Postmastectomy Functional Impairments

PURPOSE OF REVIEW

This narrative review aims to offer a thorough summary of functional impairments commonly encountered by breast cancer survivors following mastectomy. Its objective is to discuss the factors influencing these impairments and explore diverse strategies for managing them.

RECENT FINDINGS

Postmastectomy functional impairments can be grouped into three categories: neuromuscular, musculoskeletal, and lymphovascular. Neuromuscular issues include postmastectomy pain syndrome (PMPS) and phantom breast syndrome (PBS). Musculoskeletal problems encompass myofascial pain syndrome and adhesive capsulitis. Lymphovascular dysfunctions include lymphedema and axillary web syndrome (AWS). Factors such as age, surgical techniques, and adjuvant therapies influence the development of these functional impairments. Managing functional impairments requires a comprehensive approach involving physical therapy, pharmacologic therapy, exercise, and surgical treatment when indicated. It is important to identify the risk factors associated with these conditions to tailor interventions accordingly. The impact of breast reconstruction on these impairments remains uncertain, with mixed results reported in the literature.

Breast cancer treatment and recovery: pets' roles as emotional buffers and stressors

BACKGROUND

Research suggests pets foster affection, connection, and physical activity, yet has failed to address the challenges people diagnosed with cancer face in caring for their pets. The objective of this study was to better understand how pets serve as emotional buffers and/or stressors for people diagnosed with breast cancer, and how their ability to meet their pet's needs affects their well-being.

METHODS

A cross-section study of people diagnosed with breast cancer in the United States was conducted. Adults diagnosed with stages 0 (in situ) -IV breast cancer and currently the primary guardian of at least one dog or cat and owned the animal(s) for at least 6 months, were recruited for the study. A total of 211 responses, obtained between July - November 2022 were analyzed. The survey included questions about participants' demographics; attachment to their pets; physical, emotional, and functional well-being; social support received from their pet; and 'pet parenting' concerns. Descriptive statistics were calculated to describe participants' demographics. Multiple regression analyses were conducted to determine predictors of pet attachment, well-being, support from pet, and 'pet parenting' concerns.

RESULTS

People diagnosed with breast cancer derive substantial support from their pets (80% feel their pet makes them feel loved, needed, and offers a positive presence in the home), yet only 50% of participants feel this relationship is supported by their medical team. Controlling for owner demographics, heightened levels of pet-related guilt and concerns, along with lower perceived support from their pet, are all significant predictors of a lower quality of life.

CONCLUSIONS

Findings highlight the benefits pets offer people diagnosed with breast cancer, yet also the distress they feel in trying to meet their pet's needs. Assessment conversations about pet ownership, including pet-related support systems, are needed to validate people's concerns and support the identification and development of pet support teams. Medical team facilitated discussions about pet care needs is suggested to demonstrate support for the pet-parent bond and help normalize feelings of guilt related to challenges in meeting their pet's needs. These discussions could be aided through the development of research-driven intervention strategies and online, freely accessible targeted tools.

African American Women Breast Cancer Survivors: Coping with the COVID-19 Pandemic

African American women breast cancer survivors are among those with the greater burden of cancer. Breast cancer is the second leading cause of death among black women, and this death rate is 40% higher than that of white women. The COVID-19 pandemic increased the burden of morbidity and mortality among this population of cancer survivors. In this report, we explore the ways in which the COVID-19 pandemic was a source of stress for African American women breast cancer survivors and their subsequent responses to these stressors. This is a qualitative descriptive study with content analysis of data from the narratives of 18 African American breast cancer survivors. Participants were interviewed via phone and video conferencing platform and asked questions related to their experiences with the COVID-19 pandemic. The findings suggest stressors associated with (1) potential COVID-19 spreaders in their immediate environments; (2) closures and restricted access to social- and faith-based activities; (3) televised news broadcasts of COVID-19; and (4) disruptions to planned cancer prevention and control healthcare. Three categories emerged that captured the ways in which these women responded to stressors during the early phase of this pandemic: (1) seeking control in their social environments; (2) following the rules; and (3) seeking support from God, family, and friends. These findings can be used to better support breast cancer patients during the early phases of a pandemic.

A qualitative exploration of the continuum of help-seeking among Asian American breast cancer survivors

Breast cancer rates among Asian American women are increasing. Despite this, there are limited studies on help-seeking among this population. Through a qualitative exploration, this paper examines the help-seeking experiences of Asian American breast cancer survivors. Asian American women (n = 52) with early-stage breast cancer were interviewed. Findings illustrate a continuum of experiences including: keeping diagnosis personal and not asking for help, keeping diagnosis personal but asking for limited help, and sharing diagnosis and seeking support. Results indicate that seeking support is a complex process for Asian Americans with breast cancer, with implications for survivorship and quality of life.

Identifying at risk populations amongst breast cancer survivors and their common symptoms and concerns

PURPOSE

The survival rate amongst breast cancer survivors (BCS) have been increasing, with a 5-year survival rate of almost 90%. These women face many quality of life (QOL) issues either due to either cancer itself or the complex treatment regimen. Our retrospective analysis aims to identify at risk populations among the BCS and their most common concerns.

METHODS

This is a single-institution, retrospective, descriptive analysis of patients who were seen at our Breast Cancer Survivorship Program from October 2016 to May 2021. Patients completed a comprehensive survey which assessed self-reported symptoms, their concerns and degree of worry and recovery to baseline. The descriptive analysis on the patient characteristics included age, cancer stage and treatment type. The bivariate analysis included the relationship between the patient characteristics and their outcomes. Analysis of group differences was completed with Chi-square test. When the expected frequencies were five or less, Fisher exact test was used. Logistic regression models were developed to identify significant predictors for outcomes.

RESULTS

902 patients (age 26-94; median 64) were evaluated. Majority of women had stage 1 breast cancer. The most common self-reported concerns affecting the patients were fatigue (34%), insomnia (33%), hot flashes (26%), night sweats (23%), pain (22%), trouble concentrating (19%), and neuropathy (21%). Though 13% of BCS felt isolated at least 50% of their time, the majority of patients (91%) reported having a positive outlook and felt that they have a sense of purpose (89%). Younger patients were more likely to worry about their cancer more than 50% of the time (p < 0.0001). Patients that were less likely to return back to at least 50% of their pre-treatment baseline were younger (age ≤ 45) (p = 0.0280), had higher stage breast cancer (Stage 2-4) (p = 0.0061), and had chemotherapy either alone or as part of their multi-modality treatment (p < 0.0001).

CONCLUSION

According to our study, younger patients, those with higher stage breast cancer and survivors who had chemotherapy may experience significant QOL issues. Fortunately, majority of BCS report a positive and optimistic outlook post treatment. Identifying common concerns after treatments and vulnerable populations are especially important to deliver quality care and to optimize interventions.

IMPLICATIONS FOR CANCER SURVIVORS

Our study identified the most common self-reported concerns affecting BCS. In addition, our results suggest that younger patients, patients with higher stage breast cancer and survivors who had chemotherapy were more likely to have QOL issues. Despite this, our study showed, the majority of BCS reported positive outlooks and emotions.

Racial disparity in breast cancer survivorship: themes from a series of four national healthcare provider live virtual forums

PURPOSE

Significant disparity exists in the diagnosis, treatment, and survivorship outcomes among Black breast cancer (BC) survivors. Black BC survivors have more significant survivorship issues and a greater burden of illness than White counterparts. Barriers to rehabilitation exist for all BC survivors but are magnified in Black BC survivors. The purpose of this qualitative research was to document patient, clinician, and researchers' perceptions surrounding contributing factors, lived experiences, and potential solutions to racial disparity in BC survivorship.

METHODS

A narrative approach was utilized to identify themes from a series of four virtual healthcare provider forums that explored lived personal and professional experiences, issues, and potential solutions surrounding racial disparity in BC survivorship. Forums included perspectives of patients, healthcare providers, researchers, and stakeholders in the BC field. An independent thematic analysis was performed by the investigators, all of whom have emic perspectives with respect to race and/or BC.

RESULTS

Three main themes were identified related to racial disparity in BC survivorship: (1) societal and cultural contributing factors, (2) contribution of healthcare providers and systems, and (3) models of care and research considerations.

CONCLUSIONS

The findings provide compelling documentation of lived personal and professional experiences of racial disparity in BC survivorship. Potential solutions exist and must be enacted immediately to ensure equitable survivorship outcomes for Black individuals following a BC diagnosis.

IMPLICATIONS FOR CANCER SURVIVORS

Increased awareness related to racial disparity in BC survivorship among survivors, healthcare providers, and researchers will contribute to health equity and improved outcomes for Black individuals.

What's in Between the Lines: Assessing the Readability, Understandability, and Actionability in Breast Cancer Survivorship Print Materials

Educational print materials for young women breast cancer survivors (YBCS) are supplemental tools used in patient teaching. However, the readability of the text coupled with how well YBCS understand or act upon the material are rarely explored. The purpose of this study was to assess the readability, understandability, and actionability of commonly distributed breast cancer survivorship print materials. We used an environmental scan approach to obtain a sample of breast cancer survivorship print materials available in outpatient oncology clinics in the central region of a largely rural Southern state. The readability analyses were completed using the Flesch-Kincaid (F-K), Fry Graph Readability Formula (Fry), and Simple Measure of Gobbledygook (SMOG). Understandability and actionability were analyzed using Patient Education Materials Assessment Tool for Printable Materials (PEMAT-P). The environmental scan resulted in a final sample of 14 materials. The mean readability of the majority of survivorship materials was "difficult," but the majority scored above the recommended 70% in both understandability and actionability. The importance of understandability and actionability may outweigh readability results in cancer education survivorship material. While reading grade level cannot be dismissed all together, we surmise that patient behavior may hinge more on other factors such as understandability and actionability. Personalized teaching accompanying print material may help YBCS comprehend key messages and promote acting upon specific tasks.

Health literacy among long-term survivors of breast cancer; exploring associated factors in a nationwide sample

BACKGROUND

Poor health literacy may hamper health management and long-term outcomes in breast cancer survivorship. Knowledge of factors associated with poor health literacy is needed to identify survivors in need of additional support and to improve the quality of health care, but is currently scant. Here, we explore health literacy and associated factors in a nationwide sample of long-term survivors of breast cancer.

MATERIAL AND METHODS

All survivors aged 20-65 years when diagnosed with stage I-III breast cancer in 2011 or 2012 were identified through the Norwegian Cancer Registry, and invited to participate in the Survivorship, Work and Sexual Health (SWEET) study. Health literacy was measured using The European Health Literacy Survey Questionnaire-12 (HLS-EU-Q12) and analyzed as a continuous and categorical variable. Associations between health literacy and socioeconomic, physical, and mental health variables, including the most common late effects after cancer treatment, were explored in uni- and multivariable linear regression models.

RESULTS

The final sample consisted of 1355 survivors (48%) with a mean age of 60 years at survey (SD 8.7). Eight years had passed since diagnosis (SD.0.7), and the majority of survivors had high socioeconomic status. Advanced judgment calls concerning treatment and health risks were reported to be the most difficult for survivors to handle. Mean health literacy sum score was 36.2 (range 12-48, SD 5.4). Thirty-nine percent had intermediate, while 19.3% reported marginal or inadequate health literacy. Education, income, age at diagnosis, the personality trait neuroticism, and fear of cancer recurrence were significantly associated with health literacy in the multivariate model, explaining 12% of the variance in health literacy scores.

CONCLUSION

Low levels of health literacy were prevalent in this population-based sample of long-term survivors of breast cancer, despite high socioeconomic status. Communicating and interpreting risks seem to be especially challenging. Attention to health literacy at a societal and individual level is necessary in order to provide survivorship care of high quality.

Impact of persistent peripheral neuropathy on health-related quality of life among early-stage breast cancer survivors: a population-based cross-sectional study

Background

We explored the impact of persistent sensory and motor taxane-induced peripheral neuropathy (TIPN) symptoms on health-related quality of life (HRQL) among early-stage breast cancer survivors (ESBCS).

Methods

A population-based cohort of 884 residual-free ESBCS received a postal questionnaire, including the EORTC chemotherapy-induced PN (CIPN20) and the EORTC QLQ-C30 instruments. Mean scores of QLQ-C30 scales among ESBCS with and without TIPN were calculated and adjusted for confounding factors (age, lifestyle factors, co-morbidities; linear regression analyses). Interpretation of QLQ-C30 results were based on guidelines.

Results

Response rate was 79%, and 646 survivors were included in the analysis. In median, 3.6 (1.5–7.3) years had elapsed post-taxane treatment. All TIPN symptoms had a significant impact on global QoL, which worsened with increased severity of TIPN. Between 29.5% and 93.3% of ESBCS with moderate-severe TIPN reported a clinical important impairment of functioning and personal finances, 64.3–85.7% reporting “difficulty walking because of foot drop,” and 53.1–81.3% reporting “problems standing/walking because of difficulty feeling ground under feet” had impaired functioning/finances. The difference in mean scores between affected and non-affected survivors was highest for “numbness in toes/feet” and “difficulty walking because of foot drop.” Moderate-severe “difficulty climbing stairs or getting out of chair because of weakness of legs” and “problems standing/walking because of difficulty feeling ground under feet” were associated with the largest clinically important differences on all scales.

Conclusion

Persistent sensory and motor TIPN is associated with clinically relevant impairment of global QoL, functioning, and personal finances among ESBCS, which increased with level of TIPN severity.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10549-022-06670-9.

Sexual activity and functioning in long-term breast cancer survivors; exploring associated factors in a nationwide survey

PURPOSE

Sexual health is a key quality of life issue. Knowledge concerning sexual health in long-term breast cancer survivors (BCSs) is limited. Within a nationwide sample, we aimed to assess the prevalence of sexual inactivity and to explore factors associated with sexual inactivity and reduced sexual functioning among long-term BCSs.

METHODS

Long-term BCSs aged 20-65 years when diagnosed with early-stage breast cancer in 2011-2012 were identified by the Cancer Registry of Norway in 2019 (n = 2803) and invited to participate in a nationwide survey. Sexual health was measured using the multidimensional Sexual Activity Questionnaire. Factors associated with sexual inactivity and reduced sexual functioning were explored using multivariable logistic- and linear regression analyses with adjustments for relevant sociodemographic, health-, and cancer-related variables.

RESULTS

The final sample consisted of 1307 BCSs with a mean age of 52 years at diagnosis. Fifty-two percent of the BCSs were sexually inactive. Lack of interest was the most common reason for sexual inactivity. Treatment with aromatase inhibitor (OR 1.73, 95% CI 1.23, 2.43) and poor body image (OR 0.99, 95% CI 0.99, 0.995) were associated with sexual inactivity. Among sexually active BCSs, depression (B - 1.04, 95% CI - 2.10, - 0.02) and physical inactivity (B - 0.61, 95% CI - 1.21, - 0.02) were inversely related to sexual pleasure. Treatment with aromatase inhibitor (B 0.61, 95% CI 0.20, 1.01), sleep problems (B 0.37, 95% CI 0.04, 0.70), breast symptoms (B 0.01, 95% CI 0.003, 0.02), and chronic fatigue (B 0.43, 95% CI 0.05, 0.81) were associated with sexual discomfort. Chemotherapy (OR 1.91, 95% CI 1.23, 2.97), current endocrine treatment (OR 1.98, 95% CI 1.21, 3.25), and poor body image (OR 0.98, 95% CI 0.98, 0.99) were associated with less sexual activity at present compared to before breast cancer.

CONCLUSION

Treatment with aromatase inhibitor seems to affect sexual health even beyond discontinuation. Several common late effects were associated with sexual inactivity and reduced sexual functioning. To identify BCSs at risk of sexual dysfunction, special attention should be paid to patients treated with aromatase inhibitor or suffering from these late effects.

Life after breast cancer: 'Being' a young African American survivor

Objective: In the United States, 26,534 young women (≤45 years) were diagnosed with breast cancer in 2017. Young African American (AA) women have higher incidence and mortality rates than Whites and Hispanics. Yet, few published studies describe survivorship (life after breast cancer diagnosis) experiences among this group. Here, we explore the lived experience of young AA breast cancer survivorship (via quality of life [QOL]).Design: This phenomenological study was framed by the QOL Applied to Breast Cancer model. Fifteen young AA survivors from the Southern U. S. participated in two semi-structured interviews. Methods of transcendental phenomenology were used for data collection and analysis.Results: Five themes emerged from participants' (mean age = 35 years; survivorship = 4 years) descriptions of survivorship experience: (1) actively managing spiritual self, (2) actively managing physical self, (3) actively managing psychological self, (4) actively managing social self, and (5) seeking survivorship knowledge. Participants perceived survivorship as a labile 'new normal' and 'ongoing struggle,' in which spirituality and survivorship knowledge were key to restructuring their lives.Conclusions: Survivorship among young AA survivors was more fluid and complex than the QOL model explained. Findings describe young AA breast cancer survivorship and indicate areas of potential strengths and distress. Healthcare providers and ancillary staff must exercise cultural competence to assess and anticipate young AA survivors' needs and concerns. Implementing targeted survivorship interventions, accounting for cultural contexts (e.g. high spirituality) and need for age-specific survivorship information, may improve QOL among young AA survivors.

The impact of breast cancer-related lymphedema on rural and small-town Survivors' return-to-work and quality of life: A multiple-case study

Background:

Breast cancer-related lymphedema (BCRL) is a lifelong condition. Millions who develop breast cancer are younger than retirement age and at a lifetime risk for developing BCRL. Rural and small-town survivors may face unique challenges in terms of access to health care and BCRL/survivorship resources. This multiple-case study describes how BCRL influences the work experiences and quality of life (QoL) of survivors living in rural and small towns in Missouri.

Methods and Materials:

Thirteen survivors from rural and small towns in Missouri completed semi-structured interviews and a standardized QoL instrument. Cases were analyzed using in-vivo and open-coding techniques and constant cross-case comparative methods. Twelve of the 13 participants’ data are synthesized into themes to represent an illustrative case. The 13^th case is presented as a contradictory (rival) case.

Results:

Four themes are represented within the illustrative case – multiple medical encounters; the development of self-care routines; the reciprocity of work/live activities, triggers, and adjustments; and rural/small-town cultural impact. Upon BCRL diagnosis, survivors received intensive treatments, eventually establishing self-care routines. Survivors identified strategies for working around their BCRL when completing work and home responsibilities. The contradictory (rival) case was more recently diagnosed and, as such, had not established self-care and coping mechanisms in the same way.

Conclusions and implications:

Survivors alleviate BCRL symptoms and improve their QoL by establishing self-care strategies. This provides guidance for client-centered survivorship care-planning and occupational rehabilitation of rural survivors with BCRL. This study provides the foundation for developing information for rural survivors that supports mental preparation and coping skills for BCRL self-management.

Adherence to a lower versus higher intensity physical activity intervention in the Breast Cancer & Physical Activity Level (BC-PAL) Trial

PURPOSE

The first aim is to examine adherence to a lower versus higher intensity physical activity (PA) prescription in breast cancer survivors in the Breast Cancer & Physical Activity Level (BC-PAL) Trial. The second aim is to assess associations between baseline characteristics with mean PA adherence in both intervention groups combined.

METHODS

Forty-five participants were randomized to a 12-week, home-based lower (300 min/week, 40-59% heart rate reserve (HRR)) or higher (150 min/week, 60-80% HRR) intensity PA intervention, or no intervention/control. Both intervention groups received Polar A360® trackers and were included in this analysis (n=30). Study outcomes assessed on a weekly basis with the Polar A360® activity tracker throughout the intervention included relative adherence to the prescribed PA interventions (% of PA prescription goal met), and the absolute amount of PA time ≥40% of HRR. Baseline predictors of adherence included demographic characteristics, cardiorespiratory fitness, habitual PA and sedentary time, quality of life measures, and motivational variables from the Theory of Planned Behavior. For our primary aim, a linear mixed model was used to assess the effects of randomization group, time (intervention weeks 1-12), and the interaction of these factors on the natural logarithm of PA adherence. For our secondary aim, the association between each baseline predictor with the natural logarithm of mean weekly PA adherence was assessed, with randomization group added as a covariate.

RESULTS

Higher relative time within the prescribed HRR zone was noted in the lower versus higher intensity PA groups (e^β=3.12, 95% CI=1.97, 4.95). No differences in adherence across time were noted. Social support was inversely associated with relative PA time within the prescribed HRR zone (e^β=0.83, 95% CI=0.72, 0.97) and absolute PA time ≥40% of HRR (e^β= 0.82, 95% CI: 0.71, 0.93). Baseline VO_2max was inversely associated with relative PA adherence (e^β=0.98, 95% CI=0.95, 0.99). No other baseline measures were associated with PA adherence.

CONCLUSIONS

There were no significant changes in absolute PA time ≥40% of HRR across time or between groups. However, the lower intensity PA group averaged over 3 times the relative amount of PA within the prescribed HRR zone compared to the higher intensity PA group. Finally, lower peer support and cardiorespiratory fitness at baseline were associated with higher PA adherence.

IMPLICATIONS FOR CANCER SURVIVORS

The recent rise in popularity of commercially available activity trackers provides new opportunities to promote PA participation remotely, and these devices can be used to continuously and objectively measure PA levels as an indicator of intervention adherence. Future studies are needed to explore baseline predictors, facilitators, and barriers to sustained activity tracker use to promote PA behavior change and intervention adherence in cancer survivors.

TRIAL REGISTRATION

This study was registered at www.clinicaltrials.gov (No. NCT03564899) on June 21, 2018.

Breast Cancer Survivorship Experiences of Urban Hispanic Women

The purpose of this study was to explore determinates of health that impact survivorship of urban Hispanic breast cancer survivors who are at risk for experiencing poorer outcomes than others. Some challenges have been characterized, but gaps in our knowledge of the impact of some of the social determinates of health remain. Challenges likely exist prior to a diagnosis of cancer and may amplify in intensity during survivorship, potentially shortening survival and quality of life of these women. A narrative, focus group was conducted with a group of urban Hispanic breast cancer survivors. A series of linked vignettes describing survivorship challenges and late effects of breast cancer pathology and treatment were used to stimulate discussion. Three themes impacting survivorship were identified. The themes included communication (health literacy), isolation, and social support and financial cost. Communication issues resulted in delays in treatment denial of services. While these themes in cancer survivors are independent of residence (rural, suburban, or urban) and across ethnic groups, some unique issues were identified in urban Hispanic breast cancer survivors. Members of the healthcare team are in a unique position to enhance survivor's health literacy, advocate for programmatic efforts to enhance navigation roles in the hospital and communities, decrease delays in initiating care, and decrease the rate of patients lost.

Pre-diagnostic allostatic load and health-related quality of life in a cohort of Black breast cancer survivors

PURPOSE

To determine the association of pre-diagnostic allostatic load (AL) with health-related quality of life (HRQOL) among Black women with breast cancer.

METHODS

In a sample of 409 Black women with non-metastatic breast cancer enrolled in the Women's Circle of Health Follow-Up Study (WCHFS), two pre-diagnostic AL measures were estimated using medical records data from up to 12 months prior to breast cancer diagnosis: AL-lipid/metabolic profile-based measure and AL-inflammatory profile-based measure. HRQOL was assessed approximately 24 months post diagnosis, using the Functional Assessment of Cancer Therapy-Breast Cancer (FACT-B) instrument, including 5 subscale scores [presented by physical well-being (PWB), social & family well-being (SFWB), emotional well-being (EWB), functional well-being (FWB), and breast cancer-specific scale (BCS)] and 3 derived total scores [presented by trial outcome index (TOI), Functional Assessment of Cancer Therapy-General (FACT-G) and FACT-B]. We used multivariable logistic regression models, using dichotomized AL scores (lower AL: 0-3 points, higher AL: 4-8 points), to assess the associations between the two pre-diagnostic AL measures and HRQOL.

RESULTS

Higher pre-diagnostic AL was associated with poorer FWB and lower FACT-G, but these associations were statistically significant for the AL-inflammatory profile-based measure (FWB: OR 1.63, 95% CI 1.04, 2.56; FACT-G: OR 1.62, 95% CI 1.04, 2.54), but not the AL-lipid/metabolic profile-based measure (FWB: OR 1.45, 95% CI 0.81, 2.59; FACT-G: OR 1.33, 95% CI 0.75, 2.37).

CONCLUSION

These findings suggest that higher AL, particularly when measured using the inflammatory profile-based measure, was associated with poorer HRQOL, namely FWB and FACT-G, among Black breast cancer survivors.

Undergarment needs after breast cancer surgery: a key survivorship consideration

An important aspect of breast cancer survivorship is finding comfortable undergarments that work for women's post-treatment bodies. Patients who undergo mastectomy, including both those who do and do not receive reconstruction, need bras that can accommodate new breast shape, size, and feel, as well as scarring and skin sensitivity. Our research with breast cancer patients and the literature reveal that ready-to-wear bras are inadequate for the variety of patients' needs, and many women lack support and guidance to make decisions about undergarments after cancer. This commentary describes a major quality-of-life challenge for breast cancer survivors and makes recommendations for future research. Healthcare providers need more guidance and resources to be able to help their patients prepare for this aspect of survivorship. New technologies, such as biomechanical modeling, 3D body scanning, and manufacturing techniques, should be pursued in collaboration with patients, healthcare providers, and clothing designers to ease this burden for breast cancer patients.

Breast cancer survivors' perspectives on a home-based physical activity intervention utilizing wearable technology

PURPOSE

To gain breast cancer survivors' perspectives on participation in a home-based physical activity intervention and the factors that contributed to their acceptance and adherence to physical activity.

METHODS

Semi-structured interviews were conducted with six women who had participated in a 12-week, home-based physical activity intervention using Polar A360® activity trackers. Additionally, 22 participants from the physical activity interventions provided scaled responses to barriers of physical activity on weeks 3, 6, 9, and 12. Interviews were transcribed verbatim. Thematic analysis was used for qualitative data.

RESULTS

Perceptions (n = 6) were categorized into three main themes including (i) Study Environment which consisted of three subthemes acrchversusfear of failure, power of results, and reminders of cancer and moving beyond. (ii) Influence of People encompassed two subthemes, i.e., personal relationships and self as a source of motivation; and (iii) Wearable Technology which was divided into two subthemes, i.e., objective insights into health and disconnect of person and technology. From the scaled responses, the most impactful barriers for participants within the intervention groups (n = 22) were "feeling busy," "lack of motivation," and "weather."

CONCLUSION

Wearable technology was perceived largely as a facilitator to physical activity in the current study, but technologic difficulties created a barrier to physical activity adherence. Additionally, participants' perceptions of study design elements and social support influenced their acceptance and adherence to the home-based physical activity interventions and should be considered to inform the design and implementation of future studies.

"When I Needed It": Evaluation of the Use and Timing of Sharsheret's Thriving Again Program for Young Breast Cancer Survivors

Approximately 11% of all new breast cancer cases in the USA occur in women aged 45 years or younger. In 2011, CDC funded seven organizations to develop or enhance programs for young breast cancer survivors (YBCS). This paper analyzed program evaluation data collected by one of these organizations to gain a more nuanced understanding of how recipients used the newly developed program and resources for YBCS. Sharsheret's Thriving Again program was evaluated through a web-based survey of survivorship program participants. The evaluation asked questions about participant demographics, use of the kit's survivorship care plan (SCP), satisfaction with the timing of survivorship kit receipt, and factors related to survivors' use of additional Sharsheret programs. We conducted bivariate analyses of survey responses and calculated chi-square statistics for significance testing. Of the 163 women who responded to the survey, 43% were diagnosed with breast cancer at or before age 45 and 69% were of Jewish descent. The majority of women who used the SCP found it helpful to facilitate cancer treatment (94%), follow-up (85%), or discussions with providers (91%). A total of 75% of women who received the SCP kit while either recently diagnosed or undergoing treatment were satisfied with the timing of receipt. Survey respondents found the Thriving Again program and survivorship kit beneficial and indicated timing preferences for when to receive resources and support. Supporting the self-efficacy of cancer survivors may improve survivors' quality of life and is an important aspect of survivorship programs.

Lymphedema symptoms and limb measurement changes in breast cancer survivors treated with neoadjuvant chemotherapy and axillary dissection: results of American College of Surgeons Oncology Group (ACOSOG) Z1071 (Alliance) substudy

PURPOSE

Lymphedema is a potential complication of breast cancer treatment. This longitudinal substudy aimed to prospectively assess arm measurements and symptoms following neoadjuvant chemotherapy and axillary dissection in the ACOSOG/Alliance Z1071 trial to characterize the optimal approach to define lymphedema.

METHODS

Z1071 enrolled patients with cT0-4, N1-2, M0 disease treated with neoadjuvant chemotherapy. All patients underwent axillary dissection. Bilateral limb volumes, circumferences, and related symptoms were assessed pre-surgery, 1-2 weeks post-surgery, and semiannually for 36 months. Lymphedema definitions included volume increase ≥ 10% or limb circumference increase ≥ 2 cm. Symptoms were assessed by the Lymphedema Breast Cancer Questionnaire.

RESULTS

In 488 evaluable patients, lymphedema incidence at 3 years by ≥ 10%-volume-increase was 60.3% (95% CI 55.0-66.2%) and by ≥ 2 cm-circumference increase was 75.4% (95% CI 70.8-80.2%). Symptoms of arm swelling and heaviness decreased from post-surgery for the first 18 months and then were relatively stable. The 3-year cumulative incidence of arm swelling and heaviness was 26.0% (95% CI 21.7-31.1%) and 30.9% (95% CI 26.3-36.3%), respectively. There was limited agreement between the two measurements (kappa 0.27) and between symptoms and measurements (kappa coefficients ranging from 0.05-0.09).

CONCLUSIONS

Lymphedema incidence by limb volume and circumference gradually increased over 36 months post-surgery, whereas lymphedema symptoms were much lower. These findings underscore the importance of prospective surveillance and evaluation of both limb measurements and symptom assessment. Lymphedema incidence rates varied by definition. We recommend that ≥ 10% volume change criterion be used for lymphedema evaluation for referral for specialist care.

TRIAL REGISTRATION

NCT00881361.

Ablative dual-phase Erbium:YAG laser treatment of atrophy-related vaginal symptoms in post-menopausal breast cancer survivors omitting hormonal treatment

PURPOSE

First evaluation of dual-phase vaginal Er:YAG laser to omit hormonal treatment for atrophy-related symptoms in post-menopausal breast cancer survivors following prolapse surgery.

METHODS

Patients with a history of breast cancer at the time of surgery for pelvic organ prolapse were offered non-hormonal vaginal Er:YAG laser treatment when complaining of atrophy-related genitourinary syndrome of menopause. A single 10-min course of dual-phase protocol of pulsed Er:YAG laser (2940 nm, fractional ablative and thermal mode, fluence according to tissue thickness). Follow-up included subjective satisfaction, vaginal pH, vaginal health index (VHI), and complications after 6 weeks.

RESULTS

A total of 16 breast cancer survivors (age 71 years, SD 7) had been seeking treatment for pelvic floor symptoms related to vaginal atrophy at follow-up visits after prolapse surgery. All ablative vaginal Er:YAG laser outpatient procedures were successfully completed, all patients returned to daily activities without a need for analgetic medication. Evaluation was performed after 8.3 (SD 2.5) weeks. Pre-laser VHI scored 16 (SD 4.6) and post-laser VHI 20 (SD 3) with p = 0.01. Patients were satisfied in 94% (n = 15) regarding symptom relief.

CONCLUSIONS

Breast cancer survivors with atrophy-related complaints after pelvic floor surgery may benefit from vaginal application of this innovative dual protocol of Er:YAG laser technology as a non-hormonal treatment approach.

Evaluating Survivorship Experiences and Needs Among Rural African American Breast Cancer Survivors

Disparities in cancer survivorship exist among specific populations of breast cancer survivors, specifically rural African American breast cancer survivors (AA-BCS). While effective survivorship interventions are available to address and improve quality of life, interventions must be culturally tailored for relevance to survivors. Here, we report the results of our formative research using focus groups and in-depth interview to better understand unique rural AA-BCS survivorship experiences and needs in the Alabama Black Belt. Surveys were used to gather sociodemographic and cancer treatment data. Fifteen rural AA-BCS shared their experiences and concerns about keeping their cancer a secret, lack of knowledge about survivorship, lingering symptoms, religion and spirituality, cancer surveillance, and general lack of survivorship education and support. Rural AA-BCS were unwilling to share their cancer diagnosis, preferring to keep it a secret to protect family and friends. Quality-of-life issues like lymphedema body image and sexuality were not well understood. They viewed spirituality and religion as essential in coping and accepting cancer. Participants also discussed the importance of and barriers to maintaining health through regular check-ups. They needed social support from family and friends and health care providers. Overall, rural AA-BCS expressed their need for knowledge about survivorship self-management by providing a vivid picture of the realities of cancer survival based on shared concerns for survivorship support and education within the context of culture.

Characteristics associated with nonadherence to medications for hypertension, diabetes, and dyslipidemia among breast cancer survivors

OBJECTIVE

Comorbidity among breast cancer survivors is prevalent, and adherence to medication management of comorbidities may be important for both chronic disease and cancer-related outcomes. Our objective was to determine characteristics associated with nonadherence to common chronic medications among breast cancer survivors.

METHODS

We conducted a retrospective cohort study of 4216 women in an integrated care system diagnosed with early-stage breast cancer between 1990 and 2008 and alive without recurrence or second primary breast cancer in the second-year following diagnosis. Adherence to antihypertensives, oral diabetes medications, and statins was measured during the second-year post-breast cancer diagnosis using medication possession ratios (MPR). Nonadherence was defined as MPR <0.80. We estimated odds ratios (OR) and 95% confidence intervals (CI) for nonadherence to antihypertensives, oral diabetes medications, and statins by various characteristics using multivariable logistic regression.

RESULTS

Among 2308 users of antihypertensives (n = 1779), diabetes medications (n = 499) and/or statins (n = 1072), 37% were nonadherent to antihypertensives; 75% were nonadherent to diabetes medications; 39% were nonadherent to statins. In adjusted models, younger age was associated with nonadherence to all three therapeutic classes. Certain cancer treatments were associated with nonadherence to antihypertensives (radiation: OR 1.21, 95% CI 1.01-1.47; endocrine therapy: OR 1.27, 95% CI 1.03-1.52) and diabetes medications (chemotherapy: OR 1.69, 95% CI 1.17-2.21). Less frequent primary care provider visits were associated with higher odds of nonadherence to antihypertensives (OR 1.70, 95% CI 1.19-2.22); and trends showed higher Charlson comorbidity scores associated with greater adherence to diabetes medications (P < 0.001) and statins (P = 0.032).

CONCLUSIONS

Nonadherence to medications is high among breast cancer survivors, particularly diabetes medications, and is associated with cancer treatments and other patient characteristics. Additional research is warranted to understand the needs of cancer patients taking chronic medications and explore patient and provider factors influencing adherence.

Impact of a behavioral weight loss intervention on comorbidities in overweight and obese breast cancer survivors

PURPOSE

Comorbid medical conditions are common among breast cancer survivors, contribute to poorer long-term survival and increased overall mortality, and may be ameliorated by weight loss. This secondary analysis evaluated the impact of a weight loss intervention on comorbid medical conditions immediately following an intervention (12 months) and 1-year postintervention (24 months) using data from the Exercise and Nutrition to Enhance Recovery and Good health for You (ENERGY) trial-a phase III trial which was aimed at and successfully promoted weight loss.

METHODS

ENERGY randomized 692 overweight/obese women who had completed treatment for early stage breast cancer to either a 1-year group-based behavioral intervention designed to achieve and maintain weight loss or to a less intensive control intervention. Minimal support was provided postintervention. New medical conditions, medical conditions in which non-cancer medications were prescribed, hospitalizations, and emergency room visits, were compared at baseline, year 1, and year 2. Changes over time were analyzed using chi-squared tests, Kaplan-Meier, and logistic regression analyses.

RESULTS

At 12 months, women randomized to the intervention had fewer new medical conditions compared to the control group (19.6 vs. 32.2 %, p < 0.001); however, by 24 months, there was no longer a significant difference. No difference was observed in each of the four conditions for which non-cancer medications were prescribed, hospital visits, or emergency visits at either 12 or 24 months.

CONCLUSIONS

These results support a short-term benefit of modest weight loss on the likelihood of comorbid conditions; however, recidivism and weight regain likely explain no benefit at 1-year postintervention follow-up.