Illness-related and treatment-related factors in psychological adjustment to breast cancer

Psychometric properties of the Persian version of the Cancer attitude inventory

BACKGROUND

The Cancer Attitude inventory (CAI) was developed to measure attitudes toward cancer. The aim of the present study was to describe the development of the Persian version of the CAI and to evaluate its psychometric properties in an Iranian sample.

METHODS

The forward-backward method was used to translate the CAI scale from English into Persian. After linguistic validation and a pilot check, a cross-sectional study was performed and psychometric properties of the Iranian version of the questionnaire were assessed. The scale validation was conducted with a convenience sample of 820 laypeople. Construct validity was assessed through both exploratory factor analysis (EFA) and confirmatory factor analysis (CFA). Internal consistency was assessed through Cronbach's alpha analysis and test-retest analysis.

RESULTS

Five factors were identified in CAI: isolation, helplessness, fear of consequence, belief of control and independence, and fear of death. The results achieved from the CFA displayed that the data fit the model: the relative chi-square (× 2/df) = 2.98 (p < .001), and the root mean square error of approximation (RMSEA) = .07 (90% CI = .06-.07). All comparative indices of the model had scores greater than .80, demonstrating a good fit to the data. Cronbach's Alpha and the intra-class correlation coefficient (ICC) were .97, which is well above the acceptable threshold.

CONCLUSIONS

The results indicate that the Persian version of the CAI is practical, reliable and valid. Consequently, the instrument could be used in plans to create positive attitudes about cancer control and treatment among Persian people.

Quality of Life in Patients with Early Stage Breast Carcinoma Treated with Conservation Surgery and Radiotherapy. An Italian Monoinstitutional Study

Aims

To evaluate the quality of life (QOL) in patients with early stage invasive carcinoma of the breast treated with conservative surgery and postoperative irradiation.

Methods

A mailed survey to examine QOL was conducted in 227 subjects with breast cancer treated in 1990 and 1994 with conservation surgery plus definitive irradiation. The self-compiled questionnaire was developed based on a series of 38 items assessing six core areas of QOL. Furthermore, the patients were requested to evaluate the degree of information provided by the medical staff concerning the disease, the treatment and related side effects and to evaluate the effects of the treatment on their social, overall QOL, and health status.

Results

The questionnaire was completed by 156 patients (68.7%) who had a median age of 56 years (range, 28–75 years) at the time of treatment and 59 years (range, 31–82 years) at the time of the study. The physical condition was reported to be good. Data relating to sexual life were provided by more than 90% of the patients. Some limitations in sexuality, some interference with sexual desire, and some modifications during intercourse were reported by 11, 11, and 10 patients, respectively. The subjective evaluations of the cosmetic results of the therapies were judged good-excellent by 56% of the patients, 12 (8%) only had a negative perception of their body image. Twenty-five percent of the sample declared that they felt tense, 19% nervous, 18% lonely, 27% anxious and 16% depressed. Only six patients (4%) declared that the treatment had had a bad on their social life, and 18 (11%) thought that their health status has been affected by the treatment. A worsening of QOL due to the disease or the treatment was reported by 8% of the responders. The amount of information received concerning the treatment and its side effects was considered sufficient by most of the patients.

Conclusions

The results of the study revealed a satisfactory health-related QOL in patients treated with breast conservation and postoperative irradiation. A preserved favorable body image and lack of a negative impact on sexuality was observed, even though about half of the patients reported a negative judgement on esthetic outcome. Some patients had persistent psychosocial concerns. No significant additional problems attributable to radiation therapy capable of affecting QOL outcomes were reported.

Patients’ Assessment of Quality of Care: A Survey of a Group of Breast Cancer Patients in Italy

Patients’ assessment of quality of care was investigated in 825 women with breast cancer treated in a group of specialized and non-specialized institutions in Italy. A 10-page mail questionnaire explored patients’ adjustment to the disease, satisfaction with care, and quality of the information on diagnosis and treatment. Most of the 428 (52 %) responders reported good or acceptable adjustment to the disease (as reflected by acceptable performance in some daily living activities), and favorable judgment about care providers, but many women complained of hospital organizational deficiencies. A contradictory picture emerged regarding the quality of information. Completeness and thoroughness appeared seriously deficient when examined objectively using a series of explicit predefined criteria, but patients’ assessments showed in most cases moderate or high satisfaction. The paper presents these results and discusses pros and cons in the use of patients’ opinions for evaluation of quality of care.

‘I’ve got a very dichotomous difference in the way that I perceive myself’: Positive and negative constructions of body image following cancer treatment

This study investigated how women constructed body image following cancer. Four women, aged 32–67 years, who had experienced breast or bowel cancer took part in a 2-hour, in-depth focus group. Discourse analysis revealed that women orientated to positive aspects of the post-treatment body (silhouette, trust, acceptance) while acknowledging that their experiences were also traumatic (hair loss, scarring, sickness, swelling). Bodies and illness were concealed from public judgment, and women developed new trust in their bodies due to overcoming cancer; post-cancer bodies were accepted despite opportunities for normalisation. Implications for those wanting to support women during and after cancer are discussed.

Psychological Stress, Adjustment and Cross-Cultural Considerations in Breast Cancer Patients

There is a dearth of information regarding the psychological experience of breast cancer in the South African context, particularly within the black population. Existing psychological studies have focused mainly on the healthy breast or instances of non-malignant disease, largely within the white population from a Western perspective. This study addressed some of these concerns and examined and compared the nature and degree of psychological distress with reference to specific variables experienced by South African black and white breast cancer patients. Fifty women, comprising two equal groups of 25 black and white breast cancer patients were assessed and compared in terms of their levels of depression, body image dysphoria and styles of psychological adjustment during the course of their post-surgical chemotherapy treatment. There were several differences in the psychological experiences of black and white breast cancer patients. Most of the black patients were found to experience greater levels of somatisation, depression and body image dysphoria and tended to utilise less adaptive styles of adjustment to their disease. The only measure on which both groups more closely resembled each other was that of anxiety. The greater levels of psychological distress reported by most of the black patient group may be due to traditional cultural reasons which possibly predispose them to suppress emotions or somatise them rather than display these outwardly, and because of a lack of knowledge and of psycho-oncological services for this group. These patients could be regarded as being at high risk for elevated distress levels requiring psychological intervention.

Predictors of Social Support and Psychological Distress in Women with Breast Cancer

This investigation sought to understand previous well-cited and worrisome findings that women treated for breast cancer with breast-conserving surgery compared to mastectomy experience less social support and more mood disturbance, and that social support from significant others erodes over time. Ninety-three women with breast cancer and a subset of their partners completed assessments at the time of surgical treatment and at 3 and 13 months post-treatment. Contrary to the previous findings, type of surgical treatment was not related to perceptions of social support or psychological functioning. Perceptions of social support and psychological distress decreased over time, and the discrepancy between recipients’ and providers’ judgments of available support increased over time. Low levels of physical functioning led to relative increases in social support, whereas high levels of psychological distress led to relative decreases in social support. Social support as rated by patients (but not their partners) was a significant predictor of changes in psychological distress.

Aging and Breast Cancer

The level of instrumental functioning of breast cancer cases aged 55 to 84 is compared to that of women of the same age without the disease. A total of 571 cases were selected through the Metropolitan Detroit Cancer Surveillance System and interviewed three (n = 463) and 12 (n = 422) months after diagnosis about their needs in transportation, housekeeping, meal preparation, and grocery shopping. A total of 647 controls aged 55 to 84 were selected through random-digit dialing and interviewed twice over the same period (n = 539 and 478). At three months, cases aged 55 to 74 report greater difficulty and less independence than controls in completing instrumental tasks. Little difference is shown between cases and controls aged 75 to 84. Nine months later, functional status is similar for cases and controls aged 55 to 64. In contrast, cases aged 65 to 74 continue to be less independent than controls of the same age.

Tranceformations: hypnosis in brain and body

In this review, the role of hypnosis and related psychotherapeutic techniques are discussed in relation to the anxiety disorders. In particular, anxiety is addressed as a special form of mind/body problem involving reverberating interaction between mental and physical distress. The history of hypnosis as a therapeutic discipline is reviewed, after which neurobiological evidence of the effect of hypnosis on modulation of perception in the brain. Specific brain regions involved in hypnosis are reviewed, notably the dorsal anterior cingulate gyrus and the dorsolateral prefrontal cortex. The importance of hypnotizability as a trait, stable variability in hypnotic responsiveness, is discussed. Analogies between the hypnotic state and dissociative reactions to trauma are presented, and the uses of hypnosis in treating posttraumatic stress disorder, stressful situations, and phobias as well as outcome data are reviewed. Effects of hypnosis on control of somatic processes are discussed, and then effects of psychosocial support involving Supportive-Expressive Group Therapy and hypnosis on survival time for cancer patients are evaluated. The evidence indicates an important role for hypnosis in managing anxiety disorders and anxiety related to medical illness.

Intrusive thoughts and avoidance in breast cancer: Individual differences and association with psychological distress

Abstract Eighty-five women with newly diagnosed breast cancer were classified on the basis of high and low levels of cancer-related intrusive thoughts and avoidance at diagnosis, and their psychological adjustment was studied prospectively at 3 and 6 months post diagnosis. Patients who initially reported high levels of both intrusive thoughts and avoidance and those who reported high levels of intrusive thoughts but low avoidance experienced the highest levels of anxiety and depression symptoms, and continued intrusive thoughts and avoidance. Patients who were high in avoidance but low in intrusive thoughts also experienced adjustment problems, including increased intrusive thoughts, when compared with patients who were low in both types of symptoms. The findings highlight the value of considering subgroup differences in patterns of intrusion and avoidance as predictors of subsequent psychological adjustment to breast cancer.

The impact of a multimedia informational intervention on psychosocial adjustment among individuals with newly diagnosed breast or prostate cancer: a feasibility study

OBJECTIVE

To examine the impact of an 8-week cancer multimedia informational intervention on health-related outcomes among individuals newly diagnosed with cancer.

METHODS

Using a pre-/post-quasi-experimental design, participants with breast or prostate cancer (n=250) were conveniently recruited from four oncology ambulatory clinics and completed questionnaires at three points (enrolment, 1-2 weeks post-intervention, and 3 months later).

RESULTS

Repeated-measure analyses showed that, when compared to controls, the intervention significantly improved satisfaction with cancer information over time for women (p<.001), prevented deterioration in functional quality of life (p=.030) and marginally improved perceived oncologist informational support (p=.051). There were no significant differences in psychosocial adjustment among men. Unlike previously suggested, the intervention did not have a differential impact according to levels of personal resources (self-esteem, mastery, and optimism). However, for all outcomes and regardless of group, participants high in personal resources reported better adjustment across time.

CONCLUSION

Even though the hypotheses were only partially supported, the findings provide preliminary evidence that multimedia interventions can be supportive.

PRACTICE IMPLICATIONS

With increasing numbers of new cancer diagnoses, cancer survivors and more limited health care resources, further research is needed to evaluate potential benefits of health information technology in providing support to individuals facing cancer.

Cancer patients and the provision of informational social support

Research into the impact of social support on health-care patients has focused on the benefits of receiving social support. Although recipients benefit from social support, there are also potential benefits to the providers of social support that have gone relatively unexplored. The purpose of this investigation was to examine the relationship between the reception and provision of informational social support by cancer patients. Based on the work of Gouldner (1960), this investigation attempts to examine the role reciprocity plays within the social support process. The norm of reciprocity is conceptualized as a generalized moral belief rather than as a simple pattern of exchange between caregivers and care receivers. Use of reciprocity as a generalized moral belief instead of a pattern of behavioral exchange between providers and recipients of social support allows a more thorough integration theoretically and more methodical examination of the role the relationship between providers and recipients plays in this process. Specifically, this investigation employs the notion of optimal matching as part of the mechanism underlying the satisfactions derived from informational social support. The results of the logistic regression analyses suggest that reciprocity is a viable explanation of the mechanism underlying the desire to provide social support to others among cancer patients and among adults who have never been diagnosed with cancer. This relationship between the reception and the provision of informational social support remains even after controlling for age, education, gender, race, social integration, and cancer diagnosis. Implications for the social support literature are discussed.

Information satisfaction in breast and prostate cancer patients: implications for quality of life

OBJECTIVES

This study aimed to assess information needs and levels of information satisfaction in breast and prostate cancer patients. It further examined relationships between information satisfaction and multi-dimensional quality of life (QoL).

METHODS

An adapted Information Satisfaction Questionnaire (ISQ, 2004) and the Functional Assessment of Cancer Therapy QoL questionnaire (FACT-G, 1993) were randomly distributed to cancer patients during oncology clinic visits (breast cancer, n=102; prostate cancer, n=112). Hierarchal regression analyses examined information satisfaction as a predictor of global QoL and its four dimensions (i.e. physical, social, emotional, and functional well-being).

RESULTS

High levels of information needs and desire for decision involvement were identified, with patients expressing a considerable degree of information satisfaction. After controlling for demographic and illness factors, information satisfaction explained 21% of the variance in global QoL, 12% in physical well-being, 13% in social well-being, 8% in emotional well-being, and 10% in functional well-being (all p<0.001).

CONCLUSIONS

This study highlights the importance of information satisfaction for perceived QoL in individuals with cancer. It is clearly important to identify specific information requirements during the diagnosis and treatment process in order to provide information that is congruent with patients' needs.

Effect of a 2 week CPAP treatment on mood states in patients with obstructive sleep apnea: a double-blind trial

Obstructive sleep apnea (OSA) is a common disease with significant medical and psychiatric comorbidities. The literature documenting the effects of continuous positive airway pressure (CPAP) treatment on mood in OSA patients is mixed. We previously observed that 1 week of CPAP treatment did not result in improvements in mood beyond those observed in a group treated with placebo-CPAP. This study examined the effect of a 2 week CPAP treatment on mood in a placebo-controlled design in OSA patients. Fifty patients with untreated sleep apnea were evaluated by polysomnography and completed the Profile of Mood States (POMS) pre-/post-treatment. The patients were randomized for 2 weeks to either therapeutic CPAP or placebo-CPAP (at insufficient pressure). Both the therapeutic CPAP and the placebo-CPAP groups showed significant improvements in POMS total score, tension, fatigue, and confusion. No significant time x treatment effect was observed for either group. We could not show a specific beneficial impact of CPAP treatment on mood in OSA patients.

Short-term physical and emotional health outcomes of public sector ART in the Free State province of South Africa

INTRODUCTION

In order to assess the health outcomes of the South African public sector antiretroviral treatment (ART) programme, it is important to gain a better understanding of the complex relationship between ART and the multidimensional construct quality of life (QoL). Because of the gap between supply and demand, equity issues arise concerning the provisioning of ART.

OBJECTIVE

The aim of this paper is to examine how and to what extent public sector ART is related to the physical and emotional health of people living with HIV/AIDS (PLWHA).

METHODS

The stratified random sample consisted of 371 AIDS patients on ART or medically certified for ART, but still awaiting treatment. A model of the relationships between patient characteristics (age and gender) and socio-economic position (educational level, income, type of dwelling, number of rooms), ART duration, and physical and emotional QoL was tested using structural equation modelling.

RESULTS

Patients with a higher personal income (beta = .19, P < .05) and a larger dwelling (beta = .45, P < .01) were significantly more likely to enter the programme at this early stage. The model showed that the initial months of ART have been associated with significant improvements in the physical QoL (beta = .21, P < .01). Furthermore, patients on ART reported significantly higher levels of emotional well-being than patients awaiting treatment (beta = .10, P < .01). Finally, the results indicate that ART is not only directly associated with emotional QoL, but is also indirectly associated with emotional QoL via the mediating variable physical QoL (beta = .30, P < .01).

CONCLUSIONS

The study suggests that the poorest of the poor are not the first beneficiaries of the public programme. Most importantly, the present findings demonstrate the positive physical and emotional health outcomes of the first 6 months of ART in the Free State, South Africa.

Quality of life of breast cancer patients in the course of adjuvant radiotherapy

GOALS OF THE WORK

In cancer patients, there is an ongoing interest in evaluating the impact of therapeutic interventions on health-related quality of life (hrqol). However, only a few longitudinal studies are published being able to measure the influence of therapy for the patients' quality of life. Based on these data, our aim was to evaluate changes of hrqol during the course of adjuvant radiotherapy in breast cancer patients with special focus on subgroup analysis.

MATERIALS AND METHODS

Sixty-one women undergoing radiotherapy after breast conserving surgery were asked to answer the EORTC Quality of life questionnaire (EORTC-QOL-C30) three times: at the beginning of radiotherapy, in the forth week and 6 weeks after the end of treatment. To identify patients with changes of their qol during the observation time, the function scale "Global health status/Quality of life" was used enabling us to classify three subgroups: (1) unchanged hrqol (NC), (2) increasing hrqol (INC), (3) decreasing of hrqol (DEC).

MAIN RESULTS

Patients with an increasing hrqol (N = 25) demonstrated a significant increase in the role as well as in the emotional functioning scales. In patients with a decreasing hrqol (N = 15), no changes in any of the function scales were found, while a significant decrease in their cognitive functioning was observed in patients with no change in hrqol (N = 21).

CONCLUSIONS

Although the interpretation of these data is difficult because only a few data are available to compare our results, it could be demonstrated that emotional support and the ability to maintain a daily routine in additionally irradiated breast cancer patients is important to optimise hrqol. If hrqol decreases during the course of radiotherapy, the function scales of the EORTC-QOL-C30 seem to be insensitive to reflect this decrease.

Responsiveness to change to change due to supportive-expressive group therapy, improvement in mood and disease progression in women with metastatic breast cancer

OBJECTIVE

To compare the responsiveness of six questionnaires using three hypotheses of change: (i) change due to supportive-expressive group therapy (SEGT), (ii) improved mood defined as a small effect size (.2) on Profile of Mood States (POMS) Total Mood Disturbance score and (iii) progression of disease.

METHOD

Data from the "Breast Expressive-Supportive Therapy" study, a multicentre randomized controlled trial of change due to SEGT versus standard of care in women with metastatic breast cancer were used. Questionnaires studied were: POMS, Impact of Event Scale, Psychosocial Adjustment to Illness Scale (PAIS), EORTC QLQ-C30, Mental Adjustment to Cancer and a Pain visual analog scale (VAS). Responsiveness to change was evaluated using the standardized response mean. POMS was used as the standard.

RESULTS

POMS was the most responsive questionnaire to change due to SEGT. Questionnaires measuring psychosocial attributes were responsive to improvement in mood. EORTC QLQ-C30, PAIS, PAIN VAS and MAC were the most responsive to disease progression. More responsive questionnaires were associated with the smallest sample size required to detect an effect.

CONCLUSIONS

Responsiveness to change is context specific. The POMS was the most responsive questionnaire to psychosocial therapy.

Predictors of psychosocial adjustment in people with physical disease

AIMS

The purpose of this paper was to examine the demographic, medical and psychosocial variables that result in the deterioration of psychosocial adjustment in patients with physical disease, the meaning their illness has for them and their coping style.

METHODS

The study was carried out in inpatient clinics of the Istanbul Faculty of Medicine (n = 198). The following evaluation instruments were used: a semi-structured questionnaire, the Psychosocial Adjustment to Illness Scale-Self Report (PAIS-SR), the Meaning of Illness Questionnaire (MIQ), the Hospital Anxiety-Depression Scale, the Multivariate Perceived Social Support Questionnaire and the Ways of Coping Inventory (WCI). Variables to be related with psychosocial adjustment were analysed by using Forward Logistic Regression.

RESULTS

The mean age of patients was 36.9 (SD 12.9) (18-65), 55% of which were women, the average PAIS-SR score was 1.02 (SD 0.41) (0.7-2.26); 47% of the patients had poor adjustment scores. Univariate analysis showed that psychosocial adjustment was affected by having children (p = 0.02), anxiety, depression, locus of control, perceived social support (p < 0.001), information level about their illness and its treatment (p = 0.01), the subscales of WCI [escape-avoidance (p < 0.001), distancing (p = 0.002), planned problem solving (p < 0.001), positive re-appraisal (p = 0.02)]. The psychosocial adjustment of patients with respiratory or infectious illnesses or bone-muscle-skeletal disorders was even less (p = 0.03). All 33 items of the MIQ were found to have a significant impact on psychosocial adjustment (p < 0.001). According to the regression analysis, the best predictors of psychosocial adjustment were: depression (p < 0.001) and the meaning of illness for patient (p < 0.01).

CONCLUSIONS

Having a physical illness is an important stress factor. In providing assistance, a number of factors should be taken into consideration, including how the patient perceives his illness, the impact the illness has on the patient's life, and a determination of the degree of depression being experienced by the patient.

RELEVANCE TO CLINICAL PRACTICE

The study indicated some predictors in the assessment of psychosocial adjustment and care of patients with physical illness. In daily clinical practice, among the patients with physical illness, those with a negative perception of their illness and those who define depression should be given special attention for psychosocial support.

Relief of Symptoms, Side Effects, and Psychological Distress Through Use of Complementary and Alternative Medicine in Women With Breast Cancer

PURPOSE/OBJECTIVES

To identify use of complementary and alternative medicine (CAM) for relief of symptoms and side effects among women diagnosed with breast cancer and to identify demographic and clinical factors associated with the use of CAM in these patients.

DESIGN

A descriptive, cross-sectional survey.

SETTING

Clinics and community groups in the Tampa Bay area and community groups in a rural midwestern area.

SAMPLE

A convenience sample of 105 predominantly Caucasian women (mean age = 59 years) with a diagnosis of breast cancer was recruited from the Tampa Bay area and a rural midwestern area.

METHODS

The instrument used to gather the data was the Use of Complementary Therapies Survey. The reasons for choosing 33 individual CAM treatments were tabulated. The frequency of use was calculated according to four reasons: (a) to reduce physical symptoms or side effects, (b) to reduce psychological distress, (c) to gain a feeling of control over treatment, or (d) because of dissatisfaction with traditional medical care. Least-squares regression models were fit to identify independent demographic and clinical predictors of CAM therapy use.

MAIN RESEARCH VARIABLES

Use of CAM for relief of physical and psychological distress.

FINDINGS

Patients used all categories of CAM therapies to reduce physical symptoms and side effects. The most frequently cited reason for use of CAM was to reduce the symptom of psychological distress, whereas the lowest frequency of CAM use was because of dissatisfaction with traditional medical care. Traditional and ethnic medicines frequently were used to reduce physical symptoms and side effects, followed by diet and nutritional supplements. The most frequently used CAM therapy category cited for gaining a feeling of control over treatment was use of diet and nutritional supplements. Previous chemotherapy and having more than a high school education were associated with more frequent use of diet and nutritional supplements and stress-reducing techniques.

CONCLUSIONS

Frequency of specific use according to type of CAM was higher and more specific than reported in other studies. Patients who had undergone chemotherapy were most likely to use CAM.

IMPLICATIONS FOR NURSING

Oncology nurses are in a key position to identify which symptoms or side effects patients are experiencing and which CAM therapies may be helpful to relieve patients' symptoms related to treatment and psychological distress related to their cancer.

The influence of attachment and emotional support in end-stage cancer

The impact of attachment style and emotional support on negative affect in 67 end-stage cancer patients was examined via self-report inventory. Path analysis revealed high levels of both attachment anxiety and attachment avoidance were associated with lower levels of emotional support which, in turn, had a major adverse influence on patients' negative affect. In addition, attachment anxiety was also directly associated with distress. The discussion emphasises the importance of attachment theory and emotional support within the context of terminal cancer.

The effect of telephone social support and education on adaptation to breast cancer during the year following diagnosis

PURPOSE/OBJECTIVES

To find the most effective methods of providing social support for women diagnosed with breast cancer by testing the effectiveness of a telephone social support and education intervention to promote emotional and interpersonal adaptation to breast cancer.

DESIGN

Multisite, two-group experimental study with repeated measures.

SETTING

Arkansas and New Jersey.

SAMPLE

The Arkansas sample consisted of 106 women who entered the study two to four weeks postsurgery for nonmetastatic breast cancer and were randomly assigned to an experimental or control group. The comparison group consisted of 91 women from New Jersey who had participated in a previously completed study that used the same interventions and found that telephone support resulted in more positive, statistically significant adaptation to the disease.

METHODS

The experimental group received 13 months of telephone social support and education. Both groups received educational materials via a mailed resource kit. The Profile of Mood States; Visual Analogue Scale-Worry; Relationship Change Scale; University of California, Los Angeles, Loneliness Scale-Version 3; and the modified Symptom Distress Scale provided data regarding the variables of interest. Data analysis included descriptive statistics, t tests, and multivariate analysis of variance with repeated measures.

MAIN RESEARCH VARIABLES

Mood, worry, relationships with significant others, loneliness, and symptoms.

FINDINGS

Data analysis showed no significant differences between groups, and both improved on some of the outcomes. Significant time-by-location interaction effects were found when comparing the Arkansas and New Jersey samples, thereby supporting the need to consider regional differences when developing interventions.

CONCLUSIONS

The mailed educational resource kit alone appeared to be as effective as the telephone social support provided by oncology nurses in conjunction with the mailed resource kit.

IMPLICATIONS FOR NURSING

Mailed educational resource kits may be the most efficient and cost-effective way to provide educational support to newly diagnosed patients with breast cancer, but their effect may differ according to region.

Problem-solving and distress in prostate cancer patients and their spousal caregivers

GOALS OF WORK

Prostate cancer, the most common life-threatening cancer among American men, increases risk of psychosocial distress and negatively impacts quality of life for both patients and their spouses. To date, most studies have examined the relationship between patient coping and distress; however, it is also likely that what the spouse does to cope, and ultimately how the spouse adjusts, will affect the patient's adjustment and quality of life. The present study examined the relationships of spouse problem-solving coping, distress levels and patient distress in the context of prostate cancer. The following mediational model was tested: Spouses' problem-solving coping will be significantly inversely related to patients' levels of distress, but this relationship will be mediated by spouses' distress levels.

PATIENTS AND METHODS

One hundred seventy-one patients with prostate cancer and their spousal caregivers were assessed for mood; spouses were assessed for problem-solving coping skills. Structural equation modeling was used to test model fit.

MAIN RESULTS

The model tested was a good fit to the data. Dysfunctional spousal problem-solving was a significant predictor of spouse distress level but constructive problem-solving was not. Spouse distress was significantly related to patient distress. Spouse dysfunctional problem-solving predicted patient distress, but this relationship was mediated by spouse distress. The same mediational relationship did not hold true for constructive problem-solving.

CONCLUSIONS

Spouse distress mediates the relationship between spouse dysfunctional coping and patient distress. Problem-solving interventions and supportive care for spouses of men with prostate cancer may impact not only spouses but the patients as well.

Early Stage Breast Cancer: Explaining Level of Psychosocial Adjustment Using Structural Equation Modeling

In many women, the diagnosis of breast cancer leads to psychosocial adjustment problems. Biodemographic variables, coping, and social support are factors that influence psychosocial adjustment. The main objective of the present study was to identify and estimate the associations between psychosocial adjustment and biodemographic variables, coping, and social support by using Structural Equation Modeling (SEM). Eighty-seven women with newly diagnosed early stage breast cancer completed several questionnaires covering these areas. It appeared that in the period shortly after surgery, coping style, especially illness-specific coping, is of high relevance for psychosocial adjustment. In our study, we could not confirm the positive role of social support found in other studies on psychosocial adjustment. Biodemographic variables had both direct and indirect associations with psychosocial adjustment: older women and women who had had breast-conserving treatment used a more optimistic coping style; the latter group also reported higher body image; and finally, women with a more advanced stage of disease reported a reduction in recreational activities.

Measurement of Symptom Distress in Women With Early-Stage Breast Cancer

While symptom distress can alter the cancer experience, it is difficult to define and measure. This study's aims were (1) to determine whether the McCorkle Symptom Distress Scale (SDS) or the Rhodes Adapted Symptom Distress Scale (ASDS) was the more accurate measure of symptom distress in women with breast cancer; (2) correlate both scales with a visual analogue scale (VAS) measuring anxiety, a symptom frequently reported clinically; (3) determine tool preference; and (4) establish when during the first cycle of chemotherapy the highest levels of symptom distress were experienced. One hundred twenty women were recruited and measurement of symptom distress (SDS and ASDS) and anxiety (VAS) taken at the start of chemotherapy (Time 1), at the nadir (Time 2), and at the end of the cycle (Time 3). Both instruments were highly correlated and detected change over time; none was correlated with the VAS anxiety scale. Symptom distress scores were generally low, with fatigue, appearance, insomnia, and concentration causing the greatest distress. Other factors like functioning, body image, and menopausal symptoms cited as contributors to symptom distress levels were not measured and could account for low scores and perhaps suggest that symptom distress may not be accurately measured in today's women with early-stage breast cancer.

Early stage breast cancer: costs and quality of life one year after treatment by mastectomy or conservative surgery and radiation therapy

This paper reports a descriptive study of the costs and quality of life (QoL) outcome of treatments for early stage breast cancer in a cohort of Australian women, one year after initial surgical treatment. Mastectomy without breast reconstruction is compared to breast conserving surgery and radiotherapy (breast conservation). Of the 397 women eligible for the study, costing data were collected for 81% and quality of life data for 73%. The cost differences between treatment groups were mainly accounted for by adjuvant therapies, the more expensive being radiotherapy. When compared to women treated by mastectomy, those treated by breast conservation reported better body image but worse physical function. The negative impact of breast cancer and its treatment was greater for younger women, across a number of dimensions of quality of life (regardless of treatment type). While this study shows that breast conservation is more expensive than mastectomy, the QoL results reinforce the importance of patient participation in treatment decisions.

Total parenteral nutrition vs oral diet in autologous hematopoietic cell transplant recipients

Autologous HCT patients often have poor oral intake for 2-4 weeks post transplant. To compare outcomes between patients provided prophylactic total parenteral nutrition (TPN) or an oral diet (OD), 55 well nourished breast cancer/ hematopoietic cell transplantation (HCT) patients were randomized to TPN (n=27), beginning day -1, or OD (n=28). Parameters studied include length of stay (LOS), engraftment, infections, survival, weight, anthropometrics, handgrip strength, and quality of life (QOL) In all, 50% of OD patients were given TPN due to poor oral intake for 10 consecutive days. No significant differences were found between the groups for any of the above parameters except weight and anthropometrics, which were better maintained in the TPN group than the OD group. Trends were seen for increased infections, more stable handgrip strength, and improved QOL in the TPN group vs the OD group. Prophylactic TPN did result in a more intact nutritional status and preservation of lean body mass post transplant but did not impact LOS or survival when compared to OD. For this reason, TPN should be reserved for autologous HCT patients with pretransplant nutritional depletion, complications post transplant, or prolonged poor oral intake. These results should not be extrapolated to allogeneic HCT patients but are likely applicable to other well nourished autologous HCT patients.

Psychiatric aspects of women with breast cancer

Women with breast cancer face not only cancer-related taboos but also issues related to changes in sexuality, femininity, and fertility. Although increased emphasis on the woman's participation in the medical decision-making process has afforded her more treatment options, it also gives her more responsibility in determining her course of treatment through the continuum of cancer care. Patients must deal with a variety of issues related to social reintegration, long-term effects of cancer treatment, employment, disability, sexuality, family, and social networks. Screening for distress related to psychological, spiritual/religious, or social concerns can provide guidance for service delivery to those in need.

Psychosocial functioning in women who have undergone bilateral prophylactic mastectomy

The purpose of this study was to determine the current psychosocial functioning of women who had previously had a bilateral prophylactic mastectomy. Women in the province of Ontario who had undergone prophylactic mastectomy between 1991 and 2000 were asked to complete questionnaires that assessed psychological distress, sexual activity, overall satisfaction with decision to have a prophylactic mastectomy, and body image. Ninety-seven percent of the women were satisfied with their decision to have a prophylactic mastectomy, but young women (<50 years) were less likely to report satisfaction than older women (p=0.001). Women with a strong family history of breast cancer or a BRCA1 or BRCA2 mutation experienced more cancer-related distress than those with a limited family history. Women who had reconstruction following mastectomy reported higher levels of satisfaction with general body shape and appearance than those without reconstruction. In conclusion, the majority of women were satisfied with their decision to undergo prophylactic mastectomy and were not experiencing abnormal levels of psychological distress, low levels of sexual activity, or difficulties with body image.

Effects of two types of social support and education on adaptation to early-stage breast cancer

A Roy adaptation model-based support and education intervention for women with early-stage breast cancer was tested in a three-group, three-phase randomized clinical trial of a sample of 125 women. The experimental group received 13 months of combined individual telephone and in-person group support and education, Control Group 1 received 13 months of telephone-only individual support and education, and Control Group 2 received one-time mailed educational information. The experimental group and Control Group 1 reported less mood disturbance at the end of all three phases, less loneliness at the end of Phases II and III, and a higher-quality relationship with a significant other at the end of Phase II than did Control Group 2. No group differences were found for cancer-related worry or well-being. The findings suggest that individual telephone support may provide an effective alternative to in-person support groups. Further study of telephone interventions is recommended using ethnically and economically heterogeneous samples.

Influence of irradiation on therapy-associated psychological distress in breast carcinoma patients

PURPOSE

To confirm our assumptions regarding factors that apparently cause psychological distress related to adjuvant radiotherapy in breast cancer patients and to evaluate variables that can predict therapy-associated distress.

METHODS AND MATERIALS

Between January 1997 and April 1998, 111 women (33-84 years) with early-stage breast cancer were irradiated (56 Gy) after breast-conserving surgery. Patients were given self-assessment questionnaires on the first and last day of radiotherapy. Statistical analysis was performed using the structural equation model LISREL, variance analysis, and regression analysis.

RESULTS

The internal subject-related factors (coping, radiation-related anxiety, physical distress, psychological distress) reciprocally influenced each other, whereas external radiotherapy-specific factors (environmental influence, confidence in the medical staff) were causally related to coping, anxiety, and distress. Fifty-three percent of the women felt distressed because cancer affected the breast; 48% were initially afraid of radiotherapy. For 36%, anxiety was not reduced during treatment. Highly distressed women were identified by the following parameters: < or =58 years; initial anxiety; they were affected by having breast cancer, were negatively affected by environmental factors, and did not find distraction helpful.

CONCLUSION

Despite considerable individual variability in breast cancer patients, it seems possible to identify women who run a high risk of therapy-associated distress. In these patients, psychosocial support is necessary to reduce treatment-related anxiety and to stabilize confidence in the medical staff.

Clinical determinants of patient satisfaction with breast reconstruction

The main objective of this study was to examine the relationship between specific treatment variables and patient satisfaction with breast reconstruction. A questionnaire was developed that included questions on population demographics and satisfaction with the reconstruction. Of 206 women who completed the questionnaire, 23 (11.2 percent) responded that they were not satisfied, whereas 183 (88.8 percent) indicated that they were satisfied overall. A detailed retrospective chart review permitted a comparison of the treatment received by these two groups. Variables analyzed included patient age, time since surgery, reason for surgery, method and timing of reconstruction, additional surgical procedures received (mound revisions and nipple-areola complex reconstruction), and postoperative complications. Data analysis showed that the treatment received by the two groups was similar in many respects. There was no statistical association between the method or timing of reconstruction and a patient's satisfaction with the results. Furthermore, there was no difference in the number of mound revisions or nipple reconstructions performed on satisfied versus dissatisfied patients. However, the latter group experienced a substantially higher incidence of postsurgical complications (27 percent versus 61 percent, p = 0.0015). Patients were also asked to provide a written response explaining their feelings on breast reconstruction. Satisfied patients described benefits from reconstruction such as improved appearance or feelings of normalcy and wholeness. Conversely, unsatisfied patients were displeased because of poor cosmetic results, complications with the reconstructed breast, or abdominal problems. Although overall satisfaction with breast reconstruction is undoubtedly determined by multiple and complex clinical, emotional, and psychological factors, this study suggests that postoperative complications are a particularly important indicator of dissatisfaction with reconstruction.

Predicting mood disorders in breast cancer patients

Prediction of delayed psychiatric disorders in breast cancer patients by using a screening procedure was investigated. Two questionnaires, the Psychological Distress Inventory and the Hospital Anxiety and Depression Scale, were administered before and during chemotherapy, and at the first follow-up visit. A psychiatric diagnosis was assigned to 50 of the 132 patients (38%) evaluated at follow-up. Including a set of clinical and demographic variables in a logistic regression, increasing age (P=0.001) and psychiatric history (P<0.001) were associated with psychiatric morbidity at follow-up. The accuracy of the two questionnaires in predicting delayed psychiatric disorders increased from the evaluation before chemotherapy to the evaluation during chemotherapy. The most accurate prediction was observed for the concurrent evaluation at follow-up. The accuracy of three predictive models developed for each evaluation point by including age, psychiatric history and psychological distress measured with each of the two questionnaires was not significantly better than that observed using only the questionnaires' scores as predictors.

Psychological distress two years after diagnosis of breast cancer: frequency and prediction

The present prospective study aimed at (1) investigating the frequency of high levels of psychological distress in women with early-stage breast cancer almost two years after diagnosis and (2) identifying characteristics associated with long-term distress. One hundred and seventy women participated on two occasions. Two months after surgery, patients completed questionnaires measuring psychosocial variables (e.g., stressful life-events, health complaints, sleep problems, social support, subjective distress, personality factors), demographic and biomedical variables (e.g., TNM status, type of surgery). At the second measurement, subjective distress was assessed for a second time by means of the Impact of Events Scale (IES). Almost two years after diagnosis, 16% of the women reported a high level of psychological distress as measured by the Intrusion scale (IES). Best predictors of a high level of distress were: intrusive thoughts about the disease, trait-anxiety, health complaints and problems with sleeping. No significant association was found between previous life-events, social support or biomedical variables and levels of distress.

Trauma history as a predictor of psychologic symptoms in women with breast cancer

PURPOSE

To identify predictors of psychiatric problems in women with early-stage breast cancer.

PATIENTS AND METHODS

One hundred sixty women with early-stage breast cancer were recruited from three treatment centers. They filled out self-report questionnaires, including a medical history and demographic survey, the Trauma History Questionnaire, Life Event Questionnaire, Brief Symptom Inventory, Beck Depression Inventory, and Duke-UNC Functional Social Support Questionnaire, and were evaluated using the Structured Clinical Interview for DSM-III-R.

RESULTS

Hierarchical regression analyses indicated that four of five variable sets made a significant incremental contribution to outcome prediction, with 35% to 37% of the variance explained. Outcomes were predicted by demographic variables, trauma history variables, precancer psychiatric diagnosis, recent life events, and perceived social support. Cancer treatment variables did not predict outcome.

CONCLUSION

The findings highlight the important roles of trauma history and recent life events in adjustment to cancer and have implications for screening and treatment.

Applicability of a Western-developed psychosocial group intervention for Japanese patients with primary breast cancer

This paper examines the applicability of psychosocial group intervention for Japanese patients with primary breast cancer. The study included two phases. First, we examined the applicability for Japanese patients of an intervention model developed in a Western country. The model, based on the work of Fawzy and Fawzy (1994) on a structured psychosocial group intervention for cancer patients, is a series of six 1.5-h sessions that incorporate health education, coping-skills training, relaxation training and psychological support. Second, we formulated a Japanese version of the intervention model by modifying areas identified as inappropriate by participants in the first-phase study. We then evaluated this by conducting sessions of the modified model with 44 additional breast cancer patients. Of the ten participants in the first-phase pilot study, three (30%) dropped out and several inappropriate areas were reported. The areas requiring significant change were the provision of medical information and communication style with family members and doctors. No participants dropped out of the modified version, and very few found any program areas to be inappropriate. The findings suggests that psychosocial group intervention is applicable for Japanese breast cancer patients when the model accounts for cultural differences.

Body image, decision making, and breast cancer treatment

This study was performed to describe women's satisfaction with body image before and 8 weeks after the surgical treatment of breast cancer compared with women without breast cancer. Additional aims were to describe women's perceived participation in decisions regarding choice of surgical procedure to treat their breast cancer, and postoperative satisfaction with their breast cancer treatment, as well as to explore factors influencing women's decisions regarding choice of surgical procedure. The design was prospective with a descriptive, comparative design. The convenience sample included 31 women with breast cancer from an urban breast health center, and 30 women without breast cancer from the community. The majority were college educated, white, ranging in age from 29-82 years. Women with breast cancer completed instruments before and 8 weeks after surgery. Women without breast cancer completed the instruments two times 8 weeks apart. Three instruments measuring body image satisfaction were used. Participation in treatment decision-making, having a treatment choice, and posttreatment satisfaction, along with a description of important factors in decision making, were measured with open and closed-ended questions. During the study period, women with breast cancer experienced a significant decrease in satisfaction with body image after surgery (p < .004). Satisfaction with body image remained constant in the women without breast cancer. Most (94%) of the women with breast cancer reported participating in treatment decisions about the type of surgical procedure used to treat their breast cancer, had a treatment choice (77%), and were moderately to very satisfied with the outcome of their surgeries (94%). Qualitative data results suggest that women's treatment decisions were based on their perceptions of "survival," that is, which type of surgery offered the best chance for long-term survival. These data suggest that satisfaction with body image is disturbed by surgery for breast cancer despite active participation in decisions regarding selection of treatment or postoperative satisfaction with type of surgical treatment received. These outcomes suggest that women need assistance in adjusting to alterations in body image from nurses and the need for research to describe effective interventions. Future studies of body image and breast cancer treatment should be conducted with larger samples, and at different points after surgery to determine the effects of mastectomy and breast-conserving surgery on the body image of breast cancer survivors over time.

Temporal differences in coping, mood, and stress with chemotherapy

This longitudinal study examined relations among mood, coping, perceived stress, and side effects from chemotherapy in 50 individuals with stages III and IV adenocarcinoma of the lung over four consecutive combination chemotherapy courses. Results indicated that perceived stress was moderately high only at the time of pretreatment, and four coping strategies were used: seeking social support, planful problem solving, self-control, and positive reappraisal. No relations existed between coping strategies and side effects from chemotherapy, coping and perceived stress, mood and side effects, and perceived stress and side effects. Seven side effects occurred: leukopenia, decreased activity, nausea, loss of appetite, fatigue, constipation, and taste changes. In summary, receiving chemotherapy is stressful at the time of pretreatment, so nursing interventions need to be concentrated at that point.

Quality of life in the first year after breast cancer surgery: rehabilitation needs and patterns of recovery

BACKGROUND

Although mortality rates from breast cancer are declining, many breast cancer survivors will experience physical and psychological sequelae that affect their everyday lives. Few prospective studies have examined the rehabilitation needs of newly diagnosed breast cancer patients, and little is known about the predictors of health-related quality of life (QOL) in this population.

METHODS

Between 1987 and 1990, 227 women with early stage breast cancer participated in a prospective longitudinal study in which detailed information was collected through interviews, standardized measures of QOL and psychological distress, and clinical evaluation. Comparisons of physical and treatment-related problems were made according to type of surgical treatment. Multivariate regression analysis was performed to examine the predictors of QOL at one year after surgery.

RESULTS

Physical and treatment-related problems were reported frequently one month after breast cancer surgery, and occurred with equal frequency in women receiving modified radical mastectomy or breast conservation treatment. There were no significant differences in problems reported at one year by type of surgery; however, frequently reported problems include 'numbness in the chest wall or axilla,' 'tightness, pulling or stretching in the arm or axilla,' 'less energy or fatigue,' 'difficulty in sleeping,' and 'hot flashes'. There was no relationship between the type of surgery and mood or QOL. Poorer QOL one year after surgery was significantly associated with greater mood disturbance and body image discomfort one month after surgery, as well as positive lymph node involvement. Although the majority of patients experienced substantial disruptions in the physical and psychosocial dimensions of QOL post-operatively, most women recovered during the year after surgery, with only a minority (<10%) significantly worsening during that time.

CONCLUSIONS

At one year after surgery, most women report high levels of functioning and QOL, with no relationship between the type of surgery and QOL. Women who reported lower levels of QOL at one year after diagnosis had greater mood disturbance and poorer body image one month after surgery, as well as lower income and positive axillary nodes.

Use of alternative medicine by women with early-stage breast cancer

BACKGROUND

We analyzed the use of alternative medicine by women who had received standard therapy for early-stage breast cancer diagnosed between September 1993 and September 1995.

METHODS

A cohort of 480 patients with newly diagnosed early-stage breast cancer was recruited from a Massachusetts statewide cohort of women participating in a study of how women choose treatment for cancer. Alternative medical treatments, conventional therapies, and health-related quality of life were examined.

RESULTS

New use of alternative medicine after surgery for breast cancer was common (reported by 28.1 percent of the women); such use was not associated with choices about standard medical therapies after we controlled for clinical and sociodemographic variables. A total of 10.6 percent of the women had used alternative medicine before they were given a diagnosis of breast cancer. Women who initiated the use of alternative medicine after surgery reported a worse quality of life than women who never used alternative medicine. Mental health scores were similar at base line among women who decided to use alternative medicine and those who did not, but three months after surgery the use of alternative medicine was independently associated with depression, fear of recurrence of cancer, lower scores for mental health and sexual satisfaction, and more physical symptoms as well as symptoms of greater intensity. All groups of women reported improving quality of life one year after surgery.

CONCLUSIONS

Among women with newly diagnosed early-stage breast cancer who had been treated with standard therapies, new use of alternative medicine was a marker of greater psychosocial distress and worse quality of life.

Mastectomy or lumpectomy? Helping women make informed choices

PURPOSE

To develop an instrument to help clinicians inform their patients about surgical treatment options for the treatment of breast cancer and to evaluate the impact of the instrument on the clinical encounter.

METHODS

We developed an instrument, called the Decision Board, to present information regarding the benefits and risks of breast-conserving therapy (lumpectomy plus radiation therapy) and mastectomy to women with early-stage breast cancer to enable them to express a preference for the type of surgery. Seven surgeons from different communities in Ontario administered the instrument to women with newly diagnosed clinical stage I or II breast cancer over an 18-month period. Patients and surgeons were interviewed regarding acceptability of the instrument. The rates of breast-conserving surgery performed by surgeons before and after the introduction of the instrument were compared.

RESULTS

The Decision Board was administered to 175 patients; 98% reported that the Decision Board was easy to understand, and 81% indicated that it helped them make a decision. The average score on a true/false test of comprehension was 11.8 of 14 (84%) (range, 6 to 14). Surgeons found the Decision Board to be helpful in presenting information to patients in 91% of consultations. The rate of breast-conserving surgery decreased when the Decision Board was introduced (88% v 73%, P =.001)

CONCLUSION

The Decision Board is a simple method to improve communication and facilitate shared decision making. It was well accepted by patients and surgeons and easily applied in the community.