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Keywords:

  • Cancer survivors;
  • help-seeking behaviour;
  • pelvic floor symptoms;
  • post-treatment care;
  • qualitative methods

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Disclosure of interests
  9. Contribution to authorship
  10. Details of ethics approval
  11. Funding
  12. References

Objective  (1) To explore the reasons for not seeking help for severe pelvic floor symptoms after gynaecological cancer treatment. (2) To determine the willingness to undergo treatment for these symptoms. (3) To invite suggestions to improve outpatient care.

Design  Qualitative study using semistructured interviews.

Setting  Vulvar, endometrial or cervical cancer survivors treated in the Academic Medical Centre, Amsterdam, the Netherlands between1997 and 2007.

Population  Purposively selected sample from 138 eligible respondents to pelvic floor-related questionnaires, who were severely bothered by their symptoms (>75th percentile of domain sum score of questionnaires) and had not sought medical help.

Methods  After each semistructured interview, a checklist with reasons for not seeking help was complemented with newly mentioned reasons. The interviews were stopped when data saturation was accomplished, i.e. three consecutive interviewees had not revealed new reasons. The interviews were analysed by two researchers independently.

Main outcome measure  Help-seeking behaviour for bothersome pelvic floor symptoms.

Results  Fifteen interviews were conducted. Most reported reasons for not seeking help were that women found their symptoms bearable in the light of their cancer diagnosis and lacked knowledge about possible treatments. Seven women were willing to undergo treatment. Eleven women stated that care should be improved, specifically by timely referral to pelvic floor specialists and additional care by oncology nurses.

Conclusions  There is a need for standardised attention to adverse effects on pelvic floor function after cancer treatment. This could be realised by quantifying symptoms using questionnaires, standardised attention for such symptoms by gynaecological oncologists or oncology nurses, and timely referral to pelvic floor specialists of women with bothersome pelvic floor symptoms.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Disclosure of interests
  9. Contribution to authorship
  10. Details of ethics approval
  11. Funding
  12. References

There is extensive evidence that treatment for gynaecological malignancies adversely affects pelvic floor function. Women treated for endometrial, cervical and vulvar cancer encounter symptoms such as urinary and faecal incontinence, overactive bladder symptoms and constipation.1–5 Fortunately, a substantial number of these women survive their malignancy, but, as a consequence, need to live with the adverse effects of treatment. Studies performed in general female populations have shown that pelvic floor symptoms impair the quality of life.6–8 However, not all women with pelvic floor symptoms visit a doctor for medical help. For instance, less than one-half of women with stress urinary incontinence seek help.9–11 This is unfortunate as there are several highly effective treatments for stress incontinence.12–14 Community-based studies have shown that embarrassment, lack of knowledge about the causes, unfamiliarity with treatment options and the presence of concomitant symptoms are reasons for not seeking medical treatment.15–17

To the best of our knowledge, no studies have been published that have explored the help-seeking behaviour for pelvic floor symptoms of women with gynaecological malignancies. Therefore, it is not known whether their help-seeking behaviour differs from that of the general female population. Women with gynaecological cancer routinely visit their gynaecologist and radiotherapist and, consequently, could easily be referred to a pelvic floor specialist, e.g. urogynaecologist, urologist, pelvic physiotherapist or gastroenterologist. However, oncological specialists identified bladder and bowel symptoms in only 5–15% of survivors of gynaecological cancer, whereas 23–58% of these women reported severe bladder and bowel symptoms.18,19 Seeking medical help for pelvic floor symptoms should be encouraged, as many conditions can be treated adequately, especially stress urinary incontinence and constipation and, to a lesser extent, radiation cystitis and proctitis, resulting in a better quality of life.20–27 Insight into the personal factors that impede help-seeking behaviour in women with gynaecological cancer is therefore needed.28

The primary objective of this qualitative study was to explore women’s personal reasons for not seeking medical help for bothersome pelvic floor symptoms after treatment for gynaecological malignancy. Secondary objectives were to explore the willingness to undergo treatment for these symptoms and to invite suggestions to improve postoperative outpatient care.

Methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Disclosure of interests
  9. Contribution to authorship
  10. Details of ethics approval
  11. Funding
  12. References

We conducted a qualitative study administering semistructured interviews. We obtained approval from the Medical Ethical Committee of the Academic Medical Centre (AMC), Amsterdam, the Netherlands to conduct this study, and women gave written informed consent for the interview.

Patient selection for semistructured interviews was carried out in a three-step procedure. First, we performed a cross-sectional quantitative study in women treated between 1997 and 2007 for endometrial, cervical or vulvar cancer at the AMC. Women were excluded if they were unable to complete a Dutch questionnaire and/or had been treated for metastatic or recurrent disease in the year prior to the study. Women fulfilling these inclusion and exclusion criteria were sent a set of standardised questionnaires on pelvic floor-related quality of life, containing the Urogenital Distress Inventory (UDI)29,30 and the Defecatory Distress Inventory (DDI).31 Both questionnaires incorporate multiple domains. Domain scores are calculated based on the answers to the corresponding questionnaire items. Higher scores represent a higher perceived burden of symptoms.

The second step consisted of the selection of those women who scored above the 75th percentile of the domain sum scores of at least one of the questionnaires, and who reported not to have sought specialised help for these symptoms.

Third, to ensure diversity in the group of interviewees, we performed a purposive sampling procedure, i.e. we selected women on the following predefined characteristics: year of treatment, tumour localisation, age, parity, presence of co-morbidity, marital status and educational level.32,33 The sample size was determined by the criterion of data saturation, meaning that, when three consecutive women had not added a new reason for not seeking help, data collection was stopped.

The interviews were conducted by MH, a PhD student and medical doctor, who was not involved in the treatment of the interviewees. The interviews were audio-recorded. We conducted the interviews by telephone after we had determined the most feasible mode of administration by comparing face-to-face and telephone interviews in a pilot study.

Before starting the interview, the researcher ascertained that it was a convenient time and place for the interviewee to be asked medical and intimate questions. Furthermore, the interviewer assured interviewees that the content of the interviews would be kept confidential and that no information would be conveyed to their treating physician. The semistructured interviews started with two questions to confirm the presence and bother of pelvic floor symptoms and whether the interviewee had not sought medical help for these symptoms, as reported in the questionnaires. When women reported that their symptoms had disappeared or they had sought help, the interview was stopped. If these questions were endorsed, women were invited by open nonstructured questions to talk about their symptoms and the reasons for not seeking help. After summarising the information provided, the women were asked whether they could think of more reasons for not seeking medical help. If that was the case, the researcher explored and summarised these reasons again, until no further reasons were provided. Subsequently, all interviewees were read aloud a previously designed checklist of possible reasons for not seeking medical help, and were asked whether these reasons were applicable to them.

Initially, this checklist consisted of 12 reasons for not seeking medical help for pelvic floor symptoms, assembled by the authors on the basis of clinical experience and relevant literature. These reasons for not seeking help were categorised into four themes: (1) ‘pelvic floor symptoms were bearable in the light of the cancer diagnosis’; (2) ‘specialists did not do anything about the symptoms’; (3) ‘patient was reluctant to go to hospital or physician’; (4) ‘patient and/or specialists were unaware of existing treatment options’. We finalised each interview with two specific questions, asking the interviewee whether she was willing to undergo treatment for her bothersome pelvic floor symptoms and whether she could provide suggestions on how to improve post-treatment outpatient care with regard to pelvic floor symptoms. In addition, interviewees were read aloud a checklist consisting of five suggestions on how to improve such care, and were asked whether or not they endorsed these suggestions.

Analysis started directly after each interview had been conducted. Content analysis of the first four interviews was performed independently by MH and MS (a professor in medical psychology) to check the quality of the interviews (e.g. avoidance of inappropriate leading questions, sufficient probing of answers to open questions) and the identification of new reasons. Content analysis of the subsequent interviews was carried out independently by MH and EB (social scientist and PhD student). Using the constant comparative method, new reasons for not seeking medical help or suggestions to improve post-treatment outpatient care, emerging from each interview, were added to the checklists on the basis of negotiated consensus.34,35 When discrepancies occurred, the researchers re-read or re-listened to the interview and discussed the content and interpretation until they reached consensus.36 The resulting extended checklists were used for the subsequent interview. In accordance with this iterative process, each new interviewee was read aloud more comprehensive checklists, with the exception of the last three respondents whose interviews did not yield new information. As this indicated that data saturation had been accomplished, further data collection was stopped.

The first seven interviews were transcribed verbatim. As analysis was found to be straightforward, transcribing the interviews had no additional value, and therefore the interviews were analysed directly from the audio-file.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Disclosure of interests
  9. Contribution to authorship
  10. Details of ethics approval
  11. Funding
  12. References

A total of 853 sets of questionnaires was sent, 569 of which were returned, resulting in a response rate of 67%. Of the 139 (24%) women with a score above the 75th percentile of the UDI domain sum scores, 94 (68%) reported not to have sought medical help for their urogenital symptoms. One-hundred and twenty-five women (22%) had a score above the 75th percentile of the DDI domain sum scores, 74 (59%) of whom reported not to have sought medical help for defecation symptoms. The overlap of these two groups comprised 30 women, resulting in 138 eligible interviewees. The time between questionnaire completion and conductance of the interviews varied from 10 to 12 months. This period was used to enter the questionnaire data into a database, to develop the checklist and to select the women for the interview. We successively approached 24 women for the interview, selected by the purposive sampling procedure. Eight women were found not to be eligible for the interview: four stated that their symptoms had resolved in the meantime, either spontaneously (n = 2) and/or with conservative treatment (n = 2); two could not be tracked down; one had died; and one was receiving current treatment for radiation cystitis with hyperbaric oxygen. One eligible patient refused participation because of a lack of time. After 15 interviews, data saturation was accomplished. The characteristics of the women included in the study are given in Table 1.

Table 1.   Characteristics of patients and willingness to undergo treatment
InterviewYear of treatmentTumour localisationAge (years)ParityCo-morbityMarital statusEducational levelPredominant symptom‘Would you want to undergo medical treatment for your symptoms?’
  1. Predominant symptoms: FI, faecal incontinence; OAB, overactive bladder; UI, urinary incontinence.

  2. Co-morbidity: 1, chronic obstructive pulmonary disease (COPD), rheumatism, hearing impairment; 2, 3, COPD; 4, cardiovascular disease (CVD); 5, diabetes, hypertension; 6, CVD, visually impaired; 8, COPD, visually and hearing impaired, psychiatric problems; 9, rheumatism, hearing impaired; 12, hypertension; 13, diabetes, rheumatism; 15, diabetes, CVD, hypertension, rheumatism, visually and hearing impaired.

  3. Educational level: low, up to secondary school; high, grammar school or college.

 12003Cervix842YesMarriedLowUI/obstructive defecationYes
 21997Endometrium720YesSingleHighFIYes
 31997Cervix530YesMarriedHighOAB/painful bladderNot yet
 42001Cervix481YesLiving togetherLowUINot yet
 52005Endometrium612YesMarriedLowOAB/FINo
 62006Vulva850YesSingleLowOAB/FINot sure
 72003Endometrium692NoMarriedLowUI/constipationYes
 82005Cervix432YesDivorcedLowUINot yet
 92000Endometrium722YesMarriedLowOAB/FIYes
102002Cervix561NoDivorcedHighUINo
111998Cervix390NoSingleHighUI/constipationYes
121998Cervix552YesMarriedLowUI/obstructive voidingYes
132000Endometrium732YesMarriedLowOAB/UIYes
142006Cervix532NoMarriedLowConstipation/FINo
151998Endometrium753YesDivorcedLowUI/FINot sure

The mean duration of the interviews was 27 minutes (range 12–39 minutes). Twenty-one reasons for not seeking medical help for severe pelvic floor symptoms were added by interviewees to the initial 12, ten items of which belonged to the first theme ‘Pelvic floor symptoms were bearable in the light of the cancer diagnosis’. One theme was added for not seeking medical help: ‘Patient was self-reliant’. The final version of the checklist is shown in Table 2.

Table 2.   Final version of the checklist with reasons for not seeking help for pelvic floor symptoms (every statement ends with: ‘that is why I did not seek medical help’)
  1. For the added theme ‘Patient was self-reliant’, an original reason (I have adjusted my behaviour in such a way that my symptoms do not bother me so much) was moved to this theme.

Theme 1: Pelvic floor symptoms were bearable in the light of the cancer diagnosis
Original reasons
 My symptoms are a logical consequence of treatment
 My symptoms are a logical consequence of aging
 These symptoms are not as bad as cancer
 My symptoms are not as bad as other symptoms I had directly after cancer treatment
 I am still in follow-up for cancer, that is the reason I do not pay attention to these symptoms
Added reasons
 If these symptoms are the only complaints I have, after having had cancer, I call myself lucky
 I had similar symptoms before treatment of cancer, so I am used to them
 My symptoms are not as bad as symptoms of other people I know
 I have other health problems that are worse than my pelvic floor symptoms
 I do not want to be a burden to my family and friends, so I do not mention my symptoms
 The symptoms do not occur often
 I had been prepared for these symptoms to occur after treatment
 Although I have severe problems, I do not experience this as suffering
 When I visited the oncological specialist, I was so nervous, I forgot to mention my symptoms
 It is very difficult to be absent from work or other activities
Theme 2: Specialists did not do anything about the symptoms
Original reasons
 My specialist/GP told me my symptoms are a logical consequence of treatment
 My specialist/GP told me my symptoms are a logical consequence of aging
 I have mentioned my symptoms but the specialist did not react to them
Added reason
 My GP or specialist told me that I could not undergo treatment for my symptoms due to other health problems
Theme 3: Patient was reluctant to go to hospital or physician
Original reason
 I have become frightened to go to a doctor/to a hospital
Added reasons
 Sometimes I am afraid that my symptoms are the result of cancer
 I feel embarrassed about my symptoms
 I feel embarrassed to go to a doctor for my symptoms and having to get undressed
Theme 4: Patient and/or specialist were unaware of possible treatments
Original reasons
 I had no idea that I could undergo treatment for my symptoms
 My doctor told me there was nothing to do about the symptoms
Added reasons
 I assumed that when my doctor/specialist thought I had severe symptoms, he/she would refer me to a specialist for these symptoms
 I think I am the only one with these kinds of symptoms
 I do not think there is a definitive solution for my symptoms
 I do not know where to go for help
Theme 5: Patient was self-reliant
Original reason
 I have adjusted my behaviour in such a way that my symptoms do not bother me so much
Added reasons
 I thought of solutions for my symptoms myself
 The symptoms are part of my life/I have learned how to live with the symptoms
 I am not the type of person to visit a doctor regularly

Theme 1 contains most reasons that were endorsed and most reasons that were added. An example of an original reason that was often endorsed was ‘These symptoms are not as bad as cancer’, which can be illustrated by the following citation of interviewee 9:

‘I was told I am healthy again, so I do not want to complain about these symptoms.’

An example of an added reason is: ‘Although I have severe problems, I do not experience this as suffering’. Interviewee 3 explained it as follows:

‘I always consider myself lucky that I do not have many complaints, although the urge sometimes hurts so badly.’

Theme 2 (‘Specialists did not do anything about the symptoms’) consists of four reasons, one of which was added by an interviewee. Theme 3 (‘Patient was reluctant to go to hospital or physician’) included one original reason and three were added by interviewees. One illustrative reason was ‘Sometimes I am afraid that my symptoms are the result of cancer’. Interviewee 5 expressed this as follows:

‘When my bowel symptoms are very bad and I feel something, I always think: “Oh dear”. I always think the cancer will attack again.’

Theme 4 (‘Patient and/or specialists were not aware of possible treatments’) contains six reasons, four of which were added by interviewees. The original reason, which was endorsed by almost each interviewee, was ‘I had no idea that I could undergo treatment for my symptoms’. One of the added reasons was: ‘I assumed that when my doctor/specialist thought I had severe symptoms, he/she would refer me to a specialist for these symptoms’. Interviewee 5 commented:

‘I shall hear what the doctor wants with the symptoms.’

Theme 5 (‘Patient was self-reliant’) was added in its entirety. We removed the original reason, ‘I have adjusted my behaviour in such a way that my symptoms do not bother me so much’, from theme 1 to this theme as it fitted better here. Three reasons were added by interviewees. Interviewee 7 endorsed the original reason, with the following explanation:

‘I hardly ever leave the house, I resent walking with wet pants.’

At the time of the interview, seven women were willing to undergo treatment for their pelvic floor symptoms. Two interviewees (6 and 15) could not make a decision about being treated for their pelvic floor symptoms:

‘I will hear from my doctor if something has to be done.’

‘I would not undergo surgery, but anything else: yes!’

Three interviewees (3, 4 and 8) said that they would consider undergoing treatment in the near future:

‘In the light of getting older and possibly worsening of symptoms, I would consider treatment.’

‘Only when I completely wet myself.’

‘I have my own business; I cannot be away from work.’

Three interviewees (5, 10 and 14) did not want to undergo treatment, for which they provided the following reasons:

‘Because I have other health problems and fear of going to a doctor.’

‘A friend treated for urinary leaking has worse problems than before.’

‘These symptoms are not important enough and I am against taking pills.’

Eleven women generated suggestions on how to improve post-treatment care for pelvic floor dysfunction. In addition to the predefined suggestions, two suggestions were provided by interviewees (see Table 3). The two most frequently endorsed improvements, seven and eight times, respectively, were: ‘There should be timely referral to a pelvic floor specialist when pelvic floor symptoms occur after cancer treatment’ and ‘In addition to care by an oncological specialist, I would have appreciated discussing adverse-effects of cancer treatment and other discomfort with a (oncology) nurse’.

Table 3.   Suggestions for improving supportive post-treatment care
SuggestionProposed byAgreed by
  1. Suggestions added by interviewees are shown in italic. The numbers correspond to the numbers of the interviewees in Table 1.

There should be timely referral to a pelvic floor specialist when pelvic floor symptoms occur after cancer treatment 4, 7, 8, 9, 11, 13, 15
In addition to care by an oncological specialist, I would have appreciated discussing the adverse-effects of treatment and other discomfort with a (oncology) nurse 4, 5, 7, 8, 9, 10, 11, 15
Post-treatment care went well, I should have told my symptoms more clearly to my specialist 5, 7, 8, 15
I should have received more information before cancer treatment about pelvic floor symptoms that could occur or worsen by the treatment 5, 7, 8, 9, 15
My oncological specialist should have asked me more specifically about pelvic floor symptoms 8, 9, 15
Looking back, I would have wished contact with other gynaecological cancer survivors17, 9, 10, 12
Looking back, I would have appreciated psychological help10 

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Disclosure of interests
  9. Contribution to authorship
  10. Details of ethics approval
  11. Funding
  12. References

In this qualitative study, most women had expected their pelvic floor symptoms to occur as a consequence of the cancer treatment and most found their own ways of cooping with these symptoms. Moreover, most women did not seek medical help, because having had cancer overruled the importance of their pelvic floor symptoms. They called themselves lucky if these symptoms were the only complaints they suffered from after cancer treatment. Other remarkable findings were that most women reported that they had not sought medical help because they were unaware of existing treatment options, with some being explicitly told by their oncologists that nothing could be done about such symptoms. However, most women stated that they were willing to undergo treatment now or in the future if this was offered and was efficacious in their situation. To improve post-treatment outpatient care for pelvic floor dysfunction, the majority of women would have appreciated consulting a (oncology) nurse to discuss the adverse-effects of the cancer treatment and other topics. Furthermore, many women recommended timely referral to a pelvic floor specialist when pelvic floor symptoms occurred. The two suggestions made by the interviewees were to facilitate contact with other survivors of gynaecological cancer and to provide psychological help.

A number of limitations of our study merit attention. The first set of limitations concerns patient selection. We selected women who did not seek medical help for bothersome pelvic floor symptoms. The suggestions of survivors of gynaecological cancer who did seek medical help might also be interesting and useful for clinical practice. Furthermore, we identified interviewees on the basis of their UDI and DDI scores—validated questionnaires for the assessment of urogenital and defecation symptoms.30,31 In the absence of empirically based guidelines, we adopted the 75th percentile of the sum scores. This cut-off score appeared to be suitable, as all interviewees experienced severely bothersome pelvic floor symptoms. Our aim was to retrieve the primary reasons for not seeking medical help in this group of cancer survivors. We therefore adopted a purposive sampling procedure to ensure heterogeneity of the interviewees. Data saturation was accomplished with 15 interviewees, a sample size that might be considered to be quite small for a qualitative study. However, we believe that the sample size was sufficiently large and the sample composition sufficiently heterogeneous, as we succeeded in obtaining an exhaustive list of reasons for not seeking medical help. We started each interview with open questions about the help-seeking behaviour for pelvic floor symptoms of the interviewees, and used a predefined checklist that was expanded on the basis of each subsequent interview. The list of original and added reasons for not seeking medical help from this heterogeneous group of survivors of gynaecological cancer was extensive, showing a great variety. Our results and recommendations may therefore be applicable to all survivors of gynaecological cancer, as well as to women who have been treated for other oncological pelvic diseases, e.g. bladder or rectum malignancies.

Second, our secondary research objective was to invite suggestions for post-treatment outpatient care. As we also included interviewees who had already stopped their cancer follow-up, we clearly did not collect all possible suggestions for improving outpatient care. Interestingly, even this group of interviewees provided important suggestions.

Third, the use of telephone interviews can be criticised for running the risk of a lack of confidentiality or of calling at an inconvenient time.37 However, we pilot tested their feasibility and found that they were well accepted by the interviewees. One strength was that the interviews were conducted by a medical doctor, knowledgeable about treatments and symptoms, but who had no involvement in the treatment of the interviewees.38 Moreover, the interviewees were explicitly told that the information provided would be kept confidential and not conveyed to their treating physician. Furthermore, all interviews were analysed by two persons to enhance the validity of the results.

Our results differ from those found in population-based surveys, as our interviewees did not express embarrassment to seek help, did not lack knowledge about the causes of pelvic floor symptoms, and did not let concomitant symptoms play a role. In the above-mentioned population-based studies, all surveys were performed with self-report questionnaires, whereas we interviewed the patients. These different modes of data collection might explain the different results. However, survivors of gynaecological cancer have undergone multiple gynaecological examinations and counselling before cancer treatment and therefore are less embarrassed to go to a gynaecologist and do not lack knowledge about the causes of pelvic floor symptoms. Both groups of women do not seek help because they are unaware of the treatment possibilities.9–11

To the best of our knowledge, no qualitative study has been conducted on help-seeking behaviour for pelvic floor symptoms in women with gynaecological cancer. The perception by patients and physicians of post-treatment morbidity has been found repeatedly not to be in accordance.18,19,39 The results of this study suggest that oncologists ask about the adverse-effects of cancer treatment on pelvic floor function, but do not seem to continue to ask questions about the impact of these symptoms on a woman’s daily life. The reluctance of oncologists to discuss possible treatment options might be because of a lack of knowledge about treatment options for these symptoms in this complicated group of patients. For adverse-effects such as radiation enteritis and cystitis or hypotonic bladder, there is no conclusive evidence for curative options. Our interviewees, however, suffered mostly from urinary incontinence for which good treatment options exist, as documented.26,27 In addition, GPs could play a greater role by paying more attention to pelvic floor symptoms and making timely referrals as part of a ‘shared-care model’ for cancer survivors, as suggested by Oeffinger and McCabe.40

Conclusion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Disclosure of interests
  9. Contribution to authorship
  10. Details of ethics approval
  11. Funding
  12. References

Most women with gynaecological cancer consider their severe pelvic floor symptoms within the perspective of their previous cancer diagnosis and treatment, as most have been informed about the consequences of treatment and feel fortunate to be alive. However, most women would undergo treatment for these symptoms if this was proposed and was efficacious. Post-treatment care could be improved if, in addition to the routine oncological checkups by gynaecological oncologists, oncology nurses paid attention to the adverse-effects of cancer treatment on pelvic floor function and their negative impact on a patient’s quality of life. When women with gynaecological cancer report bothersome pelvic floor symptoms, pelvic floor-related quality of life questionnaires could be used to objectify the symptoms.

Subsequent referral to pelvic floor specialists, such as urogynaecologists, urologists, gastroenterologists and pelvic physiotherapists, should be considered, although future research needs to evaluate whether all existing treatment modalities are equally successful in alleviating pelvic floor symptoms in women with gynaecological cancer.

Contribution to authorship

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Disclosure of interests
  9. Contribution to authorship
  10. Details of ethics approval
  11. Funding
  12. References

MHH codesigned the study, selected the interviewees, conducted the interviews, analysed all the interviews and wrote the first draft of the paper, which was then commented on by the co-authors. MAS codesigned the study, analysed the first four interviews and contributed substantially in the writing of the paper. EFB analysed the last 11 interviews and contributed to the writing of the paper. JvdV contributed intellectually to the paper. MPB contributed intellectually to the paper. JPR devised and codesigned the study, and contributed substantially to the writing of the paper.

Details of ethics approval

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Disclosure of interests
  9. Contribution to authorship
  10. Details of ethics approval
  11. Funding
  12. References

We obtained approval from the Medical Ethical Committee of the AMC for conducting this study on 22 June 2007, and the patients gave written informed consent for the interview.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Disclosure of interests
  9. Contribution to authorship
  10. Details of ethics approval
  11. Funding
  12. References
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