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Journal of Clinical Oncology, Vol 24, No 36 (December 20), 2006: pp. 5763-5768 © 2006 American Society of Clinical Oncology. DOI: 10.1200/JCO.2006.06.9146 Attitudes and Practices of Breast Cancer Consultations Regarding Sexual Issues: A Nationwide Survey of Japanese Surgeons
From the University of Tokyo, Tokyo, Japan Address reprint requests to Miyako Takahashi, MD, PhD, Department of Social Gerontology, School of Health Sciences and Nursing, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan; e-mail: miyako{at}m.u-tokyo.ac.jp
PURPOSE: To investigate doctors' current practices and attitudes and correlates of sexuality-related consultations in clinical encounters. METHODS: A nationwide, self-administered mail survey was conducted with 1,313 board-certified Japanese breast surgeons in August 2001. Surgeons were asked about their experiences regarding consultations about sexual issues, attitudes toward sex-related statements, and advice to a patient's hypothetical question on having sex after undergoing breast cancer treatment. RESULTS: Of the surveyed sample, 635 surgeons (50.3%) responded. Of these surgeons, 32.4% had been consulted about sexual issues by patients or families. Multiple logistic regression analysis suggested that female respondents (P < .01), respondents whose hospitals conduct a large number of breast cancer operations annually (P < .01), and respondents who agreed that "Surgeons have a professional responsibility to deal with patients' sexual issues" (P < .01) were significantly more likely to be consulted. Respondents who agreed that "If any sexual problem exists, patients will raise the topic before surgeons ask them" were less likely to be consulted (P < .05). Respondents' attitudes toward the sex-related statements showed that, although the majority recognized the importance of patients' sexuality-related concerns, they did not necessarily think that surgeons had a professional responsibility to deal with them. Regarding their advice in response to the question of "Are there any particular things to be careful about when having sex after surgery?", 32.8% answered "nothing in particular." CONCLUSION: This study shows that talking about sex-related topics is still repressed in patient–doctor encounters in Japan. It is an urgent matter to increase doctors' awareness and clinical skills to deal with patients' sexual issues.
Sexuality is being increasingly regarded as an important component in the quality of life (QOL) of people with cancer.1 As cancer treatment goals shift from mere survival to achieving better QOL, a body of scientific research has grown on the sexual impact of various cancer treatments, treatment modalities, and clinical stages.2-6 Despite research highlighting increasing awareness about cancer patients' sexuality issues, health care professionals remain relatively passive to open communication about sexual issues in clinical encounters.7 Auchincloss8 identified a number of barriers to open communication, including health care professionals' definition of their responsibilities as treatment centered; lack of information about what can be done for sexual problems; the perception that the patient is mainly concerned with having cancer, not sexual issues; and embarrassment to raise the topic. Lack of sexuality-related curricula in medical and nursing schools may also explain professionals' passiveness in bringing up the issue because questioning patients about sexual functioning is not taught as a routine part of the patient encounter.9 It is also noteworthy that most of the research on health professionals' roles in dealing with cancer patients' sexual issues have mainly focused on nurses.10-12 Nurses are often recognized as support providers for patients' sexual issues,13,14 and research focusing on medical doctors' views is extremely scarce. Because doctors are the major information source on cancer treatments and rehabilitation for patients and families, it is indispensable to investigate their current practices and attitudes so that consistent and effective care for patients can be developed using a collaborative team approach. In this study, we investigated the practices and attitudes of breast surgeons toward consultations regarding sexual issues in clinical settings. Breast cancer is rapidly increasing in Japan, and the age-adjusted incidence rate is the highest among cancers affecting Japanese women.15 This study focused on breast surgeons because, given a paucity of medical oncologists, breast surgeons in Japan most often take charge of not only surgical treatments but also chemotherapy and hormone therapy. They are most commonly the doctors with whom women with breast cancer communicate about treatment options and psychosocial distress throughout their course of treatment. The purposes of this study were to investigate Japanese breast surgeons' practices and attitudes toward consultations regarding sexual issues and to reveal the correlative factors of the likelihood of consultations regarding sexual issues of patients.
The sample of this study was breast surgeons who were board-certified members of the Japanese Breast Cancer Society. A total of 1,313 surgeons were identified, and a nationwide, self-administered mail survey was conducted in August 2001. The questionnaire consisted of three parts. First, surgeons were asked whether they had ever been consulted about sexual issues by patients or families. If they had, they were asked about the contents of the consultation in a free description format. Second, surgeons were asked about their attitudes toward seven statements regarding surgeons' responsibilities in dealing with sexual issues, comfortableness with talking about sex with patients, and so on. Answers were sought using a 5-point Likert scale, which varied from "very much agree" to "very much disagree." Third, surgeons were asked for their free description responses to a hypothetical question from a patient asking, "Are there any particular things to be careful about when having sex after surgery?" To facilitate the response rate, a thank you and reminder note was sent to all surgeons after the survey return deadline.
Descriptive statistics were collated to reveal surgeons' history of consultations about sexual issues and their attitudes toward seven sexuality-related statements. To investigate correlations between surgeons' history of consultations about sexual issues, demographic backgrounds, and their attitudes toward seven statements regarding patients' sexuality issues, univariate analysis was conducted using the
Of the surveyed sample, 635 surgeons responded (response rate, 50.3%). Table 1 lists the demographic characteristics of respondents.
History of Consultation About Sexual Issues In response to the question "Have you ever been consulted by breast cancer patients or families about sexual issues?", 206 surgeons (32.4%) answered yes. One hundred eighty-one respondents (28.5%) had been consulted by patients only, five (0.1%) had been consulted by families only, and 20 (3.1%) had been consulted by both patients and families. Table 2 lists the 10 most frequent subjects of consultations relating to sexual issues based on respondents' free descriptions. The most frequently consulted topic was related to the safety of having sex. Respondents were asked questions such as "Is it okay to have sex?" or, more directly, "Will having sex cause relapse or affect prognosis?" Another frequently mentioned concern was the safety of future pregnancy. Respondents were asked about the relationship between future pregnancy and prognosis, timing of pregnancy if it is possible, and impact of cancer treatments on fetus. Other topics included the timing of resuming sex after surgery, changes in husbands' attitudes, and painful intercourse. In the univariate analysis of correlations between the history of consultation and respondents' demographic backgrounds, surgeons who had a history of consultation were more likely to be female (P = .004) and working for a hospital that conducted a large number of breast cancer operations per year (P = .002).
Respondents' Attitudes Toward Dealing With Patients' Sexual Issues in Clinical Settings Figure 1 shows respondents' attitudes toward seven statements according to their consultation history. Regarding the statement "Surgeons have a professional responsibility to deal with patients' sexual issues," 67.7% of those who had been consulted and 55.3% of those who had never been consulted agreed very much or somewhat. Respondents who had a history of consultation were significantly more likely to agree (P = .000). Regarding the statement "If a sexual problem exists, patients will raise the topic before surgeons ask them," the percentages of those who disagreed were 48.8% and 40.6% in surgeons who had been consulted versus not consulted, respectively. Respondents who had a history of consultation were significantly more likely to disagree (P = .011). The majority of surgeons (94.0% and 85.7% of consulted v nonconsulted physicians, respectively) disagreed with the statement, "It is not the time to think about sex because the patient has a life-threatening disease." Respondents who had a history of consultation were significantly more likely to disagree (P = .000). Regarding the statement "There is no need to intervene because sex is a personal matter," 62.6% and 61.7% of consulted versus nonconsulted surgeons disagreed, respectively. Concerning the statement "I feel uncomfortable to talk about sexual issues with patients," 54.2% and 43.5% of consulted versus nonconsulted surgeons disagreed, respectively, with respondents who had a history of consultation having significantly more tendency to disagree (P = .001). The majority of respondents (85.1% and 83.6% of consulted v nonconsulted surgeons, respectively) agreed that "Reliable information on the sexual impact of breast cancer is lacking." A considerable percentage of respondents (46.7% and 40.4% of consulted v nonconsulted surgeons, respectively) agreed to the statement, "I have an interest in undertaking a basic sex counseling training."
Correlative Factors for a History of Consultation About Sexual Issues Table 3 lists the result of a multiple logistic regression analysis on the correlative factors for a history of consultation about sexual issues. The results indicate that female respondents (odds ratio [OR], 3.549; 95% CI, 1.451 to 8.685; P = .006) and respondents whose hospitals conduct a large number of breast cancer operation per year (OR, 1.211; 95% CI, 1.087 to 1.350; P = .001) were significantly more likely to be consulted about sexual issues by patients. Likewise, respondents who agreed to the statement that "Surgeons have a professional responsibility to deal with patients' sexual issues" were more likely to be consulted (OR, 1.322; 95% CI, 1.092 to 1.601; P = .004). Respondents who agreed that "If any sexual problem exists, patients will raise the topic before surgeons ask them" were less likely to be consulted (OR, 0.796; 95% CI, 0.656 to 0.966; P = .021).
Free Descriptions on the Advice Question Regarding Sex After Surgery To the question "Are there any particular things to be careful about when having sex after surgery?", 208 respondents (32.8%) answered "nothing in particular." Fifty-one respondents (8.0%) did not answer the question or wrote "Do not know." Three hundred seventy-six respondents (59.2%) suggested at least one piece of advice. The most frequently mentioned suggestions were related to contraception, followed by advice on protection of the operated breast or arm near the operation site. Those with a history of consultation had a greater tendency to suggest at least one piece of advice (P = .038).
This is the first nationwide survey in Japan on surgeons' practices and attitudes toward breast cancer patients' sexual issues. Although the study was conducted in Japan, we believe the findings provide universally valuable data on improving doctors' awareness and clinical skills to deal with cancer patients' sexual problems, given the scarcity of research regarding doctors' views. Despite the fact that the participants of this study were board-certified breast surgeons who undertake the largest role in breast cancer treatment and care, the rate of respondents who had been consulted about patients' sexual issues during their career, which spanned more than 20 years on average, was only about one third. This implies that discussing sex-related topics is still repressed in patient–doctor encounters in Japan. This may be because Japanese women are reluctant to consult doctors about sexual issues. The Global Survey of Sexual Attitudes and Behaviors, which investigated various aspects of sex and relationships among 27,500 men and women aged 40 to 80 years from 29 countries, revealed that women in East Asia were the least likely to talk to a doctor about their sexual problems (9% v 18% to 40% in non-Asian country groups), although they reported higher rates of sexual dysfunction than women in Western countries.16,17 As reasons for not consulting a doctor, East Asian women answered with much higher frequencies that "I didn't think it was a medical problem" and "I didn't think a doctor could do much for me" (80% v 35% to 58% in non-Asian country clusters).16 In our recent survey of 121 Japanese breast cancer patients, less than 10% of prediagnosis sexually active respondents had consulted friends, family, or health care professionals about sexual problems after treatment.18 Although Japanese people's beliefs regarding sexual morality have changed considerably in the period since World War II, from prioritizing men's sexual pleasure to focusing on the sexual satisfaction of both partners of the couple,19 it is obvious that strong hesitation to consult someone about sexual issues still exists among Japanese women. Women's hesitation may also be compounded by doctors' passive attitudes toward patients' sexual problems. Although a majority of respondents expressed disagreement with the statements of "It's not the time to think about sex" and "There is no need to intervene because sex is a personal issue," they did not necessarily think that surgeons had the professional responsibility to do so. This finding is consistent with another questionnaire survey of Japanese breast surgeons that revealed that they considered themselves mainly responsible for medical treatment and expected other professionals, such as psychologists and nurses, to take care of patients' sexuality- and body image–related issues.20 The first step in involving doctors in the care of patients' sexual issues would be to raise awareness among them that dealing with patients' sexual issues is a part of their professional responsibility. The multiple logistic regression analysis on the correlations with the likelihood of being consulted about sexual issues revealed several notable findings. The correlation of a surgeon's female sex implies that patients with breast cancer, who are mostly women, have lower psychological barriers when speaking to staff of the same sex. This finding is consistent with an interview study with Japanese women with breast cancer in which informants showed a strong hesitation to talk about sex-related issues such as contraception and early menopause with male surgeons and wished to get informal counseling from a health care professional of the same sex.21 Although the number of female breast surgeons is steadily increasing based on the increasing numbers of women graduating medical school22 and the increasing presence of female breast surgeons at conferences, they remain a small minority. The involvement of other health care professionals such as nurses, medical social workers, and psychologists of the same sex to facilitate the discussion of this issue and promoting awareness among medical doctors are strongly recommended. The number of breast cancer operations conducted by the respondent's hospital per year was also significantly correlated with a history of sexual consultation. It may be that the surgeons who practice in tertiary referral centers are more attuned to QOL issues in cancer patients. Or it is possible that the patients of such facilities have lower psychological barriers to discussing sexual issues with doctors because they tend to receive more information relating to treatment side effects. Surgeons' awareness of their own professional responsibility to deal with sexual issues and their awareness of patients' hesitation to raise the topic in clinical settings were also correlated with a history of sexual consultation. It is reasonable to assume that surgeons with such an awareness have an atmosphere that welcomes patients' questions and actively explore patients' psychosocial and physical concerns. Regarding the hypothetical advice on what to be careful about when having sex after surgery, nearly one third of respondents answered "nothing in particular." Because there is much evidence that breast cancer treatments inflict various sexual changes among patients,2,23 not providing any advice would lead to patient confusion if any changes occurred. It must be noted that more than 40% of respondents indicated interest in undertaking basic sex counseling training. Although we should consider a socially desirable response bias, we can suppose that this high percentage reflects doctors' interest in sex counseling training to some extent supported by the fact we received many offers after this survey to talk about cancer and sexuality at medical meetings and conferences in Japan. This study provides several notable implications for education and training interventions. First, doctors should be provided with detailed information on the sexual impact of cancer treatments, information on concrete measures available such as a lubricant jelly, and written information on dealing with problems. It is possible that health care professionals tend to avoid discussing sexual issues to prevent uncovering issues with which they feel unable to handle.13 Therefore, doctors need to be informed that they do not need to be experts in sex counseling but that small interventions, such as providing patients with information brochures or brief sex counseling, can make a difference in addressing patients' sexual issues.24,25 Second, patients' psychological resistance to raise sex-related topics should be emphasized to doctors. Although doctors often fear upsetting patients by raising sexual issues, Gott et al26 state that doctors' decisions to raise the topic are influenced their perception that sex is difficult and potentially offensive to address, rather than direct personal experience supporting this belief. Therefore, doctors need to be encouraged to include information on treatment-induced sexual changes as a part of routine information giving throughout the treatment process. If appropriately trained, doctors would be able to support patients and their partners to explore sex that is enjoyable to both of them. In the last 5 years since this survey was conducted, conferences and academic journals for doctors in Japan have come to take up the issue of cancer and sexuality. However, the 1-day educational workshops on cancer and sexuality for health care professionals, organized by the authors since 2003, have attracted only 19 medical doctors among 128 participants, who were mainly nurses. Doctors seem to remain less proactive compared with nurses in dealing with cancer patients' sexual issues. We believe that the results of this research are as relevant today as they would have been 5 years ago in bridging the gap between doctors' attitudes and their actual practices toward cancer patients' sexual problems. This study has a number of limitations. First, because the sample was board-certified breast surgeons, the results may not reflect the opinions of all surgeons in Japan. In nonurban areas, general surgeons not specialized in breast cancer undertake breast cancer operations and follow-up care. Second, although the response rate (50.3%) was quite high for a survey of medical doctors, surgeons who did not respond may be even more passive toward dealing with patients' sexual issues; thus, our findings may be an underestimation of the actual situation. Third, because this study is a cross-sectional survey, we cannot conclude a causal relationship between a history of sexual consultation and correlative factors. Despite these limitations, we believe that the findings of this study have universal application in breast cancer research and practice because our finding that surgeons hold ranging passive attitudes in dealing with patients' sexual issues probably exists in a number of countries. This is supported by the findings from the Global Survey of Sexual Attitudes and Behaviors, which revealed that, although 41% of all women respondents worldwide answered that a doctor should routinely ask patients about their sexual function, only 9% had actually been asked about possible sexual difficulties in the past 3 years.16 Further research is needed on the factors that influence medical doctors' attitudes toward cancer patients' sexuality and on effective ways to promote doctors' awareness about their professional responsibility to provide quality care for patients with sexual problems. To provide consistent and collaborative care, the importance of increasing doctors' awareness and clinical skills to deal with cancer patients' sexual issues cannot be overemphasized.
The authors indicated no potential conflicts of interest.
We thank the surgeons who participated in this survey. We also thank Jane Koerner (University of Tokyo, Tokyo, Japan) for her comments on earlier drafts of this article and Chie Watanabe and Maki Taniyama (University of Tokyo) for their technical support.
Supported by Japan Society for the Promotion of Science Grant-in-Aid (C) (KAKENHI) No. 12672186 for Scientific Research. Authors' disclosures of potential conflicts of interest and author contributions are found at the end of this article.
1. Andersen BL: Sexual functioning morbidity among cancer survivors: Current status and future research directions. Cancer 55:1835-1842, 1985[CrossRef][Medline] 2. Ganz PA, Rowland JH, Desmond K, et al: Life after breast cancer: Understanding women's health-related quality of life and sexual functioning. J Clin Oncol 16:501-514, 1998[Abstract] 3. Tuinman MA, Fleer J, Sleijfer DT, et al: Marital and sexual satisfaction in testicular cancer survivors and their spouses. Support Care Cancer 13:540-548, 2005[CrossRef][Medline] 4. Monga U, Tan G, Ostermann H, et al: Sexuality in head and neck cancer patients. Arch Phys Med Rehabil 78:298-304, 1997[CrossRef][Medline] 5. Shell JA, Miller ME: The cancer amputee and sexuality. Orthop Nurs 18:53-64, 1999[Medline] 6. Lemieux L, Kaiser S, Pereira J, et al: Sexuality in palliative care: Patient perspective. Palliat Med 18:630-637, 2004 7. Kaplan HS: A neglected issue: The sexual side effects of current treatment for breast cancer. J Sex Marital Ther 18:3-19, 1992[Medline] 8. Auchincloss S: Sexual dysfunction in cancer patients: Issues in evaluation and treatment, in Holland JC, Rawland JH (eds): Handbook of Psychooncology. New York, NY, Oxford University Press, 1990, pp 383-413 9. Kats A: The sound of silence: Sexuality information for cancer patients. J Clin Oncol 23:238-241, 2005 10. Johnson BK: Prostate cancer and sexuality: Implications for nursing. Geriatr Nurs 25:341-346, 2004[CrossRef][Medline] 11. Wilmoth MC, Spinelli A: Sexual implications of gynecologic cancer treatments. J Obstet Gynecol Neonatal Nurs 29:413-421, 2000[CrossRef][Medline] 12. Maughan K, Clarke C: The effect of a clinical nurse specialist in gynaecological oncology on quality of life and sexuality. J Clin Nurs 10:221-229, 2001[Medline] 13. Stead M, Brown J, Fallowfield L, et al: Lack of communication between healthcare professionals and women with ovarian cancer about sexual issues. Br J Cancer 88:666-671, 2003[CrossRef][Medline] 14. Meerabeau L: The management of embarrassment and sexuality in health care. J Adv Nurs 29:1507-1513, 1999[CrossRef][Medline] 15. The Research Group for Population-Based Cancer Registration in Japan: Cancer incidence and incidence rates in Japan in 1994: Estimates based on data from seven population-based cancer registries. Jpn J Clin Oncol 29:361-364, 1999 16. Moreira ED, Brook G, Glasser DB, et al: Help-seeking behaviour for sexual problems: The Global Study of Sexual Attitudes and Behaviors. Int J Clin Pract 59:6-16, 2005[Medline] 17. Laumann EO, Nicolosi A, Glasser DB, et al: Sexual problems among women and men aged 40-80 y: Prevalence and correlates identified in the Global Study of Sexual Attitudes and Behaviours. Int J Impot Res 17:39-57, 2005[CrossRef][Medline] 18. Takahashi M, Abiru K, Ohshima A et al: Influence of having breast cancer on women's sexuality: A questionnaire survey of out-patients. Presented at the 14th Annual Meeting of the Japanese Breast Cancer Society, Kanazawa, Japan, July 7, 2006 19. Sexuality Research Team of The Japan Society for Sexual Science: Body and Emotion: A Survey of 1000 Japanese Aged Between 40-70 Years Old About Their Sexuality. [Japanese] Tokyo, Japan, Sangokan, 2002 20. Takahashi M, Kai I, Akabayashi A, et al: Who should meet the needs of breast cancer patients? A questionnaire survey of Japanese surgeon. Jpn J Breast Cancer 14:495-502, 1999 21. Takahashi M, Kai I: Sexuality after breast cancer treatment: Changes and coping strategies among Japanese survivors. Soc Sci Med 61:1278-1290, 2005[CrossRef][Medline] 22. Ministry of Health, Labour and Welfare: Survey on Physicians, Dentists and Pharmacists 2003, 2005. Tokyo, Japan, Ministry of Health, Labour and Welfare, 2005 23. Ganz PA, Greendale GA, Petersen L, et al: Breast cancer in younger women: Reproductive and late health effects of treatment. J Clin Oncol 21:4184-4193, 2003 24. Annon JS: The PLISSIT model: A proposed conceptual scheme for the behavioral treatment of sexual problems. J Sex Educ Ther 2:1-15, 1976[Medline] 25. Schover LR: Counseling cancer patients about changes in sexual function. Oncology (Williston Park) 13:1585-1591, 1999[Medline] 26. Gott M, Hinchliff S, Galena E: General practitioner attitudes to discussing sexual health issues with older people. Soc Sci Med 58:2093-2103, 2004[CrossRef][Medline] Submitted April 6, 2006; accepted September 29, 2006.
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Copyright © 2006 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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ABSTRACT
INTRODUCTION
2 test, Student's t test, and Mann-Whitney test as appropriate. Then, multiple logistic regression analysis was conducted to identify the correlative factors for a history of consultation about sexual issues using the variables that significantly correlated in the univariate analysis. All reported P values were two tailed, and all data analyses were conducted using the SPSS statistical software package (SPSS 13.0J; SPSS Japan Inc, Tokyo, Japan). The free descriptions were analyzed by the principal investigator and an assisting researcher who independently read the descriptions and categorized the answers into topic groups. The two researchers compared and discussed their analysis until they reached consensus. 
