Sexual functioning, sexual enjoyment, and body image in Norwegian breast cancer survivors: a 12-year longitudinal follow-up study and comparison with the general female population

Figures & data

Figure 1. Flowchart for Cohort I and Cohort II in the BC-Pop and responses on the EORTC’s QLQ-BR23 at baseline, 3, 6, and 12 months, and after 7–12 years. Patients in Cohort II had no scheduled assessment at T2 and only some patients with external RT filled out the questionnaire. Excluded patients at left panel. “Missing” are patients who did not meet at clinical visits, did not deliver the EORTC questionnaire or did not answer the EORTC sexual items. All excluded patients participated in Cohort I.

Table 1. Characteristics for the breast cancer cohort (BC-Pop) and the female general population (F-GenPop).

	BC-Pop N = 349 (%)	F-GenPop N = 2254 (%)
Age (Mean ± St. Dev.)	59 (9.2)	52 (13.2)
30–49 years	48 (13.7)	989 (39.8)
50–59 years	119 (34.0)	540 (23.9)
60–69 years	133 (38.1)	454 (20.1)
70–79 years	27 (7.7)	271 (12.0)
Marital status
Living alone	79 (22.6)	577 (25.7)
Married/ cohabitant	256 (73.4)	1666 (74)
Missing	14 (4)	11 (0.5)
Comorbidity	103 (30.7)	653 (29.0)*
Anxiety and/or depression	12 (3.4)	241 (10.7)*
Diabetes mellitus	9 (2.6)	134 (5.9)
Stroke	3 (0.9)	42 (1.8)
Cardiovascular disease	39 (11.2)	86 (3.8)
Respiratory disease	17 (4.9)	94 (4.2)*
Musculoskeletal	23 (6.6)	375 (16.6)*
Cancer (F-GenPop)		221 (9.8)
Medical characteristics
AJCC (stage)
0	20 (5.7)
I	208 (59.6)
II	93 (26.7)
III	15 (4.3)
Grade
I	81 (23.2)
II	152 (43.6)
III	106 (30.4)
To little tissue	9 (2.4)
Surgery
Conservative	276 (79.1)
Mastectomy	73 (20.9)
Radiotherapy (RT)
Local	210 (60.2)
Locoregional	96 (27.5
IORT	43 (12.3)
Chemotherapy	135 (39.2)
FEC 60	68 (19.9)
FEC 100	29 (8.5)
FEC/ taxemes/others	38 (10.8)
Endocrine therapy	181 (53.0)
Tamoxifen	125 (36.4)
Aromatase inhibitors	56 (16.4)

AJCC, American Joint Committee on Cancer, a classification system for describing the extent of disease in cancer patients. In BC-Pop comorbidity was registered by clinicians at the clinical controls and from medical records. In F-GenPop morbidity is self-reported and based on the criteria of having one or more of the given conditions. Morbidities with * in F-GenPop means having one or more morbidity that limits activities.

Table 2. Mean EORTC scores on sexual functioning, sexual enjoyment, and body image in the breast cancer cohort (BC-Pop) and the female general population (F-GenPop).

	BC-Pop						BC- Pop*	F- Gen Pop	Mean diff.	p-values
	T1	T2	T3	T4	T5	T6
Sexual functioning	26.1	23.8	28.7	30.2	31.0	23.2	27.3	55.7	−19.5	<0.001
St. Dev.	24.0	23.4	24.1	24.8	24.0	24.0	24.2	20.3
Sexual enjoyment	64.5	65.6	63.7	64.5	65.2	65.0	64.7	70.7	−6.3	<0.001
Std. Dev.	26.8	26.2	27.1	27.6	25.2	29.3	26.9	26.9
Body image	86.9	84.1	87.1	87.1	88.0	88.4	87.0	70.8	13.3	<0.001
St. Dev.	20.4	21.3	19.3	20.3	19.1	19.5	20.0	26.8

T1–T6 are mean values at given time-points in BC-Pop. The overall mean scores in BC-Pop* (average sample mean score from T1 to T6) were compared with mean scores in F-GenPop and differences were tested with Student t-tests.

Figure 2. Sexual functioning scores after different BC treatment modalities for 12 years follow-up. T1= before radiotherapy (RT, n = 333), baseline, T2 = immediately after RT (n = 251), T3 = 3 months after RT (n = 279), T4 = 6 months after RT (n = 285), T5 = 12 months after RT (n = 290), T6 = 7–12 years after RT (n = 262). The four figure panels represent longitudinal estimated sexual functioning scores (mean and 95% confidence intervals) based on type of surgery, use of chemotherapy, use of endocrine treatment and the extent of RT. The panels to the right show the LMM with estimates for the significant impact of surgery and chemotherapy on sexual functioning. The LMM for RT and endocrine treatment is displayed in Supplementary Table 1. To calculate more precise estimates of scale values in BC individuals or groups, adjusted for age and comorbidity, the numbers in the LMM model can be used as follows: for a 55-year-old woman without comorbidities who has undergone BCS, estimated sexual functioning score is 57.7 (cons) – 0.4*55 (age) = 35.7 at baseline. A woman of same age and comorbidity-status who underwent mastectomy, will have an estimated sexual functioning score of 57.7 (cons) – 0.4*55 (age) – 7.6 (mastectomy) = 28.1 at baseline.

Table 3. Sexual functioning, body image, and sexual enjoyment in breast cancer patients (BC-Pop) and female general population (F-GenPop) by age and comorbidity.

Intercept (GenPop-reference)		BC-Pop		Age		Comorbidity
		Coeff.	p-value	Coeff.	p-value	Coeff	p-value
Sexual functioning at T5	57.4	−12.2	<0.001	−0.3	<0.001	−4.3	<0.001
Sexual functioning at T6	57.1	−14.0	<0.001	−5.7	<0.001	−3.6	<0.001
Sexual enjoyment at T5	75.6	−3.6	0.019	−0.15	0.002	−2.5	0.053
Sexual enjoyment at T6	75.1	−3.7	0.040	−0.1	0.008	−2.2	0.094
Body image at T5	67.0	6.4	<0.001	0.5	<0.001	−9.9	<0.001
Body image at T6	68.5	5.8	<0.001	−5.7	<0.001	−10.7	<0.001

T5 = 1 year after radiotherapy, T6 = 7–12 years after treatment. F-GenPop is compared to the BC-Pop on Sexual Functioning, Body Image and Sexual Enjoyment (among sexually active women) at short-term (T5) and long-term (T6) follow up. The regression analyses are adjusted for age and comorbidity.

Figure 3. Sexual functioning, sexual enjoyment, and body image by age among BC survivors (BC-Pop) compared with the general female population (F-GenPop) at short-term (T5) and long-term (T6) follow-up after BC treatment. Mean EORTC scores and 95% confidence intervals are displayed on Y-axis, and age groups displayed on the X-axis.

Data availability statement

The data are available on request to the corresponding author, [email protected].