Difficulties in physical functioning reported by middle-aged and elderly women with breast cancer: a case-control comparison

Physical Functional Impairment in Breast Cancer Patients: A Cross-Sectional Expert Survey

INTRODUCTION AND AIM

Anti-cancer treatment imparts a variety of physical impairments that cause limitations in physical functioning among women with breast cancer. The aim of the study was to explore the opinions of healthcare professionals (HCPs) working with breast cancer patients on various aspects of physical functional impairments in breast cancer patients and survivors (BCP&S).

METHODOLOGY

The study was a cross-sectional survey. Taking into consideration the literature definition of 'physical function', its determinants, and literature published on relevant clinical factors in breast cancer, a survey questionnaire containing 29 questions was constructed. Thirty-seven HCPs, including physiotherapists, occupational therapists, and medical cancer experts, participated in the study. The participant's responses were obtained using a 5-point 'Agreement' Likert scale. Data analysis included a frequency table and the reliability test (Cronbach's alpha).

RESULTS

The reliability of the questionnaire used in the survey was found to be acceptable (Cronbach's alpha = 0.891). The majority of the participants were of the opinion that various parameters and determinants of 'physical function' get adversely affected in BCP&S, leading to limitations in the performance of activities of daily living (e.g., dressing and bathing), particularly in elderly and frail women. Participants agreed that such impairments in physical functioning affect social and role functioning and the overall quality of life (QoL) of women with breast cancer negatively.

CONCLUSION

This study found that various parameters and determinants of physical functioning are adversely affected in BCP&S, and physical functional impairments are prevalent in women with breast cancer, affecting their QoL negatively. Implications for breast cancer patients: This study points out the need for long-term surveillance of BCP&S for physical functional limitations and a proactive treatment approach to prevent such limitations.

Dual Affinity to RBCs and Target Cells (DART) Enhances Both Organ- and Cell Type-Targeting of Intravascular Nanocarriers

A long-standing goal of nanomedicine is to improve a drug's benefit by loading it into a nanocarrier that homes solely to a specific target cell and organ. Unfortunately, nanocarriers usually end up with only a small percentage of the injected dose (% ID) in the target organ, due largely to clearance by the liver and spleen. Further, cell-type-specific targeting is rarely achieved without reducing target organ accumulation. To solve these problems, we introduce DART (dual affinity to RBCs and target cells), in which nanocarriers are conjugated to two affinity ligands, one binding red blood cells and one binding a target cell (here, pulmonary endothelial cells). DART nanocarriers first bind red blood cells and then transfer to the target organ's endothelial cells as the bound red blood cells squeeze through capillaries. We show that within minutes after intravascular injection in mice nearly 70% ID of DART nanocarriers accumulate in the target organ (lungs), more than doubling the % ID ceiling achieved by a multitude of prior technologies, finally achieving a majority % ID in a target organ. Humanized DART nanocarriers in ex vivo perfused human lungs recapitulate this phenomenon. Furthermore, DART enhances the selectivity of delivery to target endothelial cells over local phagocytes within the target organ by 6-fold. DART's marked improvement in both organ- and cell-type targeting may thus be helpful in localizing drugs for a multitude of medical applications.

Perspectives on functional status in older adults with cancer: An interprofessional report from the International Society of Geriatric Oncology (SIOG) nursing and allied health interest group and young SIOG

Most adults with cancer are over 65 years of age, and this cohort is expected to grow exponentially. Older adults have an increased burden of comorbidities and risk of experiencing adverse events on anticancer treatments, including functional decline. Functional impairment is a predictor of increased risk of chemotherapy toxicity and shorter survival in this population. Healthcare professionals caring for older adults with cancer should be familiar with the concept of functional status and its implications because of the significant interplay between function, cancer, anticancer treatments, and patient-reported outcomes. In this narrative review, we provide an overview of functional status among older patients with cancer including predictors, screening, and assessment tools. We also discuss the impact of functional impairment on patient outcomes, and describe the role of individual members of an interprofessional team in addressing functional impairment in this population, including the use of a collaborative approach aiming to preserve function.

The relationship between depressive symptoms and shoulder mobility among older women: assessment at one year after breast cancer diagnosis

Objective: To examine the association between depressive symptoms and shoulder range of motion at one year after breast cancer diagnosis, controlling for patient characteristics, tumour stage and cancer therapy (surgery, axillary node dissection and radiation).

Design: Prospective trial of nurse case management involving 187 older women with complete data, age 60 years and older, newly diagnosed with breast cancer, from 1 November, 1993 to 31 October, 1996 in south-eastern Texas. Depressive symptoms, sociodemographic characteristics and breast cancer treatment were measured at two months and shoulder range of motion at 12 months. The relationship among the variables was evaluated with bivariate chi-square statistics and logistic regression analysis. All logistic models also included a variable indicating whether or not the woman received nurse case management, to control for intervention status.

Results: Increasing depressive symptoms at baseline were associated with lower arm mobility at 12 months following breast cancer diagnosis. Each unit increase in depressive symptoms at baseline was associated with an 8% decreased odds of having full range of motion of the shoulder (odds ratio (OR) 0.92, 95% confidence interval (CI) 0.87, 0.97), after controlling for relevant patient and treatment factors.

Conclusion(s): Older women with depressive symptoms have an elevated risk of not fully recovering shoulder mobility after being treated for breast cancer. Future studies are needed to assess benefits from early intervention with psychological and or physical interventions in the presence of depressive symptoms on shoulder mobility.

Smoking and mortality after breast cancer diagnosis: the health and functioning in women study

We examined the effect of smoking on long-term mortality from breast cancer and other causes among a cohort of women with breast cancer. A total of 975 women diagnosed with breast cancer and aged 40-84 years were followed for a median follow-up of 11 years in the U.S. Health and Functioning in Women (HFW) study. The impact of the individual smoking status and smoking intensity reported in the first few months following breast cancer diagnosis on the risk of mortality from breast cancer and other causes was examined using Cox proportional hazards models. In this study, former smoking was associated with increased risk of other-cause mortality (hazard ratio [HR] = 1.47, 95% confidence interval [CI]: 1.13-1.90), and the risk doubled with increased intensity (HR for <50 pack-years [py]: 1.36, 95% CI: 1.03-1.79; HR for ≥50 py: 2.45, 95% CI: 1.41-4.23). Current smoking (HR = 2.45, 95% CI: 1.81-3.32) and each additional 10 py smoked (HR = 1.16, 95% CI: 1.11-1.22) were associated with statistically significant increases in the risk of other-cause mortality. The effect of current smoking on other-cause mortality decreased with advancing stage and increasing body mass index (BMI). Breast cancer-specific mortality was associated with current smoking of ≥50 py (HR = 2.36, 95% CI: 1.26-4.44), and each additional 10 py smoked (HR = 1.07, 95% CI: 1.01-1. 14). Current smoking, but not former smoking, was associated with increased risk of breast cancer-specific mortality in women with local disease (HR = 2.32, 95% CI: 1.32-4.09), but not in those with regional and distant disease (HR = 1.10, 95% CI: 0.73-1.68). Our findings suggest that current smoking at the time of breast cancer diagnosis may be associated with increased risk of breast-cancer specific and other-cause mortality, whereas former smoking is associated with increased risk of other-cause mortality. Smoking cessation at the time of diagnosis may lead to better prognosis among women with breast cancer.

Effects of yoga on cancer-related fatigue and global side-effect burden in older cancer survivors

BACKGROUND

Sixty percent of cancer survivors are 65years of age or older. Cancer and its treatments lead to cancer-related fatigue and many other side effects, in turn, creating substantial global side-effect burden (total burden from all side effects) which, ultimately, compromises functional independence and quality of life. Various modes of exercise, such as yoga, reduce cancer-related fatigue and global side-effect burden in younger cancer survivors, but no studies have specifically examined the effects of yoga on older cancer survivors.

OBJECTIVES

The purpose of this study was to assess the effects of a 4-week yoga intervention (Yoga for Cancer Survivors: YOCAS©®) on overall cancer-related fatigue, and due to its multidimensional nature, the subdomains of cancer-related fatigue (general, physical, emotional, and mental) and global side-effect burden in older cancer survivors.

MATERIALS AND METHODS

We conducted a secondary analysis on data from a multicenter phase III randomized controlled clinical trial with 2 arms (standard care and standard care plus a 4-week YOCAS©® intervention). The sample for this secondary analysis was 97 older cancer survivors (≥60years of age), between 2months and 2years post-treatment, who participated in the original trial.

RESULTS

Participants in the YOCAS©® intervention arm reported significantly lower cancer-related fatigue, physical fatigue, mental fatigue, and global side-effect burden than participants in the standard care arm following the 4-week intervention period (p<0.05).

CONCLUSIONS

YOCAS©® is an effective standardized yoga intervention for reducing cancer-related fatigue, physical fatigue, mental fatigue, and global side-effect burden among older cancer survivors.

Quality of life and dietary changes among cancer patients: a systematic review

PURPOSE

To review the literature focusing on the effects of dietary behavioural changes on cancer patients' health-related quality of life (HRQOL).

METHODS

Relevant databases were searched for studies that report the relationship between dietary changes and HRQOL of people with cancer and synthesized and systematically reviewed the available evidence. Papers were assessed for methodological quality, and the themes identified were summarized.

RESULTS

The selected studies included only randomized control trials, which target changes in diet. Twelve studies were identified, which focus on the association between lifestyle changes that included changes in diet and HRQOL among cancer patients. Results have been mixed, and dietary changes have been shown to partly affect HRQOL, but other factors seem to be important as well in defining that relationship. Moreover, cancer groups with higher survival rates (prostate, breast, colorectal) seem to benefit more from dietary changes, while different HRQOL constructs are affected with no clear indication of directional benefits on physical or mental health.

CONCLUSIONS

Even though there are some indications of a direct relationship between dietary changes and HRQOL, further research should establish which areas of HRQOL are directly affected. Perhaps, nutritional changes in future interventions can be isolated in order to identify a potential direct relationship with HRQOL.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

OBJECTIVES

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

DESIGN

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

SETTING

Detroit, Michigan, USA.

PARTICIPANTS

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

OUTCOME MEASURES

Risk of mortality from breast cancer and other causes.

RESULTS

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

CONCLUSIONS

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

Patient perspectives on breast cancer treatment side effects and the prospective surveillance model for physical rehabilitation for women with breast cancer

Women's experience of breast cancer is complex, affecting all aspects of life during and after treatment. Patients' perspectives about common impairments and functional limitations secondary to breast cancer treatment, including upper extremity motion restriction, lymphedema, fatigue, weight gain, pain, and chemotherapy-induced peripheral neuropathy, are addressed. Women often report being uninformed regarding these side effects and surprised that they do not always disappear after treatment, but remain part of their lives. Breast cancer patients express strong, unmet needs for education, information, and intervention for these side effects. Evidence suggests that rehabilitation and exercise are effective in preventing and managing many physical side effects of breast cancer treatment. Nevertheless, few women are referred to rehabilitation during or after treatment, and fewer receive baseline assessments of impairment and function to facilitate early detection of impairment and functional limitations. The prospective surveillance model of rehabilitation will serve the needs of women with breast cancer by providing education and information about treatment side effects, reducing the incidence and burden of side effects through early identification and treatment, and enhancing access to timely rehabilitation. Integration of exercise as a component of the model benefits patients at every phase of survivorship, by addressing individual concerns about exercise during and after treatment and highlighting the important contribution of exercise to overall health and survival. The prospective surveillance model of rehabilitation can meet the evident and often expressed needs of survivors for information, guidance, and intervention--thus addressing, and potentially improving, overall quality of life for individuals diagnosed with and treated for breast cancer.

Exercise and Cancer Treatment Symptoms in 408 Newly Diagnosed Older Cancer Patients

While the benefits of exercise for managing cancer-and treatment-related side effects has been shown among various populations of cancer survivors, a relative dearth of information exists among older cancer patients. OBJECTIVES: To determine the prevalence of exercise participation during and after primary cancer treatment in older (≥65 years) and the oldest (≥80 years) cancer patients and to examine the relationships between exercise, symptoms, and self-rated health (SRH). MATERIALS AND METHODS: 408 newly diagnosed older cancer patients (mean age=73, range=65-92) scheduled to receive chemotherapy and/or radiation therapy reported symptoms and SRH prior to, during, and 6 months after treatment, and exercise participation during and following treatment. RESULTS: Forty-six percent of older and 41% of the oldest patients reported exercising during treatment. Sixty percent of older and 68% of the oldest patients reported exercising in the 6 months thereafter. Older patients who exercised during treatment reported less shortness of breath and better SRH during treatment, and better SRH following treatment. The oldest patients who exercised during treatment reported less memory loss and better SRH during treatment and less fatigue and better SRH following treatment. The oldest patients who exercised following treatment reported less fatigue, skin problems, and total symptom burden following treatment. CONCLUSION: These data suggest a willingness of older cancer patients to attempt exercise during and after treatment. Exercise during these times is associated with less severe symptoms; further clinical research examining the efficacy of formal exercise interventions to reduce symptoms and improve SRH in older cancer patients is needed.

Intervention fidelity: aspects of complementary and alternative medicine research

BACKGROUND

The Treatment Fidelity Workgroup (TFW) established by the National Institutes of Health provides a 5-point structure for intervention fidelity: dosing, interventionists' consistency, intervention delivery, receipt, and enactment of the intervention. Using our reflexology trial, we apply the first 3 points.

OBJECTIVES

Study objectives were to (1) evaluate key dosage dimensions associated with complementary and alternative medicine (CAM) research, (2) evaluate approaches to interventionists' consistency of delivery of CAM protocols, and (3) evaluate and discuss data that reflect CAM intervention fidelity.

METHODS

Women with late-stage breast cancer (N = 318) were randomly assigned to either 4 weeks of reflexology, placebo, or standard care.

RESULTS

Dosing consists of 3 dimensions: frequency (4 sessions), duration (30 minutes), and interval between sessions (5-9 days). Interventionist consistency revealed more than a 90% accuracy rate in following the protocol; 84% and 89% completion rate of the 4 sessions in the reflexology and placebo groups, respectively; and no differences in attrition after randomization between reflexology and placebo groups (17% and 15%, respectively). Intervention delivery, examined through debriefing data, indicated a significantly higher rate of correct guesses on group assignment in the reflexology group as compared with the placebo (82% vs 46%, P = .0002).

CONCLUSION

This study points out the relevance of dosing, interventionists' consistency, and delivery data within a CAM clinical trial, as well as the challenges of blinding.

IMPLICATIONS FOR PRACTICE

Monitoring intervention fidelity by using the key areas identified by the TFW ensures that findings from a clinical trial are meaningful and have the potential to be translated to clinical practice.

Quality of life of younger breast cancer survivors: persistence of problems and sense of well-being

OBJECTIVE

Ten years after diagnosis, women diagnosed with breast cancer at age 50 or younger were assessed to determine whether quality of life (QOL) problems found at five years persisted. We predicted that QOL in the physical and social domains would be poorer, but improvements would be found in the psychological domain.

METHODS

We re-interviewed 312 women, who had been interviewed at their five year anniversary and remained cancer free, on their QOL in three domains (physical, social, and psychological). Comparisons between their 5- and 10-year reports were performed using paired t-tests for numeric variables and McNemar's test for categorical variables. Multiple regression analysis was used to model change from 5 to 10 years in each QOL domain, given the level of QOL at 5 years.

RESULTS

The women's mean age was 55, 60% were college graduates, 79% had a partner, and 27% were non-Euro-American. Ten years after diagnosis they reported poorer general health (p<0.0001) and physical well-being (p = 0.001), less sexual activity (p = 0.009), and more chronic conditions (p<0.0001) than at 5 years. Relationships were found between: (1) the number of chronic conditions at 5 years and decreased physical, social, and psychological well-being at 10 years; and (2) a smaller social network at 5 years and poorer social functioning at 10 years.

CONCLUSIONS

Certain aspects of both physical and social QOL worsened over time. The remaining question is whether these changes can be attributed to the late effects of treatment or to normal effects of aging.

Interventions to Alleviate Symptoms Related to Breast Cancer Treatments and Areas of Needed Research

Treatments for breast cancer produce a host of side effects, which can become debilitating. Some cancer treatment-related side effects occur in up to 90% of patients during treatment and can persist for months or years after treatment has ended. As the number of breast cancer survivors steadily increases, the need for cancer control intervention research to alleviate side effects also grows. This review provides a general overview of recent clinical research studies of selected topics in the areas of symptom management for breast cancer with a focus on cognitive difficulties, fatigue, cardiotoxicity, bone loss, insomnia, and cancer pain. We review both pharmacological and behavioral intervention clinical research studies, conducted with breast cancer patients and survivors. Additionally, clinical perspectives on symptom management and recommendations for areas of needed research are provided.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

The development of an arm activity survey for breast cancer survivors using the Protection Motivation Theory

Background

Current research evidence indicates that women should return to normal use of their arm after breast cancer surgery. However, it appears some women continue to hold the view that they are supposed to protect their arm from strenuous activities because of the risk of lymphoedema. Many factors contribute to women's perceptions about lymphoedema and their ability to use their affected arm, and it is the aim of this study to explore and understand these perceptions.

Methods/design

A survey, based on the Protection Motivation Theory, has been developed and tested. The survey assesses whether subjective norms, fear and/or coping attributes predict women's intention to use their affected arm. In addition, the survey includes questions regarding cancer treatment and demographic characteristics, arm and chest symptoms, and arm function. Recruitment of 170 breast cancer survivors has begun at 3 cancer treatment sites in Sydney, Australia.

Discussion

This study will identify perceptions that help predict the extent women use their affected arm. The results will also determine whether upper limb impairments arise secondary to over-protection of the affected arm. Identification of factors that limit arm use will enable appropriate prevention and better provision of treatment to improve upper limb outcomes.

Pectoral stretching program for women undergoing radiotherapy for breast cancer

Surgery and radiotherapy commonly cause adverse musculoskeletal problems, particularly loss of strength and range of motion, in the upper quadrant of breast cancer patients. Few well-designed studies have investigated whether these impairments can be prevented. Stretching is an effective technique for increasing range of motion, hence the aim of this study was to investigate whether a stretching program reduced acute musculoskeletal impairments in patients undergoing radiotherapy for breast cancer. Sixty-four women were recruited prior to commencement of radiotherapy following breast cancer surgery. Participants were randomised to either a control or stretch group. Participants in both groups were reviewed by the physical therapist on a weekly basis for approximately 6 weeks, and were given general information about skin care and lymphedema. The control group received no advice about exercise. The stretch group received instruction on low-load, prolonged pectoral stretches, which were to be performed daily and were checked at weekly visits. Shoulder range of motion, strength, arm circumference, and quality of life measurements were taken prior to, and at completion of radiotherapy, and at 7 months after radiotherapy. There was no difference in any outcome between groups. Breast symptoms increased for both groups during radiotherapy, without loss of strength or range of movement. The incidence of lymphedema during the study was low for both groups and did not differ between groups. The pectoral stretching program did not influence the outcomes measured because the symptoms reported by patients were not a consequence of contracture.

Lifestyle intervention development study to improve physical function in older adults with cancer: outcomes from Project LEAD

PURPOSE

Declines in physical functioning (PF) among elderly cancer patients threaten quality of life and the ability to maintain independence. Adherence to healthy lifestyle behaviors may prevent functional decline.

PATIENTS AND METHODS

Project Leading the Way in Exercise and Diet (LEAD), an intervention development study of the Pepper Older Americans Independence Center, aimed to determine whether breast and prostate cancer survivors (age 65+ years) assigned to a 6-month home-based diet and exercise intervention experienced improvements in PF when compared with an attention control arm receiving general health information. An accrual target was set at 420, and PF (Short Form-36 subscale), physical activity (Community Healthy Activities Models Program for Seniors), and diet quality (index from 3-day recalls) were assessed at baseline and at 6 and 12 months (6 months after intervention).

RESULTS

This developmental project did not achieve its accrual target (N = 182); however, PF change scores were in the direction and of the magnitude projected. Baseline to 6-month change scores in the intervention versus the control arms were as follows: PF, +3.1 v -0.5 (P = .23); physical activity energy expenditure, +111 kcal/wk v -400 kcal/wk (P = .13); and diet quality index, +2.2 v -2.9 (P = .003), respectively. Differences between arms diminished during the postintervention period.

CONCLUSION

These findings suggest that home-based diet and exercise interventions hold promise in improving lifestyle behaviors among older cancer survivors, changes that trend toward improved PF. Future studies should incorporate larger sample sizes and interventions that sustain long-term effects and also take into account secular trends; these efforts will require adequate planning and resources to overcome the numerous barriers to intervening in this difficult to reach yet vulnerable population.

Risk of decline in upper-body function and symptoms among older breast cancer patients

BACKGROUND

Decline in upper-body function and development of upper-body symptoms are adverse effects of breast cancer therapy and may affect functional independence, particularly among older survivors. The long-term risks and predictors are poorly understood.

OBJECTIVE

To characterize the risk of decline in upper-body function and development of symptoms over 4 years of follow-up.

DESIGN

We used a prospective cohort design.

PARTICIPANTS

Six hundred and forty-four early stage breast cancer patients 65 years old or older at surgery enrolled in Rhode Island, North Carolina, Minnesota, and Los Angeles between 1996 and 1999.

MEASUREMENTS

Upper-body function and symptoms were self-reported at baseline, 6, 15 months, and annually thereafter to 51 months after surgery.

RESULTS

One half of the participants had a decline in upper-body function and one-quarter developed upper-body symptoms. Breast cancer patients were 5-fold more likely to have a decline in upper-body function over 4 years of follow-up than a similar cohort without breast cancer. Better baseline mental health protected against a decline in upper-body function (odds ratio [OR]=0.93, 95% confidence interval [CI] 0.88 to 0.97 for 8-point higher mental health index). Baseline obesity (OR for body mass index [BMI] > or =30 kg/m2 vs <30 kg/m2=2.5, CI=1.6 to 4.0) and axillary node dissection (OR for axillary dissection vs not=3.9, CI=1.1 to 14) predicted the development of upper-body symptoms.

CONCLUSIONS

Primary care physicians should address upper-body function and symptoms with older breast cancer patients, and inform them that these complications of breast cancer treatment are common.

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

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

Older women with breast cancer: caregiving and the risk of depression--an exploratory analysis

OBJECTIVES

The primary objective of this exploratory analysis was to assess the prevalence of caregiving among older (60+) newly diagnosed female breast cancer patients and to examine the risk of depression associated with breast cancer, caregiving, and age, at 3 months and 12 months after diagnosis.

METHODS

Data from interviews conducted for the case-control study, Health and Functioning in Women with Breast Cancer (HFW), were used for this analysis. Interviews were conducted at 3 months and 12 months post-diagnosis. Participants for this analysis were restricted to those who completed both interviews (cases n = 904; controls n = 966). Risk of depression was assessed using a self-reported depression question from the HFW instrument.

RESULTS

The multivariate analysis showed that stage of breast cancer was significantly related to depression among older women with breast cancer while controlling for various socio-demographic factors; however, caregiving did not significantly increase the risk for depression for this population.

DISCUSSION

A breast cancer diagnosis for women, regardless of age or caregiving status, presented an increased risk of depression at 3 and 12 months post-diagnosis. These and other findings and their implications for social work practice are discussed.

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

GOALS OF WORK

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

PATIENTS AND METHODS

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

MAIN RESULTS

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

CONCLUSIONS

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

Then and now: quality of life of young breast cancer survivors

BACKGROUND

Women under age 50, a quarter of all cases of breast cancer, are especially vulnerable to physical and psychosocial late effects of their treatment due to having more aggressive treatment and their relative youth.

METHODS

In person interviews were conducted with the population-based sample: 185 women who were under 50 at diagnosis and were cancer-free 5 years later. Quality of life in the physical, psychological, social, and spiritual domains was assessed and compared with results obtained a few months after diagnosis.

RESULTS

Five years after diagnosis, 92% rated their health as good or excellent, and only 10% said their health had been getting worse. Between baseline and 5 years, there were significant improvements in surgical symptoms, body image, worry about the future, patient-physician communication, intrusiveness of treatment, and all of the SF-36 measures except for general health. There were significant decreases in emotional support and the size of one's social network. More women were now menopausal (75% due to treatment) and there were fewer children at home. There were no significant changes in employment status, marital/partner status, sexual activity, sexual problems, self-esteem, and attendance at religious services or frequency of prayer. In multivariate models, a greater increase in physical quality of life was associated with reporting fewer chronic conditions, being employed, having been treated by chemotherapy and fewer had no children under age 18 living at home. A greater increase in mental quality of life was associated with fewer chronic conditions and a smaller decrease in emotional support.

CONCLUSIONS

Five years after diagnosis, young breast cancer survivors who remained cancer-free enjoyed good health and improved quality of life. Nonetheless, physical, social, and psychological concerns must be addressed so that young breast cancer survivors will continue to be resilient as they age.

Functional impact of breast cancer by age at diagnosis

PURPOSE

To explore changes in physical and psychosocial function before and after breast cancer by age at diagnosis.

PATIENTS AND METHODS

A total of 122,969 women from the Nurses' Health Study (NHS) and NHS 2, ages 29 to 71 years, who responded to pre- and postfunctional status assessments were included; 1,082 women were diagnosed with breast cancer between 1992 and 1997. Functional status was measured using the Medical Outcomes Study Short Form 36 (SF-36). Mean change in health-related quality of life (HRQoL) scores was computed across categories representing the combination of incident breast cancer (yes or no) and age at diagnosis (< or = 40, 41 to 64, or 65+ years).

RESULTS

Compared with women < or = 40 years without breast cancer, women with breast cancer experienced significant functional declines. Young (age < or = 40) women who developed breast cancer experienced the largest relative declines in HRQoL (as compared with middle-aged and elderly women) in multiple domains including physical roles (-18.8 v -11.5 and -7.5 points, respectively), bodily pain (-9.0 v -2.7 and -2.7 points), social functioning (-11.3 v -4.3 and -4.4 points) and mental health (-3.1 v 0.0 and +0.4 points). Much of the decline in HRQoL among elderly (age > or = 65) women with breast cancer was age related.

CONCLUSION

Young women may fare worse than middle-aged or elderly women in both physical and psychosocial dimensions after breast cancer diagnosis. The needs of women facing breast cancer may be better understood within a life stage framework.

Leading the Way in Exercise and Diet (Project LEAD): intervening to improve function among older breast and prostate cancer survivors

The U.S. population is aging, bringing with it an increased prevalence of chronic disease and concomitant declines in physical function. The risk of developing cancer increases significantly with age, and functional decline is much more likely once a cancer diagnosis is rendered. Thus, functional status in later life is a key concern, one that is heightened among elders who have been diagnosed with cancer. To date, however, there have been few trials that have exclusively addressed issues related to cancer survivorship among older cancer patients, and to our knowledge, none has focused on preserving or enhancing physical functioning. This paper describes the study design and methodological considerations of a randomized controlled trial to determine if a personally tailored workbook and telephone counseling program can positively affect physical activity and dietary behaviors and ultimately the physical functioning of up to 420 older men and women newly diagnosed with breast or prostate cancer. This trial is unique because the cancer diagnosis is used not only as a marker of risk for functional decline, but also as a "teachable moment" - an opportune time when elders may be more receptive to making beneficial lifestyle changes. Undoubtedly, as cure rates for cancer increase and intersect with ever-growing numbers of elderly, there will be numerous opportunities to provide and test interventions within this vulnerable population and to target functional status as a primary outcome. In reporting our methods, we hope to give others "a leg up," so that they can hurdle with greater ease the barriers we experienced, and thus advance the field more rapidly.

Functional status and the elderly cancer patient

Evaluation of functional status plays a unique role in the assessment of older cancer patients. While performance status has been the traditional method for oncologists to assess the impact of a cancer patient's disease, older cancer patients may require a more thorough evaluation of their functional status. Evaluation of functional status provides information that can predict outcomes and may provide information that can be utilized to improve function. Functional status evaluation can be useful throughout the patient's illness, at the initial diagnostic evaluation, for determining appropriate therapies, for the monitoring of therapeutic effect and finally in the palliative phase. There are many different methods available to assess functional status. Individual assessment of functional status in the context of a geriatric assessment may be an important component of the care older cancer patients receive.

Long-term follow-up of upper-body function among breast cancer survivors

We enrolled a cohort of 303 stage I or stage II breast cancer patients diagnosed in Boston, MA, between October 1992 and December 1995. We followed the patients by interview and medical record abstract for 5 years (a) to characterize the incidence and predictors of upper-body function decline and (b) to characterize the incidence and predictors of recovery of upper-body function. The incidence of decline in the first year after therapy (17.7/100 person years) was substantially higher than in the subsequent 4 years of follow-up (11.0/100 person-years, p value for test of homogeneity equal 0.028). With only one exception, no patient characteristic, therapy component, or disease trait was associated with decline over the full follow-up period. Women with less than a high school education had an adjusted relative hazard of decline of 2.3 (95% CI, 1.4-3.7) compared with women with a high school education or more, possibly reflecting occupational or environmental insults that predispose to functional impairment. Women who had reported a decline in upper-body function and who subsequently saw their breast cancer specialist were 4.8-fold more likely to report that they had recovered their upper-body function at their next interview (95% CI, 2.0, 12). This finding suggests that attention to upper-body function during follow-up visits may facilitate recovery.

Physical functioning of elderly cancer patients prior to diagnosis and following initial treatment

BACKGROUND AND OBJECTIVES

Using an instrument to measure physical functioning that was normed to the U.S. population, data were obtained from patients with a new diagnosis of breast, colon, lung, and prostate cancer. Two questions were addressed: (a) after controlling for age, and number of comorbid conditions, do site and stage of cancer predict functional limitations prior to diagnosis; (b) using age adjusted national norms on physical functioning, how well do age, number of comorbid conditions, stage, treatment and cluster of symptoms (pain, fatigue, and insomnia) explain changes in physical function between 3 months prior to and 8 weeks following diagnosis?

METHODS

Patients 65 years of age and older were accrued from 24 community oncology settings. Consenting patients were interviewed within 8 weeks of initial treatment. The SF-36 was used to measure physical functioning. Comorbidity and symptom experience were assessed through patient report and site and stage of cancer from record audits.

RESULTS

Prior to diagnosis of cancer, patients were comparable in physical functioning to the U.S. population aged 55-64, a full decade younger than the sample of cancer patients. Site and stage of disease did not account for variations in physical functioning prior to diagnosis. Compared against national norms, patients with more extensive treatments (surgery plus adjuvant therapy) reported greater loss in functioning. Pain, fatigue, and insomnia had a consistent and significant effect on losses in functioning unrelated to patients' treatments or their comorbid conditions.

CONCLUSIONS

Site and stage of cancer prior to diagnosis do not affect functioning. Older cancer patients report higher functioning than their counterparts in the U.S. population. Changes in functioning following diagnosis varied by cancer site. Treatments were related to loss in functioning, but comorbidity was not. Pain, fatigue, and insomnia were significant and independent predictors of change in patient functioning. This underscores the importance of interventions to manage symptoms early in the course of treatment for individuals.

The persistent impact of breast carcinoma on functional health status: prospective evidence from the Nurses' Health Study

BACKGROUND

Although physical and emotional function after the diagnosis of breast carcinoma have been described in clinic populations, to the authors' knowledge no previous study has measured change from the preillness level of functional health status in community-dwelling women.

METHODS

The authors conducted a 4-year (1992-96) prospective study of functional recovery after breast carcinoma in a large sample of women, aged 54-73 years. They collected multidimensional measures of self-reported functional health status in 1992, before diagnosis of breast carcinoma, and again in 1996, to examine the risk of decline associated with incident breast carcinoma.

RESULTS

After adjustment for age, baseline functional health status, and multiple covariates, women who developed incident breast carcinoma were more likely to have experienced reduced physical function, role function, vitality, and social function and increased bodily pain compared with women who remained free of breast carcinoma. Risk of decline was attenuated with increasing time since diagnosis. Risk of decline in physical function was evident across all stages of breast carcinoma, even after adjustment for women undergoing treatment for persistent or recurrent disease. We found evidence that the risk of decline among breast carcinoma cases compared with healthy women was largest among those who were most socially isolated.

CONCLUSIONS

Breast carcinoma results in persistent declines in multiple dimensions of functional health status. These prospective data suggest that previous studies reporting no difference in physical function among breast carcinoma cases compared with disease free women underestimated the deleterious effect of the disease on function. Socially isolated women are an especially vulnerable group.

Patient characteristics and treatments associated with a decline in upper-body function following breast cancer therapy

Breast cancer therapy is often followed by a decline in upper-body function. Women (303) diagnosed with stage I or II breast cancer were interviewed 5 and 21 months after surgery and their medical records were reviewed. Women with cardiopulmonary comorbidity had an odds ratio for decline at the 5-month interview of 2.8 (95% CI 1.3-5. 7), relative to women without. Women who received mastectomy (OR = 2. 5; 95% CI 0.9-6.7) or breast-conserving surgery with radiation therapy (OR = 2.9; 95% CI 1.0-8.9) were at higher risk for decline at the 5-month interview than women who received only breast-conserving surgery. Women who had axillary dissection were more likely to report numbness or pain in the axilla (OR = 6.4; 95% CI 1.2-33) at the 21-month interview than women who did not. Clinicians should consider the functional consequences of treatment when discussing treatment options and postoperative care with women who have early stage breast cancer.

Comparison of changes in physical functioning of elderly patients with new diagnoses of cancer

BACKGROUND

Controversy surrounds the impact of site of cancer and treatments on functioning of elderly cancer patients.

OBJECTIVES

This research determines (1) whether age, gender, comorbid conditions, site and stage of cancer, and treatments are related to losses in physical functioning at 4 observations during the year after diagnosis; (2) whether symptoms are a mediating variable between treatment and function; and (3) which indicators account for true change in functioning in the year after diagnosis.

METHODS

An inception cohort of 907 patients aged > or =65 years and newly diagnosed with breast, colon, lung, or prostate cancer were accrued from 24 community oncology programs. Stage and treatment data were obtained from medical records. Physical functioning was measured with the SF-36 subscale. Interviews were conducted at 6 to 8, 12 to 16, 26 to 30, and 52 weeks after diagnosis.

RESULTS

Men scored 10 points higher on physical function than women at all observation points. Patients with > or =3 comorbid conditions scored lower in functioning. Interactions between site of cancer and treatment modalities were observed. Pain, fatigue, and numbers of symptoms were independent predictors of loss of function. Surgery, female gender, and number of symptoms predicted reliable change in function.

CONCLUSIONS

Elderly patients with cancer report levels of function similar to other chronic conditions. Scores on physical function varied by site of cancer; the pattern of change was similar among sites. Age, comorbidity, treatment modalities, and symptom reports each had an independent effect on loss of functioning. Untreated breast cancer patients had lower functioning, suggesting a possible treatment bias.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Intrusiveness of illness and quality of life in young women with breast cancer

Our objective was to test a theoretical model that explains quality of life as a function of the intrusiveness of illness encroaching on the different domains of one's life. The intrusiveness of illness is explained not only by disease and treatment related factors, but also by one's psychological and social resources (Devins, 1994). To investigate this issue, a sample of 336 women aged 50 and under, recently diagnosed with breast cancer were interviewed in their homes. Consistent with Devins' model, intrusiveness of illness mediated the effect of disease and treatment factors on quality of life. Contrary to his model, some treatment factors also had direct effects while social and psychological factors had only direct effects on quality of life. Neither time post-diagnosis nor type of treatment affected the psychological component of quality of life.

Disability in older adults: evidence regarding significance, etiology, and risk

OBJECTIVES

This article synthesizes and assesses current evidence about the importance of physical disability to older adults. It then considers the applications of research findings to clinical geriatrics practice.

RESULTS

Physical disability is a major adverse health outcome associated with aging. Certain subgroups of older adults, including individuals with mobility difficulty, with preclinical functional changes, and persons who are hospitalized, are at particularly high risk of becoming disabled or experiencing disability progression. The major underlying causes of physical disability are chronic diseases, including both acute events, such as hip fracture and stroke and slowly progressive diseases such as arthritis and heart disease. These diseases appear to have task-specific effects; understanding this may assist in setting treatment and prevention goals. Comorbidity, particularly certain combinations of chronic diseases, is a strong risk factor for disability in itself. Recent trials indicate that clinical interventions may be able to prevent onset or progression of disability.

CONCLUSIONS

Available evidence now suggests clinical approaches to both treatment and prevention of disability and directions for defining optimal clinical care for the future.

The effect of medical conditions on the functional limitations of Mexican-American elderly

We examined the relationship of self-reported functional status to common medical conditions using a probability sample of 3050 noninstitutionalized Mexican-American men and women aged 65 or older and residing in the Southwestern United States (Arizona, California, Colorado, New Mexico, and Texas). All subjects were interviewed in person (n = 2,873) or by proxy (n = 177) in their homes during late 1993 and early 1994. The questionnaire obtained information on self-reported functional status and prevalence of arthritis, cancer, diabetes, stroke, heart attack, and hip fracture. The prevalence of medical conditions ranged from 4.1% for hip fracture to 40.8% for arthritis. Prevalence of impairments in seven activities of daily living ranged from 5.4% for eating to 11.7% for bathing, while 25.1% could not walk up and down stairs, and 28.9% could not walk a half mile without help. In multiple logistic regression analyses, previous diagnoses of stroke and hip fracture were most predictive of functional limitations, though all conditions examined (arthritis, cancer, diabetes, stroke, heart attack, and hip fracture) were independently associated with increased odds of impairment in some activities of daily living. In general, the odds for functional impairment associated with specific medical conditions were higher than those previously published for non-Hispanic white populations. The fact that Mexican-American elderly who live in the community and who have medical conditions, especially stroke and hip fracture, are at high risk for functional impairment probably reflects the low rate of institutionalization in this population and has implications for the provision of community-based long-term care services for Mexican-American elderly.

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

We examined differences in reported upper-body limitations between black and white breast cancer cases and controls aged 40 to 84 years at 3 and 12 months after diagnosis in the Detroit metropolitan area (n = 954 cases and 1000 controls at 3 months; n = 879 cases and 909 controls at 12 months). At 3 months black cases were more likely than white cases to report limitations in upper-body strength (30.4 versus 19.8%). No difference was found between black and white controls (8.0 versus 9.4%). At 12 months, the proportion of white patients with upper-body limitation returned to the same level as white controls. Black patients with limitations, however, did not return to the same level as black controls. Stage of disease was strongly associated with upper-body limitations, especially for black women. Race and stage differences in upper-body limitation could not be explained by differences in breast cancer treatment, financial adequacy, education, marital status, or comorbidity. Recommendations are made for more comprehensive studies of rehabilitation.

The effects of specific medical conditions on the functional limitations of elders in the Framingham Study

OBJECTIVES

The purpose of this study was to identify associations between specific medical conditions in the elderly and limitations in functional tasks; to compare risks of disability across medical conditions, controlling for age, sex, and comorbidity; and to determine the proportion of disability attributable to each condition.

METHODS

The subjects were 709 noninstitutionalized men and 1060 women of the Framingham Study cohort (mean age 73.7 +/- 6.3 years). Ten medical conditions were identified for study: knee osteoarthritis, hip fracture, diabetes, stroke, heart disease, intermittent claudication, congestive heart failure, chronic obstructive pulmonary disease, depressive symptomatology, and cognitive impairment. Adjusted odds ratios were calculated for dependence on human assistance in seven functional activities.

RESULTS

Stroke was significantly associated with functional limitations in all seven tasks; depressive symptomatology and hip fracture were associated with limitations in five tasks; and knee osteoarthritis, heart disease, congestive heart failure, and chronic obstructive pulmonary disease, were associated with limitations in four tasks each.

CONCLUSIONS

In general, stroke, depressive symptomatology, hip fracture, knee osteoarthritis, and heart disease account for more physical disability in noninstitutionalized elderly men and women than other diseases.

Delay versus help seeking for breast cancer symptoms: a critical review of the literature on patient and provider delay

Patient delay in seeking help for breast cancer symptoms and provider delay in treating those symptoms combine to decrease a woman's potential for breast cancer survival. This paper reviews the literature on patient and provider delay published since 1975. Meta-analysis of 12 studies using common definitions of patient delay estimates that 34% of women with breast cancer symptoms delay help seeking for 3 or more months. Provider delay appears to be both under researched and underestimated. This review identifies the factors that have been advanced as contributing to patient and provider delay, evaluating the support for each of these reported findings. Theory-based hypotheses emerging from the reviewed studies highlight foci for future investigations.