Does self-reported functional limitation attributed to symptoms persist 1 year after initial treatment for early breast cancer?

19519

Background and Significance: Comorbidity, disability and compromised functional status increase with age. It is unclear to what extent the symptoms related to the diagnosis and treatment of cancer play a role in activity limitation in older adults. We examined the prevalence of self-reported functional limitation in a breast cancer population, whether this limitation is attributed to various symptoms, and how this attribution changes over time from early in treatment to 9-months later. Methods: 1,011 patients with breast cancer were surveyed 3 months after diagnosis (baseline) and 933 of those patients were surveyed at 12 months after diagnosis (9 month follow up). In each survey, participants were asked whether or not they had each of 21 symptoms and whether or not each symptom caused significant activity limitation. Results: Of the 933 patients (mean age 62.7 years) who completed baseline and follow up evaluations, 420 were aged 65 years and older. At baseline, 47% of patients 65 years and older reported functional limitation compared with 44% of patients younger than 65 years (p=0.29). Activity limitation at baseline was attributed to nausea in 4% of older patients, (O) and 8% of younger patients (Y) (p=0.016), to pains in the chest area in 11% (O) and 9% (Y) (p=0.21), to joint or muscle aches in 20% (O) and 16% (Y) (p=0.13), to tiring easily in 31% (O and Y), and to depression in 9% (O) and 13% (Y) (p=0.19). At follow up 47% of patients 65 years and older reported functional limitation compared with 40% of patients younger than 65 years (p=0.02). Activity limitation at follow up was attributed to nausea in 3% (O) and 7% (Y) (p=0.003), to pains in the chest area in 11% (O) and 9% (Y) (p=0.21), to joint or muscle aches in 23% (O) and 17% (Y) (p=0.01), to tiring easily in 26% (O) and 24% (Y) (p=0.60), and to depression in 8% (O and Y). Conclusion: Self-reported functional limitation is prevalent 3 months and 1 year after breast cancer diagnosis. Self reported activity limitation in older and younger patients is not significantly different at baseline, and is significantly higher in older patients at follow up, with older patients having significantly less nausea and significantly more joint and muscle aches.

No significant financial relationships to disclose.

Activity limitation and clustering of symptoms in breast cancer patients

8540

Background: While previous cancer symptom research has been focused on individual symptoms, more recent studies have attempted to identify symptom clusters in breast cancer patients. However, there has been no large study that has examined both clustering of symptoms and activity limitation in breast cancer patients. Methods: Data were taken from a survey study of 1,011 patients found to have histologically confirmed breast cancer, identified by the Metropolitan Detroit Cancer Surveillance System. Patients were surveyed at both 3 and 12 months after diagnosis. Survey data on 1,054 control participants were also obtained for matching variables. Participants were asked whether or not they had each of 21 symptoms, and whether or not they attributed any activity limitation to each symptom. Results: Of 21 symptoms examined, prevalence of symptoms listed in Table 1 was significantly higher in cancer patients than in controls (p<0.05) at baseline. Though the prevalence of each symptom decreased significantly at follow up, each symptom remained significantly more prevalent than in the control group, with the exception of depression. Activity limitation attributed to 4 of the 5 symptoms listed in Table 1 was significantly higher than that of controls, and this difference persisted at follow up. Symptoms tended to cluster together amongst breast cancer patients. For example, at baseline, 73% of patients with depression also reported fatigue, and 30% of patients with pains in chest area also reported both fatigue and depression. These associations persisted at follow up. Symptoms were significantly correlated with each other at baseline (p<0.00005), with correlation coefficients ranging from 0.13 to 0.26, with most correlations remaining significant at follow up. Conclusion: In a large survey of breast cancer patients, symptoms were found to be associated with significant activity limitation, and tended to cluster together. This correlation persists at 12 months after diagnosis, even after treatment is complete.

[Table: see text]

No significant financial relationships to disclose.

Patterns of comorbidity and the use of health services in the Dutch population

BACKGROUND

The study objective was to examine the relation between combinations of chronic conditions in the same person and the volume and variety of health care utilization.

METHODS

Analysis of continuous Netherlands Health Interview Survey data (1990-1997). The study population consisted of adults (16 years and older) reporting at least one chronic condition from the following six disease clusters: musculoskeletal diseases, lung diseases, neurological disorders, heart diseases, diabetes, and cancer (n = 13,806). Health care utilization is categorized in terms of contacts in the preceding year with a general practitioner (GP), medical specialist, physiotherapist, home help and/or home nursing, and hospital admission. Utilization was adjusted for age, gender and year of interview. Statistical methods used are contingency table analysis and (logistic) multiple regression.

RESULTS

Almost one-fifth of the study population reported more than one chronic condition. Musculoskeletal disease, in addition to being the most common single condition, was found to be the condition most likely to occur with one of the remaining five disease clusters. Seven per cent reported not having used any services at all. Two-thirds of the study population used at least two different services in the previous year. In contrast, 26% of the study population reported comprehensive utilization patterns (GP and/or home care and/or physiotherapist and/or medical specialist and/or hospitalization: minimum of three types). Persons with more than one chronic condition reported having used more services, in terms of volume and variety, than those with only one condition.

CONCLUSIONS

There is a strong association between comorbidity and the volume and variety of health care services that are used. Since many people have comorbid conditions, their use of health services is more complex than would be suggested by a one-disease approach. New disease management systems need to be developed to reflect the multiplicity of health care needs of the growing number patients with more than one chronic condition.

Causes and consequences of comorbidity: a review

A literature search was carried out to identify and summarize the existing information on causes and consequences of comorbidity of chronic somatic diseases. A selection of 82 articles met our inclusion criteria. Very little work has been done on the causes of comorbidity. On the other hand, much work has been done on consequences of comorbidity, although comorbidity is seldom the main subject of study. We found comorbidity in general to be associated with mortality, quality of life, and health care. The consequences of specific disease combinations, however, depended on many factors. We recommend more etiological studies on shared risk factors, especially for those comorbidities that occur at a higher rate than expected. New insights in this field can lead to better prevention strategies. Health care workers need to take comorbid diseases into account in monitoring and treating patients. Future studies on consequences of comorbidity should investigate specific disease combinations.

Limiting comorbid conditions and breast cancer stage at diagnosis

BACKGROUND

Contrasting hypotheses exist regarding the relationship between comorbidity and breast cancer stage at diagnosis. One suggestion is that disabling comorbid conditions would result in a later stage diagnosis of breast cancer because such conditions would limit mobility and thus access to medical care. This article examines this hypothesis by building a comorbidity summary measure of functionally limiting comorbid conditions and by testing the effectiveness of this measure in predicting the stage at which breast cancer is diagnosed.

METHODS

Cases with newly diagnosed breast cancer were identified through the population-based Metropolitan Detroit Cancer Surveillance System, a participant of the Surveillance, Epidemiology, and End Results Program of the National Cancer Institute. Of 1191 eligible cases, 1011 (85%) were interviewed 2-4 months following diagnosis. The analyses for this study were limited to 731 cases for which there were complete data on all variables. Five individual comorbid conditions that predicted functional limitation were combined into a comorbidity summary measure: arthritis, eye conditions, gastrointestinal conditions, kidney conditions, and respiratory conditions. Breast cancer stage was categorized in relation to whether women had local or advanced (regional or remote) disease.

RESULTS

Women with two or more of these five functionally limiting conditions were about half as likely as those with none of these conditions to receive an advanced stage diagnosis of breast cancer (odds ratio [OR] = 0.49, 95% confidence interval [CI] 0.28-0.86, p = .01).

CONCLUSIONS

These findings do not support the suggestion that the presence of disabling comorbid conditions results in later stage breast cancer. The five conditions summarized by this measure, although functionally limiting, may also require greater medical monitoring due to associated symptoms and/or treatment requirements and thus lead to increased opportunities for cancer screening.

Reasons given by older people for limitation or avoidance of leisure time physical activity

OBJECTIVES

This study investigates reasons given by older people for limitation or avoidance of physical exercise.

DESIGN

Community-based longitudinal study of free-living persons age 55 years or older in Sonoma, California.

METHODS

Baseline standardized interviews were conducted (n = 2046) as part of a longitudinal study of aging and physical performance. Seventeen reasons for limitation or avoidance of physical activities were evaluated, with responses grouped as: no limitations, medical, non-medical, and combined medical and non-medical reasons. Patterns of physical activity and medical conditions and direct measures of physical function were evaluated in relation to reasons for activity limitation by multinomial logistic regression.

RESULTS

Women reported more limitations/avoidance of physical activity than men (81.0% vs 73.5%). Medical reasons increased with age. Reduced walking speed and depressive symptomatology were associated with a combination of medical and non-medical reasons in both sexes. Living arrangements were associated with non-medical reasons for women but were not for men. Non-medical reasons were associated with a 20 to 30% reduction in the number of subjects who reported physical activity at recommended levels.

DISCUSSION

Non-medical factors are important determinants of activity limitation and should serve as targets for patient care providers and future interventions to improve participation in physical activity by older people.

Evaluating pterygium severity: a survey of corneal specialists

PURPOSE

Accurate and reliable evaluation techniques are essential for clinical and epidemiologic studies. This survey of corneal specialists was designed to lay a foundation for the further development of methods for evaluating and staging pterygium.

METHODS

In a self-administered, mailed questionnaire, 213 corneal specialists rated the importance of nine symptoms, nine signs, and nine clinical tests for the severity of primary pterygium. Severity was defined as the present need for surgical intervention.

RESULTS

The most important factors for determining primary pterygium severity were the extent of encroachment onto the cornea, decreased visual acuity, restricted ocular motility, and increased rate of growth. Many patient symptoms were rated as moderately to highly important. The questionnaire was shown to have good response reliability by test-retest comparisons. Cronbach's alpha was 0.89, which indicates very good internal consistency reliability.

CONCLUSION

The survey identifies the priorities of experts in determining the severity of pterygium. More precise and clearly defined evaluation methods will enhance future clinical and epidemiologic studies of pterygium. The ranked list of pterygium signs, symptoms, and tests can serve as a guide for developing pterygium evaluation methods in the future. There is a need for a method that accurately and precisely quantifies the distance of pterygium encroachment onto the cornea and the pterygium progression rate. Furthermore, there is a need for an assessment of patient symptoms.

Cause of death in men diagnosed with prostate carcinoma

BACKGROUND

Prostate carcinoma is one of the leading causes of death in men. Although the mortality rate is high, it still may underestimate the number of deaths associated with the disease. This study was conducted to compare causes of death among men previously diagnosed with prostate carcinoma and to examine the extent to which differences in cause of death (death from prostate carcinoma vs. death from other causes) varied by age, race, clinical factors, and comorbid conditions.

METHODS

A review was conducted of the medical records of decedent members of the Kaiser Permanente Medical Care program who previously were diagnosed with prostate carcinoma between January 1980 and December 1984 (n=584). The review focused on demographic factors, symptoms, diagnostic tests, stage of disease, and treatment. Data on comorbidity were obtained from a computerized discharge summary. Logistic regression analysis was used to estimate odds ratios.

RESULTS

Approximately 54% of the decedent prostate carcinoma patients died of their prostate carcinoma. Decedents who were black, age < or = 65 years, diagnosed with more advanced disease stage, recipients of hormonal therapy, and whose death occurred > 6 months after diagnosis were more likely than others to die of prostate carcinoma. In contrast, the likelihood of dying of some other cause was associated with concurrent cardiovascular disease, after adjustment for the effects of race, age, and disease stage. There also were significant two-way age-race and age-time-to-death interactions.

CONCLUSIONS

The prognostic significance of cardiovascular disease in prostate carcinoma patients should be investigated in subsequent survival studies. A number of questions need to be addressed delineating the complex relations between coexisting diseases and their treatment.

Alcohol consumption and breast cancer stage at diagnosis

The stage at which breast cancer is diagnosed is an important determinant of prognosis. In contrast to the many investigations of the relationship between alcohol consumption and the risk of developing breast cancer, few have examined how alcohol consumption may affect the stage of this cancer at diagnosis. This article examines the relationship between alcohol intake and breast cancer stage and assesses consumption in relation to the volume of drinks consumed per week and the patterns of consumption 1 year prior to the breast cancer diagnosis. A total of 1191 women, aged 40 to 84 years, with newly diagnosed breast cancer were identified through the population-based Metropolitan Detroit Cancer Surveillance System, a participant of the Surveillance, Epidemiology, and End Results Program of the National Cancer Institute. Of these, 1011 (85%) were interviewed 2 to 4 months following diagnosis. The analyses for this article were limited to 920 cases with local and regional stage disease. The bivariate analysis showed that frequent drinkers were more likely than abstainers or infrequent drinkers to present with regional disease. Logistic regression showed that frequent drinkers were 1.45 times more likely than infrequent drinkers to be diagnosed with later stage breast cancer (95% CI: 1.01-2.10; p = 05). The association between alcohol consumption and disease stage may be due to the relationship between heavy consumption and other unhealthy behaviors. In addition, women who drink more frequently may have less awareness of and access to cancer screening services. Heavy exposure to alcohol may also contribute to accelerated tumor growth once breast cancer is present.

Association between self-reported leisure-time physical activity and measures of cardiorespiratory fitness in an elderly population

Leisure-time physical activity enhances health and functioning in older populations. However, few data are available on the correlation between self-reported leisure-time physical activity and cardiorespiratory fitness in the elderly. Treadmill exercise testing results were obtained for 1,006 members (median age 67 years) of a community-based sample. Subjects completed a standardized evaluation of medical/social history and measures of physical function. Leisure-time physical activity in the 12 months and 7 days before interview and over subjects' lifetimes was summarized as total and activity-specific METs/week and [METs * (hours/week)]. Multiple linear regression was used to investigate the cross-sectional, sex-specific associations between peak oxygen consumption (VO2) and exercise duration. After adjustment for age, body mass index, smoking history, medical morbidity, direct measures of physical functioning, forced expiratory volumes, and maximum respiratory muscle pressure, leisure-time physical activity accounted for < or = 5% of the variance of VO2 and exercise duration. Results were unchanged when analyses were restricted to subjects who achieved high levels of exercise. These data indicate that measures of aerobic capacity cannot be used to "validate" self-reported leisure-time physical activity in older subjects, and they further suggest that beneficial effects of physical activity in the elderly are the result of metabolic effects that are not reflected well by maximal aerobic capacity during exercise testing.

A census-based design for the recruitment of a community sample of older adults: efficacy and costs

PURPOSE

This is a report of the scientific and cost implications of a census-based design to identify residents aged 55 and over for a community study of the effects of aging on physical function.

METHODS

A census of residents in a study community was conducted by the use of a mailed questionnaire. For households that did not complete and return the mailed census questionnaire, contact was attempted first by telephone and then by home visit. A comparison was made of the unit costs and characteristics of subjects identified by the different methods.

RESULTS

A total of 3509 age-eligible subjects were identified (78.3% by mailer, 19.5% by telephone, and 2.0% by home visit). Costs per enrolled age-eligible subject were lower for mailing and telephone ($7.76 and $4.72 respectively) than for home visit ($36.25). Subjects identified by home visit were significantly younger than subjects identified either by mail or telephone. After adjustment for age, subjects identified by telephone had less education and income and poorer health and functional status than subjects identified by mail. With the exception of age, there were no significant differences between subjects identified by mailer and home visit.

CONCLUSIONS

A mailed questionnaire with telephone recontact is a practical strategy for community-based recruitment. Recontact of subjects by telephone can be expected to identify subjects who are not well-represented in a sample based only on a mailer. In contrast, the home visit is expensive and identifies subjects who do not differ meaningfully from those identified by mailer.

Unemployment and the likelihood of detecting early-stage breast cancer

OBJECTIVES

The objective of this study was to test the hypothesis that unexpectedly high unemployment in a community is associated with reduced odds that registered breast tumors are local.

METHODS

The hypothesis was tested with data from San Francisco for the 132 months beginning with January 1983.

RESULTS

Registered breast tumors were less likely to be local during periods of unexpectedly high unemployment (8% less likely among non-Hispanic White women and 24% less likely among African-American women).

CONCLUSIONS

Job loss may restrict access to health services. Fear of job loss may also distract women from breast self-examination and the identification of suspicious breast signs.

Upper-body strength and breast cancer: a comparison of the effects of age and disease

BACKGROUND

In most studies of functional limitations in women with breast cancer, it is difficult to determine what difficulties are associated with breast cancer and what problems are likely to be found in women of the same age without the disease. In the present study, we report the age-specific prevalence of upper-body limitations in women with breast cancer over the course of one year, compared to that experienced by women of the same age without the disease.

METHODS

Interviews were conducted with women with breast cancer ages 40-84 at 3 months (n = 934) and 12 months after diagnosis (n = 843). Controls were interviewed twice over the same period (n = 991 and 887, respectively). The main outcome was upper-body limitation, defined as the number of tasks requiring upper-body strength (0-4) reported by the respondent to be very difficult to complete or not done on doctor's orders.

RESULTS

Cases ages 40-54, 55-64, and 65-74 were approximately twice as likely as age-matched controls to report upper-body limitations, adjusting for race, education, financial status, and comorbidity. There was no case/control difference among those ages 75-84. At one year, the breast cancer patients ages 40-54 and 55-64 showed the greatest improvement.

CONCLUSIONS

Many women who survive breast cancer report significant limitations in upper-body strength in the first few months, followed, especially among younger women, by a period of recuperation. Rehabilitation and home-care programs should be designed to meet the special and more persistent needs of older women. New strategies for assessing upper-body strength are also suggested.

Comorbidity and survival in HIV-infected men in the San Francisco Men's Health Survey

The course of disease associated with infection with the human immunodeficiency virus varies widely. Some patients deteriorate rapidly, while others live for years, even after an illness that defines the acquired immunodeficiency syndrome (AIDS). In this study, comorbidity, or the presence of concurrent health problems, was investigated prospectively as a possible co-factor for different rates of decline in 395 homosexual/bisexual men in the San Francisco Men's Health Study (SFMHS) who were infected with the human immunodeficiency virus (HIV). Comorbidity data obtained from baseline interviews included both chronic and infectious diseases as well as depression. Smoking, alcohol, and drug use were also examined. The most prevalent comorbid conditions were sexually transmitted diseases (90%) and hepatitis B infection (76%). Most chronic and acute concurrent health conditions were not significant discrete predictors of survival to AIDS or death after controlling for immune status and markers of disease progression. Significantly, other risk factors (e.g., depression and smoking) were found to be associated with more rapid progression. Men with symptoms of depression had a higher risk of progression of AIDS diagnosis; the relative hazard (RH) was 1.4 (95% confidence interval [CI], 1.00-2.08); smoking was associated with higher risk of death (RH, 1.6; 95% CI, 1.20-2.17). Older age was marginally associated with poorer survival to death. No associations were found between survival and alcohol and drug use.

Comorbidity and breast cancer survival: a comparison between black and white women

The presence of concurrent health conditions (comorbidity) at the time of breast cancer diagnosis has an adverse effect on survival. It is unclear, however, whether the strength of the association between comorbidity and survival varies in different populations of breast cancer patients. It is necessary, therefore, to establish (1) whether a comorbidity index derived from a general population of patients (mostly white) would predict survival in a black population, and (2) whether comorbidity would have the same degree of relationship to mortality in black as in white populations. We studied 1196 breast cancer patients who were members of the Kaiser Permanente Medical Care Program and were diagnosed with local (n = 708), regional (n = 446), or remote (n = 49) stage breast cancer from 1973 to 1986. Mortality follow-up was completed to December 1994. Ten-year survival was studied in relation to the Charlson comorbidity index for black women and for white women, and for both groups of women combined. Compared to women with a Charlson comorbidity score of 0 (no comorbidity), patients with scores of 1, 2, and 3+ had risk ratios for ten-year mortality of 1.23 (P = 0.10), 2.58 (P < 0.001), and 3.44 (P < 0.001), respectively. This pattern of risk associated with comorbidity was similar to that found in the original Charlson study. The pattern of risk ratios for different levels of comorbidity was very similar for black and white patients. The results confirm previous studies indicating that comorbidity (in particular, the Charlson Comorbidity Index) predicts the survival of women with breast cancer, independently of other factors, such as stage of breast cancer at diagnosis. The Charlson index has prognostic significance for both black and white populations. Research is needed to determine whether the Charlson index can be improved by including health conditions that are particularly prevalent or severe in specific subgroups of women.

Imbalance in an older population: an epidemiological analysis

Difficulties with balance are associated with limitations in activities of daily living. There is little information, however, about the epidemiology of imbalance. Imbalance, defined as the inability to maintain a full-tandem stand for 10 seconds, was assessed as part of an interview with 2,018 residents of Marin County, California, age 55 and older. The likelihood of imbalance was greater in women, those aged 85 and older, and those with less than 12 years of education. It was also associated with specific chronic conditions, including a history of hypertension, stroke, or cataracts. Even after adjusting for these conditions, imbalance was associated with reduced lower-body strength as well as poor short-term memory, hip pain, vision problems, abstention from alcohol, and current cigarette smoking. With those aged 85 and older representing the fastest growing age group in developed nations, imbalance may become a major health problem.

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

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

The likelihood of returning to work after breast cancer

OBJECTIVE

This is an examination of factors associated with returning to work after the diagnosis of breast cancer.

METHODS

Three months after being diagnosed with breast cancer, 296 employed women from the Detroit metropolitan area (52 black and 244 white women) were interviewed. These women were part of a larger cohort of 1,011 breast cancer patients ages 40 to 84 interviewed for the study "Health and Functioning in Women with Breast Cancer".

RESULTS

Although most employed women returned to work within three months of the diagnosis of breast cancer, black women were twice as likely as white women to be on medical leave three months after diagnosis (OR = 1.94; 95% CI 1.04 to 3.62). Being on leave was found to be associated with the need for assistance with transportation, limitations in upper-body strength, and employment in jobs requiring physical activity. After adjusting for these factors, the racial difference was reduced and no longer statistically significant (OR = 1.34; 95% CI 0.67, 2.70).

CONCLUSION

Breast cancer rehabilitation programs should not only address the patient's physical capacity but also the daily demands she is likely to face once she leaves the hospital and returns to work.

Health and functioning among the elderly of Marin County, California: a glimpse of the future

BACKGROUND

The purpose of this study was to obtain information concerning the health status of the theoretically advantaged elderly population of Marin County, California, and to compare these data with those from other populations with different levels of socioeconomic status.

METHODS

An age-stratified sample of 2,018 community-dwelling elderly residents of Marin was selected, and these participants were interviewed between 1989 and 1991. Interview items included medical history of life-threatening diseases and chronic conditions, reported and observed disabilities, and life-style characteristics.

RESULTS

While the residents of Marin had lower mortality rates than the total U.S. population, there were few meaningful differences in measures of health and function in comparison to other elderly populations with substantially lower levels of socioeconomic status. The main exceptions were better memory performance and lower depressive symptomatology in Marin. Because of the many methodological differences, these comparisons must be viewed with caution.

CONCLUSION

The general pattern of findings in this study indicates that while death has been postponed in this socioeconomically advantaged population, the prevalence of disease and disability has not. If true, this implies that residents of an affluent community can spend a longer rather than shorter period of their late life in a state of infirmity and in need of medical care. This appears to be especially true for women.

The effect of parental history of myopia on children's eye size

OBJECTIVE

To evaluate whether eye size and shape are different in children based on their parental history of myopia.

DESIGN

A community-based cohort study of schoolchildren (aged 6 to 14 years), the Orinda (Calif) Longitudinal Study of Myopia.

SETTING

Four campuses of the Orinda Union School District, a predominantly white, high socioeconomic status community.

PARTICIPANTS

A cross-sectional volunteer sample of 716 children (662 non-myopic) in the first, third, and sixth grades in 1989, 1990, and 1991. All children in those grades were eligible for inclusion in the study.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURES

Refractive error (measured by autorefraction), corneal curvature (measured by photokeratoscopy), crystalline lens power (measured by video phakometry), and axial ocular dimensions (measured by ultrasonography).

RESULTS

With prevalent cases of myopia excluded and grade in school and "near work" controlled for, children with two myopic parents had longer eyes and less hyperopic refractive error (analysis of covariance, P < or = .01) than children with only one myopic parent or no myopic parents. A model incorporating parental history is only improved by the addition of near work for the prediction of refractive error.

CONCLUSIONS

Even before the onset of juvenile myopia, children of myopic parents have longer eyes. These results suggest that the premyopic eye in children with a family history of myopia already resembles the elongated eye present in myopia.

The effect of comorbidity on 3-year survival of women with primary breast cancer

OBJECTIVE

To determine the effect of comorbidity and stage of disease on 3-year survival in women with primary breast cancer.

DESIGN

Longitudinal, observational study.

SETTING

Metropolitan Detroit.

PATIENTS

936 women ages 40 to 84 years.

MEASUREMENTS

Data on stage of breast cancer, treatment type, and comorbidity were obtained from Metropolitan Detroit Cancer Surveillance System (MDCSS) files and medical records. Personal interviews were the source of information on social and behavioral factors. Vital status and cause of death were obtained from MDCSS files.

RESULTS

Patients who had 3 or more of 7 selected comorbid conditions had a 20-fold higher rate of mortality from causes other than breast cancer and a 4-fold higher rate of all-cause mortality when compared with patients who had no comorbid conditions. The effects of comorbidity were independent of age, disease stage, tumor size, histologic type, type of treatment, race, and social and behavioral factors. Moreover, women with severe comorbid conditions had uniformly higher mortality rates, and early diagnosis in these women conferred no survival advantage.

CONCLUSION

Comorbidity in patients with breast cancer appears to be a strong predictor of 3-year survival, independent of the effects of breast cancer stage. This finding suggest that trials assessing the efficacy of screening should routinely include measures of comorbidity.

Factors predicting stage of breast cancer at diagnosis in middle aged and elderly women: the role of living arrangements

We examined whether sociodemographic, health, and psychosocial factors predict stage at diagnosis in 444 women aged 55-84 with newly diagnosed, microscopically confirmed breast cancer. Stage was defined as local or advanced (regional or remote). One of the most interesting predictors of disease stage was living arrangement. The odds of being diagnosed with advanced disease were twice as great among women living with a spouse than among women living alone (95% CL = 1.16, 3.35), after adjusting for the effects of age, body mass index, income, comorbid conditions, smoking, and group membership. For those living with someone other than a spouse, the odds of advanced disease were 1.7 times greater than among those living alone (95% CL = 0.96, 3.06). Middle aged and older women who live alone may be more likely to monitor their own health and to use the health care system, and therefore have a greater chance of being diagnosed at an early stage of breast cancer.

Aging, comorbidity, and breast cancer survival: an epidemiologic view

This is a review of epidemiologic studies, which suggest that comorbidity (e.g., diabetes and heart disease) has an adverse effect on survival among women with incident, invasive breast cancer, adjusting for chronological age and stage of breast cancer at diagnosis. As part of this review, recent results are presented from a series of 463 breast cancer cases, identified through the Metropolitan Detroit Cancer Surveillance System. Women with two or more concurrent health conditions were 2.2 times more likely than breast cancer cases without comorbidity to die from their breast cancer over a four-year period (95% CI: 1.13, 4.18). Limiting heart disease was especially problematic. Recommendations are made for future research in this area.

Comorbidity and functional status in older women with breast cancer: implications for screening, treatment, and prognosis

This is a review of research on the effects of comorbidity and functional status on breast cancer diagnosis, treatment, and prognosis in older women. The objective is to summarize results from recent studies and recommend directions for future research (a) to develop more precise guidelines for breast cancer screening, and (b) to identify and eliminate barriers preventing the attainment of those guidelines. Research is needed to determine more clearly how comorbidity and functioning affect screening practices and stage of disease at diagnosis. There is evidence that comorbidity explains, in part, why older women receive less invasive therapy. It is unknown, however, whether these treatment decisions improve quality or duration of survival. Although it is evident that comorbidity and disability adversely affect survival, research is needed to examine the etiology, course, and effects of specific combinations of conditions. Final recommendations include using the Established Populations for Epidemiologic Studies of the Elderly (EPESE) and the Surveillance, Epidemiology, and End Results (SEER) programs to address a number of these questions.

Trends in conserving treatment of invasive carcinoma of the breast in females

This population-based study presents trends in the treatment of node-negative invasive carcinoma of the breast in females during the 1980s in the Detroit metropolitan area. It was done to determine whether or not there has been a significant shift toward conservation of the breast from 1980 to 1987. Trend analyses of surgical treatment, tumor size, node status, year of diagnosis, age and race were performed for 13,217 patients drawn from the Metropolitan Detroit Cancer Surveillance System. A significant increase in the use of conserving the breast was observed, with younger women receiving this treatment option more often than older women. Implications for a continuing shift in the biologic findings and treatment of carcinoma of the breast are discussed.

Racial differences in the early detection of breast cancer in metropolitan Detroit, 1978 to 1987

This population-based study presents trends in stage at diagnosis of invasive female breast cancer during the decade from 1978 to 1987 in the Detroit metropolitan area. Its purpose is to determine whether there has been an increase in early breast cancers: those that are smaller than 2 cm at diagnosis and have no axillary lymph node involvement. Trend analyses of tumor size, node status, year of diagnosis, age, and race were performed for 17,216 incident cases drawn from the Metropolitan Detroit Cancer Surveillance System (MDCSS). Although trends toward earlier diagnosis of breast cancer are observed, less improvement is seen for black women than white women in the presentation of breast cancer at smaller, node-free stages. Implications for breast cancer screening are discussed.

The process of recovery from breast cancer for younger and older patients. Changes during the first year

A representative community sample of 274 breast cancer (BC) patients from the Metropolitan Detroit Cancer-Surveillance System was studied longitudinally during the year after their BC diagnosis. The adjustment of these patients to their disease was examined in terms of (1) the changes in their physical and mental health functioning; and (2) the factors that predict or facilitate the recovery process, including the independent and interactive effects of age. Comparison of the outcomes at 4 and 10 months after diagnosis manifested a significant and consistent improvement in physical functioning. In contrast, there was an absence of any improvement in indicators of mental health and well-being. Whereas the cross-sectional analyses demonstrated that stage of disease had an impact on physical impairment, the longitudinal analyses revealed that physical impairment at time 1 was the significant predictor of deteriorating mental health at time 2. Furthermore, younger age was shown to exacerbate the impact of impairment on mental health. The more seriously impaired younger patients experienced significantly greater deterioration in their mental health and well-being than similarly impaired older patients. However, older age was found to exacerbate the impact of more extensive surgery on symptoms that produce limitations in activity.

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

Levels of physical functioning reported by women aged 55 to 84 with incident breast cancer were compared to those reported by women of the same age without the disease. A total of 422 breast cancer patients, identified through the Metropolitan Detroit Cancer Surveillance System, were interviewed 3 and 12 months after diagnosis. Interviews with 478 controls of the same age, identified through telephone random-digit dialing, were conducted twice during the same time period. At 3 months, patients aged 55-64 and 65-74 reported greater difficulty than controls in completing tasks requiring upper-body strength. Little difference was shown between cases and controls aged 75 to 84. After one year, patients aged 65-74 still reported higher than expected levels of difficulty in light lifting as well as pushing and lifting heavy objects. Among cases aged 55-64, only pushing and lifting heavy objects remained problematic. Estimates of the prevalence of physical difficulty will be useful in planning future breast cancer treatment and rehabilitation services.

Racial and age differences in multiple primary cancers after breast cancer: a population-based analysis

The occurrence of multiple primary cancers was evaluated among 17,944 white and black female residents of Metropolitan Detroit diagnosed with breast cancer between 1973 and 1983. Invasive second primary cancers were diagnosed among 1106 of these women, almost twice the expected number. Subsequent in situ cancers were detected four times more often than expected. Fifty-six percent of the subsequent invasive cancers were of the breast (Standardized Incidence Ratio, SIR = 3.80). Black women experienced higher risk of subsequent breast cancers (SIR = 5.30) than white women (SIR = 3.62). Highest risk was seen among women first diagnosed before age 40 (SIR for black women = 26.15, SIR for white women = 10.87) and within five years of initial diagnosis. These findings suggest that young breast cancer patients, especially black women, are at high risk of developing a second primary breast cancer soon after their initial diagnosis and should be under continued medical surveillance. The occurrence of multiple primary breast cancers among young women suggests a genetic component to risk. Identification of this subpopulation would be useful in the study of molecular and genetic markers for cancer. Subsequent colon (SIR = 1.24) and cervical (SIR = 1.54) cancers also were diagnosed significantly more often than expected, as were ovarian cancers among white women (SIR = 1.45). These findings are consistent with common etiologic factors associated with these cancers.

Racial differences in cancer incidence: the significance of age-specific patterns

Racial differences in cancer incidence between black and white populations are examined for leading cancer sites by age at diagnosis. The analysis was based on 116,858 incidents, invasive cancer cases occurring between 1973 and 1982 in black and white, male and female residents of the Detroit metropolitan area. Cases were drawn from the population-based Metropolitan Detroit Cancer Surveillance System. The results indicate that racial differences in age-specific incidence rates for many forms of cancer are more pronounced when cancer occurs in early adulthood and middle age (20 to 44 and 45 to 54 years) than in persons aged 65 and over. This is especially the case for male subjects. This may suggest that blacks and whites who survive to their senior years before developing cancer may be more alike in terms of behavior, exposures, or host susceptibility than blacks and whites for whom cancer occurs in early adulthood or middle age. The etiologic and public health implications of these race and age patterns must be considered in greater detail. Future case-control studies should include sufficient numbers of patients in both the youngest and oldest age groups to ensure that black and white differences can be adequately examined by age at diagnosis.

The severity of breast cancer at diagnosis: a comparison of age and extent of disease in black and white women

A comparison was made of the incidence rates of localized, regional, and remote breast cancer between Black and White women by age at diagnosis. The analysis is based on 17,361 cases of breast cancer, newly diagnosed between 1973 and 1982, in Black and White female residents of the Detroit metropolitan area. Cases with breast cancer classified as local, regional, or remote were drawn from the Metropolitan Detroit Cancer Surveillance System of the Division of Epidemiology at the Michigan Cancer Foundation, a participant in the Surveillance, Epidemiology, and End Results (SEER) program of the National Cancer Institute. The findings indicate that older women, particularly Black women, are at elevated risk for being diagnosed with the most advanced form of breast cancer.

Race, socioeconomic status, and health: a study of age differences in a depressed area

According to the findings of a health survey conducted among 906 young, middle-aged, and elderly residents of an economically depressed area of Alameda County, California, health status is more strongly associated with income than with race, particularly among middle-aged residents. Although income is also significantly associated with health among both young and elderly residents, it is of little substantive importance. These findings support previous research showing that a measure of income difference (less than $6,500 a year), even among residents of a depressed area, can be sufficiently sensitive to identify a group in poor health. More important, the relationship between low income and poor health is most pronounced among middle-aged residents, indicating that the public health needs of these people deserve special attention.

Marital status and cancer incidence: differences in the black and white populations

A study of 59,070 cancers newly diagnosed during the years 1978 through 1982 among black and white males and females was conducted to assess variations in age-adjusted incidence rates across four marital categories, single, married, divorced, and widowed. Population data were obtained from the 1980 Census. Distinct patterns of cancer incidence by marital status were observed for black and white males and females. Single black males had the highest age-adjusted incidence rates for all 15 of the 15 sites analyzed among men. Similarly single black females' rates were highest for 14 of the 18 sites analyzed among women. Among white females, age-adjusted incidence rates were highest or second highest in widows for 16 of 18 sites analyzed. The variation in cancer incidence by marital status was not statistically significant for white men. In addition, there is a statistically significant concordance of cancer incidence by marital status across the four race-gender groups for three digestive tract sites. Clues to cancer etiology are suggested by this study, as well as potential directions for preventive health programs.

Risk of breast cancer to relatives of young breast cancer patients

Breast cancer risk among sisters and mothers of a population-based series of 1,137 breast cancer patients diagnosed in Metropolitan Detroit before the age of 55 years was compared with risk to the same relatives of 1,001 age-matched, population-based controls. After adjusting for age of the relative, for age of the case or control, and for race, the odds ratio for breast cancer for women with affected sisters was 2.2; for women with affected daughters, 3.2; and for women with affected mothers and sisters, 9.9. Breast cancer in aunts had no independent influence on risk. Among white women, cumulative risk of breast cancer before the age of 50 years was approximately 1% for relatives of controls, 3% for sisters of older cases, but about 17% for women either with sisters diagnosed before the age of 40 years or with affected sisters and mothers. Sisters of the older patients had a 13% risk of breast cancer by 70 years of age, compared to 5% for sisters of controls. White women with affected mothers and sisters were at 50% risk by 65 years of age. This study identifies the criteria for women who could receive particular benefit from screening for breast cancer.

The significant of an ill spouse for assessing health differences in an elderly population

In a survey of 678 elderly residents of Alameda County, California, it was found that respondents who reported their spouses as being ill in the last six months were more likely to report their own health as poor than those respondents whose spouses were not previously ill. The spouse's health was found to be the best predictor of the respondent's health. Research in this area may lead to a better understanding of the elderly spouse as a source of social support and may provide geriatricians with new insights into the health risks facing the married elderly.

Methods of cancer case selection: implications for research

The race, age, and sex differences between clinically and microscopically diagnosed cancer cases for a total of 63,301 incident cases for 18 sites are reported. The cases, diagnosed during 1973-1978, were drawn from the Cancer Surveillance Section in the Division of Epidemiology at the Michigan Cancer Foundation in Detroit, a participant in the Surveillance, Epidemiology, and End Results (SEER) program. Although microscopically diagnosed cases and those diagnosed by other methods differed by race and sex for a few sites, the two case groups differed by age for 15 of the 18 sites examined. Cases without microscopic diagnoses (i.e., clinical diagnoses) tended to be older than microscopically confirmed cases. These findings indicate that in studies of certain cancer sites, the method of case selection could affect results pertaining to age differences in exposure to and effects of relevant risk factors.

Supportive exchange: an exploration of the relationship between social contacts and perceived health status in the elderly

While social ties are known to bear an important relationship to health status among the elderly, the components of that association remain unclear. This study explored the hypothesis that 'supportive exchange', or the giving and seeking of advice and other forms of assistance, bears an important relationship to perceived health status. Six-hundred and seventy-eight elderly residents of Alameda County, CA, participated in this survey research study, which examined social ties, supportive exchange, and health status. A strong relationship was found between a key dimension of supportive exchange - the giving and seeking of advice - and self-reported health status. The association between advice seeking and health status was particularly high, demonstrating that advice seeking may be as strongly associated with health status as social ties. While it is important to develop refined indices for the measurement of other dimensions of supportive exchange, this exploratory study suggests that the concept may be a useful one in furthering research on the relationship between health status and social contacts among the elderly.

Race, age and cancer incidence: a test of double jeopardy

One form of the double jeopardy hypothesis states that health declines more dramatically with age for blacks than it does for whites. This paper tests the hypothesis for black and white differences by age in cancer incidence rates. Age-specific incidence rates for 14 major cancer sites were compared in black and white, male and female populations in Detroit. Rates were based on 57,275 invasive cancer cases, diagnosed between 1973 and 1978, and drawn from the Michigan Cancer Foundation Registry, a member of the National Cancer Institute's Surveillance, Epidemiology, and End Results program. For men, differences between blacks and whites for most sites dissipate with age, reflecting a leveling trend. For women, there is no consistent trend for most sites. Double jeopardy is reflected in rates for cervical cancer. Public health programs should be targeted to elderly black women for cervical cancer screening and to middle-aged black men for multiphasic cancer prevention services.