Sexual Quality of Life in Women

with Newly Diagnosed Breast Cancer

Ellen Beckjord, PhD
Bruce E. Compas, PhD

ABSTRACT. Sexual quality of life (QOL) is a significant concern for

breast cancer survivors. This study investigated sexual quality of life in
a sample of 191 newly diagnosed breast cancer patients. Sixty percent
of the sample indicated disruption in their sexual quality of life. Sexual
QOL during treatment was significantly more disrupted among women
who received chemotherapy, were younger, had higher stage of dis-
ease, reported more depressive symptoms near time of diagnosis, and
underwent a total mastectomy. Hierarchical linear regression was used
to model sexual QOL and feelings of sexual attractiveness. Worse physi-
cal quality of life, chemotherapy, and depressive symptoms near time
of diagnosis were associated with worse sexual QOL during treatment.
An interaction between chemotherapy status and type of surgery, for feel-
ings of sexual attractiveness, suggested that chemotherapy affected sexual
attractiveness only among women who underwent a lumpectomy. These
results add to growing evidence that sexual QOL is a multidimensional

Ellen Beckjord is affiliated with Cancer Prevention Fellowship Program, National

Cancer Institute, National Institutes of Health, DHHS, 6130 Executive Boulevard,
DCCPS, 4051A, MSC 7365, Bethesda, MD 20892-7361, and The University of
Vermont, Burlington, VT. Dr. Beckjord’s current affiliation is with the Cancer Preven-
tion Fellowship Program.
Bruce E. Compas is affiliated with Vanderbilt University, Peabody #512, 230
Appleton Place, Nashville, TN 37203-5721.
Address correspondence to: Ellen Beckjord, PhD, MPH, 6130 Executive Boule-
vard, DCCPS, 4051A, MSC 7365, Bethesda, MD 20892-7361 (E-mail: beckjore@mail.
nih.gov).
Work on this manuscript was conducted at the University of Vermont.
This research was supported by NCI grant RO1 CA67936 to Bruce E. Compas.
Journal of Psychosocial Oncology, Vol. 25(2) 2007
Available online at http://jpo.haworthpress.com
© 2007 by The Haworth Press, Inc. All rights reserved.
doi:10.1300/J077v25n02_02 19
20 JOURNAL OF PSYCHOSOCIAL ONCOLOGY

construct with aspects differentially affected by variables related to can-

cer survivorship. doi:10.1300/J077v25n02_02 [Article copies available for
a fee from The Haworth Document Delivery Service: 1-800-HAWORTH.
E-mail address: <docdelivery@haworthpress.com> Website: <http://www.
HaworthPress.com> © 2007 by The Haworth Press, Inc. All rights reserved.]

KEYWORDS. Breast cancer, chemotherapy, sexual quality of life,

physical quality of life

INTRODUCTION

A substantial body of literature exists (e.g., Andersen, Anderson, &

deProsse, 1989; Bukovi6 et al., 2005; Schover et al., 2006) on the sexual
sequelae of a breast cancer diagnosis, which often are enduring, rather
than transient, disruptions in quality of life (QOL) (see Kornblith &
Ligibel, 2003; Thors, Broeckel, & Jacobsen, 2001 for reviews). Despite
an encouraging growth of research in this area (Syrjala et al., 2000),
there are still reports that sexual QOL for breast cancer survivors is not
routinely addressed by health care providers (Anllo, 2000; McKee &
Schover, 2001). Though characterizing sexual outcomes in women is
nuanced and complex (see Basson et al., 2004, for a review), here sex-
ual QOL is broadly defined to include feelings of sexual attractiveness,
interest and participation in sexual activity, and experience of sexual
function. More research is needed to identify variables related to and
predictors of sexual QOL in breast cancer survivors. Providers can then
be given specific information to identify patients who are currently
experiencing or who are likely to develop disruptions in their sexual
QOL during their course of treatment and can recommend appropriate
interventions to address sexual QOL.
Treatment variables have most commonly been investigated in the re-
search on sexual QOL for survivors of breast cancer. There is evidence
that surgical variables can affect sexual QOL, with some studies suggest-
ing that breast-conserving therapy is related to better perceptions of body
image and sexual satisfaction when compared with mastectomy (Moyer,
1997). Radiation and tamoxifen, two common treatments for women
with breast cancer, have also been investigated in relation to sexual
QOL (Mortimer et al., 1999; Taylor et al., 2002). The most substantial
evidence has supported an association between chemotherapy and prob-
lems with sexual QOL (e.g., Avis, Crawford, & Manuel, 2004). Besides
the physical effects on sexual QOL associated with decreased levels of
 Ellen Beckjord and Bruce E. Compas 21

circulating estrogen, the emotional effects of premature menopause are

believed to affect women’s concept of their own sexuality (Andersen,
Woods, & Cyranowski, 1994; see Rogers & Kristjanson, 2002, for a
review).
A number of studies have done an excellent job of comprehen-
sively investigating patient variables associated with sexual outcomes
(Broeckel et al., 2002; Ganz et al., 1998; Meyerowitz et al., 1999; Taylor
et al., 2002). Treatment with chemotherapy is consistently associated
with greater sexual difficulties in these studies. However, findings have
been inconsistent for other common variables investigated in studies of
sexual QOL. Some investigations have not found age to be associated
with sexual QOL (Broeckel et al., 2002; Meyerowitz et al., 1999), while
evidence from other studies suggests women of younger age to be associ-
ated with worse sexual QOL (e.g., Stead, 2003), experiencing premature
menopause in particular (Ganz et al., 1998). With respect to surgery,
Meyerowitz et al. (1999) did not detect any association between surgery
type and sexual outcomes. Ganz et al. (1998) observed worse sexual out-
comes among patients who underwent mastectomies, but only at the
bivariate level, while Rowland et al. (2000) reported that patients who un-
derwent mastectomy with breast reconstruction were most likely to feel
that breast cancer had negatively impacted their sexual QOL. Taylor et al.
(2002) observed a significant interaction between surgery type and che-
motherapy, such that negative effects of chemotherapy on feelings of
sexual attractiveness were significant only among women who had
received lumpectomy. Lumpectomy patients who received chemother-
apy reported worse feelings of sexual attractiveness compared with
lumpectomy patients who did not receive chemotherapy, and equal rat-
ings of sexual attractiveness compared with all women who underwent
mastectomy.
Mixed results have also been reported on the effects of emotional dis-
tress, primarily depression, on sexual QOL in breast cancer patients.
Though Meyerowitz et al. (1999) did not report an association between
depression and sexual outcomes, Taylor et al. (2002) found patients
who reported not feeling sexually attractive to report poorer psycholog-
ical well-being. Finally, some studies have shown an association be-
tween difficulties in relationships with significant others and with
sexual QOL among breast cancer survivors (Meyerowitz et al., 1999),
while others have not reported on relationships in the context of sexual
outcomes (Ganz et al., 1998), or have not collected information on this
aspect of the patient’s life (Taylor et al., 2002).
22 JOURNAL OF PSYCHOSOCIAL ONCOLOGY

Comparison across these studies has been hindered by sampling differ-

ences. For example, Taylor et al. (2002) focused on African American
women newly diagnosed with breast cancer, whereas Broeckel et al.
(2002) examined primarily Caucasian long-term survivors, diagnosed at
least five years prior to the study. The studies of Ganz et al. (1998) and
Meyerowitz et al. (1999) examined the largest patient sample, which
was of mixed ethnicity and varied in time since breast cancer diagnosis
(between one and five years).
The present study aims to build upon this previous research by con-
tinuing to investigate the main effects of, as well as the interactions be-
tween, variables related to sexual QOL among breast cancer survivors.
Strengths of the current investigation are its focus on a breast cancer
population homogeneous with respect to time since diagnosis, and the
measurement of depressive symptoms before assessment of QOL. In
this way, we can determine whether symptoms of depression near time
of diagnosis predict disruptions in sexual QOL during treatment. Con-
sistent with previous studies, we expect that disruptions in sexual QOL
will be common among this group of newly diagnosed breast cancer
survivors, and that disruption in sexual QOL will be associated with
disruption in other QOL domains. Chemotherapy is believed to have a
negative effect on sexual QOL. Further, we expect younger women to
report greater disruption in sexual QOL, and expect higher levels of
emotional distress measured near time of diagnosis to predict poorer
sexual QOL during treatment. Finally, we will examine an interaction
between chemotherapy status and surgery type to determine whether
sexual QOL and feelings of sexual attractiveness are associated with
chemotherapy only among women who undergo lumpectomy.

METHODS

Participants

A sample of 294 women diagnosed with Stages 0-III breast cancer par-
ticipated in the present study. Data on 89 women were missing on one or
more of the covariates of interest: QOL (8 women), medical (chemother-
apy for 17 women , surgery for 4 women, stage of disease in one case),
demographic (14 women), and affective (45 women). In addition data on
five women were missing on the start date of their chemotherapy and nine
were not included in analyses involving surgical data as they had not yet
 Ellen Beckjord and Bruce E. Compas 23

received their surgery at the time of baseline assessment. The final sam-
ple for the study included 191 participants. Women removed from the
dataset did not differ on any of the demographic, medical, or psycholog-
ical variables in question from those participants with no missing data
except that a larger percentage of women eliminated from the study re-
ceived chemotherapy than women retained in the study (64.5% vs.
47.4%; ␹21df = 10.41, p < 0.01).
Data Collection Occurred at Two Time Points. Symptoms of depres-
sion were measured close to time of diagnosis–women in the final sam-
ple were diagnosed, on average, 8.30 weeks prior to their depression
assessment (SD = 4.74 weeks; range 1.00-31.00 weeks earlier; Time 1).
Sexual QOL was measured about 7 weeks later; women were diag-
nosed, on average 15.46 weeks prior to their QOL assessment (SD =
6.60 weeks; range 2.71-38.57 weeks earlier; Time 2). For most women,
QOL assessment at Time 2 occurred during their post-surgical cancer
treatment. The study population had no history of any prior, treated
cancer. Representative of the area in which the study was conducted, the
sample was 98% Caucasian, 75% were married or partnered, and the
average age was 52.45 (SD = 9.78). Women had, on average, 14.73
years of education (SD = 2.38).
With respect to stage, 18% of the sample was Stage 0, 49.5% of the
sample was Stage I, 28.5% was Stage II, and 4.0% was Stage III. With
respect to type of cancer, 23% of the sample was diagnosed with either
ductal or lobular carcinoma in situ, 71.5% with invasive ductal or lob-
ular carcinoma, and the remaining 5.5% with tublar, mucinous, or
nonspecified carcinomas. Seventy-seven percent of women underwent
a partial mastectomy and 23% underwent a total mastectomy. Regard-
ing treatment, 42.5% of the sample received chemotherapy, 78.7% radi-
ation therapy, and 72.6% of the sample received hormonal therapy.
Women who began their chemotherapy before Time 2 assessment
(83.53% of women who received chemotherapy), began on average
9.13 weeks earlier (SD = 6.15; range = 0.14-22.57 weeks earlier) and re-
ceived an average of 5.93 cycles of treatment (SD = 2.86; range = 3-16
cycles). Women who underwent surgery before Time 2 (95.5% of
women) had the procedure on average 12.20 weeks before Time 2 as-
sessment (SD = 6.56 weeks; range 1.00-28.71 weeks earlier). Women
who began chemotherapy or who underwent surgery after QOL assess-
ment at Time 2 were classified as having not received chemotherapy or
surgery as part of their treatment for the purposes of these analyses.
24 JOURNAL OF PSYCHOSOCIAL ONCOLOGY

Procedure

Participants were part of a larger study investigating the helpfulness

of two types of support groups and psychosocial adjustment for women
with breast cancer. No woman had yet participated in an intervention
prior to Time 1 or Time 2 data collections. Participants were recruited
from two comprehensive breast care clinics in Vermont and New York.
Women were approached at their time of diagnosis and enrolled in the
study. The measures used were collected as part of a larger packet of
questionnaires.

Measures

The Cancer Rehabilitation Evaluation System, Short Form (CARES-

SF). The CARES-SF (Schag, Ganz, & Heinrich, 1991) was used to mea-
sure five dimensions of QOL for cancer patients approximately 15 weeks
after diagnosis (Time 2): physical, medical, psychosocial, marital, and
sexual. Higher scores on this measure indicate poorer QOL. The sexual
subscale has three items: “I do not feel sexually attractive,” “I am not in-
terested in having sex,” and “I find that the frequency of sexual inter-
course has decreased.” Internal consistency for this subscale with this
sample was adequate with an alpha of 0.78. Hierarchical regression
models also included the physical subscale of the CARES-SF. This
subscale has 10 items that focus on functional impairment (e.g., diffi-
culty with household chores, pain, appetite loss). The alpha for this
scale was 0.77.
The Beck Depression-II Inventory (BDI-II). The BDI-II (Beck,
Steer, & Brown, 1996) was used to measure emotional and somatic
symptoms of depression approximately 8 weeks post-diagnosis (Time
1). The internal consistency for this measure was good (␣ = 0.91).
Medical Data. Trained research assistants collected medical data
through chart review. Data collected included diagnosis type, disease
stage, and treatment regimen.

Data Analyses

All data analyses were conducted using SPSS Version 13.0 (2004).
Bivariate analyses for continuous variables were examined using corre-
lation, and dichotomous variables (surgery type, chemotherapy status)
were examined using t-tests. Hierarchical models used prospective
data on depression (measured 8 weeks post-diagnosis) to predict sexual
 Ellen Beckjord and Bruce E. Compas 25

QOL at approximately 15 weeks post-diagnosis and included chemo-

therapy as a dichotomous variable (receiving chemotherapy at Time 2
versus not receiving chemotherapy at Time 2). The same model was
used to individually examine the subscale item that asked about feel-
ings of sexual attractiveness. To address the hypothesized interaction
between chemotherapy status and surgery type, regression analyses
were stratified by surgery type.

RESULTS

Descriptive and Bivariate Analyses

Quality of Life. Levels of disturbance in the five indices of QOL mea-

sured by the CARES-SF at Time 2 (15 weeks post-diagnosis) and their
associations are seen in Table 1. As expected, disruptions in the various
domains of QOL were positively correlated (rs ranged from 0.25 to
0.60). Further, sexual QOL was significantly more disturbed in this
sample as compared with physical, medical, psychosocial, or marital
QOL. The average rating of sexual QOL was between “a little” and
“a fair amount” of disruption, with over 60% of women reporting at
least “a little” disruption and over 30% reporting “a fair amount” of or
more disruption in their sexual QOL.
Sexual QOL, Age, Stage, and Emotional Distress. Mean values of and
correlations among sexual QOL, age, stage of disease, and depressive

TABLE 1. Correlations, means, and tests of mean differences for QOL a

Sexual Physical Medical Psychosocial Marital

QOL QOL QOL QOL QOL
Physical QOL 0.49**
Medical QOL 0.25** 0.30**
Psychosocial QOL 0.53** 0.55** 0.57**
Marital QOL 0.48** 0.38** 0.39** 0.60**
Mean (SD) 1.34 0.71 0.38 0.83 0.55
(1.15) (0.59 (0.67) (0.67) (0.63)
Mean difference from 0.63** 0.96** 0.51** 0.78*
sexual QOL score

aHigher scores indicate poorer QOL.

**Correlation or paired difference is significant at the p ⬍ 0.01 level.

26 JOURNAL OF PSYCHOSOCIAL ONCOLOGY

symptoms are displayed in Table 2. Reported levels of depressive symp-

toms at Time 1 (approximately 8 weeks post-diagnosis) were in the
“mild” range (Beck, Steer, & Brown, 1996). Sexual QOL was signifi-
cantly correlated with age, stage, and depressive symptoms, such that
younger age, higher stage of disease, and higher levels of depressive
symptoms at Time 1 were associated with worse sexual QOL at Time 2.
Medical Variables, Age, Depression, and Sexual QOL. The bivariate
associations between treatment variables and study covariates are dis-
played in Table 3. As expected, women who received chemotherapy
reported significantly worse sexual QOL at Time 2. Further, chemother-
apy status was associated with younger age, worse stage of disease, and

TABLE 2. Correlations and mean values for sexual QOL at Time 2, age, stage,
and symptoms of depression at Time 1

Sexual QOL (Time 2) Age BDI-II (Initial)

Age ⫺0.19**
BDI-II (Time 1) 0.47** ⫺0.14
Stage 0.24** ⫺0.15** 0.14*
Mean (SD) 1.34 52.45 10.95
(1.15) (9.78) (8.71)

**Correlation is significant at the p ⬍ 0.01 level;

*Significant at the p ⬍ 0.05 level.

TABLE 3. Associations between treatment status and study covariates

Chemotherapya Mean (SD) Surgery Typeb Mean (SD)

Sexual QOLc Yes 1.96 (1.15)** TM 1.67 (1.22)*
(Time 2)
No 1.00 (1.00)** PM 1.25 (1.13)*
Age Yes 49.01 (9.32)** TM 50.05 (9.04)*
No 54.34 (9.55)** PM 53.44 (9.73)*
Stage Yes 1.69 (0.65)** TM 1.43 (0.99)*
No 0.91 (0.69)** PM 1.09 (0.67)*
BDI-II (Time 1) Yes 13.03 (9.61)* TM 11.02 (8.70)*
No 9.81 (7.99)* PM 10.80 (8.79)*

TM = Total mastectomy, PM = Partial mastectomy.

aYes (n = 67); No (n = 124).
bTM (n = 42); PM (n = 149).
cHigher scores indicate poorer QOL.
**Mean difference is significant at the p < 0.01 level;
*Mean difference significant at the p < 0.05 level; equal variances not assumed.
 Ellen Beckjord and Bruce E. Compas 27

higher levels of depressive symptoms at Time 1. With respect to surgical

status, mastectomy was associated with significantly poorer sexual
QOL, as well as younger age and worse stage of disease. Type of sur-
gery was not associated with depressive symptoms.

Hierarchical Linear Regression Analyses

Sexual Quality of Life. Results of a multivariate model examining

sexual QOL at 15 weeks post-diagnosis are presented in Table 4. As in
similar studies, a measure of physical functioning (in this case, physical
QOL) was included in the model (e.g., Taylor et al., 2002). The model
was entered in three steps: physical QOL at Time 2 (Step 1), age, stage
of disease, chemotherapy status at Time 2 (yes vs. no), and type of sur-
gery (partial vs. total mastectomy; Step 2), and symptoms of depression
at Time 1 (Step 3).
A model for the full sample is presented, followed by results strati-
fied by surgery type to examine the hypothesized interaction between
chemotherapy status and surgery type. For the full sample, worse physi-
cal QOL at Time 2, chemotherapy, and higher depressive symptoms at
8 weeks post-diagnosis were associated with poorer sexual QOL at 15
weeks post-diagnosis (Time 2). Regarding the stratified results, we
hypothesized an interaction between chemotherapy status and surgery
type suggested by the work of Taylor et al. (2002) such that chemother-
apy would negatively impact sexual adjustment only for women who
receive lumpectomy. This hypothesis was not supported in our models
of sexual QOL–chemotherapy was associated with worse sexual QOL
for all women, regardless of surgery type.
Sexual Subscale Item-Specific. An additional model was tested to
examine multivariate associations between medical and psychosocial
covariates and feelings of sexual attractiveness as measured by one item
from the CARES-SF sexual subscale (Table 5). Again, a model for the
full sample is presented, followed by results stratified by surgery type to
examine the hypothesized interaction between chemotherapy status and
surgery type.
For the full sample, results for the single item that asks about feelings
of sexual attractiveness were consistent with results for the complete
3-item CARES-SF sexual subscale: worse physical QOL at Time 2,
chemotherapy, and higher levels of depressive symptoms 8 weeks
post-diagnosis were associated with worse feelings of sexual attractive-
ness 15 weeks post-diagnosis.
28
TABLE 4. Hierarchical linear regression model of sexual QOL at Time 2

Step Model Full Sample (n = 191) Women Who Received PM Women Who Received TM
Adjusted R2 = 0.37 (n = 149) Adjusted R2 = 0.33 (n = 42) Adjusted R2 = 0.52
Standard ␤ R2 p Standard ␤ R2 p Standard R2 p
Change Change Change
1 Physical QOL 0.50 0.25 0.00 0.43 0.19 0.00 0.62 0.39 0.00
2 Physical QOL 0.40 0.07 0.00 0.32 0.09 0.00 0.58 0.10 0.00
Age ⫺0.07 0.28 ⫺0.10 0.16 0.08 0.53
Stage 0.01 0.88 0.06 0.43 ⫺0.15 0.35
Chemotherapya 0.25 0.00 0.24 0.01 0.41 0.02
Type of surgeryb 0.02 0.72
3 Physical QOL 0.26 0.08 0.00 0.17 0.08 0.04 0.39 0.09 0.00
Age ⫺0.05 0.44 ⫺0.08 0.29 0.10 0.41
Stage 0.01 0.89 0.09 0.26 ⫺0.24 0.11
Chemotherapya 0.25 0.00 0.23 0.00 0.46 0.01
Type of surgeryb 0.05 0.38
BDI-II (Time 1) 0.31 0.00 0.32 0.00 0.36 0.01

a1 = no chemotherapy at Time 2, 2 = chemotherapy at Time 2; b1 = partial mastectomy (PM), 2 = total mastectomy (TM).
 TABLE 5. Hierarchical linear regression model of feelings of sexual attractiveness at Time 2

Step Model Full Sample (n = 191) Women Who Received PM (n = 149) Women Who Received TM (n = 42)
Adjusted R2 = 0.35 Adjusted R2 = 0.28 Adjusted R2 = 0.37
Standard ␤ R2 Change p Standard ␤ R2 Change p Standard ␤ R2 Change p
1 Physical QOL 0.48 0.23 0.00 0.46 0.21 0.00 0.50 0.25 0.00
2 Physical QOL 0.41 0.05 0.00 0.34 0.08 0.00 0.49 0.03 0.00
Age 0.00 0.98 ⫺0.04 0.63 0.16 0.30
Stage 0.01 0.95 0.07 0.37 ⫺0.10 0.60
Chemotherapya 0.22 0.00 0.26 0.00 0.15 0.46
Type of surgeryb 0.01 0.89
3 Physical QOL 0.25 0.09 0.00 0.18 0.10 0.03 0.30 0.10 0.07
Age 0.03 0.69 ⫺0.01 0.94 0.18 0.22
Stage 0.00 0.97 0.10 0.19 ⫺0.20 0.30
Chemotherapya 0.22 0.00 0.26 0.00 0.20 0.30
Type of surgeryb 0.04 0.51
BDI-II (Time 1) 0.34 0.00 0.35 0.00 0.36 0.03

a1 = no chemotherapy at Time 2, 2 = chemotherapy at Time 2; b1 = partial mastectomy (PM), 2 = total mastectomy (TM).

29
30 JOURNAL OF PSYCHOSOCIAL ONCOLOGY

However, different from the results of the full sexual subscale mod-
els, a significant interaction between chemotherapy status and surgery
type was detected for feelings of sexual attractiveness (Figure 1).
The stratified models show results consistent with the findings of
Taylor et al. (2002) such that feelings of sexual attractiveness did not
differ among women who received mastectomy based on chemotherapy
status, but for women who received lumpectomy, feelings of sexual at-
tractiveness were significantly worse among those who also received
chemotherapy. Further, no differences in feelings of sexual attractive-
ness were seen between this group of women (those who received
lumpectomy and chemotherapy), and the group who received mastec-
tomy as a whole. The magnitude of reported disruption in feelings of
sexual attractiveness in Taylor et al.’s (2002) sample is comparable
with the levels reported here. Taylor et al. (2002) reported the “finding
suggests that chemotherapy serves to, in effect, equalize the impact of
types of surgery” (p. 513).

DISCUSSION

This study both replicates and extends the research on sexual QOL
among breast cancer survivors. Disruption in sexual QOL occurs for the

FIGURE 1. Feelings of sexual attractiveness by surgery type and chemother-

apy status (higher scores indicate worse feelings of sexual attractiveness)

1.91
2 1.65
1.8 1.40
Sexual attractiveness

1.6
1.4
1.2
1 0.73
0.8
0.6
0.4
0.2
0
Lumpectomy Mastectomy

No chemotherapy
Chemotherapy
 Ellen Beckjord and Bruce E. Compas 31

majority of this sample, and this disruption is rated as significantly

worse than disruption in other areas of life. These data provide contin-
ued evidence that sexual QOL should be given clinical priority among
breast cancer survivors, and that sexual QOL should be routinely
addressed from the time of diagnosis (McKee & Schover, 2001).
In contrast to some previous reports (Meyerowitz et al., 1999) but in
keeping with others (Ganz et al., 1999) emotional distress (as measured
by depressive symptoms) was significantly associated with poorer sexual
QOL. One strength of this study is the measurement of depressive symp-
toms prior to assessment of sexual QOL. Depressive symptoms mea-
sured close to time of diagnosis (about 8 weeks post-diagnosis) predicted
disruption in sexual QOL about 15 weeks post-diagnosis. This finding
supports the characterization of the weeks immediately following a
breast cancer diagnosis as a critical window with respect to later adjust-
ment. Decreasing symptoms of depression near time of diagnosis may
have benefits that extend beyond reducing affective distress–addressing
symptoms of depression may also benefit later sexual QOL (Dausch
et al., 2004).
Though we expected younger age to be associated with poorer sexual
QOL, age was not associated with sexual QOL in the multivariate mod-
els. Bivariate associations between age and other study variables were
in the expected direction, but these results suggest that treatment vari-
ables and emotional distress outweigh the effects of age on sexual QOL.
One implication of our null results for age is that assessment of and
intervention for sexual QOL should be routine for all breast cancer
survivors, regardless of age. Of note is that we were unable to examine
age in the context of menopausal status. Age may play a role in the sex-
ual QOL of breast cancer survivors among women experiencing prema-
ture menopause (e.g., Ganz et al., 1998).
As in Taylor et al.’s (2002) study of newly diagnosed African Ameri-
can breast cancer survivors, we detected an interaction between chemo-
therapy status and surgery type in our sample of newly diagnosed,
largely Caucasian breast cancer survivors. These data provide further
evidence that type of surgery moderates the effects of chemotherapy,
specifically on feelings of sexual attractiveness, such that chemother-
apy status affects sexual attractiveness only among women who un-
dergo lumpectomy. Women who underwent both lumpectomy and
chemotherapy reported feeling significantly less sexually attractive
than women who underwent lumpectomy without chemotherapy. Fur-
ther, women who received mastectomy were equally affected with re-
spect to feeling sexually attractive, regardless of chemotherapy status,
32 JOURNAL OF PSYCHOSOCIAL ONCOLOGY

and the level of their disruption was equal to that of women who
underwent both lumpectomy with chemotherapy.
Though the outcome measure of sexual attractiveness is based on a
single item from the CARES-SF sexual subscale both here and in the study
of Taylor et al. (2002) , the consistency seen between these results sug-
gest that the effect is both substantial and reliable. Further, given that
some studies have reported differences in the sexual sequlae of African
American as compared with Caucasian breast cancer survivors (Wyatt
et al., 1998), replicating the effects of the chemotherapy status and sur-
gery interaction in this largely Caucasian sample was important for
the purposes of comparison with the African American sample used
in the Taylor et al.’s (2002) study. The interaction suggests that sexual
attractiveness concerns may be of particular importance to patients
who undergo mastectomy, or to patients undergoing lumpectomy and
chemotherapy.
Finally, these results suggest that sexual QOL is a multidimensional
construct, with aspects of sexual experience affected in different ways
by variables related to survivorship. For example, the interaction between
surgery and chemotherapy status appears to be important for feelings
of sexual attractiveness, while it was nonsignificant in our model of sex-
ual QOL overall. In previous work, varying aspects of sexual QOL in
breast cancer survivors has been addressed, including sexual function
(Broeckel et al., 2002; Ganz et al., 1998), interpersonal aspects of
intimate relationships (e.g., CARES Dating Scale; Meyerowitz et al.,
1999), and feelings of sexual attractiveness (Taylor et al., 2002). Diff-
erences in findings regarding what factors affect sexual outcomes may
reflect real differences in the ways that survivorship variables are re-
lated to specific aspects of sexual QOL.

Limitations

There are a number of limitations to the present study. Additional

constructs that have been shown to affect the sexual outcomes of breast
cancer survivors, such as hormonal therapy (see Mourits et al., 2001, for
a review), change in menopausal status (e.g., Ganz et al., 1998), specific
physical symptoms, such as vaginal dryness (e.g., Meyerowitz et al.,
1999), and satisfaction with a relationship with a significant other (e.g.,
Wimberly et al., 2005), were not available for these analyses. While our
findings are consistent with studies that included data on these variables
in their analyses, it is possible that our results would differ if data on
these constructs were available. Regarding measurement, as compared
 Ellen Beckjord and Bruce E. Compas 33

with other studies (e.g., Ganz et al., 1999), our assessment of the sexual
QOL of breast cancer survivors was less comprehensive, using only the
3-item sexual subscale from the CARES-SF. In this way, the implica-
tions of our results do not extend beyond sexual QOL defined as feel-
ings of sexual attractiveness and interest and participation in sexual
activity. Also, though we included physical QOL in our multivariate
analyses to adjust for the impact that physical functioning may have
on sexual QOL, this adjustment is limited to the extent that physical
QOL represents overall physical functioning, which was not directly
measured in this study. Finally, though a replication of previous work
(Taylor et al., 2002), our findings regarding the interaction between
chemotherapy status and type of surgery on feelings of sexual attrac-
tiveness must be interpreted with some caution, as sexual attractiveness
was measured using only one item, preventing us from characterizing
the reliability of the measure. Further, given the smaller number of par-
ticipants who underwent a total mastectomy (n = 42) than those who un-
derwent a partial mastectomy (n = 149), it is possible that our observed
effect of chemotherapy on feelings of sexual attractiveness only among
women who underwent lumpectomy is a result of decreased power to
detect the effect among those who underwent mastectomy. Though the
number of women who underwent a total mastectomy in our study pop-
ulation is comparable with the sample size in the Taylor et al.’s study
(2002), further research is needed to confirm that the effects of che-
motherapy on feelings of sexual attractiveness differ based on type
of surgery.

CONCLUSIONS AND IMPLICATIONS

FOR CLINICAL PRACTICE

Research on the sexual outcomes of breast cancer survivors is provid-

ing valuable insight into the effects of cancer on women’s sexual QOL.
Beyond the main effects of chemotherapy, the ways that combinations of
treatment options differentially affect aspects of sexual QOL are begin-
ning to be better understood, allowing for more focused efforts on the part
of health care providers to identify patients for whom sexual side effects
are significant. As treatment options for breast cancer survivors evolve,
patient-provider communication can facilitate treatment decision making
for patients in choosing therapies based on preserving QOL (Fallowfield,
2004), particularly as survival rates for breast cancer continue to improve
(American Cancer Society, 2005). By simply inquiring about sexual
34 JOURNAL OF PSYCHOSOCIAL ONCOLOGY

QOL, providers can legitimize survivors’ sexual concerns, and can obtain
important patient information to facilitate recommendations for appropri-
ate educational, psychosocial, or medical interventions (see McKee &
Schover, 2001 for an excellent review). Our results suggest that assess-
ment of sexual QOL is of particular importance among breast cancer sur-
vivors who experience symptoms of depression near time of diagnosis or
who receive mastectomy or lumpectomy and chemotherapy as part of
their cancer care. Advancing the knowledge of how sexual QOL is af-
fected by cancer survivorship supports sexual concerns as a critical focus
of cancer care, and increases the likelihood that sexual concerns will be
addressed quickly, routinely, and adequately for women surviving breast
cancer.

REFERENCES
American Cancer Society. (2005). Cancer Facts & Figures. Retrieved August 1, 2005
from http://www.cancer.org.
Andersen, B.L., Anderson, B., & deProsse, C. (1989). Controlled Prospective Longi-
tudinal Study of Women with Cancer: I. Sexual Functioning Outcomes. Journal of
Consulting and Clinical Psychology, 57(6), 683-691.
Andersen, B.L., Woods, X., & Cyranowski, J. (1994). Sexual Self-Schema as a Possi-
ble Predictor of Sexual Problems Following Cancer Treatment. The Canadian
Journal of Human Sexuality, 3(2), 165-170.
Anllo, L.M. (2000). Sexual Life After Breast Cancer. Journal of Sex and Marital
Therapy, 26(3), 241-248.
Avis, N.E., Crawford, S., & Manuel, J. (2004). Psychosocial Problems Among Youn-
ger Women with Breast Cancer. Psycho-Oncology, 13, 295-308.
Basson, R., Leiblum, S., Brotto, L., Derogatis, L., Fourcroy, J., Fugl-Meyer, K.,
Graziottin, A., Heiman, J.R., Laan, E., Meston, C., Schover, L., van Lankveld, J., &
Schultz, W.W. (2004). Revised Definitions of Women’s Sexual Dysfunction. Jour-
nal of Sexual Medicine, 1(1), 40-48.
Beck, A.T., Steer, R.A., & Brown, G.K. (1996). Beck Depression Inventory–Second
Edition; Manual. The Psychological Corporation, San Antonio, TX.
Broeckel, J.A., Thors, C.L., Jacobsen, P.B., Small, M., & Cox, C.E. (2002). Sexual
Functioning in Long-Term Breast Cancer Survivors Treated with Adjuvant Che-
motherapy. Breast Cancer Research and Treatment, 75, 241-248.
Bukovi6, D., Fajdi6, J., Hrgovi6, Z., Kaufmann, M., Hojsak, I., & Stan8eri6, T. (2005).
Sexual Dysfunction in Breast Cancer Survivors. Onkologie, 28, 29-34.
Dausch, B.M., Compas, B.E., Beckjord, E., Leucken, L., Anderson-Hanley, C.,
Sherman, M., & Grossman, C. (2004). Rates of DSM-IV Diagnoses in Women
Newly Diagnosed with Breast Cancer. Journal of Clinical Psychology in Medical
Settings, 11(3), 159-169.
 Ellen Beckjord and Bruce E. Compas 35

Fallowfield, L.J. (2004). Evolution of Breast Cancer Treatments: Current Options

and Quality of Life Considerations. European Journal of Oncology Nursing, 8S,
575-582.
Ganz, P.A., Desmond, K.A., Belin, T.R., Meyerowitz, B.E., & Rowland, J.H. (1999).
Predictors of Sexual Health in Women After a Breast Cancer Diagnosis. Journal
of Clinical Oncology, 17(8), 2371-2380.
Ganz, P.A., Rowland, J.H., Desmond, K., Meyerowitz, B.E., & Wyatt, G.E. (1998).
Life After Breast Cancer: Understanding Women’s Health-Related Quality of Life
and Sexual Functioning. Journal of Clinical Oncology, 16(2), 501-514.
Kornblith, A.B. & Ligibel, J. (2003). Psychosocial and Sexual Functioning of Survi-
vors of Breast Cancer. Seminars in Oncology, 30(6), 799-813.
McKee, A.L. & Schover, L.R. (2001). Sexuality Rehabilitation. Cancer, 92,
1008-1012.
Meyerowitz, B.E., Desmond, K.A., Rowland, J.H., Wyatt, G.E., & Ganz, P.A. (1999).
Sexuality Following Breast Cancer. Journal of Sex & Marital Therapy, 25, 237-250.
Mortimer, J.E., Boucher, L., Baty, J., Knapp, D.L., Ryan, E., & Rowland, J.H. (1999).
Effect of Tamoxifen on Sexual Functioning in Patients with Breast Cancer. Journal
of Clinical Oncology, 17(5), 1488-1492.
Mourits, M.J.E., De Vries, E.G.E., Willemse, P.H.B., Ten Hoor, K.A., Hollema, H., &
Van der Zee, A.G.J. (2001). Tamoxifen Treatment and Gynecological Side Effects:
A Review. Obstetrics & Gynecology, 97(5, Part 2), 855-866.
Moyer, A. (1997). Psychosocial Outcomes of Breast-Conserving Surgery Versus
Mastectomy: A Meta-Analytic Review. Health Psychology, 16(3), 284-298.
Rogers, M. & Kristjanson, L.J. (2002). The Impact on Sexual Functioning of Chemo-
therapy-Induced Menopause in Women with Breast Cancer. Cancer Nursing, 25(1),
57-65.
Rowland, J.H., Desmond, K.A., Meyerowitz, B.E., Belin, T.A., Wyatt, G.E., & Ganz,
P.A. (2000). Role of Breast Reconstructive Surgery in Physical and Emotional
Outcomes Among Breast Cancer Survivors. Journal of the National Cancer Insti-
tute, 92(17), 1422-1429.
Schag, C.C., Ganz, P.A., & Heinrich, R.L. (1991). Cancer Rehabilitation Evaluation
System-Short form (CARES-SF). Cancer, 68, 1406-1413.
Schover, L.R., Jenkins, R., Sui, D., Adams, J.H., Marion, M.S., & Jackson, K.E.
(2006). Randomized Trial of Peer Counseling on Reproductive Health in African
American Breast Cancer Survivors. Journal of Clinical Oncology, 24, 1620-1626.
SPSS Version 13.0. (2004). SPSS Inc., Chicago, IL.
Stead, M.L. (2003). Sexual Dysfunction After Treatment for Gynaecologic and Breast
Malignancies. Current Opinion in Obstetrics and Gynecology, 15, 57-61.
Syrjala, K.L., Schroeder, T.C., Abrams, J.R., Atkins, T.Z., Brown, W.S., Sanders, J.E.,
Schubert, M.A., & Heiman, J.R. (2000). Sexual Function Measurement and Out-
comes in Cancer Survivors and Matched Controls. Journal of Sex Research, 37(3),
213-225.
Taylor, K.L., Lamdan, R.M., Siegel, J.E., Shelby, R., Hrywna, M., & Morgan-Klimi,
K. (2002). Treatment Regimen, Sexual Attractiveness Concerns and Psychological
Adjustment Among African American Breast Cancer Patients. Psycho-Oncology,
11, 505-517.
36 JOURNAL OF PSYCHOSOCIAL ONCOLOGY

Thors, C.L., Broeckel, J.A., & Jacobsen, P.B. (2001). Sexual Functioning in Breast
Cancer Survivors. Cancer Control, 8(5), 442-448.
Wimberly, S.R., Carver, C.S., Laurenceau, J., Harris, S.D., & Antoni, M.H. (2005).
Perceived Partner Reactions to Diagnosis and Treatment of Breast Cancer: Impact
on Psychosocial and Psychosexual Adjustment. Journal of Consulting and Clinical
Psychology, 73(2), 300-311.
Wyatt, G.E., Desmond, K.A., Ganz, P.A., Rowland, J.H., Ashing-Giwa, K., &
Meyerowitz, B.E. (1998). Sexual Functioning and Intimacy in African American
and White Breast Cancer Survivors: A Descriptive Study. Women’s Health: Re-
search on Gender, Behavior, and Policy, 4(4), 385-405.

doi:10.1300/J077v25n02_02