Detecting and Discussing Sexual Problems during Chemotherapy for Breast Cancer

To the Editor: The breast is a unique symbol of femininity playing an important role in body image, self-esteem, as well as sexual pleasure and stimulation (1). Treatment of breast cancer through surgery, chemotherapy, radiotherapy, hormone therapy, or a combination may cause immediate or delayed side effects that impair sexual function (e.g., dyspareunia, vaginal dryness, or reduced libido) (2,3). If left unaddressed, sexual function problems may significantly impair patients’ quality-of-life (QOL). Physicians are not only responsible for treating and caring for patients, they are also gatekeepers to support services. For good reason, patient–physician interactions tend to focus on disease symptoms and side effects during the treatment periods, and consequently may omit to discuss certain aspects of QOL including sexual function (4). Research suggests that discussion of sexual function may be disproportionately hindered by communication barriers (5). In this study, we examined the prevalence of dissatisfaction with sexual function during chemotherapy for breast cancer through patient self-report (Functional Assessment of Cancer Therapy-General [FACT-G] questionnaire (6)). We then examined whether those reporting sexual dissatisfaction discussed this issue with their physician during outpatient consultations. Subsequently, we interviewed 10 patients and 10 health professionals about their opinions of routine assessment and discussion of sexual function to identify ways in which current practice could be enhanced. Fifty-two patients completed the FACT-G questionnaire (mean age 53.4; SD 10.15, 44% curative, 56% palliative). Twenty-six (50%) completed the satisfaction with sex-life item and of these, eight (15% of the total sample) reported dissatisfaction with sexual function. Older patients were more likely to omit completing the sex-life item. Four consecutive outpatient consultations were audio-recorded for each of the 52 study patients. Physicians did not receive patients’ FACT-G scores. Despite 15% of patients reporting dissatisfaction with sexual function, sexual problems were not discussed in any of the 208 consultations. Menopause and fertility issues were discussed in one consultation (33-yearold patient). Relationships and partner support were discussed in 12 consultations. Thematic analysis of interviews with patients identified that assessment of sexual function using PROMs was acceptable. One patient indicated that they found the questions a little embarrassing, but they were not offended by being asked to answer them. Another patient said that they were happy to answer sexual function questions as sexuality was an important aspect of their overall well-being. Two patients (one early stage, one metastatic disease) did not feel that sexual function was particularly relevant to their treatment. Both women, however, could see that the questions may be relevant to some breast cancer patients. Some of the interviewees said that they would probably speak to a nurse if they had concerns about sexual function, whereas other women felt that they would deal with the issue themselves or with their partner. Women often felt that at the time of chemotherapy treatment, sexual issues were not a particular priority, but may be in the future if the problem persists. Thematic analysis of interviews with 10 health care professionals (two medical oncology consultants, three clinical oncology consultants, two registrars, and three specialist nurses) identified several barriers to discussion of sexual issues. Physicians often regarded patients’ age as a barrier. They felt that older women may not want to talk about sexual issues particularly with a physician who was younger than them. Male physicians also said that they would feel uncomfortable raising sexual issues with female patients. Address correspondence and reprint requests to: Sally Taylor, Psychosocial Oncology and Clinical Practice Research Group, St James’s Institute of Oncology, University of Leeds, Leeds, UK, or e-mail: s.s.taylor@leeds.ac. uk Joint senior authors.