Contemporary Review of the Management and Treatment of Young Breast Cancer Patients

Approximately 11% of all new breast cancer cases annually are diagnosed in young women, and this continues to be the leading cause of death in women age 20 to 49. Young, premenopausal breast cancer patients present with more advanced stages and with a higher proportion of aggressive subtypes such as triple negative and HER2-enriched tumors. Recently, the United States Preventive Services Task Force (USPSTF) lowered the age threshold to initiate screening mammograms to age 40 to aid in earlier detection. Young age at diagnosis increases the likelihood for a pathogenic mutation, and genetic testing is recommended for all patients age 50 and younger. This population is often underrepresented in landmark clinical trials, and data is extrapolated for the treatment of young women with breast cancer. Despite there being no survival benefit to more extensive surgical treatments, such as mastectomy or contralateral prophylactic mastectomy, many patients opt against breast conservation. Young patients with breast cancer face issues related to treatment toxicities, potential overtreatment of their disease, mental health, sexual health, and fertility preservation. This unique population requires a multidisciplinary care team of physicians, surgeons, genetic counselors, fertility specialists, mental health professionals, physical therapists, and dieticians to provide individualized, comprehensive care. Our aim is to (1) provide a narrative review of retrospective studies, relevant society guidelines, and clinical trials focused on the contemporary treatment and management of YBC patients and (2) discuss important nuances in their care as a guide for members of their multidisciplinary treatment team.

Female Sexual Function Index Adaptation for Breast Cancer Patients (FSFI-BC): Brazilian Portuguese Translation and Cultural Adaptation

BACKGROUND

The assessment of female sexual function after diagnosis and treatment of breast cancer is relevant, as cancer can negatively affect sexuality and, therefore, quality of life. Instruments assessing female sexuality can be useful in clinical practice. However, there are few validated instruments available for this purpose. This study aimed to translate the Female Sexual Function Index Adaptation for Breast Cancer Patients (FSFI-BC) into Brazilian Portuguese and culturally adapt it for use in Brazil.

PATIENTS AND METHODS

Translation and cross-cultural adaptation followed the linguistic validation process, according to international guidelines. The instrument was translated and back-translated by independent translators. Sixty women aged 25 to 70 years who had been diagnosed and surgically treated for breast cancer at least 6 months previously participated in the cultural adaptation process. Participants were stratified into sexually active or inactive. Internal consistency was analyzed using Cronbach's alpha coefficient.

RESULTS

Mean participant age was 52.5 years. For sexually active women, reliability analysis (Cronbach's alpha) showed excellent internal consistency between the items of the subscales 'Desire/Arousal' (α = 0.912) and 'Orgasm' (α = 0.904), and good internal consistency for 'Lubrication' (α = 0.814) and 'Pain' (α = 0.839). For sexually inactive women, excellent internal consistency was observed between the items of the subscale 'Reason for Inactivity - difficulty lubricating' (α = 0.930), and good internal consistency for the other subscales. The instrument had face and content validity.

CONCLUSIONS

FSFI-BC was translated and culturally adapted to the context of the Brazilian population.

Sexual Health in Women Affected by Gynecologic or Breast Cancer

Sexual health problems are prevalent among women affected by gynecologic or breast cancer. It is important to understand the effects cancer treatment can have on sexual health and to have the tools necessary to identify and treat sexual health problems. This Clinical Expert Series discusses practical methods for routinely screening for sexual dysfunction and reviews sexual health treatment options for women affected by cancer. We review the limitations of the current literature in addressing sexual health problems among sexually and gender minoritized communities. Finally, we discuss appropriate timing of referrals to sexual health experts, physical therapists, and sex therapists. Multiple resources available for both patients and clinicians are included.

Importance of Breast Sensation After Mastectomy: Evidence from Three Sources

Background

Every year, more than 90,000 U.S. women undergo mastectomy. More than 40% have reconstruction. Following reconstruction, most women experience persistent partial or complete numbness of the reconstructed breasts, and many experience pain. Yet, breast reconstruction procedures focus largely on esthetic outcomes with mixed impact on sensory outcomes and little attention to pain. This study examines whether and how breast sensation is important to women.

Materials and Methods

Conventional content analysis of extant qualitative data from a clinical registry (29 women with prior breast surgery for cancer, 2008-2022), a volunteer community sample (qualitative interviews with 6 women with and 5 without breast cancer, 2019), and from a Twitter social media survey (N = 32, 2022).

Results

Functions of the breast identified by women with and without cancer include breastfeeding, sexual function, and femininity. Five interrelated themes on the importance of breast sensation emerged among women with breast cancer history: sexual function, experience of partnered sex or relationship with one's sexual partner, breast embodiment, effect of breast pain on sexual function, and importance to psychological wellbeing. Women, advocates, and clinicians described a lack of patient-physician communication in this domain that exacerbates the negative impact of breast sensation loss on health and wellbeing.

Conclusions

Breast sensation is important to women following mastectomy, yet a gap exists in patient-physician communication about the impact of mastectomy and reconstruction on breast sensory function. Lessons for physicians, scientists, and skeptics are conveyed about why the basic integrity of women's bodies matters for practice and science.

Breast cancer survivorship and sexual dysfunction: a population-based cohort study

BACKGROUND

Breast cancer is the most common non-skin cancer in women and an increasing number of people are living as breast cancer survivors. While the prognosis of breast cancer continues to improve, the rates of sexual dysfunction and the risk related to cancer treatments have not been well characterized in a population-based study.

METHODS

We identified a cohort of 19,709 breast cancer survivors diagnosed between 1997 and 2017 from the Utah Cancer Registry, and 93,389 cancer-free women who were matched by age and birth state from the Utah Population Database. Sexual dysfunction diagnoses were identified through ICD-9 and ICD-10 codes from electronic medical records and statewide healthcare facilities data. Cox proportional hazard models were used to estimate hazard ratios for risk of sexual dysfunction.

RESULTS

Breast cancer survivors were at higher risk of sexual dysfunction diagnosis (9.1% versus 6.9%, HR 1.60, 95% CI 1.51-1.70) compared to the general population. This risk increased 2.05-fold within 1 to 5 years after cancer diagnosis (95% CI 1.89-2.22) and 3.05-fold in individuals diagnosed with cancer at < 50 years of age (95% CI 2.65-3.51). Cancer treatments including endocrine therapy, chemotherapy and radiation therapy were associated with an increased risk of sexual dysfunction among breast cancer survivors.

CONCLUSIONS

Risk of sexual dysfunction in breast cancer survivors is higher than in the general population, but may be underdiagnosed in the clinical setting. Health care professionals should be encouraged to address the topic of sexual health early on in the treatment of breast cancer, and routinely screen patients for symptoms of sexual dysfunction.

Body change stress, sexual function, and marital intimacy in korean patients with breast cancer receiving adjuvant chemotherapy: A cross-sectional study

Objective

A crucial factor influencing the quality of life of patients with breast cancer is marital intimacy, which, along with emotional support, helps them overcome difficult treatments. This study aimed to elucidate and confirm the effects of body change stress and sexual function in marital intimacy.

Methods

We conducted a cross-sectional survey on 190 patients with breast cancer. They completed the breast-impact of treatment scale, female sexual function index, and revised dyadic adjustment scale.

Results

The patients' average age was 46.27 (6.84), and the age distribution ranged from 25 to 59 years. These variables showed statistically significant differences according to the chemotherapy period (P ​< ​0.05) and type of surgery (P ​< ​0.05). Body change stress negatively correlated with sexual function (r ​= ​-0.523, P ​< ​0.001) and marital intimacy (r ​= ​-0.545, P ​< ​0.001). Sexual function positively correlated with marital intimacy (r ​= ​0.363, P ​< ​0.001). Marital intimacy was affected by the changes in body stress (β ​= ​-0.473, P ​< ​0.001). Sexual function did not affect marital intimacy (β ​= ​0.084, P ​= ​0.289).

Conclusions

Changes in body stress and chemotherapy treatment should be considered in patients with breast cancer for better marital intimacy. Intervention strategies that consider the characteristics discussed could improve marital intimacy for patients with breast cancer.

Breast sensorisexual function: a novel patient-reported outcome measure of sexual sensory functions of the breast

BACKGROUND

A validated measure assessing sexual sensory functions of the breast is needed to optimize sexual and other health outcomes after breast procedures.

AIM

To describe the development of a patient-reported outcome measure (PROM) to assess breast sensorisexual function (BSF).

METHODS

We applied the PROMIS standards (Patient Reported Outcomes Measurement Information System) for measure development and evaluation of validity. An initial conceptual model of BSF was developed with patients and experts. A literature review yielded a pool of 117 candidate items that underwent cognitive testing and iteration. Forty-eight items were administered to an ethnically diverse, national panel-based sample of sexually active women with breast cancer (n = 350) or without (n = 300). Psychometric analyses were performed.

OUTCOMES

The main outcome was BSF, a measure that assesses affective (satisfaction, pleasure, importance, pain, discomfort) and functional (touch, pressure, thermoreception, nipple erection) sensorisexual domains.

RESULTS

A bifactor model fit to 6 domains-excluding 2 domains with only 2 items each and 2 pain-related domains-revealed a single general factor representing BSF that may be adequately measured by the average of the items. This factor, with higher values denoting better function and with the standard deviation set to 1, was highest among women without breast cancer (mean, 0.24), intermediate among women with breast cancer but not bilateral mastectomy and reconstruction (-0.01), and lowest among those with bilateral mastectomy and reconstruction (-0.56). Between women with and without breast cancer, the BSF general factor accounted for 40%, 49%, and 100% of the difference in arousal, ability to orgasm, and sexual satisfaction, respectively. Items in each of 8 domains demonstrated unidimensionality (ie, they measured 1 underlying BSF trait) and high Cronbach's alphas for the entire sample (0.77-0.93) and the cancer group (0.71-0.95). Correlations with sexual function, health, and quality of life were positive for the BSF general factor and mostly negative for the pain domains.

CLINICAL IMPLICATIONS

The BSF PROM can be used to assess the impact of breast surgery or other procedures on the sexual sensory functions of the breast in women with and without breast cancer.

STRENGTHS AND LIMITATIONS

The BSF PROM was developed by using evidence-based standards, and it applies to sexually active women with and without breast cancer. Generalizability to sexually inactive women and other women warrants further study.

CONCLUSION

The BSF PROM is a measure of women's breast sensorisexual function with evidence of validity among women affected and unaffected by breast cancer.

Long-term survey of sexual well-being after breast reconstruction using the BREAST-Q in the Japanese population

BACKGROUND

The objective of this study was to identify response patterns related to sexual well-being following breast operations in the Japanese population.

METHODS

Patient-reported outcomes were analyzed at 1 year and 5 years after breast operations, including breast reconstruction, for Japanese women at a single center, with a focus on "Sexual well-being" in BREAST-Q. Response analysis and multiple regression analysis were performed. The scores at years 1 and 5 were also compared across three types of operation: mastectomy only, TE/Imp, and DIEP.

RESULTS

The response rate for Sexual well-being on BREAST-Q in the prospective cohort of patients with breast cancer dropped from 60.0% in postoperative year 1-34.3% in year 5. The mean score for Sexual well-being increased from 32 (year 1) to 38 (year 5). There were significant differences between respondents and non-respondents in age at year 1 (P = 0.007) and for mastectomy only (P = 0.01) and TE/Imp (P = 0.03) at year 5. In regression analysis, only DIEP was positively associated with Sexual well-being at year 1 (p < 0.001) and there were no significant factors at year 5. Among the operative procedures, scores after DIEP were significantly better than those after mastectomy only at year 1 (p < 0.001), but there was no difference at year 5. There were no significant changes from year 1 to year 5 for each operation.

CONCLUSIONS

A low response rate for Sexual well-being on BREAST-Q was found in Japanese women at 5 years postoperatively. This suggests the need for development of a modified evaluative scale that avoids nonresponse bias and considers ethnic differences.

Sexual Health after a Breast Cancer Diagnosis: Addressing a Forgotten Aspect of Survivorship

Breast cancer is the most common cancer in women. The life expectancy after a breast cancer diagnosis is improving steadily, leaving many more persons with the long-term consequences of treatment. Sexual problems are a common concern for breast cancer survivors yet remain overlooked in both the clinical setting and the research literature. Factors that contribute to sexual health concerns in breast cancer survivors are biopsychosocial, as are the barriers to addressing and treating these health concerns. Sexual health needs and treatment may vary by anatomy and gender. Multidisciplinary management may comprise lifestyle modifications, medications, sexual health aids such as vibrators, counseling, and referrals to pelvic health physical therapy and specialty care. In this article, we review the contributing factors, screening, and management of sexual difficulties in cisgender female breast cancer survivors. More information is needed to better address the sexual health of breast cancer survivors whose sexual/gender identity differs from that of cisgender women.

Comparison of Body Image and Body Exposure During Sexual Activity and Sexual Assertiveness Among Mastectomized Women with/Without Mammaplasty and Mammaplasty Volunteer Patients

Background: Mastectomy can change body image and affect the sexual activities of patients. Breast reconstruction is a way to reduce the sexual damage caused by mastectomy. Objectives: The present study aimed to compare body image and body exposure during sexual activity and sexual assertiveness among mastectomized women with/without mammaplasty and patients with cancer who volunteered for mammoplasty. Methods: This causal-comparative study was performed on the statistical population of mastectomized women with/without mammaplasty and patients who volunteered for mammoplasty within the age range of 25 - 55 years in Tehran, Iran, in 2018. The sample consisted of 37 women with mastectomy, 28 mastectomized women who volunteered for mammoplasty, and 31 women who underwent mammaplasty after mastectomy. The subjects were selected through convenience sampling in Tehran. All participants were asked to complete the Assessment of Body-Image Cognitive Distortions Questionnaire, the Body Exposure during Sexual Activities Questionnaire, and the Hurlbert Index of Sexual Assertiveness. The data were analyzed by analysis of variance using version 20th of SPSS software. Results: In terms of body-image cognitive distortions, there was no difference between the three groups. The women who underwent mammaplasty had less body exposure during sexual activity than patients who volunteered for mammoplasty (P < 0.01); however, there was no difference between the mastectomized patients and patients who underwent mammaplasty. Exposure to the body or anxious attentional focus on the body during sexual activity was reported frequently less in mastectomized women than in mammaplasty volunteers (P < 0.01). The sexual assertiveness of women who underwent reconstructive surgery was more than mastectomized women and volunteer patients for reconstructive surgery (P < 0.01). The mastectomized group had more sexual assertiveness than patients who volunteered for mammoplasty (P < 0.01). Conclusions: The results support the hypothesis that the issue of body image and its relationship with different aspects of sexual function is complex and requires considering different personality traits and factors as moderators. The importance that a woman places on the breast as a symbol of femininity and sexuality is one of the aforementioned factors. The purpose of reconstruction from the patient’s point of view and the importance that a woman gives to her appearance are other components that should be considered before proceeding with mammoplasty.

Breast-Specific Sensuality in Breast Cancer Survivors: Sexually Active or Not

BACKGROUND

We sought to better understand breast-specific sensuality (BSS) in sexually inactive breast cancer survivors.

METHODS

We conducted an anonymous cross-sectional survey of breast cancer survivors during surveillance appointments from 2014 to 2016. Sexual inactivity was defined as no sexual activity within 4 weeks prior. Categorical data were analyzed using Fisher's exact test. Multiple logistic regression adjusted for age and menopausal status, and Firth's bias correction accommodated sparse data.

RESULTS

Of 585 respondents, 546 (93.3%) were between the ages of 40 and 79 years, of whom 285 (48.7%) were sexually inactive. Favorable post-treatment appearance satisfaction was reported by 413 (71.0%) respondents. Sexually inactive respondents were more likely to score discomfort with their partner seeing their chest after surgery compared with sexually active respondents (41 [20.4%] vs. 34 [11.4%]; p = 0.002). Both sexually inactive and active respondents reported that their chest was important in intimacy after surgery but at significantly different rates (117 [44.3%] vs. 217 [72.6%]; p < 0.001). Post-surgical appearance satisfaction for sexually inactive respondents was positively associated with level of comfort with partner seeing their chest after surgery (p < 0.001) and with rating of a pleasurable caress of the treated breast (p < 0.001).

CONCLUSIONS

Over 40% of sexually inactive respondents reported their chest was important in intimacy after surgery, suggesting that BSS may be a route to intimacy for sexually inactive breast cancer survivors. Post-surgical breast appearance satisfaction significantly correlated with comfort being seen by one's partner and appreciation of a pleasurable breast caress. Optimizing breast cancer surgical aesthetic outcomes may improve survivorship.

Sexual dysfunction as a challenge in treated breast cancer: in-depth analysis and risk assessment to improve individual outcomes

The increasing number of breast cancer survivors has led to a greater emphasis on issues related to quality of life (QoL). Up to 75% of women treated for breast cancer (BC) report sexual disorders. However, most oncologists are not trained to recognize which patients are at high-risk of developing sexual disorders. Female sexual dysfunction (FSD) is common in patients with BC; we found that patients without FSD prior to BC treatment are at risk of developing FSD after treatment. Treatment of early BC relies on the combination of chemotherapy, surgery, and radiation therapy. All these treatments have side effects or sequelae identified as high-risk factors for the development of FSD. The choice of less toxic treatments in each modality could reduce the risk of FSD in some cases, without affecting the risk of recurrence or effectiveness. A comprehensive approach of BC must consider FSD as a determinant factor of QoL in survivors.

Sexuality After Cancer as an Unmet Need: Addressing Disparities, Achieving Equality

One extremely important and often neglected aspect of cancer care is sexuality. Sexuality is inherently a human trait, and this does not cease to be true after a cancer diagnosis. Multiple domains comprise sexuality, and all are at risk from cancer and its treatment. Despite the importance of sexual health, it still represents an unmet need in the United States and internationally. The disparities in meeting the sexual health needs of women with cancer extend beyond issues related to genitourinary symptoms of menopause and sexual pleasure; we propose that it extends toward the needs of sexual and gender minorities. Therefore, we focus on the delivery of sexual health care for people with cancer with an emphasis on women, women in low- and middle- income countries, and marginalized sexual and gender minorities.

Long-Term Patient Satisfaction and Quality of Life Following Breast Reconstruction Using the BREAST-Q: A Prospective Cohort Study

Background

Breast reconstruction is a promising surgical technique to improve health-related quality of life (HRQoL) in patients with breast cancer. However, the long-term risk factors associated with HRQoL after breast surgery are still unclear. Our aim was to evaluate breast satisfaction and HRQoL following breast reconstruction to identify clinical factors associated with each domain of BREAST-Q in the long-term.

Methods

Patient-reported BREAST-Q outcomes were analyzed 1 and 5 years after breast reconstruction in a single-blinded, prospective study. Multiple regression analysis was performed to identify the risk and protective factors associated with BREAST-Q scores. These scores at 1 and 5 years were also compared across three types of operation: mastectomy only, tissue expander/implant (TE/Imp), and a deep inferior epigastric perforator (DIEP) flap.

Results

Surveys were completed by 141 subjects after 1 year and 131 subjects after 5 years. Compared to mastectomy only, breast reconstruction was significantly associated with greater “Satisfaction with breasts” (TE/Imp, p &lt; 0.001; DIEP, p &lt; 0.001) and “Psychosocial well-being” (TE/Imp, p &lt; 0.001; DIEP, p &lt; 0.001), higher body mass index (BMI) resulted in lower “Satisfaction with breasts” (p = 0.004), and a history of psychiatric or neurological medication was significantly associated with “Physical well-being” at 1-year postoperatively (p = 0.02). At 5 years, reconstructive procedures were significantly positively associated with greater “Satisfaction with breasts” (TE/Imp, p &lt; 0.001; DIEP, p &lt; 0.001) and “Psychosocial well-being” (TE/Imp, p = 0.03; DIEP, p &lt; 0.001), and a bilateral procedure was a significant risk factor for lower “Psychosocial well-being” (p = 0.02).

Conclusions

The results of this study show that breast reconstruction improves “Satisfaction with Breasts” and “Psychosocial well-being” compared to mastectomy. Among all three types of operation, DIEP gave the best scores at 5 years postoperatively. Thus, autologous reconstruction is recommended for promotion of long-term HRQoL after breast surgery.

Sexuality in breast cancer survivors: sexual experiences, emotions, and cognitions in a group of women under hormonal therapy

BACKGROUND

Earlier diagnosis and improved treatments have led to better outcomes in breast cancer, making quality of life a key issue. Sexuality represents a pillar of quality of life, although it is often neglected by both healthcare providers and patients when it comes to cancer. This study aims to explore the differences in sexual functioning, distress, psychopathology, emotions, and cognitions between breast cancer patients under hormonal treatment and controls.

METHODS

Seventy-nine women (age range between 24 and 69 years) in hormonal therapy for breast cancer completed a self-reported protocol. A matched control group of 103 women was randomly extracted from an Italian general population database. Eight self-report questionnaires exploring biopsychosocial factors were administered.

RESULTS

The current study showed an impaired sexuality in breast cancer patients compared to controls. Breast cancer women under hormonal treatment were characterized by diminished or absent sexual activity (chi2 = 36.16; p < 0.001), lower level of sexual functioning in all areas except for pain (F(1,180) = 8.1; p < 0.01), higher sexual (F(1,180) = 10.08; p < 0.001) and psychological distress (F(1,180) = 6.23; p < 0.05), higher scores in Difficulties in Identifying Feelings (F(1,180) = 7.31; p < 0.01) and Externally Oriented Thinking (F(1,180) = 6.64; p < 0.05), higher level of negative emotions related to sexuality (F(1,180) = 11.13; p < 0.001), and more rigid cognition towards peculiar aspects of sexuality, such as Failure Disengagement Thoughts (F(1,180) = 22.01; p < 0.001) and Age related Beliefs (F(1,180) = 5.7; p < 0.05).

CONCLUSIONS

Health care providers do not usually assess those issues in their routine practice, so that sexuality remains an unmet need with remarkable effects on general health and quality of life.

Sexual activity and functioning in long-term breast cancer survivors; exploring associated factors in a nationwide survey

PURPOSE

Sexual health is a key quality of life issue. Knowledge concerning sexual health in long-term breast cancer survivors (BCSs) is limited. Within a nationwide sample, we aimed to assess the prevalence of sexual inactivity and to explore factors associated with sexual inactivity and reduced sexual functioning among long-term BCSs.

METHODS

Long-term BCSs aged 20-65 years when diagnosed with early-stage breast cancer in 2011-2012 were identified by the Cancer Registry of Norway in 2019 (n = 2803) and invited to participate in a nationwide survey. Sexual health was measured using the multidimensional Sexual Activity Questionnaire. Factors associated with sexual inactivity and reduced sexual functioning were explored using multivariable logistic- and linear regression analyses with adjustments for relevant sociodemographic, health-, and cancer-related variables.

RESULTS

The final sample consisted of 1307 BCSs with a mean age of 52 years at diagnosis. Fifty-two percent of the BCSs were sexually inactive. Lack of interest was the most common reason for sexual inactivity. Treatment with aromatase inhibitor (OR 1.73, 95% CI 1.23, 2.43) and poor body image (OR 0.99, 95% CI 0.99, 0.995) were associated with sexual inactivity. Among sexually active BCSs, depression (B - 1.04, 95% CI - 2.10, - 0.02) and physical inactivity (B - 0.61, 95% CI - 1.21, - 0.02) were inversely related to sexual pleasure. Treatment with aromatase inhibitor (B 0.61, 95% CI 0.20, 1.01), sleep problems (B 0.37, 95% CI 0.04, 0.70), breast symptoms (B 0.01, 95% CI 0.003, 0.02), and chronic fatigue (B 0.43, 95% CI 0.05, 0.81) were associated with sexual discomfort. Chemotherapy (OR 1.91, 95% CI 1.23, 2.97), current endocrine treatment (OR 1.98, 95% CI 1.21, 3.25), and poor body image (OR 0.98, 95% CI 0.98, 0.99) were associated with less sexual activity at present compared to before breast cancer.

CONCLUSION

Treatment with aromatase inhibitor seems to affect sexual health even beyond discontinuation. Several common late effects were associated with sexual inactivity and reduced sexual functioning. To identify BCSs at risk of sexual dysfunction, special attention should be paid to patients treated with aromatase inhibitor or suffering from these late effects.

Sexual Dysfunction in Postmenopausal Women with Breast Cancer on Adjuvant Aromatase Inhibitor Therapy

Introduction

The aim of this study was to investigate whether postmenopausal women with breast cancer (BC) on adjuvant aromatase inhibitor (AI) therapy have a higher prevalence of female sexual dysfunction (FSD). Second, the aim was to determine the quality of life (QoL) and level of anxiety depending on whether or not they are AI users.

Methods

A prospective cross-sectional study involving 168 patients was performed. Three questionnaires were carried out: sexual functioning was evaluated with the Female Sexual Function Index (FSFI), while the EORTC QLQ-BR23 measures to study QoL in patients with BC and the State-Trait Anxiety Inventory (STAI) questionnaire (trait and status) were used to assess anxiety status in patients under treatment with AIs or not.

Results

47.6% (80/168) of the postmenopausal BC survivors were not sexually active (mean time after surgery: 48.6 months) despite a relatively low mean age (56.43 years). Postmenopausal AI-treated women had significantly worse sexual function as measured by the FSFI (23.40 ± 5.26 vs. 30.16 ± 2.24; p = 0.000). There were significant differences between both groups in all domains, except orgasm. The QoL score was 37.67 ± 7.38 in AI users versus 39.00 ± 1.44 among nonusers (p = 0.053). Patients under endocrine treatment also presented STAI scores significantly higher (25.83 ± 4.99 vs. 19.00 ± 7.12; p = 0.000). Trait anxiety was high in both groups, but this was not statistically significant.

Conclusions

We observed a high prevalence of sexual inactivity among BC survivors regardless of AI use. Patients with AI use presented significantly higher prevalence of FSD, worse QoL, and greater anxiety.

Frequency of Sexual Problems and Related Psychosocial Characteristics in Cancer Patients-Findings From an Epidemiological Multicenter Study in Germany

Background

Multimodal cancer treatments are often associated with sexual problems. Identifying patients with sexual problems could help further elucidate serious issues with their sexuality and thus promote or maintain patients’ sexual health. We aimed to assess the occurrence of sexual problems in patients across different tumor locations and to explore associated sociodemographic, medical and psychosocial factors.

Methods

We included 3,677 cancer patients (mean age 58 years, age range 18–75 years, 51.4% women) from a large epidemiological multicenter study in Germany on average 13.5 months after cancer diagnosis. The occurrence and frequency of sexual problems were assessed via a binary item on the problem checklist of the Distress Thermometer (DT). Controlled associations of these problems with sociodemographic, medical and psychosocial factors including distress (DT), anxiety (GAD-7), depression (PHQ-9), quality of life (EORTC-QLQ-C30), and social support (SSUK-8) are analyzed using logistic regression analysis.

Results

We found that 31.8% of patients reported sexual problems, with a significant higher proportion in men (40.5%) compared to women (23.7%), OR 2.35, 95% CI [1.80–3.07] and a higher proportion in patients with a partner (35.6%) compared to those without a partner (3.5%), OR 2.83, 95% CI [2.17–3.70]. Tumor location was associated with occurrence of sexual problems: patients with cancer, affecting the male genital organs had the highest chance for sexual problems, OR 2.65, 95% CI [1.18–3.95]. There was no significant difference in the occurrence of sexual problems between age groups OR 0.99, 95% CI [2.13–3.53] and type of therapy (e.g., operation OR 0.91, 95% CI [0.72–1.15]). Sexual problems were further associated with elevated levels of anxiety, OR 1.05, 95% CI [1.02–1.10], less social support, OR 0.93, 95% CI [0.90–0.97] and lower quality of life in terms of impaired functioning (e.g., social function, OR 0.99, 95% CI [0.99–1.00]).

Conclusions

Sexual problems are commonly reported by patients. Male patients and those living with a partner are more likely to report sexual problems. Sexual problems are associated with different aspects of well-being. The findings imply the practical relevance to screen for sexual problems among patients and identified groups that should be particularly monitored.

Long-Term Patient Satisfaction and Quality of Life After Breast-Conserving Therapy: A Prospective Study Using the BREAST-Q

Background

Poor patient-reported satisfaction after breast-conserving therapy (BCT) has been associated with impaired health-related quality of life (HRQOL) and subsequent depression in retrospective analysis. This prospective cohort study aimed to assess the HRQOL of patients who have undergone BCT using the BREAST-Q, and to identify clinical risk factors for lower patient satisfaction.

Methods

Patients with primary breast cancer undergoing BCT were asked to complete the BREAST-Q preoperatively (T1) for baseline evaluation, then 3 to 4 weeks postoperatively (T2), and finally 1 year after surgery (T3). Clinicopathologic data were extracted from the patients’ charts. Repeated measures analysis of variance (ANOVA) was used to determine significant differences in mean satisfaction and well-being levels among the test intervals. Multiple linear regression was used to evaluate risk factors for lower satisfaction.

Results

The study enrolled 250 patients. The lowest baseline BREAST-Q score was reported for “satisfaction with breast” (mean, 61 ± 19), but this increased postoperatively (mean, 66 ± 18) and was maintained at the 1 year follow-up evaluation (mean, 67 ± 21). “Physical well-being” decreased from T1 (mean, 82 ± 17) to T2 (mean, 28 ± 13) and did not recover much by T3 (mean, 33 ± 13), being the lowest BREAST-Q score postoperatively and in the 1-year follow-up evaluation. In multiple regression, baseline psychosocial well-being, body mass index (BMI), and type of incision were risk factors for lower “satisfaction with breasts.”

Conclusion

Both the aesthetic/surgery-related and psychological aspects are equally important with regard to “satisfaction with breasts” after BCT. The data could serve as the benchmark for future studies.

The impact of mastectomy on body image and sexuality in women with breast cancer: a systematic review

Objective: The study aims to evaluate the impact of mastectomy on body image and sexuality of women with breast cancer, as well as to provide a general understanding of their quality of life. Method: This review followed the PRISMA guidelines. The expression “Mastectomy AND (sexuality OR “body image”)” was searched in Lilacs, Scielo, Pubmed and Scopus databases. Articles published in English, Portuguese and Spanish between 2010 and 2020 were selected. The text analysis was carried out by peers. Results: 69.3% (43) of the studies presented mastectomy as a technique that worsens body image, sexual functioning and quality of life of women. Less radical procedures, such as breast-conserving surgery, showed lower impact on these indicators. Breast reconstruction is an alternative to mitigate breast surgery impacts. Conclusion: Mastectomy caused the major impacts on body image, sexual functioning and quality of life. These implications need to be considered during therapeutic choice.

Communication about Sexual Health in Breast Cancer: What Can We Learn from Patients' Self-Report and Clinic Dialogue?

OBJECTIVE

Research assessing clinical communication about sexual health is limited. We compared clinical communication about sexual health across patients' self-reports and coded dialogue in breast cancer outpatients.

METHODS

134 patients had clinic visits audio-recorded and coded for sexual health communication and completed self-report questionnaires immediately after the visit. Associations between the self-report and dialogue were assessed using Phi coefficient. Agreements (present/absent) and discrepancies (omissions, commissions) about discussed topics were classified and discrepancies analyzed for themes.

RESULTS

Sexual health was discussed in 61 of 134 patient visits (46%). Associations were significant (p < .01) but differed by topic (φ = .27-.76). 37 women (23%) had ≥ 1 self-report error. Discrepancies were common (19 omissions, 29 commissions). Patients often omitted communication about sexual concerns when such concerns were not problematic, and interpreted non-specific discussions as including specific topics of concern, even when not explicitly stated. Omissions were more common for women with lower education.

CONCLUSIONS

Patients' reports of whether sexual health communication occurs does not always align with observed dialogue, and may vary by personal relevance of the topic.

PRACTICE IMPLICATIONS

There are limitations in determining the prevalence of clinical communication about sexual health through patient self-report. Explaining sexual health terms might enhance shared understanding.

Sexual Problems of Patients With Breast Cancer After Treatment: A Systematic Review

BACKGROUND

Sexual health is a crucial part of quality of life in breast cancer survivors, regardless of their relationship status. However, previous studies have rarely used qualitative methods to explore the postoperative experiences and feelings of patients with breast cancer.

OBJECTIVE

The aim of this study was to examine the causes of changes in sexual relationships of breast cancer survivors, methods for adaptation to these changes, and healthcare interventions to facilitate the patients' return to a normal life.

INTERVENTIONS/STUDY METHODS

A survey was performed by using five electronic databases and electronic journals accessed through the Internet. The following keywords were used: "breast cancer," "sexual problem," "sexual dysfunction," and "qualitative."

RESULTS

Seven articles were included in the literature review. Three main domains were explored, namely, reasons for sexual relationship changes; the way patients used to adapt to sexual life after the diagnosis of breast cancer; and intervention by healthcare workers.

CONCLUSIONS

The results of this study can facilitate and encourage health professionals to identify, examine, and solve most of the patient's sexual problems by using the functional and medical framework of the healthcare system.

IMPLICATIONS FOR PRACTICE

One practical recommendation of this study is the incorporation of sexual counseling units into the national healthcare system. Counselors in these units can help breast cancer survivors solve problems and improve sexual satisfaction between couples.

Breast-Specific Sensuality and Appearance Satisfaction: Comparison of Breast-Conserving Surgery and Nipple-Sparing Mastectomy

BACKGROUND

We demonstrated previously that lumpectomy (L) patients reported higher appearance satisfaction, appreciation of a pleasurable breast caress, and persistence of the breast during intimacy than mastectomy with reconstruction, which we used to describe breast-specific sensuality. Our current objective was to compare breast-specific sensuality between L and nipple-sparing mastectomy (NSM).

DESIGN

An anonymous, cross-sectional survey was distributed to breast cancer survivors between 2014 and 2016. Eligible patients underwent operation between 2000 and 2014, were adults older than 18 years, English-speaking, and at least one year into the post-operative period. Demographic characteristics, treatment details, Female Sexual Function Index metrics, and investigator-generated questions about appearance satisfaction and breast-specific sensuality were collected.

RESULTS

Of the 600 women who participated, 585 surveys were eligible. Surgical modality was reported as L by 406 (69.4%), mastectomy alone by 50 (8.5%), and mastectomy with reconstruction by 129 (22.1%). Nipple-preservation data were available for 47 of 129 mastectomy with reconstruction patients (36.4%), with 21 NSM and 26 non-nipple-sparing mastectomy patients. Favorable postoperative appearance satisfaction was reported by 76.2% of L and 71.4% of NSM (p = 0.039). Lumpectomy patients reported feeling more comfortable being seen undressed than NSM patients (82.4% vs 71.4%; p = 0.0003). The chest remained a part of intimacy for 65.4% of L patients vs 42.9% of NSM patients (p = 0.0009). A pleasurable breast caress was reported more frequently by L patients than NSM patients (66.2% vs 20%; p ≤ 0.0001). The breast caress was unpleasant for 40% of NSM patients, nearly 4-fold higher than L patients (11.3%; p < 0.0001).

CONCLUSIONS

NSM patients were significantly less satisfied with appearance, less comfortable being seen undressed, had decreased persistence of breast intimacy, and experienced a less pleasurable breast caress than L patients. Counseling patients about these findings will empower informed decision making, optimize expectations, and can enhance postoperative satisfaction.

A Pilot Intervention Study to Improve Sexuality Outcomes in Breast Cancer Survivors

Objective:

The main objective of the study is to assess the efficacy of the Permission, Limited information, Specific Suggestion, and sexual therapy (PLISSIT) model directly with breast cancer survivor (BCS) on sexual function and quality of life (QOL) domains.

Methods:

A pilot control trial was conducted comparing the PLISSIT model intervention to usual care. The intervention was delivered by two health professionals (nurse and professional sexual therapist) consisted of five sessions on counseling, genitalia anatomy, human sexual response, and sexual function. Data were collected before and 3 months after the intervention using the Female Sexual Function Index and the World Health Organization QOL-BREF questionnaire.

Results:

The sample consisted of 19 BCS (11 intervention, 8 controls) with a mean age of 54.5 8 years (standard deviation = 7.14) and the majority were married, Black or mixed Brazilian, received chemotherapy, radiation and/or hormonal therapy, and education varied from high school to college. There was significant improvement in physical health (P = 0.031), social relationships (P = 0.046), orgasm (P = 0.055), and pain (P = 0.049) over time and the intervention resulted in improved arousal (P = 0.038).

Conclusions:

The results suggest that the PLISSIT model may be an effective intervention for BCS in coping with and managing changes in sexuality and sexual function after treatment. It is important that nurses are aware of sexual intimacy concerns for BCS and integrate assessment into their nursing care.

Prevalence of female sexual dysfunction among women attending college presenting for gynecological care at a university student health center

Objective: To estimate the prevalence of female sexual dysfunction (FSD) among women attending college (18-29 years of age) presenting for routine gynecological care at a university-based student health center. Participants: Location: University affiliated women's health care clinic. Methods: Study design: Descriptive, cross sectional study. Primary endpoint: Estimated prevalence of FSD in the 18-29-year- old population. A subanalysis between those with and without recent sexual activity was performed. Logistic Regression was performed to identify potential predictors of FSD among those affected. Results: Of 310 women, FSFI was estimated as ranging from 35.5% (not sexually active) to 42.3% (sexually active). Those of younger age (18-21), with prior mental health diagnosis, and self-reported problems with arousal were at increased risk for FSD. Conclusion: Screening for FSD in the 18-29-year-old population is justified and recommended.

Sexuality and cancer in adolescents and young adults - a comparison between reproductive cancer patients and patients with non-reproductive cancer

BACKGROUND

Sexuality is an important aspect of quality of life for adolescent and young adults that remains understudied in cancer patients. Most current knowledge about how cancer and cancer treatments can affect patients' sexuality pertains to reproductive cancer patients (breast, gynecological, male reproductive organs), whereas only little is known about how the disease affects the sex lives of patients with other types of cancer. This study examined sexual satisfaction and sexual supportive care needs among adolescent and young adult cancer patients, with a particular focus on how the type of cancer a person has is associated with these issues differently.

METHODS

Five hundred seventy-seven (n = 424 females, 73.5%) patients between 18 and 39 years of age at diagnosis and representing all major tumor entities completed the standardized questionnaire. The analysis addressed the following topics: sexual satisfaction (Life Satisfaction Questionnaire), sexual supportive care needs (Supportive Care Needs Survey), and changes in sexuality (Questions on Life Satisfaction Modules). These topics were tested by mean differences between reproductive and non-reproductive cancer, equivalence testing and regression analyses.

RESULTS

About one third of the patients reported being dissatisfied with their sexuality and having supportive care needs in this area. Changes in sexuality were significantly more common in women with reproductive cancers than in those who had other types of cancer (t = - 2.693, p = .007), while both groups had equivalence in scores for sexual satisfaction and sexual supportive care needs. Reproductive cancers are not more associated with deterioration of sexual satisfaction (R2 = .002, p = .243), changes in sexuality (R2 = .006, p = .070) or increased sexual supportive care needs than non-reproductive cancers (R2 = .004, p = .131).

CONCLUSIONS

The results indicate that about a third of adolescents and young adults with both reproductive but also with non-reproductive cancer experience sexual dissatisfaction in similar measure. An equal percentage of these patients also express a desire to receive supportive care in this area. Consequently, health care professionals should address issues of sexuality and cancer as a matter of routine when caring for young adults even when patients have a non-reproductive cancer.

Sexual Dysfunction in Survivorship; the Impact of Menopause and Endocrine Therapy

BACKGROUND

Sexual dysfunction is common for breast cancer survivors. Premenopausal women with breast cancer are increasingly offered ovarian suppression and aromatase inhibitor (AI) therapy. We evaluated the association of menopausal status and treatment modalities on sexual dysfunction.

METHODS

We conducted a cross-sectional anonymous Female Sexual Function Index (FSFI) survey of breast cancer survivors between 2000 and 2016. Analysis utilized Kruskal-Wallis test for FSFI scores, Chi square, or Fisher's exact test for categorical data, and regression analysis for associations.

RESULTS

Of 585 respondents, 278 (47.5%) had complete FSFI scores. Of these, 24 (8.6%) were premenopausal and 80 (28.8%) were pre/perimenopausal at survey completion. Median FSFI scores for premenopausal (31.2, interquartile range [IQR] 26.8-33.6) and pre/perimenopausal (29.2, IQR 25.9-32.2) were similar, whereas postmenopausal women (25.9, IQR 21.0-30.3) were significantly lower (p = 0.0007 and p = 0.0002, respectively). Premenopausal women were less likely to meet criteria for sexual dysfunction (FSFI score ≤ 26.55) than postmenopausal women (21 versus 55%, p < 0.0001, univariate analysis [odds ratio (OR) 0.32, 95% confidence interval (CI) 0.18-0.56]). Adjusting for treatment modality did not impact the significance (OR 0.43, 95% [CI] 0.23-0.80) but revealed that AIs independently are associated with sexual dysfunction (OR 2.41, 95% CI 1.32-4.40). The interaction between menopausal status and AIs was not significant (p = 0.24).

CONCLUSIONS

Our study demonstrates that menopausal status is associated with sexual dysfunction in breast cancer patients and sexual dysfunction in premenopausal women is not impacted by treatment modality outside of aromatase inhibitor therapy. As more premenopausal patients are treated with ovarian suppression, these data may guide clinicians in counseling patients regarding sexual dysfunction expectations.

A Comparison of Patient-Reported Outcomes After Breast-Conserving Surgery and Mastectomy with Implant Breast Reconstruction

BACKGROUND

Many factors influence decisions regarding choice of breast-conserving surgery (BCS) versus mastectomy with reconstruction for early invasive breast cancer. The purpose of this study was to compare patient satisfaction following BCS and mastectomy with implant reconstruction (M-iR) utilizing the BREAST-Q patient-reported outcome measure.

METHODS

Women with stage I or II breast cancer undergoing BCS or M-iR who completed a BREAST-Q from 2010 to 2016 were identified by retrospective review of a prospective database. Baseline characteristics were compared, and linear mixed models were used to analyze associations with BREAST-Q scores over time.

RESULTS

Our study group was composed of 3233 women; 2026 (63%) had BCS, 123 (3.8%) had nipple-sparing mastectomy, and 1084 (34%) had skin-sparing or total mastectomy. Median time from surgery to BREAST-Q was 205 days for BCS and 639 days for M-iR (p < 0.001). Regardless of type of surgery, breast satisfaction scores decreased significantly over time (p < 0.001), whereas psychosocial (p = 0.001) and sexual (p = 0.004) well-being scores increased significantly over time. BCS was associated with significantly higher scores over time compared with M-iR across all subscales (all p < 0.001). Radiation was significantly associated with decreased scores over time across all subscales (all p < 0.05).

CONCLUSIONS

Breast satisfaction and quality-of-life scores were higher for BCS compared with M-iR in early-stage invasive breast cancer. These findings may help in counseling women who have a choice for surgical treatment. Breast satisfaction scores decreased over time in all women, highlighting the need for further evaluation with longer follow-up.

Choosing high-risk screening vs. surgery and the effect of treatment modality on anxiety and breast-specific sensuality in BRCA mutation carriers

Background

We have previously shown that breast cancer surgery affects breast specific sensuality, and that women who undergo mastectomy may have worse sexual function outcomes than those who undergo lumpectomy. It is less clear if patients who undergo prophylactic mastectomy are equally as affected as those with a cancer diagnosis. We sought to compare sexual function outcomes and their relationship to depression and anxiety between BRCA mutation carriers (mBRCA) with and without cancer in order to guide surgical counseling and improve survivorship outcomes.

Methods

A confidential, cross-sectional survey was distributed electronically to mBRCA at least 18 years of age. The survey included investigator-generated questions, the Female Sexual Function Index (FSFI), and the Hospital Anxiety and Depression Scale (HADS) surveys. Responses were analyzed in total and divided into two subgroups: those with and without breast cancer.

Results

Sixty-three mBRCA responded (37%) of 170 email addresses were identified, and 77% were postmenopausal. Although more than half of all mBRCA reported that the role of the breast in intimacy was important, most patients without cancer and all of those with cancer experienced an impressive decline in certain breast-specific sensuality parameters postoperatively. Among those without cancer, anxiety scores were not different between those choosing prophylactic mastectomy and high-risk screening (HRS). Sexual function as measured by the FSFI was negatively correlated with depression and anxiety in mBRCA. FSFI scores were not significantly different between those with and without cancer. However, the median FSFI of mBRCA with cancer, those undergoing HRS, and those who underwent prophylactic mastectomy indicated sexual dysfunction.

Conclusions

As the availability of genetic testing increases, more women are found to harbor BRCA mutations and must choose between HRS and prophylactic surgery. Women with BRCA mutations, both with and without breast cancer, are susceptible to derangements in sexual function during the course of both screening or treatment, and this appears to be negatively correlated to depression and anxiety.

Sexuality, a topic that surgeons should discuss with women before risk-reducing mastectomy and breast reconstruction

While sexual health is an important aspect of quality of life, sexual issues usually go unaddressed during patient-provider communication. Breast cancer treatments and specifically breast surgery impact women's sexual well-being. However, women do not receive adequate information on this subject. Women who underwent prophylactic mastectomy and breast reconstruction invariably reported that they had underestimated the impact of mastectomy and reconstruction on their sexuality, and expressed a need for information and creating realistic expectations pertaining to sexuality. Therefore, we urge breast surgeons to take the lead in addressing sexuality along with other health-related quality-of-life outcomes during pre-operative consultation.

Sexuality, fertility and pregnancy following breast cancer treatment

For women facing a new diagnosis of breast cancer, treatments can result in changes to intimate issues, including sexual health. For women of reproductive age, other significant concerns include the potential impact on fertility and the safety of pregnancy after treatment. These issues are important to acknowledge and to address, as they can impact on quality of life, not only for the patient, but may impact relationships, both present and future. In this paper we review sexual health after cancer, the importance of proactively addressing fertility, and important issues related to pregnancy following breast cancer.

Results from the American Society of Breast Surgeons Oncoplastic Surgery Committee 2017 Survey: Current Practice and Future Directions

INTRODUCTION

Oncoplastic surgery is emerging as a validated, safe, patient-centric approach to breast cancer surgery in the United States. The American Society of Breast Surgeons Oncoplastic Surgery Committee (ASBrS-OSC) conducted a survey to assess the scope of practice and level of interest in oncoplastic surgery among its members. Furthermore, the group sought to identify barriers to incorporating oncoplastic skills in a surgeon's practice.

METHODS

A 10-question survey was administered in March 2017 to the entire ASBrS membership using an online format. Three solicitations were sent. Unique identifiers allowed a single response.

RESULTS

Of the 2655 surveys sent out, 708 members responded. Nearly all (99%) respondents had at least some interest in oncoplastic surgery. The current rates of performing nipple-sparing mastectomy, adjacent tissue transfer, and breast reduction with lumpectomy were 80, 60, and 51%, respectively. A minority of respondents reported independently performing breast reductions/mammaplasties (19%) or contralateral symmetrization (10%). Barriers to learning oncoplastic surgery included surgeon's time and access to oncoplastic educational material/courses. Most respondents felt that training courses and videos may allow them to better incorporate oncoplastic techniques in their practices.

CONCLUSIONS

The interest in oncoplastic surgery among U.S. surgeons is significant, yet there are barriers to incorporate these surgical techniques into a breast surgeon's practice. As professional organizations provide access to effective training and enduring educational resources, breast surgeons will be enabled to develop their oncoplastic skill set and safely offer these techniques to their patients.