Non-response data in Sexual Well-being among Breast Reconstruction Patients— Who are we overlooking?

Abstract

Background:

Missing data can affect the representativeness and accuracy of survey results, and sexual health-related surveys are especially at a higher risk of nonresponse due to their sensitive nature and stigma. The purpose of this study was to evaluate the proportion of patients who do not complete the BREAST-Q Sexual Well-being relative to other BREAST-Q modules and compare responders versus non-responders of Sexual Well-being. We secondarily examined variables associated with Sexual Well-being at 1-year.

Methods:

A retrospective analysis of patients who underwent breast reconstruction from January 2018 to December 2021 and completed any of the BREAST-Q modules postoperatively at 1-year was performed.

Results:

2,941 patients were included. Of the four BREAST-Q domains, Sexual Well-being had the highest rate of nonresponse (47%). Patients who were separated (versus married, OR=0.69), whose primary language was not English (versus English, OR=0.60), and had Medicaid insurance (versus commercial, OR=0.67) were significantly less likely to complete the Sexual Well-being. Postmenopausal patients were significantly more likely to complete the survey than premenopausal patients. Lastly, autologous reconstruction patients were 2.93 times more likely to respond than implant-based reconstruction patients (p<0.001) while delayed (versus immediate, OR=0.70, p=0.022) and unilateral (versus bilateral, OR=0.80, p=0.008) reconstruction patients were less likely to respond. History of psychiatric diagnosis, aromatase inhibitors, and immediate breast reconstruction were significantly associated with lower Sexual Well-being at 1-year.

Conclusion:

Sexual Well-being is the least frequently completed BREAST-Q domain, and there are demographic and clinical differences between responders and non-responders. We encourage providers to recognize patterns in non-response data for Sexual-Well-being in order to ensure that certain patient population’s sexual health concerns are not overlooked.

Introduction

A major obstacle in optimizing patient reported outcomes (PROs) for research and clinical care is missing data. PROs are dependent on a patients’ desire to complete the measures, and such willingness can be influenced by patient, clinical, or procedure-related differences.¹ For example, age, income level, education, and ethnicity can affect PRO response rate.^2–4 Missing data has implications for the representativeness and accuracy of survey results. It can cause loss of power to detect change, under- or over-estimate intervention effects, and lead to selection bias.^5,6 Recognizing missing data in PROs is essential to minimize nonresponse and selection bias and to augment available data.^4,6

Sexual health concerns are common in breast cancer patients. Breast cancer patients may experience reduced sexual desire, discomfort, and poor body image during their cancer journey.^7–9 Despite the prevalence of sexual dysfunction, sexual health-related surveys may be at a higher risk of nonresponse given the stigma and the sensitive nature of some of the questions.^10–13 Age and socio-cultural barriers may hinder patients from freely discussing their sexual health with their providers.^14–16 Attitudes, experience, and interest regarding sexuality can also affect participants’ willingness to partake in sexual health surveys.^17,18 Nonetheless, there is a paucity of information on missing data in sexual health surveys among breast cancer patients. There may be a significant proportion of patients with sexual dysfunction who go unnoticed because of missing data. It is critical to identify non-responders in this patient population to ensure that all patients’ sexual health concerns are sufficiently addressed, and that sexual health outcomes research is representative of all breast cancer patients.⁴

The purpose of this study was to evaluate the proportion of patients who do not complete the BREAST-Q Sexual Well-being module relative to other modules and to compare characteristics of responders versus non-responders. We secondarily aimed to assess factors associated with the 1-year score to identify risk factors for decreased Sexual Well-being. We hypothesize that the Sexual Well-being domain is the least completed domain and that sociodemographic differences, such as age and primary language, affect response rate.

Methods

Study population

The study was approved by institutional review board of Memorial Sloan Kettering Center, an academic and National Cancer Institute-designated cancer center. Women who underwent breast reconstruction from January 2018 to December 2021 and completed at least one of the BREAST-Q modules postoperatively at 1-year were included. 2018 was chosen as the starting point as quality improvement initiative was implemented to increase BREAST-Q completion rates at that year.¹⁹ Patients without any BREAST-Q data at 1-year, younger than 18 years old, or did not undergo postmastectomy breast reconstruction were excluded.

Data Collection and Variables

Demographic data and clinical details were recorded via chart review. Variables included age at surgery, race, ethnicity, marital status, body mass index (BMI), smoking status, menopausal status, primary language, insurance, median income, and past medical history (diabetes, cardiovascular disease, hypertension (HTN), lymphedema, and history of psychiatric diagnosis). Median income was based on patients’ zip-code.²⁰ Patients with a history of psychiatric diagnosis were diagnosed with any of the following disorders, as classified by International Classification of Diseases (ICD), Tenth Revision (diagnosis codes beginning with F), or ICD Ninth Revision (diagnosis codes between 290 and 319.99) codes: anxiety, mood, substance-related, somatic, sexual/gender identity, personality, behavioral and neurodevelopmental, psychotic, sleep, and eating disorders. Clinical variables included chemotherapy, radiation, axillary lymph node dissection, sentinel lymph node biopsy, and endocrine therapy. For clinical factors, we assessed mastectomy type as well as reconstructive type, laterality, and timing. We also examined whether patients were readmitted or returned to the operating room within 90 days of their breast reconstruction.

Questionnaire

The BREAST-Q is a rigorously developed questionnaire that is validated, condition-specific and has been widely used to measure quality of life and satisfaction after breast reconstruction from the patients’ perspective.²¹ The questionnaire was administered as part of routine clinical care preoperatively and at various time points postoperatively. The four main modules include: Satisfaction with Breasts, Physical Well-being of the Chest, Psychosocial Well-being, and Sexual Well-being. Depending on the type of reconstructive surgery (autologous versus implant) patients are prompted to take additional surveys. Autologous patients are administered Physical Well-being of the Abdomen and Satisfaction with Abdomen while Implant patients are administered Satisfaction with Implants. The 1-year postoperative timepoint was based on 1-year after the definite reconstruction (direct-to-implant, exchange from TE to implant, immediate autologous, or conversion from TE to autologous). The raw score was converted to summary scores ranging from 0 to 100 using the Q-Score software, with higher scores indicating higher patient satisfaction or quality of life. A minimal clinically important difference (MCID) of 4 points was considered clinically important.²²

Statistical Analysis

Baseline demographics, surgical, and cancer characteristics were described for all patients using medians and interquartile ranges (IQR) for continuous variables and frequencies and percentages for categorical variables. We used frequencies and percentages to describe the completion of 1-year BREAST-Q scores for all domains. Variables were compared between the BREAST-Q Sexual Well-Being responders and non-responders at 1-year postoperatively using the Wilcoxon rank sum test for continuous variables and the Chi-squared test for categorical variables. All p-values were adjusted using the false discovery rate correction for multiple testing. Multivariable logistic regression was used to assess variables associated with completion of the Sexual Well-being BREAST-Q at 1-year postoperatively. Multivariable linear regression analysis of all patients with 1-year postoperative data was conducted with multiple imputation to accommodate missing preoperative scores. Patient demographic and clinical variables included in each model were hypothesized a priori.

Results

Patient Characteristics

2,941 breast reconstruction patients completed at least one BREAST-Q domain at 1-year follow-up. The median age at surgery was 49 (interquartile range: 42 to 56). Most patients were White (72%), not Hispanic or Latino (83%), and were married (70%). The median BMI was 24.2 (IQR: 21.5 to 27.8). The remaining demographic and clinical information are described in Table 1. There were 1,566 (53.2%) patients with available and 1,375 (46.8%) patients with missing Sexual Well-being scores at 1-year. The two cohorts were compared, and there were significant differences in the distribution of sociodemographic and clinical factors between the two cohorts, as described in Table 1.

Table 1.

Patient Demographics and Clinical Details for all patients, patients with Sexual Well-being Scores, and patients without Sexual Well-being Scores.

Patient Demographics	All Patients (n=2,941)	Available (n=1,566)	Missing (n=1,375)	p-value
Age at Surgery 1	49 (42, 56)	49 (42, 55)	49 (42,57)	0.3
Race  White  Asian  Black  Other	2,116 (72%) 287 (9.8%) 293 (10%) 245 (8.3%)	1,162 (74%) 135 (8.6%) 142 (9.1%) 127 (8.1%)	954 (69%) 152 (11%) 151 (11%) 118 (9.6%)	0.021
Ethnicity  Not Hispanic  Hispanic  Unknown	2,451 (83%) 299 (10%) 191 (6.5%)	1,326 (85%) 140 (8.9%) 100 (6.4%)	1,125 (82%) 159 (12%) 91 (6.6%)	0.057
Marital Status  Married  Separated  Single	2,046 (70%) 292 (9.95%) 603 (21%)	1,124 (72%) 128 (8.2%) 314 (20%)	922 (67%) 164 (12%) 289 (21%)	0.001
Language  English  Non-English	2,840 (97%) 101 (3.4%)	1,533 (98%) 33 (2.1%)	1,307 (95%) 68 (4.9%)	<0.001
Income 1	$103,548 ($77,044, $131,412)	$106,631 ($79,524, $131,412)	$101,405 ($73,856, $131,013)	0.024
Insurance  Commercial  Medicaid  Medicare  Self-Pay	2,345 (80%) 184 (6.3%) 385 (13%) 27 (0.9%)	1,290 (82%) 75 (4.8%) 190 (12%) 11 (0.7%)	1,055 (77%) 109 (7.9%) 195 (14%) 16 (1.2%)	<0.001
Body Mass Index (BMI) 1	24.2 (21.5, 27.8)	24.3 (21.6, 28.1)	24.2 (21.3 27.7)	0.3
Smoking Status  Never Smoker  Current Smoker  Former Smoker	2,233 (76%) 75 (2.6%) 633 (22%)	1,186 (76%) 33 (2.1%) 347 (22%)	1,047 (76%) 42 (3.1%) 286 (21%)	0.2
Menopause Status  Premenopausal  Postmenopausal  Unknown	322 (11%) 1,191 (40%) 1,428 (49%)	136 (8.7%) 615 (39%) 815 (52%)	186 (14%) 576 (42%) 613 (45%)	<0.001
Comorbidities  Diabetes  Cardiovascular Disease  Hypertension  Psychiatric Diagnoses  Lymphedema	164 (5.6%) 704 (24%) 665 (23%) 1,651 (56%) 246 (8.4%)	81 (5.2%) 390 (25%) 332 (21%) 890 (57%) 141 (9.0%)	83 (6.0%) 314 (23%) 333 (24%) 761 (55%) 105 (7.6%)	0.3 0.2 0.051 0.4 0.2
Clinical Characteristics
Lymph Node  Axillary lymph node dissection  Sentinel lymph node biopsy	581 (20%) 2,263 (77%)	297 (19%) 1,219 (78%)	284 (21%) 1,044 (76%)	0.3 0.2
Chemotherapy  None  Neoadjuvant  Adjuvant	654 (22%) 1,185 (40%) 1,102 (37%)	363 (23%) 614 (39%) 589 (38%)	291 (21%) 571 (42%) 513 (37%)	0.3
Radiation  None  Neoadjuvant  Adjuvant	2,135 (73%) 310 (11%) 496 (17%)	1,153 (74%) 181 (12%) 232 (15%)	982 (71%) 129 (9.4%) 264 (19%)	0.003
Aromatase inhibitor	1,045 (63%)	532 (34%)	513 (37%)	0.059
Mastectomy Type  Skin sparing  Nipple sparing	2,586 (88%) 355 (12%)	1,379 (88%) 187 (12%)	1,207 (88%) 168 (12%)	0.8
Timing of Reconstruction  Immediate  Delayed	2,406 (82%) 535 (18%)	1,256 (80%) 310 (20%)	1,150 (84%) 225 (16%)	0.016
Laterality  Bilateral  Unilateral	1,724 (59%) 1,217 (41%)	964 (62%) 602 (38%)	760 (55%) 615 (45%)	<0.001
Reconstruction Method  Implant  Autologous	2,023 (69%) 918 (31%)	974 (62%) 592 (38%)	1,049 (76%) 326 (24%)	<0.001
Complications
Readmission within 90 days	250 (8.5%)	133 (8.5%)	117 (8.5%)	>0.9
Reoperation within 90 days	522 (18%)	289 (18%)	233 (17%)	0.3

¹Median (Interquartile Range)

BREAST-Q Completion Rates

Of the 2,941 patients who completed at least one BREAST-Q module at 1-year, the nonresponse data for the four main BREAST-Q modules were as follows: 44% for Satisfaction with Breasts, 43% for Physical Well-being of the Chest, 43% for Psychosocial Well-being, and 47% for the Sexual Well-being (Figure 1).

Figure 1.

Proportion of Nonresponse for each BREAST-Q Module

Likelihood of BREAST-Q Sexual Well-being Completion

Patients who were separated (versus married, OR=0.69, 95% CI: 0.53, 0.90; p=0.006), whose primary language was not English (versus English, OR=0.60, 95% CI: 0.37, 0.96; p=0.034), and had Medicaid insurance (versus commercial, OR=0.67, 95% CI: 0.48, 0.94; p=0.021) were less likely to complete the Sexual Well-being survey relative to the other BREAST-Q domains. Postmenopausal patients were significantly more likely to complete the survey than premenopausal patients (OR=1.66, 95% CI: 1.23, 2.24; p<0.001). Patients who underwent autologous reconstruction were also more likely to respond to Sexual Well-being (versus implant, OR=2.93, 95% CI: 2.32, 3.71; p<0.001) whereas patients who underwent unilateral (versus bilateral, OR=0.80, 95% CI: 0.67, 0.94; p=0.008) and delayed reconstruction (versus immediate, OR=0.70, 95% CI: 0.52, 0.95; p=0.022) were less likely to respond. Although not significant, Asian patients were less likely to complete Sexual Well-being than White patients (OR=0.78, 95% CI: 0.59, 1.02; p=0.07) (Table 2).

Table 2.

Logistic regression model for completion of BREAST-Q Sexual Well-being at 1-year (n=2,941)

Patient Demographics	OR1	95% CI1	p-value
Age at Surgery	1.00	0.99, 1.01	0.9
Race  White  Asian  Black  Other	— 0.78 0.80 0.98	— 0.59, 1.02 0.60, 1.06 0.72, 1.33	0.070 0.12 0.9
Ethnicity  Not Hispanic  Hispanic  Unknown	— 0.80 0.98	— 0.60, 1.05 0.71, 1.33	0.11 0.9
Marital Status  Married  Separated  Single	— 0.69 1.00	— 0.53, 0.90 0.82, 1.22	0.006 >0.9
Language  English  Non-English	— 0.60	— 0.37, 0.96	0.034
Income	1.00	1.00, 1.00	0.7
Insurance  Commercial  Medicaid  Medicare  Self-Pay	— 0.67 0.95 0.56	— 0.48, 0.94 0.72, 1.25 0.24, 1.22	0.021 0.7 0.15
Body Mass Index (BMI)	1.0	0.98, 1.01	0.5
Smoking Status  Never Smoker  Current Smoker  Former Smoker	— 0.72 1.06	— 0.44, 1.17 0.88, 1.28	0.2 0.5
Menopause Status  Premenopausal  Postmenopausal  Unknown	— 1.66 2.08	— 1.23, 2.24 1.61, 2.69	<0.001 <0.001
Comorbidities  Diabetes  Cardiovascular Disease  Hypertension  Psychiatric Diagnoses  Lymphedema	1.06 1.02 0.88 1.05 1.29	0.76, 1.50 0.82, 1.27 0.72, 1.07 0.90, 1.24 0.82, 1.81	0.7 0.9 0.2 0.5 0.14
Clinical Characteristics
Lymph Node  Axillary lymph node dissection  Sentinel lymph node biopsy	1.04 1.28	0.65, 1.68 0.81, 2.04	0.9 0.3
Chemotherapy  None  Neoadjuvant  Adjuvant	— 0.87 1.07	— 0.69, 1.11 0.86, 1.33	0.3 0.6
Radiation  None  Neoadjuvant  Adjuvant	— 1.08 0.93	— 0.81, 1.46 0.73, 1.19	0.6 0.6
Aromatase inhibitor	0.95	0.80, 1.14	0.6
Mastectomy Type  Skin sparing  Nipple sparing	— 0.92	— 0.72, 1.17	0.5
Timing of Reconstruction  Immediate  Delayed	— 0.70	— 0.52, 0.95	0.022
Laterality  Bilateral  Unilateral	— 0.80	— 0.67, 0.94	0.008
Reconstruction Method  Implant  Autologous	— 2.93	— 2.32, 3.71	<0.001
Complications
Readmission within 90 days	0.85	0.63, 1.14	0.3
Reoperation within 90 days	1.12	0.90, 1.39	0.3

¹OR=Odds Ratio, CI= Confidence Interval

Factors associated with 1-year Sexual Well-being

As shown in Table 3, patients with higher preoperative Sexual Well-being scores had significantly higher scores postoperatively (β=0.39, 95% CI: 0.32, 0.46; p<0.001). History of psychiatric diagnoses (β=−4.4, 95% CI: −8.0, −2.9; p<0.001) and a receipt of aromatase inhibitor (β=−3.5, 95% CI: −6.4, −0.58; p=0.019) were significantly associated with lower Sexual Well-being at 1-year. Patients who have diabetes (β=6.3, 95% CI: 0.70, 12; p=0.027) and underwent delayed reconstruction (versus immediate, β=6.5, 95% CI: 2.0, 11; p=0.005) had significantly higher Sexual Well-being. Diabetes, history of psychiatric diagnosis, and delayed reconstruction met the MCID of 4.

Table 3.

Multiple linear regression model for Sexual Well-being at 1-year where Multiple Imputation is used to Impute Missing Preoperative Scores (n=1,566)

Patient Demographics	Beta	95% CI1	p-value
Preoperative Sexual Well-being	0.39	0.32, 0.46	<0.001
Age at Surgery	0.05	−0.14, 0.23	0.6
Race  White  Asian  Black  Other	— −0.13 −4.5 1.7	— −4.5, 4.2 −9.1, 0.12 −3.1, 6.5	>0.9 0.056 0.5
Ethnicity  Not Hispanic  Hispanic  Unknown	— −3.2 −0.47	— −7.9, 1.5 −5.5, 4.6	0.2 0.9
Marital Status  Married  Separated  Single	— −2.2 −1.7	— −6.9, 2.4 −4.9, 1.5	0.3 0.3
Language  English  Non-English	— 2.2	— −6.6, 11	0.6
Income	0.00	0.00, 0.00	0.054
Insurance  Commercial  Medicaid  Medicare  Self-Pay	— −1.5 −0.73 6.5	— −7.3, 4.3 −5.0, 3.6 −7.7, 1`	0.6 0.7 0.4
Body Mass Index (BMI)	−0.16	−0.44, 0.11	0.3
Smoking Status  Never Smoker  Current Smoker  Former Smoker	— −2.9 1.9	— −11, 5.4 −1.1, 4.9	0.5 0.2
Menopause Status  Premenopausal  Postmenopausal  Unknown	— −2.1 −1.4	— −7.2, 3.0 −6.0, 3.1	0.4 0.5
Comorbidities  Diabetes  Cardiovascular Disease  Hypertension  Psychiatric Diagnoses  Lymphedema	6.3 −2.7 2.4 −5.4 −2.3	0.70, 12 −6.1, 0.72 −0.78, 5.5 −8.0, −2.9 −7.5, 2.9	0.027 0.12 0.14 <0.001 0.4
Clinical Characteristics
Lymph Node  Axillary lymph node dissection  Sentinel lymph node biopsy	−0.88 1.3	−8.6, 6.9 −6.3, 8.9	0.8 0.7
Chemotherapy  None  Neoadjuvant  Adjuvant	— −1.2 −0.07	— −5.1, 2.8 −3.5, 3.4	0.6 >0.9
Radiation  None  Neoadjuvant  Adjuvant	— −0.86 −0.59	— −5.4, 3.7 −4.6, 3.4	0.7 0.8
Aromatase inhibitor	−3.5	−6.4, −0.58	0.019
Mastectomy Type  Skin sparing  Nipple sparing	— 1.8	— −2.0, 5.6	0.4
Timing of Reconstruction  Immediate  Delayed	— 6.5	— 2.0, 11	0.005
Laterality  Bilateral  Unilateral	— 0.69	— −2.0, 3.3	0.6
Reconstruction Method  Implant  Autologous	— 2.3	— −0.97, 5.6	0.2
Complications
Readmission within 90 days	−4.0	−8.6, 0.60	0.088
Reoperation within 90 days	−2.1	−5.4, 1.3	0.2

¹CI= Confidence Interval

Discussion

A major advantage of PROs in routine clinical care is that providers can identify problems that patients may be experiencing and to take appropriate actions.^23,24 Consequently, patients who do not complete the BREAST-Q Sexual Well-being survey may go unnoticed in clinical settings even if they experience sexual dysfunction. Recognizing factors in nonresponse will ensure that everyone is receiving appropriate care and that all patient groups are well represented in Sexual Well-being outcomes research.²⁵ As we hypothesized, we found that Sexual Well-being was the least completed BREAST-Q domain. We also identified demographic and clinical factors that differed between responders and non-responders.

Our results demonstrated patients who are separated are less likely to respond to Sexual Well-being than married patients. This is concerning as studies indicate that patients without marital partners have an increased likelihood of sexual dysfunction and experience more problems with orgasm, satisfaction, and pain.^26,27 While income and race were not associated with nonresponse, we did find that insurance coverage affected the likelihood of completing Sexual Well-being. Patients under Medicaid insurance are less likely to respond to Sexual Well-being than patients with commercially available insurance. Insurance coverage can act as a surrogate marker for income and race, as more patients of lower socioeconomic status and ethnic minorities have public insurances.^28–31 Previous studies have suggested that patients with lower socioeconomic status experience more sexual dysfunction and lower sexual frequency.^13,32–34 Patients of ethnic minority backgrounds may also feel uncomfortable accessing sexual health-related services and completing sexual health surveys due to perceived irrelevance, cultural taboo, or fear of shame and judgement.^3,16,35 Thus, despite experiencing more sexual dysfunction than their counterparts, patients who are not married and have Medicare insurances may be overlooked in clinical care and in outcomes research.

The current examination suggests that those whose primary language is not English, despite completing at least one of the other three BREAST-Q domains, are less likely to complete Sexual Well-being. Existing literature corroborates this claim, indicating that a significant proportion of minority patients’ sexual health concerns may be disregarded.^4,36,37 For example, Ahlmark et al reported that content and language of questionnaires are barriers for immigrant and non-Western descendants in responding to surveys.³⁸ Even if patients are familiar with English, but are not fluent, survey items may not be completely understood as intended due to cultural or religious contexts.³⁹ Since non-English speaking patients are less likely to complete Sexual Well-being, strategies to improve survey collection in these populations are necessary.⁴⁰ Validated PROs in languages other than English or translators should be available in clinical settings so that patients are able to articulate their concerns.³⁶ For example, BREAST-Q has been validated in multiple languages.^41–43 Further, although our institution provides translators for patients, more efforts are needed to incorporate translators when patients are completing the BREAST-Q. Another approach is to explain to patients that the purpose of Sexual Well-being is to identify any concerns preemptively to improve their quality of life; this may help motivate patients to complete the questionnaires.⁴⁴ It is imperative that providers recognize sociodemographic factors that affect response rate, and approach conversations about patients’ sexual health during follow-ups.

Interestingly, we found that postmenopausal patients are more likely to complete Sexual Well-being than premenopausal patients. Postmenopausal status is associated with sexual dysfunction and worse Female Sexual Function Index survey scores.^45,46 It is reassuring that despite having more sexual health concerns, postmenopausal patients are more likely to respond to the Sexual Well-being survey. At the same time however, premenopausal breast cancer can be more aggressive and for those premenopausal patients who require endocrine therapy, sexual dysfunction and hot flashes are common.^47,48 Fertility is another concern for many premenopausal patients.⁴⁷ Therefore, while it is encouraging that postmenopausal patients are completing Sexual Well-being, more efforts need to be made to ensure that premenopausal patients are responding to the survey and that their sexual health concerns are addressed.

Lastly, our findings suggest that reconstructive factors may affect response rates. Implant-based reconstruction patients are less likely to complete the Sexual Well-being than autologous-based, which is concerning as implant-based reconstruction is more common than autologous reconstruction. This suggests that a significant proportion of breast cancer patients’ Sexual Well-being may not be captured.⁴⁹ We also found that patients with unilateral and delayed reconstruction are less likely to complete the Sexual Well-being. Reasons for these relationships are less clear, and additional studies are necessary to understand the impact of laterality and timing on Sexual Well-being response rates.

The lack of responses from certain patients can compromise the accuracy of study results, and findings may not fully represent the intended patient population.¹³ For example, we demonstrated that patients of separated marital status are less likely to complete the survey, but in our linear regression model, marital status was not a predictor of Sexual Well-being score at 1-year. Previous studies suggest that separated patients experience negative changes in sexual health after breast cancer, but given the decreased likelihood of responding, our results may not reflect the possible association.^50,51 Moreover, delayed reconstruction patients are less likely to complete the survey but have significantly higher Sexual Well-being at 1-year. It is possible that delayed and immediate reconstruction patients have similar long-term Sexual Well-being, but the available data for delayed reconstruction is skewed towards higher scores. Therefore, while our study suggests several factors that are associated with decreased Sexual Well-being at 1-year, it is important to cautiously assess the results as our findings may not be transferrable to the general population due to nonresponse.

Limitations of the study include the retrospective design, single-institution population setting, and selection bias. Given that our patient population was primarily White and not Hispanic, future missing data studies should examine nonresponse in Sexual Well-being in other patient populations. Another limitation is the order of the BREAST-Q modules when administered to patients. At our institution, Sexual Well-Being is the last of the 4 major domains completed, with BREAST-Q administered in the following order: Satisfaction with Breasts, Psychosocial Well-being, Physical Well-being of the Chest, and Sexual Well-being. If patients undergo abdomen-based autologous reconstruction, there are two more modules before Sexual Well-being: Physical Well-being of the Abdomen and Satisfaction with Abdomen. If patients undergo an implant-based reconstruction, they are prompted to take Satisfaction with Implants after the Sexual Well-being. Therefore, it is possible that survey fatigue contributes to the lower completion rate of Sexual Well-being.^52,53 While we did not examine the completion rates for these additional BREAST-Q domains, future studies should examine completion rates for these adjunct domains. Nonetheless, a few findings conflict with this sentiment. First, even though Physical Well-being of the Chest is administered after Satisfaction with Breasts, the completion rate for Physical Well-being of the Chest is higher. Further, before Sexual Well-Being, autologous reconstruction patients have two more surveys to take than implant reconstruction patients, yet our findings suggest that patients who undergo autologous reconstruction are significantly more likely to complete Sexual Well-being than those who undergo implant reconstruction. This suggests that survey fatigue may not be the sole contributing factor to the lower completion rate. Since the order of BREAST-Q domains is institution-based, other institutions should also examine their non-response rates in Sexual Well-being or determine how different orders of BREAST-Q domains can influence response rates.

Conclusion

Of the primary BREAST-Q domains, Sexual Well-being is the least frequently completed. Patients who are separated, whose primary language is not English, and have public insurances are less likely to complete the Sexual Well-being domain. Additional factors such as menopause status and reconstructive types may influence nonresponse in Sexual Well-being. We encourage providers to recognize patterns in non-response data for the BREAST-Q Sexual-Well-being to ensure all patients’ sexual health concerns are addressed even if they do not complete the survey.

Synopsis:

In this retrospective analysis of 2,941 postmastectomy breast reconstruction patients, we found that Sexual Well-being is the least completed BREAST-Q domain. We identified marital status, primary language, and insurance as risk factors for completion of the Sexual Well-being. Patterns in nonresponse for Sexual-Well-being need to be better understood so that every patient’s sexual health concerns is properly addressed.