Psychological outcomes of different treatment policies in women with early breast cancer outside a clinical trial

Centralised treatment, entry to trials and survival

A review was carried out of the published literature on survival rates for cancer in relation to patterns of organisation of medical care, specifically treatment at specialist centres or at hospitals treating larger numbers of patients and treatment by protocol, usually within the context of a clinical trial. Centralised referral or entry to trials was frequently associated with a higher survival rate, particularly for the less common cancers, and was never found to be associated with a lower survival rate. Few studies were identified for any one cancer site and some antedated current methods of treatment. At a time when the health service in the United Kingdom is undergoing far-reaching organisational change, further research is needed to establish the most beneficial patterns of care for people with cancer. Population-based cancer registries are an invaluable source of data for such studies.

Relationship between preferences for decisional control and illness information among women with breast cancer: a quantitative and qualitative analysis

This study examined relationships between cancer patients' preferences for involvement in making treatment decisions and preferences for information about diagnosis, treatment, side effects, and prognosis. Participants were 35 women with stage I and II breast cancer recruited from two medical oncology and radiation oncology clinics. Following administration of card sort measures of preference for involvement in treatment decision making and information needs, a semi-structured interview was conducted to provide patients with an opportunity to elaborate on their role preferences and health care experiences. Results showed that patients who desired an active role in treatment decision making also desired detailed information. This relationship was not as clear for passive patients. Relative to passive patients, active patients desired significantly more detailed explanations of their diagnosis, treatment alternatives, and treatment procedures. Active patients also preferred that their physicians use the words 'cancer' or 'malignancy' when referring to their illness while passive patients preferred that their physicians use a eupheumism. Further research is needed to critically detail the advantages and disadvantages of the active and passive roles and their impact on disease progression and psychological well-being.

The prevalence of menopausal symptoms in patients treated for breast cancer

A survey has been performed to discover the prevalence of menopausal symptoms in 108 patients successfully treated for breast cancer. Patients were assessed by them answering a custom designed questionnaire, and the use of the Hospital Anxiety and Depression (HAD) scale and the Greene Climacteric Scale. During the first year after treatment 70% of women suffered such symptoms; overall 60% of women surveyed were affected. Adjuvant hormonal treatment was the largest contributing factor in the development of symptoms. There was a relationship with borderline cases of anxiety, but not with definite cases of anxiety, as measured by the HAD scale. The high proportion of women shown to be affected means that treatment of menopausal symptoms should be incorporated into randomized trials of adjuvant therapy.

Quality of life as an indicator of outcome in the treatment of cancer patients: the purchaser perspectives

Evaluation of treatment can be seen as part of a wider concern to measure quality of care, as well as about the need to monitor and improve the effectiveness of services. Quality of life issues will be of increasing interest to those involved in the commissioning of health-care services. Cancer is used to illustrate how the quality of life of patients, both during and after treatment, can be measured and the information used by purchasers to consider the relative effectiveness of different methods of treatment. This in turn can inform the overall purchasing strategy of commissioning agencies.

Psychological distress in cancer patients with advanced disease

The objective of this study is to explore the nature and extent of the cognitive behavioral response to treatment, and the accompanying anxiety and/or depression in cancer patients with advanced disease. In a multicenter study, 247 patients treated with palliative radiotherapy filled out a questionnaire before start of treatment. The questionnaire consisted of Impact of Event Scale (IES), General Health Questionnaire (GHQ-20), and two questions assessing pain intensity. Seventy percent of the patients reported a high level of psychological distress. The mean score of the patient population on the IES was 14.4 (IES intrusion) and 15.3 (IES avoidance). The mean Likert score on the GHQ-20 was 27.3. Patients with poor performance status and pain were most distressed. In order to improve patients' care and support, cases at risk must be identified. In the present population, psychological distress is related to pain and reduced performance status.

Surgical treatment for early breast cancer: should the patient decide?

Conservative surgery followed by a course of radiotherapy has been shown to be as effective as mastectomy in terms of survival and disease-free interval. This has led to an increase in the number of surgeons who undertake conservative surgery for early breast cancer. However, some studies have shown that, when offered a choice of surgery, some women elect mastectomy. Such results highlight the need for patients to be fully involved in the decision made about surgery, especially in the circumstances where there is more than one surgical option and a choice of surgery can be offered.

Quality of life measurement in breast cancer

Appropriate assessment of quality of life parameters should be a mandatory requirement when determining the outcome of different treatments for breast cancer. Such measures provide useful, sometimes counterintuitive information concerning treatment costs and benefits and can help guide the clinician with management decisions. It is important to choose well-validated measures of quality of life to enable comparison between studies assessing the impact of different therapeutic modalities and psychosocial interventions.

Is there a role for preference assessments in research on quality of life in oncology?

The development of ways to evaluate interventions that may have an impact on quality of life is a rapidly-developing area of research in clinical oncology, especially within the context of randomized controlled trials. We propose a role for assessments of preferences in such evaluations, including preference studies designed to assess attitudes toward the clinical acceptability of interventions, and preference trials designed to assess choice behaviour in relation to interventions. We suggest that such preference assessments represent a specific case of a more general issue: the need to develop an 'ethics of evidence', that is, standards for the creation, assessment and communication of evidence. We then outline a framework within which an 'ethics of evidence' might be developed, and suggest that the framework also may provide a useful model for the processes involved in the transfer of research results into clinical practice. As an illustration, we consider the problem of decision making in circumstances where the choice of therapy depends primarily on the patient's own preferences, as, for example, in the choice of mastectomy or breast-conserving treatment in early-stage breast cancer. The long-term goal is to develop criteria which might be used to foster shared rational decision making in such circumstances.

Does the breast cancer dollar make sense?

The past decade has witnessed a transformation of breast cancer management. Innovative developments such as widespread mammographic screening, breast-conserving approaches to primary disease and adjuvant systemic therapy have improved the quality of breast cancer care in the community. These and other therapeutic developments have been accompanied by substantial increases in consumption of health care resources. With the exception of adjuvant systemic therapy for node-positive disease, the evidence that such increases have been associated with commensurate improvements in disease outcome is weak. Indefinite continuation of this trend may prove incompatible with socioeconomic realities.

Mastectomy or conservation for early breast cancer: psychological morbidity

A consecutive series of 197 women under 70 years of age with operable breast cancer, randomised to treatment by a conservation technique in comparison to mastectomy, were assessed using structured interviews. The prevalence of cases of anxiety and depression was high before treatment commenced, there were fewer cases in the conservation group but no significant difference at 3 or 12 months in the number of new cases, social adjustment, or capacity to return to work. Attitudes to treatment showed significant differences between the groups, more women in the conservation group were able to wear their usual clothes and most women rated the cosmetic result highly. Patients were more likely to stop sexual intercourse completely after mastectomy. An effective conservation technique should be an attractive treatment choice available to selected women with early breast cancer.

The impact of a breast cancer screening programme on quality-adjusted life-years

Trials have shown that breast cancer screening is effective in reducing breast cancer mortality and gaining life-years. The question is whether taking into account the impact of a screening programme on quality of life would lead to a less positive view. Screening may have effects on quality of life in the short run for women participating and effects in the long run as a result of the expected shift in the number of women experiencing early and advanced phases of the disease, after the initiation of the programme. In this study 4 steps have been taken: (I) published studies on quality of life and breast cancer (screening) up to 1989 have been reviewed and summarized and, based on these data, the consequences of breast cancer and treatment have been described; (2) values have been assigned to the disease and treatment phases by experts in breast cancer and public health (N = 31, response 87%); (3) these values have been inserted in the MISCAN model predicting the prevalence of disease/treatment phases with and without a 2-yearly screening programme for women aged 50-70 and multiplied by the duration of these phases; (4) analyses have been done to establish the sensitivity of the results for the values inserted. The programme of 2-yearly mammographic screening for women aged 50-70 is predicted to be 8% "less effective" (range -19.7 to +3.2%) when computing quality-adjusted life-years. We conclude that this adjustment is too small to attribute a major role to quality of life in the decision to undertake a large-scale breast cancer screening programme.

Two simple indexes used to evaluate the impact of therapy on the quality of life of patients receiving primary chemotherapy for operable breast cancer

The psychometric characteristics of two indexes used to evaluate the subjective morbidity of chemotherapy regimens were analyzed. Both indexes assessed the duration of discomfort as perceived by the patient throughout therapy. The first index asked patients to state the number of days spent with 'discomfort', and the second index asked them which days they would like to eliminate altogether because of the unbearable symptoms experienced on those days. While the first index gives some idea of the duration of suffering, without defining it, the second highlights a specific time when the quality of her life was unacceptable to the patient. We studied these indexes in the form of a questionnaire completed by 168 women who had entered a cancer clinical trial. This trial evaluated the efficacy of primary chemotherapy in rendering conservative surgery feasible in women with operable breast cancer, but whose tumor size was greater than 3 cm. Four different treatment regimens were used: CMF, FAC, FEC, FNC (C = cyclophosphamide, M = methotrexate, F = fluorouracil, A = adriamycin, E = epirubicin, N = mitoxantrone). Seventy-nine patients were interviewed during chemotherapy and 89 during follow-up visits. Initial assessment of the reliability, discriminant and concurrent validity of the two indexes produced satisfactory results. Finally, we analyzed the responses given by 168 patients for a total of 600 treatment cycles. The average value of 'discomfort' was 3 days, whereas the average value of days 'to be eliminated' was 1. The range of subjective morbidity (for every cycle of treatment: 'discomfort = 0-30 days; 'to be eliminated' = 0-20 days) was very broad.(ABSTRACT TRUNCATED AT 250 WORDS)