Health-Related Quality of Life and Psychosocial Status in Breast Cancer Prognosis: Analysis of Multiple Variables

Psychological adjustment to chronic disease

This Review discusses physiological, emotional, behavioural, and cognitive aspects of psychological adjustment to chronic illness. Reviewing the reports of the past decade, we identify four innovative and promising themes that are relevant for understanding and explaining psychological adjustment. In particular, the emphasis on the reasons why people fail to achieve a healthy adjustment has shifted to the identification of factors that help patients make that adjustment. To promote psychological adjustment, patients should remain as active as is reasonably possible, acknowledge and express their emotions in a way that allows them to take control of their lives, engage in self-management, and try to focus on potential positive outcomes of their illness. Patients who can use these strategies have the best chance of successfully adjusting to the challenges posed by a chronic illness.

The effect of psychosocial factors on breast cancer outcome: a systematic review

Introduction

We sought to review the available evidence regarding the effect of psychosocial factors on the survival of breast cancer patients.

Methods

We systematically searched the PubMed and PsycINFO databases to identify relevant studies.

Results

We identified 31 studies examining the association of various psychosocial parameters with overall breast cancer survival/disease free survival and 6 studies examining whether psychological intervention influences the disease outcome. Of the 31 studies summarized in this overview, 25 (80.6%) showed a statistically significant association between at least one psychosocial variable and disease outcome. Parameters associated with better breast cancer prognosis are social support, marriage, and minimizing and denial, while depression and constraint of emotions are associated with decreased breast cancer survival; however, the role of these factors has not been verified in all studies.

Conclusion

Most of the studies show a significant relationship between psychosocial factors and survival, but the actual psychosocial variables related to survival are not consistently measured across studies and the findings for many of the psychosocial variables with survival/recurrence are not consistent across studies. Thus, more research is warranted regarding the role of social support, marriage, minimizing and denial, depression and constraint of emotions on breast cancer survival.

Expressive Writing in Women With Advanced Breast Cancer

PURPOSE/OBJECTIVES

To explore the relationships between patterns of affective word use (words with positive or negative connotations) in expressive writing conducted over four consecutive days and quality of life (QOL) three months after the writing exercise in women with metastatic breast cancer.

DESIGN

Descriptive, correlational.

SETTING

Six clinical sites in New England.

SAMPLE

68 women with metastatic breast cancer.

MAIN RESEARCH VARIABLES

Patterns of positive and negative affective word use and QOL.

METHODS

Usage patterns of affective words in expressive writing were identified through the Linguistic Inquiry and Word Count (LIWC). Relationships between patterns of affective word use and QOL were explored. QOL was measured at baseline and three months after the writing exercise by the Functional Assessment of Cancer Therapy-Breast. Correlations between patterns of word use and QOL were investigated using general linear regression.

FINDINGS

A significant relationship was found between positive-affect word use and emotional well-being. Manual scoring of 10 expressive writing texts to validate LIWC data identified a significant difference between LIWC and manual counts for negative language. Contextual evaluation suggested marked ambivalence in how the women wrote about cancer.

CONCLUSIONS

A positive relationship between affective language in disclosure and QOL was demonstrated, illustrating a cognitive process occurring in expressive writing.

IMPLICATIONS FOR NURSING

The findings suggest that expressive writing is a positive, helpful intervention for patients with cancer attempting to reintegrate the experience in life. Nurses should gain deeper understanding of underlying cognitive processes of disclosure to identify the most effective manner in which to use such interventions.

Coping with breast cancer: a qualitative analysis of reflective journals

Non-disclosure of emotions has been shown to inhibit individuals' adjustment to illness and formulation of adequate coping mechanisms. The purpose of this qualitative study was to examine responses to the diagnosis and treatment of breast cancer and patterns of coping through an analysis of written reflective journals. Eight women submitted their journals to the researchers for analysis. Issues identified were (1) the assumption of an adaptive position; (2) the need for tangible evidence of love and support with three divergent responses, and (3) the need for something more. Specific patterns were identified within each issue.

Impaired natural killer cell lysis in breast cancer patients with high levels of psychological stress is associated with altered expression of killer immunoglobin-like receptors

BACKGROUND

We previously reported that cancer-related psychological stress is associated with reduced natural killer (NK) cell lysis. We hypothesized that reduced NK cell cytotoxicity in patients with increased levels of stress would correlate with alterations in the expression of inhibitory NK cell receptors (killer immunoglobulin-like receptors, or KIRs). The specific aim of this study was to examine KIR expression in patients with high or low levels of psychologic stress and correlate alterations in KIR expression with NK cell function.

MATERIALS AND METHODS

Two hundred twenty-seven patients underwent baseline evaluation of cancer-related psychological stress and were randomized to psychosocial intervention versus observation. From this population, two groups were defined based on pretreatment measurements of NK lytic activity, stress levels, and the availability of cryopreserved peripheral blood mononuclear cells (PBMC). Group I (n=9) had low stress by the Impact of Events Scale (IES), and high NK cell lysis at the 50:1 effector: target ratio (NK(50)=52-89%). Group II (n=8) had high stress and low NK(50) (27-52%). Lymphokine activated killer (LAK) activity, antibody dependent cellular cytotoxicity (ADCC), and expression of cytokine receptors, adhesion molecules, and killer immunoglobulin-like receptors (KIRs) were assessed in PBMC.

RESULTS

Incubation of PBMC with NK-stimulatory cytokines (IL-2, IL-12, or IL-15) led to significant increases in cytotoxic activity regardless of IES/NK(50) scores. There were no significant group differences in NK cell surface expression of the IL-2 receptor components CD25 and CD122, antibody-dependent lysis of HER2/neu-positive SKBr3 cells treated with an anti-HER2/neu monoclonal antibody, expression of adhesion molecules (CD2, CD11a, CD18) and markers of activation (CD69), or expression of the KIRs CD158a, NKG2a, NKB1, and CD161. However, levels of CD158b were significantly higher in Group I after incubation in media alone or with IL-2, and CD94 expression was significantly lower in Group I after incubation with IL-2.

CONCLUSIONS

In this study of a small subset of breast cancer patients chosen from a previous clinical trial of psychosocial intervention for breast cancer, impaired NK lysis in breast cancer patients with high levels of psychological stress was associated with alterations in surface expression of killer immunoglobulin-like receptors. However, immune effectors retained the ability to lyse antibody-coated targets and to initiate lymphokine-activated killer activity, irrespective of stress levels or baseline NK(50).

The effects of an individualized exercise intervention on body composition in breast cancer patients undergoing treatment

CONTEXT AND OBJECTIVE

Changes in metabolism have been reported in the majority of patients undergoing cancer treatment, and these are usually characterized by progressive change in body composition. The effects of aerobic exercise programs to combat the cancer and cancer treatment-related side effects, which include the negative changes in body composition, have been extensively reported in the literature. However, few resistance exercise intervention studies have hypothesized that breast cancer patients might benefit from this type of exercise. The purpose of this study was to determine whether exercise protocols that emphasize resistance training would change body composition and strength in breast cancer patients undergoing treatment.

DESIGN AND SETTING

Randomized controlled trial, at the Campus Recreation Center and Rocky Mountain Cancer Rehabilitation Institute of the University of Northern Colorado, and the North Colorado Medical Center.

METHODS

Twenty inactive breast cancer patients were randomly assigned to a 21-week exercise group (n = 10) or a control group (n = 10). The exercise group trained at low to moderate intensity for 60 minutes on two days/week. The primary outcome measurements included body composition (skinfold method) and muscle strength (one repetition maximum).

RESULTS

Significant differences in lean body mass, body fat and strength (p = 0.004, p = 0.004, p = 0.025, respectively) were observed between the groups at the end of the study.

CONCLUSION

The results suggest that exercise emphasizing resistance training promotes positive changes in body composition and strength in breast cancer patients undergoing treatment.

Psychological distress and fatigue predicted recurrence and survival in primary breast cancer patients

This study examined whether psychological distress in newly diagnosed breast cancer patients was associated with their survival. We analyzed data from 1,588 breast cancer patients who filled in the EORTC QLQ-C30 questionnaire and the Hospital Anxiety and Depression Scale (HADS) 2 months after their primary operation. The median follow-up time was 12.9 years. Psychological distress (EORTC QLQ-C30 emotional function; HADS anxiety; HADS depression) and EORTC fatigue, physical function, and overall ratings were used to predict recurrence-free and overall survival, controlling for the known clinical and histopathological prognostic factors (biological model) using Cox multivariate regression analysis. Low levels of psychological distress (good EORTC emotional function) and low fatigue independently predicted longer recurrence-free and overall survival, controlling for biological factors. Lack of anxiety (HADS) also predicted longer recurrence-free survival. When added in combination to the biological model, fatigue remained a significant predictor of recurrence-free survival (P = 0.0004; risk ratio 1.32 (1.13-1.54)) and emotional function remained a significant predictor of overall survival (P = 0.0074; risk ratio 0.81 (0.70-0.95)). Low psychological distress and a low level of fatigue may cause a greater cancer resistance or may reflect underlying mental and physical robustness.

Advanced breast cancer: aetiology, treatment and psychosocial features

Breast cancer is a common form of cancer in women of varying age. Due to the relationship between breasts, sexuality and reproduction, this form of cancer has an interconnected psychological and psychosocial influence on the well-being of women. Current understanding of the aetiology and pathogenesis of the disease has evolved as evidence supporting a role for genes such as the HER2 gene has emerged. HER2-positive breast cancer is a particularly progressive form of the disease as a result of its ability to differentiate and spread. Trastuzumab (Herceptin) forms part of the current treatment for this form of breast cancer; albeit costly, it has been shown to improve survival rates in women. For this reason it is now a recommended treatment for early-stage breast cancer. During and after treatment cycles, the breast cancer nurse and medical practitioners should be available to provide emotional support and advice on the manifestations of the disease, coping strategies and how breast cancer patients manage close family relatives.

Evaluating the organization and delivery of breast cancer services: use of performance measures to identify knowledge gaps

OBJECTIVES

This paper identifies gaps in our knowledge about the quality of breast cancer care in Canada to understand where programs and resources are required to enhance health services and research capacity.

METHODS

A modified Delphi approach was employed involving a 15-member multidisciplinary panel of health professionals and two rounds of rating followed by deliberation to develop evidence- and consensus-based performance measures. A literature search for Canadian health services research in breast cancer was conducted based on the indicator topics. Eligible articles were identified in indexed databases of medical literature and funded research from 1995 to 2006.

RESULTS

The multidisciplinary panel selected 34 indicators spanning access to services, patient outcomes, diagnosis and staging, surgery, adjuvant therapy, pathology, and follow-up care. A total of 78 articles (66 quantitative; 12 exploratory) on these topics were reviewed. Apart from two aspects of care (communication of treatment options, supportive care), the yield of Canadian breast cancer health services research did not increase subsequent to a review conducted 10 years ago which recommended greater efforts in this area.

CONCLUSIONS

Research involving quantitative and qualitative methods is needed to increase our understanding about the organization and delivery of services for breast cancer diagnosis, treatment and follow-up care. Since it is unclear how to balance competing research demands, innovative strategies are required to assemble resources for health services research on breast cancer. This could include the promotion of partnerships between researchers and policy-makers across jurisdictions, and the pooling of resources between organizations, regions or networks.

Sexual Minority Women's Coping and Psychological Adjustment after a Diagnosis of Breast Cancer

OBJECTIVE

To determine factors that influence sexual minority women's coping responses and adjustment to breast cancer.

METHODS

We conducted a cross-sectional study with 64 sexual minority women with breast cancer who were recruited through targeted community-based sampling. In this study, sexual minority women consisted of three sexual orientation groups: those who self-reported partnering with women and those with a lesbian or bisexual identity. We determined the number of years of sexual minority status and disclosure of sexual orientation and used standardized measures to assess these women's coping and adjustment to breast cancer. Data were analyzed using statistical methods as appropriate for the level of data.

RESULTS

We determined that sexual minority factors, such as sexual orientation group, influenced coping and adjustment even after illness and social support factors were controlled. In multivariate analyses, women who identified as lesbians or bisexuals used less maladaptive coping compared with women who reported partnering with women. The association between reporting a lesbian identity and lower distress approached significance in multivariate regression equations.

CONCLUSIONS

Of the sexual minority factors that were considered, sexual orientation group, number of years of sexual minority status, and disclosure of sexual minority status, only sexual orientation group was related to coping and lower distress. Contrary to expectations, disclosure of sexual orientation did not relate to coping and lower distress. The findings support the need for future studies to include different aspects of sexual minority status, in particular, clearly defined sexual orientation groups.