Psychosexual adaptation to breast cancer surgery

Pooled analysis of NeoCARH and NeoCART trials: patient-reported outcomes in patients with early-stage breast cancer receiving platinum-based or anthracycline-based neoadjuvant chemotherapy

PURPOSE

Anthracycline-based or platinum-based neoadjuvant chemotherapy belongs to the standard treatment for early-stage breast cancer (EBC) that is either triple-negative or human epidermal growth factor receptor 2 positive (HER2 +). Currently, there is a paucity of data comparing their impact on health-related quality of life (HRQoL).

METHODS

Triple-negative or HER2 + EBC from our two prospective randomized controlled trials, neoCARH and neoCART, were divided into two groups based on the neoadjuvant chemotherapy regimens they received: anthracycline-based or platinum-based group. HRQoL was the exploratory endpoint in these two trials, which was assessed using the European Organization for Research and Treatment of Cancer Quality of Life-Core30 and Breast23 questionnaires. The primary variable of interest was the C30 summary score (C30-SumSc). Assessments were carried out at baseline, after neoadjuvant chemotherapy, and 1 year and 2 years after diagnosis.

RESULTS

The mean questionnaires' compliance rate was 95.0%. After neoadjuvant chemotherapy, 210 patients had evaluable HRQoL data, the mean least square change from baseline for the platinum-based group was - 15.997 (95% confidence interval (CI): - 17.877 to - 14.117), and it was - 20.156 (95% CI: - 22.053 to - 18.258) for the anthracycline-based group (difference: 4.159, 95% CI: 1.462 to 6.855, P = 0.003, minimal important difference = 3). For the majority of the domains of interest assessed by the C30 and BR23 questionnaires, the platinum-based group demonstrated superior outcomes in comparison to the anthracycline-based group.

CONCLUSION

Patients receiving platinum-based or anthracycline-based regimens both experienced worsened HRQoL after neoadjuvant chemotherapy; however, the former provided relatively better HRQoL compared with the latter.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov: NCT03140553. Registered 4 May 2017 (neoCARH). NCT03154749. Registered 16 May 2017 (neoCART).

3D and 4D Printing in the Fight against Breast Cancer

Breast cancer is the second most common cancer worldwide, characterized by a high incidence and mortality rate. Despite the advances achieved in cancer management, improvements in the quality of life of breast cancer survivors are urgent. Moreover, considering the heterogeneity that characterizes tumors and patients, focusing on individuality is fundamental. In this context, 3D printing (3DP) and 4D printing (4DP) techniques allow for a patient-centered approach. At present, 3DP applications against breast cancer are focused on three main aspects: treatment, tissue regeneration, and recovery of the physical appearance. Scaffolds, drug-loaded implants, and prosthetics have been successfully manufactured; however, some challenges must be overcome to shift to clinical practice. The introduction of the fourth dimension has led to an increase in the degree of complexity and customization possibilities. However, 4DP is still in the early stages; thus, research is needed to prove its feasibility in healthcare applications. This review article provides an overview of current approaches for breast cancer management, including standard treatments and breast reconstruction strategies. The benefits and limitations of 3DP and 4DP technologies are discussed, as well as their application in the fight against breast cancer. Future perspectives and challenges are outlined to encourage and promote AM technologies in real-world practice.

Past, Present, and Future of Soft-Tissue Prosthetics: Advanced Polymers and Advanced Manufacturing

Millions of people worldwide experience disfigurement due to cancers, congenital defects, or trauma, leading to significant psychological, social, and economic disadvantage. Prosthetics aim to reduce their suffering by restoring aesthetics and function using synthetic materials that mimic the characteristics of native tissue. In the 1900s, natural materials used for thousands of years in prosthetics were replaced by synthetic polymers bringing about significant improvements in fabrication and greater realism and utility. These traditional methods have now been disrupted by the advanced manufacturing revolution, radically changing the materials, methods, and nature of prosthetics. In this report, traditional synthetic polymers and advanced prosthetic materials and manufacturing techniques are discussed, including a focus on prosthetic material degradation. New manufacturing approaches and future technological developments are also discussed in the context of specific tissues requiring aesthetic restoration, such as ear, nose, face, eye, breast, and hand. As advanced manufacturing moves from research into clinical practice, prosthetics can begin new age to significantly improve the quality of life for those suffering tissue loss or disfigurement.

Differential impact of endocrine therapy and chemotherapy on quality of life of breast cancer survivors: a prospective patient-reported outcomes analysis

BACKGROUND

In early breast cancer (BC), there has been a trend to escalate endocrine therapy (ET) and to de-escalate chemotherapy (CT). However, the impact of ET versus CT on the quality of life (QoL) of early BC patients is unknown. Here, we characterize the independent contribution of ET and CT on patient-reported outcomes (PROs) at 2 years after diagnosis.

PATIENTS AND METHODS

We prospectively collected PROs in 4262 eligible patients using the European Organization for Research and Treatment of Cancer QLQ-C30/BR23 questionnaires inside CANTO trial (NCT01993498). The primary outcome was the C30 summary score (C30-SumSc) at 2 years after diagnosis.

RESULTS

From eligible patients, 37.2% were premenopausal and 62.8% postmenopausal; 81.9% received ET and 52.8% CT. In the overall cohort, QoL worsened by 2 years after diagnosis in multiple functions and symptoms; exceptions included emotional function and future perspective, which improved over time. ET (Pint = 0.004), but not CT (Pint = 0.924), had a persistent negative impact on the C30-SumSc. In addition, ET negatively impacted role and social function, pain, insomnia, systemic therapy side-effects, breast symptoms and further limited emotional function and future perspective recovery. Although CT had no impact on the C30-SumSc at 2-years it was associated with deteriorated physical and cognitive function, dyspnea, financial difficulties, body image and breast symptoms. We found a differential effect of treatment by menopausal status; in premenopausal patients, CT, despite only a non-significant trend for deteriorated C30-SumSc (Pint = 0.100), was more frequently associated with QoL domains deterioration than ET, whereas in postmenopausal patients, ET was more frequently associated with QoL deterioration, namely using the C30-SumSc (Pint = 0.004).

CONCLUSION(S)

QoL deterioration persisted at 2 years after diagnosis with different trajectories by treatment received. ET, but not CT, had a major detrimental impact on C30-SumSc, especially in postmenopausal women. These findings highlight the need to properly select patients for adjuvant ET escalation.

Advancements in Soft-Tissue Prosthetics Part A: The Art of Imitating Life

Physical disfigurement due to congenital defects, trauma, or cancer causes considerable distress and physical impairment for millions of people worldwide; impacting their economic, psychological and social wellbeing. Since 3000 B.C., prosthetic devices have been used to address these issues by restoring both aesthetics and utility to those with disfigurement. Internationally, academic and industry researchers are constantly developing new materials and manufacturing techniques to provide higher quality and lower cost prostheses to those people who need them. New advanced technologies including 3D imaging, modeling, and printing are revolutionizing the way prostheses are now made. These new approaches are disrupting the traditional and manual art form of prosthetic production which are laborious and costly and are being replaced by more precise and quantitative processes which enable the rapid, low cost production of patient-specific prostheses. In this two part review, we provide a comprehensive report of past, present and emerging soft-tissue prosthetic materials and manufacturing techniques. In this review, part A, we examine, historically, the ideal properts of a polymeric material when applied in soft-tissue prosthetics. We also detail new research approaches to target specific tissues which commonly require aesthetic restoration (e.g. ear, nose and eyes) and discuss both traditional and advanced fabrication methods, from hand-crafted impression based approaches to advanced manufactured prosthetics. We discuss the chemistry and related details of most significant synthetic polymers used in soft-tissue prosthetics in Part B. As advanced manufacturing transitions from research into practice, the five millennia history of prosthetics enters a new age of economic, personalized, advanced soft tissue prosthetics and with this comes significantly improved quality of life for the people affected by tissue loss.

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.

The impact of chemotherapy-induced cognitive impairment on the psychosocial adjustment of patients with nonmetastatic colorectal cancer

Colorectal cancer is the third most commonly diagnosed cancer in Canada. Chemotherapy often is used as treatment for colorectal cancer, and studies have documented cognitive changes in patients after chemotherapy treatment. What remains unclear is the impact of such changes on a person's roles and relationships, herein referred to as psychosocial adjustment. The purpose of this research was to explore group differences in psychosocial adjustment and chemotherapy-induced cognitive impairment in patients with colorectal cancer. Participants were assessed cross-sectionally, at various time points along their treatment trajectory, using the Psychosocial Adjustment to Illness Scale-Self-Report (PAIS-SR) and the Cambridge Neuropsychological Test Automated Battery (CANTAB). A statistically nonsignificant negative association was indicated between PAIS-SR and CANTAB results, indicating that they would have no meaning in a clinical context. No differences between groups were observed in terms of cognitive ability; however, patients who completed chemotherapy appeared to be at a higher risk for psychosocial maladjustment. This study suggests that cognitive changes do not influence patients' relationships and functional roles, as indicated from the PAIS-SR.

Addressing intimacy and partner communication after breast cancer: a randomized controlled group intervention

While quality of life for most breast cancer survivors (BCS) returns to normal by 1 year post-treatment, problems in sexual function and intimacy often persist. The present study tested the efficacy of a 6-week psycho-educational group intervention in improving BCS's sexual well-being. We conducted a mailed survey of BCS 1-5 years post-diagnosis to identify a sample of women who reported moderately severe problems in body image, sexual function or partner communication, and were deemed eligible for the randomized intervention trial. Using a pre-randomized design, 70% (n = 284) were assigned to a 6-week psycho-educational group intervention and 30% (n = 127) were assigned to a control condition (print material only); however, only 83 BCS agreed to participate in the intervention. Four months post-intervention, the intervention and control groups were not significantly different on the primary outcome of emotional functioning; however, BCS randomized to the intervention group were more likely to report improvements in relationship adjustment and communication as well as increased satisfaction with sex compared to controls. Members of the intervention group who were the least satisfied with their sexual relationship appeared to improve the most. Although modest in its effects, this intervention can be delivered in standard clinical settings. Having an identified treatment may help reduce physician reluctance to ask BCS about problems in intimacy and as appropriate, refer them for timely help.

In sickness and in health: maintaining intimacy after breast cancer recurrence

Sexual well-being after breast cancer recurrence has received little clinical attention. In discussing the sexual difficulties after recurrence we draw upon our longitudinal studies of newly diagnosed patients. It is noted that sexuality declines after a patient's initial diagnosis and treatment, with further decline after recurrence. However, data suggest that couples strive to maintain intimacy as the health of the patient falters, providing further evidence of the resilience of patients coping with a worsened prognosis.

Sexual well-being among partnered women with breast cancer recurrence

PURPOSE

A woman's risk for sexual disruption after breast cancer recurrence has received little clinical or research attention.

PATIENTS AND METHODS

Breast cancer patients recently diagnosed with recurrence (n = 60) were initially assessed at baseline and completed follow-ups at 4, 8, and 12 months. They were compared by age, stage, and duration and frequency of follow-up with matched patients who remained disease free (n = 120). Using linear mixed modeling, the groups were compared in their trajectories of change on measures of sexuality, relationship satisfaction, cancer-specific stress, and physical functioning. Recurrence subgroups, those with locoregional versus distant disease and those younger versus older than 52 years, were also compared.

RESULTS

At baseline, the recurrence group had significantly lower intercourse frequency and physical functioning compared with the disease-free group and these differences were maintained. There were no significant differences in the frequencies of kissing or sexual and relationship satisfactions. For the recurrence group patients, the heightened stress of the diagnostic/early recurrence treatment period declined to the lower disease-free levels by 12 months. This effect was largely due to improvement of the patients with distant disease. Finally, sexual changes were most notable for younger patients.

CONCLUSION

To our knowledge, this is the first longitudinal, controlled study of sexuality-sexuality in the context of other quality of life domains-for women coping with recurrence. Despite disruption, patients maintained their sexual lives. Younger and distant recurrence patients, however, may have greatest risk of sexual disruption. The factors contributing to sexual disruption remain unknown, and studies investigating strategies to help patients maintain this aspect of quality of life are needed.

The Diagnosis of Breast Cancer: Transition From Health to Illness

PURPOSE/OBJECTIVES

To gain a better understanding of the common meanings and shared experiences that women encounter after a diagnosis of breast cancer.

RESEARCH APPROACH

Qualitative using Heideggerian hermeneutics.

SETTING

Tertiary breast care center in suburban Buffalo, NY.

PARTICIPANTS

Purposive, convenience sampling recruited 30 women.

METHODOLOGIC APPROACH

Secondary analysis on tape-recorded interviews of women receiving their last cycle of chemotherapy. Narratives were interpreted using the seven-stage hermeneutic process.

MAIN RESEARCH VARIABLES

Life experiences, shared meanings, and perceptions.

FINDINGS

Four themes emerged: Changing Health Overnight, Erasing of a Former Self, Appraising of Illness, and Approaching the Future Now What? The constitutive pattern was transitioning from health to illness.

CONCLUSIONS

Women experience a precipitous change in their lives after a diagnosis of breast cancer. How they mentally and emotionally approached diagnosis and treatment affected their symptom experience and outcomes.

INTERPRETATION

This study provides oncology nurses with the awareness that beyond physical symptoms, women experience profound and precipitous emotional transformation following a diagnosis of breast cancer. It gives meaning to the devastation and symptom distress women experience that may be lessened if they are given adequate information and support. Women in the study who approached diagnosis and treatment more positively better incorporated the breast cancer process into their lives and better managed the side effects of treatment.

Body image and sexual problems in young women with breast cancer

PURPOSE

The purpose of this study was to determine the frequency of body image and sexual problems in the first months after treatment among women diagnosed with breast cancer at age 50 or younger.

BACKGROUND

Breast cancer treatment may have severe effects on the bodies of younger women. Surgical treatment may be disfiguring, chemotherapy may cause abrupt menopause, and hormone replacement is not recommended.

METHODS

A multi-ethnic population-based sample of 549 women aged 22-50 who were married or in a stable unmarried relationship were interviewed within seven months of diagnosis with in situ, local, or regional breast cancer.

RESULTS

Body image and sexual problems were experienced by a substantial proportion of women in the early months after diagnosis. Half of the 546 women experienced two or more body image problems some of the time (33%), or at least one problem much of the time (17%). Among sexually active women, greater body image problems were associated with mastectomy and possible reconstruction, hair loss from chemotherapy, concern with weight gain or loss, poorer mental health, lower self-esteem, and partner's difficulty understanding one's feelings. Among the 360 sexually active women, half (52%) reported having a little problem in two or more areas of sexual functioning (24%), or a definite or serious problem in at least one area (28%). Greater sexual problems were associated with vaginal dryness, poorer mental health, being married, partner's difficulty understanding one's feelings, and more body image problems, and there were significant ethnic differences in reported severity.

CONCLUSIONS

Difficulties related to sexuality and sexual functioning were common and occurred soon after surgical and adjuvant treatment. Addressing these problems is essential to improve the quality of life of young women with breast 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.

Perceived partner reactions to diagnosis and treatment of breast cancer: impact on psychosocial and psychosexual adjustment

Two studies examined breast cancer patients' perceptions of their partners' reactions to their diagnosis and treatment as influences on 3 aspects of patients' well-being: psychosexual adjustment, emotional distress, and marital satisfaction. Study 1, cross-sectional, indicated that partner initiation of sex, frequency of sex, a positive 1st sexual experience after treatment, and especially perception of the partner's emotional involvement in the relationship, were relevant to these outcomes. Study 2, longitudinal, confirmed many of these findings in prospective tests across 1 year of recovery after surgery. Partner involvement prospectively predicted all 3 outcomes. Partner initiation of sex predicted greater marital satisfaction; partner adverse reaction to the scar predicted less marital satisfaction. Rated quality of the 1st sexual experience after treatment predicted less distress. The pattern suggests that women's impressions of their partners' emotional involvement after surgery for breast cancer forecast their adjustment in sexual, marital, and emotional arenas over the following year.

Does a History of Childhood Sexual Abuse Affect Sexual Outcomes in Breast Cancer Survivors?

Purpose

Little is known about a history of childhood sexual abuse (CSA) in breast cancer survivors and its relationship to sexual functioning after cancer. As part of a larger survey study examining sexuality and intimacy in breast cancer survivors, we conducted in-person interviews with a subsample of participants.

Methods

A total of 147 women in Los Angeles, CA, and Washington, DC, completed a structured interview that addressed sexual socialization and a history of sexual abuse. Trained female interviewers conducted the interviews. Descriptive statistics and regression analyses were used to examine the prevalence of CSA, and its potential impact on sexual health and functioning.

Results

One in three women reported at least one CSA incident. Among women who had experienced CSA, 71% reported a single incident, and 22% reported a penetrative form of sexual contact. In multivariate regression analyses examining physical and psychological aspects of sexuality and body image, CSA was not a significant predictor of physical discomfort. However, a history of penetrative CSA was a significant predictor of psychological discomfort (P = .02).

Conclusion

The prevalence of CSA in this sample was similar to the general population literature on this topic. In this small sample, a past history of CSA did not contribute significantly to the physical discomforts associated with sexual intimacy after breast cancer; however, our findings suggest that a past history of penetrative CSA is associated with increased psychological discomfort, and may warrant additional examination in future research.

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.

External breast prosthesis use: experiences and views of women with breast cancer, breast care nurses, and prosthesis fitters

After mastectomy, the provision of an appropriate breast prosthesis can help to improve body image and quality of life and reduce associated emotional distress. Although up to 90% of women use an external breast prosthesis after mastectomy, little is known about their experiences and satisfaction with breast prosthesis use. Focus groups were conducted with women who had been fitted with an external breast prosthesis, breast care nurses, and prosthesis fitters to explore women's experiences of prosthesis use. Qualitative thematic content analysis of focus group transcripts indicated that whereas women's initial reaction to the prosthesis generally was negative, this improved over time. Provision of adequate information and support, characteristics of the fitter and the fitting experience, and relationships with breast care nurses and prosthesis fitters were important to women's acceptance and satisfaction with their prosthesis. The study results highlighted the key role that breast care nurses play and the underestimation of the prosthesis fitter's role. Common themes concerning the impact of prosthesis use included body image, appearance, and feminine identity. These findings have important implications for professionals involved in the delivery of breast prostheses services.

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.

Treatment regimen, sexual attractiveness concerns and psychological adjustment among African American breast cancer patients

BACKGROUND

Among a sample of African American women recently diagnosed with breast cancer, we assessed the consequences of different treatment regimens on sexual attractiveness concerns, and the impact of sexual attractiveness concerns on current and subsequent psychological adjustment.

PATIENTS AND METHODS

The sample included 91 African American women with breast cancer; 90% had Stage I or II disease, 48% had chemotherapy, 47% had a lumpectomy, and 53% received a mastectomy. Feelings of sexual attractiveness and psychological adjustment were assessed an average of 3 months following surgery and again 4 months post-baseline.

RESULTS

Regression analyses revealed that chemotherapy was associated with greater concerns about sexual attractiveness among lumpectomy patients (p<0.05), but not among mastectomy patients (p>0.20). The interaction also suggested that chemotherapy equalized the impact of types of surgery, as there was no difference on sexual attractiveness between surgery groups among women who had received chemotherapy (p>0.20). However, among women who had not received chemotherapy, mastectomy patients reported greater sexual attractiveness concerns (p<0.01). Finally, regression analyses revealed that feelings of sexual attractiveness were an important component of psychological well-being, both cross-sectionally (p<0.001) and longitudinally (p<0.001).

CONCLUSION

Assessment of the combined impact of different treatment regimens on feelings of sexual attractiveness is particularly important given the current consensus that all breast cancer patients should receive chemotherapy, regardless of nodal status. Further, concerns about sexual attractiveness should be considered for inclusion as one component of psychosocial support programs for African American women with breast cancer, as our results suggested that they played a significant role in psychological adjustment.

Contextual variables, emotional state, and current and expected quality of life in breast cancer survivors

PURPOSE/OBJECTIVES

To determine the relationship between contextual variables, emotional state, and quality of life (QOL) now and expectations for the future in survivors of breast cancer.

DESIGN

Descriptive and nonexperimental.

SETTING AND SAMPLE

148 volunteers and women with breast cancer involved in a program by the American Cancer Society. Most subjects were middle-aged (mean = 52.4, SD = 11.56), were married (72%), and had graduated high school (38%). Time since diagnosis was 0.3-19 years (mean = 3.54, SD = 3.61); 74% were diagnosed more than five years ago, 54% were not receiving any treatment, and 66% had localized breast cancer.

METHODS

At home, participants completed a self-report survey for personal and contextual variables, Positive and Negative Affect Scale, QOL Measurement, and Global Life Satisfaction Scale.

MAIN RESEARCH VARIABLES

Time since diagnosis, extent of cancer, emotional state, QOL, and global life satisfaction.

FINDINGS

Women had high positive affect (mean = 37.96) and low negative affect (mean = 17.13). QOL and life satisfaction were high. Time since diagnosis and extent of disease were related weakly to negative affect and QOL (p < 0.001). Positive and negative affect were related moderately to QOL and life satisfaction (p < 0.001). Current personal life satisfaction was significantly greater than breast cancer survivors' estimates for "most people," and survivors expected life satisfaction to increase significantly in five years (p < 0.001). Significant differences in QOL were found between those who were diagnosed recently and those who were diagnosed 10 or more years previously.

CONCLUSIONS

Despite breast cancer, women have positive affect, good QOL, and life satisfaction. Contextual variables were related weakly to outcomes; emotions were related more strongly to outcomes. Survivors were more satisfied with life than they estimated others to be and expected satisfaction to increase in the future.

IMPLICATIONS FOR NURSING

Nurses may use these findings to encourage patients who are newly diagnosed with breast cancer. Women with breast cancer adapt well despite potential negative outcomes, and survivors even report better QOL than they estimate for most people.

Participation in psychosocial group intervention among Japanese women with primary breast cancer and its associated factors

Though psychosocial group intervention is considered in the West to be an important source of support for reducing psychosocial distress in cancer patients, in Asian countries, there has been no research as yet on the needs for such intervention. This study investigated the level of participation and interest in psychosocial group intervention plus any associated factors in 151 primary breast cancer patients. All were less than 65 years old at 4-18 months post-surgery. Of the 126 subjects who responded (response rate 83%), 53 (42%) participated (participants) and 73 (58%) did not (non-participants). Participation was greater among those with a high level of anxiety measured by the Hospital Anxiety and Depression Scale (HADS) (odds ratio [OR], 3.25; 95% confidence interval [CI], 1.07-10.42), those who had undergone surgery within the last 12 months (OR, 3.10; 95% CI, 1.35-7.55), and those who were 50-65 years old (OR, 3.08; 95% CI, 1.33-7.66). Among the non-participants, 53 (73%) were interested in the intervention while 20 (27%) were not. Non-participants without any interest in the psychosocial group intervention had significantly higher anxiety levels than those with interest (t=-2.08; df=71; p=0.03). These results suggest that most Japanese breast cancer patients who need psychological support can be sought out by asking whether they are willing to participate in a psychosocial group intervention. However, the minority not interested in any psychological group intervention might need other supports such as medication or individual psychotherapy.

Factors related to sexual function in postmenopausal women with a history of breast cancer

BACKGROUND

The normal life expectancy of survivors of early-stage breast cancer (BCS) underscores the need to address long-term quality of life issues in these women. Sexual dysfunction persists after breast cancer treatment, despite recovery in other domains.

OBJECTIVE

To examine associations between a broad array of characteristics and sexuality in BCS.

PARTICIPANTS

Sixty-one postmenopausal BCS who were participants in a randomized, controlled trial of nonhormonal interventions for menopause symptoms and who had a partnered, intimate relationship.

METHODS

Cross-sectional analysis of baseline trial data. Outcomes were standardized scales of sexual interest, dysfunction, and satisfaction. Candidate predictors included demographic, anatomical, medical, psychological, sociocultural, and hormonal characteristics. Forward, stepwise regression was used.

RESULTS

Relationship quality, vaginal discomfort, education, and hot flashes were each associated with two of the three domains of sexuality assessed. Ten other factors entered predictive models: age, time since diagnosis, breast conservation, comorbidity, urinary incontinence, perceived health, body image, bioavailable testosterone, luteinizing hormone, and sex hormone binding globulin. Each of these 10 factors was associated with only one sexuality domain.

CONCLUSIONS

In this small sample of BCS, we found multiple correlates of sexuality. Most seem to impact uniquely on individual domains of sexual function. Several characteristics are modifiable and could be targets for intervention.

Attention and symptom distress in women with and without breast cancer

BACKGROUND

The cognitive capacity to direct attention (CDA) is essential for self-care and independent functioning. Older women may be more vulnerable to fatigue-related losses in CDA following surgery for breast cancer. Normal functional variations in CDA associated with aging might affect attentional responses in older women newly diagnosed with breast cancer, and factors such as extent of surgery or symptom distress might influence CDA over time.

OBJECTIVES

To examine (a) differences in CDA and symptom distress in older women newly diagnosed with breast cancer as compared to a control group of older women without breast cancer; (b) the pattern of change in CDA and symptom distress from the pretreatment period to 3 months after surgery; and (c) to examine the relationship of CDA with symptom distress and extent of surgery over time.

METHODS

Women, 55 to 79 years of age, newly diagnosed with breast cancer (N = 47), were assessed with measures of CDA and symptom distress: (a) before surgery, (b) at 2 weeks postsurgery, and (c) 3 months postsurgery. To account for normal variations associated with aging, 48 women of similar age without breast cancer were assessed following a routine screening mammogram and 3 months later.

RESULTS

Before treatment, the breast cancer group scored significantly lower than the control group (p < .05) on measures of CDA and higher on symptom distress. Repeated measures ANOVA showed significant main effects of group, but not time, for the measures of CDA and symptom distress with the breast cancer group having worse status than the control group. For CDA only, there was a significant group by time interaction effect (p = .005) so that the breast cancer group showed a gradual gain in CDA over time.

CONCLUSIONS

Reduced performance in a cognitive function was observed before treatment and found to persist over an extended interval in older women newly diagnosed with breast cancer.

Measurement of psychosocial adjustment to breast cancer: a unidimensional or multidimensional construct?

Using data from a longitudinal study of Hoskins' 'Patterns of Adjustment to Breast Cancer among Women and their Partners', a conceptually derived multidimensional formulation of psychosocial adjustment was empirically tested. The Psychosocial Adjustment to Illness Scale was administered to both patients and partners at six times post-definitive surgery, i.e., 7-10 days, 30 days, 60 days, 90 days, 180 days, and one year. Extensive factor analytic studies were performed on data from the Psychosocial Adjustment to Illness Scale at four of the collection times when complete data sets were available for 128 patients and 121 partners. Results of the principal components analysis with varimax rotation were compared to factor analyses reported by the developers of the scale. The seven-factor matrix reported by Derogatis was not reproduced; instead, one factor was consistently identified at each of the four time periods as the best solution. Although items from all seven domains of the scale loaded on the single factor, items pertaining to psychological distress and role performance in the domestic and social environments were most prominent. These data support the need to validate empirically hypothesized separate dimensions of psychosocial adjustment to breast cancer in both patients and partners as proposed in a number of widely used tests.

Quality of Life Across the Continuum of Breast Cancer Care

This article examines the quality of life concerns for women across the continuum of breast cancer care-from screening and high-risk status through palliative care. The psychosocial and quality of life concerns of women regarding breast cancer have been extensively studied, with much information available about these issues. Better awareness of these issues will facilitate the optimum care of women as they face screening, diagnosis, and treatment of this disease.

A randomized controlled trial of a brief psychoeducational support group for partners of early stage breast cancer patients

Partners of breast cancer patients are relied upon for support at a time when their own coping abilities are taxed by the challenge of cancer, yet few studies have investigated psychosocial interventions that include or target the patient's 'significant other'. Of the 118 consecutive patients approached, 36 patients and their partners participated in a randomized controlled trial of a brief psychoeducational group program for partners only. Psychometric instruments (including the Profile of Mood States (POMS), the Index of Marital Satisfaction (IMS) and DUKE-UNC Functional Social Support Scale (FSSS)) were administered pre-test, post-test and at 3 months follow-up. The Mental Adjustment to Cancer Scale (MAC) was also completed by patients. Three months after the intervention, partners had less mood disturbance than did controls. Patients whose partners received the intervention reported less mood disturbance, greater confidant support (CS) and greater marital satisfaction.

Assessing head and neck cancer patient outcome domains

BACKGROUND

The purpose of this study was to assess the relative importance on patients' lives of multiple outcomes resulting from the management of head and neck cancer (HNC).

METHODS

HNC patients filled out a disease-specific quality of life (QOL) survey covering 5 domains (speech, eating, aesthetics, pain/discomfort, and social/role functioning). Logistic regression was used to determine which of these domains best predicted the patients' response to a single, overall QOL assessment.

RESULTS

In univariate analyses, all 5 domains were significantly correlated to QOL (p<.0001), with correlation coefficients ranging from.48 for eating to.64 for social/role functioning. Logistic regression indicated that speech and eating best predicted QOL (R(2) =.4647), with odds-ratios of 2. 96 for speech and 2.49 for eating.

CONCLUSIONS

These data demonstrated that, for this group of patients, speech has the most impact on well-being, whereas eating has a substantial, unrelated influence. This is important information in counseling patients about treatment plans that have different levels of impairment.

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.

Participation in treatment decision-making by women with early stage breast cancer

OBJECTIVE: This study aimed to assess the way women treated for early stage breast cancer perceived the treatment selection process. The purpose was to understand more fully patients' experiences of the decision process and their preferences for participation in treatment decisions. SETTING AND PARTICIPANTS: The study informants were 40 women, treated at a teaching hospital in Sydney Australia, who were interviewed face to face 1 year after their first treatment for stage I or stage II breast cancer. METHODS: This study used a qualitative approach, based on the analysis of interview transcripts. The main areas covered were how the informants' treatment decisions were made and their preferences for participation in treatment decisions. Content and thematic analyses were conducted with findings presented using verbatim quotations for illustration. RESULTS AND CONCLUSIONS: Many of the informants who preferred not to participate in decisions also failed to recognize the need for value judgements (as well as medical expertise) in the decision-making process. Some informants believed they ought to be responsible for the consequences whilst others did not. Difficulties were identified in patient utilization of medical information for treatment decision-making, and also in establishing preferences for the risks and benefits of treatments where few patients had prior experience of the potential outcomes. The findings indicate that patient participation in treatment decision-making is a more complex issue than simply giving patients information and choices. Ways of enhancing patients' involvement in the treatment selection process are discussed.

Predictors of sexual health in women after a breast cancer diagnosis

PURPOSE

To identify variables that might be predictive of sexual health (interest, dysfunction, and satisfaction) in a large sample of breast cancer survivors, with a validation conducted in a second, independent sample.

PATIENTS AND METHODS

On the basis of a conceptual framework of sexual health in breast cancer survivors, we performed multivariable regression analyses to estimate sexual interest, dysfunction, and satisfaction in both samples. Additional analyses were performed using stepwise regression and recursive partitioning to explore in each sample the relative contributions of the independent variables toward predicting the outcome measures.

RESULTS

The models for sexual interest accounted for at least 33% of the variance, and the significant predictors common to the two samples were having a new partner since the diagnosis of breast cancer, mental health score, and body image score. For sexual dysfunction, the models in the two samples explained at least 33% of the variance, and the common significant predictors were vaginal dryness, past chemotherapy use, and having a new partner since diagnosis. The sexual satisfaction models explained at least 27% of the variance, with the common significant predictors being the quality of the partnered relationship and sexual problems in the partner.

CONCLUSION

Among the predictors of sexual health, several are mutable (vaginal dryness, emotional well-being, body image, the quality of the partnered relationship, and sexual problems in the partner), and these should be considered for future interventions to address the sexual health and well-being of breast cancer survivors.

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.

Pretreatment symptom distress in women newly diagnosed with breast cancer

Although the initial phase of illness is recognized as important in the overall process of adjustment after a diagnosis of breast cancer, little is known about pretreatment patterns of symptom distress. Seventy-four women ages 25 to 79 years and newly diagnosed with breast cancer were studied to determine physical, cognitive, and affective distress in the pretreatment period. Severity of distress was assessed about 11 days before primary surgery using the Symptom Distress Scale (SDS), Attentional Function Index (AFI), and Profile of Mood States (POMS). Higher levels of distress (SDS) were related to a triad of symptoms, insomnia, fatigue, and loss of concentration. Also, lowered effectiveness in cognitive function (AFI) and significant disturbances in mood state (POMS) were observed. Overall, a greater number of symptoms was associated with lowered cognitive function (r = -0.47; p < 0.01) and greater mood disturbance (r = 0.65; p < 0.01). Younger women younger than 55 years of age (n = 25) reported significantly (p = 0.02) greater overall symptom distress (SDS) than older women (n = 49). Interestingly, severity of distress did not differ in groups anticipating breast-conserving surgery (n = 35) instead of mastectomy (n = 39). The findings showed a discernible pattern of symptom distress before any treatment in women newly diagnosed with breast cancer, indicating a need for early intervention to promote the initial process of adjustment.

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.

Effect of tamoxifen on sexual functioning in patients with breast cancer

PURPOSE

To define the incidence of sexual dysfunction in a population of women with breast cancer treated with tamoxifen.

PATIENTS AND METHODS

Breast cancer patients with a performance status of 0 to 2 who had been treated with tamoxifen for 2 to 24 months completed the following measures: the Center for Epidemiologic Studies-Depression Scale, the Sexual History Form, and the Breast Cancer Prevention Trial Symptom Checklist. Forty-nine of the participants underwent gynecologic examinations with vaginal smears for determination of estrogen effect.

RESULTS

Fifty-seven women were entered onto the trial. Sexual desire, arousal, and ability to achieve orgasm were comparable to norms established in participants in the Tamoxifen Prevention Trial (National Surgical Adjuvant Breast and Bowel Project P-01). Pain, burning, or discomfort with intercourse was reported in 54% of patients and did not correlate with age, surgical treatment of the primary cancer, or chemotherapy. Estrogen effect was seen on the vaginal smears of 34 of 49 participants and was more common in older patients (P = .054). The presence of estrogen effect correlated with negative reactions during sex (P = .02) and vaginal dryness or tightness (P = .046).

CONCLUSION

Women treated with tamoxifen in the adjuvant setting experienced symptoms of sexual dysfunction. The individual contributions of chemotherapy and tamoxifen to sexual dysfunction warrant prospective study.

Supportive nursing care around breast cancer surgery: an evaluation of the 1997 status in The Netherlands

This study aimed to assess nurses' involvement in the supportive care of patients with recently diagnosed breast cancer in Dutch hospitals. A questionnaire used to evaluate various aspects of nursing care for breast cancer patients was sent to the surgical nursing teams in all 120 Dutch hospitals that provide surgical treatment for these patients. Nursing care was defined to be optimal if it met the following criteria: (a) Specialized nursing support is provided to all patients during admission and in the outpatient departments both before and after surgery. (b) A protocol is in place outlining standard nursing procedures for breast cancer patients. (c) Formal communication about each breast cancer patient exists between the nurses involved. On the basis of this definition, it was found that optimal nursing care was provided in only 6% of the hospitals. Nursing care fell short mainly in the outpatient setting. This shortcoming also was recognized by most respondents, and many were already planning improvements. Nurses had varying opinions about their responsibility to provide the patient with information about the disease and its treatment, and consensus was lacking. In summary, nursing care for newly diagnosed breast cancer patients in Dutch hospitals needs improvement, especially in the outpatient setting.

Impact of different adjuvant therapy strategies on quality of life in breast cancer survivors

Little is known about the long-term effects of adjuvant therapy on quality of life, sexual functioning and symptoms in breast cancer survivors. Between January 1996 and June 1997, we surveyed 1098 women who had been diagnosed with early stage breast cancer between 1 and 5 years earlier. The breast cancer survivors were recruited in two large metropolitan centers in the USA. They completed a survey battery that contained standardized measures of health-related quality of life (HRQL), depression, body image, sexual functioning, and symptoms. A total of 1096 had usable responses for these analyses. In this sample, n = 356 had received tamoxifen (TAM) alone, n = 180 received chemotherapy (CHEM) alone, n = 395 received CHEM + TAM, and n = 265 received no adjuvant therapy (NO RX). There were significant differences in the mean age of each group, with the TAM group being the oldest (mean 62.6 years) and the CHEM group being the youngest (mean 46.8 years). Both age and time since diagnosis were controlled for in all statistical analyses. We found no significant differences in global quality of life among the four treatment groups. For the MOS-SF-36, there were no significant differences on the subscale scores except for the physical functioning subscale (p = 0.0002); the NO RX group had the highest functioning. There were no significant differences in depression scores among the four treatment groups. The MOS-SF-36 physical functioning composite score differed by treatment group (p = 0.012); the NO RX group had a physical functioning composite score that was at the mean for a normal healthy population of women, while those in the adjuvant treatment groups scored slightly lower. The mental health composite score was not significantly different among the four treatment groups and approximated scores from the normal population of healthy women. There were no differences in body image scores among the four treatment groups; however, sexual functioning scores did differ (p = 0.0078) with patients receiving chemotherapy (either alone or with tamoxifen) experiencing more problems. Hot flashes, night sweats, and vaginal discharge differed by treatment (p = 0.0001); all symptoms were reported more often in breast cancer survivors on tamoxifen. Vaginal dryness and pain with intercourse also differed significantly by adjuvant treatment, occurring more often in survivors treated with chemotherapy. Overall, breast cancer survivors function at a high level, similar to healthy women without cancer. However, compared to survivors with no adjuvant therapy, those who received chemotherapy have significantly more sexual problems, and those treated with tamoxifen experience more vasomotor symptoms.

Women's perceptions of group support and adaptation to breast cancer

Formal cancer support groups are thought to assist women to adapt to the physiological and psychosocial sequelae of breast cancer. To shed some light on this untested clinical assumption, this Roy Adaptation Model of Nursing-based study was designed to explore women's own reports about their adaptation to breast cancer and their participation in support groups. This article reports the results of the quantitative content analysis of structured telephone interviews with 70 women who participated in group social support and education for breast cancer. Almost three-quarters of the women expressed a positive change in attitude towards breast cancer, and all regarded participation in the groups as positive. A majority reported adaptive physiological, self-concept, role function, and interdependence mode effects of breast cancer and group participation. Additional research is needed to show how different types of cancer support groups, including social support and education groups and psychotherapy groups, contribute to women's responses. Research is also needed to separate the effects of group social support and education from other sources of social support that may have contributed to the women's responses, and to further explore feelings of normalization expressed by some women.

Type of mastectomy and quality of life for long term breast carcinoma survivors

BACKGROUND

Despite numerous studies of partial mastectomy and psychologic morbidity in the first 24 months following surgery, little is known about the long term psychosocial repercussions of partial and total mastectomy.

METHODS

The effect of the type of mastectomy on psychologic adjustment was assessed among 124 breast carcinoma survivors, 47 of whom underwent partial mastectomy and 77 of whom underwent total mastectomy, 8 years after initial treatment. Interviews were also conducted 3 and 18 months after surgery. Psychologic distress was assessed using the Psychiatric Symptom Index. Other outcomes included physical symptoms, patients' perceptions of their own health, satisfaction with the type of surgery performed and with the appearance of the scar, and marital and sexual adjustments.

RESULTS

No statistically significant differences between partial and total mastectomy were observed with respect to long term quality of life. Age at diagnosis modified the relation between the type of mastectomy and psychologic distress in both the short term and the long term (P = 0.04). Among women younger than 50 years, partial mastectomy appeared to be protective against distress when compared with total mastectomy. In contrast, among women age 50 years or older, partial mastectomy was associated with higher psychologic distress levels at all interviews.

CONCLUSIONS

Assessed globally, partial and total mastectomy appear to be equivalent treatments in terms of patients' long term quality of life. However, both short term and long term distress levels after partial and total mastectomy may depend on patients' age at diagnosis. The findings of this study suggest that the increased use of partial mastectomy may lessen the negative effects of breast carcinoma on younger survivors' quality of life. Nevertheless, total mastectomy may be an appropriate initial treatment for some women who truly choose it.

Fatigue in women with breast cancer receiving radiation therapy

Fatigue is a common complaint of individuals receiving treatment for cancer. There is a dearth of rigorous research investigating the clinical course and prognosis of fatigue over the course of radiation therapy. Seventy six patients with breast cancer receiving external radiation therapy were followed longitudinally from the onset of treatment to 6 months post-treatment. Fatigue significantly increased over the course of treatment, was highest at the last week of treatment, and returned to pretreatment levels by 3 months after treatment. Fatigue was not influenced by the patient's age, stage of disease, time since surgery, weight, and length of time since diagnosis. Fatigue was significantly related to symptom distress, psychologic distress, and self-reported fatigue relief strategies. The most frequently reported self-relief strategies were "sit" and "sleep." Fatigue had a negative impact on the patient's quality of life. Impairment in quality of life was evident by the end of treatment, with improvement by 3 and 6 months after treatment. The second week through to the last week of radiation therapy are critical times to target interventions for the management of fatigue. The amelioration of concomitant symptoms is a supportive approach that might be helpful. Self-help strategies focusing on the cessation of activity and increasing rest were reported as successful by patients.

Self-perceptions of women after early breast cancer surgery

AIMS

To discover satisfaction with treatment decision and the late influences of surgery for early breast cancer on the lives and self-perceptions of women.

METHODS

A two-part mail survey was returned by 90 women aged 2.8-7.6 years after breast-conserving treatment (BCT) and by 56 women aged 3.0-8.0 years after modified radical mastectomy (MRM).

RESULTS

Approximately one-third of all patients felt the information and time before the treatment decision was inadequate. Most women in both treatment groups had participated in treatment decision-making. When the surgeon alone had made the choice it did not affect satisfaction with the treatment result. Few patients regretted the treatment modality chosen. The majority of patients felt no discomfort in their treated breast, but a quarter of all the women suffered from rib pain. Fifteen of 52 sexually active women reported of reduced breast pleasure sensation in their resected breast. The women in both treatment groups were asked to score a summary satisfaction index (SSI) on a scale of 0-10 for seven different areas of life: cosmesis, function, work, home, recreation/sports, social life and sexuality. SSI was used as a measure of quality of life. There was a difference in all these categories between BCT and MRM groups, the former giving significantly higher values. Post-menopausal women tended to be more-satisfied than younger women and women over 70 years showed no difference in satisfaction between the two treatment modalities. Treatment of early breast cancer caused little morbidity in the long run. After MRM slightly more local symptoms were reported.

CONCLUSIONS

Most women treated with breast-conserving surgery esteemed their life normal or close to normal, giving us a reason to favour BCT when suitable. For women over 70 years old mastectomy remains a viable alternative.

Coping and psychosocial adaptation: longitudinal effects over time and stages in breast cancer

OBJECTIVES

This study examined the relationship between coping and psychosocial adaptation in cancer patients over time and across distinct clinical events.

METHODS

In a prospective longitudinal study 74 patients with breast cancer were observed for 3 to 5 years at 3- to 6-month intervals. A total of 684 interviews were conducted at different observation points. Three rating scales were used to assess coping and adjustment: first, the Bernese Coping Modes, an observer rating scale devised to elicit 26 coping modes aggregated in this paper as the five Basic Coping Strategies of support, self-control, denial, diverting, and negative-emotional; second, an observer rating scale to ascertain psychosocial adaptation; and third, a self-rating scale as a measure of either emotional distress or well-being.

RESULTS

a) When aggregated in illness stages, coping and distress data on the observed clinical time points showed greater variability than time measures alone (analysis of variance (ANOVA) for repeated measures p < .001). b) A significant relationship between the Basic Coping Strategies and psychosocial adaptation was demonstrated using discriminant and correlational analysis. Furthermore, in stage-dependent Pearson r correlations (p < .05 to .001), a clear-cut relationship was found for hospitalization, chemotherapy, and rehabilitation, but not for convalescence and metastasis. c) A positive relationship was demonstrated between psychosocial adaptation and strategies that can be generally categorized as good forms of coping such as support and self-control, and, to a lesser degree, diverting and denial. Conversely, poor coping exerted a negative effect on almost all illness stages and on most criteria of adjustment.

CONCLUSIONS

In long-term studies on psychosocial adaptation and coping, stage-related measures should be preferred to time measures alone. The implications of different strategies for the psychological treatment of cancer patients are discussed.

Local Management of Primary Breast Cancer

BACKGROUND: Various options are available for the local control of cancer in the breast -- mastectomy, conservation therapy, and mastectomy with reconstruction. METHODS: To evaluate the benefits and drawbacks of the available management options, the authors combine their extensive experience with a review of the literature on outcomes from these approaches. RESULTS: Conservation therapy provides survival outcomes similar to those from mastectomy. Differences in local recurrence rates can be minimized by close adherence to guidelines for patient selection, operative approach, and radiation technique. CONCLUSIONS: The role of the physician in selecting a local therapy for breast cancer has changed from one of informing the patient of the treatment to assessing the presence of medical contraindications to any of the treatments, educating the patients on each treatment approach, providing access to multidisciplinary consultation, and allowing the patient to choose an appropriate treatment approach.