Vaginal and sexual health after radiotherapy for anal cancer: A Danish prospective cohort study

Background: Vaginal and sexual symptoms after radiotherapy for anal cancer are recognised but not well characterised longitudinally. Purpose: To describe the prevalence, severity, and trajectories of vaginal and sexual symptoms up to five years after curative-intent radiotherapy for anal cancer, using clinician-graded toxicity and validated patient-reported outcomes. Methods: We conducted a sub-study within the DACG-I prospective cohort (NCT 05570279), which included women with anal cancer treated with curatively-intended radiotherapy between 2015–2021. Patient-reported outcomes (EORTC QLQ-CR29, QLQ-CX24) and clinician-graded vaginal toxicity (CTCAE v4.0) were collected at baseline and 1, 3, and 5 years. Symptom prevalence was summarised descriptively. Longitudinal changes were evaluated using linear mixed-effects models on linearly transformed EORTC scores. Results: Of 231 enrolled women, 221 provided baseline data. Sexual activity was reported by approximately 25% of participants at each time point. CTCAE grade 2–3 events were uncommon but increased for selected symptoms, including vaginal dryness. Patient-reported symptoms were more frequent. Among sexually active women, moderate to severe vaginal dryness, shortness and tightness affected 28–42% from one year onwards. EORTC scores showed clinically important deteriorations from baseline to one year in dyspareunia, vaginal and sexual symptoms, sexual worry, and sexual enjoyment, with limited recovery over time. Subgroup differences by age, T stage and prescribed dose were small and inconsistent. Conclusions: Vaginal and sexual symptoms after radiotherapy for anal cancer are common, develop early and show little recovery over five years. Systematic assessment and structured survivorship pathways are needed to address these long-term effects.