Effects of the Better Model Based Counseling on Sexuality of Women with Breast Cancer

Abstract

Purpose

Breast cancer and side effects of its treatment cause many problems such as body image, impaired quality of life, and sexual dysfunction. The aim of this experimental study is to determine the effect of BETTER Model-based counseling programme on sexual problems of female patients with breast cancer.

Methods

This study was conducted with experimental and control group design. The data of the study were obtained between April 2016 and March 2018. The sample group consisted of 60 women who agreed to participate in the study. Information Form, “EORTC Quality of Life Questionnaire-BR23”, “Female Sexual Function Index”, and “Body Cathexis Scale” were used in order to collect the data. The “Better Model”-based counseling programme was applied in four sessions a week in the experimental group. The scales were applied again one month after the last session. The women in the control group were subjected to routine hospital control after the scales were applied. The scales were applied again in this group one month later.

Results

After the “Better Model”-based counseling programme was applied,the women in the experimental group had higher scores from lubrication, orgasm, and pain subscales, and overall female sexual function index. Besides, the women in the experimental group had higher scores from body image subscale of functional scale of the quality of life questionnaire.

Conclusions

In the study, it was detected that the “Better Model”-based counseling was effective in raising and enhancing sexual health awareness and decreasing the existing sexual issues in women with breast cancer.

Introduction

Breast cancer is the most common type of cancer affecting women in Turkey. Interventions are realized for diagnostic purposes at first in patients with breast cancer, which is followed by surgical treatments and intensive therapies such as chemotherapy, radiotherapy and hormonal therapies (Alacacıoğlu et al., 2014, p. 1–8; Chang et al., 2019; Greaney et al., 2015, p. 1–2; Hassen et al., 2019, p. e0222629). Hormonal therapy is important in the treatment of breast cancer. Anti-estrogenic agents are used in hormonal therapy for patients with breast cancer. However, this treatment leads to changes in ovarian functions as well as menopausal symptoms, sexual functioning and fertility (Alacacıoğlu et al., 2014, p. 1–8; Chang et al., 2019; Hungr et al., 2017, p. 114–115; Lopresti et al., 2018, p. 404–405). Due to breast cancer and its treatment, sexual functioning deteriorates in 41% of sexually active patients (Chang et al., 2019). Women may experience sexual problems such as lack of sexual desire due to androgen deficiency, lack of satisfaction with sexuality, loss of interest in partners, atrophy in the vagina, dryness, dyspareunia, difficulty in arousal, and inability to reach orgasm. As breast is one of the important sexual arousal regions of the female body, women's sensation ofpleasure is affected by the treatments (Boquiren et al., 2016, p. 66–67; Chang et al., 2019; Fergus et al., 2015, p. 1–2; Hummel et al., 2015, p. 321–322; Kedde et al., 2013, p. 1993–1994; Pillai-Friedman & Ashline, 2014, p. 436–437; Pinto, 2013).

Breast plays a key role in body image, too (Boquiren et al., 2016, p. 66–67; Fergus et al., 2015, p. 1–2; Hummel et al., 2015, p. 321–322; Kedde et al., 2013, p. 1993–1994; Pillai–Friedman & Ashline, 2014, p. 436–437; Rush et al., 2015, p. 1107–1109). Women consider breast as a body part associated with sexuality and femininity (Alacacıoğlu et al., 2014, p. 1–8; Fergus et al., 2015, p. 1–2; Kedde et al., 2013, p. 1993–1994; Pillai–Friedman & Ashline, 2014, p. 436–437). Breast cancer and its treatments such as mastectomy, chemotherapy, radiotherapy, and hormonal therapy cause scar and body image–related problems (Alacacıoğlu et al., 2014, p. 1–8; Fergus et al., 2015, p. 1–2; Hassen et al., 2019, p. e0222629; Hungr et al., 2017, p. 114–115; Kedde et al., 2013, p. 1993–1994; Pillai–Friedman & Ashline, 2014, p. 436–437). Having a breast deformity or losing breast can lead women to suffer from negative alterations related to body image. Changes in physical appearance influence the perception of worthiness, attractiveness, and sexual activity (Alacacıoğlu et al., 2014, p. 1–8; Gokgoz et al., 2011, p. 140–142; Hummel et al., 2015, p. 321–322; Hungr et al., 2017, p. 114–115;Kedde et al., 2013, p. 1993–1994; Krebber et al., 2014, p. 121–122; Pillai–Friedman & Ashline, 2014, p. 436–437).

Sexual health is an important part of quality of life. Diagnosis of breast cancer and side effects of its treatment can impair the quality of life by harming intimate relationships and sexual functioning (Alacacıoğlu et al., 2014, p. 1–8; Boquiren et al., 2016, p. 66–67; Chang et al., 2019; Hassen et al., 2019, p. e0222629; Hummel et al., 2015, p. 321–322; Hungr et al., 2017, p. 114–115; Kedde et al., 2013, p. 1993–1994; Wu et al.,2019, p. 10563–10571). Also, factors such as fear of cancer recurrence, fatigue, pain, decreased feelings of attractiveness and femininity and changes in body image influence the quality of life. Hence, enhancing the quality of life is important as much as systemic therapies (Lopresti et al., 2018, p. 404–405).

Nurses spend most of their working time with patients. They play important roles in evaluating sexual life in breast cancer, detecting potential sexual issues, promoting sexual health, coping with sexual problems, referring these individuals to relevant departments when necessary and enhancing the overall quality of life. Women with breast cancer experience less sexual problems after nursing interventions (Boquiren et al., 2016, p. 66–67; Demirci et al., 2011, p. 1283; Kedde et al., 2013, p. 1993–1994; Krebber et al., 2014, p. 121–122; Pinto, 2013). Interventions applied for female sexual dysfunction range from lifestyle changes, education, sexual counseling, sex aids (lidocaine preparations, lubricants etc.), and dietary supplements to non-hormonal medications. All of these approaches are useful (Awan & Esfahani, 2018, p. 285–286). However, it is often difficult to talk about sexuality, thus leading nurses not to address this issue (Almeida et al., 2019, p. 1109–1110). Sexual problems are not routinely asked and even little counseling is provided for these problems (Katz, 2005, p. 238–239). In Turkey, likewise, women with breast cancer are not asked about their sexual problems so nurses do not provide the related counseling. However, professional nursing care for patients with breast cancer should include counseling on psychosocial and sexual issues (Johnson et al., 2018).

There are models of clinical nursing care that are used to provide care in hospitals and health services particularly as they are related to acute and inpatient care (Fairbrother et al., 2015). Nursing models represent theorizing of nursing practises and are of prime importance in learning how to realize them and organizing delivery of nursing care (Pearson et al., 2005, p. 21–22). Numerous tools and models are used for assessing sexual function and providing interventions for sexual problems (Mick et al., 2004, p. 84–85). It is important to use appropriate models for communication between healthcare professionals and patients. Models such as BETTER (Bring up the topic, Explain, Telling, Timing, Education, Recording), PLISSIT (Permission, Limited Information, Specific Suggestion, Intensive Therapy), ALARM (Activity, Libido, Arousal, Resolution, Medical information), and PLEASURE can guide nurses by providing a framework involving appropriate steps in order to address sexual health issues of patients. These models can also help nurses talk about the topic of sexual health with their patients and they can help to promote women's sexual health using these models (Almeida et al., 2019, p. 1109–1110; Mick et al., 2004, p. 84–85).

The BETTER Model was developed to assist oncology nurses to involve sexuality assessment into care of cancer patients (Katz, 2005, p. 238–239; Mick et al., 2004, p. 84–85) and could be used to talk about sexuality in the field of oncology, to evaluate sexuality, and to provide maintenance standards and holistic care for the patients (Mick et al., 2004, p. 84–85). Thus, it becomes possible to plan and implement the counseling programmes on sexual problems, direct patients to receive consulting services as required, and maintain sexual health. The BETTER Model is an acronym (Mick et al., 2004, p. 84–85) including B standing for bringing up the topic, E standing for explaining quality-of-life issues including sexuality, T standing for telling patients that resources will be found for addressing their concerns, the other T standing for timing of intervention, E standing for educating patients about the side effects of treatments, and R standing for recording (Katz, 2005, p. 238–239; Mick et al., 2004, p. 84–85). Some studies have reported that the use of sexual counseling strategies increases sexual function and marital intimacy and alleviates pain and sexual distress, and these strategies are also effective and useful since healthcare professionals are able to get access to them for use (Almeida et al., 2019, p. 1109–1110; Faghani & Ghaffari, 2016, p. 4845–4846; Nho, 2013, p. 681–682).

In studies conducted on sexuality of cancer patients in Turkey, PLISSIT has been frequently used. Although the BETTER Model was originally developed for cancer patients, it is not frequently used in Turkey to address sexual problems of patients with breast cancer. Since the BETTER model is a model developed for sexual counseling for cancer patients, it will be more appropriate to use this model. The aim of this study is to determine the effect of BETTER model-based counseling programme on sexual problems of women with breast cancer.

Hypotheses

H_o: There is no difference between the scale scores of patients with breast cancer who receive and do not receive the better model-based nursing counselling for sexual problems.

H₁: There is a difference between the scale scores of patients with breast cancer who receive and do not receive the better model-based nursing counselling for sexual problems.

Methods

Study design, setting, and sample

This study with experimental and control group design was conducted in an oncology hospital. The population of the study consisted of female patients with breast cancer who applied to the oncology hospital. The sample comprised women with breast cancer who met the inclusion criteria. The sample size was calculated to be 60 patients with breast cancer using G-Power 3.0.10 power analysis program at 5% alpha error probability. 116 women with breast cancer applied to the clinic, 32 of them did not meet the inclusion criteria and 7 declined to participate in the study. Seventeen women did not have a sexual intercourse within the last month, two women could not be contacted, and one woman did not want to continue the study, so they were excluded from the study. Thus, the study was completed with 60 women with breast cancer. Random numbers table was used for randomization and the patients were assigned to control and experimental groups. The participants were not informed about whether they were included in the experimental or control group but the researcher knew the women included in the experimental group as she would provide consulting to them. This study was conducted with blinded outcome assessment and analysis. RCT number was received (NCT04297657).

The inclusion criteria were determined as follows:

• Undergoing mastectomy, (It has been reported that postoperative sexual functions and body image of patients with early stage breast cancer would worse, especially after mastectomy (Ganz et al., 1998, p. 501; Al-Ghazal et al., 2000, p. 1938–1943; Yeo et al., 2004, p. 132–139; Pérez et al., 2010, p. 924–937) therefore mastectomy patients were selected)

• Having primary diagnosis of breast cancer and being at stage I-II (Sexual problem outcomes may vary among women with and without invasive breast cancer due to adjuvant treatment plans or type of surgery (Pérez et al., 2010) therefore, only patients with early stage breast cancer were included in this study)

• Being in full remission and receiving no other treatment except for hormonal therapy (Only patients who received hormonal therapy were included in the study since chemotherapy and radiotherapy have many side effects and it is thought that patients cannot be contacted in this process)

• Being literate and sexually active,

• Having spouses without sexual health problems,

• Having no psychiatric illness

• Being capable of communicating verbally and agreeing to participate in the study

The exclusion criteria were determined as follows:

• Being involved in another sexuality-related treatment program or participating in another study on sexuality

• Suffering from another type of cancer or recurrence/metastasis and having previously received an effective treatment for another type of cancer,

• Having no sexual intercourse within the last month,

• Suffering from neurological and psychiatric disorders

Flow diagram

Ethical considerations

Ethics committee approval was obtained from clinical trials ethics committee of the university (IRB No: 10840098-604.01.01-E.1465).. In order to conduct the study, institutional permission was received from the educational planning and coordination board of the related hospital. Verbal and written consents of the women who were voluntary to participate in the study were obtained. All procedures of the study were realized based on the Declaration of Helsinki and its later amendments.

Data collection tools

The data were collected through Information Form, “Female Sexual Function Index (FSFI),” “EORTC Quality of Life Questionnaire-BR23,” and “Body Cathexis Scale (BCS).” In addition, “Counselling Booklet and compact disc” prepared by the nursing researcher was given to those in the experimental group.

Information Form

This form was prepared by the nursing researcher and has 39 questions about obstetric and socio-demographic characteristics of the participants as well as their disease, treatment and sex life status-related characteristics.

Female Sexual Function Index (FSFI)

This index has nineteen items about sexual functioning of the patients during the last one month. It has six subscales (desire, lubrication, arousal, orgasm, satisfaction, and pain). High scores signify positive assessments. Total score of the scale ranges between two and thirty-six points. The scale’s cutoff point is 26.55 and getting a score of ≤26.55 is considered to have sexual dysfunction. It is a valid and reliable scale that could be used in Turkish women (Cronbach's alpha coefficient of 0.98) (Aygin & Eti-Aslan, 2005, p. 393–399; Pinto, 2013; Rosen et al., 2000, p. 191–208). In this study, Cronbach's Alpha coefficient was found to be 0.90.

EORTC Quality of Life Questionnaire-BR23

This scale is widely used in patients with cancer. The EORTC is a continuation of the “Quality of Life Questionnaire-C30 Version 3.0” and has 23 items about the side effects of breast cancer treatments, sexuality, body image, and future expectations. Total score of the scale ranges between zero and one hundred points. While higher scores in Functional Scale are evaluated positively, lower scores in the Symptom Scale are evaluated positively. It is a valid and reliable scale for Turkish community (Demirci et al., 2011, p. 1283–1287; Beser & Oz, 2003, p. 47–58; Gokgoz et al., 2011, p. 140–152; The European Organization for Research and Treatment of Cancer (EORTC), 2001). In this study, Cronbach's Alpha coefficient was calculated as 0.81.

Body Cathexis Scale (BCS)

Breast plays an important role in body image of women. Circumstances such as breast cancer and mastectomy which alter the structure, function, and appearance of the body parts negatively affect body image. Women with breast cancer experience body image-related problems (Boquiren et al., 2016, p. 66–76; Fergus et al., 2015, p. 1–14; Greaney et al., 2015, p. 1–11; Hummel et al., 2015, p. 321–332; Kedde et al., 2013, p. 1993–2005;Pillai-Friedman & Ashline, 2014, p. 436–453; Rush et al., 2015, p. 1107–1118). Therefore, this scale was used to determine presence of any issue of the participants about body image. This 40-item scale aims to measure the happiness level of people about their body parts and their functions. Total score ranges between 40 and 200 points. This scale has no cutoff point. High scores signify a high degree of satisfaction. Turkish validity and reliability study of this scale was conducted (Cronbach's Alpha value of 0.91) (Hovardaoglu, 1990; Secord & Jourard, 1953). In this study, its Cronbach's Alpha coefficient was found to be 0.84.

Counseling booklet and compact disc

The counseling booklet prepared by the researcher in accordance with literature consisted of four parts; physical and psychosocial effects of breast cancer and its treatments, sexuality-sexual health, breast cancer treatments and their effect on sexual health, and recommendations for sexual problems associated with breast cancer. The counseling compact disk was about 55 minutes long and it was prepared by the researcher based on the information in the booklet and recorded. Thus, it was thought that the women could access the information at any time.

Data collection process

Before starting the study, the researcher attended the Sexual Therapy Education Certificate Program to investigate and educate women with breast cancer better. After she completed the certificate program, necessary permissions were obtained from the related institution.

The women, who applied the outpatient clinics of the hospital for control and met the inclusion criteria, were selected according to the random number table and assigned to the experimental or control group. Verbal and written consent was obtained from the participants. The women were interviewed through the face-to-face interview method by applying the Information Form and the Scales in an appropriate environment that allows for privacy. An appointment was made with the women in the experimental group for interview at an appropriate time for them and a suitable environment in the hospital. In accordance with BETTER Model stages, a counseling for sexual health of the patients was planned and provided. In the experimental group, the counseling programme based on BETTER Model was conducted in four sessions with one-week intervals. The interview with the experimental group lasted for averagely 45-60 minutes. In addition, those in the experimental group were given a counseling booklet and compact disk. The topics of interest among women were noted during the sessions and after the information on the subject was received, feedback was given to them through a phone call. The scales were applied again one month after the fourth session.

In the control group, the women were subjected to routine hospital control after the scales were applied. The same questionnaires were applied again one month later. The interview lasted for averagely 10–15 minutes. The women included in the control group were informed about their sexual health upon completion of the data collection tools and these women were given a counseling booklet and compact disk, prepared by the researcher, free of charge. No payment was made to the participants.

Counseling process

Control group

	Content
Session I	Meeting women Informing them about the study and getting their written consents and if the patient is not available for counseling, making an appointment for an appropriate time. Application of “Information Form”', “Female Sexual Function Index (FSFI)”, “EORTC QLQ-BR23 Quality of Life Questionnaire”, and “Body Cathexis Scale (BCS)”
Session II	Routine hospital care
Session III	Routine hospital care
Session IV*	Applying “Female Sexual Function Index (FSFI)”, “EORTC QLQ-BR23 Quality of Life Questionnaire”, and “Body Cathexis Scale (BCS)”

*The fourth session took place one month after the first session.

Intervention group

	BETTER	Content
Session I *	B- Bringing up the topic	Meeting women Informing them about the study and getting their written consents and if the patient is not available, making an appointment for an appropriate time. Applying “Information Form”', “Female Sexual Function Index (FSFI)”, “EORTC QLQ-BR23 Quality of Life Questionnaire”, and “Body Cathexis Scale (BCS)” Allowing the patient to explain sexual problems Giving information about breast cancer and its physical and psychosocial effects
Session II*	E- Explaining that sex is an important part of quality of life	Giving training on sexuality and sexual health (definitions related to sexuality, genitals,sexual function, stages of sexual response, sexual dysfunctions etc.) Correcting false information and beliefs about sexuality and talking about sexual myths Giving information about the relationship between sexual health and quality of life
Session III*	T- Telling patients that resources will be found to address their concerns	Talking with the patient about their anxieties and fears and finding resources about the problems they are experiencing Giving the counseling booklet and compact disk
In all sessions	T- Timing of intervention	Patients who are not ready to discuss sexual issues may request information in the future. Arranging a meeting with these patients on a suitable day
Session IV*	E- Education regarding sexual side effect of treatment	Providing information on effects of breast cancer treatments and their side effects on sexuality (surgical treatment, chemotherapy, radiation therapy, hormone therapy and effects on sexual health etc.) Making suggestions for sexual problems (vaginal dryness, lack of sexual desire, dyspareunia, decreased sexual satisfaction, protection from infections, fatigue, hair loss, insomnia, deterioration in body image, loss of breast etc.) in breast cancer
In all sessions	R- Recording	Summarizing and recording the sessions Applying “Female Sexual Function Index (FSFI)”, “EORTC QLQ-BR23 Quality of Life Questionnaire”, and “Body Cathexis Scale (BCS)”**

*Sessions were held with one-week interval.

**The scales were applied again one month after the fourth session.

Data analysis

The data of the study were analyzed using IBM SPSS Statistics 23 programme. In the data assessment, frequency distributions (n, %) were given for categorical variables. When deciding on the hypothesis test to be used, the compatibility of the numerical variable to the normality assumption was examined. Independent Samples t test (parametric tests) was used for the normally distributed variables, Mann Whitney U test (non-parametric tests) was used for non-normally distributed variables. Mean and standard deviation were used as descriptive statistics for the variables using parametric testing. Median, minimum and maximum were used as descriptive statistics for the variables using non-parametric tests. Chi-Square was used to examine whether or not there was a correlation between two independent categorical variables. Cronbach’s Alpha reliability coefficient was used for the scale reliability. Statistical significance was evaluated at significance level of 5%, confidence interval of 95%, and p < 0.05.

Results

Mean age of the women with breast cancer was 40.6 ± 4.7 and 40.0 ± 4.4, respectively (p=.474). All of the women had health insurance. When the women with breast cancer in the experimental and control groups were evaluated, no statistically significant difference was found between the groups in terms of age, body mass index, education, work status, income level, and family structure (Table 1).

Table 1.

Characteristics regarding demographics, disease, and the treatment they receive in women with breast cancer (N = 60).

	Intervention group (n = 30)		Control group (n = 30)
	Mean ± SD	Med.	Mean ± SD	Med.	Test	p
Age	40.6 ± 4.7	42.0	40.0 ± 4.4	41.0	ZMWU= − 0.716	.474a
BMI	27.8 ± 5.3	27.1	27.9 ± 4.1	27.5	t=−0.496	.622b
	n	%	n	%	χ 2	p
Educational status
8 years and less	16	53.3	21	70.0	1.763	.184c
More than 8 years	14	46.7	9	30.0
Employment status
Employed	7	23.3	6	20.0	0.098	.754c
Unemployed	23	76.7	24	80.0
Income status
Income less than expenditure	2	6.7	7	23.3	2.092	.148c
Income is equivalent to expenditure	28	93.3	22	73.3
Family type
Nuclear family	26	86.7	23	76.7	1.002	.317c
Extended family	4	13.3	7	23.3
Stage of disease
Stage 1	7	23.3	12	40.0	1.926	.165c
Stage 2	23	76.7	18	60.0
Operation time (years)
2 years and less	15	50.0	19	63.3	1.086	.297c
More than 2 years	15	50.0	11	36.7
Status of receiving chemotherapy
Yes	29	96.7	28	93.3	0.351	.999c
No	1	3.3	2	6.7
Status of receiving radiotherapy
Yes	24	80.0	25	83.3	0.111	.739c
No	6	20.0	5	16.7
Medication used in hormonal treatment
Tamoxifen	15	50.0	18	60.0	0.606	.436c
Tamoxifen + Goserelin	15	50.0	12	40.0
	Mean ± SD	Med.	Mean ± SD	Med.	ZMWU	p
Number of chemotherapy cycles	7.5 ± 2.7	6.0	7.3 ± 3.1	8.0	−0.607	.544a
Duration of radiotherapy (days)	28.4 ± 4.2	30.0	28.0 ± 6.0	27.0	−0.686	.493a
Duration of hormonal treatment (months)	23.8 ± 19.6	24.0	23.1 ± 15.7	20.0	−0.327	.744a

^aMann Whitney U; ^bIndependent sample T test; ^cChi-square test; BMI: body mass index.

Stage 2 breast cancer was observed in 76.7% of the women in the experimental group and 60% of the women in the control group (p=.165). No statistically significant difference was detected between the two groupsin terms of the stages of the disease. All women in the study group underwent surgical mastectomy and none of them received any treatment such as radiotherapy or chemotherapy prior to the surgery. All of the participants received hormonal therapy and their treatment was still continuing. Their hormonal therapies began concurrently with radiotherapy. Experimental and control groups were similar in terms of drugs used in hormonal treatment (p=.436). When the hormonal therapy periods of the women were examined, it was found that mean duration of the treatment was 23.8 ± 19.6 months for the experimental group and 23.1 ± 15.7 months for the control group (p=.744). No statistically significant difference was detected between the groups in terms of the treatments such as mastectomy, chemotherapy, radiotherapy, and hormonal therapy (Table 1).

When the sex lives of the participants were examined, it was found that 86.7% of the women in the experimental group and 93.3% of the women in the control group did not have a problem in their sex life prior to the breast cancer treatments (mastectomy, radiotherapy, chemotherapy, and hormonal therapy) (p=.671). When the current sex lives of the women were examined, 70.0% of those in the experimental group and 53.3% of those in the control group had sexual health problems after the cancer and its treatments such as radiotherapy and chemotherapy (p=.184) (Table 2).

Table 2.

Sexual health related characteristics in women with breast cancer (n = 60).

	İntervention group (n = 30)		Control group (n = 30)		Test
	n	%	n	%	χ²	p
Asking questions about sexual life during the course of treatment (mastectomy, chemotherapy, radiotherapy, hormonal therapy etc.)
Yes	10	33.3	6	20.0	1.364	.243b
No	20	66.7	24	80.0
Problems in sex life before treatment (mastectomy, chemotherapy, radiotherapy, hormonal therapy etc.)
Yes	4	13.3	2	6.7	0.741	.671b
No	26	86.7	28	93.3
Problems in sex life at present
Yes	21	70.0	16	53.3	1.763	.184b
No	9	30.0	14	46.7
Satisfaction with sex life
Yes	13	43.3	17	56.7	1.067	.302b
No	17	56.7	13	43.3
Satisfaction of the spouse with sex life
Yes	15	50.0	22	73.3	3.455	.063b
No	15	50.0	8	26.7
Time period for first intercourse after surgery
Below 5 months	19	63.3	22	73.3	0.693	.405b
5 months and above	11	36.7	8	26.7
Using lubricant during sexual intercourse
Yes	3	10.0	0	0.0	3.158	.237b
No	27	90.0	30	100.0
	Mean ± SD	Median	Mean ± SD	Median	ZMWU	p
Duration of being sexually active (years)	19.4 ± 6.2	20.0	19.4 ± 7.0	19.5	−0.163	.871a
Frequency of sexual intercourse per week
Before the disease	2.8 ± 1.1	3.0	2.5 ± 1.0	2.5	−0.987	.324a
After the disease	1.8 ± 1.1	1.0	1.3 ± 0.4	1.0	−1.493	.135a

^aMann Whitney U; ^bChi-Square Test.

It was determined that 56.7% of the women in the experimental group and 43.3% of the women in the control group responded negatively to the question about satisfaction with their sex life (p=.302). 50.0% of those in the experimental group and 73.3% of those in the control group stated that their spouses were satisfied with their sex lives (p=.063). Experimental and control groups were similar in terms of the time elapsed between their first sexual intercourse and mastectomy surgery (p=.405). 10.0% of the women in the experimental group stated that they used lubricants during sexual intercourse (p=.237). When the frequency of sexual intercourse before and after the disease was examined in the experimental and control groups, weekly frequency of sexual intercourse before the disease was 2.8 ± 1.1 and 2.8 ± 1.1 (p=.324), respectively. On the other hand, weekly frequency of sexual intercourse after the disease was 1.8 ± 1.1 in the experimental group and 1.3 ± 0.4 in the control group (p=.135). There was no statistically significant difference between the groups in terms of sexual health characteristics (Table 2).

No statistically significant difference was found in the first evaluation of women with breast cancer based on the subscale and total scores of “Female Sexual Function Index (FSFI)”. However, in the final evaluation, a statistically significant difference was detected in terms of lubrication (p=.017), orgasm (p=.049), pain (p=.024) subscales and FSFI total score (p=.033) (Table 3).

Table 3.

Comparison of mean score points of first-preliminary-evaluations and final evaluations of women's female sexual function index in women with breast cancer (n = 60).

Female Sexual Function Index (FSFI)	İntervention group (n = 30)		Control group (n = 30)		İntervention/Control FPE/FE
	Mean ± SD	Median	Mean	Median	Test	p
Desire
First preliminary eval.	2.7 ± 0.9	2.4	2.9 ± 0.8	3.0	ZMWU= −1.044	.297a
Final eval.	3.1 ± 1.1	3.3	3.0 ± 0.8	3.0	ZMWU= −0.316	.752a
Arousal
First preliminary eval.	3.2 ± 0.9	3.6	3.1 ± 0.7	3.3	ZMWU= −0.723	.470a
Final eval.	3.4 ± 0.8	3.6	3.2 ± 0.8	3.3	T= −0.785	.436b
Lubrication
First preliminary eval.	3.9 ± 0.6	3.9	3.9 ± 0.9	4.0	ZMWU= −0.397	.691a
Final eval.	4.5 ± 0.8	4.5	3.9 ± 0.8	3.9	T= −2.446	.017b*
Orgasm
First preliminary eval.	3.6 ± 0.9	3.6	3.5 ± 0.8	3.6	ZMWU= −0.297	.767a
Final eval.	4.1 ± 1.0	4.4	3.6 ± 0.9	3.6	ZMWU= −1.971	.049a*
Satisfaction
First preliminary eval.	3.7 ± 0.9	4.0	3.9 ± 1.0	4.0	ZMWU= −0.969	.333a
Final eval.	4.1 ± 1.1	4.8	3.8 ± 1.1	4.0	ZMWU= −1.449	.147a
Pain
First preliminary eval.	4.2 ± 1.2	4.4	3.9 ± 0.9	3.6	ZMWU= −1.113	.266a
Final eval.	4.7 ± 1.2	4.8	4.0 ± 1.1	3.6	ZMWU= −2.252	.024a*
Total FSFI
First preliminary eval.	21.5 ± 3.7	22.8	21.4 ± 3.9	21.2	ZMWU=0.000	.999a
Final eval.	24.1 ± 4.6	25.6	21.7 ± 4.2	21.8	ZMWU= −2.137	.033a*

^aMann Whitney U; ^bIndependent Sample T Test; *p < 0.05; FPE: first-preliminary-evaluation; FE: final evaluation.

The two groups were found to be similar in the first evaluation of women when their subscale mean scores of “EORTC Quality of Life Questionnaire-BR23” functional scale were examined. When the mean scores of functional scale were examined in the final evaluation, a statistically significant difference was observed between the two groups in terms of body image (p=.020). When the mean scores obtained by the women from “EORTC Quality of Life Questionnaire-BR23” symptom scale during the first and final evaluations were examined, the two groups were found to be similar (Table 4).

Table 4.

Comparison of mean score points in the first-preliminary evaluations and final evaluations of QLQ-BR23 quality of life scale in women with breast cancer (n = 60).

EORTC QLQ-BR23 quality of life questionnaire	İntervention group (n = 30)		Control group (n = 30)		İntervention/Control FPE/FE
					Test
	Mean ± SD	Median	Mean ± SD	Median	ZMWU	p
Functional scales
Body image
First preliminary eval.	81.9 ± 23.1	100.0	64.4 ± 37.3	75.0	−1.766	.077a
Final eval.	83.3 ± 21.3	100.0	64.7 ± 33.2	66.6	−2.323	.020a*
Sexual functioning
First preliminary eval.	45.5 ± 16.3	50.0	47.7 ± 26.8	50.0	−0.114	.909a
Final eval.	50.5 ± 17.7	50.0	41.6 ± 16.2	33.3	−1.877	.061a
Sexual enjoyment
First preliminary eval.	45.5 ± 25.5	33.3	54.4 ± 29.6	66.6	−1.430	.153a
Final eval.	46.6 ± 28.5	50.0	45.5 ± 20.5	33.3	−0.249	.803a
Future perspective
First preliminary eval.	45.5 ± 39.6	33.3	54.4 ± 39.6	66.6	0.833	.405a
Final eval.	51.1 ± 44.4	66.6	58.8 ± 33.5	66.6	−0.567	.570a
Symptom scales / Items					Test	p
Systemic therapy side effects					T
First preliminary eval.	42.8 ± 20.8	40.4	41.2 ± 18.9	38.1	−0.309	.759b
					Test	p
Final eval.	32.5 ± 19.5	28.5	33.8 ± 15.2	30.9	ZMWU
					−0.424	.672a
Breast symptoms
First preliminary eval.	23.3 ± 26.3	16.6	11.9 ± 19.5	8.3	−1.810	.070a
Final eval.	10.2 ± 12.8	8.3	8.0 ± 14.7	4.1	−1.337	.181a
Arm symptoms
First preliminary eval.	27.7 ± 28.1	11.1	22.9 ± 24.0	16.6	−0.618	.536a
Final eval.	22.9 ± 21.4	16.6	21.8 ± 22.8	11.1	−0.370	.711a
Upset by hair loss
First preliminary eval.	30.0 ± 41.3	0.0	28.8 ± 44.4	0.0	−0.259	.796a
Final eval.	11.1 ± 22.0	0.0	26.6 ± 41.4	0.0	−1.248	.212a

^aMann Whitney U; ^bIndependent Sample T Test; *p < 0,05; FPE: first-preliminary-evaluation; FE: final evaluation.

While “Body Cathexis Scale (BCS)” mean scores of the women with breast cancer were examined, no statistically significant difference was found between the two groups (Table 5).

Table 5.

Comparison of mean score points of first-preliminary evaluations and final evaluations of body perception scale in women with breast cancer (n = 60).

			İntervention/ Control FPE/FE
	İntervention group (n = 30)	Control group (n = 30)	Test
Body Cathexis Scale (BCS)	Mean ± SD	Mean ± SD	T	p
First-preliminary evaluation	138.7 ± 15.3	143.7 ± 12.3	1.411	.164a
Final evaluation	138.7 ± 15.3	145.0 ± 13.9	0.009	.993a

^aIndependent sample T Test; *p < 0.05; FPE: first-preliminary evaluation; FE: final evaluation .

Discussion

The experimental and control groups were similar in terms of personal characteristics such as age, education, body mass index, working status, income level, and family structure. For the accuracy and reliability of the study results, it was important that the groups showed similarities and there was no significant difference between the groups in terms of demographic characteristics. In the first assessment, Female Sexual Function Index (FSFI), EORTC QLQ-BR23 Quality of Life Questionnaire, and Body Cathexis Scale (BCS) scores of the women with breast cancer were similar to one another. This was also important in terms of equality of the groups.

As the treatment of breast cancer, the patient receives surgical treatments and intensive therapies (Alacacıoğlu et al., 2014, p. 1–8; Greaney et al., 2015, p. 1–11; Hungr et al., 2017, p. 114–122; Johnson et al., 2018). In terms of undergoing surgery, chemotherapy, radiotherapy and hormonal therapy, no significant difference was detected between the experimental and control groups. Breast cancer is a chronic disease that has been studied for many years. Similar treatment protocols are used in a lot of countries. The treatments such as mastectomy, chemotherapy, radiotherapy, and hormonal therapy used in this group were similar to the ones previously performed in Turkey and in the world (Alacacıoğlu et al., 2014, p. 1–8; Chang et al., 2019). It is known that treatments of breast cancer adversely affect sexual health of the patients (Boquiren et al., 2016, p. 66–76; Chang et al., 2019; Kedde et al., 2013, p. 1993–2005). Similarity of the two groups in terms of receiving surgical treatment, radiotherapy, chemotherapy and hormonal therapy was found to be crucial in alleviating the adverse effects of the treatments on the sexual health of women.

Due to cancer treatments, women may experience sexual problems. Also, women's sensation of pleasure is affected by the treatments (Boquiren et al., 2016, p. 66–76; Fergus et al., 2015, p. 1–14; Hummel et al., 2015, p. 321–332; Kedde et al., 2013, p. 1993–2005; Pillai-Friedman & Ashline, 2014, p. 436–453; Pinto, 2013). Similarly, Biglia et al. (2010), Panjari et al. (2011), Boquiren et al., (2016), and Leila et al. (2016), identified in their studies that during and after treatments of breast cancer patients, they experienced sexual problems such as lack of sexual desire, vaginal dryness, inability to reach orgasm, and pain and they found that women's sexual functions were poor and their scale scores related to sexuality were low. The nursing support regarding sexuality has a great importance. It was reported that women with breast cancer who received counseling from nursesexperienced fewer sexual problems (Kedde et al., 2013, 1993-2005; Kennedy et al., 2015, 1-6; Mick et al., 2004, 84-86; Yu & Sherman, 2015, 565-577; Zeng et al., 2012, 257-263). In their study, Jun et al. (2011) stated that nurses applied a 2-hour weekly programme for 6 weeks, thus resulting in positive changes in the sexual satisfaction of the experimental group members. In their study, Perz et al. (2015) revealed that counseling increased awareness of the patients regarding changes in sexual life after cancer, helped them cope with the changes in their sexual health and enhanced communication between couples regarding sexuality. In this study, it was found that the experimental group had higher scores of lubrication, orgasm, pain and overall FSFI after the nursing counseling. During the nursing counseling programme, recommendations about vaginal lubricants and advices to cope with lack of lubrication, desire, orgasm, satisfaction and pain might have affected the results and might have increased the women's scores in lubrication, orgasm, and pain subscales and overall FSFI. It can be asserted that BETTER Model-based counseling is effective in coping with sexual problems and raising awareness among breast cancer patients. Further studies using the better model in sexual counseling are recommended.

Breast cancer and the side effects of its treatments cause many problems such as scar, body image and sexual problems. These problems adversely affect the quality of life as well (Alacacıoğlu et al., 2014, p. 1–8; Boquiren et al., 2016, p. 66–76; Demirci et al., 2011, p. 1283–1287; Fergus et al., 2015, p. 1–14; Kedde et al., 2013, p. 1993–2005; Krebber et al., 2014, p. 121–130; Pillai-Friedman & Ashline, 2014, p. 436–453; Wu et al.,2019, p. 10563–10571). In this study, mean score of the experimental group in body image item of “EORTC Quality of Life Questionnaire-BR23” was higher than the score of the control group during the final evaluation. During the counseling programme, recommendations about the use of wearable breast prosthesis might be effective on body image. In addition, although there was no statistically significant difference, the increase in the sexual function and sexual enjoyment scores of the experimental group in the final evaluation was a favorable outcome. Demirci et al. (2011), Gokgoz et al. (2011), and Leila et al. (2016) used “EORTC Quality of Life Questionnaire-BR23” in their studies. When the results of the present study were compared with the results of these studies, it was understood that different results were obtained in these studies. This situation might be due to the fact that in their studies the researchers included patients who were older, were still undergoing treatments such as radiotherapy/chemotherapy or receiving no treatment. This study involved women who received no other treatment except for hormonal therapy and had a mean age of 40 years. Age and treatments are known to be important factors in sexual health. Women with breast cancer in different stages of the disease were included in these studies. So, the results may be different from each other.

Diagnosis of breast cancer can impair the quality of life by harming intimate relationships and sexual functioning (Mick et al., 2004, p. 84–86). Breast cancer treatments are known to cause many side effects. All these factors can have negative effects on patients’ mood, quality of life, and activities of daily living, including sexual ones (Alacacıoğlu et al., 2014, p. 1–8; Boquiren et al., 2016, p. 66–76; Chang et al., 2019; Demirci et al., 2011, p. 1283–1287; Fergus et al., 2015, p. 1–14; Kedde et al., 2013, p. 1993–2005; Krebber et al., 2014, p. 121–130; Pillai-Friedman & Ashline, 2014, p. 436–453; Pinto, 2013; Wu et al., 2019, 10563–10571). Therefore, the purpose of nurses is to reduce the negative impacts of the treatments on the patients’ quality of life. In their study, Rush et al. (2015) proposed to develop strategies for the patients to follow to enhance their quality of life. On the other hand, in their study Perz et al., (2015) did not observe any improvement in quality of life, satisfaction in sexual intercourse and sexual function of the participants. In this study, the “EORTC Quality of Life Questionnaire-BR23” scores did not change. The results did not support the results of Rush et al. (2015) while they supported the findings obtained by Perz et al., (2015). Sexuality is an integral part of quality of life (Katz, 2005, p. 238–241) but as the content of the counseling programme in the study was predominantly related to sexual health, it was natural result that it was not effective in improving all of the areas related with quality of life. For this reason, it is recommended to conduct nursing interventions to enhance all areas of quality of life in future studies.

Breast has a key role in body image. Situations such as breast cancer and mastectomy which cause changes in the structure, function, and appearance of the body parts have a negative effect on body image. Patients undergo changes in their perceptions of femininity, feel themselves less attractive, and develop anxiety about their body image and sexuality (Boquiren et al., 2016, p. 66–76; Greaney et al., 2015, p. 1–11; Hummel et al., 2015, p. 321–332; Pillai-Friedman & Ashline, 2014, p. 436–453;Wu et al., 2019, p. 10563–10571). Boquiren et al., (2016) found that 88.2% of 127 sexually active women over the age of 18 were not satisfied with the appearance of their body. Leila et al. (2016) determined that the body image alteration had no effect on the sexuality. In this study, there was no difference between the two groups after the counseling. Other approaches were found to be necessary to improve body image. Consulting on wearable breast prostheses, lymphedema, weight gain / loss, hair loss, changes in skin and nails is thought to be beneficial in improving body image.

Strengths and limitations of the study

The strengths of this study are that the study was experimental and there has not been much study using BETTER Model for sexual health in Turkey. Women with breast cancer stated that their medical treatments were met, doctors and nurses were mostly focused on treatment, and they gave little time to education and counseling. They stated that they couldn't ask questions about sexuality to doctors and nurses because they were afraid. But they had the chance for asking to researcher, applied the recommendations to cope with the problems during counseling programme and thanked. During the counseling programme, the patients were given a counseling booklet for reading and a compact disk for listening. This made it easier for women to access information later. The women gave a favorable opinion about the counseling compact disk.

Limitations of this study are that the study was conducted in a single center and within time constrains, not including spouses. Family problems and relationship between spouses’ effect on sexual health was unknown. Sexual health problem could be kept secret due to taboos.

Conclusion

Counseling provided by nurses based on the BETTER Model was effective in raising the awareness regarding sexual health after breast cancer treatments and reducing sexual health problems. It is recommended to conduct further studies using the better model in sexual counseling, to include spouses in the studies, and to collect data on the relationship between the woman and her husband/partner.

Ethical approval

Ethics committee approval is obtained from institutional review boardof university (IRB No: 10840098-604.01.01-E.1465). Institutional permission is received from the Educational Planning and Coordination Board of the Hospital. Verbal and written consent is obtained from the women who volunteered to participate in the study.

Disclosure statement

No potential conflict of interest was report was reported by the author(s).

Authorcontributions

Zeynep Ozkan Olcer:conceptualization, methodology, software,formal analysis, data curation, investigation, visualization, resources,writing-original draft preparation. Umran Oskay:conceptualization, methodology, supervision, validation, data curation, formal analysis, reviewing and editing.