Investigation of the effectiveness of adjuvant hormonal treatment on depression, sleep quality and sexual function in hormone receptor positive early stage breast cancer

Aim: Breast cancer is the most common type of cancer in women worldwide and in our country. Breast cancer diagnosis creates a crisis situation that affects women's lives in different ways, such as physically, psychologically, socially and spiritually. This crisis situation may also cause depression and sleep disturbance in patients. Sexual problems in women with breast cancer may be a result of anxiety and depression when diagnosed with cancer, as well as side effects of surgery, chemotherapy, radiotherapy and hormone treatments. Adjuvant hormonal therapy reduces disease recurrence in receptor positive tumors and increases survival rates. However, sexual problems can be observed in patients due to gynecological side effects caused by the anti-estrogenic effect of Tamoxifen. Although it is very common, depression, insomnia and sexual problems can be ignored by both healthcare professionals and researchers. In this study, it was aimed to improve the quality of life of patients by emphasizing the importance of follow-up and treatment of depression, sleep and sexual dysfunction in early breast cancer patients receiving hormonotherapy. Materials and Methods: Our study was performed between September 2018 and March 2020 with the participation of 105 patients who were diagnosed with hormone receptor positive, early stage (stage I-III) breast cancer and at least 3 months followed by the medical oncology outpatient clinic of Ankara Atatürk Training Research Hospital and Bilkent City Hospital. Patients who were 18 years of age or older, diagnosed with stage I-III breast cancer according to the TNM Staging System, had at least 3 months of hormonal treatment, volunteer to participate in the study and had no communication problems were included the study. Patients were selected independently of chemotherapy or radiotherapy history, and patients with distant organ metastases were excluded from the study. Sociodemographic form, Beck Depression Inventory and Pittsburgh Sleep Quality Index (PSQI) and Female Sexual Function Index (FSFI) were used as data collection tools. The questionnaires were administered in a single interview, using face-to-face interview technique, taking care of the principle of volunteering, and obtaining verbal consent from the patient. Cancer type and stage, chemotherapy, radiotherapy information were accessed from the patient file. IBM SPSS 20 (Statistics Program for Social Scientists) program was used for statistical analysis. Results: When the demographic characteristics of the patients included in the study were examined; 105 women were included in the study and the average age of the individuals was 53. 80% of the patients were married, 19% were divorced, and the median number of children that women had was 2. 67% of the cases were housewives, 21% were retired and 17% were still working actively. In our study, when the Beck Depression score information was examined, the median score value was calculated as 10 (0-33). This value was lower than the median value in 55.8% of patients, high in 44.2%, and a tendency to depression was observed in 46 patients. In our study, the mean PSQI score was 7 (1-16). When the sleep quality rates were examined, good sleep quality was observed in 41 (39.4%) patients and poor sleep quality in 63 (60.6) patients. The median FSFI score of the patients was 2.6 (2-34). As a result, the tendency to depression, sleep and sexual dysfunction was observed in patients participating in the study. When the demographic and pathological features (LVI, PNI, ECE) of patients with low Beck Depression, PSQI and FSFI scores were compared against high ones, no statistically significant relationship was found (p>0.05). However, the relationship between marital status and FSFI score was found to be statistically significant and the effect of being married on sexual functioning was negative (P = 0.04). Although not statistically significant, poor sleep quality (p=0.36) was found in 60.9% of postmenopausal patients and sexual dysfunction was found in 83.1% (p=0.09). No significant relationship was found between adjuvant chemotherapy, radiotherapy and trastuzumab treatment status and duration of treatment and Beck Depression, PSQI and FSFI score values (p> 0.05). There was no significant difference between those receiving LHRH treatment and those who did not (p> 0.05). No statistically significant relationship was observed between the hormonotherapy derivative (tamoxifen / anastrozole / letrozole) received by the patients and Beck depression, PSQI and FSFI score. When ER and PR positivity of the patients were examined, no significant correlation was found between these values and Beck depression and PSQI values. In patients with positive PR status, a tendency to sexual dysfunction was observed and found statistically significant (p=0.005). There was no statistically significant relationship between ER positivity and FSFI (p = 0.15). Although it was not statistically significant, while the percentage of ER decreased the beck score increased, that is, a tendency to depression was observed (p = 0.06). There was a strong (p <0.001) correlation between the PUKI and Beck values of the patients, and an opposite and moderate correlation (p <0.001) between the FSFI and BECK values. In summary, it was found that sleep depression and sexual dysfunction increased with depression in patients. Conclusion: In our study, we evaluated the cross-sectional status of breast cancer patients who were hormone receptor positive and who received hormonal therapy. Although hormonal therapy is not a risk factor, we found tendency to depression, sleep disturbance and sexual dysfunction in most patients. Sleep quality and sexual dysfunction in breast cancer patients are associated with depression both cause and effect. In our study, there was a moderate correlation (p <0.001) between depression and sexual dysfunction, and a high correlation (p <0.001) between depression and sleep quality. No statistically significant difference was observed between depression, sleep quality and sexual dysfunction scores of patients who received different hormonotherapy agents. The high incidence of depression in breast cancer itself makes it particularly difficult to isolate and measure the psychological impact of hormonal treatments on patients. There are many predisposing factors that make this effect difficult. In our study, although most of them were not statistically significant, it was revealed that some sociodemographic features (marital status, menopause), some adjuvant treatment, their duration and hormone receptor status may affect sexual functionality. Future research may shed light on the size of these independent risk factors and as a result, it may guide treatment decisions for breast cancer patients in the coming years. Key Words: Breast cancer, hormonotherapy, tamoxifen, Beck Depression, PSQI, FSFI