Copyright © 1994, Meniscus Health Care Communications
Kerry V. Harwood is an Oncology Clinical Nurse Specialist, Duke University Medical Center, Durham, NC, and Anne P. O'Connor is Oncology Nurse Specialist, Pittsburgh Cancer Institute, University of Pittsburgh Medical Center, Pittsburgh, PA.
Innovations in Oncology Nursing, Vol. 10, No. 23, 1994
Reprinted with permission of the publisher
The study of sexuality after breast cancer is evolving. Insight can be gained from a limited number of studies addressing sexual aspects of life after breast cancer. However, interpretation of available findings is hampered by methodological limitations of the studies. Anecdotal insights are available through the lay literature, detailing the experience of women with breast cancer and their partners. The impact of breast cancer on sexuality can be considered with the context of:
At the other end of he spectrum, Kitzinger, drawing from women's own experiences, describes sexuality as more than biologic and as involving the entire context of women's lives, relationships, and emotions . Valid research and appropriate intervention in the area of sexual health require that the practitioner appreciate the complexity of the interaction among factors that influence sexuality. One model is the World Health Organization (WHO) definition of sexual health: "Sexual health is the integration of the somatic, emotional, intellectual, and social aspects in ways that are positively enriching and that will enhance personality, communication, and love." 
Patient goals for sexuality are highly individual and may be incorrectly defined if assessment is based on stereotypes. For example, one should not assume that older women are not interested in sex. Most women over age 65 remain interested in their body image and are sexually active. Until a patient's feelings about sexuality are known, an older woman's concerns should be addressed in a manner similar to that for a younger person. Older women may be experiencing equal loss but not be as comfortable in expressing these feelings. Similarly, no blanket assumptions can be correctly made regarding sexual health goal in women who are not married or women whose physical appearance deviates significantly from the caregiver's stereotype of sexual attractiveness.
Another component of sexual behavior is choosing a partner. The major task of young adulthood is developing intimacy, learning to give and receive love, and choosing a partner. Sex can be a significant part of that intimacy and can serve as a way of communicating and expressing trust in a relationship.  In discussing sexuality with patients, it is important to remember that the sexual partner may be male or female. Fantasy, masturbation, and foreplay are also elements of normal sexuality.
Each of these elements, e.g. sexual self-image, partner selection, and sexual activity, has the potential to be disrupted by breast cancer.
Within the context of sexuality lie the specifics of the physiologic sexual response. Figure 1 depicts the normal female sexual response curve. Understanding the stages of female sexual response facilitates awareness of illness and treatment issues that can affect progression in sexual response.
Increasingly, women are offered breast-conserving treatment for breast cancer. The principal objective of a breast-conserving procedure is to preserve the integrity of the woman's body image. This involves an additive assumption that such a procedure will be less physically and psychologically disable tan a mastectomy. Yes, when one considers the many facets of sexuality, that assumption may not hold. Does a breast-conserving procedure affect a woman's sexuality in a less profound way than complete removal of the breast?
Two comprehensive reviews have described studies comparing quality of life, including sexuality, in patients receiving mastectomy versus breast-conserving treatment. [9,10] Most quality-of-life outcomes were not difference between the treatment groups. Conserving a woman's breast did consistently improve the ability to preserve body image. Although no differences in sexual functioning between mastectomy and breast-conservation patients was noted in the majority of studies, when studies did detect a difference, the benefit consistently favored breast conservation.
Breast-conserving treatment usually includes both limited surgery and breast irradiation. McCormick and colleagues explored women's perceptions of their treated breast in a group of 74 women at least 1 year after treatment.  Although the vast majority of women were very satisfied, both cosmetically and sexually, significant changes were noted in comparing the treated versus the untreated breast. Of 64 participants who were sexually active, 48% noted increased breast discomfort, 39% avoided the treated breast, and 20% stated their partners avoided it.
Why were not more significant differences in sexuality following the alternative breast surgeries? Schover suggest that factors other than the extent of breast surgery may play a larger role in sexual satisfaction, including overall psychological health, satisfaction with the relationship and precancer sex life.  Another factor in sexual dysfunction following breast cancer may be the impact of systemic therapies utilized in addition to breast surgery.
Reasons commonly cited for seeking reconstruction are to be free of the external prosthesis; to "feel whole again"; to reestablish symmetry; to be less inhibited sexually and reduce self-consciousness about appearance; and to be less preoccupied with the underlying threat of cancer.  Contrary to earlier concerns, women who pursue reconstruction demonstrate positive coping skills and high self-esteem. [15,16] Other factors affecting a woman's choice of reconstruction include other health factors, age, social support network, and availability of third-party reimbursement.
In a recent study of women's response to reconstruction, Rowland and colleagues describe the characteristics and psycho social outcomes of 58 women undergoing delayed breast reconstruction.  Of the women studied, 83% were very satisfied overall with the results. Comparing pre-and post-operative interviews, women were more comfortable with their sexuality, more satisfied with sexual activity, more willing to show others the surgical site, and less concerned about their health without the mastectomy site, which is a constant reminder of cancer. In extrapolating these data, it is important to keep in mind the characteristics of the sample. In this case, the sample consisted of women who self-referred for delayed reconstruction. They were prominently well-educated, employed, married white women with a median age of 42 years. About half described impaired sexual functioning since mastectomy, and participants scored very positively on a scale of self-esteem. The vast majority had not received adjuvant chemotherapy.
Positive outcomes following breast reconstruction, including self-image and feeling less self-conscious both socially and sexually, have been described to by other investigators as well. [18,19]
Second, sexual dysfunction occurs frequently within the healthy population as well. Studies of women with diabetes, chronic alcoholism and epilepsy demonstrated frequencies of sexual dysfunction ranging from 20% to 32%, with none of these groups differing significantly from the control group frequency of 23%.
Several factors may place women at higher risk of sexual dysfunction after breast cancer. Diagnosis in the 20s or 30s is difficult, as developing intimacy, choosing one's life partner, and childbearing are high developmental priorities. Previous sexual problems, poor psychological adjustment, and unhappy relationships or the absence of a committed partner at time of diagnosis may also place women at risk.
Illness can affect sexuality in a variety of ways unrelated to specific effects on sex organs. Concerns regarding mortality and finances can override one's ability to think of anything else. Illness can influence one's self-esteem by forcing a change in roles, inability to continue work, and dependence on others. Depression may sap energy or exacerbate the fatigue caused by various treatments. Pain or other physical discomforts may interfere with progression of sexual response. Chronic illness can bring about feelings of self-involvement that shut out all emotions except the need for "a solution, a cure, a reprieve." One of the first emotions to go in the midst of this self-involvement is the need to give pleasure to another.
Partners are concerned about how to express their love physically after breast surgery. Signs of affection such as hugging or fondling the breast may cause pain and discomfort in the post-operative period or even long after radiation therapy. It may take some time before both the woman and her partner feel comfortable engaging in sex. The couple's former patterns of lovemaking may need some adjustments. Alternative types of foreplay, as well as alternative position, may need to be considered.
Practical considerations like medical bills, home finances, and balancing additional home responsibilities with occupational pressures can drain the energy of spouses. These stresses can lead to feelings of powerlessness which may disrupt the frequency, pleasure, and importance of sexual activity for the partner of a woman with breast cancer.
All of these issues -- anxiety regarding the prognosis, fear of causing pain, and the stresses of altered roles and additional expenses -- can alter a partner's willingness to initiate sexual contact. partners may withdraw sexual energy from the relationship as a form of self-protection.  Conversely, some couples find that the intimate bonds forged in battling breast cancer together actually enhance their sexual relationship.
The opportunity to participate actively in the treatment-planning process and seek surgical treatment geared toward one's self-esteem/body image may determine satisfaction as strongly as any specific treatment option. The impacts of systemic therapies and patient perspectives on sexuality, discussed in more detail elsewhere in this publication, are also critical areas for oncology nursing practice and research.
Kiebert GM, deHaes JCJM, van de Velde, CJH. "The impact of breast-conserving treatment and mastectomy on the quality of life of early-stage breast cancer patients: a review." J. Clin. Oncol. 1991; 9:1059-1070.
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