Sexual dysfunction and quality of life in cervical and endometrial cancer patients before and after low-dose-rate brachytherapy: a cohort study from Northeast Mexico.

Sexual dysfunction and quality of life in cervical and endometrial cancer patients before and after low-dose-rate brachytherapy: a cohort study from Northeast Mexico. | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Sexual dysfunction and quality of life in cervical and endometrial cancer patients before and after low-dose-rate brachytherapy: a cohort study from Northeast Mexico. Celia B. González Alcorta, Adelina Alcorta Garza, Daneli Ruiz Sánchez, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5357103/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background and objective. The available research on low-dose-rate (LDR) brachytherapy in gynecology cancer has focused mainly on treatment toxicity. It does not include aspects such as sexual desire, sexual arousal, orgasm, satisfaction, or quality of life. This study assessed sexual function and quality of life before and after LDR brachytherapy in cervical and endometrial cancer patients. We also identified risk factors that contribute to the loss of sexual function and those associated with an improvement in quality of life 3–6 months post-brachytherapy. Methods. We prospectively followed a cohort of patients with a histopathological diagnosis of cervical and endometrial cancer treated with LDR intracavitary brachytherapy between February 2020 and November 2022 (n = 139). We used the SyDSF-AP, FACT-G, PHQ-9, and PHQ-15 scales collected through a self-administered questionnaire before and 3–6 months after treatment. The incidence rates were estimated. Binary and ordinal multiple logistic regression were used to examine risk factors for sexual dysfunction (coded as yes vs. no) and quality of life (coded as worsened, remained poor or fair, improved) after LDR brachytherapy, respectively. Results. The incidence of sexual dysfunction was 14.4%, with 30% of individuals already experiencing sexual dysfunction at baseline. Higher education decreased the likelihood of starting or maintaining sexual dysfunction (adjusted odds ratio 0.10, 95% CI 0.01, 0.97). Physical well-being improved after treatment (69.3 ± 24.1 vs 78.7 ± 20.2, p < 0.001; effect size = 0.34). Age, major depression, and sexual dysfunction reduced the likelihood of starting or maintaining a good quality of life. Conclusions. More than 1 in 10 patients developed sexual dysfunction and physical well-being was the only area that improved after treatment. Schooling was associated with sexual dysfunction. In contrast, age, depression, and sexual dysfunction negatively impact quality of life. Research in this area helps increase awareness and understanding of how healthcare providers can better support sexual and health-related well-being. Sexual dysfunction Quality of life Low-dose rate Brachytherapy Figures Figure 1 Background There are five main types of gynecological cancer: cervix, uterine (usually endometrial), ovarian, vaginal, and vulvar. The Global Cancer Observatory reported that cervical cancer was the fifth most common malignant disorder in 2022, with an incidence rate of 14.1%. Cervical cancer ranked third, and uterine cancer ranked fifth among the most common malignant disorders in Mexico and the United States (13.2% and 22.5%, respectively). Cervical cancer leads to the highest number of gynecologic cancer deaths worldwide and poses a significant burden, especially in low- and middle-income countries. For example, cervical cancer has the highest mortality rate among gynecological cancers in Mexico (6.2%) [ 1 ]. Brachytherapy is a widely used local treatment for various gynecologic cancers. For patients with cervical cancer, brachytherapy after external beam radiation therapy is standard practice. Additionally, this treatment is utilized for endometrial cancer patients following hysterectomy to eliminate any residual cancer cells that may remain after surgery. Uterine cancer patients who are unable to undergo surgery also receive brachytherapy [ 2 – 4 ]. Brachytherapy can have early side effects, such as local irritation and discomfort, pain, swelling, vaginal bleeding, diarrhea, and urinary frequency or urgency [ 5 , 6 ]. Over time, the pelvic floor muscles may be affected, causing complications such as urinary and anal incontinence [ 7 , 8 ]. Radiotherapy can damage the vaginal structure, resulting in psychological stress related to sexual dysfunction. The length of the vagina may be shortened, and both lubrication and elasticity may be reduced. Consequently, stenosis, dryness, and dyspareunia are common symptoms [ 9 – 11 ]. Survivors of gynecological cancer often face a variety of psychological challenges, including decreased libido, changes in body image, and anxiety related to sexual performance. They may also encounter social issues, such as difficulty maintaining previous sexual roles, emotional distancing from their partner, and concerns about perceived changes in their partner's level of sexual interest following diagnosis and treatment [ 12 , 13 ]. All these physical, psychological, and social effects may significantly impact sexual and health-related quality of life. Research in this area helps increase awareness and understanding of how healthcare providers can better address factors that affect women's quality of life, leading to more effective interventions and support for preserving sexual and health-related well-being. Brachytherapy can involve a low-dose-rate (LDR) of radiation (0.4–2.0 Gy/h; the radiation source stays in place for 1 to 7 days) or a high-dose-rate (HDR)(greater than 12 Gy/h; the radiation source is left in place for 10–20 minutes twice a day for 2–5 days or once a week for 2–5 weeks) [ 14 ]. Over time, HDR has replaced LDR [ 15 ]. The speed and intensity of radiation delivery are the main distinctions; HDR provides a quick, intense dose, whereas LDR offers a slower, more prolonged dose. The choice between LDR and HDR depends on the type and the location of cancer, the patient’s health, and access to specialized equipment. Efforts to increase the availability of HDR brachytherapy in Latin America and Mexico include investing in healthcare infrastructure, enhancing training programs, and addressing disparities in access to care[ 16 ]. Some studies have analyzed the impact of HDR brachytherapy on both sexual function and quality of life in patients with gynecological cancer [ 12 , 17 – 19 ]. In contrast, studies on LDR brachytherapy have focused mainly on treatment toxicity, e.g., vaginal mucosal changes, vaginal stenosis, and vaginal pain. They do not include sexual desire, sexual arousal, orgasm, satisfaction, or quality of life [ 20 – 23 ]. Understanding the impact of LDR brachytherapy on sexual function and quality of life can help guide healthcare policies, funding, and education to address these important issues for cancer survivors in regions operating LDR units. The objective of the present study was to assess sexual function and quality of life before and after LDR brachytherapy in patients with cervical and endometrial cancer. We also identified risk factors that contribute to the loss of sexual function and those associated with an improvement in quality of life 3–6 months post-brachytherapy. Methods We prospectively followed a cohort of patients with a histopathological diagnosis of cervical and endometrial cancer treated with LDR intracavitary brachytherapy between February 2020 and November 2022. The participants were selected consecutively while they were in the outpatient clinic of the oncology service at the “Dr. José Eleuterio González” University Hospital, a tertiary public teaching hospital located in Monterrey, Mexico (Fig. 1 ). The selection criteria included age 18 or older and no neurological or cognitive conditions. Participants were required to have a confirmed diagnosis of cervical or endometrial cancer. The loss rate was 35.3%; responders did not differ from nonresponders in terms of age at diagnosis, education, marital status, occupation, origin, stage of disease, surgery, external radiotherapy, chemotherapy, or the number of brachytherapy sessions (p > 0.05). A minimum sample size of 97 was estimated based on an expected incidence of sexual dysfunction (SyDSF-AP ≥ 2) of 50% at 3–6 months post-brachytherapy, with a margin of error of 10%, and a confidence level of 95%. Brachytherapy parameters The brachytherapy procedure adhered to institutional standards and its delivery was homogeneous over time. Patients were hospitalized for the entire duration of the procedure. The treatment consisted of administering 20 to 60 Gy 5 mm below the vaginal surface using LDR cesium-137 sources. The dose rate ranged from 0.4 to 0.6 Gy/hour (10–15 Gy/day). X-rays were used to estimate the doses to the International Commission of Radiation Units and Measurements points, ensuring precise and effective radiation application. The applicators were withdrawn without anesthesia, and the sources were removed after the necessary time. In patients undergoing surgical treatment, chemotherapy, or external radiotherapy, at least 50% of the chemotherapy or external radiotherapy sessions should have been completed before the administration of brachytherapy. Alternatively, at least one month must have elapsed since the surgery. All patients were evaluated at 1 month post-treatment and between the 3rd and 6th month after therapy. Study variables Sexual function. It was measured using the Health and Feminine Sexual Dysfunction in Primary Care (SyDSF-AP) scale developed and validated in Spanish by Casas Aranda et al. [ 24 ]. Sexual function was assessed based on the experience of symptoms in the past 3 months. The sexual function domain encompassed 9 items regarding sexual satisfaction, sexual desire, sexual enjoyment, sexual arousal, dyspareunia, orgasm, sexual difficulties with a partner, the ability to live without sex, and feelings of depression or nervousness because of sexual problems (Cronbach’s alpha before and after brachytherapy = 0.56 and 0.60, respectively). The SyDSF-AP scale responses were on a 6-point Likert scale ranging from 0 (never) to 5 (always). The positively phrased questions were reversed so that a higher score indicated poor sexual function. The responses were averaged and categorized into the presence and absence of sexual dysfunction based on a cut-off point ≥ 2 (equivalent to sometimes, often, almost always, and always). Quality of life . It was measured using the Functional Assessment of Cancer Therapy - General Scale (FACT-G) developed in 1993 for evaluating patients receiving cancer treatment [ 25 ] and validated in Spanish [ 26 ]. It assessed the quality of life over the last 7 days and consisted of 4 dimensions: a) physical well-being (e.g., “I lack energy”), with 7 items (Cronbach’s alpha before and after brachytherapy = 0.86 and 0.82, respectively), b) family and social well-being (e.g., “I receive emotional support from part of my family”), with 7 items (Cronbach’s alpha before and after brachytherapy = 0.77 and 0.72, respectively), c) emotional well-being (e.g., “I feel sad”), with 6 items (Cronbach’s alpha before and after brachytherapy = 0.74 and 0.71, respectively), and d) functional well-being (e.g., “I sleep well”), with 7 items (Cronbach’s alpha before and after brachytherapy = 0.81 and 0.78, respectively). FACT-G scale responses were provided on a 5-point Likert scale ranging from 0 (not at all) to 4 (very much). The negatively phrased questions were reversed so that a higher score indicated a better quality of life. The score was transformed to a 0-100 scale, and the responses were averaged and categorized into poor (0–25, equivalent to not at all and a little bit), fair (26–74, equivalent to somewhat), and good quality of life (75–100, equivalent to quite a bit and very much). Somatic and depressive symptom severity. Two patient health questionnaires were used, the PHQ-15 [ 27 ] and the PHQ-9 [ 28 ]. The PHQ-15 assessed physical problems that may have bothered the patient over the last 4 weeks, whereas the PHQ-9 evaluated depressive symptoms during the previous 2 weeks. Both were available in Spanish [ 29 , 30 ]. The PHQ-15 consisted of 15 items, for example, “I have had stomach pain” (Cronbach’s alpha before and after brachytherapy = 0.85 and 0.83, respectively), with responses on a 3-point Likert scale ranging from 0 (not bothered all) to 2 (bothered a lot). A higher score indicated greater severity of somatic symptoms. The sum of the responses was categorized into minimal (0–4), mild (5–9), moderate (10–14), and high (15–30). The PHQ-9 consisted of 9 items, such as “I feel little interest or pleasure in doing things” (Cronbach’s alpha before and after brachytherapy = 0.82 and 0.73, respectively), with responses on a 4-point Likert scale ranging from 0 (never) to 3 (almost every day). A higher score indicated greater severity of depressive symptoms. The sum of the responses was categorized, with a score ≥ 9 indicating major depression; this cut-off point was used because it demonstrated a sensitivity of 95% [ 27 ]. Sociodemographic. Age, schooling, marital status, occupation, origin, and parity. Information on sexual function, quality of life, somatic and depressive symptoms, and sociodemographics was collected through a self-administered questionnaire between the 3rd and 6th month after LDR brachytherapy. Medical files provided information on the patient’s history of diabetes, hypertension, and other health conditions. Brachytherapy characteristics (technique, number of sessions, and total days of protraction) and other treatments used (surgery, external radiotherapy, and chemotherapy). Also, data were gathered on side effects/ complications (gastrointestinal, genitourinary, fistula, colostomy, and nephrostomy) and response to oncologic treatment (recurrence, progression, or persistence of cancer). The classification of disease stage followed the International Federation of Gynecology and Obstetrics. Statistical analysis. Descriptive statistics, including means and standard deviations, were used for continuous variables, whereas frequency distributions were applied for categorical variables. The incidence of major depression, moderate to severe somatic symptoms, sexual dysfunction, and good quality of life was estimated based on the change from absent to present status at 3–6 months after brachytherapy. The Wilcoxon signed-rank test for two related samples was used to compare the mean scores of the quality-of-life domains and the mean number of bothersome somatic and depressive symptoms. The effect size was estimated when the difference between the quality-of-life domain's pre- and post-measurement was significant. Binary multiple logistic regression was used to examine risk factors for sexual dysfunction (dependent variable coded yes vs. no) and ordinal multiple logistic regression was used to examine risk factors for quality of life (dependent variable coded worsened, remained poor/fair, improved) after LDR brachytherapy. Odds ratios (ORs) and 95% confidence intervals (CIs) were estimated. In both models, age, schooling, major depression, moderate to severe somatic symptoms, comorbidities, and side effects/complications were considered the independent variables, while disease stage, surgery, chemotherapy, external radiotherapy, and total days of protraction were used as control variables. Results The mean age of the study population was 46.2 ± 12.7 years, and the mean number of pregnancies was 3.4 ± 1.7. Most participants were married or living with a partner, had a low level of education, were housewives, and came from the country's Northeast (Nuevo Leon and Tamaulipas). One in 5 patients had diabetes or hypertension, and more than 40% of the participants experienced gastrointestinal side effects (Table 1 ). Table 1 Sociodemographic profile and intercurrent diseases (n = 139) n % Married or living with a partner 89 65.0 Schooling Elementary 48 34.5 Secondary 51 36.7 High school 25 18.0 Professional/postgraduate 15 10.8 Employment status Housewife 83 59.7 Employed 41 29.5 Unemployed/retired 15 10.8 Origin Nuevo Leon 50 36.0 Tamaulipas 54 38.8 Other 35 25.1 Intercurrent diseases Any comorbidity 43 30.9 Diabetes 28 20.1 Hypertension 31 22.3 Other (hypothyroidism, psoriasis, arthritis) 7 5.0 Side effects/complications Gastrointestinal 61 43.9 Genitourinary 25 18.0 Fistula 31 22.3 Colostomy 21 15.1 Nephrostomy 4 2.9 The disease stages were as follows: 20.4% stage IA or IB, 21.9% stage IIA or IIB, 10.9% stage IIIA or IIIB, 23.4% stage IIIC, and 23.4% stage IVA or IVB. The cancer recurrence, progression, and persistence rates were 2.9%, 5.8%, and 10.8%, respectively. Cervical cancer predominated over endometrial cancer (82% and 18%, respectively). Analysis by tumor site revealed that more patients with endometrial cancer were in stage IA or IB and underwent surgery. Whereas more patients with cervical cancer were in stage IVA or IVB and received chemotherapy. There were also differences in the number of sessions and brachytherapy technique (Table 2 ). Table 2 Clinical profile according to the tumor site (n = 139) Tumor site Cervix (n = 114) Endometrium (n = 25) p-value a Disease stage IA or IB 15.9% 41.7% 0.01 IIA or IIB 21.2% 25.0% 0.955 IIIA or IIIB 8.8% 20.8% 0.200 IIIC 25.7% 12.5% 0.237 IVA or IVB 28.3% 0.0% 0.006 Surgery 23.7% 92.0% 0.00001 Chemotherapy 78.1% 44.0% 0.001 External radiotherapy 96.5% 88.0% 0.210 Number of brachytherapy sessions 1 7.9% 48.0% 0.00001 2 or 3 92.1% 52.0% 0.00001 Brachytherapy technique Colpostat 20.5% 91.7% 0.00001 Fletcher 73.2% 8.3% 0.00001 Miniovoids 6.3% 0% 0.443 Total days of protraction 79.3 ± 25.5 75.0 ± 28.6 0.137 Recurrence 3.5% 0.0% 0.772 Progression 5.3% 8.0% 0.954 Persistence 12.3% 4.0% 0.394 a Test on the difference between two proportions The mean number of bothersome somatic symptoms at 3–6 months was lower than before brachytherapy (8.3 ± 5.4 vs. 6.4 ± 4.2, p < 0.001). The mean number of depressive symptoms also decreased (7.2 ± 6.0 vs. 5.3 ± 5.1, p < 0.01). The incidence of major depression was 6.7%. Sexual function. All patients who answered the questions about sexual function were sexually active. Sexual arousal and the ability to live without sex were the most frequently affected functions. There was no difference in the frequency of patients with dysfunctions before and after brachytherapy (p > 0.05) (Table 3 ). The incidence of sexual dysfunction was 14.4%; 30% of patients already had sexual dysfunction at baseline, and it persisted, whereas the other 55.6% continued without sexual dysfunction or improved. Higher education decreased the risk of starting or maintaining sexual dysfunction after brachytherapy, independent of confounding factors (Table 4 ). Table 3 Sexual function before and 3–6 months after LDR brachytherapy Brachytherapy p-value c Sexual function Before (n = 139) After (n = 90) Sexual satisfaction a 23.0% 23.3% 0.954 Sexual desire has gone down b 25.2% 26.7% 0.910 Sex enjoyment has gone down b 22.3% 27.8% 0.617 Sexual arousal a 38.8% 32.2% 0.208 Dyspareunia b 13.7% 14.4% 0.874 Orgasms a 30.9% 22.2% 0.110 Sexual difficulties with a partner, not when masturbating b 5.0% 1.1% 0.194 Could live without sex (sexual interest) b 31.7% 32.2% 0.916 Depressed and nervous because of sexual problems b 5.0% 8.9% 0.458 a Never + almost never, b Always + almost always. C Test on the difference between two proportions Table 4 Risk factors for developing or maintaining sexual dysfunction 3–6 months after LDR brachytherapy (n = 90) Sexual dysfunction Absent Present (started after or maintained) OR 95% CI Age 45.7 ± 11.6 46.9 ± 13.5 1.00 1.0, 1.1 Schooling Elementary 30.0% 45.0% Ref Secondary 40.0% 35.0% 0.40 0.1, 1.3 High school 18.0% 15.0% 0.50 0.1, 1.8 Professional/postgraduate 12.0% 5.0% 0.10 0.01, 0.97* Major depression persisted or started after brachytherapy 16.0% 25.0% 1.00 0.2, 4.0 Moderate to severe somatic symptoms persisted or started after brachytherapy 16.00% 27.50% 3.50 0.7, 16.9 Comorbidity (any) 30.00% 32.5% 0.90 0.3, 2.7 Side effects/complications (any) 66.0% 67.5% 0.70 0.2, 2.2 Other variables present in the multivariate binary logistic regression model included disease stage (p = 0.21), surgery (p = 0.40), chemotherapy (p = 0.82), and external radiotherapy (p = 1.0); *p < 0.05 Quality of life. Physical well-being improved 3 to 6 months after brachytherapy (69.3 ± 24.1 vs. 78.7 ± 20.2, p < 0.001; effect size = 0.34). Emotional health was the most affected area, remaining unchanged with poor or fair well-being (Table 5 ). Factors such as age, major depression, and sexual dysfunction reduced the likelihood of starting or maintaining a good quality of life after brachytherapy, independent of confounding factors (Table 6 ). Table 5 Quality of life before and 3–6 months after LDR brachytherapy (n = 90) Brachytherapy Quality of life Area Before After Worsened It remained poor or fair Improved or remained good Physical 69.3 ± 24.1 78.7 ± 20.2* 12.8% 16.3% 70.9% Family and Social 78.1 ± 18.8 76.4 ± 18.0 18.0% 23.6% 58.4% Emotional 67.1 ± 22.0 71.3 ± 21.2 13.8% 33.3% 52.9% Functional 70.0 ± 21.1 73.7 ± 19.4 18.9% 24.4% 56.7% Overall 71.3 ± 14.7 74.9 ± 13.8 15.3% 24.7% 60.0% The Wilcoxon signed-rank test for two related samples: *p < 0.001 Table 6 Risk factors for starting or maintaining a good quality of life 3–6 months after LDR brachytherapy (n = 90) Quality of life Worsened It remained poor or fair Improved or remained good OR 95% CI Age (years) 53.0 ± 13.4 41.6 ± 10.5 45.9 ± 12.2 0.96 0.92, 1.0* Schooling, high school or higher 15.4% 19.0% 29.4% 0.84 0.5, 1.4 Major depression persisted or started after brachytherapy 23.1% 52.4% 2.0% 0.20 0.1, 0.8* Moderate to severe somatic symptoms persisted or started after brachytherapy 30.8% 42.9% 5.9% 0.30 0.1, 1.2 Side effects/complications (any) 84.6% 76.2% 62.7% 0.90 0.3, 2.5 Comorbidity (any) 38.5% 28.6% 31.4% 0.70 0.2, 1.9 Sexual dysfunction 69.2% 61.9% 31.4% 0.30 0.1, 0.7** Other variables present in the multivariate ordinal logistic regression model included disease stage (p = 0.25), surgery (p = 0.38), chemotherapy (p = 0.17), external radiotherapy (p = 0.11), and total days of protraction (p = 0.91); *p < 0.05, **p ≤ 0.01 Discussion We estimated sexual dysfunction and quality of life before and after LDR brachytherapy in patients with cervical and endometrial cancer in a region where HDR brachytherapy units are not widely available. Sexual dysfunction was present in 44.4% of the study population (14.4% were new cases and 30% were prevalent cases). Roberts et al. [31] reported that 62.5% of endometrial and cervical cancer patients had at least one sexual difficulty after completing brachytherapy, chemotherapy, or external radiotherapy for more than 8 months. In the general population, female sexual problems affect up to 43% of women [32]. Three areas of sexual dysfunction frequently overlap interest/arousal, orgasmic, and genital-pelvic pain or penetration[33]. We found that sexual interest and sexual arousal were the most frequent dysfunctions both before and after brachytherapy. Zomkowski et al. [17] reported a negative effect on lubrication (p= 0.05) and desire (p= 0.06) 7 days after the completion of HDR treatment. Kirchheiner et al. [18] documented less sexual activity than did a healthy population at baseline and 3 months after the combination of HDR, external beam radiotherapy, and chemotherapy. Cancer patients who are not receiving radiotherapy also present sexual dysfunctions. Studies have shown that patients with cervical and endometrial cancer experience more dysfunctions in terms of sexual arousal and orgasm intensity than healthy individuals do, along with entry dyspareunia [34, 35]. Sexual dysfunction is a common issue among patients with cervical and endometrial cancer due to a combination of physical (fatigue, chronic pain), psychological (body image issues, anxiety, depression, fear of recurrence), and cultural issues (rights to enjoy a full sexual life, willingness to discuss sexual health concerns and seek help). Women may avoid or have less frequent sex because they fear that it could cause a recurrence of cancer or because they or their partners are concerned that cancer could be transmitted through sexual activity [36]. We found that women with higher education levels had a lower risk of sexual dysfunction after brachytherapy, which is consistent with the findings of previous studies [37, 38]. Women with higher levels of education often express greater concern about their sexuality than women with lower levels of education do [39]. Access to care also contributes to the problem of sexual dysfunction due to the absence or insufficient availability of sexual health counseling or therapy services. Furthermore, women with cervical and endometrial cancer do not necessarily seek health care regarding their sexual function because they feel uncomfortable discussing their sex life with healthcare providers. Healthcare providers, for their part, may also feel uncomfortable talking about sexual health due to a lack of training, fear of offending or embarrassing the patient, underestimation of the incidence/prevalence of sexual dysfunction, and lack of knowledge about the impact of sexual dysfunction on the well-being of patients with cervical and endometrial cancer. Patients with gynecologic cancer should receive counseling on how to cope with anticipated changes in sexual functioning. Addressing sexual dysfunction in patients with cervical and endometrial cancer requires a multidisciplinary approach, including medical treatment, psychological support, and counseling [32, 40]. Physical well-being significantly improved after LDR brachytherapy, with differences of +9.4 compared with baseline. The physical domain is related to treatment side effects, which may negatively influence quality of life. We found that the number of severe somatic symptoms was reduced, which can explain the improvement in physical well-being. Zomkowski et al. [17] reported no improvement in well-being 7 days after HDR brachytherapy, only in specific symptoms (appetite, diarrhea, and constipation). Emotional health was the area most affected, and it remained unchanged, similar to previous reports [17, 18]. Family and social health ranked high both before and after brachytherapy. This contrasts with the findings of Zomkowski et al. [17] who found social well-being was the second most affected area, with no significant change between measurements. Kirchheiner et al. [18] reported that social functioning was low at baseline but improved and reached a level comparable to that of the reference population during the first 6 months. These results highlight the importance of analyzing short-term quality-of-life effects in different populations for planning interventions accordingly. Age, depression, and sexual dysfunction were unfavorable factors for starting or maintaining a good quality of life after brachytherapy. Somanna et al. [41] reported that older age (≥ 60 years) increased the risk for a lower global health status than did age ≤ 45 years in cervical cancer patients. Aging is associated with a decline in physical function, which can be exacerbated by cancer and its treatments, resulting in greater physical limitations and reduced quality of life. Older patients may also have more difficulty tolerating aggressive cancer treatments, leading to more severe side effects and complications that negatively affect their quality of life. It is necessary to continue this line of research to expand the knowledge in the field. Depression can exacerbate physical symptoms such as pain, fatigue, and sleep disturbances, severely impacting daily functioning and quality of life. It can overshadow positive experiences and reduce overall life satisfaction. Effective management of depression through therapy, medication, or a combination of both can significantly improve quality of life. Strengthening social support networks and encouraging social engagement can also help mitigate the negative impact of depression. Sexual health in cancer patients is a marker of quality of life, and information should be provided about the sexual consequences of surgery. It is important to identify which patients may suffer from sexual health issues to help improve their quality of life. Therefore, sexual function should be assessed at regular intervals [32]. Study limitations. Cultural factors such as shyness and embarrassment could have influenced sexual function responses, leading to the underestimation of sexual dysfunction rates. We did not include a healthy comparison group; it would be interesting to consider one in future studies. Several patients expressed interest in learning more about their treatment and the impact it could have on their sexual function. These patients received counseling from a health professional trained to guide and educate them about preventing or improving their sexual function. Expanding this issue into a line of research to compare the impact of such health promotion would be valuable. The therapeutic regimens were heterogeneous, but we could not analyze population subgroups, such as brachytherapy combined with radiotherapy versus brachytherapy combined with surgery because sample sizes were small. Most patients lacked health insurance and belonged to an economically unprotected social class; therefore, the results cannot be generalized to patients in middle and high socioeconomic statuses with private healthcare. Additionally, there is a recognized bias toward urban residents, as most participants lived in the metropolitan area of Monterrey, Mexico. Future studies should include residents of rural areas to evaluate whether the results differ by area of residence. Conclusion This study focused on a Mexican population from the Northeast of the country and was the first to assess sexual function and quality of life before and 3–6 months after LDR brachytherapy in a cohort of patients with cervical and endometrial cancer. More than 1 in 10 patients developed sexual dysfunction, and 3 in 10 experienced it before treatment. Physical well-being was the only quality of life category that significantly improved after treatment. Higher education reduces the risk of starting or maintaining sexual dysfunction. In contrast, older age, major depression, and sexual dysfunction negatively impacted the ability to start or maintain a good quality of life. Research in this area helps increase awareness and understanding of how healthcare providers can better support sexual and health-related well-being. Abbreviations LDR Low-dose-rate HDR High-dose-rate SyDSF-AP Feminine Sexual Dysfunction in Primary Care FACT-G Functional Assessment of Cancer Therapy - General scale PHQ Patient Health Questionnaires OR Odds ratio CI Confidence intervals Declarations Author contributions CBG and AA conceptualized and designed the study. DR, BAS, ILG, and PAL conducted and supervised data collection. JFG contributed to the clinical aspects of the oncology field, while OV administered the project. FA was in charge of data curation. AA analyzed the data. CBG and AA interpreted data results. CBG wrote the original draft. All authors reviewed and provided input into the final version of the manuscript. Funding. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Data availability The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request. Ethics approval and consent to participate The protocol was approved by the Ethics, Biosafety, and Research Committees of the Dr. José Eleuterio González Hospital, of the Autonomous University of Nuevo León, Mexico (CI22-00242). The study adhered to the guidelines of the Declaration of Helsinki for medical research involving human participants. Participation was voluntary, and participants could withdraw at any time without needing to justify their decision. All the participants signed informed consent forms before beginning the study data collection. Consent for publication Not applicable. Competing interests The authors declare that they have no competing interests. Author details Oncology Service, Area of Radiooncology. University Cancer Center. University Hospital "José E. González". Universidad Autónoma de Nuevo León. Monterrey, Mexico. Oncology Service, Area of Psychooncology, Liaison Medicine, and Palliative Care. University Cancer Center. University Hospital "José E. González". Universidad Autónoma de Nuevo León. Monterrey, Mexico. Oncology Service. University Cancer Center. University Hospital "José E. González". Universidad Autónoma de Nuevo León. Monterrey, Mexico. Oncology Service, Area of Medical Oncology and Radiooncology. University Cancer Center. University Hospital "José E. González". Universidad Autónoma de Nuevo León. Monterrey, Mexico. Oncology Service, Area of Oncologic Surgery. University Cancer Center. University Hospital "José E. González". Universidad Autónoma de Nuevo León. Monterrey, Mexico. References International Agency for Research on Cancer. Cancer Today. Population factsheets. 2024. https://gco.iarc.who.int/today/en/fact-sheets-populations#countries. Accessed 17 Jul 2024. Chargari C, Deutsch E, Blanchard P, Gouy S, Martelli H, Guérin F, et al. Brachytherapy: An overview for clinicians. CA Cancer J Clin. 2019;69:386–401. Holschneider CH, Petereit DG, Chu C, Hsu I-C, Ioffe YJ, Klopp AH, et al. Brachytherapy: A critical component of primary radiation therapy for cervical cancer. Brachytherapy. 2019;18:123–32. The University of Texas MD Anderson Cancer Center. Brachytherapy. 2024. https://www.mdanderson.org/treatment-options/brachytherapy.html. Accessed 17 Jul 2024. Chen J, Zhang N, Liu Y, Han D, Mao Z, Yang W, et al. Analysis of Applicator Insertion Related Acute Side Effects for Cervical Cancer Treated With Brachytherapy. Front Oncol. 2021;11. Hannoun-Levi J-M, Chand-Fouche M-E, Gautier M, Dejean C, Marcy M, Fouche Y. Interstitial preoperative high-dose-rate brachytherapy for early stage cervical cancer: Dose–volume histogram parameters, pathologic response and early clinical outcome. Brachytherapy. 2013;12:148–55. Greear G, Lefkowits C, Parrillo LM, Flynn BJ. Incontinence, Voiding Dysfunction, and Other Urologic Complications After Radiotherapy for Gynecologic Malignancies. Curr Bladder Dysfunct Rep. 2016;11:88–97. Hazewinkel MH, Sprangers MAG, van der Velden J, van der Vaart CH, Stalpers LJA, Burger MPM, et al. Long-term cervical cancer survivors suffer from pelvic floor symptoms: A cross-sectional matched cohort study. Gynecol Oncol. 2010;117:281–6. Barcellini A, Dominoni M, Dal Mas F, Biancuzzi H, Venturini SC, Gardella B, et al. Sexual Health Dysfunction After Radiotherapy for Gynecological Cancer: Role of Physical Rehabilitation Including Pelvic Floor Muscle Training. Front Med. 2022;8. Delishaj D, Barcellini A, D’Amico R, Ursino S, Pasqualetti F, Fumagalli IC, et al. Vaginal toxicity after high-dose-rate endovaginal brachytherapy: 20 years of results. J Contemp Brachytherapy. 2018;10:559–66. Stinesen Kollberg K, Waldenström A-C, Bergmark K, Dunberger G, Rossander A, Wilderäng U, et al. Reduced vaginal elasticity, reduced lubrication, and deep and superficial dyspareunia in irradiated gynecological cancer survivors. Acta Oncol (Madr). 2015;54:772–9. de Freitas Corpes E, dos Anjos Gonçalves G, Caroline Andrade Oliveira A, da Silva Pacífico V, Christina Moura Barbosa Castro R, Cesar de Almeida P, et al. Effects of brachytherapy on quality of life and functionality in the treatment of cervix cancer. Cogitare Enferm. 2022;:1–11. Abbott-Anderson K, Kwekkeboom KL. A systematic review of sexual concerns reported by gynecological cancer survivors. Gynecol Oncol. 2012;124:477–89. American Cancer Society. Getting Internal Radiation Therapy (Brachytherapy). 2024. https://www.cancer.org/cancer/managing-cancer/treatment-types/radiation/internal-radiation-therapy-brachytherapy.html. Accessed 17 Jul 2024. Abdel-Wahab M, Grover S, Zubizarreta EH, Polo Rubio JA. Addressing the burden of cervical cancer through IAEA global brachytherapy initiatives. Brachytherapy. 2020;19:850–6. Maldonado Magos F, Lozano Ruíz FJ, Pérez Álvarez SI, Garay Villar O, Cárdenas Pérez C, Bautista Hernández MY, et al. Radiation oncology in Mexico: Current status according to Mexico’s Radiation Oncology Certification Board. Reports Pract Oncol Radiother. 2020;25:840–5. Zomkowski K, Toryi AM, Sacomori C, Dias M, Sperandio FF. Sexual function and quality of life in gynecological cancer pre- and post-short-term brachytherapy: a prospective study. Arch Gynecol Obstet. 2016;294:833–40. Kirchheiner K, Pötter R, Tanderup K, Lindegaard JC, Haie-Meder C, Petrič P, et al. Health-Related Quality of Life in Locally Advanced Cervical Cancer Patients After Definitive Chemoradiation Therapy Including Image Guided Adaptive Brachytherapy: An Analysis From the EMBRACE Study. Int J Radiat Oncol. 2016;94:1088–98. Facondo G, Vullo G, De Sanctis V, Vitiello C, Nieddu L, Alfò M, et al. Quality of life and sexual functioning among endometrial cancer patients treated with one week adjuvant high-dose-rate vaginal brachytherapy schedule. J Contemp Brachytherapy. 2022;14:341–6. Haie-Meder C, Kramar A, Lambin P, Lancar R, Scalliet P, Bouzy J, et al. Analysis of complications in a prospective randomized trial comparing two brachytherapy low dose rates in cervical carcinoma. Int J Radiat Oncol. 1994;29:953–60. Autorino R, Tagliaferri L, Campitelli M, Smaniotto D, Nardangeli A, Mattiucci GC, et al. EROS study: evaluation between high-dose-rate and low-dose-rate vaginal interventional radiotherapy (brachytherapy) in terms of overall survival and rate of stenosis. J Contemp Brachytherapy. 2018;10:315–20. Zuliani AC, Cairo AA, Barros Esteves SC, Santos Watanabe CC, de Oliveira Cunha M, de Souza GA. Adjuvant radiotherapy in early stage endometrial cancer. Rev Assoc Med Bras. 2011;57:438–42. Blanchard P, Monnier L, Dumas I, Morice P, Pautier P, Duvillard P, et al. Low-Dose-Rate Definitive Brachytherapy for High-Grade Vaginal Intraepithelial Neoplasia. Oncologist. 2011;16:182–8. Casas Aranda I, Guirao Sánchez L, García-Giralda Ruiz L, Alfaro González J V, Sandoval Martínez C, García-Giralda Ruiz FJ. SyDSF-AP: un cuestionario de 21 ítems para aproximarnos a la salud sexual y detectar las disfunciones sexuales femeninas en Atención Primaria. Med Fam Semer. 2007;33:9–13. Cella DF, Tulsky DS, Gray G, Sarafian B, Linn E, Bonomi A, et al. The Functional Assessment of Cancer Therapy scale: development and validation of the general measure. J Clin Oncol. 1993;11:570–9. Dapueto JJ, Francolino C, Gotta I, Levin R, Alonso I, Barrios E, et al. Evaluation of the Functional Assessment of Cancer Therapy-General Questionnaire (FACT-G) in a South American Spanish speaking population. Psychooncology. 2001;10:88–92. Kroenke K, Spitzer RL, Williams JBW. The PHQ-15: Validity of a New Measure for Evaluating the Severity of Somatic Symptoms. Psychosom Med. 2002;64:258–66. Kroenke K, Spitzer RL, Williams JBW. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16:606–13. Ros Montalbán S, Comas Vives A, Garcia-Garcia M. Validation of the Spanish version of the PHQ-15 questionnaire for the evaluation of physical symptoms in patients with depression and/or anxiety disorders: DEPRE-SOMA study. Actas Esp Psiquiatr. 2010;38:345–57. Saldivia S, Aslan J, Cova F, Vicente B, Inostroza C, Rincón P. Propiedades psicométricas del PHQ-9 (Patient Health Questionnaire) en centros de atención primaria de Chile. Rev Med Chil. 2019;147:53–60. Roberts K, Chong T, Hollands E, Tan J, Mohan GRKA, Cohen PA. Screening for sexual health concerns in survivors of gynecological cancer. Support Care Cancer. 2020;28:599–605. Boa R, Grénman S. Psychosexual health in gynecologic cancer. Int J Gynecol Obstet. 2018;143:147–52. Del Pup L, Villa P, Amar ID, Bottoni C, Scambia G. Approach to sexual dysfunction in women with cancer. Int J Gynecol Cancer. 2019;29:630–4. Aerts L, Enzlin P, Verhaeghe J, Poppe W, Vergote I, Amant F. Long-Term Sexual Functioning in Women After Surgical Treatment of Cervical Cancer Stages IA to IB: A Prospective Controlled Study. Int J Gynecol Cancer. 2014;24:1527–34. Aerts L, Enzlin P, Verhaeghe J, Poppe W, Vergote I, Amant F. Sexual Functioning in Women After Surgical Treatment for Endometrial Cancer: A Prospective Controlled Study. J Sex Med. 2015;12:198–209. Spagnoletti BRM, Bennett LR, Keenan C, Shetty SS, Manderson L, McPake B, et al. What factors shape quality of life for women affected by gynaecological cancer in South, South East and East Asian countries? A critical review. Reprod Health. 2022;19:70. Jaafarpour M, A K, J K, Z S. Female Sexual Dysfunction: Prevalence and Risk Factors. J Clin Diagnostic Res. 2013. https://doi.org/10.7860/JCDR/2013/6813.3822. Lo SS-T, Kok W-M. Sexual Behavior and Symptoms among Reproductive Age Chinese Women in Hong Kong. J Sex Med. 2014;11:1749–56. Thapa N, Maharjan M, Xiong Y, Jiang D, Nguyen T-P, Petrini MA, et al. Impact of cervical cancer on quality of life of women in Hubei, China. Sci Rep. 2018;8:11993. Sanchez Varela V, Zhou ES, Bober SL. Management of sexual problems in cancer patients and survivors. Curr Probl Cancer. 2013;37:319–52. Somanna SN, Sastry N, Chaluvarayaswamy R, Malila N. Quality of life and Its Determinants among Cervical Cancer Patients in South India. Asian Pacific J Cancer Prev. 2022;23:2727–33. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5357103","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":375000953,"identity":"50fa37fa-127f-4a82-90c2-933ce853cf79","order_by":0,"name":"Celia B. González Alcorta","email":"","orcid":"","institution":"Universidad Autónoma de Nuevo León","correspondingAuthor":false,"prefix":"","firstName":"Celia","middleName":"B. González","lastName":"Alcorta","suffix":""},{"id":375000956,"identity":"a79f22ca-212e-43c9-828a-011c31646b59","order_by":1,"name":"Adelina Alcorta Garza","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA3klEQVRIiWNgGAWjYFCCBAaGB2AG8wEgISFDnBYgYuBhYANREjykaOExYADThAB/e/LBDwk1Nvn27Gc+v7pRY8HDwH746AZ8WiTOPEuWSDiWZtnDk7vNOucY0GE8aWk38FpzI8dAIrHhsAEPQ+424xw2oBYJHjO8WuRv5H/+AdbC/+aZcc4/IrQY3ACaDNYikcP8OLeNCC2GZ56ZWQD9YsBz45kZc26fBA8bIb/IHU9+fONDjY0Be3/y48853+rk+NkPH8PvfSTAJgEmiVUOAswfSFE9CkbBKBgFIwcAAL2QRm5lyo0KAAAAAElFTkSuQmCC","orcid":"","institution":"Universidad Autónoma de Nuevo León","correspondingAuthor":true,"prefix":"","firstName":"Adelina","middleName":"Alcorta","lastName":"Garza","suffix":""},{"id":375000959,"identity":"f1e5c8a3-5f11-480e-9a9e-26aae8c65a85","order_by":2,"name":"Daneli Ruiz Sánchez","email":"","orcid":"","institution":"Universidad Autónoma de Nuevo León","correspondingAuthor":false,"prefix":"","firstName":"Daneli","middleName":"Ruiz","lastName":"Sánchez","suffix":""},{"id":375000961,"identity":"035e727a-40b0-4129-b773-a76879549c57","order_by":3,"name":"Blanca Angélica Soto Martínez","email":"","orcid":"","institution":"Universidad Autónoma de Nuevo León","correspondingAuthor":false,"prefix":"","firstName":"Blanca","middleName":"Angélica Soto","lastName":"Martínez","suffix":""},{"id":375000964,"identity":"7dda065b-9e62-4a55-9e6c-0ae3f2559f69","order_by":4,"name":"Fernando Alcorta Núñez","email":"","orcid":"","institution":"Universidad Autónoma de Nuevo León","correspondingAuthor":false,"prefix":"","firstName":"Fernando","middleName":"Alcorta","lastName":"Núñez","suffix":""},{"id":375000965,"identity":"bce61214-02a6-4266-949f-7b3756ac4be9","order_by":5,"name":"Itzel Lidey Galaviz Reynoso","email":"","orcid":"","institution":"Universidad Autónoma de Nuevo León","correspondingAuthor":false,"prefix":"","firstName":"Itzel","middleName":"Lidey Galaviz","lastName":"Reynoso","suffix":""},{"id":375000966,"identity":"9fb94558-012d-4a5b-b453-1b1bf35fc8e7","order_by":6,"name":"Paola A. López Sierra","email":"","orcid":"","institution":"Universidad Autónoma de Nuevo León","correspondingAuthor":false,"prefix":"","firstName":"Paola","middleName":"A. López","lastName":"Sierra","suffix":""},{"id":375000967,"identity":"f23a130f-e66f-4449-9541-b9b1fcf87092","order_by":7,"name":"Juan Francisco González Guerrero","email":"","orcid":"","institution":"Universidad Autónoma de Nuevo León","correspondingAuthor":false,"prefix":"","firstName":"Juan","middleName":"Francisco González","lastName":"Guerrero","suffix":""},{"id":375000968,"identity":"f9e1f615-f557-4a48-aa6f-68b7927195e4","order_by":8,"name":"Oscar Vidal Gutiérrez","email":"","orcid":"","institution":"Universidad Autónoma de Nuevo León","correspondingAuthor":false,"prefix":"","firstName":"Oscar","middleName":"Vidal","lastName":"Gutiérrez","suffix":""}],"badges":[],"createdAt":"2024-10-29 22:23:12","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5357103/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5357103/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":69443219,"identity":"84b1b20c-2d18-4681-a526-4d6b9ca01b34","added_by":"auto","created_at":"2024-11-20 11:34:17","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":61080,"visible":true,"origin":"","legend":"\u003cp\u003eStudy design\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-5357103/v1/1460b6c878637f320e142f4b.png"},{"id":75562435,"identity":"d24d8aec-882c-4152-bdc2-55768d759463","added_by":"auto","created_at":"2025-02-06 00:46:26","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":990690,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5357103/v1/72fd6467-e497-47f1-8115-166da22def53.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Sexual dysfunction and quality of life in cervical and endometrial cancer patients before and after low-dose-rate brachytherapy: a cohort study from Northeast Mexico.","fulltext":[{"header":"Background","content":"\u003cp\u003eThere are five main types of gynecological cancer: cervix, uterine (usually endometrial), ovarian, vaginal, and vulvar. The Global Cancer Observatory reported that cervical cancer was the fifth most common malignant disorder in 2022, with an incidence rate of 14.1%. Cervical cancer ranked third, and uterine cancer ranked fifth among the most common malignant disorders in Mexico and the United States (13.2% and 22.5%, respectively). Cervical cancer leads to the highest number of gynecologic cancer deaths worldwide and poses a significant burden, especially in low- and middle-income countries. For example, cervical cancer has the highest mortality rate among gynecological cancers in Mexico (6.2%) [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Brachytherapy is a widely used local treatment for various gynecologic cancers. For patients with cervical cancer, brachytherapy after external beam radiation therapy is standard practice. Additionally, this treatment is utilized for endometrial cancer patients following hysterectomy to eliminate any residual cancer cells that may remain after surgery. Uterine cancer patients who are unable to undergo surgery also receive brachytherapy [\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eBrachytherapy can have early side effects, such as local irritation and discomfort, pain, swelling, vaginal bleeding, diarrhea, and urinary frequency or urgency [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Over time, the pelvic floor muscles may be affected, causing complications such as urinary and anal incontinence [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Radiotherapy can damage the vaginal structure, resulting in psychological stress related to sexual dysfunction. The length of the vagina may be shortened, and both lubrication and elasticity may be reduced. Consequently, stenosis, dryness, and dyspareunia are common symptoms [\u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Survivors of gynecological cancer often face a variety of psychological challenges, including decreased libido, changes in body image, and anxiety related to sexual performance. They may also encounter social issues, such as difficulty maintaining previous sexual roles, emotional distancing from their partner, and concerns about perceived changes in their partner's level of sexual interest following diagnosis and treatment [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. All these physical, psychological, and social effects may significantly impact sexual and health-related quality of life. Research in this area helps increase awareness and understanding of how healthcare providers can better address factors that affect women's quality of life, leading to more effective interventions and support for preserving sexual and health-related well-being. Brachytherapy can involve a low-dose-rate (LDR) of radiation (0.4\u0026ndash;2.0 Gy/h; the radiation source stays in place for 1 to 7 days) or a high-dose-rate (HDR)(greater than 12 Gy/h; the radiation source is left in place for 10\u0026ndash;20 minutes twice a day for 2\u0026ndash;5 days or once a week for 2\u0026ndash;5 weeks) [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Over time, HDR has replaced LDR [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. The speed and intensity of radiation delivery are the main distinctions; HDR provides a quick, intense dose, whereas LDR offers a slower, more prolonged dose. The choice between LDR and HDR depends on the type and the location of cancer, the patient\u0026rsquo;s health, and access to specialized equipment. Efforts to increase the availability of HDR brachytherapy in Latin America and Mexico include investing in healthcare infrastructure, enhancing training programs, and addressing disparities in access to care[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Some studies have analyzed the impact of HDR brachytherapy on both sexual function and quality of life in patients with gynecological cancer [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan additionalcitationids=\"CR18\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. In contrast, studies on LDR brachytherapy have focused mainly on treatment toxicity, e.g., vaginal mucosal changes, vaginal stenosis, and vaginal pain. They do not include sexual desire, sexual arousal, orgasm, satisfaction, or quality of life [\u003cspan additionalcitationids=\"CR21 CR22\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Understanding the impact of LDR brachytherapy on sexual function and quality of life can help guide healthcare policies, funding, and education to address these important issues for cancer survivors in regions operating LDR units.\u003c/p\u003e \u003cp\u003eThe objective of the present study was to assess sexual function and quality of life before and after LDR brachytherapy in patients with cervical and endometrial cancer. We also identified risk factors that contribute to the loss of sexual function and those associated with an improvement in quality of life 3\u0026ndash;6 months post-brachytherapy.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eWe prospectively followed a cohort of patients with a histopathological diagnosis of cervical and endometrial cancer treated with LDR intracavitary brachytherapy between February 2020 and November 2022. The participants were selected consecutively while they were in the outpatient clinic of the oncology service at the \u0026ldquo;Dr. Jos\u0026eacute; Eleuterio Gonz\u0026aacute;lez\u0026rdquo; University Hospital, a tertiary public teaching hospital located in Monterrey, Mexico (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe selection criteria included age 18 or older and no neurological or cognitive conditions. Participants were required to have a confirmed diagnosis of cervical or endometrial cancer. The loss rate was 35.3%; responders did not differ from nonresponders in terms of age at diagnosis, education, marital status, occupation, origin, stage of disease, surgery, external radiotherapy, chemotherapy, or the number of brachytherapy sessions (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). A minimum sample size of 97 was estimated based on an expected incidence of sexual dysfunction (SyDSF-AP\u0026thinsp;\u0026ge;\u0026thinsp;2) of 50% at 3\u0026ndash;6 months post-brachytherapy, with a margin of error of 10%, and a confidence level of 95%.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eBrachytherapy parameters\u003c/h2\u003e \u003cp\u003eThe brachytherapy procedure adhered to institutional standards and its delivery was homogeneous over time. Patients were hospitalized for the entire duration of the procedure. The treatment consisted of administering 20 to 60 Gy 5 mm below the vaginal surface using LDR cesium-137 sources. The dose rate ranged from 0.4 to 0.6 Gy/hour (10\u0026ndash;15 Gy/day). X-rays were used to estimate the doses to the International Commission of Radiation Units and Measurements points, ensuring precise and effective radiation application. The applicators were withdrawn without anesthesia, and the sources were removed after the necessary time. In patients undergoing surgical treatment, chemotherapy, or external radiotherapy, at least 50% of the chemotherapy or external radiotherapy sessions should have been completed before the administration of brachytherapy. Alternatively, at least one month must have elapsed since the surgery. All patients were evaluated at 1 month post-treatment and between the 3rd and 6th month after therapy.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy variables\u003c/h3\u003e\n\u003cp\u003e\u003cb\u003eSexual function.\u003c/b\u003e It was measured using the Health and Feminine Sexual Dysfunction in Primary Care (SyDSF-AP) scale developed and validated in Spanish by Casas Aranda et al. [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Sexual function was assessed based on the experience of symptoms in the past 3 months. The sexual function domain encompassed 9 items regarding sexual satisfaction, sexual desire, sexual enjoyment, sexual arousal, dyspareunia, orgasm, sexual difficulties with a partner, the ability to live without sex, and feelings of depression or nervousness because of sexual problems (Cronbach\u0026rsquo;s alpha before and after brachytherapy\u0026thinsp;=\u0026thinsp;0.56 and 0.60, respectively). The SyDSF-AP scale responses were on a 6-point Likert scale ranging from 0 (never) to 5 (always). The positively phrased questions were reversed so that a higher score indicated poor sexual function. The responses were averaged and categorized into the presence and absence of sexual dysfunction based on a cut-off point\u0026thinsp;\u0026ge;\u0026thinsp;2 (equivalent to sometimes, often, almost always, and always).\u003c/p\u003e \u003cp\u003e \u003cb\u003eQuality of life\u003c/b\u003e. It was measured using the Functional Assessment of Cancer Therapy - General Scale (FACT-G) developed in 1993 for evaluating patients receiving cancer treatment [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] and validated in Spanish [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. It assessed the quality of life over the last 7 days and consisted of 4 dimensions: a) physical well-being (e.g., \u0026ldquo;I lack energy\u0026rdquo;), with 7 items (Cronbach\u0026rsquo;s alpha before and after brachytherapy\u0026thinsp;=\u0026thinsp;0.86 and 0.82, respectively), b) family and social well-being (e.g., \u0026ldquo;I receive emotional support from part of my family\u0026rdquo;), with 7 items (Cronbach\u0026rsquo;s alpha before and after brachytherapy\u0026thinsp;=\u0026thinsp;0.77 and 0.72, respectively), c) emotional well-being (e.g., \u0026ldquo;I feel sad\u0026rdquo;), with 6 items (Cronbach\u0026rsquo;s alpha before and after brachytherapy\u0026thinsp;=\u0026thinsp;0.74 and 0.71, respectively), and d) functional well-being (e.g., \u0026ldquo;I sleep well\u0026rdquo;), with 7 items (Cronbach\u0026rsquo;s alpha before and after brachytherapy\u0026thinsp;=\u0026thinsp;0.81 and 0.78, respectively). FACT-G scale responses were provided on a 5-point Likert scale ranging from 0 (not at all) to 4 (very much). The negatively phrased questions were reversed so that a higher score indicated a better quality of life. The score was transformed to a 0-100 scale, and the responses were averaged and categorized into poor (0\u0026ndash;25, equivalent to not at all and a little bit), fair (26\u0026ndash;74, equivalent to somewhat), and good quality of life (75\u0026ndash;100, equivalent to quite a bit and very much).\u003c/p\u003e \u003cp\u003e \u003cb\u003eSomatic and depressive symptom severity.\u003c/b\u003e Two patient health questionnaires were used, the PHQ-15 [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] and the PHQ-9 [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. The PHQ-15 assessed physical problems that may have bothered the patient over the last 4 weeks, whereas the PHQ-9 evaluated depressive symptoms during the previous 2 weeks. Both were available in Spanish [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. The PHQ-15 consisted of 15 items, for example, \u0026ldquo;I have had stomach pain\u0026rdquo; (Cronbach\u0026rsquo;s alpha before and after brachytherapy\u0026thinsp;=\u0026thinsp;0.85 and 0.83, respectively), with responses on a 3-point Likert scale ranging from 0 (not bothered all) to 2 (bothered a lot). A higher score indicated greater severity of somatic symptoms. The sum of the responses was categorized into minimal (0\u0026ndash;4), mild (5\u0026ndash;9), moderate (10\u0026ndash;14), and high (15\u0026ndash;30). The PHQ-9 consisted of 9 items, such as \u0026ldquo;I feel little interest or pleasure in doing things\u0026rdquo; (Cronbach\u0026rsquo;s alpha before and after brachytherapy\u0026thinsp;=\u0026thinsp;0.82 and 0.73, respectively), with responses on a 4-point Likert scale ranging from 0 (never) to 3 (almost every day). A higher score indicated greater severity of depressive symptoms. The sum of the responses was categorized, with a score\u0026thinsp;\u0026ge;\u0026thinsp;9 indicating major depression; this cut-off point was used because it demonstrated a sensitivity of 95% [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cb\u003eSociodemographic.\u003c/b\u003e Age, schooling, marital status, occupation, origin, and parity.\u003c/p\u003e \u003cp\u003eInformation on sexual function, quality of life, somatic and depressive symptoms, and sociodemographics was collected through a self-administered questionnaire between the 3rd and 6th month after LDR brachytherapy. Medical files provided information on the patient\u0026rsquo;s history of diabetes, hypertension, and other health conditions. Brachytherapy characteristics (technique, number of sessions, and total days of protraction) and other treatments used (surgery, external radiotherapy, and chemotherapy). Also, data were gathered on side effects/ complications (gastrointestinal, genitourinary, fistula, colostomy, and nephrostomy) and response to oncologic treatment (recurrence, progression, or persistence of cancer). The classification of disease stage followed the International Federation of Gynecology and Obstetrics.\u003c/p\u003e \u003cp\u003e \u003cb\u003eStatistical analysis.\u003c/b\u003e Descriptive statistics, including means and standard deviations, were used for continuous variables, whereas frequency distributions were applied for categorical variables. The incidence of major depression, moderate to severe somatic symptoms, sexual dysfunction, and good quality of life was estimated based on the change from absent to present status at 3\u0026ndash;6 months after brachytherapy. The Wilcoxon signed-rank test for two related samples was used to compare the mean scores of the quality-of-life domains and the mean number of bothersome somatic and depressive symptoms. The effect size was estimated when the difference between the quality-of-life domain's pre- and post-measurement was significant. Binary multiple logistic regression was used to examine risk factors for sexual dysfunction (dependent variable coded yes vs. no) and ordinal multiple logistic regression was used to examine risk factors for quality of life (dependent variable coded worsened, remained poor/fair, improved) after LDR brachytherapy. Odds ratios (ORs) and 95% confidence intervals (CIs) were estimated. In both models, age, schooling, major depression, moderate to severe somatic symptoms, comorbidities, and side effects/complications were considered the independent variables, while disease stage, surgery, chemotherapy, external radiotherapy, and total days of protraction were used as control variables.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe mean age of the study population was 46.2\u0026thinsp;\u0026plusmn;\u0026thinsp;12.7 years, and the mean number of pregnancies was 3.4\u0026thinsp;\u0026plusmn;\u0026thinsp;1.7. Most participants were married or living with a partner, had a low level of education, were housewives, and came from the country's Northeast (Nuevo Leon and Tamaulipas). One in 5 patients had diabetes or hypertension, and more than 40% of the participants experienced gastrointestinal side effects (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSociodemographic profile and intercurrent diseases (n\u0026thinsp;=\u0026thinsp;139)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarried or living with a partner\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e65.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSchooling\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eElementary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e34.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSecondary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e36.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e18.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProfessional/postgraduate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmployment status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHousewife\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e59.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e29.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnemployed/retired\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOrigin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNuevo Leon\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e36.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTamaulipas\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e38.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e25.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntercurrent diseases\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAny comorbidity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e30.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypertension\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e22.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther (hypothyroidism, psoriasis, arthritis)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSide effects/complications\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGastrointestinal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e43.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGenitourinary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e18.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFistula\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e22.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eColostomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNephrostomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe disease stages were as follows: 20.4% stage IA or IB, 21.9% stage IIA or IIB, 10.9% stage IIIA or IIIB, 23.4% stage IIIC, and 23.4% stage IVA or IVB. The cancer recurrence, progression, and persistence rates were 2.9%, 5.8%, and 10.8%, respectively. Cervical cancer predominated over endometrial cancer (82% and 18%, respectively). Analysis by tumor site revealed that more patients with endometrial cancer were in stage IA or IB and underwent surgery. Whereas more patients with cervical cancer were in stage IVA or IVB and received chemotherapy. There were also differences in the number of sessions and brachytherapy technique (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eClinical profile according to the tumor site (n\u0026thinsp;=\u0026thinsp;139)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eTumor site\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCervix\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;114)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEndometrium (n\u0026thinsp;=\u0026thinsp;25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep-value\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDisease stage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIA or IB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15.9%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e41.7%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIIA or IIB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21.2%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.955\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIIIA or IIIB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8.8%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20.8%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.200\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIIIC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.237\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIVA or IVB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e28.3%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.006\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e92.0%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.00001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChemotherapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e78.1%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e44.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExternal radiotherapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e96.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e88.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.210\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of brachytherapy sessions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.9%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e48.0%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.00001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2 or 3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e92.1%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e52.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.00001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBrachytherapy technique\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eColpostat\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e91.7%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.00001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFletcher\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e73.2%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.00001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMiniovoids\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.443\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal days of protraction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e79.3\u0026thinsp;\u0026plusmn;\u0026thinsp;25.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e75.0\u0026thinsp;\u0026plusmn;\u0026thinsp;28.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.137\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRecurrence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.772\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProgression\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.954\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePersistence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12.3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.394\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003csup\u003ea\u003c/sup\u003e Test on the difference between two proportions\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe mean number of bothersome somatic symptoms at 3\u0026ndash;6 months was lower than before brachytherapy (8.3\u0026thinsp;\u0026plusmn;\u0026thinsp;5.4 vs. 6.4\u0026thinsp;\u0026plusmn;\u0026thinsp;4.2, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The mean number of depressive symptoms also decreased (7.2\u0026thinsp;\u0026plusmn;\u0026thinsp;6.0 vs. 5.3\u0026thinsp;\u0026plusmn;\u0026thinsp;5.1, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01). The incidence of major depression was 6.7%.\u003c/p\u003e \u003cp\u003e \u003cb\u003eSexual function.\u003c/b\u003e All patients who answered the questions about sexual function were sexually active. Sexual arousal and the ability to live without sex were the most frequently affected functions. There was no difference in the frequency of patients with dysfunctions before and after brachytherapy (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). The incidence of sexual dysfunction was 14.4%; 30% of patients already had sexual dysfunction at baseline, and it persisted, whereas the other 55.6% continued without sexual dysfunction or improved. Higher education decreased the risk of starting or maintaining sexual dysfunction after brachytherapy, independent of confounding factors (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSexual function before and 3\u0026ndash;6 months after LDR brachytherapy\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eBrachytherapy\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ep-value \u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSexual function\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBefore\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;139)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAfter\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;90)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSexual satisfaction \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e23.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e23.3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.954\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSexual desire has gone down \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e25.2%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e26.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.910\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex enjoyment has gone down \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e22.3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e27.8%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.617\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSexual arousal \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e38.8%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e32.2%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.208\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDyspareunia \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e13.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e14.4%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.874\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOrgasms \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e30.9%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e22.2%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.110\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSexual difficulties with a partner, not when masturbating \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.1%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.194\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCould live without sex (sexual interest) \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e31.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e32.2%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.916\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDepressed and nervous because of sexual problems \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8.9%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.458\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003csup\u003ea\u003c/sup\u003e Never\u0026thinsp;+\u0026thinsp;almost never, \u003csup\u003eb\u003c/sup\u003e Always\u0026thinsp;+\u0026thinsp;almost always. \u003csup\u003eC\u003c/sup\u003e Test on the difference between two proportions\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eRisk factors for developing or maintaining sexual dysfunction 3\u0026ndash;6 months after LDR brachytherapy (n\u0026thinsp;=\u0026thinsp;90)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eSexual dysfunction\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAbsent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePresent\u003c/p\u003e \u003cp\u003e(started after or maintained)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e45.7\u0026thinsp;\u0026plusmn;\u0026thinsp;11.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e46.9\u0026thinsp;\u0026plusmn;\u0026thinsp;13.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.0, 1.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSchooling\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eElementary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSecondary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.1, 1.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.1, 1.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProfessional/postgraduate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.01, 0.97*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMajor depression persisted or started after brachytherapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.2, 4.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModerate to severe somatic symptoms persisted or started after brachytherapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16.00%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27.50%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.7, 16.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComorbidity (any)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30.00%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.3, 2.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSide effects/complications (any)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e66.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e67.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.2, 2.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eOther variables present in the multivariate binary logistic regression model included disease stage (p\u0026thinsp;=\u0026thinsp;0.21), surgery (p\u0026thinsp;=\u0026thinsp;0.40), chemotherapy (p\u0026thinsp;=\u0026thinsp;0.82), and external radiotherapy (p\u0026thinsp;=\u0026thinsp;1.0); *p\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eQuality of life.\u003c/b\u003e Physical well-being improved 3 to 6 months after brachytherapy (69.3\u0026thinsp;\u0026plusmn;\u0026thinsp;24.1 vs. 78.7\u0026thinsp;\u0026plusmn;\u0026thinsp;20.2, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001; effect size\u0026thinsp;=\u0026thinsp;0.34). Emotional health was the most affected area, remaining unchanged with poor or fair well-being (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). Factors such as age, major depression, and sexual dysfunction reduced the likelihood of starting or maintaining a good quality of life after brachytherapy, independent of confounding factors (Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eQuality of life before and 3\u0026ndash;6 months after LDR brachytherapy (n\u0026thinsp;=\u0026thinsp;90)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eBrachytherapy\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e \u003cp\u003eQuality of life\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eArea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBefore\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAfter\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eWorsened\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eIt remained poor or fair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eImproved or remained good\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePhysical\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e69.3\u0026thinsp;\u0026plusmn;\u0026thinsp;24.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e78.7\u0026thinsp;\u0026plusmn;\u0026thinsp;20.2*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12.8%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e16.3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e70.9%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFamily and Social\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e78.1\u0026thinsp;\u0026plusmn;\u0026thinsp;18.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e76.4\u0026thinsp;\u0026plusmn;\u0026thinsp;18.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e23.6%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e58.4%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmotional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e67.1\u0026thinsp;\u0026plusmn;\u0026thinsp;22.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e71.3\u0026thinsp;\u0026plusmn;\u0026thinsp;21.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13.8%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e33.3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e52.9%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFunctional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e70.0\u0026thinsp;\u0026plusmn;\u0026thinsp;21.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e73.7\u0026thinsp;\u0026plusmn;\u0026thinsp;19.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18.9%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e24.4%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e56.7%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOverall\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e71.3\u0026thinsp;\u0026plusmn;\u0026thinsp;14.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e74.9\u0026thinsp;\u0026plusmn;\u0026thinsp;13.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15.3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e24.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e60.0%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe Wilcoxon signed-rank test for two related samples: *p\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eRisk factors for starting or maintaining a good quality of life 3\u0026ndash;6 months after LDR brachytherapy (n\u0026thinsp;=\u0026thinsp;90)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003eQuality of life\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWorsened\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIt remained poor or fair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eImproved or remained good\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eOR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e53.0\u0026thinsp;\u0026plusmn;\u0026thinsp;13.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41.6\u0026thinsp;\u0026plusmn;\u0026thinsp;10.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e45.9\u0026thinsp;\u0026plusmn;\u0026thinsp;12.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.92, 1.0*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSchooling, high school or higher\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15.4%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e29.4%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.5, 1.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMajor depression persisted or started after brachytherapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23.1%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e52.4%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.1, 0.8*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModerate to severe somatic symptoms persisted or started after brachytherapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30.8%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e42.9%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5.9%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.1, 1.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSide effects/complications (any)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e84.6%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e76.2%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e62.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.3, 2.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComorbidity (any)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e38.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28.6%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e31.4%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.2, 1.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSexual dysfunction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e69.2%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e61.9%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e31.4%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.1, 0.7**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eOther variables present in the multivariate ordinal logistic regression model included disease stage (p\u0026thinsp;=\u0026thinsp;0.25), surgery (p\u0026thinsp;=\u0026thinsp;0.38), chemotherapy (p\u0026thinsp;=\u0026thinsp;0.17), external radiotherapy (p\u0026thinsp;=\u0026thinsp;0.11), and total days of protraction (p\u0026thinsp;=\u0026thinsp;0.91); *p\u0026thinsp;\u0026lt;\u0026thinsp;0.05, **p\u0026thinsp;\u0026le;\u0026thinsp;0.01\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eWe estimated\u0026nbsp;sexual dysfunction and quality of life before and after LDR brachytherapy in patients with cervical and endometrial cancer in a region where HDR brachytherapy units are not widely available. Sexual dysfunction was present in 44.4% of the study population\u0026nbsp;(14.4% were new cases and 30% were prevalent cases). Roberts et al.\u0026nbsp;[31]\u0026nbsp;reported that 62.5% of endometrial and cervical cancer patients had at least one sexual difficulty after completing brachytherapy, chemotherapy, or external radiotherapy for more than 8 months. In the general population, female sexual problems affect up to 43% of women\u0026nbsp;[32]. Three areas of sexual dysfunction frequently overlap interest/arousal, orgasmic, and genital-pelvic pain or penetration[33]. We found that sexual\u0026nbsp;interest and sexual arousal were\u0026nbsp;the most frequent dysfunctions both before and after brachytherapy. Zomkowski et al.\u0026nbsp;[17]\u0026nbsp;reported a negative effect on\u0026nbsp;lubrication (p= 0.05) and desire (p= 0.06) 7 days after the completion of HDR treatment.\u0026nbsp;Kirchheiner et al.\u0026nbsp;[18]\u0026nbsp;documented\u0026nbsp;less sexual activity than did a healthy population at baseline and 3 months after the combination of HDR, external beam radiotherapy, and chemotherapy. Cancer patients who are not receiving radiotherapy also present sexual dysfunctions. Studies have shown that patients with cervical and endometrial cancer experience more dysfunctions in terms of sexual arousal and orgasm intensity than healthy individuals do, along with entry dyspareunia\u0026nbsp;[34, 35]. Sexual dysfunction is a common issue among patients with cervical and endometrial cancer due to a combination of physical (fatigue, chronic pain), psychological (body image issues, anxiety, depression, fear of recurrence), and cultural issues (rights to enjoy a full sexual life,\u0026nbsp;willingness to discuss sexual health concerns and seek help). Women may avoid or have less frequent sex because they fear that it could cause a recurrence of cancer or because they or their partners are concerned that cancer could be transmitted through sexual activity\u0026nbsp;[36]. We found that women with higher education levels had a lower risk of sexual dysfunction after brachytherapy, which is consistent with the findings of previous studies\u0026nbsp;[37, 38]. Women with higher levels of education often express greater concern about their sexuality than women with lower levels of education do\u0026nbsp;[39]. Access to care also contributes to the problem of sexual dysfunction due to the absence or insufficient availability of sexual health counseling or therapy services. Furthermore, women with cervical and endometrial cancer do not necessarily seek health care regarding their sexual function because they feel uncomfortable discussing their sex life with healthcare providers. Healthcare providers, for their part, may also feel uncomfortable talking about sexual health due to a lack of training, fear of offending or embarrassing the patient, underestimation of the incidence/prevalence of sexual dysfunction, and lack of knowledge about the impact of sexual dysfunction on the well-being of patients with cervical and endometrial cancer. Patients with gynecologic cancer should receive counseling on how to cope with anticipated changes in sexual functioning. Addressing sexual dysfunction in patients with cervical and endometrial cancer requires a multidisciplinary approach, including medical treatment, psychological support, and counseling\u0026nbsp;[32, 40].\u003c/p\u003e\n\u003cp\u003ePhysical well-being significantly improved after LDR brachytherapy, with differences of\u0026nbsp;+9.4 compared with baseline. The physical domain is related to treatment side effects, which may negatively influence quality of life. We found that the number of severe somatic symptoms was reduced, which can explain the improvement in physical well-being.\u0026nbsp;Zomkowski et al.\u0026nbsp;[17]\u0026nbsp;reported no improvement in well-being 7 days after HDR brachytherapy, only in specific symptoms (appetite, diarrhea, and constipation).\u0026nbsp;Emotional health was the area most affected, and it remained unchanged, similar to previous reports\u0026nbsp;[17, 18]. Family and social health ranked high both before and after brachytherapy.\u0026nbsp;This contrasts with the findings of Zomkowski et al.\u0026nbsp;[17]\u0026nbsp;who found social well-being was the second most affected area, with no significant change between measurements.\u0026nbsp;Kirchheiner et al.\u0026nbsp;[18]\u0026nbsp;reported that social functioning was low at baseline but improved and reached a level comparable to that of the reference population during the first 6 months. These results highlight the importance of analyzing short-term quality-of-life effects in different populations for planning interventions accordingly.\u0026nbsp;Age, depression, and sexual dysfunction were unfavorable factors for starting or maintaining a good quality of life after brachytherapy.\u0026nbsp; Somanna et al.\u0026nbsp;[41]\u0026nbsp;reported that older age (\u0026ge; 60 years) increased the risk for a lower global health status than did age \u0026le; 45 years in cervical cancer patients. Aging is associated with a decline in physical function, which can be exacerbated by cancer and its treatments, resulting in greater physical limitations and reduced quality of life. Older patients may also have more difficulty tolerating aggressive cancer treatments, leading to more severe side effects and complications that negatively affect their quality of life. It is necessary to continue this line of research to expand the knowledge in the field. Depression can exacerbate physical symptoms such as pain, fatigue, and sleep disturbances, severely impacting daily functioning and quality of life.\u0026nbsp;It\u0026nbsp;can overshadow positive experiences and reduce overall life satisfaction.\u0026nbsp;Effective management of depression through therapy, medication, or a combination of both can significantly improve quality of life. Strengthening social support networks and encouraging social engagement can also help mitigate the negative impact of depression. Sexual health in cancer patients is a marker of quality of life, and information should be provided about the sexual consequences of surgery.\u0026nbsp;It is important to identify which patients may suffer from sexual health issues to help improve their quality of life. Therefore, sexual function should be assessed at regular intervals\u0026nbsp;[32].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy limitations.\u003c/strong\u003e Cultural factors such as shyness and embarrassment could have influenced sexual function responses, leading to the underestimation of sexual dysfunction rates. We did not include a healthy comparison group; it would be interesting to consider one in future studies. Several patients expressed interest in learning more about their treatment and the impact it could have on their sexual function. These patients received counseling from a health professional trained to guide and educate them about preventing or improving their sexual function. Expanding this issue into a line of research to compare the impact of such health promotion would be valuable. The therapeutic regimens were heterogeneous, but we could not analyze population subgroups, such as brachytherapy combined with radiotherapy versus brachytherapy combined with surgery because sample sizes were small. Most patients lacked health insurance and belonged to an economically unprotected social class; therefore, the results cannot be generalized to patients in middle and high socioeconomic statuses with private healthcare. Additionally, there is a recognized bias toward urban residents, as most participants lived in the metropolitan area of Monterrey, Mexico. Future studies should include residents of rural areas to evaluate whether the results differ by area of residence.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study focused on a Mexican population from the Northeast of the country and was the first to assess sexual function and quality of life before and 3\u0026ndash;6 months after LDR brachytherapy in a cohort of patients with cervical and endometrial cancer. More than 1 in 10 patients developed sexual dysfunction, and 3 in 10 experienced it before treatment. Physical well-being was the only quality of life category that significantly improved after treatment. Higher education reduces the risk of starting or maintaining sexual dysfunction. In contrast, older age, major depression, and sexual dysfunction negatively impacted the ability to start or maintain a good quality of life. Research in this area helps increase awareness and understanding of how healthcare providers can better support sexual and health-related well-being.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eLDR \u0026nbsp;\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Low-dose-rate\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHDR \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;High-dose-rate\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSyDSF-AP \u0026nbsp; \u0026nbsp; \u0026nbsp;Feminine Sexual Dysfunction in Primary Care\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFACT-G \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Functional Assessment of Cancer Therapy - General scale\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePHQ \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Patient Health Questionnaires\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOR \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Odds ratio\u003c/p\u003e\n\u003cp\u003eCI \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Confidence intervals \u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCBG and AA conceptualized and designed the study. DR, BAS, ILG, and PAL \u0026nbsp; conducted and supervised data collection. JFG contributed to the clinical aspects of the oncology field, while OV administered the project. FA was in charge of data curation. AA analyzed the data. CBG and AA interpreted data results. CBG wrote the original draft. All authors reviewed and provided input into the final version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding.\u0026nbsp;\u003c/strong\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe protocol was approved by the Ethics, Biosafety, and Research Committees of the Dr. Jos\u0026eacute; Eleuterio Gonz\u0026aacute;lez Hospital, of the Autonomous University of Nuevo Le\u0026oacute;n, Mexico\u0026nbsp;(CI22-00242). The study adhered to the guidelines of the Declaration of Helsinki for medical research involving human participants.\u0026nbsp;Participation was voluntary, and participants could withdraw at any time without needing to justify their decision.\u0026nbsp;All the participants signed informed consent forms\u0026nbsp;before beginning the study data collection.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor details\u003c/strong\u003e\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eOncology Service, Area of Radiooncology.\u0026nbsp;University Cancer Center. University Hospital \u0026quot;Jos\u0026eacute; E. Gonz\u0026aacute;lez\u0026quot;. Universidad Aut\u0026oacute;noma de Nuevo Le\u0026oacute;n. Monterrey, Mexico.\u003c/li\u003e\n \u003cli\u003eOncology Service, Area of Psychooncology, Liaison Medicine, and Palliative Care.\u0026nbsp;University Cancer Center. University Hospital \u0026quot;Jos\u0026eacute; E. Gonz\u0026aacute;lez\u0026quot;. Universidad Aut\u0026oacute;noma de Nuevo Le\u0026oacute;n. Monterrey, Mexico.\u003c/li\u003e\n \u003cli\u003eOncology Service. University Cancer Center.\u0026nbsp;University Hospital \u0026quot;Jos\u0026eacute; E. Gonz\u0026aacute;lez\u0026quot;. Universidad Aut\u0026oacute;noma de Nuevo Le\u0026oacute;n. Monterrey, Mexico.\u003c/li\u003e\n \u003cli\u003eOncology Service, Area of Medical Oncology and Radiooncology.\u0026nbsp;University Cancer Center. University Hospital \u0026quot;Jos\u0026eacute; E. Gonz\u0026aacute;lez\u0026quot;. Universidad Aut\u0026oacute;noma de Nuevo Le\u0026oacute;n. Monterrey, Mexico.\u003c/li\u003e\n \u003cli\u003eOncology Service, Area of Oncologic Surgery. \u0026nbsp;University Cancer Center. University Hospital \u0026quot;Jos\u0026eacute; E. Gonz\u0026aacute;lez\u0026quot;. Universidad Aut\u0026oacute;noma de Nuevo Le\u0026oacute;n. Monterrey, Mexico.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eInternational Agency for Research on Cancer. Cancer Today. Population factsheets. 2024. https://gco.iarc.who.int/today/en/fact-sheets-populations#countries. Accessed 17 Jul 2024.\u003c/li\u003e\n\u003cli\u003eChargari C, Deutsch E, Blanchard P, Gouy S, Martelli H, Gu\u0026eacute;rin F, et al. Brachytherapy: An overview for clinicians. CA Cancer J Clin. 2019;69:386\u0026ndash;401.\u003c/li\u003e\n\u003cli\u003eHolschneider CH, Petereit DG, Chu C, Hsu I-C, Ioffe YJ, Klopp AH, et al. Brachytherapy: A critical component of primary radiation therapy for cervical cancer. Brachytherapy. 2019;18:123\u0026ndash;32.\u003c/li\u003e\n\u003cli\u003eThe University of Texas MD Anderson Cancer Center. Brachytherapy. 2024. https://www.mdanderson.org/treatment-options/brachytherapy.html. Accessed 17 Jul 2024.\u003c/li\u003e\n\u003cli\u003eChen J, Zhang N, Liu Y, Han D, Mao Z, Yang W, et al. Analysis of Applicator Insertion Related Acute Side Effects for Cervical Cancer Treated With Brachytherapy. Front Oncol. 2021;11.\u003c/li\u003e\n\u003cli\u003eHannoun-Levi J-M, Chand-Fouche M-E, Gautier M, Dejean C, Marcy M, Fouche Y. Interstitial preoperative high-dose-rate brachytherapy for early stage cervical cancer: Dose\u0026ndash;volume histogram parameters, pathologic response and early clinical outcome. Brachytherapy. 2013;12:148\u0026ndash;55.\u003c/li\u003e\n\u003cli\u003eGreear G, Lefkowits C, Parrillo LM, Flynn BJ. Incontinence, Voiding Dysfunction, and Other Urologic Complications After Radiotherapy for Gynecologic Malignancies. Curr Bladder Dysfunct Rep. 2016;11:88\u0026ndash;97.\u003c/li\u003e\n\u003cli\u003eHazewinkel MH, Sprangers MAG, van der Velden J, van der Vaart CH, Stalpers LJA, Burger MPM, et al. Long-term cervical cancer survivors suffer from pelvic floor symptoms: A cross-sectional matched cohort study. Gynecol Oncol. 2010;117:281\u0026ndash;6.\u003c/li\u003e\n\u003cli\u003eBarcellini A, Dominoni M, Dal Mas F, Biancuzzi H, Venturini SC, Gardella B, et al. Sexual Health Dysfunction After Radiotherapy for Gynecological Cancer: Role of Physical Rehabilitation Including Pelvic Floor Muscle Training. Front Med. 2022;8.\u003c/li\u003e\n\u003cli\u003eDelishaj D, Barcellini A, D\u0026rsquo;Amico R, Ursino S, Pasqualetti F, Fumagalli IC, et al. Vaginal toxicity after high-dose-rate endovaginal brachytherapy: 20 years of results. J Contemp Brachytherapy. 2018;10:559\u0026ndash;66.\u003c/li\u003e\n\u003cli\u003eStinesen Kollberg K, Waldenstr\u0026ouml;m A-C, Bergmark K, Dunberger G, Rossander A, Wilder\u0026auml;ng U, et al. Reduced vaginal elasticity, reduced lubrication, and deep and superficial dyspareunia in irradiated gynecological cancer survivors. Acta Oncol (Madr). 2015;54:772\u0026ndash;9.\u003c/li\u003e\n\u003cli\u003ede Freitas Corpes E, dos Anjos Gon\u0026ccedil;alves G, Caroline Andrade Oliveira A, da Silva Pac\u0026iacute;fico V, Christina Moura Barbosa Castro R, Cesar de Almeida P, et al. Effects of brachytherapy on quality of life and functionality in the treatment of cervix cancer. Cogitare Enferm. 2022;:1\u0026ndash;11.\u003c/li\u003e\n\u003cli\u003eAbbott-Anderson K, Kwekkeboom KL. A systematic review of sexual concerns reported by gynecological cancer survivors. Gynecol Oncol. 2012;124:477\u0026ndash;89.\u003c/li\u003e\n\u003cli\u003eAmerican Cancer Society. Getting Internal Radiation Therapy (Brachytherapy). 2024. https://www.cancer.org/cancer/managing-cancer/treatment-types/radiation/internal-radiation-therapy-brachytherapy.html. Accessed 17 Jul 2024.\u003c/li\u003e\n\u003cli\u003eAbdel-Wahab M, Grover S, Zubizarreta EH, Polo Rubio JA. Addressing the burden of cervical cancer through IAEA global brachytherapy initiatives. Brachytherapy. 2020;19:850\u0026ndash;6.\u003c/li\u003e\n\u003cli\u003eMaldonado Magos F, Lozano Ru\u0026iacute;z FJ, P\u0026eacute;rez \u0026Aacute;lvarez SI, Garay Villar O, C\u0026aacute;rdenas P\u0026eacute;rez C, Bautista Hern\u0026aacute;ndez MY, et al. Radiation oncology in Mexico: Current status according to Mexico\u0026rsquo;s Radiation Oncology Certification Board. Reports Pract Oncol Radiother. 2020;25:840\u0026ndash;5.\u003c/li\u003e\n\u003cli\u003eZomkowski K, Toryi AM, Sacomori C, Dias M, Sperandio FF. Sexual function and quality of life in gynecological cancer pre- and post-short-term brachytherapy: a prospective study. Arch Gynecol Obstet. 2016;294:833\u0026ndash;40.\u003c/li\u003e\n\u003cli\u003eKirchheiner K, P\u0026ouml;tter R, Tanderup K, Lindegaard JC, Haie-Meder C, Petrič P, et al. Health-Related Quality of Life in Locally Advanced Cervical Cancer Patients After Definitive Chemoradiation Therapy Including Image Guided Adaptive Brachytherapy: An Analysis From the EMBRACE Study. Int J Radiat Oncol. 2016;94:1088\u0026ndash;98.\u003c/li\u003e\n\u003cli\u003eFacondo G, Vullo G, De Sanctis V, Vitiello C, Nieddu L, Alf\u0026ograve; M, et al. Quality of life and sexual functioning among endometrial cancer patients treated with one week adjuvant high-dose-rate vaginal brachytherapy schedule. J Contemp Brachytherapy. 2022;14:341\u0026ndash;6.\u003c/li\u003e\n\u003cli\u003eHaie-Meder C, Kramar A, Lambin P, Lancar R, Scalliet P, Bouzy J, et al. Analysis of complications in a prospective randomized trial comparing two brachytherapy low dose rates in cervical carcinoma. Int J Radiat Oncol. 1994;29:953\u0026ndash;60.\u003c/li\u003e\n\u003cli\u003eAutorino R, Tagliaferri L, Campitelli M, Smaniotto D, Nardangeli A, Mattiucci GC, et al. EROS study: evaluation between high-dose-rate and low-dose-rate vaginal interventional radiotherapy (brachytherapy) in terms of overall survival and rate of stenosis. J Contemp Brachytherapy. 2018;10:315\u0026ndash;20.\u003c/li\u003e\n\u003cli\u003eZuliani AC, Cairo AA, Barros Esteves SC, Santos Watanabe CC, de Oliveira Cunha M, de Souza GA. Adjuvant radiotherapy in early stage endometrial cancer. Rev Assoc Med Bras. 2011;57:438\u0026ndash;42.\u003c/li\u003e\n\u003cli\u003eBlanchard P, Monnier L, Dumas I, Morice P, Pautier P, Duvillard P, et al. Low-Dose-Rate Definitive Brachytherapy for High-Grade Vaginal Intraepithelial Neoplasia. Oncologist. 2011;16:182\u0026ndash;8.\u003c/li\u003e\n\u003cli\u003eCasas Aranda I, Guirao S\u0026aacute;nchez L, Garc\u0026iacute;a-Giralda Ruiz L, Alfaro Gonz\u0026aacute;lez J V, Sandoval Mart\u0026iacute;nez C, Garc\u0026iacute;a-Giralda Ruiz FJ. SyDSF-AP: un cuestionario de 21 \u0026iacute;tems para aproximarnos a la salud sexual y detectar las disfunciones sexuales femeninas en Atenci\u0026oacute;n Primaria. Med Fam Semer. 2007;33:9\u0026ndash;13.\u003c/li\u003e\n\u003cli\u003eCella DF, Tulsky DS, Gray G, Sarafian B, Linn E, Bonomi A, et al. The Functional Assessment of Cancer Therapy scale: development and validation of the general measure. J Clin Oncol. 1993;11:570\u0026ndash;9.\u003c/li\u003e\n\u003cli\u003eDapueto JJ, Francolino C, Gotta I, Levin R, Alonso I, Barrios E, et al. Evaluation of the Functional Assessment of Cancer Therapy-General Questionnaire (FACT-G) in a South American Spanish speaking population. Psychooncology. 2001;10:88\u0026ndash;92.\u003c/li\u003e\n\u003cli\u003eKroenke K, Spitzer RL, Williams JBW. The PHQ-15: Validity of a New Measure for Evaluating the Severity of Somatic Symptoms. Psychosom Med. 2002;64:258\u0026ndash;66.\u003c/li\u003e\n\u003cli\u003eKroenke K, Spitzer RL, Williams JBW. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16:606\u0026ndash;13.\u003c/li\u003e\n\u003cli\u003eRos Montalb\u0026aacute;n S, Comas Vives A, Garcia-Garcia M. Validation of the Spanish version of the PHQ-15 questionnaire for the evaluation of physical symptoms in patients with depression and/or anxiety disorders: DEPRE-SOMA study. Actas Esp Psiquiatr. 2010;38:345\u0026ndash;57.\u003c/li\u003e\n\u003cli\u003eSaldivia S, Aslan J, Cova F, Vicente B, Inostroza C, Rinc\u0026oacute;n P. Propiedades psicom\u0026eacute;tricas del PHQ-9 (Patient Health Questionnaire) en centros de atenci\u0026oacute;n primaria de Chile. Rev Med Chil. 2019;147:53\u0026ndash;60.\u003c/li\u003e\n\u003cli\u003eRoberts K, Chong T, Hollands E, Tan J, Mohan GRKA, Cohen PA. Screening for sexual health concerns in survivors of gynecological cancer. Support Care Cancer. 2020;28:599\u0026ndash;605.\u003c/li\u003e\n\u003cli\u003eBoa R, Gr\u0026eacute;nman S. Psychosexual health in gynecologic cancer. Int J Gynecol Obstet. 2018;143:147\u0026ndash;52.\u003c/li\u003e\n\u003cli\u003eDel Pup L, Villa P, Amar ID, Bottoni C, Scambia G. Approach to sexual dysfunction in women with cancer. Int J Gynecol Cancer. 2019;29:630\u0026ndash;4.\u003c/li\u003e\n\u003cli\u003eAerts L, Enzlin P, Verhaeghe J, Poppe W, Vergote I, Amant F. Long-Term Sexual Functioning in Women After Surgical Treatment of Cervical Cancer Stages IA to IB: A Prospective Controlled Study. Int J Gynecol Cancer. 2014;24:1527\u0026ndash;34.\u003c/li\u003e\n\u003cli\u003eAerts L, Enzlin P, Verhaeghe J, Poppe W, Vergote I, Amant F. Sexual Functioning in Women After Surgical Treatment for Endometrial Cancer: A Prospective Controlled Study. J Sex Med. 2015;12:198\u0026ndash;209.\u003c/li\u003e\n\u003cli\u003eSpagnoletti BRM, Bennett LR, Keenan C, Shetty SS, Manderson L, McPake B, et al. What factors shape quality of life for women affected by gynaecological cancer in South, South East and East Asian countries? A critical review. Reprod Health. 2022;19:70.\u003c/li\u003e\n\u003cli\u003eJaafarpour M, A K, J K, Z S. Female Sexual Dysfunction: Prevalence and Risk Factors. J Clin Diagnostic Res. 2013. https://doi.org/10.7860/JCDR/2013/6813.3822.\u003c/li\u003e\n\u003cli\u003eLo SS-T, Kok W-M. Sexual Behavior and Symptoms among Reproductive Age Chinese Women in Hong Kong. J Sex Med. 2014;11:1749\u0026ndash;56.\u003c/li\u003e\n\u003cli\u003eThapa N, Maharjan M, Xiong Y, Jiang D, Nguyen T-P, Petrini MA, et al. Impact of cervical cancer on quality of life of women in Hubei, China. Sci Rep. 2018;8:11993.\u003c/li\u003e\n\u003cli\u003eSanchez Varela V, Zhou ES, Bober SL. Management of sexual problems in cancer patients and survivors. Curr Probl Cancer. 2013;37:319\u0026ndash;52.\u003c/li\u003e\n\u003cli\u003eSomanna SN, Sastry N, Chaluvarayaswamy R, Malila N. Quality of life and Its Determinants among Cervical Cancer Patients in South India. Asian Pacific J Cancer Prev. 2022;23:2727\u0026ndash;33.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Sexual dysfunction, Quality of life, Low-dose rate, Brachytherapy","lastPublishedDoi":"10.21203/rs.3.rs-5357103/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5357103/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground and objective.\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThe available research on low-dose-rate (LDR) brachytherapy in gynecology cancer has focused mainly on treatment toxicity. It does not include aspects such as sexual desire, sexual arousal, orgasm, satisfaction, or quality of life. This study assessed sexual function and quality of life before and after LDR brachytherapy in cervical and endometrial cancer patients. We also identified risk factors that contribute to the loss of sexual function and those associated with an improvement in quality of life 3\u0026ndash;6 months post-brachytherapy.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods.\u003c/b\u003e\u003c/p\u003e \u003cp\u003eWe prospectively followed a cohort of patients with a histopathological diagnosis of cervical and endometrial cancer treated with LDR intracavitary brachytherapy between February 2020 and November 2022 (n\u0026thinsp;=\u0026thinsp;139). We used the SyDSF-AP, FACT-G, PHQ-9, and PHQ-15 scales collected through a self-administered questionnaire before and 3\u0026ndash;6 months after treatment. The incidence rates were estimated. Binary and ordinal multiple logistic regression were used to examine risk factors for sexual dysfunction (coded as yes vs. no) and quality of life (coded as worsened, remained poor or fair, improved) after LDR brachytherapy, respectively.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults.\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThe incidence of sexual dysfunction was 14.4%, with 30% of individuals already experiencing sexual dysfunction at baseline. Higher education decreased the likelihood of starting or maintaining sexual dysfunction (adjusted odds ratio 0.10, 95% CI 0.01, 0.97). Physical well-being improved after treatment (69.3\u0026thinsp;\u0026plusmn;\u0026thinsp;24.1 vs 78.7\u0026thinsp;\u0026plusmn;\u0026thinsp;20.2, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001; effect size\u0026thinsp;=\u0026thinsp;0.34). Age, major depression, and sexual dysfunction reduced the likelihood of starting or maintaining a good quality of life.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusions.\u003c/b\u003e\u003c/p\u003e \u003cp\u003eMore than 1 in 10 patients developed sexual dysfunction and physical well-being was the only area that improved after treatment. Schooling was associated with sexual dysfunction. In contrast, age, depression, and sexual dysfunction negatively impact quality of life. Research in this area helps increase awareness and understanding of how healthcare providers can better support sexual and health-related well-being.\u003c/p\u003e","manuscriptTitle":"Sexual dysfunction and quality of life in cervical and endometrial cancer patients before and after low-dose-rate brachytherapy: a cohort study from Northeast Mexico.","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-11-20 11:34:12","doi":"10.21203/rs.3.rs-5357103/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"136fbda1-26f0-4e2b-9299-e3a6a1f5dd8b","owner":[],"postedDate":"November 20th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-02-06T00:38:15+00:00","versionOfRecord":[],"versionCreatedAt":"2024-11-20 11:34:12","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5357103","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5357103","identity":"rs-5357103","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}