Cancer-Related Concerns among Women Newly Diagnosed with Gynecological Cancer: An Exploration of Age Group Differences

Abstract

The diagnosis and treatment of gynecological cancer is often marked by physical and psychosocial challenges.^1,2,3,4 While there is variation across different gynecological cancers for treatment, side effects, and prognosis, women report similar cancer-related concerns, including physical symptoms⁵, treatment effects⁵, sexual dysfunction ^6,7 cancer recurrence/progression ⁸, and financial problems.⁹ Qualitative research of ovarian cancer patients adds additional concerns, including adverse effects on personal relationships and inability to work.¹⁰ These cancer-related concerns can be distressing. Indeed, about one quarter of patients report clinical levels of depression¹¹, more than half endorse clinically significant cancer-specific distress¹², and distress upon initial screening.¹³ These data highlight the importance of addressing psychosocial needs of gynecological cancer patients. Identifying prevalent cancer-related concerns and factors associated with the concerns may assist in facilitating psychological adaption.

Age at diagnosis is a relevant factor when exploring cancer-related concerns. Developmentally, different stages of the life cycle are marked by specific biopsychosocial needs and characteristics¹⁴, which can be disrupted by a cancer diagnosis. Rowland¹⁵ provided approximate age groups representing these stages: (1) the young adult (≤ 30 years) focuses on goals related to independence and formation of relationships; (2) the mature adult (31–45 years) pursues marriage, childrearing, and career establishment/development; (3) the middle adult (46–65 years) adjusts to children leaving the home, experiences peaks in careers, and adapts to menopausal changes; and (4) the aging adult (>65 years) copes with losses of partners and loved ones, retirement, and decreased physical functioning. The age ranges are approximations as there is variability in match between age and developmental stage.

Gynecological cancer tends to be diagnosed in a woman’s sixties, with the median age approximately 60 for endometrial¹⁶, 63 for ovarian and 68 for vulvar.¹⁷ Cervical cancer tends to be diagnosed at earlier age.¹⁷ Due to the average age for most gynecological cancers, this study focused on women in three developmental stages: young adult (≤ 45 years), middle adult (46–64 years), and older adult (≥65 years). Our young adult stage combined women in their twenties and 31–45 years due to the low incidence of these cancers in the first age group^{16, 17} and relevant similarities in terms of relationship and family development.¹⁵ Furthermore, prior studies have combined these two age groups.¹⁸

Developmental life stage theory¹⁵ hasn’t been specifically applied in studies of gynecological cancer patients, but there is evidence suggesting age-related differences in psychological distress and cancer-related concerns. Younger women tend to report greater psychological distress.^12,13,19,20 Younger survivors of breast or endometrial cancer (18–55 years) reported more appearance-related concerns, sexual problems, and long-term treatment concerns than older survivors (≥65 years).²¹ Qualitative research indicated that ovarian cancer patients (≤45 years) express concerns over menopause symptoms, finances, and job-related issues.⁹

While these studies suggest age group differences, more research is needed to fully understand cancer-related concerns based on developmental life stage. First, greater frequency and intensity of cancer-related concerns is linked to psychological distress.^{22, 23} Second, identifying relevant concerns may assist in informing psychosocial assessment and intervention for specific age groups. Third, many studies focus on global distress and utilize correlational analyses^{12, 20}, which may hinder tailored recommendations.

The primary goal of the study was to utilize developmental life stage theory¹⁵ to explore cancer-related concerns among women newly diagnosed with gynecological cancer in three age groups: young (≤45 years), middle (45–64 years), and older (≥65 years). The cancer-related domains consisted of concerns nominated in prior research²⁴ and included physical functioning, cancer treatment, sexual functioning, body image, emotional functioning, disease progression/death, own well-being, partner well-being, relationship with partner, relationship with others, finances, and employment. The first aim was to characterize cancer-related concerns for each age group. The second aim was to compare age groups on overall cancer-related concern and degree of concern in each domain.

Method

Results

Discussion

This exploratory study examined specific cancer-related concerns among women newly diagnosed with gynecological cancer utilizing developmental life stage theory.¹⁵ The major finding confirmed that age at diagnosis, an approximation of developmental life stage, may influence degree of concern over specific cancer-related issues. Given that cancer-related concerns are linked to overall psychological distress^22,23, it becomes clinically important to explore these areas with women who may be at risk.

In terms of the first aim, women in the young group reported the greatest level of concern over their own emotional functioning. While there is evidence suggesting that younger women are at risk of greater psychological distress¹², our findings confirm that young women are concerned about the impact of cancer on emotional functioning. Therefore, professionals may consider providing young women with information and support regarding the emotional impact of cancer. Young women also reported high levels of concern over their partners’ well-being and sexual functioning, suggesting that these may also be areas to assess and treat. From a developmental life stage perspective, an important goal in this stage is likely partnership and establishing a family¹⁵, both of which may be related to sexual functioning and partner well-being.

The middle and older groups reported the greatest concern over their own well-being, their partners’ well-being, and disease progression/death, suggesting that these may be areas to target for assessment and intervention. Existential concerns help to explain the priority attributed to these issues. Women in the middle group are likely faced with adult children leaving the house and starting their own families, potentially freeing them up to focus on their relationship with their partner. Women in the older group are likely to have experienced the loss of loved ones or friends who have lost partners due to aging and health-related issues, which may contribute to their concern over their partners, as well as concern over the possibility of their own disease progression. Both groups reported the least concern over the impact of cancer on sexual functioning, highlighting how this ceases to be as great a concern for older women. Physical impairment was the only other concern ranked a priority, consistent with clinical experience.

In terms of our second aim, there were age group differences in overall and specific cancer-related concern. Young women reported greatest overall cancer-related concern and differences in the impact of cancer on emotional functioning, sexual functioning and finances. Relationships, having children and raising a family are central tasks for this age group that become disrupted by cancer. Any related grief needs to be addressed by supportive clinical interventions.

Marital status did not impact the relationship between age and sexual functioning concern, suggesting the importance of considering sexual concerns regardless of marital status. A recent systematic review of sexual concerns among gynecological cancer survivors¹⁰ suggested that a substantial number of women report psychological concerns related sexuality (e.g., fear, sense of femininity), but the tendency is to focus on physical concerns (e.g., pain, vaginal dryness). Most studies included women post-treatment and further from diagnosis. Our findings suggest that cancer-related sexual concerns are prevalent, particularly in young women, shortly after diagnosis. Therefore, a thorough assessment of both physical and psychological concerns related to sexuality close to diagnosis may assist professionals in recommending interventions that have shown promise in improving sexual functioning or reducing sexuality-related distress in this population. ^{32, 33}

Finally, older women reported significantly less concern over the financial impact of cancer. These women are likely to be transitioning from work to retirement. Young and middle women may experience more concern over the financial impact and professionals should consider how these concerns may influence a woman’s overall adjustment.

The cancer-related concerns that did not differ significantly between age groups were physical symptoms, cancer treatment, partner well-being, relationship with partner, disease progression/death, and relationship with others. These may be such relevant existential concerns for all patients that age-related differences do not emerge. Similarly, in terms of concern over disease progression/death, women in all age groups reported comparable levels of concern. While some studies have suggested that younger women report greater worry over death³⁴, other studies have found no age differences.³⁵ Regardless of developmental life stage, threat to one’s life appears may be a universally significant concern.

There are limitations that should be taken into consideration. First, the study is exploratory in nature. We did not sample equally for age and thus there were not an equal number of women across the groups. Future studies could oversample women in the young and older groups to gain greater statistical power to determine group differences. Second, the sample was homogenous and represents women who agreed to participate in a randomized clinical trial. Results may not generalize to a broader population. Third, the cancer-related concerns were measured by a Likert rating and not a standardized measure. Finally, there may be additional variables that were not explored in the study that impact the degree of concern. For example, it may be important to consider the impact of having children and how this may contribute to cancer-related concern in specific domains.

Despite these limitations, the findings revealed clear age group differences in cancer-related concerns among women diagnosed with gynecological cancer. Professionals may benefit from considering the impact of cancer from a developmental life stage perspective. A thorough assessment of specific cancer-related concerns may assist professionals in recommending specific psychosocial interventions to address these concerns.

Acknowledgments

Footnotes

Contributor Information

Shannon Myers Virtue, Rutgers Cancer Institute of New Jersey.

Sharon L. Manne, Rutgers Cancer Institute of New Jersey.

Melissa Ozga, Memorial Sloan Kettering Cancer Center.

David Kissane, Monash University and Memorial Sloan Kettering Cancer Center.

Stephen Rubin, University of Pennsylvania School of Medicine.

Carolyn Heckman, Fox Chase Cancer Center.

Norm Rosenblum, Jefferson Medical College of Thomas Jefferson University.

John J. Graff, Rutgers Cancer Institute of New Jersey.

References