Psychological distress after initial treatment for breast cancer: a comparison of partial and total mastectomy

Impact of High-Intensity Circuit Resistance Exercise on Physical Fitness, Inflammation, and Immune Cells in Female Breast Cancer Survivors: A Randomized Control Trial

Questions remain about whether resistance exercise has a positive effect on immune and inflammatory cells. The purpose of this study was to evaluate the effect of 12 weeks of high-intensity circuit resistance exercise (HCRE) on inflammation and immune cells, and physical fitness, of female breast cancer survivors (FBCSs). Thirty FBCSs were randomly assigned to the HCRE (n = 15) and control (n = 15) groups. HRCE was administered for 50 min a day, 2–3 times a week, for 12 weeks. The control group only performed activities of daily living during the study period. Baseline and post-intervention measures included body composition, muscular strength, muscular endurance, flexibility, reaction time, balance, inflammation, and immune cell measurements. The results showed that HCRE improved body mass index, body fat, muscle mass, grip strength, back muscle strength, sit-up, whole-body reaction, standing on one leg with eyes closed, Y-balance test, and NKCA in FBCSs. The improvement of physical strength and immune cells of FBCSs was achieved using the 12-week HRCE program. Future studies must analyze various exercise intensities and types, and should be conducted on other cancer survivors. In addition, strategies should be developed to allow FBCSs to participate in resistance training.

Richard Packiam CD, Chai Ping Ping D, Binti Zolpakar PM, A.P. Selvakumar V, Binti Abdul Ali SR, Binti Hasrudin AF, Sutikno J. Study on the quality of life among cancer survivors attending a tertiary care cancer center in Malaysia

Background

Cancer is a major public health problem across the globe. According to the Malaysian National Cancer Registry Report (MNCR), between 2007 and 2011, there has been a greater increase in the number of reported cancer cases among females (99.3 per 100,000 people) than males (86.9 cases per 100,000 people). Nearly 15 million new cancer cases were projected by 2020. We conducted this study to assess the quality of life (QoL) among cancer patients.

Design and Methods

This was a cross-sectional study conducted in the oncology department of Malaysian hospitals from October to November 2019. The study population comprised Malaysians in the age range of18 to 100 years diagnosed with cancer, irrespective of their treatment status, cancer type and prognosis. A pre-tested structured questionnaire was used in seventy cancer patients' using a convenient sampling method. Data were collected using a questionnaire survey after obtaining permission from the hospital administrators. Data were entered in MS Excel and analysis was done using the SPSS-version 23. Participants' socio-demographic characteristics were described using descriptive statistics. Results are presented using graphs, tables, mean, percentages, standard deviation, frequency, and significance. Analysis of variance (ANOVA) test was performed to find out the association between socio-demographic variables and overall QoL scores of the patients.

Results

Of the seventycancer patients, 29 (41.43%) were males and 41 (58.57%) were females. The most affected socio-demographic factors were marital status and occupation (employment). It was found that there were 55 (78.57%) married patients and 49 (70%) employed patients. QoL of most of the patients was influenced by the education level and treatment. It was found that 35 (50%) of them had low QoL scores. It was observed that QoL among the study participants was significantly (p<0.05) associated with their level of education and the level of treatment.

Conclusions

There is a need to develop measures for community education, involvement of family physicians for the treatment of cancer and to increase awareness to improve the QoL among cancer patients. The focus should be on the development of strategies empowering patients to seek treatment and gain control over their illness with the collaboration with primary care physicians.

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.

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

Aims

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

Methods

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

Results

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

Conclusions

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

The use of psychological supportive care services and psychotropic drugs in patients with early-stage breast cancer: a comparison between two institutions on two continents

The aim of this study was to evaluate the mental health consumption among patients with early-stage breast cancer in two radiation oncology departments in two countries (USA and Italy). Data were extracted from the medical records of consecutive patients treated between 2014 and 2015 in two centers. Extracted data included patient's demographics, treatment, referral to psychological supportive care programs, and prescribed psychotropic drugs. Data from the two centers were compared using Student's t, Wilcoxon, Fisher's exact, and Jonckheere-Terpstra tests. Adjusted relative risks (RR) were estimated using Poisson regression. A total of 231 (Italy = 110, USA = 121) patients were included, with a mean age of 60 years. The crude rate of psychological supportive care visits was similar in the US versus the Italian cohort (28.9 vs. 21.8%, p = 0.23). The crude rate of prescribed psychotropic drug was higher in the US cohort versus Italian cohort (43.8 vs. 18.2%, p < 0.0001). These differences remained significant after adjusting for breast cancer subtype, stage, and treatment (RR 1.8, 95 CI 1.17-2.76). Between 20 and 30% of patients receive psychological supportive care during treatment for breast cancer. The use of psychotropic medication was higher in the US cohort than the cohort from Italy. The reasons for these differences might be related to social and cultural differences and the method of prescribing medication.

Predictors of initial levels and trajectories of anxiety in women before and for 6 months after breast cancer surgery

BACKGROUND

The diagnosis of breast cancer, in combination with the anticipation of surgery, evokes fear, uncertainty, and anxiety in most women.

OBJECTIVE

Study purposes were to examine in patients who underwent breast cancer surgery how ratings of state anxiety changed from the time of the preoperative assessment to 6 months after surgery and to investigate whether specific demographic, clinical, symptom, and psychosocial adjustment characteristics predicted the preoperative levels of state anxiety and/or characteristics of the trajectories of state anxiety.

INTERVENTIONS/METHODS

Patients (n = 396) were enrolled preoperatively and completed the Spielberger State Anxiety inventory monthly for 6 months. Using hierarchical linear modeling, demographic, clinical, symptom, and psychosocial adjustment characteristics were evaluated as predictors of initial levels and trajectories of state anxiety.

RESULTS

Patients experienced moderate levels of anxiety before surgery. Higher levels of depressive symptoms and uncertainty about the future, as well as lower levels of life satisfaction, less sense of control, and greater difficulty coping, predicted higher preoperative levels of state anxiety. Higher preoperative state anxiety, poorer physical health, decreased sense of control, and more feelings of isolation predicted higher state anxiety scores over time.

CONCLUSIONS

Moderate levels of anxiety persist in women for 6 months after breast cancer surgery.

IMPLICATIONS FOR PRACTICE

Clinicians need to implement systematic assessments of anxiety to identify high-risk women who warrant more targeted interventions. In addition, ongoing follow-up is needed to prevent adverse postoperative outcomes and to support women to return to their preoperative levels of function.

Co-occurrence of anxiety and depressive symptoms following breast cancer surgery and its impact on quality of life

PURPOSE

Little is known about the prevalence of combined anxiety and depressive symptoms (CADS) in breast cancer patients. Purpose was to evaluate for differences in demographic and clinical characteristics and quality of life (QOL) prior to breast cancer surgery among women classified into one of four distinct anxiety and/or depressive symptom groups.

METHODS

A total of 335 patients completed measures of anxiety and depressive symptoms and QOL prior to and for 6 months following breast cancer surgery. Growth Mixture Modelling (GMM) was used to identify subgroups of women with distinct trajectories of anxiety and depressive symptoms. These results were used to create four distinct anxiety and/or depressive symptom groups. Differences in demographic, clinical, and symptom characteristics, among these groups were evaluated using analyses of variance and Chi square analyses.

RESULTS

A total of 44.5% of patients were categorized with CADS. Women with CADS were younger, non-white, had lower performance status, received neoadjuvant or adjuvant chemotherapy, had greater difficulty dealing with their disease and treatment, and reported less support from others to meet their needs. These women had lower physical, psychological, social well-being, and total QOL scores. Higher levels of anxiety with or without subsyndromal depressive symptoms were associated with increased fears of recurrence, hopelessness, uncertainty, loss of control, and a decrease in life satisfaction.

CONCLUSIONS

Findings suggest that CADS occurs in a high percentage of women following breast cancer surgery and results in a poorer QOL. Assessments of anxiety and depressive symptoms are warranted prior to surgery for breast cancer.

Women's decision satisfaction and psychological distress following early breast cancer treatment: a treatment decision support role for nurses

This prospective cross-sectional study investigated Australian women's (n = 104) decision satisfaction with cancer treatment decision for early breast cancer as well as their psychological distress 3-4 months following surgery. Women's satisfaction was surveyed using the Treatment Decision Satisfaction Questionnaire, and the Brief Symptom Inventory-18 was used to measure psychological distress. Women who were living alone, who worked as professionals and who were not involved in the decision-making process by their doctors were less likely to be satisfied with their decision process, outcome and their overall treatment decision. Following treatment, 26.0% of women were distressed; 18.3% experienced anxiety; 19.2% somatization; and 27.9% depression. Women who experienced somatization were more likely to be dissatisfied with the treatment decision (P = 0.003) as were those who reported psychological distress (P = 0.020). Women who were involved in choosing their treatment were more satisfied with their decision. Many women experienced distress following breast cancer treatment and might have required referral for psychological assessment, management and long-term support. Women who experienced distress were more likely to be dissatisfied with the treatment decision (or vice versa).

A prospective study of mastectomy patients with and without delayed breast reconstruction: long-term psychosocial functioning in the breast cancer survivorship period

INTRODUCTION

For women who have mastectomy, breast reconstruction is an option which may improve psychosocial functioning. The purpose of this study was to evaluate changes in psychosocial functioning over a long follow-up period after mastectomy, specifically examining the differences between those with mastectomy alone and those who underwent postmastectomy delayed breast reconstruction (DBR).

METHODS

This was a prospective longitudinal survey study of women with mastectomy in which a repeated measures design was used to compare psychosocial function scores over 3 timepoints: 1) pre-mastectomy; 2) one year post-mastectomy; and 3) long-term post-mastectomy (mean 6.3 years). In addition, psychosocial functioning was compared between the mastectomy alone group and the group who elected for DBR.

RESULTS

67 women who completed questionnaires at all three time points were included. The long-term follow-up time post-mastectomy was 75.2 months (6.3 years). Twenty-eight women (41.8%) underwent DBR in the study period. For the entire cohort, between one-year and long-term post-mastectomy, there were significant improvements in scores for body concerns (P = 0.03), cancer-related distress (P = 0.01), and total distress (P = 0.04). At long-term follow-up, women with DBR had significantly higher levels of total distress (P = 0.01), obsessiveness (P = 0.03), and cancer-related distress (P = 0.02) compared to those with mastectomy alone. There were no differences in quality of life between the two groups at any time point.

CONCLUSIONS

Psychosocial functioning improves over time in patients treated with mastectomy in the long-term breast cancer survivorship period, which may be related to the effect of time post-treatment, rather than an effect of choice for or against DBR.

Polymorphisms in Tumor Necrosis Factor-α Are Associated With Higher Anxiety Levels in Women After Breast Cancer Surgery

INTRODUCTION

Before and after breast cancer surgery, women have reported varying anxiety levels. Recent evidence has suggested that anxiety has a genetic basis and is associated with inflammation. The purposes of the present study were to identify the subgroups of women with distinct anxiety trajectories; to evaluate for differences in the phenotypic characteristics between these subgroups; and to evaluate for associations between polymorphisms in cytokine genes and subgroup membership.

PATIENTS AND METHODS

Patients with breast cancer (n = 398) were recruited before surgery and followed up for 6 months. The patients completed the Spielberger State Anxiety Inventory and provided a blood sample for genomic analyses. Growth mixture modeling was used to identify the subgroups of patients with distinct anxiety trajectories.

RESULTS

Two distinct anxiety subgroups were identified. The women in the higher anxiety subgroup were younger and had a lower functional status score. Two single nucleotide polymorphisms in tumor necrosis factor-α (rs1799964, rs3093662) were associated with the higher anxiety subgroup.

CONCLUSION

The results of the present exploratory study suggest that polymorphisms in cytokine genes could partially explain the interindividual variability in anxiety. The determination of phenotypic and molecular markers associated with greater levels of anxiety can assist clinicians to identify high-risk patients and initiate appropriate interventions.

Trajectories of Depressive Symptoms in Women Prior to and for Six Months After Breast Cancer Surgery

Depressive symptoms are common in women with breast cancer. This study evaluated how ratings of depressive symptoms changed from the time of the preoperative assessment to 6 months after surgery and investigated whether specific demographic, clinical, and symptom characteristics predicted preoperative levels of and/or characteristics of the trajectories of depressive symptoms. Characteristics that predicted higher preoperative levels of depressive symptoms included being married/partnered; receipt of adjuvant chemotherapy; more fear of metastasis; higher levels of trait anxiety, state anxiety, sleep disturbance, problems with changes in appetite; more hours per day in pain; and lower levels of attentional function. Future studies need to evaluate associations between anxiety, fears of recurrence, and uncertainty, as well as personality characteristics and depressive symptoms.

Prescription and adherence to lymphedema self-care modalities among women with breast cancer-related lymphedema

PURPOSE

To profile the prescription for and adherence to breast cancer-related lymphedema (BCRL) self-care modalities among breast cancer (BrCa) survivors with BCRL in a 12-month randomized weightlifting trial.

METHODS

We developed a questionnaire that assessed prescription for and adherence to 10 BCRL self-care modalities that included physical therapy exercise, pneumatic compression pump, medication, lymphedema bandaging, arm elevation, self-administered lymphatic drainage, therapist-administered lymphatic drainage, compression garments, skin care, and taping. We measured prescription for and adherence to BCRL self-care modalities at baseline, 3, 6, and 12 months. Longitudinal logistic regression was used to estimate the odds ratio (OR) and 95 % confidence interval (95 % CI) associated with prescription for and adherence to BCRL modalities over time.

RESULTS

This study included 141 BrCa survivors with BCRL. Women were prescribed an average of 3.6 ± 2.1 BCRL self-care modalities during the study. The prescription for therapist-administered lymphatic drainage (OR = 0.92, 95 % CI 0.88-0.96), pneumatic compression pump use (OR = 0.94, 95 % CI 0.89-0.98), and bandaging (OR = 0.96, 95 % CI 0.93-0.99) decreased over 12 months of follow-up. No other prescribed BCRL self-care modalities changed during the study. Over 12 months, the average adherence to all BCRL self-care modalities varied with 13, 24, 32, and 31 % of women reporting <25, 25-49, 50-74, and ≥75 % adherence, respectively. Over 12 months, there was a noticeable change from high to low adherence in self-administered lymphatic drainage, such that there was a 15 % increased likelihood of adherence <25 % compared to ≥75 % (OR = 1.15 (95 % CI 1.05-1.26); p = 0.002). The adherence patterns of all other modalities did not change over follow-up.

CONCLUSIONS

Our findings suggest the prescription for BCRL self-care modalities is variable. The average adherence to BCRL self-care was non-optimal. Future research is necessary to prepare BrCa survivors with the knowledge, skills, abilities, and resources necessary to care for this lifelong condition.

Does chemotherapy really affect the quality of life of women with breast cancer?

Purpose

The aims of this cross-sectional study were to explore and evaluate the impact of adjuvant chemotherapy on quality of life in breast cancer patients according to the survival time from surgery.

Methods

Completed questionnaires were collected from 534 women with breast cancer. Clinical and sociodemographic characteristics were reviewed and Functional Assessment of Cancer Therapy-Breast cancer instrument, global quality of life, Beck Depression Inventory, and unmet sexuality needs were administered. Descriptive statistics, t-tests, chi-square tests and multiple analysis of covariance were performed while controlling for confounding variables.

Results

Statistically significant differences were found between chemotherapy and no chemotherapy group on depression (p=0.026), unmet sexuality needs (p=0.010), breast cancer specific concerns (p=0.010), physical well-being (p=0.001), and emotional well-being (p=0.028). Chemotherapy effects also varied according to survival time since surgery such as for group 1 (<1 year since surgery), significant differences were found on Beck Depression Inventory (p=0.042), unmet sexuality needs (p=0.016), breast cancer subscale (p=0.004), and physical well-being (p=0.016) and for group 3 (>3 years since surgery) on depression (p=0.019) and physical well-being (p=0.028) respectively; however, there were no significant differences between chemotherapy and no chemotherapy group for group 2 (1-3 years since surgery).

Conclusion

As expected, breast cancer patients who underwent adjuvant chemotherapy experienced significantly worse quality of life than those who did not receive chemotherapy. Furthermore, the adverse chemotherapy effects on the quality of life appear to vary according to the time since surgery. These results suggest that health care professionals may need to address long-term as well as short-term chemotherapy side-effects and intervene accordingly to enhance quality of life of breast cancer patients.

Breast conservation surgery and radiation for a patient with synchronous primary breast cancers and BRCA1/BRCA2 positivity: is mastectomy required?

The role of breast conservation in patients expressing BRCA1 and BRCA2 genetic mutations is controversial. A patient who was found to have bilateral synchronous breast cancers and expressed a BRCA genetic mutation was recently evaluated. The patient had a strong desire for breast preservation. This case and a review of the pertinent literature are presented to discuss the role of breast conservation and radiation in patients with BRCA1 or BRCA2 genetic mutations.

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.

Self-efficacy, perceived preparedness, and psychological distress in women completing primary treatment for breast cancer

The present analyses were conducted to examine demographic and clinical variables associated with mood and health-related distress in a sample of 440 women completing primary treatment for early-stage breast cancer. The authors' aim was to test the hypothesis that higher levels of self-efficacy and perceived preparedness for the end of treatment--the reentry phase--are associated with better mood and lower health-related distress in this sample. Women who had received chemotherapy and who were younger (<50 years) had significantly higher mood disturbance and health-related distress scores. Younger age, preparedness, and self-efficacy predicted 36% of the variance in mood disturbance scores. Self-efficacy and age predicted 26% of the variance in health-related distress. Although further research is needed, our findings suggest that self-efficacy and perceived preparedness represent important constructs to target in the development of interventions for women at the reentry transition.

Long-term cosmesis after lumpectomy and brachytherapy in the management of carcinoma of the previously irradiated breast

OBJECTIVE

To evaluate the cosmetic outcome of brachytherapy after lumpectomy in the management of carcinoma of the previously irradiated breast.

MATERIALS AND METHODS

Between January 1998 and April 2008, 26 patients with TIS or T1 breast carcinoma were offered interstitial or intracavitary brachytherapy after lumpectomy in a previously irradiated breast as an alternative to salvage mastectomy. Twenty-five of 26 patients had prior lumpectomy followed by standard postoperative external beam radiotherapy for early stage carcinoma of the breast [dose range 5000-6040 cGy]. One patient developed breast cancer after full mantle irradiation [4500 cGy to the mediastinum and axillae] for Hodgkin Lymphoma 27 years earlier. All tumors were excised with final margins of resection free of disease per National Surgical Adjuvant Breast and Bowel Project definition. After lumpectomy, tumor bed implantation was carried out utilizing a low dose rate interstitial technique in 22 patients, whereas 3 patients were treated with high dose rate brachytherapy using the MammoSite brachytherapy catheter and 1 patient was treated with high dose rate brachytherapy using the Contura catheter. The low dose rate treatment consisted of 4500 to 5000 cGy at 35 to 50 cGy per hour to the tumor bed plus a 1.0 cm margin, whereas the high dose rate treatment consisted of 3400 cGy in twice daily fractions of 340 cGy currently used in National Surgical Adjuvant Breast and Bowel Project B-39. Cosmesis was graded according to the B-39 cosmesis scale for de novo treatments: grade I as excellent, grade II as good, Grade III as fair, and Grade IV as poor.

RESULTS

Eighteen patients were scored as grade I, 6 as grade II, and 2 as grade III. No patient received a Grade IV score. All 4 balloon brachytherapy patients were scored as Grade I. Twenty-five of 26 patients remained free of local failure with a median follow-up of 38 months (range 6-75 months). The only patient to develop a second local recurrence was graded as grade I before salvage mastectomy. Two patients developed wound dehiscence after immediate postlumpectomy implantation. Two have succumbed to metastatic breast carcinoma at 17 and 24 months after salvage implant therapy. An additional patient has succumbed to chronic obstructive pulmonary disease. All patients, regardless of cosmesis grade were satisfied with their decision for repeat conservation therapy. Factors affecting cosmesis were distance from the implant to the skin, the type of device used, and the amount of residual breast tissue after repeat lumpectomy.

CONCLUSIONS

The cosmetic effect of brachytherapy after lumpectomy in the management of recurrent carcinoma of the previously irradiated breast is acceptable in highly selected patients. Intracavitary technique may provide superior cosmetic results for patients retreated with brachytherapy for salvage.

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

Ductal carcinoma in situ (DCIS) has an excellent prognosis, but its management can resemble that of early invasive breast cancer. We compared aspects of quality of life of women with DCIS to that of women with invasive disease during the first year after treatment initiation. Participants came from consecutive series of women with newly diagnosed, non-metastatic breast cancer treated in eight Quebec hospitals in 2003. Psychological distress and health-related quality of life were measured using the Psychiatric Symptom Index (PSI) and the SF-12 mental and physical component scales (MCS, PCS). Data were obtained 1, 6, and 12 months after the start of treatment. We used generalized linear models to compare mean scores and explored the possible clinical significance of between-group differences with effect size (ES). Participation and retention among eligible women were high, 86 and 97%, respectively. Among the 800 women who completed all interviews, 13.4% (n = 107) had DCIS and 86.6% (693) invasive disease. No statistically significant between-group differences were found at 1, 6, or 12 months in psychological state (PSI and MCS: P values from 0.065 to 0.904; ES from -0.01 to -0.21). Women with DCIS reported significantly higher levels of physical health, particularly when compared at 1 month to women with invasive disease who had chemotherapy (P value < 0.0001; ES = 0.82). Measured in symptoms of psychological distress, the better prognosis or less aggressive management of DCIS does not offset the general psychological effects of a cancer diagnosis to any great degree.

Breast conservation surgery and interstitial brachytherapy in the management of locally recurrent carcinoma of the breast: the Allegheny General Hospital experience

PURPOSE

To evaluate lumpectomy followed by interstitial brachytherapy as an acceptable salvage therapy for women who have developed localized recurrence of breast cancer after conservation surgery and postoperative external radiotherapy.

METHODS AND MATERIALS

Between 1/1998 and 10/2006, 21 patients with T0 or T1 in-breast recurrence of carcinoma were offered interstitial low-dose rate brachytherapy after tumor re-excision as an alternative to salvage mastectomy. All patients had failed lumpectomy followed by standard postoperative external beam radiotherapy (range, 5000-6040cGy) as treatment for the initial breast carcinoma. Seven recurred as ductal carcinoma in situ, 2 as infiltrating lobular carcinoma, and 12 as recurrent invasive carcinoma. The recurrent tumors were excised with final margins of resection free of residual disease per National Surgical Adjuvant Breast and Bowel Project definition. Tumor bed implantation was then carried out with an interstitial technique using (192)Ir with the target volume consisting of the tumor bed plus a minimum 1.0-cm clinical margin. The required minimum dose delivered to the target volume was 4500-5000cGy (range, 4500-5530).

RESULTS

Twenty of 21 patients were free of local disease with a median observation time of 40 months (range, 3-69). The single patient who developed a second local recurrence was treated successfully with simple mastectomy. Two patients succumbed to systemic disease at 17 and 24 months after salvage implant therapy. One patient developed a contralateral breast cancer. Cosmetic results defined by the National Surgical Adjuvant Breast and Bowel Project cosmesis scale were acceptable. One patient developed a localized seroma requiring multiple needle aspirations before complete resolution. Two patients developed localized skin breakdown in the tumor bed. One healed after 6 months of conservative treatment. The other healed 9 months later with Grade II cosmesis. This patient also developed a concurrent postoperative wound infection.

CONCLUSIONS

Repeat lumpectomy followed by brachytherapy is feasible and may be an acceptable alternative to salvage mastectomy in patients who locally fail conservation breast therapy; however, longer followup and greater patient numbers may be needed to better define the role of salvage brachytherapy.

Day Surgery for Breast Cancer: Effects of a Psychoeducational Telephone Intervention on Functional Status and Emotional Distress

PURPOSE/OBJECTIVES

To determine the efficacy of a nursing intervention based on self-regulation theory known as the Attentional Focus and Symptom Management Intervention (AFSMI) in enhancing physical and emotional well-being in women who underwent day surgery for breast cancer.

DESIGN

Randomized clinical block trial; subjects were randomly allocated to the experimental group (n = 61) or the usual care (control) group (n = 56). Subjects in the experimental group received the AFSMI during two phone sessions, at 3-4 days and 10-11 days after surgery.

SETTING

The convenience sample was drawn from five regional centers located in different geographic areas (urban and rural regions) in Quebec, Canada.

SAMPLE

117 patients with primary breast cancer who underwent day surgery as part of their initial treatment for cancer.

METHODS

Data collection and nursing intervention via telephone interviews.

MAIN RESEARCH VARIABLES

Functional status and emotional distress.

FINDINGS

Significant differences between the experimental and control group were found at post-test on home management, total mood disturbance, confusion, and tension scores.

CONCLUSIONS

The AFSMI was effective in reducing emotional distress and enhancing physical functioning.

IMPLICATIONS FOR NURSING

Findings validate the use of the self-regulation model in designing individualized nursing interventions. Redirecting attention and focusing on concrete objective features hold potential in developing other innovative nursing interventions.

Traitement du cancer du sein et de l'utérus : impact physiologique et psychologique sur la fonction sexuelle

The analysis of the impact of breast and uterus cancer and their treatments on sexual function remains a tricky approach, especially due to some difficulties of communication between patient and medical staff. Some cultural, social, physiological and psychological considerations can change the evolution of sexual function during and after cancer treatment. For breast cancer, mastectomy or conservative approach, as well as radiotherapy and chemotherapy, can induce a modification of body image, femininity, power of seduction and sexuality. For uterus cancer, radio-surgical treatments can induce local (shrinking or vagina dryness,...) or general (early menopause) modifications leading to a decrease of sexual relations. The present analysis of the literature gives a better knowledge of the sexual function troubles according to the type, stage and treatment of the cancer as well as the context in which it appears, especially in regard to personal, family (couple relation before the disease occurrence), social and cultural considerations. A critical point is to introduce, as soon as possible, in the therapeutic program, a global approach including side effects on sexual function and to analyze very carefully the own ability of the patient to manage the difficulties occurring during the treatment.

Conceptualization and sources of costs from breast cancer: Findings from patient and caregiver focus groups

Assessment of economic burden of breast cancer to patient and family has generally been overlooked in assessing the impact of this disease. We explored economic aspects from the perspective of women and their caregivers. Focus groups were conducted in 3 Quebec cities representing urban and semi-urban settings: 3 with 26 women first treated for non-metastatic breast cancer in the past 18 months, and 3 with 24 primary caregivers. We purposefully selected participants with different characteristics likely to affect the nature or extent of costs. Thematic content analysis was conducted on verbatim transcripts. Costs of breast cancer could be substantial, but were not the most worrisome aspect of the illness during treatments. Some costs were considered unavoidable, others depended on ability to pay. Costs occurred over a long period, with long term impact, and were borne by the whole family and not just the woman. Principal cost sources discussed were those associated with accessing health care, wage losses, reorganization of everyday life, and coping with the disease. This study provided deeper understanding of cost dynamics and the experience of costs among Canadian women with non-metastatic breast cancer, whose treatment and medical follow-up costs are borne through a system of universal, publicly funded health care.

The value of the Hospital Anxiety and Depression Scale (HADS) for comparing women with early onset breast cancer with population-based reference women

BACKGROUND

The Hospital Anxiety and Depression Scale (HADS) is frequently used in cancer studies, yet its utility for comparing people with cancer with people in the community is uncertain.

METHODS

HADS scores were obtained from population-based samples of women with (n = 731) and without (n = 158) early-onset breast cancer. Psychometric properties were examined using differential item functioning (DIF) which is the presence of systematic group differences in certain response items independent of the trait being measured.

RESULTS

Women with breast cancer scored lower than reference women on anxiety (mean (SD) 7.5 (4.3) vs. 8.2 (4.0); p = 0.06) and depression (3.3 (3.2) vs. 4.2 (3.0); p = 0.003). Group differences remained following adjustment for demographics. Time since diagnosis was not related to anxiety or depression scores. DIF was present in two anxiety and five depression items. Adjustment for DIF did not substantially change the anxiety or depression group differences.

CONCLUSION

Specific sampling or DIF effects do not explain the observation that women with breast cancer have lower levels of anxiety and depression than population controls. The psychometric properties of the HADS appear to be acceptable in these groups.

Quality of life at the end of primary treatment of breast cancer: first results from the moving beyond cancer randomized trial

BACKGROUND

During the last decade, survival rates for breast cancer have increased as a result of earlier detection and increased use of adjuvant therapy. Limited data exist on the psychosocial aspects of the transitional period between the end of primary treatment and survivorship. We investigated the baseline psychosocial status of women enrolled in a randomized trial testing two psychosocial interventions for women at the end of primary treatment.

METHODS

Participants, identified within 1 month after surgery (registration), provided demographic information and limited measures of quality of life. They were followed until they finished primary treatment (enrollment), at which time they completed a mailed baseline survey that included standardized measures of quality of life (including standardized scales of physical and emotional functioning), mood, symptoms, and sexual functioning. A total of 558 patients (mean age = 56.9 years) were enrolled in the study between July 1, 1999, and June 30, 2002. Health outcomes were examined according to treatment received: mastectomy with and without chemotherapy, and lumpectomy with and without chemotherapy. All statistical tests were two-sided.

RESULTS

Among all treatment groups, patients who had a mastectomy had the poorest physical functioning at registration (P<.001) and at enrollment (P=.05). At enrollment, mood and emotional functioning were similar among all patients, with no differences by type of treatment received. At enrollment, symptoms, including muscle stiffness, breast sensitivity, aches and pains, tendency to take naps, and difficulty concentrating, were common among patients in all groups and were statistically significantly associated with poor physical functioning and emotional well-being. Sexual functioning was worse for women who received chemotherapy than for those who did not, regardless of type of surgery (P<.001).

CONCLUSIONS

At the end of primary treatment for breast cancer, women in all treatment groups report good emotional functioning but report decreased physical functioning, particularly among women who have a mastectomy or receive chemotherapy. Clinical interventions to address common symptoms associated with treatment should be considered to improve physical and emotional functioning at the end of primary treatment for breast cancer.

Body esteem and mood among sedentary and active breast cancer survivors

OBJECTIVES

To assess mood states and body esteem in 2 groups of breast cancer survivors, regular exercisers and sedentary women, and to examine these variables among younger and older women in each group.

PATIENTS AND METHODS

Between 1998 and 2002, we conducted a cross-sectional study among early-stage breast cancer survivors at the Miriam Hospital in Providence, RI, comparing 40 women who reported regular exercise with 79 sedentary women. We used multivariate and univariate analyses to compare the exercisers with sedentary women on fitness, physical activity, and questionnaire measures of body esteem and mood. Analyses were repeated after the 2 groups were subdivided by age (< 50 years vs > or = 50 years).

RESULTS

Regular exercisers (mean +/- SD age, 54.57 +/- 9.18 years) reported significantly more positive attitudes toward their physical condition and sexual attractiveness; significantly less confusion, fatigue, depression, and total mood disturbance; and higher vigor than sedentary women (mean +/- SD age, 52.33 +/- 9.11 years). Both younger and older exercisers had higher physical condition scores than their sedentary peers. Older exercisers reported higher vigor and less confusion, anger, fatigue, depression, and total mood disturbance than sedentary women, regardless of age. Younger exercisers reported higher vigor than their sedentary peers and less confusion than older sedentary women.

CONCLUSIONS

In this largely white sample of well-educated women, breast cancer survivors who exercised (particularly older women) reported higher body esteem and better mood than sedentary breast cancer survivors.

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.

Psychosocial and sexual functioning of survivors of breast cancer

The literature documents that the majority of breast cancer survivors have adjusted well after their first 2 years since diagnosis. However, there is a subset of survivors reporting psychological distress, including depression and anxiety, involving approximately 30% by 4 years post-treatment, but widely ranging from 5% to 50%, depending on when diagnosed and time since treatment completion. Further, a large proportion of survivors report cancer-related problems long after treatment completion, including cancer-related distress involving body image, fear of recurrence, post-traumatic stress disorder (PTSD), and sexual problems. Those with long-term medical sequelae, such as lymphedema, have worse adjustment compared to those who do not. Future research directions are suggested.

Breast Cancer in Older Women: Quality of Life and Psychosocial Adjustment in the 15 Months After Diagnosis

Purpose: We examined the health-related quality of life (QOL) of a cohort of older women with breast cancer after their diagnosis.

Patients and Methods: Six hundred ninety-one women aged 65 years and older were interviewed approximately 3 months after breast cancer surgery and two additional times in the following year using standardized QOL measures. Demographic factors, breast cancer treatments, and comorbid conditions were used to model ratings of health-related QOL over time. Self-perceived health and psychosocial adjustment at 15 months after surgery were modeled.

Results: Physical and mental health scores declined significantly in the follow-up year, independent of age. However, a cancer-specific psychosocial instrument showed significant improvement in scores. Better 3-month physical and mental health scores, as well as better emotional social support, predicted more favorable self-perceived health 15 months after surgery. Psychosocial adjustment at 15 months was significantly predicted by better mental health, emotional social support, and better self-rated interaction with health care providers assessed at 3 months.

Conclusion: Contrary to reports from younger women with breast cancer, we observed significant declines in the physical and mental health of older women in the 15 months after breast cancer surgery, whereas scores on a cancer-specific psychosocial QOL measure improved over time, consistent with patterns in younger women. Predictive models indicate that older women with impaired physical functioning, mental health, and emotional social support after surgery have poorer self-perceived health and psychosocial adjustment 1 year later. Interventions to address the physical and emotional needs of older women with breast cancer should be developed and evaluated to determine their impact on subsequent health-related QOL.

Dietary change after breast cancer: extent, predictors, and relation with psychological distress

PURPOSE

Some women may try to cope with breast cancer by making lifestyle modifications, possibly in the hope of improving disease outcome. We assessed extent, predictors, and effect on psychological distress of dietary changes in the year after diagnosis among 250 women with newly diagnosed, nonmetastatic breast cancer.

PATIENTS AND METHODS

Data came from medical records, and from interviews 3 days and 12 months after initial treatment.

RESULTS

At 12 months, 41% (n = 103) reported dietary changes at some time since diagnosis, with decreases in meat (77%) and increases in fruit and vegetable intake (72%) being the most frequent. Women reporting changes were more likely to be younger, to have positive nodes, to be receiving adjuvant therapy, and to be more distressed initially. The mean 0 to 12 month decrease in psychological distress was greater in women who reported changes (9 points) than those who did not (4.7 points) (P =.03), although regression toward the mean cannot be excluded.

CONCLUSION

A sizable proportion of women made dietary changes on their own initiative. Most changes reported were generally consistent with current scientific hypotheses about dietary changes that might favorably affect prognosis. The profile of women reporting changes suggests a group with more concerns about recurrence, who may have initiated dietary change to help cope with and gain a sense of control over the disease, and possibly to improve prognosis. Our results suggest that newly diagnosed women could be receptive to explicit attention to diet as part of psychosocial care. However, this interest in dietary change may not, as yet, have been maximally channeled into trying to improve the care and quality of life of women facing diagnosis, treatments, and fears about recurrence.

The psychological impact of post-operative arm morbidity following axillary surgery for breast cancer: a critical review

In this paper we review the published research that has investigated the psychological impact of arm morbidity associated with axillary dissection for early breast cancer. This critique is particularly timely given the drive towards minimally invasive techniques, such as sentinel node biopsy, which aim to reduce the incidence and severity of post-operative arm problems. Reported symptoms are multifactorial and include numbness, pain, swelling, weakness/stiffness, and restricted shoulder mobility of the affected arm. Conclusions from the few studies that have investigated the severity, incidence, duration and psychological impact of such disability are often limited by methodological problems. We identify these limitations and examine assessment tools used to determine the psychological impact of lymphoedema. The paper highlights the need for methodological rigor in study design, and the careful selection of appropriate, sensitive, reliable and clinically meaningful outcome measures to evaluate the impact of post-operative arm morbidity.

Quality of life in breast cancer patients: a cluster analytic approach. Empirically derived subgroups of the EORTC-QLQ BR 23--a clinically oriented assessment

Quality of life (QOL) questionnaires are integrated into clinical trials in order to evaluate different treatments, and rarely used in a diagnostic sense. The aim of this study was to identify clinically meaningful subgroups by means of established QOL tools. Since January 1995, a field study funded by the German Ministry of Health was conducted to evaluate quality of care of breast cancer patients in eastern Thuringia. During the follow-up period, the European Organization of Research and Treatment of Cancer (EORTC), Quality of Life C30 and the breast specific module BR23 were mailed. One-hundred-fifty-eight women answered both questionnaires. A cluster analysis was performed to distinguish subgroups on the basis of QOL-BR23 scores. According to the QOL outcomes, four subgroups could be described. There was a strong relation to operative treatment (p < 0.05), while no association with the adjuvant treatment strategy was observed. The subsets identified on the basis of BR23 scores were significantly related to all C30 domains. It was possible to demonstrate the clinical validity in terms of clinical and sociodemographic data. No association was found with the marital status or the highest level of education, while a worsening of the financial situation was associated. It could be shown that a distinction of patient subgroups based on clinically meaningful BR23 data is possible. Subgroups with specific profiles could be identified. In the future, the characterisation of subgroups could provide a possibility to generate indications for specific supportive interventions.

Stressful life events and survival after breast cancer

OBJECTIVE

This study assessed the relation of stressful life events with survival after breast cancer.

METHODS

This study was based on women with histologically confirmed, newly diagnosed, localized or regional stage breast cancer first treated in 1 of 11 Quebec City (Canada) hospitals from 1982 through 1984. Among 765 eligible patients, 673 (88%) were interviewed 3 to 6 months after diagnosis about the number and perceived impact of stressful events in the 5 years before diagnosis. Three scores were calculated: number of events; number weighted by reported impact; and for almost 80% of events, number weighted by community-derived values reflecting adjustment required by the event. Scores were divided into quartiles to assess possible dose-response relationships. Survival was assessed in 1993. Hazard ratios and 95% confidence intervals (CIs) comparing all-cause and breast cancer-specific mortality were calculated with adjustment for age, presence of invaded axillary nodes, adjuvant radiotherapy, and systemic therapy (ie, chemotherapy and hormone therapy).

RESULTS

When quartiles 2, 3, and 4 were compared with the appropriate lowest quartile, adjusted hazard ratios for all-cause mortality were 0.99 (CI = 0.70-1.38), 0.97 (CI = 0.73-1.31), and 1.04 (CI = 0.78-1.40) for number, number weighted by impact, and number weighted by community-derived values, respectively. Results were essentially similar for the relation between stressful life events limited to those occurring within the 12 months before diagnosis and overall mortality and between stressful life events in the 5 years before diagnosis and breast cancer-specific mortality.

CONCLUSIONS

Stress was conceptualized as life events presumed to be negative, undesirable, or to require adjustment by the person confronting them. We found no evidence indicating that this kind of stress during the 5 years before diagnosis negatively affected survival among women with nonmetastatic breast cancer. Evidence from this study and others on the lack of effect of this type of stress on survival may be reassuring for women living with breast cancer.

Work problems after breast cancer: an exploratory qualitative study

People treated for cancer have reported a variety of problems at work. However, there is little data on work experience after breast cancer, particularly for women treated in recent years. This exploratory qualitative study was conducted among 13 breast cancer survivors who had paid employment at diagnosis, returned to work afterwards, and mentioned work-related problems to a clinic nurse or physician. Unstructured, thematic interviews were undertaken. Qualitative thematic content analysis was conducted to identify and group themes which emerged from participants' discourse. Women in various types of jobs reported experiencing job loss, demotion, unwanted changes in tasks, problems with the employer and co-workers, personal changes in attitudes to work and diminished physical capacity. These work problems also preoccupied people treated for cancer more than two decades ago. New areas of concern also emerged: possible positive and negative effects of learning (implicitly or explicitly) about the diagnosis while at work and lack of discussion with health professionals about work and return-to-work issues, suggesting that health professionals' behaviour may influence women's work experience right from diagnosis. The identification of these new problems and confirmation of previously reported ones underlines the pertinence of determining how important and widespread these problems are in women now being treated for breast cancer.

Surgical options for the early-stage breast cancer: factors associated with patient choice and postoperative quality of life

Patients with early-stage breast cancer have three surgical options: lumpectomy with radiotherapy, mastectomy alone, and mastectomy with breast reconstruction. Our objective was to compare women in these three groups with respect to demographics, preoperative counseling, postoperative body image, and quality of life. Women having undergone surgery for stage 1 or 2 breast cancer between 1990 and 1995 were selected by random sampling of hospital tumor registries and were mailed a self-administered questionnaire, which included the Medical Outcomes Survey Short Form 36. Patients were stratified into three mutually exclusive groups: lumpectomy with axillary node dissection and radiotherapy, modified radical mastectomy, and modified radical mastectomy with breast reconstruction. In total, 267 of 525 surveys were returned (50.9 percent). Compared with mastectomy patients, breast reconstruction patients were younger (p < 0.001), better educated (p = 0.001), and more likely Caucasian (p = 0.02). Among mastectomy patients, 54.9 percent recalled that lumpectomy had been discussed preoperatively and 39.7 percent recalled discussion of breast reconstruction. Post-operative comfort with appearance was significantly lower for mastectomy patients. The relationship between type of surgery and postoperative quality of life varied with age. Under 55, quality of life was lowest for mastectomy patients on all but two Medical Outcomes Survey Short Form 36 subscales. Over 55, quality of life was lowest for lumpectomy patients on all subscales (p < 0.05 for all subscales except social functioning and role-emotional). Treatment choice may be related to age, race, education, and preoperative counseling. Whereas the effect of breast cancer on a woman's life is complex and individual, the type of surgery performed is a significant variable, whose impact may be related to patient age.

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.

Anxiety and depression in breast cancer patients at low risk of recurrence compared with the general population: a valid comparison?

Breast cancer and its treatment have been associated with psychological morbidity. In this study our aim was to quantify the excess anxiety and depression resulting from breast cancer. We compared 538 newly diagnosed breast cancer patients at low risk of recurrence (87.0% responded) to 872 women randomly selected from the Danish general population (69.7% responded) using the Hospital Anxiety and Depression Scale (HADS). Contrary to expectations, the proportions classified as "cases" of anxiety and depression were not significantly different in the two groups. The breast cancer patients' mean HADS scores were significantly lower than those in the general population sample (anxiety, P = 0.021; depression, P < 0.001), indicating less anxiety and depression. However, we question the validity of this comparison. The HADS may not be suitable for use in the general population and there may be methodological problems in comparisons of groups whose life situations are very different.

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.

Exercise in the rehabilitation of breast cancer survivors

With the increase in the number of women who have survived breast cancer, there is a growing need to attend to the physical and emotional effects of cancer and its treatment as experienced by these survivors. Psychological distress, fatigue, weight gain, premature menopause and changes in body image are some of the long-term sequelae of breast cancer. Exercise as an adjunctive treatment may help to attenuate these effects and thereby contribute to rehabilitation of women with breast cancer. We present data from the exercise literature and from studies on breast cancer patients that support this role of exercise. Following a critique of the research efforts, we present a brief outline of questions that should be addressed in evaluating the role of exercise in cancer rehabilitation.

Quality of life in patients with ductal carcinoma in situ of the breast treated with conservative surgery and postoperative irradiation

AIM OF THE STUDY

To evaluate the quality of life (QL) in patients with ductal carcinoma in situ of the breast treated with conservative surgery and postoperative irradiation.

MATERIAL AND METHODS

A self-completed questionnaire covering many disease-, symptom-, and treatment-specific issues was administered to 106 conservatively treated patients affected by non-infiltrating breast cancer. The questionnaire was based on a series of 34 items assessing five main fields of post-treatment adjustment: physical well being, sexual adaptation, aesthetic outcome, emotional/psychological well being, relational behaviour. Furthermore, the patients were requested to evaluate the degree of information provided by the medical staff concerning surgical procedures and radiation therapy, and to evaluate the effects of the treatment on their social and overall life.

RESULTS

The questionnaire was completed by 83 patients (78%), who had a median follow-up of 54.5 months. This final sample had a median age of 50 years (range 29-88) at the time of treatment and 54 years (range 32-94) at the time of study. The patients claimed to be in good physical condition. Data relating to sexual life were provided by 93% of the sample. Some limitations in sexuality, some interference with sexual desire, and some modifications during intercourse were reported by 5, 6, and 5 patients, respectively. The subjective evaluations of the cosmetic results of the therapies were generally good. Only 13 patients (16%) reported the perception of a worsened body image. Forty-six percent of the sample (38 patients) declared that they felt tense, 48% (39 patients) nervous, 29% (38 patients) lonely, 59% (41 patients) anxious, and 41% (34 patients) depressed. Only seven patients (8%) declared that the treatment had had a bad effect on their social life, and 15 (18%) thought that their current life had been affected by the treatment. The amount of information received concerning the disease and treatment (surgery and radiotherapy) was considered sufficient by 79%, 75%, and 79% of the sample, respectively.

CONCLUSIONS

This study revealed a good QL in patients treated with breast conservation and postoperative irradiation, with a preserved favourable body image and a lack of negative impact on sexuality. Radiation therapy did not lead to any significant additional problems capable of affecting the QL.

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.

Marital stability after breast cancer

BACKGROUND

The belief that husbands desert wives who have breast cancer is not uncommon and may be a source of stress for women confronting this disease. To assess the validity of this belief, we examined the role of breast cancer as a determinant of marital breakdown by comparing the frequencies of marital breakdown among women with breast cancer and among control women from Quebec City and surrounding regions.

METHODS

Secondary analyses were performed on data collected from women who were newly diagnosed with nonmetastatic breast cancer in 1984 or during the period from 1990 through 1992 and then interviewed 3 months, 18 months, and 8 years after diagnosis (1984 cohort) or interviewed 2 weeks, 3 months, and 12 months after diagnosis (1990-1992 cohort). Population-based control subjects (four groups) were recruited through random-digit dialing and from participants in the Quebec Health Surveys for 1987 and 1992. Eligible subjects were those who were living with a spouse at the time of interview and those who reported divorce or separation in the time periods examined. Marital breakdown in the past 12 months and 5 years and current marital satisfaction and adjustment were assessed. All P values are two-sided.

RESULTS

Marital breakdown was never higher in women with breast cancer than in control women. Among women with breast cancer, low marital satisfaction within 3 months of diagnosis predicted further marital difficulties (a breakdown-P = .02 at 12-month interview and P = .01 at 18-month interview; low marital satisfaction- P<.0001 at 12-month interview and P = .005 at 18-month interview).

CONCLUSIONS

For the times studied, breast cancer does not appear to be associated with marital breakdown among Quebec women. Marital difficulties occurred mainly among the small proportion of women who probably already had marital difficulties when diagnosed.