Breast Cancer Patients' Fear of Treatment: Results from the Multicenter Longitudinal Study BRENDA II

Utilisation of traditional medicine among women diagnosed with breast cancer in Ghana: a descriptive phenomenological study

BACKGROUND

Women living with breast cancer (BC) rely on traditional medicine (TM) in addition to orthodox medicine. There is a need to understand how and why women diagnosed with BC utilise TM. This study explored and described the lived experiences of women living with BC in terms of their utilisation of traditional medicine.

METHODS

A descriptive phenomenology design was used to purposively conduct 20 face-to-face in-depth interviews using a semi-structured interview guide. Data were analysed using NVivo-12 based on Collaizzi's framework for thematic data analysis.

RESULTS

Overall, five main themes emerged, namely: sources of knowledge on TM, motivations for using TM, treatment modalities, timing for the initiation of TM, the reasons for discontinuing use of TM, and the decision to seek orthodox medicine. Under the category of motivations for using TM, four themes emerged: financial difficulties and perceived cost effectiveness of TM, influence of social networks, including family and friends, assurance of non-invasive treatment, delays at the healthcare facility, and side effects of orthodox treatment. Non-invasive treatments included herbal concoctions, natural food consumption, and skin application treatments. Regarding the timing of initiation, TM was used in the initial stage of symptom recognition prior to the decision to seek orthodox medicine, and was also used complementarily or as an alternative after seeking orthodox medicine. However, patients eventually stopped using TM due to the persistence of symptoms and the progression of cancer to a more advanced stage, and disapproval by orthodox practitioners.

CONCLUSION

Women living with BC in Ghana utilise traditional medicine (TM) for many reasons and report their family, friends and the media as a main source of information. A combination of herbal concoctions and skin application modalities is obtained from TM practitioners to treat their BC. However, they eventually discontinue TM when symptoms persist or when disapproval is expressed by their orthodox healthcare providers. We conclude that there is an opportunity to better integrate TM into the standard of oncological care for BC patients.

A cross-sectional study of fear of surgery in female breast cancer patients: Prevalence, severity, and sources, as well as relevant differences among patients experiencing high, moderate, and low fear of surgery

BACKGROUND

Fear of surgery has been associated with more postoperative pain, disability, and a lower quality of life among patients undergoing various surgical procedures. While qualitative studies indicate breast cancer patients to be afraid of surgery, detailed quantitative analyses are lacking. The present research aimed at investigating the prevalence, severity, and sources of fear of surgery in this patient group and to compare patients reporting different degrees of such fear.

METHODS

This cross-sectional study included 204 breast cancer patients, 18-70 years old, and scheduled for surgery at Oslo University Hospital, Norway. Following their preoperative visit participants completed validated psychological questionnaires online. Among these, the primary outcome measure, the Surgical Fear Questionnaire (SFQ; scores: 0-10 per item, 0-80 overall). Patients were grouped based on SFQ-percentiles (<25th = little, 25th-75th = moderate and >75th percentile = high fear) and compared on psychological (anxiety, depression, experienced injustice, optimism and expected postsurgical pain), sociodemographic, and medical outcomes.

RESULTS

195 patients completed the SFQ. On average fear of surgery was low (M = 26.41, SD = 16.0, median = 26, min-max = 0-80), but omnipresent. Only 1.5% (n = 3) indicated no fear at all. Overall, patients feared surgery itself the most (M = 3.64, SD = 2.8). Groups differed significantly (p < .001) in their experience of anxiety, depression, and injustice, as well as their disposition to be optimistic, and expectance of postsurgical pain. Differences between groups concerning demographic and medical information were largely insignificant.

DISCUSSION

This study was the first to demonstrate fear of surgery to be prevalent and relevant among female breast cancer patients. The higher a patients' fear group, the poorer their preoperative psychological constitution. This, largely irrespective of their current diagnoses or treatments, medical history, and demographics. Fear of surgery might thus cater as a prognostic marker and treatment target in this patient group. However, given the cross-sectional character of the present data, prognostic studies are needed to evaluate such claims.

Identifying and Reducing Barriers to Breast Imaging

Purpose of Review

The purpose of this review is to discuss disparities in breast health care access and outcomes related to race, gender, cultural diversity, sexual orientation, socioeconomic status, geographic location, and disability. The authors recognize the complexity of eliminating inequalities in health care but are optimistic that all patients will one day have equal access to care through dialogue, acknowledgment, recognition, and action.

Recent Findings

After lung cancer, breast cancer is the second leading cause of death among American women. Mammography as a preventative screening tool has resulted in significant reductions in breast cancer mortality. Despite existing breast cancer recommendations, it has been projected that 43,250 women will die from breast cancer in 2022.

Summary

Disparities in healthcare outcomes exist for many reasons including inequalities based on race, gender, cultural diversity, religion, sexual orientation, and socioeconomic status. Disparities, no matter how large or complex, are not insurmountable.

Factors Associated with the Decision to Decline Chemotherapy in Metastatic Non-Small Cell Lung Cancer

(1) Background: Disparities in cancer treatment and outcomes have long been well-documented in the medical literature. With the eruption of advances in new treatment modalities, the long-existing disparities are now being further uncovered and brought to the attention of the medical community. While social health determinants have previously been linked to treatment disparities in lung cancer, we analyzed data from the National Cancer Database to explore sociodemographic and geographic factors related to accepting or declining physician-recommended chemotherapy. Patients diagnosed with metastatic lung cancer between 2004 and 2016 who declined chemotherapy recommended by their physicians were included in this study. Multivariate logistic regression analysis was performed. Cox Regression and Kaplan-Meier analyses were performed to look for survival characteristics. (2) Results: 316,826 patients with Stage IV lung cancer were identified. Factors related to a higher rate of refusal by patients included older age > 70, female sex, low income, lack of insurance coverage, residency in the New England region, and higher comorbidity. Patients living in areas with lower education were less likely to decline chemotherapy. (3) Conclusion: Further understanding of the factors impacting treatment decisions would be essential to improve the efficacy of care delivery in patients with cancer and reduce reversible causes of disparity.

Conservative surgical staging as a means to preserve fertility in patients with dysgerminoma: a case report

Ovarian tumor is a rare condition in pediatrics. Due to the improvement in surgical techniques and chemotherapy in recent years, it is currently possible to preserve fertility in selected cases of patients who desire motherhood.

Case presentation

We present a case of pregnancy following conservative surgery and complete chemotherapy for ovarian dysgerminoma stage IIA. A 16-year-old female presented with complaints of abdominal mass and discomfort. Histopathological examination displayed dysgerminoma arising from the right ovary. Conservative treatment with right salpingo-oophorectomy and six cycles of chemotherapy was performed. Within 2 years following the surgery, the patient conceived and did not indicate tumor recurrence.

Clinical discussion

Dysgerminoma is the most common ovarian malignant germ cell tumor and usually affects women at a young age. Conservative surgery followed by chemotherapy is the treatment of choice, particularly in young patients with a strong desire to have a family. Conservative fertility-sparing surgery does not have inferior outcomes in terms of survival or recurrence. It is possible that in certain cases, patients previously treated for ovarian cancer may retain their fertility, thereby improving their quality of life.

Conclusion

Most patients with dysgerminoma can be treated with the maintenance of normal reproductive function. Reassurance regarding the high probability of conceiving and having normal children after conservative surgery and chemotherapy should be informed to the patient and family.

Comprehensive preoperative psychological assessment of breast cancer patients

In the context of the traumas suffered by patients following the oncological diagnosis and the expectation of the surgical intervention, it is important to unitary and multidimensional identify the psychological status, using a single interview structured to cover these psychological vulnerabilities. The overall psychological picture can help the psycho-oncologist to adapt his psychotherapeutic interventions to relieve the stress caused by the oncological diagnosis and specific treatment. 58 patients with a breast cancer diagnosis and 61 patients with breast lumps diagnosis who were waiting for the histopathological result, received several scales for assessing emotional distress, the level self-esteem, depression, anxiety and cognitive dysfunctions levels. The analysis of the answers led to the multidimensional identification of differences between the two categories of patients and establishing correlations between personality traits and the development of certain psychological changes. Statistically significant differences (p < 0.05) were observed between patients with breast cancer and those with breast lumps awaiting histopathological diagnosis, in the areas of self-esteem, depression and cognitive schemas. Diagnosed patients have predominantly dysfunctional attitudes such as negative emotions and cognitive schemas related to catastrophe and self-deprecation, while undiagnosed patients, have cognitive schemas related to low tolerance for frustration and absolutist requirements and lower dysfunctional attitudes. A global assessment with a single psychological tool can capture the overall picture of the cancer patient, including possible triggers and maintenance of symptoms, with the psychological consequences of the disease that are reflected somatically, as well as predisposing factors in the history that generates these feelings.

A longitudinal study on the changes in the self‐efficacy of breast cancer patients during adjuvant chemotherapy

AIM

We aimed to investigate the changes in the self-efficacy of patients with breast cancer (BC) during adjuvant chemotherapy.

DESIGN

A longitudinal study was conducted.

METHODS

One hundred thirty patients with BC who underwent postoperative adjuvant chemotherapy at a medical centre in northern Taiwan were evaluated using self-efficacy survey tools before the first (T1), second (T2) and last (T3) cycles of adjuvant chemotherapy. The independent t-test, Kruskal-Wallis test, one-way analysis of variance, Pearson's correlation coefficient and generalized estimating equation were used for data analysis.

RESULTS

The self-efficacy measures of patients with BC were significantly higher at both T2 and T3 than at T1 (p < 0.001). Religious beliefs and changes in self-efficacy showed a significant correlation (p = 0.04). These findings will facilitate timely interventional measures to improve self-efficacy in patients with maladaptive behaviours, alleviate psychological distress and reduce the risk of future disease recurrence.

How Does Hedonic Aroma Impact Long-Term Anxiety, Depression, and Quality of Life in Women with Breast Cancer? A Cross-Lagged Panel Model Analysis

Depression and anxiety are common symptoms during and after adjuvant chemotherapy treatment for breast cancer (BC), with implications on quality of life (QoL). The present study evaluates the temporal relationship between anxiety, depression, and QoL (primary outcomes), as well as the impact of hedonic aroma (essential oils) on this relationship. This is a secondary analysis of a previously reported randomized controlled trial, with two groups: an experimental group (n = 56), who were subjected to the inhalation of a self-selected essential oil during chemotherapy, and a control group (n = 56), who were only subjected to the standard treatment. The hedonic aroma intervention occurred in the second (T1), third (T2), and fourth (T3) chemotherapy sessions, three weeks apart from each other. The follow-up (T4) assessments took place three months after the end of the treatment. Cross-lagged panel models were estimated in the path analysis framework, using structural equation modeling methodology. Regarding the control group, the cross-lagged panel model showed that anxiety at T1 predicted anxiety at T3, which in turn predicted both QoL and depression at T4. In the experimental group, hedonic aroma intervention was associated with stability of anxiety and QoL over time from T1 to T3, with no longitudinal prediction at T4. For women undergoing standard chemotherapy treatment, anxiety was the main longitudinal precursor to depression and QoL three months after chemotherapy. Thus, essential oils could complement chemotherapy treatment for early-stage BC as a way to improve long-term emotional and QoL-related adjustment.

Geographical Disparities and Factors Associated With the Decision to Decline Chemotherapy in Breast Cancer

PURPOSE

Social determinants of health have been linked to treatment-related disparities in breast cancer. We analyzed data from a large national registry to explore factors related to accepting or declining recommended chemotherapy and whether patients' decisions vary geographically across the United States.

METHODS

We used the National Cancer Database to study treatment decision making in patients with advanced breast cancer (American Joint Committee on Cancer clinical stage III-IV) between 2004 and 2017. We focused the analysis on patients who were recommended chemotherapy by their physicians but who declined this treatment. Multivariate logistic regression analysis was performed.

RESULTS

A total of N = 215,284 patients with stage III and IV breast cancers were included. Patients in the New England region were more likely to refuse chemotherapy compared with the rest, with patients in the East South Central regions (AL, KY, MS, and TN) and West South Central (AR, LA, OK, and TX) noted to be least likely to refuse chemotherapy. Factors related to a higher rate of refusal by patients included older age > 70 years; hormone receptor-positive tumors; and having higher comorbidity. Patients identified as Hispanic, those who are privately insured, and patients at academic institutions were less likely to decline chemotherapy.

CONCLUSION

This analysis identified a significant difference in rates of refusal of recommended chemotherapy by geographical location, insurance status, and treatment facility after adjusting for known social determinants of health. Further understanding of the factors affecting treatment decisions would be important to improve the efficacy of care delivery in patients with cancer and reduce reversible causes of disparity.

Financial difficulties in breast cancer survivors with and without migration background in Germany-results from the prospective multicentre cohort study BRENDA II

Purpose

We aimed to explore the trajectory of financial difficulties among breast cancer survivors in the German health system and its association with migration background.

Methods

In a multicentre prospective study, breast cancer survivors were approached four times (before surgery, before and after adjuvant therapy, five years after surgery) and asked about their migration history and financial difficulties.

Migrants were defined as born/resided outside Germany or having citizenship/nationality other than German. Financial difficulties were ascertained with the financial difficulties item of the European Organisation for Research and Treatment of Cancer Core Instrument (EORTC QLQ-C30) at each time-point (cut-off > 17). Financial difficulties were classified in trajectories: always (every time-point), never (no time-point), initial (first, not fourth), delayed (only fourth), and acquired (second and/or third, not first).

A logistic regression was conducted with the trajectories of financial difficulties as outcome and migration background as exposure. Age, trends in partnership status, and educational level were considered as confounders.

Results

Of the 363 participants included, 49% reported financial difficulties at at least one time-point.

Financial difficulties were reported always by 7% of the participants, initially by 5%, delayed by 10%, and acquired by 21%.

Migrants were almost four times more likely to report delayed (odds ratio [OR] = 3.7; 95% confidence interval [CI] 1.3, 10.5) or acquired (OR = 3.6; 95% CI 1.6, 8.4) financial difficulties compared to non-migrant participants.

Conclusion

Survivors with a migration background are more likely to suffer from financial difficulties, especially in later stages of the follow-up. A linguistically/culturally competent active enquiry about financial difficulties and information material regarding supporting services/insurances should be considered.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00520-022-07074-7.

Longitudinal Prospective Evaluation of Quality of Life After Axillary Lymph Node Dissection

BACKGROUND

Patients often fear axillary lymph node dissection (ALND) because of its associated complications; however, its effect on quality of life (QOL) is not well described. We aimed to evaluate the effect of ALND on QOL over time and to identify predictors of worse QOL.

PATIENTS AND METHODS

Breast cancer patients undergoing ALND were enrolled in a prospective lymphedema screening study. Arm volumes were measured and QOL questionnaires completed at baseline, postoperatively, and at 6-month intervals. The upper limb lymphedema-27 questionnaire was used to assess the effect of upper extremity symptoms on QOL in three domains (physical, psychological, and social). Predictors of QOL were identified by univariate and multivariable regression analyses.

RESULTS

From November 2016 through March 2020, 304 ALND patients were enrolled; 242 patients with at least two measurements and 6 months of follow-up were included. Median age was 48 years, and median follow-up was 1.2 years. The 18-month lymphedema rate was 18%. Overall, QOL scores in all three domains decreased postoperatively and improved over time. On multivariable analysis, after adjusting for baseline scores, symptoms necessitating lymphedema therapy referral (p = 0.006) were associated with worse physical QOL. Younger age (p = 0.005) and lymphedema therapy referral (p = 0.006) were associated with worse psychological QOL. Arm volume was not correlated with QOL.

CONCLUSIONS

QOL scores initially decreased after ALND but improved by 6 months post-surgery. Decreases in QOL were independent of arm volume. Patients with worse QOL more often sought lymphedema therapy, although the effect of therapy on QOL remains unknown.

Outcome analysis of primary breast cancer patients who declined adjuvant chemotherapy-results from the prospective multi-center BRENDA II study

BACKGROUND

This study examined 5-year overall, recurrence and distant metastasis-free survival (OS, RFS, MFS) of high- and intermediate-risk breast cancer (BC) patients who declined guideline-recommended adjuvant chemotherapy (CHT).

METHODS

In the prospective multicenter cohort study BRENDA II, patients with primary BC were sampled over a period of four years (2009-2012). A multi-professional team (tumorboard) discussed recommendation for adjuvant CHT according to the German guideline. Potential differences in 5 year survival were analyzed using Kaplan-Meier curves and Cox regression. The hazard ratios (HR) were adjusted for age, Charlson Comorbidity Score, American Society of Anesthesiologist (ASA) physical status classification, and endocrine therapy.

RESULTS

A total of 759 patients were enrolled of which 688 could receive CHT according to the guidelines (n = 219 had a clear indication, in n = 304 it was possible). For 360 patients, the tumorboard advised to perform CHT, for 304 it advised against and in 24 cases, no decision was documented. Of those with a positive suggestion, 83% received CHT. Until 5 years after diagnosis, 57 patients were deceased, 41 had at least one distant metastasis and 29 a recurrence. There was no evidence for differences in OS and MFS in patients who declined CHT despite tumorboard recommendation (HR 3.5, 95% CI 0.8-15.1 for OS, HR 1.9, 95% 0.6-6.6 for MFS). Patients who received CHT had significantly better 5-year RFS compared to those who declined (HR 0.3, 95% CI 0.1-0.9, p = 0.03). There was no evidence for different survival in those who had no CHT because of comorbidity and those who declined actively, neither for OS, MFS nor RFS.

CONCLUSION

The prospective BRENDA II study demonstrates benefit in RFS by guideline adherence in adjuvant breast cancer treatment, indicating prospectively the value of internationally validated guidelines in breast cancer care.

Radiation Therapy for Advanced Mucinous Carcinoma of the Breast With a Malignant Wound: A Case Report

Patients with breast cancer who refuse standard treatment often suffer from malignant wounds due to the growth of local tumors. However, treatment strategies for patients with unresectable locally advanced breast cancer who refuse standard treatment remain unclear. Usually, such cases are treated with palliative irradiation and do not achieve local control by irradiation alone. This is the first case report discussing the role of high-dose local irradiation and the treatment course for a patient with a massive breast tumor (mucinous adenocarcinoma) who refused standard treatment. A 44-year-old female was diagnosed with mucinous carcinoma of the breast in the right breast (cT1N0M0, cStage I). She refused standard treatment for six years. She visited the emergency department because of acute bleeding from the right breast with malignant wounds. Macroscopically, the tumor in the right breast measured over 20 cm in diameter. The tumor was exudative, exhibited ulceration and slight bleeding, and emitted an odor. Imaging findings showed multiple lymph nodes and bone metastases, and the final diagnosis was stage IV breast cancer (cT4bN1M1). Although the surgeon recommended chemotherapy for breast cancer, the patient refused chemotherapy or other therapy due to concerns regarding treatment-related complications. Considering the symptoms of advanced breast cancer with malignant wounds, she finally agreed to receive radiation therapy (RT). We performed RT at 70 Gy in 35 fractions over seven weeks. The tumor-associated symptoms disappeared after RT. Three months after RT, the tumor had almost disappeared. We administered luteinizing hormone-releasing hormone agonists after RT. Two years after RT, she died due to multiple liver metastases and ascites; however, there was no disease progression in the right breast. High-dose RT for locally advanced mucinous carcinoma of the breast with malignant wounds is considered an effective therapeutic option.

Evaluation of overall survival and barriers to surgery for patients with breast cancer treated without surgery: a National Cancer Database analysis

Surgery remains the foundation of curative therapy for non-metastatic breast cancer, but many patients do not undergo surgery. Evidence is limited regarding this population. We sought to assess factors associated with lack of surgery and overall survival (OS) in patients not receiving breast cancer surgery. Retrospective cohort study of patients in the US National Cancer Database treated in 2004-2016. The dataset comprised 2,696,734 patients; excluding patients with unknown surgical status or stage IV, cT0, cTx, or pIS, metastatic or recurrent disease resulted in 1,192,294 patients for analysis. Chi-square and Wilcoxon rank-sum tests were used to assess differences between groups. OS was analyzed using the Kaplan-Meier method with a Cox proportional hazards model performed to assess associated factors. In total 50,626 (4.3%) did not undergo surgery. Black race, age >50 years, lower income, uninsured or public insurance, and lower education were more prevalent in the non-surgical cohort; this group was also more likely to have more comorbidities, higher disease stage, and more aggressive disease biology. Only 3,689 non-surgical patients (7.3%) received radiation therapy (RT). Median OS time for the non-surgical patients was 58 months (3-year and 5-year OS rates 63% and 49%). Median OS times were longer for patients who received chemotherapy (80 vs 50 (no-chemo) months) and RT (85 vs 56 (no-RT) months). On multivariate analysis, age, race, income, insurance status, comorbidity score, disease stage, tumor subtype, treatment facility type and location, and receipt of RT were associated with OS. On subgroup analysis, receipt of chemotherapy improved OS for patients with triple negative (HR 0.66, 95% CI 0.59-0.75, P < 0.001) and HER2+ (HR 0.74, 95% CI 0.65-0.84, P < 0.001) subgroups while RT improved OS for ER+ (HR 0.72, 95% CI 0.64-0.82, P < 0.001) and favorable-disease (ER+, early-stage, age >60) (HR 0.61, 95% CI 0.45-0.83, P = 0.002) subgroups. Approximately 4% of women with breast cancer do not undergo surgery, particularly those with more aggressive disease and lower socioeconomic status. Despite its benefits, RT was underutilized. This study provides a benchmark of survival outcomes for patients who do not undergo surgery and highlights a potential role for use of RT.

Breaking News of Cancer Diagnosis: A Qualitative Study on the Experiences and Emotional Needs of Patients With Cancer in a Multiethnic Asian Setting

PURPOSE

The breaking of news of a cancer diagnosis is an important milestone in a patient's cancer journey. We explored the emotional experiences of patients with cancer during the breaking of news of a cancer diagnosis and the arising needs in a multiethnic Asian setting with limited supportive cancer care services.

METHODS

Twenty focus group discussions were conducted with 102 Asian patients with cancer from diverse sociodemographic backgrounds. Thematic analysis was performed.

RESULTS

While most participants, especially younger patients with young children, experienced intense emotional distress upon receiving a cancer diagnosis, those with a family history of cancer were relatively calm and resigned. Nonetheless, the prior negative experience with cancer in the family made affected participants with a family history less eager to seek cancer treatment and less hopeful for a cure. Although a majority viewed the presence of family members during the breaking of bad news as important, a minority opted to face it alone to lessen the emotional impact on their family members. Difficulties disclosing the news of a cancer diagnosis to loved ones also emerged as an important need. Sensitive and empathetic patient-physician communication during the breaking of news of a cancer diagnosis was stressed as paramount.

CONCLUSION

A patient-centered communication approach needs to be developed to reduce the emotional distress to patients and their families after the breaking of bad news of a cancer diagnosis. This is expected to positively affect the patients' subsequent coping skills and attitudes toward cancer, which may improve adherence to cancer therapy.

Survivors of primary breast cancer 5 years after surgery: follow-up care, long-term problems, and treatment regrets. Results of the prospective BRENDA II-study

PURPOSE

This study aims to answer the questions where breast cancer patients in Germany receive follow-up care (with what types of doctors) and what are the long-term problems and treatment regrets of breast cancer patients.

METHODS

In the prospective multicenter cohort study BRENDA II ("Breast Cancer under Evidence-Based Guidelines"), 456 patients with primary breast cancer were sampled consecutively over a period of 4 years (2009-2012) and contacted again 5 years after surgery. Long-term problems were elicited on a 4-point Likert scale ranging from 0 ('not at all') to 3 ('very much').

RESULTS

82% of the patients receive follow-up (FU) at the private practice gynecologist. In 22%, the initial treating hospital is involved in the FU, and in 20% the general practitioner does this (multiple answers possible). Long-term problems attributed to the treatment were most often related to endocrine therapy (mean 1.29) and to chemotherapy (mean 0.94). Most of the patients were happy to have had radiotherapy (95%). For chemotherapy, endocrine therapy, and antibody therapy, the satisfaction for the treatment decision was 87%, 87%, and 84% respectively. Among patients who reported they regretted having undergone a recommended treatment, it was most often for endocrine therapy (5%) and chemotherapy (4%).

CONCLUSION

In Germany, different specialists are involved in the patients' FU care for BC. The detection of long-term problems due to BC treatment is an essential part of FU care.

Association between cognitive impairment and guideline adherence for application of chemotherapy in older patients with breast cancer: Results from the prospective multicenter BRENDA II study

BACKGROUND

This study examined the association between cognitive impairment and guideline adherence for application of chemotherapy in older patients with breast cancer.

PATIENTS AND METHODS

In the prospective multicenter cohort study BRENDA II, patients aged ≥65 years with primary breast cancer were sampled over a period of 4 years (2009-2012). A multiprofessional team (tumor board) discussed recommendation for adjuvant chemotherapy according to the German S3 guideline. Cognitive impairment was screened by the clock-drawing test (CDT) prior to adjuvant treatment.

RESULTS

Two hundred and sixty-three patients were included in the study and CDT data were available for 193 patients. Thirty-one percent of the patients had cognitive impairment with different degree of severity. In high-risk patients (n = 61) tumor board recommendation in favor of chemotherapy was 90% and in intermediate-risk patients (n = 170) 27%. Not receiving recommendation for chemotherapy in spite of guideline recommendation was more frequent in patients with cognitive impairment (67%) vs patients without cognitive impairment (46%) with P = 0.02 (OR 2.4, 95% confidence interval (CI) 1.2-4.9). Age, education, migration background and comorbidities were not associated with chemotherapy recommendation by the tumor board among cognitively impaired patients. Once the tumor board had recommended chemotherapy, application of chemotherapy was similar in both groups of patients with or without cognitive impairment.

CONCLUSION

Almost one third of older patients with breast cancer are affected by cognitive impairment prior to adjuvant treatment. In these patients, cognitive impairment was associated with tumor board decision against chemotherapy in spite of a positive guideline recommendation.

Perceptions and beliefs of lay people from northern Uganda regarding surgery for diagnosis and treatment of cervical cancer

OBJECTIVE

To explore perceptions and beliefs of people in a rural community in northern Uganda regarding surgery for the diagnosis and treatment of cervical cancer. The aim of the study was to inform interventions to reduce delay and improve timely diagnosis and prompt appropriate treatments for patients with symptoms of cervical cancer.

METHODS

A semi-structured study guide informed by Kleinman's explanatory model for illness was used to collect data during 24 focus group discussions involving 175 men and women aged 18 to 59 years in Gulu, northern Uganda. Using thematic analysis, themes and subthemes were identified from the data through an iterative process and consensus among the authors.

RESULTS

Surgery for diagnosis and management of cervical cancer was perceived as (1) appropriate when performed at early stage of cancer and by senior doctors, but (2) a potential catalyst for the spread of cancer and early death; and (3) a challenge to childbearing and motherhood as well as a source of distress to women and families if surgery involved removal of the uterus with subsequent permanent infertility.

CONCLUSIONS

There are some negative perceptions about surgery for cervical cancer that may deter prompt help-seeking for symptoms. However, targeted messages for public awareness interventions to promote help-seeking can be built on the positive perceptions and beliefs that surgery could be curative when undertaken for early-stage cancer and by skilled doctors.