Quality of Life Following Breast-Conserving Therapy or Mastectomy: Results of a 5-Year Prospective Study

A new approach to the tradeoff between quality and accessibility of health care

INTRODUCTION

Quality of care is associated with patient volume. Regionalization of care is therefore one of the approaches that is suited to improve quality of care. A disadvantage of regionalization is that the accessibility of the facilities can decrease. By investigating the tradeoff between quality and accessibility it is possible to determine the optimal amount of treatment locations in a health care system. In this article we present a new model to quantitatively 'solve' this tradeoff. We use the condition breast cancer in the Netherlands as an example.

MATERIALS AND METHODS

We calculated the expected quality gains in Quality Adjusted Lifetime Years (QALY's) due to stepwise regionalization using 'volume-outcome' literature for breast cancer. Decreased accessibility was operationalized as increased (travel) costs due to regionalization by using demographic data, drive-time information, and the national median income. The total sum of the quality and accessibility function determines the optimum range of treatment locations for this particular condition, given the 'volume-quality' relationship and Dutch demographics and geography.

RESULTS

Currently, 94 locations offer breast cancer treatment in the Netherlands. Our model estimates that the optimum range of treatment locations for this particular condition in the Netherlands varies from 15 locations to 44 locations.

CONCLUSION

Our study shows that the Dutch society would benefit from regionalization of breast cancer care as possible quality gains outweigh heightened travel costs. In addition, this model can be used for other medical conditions and in other countries.

Selected elements of socio-demographic status and lifestyle as factors determining subjective assessment of life in women after mastectomy

Aim of the study

The main objective of the study is to specify whether socio-demographic factors and physical activity result in differences in subjective assessment of life in women diagnosed with breast cancer.

Material and methods

The study group consisted of 145 women who had been diagnosed with breast cancer. The women had undergone radical surgery, chemotherapy and radiotherapy. The participants filled in an anonymous questionnaire which contained a number of detailed questions relating to their socio-demographic standing, life style, condition and the current self-assessment of life after breast cancer. In order to assess the differences between groups made on the basis of socio-economic variables, the Kruskal-Wallis rank test was used. For a comprehensive assessment of relations, multiple correspondence analysis on the basis of Burt tables was used.

Results

Their mean age at the time of the study was 57.1 years. The analysis of the effect of education and marital status on differences in the assessment of quality of life showed that these variables resulted in differences in the sphere related to social contacts (better educated women more often avoided social contacts) and in feeling of fatigue and exhaustion (the participants who were in a relationship indicated less fatigue and exhaustion).

Conclusions

Mastectomy caused by breast cancer in women and related chemotherapy and radiotherapy negatively affect the physical and emotional condition of patients involving mental stress. Selected socio-demographic factors and elements of life style co-exist with each other, interpenetrating; thus the assessment of quality of life should comprise a set of factors and take into consideration their mutual interrelations.

Assessing the body image: relevance, application and instruments for oncological settings

PURPOSE

Body image is the sum of physical, cognitive, emotional, and relational elements that, when integrated, allow the development of a whole, healthy self-identity. Even though body image is normally studied in relation to eating disorders, it can also be influenced by other pathologies, including cancer. In oncology, an effective body image assessment is fundamental. The physical effects of cancer and cancer treatments are important and frequently irreversible also on a functional and emotional level; however, only few surveys have investigated body image in this peculiar context.

METHODS

An extensive literature review was carried out in PubMed and PsycINFO. We considered articles published from 1990 to 2010.

RESULTS

Two hundred sixty-three papers matched the search criteria. Assessment methodologies included clinical interviews, self-report measures, questionnaires, symptom check lists, and graphic tests and projective techniques. After excluding the instruments that referred to eating disorders, validated only for adolescents, and/or projective and graphic tests, we found 81 articles with six questionnaires specifically dedicated to body image assessment in oncology.

CONCLUSIONS

From our systematic review, we could identify six instruments specifically designed for assessing body image in the oncological area. In this paper, we discuss their general characteristics, psychometrics properties and the clinical implications, and body image relevance on the quality of life in cancer patients.

Effects of physical activity on common side effects of breast cancer treatment

Motivating women with breast cancer to engage in regular physical activity may be an enormous challenge given the common side effects of breast cancer treatment. The objective of this narrative review is to briefly summarize recent research evidence examining the influence of physical activity on commonly occurring side effects of breast cancer treatment. Overall, current research evidence indicates that regular participation in physical activity after breast cancer diagnosis may mitigate common side effects of breast cancer adjuvant therapy, including fatigue, depression, impaired quality of life, decreased muscular strength, decreased aerobic capacity, and weight gain. Future research could examine the influence that physical activity has on the effectiveness of breast cancer treatment. Implications for health care professionals are discussed.

Breast cancer, sickness absence, income and marital status. A study on life situation 1 year prior diagnosis compared to 3 and 5 years after diagnosis

BACKGROUND

Improved cancer survival poses important questions about future life conditions of the survivor. We examined the possible influence of a breast cancer diagnosis on subsequent working and marital status, sickness absence and income.

MATERIALS

We conducted a matched cohort study including 4,761 women 40-59 years of age and registered with primary breast cancer in a Swedish population-based clinical register during 1993-2003, and 2,3805 women without breast cancer. Information on socioeconomic standing was obtained from a social database 1 year prior and 3 and 5 years following the diagnosis. In Conditional Poisson Regression models, risk ratios (RRs) and 95% confidence intervals (CIs) were estimated to assess the impact of a breast cancer diagnosis.

FINDINGS

Three years after diagnosis, women who had had breast cancer more often had received sickness benefits (RR = 1.49, 95% CI 1.40-1.58) or disability pension (RR = 1.47, 95% CI 1.37-1.58) than had women without breast cancer. We found no effect on income (RR = 0.99), welfare payments (RR = 0.98), or marital status (RR = 1.02). A higher use of sickness benefits and disability pension was evident in all stages of the disease, although the difference in use of sickness benefits decreased after 5 years, whereas the difference in disability pension increased. For woman with early stage breast cancer, the sickness absence was higher following diagnosis among those with low education, who had undergone mastectomy, and had received chemo- or hormonal therapy. Neither tumour size nor presence of lymph nodes metastasis was associated with sickness absence after adjustment for treatment.

INTERPRETATION

Even in early stage breast cancer, a diagnosis negatively influences working capacity both 3 and 5 years after diagnosis, and it seems that the type of treatment received had the largest impact. A greater focus needs to be put on rehabilitation of breast cancer patients, work-place adaptations and research on long-term sequelae of treatment.

Heath-related quality of life in Spanish breast cancer patients: a systematic review

Background

Breast cancer is one of the oncological diseases in which health-related quality of life (HRQL) has been most studied. This is mainly due to its high incidence and survival. This paper seeks to: review published research into HRQL among women with breast cancer in Spain; analyse the characteristics of these studies; and describe the instruments used and main results reported.

Methods

The databases consulted were MEDLINE, EMBASE, PsycINFO, Dialnet, IBECS, CUIDEN, ISOC and LILACS. The inclusion criteria required studies to: 1) include Spanish patients, and a breakdown of results where other types of tumours and/or women from other countries were also included; and, 2) furnish original data and measure HRQL using a purpose-designed questionnaire. The methodological quality of studies was assessed.

Results

Spain ranked midway in the European Union in terms of the number of studies conducted on the HRQL of breast cancer patients. Of the total of 133 papers published from 1993 to 2009, 25 met the inclusion criteria. Among them, only 12 were considered as having good or excellent quality. A total of 2236 women participated in the studies analysed. In descending order of frequency, the questionnaires used were the EORTC, FACT-B, QL-CA-Afex, SF-12, FLIC, RSCL and CCV. Five papers focused on validation or adaptation of questionnaires. Most papers examined HRQL in terms of type of treatment. Few differences were detected by type of chemotherapy, with the single exception of worse results among younger women treated with radiotherapy. In the short term, better results were reported for all HRQL components by women undergoing conservative rather than radical surgery. Presence of lymphedema was associated with worse HRQL. Three studies assessed differences in HRQL by patients' psychological traits. Psychosocial disorder and level of depression and anxiety, regardless of treatment or disease stage, worsened HRQL. In addition, there was a positive effect among patients who reported having a "fighting spirit" and using "denial" as a defence mechanism. One study found that breast cancer patients scored worse than did healthy women on almost all SF-12 scales.

Conclusion

Research into health-related quality of life of breast-cancer patients is a little developed field in Spain.

Changes in sexual problems over time in women with and without early-stage breast cancer

OBJECTIVE

We aimed to evaluate whether age-matched women with and without early-stage breast cancer differentially experience sexual problems over time and whether changes in patients' problems differ by type of surgical procedure.

METHODS

We conducted four interviews (4-6 wk, 6 mo, and 1 and 2 y) after tumor resection (patients) or after a negative/benign screening mammogram (controls). Mixed-effects models with repeated ordinal measurements tested the effects of time and diagnostic group (stages 0, I, and IIA vs controls) and, for patients, the effects of time and type of surgical procedure (mastectomy vs lumpectomy) using a newly developed nine-item sexual-problem measure. Two-sided P values < 0.05 were considered significant.

RESULTS

Using data from 1,033 women (17.3% stage 0, 33.4% stage I/IIA, and 49.3% controls; mean age, 57.1 y; 23.1% nonwhite; 64.7% married), two factors measuring problems with sexual attractiveness and sexual interest/enjoyment emerged in exploratory factor analysis (alpha > or = 0.74 for each subscale and the nine-item measure). Patients and controls reported few sexual problems on average, but controls were more likely to report sexual problems on the nine-item measure over time and stage I patients were less likely to report problems with sexual attractiveness over time (each P < 0.05) compared with at baseline. Patients who underwent mastectomy (35.7%) were 2.7 times more likely to report sexual problems on the nine-item measure at 2-year follow-up compared with baseline (P = 0.0339).

CONCLUSIONS

Patients and controls experienced few sexual problems over time, and in fact, controls were more likely to report sexual problems at subsequent interviews, whereas patients were not.

Trait anxiety predicts disease-specific health status in early-stage breast cancer patients

Purpose

The objectives of this study were to examine the differences in health status (HS) of women with breast cancer (BC) at different moments in time, and between women scoring high and not high on trait anxiety, and to identify possible predictors of HS 6 and 12 months after surgery.

Methods

Patients (N = 223) completed a trait anxiety questionnaire before diagnosis. Women who received a diagnosis of BC completed a BC-specific HS questionnaire 1, 3, 6 and 12 months after surgery. ANCOVA for repeated measures and multiple regression analysis were used in the analyses.

Results

Women scoring high on trait anxiety had significant (P < .005) lower Body image, worse Future perspective and Sexual functioning, and more Side-effects than women who did not score high on trait anxiety. At 6 and 12 months after surgery, the same aspects of HS were predicted by higher trait anxiety scores.

Conclusions

Higher scores on trait anxiety resulted in worse scores on four HS domains, indicating that there should be more attention for this group of patients, even before treatment starts.

Concepção de corpo em Merleau-Ponty e mulheres mastectomizadas

O câncer de mama tem sido o responsável pelos maiores índices de mortalidade no mundo, tornando-se uma das grandes preocupações em saúde, no que diz respeito à saúde da mulher. Em relação à terapêutica, embora existam amplas abordagens de intervenções que possibilitam melhores perspectivas de cura, a mastectomia constitui-se como base de tratamento. Artigo de reflexão filosófica, teve como objeto de estudo mulheres que vivenciaram a mastectomia objetivando refletir a concepção de corpo destas mulheres a partir da obra Fenomenologia da Percepção de Merleau-Ponty e de autores que trabalham com a temática referente à mulher mastectomizada.

Changes in quality of life in patients with breast cancer

AIM

To describe and compare changes in quality of life in two groups of patients with breast cancer and to identify factors predicting negative changes in quality of life within six months.

BACKGROUND

Women with breast cancer suffer from various treatment side-effects, from psychological and social symptoms as well as decreased quality of life, creating a need for support that may persist throughout the breast cancer experience.

DESIGN

This six-month longitudinal study involved a sample of 164 women, who were quasi-randomized between intervention (n = 85) and control groups (n = 79) after breast cancer surgery. Intervention group received support and education via telephone one week after the breast cancer surgery and face-to-face support six months after the surgery. Quality of life was estimated one week and six months after breast cancer surgery, using the Quality of Life Index-Cancer Version (QLI-CV) and the European Organisation for Research and Treatment of Cancer Breast Cancer-Specific Quality of Life questionnaire (EORTC QLQ-BR23).

METHOD

Data were analysed statistically using descriptive statistics and non-parametric tests. Factors predicting negative changes in quality of life within six months were investigated using logistic regression models with the enter method.

RESULTS

Significant group difference in the magnitude of changes within six months was found in future outlook. Logistic regression analyses revealed six significant predictors of negative changes in quality of life within six months: education, employment status, having underaged children, chemotherapy, radiotherapy and hormonal therapy.

CONCLUSION

The results of this study underline the importance of identifying quality of life changes in patients with breast cancer and paying attention to those women with difficulties in adapting to being a cancer survivor.

RELEVANCE TO CLINICAL PRACTICE

The findings of this study provide evidence which may help to create appropriate supportive interventions for both acute and long-term settings.

Health-related quality of life after breast-conserving surgery and intraoperative radiotherapy for breast cancer using low-kilovoltage X-rays

BACKGROUND

Intraoperative radiotherapy (IORT) is currently being evaluated as a novel approach during breast-conserving surgery (BCS). IORT can be used either as a tumor bed boost followed by external-beam radiotherapy (EBRT) or as a single treatment. In a matched-pair study, we assessed quality of life (QoL) in 69 patients with early breast cancer treated with BCS and/or IORT and/or EBRT.

METHODS

Patients were matched for age and time since BCS. IORT was provided with 50 kV x-rays (Intrabeam) delivering 20 Gy at the applicator surface. EBRT (46 to 50 Gy in 2-Gy fractions in the IORT with EBRT group, and 56 Gy in 2-Gy fractions in the EBRT group) was initiated after completion of wound healing and/or chemotherapy. The mailed questionnaires included the European Organization for the Research and Treatment of Cancer QLQ-C30 and BR23, FACT-F, HADS, Body Image Scale, and Rosenberg Self-Esteem Scale. At 18 to 70 months' follow-up (median 47 months), all patients were disease free.

RESULTS

We found only a few differences between the three groups. There was a trend toward more pain (mean ± standard deviation; 42.8 ± 32.9 vs. 27.5 ± 34.7) and reduced QoL (57.6 ± 20.7 vs. 70.3 ± 23.9) after IORT with EBRT compared with EBRT, respectively. IORT patients reported comparable QoL (70.3 ± 23.0), and less breast symptoms and body image concerns compared to EBRT (8.6 ± 12.3 vs. 19.2 ± 23.8, and 1.7 ± 3.3 vs. 3.4 ± 4.4, respectively). IORT alone resulted in significantly fewer breast symptoms (8.6 ± 12.3; P = 0.012) and less pain (23.9 ± 24.5, P = 0.041) compared with IORT with EBRT (26.1 ± 27.6; 42.8 ± 32.9, respectively).

CONCLUSIONS

Patients with early breast cancer after BCS and IORT with or without EBRT present with comparable QoL like patients receiving EBRT without a boost. IORT patients show the lowest rate of breast symptoms.

Effects of breast cancer surgery and surgical side effects on body image over time

We examined the impact of surgical treatments (breast-conserving surgery [BCS], mastectomy alone, mastectomy with reconstruction) and surgical side-effects severity on early stage (0-IIA) breast cancer patients' body image over time. We interviewed patients at 4-6 weeks (T1), six (T2), 12 (T3), and 24 months (T4) following definitive surgical treatment. We examined longitudinal relationships among body image problems, surgery type, and surgical side-effects severity using the Generalized Estimating Equation approach, controlling for demographic, clinical, and psychosocial factors. We compared regression coefficients of surgery type from two models, one with and one without surgical side-effects severity. Of 549 patients enrolled (mean age 58; 75% White; 65% BCS, 12% mastectomy, 23% mastectomy with reconstruction), 514 (94%) completed all four interviews. In the model without surgical side-effects severity, patients who underwent mastectomy with reconstruction reported poorer body image than patients who underwent BCS at T1-T3 (each P < 0.02), but not at T4. At T2, patients who underwent mastectomy with reconstruction also reported poorer body image than patients who underwent mastectomy alone (P = 0.0106). Adjusting for surgical side-effects severity, body image scores did not differ significantly between patients with BCS and mastectomy with reconstruction at any interview; however, patients who underwent mastectomy alone had better body image at T2 than patients who underwent mastectomy with reconstruction (P = 0.011). The impact of surgery type on body image within the first year of definitive surgical treatment was explained by surgical side-effects severity. After 2 years, body image problems did not differ significantly by surgery type.

Comparison of early quality of life in patients treated with radiotherapy following mastectomy or breast conservation therapy: a prospective study

INTRODUCTION

To compare quality of life (QOL) in breast cancer patients from a developing country after breast conservation surgery (BCS) or mastectomy and adjuvant radiotherapy (RT).

MATERIALS AND METHODS

In a 6-month period, all consecutive early and locally advanced breast cancer patients treated with either BCS or mastectomy and treated with RT were analyzed. All patients who underwent mastectomy were treated with 45 Gray/20#/4 weeks. Patients with BCS were treated with a dose of 45-50 Gray/25#/5 weeks to whole breast followed by tumor bed boost (15 Gray/6#/6 days with suitable energy electrons). Prospective evaluation of QOL using EORTC QLQ C30 and breast cancer specific QLQ BR23 was done before starting RT (baseline), at mid-RT and at RT conclusion for all patients.

RESULTS

One hundred and thirteen patients had mastectomy and 142 patients underwent BCS. Reliability test (Cronbach alpha) for questionnaire filling was 0.669-0.886. At pre-RT assessment, global QOL scores in mastectomy and BCS groups were 71.1 and 71.3, respectively. There was no significant difference in pre-RT EORTC QLQ C30 functional and symptom domains between mastectomy and BCS patients. However, social function domain score was higher in patients who underwent mastectomy (83 versus 73.9; p=0.018). In QLQ BR23 domains, body image and sexual functioning domains were similar between the two groups. However, sexual enjoyment (10.9 versus 47.6; p=0.006) and future perspective (7.4 versus 37.1; p=0.036) domains were significantly better in BCS arm. There was no difference between systemic side effect (BRSSE), breast symptom (BRBS) and arm symptom (BRAS) domain scores between the groups. There was no significant difference in change of QOL scores between mastectomy and BCS patients at RT completion as compared to baseline.

CONCLUSIONS

There was no significant difference in quality of life in patients with BCS versus those with mastectomy. However, patients who underwent BCS had better sexual enjoyment and future perspective scores compared with mastectomy patients. There was no significant change of QOL domain scores after RT in mastectomy and BCS patients.

Clinical evaluation of the flotrac/Vigileo system for continuous cardiac output monitoring in patients undergoing regional anesthesia for elective cesarean section: a pilot study

BACKGROUND

Spinal anesthesia for cesarean delivery may cause severe maternal hypotension and a decrease in cardiac output. Compared to assessment of cardiac output via a pulmonary artery catheter, the FloTrac/Vigileo system may offer a less invasive technique. The aim of this study was to evaluate cardiac output and other hemodynamic measurements made using the FloTrac/Vigileo system in patients undergoing spinal anesthesia for elective cesarean section.

METHODS

A prospective study enrolling 10 healthy pregnant women was performed. Hemodynamic parameters were continuously obtained at 15 main points: admission to surgery (two baseline measurements), after preload, after spinal anesthesia administration and 4 time points thereafter (4, 6, 8 and 10 min after anesthesia), at skin and uterine incision, newborn and placental delivery, oxytocin administration, end of surgery, and recovery from anesthesia. Hemodynamic therapy was guided by mean arterial pressure, and vasopressors were used as appropriate to maintain baseline values. A repeated measures ANOVA was used for data analysis.

RESULTS

There was a significant increase in heart rate and a decrease of stroke volume and stroke volume index up to 10 min after spinal anesthesia (P < 0.01). Importantly, stroke volume variation increased immediately after newborn delivery (P < 0.001) and returned to basal values at the end of surgery. Further hemodynamic parameters showed no significant changes over time.

DISCUSSION AND CONCLUSIONS

No significant hemodynamic effects, except for heart rate and stroke volume changes, were observed in pregnant women managed with preload and vasopressors when undergoing elective cesarean section and spinal anesthesia.

Second operation is not related to psychological outcome in breast cancer patients

To examine the effect of multiple surgical treatments on psychological outcomes in women with early stage breast cancer (BC) in a prospective follow-up study. Questionnaires for depressive symptoms (CES-D), fatigue (FAS), anxiety (STAI-State), physical health (WHOQOL-100), psychological health (WHOQOL-100) and overall quality of life and general health (WHOQOL-100) were completed before diagnosis (Time-1) and 1 (Time-2), 3 (Time-3), 6 (Time-4) and 12 (Time-5) months after the last surgical treatment. From the 217 participating women with early stage BC, 78 (35.9%) needed an additional surgical treatment. Using general linear model (repeated measures), psychosocial outcomes over time were investigated for the breast conserving therapy and mastectomy group, accounting for type of surgery, disease stage and hormonal therapy. Psychological outcomes did not significantly change over time, with the exception of anxiety [Wilks' Lambda = 0.72, F (4,86) = 8.55, p < 0.0001, partial eta squared = 0.29]. On average, women with 1 and women with 2 surgical treatments did not differ on any outcome measure. No interaction effects were found, indicating that changes in outcomes over time were the same for both groups. Women who had a repeat surgical treatment did not score differently on psychological outcome measures compared with women who were treated "efficiently."

Sexual desire and satisfaction in sexual life affecting factors in breast cancer survivors after mastectomy

The purpose of this study was to examine impact of treatment and personality characteristics, and support need for femininity and body image on sexual desire and sexual satisfaction of women with breast cancer. The sample consisted of 123 married women who previously underwent mastectomy and applied to medical oncology clinics of a university hospital. Sexual desire of the women in this study was low, and they were slightly satisfied with sexual life. Consequently, the women required supporting needs of femininity and body image. The result of this study could be utilized to determine sexual desire and satisfaction related to sexual life of women with breast cancer.

Quality assessment of neoadjuvant therapy use in breast conservation: barriers to implementation

Neoadjuvant systemic therapy (NST) for operable breast cancer can increase the options for conservative surgery in patients with breast cancer. We performed an analysis of a breast cancer outcomes database as a quality assessment of neoadjuvant therapy use in relation to breast conservative rate (BCR). Data were reviewed from a breast cancer database established to monitor outcomes of breast cancer surgery at a tertiary care breast cancer clinic. The frequency of NST-use was correlated to tumor size and BCR. Cause-specific factors for omitting NST in patients undergoing mastectomy for tumors 3 cm or greater were determined. NST was employed in 29 of 241 (12%) cases of invasive breast carcinoma treated surgically from 2003 to 2005. Although a significant decrease in BCR occurred in tumors >3 cm, NST was not frequently employed until tumors reached >5 cm. Defined contraindications to breast conservation (65%) and patient choice for mastectomy (30%) were the two most common reasons for omitting NST in tumors > or = 3 cm. Despite the initial appearance of NST under-utilization in tumors measuring between 3-5 cm, appropriate exclusion of patients not suitable for breast conservation and patient choice for mastectomy both emerged as leading factors for the omission of NST in this group. Use of NST is an important quality metric in optimizing breast conservation. Patient education and greater understanding of patient-related barriers to NST may help improve BCR.

Tumor aromatase expression as a prognostic factor for local control in young breast cancer patients after breast-conserving treatment

Introduction

We sought to determine whether the levels of expression of 17 candidate genes were associated with locoregional control after breast-conserving treatments of early-stage breast cancers in young, premenopausal women.

Methods

Gene expression was measured by using RT-PCR in the breast tumors of a series of 53 young (younger than 40 years), premenopausal patients. All treatments consisted of primary breast-conserving surgery followed by whole-breast radiotherapy (± regional lymph nodes) with or without systemic treatments (chemotherapy ± hormone therapy). The median follow-up was 10 years.

Results

The 10-year locoregional control rate was 70% (95% CI, 57% to 87%). In univariate analysis, no clinical/pathologic prognostic factors were found to be significantly associated with decreased locoregional control. Expression of three genes was found to be significantly associated with an increased locoregional recurrence rate: low estrogen-receptor β, low aromatase, and high GATA3. Two others were associated with only a trend (P < 0.10): low HER1 and SKP2. In multivariate analysis, only the absence of aromatase was significantly associated with an increased locoregional recurrence rate (P = 0.003; relative risk = 0.49; 95% CI 0.29 to 0.82).

Conclusions

Recent data give credit to the fact that breast cancer in young women is a distinct biologic entity driven by special oncogenic pathways. Our results highlight the role of estrogen-signaling pathways (mainly CYP19/aromatase, GATA3, and ER-β) in the risk of locoregional recurrence of breast cancer in young women. Confirmation in larger prospective studies is needed.

Quality of life after breast cancer surgery: What have we learned and where should we go next?

Treatment options for women with newly diagnosed breast cancer include breast conservation therapy and mastectomy with or without reconstruction, which provide equivalent cancer outcomes in properly selected patients. Although multiple studies have evaluated breast surgery quality-of-life outcomes, the data are inconsistent. This factor is important to consider when counseling patients and defining surgical quality measures.

Impact of diabetes mellitus on complications and outcomes of adjuvant chemotherapy in older patients with breast cancer

PURPOSE

To evaluate whether diabetes affects patterns of adjuvant chemotherapy use, toxic effects of chemotherapy, and breast cancer outcomes.

PATIENTS AND METHODS

By using the Surveillance, Epidemiology, and End Results-Medicare database, we identified patients aged 66 years or older who had stages I through III breast cancer that was diagnosed between 1992 and 2002. Multivariable regression analyses were performed to determine the effect of diabetes on use of chemotherapy, toxicities, and outcomes. The risks of all-cause mortality and breast cancer-specific (BCS) mortality were estimated with the Kaplan-Meier method.

RESULTS

Our cohort had 70,781 men and women, of whom 14,414 (20.36%) had diabetes. Among people who received chemotherapy (n = 11,826), 21.0% were diabetics. In this group, diabetics had lower odds of receiving anthracyclines (odds ratio [OR], 0.78; 95% CI, 0.71 to 0.87) and taxanes (OR, 0.86; 95% CI, 0.75 to 0.99). Diabetes was associated with increased odds of being hospitalized for any chemotherapy toxicity (OR, 1.38; 95% CI, 1.23 to 1.56), for infection or fever (OR, 1.43; 95% CI, 1.2 to 1.7), for neutropenia (OR, 1.22; 95% CI, 1.03 to 1.45), for anemia (OR, 1.24; 95% CI, 1.05 to 1.47), and for any cause (OR, 1.32; 95% CI, 1.19 to 1.46). Patients with diabetes had higher all-cause mortality (hazard ratio [HR], 1.35; 95% CI, 1.31 to 1.39). There was a significant interaction between diabetes and chemotherapy use for BCS mortality. Diabetic and nondiabetic patients who did not receive chemotherapy had similar BCS mortality, but diabetic patients who did receive chemotherapy had higher BCS mortality than nondiabetic patients (OR, 1.20; 95% CI, 1.07 to 1.35).

CONCLUSION

In this observational, hypothesis-generating study, patients who have breast cancer and diabetes are at increased risk of chemotherapy-related toxicities compared with nondiabetic patients who are receiving chemotherapy and have higher all-cause mortality.

A prospective examination of perceived stress as a mediator of the relationship between life-events and QOL following breast cancer

OBJECTIVES

This study prospectively investigated the relationship between life-events, perceived stress, and quality of life (QOL) following breast cancer diagnosis, using the bio-behavioural model of cancer stress as a framework.

DESIGN

A longitudinal, self-report design was used.

METHODS

Three waves of data from 10,543 mid-aged Australian women (aged 45-50 at Survey 1) were collected over 5 years as part of a population-based survey. From this group a subsample (N=140) were identified who did not have breast cancer at Survey 1, but who subsequently developed breast cancer. Random regression growth curve analyses were used to investigate whether perceived stress mediated the relationship between initial life-events and change in QOL functioning overtime.

RESULTS

Prospective evidence was generated for each of the three criteria for testing mediation. As the number of life-events before breast cancer increased, women were significantly more likely to experience corresponding increases in perceived stress over the 5-year period. As the level of perceived stress before breast cancer increased, women were more likely to experience deteriorations overtime in role emotional, role physical, vitality, bodily pain, physical functioning, and social functioning. As the number of life-events before breast cancer increased, women were at significant risk of experiencing deteriorations overtime in bodily pain, social functioning, role emotional, and vitality. Mediational analyses revealed that perceived stress fully mediated the relationship between initial life-events and two QOL domains; role-emotional and social functioning.

CONCLUSION

Results partially supported the bio-behavioural model of cancer stress, but the model does not appear to fit the data as well as predicted, and may require revision.

Racial/ethnic differences in breast cancer outcomes among older patients: effects of physician communication and patient empowerment

OBJECTIVES

To examine racial/ethnic disparities in older women's health-related quality of life (QoL) and type of breast cancer treatment as mediated by physician-level and individual-level variables.

METHODS

A cross-sectional survey of a population-based, consecutive sample identified through the Los Angeles Cancer Surveillance Program of Latina (n = 99), African American (n = 66), and White (n = 92) women aged 55 years or older (N = 257) between 3 and 9 months after primary breast cancer diagnosis and at least 1 month posttreatment. An exploratory, empirically developed latent variable model tested the relationships among demographic and physician-related variables, patient attitudes, and health-related outcomes. Health-related outcomes included QoL measures and receipt of breast conserving surgery (BCS).

RESULTS

Latinas reported less BCS and poorer QoL compared with Whites. Physician communication that can empower patients, in terms of patient efficacy in patient?physician interactions and breast cancer knowledge, mitigated racial/ethnic disparities in receipt of BCS. Physician emotional support was not related to patient cognitive empowerment and treatment outcomes. Medical mistrust in minority women was related to less self-efficacy and less positive coping, as well as, both directly and indirectly, to reduced QoL. Latinas reported poorer QoL in the tested model.

CONCLUSION

Physician communication style, specifically information giving and participatory decision making, may empower older women with breast cancer and help mitigate racial/ethnic disparities in surgical treatment received.

Do chronological age and selected socio-demographic factors affect quality of life in females with breast cancer?

The main aim of this study is to determine whether chronological age and selected socio-demographic factors affect quality of life in females with breast cancer. The sample group consisted of 145 females between 32.0 and 84.4 years of age, after radical surgery treatment, chemotherapy, radiotherapy and undergoing hormonotherapy. The results indicate no significant differences between individuals varied by chronological age, and by place of residence. The time elapsed since the diagnosis was a significant differentiating factor in terms of the self-reported extent of positive emotions, cognitive problems and sexual functioning. Higher educated females were more inclined to social avoidance and more severely affected by fatigue - those with partners more so than single ones. The distress related to the disease and its treatment degrades the patients' quality of life so severely that other factors, such as socio-demographic, chronological age or period since diagnosis, do not play as an important role in a subjective evaluation of quality of life. One needs to be cognizant of the variety of coexisting factors, including psychological and characterological, that contribute to the quality of life evaluation.

Quality of life and patient-reported outcomes in the older breast cancer patient

As the world population ages, the incidence of cancer will probably also increase as it is a disease predominantly affecting older people. However, those aged 70 years or more have largely been excluded from clinical trials. This review focuses on breast cancer. Increasingly there is recognition that many older breast cancer patients are being undertreated and could and should be offered the same treatments as younger patients. Comprehensive assessment of the quality of any survival benefit from treatments is also needed to ensure that in the future older patients can make fully informed decisions about their treatment options. The aim of this overview is two-fold: first to describe methods by which to assess quality of life; and second to review the recent surgical, radiotherapy, chemotherapy and other studies that include such assessment with older breast cancer patients. Current studies are also outlined, including quality of life assessments, and recommendations are made for future research in this area.

The psychosocial concerns and needs of women recently diagnosed with breast cancer: a qualitative study of patient, nurse and volunteer perspectives

OBJECTIVE

To qualitatively identify the concerns and needs of Australian women recently diagnosed with breast cancer.

BACKGROUND

Breast cancer diagnosis can lead to impairment in multiple areas of psychosocial well-being, including physical, social and emotional functioning. Research has therefore begun to focus on identifying and addressing survivors' concerns and needs, with most research examining the time of treatment completion. However diagnosis and treatment are also key times of psychological need, and less is known about the psychosocial concerns and needs at these times.

RESEARCH DESIGN

Seven focus group interviews were conducted examining three categories of participants: (i) patients diagnosed with early-stage breast cancer within the past 12 months, (ii) oncology nurses, and (iii) volunteers who work with cancer patients. Sampling was discontinued when informational redundancy was achieved.

SETTING AND PARTICIPANTS

Thirty-four participants took part in one of seven focus group meetings held in a hospital patient resource room.

RESULTS

A wide variety of psychosocial concerns and needs were discussed, and five specific areas of concern were identified: (i) coping with side-effects; (ii) dealing with self-concept change; (iii) stress and adjustment reactions; (iv) having to manage others' unhelpful beliefs, expectations and emotions; and (v) issues with survival and growth. There was a large degree of consistency in the concerns and needs identified by the different group categories.

CONCLUSION

In general, the concerns and needs expressed were consistent with survivorship issues previously identified in the literature; however, several new insights were obtained. Clinical implications of these findings are discussed.

Quality of life in patients with breast cancer before and after diagnosis: an eighteen months follow-up study

Background

Measuring quality of life in breast cancer patients is of importance in assessing treatment outcomes. This study examined the impact of breast cancer diagnosis and its treatment on quality of life of women with breast cancer.

Methods

This was a prospective study of quality of life in breast cancer patients. Quality of life was measured using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30) and its breast cancer supplementary measure (QLQ-BR23) at three points in time: baseline (pre diagnosis), three months after initial treatment and one year after completion of treatment (in all 18 months follow-up). At baseline the questionnaires were administered to all suspected identified patients while both patients and the interviewer were blind to the final diagnosis. Socio-demographic and clinical data included: age, education, marital status, disease stage and initial treatment. Repeated measure analysis was performed to compare quality of life differences over the time.

Results

In all, 167 patients diagnosed with breast cancer. The mean age of breast cancer patients was 47.2 (SD = 13.5) years and the vast majority (82.6%) underwent mastectomy. At eighteen months follow-up data for 99 patients were available for analysis. The results showed there were significant differences in patients' functioning and global quality of life at three points in time (P < 0.001). Although there were deteriorations in patients' scores for body image and sexual functioning, there were significant improvements for breast symptoms, systematic therapy side effects and patients' future perspective (P < 0.05).

Conclusion

The findings suggest that overall breast cancer patients perceived benefit from their cancer treatment in long-term. However, patients reported problems with global quality of life, pain, arm symptoms and body image even after 18 months following their treatments. In addition, most of the functional scores did not improve.

Health-related quality of life in breast cancer patients: a bibliographic review of the literature from 1974 to 2007

Background

Quality of life in patients with breast cancer is an important outcome. This paper presents an extensive overview on the topic ranging from descriptive findings to clinical trials.

Methods

This was a bibliographic review of the literature covering all full publications that appeared in English language biomedical journals between 1974 and 2007. The search strategy included a combination of key words 'quality of life' and 'breast cancer' or 'breast carcinoma' in titles. A total of 971 citations were identified and after exclusion of duplicates, the abstracts of 606 citations were reviewed. Of these, meetings abstracts, editorials, brief commentaries, letters, errata and dissertation abstracts and papers that appeared online and were indexed ahead of publication were also excluded. The remaining 477 papers were examined. The major findings are summarized and presented under several headings: instruments used, validation studies, measurement issues, surgical treatment, systemic therapies, quality of life as predictor of survival, psychological distress, supportive care, symptoms and sexual functioning.

Results

Instruments-Several valid instruments were used to measure quality of life in breast cancer patients. The European Organization for Research and Treatment of Cancer Core Cancer Quality of Life Questionnaire (EORTC QLQ-C30) and its breast cancer specific complementary measure (EORTC QLQ-BR23) and the Functional Assessment Chronic Illness Therapy General questionnaire (FACIT-G) and its breast cancer module (FACIT-B) were found to be the most common and well developed instruments to measure quality of life in breast cancer patients. Surgery-different surgical procedures led to relatively similar results in terms of quality of life assessments, although mastectomy patients compared to conserving surgery patients usually reported a lower body image and sexual functioning. Systemic therapies-almost all studies indicated that breast cancer patients receiving chemotherapy might experience several side-effects and symptoms that negatively affect their quality of life. Adjuvant hormonal therapies also were found to have similar negative impact on quality of life, although in general they were associated with improved survival. Quality of life as predictor of survival-similar to known medical factors, quality of life data in metastatic breast cancer patients was found to be prognostic and predictive of survival time. Psychological distress-anxiety and depression were found to be common among breast cancer patients even years after the disease diagnosis and treatment. Psychological factors also were found to predict subsequent quality of life or even overall survival in breast cancer patients. Supportive care-clinical treatments to control emesis, or interventions such as counseling, providing social support and exercise could improve quality of life. Symptoms-Pain, fatigue, arm morbidity and postmenopausal symptoms were among the most common symptoms reported by breast cancer patients. As recommended, recognition and management of these symptoms is an important issue since such symptoms impair health-related quality of life. Sexual functioning-breast cancer patients especially younger patients suffer from poor sexual functioning that negatively affect quality of life.

Conclusion

There was quite an extensive body of the literature on quality of life in breast cancer patients. These papers have made a considerable contribution to improving breast cancer care, although their exact benefit was hard to define. However, quality of life data provided scientific evidence for clinical decision-making and conveyed helpful information concerning breast cancer patients' experiences during the course of the disease diagnosis, treatment, disease-free survival time, and recurrences; otherwise finding patient-centered solutions for evidence-based selection of optimal treatments, psychosocial interventions, patient-physician communications, allocation of resources, and indicating research priorities were impossible. It seems that more qualitative research is needed for a better understanding of the topic. In addition, issues related to the disease, its treatment side effects and symptoms, and sexual functioning should receive more attention when studying quality of life in breast cancer patients.

Quality of life after sentinel lymph node biopsy or axillary lymph node dissection in stage I/II breast cancer patients: a prospective longitudinal study

Background

Breast cancer patients’ quality of life (QoL) after surgery has been reported to improve significantly over time. Little is known about QoL recovery after sentinel lymph node biopsy (SLNB) in comparison to axillary lymph node dissection (ALND).

Methods

175 of 195 stage I/II breast cancer patients completed the EORTC QLQ-C30: one day before surgery (T0) and after 6 (T1), 26 (T2), 52 (T3) and 104 (T4) weeks. Of these, 54 patients underwent SLNB, 56 SLNB+ALND and 65 ALND. General linear models and paired T-tests between T0–T4 and T1–T4 were computed. Complications, radiotherapy and systemic therapy were added to the model.

Results

Significant time effects were found on physical, role and emotional functioning. Physical and role functioning decreased between T0 and T1. At T4, SLNB patients’ functioning had increased to their T0 level; ALND (+/– SLNB) patients’ functioning had increased, but had not improved to T0 level. Emotional functioning increased linearly between T0 and T4. At T4, emotional functioning was significantly higher in all groups as compared with T0. No significant group or interaction (time × group) effects were found. Complications and chemotherapy had a significant negative effect on role, emotional and cognitive functioning. Complications had a significant effect on social functioning also. Effect sizes varied between 0.00 and 0.06.

Conclusion

Two years post surgery, breast cancer patients’ QoL is comparable to that shortly before surgery. Women rated their emotional functioning as even better. SLNB is not associated with a better QoL than ALND. However, undergoing systemic therapy and/or experiencing complications affects QoL negatively.

Perceived barriers to self-management in Malaysian women with breast cancer

Naturalistic inquiry using focus group interviews was undertaken to explore experiences and perceived barriers to self management in women with breast cancer. The aim was to identify their perceived barriers to self management to aid the development of rehabilitation programmes. Successful programmes are strongly linked to patients' perceived needs. Four focus groups consisted of 39 women, were purposively recruited. Women's needs within the three areas of medical, emotional and role management of breast cancer were explored. The main barriers were unavailability of information, inability to access services-and-support, and socioeconomic-cultural issues (entrenched myths, low-socioeconomic status, and inadequate insurance-health legislative coverage). The findings provide the critically lacking 'expert-view' of survivors, who verified the importance of the medical, emotional and role management tasks, and highlighted barriers and structural solutions. With breast cancer becoming recognised as a form of chronic illness, this study is timely.

High-resolution mapping of DNA breakpoints to define true recurrences among ipsilateral breast cancers

BACKGROUND

To distinguish new primary breast cancers from true recurrences, pangenomic analyses of DNA copy number alterations (CNAs) using single-nucleotide polymorphism arrays have proven useful.

METHODS

The pangenomic profiles of 22 pairs of primary breast carcinoma (ductal or lobular) and ipsilateral breast cancers from the same patients were analyzed. Hierarchical clustering was performed using CNAs and DNA breakpoint information. A partial identity score developed using DNA breakpoint information was used to quantify partial identities between two tumors. The nature of ipsilateral breast cancers (true recurrence vs new primary tumor) as defined using the clustering methods and the partial identity score was compared with that based on clinical characteristics. Metastasis-free survival was compared among patients with primary tumors and true recurrences as defined using the partial identity score and by clinical characteristics. All statistical tests were two-sided.

RESULTS

All methods agreed on the nature of ipsilateral breast cancers for 14 pairs of samples. For five pairs, the clinical definition disagreed with both clustering methods. For three pairs, the two clustering methods were discordant and the one using DNA breakpoints agreed with the clinical definition. The partial identity score confirmed the nature of ipsilateral breast cancers as defined by clustering of DNA breakpoints in 21 of 22 pairs. The difference in metastasis-free survival of patients with new primary tumors and those with true recurrences was not statistically significant when tumors were defined based on clinical and histologic characteristics (5-year metastasis-free survival: 76%, 95% confidence interval [CI] = 52% to 100% for new primary tumors and 38%, 95% CI = 17% to 83% for true recurrences; P = .18; new primary tumor vs true recurrence, hazard ratio = 2.8, 95% CI = 0.6 to 13.7), but the difference was statistically significant when tumors were defined using the partial identity score (5-year metastasis-free survival: 100% for new primary tumors and 29%, 95% CI = 11% to 78% for true recurrences; P = .01).

CONCLUSIONS

DNA breakpoint information more often agreed with the clinical determination than CNAs in this population. The partial identity score, which was calculated based on DNA breakpoints, allows statistical discrimination between new primary tumors and true recurrences that could outperform the clinical determination in terms of prognosis.

Management of sexual dysfunction in postmenopausal breast cancer patients taking adjuvant aromatase inhibitor therapy

Treatment with aromatase inhibitors for postmenopausal women with breast cancer has been shown to reduce or obviate invasive procedures such as hysteroscopy or curettage associated with tamoxifen-induced endometrial abnormalities. The side effect of upfront aromatase inhibitors, diminished estrogen synthesis, is similar to that seen with the natural events of aging. The consequences often include vasomotor symptoms (hot flushes) and vaginal dryness and atrophy, which in turn may result in cystitis and vaginitis. Not surprisingly, painful intercourse (dyspareunia) and loss of sexual interest (decreased libido) frequently occur as well. Various interventions, both non-hormonal and hormonal, are currently available to manage these problems. The purpose of the present review is to provide the practitioner with a wide array of management options to assist in treating the sexual consequences of aromatase inhibitors. The suggestions in this review are based on recent literature and on the recommendations set forth both by the North American Menopause Association and in the clinical practice guidelines of the Society of Gynaecologists and Obstetricians of Canada. The complexity of female sexual dysfunction necessitates a biopsychosocial approach to assessment and management alike, with interventions ranging from education and lifestyle changes to sexual counselling, pelvic floor therapies, sexual aids, medications, and dietary supplements-all of which have been reported to have a variable, but often successful, effect on symptom amelioration. Although the use of specific hormone replacement-most commonly local estrogen, and less commonly, systemic estrogen with or without an androgen, progesterone, or the additional of an androgen in an estrogenized woman (or a combination)-may be highly effective, the concern remains that in patients with estrogen-dependent breast cancer, including those receiving anti-estrogenic adjuvant therapies, the use of these hormones may be attended with potential risk. Therefore, non-hormonal alternatives should in all cases be initially tried with the expectation that symptomatic relief can often be achieved.First-line therapy for urogenital symptoms, notably vaginal dryness and dyspareunia, should be the non-hormonal group of preparations such as moisturizers and precoital vaginal lubricants. In patients with estrogen-dependent breast cancer (notably those receiving anti-estrogenic adjuvant therapies) and severely symptomatic vaginal atrophy that fails to respond to non-hormonal options, menopausal hormone replacement or prescription vaginal estrogen therapy may considered. Systemic estrogen may be associated with risk and thus is best avoided. Judicious use of hormones may be appropriate in the well-informed patient who gives informed consent, but given the potential risk, these agents should be prescribed only after mutual agreement of the patient and her oncologist.