Why a Trauma-Informed Approach Is Ideal in Gynecologic Cancer Care

Christina M. Wilson, PhD, CRNP, WHNP-BC

For patients who are traumatized by their cancer treatments, a trauma-based approach may be necessary to help patients feel comfortable coming in for visits, according to Christina M. Wilson, PhD, CRNP, WHNP-BC.

Wilson is an assistant professor with the School of Nursing at the University of Alabama at Birmingham as well as in the Division of Gynecologic Oncology. In addition to caring for patients with cancer in a clinical setting, Wilson has research interests in sexual health issues for patients with cancer and other adverse events associated with treatment. Wilson recently co-authored an article in the Clinical Journal of Oncology Nursing about trauma-informed care in oncology. In an interview with Oncology Nursing News, she shared the main takeaways for oncology nurses.

Understanding the Root of Trauma

“Patients with gynecologic cancer undergo numerous gynecologic or pelvic exams,” Wilson explained. “It can get very intrusive [since that is] a private and intimate area.”

She added that while women in the general population might need to undergo these invasive examinations annually at their well-woman check-ups, women with gynecologic cancer often must go in for appointments every 3, 6, or 9 months—sometimes even more frequently—depending on what treatment they are receiving.

Different treatments are associated with varying levels of invasiveness. For example, with brachytherapy, providers may need to place something other than a speculum within the vagina so that they can see.

Wilson shared an example of a 54-year-old woman with endometrial cancer who had undergone abdominal hysterectomy and brachytherapy. Following the brachytherapy, she experienced rectal bleeding and rectovaginal pain, and consequently grew to be afraid of pelvic examinations and sex. She told her providers that every time she thought about sex or through about an exam, she would become “terrified” and feel as though she was “reliving those experiences.” She did not want to have a pelvic examination and began missing appointments.

Applying a Trauma-Informed Approach

There are 5 pillars of trauma-informed care, Wilson explained. These are safety, choice, collaboration, trustworthiness, and empowerment. By promoting these principles, providers are less likely to retraumatize their patients.

“In terms of a trauma-informed care approach, we want to focus on safety and choice, as well as collaboration, trustworthiness and empowerment,” Wilson explained, “We make sure that the patient, themself, is really in control of what is going on, and that we are creating an environment where they feel comfortable and have the decision-making power.”

For this specific patient, a trauma-based approach was implemented. First, a chaperone was present at the exam to ensure that the patient felt safe. The patient was offered some choices for her visit: she was able to defer parts of her examination and have input on the speculum size as well as depth of the examination.

The follow-up care approach was the result of collaboration between the patient and her providers. They commenced a stepwise incremental approach where the patient came in every 2 weeks.

When they started, the patient was only comfortable sharing her surgical scars with her providers. However, over the course of 3 months, she grew to be comfortable undergoing a speculum examination using a medium Pederson speculum. At this point, not only were the pelvic examinations becoming more tolerable, but she shared interest in reengaging in sexual activity. Her health team focused on using dilators to promote her sexual health.

Advice for Clinicians

As Wilson explained, even for patients without a history of trauma, the procedures used in the gynecologic cancer setting can be very intrusive. Therefore, with every patient, is important to make sure they can ask a lot of questions, make sure they really understand what the procedure will involve beforehand so that there are no surprises, and work together throughout follow-up care.

“This patient did not have a history of any type of physical, emotional, or sexual abuse, but she still felt traumatized by her treatment,” Wilson said, adding that just because the patient was missing appointments did not mean she did not realize their importance.

“Understanding why she did not want those pelvic exams, and that there is something else going on inside of her, was so important,” she said.

Wilson encourages clinicians to be patient and allow flexibility with their approach so that patients can feel in control. She concluded by saying that compromising for a less comprehensive screening that makes the patient feel more comfortable is better than have a patient who is too afraid to come in for any screening at all.

“Work with patients gradually,” she said. “Even if it is just doing a small speculum exam, where you may not be able to see everything, but you can see something and where the patient will willingly come in for treatment, that is better than the patient just not coming and not having any follow up.”

Reference

Wilson CM, Parrish H. How can a trauma-informed care approach be applied to patients with gynecologic cancer? Clin J Oncol Nurs. 2023;27(5):576. 10.1188/23.CJON.576