Psychological distress and physical health in the year after diagnosis of DCIS or invasive breast cancer

How Did Breast Cancer Patients Fare during Different Phases of the COVID-19 Pandemic in Norway Compared to Age-Matched Controls?

Little is known about how health-related quality of life (HRQoL) in breast cancer cases differed from that of controls during and after the COVID-19 pandemic. This study used data from an ongoing, nationwide HRQoL survey of 4279 newly diagnosed breast cancer cases and 2911 controls to investigate how breast cancer patients fared during different phases of the pandemic compared to controls. Responders during 2020-2022 were categorized into three COVID-19-related phases: the social restrictions phase, the high infection rate phase, and the post-pandemic phase. Across phases, breast cancer cases had significantly worse scores in most HRQoL domains compared to controls. Apart from slightly more insomnia in the high infection rate phase for both cases and controls, and better social functioning for young cases in the post-COVID-19 phase, the case-control differences in HRQoL remained consistent across phases. When the phases were assessed as one period, young women and those living with children <18 years of age fared the worst among breast cancer cases, while single women fared the worst among controls. In contrast, controls living with children <18 years of age exhibited better HRQoL than controls without children. In summary, women with breast cancer did not appear to fare differently than controls in terms of HRQoL across COVID-19 phases. However, breast cancer cases with young children fared worse in their HRQoL than other breast cancer cases.

The long-term psychosocial consequences of screen-detected ductal carcinoma in situ and invasive breast cancer

OBJECTIVE

Ductal carcinoma in situ (DCIS) is a risk factor for invasive breast cancer (IBC). The prognosis of DCIS is considerably better than for IBC, yet women do not distinguish between the threat. We aimed to compare the psychosocial consequences of screen-detected DCIS and IBC, and to examine this comparison over time.

METHODS

We surveyed a Danish mammography-screening cohort from 2004 to 2018. We assessed outcomes at six-time points: baseline, 1, 6, 18, 36 months, and 14 years after the screening. We measured psychosocial consequences with the Consequences Of Screening - Breast Cancer (COS-BC): a condition-specific questionnaire that is psychometrically validated and encompasses 14 psychosocial dimensions. We used weighted linear models with generalized estimating equations to compare responses between groups. We used a 1% level of significance.

RESULTS

170 out of 1309 women were diagnosed with breast cancer (13.0%). 23 were diagnosed with DCIS (13.5%) and 147 with IBC (86.5%). From baseline to six months after diagnosis, there were no significant differences between women with DCIS and IBC. However, mean scores indicated that IBC generally was more affected than DCIS. After six months, we observed that women with DCIS and IBC might be affected differently in the long term; mean scores and mean differences showed that IBC were more affected on some scales, while DCIS were on others.

CONCLUSION

Overall, the DCIS and IBC experienced similar levels of psychosocial consequences. Women might benefit from renaming DCIS to exclude cancer nomenclature.

Evaluation of parking-related financial toxicity associated with cancer treatments in Western Canada

INTRODUCTION/BACKGROUND

Patients and their caregivers incur numerous out-of-pocket costs while receiving oncologic treatments. These expenses are often overlooked by clinicians, even in countries with publicly funded healthcare systems. Parking fees are one such category of expenses that contribute to financial toxicity in cancer care. Patients with cancer often have protracted treatment courses, especially if they are receiving external beam radiation therapy. It is not clear if cancer center parking fees influence city-specific indices such as city-specific cost of living. The aim of this study was to evaluate cancer center parking fees in Western Canada and to elucidate any correlation between daily cost of parking and the city-specific indices.

METHODS

This was a cross sectional study conducted from February 1st, 2022, to March 1st, 2022. An online search was undertaken to obtain the publicly available parking information for the regional and community cancer centers in the provinces of British Columbia, Alberta, Manitoba, and Saskatchewan. Telephone calls were made with parking offices or switchboards to obtain this information for the cancer centers that did not have online information on parking. Cancer center address transit scores, median city household income, and city-specific cost of living scores were obtained online for the cities where the cancer centers were located. Pearson correlation and a zero-inflated negative binomial model were used for statistical analysis.

RESULTS

Data was collected from 115 community and regional cancer centers distributed across the 4 provinces. The median hourly parking fee across all provinces was 2.00 Canadian Dollars (CAD) (Interquartile range (IQR), 0-4.25), whereas the median daily cost of parking was 9.50 CAD (IQR, 0-13.13). The median cancer center address transit score was 41.00 (IQR, 12.00-50.50). There was a statistically significant (p=0.029) positive correlation between the daily cost of parking and city cost of living. The correlation coefficient between the two variables was 0.412. Furthermore, there was a statistically significant (p<0.001) positive correlation between daily cost of parking and cancer center address transit score. The correlation coefficient between the two variables was 0.676. In addition, there was a strong negative correlation between the cancer center address transit score and the presence of free parking with a correlation coefficient of -0.613 (p<0.001). There was a nonsignificant (p=0.88) negative correlation between cost of living and the presence of free parking with a correlation coefficient of -0.028.

DISCUSSION

The results of this study demonstrate that daily cost of parking for community and regional cancer centers in Western Canada significantly influences city-specific cost of living and cancer center address transit scores to a varying degree. This demonstrates that the influence of parking fees on patients with cancer is multilayered with significant direct and indirect effects. This can contribute to loss of wage and added financial burden on patients and their caregivers in higher-cost provinces. The presence of free parking at community and regional cancer centers had a statistically significant negative correlation with the cancer center address transit score. This suggests that cities with more free parking also have less robust public transit systems. Conversely, the presence of an extensive public transit system leads to a lower likelihood of free parking being available at cancer centers.

CONCLUSION

The presence of a strong public healthcare system does not necessarily address all aspects of cancer-related financial toxicity. There is strong evidence of both positive and negative correlations between city specific indices and cancer center parking fees in Western Canada. Policy makers and stakeholders should be cognizant of this interplay between the various city specific indices and parking fees for patients with cancer. Policies on provincial and federal levels should be implemented to address this increasingly problematic burden on oncologic patients.

Healthcare utilization in cancer survivors: six-month longitudinal cohort data

PURPOSE

To describe healthcare utilization and reasons for delaying medical care and to identify factors that influence high healthcare utilization and care delay among cancer survivors.

METHODS

Baseline (n = 991) and 6 month follow-up data (n = 777) were collected among breast, prostate, and colorectal cancer survivors from 32 US cancer centers. Participants completed surveys on healthcare utilization (e.g., number of visits to specific providers) and delay of medical care. We categorized participants as high or low users based on median number of visits. We used logistic regression models to examine factors that predicted high healthcare utilization or delay.

RESULTS

Survivors reported a median of 10.5 visits to healthcare providers and 28% reported ever delaying medical care over 6 months. Compared to prostate cancer survivors, breast and colorectal survivors were 2.4 times more likely (CI = 1.2-4.8) and 4 times more likely (CI = 2.2-7.3) to be high healthcare users, respectively. A higher quality of life score predicted high healthcare utilization (OR = 2.4, CI = 2.0-2.8) and delay of medical care (OR = 1.8, CI = 1.5-2.2). Black survivors were 1.5 times more likely than White survivors to be high healthcare users (CI = 1.1-2.0) and respondents reporting a race category other than White or Black were 1.8 times more likely to delay care (CI = 1.3-2.5). Lower levels of self-efficacy predicted greater healthcare use (OR = 0.7, CI = 0.6-0.8) and delay (OR = 0.6, CI = 0.5-0.7).

CONCLUSION

Our findings suggest that race, education, marital status, cancer type, time since diagnosis, quality of life, and self-efficacy are associated with both high healthcare utilization and delay among cancer survivors.

Emerging Understanding About the Impact of Financial Toxicity Related to Cancer: Canadian Perspectives

OBJECTIVE

This article offers an overall summary of the current situation concerning cancer-related financial toxicity from the perspective of Canadian patents and survivors. The focus is on describing the financial effects experienced by the patient and survivor and family, which they attribute to the cancer diagnosis, treatment, and other factors that contribute to their financial distress.

DATA SOURCES

The information was drawn from peer-reviewed research literature generated by Canadian researchers regarding out-of-pockets costs, loss of income, and the impact of financial burden over the past 2 decades. Priority was given to understanding what patients and survivors and caregivers perceived as financial burden and distress (stress and strain).

CONCLUSION

Canadian patients and family members reported financial burden (out-of-pocket costs, loss of income) and financial distress following the diagnosis and treatment of cancer. Heightened distress from financial burden was reported between 38% and 71% within various samples. Patients and survivors indicated the distress and challenges managing the financial situation had a profound impact on their everyday living and quality of life. Many were surprised by the increased costs, given the county's universal health care system. Baseline financial status, competency in managing finances, and lost wages were significant factors in the distress experienced by patients and family members.

IMPLICATIONS FOR NURSING PRACTICE

Oncology nurses need to be aware of financial toxicity as a potential side effect of cancer. It may emerge during treatment but can extend well beyond the end of treatment. Early screening and assessment followed by dialogue about the potential impact with patients and family members is important. Routine monitoring of distress related to financial toxicity should be part of ongoing care with appropriate referral to relevant recourses as needed.

Distress Thermometer in breast cancer: systematic review and meta-analysis

Objective

This meta-analysis aimed to reach a summarised estimate of distress prevalence screened by Distress Thermometer (DT) among patients with breast cancer and compare different pooled prevalence estimated between different subgroups.

Methods

Two independent interviewers conducted a systematic search from PubMed, EMBASE, Ovid and Cochrane Library and checked related reviews and meta-analyses for eligible studies. The studies that identified distress of patients with breast cancer with DT were included. After extracting demographic characteristics and distress prevalence, the pooled analysis and the forest plot were completed by using STATA V.12.0 software. We conducted a subgroup analysis based on demographic and methodological characteristics of the studies. The publication bias was estimated by funnel plot.

Results

Seventeen studies describing 3870 patients with breast cancer were included in this meta-analysis. The distress prevalence of patients with breast cancer varied from 25.3% to 71.7% among these studies. The pooled distress prevalence was 50% (95% CI 49% to 52%) for the overall sample. The pooled distress prevalence rates in DT ≥7, DT ≥5 and DT ≥4 subgroups were 37% (95% CI 35% to 40%), 45% (95% CI 40% to 49%) and 62% (95% CI 60% to 65%), respectively. The distress prevalence had statistically significant differences between subgroups, which were differentiated by the initial time of distress identified, papers’ publication time, patients’ average age and country. There was no publication bias among the included studies.

Conclusion

The distress prevalence was high among patients with breast cancer. Routine and timely screening of distress for patients with breast cancer is of great significance in oncology management.

Overutilization in laboratory medicine: tackling the problem with quality improvement science

Overutilization of tests and treatments is a widespread problem in contemporary heath care, and laboratory medicine is no exception. It is estimated that 10-70% of laboratory tests may be unnecessary, with estimates in the literature varying depending on the situation and the laboratory test. Inappropriate use of laboratory tests can lead to further unnecessary testing, adverse events, inaccurate diagnoses, and inappropriate treatments. Altogether, this increases the risk of harm to a patient, which can be physical, psychological, or financial in nature. Overutilization in healthcare is driven by complex factors including care delivery models, litigious practice environments, and medical and patient culture. Quality improvement (QI) methods can help to tackle overutilization. In this review, we outline the global healthcare problem of laboratory overutilization, particularly in the developed world, and describe how an understanding of and application of quality improvement principles can help to address this challenge.

The Mediation and Suppression Effect of Demoralization in Breast Cancer Patients After Primary Therapy: A Structural Equation Model

BACKGROUND

Because of the increasing 5-year survival rate of breast cancer, adjustment to breast cancer survivorship is pertinent to the patient's life after diagnosis. Despite the psychological changes occurring during the transitional period (first 5 years after diagnosis) and after primary therapy having a known, critical effect on survivorship status, the data related to this topic are very limited.

PURPOSE

This study was designed to examine the relationships among demoralization, stress, sleep disturbance, and psychological well-being in women with breast cancer after primary therapy.

METHODS

Two hundred eight women with breast cancer (mean age = 51.96 ± 8.27) participated in a cross-sectional study in central Taiwan. Recruitment was conducted using convenience snowball sampling at a local teaching hospital. All of the participants had completed primary therapy and were in the 5-year postdiagnosis period. The average duration of cancer was 28 months. The participants completed the Stress of Breast Cancer after Primary Therapy Scale, Demoralization Scale, Pittsburgh Sleep Quality Inventory, and Ryff's Psychological Well-Being Scale-Short Form. Data were analyzed using a structural equation model to find plausible path relationships among stress, demoralization, sleep disturbances, and psychological well-being.

RESULTS

Demoralization was shown to completely mediate the effect of stress on sleep disturbances. In addition, the predictive effect of sleep disturbances on psychological well-being was overwhelmingly explained by demoralization when competing with sleep disturbances. Furthermore, a positive path was found between stress and psychological well-being because of the suppression effect of demoralization.

CONCLUSIONS/IMPLICATIONS FOR PRACTICE

Demoralization was found to be a mediator that suppressed the relationships among stress, sleep disturbances, and psychological well-being in the adaptation process of patients with breast cancer after primary therapy. This article adds to the limited research on women with breast cancer after primary therapy who are in their initial 5 years of diagnosis. In addition, this study used structural equation model to find the plausible path relationships among the psychological factors involved in the well-being of women with breast cancer. Supporting patients with cancer and effectively reducing their perceived demoralization will be key to transforming stress into personal growth and a facilitator of long-term recovery.

Ductal carcinoma in situ (DCIS): The importance of patient-reported outcomes (PRO)

Purpose

Patient reported outcomes (PROs) are an optimal method for assessing quality of life (QOL), including physical and psychosocial health. This review summarizes PROs frequently assessed in the setting of a DCIS diagnosis.

Recent findings

Health-related QOL has generally been found to be modestly affected in women with DCIS and similar to women with invasive breast cancer. Several studies reported a substantial negative impact on sexual health and body image, including some differences based on surgery type. Some patients experience pain after treatment, although many physical symptoms resolve. The prevalence of anxiety and depression varied based on assessment timing, with symptoms improving over time. Women with DCIS often overestimate the risks associated both with DCIS and invasive cancer.

Summary

PROs provide critical information regarding the experiences of women following a DCIS diagnosis. Continued inclusion of PROs in clinical trials is warranted, further informing treatment decisions and adequately preparing patients for what to expect following treatment.

The impact of ductal carcinoma in situ on health services utilization

PURPOSE

To determine the intermediate-term impact of diagnosis and treatment of ductal carcinoma in situ of the breast (DCIS) on health services utilization, we compared utilization by cases of DCIS to unaffected controls.

METHODS

We identified a population-based cohort of Ontario females diagnosed with DCIS between 2010 and 2015. We matched 5 controls without any history of cancer to each case, on the date of diagnosis of the case (the index date), by age, annual mammography history, socioeconomic status, and comorbidity. We identified billing claims and hospital records, during the interval 13 to 60 months prior to, and subsequent to the index date, and computed rates per 100 person-years during both intervals, to conduct a difference-in-differences analysis. We used negative binomial regression to test if the change in rates in health services differed between cases and controls.

RESULTS

Visits with a breast diagnosis code, and claims for breast surgery and imaging, were significantly increased among cases compared to controls (all p values < 0.0001) after DCIS;however, there was no increase in visits for anxiety or depression (RR 1.13 (95% CI 0.97, 1.32, p = 0.11), visits to psychiatrists (RR 1.07 (95% CI 0.82, 1.40) p = 0.6), or hospital procedures other than breast surgery (RR 1.10 (95% CI 0.88, 1.37) p = 0.4).

CONCLUSIONS

DCIS is associated with more visits and procedures related to the breast compared to controls following diagnosis and treatment, but other health services utilization and visits related to anxiety and depression were not increased.

Psychological morbidity in women diagnosed with ductal carcinoma in situ compared with women with early breast cancer receiving radiotherapy

PURPOSE

Despite having an excellent prognosis, patients with ductal carcinoma in situ (DCIS) report significant anxiety and depression following diagnosis. This study evaluated psychological morbidity using the Edmonton Symptom Assessment Scale (ESAS) in patients with DCIS compared with women with early-stage invasive breast cancer (EIBC) receiving radiotherapy (RT).

METHODS

We identified patients diagnosed with DCIS or EIBC (stage I or II breast cancer) from 2011 to 2017 who had at least one ESAS completed pre- and post-RT. Data on systemic treatment, radiation, patient demographics, and disease stage were extracted from existing databases. Psychological morbidity was evaluated through measurement of depression, anxiety, and overall wellbeing within the ESAS. The Wilcoxon rank-sum test or chi-square test was performed for continuous or categorical variables.

RESULTS

This study included 137 women with DCIS and 963 women with EIBC. ESAS was completed on average 28 days before RT (baseline) and 142 days after RT. Baseline ESAS scores showed significantly higher rates of depression among women with EIBC compared with those with DCIS (p = 0.006). Patients with EIBC also reported higher levels of anxiety and lower overall wellbeing than patients with DCIS, but this difference was not statistically significant. Post-RT ESAS scores showed significantly higher anxiety in patients with EIBC compared with DCIS (p = 0.049). Post-RT measures of anxiety and overall wellbeing were higher in patients with EIBC but differences were not statistically significant.

CONCLUSION

Women with DCIS experience relatively less psychological morbidity than women with EIBC, pre- and post-RT.

Quality of DCIS information on the internet: a content analysis

PURPOSE

Women with ductal carcinoma in situ (DCIS) experience lingering confusion and anxiety, and may use the Internet for supplemental information. This study assessed the content and quality of DCIS information on the Internet.

METHODS

We searched Google for English-language, publicly available DCIS information tools published from 2010 to current by non-profit organizations. We summarized tool characteristics, DCIS labels, and information important to women with DCIS corresponding to domains of a patient-centred care (PCC) framework. Tool quality was appraised with the DISCERN instrument.

RESULTS

Of 39 tools included, most were plain language summaries published since 2016. Tools employed a median of 2.0 labels (range 1.0 to 5.0) for DCIS, most frequently non-invasive breast cancer (29, 74.4%), abnormal cells (14, 35.9%), pre-cancer (14, 35.9%), and early form of breast cancer (13, 33.3%). Tools addressed a median of 4.0 (range 2.0 to 5.0) PCC domains. Few tools contained content in the domains of fostering the relationship (30.8%), addressing emotions (41.0%), or follow-up (41.0%); 74.4% noted the risk of progression or recurrence but provided vague details. Tools were assessed as high (25.6%), moderate (48.7%), and low (25.6%) quality.

CONCLUSIONS

Few DCIS information tools available to women on the Internet meet quality criteria for consumer health information or address concerns of importance to women with DCIS. By identifying a range of poorly defined terms used to label DCIS, and specific content domains that were lacking, this study identified how existing tools could be improved, and identified higher-quality tools that clinicians can use when discussing DCIS with patients.

National consensus recommendations on patient-centered care for ductal carcinoma in situ

PURPOSE

The purpose of this research was to generate recommendations on strategies to achieve patient-centered care (PCC) for ductal carcinoma in situ (DCIS).

METHODS

Thirty clinicians (surgeons, medical/radiation oncologists, radiologists, nurses, navigators) who manage DCIS and 32 DCIS survivors aged 18 or older were nominated. Forty-six recommendations to support PCC for DCIS were derived from primary research, and rated in a two-round Delphi process from March to June 2018.

RESULTS

A total of 29 clinicians and 27 women completed Round One, and 28 clinicians and 22 women completed Round Two. The 29 recommendations retained by both women and clinicians reflected the PCC domains of fostering patient-physician relationship (5), exchanging information (5), responding to emotions (1), managing uncertainty (4), making decisions (9), and enabling patient self-management (5). An additional 13 recommendations were retained by women only: fostering patient-physician relationship (1), exchanging information (3), responding to emotions (2), making decisions (3), and enabling patient self-management (4). Some recommendations refer to processes (i.e., ask questions about lifestyle or views about risks/outcomes to understand patient preferences); others to tools (i.e., communication aid). Panelists recommended a separate consensus process to refine the language that clinicians use when describing DCIS.

CONCLUSIONS

This is the first study to generate guidance on how to achieve PCC for DCIS. Organizations that deliver or oversee health care can use these recommendations on PCC for DCIS to plan, evaluate, or improve services. Ongoing research is needed to develop communication tools, and establish labels and language for DCIS that optimize communication.

Associations Between Breast Cancer Survivorship and Adverse Mental Health Outcomes: A Systematic Review

Background

We aimed to systematically review the evidence on adverse mental health outcomes in breast cancer survivors (≥1 year) compared with women with no history of cancer.

Methods

Studies were identified by searching MEDLINE, PsycINFO, the Cumulative Index to Nursing and Allied Health Literature, and the Social Sciences Citation Index, and through backward citation tracking. Two researchers selected the studies, extracted data, and assessed the risk of bias.

Results

Sixty studies were included. Of 38 studies of depression, 33 observed more depression in breast cancer survivors; this was statistically significant in 19 studies overall, including six of seven where depression was ascertained clinically, three of four studies of antidepressants, and 13 of 31 that quantified depressive symptoms. Of 21 studies of anxiety, 17 observed more anxiety in breast cancer survivors, statistically significant in 11 studies overall, including two of four with clinical/prescription-based outcomes, and in eight of 17 of anxiety symptoms. Breast cancer survivors also had statistically significantly increased symptoms/frequency of neurocognitive dysfunction (18 of 24 studies), sexual dysfunctions (5 of 6 studies), sleep disturbance (5 of 5 studies), stress-related disorders/PTSD (2 of 3 studies), suicide (2 of 2 studies), somatisation (2 of 2 studies), and bipolar and obsessive-compulsive disorders (1 of 1 study each). Studies were heterogeneous in terms of participants' characteristics, time since diagnosis, ascertainment of outcomes, and measures reported. Approximately one-half of the studies were at high risk of selection bias and confounding by socio-economic status.

Conclusions

There is compelling evidence of an increased risk of anxiety, depression and suicide, and neurocognitive and sexual dysfunctions in breast cancer survivors compared with women with no prior cancer. This information can be used to support evidence-based prevention and management strategies. Further population-based and longitudinal research would help to better characterize these associations.

Interventions are needed to support patient-provider decision-making for DCIS: a scoping review

PURPOSE

Prognostic and treatment uncertainty make ductal carcinoma in situ (DCIS) complex to manage. The purpose of this study was to describe research that evaluated DCIS communication experiences, needs and interventions among DCIS patients or physicians.

METHODS

MEDLINE, EMBASE, CINAHL and The Cochrane Library were searched from inception to February 2017. English language studies that evaluated patient or physician DCIS needs, experiences or behavioural interventions were eligible. Screening and data extraction were done in duplicate. Summary statistics were used to describe study characteristics and findings.

RESULTS

A total of 51 studies published from 1997 to 2016 were eligible for review, with a peak of 8 articles in year 2010. Women with DCIS lacked knowledge about the condition and its prognosis, although care partners were more informed, desired more information and experienced decisional conflict. Many chose mastectomy or prophylactic mastectomy, often based on physician's recommendation. Following treatment, women had anxiety and depression, often at levels similar to those with invasive breast cancer. Disparities were identified by education level, socioeconomic status, ethnicity and literacy. Physicians said that they had difficulty explaining DCIS and many referred to DCIS as cancer. Despite the challenges reported by patients and physicians, only two studies developed interventions designed to improve patient-physician discussion and decision-making.

CONCLUSIONS

As most women with DCIS undergo extensive treatment, and many experience treatment-related complications, the paucity of research on PE to improve and support informed decision-making for DCIS is profound. Research is needed to improve patient and provider discussions and decision-making for DCIS management.

Cancer-Related Cognitive Impairment in Breast Cancer Patients: Influences of Psychological Variables

Approximately 3.1 million women in the US are living with breast cancer and up to 75% of these women experience cancer-related cognitive impairment (CRCI). CRCI is described as impairments in memory, verbal fluency, thought processes, and attention span. Despite the high prevalence of breast cancer, only a few studies have been published on CRCI and most of these studies primarily focused on its pathophysiological mechanism. However, recent evidence has demonstrated that breast cancer patients with CRCI are more likely to have high level of psychologic distress, suggesting a possible relationship between CRCI and psychologic distress. This review aims to examine existing literature that describes CRCI in relation to psychological distress among breast cancer patients. One thousand four hundred and ninety-eight articles were searched using PubMed, CINAHL, and PsycINFO. Thirteen studies met inclusion criteria, and one article was additionally pulled from article reference lists. Of these19 studies, psychologic distress has been operationalized in varied ways such as anxiety (n = 3), depression (n = 2), both anxiety and depression (n = 4), stress (n = 4), worry (n = 2), mental fatigue (n = 1), and undefined psychological distress (n = 2). Except for six studies designed as a longitudinal study, the rest of studies used a cross-sectional design. Twelve studies used both subjective and objective measures to assess cognitive function. We found that the patients with high psychological distress displayed lower performance on cognitive function tests. Our finding indicates that psychological variables contributed to CRCI that breast cancer patients experienced. Areas for further investigation are proposed that will advance the care of breast cancer patients with CRCI.

Evidence for overuse of medical services around the world

Overuse, which is defined as the provision of medical services that are more likely to cause harm than good, is a pervasive problem. Direct measurement of overuse through documentation of delivery of inappropriate services is challenging given the difficulty of defining appropriate care for patients with individual preferences and needs; overuse can also be measured indirectly through examination of unwarranted geographical variations in prevalence of procedures and care intensity. Despite the challenges, the high prevalence of overuse is well documented in high-income countries across a wide range of services and is increasingly recognised in low-income countries. Overuse of unneeded services can harm patients physically and psychologically, and can harm health systems by wasting resources and deflecting investments in both public health and social spending, which is known to contribute to health. Although harms from overuse have not been well quantified and trends have not been well described, overuse is likely to be increasing worldwide.

Impact of physical activity in group versus individual physical activity on fatigue in patients with breast cancer: A pilot study

BACKGROUND

Physical activity improves the quality of life of cancer survivors, but whether there is a difference between individual vs. group physical activity is unknown.

OBJECTIVES

To compare fatigue at 12 weeks in breast cancer survivors after participation in a program of group vs. individual video-assisted physical activity.

METHODS

This was a randomized phase II pilot study carried out in breast cancer survivors at a tertiary breast cancer center. Eligible patients were randomized to individual or group 12-week physical activity program. The primary outcome was fatigue (FACT-F). Aerobic capacity (6-min walk test), muscular strength, and quality-of-life (FACT-G and FACT-B) were assessed. Because of poor accrual, 200 consecutive breast cancer patients were surveyed about their physical activity habits to assess reasons for low recruitment.

RESULTS

For all participants (n = 26; n = 12 for group vs. n = 14 for individual), there were some improvement in FACT-F, FACT-G, FACT-B, physical activity level, aerobic capacity, and shoulder strength. Among the 200 patients surveyed, 58% were interested to increase their physical activity level, 15% declared that they were already exercising enough, 9% declared being unable to, 3% declared having no time, and 2% declared having no interest, and other reasons (13%). Among the 200 patients surveyed, 25% preferred in group, 57% preferred alone, and 18% had no preference.

CONCLUSION

Low recruitment precluded conclusions about the efficacy of physical activity practiced in group vs. individually, but both groups derived a benefit. Low willingness to change exercising habits could be the biggest barrier to physical activity in breast cancer survivors.

Pain, sensory disturbances and psychological distress are common sequelae after treatment of ductal carcinoma in situ: a cross-sectional study

Sequelae such as pain, sensory disturbances and psychological distress are well known after treatment for invasive breast cancer (IBC). Patients treated for ductal carcinoma in situ (DCIS) receive a similar treatment as low-risk IBC. The aim of this cross-sectional study was to describe prevalence of postoperative pain, sensory disturbances, psychological distress and rehabilitation needs among Danish women with DCIS.

METHODS

A total of 574 women treated for DCIS in Denmark in 2013 and 2014 were enrolled and 473 (82%) completed a detailed questionnaire on demographic factors, pain, sensory disturbances, psychological aspects and rehabilitation needs 1-3 years after surgery.

RESULTS

Median age was 60 years. A total of 33% of patients reported any pain and 12% reported moderate to severe pain in the area of surgery. Younger age (<50 years OR 4.7 (95% CI: 1.6-14.0, p = 0.006)), aged 50 to 65 years OR 2.8 (95% CI: 1.1-7.0, p = 0.02) and anxiety and depression (measured by HADS_total >15 OR of 3.1 (95% CI: 1.5-6.3, p = 0.003)) were significantly associated with moderate to severe pain. Approximately one-third of the patients reported sensory disturbances such as pins and needles (32%), numbness (37%) and painful itch (30%) and 94 women (20%) reported anxiety ≥8, 26 (6%) depression and 51 (11%) reported distress.

CONCLUSIONS

This cross-sectional study showed that women treated for DCIS suffered from pain, sensory disturbances and psychological impairment and had unmet rehabilitation needs. Further research is warranted, specifically addressing rehabilitation after diagnosis and treatment of DCIS.

Patient-reported outcomes in ductal carcinoma in situ: A systematic review

Ductal carcinoma in situ (DCIS) is a pre-invasive breast cancer with excellent prognosis but with potential adverse impacts of diagnosis and treatment on quality of life and other patient-reported outcomes (PROs). We undertook a systematic review to synthesise current evidence about PROs following diagnosis and treatment for DCIS. We searched five electronic databases (from database inception to November 2015), cross-referenced and contacted experts to identify studies that reported PROs after DCIS treatment. Two reviewers independently applied inclusion and quality criteria, and extracted findings. Of 2130 papers screened, 23 were eligible, reporting 17 studies. Short- and long-term PRO evidence about differences between DCIS treatment options was lacking. Evidence pooled across treatments indicated core aspects of quality of life (physical, role, social, emotional function, pain, fatigue) and psychological distress (anxiety, depression) were impacted significantly initially, with most aspects returning to population norms by 6-12 months, and all by 2 years post-operatively. Fears of recurrence and dying from breast cancer were exaggerated, occurred early and persisted for many years. Sexuality and body image impacts were generally low and resolved within 1-3 months after surgery. A minority of women experienced considerable impact, including depression and sexual issues associated with body image problems. Well-powered PRO studies are required to track recovery trajectories and long-term impacts of the range of contemporary and emerging local and systemic treatments for DCIS. PRO data would enable care providers to prepare patients for short-term sequelae and enable patients who have treatment options to exercise preferences in choosing among them.

Predicting general and cancer-related distress in women with newly diagnosed breast cancer

BACKGROUND

Psychological distress can impact medical outcomes such as recovery from surgery and experience of side effects during treatment. Identifying the factors that explain variability in distress would guide future interventions aimed at decreasing distress. Two factors that have been implicated in distress are illness perceptions and coping, and are part of the Self-Regulatory Model of Illness Behaviour (SRM). The model suggests that coping mediates the relationship between illness perceptions and distress. Despite this; very little research has assessed this relationship with cancer-related distress, and none have examined women with screen-detected breast cancer. This study is the first to examine the relative contribution of illness perceptions and coping on general and cancer-related distress in women with screen-detected breast cancer.

METHODS

Women recently diagnosed with breast cancer (N = 94) who had yet to receive treatment completed measures of illness perceptions (Revised Illness Perception Questionnaire), cancer-specific coping (Mental Adjustment to Cancer Scale), general anxiety and depression (Hospital Anxiety and Depression scale), and cancer-related distress.

RESULTS

Hierarchical regression analyses revealed that medical variables, illness perceptions and coping predicted 50% of the variance in depression, 42% in general anxiety, and 40% in cancer-related distress. Believing in more emotional causes to breast cancer (β = .22, p = .021), more illness identity (β = .25, p = .004), greater anxious preoccupation (β = .23, p = .030), and less fighting spirit (β = -.31, p = .001) predicted greater depression. Greater illness coherence predicted less cancer-related distress (β = -.20, p = .043). Greater anxious preoccupation also led to greater general anxiety (β = .44, p < .001) and cancer-related distress (β = .37, p = .001). Mediation analyses revealed that holding greater beliefs in a chronic timeline, more severe consequences, greater illness identity and less illness coherence increases cancer-specific distress (ps < .001) only if women were also more anxiously preoccupied with their diagnosis.

CONCLUSIONS

Screening women for anxious preoccupation may help identify women with screen-detected breast cancer at risk of experiencing high levels of cancer-related distress; whilst illness perceptions and coping could be targeted for use in future interventions to reduce distress.

Time-dependent risk of depression, anxiety, and stress-related disorders in patients with invasive and in situ breast cancer

Despite concerns about the mental health of breast cancer patients, little is known regarding the temporal risk pattern and risk factors of common mental disorders among these patients. We estimated standardized incidence ratios (SIRs) of depression, anxiety and stress-related disorders in a Swedish nationwide cohort of 40,849 women with invasive and 4,402 women with in situ breast cancer (2001-2010, median follow-up = 4.5 years). The impact of patient, tumor and treatment characteristics was analyzed using flexible parametric survival models in a regional cohort of 7,940 invasive breast cancer patients (2001-2013, median follow-up = 7.5 years). Women with invasive breast cancer showed increased rates of depression, anxiety and stress-related disorders [overall SIR (95% CI) = 1.57 (1.46-1.69), 1.55 (1.43-1.68) and 1.77 (1.60-1.95), respectively]. SIRs were highest shortly after diagnosis, but remained increased up to 5 years. Younger age at diagnosis, comorbidity, higher-grade disease, lymph node involvement and chemotherapy were independently associated with the risk of depression and anxiety in invasive cancer patients, with chemotherapy and higher-grade disease conferring short-term risk only, while comorbidities were mainly associated with late-onset events. No clinical risk factors were identified for stress-related disorders except for a greater risk associated with younger age. Patients with in situ cancer only showed an increased incidence of stress-related disorders during the first 6 months after diagnosis [SIR (95% CI) = 2.76 (1.31-5.79)]. The time-dependent risk profile of invasive cancer patients may guide health care professionals for timely and targeted psycho-oncologic interventions.

A randomized clinical trial of a supportive versus a skill-based couple-focused group intervention for breast cancer patients

OBJECTIVE

The aims of this study were to evaluate the efficacy of the 2 types of couple-focused group interventions on couples' psychological and relationship functioning, and to examine possible moderators for each intervention.

METHOD

Three hundred and two women with early stage breast cancer who were recruited within 1 year of diagnosis and their spouses were randomly assigned to either an 8 session enhanced couple-focused group intervention (ECG) or a couples' support group (SG). Couples completed surveys at 4 time points: preintervention, 1 week postgroup, 6 months, and 1 year.

RESULTS

Analyses indicated that anxiety, depressive symptoms, and cancer-specific distress declined and positive well-being improved for couples enrolled in both ECG and SG. Thus, neither treatment was superior in terms of reduction of distress or improvements in positive well-being. Moderator effects indicated that, among patients reporting higher levels of cancer-specific preintervention distress, anxiety, depression, and well-being over the 1-year postintervention time period were significantly lower among SG couples than ECG couples. When patient cancer-specific preintervention distress was low, these 3 outcomes were more positive in ECG relative to SG. A similar pattern with regard to anxiety was illustrated when the moderator effects for perceived partner unsupportive behavior was examined, and a similar pattern was seen for anxiety and well-being for preintervention marital satisfaction.

CONCLUSIONS

A couple-focused supportive group therapy may be more effective for distressed patients, whereas a structured, skills-based couples' group therapy may be more effective for less distressed patients. (PsycINFO Database Record

Outcomes of Active Surveillance for Ductal Carcinoma in Situ: A Computational Risk Analysis

BACKGROUND

Ductal carcinoma in situ (DCIS) is a noninvasive breast lesion with uncertain risk for invasive progression. Usual care (UC) for DCIS consists of treatment upon diagnosis, thus potentially overtreating patients with low propensity for progression. One strategy to reduce overtreatment is active surveillance (AS), whereby DCIS is treated only upon detection of invasive disease. Our goal was to perform a quantitative evaluation of outcomes following an AS strategy for DCIS.

METHODS

Age-stratified, 10-year disease-specific cumulative mortality (DSCM) for AS was calculated using a computational risk projection model based upon published estimates for natural history parameters, and Surveillance, Epidemiology, and End Results data for outcomes. AS projections were compared with the DSCM for patients who received UC. To quantify the propagation of parameter uncertainty, a 95% projection range (PR) was computed, and sensitivity analyses were performed.

RESULTS

Under the assumption that AS cannot outperform UC, the projected median differences in 10-year DSCM between AS and UC when diagnosed at ages 40, 55, and 70 years were 2.6% (PR = 1.4%-5.1%), 1.5% (PR = 0.5%-3.5%), and 0.6% (PR = 0.0%-2.4), respectively. Corresponding median numbers of patients needed to treat to avert one breast cancer death were 38.3 (PR = 19.7-69.9), 67.3 (PR = 28.7-211.4), and 157.2 (PR = 41.1-3872.8), respectively. Sensitivity analyses showed that the parameter with greatest impact on DSCM was the probability of understaging invasive cancer at diagnosis.

CONCLUSION

AS could be a viable management strategy for carefully selected DCIS patients, particularly among older age groups and those with substantial competing mortality risks. The effectiveness of AS could be markedly improved by reducing the rate of understaging.

A Nationwide Cross-Sectional Survey of UK Breast Surgeons' Views on the Management of Ductal Carcinoma In Situ

Background. There is wide variation in the management of Ductal Carcinoma In Situ (DCIS) nationwide. We aimed to investigate whether the attitudes of surgeons towards different aspects of DCIS treatment varied by seniority of surgeon or by geographical region within the UK. Materials and Methods. A nationwide online survey targeted at UK breast surgeons was undertaken. The anonymous survey contained questions regarding demographics of respondents and specific questions regarding DCIS management that were identified as areas of uncertainty during a systematic search of the literature. Results. Responses from 80 surgeons were obtained. Approximately 57% were male and the majority were consultant or specialist registrar. Approximately 63% of participants were based in district general hospitals with all training deaneries represented. Surgeons' views on the prognosis and management of DCIS varied geographically across the UK and terminology for DCIS varied with surgeon seniority. Surgeons' views particularly differed from national guidance on indications for SLNB, tamoxifen, and follow-up practice. Conclusion. Our survey reaffirms that, irrespective of national guidelines and attempts at uniformity, there continues to be a wide variety of views amongst breast surgeons regarding the ideal management of DCIS. However, by quantifying this variation, it may be possible to take it into account when examining long-term trends in nationwide treatment data.

Partnership Status and Socioeconomic Factors in Relation to Health Behavior Changes after a Diagnosis of Ductal Carcinoma In Situ

BACKGROUND

Change in health behaviors can occur among women newly diagnosed with ductal carcinoma in situ (DCIS). We sought to understand whether partnership status and socioeconomic status (SES) affected behavioral changes in body weight, physical activity, alcohol consumption, and smoking.

METHODS

The Wisconsin In Situ Cohort (WISC) study comprises 1,382 women diagnosed with DCIS with information on demographics, SES factors, and pre- and post-DCIS diagnosis health-related behaviors. Logistic regression models were used to determine the association between partnership status, education, and income with change in behavior variables.

RESULTS

Higher educational attainment was associated with lower likelihood of stopping physical activity [OR, 0.45; 95% confidence interval (CI), 0.32-0.63; college vs. high school degree], or starting to drink alcohol (OR, 0.34; 95% CI, 0.15-0.80). Results suggested that higher family income was associated with lower likelihood of gaining >5% body mass index (P = 0.07) or stopping physical activity (P = 0.09). Living with a partner was not strongly associated with behavior changes.

CONCLUSION

Higher educational attainment and higher income, but not living with a partner, were associated with positive health behaviors after a DCIS diagnosis.

IMPACT

The associations between higher educational attainment and, to a lesser extent, higher income with positive health behaviors underscore the importance of considering SES when identifying those at risk for negative behavioral change after DCIS diagnosis.

A randomized controlled trial of cognitive-behavioral stress management in breast cancer: survival and recurrence at 11-year follow-up

Non-metastatic breast cancer patients often experience psychological distress which may influence disease progression and survival. Cognitive-behavioral stress management (CBSM) improves psychological adaptation and lowers distress during breast cancer treatment and long-term follow-ups. We examined whether breast cancer patients randomized to CBSM had improved survival and recurrence 8-15 years post-enrollment. From 1998 to 2005, women (N = 240) 2-10 weeks post-surgery for non-metastatic Stage 0-IIIb breast cancer were randomized to a 10-week, group-based CBSM intervention (n = 120) or a 1-day psychoeducational seminar control (n = 120). In 2013, 8-15 years post-study enrollment (11-year median), recurrence and survival data were collected. Cox Proportional Hazards Models and Weibull Accelerated Failure Time tests were used to assess group differences in all-cause mortality, breast cancer-specific mortality, and disease-free interval, controlling for biomedical confounders. Relative to the control, the CBSM group was found to have a reduced risk of all-cause mortality (HR = 0.21; 95 % CI [0.05, 0.93]; p = .040). Restricting analyses to women with invasive disease revealed significant effects of CBSM on breast cancer-related mortality (p = .006) and disease-free interval (p = .011). CBSM intervention delivered post-surgery may provide long-term clinical benefit for non-metastatic breast cancer patients in addition to previously established psychological benefits. Results should be interpreted with caution; however, the findings contribute to the limited evidence regarding physical benefits of psychosocial intervention post-surgery for non-metastatic breast cancer. Additional research is necessary to confirm these results and investigate potential explanatory mechanisms, including physiological pathways, health behaviors, and treatment adherence changes.

The Effects of Surgery Type and Chemotherapy on Early-Stage Breast Cancer Patients' Quality of Life Over 2-Year Follow-up

BACKGROUND

We examined the effects of surgery type and adjuvant chemotherapy on change in early-stage breast cancer patients' quality of life (QOL) over time.

METHODS

A cohort of 549 patients (33.5% ductal carcinoma in situ, 66.5% stages I/IIA) were interviewed a mean 6.1 weeks (Time1), and 6.2 (Time2), 12.3 (Time3), and 24.4 (Time4) months following definitive breast-conserving surgery (BCS) or mastectomy. QOL was measured using the total Functional Assessment of Cancer Therapy-Breast (FACT-B). Adjusting for demographic, psychosocial, and clinical variables, multiple linear regression models estimated the associations between QOL and each of surgery type, chemotherapy, and their 2-way interaction at each interview. Adjusted generalized estimating equation (GEE) models tested Time1-Time4 change in QOL.

RESULTS

At Time2, chemotherapy (P < .001) and BCS (P < .001) were independently associated with worse QOL in adjusted linear regression, and the adverse effect of chemotherapy was prominent among patients who received BCS compared with those who received mastectomy (P interaction = .031). In the GEE model, QOL significantly improved over time among patients who received BCS (P trend = .047), mastectomy (P trend = .024), and chemotherapy (P trend < .001), but not among patients who did not receive chemotherapy (P trend = .720). All patients completed adjuvant chemotherapy and radiation by Time3. Regardless of surgery type, patients receiving chemotherapy reported lower QOL following surgery, and QOL improved after completion of adjuvant treatment.

CONCLUSIONS

Chemotherapy had a short-term negative impact on QOL after definitive surgical treatment regardless of surgery type. QOL rebounded after completion of adjuvant treatment.

Indicators of distress in newly diagnosed breast cancer patients

Background. The diagnosis, treatment, and long-term management of cancer can present individuals with a multitude of stressors at various points in that trajectory. Psychosocial distress may appear early in the diagnostic process and have negative effects on compliance with treatment and subsequent quality of life.

Purpose. The aim of the study was to determine early-phase predictors of distress before any medical treatment.

Method. Consistent with the goals of the study, 123 newly diagnosed breast cancer patients (20 to 74 years old) completed multiple indicators of knowledge about breast cancer management and treatment, attitudes toward cancer, social support, coping efficacy, and distress.

Results. SEM analysis confirmed the hypothesized model. Age was negatively associated with the patient’s knowledge (β = − 0.22), which, in turn, was positively associated with both attitudes toward breast cancer (β = 0.39) and coping self-efficacy (β = 0.36). Self-efficacy was then directly related to psychological distress (β = − 0.68).

Conclusions. These findings establish indicators of distress in patients early in the cancer trajectory. From a practical perspective, our results have implications for screening for distress and for the development of early interventions that may be followed by healthcare professionals to reduce psychological distress.

Empowerment needs of women with breast cancer: a qualitative study

Background:

Due to the increasing number of women suffering from breast cancer worldwide, promoting the empowerment of these patients is an important factor affecting their survival.

Objectives:

Few studies have investigated the empowerment needs of the breast cancer women, especially in Iran. Therefore, this study was performed to explain the empowerment needs of women with breast cancer in Iran.

Patients and Methods:

In this qualitative study, 19 women with breast cancer were interviewed regarding their empowerment needs using the individual open-ended and, in-depth interviews and then the qualitative data were analyzed through content analysis.

Results:

Three main categories of empowerment needs from the participants’ perspectives were as follows: 1- information: the initial empowerment plans (timely and comprehensive information, coordination and continuity of information, easy and full-time access to information), 2- beliefs: the approval of the empowerment plans for execution (actuality, trust and hope and new beliefs), and 3- skills: efficient execution of the empowerment plans (communication skills, expression the needs, emotions, questions and use of the internet).

Conclusions:

It seems that promoting the empowerment of women with breast cancer is essential. Factors found in this study and also in similar studies, in which empowerment needs are explained in-depth through the experiences of the patients, should be considered and used in the treatment, educational and counseling programs to promote the empowerment of women with breast cancer.

Long-term risk perceptions of women with ductal carcinoma in situ

INTRODUCTION

Previous research has demonstrated that many women with ductal carcinoma in situ (DCIS) overestimate their risk for future breast cancer at the time of diagnosis and soon thereafter. This study aims to evaluate risk perceptions after 5 years.

PATIENTS AND METHODS

In a longitudinal cohort study, we mailed long-term follow-up surveys to 315 women who had previously responded to a survey 18 months after they were diagnosed with DCIS, excluding those who had experienced recurrence and those not treated at our institution. We evaluated risk perceptions with items used previously in the cohort.

RESULTS

One hundred ninety-three women (61%) responded. The median time since diagnosis was 5.9 years. We excluded 12 because of recurrence. Of the 181 remaining, 32% perceived at least a moderate 5-year risk for developing DCIS again, 43% perceived at least a moderate lifetime risk for developing DCIS again, 27% perceived at least a moderate 5-year risk for invasive breast cancer, 38% perceived at least a moderate lifetime risk for invasive breast cancer, and 24% perceived at least a moderate risk for DCIS spreading to other body parts. In a multivariate model, worse financial status and higher perceived risk in the previous survey were the only predictors of at least a moderate perception of risk for DCIS spreading.

CONCLUSION

Women with a history of DCIS continue to harbor inaccurate perceptions of their risk for future breast cancer events even 5 years after diagnosis.

Regression of ductal carcinoma in situ after treatment with acupuncture

This report describes a case of ductal carcinoma in situ (DCIS) that regressed after treatment with acupuncture, Chinese herbs, and other complementary and alternative medicine (CAM). The natural history of DCIS remains to be elucidated, and it is unclear whether all DCIS cases progress to invasive breast cancer. Surgery plus radiation therapy or mastectomy is recommended for women in whom this potentially nonprogressive cancer is detected. This case supports the developing trend toward active surveillance in lieu of breast-disfiguring surgery and offers evidence that CAM therapies may be of value in preventing progression of DCIS to invasive breast cancer.

Out-of-pocket costs in the year after early breast cancer among Canadian women and spouses

BACKGROUND

We lack comprehensive information about the extent of out-of-pocket costs after diagnosis of early breast cancer and their effects on the family's financial situation.

METHODS

This longitudinal study assessed out-of-pocket costs and wage losses during the first year after diagnosis of early breast cancer among Canadian women and spouses. Out-of-pocket costs for treatments and follow-up, consultations with other practitioners, home help, clothing, and natural health products were estimated, with information collected from telephone interviews. Generalized linear models were used to identify women at risk of having higher costs and the effects of out-of-pocket costs on perceptions of the family's financial situation.

RESULTS

Overall, 829 women (participation, 86.2%) and 391 spouses participated. Women's median net out-of-pocket costs during the year after diagnosis were $1002 (2003 Canadian dollars; mean = $1365; SD = $1238), and 74.4% of these costs resulted from treatments and follow-up. Spouses' median costs were $111 (mean = $234; SD = $320), or 9% of couples' total expenses. In multivariable analyses, the percentage of women with out-of-pocket costs of $1773 or more (upper quartile) was statistically significantly associated with higher education, working at diagnosis, living more than 50 km from the hospital where surgery was performed, and having two and three different types of adjuvant treatment (all 2-sided P values ≤ .01). However, when considered simultaneously with wage losses, out-of-pocket costs were not associated with perceived deterioration in the family's financial situation; rather, wage losses were the driving factor.

CONCLUSIONS

Overall, out-of-pocket costs from breast cancer for the year after diagnosis are probably not unmanageable for most women. However, some women were at higher risk of experiencing financial burden resulting from these costs.

Psychosexual functioning and body image following a diagnosis of ductal carcinoma in situ

INTRODUCTION

There has been exponential growth in diagnoses of ductal carcinoma in situ (DCIS) in the past decade, yet little is known about sexual functioning and body image in women after diagnosis of DCIS. This is of particular importance because many of the parallel treatment modalities also used to treat invasive breast cancer, e.g., surgery and hormonal therapy, have been shown to have a detrimental effect on psychosexual function.

AIM

The aim was to explore changes in sexual function and body image after diagnosis and treatment of in situ cancer.

MAIN OUTCOME MEASURES

Evidence-based self-report measures assessing psychosexual functioning and body image.

METHODS

Women diagnosed with DCIS within the past 3 months and who reported being sexually active completed measures assessing various aspects of psychosocial and sexual functioning and body image. Outcomes were evaluated at baseline, 9-, and 18-month time points. All statistical tests were two sided.

RESULTS

Three hundred four women completed this prospective survey. Overall, sexual function in women with DCIS appears to be very similar to women in the general population and does not seem to be significantly disrupted by a diagnosis of DCIS. Sexual function and body image were notably stable across the 18-month length of follow-up. Of those patients who underwent mastectomy, there were no differences in sexual satisfaction for patients who had reconstruction compared with patients who did not.

CONCLUSION

Although it has been shown that women with DCIS have a number of psychosocial challenges, results from this large-scale prospective study of women suggest that sexual function and body image may not be significantly negatively affected by this diagnosis. Of note, these results were also the case for women who underwent mastectomy and hormonal therapy. These findings are reassuring for both patients and physicians in the context of decision making about treatment options.

Quality of life over time in women diagnosed with ductal carcinoma in situ, early-stage invasive breast cancer, and age-matched controls

Little is known about quality-of-life (QOL) differences over time between incident ductal carcinoma in situ (DCIS) and early-stage invasive breast cancer (EIBC) cases as compared with same-aged women without breast cancer (controls). We prospectively recruited and interviewed 1,096 women [16.8% DCIS, 33.3% EIBC (25.7% Stage I; and 7.6% Stage IIA), 49.9% controls; mean age 58; 23.7% non-white] at mean 6.7 weeks (T1), and 6.2 (T2), 12.3 (T3), and 24.4 months (T4) after surgery (patients) or screening mammogram (controls). We tested two hypotheses: (1) DCIS patients would report lower levels of QOL compared with controls but would report similar QOL compared with EIBC patients at baseline; and (2) DCIS patients' QOL would improve during 2-year follow-up and approach levels similar to that of controls faster than EIBC patients. We tested hypothesis 1 using separate general linear regression models for each of the eight subscales on the RAND 36-item Health Survey, controlling for variables associated with at least one subscale at T1. Both DCIS and EIBC patients reported lower QOL at T1 than controls on all subscales (each P<0.05). We tested hypothesis 2 using generalized estimating equations to examine change in each QOL subscale over time across the three diagnostic groups adjusting for covariates. By T3, physical functioning, role limitations due to physical problems, energy/fatigue, and general health each differed significantly by diagnostic group at P<0.05, because of larger differences between EIBC patients and controls; but DCIS patients no longer differed significantly from controls on any of the QOL subscales. At T4, EIBC patients still reported worse physical functioning (P=0.0001) and general health (P=0.0017) than controls, possibly because of lingering treatment effects. DCIS patients' QOL was similar to that of controls two years after diagnosis, but some aspects of EIBC patients' QOL remained lower.

Out-of-pocket costs for accessing adjuvant radiotherapy among Canadian women with breast cancer

PURPOSE

Patients with breast cancer incur out-of-pocket costs when they receive adjuvant radiation. These treatments are administered in dedicated centers on a daily basis over 4 to 5 weeks. We assessed the extent of out-of-pocket costs to access radiotherapy and identified women at risk of experiencing higher costs.

PATIENTS AND METHODS

This prospective study was conducted among 800 women from eight Quebec hospitals (participation, 86%), of whom 693 women received adjuvant radiotherapy. Costs to access treatment (transportation, parking, lodging, and meals) were estimated on the basis of information collected by telephone interviews. Generalized linear models were used to identify women at risk of having higher costs.

RESULTS

Mean and median total costs (including financial aid received) to access radiotherapy were 445 Canadian dollars (Can$; standard deviation, Can$407) and Can$311, respectively. Women who lived at home but far from the radiotherapy center had the highest risk of experiencing weekly costs of at least Can$122 (highest quartile; prevalence ratio [PR], 5.8; 95% CI, 4.7 to 7.1) followed by women who lived away from home and farther from the center (PR, 4.5; 95% CI, 3.4 to 6.0) and by women who lived away from home and closer to the center (PR, 2.14; 95% CI, 1.3 to 3.5). When women stayed at a cancer lodge during treatment, costs were reduced by 80%.

CONCLUSION

Considered in and of themselves, out-of-pocket costs for access to radiotherapy appeared relatively modest. Financial assistance initiatives for women who lived away from home during treatments contributed to a substantial reduction of access costs. These efforts should be maintained, but financial assistance should also target patients with cancer who live at home during treatments but have to travel relatively long distances on a daily basis.

The shifting nature of women's experiences and perceptions of ductal carcinoma in situ

AIM

This paper is a report of a descriptive qualitative study of the evolution of women's perceptions and experiences of ductal carcinoma in situ from the period near to diagnosis to 1 year later.

BACKGROUND

Ductal carcinoma in situ is a non-invasive breast condition where cancer cells are detected but confined to the ducts of the breast. With treatment, the condition has a positive prognosis but ironically patients undergo treatment similar to that for invasive breast cancer. There is a lack of longitudinal qualitative research studying women's experiences of ductal carcinoma in situ, especially among newly diagnosed patients, and how experiences change over time.

METHODS

Forty-five women took part in an initial interview following a diagnosis of ductal carcinoma in situ and 27 took part in a follow-up interview 9-13 months later. Data were collected between January 2007 and October 2008. Transcripts were analysed using a hybrid approach to thematic analysis.

FINDINGS

Women's early perceptions of ductal carcinoma in situ merged and sometimes conflicted with their lay beliefs of breast cancer. Perceptions and experiences of the condition shifted over time. These overriding aspects were evident in four themes identified across the interviews: (i) perceptions of ductal carcinoma in situ vs. breast cancer, (ii) from paradox to acceptance, (iii) personal impact, and (iv) support and interactions with others.

CONCLUSION

This study represents one of the few longitudinal qualitative studies with newly diagnosed patients, capturing women's initial and shifting experiences and perceptions of the condition. The issues identified need to be recognized in clinical practice and supported appropriately.

A longitudinal study of psychosocial distress in breast cancer: prevalence and risk factors

This longitudinal study was conducted among 102 women with non-metastasic breast cancer to identify the time evolution and prevalence of distress at specific times through diagnosis and treatment of disease: preliminary diagnosis, surgery, definitive diagnosis and chemotherapy. Additionally, the study aimed to examine the role of demographic, medical and psychosocial factors on distress. The results indicated that prevalence of distress was higher at initial diagnosis (25%) than the following time points (approximately 17%). The differences inter-individuals in the levels of distress were observed over the four assessments. No relation between distress and demographic and medical factors was found. However, psychosocial aspects were significant risk factors. Patterns of emotional suppression and specific coping responses like helplessness/hopelessness, anxious preoccupation, cognitive avoidance and fatalism were positively related to distress, whereas fighting spirit and perceived social support showed a protective role. Moreover, helplessness/hopelessness and anxious preoccupation jointly predicted 75% of cases and 98% non-cases of distress. Finally, a mediational model between emotional suppression and distress through helplessness/hopelessness was tested. Results support the necessity of routine distress screening all through the illness. Implications of data for psychosocial interventions with breast cancer patients are highlighted.

Quality-of-life issues in patients with ductal carcinoma in situ

Ductal carcinoma in situ (DCIS) as we know it today is a clinical entity that is primarily discovered through the finding of microscopic calcifications on a screening mammogram. Asymptomatic women who are found to have DCIS receive treatments that are similar to women with invasive breast cancer and experience substantial psychological distress in spite of having an excellent prognosis and normal life expectancy. More research is needed to determine the best way to communicate with women about this condition and to match the extent of treatment with the risk of serious future disease. Clinical and research efforts should focus on reducing the anxiety and psychological distress associated with the diagnosis of DCIS.

Physical and psychosocial recovery in the year after primary treatment of breast cancer

PURPOSE

The 2000 National Institutes of Health Consensus Conference on Adjuvant Therapy of Breast Cancer recommended chemotherapy for all women with invasive cancer greater than 1 centimeter. Studies of long-term breast cancer survivors have found poorer quality of life (QOL) in women who received adjuvant chemotherapy. The aim of this article is to characterize physical and psychosocial recovery as a function of chemotherapy receipt in the year after medical treatment completion.

PATIENTS AND METHODS

Prospective longitudinal survey data (RAND SF-36 and Breast Cancer Prevention Trial [BCPT] Symptom Scales) collected from 558 women with breast cancer enrolled on the Moving Beyond Cancer (MBC) psychoeducational intervention trial were compared according to receipt of chemotherapy. MBC study enrollment occurred within 4 weeks after the end of primary treatment (eg, surgery, chemotherapy, radiation). Self-report questionnaire data collected at enrollment and at 2, 6, and 12 months thereafter were examined, controlling for intervention and with propensity score adjustment for imbalance of covariates. Outcome analyses were carried out by fitting linear mixed models by using SAS PROC MIXED.

RESULTS

Longitudinal SF-36 scale scores did not differ by chemotherapy treatment exposure, and both groups improved significantly (P < .01) in the year after primary treatment ended. However, adjuvant chemotherapy treatment was associated with significantly more severe physical symptoms, including musculoskeletal pain (P = .01), vaginal problems (P < .01), weight problems (P = .01), and nausea (P = .03).

CONCLUSION

Physical and psychosocial functioning improved significantly after breast cancer treatment, independent of receipt of adjuvant chemotherapy. Women who received chemotherapy experienced more severe and persistent physical symptoms that should be more effectively managed as part of survivorship care.

Distrés emocional y problemas asociados en población oncológica adulta

Objetivo: en este estudio se estima la prevalencia de distrés, se identifican los problemas asociados y se analiza el conocimiento y uso que hacen los pacientes sobre los recursos psicosociales disponibles en el centro hospitalario. Método: se lleva a cabo un estudio transversal en el que participan 203 pacientes oncológicos que están recibiendo tratamiento quimioterápico. En la evaluación se emplean el Inventario de Síntomas Breve-18 (BSI-18), el Listado de Problemas de NCCN y una encuesta sobre el conocimiento y uso de los recursos asistenciales del centro hospitalario. Resultados: la prevalencia de distrés en la muestra total es del 26%. Los problemas físicos son la principal fuente de distrés: fatiga, dolor, sequedad o picor en la piel y problemas de sueño, entre los más prevalentes. El BSI-18 y la Lista de Problemas muestran correlaciones estadísticamente significativas (r = 0,74; Rango: r = 0,69 y r = 0,18). Sólo el 21% de los casos clínicos de distrés utiliza los servicios psicosociales disponibles. El 79% restante indica no hacer uso de los mismos por considerar no necesitarlos o por desconocer su existencia. Conclusiones: aunque la mayor parte de los participantes muestran un buen ajuste a la enfermedad, un porcentaje significativo presenta niveles clínicos de distrés. Es crucial llevar a cabo cribados rutinarios de la respuesta de distrés para su manejo/control temprano, e informar a la población sobre los recursos psicosociales disponibles, concienciándolos de la importancia de su uso en momentos de vulnerabilidad.