Sexual satisfaction of Indonesian women with breast cancer in Central Java, Indonesia

Sexual satisfaction of Indonesian women with breast cancer in Central Java, Indonesia Yan Wisnu Prajoko1*, Tommy Supit2 Background: The negative impact of breast cancer diagnosis on the sexuality of women patients is well-known. Sexual dissatisfaction arises from the disruption of physical appearance by the tumor or as a result of both operative or non-operative treatments. This study aimed to describe the perception of sexuality and its quality of breast cancer in Indonesian women. Methods: This descriptive study recruited women diagnosed with breast cancer that have undergone chemotherapy, radiotherapy, and surgery, either in singular, combination, or no treatment at all. The sexuality was assessed using the Indonesian version of the Sexual Satisfaction Questionnaire (SEXSAT-Q). Results: A total of 113 female breast cancer patients ranging from 20 to 71 years old participated in the study. The majority of respondents were clinically diagnosed with stage II (36.2%) or higher (54.9%). Most patients underwent surgery (91.1%) and chemotherapy (85.8%). Before the diagnosis of cancer, the level of sexual satisfaction was good on average, which remained stagnant for 64 (56.6%) participants during cancer treatment. Significant anxiety and distress were reported by 35 patients (31.0%), depression by 21 patients (18.6%), and tiredness by 48 patients (42.5%). Conclusion: The sexual satisfaction of women with breast cancer patients in our study group is average on general, prior or after cancer diagnosis. However, the treatment’s negative psychological impact is quite profound, affecting almost half of the study participants.


INTRODUCTION
Breast cancer is a major cause of severe morbidity and mortality in women. 1 Patients with breast cancer may lose a part or all breast tissue, extensive scarring, and the skin resulting in loss of breast or poor breast appearance. These conditions is distressing because it became the symbol of womanhood and sexuality. Mood changes following cancer treatment can also cause severe disability and emotional burden. 2, 3 Recent trends revealed that more women are being diagnosed with an advanced stage disease at a younger age who are sexually more active than their older counterparts. 4 Sexual satisfaction can be defined as a good state of physical, mental, and social well-being about onesexuality.
It requires a positive perception of body image and the possibility of having pleasurable sexual experiences, free of coercion and discrimination. The physical and emotional impact of breast cancer is apparent at the time of diagnosis, which usually worsened after receiving treatment. 5 Research that explores the impact of breast cancer on the sexuality of Southeast Asian women is minimal. To date, no study has described the sexuality of breast cancer patients in Indonesia. The Nation has the world's largest Muslim population that is generally conservative towards sexual topics, especially females, who usually refrain from discussing the sexual topic. 6 This situation creates challenges for healthcare workers to identify and manage the issue. This study aimed to evaluate the perception of sexuality and sexual satisfaction among Indonesian women with breast cancer in Central Java, Indonesia.

Questionnaire
This descriptive research utilized an established questionnaire, the Sexual Satisfaction Questionnaire (SEXSAT-Q), to evaluate breast cancer patients' sexuality and sexual life quality. 7 The SEXSAT-Q comprised of 17 questions that evaluate sexuality in a cancer patient in 6 different dimensions: sexual satisfaction (question number 1, 10, and 14), sex drive (question number 11, 12, and 13), body image (question number 7, 8, and 9), psychological coping (question number

Study Participants and Data Collection
The study participants were female breast cancer patients with a histopathological confirmation. By convenience sampling, the respondents were approached face-toface by the researcher while waiting in the outpatient clinic prior, undergoing, or posttreatment (chemotherapy, radiotherapy, surgery, and hormonal therapy) in Dr.
Kariadi General Hospital, Semarang, Indonesia. One female medical doctor unaffiliated with our institution carried out the data collection from 6 July 2020 until 17 July 2020. Before filling out the questionnaire all participants were assured of their anonymity, and their responses will not affect the medical service they receive. After informed consent, each respondent was given an unlimited amount of time to finish the questionnaire. The data collector's standard approach would be first explaining the goal of the research, which was purely for academic reasons. The researcher was allowed to guide the respondent to fill out the questionnaire when requested. Family members were allowed to assist participants who were unable to read or write. However, the participants were encouraged to avoid being influenced by a family member or other participants. Patients who refused to participate were considered to be clinically unfit or failed to answer the questionnaire completely were excluded.
Ethical clearance was granted by the Hospital Research Ethics Committee

DISCUSSION
The majority of participants in this study possess a minimal level of formal education. The level of education should theoretically reduce breast cancer incidence, with highly educated women are more likely to be aware of cancer and performed self-breast examination. However, a recent meta-analysis identified that women with a higher education level had a significantly higher risk of developing breast cancer (relative risk 1.22, 95% CI), which may be associated with alcohol use, age of parity, and menopause. 8 Most breast cancer women will encounter some surgery in combination with radiation therapy, chemotherapy, or both. The surgery takes place as the first part of the therapy plan with the primary goal to remove the tumor and accurately define the stage of the disease. 9 Information regarding the impact of breast cancer on women in South-East Asia is limited. This study evaluates the impact of breast cancer and its treatment on the patients' sexual life and identifies critical factors that contribute to dissatisfaction using SEXSAT-Q assessment. The impact of a cancer diagnosis on the individual's personal, family, social, and professional life is profound. 10 Alteration in one's sexual life is maybe one of the most challenging problems. Sexual dysfunction is common in breast cancer patients, particularly among women patients. Wang et al. described 15%-64% of women with breast cancer experience symptoms of sexual dysfunction. 11 Sexual dysfunction is a sexual problem that leads to personal distress or interpersonal    difficulty. The problems include the sexual response cycle (lack of sexual desire, impaired arousal, inability to achieve orgasm), sexual pain, and a general decrease in sexual satisfaction. 12  Compared to their healthy counterparts, women with breast cancer considered sex life less important while significantly less satisfied with their sex life. Personal misconceptions about doing sex with their partner worsened this negative condition. 14 This is also related to the patients' self-confidence in terms of their body image. Women diagnosed with breast cancer may possess low self-esteem because of the changes in body image disruption caused by disease and therapy. 15 Self-confidence has been identified as an important predictor of quality of life. According to the Global Survey of Sexual Attitudes and Behaviors (GSSAB), 80% of women in East Asia tend to desist from talking about their sexual problems versus 50-63% in Non-Ease Asia countries. Therefore, healthcare professionals' psycho-social support is essential before and/or directly after medical intervention for every patient with breast cancer. 16 This study describes the perceptions of sexual satisfaction among Indonesian women with breast cancer in Central Java. There are some limitations to this study. First, this is a qualitative descriptive study. Therefore a correlation between patients' sociodemographic, clinical staging, and sexual satisfaction cannot be made. Second, this study used a questionnaire as a method to obtain information on behavioral changes that might lead to selfreported bias.

CONCLUSION
The sexual satisfaction of women with breast cancer patients in our study group is average in general, before or after cancer diagnosis. However, the treatment's negative psychological impact is quite profound, affecting almost half of the study participants.

DISCLOSURE
The author reports no conflict of interest in this work.

FUNDING
None.