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The psychological, social, and sexual consequences of gestational trophoblastic disease

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Abstract

Seventy-six women diagnosed with gestational trophoblastic disease (GTD) from 1985 to 1989 completed questionnaires evaluating their status on mood disturbance, marital satisfaction, sexual functioning, psychosocial response to illness, and report of the most stressful event occurring within the past year. Multivariate analyses of variance (MANOVA) were conducted on dependent measures to examine differences between diagnostic groups (partial mole, complete mole, persistent disease), time from diagnosis (<1 year, 1–2 years, or 3–5 years from diagnosis), and follow-up status (active disease or remission). MANOVAs revealed no significant differences in the dependent measures based on time from diagnosis, type of medical treatment received, or type of molar disease. The metastatic disease group displayed significantly greater mood disturbance (F(1, 66) = 17.63, P < 0.0001) and reported suffering clinically significant levels of distress and significantly greater levels of distress in response to the illness (F(33, 39) = 2.32, P < 0.006). Women with active disease also reported significantly greater levels of distress in response to the illness (F(33, 39) = 2.76, P < 0.001). Across disease types, GTD patients experience clinically significant levels of anxiety, anger, fatigue, confusion, and sexual problems and are significantly impacted by pregnancy concerns for protracted periods of time.

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... Berkowitz [17] and Wenzel [18] were the first to publish evidence on the psychological, social and sexual impact of GTD, and since then less than 30 studies have generated evidence on the impact of GTD. Medical outcomes are generally well researched in GTD, psychosocial research is limited and all these studies demonstrate methodological limitations arising from the difficulty in researching complex issues in a rare disease. ...
... Childless GTD patients seem to be at greatest risk of developing anxiety, as in several studies, having a child already proved to have a protective role in terms of psychological well-being over the course of a GTD illness trajectory [18,28,34]. For those who have difficulty conceiving either pre or post GTD, and for the older woman, the delay in childbearing brought on by GTD can increase their concerns over future opportunities for having children [28,30]. ...
... Children again prove to have a protective effect, women with children had less overall depression compared to women without children [25,30]. Childless women also report feeling less attractive and the GTD having a greater impact on their sense of self [18], with 33% in one study feeling the condition had a profound negative effect on their role as a woman [34] . ...
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KEY HIGHLIGHTS: 1) GTD care is traditionally based in the biomedical model of health but this is now changing towards a more holistic model based on a whole person approach incorporating physical, psychological and social factors, rather than only their physical condition or symptoms 2) Research investigating psychosocial issues is limited in GTD but there is evidence of the significant impact of GTD on physical, psychological, and social wellbeing including anxiety, sexual dysfunction and fertility-related distress. For survivors of GTD overall quality of life is good. 3) GTD nurses are now more common within GTD multidisciplinary teams internationally and can bridge the gap between biomedicine and holistic practice 4) GTD nurses can provide accessible and dedicated expert GTD holistic care alongside MDT colleagues with continuity and compassion 24.1 INTRODUCTION Gestational Trophoblastic Disease (GTD) is a rare, complex condition with an excellent prognosis for the majority of women affected thanks to the development of significant medical expertise in this area. As was common in medicine in the 20 th Century the treatment of GTD was based within the biomedical model of health, but this approach has evolved with time towards a more holistic approach to GTD care. Nurses are increasingly commonplace within GTD multidisciplinary teams worldwide as they aim to support their patients on their disease journey taking a whole person approach, acknowledging the numerous psychosocial challenges associated with a GTD diagnosis. Limited research has explored the physical, psychological and social impact of GTD from the patient's perspective. This chapter will aim to outline the shift towards holistic models of care within international GTD practice and the role of GTD nurses, whilst also providing an overview of current evidence on the impact of GTD and its treatment on physical, psychological and social well-being and quality of life, to frame this shift and guide future service development. 24.2 BACKGROUND TO HOLISTIC MODELS OF CARE IN GTD Gestational Trophoblastic Disease is a rare condition that affects women during or after pregnancy. It is a disease of the cells that form the outer lining of the placenta, known as trophoblastic cells. GTD is an umbrella term for a range of conditions, ranging from the premalignant disorders of complete or partial molar pregnancy (MP), through to the malignant conditions of invasive mole,
... Specifically, women with GTN are more likely to experience high levels of anxiety compared to those with hydatidiform moles. This may be due to the long-term physical and psychological consequences produced by chemotherapy, which is mandatory in cases of malignant disease [37,40]. Additionally, patients with metastatic cancer are considered particularly at risk of developing anxiety disorders [37]. ...
... This may be due to the long-term physical and psychological consequences produced by chemotherapy, which is mandatory in cases of malignant disease [37,40]. Additionally, patients with metastatic cancer are considered particularly at risk of developing anxiety disorders [37]. In some cases, anxiety symptoms are secondary to other emotional responses triggered by the diagnosis, which often elicits a sense of confusion, uncertainty, anger, and frustration. ...
... In some cases, anxiety symptoms are secondary to other emotional responses triggered by the diagnosis, which often elicits a sense of confusion, uncertainty, anger, and frustration. These feelings may persist over time and in certain circumstances may lead to a state of emotional exhaustion [22,24,37]. ...
Article
Gestational Trophoblastic Disease (GTD) represents a spectrum of rare pregnancy-related disorders, including both premalignant and malignant entities. Although GTD’s medical outcomes have been widely explored, limited data are available regarding the related psychological, sexual and fertility issues. The present chapter aims to enhance comprehension of the psychosocial impact of GTD by discussing the main quantitative and qualitative evidence available in this field. Although patients globally report a good quality of life, clinically significant levels of anxiety and depression have been consistently found across studies. Similarly, despite the quality of couple relationships being generally satisfactory, they often complain of a lack of sexual desire. Moreover, pregnancy loss may raise significant and long-term fertility-related concerns. Specific socio-demographic and clinical factors have been identified as predictors of psychosocial outcomes. On a clinical level, research suggests there is a need to provide multidisciplinary care to patients.
... An advanced search of the biomedical and psychological literature databases from 1966 to 2010 revealed that limited data have evaluated the quality of life and emotional and sexual impact of molar pregnancy in patients and their partners [1][2][3][4][5][6][7][8]. This is surprising in a disease where the prevalence has been reported to vary from 1 in 200 to 1 in 2000 pregancies and where women undergo the stress of a surgical procedure, possible management with chemotherapy, loss of a pregnancy and delay in future childbearing. ...
... Molar pregnancy is more common at the end of the reproductive lifespan. Previous studies have reported that the delivery of a live child is the single strongest association with positive psychological recovery [1][2][3][4][5][6][7][8]. It follows that the preservation of the partnership between the affected woman and her partner is a relevant issue for long-term recovery. ...
... In contrast, time from diagnosis and chemotherapy did not impact upon outcome measures in multivariate analysis. This observation has been previously noted [5,6]. ...
Article
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Molar pregnancy is a complication of 1 in 200-2000 pregnancies whereby abnormal placental tissue proliferates in the absence of a fetus and may lead to metastases. The disease origin lies in dispermy or dual fertilisation of the egg. The aim of this study was to explore the impact of molar pregnancy upon the male partner. Institutional ethics committee approval and individual consent were obtained. All women listed on the state molar pregnancy database who were receiving active follow-up (n = 102) and a random sample of women who had been registered in the previous 30 years (n = 56) were sent a postal survey outlining the purpose of the study and an invitation for their partner to participate. Sixty-six women gave permission for their partner to participate in the study. Questionnaires included the Hospital Anxiety and Depression Scale, Satisfaction with Life Scale and Sexual History Form 12. Responding partners were also invited to make comments about any aspect of particular concern. A reminder mail out was issued after 6 weeks. The response rate was 62% (N = 41). The key findings were that 32.5% and 12.5% of men met the case criteria for anxiety and depressive disorder, respectively. These figures represent a doubling of usual community rates for anxiety disorder. However, overall quality of life and sexual functioning outcomes were consistent with community samples. The presence of children played a protective role and was associated with significantly better psychological function and quality of life in univariate and multivariate analysis. Qualitative results complemented the quantitative data, with anxiety as the dominant emotional theme. There are high persisting levels of anxiety in male partners of women with molar pregnancy. Partners may benefit from therapy where anxiety disorders are detected. Copyright © 2011 John Wiley & Sons, Ltd.
... Moreover, we may hypothesise that childless, younger women are driven by a stronger need to become a parent, thus the sudden interruption of their goal (due to the GTD diagnosis, treatment and follow-up) has a more negative impact on them. With regards to this aspect, Wenzel and colleagues [37] found that 47% of women suffering from GTD declared that after the treatment having a child was even more important, not only for themselves, but for their respective partners too. ...
... In our study neither depression nor anxiety levels were influenced by the presence of children prior to the GTD diagnosis. This result contrasts our study hypothesis and previous research, which underlines this element as a protective factor for GTD patients, associated with significantly better psychological function and quality of life scores [6,11,37,39]. In this study we found that children are protective only in terms of infertility-related stress. ...
Article
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Gestational Trophoblastic Disease (GTD) comprises a group of disorders that derive from the placenta. Even if full recovery is generally expected, women diagnosed with GTD have to confront: the loss of a pregnancy, a potentially life-threatening diagnosis and delays in future pregnancies. The aim of the study is to evaluate the psychological impact of GTD, focusing on perceived fertility, depression and anxiety. 37 patients treated for GTD at San Raffaele Hospital, Milan, took part in the study. The STAI-Y (State-Trait Anxiety Inventory), the BDI-SF (Beck Depression Scale-Short Form) and the FPI (Fertility Problem Inventory) were used. Patients were grouped on the basis of presence of children (with or without), age (< or ≥35) and type of diagnosis (Hydatidiform Mole, HM, or Gestational Trophoblastic Neoplasia, GTN). Differences in the values between variables were assessed by a t-type test statistic. Three-way ANOVAs were also carried out considering the same block factors. The study highlights that women suffering from GTN had higher depression scores compared to women suffering from HM. A significant correlation was found between anxiety (state and trait) and depression. Younger women presented higher Global Stress scores on the FPI, especially tied to Need for Parenthood and Relationship Concern subscales. Need for Parenthood mean scores significantly varied between women with and without children too. We can conclude that fertility perception seems to be negatively affected by GTD diagnosis, particularly in younger women and in those without children. Patients should be followed by a multidisciplinary team so as to be supported in the disease's psychological aspects too.
... 8 Earlier studies have established elevated levels in various psychological domains, such as anxiety, depression, distress and reproductive concerns. All these studies, however, [9][10][11][12][13][14][15] had a retrospective design, as psychological complaints were evaluated several years after diagnosis, possibly causing recall bias. In general, recall bias leads to less reliable results when more time has passed. ...
... Previous retrospective studies focusing on GTD patients also reported psychological impact such as anxiety, depression, stress reactions and reproductive concerns. [9][10][11][12][13][14]27 One study analysing GTD patients used the HADS-A and reported lower anxiety rates than our study. 10 This could be explained by the fact that the time between diagnosis and completing the questionnaires was nearly 5 years and anxiety is likely to diminish over time. ...
Article
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Objective: To evaluate the short-term psychological consequences of Gestational Trophoblastic Disease (GTD). Design: A prospective observational multicentre cohort study. Setting: Nationwide in the Netherlands POPULATION: GTD patients. Methods: Online questionnaires directly after diagnosis. Main outcome measures: Hospital Anxiety and Depression Scale (HADS), Distress Thermometer (DT), Impact of Event Scale (IES) and Reproductive Concerns Scale (RCS). Results: 60 GTD patients were included between 2017 and 2020. Anxious feelings (47%) were more commonly expressed than depressive feelings (27%). Patients experienced moderate to severe adaptation problems in 88%. Patients who already had children were less concerned about their reproductivity than patients without children (mean score 10.4 versus 15.0, p = 0.031) and patients with children experienced lower distress (IES mean score 25.7 versus 34.7, p = 0.020). In addition, patients with previous pregnancy loss scored lower for distress than patients without pregnancy loss (IES mean score 21.1 versus 34.2, p = 0.002). Discussion: We recommend physicians to monitor physical complaints and the course of psychological wellbeing over time in order to provide personalized supportive care in time for patients who have high levels of distress at baseline. Conclusions: GTD patients experience increased levels of distress, anxiety and depression, suggesting the diagnosis has a substantial effect on the psychological wellbeing of patients. The impact of GTD diagnosis on intrusion and avoidance seems to be ameliorated in patients who have children or who have experienced previous pregnancy loss.
... The influence of quality of life (QOL) after molar pregnancy has been shown by several authors. 14,15 Recently Ferreira et al 16 published their study on the assessment of QOL and psychologic aspects in patients with GTD. However, they did not address the aspects of follow-up, and both women with spontaneous normalization and women with PTD were included (n = 54). ...
Article
To investigate the psychological consequences of hCG measurements during follow-up in patients with low-risk gestational trophoblastic disease. The length of follow-up of patients with molar pregnancy and spontaneous normalization of the hCG level is currently discussed, in consideration of the low incidence of recurrent disease. Patients registered in the Dutch Central Registry of Hydatidiform Mole between January 2006 and December 2007 were eligible for this study. Patients received a questionnaire containing questions about follow-up and anxiety and stress during this period. Seventy-six patients were eligible for the study. An inverted correlation (r = -0.35, p = 0.003) was found between the age of patients and the level of anxiety. Anxious patients scored higher for fear of recurrence (r = 0.49, p < 0.0001), of infertility (r = 0.40, p = 0.001) and of conceiving again (r = 0.30, p = 0.01). They experienced the measurements as a burden (r = 0.35, p = 0.003). Fewer patients (24%) were insecure before the monthly hCG measurement, compared to 51% during weekly measurements. The majority of women (80%) completed the follow-up and confirmed that they would come for weekly and monthly hCG measurements if it were optional. Follow-up after low-risk GTD has psychologic consequences but provides reassurance as well. Therefore, women tend to accept the offered surveillance and refrain from pregnancy. Women with GTD should be counseled about the minor risk of recurrence and the consequences of follow-up.
... The first result contrasts with previous research, which underlined the role of children as a protective factor for GTD patients. 7,8,42 Regarding the relationship between psychological symptoms of depression or anxiety and time elapsed since diagnosis, we have considered a comparatively short time of follow-up (7 months on average). However, our results are in line with other studies that consider a comparable lapse of time (6 months or < 1 year) 26,43 and also with previous research that evaluated longer periods of time. ...
Article
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Objective: To evaluate the impact of a forced delay in childbearing during thefollow-up period on the perceived fertility of patients with gestational trophoblastic disease (GTD), and to investigate how women react to the monitoring period, with particular attention to fertility concerns, personal perceptions of the impact of GTD on reproductive outcomes, and psychological symptoms of depression and anxiety. Study design: Twenty women treated for GTD at San Raffaele Hospital, Milan, took part in the study. Depression, anxiety, and infertility-related stress were assessed using the Beck Depression Inventory-Short Form, the State-Trait Anxiety Inventory, and the Fertility Problem Inventory, respectively. Results: A significant difference in depression levels was found between women with hydatiform mole and women with gestational trophoblastic neoplasia (p = 0.02). On the contrary, anxiety and depression levels did not vary on the basis of time elapsed since diagnosis, presence of children, and age (< 35 years). A significant correlation was also found between anxiety (state and trait) and depression (rho(s) = 0.62, p = 0.002 and rho(s) = 0.59, p = 0.005. respectively). There was no association between infertility-related stress and anxiety or depression or time elapsed since diagnosis. Additionally, such stress did not change between women with or without children. Conclusion: Women with GTD diagnosis should be followed by a multidisciplinary team so as to be supported in the disease's psychological aspects, too.
... At present Hydatidiform Mole and Gestational Trophoblastic Neoplasia are both highly curable diseases [27]. Despite the fact that a full recovery is generally expected, women diagnosed with GTD have to confront the loss of a pregnancy, a potentially life-threatening diagnosis, surgical and/or chemotherapy treatment and delays in future pregnancies [28]. Currently, the psychological impact of this condition for both the patient and her partner has been studied; focus has been specifically on the psychopathological consequences of the disease [8-10, 28-30], on patient quality of life [10,[30][31][32] and on fertility-related stress [8,9,31,33]. ...
Article
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Background: Gestational Trophoblastic Disease comprises a group of benign and malignant disorders that derive from the placenta. Using Leventhal's Common-Sense Model as a theoretical framework, this paper examines illness perception in women who have been diagnosed with this disease. Methods: Thirty-one women diagnosed with Gestational Trophoblastic Disease in a hospital in Italy were asked to complete the Illness Perception Questionnaire-Revised to measure the following: illness Identity, illness opinions and causes of Gestational Trophoblastic Disease. Results: High mean scores were observed in the Emotional representations and Treatment control subscales. A significant difference emerged between hydatidiform mole patients and those with gestational trophoblastic neoplasia on the Identity subscale. A significant correlation emerged between "time since diagnosis" and the Treatment control subscale. Discussion: This study is the first to investigate illness perception in Gestational Trophoblastic Disease. From a clinical perspective the results highlight the need for multidisciplinary support programs to promote a more realistic illness perception.
... Women diagnosed with hydatidiform mole or GTN generally have very good prognoses [6]. Despite the fact that a full recovery is generally expected, women diagnosed with GTD have to face the loss of a pregnancy, a potentially life-threatening diagnosis, surgical and/or chemotherapy treatment, and delays in future pregnancies [32]. Thus, a wide range of psychosocial stressors are elicited by this disease. ...
Article
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Gestational Trophoblastic Disease encompasses a group of pregnancy-related disorders that derive from the placenta. Taking Leventhal's Common Sense Model as a starting point, this study aims to investigate how illness perception could influence patients' psychological adaptation to these rare diseases. Thirty-seven women completed: the Illness Perception Questionnaire-Revised, the Beck Depression Inventory Short Form, the State-Trait Anxiety Inventory, and the Fertility Problem Inventory. Results show that the perception of severe illness consequences significantly predicts the level of anxiety patients reported at the time of questionnaire completion. Furthermore , mental representations of illness present a significant association with infertility related stress. Specifically, the belief in the efficacy of the treatment results in fewer feelings of discomfort and isolation from family and social context due to infertility related problems. Since patients' illness perception was found to have a specific impact on both anxiety and infertility-related stress, this variable should be considered in the planning of a clinical intervention.
... Women diagnosed with low-risk GTN have to live with the loss of a pregnancy, a life-threatening diagnosis, surgery, chemotherapy treatment and postponement of future pregnancies. 26,27 In this study, all women were cured of their disease; however, there was one death in our study, giving an overall survival rate of 97.3%. ...
Article
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Background: Gestational trophoblastic neoplasia (GTN) is classified as a highly curable group of pregnancy-related malignancies; however, approximately 15% will be persistent and require chemotherapy. Up to 25% of these women will develop resistance and 2% will develop disease relapse after initial chemotherapy. Despite the need for further chemotherapy in these women, cure rates are high. Objective: To evaluate the outcomes of women diagnosed with low-risk GTN, assessing the type of treatment, the number of chemotherapy cycles received, development of resistance or disease relapse, survival, and to assess the feasibility of changing to a new drug regimen. Methods: From March 2012 until February 2015, a retrospective study was conducted and 38 cases with low-risk GTN were reviewed. The number of cycles, type of treatment received, duration of treatment, development of resistance and disease relapse, and adverse side effects were analysed. Results: The median duration of follow-up was 12?months. Disease-free survival was 100% and primary complete remission rates were achieved in 85.3% of patients who were treated with actinomycin D and 25% patients who were treated with methotrexate (MTX). A change in chemotherapy was required for nine patients. One patient developed disease relapse. Nausea, fatigue and constipation were the most frequent adverse events reported with actinomycin D. All women were cured of their disease. Conclusion: All women were successfully treated and achieved complete remission. Changing from MTX to actinomycin D as first-line chemotherapy for women with low-risk GTN was feasible and safe.
Article
Although women diagnosed with cancer during their childbearing years are at significant risk for infertility, we know little about the relationship between infertility and long-term quality of life (QOL). To examine these relationships, we assessed psychosocial and reproductive concerns and QOL in 231 female cancer survivors. Greater reproductive concerns were significantly associated with lower QOL on numerous dimensions (P<.001). In a multiple regression model, social support, gynecologic problems, and reproductive concerns accounted for 63% of the variance in QOL scores. Women who reported wanting to conceive after cancer, but were not able to, reported significantly more reproductive concerns than those who were able to reproduce after cancer (P<.001). These preliminary data suggest that at least for vulnerable subgroups, the issue of reproductive concerns is worthy of additional investigation to assist cancer survivors living with the threat or reality of infertility.
Article
To identify predictors of quality of life (QOL) among women diagnosed with gestational trophoblastic tumor (GTT) 5-10 years earlier. Utilizing a cross-sectional, descriptive design, 111 survivors completed a comprehensive QOL interview. Univariate analyses revealed that numerous psychosocial variables correlated highly with overall QOL. However, multivariate analysis indicated that the significant predictors of long-term QOL were cancer-specific distress, social support, spiritual well-being, reproductive concerns, gynecologic pain and sexual functioning. These 6 variables accounted for 77% of the variance in the overall QOL score. Post hoc analyses demonstrated that each of the predictors had unique effects on the QOL score. The variables identified in this model can guide future research and clinical care to reduce short- and long-term burdens associated with GTT.
Article
Molar pregnancy is an unusual complication of pregnancy whereby abnormal placental tissue proliferates in the absence of a fetus. There is usually a protracted follow-up period where pregnancy is contra-indicated. Whilst the medical outcomes of the disease have been well explored, limited data have evaluated the impact on psychological symptomatology, sexual function, and quality of life. Institutional ethics approval and individual consent were obtained. All women listed on the hospital molar pregnancy register receiving active follow-up (n = 102) and a random sample of women who had been registered in the previous 30 years (n = 56) were sent a postal survey outlining the purpose of the study and an invitation to participate. Questionnaires included the Hospital Anxiety and Depression Scale (HADS), Satisfaction with Life Scale (SWLS), and Sexual History Form 12 (SHF-12). The response rate was 54%. The key findings were that 60%, 55%, and 18% of women scored > or =10 on the total HADS, > or =8 on HADS-A, and >8 on HADS-D, respectively. The presence of children played a protective role and was associated with significantly better psychological function and quality of life. SWLS were in the lower end of ranges reported for community controls (mean of 23.9). Chemotherapy had an adverse impact on quality of life ratings (SWLS for chemotherapy yes = 21.7, no = 25). Sexual dysfunction was similar to community samples and was independent of age, time since diagnosis, chemotherapy requirement, and presence of children. Qualitative results complemented the quantitative data with similar emotional themes identified as well as issues related to the medical condition, care, and support networks. Women with a molar pregnancy may benefit from a multidisciplinary approach to management that addresses their psychological and sexual needs in addition to medical aspects of care.
Article
To describe the quality of life (QoL) and long-term psychosocial sequelae in women diagnosed with gestational trophoblastic tumor (GTT) 5-10 years earlier. Utilizing a cross-sectional descriptive design, 111 survivors completed a comprehensive QoL interview. Participants were predominantly married and non-Hispanic white, with a mean age at diagnosis of 30 years and a current mean age of 37 years. This disease-free sample enjoys a good QoL, with physical, social and emotional functioning comparable to or better than comparative norms. However, certain psychological survivorship sequelae persist. Additionally, a sizable number of survivors currently experience significant reproductive concerns. Participants reporting good QoL were less likely to report ongoing coping efforts related to having had this illness, more likely to report greater social support (P < .0001), greater sexual pleasure (P = .0063), and less GTT-specific distress (P < .0001). Fifty-one percent of respondents expressed that they would likely participate in a counseling program today to discuss psychosocial issues raised by having had GTT, and 74% stated that they would have attended a support group program during the initial treatment if it had been offered. This information provides insight into the complex survivorship relationships between QoL and sequelae of GTT.
Article
This study compared subsequent pregnancy outcome in patients with complete and partial hydatidiform moles. Among 1052 patients with molar pregnancy (complete mole, 801; partial mole, 251) monitored at Chiba University Hospital between 1981 and 1999, 891 patients (84.7%) had spontaneous resolution of human chorionic gonadotrophin (HCG) after mole evacuation, and 161 patients (15.3%) required chemotherapy. Of the 891 patients, 438 (49.2%) had 650 subsequent pregnancies. The pregnancy outcome was not significantly different in patients with complete and partial moles, and was comparable with that in the general Japanese population. The incidence of repeat molar pregnancy in patients with complete and partial mole (1.3 and 1.5% respectively) was 5-fold higher than that of the general population, while no increased risk of persistent gestational trophoblastic tumour (GTT) associated with later molar pregnancy was observed. During HCG follow-up, 10 patients (1.1%) developed secondary high-risk GTT between 14 and 54 months after mole evacuation. The incidence of high-risk GTT in patients with and without subsequent pregnancies was 0.46% (2/438) and 1.8% (8/453) respectively (P = 0.1243). In conclusion, patients with complete and partial mole can anticipate a normal future reproductive outcome, and pregnancies after experiencing hydatidiform mole may not affect the development of high-risk GTT.
Article
Patients with gestational trophoblastic disease (GTD) can usually achieve complete sustained remission while retaining their fertility even in the presence of wide-spread metastasis. Following complete and partial mole, our patients had 1,239 and 205 later pregnancies, respectively, which resulted in 68.6% and 74.1% term live births, respectively. Patients with either type of hydatidiform mole have, in general, a normal later pregnancy experience. After one molar pregnancy, the risk of a molar pregnancy in a later conception was about 1%. Our patients who received chemotherapy for persistent gestational trophoblastic tumor had 522 later pregnancies, which resulted in 358 (68.6%) term live births and only 10 (2.5%) major and minor congenital anomalies. Data from other centers involving 2,598 later pregnancies also indicate that after chemotherapy patients can generally anticipate a normal future reproductive outcome.
Article
To determine the outcome of pregnancies occurring before completion of human chorionic gonadotropin follow-up in patients treated with chemotherapy for gestational trophoblastic tumor. Retrospective record review of patients with gestational trophoblastic tumor who conceived before standard hCG follow-up was completed during 1973-1998. Forty-three patients treated for gestational trophoblastic tumors conceived before human chorionic gonadotropin follow-up was completed. The antecedent pregnancy was complete mole in 31 (72.1%) and partial mole in 12 (27. 9%) patients. Of the 43 patients, 39 (90.7%) had stage I, 1 had stage II, and 3 had stage III disease. The mean interval from human chorionic gonadotropin remission to new pregnancy was 6.3 months (range 1-11 months). Ten patients underwent elective termination and four patients were lost to follow-up. Of the remaining 29 patients, 22 (75.9%) had term live births, 3 (10.3%) had preterm delivery, 3 had spontaneous abortion, and 1 (3.5%) had a repeat mole. Two cases of fetal anomalies were detected; one was inherited polydactyly and the other was hydronephrosis. One patient developed choriocarcinoma with lung involvement and underwent cesarean section at 28 weeks; a normal fetus was delivered and no choriocarcinoma was detected in the placenta. Pregnancies occurring in patients treated for gestational trophoblastic tumor before standard human chorionic gonadotropin follow-up is completed may continue under close clinical surveillance since the majority have a favorable outcome. However, patients should also be advised of the low but important risk of delayed diagnosis in case tumor relapse develops during early subsequent pregnancy.
Article
The female identity of women who suffer from hydatidiform mole developing into persistent trophoblastic disease is threatened in two ways. The reproductive failure is shortly followed by a disease originating in the uterus requiring chemotherapy. Although somatic treatment results are excellent, the psychological effects may be severe and protracted. We conducted a study of 22 women who were between 6 months and 5 years after the end of successful treatment. It appeared that 19 women suffered from psychological sequelae. The three oldest women of the study group, 50 years or older, belonged to the group of women demonstrating signs of prolonged psychological effects.
Article
To evaluate the subsequent reproductive outcomes in patients with complete and partial molar pregnancy and gestational trophoblastic neoplasia (GTN) at the New England trophoblastic Disease Center between June 1, 1965, and December 31, 2007. Questionnaires regarding subsequent pregnancies were mailed to all patients with current mailing addresses at the New England Trophoblastic Disease Center. The subsequent reproductive outcomes in patients with complete and partial molar pregnancies and persistent GTN were in general the same as those in the general population. However, after an episode of molar pregnancy the incidence of molar pregnancy in a later gestation was approximately 1%. Additionally, after successful chemotherapy for GTN, the incidence of stillbirth was 1.4% in later pregnancies. Patients with molar pregnancies and GTN should be reassured that they can in general expect a normal future reproductive outcome.
Article
This review was undertaken to describe current understanding of the natural history of molar pregnancy and persistent gestational trophoblastic neoplasia (GTN) as well as recent advances in their management. Recent literature related to molar pregnancy and GTN was thoroughly analyzed to provide a comprehensive review of the current knowledge of their pathogenesis and treatment. Studies in patients with familial recurrent molar pregnancy indicate that dysregulation of parentally imprinted genes is important in the pathogenesis of complete hydatidiform mole (CHM). CHM is now being diagnosed earlier in pregnancy in the first trimester changing the clinical presentation and making the histologic appearance more similar to partial hydatidiform mole (PHM) and hydropic abortion. While the classic presenting symptoms of CHM are less frequent, the risk of developing GTN remains unchanged. Flow cytometry and immunostaining for maternally-expressed genes are helpful in distinguishing early CHM from PHM or hydropic abortion. Patients with molar pregnancy have a low risk of developing persistent GTN after achieving even one non-detectable hCG level (hCG <5 mIU/ml). Patients with persistent low levels of hCG should undergo tests to determine if the hCG is real or phantom. If the hCG is real, then further tests should determine what percentage of the total hCG is hyperglycosylated hCG and free beta subunit to establish a proper diagnosis and institute appropriate management. Patients with non-metastatic GTN have a high remission rate with many different single-agent regimens including methotrexate and actinomycin D. Patients with high-risk metastatic GTN require aggressive combination chemotherapy in conjunction with surgery and radiation therapy to attain remission. After achieving remission, patients can generally expect normal reproduction in the future. Our understanding of the natural history and management of molar pregnancy and GTN has advanced considerably in recent years. While most patients can anticipate a high cure rate, efforts are still necessary to develop effective new second-line therapies for patients with drug-resistant disease.
Article
To assess quality of life (QoL) and psychological aspects in patients with gestational trophoblastic disease (GTD). This cross-sectional self-report study was conducted among 54 women. Validated question-naires assessed QoL (WHO-QOL-bref), symptoms of depression (Beck Depression Inventory [BDI]) and anxiety (State-Trait Anxiety Inventory [STAI]). Most patients rated overall QoL as good (44.44%) and were satisfied with their health status (42.59%). Mean QoL domain score was lowest for psychologic health (53.86 +/- 21.46) and highest for social relationships (65.74 +/- 22.41). BDI mean was 15.81 +/- 11.15, indicating dysphoria. STAI means were 46 +/- 6.46 for trait-anxiety and 43.72 +/- 4.23 for state-anxiety, both evidencing medium-high anxiety. Among employed patients, environment domain mean was the highest (p = 0.024). Presence of children resulted in lowest means for physical health (p = 0.041) and environment (p= 0.045). Patients desiring children showed significantly higher means for physical health (p = 0.004), psychological health (p = 0.021) and environment (p = 0.003). Chemotherapy had no significant influence on QoL (p > 0.05). This study evidenced psychological impact on GTD patients, suggesting specialized care centers should provide psychological interventions during treatment and follow-up of GTD patients, highlighting the importance of a multidisciplinary approach.
Article
Clinical observation suggests a protracted psychosocial recovery after gestational trophoblastic disease (GTD), although this has not been well studied. We describe long-term psychological morbidity, sexual functioning, and relationship outcomes after GTD. Cross-sectional analysis was made of 176 Australian women previously diagnosed with GTD recruited from a statewide registry. Participants comprised 149 women (85%) who did not require chemotherapy and 27 women (15%) who required chemotherapy for malignant or persistent GTD/molar disease (gestational trophoblastic tumor [GTT]). Data were collected from medical records and via validated self-report questionnaires. The participants were 94 women (53%) with partial mole, 75 women (43%) with complete mole, 4 women (2%) with choriocarcinoma, and 3 women (2%) with hydatidiform mole not otherwise specified. The mean (SD) age at diagnosis and time since diagnosis were 32.1 (6.3) and 4.7 (3.3) years, respectively. Elevated levels of depression and anxiety were reported by 22% and 26% of the women, respectively. One fifth to half of the women experienced some GTD-related avoidant and intrusive phenomena, the latter being more prominent among women who had not had chemotherapy. Sexual dysfunction was reported by 52% of the women. Most women (81%) felt well supported by their partners during the illness, 19% thought the relationship had changed, and 26% perceived that GTD had negatively affected sex life. This perception was stronger in those who received chemotherapy, although objective measures of sexual morbidity showed no group differences. Socially disadvantaged women and those who did not conceive subsequent to the diagnosis had poorer psychosocial outcomes. Notwithstanding limitations, this study is the largest of its type to date. Psychological morbidity rates exceeded community norms, but sexual dysfunction rates, although high, are likely consistent with local norms. These findings highlight the long-term burden of GTD and the importance of a supportive care component in management, even among those who do not require chemotherapy. Socially disadvantaged women and those who do not conceive subsequent to GTD diagnosis require greater psychosocial support.
Article
Gestational trophoblastic disease is one of the few human malignancies that is curable, even in advanced stages of the disease. However, appropriate management and follow-up are essential components in curing this disease. Observational, retrospective and prospective studies evaluating the efficacy of medical and surgical management of gestational trophoblastic disease were analyzed to provide a comprehensive review of current and new treatment modalities. We searched PubMed, Medline and the Library of Congress from January 1965 to January 2010. The reader will obtain information on how to classify gestational trophoblastic neoplasia (GTN) into low- and high-risk groups, as well as learn the medical and surgical management of low- and high-risk GTN and recurrent GTN. The effectiveness of treatment regimens and subsequent fertility is also reviewed. GTN is highly responsive to chemotherapy. However, surgery is an important adjunct in select cases. Even in advanced-stage or recurrent disease, cure can be achieved and fertility preserved.
Article
Little is known about patients' understanding of the causes, treatments, and implications of gestational trophoblastic disease (GTD). Clinical observation suggests that such health literacy is limited. We report on the perceptions of causes and treatment of GTD and its impact on fertility and reproductive outcomes. Cross-sectional analysis of 176 Australian women previously diagnosed with GTD (no longer receiving follow-up/treatment) recruited from a state-wide registry. Participants comprised 149 (85%) women with GTD who did not require chemotherapy and 27 (15%) women who required chemotherapy for malignancy or persistent molar disease. Data were collected from medical records and via self-report questionnaire. Participants were 94 women (53%) with partial mole, 75 (43%) with complete mole, 4 (2%) with choriocarcinoma, and 3 (2%) with hydatidiform mole not otherwise specified. Mean (SD) age at diagnosis and time since diagnosis were 32.1 (6.3) and 4.7 (3.3) years, respectively. Chance/bad luck was the most endorsed cause (n = 146, 83%); 23 (13%) thought GTD was hereditary and 10 (6%) identified a chromosomal etiology. Between 24% and 32% were unsure of the role of alcohol/drugs, venereal diseases, smoking, pollution, contraceptives, and lowered immunity. Surgical/medical procedure (n = 127, 72%) and healthy diet (n = 53, 30%) were the most endorsed treatments. Between 18% and 23% were unsure of the treatment effectiveness of diet, vitamins, exercise, complementary therapy, and contraception. All women treated with chemotherapy understood the rationale thereof; 23 (85%) perceived chemotherapy to be successful, and 19 (70%) could name the agent. Few women perceived a negative impact on their fertility (n = 28, 16%); 52 (30%) were reluctant to conceive again and 100 (57%) questioned their ability to have healthy children. After diagnosis, 111 (63%) had at least 1 live birth. Notwithstanding limitations, this study is the largest of its type to date. These descriptive data enhance our understanding of patients' experience on GTD, highlight the scope of GTD health literacy, and may be useful for clinicians to adjust the content of their patient education.
Article
Most women with gestational trophoblastic disease are of reproductive age. Because the disease is readily treatable with favourable prognosis, fertility becomes an important issue. Hydatidiform mole is a relatively benign disease, and most women do not require chemotherapy after uterine evacuation. A single uterine evacuation has no significant effect on future fertility, and pregnancy outcomes in subsequent pregnancies are comparable to that of the general population, despite a slight increased risk of developing molar pregnancy again. If women develop persistent trophoblastic disease, single or combined chemotherapy will be needed. Although ovarian dysfunction after chemotherapy is a theoretical risk, a term live birth rate of higher than 70% has been reported without increased risk of fetal abnormalities. Successful pregnancies have also been reported after choriocarcinoma. Only a few case reports have been published on fertility-sparing treatment in placental-site trophoblastic tumour, and the successful rate is about 67%. Women are advised to refrain from pregnancy for at least 6 months after a molar pregnancy, and at least 12 months after a gestational trophoblastic neoplasia. Most of the contraceptive methods do not have an adverse effect on the return of fertility. Finally, at least one-half of these women suffer from some form of psychological or sexual problems. Careful counselling and involvement of a multi-disciplinary team are mandated.
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IntroductionClassificationPremalignant pathology and presentationMalignant pathology and presentationPrognostic factors and treatment groupsPersonal and psychological issues
Article
Objective: The purpose of this study was to identify the clinical factors associated with time to hCG remission among women with low-risk postmolar GTN. Methods: This study included a non-concurrent cohort of 328 patients diagnosed with low-risk postmolar GTN according to FIGO 2002 criteria. Associations of time to hCG remission with history of prior mole, molar histology, time to persistence, use of D&C at persistence, presence of metastatic disease, FIGO score, hCG values at persistence, type of first line therapy and use of multiagent chemotherapy were investigated with both univariate and multivariate analyses. Results: Overall median time to remission was 46 days. Ten percent of the patients required multi-agent chemotherapy to achieve hCG remission. Multivariate analysis incorporating the variables significant on univariate analysis confirmed that complete molar histology (HR 1.45), metastatic disease (HR 1.66), use of multi-agent therapy (HR 2.00) and FIGO score (HR 1.82) were associated with longer time to remission. There was a linear relationship between FIGO score and time to hCG remission. Each 1-point increment in FIGO score was associated with an average 17-day increase in hCG remission time (95% CI: 12.5-21.6). Conclusions: Complete mole histology prior to GTN, presence of metastatic disease, use of multi-agent therapy and higher FIGO score were independent factors associated with longer time to hCG remission in low-risk GTN. Identifying the prognostic factors associated with time to remission and effective counseling may help improve treatment planning and reduce anxiety in patients and their families.
Article
Quality of life (QOL) is a fundamental consideration for patients with life threatening diseases. Major evolving paradigms are discussed: improved QOL with laparoscopic surgery, the impact on QOL of intraperitoneal chemotherapy for optimally cytoreduced ovarian cancer, combination therapy, sexuality, and survivorship. The goals of treatment for many patients with gynecologic tumors remain largely palliative, and patient reported QOL is the primary outcome determining the utility of treatment. Particularly in this area, QOL endpoints are increasingly important in clinical trials. The QOL issues facing gynecologic cancer patients, the use of validated QOL instruments, recent advances in the evaluation of interventions, and changes in concepts related to QOL are reviewed.
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Although women diagnosed with cancer during their child- bearing years are at signifi cant risk for infertility, we know little about the relationship between infertility and long- term quality of life (QOL). To examine these relationships, we assessed psychosocial and reproductive concerns and QOL in 231 female cancer survivors. Greater reproductive concerns were signifi cantly associated with lower QOL on numerous dimensions ( P
Article
Objective: The objective of the study was to investigate whether a history of hydatidiform mole (HM) is associated with an increased risk of adverse outcomes in subsequent pregnancies. Study design: This was a nationwide cohort study with data from population-based registers. The study population consisted of all children registered in the Swedish Medical Birth Register 1973-2009 (n = 3,730,825). Odds ratios (ORs) with 95% confidence intervals (CIs) were estimated for adverse maternal and offspring pregnancy outcomes by maternal history of HM prior to the delivery, with children to women with no maternal history of HM as the reference. Risk estimates were adjusted for maternal age at delivery and maternal country of birth. Results: A history of HM was not associated with an increased risk of adverse maternal outcomes in subsequent pregnancies (n = 5186). Women exposed to a molar pregnancy prior to the index birth were at an almost 25% increased risk of preterm birth (OR, 1.23; 95% CI, 1.06-1.43), whereas women with at least 1 birth between the HM and the index birth were at an increased risk of a large-for-gestational-age birth and stillbirth (OR, 1.35; 95% CI, 1.10-1.67 and OR, 1.81; 95% CI, 1.11-2.96, respectively). The risk of repeat mole was 0.4%. Conclusion: Women with a history of HM are at no increased risk of adverse maternal outcomes in subsequent pregnancies but have an increased risk of large-for-gestational-age birth, stillbirth, and preterm birth. However, in absolute terms, the risk of subsequent adverse offspring outcomes is very low.
Article
Gestational trophoblastic disease consists of a group of interrelated diseases, including molar pregnancy, placental site trophoblastic tumor, and choriocarcinoma. Advances in the diagnosis and management of gestational trophoblastic diseases over the past 5 years were reviewed. Molar pregnancy is now categorized as complete or partial on the basis of gross and microscopic histopathologic and karyotypic findings. Early detection of persistent gestational trophoblastic tumor (GTT) depends on careful postmolar gonadotropin follow-up and consideration of the diagnosis for any woman of reproductive age with unexplained gynecologic and/or systemic symptoms. Triple therapy with methotrexate, actinomycin D, and cyclophosphamide was once the preferred treatment for patients with high risk metastatic GTT but induced remission in only about 50%. Treatment with etoposide, methotrexate, actinomycin D, cyclophosphamide, and vincristine is now the preferred regimen for treatment of high risk metastatic GTT and has been shown to induce remission in about 70% of patients. Important advances have been made in the diagnosis and treatment of patients with gestational trophoblastic disease, and patients can be reassured that they can anticipate normal reproductive functioning.
Chapter
Gestational trophoblast tumours (GTT) form a family of related conditions arising from the cells of conception. All the diagnoses in this group are rare, but the combination of rarity, emergency presentations and high curability make the subject of clinical importance to all working in women's healthcare. The most frequently occurring forms of GTT are partial and complete molar pregnancies, which have a combined incidence of less than 1 per 500 conceptions in women aged 18–35. Most women with a molar pregnancy will be cured with an evacuation, and for those requiring chemotherapy treatment cure rates should approach 100%. Choriocarcinoma and placental site trophoblast tumours are the rarest forms of GTT and can present with a wide variety of symptoms, depending on disease location. These GTT patients are frequently unwell at presentation and benefit significantly from prompt diagnosis and in most cases treatment will be curative. This chapter examines the scientific background and clinical management of this rare group of tumours.
Article
Recent advances have increased our understanding of gestational trophoblastic disease, and epidemiologic studies have demonstrated that there are important differences in risk factors for complete and partial mole. Complete moles are now increasingly being diagnosed in the first trimester, affecting their clinical presentation and pathologic characteristics. While important advances have been made in chemotherapy, it is now recognized that etoposide is associated with a risk of second tumors. Several studies have advanced understanding of the molecular biology of gestational trophoblastic disease, and this is important for the eventual development of new and innovative therapy.
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This paper reports on the feasibility and preliminary effects of a decision aid (DA) about female fertility preservation (FP). We conducted a pilot multicentre randomized controlled trial of women with breast cancer aged 18-40 who were randomized to brochures or the DA. Over 18 months, 62 women were eligible, of which 42 were invited by their healthcare provider (74%) to participate in the study. A total of 36 women signed up for participation and 26 (72%) were randomized to brochures (n = 13) or the DA (n = 13). In both groups, many women (87%) read the brochures and eight women used all available brochures. In the intervention group, 7/13 women logged in to the DA. Women who received brochures had slightly less decisional conflict, whereas knowledge improved in both groups. Our results indicate that both brochures about FP and a detailed DA have beneficial effects with regard to knowledge, but the DA seemed to introduce slightly more decisional conflict (DC) than the brochures. Although we encountered challenges with recruitment, our design and measurements seem feasible and the effects of the information materials seem promising, hence justifying conducting a larger study.
Article
Current therapy for molar pregnancy and gestational trophoblastic neoplasias (GTNs) has resulted in high cure rates with preservation of fertility, even in the setting of chemotherapy for widespread metastatic disease. Data from the New England Trophoblastic Disease Center on later pregnancies following complete and partial mole, as well as persistent GTN show that patients can, in general, anticipate normal subsequent pregnancy outcome. Nevertheless, patients and their partners often express anxiety and fear related to the risk of disease recurrence and the outcome of subsequent pregnancies after treatment for gestational trophoblastic disease. These psychosocial sequelae may persist for years in both patients and their partners.
Article
This study reports on the development of the Dyadic Adjustment Scale, a new measure for assessing the quality of marriage and other similar dyads. The 32 item scale is designed for use with either married or unmarried cohabiting couples. Despite widespread criticisms of the concept of adjustment, the study proceeds from the pragmatic position that a new measure, which is theoretically grounded, relevant, valid, and highly reliable, is necessary since marital and dyadic adjustment continue to be researched. This factor analytic study tests a conceptual definition set forth in earlier work and suggests the existence of four empirically verified components of dyadic adjustment which can be used as subscales [dyadic satisfaction, dyadic cohesion, dyadic consensus and affectional expression]. Evidence is presented suggesting content, criterion related, and construct validity. High scale reliability is reported. The possibility of item weighting is considered and endorsed as a potential measurement technique, but it is not adopted for the present Dyadic Adjustment Scale. It is concluded that the Dyadic Adjustment Scale represents a significant improvement over other measures of marital adjustment, but a number of troublesome methodological issues remain for future research.
Article
Assessment of sexual frequency, function, and behavior, as well as marital happiness and psychological distress was performed for 61 women with early stage, invasive cervical cancer at the time of diagnosis. Cancer treatment was radical hysterectomy alone for 26 women and radiotherapy with or without surgery for 37. Followups took place at 6 and 12 months after cancer therapy. Women's sexual satisfaction, capacity for orgasm, and frequency of masturbation remained stable, whereas frequency of sexual activity with a partner and range of sexual practices decreased significantly by one year. Women who received irradiation with or without surgery resembled women who underwent radical hysterectomy alone at 6 months. By one year, however, the radiotherapy group had developed dyspareunia, which was reflected in gynecologist ratings at pelvic examination. The women receiving radiotherapy also had more problems with sexual desire and arousal, and were less likely to resume several daily life activities. Cancer treatment modality was not related to marital happiness or stability, however.
Article
Forty-two of sixty-seven patients (62.7%) treated for high-risk metastatic trophoblastic disease achieved and maintained complete remissions. The survival rate was significantly improved in those patients with scores lower than 8 according to a modification of the World Health Organization (WHO) prognostic scoring system. A low score was associated with a higher probability of response to single-agent therapy, although the difference was not statistically significant. The score, however, was significantly associated with response to multiagent chemotherapy with methotrexate, actinomycin D, and cyclophosphamide (P = 0.0004). Therefore, future trials of new combinations of chemotherapy in high-risk patients should be stratified according to the patients' prognostic scores.
Article
Thesis (Ph. D.)--Arizona State University, 1988. Vita. Includes bibliographical references (leaves [116]-123).
Article
Radioimmunoassays and bioassays based on the reactions of the native molecule of human chorionic gonadotropin (HCG) fail to differentiate HCG from pituitary luteinizing hormone (LH). An assay based on the beta-subunit of HCG which detects HCG exclusively has been used in our laboratory to monitor patients undergoing chemotherapy for gestational trophoblastic disease (GTD). We have been able to differentiate minimal, persisting tumor activity from normal levels of pituitary gonadotropins and have based therapy on these findings. Alternatively, treatment has been terminated when HCG is no longer detectable in the serum. Tumor activity has been detected in the beta-subunit assay at a time when biologic activity in the urine indicated remission.
Article
Three hundred and seventeen patients with gestational trophoblastic tumors were investigated and treated between 1957-1973. The risk of trophoblastic tumor was influenced by the outcome of the antecedent pregnancy (hydatidiform mole, non-mole abortion, term delivery) and the ABO blood groups of the mating couple; it was also influenced by the patient's age. The response to treatment with chemotherapy and , where appropriate, with surgery and radiotherapy, was influenced prfoundly by several factors. These included 1) the outcome of the antecedent pregnancy, 2) the total body burden of tumor at the time treatment stated as reflected by the urinary output of human chorionic gonadotrophin (CG), 3) the interval between the antecedent pregnancy and the start of chemotherapy, 4) the ABO groups of the mating couple, 5) the extent of mononuclear cell infiltration in the tumor, 6) the immunological status of the patient at the start of treatment, 7) the size of tumor masses, 8) the site of metastases and particularly the presence of intracranial metastases, and possibly by 9) the age and 10) the parity of the patient. A detailed study of the HLA antigens of the patient, her husband, and antecedent child has shown no positive effect on risk or prognosis. These data provide a basis for a scoring system that allows the prognosis to be defined at the time of diagnosis and facilitates tisk of drug resistance. Applied retrospectively to the cases from which the scoring system was generated, prognostic groups with survival rates ranging from 0-100% can be defined. Unfavorable prognostic factors combine so as to increase the probability of drug resistance.
Article
This report concerns 347 patients with primary hydatidiform moles studied during the first 6 years (1966-1972) of operation of the Southeastern Regional Trophoblastic Disease Center. Aside from a decreased incidence, molar pregnancy in the United States follows a pattern similar to that elsewhere in the world. Abnormal bleeding is the key to early diagnosis, and the frequent use of sensitive HCG assays is the key to proper followup. Twenty percent of patients with hydatidiform moles can be expected to develop subsequent malignant sequelae. Bilateral ovarian enlargement and/or a large-for-dates- uterus should alert the physician to a greater potential for this outcome. Spontaneous elimination of HCG from the circulation following moler pregnancy, as indicated by sensitive assay, would predict a benign postmolar course; no patient in the current series who once achieved undetectable levels of HCG developed malignant trophoblastic disease.
Article
The incidence and etiology of major life difficulties for women with survivable cancer were studied. Women with early stage cancer (n = 65) were assessed after their diagnosis but prior to treatment and then reassessed at 4, 8, and 12 months posttreatment. Two matched comparison groups, women diagnosed and treated for benign disease (n = 22) and healthy women (n = 60), were also assessed longitudinally. Results for four life areas are reported: (a) The emotional response to the life-threatening diagnosis and anticipation of treatment was characterized by depressed, anxious, and confused moods, whereas the response for women with benign disease was anxious only. In both cases, these responses were transitory and resolved posttreatment. (b) There was no evidence for a higher incidence of relationship dissolution of poorer marital adjustment; however, 30% of the women treated for disease reported that their sexual partners may have had some difficulty in reaching orgasm (i.e., delayed ejaculation) after the subjects' treatment. (c) There was no evidence for impaired social adjustment. (d) Women treated for cancer retained their employment and their occupations; however, their involvement (e.g., hours worked per week) was significantly reduced during recovery. These data and those in a companion report (Andersen, Anderson, & deProsse, 1989) suggest "islands" of significant life disruption following cancer; however, these difficulties do not appear to portend global adjustment vulnerability.
Article
Low-risk metastatic gestational trophoblastic disease is almost uniformly curable with chemotherapy if the diagnosis is correct. Recent clinical investigations have focused on reducing the toxicity and cost of chemotherapy. This article discusses the diagnosis and current management.
Article
Assessment of sexual frequency, function, and behavior, as well as martial happiness and psychological distress was performed for 61 women with early stage, invasive cervical cancer at the time of diagnosis. Cancer treatment was radical hysterectomy alone for 26 women and radiotherapy with or without surgery for 37. Followups took place at 6 and 12 months after cancer therapy. Women's sexual satisfaction, capacity for orgasm, and frequency of masturbation remained stable, whereas frequency of sexual activity with a partner and range of sexual practices decreased significantly by one year. Women who received irradiation with or without surgery resembled women who underwent radical hysterectomy alone at 6 months. By one year, however, the radiotherapy group had developed dyspareunia, which was reflected in gynecologist ratings at pelvic examination. The women receiving radiotherapy also had more problems with sexual desire and arousal, and were less likely to resume several daily life activities. Cancer treatment modality was not related to marital happiness or stability, however.
Article
Seventy-three patients with metastatic high-risk gestational trophoblastic disease were treated with methotrexate, actinomycin D, and cyclophosphamide chemotherapy at the Brewer Trophoblastic Disease Center between 1968 and 1982. Forty-six patients were treated primarily with methotrexate, actinomycin D, and cyclophosphamide because of the presence of one or more high-risk factors. Twenty-seven additional patients who had not responded to initial single-agent chemotherapy with methotrexate and/or actinomycin D were subsequently treated with methotrexate, actinomycin D, and cyclophosphamide. Adjuvant surgery and radiotherapy were used in selected patients. The overall cure rate was 51% (37 of 73): 63% (29 of 46) for primary treatment and 30% (eight of 27) for secondary treatment (P less than .01). Several factors that influenced response to primary treatment with methotrexate, actinomycin D, and cyclophosphamide chemotherapy were determined: 1) clinicopathologic diagnosis of choriocarcinoma versus invasive mole (59 versus 100%), 2) metastases to sites other than the lung and/or vagina (44 versus 74%), 3) antecedent term gestation compared with hydatidiform mole or abortion (50 versus 75%), and 4) presence of three or more high-risk factors (27 versus 74%). There were no significant differences in cure rates during the course of the study period.
Article
Gestational trophoblastic disease has several special aspects as compared with others tumors of the female genital tract. It occurs in young women who want to start a family and expect to have a normal pregnancy. It can be very effectively treated with chemotherapeutic agents, and the subsequent reproductive potential of these young women is not affected. In a survey of 105 Chinese residents of Hong Kong who had had the disease, it was found that their emotional reactions to the disease and treatment, the effects of such on their self-esteem, martial and sexual life, and their attitudes towards their physicians and future pregnancy were different from those of their Western counterparts.
Article
Fifty-one patients are presented who were treated for poor-prognosis gestational trophoblastic disease by physicians at Duke University Medical Center (Southeastern Regional Trophoblastic Disease Center) between 1968 and 1978. Disease in 72% (37 of 51 patients) is currently in remission (8 months to 10 years). Treatment was primarily by multiagent chemotherapy, with adjunctive surgery and radiation therapy in selected patients. Unsuccessful chemotherapy prior to treatment at this center, a prolonged interval from the antecedent pregnancy to treatment, and liver metastases portended a worse prognosis in these patients.
Article
Gynecologists and other health care professionals must be aware that gestational trophoblastic neoplasia may have an important psychological and social impact upon patients. The care of these patients must extend beyond the administration of chemotherapy and fastidious hormonal monitoring. The emotional needs of the patients and their families must be carefully evaluated. We must be sensitive to the potential psychological and social needs of these patients during their course of treatment and follow-up.
Article
This study analyzes the ways 100 community-residing men and women aged 45 to 64 coped with the stressful events of daily living during one year. Lazarus's cognitive-phenomenological analysis of psychological stress provides the theoretical framework. Information about recently experienced stressful encounters was elicited through monthly interviews and self-report questionnaires completed between interviews. At the end of each interview and questionnaire, the participant indicated on a 68-item Ways of Coping checklist those coping thoughts and actions used in the specific encounter. A mean of 13.3 episodes was reported by each participant. Two functions of coping, problem-focused and emotion-focused, are analyzed with separate measures. Both problem- and emotion-focused coping were used in 98% of the 1,332 episodes, emphasizing that coping conceptualized in either defensive or problem-solving terms is incomplete- both functions are usually involved. Intraindividual analyses show that people are more variable than consistent in their coping patterns. The context of an event, who is involved, how it is appraised, age, and gender are examined as potential influences on coping. Context and how the event is appraised are the most potent factors. Work contexts favor problem-focused coping, and health contexts favor emotion-focused coping. Situations in which the person thinks something constructive can be done or that are appraised as requiring more information favor problem-focused coping, whereas those having to be accepted favor emotion-focused coping. There are no effects associated with age, and gender differences emerge only in problem-focused coping: Men use more problem-focused coping than women at work and in situations having to be accepted and requiring more information. Contrary to the cultural stereotype, there are no gender differences in emotion-focused coping.
Controlled prospective longitudinal study of women with cancer. II. Psychological outcomes
  • Andersen