Symptom management in premenopausal patients with breast cancer

Subsequent primary cancer risk and mortality among premenopausal breast cancer survivors

Patients with premenopausal breast cancer (preBC) usually have long-term survivorship. However, less is known about the risk pattern of subsequent primary cancer (SPC) and noncancer diseases among them. Here, this study aimed to evaluate the risk of developing SPCs and mortality among preBC survivors. In this population-based, retrospective cohort study, 5-year preBC survivors diagnosed at age 20-59 years during 1992-2014, in the 11 Surveillance, Epidemiology and End Result registries were included. Standardized incidence ratio (SIR) and standardized mortality ratio (SMR) were estimated for SPCs and mortality by cause, respectively. Among 181,947 survivors (mean age at diagnosis, 49.1 years; 65.9% White), there were 12,503 SPC cases, 4,280 SPC-related deaths, and 10,591 noncancer-related deaths. SPC risk was increased compared with the general population (SIR 1.06, [95% CI, 1.04-1.08]). The elevated risk was primarily associated with soft tissue cancer, bones/joints cancer, and acute non-lymphocytic leukemia (SIRs 2.01 [95% CI, 1.73-2.33], 1.78 [95% CI, 1.21-2.53], and 1.68 [95% CI, 1.46-1.93], respectively). Young-onset, Asian survivors, those with hormone receptor-negative BC, and initially treated with chemo-radiotherapy were at high-risk. The risk of dying from SPCs was also increased (SMR 1.07, [95% CI, 1.04-1.10]) and featured with similarly vulnerable subpopulations. Survivors of non-White ethnicity had a higher risk of dying from noncancer diseases. This study highlighted the excess risk of developing and dying from SPCs among preBC survivors, suggesting that targeted healthcare is warranted. Strategies for SPCs and noncancer comorbidity management are in great demand to achieve better long-term survivorship among preBC patients.

Gynecological complications in long-term survivors after allogeneic hematopoietic cell transplantation—a single-center real-life cross-sectional study

Background and objectives

Hematopoietic stem cell transplantation (HCT) is a treatment for hematopoietic diseases. However, most cured female patients may suffer from premature ovarian insufficiency (POI) after HCT, which is mainly caused by the pre-HCT conditioning regimen. Hence, this study aims to explore the impact of HCT treatment on reproductive and ovarian functions in female survivors.

Methods

A total of 55 female participants under the age of 40, who underwent HCT and met the inclusion criteria were enrolled. Data related to blood disease, menstruation, and fertility in the 3 years following HCT were collected.

Results

The involved patients received transplantation at different age stages, ranging from 8 to 37. All patients, except those with aplastic anemia (AA; 5/55), received a myeloablative conditioning regimen, usually modified total body irradiation/cyclophosphamide (TBI/Cy; 25/55) or modified Busulfan/cyclophosphamide (Bu/Cy; 23/55). Among women (42/55) who menstruated before HCT, 16.67% (7/42) had a spontaneous menstrual relapse and 83.3% (35/42) had amenorrhea after HCT. 72.7% (40/55) could be regarded as having POI. This proportion included 100% (25/25) of women aged 21–40 at the time of HCT, 62.5% (15/24) of those aged 11–20, and 0% (0/6) of those ≤10 years old. Patients with AML were more likely to have POI (95.7%). Patients aged ≤10 years (0%) or 11–20 years (16.7%) at the time of HCT were less likely to have moderate to severe menopause than those 21–40 years old (44%).

Conclusion

The prevalence of POI following HCT was high and POI was associated with age, conditioning regimen, and type of blood disease.

Has oncofertility information for male patients improved? Objective assessment of internet-based fertility preservation resources at NCI cancer centers from 2015 to 2020

PURPOSE

Fertility preservation is a critical patient counseling component following cancer diagnosis. The aim of this study was to compare change and quality of fertility preservation information available to patients on the websites of National Cancer Institute (NCI)-designated cancer centers over 5 years (2015 to 2020) for both women and men.

METHODS

All NCI-designated cancer center websites were queried for information on oncofertility in 2020 publicly available to patients using the methodology and rubric previously employed in 2015. Data was evaluated based on each center's city, county, and state by demographic data obtained from the US Census. Additionally, the yearly number of in vitro fertilization (IVF) cycles performed in the city, county, and state of each NCICC was included using websites of clinics reporting data to the Society for Assisted Reproductive Technology.

RESULTS

Significantly NCICCs have a standalone pages for fertility preservation in 2020 compared with 2015 (p = 0.004). There is a statistically significant association between discussion of male fertility and the number of fertility centers in the county and state of the NCICC (p = 0.04 and p = 0.001). NCICCs in counties in the highest quartile of per capita income were significantly more likely to address male fertility (p = 0.03).

CONCLUSIONS

Oncofertility information on NCICC websites has improved between 2015 and 2020. The impact of cancer treatment on male fertility, while improved, is still limited, particularly in counties with lower per capita income.

Evidence-based approaches for the management of side-effects of adjuvant endocrine therapy in patients with breast cancer

The growing availability of more effective therapies has contributed to an increased survival of patients with breast cancer. In hormone receptor-positive early disease, increased survival is strongly correlated with the use of adjuvant endocrine therapy, but this therapy can cause side-effects that have major consequences in terms of treatment adherence and patients' quality of life. In premenopausal breast cancer survivors, these side-effects might be even more prominent due to the abrupt suppression of oestrogen associated with the most intense endocrine therapies. An important ambition of cancer care in the 21st century is to recover pre-cancer quality of life and emotional and social functions, which is only possible through the mitigation of the side-effects of anticancer treatments. This Review presents a comprehensive summary of the efficacy and safety data of the available interventions (hormonal and non-hormonal pharmacological strategies, non-pharmacological approaches, and complementary and alternative medicine) to control selected side-effects associated with adjuvant endocrine therapy (hot flashes, sexual dysfunction, weight gain, musculoskeletal symptoms, and fatigue), providing updated, evidence-based approaches for their management.

The unmet need for oncofertility preservation in women: Results of a survey by different oncological specialists in Lazio, Italy

In recent years, we have witnessed a growing interest in the prevention of the loss of reproductive efficacy in young women as a result of cancer or its treatments. Indeed, recent studies have shown that loss of fertility impacts deeply on young women and sometimes may be even more stressful than the cancer diagnosis itself. In fact, the risk of treatment-associated infertility and premature menopause is a major concern for patients. Nevertheless, the approach to fertility preservation in women diagnosed with cancer is far from being standardized, and counseling strategies are poorly adopted in clinical practice. In Italy, the federal structure of public health makes it difficult to refer patients to local referral centers experienced in fertility preservation. In particular, a need exists to identify oncologists in the Lazio region specialized in fertility preservation and those facilities who are able to counsel patients regarding their sexuality. For these reasons, the Lazio section of Italian Association of Medical Oncology has led an oncofertility and oncosexuality survey to assess deficiencies in the path to start fertility preservation procedures and to help patients with cancer-related sexual problems. In total, 273 healthcare providers participated in the survey. Overall, the participants had a low interest in their patients' infertility problems, which led to a poor referral of patients to fertility preservation centers. This behavior demonstrated by healthcare providers is attributed to the necessity to rapidly start oncological treatments, the lack of knowledge of referral centers, and the little experience in tackling the subject with the patients. The interviewees also recognize communication difficulties related to lack of information on issues, absence of rehabilitations paths, and embarrassment.

Topical treatment of vaginal dryness with a non-hormonal cream in women undergoing breast cancer treatment - An open prospective multicenter study

This open, prospective, multicenter, observational study was performed to investigate the efficacy and safety of a non-hormonal cream in women undergoing breast cancer treatment and experiencing vulvovaginal dryness symptoms. Overall, 128 patients from 22 study centers participated. The cream was applied to the vagina and vulva for 28 days. For the efficacy analysis, changes in subjective symptoms (feeling of dryness, itching, burning, pain independent of sexual intercourse, dyspareunia, urinary incontinence) were evaluated. Additionally, the following objective diagnostic findings were assessed by a physician: thinning of vaginal epithelium, redness, petechiae, and discharge. Safety and tolerability were assessed by evaluating type and frequency of adverse events, including adverse medical device-related effects. The frequency and intensity of all subjective symptoms significantly improved from baseline at 28 days (p<0.0001). Additionally, 21.4% of patients were completely free of symptoms (p<0.0001) and urinary incontinence was improved or eliminated in 30.8% of women. The overall sum score for all four objective findings was significantly improved from baseline at 28 days (p<0.0001). The frequency of petechial bleedings was significantly reduced (p<0.0001). Further, significant decreases in the severity of vaginal epithelium thinning, redness and petechiae were observed (p<0.0001). More than 88% of patients and investigators assessed the efficacy and tolerability as being good or very good. No serious adverse events were documented. This study demonstrates that the investigated cream is an effective and safe non-hormonal, topical option in the treatment of vulvovaginal dryness symptoms in patients undergoing breast cancer treatment for. However, the study duration and follow-up time of 4 weeks as well as the non-randomized trial design are limitations of the study.

Fertility preservation in adolescent and young adult cancer patients: From a part of a national survey on oncofertility in Japan

PURPOSE

This study evaluated the current status of reproductive disorders and provision of information on oncofertility to female adolescent and young adult (AYA) cancer patients in Japan.

METHODS

A national survey of AYA cancer survivors was conducted. Children were <15 years old, and AYAs were 15-39 years old. Results from the survivors of other than gynecological disease who underwent chemotherapy were analyzed.

RESULTS

Among the survivors, 41.4% were concerned about their reproductive function and infertility, and 36.2% were aware of menstrual cycle abnormalities. Among them, 15.5% (n = 20) of all and 21.2% (n = 17) of the AYA-onset survivors suffered infertility due to chemo- or radiotherapy and gave up childbearing. These rates were significantly higher than those of healthy AYAs. Although 80.8% of AYA-onset survivors answered that they had received information on reproductive function and infertility, only 55.8% had received information on fertility preservation methods. Furthermore, only 22.4% of all and 42.3% of AYA-onset survivors had received pretreatment information on fertility preservation methods.

CONCLUSIONS

Not a few AYA cancer survivors reported reproductive dysfunction. These findings indicate that information provided on therapy-related problems before cancer treatment in Japan was insufficient and highlight the need to improve patient decision-making and support systems for fertility preservation.

A biopsychosocial model of resilience for breast cancer: A preliminary study in mainland China

PURPOSE

Patients diagnosed with breast cancer exhibited critical biopsychosocial functions following surgery or adjuvant treatment; therefore, it is important that they exhibit resilience. A Resilience Model for Breast Cancer (RM-BC) was developed using Chinese breast cancer patients to increase our understanding of how resilience outcomes are positively and negatively affected by protective and risk factors, respectively.

METHODS

Chinese women with breast cancer completed the questionnaires within 1 week of beginning treatment. Exploratory Structural Equation Modeling was used to evaluate the RM-BC using a sample size of 342 patients.

RESULTS

RM-BC suggested satisfactory goodness-of-fit indices and 67 percents of variance for resilience was explained. The Fit Indices for the measurement model were as follows: CFI = 0.909, GFI = 0.911, IFI = 0.897, NFI = 0.922, PNFI = 0.896, PCFI = 0.884, and RMSEA = 0.031. Three risk factors - emotional distress, physical distress, and intrusive thoughts - and four protective factors - self-efficacy, social support, courage-related strategy, and hope - were recognized.

CONCLUSION

The resilience model allows for a better understanding of Chinese breast cancer patients' resilience integration while undergoing treatment and provides an effective structure for the development of resilience-focused interventions that are grounded in their experiences. A randomized trial has provided evidences of feasibility in Chinese women with breast cancer and the resilience model could be used as a useful framework for more resilience intervention in the future.

The assessment and management of chemotherapy-related toxicities in patients with breast cancer, colorectal cancer, and Hodgkin's and non-Hodgkin's lymphomas: A scoping review

PURPOSE

The purpose of the eSMART (Electronic Symptom Management using the Advanced Symptom Management System (ASyMS) Remote Technology) study is to evaluate the use of mobile phone technology to manage chemotherapy-related toxicities (CRTs) in people with breast cancer (BC), colorectal cancer (CRC), Hodgkin's lymphoma (HL), and non-Hodgkin lymphoma (NHL)) across multiple European sites. One key objective was to review the published and grey literature on assessment and management of CRTs among patients receiving primary chemotherapy for BC, CRC, HL, and NHL to ensure that ASyMS remained evidence-based and reflected current and local practice.

METHODS

Three electronic databases were searched for English papers, with abstracts available from 01/01/2004-05/04/2014. For the grey literature, relevant clinical practice guidelines (CPGs)/evidence-based resources (EBRs) from the main international cancer organisations were reviewed as were symptom management (SM) protocols from the sites.

RESULTS

After full-text screening, 27 publications were included. The majority (n = 14) addressed fatigue and focused on BC patients. Relevant CPGs/EBRs were found for fatigue (n = 4), nausea/vomiting (n = 5), mucositis (n = 4), peripheral neuropathy (n = 3), diarrhoea (n = 2), constipation (n = 2), febrile neutropenia/infection (n = 7), palmar plantar erythrodysesthesia (PPE) (n = 1), and pain (n = 4). SM protocols were provided by >40% of the clinical sites.

CONCLUSIONS

A need exists for empirical research on SM for PPE, diarrhoea, and constipation. Research is needed on the efficacy of self-care strategies in patients with BC, CRC, HL, and NHL. In general, consistency exists across CPGs/EBRs and local guidelines on the assessment and management of common CRTs.

Walking in the shoes of patients, not just in their genes: a patient-centered approach to genomic medicine

Genomic technologies are increasing the precision with which clinicians can assess an individual patient's risk for developing diseases and identify which patients are likely to benefit from specific treatments. Also advocating for a shift away from a one-size-fits-all approach is the growing emphasis on "patient-centered" care. Using examples from breast cancer, we make a case for why, in order to optimize patient health outcomes, genomic medicine will need to be practiced within a patient-centered framework. We present a six-function conceptual framework for patient-centered care and discuss findings from a national survey evaluating the patient-centeredness of care delivered in the USA.

Genitourinary Syndrome of Menopause in Breast Cancer Survivors: Are We Facing New and Safe Hopes?

Breast cancer survivors (BCSs) often suffer from menopausal symptoms induced by systemic treatments, with a consequent negative effect on quality of life. Since the introduction of aromatase inhibitors as the standard therapy for hormone-dependent tumors, genitourinary syndrome of menopause (GSM) has become a main problem for BCSs. This new terminology refers to the wide range of vaginal and urinary symptoms related to menopause, which can be relieved by estrogen therapy. Unfortunately, systemic hormone therapy is contraindicated for BCSs and also vaginal estrogens at standard dosage might influence the risk of recurrence because they cause a significant increase of circulating estrogens. Nonhormonal vaginal moisturizers or lubricants are the first choice for BCSs but only have limited and short-term efficacy. New strategies of management of GSM are now available, including: (1) low-dose or ultra low-dose vaginal estrogens; (2) oral selective estrogen receptor modulators (ospemifene); (3) androgen therapy; (4) physical treatment with vaginal laser; and (5) psychosocial interventions. In this review we discuss and analyze these different options.

Ovarian stimulation and in-vitro fertilization outcomes of cancer patients undergoing fertility preservation compared to age matched controls: a 17-year experience

PURPOSE

To compare the in-vitro fertilization (IVF) outcomes of cancer patients who underwent oocyte retrieval and embryo/oocyte cryopreservation prior to gonadotoxic therapy to those of age and time-matched controls with tubal factor infertility.

METHODS

All cancer patients who underwent embryo/oocyte cryopreservation at our institution from 1997 to 2014 were reviewed. Primary outcomes were total dose of gonadotropins used, number of oocytes retrieved, and number of 2pn embryos obtained. Outcomes were compared to age-matched controls with tubal-factor infertility who underwent a fresh embryo transfer within the same relative time period as the IVF cycle of the cancer patient.

RESULTS

Sixty-three cancer patients underwent 65 IVF cycles, and 21 returned for frozen embryo transfer. One hundred twenty-two age-matched controls underwent IVF cycles with fresh transfer, and 23 returned for frozen embryo transfer. No difference was seen between cancer patients and controls with respect to total ampules of gonadotropin used (38.0 vs. 35.6 respectively; p = 0.28), number of oocytes retrieved (12.4 vs. 10.9 respectively; p = 0.36) and number of 2pn embryos obtained (6.6 vs. 7.1 respectively; p = 0.11). Cumulative pregnancy rate per transfer for cancer patients compared to controls was 37 vs. 43 % respectively (p = 0.49) and cumulative live birth rate per transfer was 30 vs. 32 % respectively (p = 0.85). Cancer patients had a higher likelihood of live birth resulting in twins (44 vs. 14 %; p = 0.035).

CONCLUSIONS

Most IVF outcomes appear comparable for cancer patients and age-matched controls. Higher twin pregnancy rates in cancer patients may reflect lack of underlying infertility or need for cancer-specific transfer guidelines.

Subgroup effects in a randomised trial of different types and doses of exercise during breast cancer chemotherapy

Background:

The Combined Aerobic and Resistance Exercise Trial tested different types and doses of exercise in breast cancer patients receiving chemotherapy. Here, we explore potential moderators of the exercise training responses.

Methods:

Breast cancer patients initiating chemotherapy (N=301) were randomly assigned to three times a week, supervised exercise of a standard dose of 25–30 min of aerobic exercise, a higher dose of 50–60 min of aerobic exercise, or a higher dose of 50–60 min of combined aerobic and resistance exercise. Outcomes were patient-reported symptoms and health-related fitness. Moderators were baseline demographic, exercise/fitness, and cancer variables.

Results:

Body mass index moderated the effects of the exercise interventions on bodily pain (P for interaction=0.038), endocrine symptoms (P for interaction=0.029), taxane/neuropathy symptoms (P for interaction=0.013), aerobic fitness (P for interaction=0.041), muscular strength (P for interaction=0.007), and fat mass (P for interaction=0.005). In general, healthy weight patients responded better to the higher-dose exercise interventions than overweight/obese patients. Menopausal status, age, and baseline fitness moderated the effects on patient-reported symptoms. Premenopausal, younger, and fitter patients achieved greater benefits from the higher-dose exercise interventions.

Conclusions:

Healthy weight, fitter, and premenopausal/younger breast cancer patients receiving chemotherapy are more likely to benefit from higher-dose exercise interventions.

Effects of exercise dose and type during breast cancer chemotherapy: multicenter randomized trial

BACKGROUND

Exercise improves physical functioning and symptom management during breast cancer chemotherapy, but the effects of different doses and types of exercise are unknown.

METHODS

A multicenter trial in Canada randomized 301 breast cancer patients to thrice-weekly supervised exercise during chemotherapy consisting of either a standard dose of 25 to 30 minutes of aerobic exercise (STAN; n = 96), a higher dose of 50 to 60 minutes of aerobic exercise (HIGH; n = 101), or a combined dose of 50 to 60 minutes of aerobic and resistance exercise (COMB; n = 104). The primary endpoint was physical functioning assessed by the Medical Outcomes Survey-Short Form (SF)-36. Secondary endpoints were other physical functioning scales, symptoms, fitness, and chemotherapy completion. All statistical tests were linear mixed model analyses, and the P values were two-sided.

RESULTS

Follow-up assessment of patient-reported outcomes was 99.0%. Adjusted linear mixed-model analyses showed that neither HIGH (+0.8; 95% confidence interval [CI] = -0.8 to 2.4; P = .30) nor COMB (+0.5; 95% CI = -1.1 to 2.1; P = .52] were superior to STAN for the primary outcome. In secondary analyses not adjusted for multiple comparisons, HIGH was superior to STAN for the SF-36 physical component summary (P = .04), SF-36 bodily pain (P = .02), and endocrine symptoms (P = .02). COMB was superior to STAN for endocrine symptoms (P = .009) and superior to STAN (P < .001) and HIGH (P < .001) for muscular strength. HIGH was superior to COMB for the SF-36 bodily pain (P = .04) and aerobic fitness (P = .03). No differences emerged for body composition or chemotherapy completion.

CONCLUSIONS

A higher volume of aerobic or combined exercise is achievable and safe during breast cancer chemotherapy and may manage declines in physical functioning and worsening symptoms better than standard volumes.

Menopausal symptoms among breast cancer patients: a potential indicator of favorable prognosis

Menopausal symptoms have been suggested to be an indicator of better prognosis among patients treated for breast cancer, because women who experience these symptoms usually have a lower level of estrogen. We tested this hypothesis in a population-based, prospective cohort study involving 4,842 women with stage 0 to III primary breast cancer who were enrolled in the Shanghai Breast Cancer Survival Study between March 2002 and April 2006, were aged 20 to 75 years, and were recruited 6 months post-diagnosis. They were followed-up by in-person surveys and record linkages with the vital statistics registry. Cox regression analysis was used to evaluate the association of menopausal symptoms at baseline with breast cancer recurrence. Approximately 56% of patients experienced at least one menopausal symptom, including hot flashes, night sweats, and/or vaginal dryness at baseline. During a median follow-up period of 5.3 years, 720 women had a recurrence. Experiencing hot flashes or having ≥2 menopausal symptoms was associated with lower risk of recurrence among premenopausal women (hazard ratio [HR]=0.77, 95% confidence interval [CI]: 0.62-0.96 for hot flashes; 0.73, 0.56-0.96 for ≥2 menopausal symptoms). Lower recurrence risk in relation to hot flashes was also observed among women who were not overweight/obese (HR=0.78, 95% CI: 0.64-0.99), those with relatively low waist-to-hip ratio (WHR) (HR=0.77, 95% CI: 0.61-0.97), and those who used tamoxifen (HR=0.75, 95% CI: 0.58-0.98). Consistently experiencing multiple menopausal symptoms was associated with lower recurrence risk among women with low WHR or who used tamoxifen. This large, population-based cohort study of women with breast cancer confirms that experiencing menopausal symptoms is an indicator of favorable breast cancer prognosis.

A neglected issue on sexual well-being following breast cancer diagnosis and treatment among Chinese women

Background

Changes to sexual well-being can be one of the most problematic quality of life issues following the diagnosis and treatment of breast cancer. The objectives of the present study were to evaluate changes to sexual well-being following breast cancer, to expand upon the existing body of knowledge pertaining to breast cancer and sexuality, and to provide the necessary information for implementing future interventions that may help improve the quality of life in breast cancer patients.

Methods

This study was mixed with qualitative and quantitative designs. Twenty patients with breast cancer were recruited for in-depth interviews. The central questions covered a patient’s cancer experience and perceptions of sexual activities following breast cancer. According to the findings of the qualitative study, we performed a quantitative study using a structured questionnaire to collect data on patient’s experience and attitude to sexual well-being following breast cancer diagnosis and treatment.

Results

Based on the qualitative analysis, seven main themes emerged: (1) Decrease in sexual frequency; (2) Lack of sexual interest; (3) Menopausal symptoms; (4) Body image changes; (5) Effects on marital relationship; (6) Misconceptions about sex; (7) The need for professional consultation. Results from the quantitative study further supported the findings from the qualitative analysis, where changes to sexual well-being were common following cancer diagnosis and treatment and it was a neglected issue among Chinese women.

Conclusions

The present study highlights the significant changes to sexual well-being following breast cancer, in addition to the lack of knowledge and misconceptions of sexual activity among patients. Addressing these problems will help improve a patient’s quality of life. The findings of this study could help healthcare professionals recognize the sexual issues faced by women with breast cancer and ultimately promote a healthy life.

Fertility counseling of young breast cancer patients

Approximately 6% of women with breast cancer are diagnosed before the age of 40. Young age is an independent predictor of adverse outcome and most young breast cancer patients receive systemic treatment with chemotherapy, hormonal therapy or both. The loss or impairment of fertility is a potential side effect of antineoplastic treatments. Due to the rising trend to delaying pregnancy in life, an increasing proportion of young cancer patients who are yet to have a pregnancy will face the problem of iatrogenic menopause in the future. The incidence of anticancer-treatment-related ovarian failure depends on the type of chemotherapy regimen administered, the use of tamoxifen and the age of patients. It rises with increasing age, in the range of 22-61% and 61-97% in women aged <40 years and >40 years respectively. Although there is a clear trend to increasing incidence of ovarian failure with the rise in aging, there may be a small proportion of patients who became amenorrhoeic despite the very young age, thus indicating that also individual factors still unknown may affect the probability of treatment-related ovarian failure. A prompt referral of patients to reproductive counseling and a multidisciplinary team including Oncology and Reproductive Units are essential to face the management of fertility issues in cancer patients. Fertility counseling should include a detailed description of all the available techniques to preserve fertility. The main available fertility preservation techniques, standard and experimental, for young breast cancer patients include: temporary ovarian suppression during chemotherapy with gonadotropin-releasing hormone analogues, embryo cryopreservation, cryopreservation of oocytes and cryopreservation of ovarian tissue. Research efforts are still necessary to improve the efficacy and safety of the available fertility preservation strategies as well as an efficient collaboration between oncologists and gynecologists is necessary to improve patients' access to the strategies themselves.

Patient perceptions of reproductive health counseling at the time of cancer diagnosis: a qualitative study of female California cancer survivors

PURPOSE

We sought to determine what women recall about reproductive health risks (RHR) from cancer therapy at the time of cancer diagnosis in order to identify barriers to reproductive health counseling (RHC) and fertility preservation (FP).

METHODS

Data were obtained by surveying 1,041 female cancer survivors from the California Cancer Registry. Inclusion criteria included women age 18-40 with a diagnosis of leukemia, Hodgkin's disease, non-Hodgkin's lymphoma, breast or GI cancer diagnosed between 1993 and 2007. Women were asked to respond to an open-ended question: "what did your doctor tell you about how cancer treatment could affect your ability to get pregnant?" Framework analysis was used to identify themes surrounding patient perceptions of RHC.

RESULTS

Of the patients, 51.8 % (361 out of 697) recalled receiving reproductive health counseling and 12.2 % (85 out of 697) recalled receiving FP counseling. Of the patients, 45.3 % (277 out of 612) reported that uncertain prognosis, risk of recurrence or vertical transmission, age, parity, or uncertain desire may have prevented them from receiving timely and essential information on RHRs. Communication barriers included omission of information, failure to disclose RHRs, and presentation of incorrect information on FP.

DISCUSSION

In a sample of women diagnosed with cancer of reproductive age, almost half did not recall counseling on RHRs and few recalled FP counseling. Communication barriers between physicians and patients regarding fertility may lead to uninformed (reproductive health) RH decisions.

IMPLICATIONS FOR CANCER SURVIVORS

Many women may not receive adequate information about RHRs or FP at the time of cancer diagnosis. Advancements in reproductive technology and emerging organizations that cover financial costs of FP have dramatically changed what options women have to preserve their fertility. Routine and thoughtful RHR and FP counseling, as well as collaborative cancer care will help ensure that women diagnosed with cancer are provided with the services and information they need to make an informed choice about their reproductive future.

Effect of anti-anxiety treatment on sevoflurane requirement and postoperative recovery in patients undergoing radical gastrectomy

AIM: To investigate the effect of anti-anxiety treatment with lorazepam and midazolam on sevoflurane requirement and postoperative recovery in patients undergoing radical gastrectomy.

METHODS: Sixty patients undergoing radical gastrectomy were divided into two groups: observation group and control group. The observation group was administered with lorazepam the night before surgery and midazolam 40 min before the induction of anesthesia, while the control group was not given such drugs. BIS monitoring was used to control the depth of anesthesia. The Spielberger State-Trait Anxiety Inventory (STAI) scores were obtained preoperatively, while the requirement of sevoflurane during operation and the VAS scores 2 h, 6 h and 24 h postoperatively were also calculated.

RESULTS: The observation group had lower STAI scores (S-AI: 53.6 ± 4.45 vs 62.70 ± 3.98, P < 0.05; T-AI: 54.78 ± 3.97 vs 65.65 ± 4.21, P < 0.05) and less requirement of sevoflurane during operation (34.7 ± 0.46 vs 36.2 ± 0.44, P < 0.05). The VAS scores at 6 and 24 hours postoperatively were lower in the observation group (6 h: 3.45 ± 1.60 vs 4.89 ± 1.91, P < 0.05; 24 h: 3.51 ± 1.76 vs 5.17 ± 1.71, P < 0.05) than in the control group. There were no significant differences in awaking time and extubation time between the two groups (both P > 0.05).

CONCLUSION: Combined use of lorazepam and midazolam can reduce preoperative anxiety, intraoperative sevoflurane requirement, and postoperative pain in patients undergoing radical gastrectomy.

Web-based tailored education program for disease-free cancer survivors with cancer-related fatigue: a randomized controlled trial

PURPOSE

To determine whether an Internet-based tailored education program is effective for disease-free cancer survivors with cancer-related fatigue (CRF).

PATIENTS AND METHODS

We randomly assigned patients who had completed primary cancer treatment within the past 24 months in any of four Korean hospitals and had reported moderate to severe fatigue for at least 1 week to participate in a 12-week, Internet-based, individually tailored CRF education program or to receive routine care. We based the program on the CRF guidelines of the National Comprehensive Cancer Network (NCCN) and incorporated the transtheoretic model (TTM). At baseline and 12 weeks, we used the Brief Fatigue Inventory (BFI) and Fatigue Severity Scale (FSS) as primary outcomes and the Hospital Anxiety and Depression Scale (HADS) and European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire C30 (EORTC QLQ-C30) for secondary outcomes.

RESULTS

We recruited 273 participants and randomly assigned 136 to the intervention group. Compared with the control group, the intervention group had an improvement in fatigue as shown by a significantly greater decrease in BFI global score (-0.66 points; 95% CI -1.04 to -0.27) and FSS total score (-0.49; 95% CI, -0.78 to -0.21). In secondary outcomes, the intervention group experienced a significantly greater decrease in HADS anxiety score (-0.90; 95% CI, -1.51 to -0.29) as well as global quality of life (5.22; 95% CI, 0.93 to 9.50) and several functioning scores of the EORTC QLQ-C30.

CONCLUSION

An Internet-based education program based on NCCN guidelines and TTM may help patients manage CRF.

Community-based exercise program effectiveness and safety for cancer survivors

PURPOSE

Clinical trials have demonstrated the benefits of exercise for cancer survivors. This investigation determined the effectiveness and safety of a disseminated community-based exercise program for cancer survivors who had completed treatment.

METHODS

Personal trainers from regional YMCAs received training in cancer rehabilitation and supervised twice-a-week, 12-week group exercise sessions for survivors. At baseline and post-program, validated measures assessed patient-reported outcomes (PRO) and physiologic measurements.

RESULTS

Data were collected from 221 survivors from 13 YMCA sites and 36 separate classes. All participants had data available at one time point, while matched baseline and post-program PRO and physiologic data were available for 85% (N = 187). Participants with matched data were largely female (82%), with mean age of 58 (range, 28-91 years). Time since diagnosis ranged from 1 to 48 (mean, 5.6 years), and mean time since last treatment was 3.0 (range, 1-33 years). Physiological improvements were significant in systolic (P < 0.001) and diastolic (P = 0.035) blood pressure, upper and lower body strength, the 6-min walk test (P = 0.004), and flexibility (P < 0.001). Participants reported improvements in overall health-related quality of life (P < 0.001), social support (P = 0.019), body pain (P = 0.016), fatigue (P < 0.001), insomnia (P < 0.001), and overall musculoskeletal symptoms (P = <0.001). Few injuries or lymphedema events occurred during classes.

CONCLUSIONS

Community-based exercise groups for cancer survivors of mixed diagnoses and ages, who have completed active treatment, have physiologic and psychosocial benefits, and are safe.

IMPLICATIONS FOR CANCER SURVIVORS

Survivors may expect significant benefit from participating in a community-based exercise program tailored to meet their individual needs as a survivor.

Pretreatment fertility counseling and fertility preservation improve quality of life in reproductive age women with cancer

BACKGROUND

The post-treatment quality of life (QOL) impacts of receiving precancer-treatment infertility counseling and of pursuing fertility preservation have not been described in large-scale studies of reproductive age women with cancer.

METHODS

In total, 1041 women who were diagnosed between ages 18 and 40 years responded to a retrospective survey and reported whether they received infertility counseling before cancer treatment and whether they took action to preserve fertility. Five cancer types were included: leukemia, Hodgkin disease, non-Hodgkin lymphoma, breast cancer, and gastrointestinal cancer. Validated QOL scales were used: the Decision Regret Score, the Satisfaction with Life Scale (SWLS), and the brief World Health Organization QOL questionnaire.

RESULTS

Overall, 560 women (61%) who received treatment that potentially could affect fertility were counseled by the oncology team, 45 (5%) were counseled by fertility specialists, and 36 (4%) took action to preserve fertility. Pretreatment infertility counseling by a fertility specialist and an oncologist resulted in lower regret than counseling by an oncologist alone (8.4 vs 11.0; P < .0001). The addition of fertility preservation (6.6 vs 11.0; P < .0001) also was associated with even lower regret scores than counseling by an oncologist alone. Further improvements also were observed in SWLS scores with the addition of fertility specialist counseling (23.0 vs 19.8; P = .09) or preserving fertility (24.0 vs 19.0; P = .05).

CONCLUSIONS

Receiving specialized counseling about reproductive loss and pursuing fertility preservation is associated with less regret and greater QOL for survivors, yet few patients are exposed to this potential benefit. Women of reproductive age should have expert counseling and should be given the opportunity to make active decisions about preserving fertility.

Acute ovarian failure underestimates age-specific reproductive impairment for young women undergoing chemotherapy for cancer

BACKGROUND

The authors sought to describe the age-specific impact of infertility and early menopause after chemotherapy among reproductive age women with cancer.

METHODS

A total of 1041 women diagnosed with cancer between the ages of 18 and 40 years responded to a retrospective survey on reproductive health history. Five cancer types were included: leukemia, Hodgkin disease (HD), non-Hodgkin lymphoma (NHL), breast cancer, and gastrointestinal(GI) cancer. Survey questions addressed acute ovarian failure (cessation of menses after treatment), early menopause (menopause before 45 years old), and infertility (failed conception). Logistic regression was used to determine the proportions of acute ovarian failure and infertility based on age at diagnosis. Censored data methods were used to determine the probability of early menopause.

RESULTS

Six hundred twenty women received chemotherapy alone. The percentage reporting acute ovarian failure was 8%, 10%, 9%, and 5% for HD, NHL, breast cancer, and GI cancer, respectively. Acute ovarian failure increased significantly with age at diagnosis (P < .05). In subjects not reporting acute ovarian failure, the incidence of infertility was at least 40% at age 35 years and increased significantly with age at diagnosis in HD and breast cancer (P < .05). The estimated probability of early menopause was at least 25% at age 30 years and increased significantly with younger age at diagnosis in HD, NHL, and GI cancer (P < .05).

CONCLUSIONS

For patients to receive appropriate counseling, it is important that they understand the potential increased risk of infertility and early menopause beyond that of acute ovarian failure. These findings can provide improved, age-specific counseling regarding reproductive impairment for young women diagnosed with cancer.

A pilot phase II trial of magnesium supplements to reduce menopausal hot flashes in breast cancer patients

BACKGROUND

We tested if magnesium would diminish bothersome hot flashes in breast cancer patients.

METHODS

Breast cancer patients with at least 14 hot flashes a week received magnesium oxide 400 mg for 4 weeks, escalating to 800 mg if needed. Hot flash score (frequency × severity) at baseline was compared to the end of treatment.

RESULTS

Of 29 who enrolled, 25 women completed treatment. The average age was 53.5 years; six African American, the rest Caucasian; eight were on tamoxifen, nine were on aromatase inhibitors, and 14 were on anti-depressants. Seventeen patients escalated the magnesium dose. Hot flash frequency/week was reduced from 52.2 (standard error (SE), 13.7) to 27.7 (SE, 5.7), a 41.4% reduction, p = 0.02, two-sided paired t test. Hot flash score was reduced from 109.8 (SE, 40.9) to 47.8 (SE, 13.8), a 50.4% reduction, p = 0.04. Of 25 patients, 14 (56%) had a >50% reduction in hot flash score, and 19 (76%) had a >25% reduction. Fatigue, sweating, and distress were all significantly reduced. Side effects were minor: two women stopped the drug including one each with headache and nausea, and two women had grade 1 diarrhea. Compliance was excellent, and many patients continued treatment after the trial.

CONCLUSIONS

Oral magnesium appears to have helped more than half of the patients and was well tolerated. Side effects and cost ($0.02/tablet) were minimal. A randomized placebo-controlled trial is planned.

Factors associated with the prescription of antidepressive medication to breast cancer patients

We evaluated factors associated with use of antidepressant medication subsequent to a diagnosis of breast cancer. We also evaluated the effect of participation in a cancer rehabilitation program on use of antidepressants.

MATERIAL AND METHODS

We conducted a register-based cohort study of 1 247 women with breast cancer diagnosed between 1998 and 2006 who attended a week-long rehabilitation program and a comparison group of 2 903 women who did not attend the program matched through the registers of the Danish Breast Cancer Cooperative Group. The associations between breast cancer-related, treatment-related, and sociodemographic factors and use of antidepressants were evaluated in multivariate Cox proportional hazard models separated on use of antidepressants before diagnosis of breast cancer.

RESULTS

The mean follow-up for the 4 150 women in the study was 3.3 years (5-95% range, 0.3-7.0 years) and 1 020 (25%) were users of antidepressants after diagnosis of breast cancer. Among women who had not used antidepressants before their breast cancer, the diagnosis of a new primary cancer increased the adjusted hazard ratio (HR) to 3.34 (95% CI, 1.50-7.76), and recurrence of breast cancer increased the HR for first use of antidepressants to 2.56 (95% CI, 1.86-3.52). Unemployment was associated significantly with use of antidepressants, whereas having no children living at home, lower income, and the number of tumor-positive axillary lymph nodes were of borderline significance. No effect of the rehabilitation program was observed on first use of antidepressants after breast cancer.

DISCUSSION

Diagnosis of a new cancer or recurrence of breast cancer considerably increased the rate of use of antidepressants. Sociodemographic rather than disease- or treatment-related characteristics at the time of diagnosis were associated with first use of antidepressants after a breast cancer diagnosis.

A changing perspective: improving access to fertility preservation

Approximately 120,000 young women are diagnosed with cancer every year in the USA. Many will have treatment that can reduce their fertility, although few will learn this fact before their treatment commences. This presents a tremendous quality of life issue post-treatment, as evidenced in this Perspectives by a personal account from a 23-year-old woman diagnosed with breast cancer. Clinicians must increase awareness about patients' desires for motherhood and awareness about their individual reproductive potential. We demonstrate novel evidence about the wide variability in ovarian reserve in women of similar age, using assessment by antral follicle count. We show how a unified approach between oncology and fertility teams can help patients better understand their risk of treatment-related infertility, as well as how to take effective measures to mitigate it. Finally, we present options for fertility preservation, based on the time point at which consultation occurs.

Non-hormonal interventions for hot flushes in women with a history of breast cancer

BACKGROUND

Hot flushes are common in women with a history of breast cancer. Hormonal therapies are known to reduce these symptoms but are not recommended in women with a history of breast cancer due to their potential adverse effects. The efficacy of non-hormonal therapies is still uncertain.

OBJECTIVES

To assess the efficacy of non-hormonal therapies in reducing hot flushes in women with a history of breast cancer.

SEARCH STRATEGY

We searched the Cochrane Breast Cancer Group Specialised Register, CENTRAL (The Cochrane Library), MEDLINE, EMBASE, LILACS, CINAHL, PsycINFO (August 2008) and WHO ICTRP Search Portal. We handsearched reference lists of reviews and included articles, reviewed conference proceedings and contacted experts.

SELECTION CRITERIA

Randomized controlled trials (RCTs) comparing non-hormonal therapies with placebo or no therapy for reducing hot flushes in women with a history of breast cancer.

DATA COLLECTION AND ANALYSIS

Two authors independently selected potentially relevant studies, decided upon their inclusion and extracted data on participant characteristics, interventions, outcomes and the risk of bias of included studies.

MAIN RESULTS

Sixteen RCTs met our inclusion criteria. We included six studies on selective serotonin (SSRI) and serotonin-norepinephrine (SNRI) reuptake inhibitors, two on clonidine, one on gabapentin, two each on relaxation therapy and homeopathy, and one each on vitamin E, magnetic devices and acupuncture. The risk of bias of most studies was rated as low or moderate. Data on continuous outcomes were presented inconsistently among studies, which precluded the possibility of pooling the results. Three pharmacological treatments (SSRIs and SNRIs, clonidine and gabapentin) reduced the number and severity of hot flushes. One study assessing vitamin E did not show any beneficial effect. One of two studies on relaxation therapy showed a significant benefit. None of the other non-pharmacological therapies had a significant benefit. Side-effects were inconsistently reported.

AUTHORS' CONCLUSIONS

Clonidine, SSRIs and SNRIs, gabapentin and relaxation therapy showed a mild to moderate effect on reducing hot flushes in women with a history of breast cancer.

Factors associated with cancer-related fatigue in breast cancer patients undergoing endocrine therapy in an urban setting: a cross-sectional study

BACKGROUND

Fatigue is prevalent in breast cancer survivors and has profound effects on daily life. The interference of fatigue with endocrine therapy may be difficult to separate. This study investigates the prevalence and severity of fatigue and identifies the demographic, clinical, and lifestyle factors associated with cancer-related fatigue (CRF) in breast cancer patients undergoing endocrine therapy in an urban area.

METHODS

Women with stage I-IIIA breast cancer were recruited and asked to participate (n = 371) in the study. The 315 women who responded to the questionnaire (84.9%), 54 (17.1%) had completed endocrine therapy and 261 (82.9%) were still undergoing endocrine therapy. The patients had been diagnosed at an average of 31 months prior to recruitment (range, 7 to 60 months); the average age was 48 (range, 33 to 72) years. The 11-point scale and Visual Analog Scale (VAS) were employed to quantify the level of fatigue experienced by the patients. Logistic regression analyses and a trend test method were performed to evaluate factors associated with CRF.

RESULTS

Among the 315 patients, 189 (60%) had experienced or were experiencing CRF during endocrine therapy. Logistic regression analysis was performed to identify factors associated with CRF, including BMI (body mass index), clinical stage, menopausal status, duration of endocrine therapy, physical activity, and diet. Factors unrelated to CRF were age, marital status, treatment, endocrine therapy drugs, alcohol intake, and smoking. The trend test method revealed an association between physical activity and dietary level and the intensity of CRF.

CONCLUSIONS

The present findings suggest that fatigue is an important problem in the majority of breast cancer patients during endocrine therapy. We found that BMI, clinical stage, menopausal status, duration of endocrine therapy, physical activity, and diet are associated with fatigue. Future research should focus on the impact factors of CRF and lifestyle in the management of breast cancer patients.

Low-dose vaginal estrogens or vaginal moisturizer in breast cancer survivors with urogenital atrophy: a preliminary study

The study aim is to evaluate the efficacy and safety of two low-dose vaginal estrogen treatments (ETs) and of a non-hormonal vaginal moisturizer in postmenopausal breast cancer survivors with urogenital atrophy. Eighteen patients receiving estriol cream 0.25 mg (n = 10) or estradiol tablets 12.5 microg (n = 8) twice/week for 12 weeks were evaluated and compared with eight patients treated with polycarbophil-based moisturizer 2.5 g twice/week. Severity of vaginal atrophy was assessed using subjective [Vaginal Symptoms Score (VSS), Profile of Female Sexual Function (PFSF)] and objective [Vaginal Health Index (VHI), Karyopycnotic Index (KI)] evaluations, while safety by measuring endometrial thickness and serum sex hormones levels. After 4 weeks, VSS and VHI were significantly improved by both vaginal ETs, with further improvement after 12 weeks. PFSF improved significantly only in estriol group (p = 0.02). Safety measurements did not significantly change. Vaginal moisturizer improved VSS at week 4 (p = 0.01), but score returned to pre-treatment values at week 12; no significant modification of VHI, KI, PFSF was recorded. Both low-dose vaginal ET are effective for relieving urogenital atrophy, while non-hormonal moisturizer only provides transient benefit. The increase of serum estrogens levels during treatment with vaginal estrogen at these dosages is minimal.

Change in lifestyle behaviors and medication use after a diagnosis of ductal carcinoma in situ

Women with ductal carcinoma in situ (DCIS) of the breast represent a growing cancer survivor population with a diagnosis of uncertain malignant potential. These survivors face an absence of scientific guidelines regarding lifestyle changes that can help to prevent a breast cancer recurrence. In this first report from the Wisconsin In Situ Cohort (WISC) study, we examine how women are currently changing their lifestyle behaviors and medication use following a diagnosis of DCIS. At study entry (1997-2006), 1,959 subjects (78% of eligible) with DCIS were identified from the Wisconsin cancer registry and administered an interview assessing behaviors prior to diagnosis. Follow-up interviews were completed every 2 years after the initial interview, beginning in 2003 and continuing through 2006. After adjusting for age and calendar year, women were 2.2 kg (95% CI 1.4, 3.0) heavier, 35% (95% CI 20, 47) less likely to be a smoker, 19% (95% CI -1, 43) more likely to use non-steroidal anti-inflammatory drugs, and 57% (95% CI 26, 95) more likely to use antidepressants after a DCIS diagnosis compared to 1 year prior to diagnosis. Use of postmenopausal hormones decreased sharply (OR = 0.06; 95% CI 0.04, 0.09) following a DCIS diagnosis. These findings indicate that women make substantial changes in their behaviors after a DCIS diagnosis. This cohort will be further monitored to evaluate the association between these behaviors and health outcomes following DCIS.