers affect-
ing women, and a more concentrated effort at the
many and sometimes unique issues gynaecologic
cancer survivors face is warranted. Additionally,
since many survivors do not have access to or aware-
ness of the full range of resources available, research
should also continue to examine health disparities
and develop outreach options for underdeveloped
regions and underserved populations.
Key Points
• Gynaecological cancers account for 11% of
all cancers diagnosed in women.
• The gynaecological cancer patient’s physical
and emotional symptom burden negatively
impacts health-related and overall quality of
life.
• Quality-of-life concerns in gynaecological
cancer vary by disease site and can include
issues related to physical functioning (e.g.
urinary and faecal incontinence, dyspareunia,
lymphoedema) and psychosocial functioning
(e.g. body image concerns, role changes,
anxiety, depression, sexual dysfunction).

• Cognitive changes such as memory loss, short-
term memory impairment and difficulty
concentrating or learning new skills are
common following treatment for
gynaecological cancer.
• For many cancer patients, anxiety is often
focussed around fear of cancer recurrence.
• Although about a quarter of all cancer patients
experience depression, few are offered
treatment for their depressive symptoms. This
is thought to be due to the underestimation of
depressive symptoms on the part of providers
as well as the expectation among both patients
and providers that depression is a normal part
of the cancer experience.
• Many women respond to worries about
death with avoidance strategies like
distraction; others take a more task-oriented
approach, making lists and getting legal
documentation in order, or an emotion-
oriented approach, using positive self-talk
and relying on ‘inner psychological strength’
to cope.
• Psychosocial assessment should be part of the
routine care of women with gynaecological
cancer. Tools for doing this are available.
Multidisciplinary approaches including
medical, physical therapy and psychological
treatments are associated with improved
quality of life.
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