Body image, sexual activity, and side effects of treatments across the first year after surgery in women facing breast cancer: The influence of attachment insecurity

Abstract

Objectives: The aim of this study was to assess, across the first year after surgery, the influence of attachment insecurity, that is, avoidant and anxious tendencies, on body image, sexual activity, and side effects of treatments in women diagnosed with breast cancer.

Design: A total of 110 women with non-metastatic breast cancer were surveyed 2 weeks (T1), 3 months (T2), and 12 months (T3) after surgery.

Methods: Self-reported questionnaires were used to assess attachment tendencies (avoidance and anxiety), medical data (cancer stage, oncological treatment), sociodemographic data (age, socioeconomic level, relational status), and the three outcomes.

Results: Generalized linear modeling showed that (1) having more avoidant and anxious attachment tendencies predicted a more negative body image, as did being younger and having undergone a mastectomy; (2) having more avoidant attachment tendencies predicted being sexually inactive, as did having undergone neoadjuvant chemotherapy or adjuvant hormonal therapy, whereas being younger and in a committed relationship predicted being sexually active; and (3) attachment tendencies did not predict the intensity of side effects, whereas a higher cancer stage and being at the beginning of treatment predicted more side effects.

Conclusions: Women with avoidant and anxious attachment tendencies may be especially vulnerable to the consequences of oncological treatment, in particular regarding body image and sexual activity.

Keywords:

• attachment
• body image
• breast cancer
• postsurgical period
• sexual activity
• side effects

Introduction

Breast cancer surgery, as well as neoadjuvant and adjuvant treatment, are intensive and invasive and may result in negative psychological and somatic outcomes. The literature reports important individual variability in the degree to which women are affected by these outcomes.^1–3 Individual variability is caused by aspects of the disease (its severity, e.g.), but also by psychological variables related to individual and interpersonal factors.⁴ Among these variables, attachment tendencies have lately been receiving more attention, as they have been shown to influence adjustment to various medical conditions and to be related to somatic symptom reporting in the general population.^5–7

In adulthood, two attachment tendencies have been described, which are derived from the individual’s developmental relational history⁸: avoidance and anxiety. Avoidance refers to the tendency to repress emotional needs as a consequence of a history of attachment needs being rejected by the caregivers. Anxiety refers to the tendency to feel helplessness as a consequence of a history of inconsistent responses of the caregivers. These tendencies organize the emotional response to negative stimuli in structured patterns.⁹ People low on avoidance and anxiety dimensions present a secure pattern: they are efficient in the regulation of negative emotions and they are at ease in requesting support when needed, as they trust others.¹⁰ Conversely, people who are high on avoidance or anxiety dimensions, or who are high on both, show insecure patterns. More avoidant individuals tend to deny their emotional needs, to minimize difficulties, and to avoid requesting support from others, as they do not trust them. More anxious individuals, in contrast, tend to overemphasize their inability to cope with a threatening situation and to exaggerate their difficulties; they tend to frequently request support and increased closeness with others, sometimes through compulsive sexual behaviors, but the responses they receive never seem to meet their needs. Individuals high on both avoidance and anxiety are stuck between the need to be close to others and their distrust toward others; this creates intense distress and even disorganized responses. Studies on attachment have shown that attachment insecurity is related to more negative outcomes when someone is facing a negative event in several domains of life, including those that are health related.^7,11,12

Several models have been proposed to specifically explain the links between attachment and health.^11,13–15 The main pathways that they describe can be summarized as follows. First, there is a dysregulated response at a physiological level in more insecure individuals when they face a stressful situation such as a health-related issue. Second, attitude and behaviors are altered through modulation of the perception of threatening situations such as a disease: more avoidance induces underestimation of the threat, whereas more anxiety induces overestimation. Third, insecurity alters the regulation of emotions through internalized capacities (coping skills are lower), or through the aptitude to request help from others (lower in more avoidant individuals) or to perceive support provided by others (lower in more anxious individuals). Fourth and finally, more insecure individuals are more likely to engage in health-risk behaviors, such as non-adherence to their medical treatment.^7,9

In the psycho-oncology domain, studies have shown that insecure attachment tendencies are linked to poorer psychological adjustment to diverse types of cancer.^16,17 Moreover, insecure cancer patients tend to trust their physicians less than do more secure patients.^17–19 Regarding breast cancer, Schmidt et al found that attachment anxiety predicts more negativity and that attachment avoidance was linked to more passivity.²⁰ Cicero et al. found that attachment anxiety was linked with high levels of hopelessness and anxious preoccupation about the disease.²¹ In our own studies, we have found that in the immediate postsurgical period (2 weeks after surgery), women who were more avoidant were more likely to report a negative body image and women who were more anxious were more likely to report higher psychological distress.²² Moreover, higher attachment anxiety predicted more negative criticisms directed toward the partner caregiver.²³

The existing studies have confirmed the role played by attachment tendencies in the adjustment to breast cancer. However, data were often obtained from a sample of individuals with various medical conditions rather than from those with only breast cancer; moreover, medical data were rarely included as predictors in the studies, although more invasive surgery or more intensive treatment may explain more negative psychological outcomes. Finally, the effect of attachment has not been assessed across time.

Our aim in the present study was, thus, to expand the existing results and to consider attachment theory as a basis for understanding individual variability regarding the report of three specific outcomes of oncological treatment in patients with non-metastatic breast cancer across the first year after surgery. The three outcomes are among those most frequently cited by women: a negative body image,^24,25 impairment of sexual functioning,^26,27 and the side effects of treatment such as fatigue or pain in the arm or breast.²⁸ These outcomes, which are directly related to treatment, have been studied less than psychological outcomes such as distress. However, they may be intense and pervasive, and they may contribute in the long run to the emergence of psychopathological issues such as depression and anxiety in more vulnerable women.^29,30 Moreover, the side effects of treatment affect quality of life and require extensive support.^31,32

We hypothesized that, congruent with the data available in the literature, attachment tendencies would be linked with body image, being sexually active, and the side effects of treatment, even when time, sociodemographic data, disease characteristics, type of surgery, and neoadjuvant and adjuvant treatment variables are accounted for. Specifically, we expected higher anxious tendencies to be linked with the report of a more negative body image, a higher probability of being sexually active (as sexuality may be used compulsively as a means of trying to get comfort from a supporting other), and more side effects of treatments; in contrast, we expected higher avoidant tendencies to be linked with a lower report of these outcomes.

Materials and methods

This study had a longitudinal design, including three measurement points: 2 weeks (T1), 3 months (T2), and 12 months (T3) after breast surgery. The first two points (T1 and T2) corresponded to standard postsurgical follow-up meetings with the referent nurse at the Breast Center of the University Hospital of Lausanne, Switzerland. For T1, the time frame for entering the study was 2 to 5 weeks after surgery. The third point (T3) was at the beginning of the rehabilitation phase; this meeting also took place at the hospital with the referent nurse.

Sample

A total of 208 women with breast cancer were contacted at the Breast Centre. Participants had to be able to speak and read French and to be at least 18-year old. The exclusion criterion regarding the disease was having metastatic cancer. Of the women who were contacted, 140 agreed to participate, a 67.3% acceptance rate. Sixteen women resigned between initial acceptance and T1, seven between T1 and T2, and seven between T2 and T3. The final sample thus consisted of 110 participants. The main reasons for refusal or resignation were having no desire to be part of research, lacking energy and time, and feeling stressed.

Characteristics of the sample are described in Table 1.

Table 1. Sample characteristics (N = 110).

				N (valid %)
Variable	M (SD)	N (valid %)	T1	T2	T3
Sociodemographic variable
Age at T1 (in years)	53.3 (12.6)
In a committed relationship		85 (77.3)
Married		52 (47.3)
Hollingshead ISP
Upper		26 (23.6)
Upper-middle		23 (20.9)
Middle		28 (25.5)
Lower-middle		17 (15.5)
Lower		11 (10.0)
Cancer stage
0 (in situ)		13 (11.8)
I		44 (40.0)
II		38 (34.5)
III		15 (13.6)
Neoadjuvant chemotherapy		21 (19.3)
Surgery
Mastectomy		60 (54.5)
Breast-conserving therapy		50 (45.5)
Adjuvant treatment
Chemotherapy			14 (12.7)	10 (9.1)	0
Hormonal therapy			27 (24.5)	55 (50.0)	81 (73.6)
Radiotherapy			18 (16.4)	9 (8.2)	1 (0.9)
Trastuzumab			4 (3.6)	8 (7.3)	6 (5.5)

Note. ISP: Index of Social Position; T1: 2 weeks after breast surgery; T2: 3 months after breast surgery; T3: 12 months after breast surgery.

Procedure

Women were asked to participate in the research by their referent nurse at the presurgical consultation at the Breast Centre; documents about the research were provided to the women who agreed to participate and signed consent forms were obtained. At T1, the referent nurse completed an ad hoc questionnaire relative to medical data; information collected included cancer stage (0, 1, 2, or 3), type of surgery (mastectomy versus breast-conserving therapy), possible neoadjuvant chemotherapy, and type of adjuvant treatment (chemotherapy, hormonal therapy, radiotherapy, and trastuzumab). Self-reported questionnaires related to the other study variables were administered at each measurement point. Participants received compensation of CHF 30.- at each visit for their participation.

The present study was a continuation of a previous study from the immediate postsurgical period (T1) with a sample of 75 women, most of them being part of the sample of 110 for this study.²²

This study was conducted in accordance with the protocol approved by the Ethical Committee of the State of Vaud, Switzerland.

Self-reported questionnaires

The Revised Experiences in Close Relationships questionnaire (ECR-R³³; French version³⁴) was used to assess attachment. This instrument consists of 36 items that assess attachment anxiety (example of item: “I'm afraid that I will lose my partner's love”) and avoidance (example of item: “I find it difficult to allow myself to depend on romantic partners”). Participants were asked to rate each item by using 7-point rating scales from 1 (disagree strongly) to 7 (agree strongly). A total score is computed for each of the two dimensions by summing the 18 related items; the higher the score, the higher the individual on the dimension. Fourteen items have to be reverse-scored, as they are formulated in the secure direction. Internal consistency of the questionnaire was high for both dimensions: α = .89 for avoidance and α = .87 for anxiety at T1; .90 and .88, respectively, at T2; and .92 and .88, respectively, at T3.

The Body Image Scale (BIS)³⁵ is a 10-item questionnaire specifically designed for body image modification in patients with cancer. Women rate questions concerning their body image on a 4-point Likert scale: 0 (not at all), 1 (a little), 2 (quite a bit), and 3 (very much). Example questions are, “Have you felt less physically attractive as a result of your disease or treatment?” and “Have you been feeling self-conscious about your appearance?” A total score was computed by calculating the sum of the 10 questions. The higher the score, the more negative the body image (α = .94 at T1, .93 at T2, and .94 at T3).

The Sexual Activity Questionnaire (SAQ)³⁶ was used to assess the present sexual functioning of the women. For this study, we used a French version of the SAQ that was made available from the Institut Curie (Paris, France). A preliminary question—“Do you engage in sexual activity with anyone at the moment?”—filtered the answers to the questionnaire. Women who answered “yes” to this question were asked to answer 10 questions about their present sexual functioning. However, a high rate of missing data for these 10 questions led us to focus only on the answers to the filter question about “being sexually active” with a binary yes/no answer.

The European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire, Breast Cancer Module (EORTC QLQ-BR23),³⁷ was used to assess the side effects of treatment. We used the 15 items related to the “Symptoms” domain of the module, divided into four scales: therapy side effects, breast symptoms, arm symptoms, and upset by hair loss. Although the label for the scales of this domain is “symptom scales,” we preferred to use the term “side effects,” as the items of the scales are clearly related to treatment, whereas the term “symptoms” may also refer to the disease itself. Women were asked to rate the items along 4-point Likert scales: 1 (not at all), 2 (a little), 3 (quite a bit), and 4 (very much). The higher the score, the worse the outcome. Internal consistency for the total symptoms score was .82 at T1, .83 at T2, and .89 at T3.

A questionnaire specifically designed for the study was used to collect the sociodemographic data; relational status was assessed in terms of “being in a committed relationship.”

Statistical analyses

A full set of descriptive statistics (including mean and standard deviation) was computed for all variables of the study. As we had several types of scales (nominal and ordinal) and repeated measures across several time points, we performed generalized linear mixed model (GLMM) analyses: on the one hand, they allow us to simultaneously consider within-person and between-person variations across time, and, on the other hand, they are suitable for non-normally distributed variables.³⁸ Age, relational status, cancer stage, type of surgery, neoadjuvant treatment, type of adjuvant treatment, and attachment tendencies were entered as independent variables, as well as the new variable “time” created to represent the three measurement points. Body image, being sexually active, and side effects of treatments were entered as dependent variables. The link with the model was set to identity in the GLMM procedures for two continuous variables: body image and side effects of treatments. To gain statistical power, and given the high internal consistency of the four subscales taken together and their strong intercorrelations, we used a mean score of the four “Symptoms” subdomains of the EORTC QLQ-BR23 in order to have one index for the side effects of treatment. Regarding the variable related to being sexually active, the link with the model was set to LOGIT, as it is a binary variable.

Results

Descriptive statistics and preliminary analysis

Descriptive statistics for the study variables are provided in Table 2. The mean for attachment anxiety was slightly higher than that for attachment avoidance at the three time points. Regarding body image, the total mean was around 10 at the three time points, indicating that, on average, women reported “little” distress associated with body image modifications. Regarding side effects of treatment, the mean for each scale was around 2 at all time points, which corresponds to the anchor “a little” of the questionnaire, with the exception of the “being upset by hair loss” scale for which the mean tended toward 2.5 at T2 and T3, between “a little” and “quite a bit.”

Table 2. Descriptive data for attachment tendencies and study outcomes (N = 110).

		T1		T2		T3
Variable	Theoretical range	Mean (SD)	Actual range	Mean (SD)	Actual range	Mean (SD)	Actual range
ECR-R Attachment
Avoidance	1–7	2.56 (1.07)	1.00–5.83	2.59 (1.18)	1.00–5.56	2.77 (1.28)	1.00–6.44
Anxiety	1–7	3.00 (1.13)	1.00–5.78	2.86 (1.20)	1.00–5.67	2.97 (1.17)	1.11–6.38
BIS negative body image
Total	0–30	10.9 (8.8)	0–29	10.6 (8.1)	0–30	9.6 (8.1)	0–29
EORTC QLQ-BR23
Systemic therapy side effects (BRST)	1–4	1.84 (0.62)	1.00–3.86	2.09 (0.64)	1.00–3.86	1.81 (0.57)	1.00–3.71
Upset by hair loss (BRHL)	1–4	2.02 (1.14)	1.00–4.00	2.30 (1.11)	1.00–4.00	2.37 (1.24)	1.00–4.00
Arm symptoms (BRAS)	1–4	1.92 (0.70)	1.00–4.00	1.69 (0.70)	1.00–4.00	1.67 (0.71)	1.00–4.00
Breast symptoms (BRBS)	1–4	2.21 (0.63)	1.00–3.75	1.90 (0.66)	1.00–3.75	1.75 (0.61)	1.00–3.50
Mean	1–4	1.99 (0.51)	1.05–3.44	1.96 (0.51)	1.00–3.19	1.79 (0.55)	1.00–3.44

Note. ECR-R: Revised Experiences in Close Relationships questionnaire; BIS: Body Image Scale; EORTC QLQ-BR23: European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire, Breast Cancer Module; T1: 2 weeks after breast surgery; T2: 3 months after breast surgery; T3: 12 months after breast surgery.

Correlation analysis showed that at each time point considered separately, attachment avoidance and anxiety were positively linked with negative body image (see Table 3).

Table 3. Pearson 2-tailed correlations between attachment and study outcomes (N = 110).

	1	2	3	4	5	6	7	8	9	10	11
1. Attachment avoidance T1	_
2. Attachment avoidance T2	.69***	_
3. Attachment avoidance T3	.54***	.63***	_
4. Attachment anxiety T1	.48***	.40***	.29**	_
5. Attachment anxiety T2	.44***	.51***	.39***	.64***	_
6. Attachment anxiety T3	.46***	.37***	.57**	.52***	.57***	_
7. BIS negative body image T1	.24*	.38***	.29**	.34**	.36***	.27**	_
8. BIS negative body image T2	.12	.31**	.22*	.24*	.31**	.20	.74***	_
9. BIS negative body image T3	.12	.31**	.29**	.27*	.26*	.32**	.73***	.77***	_
10. EORTC QLQ-BR23 side effects mean T1	.21*	.31**	.19	.23*	.14	.09	.49***	.36***	.41***	_
11. EORTC QLQ-BR23 side effects mean T2	–.01	.07	.06	.24*	.21	.03	.40***	.40***	.38***	.37***	_
12. EORTC QLQ-BR23 side effects mean T3	.08	.30**	.21*	.15	.15	-.01	.35***	.35***	.44***	.40***	.59***

Note. BIS: Body Image Scale; EORTC QLQ-BR23: European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire, Breast Cancer Module; T1: 2 weeks after breast surgery; T2: 3 months after breast surgery; T3: 12 months after breast surgery.

*p < .05. **p < .01. ***p < .001.

Both avoidance and anxiety were linked with side effects of treatment at T1, there was no link at T2, and only avoidance was linked with side effects at T3. In all cases, the higher the insecurity of attachment, the worse the outcomes.

Finally, regarding sexuality, at T1, 49 women reported being sexually active (45%), 48 at T2 (44%), and 48 at T3 (44%). A t-test showed no difference in attachment tendencies at T1 between sexually active participants and those who were not active; at T2, women who were not active were more avoidant than were women who were active, t (92) = 4.19, p < .001; and at T3, women who were not active were more anxious than were women who were active, t (93) = 2.01, p = .047.

Attachment as a predictor of outcomes

The results of the estimates for the fixed effects of the GLMM are displayed in Table 4. The results showed, first, that body image is more negative at 3 months than at 12 months after surgery. It is predicted by age (the younger the women, the more negative their body image), surgery (mastectomy predicts a more negative image), and attachment tendencies: both more avoidant and more anxious tendencies are related to a more negative image. Second, being sexually active is related to age (the older the women, the less sexually active they remain), relational status (women in a committed relationship tend to stay sexually active), cancer stage (a lower stage predicts staying active), some of the oncological treatment variables (neoadjuvant chemotherapy and adjuvant hormonal therapy both predict not being active), and avoidant attachment tendencies, which predict not being active. Third, side effects of treatment are predicted by cancer stage (a lower cancer stage predicts fewer side effects) and time (fewer side effects at 12 months after surgery than at 2 weeks after surgery).

Table 4. Estimates of the fixed effects of attachment on body image, being sexually active, and side effects of treatment (N = 110).

	Negative body image (BIS)				Sexually active (SAQ)				Side effects of treatment (EORTC QLQ-BR23)
Parameter	B	SE	95% CI	p	B	SE	95% CI	p	B	SE	95% CI	p
Intercept	5.73	4.0	[–2.13, 13.60]	.153	1.04	1.53	[–1.96, 4.05]	.496	2.15	0.29	[1.57, 2.73]	<.001
Age	–0.16	0.04	[−0.24, −0.09]	<.001	–0.03	0.01	[–0.06, 0.00]	.043	0.00	0.01	[–0.01, 0.00]	.705
In a committed relationship
Yes^(No)	1.58	1.14	[−0.65, 3.82]	.165	0.89	0.43	[–0.24, 1.74]	.044	0.00	0.08	[–0.16, 0.17]	.916
Cancer stage
0^(3)	–0.60	1.80	[−4.14, 2.92]	.736	2.71	0.80	[1.13, 4.28]	<.001	–0.37	0.13	[–0.63, −0.11]	.005
1^(3)	–2.06	1.57	[−5.14, 1.01]	.189	2.38	0.73	[0.95, 3.81]	<.001	–0.41	0.12	[–0.64, −0.18]	<.001
2^(3)	–0.66	1.42	[−3.45, 2.13]	.642	2.24	0.65	[0.96, 3.51]	<.001	–0.19	0.10	[–0.39, 0.01]	.064
Surgery
Breast-conserving therapy^(Mastectomy)	–4.92	0.94	[–6.77, −3.08]	<.001	0.11	0.33	[–0.54, 0.76]	.745	0.02	0.07	[–0.12, 0.15]	.801
Neoadjuvant chemotherapy
Yes^(No)	2.06	1.29	[0.47, 4.60]	.111	–1.37	0.48	[–2.30, −0.44]	.004	0.02	0.09	[–0.17, 0.20]	.867
Adjuvant hormonal therapy
Yes^(No)	1.00	1.01	[–0.98, 2.97]	.322	–1.09	0.38	[–1.82, −0.35]	.004	0.06	0.07	[–0.09, 0.21]	.429
Adjuvant chemotherapy
Yes^(No)	1.76	1.77	[–1.70, 5.22]	.319	–0.60	0.65	[–1.88, −0.68]	.355	–0.16	0.13	[–0.42, 0.09]	.214
Adjuvant radiotherapy
Yes^(No)	2.48	1.47	[–0.39, 5.35]	.091	–0.04	0.54	[–1.09, 1.02]	.943	0.09	0.09	[–0.12, 0.21]	.394
Adjuvant trastuzumab
Yes^(No)	–0.46	2.07	[–4.52, 3.59]	.823	–0.53	0.74	[–1.98, 0.91]	.468	–0.24	0.15	[–0.54, 0.06]	.113
Time
2 weeks^(12 months)	1.43	1.17	[–0.86, 3.72]	.222	0.31	0.42	[–0.51, 1.13]	.463	0.19	0.09	[0.03, 0.37]	.021
3 months^(12 months)	2.10	1.07	[0.01, 4.19]	.049	–0.08	0.37	[–0.81, 0.65]	.833	0.14	0.08	[–0.01, 0.30]	.070
Attachment avoidance	1.88	0.47	[0.95, 2.80]	<.001	–0.37	0.19	[–0.74, −0.01]	.045	0.05	0.03	[–0.02, 0.12]	.127
Attachment anxiety	1.29	0.44	[0.43, 2.16]	.003	0.12	0.19	[–0.19, 0.43]	.440	0.03	0.04	[–0.04, 0.09]	.448

Note. BIS: Body Image Scale; SAQ: Sexual Activities Questionnaire; EORTC QLQ-BR23: European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire, Breast Cancer Module; CI: confidence interval.

Discussion

In this study, the influence of attachment tendencies on the report of three types of outcomes of oncological treatment of breast cancer across the first year after surgery was assessed. The first outcome was body image: all women in our sample underwent surgery that left their body with signs of the operation. We expected avoidant individuals to downplay the inconvenience due to the surgery and, in contrast, anxious individuals to report more negative outcomes.^39,40 Although results showed that the role of attachment anxiety was congruent with our expectations, this was not the case for avoidance: more avoidant individuals were also more likely to report a more negative body image. The explanation could be that the regulation strategy that avoidant individuals use to deal with minor stressors such as daily hassles failed to repress emotional activation following surgery.⁹ Indeed, an external mark on the body reveals that the woman had to face a disease and so had to cope with a difficult experience; that is, it makes vulnerability visible, which may have caused avoidant defenses to be not sufficient to deny vulnerability. As a consequence, negative emotional activation remained elevated. As proposed in the models that link attachment and health,^11,14,15 the heightened perception of a negative body image may thus be the direct consequence of a failure to regulate emotions, with a “threat”—the alteration of the body—remaining highly distressing even after the immediate postsurgical period is over.

Several other variables were related to concerns about body image, the first being the type of surgery, as mastectomy predicted a more negative image, which has been described in the literature.^24,41 The second related variable was age: in line with the results of other studies, younger women were more concerned with their physical appearance than were older women.^42,43 Finally, concerns lowered slightly at 12 months; further studies are needed to examine how body image continues to evolve in the long term.

The second outcome was being sexually active. We intended to assess several dimensions of sexual functioning, but because of missing data, we were able to analyze only the general binary question at the start of the questionnaire (“Do you engage in sexual activity with anyone at the moment?”) without specifying what was meant by “sexual activity.” Our results showed that women who are more avoidant are more likely to have stopped any sexual activities. This may be a consequence of the main defensive process in more avoidant people, that is, to withdraw from the emotional facets of relationships, just as they are reluctant to request support from others. This finding therefore tends to show not only that the disease elicits avoidance of disease-related support, but that it also causes a more general withdrawal from close relationships, as is the case in more avoidant individuals in any situation that elicits an emotional arousal.⁴⁴ Because of lack of data about sexual functioning, however, we were unable to assess the extent to which more avoidant women tend to not mention any possible sexual difficulties. The same limitation applies to attachment anxiety, for which we found no link with sexual activity.

On the other hand, several other variables were linked with being sexually active. First, younger women were more likely to be sexually active despite the disease, as was also the case for women in a committed relationship.^45,46 The latter result shows the possible protective effect of being in a couple relationship when facing a disease.^47,48 Second, a higher cancer stage, adjuvant hormonal therapy, and having undergone neoadjuvant chemotherapy, in contrast, predicted sexual inactivity, which may be explained by the effect of the disease and by the side effects of the treatments.^49,50

The third outcome was the side effects of adjuvant treatment. Contrary to our expectations, there was no effect of attachment tendencies; we expected women who are more anxious to report more side effects as a result of an overestimation of these outcomes, but this was not the case. The high number of somatic symptom reports that are described in anxious individuals in studies on general health may be related to somatoform disorders or may reflect hypervigilance for minor somatic disturbances; for more anxious individuals, more intense somatic symptoms such as those following cancer treatment may be sufficient to serve as “alert signals” in order to solicit support from others. Conversely, there was no underestimation in more avoidant individuals, perhaps because the intensity of the side effects makes underestimation impossible.

Regarding the other variables, cancer stage was related to side effects. As the stage is related to the type of treatment, there may be a confounding effect between the variables. Finally, there was an effect of time, which is logical, as most side effects are supposed to progressively disappear after the treatment is finished, even though some long-term sequelae are described in the literature (such as chronic fatigue; see Ref. [51])

These results have important clinical implications. Women with insecure tendencies are more likely to experience heightened negative psychological outcomes of treatment; this effect occurs over time, at least during the first postsurgical year. Lasting negative outcomes put these women more at risk of secondary psychopathology such as depression and anxiety. They are thus more likely to require psychological and medical care through a longer period; as a consequence, the earlier they are supported, the less care they may need in the long run. A program that aims to improve coping skills in women facing breast cancer should, thus, consider these attachment tendencies. Differences in attachment security are, for example, linked to differences in preferences regarding emotionally loaded information: studies in other medical domains have shown that anxious individuals need to receive as much information as possible regarding medical procedures, whereas avoidant individuals prefer not to know much.^52,53 In a patient-centered perspective, these differences have to be considered to ensure that support fits the needs of the patients.^54,55

The study has several limitations. First, our sample is small, and so the results need to be confirmed in a larger sample. Second, we were not able to assess sexual functioning in detail, as too many data were missing. Finally, studies on adjustment to the stress of breast cancer should consider not only the relational status of the woman but also the quality of the relationship she has with her partner and the partner’s point of view and own attachment tendencies. Notwithstanding these limitations, our study confirms the importance of taking attachment tendencies into account to understand adjustment to the disease and to the treatment in women with breast cancer. The extent to which this effect persists in the long run in breast cancer patients is still an open question. In a future follow-up, we aim to assess the role of attachment tendencies in the psychological recovery of survivors of our sample at 5 years (or more) after surgery.

Data availability statement

The data that support the findings of this study are available on request from the corresponding author, NF. The data are not publicly available due to confidentiality.

Disclosure statement

No potential conflict of interest was reported by the authors.

Additional information

Funding

This project benefited from the support of the Swiss National Center of Competence in Research LIVES – Overcoming vulnerability: life course perspectives, which is financed by the Swiss National Science Foundation, and of the Swiss Cancer League, grant KLS 3396-02-2014