Ductal carcinoma in situ (DCIS) of the breast: the need for psychosocial research

Accelerated partial breast irradiation compared with whole breast radiation therapy: a breast cancer cohort study measuring change in radiation side-effects severity and quality of life

PURPOSE

Radiotherapy (RT) after breast-conserving surgery for early-stage breast cancer patients has similar survival benefits with whole breast RT (WBRT) or accelerated partial breast irradiation (APBI). However, the impact of RT type and side-effects severity on change in quality of life (QOL) is unknown. We examined changes in RT side-effects severity and QOL by RT type.

METHODS

We analyzed data from a cohort of 285 newly diagnosed early-stage breast cancer patients with tumor size ≤3.0 cm and lymph node-negative disease. Patients (93 [32.6%] stage 0; 49 [17.2%] non-white; mean age = 59.3 years) completed four interviews (6 weeks, 6, 12, and 24 months) after definitive surgical treatment. We measured severity of RT side effects, fatigue and skin irritation, using a 5-point scale (1 "not at all" to 5 "all the time") and measured QOL using the Functional Assessment of Cancer Therapy-Breast (FACT-B) and RAND 36-item Health Survey Vitality subscale. Repeated-measures analysis of covariance of each outcome controlled for demographic, clinical/treatment, and psychosocial factors.

RESULTS

Patients initiated RT by 6 months (113 received APBI; 172 received WBRT) and completed RT by 12 months. Patients receiving WBRT (vs. APBI) reported greater increase in fatigue and skin irritation severity from 6-week to 6-month interviews (each P < 0.001). Improvement in neither total FACT-B nor Vitality differed significantly by RT type over 2-year follow-up.

CONCLUSIONS

Findings suggest that early-stage breast cancer patients can benefit from less-severe, short-term side effects of APBI with no differential impact on QOL change within 2-year follow-up.

Worry about cancer progression and low perceived social support: implications for quality of life among early-stage breast cancer patients

BACKGROUND

Worry about cancer progression and perceived social support can affect cancer survivors' quality of life (QOL).

METHODS

In 480 early-stage breast cancer survivors, we examined how worry about cancer progression and perceived social support 6 months after definitive surgery were associated with QOL (RAND 36-item Health Survey) at 6-, 12-, and 24-month follow-up.

RESULTS

At 6 months post-surgery, higher worry was associated with worse QOL for five of eight subscales. Lower social support was associated with worse QOL for four subscales. The negative effects of worry and limited social support dissipated for four subscales (worry) and two subscales (social support) by 12-month follow-up and for all subscales by 24-month follow-up. Social support at 6 months moderated the relationship between T2 worry and T4 emotional well-being; post hoc tests did not clarify the nature of the interaction.

CONCLUSION

Early-stage breast cancer survivors who worry about cancer progression and/or have low social support may experience lower levels of QOL that can take several months to resolve.

Quality of life over time in women diagnosed with ductal carcinoma in situ, early-stage invasive breast cancer, and age-matched controls

Little is known about quality-of-life (QOL) differences over time between incident ductal carcinoma in situ (DCIS) and early-stage invasive breast cancer (EIBC) cases as compared with same-aged women without breast cancer (controls). We prospectively recruited and interviewed 1,096 women [16.8% DCIS, 33.3% EIBC (25.7% Stage I; and 7.6% Stage IIA), 49.9% controls; mean age 58; 23.7% non-white] at mean 6.7 weeks (T1), and 6.2 (T2), 12.3 (T3), and 24.4 months (T4) after surgery (patients) or screening mammogram (controls). We tested two hypotheses: (1) DCIS patients would report lower levels of QOL compared with controls but would report similar QOL compared with EIBC patients at baseline; and (2) DCIS patients' QOL would improve during 2-year follow-up and approach levels similar to that of controls faster than EIBC patients. We tested hypothesis 1 using separate general linear regression models for each of the eight subscales on the RAND 36-item Health Survey, controlling for variables associated with at least one subscale at T1. Both DCIS and EIBC patients reported lower QOL at T1 than controls on all subscales (each P<0.05). We tested hypothesis 2 using generalized estimating equations to examine change in each QOL subscale over time across the three diagnostic groups adjusting for covariates. By T3, physical functioning, role limitations due to physical problems, energy/fatigue, and general health each differed significantly by diagnostic group at P<0.05, because of larger differences between EIBC patients and controls; but DCIS patients no longer differed significantly from controls on any of the QOL subscales. At T4, EIBC patients still reported worse physical functioning (P=0.0001) and general health (P=0.0017) than controls, possibly because of lingering treatment effects. DCIS patients' QOL was similar to that of controls two years after diagnosis, but some aspects of EIBC patients' QOL remained lower.

Challenges in ductal carcinoma in situ risk communication and decision-making: report from an American Cancer Society and National Cancer Institute workshop

In September 2010, the American Cancer Society and National Cancer Institute convened a conference to review current issues in ductal carcinoma in situ (DCIS) risk communication and decision-making and to identify directions for future research. Specific topics included patient and health care provider knowledge and attitudes about DCIS and its treatment, how to explain DCIS to patients given the heterogeneity of the disease, consideration of nomenclature changes, and the usefulness of decision tools/aids. This report describes the proceedings of the workshop in the context of the current literature and discusses future directions. Evidence suggests that there is a lack of clarity about the implications and risks of a diagnosis of DCIS among patients, providers, and researchers. Research is needed to understand better the biology and mechanisms of the progression of DCIS to invasive breast cancer and the factors that predict those subtypes of DCIS that do not progress, as well as efforts to improve the communication and informed decision-making surrounding DCIS.

The shifting nature of women's experiences and perceptions of ductal carcinoma in situ

AIM

This paper is a report of a descriptive qualitative study of the evolution of women's perceptions and experiences of ductal carcinoma in situ from the period near to diagnosis to 1 year later.

BACKGROUND

Ductal carcinoma in situ is a non-invasive breast condition where cancer cells are detected but confined to the ducts of the breast. With treatment, the condition has a positive prognosis but ironically patients undergo treatment similar to that for invasive breast cancer. There is a lack of longitudinal qualitative research studying women's experiences of ductal carcinoma in situ, especially among newly diagnosed patients, and how experiences change over time.

METHODS

Forty-five women took part in an initial interview following a diagnosis of ductal carcinoma in situ and 27 took part in a follow-up interview 9-13 months later. Data were collected between January 2007 and October 2008. Transcripts were analysed using a hybrid approach to thematic analysis.

FINDINGS

Women's early perceptions of ductal carcinoma in situ merged and sometimes conflicted with their lay beliefs of breast cancer. Perceptions and experiences of the condition shifted over time. These overriding aspects were evident in four themes identified across the interviews: (i) perceptions of ductal carcinoma in situ vs. breast cancer, (ii) from paradox to acceptance, (iii) personal impact, and (iv) support and interactions with others.

CONCLUSION

This study represents one of the few longitudinal qualitative studies with newly diagnosed patients, capturing women's initial and shifting experiences and perceptions of the condition. The issues identified need to be recognized in clinical practice and supported appropriately.

Changes in sexual problems over time in women with and without early-stage breast cancer

OBJECTIVE

We aimed to evaluate whether age-matched women with and without early-stage breast cancer differentially experience sexual problems over time and whether changes in patients' problems differ by type of surgical procedure.

METHODS

We conducted four interviews (4-6 wk, 6 mo, and 1 and 2 y) after tumor resection (patients) or after a negative/benign screening mammogram (controls). Mixed-effects models with repeated ordinal measurements tested the effects of time and diagnostic group (stages 0, I, and IIA vs controls) and, for patients, the effects of time and type of surgical procedure (mastectomy vs lumpectomy) using a newly developed nine-item sexual-problem measure. Two-sided P values < 0.05 were considered significant.

RESULTS

Using data from 1,033 women (17.3% stage 0, 33.4% stage I/IIA, and 49.3% controls; mean age, 57.1 y; 23.1% nonwhite; 64.7% married), two factors measuring problems with sexual attractiveness and sexual interest/enjoyment emerged in exploratory factor analysis (alpha > or = 0.74 for each subscale and the nine-item measure). Patients and controls reported few sexual problems on average, but controls were more likely to report sexual problems on the nine-item measure over time and stage I patients were less likely to report problems with sexual attractiveness over time (each P < 0.05) compared with at baseline. Patients who underwent mastectomy (35.7%) were 2.7 times more likely to report sexual problems on the nine-item measure at 2-year follow-up compared with baseline (P = 0.0339).

CONCLUSIONS

Patients and controls experienced few sexual problems over time, and in fact, controls were more likely to report sexual problems at subsequent interviews, whereas patients were not.

Effects of breast cancer surgery and surgical side effects on body image over time

We examined the impact of surgical treatments (breast-conserving surgery [BCS], mastectomy alone, mastectomy with reconstruction) and surgical side-effects severity on early stage (0-IIA) breast cancer patients' body image over time. We interviewed patients at 4-6 weeks (T1), six (T2), 12 (T3), and 24 months (T4) following definitive surgical treatment. We examined longitudinal relationships among body image problems, surgery type, and surgical side-effects severity using the Generalized Estimating Equation approach, controlling for demographic, clinical, and psychosocial factors. We compared regression coefficients of surgery type from two models, one with and one without surgical side-effects severity. Of 549 patients enrolled (mean age 58; 75% White; 65% BCS, 12% mastectomy, 23% mastectomy with reconstruction), 514 (94%) completed all four interviews. In the model without surgical side-effects severity, patients who underwent mastectomy with reconstruction reported poorer body image than patients who underwent BCS at T1-T3 (each P < 0.02), but not at T4. At T2, patients who underwent mastectomy with reconstruction also reported poorer body image than patients who underwent mastectomy alone (P = 0.0106). Adjusting for surgical side-effects severity, body image scores did not differ significantly between patients with BCS and mastectomy with reconstruction at any interview; however, patients who underwent mastectomy alone had better body image at T2 than patients who underwent mastectomy with reconstruction (P = 0.011). The impact of surgery type on body image within the first year of definitive surgical treatment was explained by surgical side-effects severity. After 2 years, body image problems did not differ significantly by surgery type.

Psychological distress and physical health in the year after diagnosis of DCIS or invasive breast cancer

Ductal carcinoma in situ (DCIS) has an excellent prognosis, but its management can resemble that of early invasive breast cancer. We compared aspects of quality of life of women with DCIS to that of women with invasive disease during the first year after treatment initiation. Participants came from consecutive series of women with newly diagnosed, non-metastatic breast cancer treated in eight Quebec hospitals in 2003. Psychological distress and health-related quality of life were measured using the Psychiatric Symptom Index (PSI) and the SF-12 mental and physical component scales (MCS, PCS). Data were obtained 1, 6, and 12 months after the start of treatment. We used generalized linear models to compare mean scores and explored the possible clinical significance of between-group differences with effect size (ES). Participation and retention among eligible women were high, 86 and 97%, respectively. Among the 800 women who completed all interviews, 13.4% (n = 107) had DCIS and 86.6% (693) invasive disease. No statistically significant between-group differences were found at 1, 6, or 12 months in psychological state (PSI and MCS: P values from 0.065 to 0.904; ES from -0.01 to -0.21). Women with DCIS reported significantly higher levels of physical health, particularly when compared at 1 month to women with invasive disease who had chemotherapy (P value < 0.0001; ES = 0.82). Measured in symptoms of psychological distress, the better prognosis or less aggressive management of DCIS does not offset the general psychological effects of a cancer diagnosis to any great degree.

Results of 23,810 Cases of Ductal Carcinoma-in-situ

BACKGROUND

Screening mammography has increased the number of patients diagnosed with ductal carcinoma-in-situ (DCIS) in the past 20 years. The Florida Cancer Data System is the largest single source incident cancer registry in the United States. We analyzed this registry to determine the changing incidence and treatment patterns for DCIS.

METHODS

Patients with DCIS from 1981 to 2001 were identified. Age-adjusted rate, descriptive statistics, and incidence of future DCIS and invasive breast cancer were calculated.

RESULTS

A total of 23,810 DCIS patients were identified. The age-adjusted rate of DCIS has risen from 2.4 to 27.7 per 100,000 women between 1981 and 2001. Median age was 64 years; 85% of patients were white, 6.6% African American, and 7.5% Hispanic. Median tumor size was .9 cm. Forty-seven percent of patients had breast-conserving therapy (BCT). Half of the 53% of patients undergoing mastectomy underwent a modified radical mastectomy. Eight percent received no surgical treatment. Sentinel lymph node biopsy was used in 2.7% of patients who underwent a mastectomy. After BCT, 37.5% received adjuvant radiotherapy, and only 13% were treated with hormonal therapy.

CONCLUSIONS

The incidence of DCIS has risen dramatically with the advent of screening mammography. Increasing numbers of these patients are treated with BCT, although a large proportion are still treated with mastectomy, in some cases combined with axillary dissection. Sentinel lymph node biopsy and tamoxifen are important components of therapy, the use of which is slowly increasing in the treatment of DCIS.

Receiving a screen-detected diagnosis of cancer: The experience of participants in the UK flexible sigmoidoscopy trial

The experience of receiving a screen-detected diagnosis of colorectal cancer was explored using open-ended interviews. Twenty four people who had been diagnosed with cancer at flexible sigmoidoscopy screening were interviewed at their homes over the telephone. Thematic analysis of the transcripts showed that the experience of gaining a diagnosis of cancer through screening was characterised by a lack of prior expectation that cancer would be detected and feelings of shock. This was largely because of the absence of symptoms and current feelings of well-being. Some interviewees expressed feelings of relief and gratitude at having cancer diagnosed at an early enough stage that 'something could be done about it'. The experience of receiving a screen-detected diagnosis could be summarised as one of 'moderated shock' whereby the shock of the unexpected diagnosis was often moderated by the news that the cancer had been caught early. Whilst these screen-detected cancers were diagnosed relatively rapidly, a significant number of interviewees had a period in which they were effectively 'symptomatic' (e.g. knew they had an adenoma but did not know whether it was malignant or benign). However, they did not use this period to prepare themselves for a possible cancer diagnosis. Raising awareness of the adenoma-carcinoma sequence may help reduce the shock of a screen-detected diagnosis. However, any interventions aimed at reducing the distress of a screen-detected cancer would need to consider the overall benefit to screening attenders, most of whom will have benign polyps detected.

"Well, have I got cancer or haven't I?" The psycho-social issues for women diagnosed with ductal carcinoma in situ

OBJECTIVES

To explore women's experience of being diagnosed with ductal carcinoma in situ (DCIS) in relation to the following: response to the diagnosis; understanding about the diagnosis; satisfaction with information; satisfaction with the level of involvement in treatment decision-making and satisfaction with support services.

DESIGN

An explorative descriptive qualitative design was used to facilitate an in-depth exploration of women's experiences.

SETTING AND PARTICIPANTS

Five focus group interviews were conducted in New South Wales (NSW), Australia, involving 26 women diagnosed with DCIS.

RESULTS

DCIS is a non-invasive breast disease, that in most cases will not recur if treated, and cannot of itself metastasize to other parts of the body. However, this study found that women were confused about whether or not they had cancer that could result in death. Women's confusion was compounded by the use of the term "carcinoma" and by the recommendation of treatments such as mastectomy. Women's confusion was not alleviated by appropriate information, with most women reporting dissatisfaction with the information they received specifically about DCIS.

CONCLUSIONS

This study identifies that a diagnosis of DCIS has a significant psychological impact on women. The communication challenges highlighted in this study are not only relevant to DCIS but to any other disease in which the natural history is uncertain and the evidence about treatment effectiveness is still emerging. Further research is needed in areas such as DCIS to explore the difficulties experienced in doctor-patient communication and their impact on patient outcomes, and how to optimize doctor-patient communication.