Iran Journal of Nursing

Introduction
Cancer can affect various aspects of the life of patients and their families. Women with cancer often experience severe psychological disorders, which leads to a decrease in their quality of life. As a type of cancer, breast cancer causes irreparable damage to the sexual organs due to performing surgical treatment (mastectomy), chemotherapy, and radiotherapy. This can lead to sexual dysfunction. This study aims to compare the sexual health status of women with and without breast cancer in Zanjan, Iran.

Methods
This case-control study was a part of a larger study, whose participants were 75 women with breast cancer and 75 healthy women referred to the Mehraneh Charity Clinic and the Oncology Clinic of Valiasr Hospital in Zanjan City in 2018. The participants were selected by a convenience sampling method. The sample size was determined 75 per group based on the study by Shahid Sales et al. [17] (where the mean and score of the sexual distress score for the case and control groups were 23.54±7.3 and 25.92±4.34, respectively), and by considering an alpha level of 5%, a test power of 95%, and 10% sample dropout.
The inclusion criteria for patients were: being married and sexually active (self-report), treatment by surgery and/or chemotherapy, at least 3 months have passed since the end of the treatment, and a score higher than 11 in the female sexual distress scale-revised (FSDS-R). Having other types of cancer, having a history of mental illness at least in the past year (self-report), drug abuse, alcohol consumption, recurrence of the disease, hospitalization during the study, pregnancy, and the initiation of psychiatric drug treatments were the exclusion criteria for patients. The healthy women (controls) were at the reproductive age, who were the close and distant relatives of patients (case group), and had health records in the health centers of the city. The inclusion criteria for the healthy group were: not using psychotropic or narcotic drugs, no mental disorder, and no any chronic disease according to their self-reports. Exclusion criteria were pregnancy and unwillingness to continue participation in the study.
The data were collected using a form that surveys sociodemographic, disease-related, and treatment-related information, the FSDS-R that measures sexual distress, and the female sexual function index (FSFI) that evaluates sexual function. Data analysis were conducted in SPSS software, version 20. Chi-square test (for categorical data), and Mann-Whitney U test (for non-parametric data) were used to compare women with and without breast cancer. P<0.05 was considered as statistically significant.

Results
The mean age of patients was 36.49±6.53 years and the mean age of controls was 36±0.72 years. There was no statistically significant difference between the two groups in terms of some demographic variables such as age, educational level of women and their husbands, occupation of women and their husbands, place of residence, and number of children (P>0.05).The mean score of FSFI in all subscales in the patient group was lower than in the control group. This difference was statistically significant only in the dimension of desire (P=0.003). regarding the sexual distress variable, the mean FSDS-R score of healthy women was lower than that of women with breast cancer, but this difference was not statistically significant (P>0.05).

Conclusion
In the present study, the difference between women with and without breast cancer was significant only in the desire domain of sexual function. There was no statistically significant difference between the two groups in sexual distress and in other domains of sexual function. Therefore, it seems that women with breast cancer need to use counseling and supports to control the role of drugs in reducing sexual desire as much as possible. More studies are recommended in this regard and to investigate the effect of various factors on solving the sexual problems of women with breast cancer in Iran.

Ethical Considerations
Compliance with ethical guidelines
The study was approved by the ethics committee of Zanjan University of Medical Sciences (Code: IR.ZUMS.REC.1395.156). Sampling was done after obtaining informed consent from the participants. They were assured that their information would remain confidential and were free to leave the study at any time.

Funding
The study was funded by Zanjan University of Medical Sciences. 

Authors' contributions
Conceptualization and Supervision: Mina Esmkhani, Effat Merghati Khoei; Writing original draft, Mina Esmkhani, Samaneh Youseflo; Review & editing, and data collection: Mina Esmkhani, Monireh Moharram Nezhad-Fard, Fateme Ghanbarpour; data analysis: Samaneh Youseflo, Mohsen Hosseinzadeh.

Conflict of interest
The authors declare no conflict of interest.

Acknowledgments
The authors would like to thank the Oncology Clinic of Valiasr Hospital and Mehrona Charity Clinic, Dr. Minoush Moghimi (oncologist at Valiasr Hospital), and all the women participated in this study for their cooperation.


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