Mancha et al. Health and Quality of Life Outcomes (2019) 17:143 https://doi.org/10.1186/s12955-019-1197-7 RESEARCH Open Access Development and validation of a sexual relations satisfaction scale in patients with breast cancer — “SEXSAT-Q” Rosario González Mancha1, Montserrat Muñoz2, Luis de la Cruz-Merino3, Lourdes Calvo4, Josefina Cruz5, Jose Manuel Baena-Cañada6, Yolanda Fernandez7, Manuel Ramos8, Cesar Augusto Rodriguez9, Jose Ignacio Chacón10, Isabel Palomero11, Julia Llinares12, María Rivero12* and Miguel Ángel Ruiz13 Abstract Purpose: Because the currently available questionnaires to evaluate sexual changes on breast cancer women only address the sexual sphere with a few questions our purpose was to develop a questionnaire that assesses changes in sexual dysfunction and satisfaction in women treated for breast cancer. Methods: A sample was selected of women aged between 18 and 65 who had had surgery for breast cancer, completed neoadjuvant/adjuvant chemotherapy treatment and could be receiving adjuvant hormonal treatment, with an active sex life at least 3 months before starting treatment. Metastatic disease was excluded. A questionnaire structured in 4 dimensions was developed. The MOS SF-12 and QLQ-BR23 questionnaires were also provided. The following metric properties were evaluated: item analysis; internal consistency; temporal stability; construct validity; concurrent, convergent and divergent validity; and feasibility. Results: Three samples were recruited: a pilot sample of 20; a reduction sample of 152; and a validation sample of 148. The presence of 6 dimensions was confirmed: 1) Loss of sex drive; 2) worsening of body image; 3) psychological coping; 4) discomfort during intercourse; 5) satisfaction with sexual relations; and 6) satisfaction with breast reconstruction. Good goodness-of-fit statistics were obtained (χ2/df = 1.5, GFI = 0.9, AGFI = 0.84, CFI = 0.959, RMSEA = 0.062). Reliability was good (α = 0.855), as was test–retest stability (r = 0.838). The correlation with the convergent questionnaires proved to be higher than that obtained with generic measurements. Conclusions: We were able to develop a short questionnaire (17 items) capable of measuring sexual satisfaction in women with breast cancer with good metric properties. Keywords: Breast, Cancer, Sexual, Satisfaction, Dysfunction, Questionnaire Introduction the disease itself, and find it both hard to accept and dif- Being diagnosed with cancer brings changes to an indi- ficult to discuss in the clinic. Moreover, the doctor often vidual’s personal, family, social, professional and finan- devotes little time to asking about changes experienced cial life and to their sexual relations with their partner in sexuality. [1]. In addition, a person’s body image can be altered by In view of the above we decided that breast cancer some surgical treatments which mainly affect an individ- would be an appropriate disease in which to conduct a ual’s psychological and sexual sphere [2, 3]. This situ- study on sexual dysfunction, owing to its high incidence ation can be made even worse by extended courses of and variability of age, geographic location, level of edu- treatment. Most patients feel an additional loss, beyond cation, etc. [4, 5]. The aim of this study was to develop and validate an understandable and easy to complete * Correspondence: maria.rivero@pfizer.com questionnaire (“Sexual Satisfaction Questionnaire” (SEX- 12 Laboratorios Pfizer España, Avenida de Europa, 20 – B- Parque Empresarial SAT-Q)), which covered the issues of concern of the pa- La Moraleja, 28108 Alcobendas (Madrid), Spain tients and was capable of distinguishing what their main Full list of author information is available at the end of the article © The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Mancha et al. Health and Quality of Life Outcomes (2019) 17:143 Page 2 of 9 problem was for use in the Spanish population of inclusion criteria. There were 4 samples; a pilot sample women with breast cancer (Additional file 1: Sexual Sat- with 20 patients enrolled; a reduction sample with 156 isfaction Questionnaire). The currently available ques- patients enrolled; a validation sample with 148 patients tionnaires are quite limited and only address the sexual and a sub-sample of 61 patients at the re-test sample. sphere with a few questions and with no questions ex- The pilot sample consisted of 20 patients recruited in ploring sexual satisfaction [6, 7]. a randomized manner by the participating researchers. In 2016 a meta-analysis was published that includes a This sample was used to detect problems in understand- systematic review of published studies addressing the ing and/or reading the suggested questions and to col- sexual dysfunction in women with various cancer types lect comments from patients. Only 3 sites participated in (endometrial cancer, cervical cancer, vulvar cancer, the recruitment of the pilot sample (Virgen del Rocio, breast cancer, etc.) using a validated diagnostic tool. In Virgen de la Macarena, Clinic i Provincial). For the re- this meta-analysis, eleven studies referred to breast can- duction sample, 156 patients who fulfilled selection cri- cer were included [8]. The authors concluded that teria were included. In this sample a wider questionnaire women with cancer showed low index scores with a high was delivered allowing to eliminate the questions that prevalence of sexual dysfunction. were not understood as relevant or that did not dis- In the general population, a questionnaire was devel- criminate the samples. This selection was random and oped to assess women sexual function suggesting im- sequential, covering the pre-determined quotas. In the portant gender differences in the patterning of female recruitment of this sample all sites participated. The sexual function in comparison with similar questionnaire validation sample consisted of 148 additional patients. studies in males [9]. This sample completed the Case Report Form (CRF) Although breast cancer is the most frequent cancer in that included: the reduced questionnaire, the valid- women and the second most common cancer in the world ation questionnaires, and the clinical evaluation of the (25% of all cancers) [10]. A specific questionnaire that mea- responsible researcher. All sites participated in the re- sures changes in sexual dysfunction and satisfaction in these cruitment of the reduction sample. The reduced ques- women treated for breast cancer has not been developed. tionnaire was provided for a second time to a subsample of 61 patients with an allowed time win- Patients and methods dow from 1 week to 15 days to check the temporary Patients stability of the measurements without mediating Between October 2009 and July 2011 we enrolled female changes in the clinical intervention. outpatients with breast cancer, aged between 18 and 65, with active sex lives at least 3 months before starting treatment, who could had undergone conservative sur- Methodology gery or mastectomy with or without immediate or de- We designed an observational, cross-sectional, multicen- layed reconstruction. They had completed neoadjuvant/ tre study performed along routine clinical practice there- adjuvant chemotherapy at least 3 months and up to 3 fore, without interfering with the patients’ regular years beforehand and they were allowed to be receiving treatment. The study was developed by 11 Spanish hormone treatment. Women who were exclusively re- Breast Cancer Oncologists in 11 Spanish sites. Every ceiving adjuvant hormonal therapy had completed at physician selected a sample of patients that met the in- least one year and no more than 3 years of treatment. clusion criteria in their daily clinical practice. The study The patients had to be able to understand and answer was supervised by a panel of experts made up of 3 clin- the study questionnaires. Patients with metastatic disease ical investigators and one methodologist and approved were excluded. All of the patients signed the informed by the ethics committees of all the participating sites. consent form. Every patient received information about the objective of Patients were analysed by, time since last period on the study, the expected benefits and the voluntary nature enrolment in the study, regardless of age, ovarian reserve of the study, and gave its informed consent prior to their and whether or not they were receiving hormone treat- inclusion. ment. We defined as postmenopausal women with 12 or We extracted written testimonies provided by patients more months of amenorrhoea, perimenopausal women with breast cancer and compiled the experience of the with less than 12 months of amenorrhoea and premeno- investigators in their clinical practice to identify the di- pausal women who continued to have normal menses. mensions and items to be included in the questionnaire In each participating centre, the researcher performed and 4 dimensions of interest were identified: 1) Sexual a random probabilistic sampling by sequential recruit- dysfunction; 2) Dissatisfaction with self-image; 3) Anx- ment according to the attention demand among those iety generated by the treatment; and 4) Overall rating of patients who come to consultation and meet the quality of sexual activity. Mancha et al. Health and Quality of Life Outcomes (2019) 17:143 Page 3 of 9 The study involved 4 phases Instruments Pilot sample, to check item legibility and comprehensibility Perceived health status visual analogue scale Reduction of the Questionnaire, to check whether the pa- A visual analogue scale included in the EuroQol ques- tients’ responses were in line with the structure pro- tionnaire to assess the patient’s current health status posed, to assess the metric properties of the items and [22]. The scale is graduated and marked at intervals of to reduce the questionnaire. ten, running from 0 (worst imaginable health status) to The reduction of the questionnaire and the determin- 100 (best imaginable health status). ation of the dimensions were accomplished through a sequence of exploratory factor analyses and an internal Quality of life consistency analysis. Principal Components and Princi- Spanish version of the generic SF-12 quality of life ques- pal axis were used; and Varimax (orthogonal) and Obli- tionnaire validated in Spain [23–25]. This questionnaire min (oblique) rotations were performed. K1 rule [11, is self-administered with supervision and has 12 items 12], percentage of explained variance and size of the ei- and two summary components: physical health and genvalues after rotation [13] were studied to deter- mental health. mine the number of factors given the known behaviour to underestimate or overestimate the cor- Cancer-specific quality of life questionnaire rect number of factors [14]. Internal consistency was Spanish version of the EORTC QLQ- BR-23 cancer-spe- assessed using Cronbach’s alpha and alpha change cific quality-of-life questionnaire [26]. This questionnaire when removing items. has 23 items that measure 5 dimensions: side effects of The questionnaire’s length was reduced following Gor- therapy; arm symptoms; breast symptoms; body image; such and Russell proposals [15–17]. Firstly, items with a and sexual functioning. It also has 2 items assessing clear floor or ceiling effect (more than 50% of responses sexuality and future perspective. in the first or last response categories) were discarded. Next, an exploratory factor analysis was conducted with Results the 26 items of the scale to determine the number of Pilot sample underlying factors. Lastly, the dimensionality and in- All patients completed the questionnaire properly and ternal consistency [18] of each subscale was analysed, as- the average response time was 5 min 40s. Compiled suming unidimensionality. comments referred to font size, difficulties in properly Validation; including the questionnaire in a case re- interpreting time from disease diagnosis and relevance port form together with relevant clinical information, of questions related to reconstructive surgery. A ques- socio-demographic information and additional instru- tion relating satisfaction with current sexual relations ments: MOS SF-12, QLQ-BR23, and EuroQol visual was added, leading to the long version of the question- analogue scale. naire with 24 questions. Re-test sample: 61 patients who completed the reduced questionnaire a second time a week later to estimate Reduction of the questionnaire test–retest reliability. The reduction sample was composed of 152 assessable The following metric properties were studied: (1) women (see Table 1). feasibility: administration time, floor and ceiling ef- The questionnaire was well understood and accepted fects, and percentage of missing values for each item; by patients. Most of the questions showed no ceiling or (2) reliability: internal consistency [19] and item- floor effects. Overall, 84% of patients thought that the total correlation; test–retest reliability (Pearson cor- questionnaire was suitable or very suitable for assessing relation) and intraclass correlation coefficient [20]; their personal situation. (3) content validity: this was ensured by the expert The exploratory factor analysis resulted in a 5-di- group and by consultation with the patients; (4) con- mensional solution, accounting for 71% of available struct validity: Confirmatory factor analysis was ap- variance (see Table 2): 1) loss of sex drive; 2) worsen- plied; (5) concurrent validity: SEXSAT-Q scores were ing of body image; 3) psychological coping; 4) dis- correlated with SF-12, QLQ-BR23, and EuroQol comfort during intercourse; and 5) satisfaction with VAS; (6) discriminant validity: items were assessed sexual relations. to discriminate between patients in Q1 and Q4. The Reliability statistics for the full scale were good, α = following goodness-of-fit criteria were used [21]: χ2 0.871 (Table 3). Three dimensions obtained high values: (p > 0.05), χ2/df ≤ 2, GFI ≥ 0.9, AGFI> 0.9, CFI > 0.9, effects of menopause, body image and psychological RMSEA< 0.08). coping. The discomfort during sex dimension showed All the statistical analyses were carried out using IBM modest reliability and ended up with 2 items. The satis- SPSS 20 and AMOS 20 software. faction with sexual relations dimension had higher Mancha et al. Health and Quality of Life Outcomes (2019) 17:143 Page 4 of 9 Table 1 Socio-demographic description of the reduction and and a good fit was obtained (χ2 = 101.5, df = 67; p = validation samples 0.004, χ2/df = 1.5, GFI = 0.9, AGFI = 0.84, CFI = 0.959, Reduction Sample Validation RMSEA = 0.062). All the dimensions of the question- N = 152 Sample naire proved to be closely interrelated, except for the N = 148 more psychological dimensions. Age (years): Mean (SD) 49.5 (7.8) 47.9 (8.4) Reliability statistics for the full scale were good, with Studies (%) α = 0.855 (not including the items referring to recon- Primary 39.1 28.9 struction) and test–retest r = 0.838. Dimension reliabil- Secondary 31.1 33.8 ities ranged from α = 0.517 to α = 0.876, with better Graduate 29.8 37.3 test–retest stability (r = 0.762 to r = 0.868). Correlations of the total score with other concurrent Actual couple: Yes (%) 98.7 97.9 measurements were moderate with the SF-12 physical Relationship (years): Mean (SD) 23.7 (11.5) 24.1 (10.2) component and mental component. Correlation with the Contraceptive: Yes (%) 31.3 46.9 EQ-5D VAS was somewhat higher and the highest cor- Climacteric stage (%) relation was with the QLQ-BR23 (Table 4). Correlations Pre-menopause 12.6 25.3 of the three sexual relations items in the QLQ-BR23 and Perimenopause 14.6 14.4 the satisfaction with sexual relations dimension was r = 0.715 and with Loss of sex drive r = − 0.632. Post-menopause 72.8 60.3 The mean observed total score was 61.0, which Breast-Conserving Surgery (%) 58.3 was relatively high compared to the average score on Mastectomy (%) 42.9 the metric and the distribution of the scores had a Severity (%) slight negative skew. Table 5 shows the algorithm Stage I 47.3 for calculating the scores in the dimensions along Stage II 42.5 with the mean score and standard deviation for each dimension. Stage III 9.5 Comparing the mean scores on the dimensions, di- Adjuvant Chemotherapy (%) 85.5 mension 3 (satisfaction with body image) showed a sig- Duration (month): Mean (SD) 5 (2.87) nificantly higher mean than the other dimensions. By Adjuvant Hormonotherapy (%) 82.6 contrast, the lowest means were obtained in dimension Duration (month); Mean (SD) 50.4 (NR) 1 (satisfaction with sexual relations) which were not sig- Complementary Radiotherapy (%) 81.5 nificantly different from each other, nor were they sig- nificantly different from the average on dimension 4. When the satisfaction with breast reconstruction dimen- reliability, but also did not reach a value of 0.7. The scale sion, is considered for the patients to whom it applies, referring to breast reconstruction was only relevant for the average level of satisfaction is the lowest of all the 20 patients. dimensions. The final questionnaire was made up of 17 items orga- nised into 6 dimensions. The reconstruction dimension Discussion was separated from the others. Although there are quality-of-life questionnaires for can- cer patients (EORTC-QLQ-BR23) containing the odd Validation question relating to sexuality or self-image, no question- The validation sample consisted of 148 patients (see naire has been developed to date that focuses entirely on Table 1). this subject. The inclusion of questions concerning pa- Blank responses did not exceed 4%. None of the items tients’ sexuality in the above questionnaires points to the showed a floor or ceiling effect except items 4 and 8, importance of this issue as an integral part of health-re- with 54 and 62% of responses in the lower category, re- lated quality of life. spectively (see Fig. 1 showing the mean scores for each Analysis of the dimensionality of the scale detected 5 item). interrelated dimensions referring to: effects of meno- Items that did not distinguishing between Q1 and Q4 pause; body image; psychological coping with the dis- groups were item 1 (it was left as a comparison for ques- ease; discomfort during intercourse; and satisfaction tions 10 and 14) and item 15 (the effective sample size with sexual intercourse; plus a sixth dimension on satis- for it was very small). faction with breast reconstruction. Confirmatory factor analysis attained a stable solution In both reduction and validation phases the questions (Fig. 2), with all parameters being statistically significant, concerning reconstruction was only relevant for those Mancha et al. Health and Quality of Life Outcomes (2019) 17:143 Page 5 of 9 Table 2 Exploratory factor analysis estimated factor loadings (each dimension isolated) Factor 1 2 3 4 5 6 Q1. Sexual relations satisfactory before 0.566 Q10. Sexual relations satisfactory during tx 0.850 Q14. Sexual relations satisfactory currently 0.860 Q11. Sex life has been pushed into the background 0.824 Q12. Decreased sex drive since diag. 0.908 Q13. I have more trouble reaching orgasm since diag. 0.899 Q7. Embarrassed to show my body 0.761 Q8. I have trouble looking in the mirror and accepting myself 0.525 Q9. My body image has worsened 0.751 Q2. Distressed since diagnosis 0.796 Q3. Depressed since tx 0.812 Q6. More tired than before 0.800 Q4. Fear of pain during sex 0.838 Q5. Pain owing to vaginal dryness 0.838 Q22. Satisfaction with surgery .772 Q23. Surgery improved sexual relations .845 Q24. Trust Surgery will improve sexual relations .878 First Eigenvalue 1.783 2.312 1.825 1.93 1.403 2.081 Accounted Variance (%) 59.44 77.07 60.82 64.44 70.17 69.67 patients it applied to. This dimension needs to be taken The reliability of the total scale was good (α = 0.855), into account separately. For this reason, we have pro- indicating that it is possible to obtain sufficiently accur- vided two methods of correction (Table 5) for patients ate measurements from the construct. who have had or not reconstruction. With respect to validation with other scales, our scale In the confirmatory analysis of the dimensionality of the correlated significantly with the QLQ-BR23 specific scale, 5 interrelated dimensions were again identified, re- quality-of-life scale and to a somewhat lesser degree with ferred to satisfaction with sexual relations: decreased sex the EuroQoL generic quality-of-life scale and the phys- drive; body image; psychological coping with the disease; ical and mental components of health status on the SF- discomfort during intercourse; and discomfort during sex- 12. While correlations with sexual relations items in the ual relations. Furthermore, a 6th dimension on satisfaction QLQ-BR23 were high and significant. Therefore, we may with breast reconstruction was maintained. affirm that our scale is found to be related to patients’ Table 3 Reliability Cronbach’s Cronbach’s 95% ICC Test– Items α α Retest Lower Upper Reduction Validation r Satisfaction with sexual relations 0.659 0.711 0.619 0.784 0.862 3 Loss of sex drive 0.801 0.876 0.836 0.908 0.781 3 Body image 0.861 0.856 0.810 0.892 0.808 3 Psychological coping 0.840 0.774 0.701 0.831 0.762 3 Discomfort during intercourse 0.553 0.517 0.328 0.654 0.868 2 a Reconstruction 0.772 0.701 0.371 0.873 3 Full scale 0.871 0.855 0.816 0.889 0.838 14 a Not available Mancha et al. Health and Quality of Life Outcomes (2019) 17:143 Page 6 of 9 Fig. 1 Average score on the questionnaire questions (Minimum = 0, Maximum = 4). The higher the score, the higher the satisfaction Fig. 2 Confirmatory factor analysis maximum likelihood estimates. Note: Boxes represent observed variables and circles un-observed error variables. One-headed lines represent regression effects and the values above them, raw estimated regression weights, two-headed arrows represent correlations between latent variables. Values above exogenous variables represent variances Mancha et al. Health and Quality of Life Outcomes (2019) 17:143 Page 7 of 9 Table 4 Observed correlation with other concurrent validation scales Scale Sex. Sat. SF-12 PC SF-12 MC VAS EQ-5D QLQ-BR23 Sexual satisfaction — Total 1 SF-12 Physical Component −0.387 1 SF-12 Mental Component −0.407 0.114† 1 VAS EQ-5D −0.526 0.546 0.542 1 QLQ-BR23 total 0.608 −0.432 −0.535 −0.622 1 All correlations p < 0.001. † Not significant (p = 0.177) quality of life but is found to measure aspects somewhat of these women based on this scale, or in determining if different to quality of life itself. a new drug has a negative impact in sexual life compar- Clinically, satisfaction scores are quite high, with an ing to the standard treatment in a head-to-head trial. average exceeding the midpoint of the metric (63 out of Further research is needed in order to assess the relation 100). The dimension on which the least satisfaction was of sexual satisfaction with important mental health indi- expressed was the one on breast reconstruction, although cators (such as anxiety, depression, anger and hostility), this dimension was only relevant for 14% of the sample. along with their forecasting capabilities in predicting The outcomes and survival of women with breast cancer treatment acceptability and the possible need of psycho- have experienced a significant improvement in the last logical support or additional treatment. years comparing to the past decades [27]. This is related This questionnaire to date is the only one published to the greater life expectancy and the development of new that focuses on sexual relations satisfaction exclusively personalized therapies that improve the quality of life of in breast cancer patients. It can be employed as an easy these patients [28]. Nowadays women with breast cancer tool for physicians to facilitate the communications live longer and better, but to date the assessment of their about sexuality satisfaction between the oncologists and sexual life has not been integrated into the decision mak- breast cancer female patients, integrating this dimension ing of therapeutic algorithms although it has demon- as an important part of the health-related quality of life strated to impact in their quality of life [29]. of these women. An important limitation of the study is This specific sexual satisfaction questionnaire in breast the limited sample size. The questionnaire should be val- cancer is an easy tool for physicians that could facilitate idated in a larger sample to obtain additional informa- the communications between the oncologists and breast tion that could make comparisons between the cancer female patients and could help in the election of individual treatments and other aspects that could be re- the most suitable treatment for each woman (Additional lated to sexual satisfaction in this population. Aspects as file 1: Sexual Satisfaction Questionnaire). sexual orientation or decrease of frequency of relation- The advances in cancer management are directed to- ships were not included in the questionnaire, and could wards the personalized medicine that tries to attend all be also affected by the disease. the spheres of the disease including the sexual life. The The validation process has been limited to ensure con- integration of this questionnaire into the decision mak- cept and structural validity. More evidences are planned to ing process is a topic of increasing interest and could be gathered about sensitivity to change, predictive validity orientate the design of future clinical trials. It could be and known groups validity. Sexual satisfaction is conceived of great interest to compare the impact that two thera- as very important sphere of personal, social and family peutic approaches have in the sexual life and satisfaction roles, but it is also true that this importance varies with age, Table 5 SEXSAT scoring algorithm, number of items and descriptive statistics by dimension Dimension Shorthand items Scoring Algorithm Mean SD Satisfaction with sexual relations SR 3 SR = (X1 + X10 + X14) × 8.33 56.6 23.7 Loss of sex drive SDr 3 SDr = 100 – (X11 + X12 + X13) × 8.33 51.1 34.4 Body image BI 3 BI = 100 – (X7 + X8 + X9) × 8.33 76.8 27.3 Psychological coping PCo 3 PCo = 100 – (X2 + X3 + X6) × 8.33 59.4 26.7 Discomfort during intercourse DI 2 DI = 100 – (X4 + X5) × 12.5 66.5 30.2 Reconstruction RE 3 RE = (X15 + X16 + X17) × 8.33 53.7 29.0 Full scale TOT 17 TOT = (SR + SDr + BI + PCo + DI + RE) / 6 59.0 21.5 Full scale without reconstruction TOT2 14 TOT2 = (SR + SDr + BI + PCo + DI) / 5 62.0 20.0 Note: The higher the score, the higher the quality of life. SD standard deviation Mancha et al. Health and Quality of Life Outcomes (2019) 17:143 Page 8 of 9 and it could even become meaningless in the elder age. Ethics approval and consent to participate From the perspective of construct validity, it would be in- The study was approved by the autonomic ethics committee for clinical trials of Andalucía (Hospital Virgen del Rocio 07/2009) and by all of the teresting to study at what point of personal ontogenetic de- participating sites. All the patients signed the informed consent form. velopment sexual satisfaction becomes trivial. Consent for publication Not applicable. Conclusions The obtained results show that this instrument may be Competing interests used on a day-to-day basis to determine the level of sat- MRS and JLL are employees of Pfizer S.L.U. MAR has received Research isfaction with their sexual relations of patients with Funding/Contracted Research from Pfizer. All remaining authors have declared no conflicts of interest. breast cancer in regular medical practice, and it might even help differentiate treatments in terms of how they Author details 1 affect this satisfaction dimension. Medical Oncology Department, Hospital Universitario Virgen del Rocío, Seville, Spain. 2Medical Oncology Department, Hospital Universitario Clínic Therefore we may conclude that the SEXSAT-Q ques- —, Barcelona, Spain. 3Medical Oncology Department, Hospital Universitario tionnaire is an instrument capable of measuring sexual Virgen de la Macarena, Seville, Spain. 4Medical Oncology Department, satisfaction in patients with breast cancer through the Complejo Hospitalario Universitarios A Coruña (CHUAC), A Coruña, Spain. 5 Medical Oncology Department, Hospital Universitario de Canarias, Santa assessment of 5 dimensions: 1) Loss of sex drive; 2) Cruz de Tenerife, Spain. 6Medical Oncology Department, Hospital Puerta del worsening of body image; 3) psychological coping; 4) Mar, Cádiz, Spain. 7Medical Oncology Department, Hospital Universitario discomfort during intercourse; 5) satisfaction with sexual Central de Asturias, Oviedo, Spain. 8Medical Oncology Department, Centro Oncológico de Galicia, A Coruña, Spain. 9Medical Oncology Department, relations; plus an additional dimension on satisfaction Hospital Clínico Universitario de Salamanca — IBSAL, Salamanca, Spain. with breast reconstruction (Additional file 1: Sexual Sat- 10 Medical Oncology Department, Hospital Universitario Virgen de la Salud, isfaction Questionnaire). Toledo, Spain. 11Medical Oncology Department, Hospital Universitario Gregorio Marañón, Madrid, Spain. 12Laboratorios Pfizer España, Avenida de We need to gather a larger sample to obtain additional Europa, 20 – B- Parque Empresarial La Moraleja, 28108 Alcobendas (Madrid), data on validation of the breast reconstruction dimension. Spain. 13Psychology Department, Universidad Autónoma de Madrid, Madrid, Spain. Limitations Received: 26 April 2018 Accepted: 17 July 2019 Two dimensions present reliabilities bellow 0.8 and they should be employed with care when used isolated for References diagnostic purposes. 1. Bermejo de las Heras B, Cortes Ramon y Cajal J, Galve Calvo E, de la Haba Rodriguez J, Garcia Mata J, Moreno Anton F, et al. The economic burden of Additional file metastatic breast cancer in Spain. European Journal of Hospital Pharmacy. 2018. 2. Prates ACL, Freitas-Junior R, Prates MFO, Veloso MF, Barros NM. Influence of Additional file 1: Sexual Satisfaction Questionnaire. (DOCX 58 kb) body image in women undergoing treatment for breast Cancer. Revista brasileira de ginecologia e obstetricia : revista da Federacao Brasileira das Sociedades de Ginecologia e Obstetricia. 2017;39(4):175–83. Abbreviations 3. Kim MK, Kim T, Moon HG, Jin US, Kim K, Kim J, et al. Effect of cosmetic AGFI: Adjusted Goodness-of-Fit Statistic; CFI: Comparative Fit Index; outcome on quality of life after breast cancer surgery. European journal of EORTC: European Organisation for Research and Treatment of Cancer; surgical oncology : the journal of the European Society of Surgical EuroQol VAS: Euro Quality of Life Visual Analogue Scale; GFI: Goodness-of-fit Oncology and the British Association of Surgical Oncology. 2015;41(3):426– statistic; MOS SF-12: Medical Outcomes Study - Short Form Health Survey; 32. QLQ-BR23: Quality of Life Questionnaire-Breast Cancer Module; RMSEA: Root 4. Guo F, Kuo YF, Shih YCT, Giordano SH, Berenson AB. Trends in breast cancer Mean Square Error of Approximation; SEXSAT-Q: Sexual Satisfaction mortality by stage at diagnosis among young women in the United States. Questionnaire Cancer. 2018;124(17):3500–9. 5. Dubey AK, Gupta U, Jain S. Breast cancer statistics and prediction Acknowledgements methodology: a systematic review and analysis. Asian Pacific journal of To all the patients who selflessly contributed to the conduct of the study cancer prevention : APJCP. 2015;16(10):4237–45. and especially to M.A. Mendo Gastalver and her husband F.J. Reyes 6. The European Organization for Research and Treatment of Cancer: Quality Rodriguez, for contributing with their experience and enthusiasm. of Life Questionnaire (EORTC QLQ-C30). http://groups.eortc.be/qol/eortc- qlq-c30. Accessed on 10 Sept 2018. Authors’ contributions 7. The European Organization for Research and Treatment of Cancer: Breast RGM developed the scientific rational of the study. 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