For Teachers & Professionals

Breast cancer, sexuality and communication

According to the 2021 reports of the WHO – World Health Organization, there were 7.8 million women alive who were diagnosed with breast cancer in the past 5 years, making it the world's most prevalent type of cancer. 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 report sexual disorders. Treatment of early breast cancer relies on a combination of chemotherapy, surgery, and radiation therapy. All these treatments, beyond the cancer itself, have side effects or sequences identified as high-risk factors for the development of female sexual dysfunctions. Despite these data, conversations about the consequences on sexuality are not happening often between cancer patients and healthcare providers. Often healthcare providers wait for the patients to bring up the topic and the patients tend to avoid it for discomfort or to bring it up only if it is of the uttermost importance in the short period. But if we take an example, in a recent study it was found that unpartnered women reported themselves to be sexually inactive, and perhaps, for this reason, they seemed relatively more likely to speak about concerns about body image rather than sexual function concerns. But this also means that if they do find a partner meanwhile, they are not informed about or prepared for the consequences they might encounter in sexual function. 

So what should doctors bear in mind when having a conversation with breast cancer patients?

1. Knowing the impact of the treatments on sexual function 

First of all, it’s important to view the treatments not only from a medical perspective but from that of the patient. For example, the conversations shouldn’t be only about informed consent for surgeries. These types of conversations do not necessarily include a great deal of depth concerning what these changes would mean in terms of the daily impact or coping with the changes. The treatments of breast cancer have particular consequences for the female body, which can directly influence a woman’s self-esteem, appearance and sexual desire. For example, after chemotherapy and hormone therapy important adverse effects are present in terms of vaginal dryness, dyspareunia and sexual well-being. For what concerns mastectomy, losing the breast seems to be the only choice for women with breast cancer to be declared cancer-free. While “losing their breast” could give a sense of security and happiness for a second chance to live, it could also impact their identity as a woman because of the disfigured body appearance. Women may feel “less feminine”, they don’t feel enough in respect to an inner ideal standard, thus leading to not feeling enough for their partner and avoiding sexual intimacy. In turn, this could discourage the partner from searching for further intimate contacts, making the woman feel less desired and leading to a vicious cycle. Discussions about the sensitivity after surgery are also important. 

2. Discussing treatment options 

The choice of less toxic treatments in each modality could reduce the risk of female sexual dysfunctions in some cases, without affecting the risk of recurrence or effectiveness. Most women prefer to receive information about the impact on intimacy and sexuality from a nurse or primary doctor. The preferred method of communication is a conversation with a professional together with their partner or a personal conversation with a professional, supported by a brochure or website.

The timing in which the information is given is also important. Intimacy and sexuality should be repeatedly included in consultations, at every stage of the disease but especially shortly after the treatment has started. 

3. How to raise the topic of sexual concerns 

Discussing sexual concerns could be incorporated into a continuous discussion about the effects on general health. 

Some might be concerned about how to address sexual topics for an unpartnered person. For example, one unpartnered woman suggested that a provider might say to her, ‘I know you are…not married, but here is some information that I know you can use…’ so it’s up to her to decide if she wants to use it or not. Some patients hope that their providers specifically ask about sexual concerns and normalize their concerns. The information should be delivered with a balance of empathy and directness. An important model that can be followed to know how to address this topic is the PLISSIT model. 

At a minimum, the breast cancer care provider could identify whether or not sexual health is an issue and make then an appropriate referral. 

4. Be aware of personal and contextual barriers 

There might be barriers that could limit dialogue between patients and healthcare providers. One of the strongest barriers tends to be owning negative beliefs about discussing sexual concerns, such as “sexual dysfunctions are of lower priority”. Also, leaving the topic at the end of the discussion and with a shorter time might make the patient feel as if it is effectively of lower importance and not leave the proper time to go deeper. 

Another negative belief held by healthcare providers is that “patients don’t want to talk about it”. According to this opinion, raising sexual concerns with patients who are uncomfortable could have detrimental effects on the patient-provider relationship. In this case, there are factors mediating the possible discomfort as the trust in the patient-provider relationship, the perception that the expressions of sexual concerns would be well received by their providers and positive prior experiences in discussing sexual concerns that could lead the patient to feel secure to bring it up again. Once the provider has raised the discussion, to not push the patient, it could be up to her to decide on the path of speech. 

Time and privacy could also be constraints. It should be made sure that sexual difficulties are discussed in a private room and with proper time as for any other information that is given to the patient. 

Being aware of communication dynamics and limitations is of fundamental importance when one has to deliver information on and deal with a sensitive topic such as sexuality and will serve as a basis to develop further and specific interventions.

REFERENCES 

• Albers L. F., Van Ek G. F., Krouwel E. M., Oosterkamp-Borgelink C. M., Liefers G. J., Den Ouden M. E. M., Den Oudsten B. L., Krol-Warmerdam E. E. M.,Guicherit O. R.,Linthorst-Niers E., Putter H., Pelger R. C. M. & Elzevier H. W. (2020). Sexual Health Needs: How Do Breast Cancer Patients and Their Partners Want Information?, Journal of Sex & Marital Therapy, 46:3, 205-226, DOI: 10.1080/0092623X.2019.1676853 

• Assad H., Badhwar G., Bhama S., Vakhariya C., Goodman J. R., (2014). Impact of breast cancer diagnosis and treatment on sexual dysfunction. Journal of Clinical Oncology. 32:26_suppl, 125-125 

• Barsky, R. J., Beach, M. C., Smith, K. C., Bantug, E. T., Casale, K. E., Porter, L. S., Bober, S. L., Tulsky, J. A., Daly, M. B., & Lepore, S. J. (2017). Effective patient-provider communication about sexual concerns in breast cancer: a qualitative study. Support Care Cancer. doi:10.1007/s00520-017-3729-1 

• Den Ouden, M.E.M., Pelgrum-Keurhorst, M.N., Uitdehaag, M.J. et al., (2019). Intimacy and sexuality in women with breast cancer: professional guidance needed. Breast Cancer. 26, 326–332. doi:10.1007/s12282-018-0927-8 

• Hernández-Blanquisett A, Quintero-Carreño V, Álvarez-Londoño A, Martínez-Ávila MC and Diaz-Cáceres R (2022). Sexual dysfunction as a challenge in treated breast cancer: in-depth analysis and risk assessment to improve individual outcomes. Front. Oncol. 12:955057. doi:10.3389/fonc.2022.955057 

• Runowicz CD, Leach CR, Henry NL, Henry KS, Mackey HT, Cowens-Alvarado RL. (2016). American Cancer Society/American society of clinical oncology breast cancer survivorship care guideline. CA: A Cancer J Clin. 66. doi:10.3322/caac.21319 

• Streicher L, Simon JA. (2018). Sexual function post-breast cancer. Cancer treatment and research. Springer Cham Copyright Information: Springer International Publishing AG. Doi:10.1007/978-3-319-70197-4_11