Limitations in upper-body strength associated with breast cancer: a comparison of black and white women

The effects of poloxamer and sodium alginate mixture (Guardix-SG®) on range of motion after axillary lymph node dissection: A single-center, prospective, randomized, double-blind pilot study

PURPOSE

Restricted shoulder mobility is a major upper extremity dysfunction associated with lower quality of life and disability after breast cancer surgery. We hypothesized that a poloxamer and sodium alginate mixture (Guardix-SG®) applied after axillary lymph node dissection (ALND) would significantly improve shoulder range of motion (ROM) in patients with breast cancer.

METHODS

We conducted a double-blind, randomized, prospective study to evaluate the clinical efficacy and safety of Guardix-SG® for the prevention of upper extremity dysfunction after ALND. The primary outcome measure was shoulder ROM at baseline (T0) and 3 (T1), 6 (T2), and 12 months (T3) after surgery. Secondary outcome measures were the Disabilities of the Arm, Shoulder, and Hand score(DASH), pain associated with movement, which was assessed using a numeric rating scale, and lymphedema assessed using body composition analyzer.

RESULTS

A total of 83 women with breast cancer were randomly assigned to either the Guardix-SG® group or the control group. In the Guardix-SG® group (n = 37), Guardix-SG® was applied to the axillary region after ALND. In the control group (n = 46), ALND was performed without using Guardix-SG®. Comparing ROM for shoulder flexion before surgery (178.2°) and 12 months after surgery (172.3°), that was restored 12 months after surgery in the Guardix-SG® group, and there was no statistically significant difference between that at before surgery and 12 months after surgery (p = 0.182). No adverse effect was observed in either group.

CONCLUSIONS

The results of this study have shown that Guardix-SG® help improve shoulder ROM without causing adverse effects in patients who underwent breast cancer surgery. However, there was no statistically significant difference from the control group. A further large-scale study is needed to obtain a more conclusive conclusion.

TRIAL REGISTRATION

CRISKCT0003386; https://cris.nih.go.kr (20181207).

Shoulder impairment before breast cancer surgery

OBJECTIVE

To compare pre- and post-operative shoulder active range of motion (AROM) values from female breast cancer survivors to population norm values for shoulder AROM; and to compare shoulder AROM differences pre- and post-surgery between female African American and White breast cancer survivors (BCA).

STUDY DESIGN

This pilot study used a convenience sample and longitudinal design measuring participants 2 times (T0 = baseline, after biopsy but within 2 weeks before BCA surgery; T1 = 2nd postoperative week).

BACKGROUND

The U.S. has the largest BCA survivor population in history and yet the mortality burden remains highest among AA BCA survivors. AAs may also have greater burden of physical and functional side effects compared to whites and the general population.

METHODS AND MEASURES

The data were collected from a convenience sample (n = 33; nAA = 9, nW = 24) and included data on shoulder AROM, medical chart review for pre- and co-morbid conditions, and self-reported demographics and medical history. We used t-tests to compare sample AROM means to population norms. We then compared our sample across 2 timepoints (T0 = pre-surgery; T1 = 2 weeks post-surgery) using independent samples t-tests and repeated measures analysis of variance (p < .05) to compare AA to White sub-samples AROM means.

RESULTS

African Americans had significantly less shoulder abduction (at T0) and flexion (at T1) than whites. However, 100% had significantly reduced AROM for all movements at T0 (prior to surgery but after biopsy) when compared to population norms.

CONCLUSIONS

The significant reduction in shoulder AROM after biopsy but before surgery points to a possible unmet need for early physical therapy intervention. Further research using randomized controlled trial design is recommended.

Long-term outcomes among African-American and white women with breast cancer: what is the impact of comorbidity?

OBJECTIVES

We examined the association between comorbidity and long-term mortality from breast cancer and other causes among African-American and white women with breast cancer.

METHODS

A total of 170 African-American and 829 white women aged 40-84years were followed for up to 28years with median follow-up of 11.3years in the Health and Functioning in Women (HFW) study. The impact of the Charlson Comorbidity Score (CCS) in the first few months following breast cancer diagnosis on the risk of mortality from breast cancer and other causes was examined using extended Cox models.

RESULTS

Median follow-up was significantly shorter for African-American women than their white counterparts (median 8.5years vs. 12.3years). Compared to white women, African-American women had significantly fewer years of education, greater body mass index, were more likely to have functional limitations and later stage at breast cancer diagnosis, and fewer had adequate financial resources (all P<0.05). Proportionately more African-American women died of breast cancer than white women (37.1% vs. 31.4%, P=0.15). A positive and statistically significant time-varying effect of the Charlson Comorbidity Score (CCS) on other-cause mortality persisted throughout the first 5years of follow-up (P<0.001) but not for its remainder.

CONCLUSIONS

Higher CCS was associated with increased risk of other-cause mortality, but not breast cancer specific mortality; the association did not differ among African-American and white women.

The impact of functional limitations on long-term outcomes among African-American and white women with breast cancer: a cohort study

OBJECTIVES

We examined the impact of functional limitations and functional decline during the first year following breast cancer diagnosis on the risk of mortality from breast cancer and other causes among African-American and white women, respectively.

DESIGN

The Health and Functioning in Women (HFW) cohort study.

SETTING

Detroit, Michigan, USA.

PARTICIPANTS

A total of 162 African-American and 813 white women aged 40-84 years with newly diagnosed breast cancer identified through the Metropolitan Detroit Cancer Surveillance System over a 7-month period between 1984 and 1985 and followed for up to 28 years (median 11 years).

OUTCOME MEASURES

Risk of mortality from breast cancer and other causes.

RESULTS

Statistically significant increases in the risk of other-cause mortality were found for each unit increase in the number of self-reported functional limitations (HR=1.08, 95% CI 1.03 to 1.14), 0 vs ≥1 functional limitations (HR=1.47, 95% CI 1.13 to 1.91), difficulty in pushing or pulling large objects (HR=1.34, 95% CI 1.04 to 1.73), writing or handling small objects (HR=1.56, 95% CI 1.00 to 2.44), and walking half a mile (HR=1.60, 95% CI 1.19 to 2.14). Functional limitations and functional decline did not explain racial disparities in the survival of this cohort. Functional decline was associated with increased risk of other-cause mortality in women with regional and remote disease but not in women with localised disease. Whereas measures of functional limitation were not associated with breast cancer-specific mortality, each unit of functional decline (HR=1.17, 95% CI 1.05 to 1.31) and decline in the ability to sit ≥1 h (HR=2.06, 95% CI 1.13 to 3.76) were associated with increased risk of breast cancer-specific mortality. Measures of functional decline were associated with increased risk of breast cancer mortality in overweight and obese women, but not in women of normal weight.

CONCLUSIONS

Whereas functional limitations were associated with increased risk of other-cause mortality, functional decline was associated with increased risk of breast cancer mortality.

Employment after a breast cancer diagnosis: a qualitative study of ethnically diverse urban women

Employment status is related to treatment recovery and quality of life in breast cancer survivors, yet little is known about return to work in immigrant and minority survivors. We conducted an exploratory qualitative study using ethnically cohesive focus groups of urban breast cancer survivors who were African-American, African-Caribbean, Chinese, Filipina, Latina, or non-Latina white. We audio- and video-recorded, transcribed, and thematically coded the focus group discussions and we analyzed the coded transcripts within and across ethnic groups. Seven major themes emerged related to the participants' work experiences after diagnosis: normalcy, acceptance, identity, appearance, privacy, lack of flexibility at work, and employer support. Maintaining a sense of normalcy was cited as a benefit of working by survivors in each group. Acceptance of the cancer diagnosis was most common in the Chinese group and in participants who had a family history of breast cancer; those who described this attitude were likely to continue working throughout the treatment period. Appearance was important among all but the Chinese group and was related to privacy, which many thought was necessary to derive the benefit of normalcy at work. Employer support included schedule flexibility, medical confidentiality, and help maintaining a normal work environment, which was particularly important to our study sample. Overall, we found few differences between the different ethnic groups in our study. These results have important implications for the provision of support services to and clinical management of employed women with breast cancer, as well as for further large-scale research in disparities and employment outcomes.

Prognostic impact of comorbidity among long-term breast cancer survivors: results from the LACE study

BACKGROUND

Little is known about the long-term impact of comorbidity among women with breast cancer.

METHODS

We studied a prospective cohort of 2,272 women with breast cancer, who were recruited following initial breast cancer treatment. Associations of the Charlson comorbidity index (CCI) and hypertension with survival were evaluated in delayed entry Cox proportional hazards models.

RESULTS

During a median follow-up of nine years, higher CCI scores were independently associated with an increased risk of death from all causes [HR, 1.32; 95% confidence interval (CI), 1.13-1.54] and from nonbreast cancer causes (HR, 1.55; 95% CI, 1.19-2.02), but not from breast cancer (HR, 1.14; 95% CI, 0.93-1.41). Hypertension was independently associated with an increased risk of death from all causes (HR, 1.55; 95% CI, 1.20-1.99), from nonbreast cancer causes (HR, 1.67; 95% CI, 1.10-2.54), and from breast cancer (HR, 1.47; 95% CI, 1.03-2.09), but these associations were no longer significant after adjustment for antihypertensive medication. The relationship between the CCI and overall survival was the strongest among women with stage I disease (stage I, HR, 1.65; 95% CI, 1.26-2.16 vs. stage III, HR, 0.53; 95% CI, 0.23-1.25).

CONCLUSION

The CCI was independently associated with lower overall and nonbreast cancer survival, but not with breast cancer-specific survival.

IMPACT

Comorbidity may play an important role in breast cancer outcomes.

Return to work in low-income Latina and non-Latina white breast cancer survivors: a 3-year longitudinal study

BACKGROUND

Previous research has found an 80% return-to-work rate in mid-income white breast cancer survivors, but little is known about the employment trajectory of low-income minorities or whites. We set out to compare the trajectories of low-income Latina and non-Latina white survivors and to identify correlates of employment status.

METHODS

Participants were low-income women who had localized breast cancer, spoke English or Spanish, and were employed at the time of diagnosis. Interviews were conducted 6, 18, and 36 months after diagnosis. Multivariate logistic regression was used to identify independent correlates of employment status at 18 months.

RESULTS

Of 290 participants, 62% were Latina. Latinas were less likely than non-Latina whites to be working 6 months (27% vs 49%; P = .0002) and 18 months (45% vs 59%; P = .02) after diagnosis, but at 36 months there was no significant difference (53% vs 59%; P = .29). Latinas were more likely to be manual laborers than were non-Latina whites (P < .0001). Baseline job type and receipt of axillary node dissection were associated with employment status among Latinas but not non-Latina whites.

CONCLUSIONS

Neither low-income Latinas nor non-Latina whites approached the 80% rate of return to work seen in wealthier white populations. Latinas followed a protracted return-to-work trajectory compared to non-Latina whites, and differences in job type appear to have played an important role. Manual laborers may be disproportionately impacted by surgical procedures that limit physical activity. This can inform the development of rehabilitative interventions and may have important implications for the surgical and postsurgical management of patients.

Design and implementation of the Exercise for Health trial -- a pragmatic exercise intervention for women with breast cancer

BACKGROUND

Exercise for Health was a pragmatic, randomised, controlled trial comparing the effect of an eight-month exercise intervention on function, treatment-related side effects and quality of life following breast cancer, compared with usual care. The intervention commenced six weeks post-surgery, and two modes of delivering the same intervention was compared with usual care. The purpose of this paper is to describe the study design, along with outcomes related to recruitment, retention and representativeness, and intervention participation.

METHODS

Women newly diagnosed with breast cancer and residing in a major metropolitan city of Queensland, Australia, were eligible to participate. Consenting women were randomised to a face-to-face-delivered exercise group (FtF, n = 67), telephone-delivered exercise group (Tel, n = 67) or usual care group (UC, n = 60) and were assessed pre-intervention (5-weeks post-surgery), mid-intervention (6 months post-surgery) and 10 weeks post-intervention (12 months post-surgery). Each intervention arm entailed 16 sessions with an Exercise Physiologist.

RESULTS

Of 318 potentially eligible women, 63% (n = 200) agreed to participate, with a 12-month retention rate of 93%. Participants were similar to the Queensland breast cancer population with respect to disease characteristics, and the randomisation procedure was mostly successful at attaining group balance, with the few minor imbalances observed unlikely to influence intervention effects given balance in other related characteristics. Median participation was 14 (min and max: 0 and 16) and 13 (min and max: 3 and 16) intervention sessions for the FtF and Tel, respectively, with 68% of those in Tel and 82% in FtF participating in at least 75% of sessions.

DISCUSSION

Participation in both intervention arms during and following treatment for breast cancer was feasible and acceptable to women. Future work, designed to inform translation into practice, will evaluate the quality of life, clinical, psychosocial and behavioural outcomes associated with each mode of delivery.

Long-term prognostic role of functional limitations among women with breast cancer

BACKGROUND

The long-term prognostic role of functional limitations among women with breast cancer is poorly understood.

METHODS

We studied a cohort of 2202 women with breast cancer at two sites in the United States, who provided complete information on body functions involving endurance, strength, muscular range of motion, and small muscle dexterity following initial adjuvant treatment. Associations of baseline functional limitations with survival were evaluated in delayed entry Cox proportional hazards models, with adjustment for baseline sociodemographic factors, body mass index, smoking, physical activity, comorbidity, tumor characteristics, and treatment. Difference in covariates between women with and without limitations was assessed with Pearson χ(2) and Student t tests. All statistical tests were two-sided.

RESULTS

During the median follow-up of 9 years, 112 deaths were attributable to competing causes (5% of the cohort) and 157 were attributable to breast cancer causes (7% of the cohort). At least one functional limitation was present in 39% of study participants. Proportionately, more breast cancer patients with functional limitations after initial adjuvant treatment were older, less educated, and obese (P < .001). In multivariable models, functional limitations were associated with a statistically significantly increased risk of death from all causes (hazard ratio [HR] = 1.40, 95% confidence interval [CI] = 1.03 to 1.92) and from competing causes (HR = 2.60, 95% CI = 1.69 to 3.98) but not from breast cancer (HR = 0.90, 95% CI = 0.64 to 1.26). The relationship between functional limitations and overall survival differed by tumor stage (among women with stage I and stage III breast cancer, HR = 2.02, 95% CI = 1.23 to 3.32 and HR = 0.74, 95% CI = 0.42 to 1.30, respectively).

CONCLUSION

In this prospective cohort study, functional limitations following initial breast cancer treatment were associated with an important reduction in all-cause and competing-cause survival, irrespective of clinical, lifestyle, and sociodemographic factors.

Upper-body morbidity following breast cancer treatment is common, may persist longer-term and adversely influences quality of life

BACKGROUND

Impairments in upper-body function (UBF) are common following breast cancer. However, the relationship between arm morbidity and quality of life (QoL) remains unclear. This investigation uses longitudinal data to describe UBF in a population-based sample of women with breast cancer and examines its relationship with QoL.

METHODS

Australian women (n=287) with unilateral breast cancer were assessed at three-monthly intervals, from six- to 18-months post-surgery (PS). Strength, endurance and flexibility were used to assess objective UBF, while the Disability of the Arm, Shoulder and Hand questionnaire and the Functional Assessment of Cancer Therapy-Breast questionnaire were used to assess self-reported UBF and QoL, respectively.

RESULTS

Although mean UBF improved over time, up to 41% of women revealed declines in UBF between six- and 18-months PS. Older age, lower socioeconomic position, treatment on the dominant side, mastectomy, more extensive lymph node removal and having lymphoedema each increased odds of declines in UBF by at least two-fold (p<0.05). Lower baseline and declines in perceived UBF between six- and 18-months PS were each associated with poorer QoL at 18-months PS (p<0.05).

CONCLUSIONS

Significant upper-body morbidity is experienced by many following breast cancer treatment, persisting longer term, and adversely influencing the QoL of breast cancer survivors.

Longitudinal change of treatment-related upper limb dysfunction and its impact on late dysfunction in breast cancer survivors: a prospective cohort study

BACKGROUND AND OBJECTIVES

To investigate the prevalence of upper limb dysfunction (ULD) and subtypes after breast cancer surgery and to identify factors associated with late ULD.

METHODS

Among 191 enrolled patients, 191 were evaluated at 3 months, 187 at 6 months, and 183 at 12 months after surgery. Pain, shoulder range of motion, muscle strength, and arm circumference were assessed. Based on symptoms and physical examinations, the types of ULD common after breast cancer treatment were diagnosed and categorized.

RESULTS

The prevalence of ULD after surgery were 24.6%, 20.9%, and 26.8% at 3, 6, and 12 months, respectively. The most common types of ULD were pectoralis tightness at 3 and 6 months and lymphedema at 12 months. Patients with pectoralis tightness or lymphedema at 3 or 6 months showed a higher prevalence of rotator cuff disease at 12 months compared with those without early pectoralis tightness or lymphedema.

CONCLUSIONS

The major post-operative ULD were pectoralis tightness at 3 and 6 months and lymphedema at 12 months. Late ULD such as rotator cuff disease were associated with pectoral tightness or lymphedema at earlier stages. Diagnosis and treatment of ULD should take place as soon as possible after surgery.

Factors influencing changes in employment among women with newly diagnosed breast cancer

BACKGROUND

Although studies have demonstrated that women are less likely to work after they are diagnosed with breast cancer, the influence of cancer treatments on employment is less clear. The authors of this report assessed whether chemotherapy or radiation therapy was associated with a disruption in employment during the year after a breast cancer diagnosis.

METHODS

Using a database of health insurance claims that covered 5.6 million US residents, 3,233 women aged <or=63 years were identified who were working full time or part time when they were diagnosed with breast cancer between 1998 and 2002. All changes in employment during the year after a breast cancer diagnosis were identified. Using a Cox proportional hazards model that incorporated time-varying treatment variables, the authors evaluated the impact of chemotherapy and radiation therapy on the likelihood of experiencing an employment disruption.

RESULTS

Although most women (93%) continued to work, chemotherapy recipients were more likely than nonrecipients to go on long-term disability, stop working, or retire (hazards ratio, 1.8; P < .01). Women aged >or=54 years were more likely to experience a change in employment than women aged <or=44 years (P < .01). Radiation therapy did not influence employment (P = .22).

CONCLUSIONS

In this population of employed, insured women, chemotherapy had a negative impact on employment. This finding may aid treatment decision making and could foster the development of interventions that support a patient's ability to continue working after treatment. It also reinforces the need to assess the impact of treatments, especially new treatments, on patient-centered outcomes such as employment.

Breast cancer and the role of exercise in women

Cancer of the breast is a significant health problem for women from the time of diagnosis through the treatment and survivorship trajectory. The disease and treatments are an assault to a woman's body, resulting in sequelae that can be debilitating. Although women diagnosed with breast cancer are living longer, concerns about functional limitations, recurrence, and survival remain paramount. Physical activity and exercise are preventative and rehabilitative measures that can be employed at various points along the breast cancer trajectory. Current research supports the beneficial role that physical activity and exercise play in reducing the risk for developing breast cancer and preventing or attenuating disease and treatment-related impairments.

The older cancer survivor

Cancer is an age-related disease, and has increased in prevalence as the population has grown older. Improvements in screening and the availability of better therapeutic options contribute to burgeoning numbers of cancer survivors, who number more than 24 million worldwide. Sixty-one percent of these survivors are at least 65 years old. This review is an attempt to consolidate some of the data available in the area of cancer survivorship, with emphasis on the elderly. Our aim is to provide a better description of the population, elucidate specific physical and psychosocial sequelae secondary to cancer and it's treatment, and better understand how comorbid conditions, functional status, body-weight, and other issues contribute to quality of life, and overall health. This paper also suggests some surveillance guidelines for following elderly cancer survivors and identifies areas that require further research.

Psychosocial determinants and outcomes of chemotherapy in older women with breast cancer: what do we know? What do we need to know?

With the aging of the U.S. population and rising breast cancer incidence with advancing age, the absolute number of women aged 65 years and older diagnosed with and surviving breast cancer will dramatically increase over the coming decades. Despite this demographic imperative, we know little about the impact of adjuvant therapies in this age group. We synthesized data to describe key findings and gaps in knowledge about the outcomes of adjuvant breast cancer treatment in women aged 65 years and and older ("older women"). We reviewed research published between 1995 and June 2005 on breast cancer outcomes among older women treated with adjuvant therapy for breast cancer. Outcomes included communication, emotional distress, satisfaction, and multiple quality-of-life domains. Only 16 articles focused exclusively on older women and chemotherapy; and only one included a large sample of older women (N = 1755). Most common domains included comorbidities, symptoms, and survival. Of the 13 clinical trials and three observational studies we reviewed, only one clinical trial measured quality of life and psychological factors such as coping. None of the studies examined patient preferences or patient-physician communication (processes of care) in older women. Few studies have been designed to specifically evaluate adjuvant therapy processes and outcomes among older women, especially interactions between treatment and comorbidity, and the impact of the processes of care on outcomes. In addition, only narrow segments of the older population with breast cancer (e.g., well-educated, nonminority women) have been included in trials to date. Thus, at present we do not have sufficient data to assist physicians and their older patients in developing adjuvant treatment decisions and plans tailored to older women's needs, preferences, and concerns.

Correlates of return to work for breast cancer survivors

PURPOSE

To identify correlates of return to work for employed breast cancer survivors.

PATIENTS AND METHODS

Patients included 416 employed women with newly diagnosed breast cancer identified from the Metropolitan Detroit Cancer Surveillance System. Patients were interviewed by telephone 12 and 18 months after diagnosis. Correlates of return to work at 12 and 18 months were identified using multivariate logistic regression.

RESULTS

More than 80% of patients returned to work during the study period, and 87% reported that their employer was accommodating to their cancer illness and treatment. After adjusting for demographic characteristics, health status, cancer stage, treatment, and job type, heavy lifting on the job (odds ratio = 0.42; 95% CI, 0.18 to 0.99), perceived employer accommodation for cancer illness and treatment (odds ratio = 2.2; 95% CI, 1.03 to 4.8), and perceived employer discrimination because of a cancer diagnosis (odds ratio = 0.27; 95% CI, 0.10 to 0.71) were independently associated with return to work at 12 months after breast cancer diagnosis, and perceived employer accommodation (odds ratio = 2.3; 95% CI, 1.06 to 5.1) was independently associated with return to work at 18 months after breast cancer diagnosis.

CONCLUSION

A high percentage of employed breast cancer patients returned to work after treatment, and workplace accommodations played an important role in their return. In addition, perceived employer discrimination because of cancer was negatively associated with return to work for breast cancer survivors. Employers seem to have a pivotal role in breast cancer patients' successful return to work.

Objective and Subjective Upper Body Function Six Months Following Diagnosis of Breast Cancer

Whether based on self-reported disability or direct physical measurements, studies of upper body function (UBF) among women with breast cancer consistently reveal high prevalence of limitation. Unfortunately, limited research and conflicting results undermine the ability to identify those factors that contribute to these UBF problems. This study describes the influence of selected personal and treatment characteristics on UBF, six-months following treatment for unilateral breast cancer, in a population-based sample of women residing in Southeast Queensland, Australia (n = 214). UBF was assessed by three objective measures (upper body strength and endurance, flexibility and hand grip strength) and two subjective measures (Disability of the Arm, Shoulder and Hand questionnaire and arm morbidity scale of the Functional Assessment of Cancer Treatment, Breast questionnaire). Modest correlations between the various UBF measures suggest that each captures a somewhat different dimension of physical function and disability. Advancing age, being treated on the non-dominant side, more childcare responsibilities, lower socioeconomic status, more extensive lymph node removal, having lymphoedema, and UBF scores of the untreated side emerged as significant correlates depending on whether UBF was assessed objectively or subjectively. There also was evidence that the relationships between the UBF measure of flexibility and (i) radiation treatment and (ii) side of treatment were modified depending on dominance. These results highlight the necessity of taking dominance into account when assessing functional impairment among breast cancer survivors. The findings also highlight the importance of considering whether subjective or objective UBF measures are more relevant in the design of future studies.

How do recovery advice and behavioural characteristics influence upper-body function and quality of life among women 6 months after breast cancer diagnosis?

GOALS OF WORK

After breast cancer treatment, women may experience significant and enduring problems relating to upper-body function (UBF) and quality of life (QoL). Women are often given advice to avoid problems, despite little scientific evidence to support or refute the advice given.

PATIENTS AND METHODS

This study addressed the relationships between recovery advice and subsequent behaviours on QoL (Functional Assessment of Cancer Therapy, Breast questionnaire) and UBF (Disability of Arm, Shoulder and Hand questionnaire) 6 months after treatment for unilateral breast cancer among a population-based sample of women residing in southeast Queensland (n=287).

MAIN RESULTS

Eighty-seven percent (n=249) of women reported that they received advice on facilitating arm function during their hospital stay, whereas 72% received subsequent recovery advice from medical and/or allied health professionals. Reported QoL and UBF were similar between groups, irrespective of advice received. Behaviours of interest included adherence to advice given, participation in breast cancer programmes and whether women had flight travel, used the treated side as much as the untreated side or had trauma, sunburn, injections and/or blood pressure readings on the treated side in the previous 6 months. QoL and UBF were highest among those who followed minimal advice, who used their treated side as much as their untreated side and who did not participate in any breast cancer programme (p<0.05).

CONCLUSIONS

The findings neither support nor refute current recommendations made to women with breast cancer, but rather raise questions about the value of this recovery advice. The study also provides novel findings regarding relationships between certain behaviours and QoL among breast cancer survivors.

Effects of chronic widespread pain on the health status and quality of life of women after breast cancer surgery

Background

Most research and treatment of post-breast cancer chronic pain has focused on local or regional pain problems in the operated area. The purpose of this pilot study was to compare and contrast the pain characteristics, symptom impact, health status, and quality of life of post-breast cancer surgery women with regional chronic pain versus those with widespread chronic pain.

Methods

A cross-sectional, descriptive design compared two groups of women with chronic pain that began after surgery: regional pain (n = 11) and widespread pain (n = 12). Demographics, characteristics of the surgery, as well as standardized questionnaires that measured pain (Brief Pain Inventory (BPI), Short Form McGill Pain Questionnaire (MPQ-SF)), disease impact (Fibromyalgia Impact Questionnaire (FIQ), Functional Assessment of Cancer Therapy-Breast (FACT-B)), health status (Medical Outcomes Short Form (SF-36)) and quality of life (Quality of Life Scale (QOLS)) were gathered.

Results

There were no significant differences between the groups on any demographic or type of surgery variable. A majority of both groups described their pain as aching, tender, and sharp on the MPQ-SF. On the BPI, intensity of pain and pain interference were significantly higher in the widespread pain group. Differences between the two groups reached statistical significance on the FIQ total score as well as the FACT-B physical well-being, emotional well-being and breast concerns subscales. The SF-36 physical function, physical role, and body pain subscales were significantly lower in the widespread pain group. QOLS scores were lower in the widespread pain group, but did not reach statistical significance.

Conclusion

This preliminary work suggests that the women in this study who experienced widespread pain after breast cancer surgery had significantly more severity of pain, pain impact and lower physical health status than those with regional pain.

Assessing task "burden" of daily activities requiring upper body function among women following breast cancer treatment

GOALS OF WORK

To determine which individual or groups of "upper-body" daily tasks are considered most burdensome to women following breast cancer treatment, and to assess whether certain patient or treatment characteristics influence task burden.

PATIENTS AND METHODS

A convenience sample of breast cancer survivors (n =619) completed a self-administered questionnaire regarding 48 daily tasks requiring upper-body function. Women were asked to rate how frequent and physically demanding each task was using a five-point Likert scale, and the product of task frequency and physical demand determined overall task burden. Tasks were ranked to identify the most burdensome individual tasks, while a factor analysis was performed to define independent constructs (groupings) among the tasks. Multiple linear regression models were fitted to consider the independent influences on task groups of various participant characteristics.

MAIN RESULTS

Factor analysis identified seven distinct task groups and the individual tasks considered most burdensome fell in five of these groups, specifically whole body, flexibility, carrying/upper-body strength, hand and weighted flexion tasks. Having lymphoedema or poor fitness was associated with upper-body disability involving all seven task groups, whereas other patient and treatment characteristics were related only to certain types of activities.

CONCLUSIONS

Breast cancer survivors report difficulty with a range of upper-body tasks, particularly if they also have lymphoedema or poor fitness. Using all or some of the tasks within the reported constructs in a questionnaire format, or the functional requirements of the most burdensome tasks to develop more objective and quantitative measures, would provide a solid base for the measurement of upper-body function in women with breast cancer.

Outcomes and quality of life following breast cancer treatment in older women: when, why, how much, and what do women want?

BACKGROUND

There are few comprehensive reviews of breast cancer outcomes in older women. We synthesize data to describe key findings and gaps in knowledge about the outcomes of breast cancer in this population.

METHODS

We reviewed research published between 1995 and June 2003 on breast cancer quality of life and outcomes among women aged 65 and older treated for breast cancer. Outcomes included communication, satisfaction, and multiple quality of life domains.

RESULTS

Few randomized trials or cohort studies that measured quality of life after treatment focused exclusively on older women. Studies from older women generally noted that, with the exception of axillary dissection, type of surgical treatment generally had no effect on long-term outcomes. In contrast, the processes of care, such as choosing therapy, good patient-physician communication, receiving treatment concordant with preferences about body image, and low perceptions of bias, were associated with better quality of life and satisfaction.

CONCLUSIONS

With the exception of axillary dissection, the processes of care, and not the therapy itself, seem to be the most important determinants of long-term quality of life in older women.

Predictors of long-term outcomes in older breast cancer survivors: perceptions versus patterns of care

PURPOSE

There are few data on sequelae of breast cancer treatments in older women. We evaluated posttreatment quality of life and satisfaction in a national population.

PATIENTS AND METHODS

Telephone surveys were conducted with a random cross-sectional sample of 1,812 Medicare beneficiaries 67 years of age and older who were 3, 4, and 5 years posttreatment for stage I and II breast cancer. Regression models were used to estimate the adjusted risk of decrements in physical and mental health functioning by treatment. In a subset of women (n = 732), additional data were used to examine arm problems, impact of cancer, and satisfaction, controlling for baseline health, perceptions of ageism and racism, demographic and clinical factors, region, and surgery year.

RESULTS

Use of axillary dissection was the only surgical treatment that affected outcomes, increasing the risk of arm problems four-fold (95% confidence interval, 1.56 to 10.51), controlling for other factors. Having arm problems, in turn, exerted a consistently negative independent effect on all outcomes (P </=.001). Processes of care were also associated with quality of life and satisfaction. For example, women who perceived high levels of ageism or felt that they had no choice of treatment reported significantly more bodily pain, lower mental health scores, and less general satisfaction. These same factors, as well as high perceived racism, were significantly associated with diminished satisfaction with the medical care system.

CONCLUSION

With the exception of axillary dissection, the processes of care, and not the therapy itself, are the most important determinants of long-term quality of life in older women.

Unemployment and the detection of early stage breast tumors among African Americans and non-Hispanic whites

PURPOSE

To test the hypothesis that high unemployment predicts reduced detection of local breast tumors among African American and non-Hispanic white women in the Detroit, Michigan and Atlanta, Georgia SEER catchment areas.

METHODS

We test the hypothesis with data for the 156 months from January 1985 through December 1997.

RESULTS

In situ and local breast tumors in African American and non-Hispanic white women were less likely to be detected during periods of high unemployment.

CONCLUSIONS

Contracting labor markets may impede women with symptoms from getting proper medical attention or distract women from discovering symptoms they would otherwise detect. African American women appear at greatest risk of having a tumor going undetected by virtue of labor market performance.

Treatment choices and response rates in African-American women with breast carcinoma

BACKGROUND

Breast cancer mortality rates are higher among African-American women compared with white American women, yet little is known regarding ethnicity-related variation in patterns of primary surgical treatment, locoregional recurrence rates, and response to induction chemotherapy.

METHODS

The available literature was reviewed to evaluate outcome from breast-conservation therapy in African-American women and response rates to systemic therapy.

RESULTS

Breast-conservation therapy appears to be underused among African-American women, a pattern that is noted also among white women with breast carcinoma. Higher rates of locoregional recurrence are seen among African-American women regardless of whether they receive breast-conserving treatment or undergo mastectomy, and this appears to be a function of primary tumor biology. Response rates to appropriately delivered systemic therapy are similar for African-American patients and white patients.

CONCLUSIONS

Despite the apparent increased aggressiveness of disease seen in African-American women with breast carcinoma, patterns of response to local and systemic therapy are similar to the patterns seen in white women with breast carcinoma.

Sequelae of axillary lymph node dissection in older women with stage 1 and 2 breast carcinoma

BACKGROUND

There are few data on the long-term sequelae of axillary dissection among older breast carcinoma patients. We describe the impact of axillary dissection in a cohort of older women.

METHODS

A longitudinal cohort of 571 patients with Stage 1 and 2 breast carcinoma, 67 years and older, diagnosed between 1995 and 1997 from 29 hospitals in five regions, and followed for 2 years. Data were collected from patients and medical charts. The primary outcome was posttreatment quality of life. Generalized estimation equation longitudinal modeling was used to evaluate the outcome, controlling for baseline function, comorbidity, age, clinical status, and other factors.

RESULTS

Sixty percent of women reported arm problems at some time in the 2 years after surgery. The cumulative risk of having arm problems 2 years posttreatment was three times higher (95% confidence interval 1.94-4.67) for women who underwent axillary surgery compared with women without axillary surgery, controlling for covariates. The effects of having axillary dissection and arthritis were multiplicative 2 years postsurgery. Arm problems were, in turn, the primary determinate of lower physical and mental functioning (P = 0.0001 and 0.04, respectively), controlling for other factors. Undergoing axillary dissection did not lessen fears about recurrence.

CONCLUSIONS

Arm problems after axillary dissection have a consistent negative impact on quality of life, suggesting that the risks may outweigh the potential benefits in this population.

Impact of breast carcinoma on African-American women: the Detroit experience

BACKGROUND

National and regional population-based data have demonstrated substantially worse outcome in African-American patients with breast carcinoma when compared with white patients, as well as a younger age distribution among African-American patients with breast carcinoma. The extent to which various socioeconomic, environmental, lifestyle, and genetic factors interact to account for this ethnicity-related disparity in survival is poorly understood. Greater than one-half of the inner-city population of Detroit, Michigan is African American, and greater metropolitan Detroit has been one of the contributing registries for the Surveillance, Epidemiology, and End Results (SEER) program since its inception in 1973. The impact of breast carcinoma on African Americans in the Detroit area is therefore well documented and provides significant insight into the history, epidemiology, and biology of this major public health care problem.

METHODS

A review of the medical literature published over the past 20 years regarding African-American patients with breast carcinoma was performed. The pertinent findings were summarized in the context of advances made in breast carcinoma screening, treatment, and risk reduction during that period.

RESULTS

The large African-American population of Detroit is a major factor contributing to the excessive breast carcinoma mortality rate reported for this city, which is one of the highest in the United States. Improvements in early detection of breast carcinoma by using screening mammography have been apparent in the earlier stage distributions of breast carcinoma observed in both white and African-American patients; however, progress has lagged substantially for the latter group. Detroit SEER registry data also have shown a younger age distribution of African-American patients with breast carcinoma and higher rates of estrogen receptor negative tumors. Finally, preliminary data from health maintenance organizations have suggested improved breast carcinoma outcome for African Americans who possess greater socioeconomic benefits, but disparities in disease stage at presentation persist.

CONCLUSIONS

The diverse Detroit community is ideally suited for breast carcinoma screening programs and clinical investigations that seek to address and overcome ethnicity-related survival disparities and barriers to health care. Findings from these studies can be correlated with results from similar projects in other geographic areas.

Risk factors for a decline in upper body function following treatment for early stage breast cancer

PURPOSE

To identify risk factors for a decline in upper body function following treatment for early stage breast cancer.

METHODS

We conducted a cross-sectional observational study of 213 women > 55 years of age newly diagnosed with early stage breast cancer interviewed three to five months following their definitive surgery. Patients were classified as having impaired upper body function related to their breast cancer treatment if: 1) they reported having no difficulty in performing any of three tasks requiring upper body function (pushing or pulling large objects; lifting objects weighing more than 10 pounds; and reaching or extending arms above shoulder level) prior to treatment, but reported that any of these tasks were somewhat or very difficult in the four weeks prior to interview, or 2) they reported that performing any of the three tasks requiring upper body function was somewhat difficult prior to treatment, but reported that any of these tasks were very difficult in the four weeks prior to interview.

RESULTS

In multiple logistic regression models, both the extent and type of primary tumor therapy and cardiopulmonary comorbidity were significantly associated with a decline in upper body function following breast cancer treatment.

CONCLUSION

Given the critical importance of upper body function in maintaining independent living, clinicians should consider the functional consequences of treatment when they discuss treatment options and post-operative care with older women who have early stage breast cancer.

Unemployment and the likelihood of detecting early-stage breast cancer

OBJECTIVES

The objective of this study was to test the hypothesis that unexpectedly high unemployment in a community is associated with reduced odds that registered breast tumors are local.

METHODS

The hypothesis was tested with data from San Francisco for the 132 months beginning with January 1983.

RESULTS

Registered breast tumors were less likely to be local during periods of unexpectedly high unemployment (8% less likely among non-Hispanic White women and 24% less likely among African-American women).

CONCLUSIONS

Job loss may restrict access to health services. Fear of job loss may also distract women from breast self-examination and the identification of suspicious breast signs.