Hi, I'm Dr. Sarah Huang. I'm here today with Dr. Megan Clark and Dr. Sonal Oza, and we're going to be discussing the physiatric approach to gynecologic cancers. I'm going to start off our session today by talking a little bit about the pelvic floor to give you all a little bit of background so that we can build later on the session on these concepts. So I'm going to review the pelvic floor anatomy as well as discuss pelvic floor function and pelvic floor dysfunction. Pelvic floor anatomy. So the pelvic floor is the fascia and muscles of the pelvis that support the bladder, uterus, and rectum. The pelvic floor muscles are a striated group of muscles arranged in a dome-shaped sheet, and these muscles are typically thought of as a sling. There's three layers of muscle. Layer one is the superficial layer, and the major function of that layer of muscles is sexual function. These muscles also play a minor role in support and incontinence. The layer two is the layer that is the middle layer of the three muscles, and these muscles are important for control of urinary and bowel function. These muscles are mostly sphincter muscles, and we'll focus less on this on this layer today. The third layer of muscles, which is the deep muscles, are a very important group of muscles for support as well as for maintaining continence. So as I mentioned before, layer one is a superficial perineal layer. These are the superficial pelvic floor muscles and contain ischiocavernosis, bulbospongiosis, and the superficial transverse perineal muscles. Layer three is the pelvic diaphragm layer or the deep layer of the pelvic floor muscles. I'm not going to go through this table in great detail, but this is a table from Eckmeyer's article, and I have that. I'm sorry, I forgot the link on the bottom here, but I do have that on other slides if you want to look it up or use this as a reference. But again, the layer three of the pelvic diaphragm is composed of levator ani and coccygeus muscles. Levator ani is further broken up into three muscles, which you see labeled here as one, two, and three. Layer one is the puborectalis muscle, layer two is a pubococcygeus muscle, and layer three, that triangle muscle on the side there, is iliococcygeus. And again, these three muscles together combine to make levator ani muscle. Number four on this diagram is the obturator internus muscle. Number five, another triangular muscle, is the coccygeus muscle, and number six is a piriformis muscle. So the lateral wall of the pelvic floor is really formed by obturator internus and the piriformis muscle. So I want to talk about pelvic floor dysfunction, but I think an important thing to know before we talk about dysfunction is what the function of the pelvic floor actually is. So the pelvic floor has five major roles. The support of the internal organs structurally, which I'm going to talk a little bit more about. The pelvic floor muscles are also known as the floor of the core. So these are really important stabilizing muscles. These muscles are also important for maintaining continence, sexual function, as well as circulation as these muscles help with the drainage of lymphatic system in the pelvis. So when we talk about pelvic floor function, we're talking about the coordinated contraction and relaxation of these muscles. Active support is maintained through a constant state of muscular contraction, while passive support comes from the surrounding connective tissue and fascia. An increase in intra-abdominal pressure can lead to the pelvic floor muscles reflexively contracting and causes closure of the vagina and urethral and anal sphincters. Relaxation occurs briefly and intermittently during the process of normal micturition and defecation. Micturition occurs when the bladder detrusor muscles contract, the urethral sphincter relaxes through involuntary autonomic nervous control, and the pelvic floor muscles voluntarily relax. This mostly occurs with the pubococcygeus muscle. These three things will lead to micturition. With defecation, the anal sphincter and the puborectalis muscles simultaneously relax, which causes the opening of the recto-anal angle and allows for feces to pass. So if you look at the picture below, that is a picture of the puborectalis muscle. The puborectalis muscle is a u-shaped muscle that when at a resting state is actually contracting. And because of this contraction, it's causing the angle in the recto-anal junction. This constant state of contraction of the muscle and thus the angle allows prevents the passage of stool at times when Okay, so sexual function is another important part of the pelvic floor that I mentioned previously. This is coordinated by the pelvic floor muscles, the genitalia, and the autonomic nervous system. During the excitement phase, the physiological and physical factors initiate arousal, cause a generalized vasocongestion, and lubrication of the vaginal anterior. During orgasm, the pelvic floor muscles, anal sphincter, and uterus all undergo repeated quick muscle contractions. So when we talk about pelvic floor dysfunction, there are a number of reasons that can lead to pelvic floor dysfunction. One of those is to gynecological cancers and their treatment. Okay, so that includes radiation, surgery, various medications, as well as poor mobility. So what does it mean when we talk about pelvic floor dysfunction? It just means that the muscles are not working as they should, and so a lot of those functions that I previously mentioned can be altered. So when we have a non-contracting pelvic floor or a weak pelvic floor, that can result in incontinence, a baller bladder, as well as pelvic organ prolapse. When we talk about a non-relaxing pelvic floor or a high-tone pelvic floor, that can result in pain, dyspareunia, constipation, as well as some urinary symptoms, including frequency and urgency. Oftentimes, what we'll see is a combination of the two, where we see a non-contracting and non-relaxing pelvic floor, and so the patients may have some combination of what I mentioned previously, such as pain and incontinence. So when we talk about pelvic floor dysfunction, this can lead to a lot of issues, which we'll get into later in our session, including urinary and fecal incontinence, pelvic organ prolapse, urinary frequency and urgency, defecatory dysfunction or chronic constipation, sexual dysfunction, chronic pelvic pain, and coccydynia. I also just want to mention, to close us out, that we will be discussing gynecologic cancers today, but it's important to note that the concepts that we're talking about really hold true for other pelvic and abdominal cancers as well, specifically colorectal cancer and some of the urologic cancers. So keep that in mind as you're listening to the rest of the session. Thank you, and I'm going to turn it over to Dr. Clark, who's going to go into a little bit more detail about gynecologic cancers. Thank you, Dr. Wong. So like she had mentioned, we'll talk a little bit more about some of the specific cancers that can affect this area, as well as some of the treatment modalities that we use for those cancers, and then we'll kind of transition into how those different functions function through this also. So as we work through those genital system cancers, kind of the presentation and then treatment modalities also. So in gynecologic cancers, and also to include pelvic cancers, they actually make up a pretty big chunk of the total cancer pie. So in this busy slide, we're looking at more of all of the major types and kinds of cancers that are diagnosed and the estimated cancers for this year alone. As you can see, we're nearing 2 million new cancer cases every year. If we group these up and we look at those individual cancers as kind of systems, obviously for women, breast cancer being the most prevalent, but for genital system cancers in women, we have over 100,000 new cases just this year alone. And then when we look at the male population, there are over 200,000. Now for men, their number one is prostate cancer, which makes up about 94% of this number, but still a fairly large number of new diagnoses. So of the genital system cancers, so a little bit more drawn out, we'll talk about each of these in particular. So endometrial or uterine cancer is the most common GYN malignancy that we'll see in the U.S. in our women, and this can involve any layer of the uterus, but most commonly we'll see this involving the endometrium. So because it involves the endometrium, those patients will typically present with bleeding either between periods or any kind of bleeding after menopause will lead to the thought of this. There can also be pelvic pain associated with this as well. And risk factors for this population, obviously any kind of hormonal imbalance. So if there is increased estrogen, they're at a higher risk, which also ties to obesity as a risk factor. Tamoxifen can be a risk factor for development of endometrial cancer, and tamoxifen is one of the adjuvant treatments that we'll use commonly in breast cancer. So it's one of the reasons we continue to screen for pelvic cancers in our breast cancer population. Also, the pregnancy state and then any extra years add some risk to development of endometrial cancer. In the patients who are diagnosed with endometrial cancer, surgical treatment is typically used. In some cases, it'll be a complete hysterectomy and they'll also take out the oophorectomy as well. Lymph nodes can be removed in these surgeries also, and sometimes in some of the higher risk patients, we'll also use radiation therapy. We'll talk a little bit more about radiation therapy coming up. Women may use chemotherapy as well for their treatment. The other type of common cancers we'll see in women is cervical cancer. Now for the US, it's about 13% of GYN cancers, but this is the most common GYN cancer worldwide. And actually, this is the third most common cancer worldwide. Typically we attribute this to the HPV virus or the human papillomavirus, and we see it in younger populations because of that also. In those younger populations, early cases are usually asymptomatic, but if we can catch it early, we can usually just treat this surgically. So surgically, usually we'll do some sort of simple partial removal or a simple hysterectomy. But as those cases advance, you can kind of see through the pictures there, we'll develop more radical hysterectomies or lymphadenectomies will be required. Advanced cases will also require usually some type of radiation therapy plus or minus some adjuvant chemo with it. Typically that chemo and radiation combined is preferred because it does typically improve overall survival and will reduce local recurrence. Of course, for the cervical cancer and with some of the other cancers we'll see too, it's a public service announcement for the HPV vaccine because we are seeing increased cancer rates. So the HPV vaccine, especially for cervical cancer, is particularly important. So there's your public service announcement for the day. Ovarian cancer, less commonly seen in the U.S., but usually more severe when it is caught because these cases are typically asymptomatic early on. And so by the time we see these patients in clinic and by the time they're diagnosed, they already have advanced disease and it leads to higher morbidity and mortality rates. For this, we're doing a larger debulking surgery, again, because of that advanced metastatic disease. We're also using more chemotherapy. So a lot of the platinum-based chemo regimens will be used with this. But even with that and even with the larger surgeries that are used, there's still a very high relapse rate, obviously, because of that metastatic spread. Fulvar cancer, this makes up about 5% of GYN malignancies. This used to just be seen in older women, but again, with the HPV prevalence, we're seeing it in younger women more often. This is a primary surgery. It usually requires some type of groin dissection, which is a difficult surgery. It's a difficult area to heal. And so the surgical treatment can be very difficult, oftentimes requires some lymph node removal locally as well, and potentially some chemo radiation if there are unresectable or some locally advanced disease that we'll see with this. Not to leave out the boys, prostate cancer through this region, obviously very common. So while we'll see this very typically, treatment is variable. So depending on age, because of its slow progression, and or if it's a less aggressive tumor, we can kind of change and individualize our treatment plan a little bit. So for the over 75 age range and a less aggressive tumor, a lot of times we'll just kind of have some active surveillance, but in the younger group, so under 65, we'll usually look at radical prostatectomy. Sometimes if the disease becomes more advanced, so if it's a more aggressive tumor or there is some local advanced disease, we'll use some hormonal therapy as well as chemotherapy and radiation therapy. So we talked to some about the most common cancer types, and I briefly mentioned what their treatment modalities might be, but let's talk a little bit more about those treatment modalities themselves. Because as wonderful as, as these treatments are, and as good as we've gotten at killing cancer cells, sometimes their side effects are equally brutal. So chemotherapy, I'm not an artist, but my artist rendition of what chemotherapy does to this normal, happy, healthy person is something like that. Because the side effects and the possible side effects from chemotherapy are endless. These are some of them that are included in some of the common ones that we'll see. But chemotherapy really is just searching out to try to kill the cancer cells before it kills too many of our good, healthy cells. So in our populations, depending on their age, depending on their comorbid medical conditions, depending on what they're coming in with, we can either exacerbate pre-existing problems or we can create all new problems for people. Some of these side effects can improve over time. Some of these, we just have to try to mediate the best we can and try to control symptomatically as best we can. Additionally, when we're talking about some of the treatments, hormonal therapies are often used. So the androgen deprivation therapy, when we're talking about prostate cancer in particular, can help to reduce some of the recurrence, can help to slow spread. But androgen deprivation therapy comes with its own side effects. A lot of fatigue, a lot of loss of libido, the men will talk about erectile dysfunction. Because the problem is, is we all feel better with hormones. Hormones do the body good. And so when we block the problems, this can also be true. And the point like Dr. Wong had made about other cancers than just the GYN cancers leading to pelvic floor dysfunction, in that even our breast cancer patients who are using hormonal therapies as an adjuvant treatment can end up with pelvic related symptoms because of that hormone blockade. So androgen deprivation therapy or any of the hormonal therapies can also contribute to these types of symptoms that we'll see in patients coming in with pelvic floor problems. Additionally, radiation therapy can be used. Now radiation therapy is kind of its own beast in and of itself. But there are different types of radiation therapy that we can utilize. So the brachytherapy is a little bit more targeted treatment, in that we're using seeds or little radioactive sources close to or into the tumors themselves. So we can use this at lower high rate dose rate, but we're using it locally at the source versus some of the other therapy techniques that we think of typically, right? So external beam radiotherapy, where we're just shooting in the general direction, right? The shotgun approach, we're just kind of point and point and aim. And some of our more targeted therapies or image guided therapies that help to kind of conform that radiation around the cancer itself. So in this picture showing the conventional radiation where we're just hitting a huge target versus some of those image guided. So image guided radiotherapy, we're using that more accurate kind of 3D versus 2D targeting to be able to get those areas. This can be further delineated and we can use different modulations to help reduce that extra radiation field. But we're really working to try to target down and reduce that kind of collateral damage that we'll see from our previous just external beam radiation. So obviously the problem being and why we want to target it down, radiation is very effective against cancer cells, but it can be very damaging to the surrounding tissues. So we see this very commonly on the skin. It's easier to see when we think of those general radiation burns, but you have to imagine this isn't just happening at the surface layer of the skin. We're sending these beams all the way through these patients. So the damage that we see in the fibrosis that we see can be very locally affecting, whether that's the bowel causing gas or cramping or diarrhea, it can be bladder irritation. So these patients will have bleeding or hematuria because of bladder or urethral involvement. Vaginal irritation can occur with this. Of course, the skin irritation, fatigue, some of those general topics as well. Lastly, surgical treatments, either talking about, you know, and this showing the variations of just the hysterectomy versus total versus BSO and how much of the system you're taking out versus some of those surgeries we were talking about, larger tumor debulking or groin dissections, lymphadenectomies, obviously causing more difficulty because of wound dehiscence, difficulty healing, large recovery times, and then of course the lymphadenectomy leading to things like lymphedema and some of the other difficulties that can arise from large surgeries. So as we start talking about some of those difficulties that can arise, I will turn over to continue the discussion. All right, so my name is Dr. Oza and so I'll transition this morning's presentation into talking about the role of pelvic floor rehabilitation in what I would call an underutilized service when it comes to gynon survivorship. And so we'll go through common impairments in this patient population, starting with bladder function, followed by bowel function, and then sexual health, and then introduce common clinical interventions, and then specific treatment considerations for this particular patient population, and then conclude with sharing our clinical experience of how we're trying to better capture this population at our individual cancer center. And so we know that women with gynecologic cancers can experience changes in their pelvic floor muscle strength and coordination, as described in the previous two talks, and this can be secondary to surgery, radiotherapy, and those hormonal tissue effects on quality. And so studies have looked at the pathologic changes of the tissue quality, both at the microscopic and gross level, and it has been shown that there are changes that occur in the neurologic function, and then also changes of the surrounding fascia, and then structural changes to the muscle. There was one study that looked at cervical cancer patients and identified changes in muscle strength using manometry, both at resting state and at the contracted state, compared to non-cancer controls. And there's also been identified changes in resistance to passive stretch. So we know that there are structural changes that are occurring at the level of the pelvic floor as a result of multitude of treatment modalities. And so then we go into how does this affect pelvic floor function. And so starting with bladder dysfunction, it's thought that most patients do present more with a stress urinary incontinence picture, and overall the rates of urinary dysfunction are likely higher after radiation therapy, and that will be a common theme, I think, across looking at various types of pelvic floor dysfunction. It's the not-so-funny gift that keeps on giving when it comes to radiotherapy. And looking at specifically the female gynont population, just due to the age of often a time of diagnosis, and a number of individuals already experience some level of bladder dysfunction at baseline, which may or may not be related to the tumor burden. One cross-sectional study identified around 30 to 60 percent of women experiencing symptoms at baseline, and around 20 percent reported these to be moderate or severe. And then, of course, as predicted, urinary dysfunction can certainly worsen after treatment. And so the data presented in the table here is a collection of a systematic review of 31 studies, and they tried to break it down by cervical and uterine cancer. And as you can see here, there is some level of pretreatment urinary dysfunction, and then overall it was thought, or the data does seem to suggest, that the rates of dysfunction do increase, perhaps on the upwards of 40 to 76 percent. But as you can see, there is such a wide range of incidents. I'm perhaps highlighting the the differences in study quality, and making note that most of these studies in this review were actually cross-sectional. And interestingly, a case control study did not find gynecologic cancer to be associated with urinary incontinence. So to summarize that, we do have some evidence, there is some literature, but this area is just so widely underexplored that it's hard to to truly quantify, or to help for us to truly conclude, you know, what are these changes and how do we quantify them. But this is what the research at this time currently suggests. And regardless, I think it's relevant for us as physiatrists, because qualitative work has revealed that women post gynecologic cancers participate less in community-based activities, exercise, and engagement in sexual relationships because of these incontinent symptoms. So recognizing that these impairments are affecting function at both the individual level and in interpersonal relationships. So all the more reason for us to further inquire about the severity, about the bother, and how we can mitigate these symptoms. And so just as bladder function may be affected, bowel function may also be impacted. And again, perhaps seeing this more in those patients that receive radiation therapy. And so this here is data presented from another cross-sectional study that compared individuals that had received only surgery versus those who had received some form of radiotherapy. And on whole, those that had received radiation therapy tended to report a higher frequency of bowel movements and then a higher percentage of diarrhea as well that persisted several months after completing active treatment. And then transitioning to sexual dysfunction, which is probably one of the highest reported unmet needs in this patient population. And sexual dysfunction may be due to a myriad of issues. And this can relate to changes in vaginal length, stenosis of the canal, and then the changes in tissue quality that were previously described, particularly as a result of radiation therapy. And so I'm looking at that some of the most common symptoms do involve dyspareunia. And then oftentimes this might be due to vaginal dryness. And then this data presented here again is from that same systematic review. And they did try again to differentiate between cervical versus uterine cancers and found and identified rates anywhere from 12 to 16 percent of dyspareunia in the cervical cancer population, 7 to 40 percent in the uterine cancer population, and then at least vaginal dryness was reported in cervical cancer anywhere from 16 to 50 percent. So certainly a predominant symptom and anecdotally frequently reported in clinic. And so these there are structural tissue changes that may occur. But then women will also report changes in the kind of sexual function. So the reduction in arousal, inability to achieve orgasm, and then as a result reduced rates of participating in sexual activity. There is one study that compared individuals post gynecologic treatment versus non-cancer controls and found that rates in the control population sexual activity participant patient rates were around 90 percent. And those post cancer treatment reported rates around 50 percent. So certainly a difference between the two populations here. And so how do we as physiatrists manage these impairments? And I would say largely the interventions are similar to our non-cancer population, but there are some considerations. And I think one of the predominating ones is are those changes in tissue quality that occur? And then just how friable the tissue is, particularly again after radiation therapy. There may be a greater role and emphasis on manual therapy to really break up that scar tissue that can present after surgery, but then also after radiation therapy as well. In both surgical and radiation treated patients, there have been documented changes in vaginal length of anywhere in the upwards of two to three centimeters. So using that manual therapy to really break down that tissue can be particularly effective in this patient population. Vaginal dryness is a highly reported symptom. So we moisturize, moisturize, moisturize. One of the challenges is whether or not patients are eligible to apply topical estrogen to really help with lubrication. And this may just be due to the nature of their cancer and the concern of excess hormone. So it does require some more conversations with the oncology team as to what is safe and appropriate in this patient population. And I think there are those added layers of concurrent medical and emotional complexities. Patients are maybe undergoing additional treatment due to recurrence. There are changes in body image that occur. Rates of anxiety and depression are particularly notable after gynecological treatment as well. And so as a rehab physician, recognizing the role of personal attitudes and emotions and mood status can affect their function, but then also ability to adhere to our treatment recommendations. And so one of the common treatment recommendations for that vaginal stenosis change in length and ability to continue with those important vaginal exams is vaginal dilator insertion after radiotherapy. And current recommendations call for women to use the dilator for about two to three times a week for 10 minutes for about 6 to 24 months. There is variability across cancer centers and some call for a lifelong use of dilators. But then how adherent are patients to dilators? We know in the non-cancer population adherence rates are relatively low. And so this was a randomized controlled study across a couple cancer centers where they administered kind of standard dilator instructions versus an intervention group that received more detailed instruction and intervention based on the trans-theoretical model of behavior change and also received follow-up calls several weeks after initially receiving the instructions. And what was notable in this patient population is that around a quarter of them used a vibrator or dilator prior to diagnosis and then around half of these participants were sexually inactive at the time of receiving the vaginal brachytherapy. And so what do they find for adherence rates? They looked at adherence rates versus one or three times a week. As you can see, more individuals were likely to use it at least once a week and the rates were around 60% at six weeks, but that did drop to about 16% at six months. And then those individuals who reported three times a week, adherence was not too surprisingly much lower at 15 to 33% and that also dropped to 8 to 11% at six months. Interestingly, the rates of adherence were not different between the standard of care dilator instructions versus those that had received those additional exploration of motivation and barriers to adherence and the frequency of follow-up calls by the nurses. In this study, and then also summarizing what's been found in other studies, barriers to dilator use may include time, fatigue, anticipatory emotions, embarrassment of having to use a dilator, and then certainly a component of treatment related PTSD. It's a reminder of their cancer. It's a reminder of, in some patients, the trauma that they perceived to have experienced. In this particular randomized control trial, factors related to non-adherence, those actually with the higher level of education were less likely to adhere to the dilator regimen, those with the higher weight. And then it calls for the question of, you know, is more reminders actually less motivating to continue or adhere to the regimen? It's hard to say. I think this would need to be further explored with qualitative studies to better understand why women chose to adhere or not adhere. Another common interventions that in the particular resonate with us is focusing on improving the strength and coordination of the pelvic floor musculature with the hopes of then improving bladder, bowel, and sexual function. And there have been a couple of randomized control trials in the Guymont patient population. As you can see here, they're relatively small. There's variability in the time point post-treatment, and their interventions themselves, of course, vary. There's ones that included focusing solely on pelvic floor muscle contraction, both on endurance training and strength training. And then others also incorporated bio feedback, counseling, and in general physical exercise. And the results were variable among their randomized control studies here. I think we can say overall that there were tangible increases in pelvic floor muscle strength, but buried in terms of whether or not this translated into improved bowel, bladder, and sexual function. And this may be due to perhaps the variability in interventions, but then also the outcome measures that were being captured, and also understanding what else might be contributing to the bowel, bladder, and sexual dysfunction. So certainly an area to be further explored with larger and more robust clinical trials. And so because we know that there is some level of impairment as it relates to bowel, bladder, and sexual function in this patient population, the exact quantity of impairment has yet to be fully explored. The exact type of intervention that is most effective has yet to be fully identified, but we know that we have to help this patient population. And so I think the role of the physiatrist is similar to our other patient populations where we do our comprehensive evaluation and try to develop a personalized patient-centered plan. And so here is just a slide kind of describing these are three patients that I saw in clinic over the past two weeks. As you can see there's variability in age, variability in diagnosis, and then variability in their treatment regimen. But presenting with a multitude symptom burden such as vaginal pain, bowel and bladder urgency, fatigue, and peripheral neuropathy, changes in motivation, changes in physical exercise participation. So can certainly highlight the need of a physiatric evaluation. And perhaps a common theme that I'm noticing and perhaps our younger patient population is how these changes in mood and motivation affect their ability to care for themselves at home, their family members, and then also lower work participation rates in this patient population. So certainly a significant role for us to be a part of their care. And then I'll conclude with describing well how do we how can we integrate ourselves into the Cancer Center. And so one thing that we've done at our Cancer Center is we're focusing on sexual health just because of the high rates of that changes in sexual health and interest among the patient population. So we've developed this interdisciplinary team that's comprised of our women's health nurse practitioner, social worker, myself as the PM&R physician, and then our enthusiastic pelvic floor physical therapy team to improve sexual health. And from the rehab perspective this is really kind of the gateway into pelvic floor rehab. We use this as an opportunity to identify patients but then also explore changes in bowel, bladder, and then overall physical function as well. And the challenge of course lies in how do we integrate ourselves into the already busy clinical workflow. So one of the things that we as a team are piloting is to incorporate a screening questionnaire that's embedded in the EPIC, our EMR's workflow, asking the oncology clinical staff to ask these two simple questions and if patients respond yes they receive a referral to our sexual health program where then our program coordinator has a set of screening questions to try and at least initially allocate a patient to our nurse practitioner, our social worker, or myself, recognizing that patients may then see all of us or some of us throughout their care. And so highlighted here are some examples of patient resources and physician resources that may be helpful for you and at your particular institution. Sloan Kettering does have a number of patient education sheets and interactive websites on how to use a dilator, how to perform kegels, and then a list of various moisturizers and lubricants as a start to provide patients with some tools and then some physician-based resources for us to receive further training and instruction. So thank you for having me here today.

pelvic floor

physiatric intervention

gynecologic cancers

pelvic dysfunction

treatment interventions

emotional factors

pelvic organ prolapse

interdisciplinary teams