Quality of life in stage II breast cancer: an instrument for clinical trials

Psychological Aspects of Breast Cancer

Breast cancer is the most commonly diagnosed cancer in women. Associated psychological symptoms include stress, adjustment difficulties, anxiety, depression, impaired cognitive function, sleep disturbances, altered body image, sexual dysfunction, and diminished overall well-being. Distress screening and assessment identifies women who will benefit from therapeutic interventions. Addressing these symptoms improves compliance with treatment and outcomes including disease-related outcomes, psychological symptoms, and quality of life. The most effective treatments include teaching coping skills such as expressing emotion, along with other structured cognitive behavioral, interpersonal, and mindfulness approaches. Patients should be provided these psychosocial supports throughout their cancer journey.

Unified estimation for Cox regression model with nonmonotone missing at random covariates

This article investigates a unified estimator for Cox regression model (Cox, 1972) when covariate data are missing at random (Rubin, 1976). It extends the idea of using parametric working models (Zhao and Liu, 2021) to extract the partial information contained in the incomplete observations. The working models are flexible and convenient to deal with nonmonotone missing data patterns. It can also incorporate auxiliary variables into the analysis to reduce estimation bias and improve efficiency. The unified estimator is consistent and more efficient than the (weighted) complete case estimator. Similar to multiple imputation (MI) method (Rubin, 1987 and 1996), the proposed method is also based on standard (weighted) complete data analysis and can be easily implemented in standard software. Simulation studies comparing the unified estimator with the substantive model compatible modification of the fully conditional specification MI (SMC-FCS) estimator (Bartlett et al., 2015) in various settings indicate that the unified estimator is consistent and as efficient as SMC-FCS estimator. Data from a clinical trial in patients with early breast cancer are analyzed for illustration.

Weighted generalized estimating equations and unified estimation for longitudinal data with nonmonotone missing data patterns

Missing data are a major complication in longitudinal data analysis. Weighted generalized estimating equations (WGEEs, Robins et al, J Am Stat Assoc 1995;90:106-121) were developed to deal with missing response data. They have been extended for data with both missing responses and missing covariates (Chen et al, J Am Stat Assoc 2010;105:336-353). However, it may introduce more variability in dealing with the correlation structure of the responses. We propose new WGEEs for missing at random data where both response and (time-dependent) covariates may have values missing in nonmonotone missing data patterns. We also explain how to improve the estimation efficiency of WGEEs using a unified approach (Zhao and Liu, AStA Adv Stat Anal 2021;105(1):87-101). The proposed unified estimator is consistent and more efficient than the regular WGEE estimator. It is computationally simple and can be directly implemented in standard software. Simulation studies for both continuous response and binary response data are provided to examine the performance of the proposed estimators. A clinical trial example investigating the quality of life of women with early-stage breast cancer and the associated factors is analyzed.

Partial breast irradiation versus whole breast radiotherapy for early breast cancer

BACKGROUND

Breast-conserving therapy for women with breast cancer consists of local excision of the tumour (achieving clear margins) followed by radiotherapy (RT). Most true recurrences occur in the same quadrant as the original tumour. Whole breast radiotherapy (WBRT) may not protect against the development of a new primary cancer developing in other quadrants of the breast. In this Cochrane Review, we investigated the delivery of radiation to a limited volume of the breast around the tumour bed (partial breast irradiation (PBI)) sometimes with a shortened treatment duration (accelerated partial breast irradiation (APBI)).

OBJECTIVES

To determine whether PBI/APBI is equivalent to or better than conventional or hypofractionated WBRT after breast-conserving therapy for early-stage breast cancer.

SEARCH METHODS

On 27 August 2020, we searched the Cochrane Breast Cancer Group Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL and three trial databases. We searched for grey literature: OpenGrey (September 2020), reference lists of articles, conference proceedings and published abstracts, and applied no language restrictions.

SELECTION CRITERIA

Randomised controlled trials (RCTs) without confounding, that evaluated conservative surgery plus PBI/APBI versus conservative surgery plus WBRT. Published and unpublished trials were eligible.

DATA COLLECTION AND ANALYSIS

Two review authors (BH and ML) performed data extraction, used Cochrane's risk of bias tool and resolved any disagreements through discussion, and assessed the certainty of the evidence for main outcomes using GRADE. Main outcomes were local recurrence-free survival, cosmesis, overall survival, toxicity (subcutaneous fibrosis), cause-specific survival, distant metastasis-free survival and subsequent mastectomy. We entered data into Review Manager 5 for analysis.

MAIN RESULTS

We included nine RCTs that enrolled 15,187 women who had invasive breast cancer or ductal carcinoma in-situ (6.3%) with T1-2N0-1M0 Grade I or II unifocal tumours (less than 2 cm or 3 cm or less) treated with breast-conserving therapy with negative margins. This is the second update of the review and includes two new studies and 4432 more participants. Local recurrence-free survival is probably slightly reduced (by 3/1000, 95% CI 6 fewer to 0 fewer) with the use of PBI/APBI compared to WBRT (hazard ratio (HR) 1.21, 95% confidence interval (CI) 1.03 to 1.42; 8 studies, 13,168 participants; moderate-certainty evidence). Cosmesis (physician/nurse-reported) is probably worse (by 63/1000, 95% CI 35 more to 92 more) with the use of PBI/APBI (odds ratio (OR) 1.57, 95% CI 1.31 to 1.87; 6 studies, 3652 participants; moderate-certainty evidence). Overall survival is similar (0/1000 fewer, 95% CI 6 fewer to 6 more) with PBI/APBI and WBRT (HR 0.99, 95% CI 0.88 to 1.12; 8 studies, 13,175 participants; high-certainty evidence). Late radiation toxicity (subcutaneous fibrosis) is probably increased (by 14/1000 more, 95% CI 102 more to 188 more) with PBI/APBI (OR 5.07, 95% CI 3.81 to 6.74; 2 studies, 3011 participants; moderate-certainty evidence). The use of PBI/APBI probably makes little difference (1/1000 less, 95% CI 6 fewer to 3 more) to cause-specific survival (HR 1.06, 95% CI 0.83 to 1.36; 7 studies, 9865 participants; moderate-certainty evidence). We found the use of PBI/APBI compared with WBRT probably makes little or no difference (1/1000 fewer (95% CI 4 fewer to 6 more)) to distant metastasis-free survival (HR 0.95, 95% CI 0.80 to 1.13; 7 studies, 11,033 participants; moderate-certainty evidence). We found the use of PBI/APBI in comparison with WBRT makes little or no difference (2/1000 fewer, 95% CI 20 fewer to 20 more) to mastectomy rates (OR 0.98, 95% CI 0.78 to 1.23; 3 studies, 3740 participants, high-certainty evidence).

AUTHORS' CONCLUSIONS

It appeared that local recurrence-free survival is probably worse with PBI/APBI; however, the difference was small and nearly all women remain free of local recurrence. Overall survival is similar with PBI/APBI and WBRT, and we found little to no difference in other oncological outcomes. Some late effects (subcutaneous fibrosis) may be worse with PBI/APBI and its use is probably associated with worse cosmetic outcomes. The limitations of the data currently available mean that we cannot make definitive conclusions about the efficacy and safety or ways to deliver PBI/APBI. We await completion of ongoing trials.

Identification and Analysis of the Blood lncRNA Signature for Liver Cirrhosis and Hepatocellular Carcinoma

As one of the most common malignant tumors, hepatocellular carcinoma (HCC) is the fifth major cause of cancer-associated mortality worldwide. In 90% of cases, HCC develops in the context of liver cirrhosis and chronic hepatitis B virus (HBV) infection is an important etiology for cirrhosis and HCC, accounting for 53% of all HCC cases. To understand the underlying mechanisms of the dynamic chain reactions from normal to HBV infection, from HBV infection to liver cirrhosis, from liver cirrhosis to HCC, we analyzed the blood lncRNA expression profiles from 38 healthy control samples, 45 chronic hepatitis B patients, 46 liver cirrhosis patients, and 46 HCC patients. Advanced machine-learning methods including Monte Carlo feature selection, incremental feature selection (IFS), and support vector machine (SVM) were applied to discover the signature associated with HCC progression and construct the prediction model. One hundred seventy-one key HCC progression-associated lncRNAs were identified and their overall accuracy was 0.823 as evaluated with leave-one-out cross validation (LOOCV). The accuracies of the lncRNA signature for healthy control, chronic hepatitis B, liver cirrhosis, and HCC were 0.895, 0.711, 0.870, and 0.826, respectively. The 171-lncRNA signature is not only useful for early detection and intervention of HCC, but also helpful for understanding the multistage tumorigenic processes of HCC.

Acute Toxicity and Quality of Life of Hypofractionated Radiation Therapy for Breast Cancer

PURPOSE

To assess the acute toxicity and quality of life (QOL) of hypofractionation compared with conventional fractionation for whole breast irradiation (WBI) after breast-conserving surgery.

METHODS AND MATERIALS

Women with node-negative breast cancer who had undergone breast-conserving surgery with clear margins were randomly assigned to conventional WBI of 5000 cGy in 25 fractions over 35 days or hypofractionated WBI of 4256 cGy in 16 fractions over 22 days. Acute skin toxicity and QOL were assessed at baseline and 2, 4, 6, and 8 weeks from the start of treatment for a subgroup of patients. QOL was assessed at baseline and 4 weeks posttreatment for all patients. In the acute toxicity substudy, repeated measures modeling was used to investigate treatment by time interactions over the 8-week period for acute toxicity and QOL mean change score. QOL mean change score from baseline to 4 weeks posttreatment was compared for all patients.

RESULTS

In the acute toxicity substudy, 161 patients participated. In the main trial, 1152 patients participated. Acute skin toxicity was initially similar between groups but was less with hypofractionation compared with conventional fractionation toward the end of the 8-week period (P < .001). QOL at 6 weeks from the start of treatment was improved with hypofractionation for the skin side effects, breast side effects, fatigue, attractiveness, and convenience domains (all P < .05). In the main trial, hypofractionation resulted in improved overall QOL and QOL attributed to skin side effects, breast side effects, and attractiveness (all P < .01).

CONCLUSIONS

Hypofractionated WBI compared with conventional WBI resulted in less acute toxicity and improved QOL. This further supports the benefits of hypofractionation.

Life Quality Index Assessment in Breast Cancer Patients

Breast cancer (BC) is the most common cancer in Indian females whether they are from urban or rural area. Quality of life after treatment in BC patients is a very vital issue as its assessment will guide the clinicians, hospital authorities, and administrators to take appropriate steps to improve the delivery of treatment and address the concern. Improvement in QOL should be one of the ultimate aims of treatment in BC. The aim of this review is to collect and examine literature available on QOL in breast cancer patients and define what type of issues or domains should be studied. Four factors including chemotherapy treatment received by the patient, associated comorbidities, social support to patients from family, friends, support groups, and income of family have been found to have a strong association with QOL in BC patients/survivors. QOL assessment should include an instrument which assesses physical health, social health, psychological health, and spiritual health. There are less studies having all above domains so more studies are required for better understanding of QOL issue in BC patients/survivors.

Evaluación de la calidad de vida relacionada con la salud pre y post trasplante hepático, en pacientes de un hospital de alta complejidad

El trasplante hepático es la alternativa terapéutica indicada en pacientes con enfermedad hepática terminal para mejorar su sobrevida y calidad de vida. El objetivo de este estudio fue evaluar la calidad de vida relacionada con la salud (CVRS) de pacientes con cirrosis hepática antes y después de trasplante hepático. Se incluyeron 33 personas adultas que estaban en lista de espera para trasplante en la institución, se aplicó una serie de cuestionarios antes y después del trasplante: para evaluar la calidad de vida se utilizaron el LDQOL-1 (específico para enfermedad y trasplante hepático) y SF36 (para población general); para evaluar los síntomas depresivos y ansiosos, se utilizaron el BDI y STAI, respectivamente. Los resultados señalan una mejoría en la CVRS, así como disminución de los síntomas ansiosos y depresivos posterior al trasplante.

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

Aims

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

Methods

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

Results

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

Conclusions

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

Patient-Reported Outcomes in Breast Oncology: A Review of Validated Outcome Instruments

Aims and background

Patient-reported outcomes (PROs) include areas of health-related quality of life but also broader concepts such as patient satisfaction with care. The aim of this review is to give an account of all instruments with potential use in patients with a history of treatment for breast cancer (including surgery, chemotherapy and/or radiotherapy) with evidence of validation in the breast cancer population.

Methods

All instruments included in this review were identified as PRO measures measuring breast-related quality of life and/or satisfaction that had undergone development and validation with breast oncology patients. We specifically looked for PRO measures examining patient satisfaction and/or quality of life after breast cancer treatment. Following an evaluation of 323 papers, we identified 15 instruments that were able to satisfy our inclusion criteria.

Results

These instruments are the EORTC QOL-C30 and QLQ-BR23 (European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Breast Cancer Module), the FACT-B (Functional Assessment of Cancer Therapy-Breast Cancer), the SLDS-BC (Satisfaction with Life Domains Scale for Breast Cancer), the BIBCQ (Body Image after Breast Cancer Questionnaire), the HIBS (Hopwood Body Image Scale), the PBIS (Polivy Body Image Scale), the MBROS (Michigan Breast Reconstruction Outcomes Study) Satisfaction and Body Image Questionnaires, the BREAST-Q, the BCTOS (Breast Cancer Treatment Outcome Scale), the BCQ, the FACT-ES (Functional Assessment of Cancer Therapy-Endocrine System), the MAS (Mastectomy Attitude Scale), and the Breast Cancer Prevention Trial Symptom Checklist (BCPT).

Conclusions

Suggestions for future directions include (1) to use and utilize validated instruments tailored to clinical practice; (2) to develop a comprehensive measurement of surgical outcome requiring the combination of objective and subjective measures; (3) to aim for a compromise between these two competing considerations in the form of a scale incorporating both generalizability in cancer-related QOL and specificity in breast cancer issues.

Quality of life of elderly patients with solid tumours undergoing adjuvant cancer therapy: a systematic review

OBJECTIVES

The measurement of quality of life (QoL) in elderly cancer population is increasingly being recognised as an important element of clinical decision-making and the evaluation of treatment outcome. This systematic review aimed to summarise the evidence of QoL during and after adjuvant therapy in elderly patients with cancer.

METHODS

A systematic search was conducted of studies published in CINAHL plus, CENTRAL, PubMed, PsycINFO and Web of Science from the inception of these databases to December 2016. Eligible studies included RCTs and non-RCTs in which QoL was measured in elderly patients (aged 65 years or above) with stage I-III solid tumours who were undergoing adjuvant chemotherapy and/or radiotherapy. Because of the heterogeneity and the insufficient data among the included studies, the results were synthesised narratively.

RESULTS

We included 4 RCTs and 14 non-RCTs on 1785 participants. In all four RCTs, the risk of bias was low or unclear for most items but high for detection. Of the 14 non-RCTs, 5 studies were judged to have a low or moderate risk of bias for all domains, and the other 9 studies had a serious risk of bias in at least one domain. The bias was observed mainly in the confounding and in the selection of participants for the study. For most elderly patients with breast cancer, the non-significant negative change in the QoL was transient. A significant increase in the QoL during the course of temozolomide in elderly patients with glioblastoma but a decreasing trend in QoL after radiotherapy was shown. This review also shows a uniform trend of stable or improved QoL during adjuvant therapy and at follow-up evaluations across the studies with prostate, colon or cervical cancer population.

CONCLUSIONS

This review suggests that adjuvant chemotherapy and radiotherapy may not have detrimental effects on QoL in most elderly patients with solid tumours.

Quality of life of breast and cervical cancer survivors

Background

Breast and cervical cancer are the most common cancers affecting women. The symptom distresses experienced by cancer survivors are critical factors influencing their quality of life (QOL). This study investigated the QOL of breast and cervical cancer survivors, their physical, psychological and social conditions.

Methods

The participants were older than 20 years, had been diagnosed with breast or cervical cancer for more than 2 years, and had completed their cancer treatment. The survey incorporated the QOL questionnaires developed by the European Organization of Research and Treatment for Cancer and a self-designed questionnaire.

Results

The mean age at diagnosis was 48.89 ± 8.53 years for the breast cancer survivors and 49.00 ± 10.30 years for the cervical cancer survivors. The corresponding QOL scores were 75.33 ± 20.25 and 75.56 ± 17.93. The factors influencing QOL of breast cancer survivors were household income, number of comorbidities, stage of cancer, type of cancer treatment and duration of illness, whereas the factor related to QOL of cervical cancer survivors was only household income.

Conclusions

The QOL of the two groups was similar. Healthcare providers should demonstrate greater concern toward breast and cervical cancer survivors.

Partial breast irradiation for early breast cancer

BACKGROUND

Breast-conserving therapy for women with breast cancer consists of local excision of the tumour (achieving clear margins) followed by radiotherapy (RT). RT is given to sterilize tumour cells that may remain after surgery to decrease the risk of local tumour recurrence. Most true recurrences occur in the same quadrant as the original tumour. Whole breast radiotherapy (WBRT) may not protect against the development of a new primary cancer developing in other quadrants of the breast. In this Cochrane review, we investigated the delivery of radiation to a limited volume of the breast around the tumour bed (partial breast irradiation (PBI)) sometimes with a shortened treatment duration (accelerated partial breast irradiation (APBI)).

OBJECTIVES

To determine whether PBI/APBI is equivalent to or better than conventional or hypo-fractionated WBRT after breast-conserving therapy for early-stage breast cancer.

SEARCH METHODS

We searched the Cochrane Breast Cancer Group Specialized Register (4 May 2015), the Cochrane Central Register of Controlled Trials (CENTRAL) (2015, Issue 5), MEDLINE (January 1966 to 4 May 2015), EMBASE (1980 to 4 May 2015), CINAHL (4 May 2015) and Current Contents (4 May 2015). We searched the International Standard Randomised Controlled Trial Number Register (5 May 2015), the World Health Organization's International Clinical Trials Registry Platform (4 May 2015) and ClinicalTrials.gov (17 June 2015). We searched for grey literature: OpenGrey (17 June 2015), reference lists of articles, several conference proceedings and published abstracts, and applied no language restrictions.

SELECTION CRITERIA

Randomized controlled trials (RCTs) without confounding, that evaluated conservative surgery plus PBI/APBI versus conservative surgery plus WBRT. Published and unpublished trials were eligible.

DATA COLLECTION AND ANALYSIS

Two review authors (BH and ML) performed data extraction and used Cochrane's 'Risk of bias' tool, and resolved any disagreements through discussion. We entered data into Review Manager 5 for analysis.

MAIN RESULTS

We included seven RCTs and studied 7586 women of the 8955 enrolled.Local recurrence-free survival appeared worse for women receiving PBI/APBI compared to WBRT (hazard ratio (HR) 1.62, 95% confidence interval (CI) 1.11 to 2.35; six studies, 6820 participants, low-quality evidence). Cosmesis (physician-reported) appeared worse with PBI/APBI (odds ratio (OR) 1.51, 95% CI 1.17 to 1.95, five studies, 1720 participants, low-quality evidence). Overall survival did not differ with PBI/APBI (HR 0.90, 95% CI 0.74 to 1.09, five studies, 6718 participants, high-quality evidence).Late radiation toxicity (subcutaneous fibrosis) appeared worse with PBI/APBI (OR 6.58, 95% CI 3.08 to 14.06, one study, 766 participants, moderate-quality evidence). Acute skin toxicity appeared reduced with PBI/APBI (OR 0.04, 95% CI 0.02 to 0.09, two studies, 608 participants). Telangiectasia (OR 26.56, 95% CI 3.59 to 196.51, 1 study, 766 participants) and radiological fat necrosis (OR 1.58, 95% CI 1.02 to 2.43, three studies, 1319 participants) appeared worse with PBI/APBI. Late skin toxicity (OR 0.21, 95% CI 0.01 to 4.39, two studies, 608 participants) and breast pain (OR 2.17, 95% CI 0.56 to 8.44, one study, 766 participants) appeared not to differ with PBI/APBI.'Elsewhere primaries' (new primaries in the ipsilateral breast) appeared more frequent with PBI/APBI (OR 3.97, 95% CI 1.51 to 10.41, three studies, 3009 participants).We found no clear evidence of a difference for the comparison of PBI/APBI with WBRT for the outcomes of: cause-specific survival (HR 1.08, 95% CI 0.73 to 1.58, five studies, 6718 participants, moderate-quality evidence), distant metastasis-free survival (HR 0.94, 95% CI 0.65 to 1.37, four studies, 3267 participants, moderate-quality evidence), relapse-free survival (HR 1.36, 95% CI 0.88 to 2.09, three studies, 3811 participants), loco-regional recurrence-free survival (HR 1.80, 95% CI 1.00 to 3.25, two studies, 3553 participants) or mastectomy rates (OR 1.20, 95% CI 0.77 to 1.87, three studies, 4817 participants, low-quality evidence). Compliance was met: more than 90% of the women in all studies received the RT they were assigned to receive. We found no data for the outcomes of costs, quality of life or consumer preference.

AUTHORS' CONCLUSIONS

It appeared that local recurrence and 'elsewhere primaries' (new primaries in the ipsilateral breast) are increased with PBI/APBI (the difference was small), but we found no evidence of detriment to other oncological outcomes. It appeared that cosmetic outcomes and some late effects were worse with PBI/APBI but its use was associated with less acute skin toxicity. The limitations of the data currently available mean that we cannot make definitive conclusions about the efficacy and safety or ways to deliver of PBI/APBI. We await completion of ongoing trials.

Pretreatment quality of life, performance status and their relation to treatment discontinuation and treatment changes in high-risk breast cancer patients receiving chemotherapy: results from the prospective randomized ADEBAR trial

BACKGROUND

Health-related quality of life (QoL) is a self-assessed construct indicating how people feel in regard to aspects of their health. Performance status (PS) is evaluated by the treating physician. We examined whether pretreatment QoL and PS are related to subsequent treatment discontinuation and treatment changes in high-risk breast cancer patients receiving chemotherapy.

METHODS

We conducted a prospective cohort study with data from a randomized phase III trial comparing FEC- and EC-DOC-chemotherapy in patients with primary breast cancer (ADEBAR). We examined the patient's request to discontinue the study, discontinuation due to toxicity, the prolongation of therapy, and dose reduction. Baseline QoL was assessed using the EORTC QLQ-C30. PS was evaluated using the Eastern Cooperative Oncology Group Scale (ECOG). Four QoL scales were selected prior to analysis as outcomes: global health, physical functioning, emotional functioning, and fatigue. Multivariate binary logistic regression analyses were used to test for differences within the independent variables.

MAIN RESULTS

1322 patients were included. 1094 (82.8 %) patients completed therapy according to protocol. 6.3 % stopped therapy due to toxicity and 4.4 % refused treatment. Global health was not related to any of the four QoL outcomes. Physical functioning had the strongest impact on QoL, when comparing the fittest group to the lowest quintile [OR 2.14 (95 % CI 1.00-4.60)]. ECOG 0 compared to worse than 1 was strongly correlated to therapy discontinuation due to toxicity [OR 20.15 (95 % CI 9.48-42.83)] and treatment refusal [OR 8.32 (95 % CI 3.81-18.14)].

CONCLUSIONS

Pretreatment QoL, especially physical functioning, is associated with subsequent therapy discontinuation due to toxicity and with changes of the treatment protocol. Pretreatment performance status is strongly associated with therapy discontinuation due to toxicity and with treatment refusal.

Challenges in shared decision making in advanced cancer care: a qualitative longitudinal observational and interview study

Background

Patients' preferences and expectations should be taken into account in treatment decision making in the last phase of life. Shared decision making (SDM) is regarded as a way to give the patient a central role in decision making. Little is known about how SDM is used in clinical practice in advanced cancer care.

Objective

To examine whether and how the steps of SDM can be recognized in decision making about second‐ and third‐line chemotherapy.

Methods

Fourteen advanced cancer patients were followed over time using face‐to‐face in‐depth interviews and observations of the patients' out‐clinic visits. Interviews and outpatient clinic visits in which treatment options were discussed or decisions made were transcribed verbatim and analysed using open coding.

Results

Patients were satisfied with the decision‐making process, but the steps of SDM were barely seen in daily practice. The creation of awareness about available treatment options by physicians was limited and not discussed in an equal way. Patients' wishes and concerns were not explicitly assessed, which led to different expectations about improved survival from subsequent lines of chemotherapy.

Conclusion

To reach SDM in daily practice, physicians should create awareness of all treatment options, including forgoing treatment, and communicate the risk of benefit and harm. Open and honest communication is needed in which patients' expectations and concerns are discussed. Through this, the difficult process of decision making in the last phase of life can be facilitated and the focus on the best care for the specific patient is strengthened.

Effects of Theodore Millon's Teaching, Mentorship, Theory, and Scientific Contributions on Health Psychology and Behavioral Medicine Research and Practice

This article summarizes the impact of Theodore Millon's work on the disciplines of health psychology and behavioral medicine over the past 5 decades spanning from the late 1960s to present. The article is written from my perspectives as a graduate student mentored by Millon on through my faculty career as a collaborator in test construction and empirical validation research. Several of the most recent entries in this summary reflect projects that were ongoing at the time of his passing, revealing the innovation and visionary spirit that he demonstrated up until the end of his life. Considering that this summary is restricted to Millon's contributions to the disciplines of health psychology and behavioral medicine, this work comprises only a small portion of his larger contribution to the field of psychology and the areas of personality theory and psychological assessment more broadly.

Therapy choices and quality of life in young breast cancer survivors: a short-term follow-up

BACKGROUND

Premenopausal women represent approximately 35% of new breast cancer diagnoses. Diagnosis and treatment may lead to substantial disruption in quality of life (QOL).

METHODS

Premenopausal patients (aged 18 to 50 years) treated for nonmetastatic breast cancer completed a mailed questionnaire. Multiple self-reported QOL measures and clinical data were collected. Cluster analysis and Cronbach's α were used to validate the survey. Analysis of variance was performed for specific interventions. Lower interference scores conveyed higher QOL.

RESULTS

The response rate was 49.8%. Cronbach's α was 0.96. Immediate contralateral prophylactic mastectomy (CPM) carried the highest interference (mean, 3.3148) with sexuality compared with no CPM (mean, 2.85) or delayed CPM (P = .03). Breast conservation had the least interference with appearance (P < .01) and work and finances (P = .02).

CONCLUSIONS

Therapeutic mastectomy and CPM with or without reconstruction may adversely affect QOL. These findings suggest that the choice and timing of interventions may significantly affect patient satisfaction.

Interim cosmetic and toxicity results from RAPID: a randomized trial of accelerated partial breast irradiation using three-dimensional conformal external beam radiation therapy

PURPOSE

To report interim cosmetic and toxicity results of a multicenter randomized trial comparing accelerated partial-breast irradiation (APBI) using three-dimensional conformal external beam radiation therapy (3D-CRT) with whole-breast irradiation (WBI).

PATIENTS AND METHODS

Women age > 40 years with invasive or in situ breast cancer ≤ 3 cm were randomly assigned after breast-conserving surgery to 3D-CRT APBI (38.5 Gy in 10 fractions twice daily) or WBI (42.5 Gy in 16 or 50 Gy in 25 daily fractions ± boost irradiation). The primary outcome was ipsilateral breast tumor recurrence (IBTR). Secondary outcomes were cosmesis and toxicity. Adverse cosmesis was defined as a fair or poor global cosmetic score. After a planned interim cosmetic analysis, the data, safety, and monitoring committee recommended release of results. There have been too few IBTR events to trigger an efficacy analysis.

RESULTS

Between 2006 and 2011, 2,135 women were randomly assigned to 3D-CRT APBI or WBI. Median follow-up was 36 months. Adverse cosmesis at 3 years was increased among those treated with APBI compared with WBI as assessed by trained nurses (29% v 17%; P < .001), by patients (26% v 18%; P = .0022), and by physicians reviewing digital photographs (35% v 17%; P < .001). Grade 3 toxicities were rare in both treatment arms (1.4% v 0%), but grade 1 and 2 toxicities were increased among those who received APBI compared with WBI (P < .001).

CONCLUSION

3D-CRT APBI increased rates of adverse cosmesis and late radiation toxicity compared with standard WBI. Clinicians and patients are cautioned against the use of 3D-CRT APBI outside the context of a controlled trial.

Evaluating the well-being of public library workers

This study aimed to develop and pilot a questionnaire to determine the ways in which working in a UK public library system can impact the well-being of those deployed in the sector. The methodological framework was based on an approach used to evaluate the well-being of patients in a clinical setting. Based on the responses of 466 employees, the results identified eight dimensions of library worker well-being; organizational, advancement, job design aspects, physical health, psychological health, interpersonal relationships, workload and facilities. Analyses indicated that organizational aspects most impaired well-being and longer-serving employees were worst affected. The findings offer a new, evidence-based perspective on the well-being issues that public library workers perceive to be most important and challenge earlier claims regarding stress and burnout. Also considered is the relevance of employer-sponsored wellness programmes where improvement in organizational performance is the prime reason behind provision.

Validity of the Greek EORTC QLQ-C30 and QLQ-BR23 for measuring health-related quality of life in breast cancer patients

The aim of this study was to assess construct validity and internal consistency reliability of the Greek EORTC QLQ-C30 and QLQ-BR23 instruments. A sample of female breast cancer patients (n= 105) were self-administered the QLQ-C30, QLQ-BR23 and SF-36 and questions on treatment and socio-demographic status. Hypothesised scale structure, reliability (Cronbach's α) and construct validity (convergent, discriminative, concurrent and known-groups) were assessed. Multitrait scaling confirmed scale structure of the QLQ-C30 and QLQ-BR23 with good item convergence (92% and 85%), and discrimination (87% and 84%) rates. Cronbach's α was >0.70 for all but one scale (cognitive functioning). Strength of Spearman's correlations between the QLQ-C30 and SF-36 scales assessing similar health-related quality of life dimensions ranged from 0.25 to 0.64 (P < 0.01). Construct validity was confirmed with satisfactory results for interscale correlations and known-groups comparisons. QLQ-BR23 scales showed comparatively low (<0.40) correlations with QLQ-C30 functional scales, and higher correlations with conceptually related symptom scales. Most QLQ-C30 and QLQ-BR23 scales discriminated between pre-treatment and current treatment patients. The overall psychometric results for the Greek version of the QLQ-C30 and QLQ-BR23 confirmed it as a reliable and valid questionnaire for assessing breast cancer-specific HRQoL in Greece.

Quality-of-life considerations in the treatment of early-stage breast cancer in the elderly

Breast cancer is a common tumour in the elderly population and management of early disease in particular is a major challenge for oncologists and geriatricians alike. An important aspect is a differentiated knowledge about the short-term effects and long-term perspectives regarding levels of functioning and subjective well-being associated with different treatment strategies. The article focuses on available quality-of-life (QOL) measurement instruments in elderly patients with early breast cancer and the impact of various local or systemic treatments on QOL scores. A selective literature search was carried out in the PubMed database from January 2000 to May 2010 using the terms 'early breast cancer', 'elderly' and 'quality of life'. Contributions to international congresses on breast cancer in 2009 were also included. Of the 80 articles retrieved, 46 publications were excluded from further consideration due to failure to fulfil inclusion criteria (e.g. not restricted to the elderly, inclusion of patients with metastatic disease, no adjuvant treatment). Sixteen papers focusing on complementary treatment were also rejected. The remaining 18 articles were extensively reviewed. The selection of described QOL measurements was very heterogeneous in these 18 studies. Commonly used QOL instruments were the European Organization for Research and Treatment of Cancer QOL questionnaires (EORTC QLQ-C30, EORTC QLQ-BR23) and the Functional Assessment of Cancer Therapy questionnaires (FACT-G, FACT-B) and its subscales. Additionally, the Medical Outcomes Study 36-Item Short-Form Health Survey (MOS-SF-36), the Hospital Anxiety and Depression Scale (HADS) and the International Breast Cancer Study Group (IBCSG) approach were used by various study groups. The general limitations of QOL assessment in the elderly population are discussed in the review. Surgery, when considered from a technical point of view, does not differ significantly with patient age. Furthermore, age in itself should not be a contraindication to breast-conserving surgery (BCS) because QOL appears somewhat better after conservative surgical treatment. Avoiding axillary surgery and undergoing sentinel lymph node dissection in elderly patients are both associated with better short-term QOL. However, conventional axillary surgery has little effect on long-term QOL in older women. The advent of innovative radiotherapy techniques has resulted in marked improvements in short-term tolerability together with reductions in the incidence and severity of late normal tissue damage. A potential alternative to conventional postoperative radiotherapy after BCS in the future is the intraoperative radiotherapy technique. Chemotherapy has considerable effects on QOL in breast cancer patients. Most studies found that overall QOL was maintained or improved in patients receiving either aromatase inhibitors or tamoxifen but patients reported different adverse effects. For the majority of older breast cancer survivors, cancer-specific well-being and general emotional health do not change substantially after a breast cancer diagnosis. In summary, issues related to baseline co-morbidities in frail elderly, the adverse effects of novel chemotherapeutic agents (e.g. nanoparticle albumin-bound paclitaxel) or target drugs (biologicals) and compliance in the elderly population should receive more attention in evaluations of QOL in elderly breast cancer patients. Future studies that include QOL measurements should also provide details on the data collection and quality control methodologies used.

Fatigued breast cancer survivors: the role of sleep quality, depressed mood, stage and age

Cancer-related fatigue is associated with lower health-related quality of life and the majority of breast cancer survivors experience persistent fatigue after finishing treatment. The present study examines age, cancer stage, sleep quality and depressed mood as predictors of five dimensions of fatigue in 70 fatigued breast cancer survivors who no longer evidenced any signs of cancer and were finished with treatment. Discriminant function analyses were used to predict fatigue subgroup membership (higher, lower) from age, stage, mood and sleep for five subtypes: General, Mental, Emotional, and Physical fatigue, and Vigour. Significant discriminant functions were found for all subtypes. Findings suggest that age, staging, mood and sleep are all important predictors, but there are differential relationships when subtypes of fatigue are considered. Given current limitations in treating fatigue directly, interventions targeting mood and sleep should be considered as alternate approaches to reduce fatigue.

Cyclophosphamide, epirubicin, and Fluorouracil versus dose-dense epirubicin and cyclophosphamide followed by Paclitaxel versus Doxorubicin and cyclophosphamide followed by Paclitaxel in node-positive or high-risk node-negative breast cancer

PURPOSE Cyclophosphamide, epirubicin, and fluorouracil (CEF) and doxorubicin and cyclophosphamide (AC) followed by paclitaxel (T) are commonly used adjuvant regimens in women with early breast cancer. In a previous trial in women with locally advanced breast cancer, 3 months of high-dose epirubicin and cyclophosphamide (EC) administered every 2 weeks (dose-dense) was equivalent to 6 months of CEF. We hypothesized that 3 months of paclitaxel after dose-dense EC (EC/T) would be superior to CEF or AC/T. METHODS After lumpectomy or mastectomy, women 60 years of age or younger with axillary node-positive or high-risk node-negative breast cancer were randomly assigned to receive CEF, EC/T, or AC/T for 6 months. This article reports the interim analysis for recurrence-free survival (RFS), which was planned after 227 recurrences. Results A total of 2,104 patients were enrolled. The median follow-up is 30.4 months. Hazard ratios for recurrence are as follows: AC/T versus CEF, 1.49 (95% CI, 1.12 to 1.99), P = .005; AC/T versus EC/T, 1.68 (95% CI, 1.25 to 2.27), P = .0006; and EC/T versus CEF, 0.89 (95% CI, 0.64 to 1.22), P = .46. Three-year RFS rates for CEF, EC/T, and AC/T are 90.1%, 89.5%, and 85.0%, respectively. There was more febrile neutropenia with CEF (22.3%) and EC/T (16.4%) compared with AC/T (4.8%), but more neuropathy with the last two regimens. CONCLUSION Three-weekly AC/T is significantly inferior to CEF or EC/T in terms of RFS. It is too early to detect any difference between CEF and dose-dense EC/T.

Assessment of palliative response in hyperthermia

It is important that clinical studies of hyperthermia will be able to define its contribution to palliative therapy. A variety of validated methods has been developed for assessing palliative therapy but none have been used in clinical studies of hyperthermia. In the present paper some of the methods available for the assessment of palliative therapy are reviewed. The necessary criteria for assessment of instruments for palliation, as well as the choice of method, is discussed. A simple strategy is proposed: use established methods and take advice on which to choose; selectively add relevant items, should this be necessary; use assessments made by patients as well as by clinicians; use the test instruments at least three times (before, during and after treatment), and pre-test it on a small series of patients before embarking upon a major study. It is hoped that, by drawing attention to the availability of such methods for evaluating palliation, they might prove important in more accurately evaluating the role of hyperthermia in the palliative treatment of cancer.

Coping with illness and subjective theories of illness in adult patients with haematological malignancies: systematic review

In parallel to development of individualised antineoplastic treatment, scientific interest in patients' subjective theories of illness (STOI) has emerged in the oncological community. STOI depend decisively on patients' information about their disease. Coping with illness is dependent from the individual situation and context, and it is generally modulated by patients' STOI. The purpose is fivefold: (1) to provide a thorough literature review about coping and about STOI in adult haematological patients, (2) to survey through which indicators the topics were operationalized in studies, (3) to clarify the kind of coherence between these two topics, (4) to explicate the interaction between STOI and other variables, and (5) to verify the clinical relevance of both topics. We searched 19 electronic databanks for English biomedical literature manuscripts (1995-2008) on this subject. Twenty-six studies met our criteria and varied in haematological entity, treatment concept, sample size and methodological design. We conclude that a subjective-individual regulation of patient's mental stability during a cytotoxic chemotherapy is important. Successful coping strategies develop not only based on objective, but also subjective evaluation mechanisms. We deduce consequences for doctor-patient communication and psychosocial care in haematology. The newly developed process model of subjective regulation in cancer patients, in general, views the oncological treatment process as a procedural mental evaluation.

Health-related quality of life in breast cancer patients: a bibliographic review of the literature from 1974 to 2007

Background

Quality of life in patients with breast cancer is an important outcome. This paper presents an extensive overview on the topic ranging from descriptive findings to clinical trials.

Methods

This was a bibliographic review of the literature covering all full publications that appeared in English language biomedical journals between 1974 and 2007. The search strategy included a combination of key words 'quality of life' and 'breast cancer' or 'breast carcinoma' in titles. A total of 971 citations were identified and after exclusion of duplicates, the abstracts of 606 citations were reviewed. Of these, meetings abstracts, editorials, brief commentaries, letters, errata and dissertation abstracts and papers that appeared online and were indexed ahead of publication were also excluded. The remaining 477 papers were examined. The major findings are summarized and presented under several headings: instruments used, validation studies, measurement issues, surgical treatment, systemic therapies, quality of life as predictor of survival, psychological distress, supportive care, symptoms and sexual functioning.

Results

Instruments-Several valid instruments were used to measure quality of life in breast cancer patients. The European Organization for Research and Treatment of Cancer Core Cancer Quality of Life Questionnaire (EORTC QLQ-C30) and its breast cancer specific complementary measure (EORTC QLQ-BR23) and the Functional Assessment Chronic Illness Therapy General questionnaire (FACIT-G) and its breast cancer module (FACIT-B) were found to be the most common and well developed instruments to measure quality of life in breast cancer patients. Surgery-different surgical procedures led to relatively similar results in terms of quality of life assessments, although mastectomy patients compared to conserving surgery patients usually reported a lower body image and sexual functioning. Systemic therapies-almost all studies indicated that breast cancer patients receiving chemotherapy might experience several side-effects and symptoms that negatively affect their quality of life. Adjuvant hormonal therapies also were found to have similar negative impact on quality of life, although in general they were associated with improved survival. Quality of life as predictor of survival-similar to known medical factors, quality of life data in metastatic breast cancer patients was found to be prognostic and predictive of survival time. Psychological distress-anxiety and depression were found to be common among breast cancer patients even years after the disease diagnosis and treatment. Psychological factors also were found to predict subsequent quality of life or even overall survival in breast cancer patients. Supportive care-clinical treatments to control emesis, or interventions such as counseling, providing social support and exercise could improve quality of life. Symptoms-Pain, fatigue, arm morbidity and postmenopausal symptoms were among the most common symptoms reported by breast cancer patients. As recommended, recognition and management of these symptoms is an important issue since such symptoms impair health-related quality of life. Sexual functioning-breast cancer patients especially younger patients suffer from poor sexual functioning that negatively affect quality of life.

Conclusion

There was quite an extensive body of the literature on quality of life in breast cancer patients. These papers have made a considerable contribution to improving breast cancer care, although their exact benefit was hard to define. However, quality of life data provided scientific evidence for clinical decision-making and conveyed helpful information concerning breast cancer patients' experiences during the course of the disease diagnosis, treatment, disease-free survival time, and recurrences; otherwise finding patient-centered solutions for evidence-based selection of optimal treatments, psychosocial interventions, patient-physician communications, allocation of resources, and indicating research priorities were impossible. It seems that more qualitative research is needed for a better understanding of the topic. In addition, issues related to the disease, its treatment side effects and symptoms, and sexual functioning should receive more attention when studying quality of life in breast cancer patients.

Quality of life and adjuvant systemic therapy for early-stage breast cancer

Adjuvant chemotherapy and hormonal therapy reduce the risk of recurrence and death due to breast cancer, but often at considerable cost to the health-related quality of life (HRQL) of patients. The short-term effects of chemotherapy on HRQL are well known and are accepted by most patients for modest gains in survival. The long-term effects of chemotherapy-induced menopause and hormonal therapy on HRQL are poorly recognized. Vasomotor symptoms and altered sexual function are common, distressing and inadequately treated. HRQL information is helpful in describing likely effects of adjuvant treatment, facilitating informed decision-making, identifying health problems to guide research into potential solutions, guiding treatment strategies for interventions with equivalent survival and guiding resource allocation. New technologies will make HRQL information increasingly available for individual patient care.

The role of health-related quality of life in early discontinuation of chemotherapy for breast cancer

To examine the role of health-related quality of life (HRQOL) in early treatment discontinuation among women enrolled in a breast cancer clinical trial. A total of 464 women were enrolled in the Eastern Cooperative Oncology Group randomized controlled trial of adjuvant regimens comparing six cycles of cytoxan, adriamycin and 5-flurouricil (5-FU) with a 16-week regimen (weekly therapy with cytoxan, adriamycin, vincristine, methotrexate, and 5-FU) among women with lymph node positive breast cancer. One hundred sixty-four women participated in the HrQL substudy using the Breast Chemotherapy Questionnaire, which was designed to measure HRQOL in women receiving chemotherapy. Changes in global HRQOL score were examined over time as a predictor of early treatment discontinuation using generalized estimation equations (GEE) modeling and Cox proportional hazards regression. We considered early treatment discontinuation as a longitudinal binary variable determined at each time point HRQOL was measured. The results of multivariate GEE model fitting indicated that declines in HRQOL (p=0.04), older age (p=0.02), higher degree of nausea (p=0.02), higher degree of neurosensory toxicity (0.03) and lower degrees of hair loss (p=0.004) were correlated with early treatment discontinuation. We then fitted a proportional hazard regression model for time to early discontinuation with HRQOL score as a time-dependent covariate. The results were identical. Declines in HRQOL during therapy predicted early treatment discontinuation even after accounting for age and chemotherapy-related side effects. In the age of ever more aggressive treatments for breast cancer, women's perception of the impact of these treatments on their lives will become more important.

Funding Patient-Reported Outcomes in Cancer Clinical Trials

We surveyed four cooperative groups to identify current funding sources for the collection and analysis effort associated with the inclusion of patient-reported outcome (PRO) data in cancer clinical trials. Survey questions included what proportion of staff effort was funded through the Cancer Therapy Evaluation Program (CTEP) and the Community Clinical Oncology Program (CCOP) grants. In addition, the groups were asked to what extent outside funding was solicited to cover an underfunded PRO effort (eg, the pharmaceutical industry, foundations, or National Institutes of Health grants). All four groups noted the challenge of making limited resources cover a number of trial responsibilities. PRO effort is usually bundled with effort required for all clinical trial data. There is variation in the use of the CTEP and CCOP grants to fund PRO research. The groups differed with respect to both the types and amount of outside funding used. This survey focused on funding sources for the conduct of PRO research in cooperative group trials; it did not assess the specific cost components associated with collecting and analyzing these data. In general, the costs for conducting PRO research have been bundled with other study costs because in most cases, the PRO has been considered an integral component of the trial. However, these data also suggest that PRO research has required the use of outside funding sources in the four surveyed cooperative groups and that PRO economic issues require attention if we are to continue the inclusion of these outcomes in cancer clinical trials.

Benefit from preoperative radiotherapy in rectal cancer treatment: disease-free patients' and oncologists' preferences

Preoperative radiotherapy (PRT) in resectable rectal cancer improves local control but increases probability of faecal incontinence and sexual dysfunction. Consensus was reached in 2001 in the Netherlands on a guideline advising PRT to new patients. Purpose was to assess at what benefit oncologists and rectal cancer patients prefer PRT followed by surgery to surgery alone, and how oncologists and patients value various treatment outcomes. Sixty-six disease-free patients and 60 oncologists (surgical, radiation, medical) were interviewed. Minimally desired benefit from PRT (local control) was assessed using the Treatment Tradeoff Method. Importance of survival, local control, faecal incontinence, and sexual dysfunction in determining treatment outcome preferences was assessed using Adaptive Conjoint Analysis. The range of required benefit from PRT varied widely within participant groups. Seventeen percent of patients would choose PRT at a 0% benefit; 11% would not choose PRT for the maximum benefit of 11%. Mean minimally desired benefit excluding these two groups was 4%. For oncologists, the required benefit was 5%. Also, how strongly participants valued treatment outcomes varied widely within groups. Of the four outcomes, participants considered incontinence most often as most important. Relative treatment outcome importance differed between specialties. Patients considered sexual functioning more important than oncologists. Large differences in treatment preferences exist between individual patients and oncologists. Oncologists should adequately inform their patients about the risks and benefits of PRT, and elicit patient preferences regarding treatment outcomes.

Measuring quality of life in cosmetic and reconstructive breast surgery: a systematic review of patient-reported outcomes instruments

BACKGROUND

Patient-reported outcomes in cosmetic and reconstructive breast surgery are increasingly important for clinical research endeavors. Traditional surgical outcomes, centered on morbidity and mortality, remain important but are no longer sufficient on their own. Quality of life has become a crucial research topic augmenting traditional concerns focused on complications and survival. Given this, reliable and valid patient questionnaires are essential for aesthetic and reconstructive breast surgeons.

METHODS

The authors performed a systematic literature review to identify patient-reported outcome measures developed and validated for use in cosmetic and reconstructive breast surgery patients. Qualifying instruments were assessed for adherence to international guidelines for health outcomes instrument development and validation.

RESULTS

The authors identified 227 health outcomes questionnaires used in breast surgery studies. After 135 generic instruments, 65 ad hoc instruments, seven oncologic instruments, 11 education questionnaires, and two non-English-language questionnaires were excluded, seven measures remained. Detailed analysis revealed that six of the seven measures had undergone limited development and validation. Only one measure, the Breast-Related Symptoms Questionnaire, demonstrated adequate development and validation in its target population. It had, nevertheless, significant content limitations.

CONCLUSIONS

Valid, reliable, and responsive instruments to measure patient-reported outcomes in cosmetic and reconstructive breast surgery are lacking. To demonstrate the benefits of aesthetic and reconstructive breast surgery, future research to rigorously develop and validate new cosmetic and reconstructive breast surgery-specific instruments is needed.

A dose escalation trial of adjuvant cyclophosphamide and epirubicin in combination with 5-fluorouracil using G-CSF support for premenopausal women with breast cancer involving four or more positive nodes

BACKGROUND

Dose-dense and dose-intensive regimens have improved the outcome of breast cancer in high-risk women with operable disease.

PATIENTS AND METHODS

Sixty-three premenopausal women with Stage 2, 3 breast cancer and > or =4 positive axillary nodes were treated in three successive cohorts with 70 mg/m(2) of epirubicin, 500 mg/m(2) of 5-fluorouracil and G-CSF every 14 days for 12 cycles. Cyclophosphamide (C) was given at 700 mg/m(2), 900 mg/m(2), and 1100 mg/m(2) doses. Patients were evaluated for dose-limiting toxicities (DLTs) in the first four cycles, the primary endpoint of the trial.

RESULTS

No DLTs were seen at C 700 mg/m(2); at C 900 mg/m(2) two of 16 patients experienced febrile neutropenia and poor performance status; at C 1100 mg/m(2), 1 of 31 patients experienced poor performance status. Over 6 months, febrile neutropenia, grade 4 thrombocytopenia, grade 3 anemia and severe fatigue were observed. Clinical congestive heart failure occurred in three patients over 4 years.

CONCLUSION

A dose-intense and dose-dense regimen of cyclophosphamide, epirubicin and 5-fluorouracil was delivered with G-CSF without apparent increase in acute toxicity. Cyclophosphamide could be increased to more than twice the standard dose at the cost of more anemia and fatigue.

Quality of life assessment in women with breast cancer: benefits, acceptability and utilization

In 2006, breast cancer was the third leading cause of death in American women; however, more women survive breast cancer than any other type of cancer. As the disease progresses, it is important to know how one's health-related quality of life (QOL) is affected for those who receive treatment, those who survive, and those who remain disease-free. The purpose of this study was to summarize the benefits, challenges, and barriers of QOL measurement for female breast cancer patients. A PubMed literature search was conducted using the terms "quality of life" and "breast cancer." The search was then refined with terms related to QOL assessment instruments. The research team reviewed over 100 of the 2,090 articles identified. From the results, a detailed outline of QOL instruments is presented, and the effectiveness of QOL instruments is discussed. In the current literature review, both generic and breast cancer specific QOL instruments, examining computerized and paper-and-pencil versions, are explained as well as the advantages, acceptability, and problems of these assessments. Potential barriers to implementation are also discussed. The implementation of QOL assessment tools in breast cancer clinical practice is discussed, with evidence detailing how such tools would benefit patients.

Do Anxiety, Body Image, Social Support and Coping Strategies Predict Survival in Breast Cancer? A Ten-Year Follow-Up Study

A longitudinal study enrolled 75 women with primary breast cancer. Before the confirmation of diagnosis, authors measured trait-anxiety and body satisfaction. Three weeks after diagnosis, coping strategies and state-anxiety were evaluated. The number of days of survival was measured 10 years after diagnosis. In Cox proportional-hazards models adjusting for severity of disease and age, high social support and low state-anxiety predicted an increased risk of death from breast cancer. A significant increased risk of death in women with low scores on the Body Image Questionnaire appeared only in the univariate model.

Do patients with localized prostate cancer treatment really want more aggressive treatment?

PURPOSE

Examine whether patients with prostate cancer choose the more aggressive of two radiotherapeutic options, whether this choice is reasoned, and what the determinants of the choice are.

PATIENTS AND METHODS

One hundred fifty patients with primary prostate cancer (T(1-3)N(0)M(0)) were informed by means of a decision aid of two treatment options: radiotherapy with 70 Gy versus 74 Gy. The latter treatment is associated with more cure and more toxicity. The patients were asked whether they wanted to choose, and if so which treatment they preferred. They also assigned importance weights to the probability of various outcomes, such as survival, cure and adverse effects. Patients who wanted to choose their own treatment (n = 119) are described here.

RESULTS

The majority of these patients (75%) chose the lower radiation dose. Their choice was highly consistent (P < or = .001), with the importance weights assigned to the probability of survival, cure (odds ratio [OR] = 6.7 and 6.9) and late GI and genitourinary adverse effects (OR = 0.1 and 0.2). The lower dose was chosen more often by the older patients, low-risk patients, patients without hormone treatment, and patients with a low anxiety or depression score.

CONCLUSION

Most patients with localized prostate cancer prefer the lower radiation dose. Our findings indicate that many patients attach more weight to specific quality-of-life aspects (eg, GI toxicity) than to improving survival. Treatment preferences of patients with localized prostate cancer can and should be involved in radiotherapy decision making.

Breast cancer patients on adjuvant chemotherapy report a wide range of problems not identified by health-care staff

BACKGROUND

Adjuvant chemotherapy for primary breast cancer is associated with significant side effects. The aims of this study were (1) to compare health-related quality of life (HRQL) in patients undergoing adjuvant chemotherapy to patients not on chemotherapy and (2) to compare these results against a survey investigating health-care professionals' knowledge of HRQL.

METHODS

Patients on adjuvant cyclophosphamide, methotrexate, fluoracil chemotherapy were compared to 'low-risk' patients not on chemotherapy ('control group'). A questionnaire including the EORTC QLQ-C30, the Hospital Anxiety and Depression Scale (HADS), and the DBCG 89 Questionnaire was administered six times during a 2-year period. Forty-six experienced health-care professionals were asked which quality-of-life issues they thought were affected by adjuvant chemotherapy.

RESULTS

After 2 years, 159 of 242 patients on chemotherapy and 148 of 199 patients in the control group were alive and recurrence-free and had completed all questionnaires. Worse HRQL during chemotherapy was seen, as had been previously suggested, for 23 of 30 variables. A number of the health-care professionals had not indicated patients to have these side effects. Several side effects persisted after the chemotherapy.

CONCLUSIONS

This study provides the most comprehensive description of HRQL in adjuvant therapy to date. The discrepancy between patients and doctors/nurses suggests that patients have been insufficiently informed about the impact of chemotherapy on quality of life. The results of this study provide a basis for information that can be given to patients, and indicate that the care offered to patients in chemotherapy should seek to prevent, identify, and alleviate a very broad range of problems.

Chemotherapy versus ovarian ablation as adjuvant therapy for breast cancer: impact on health-related quality of life in a randomized trial

BACKGROUND

Ovarian ablation is an effective adjuvant therapy for primary breast cancer but little is known about its quality of life impact relative to the more widely used adjuvant chemotherapy. This randomized study compared quality of life outcomes of adjuvant ovarian ablation versus cyclophosphamide, methotrexate, fluoracil (CMF) chemotherapy.

METHODS

The Danish Breast Cancer Cooperative Group (DBCG) trial 89-b randomized premenopausal patients with receptor-positive, primary breast cancer between nine cycles of CMF chemotherapy given every 3 weeks and ovarian ablation by oophorectomy. In total, 317 randomized patients were invited to take part in a longitudinal quality of life study with assessments at 1, 3, 5, 9, 15, and 24 months after randomization. The questionnaire included the EORTC QLQ-C30, the Hospital Anxiety and Depression Scale, and additional items assessing potential symptoms not included in the standard instruments.

RESULTS

After 2 years, 260 women were alive and recurrence-free, and 196 of these (75%) had completed all six questionnaires. Overall, patients in the chemotherapy group had more symptomatology at the first three assessments (i.e., during the 6 months treatment period), except for hot flushes/sweats. There were few differences between groups at later assessments. In chemotherapy patients, the likelihood of preserving ovarian function decreased steeply with increasing age. CMF chemotherapy and ovarian ablation have similar impact on recurrence and survival.

CONCLUSION

Chemotherapy had more negative impact on health-related quality of life but preserved ovarian function in some younger patients.

[Oncology and quality of life. Study in head and neck cancer]

The principal endpoints in oncology are survival with improvement of quality of life in cancer patients.

OBJECTIVES

To give an accurate account of current literature on quality of life and head and neck cancers.

METHODS

Two keys words are used: "quality of life" and "cancer" enabling to trace articles in Medical and Human Science journals. Analysis and synthesis of these documents.

RESULTS

Quality of life is difficult to evaluate as it is a multidimensional concept with three main symptom domains: physical, psychological and social. Several quality of life evaluation scales have been developed enabling authors to estimate the effects of disease on patients as well as treatment-related symptoms. Reports on quality of life in ENT patients have offered improved knowledge on patient experience and aftereffects, and therapies have been adapted and improved in view of such studies.

CONCLUSION

Quality of life evaluation tools need to be improved. At present, most tools only partially evaluate patient quality of life, concentrating on the global impact of disease and its treatment on patients' physical and psychological condition. The "sociability" of individual patients is rarely evaluated, and the development of qualitative studies in this domain will enable improved understanding of the social factors involved in each patient's adaptability to disease, its treatment and after-effects.

Review of Determinants of Patients’ Preferences for Adjuvant Therapy in Cancer

Purpose

Many studies have determined cancer patients’ preferences for adjuvant therapy, for example, by asking patients the extent of benefit they would need in order to accept the therapy. However, little is known about the determinants that influence these preferences. Our research goal was to explore which determinants underlie patients’ preferences by means of a literature review.

Methods

PubMed searches were conducted to identify studies in which cancer patients’ preferences for adjuvant therapy had been elicited by means of a treatment preference instrument. Twenty-three papers were evaluated with regard to reported relationships between preferences and potential determinants. A total of 40 determinants were recorded and classified into one of seven categories: (1) treatment-related determinants, (2) sociodemographic characteristics and current quality of life, (3) clinical characteristics, (4) measurement instrument-related determinants, (5) time-related determinants, (6) cognitive/affective determinants, and (7) specialist-related determinants.

Results

The benefit and toxicity of treatment, experience of the treatment, and having dependents (eg, children) living at home were important determinants of patients’ preferences. Furthermore, qualitative data suggested that cognitive/affective and specialist-related determinants might have a large impact on patients’ treatment preferences.

Conclusion

Our results show that patients’ preferences cannot fully be explained on the basis of treatment-related determinants and patient and clinical characteristics. More research is needed in the area of cognitive/affective and specialist-related determinants because of the lack of quantitative results. Furthermore, we recommend carrying out larger studies in which the (internal) relationships between determinants and preferences are assessed in the context of a cognitive cost-benefit model.

Nausea and vomiting in pregnancy: results of a survey that identified interventions used by women to alleviate their symptoms

Nausea and vomiting of pregnancy (NVP) affects most pregnant women. There are safe and effective treatments available; however, most women choose to avoid pharmacological therapies and try lifestyle and dietary changes to treat their condition. To date, no attempt has been made to quantify women's experience with a variety of interventions. This study aims to identify factors commonly reported by women that alleviate their symptoms of NVP. Five hundred women with NVP, calling a pregnancy healthline between February 1996 and July 1999, completed a questionnaire where they were asked to rate which of 21 factors helped and to what extent each factor helped to improve their NVP symptoms. For each item, the 'frequency' (percentage of women who indicated that item as an improvement) and 'mean importance' (mean importance score of women who indicated that item as an improvement) were multiplied to give the 'overall impact' score. All 500 women reported that dietary and lifestyle changes helped to improve their NVP symptoms. However, most items were rated low and only 31% of women reported benefit from the use of pharmacological treatment. In conclusion, this study has identified that NVP is a multifaceted condition. Lifestyle changes including validation, supportive counseling and dietary adjustments are important components, that can be used to counsel women with NVP, concomitantly with safe and effective treatment.

Patient centered decision making in palliative cancer treatment: a world of paradoxes

Patient centered palliative cancer care would imply, first, the introduction of psychosocial endpoints when evaluating treatment and making decisions. Second, patient control would have to be enhanced by information giving and increased decision involvement. We have indicated that paradoxes exist when a patient centered approach is advocated in the context of palliative cancer care. So-called patient oriented outcomes, like quality of life, once introduced seem to be disregarded by many patients themselves and survival is given a more important weight. Likewise, physicians seem to be inclined to treat patients aggressively for little benefit rather than providing supportive care. Both parties seem to prefer to do something actively to maintain a semblance of control over the disease process. Giving treatment, even if aggressive, is a way to avoid the confrontation with the little efficacy that the physician has to offer to incurable cancer patients. This mechanism is reflected in the content of conversations in palliative care. Patient centered care would imply that patient control and autonomy are enhanced. However, again paradoxically, many patients seem to want to avoid information and leave the decisions to be made by their doctors. Physicians, then, follow such wishes while paying more attention to aggressive therapy than to the notion of watchful waiting. This may help to avoid the painful confrontation with bad news. Dilemmas then remain. Patients wishing to maintain hope and avoid emotional impact of a full understanding of their prognosis may rather not be informed brusquely about prognosis or the aims of supportive therapy and forced to make an informed decision. However, by giving more aggressive, maybe even futile, treatment, and withholding supportive care patients may receive less than 'quality end-of-life care'. Therefore, information about less intrusive strategies should still be given in a cautious manner, while regarding the patient's defenses respectfully.

Health-related quality-of-life measurement in randomized clinical trials in breast cancer--taking stock

Measurement of health-related quality-of-life (HRQOL) in randomized clinical trials in breast cancer has become common. In this review, we take stock of the contribution that HRQOL measurement in breast cancer clinical trials makes to clinical decision making regarding selection of optimal treatment. A series of MEDLINE searches was conducted to identify all randomized trials in breast cancer that included self-reported HRQOL or psychosocial outcomes. A total of 256 citations were identified that included HRQOL or psychosocial outcomes in breast cancer patients, and 66 of these involved randomized clinical trials of treatment. These 66 reports of breast cancer clinical trials of treatment are discussed in this review. Forty-six of the trials evaluated biomedical interventions, and 20 evaluated psychosocial interventions. Among the biomedical trials, eight trials evaluated HRQOL in primary management of breast cancer, seven trials evaluated HRQOL in adjuvant therapy of breast cancer patients, 20 trials involved metastatic breast cancer, eight trials involved symptom control/supportive care, and three trials evaluated different approaches to investigation or follow-up of breast cancer patients. Among the psychosocial trials, 13 trials evaluated HRQOL in adjuvant therapy of breast cancer patients, and their partners or spouses, six trials involved metastatic breast cancer, and one trial focused on symptom control. We found that the contribution of HRQOL measurement to clinical decision making depended on the clinical setting. In primary management of breast cancer, where medical outcomes of several treatment options are equivalent, HRQOL measurement provided added information for clinical decision making beyond that of traditional medical outcomes. In trials in the adjuvant setting, HRQOL measurement did not influence clinical decision making. In metastatic disease, HRQOL outcomes provided little information beyond that obtained from traditional medical outcomes, including toxicity. In the symptom control/supportive care setting, results of HRQOL questionnaires targeting specific symptoms (e.g., emesis) guided treatment decisions. In psychosocial intervention trials, psychosocial and/or HRQOL measurements often provided the only outcome information; therefore, selection of instruments that captured attributes likely to be altered by the intervention was essential. Until results of ongoing trials in breast cancer are available, caution is recommended in initiating new HRQOL studies unless treatment equivalency is expected, or unless the HRQOL questions target unique or specific issues that can only be addressed through patient self-report, including outcomes of psychosocial interventions.

Prospective comparison of breast pain in patients participating in a randomized trial of breast-conserving surgery and tamoxifen with or without radiotherapy

PURPOSE

To determine whether breast pain affects quality of life (QOL) after breast-conserving surgery and tamoxifen (TAM) with or without adjuvant breast radiotherapy (RT).

METHODS AND MATERIALS

A randomized clinical trial was carried out at the Princess Margaret Hospital between 1992 and 2000 to evaluate the need for breast RT in addition to TAM in women >or=50 years treated with breast-conserving surgery for T1-T2N0 breast cancer. A companion study to assess breast pain was carried out during the last 2 years of the randomized clinical trial. The short-form McGill Pain Questionnaire (SF-MPQ), the European Organization for Research and Treatment of Cancer (EORTC) QOL (QLQ-C30) and EORTC breast cancer module (QLQ-BR23) questionnaires were completed by patients within 1 week of randomization in the randomized clinical trial (baseline) and at 3, 6, and 12 months.

RESULTS

Eighty-six patients participated in the breast pain study; 41 received RT plus TAM and 45 received TAM alone. The median age was 70 years (range 51-80). The baseline pain and QOL scores were similar for the two groups. No significant difference was found between the two groups for each scale of the QLQ-C30 and QLQ-BR23 questionnaires at 3, 6, or 12 months (p >0.100), except that at 12 months, the score for role function (QLQ-C30) was higher in the RT plus TAM group than in the RT-only group (p = 0.02). At 3 months, the difference between the mean scores for the SF-MPQ was 0.553 (p = 0.47). At 12 months, the pain scores had decreased in both groups; the difference was 0.199 (p = 0.71). The number of breast operations or surgical complications did not correlate with breast pain in either group. Acute RT toxicity scores did not correlate with breast pain or QOL scores at 12 months.

CONCLUSION

These results suggest that breast RT does not significantly contribute to breast pain or adversely impact the QOL up to 12 months after treatment in postmenopausal patients with node-negative breast cancer who take TAM.

A taxonomy of the uses of health-related quality-of-life instruments in cancer care and the clinical meaningfulness of the results

OBJECTIVES

To propose a taxonomy of psychometrically based, health-related quality-of-life instruments related to three levels of decision-making of health care: the macro, meso and micro levels. The choice of appropriate health-related quality-of-life instruments for each level of desired decision making in various clinical settings is illustrated. A secondary objective was to describe solutions for some of the difficulties inherent in the interpretation of the results of health-related quality-of-life assessment.

DESIGN

The three main levels of clinical decision making are listed and the instruments used most frequently in cancer clinical trials are reviewed from the medical literature.

PROPOSALS

Generic and utility-based instruments are likely to be the most valuable at the macro level of decision making, whereas condition-specific, disease-specific, and situation-specific instruments are most useful for decision making at the meso and micro levels. A determination of the proportions of patients who have reached a meaningful change in health-related quality-of-life scores (eg, > or =10 for scales of 1-100) over a standard period is a rational approach to interpreting the significance of changes in scores.

CONCLUSIONS

Awareness of the level of decision making that is involved in the clinical assessment of health-related quality of life can be helpful in choosing instruments that are appropriate for various clinical settings. Some of the difficulties in interpreting the meaning of changes in health-related quality-of-life scores can be overcome by comparing the proportions of patients who have achieved a preset magnitude of change.