Prevalence and associated factors of sexual problems after early-stage breast cancer treatment: results of a French exploratory survey
Anne Bre´dart1,2!, S. Dolbeault1,3,4, A. Savignoni5, C. Besancenet1, P. This6, A. Giami7, S. Michaels8, C. Flahault1, M.-C. Falcou5, B. Asselain5 and L. Copel9
1Psycho-Oncology Unit, Supportive Care Department, Institut Curie, Paris, France
2Universite´ Paris Descartes, UMR-S0669, Paris, France
3Inserm, U 669, Paris, France
4Univ Paris-Sud and Univ Paris Descartes, UMR-S0669, Paris, France
5Biostatistics Department, Institut Curie, Paris, France
6Genetic and Breast Disease Department, Institut Curie, Paris, France
7Inserm, U 822, Paris, France
8Center for Gender Studies, University of Chicago, Chicago, IL, USA
9Palliative Care Unit, Supportive Care Department, Institut Curie, Paris, France
Abstract
Objective: The objective of this study was to assess the prevalence and associated factors of sexual activity, sexual problems or sexual satisfaction in French early-stage breast cancer survivors (BCS).
Methods: Eight hundred and fifty eligible, post-treatment (6 months–5 years) female patients, aged 18–70 years, randomly selected from a consultation list, were invited to fill in questionnaires exploring quality of life (EORTC QLQ-C30 and QLQ-BR23), body image scale, and sexuality (Sexual Activity Questionnaire–SAQ; Relationship and Sexuality Scale;
French Sexual Behaviour Survey—CSF).
Results: Fifty-three percent of BCS agreed to participate. Participating women (n5378) were younger, more often premenopausal at diagnosis and with a more recent diagnosis than non-respondents. The prevalence of sexual problems was significantly higher in BCS compared with adjusted data from a French female representative sample (po0.0001). In logistic regression, no sexual activity (R250.37) or sexual dissatisfaction (R250.28) were associated with the feeling of emotional separation in the couple or of partner’s fear of sexual intercourse, lower emotional functioning, poorer body image, or co-morbidities. In sexually active women (71% of respondents), lower frequency of sexual activity (R250.26), lower sexual pleasure (R250.22), or higher sexual discomfort (R250.22) were associated with the feeling of emotional separation in the couple or of partner’s fear of sexual intercourse, lower emotional functioning, age (450 years), nausea, or insomnia (all Hosmer–Lemeshow tests:p5NS).
Conclusions: Psychological factors including the perception of the couple relationship appeared prominent in BCS women’s experience of sexual problems.
Copyrightr2010 John Wiley & Sons, Ltd.
Keywords: breast cancer; survivors; sexual problems; factors; quality of life; body image; couple relationship
Introduction
High levels of post-treatment quality of life are reported after early-stage breast cancer treatment [1–3]. However, a number of disorders can persist, in particular sexual difficulties [1,4–6]. Definition of female sexual dysfunction refers to lack of healthy/
expected/normal, sexual response/interest where psychological, biological, interpersonal, and con- textual factors may contribute [7]. In the context
of breast cancer treatment, sexual function can be affected by sex hormone deficiency [8–11] or by alteration of body image [12,13] leading to decreased libido, disorders of sexual arousal or lubrication, dyspareunia or anorgasmia. These disorders can lead to loss of sexual satisfaction related to pain and disappointment, in turn leading to reduced sexual activity. Emotional well-being and the quality of the relationship with the partner can be affected by the level of distress generated
* Correspondence to: Institut Curie, 26 rue d’Ulm, 75005 Paris Cedex 05, France.
E-mail: [email protected]
Received: 29 October 2009 Revised: 5 May 2010 Accepted: 10 May 2010
within the couple by the diagnosis of breast cancer [14,16,19], which can induce relational tensions or communication problems, particularly among younger couples [21].
Although most women regain their usual sexual activity after breast cancer treatment [4,8,14,22,23], they nevertheless report more preoccupations concerning their sexuality than the general female population [8,15]. A number of studies conducted in the West [4,15,16,22,24] or in Asia [23] provide information about the perception of sexuality among women after treatment for early-stage breast cancer. To our knowledge, no such data are available in France [25]. As cultural factors or healthcare-related factors can affect the woman’s perception of her sexuality, it seemed important to specifically assess the impact of treatment of early- stage breast cancer on sexuality in French women.
Besides, although sexual problems after breast cancer surgery and chemotherapy have frequently been reported [8,12–14], limited data currently exist concerning the role of the adjuvant endocrine therapy, including aromatase inhibitors, on sexual outcomes in early-stage breast cancer survivors (BCS) [11]. Moreover, the impact of endocrine treatment has been more frequently investigated in younger breast cancer patients [14,26,27].
The objectives of this study were: (1) to assess the frequency of sexual activity and the perception of sexual functioning (libido, pain, and pleasure) in early-stage BCS in comparison to adjusted data from a representative sample of the French women population, (2) to explore factors associated to the absence or to the lower frequency of sexual activity, lower sexual pleasure, higher sexual dis- comfort, or sexual dissatisfaction among socio- demographic, clinical, psychological, or relational characteristics.
It was hypothesised that the BCS study sample would be more highly affected by sexual difficulties than women from the general population [8,12,14,15,22,23] and that sexual outcomes would be related to demographic and personal characteristics, breast cancer-related medical vari- ables, body image, the partner relationship and health-related quality of life [16] having undergone a mastectomy [12,13], past chemotherapy [5], past or current endocrine treatment [11], especially aromatase inhibitors [28], older age [4,15], marital status [14] or specifically no new partner [16], lower emotional functioning [8,14–16], poorer body image [14,16,27], as well as dissatisfaction in the couple relationship [8,14,16,24]. Concomitant somatic conditions and lower functioning [30], menopausal transition [8,14], menopausal symp- toms (fatigue, pain, and nausea) [31], time elapsed since breast cancer diagnosis [4,8,14,22,23], or breast cancer treatment side effects, arm or breast sequelae [32] were also explored as potential factors of sexual outcomes.
Patients and methods
Study population
A series of 850 women followed for breast cancer (6 months–5 years after completion of radio- therapy) was randomly selected from the series of 6522 patients attending a surveillance visit at the Institut Curie between 2002 and 2005. Inclusion criteria included: (1) female gender, (2) age between 18 and 70 years, (3) first diagnosis of early-stage breast cancer, and (4) ability to understand French and provide informed consent. Women with local recurrence or a new cancer, metastatic disease, ongoing breast cancer treatment or treatment completed during the previous 6 months (except for endocrine therapy) or for more than 5 years, and those with documented psychiatric illness were not included.
The reference sample was composed of women aged 18 to 69 years randomly selected from the French women population in the context of a sexual behaviour survey [33]. This was carried out by telephone (CATI) and obtained a 98% response rate for the specific questions for comparison with the BCS sample.
Data collection procedure
In the absence of refusal to participate in the study, selected BCS were provided with a set of question- naires to be filled in at home and returned by means of a reply-paid envelope. In the absence of response after 2 weeks, patients were contacted by telephone. This study protocol was approved by theCommission Nationale Informatique et Liberte´s (CNIL: French Information Technology and Privacy Commission).
Measurements or assessment tools
In addition to sociodemographic data collected from the patient’s interview, the following medical data were extracted from the patient’s medical file:
stage of disease, hormonal status at the time of diagnosis, treatment(s) administered or underway (in case of endocrine therapy), time since diagnosis or end of treatment, somatic and psychiatric history and concomitant diseases.
Self-reported questionnaires included:
! The EORTC QLQ-C30 questionnaire (version 3) [34] and the breast cancer-specific module EORTC QLQ-BR23 [35] which were used to evaluate the woman’s quality of life profile. These questionnaires provide scores ranging from 0 to 100, so that a high score on a functioning scale or overall quality of life scale indicates good functioning or a good level of overall quality of life, respectively.
Inversely, a high score on a symptom scale indicates more severe symptoms or problems.
! The Body Image Scale (BIS, [36]) was chosen to evaluate problems of body image. This scale comprises 10 items for which a total score is calculated, ranging from 0 to 30; a higher score indicates a higher frequency of body image problems.
! Three distinct tools were chosen to evaluate sexuality: the Sexual Activity Questionnaire (SAQ), [37], the Relationship & Sexuality questionnaire) [26]. In addition, questions derived from a French survey addressing sexual behaviours (CSF) [33] were included to allow for comparison with standard data.
! The SAQ questionnaire [37] comprises ques- tions on sexual status, reasons for a possible absence of sexual activity, and items evaluat- ing: (1) sexual pleasure, with scores ranging from 0 to 18 where a high score corresponds to a higher degree of pleasure; (2) discomfort during sexual intercourse (vaginal dryness, pain during sexual intercourse) with scores ranging from 0 to 6, where a high score corresponds to a lower degree of discomfort.
! Three items of the Relationship & Sexuality questionnaire evaluating the perception of relationship with the partner or of partner’s fear of sexual intercourse were selected as potential associated factors.
The BIS and Relationship & Sexuality items were translated into French [38]. A SAQ French version was made available from the SAQ deve- lopers. These questionnaires were pilot-tested and tested for internal consistency and construct validity. Cronbach’s alphas for the French versions BIS, SAQ and Relationship and Sexuality overall scales were 0.93, 0.84, 0.91, respectively. For the SAQ pleasure and discomfort sub-scales, Cronbach’s alphas were 0.85 and 0.84, respectively [39].
Statistical analyses
w2 tests or t-tests were used to compare socio- demographic and clinical characteristics between respondents and non-respondents. w2 tests were also performed for the four-level single CSF items addressing frequency of sexual intercourse, painful intercourse, absence or lack of sexual desire, or difficulty achieving orgasm comparing the two independent samples of BCS and French women. As the study breast cancer sample was younger and more highly educated than the French women sample, we assigned weights to the observations from the reference sample to match the age and education distribution found in the study sample.
Stepwise forward logistic regression analyses were performed to identify independent factors that best explained score variance in the outcome variables while taking into account multicollinearity. Hosmer
and Lemeshow’s R2 were computed; R2 can vary between 0 (indicating that the predictors are useless at predicting the outcome variable) and 1 (indicating that the model predicts the outcome variable perfectly) [40, p 269]. Hosmer–Lemeshow tests were performed to assess the goodness-of-fit of the models (a good model produces a nonsignificant w2[41, p 459]).
To preserve statistical power, candidate variables were first evidenced from univariate regression analyses; levels of p-valueo0.15 were chosen to allow for possible variables to be significant while adjusted on others in subsequent multivariate analyses [41, p 456].
These analyses were performed, on the overall sample, for the following outcomes: (1) presence of sexual activity (single ‘yes/no’ item); and (2) satisfaction with sexual life (single item with responses categorised in ‘‘not at all/a little’’ versus
‘rather/very’) and, on the sample of women reporting current sexual activity, for the following criteria: (3) Frequency of sexual activity (single item with responses categorised in: ‘‘less frequent/
similar’’ versus ‘‘more frequent’’ than usual);
(4) SAQ-Pleasure and (5) SAQ-Discomfort scales.
For the SAQ-Pleasure and Discomfort scales, cut- off scores were chosen so as to distinguish women with ‘‘little or less’’ versus ‘‘somewhat or more’’
problems (cut-off value of 12 for the SAQ-Pleasure 6-item scale and of 4 for SAQ-Discomfort 2-item scale).
Potential associated factors included age, marital status, menopausal status at time of BC diag- nosis, psychiatric history, co-morbidities, time since BC diagnosis and questionnaires completion, type of treatments, body image, three items of the Relationship and Sexuality Scale [26], and the EORTC QLQ-C30 or BR23 functioning and fatigue, appetite loss, nausea, pain, insomnia, side effects, arm and breast problem scales.
For age, the cut-off score refers to the pre-, transition-, and post-menopause phase; for the remaining variables, considering the skewed score distribution, the cut-off chosen refers to the median for the time since BC diagnosis and questionnaires completion or to the first or third quartile for the BIS and EORTC QLQ-C30 and BR23 scales.
Statistical analyses were performed with R soft- ware [42].
Results
Sample characteristics
Of the 850 women selected, 453 (53%) agreed to participate in the study and 378 (45%) returned completed questionnaires. When specified (pro- vided by 270 (57%) of the women), the reasons for refusal to participate in this study included: lack of
time (16%), feeling of intrusion (8%), difficulties talking about sexuality (7.5%), no particular problems (6.5%), no interest in sexuality (6.5%), the fact of living alone, being single, widowed, separated, or divorced (6%), feeling of not being concerned (4%), impression that sexuality before the cancer was already deficient (2.5%), fatigue (2.5%), a desire to forget the experience of cancer (2.5%), age (2%), presence of other health problems (1%), alteration of the spouse’s health state (0.7%).
Sociodemographic and clinical characteristics are displayed in Table 1. A significantly higher participation rate was observed among younger women, women closer to date of diagnosis at time of the survey and who were premenopausal at time of diagnosis.
Sexual activity and sexual problems
Among the 378 BCS respondents, 109 (29%) reported that they did not have any sexual activity at the survey time; reasons were mainly not only because of the absence of a partner (number of women providing this reason: n549) and loss of interest in sex (n535) but also because of the woman’s physical problems (n517), fatigue (n512), or her partner’s problems: fatigue (n58), loss of interest (n58), or physical problems (n57).
Differences in the frequency of sexual inter- courses in the past month, painful sexual inter- courses, absence or lack of sexual desire, and inability to achieve orgasm between the observed distribution in the BCS sample and the adjusted results from the CSF were all highly significant (all po0.0001) (Figure 1).
Associated factors of sexual activity, frequency of sexual activity, pleasure, discomfort, or sexual satisfaction On the overall sample (N5378), univariate analy- sis identified the following associated factors for absence of sexual activity or for dissatisfaction with sexual life: age greater than 55 years, absence of a partner, more recent BC diagnosis, BC treatment- induced menopause, presence of concomitant disease(s), history of mental illness, body image problems, feeling of emotional separation in the couple relationship, feeling of dissatisfaction with the partner’s hugs/kisses, feeling that the partner is afraid of sexual intercourse, poorer scores on the different scales of the EORTC quality of life questionnaire, and the breast cancer module except on the breast problem sub-scale (Table 2).
On the subsample of women reporting current sexual activity (N5268), associated factors for a decreased frequency of sexual activity, decreased sexual pleasure (SAQ-Pleasure sub-scale), or great- er sexual discomfort (SAQ-Discomfort scale) included: age greater than 50 years, BC treatment- induced menopause, previous/ongoing treatment with anti-aromatase, body image problems, feeling of emotional separation in the couple relationship, feeling of dissatisfaction with the partner’s hugs/
kisses, feeling that the partner is afraid of sexual intercourse, absence of a new partner during the previous 6 months, presence of lower scores on the different scales of the EORTC quality of life questionnaire, and the breast cancer module except on the breast problem sub-scale (Table 2).
On the overall sample (n5378), in multivariate analysis, sexual activity was 2.5 less likely in women who felt an emotional separation in the couple relationship and five times less likely in women who perceived fear of sexual intercourse by their partner (R250.37). Dissatisfaction with sexual life was 2.1 times more likely in women with one or more concomitant diseases, 2.2 times more likely in women with poorer body image, and Table 1. Sociodemographic and clinical characteristics of
respondents
Respondents (N5378)
Non- respondents
(N5472) Age, Mean (standard deviation)! 53 (8) 56 (8) Marital status
Married/living with a partner 286 (76) —
Divorced/separated 53 (14) —
Widowed 17 (5) —
Single 22 (6) —
Level of education
Primary/college 50 (13) —
High school/technical college 142 (38) —
Tertiary 184 (49) —
Missing data 2 —
Work status
Full-time/part-time 218 (58) —
Sick leave/unemployed/housewife 54 (15) —
Retired 82 (22) —
Other 23 (6) —
Missing data 1 —
Interval between diagnosis and inclusion in study (months)
Mean (standard deviation)! 35 (12) 38 (13)
Lumpectomy 63 (31) 57 (23)
Breast reconstruction 53 (14) 53 (11)
Immediate breast reconstruction 24 (45) 22 (5) Axillary lymph node dissection 261 (69) 306 (65)
Chemotherapy 175 (46) 191 (40)
Radiotherapy 348 (92) 440 (93)
Endocrine therapy ongoing or stopped during previous 3 months
232 (61) 279 (59) Post-menopausal (at diagnosis)!!! 182 (48) 239 (58)
Missing data 2 —
If present, type of endocrine therapy Pre-menopausal
Tamoxifen only 87 (23) —
Anti-aromatase only 26 (7) —
Agonist or Arimidex1Agonist 9 (2) —
Menopausal
Tamoxifen only 14 (4) —
Anti-aromatase only 87 (23) —
!po0.001,!!!po0.05.
16.3 times more likely in women who perceived fear of sexual intercourse by their partner whereas this was twice less likely in women with higher emotional functioning (R250.28) (Table 3).
On the subsample of women reporting current sexual activity (n5268), the same or higher frequency of sexual activity were five times less likely in women who perceived fear of sexual intercourse by their partner and 2.1 times more likely in women with higher emotional functioning (R250.26). Lower sexual pleasure was 13.5 times more likely in women who perceived fear of sexual intercourse by their partner and 2.5 times less likely in women with higher role functioning (R250.22).
Higher degree of sexual discomfort was, respec- tively, 3.9 and 4.7 times more likely in women aged above 50 years and above 55 years, 3.6 times more likely in women who felt an emotional separation in the couple relationship and, respectively 2.6 and 2.4 times more likely in women who presented nausea or insomnia (R250.22). For all these models, Hosmer–Lemeshow tests produced non- significant w2 (Table 3).
Discussion
This cross-sectional study highlighted that a substantial number of BCS experienced sexual problems (decreased libido or ability to achieve orgasm, dyspareunia) in the period between 6 months and 5 years after completion of treat- ment, in comparison to a French women represen- tative sample.
Most women responding to this survey reported ongoing sexual activity (71%) as in other similar BCS samples from different cultural settings [4,22,23,26] or in women from the general popula- tion [43,44].
However, in contrast with the general popula- tion for whom the leading reason for sexual inactivity was the absence of a partner [43,44], as in Meyerowitz et al. [8] and Fobair et al. [14], in these French BCS, lack of interest in sexual activity, physical problems, or fatigue were fre- quently mentioned.
The strongest associated factors of sexual out- comes were the perception of the couple relation- ship and/or a feeling that the partner is afraid of sexual intercourse. Poorer emotional or role functioning, or body image problems were asso- ciated with a higher decreased sexual pleasure or sexual dissatisfaction.
Advancing age or symptoms like nausea or insomnia were associated with sexual discomfort.
Advancing age also appeared in the literature to be associated with a decline of sexual functioning due to decreased sexual arousal or ability to achieve orgasm [4] as well as problems of lubrication and dyspareunia [15].
These study results are concordant with the data of the literature concerning the major role of psycho- logical on sexual outcomes [8,14–16,19,24].
Although women responding to this survey may attribute their decreased sexual desire to their breast cancer or its treatment, objective clinical factors were not related to this outcome. Sexual satisfaction was related to the presence of concomitant diseases
Frequency of sexual intercourse/month
0 10 20 30 40 50 60 70
0
Painful sexual intercourse
0 10 20 30 40 50 60 70 80
Often Never
Absence or lack of sexual desire
0 5 10 15 20 25 30 35 40
Difficulty achieving orgasm
0 5 10 15 20 25 30 35 40
Sometimes Rarely Often Sometimes Rarely Never
Often Sometimes Rarely Never
1-2 3-4 > 5
Population sample Breast sample Population sample
Breast sample
Population sample
Breast sample Breast sample
Population sample
Figure 1. Percent of responses for French sexual behaviour survey item in breast cancer and French female population samples, French sexual behaviour survey data for French female population sample are adjusted for age and education level,w2tests, allpo0.0001
Table2.Significantfactorsinunivariatelogisticregressionanalysisforalldependentvariablesa,b,c FactorsClassesPresenceofsexualactivity (N5378) (YesversusNo) Frequencyofsexualactivity (N5268) (sameormoreversusless) SAQPleasurescale (N5268) (Scoreso12versusX12) SAQDiscomfortscales (N5268) (Scoreso4versusX4)
Sexualsatisfactionitem (N5378) (Notatall/alittleversus rather/very) bOR[95%CI]pbOR[95%CI]pbOR[95%CI]pbOR[95%CI]pbOR[95%CI]p Age[50–55]"0.40.7[0.4;1.3]0.04——————1.02.8[1.4;5.4]o0.0001——— 455"0.60.5[0.3;0.9]————1.33.7[2.1;6.6]—— MaritalstatusNopartner"1.70.2[0.1;0.3]o0.0001———————0.82.2[1.3;3.8]0.004 Menopausalstatusat timeofcancerdiagnosisYes"0.60.5[0.3;0.8]0.007——————0.72.0[1.2;3.2]0.007——— Mood,anxiousoraddictive disorder(lifetime)Morethan1"0.60.6[0.4;0.9]0.01———————————— SomaticcomorbidconditionMorethan1"0.40.7[0.4;1.0]0.06—————————0.61.9[1.2;2.9]0.004 Timesincecancerdiagnosis andquestionnairep36months"0.70.5[0.3;0.8]0.002—————————0.41.5[1.0;2.3]0.08 LumpectomyYes——————————————— ChemotherapyYes0.41.6[1.0;2.4]0.06———0.51.6[1.0;2.6]0.06———0.41.5[0.9;2.2]0.09 Endocrinetherapy(current orinterruptedsincelessthan 3months)
Yes———"0.50.6[0.3;1.1]0.08———0.51.6[1.0;2.7]0.07——— Ifpresent,typeofendocrine therapy(past/current)Tamoxifen0.41.5[0.8;2.7]0.09——————0.21.2[0.7;2.1]——— Anti-aromatase"0.30.8[0.5;1.3]————0.82.2[1.2;4.0]0.03—— Bodyimagescale(BIS)X10———"1.00.4[0.2;0.6]0.00050.92.6[1.5;4.6]0.0010.51.6[0.9;2.8]0.091.23.4[2.1;5.5]o0.0001 PartnerandIhavegot emotionallyseparatedRathermuch/much/ verymuch"1.50.2[0.1;0.4]o0.0001"1.00.4[0.2;0.7]0.021.02.8[1.3;6.1]0.011.02.8[1.3;5.8]0.021.33.5[1.9;6.4]o0.0001 Satisfiedwithfrequencyof hugs/kissesNotatall/slightly/ rathermuch"1.20.3[0.1;0.7]o0.0001"1.40.3[0.1;0.5]o0.00012.68.5[4.8;15.2]o0.00010.92.4[1.4;4.1]0.0032.512.4[6.1;25.4]o0.0001 Perceivepartnerafraidof sexualintercourseSometimes/often/always"1.60.2[0.1;0.4]o0.0001"2.20.1[0.1;0.2]o0.00012.612.9[4.9;33.9]o0.00011.33.6[1.8;6.9]0.00042.918.3[8.9;37.3]o0.0001 Newpartnerinthelast 6monthsYes——————"1.80.2[0.04;0.8]0.01—————— EORTCphysicalfunctioning4800.41.5[1.0;2.5]0.080.72.0[1.1;3.6]0.02"0.50.6[0.3;1.0]0.06"0.50.6[0.4;1.1]0.09"0.50.6[0.4;1.0]0.03 EORTCRolefunctioning4850.82.2[1.4;3.4]0.0011.13.0[1.8;5.3]0.0001"1.10.4[0.2;0.6]0.0001"0.60.5[0.3;0.9]0.01"0.90.4[0.3;0.7]0.0001 EORTCemotional functioning4750.51.7[1.1;2.7]0.021.23.3[1.9;5.9]o0.0001"0.80.5[0.3;0.7]0.002"0.70.5[0.3;0.7]0.009"1.30.3[0.2;0.5]o0.0001 EORTCcognitive functioning4750.72.0[1.3;3.2]0.0030.82.3[1.3;4.0]0.004"0.90.4[0.2;0.7]0.001"0.60.5[0.3;0.9]0.02"1.00.4[0.2;0.6]o0.0001 EORTCsocialfunctioning4750.51.7[1.0;2.9]0.041.02.7[1.5;5.1]0.002"0.80.5[0.3;0.9]0.01"0.60.5[0.3;1.0]0.04"0.90.4[0.2;0.7]0.0006
but not, in multivariate analysis, to cancer-related factors. Cancer treatments did not appear associated with sexual dysfunction. In univariate analysis, chemotherapy or endocrine treatment but not surgery showed a trend of association with sexual outcomes. This may be explained by the period (6 months to 5 years post-treatment) in which this survey was performed resulting in a significant number of women (59%) still undergoing endocrine treatment. In addition, chemotherapy may have long-term effect especially on younger women due to its impact on ovarian functioning [27].
In line with the literature [8,15,26,28,29,47,48], the type of breast surgery was not associated with sexual outcomes. However, body image problems played a pejorative role, as evidenced in other studies [14,16,29]. A negative body image encom- passes perceived lack of femininity, sexual or physical attractiveness; it may be linked to factors like mood [45], appearance investment [46], or marital satisfaction [45]. These psychological aspects may mediate the relationship between breast cancer treatment and sexual difficulties [14].
This study adds to the recent cross-cultural data on the impact of breast cancer on women’s sexuality, highlighting the importance of sexual difficulties regardless of cancer treatment and especially in relation to psychological factors [23,47]. Specifically, the perception of the couple relationship including the women’s feeling that cancer and its treatment resulted in emotional separation in the couple or that it elicited her partner’s fear of sexual intercourse was strongly associated to all sexual outcomes.
A number of limitations to this research need to be considered. First, this study was performed in a single hospital, achieved a restricted response rate of 45% and involved mainly younger BCS and women whose cancer had been diagnosed more recently compared with non-participants. Hence, we cannot generalise the results of this study to all early-stage BCS aged up to 70 years old, at 6 months to 5 years after BC treatment.
More than half of the women who did not want to participate in this study indicated one (or more) motives for refusal and most of these were related to sexual concerns such as difficulty talking about sexuality, presence of sexual pro- blems unrelated to cancer but to age, other physical problems or spouse problems, or no interest in sexuality. This suggests that our data may under- estimate the rate of sexual difficulties in BCS.
Younger BCS were more inclined to answer this survey suggesting that older women may under- report sexual concerns or difficulties and that these aspects may be neglected in the care and follow-up of older BCS.
Second, owing to sample size limitation, this cross-sectional study did not include more specific psychological or interpersonal factors of sexual
EORTCfatigue430"0.70.5[0.3;0.8]0.003"1.10.3[0.2;0.6]o0.00011.02.7[1.6;4.4]0.00010.61.9[1.1;3.0]0.010.92.5[1.6;3.8]o0.0001 EORTCappetiteloss40"0.90.4[0.2;0.8]0.01———————————— EORTCnausea40"0.60.6[0.3;1.0]0.05"0.90.4[0.2;0.8]0.010.92.5[1.2;5.3]0.010.92.4[1.1;4.9]0.020.82.3[1.3;4.2]0.006 EORTCpain40"0.80.5[0.3;0.8]0.001"0.60.5[0.3;0.9]0.020.72.1[1.3;3.4]0.003———0.92.5[1.6;3.9]0.0001 EORTCinsomnia433"0.3"0.80.4[0.2;0.8]0.0040.71.9[1.2;3.2]0.010.92.5[1.5;4.3]0.00040.72.0[1.3;3.2]0.003 EORTCglobalhealthstatus4700.51.7[1.1;2.7]0.020.92.3[1.4;4.0]0.002"0.40.7[0.4;1.1]0.09———"0.70.5[0.3;0.8]0.001 EORTCsideeffects433"0.70.5[0.3;0.9]0.02"1.00.4[0.2;0.8]0.020.82.3[0.9;5.4]0.061.33.6[1.5;8.9]0.0031.43.9[1.9;8.1]0.0001 EORTCarmproblems433"0.80.5[0.3;0.8]0.01———0.92.5[1.1;5.4]0.021.02.8[1.3;6.1]0.0060.92.5[1.4;4.6]0.002 EORTCbreastproblems433——————————————— b,standardizedregressioncoefficient;SE,standarderror;OR,oddsratio;CI,confidenceinterval. aSAQreferstoSexualActivityQuestionnaire;ahigherscoreintheSAQmulti-itemrespectivelymeanshigherpleasure,lowerdiscomfort;ahigherscorefortheEORTCfunctionalandglobalhealthstatusscalesmeanshigherfunctioning,higherglobalhealth status;ahigherscoreforsymptomscalesmeanshighersymptoms;ahigherscorefortheBodyImageScale(BIS)meanshigherbodyimageproblems. bCut-offscoreselection:fortheSAQmulti-itemscales,thecut-offchosenrefersrespectivelyto4fortheDiscomfortscaleor12forPleasurescale;forage,thecut-offscoresrefertopre/transitionandpostmenopause;fortimesincecancerdiagnosisand questionnaireadministration,thecut-offchosenreferstothemedian;fortheBISandEORTCQLQscales,thecut-offscorereferstothefirstorthirdquartile. cResultsarereportedifpvaluesignificantat0.15otherwisecellsarefilledwithanhyphen.
difficulties and so does not allow for identifying mechanisms by which these problems arise. For example, pre-existing sexual or marital problems [14,23,27] or sexual problems in the partner [16] may have been present before the diagnosis of cancer and may predispose to sexual disorders after cancer.
A recent study starts to shed light on the personality factors associated to sexual problems in early-stage BCS [48]. Our findings coupled with this later underline that psychosocial interventions could be helpful regarding sexual difficulties in BCS. Different initiatives addressing the individual breast cancer patient or the couple show promise [20,49].
In conclusion, a significant number of French BCS present sexual suffering during surveillance phase comparatively to women from the general population. A systematic and predominant role of psychological factors to sexual difficulties was
observed. These aspects should draw the clinician’s attention in the follow-up of BCS. Psychological problems are modifiable factors, providing hope for relief of the suffering caused by sexual diffi- culties in women after BC treatment.
Acknowledgements
This research was financially supported by Simone Pe´re`le/
Socoloir group. The authors express their gratitude to all patients who accepted to share their experience with us.
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Table 3. Significant factors in multivariate logistic regression analysis for all dependent variablesa,b
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