International Journal of Environmental Research and Public Health Review Sexual Function in Women with Breast Cancer: An Evidence Map of Observational Studies Nelson Rodrigues-Machado 1,2, *,† , M. Jesús Quintana 1,3,4,5,6 , Raquel Gómez-Gómez 2 and Xavier Bonfill-Cosp 1,3,4,5,6 1 Department of Paediatrics, Obstetrics & Gynaecology and Preventive Medicine, Universtitat Autònoma de Barcelona, 08193 Bellaterra, Spain 2 Hospital Universitari Vall d’Hebron, 08035 Barcelona, Spain 3 Institut d’Investigació Biomèdica Sant Pau (IIB Sant Pau), 08041 Barcelona, Spain 4 Hospital de la Santa Creu i Sant Pau, 08025 Barcelona, Spain 5 Centro Cochrane Iberoamérica, 08025 Barcelona, Spain 6 Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), 28029 Madrid, Spain * Correspondence: nelson_machado85@hotmail.com † Nelson Rodrigues-Machado is a PhD candidate at the Methodology of Biomedical Research and Public Health program, Universitat Autònoma de Barcelona. Abstract: Breast cancer (BC) is the leading cause of cancer in women, and has implications for sexual function (SF). In this study, we used an evidence map to identify, describe, and organise the current available evidence regarding SF in women with BC. We searched the MEDLINE, PsycINFO, and CINAHL databases for observational studies assessing SF in women with BC published in English, Spanish, Portuguese, and French between 2000 and 2021 (sample ≥ 50 women). Of the 64 included studies (13,257 women with BC), 58 were published since 2010. Women who were married, partnered, or in relationships represented 74.1% of the entire sample. Only a single study was conducted on Citation: Rodrigues-Machado, N.; women representing a sexual minority. We identified 22 assessment instruments and 40 sexual Quintana, M.J.; Gómez-Gómez, R.; dysfunction (SdF) domains. The number of publications on SF in women with BC has increased in Bonfill-Cosp, X. Sexual Function in the last 10 years, but still remains low. Some groups of women are underrepresented, and some SdF Women with Breast Cancer: domains are underdiagnosed, with the assessment instrument used affecting which domains are An Evidence Map of Observational studied. Women with BC need to be better screened, as their quality of life (QoL) is affected by SdF. Studies. Int. J. Environ. Res. Public Health 2022, 19, 13976. https:// doi.org/10.3390/ijerph192113976 Keywords: breast cancer; breast neoplasms; cancer; evidence map; oncology; psychosexual disorders; quality of life; sexual dysfunction; sexual function; women Academic Editor: Paul B. Tchounwou Received: 23 September 2022 Accepted: 22 October 2022 Published: 27 October 2022 1. Introduction Publisher’s Note: MDPI stays neutral Female breast cancer (BC) is the fifth leading cause of cancer mortality worldwide; it with regard to jurisdictional claims in accounts for one in four cancer cases and one in six cancer deaths. In 2020, BC represented published maps and institutional affil- 11.7% of all new cancer cases (an estimated 2.3 million new cases). The incidence rates are iations. 88% higher in emerging countries than in transitioned countries, and countries with lower human-development-index (HDI) scores have a 17% higher mortality rate than countries with higher HDI scores [1]. In recent years, BC survival has improved due to early detection strategies and ac- Copyright: © 2022 by the authors. cess to timely, effective, and affordable care [2]. However, health providers and health Licensee MDPI, Basel, Switzerland. systems need to address BC survivor issues and concerns regarding the treatment and This article is an open access article disease course. distributed under the terms and In a recent systematic review on adverse mental health outcomes, the researchers conditions of the Creative Commons revealed that BC survivors have an increased risk of anxiety, depression, neurocognitive Attribution (CC BY) license (https:// dysfunction, sexual dysfunction (SdF), and suicide compared with noncancer groups. The creativecommons.org/licenses/by/ prevalence of SdF, in particular, is reported to range between 20% and 60% [3]. In another 4.0/). Int. J. Environ. Res. Public Health 2022, 19, 13976. https://doi.org/10.3390/ijerph192113976 https://www.mdpi.com/journal/ijerph Int. J. Environ. Res. Public Health 2022, 19, 13976 2 of 21 study, the researchers reported that women with BC have a high prevalence of SdF (73.4%) and lower average sexual function (SF) scores [4]; the main problems include penetration pain, desire, lubrication, dysfunctional excitement, and reproductive concerns [5,6]. In a study conducted in our hospital to evaluate the social, economic, and professional impacts of BC on women, the researchers found that SF was the most affected quality- of-life (QoL) dimension, and especially during treatment, with a score of 20.7% in the European Organisation for Research and Treatment of Cancer Quality of Life 23-item breast cancer questionnaire [7]. According to the fifth edition of the Diagnostic and Statistical Manual of Mental Health Disorders (DSM-5) [8], SdF covers a heterogeneous group of disorders that are typically characterised by a clinically substantial impairment in a person’s ability to sexually respond or experience sexual pleasure. Female SF, for which researchers have characterised several models in the literature, comprises more than just arousal and orgasm [9]. We need to organise the substantial evidence reported in the scientific literature assessing SF in women who have had BC through a standardised methodology. The Global Evidence Mapping (GEM) initiative was established in 2007 to provide a general overview of the existing research on traumatic brain and spinal cord injuries [10]. Such evidence maps, which are based on systematic and wide-ranging searches to iden- tify knowledge gaps and future research needs, present results in a user-friendly format (often a visual, graph, or searchable database) [11]. They are both a useful first step in the systematic review process and support for the decision-making process for policy and practice [12,13]. The purpose of our evidence map was to identify, describe, and organise the available evidence regarding SF in women who have BC in order to aid a better understanding of the existing studies, identify the evidence gaps in the literature, and make recommendations for future research. 2. Materials and Methods 2.1. Study Design We based this mapping review, which we carried out in accordance with the GEM initiative, on a methodology that involved three core tasks: setting the map boundaries and context; searching for and selecting relevant studies; reporting on the yield and study characteristics [10]. We also followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Extension for Scoping Reviews (PRISMA-ScR) recommendations [14]. We designed a protocol and published it in the Open Science Framework (https://osf.io/ 4qbgu/). 2.2. Eligibility Criteria We considered observational studies with samples of ≥50 women with BC, published between January 2000 and March 2021 in English, Spanish, Portuguese, or French, and evaluating SF using a specific structured measure, as eligible studies. We did not include older published studies, as sexuality is a controversial subject that is influenced by multiple factors and is variable over the years. 2.3. Search Strategy We performed the systematic literature searches for original articles in the following databases: MEDLINE (via PubMed), PsycINFO, and CINAHL. We conducted the last search on 7 March 2021. We used comprehensive controlled vocabulary and free-text terms. The full electronic search strategy for MEDLINE (via PubMed) was as follows: ((“breast neoplasms” [mesh] OR “breast cancer” [ti]) AND (“sexuality” [majr] OR “sexual dysfunction, physiological” [mesh] OR “sexual activit*” [tiab] OR “sexual dysfunction” [tiab] OR “sexual function*” [tiab] OR “sexual interest*” [tiab] OR “sexual desire*” [tiab] OR “sexuality” [tiab] OR “sexual*” [ti])). We adapted the search strategy to the requirements of each database. 2.4. Study Selection We imported the retrieved studies into COVIDENCE reference manager softw We19,first Int. J. Environ. Res. Public Health 2022, 13976 eliminated duplicate articles, after which two independent researchers 3 of 21 scre the titles and abstracts and applied the predefined eligibility criteria to remove ineli studies. We next eliminated the full texts of the eligible studies to make a final dec 2.4. Study Selection regarding the eligibility. We resolved the disagreements in a final online meeting clearlyWe imported justified thereasons the retrieved studies for into COVIDENCE the study exclusions. reference manager software. We first eliminated duplicate articles, after which two independent researchers screened the titles and abstracts and applied the predefined eligibility criteria to remove ineligible 2.5. Data Extraction studies. We next eliminated the full texts of the eligible studies to make a final decision To manage regarding the dataWe the eligibility. and records, resolved the we designed aintemplate disagreements form a final online in Microsoft meeting. We Wo clearly justified the reasons for the study exclusions. individually record the data for each included study. We recorded data on the auth publication years, journals, study designs, countries, objectives, participants (marita 2.5. Data Extraction tus, sexual orientation, To manage andrecords, the data and age recorded as mean/median we designed a template formor in range), Microsoftinstruments Word to use assess sexual function, and domains. individually record the data for each included study. We recorded data on the authors, publication years, journals, study designs, countries, objectives, participants (marital status, 3.sexual orientation, and age recorded as mean/median or range), instruments used to assess Results sexual function, and domains. 3.1. Selected Studies 3. Results After we removed the duplicates, we screened a total of 1516 titles and abstract 3.1. Selected Studies eligibility. Of the 254 articles selected for full-text screening, we included 64 that me After we removed the duplicates, we screened a total of 1516 titles and abstracts for eligibility criteria in this review. We present the details on the study inclusion and rea eligibility. Of the 254 articles selected for full-text screening, we included 64 that met the for exclusion in the eligibility criteria flowchart in this in present review. We Figurethe 1. details on the study inclusion and reasons for exclusion in the flowchart in Figure 1. Figure 1. Preferred Reporting Items for Systematic Reviews and Meta-Analysis flow diagram of study selection process. Int. J. Environ. Res. Public Health 2022, 19, 13976 4 of 21 3.2. Study Characteristics We present the details of the authors, years of publication, designs, countries, ob- jectives, and participants for the 64 studies in Table 1. The 64 studies, with minimum and maximum sample sizes of 55 and 1957, respectively, included 13,257 women with BC. One study was conducted with 85 lesbian or bisexual women with a female partner, and 51 studies provided data on the mean age, which ranged from 31.4 to 63.4 years. Of the 59 studies (9825 women, 74.1%) that included women who were married, partnered, or in a relationship, in 19 of them, the researchers exclusively focused on women with this profile. Table 1. Characteristics of studies included in evidence map. Participants Author, Year Journal Study Design Country Objective (Age in Years) To assess whether there is any Abasher, decrease in sexual function as 100 BC/100 CG Psycho-Oncology Case–control Sudan 2009 [15] a result of breast (range: 25–55) cancer treatment. To prospectively investigate the presence of sexual dysfunctions and the psychological and 149 BC/81 CG relational functioning in women (mean ME: Aerts et al., after mastectomy and The Breast Prospective Belgium 54.51/mean BCT: 2014 [16] breast-conserving therapy, and 57.26/mean CG: to compare the sexual 56.12) functioning of breast cancer patients with a control group of healthy women. To investigate the anxiety, Asian Pacific depression, and sexual Alacacioglu et al., 100 BC Journal of Cross-sectional Turkey satisfaction levels of Turkish 2014 [17] (mean: 44.7) Cancer Prevention breast cancer patients and their partners. To evaluate the impact of breast reconstruction after mastectomy 90 BC (mean RG: Archangelo et al., on specific aspects of the patient Clinics Cross-sectional Brazil 47.5/mean ME: 2019 [18] quality of life, including sexual 48/mean CG: 47) function, body image, and depression. To identify the clinical, social, and economic determinants of Assogba et al., health-related quality of life, and 218 BC Cancers Cross-sectional France 2020 [19] to describe other living (mean: 47.5) conditions of young long-term breast cancer survivors. To characterise sexual functioning in women recently Bober et al., Journal of 304 BC Prospective USA diagnosed with ductal carcinoma 2013 [20] Sexual Medicine (median: 50.3) in situ, as well as at 9 and 18 months of follow-up. To compare the sexual function of breast cancer survivors (cases) 85 BC/85 CG Boehmer et al., The Journal of to an age- and (mean BC: Case–control USA 2014 [21] Sex Research partner-status-matched control 51.6/mean CG: group of sexual minority women 50.9) without cancer. Int. J. Environ. Res. Public Health 2022, 19, 13976 5 of 21 Table 1. Cont. Participants Author, Year Journal Study Design Country Objective (Age in Years) To assess the prevalence and associated factors of the sexual Brédart et al., activity, sexual problems, and 378 BC Psycho-Oncology Cross-sectional France 2011 [22] sexual satisfaction of French (mean: 53) early-stage breast cancer survivors. To determine the effect of mood, anxiety, and depression on Bueno-Robles sexual health, and the impact on 103 BC Psicooncología Cross-sectional Colombia et al., 2015 [23] Colombian women who have (mean: 48) undergone treatment for breast cancer. To determine whether there are changes in the sexuality of women after breast cancer, to understand the sexual function Cobo-Cuenca of women with breast cancer in 514 BC Plos One Cross-sectional Spain et al., 2018 [5] Spain, and to describe the (mean: 46.34) relationship between the sociodemographic and clinical variables and sexual dysfunction. To describe sexual function state Cordoba-de Juan in women treated for breast 109 BC Fisioterapia Cross-sectional Spain et al., 2019 [24] cancer over a year after the (median: 56.89) diagnosis of breast cancer. To evaluate the trends in sexual function in women with breast Cornell et al., Annals of cancer from the time of diagnosis 226 BC Prospective USA 2017 [25] Surgical Oncology to designated follow-up surgery (median: 56) using a validated sexual questionnaire. To use the Female Sexual Function Index questionnaire to evaluate and compare the 74 BC sexuality of women who (mean CM: Cortés-Flores Aesthetic Cross-sectional Mexico underwent conservative 46/mean MRM: et al., 2017 [26] Plastic Surgery mastectomy, mastectomy alone, 50.1/mean MRMR: and breast reconstruction after 45.2) cancer treatment in private practice in Mexico. To better understand the relationship between sexuality Davis et al., The 72 BC Cross-sectional USA and quality of life in women 2010 [27] Nurse Practitioner (mean: 61.03) who have undergone surgical treatment for breast cancer. To investigate the prevalence of sexual dysfunction in Ellouz et al., 100 BC Sexologies Cross-sectional Tunisia a population of women followed 2019 [28] (mean: 42.6) for breast cancer, and the factors associated with it. Int. J. Environ. Res. Public Health 2022, 19, 13976 6 of 21 Table 1. Cont. Participants Author, Year Journal Study Design Country Objective (Age in Years) To compare the differences in the sexual function of breast cancer patients undergoing breast Elmas et al., Turkish Journal 71 BC Prospective Turkey cancer surgery and modified 2020 [29] of Oncology (median: 43) radical mastectomy followed by chemotherapy and radiation therapy. To evaluate the influence of chemotherapy for breast cancer Farthmann et al., Supportive Care 79 BC Prospective Germany on women’s health-related 2016 [30] in Cancer (mean: 47.46) quality of life, sexual function, and depression. To explore the prevalence of clinically relevant sexual dysfunction among breast cancer survivors on adjuvant endocrine therapy, determine the associated factors of sexual Fogh et al., 333 BC Acta Oncologica Cross-sectional Denmark dysfunction, explore the extent 2021 [31] (mean: 58.74) of the distress caused by specific impairments in sexual function, and analyse whether these were perceived as consequences of breast cancer treatment by breast cancer survivors. Asian Pacific Fouladi et al., 144 BC Journal of Cross-sectional Iran Not stated 2021 [32] (mean: 31.4) Cancer Prevention To document changes in the gynaecological symptoms, sexual problems, and sexual dysfunction (as per DMS-IV criteria) among postmenopausal Breast Cancer Frechette et al., women with early-stage breast 66 BC Research Prospective Canada 2013 [33] cancer over a 6-month period (mean: 61) and Treatment following the initiation of endocrine therapy, and to identify the predictors of sexual dysfunction 6 months after endocrine treatment. To evaluate the impact of different treatment strategies and Gambadrella 122 BC Endocrine Cross-sectional Italy steroid hormone levels on sexual et al., 2018 [34] (mean: 46.9) function in 122 breast cancer women. To assess the associations of the American Journal breast cancer surgical modality Gandhi et al., of Cross-sectional USA and adjuvant therapy on 278 BC 2019 [35] Clinical Oncology women’s sexual dysfunction in survivorship. Int. J. Environ. Res. Public Health 2022, 19, 13976 7 of 21 Table 1. Cont. Participants Author, Year Journal Study Design Country Objective (Age in Years) To elucidate the issue and contribute to the existing Journal of knowledge on the topic, and to Harirchi et al., Experimental & provide necessary information 216 BC Prospective Iran 2012 [36] Clinical for implementing possible future (mean: 44.3) Cancer Research interventions to improve the quality of life of breast cancer patients. To use a reliable and valid measure to examine the sexual function of women younger than Herbenick et al., 115 BC Cancer Nursing Cross-sectional USA 50 years at the time of their 2008 [37] (median: 37.8) breast cancer diagnosis, and to explore their interest in sexual enhancement products. To examine the pretreatment and post-treatment anxiety, 56 BC/52 CG İzci et al., European Journal Prospective Turkey depression, and sleep and sexual (mean BC: 53/mean 2020 [38] of Breast Health function levels in patients with CG: 52.5) breast cancer. To determine the prevalence of sexual dysfunction in young women with breast cancer, and 332 BC/1430 CG Kedde et al., Supportive Care Case–control Netherlands to assess the relationship (mean BC: 38.7/CG 2013 [39] in Cancer between the treatment range: 22–49) administered for breast cancer and sexual dysfunction. To evaluate the correlates and impact factors of the sexual Kowalczyk et al., Clinical function, prevalence of sexual 128 BC Retrospective Poland 2019 [40] Breast Cancer dysfunction, quality of sexual (median: 52.5) life, and body image of female breast cancer survivors. To examine the association between the use of endocrine Landi et al., Cancer 548 BC Cross-sectional USA therapy and incident urinary 2016 [41] Causes & Control (mean: 58.1) incontinence and sexual dysfunction. To explore the types and roles of the relationships between the Lashani et al., Supportive Care sexual function, sense of 181 BC Cross-sectional Iran 2020 [42] in Cancer coherence, and wellbeing in (mean: 47.04) a sample of Iranian female breast cancer survivors. To examine the changes in the sexual activity and function of younger breast cancer survivors Lee et al., South 304 BC Psycho-Oncology Cross-sectional who were sexually active before 2015 [43] Korea (median: 46) diagnosis, and to explore the risk factors that have negative impacts on them. Int. J. Environ. Res. Public Health 2022, 19, 13976 8 of 21 Table 1. Cont. Participants Author, Year Journal Study Design Country Objective (Age in Years) To investigate the sexual dysfunction and reproductive concerns in women under the age of 40 years at breast cancer Ljungman et al., diagnosis, and to identify 181 BC Psycho-Oncology Prospective Sweden 2018 [6] predictors of high levels of (mean: 36.5) problems and potential interdependence between sexual dysfunction and reproductive concerns. To evaluate the sexual functioning of postmasectomy breast cancer patients and its European Journal Manganiello associations with their quality of 100 BC of Cross-sectional Brazil et al., 2011 [44] life, the personal characteristics (-) Oncology Nursing of women and their partners, breast reconstruction, cancer staging, and adjuvant therapies. To analyse the sexual activity, 183 BC/62 OC/ Archives of sexual functioning, and quality 60 HG Mayer et al., Gynecology Retrospective Germany of life in patients after the (median BC: 2019 [45] and Obstetrics completion of treatment for 56/median OC: breast cancer and ovarian cancer. 53/median CG: 46) To report on the changes in the psychosocial functioning over 1 year following breast cancer 190 BC surgery in three groups of (mean MA: Metcalfe et al., Annals of Prospective Canada women, including those with 53.5/mean MIR: 2012 [46] Surgical Oncology mastectomy alone, those with 46.2/mean DR: mastectomy and immediate 51.6) reconstruction, and those with delayed reconstruction. To fill in a gap in the present literature by describing women’s Notari et al., 2018 European Journal 75 BC Cross-sectional Switzerland sexual functioning in the early [47] of Cancer Care (mean: 52.55) weeks of active treatment for breast cancer. To investigate the self-reported sexual health outcomes of breast 105 BC/97 NBC Oberguggenberger cancer survivors in routine BMC Cancer Cross-sectional Germany (mean BC: 49/mean et al., 2017 [48] after-care in comparison with NBC: 49) women with no previous or current breast cancer. To assess the sexual function of Turkish women undergoing a surgical procedure, and to determine whether there were Öztürk et al., Japan Journal of differences between Turkish 100 BC Cross-sectional Turkey 2016 [49] Nursing Science women undergoing (mean: 47) postmastectomy breast reconstruction and those undergoing breast-conserving surgery or mastectomy alone. Int. J. Environ. Res. Public Health 2022, 19, 13976 9 of 21 Table 1. Cont. Participants Author, Year Journal Study Design Country Objective (Age in Years) To investigate the prevalence of the sexual dysfunction and identify the associated Paiva et al., Archives of 216 BC Cross-sectional Brazil conditions in a patient 2016 [50] Sexual Behavior (mean: 51.9) population of Brazilian breast cancer survivors, focusing on obesity-related conditions. To study the relationships among menopausal symptoms, Park et al., Supportive Care South sexual function, depression, and 200 BC Cross-sectional 2013 [51] in Cancer Korea quality of life in women with (mean: 45.64) breast cancer undergoing chemotherapy. To prospectively examine the short- and long-term effects of mastectomy with reconstruction, 258 BC mastectomy without (mean MWR: Parker et al., Annals of reconstruction, and Prospective USA 49.2/mean MA: 2007 [52] Surgical Oncology breast-conserving therapy on 52.8/mean BCT: aspects of psychosocial 53.7) adjustment and quality of life in a sample of 258 women with breast cancer. To assess the prevalence of sexual health issues in a plastic 90 BC/149 NBC Qureshi et al., Aesthetic surgery patient population (mean BC: Cross-sectional USA 2018 [53] Surgery Journal including breast cancer survivors 51.2/mean NBC: and women without 47) breast cancer. To assess four self-reported sexual morbidity domains, including sexual function, sexual distress, body change stress, and body satisfaction, in a sample of long-term breast cancer survivors, and to evaluate the influence of select psychosocial and medical factors based on the Raggio et al., Psychology & extant literature, including age, 83 BC Cross-sectional USA 2014 [54] Health treatment modality (mean: 56.21) (e.g., mastectomy, specific treatment effects (e.g., weight gain and premature menopause), and psychosocial factors (e.g., depression, marital/relationship status and satisfaction, and quality of life)), within and across four sexual morbidity domains. Int. J. Environ. Res. Public Health 2022, 19, 13976 10 of 21 Table 1. Cont. Participants Author, Year Journal Study Design Country Objective (Age in Years) To determine, in a sample of BC outpatients, how commonly women sought help for sexual concerns from a healthcare provider, from other individuals, or from alternate sources, and to Reese et al., The Journal of 144 BC Cross-sectional USA examine whether the 2020 [55] Sexual Medicine (mean: 56) help-seeking was associated with women’s sexual function/activity, self-efficacy for clinical communication about sexual health, or sociodemo- graphic/medical characteristics. To document the prevalence of and factors associated with low desire, sexually related personal Robinson et al., The Journal of 625 BC Cross-sectional Australia distress, hypoactive sexual desire 2017 [56] Sexual Medicine (median: 65.1) dysfunction, and pelvic-floor dysfunction in women 10 years after breast cancer diagnosis. To explore the impact of mastectomy type on sexual 60 BC Breast Cancer function, as measured by the (median TMRM: Rojas et al., Research and Cross-sectional USA Female Sexual Function Index, 52/median SSM: 2017 [57] Treatment satisfaction with appearance, 50.57 median NSM: and the reconstructed breast’s 46.5) role in intimacy. To describe the changes in these outcomes from 1 to 5 years following diagnosis comparing 826 BC bilateral mastectomy vs. (mean BCS: Rosenberg et al., Jama Surgery Prospective USA breast-conserving surgery and 35.9/mean UM: 2020 [58] unilateral mastectomy, as well as 36.4/mean BM: to examine the differences by 36.1) primary surgery type, receipt of radiation, and reconstruction. To examine whether individual and partner sexual functioning, affectionate behaviour, emotional closeness, and depressive symptoms are Rottmann et al., associated with change over time 287 BC Acta Oncologica Longitudinal Denmark 2017 [59] in the satisfaction with the sex (mean: 55.77) lives of sexually active heterosexual couples dealing with BC, and to explore whether the associations differ between patients and partners. Int. J. Environ. Res. Public Health 2022, 19, 13976 11 of 21 Table 1. Cont. Participants Author, Year Journal Study Design Country Objective (Age in Years) To examine the characteristics of women undergoing lumpectomy, mastectomy with reconstruction, 1957 B Journal of the and mastectomy alone, and the (mean MWR: Rowland et al., National Cross-sectional USA relationship of the different 50.3/mean LG: 2000 [60] Cancer Institute surgical treatments to specific 55.9/mean MA: aspects of the health-related 58.9) quality of life, body image, and physical and sexual functioning. To compare sexual function, self-esteem, and quality of life in 186 BC/204 CG Safarinejad et al., young women with breast cancer (mean BC: Psycho-oncology Cross-sectional Iran 2013 [61] by lumpectomy with those from 37.7/mean CG: the age-matched general 37.2) female population. To investigate menopausal symptoms, psychological symptoms (including anxiety and depression), sexual function, and body image experienced by younger Australian women with Sayakhot et al., 114 BC Menopause Cross-sectional Australia breast cancer, and to examine the 2011 [62] (mean: 47.2) effect of different breast cancer treatments (chemotherapy, adjuvant endocrine therapy, and ovariectomy) on the menopausal, physical, and psychological symptoms. To prospectively evaluate the body image scale and impact of Sbitti et al., BMC 120 BC Cross-sectional Morocco breast cancer therapy on the 2011 [63] Women’s Health (mean: 45.3) sexuality of women from Morocco. To provide a more detailed picture of the sexual problems Schover et al., The Journal of during the first two years on 129 BC Cross-sectional USA 2014 [64] Sexual Medicine aromatase inhibitor therapy, to (mean: 63.4) provide a benchmark for a prospective intervention trial. Asian Pacific To investigate sexual function Shandiz et al., 94 BC Journal of Cross-sectional Iran and factors affecting it in women 2016 [65] (mean: 45.20) Cancer Prevention with breast cancer. To evaluate sexual health in long-term breast cancer survivors compared with aged-matched controls, determine the impact of chemotherapy and endocrine Breast Cancer 248 BC/159 CG Soldera et al., therapy on the sexual Research Prospective Canada (mean BC: 62/mean 2018 [66] functioning, and compare the and Treatment CG: 59) related symptoms, such as the gynaecological, vasomotor, and bladder complaints, between groups to potentially explain the source of any differences in sexual function. Int. J. Environ. Res. Public Health 2022, 19, 13976 12 of 21 Table 1. Cont. Participants Author, Year Journal Study Design Country Objective (Age in Years) To compare negative emotions, body image, sexual schemas, and sexual 105 BC/100 CG Sorouri et al., Archives of Cross-sectional Iran function in women with breast (mean BC: 2019 [67] Psychiatry Research cancer after mastectomy and 41.09/mean CG: 41.5) healthy women. To investigate how testosterone levels, mood, body image, depression, relationship quality, and Speer et al., age influence the sexual function of 55 BC The Breast Journal Case–control USA 2005 [68] female BCSs who have been treated (mean: 53.4) with surgery, radiation, chemotherapy, or adjunctive hormone therapy. To explore the mediating role of body image (dissatisfaction) between Tahir et al., 118 BC Psycho-Oncology Cross-sectional Pakistan sexual functioning (SF) and marital 2020 [69] (mean: 39.58) intimacy in Pakistani women with breast cancer. To compare the sexual function and 172 BC Tucker et al., Supportive Care quality of life in female breast cancer Cross-sectional Australia (mean BSO: 53/mean 2020 [70] in Cancer survivors with and without a history no BSO: 58) of bilateral salpingo-oophorectomy. To investigate the prevalence of the sexual dysfunction in women with a prior history of breast cancer following risk-reducing salpingo-oophorectomy (RRSO), and to compare this to women without Tucker et al., a previous diagnosis of breast cancer. 60 BC The Breast Cross-sectional Australia 2016 [71] The secondary objectives were to (mean: 50) describe the effects of mastectomy, breast reconstruction, and antioestrogen therapy on the sexual function and quality-of-life outcomes of women with a previous diagnosis of breast cancer after RRSO. To determine the frequency of sexual dysfunction and factors affecting Usta et al., International Journal 118 BC Cross-sectional Turkey sexual dysfunction in women with 2017 [72] of Caring Sciences (mean: 47.74) breast cancer receiving chemotherapy. To record how the treatment of breast and gynaecological cancer may affect the subjective perception of the interpersonal relation of the couple European Journal of Vaidakis et al., with respect to female sexuality. The 67 BC Gynaecological Prospective Greece 2014 [73] authors also attempted to associate (mean: 50.5) Oncology and evaluate disorders of desire, arousal, orgasm, and pain, as well as problems of the sexual relationship, with cancer diagnosis and treatment. To examine the incidence of sexual problems after breast cancer in a real-world setting, the predictors of Webber et al., 92 BC The Oncologist Prospective Australia sexual problems over 12 months after 2011 [74] (mean: 49.8) adjuvant therapy, and the potential impact of sexual problems on the quality of life. Int. J. Environ. Res. Public Health 2022, 19, 13976 13 of 21 Table 1. Cont. Participants Author, Year Journal Study Design Country Objective (Age in Years) To identify the unobserved distinct latent classes/subgroups of breast cancer patients in China Yuan et al., Supportive Care with respect to various sexual 123 BC Cross-sectional China 2020 [75] in Cancer health measures, and to examine (mean: 42.80) the association of the latent membership with the individual characteristics. To evaluate the frequency and type of sexual dysfunction in 100 patients treated for nonmetastatic breast cancer in post-treatment monitoring in Zaied et al., 100 BC Bulletin du Cancer Cross-sectional Tunisia external consultation 2013 [76] (mean: 47.24) Int. J. Environ. Res. Public Health 2022, 19, x FOR PEER REVIEW (Department of Oncological 11 of 1 Medicine, CHU Farhat Hached, Sousse), and to identify the predictive factors of these disorders. modified radical mastectomy with reconstruction; MWR: mastectomy with reconstruction; NBC: n BC: breast cancer; BCT: breast cancer therapy; BCS: breast-conserving surgery; BM: bilateral mastectomy; breast cancer; BSO: bilateral NSM: nipple-sparing salpingo-oophorectomy; mastectomy; CM: conservative OC: ovarian mastectomy; cancer; CG: control RG: group; DR:reconstruction delayed recon- group SSM: skin-sparing struction; mastectomy; LG: lumpectomy group; MA:TMRM: total/modified mastectomy radicalMIR; alone; ME: mastectomy; mastectomy; mastectomyUM: unilateral maste with immediate reconstruction; tomy; MRM: modified USA: United radical States of mastectomy; MRMR: modified radical mastectomy with reconstruction; America. MWR: mastectomy with reconstruction; NBC: no breast cancer; NSM: nipple-sparing mastectomy; OC: ovarian cancer; RG: reconstruction group; SSM: skin-sparing mastectomy; TMRM: total/modified radical mastectomy; UM: Regarding unilateral mastectomy; USA: United States the publication years,of America. most of the studies (n = 58) were published betwee 2011 and 2021 (Figure 2), and most (n = 42) were cross-sectional in design. As for the re Regarding the publication years, most of the studies (n = 58) were published between gions 2011 and countries, and 2021 (Figure202),studies were and most conducted (n = in North America, 42) were cross-sectional 16 inAs in design. Europe, for the 11 in th Middle regions East, 5 in Australia, and countries, 20 studies4 in South were America, conducted 4 in America, in North Africa, 316 ininEast Asia, Europe, 11and 1 in Sout in the Asia Middle East, 5 in Australia, 4 in South America, 4 in Africa, 3 in East Asia, and 1 in Southand n = 6 (Figure 3). The USA and Iran were the most represented countries (n = 16 Asia (Figure 3). respectively), The USAby followed and Iran wereand Australia the most represented Turkey countries (n = 16 and n = 6, (n = 5 each). respectively), followed by Australia and Turkey (n = 5 each). Figure2. Figure Distribution ofofarticles 2. Distribution articlesbyby year. year. Int. J. Environ. Res. Public Health 2022, 19, 13976 14 of 21 Figure 2. Distribution of articles by year. Figure 3.3. Distribution Figure Distributionofofarticles articlesbyby country. country. 3.3. SF Assessment 3.3. SF Assessment In most of the studies, the researchers used a single instrument to assess the SF, al- thoughIn six most of theused studies studies, the researchers two instruments. Weused a single present instrument the summaries of to theassess the SF, alt- 22 different instruments that we identified in Table S1. The most frequently used instrument wasdifferent hough six studies used two instruments. We present the summaries of the 22 the instruments Female Sexual that we identified Function Index (nin=Table S1. The most 35), followed by thefrequently used instrument Sexual Activity Questionnaire was the Female (n Sexual Function = 8), PROMIS Index (nand Sexual Function = 35), followedMeasures Satisfaction by the Sexual Activity Brief Profile Questionnaire (SexFS) (n = 4), (n and = 8),Watts PROMIS Sexual Function Sexual Questionnaire Function and Cancer and Satisfaction Rehabilitation Measures Evaluation Brief Profile (SexFS)System (n = 4), and Short Form (CARES-SF) sexual subscale (n = 3 each). The instruments Watts Sexual Function Questionnaire and Cancer Rehabilitation Evaluation System used in just a singleShort study were as follows: the Short Sexual Function Scale; Specific Sexual Problems Form (CARES-SF) sexual subscale (n = 3 each). The instruments used in just a single study Question- naire; were asGolombock–Rust Inventory follows: the Short SexualofFunction Sexual Satisfaction; Questionnaire Scale; Specific on Women’s Sexual Problems Sexual Questionnaire; Function; MacCoy Female Sexuality Questionnaire; Sexual Complaint Screener for Women; Sexual Function Questionnaire; Arizona Sexual Experience Scale; Short Form of the Ques- tionnaire for Screening Sexual Dysfunction; Changes in Sexual Function Questionnaire; Sexual Quotient–Female Version; Sexual Interest and Desire Inventory–Female; Sexual Functioning Questionnaire–Women; Short Form of the Personal Experience Questionnaire; 10-item Menopausal Sexual Interest Questionnaire; 28-item Sexual Function Questionnaire; Relationship and Sexuality Questionnaire. We identified a total of 40 independently assessed domains, as follows: desire and satisfaction (n = 41 each); orgasm (n = 40); lubrication (n = 39); arousal (n = 37); pain (n = 36); pleasure (n = 8); discomfort and interest (n = 6 each); frequency (n = 5); vaginal discomfort (n = 4); relationship (n = 3); vaginismus, excitation, habit, vulvar discomfort–labial, and vul- var discomfort–clitoral (n = 2 each). Other domains were evaluated only in a single study (swelling of the labia; reduced length of the vagina; reduced elasticity of the vagina; commu- nication; avoidance; touch; anticipatory anxiety; sexual initiative; masturbation problems; activity; sexual drive; sexual aversion; importance; tiredness; sexual attractiveness; feeling; responsibility; libido; partner problems; responsiveness; sexual enjoyment; distress). In 32 studies, researchers report data on the relationship between SdF and age, which is associated with older age groups (n = 14), younger age groups (n = 3), and non-associated with age (n = 15). The type of treatment was negatively related to SdF, whether it was mastectomy (n = 15/29), chemotherapy (n = 11/28), or hormone therapy (n = 11/30). 4. Discussion On this evidence map, we included 64 studies published in the last 20 years, compris- ing a total of 13,257 women with BC for whom SdF was assessed. We observed an evident increase in the number of publications over time (58 of the 64 included studies were pub- Int. J. Environ. Res. Public Health 2022, 19, 13976 15 of 21 lished in the last 10 years), which suggests a growing interest in understanding how BC impacts women’s SF. However, given the importance of the issue, we consider the number of publications to be too low. SdF is a common side effect of cancer treatments, and so it is imperative for health providers to routinely include a comprehensive evaluation of sexual health in the workups for such patients from the outset [77]. Female sexuality is a complex issue, as physiological, psychological, and sociocultural factors and interpersonal relationships all play a part, not to mention the fact that the delayed study of this issue may be due to the historical stigmatisation of women and their sexuality [78]. Interestingly, most of the included women were married, partnered, or in relationships, with a substantial number of researchers selecting this status as an inclusion criterion, which suggests that women without partners, who may experience their sexuality in a different way (e.g., masturbation), are underrepresented. Only one study was conducted with lesbian or bisexual women having a female partner [21]. Researchers have found that SF is independent of sexual orientation, and the fact that sexual minorities appear to have different social attitudes and sexual practices may imply specific consequences of the physical effects of cancer and its treatment for lesbian, gay, and bisexual populations [79–81]. The limited literature on SF in women with BC from sexual minorities remains a key aspect of survivor health outcomes that requires further study [82,83]. On our evidence map, we identified 22 validated instruments used by the authors to assess SF in women with BC. Authors used the Female Sexual Function Index in over 50% of the studies (n = 35). This brief 19-item multidimensional self-report instrument for assessing the key dimensions of SF in women, which incorporates the criteria of SdF as defined and recognised by international diagnostic systems [8], was designed and validated for use in clinical trials and epidemiological studies [84]. Women with BC found it to be the right length, easy to complete, and relevant to their experience, and it also demonstrates excellent psychometric properties (high internal consistency, test–retest reliability, and evidence of construct validity) [85]. The second most-used instrument was the Sexual Activity Questionnaire, which is rapidly and easily administered and an acceptably reliable measure. The questionnaire describes SF in terms of the levels of sexual activity, pleasure, and discomfort [86], has been demonstrated to be a useful instrument for measuring sexual activity in women with cancer [87], has been validated in different countries, and has good psychometric properties [88–90]. The PROMIS Sexual Function and Satisfaction Measures Brief Profile (SexFS) is also widely used, which is another reliable and valid tool for measur- ing self-reported SF and satisfaction among men and women with cancer. The instrument is comprehensive in scope, covering both physical and psychological constructs, and provides a comprehensive assessment of satisfaction and key SF domains [91]. Although researchers have previously validated all the instruments and they have good psychometric properties, their scopes differ, and they do not evaluate the same domains. Furthermore, some authors present results as a total SF score, overlooking the fact that an individual may have several simultaneous SdF disorders and that diagnosis should be individual [8]. The researchers assessed a total of 40 domains with the 22 assessment instruments. The most studied domains were desire, satisfaction, orgasm, lubrication, arousal, and pain. Some of the domains reflect internationally accepted classifications as reviewed by the Fourth International Consultation on Sexual Medicine [92], with the following considered to reflect SdF: hypoactive sexual desire dysfunction; female sexual arousal dysfunction; female orgasmic dysfunction; female genital–pelvic pain dysfunction; persistent genital arousal disorder; postcoital syndrome; hypohedonic orgasm; painful orgasm. However, several of the domains reflected in our review are not included in international classifications, which indicates a lack of agreement and the need for further work regarding the definitions and diagnostic criteria, given the need to avoid underestimating SdF [93]. No single assessment instrument measured all the reported domains, which is a fact that adds further complexity Int. J. Environ. Res. Public Health 2022, 19, 13976 16 of 21 to the concept of SdF and leads to the underestimation and underdiagnosis of potential SdF in women with BC. Finally, in some studies, researchers report measures of the relationships between SdF and age, mastectomy, chemotherapy, and hormone therapy. While Park et al. found that older women were more likely to have a poorer QoL than younger women, especially in terms of the items directly related to sexuality [94], other researchers found that younger women experienced more SF problems [95,96]. Some of the heterogeneity in the data may be explained by the age cut-off for younger versus older women, as well as certain sociocultural factors. In relation to the type of treatment, in a systematic review, the authors report that surgical options other than mastectomy have a better impact on the SF of women with BC [97]. In another study, the authors report that hormone therapy has significant side effects for the QoL of women, including SdF, specifically in terms of the loss of sexual interest, vaginal dryness, and pain during sex [98]. The loss of ovarian function and subsequent early menopause, as side effects due to chemotherapy, often cause SdF symptoms [99]. Nonetheless, certain individual features (e.g., culture, religion, and psychological and physical status) may also influence the way women experience BC. 4.1. Study Limitations This evidence map has some limitations. The search was last updated in March 2021, which means that we may have missed studies published after that date. Furthermore, we only searched three databases; however, these databases are comprehensive, and so we consider that this limitation did not substantially affect our main findings. Another limitation was that we only selected specific SF assessment instruments and excluded studies based on general instruments (e.g., QoL instruments) that only partially evaluate certain aspects of SF. Although we recognise the importance of general instruments, we consider that specific measures may be more sensitive for the detection of small changes in this specific concept. As for the strengths, as far as we are aware, ours may be the first evidence map that provides a comprehensive synthesis of the available evidence on SF in women with BC reported in the last 20 years. Furthermore, we based our evidence map on a standardised methodology that requires a systematic search and enables the results to be presented for easy and user-friendly interpretation. 4.2. Clinical Implications The evidence map methodology used in this study highlights the important knowl- edge gaps and identifies future research needs. Our review suggests that SF in women with BC is a broad and complex concept. We suggest that health providers, researchers, and policymakers may need to rethink the concept of SF in a more inclusive way, and they should furthermore consider improving the assessment instruments used to date by including every domain, thereby avoiding underdiagnosis. A valid, reliable, interesting, and easy-to-use measurement instrument allows us to more precisely evaluate SF. Although every health system depends on its own principles, culture, and resources, we strongly recommend that clinicians use/introduce the most suitable instrument in their clinical practice to support decision-making and improve the QoL of woman with BC. 5. Conclusions This evidence map provides a broad vision on how the research on SF in women with BC has been conducted so far. While studies of SF in women with BC have substantially increased in number over the last 10 years, the importance and frequency of this health problem indicate that the number is still too low. Most of the studies include only women who are married, partnered, or in relationships, which leaves single, lesbian, and bisexual women underrepresented, which can be solved with new studies conducted on these specific groups of women. Int. J. Environ. Res. Public Health 2022, 19, 13976 17 of 21 Although the studies include a significant number of SF-related domains, this very much depended on the specific assessment instrument used, leading to the underestimation and underdiagnosis of some dysfunctions. Therefore, SdF should not be undervalued, as it can cause suffering in these women and might delay recovery. Future research should focus on ways to better screen for SdF in women with BC and improve their QoL. Supplementary Materials: The following supporting information can be downloaded at: https:// www.mdpi.com/article/10.3390/ijerph192113976/s1, Table S1: Assessment instruments used. Author Contributions: Conceptualisation, N.R.-M., M.J.Q. and X.B.-C.; methodology, N.R.-M., M.J.Q. and X.B.-C.; software, N.R.-M., M.J.Q. and X.B.-C.; formal analysis, N.R.-M., M.J.Q. and X.B.-C.; investigation, N.R.-M.; data curation, N.R.-M., M.J.Q., R.G.-G. and X.B.-C.; writing—original draft preparation, N.R.-M.; writing—review and editing, N.R.-M., M.J.Q. and X.B.-C.; supervision, M.J.Q. and X.B.-C. All authors have read and agreed to the published version of the manuscript. Funding: This research received no external funding. Institutional Review Board Statement: Not applicable. Informed Consent Statement: Not applicable. Data Availability Statement: All the data generated or analysed during this study are included in the published review article. Conflicts of Interest: The authors declare no conflict of interest. References 1. Sung, H.; Ferlay, J.; Siegel, R.L.; Laversanne, M.; Soerjomataram, I.; Jemal, A.; Bray, F. 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