Sexuality and Breast Cancer Survivorship
Women with breast cancer may experience loss of sexual desire, decreased arousability, diminished orgasmic capacity, impaired vaginal physiology, depression, and a lessened sense of “femaleness.” Untreated sexual problems negatively affect intimate relationships, self-confidence, and physical well-being.
Addressing the issue of sexual function before cancer treatment begins alerts the patient to the clinician’s interest in this aspect of survivorship and increases the chance that the patient will bring future sexual problems to the attention of the treatment team. Depending on the nature of the problem and the disease context, interventions are available for treatment of sexual problems in breast cancer survivors.
These include vaginal moisturizers, lubricants, medications or psychological therapy to alleviate depression-related sexual dysfunction, and couples therapy to address sexual and more general issues.
According to Pelusi, sexuality is a complex and subjective concept that changes with age and experience and involves more than just being physically able to perform a sex act or conceive a child (Pelusi, 2006). Sexuality can include sexual response (interest, function, and satisfaction), body image (how a woman sees herself physically and views her overall health and sexuality), sexual roles, and relationships. Ultimately, “sexuality is a personal expression of one’s self and one’s relationship with others” (Pelusi, 2006).
A number of studies have looked at quality of life, including sexual function, in breast cancer survivors (Dorval et al., 1998; Ganz et al., 1998; Ganz et al., 2002; Kornblith et al., 2003; Bloom et al., 2004; Casso et al., 2004; Ganz et al., 2004; Kroenke et al., 2004; Arndt et al., 2005; Schultz et al., 2005). These studies suggest that sexuality in some women may be altered by breast cancer diagnosis and treatment.
Ganz et al. (1998) studied health-related quality of life and sexual functioning in a cross-sectional sample of breast cancer survivors from Los Angeles and Washington, D.C., who had been diagnosed 1-5 years earlier with early-stage (stage 0-II) disease, had completed all breast cancer therapy other than tamoxifen, and had no evidence of recurrent disease.
In this study, the respondents, who had a mean age of 56.2 years, reported health-related quality of life and sexual functioning that was similar to that of healthy age-matched women. With further follow-up, when women were 5-10 years from diagnosis, there was no change in the frequency of pain with intercourse, no change in sexual interest, and no change in body image, although there was a significant decline in the frequency of sexual activity (Ganz et al., 2002). In the Moving Beyond Cancer Study (Ganz et al., 2004), breast cancer survivors who had completed primary treatment that included chemotherapy were more likely to report worse sexual functioning than were survivors who had not received chemotherapy, regardless of the type of surgery.
Kornblith et al. (2003) found that 20 years after adjuvant therapy, 29% of survivors of early-stage breast cancer reported sexual problems that they attributed to having had cancer. Another study compared breast cancer survivors 8 years after diagnosis with controls who never had cancer and were matched by age and area of residence (Dorval et al., 1998). In this study, no differences were found between the two groups in the women’s satisfaction with their marital relationship or being sexually active with their spouse in the previous 12 months. Survivors, however, were less likely to be satisfied with their sexual life.
While a few studies have suggested that younger breast cancer survivors may be more likely than older breast cancer survivors or age-matched controls to report a decline in sexual function (Casso et al., 2004; Kroenke et al., 2004; Arndt et al., 2005), another study of young breast cancer survivors found no significant changes in sexual activity or sexual problems over time (Bloom et al., 2004).
It is important that we as healthcare teams provide an environment in which patients can discuss topics such as decreased libido, vaginal dryness, dyspareunia, and changes in body image as a result of sequelae of surgery or other therapy-for example, alopecia or weight gain. At M. D. Anderson Cancer Center, our teams caring for breast cancer survivors include nurses, physician extenders such as advanced practice nurses, physician assistants, social workers, and surgical, radiation, and medical oncologists.
We also work with our colleagues in the Departments of Gynecologic Oncology and Psychiatry; one of the advanced practice nurses in the Department of Psychiatry has a special interest in sexual dysfunction among breast cancer survivors.
Karin M. E. Hahn
The University of Texas, Department of Breast Medical Oncology
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