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

Physical functioning and depression among older persons with cancer

PURPOSE

The purpose of this study was to help identify factors to assess which elderly patients are likely to experience problems with physical and psychological functioning in association with cancer or its treatment.

DESCRIPTION OF STUDY

A study was undertaken with a sample of 420 patients with cancer who were between the ages of 65 and 98 years and had received an incident diagnosis of breast, colon, lung, or prostate cancer. An analysis of covariance technique was used to determine how cancer site, treatment type, stage of disease, gender, age, comorbidity, symptom severity, and pre-diagnosis levels of physical functioning were related to physical functioning deficit, and how all of these in turn influenced patient depressive symptomatology.

RESULTS

Pre-diagnosis physical functioning, symptom severity, and days since surgery were significant predictors of physical functioning deficit. Patients who had been treated only with surgery experienced greater physical functioning deficits than did patients who had received both surgery and adjuvant therapy. This apparent anomaly was partly explained by the time interval from surgery to interview. Higher levels of symptom severity, lower levels of prior physical functioning, and greater physical functioning deficits all predicted higher levels of depressive symptomatology.

CLINICAL IMPLICATIONS

In the care of elderly patients with cancer, it is important for healthcare providers to consider the pre-diagnosis levels of physical functioning of patients with cancer to understand and anticipate the physical and psychological consequences of cancer and its treatment. Equally important is the proper management of patient symptoms in maximizing both the physical and psychological quality of life.

The persistent impact of breast carcinoma on functional health status: prospective evidence from the Nurses' Health Study

BACKGROUND

Although physical and emotional function after the diagnosis of breast carcinoma have been described in clinic populations, to the authors' knowledge no previous study has measured change from the preillness level of functional health status in community-dwelling women.

METHODS

The authors conducted a 4-year (1992-96) prospective study of functional recovery after breast carcinoma in a large sample of women, aged 54-73 years. They collected multidimensional measures of self-reported functional health status in 1992, before diagnosis of breast carcinoma, and again in 1996, to examine the risk of decline associated with incident breast carcinoma.

RESULTS

After adjustment for age, baseline functional health status, and multiple covariates, women who developed incident breast carcinoma were more likely to have experienced reduced physical function, role function, vitality, and social function and increased bodily pain compared with women who remained free of breast carcinoma. Risk of decline was attenuated with increasing time since diagnosis. Risk of decline in physical function was evident across all stages of breast carcinoma, even after adjustment for women undergoing treatment for persistent or recurrent disease. We found evidence that the risk of decline among breast carcinoma cases compared with healthy women was largest among those who were most socially isolated.

CONCLUSIONS

Breast carcinoma results in persistent declines in multiple dimensions of functional health status. These prospective data suggest that previous studies reporting no difference in physical function among breast carcinoma cases compared with disease free women underestimated the deleterious effect of the disease on function. Socially isolated women are an especially vulnerable group.

Responsiveness to threats and incentives, expectancy of recurrence, and distress and disengagement: moderator effects in women with early stage breast cancer

Models of neurobiological systems linking personality, motivation, and emotion can be integrated with the expectancy construct to suggest hypotheses about distress and giving up in response to adversity. In 220 women with breast cancer, threat responsiveness-sensitivity of the behavioral inhibition system (BIS)-and incentive responsiveness-sensitivity of the behavioral activation system (BAS)-and expectancies about cancer recurrence were measured. It was predicted and found that high BIS sensitivity interacted with recurrence expectancy to predict elevated distress and disengagement. Low BAS sensitivity (reward responsiveness) also interacted with expectancy of recurrence to predict elevated disengagement. In contrast, high BAS sensitivity (fun seeking) interacted with recurrence expectancy to predict elevated distress. Discussion centers on theoretical implications and possible applications.

Psychological impact of diagnosis and risk reduction among cancer survivors

Life-threatening health events prompt psychological distress that may motivate individuals to reduce health risks. If so, interventions timed to take advantage of these 'teachable moments' could be particularly effective. To explore this association, early stage prostate and breast cancer patients were identified from a hospital-based tumor registry within 6 years of diagnosis. These patients (n=920) completed a mailed survey assessing the Horowitz impact of events scale, risk behaviors and readiness to change the behaviors. Breast cancer patients, younger patients and those reporting poor health status reported the greatest impact of the cancer diagnosis. Impact was inversely associated with time from diagnosis for prostate, but not breast cancer patients. Prostate patients who reported exercising regularly had lower impact scores than those who were not exercising (medians: 0.13 vs 0.56, respectively; p=0.02). Breast patients who were eating five or more fruits and vegetables reported lower impact scores than those who were not eating the recommended servings (0.75 vs 1.06, respectively; p=0.03). Breast patients who were non-smokers reported lower impact scores than smokers (0.88 vs 1.31, respectively; p=0. 02). Prospective studies are needed to understand the psychological impact of cancer diagnosis and how it might facilitate or impede the adoption of health promoting behaviors.

Partner abandonment of women with breast cancer. Myth or reality?

PURPOSE

The purpose of this article is to determine the existing evidence related to marital breakdown after a breast cancer diagnosis by reviewing studies that highlight two current belief models: the lay belief model and the clinical belief model.

OVERVIEW

The small number of studies conducted on this topic since 1988 revealed no data to confirm the lay belief model, which proposes that women with breast cancer are abandoned by their partners. The evidence appears to support the clinical belief model that the majority of marital relationships remain stable after breast cancer and that breakdown is most likely in those relationships with pre-existing difficulties.

CLINICAL IMPLICATIONS

This review indicates that it may be important for clinicians to routinely ask about the quality of the marital relationship as part of the initial assessment, because it appears that this may be a main predictor of post-diagnosis marital adjustment. In addition, greater dissemination of the findings of this review through the media and through cancer organizations is needed to more accurately reflect the experience of couples facing breast cancer and, thus, to begin to change the public perception of partner desertion after breast cancer. This could help both women with breast cancer and women from the general population who may one day confront a breast cancer diagnosis.

Quality of life after adjuvant chemotherapy for breast cancer

PURPOSE

To evaluate the quality of life of breast cancer patients previously treated with adjuvant chemotherapy.

METHOD

Registry data were used to recruit a sample of breast cancer patients (N = 61; mean age = 51.6 years) with no current evidence of disease who had completed adjuvant chemotherapy between 3 and 36 months earlier (average = 15.87 months). In addition, a peer nomination procedure was used to recruit an age-matched comparison group of women with no history of cancer (N = 59; mean age = 51.5 years). Both groups were mailed a survey to complete that included the Medical Outcomes Study Short Form 36 (SF-36) and the Center for Epidemiologic Studies Depression Scale (CES-D). These data were used to test the hypothesis that breast cancer patients previously treated with adjuvant chemotherapy experience impaired quality of life relative to their peers and to identify demographic and medical factors associated with individual differences in patient quality of life.

RESULTS

Consistent with predictions, the postchemotherapy group scored poorer than the noncancer comparison group on the CES-D and on six of the eight subscales as well as the physical component summary scale of the SF-36 (p < 0.05). With regard to individual differences in patient quality of life, younger age and unmarried status were positively related to poorer mental well-being and greater depressive symptomatology (p < 0.05). Time since cancer diagnosis and chemotherapy completion were also positively related to greater depressive symptomatology (p < 0.05). In contrast, none of the demographic or medical variables assessed were related to physical well-being (p > 0.05).

CONCLUSIONS

Breast cancer patients appear to experience problems in multiple quality of life domains following the completion of adjuvant chemotherapy treatment. Demographic and medical characteristics explain individual differences in mental but not physical aspects of patient quality of life. These findings demonstrate the need for interventions to improve the quality of life in breast cancer patients previously treated with adjuvant chemotherapy.

Patient characteristics and treatments associated with a decline in upper-body function following breast cancer therapy

Breast cancer therapy is often followed by a decline in upper-body function. Women (303) diagnosed with stage I or II breast cancer were interviewed 5 and 21 months after surgery and their medical records were reviewed. Women with cardiopulmonary comorbidity had an odds ratio for decline at the 5-month interview of 2.8 (95% CI 1.3-5. 7), relative to women without. Women who received mastectomy (OR = 2. 5; 95% CI 0.9-6.7) or breast-conserving surgery with radiation therapy (OR = 2.9; 95% CI 1.0-8.9) were at higher risk for decline at the 5-month interview than women who received only breast-conserving surgery. Women who had axillary dissection were more likely to report numbness or pain in the axilla (OR = 6.4; 95% CI 1.2-33) at the 21-month interview than women who did not. Clinicians should consider the functional consequences of treatment when discussing treatment options and postoperative care with women who have early stage breast cancer.

Functioning in daily living and psychological well-being of female cancer patients

The objective of this prospective study was to compare outcomes concerning psychological and physical functioning of patients with various gynecological malignancies. A sample of 119 newly diagnosed cancer patients completed two questionnaires evaluating psychological well-being and functioning in daily living. Outcome measures were obtained at three time points: before surgery, 3 months after surgery, and 1 year after surgery. The results showed that the psychological well-being improved significantly from the first to the third time point for the sample as a whole. After surgery, patients with ovarian and cervical cancer showed slightly lower scores than patients with endometrial cancer. The level of functioning in daily living declined 3 months after surgery for all except endometrial cancer patients, but increased significantly at the 1 year follow-up. At all three time points the mean differences for psychological well-being and functioning in daily living were not statistically significant among subgroups. Physical and psychological well-being of the patients treated for gynecological malignancies is affected independently of age, cancer site and stage of disease. However, throughout the observational period the psychological well-being scores were lower than those of patients with other chronic illnesses or healthy subjects. Therefore, we conclude that psychological interventions for patients facing gynecological cancer treatment should be provided as an integral component of cancer management.

Qualitative research for the study of cancer and age

Qualitiative research emphasizes identification, illumination, and understanding of phenomena, the meaning and theory behind which are unpresumed by the investigator. Although quantitative techniques are used to test predetermined hypotheses, qualitative techniques are used to generate hypotheses. Qualitative techniques have only begun to be used in medical research in the past decade but are especially useful in exploring content areas about which little is known and in eliciting and understanding the patient's perspective. Despite the aging of the United States population, the cancer illness experience has not been well studied in older patients. Because communication preferences, treatment decision-making styles, psychosocial issues, and the illness experience itself may be significantly different for older persons diagnosed with cancer than for younger persons, qualitative research techniques can be used to identify those differences critical to the effective health care of this burgeoning population.

Couples' patterns of adjustment to colon cancer

The objectives for this longitudinal study were to: (a) compare colon cancer patients' and their spouses' appraisal of illness, resources, concurrent stress, and adjustment during the first year following surgery; (b) examine the influence of gender (male vs female) and role (patient vs spouse caregiver) on study variables; (c) assess the degree of correlation between patients' and spouses' adjustments; and (d) identify factors that affect adjustment to the illness. Fifty-six couples were interviewed at one week post diagnosis, and at 60 days and one year post surgery. Based on a cognitive-appraisal model of stress, the Smilkstein Stress Scale was used to measure concurrent stress; the Family APGAR, Social Support Questionnaire, and Dyadic Adjustment Scale were used to measure social resources; the Beck Hopelessness Scale and Mishel Uncertainty in Illness Scales were used to measure appraisal of illness; and the Brief Symptom Inventory and Psychosocial Adjustment to Illness Scale were used to measure psychosocial adjustment. Repeated Measures Analysis of Variance indicated that spouses reported significantly more emotional distress and less social support than patients. Gender differences were found, with women reporting more distress, more role problems, and less marital satisfaction, regardless of whether they were patient or spouse. Both patients and spouses reported decreases in their family functioning and social support, but also decreases in emotional distress over time. Moderately high autocorrelations and modest intercorrelations were found among and between patients' and spouses' adjustment scores over time. The strongest predictors of patients' role adjustment problems were hopelessness and spouses' role problems. The strongest predictors of spouses' role problems were spouses' own baseline role problems and level of marital satisfaction. Interventions need to start early in the course of illness, be family-focused, and identify the couples at risk of poorer adjustment to colon cancer.

The quality of life of African American women with breast cancer

The objectives of this study were to describe the quality of life of African American women with breast cancer and test a model of factors that may affect their quality of life. A stress-coping framework that included person (demographics, current concerns, and optimism), social resources (family functioning), and illness-related factors (symptom distress, medical characteristics), as well as appraisal of illness and quality of life, was used to guide this exploratory, cross-sectional study. Participants included 98 African American women who were approximately 4 years postdiagnosis. The women reported a fairly high quality of life, were generally optimistic, and had effective family functioning. Although symptom distress was generally low, a sizable number of women reported problems with energy loss, sleep disturbances, and pain. The model explained 75% of the variance in quality of life, with appraisal, family functioning, symptom distress, and recurrence status each explaining a significant amount of the variance. Current concerns had an indirect effect on quality of life that was mediated by appraisal. These findings underscore the importance of helping women foster a positive appraisal of their illness, manage current concerns, maintain family functioning, and reduce symptom distress, because each of these factors indirectly or directly affects their quality of life.

Quality of life in the first year after breast cancer surgery: rehabilitation needs and patterns of recovery

BACKGROUND

Although mortality rates from breast cancer are declining, many breast cancer survivors will experience physical and psychological sequelae that affect their everyday lives. Few prospective studies have examined the rehabilitation needs of newly diagnosed breast cancer patients, and little is known about the predictors of health-related quality of life (QOL) in this population.

METHODS

Between 1987 and 1990, 227 women with early stage breast cancer participated in a prospective longitudinal study in which detailed information was collected through interviews, standardized measures of QOL and psychological distress, and clinical evaluation. Comparisons of physical and treatment-related problems were made according to type of surgical treatment. Multivariate regression analysis was performed to examine the predictors of QOL at one year after surgery.

RESULTS

Physical and treatment-related problems were reported frequently one month after breast cancer surgery, and occurred with equal frequency in women receiving modified radical mastectomy or breast conservation treatment. There were no significant differences in problems reported at one year by type of surgery; however, frequently reported problems include 'numbness in the chest wall or axilla,' 'tightness, pulling or stretching in the arm or axilla,' 'less energy or fatigue,' 'difficulty in sleeping,' and 'hot flashes'. There was no relationship between the type of surgery and mood or QOL. Poorer QOL one year after surgery was significantly associated with greater mood disturbance and body image discomfort one month after surgery, as well as positive lymph node involvement. Although the majority of patients experienced substantial disruptions in the physical and psychosocial dimensions of QOL post-operatively, most women recovered during the year after surgery, with only a minority (<10%) significantly worsening during that time.

CONCLUSIONS

At one year after surgery, most women report high levels of functioning and QOL, with no relationship between the type of surgery and QOL. Women who reported lower levels of QOL at one year after diagnosis had greater mood disturbance and poorer body image one month after surgery, as well as lower income and positive axillary nodes.

Subtle differences in quality of life after breast cancer surgery

BACKGROUND

Lumpectomy with axillary dissection (LAD) has taken its place alongside mastectomy (M) as the treatment of choice for stage I and II breast cancer. Its appeal is based on lessening disfigurement and thus improving quality of life.

METHODS

We used the SF-36 Health Survey modified with ten questions relevant to breast cancer surgery to evaluate whether quality of life with LAD was better than with mastectomy in women with stage I and II disease. The additional questions addressed satisfaction with intimate relationships and sexuality, and explored impact on the way women dress, use bathing suits, hug people, are comfortable with nudity, and rate their sexual drive and sexual responsiveness.

RESULTS

LAD was not associated with statistically significant better quality-of-life scores on any SF-36 questions, except vitality (P = .02). No differences were noted in the areas of intimacy and sexual satisfaction. LAD patients reported significant differences in matters of dress, use of bathing suits, hugging, comfort with nudity, and sexual drive compared to patients undergoing mastectomy.

CONCLUSIONS

The SF-36 health survey detected few differences in quality of life measures between patients with LAD and those with mastectomy. However, LAD impacts favorably on the way women dress, on comfort with nudity, and on sexual drive.

Exercise in the rehabilitation of breast cancer survivors

With the increase in the number of women who have survived breast cancer, there is a growing need to attend to the physical and emotional effects of cancer and its treatment as experienced by these survivors. Psychological distress, fatigue, weight gain, premature menopause and changes in body image are some of the long-term sequelae of breast cancer. Exercise as an adjunctive treatment may help to attenuate these effects and thereby contribute to rehabilitation of women with breast cancer. We present data from the exercise literature and from studies on breast cancer patients that support this role of exercise. Following a critique of the research efforts, we present a brief outline of questions that should be addressed in evaluating the role of exercise in cancer rehabilitation.

Coping and adjustment to breast cancer

This study examined possible predictors of adjustment to breast cancer. Sixty-one women participated soon after they were diagnosed with Stage I or Stage II breast cancer. Measures were gathered at diagnosis and again 4 months later. Predictor variables included aspects of the disease and treatment process and reported coping behavior. The most consistent predictor of distress and, to a lesser extent, quality of life, was avoidant coping: women who reported more avoidant coping were more distressed. These data fit well with most previous research and suggest one way of identifying women who may be more at risk for special difficulties coping with the diagnosis of breast cancer.

Adjustment to breast cancer: age-related differences in coping and emotional distress

Women who are diagnosed with breast cancer are at high risk for experiencing affective distress; however, previous research suggests that older women may be less likely than younger women to experience extreme distress. Two issues remain unclear regarding age and affective distress: (a) the psychological processes that account for the association of age and distress, and (b) whether this association remains stable over the course of treatment and recovery from breast cancer. This study investigated symptoms of anxiety and depression in 80 women ages 36-80 years old with newly diagnosed breast cancer near the time of their diagnosis and at 3 and 6 months post-diagnosis. Disease severity and coping style were also examined. Symptoms of anxiety/depression and age were negatively correlated near the time of diagnosis. Path analysis controlling for disease severity revealed that coping involving the ventilation of emotion fully mediated the effect of age on symptoms of anxiety and depression. However, the association of age with symptoms of anxiety/depression was no longer significant at 3 and 6 months post-diagnosis, although emotional ventilation still predicted greater emotional distress at 6 months. These findings suggest that age is a salient factor to consider in the psychological adjustment of women with breast cancer near the time of initial diagnosis, with younger women exhibiting greater affective distress and a tendency to engage in less adaptive ways of coping. However, younger and older women do not differ in their adjustment over the subsequent course of their treatment and initial recovery. The use of emotional ventilation coping remains associated with poorer adjustment, independent of patients' age.

Impact of different adjuvant therapy strategies on quality of life in breast cancer survivors

Little is known about the long-term effects of adjuvant therapy on quality of life, sexual functioning and symptoms in breast cancer survivors. Between January 1996 and June 1997, we surveyed 1098 women who had been diagnosed with early stage breast cancer between 1 and 5 years earlier. The breast cancer survivors were recruited in two large metropolitan centers in the USA. They completed a survey battery that contained standardized measures of health-related quality of life (HRQL), depression, body image, sexual functioning, and symptoms. A total of 1096 had usable responses for these analyses. In this sample, n = 356 had received tamoxifen (TAM) alone, n = 180 received chemotherapy (CHEM) alone, n = 395 received CHEM + TAM, and n = 265 received no adjuvant therapy (NO RX). There were significant differences in the mean age of each group, with the TAM group being the oldest (mean 62.6 years) and the CHEM group being the youngest (mean 46.8 years). Both age and time since diagnosis were controlled for in all statistical analyses. We found no significant differences in global quality of life among the four treatment groups. For the MOS-SF-36, there were no significant differences on the subscale scores except for the physical functioning subscale (p = 0.0002); the NO RX group had the highest functioning. There were no significant differences in depression scores among the four treatment groups. The MOS-SF-36 physical functioning composite score differed by treatment group (p = 0.012); the NO RX group had a physical functioning composite score that was at the mean for a normal healthy population of women, while those in the adjuvant treatment groups scored slightly lower. The mental health composite score was not significantly different among the four treatment groups and approximated scores from the normal population of healthy women. There were no differences in body image scores among the four treatment groups; however, sexual functioning scores did differ (p = 0.0078) with patients receiving chemotherapy (either alone or with tamoxifen) experiencing more problems. Hot flashes, night sweats, and vaginal discharge differed by treatment (p = 0.0001); all symptoms were reported more often in breast cancer survivors on tamoxifen. Vaginal dryness and pain with intercourse also differed significantly by adjuvant treatment, occurring more often in survivors treated with chemotherapy. Overall, breast cancer survivors function at a high level, similar to healthy women without cancer. However, compared to survivors with no adjuvant therapy, those who received chemotherapy have significantly more sexual problems, and those treated with tamoxifen experience more vasomotor symptoms.

Telephone counseling of breast cancer patients after treatment: a description of a randomized clinical trial

The Telephone Counseling Trial for Breast Cancer Survivors is a randomized, controlled study designed to test the impact of a telephone-based counseling intervention on quality of life of early-stage breast cancer patients who have completed adjuvant treatment. A psychoeducational counseling model is utilized to promote adaptive coping to re-entry stressors and survivorship issues. Adaptation is fostered through the exploration of thematic materials, application of active coping strategies, encouragement of a personal expression of the breast cancer experience and the provision of psychological support. Patients are being recruited in collaboration with two NCI-designated clinical cooperative oncology groups: the Eastern Cooperative Oncology Group (ECOG) and the Southwest Cooperative Oncology Group (SWOG). The recruitment goal is 400 breast cancer survivors with Stage 1, Stage 2 and Stage 3 disease (with no greater than 10 positive lymph nodes involved). Patients are being enrolled by data managers on-site during their last treatment visit. The intervention is being delivered by the Cancer Information and Counseling Line (CICL) of the AMC Cancer Research Center. It includes 16 telephone outcalls which are delivered over a 12-month period. Primary outcome measures are quality of life, mood, social support, self-efficacy, and sexual functioning, assessed at baseline, 3, 6, 12 and 18 months follow-up. This article provides a description of the intervention protocol and study design. It is argued that this study could provide a model for developing and testing other psychosocial interventions within clinical cooperative groups nationwide.

Factors affecting baseline quality of life in two international adjuvant breast cancer trials. International Breast Cancer Study Group (IBCSG)

Quality of life (QL) is used to assess treatments in clinical trials but may be influenced by other factors. We analysed the impact of biomedical, sociodemographic and cultural factors on baseline QL indicators in two International Breast Cancer Study Group trials. Patients with stage II breast cancer were randomized within 6 weeks of primary surgery to various adjuvant treatments. They were asked to assess five indicators of QL at baseline. QL forms were available for 1231 (83%) of the 1475 premenopausal and 989 (82%) of the 1212 post-menopausal patients, who were from nine countries and spoke seven languages. Culture (defined as language/country groups) had a statistically significant impact on baseline QL measures. Premenopausal patients with poor prognostic factors showed a tendency to report worse QL, with oestrogen receptor status as an independent predictor for mood (P = 0.0005). Older post-menopausal patients reported better emotional wellbeing (P = 0.002), mood (P = 0.002), and less effort to cope (P = 0.0009) compared with younger post-menopausal patients. Co-morbidity, type of surgery, treatment assignment and sociodemographic factors showed a statistically significant impact in post-menopausal patients only. Cultural and biomedical factors influenced baseline QL and should be considered when evaluating the impact of treatment on QL in international breast cancer clinical trials.

Couples' adjustment to breast cancer and benign breast disease: a longitudinal analysis

A comprehensive comparison of couples' adjustment to benign (n = 73 couples) and malignant breast disease (n = 58 couples) at the time of diagnosis and at two follow-up assessments at 60 days and 1 year is reported. Specific objectives were to: (a) compare the concurrent stress, resources, appraisal, and patterns of adjustment of couples in the benign and malignant groups; (b) compare the psychosocial responses of patients versus spouses; and (c) determine the amount of correspondence in levels of adjustment reported by patients and their husbands over time. Multiple instruments with reported reliability and validity were used to measure study variables: Smilkstein Stress Scale, Dyadic Adjustment Scale, Family APGAR, Social Support Questionnaire, Mishel Uncertainty in Illness Scale, Beck Hopelessness Scale, Brief Symptom Inventory, and Psychosocial Adjustment to Illness Scale. Mixed design analyses of covariance (ANCOVA) were used to assess differences between and among couples and examine changes in study variables over time. Significant differences were found in the resources, appraisal, and patterns of adjustment reported by couples in the benign and malignant groups. Couples facing breast cancer reported greater decreases in their marital and family functioning, more uncertain appraisals, and more adjustment problems associated with the illness. In addition, there was a high degree of correspondence between the levels of adjustment reported by women with breast cancer and their husbands over time. Couples who reported high distress or a high number of role problems at diagnosis were likely to remain highly distressed at 60 days and 1 year. Study findings underscore the importance of assisting couples, not just patients, to manage the adjustment difficulties associated with breast cancer.

Couples' adjustment to breast cancer and benign breast disease: a longitudinal analysis

A comprehensive comparison of couples' adjustment to benign (n = 73 couples) and malignant breast disease (n = 58 couples) at the time of diagnosis and at two follow-up assessments at 60 days and 1 year is reported. Specific objectives were to: (a) compare the concurrent stress, resources, appraisal, and patterns of adjustment of couples in the benign and malignant groups; (b) compare the psychosocial responses of patients versus spouses; and (c) determine the amount of correspondence in levels of adjustment reported by patients and their husbands over time. Multiple instruments with reported reliability and validity were used to measure study variables: Smilkstein Stress Scale, Dyadic Adjustment Scale, Family APGAR, Social Support Questionnaire, Mishel Uncertainty in Illness Scale, Beck Hopelessness Scale, Brief Symptom Inventory, and Psychosocial Adjustment to Illness Scale. Mixed design analyses of covariance (ANCOVA) were used to assess differences between and among couples and examine changes in study variables over time. Significant differences were found in the resources, appraisal, and patterns of adjustment reported by couples in the benign and malignant groups. Couples facing breast cancer reported greater decreases in their marital and family functioning, more uncertain appraisals, and more adjustment problems associated with the illness. In addition, there was a high degree of correspondence between the levels of adjustment reported by women with breast cancer and their husbands over time. Couples who reported high distress or a high number of role problems at diagnosis were likely to remain highly distressed at 60 days and 1 year. Study findings underscore the importance of assisting couples, not just patients, to manage the adjustment difficulties associated with breast cancer.

Posttraumatic distress symptoms in operable breast cancer III: status one year after surgery

One hundred and six patients with operable breast cancer were studied at intervals one day before surgery, and at six weeks and one year post-operatively by means of taped clinical interviews and self-report questionnaires (Impact of Event Scale (IES) and General Health Questionnaire (GHQ-28)). A year after surgery, nine percent reported a high level of intrusive symptoms and 10% of avoidance symptoms compared to 18% and 14% after six weeks, respectively. Based on questionnaire data, a year after surgery, thirteen patients (12%) were estimated to have a posttraumatic stress disorder (PTSD) compared to fifteen patients (14%) after six weeks. Severity of posttraumatic stress symptoms (PTSS) after one year was significantly associated with impaired psychosocial functioning over the last year previous to surgery (p < 0.05), negative life events during the year before surgery (p < 0.05), health problems during the previous ten years (p < 0.01), and a personality trait characterized by high emotional reactivity (p < 0.001). Crisis support in the acute situation, type of surgery, axillary-node metastases, and postoperative adjuvant chemotherapy did not predict subsequent PTSS. Premorbid health variables, personality, and level of distress six weeks after surgery were most important risk factors for persistent PTSS in our patients with operable breast cancer stage I and II.

Supportive and negative responses in the partner relationship: their association with psychological adjustment among individuals with cancer

This study examined the association between positive and negative aspects of spouse responses and psychological adjustment among 158 individuals with cancer. Two contextual variables, gender and disease-related functional impairment, were taken into account when examining the association between spouse responses and patient psychological distress and well-being. Results indicated that negative aspects of close relationships played a comparatively stronger role than positive aspects in their associations with both psychological distress and well-being. For negative spouse responses, patient gender did not moderate the effects of these responses upon psychological outcomes. For positive aspects of spouse support, both gender and functional disability moderated the association between spouse support and psychological outcomes. These findings are integrated with the general literature on positive and negative aspects of close relationships. Implications for clinical interventions are also discussed.

The emergence of the 'waiting game': a critical examination of the psychosocial issues in diagnosing breast cancer

Undergoing diagnostic investigations for symptoms of breast disease constitutes an intensely stressful experience for any woman. The widespread use of contemporary fine-needle techniques throughout specialist breast clinics, whilst removing the necessity of hospitalization and general anaesthesia for many women, has introduced the notion of the 'waiting game'. The ability to ascertain definitive results within a matter of hours has led to diversification in the structure of diagnostic breast services; however, the significance of the 'waiting game' in terms of distress experienced by women has not been investigated. This paper systematically reviews the research that has explored psychosocial morbidity in this phase of the disease trajectory, and provides summative recommendations for further research.

Patient, physician and presentational influences on clinical decision making for breast cancer: results from a factorial experiment

This study examines the influence of six patient characteristics (age, race, socioeconomic status, comorbidities, mobility and presentational style) and two physician characteristics (medical specialty and years of clinical experience) on physicians' clinical decision making behaviour in the evaluation treatment of an unknown and known breast cancer. Physicians' variability and certainty associated with diagnostic and treatment behaviour were also examined. Separate analyses explored the influence of these non-medical factors on physicians' cognitive processes. Using a fractional factorial design, 128 practising physicians were shown two videotaped scenarios and asked about possible diagnoses and medical recommendations. Results showed that physicians displayed considerable variability in response to several patient-based factors. Physician characteristics also emerged as important predictors of clinical behaviour, thus confirming the complexity of the medical decision-making process.

Physical and psychosocial outcomes in cancer patients: a comparison of different age groups

In a cross-sectional study, we investigated the relationship between age, physical health, social and economic resources, functional status, activities of daily living (ADL) and disease-related variables of 227 patients with cancer. Using multidimensional outcome measures we examined age differences in three age groups (< 45, 46-65, > 65 years) and identified predictors of performing ADL. The results indicated that older patients have outcomes similar to those of younger patients. There were no significant differences in quality of life, performance status and physical health among the three age groups. The only areas where age-related differences were found were co-morbidity and cancer-related impairments. Patients aged 45-65 years and patients 65 years and older reported a higher level of co-morbidity and more cancer-related impairments than those aged 45 and younger. Although older patients had higher co-morbidity, they showed similar Karnofsky Performance Status (KPS) scores to those of their younger counterparts. The regression analysis revealed social resources, self-reported health, performance status and complexity of care as significant predictors of patients' ADL, but not age, co-morbidity or severity of treatment. The findings support the conclusion that differences in performing ADL between younger and older patients with cancer are minimal and tend to be due to co-morbidity. Thus, treatment should be decided by a patient's physical health rather than by age.

An evaluation of the quality of life among long-term survivors of breast cancer

Attention to the quality of life (QOL) among long-term of breast cancer is long overdue. Modest improvements in overall survival have led to a greater emphasis on how women are living with the disease. The purpose of this paper is to report the results of a descriptive study that evaluated the quality of life of 294 breast cancer survivors, and to review the continuum of positive and negative QOL outcomes in this population. Members of the National Coalition for Cancer Survivorship (NCCS) were surveyed and received two QOL instruments: the Quality of Life-Cancer Survivors Tool (QOL-CS) and the Functional Assessment of Cancer Therapy (FACT-G), and a demographic data tool. The main research variables were the subscales (Physical, Psychological, Social, and Spiritual Well-being) and individual items of the QOL-CS and the FACT-G. Results indicated that: a) fatigue, aches and pains, and sleep problems were persistent after treatment ended; b) psychological distress from cancer diagnosis and treatment, and fear of recurrent, metastatic, and recurrent disease were problematic over time; c) family distress, sexuality, and family burden issues were of greatest social concern; and d) uncertainty over the future plagued breast cancer survivors long-term. Breast cancer survivors also reported good outcomes in hopefulness, having a life purpose, and having a positive change after the treatment.

CONCLUSIONS

breast cancer survivors experienced long-term changes after completion of treatment which affected overall quality of life. However, many positive benefits were also gained which helped to balance the worse outcomes.

Psychosocial adjustment and quality of life in women with breast cancer and benign breast problems: a controlled comparison

Comparison of psychosocial adjustment in women with breast cancer (BC) and women with benign breast problems (BBP) has been hampered by a failure to control for age differences between these groups, as well as a failure to assess positive psychosocial adaptation in addition to psychological distress. Age-matched women with breast cancer (n = 80) and benign breast problems (n = 80) completed measures of psychological distress, positive psychosocial adaptation, and general quality of life (QOL). Breast cancer patients had completed primary treatment for breast cancer a mean of 24.6 months prior to participation (range, 6-57 months). Comparison of the BC and BBP groups indicated that the BC group reported (1) poorer physical health and functioning, (2) no differences in psychological distress, and (3) greater positive psychosocial adaptation, such as improved life outlook, enhanced interpersonal relationships, and deeper spiritual and religious satisfaction. Results support the theoretical position that cancer is a transitional event, that is, a traumatic event that alters an individual's assumptive world with the potential to produce long-lasting changes of both a positive as well as negative nature. This underscores the importance of using measures of both psychological distress and positive psychosocial adaptation when assessing psychological adjustment following transitional events such as breast cancer.

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.

Counseling Needs of Women With Breast Cancer: What the Women Tell Us

Research has demonstrated that some women treated for breast cancer are at risk for significant and persistent emotional distress and disrupted quality of life. Factors identified that appear to make women psychologically vulnerable include younger age at diagnosis, a history of high life stress or depression prior to diagnosis, and more advanced disease. Research has quickly moved to develop and implement psychological interventions to help these women, although little is known about the patients' perceptions of their need for, and use of, such services. This article presents research that focuses on the perceptions of the women themselves using a survey technique.

Breast cancer in young women

Breast cancer is an uncommon disease in women under the age of 40 years, reportedly accounting for 7.5% of reported cases. Delay in diagnosis is attributable to a clinically low index of suspicion, difficulty in examining dense and nodular breasts in younger women, and less frequently performed screening mammography. Genetic mutations should be suspected in women with breast cancer who are under the age of 30 years. In relation to older women, younger women have more adverse pathologic features and have a poorer prognosis. Younger age, per se, is not a contraindication to breast-conserving surgery. In node-negative young women, the benefits of adjuvant chemotherapy need to be considered in relation to the short- and long-term risks of treatment. A strong support system should be in place to deal with the adverse psychosocial impact of the disease.

Coping strategies and psychiatric morbidity in women attending breast assessment clinics

This study examined the role of coping strategies and personality characteristics in mediating psychiatric morbidity in subjects facing possibly serious breast disease. Participating were 121 women aged 20 to 65 undergoing breast fine needle biopsy for a suspicious lesion on mammography. All subjects received psychosocial assessments including the 12-item General Health Questionnaire (GHQ-12), the Eysenck Personality Inventory (EPI) and the Coping Strategies Inventory. The results show that neuroticism was the only EPI subscore significantly correlated with GHQ-12 score. A habitual method of coping with adversity known as 'engagement' has a negative correlation with GHQ-12 score; that is, patients who actively confront their illness and the uncertainty that surrounds it show better psychological health. Stepwise multiple regression reveals that neuroticism and an engagement coping strategy are the most significant predictors towards GHQ-12 score prior to the diagnosis of breast cancer.

Self-esteem and cancer: theory and research

OBJECTIVE

To examine the relationship between self-esteem and the psychosocial response to cancer.

METHODS

The authors review methodological issues associated with measuring self-esteem in patients with cancer and examine existing empirical studies in light of these issues.

RESULTS

Self-esteem in cancer has been variously viewed as an outcome variable, a mediator of other psychosocial outcomes, and as a personal resource that facilitates coping. Unidimensional measures of global self-esteem have been most often employed in research studies, despite increasing recognition that self-esteem is multidimensional. Evaluation of global self-esteem has generally revealed no differences between cancer patients and controls. Aspects of multidimensional self-esteem, particularly body self-esteem, appears to be disturbed in many patients with cancer.

CONCLUSIONS

The clinical and theoretical literature have emphasized the importance of self-esteem to the psychosocial response to cancer. Empirical study of self-esteem in cancer has been limited by conceptual and methodological issues. Strategies for future research are discussed.

Management of breast cancer in the elderly

This paper examines data which has been published on breast cancer in the elderly and concludes that, wherever possible, combined modality treatment should be offered to elderly breast cancer patients. It appears from an examination of the literature that single modality treatment in the form of hormone treatment often results in very high rates of loco-regional recurrence.

Breast cancer in elderly women: a retrospective analysis of combined treatment with tamoxifen and once-weekly irradiation

PURPOSE

To evaluate retrospectively the efficacy of combined modality treatment (hormone therapy and hypofractionated radiotherapy) in a population of very elderly women with breast cancer.

METHODS AND MATERIALS

Records on 70 patients of median age 81 years, treated between January 1988 and February 1994, whose median follow-up is now 36 months, have been evaluated. Information obtained included clinical stage at diagnosis, histology, tumor grading, hormone receptor levels, details of treatment, type of failure, survival data, and status at last follow-up examination. Treatment consisted of Tamoxifen 20 mg daily and a hypofractionated course of high dose-per-fraction once-weekly radiotherapy. In the majority of cases this consisted of seven exposures of 6.5 Gy (five to the involved breast, and two to the tumor bed) given over 6 weeks, on a 60Co unit. Nodes were treated when clinically involved, to a dose of 27.5-30 Gy in five to six fractions.

RESULTS

At median follow-up of 36 months, the overall survival rate is 87% [confidence interval (CI) 78-95%], the disease specific survival rate is 88% (CI 80-96%), and 72% (CI 60-84%) of patients are free of disease. The local control rate at 36 months is 86% (CI 76-95%). When analyzed by T stage, 81% of T1 patients, 96% of T2 patients, 60% of T3 patients and, paradoxically 100% of T4 patients were in local control at 36 months, although at that point there were just four such patients available for consideration in the T4 group. Initial response to hormone therapy does not appear to be a predictive indicator for ultimate loco-regional control. There is a trend towards greater probability of loco-regional failure if total dose delivered to the breast is less than 35 Gy.

CONCLUSIONS

Women of elderly age are often denied combined modality therapy, because of coexistant disease or fears held by the responsible physicians that elderly patients are unable to tolerate surgery or protracted courses of radiotherapy. Consequently, many are treated by tamoxifen alone with poor results. This study demonstrates that very high rates of loco-regional control are achievable using hormonal treatment combined with high dose-per-fraction once-weekly radiotherapy.

The impact of age, treatment, and symptoms on the physical and mental health of cancer patients. A longitudinal perspective

BACKGROUND

To describe continuing care and rehabilitation needs of cancer patients, a longitudinal design (6 months) was performed among patients 50 years of age and older with solid tumors. The study examined how age, type of treatment, site of cancer, and symptom experience affect physical functioning and their mental health; age, site of cancer and the interval of time out of treatment influence changes in their symptom experience; and age, site of cancer, the interval of time out of treatment, and changes in symptom experience influence changes in physical and mental health.

METHODS

Patients (n = 111) who completed an intake and a 6-month self-administered questionnaire were included. Treatment included chemotherapy, radiation, or hormonal treatment at intake and for 6 months. Scales of nine symptoms and physical health using activities of daily living and measures of vigorous function were composed. Mental health was measured by the Center for Epidemiological Studies--Depression Scale.

RESULTS

The analyses yielded the following findings: (1) Primary site may have had an impact on symptom experience, limitations in functioning, and mental health if more patients with lung cancer had survived to 6 months. (2) Age, gender, treatment, or change in treatment had no impact on symptoms, functioning, or mental health at intake or changes in these variables. (3) Symptom experience at intake and the changes in symptoms predicted physical functioning and mental health at intake and the changes in these variables over time. (4) Gender differences were important in predicting mental health.

CONCLUSIONS

Strategies for continuing care and rehabilitation need to focus on symptom management, and strategies need to be different for male and female patients.

Surviving cancer

Research trends on quality of life outcomes for cancer survivors are discussed. Epidemiologic data indicate that female cancer survivors, coming primarily from patient groups with gynecologic, breast, and colorectal cancers, will outnumber male survivors 3 to 1. Male survivors will come from the ranks of patient groups with colorectal and other digestive tumors (such as stomach cancer), prostate, and bladder cancers. With the exception of breast cancer, there have been few well controlled descriptive, longitudinal studies of cancer survivors, with data on men being notably absent. A strategy for identifying differential levels of risk for psychologic morbidity for cancer survivors is proposed. Other important psychologic individual difference variables were identified: control, optimism, and stable coping strategies may be useful in the prediction of mental health outcomes; conscientiousness in the prediction of health behaviors; and sexual self-schema in the prediction of sexual outcomes. Finally, data suggest that psychologic and behavioral outcomes can be improved with psychologic interventions, but it is likely that even greater gains could be achieved if health behavior components were added. New directions for research include study of individual differences, examination of active components of multifaceted interventions, and study of the health consequences of interventions. In the latter regard, a biobehavioral model of stress and cancer is offered to integrate psychologic, behavioral, biologic, and disease factors into testable new research directions.

Subtypes of psychosocial adjustment to breast cancer

By means of cluster analytic techniques, four subtypes of psychosocial adjustment were identified in a sample of 122 breast cancer patients who completed the Psychosocial Adjustment to Illness Scale. Internal consistency and internal validity of the derived typology were suggested by the finding that two different hierarchical agglomerative clustering methods (average linkage between groups, Ward's) produced similar solutions. Three of the derived subtypes reported normal affect levels but different patterns of relative strengths and dysfunctions, while the fourth subtype appeared to be highly distressed and globally maladjusted. External validation was demonstrated by differentiating the subtypes on variables of negative affect, avoidance coping, and fighting spirit. The clinical and heuristic implications of these findings are discussed. The findings highlight the need for comprehensive assessment of psychosocial functioning of cancer patients. They demonstrate that even non-emotionally distressed patients can have very different profiles of adjustment and may benefit from correspondingly individually tailored psychosocial interventions.

Age-related differences in breast cancer treatment

BACKGROUND

More than half of the cases of breast cancer treated in the United States occur in women over age 65. This study investigates age-related differences in breast cancer therapy.

METHODS

A retrospective review of all women with primary operable invasive breast cancer treated at the University of Michigan Breast Care Center over a 30-month period showed a total of 77 older patients aged > or = 65 years (median, 71; oldest patient, 92) for whom full information was available regarding comorbidity, tumor stage and histology, and details of surgery, radiation, and chemohormonal therapy and complications. Fifty-one similar younger patients aged 55-64 years (median, 59) were identified for comparison. Patients were classified as either having received standard treatment or non-standard treatment. Standard therapy was prospectively defined as follows: local/regional--lumpectomy and axillary lymph node dissection plus radiation therapy or modified radical mastectomy; systemic--chemotherapy and/or tamoxifen for stage II disease. A comorbidity score calculated for each patient assigned one point each for nursing home residence, nonambulatory status, recent surgery, and each medical problem requiring drug therapy.

RESULTS

When overall treatment (local/regional plus systemic) was assessed, proportionately fewer older patients (55 of 77 versus 47 of 51; p < 0.01) received standard treatment. Fewer older than younger patients (62 of 77 versus 50 of 51; p < 0.01) received surgical therapy that included an axillary dissection. A smaller proportion of older patients received radiation therapy following lumpectomy and axillary lymph node dissection (26 of 29 versus 19 of 19; N.S.). Overall, only 59 of 77 older patients versus 50 of 51 younger patients (p < 0.001) received standard local/regional care. Similar proportions of younger and older patients (19 of 22 and 24 of 30, respectively) received standard systemic therapy for stage II breast cancer, but older patients were less likely to receive chemotherapy than younger patients (7% versus 50%; p < 0.001). Treatment-related complications were not age-related but were more frequent in patients receiving standard treatment than in patients receiving nonstandard treatment (45 of 102 versus two of 26; p < 0.001). Comorbidity score correlated with the use of nonstandard therapy but not with age. The scores for both older and younger patients receiving overall standard treatment were 0.8 versus 1.5 and 1.4, respectively, in patients receiving nonstandard treatment. Interestingly, explanations for decisions to deviate from standard treatment guidelines were often not identified. Comorbidity was explicitly noted in only one of four younger patients who received nonstandard treatment therapy. In 22 older patients who received nonstandard treatment, comorbidity was cited in eight cases, patient age was cited in six cases, and patient choice was cited in four cases. Follow-up (median, 34 months) did not show that disease-free or overall survival differences were related to age or to treatment (standard versus nonstandard).

CONCLUSIONS

These data demonstrate age-related variations in breast cancer treatment in a multidisciplinary breast care unit. Lower complication rates and equivalent short-term outcomes in women who received nonstandard therapy suggest good clinical judgment may have played a role in these differences. Although age-related patient preferences and comorbidity are relevant, the age-related attitudes of caregivers must also be taken into account to fully explain these variations.

Predicting sexual and psychologic morbidity and improving the quality of life for women with gynecologic cancer

The research progress made in the 1980s on understanding psychologic outcomes after gynecologic cancer has continued since the 1986 conference. To facilitate future intervention research, a model for predicting the risk for psychologic and behavioral morbidity is provided. This model clarifies psychologic, behavioral, and medical routes leading to a reduced quality of life. Although few intervention studies have been conducted with gynecologic patients, studies in other patients with cancer suggest that psychologic interventions can reduce emotional distress, enhance coping, and improve general adjustment and sexual functioning, in particular. The final section of this article discusses future research directions and challenges institutions and study groups to support quality-of-life research for women with gynecologic cancer.

Psychological interventions for cancer patients to enhance the quality of life

Although the thrust of the nation's cancer objectives for the year 2000 is prevention and screening, each year approximately 1 million Americans are diagnosed and must cope with the disease and treatments. They do so with the aid of family, friends, and the health care system, but accumulating data suggest that psychological interventions may be important for reducing emotional distress, enhancing coping, and improving "adjustment." Experimental and quasi-experimental studies of psychological interventions are reviewed, and discussion of treatment components and mechanism is offered. A final section discusses future research directions and challenges to scientific advance.

Psychological interventions for cancer patients to enhance the quality of life

Although the thrust of the nation's cancer objectives for the year 2000 is prevention and screening, each year approximately 1 million Americans are diagnosed and must cope with the disease and treatments. They do so with the aid of family, friends, and the health care system, but accumulating data suggest that psychological interventions may be important for reducing emotional distress, enhancing coping, and improving "adjustment." Experimental and quasi-experimental studies of psychological interventions are reviewed, and discussion of treatment components and mechanism is offered. A final section discusses future research directions and challenges to scientific advance.

Exploring the influence of multiple variables on the relationship of age to quality of life in women with breast cancer

This paper explores the relationship between age, psychosocial status and quality of life in a community based sample (n = 229) of newly-diagnosed breast cancer patients. A casement display methodology is used to examine the influence of demographic and medical variables on the outcome variables of interest (psychosocial status and quality of life) and their relationship to age. Based on the literature, a positive relationship between age and psychosocial status was predicted, but the relationship between age and quality of life was uncertain. For the whole sample, a weakly positive relationship between age and measures of psychosocial status and quality of life was observed. In the exploratory studies using the casement plots, the positive relationship between age and quality of life was most strong and significant in married women and in women who had received segmental mastectomy. Among sub-groups examined according to marital status and type of surgery, a positive relationship between age, psychosocial status and quality of life was observed only in married women who received segmental mastectomy. Additional preliminary observations were made about the relationship of household income and age to the outcome variables being studied. The casement plot methodology permits the simultaneous evaluation of multiple variables as a preliminary step before hypothesis development and should be considered when complex clinical problems are being evaluated.