We found support for both antecedent and mediating variables in explaining a significant amount of variance of the four quality of life domains in ovarian germ cell tumor survivors. First, dimensions of health were related to antecedent and mediating variables. Fewer gynecological symptoms and younger age at diagnosis were associated with better physical functioning. Cella31
found late effects on general health and physical functioning for Hodgkin’s survivors. A theoretically identified mediator - social support - also predicted general health. Ovarian germ cell cancer survivors who reported more social support reported better general health. Vitality as measured by the SF36 is also an indicator of physical functioning. Fewer gynecological symptoms and greater family functioning were associated with higher scores on vitality. Finally, the inclusion of cisplatin in the treatment regimen is associated with long-standing neurotoxicity.32, 33
Ovarian germ cell tumor patients are usually treated successfully and little attention has been directed toward psychological distress that may result from the cancer experience. Thorne (2005) addressed the prevalence of psychosocial distress in cancer patients and its resulting impact on both the patient’s QOL and the health care system which included increased use of health care at all levels.34
The present results support the influence of both social support and self efficacy on psychological QOL outcomes in ovarian germ cell tumor survivors. Both general social support and family functioning contributed to prediction of QOL variables indicating that it is important to measure both general social support and family functioning.
Several questions on the self-efficacy scale used in this research included a woman’s perceived confidence in communicating with health care providers. The more confidence a survivor has in her ability to communicate the better long-term QOL outcomes. Additionally, for most cancer patients, health care provider support is an important component of general support. A body of evidence is emerging that describes the impact of healthcare provider and patient communication on psychosocial distress in cancer survivors. As a result, several studies have directed interventions to increase communication and addressed both the provider and patient.35, 36
Results from this study may support interventions that increase a patient’s self efficacy regarding communication with health care providers as part of an attempt to improve long term psychological distress in cancer patients.
Social support and family functioning were positively related to dyadic adjustment scores. In addition, sexual pleasure also was higher for women who had fewer gynecological symptoms and were married. Sexual discomfort was highest in those with more menstrual/gynecological symptoms and more reproductive concerns. In contrast, previous literature has found that younger breast cancer survivors reported more pain with intercourse. Avis.37
Cimprich found a greater impact on sexuality for younger as compared to older breast cancer survivors.38
The older sample of ovarian germ cell tumor survivors in this report was probably closer in age to the younger breast cancer survivors. However, it is obvious that factors such as menstrual/gynecological symptoms and reproductive concerns were associated with sexual functioning. Menstrual and gynecological symptoms were also strong predictors of QOL, including general health and sexual functioning. It would be important for health care providers to be aware of the impact that these symptoms have on QOL.
We used Spiritual well-being and the Post Traumatic Growth Inventory as global measures of spiritual well-being. Although Spiritual well-being using the FACIT-SP was associated with current age, self efficacy and social support, the PTGI total and PTGI Spirituality was more difficult to predict. Higher scores on spirituality were associated with greater self-efficacy and greater social support as well as by being older at interview. Post-traumatic growth inventory total scores were better for those whose chemotherapy regimen included cisplatin and bleomycin which seems counterintuitive. Possible, women with lingering side effects such as neurotoxicity try to cognitively reframe as a coping mechanism. For spiritual post traumatic growth, the data suggest that getting older, and perhaps wiser, is one of the few predictors of turning a bad experience into a positive outlook. Because a positive growth experience is one of the few potential benefits of the cancer experience, it behooves us to better understand its predictors.
Finally, means and standard deviations of QOL outcome variables were compared with published data. Scores for this sample were very similar to reports from other populations (). Although our data suggest avenues for interventions on several variables, it is evident that overall, the ovarian germ cell population was similar to other populations reported in the literature.
Strengths of this study include the fact that all participants were prospectively identified by the fact that they were initially enrolled on prospective clinical trials. Further, duration of follow-up since chemotherapy is quite long for the majority of patients. However, results of this study must be considered within the context of several limitations. First, this was a cross-sectional survey, and as such, it is difficult to determine if the antecedent and mediating variables did indeed come before the outcomes. That is, the direction of causality may be reversed or even bi-directional. Our analyses were based on a theoretical model that specified direction, however, only a prospective study could determine if these findings are supported. Secondly, although all patients in the described GOG trials were eligible, some could not be contacted. Even though the study team made vigorous efforts to contact all potentially eligible patients, the sample represented here may not be representative of the population in general. Third, although measures were chosen that had demonstrated validity and reliability, limitations of self-report biases must be considered. Finally, it is possible that some associations mentioned in this study may have occurred by chance and are not reproducible. It is possible that unknown variables may have confounded results.
These results have a number of implications for those providing care for patients with ovarian germ cell tumors. First, the general psychological health and quality of life seems to be quite good for survivors of ovarian germ cell tumor survivors and tends to improve over time. The importance of fertility preservation is again emphasized and vigorous efforts to maintain reproductive potential during the initial surgical procedure continued to be warranted. Further, this study has emphasized the importance of menstrual and gynecologic symptoms in many aspects of survivor quality of life. Health care professionals should seek and aggressively manage these symptoms, with the knowledge that symptom control can have substantial implications for quality of life. Survivor self-efficacy and social support have profound implications for many aspects of quality of life. Attempts to maximize these characteristics should begin and the time of diagnosis and continue throughout the treatment and follow-up phases, with the clear understanding that improvement in these qualities can have substantial benefits for survivors. Finally, there are suggestions that improved patient-provider communication can positively alter self-efficacy making health care communication an important concern during diagnosis and treatment.