11. Psycho-oncological aspects, patient education, palliative care, rehabilitation, physiotherapeutic treatment in the context of rehabilitation – Endometrial Cancer
11.1 Psycho-oncological aspects
This chapter was prepared following the already existing S3 Guidelines “Psycho-oncological diagnosis, counseling and treatment of adult cancer patients”, version 1.1, January 2014, AWMF register number: 032/051OL, http://www.leitlinienprogramm-onkologie.de/leitlinien/psychoonkologie/ [814] as well as “Diagnosis, therapy and follow-up of the patient with cervical carcinoma”, version 2.1, September 2021, AWMF register number: 032/033OL, http://www.leitlinienprogramm-onkologie.de/leitlinien/zervixkarzinom/) [219] created.
Patients with endometrial cancer and their families may face multiple physical, psychological, social, and spiritual/religious stresses
- Consensus
- Consent
Background
As a result of their tumor disease, patients with endometrial cancer and their families face a wide range of different physical, psychological, occupational, social and spiritual stresses that can impact all areas of their lives [815], [816], [817], [818], [819], [820]. As mortality decreases, the number of long-term survivors also increases, and they face the associated risk of increased chronic morbidity [821], [822] and possible limitations in their quality of life [821], [822], [823].
During and after treatment of endometrial cancer, physical complaints are predominantly the result of the therapies performed [824], [825], [826], [827] in the foreground are: residual dysfunctions in the pelvis, such as urinary and fecal incontinence [824], pain [824], [828], vaginal dryness, pain during sexual intercourse (dyspareunia) [829], [830], but also menopausal complaints caused by the ovariectomy (and if necessary by anti-hormonal therapies, which, however, are used only in cases of far advanced endometrial carcinoma). Persistent postoperative pain leads to high subjective distress in the women affected by it, with a severe reduction in quality of life.
The frequently occurring psychological stress factors include emotional changes, limitations in previous role function, contact and interaction skills, problem solving and coping with the disease and the inability to mobilize social resources. Their effects show up primarily as impairments in everyday life, occupational and social contexts [831]. In the study on the four-week prevalence of psychological disorders in different tumor diseases by Mehnert et al. [817], patients with gynecological tumors were in fifth place.
Across all tumor entities, a mean of 32.6% of all patients received a diagnosis of a comorbid mental disorder. Patients with gynecological tumors had a four-week prevalence of any mental disorder of 36%, which is slightly higher in direct comparison with other tumor diseases and significantly higher in comparison with the German general population (20%). Leading were adjustment disorders at approximately 13%, followed by anxiety disorders (ICD-10 F41.– [832]) at 12% and depressive disorders (ICD-10 F32.– [832]) at 7.5%. There is evidence that the presence of anxiety disorders or depression can lead to worsening of pain symptomatology. Improvements in psychological symptomatology, for example through (psycho)therapeutic interventions, may lead to improvements in subjectively perceived pain intensity [828]. A longitudinal study of patients with early-stage endometrial cancer demonstrated that the prevalence of anxiety or depression (HADS scores ≥ 11) around the time of surgery was approximately 16% [833]. Also in the longitudinal course the long-term survivors still showed elevated anxiety as well as depression scores compared to age-adjusted norm comparison group [834].
In some studies, the occurrence of psychological symptoms such as anxiety or depression proved to be independent of the stage of the disease, but dependent on the extent of therapy administered. With regard to the development of depression or anxiety disorders, an exclusively surgical therapy without additional irradiation showed positive results in the long-term follow-up [835], [836].
Although endometrial cancer is rare in women of childbearing age, fertility-preserving measures are becoming increasingly important in this group of patients, as more and more women are delaying their first pregnancy. In the future, therefore, there may also be an increase in the incidence of this condition in patients who have not yet completed family planning [816], [837]. However, not all patients with childbearing potential and endometrial cancer can be offered fertility-preserving measures [837]. Therefore, it is recommended that the issue of childbearing is addressed before starting treatment to allow patients and their partners to deal with their family planning in a timely and realistic manner.
In contrast, older female cancer patients are particularly susceptible to the development of physical as well as psychological stress, anxiety and depressive symptoms. Increasing frailty, functional limitations such as incontinence, disabilities in coping with everyday life and cognitive deficits should be mentioned here [838], [839], as well as the loss of social support due to an environment that is also aging. At the same time, older age may also have a positive effect on disease management and coping strategies due to the associated experience of life, illness and crisis [838], .
Kornblith et al. [840] conducted telephone catamneses of American patients with breast or endometrial cancer one year after diagnosis of their tumor disease. They found that younger patients had significantly worse quality of life outcomes than older patients, particularly in dealing with psychological distress, tumor treatment and its physical consequences, sexual problems, and coping with difficult everyday situations.
Social dysfunction manifests as impairments in everyday life (e.g. real or feared limitations in mobility due to incontinence), in occupational limitations (performance, type and extent of employment, ability to make contact) or in family and social interactions [841], [836].
11.1.1 Psychosocial support
Cancer patients and their relatives shall be informed about psychosocial support, counseling and treatment services as early as possible in all phases of the disease and shall be given access to these services according to their individual needs.
- Consensus
- Strong consensus
Background
Psychosocial counseling and psycho-oncological treatment of patients with endometrial cancer is an integral part of oncological treatment and diagnostics. It is a multiprofessional task that can be needed and realized by the affected women, as well as by their relatives, at any time of treatment, at diagnosis, during the treatment phases, in aftercare and during rehabilitation [842], [843], [816] [818]. Psycho-oncological care for patients is realized on the basis of an interdisciplinary approach between all professional groups involved in the treatment [842].
Psychosocial assistance includes patient-oriented information (including low-threshold through business cards and posters of the offering services), counseling, a qualified psychosocial diagnosis as well as targeted psychosocial support and, if necessary, treatment. It includes the processing of the disease, the treatment and the side effects and subsequent problems that occur, as well as dealing with persisting functional disorders and other restrictions associated with the disease or treatment, such as economic difficulties and questions about returning to working life.
In concrete terms, therefore, these measures can be provided in the form of psychological/psycho-oncological interventions, counseling by social workers, as part of oncological rehabilitation, or by other professional institutions (e.g. cancer counseling centers). These aids are directed at those affected and their relatives in the surrounding area and concern the entire phase of the disease from diagnosis, information, therapy, supportive treatment, rehabilitation, aftercare and, if necessary, palliative medical care [842].
Rowlands et al.[835][844] conducted a catamnesis study of endometrial cancer patients whose tumor diagnosis was 3–5 years ago and asked about existing needs and possible needs for psychosocial support. The main issues mentioned by about a quarter of the women surveyed were the best possible medical treatment, the willingness of the treating physicians and the professional team to talk and good accessibility of medical facilities. About 16% wished for emotional support and help in dealing with fear of recurrence or progression, persistent consequences of therapy or everyday stress management. 12% wished for more understanding from those around them of the significance and continuing effects of the tumor disease, which in the eyes of unaffected persons was supposed to have been overcome, on the current attitude and organization of life of the affected women. In particular, about 10% of the respondents expressed a desire for support in better dealing with the uncertainty of making life decisions after the disease. Furthermore, they wished for help in better dealing with their own demands or expectations, especially from outsiders, after supposedly overcoming tumor disease (long-term survival) [841]. According to initial study results, survivorship plans are especially useful for patients with active information-seeking processing strategies, while patients with distracting avoidance behavior benefit less from them [845]. Survivorship programs should therefore be tailored to the individual needs of the different patient groups.
Regarding psychosocial aspects, regardless of the underlying diagnosis, reference is made to the S3 Guideline “Psycho-oncological diagnosis, counseling and treatment of adult cancer patients”, version 1.1, January 2014, AWMF register number: 032/051OL, http://www.leitlinienprogramm-onkologie.de/leitlinien/psychoonkologie/ [842].
It is significant for the assessment of the subjective need for psychosocial counseling, support or treatment that the physical condition of the patients and the subjective condition correlate only poorly [822], [846], [847], [848]. Therefore, it is important to actively inquire about potentially stressful contextual factors, such as the family, financial, professional or partnership situation, in the (doctor-patient) discussion and to refer to further psychosocial services.
The recommendations were adapted from the S3 Guideline “Psycho-oncological diagnosis, counseling and treatment of adult cancer patients”, version 1.1, January 2014, AWMF register number: 032/051OL, http://www.leitlinienprogramm-onkologie.de/leitlinien/psychoonkologie/ [842].
Standardized and validated screening procedures should be used to identify psychosocial distress as well as psycho-oncological treatment needs [849]. The use of a psycho-oncological screening instrument should be performed as early as possible and repeated at appropriate intervals if clinically indicated or if the patient's disease status changes (e.g. recurrence or progression of the disease).
According to the guidelines in the above-mentioned S3 Guideline “Psycho-oncological diagnosis, counseling and treatment of adult cancer patients” [842] the following procedures are recommended (LoE 1b): the Distress Thermometer, the Hospital Anxiety and Depression Scale (HADS), the Questionnaire on Burden of Cancer Patients* (FBK), the Depression Module of the Patient Health Questionnaire (PHQ-9) or the Generalized Anxiety Disorder Scale-7 (GAD-7) [821]. In case of a positive result of a screening, a diagnostic interview for further diagnostic clarification should take place. Further diagnostic clarification should then take place according to the individual problems in the psychological/social/somatic area identified in the interview.
Table 13: Recommendations of the S3 Guideline “Psycho-oncological diagnosis, counseling and treatment of adult cancer patients”, version 1.1, update as of June 2021
| 11.3 | Assessment of psychosocial distress and individual psycho-oncological treatment needs should occur as early as possible and then repeatedly during the course of the disease. |
| 11.4 | All patients shall receive screening for psychosocial distress. Psycho-oncological screening should be performed as early as possible at appropriate intervals, when clinically indicated or repeatedly during the course of the disease if there is a change in a patient's disease status (e.g., recurrence or progression), and in long-term survivors. |
| 11.5 | Validated and standardized screening instruments should be used to assess psychosocial distress. The screening instruments to be used are the Distress Thermometer (DT), the Hospital Anxiety and Depression Scale (HADS), the Burden of Cancer Patients Questionnaire (FBK), the depression module of the Patient Health Questionnaire (PHQ-9), or the Generalized Anxiety Disorder Scale-7 (GAD-7) (LoE 1b). |
| 11.6 | In addition to the stress screening, subjective psychosocial support needs should be asked (EC). |
| 11.7 | If the screening is positive and/or the patient requests it, a diagnostic interview to clarify psychosocial stress and psychological comorbidity should take place. |
| 11.8 | Further diagnostic clarification should take place according to the individual problems in the psychological/social/somatic area identified in the interview. |
11.1.2 Indication for psycho-oncological interventions
The indication for psycho-oncological interventions shall be made according to the identified individual need, the setting, and the patient's disease phase (initial diagnosis, surgery, adjuvant therapy, recurrence-free phase, relapse phase, palliative phase, long-term survival) and should take into account the patient's wishes.
- Consensus
- Consent
Background
The recommendation was adapted from the already mentioned S3 Guideline “Psycho-oncological diagnosis, counseling and treatment of adult cancer patients” [842].
In the majority of patients, there are no psychological disorders in the narrower sense, but strong stresses as a result of a new and often unexpected (objectively or subjectively) life-threatening situation. The goals of psycho-oncological interventions are therefore the provision of information, education, reduction of psychological stress, preservation of psychological functioning and thus improvement in the quality of life of those affected and their relatives. Tailored to the respective individual needs [842], [850], advice, support and, if necessary, (psychotherapeutic) treatment are provided to the women concerned and their partners and relatives [839]. In a multiprofessional network [842][816], [822], the aim is to support those affected in coming to terms with and processing the disease, and in doing so to structure and shape everyday life with the restrictions and the real threat posed by the tumor disease [821].
Psycho-oncological interventions are defined according to the S3 Guideline “Psycho-oncological diagnosis, counseling and treatment of adult cancer patients” [842] as a non-pharmacological intervention in which psychological methods, such as psychoeducation, stress management training, psychotherapy, relaxation methods alone or in combination are carried out by a professional therapist in a face-to-face interaction with cancer patients in order to reduce their psychological and social distress and increase their quality of life. Psycho-oncology interventions include:
- Relaxation techniques,
- Psychoeducation,
- Psychotherapy (individual, group, couple therapy),
- Psychosocial counseling,
- Artistic therapy
These psycho-oncological interventions are indicated for severe psychological distress, couple conflicts as well as for psychological disorders, especially depressive disorders and anxiety disorders [842], [851]. A systematic review with meta-analysis demonstrated that psycho-oncological interventions are effective in cancer patients with various diagnoses, although few intervention studies were available in patients with endometrial cancer [852]. A randomized intervention trial for patients with gynecologic diseases (psychoeducational intervention for targeted improvement of illness processing and communication) including patients with endometrial cancer showed significant effects in terms of improvement of depression, distress and general psychological well-being compared to a general counseling intervention and control condition (care as usual) [853].
A systematic literature review of non-pharmacological interventions in patients with endometrial cancer [854] examined the efficacy of specific interventions on lifestyle changes (diet, weight reduction, exercise) (n = 10 studies) with different outcome measures (quality of life, self-efficacy, attitude change, anxiety, depression). Nine studies examined quality of life as a primary endpoint and six studies examined quality of life as a secondary endpoint. Significant improvements for global quality of life were found in two studies and for domain-specific quality of life in three studies with small to moderate effect sizes. Very few studies examined psycho-oncology interventions or specific interventions to improve sexual function, social function or psychological function. The authors see a high need for high-quality studies in the area of psychological interventions for this target group.
Diagnostic workup as well as indication for psycho-oncological interventions should be done according to the S3 Guideline “Psycho-oncological Diagnosis, Counseling and Treatment of Adult Cancer Patients“ [842]. The S3 Guideline Psycho-oncology formulates a graded clinical care algorithm for psychosocial care of patients and their relatives based on the results of psychosocial screening, identified need for intervention, diagnostic workup, clinical evidence, setting, disease phase and patient preference [842].
11.1.3 Sexuality and endometrial cancer
The topic of sexuality shall be actively addressed in the various phases of the treatment process and follow-up care for patients with endometrial cancer, in order to assess the need for support and to be able to initiate appropriate assistance.
- Consensus
- Consent
Background
The recommendation was adapted from the S3 Guideline “Diagnostics, therapy and follow-up of patients with cervical carcinoma”.
(Version 2.1, September 2021, AWMF registry number: 032/033OL, [843])
Not by the diagnosis of endometrial carcinoma itself, but by the treatment and its consequences, body perception, body image, enjoyment ability as well as the body-related psychological experience of the affected women change [836], [847]. In addition, extensive surgical procedures affect the libido of female patients. Anxiety and depression also affect self-esteem as well as subjectively perceived sexual attractiveness [821], [822]. Symptoms such as postoperative pain [831]fecal or urinary incontinence [824], fatigue, and feelings of shame can also affect libido and sexual activity [823], [855][856]. Sexual difficulties are associated with lower quality of life and higher emotional distress [823].
Questions about libido changes, impairments in sexual intercourse as well as problems of sexual identity are repeatedly named as significant in different studies, but are still too little actively addressed in everyday care – in the practice or in the hospital –, even today [816], [822], [823]. In a study by Sporn et al. [823] with 800 interviewed male and female tumor patients, 59 % of the interviewed women, among them also endometrial cancer patients, wished to be able to talk about sexual topics with the treating physicians.
Treating physicians themselves report that they very rarely ask their patients about sexual concerns or difficulties [825], [830]. As possible obstacles were named: Time pressure during patient contacts, lack of knowledge about and insufficient training in the diagnosis and treatment of sexual disorders, and uncertainty, subjective discomfort, and lack of information about sexual desires and activities of their patients [823], [830]. Another barrier identified was that only about 63% saw a way to successfully refer affected patients to further counseling services or offer treatment options after such a conversation [830].
Patients and their relatives rarely address their questions or difficulties with the topic of sexuality on their own initiative. It is therefore all the more important that the impulse to actively address these issues or to pick up on corresponding signals in an encouraging manner comes from the professional team [822].
With regard to the „right time“, different and very individual aspects and phases of disease processing play a role. Professional support at the time of diagnosis or during primary therapy is initially informative for some patients [816], [822]. Side effects or follow-up problems, e.g. for sexuality, may initially appear to be of lower priority, but then gain importance after completion of treatment or during follow-up [823], [835], [857]. Addressing sexual health is also an important part of programs for long-term survivors (survivors) [858].
Evidence suggests that single women at an earlier stage of treatment, such as immediately after surgery, want to talk about intimacy and sexuality more often than women who are married or in a committed partnership [822]. After completion of treatment, during the follow-up phase and also in the long term, psychological, socio-demographic factors such as age, school education, social support and relationships as well as the type of treatment carried out (surgery, radiation, chemotherapy, anti-hormonal treatment) are important with regard to psychological as well as sexual well-being [825], [835].
The more naturally and openly possible problems are proactively addressed in the conversation between the patient and the physician, the easier it will be for the patient to verbalize her difficulties or fears [816], [857]. Ongoing communication between patients, family members, and the treatment team is important to identify who needs what and who needs more or different information or support [816].
A number of tools are available for diagnosing sexual problems in endometrial cancer patients, which can be used to identify the problem and prepare for the medical interview [859]. Although no gold standard is available for this topic area, the Female Sexual Function Index (FSFI) can be recommended as a method [860], [861]. The questionnaire is also available in a German validated version [862].
11.2 Patient education
This chapter was prepared in close accordance with the following national and international guidelines:
- „Diagnosis, therapy and follow-up of breast carcinoma.“ [863]
- „Diagnosis, therapy and follow-up of malignant ovarian tumors“ [528], „Diagnosis, therapy and follow-up of patients with cervical carcinoma“ [843]
- „Psycho-oncological diagnosis, counseling and treatment of adult cancer patients“ [842]
- „Early detection, diagnosis and therapy of the different stages of prostate carcinoma“ [864]
- "American Society of Clinical Oncology Consensus Guideline 2017" [865]
11.2.1 Patient information and educational content
11.2.1.1 Information materials
Qualified and relevant information materials (print or internet media, e.g. the patient guideline on uterine cancer), which have been prepared according to defined quality criteria for health information, shall be made available to patients in order to support them in their self-determined decision for or against medical measures through generally understandable risk communication (e.g. indication of absolute risk reductions).
- Consensus
- Strong consensus
Background
Due to the use of new information technologies, such as the Internet, and the increasing need of patients for information and co-determination in the treatment of their disease, the comprehensible provision of information and differentiated education of the patient is becoming increasingly important. Its importance for the doctor-patient relationship, the course of the disease and the achievement of the therapeutic goal has been proven by numerous studies [866], [867], [868]. An open-ended patient education in combination with a joint (participative) decision-making enables a trustful cooperation. According to the established model of Beauchamp and Childress, four ethical principles operate in these interactions
:1. Respect for patient autonomy2
. Non-harm (non-maleficence)
3. caring (beneficence)
4. equality and justice [868].
Two of these principles are often in tension with each other: the patient's self-determination (autonomy) and the physician's care [Horton]. The goal is the farthest possible respect for the autonomy of the patient, it justifies the principles in the „informed consent“. Patients can speak out for or against medical measures in diagnostics and therapy or also decide for a „not-knowing-want“.
In order for patients to be able to make a decision in the sense of effective consent („informed consent“), potential information deficits must be evaluated and compensated for by physicians. Personal discussions between patients and physicians are of particular importance as a basis for trusting and respectful communication.
11.2.1.2 Diagnosis transmission
The patient shall be offered to include her partner or relatives/trustworthy persons in the conversation(s) for the purpose of communicating the diagnosis and in further conversations during therapy and for follow-up care.
- Consensus
- Consent
During the medical consultation, the patient's individual preferences, needs, concerns and fears shall be determined and taken into account. If a patient requires more than one consultation, the offer of further consultations shall be made.
- Consensus
- Strong consensus
Background
The information and education obligations towards patients have been regulated since 2013 in the new „Act on the Improvement of Patients' Rights“ (PatRechte G (entered into force on 26.02.2013) [869]. The following aspects are the subject of the law:
- Information obligations between practitioner and patient,
- Consent,
- Obligations to provide information,
- Documentation of treatment,
- Inspection of the patient's file,
- burden of proof for liability in the event of treatment and information errors.
This legal regulation is associated with obligations of a statutory nature that go beyond the scope of recommendations in a guideline [869].
The participatory decision making has thereby a high value („shared decision making“) [863]. The prerequisite for this is the patient-centered discussion. The information provided by the physician should be comprehensive, truthful, complete with regard to the type of measure, purpose, benefits and risks and, in particular, comprehensible (including information on frequencies instead of relative percentages) [870], [871]. The patient's individual somatic, psychological and social situation, age and comorbidities must be taken into account during the discussion. In this context, the patient's fears and concerns, specific burdens, and in particular her need for information, her treatment expectations, and her preferences must be addressed directly by the physician [863], [872], [873], [874], [875].
The patient's medical education should include the following aspects: Information about the disease, examination results obtained, the course of treatment to date, diagnostic and therapeutic options including the side effects to be expected, as well as assessments of the associated prognoses and the impact on the patient's life planning [863], [876], [877]. Accompanying, supporting and helpful for a decision-making of the patient is the provision and access to written information [876], [O'Connor, A. M. et al. 2000]. This includes professional and competent, comprehensibly prepared and quality-assured information materials [863], [876], [877].
11.2.1.3 Information dissemination and education
The communication of information and education of the patient shall take place at an early stage and according to the basic principles of patient-centered communication, which enables participatory decision-making. This should include the following aspects:
- Expression of empathy and active listening,
- Addressing difficult issues directly and empathetically,
- Avoidance of technical medical vocabulary, explanation of technical terms when appropriate,
- Strategies to improve understanding (repetition, summarizing important information, use of graphics, etc.),
- Encouragement to ask questions,
- Permission and encouragement to express feelings,
- Offering further help.
- Consensus
- Consent
Change note
The communication of information and education of the patient should take place early and according to the basic principles of patient-centered communication, which enables participatory decision-making.Evidence tables (1)
Test123To improve patient education, physicians should complete quality-assured training on communication with patients.
- Consensus
- Strong consensus
Background
Receiving a cancer diagnosis causes anxiety and helplessness in the patient and her relatives. The complex treatment is also difficult for them to understand. The treating physicians must be able to deal with these feelings in order to have a successful conversation for both sides [865].
11.2.1.4 Information about self-help organizations
The patient shall be made aware of self-help options and given contact information for self-help organizations.
- Consensus
- Consent
Background
As soon as the histopathological diagnosis of endometrial carcinoma is confirmed, the patient should be informed by her treating physician according to the criteria described [863]. Basic patient education is usually already provided by the general practitioner or the physician who made the initial diagnosis or who diagnosed recurrence or metastasis. Since the period between and during the diagnosis and the start of therapy is often very difficult for patients, the possibilities of self-help, psycho-oncological care or psychosocial cancer counseling should be pointed out at this early stage depending on the situation (see [842]). Contact details for self-help organizations can be obtained from the National Contact and Information Center for the Initiation and Support of Self-Help Groups (NAKOS), e-mail: selbsthilfe@nakos.de, Internet: www.nakos.de.
Contact information for counseling services and contact points for patients with endometrial cancer will also be available in the accompanying Patient Guideline. This is freely available on the Internet, e.g., on the pages of the Oncology Guidelines Program (http://www.leitlinienprogramm-onkologie.de/home/) and the pages of the AWMF (http://www.awmf.org/leitlinien/patienteninformation.html). The final therapy recommendation, its alternatives and the respective effects will then be discussed, if necessary, in a renewed conversation with the doctors who will ultimately treat the patient (e.g. treatment within the framework of studies, is surgery possible, etc.), because often not all information about the disease (staging, etc.) is available at the time of initial diagnosis. It is at the patient's discretion whether her partner or relatives or persons she trusts should be included in the discussion(s). The conversation should take place in a form and setting that is understandable and appropriate for the patient [879].
The physician must inform the patient truthfully without diminishing the content. The patient should not be deprived of hope for a cure or relief, depending on the stage of the disease. The physician providing the information must ensure that the information provided is in line with the current state of medical knowledge and takes medical progress into account [863]. The patient should always be given time to think about the decision on the type of therapy. Only then will the patient sign the informed consent.
11.2.1.5 Information about therapy options
Patients with endometrial cancer shall be informed about the treatment options described in this Guideline that are relevant for them, their prospects of success and their possible effects. In particular, the impact on their physical appearance, sexual life, urinary and fecal control (incontinence) and aspects of female self-image (self-image, fertility, menopausal symptoms) shall be addressed.
- Consensus
- Strong consensus
Background
In addition to his or her duty to inform (§ 630c), the attending physician is required by § 630d of the “Gesetz[es] zur Verbesserung der Rechte von Patientinnen und Patienten” [Act Improving the Rights of Patients] (PatRechte G) [880] to inform the patient orally, in person and in good time “[…] of all circumstances essential to consent. This includes in particular the nature, scope, implementation, expected consequences and risks of the measure as well as its necessity, urgency, suitability and prospects of success with regard to the diagnosis or therapy. The information must also refer to alternatives to the measure if several medically equally indicated and customary methods can lead to substantially different burdens, risks or chances of recovery.” https://www.bundesaerztekammer.de/fileadmin/user_upload/downloads/Patientenrechtegesetz_BGBl.pdf.
Specifically, this is education about treatment recommendations, especially if they are consented to in a case-based, interdisciplinary conference. The principles of treatment and potential expected benefit(s) or risk(s) should be presented. Alternative forms of treatment that may be considered for the patient, for example in the context of participation in a clinical trial, should be explained. The effects on the patient's lifestyle and quality of life should be discussed.
11.3 Palliative care
More detailed information on this topic can be found in the S3 Guideline Palliative Medicine (S3-Leitlinie Palliativmedizin).
Selected key recommendations from the S3 Guideline Palliative Medicine
All patients shall be offered palliative care (APV or SPV) after diagnosis of non-curable endometrial cancer, regardless of whether tumor-specific therapy is used.
- Recommendation grade
- A: Starke Empfehlung für oder gegen ein Maßnahme - verwendete Ausdrucksweise = soll/soll nicht
- Level of evidence
- 1-
LoE from S3 palliative care.
- Consensus
- Strong consensus
Change note
All patients should be offered palliative care after diagnosis of a non-curable cancer, regardless of whether tumor-specific therapy is used.̈For patients with non-curable endometrial cancer, the complexity of the palliative situation shall be repeatedly assessed; this includes: the needs of the patient and her family, the patient's functional status and the disease phase.
- Consensus
- Strong consensus
Patients with non-curable endometrial cancer and high complexity of their situation shall receive specialized palliative care.
- Recommendation grade
- A: Starke Empfehlung für oder gegen ein Maßnahme - verwendete Ausdrucksweise = soll/soll nicht
- Level of evidence
- 3
LoE from S3 palliative care.
- Consensus
- Strong consensus
- References
- [723]
Background (as of 2021)
Palliative medicine or palliative care (synonym: palliative care) is defined as a multiprofessional approach to improving the quality of life of patients and their families facing problems associated with a life-threatening illness. This is done by preventing and relieving suffering, by early recognition, careful assessment and treatment of pain and other problems of a physical, psychosocial and spiritual nature (Expanded S3 Guideline Palliative Care for Patients with Non-curable Cancer Long version 2.2 – September 2020 AWMF Register Number: 128/001OL, https://www.leitlinienprogramm-onkologie.de/leitlinien/palliativmedizin/, S3 Guideline Diagnosis, Therapy and Follow-up of the Patient with Cervical Carcinoma Long Version 2.1 – May 2021 AWMF Register Number: 032/033OL, https://www.leitlinienprogramm-onkologie.de/leitlinien/zervixkarzinom/.
From the WHO definition of palliative care derives a holistic approach taking into account all four dimensions of the person. This is also the basis for the inclusion of the family in therapeutic efforts, which does not end with the patient's death but includes the mourning phase. Palliative care requires a multiprofessional and interdisciplinary team approach. Early integration (principle of involving (specialized) palliative care as systematically as possible in parallel with tumor-modifying treatment) has been shown to be relevant to quality of life and, in individual cases, survival, and is now considered the standard of care. Palliative care affirms life and recognizes dying as a normal process and thus does not aim to delay or hasten dying.
Patients who are not curatively treatable by surgery, radiochemotherapy or postoperative adjuvant radiochemotherapy and have advanced endometrial cancer with or without distant metastases (M1b, c) can usually be assumed to have incurable disease.
Needs of the patients
The most important/overriding palliative medical therapy goal – the individual quality of life – can only be evaluated and defined together with the patient. Burdens of the patient can be physical, psychosocial, spiritual and existential. The need for support should be regularly determined together with the patient using suitable, validated and multidimensional instruments.
A prerequisite for the treatment of patients and a component of palliative medical basic values is the high appreciation of patient autonomy and participation (patient guideline S3-guideline palliative medicine). IIn addition to the above-mentioned routine recording of the patient's self-assessment of quality of life and symptom burden, this also includes the monitoring of therapy decisions in compliance with the medical ethics principles of benefit, harm, patient autonomy and appropriateness (justice). Discussions about possible therapy options should also include palliative care services. The patient guideline on palliative care contains valuable suggestions for preparing for discussions with physicians, which patients can use as a checklist. Relatives or other trusted persons named by the patient should be included in the discussions. In order to enable the patient to ensure that her confidants can represent the patient's will as well as possible, even in the event of disorders of consciousness that may occur in the course of the illness, they should be involved in determining the patient's treatment wishes and goals, and, if necessary, in drawing up a health care proxy and a living will. The living will should be drafted as specifically as possible and contain plans for probable or possible emergency situations in the course of the disease (S3 guideline on palliative), [881].
Care structures
Palliative care includes medical symptom control, palliative care, and psychosocial support from the onset of non-curable tumor disease until death. In the palliative situation, all necessary measures are oriented to the patient's individual therapeutic and life goals. The S3 Guideline presents a two-stage concept of palliative care: patients with low-to-moderate and less complex symptoms receive palliative care (general palliative care, (Allgemeine Palliativversorgung, APV)) through the primary care teams, (gynecologists, family physicians, social services). For patients who continue to suffer from a high level of physical, psychosocial or spiritual stress despite qualified palliative medical measures, specialized palliative medical (co-) treatment is advisable (spezialisierte palliativmedizinische (Mit)behandlung SPV)). This is provided in the outpatient setting by the palliative care teams of SAPV and by hospice services; in hospitals, treatment is provided by the palliative care service or in specialized palliative care units [882].
Through legislation, the following options for outpatient palliative care and palliative care in facilities are regulated and refinanced:
1. Outpatient care by specially qualified contract physicians is possible, billing of palliative care with the introduction of fee schedule figures in the EBM:
This includes “coordination of palliative medical and nursing care in cooperation with other specialized service providers such as contract physicians, psychotherapists, nursing services, psychosocial care services, hospices, as well as guidance and counseling of the care and reference persons”.
[Source: § 87 para. 1b SGB V, Bundesmantelvertrag (BMV-Ä): Annex 27 and 30, EBM Chap. 37 “Particularly qualified and coordinated palliative medical care”, EBM chap. 33 general care by contract physicians without an additional designation in palliative medicine].
2. Additional services such as the individual palliative care measures that can be provided by home health care such as wound care and other individual measures, and a complex code introduced in 2017. The name of the complex service 24a is “Symptom control in palliative patients”. This includes all treatment care services that become necessary in case of need in a complex symptom event and also includes crisis intervention in close consultation with the prescribed contract physician.
[Source: Guideline of the Joint Federal Committee on Home Nursing (HKP Guideline), § 37 SGB V] .
3. SAPV (spezialisierte ambulante Palliativversorgung) as specialized outpatient palliative care, which is intended for patients who require particularly complex care if there are indications of a complex symptom occurrence, the treatment of which requires specific palliative medical and/or palliative nursing knowledge and experience as well as an interdisciplinary coordinated concept. SAPV is provided by a specially designated SAPV team [Sources: Framework recommendations SAPV for adults (as of 2021), SAPV guideline of the Federal Joint Committee, § 37b SGB V, § 132d SGB V)].
4. Outpatient hospice work and inpatient hospice care [Source: § 39a SGB V, framework recommendations of the health insurance funds and service providers].
5. Special offers for female patients in licensed nursing homes and facilities of integration assistance for disabled people concern “health care planning for the last phase of life”. This includes an extensive consultation of the patient and the relatives in relation to the medical and nursing care and care in the last phase of life; possibilities of the assistance and offers are to be pointed out in the context of one or more case discussions. The patient's wish for end-of-life care should also be addressed and emergency situations discussed in advance. The attending physician is to be involved.
[Source: § 132 g SGB V, Hospice and Palliative Act].
Treatment of special symptoms
Patients with endometrial carcinoma often have a high symptom burden even in the locally advanced stage. Bowel obstruction/constipation, urinary retention, fistula formation, vaginal discharge and/or genital bleeding, cloacal formation and depression and fatigue are common [883].
Constipation and Malignant Intestinal Obstruction (MIO).
Regarding specific therapeutic procedures, please refer to the article “Palliative Concepts in Ovarian Cancer” [883] and to Chapters 13 and 14 of the expanded S3 Guideline “Palliative Care with a Non-curable Cancer” of the Oncology Guideline Program (S3 Guideline Palliative Care).
Fistula formation
Fistula tracts can develop especially between the vagina and the intestine (enterovaginal fistula) and between the vagina and the urinary bladder (vesicovaginal fistula). They are either tumor-related due to invasive growth, but can also be therapy-related, e.g. postoperative or after radiation therapy [883]. Fistulas to the bladder or into the bowel are particularly distressing for patients because of the incontinence for urine or stool they cause. Surgical repair by means of fistula closure is not possible in most cases or is not advisable because of the high risk of recurrence. In patients with a life expectancy of days to weeks, symptom-based care with pads, incontinence pants or catheters is reasonable [883]. If a longer life expectancy of months to years is anticipated, permanent diversion through an anus praeter or urinary diversion should be discussed with patients. In view of the foreseeable negative effects of long-term incontinence as a result of the fistula, patients should be empathetically relieved of the fear of the expected limitations on quality of life caused by artificial urinary or fecal diversion. The reference to the modern, odorless and securely connectable systems is decisive for acceptance.
Vascular erosion
Bleeding due to tumor ingrowth into adjacent vessels is potentially life-threatening for the patient. In the acute situation, usually only local compression with immediate vascular surgery is possible. In cases of insidious onset with permanent oozing bleeding, both local radiation and targeted angiographic embolization may be considered. Both approaches are equivalent in terms of local control, but usually of short efficacy without additional antineoplastic therapy, which is usually not indicated in the advanced palliative situation [883]. In patients in good general condition with sufficiently assessed life expectancy, targeted surgical coverage should also be considered.
Genital bleeding
Genital bleeding may be an expression of local recurrence, metastasis or – more rarely – due to tumor penetration into the vagina. Small foci of bleeding can be well controlled in the short term with local application of silver nitrate or Monsel solution. Tight tamponade may also be useful, as well as local radiation therapy as brachytherapy, or small-volume percutaneous if necessary. In some circumstances, the use of a laser for coagulation may also be useful. If life expectancy is prolonged, palliative hysterectomy or colpectomy may also be offered to control bleeding [883].
Vaginal discharge
Permanent foul-smelling vaginal discharge is mostly caused by tumor necrosis and/or infection and means an immense restriction of the patient's quality of life. Even a small amount of discharge affects the well-being and partnership. If the symptoms are pronounced, shame, disgust and also odor-related environmental reactions such as exclusion or rejection are added. With longer life expectancy – if not already done – simple hysterectomy is the treatment of choice. Radiation is a good alternative to the purely symptom-oriented approach. In mild manifestations, local sitz baths with antiseptic substances for local cleansing are also helpful and possible ([883]. Since colonization with anaerobes is mostly responsible for the odor, low doses of metronidazole can also be used intermittently to reduce the odor ([883], [723]).
Since resistance and resistance developments must also be taken into account in the palliative situation; antibiotic therapy should be calculated, i.e., the selection of the antibiotic is based on the most probable pathogens. Systemic antibiotic administration, for example with metronidazole (* off-label use), reduces the number of anaerobic germs, especially in the deeper wound layers, which cannot be reached with germ-reducing products. The recommendation is three times daily 400 mg orally or 500 mg i. v. (for 14 days). If necessary, treatment can be longer (“low-dose antibiotic therapy” 200 mg 2 times daily), depending on the patient's current situation, remaining lifespan and the burden of odor on the patient and his relatives ([723]).
Urinary retention
Compression of one or both ureters up to complete obstruction is also a frequently encountered symptom in endometrial carcinoma [883]. Due to the outflow obstructing compression, infections of the urinary tract occur frequently. In the course of the disease, the retention parameters increase up to uremia in case of complete obstruction. Death from uremia is painless and in the vast majority of cases means peaceful sleep. In patients with a very short prognosis, the indication for urinary diversion should therefore be very strict, since death from a cloaca usually means a much more symptom-laden course of death. If life expectancy is longer, urinary diversion is a highly effective and efficient measure. With existing patency of the ureters, the double J catheter is available. Apart from occasional pressure or foreign body sensation and the need for regular checks and changes with appropriate visits to the doctor, no restrictions are to be expected. The risk of infection is only marginally increased; there is no indication for antibiotic prophylaxis.
In case of a complete occlusion of the ureters or tumor-related locally increased risk of bleeding, percutaneous nephrostomy is a good option. This can be performed unilaterally or bilaterally. Similar to fistula treatment, empathic education and guidance is essential for acceptance. The modern odor-proof and tightly adherent drainage bags, if handled well, usually mean hardly any restrictions on the quality of life [883]
Tumor-related cloacal formation
Cloaca is the most serious specific palliative care problem. Tumor-related infiltration of the bladder and rectum creates a common excretory tract with no possibility of voluntary control of excretion. Constant urinary and fecal incontinence as well as additional infectious or necrotic foetid discharge massively limit the quality of life. In addition to the physical problems, the patients also suffer massive psychological problems, since in many cases this situation causes complete exclusion from the personal and nursing environment. Early phases of cloacal formation are to be treated in the same way as fistula treatment. Artificial stool and urine diversion, if necessary in combination with palliative radiotherapy, can provide relief. These measures are also often suitable in the presence of distant metastases to alleviate the stressful effects of cloacal formation and to achieve a significant short-term improvement in the quality of life for patients. Nursing measures such as pads, incontinence pants or catheters inevitably quickly reach their limits. Helpful advice can be found in Chapter 15 “Wound care” of the extended S3 Guideline “Palliative care with a non-curable cancer” of the Oncology Guidelines Program (AWMF register number 128/001OL, version 2.1 - January 2020 (S3 guideline palliative care).
Depending on the overall situation, exenteration with palliative intent for symptom control may also be reasonable. The usefulness and feasibility of such a measure should be carefully discussed and weighed with the patient, especially in the palliative situation. In individual cases, such operations may even lead to a prolongation of life and provide a better starting point for other palliative therapy options. In the discussion, the patient's level of suffering is the decisive factor and an individual consideration of the lethality of the operation and the massive burden of cloacal formation is necessary [883].
11.4 Rehabilitation
Medical-oncological rehabilitation serves the specific treatment of disease and therapy sequelae. All patients with endometrial carcinoma shall be informed and advised about the legal options for applying for and receiving rehabilitation services.
- Consensus
- Strong consensus
Therapy-related disorders, such as abdominal wall and adhesion discomfort, sexual dysfunction, pain during intercourse, vaginal dryness, urinary bladder and bowel dysfunction shall be inquired about and treated not only during primary therapy but also during rehabilitation and follow-up.
- Consensus
- Strong consensus
Before rehabilitation
All patients are to be informed and advised in detail about the legal options for follow-up rehabilitation, curative treatment and outpatient rehabilitation offers. For this purpose, the respective attending physician and social worker are to work together. The rehabilitation ability results from a positive motivation of the patient and the physical and psychological ability to use the offered rehabilitation programs in a goal-oriented way.
The need for rehabilitation in the somatic and psychosocial area results from the determination of the disease and treatment sequelae with orientation to classification principles of the ICF classification of the WHO (2001). These can be differentiated in more detail into functional disorders, ability disorders, impairments as well as context and risk factors and can also be coded.
Accordingly, the assessment of the need for rehabilitation (e.g., in the application process) requires consideration of bio-psycho-social impairments in addition to bio-medical health problems.
Rehabilitation is carried out on an inpatient or outpatient basis, if necessary as a mixed form, but always in an interdisciplinary and multimodal approach.
Aims of rehabilitation
Oncological rehabilitation is the next therapeutic step for patients with endometrial carcinoma after completion of primary therapy in order to return to everyday family, social and professional normality.
The overall global goal of oncological rehabilitation is the regaining of physical, mental and social well-being. In the case of chronic disease sequelae, support and care are provided to help patients accept or compensate for unavoidable disabilities and discomforts, and to help them lead their lives again to their own satisfaction.
The aim of oncological rehabilitation is to significantly improve or restore a significantly endangered or already reduced ability to work, or at least to prevent a deterioration.
The aim of oncological rehabilitation is to avoid the need for care or to postpone the need for care.
Overcoming physical, psychological and social consequences
Oncological rehabilitation is carried out in a multidisciplinary setting based on ICF and a bio-psycho-social model:
- Diagnosis of the sequelae of cancer and therapy
- Preparation of an individual rehabilitation plan
- Multidisciplinary treatment of specific sequelae, e.g. local sequelae due to surgery or radiotherapy or due to estrogen deficiency, dyspareunia, lower urinary tract or bowel disorders, lymphedema or chronic tumor-associated fatigue syndrome
- Sports and physical therapy training program to increase strength and conditioning and to overcome or compensate for specific sequelae
- Physical therapy, provision of aids
- Occupational therapy
- Psycho-oncological services with individual and group sessions, relaxation techniques, creative therapies
- Social counseling on professional, domestic, family or social situation
- Provision of information on the disease and on healthy lifestyles
- Motivation and training for a healthy lifestyle and for dealing with illness and health independently
Professional assistance
Sequelae caused by endometrial carcinoma and the antitumor therapies carried out can have an adverse effect on occupational performance. After cancer, there is a higher risk of unemployment, job change, reduction in hours and lower pay.
An important task of oncological rehabilitation is to help compensate for these disadvantages and risks:
- Is the rehabilitant's performance capacity sufficient to meet the demands of the workplace in the medium term?
- Can the rehabilitant continue to perform her job to the same extent as before?
- Does the rehabilitant need equipment for the workplace that is appropriate to her condition?
- Is it necessary to change jobs within the company?
- Does the rehabilitant need services for participation (e.g. further vocational training)?
- Is the rehabilitant's ability to perform at work suspended?
Oncological rehabilitation is suitable to competently support patients on their way back to working life. In doing so, it does justice to the mandate from the Basic Law “No one may be disadvantaged because of their disability” (Art. 3 Para. 3 Sentence 2 GG) and the Social Code lX “Right to participation”.
In the medical discharge report of the rehabilitation clinic, a socio-medical performance assessment is prepared for patients who are of working age, which, in addition to assessing the previous activity profile, also refers to the capacity for the general labor market.
Evidence
Many therapeutic measures in oncological rehabilitation are provided on the basis of scientifically proven effectiveness. For methodological reasons, corresponding studies are usually conducted with the frequent diagnoses of breast cancer, prostate cancer and colorectal cancer. Evidence has been described for the effects described below; we consider the analogy to patients with endometrial carcinoma to be appropriate:
- Exercise therapy: improve fatigue symptoms, increase exercise capacity and physical functionality, improve body image, decrease depression, improve quality of life (a)
- Patient education: reduction in physical symptoms, improvement in quality of life, improvement in mood (b)
- Health education: decrease uncertainty, increase quality of life, improve well-being (c)
- Nutrition education practical: intentional weight loss through practical intervention (d)
- Psychological counseling and therapy: improvement quality of life, improvement fatigue and stress, improvement anxiety and depression (f)
- Relaxation training: reduction of pain, improvement of quality of life, reduction of anxiety and depression (e).
Payment and legal basis
Rehabilitation services are services for participation, which can be paid for by a rehabilitation provider (e.g. German pension insurance, statutory health insurance, statutory accident insurance). In the field of oncological rehabilitation, the pension insurances are the service providers with the most frequent responsibility. According to German social legislation, disabled people or people at risk of disability receive rehabilitation services to promote their self-determination and equal participation in life in society, and to avoid or counteract disadvantages. The services are provided by the responsible rehabilitation provider in accordance with the Ninth Book of the German Social Code (SGB) and the benefit laws applicable to the respective rehabilitation provider (for example, SGB V in the case of SHI or SGB VI in the case of DRV).
Bio-psycho-social model
The bio-psycho-social understanding of illness is a prerequisite in medical and professionall rehabilitation for the initiation (including application/report) as well as for the (therapeutic) content of the rehabilitation and planning of the individual rehabilitation goals. The rehabilitation providers implement the recommendation of the WHO to apply the International Classification of Functioning, Disability and Health (ICF) in the field of health care.
ICF
The ICF complements the International Statistical Classification of Diseases and Related Health Problems (ICD) where the focus is not on the diseases (diagnosis and findings) themselves, but includes associated impairments in, among other things, earning capacity, mobility, communication, self-care, home life or participation in social life.
11.4.3 Treatment of Cancer-related Fatigue
Endometrial cancer patients should be informed about tumor-associated fatigue and screened systematically and repeatedly during the different treatment phases. Screening according to NCCN is recommended.
- Consensus
- Strong consensus
If there is a value > 3 in the screening, there should be a diagnostic assessment for further clarification and specific advice on fatigue management and treatment if needed.
- Consensus
- Strong consensus
For moderate or severe fatigue, moderate strength and endurance training should be provided based on physical performance level.
- Recommendation grade
- B: Empfehlung für oder gegen eine Maßnahme - verwendete Ausdrucksweise = sollte/sollte nicht
- Level of evidence
- 2
Guideline adaptation S3-guideline palliative care
- Consensus
- Strong consensus
- References
- [723]
Psychoeducation or cognitive behavioral therapy should be offered for moderate or severe fatigue.
- Recommendation grade
- B: Empfehlung für oder gegen eine Maßnahme - verwendete Ausdrucksweise = sollte/sollte nicht
- Level of evidence
- 2
Guideline adaptation S3 guideline palliative care
- Consensus
- Strong consensus
- References
- [723]
For moderate or severe fatigue, mindfulness-based stress reduction (MBSR) and yoga can be offered.
- Recommendation grade
- 0: offene Empfehlung (Option) bzgl. einer Maßnahme - verwendete Ausdrucksweise = kann
- Level of evidence
- 1
Guideline adaptation S3 Guideline Complementary Medicine
- Consensus
- Strong consensus
- References
- [884]
Yoga should be recommended to reduce fatigue in these patients.
- Recommendation grade
- B: Empfehlung für oder gegen eine Maßnahme - verwendete Ausdrucksweise = sollte/sollte nicht
- Level of evidence
- 1
Guideline adaptation S3 Guideline Complementary Medicine
- Consensus
- Strong consensus
- References
- [884]
Fatigue is a common consequence of cancer and therapies, in the treatment phase 70-90% of all patients are affected, in one third the symptomatology persists after years ( Extended S3 Guideline Palliative care for patients with a non-curable cancer long version 2.2 – September 2020, AWMF register number: 128/001OL https://www.leitlinienprogramm-onkologie.de/leitlinien/palliativmedizin/.
The NCCN defines tumor-associated fatigue as “a worrisome, persistent, subjective feeling of physical, emotional, and/or cognitive fatigue or exhaustion related to tumor disease or tumor treatment that is unrelated to current activities and interferes with usual functioning” [885].
To identify tumor-associated fatigue, NCCN [885] suggests a screening tool that is used to assess the subjective degree of fatigue experienced on a numerical scale ranging from 0 (no fatigue) to 10 (most severe fatigue). For patients older than 12 years, a score between 0 and 3 is considered as no or mild fatigue, between 4 and 6 as moderate fatigue and between 7 and 10 as severe fatigue.
There are ESMO guidelines [886] as well as NCCN guidelines on cancer-related fatigue and specific aspects of fatigue are also addressed in various German-language guidelines, e.g., in great detail in the S3 Guideline Palliative Medicine (https://www.leitlinienprogramm-onkologie.de/leitlinien/palliativmedizin/) and in the guideline Complementary Medicine in Oncological Patients (https://www.leitlinienprogramm-onkologie.de/leitlinien/komplementaermedizin/). A separate guideline or a comprehensive separate chapter, e.g. in the Guideline Supportive Therapy in Oncological Patients, does not exist at present.
In the various guidelines, different treatment elements in the management of fatigue can be found:
- Information and education
- Systematic and repeated screening (with validated instruments)
- Diagnostic assessment (focused history, identification of other influenceable physical, psychological and social factors that can lead to fatigue; treatment/influence of these factors)
- Counseling and treatment services for the management of fatigue.
11.4.1 Physiotherapeutic treatment in the context of rehabilitation after endometrial carcinoma
The physiotherapeutic part of the aftercare focuses on the treatment of various side effects of cancer therapy (surgery, radiation or chemotherapy). This includes therapy of incontinence (ICD-10 codes see below), lymphedema (here: of the lower extremities: ICD-10 I89.0) [1] to interventions to alleviate fatigue syndrome (ICD-10 G93.3) [1].
Treatment of gynecologic tumors by surgery or radiation therapy may result in pelvic dysfunction. These are symptoms of urinary incontinence (urge, stress and mixed) (ICD-10 N39.42, N39.3, N39.48) [1] and fecal incontinence (ICD-10 R15) [1], pain, dyspareunia (N94.1) [1] (e.g. due to shortened or scarred vagina), circulatory changes or lack of elasticity of scar tissue.
Various physiotherapeutic passive (scar mobilization, stretching of vaginal tissue, positioning, complex physical decongestive therapy, etc.) and active techniques (instruction in low-pain everyday behavior, circulatory gymnastics, decongestive exercises, measures of exercise therapy and forms of training) can reduce these disorders.
11.4.2 Incontinence therapy
11.4.2.1 Urinary incontinence
Patients with stress urinary incontinence and/or fecal incontinence should be offered pelvic floor muscle training after endometrial cancer.
- Consensus
- Strong consensus (100%)
Background
In the treatment of urge incontinence, various forms of therapy such as bladder training, pelvic floor muscle training and educational measures show good results, which are quite comparable to drug treatment [887], [888], [889]. Another option in the treatment of urge incontinence could be treatment with functional electrical stimulation [889], [890].
With regard to stress incontinence, pelvic floor training remains the treatment of choice [891], [892], [893]. Pelvic floor training is particularly effective for stress and mixed incontinence and especially for women under 60 years of age [894]. In addition, there is evidence that supervised training is more successful than when training is done independently [892]. If supportive forms of therapy are used in addition to pelvic floor training after appropriate diagnostics, such as device-supported biofeedback or electrostimulation, these can reinforce the pelvic floor training [895], [896].
There is strong evidence for anal sphincter or pelvic floor training in the treatment of fecal incontinence [897], [898]. Whether the additional use of biofeedback and electrical stimulation show better results than pelvic floor training alone is unclear [897], [898].
11.4.3 Lymphedema therapy
If lymphedema is manifest, patients should be offered therapy after endometrial cancer according to the “S2k Guideline Diagnostics and Therapy of Lymphedema (AWMF Reg. No. 058-001) May 2017”.
- Consensus
- Strong consensus
Background
Extensive removal of lymph nodes in pelvic or additionally para-aortic localization or radio(chemo)therapy alone or adjuvant with different target volumes may lead to lymphedema in the lower extremities. Data on prevalence vary widely. This is due to the different therapies and also times of inventory.
Long-term observations show an increase even 10 years after therapy [899]. The diagnosis of lymphedema is made by a precise clinical examination using the “skin fold test according to Stemmer” (lifting of tissue between thumb and index finger), which is always performed in a lateral comparison. With the aid of a tape measure, the circumference of the legs can be measured in a standardized manner over time. It makes sense to always measure at the same points on several parts of the lower and upper thighs and without pulling on the tape measure. The date and time of day should also be noted, since edema fluctuates throughout the day or depending on the season (summer/winter). (S2k Guideline “Diagnostics and therapy of lymphedema”, May 2017, AWMF register number: 058-001 http://www.awmf.org/leitlinien/detail/ll/058-001.html).
Both legs should be measured already before surgery as initial findings and regularly thereafter. Oncological follow-up appointments, for example, offer favorable measurement times. Studies on the treatment of lymphedema of the lower extremities are very unsatisfactory. However, experience from breast cancer research in lymphedema of the upper extremities can be used and these data extrapolated. Combined physiotherapy (complex physical decongestive therapy) consisting of skin care, manual lymphatic drainage, exercise therapy and compression is the most appropriate treatment method here [900].
Twice weekly therapy frequency is recommended in the initial stage and once weekly therapy frequency is recommended in the chronic stage. The exercise program does not increase risk, but has a positive effect on mobility and quality of life [901], [902]. For the permanent volume reduction of lymphedema, compression (bandages or stockings) as well as laser therapy are particularly suitable [903], [904]. Laser therapy is hardly used in Germany. Compression with bandages seems to be more effective than pneumatic compression. Kinesio tape can be an alternative to conventional bandages, but is associated with increased costs [905]. There is currently no evidence for the effectiveness of manual lymphatic drainage as edema prevention.
Evidence tables
Test123
| Clement, N. S. et al. Metformin for endometrial hyperplasia. Cochrane Database Syst Rev. 10. Cd012214. 2017 | ||||
|---|---|---|---|---|
| Evidence level/Study Types | P - I - C | Outcomes/Results | Literature References | |
| Evidence level: 1 Study type: Systematic review and meta-analysis (3 studies) To determine the effectiveness and safety of metformin in treating women with endometrial hyperplasia. Databases: Cochrane Gynaecology and Fertility Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), PubMed, Google Scholar, OpenGrey, Latin American Caribbean Health Sciences Literature (LILACS), and two trials registers . We searched the bibliographies of all included studies and reviews on this topic. We also handsearched the conference abstracts of the European Society of Human Reproduction and Embryology (ESHRE) 2015 and the American Society for Reproductive Medicine (ASRM) 2015. Search period: Inception to 01/2017. Inclusion Criteria: Randomised controlled trials (RCTs) and cross-over trials comparing metformin (used alone or in combination with other medical therapies) versus placebo or no treatment, any conventional medical treatment, or any other active intervention for women with histologically confirmed endometrial hyperplasia of any type. Exclusion Criteria: Not meeting inclusion criteria. |
Population: We included women with histologically confirmed endometrial hyperplasia of any type. Intervention: Metformin. We also included trials that provided co-interventions (e.g. metformin plus progesterone vs progesterone), but we planned to analyse results of these studies separately. Comparison: with placebo or no treatment, conventional medical treatment (typically progestogens, e.g. oral or intrauterine), or any other active intervention |
Primary: 1. Regression of endometrial hyperplasia histology (with or without atypia) towards normal histology Secondary: 2. Recurrence of endometrial hyperplasia 3. Progression of endometrial hyperplasia to endometrial cancer 4. Hysterectomy rate 5. Abnormal uterine bleeding 6.Health-related quality of life, as reported in the included studies 7. Adverse effects during treatment, as reported in the included studies. Results: Only summary results described here, due to length. Study overview: 3 RCTs were included in which a total of 77 women took part. We rated the quality of the evidence as very low for all outcomes owing to very serious risk of bias (associated with poor reporting, attrition, and limitations in study design) and imprecision. Results: We performed a meta-analysis of two trials with 59 participants. Whenmetformin was compared with megestrol acetate in women with endometrial hyperplasia, we found insufficient evidence to determine whether there were differences between groups for the following outcomes: regression of endometrial hyperplasia histology towards normal histology (odds ratio (OR) 3.34, 95% confidence interval (CI) 0.97 to 11.57, two RCTs, n = 59, very low-quality evidence), hysterectomy rates (OR 0.91, 95% CI 0.05 to 15.52, two RCTs, n = 59, very low-quality evidence), and rates of abnormal uterine bleeding (OR 0.91, 95% CI 0.05 to 15.52, two RCTs, n = 44 , very lowquality evidence). We found no data for recurrence of endometrial hyperplasia or health-related quality of life. Both studies (n = 59) provided data on progression of endometrial hyperplasia to endometrial cancer as well as one (n = 16) reporting some adverse effects in the metformin arm, notably nausea, thrombosis, lactic acidosis, abnormal liver and renal function among others. Another trial including 16 participants compared metformin plus megestrol acetate versus megestrol acetate alone in women with endometrial hyperplasia.We found insufficient evidence to determine whether there were differences between groups for the following outcomes: regression of endometrial hyperplasia histology towards normal histology (OR 9.00, 95% CI 0.94 to 86.52, one RCT, n = 16, very low-quality evidence), recurrence of endometrial hyperplasia among women who achieve regression (OR not estimable, no events recorded, one RCT, n = 8, very low-quality evidence), progression of endometrial hyperplasia to endometrial cancer (OR not estimable, no events recorded, one RCT, n = 13, very low-quality evidence), or hysterectomy rates (OR 0.29, 95% CI 0.01 to 8.37, one RCT, n = 16, very low-quality evidence). Investigators provided no data on abnormal uterine bleeding or health-related quality of life. In terms of adverse effects, three of eight participants (37.5%) in the metformin plus megestrol acetate study arm reported nausea. Authors’ conclusions Author's Conclusion: Implications for practice: Review authors found insufficient evidence to support or refute the use ofmetformin given alone or in combination with standard therapy, specifically megestrol acetate, for treatment of women with endometrial hyperplasia. |
3 studies included: Shan 2014, Sharifzadeh 2016, Tabiriz 2014. |
|
| Methodical Notes | ||||
| Funding Sources: Internal sources • No sources of support, UK. External sources • No sources of support, UK. COI: Declared, see article. Study Quality: Study quality was evaluated by Cochrane risk of bias tool and the overall quality of evidence was evaluated using GRADE. "Using GRADE, review authors determined that the evidence was of very low quality both for the main comparison of metformin versus megestrol acetate and for the additional comparison of metformin plus megestrol acetate versus megestrol acetate alone. For both comparisons, we downgraded the quality of evidence owing to very serious risk of bias (associated with poor reporting, attrition, and limitations in study design) and imprecision as major factors. All studies had very small sample sizes, especially when assessing relatively rare events such as progression of endometrial hyperplasia to endometrial cancer. Confidence intervals were compatible with a large effect in one or both groups, or with a null effect." Heterogeneity: We assessed statistical heterogeneity using themeasure of I². We considered an I² greater than 50% to indicate substantial heterogeneity. No significant heterogeneity present in the analyses. Publication Bias: Planned but not executed due to feasibility, due to n<10. "We planned that if we included 10 ormore studies in a single analysis, we would use a funnel plot to explore the possibility of small-study effects" Notes: |
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