Gérard Bailly
email: gerard.bailly@gipsa-lab.inpg.fr

Oxana Govokhina
email: ogovokhina@yahoo.fr

Gaspard Breton
email: gaspard.breton@orange-ftgroup.com

Frédéric Elisei
email: frederic.elisei@gipsa-lab.inpg.fr

Christophe Savariaux
email: christophe.savariaux@gipsa-lab.inpg.fr

A trainable trajectory formation model TD-HMM parameterized for the LIPS 2008 challenge

Keywords:

We describe here the trainable trajectory formation model that will be used for the LIPS'2008 challenge organized at InterSpeech'2008. It predicts articulatory trajectories of a talking face from phonetic input. It basically uses HMMbased synthesis but asynchrony between acoustic and gestural boundaries -taking for example into account non audible anticipatory gestures -is handled by a phasing model that predicts the delays between the acoustic boundaries of allophones to be synthesized and the gestural boundaries of HMM triphones. The HMM triphones and the phasing model are trained simultaneously using an iterative analysissynthesis loop. Convergence is obtained within a few iterations. Using different motion capture data, we demonstrate here that the phasing model improves significantly the prediction error and captures subtle contextdependent anticipatory phenomena.

Introduction

Embodied conversational agents -virtual characters as well as anthropoid robots -should be able to talk with their human interlocutors. They should compute facial movements from symbolic input. Given history of the conversation and thanks to a model of the target language, dialog managers compute a phonetic string with phoneme durations. This minimal information can be enriched with details of the underlying phonological and informational structure of the message, facial expressions, or paralinguistic information that has an impact on speech articulation (mental or emotional state). A trajectory formation model has thus to be built that computes articulatory parameters from such a symbolic specification of the speech task. These articulatory parameters will then drive the talking head (the shape and appearance models of a talking face or the control model of the robot). Human interlocutors are very sensitive to discrepancies between the visible and audible consequences of articulation [START_REF] Dixon | The detection of audiovisual desynchrony[END_REF][START_REF] Mcgurk | Hearing lips and seeing voices[END_REF] and have strong expectations on articulatory variability [START_REF] Whalen | Coarticulation is largely planned[END_REF] resulting from the under-specification of articulatory targets and planning. The effective modeling of coarticulation in speech is therefore a challenging issue for trajectory formation systems and still an unsolved problem. Audiovisual speech synthesizers should therefore cope not only with the modeling of adequate inter-articulatory coordination but also with the correct synchronization of audible and visible articulation [START_REF] Grant | Discrimination of auditory-visual synchrony[END_REF]. Central to all speech synthesizers using rules, stored segments or trajectory formation models to generate speech from phonological input is the choice of speech landmarks. In most systems acoustic boundaries between phones are used as such landmarks for prosody characterization or generation. The TD-HMM system [START_REF] Govokhina | Learning optimal audiovisual phasing for a HMM-based control model for facial animation[END_REF] proposes an original model for the re-estimation of phoneme-sized Hidden Markov Models (HMM). The HTS system [START_REF] Tokuda | Speech parameter generation algorithms for HMM-based speech synthesis[END_REF] generate the final articulatory trajectory.

State-of the art

Numerous control models have been proposed for audiovisual text-to-speech synthesis [START_REF] Bailly | Audiovisual speech synthesis[END_REF]. The most popular solution consists in linking an animated head to an existing acoustic text-to-speech system. The trajectory formation model driving the head uses acoustic phoneme boundaries computed by the system to anchor the coarticulation model. Coarticulation is usually predicted using rules [START_REF] Beskow | Rule-based Visual Speech Synthesis[END_REF] or by exploiting an explicit coarticulation model [START_REF] Bailly | Evaluation of movement generation systems using the point-light technique[END_REF][START_REF] Cohen | Modeling coarticulation in synthetic visual speech[END_REF] that anchor the positions and spans of the phoneme-specific gestural targets. For predicting tongue movements captured by electromagnetic midsagittal articulography (EMMA), Kaburagi and Honda [START_REF] Kaburagi | A model of articulator trajectory formation based on the motor tasks of vocal-tract shapes[END_REF] add dynamic features in the specification of gestural targets of triphones in order to cope with inter-gestural phasing relations. Data-driven trajectory formation systems automatically capture regularities of the context-dependent gestural realization of phoneme-sized segments [START_REF] Weiss | Framework for data-driven video-realistic audio-visual speech synthesis[END_REF]. Concatenative audiovisual speech synthesis encapsulates short-term and long-term coarticulation effects by storing multimodal segments depending on the size of the segments. The problem of possible asynchronies is thus pushed in the segmentation and smoothing of boundaries and eventually in the compression/expansion of segments. HMM are now used for speech synthesis and particularly as trajectory formation systems [START_REF] Tamura | Visual speech synthesis based on parameter generation from HMM: speech-driven and textand-speech-driven approaches[END_REF][START_REF] Zen | An introduction of trajectory model into HMM-based speech synthesis[END_REF]. HMM can in fact capture inter-gestural phasing relations thanks to the state-dependent static and dynamic probability density functions characterizing the HMM states. A third possibility consists in computing articulation directly from speech signals. Proposals range from frame-based linear [START_REF] Kuratate | Audio-visual synthesis of talking faces from speech production correlates[END_REF] or nonlinear models to GMM (Gaussian Mixture Model) -based or HMM-based mapping models that take as input a large speech window surrounding the current analysis frame [START_REF] Tamura | Visual speech synthesis based on parameter generation from HMM: speech-driven and textand-speech-driven approaches[END_REF]. The key problem is here to determine the span of coarticulation and hope that the mapping model will learn context-dependent phasing patterns from training data. A HMM-based trajectory formation system is here described. It includes a phasing model that predicts the delays between the acoustic boundaries of allophones to be synthesized and the gestural boundaries of HMM triphones that are proposed by unconstrained HMM alignment. We show that the modeling of audiovisual asynchrony has an impact on the performance of the whole system.

Data and articulatory model

In order to be able to compare up-to-date data-driven methods for audiovisual synthesis, a main corpus of 697 sentences pronounced by a female speaker was recorded. Using a greedy algorithm, the phonetic content of these sentences was designed in order to maximize statistical coverage of triphones (differentiated also with respect to syllabic and word boundaries). We used the motion capture technique developed at ICP [START_REF] Elisei | Creating and controlling video-realistic talking heads[END_REF][START_REF] Revéret | MOTHER: a new generation of talking heads providing a flexible articulatory control for video-realistic speech animation[END_REF] that consists in collecting precise 3D data on selected visemes. 3D movements of facial fleshpoints (see Figure 1) are acquired using photogrammetry and hand-fitted generic models. Visemes are selected by an analysis-by-synthesis technique [START_REF] Bailly | Degrees of freedom of facial movements in face-to-face conversational speech[END_REF] that combines robust automatic tracking with semi-automatic correction. Our shape models are built using a so-called guided Principal Component Analysis (PCA) where a priori knowledge is introduced during the linear decomposition. We in fact compute and iteratively subtract predictors using carefully chosen data subsets [START_REF] Badin | Three-dimensional linear articulatory modeling of tongue, lips and face based on MRI and video images[END_REF]. For speech movements, this methodology enables us to extract six components directly related to jaw, proper lip movements and clear movements of the throat linked with underlying movements of the larynx and hyoid bone. The resulting articulatory model also includes components for head movements and basic facial expressions but only components related to speech articulation are considered here. The average modeling error is less than 0.5mm for beads located on the lower part of the face.

The trajectory formation system

The principle of speech synthesis by HMM was first introduced by Donovan for acoustic speech synthesis [START_REF] Donovan | Trainable speech synthesis[END_REF] and extended to audiovisual speech by the HTS working group [START_REF] Tamura | Text-to-audio-visual speech synthesis based on parameter generation from HMM[END_REF]. The HMM-trajectory synthesis technique comprises training and synthesis parts.

Basic principles

An HMM and a duration model for each state are first learned for each segment of the training set. The input data for the HMM training is a set of observation vectors. The observation vectors consist of static and dynamic parameters, i.e. the values of articulatory parameters and their temporal derivatives. The HMM parameter estimation is based on ML (Maximum-Likelihood) criterion [START_REF] Tokuda | Speech parameter generation algorithms for HMM-based speech synthesis[END_REF]. Usually, for each phoneme in context, a 3-state left-to-right model is estimated with single Gaussian diagonal output distributions. The state durations of each HMM are usually modeled as single Gaussian distributions. A second training step can also be added to factor out similar output distributions among the entire set of states (state tying). This step is not used here. The synthesis is then performed as follows. A sequence of HMM states is built by concatenating the context-dependent phone-sized HMM corresponding to the input phonetic string. State durations for the HMM sequence are determined so that the output probabilities of the state durations are maximized (thus usually by z-scoring) Once the state durations have been assigned, a sequence of observation parameters is generated using a specific ML-based parameter generation algorithm [START_REF] Zen | An introduction of trajectory model into HMM-based speech synthesis[END_REF].

Comments

States capture parts of the inter-articulatory asynchrony since transient and stable parts of the trajectories of different parameters are not obligatory modeled by the same state (this surely explains why complex HMM structures aiming at explicitly coping with audiovisual asynchronies do not outperform the basic ergodic structure [START_REF] Hazen | Visual model structures and synchrony constraints for audio-visual speech recognition[END_REF]). Within a state articulatory dynamics is captured and is then reflected in the synthesized trajectory. By this way, this algorithm may capture implicitly part of short-term coarticulation patterns and inter-articulatory asynchrony. Larger coarticulation effects can also be captured since triphones intrinsically depend on adjacent phonetic context. These coarticulation effects are however anchored to acoustic boundaries that are imposed as synchronization events between the duration model and the HMM sequence. Intuitively we can suppose that context-dependent HMM can easily cope with this constraint but we will show that adding a context-dependent phasing model helps the trajectory formation system to better fit observed trajectories.

Adding and learning a phasing model

We propose to add a phasing model to the standard HMMbased trajectory formation system (see Figure 2) that learns the time lag between acoustic and gestural units i.e. between acoustic boundaries delimiting allophones and gestural boundaries delimiting pieces of the articulatory score observed by the context-dependent HMM sequence. We use here a very simple phasing model: a unique time lag is associated with each context-dependent HMM. This lag is computed as the mean delay between acoustic boundaries and unconstrained alignment of triphones with articulatory trajectories of training utterances. This delay is learnt by an iterative process consisting of an analysis-synthesis loop:

1. Standard context-dependent HMM are learnt using acoustic boundaries as delimiters for gestural parameters 2. Once trained, forced alignment of training trajectories is performed (Viterbi alignment in Figure 2). 3. Deviations of the resulting segmentation with acoustic boundaries are collected. The average deviation of the right boundary of each contextdependent HMM is then computed and stored. The set of such mean deviations constitutes the phasing model. 4. New gestural boundaries are computed applying the current phasing model to the initial acoustic boundaries. Additional constraints are added to avoid collapsing: a minimal duration of 30 ms is guaranteed for each phone.

Experiments and results

All sentences are used for training. A leave-one-out process for TD-HMM has not been performed since a contextdependent HMM is built only if at least 10 samples are available in the training data; otherwise context-independent phone HMM are trained and used. TD-HMM is compared with concatenative synthesis using multi-represented diphones: synthesis of each utterance is performed simply by using all diphones of other utterances. Figure 3 compares mean correlations obtained by the concatenative synthesis with the TD-HMM at each iteration.

Convergence is obtained after typically 2 or 3 iterations. (jaw rotation, lip rounding, lower and upper lip opening, jaw retraction). First data are predicted by concatenative synthesis using multi-represented diphones [START_REF] Bailly | Evaluation of movement generation systems using the point-light technique[END_REF]. Second data are predicted by HMM using acoustic boundaries. The rest of the data give results obtained after the successive iteration of the estimations of the phasing model.

Conclusions

We have demonstrated here that the prediction accuracy of an HMM-based trajectory formation system is improved by modeling the phasing relations between acoustic and gestural boundaries. The phasing model is learned using an analysissynthesis loop that iterates HMM estimations and forced alignments with the original data. We have shown that this scheme improves significantly the prediction error and captures both strong (prephonatory gestures) and subtle (rounding) context-dependent anticipatory phenomena.

The interest of such an HMM-based trajectory formation system is double: (a) it provides accurate and smooth articulatory trajectories that can be used straightforwardly to control the articulation of a talking face or used as a skeleton to anchor multimodal concatenative synthesis [see notably the TDA proposal in 11]; (b) it also provides gestural segmentation as a by-product of the phasing model. These gestural boundaries can be used to segment original data for multimodal concatenative synthesis.

A more complex phasing model can also be build -using for example CART trees -by identifying phonetic or phonological factors influencing the observed lag between visible and audible traces of articulatory gestures. We will use this trainable trajectory formation model TD-HMM for the LIPS'08 lipsync challenge and drive the articulated 3D clone (cf. Figure 5) with the articulatory scores computed using 3D data from one English female speaker under analysis at our laboratory.

Figure 1 .

 1 Figure 1. 125 colored beads have been glued on the subject's face along Langer's lines so as to cue geometric deformations caused by main articulatory movements when speaking.

Figure 4 Figure 2 .

 42 Figure 2. Training consists in iteratively refining the contextdependent phasing model and HMMs (plain lines and dark blocks). The phasing model computes the average delay between acoustic boundaries and HMM boundaries obtained by aligning current context-dependent HMMs with training utterances. Synthesis simply consists in forced alignment of selected HMMs with boundaries predicted by the phasing model (dotted lines and light blocks).

Figure 3 :

 3 Figure 3: Mean correlations (together with standard deviations) between original and predicted trajectories for the main five articulatory parameters

Figure 4 :

 4 Figure 4: Comparing natural and synthetic trajectories for the first 3 main articulatory parameters (jaw opening, lip spreading and lower lip opening). Vertical dashed lines at the bottom of each caption are acoustic boundaries while gestural boundaries are given by the top plain lines. Note the large delay of the non audible closure at the end of the utterance.

Acknowledgements

The GIPSA-Lab/MPACIF team thanks Orange R&D for their financial support as well as the Rhône-Alpes region and the PPF "Multimodal Interaction". Figure 5: The articulated 3D clone textured with the front image of Figure 1.


MSc Thierry Almont
email: almont.t@theral.fr

Anne-Deborah Bouhnik
email: anne-deborah.bouhnik@inserm.fr

MSc Ali Ben Charif
email: ali.ben-charif.1@ulaval.camkb

PhD D,E , Marc-Karim Bendiane
email: marc-karim.bendiane@inserm.frcc

MSc, PhD C Corinne Couteau
email: couteau.c@chu-toulouse.fr

MD B Cécile Manceau
email: cecile.manceau2@gmail.com

MD, MPH, PhD C Julien Mancini
email: julien.mancini@univ-amu.fr

Eric Huyghe
email: eric.huyghe@yahoo.fr

PhD A,B , Anne-Déborah Bouhnik

MD, MSc Éric Huyghe

MSc Anne-Déborah Bouhnick

Sexual Health Problems and Discussion in Colorectal Cancer Patients Two Years After Diagnosis: A National Cross-Sectional Study

Keywords: Oncosexology, Sexual Quality of life, Discussion about sexuality, Colorectal Cancer, Supportive care, VICAN survey

de niveau recherche, publiés ou non, émanant des établissements d'enseignement et de recherche français ou étrangers, des laboratoires publics ou privés.

INTRODUCTION

Colorectal cancer (CRC) is the third most frequent cancer (2nd in women), with 43 068 new cases diagnosed in France in 2015 [START_REF]Les cancers en France en[END_REF]. With a 5-year survival estimated at 56%, the CRC is the digestive cancer with the best survival prognosis [START_REF] Mazeau-Woynar | Survie attendue des patients atteints de cancers en France: état des lieux[END_REF], making quality of life an area that deserves greater attention, including sexuality. Cancer survivors are a population at risk of treatment-related sexual impairments [START_REF] Schover | Sexual dysfunction and infertility as late effects of cancer treatment[END_REF][START_REF] Sadovsky | Cancer and sexual problems[END_REF]. Between 40% and 100% of patients subsequently experience sexual disorders [START_REF] Sadovsky | Cancer and sexual problems[END_REF][START_REF]The prevalence and types of sexual dysfunction in people with cancer[END_REF], particularly those with pelvic or breast tumors [START_REF] Bober | Sexuality in adult cancer survivors: challenges and intervention[END_REF][START_REF] Brotto | Psychological interventions for the sexual sequelae of cancer: a review of the literature[END_REF].

Overall, in CRC patients, up to 88% of men and a half of women experience sexual disorders after treatment [START_REF] Traa | Sexual (dys)function and the quality of sexual life in patients with colorectal cancer: a systematic review[END_REF], with high rates in rectal cancer patients (up to 69% of men an 62% of women) [START_REF] Hendren | Prevalence of male and female sexual dysfunction is high following surgery for rectal cancer[END_REF]. CRC come with specific treatment-related effects on sexual health, including physical aspects like ostomy, rectal discharge, gas, incontinence, but also psychosexual consequences like body image, depression and anxiety [START_REF] Krouse | Quality of life outcomes in 599 cancer and non-cancer patients with colostomies[END_REF][START_REF] Mols | Living with the physical and mental consequences of an ostomy: a study among 1-10-year rectal cancer survivors from the population-based PROFILES registry[END_REF]. Personal distress is higher in cancer patients with low personal control who perceive their partner as having unsupportive behavior [START_REF] Dagan | Spousal support and changes in distress over time in couples coping with cancer: the role of personal control[END_REF]. In couples coping with CRC, partners' supportiveness is reported to possibly maintain relationship satisfaction [START_REF] Hagedoorn | Relationship satisfaction in couples confronted with colorectal cancer: the interplay of past and current spousal support[END_REF]. Unfortunately, literature concerning treatment-related sexual disorders in CRC has several limits. Systematic reviews about sexual functioning in CRC patients after treatment highlighted wide ranges in the prevalence of sexual dysfunctions possibly related to methodological limits (i.e. small sample size, retrospective design, and empirical evaluation) [START_REF] Cornish | The effect of restorative proctocolectomy on sexual function, urinary function, fertility, pregnancy and delivery: a systematic review[END_REF][START_REF] Ho | Sexual function after treatment for rectal cancer: a review[END_REF]. Another weakness is that most of the literature focuses on excitement (erectile function in men and lubrication in women) [START_REF] Cornish | The effect of restorative proctocolectomy on sexual function, urinary function, fertility, pregnancy and delivery: a systematic review[END_REF][START_REF] Breukink | Physical and psychological effects of treatment on sexual functioning in colorectal cancer survivors[END_REF][START_REF] Daniels | Female urogenital dysfunction following total mesorectal excision for rectal cancer[END_REF][START_REF] Lange | Cooperative clinical investigators of the D (2009) Risk factors for sexual dysfunction after rectal cancer treatment[END_REF][START_REF] Frick | Survivorship after lower gastrointestinal cancer: Patient-reported outcomes and planning for care[END_REF], with a few data concerning the other domains of sexual function, like sexual desire and orgasm difficulties [START_REF] Traa | Sexual (dys)function and the quality of sexual life in patients with colorectal cancer: a systematic review[END_REF][START_REF] Hendren | Prevalence of male and female sexual dysfunction is high following surgery for rectal cancer[END_REF][START_REF] Ho | Sexual function after treatment for rectal cancer: a review[END_REF]. Finally, there is a lack of detailed evaluation regarding women, comparing colon and rectal cancer, and analyzing the impact of ostomy and fecal incontinence.

Recently, the French national VICAN survey assessed several aspects of cancer patients' quality of life 2 years after diagnosis, including sexual health problems [START_REF]La vie deux ans après un diagnostic de cancer -De l'annonce à l'après cancer[END_REF][START_REF] Charif | Sexual health problems in French cancer survivors 2 years after diagnosis-the national VICAN survey[END_REF][START_REF] Bouhnik | The labour market, psychosocial outcomes and health conditions in cancer survivors: protocol for a nationwide longitudinal survey[END_REF]. However, since the VICAN survey focused on the impact of cancer on employment, previous reports did not provide detailed information on patients' sexual life. Therefore, we aimed at focusing thoroughly on VICAN CRC patients' sexual health and disorders 2 years after diagnosis. A second objective was to assess discussion about sexuality with Health Care Providers (HCPs).

METHODS

Study design

The VICAN survey is a nationwide longitudinal study that currently includes two crosssectional surveys (at 2 and 5 years after diagnosis) with the same objectives and various topics for cancer survivors [START_REF] Bouhnik | The labour market, psychosocial outcomes and health conditions in cancer survivors: protocol for a nationwide longitudinal survey[END_REF][START_REF] Alleaume | Chronic neuropathic pain negatively associated with employment retention of cancer survivors: evidence from a national French survey[END_REF]. For more details, the methodology of the "Vie après cancer" (VICAN) study was published elsewhere [START_REF] Bouhnik | The labour market, psychosocial outcomes and health conditions in cancer survivors: protocol for a nationwide longitudinal survey[END_REF].

Setting

The VICAN 2-year survey was carried out in France between March and December 2012. It included cancer patients initially diagnosed or managed in public centers (academic or nonacademic hospital), comprehensive cancer centers, and/or private centers [START_REF] Bouhnik | The labour market, psychosocial outcomes and health conditions in cancer survivors: protocol for a nationwide longitudinal survey[END_REF].

Participants

The VICAN study targeted men and women aged 20-84 at the time of the survey, diagnosed between January and June 2010 and registered in the Long Duration Disease File of the National Health Insurance File of one of the three main French Health Insurance Schemes which cover >90% of the population. It was restricted to 12 cancer sites with good, intermediate or poor prognosis, accounting for 88 % of cancer incidence in France. Eligibility was French-speaking patients diagnosed with first malignant cancer and living in France for at least 2 years [START_REF] Bouhnik | The labour market, psychosocial outcomes and health conditions in cancer survivors: protocol for a nationwide longitudinal survey[END_REF]. For the purposes of the current study, we restricted to CRC patients.

Data collection

Three sources of data were used in the VICAN survey: patient questionnaires, medical surveys completed by physicians who initiated cancer treatment and medico-administrative databases. Patients were identified with the medico-administrative databases and received a letter of invitation to participate in computer-assisted telephone interviews.

Patient questionnaire included socio-demographic characteristics, comorbidities and the sexual health validated psychometric scale.

Sexual health assessment

Sexual health from the onset of cancer was evaluated using 6 items from the « Relationship and Sexuality Scale (RSS) », validated by Berglund et al. [START_REF] Berglund | Effect of endocrine treatment on sexuality in premenopausal breast cancer patients: a prospective randomized study[END_REF]. The RSS has been developed for women, but the items in this questionnaire are not gender-dependent and have been used previously for assessing relationship and sexuality in both genders [START_REF] Tavallaii | Correlation between sexual function and postrenal transplant quality of life: does gender matter?[END_REF][START_REF] Assari | Association between Sexual Function and Marital Relationship in Patients with Ischemic Heart Disease[END_REF][START_REF] Charif | Sexual health problems in French cancer survivors 2 years after diagnosis-the national VICAN survey[END_REF].

The first 3 items used are from the "sexual function" dimension in the RSS and were used to measure patients' perception of deterioration of the following factors since cancer diagnosis: sexual desire (range 0 to 3), orgasm (range 0 to 4) and frequency of sexual intercourse (range 0 to 4). For each of these three items, higher scores were indicative of poorer perceived sexual conditions.

The last 3 items used are from the "sexual frequency" dimension in the RSS, assessing satisfaction with the frequency of hugs and kisses, satisfaction with the frequency of intercourse and frequency (no.) of intercourse during the last 2 weeks. Each item was scored from 0 to 4, higher scores indicating higher frequency.

All the 6 items, out of the 9 proposed by Berglund et al. [START_REF] Berglund | Effect of endocrine treatment on sexuality in premenopausal breast cancer patients: a prospective randomized study[END_REF], were used separately. In that respect, unless each item in Berglund's scale is validated, the scores on the individual items have face validity only.

Cancer site

The International Classification of Diseases (ICD-10) from the medico-administrative databases was used to classify patients with "Colon cancer" (Cecum, C18 + Rectosigmoid junction, C19) and "Rectal cancer" (Rectum, C20).

Medical characteristics

Medical and medico-administrative databases were used to collect data on patient treatments including surgery, chemotherapy regimen, radiotherapy and endocrine therapy. Missing data were completed with patients and physician-reported information.

Ostomy

Medical and medico-administrative databases were used to collect information about the existence of permanent or temporary ostomy. Missing data were supplemented with information from patients' and physicians' questionnaires.

Fecal incontinence

We used patient-reported information about their experiencing of fecal incontinence through ostomy or the anus, when applicable.

Discussion about sexuality with HCPs

Patient questionnaires included an item on sexuality-related discussions with HCPs: "Since cancer diagnosis, have you talked about your sexual health with health care staff?" Four responses were proposed: "yes, at the initiative of the staff," "yes, on my own initiative," "no, I did not wish to," and "no, nobody proposed it to me." This item referred to any visit during the past 2 years since diagnosis and was inspired by similar measurements developed by Gilbert et al. [START_REF] Gilbert | Talking about sex with health professionals: the experience of people with cancer and their partners[END_REF]; their three simple items were combined into a one-item measurement.

Study size

The final VICAN study sample included 4 349 participants (global response rate of 43.7 %), including 487 CRC patients [START_REF] Bouhnik | The labour market, psychosocial outcomes and health conditions in cancer survivors: protocol for a nationwide longitudinal survey[END_REF].

Statistical analysis

A weighting procedure was first performed to make the CRC sample representative of the target population according to age and insurance plan disease. The weights were calculated in order to make the sample structure identical, in terms of age and health insurance scheme, to that observed in the sampling frame. For each stratum of the sample, the weight of the survey was calculated as the inverse of the survey rate (total number selected individuals / size of the stratum in the frame).

We analyzed data using Mann-Whitney and t-tests to compare age, and RSS scores by gender, cancer site, ostomy and fecal incontinence. Chi-square and Fisher exact tests were used to compare discussion rates and social, medical and RSS categories by gender, cancer site, ostomy and fecal incontinence. Univariate linear regressions were performed to describe variables associated with each RSS sexual item. Univariate logistic regressions were performed to describe factors associated with the discussion about sexuality. All variables whose critical probability (p) was <.20 in univariate analyses were eligible for the multivariate models. When eligibility was were not applicable, potential confusing variables were systematically entered in the regression models (age, gender, partnership, having children, education, having a job, household income, cancer treatments and having diabetes).

Statistical analyses were performed using Stata version 14 (Stata Corp., College Station, TX, USA) and weighted to ensure representativeness at a national level. Statistical significance was considered to be p < .05. Findings are reported according to the STROBE statement.

RESULTS

Participants

The sample included 487 patients with CRC, who responded to a phone survey, 2 years after their diagnosis. (Figure 1)

Characteristics of participants

Descriptive results of participants are outlined in Table 1. Most CRC patients were men (n=258, 53%), older and more likely to live in couple or have diabetes than women. There was no difference between men and women in occupation, education and monthly income.

The studied sample was composed of 374 colon (77%) and 113 rectal (23%) cancers. Women had a higher proportion of colon cancer than men (p=.002) and underwent less frequently radiotherapy (p<.001). (Table 1)

Sexual disorders

Overall, 54% (235/435) of patients reported a decrease in sexual desire, 61% (246/402) a decrease in frequency of intercourse, and 48% (191/395) a decrease in the possibility to reach an orgasm. However, 89% (339/382) of patients were satisfied with the frequency of hugging and kissing, and 77% (301/389) with the frequency of intercourse. Of the respondents, 60% (235/435) declared they had at least one sexual intercourse during the last two weeks. Men and women were comparable for all assessed sexual issues.

Decrease in sexual desire

Factors positively associated with a decrease in sexual desire in multivariate analyses were rectal cancer and fecal incontinence, while patients with higher monthly income were less likely to report a decrease in their sexual desire. (Table 2)

Decrease in the frequency of intercourse

Employment status at diagnosis, chemotherapy, surgery and fecal incontinence were factors independently associated with a decrease in the frequency of intercourse, while patients with higher monthly income were also less likely to report a decrease in the frequency of sexual intercourse. (Table 3)

Difficulty to reach orgasm

Age, employment status at diagnosis, cancer site and fecal incontinence were factors independently associated with difficulty to reach orgasm, while patients with a higher education or diabetes were less likely to report such a difficulty. (Table 4)

Satisfaction with the frequency of hugging and kissing

Factors negatively associated with satisfaction with the frequency of hugging and kissing in multivariate analyses were age, having dependent children, chemotherapy and fecal incontinence. (Table 5)

Satisfaction with the frequency of intercourse

Age, employment status at diagnosis and fecal incontinence were factors negatively associated with satisfaction with the frequency of intercourse, while patients with higher income were more likely to be satisfied. (Table 6)

Frequency (no.) of intercourse during the last two weeks

Age, chemotherapy and fecal incontinence were negatively associated with the frequency (no.) of intercourse during the last two weeks in multivariate analyses, while patients with ostomy were more likely to report a higher frequency. (Table 7)

Discussion about sexuality

Of the 466 respondents, only 16% of patients recalled having discussed sexuality with the medical team. In the univariate analysis women and colon cancers had received an information significantly less frequently than men (11% of women vs. 20% of men: p=.025) and rectal cancers (11% of colon cancers vs. 33% of rectal cancers: p .004), respectively. In

the

DISCUSSION

To our knowledge, our study is the first to assess both sexual health problems and discussion about it in a large national representative sample of CRC patients. We found frequent sexual problems, but a lack of information delivery concerning these problems. However, physicians might often assume that this finding is almost exclusively true for patients with rectal cancer. Indeed, surgery of rectal cancer may damage vasculo-nervous bundles, what may result in a neurogenic erectile dysfunction in males and may disrupt sexual response in women [START_REF] Breukink | Physical and psychological effects of treatment on sexual functioning in colorectal cancer survivors[END_REF].

Surgery and/or radiotherapy of colon cancer should not result in such organic disturbances.

Our results confirm that rectal cancer patients are a population facing a high risk of sexual troubles 2 years after cancer diagnosis, since, in multivariate analyses, they had a higher alteration of sexual desire in 68% and more difficulty reaching an orgasm in 71%, than patients with colon cancer. Additionally, a higher proportion of rectal cancer patients were more dissatisfied with the frequency of intercourse and less likely to have intercourse during the last two weeks, in univariate analyses only. However, colon cancer should not be overlooked, as a significant proportion of patients treated for a colon cancer have a deterioration of their sexual life following cancer treatment. Whereas Frick et al. only observed erectile dysfunction in 17.9% of male colon cancer survivors and sexual changes in 36.8% of female colon cancer survivors [START_REF] Frick | Survivorship after lower gastrointestinal cancer: Patient-reported outcomes and planning for care[END_REF], we observed more recurrent issues in this population with an alteration of libido in 50%, a difficulty to reach orgasm in 42%, and 37% of patients with colon cancer having no intercourse during the last two weeks.

Therefore, we may argue that whatever the location of CRC, the issue of sexuality should be addressed to the patients.

Comparing genders, CRC women have similar RSS scores as men for any of the studied items. Rates for decrease in desire, frequency of intercourse and orgasm RSS items rank high both in men and women (at least 1 patient out of 2). In another study including 78 CRC patients undergoing chemotherapy [START_REF] Almont | Sexual health and needs for sexology care in digestive cancer patients undergoing chemotherapy: a 4-month cross-sectional study in a French University Hospital[END_REF], we also found a high frequency of disorders in women (87% had at least desire, excitement and pain issues at the same time). Interestingly, in this previous study, we found that sexual rehabilitation interventions in digestive cancer were less effective in women than in men, even though women were willing to use a sexual health service as frequently as men (45% vs. 43%, respectively; p=.820) [START_REF] Almont | Sexual health and needs for sexology care in digestive cancer patients undergoing chemotherapy: a 4-month cross-sectional study in a French University Hospital[END_REF]. Physicians should not conclude wrongly that women with CRC would not deserve sexual rehabilitation.

Correspondingly, a recent Internet-based survey involving 1129 lower gastrointestinal cancer survivors, showed that sexual changes were reported by 36.8%, 62% and 45.2% of female colon, rectal and anal cancer survivors (p<.01), respectively [START_REF] Frick | Survivorship after lower gastrointestinal cancer: Patient-reported outcomes and planning for care[END_REF]. It is urgent to develop specific interventions for women as effective as those available for men.

Regarding their effects, our results clearly show that ostomy or fecal incontinence are a group with a significant impact on sexuality. While patients with fecal incontinence during the past seven days have a deterioration of all the RSS sexual life items (desire, number and frequency of intercourse, capacity to reach orgasm, satisfaction with hugging and kissing and satisfaction with frequency of intercourse) after multivariate analyses, patients who have been treated with an ostomy have similar RSS item issues than patients without. This result can be explained by the fact that only 34 patients (7%) still have an ostomy 2 years after diagnosis.

The psychological impact of ostomy, notably on self-esteem and body image have ever been highlighted [START_REF] Kilic | The effect of permanent ostomy on body image, self-esteem, marital adjustment, and sexual functioning[END_REF][START_REF] Aktas | Body Image Perceptions of Persons With a Stoma and Their Partners: A Descriptive, Cross-sectional Study[END_REF]. However, for long, digestive surgeons have worked to develop surgical procedures that do not require the wearing of a definitive stoma [START_REF] Saito | Early results of intersphincteric resection for patients with very low rectal cancer: an active approach to avoid a permanent colostomy[END_REF][START_REF] Dumont | Surgical strategy for low rectal cancers[END_REF][START_REF] Da Silva | Perineal colostomy: an alternative to avoid permanent abdominal colostomy: operative technique, results and reflection[END_REF]. For this reason, rectal cancer surgery with anterior resection and colo-anal anastomosis is presented as better preserving sexual quality of life than abdominoperineal amputation, imposing the wearing of a definitive stoma. The reality is more complex. Our results show that, even if both ostomy and fecal incontinence impact sexual desire and frequency of intercourse, in univariate analyses, the troubles are more critical for fecal incontinence, concerning all 6 items measured in multivariate analyses. Another element of understanding is that patients with ostomy discussed more frequently sexuality with the medical team, contrary to fecal incontinence which was not associated with the discussion about sexuality.

Concerning communication about sexuality, a lack of information delivery about sexual impacts of CRC and its treatment has been observed by several studies [START_REF] Charif | Sexual health problems in French cancer survivors 2 years after diagnosis-the national VICAN survey[END_REF][START_REF] Almont | Sexual quality of life and needs for sexual care of cancer patients admitted for radiotherapy : a 3-month cross-sectional study[END_REF][START_REF] Ussher | Talking about sex after cancer: a discourse analytic study of health care professional accounts of sexual communication with patients[END_REF][START_REF] Mancini | Infertility induced by cancer treatment: inappropriate or no information provided to majority of French survivors of cancer[END_REF][START_REF] Hordern | Issues of intimacy and sexuality in the face of cancer: the patient perspective[END_REF][START_REF] Eker | The impact of cancer and its treatment on sexual desire, satisfaction and functioning: findings from an exploratory study in rural Turkey[END_REF]. Unlike those studies, we observed no statistically significant difference between men and women in information delivery after multiple adjustments. However, in our CRC population, only 16% of patients (11% women and 20% men) reported having discussed sexuality with the medical team throughout their care management. This result highlights the need for improving information delivery and counseling in CRC patients. In that respect, Reese et al. performed a pilot study of a telephone-based intervention teaching CRC patients and their partners cognitive and behavioral skills for coping with sexual changes. The authors concluded that such an intervention is feasible and holds promise for improving sexual and intimacy outcomes in CRC patients and their partners [START_REF] Reese | Pilot feasibility study of a telephonebased couples intervention for physical intimacy and sexual concerns in colorectal cancer[END_REF].

The deficient proportion of informed patients may be explained by the fact that 77% of our sample was composed of colon cancer. The non-pelvic location could have led oncologists to consider that the risk of sexual damage was not an important issue. However, even the sexual function is less likely to be impacted in colon cancers, this cancer site is known to come with specific physical and psychosexual issues [START_REF] Mols | Living with the physical and mental consequences of an ostomy: a study among 1-10-year rectal cancer survivors from the population-based PROFILES registry[END_REF]. Low rates of informed patients could also be explained by all the barriers to communication about sexuality reported in literature, like lack of time, embarrassment, discomfort, lack of knowledge, lack of confidence, difficulties to refer patients to a specialist, uncertainty regarding responsibility for active counselling, sex as irrelevant or inappropriate for some patients, or structural constraints in the clinical setting [START_REF] Ussher | Talking about sex after cancer: a discourse analytic study of health care professional accounts of sexual communication with patients[END_REF][START_REF] Dyer | Why don't healthcare professionals talk about sex? A systematic review of recent qualitative studies conducted in the United kingdom[END_REF][START_REF] Julien | Identification of barriers to sexual health assessment in oncology nursing practice[END_REF][START_REF] Park | Sexual health communication during cancer care: barriers and recommendations[END_REF].

We also observed that patients aged under 55 (sample mean age) received more frequently information about sexuality than older ones. This result highlight that stereotypical beliefs regarding the sexuality of seniors remain a steady issue [START_REF] Puts | A systematic review of unmet needs of newly diagnosed older cancer patients undergoing active cancer treatment[END_REF][START_REF] Milbury | The association between psychosocial and medical factors with long-term sexual dysfunction after treatment for colorectal cancer. Supportive care in cancer : official journal of the Multinational Association of Supportive Care in[END_REF]. Therefore, it would be valuable to convince health care professionals that sexuality remains a fundamental component of quality of life, regardless of the age of patients [START_REF] Hall | Young adult cancer survivors' psychosocial well-being: a cross-sectional study assessing quality of life, unmet needs, and health behaviors. Supportive care in cancer : official journal of the Multinational Association of Supportive Care in[END_REF][START_REF] Li | Interpreting differences in patterns of supportive care needs between patients with breast cancer and patients with colorectal cancer[END_REF][START_REF] Mccallum | Sexual health and gynecological cancer: conceptualizing patient needs and overcoming barriers to seeking and accessing services[END_REF][START_REF] Reese | Sexual concerns in lung cancer patients: an examination of predictors and moderating effects of age and gender[END_REF].

Since main barriers to the discussion are well documented, healthcare providers should now be encouraged to seek training in sexual health, particularly in oncosexology as it relates to cancer and its treatments. A previous survey including 165 healthcare professionals providing sexology care to cancer patients showed that 75.8% of respondents would like specific training in oncosexology, even those who were already degreed in sexology [START_REF] Almont | Sexual health in cancer: the results of a survey exploring practices, attitudes, knowledge, communication, and professional interactions in oncology healthcare providers[END_REF]. This illustrates the fact that oncosexology is an emerging specific field of sexology necessitating specific training programs [START_REF] Huyghe | Training in oncosexology: current and future provisions[END_REF].

Study strengths and limitations

The strengths of our study were the sample size, its national representativeness using the data of a large-scale nation-wide survey, and the possibility to compare colon and rectal cancers based on detailed and reliable data from the combination of patient-reported outcomes, medical records and medico-administrative databases.

However, the cross-sectional analysis performed was a limitation without any assessment of sexuality before cancer diagnosis for the 3 items evaluating 3 "sexual frequency".

Another limit concerns missing data treated by using standard complete data methods.

Nevertheless, missing data regarding information were relatively rare (4%) and were limited from 11% to 21% for the RSS, depending on the items.

Finally, the VICAN survey shares the general limitations of any approach using self-reported questionnaires, like memory or social desirability bias for instance.

CONCLUSION

This study is an original approach to sexuality assessment in CRC patients, comparing colon versus rectal cancer, as well as assessing the impact of ostomy and fecal incontinence. It revealed that more than half of patients experience an impact of disease and treatments on their sexual life two years after diagnosis. These results highlight the need for specific and effective sexual rehabilitation interventions, especially for patients with fecal incontinence and rectal cancer. Such an implementation may help them to improve their sexual prognosis.

Another interest of this study is to sensitize health care professionals about the lack of communication about sexuality with the medical team particularly seniors, those without ostomy, and those not having radiotherapy, who were populations less likely to discuss sexuality.

LIST OF ABBREVIATIONS

  weighted multivariate analysis, factors remaining independently associated to discussion

	about sexuality are younger age (OR=2.76 [1.31; 5.84], p=.007), having ostomy (OR=2.93
	[1.27; 6.73], p=.011) and radiotherapy (OR=2.78 [1.23; 6.27], p=.014). (Table 8).

Table 1 : Patients' characteristics

 1

	CRC, Colorectal Cancer
	HCPs, Health Care Providers
	OR, Odds Ratio
	RSS, Relationship and Sexuality Scale
	VICAN, Vie après Cancer (life after cancer)
	DECLARATIONS

Table 2 : Factors associated with decrease in sexual desire

 2

	5 6
					Weighted univariate analysis	Weighted multivariate stepwise analysis
		Decrease in sexual desire	n	mean ± sd	p	Coef.	[95% Conf. Interval]	p
		Age (mean ± sd)	54.40 ± 12.64 435	1.67 ± .75	.479		removed a
			Women	200	1.76 ± .82
		Gender				.122
			Men	235	1.59 ± .68		-.14	[-.33; .05]	.151
		Partnered at time of survey	No Yes	62 373	1.68 ± .86 1.67 ± .73	.777		removed a
		Having at least 1 dependent child at home at time of survey	No Yes	288 147	1.72 ± .76 1.57 ± .73	.516		not included
		Education	< Bachelor Degree ≥ Bachelor Degree	242 192	1.74 ± .77 1.58 ± .72	.007 **	-.16	[-.34; .02]	.085
		Have a job at diagnosis	No Yes	182 253	1.69 ± .84 1.66 ± .68	.386		not included
		Household income at time of survey	≤ 1,500 € > 1,500 €	217 199	1.76 ± .78 1.57 ± .70	.002 **	-.21	[-.40; -.02]	.028 *
			Colon	333	1.61 ± .74
		Cancer site				.001 ***
			Rectum	102	1.87 ± .77		.32	[.11; .53]	.003 **
		Treatment including radiotherapy	No Yes	328 107	1.60 ± .74 1.89 ± .76	.002 **		removed a
		Treatment including chemotherapy	No Yes	149 286	1.45 ± .69 1.78 ± .76	.013 *	.18	[-.01 ; .36]	.067
		Treatment including surgery	No Yes	215 220	1.55 ± .72 1.78 ± .76	.002 **		removed a
		Treatment including ostomy	No Yes	345 90	1.63 ± .74 1.81 ± .79	.026 *		removed a
		Fecal incontinence	No	344	1.58 ± .72
		during the past 7				< .001 ***
		days	Yes	91	2.02 ± .76		.48	[.24; .73]	< .001 ***
			No	408	1.68 ± .75
		Diabetic				.577		not included
			Yes	27	1.56 ± .75
	7 8 9	a removed because p>.20 in multivariate model * p ≤ .05; ** p ≤ .01; *** p ≤ .001

Table 3 : Factors associated with decrease in the frequency of intercourse 10 11

 3

				Weighted univariate analysis	Weighted multivariate stepwise analysis
	Decrease in the frequency of intercourse	n	mean ± sd	p	Coef.	[95% Conf. Interval]	p
	Age (mean ± sd)	53.93 ± 12.44 402	2.95 ± .94	.329	.01	[-.00; .02]	.173
		Women	179	2.96 ± .96
	Gender				.767		removed a
		Men	223	2.95 ± .92
	Partnered at time of survey	No Yes	42 360	2.93 ± 1.07 2.95 ± .93	.439		removed a
	Having at least 1 dependent child at home at time of survey	No Yes	258 144	2.91 ± .95 3.02 ± .92	.046 *		removed a
		< Bachelor Degree	221	3.00 ± .94
	Education				.199		removed a
		≥ Bachelor Degree	180	2.89 ± .94
	Have a job at diagnosis	No Yes	160 242	2.84 ± .98 3.02 ± .91	.007 **	.33	[.05; .62]	.022 *
	Household income at time of survey	≤ 1,500 € > 1,500 €	197 189	3.06 ± .97 2.84 ± .91	.041 *	-.32	[-.54; -.10]	.005 **
		Colon	305	2.85 ± .94
	Cancer site				.001 ***		removed a
		Rectum	97	3.26 ± .89
	Treatment including radiotherapy	No Yes	300 102	2.81 ± .93 3.35 ± .86	.001 ***		removed a
	Treatment including chemotherapy	No Yes	138 264	2.65 ± .86 3.11 ± .95	.002 **	.25	[.01 ; .49]	.040 *
	Treatment including surgery	No Yes	199 203	2.72 ± .93 3.17 ± .90	< .001 ***	.39	[.15 ; .63]	.001 **
	Treatment including ostomy	No Yes	320 82	2.88 ± .94 3.24 ± .88	.002 **		removed a
	Fecal incontinence	No	319	2.85 ± .92
	during the past 7				< .001 ***
	days	Yes	83	3.35 ± .90		.46	[.19; .73]	.001 ***
		No	378	2.98 ± .94
	Diabetic				.029 *
		Yes	24	2.50 ± .78		-.38	[-.80; .03]	.072
	a removed because p>.20 in multivariate model

Table 4 : Factors associated with difficulty to reach an orgasm 15 16

 4

					Weighted univariate analysis	Weighted multivariate stepwise analysis
		Difficulty to reach an orgasm	n	mean ± sd	p	Coef.	[95% Conf. Interval]	p
		Age (mean ± sd)	53.71 ± 12.38 395	2.73 ± .91	.300	.02	[.01; .03]	.002 **
			Women	177	2.72 ± .90
		Gender				.985		removed a
			Men	218	2.73 ± .92
		Partnered at time of survey	No Yes	40 355	2.52 ± .96 2.75 ± .90	.878		removed a
		Having at least 1 dependent child at home at time of survey	No Yes	252 143	2.77 ± .91 2.64 ± .90	.785		not included
		Education	< Bachelor Degree ≥ Bachelor Degree	216 178	2.83 ± .96 2.60 ± .83	.008 **	-.30	[-53; .-.07]	.011 *
		Have a job at diagnosis	No Yes	155 240	2.74 ± .92 2.72 ± .90	.082	.30	[.02; .59]	.034 *
		Household income at time of survey	≤ 1,500 € > 1,500 €	191 187	2.74 ± .99 2.70 ± .83	.237		not included
			Colon	303	2.61 ± .89
		Cancer site				< .001 ***
			Rectum	92	3.10 ± .89		.31	[.06; .56]	.014 *
		Treatment including radiotherapy	No Yes	298 97	2.60 ± .85 3.10 ± .98	< .001 ***	.23	[-.09; .56]	.152
		Treatment including chemotherapy	No Yes	136 259	2.51 ± .79 2.84 ± .95	.025 *	.19	[-.05 ; .43]	.127
		Treatment including surgery	No Yes	197 198	2.53 ± .85 2.92 ± .93	.006 **		removed a
		Treatment including ostomy	No Yes	315 80	2.65 ± .88 3.01 ± .99	.114		removed a
		Fecal incontinence	No	316	2.61 ± .84
		during the past 7				< .001 ***
		days	Yes	79	3.18 ± 1.05		.63	[.37; .89]	< .001 ***
			No	373	2.75 ± .92
		Diabetic				.027 *
			Yes	22	2.36 ± .73		-.55	[-.92; -.18]	.004 **
	17 18 19 20	a removed because p>.20 in multivariate model * p ≤ .05; ** p ≤ .01; *** p ≤ .001

Table 5 : Factors associated with satisfaction with frequency of hugging and kissing 21 22

 5

				Weighted univariate analysis	Weighted multivariate stepwise analysis
	Satisfaction with frequency of hugging and kissing	n	mean ± sd	p	Coef.	[95% Conf. Interval]	p
	Age (mean ± sd)	54.23 ± 12.55 382 2.12 ± 1.14	.336	-.01	[-.03; -.00]	.031 *
		Women	171 2.02 ± 1.08
	Gender				.259		removed a
		Men	211 2.19 ± 1.18
	Partnered at time of survey	No Yes	27 355 2.15 ± 1.11 1.67 ± 1.41	.430		removed a
	Having at least 1 dependent child at home at time of survey	No Yes	248 2.17 ± 1.15 134 2.01 ± 1.12	.209	-.35	[-62; -.07]	.013 *
	Education	< Bachelor Degree ≥ Bachelor Degree	213 2.08 ± 1.16 168 2.17 ± 1.12	.663		not included
	Have a job at diagnosis	No Yes	154 2.14 ± 1.14 228 2.11 ± 1.14	.853		not included
	Household income at time of survey	≤ 1,500 € > 1,500 €	185 2.02 ± 1.17 180 2.23 ± 1.06	.111		removed a
		Colon	288 2.12 ± 1.14
	Cancer site				.737		not included
		Rectum	94	2.11 ± 1.15
	Treatment including radiotherapy	No Yes	286 2.15 ± 1.12 96 2.01 ± 1.19	.143		removed a
	Treatment including chemotherapy	No Yes	136 2.35 ± 1.07 246 1.99 ± 1.16	.027 *	-.43	[-.72; -.14]	.004 **
	Treatment including surgery	No Yes	188 2.13 ± 1.09 194 2.10 ± 1.19	.926		not included
	Treatment including ostomy	No Yes	305 2.10 ± 1.13 77 2.21 ± 1.17	.885		not included
	Fecal incontinence	No	303 2.19 ± 1.11
	during the past 7				.017 *
	days	Yes	79	1.85 ± 1.21		-.50	[-.92; -.09]	.016 *
		No	362 2.13 ± 1.14
	Diabetic				.166		removed a
		Yes	20	1.85 ± 1.23

a removed because p>.20 in multivariate model

Table 6 : Factors associated with satisfaction with frequency of intercourse 26 27

 6

					Weighted univariate analysis	Weighted multivariate stepwise analysis
		Satisfaction with frequency of intercourse	n	mean ± sd	p	Coef.	[95% Conf. Interval]	p
		Age (mean ± sd)	53.70 ± 12.44 389 1.68 ± 1.19	.516	-.02	[-.03; -.00]	.013 *
			Women	171 1.64 ± 1.17
		Gender				.978		removed a
			Men	218 1.72 ± 1.20
		Partnered at time of survey	No Yes	39 350 1.73 ± 1.17 1.28 ± 1.30	.361		removed a
		Having at least 1 dependent child at home at time of survey	No Yes	251 1.65 ± 1.18 138 1.75 ± 1.20	.921		not included
			< Bachelor Degree	216 1.60 ± 1.18
		Education				.347		not included
			≥ Bachelor Degree	172 1.77 ± 1.19
		Have a job at diagnosis	No Yes	151 1.72 ± 1.24 238 1.66 ± 1.15	.157	-.37	[-.71; -.02]	.037 *
		Household income at time of survey	≤ 1,500 € > 1,500 €	187 1.54 ± 1.17 186 1.82 ± 1.17	.007 **	.41	[.12; .69]	.005 **
			Colon	295 1.78 ± 1.18
		Cancer site				.005 **		removed a
			Rectum	94	1.36 ± 1.15
		Treatment including radiotherapy	No Yes	290 1.83 ± 1.15 99 1.25 ± 1.21	.002 **	-.37	[-.77; -.04]	.075
		Treatment including chemotherapy	No Yes	136 1.94 ± 1.06 253 1.54 ± 1.23	.026 *	-.26	[-.58; .05]	.100
		Treatment including surgery	No Yes	190 1.83 ± 1.14 199 1.54 ± 1.22	.020 *		removed a
		Treatment including ostomy	No Yes	310 1.71 ± 1.18 79 1.58 ± 1.20	.709		not included
		Fecal incontinence	No	309 1.82 ± 1.15
		during the past 7				< .001 *
		days	Yes	80	1.16 ± 1.18		-.71	[-1.06; -.37]	< .001 ***
			No	366 1.67 ± 1.17
		Diabetic				.894		not included
			Yes	23	1.91 ± 1.38
	28 29 30	a removed because p>.20 in multivariate model * p ≤ .05; ** p ≤ .01; *** p ≤ .001

Table 8 : Factors associated with discussing sexuality with the medical team Since cancer diagnosis, have you talked about your sexual health with health care staff

 8

			?			n (%)
			Yes, at the initiative of the staff		27 (6)
	Yes
			Yes, on my own initiative		48 (10)
			No, I did not wish to		110 (23)
	No
			No, nobody proposed it to me		281 (58)
			Cannot remember			6 (1)
			Refused to answer			5 (1)
			Missing data			10 (2)
			Weighted univariate analysis	Weighted multivariate stepwise analysis
	Discussing sexuality with the medical team:	Yes/No (%)	p	OR	[95% Conf. Interval]	p
		Women	24/193 (11)		-	-	-
	Gender			.025 *
		Men	51/198 (20)		2.02	[.93; 4.40]	.075
		> 55	15/151 (9)
	Age			.005 **
		≤ 55	60/240 (20)		2.77	[1.31; 5.84]	.007 **
		Yes	66/318 (17)
	Partnered			.107		removed a
		No	9/73 (11)
		Colon	39/318 (39)
	Cancer site			.004 **		removed a
		Rectum	36/73 (33)
	Treatment including radiotherapy	No Yes	31/321 (9) 44/70 (39)	< .001 ***	-2.78	-[1.23; 6.27]	-.014 *
	Treatment including chemotherapy	No Yes	11/153 (7) 64/238 (21)	.009 **		removed a
	Treatment including surgery	No Yes	18/219 (9) 57/180 (24)	.001 ***		removed a
	Treatment including ostomy	No Yes	44/325 (12) 31/66 (32)	< .001 ***	-2.93	-[1.27; 6.73]	-.011 *
	Fecal incontinence	No	49/319 (13)
	during the past 7			.040 *		removed a
	days	Yes	26/72 (26)
		No	73/364 (17)
	Diabetic			.253		not included
		Yes	2/27 (7)

a removed because p>.20 in multivariate model * p ≤ .05; ** p ≤ .01; *** p ≤ .001

* p ≤ .05; ** p ≤ .01; *** p ≤ .001 13

* p ≤ .05; ** p ≤ .01; *** p ≤ .001

Acknowledgements

We gratefully acknowledge the VICAN Group for allowing us to analyze their data.

Funding

The VICAN study was funded by the French National Institute of Cancer (Institut National du Cancer, INCa) "Contrat de recherche et développement no 05-2011". TA was supported by the French National League Against Cancer (PhD grant n° TDTJ12441-2013e2016).

Only the authors have responsibility for the information provided in this article.

Ethics approval

The VICAN study complied with the Helsinki declaration and was approved by three French [START_REF] Bouhnik | The labour market, psychosocial outcomes and health conditions in cancer survivors: protocol for a nationwide longitudinal survey[END_REF].

Competing interests

The authors declare that they have no competing interests.

Authors' contributions

Julien Mancini was involved in VICAN survey conception and design, manuscript drafting, interpretation of data and critical discussion.