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JOURNAL CLUB
Sexuality and Intimacy Issues
Facing Women With Breast Cancer
Carole Huber, MS, ARNP-BC, OCN®, Teresita Ramnarace, RN, BSN, RN-BC,
and Ruth McCaffrey, DNP, ARNP-BC

This article has been chosen as being particularly suitable for reading and discussion in a Journal Club format.

The following questions are posed to stimulate thoughtful critique and exchange of opinions, possibly leading
to changes on your unit. Formulate your answers as you read the article. Photocopying of this article for group
discussion purposes is permitted.
1. How does the information reviewed in this article match our experience with our own patients?
2. What is an example of a way in which we have addressed sexuality or intimacy issues with one of our patients?
3. What are some of the ways in which we assess sexuality and intimacy issues with our patients regardless of their diag-
noses?
4. In what ways can we improve those assessment techniques?
5. What resources are available to assist patients when we uncover sexuality and intimacy concerns?
6. What are some things we might do to preempt the occurrence of such problems or to prepare patients for the possibility
that they might occur?
At the end of the session, take time to recap the discussion and make plans to follow through with suggested strategies.

Purpose/Objectives: To explore the sexuality and intimacy experi- Key Points . . .

ences facing women with breast cancer.
Data Sources: Published articles; OVID, PsycINFO, and Florida
➤ Postoperative expectations for breast reconstruction following
Atlantic University databases; Web sites; and books.
Data Synthesis: Patient perceptions and knowledge of mastectomy surgery for breast cancer should be addressed preoperatively.
and chemotherapy-induced menopause in regard to lifelong sexual ex- ➤ Strong partner support aids in good sexual functioning.
periences are lacking. Healthcare providers must institute much-needed ➤ Long-term issues after diagnosis and treatment of breast can-
education and open lines of communication. cer, including early menopause, should be assessed and ad-
Conclusions: The physical and psychological results of breast cancer
dressed.
diagnosis and treatment alter human sexuality. Breast cancer’s survival
rate is at an all-time high, increasing the number of people who will be
living with such issues on a daily basis and shifting the focus from acute
care concerns to chronic disease concerns.
Implications for Nursing: Healthcare providers should assess indi-
ence that affects the mind, body, and spirit (Hordern, 2000).
vidual patients for potential issues they may face. By identifying prob- Oncology nurses are positioned to identify symptoms related
lems, they can challenge health care to focus on the long-term problems to changes in sexual function that often are neglected by other
associated with sexuality and intimacy issues facing patients. healthcare providers who may avoid the discussion of treat-
ments and outcomes associated with breast cancer diagnosis.
The purpose of this article is to explore sexuality and intimacy
issues facing women with breast cancer and the management

C
lose your eyes, and think of the seven most important
of such issues by healthcare providers.
women in your life. At least one of them will be faced
with the diagnosis of breast cancer in her lifetime
(American Cancer Society, 2005). The physical and psycho- Carole Huber, MS, ARNP-BC, OCN®, is an advanced registered
logical results of a breast cancer diagnosis can result in many nurse practitioner and Teresita Ramnarace, RN, BSN, RN-BC, is
changes in quality of life. Altered sexual functioning, feelings a nurse clinician, both at Bethesda Memorial Hospital in Boynton
of sexual inadequacy, and loss of sexual intimacy with a part- Beach, FL, and Ruth McCaffrey, DNP, ARNP-BC, is an associate
ner all are possible after a diagnosis of breast cancer. Defining professor in the Christine E. Lynn College of Nursing at Florida
human sexuality is a complex task that extends far beyond Atlantic University in Boca Raton. (Submitted December 2005. Ac-
the reach of physical sexual function, and human sexuality is cepted for publication March 24, 2006.)
conceptualized uniquely by each individual as a lived experi- Digital Object Identifier: 10.1188/06.ONF.1163-1167

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 Background and Significance breast cancer. They used search terms such as sexuality,
intimacy, breast cancer, and human sexuality. Search pa-
The devastating diagnosis of breast cancer will become reality rameters included English-only, qualitative or quantitative
for about 211,000 American women in 2006 (Susan G. Komen research articles from 2000–2005. The search identified five
Breast Cancer Foundation, 2005). The ravages that ensue from important studies.
diagnosis and treatment present tremendous challenges for
women and their partners. Sexuality and intimacy are significant Study 1
issues in the lives of patients with breast cancer (Hordern, 2000; Wimberly, Carver, Laurenceau, Harris, and Antoni (2005)
Katz, 2005; Kneece, 2003, 2004; Rogers & Kristjanson, 2002; combined the results of a cross-sectional study (examining
Wilmoth, Coleman, Smith, & Davis, 2004). Western society women with partners during a single time point during the
reveres female breasts as central to female sexual identity. The first year after surgery) with a second, longitudinal study
total or partial loss of a female breast may lead to altered self- (examining women after the first year of surgery). Scores
image and interfere in the sexual lives of the women affected from the two samples were obtained using several multi-
(Rogers & Kristjanson, 2002; Wilmoth et al.). In addition, fa- item scales.
tigue, early menopause, hot flashes, dyspareunia, mood swings, The first sample yielded 170 and the second sample 48 sub-
lowered libido, and vaginal dryness can diminish normal sexual jects, all of whom were postsurgical female patients with stage
responses and alter women’s perceptions of intimacy (Hordern; 0–II breast cancer from Miami, FL. Both samples were asked
Kneece, 2003; Wilmoth et al.). about their beliefs about their partners’ reactions to the diag-
Healthcare providers often forget or avoid discussion of sexu- nosis and treatment and the influence of those beliefs on their
ality in relation to cancer treatment. In a study of 126 women psychosexual adjustment, marital satisfaction, and emotional
who had surgical intervention with adjuvant chemotherapy, distress. Partners’ reactions were indirectly assessed through
87% claimed that they were not educated about possible sexual the women’s perceptions of how their partners reacted to them
alteration after treatment (Kneece, 2003). In addition, all of the as they tried to cope with the diagnosis of breast cancer and
women in that study had sexuality issues, but only about one- the partial or total loss of a breast.
third of them queried their healthcare providers regarding the is- The first sample described positive partner perceptions
sues. Those who did communicate about the sexual side effects during the first sexual experience after surgery (p = 0.05).
of treatment with their healthcare providers rated the handling Researchers believed that this established the presence of
of that discussion as inadequate. The results of the study show adequate psychosexual adjustment in the couples. Female
that healthcare providers need to better understand the sexuality participants who felt that their partners were not disturbed
and intimacy needs of women with breast cancer and their part- by their surgical scars during the first sexual experience after
ners. To open the lines of communication, healthcare providers surgery reported greater feelings of femininity and attractive-
must have an understanding of the importance of discussing the ness. Emotional distress was noted to be greater in the women
sexuality issues of patients with breast cancer (Hordern, 2000; who perceived their partners to be less emotionally involved.
Katz, 2005; Kneece, 2003; Schnipper, 2003). Study results showed that women feeling that their partners
Sexual dysfunction in patients with breast cancer has emo- were emotionally involved was directly correlated to higher
tional and physical variables, and each woman experiences levels of marital satisfaction, better psychosexual adjustment,
sexual dysfunction in her own unique way. Women may and less emotional distress.
become distraught over the physical disfigurement of mas- Wimberly et al. (2005) also interviewed women (N = 48)
tectomy because it alters self-image and the ability to enjoy over a one-year period after breast cancer diagnosis. Emo-
sexual stimulation after the loss of nipple sensation. Others tional involvement on the part of partners did not correlate
may be affected by chemotherapy that can change hormonal to the frequency of sexual interaction in the study. It did,
balances by inducing menopause and causing infertility. The however, relate to the women’s perceptions of their partners’
temporary effects of chemotherapy-induced alopecia, nausea, willingness to initiate sex (r = 0.75). The study confirmed
vomiting, and fatigue often contribute to inhibited sexual de- that women’s well-being was associated with a perception of
sire. In addition, painful radiation-induced dermatitis, along partners’ encouraging emotional support.
with the fatigue experienced during radiation therapy, can The researchers reached several conclusions based on the
affect desire for intimacy (Kneece, 2003, 2004). women’s perception of their partners’ beliefs. The results
For patients with breast cancer and their partners, changes clearly indicated that a partner’s emotional involvement was
in sexual and intimate relationships can be significant and life a strong predictor for a woman’s sexual, marital, and emo-
altering (Kneece, 2003). The purpose of this literature review tional adjustment after breast cancer. Another finding associ-
is to explore sexuality and intimacy issues that affect the lives ated with the study was that age negatively affected sexual
of patients with breast cancer and the healthcare response to frequency. In addition, the women reported less perceived
those patients’ needs. Five important research studies will be negativity by their partners related to surgical scars, as well
examined and described to discover more about sexuality and as an increase in partner-initiated sexual activity for patients
intimacy in patients with breast cancer. By using the results of who had undergone lumpectomy versus mastectomy (Wim-
the research, healthcare providers can become better informed berly et al., 2005).
about the communication challenges. The study findings refine the belief that women’s ability
to adjust psychosexually after breast cancer diagnosis and
Literature Review treatment is affected by their partners’ perceived acceptance.
Based on the data, healthcare providers should be involved
The authors conducted a search for relevant recent re- in discussing and counseling women and their partners about
search studies on the topic of sexuality in patients with sexuality and referring them for therapy if needed.

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Study 2 perceptions of postsurgical expectations and body self-image
Yurek, Farrar, and Anderson (2000) studied patients with preoperatively may further enlighten the research.
stage II or III breast cancer postoperatively and prior to Yurek et al. (2000) identified a need for evaluation of sexual
adjuvant therapy. They compared groups in relation to post- and body-change stress in patients who are considering recon-
operative sexuality and body-change stress. Body-change structive surgery. Assessment should include the reasons for
stress is stress as a result of changes in body structure and the choice of reconstruction and postoperative expectations.
includes situational stress and self-image disturbance. The Yurek et al. laid the foundation for healthcare providers to
study had a sample of 190 women; 78 underwent breast- discuss the benefits and risks for women considering recon-
conserving therapy or lumpectomy with lymph node biopsy, structive surgery. For women who want to feel whole again,
29 had modified radical mastectomies with reconstruction, want clothes to fit better, and want to feel that their outward
79 had modified radical mastectomies, and 4 had bilateral appearances are important, further education may be war-
mastectomies; 122 reported being preoperatively sexually ranted to give complete informed consent. Patients who are at
active. higher risk for postoperative sexual stress should be identified
Significant findings suggested that patients who under- and made aware of educational initiatives and perhaps receive
went modified radical mastectomy with reconstruction had intense preoperative and postoperative counseling.
poorer rates of sexual activity and responsiveness postop- Study 3
eratively than those who received breast-conserving therapy
or modified radical mastectomy. Data were analyzed using Wilmoth (2001) conducted a qualitative, grounded theory
multivariate statistics, analysis of covariance, and regression study to uncover the feelings and emotions surrounding sexu-
analyses. Analyses for approach and avoidance of sexual ality in women after receiving treatment for breast cancer.
behavior and activities indicated that the frequency of cur- She studied the experiences of patients with breast cancer for
rent sexual behavior was significantly lower for the women six months, 10 years after diagnosis. The sample consisted
who received modified radical mastectomy with reconstruc- of 18 women, most of whom had received adjuvant therapy;
– 39% had received breast-conserving therapy and 61% had
tion (X = 12.71) than the frequency of behavior of women
who undergone mastectomy.
– received either lumpectomy (breast-conserving – therapy,
The study focused on four areas of altered sexuality, in-
X = 18.06) or modified radical mastectomy (X = 16.57). The
breast-conserving therapy and modified radical mastectomy cluding missing parts, loss of bleeding/becoming old, loss of
groups showed statistical equivalent for sexual outcomes, sexual sensations, and loss of womanhood. Wilmoth’s (2001)
including postoperative sexual activity levels (F = 3.34, focus in the study was how the adjustment of living with a
p < 0.05), orgasm and resolution (F = 5.62, p < 0.01), and diagnosis of breast cancer brought to the surface an altered
sexual satisfaction levels (F = 4.37, p < 0.05), which indicates sexual self. The results yielded the identification of “losses”
that women treated with breast-conservation therapy reported that lead to an altered sexual self. The loss of body parts in-
significantly greater arousal throughout sexual activity than cluded the breast and alopecia. Many of the women felt that
did women treated with modified radical mastectomy; orgasm loss of a breast related to a maternal loss because their breasts
and resolution and general satisfaction results showed that nourished their children and defined them as women. Loss of
women who received breast-conserving therapy or modified sexual sensations, including breast sensation, led to changes in
radical mastectomy had significantly more indications of or- desire and orgasm and dyspareunia. Loss of womanhood was
gasm and feelings of sexual satisfaction during their current a theme that dealt with women’s inner feelings, believing that
sexual activities than did women who received modified radi- they were less of a woman and that loss of bleeding translated
cal mastectomy with reconstruction (Yurek et al., 2000). into growing old. Many women had positive changes regard-
Based on sexuality patterns of women diagnosed and sur- ing their sexuality when their partners provided reassurance
gically treated for breast cancer (breast-conserving therapy, that they still were sexually desirable.
modified radical mastectomy, and modified radical mastec- Practice implications as noted by Wilmoth (2001) included
tomy with reconstruction), the study supports that postop- the need to increase the level of emotional support offered by
erative sexual behavior is disturbed in patients who undergo healthcare providers. This was especially true when reflecting
reconstruction. This leads to the conclusion that reconstruc- on chemotherapy-induced menopausal changes, vaginal dryness,
tion offers no decrease in body-change stress in the early dyspareunia, heart disease, and osteoporosis. Wilmoth stated
postoperative period. In addition, the women who underwent that her results revealed legal and ethical obligations to open
modified radical mastectomy with or without reconstruction lines of communication, especially related to sexual health, with
reported stress changes that were, in some cases, double the women after breast cancer treatment. Wilmoth described that an
rate for those who underwent breast-conserving therapy. The altered sexual self is not an experience unique to women with
changes included situational distress and avoidance behaviors. breast cancer but that all women experience it after menopause.
Those who experienced negative self-image reported dimin- However, the problems are more evident in women with breast
ished sexual responsiveness and increased body-change stress, cancer because of the abrupt onset, morbidity, and mortality of
including sexual embarrassment and diminished arousability, cancer diagnosis and the physical disfigurement of treatment.
ultimately altering coping skills and causing disruption of
sexual relations and intercourse. The authors noted that other Study 4
factors contribute to the disruption of sexual intimacy, includ- Holmberg, Scott, Alexy, and Fife (2001) undertook a
ing the diagnosis of cancer itself, hospitalization, and the qualitative pilot study with a sample of 15 men and women to
surgical recovery period. Further evaluation of body-change examine the relationships and roles of women in regard to in-
stress at later postoperative periods may yield more informa- teraction with their partners, families, friends, and colleagues.
tion. The addition of baseline evaluations to assess patient The two foci of the study were intimacy and relationships

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with families, friends, and colleagues, but only intimacy will The study results suggested that relieving vaginal dryness
be examined in this article. may assist breast cancer survivors in improving sexual func-
The study focused on the couples’ views on the physical- tioning. In addition, discussions between healthcare providers
ity of intimate relationships and sexual functioning as they and patients about sexuality and methods to improve arousal
relate to postoperative and treatment-related changes. Body and orgasm would be beneficial to breast cancer survivors and
image and self-esteem issues included changes in physical their partners. Counseling to improve marital functioning may
features and, less importantly, sexual function. The male help strengthen relationships between breast cancer survivors
partners expressed the most concern, not about loss of sexual and their partners.
relations but about fear of potential mortality of the disease
process. Partnered women cited that they had consistent sup- Discussion
port from their partners. The findings between partnered and
unpartnered women were contrasting. Unpartnered women Research associated with sexuality and intimacy issues
were more emotionally angered and saddened, receiving little among patients with breast cancer clearly illustrates that
emotional support from former partners. This often included women and their partners may experience lifelong sexual
verbalization of a lack of sexual desirability expressed by dysfunction after diagnosis. Breast cancer survivors now face
former partners, which resulted in fear of similar responses by the challenges associated with chronic disease (Mallinger,
future partners. Holmberg et al. (2001) discussed that nega- Griggs, & Shields, 2005).
tivity in such relationships may be related to the fact that the Wimberly et al. (2005) revealed that when a sexual partner
relationships had previous problems. Women in both groups is emotionally involved, greater sexual, marital, and emotional
cited diminished sexual responses, decreased desire, fatigue, adjustments occur. The finding was reinforced in that strong
menopausal symptoms, and depression as reasons for changes partner support aided in healthier sexual outcomes (Broeckel
in sexual activity. et al., 2002; Holmberg et al., 2001; Wilmoth, 2001). Holm-
In the study, the partnered women’s perceptions of their berg et al. enhanced the theme by including the differences
mates’ responses were unchanged from their previous sexual between partnered and unpartnered women, offering a strong
encounters; however, when the men were queried, they indi- correlation between a good relationship support system and
cated that they indeed had a decrease in sexual desire. The a better outcome in sexual health. The research reinforces the
men unanimously believed that in the acute stages of diagno- findings of Wimberly et al. and Wilmoth, which stressed that
sis and treatment, sex was a frivolous issue in comparison to positive partner support was strongly correlated with better
the potential mortality of their partners. relationships and sexual adjustment and may even strengthen
Holmberg et al. (2001) provided evidence that the diag- such relationships. Furthermore, researchers concluded that
nosis of breast cancer actually may strengthen partnered unpartnered women faced greater challenges in current bad
relationships. Changes that affected relationships included the relationships, which may make strong sexual relationships
inability to discuss issues of loss, mortality, and morbidity; with future partners difficult (Holmberg et al.).
how conflicts were handled; and how femininity was viewed. The research identified that menopausal changes influenced
Unpartnered women faced greater challenges. Important find- sexual health. Depression, fatigue, vaginal dryness, lowered
ings included the necessity of open lines of communication, libido, anorgasmia, and hot flashes add to the list of issues that
encouragement of positive feminine attributes despite physical diminish sexual functioning. In addition, fears of mortality
changes, encouragement of partner support, and the need to and diagnosis of cancer itself are on the minds of men and
identify the special needs of unpartnered women. women. Total or partial breast loss and menopausal symptoms
also can alter sexual functioning and pleasure (Broeckel et al.,
Study 5 2002; Holmberg et al., 2001; Wilmoth, 2001).
A comparison study by Broeckel, Thors, Jacobsen, Small, Surprising evidence illustrated that women who under-
and Cox (2002) compared sexual functioning in long-term pa- went modified radical mastectomy with reconstruction had
tients with breast cancer to women with no history of cancer. poorer rates of sexual responsiveness and sexual activity,
The sample included 119 women: 58 with breast cancer and which produced greater sexual stress (Yurek et al., 2000).
61 who had not been diagnosed. Subjects were evaluated us- Future research is needed to confirm and explore such pos-
ing the Multidimensional Fatigue Symptom Inventory, Center sibilities.
for Epidemiologic Studies–Depression Scale, Menopausal
Symptom Checklist, and Medical Outcomes Study. Nursing Implications
The breast cancer survivors reported poorer sexual function-
ing (p < 0.01). Additional findings included diminished sexual Sexuality and intimacy are significant factors in quality of
interest, inability to relax and take pleasure in sex, difficulties life. Most treating physicians and clinicians do not address
with sexual arousal, and anorgasmia. The breast cancer sur- or are uncomfortable addressing patients about their sexual
vivors reported more fatigue (p < 0.05), greater depression, concerns after treatment. Healthcare providers often lack
increases in severity of hot flashes and vaginal dryness, and knowledge about post-treatment sexuality and sexual func-
poorer marital functioning in comparison to the noncancer tioning. To open the lines of communication, healthcare pro-
group. In relation to the potential mediators and level of sexual fessionals must develop an understanding of the importance
functioning, the results demonstrated greater sexual dysfunc- of sexuality issues for patients with breast cancer (Hordern,
tion (p < 0.05), greater fatigue (r = 0.31), greater depression 2000; Katz, 2005; Kneece, 2003; Mallinger et al., 2005;
(r = 0.27), increased hot flashes (r = 0.20), greater vaginal Schnipper, 2003). Healthcare providers must have appropri-
dryness (r = 0.36), and poorer marital functioning (r = –0.28) ate understanding of the breast cancer treatments they will
as compared to women who did not have breast cancer. deliver, ways to assess individual patients with breast cancer,

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methods to evaluate sexual relationships, and ways to open the nosis and treatment of breast cancer. A diagnosis of breast
lines of communication with their patients. Those tenets are cancer brings fears associated with morbidity and mortal-
the basis of the nursing process and of all patient education. ity. Survival rates are at an all-time high (American Cancer
Comfort can be achieved by becoming knowledgeable about Society, 2005; Susan G. Komen Breast Cancer Foundation,
the subjects at hand. 2005), but survivors now face greater challenges for the rest
Mallinger et al. (2005) suggested that patients may be un- of their lives. Research clearly indicates that strong relation-
able to verbalize their needs or understand medical informa- ships help support and heal emotional wounds, while weaker
tion, especially during the diagnosis and treatment phases. relationships tend to continue to promote discord. In addition,
Healthcare providers should openly discuss topics about patients lack knowledge about the sexual effects of cancer and
sexuality at multiple points along the care trajectory. treatment, so healthcare providers must provide much-needed
The first step in managing sexual problems is to assess education and open lines of communication (Hordern, 2000;
the problem adequately (Tan, Waldman, & Bostick, 2002). Kneece, 2003; Wilmoth, 2001).
Patients with breast cancer and their partners need to receive Healthcare providers should identify and assess individual
appropriate pharmacologic interventions, counseling, support, patients for menopausal status, partnered relationships, sexual
and guidance regarding sexual changes. Educational materials needs and desires, strength of interpersonal and intimate rela-
such as pamphlets, compact disks, videotapes, and Web sites tionships, and postoperative and post-treatment expectations.
should be offered to aid such men and women. The American They also should assess and counsel such patients from diagno-
Cancer Society offers a useful resource at www.cancer.org/ sis and beyond. Breast cancer often alters the sexual functioning
docroot/MBC/content/MBC_2_3x_Sexuality.asp. Treatment of women and their partners long after treatment is completed.
of sexual dysfunction must be individualized to the specific Healthcare professionals must recognize the psychosocial and
needs of each individual woman. physical needs of patients to address and promote healthy sexual
self-images and sexual lives for breast cancer survivors.
Conclusion Author Contact: Carole Huber, MS, ARNP-BC, OCN®, can be
The purpose of this literature review was to examine the reached at chuber@fau.edu, with copy to editor at ONFEditor@ons
sexuality and intimacy problems among women after diag- .org.

References
American Cancer Society. (2005). Cancer statistics 2005 presentation. chemotherapy-induced menopause in women with breast cancer. Cancer
Retrieved September 22, 2005, from http://www.cancer.org/docroot/PRO/ Nursing, 25, 57–65.
content/PRO_1_1_Cancer_Statistics_2005_Presentation.asp Schnipper, H.H. (2003). Life after breast cancer. Journal of Clinical Oncol-
Broeckel, J.A., Thors, C.L., Jacobsen, P.B., Small, M., & Cox, C.E. (2002). ogy, 21(9, Suppl.), 104–107.
Sexual functioning in long-term breast cancer survivors treated with Susan G. Komen Breast Cancer Foundation. (2005). Breast facts. Retrieved Sep-
adjuvant chemotherapy. Breast Cancer Research and Treatment, 75, tember 22, 2005, from http://www.komen.org/intradoc-cgi/idc_cgi_isapi.dll?
241–248. IdcService=SS_GET_PAGE&nodeId=443
Holmberg, S.K., Scott, L.L., Alexy, W., & Fife, B.L. (2001). Relationship Tan, G., Waldman, K., & Bostick, R. (2002). Psychological issues, sexuality,
issues of women with breast cancer. Cancer Nursing, 24, 53–60. and cancer. Sexuality and Disability, 20, 297–317.
Hordern, A. (2000). Intimacy and sexuality for the woman with breast cancer. Wilmoth, M.C. (2001). The aftermath of breast cancer: An altered sexual self.
Cancer Nursing, 23, 230–236. Cancer Nursing, 24, 278–286.
Katz, A. (2005). The sounds of silence: Sexuality information for cancer Wilmoth, M.C., Coleman, E.A., Smith, S.C., & Davis, C. (2004). Fatigue,
patients. Journal of Clinical Oncology, 23, 238–241. weight gain, and altered sexuality in patients with breast cancer: Explora-
Kneece, J.C. (2003). Helping your mate face breast cancer (5th ed.). Colum- tion of a symptom cluster. Oncology Nursing Forum, 31, 1069–1075.
bia, SC: Educare Publishing. Wimberly, S.R., Carver, C.S., Laurenceau, J.P., Harris, S.D., & Antoni, M.H.
Kneece, J.C. (2004). Your breast cancer treatment handbook: Your guide to (2005). Perceived partner reactions to diagnosis and treatment of breast
understanding the disease, treatments, emotions and recovery from breast cancer: Impact on psychosocial and psychosexual adjustment. Journal of
cancer. Columbia, SC: Educare Publishing. Consulting and Clinical Psychology, 73, 300–311.
Mallinger, J.B., Griggs, J.J., & Shields, C.G. (2005). Patient-centered care and Yurek, D., Farrar, W., & Anderson, B.L. (2000). Breast cancer surgery:
breast cancer survivors’ satisfaction with information. Patient Education Comparing surgical groups and determining individual differences in
and Counseling, 57, 342–349. postoperative sexuality and body change stress. Journal of Consulting and
Rogers, M., & Kristjanson, L.J. (2002). The impact on sexual functioning of Clinical Psychology, 68, 697–709.

ONCOLOGY NURSING FORUM – VOL 33, NO 6, 2006

1167