Abstract
Background:
Up to 85% of breast cancer patients report sexual health concerns, but their concerns are not adequately addressed by providers. Sexual dysfunction among breast cancer patients remains understudied. We aimed to investigate the impact of breast-conserving therapy (BCT) and postmastectomy breast reconstruction (PMBR) on the sexual health of breast cancer patients and frequency of sexual medicine consultation in postoperative care.
Methods:
We conducted a retrospective analysis of patients who underwent BCT or PMBR and completed the Sexual Well-being of the BREAST-Q BCT and Reconstruction modules from January 2010 to October 2022. We compared Sexual Well-being scores between BCT and PMBR patients overtime up to 5-years postoperatively, delineated associated demographic and clinical factors with Sexual Well-being, and evaluated the frequency of sexual medicine consultations.
Results:
Of 15,857 patients, 8,510 (53.7%) underwent BCT and 7,347 (46.3%) underwent PMBR. PMBR patients had significantly lower Sexual Well-being scores than BCT patients from preoperative to 5-year postoperative. Regression analyses showed that PMBR patients scored 7.6 points lower at 1-year than BCT patients. Separated marital status, higher body mass index, cardiovascular disease, hyperlipidemia, psychiatric diagnosis, and neoadjuvant chemotherapy were associated with significantly lower Sexual Well-being. 299 (3.5%) of BCT and 400 (5.4%) of PMBR patients received sexual medicine consultations.
Conclusion:
Sexual health concerns must be considered in breast cancer care, particularly among patients who undergo PMBR. Although many patients experience sexual dysfunction, most do not receive a sexual medicine consultation, suggesting an opportunity for providers to improve breast cancer patients’ sexual health.
INTRODUCTION
Sexual health is a survivorship concern that remains unaddressed among breast cancer patients.1–3 Up to 85% of breast cancer patients report sexual dysfunction as a consequence of their diagnosis or treatment, including surgeries, radiation, chemotherapy, and endocrine therapy.3,4 Sexual dysfunction-related symptoms include dyspareunia, fatigue, reduced libido, reduced intercourse frequency, lack of sensation in breasts or nipples, and difficulty achieving orgasm.3–7 Despite the prevalence of sexual dysfunction, less than 7% of breast cancer patients report receiving medical guidance for sexual dysfunction.8,9 Addressing sexual health concerns with breast cancer patients and offering treatment options are necessary to break the taboo surrounding these discussions.4,10
The widespread use of patient-reported outcomes (PRO) measures like the BREAST-Q has allowed us to better understand a patient’s perception of their quality of life after breast cancer surgery, but there is a paucity of PRO data on the impact of surgery on sexual health.2,11,12 In this statistically powered study, we sought to assess the impact of breast cancer surgery on sexual health by comparing BREAST-Q Sexual Well-being scores between patients who underwent breast-conserving therapy (BCT) or postmastectomy breast reconstruction (PMBR). We examined trends in Sexual Well-being scores, demographic and clinical factors associated with lower scores, as well as the frequency of sexual medicine consultations. Sexual medicine consultations are available as a part of the Female Sexual Medicine & Women’s Health Program at our institution. We hypothesized that sexual health would be impacted significantly by patient- and treatment-level factors and that sexual medicine consultations would be utilized infrequently.
METHODS
Study Population
Following institutional review board-approval, we conducted a retrospective study of our prospectively maintained BREAST-Q scores to evaluate Sexual Well-being in BCT and PMBR patients. All patients who underwent BCT or PMBR from January 2010 to October 2022 were eligible for inclusion. BCT patients who had oncoplastic procedures were included. Patients without any BREAST-Q Sexual Well-being (preoperative to 5-years postoperative) or younger than 18 years of age were excluded.
Data Collection
Patient demographics, clinical, and surgical data were abstracted (Table 1). Median household income was determined by patients’ zip-code. Clinical variables included axillary lymph node dissection (ALND), sentinel lymph node biopsy (SLNB), chemotherapy (neoadjuvant, adjuvant), adjuvant radiation, aromatase inhibitor, and tamoxifen. Receipt of aromatase inhibitor and tamoxifen included both neoadjuvant and adjuvant as the data regarding the timing was not available.
Table 1.
Patient Characteristics
| Patient Demographics | All (n=15,857) | BCT (n=8,510) | PMBR (n=7,347) | p-value2 |
|---|---|---|---|---|
| Age at Surgery1 | 54 (46, 63) | 58 (50, 66) | 49 (43, 57) | <0.001 |
| Race | 0.035 | |||
| White | 12,120 (76.4%) | 6,465 (76.0%) | 5,655 (77.0%) | |
| Asian | 1,312 (8.3%) | 740 (8.7%) | 572 (7.8%) | |
| Black | 1,293 (8.2%) | 671 (7.9%) | 622 (8.5%) | |
| Other | 1,132 (7.1%) | 634 (7.5%) | 498 (6.8%) | |
| Ethnicity | <0.001 | |||
| Not Hispanic | 13,997 (88.3%) | 7,432 (87.3%) | 6,565 (89.4%) | |
| Hispanic | 1,116 (7.0%) | 560 (6.6%) | 556 (7.6%) | |
| Unknown | 744 (4.7%) | 518 (6.1%) | 226 (3.1%) | |
| Marital Status | <0.001 | |||
| Married | 11,217 (70.7%) | 5,938 (69.8%) | 5,279 (71.9%) | |
| Separated | 1,209 (7.6%) | 1,131 (13.3%) | 78 (1.1%) | |
| Single | 3,324 (21.0%) | 1,360 (16.0%) | 1,964 (26.8%) | |
| Unknown | 107 (0.7%) | 81 (1.0%) | 26 (0.4%) | |
| Median Household Income3 | 0.004 | |||
| <100K | 7,264 (45.8%) | 3,989 (46.9%) | 3,275 (44.6%) | |
| >=100K | 8,593 (54.2%) | 4,521 (53.1%) | 4,072 (55.4%) | |
| Body Mass Index (BMI)1 | 24.7 (21.7, 28.8) | 25.7 (22.4, 30.0) | 23.7 (21.1, 27.3) | <0.001 |
| Insurance | <0.001 | |||
| Private | 11,204 (70.7%) | 5,326 (62.6%) | 5,878 (80.0%) | |
| Public | 4,653 (29.3%) | 3,184 (37.4%) | 1,469 (20.0%) | |
| Religion Status4 | <0.001 | |||
| Religious | 11,125 (70.2%) | 6,061 (71.2%) | 5,064 (68.9%) | |
| Nonreligious | 3,658 (23.1%) | 1,828 (21.5%) | 1,830 (25.0%) | |
| Other | 1,074 (6.8%) | 621 (7.3%) | 453 (6.2%) | |
| Smoking Status | <0.001 | |||
| Never Smoker | 11,844 (74.7%) | 6,287 (73.9%) | 5,557 (75.6%) | |
| Current/Former Smoker | 2,922 (18.4%) | 1,922 (22.6%) | 1,000 (13.6%) | |
| Unknown | 1,091 (6.9%) | 301 (3.5%) | 790 (10.8%) | |
| Menopause Status | <0.001 | |||
| Premenopausal | 4,719 (29.8%) | 1,223 (14.4%) | 3,496 (47.6%) | |
| Perimenopausal | 816 (5.1%) | 280 (3.3%) | 536 (7.3%) | |
| Postmenopausal | 4,904 (30.9%) | 2,340 (27.5%) | 2,564 (34.9%) | |
| Unknown | 5,418 (34.2%) | 4,667 (54.8%) | 751 (10.2%) | |
| Comorbidities | ||||
| Diabetes | 1,218 (7.7%) | 758 (8.9%) | 460 (6.3%) | <0.001 |
| Cardiovascular Disease | 2,916 (18.4%) | 1,136 (13.3%) | 1,780 (24.2%) | <0.001 |
| Hypertension | 4,475 (28.2%) | 2,825 (33.2%) | 1,650 (22.5%) | <0.001 |
| Psychiatric Diagnoses | 7,454 (47.0%) | 3,560 (41.8%) | 3,894 (53.0%) | <0.001 |
| Autoimmune Disease | 2,216 (14.0%) | 878 (10.3%) | 1,338 (18.2%) | <0.001 |
| Lymphedema | 931 (5.9%) | 320 (3.8%) | 611 (8.3%) | <0.001 |
| Hyperlipidemia | 3,475 (22.0%) | 2,122 (24.9%) | 1,353 (18.4%) | <0.001 |
| Clinical Characteristics | ||||
| Sentinel Lymph Node Biopsy | 11,734 (74.0%) | 5,485 (64.5%) | 6,249 (85.1%) | <0.001 |
| Axillary Lymph Node Dissection | 1,936 (12.2%) | 366 (4.3%) | 1,570 (21.4%) | <0.001 |
| Chemotherapy | ||||
| Neoadjuvant | 3,917 (24.7%) | 841 (9.9%) | 3,076 (41.9%) | <0.001 |
| Adjuvant | 4,116 (26.0%) | 1,653 (19.4%) | 2,463 (33.5%) | <0.001 |
| None | 7,824 (49.3%) | 6,016 (70.7%) | 1,808 (24.6%) | |
| Adjuvant Radiation | 7,209 (45.5%) | 6,030 (70.9%) | 1,179 (16.0%) | <0.001 |
| Aromatase Inhibitor | ||||
| Adjuvant/Neoadjuvant | 4,295 (27.1%) | 1,949 (22.9%) | 2,346 (31.9%) | <0.001 |
| Tamoxifen | ||||
| Adjuvant/Neoadjuvant | 1,056 (6.7%) | 333 (3.9%) | 723 (9.8%) | <0.001 |
| Mastectomy Type | ||||
| Nipple-sparing | 910 (12.4%) | |||
| Skin-sparing | 6,437 (87.6%) | |||
| Timing of Reconstruction | ||||
| Delayed | 1,876 (25.5%) | |||
| Immediate | 5,471 (74.5%) | |||
| Laterality | ||||
| Bilateral | 4,304 (58.6%) | |||
| Unilateral | 3,043 (41.4%) | |||
| Reconstruction Type | ||||
| Autologous | 1,299 (17.7%) | |||
| Implant | 6,048 (82.3%) | |||
| Contralateral Prophylactic Mastectomy | 3,085 (42.0%) | |||
| Sexual Medicine consultations | 699 (4.4%) | 299 (3.5%) | 400 (5.4%) | <0.001 |
Abbreviations: BCT, breast-conserving therapy; PMBR, postmastectomy breast reconstruction
Median (IQR); n (%)
Wilcoxon rank sum test; Pearson’s Chi-squared test; Fisher’s exact test
Median household income was determined based on patients’ zip-code.
Religion was self-reported
Definitive PMBR comprised immediate autologous, direct-to-implant, and tissue expander (TE) exchange to permanent prothesis. For patients with delayed reconstruction or two-staged reconstruction with a TE, we included an additional timepoint, noted as “mastectomy/TE only.” This timepoint indicates when delayed reconstruction patients had mastectomy only and when two-stage reconstruction patients had TE placement only, before exchange to implant or autologous reconstruction.
BREAST-Q
BREAST-Q (version 1 or 2) is routinely administered to all breast cancer surgery patients, and the scores are prospectively maintained. For the purposes of this study, we abstracted BREAST-Q Sexual Well-being scores at preoperative (prior to breast surgery and after neoadjuvant therapy) and postoperative at 6-months and 1 to 5-years after BCT or definitive PMBR. We also abstracted BREAST-Q Physical Well-being of the Chest, Satisfaction with Breasts, and Psychosocial Well-being at preoperative and 1-year to correlate with Sexual Well-being.
It is important to note that sexual health is complex and multidimensional, and the BREAST-Q Sexual Well-being scale focuses on the role of breasts in sexual health. Therefore, in this study, the term “Sexual Well-being” refers to the role of breasts in sexual health as measured with the BREAST-Q Sexual Well-being survey, while “sexual health” refers to sexual health overall. The Sexual Well-being scale measures sexual health and body-image issues with items that ask about feelings of sexual attractiveness when clothed and unclothed, sexual confidence as it relates to one’s breasts, and how comfortable or at ease one feels during sexual activity.13 Values for BREAST-Q Sexual Well-being are converted to summary scores ranging from 0 to 100 via Q-Score software. Higher scores demonstrate increased patient satisfaction. A minimal clinically important difference (MCID) of 4 points is considered clinically important.14,15
Sexual Medicine Consultations
At our institution, Female Sexual Medicine & Women’s Health Program offers sexual medicine consultations. The team provides resources, education, strategies, and treatment to improve sexual health. A sexual medicine consultation was a binary outcome indicating whether patients received consultation, determined by whether patients have a note by the team. We compared patients who received a consultation with those who did not by analyzing patients with a preoperative BREAST-Q Sexual Well-being score, as patients received a consultation at different time points in their breast cancer process (i.e., at the time of diagnosis, during systemic therapy, or after surgery).
Statistical Analysis
Baseline demographics, clinical, and surgical characteristics were described for all patients using medians and interquartile ranges (IQR) for continuous variables and frequencies and percentages for categorical variables. Patient characteristics were compared between BCT and PMBR cohorts with a Wilcoxon rank sum test for continuous variables and Pearson’s chi-squared and Fisher’s exact tests test for categorical variables. Primary outcome was BREAST-Q Sexual Well-being scores, and the secondary outcome was a sexual medicine consultation. A test was performed to calculate the minimum sample size and was determined to be 400 patients in each cohort to achieve 80% power.
BREAST-Q Sexual Well-being scores at each time point were compared between BCT and PMBR patients using Wilcoxon rank sum test. The Wilcoxon signed-rank test was used to make pairwise comparisons between the scores at all available timepoints, separately for BCT and PMBR. All p-values were adjusted for multiple comparisons using the Benjamini-Hochberg false discovery rate correction.16 Pearson correlation coefficients and their corresponding 95% Confidence intervals were used to estimate correlations between Sexual Well-being and other BREAST-Q domains preoperatively and at one year postoperatively. Hypothesis testing was conducted to evaluate whether these correlations were significantly different from zero.
Multivariable linear regression analysis of preoperative and 1-year postoperative Sexual Well-being scores were conducted, hypothesized a priori. A multivariable logistic regression model was used to determine odds ratios (ORs) and 95% Confidence Intervals (CIs) of receiving a sexual medicine consultation. We assessed model fit using the Hosmer-Lemeshow goodness of fit test and computed the area under the receiving operating characteristic (ROC) curve. All statistical analyses were performed in R version 4.2.2.
RESULTS
From January 2010 to October 2022, 15,857 breast cancer surgery patients were included: 8,510 (53.7%) BCT patients and 7,347 (46.3%) PMBR patients. Of these BCT and PMBR patients, 5,236 had preoperative Sexual Well-being scores and 6,870 had postoperative scores at 1-year. Key patient characteristics are described in Table 1.
BCT versus PMBR
BCT patients were significantly older (median 58 [IQR 50, 66] vs 49 [43,57]) and had higher BMI (median 25.7 [22.4, 30.0] vs 23.7 [21.1, 27.3]) than PMBR patients (Table 1). PMBR patients had significantly lower Sexual Well-being scores than BCT patients at all timepoints, from preoperative to 5-years postoperatively (Figure 1). The preoperative score was statistically higher in the BCT cohort than the PMBR cohort (62 [48, 74] vs 59 [47, 70], but this difference did not meet the MCID of 4. All postoperative Sexual Well-being scores for BCT patients were statistically and clinically higher than for PMBR patients (Table 2).
Figure 1.
Median (IQR) BREAST-Q Sexual Well-being Scores Between BCT and PMBR
Table 2.
BREAST-Q Sexual Well-being Scores Over Time by Procedure Type (Median [IQR])
| p-valuea | |||
|---|---|---|---|
| Preoperative | n=2,952 | n=2,284 | |
| 62 (48,74) | 59 (47,70) | 0.009 | |
| Mastectomy/TE Only | n=0 | n=2,052 | |
| - | 41(0,56) | - | |
| Postoperative 6 Months | n=2,265 | n=2,816 | |
| 66 (48,84) | 49 (36,63) | <0.001 | |
| Postoperative 1-Year | n=3,436 | n=3,434 | |
| 66 (48,84) | 50 (39,66) | <0.001 | |
| Postoperative 2-Years | n=2,551 | n=2,514 | |
| 66 (48,84) | 52 (39,66) | <0.001 | |
| Postoperative 3-Years | n=1,819 | n=2,062 | |
| 66 (48,84) | 53 (39,66) | <0.001 | |
| Postoperative 4-Years | n=1,151 | n=1,592 | |
| 66 (48,84) | 53 (39,66) | <0.001 | |
| Postoperative 5 ears | n=837 | n=1,192 | |
| 62 (46,79) | 53 (39,66) | <0.001 |
Abbreviations: BCT, breast-conserving therapy; PMBR, postmastectomy breast reconstruction
Wilcoxon rank sum test
In the BCT cohort, Sexual Well-being scores significantly improved from preoperative to 6-month postoperative (59 [48, 70] to 66 [48, 84], p<0.001) and remained relatively stable from 6-months to 5-years postoperative (Table, Supplemental Digital Content 1). In the PMBR cohort, Sexual Well-being significantly decreased from preoperative to mastectomy/TE only timepoint (59 [48,74] to 34 [0, 50], p<0.001). This was followed by an improvement from mastectomy/TE only to 6-months postoperative (41 [0, 36] to 48 [36, 63], p<0.001). Sexual Well-being continued to increase until 2-years postoperatively (p<0.001). All postoperative scores were lower than preoperative scores (p<0.001) (Table, Supplemental Digital Content 2).
Correlating Sexual Well-being to other BREAST-Q domains.
Physical Well-being of the Chest, Satisfaction with Breasts, and Psychosocial Well-being were significantly correlated with Sexual Well-being at preoperative and 1-year postoperative (p<0.001). The strongest correlation was observed between Psychosocial Well-being and Sexual Well-being at preoperative (r=0.536, 95% CI: 0.515, 0.555, p<0.001) and at 1-year (r=0.632, 95% CI: 0.615, 0.647, p<0.001).
Factors Associated with Preoperative Sexual Well-being
Preoperative Sexual Well-being scores were comparable between BCT and PMBR patients (Table 3). Factors associated with lower preoperative Sexual Well-being scores included older age, Asian race, separated or single marital status, higher BMI, neoadjuvant chemotherapy, and comorbidities including cardiovascular disease, autoimmune disease, hyperlipidemia, and psychiatric diagnosis. Black patients scored 4.3 higher than White patients (β=4.3; 95% CI: 1.9, 6.7; p<0.001). Black race, psychiatric diagnosis, and neoadjuvant chemotherapy met the MCID of 4. Diagnostic plots showed no evidence of violation of model assumptions. Further, there was no evidence of multicollinearity, as evidenced by variance inflation factors all <3.4.
Table 3.
Multivariable-Adjusted Linear Regression Model for BREAST-Q Sexual Well-being for All Patients with Preoperative Scores (n=5,236)
| Characteristics | Beta | 95% Confidence Interval | p-value |
|---|---|---|---|
| Procedure | |||
| Breast-Conserving Therapy | — | — | |
| Postmastectomy Breast Reconstruction | −0.63 | −2.7, 1.4 | 0.6 |
| Age at Surgery1 | −0.09 | −0.17, −0.01 | 0.024 |
| Race | |||
| White | — | — | |
| Asian | −2.1 | −4.3, −0.01 | 0.049 |
| Black | 4.3 | 1.9, 6.7 | <0.001 |
| Other | −0.13 | −2.6, 2.4 | >0.9 |
| Ethnicity | |||
| Not Hispanic | — | — | |
| Hispanic | 1.3 | −1.2, 3.8 | 0.3 |
| Unknown | 1.6 | −1.0, 4.3 | 0.2 |
| Marital Status | |||
| Married | — | — | |
| Separated | −3.5 | −5.8, −1.2 | 0.003 |
| Single | −2.3 | −3.9, −0.78 | 0.003 |
| Unknown | −1.9 | −8.4, 4.7 | 0.6 |
| Income | |||
| <100K | — | — | |
| ≥100K | 0.11 | −1.1, 1.3 | 0.9 |
| Body Mass Index (BMI)1 | −0.66 | −0.77, −0.54 | <0.001 |
| Insurance | |||
| Private | — | — | |
| Public | −0.86 | −2.6, 0.87 | 0.3 |
| Religion Status | |||
| Religious | — | — | |
| Nonreligious | −1.1 | −2.5, 0.40 | 0.2 |
| Other | 1.5 | −0.80, 3.9 | 0.2 |
| Smoking Status | |||
| Never Smoker | — | — | |
| Current/Former Smoker | −1.1 | −2.7, 0.54 | 0.2 |
| Unknown | −1.8 | −4.5, 0.80 | 0.2 |
| Menopause Status | |||
| Premenopausal | — | — | |
| Perimenopausal | 0.86 | −2.7, 4.4 | 0.6 |
| Postmenopausal | 1.4 | −0.68, 3.5 | 0.2 |
| Unknown | 1.2 | −0.99, 3.4 | 0.3 |
| Comorbidities | |||
| Diabetes | −1.6 | −4.1, 0.89 | 0.2 |
| Cardiovascular Disease | −3.9 | −5.9, −1.9 | <0.001 |
| Hypertension | −0.65 | −2.2, 0.87 | 0.4 |
| Psychiatric Diagnoses | −5.9 | −7.1, −4.6 | <0.001 |
| Autoimmune Disease | −2.2 | −4.1, −0.39 | 0.018 |
| Lymphedema | 1.3 | −2.2, 4.7 | 0.5 |
| Hyperlipidemia | −1.8 | −3.3, −0.23 | 0.024 |
| Clinical Characteristics | |||
| Chemotherapy (vs. No Chemotherapy) | |||
| Neoadjuvant | −7.1 | −8.8, −5.3 | <0.001 |
| Aromatase Inhibitor Use | 0.07 | −1.4, 1.6 | >0.9 |
| Tamoxifen | 1.7 | −0.92, 4.3 | 0.2 |
Median (IQR); n (%)
Factors Associated with 1-year Postoperative Sexual Well-being
At 1-year postoperative, BCT patients scored 7.6 points higher than PMBR patients (β=−7.6; 95% CI: −9.7, −5.5; p<0.001) (Table 4). Older patients had significantly higher scores postoperatively. Factors associated with lower postoperative scores were Asian race, separated or single marital status, higher BMI, ALND, SLNB, neoadjuvant chemotherapy, aromatase inhibitor, and comorbidities including cardiovascular disease, hyperlipidemia, and psychiatric diagnoses. PMBR, separated marital status, psychiatric diagnosis, and ALND met the MCID. Receipt of adjuvant radiation and tamoxifen were not significantly associated with postoperative Sexual Well-being. This model also appeared to comply with the assumptions required by the multiple linear regression model.
Table 4.
Multivariable-Adjusted Linear Regression Model for BREAST-Q Sexual Well-being at 1-Year Postoperatively for All Patients (n=6,870)
| Characteristics | Beta | 95% Confidence Interval | p-value |
|---|---|---|---|
| Procedure | |||
| Breast-Conserving Therapy | — | — | |
| Postmastectomy Breast Reconstruction | −7.6 | −9.7, −5.5 | <0.001 |
| Age at Surgery1 | 0.14 | 0.06, 0.22 | <0.001 |
| Race | |||
| White | — | — | |
| Asian | −3.9 | −6.1, −1.7 | <0.001 |
| Black | −0.46 | −2.8, 1.9 | 0.7 |
| Other | −0.64 | −3.1, 1.8 | 0.6 |
| Ethnicity | |||
| Not Hispanic | — | — | |
| Hispanic | −1.3 | −3.7, 1.1 | 0.3 |
| Unknown | −1.3 | −4.1, 1.4 | 0.3 |
| Marital Status | |||
| Married | — | — | |
| Separated | −5.6 | −8.2, −3.1 | <0.001 |
| Single | −3.4 | −4.9, −2.0 | <0.001 |
| Unknown | 0.88 | −5.7, 7.4 | 0.8 |
| Income | |||
| <100K | — | — | |
| ≥100K | 0.52 | −0.67, 1.7 | 0.4 |
| Body Mass Index (BMI)1 | −0.36 | −0.47, −0.24 | <0.001 |
| Insurance | |||
| Private | — | — | |
| Public | 0.64 | −1.0, 2.3 | 0.4 |
| Religion Status | |||
| Religious | — | — | |
| Nonreligious | −0.75 | −2.1, 0.64 | 0.3 |
| Other | −0.08 | −2.5, 2.3 | >0.9 |
| Smoking Status | |||
| Never Smoker | — | — | |
| Current/Former Smoker | −1.2 | −2.7, 0.37 | 0.14 |
| Unknown | −0.94 | −3.3, 1.4 | 0.4 |
| Menopause Status | |||
| Premenopausal | — | — | |
| Perimenopausal | −2.3 | −5.1, 0.36 | 0.089 |
| Postmenopausal | −0.91 | −2.7, 0.90 | 0.3 |
| Unknown | −0.93 | −2.7, 0.85 | 0.3 |
| Comorbidities | |||
| Diabetes | 0.96 | −1.4, 3.3 | 0.4 |
| Cardiovascular Disease | −2.9 | −4.7, −1.1 | 0.001 |
| Hypertension | 0.29 | −1.2, 1.8 | 0.7 |
| Psychiatric Diagnoses | −7.4 | −8.6, −6.2 | <0.001 |
| Autoimmune Disease | −1.6 | −3.3, 0.12 | 0.068 |
| Lymphedema | −2.9 | −5.8, 0.12 | 0.060 |
| Hyperlipidemia | −1.6 | −3.2, −0.11 | 0.036 |
| Clinical Characteristics | |||
| Chemotherapy (vs. None) | |||
| Neoadjuvant | −2.6 | −4.4, −0.87 | 0.003 |
| Adjuvant | −0.60 | −2.2, 0.97 | 0.5 |
| Radiation (vs. None) | |||
| Adjuvant | 1.1 | −0.52, 2.7 | 0.2 |
| Axillary Lymph Node Dissection | −4.4 | −6.4, −2.4 | <0.001 |
| Sentinel Lymph Node Biopsy | −1.7 | −3.3, −0.13 | 0.034 |
| Aromatase Inhibitor Use | −2.5 | −3.9, −1.1 | <0.001 |
| Tamoxifen | −0.36 | −2.7, 2.0 | 0.8 |
| Laterality | |||
| Bilateral | — | — | |
| Unilateral | 1.0 | −0.60, 2.6 | 0.2 |
Median (IQR); n (%)
Sexual Medicine Consultations
400 (5.4%) PMBR patients received a sexual medicine consultation, compared to 299 (3.5%) BCT patients (p<0.001, Table 1). Multivariable-adjusted logistic regression demonstrated that PMBR patients were significantly less likely to receive a sexual medicine consultation than BCT patients (OR=0.47; 95% CI: 0.27, 0.82; p=0.008) (Table 5). Factors associated with a higher likelihood of having a sexual medicine consultation were Hispanic ethnicity, non-religious, psychiatric diagnosis, SLNB, and aromatase inhibitor use. In contrast, patients of older age, higher BMI, and current/former smoking status were less likely to receive a consultation. Other social determinants of health like income and insurance were not significantly associated with consultations. The area under the ROC curve was 0.79, suggesting good discrimination capabilities. The Hosmer-Lemeshow test did not indicate any evidence of poor fit (p=0.6).
Table 5.
Multivariable-Adjusted Logistic Regression Model for Sexual Medicine Consultation for All patients with Preoperative BREAST-Q Sexual Well-being Scores (n=5,236)
| Characteristics | Beta | 95% Confidence Interval | p-value |
|---|---|---|---|
| Procedure | |||
| Breast-Conserving Therapy | — | — | |
| Postmastectomy Breast Reconstruction | 0.47 | 0.27, 0.82 | 0.008 |
| Sexual Well-being Preoperative Score | 0.99 | 0.99, 1.00 | 0.053 |
| Age at Surgerya | 0.96 | 0.94, 0.98 | <0.001 |
| Race | |||
| White | — | — | |
| Asian | 0.73 | 0.41, 1.21 | 0.2 |
| Black | 1.21 | 0.69, 2.04 | 0.5 |
| Other | 1.09 | 0.63, 1.82 | 0.7 |
| Ethnicity | |||
| Not Hispanic | — | — | |
| Hispanic | 1.91 | 1.15, 3.05 | 0.009 |
| Unknown | 0.97 | 0.48, 1.80 | >0.9 |
| Marital Status | |||
| Married | — | — | |
| Separated | 0.37 | 0.11, 0.93 | 0.062 |
| Single | 0.87 | 0.61, 1.22 | 0.4 |
| Unknown | 2.64 | 0.71, 7.81 | 0.11 |
| Income | |||
| <100K | — | — | |
| ≥100K | 0.84 | 0.63, 1.13 | 0.2 |
| Body Mass Index (BMI)a | 0.94 | 0.91, 0.97 | <0.001 |
| Insurance | |||
| Private | — | — | |
| Public | 0.78 | 0.49, 1.22 | 0.3 |
| Religion Status | |||
| Religious | — | — | |
| Nonreligious | 1.40 | 1.02, 1.90 | 0.033 |
| Other | 0.85 | 0.47, 1.47 | 0.6 |
| Smoking Status | |||
| Never Smoker | — | — | |
| Current/Former Smoker | 0.59 | 0.36, 0.92 | 0.025 |
| Unknown | 1.07 | 0.60, 1.82 | 0.8 |
| Menopause Status | |||
| Premenopausal | — | — | |
| Perimenopausal | 0.44 | 0.13, 1.10 | 0.12 |
| Postmenopausal | 1.38 | 0.89, 2.12 | 0.14 |
| Unknown | 0.90 | 0.57, 1.41 | 0.6 |
| Comorbidities | |||
| Diabetes | 0.64 | 0.26, 1.34 | 0.3 |
| Cardiovascular Disease | 0.81 | 0.50, 1.25 | 0.4 |
| Hypertension | 0.91 | 0.61, 1.34 | 0.6 |
| Psychiatric Diagnoses | 2.07 | 1.53, 2.84 | <0.001 |
| Autoimmune Disease | 1.08 | 0.73, 1.56 | 0.7 |
| Lymphedema | 1.58 | 0.80, 3.07 | 0.2 |
| Hyperlipidemia | 1.13 | 0.75, 1.68 | 0.5 |
| Clinical Characteristics | |||
| Chemotherapy | |||
| Neoadjuvant | 1.42 | 0.89, 2.25 | 0.14 |
| Adjuvant | 1.37 | 0.92, 2.03 | 0.12 |
| Radiation | |||
| Adjuvant | 1.05 | 0.73, 1.49 | 0.8 |
| Axillary Lymph Node Dissection | 0.96 | 0.62, 1.46 | 0.8 |
| Sentinel Lymph Node Biopsy | 2.76 | 1.75, 4.53 | <0.001 |
| Aromatase Inhibitor Use | 2.65 | 1.95, 3.61 | <0.001 |
| Tamoxifen | 1.41 | 0.85, 2.25 | 0.2 |
| Laterality | |||
| Bilateral | — | — | |
| Unilateral | 0.93 | 0.64, 1.34 | 0.7 |
Median (IQR); n (%)
DISCUSSION
In this statistically powered analysis of breast cancer patients, PMBR patients had consistently lower BREAST-Q Sexual Well-being scores at all timepoints, and at 1-year, scored 7.6 points lower than BCT patients. BCT patients experienced an improvement in their Sexual Well-being from preoperative to 6-months postoperative, whereas PMBR patients’ postoperative scores did not return to baseline. Our findings build on the existing literature, which suggests that compared to PMBR patients, BCT patients restore their Sexual Well-being quicker. As previous studies suggest, BCT patients may be more satisfied with their appearance, consider their breasts as important for intimacy, and experience pleasure with caress of the breast.17–19 In addition, our unpublished study suggests that only 15% of skin-sparing patients have nipple reconstruction by 1-year. It is therefore possible that BCT patients have higher Sexual Well-being because of nipple preservation.20–22 For breast cancer patients who are eligible for either BCT or mastectomy, BCT may be the superior choice for patients who wish to maintain their Sexual Well-being. Providers should thoroughly counsel patients on the benefits of BCT on Sexual Well-being compared to PMBR.
In our PMBR cohort, Sexual Well-being scores were lowest following mastectomy and prior to definitive PMBR. Mastectomy alone can negatively affect a patient’s sexuality and body image.23,24 PMBR can help patients overcome the psychological trauma associated with loss of the breast and alleviate their self-esteem and body image concerns, which contribute to improved sexual health.5,17,25 Previous studies demonstrate that PMBR patients have higher PRO scores in sexual health compared to those with mastectomy alone.6,26 Patients who undergo two-staged reconstruction may also experience sexual dysfunction when they only have the TE, and definitive PMBR can help improve their Sexual Well-being.27,28 Providers should counsel their patients on potential sexual health decline after mastectomy without reconstruction or following TE placement, and possible relief with definite reconstruction.29 The benefits of definite breast reconstruction after mastectomy cannot be overlooked.
Our study revealed that Sexual Well-being scores after PMBR may stabilize or even improve over time. This may be related to the diminishing physical pain of breast cancer and treatments over time.30,31 However, a patient’s Sexual Well-being may not return to “normal” or baseline even 5-years after PMBR. PMBR can profoundly impact how patients feel about their body and sexuality, including changes in shape, look, and feel of their breasts.32 For example, one study showed that prior to mastectomy, 93% of patients reported that their chests play an important role during intimacy and sex, compared to 77% after PMBR.33 Despite the advantages of PMBR, there are consequences of replacing native breasts on patients’ sexual health.
Improvements in counseling can enhance patient care and satisfaction with sexual health.34,35 Our findings suggest an opportunity for providers to identify breast cancer patients who may have Sexual Well-being concerns. In our study, PMBR, separated marital status, higher BMI, cardiovascular disease, hyperlipidemia, history of psychiatric diagnosis, and neoadjuvant chemotherapy were significantly associated with lower Sexual Well-being scores at preoperative and postoperative. Previous studies also maintain the benefits of marriage and partnership32,36,37 as well as the negative impact of increased BMI38 and poor mental health39,40 on sexual health among breast cancer patients. We also found the strongest correlation between Psychosocial and Sexual Well-being at preoperative and 1-year postoperative, underscoring the intersection between mental and sexual health. Reduced blood flow in cardiovascular disease has been shown to impair sexual arousal in women, and sexual dysfunction is significantly more common in women with hypertension and hyperlipidemia.41–43 Chemotherapy can induce hair loss, skin changes, and fatigue that worsen patients’ sexual health and perceptions of their bodies.37,44,45 Although we did not find significant correlation between adjuvant radiation and Sexual Well-being, radiation may negatively influence sexual health and warrants further investigation, especially in BCT patients.46
At 1-year, we found that the receipt of ALND, SLNB, and aromatase inhibitor were also significantly associated with lower Sexual Well-being. ALND has previously been linked with development of lymphedema and worse physical function, which could contribute to compromised sexual health.47,48 Additionally, despite their benefits, aromatase inhibitors are significantly associated with sexual dysfunction.49–51 One study highlighted that the leading reason for sexual dysfunction in breast cancer patients may be aromatase inhibitors, rather than surgical modality, chemotherapy, or radiation.7 We did not find a significant association between tamoxifen and Sexual Well-being; this parallels with a previous study on how aromatase inhibitors are associated with increased vaginal dryness and dyspareunia, relative to tamoxifen.51 There may be differences within PMBR, such as, between implant-based and autologous-based PMBR. Existing literature suggests that autologous patients have higher Sexual Well-being than implant patients, although a specific comparative examination of implant and autologous PMBR and Sexual Well-being is necessary.37,52 Additional studies examining factors associated with lower Sexual Well-being in PMBR only (i.e, skin sparing mastectomy, pocket dissection, and type of flap) are worthwhile in future studies.
Sexual Medicine Consultations
Our Female Sexual Medicine & Women’s Health Program is comprised of professionals in sexual medicine, gynecology, and psychiatry.3,53 Their goal is for patients to reconnect with their bodies. Specifically for breast cancer patients, consultations help identify other areas of their bodies for arousal and to be more confident with their sexuality despite the loss of their natural breasts.53 Our analysis showed that despite the availability of the program, only a small proportion of breast cancer patients received the consultation, emphasizing the underutilization of this potential intervention.
We identified factors associated with increased likelihood of receiving a sexual medicine consultation. A greater proportion of BCT patients utilize the service than PMBR patients, and PMBR patients are significantly less likely to receive a consultation. One contributing factor may be treatment and financial burden of PMBR. Since PMBR patients tend to have more advanced cancers, they may be spending more hours and finances on their treatments than BCT patients, which impede them from accessing sexual health consultations.54 However, PMBR patients report significantly lower Sexual Well-being scores. This underscores an opportunity for providers to offer an intervention to PMBR patients.
Several reasons may contribute to the underutilization of consultations among breast cancer patients. Foremost, our institution currently lacks an established referral pathway from breast or plastic surgery to sexual medicine consultation; some providers or patient navigators may routinely offer sexual medicine consultations while others may not. In addition, while we did not find that insurance coverage affected receiving consultation, there may be challenges with accessing sexual health consultations for patients with public or no insurance that we were not able to discern. Patients also may feel embarrassed to discuss sexual health due to its stigma. Furthermore, although examining the efficacy of sexual medicine consultation was out of the scope of this study, Carter et al reported an improvement in cancer patients’ sexual dysfunction after sexual health consultations.53 In our qualitative study of PMBR patients who received sexual medicine consultations, participants shared that the consultations empowered them in their sexual health. It provided them a space to discuss their sexual health concerns and helped them take ownership of their bodies. Patients also advocated that providers use BREAST-Q or other surveys to prompt conversation on sexual health. Overall, patients expressed that they want sexual health to be a standard of care and that more providers initiate conversations. Given the underutilization of sexual medicine consultations observed in our analysis and the effectiveness of these interventions reported in the literature, our study suggests an opportunity for providers to improve PMBR patients’ sexual health.
Sexual medicine consultations may not be readily available at all institutions. Support for sexual dysfunction does not necessarily have to be at a designated program. Providers can offer referrals for outside sex therapists, psychosocial support, and even conservative measures, such as yoga, meditation, and moisturizers.3,55 Providing education and space for patients to express their sexual health concerns may also help alleviate patients’ concerns.46 We have written a guide on tools for providers on addressing sexual health concerns throughout the continuum of the breast cancer journey.56
Our study is limited by the content of the BREAST-Q Sexual Well-being scale. Sexual health is not one-dimensional, comprising sexuality, body image, intimacy, arousal, and partners.12,32 Since the BREAST-Q Sexual Well-being focuses on the role of breasts on sexual health, we did not assess other components (i.e, vaginal health issues and effects of chemotherapy) of sexual health. In future studies, we plan to use more comprehensive scales, such as the such as Female Sexual Function Index (FSFI),57 to capture additional dimensions of sexual health. Another limitation is that we did not assess the proportion of referrals distributed, reasons for sexual medicine consultation referral, or distinguish the referring provider. Identifying patients who are receiving referrals but not fulfilling them and the driving reasons for consultations could strengthen our referral pathway. We also did not examine the impact of sexual medicine consultations on Sexual Well-being as BREAST-Q is not administered as a part of sexual medicine consultations. We were interested in understanding the effect of the consultations on patients’ scores and sought to analyze patients’ Sexual Well-being scores last score before the consultations and first score after the consultation. However, only a small proportion of patients had scores available at both timepoints (n=152) and the difference was not significant (p=0.244). This may because available scores were at vastly different timepoints relative to the consultation (i.e, day after consultation versus 1-year after consultation), which made it challenging to assess the impact of the consultations on patients’ sexual health. Our future studies will prospectively assess the impact of sexual medicine consultations on BREAST-Q Sexual Well-being. Moreover, an inherent limitation in PRO research is nonresponse bias, which may be augmented in Sexual Well-being surveys due to its stigma and sensitivity. We have evaluated factors associated with nonresponse in Sexual Well-being in another study.58 We will use approaches for handling missing data to minimize nonresponse bias in our future work. As in all PRO research, it is therefore important to cautiously assess and interpret the results. Although the BREAST-Q scores are collected prospectively, all other variables were collected retrospectively; as a result, we are limited by the data that is available in our databases. We also did not evaluate Sexual Well-being after each therapy (i.e, chemotherapy, radiation), although they were included in the regression models, as our goal was to assess the impact of surgery on Sexual Well-being. Lastly, this is a single institutional study, and our findings may not be transferable to the general population. Future multi-institutional examinations of sexual dysfunction in breast cancer patients throughout the continuum of breast cancer care and benefits of interventions are necessary.
CONCLUSION
Sexual health is an essential aspect in the care of breast cancer patients. Our analyses showed that PMBR has a greater negative impact on BREAST-Q Sexual Well-being scores than BCT, and patient-specific factors and therapeutic interventions may have detrimental effects on a patient’s Sexual Well-being. Only a small fraction of breast cancer patients receives sexual medicine consultations, suggesting an opportunity for patients to counsel these patients about sexual health and encourage them to seek sexual health interventions.
Supplementary Material
Table, Supplemental Digital Content 1. Median and IQR BREAST-Q Sexual Well-being scores over time for Breast-Conserving Therapy
Table, Supplemental Digital Content 2. Median and IQR BREAST-Q Sexual Well-being scores over time for Postmastectomy Breast Reconstruction
Sources of Support:
This research was funded in part through the NIH/NCI Cancer Center Support Grant P30 CA008748, which funds the research infrastructure at Memorial Sloan Kettering Cancer Center.
Financial Disclosures and Potential Conflicts of Interest:
Carrie S. Stern, MD—equity in MirrorMe3D. Jeanne Carter, PhD—provision of services to the Gynecology Oncology Group Foundation. Dr. Babak Mehrara is the PI of investigator-initiated grants from Pfizer, Regeneron, and Integra Corporations. He also receives royalty payments from Elsevier and Mediflix. The remaining authors declare no conflicts of interest.
Footnotes
Disclaimers: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
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Supplementary Materials
Table, Supplemental Digital Content 1. Median and IQR BREAST-Q Sexual Well-being scores over time for Breast-Conserving Therapy
Table, Supplemental Digital Content 2. Median and IQR BREAST-Q Sexual Well-being scores over time for Postmastectomy Breast Reconstruction