Sexual health complaints associated with post-treatment gynecological cancer: qualitative research

Sexual health complaints associated with post-treatment gynecological cancer: qualitative research Luciane Machado Pizetta (  lpizetta@inca.gov.br ) Centro Federal de Educação Tecnológica Celso Suckow da Fonseca (CEFET/RJ), Brazil Augusto Cunha Reis Centro Federal de Educação Tecnológica Celso Suckow da Fonseca (CEFET/RJ), Brazil Mirian Picinini Méxas Fluminense Federal University Carmen Lucia Paula Centro Federal de Educação Tecnológica Celso Suckow da Fonseca (CEFET/RJ), Brazil Edria Aparecida Ferreira Escola Nacional de Saúde Pública Sérgio Arouca Research Article Keywords: Genital Neoplasms, Female, Survivors, Sexual Health, Qualitative analysis Posted Date: August 25th, 2022 DOI: https://doi.org/10.21203/rs.3.rs-1968832/v1 License:   This work is licensed under a Creative Commons Attribution 4.0 International License. Read Full License Page 1/9 Abstract Objective: Investigate the most important sexual health complaints of women after gynecological cancer treatment associated with the healthcare provided. Methodology: This is qualitative descriptive research, using semi-structured interviews with a group of 25 Brazilian women recruited by an ambulatory gynecology department in a public oncology hospital located in Rio de Janeiro, Brazil. Interviews were conducted on the major sexual complaints posttreatment and the challenges they face in meeting their needstheir needs associated with the disease. The data were analyzed using the content analytical method. To get the real experiences of the study, the researchers followed the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines and organized the treatment method into categories and subcategories of themes. Results: Women survivors after gynecological cancer treatment experienced the most common complaints: the pain and changes in the body that prevented them from performing simple tasks, the undesirable effects of sexual dysfunction, psychological and emotional changes, and di culties in their relationship with their partner. In addition, there was the sharing of relationships that were common among women and the speci c speci cities of the experience in the treatment performed. Conclusion: Many cancer survivors have sexual health problems and post-treatment concerns, thus, thus, access to effective interventions and the provision of survivorship care may improve your their health. Introduction Gynecological cancer such as the cervix is the fourth most common type diagnosed in women worldwide [1] and Brazil is the third primary location of cancer incidence and mortality in women in the country [2]. Despite the high number of incidences of cases of the disease, the early detection and treatment of the disease at an early stage [3, 4] enabled high chances of cure, increased improvements in survival and consequently an increase in the number of survivors [5, 6]. De ning when patients should be considered "survivors" in the clinical trajectory of cancer is highly debated because some de nitions propose cutoff points of 3 or 5 years after the diagnosis of cancer and others consider that patients become "survivors" after the completion of primary cancer treatment and have those who reject the term "survivor" and identify as a cancer patient, or a person living with cancer or a cancer victim [7, 8]. Survivorship consists of three stages acute survival, extended survival, and permanent survival. Acute survival begins with the diagnosis until the initial treatment, where the patient faces the consequences of the treatment, that is, the side effects, fear and anxiety nally, permanent survival in which there is no evidence of the active state of the disease for a minimum period of ve years [9]. However, even with the end of treatment and the disease in its inactive state, patients who faced the disease report a negative impact on their sexual life and sexual dysfunction affects between 40–100% of gynecological cancer survivors [10]. In fact, many women are traumatized, and their sex life is deeply affected, for example, 50–67% of American gynecological cancer survivors reported not having resumed sexual activity within 1 year after treatment and these high rates of sexual inactivity may be due to adverse treatment effects, such as decreased libido, lack of vaginal elasticity, shortening of the vaginal cavity, vaginal atrophy, dryness, premature menopause and dyspareunia [11]. These physiological changes combined with psychosocial factors, such as changes in body image and long-term fatigue, may contribute to lower satisfaction with sexual function [12]. In addition, various cancer treatments affect the reproductive organs and hormonal system, which can also cause temporary or permanent subfertility in women, especially for the younger [13]. Thus, each patient should receive advice on possible consequences of treatment that affect gynecological and sexual functioning; However, previous studies have shown that gynecological cancer survivors report a need for information and care for their sexual concerns and many receive no information or professional support [14, 15]. Despite the importance of the topic, there is insu cient literature exploring the survivorship care needs of patients with gynecological cancer, such that, the research was developed to discuss an overview of sexual dysfunction with respect to women who are cancer survivors [16]; others examined the prevalence of sexual dysfunction among Thai women survivors of gynecologic cancer [17]; a study was conducted to better understand the barriers and facilitators identi ed by patients to obtain and access sexual health services and overcome barriers to access [18] and nally studied the relationship between sexual dysfunction and marital satisfaction in gynecologic cancer survivors in Malaysia [19]. In this sense, in this study, it was necessary to discuss the survival experience in Brazil among the most common cancers among women in the region and because there is a lack of research on this subject in the country. We conducted qualitative research to study key complaints in women's sexual health after gynecological cancer treatment associated with the healthcare provided. Methods Study project A descriptive qualitative design was used, using semi structured interviews, to understand and perceive patients living with and beyond gynecological cancer by recognizing the symptoms of healthcare interventions received. The study is presented in accordance with Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines [20]. Sample of participants Page 2/9 An intentional sample of patients undergoing gynecological cancer treatment was selected for this study, and inclusion and exclusion criteria are presented in Table 1. Twenty- ve participants were selected from an external gynecological unit at a public oncology hospital in Rio de Janeiro, Brazil. This convenience sampling method is a non-probability technique, chosen for the ease and availability of access to respondents, and to enable a low operational cost for research [21]. Table 1 Criteria for inclusion and exclusion of patients Criteria for inclusion Criteria for exclusion • 18+ years at time of interview. • Diagnosis of gynecological cancer in women (cervical, ovary, vulva, endometrium) • Treatment completed (surgical, radiotherapy, chemotherapy or combination) • Ability to offer informed consent. • Communicate in Portuguese • Receive continuous treatment in case of recurrence, palliative care or end of life. • Treatment has not yet concluded. Data collection A thematic guide has been developed and iterated to re ect the research objective [22]. Four pilot interviews were conducted with gynecological cancer survivors to check for doubtful or ambiguous content, so few changes were made to improve the interpretation of the questions. The interviews for this study were individual and were conducted between February and April 2022 by phone due to health restrictions related to the COVID-19 pandemic and allowed participants to freely select their location during the interview, thereby increasing the safety of participants and authors. Participants were intruders to move to a non-disturbed location during the interview. The length of the interviews varied between 30 and 60 minutes and, at the request of the interviewees, there was no audio recording because, according to the participants, they felt constrained by the impact that personal information had on each other's lives. They were convinced that the decision to participate was voluntary and would not affect their healthcare. In addition, they could discontinue the study at any time full information was provided to interested women, together with a brief questionnaire requesting socio-demographic and clinical details. Interested parties were invited to read and agree to the TCLE (Term of Consent Free and Clari ed) provided online by the Google Forms app, an online tool that e ciently and easily collects information. All interviews began with broad questions (what challenges do you encounter as a cancer survivor?) establish a friendly and con dent environment and proximity between the interviewer and the participants. Then, more speci c questions were posed according to the research objectives. Flexible redrafting of questions and the use of surveys were among the strategies used to encourage participants to answer the most relevant questions. Validation of the interviewee was ensured by asking participants at the end of the interview if they had something to add or clarify. The interview questions can be found in Table 4. Data analysis Each interview was transcribed fully by the researcher to ensure familiarity and the understanding of the story of each participant; and the data were analyzed using content analysis, a systematic and objective method used to describe a particular phenomenon [23, 24]. The speci c procedures were as follows: we repeatedly read all the transcripts to understand the general signi cance of cognition and understanding the data; after determining important sentences based on the research questions, the sentences were categorized based on criteria such as feelings, perceptions, and experiences. Finally, interactive discussions between team members were established to re ne the themes and ensure the common sense of the information collected during the interviews. Reliable ndings The reliability of the analysis was established by applying a rich presentation of the results with appropriate citations and a discussion of interpretation and considerations con rming the transferability of the research, the interview content and the results of the data analysis were communicated and veri ed by telephone and in-person interviews between researchers. In order to con rm the study, the authors reviewed the research procedures and ndings obtained from the information provided by the study participants. The patient identi cation codes, and topic segmentation categories were crossed between the researchers. Ethical considerations The National Cancer Institute Ethics Committee approved the study by noticeº 5.234.121 and CAEE nº 53733421.6.0000.5274, and the respondent informed consent form, along with the information and signature on the consent form. All documents were con dential and in con dence. All interviews were examined by the transcriber and principal investigator only, and each participant was identi ed by a speci c code number rather than by name. Results Sample characteristics Page 3/9 The average age of participants was 46 years and 36% (n = 9) had completed treatment in the 6-month period, 72% (n = 18) of respondents had cervical cancer and only 40% (n = 10) of this sample completed chemotherapy, radiotherapy, and brachytherapy or simple or radical surgery. Most of the 80% (n = 20) had early menopause as a result of treatment, seriously affecting their hormonal and reproductive health, particularly in women under the age of 45 (44% - n = 11). All participants indicated active sexual activity, however, only 60% (n = 15) reported having regular sexual intercourse once per week, as shown in Table 2. Table 2 Patient Characteristics (n = 25) ID Patient Age Status Type tumor Treatment Hysterectomy Braquiterapia Radioterapia Quimioterapia Cirurgia Radical Early menopause Time completion of treatment Simples 1 50 Single Cervical Yes Yes Yes No Yes 5 anos 2 50 Married Cervical Yes Yes Yes No Yes 5 anos 3 52 Married Cervical Yes Yes Yes No Yes 5 anos 4 34 Married Ovário No No No Yes Yes 6 meses 5 54 Married Endométrio Yes Yes Yes No No 3 anos 6 47 Married Cervical Yes Yes Yes No Yes 3 anos 7 25 Married Cervical Yes Yes Yes No Yes 2 anos 8 43 Married Cervical Yes Yes Yes No Yes 2 anos 9 43 Married Cervical Yes Yes Yes No Yes 6 meses 10 42 Married Cervical Yes Yes Yes Yes Yes 6 meses 11 40 Married Cervical Yes Yes Yes No Yes 6 meses 12 42 Married Cervical Yes Yes Yes No Yes 6 meses 13 52 Married Cervical Yes Yes Yes No Yes 2 anos 14 62 Married Endométrio Yes Yes Yes No No 1 ano 15 51 Married Endométrio Yes Yes Yes Yes Yes No 4 anos 16 56 Married Endométrio No No No Yes Yes No 4 anos 17 50 Married Ovário No No No Yes Yes Yes 6 meses 18 43 Married Cervical Yes Yes Yes Yes Yes 6 meses 19 48 Married Cervical Yes Yes Yes Yes Yes Yes 2 anos 20 60 Single Endométrio Yes Yes Yes Yes Yes No 5 anos 21 40 Married Cervical Yes Yes Yes No Yes 5 anos 22 39 Solteira Cervical Yes Yes Yes No Yes 3 anos 23 37 Married Cervical Yes Yes Yes No Yes 2 anos 24 59 Married Cervical Yes Yes Yes Yes Yes 6 meses 25 32 Married Cervical Yes Yes Yes Yes Yes 6 meses Yes Yes Yes Yes Yes Participants provided detailed accounts of their post-treatment experiences and related events. After analyzing the interviews, three types of categories were derived from the guide of the interview questionnaire: (1) di culties of the post-treatment survivor, it is the health adversities that are found by the patients, and the means they have been able to face them; [2] health care, that is, the support of medical or multidisciplinary assistance in dealing with adverse symptoms resulting from subsequent treatment; (3) psychosocial aspects, effects on emotional, psychological, social, familial and marriage relationship (Table 3). Page 4/9 Table 3 Categories, sub-categories, and some citations from participants Main categories Sub-categories Citations from participants Survivorship di culties after treatment. Pain in the body "After the radiotherapy sessions, I started having bowel problems that I hadn't had before... sometimes I bleed and I'm terri ed." (patient 10) 'Articular pain is terrible... I have insomnia and I sleep badly because I cannot relax because the pain in my legs is unbearable." (patient 11) "I feel a lot of pain in the bottom of my body, some days I can't get out of bed." (patient 7) "I had swelling and pain in the abdomen, it got really big... it made it hard even to move." (patient 19) Complaints in sexuality "After the treatment, everything worsened, I began to feel a lot of pain during intercourse, I have vaginal dryness and shortening and no desire to have sex with my husband." (patient 2) "I avoid sleeping with my husband just because I don't have a libido anymore, my libido is completely over." (patient 3) "I had vaginal dryness and stenosis; and did not want to have sexual intercourse... I nally got into a serious conversation with my husband and told him he could nd another woman to satisfy him.” (patient 4) Demotivated and unhealthy Healthcare Multiprofessional medical support "I still can't do my daily activities and I feel very tired, which prevents me from doing small housework." (patient 12) 'After treatment, I have moments that t me in one day and in others, I just want to sleep and not do anything else... I only get up because I have a little kid who's counting on me." (patient 25) I went to the cancer hospital for my treatment and I also saw a psychologist and Psychiatrist because my anxiety was very high and I also had a compulsion for food... I really had to get medical help". (patient 22) "I got help from the outpatient sexuality clinic because there is a nurse who explains, advises and makes me better... the conversations I have had with this nurse have made me understand that the disease can best be dealt with when we receive assistance." (patient 20) "I used integrative medicine to reduce anxiety... when I'm very anxious, I do a self sabotage like not taking medication properly, I feed myself badly and do not do the physical exercises that are important to me." (patient 17) "I do physiotherapy with exercises for vaginal dilation, because I feel that I am "closed" and the vaginal pain and discomfort are strong." (patient 15) Doctor-patient communication At the cancer hospital, I had all the support I needed, as well the nurses also gave me all the necessary instructions about the symptoms that we could have and how to minimize them." (patient 19) The medical team was very communication and helpful and immediately after the treatment, I had a medical consult that told me what symptoms I might have, including some that might persist for years." (patient 24) "I got the support of the medical team and they also directed me to physiotherapy... But I think a professional is necessary to support couples, that we might share this pain that my husband and I'm going through this because our relationship has been affected in a very negative way." (patient 9) 'I didn't have the communication and support I needed.. for the treatment of the illness I had all the support, but in the psychological and sexual part had a lot of faults... and it directly interferes with my personal life because those are issues that affect my quality of life." (patient 21) Psychosocial aspects Emotional and mental reactions " I had a post-treatment counselling, but I was so disgusted with the suffering that the disease brought me that I don't want to do any more treatment!" (Patient 24) "After so much suffering I have endured, I have had many psychological scars... you are suffering pain in your body which also affects your soul... I didn't want people to feel sorry for me, but to have access to meaningful counselling to end so much suffering." (patient 4) "I always sought to have a positive thought, I spoke to myself that the disease would not abate me and I would not lose to this disease... from diagnosis to the end of treatment I had this optimistic attitude and it was essential not to lose hope" (Patient 14) "In addition to my health issue, I have a daughter who needs special care and that made me more anxious because I needed to take care of her and myself... Ultimately, I had to seek psychiatric medical assistance to heal my mind." (patient 13) “I believe that family and medical support were essential so that I had no negative thoughts and I always thought that everything would pass and that at the end, everything would be all right... it was the support of the people and of God that made all the difference for me”. (Patient 16) Changes in my self-esteem "I've been really bitter about the problem I have with vaginal stenosis, because it impacts my self-esteem and relationship, and it makes me sad and very afraid to never be the same woman again.” (patient 6) "I had a really big scar and it was embarrassing for me... people in the street still comment, and it makes me even worse." (patient 18) “When I was in treatment and even after it was over, I made a point of always being done and tidy, didn't let me down with the disease... even people near me as family members didn't believe I was sick... in an episode that occurred to me, a friend came to say, I stopped visiting you because I was afraid to see you skinny, bald, ugly... while I was happy, I was also disappointed that people have biases and misconceptions about the disease." (patient 9) Page 5/9 Main categories Sub-categories Citations from participants Sexuality and conjugal relationship “My relationship after treatment has changed, and even sexual relations, but since we talked a lot, it was fundamental for us to keep going together... Nowadays, my husband and I are closer and I can have pleasure and libido intercouse.” (patient 2) “The discovery of the disease is a big shock in our lives and it directly affects the conjugal relationship, but as I was married for many years and having a deep love for him and him for me, it was easier to face obstacles and get through all this". (patient 16) "The relationship with my husband has changed a lot, and we don't have an intimate life with each other before, and it negatively affects our relationship... we're a young couple and we can't have children and we can't have intimate contact because of the pain I'm experiencing, it's terrible." (patient 7) "My husband stayed with me throughout the treatment, however, like a couple, we no longer have any intimacy... I don't want anything else, because I'm afraid and I'm in pain, and it ends up pushing us away as husband and wife". (patient 2) The list of questions has been reviewed and modi ed by authors with cancer experience and expertise and the questionnaire was structured as follows: 1) opening questions, 2) transition questions, 3) key or main questions and 4) nal question (Table 4) [25]. Once the interviews were completed, the key discussion points were summarized to check for additional items or omissions. Table 4 – Interview Questions Questions Openness 1. What were your main general di culties at the end of treatment? Transition 1) 2. What type of medical/multidisciplinary care was received after cancer treatment had ended? 2) 3. Have you sought medical/multidisciplinary assistance? Main 3) 4. What are your main sexual-related adverse symptoms or complaints as a cancer survivor? 4) 5. Have any physicians or medical professionals shared information about the adverse symptoms of the disease and treatment? 5) 6. Do you have mental health problems (depression, anxiety...)? 7. Did your relationship with your partner change post-treatment? 8. 8. Have your self-esteem and body image changed as a result of treatment? Final 8) 9. Is there anything you want to add or anything else that's relevant? Survivorship Di culties After Treatment One of the main themes of this study was the attempt of women to confront di culties, especially in the eld of health after the end of treatment. In fact, they were concerned about several questions and expressed that pain is the most notable complaint, detected mainly in the joints, legs, and arms. In addition, tiredness and fatigue were also very common symptoms that interfered with simple tasks in daily life. Some patients also believe that after radiotherapy sessions, intestinal problems have developed that have impeded its proper functioning; and to minimize this discomfort, many have adopted a healthy diet because it has directly helped the entire intestinal tract and consequently their well-being. Other di culties encountered, referring to complaints about sexuality, 23 respondents (92%) indicated that they had sequelae from treatment. Vaginal dryness, lack of libido, and vaginal shortening were the most common complaints and tended to persist for years after completion of treatment. And this discomfort may have been experienced both in women and caused discomfort in their partners due to excessive vaginal dryness and narrowing of the vaginal canal. Thus, as a result of this problem, strong emotional and psychological upheavals have been faced by patients in their romantic relationships, because the severe pain experienced during the sexual act cause a lot of fear, and many of them admitted that they no longer felt the desire and preferred not to have close contact with their companions. Healthcare The second category in this study was the care and health care received by the cancer hospital. Obviously, communication with health professionals was a resource highly valued and used by patients; even, in many cases, when they nished treatment, many felt "lost" and professional help was very important because it made it possible to discuss and resolve doubts that tormented them. In addition, 18 women (72%) answered that soon after the end of treatment, they performed physiotherapy sessions because of problems such as vaginal shortening, and with these professionals’ learned exercises that improved complaints and then could be reapplied at home so that the results were more satisfactory. Many patients realized the importance of the health care services received, however, 3 women (12%) indicated that they did not know about the services offered by an outpatient sexuality clinic that aims to provide information about sexuality and guidance on the use of important medications to minimize the adverse effects of sexual health complaints. Finally, when women understood the importance and expressed interest in participating in these outpatient activities, they were more comfortable with the issues and even Page 6/9 had the opportunity to participate in support groups where they interacted, made friends, and strengthened their bonds so that, together, they could get through these di cult times more discreetly. Psychosocial Aspects The third theme was the psychosocial approach, where women survivors, in addition to all the health issues they face, other challenges arise, such as a negative self-image, deteriorating relationships and intimacy, fear of death, recurrence of illness, and concern for the future of children. Thus, the pleasant intimacy in their married life after cancer was one of the more stressful and experiences painful for the couple, so the demonstration of affection was more and more distant acts. Some participants reported that after treatment therapy sessions there was a marked decline in libido and sexual pleasure, and with that, they lost interest in sexual intercourse and fear of pain during sexual intercourse, further distancing them from their husbands. Perceptions related to self-image were other reported experiences that caused a lot of discomfort in women, as they had to accept themselves and bring the new identity of their bodies closer together, and many interviewees indicated that they did not nd any positive perspectives in this regard. Consequently, through so many unpleasant experiences, psychological aspects have been extremely affected, and complaints like anxiety and depression have been reported frequently in women, and unfortunately, not all of them could get the treatment and psychiatric care required to minimize these symptoms, and this is due to the insu cient number of health professionals working in this specialty in public health hospitals in the country. Discussion These results showed the experiences of Brazilian women who underwent post-cancer gynecologic treatment. As observed by participants, at the end of treatment were not only sexual activities that were impacted by the disease but also intimate relations between couples and above all various aspects of their physical and mental health. With reports of women those gynecological cancers directly affect their sexual organs, in addition to surgical procedures that cause large scars and loss of their ovaries and uterus, many of them think they have lost their femininity, however, there is no scienti c evidence that these treatments modalities have a stronger effect on female sexual functioning [26]. As such, the rst category of our study was "challenges for survivors after treatment". In fact, after the illness, women suffered multiple sequelae and complaints, with pain in their bodies that weakened them and prevented them from simply doing their homework or maybe even taking care of their kids [27]. In addition to weakening their health, other aspects of their lives are affected, such as work capacity and nancial issues, and most respondents expressed concern about the nancial di culties they encountered in the treatment of the illness and the inability to return to work because many believe they do not have the capacity to resist the efforts that should be made; and others who had their jobs were laid off after the end of treatment, and the justi cation was due to the long period of absence and inability to return to work [28]. In health care, many were satis ed with the treatment received by the cancer hospital or by the health professionals who work there and care for them, however, this is unfortunately not a reality in all public hospitals in the country, because most suffer from a scarcity of hospital supplies, and human resources with good skills and there is little experience with cancer in the workforce [29]. The reports of the participants reinforce this reality, and many have cited the di culty of obtaining the correct diagnosis of the disease and when they arrived at the cancer hospital, the tumors were very advanced. Many patients treated in public health hospitals across the country have nancial di culties and depend only on this health system for treatment; and with the high demand for patients treat cancer and the availability of a few hospitals offering this kind of treatment, it makes it even more di cult for patients to start treatment at the appropriate time [30]. So, when starting treatment, patients need the largest number of sessions of services such as chemotherapy and radiation therapy, which ultimately, serious harm to their health and, therefore, the undesirable symptoms and complaints are more severe [31]. As the results showed, more than half of the participants sought information about what e cient forms of health care they should have at the end of cancer treatment. One nding of this study was the sad account of the experience of fteen participants who after gynecological cancer, suffered from the physical and mental side effects, and as they got worse, realized that their husbands were not as interested in them as in the past. Some of the participants stated that they suffered from complaints of stenosis and vaginal dryness because of the side effects of chemotherapy and radiotherapy, and even with the use of gel and lubricating lotion the problem persisted. As a result, sexual intercourse was disrupted and caused signi cant stress and wear and tear in their personal relationships [32]. Surveyed women who had a hysterectomy and, after surgery, reported a decrease in intimacy with their partner and therefore interruption in sexual intercourse, and the big problem was that most of these participants reported that they had no dialogue with their partners and did not discuss the di culties they were experiencing, which resulted in further con icts among them. In the results of our research, we also found women with intercourse who were trying to nd excuses and ways to escape sexual intercourse with their husbands; because what they believed was important was being alive and being cancer survivors [33]. Conclusion Participants' experiences after gynecological cancer treatment can be characterized by three major themes: (1) survival di culties in patients with symptoms and side effects, (2) health care and care, (3) psychosocial, including emotional, psychological, and relational aspects. It is important to emphasize that patient-health professional relationships have been key to ensuring the quality of life as well as those who have adopted and obtained an integrated care plan, could improve their complaints and symptoms and therefore your psychosocial burden. Page 7/9 Limitations Although we have tried to search for greater diversity in the sample group comprised of women who have had cancer of every gynecological female pathway, the outcomes represent a small proportion of patients who suffer from these sexual health issues. It is remarkable the scope and expansion of studies for other types of tumors and approaches in speci c areas which affect the complaints of these patients. Abbreviations COREQ Consolidated Criteria for Reporting Qualitative Research WCR Workd Cancer Resarch INCA Instituto Nacional de Câncer TCLE Term of Consent Free and Clari ed Declarations Author contribution All authors contributed to the study conception and design. Conception and design of the study Augusto C Reis, Mirian P Mexas and Luciane M Pizetta, data collection Carmen L Paula, Edria A Ferreira, Luciane M Pizetta, formal analysis Luciane M Pizetta, writing of the original draft Augusto C Reis and Luciane M Pizetta, writing and editing Augusto C Reis, Carmen L Paula, Edria A Ferreira, Mirian P Mexas and Luciane M Pizetta and supervision Augusto C Reis, Mirian P Mexas. All authors commented on previous versions of the manuscript. All authors read and approved the nal manuscript. Funding is Not applicable. Declarations Ethical approval the study was approved by the Ethics Committee of Nacional Cancer Institute (registration number: 53733421.6.0000.5274). Consent to participate Written informed consent were obtained from all participants. Competing interests The authors declare no competing interests. Consent for publication Not applicable. References 1. World Cancer Research (2020) Estatística sobre câncer. Available from: https://www.wcrf.org/dietandcancer/cervical-cancer-statistics/ 2. Instituto Nacional de Câncer (INCA) Estimativa 2020 - Incidência de Câncer no Brasil. Available from: https://www.inca.gov.br/sites/ufu.sti.inca.local/ les/media/document/estimativa-2020-incidencia-de-cancer-no-brasil.pdf. 3. Götze, H, Friedrich, M, Taubenheim et al (2020) Depression and anxiety in long-term survivors 5 and 10 years after cancer diagnosis. Supportive Care in Cancer 28(1):211–220. https://doi.org/10.1007/s00520-019-04805-1 4. Sung UL, Young AK, Young-Ho et al (2017) Allgemeiner Gesundheitsstatus Langzeitüberlebender von Gebärmutterhalskrebs nach Strahlentherapie. Strahlentherapie Und Onkologie 193(7):543–551. https://doi.org/10.1007/s00066-017-1143-8 5. Kim, JY, Chun, M, Kim et al (2020) Identi cation of Korean cancer survivors’ unmet needs and desired psychosocial assistance: A focus group study. PLoS ONE 15(1):1–11. https://doi.org/10.1371/journal.pone.0228054 . Shin, J, Shin, DW, Lee, J et al (2020). Association between perception of care coordination and health outcomes in Korean cancer survivors. Health and Quality of Life Outcomes 18(1):1–10. https://doi.org/10.1186/s12955-020-1279-6 7. Harris, MG (2019). Sexuality and Menopause: Unique Issues in Gynecologic Cancer. Seminars in Oncology Nursing 35(2):211–216. https://doi.org/10.1016/j.soncn.2019.02.008 . Knaul, FM, Doubova, SV, Gonzalez RM C et al (2020) Self-identity, lived experiences, and challenges of breast, cervical, and prostate cancer survivorship in Mexico: A qualitative study. BMC Cancer 20(1):1–11. https://doi.org/10.1186/s12885-020-07076-w 9. Mullan, F (1985) Seasons of Survival: Re ections of a Physician with Cancer. The New England Journal of Medicine 313:270-273. DOI: 10.1056/NEJM198507253130421 10. Rizzuto I, Oehler MK, Lalondrelle S (2021) Sexual and Psychosexual Consequences of Treatment for Gynaecological Cancers. Clinical Oncology, 33(9): 602-607. 11. Buzaglo, JS, Zaleta, AK, McManus, S et al (2020). CancerSupportSource®: validation of a revised multi-dimensional distress screening program for cancer patients and survivors. Supportive Care in Cancer 28(1):55–64. https://doi.org/10.1007/s00520-019-04753-w 12. Schover LR, Kaaij M, Dorst E et al (2014) Sexual dysfunction and infertility as late effects of cancer treatment. EJC supplements: EJC: o cial journal of EORTC, European Organization for Research and Treatment of Cancer 12(1):41–53. 13. Vassilakopoulou M, Boostandoost E, et al (2016) Anticancer treatment and fertility: Effect of therapeutic modalities on reproductive system and functions, Critical Reviews in Oncology/Hematology 97:328-334. Page 8/9 14. Hubbs, JL, Michelson, DEL, Vogel, RI et al (2019) Sexual quality of life after the treatment of gynecologic cancer: what women want. Supportive Care in Cancer 27(12):4649–4654. https://doi.org/10.1007/s00520-019-04756-7 15. Frimer, TLB, Shankar, V, Cardaci, R et al (2019) The association of sexual dysfunction with race in women with gynecologic malignancies. Gynecologic Oncology Reports 30:0–3. https://doi.org/10.1016/j.gore.2019.100495 1 . Goldman, M and Abel, MK (2021) Oncology Survivorship and Sexual Wellnessfor Women 48:499–512. 17. Dandamrongrak, P, Chaiwong, S, Ekalaktam, P, Achariyapota, V (2021) Sexual dysfunction in Thai gynecologic malignancies survivors: A singleinstitutional cross-sectional observational survey. Journal of Obstetrics and Gynaecology Research 47(11):4005–4013. https://doi.org/10.1111/jog.14980 1 . Dai, Y., Cook, O. Y., Yeganeh, L., Huang, C., Ding, J., & Johnson, C. E. (2020). Patient-Reported Barriers and Facilitators to Seeking and Accessing Support in Gynecologic and Breast Cancer Survivors With Sexual Problems: A Systematic Review of Qualitative and Quantitative Studies. Journal of Sexual Medicine, 17(7), 1326–1358. https://doi.org/10.1016/j.jsxm.2020.03.004 19. Hatta, S, Woon, LSC, Sumayyah, NMN, Nasir, MS (2021) Psychosocial Determinants of Marital Satisfaction Among Gynecologic Cancer Survivors in Malaysia. Frontiers in Psychiatry 12:1–8. https://doi.org/10.3389/fpsyt.2021.744922 20. Seol, KH, Bong, SH, Kang, DH, Kim, JW (2021) Factors associated with the quality of life of patients with cancer undergoing radiotherapy. Psychiatry Investigation 18(1):80–87. https://doi.org/10.30773/pi.2020.0286 21. Palinkas LA, Horwitz SM, Green CA, Wisdom JP, Duan N, Hoagwood K (2015) Amostragem objetiva para coleta de dados qualitativos e análise em pesquisa de implementação de método misto. Administração e política em saúde mental 42(5):533–44. 22. Dornan, M, Semple, C, Moorhead, A (2022) Experiences and perceptions of social eating for patients living with and beyond head and neck cancer: a qualitative study. Supportive Care in Cancer 30(5):4129–4137. https://doi.org/10.1007/s00520-022-06853-6 23. Downe-Wamboldt, B (1992) Content analysis: Method, applications, and issues. Health Care for Women International 13(3):313–321. https://doi.org/10.1080/07399339209516006 24. Bardin, L (2011) Análise de conteúdo. São Paulo: Edições 70. 25. Krueger RA, Casey MA. (2010) Focus group interviewing. Handbook of practical program evaluation 3rd edition San Francisco (CA): Jossey-Bass. 2 . Lin, H, Fu, HC, Wu, CH, Tsai, YJ, Chou, YJ, Shih, CM, Ou, YC (2022) Evaluation of sexual dysfunction in gynecologic cancer survivors using DSM-5 diagnostic criteria. BMC Women’s Health 22(1):1–7. https://doi.org/10.1186/s12905-021-01559-z 27. Ashmore, LA, Stewart, H, Hutton, D et al (2020) Digital support for living with and beyond gynaecological cancer. Radiography 26(4):270–276. https://doi.org/10.1016/j.radi.2020.03.014 2 . Zeng, Y, Cheng, ASK, Liu, X, Chan, CCH (2017) Cervical cancer survivors’ perceived cognitive complaints and supportive care needs in mainland China: A qualitative study. BMJ Open 7(6):1–8. https://doi.org/10.1136/bmjopen-2016-014078 29. Viani, GA, Gouveia, AG, Bratti, VF, Pavoni, JF, et al (2022). Prioritising locations for radiotherapy equipment in Brazil: a cross-sectional, population-based study and development of a LINAC shortage index. The Lancet Oncology 23(4):531–539. https://doi.org/10.1016/s1470-2045(22)00123-1 30. Silva, CB, Garnelo, L, Herkrath, FJ (2022) Barriers to Access the Pap Smear Test for Cervical Cancer Screening in Rural Riverside Populations Covered by a Fluvial Primary Healthcare Team in the Amazon. 31. Fonseca, B. de P., Albuquerque, P. C., Saldanha, R. de F., & Zicker, F. (2022). Geographic accessibility to cancer treatment in Brazil: A network analysis. The Lancet Regional Health - Americas 7:100-153. https://doi.org/10.1016/j.lana.2021.100153 32. Alshawish, E, Qadous, MS, Yamani, MA (2020) Experience of Palestinian Women After Hysterectomy Using a Descriptive Phenomenological Study. The Open Nursing Journal, 14(1):74–79. https://doi.org/10.2174/1874434602014010074 33. Schmidt, A, Sehnem, GD, Cardoso, LS, Quadros, JS, Ribeiro, AC, Neves, ET (2019) Sexuality experiences of hysterectomized women. Escola Anna Nery 23(4):1–9. https://doi.org/10.1590/2177-9465-ean-2019-0065 Page 9/9