Psychological issues: concerns and management

People with gynaecological cancer as well as those with chronic pelvic diseases may be prone to issues with role identity, sexual and body image, depression and anxiety, agitation, and confusion.

Role identity

Women rarely have single roles, and with terminal illness, many of these identities are lost. Women often have a strong identity with being the mother and primary care giver for the family. It is a painful struggle to give this up and allow others to attend to their needs and look after them. Women may have to give up identities as career women, artists, or other roles that require a level of activity and en­gagement they can no longer sustain. Together with this, they may lose their income, support, and social network. Loss of income may be an overriding worry as well as the burden they might place fi­nancially and socially on their families. The inability to fulfil a role as a sexual partner can be a painful loss in a relationship. Failure to fulfil these roles as well as an inability to fulfil hoped-for roles, such as grandmother or mother, take a deep toll. Women and their supporters have to deal with many simultaneous losses that add to their grief and to a sense of loss of value. All of these are worthy of addressing to find ways to empower and support the woman as she adjusts to new circumstances.

Sexual problems and body image concerns

Cancer can be very disfiguring. Problems can relate to the under­lying disease or long-term scarring. External manifestations bring the cancer to the surface, while hidden disease might be associated with considerable shame. It should not be assumed that patients with advanced illness do not have sexual needs and the desire for in­timacy. Sexuality is an integral part of the way women see themselves and is intricately linked with the experience of pleasure and joy.

Frequent sexual concerns of patients with cancer are discharge, ‘loss of interest in sexual activity, difficulty becoming sexually aroused, pain with sexual activity, changes in orgasmic response and concern about incontinence' (30). Vaginal dryness, atrophy, and anatomical changes after surgery or radiotherapy may be problem­atic (31, 32).

Illness, generally, causes fatigue and decreased libido. However, with gynaecological disease there are specific problems. If the topic is not intentionally and sensitively opened it is very easy to overlook this important aspect of life. Simply put, ‘We don't ask!' (33). Instead, healthcare workers often make assumptions such as ‘sexual health is not important when one has cancer' or that ‘prognosis is too poor for the patient to care' or ‘I don't have time for this' (30). Unless the healthcare practitioner intentionally opens the discussion, the pa­tient may be reluctant or too embarrassed to bring up the subject. Gynaecological cancer survivors may have high rates of sexual in­activity and sexual dysfunction (34). Many of these problems can be addressed and improved (35).

Treatment

In the palliative care setting, treatment for sexual dysfunction (Table 69.3) still follows the same tenets as general treatment. Simple ques­tions that are open ended can lead to an important discussion. Simply raising the question of whether a woman is sexually active and what has changed with her treatment and disease progression may be enough to open the door. Further exploring what needs are not being met and normalizing sexuality as part of life and even end of life can allow some problem-solving to occur. The use of vaginal dilators for stenosis and scarring from treatment, lubricants, and even oestrogen all may assist in overcoming issues related to treat­ment or disease.

Depression and anxiety

These are important symptoms which need to be identified and treated aggressively (36). They may significantly impact quality of life and may aggravate all the other physical symptoms.

Antidepressants, such as amitriptyline, venlafaxine, and duloxetine, are useful for neuropathic pain and selective serotonin reuptake inhibitors for panic as well as depression. Citalopram is safest if hepatic impairment is present. The goal with palliative care is to avoid polypharmacy and to aim to have as few medications as possible with the lowest side effect profile, while taking into ac­count metastatic disease and the risk of hepatic and renal failure. The

Table 69.3 Sexual dysfunction contributors

Source data from Ramondetta L. Challenges in the treatment of sexual function in patients with gynecological cancers. Presentation given at AORTIC conference 2015, Marrakesh, Morocco.

decision when to start pharmacological treatment may be difficult but an important guide is to ask if mood is interfering with quality of life, sleep, or treatment decisions.

Agitation and confusion

Agitation with confusion needs to be distinguished from anxiety and panic as it requires different treatment. It may be part of underlying delirium but occasionally true psychosis may be triggered, especially if there is pre-existing psychiatric illness. If delirium is suspected, exclude infection, especially urinary tract, hypercalcaemia and other metabolic disturbance, renal and hepatic failure, and brain metastases. All of these may have specific therapies that can reverse the symptoms quickly.

Agitation may also occur at the end of life, especially when there is a prior history of behavioural problems, substance abuse, drug with­drawal, or psychiatric illness or if there are many unresolved issues and a sense of panic about addressing them before death.

Treatment must first address reversible factors. Then non- pharmacological measures, antipsychotics (haloperidol is safe in low doses and safe in hepatic impairment), and anxiolytics (lorazepam by mouth or IMI) can be used. Corticosteroids are useful for brain metastases but they should be used with caution because they may aggravate the mental disturbance.

Hypercalcaemia is more common with bone metastases—and may first have symptoms of persistent nausea, thirst, altered mood, confusion, worsening pain, and constipation before agitation. Hydration and bisphosphonates can help although gauging the benefit versus the time to death is important before starting such therapy.

Dying

Discussions about death and dying are generally avoided by both patients and healthcare workers. In some cultures, it is totally taboo. However, if we are to deal effectively with the end of life we need to develop the skills to explore feelings, beliefs, fantasies, and prac­tical issues.

There is a role for health professionals to provide significant sup­port beyond palliative care for symptoms. Even nearing death, there may be things to look forward to and goals to achieve. It might be a chance to reach closure with individuals or a chance to see one last school play, a graduation, a major birthday, or meet a new grand­child. Having a discussion that focuses on goals the patient hopes to achieve and the symptom management required to achieve those goals, can provide closure and healing for families, patients, and caregivers alike.