Sexuality and Body Image Concerns After Treatment for Breast Cancer

April 1, 2008

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 [Taxol]) followed by radiation therapy.

ABSTRACT: A mastectomy left this patient with sexual problems and an altered sense of femininity. Communication models exist that can facilitate nurse-patient conversations about sexuality.

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 [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.

Discussion

Today, women can feel encouraged because survival rates for breast cancer are at an all-time high.[1] Yet the literature continues to remind us that a wide range of problems will also result from treatment of this illness, and many are particularly related to sexuality and intimacy.[2–4]

Treatment for breast cancer can entail not only surgery, but also a combination of modalities including chemotherapy, radiation, and hormonal therapies.[5–6] Some studies report an advantage for breast conservation in relation to body image, pleasure and frequency of breast caressing, and frequency of intercourse.[7–8] Rowland et al reported that women who received lumpectomy experienced a better outcome than those with mastectomy alone, and women who had mastectomy with reconstruction reported the most negative impact on their sex lives.[9]

Nevertheless, other studies have found that type of surgery did not impact sexual function as much as administration of chemotherapy and/or hormonal manipulation using tamoxifen in addition to the surgery.[4,10] Sexuality issues associated with the aforementioned treatments can range from premature menopause, severe hot flashes, loss of vaginal lubrication with eventual atrophy of the vulva and vaginal mucosa, and urinary symptoms (eg, frequency, urgency, dysuria, and incontinence) to psychological aspects such as mood swings, a negative body image, lost feelings of sexual attractiveness, or discomfort with nudity in sexual situations.[3,4,11] Ganz et al also remind us that two other important predictors of sexual dysfunction in this population are the quality of the partnered relationship and whether or not the partner has sexual problems of his/her own.[4]

A diagnosis of breast cancer and its ensuing treatment is traumatic and can have a significant impact on a woman’s psychosexual functioning and intimate relationships. Ganz et al explain that breast cancer survivors report issues of body image, sexuality, and partner communication rarely are addressed by health care providers.[12] Reasons for this nonaction may include attitudes toward and comfort level with the subject of sexuality, the knowledge and education of the professional, and knowing how and when to broach the subject.[13] Ideally, assessment would be an in-depth and ongoing discussion throughout the treatment process, but most nurses do not take this kind of sexual history, often owing to lack of time.

Two commonly used models available can promote communication about sexuality and may increase nurses’ comfort level with this discussion. The
PLISSIT model (P = permission, LI = limited information, SS = specific suggestions, IT = intensive therapy) has been in use for more than three decades and is the shorter of the two models.[14] The second is the BETTER model (B = bring up the topic, E = explain sexuality as part of quality of life, T = tell patient about appropriate resources, T = timing, E = educate about side effects, R = record in patient chart) and is more specific.[15] Because even these models may be too lengthy for the busy nurse, Spaulding advises us to ask one simple question: “Do you feel that your sexuality has changed since your diagnosis?”[16]

Although this case study portrays the treatment of a premenopausal woman, breast cancer is primarily a disease of postmenopausal women. These women have many of the same sexuality concerns, even if they have some special issues such as the social stigma of being “old,” physical irritations such as arthritis pain and the deterioration of eyesight and hearing, and the loss of friends and/or a spouse. Interestingly, Ghizzani et al discovered that in older women with breast cancer, marital contentment did not affect sexual function and illness adjustments; both depended more on an extended network of emotional support.[17]

For younger women, adequate sexual function depended on how well the marital relationship functioned. For women of all ages, however, the resumption of a satisfying sexual relationship depended on the couple’s ability to communicate their intimate and/or fearful feelings to each other.[17] One particular concern of premenopausal women is fertility; while an in-depth discussion of the issue is beyond the scope of this case study, it is imperative that counseling be provided and not put on the “back burner.” This aspect may be overlooked because the oncologist is interested in first curing the cancer and not adding to the patient’s anxiety; or may feel there are only limited treatment strategies to restore fertility, which will be frustrating to the patient; or simply may believe the patient will not survive.[18]

Women with breast cancer will continue to be more assertive and ask for assistance in dealing with treatment related sexuality problems, even though professionals may struggle with understanding and comfort with their own knowledge, attitudes, and beliefs around sexuality. Shell has provided an overview of evidence-based practice for sexual dysfunction symptom management for all adults with cancer, whereas Huber et al provided a discussion of five important studies related to sexuality in breast cancer patients.[2,19] Clearly, more research is needed to develop empirically supported interventions for women with breast cancer. We must persist in our holistic thinking about the woman with breast cancer and continue to extend our efforts beyond the disease itself.

Disclosures:

Financial Disclosure: The author has no significant financial interest or other relationship with the manufacturers of any products or providers of any service mentioned in this article.

References:

References

1. American Cancer Society: Cancer Facts and Figures 2007: Basic Cancer Facts. Atlanta, 2004.

2. Huber C, Ramnarace T, McCaffrey R: Sexuality and intimacy issues facing women with breast cancer. Oncol Nurs Forum 33(6):1163–1167, 2006.

3. Fobair P, Stewart SL, Chang S, et al: Body image and sexual problems in young women with breast cancer. Psychoonocology 15(7):579–594, 2006.

4. Ganz P, Greendale GA, Petersen L, et al: Managing menopausal symptoms in breast cancer survivors: Results of a randomized controlled trial. J Natl Cancer Inst 92(13):1054–1064, 2000.

5. Wilmoth MC: The aftermath of breast cancer: An altered sexual self. Cancer Nurs 24: 278–286, 2001.

6. Yurek D, Farrar W, Andersen BL: Breast cancer surgery: Comparing surgical groups and determining individual differences in postoperative sexuality and body change stress.

J Consult Clin Psychol 68(4):697–709, 2000.

7. Bruner DW, Boyd CP: Assessing women’s sexuality after cancer therapy: Checking assumptions with the focus group technique. Cancer Nurs 22(6):438–447, 1999.

8. Wilmoth MC, Townsend J: A comparison of the effects of lumpectomy versus mastectomy on sexual behaviors. Cancer Pract 3(5):279–285, 1995.

9. Rowland JH, Desmond KA, Meyerowitz BE, et al: Role of breast reconstructive surgery in physical and emotional outcomes among breast cancer survivors. J Natl Cancer Inst 92(17):1422–1429, 2000.

10. Young-McCaughan S: Sexual functioning in women with breast cancer after treatment with adjuvant therapy. Cancer Nurs 19(4):308–319, 1996.

11. Anillo LM: Sexual life after breast cancer. J Sex Marital Ther 26(3):241–248, 2000.

12. Ganz PA, Rowland JH, Desmond K, et al: Life after breast cancer: Understanding women’s health-related quality of life and sexual functioning. J Clin Oncol 16(2):501–514, 1998.

13. Shell JA: Including sexuality in your nursing practice, in Wilmoth MC (ed): Nursing Clinics of North America. Sexuality and Chronic Illness: Assessment and Interventions, pp 685–696. Philadelphia, PA, Saunders, 2007.

14. Annon JS: The Behavioral Treatment of Sexual Problems, vol 1. Honolulu, HI, Enabling Systems, 1974.

15. Mick J, Hughes M, Cohen M: Sexuality and cancer: How oncology nurses can address it BETTER [abstract]. Oncol Nurs Forum 30(Suppl 2):152–153, 2003.

16. Spaulding S: No patient assessment is complete without asking one simple question. ONS News 21(9):6, 2006.

17. Ghizzani A, Pirtoli L, Bellezza A, et al: The evaluation of some factors influencing the sexual life of women affected by breast cancer. J Sex Marital Ther 21(1):57–63, 1995.

18. Duffy CM, Allen SM, Clark MA: Discussions regarding reproductive health for young women with breast cancer undergoing chemotherapy. J Clin Oncol 23(4):766–773, 2005.

19. Shell JA: Evidence-based practice for symptom management in adults with cancer: Sexual dysfunction. Oncol Nurs Forum 29(1):53–66.

20. Shell JA: Body image and sexual functioning, in Dow K (ed): Nursing Care of Women with Cancer, pp 264–281.

St. Louis, MO, Mosby, 2007.

21. Shell JA: Sexuality, in Langhorne ME, Fulton JS, Otto SE (eds): Oncology Nursing, pp 546–564. St. Louis, MO, Mosby, 2007.

22. Barton D, Wilwerding MB, Carpenter L: Libido as part of sexuality in female cancer survivors. Oncol Nurs Forum 31(3):599–607, 2004.