Although SH is an important dimension of quality of life and BC diagnosis and therapies are associated with a high risk of developing transient or permanent sexual disturbs, very few women obtain information or have access to an appropriate counseling focused on sexual issues after BC diagnosis.
Our study confirms the lack of communication between patients and health-care professionals on SH in women with BC. Our results are consistent with the data in the literature with nearly 4 out of 5 women not having received information from health professionals [26, 39].
Furthermore, we found a significant deterioration in women's self-rated satisfaction with their quality of sexual life compared to pre-diagnosis . It is also interesting to note that almost one in five women was not satisfied with her SH before BC was diagnosed. These figures are consistent with those carried out by Lammerink et al in 2017 in the Dutch general population in 521 sexually active and healthy women, of whom more than a quarter had sexual dysfunction .
Women preferred to be provided with information on SH throughout their treatment plan, starting at diagnosis, as recommended by the American Society of Clinical Oncology (ASCO, ) and by national societies, such as the French Association of Supportive Oncological Care (AFSOS, ). Participation of the partner to the discussion on SH was essential for most of participants . Despite the lack of training of oncologists in SH, they were the favorite interlocutors for women, certainly due to the relationship of trust that can develop throughout the whole BC care pathway . Thus, oncologists are expected to initiate the discussion [25, 32] on the impact of BC on SH, preferably during face-to-face consultations, with a clear and inclusive language that put the women and their partners at ease to raise specific questions on this topic.
We were able to draw some interesting data from our exploratory analyses. Indeed, as already shown in other studies , age did not affect sexual satisfaction, although SH seemed to be a little less essential to discuss for older women.
As expected, metastatic status appeared to be more associated with poorer quality of sexual life , but SH issues was as much important to discuss as for women with early BC.
In contrast to previous studies [10, 13], current oncological treatment at the time of the survey (such as chemotherapy or hormone therapy) did not appear to be associated with decreased sexual satisfaction. However, these results are only exploratory and need to be confirmed by additional studies.
Better management of SH has the potential to increase adherence to treatments [42, 43], to reduce certain symptoms such as anxiety or depression associated to BC care and to improve communication within the couple and in the family [18, 44–46], with a substantial positive effect on the daily well-being.
The first step is to inform about the consequences of the disease and its treatments on SH and provide advices on the possible remedies for the woman and the couple. Regardless of age , disease curability  and phase of treatment , early and regular support on SH must be offered to all women facing BC diagnosis and treatments, in full respect of woman’s preferences, cultural diversities and feelings .
To this purpose, health professionals should receive adequate training to discuss sexual disorders with their patients and to provide them appropriate counseling .
Our study has some limitations. First, it was conducted in a single large cancer center to which are frequently referred patients with more complex or advanced BC or at younger age, who may require a highly specialized multidisciplinary approach, so it is likely that the survey participants are not sufficiently representative of the overall population with BC. Indeed, being the majority of women in our sample highly educated, it is likely that many of them may have voluntarily addressed to a highly specialized center. However, in our study, we used wide inclusion and exclusion criteria to assess patient-care provider communication on SH in a heterogeneous population with different BC stages and treatments and coming from various geographic areas, so making our results more generalizable. Furthermore, the age structure of our sample is fairly representative of that of women with BC in France . Second, because our study was based on the response to a questionnaire that was collected only once over the BC care pathway, we were not able to assess the longitudinal evolution of sexual quality of life over treatment and follow-up and we cannot exclude a recall bias when women were asked to compare their current SH with the one before BC diagnosis. Third, we cannot use a validated questionnaire, as to our knowledge a questionnaire validated to evaluate communication on SH in patients with cancer does not exist. However, our questionnaire was created after a large literature review, piloted and reviewed by a multidisciplinary team. Finally, we were not able to precisely estimate the rate of refusal to participate as multiple channels were used to address women with BC. Indeed, we expected a higher recruitment. It was not reached probably for multiple reasons, such as the heavy emotional context faced by patients consulting for BC, the content of the survey as well as the major changes in outpatient visits due to the Covid-19 pandemic. This lower recruitment makes BEROSE study not powered for identifying factors associated to SH and likelihood of communicating on this topic.
In conclusion, SH, although recognized as central component of quality of life remains in general and in particular in the oncological field, a theme that is rarely mentioned. Our study clearly underlined that all patients, regardless of age, BC stages and ongoing treatment, are concerned about the possible impact of BC treatments on sexual function and are interested in maintaining a good sexual quality of life [24, 41].