Ann Surg Oncol DOI 10.1245/s10434-016-5365-2
ORIGINAL ARTICLE – BREAST ONCOLOGY
Influential Forces in Breast Cancer Surgical Decision Making and the Impact on Body Image and Sexual Function Rebecca M. Kwait, MD1, Sarah Pesek, MD2, Michaela Onstad, MD3, David Edmonson, MD1, Melissa A. Clark, PhD4, Christina Raker, ScD5, Ashley Stuckey, MD1, and Jennifer Gass, MD1 1
The Program in Women’s Oncology, Women and Infants Hospital Breast Health Center, Warren Alpert School of Medicine/Brown University, Providence, RI; 2St. Peter’s Health Partners Medical Associates, St. Peter’s Hospital, Albany, NY; 3Department of Gynecologic Oncology, MD Anderson Cancer Center, Houston, TX; 4Center for Health Policy and Research, Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA; 5 Division of Research, Women and Infants’ Hospital of Rhode Island, Providence, RI
ABSTRACT Background. Shared decision making with one’s partner and body image satisfaction may affect surgical choices of breast cancer patients. This study analyzed whether partner opinion was associated with choice of operation and whether comfort level with one’s partner was altered postoperatively. Methods. A prospective anonymous survey was administered to breast cancer patients who underwent breast surgery between 2000 and 2014. Categorical variables were compared by v2 or Fisher’s exact test. Results. Women who elected to undergo mastectomy with reconstruction (MR) placed greater emphasis on their own decision making than on input from their partner, surgeon, or others (56.5 vs. 8.3 vs. 23.2 vs. 12, respectively), whereas those who chose lumpectomy (L) placed similar weight on surgeon input and self-input (44.2 vs. 42.7 %). Only 7.5 % of all patients identified their partner as the greatest influence on their surgical choice. Preoperatively, the L group was the most comfortable with their partner seeing their chest (91.9 % L vs. 83.9 % MR vs. 75.9 % mastectomy alone (M); p = 0.01), and postoperatively, the comfort levels for all were remarkably decreased. Furthermore, if a patient was a candidate for L but chose MR, the role her chest played in intimacy dropped more compared with those who chose L (83.8 % L vs. 91.7 % MR;
Ó Society of Surgical Oncology 2016 First Received: 28 March 2016 R. M. Kwait, MD e-mail:
[email protected]
p = 0.3 preoperatively to 65.1 % L vs. 42.9 % MR; p = 0.01 postoperatively). Conclusions. When making surgical decisions, most patients indicate that they value their own opinion over that of others. Mastectomy, regardless of reconstruction, leads to a significant reduction in comfort with one’s partner postoperatively compared with lumpectomy. This information may be helpful in counseling couples at the time of consultation for breast cancer treatment.
Breast cancer, the most common female cancer in the United States, has seen great advances in screening and treatment, leading to prolonged survival, with 5 years rates as high as 98.6 % for localized disease and 84.9 % for regional disease.1,2 As a result, survivorship outcomes have become an increasingly important consideration among patients, with quality of life after treatment influencing therapeutic decision making.3 The impact of a breast cancer diagnosis has been well described, with negative consequences in terms of body image, sexual function, and mental health.4–6 While initial evaluations of the association between surgical method and sexuality outcomes failed to demonstrate differences based on surgery type, more recent studies have shown a small advantage favoring breast conservation over mastectomy with regard to body image and preserved sexual function.7–14 As the proportion of early-stage breast cancer patients choosing mastectomy increases, evaluating the factors driving these decisions remains essential.15–17 Although it is difficult to identify regret for those choosing mastectomy when breast conservation was possible, Frost reported 20–35 % of women describing adverse effects on
R. M. Kwait et al.
appearance satisfaction, feelings of femininity, and sexual relationship in the prophylactic setting.18 Thus, the consequences of more extensive surgery beyond that required to treat the cancer and the impact for survivorship need to be identified.18–20 At the diagnosis of breast cancer, a patient may feel particularly vulnerable, and a critical role for the patient’s partner is to provide emotional, social, physical, informational, and financial support. A strong partner relationship may thus improve quality of life for breast cancer survivors. These patients have described their partner as their most important confidant, especially when verbalizing fears of recurrence and the impact of the disease on their families.21 Perception of greater partner support also has been associated with greater relationship satisfaction and less sexual difficulty among breast cancer patients.22 However, the partner’s role in treatment decision making remains nuanced. While a prior study has investigated a partner’s influence on choices regarding chemotherapy, to our knowledge, no studies to date have evaluated the influence of a partner in surgical decision making.23 Factors that women may consider when choosing between lumpectomy and mastectomy include freedom from recurrence, genetic predisposition and family history, adequacy of future screening, body image concerns, and aversion to extensive surgery.24,25 Additionally, concern for remaining emotionally, physically, and sexually desirable to her partner likely plays a role. It remains unclear how patients weigh these considerations and how the partner’s perspective factors into their choices. Breast cancer surgery may dramatically affect the role of the remaining breast or chest wall in intimacy. A greater decrease in sexual satisfaction after mastectomy compared with lumpectomy has been described in recent work, with the negative impact of radiation regardless of surgery identified as well.9,10,26–28 With advances in surgical techniques, breast reconstruction can recreate a naturally appearing breast. Certainly, studies have shown better sexual function among patients receiving reconstruction relative to those treated with mastectomy alone, often correlated with increased self-esteem and improved body image.29,30 Our study has shown, however, that the role the breast plays during intimacy is significantly reduced regardless of surgical method.31 We aimed to investigate whom breast cancer patients identify as having a significant influence on their surgical decision making. Additionally, we examined the sexual experience postoperatively to evaluate the role of the surgically altered breast in sexual functioning after each type of operation.
METHODS We performed a single-center cross-sectional survey of English-speaking, female breast cancer patients older than 18 years who underwent surgical treatment between 2000 and 2014. All the patients underwent surgery at the Women and Infants’ Hospital, a Brown University-affiliated nonprofit teaching institution. Approval was obtained from the institutional review board. Patients were identified by chart review during follow-up visits at least 1 year after surgery, at which point they were invited to complete a paper questionnaire labeled ‘‘Survivorship Sexual Function Survey.’’ The implied consent was described in the cover letter, and all surveys were completed anonymously, then collected via a clinic-based drop box or return mail. The questions asked in the survey included breastspecific investigator-generated items aimed at evaluating surgical decision making, appearance satisfaction, and sexual functioning postoperatively. Additionally, the information collected included surgical method offered and chosen, adjuvant therapies, and demographic data. The surgical choices included lumpectomy and mastectomy with or without reconstruction, and patients were deemed eligible for lumpectomy if they indicated in the survey that their surgeon offered them this option. Following national guidelines, lumpectomy candidates presented with tumor or tumors that could be removed entirely as one specimen, and we determined whether a good cosmetic result was deemed achievable. Sexual function was assessed using the female sexual function index (FSFI), a 19-item instrument that specifically assesses sexual functioning via six domains including desire, arousal, lubrication, orgasm, satisfaction, and pain. This tool was developed based on the major categories of female sexual dysfunction as defined by the diagnostic and statistical manual of mental disorders (DSM).24 Baser et al.32 validated the FSFI with cancer survivors, demonstrating its reliability and validity, making it the most commonly used tool for measuring sexual dysfunction in cancer patients. Higher scores correspond with better sexual function, and an overall score of 26.55 or lower is associated with sexual dysfunction.33 The reliability factor for this tool is reported to be 0.89, and it has been validated in other cultures.24,34 However, 15 of the 19 items in the tool include a response ‘‘no sexual activity,’’ which is assigned a score of zero. Scoring these items for women who are not sexually active has been criticized as biasing the results toward greater sexual dysfunction than may actually exist.32,35–37 Our analytic sample, therefore, was limited to those who reported sexual activity and scored less than eight zero responses. All study results were obtained from the patient responses without further chart review. Survey items left
Decision- Making in Breast Cancer Surgery
TABLE 1 Demographics overall and by type of surgery Total n (%)
Lumpectomy n (%)
Mastectomy without reconstructions n (%)
Mastectomy with reconstruction n (%)
396
269 (67.9)
34 (8.6)
93 (23.5)
\40
12 (3.0)
6 (2.2)
2 (5.9)
4 (4.3)
40–59
210 (53.0)
128 (47.6)
15 (44.1)
67 (72.0)
60–79
157 (39.6)
120 (44.6)
16 (47.1)
21 (22.6)
[80 Unknown
8 (2.0) 9 (2.3)
8 (3.0) 7 (2.6)
0 (0.0) 1 (2.9)
0 (0.0) 1 (1.1)
White
354 (89.4)
239 (88.9)
29 (85.3)
86 (92.5)
Black
13 (3.3)
8 (3.0)
2 (5.9)
3 (3.2)
Native American
2 (0.5)
2 (0.7)
0 (0.0)
0 (0.0)
Asian
3 (0.8)
2 (0.7)
0 (0.0)
1 (1.1)
Hispanic
4 (1.0)
2 (0.7)
0 (0.0)
2 (2.2)
Other
10 (2.5)
8 (3.0)
2 (5.9)
0 (0.0)
Unknown
10 (2.5)
8 (3.0)
1 (2.9)
1 (1.1)
n (%) Age (years)
0.001
Ethnicity
0.5
Menopausal status
0.1
Postmenopausal
288 (72.7)
200 (74.3)
26 (76.5)
62 (66.7)
Perimenopausal
31 (7.8)
19 (7.1)
1 (2.9)
11 (11.8)
Premenopausal
21 (5.3)
9 (3.3)
3 (8.8)
9 (9.7)
Unknown
56 (14.1)
41 (15.2)
4 (11.7)
11 (11.8)
In a relationship Yes
p value
0.9 307 (77.5)
207 (77.0)
25 (73.5)
75 (80.6)
No
81 (20.5)
56 (20.8)
8 (23.5)
17 (18.3)
Unknown
8 (2.0)
6 (2.2)
1 (2.9)
1 (1.1)
Yes
280 (70.7)
182 (67.7)
24 (70.6)
74 (79.6)
No
105 (26.5)
77 (28.6)
10 (29.4)
18 (19.3)
Unknown
11 (2.8)
10 (3.7)
0 (0.0)
1 (1.1)
Sexually active
0.2
blank were excluded from the analysis of that particular question or reported as ‘‘unknown’’ for demographic data. Likert-type response options for breast sensuality questions were combined for analysis. The top two options were combined, and the bottom two options were combined, leaving a third ‘‘neutral’’ category when it was applicable (e.g., ‘‘very satisfied,’’‘‘moderately satisfied,’’ ‘‘about equally satisfied and dissatisfied,’’ ‘‘moderately dissatisfied,’’ and’’very dissatisfied’’). With regard to questioning about who had the greatest impact on surgical decision making, within-patient correlation of multiple response options was handled by robust standard errors. Statistical analyses were performed using SAS 9.3 software (SAS Institute, Cary, NC, USA). Categorical variables were compared by v2 or Fisher’s exact test. Continuous variables were compared by the Wilcoxon rank-sum or Kruskal–Wallis test. All p values presented are
two-tailed, with p values lower than 0.05 considered statistically significant. RESULTS The survey was completed by 404 patients. The participation rate was approximately 43 %, with most decliners citing ‘‘not sexually active’’ as the reason for not participating. Eight surveys were excluded from the analysis because five patients did not record the surgical procedure and three patients indicated multiple definitive operations. Overall, 396 surveys were included in the final analysis. The surgical procedures were divided into lumpectomy (L; n = 269, 67.9 %), mastectomy alone (M; n = 34, 8.6 %), and mastectomy with reconstruction (MR; n = 93, 23.5 %) groups. More than half of the respondents were in the age range of 40–59 years (53 %). This age and surgical procedure distribution appears to be consistent with the
R. M. Kwait et al. 60
50
% of Responses
FIG. 1 People identified as having had the greatest impact on surgical decision making when choosing between lumpectomy and mastectomy with or without reconstruction for the treatment of breast cancer
40 Self (p=0.02)
30
Partner (p=0.9) Surgeon (p<0.0001)
20
Others (p=0.1) 10
0 Lumpectomy (L)
FIG. 2 Pre-operative to post-operative changes in breast-specific parameters among mastectomy with reconstruction (MR), mastectomy alone (M) and lumpectomy (L) groups. * M group excluded from this parameter
Mastectomy without Reconstruction (M)
Mastectomy with Reconstruction (MR)
Total
p=1.0 Comfort undressed with partner
p=0.04 Importance of the breast in intimacy MR p=0.04
M
Satisfied with appearance L p=0.1 Pleasureable caress of the breast*
0
10
20
30
40
50
60
70
80
90
Percent decrease pre-op to post-op (%)
tumor registry data, with average ages of 49 years for MR and 58 years for L and a 72 % breast conservation rate during the entire study period. The majority of the patients were Caucasian (89.4 %) and postmenopausal (72.7 %). A total of 77.5 % of the women reported being in a relationship, with no difference between surgical groups (p = 0.9). The women who chose MR tended to be both younger and more sexually active (79.6 % MR vs. 70.6 % M vs. 67.7 % L; p = 0.2) (Table 1). Of the partnered patients (n = 307), 74.4 % reported attendance of their partner at their surgical consultation, with no difference between surgical groups regarding partner presence (76.5 % MR vs. 67.8 % M vs. 74.4 % L; p = 0.6). At the time of surgical decision making, the groups did not differ regarding importance of satisfying their partner, with the majority of patients finding it unimportant (56.8 % MR vs. 64.3 % M vs. 58.3 % L; p = 0.8).
In our examination of who had the greatest influence on surgical decision making, the women identified themselves as most important when choosing mastectomy, especially with reconstruction (56.5 % MR vs. 46.3 % M vs. 42.7 % L; p = 0.02). Alternatively, those who chose lumpectomy identified their surgeon as most influential (44.2 % L vs. 39.0 % M vs. 23.2 % MR; p \ 0.0001). Overall, 7.5 % of the patients identified their partner as the greatest influence on their surgical choice. Yet, within this subgroup, the patients who chose MR valued their partner’s opinion more than those who chose M or L, although this difference was not statistically significant (8.3 % MR vs. 7.3 % M vs. 7.2 % L; p = 0.9) (Fig. 1). Analyzing investigator-generated breast-specific questions, we found preoperatively that most of the patients in all the groups were satisfied with the appearance of their breast (85.1 % L vs. 84.8 % M vs. 76.3 % MR; p = 0.4),
Decision- Making in Breast Cancer Surgery TABLE 2 For patients offered a lumpectomy, depending on whether they chose a lumpectomy or a mastectomy with reconstruction, their view on the importance of breasts in sexual intimacy changed drastically after surgery Chose lumpectomy n (%)
Chose mastectomy with reconstruction n (%)
Important
218 (83.8)
33 (91.7)
Not important
42 (16.2)
3 (8.3)
164 (65.1)
15 (42.9)
88 (34.9)
24 (60.0)
51 (20.4)
17 (48.6)
Role of breasts in intimacy before surgery
0.3
Role of chest in intimacy after surgery Important Not important Change in role of chest in intimacy Important?not important
p value
0.01
0.003
No change
194 (77.6)
18 (51.4)
Not important?important
5 (2.0)
0 (0.0)
described the breast as important during intimacy (83.0 % L vs. 79.4 % M vs. 89.0 % MR; p = 0.3), and found caress of the breast pleasurable (90.3 % L vs. 85.3 % M vs. 92.3 % MR; p = 0.3). The lumpectomy patients were the most comfortable with their partner seeing their chest before surgery (91.9 % L vs. 75.9 % M vs. 83.9 % MR; p = 0.01), and this distribution persisted postoperatively, although a significant drop occurred for all the groups (79.2 % L vs. 53.8 % M vs. 66.7 % MR; p = 0.01). Postoperatively, appearance satisfaction (74.9 % L vs. 36.4 % M vs. 69.9 % MR; p = 0.0002), the chest as part of intimacy (64.8 % L vs. 48.5 % M vs. 43.3 % MR; p = 0.001), and pleasurable breast caress (70.6 % L vs. 15.3 % MR; p \ 0.0001) all dropped significantly and substantially (Fig. 2). Importantly, the decrease in breast intimacy was significantly greater for the MR group. For the patients who chose MR when eligible for L, the role the reconstructed breast played in intimacy dropped more significantly than for the women who chose L (65.1 % L vs. 42.9 % MR; p = 0.01) despite similar rates in the groups preoperatively (83.8 % L vs. 91.7 % MR; p = 0.3). These results demonstrated that nearly half of the patients who chose MR (48.6 %) devalued the breast in intimacy postoperatively. Comparatively, only 20.4 % of the patients who chose L experienced this change (p = 0.003) (Table 2). The measurements of postoperative sexual functioning show median FSFI scores not significantly different between surgical groups (26.5 L vs. 24.6 M vs. 29.1 MR; p = 0.4), although less sexual dysfunction was observed in the MR group (48.3 % L vs. 60.0 % M vs. 35.2 % MR; p = 0.1). When the FSFI scores were stratified by breast-specific measures, the scores were significantly lower for appearance dissatisfaction, discomfort being undressed with partner, and loss of both pleasurable breast caress and the
breast as part of intimacy. Sexual dysfunction ranged from 58.3 to 80 % in these less satisfied groups (Table 3). The surgery groups did not differ significantly in median FSFI scores with regard to adjuvant treatment except for the patients who underwent L or MR when taking an aromatase inhibitor (Table 3). DISCUSSION A diagnosis of breast cancer is not only a physical but also an emotional journey requiring support from a patient’s social network. A partner often provides this role.38,39 In survivorship, a patient’s favorable social wellbeing in the first year correlates with improved survival outcomes.40 Specific to breast cancer patients, the breast relates to attraction, intimacy, and sexuality.41 Certainly, a woman defines a new normal for herself and her breasts in survivorship. The treated breast has been categorized as medicalized (diseased), functional (lactational), gendered (femininity), or sexualized (intimacy).42 Each of these views can alter emotions surrounding a sexual encounter, potentially instilling disinterest and negatively affecting the partner relationship. In a cross-sectional study of 170 breast cancer survivors, the women with an emotionally involved partner described better intimate experience and improved marital satisfaction.43 Perceived sexual interest also was a significant predictor of psychosocial adjustment during recovery. We hypothesized that breast cancer patients would value their partner’s opinion during surgical decision making. In our study, however, most patients identified themselves as the greatest influence on their surgical choice, followed by their surgeon. In comparison, Stiggelbout et al.23 found that patients unanimously reported the opinion of their specialist to be the most important with regard to
R. M. Kwait et al. TABLE 3 Female sexual function index (FSFI) scores among those who reported sexual activity in the past 4 weeks and who had fewer than eight zero responses, as related to postoperative outcomes (overall) and adjuvant treatments (separated by surgery groups)a n
FSFI median
Range
IQR
p valueb
0.05
FSFI dysfunction (B26.55) n (%)
p valuec
57 (42.2)
0.2
Overall Satisfaction with appearance of chest after surgery Satisfied 135 27.7
7.2–36.0
21.5–31.7
Equal
26
27.5
9.5–34.5
21.1–29.2
12 (46.2)
Dissatisfied
24
23.0
13.0–32.1
21.1–27.2
15 (62.5)
Comfortability with partner seeing chest after surgery Comfortable
142
27.8
9.5–36.0
21.9–31.6
Equal
17
21.3
7.2–31.4
16.7–26.2
0.004
11 (64.7)
59 (41.5)
Uncomfortable
24
25.0
13.0–35.7
20.5–29.2
14 (58.3)
0.08
Importance of chest in intimacy after surgery Important
130
27.9
9.5–36.0
22.0–31.6
Not important
54
23.5
7.2–34.8
18.7–29.2
0.004
51 (39.2)
0.02
32 (59.3)
Pleasurability of having treated breast caressed Pleasurable
66
27.8
15.3–36.0
23.8–32.8
Equal
48
28.5
11.3–35.2
21.4–30.6
0.002
18 (37.5)
25 (37.9)
Unpleasant
15
19.1
7.2–31.3
15.5–25.9
12 (80.0)
0.009
Lumpectomy (L) Radiation Yes
107
25.9
7.2–36.0
21.1–30.0
No
9
30.9
15.3–33.6
26.7–31.7
Yes
47
24.2
7.2–36.0
21.1–29.8
No
69
27.6
10.8–35.6
21.5–31.2
Yes
32
28.4
16.8–35.6
22.9–32.1
No
82
25.7
7.2–36.0
20.1–29.7
Yes
44
23.3
7.2–35.7
19.0–29.1
No
71
27.8
13.2–36.0
21.8–30.9
0.2
54 (50.5)
0.2
2 (22.2)
Chemotherapy 0.3
25 (53.2)
0.5
31 (44.9)
Tamoxifen 0.08
12 (37.5)
0.2
43 (52.4)
AIc 0.04
27 (61.4)
0.03
28 (39.4)
Mastectomy without reconstruction (M) Radiation Yes No Chemotherapy
8
22.9
13.0–32.1
20.4–28.6
7
26.5
22.0–33.0
23.4–30.3
Yes
10
23.6
13.0–32.1
20.9–25.8
No
5
27.9
22.0–33.0
26.5–30.3
Yes
7
23.7
22.0–32.1
22.0–31.4
No
8
25.2
13.0–33.0
20.4–29.1
Yes
4
23.9
13.0–30.3
16.4–29.1
No
11
24.6
20.9–33.0
22.0–31.4
0.3
6 (75.0)
0.3
3 (42.9) 0.2
8 (80.0)
0.09
1 (20.0)
Tamoxifen 0.8
4 (57.1)
1.0
5 (62.5)
AIc 0.5
2 (50.0)
1.0
7 (63.6)
Mastectomy with reconstruction (MR) Radiation Yes
20
29.3
13.2–35.2
20.2–32.1
No
34
28.8
10.7–34.8
21.9–31.3
0.7
7 (35.0) 12 (35.3)
1.0
Decision- Making in Breast Cancer Surgery TABLE 3 continued n
FSFI median
Range
IQR
p valueb
Yes
33
27.8
10.7–35.2
19.1–30.5
0.1
No
21
30.6
15.3–35.2
25.9–31.7
Yes
11
31.7
21.3–35.2
28.4–33.2
No
42
27.5
10.7–35.2
19.1–30.6
15 39
18.1 30.5
10.7–30.1 15.3–35.2
15.3–25.9 27.1–32.0
FSFI dysfunction (B26.55) n (%)
p valuec
13 (39.4)
0.6
Chemotherapy 6 (28.6)
Tamoxifen 0.03
2 (18.2)
0.3
17 (40.5)
AIc Yes No
\0.0001
12 (80.0) 7 (17.9)
\0.0001
IQR interquartile range, AI aromatase inhibitor a
Sexual dysfunction indicated by a score lower than 26.55
b
p value comparing FSFI median scores and ranges
c
p value comparing proportions with FSFI dysfunction
chemotherapy choices. Given the complexity of the risks, benefits, and consequences of chemotherapy, expertise may be deemed more crucial. In our study, it appeared that patients most commonly trusted themselves to make the right decision regarding choice of operation, and when unsure, followed the recommendations of their surgeon. Also, when a patient was guided to lumpectomy but chose mastectomy, she was more likely to report valuing her own decision. Given that the focus of our study was on the association of support systems with decision making, we cannot comment on the influence of other factors such as media, family history, and fear of recurrence. Despite the independence of most patients in making their own surgical choices, the type of surgery may have significant consequences for the partner relationship. Although most of our participants were 2 years beyond surgery, the majority were persistently less comfortable being seen undressed by their significant other. Additionally, most of the patients had a reduced sensation of pleasurable breast caress, with a most profound drop from 92.3 to 15.3 % in the most sexually active MR group. Both of these findings may contribute to an altered sexual experience. Given that the MR group was the most reliant on self decision making, a concerning subgroup comprised the patients undergoing MR who were eligible for L. In this subgroup, the role of the breast in intimacy dropped the most dramatically. Clinicians need to include these consequences as part of informed surgical consent. Although breast reconstruction can recreate the appearance of a normal breast, the reconstructed breast form may not negate the sexual dysfunction that can occur.44,45
Regardless, in our study, as in others, the sexual dysfunction rates did not differ significantly between the surgery groups.46–48 Interestingly, however, higher FSFI scores were reported in the MR group. We continue accruing patients to define this further as well as to evaluate how the emergence of newer oncoplastic approaches and nipplesparing mastectomy may influence results. Overall, what did appear to correlate with sexual dysfunction was dissatisfaction with the appearance of one’s chest and feeling uncomfortable undressed with one’s partner. Additionally, preserving the breast as a sensual organ during intimacy and maintaining pleasure with caress also correlated with higher and non-dysfunctional FSFI scores. The limitations of our study included the convenience sample survey structure that asked patients to recall past events. The anonymity prohibited ability to confirm details of self-reported data, so inaccuracy of responses is possible. However, the unidentified nature of the survey likely allowed more honest responses, and for this reason, it was chosen. Although the FSFI is a validated screening tool, the nature of the questions may have caused reporting bias because some patients may not have felt comfortable truly admitting to sexual difficulties despite anonymity. Also, among nonresponders, the fraction of sexually active and partnered patients was unknown, which could have biased the results, and the investigator-generated questions on breast sensuality have not been validated. Finally, we were not able to control for the more global impact a breast cancer diagnosis may have on sexual function. In conclusion, breast cancer patients are often self-reliant in surgical decision making. Although sexual dysfunction is pervasive in survivorship, in our study, it was most prevalent
R. M. Kwait et al.
with appearance dissatisfaction and loss of breast intimacy. Because surgical choices have an impact on survivorship outcomes, patients need preoperative education to enhance their understanding of the late and long-term side effects of their chosen operation, especially those choosing more extensive surgery than indicated. ACKNOWLEDGMENTS We thank Christy Gandhi, BA, and Paige McCann, MS, RN, WHNP, for all of their help with data collection. DISCLOSURE
None.
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