We examined the feelings, physical changes, and sexual activity of CIN patients before and after intervention. There are numerous reports investigating the above data in cervical cancer, as well as in CIN. However, since different survey questionnaires have been used and reported in cancer12,13 and CIN14,15, it remains unclear how beneficial intervention for CIN is compared to cancer. The purpose of this study was to analyze CIN patients with survey questionnaires typically used for cancer patients. We speculated that by analyzing cancer patients using the same survey questionnaire in the future, we would be able to determine how advantageous CIN treatment is compared to cancer. EORTC initiated a research program to develop an integrated, modular approach for evaluating the quality of life of patients participating in international clinical trials16. The EORTC QLQ-30 is a reliable and valid measure of the quality of life of cancer patients. The EORTC QLQ-24 was developed for patients with cervical cancer to supplement the EORTC QLQ-30 core questions17. Therefore, both questionnaires have been used for surgery, chemotherapy, or radiation therapy in patients with cervical cancer 18–23.
In contrast, Klügel et al conducted a questionnaire survey using scores on the Hospital Anxiety and Depression Scale (HADS) and health-related quality of life (SF-12) for patients with CIN2. Their depression or anxiety symptoms were significant compared with those of healthy women, and the intervention did not lead to any improvement in symptoms24. Others reported that the intervention for CIN led to improvements in self-assessment, based on the use of their original questionnaire 25,26. The standardized questionnaires should be used worldwide for objective evaluation and comparison across languages and regions. Even when the intervention methods differ, using the same questionnaire allows for easier comparison and examination of different treatment approaches. In fact, the EORTC QLQ-30 and QLQ-24 have already been used for patients undergoing trachelectomy27. This means that we can also compare the results for trachelectomy patients with the findings of this study.
Reports in the literature have addressed the issue of patients experiencing emotional instability upon receiving a diagnosis of CIN24,28–30. Feelings of sadness, anger, disappointment, and fear are common, as well as anxiety associated with undergoing colposcopy examinations 31. Understanding the physical and psychological changes that patients undergo before and after treatment is particularly crucial for healthcare professionals providing patient-centered care. However, limited information is available regarding these aspects, which underscores the need for further research26,29. Since ablation was considered to be less invasive and did not significantly affect the patient's daily life, little attention was paid to the patient's emotional and physical changes before and after the procedure. Hence, few articles about this particular aspect of ablation are available. Therefore, during this clinical trial for ablation, the questionnaire survey was administered to patients before and after surgery. As anticipated, there were almost negligible variations noted in the questionnaire items between the pre- and postoperative assessments. However, we found that emotional functioning, body image, symptom experience, and physical functioning were statistically changed before and after surgery. Analysis of the relationship between body image (including attractiveness, femininity, and body dissatisfaction) and emotional functioning (such as tension, worries, irritability, and depression) has revealed positive effects of the surgery on women's mental health. These effects include restoring confidence in their bodies and reducing anxiety. The symptom experience, including discharge and abnormal bleeding, also improved after treatment. There was a significant difference in discharge between 3 months and 6 months post-surgery. The cause of discharge may not be solely attributed to the CIN but could also be a symptom resulting from cervical erosion due to the surgery. It gradually decreases after surgery, thereby contributing to improved quality of life. Regarding abnormal bleeding, a significant difference was observed between pre-surgery and 3 months post-surgery, while no difference was found between 3 months and 6 months post-surgery. This suggests that wound healing is achieved within at least 3 months post-surgery. Generally, patients do not report bleeding beyond two months post-surgery, thus aligning with both the survey results and clinical observations. In terms of physical functioning, an equivocal difference was noted between pre-surgery and three months post-surgery. This can be attributed to the patients' subjective perception of feeling less active or experiencing difficulty in movement after surgery, rather than being an indication of any actual physical issues.
For the question about sexual activity, about one-third of patients did not have any sexual intercourse within the last four weeks before surgery. In this particular group, there was a delay between the confirmation of the disease diagnosis and the start of treatment, so during that time, they may not feel like engaging in sexual intercourse. At 3 months postoperatively, 4/5 of the patients were not having sex, presumably because of their symptoms. This number makes sense as it takes one or two months for the wound to heal. Since ablation is less invasive than excision, we expected that there would be fewer complaints of pain during sexual intercourse, and our results from Q53 of QLQ-CX24 actually indicated that the postoperative pain score at 6 months was the same as the preoperative score in Table 5. Six months after surgery, the frequency data had thus recovered to preoperative levels. Since there was no comparison with healthy couples, it remains unclear how much the disease affects sex, but this study was the first to demonstrate that sexual activity conditions had returned to preoperative levels at least 6 months after surgery.
There were some limitations to this study. The population was small. It should also be noted that, among the enrolled patients, 71.8% were parous women and 97.4% were married. It is important to acknowledge that different results may be obtained for patients who are unmarried and nulliparous. The QLQ-C30 questionnaire was originally prepared for cervical cancer, so it has not been completely adapted for CIN. However, a QLQ-CX24 questionnaire survey for CIN has been published in a previous study32. There is a questionnaire survey that is specific to dysplasia, known as the FACIT-CD33, but it currently has no Japanese translation and thus could not be used in this study. In conclusion, diathermy for precancerous lesions of the cervix primarily has a positive impact on the psychological aspects of the patient, including the restoration of pre-surgery quality of life, rebuilding confidence in the female body, and alleviation of anxiety. There is always a question of how honest patients will be when answering questions about their sexual activity. It may be necessary to take precautions in the future, such as sending survey questionnaires to a different institution from the one where the clinical doctor works, in order to ensure the confidentiality of personal information. However, if surveys are conducted by mail, there is a risk of even lower response rates. In Japan, it is believed that there is a large number of people who consider it extremely embarrassing to answer questions about sexual activity. The actual response rate to such questions in this survey was low, and thus the statistical analysis was not conducted.
This study has certain strengths. As a prospective clinical trial, we administered the questionnaire survey before and after surgery, so we were able to conduct the survey under protocol. The age group was narrowed down to 20–30 years of age. The use of a questionnaire that is employed worldwide will make it easy to compare the scores with those of other treatments, including radical hysterectomy and trachelectomy, in the future27,34–36. In conclusion, diathermy for precancerous lesions of the cervix primarily has a positive impact on the psychological aspects of the patient, including the restoration of pre-surgery quality of life, rebuilding confidence in the female body, and alleviation of anxiety.