(a source of natural progesterone). A few of these substances have been tested among breast cancer survivors in randomized controlled trials, but have not been found to be effective (Jacobson et al., 2001; Van Patten et al., 2002; Amato et al., 2002; Tice et al., 2003).

Sexual function Understanding sexual functioning following treatment of breast cancer is difficult because there is a general decline in libido and an increase in vaginal dryness with normal aging. These problems are, however, often exacerbated as a result of breast cancer treatment (Ganz, 2001b). Many women who are treated with adjuvant chemotherapy report loss of libido, body image concerns, decreased breast sensitivity, and a decline in sexual activity. However, sexual functioning among a large cohort of breast cancer survivors when assessed on average 3 years after their breast cancer diagnosis was found to be very similar to that of healthy women (Ganz et al., 1998a; Meyerowitz et al., 1999). Predictors of sexual dysfunction in breast cancer survivors include being younger at diagnosis, a history of chemotherapy, and having treatment-induced amenorrhea (Ganz et al., 1998a, 1999). There is little evidence of a link between type of surgical treatment (e.g., lumpectomy versus mastectomy) and sexual functioning, but women who have had a mastectomy report poorer body image (Rowland et al., 2000; Thors et al., 2001). Tamoxifen does not appear to adversely affect sexual functioning among breast cancer survivors (Fallowfield et al., 2001; Ganz, 2001a). Few differences in sexual function between African-American and white breast cancer survivors have been reported; however, studies generally have been limited to women who are well educated, high income, and highly functional (Wyatt et al., 1998). The American Cancer Society’s (ACS’s) website has information on sexuality for women and their partners (ACS, 2004b). Cognitive and behavioral sexual rehabilitation interventions are available to assist persons with cancer in understanding and adjusting to the physical changes caused by cancer treatment (Gallo-Silver, 2000).

Pregnancy and lactation Reproductive-age women making treatment decisions need to be apprised of the benefits and adverse effects of treatment on reproductive function to aid in their decision making (Friedlander and Thewes, 2003). Patients are often advised to wait 2 years after diagnosis before becoming pregnant because of the higher rate of recurrence of breast cancer in this period. Women under age 35 may have a higher likelihood of relapse than older patients, which may affect reproductive decision making. For older women, a decision to delay pregnancy may diminish their chances of becoming pregnant. Evidence on the consequences of breast cancer for the estimated 3 to 7 percent of survivors who become pregnant is limited, but reassuring. To date, most studies have not shown increases in cancer

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