Diana Zach

Prospective long-term follow-up of sexuality and body image in women with primary vulvar cancer

To investigate the development of sexual activity, sexual function, and body image in women with primary vulvar cancer from the time of diagnosis to 24 months after the end of treatment. This nationwide prospective cohort study assessed health-related quality of life in women with newly diagnosed vulvar cancer using validated patient-reported outcome measures (EORTC-QLQ-VU34 [European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Vulva 34], Supportive Care Needs Survey Short Form) and self-constructed questions at diagnosis, and at 3, 12, and 24 months after the end of treatment. For this study, outcomes concerning sexuality and body image were analyzed. Results were displayed as mean scale scores and proportions. The longitudinal changes of scale and item scores were estimated by linear mixed-effects models with patient random intercept for continuous/numerical outcomes, and by generalized linear mixed models for binary response variables. Between August 2019 and August 2021, 138 of 153 consenting women (90%) returned at least 1 questionnaire, and 90 women (59%) completed the questionnaires at all 4 time points. Sexual activity increased from 9.8% at diagnosis to 22.8% after 24 months (odds of being sexually active at 24 months were 6 times higher than at baseline, p = .003). Vulvar cancer was one of the reasons for not being sexually active for 37.5% of the participants at baseline and 26.9% at 24 months. Most women (73.5%) were not satisfied with their sex life at baseline. At least at one time point, 25.4% of the women found sex important, and 32.6% needed help with changes in sexual feelings. The mean scale scores of sexual functioning and body image did not change over time. Sexual activity was low, largely due to the vulvar cancer diagnosis. Most women were not satisfied with their sex life. A substantial proportion of the women found sex important and expressed a need for help with sexual feelings.

The impact of local symptoms on health‐related quality of life in vulvar cancer survivors—A nationwide prospective study

AbstractIntroductionVulvar cancer may cause serious local symptoms that may impact negatively on the woman's health‐related quality of life (HRQOL). However, knowledge about the prevalence of vulvar and lymphedema symptoms at diagnosis and during follow‐up is limited. The aim of this study was to evaluate the longitudinal development of vulvar and lymphedema symptoms as well as the trajectory of HRQOL in women with vulvar cancer. Furthermore, associations between vulvar symptoms and HRQOL were investigated.Material and MethodsIn this nationwide prospective cohort study, women completed validated patient‐reported outcome measures; the EORTC‐QLQ C30 and the EORTC‐QLQ‐VU34 at diagnosis, three, and 12 months post‐treatment. Mean scores of symptom‐ and functioning scales were calculated over time. Heatmaps were used to visualize proportional changes in the prevalence of symptoms at baseline and 12 months after treatment. Linear mixed‐effects models with patient‐specific random intercepts were specified to estimate changes in mean scores of HRQOL over time. Additionally, adjusted linear mixed‐effects models were applied to investigate the effect of the most prevalent vulvar symptom on HRQOL. The study has been registered at ClinicalTrials.gov (NCT 04152512).ResultsBetween 2019 and 2021, 153 women consented to participate in the study, and 140 (92%) completed the patient‐reported outcome measures at least once. In total, 105 (69%) completed the patient‐reported outcome measures at all three time points. The most prevalent reported symptom was itchy, irritated skin in the vulva, which decreased from 82% at diagnosis to 56% 12 months after treatment. All vulvar symptoms, except narrowing of the vaginal entrance, improved over time but persisted in large proportions of the women. Women with severe vulvar symptoms reported a significant decline in HRQOL. A deterioration of leg swelling symptoms was reported by 33% of the women. Emotional‐, role‐, social‐, and cognitive functioning, global and mental health improved significantly after treatment.ConclusionLocal vulvar symptoms were highly prevalent at diagnosis; however, as most aspects of HRQOL, they improved significantly during the first year of follow‐up. Severe vulvar symptoms were associated with impaired HRQOL. Symptoms of leg lymphedema increased after treatment. © 2025 The Authors. Acta Obstetricia et Gynecologica Scandinavica published by John Wiley & Sons Ltd on behalf of Nordic Federation of Societies of Obstetrics and Gynecology (NFOG).

Time to extend the indication for sentinel node biopsy in vulvar cancer? Results from a prospective nationwide Swedish study

To assess detection rates and negative predictive values of sentinel node biopsy in vulvar squamous cell carcinoma with tumors ≥4 cm, multifocal tumors, and in locally recurrent disease. Between December 2019 and December 2022, patients with vulvar squamous cell carcinoma with tumors ≥4 cm (group 1), multifocal tumors (group 2), or a first local recurrence without or with previous groin treatment (groups 3 and 4, respectively) were included in a prospective, nationwide multicenter interventional pilot study. The participants underwent a sentinel node biopsy followed by inguinofemoral lymph node dissection. Detection rates, negative predictive values, the proportion of micrometastases, and isolated tumor cells were determined separately for each group. In all, 64 women were included, 36 women in group 1 (56%), and 17 women in group 2 (27%). Due to the small number and heterogeneity of the 11 women in groups 3 and 4, they were excluded from further analyses. In groups 1 and 2, 25 women (47%) were diagnosed with node-positive disease, and in 16 women (64%) only in the sentinel nodes. The detection rates varied between 94.1-100% per patient and 84.1-85.3% per groin. No false-negative sentinel nodes were identified, giving a negative predictive value of 100% for group 1 (95% CI 91.2% to 100%) and for group 2 (95% CI 83.9% to 100%). Of the node-positive patients, 32% had micrometastasis or isolated tumor cells only. One third of the metastases were detected by ultrastaging. In 27% of the non-mapping groins, metastases were found in the lymphadenectomy specimen, and in 75% the metastases showed extranodal growth. In this small cohort of patients, we provide further data that may widen the indication of the sentinel node technique to women with tumors ≥4 cm and multifocal tumors. NCT04147780.

Anxiety and depression among women with newly diagnosed vulvar cancer – A nationwide longitudinal study

AbstractIntroductionOur objective was to investigate the trajectories of anxiety, depression, emotional and social functioning in women with newly diagnosed vulvar cancer from the time of diagnosis to 12 months after treatment. A further aim was to identify risk factors for high levels of anxiety.Material and methodsPROVE (PROspective Vulvar Cancer Evaluation) is a nationwide longitudinal cohort study investigating quality of life in women with newly diagnosed vulvar cancer by the following validated patient‐reported outcome measures at diagnosis, and 3 and 12 months after treatment: The Hospital Anxiety and Depression Scale, the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire C30, and the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Vulvar module VU34. Mean scores, changes over time and associations were analyzed by generalized estimated equations and log‐linear regression models, adjusted for possible confounders.ResultsBetween 2019 and 2021, 105 (69%) women completed the questionnaires at all three time points. At diagnosis, 42% of the women reported elevated anxiety levels, decreasing significantly to 30% during the first 12 months. Insomnia, persisting vulvar symptoms and high information needs were significantly associated with a high level of anxiety (relative risk [RR] 2.1, 95% CI 1.2–3.7 for insomnia; RR 2.8, 95% CI 1.7–4.6 for vulvar symptoms, RR 2.7, 95% CI 1.5–4.9 for information needs). We found a trend towards a higher level of anxiety in younger women (<65 years: RR 1.5, 95% CI 1.0–2.5). Participants reported a low and stable prevalence of depression (14%) and high social functioning throughout the study period.ConclusionsWomen with newly diagnosed vulvar cancer report a high level of anxiety at diagnosis. Despite a significant improvement, anxiety remains widely prevalent during the first year of follow‐up. Targeting insomnia, vulvar symptoms and unmet needs may decrease anxiety during surveillance.

Can we extend the indication for sentinel node biopsy in vulvar cancer? A nationwide feasibility study from Sweden

In squamous cell vulvar cancer, sentinel node biopsy is accepted as standard treatment in well-defined patient groups and has reduced surgical morbidity considerably. Currently, due to the lack of evidence, it cannot be offered to patients with tumors of 4 cm diameter or greater or with multifocal tumors, or in local recurrences. This study is primarily a pilot and feasibility trial, aiming to evaluate if the prerequisites concerning detection rate and negative predictive value are satisfactory before the implementation of a multinational trial. Sentinel node biopsy has an acceptable negative predictive value and detection rate in the study cohort. This study is planned as a prospective, national, multicenter interventional trial. Participating patients will undergo a sentinel node biopsy in addition to an inguinofemoral lymphadenectomy. Inclusion criteria: for women in group 1, a primary tumor ≥4 cm in diameter; in group 2, a multifocal primary tumor; in group 3, a local recurrence without previous inguinofemoral lymphadenectomy or radiation to the groins; in group 4, a local recurrence, with previous inguinofemoral lymphadenectomy and/or radiation to the groins. The primary endpoints are the detection rate and the negative predictive value of the sentinel node procedure. In each of the four study arms, recruitment of 20-30 patients is planned. ESTIMATED DATES FOR COMPLETING RECRUITMENT AND PRESENTING RESULTS: Recruitment will take place between November 2019 and October 2021. Results will be available in December 2021. The trial is registered at "ClinicalTrials.gov" (ID: NCT04147780).

Practical strategies for environmentally sustainable practices in gynecologic oncology

Sustainability in health care is an increasingly urgent priority, and gynecologic oncology (as a resource-intensive surgical specialty) offers opportunities to reduce environmental impact without compromising patient care. This review provides actionable, evidence-based strategies that individual clinicians, departments, and institutions can readily implement into routine practice. Practical anesthetic strategies, such as total intravenous anesthesia, regional anesthesia, and low-flow techniques, substantially decrease greenhouse gas emissions. Transitioning from disposable to reusable surgical instruments, drapes, and gowns significantly curbs waste. Energy-efficient solutions in the operating room, including optimized heating, ventilation, air conditioning systems, as well as light emitting diode lighting, minimize unnecessary energy use. Optimizing diagnostic imaging through clinical justification and powering down equipment when feasible further decreases energy consumption. Pharmaceutical-related strategies, including accurate chemotherapy dosing, safe medication disposal through drug take-back programs, and environmentally conscious procurement, mitigate harmful emissions and pharmaceutical waste. Surgical techniques such as sentinel lymph node biopsy, rather than extensive lymphadenectomy, also support sustainability goals by reducing resource consumption and procedural waste. Digital innovations, notably telemedicine, demonstrate clear environmental advantages by minimizing patient travel, particularly for routine follow-up and the collection of patient-reported outcomes. Enhanced Recovery After Surgery protocols, promoting shorter hospital stays and digital preoperative assessments, represent additional avenues for improvement. Preventive interventions, such as human papillomavirus vaccination programs and early cancer screening, are vital long-term sustainability investments, reducing resource-intensive treatments associated with advanced disease. By highlighting practical examples from recent studies and clinical experience, this review aims to encourage widespread adoption of sustainable practices in gynecologic oncology, aligning clinical excellence with global environmental goals.

Pelvic exenteration for vulvar cancer: contemporary outcomes from a multinational cohort study

Women with vulvar cancer are considerably older than those with other gynaecological malignancies, raising concerns about the tolerability of radical surgery. Yet, for locally advanced or recurrent disease, pelvic exenteration may be the only curative option. Robust evidence to guide decision-making in this population is lacking. This multicentre observational cohort study used data from the COREPEX registry including women who underwent anterior or total pelvic exenteration between 2005 and 2023 across 20 European tertiary referral centres. The primary outcome was overall survival (OS); secondary outcomes were progression-free survival (PFS) and major postoperative complications. Associations were assessed using multivariable Cox and binomial regression models adjusted for relevant covariates. Among 861 women, 79 (9.2%) had vulvar cancer. Median follow-up was 49 months for OS and 40 months for PFS. Women with vulvar cancer were older and more often overweight. Five-year OS was 32% (95% CI, 19-46) in vulvar cancer versus 29% (95% CI, 25-34) in other cancers, adjusted HR 1.05 (95% CI, 0.75-1.46). Five-year PFS was 34% versus 29%, adjusted HR 0.96 (95% CI, 0.69-1.34). Major complications occurred in 33% vs 29%, adjusted RR 1.12 (95% CI, 0.77-1.58). Lymph node metastases, positive margins, and recurrent or persistent disease independently predicted poorer survival. Despite their older age, women with vulvar cancer had survival and morbidity comparable to those with other gynaecological malignancies. These findings support pelvic exenteration as a curative option for selected women with vulvar cancer when complete resection is feasible.

Sentinel Node Extended in Squamous Cell Vulvar Cancer

The aim of this study is to investigate the feasibility of sentinel node biopsy in patients with squamous cell vulvar cancer, currently not regarded suitable for the sentinel node technique, i.e. patients with tumors ≥4cm, multifocal tumors or locally recurrent disease. A positive result of this pilot study might constitute the basis for a future full-scale multinational trial.

Quality of Life, Unmet Needs and Satisfaction With Care After Vulvar Cancer

The aim of this prospective, longitudinal Swedish multi-center study is to assess the quality of life, treatment-related morbidity, unmet needs and satisfaction with care after treatment for vulvar cancer, evaluated by a validated questionnaire.