Quality of sexual life and associated factors: a cross-sectional survey of Chinese breast cancer patients

This study aimed to explore Chinese breast cancer patients’ quality of sexual life (QSL) and factors associated with QSL. The questionnaires in this cross-sectional study include the general information questionnaire, cognition and assessment of sexual health questionnaire, Self-acceptance Questionnaire (SAQ), Medical Coping Modes Questionnaire (MCMQ), and Quality of Sexual Life Questionnaire (QSLQ); 201 breast cancer patients were required to complete the questionnaires assessing characteristic information, cognition and assessment of sexual health, QSL, self-acceptance, and coping style. Finally, hierarchical regression was used to analyze the factors associated with QSL in Chinese breast cancer patients. The mean age (at the time of the survey) of the breast cancer patients was 48.31±9.15. The mean score of the QSLQ (range 28–140) was 75.14±16.57. Hierarchical regression analysis showed that the associated factors of breast cancer patients’ QSL included age (at the time of the survey), education level, type of surgery, cognition and assessment of sexual health, self-acceptance, and avoidance and acceptance-resignation coping styles, that independent variables explained 60.4% of the variance. The QSL among Chinese breast cancer patients needs to be improved. Our findings indicated that breast cancer patients with older age, lower education level, or modified radical mastectomy have poor QSL. Breast cancer patients learn correct information about sexual health, enhance self-acceptance, and reduce acceptance-resignation, and avoidance coping could be intervention strategies to improve their QSL.


Introduction
According to global data in 2020, breast cancer has replaced lung cancer as the most common cancer, with 2.26 million new cancer cases per year worldwide [1]. A recent study showed that the 5-year survival rate of breast cancer patients in China has reached 90.0% [2]. The high-incidence breast cancer population includes women aged 45 to 55 years, and most of these women are married and live with their spouses; thus, their sexual life plays an important role in their relationship and quality of life [3].
However, surgery for breast cancer causes patients to lose their breasts, which are important organs of female secondary sexual characteristics. In addition, chemotherapy, radiotherapy, and endocrine treatment can cause hair loss, vaginal dryness, and low sexuality for patients, which will have a negative effect on their sexual life [4,5]. A meta-analysis showed that 73.4% of breast cancer patients experience Rongfei Suo and Fenglian Ye contributed equally to this work. sexual dysfunction after treatment, including low sexuality, vaginal dryness, and a decrease in sexual activity [6]. The quality of sexual life (QSL) of breast cancer patients is the evaluation of the objective state and subjective feeling of sexual life after undergoing surgery, chemotherapy, radiotherapy, or endocrine therapy [7]. QSL also refers to an individual's perception of his or her position in the context of their culture, values, goals, expectations, standards, and priorities [5]. In China, sex is considered a topic of personal privacy; thus, the QSL of breast cancer patients is often overlooked.
According to the stress and coping model, individual characteristics, cognition, assessment, and coping style of stress affect health outcomes [8]. Previous studies have shown that demographic characteristics, such as age, income level, academic education level, the stage of cancer, and the type of surgery, are independent risk factors for sexual dysfunction [4,5,9]. In addition, breast cancer patients' correct cognition and assessments of their sexual life are great barriers to sexual activity among breast cancer patients [10]. Studies also found that sexual activity was not associated with the progression of breast cancer; however, many patients still consider sexual activity to be related to poor therapeutic effects, recurrence, or metastasis; thus, they always feel anxious and even fearful about sexual activity after being diagnosed with breast cancer [10,11]. Research by Rui Yan et al. [10] has shown that breast cancer patients with the belief that "sex may cause the recurrence or metastasis of breast cancer" have a lower frequency of sexual activity and lower sexual satisfaction.
In addition, patients' correct assessment of their physical and mental state is also an essential factor in their sexual life [11]. Due to treatment, breast cancer patients may experience self-image changes with mastectomies, hair loss, and other factors, and their assessment and acceptance of these changes are also an important part of their self-acceptance [9]. Self-acceptance is related to a positive attitude to assess self-worth and accept all aspects of one's self [12]. Studies have shown that breast cancer patients' negative attitudes toward their social, mental, and physiological changes could lead to worse sexual health outcomes [13][14][15].
Furthermore, the stress and coping model has shown that people choose coping styles for stress after evaluating their stress, and these coping styles always affect their health outcomes [8]. As one of the essential health outcomes, breast cancer patients' QSL could be affected by their coping styles. Similar studies of breast cancer patients indicated that coping styles were correlated with sexuality, and patients who used more avoidance and self-blame coping styles or fewer positive coping styles reported low sexuality [14][15][16]. Because sexuality is an essential part of sexual life, the coping style of breast cancer patients could relate to their QSL.
Today, there is a growing number of breast cancer survivors worldwide, and how to improve their quality of life has received much attention. Therefore, sexual life, as an indispensable component of quality of life, should also be a focus. However, QSL has obviously not received enough attention in previous studies, especially in China, where there are relatively few studies on QSL in breast cancer patients [7]. This study was carried out to acquire a deeper understanding of QSL and its associated factors.

Participants
From July 2021 to May 2022, female breast cancer patients in a third-class hospital were recruited by convenience sampling method to participate in this study. The inclusion criteria were as follows: (a) patients with primary breast cancer confirmed by pathology; (b) patients who underwent total breast resection or breast-conserving surgery; (c) patients with a primary school education or above; and (d) patients who signed informed consent forms. The exclusion criteria were as follows: (a) patients with distant metastasis of breast cancer; (b) patients who had a history of mental illness or those taking antipsychotic medications; and (c) patients suffering from other cancers or serious life-threatening diseases. The sample size of this study was required to be 194, according to the formula N ≥ 50+8*M (M: the number of independent variables; M = 18 in this study), which is based on multivariate analysis [17]. Therefore, 210 breast cancer patients who met the criteria were included in the study; 6 patients refused to complete the questionnaire, 3 patients submitted the questionnaire with vague answers and refused to give clear answers, and 201 patients with valid questionnaires were ultimately included.
All the questionnaires in this study were collected by surgical nurses with scientific and specialized knowledge of breast cancer. This study was approved by the Ethics Committee of the Fifth Affiliated Hospital of Sun Yat-sen University, and the ethics batch number is K94-1.

Characteristics information
Patient characteristics were collected from the general information questionnaire, which includes demographic and disease-related characteristics.

Cognition and assessment of sexual health
According to previous studies on the cognition and assessment of sexual health in breast cancer patients, we included seven questions (C1: Do you think your sex life will cause unhealthy outcomes? C2: Do you think the occurrence of breast cancer is related to your sexual life? C3: Do you agree that your sexual life will cause the recurrence of breast cancer? C4: Have you received sexual health education? C5: Do you need to learn some information about sexual life after breast cancer surgery? C6: Who should provide relevant knowledge of sexual life after breast cancer surgery? C7: Does your husband need to learn some information about sexual life after your breast cancer surgery?) to survey breast cancer patients regarding their cognition and assessment of sexual health [11].

Self-acceptance
The self-acceptance of breast cancer patients was measured by the Self-acceptance Questionnaire (SAQ), which was compiled by psychological experts in 1999 [18]. The scale has 16 items and 2 dimensions, including the self-evaluation factor and the self-acceptance factor. The total score of all items ranges from 16 to 64 points and is scored with a 4-point Likert scale; a higher total score means better selfacceptance. In this study, Cronbach's α was 0.709.

Coping styles
The Medical Coping Modes Questionnaire (MCMQ) [19] was used to measure the coping styles of breast cancer patients facing cancer. The questionnaire is scored using a 4-point Likert scale and includes 20 items and 3 dimensions: confrontation (8 items), avoidance (7 items), and acceptance-resignation (5 items). A higher total score for the dimension means a higher frequency of coping styles used by participants. In this study, Cronbach's α of the questionnaire was 0.735.

Quality of sexual life
The Quality of Sexual Life Questionnaire (QSLQ) for breast cancer patients was compiled by Chinese scholar Jing Liwei Equals in 2018 [20]. The questionnaire consisted of 28 items and 5 dimensions, including physiological sex (8 items), psychological sex (7 items), sexual relationship (5 items), body image (5 items), and sexual cognition (3 items). The questionnaire is scored using a 5-point Likert scale (1 = strongly agree, 5 = strongly disagree), and the total score of the questionnaire ranges from 28 to 140. A high score indicates better QSL. Cronbach's α of the questionnaire was 0.924.

Statistical analysis
Social Sciences version 20.0 (SPSS 20.0) was used for all data analyses in this study. The mean (M) ± standard deviation (SD) is used to describe quantitative data with a normal distribution, and frequencies/percentages are used to describe the classified data. In our study, the dependent variable was breast cancer patients' QSL, and the independent variables included individual characteristics, cognition and assessment of sexual health, self-acceptance, and coping styles. T tests and oneway ANOVA were used to examine the differences in QSL in breast cancer patients with different characteristics and cognition of sexual health. In addition, Pearson correlation analysis was used to examine the correlations among self-acceptance, coping styles, and QSL. Finally, we selected independent variables with significant correlations or differences (p < 0.05) for hierarchical regression analysis [21], which was used to examine the associations between the independent variables and QSL in breast cancer patients.

Quality of sexual life and individual characteristic information
In this study, the average score of the QSLQ was 75.14 ± 16.57, and it was significantly different in patients with different characteristics. The mean age (at the time of the survey) of the breast cancer patients was 48.31 years (SD = 9.15), which was negatively correlated with QSL (r = −0.364, P < 0.001). They reported a mean marriage length of years of 23.08 (SD =10.21), the mean age at the time of marriage was 25.36 (SD=4. 35), and their marriage length of years also negatively correlated with the QSL (r = −0.269, P < 0.001). In addition, the difference in the QSL among breast cancer patients with different surgical methods, education levels, and residence types was significant (P < 0.05), as shown in Table 1.

Cognition and assessment of sexual health
Data about the cognition and assessment of sexual health among patients after breast cancer surgery were collected: C4 and C6 were insignificantly associated with the QSL score, and other variables all showed significant associations with QSL (P < 0.05; see Table 2).

The correlations among self-acceptance, coping style, and QSL
The results of the correlation analysis showed that in breast cancer patients, QSL was positively correlated with the selfacceptance factor (P < 0.05). In addition, avoidance and acceptance-resignation coping styles were negatively correlated with QSL (P < 0.05), and the confrontation coping style was positively correlated with QSL (P < 0.05) ( Table 3).

Hierarchical regression analysis
The results of hierarchical regression analysis showed that the VIFs of all independent variables in models 1 to 4 were all <10, indicating that there was no multicollinearity that seriously interfered with the stability of parameter estimation [22]. In model 1, age (at the time of the survey), marriage length, education level, and type of surgery were significantly associated with QSL, and a total of 34.8% of the variance was explained. In model 2, cognition and assessment of breast cancer sexual health explained an additional 11.0% of the variance in QSL. In addition, C1, C5, and C7 were significantly associated with QSL. In model 3, the self-acceptance factor explained an additional 2.7% of the variance. In model 4, avoidance and acceptance-resignation coping styles were significantly associated with QSL, and these two variables explained an additional 11.9% of the variance. Finally, age (at the time of the survey), education level, the type of surgery, C1, C5, C7, and avoidance and acceptance-resignation coping styles were significantly associated with QSL, and all the independent variables explained 60.4% of the variance (Table 4).

Discussion
In this study, we identified factors associated with QSL among breast cancer patients, including age (at the time of the survey), education level, the type of surgery, the cognition and assessment of sexual health, self-acceptance, and coping style. They have different predictions of sexual health in different ways. Our study's results have shown that the age (at the time of the survey) of breast cancer patients was negatively associated with their QSL. Similarly, the study of Aiying et al. [23] found that older female breast cancer patients faced a series of physical changes, such as a reduction in sex hormone secretion and vaginal atrophy, which are essential negative factors affecting the quality of women's sexual lives. In addition, our study proved that breast loss could contribute to poor QSL in breast cancer patients. Nasrin et al. [22] also found that the sexual satisfaction of patients after total mastectomy was significantly lower than that of patients after breast-conserving surgery. Moreover, the results also showed that the more education breast cancer patients had, the better their QSL was, which might be related to the fact that patients with higher education levels can have easier access to knowledge about sexual health and are more active in seeking help when they have sexual health problems.   Therefore, when we make plans to help breast cancer patients improve their QSL, their age, education level, and the type of surgery should be considered. In this study, a large majority of breast cancer patients expressed the worry that their sexual life was associated with unhealthy outcomes, and they were also proven to have a lower level of QSL than those who did not express this worry. The qualitative study of Gong et al. [11] found that due to the lack of correct cognition of sexual health, breast cancer patients might have poor treatment outcomes, cancer recurrence, and complications with sexual life in China. Besides, in addition, some patients acquired advice and information from others that led to misunderstandings and even believed that cancer cells may spread to their spouses through sex [24]. In our results, the majority of patients expressed the need for themselves or their husbands to learn about sexual life after breast cancer surgery. Research on the sexual health needs of breast cancer patients and their partners has illustrated that there are many unmet needs for information regarding sexuality among breast cancer patients and their partners [25,26]. There was another interesting finding that breast cancer patients who express the need for relevant knowledge about sexual health and breast cancer surgery have lower levels of QSL, which was similar to those who think their husbands also need relevant knowledge. These findings reflect the inadequacy of sexual health education for breast cancer patients and their husbands and suggest that correct cognition of sexual health may be effective in improving breast cancer patients' QSL. A study found that sexual health education for breast cancer patients and their spouses can help them in resolving their sexual intimacy problems [26]. The worry regarding cognition and assessment can lead to unhealthy behavior; consequently, correct and consistent sexual health education for breast cancer patients is important. The meta-analysis of Xu et al. [27] showed that cognitive behavioral therapy can help breast cancer patients' relieve their sexual distress and improve sexual function. In our analysis, the self-acceptance of breast cancer patients was a positive predictor of their QSL. Cong et al. [18] found that the acceptance of one's own body is the basis of individual self-acceptance. For breast cancer patients, surgery and other adjuvant therapy will change their body image, including the loss of their breasts and hair; they often find it difficult to accept these changes, lose their confidence, and even feel stigma, which could affect their sexual function [13,28].
Shuang-Qin et al. [29] found that these changes in body image also make breast cancer patients resist some intimate behaviors that involve exposing their breasts. In addition to the change in body image, breast cancer treatments can also cause the loss of some social functions and family roles and lead to poor psychosocial and psychological states, which are important in the development of self-acceptance in breast cancer patients [30]. According to the Female Sexual Health Model, psychosocial and psychological states were both important influencing factors of female sexuality, and it has been proposed that intimacy is a driving force for female desire and sexual activity [30,31]. As a result, poor self-acceptance may reduce confidence when breast cancer patients face their partners, decrease intimacy with their partners, and cause poor mental health, thus decreasing their QSL.
The results indicated that the avoidance coping style is a negative predictor of breast cancer patients' QSL. The study by Su-Ying et al. [15] found that breast cancer patients use more negative dyadic coping styles, such as avoidance and self-blame coping styles, ultimately contributing to poor sexual relationships. Patients with more avoidance may deliberately try to hide their worries and deny their concerns about sexual health-related issues, which not only fails to help them solve relevant problems in their sexual life but also causes estrangement in couples and further deteriorates the intimate relationship between husbands and wives [32][33][34]. Studies recently demonstrated that constructive communication and discussion between breast cancer couples could facilitate adjustment to cancer-related sequelae (such as sexual problems) [35,36].
In addition, the results of the study also showed that the acceptance-resignation coping style was associated with poorer QSL. This is similar to the results of Cui et al. [37]; in their study, the acceptance-resignation coping style had a negative predictive effect on breast cancer patients' sexual adaptation. As a maladaptive way of coping, the acceptance-resignation coping style will cause patients to gradually lose confidence, overcompromise, and produce more and more negative emotions, which is not conducive to their sexual health problems in the treatment process, resulting in a low level of sexual quality [37]. Such findings suggest that helping breast cancer patients avoid adopting avoidance coping or acceptance-resignation styles can help them solve sexual health-related dilemmas and effectively improve their QSL.

Limitations
There are some limitations in this study. First, a crosssectional design was used in this study; thus, the dynamic process of breast cancer patients' QSL with time cannot be explored, and we cannot conclude whether patients had sexual problems before the diagnosis of breast cancer. In future studies, it will be necessary to carry out longitudinal studies on QSL in breast cancer patients. Second, all participants in this study were from one hospital, which might reduce the representativeness of the sample. To explore the QSL of breast cancer patients more fully, a multicenter study is essential. Third, because of the lack of a sexual health measurement scale regarding the cognition and assessment of breast cancer patients, seven questions developed in a qualitative study were used to survey patients' cognition and assessment of their sexual health. Therefore, developing a scale for measuring cognition and assessing sexual health in breast cancer patients is very important to their QSL.

Conclusion
From the above findings, we can conclude four significant points about breast cancer patients' QSL: (1) Personal characteristics, such as age, education level, and the type of surgery, need to be considered when attempting to improve patients' QSL; (2) sexual education is urgently needed to prevent the incorrect cognition and assessment of sexual health, which is a barrier to QSL in breast cancer patients; (3) helping patients reconstruct their selfconfidence and reaccept themselves is good for improving QSL; and (4) acceptance-resignation and avoidance coping styles should be reduced in breast cancer patients. Our study is the first to explore the predictive effects of the cognition and assessment of sexual health, self-acceptance, and coping style on QSL in Chinese breast cancer patients. In future studies, more associated factors of QSL in Chinese breast cancer patients should be included.