As the treatment progressed, the proportion of sexual activity showed a tendency to decrease first and then increased after diagnosis. The sexual activity of breast cancer patients in this study at each follow-up time point was T1 39.1%, T2 52.4%, T3 51.4%, and T4 63.1%, which was closer to the results of the German scholar Farthmann's study (Farthmann et al.,2016). However, the level of sexually active ratio varies at different stages of the disease.
All patients became sexually active before diagnosis, but there was some time of sexual suspension after diagnosis. After diagnosis, the proportion of patients with sexual activity in DU Hua’s study was higher than 5.02% (Du et al.,2019) and the 20.83% reported by Cavalheiro et al. (Cavalheiro et al.,2012), reaching 39.1%. This result suggests that with social development in China, breast cancer patients place a higher value on sexuality in early-stage disease. This result suggests that with social development, breast cancer patients place a higher value on sexuality after the disease and may also be related to the difference in treatment status that the patients were in at the time of the survey.
Approximately half of the patients in this study suspended their sexual life during treatment continuation, which was consistent with the Farthmann study (55.6%). In the present results, the level of sexual activity of patients in the early recovery stage (9 months after diagnosis and approximately 3 months after finishing antitumor treatment) was 63.1%, which was higher than that in the study by Italian scholar Biglia et al. (Biglia et al.,2010)(34.3%ཞ37.1%) but lower than that reported by Belgian scholar Aerts et al. (Aerts et al.,2014)(64%ཞ71%). Forty of these patients (17.8%) completely suspended sex throughout the follow-up period, which was lower than the 29.29% in the DU Hua study (Du et al.,2019). Our findings indicated that the level of sexual activity in breast cancer patients needs further improvement. Early attention and early recovery can be helpful in returning and enhancing the patient's quality of sexual life. Since the maximum follow-up period of this study was 9 months after diagnosis, the best level and time point of sexual activity recovery in patients could not be explored, and further studies are needed (Avis et al.,2018; Lee, Kim, and Jeon,2015).
The different tendency of the sexual activity during treatment may be due to different criteria for evaluating and defining sexual activity in breast cancer patients. Chinese researcher Yuan Xiaoling distinguished active from inactive by whether patients had sex in the past 1 month (Yuan, 2019). American scholar Avis defined sexually active by asking patients whether they were sexually active in the past 1 month (Avies et al.,2018), and Korean scholar Maria Lee identified patients who had sex more than 1 time per month as type active (Lee, Kim, and Jeon,2015). Although there are some differences in the current definition of sexually active in different countries, for this special group, we believe that patients who can have sexual intercourse 1 and more times in the past 1 month can be considered sexually active.
The overall trend in our sexual activity may be related to the difference in treatment status that the patients were in at the time of the survey. But it suggests that the diagnosis and the early stage of disease treatment have a great impact on patients' sexual activity. We should help them to resume sexual life as early as possible to accommodat e the disease progression. However, the optimal point of time for sexual resumption needs to continue to be studied.
There was significant heterogeneity in sexual activity between the highly active group and the low active group, with serious polarization. The trajectory model of sexual activity development showed two trends in the sexual activity status of breast cancer patients during the treatment phase: the "high active group" accounted for 62.3% of the patients, who were active at approximately 50% at T1 and recovered to a high level of approximately 80% at T2ཞT4; the "low active group. The percentage of the "low active group" was 37.7%, and the sexual activity was very low throughout the follow-up period, close to 0, and recovered only approximately 40% at T4. The results of this study showed that there is significant heterogeneity in the sexual activity status of breast cancer patients after the disease. Clinical interventions should focus on low activity. Sexually active patients with high and low activity should be given different intervention protocols. We should understand these differences for the rehabilitation of sexual function for giving breast cancer clinical intervention. We clarify the different levels of sexual activity and related factors and improve the level of individualized intervention.
The trajectory model of sexual activity development provide a rich and valuable information for a deeper understanding of the sexual function status of breast cancer patients. The results of the sexually active group reached about two times the inactive group, indicating that the effect of cancer treatment on the sexual activity level of most patients was limited, and patients still maintained a high level of sexual needs. We need to be confident in the recovery of sexual life of breast cancer patients. The ubiquity of health literacy in China, it helps patients to adapt and recover from the disease to meet needs beyond disease and treatment (Li, Jin and Jin,2021; Keselman,2019). The clinical features of the disease need to be further explored as to why this change occurs.
Patients in the high active group were sexually active up to 50% at the T1 stage, suggesting that clinical interventions on sexual function of breast cancer patients can be carried out at an early stage to help patients establish correct cognition of sexual life, better restart their sexual life and improve the level of sexual activity. For patients with high sexual activity levels, we can focus on sexual life quality improvement to reduce the influence of disease and treatment factors on sexual life quality. For patients with a low level of sexual activity, the focus should be on understanding the reasons why the patients stopped having sex, and the intervention should focus on giving the patients the will and confidence to restart their sexual life and further improve the quality of sexual life on this basis.
The results of the influencing factors of the trajectory model suggested that demographic and clinical information other than age (Klein, Paluch-Shimon and Braun, 2022) did not affect the trajectory of treatment sexual activity, while patients' pretreatment sexual desire and vaginal lubrication were independent influences on the trajectory of sexual activity. Patients with good basal sexual desire and vaginal lubrication were more inclined to have a high level of sexual activity during treatment, independent of clinical information about the disease. The results are not entirely consistent with the findings of previous studies. A Korean longitudinal study that followed patients from diagnosis to six months after the end of treatment found that receiving chemotherapy, thyroid dysfunction, and depression were risk factors for sexual inactivity (Tucker et al., 2021). Yuan showed through a cross-sectional survey that older age, low economic level, health insurance for NPS and those without health insurance, and receiving chemotherapy were influential factors for low sexual activity in breast cancer patients.
Few studies have focused on the impact of patients' underlying sexual function status on the quality of sexual life after the disease. According to the DSM 5th edition published by APA in 2013, sexual desire disorders are mainly divided into hypoactive and aversive sexuality, when patients reduce, avoid or even avert the occurrence of sexual life, resulting in a reduction in the frequency of sexual life or even its suspension (American Psychiatric Association, 2013). Thus, sexual desire is directly related to sexual activity. We found that patients with good levels of basal libido and vaginal lubrication may better cope with decreased libido and reduced vaginal lubrication brought about by treatment. It directly affects their adaptation and recovery of their sexual function status after the disease. Most of the patients included in our study were around menopause. More of them already had reduced vaginal discharge before treatment, which was further aggravated by a series of antitumor treatments, especially chemotherapy and endocrine therapy, with damage to the endocrine system and difficulties in vaginal lubrication, the most obvious manifestation of which is the reduction of vaginal discharge as a structural change of the reproductive organs. Directly dryness and difficulties in sexual intercourse The most apparent manifestation is the reduction of vaginal secretions, a structural change in the genital organs, which directly leads to dryness and difficulty in sexual intercourse, thus reducing or even refusing sex (Tucker et al.,2016; Kuehn et al.,2019).
In contrast to conventional perceptions, this study found that patients aged 50 years were more likely to maintain higher levels of sexual activity after diagnosis. In comparison, younger women had worse levels of sexual activity and were prone to less frequent or suspended sexual intercourse. This is consistent with Klein's findings (Klein, Paluch-Shimon, and Braun, 2022). The reason is that the physiological changes related to sexual function before and after treatment are more different in younger breast cancer patients than in older patients (Radecka B, Litwiniuk M,2016), whose sexual adaptation and recovery are more challenging. Studies have shown that oncologic treatment is usually more devastating for younger women, who are more likely to experience menopausal symptoms induced by ovarian failure and to be affected by postoperative body image changes (Gabriel and Domchek,2010; Lee and Han,2014), which can be both psychologically and physiologically devastating, resulting in low libido, sexual activity, and a decrease in overall sexual quality of life (Harirchi et al.,2012; Marsh et al.,2020). In contrast, older patients, especially postmenopausal patients, have adapted to the postmenopausal physiological state and have less pronounced endocrine-related side effects caused by drug therapy. Therefore, the young breast cancer population should be given active attention as a sexually active and vulnerable group, and it is crucial to enhance the sexual activity and quality of life of young patients to improve the overall health of breast cancer in the future.
In this study, patients' basic demographic information, clinical treatment, disease information, and pretreatment sexual function level were included in the analysis of factors influencing the trajectory of sexual activity to provide a basis for predicting changes in the development of sexual activity after patient diagnosis on the one hand and to explore whether the baseline level of patients' sexual function at baseline has an impact on the trajectory of sexual activity from various dimensions of patients' sexual function at baseline, with a view to providing future interventions. A longitudinal study in Korea found that patients undergoing chemotherapy were more likely to be sexually active. A Korean longitudinal study found that receiving chemotherapy, thyroid dysfunction, and depression were risk factors for sexual inactivity (Tucker et al.,2016). A cross-sectional survey by Yuan Xiaoling in China showed that older age, low economic level, medical insurance for NPS and those without medical insurance, and being on chemotherapy were influential factors for low sexual activity in breast cancer patients (Yuan, 2019). The results of this study showed that neither demographic nor clinical information other than age was an influential factor in the trajectory of sexual activity, suggesting that the level of sexual activity in breast cancer patients is more related to their sexual function. The trajectory of breast cancer patients' sexual activity during the treatment period was derived from the trajectory model based on the data of five follow-ups, which reflects the stage development of breast cancer patients' sexual activity, not the status of a single time point, and helps medical professionals understand the sexual activity of this group more comprehensively and deeply, and the results may be more convincing. However, the follow-up period of this study was limited, and further exploration of the trajectory of sexual activity changes in breast cancer patients during the recovery period and understanding of the effects of somatic symptoms and functional psychosocial recovery on the level of sexual activity should be conducted.
Limitations
There are 2 limitations of this study. First, although the study population was obtained from tertiary care hospitals specializing in oncology in Southwest China, the study population has some limitations because it is a single-center study. Second, although the study subjects were followed up for 9 months, the observation period was relatively short.
Future Direction
Since sexual function changes over time, further studies with larger sample sizes and multicenter studies are needed to observe sexual function between low- and high-activity groups. Considering the physiological and psychological problems caused by surgery and endocrine therapy for young breast cancer patients, which can lead to loss of libido and sexual dysfunction, the sexual function of young female breast cancer patients is a key concern.