Mastectomy versus breast conservation surgery: Mental health effects at long-term follow-up

Newly Diagnosed Mental Health Disorders in Patients With Breast Cancer Receiving Radiation Therapy

PURPOSE

Patients with a mental health disorder (MHD) have higher age-adjusted mortality compared with the general population. Few reports investigate factors contributing to MHD among patients with breast cancer receiving radiation therapy. We report the incidence of acquired MHD after the diagnosis of breast cancer and treatment with radiation therapy.

METHODS AND MATERIALS

Using a single institution, prospectively maintained database, we analyzed patients with breast cancer treated with radiation therapy between 2012 and 2017. We cross-referenced these patients with newly acquired International Classification of Diseases, Tenth Revision (ICD-10) MHD codes (F01-F99) within 3 years postbreast cancer diagnosis. The study included baseline National Comprehensive Cancer Network® (NCCN) distress tool scores and area deprivation index (ADI). Univariate and multivariable (MVA) Cox regression analyses were conducted to evaluate factors affecting new MHD onset.

RESULTS

Of the 967 included patients, 318 (33%) developed an MHD after their breast cancer diagnosis, which was predominately anxiety (45.1%) and depression (20.1%) related, with a median (IQR) time to diagnosis of 30 (24-33) months. Univariate analysis showed lymph node-positive disease, receipt of chemotherapy, receipt of a mastectomy, high comorbidity index, divorced status, retired status, and fourth-quartile ADI as significant predictors. On MVA, only receipt of chemotherapy (hazard ratio [HR], 1.70; P = .014) and divorced status (HR, 2.04; P = .009) remained significant. Fourth-quartile ADI, retired status, and high comorbidity index showed trends toward significance (HR, 1.78, P = .065; HR, 1.46, P = .094; HR, 1.41, P = .059, respectively). On MVA examining the effects of the radiation therapy type on MHD, whole breast with regional nodal irradiation (HR, 2.31, P = .015) and postmastectomy radiation therapy (HR, 1.88, P = .024) were both strong predictors of MHD development. Additionally, an NCCN distress tool score of >3 was also predictive of MHD onset.

CONCLUSIONS

In this cohort, 1 in 3 patients with localized breast cancer developed a new MHD, predominantly related to anxiety and depression. MHD risk was higher among divorced patients, those receiving chemotherapy, and patients receiving postmastectomy radiation therapy or whole breast with regional nodal irradiation. These findings highlight the importance of future studies and targeted interventions to support this vulnerable population.

Social support and psychosocial functioning in women after mastectomy

OBJECTIVE

Social support has been reported as beneficial for the psychological functioning of people coping with a disease. The objective of this study was to verify whether levels of perceived social support are associated with psychosocial functioning in women who have had a mastectomy and whether specific types of social support are linked to specific indices of functioning.

METHOD

Seventy women with a history of mastectomy completed questionnaires measuring their psychosocial functioning as related to their health status: Disease-Related Appraisal Scale, Acceptance of Life with the Disease Scale and Beck Depression Inventory. All participants also completed a measure of perceived social support (Disease-Related Social Support Scale).

RESULTS

Women who reported higher levels of perceived social support revealed statistically significantly lower levels of depressive symptoms, higher appraisals of their disease in terms of challenge and value, and lower appraisals of their disease in terms of obstacle/loss. Women with greater social support also revealed higher levels of acceptance of life with the disease compared to those with less social support. Regression analyses showed that spiritual support was the type of support that significantly accounted for the variance in the majority of functioning indices. Some indices of functioning were also significantly accounted for by emotional and instrumental support.

SIGNIFICANCE OF THE RESULTS

The process of psychological adjustment to a life-threatening disease such as breast cancer depends on multiple variables; however, social support, including spiritual support, seems to be one significant contributor to this process.

Assessment of the quality of life in breast cancer depending on the surgical treatment

PURPOSE

The objective of the study is to describe QoL in women who have undergone surgical treatment for breast cancer (BC). The focus of the description is the differences in QoL between women treated by modified radical mastectomy (MRM) and women who underwent breast-conserving surgery (BCS) at the Breast and Endocrine Surgery Department of the Clinical Center of Niš, Serbia.

METHOD

From January 1, 2014, until December 31, 2017, 300 patients were treated with BCS and 300 patients with MRM. To assess the QOL, a total of 600 BC patients completed the WHOQOL-BREF questionnaires. The results were analyzed using the t test and chi-square test. WHOQOL produces a quality of life profile. It derives four domain scores: physical health, psychological, social relationships, and environment. Social and demographic factors (age, education, marital status) were collected in both groups.

RESULT

In all four domains, patients treated with conserving surgeries scored higher than patients treated with radical mastectomy. This result was controlled for a set of demographic variables. The differences in QoL scores are present on all levels of controlling variables.

CONCLUSION

According to the results of this study, the QoL in women after an MRM is significantly lower than the QoL in women after BCS. It is especially true for the environment domain. Conserving surgery should be recommended and specific, and patient-centered interventions for increasing QoL of the patients who opted for radical mastectomy should be designed. The intervention should focus on social and environmental domains.

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

Aims

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

Methods

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

Results

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

Conclusions

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

The Absent Breast: Speaking of the Mastectomied Body

Worldwide, approximately 1 in 11 women have breast cancer at some time in their lifetime. The majority are successfully treated with surgery, then radiotherapy and/or chemo-therapy. Survival brings its own problems, however, including an underlying ontological problem: What is the part of the body left after a mastectomy? Women talking about their experiences of mastectomy are faced with complex referential tasks with regard to their bodies at different stages of the past and present, within different discourses (medical, sexual, maternal), and from different perspectives (the individual and the generic, their own perspective and that of their medical professionals). Drawing on anthropological research conducted among Australian women, we illustrate how women resolve difficulties of reference to the site of the mastectomy, and examine the shifts in perspective that are marked by different lexical choices.

Predictors of Social Support and Psychological Distress in Women with Breast Cancer

This investigation sought to understand previous well-cited and worrisome findings that women treated for breast cancer with breast-conserving surgery compared to mastectomy experience less social support and more mood disturbance, and that social support from significant others erodes over time. Ninety-three women with breast cancer and a subset of their partners completed assessments at the time of surgical treatment and at 3 and 13 months post-treatment. Contrary to the previous findings, type of surgical treatment was not related to perceptions of social support or psychological functioning. Perceptions of social support and psychological distress decreased over time, and the discrepancy between recipients’ and providers’ judgments of available support increased over time. Low levels of physical functioning led to relative increases in social support, whereas high levels of psychological distress led to relative decreases in social support. Social support as rated by patients (but not their partners) was a significant predictor of changes in psychological distress.

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

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

Quality of life among women recently diagnosed with invasive breast cancer: the Pathways Study

Few studies have assessed quality of life (QOL) of women diagnosed with breast cancer within the first few weeks of their initial diagnosis. We describe QOL among 950 women recently diagnosed with invasive breast cancer. Starting in January 2006, we invited women aged > or =21 years who were diagnosed with first primary invasive breast cancer within Kaiser Permanente Northern California (KPNC) to enroll in the Pathways Study, a prospective study of breast cancer survivorship. QOL was measured using the Functional Assessment of Cancer Therapy-Breast Cancer (FACT-B), along with sociodemographic and social support information. Clinical characteristics were obtained from the KPNC cancer registry and electronic medical record. We used multivariable linear regression models to identify factors associated with QOL scores calculated from the FACT-B. The mean age +/- SD of the sample was 59.6 years (+/-11.9 years), and the mean time +/-SD from diagnosis until interview was 8.0 weeks (+/-3.2 weeks). Younger age at diagnosis was associated with lower scores in all QOL domains (P < 0.01), and later stage at diagnosis was associated with lower scores in all domains (P < 0.05) except for social well-being. Higher levels of social support were associated with higher QOL except for physical well-being (P < 0.05). These associations were stronger within 2 months of breast cancer diagnosis. Quality of life as influenced by a diagnosis of breast cancer is an important factor in cancer survivorship. Age, stage at diagnosis, and social support are key factors in this important variable.

The Portuguese version of the body image scale (BIS) - psychometric properties in a sample of breast cancer patients

PURPOSE

The aim of this study was to analyse the psychometric properties of the Portuguese version of the body image scale (BIS; Hopwood, P., Fletcher, I., Lee, A., Al Ghazal, S., 2001. A body image scale for use with cancer patients. European Journal of Cancer, 37, 189-197). This is a brief and psychometric robust measure of body image for use with cancer patients, independently of age, cancer type, treatment or stage of the disease and it was developed in collaboration with the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Study Group.

METHOD

The sample is comprised of 173 Portuguese postoperative breast cancer patients that completed a battery of measures that included the BIS and other scales of body image and quality of life, in order to explore its construct validity.

RESULTS

The Portuguese version of BIS confirmed the original unidimensional structure and demonstrated adequate internal consistency, both in the global sample (alpha=.93) as in surgical subgroups (mastectomy=.92 and breast-conserving surgery=.93). Evidence for the construct validity was provided through moderate to largely sized correlations between the BIS and other related measures. In further support of its discriminant validity, significant differences in BIS scores were found between women who underwent mastectomy and those who underwent breast-conserving surgery, with the former presenting higher scores. Age and time since diagnosis were not associated with BIS scores.

CONCLUSIONS

The Portuguese BIS proved to be a reliable and valid measure of body image concerns in a sample of breast cancer patients, allowing a brief and comprehensive assessment, both on clinical and research settings.

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

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

Change in Need for Psychosocial Support for Women with Early Stage Breast Cancer

To simulate the longitudinal needs of patients treated for breast cancer, 2 groups of women were recruited. Patients within 6 months of diagnosis were considered in the early group and those 6-12 months after diagnosis were categorized as the late group. Participants were asked to identify effective and ineffective methods of psychosocial support and how those needs changed. Thirty-one women participated in the focus groups. Women in the early group identified problems related to their surgery and chemotherapy; those in the late group focused on symptoms associated with menopause. An exaggerated fear of disease recurrence and death were common to both groups. Most women found it difficult to strike a balance between wanting emotional support and wanting to be treated as normal. The provision of concrete medical information in the form of pathology and laboratory reports and information from health care professionals provided comfort and control. Spouses and partners were helpful in providing tangible assistance with transportation and childcare while female friends were more likely to share emotions. Organized support groups were helpful to only 13%. Participants acknowledged a need to learn how to identify their psychosocial needs and to ask for support from friends and family. Medical information provided patients with a sense of control and comfort. Women with breast cancer need to identify effective sources of emotional support and should be taught how to communicate those needs to their families and friends.

A Review of Age Differences in Psychological Adjustment to Breast Cancer

This article reviews recent literature on age differences in psychological adjustment to breast cancer. Overall, studies have shown that older women experience less psychological distress in terms of anxiety, depression, and posttraumatic stress symptoms. Age differences in health status, treatment provision, social support, and other life circumstances may contribute to differential patient adjustment. Coping also may mediate the relationship between age and affective responses, but the confounding of coping and distress in widely used inventories precludes definitive conclusions. Future research should explore the contextual mechanisms underlying age differences in adjustment.

Partial breast irradiation as sole therapy for low risk breast carcinoma: early toxicity, cosmesis and quality of life results of a MammoSite brachytherapy phase II study

PURPOSE

The MammoSite is a device that was developed with the goal of making breast-conserving surgery (BCT) more widely available. Our objective was to evaluate the MammoSite device performances after an open cavity placement procedure and quality of life in highly selected patients with early-stage breast cancer.

METHODS AND MATERIALS

From March 2003 to March 2005, 43 patients with T1 breast cancer were enrolled in a phase II study. The median age was 72 years. Twenty-five (58%) patients were treated with high-dose rate brachytherapy using the MammoSite applicator to deliver 34Gy in 10 fractions. The main disqualifying factor was pathologic sentinel node involvement (10/43; 23%). There were no device malfunctions, migration or rupture of the balloon.

RESULTS

After a median follow-up of 13 months, there were no local recurrences and one contralateral lobular carcinoma. Seventeen (68%), 13 (52%), 8 (32%), 5 (20%) and 2 (8%) patients had erythema, seroma, inflammation, hematoma and sever infection, respectively. Only 2 patients developed telangiectasia. At 1 year the rate of "good to excellent" cosmetic results was 84%. Significant changes in QoL were observed for emotional and social well-being between 3 and 12 months. At 24 months, only emotional well-being subscore changes were statistically significant (p=0.015).

CONCLUSIONS

Our data in patients older than 60 years support the previously published data. Histologic features were the main disqualifying criteria. With higher skin spacing levels we observed very low incidence of telangiectasia. QoL evaluation indicates that baseline scores were satisfactory. Changes concerned emotional and social well-being.

Effect of Esthetic Outcome After Breast-Conserving Surgery on Psychosocial Functioning and Quality of Life

Purpose

Although breast-conserving surgery (BCS) is often assumed to result in minimal deformity, many patients report postoperative breast asymmetry. Understanding the effect of asymmetry on psychosocial functioning is essential for patients to make an informed choice for surgery.

Patients and Methods

All women who underwent BCS at the University of Michigan Medical Center (Ann Arbor, MI) during a 4-year period were surveyed using a mailed questionnaire (N = 714; response rate = 79.5%). Women were queried regarding five aspects of psychosocial functioning: quality of life (QOL), depression, fear of recurrence, stigmatization, and perceived change in health status. Postoperative breast asymmetry was assessed using items from the Breast Cancer Treatment and Outcomes Survey. Multiple regression was used to examine the relationship between breast asymmetry and each outcome, controlling for age, time from surgery in years, race, education level, disease stage, surgical treatment, and the occurrence of postoperative complications.

Results

Women with pronounced breast asymmetry were significantly more likely to feel stigmatized as a result of their breast cancer treatment (odds ratio [OR] = 4.58; 95% CI, 2.77 to 7.55) and less likely to report unchanged or improved health after treatment (OR = 0.43; 95% CI, 0.27 to 0.66). Minimal breast asymmetry was associated with higher QOL scores (86.3 v 82.4, P < .001). Finally, women with pronounced breast asymmetry were more likely to exhibit depressive symptoms (minimal asymmetry, 16.2%; moderate asymmetry, 18.0%; pronounced asymmetry, 33.7%, Wald test = 16.6; P = .002).

Conclusion

Pronounced breast asymmetry after BCS is significantly correlated with poor psychosocial functioning. Identifying patients at risk for postoperative asymmetry at the time of consultation may allow for improved referral for supportive counseling, prosthetics, and reconstruction.

Age Differences in Treatment Decision Making for Breast Cancer in a Sample of Healthy Women: The Effects of Body Image and Risk Framing

PURPOSE/OBJECTIVES

To examine the effects of age, body image, and risk framing on treatment decision making for breast cancer using a healthy population.

DESIGN

An experimental 2 (younger women, older women) X 2 (survival, mortality frame) between-groups design.

SETTING

Midwestern university.

SAMPLE

Two groups of healthy women: 56 women ages 18-24 from undergraduate psychology courses and 60 women ages 35-60 from the university community.

METHODS

Healthy women imagined that they had been diagnosed with breast cancer and received information regarding lumpectomy versus mastectomy and recurrence rates. Participants indicated whether they would choose lumpectomy or mastectomy and why.

MAIN RESEARCH VARIABLES

Age, framing condition, treatment choice, body image, and reasons for treatment decision.

FINDINGS

The difference in treatment selection between younger and older women was mediated by concern for appearance. No main effect for risk framing was found; however, older women were somewhat less likely to select lumpectomy when given a mortality frame.

CONCLUSIONS

Age, mediated by body image, influences treatment selection of lumpectomy versus mastectomy. Framing has no direct effect on treatment decisions, but younger and older women may be affected by risk information differently.

IMPLICATIONS FOR NURSING

Nurses should provide women who recently have been diagnosed with breast cancer with age-appropriate information regarding treatment alternatives to ensure women's active participation in the decision-making process. Women who have different levels of investment in body image also may have different concerns about treatment, and healthcare professionals should be alert to and empathetic of such concerns.

Early effect of surgery on quality of life in women with operable breast cancer

BACKGROUND

Quality of life (QOL) after a diagnosis of breast cancer varies considerably across individuals. The treatment modality of the patients significantly contributes to their QOL. The present study reports the initial findings on the early effects of surgery in patients with breast cancer.

METHODS

Two hundred and fifty-one women with breast cancer undergoing surgery were interviewed prior to and after the surgery using the Functional Assessment of Cancer Therapy for Breast (FACT-B). Trial Outcome Index (TOI) was calculated besides total and subscale scores. The results were analyzed using paired t-test and two-sample paired Wilcoxon signed rank test. Multivariate analysis was carried out using repeated measures general liner model with 2-way interactions.

RESULTS

Significant reduction in physical well-being (P = 0.001), functional well-being (P = 0.00) and the breast-specific subscale (P = 0.000) was observed after surgery. No significant change was observed in social or emotional well-being. Total FACT scores and TOI too showed significant declines (P = 0.000; and P = 0.000 respectively) on univariate analysis. Multivariate analysis, however, showed no difference in QOL after surgery, but QOL was significantly poor among women undergoing mastectomy.

CONCLUSIONS

Results of the present study indicate no significant change in overall QOL immediately after the surgery, probably reflecting strong family and social support for these women. QOL was significantly better among women undergoing breast conservation compared with mastectomy.

Quality of life determinants in women with breast cancer undergoing treatment with curative intent

BACKGROUND

The diagnosis of breast cancer and its subsequent treatment has significant impact on the woman's physical functioning, mental health and her well-being, and thereby causes substantial disruption to quality of life (QOL). Factors like patient education, spousal support and employment status, financial stability etc., have been found to influence QOL in the breast cancer patient. The present study attempts to identify the determinants of QOL in a cohort of Indian breast cancer patients.

PATIENTS AND METHODS

Functional Assessment of Cancer Therapy-Breast (FACT-B) Version 4 Malayalam was used to assess quality of life in 502 breast cancer patients undergoing treatment with curative intent. The data on social, demographic, disease, treatment, and follow-up were collected from case records. Data was analysed using Analysis of Variance (ANOVA) and multinomial logistic regression.

RESULTS

The mean age of the patients was 47.7 years with 44.6% of the women being pre-menopausal. The FACT-B mean score was 90.6 (Standard Deviation [SD] = 18.4). The mean scores of the subscales were - Physical well-being 19.6 (SD = 4.7), Social well-being 19.9 (SD = 5.3), Emotional well-being 14 (SD = 4.9), Functional well-being 13.0 (SD = 5.7), and the Breast subscale 23.8 (SD = 4.4). Younger women (< 45 years), women having unmarried children, nodal and/or metastatic disease, and those currently undergoing active treatment showed significantly poorer QOL scores in the univariate analysis. However multivariate analysis indicated that the religion, stage, pain, spouse education, nodal status, and distance travelled to reach the treatment centre as indicative of patient QOL.

CONCLUSION

QOL derangements are common in breast cancer patients necessitating the provisions for patient access to psychosocial services. However, because of the huge patient load, a screening process to identify those meriting intervention over the general population would be a viable solution.

Development and validation of the Communication and Attitudinal Self-Efficacy scale for cancer (CASE-cancer)

We sought to develop a reliable and valid measure of patient self-efficacy within the context of productive communication and positive attitude for cancer patients. A set of 19 potential items for the Communication and Attitudinal Self-Efficacy scale for cancer (CASE-cancer) was pilot tested with 50 cancer patients. Based on the pilot test, item valence was made consistent (i.e., all items worded positively) and the response scale was simplified. The CASE-cancer was then administered to 127 persons receiving cancer treatment at general oncology clinics in Shreveport, Louisiana and Chicago, Illinois. Psychometric analyses revealed three 4-item factors: understanding and participating in care, maintaining a positive attitude, and seeking and obtaining information. The CASE-cancer proved to have high internal consistency and construct validity. Moreover, scale items performed similarly across literacy levels. The CASE-cancer is a psychometrically-sound tool that may provide new information on important mediating factors of cancer care. Our two-step approach to presenting response options may also provide a model for helping lower literate patients more accurately respond to survey items.

Quality of life and health status in breast carcinoma

Quality of life is of increasing importance in clinical oncology studies. When analysing publications concerning quality of life in breast cancer, however, the majority of the articles appear to study health status and not quality of life. Therefore five recommendations were formulated to apply reading a 'quality of life' article. With the use of these recommendations an article can be evaluated and the clinical significance can be assessed.

Psychosocial and sexual functioning of survivors of breast cancer

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

Psychiatric aspects of women with breast cancer

Women with breast cancer face not only cancer-related taboos but also issues related to changes in sexuality, femininity, and fertility. Although increased emphasis on the woman's participation in the medical decision-making process has afforded her more treatment options, it also gives her more responsibility in determining her course of treatment through the continuum of cancer care. Patients must deal with a variety of issues related to social reintegration, long-term effects of cancer treatment, employment, disability, sexuality, family, and social networks. Screening for distress related to psychological, spiritual/religious, or social concerns can provide guidance for service delivery to those in need.

Depression and cancer: mechanisms and disease progression

Depression and cancer commonly co-occur. The prevalence of depression among cancer patients increases with disease severity and symptoms such as pain and fatigue. The literature on depression as a predictor of cancer incidence is mixed, although chronic and severe depression may be associated with elevated cancer risk. There is divided but stronger evidence that depression predicts cancer progression and mortality, although disentangling the deleterious effects of disease progression on mood complicates this research, as does the fact that some symptoms of cancer and its treatment mimic depression. There is evidence that providing psychosocial support reduces depression, anxiety, and pain, and may increase survival time with cancer, although studies in this latter area are also divided. Psychophysiological mechanisms linking depression and cancer progression include dysregulation of the hypothalamic-pituitary-adrenal axis, especially diurnal variation in cortisol and melatonin. Depression also affects components of immune function that may affect cancer surveillance. Thus, there is evidence of a bidirectional relationship between cancer and depression, offering new opportunities for therapeutic intervention.

Depression in cancer: new developments regarding diagnosis and treatment

Considerable data demonstrate the high prevalence of symptoms of depression in patients with a wide variety of neoplastic disorders. Moreover, the dire consequences of these depressive symptoms in cancer patients have been well documented. Recent conceptual developments in the potential contributing mechanisms include increasing appreciation of the possibility that behavioral alterations in cancer patients may represent a "sickness syndrome" that results from activation of the inflammatory cytokine network. This sickness syndrome, which has been well documented in patients and laboratory animals exposed to inflammatory cytokines, includes symptoms that overlap with those seen in major depression. Conceptualizing these symptoms as components of cytokine-mediated sickness behavior has several important, and potentially novel, implications, including 1) an expansion of the neurobehavioral symptoms that are relevant to diagnosis and treatment; and 2) an increased appreciation of the potential diagnostic utility of peripheral markers of inflammation, as well as cytokine-related neurocircuitry alterations as defined by brain imaging. Treatment implications focus on the pathways by which inflammatory cytokines influence behavior, including therapeutic targets such as the inflammatory cytokines themselves, corticotropin-releasing hormone, and monoaminergic neurotransmitters and their precursors. Finally, recent data suggest that aggressive treatment strategies initiated before inflammation-inducing cancer treatments might prevent behavioral alterations, including depression, before they occur.

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

BACKGROUND

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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

Traumatic stress symptoms among women with recently diagnosed primary breast cancer

This study examined the concurrent and longitudinal relationships between traumatic stress symptoms and demographic, medical, and psychosocial variables among women recently diagnosed with primary breast cancer. Participants were 117 women drawn from a parent study for women recently diagnosed with primary breast cancer. At baseline, the Impact of Event Scale (IES) total score was related to intensity of postsurgical treatment and lower emotional self-efficacy. At the 6-month follow-up, the IES total score was significantly related to younger age, to the increased impact of the illness on life, and to the baseline IES total score assessment. These results suggest that it is important to intervene for traumatic stress symptoms soon after the diagnosis of breast cancer. Furthermore, these results suggest women at greatest risk are those who are younger, who receive postsurgical cancer treatment, who are low in emotional self-efficacy and whose lives are most affected by having cancer.

Life after breast cancer: Australian women's stories of support

Quality support is crucial to the care of women diagnosed with breast cancer. Little qualitative research has been conducted in this area. Semi-structured interviews were conducted with six women in New South Wales, Australia, to explore their experiences of breast cancer. Specifically the study focused on the support the women felt they needed at different times during their illness experience, how this was given and by whom. The qualitative data from the interviews supported previous research in that the diagnosis of breast cancer was devastating. Their primary source of support was family and friends with their surgeon and general practitioner providing some support. Overall the women felt they received physical support. However, emotional support was lacking, especially from nurses.

The impact on sexual functioning of chemotherapy-induced menopause in women with breast cancer

This article presents a comprehensive review and synthesis of empirical and conceptually based literature documenting the impact of chemotherapy-induced menopause on the sexual functioning of women with breast cancer. A literature search of the CINAHL, MEDLINE, and Psych Lit from 1980 to 1999 databases was undertaken. This literature was systematically assessed to determine key findings and conclusions. Two major themes were identified and are reported here: physical and psychological sequelae associated with altered sexual functioning. Recommendations and suggestions for further directions in research are identified.

Impact of surgery and chemotherapy on the quality of life of younger women with breast carcinoma: a prospective study

BACKGROUND

Studies that prospectively and simultaneously evaluate, within the first year of diagnosis, the impact of surgery and chemotherapy on quality of life (QOL) of younger women (60 years or younger) with early stage breast carcinoma are limited.

METHODS

Quality of life of 103 women who had surgery (lumpectomy, 49; mastectomy, 54) approximately 1 month before the start of the study was evaluated at baseline and again after 5 months. Thirty-two women received chemotherapy during the study.

RESULTS

Over time, subjects reported improvement in body image and physical, emotional, and functional well-being (P < 0.001). They were less bothered by swollen/tender arms and worried less about risk of cancer to family members (P < 0.001). However, satisfaction with sex life, social support, and social/family well-being declined (P < 0.001). In the period closer to surgery, women with mastectomy reported poorer body image (P = 0.001) and worse functional (P = 0.08) and physical well-being (P = 0.10). Women with lumpectomy worried more about the effects of stress on their illness (P < 0.01) and had lower emotional well-being (P = 0.06). By 6 months after surgery, the two groups reported similar QOL scores. Chemotherapy had a negative impact on women's sexual functioning (P = 0.01) and their physical well-being (P = 0.09). Women who received chemotherapy also reported more shortness of breath (P = 0.07). Post hoc analysis showed that women with breast reconstruction had higher emotional well-being at baseline than those with lumpectomy (P = 0.001) and mastectomy alone (P < 0.01).

CONCLUSIONS

Younger women with breast carcinoma could experience a range of adjustment problems at various points in the treatment cycle. Interventions that would help reduce the negative impact of treatment on QOL need to be designed and integrated into routine clinical practice.

Psychosocial stages and quality of life of women with breast cancer

Certain issues are universal for all women with breast cancer, irrespective of age, ethnic group, or stage of disease. Yet, along with common concerns, experiences, and anxieties, each woman may encounter a unique set of problems. Ultimately, each woman's adaptation and choices will be strongly influenced by her personal history, her psychosocial stage, and her life-cycle concerns. Changes in the criteria norms for the psychosocial stages of women's lives and their subsequent influence on quality of life are issues that have substantial implications for nursing and other healthcare professions. Younger and older women have different needs, concerns, and quality of life issues in a context of psychosocial life stages that have changed significantly across the post-World War II generations. The experience of breast cancer is perceived differently by women of distinct psychosocial life stages. At each critical life stage, the unique emerging problems require specific psychosocial supports that can reduce or avert the ensuing emotional distress. The planning and implementation of care must be tailored to address the differences demonstrated by age and psychosocial life stage, and to enhance quality of life outcomes for survivors of breast cancer, both young and old.

Should patients have control over their own health care?: empirical evidence and research issues

Available research indicates that purported patient insufficiencies in ability to process information and make rational and reliable decisions have likely been overestimated. Furthermore, data indicate that nonscientific factors often play a role in physician decision-making and that physicians may not value different health outcomes in the same way as patients. Though the data on patient cognitive functioning are limited because of heavy reliance on patient responses in hypothetical versus actual decision-making situations, these findings lend credence to arguments that patients should have increased control over their own health care. Research on the effects of interventions designed to enhance patient control indicates that: (a) patients generally respond positively to increased information, but few studies have evaluated the effects of information as a precursor to decision-making; (b) the few studies using simple behavioral control interventions have shown generally positive effects on a range of patient outcomes; and (c) studies of decisional control (with breast cancer patients) have had experimental confounds which prohibit conclusions regarding effectiveness. Areas in greatest need of research include: (a) further exploration of the utility of noninvasive behavioral control interventions in different settings; (b) measuring the impact of control manipulations on patient perception of control as well as patient control-related behaviors; (c) matching patient differences in desire for control to experimental conditions and to physician differences in receptiveness to patient control; and (d) clinical trials in which patients facing critical decisions in trade-off situations are actually given a choice.

Women's experience of breast conserving treatment for breast cancer

The implementation of the National Breast Screening Programme in the UK, and subsequent increase in early detection of small cancers, has facilitated breast conserving treatment for more women with a breast cancer diagnosis than ever before. While a substantial body of literature has evolved regarding psychosocial morbidity and support needs of women at diagnosis and during treatment, there are specific gaps in the current knowledge base. The purpose of this study was to describe the experiences of women who had breast conserving treatment for early breast cancer, focusing on issues related to diagnosis, surgery, and radiotherapy. The study was designed within the context of clinical audit, with a view to informing service development. Seventy-six women who had undergone breast conserving surgery within the last 3-12 months, completed a self-report questionnaire. Findings indicated that although the majority of women expressed satisfaction with their treatment overall, a number of specific areas require attention from healthcare professionals. Further research is required to validate these findings and to explore: potential implications of different referral routes; information and support needs preceding definitive diagnosis; particular needs of those women with ductal carcinoma in situ (DCIS) vs. invasive disease; 'end of treatment' and ongoing information and support needs.

The effects of type of surgery and time on psychological adjustment in women after breast cancer treatment

BACKGROUND

The aim of the present study was to examine whether type of surgery, age, and time since surgery influenced psychological distress and quality of life (QOL) in women treated for breast cancer.

METHODS

We surveyed 183 women who had undergone surgery for breast cancer. Psychological distress was measured with the Mental Health Inventory and QOL was measured with the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire.

RESULTS

After controlling for stage of disease, radiation treatment, and age, there was a statistically significant interaction between type of surgery and time since surgery for the Mental Health Inventory total score, and a marginal interaction between type of surgery and time since surgery for the Global health status/QOL score. Women who had breast conservation surgery experienced significantly greater levels of psychological distress and marginally worse QOL from 40 months after surgery onward than did women who received a mastectomy.

CONCLUSIONS

The effects of different surgical treatments for breast cancer on psychological distress and QOL become apparent only after a period of several years. Women, therefore, need counseling on the potentially positive and negative psychological implications of different surgical treatments for breast cancer.

Involvement in decision-making and breast cancer survivor quality of life

Advances in treatment for breast cancer have improved women's chances of surviving this disease, while giving patients more treatment options than in the past. This study examined the influence of patient involvement in decision-making on survivor quality of life. A prevalence sample of breast cancer survivors were interviewed about their involvement in decision-making about their cancer treatment and follow-up care. A series of multivariate regression analyses were then conducted to examine how involvement in decision-making about cancer treatment and follow-up care contributed to survivor quality of life. Analyses revealed involvement in decision-making about the use of testing for recurrent disease (TFR) as part of follow-up care is associated with improved quality of life in several domains (p < 0.05). This association of improved quality of life with involvement in decision-making about follow-up TFR was independent of associations of quality of life with surgical treatment received, involvement in decision-making about surgical treatment, frequency of TFR, use of mammography, age, income, education, and years since diagnosis. This suggests that efforts to increase patient involvement in decision-making about follow-up care may improve quality of life for breast cancer survivors.

Cosmetic results in 242 patients treated by conservative surgery for breast cancer

The surgery of breast cancer has changed lately in favour of breast conserving treatment, the main purpose of which is to provide good cosmetic results together with radical resection of the tumour. In this paper we describe the cosmetic results obtained in 242 patients treated by conservative surgery (226 quadrantectomies, 93%, and 16 lumpectomies, 7%) for low risk breast cancer. Several of these resections were combined with plastic surgical techniques for residual breast reshaping. The technique chosen depended on the site of tumour, width of resection, and breast volume. The cosmetic assessment was made by the patient and the physician. Our data suggest that better cosmetic results may be obtained when plastic surgical procedures are combined with conservative surgery for breast cancer.

Anxiety and the blues after breast cancer: how common are they?

A number of myths exist concerning the psychological impact of breast cancer. Primary among these is the belief that women with breast cancer have greater emotional disability than individuals with other diseases or the population at large. While research has shown that women cope remarkably well with a diagnosis of breast cancer, an understanding of the key periods of anxiety and primary stressors is crucial to the overall psychological and medical management plan. While psychopharmacologic therapy may be indicated for women with breast cancer, it is rarely sufficient and should be combined with effective psychosocial interventions such as group therapy.

Predictors of sexual health in women after a breast cancer diagnosis

PURPOSE

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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

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

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

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

AIM OF THE STUDY

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Recruitment for complementary/alternative medicine trials: who participates after breast cancer

BACKGROUND

Despite the popularity and widespread practice of complementary/alternative medicine (CAM), researchers may face problems accruing patients to randomized clinical trials, considered the gold standard of biomedical research. Strict exclusion criteria and barriers to participation may limit accrual. Inadequate numbers of subjects decrease the ability of studies to detect an effect that exists and generalize their findings. This article describes the recruitment experience of a CAM trial, details reasons for non-participation, and contrasts participants and non-participants on demographic, clinical, and treatment-related variables.

METHODS

Women who were Houston area residents and spoke English, had primary breast cancer (excluding Stage IV), and were 1 to 30 months posttreatment with no steroids, tamoxifen, substance abuse, psychiatric or heart disease, or immune deficiency were eligible. The enrollment process involved three contacts (i.e. introductory letter and brochure, telephone calls, and reminder post cards). Potential participants were told that the study would require blood samples (30 cc) to assess immune function; psychosocial measures to assess emotional well-being, quality-of-life, social support, and coping strategies; and possible assignment to six weekly support or imagery sessions. Factors influencing recruitment and reasons for non-participation were assessed by stratified analysis and multivariate logistic regression.

RESULTS

Of 158 eligible participants, 30% (N = 47) consented to participate. Primary reasons for non-participation included work/childcare (33.3%), transportation/travel (30.6%), and lack of interest (24.3%). Participants were more likely to be 40-54 years of age versus younger or older, divorced/separated, and able to pay some/all medical expenses. Divorced or separated women appeared to be more likely to participate, regardless of financial status.

CONCLUSIONS

Researchers must assess the impact of exclusion criteria on accrual and recognize the special needs of their target population. Although age, marital status, and pay status were the strongest predictors of participation, these factors are not amenable to intervention. Based on this study, researchers might boost accrual by providing interventions available during the day and evening to accommodate working women, child care services, transportation, or reimbursement for travel costs.

A comparison of social functioning among black and white women with breast cancer

Results of a comparative study of interviews with 102 women (61 white, 41 black) who were treated for breast cancer suggest that black women have more difficulty in social functioning, especially the resumption of household activities. Implications for social work practice are discussed.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Psychological distress in HIV-1 disease in relationship to hypocholesterolemia

OBJECTIVE

Altered levels of serum cholesterol, which are prevalent in early HIV-1 infection, have been associated with disturbances in mood state and behavior. The objective of this study was to evaluate the relationship of serum cholesterol status and psychological distress in HIV-1 seropositive and seronegative men.

METHOD

The association between serum cholesterol level and psychological distress, measured with the Profile of Mood States (POMS), was examined in 169 individuals (117 HIV-1 seropositive and 52 seronegative homosexual men), controlling for negative life events, social support, coping style, and HIV-1 serostatus.

RESULTS

Individuals with hypocholesterolemia (serum cholesterol levels < 150 mg/dL), exhibited significantly higher levels of distress, relative to individuals with values of cholesterol > 150 mg/dL (p = 0.01). HIV-1 seropositive men had significantly lower cholesterol levels (p = 0.0001) and higher levels of distress than the seronegative men (p = 0.03). A significant interaction between negative life events and cholesterol status was demonstrated as well (p = 0.04).

CONCLUSIONS

Hypocholesterolemia appears to be associated with increased psychological distress. Whereas the causal direction of the cholesterol-distress association cannot be specified, our results suggest that HIV-1 infected men with low cholesterol levels may benefit from being monitored for changes in distress level, so that appropriate psychosocial intervention can be instituted, as necessary.