Sexuality and Body Image Concerns After Treatment for Breast Cancer

The patient, KC, is a 41-year-old Caucasian female. She has been married to SC for 16 years and has three children, aged 14, 11, and 9 years old. She has always been a homemaker with plenty of energy and says that she has been “the rock” during any crisis. KC was diagnosed with T2N1M0 poorly differentiated invasive ductal carcinoma of the breast with lobular features in 2007. She decided to have a mastectomy without immediate reconstruction because she did not know if reconstruction was what she wanted. She has also undergone four courses of chemotherapy (doxorubicin [Adriamycin] and paclitaxel(Drug information on paclitaxel) [Taxol]) followed by radiation therapy.

During chemotherapy, she lost her hair (including eyebrows and eyelashes), gained weight (>10 lbs), and experienced severe fatigue. KC is an attractive woman with a slim build, and the weight gain affected her self-image negatively. She also felt uncomfortable with her appearance because she did not like her wig or the fact that she had to pencil in eyebrows and wear false eyelashes. Since receiving chemotherapy, she suffers from hot flashes and has lost the ability to lubricate vaginally during intercourse, which causes some dyspareunia. She has now completed her radiation therapy, has more energy, and is pleased that her hair is growing back a lighter color with curls and waves; she says this increases her feeling of femininity.

Her relationship with her husband before her cancer diagnosis had been precarious at best. She described SC as a rather self-centered man who had never flattered her or made her feel special; she said she felt she always had to “dig for a compliment.” KC has always had a good self-image and said she never depended on her husband for reinforcement of her feminine sense of self. She did state that she thought he would “step up to the plate” during her illness, but that instead he seemed to make more demands on her and she has not felt well supported by him during her treatment, which has been a disappointment.

Although KC has never mentioned that her missing breast was repulsive to SC or that he verbalized displeasure, KC no longer feels comfortable during love-making. She reports that this is due not only to her missing breast and loss of adequate vaginal lubrication, but also because she feels resentment toward SC for not “being there” for her.

Nursing Management

The medical family therapist/clinical nurse specialist (CNS) addressed sexual function with KC during their second clinical session together and discussed the subject in meetings several times thereafter. KC’s husband declined to attend any of these sessions. KC’s surgery had been performed in another state and she began chemotherapy and radiation therapy after moving to her present location. She verbalized that no one had spoken to her about how this diagnosis and treatment would affect her sense of femininity, even though a mastectomy had been performed and her body image was violated.

KC had previously had breast implants placed because of issues with small breasts. Once she learned she would have to have a mastectomy, she decided to have the implants removed prior to surgery. She said she did not speak about this in depth with her husband either, because her femininity had never been an important issue between them before this illness. She was told that reconstruction would be available to her after her treatment was completed, but this process was not reviewed with her in detail (eg, she was not told that her reconstructed breast would feel numb).

During the session with the CNS, she became teary-eyed and seemed to relax more in her chair as she began to speak about how her femininity and sexuality had been affected. She felt betrayed by her body because she had always tried to live a healthy life, and she saw her illness as an insult to her sense of self.

Even though KC had three children and was 41 years old, she was still instructed that she would most likely experience premature menopause as a result of chemotherapy, and would have difficulty getting pregnant again or perhaps would not be able to conceive at all. She was not pleased about the potential for hot flashes and vaginal dryness, but was relieved to learn that this was a normal process. KC was directed to available products for hot flashes and vaginal dryness. Further discussion ensued related to reconstruction, and KC said she was reluctant to have additional surgery and knew that a reconstructed breast would not look like her own. However, she was also unhappy with the thought of always having to have a prosthesis in place and wondered how her clothes would fit, especially during the summer.

Because KC’s hair was growing back now, she was encouraged to speak with her cosmetologist about styles and colors. She was also referred to a marriage and family therapist for counseling related to the issues with her husband. She expressed interest in working not only on the relationship with her husband but also on her own issues. After going through this treatment process, KC says that she has learned a great deal about herself as a woman, and realizes how strong and steadfast she was as she traveled the illness trajectory.