Breast cancer survivors: psychosocial concerns and quality of life

Health profiles of 814 very long-term breast cancer survivors

BACKGROUND

Information regarding the long-term health impact of cancer and cancer treatments on survivors is gradually accumulating but is generally limited to the first few years after diagnosis.

PATIENTS AND METHODS

We analyzed health information provided by 814 breast cancer survivors whose cancer was diagnosed >or= 15 years earlier and compared the information with that of female survivors of other cancers. These women were identified from a larger cohort of very long-term survivors of cancer who responded to a health survey.

RESULTS

All survivors underwent surgery as part of their cancer therapy, and 334 (41%) also received chemotherapy. Survivors of breast cancer reported significantly more arthritis/osteoporosis, cataracts, and heart problems than other cancer survivors. Those who were treated with chemotherapy reported more psychologic problems, loss of memory, and circulation problems than those who did not receive chemotherapy. A third (30.4%) of the breast cancer survivors reported that cancer had affected their health.

CONCLUSION

Very long-term survivors of breast cancer generally report good health and quality of life, as do very long-term survivors of other cancers. Nevertheless, 30.4% of breast cancer survivors report that cancer has affected their health. A number of distinctions are noted that can serve a basis for further hypothesis-driven research.

Quality of life of cancer survivors after physical and psychosocial rehabilitation

As the number of newly diagnosed cancer patients and the survival rates of cancer increase, more and more cancer patients are facing distressing physical and psychosocial problems as a result of their cancer and its treatment. To address these problems, a 12-week rehabilitation group program for cancer patients (all cancer types), combining physical exercise and psycho-education, was tested in a longitudinal cohort study (n=658). At baseline, participants reported a low quality of life, measured by the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire (QLQ-C30) (range 0-100). Halfway through the intervention significant improvements were found in all domains, except cognitive functioning. At the end of rehabilitation, participants had reached significant improvements on all outcome variables: in global quality of life (from 63.0 to 71.9), emotional functioning (from 66.2 to 74.4), cognitive functioning (from 70.5 to 74.4) and fatigue level (reduction from 49.8 to 41.8) while, moreover, non-breast cancer patients showed clinically relevant improvement in physical functioning (from 67.3 to 80.4) and social functioning (from 63.4 to 79.4) and non-working patients showed a clinically relevant improvement in role functioning (from 57.0 to 69.6).

Symptoms, symptom beliefs, and quality of life of older breast cancer survivors: a comparative study

PURPOSE/OBJECTIVES

To compare symptoms, symptom beliefs, and quality of life (QOL) of older breast cancer survivors to those of older women without breast cancer.

DESIGN

Descriptive, correlational study.

SETTING

Urban and rural communities in the Midwest United States.

SAMPLE

18 breast cancer survivors and 24 women without breast cancer, older than age 64 (X age = 76 years).

METHODS

In-home interviews using structured instruments.

MAIN RESEARCH VARIABLES

Symptom distress (number of and distress from symptoms), symptom beliefs, chronic health problems, and QOL.

FINDINGS

No group differences existed in demographic characteristics, symptom number, symptom bother, chronic health conditions, or QOL. Women in both groups most often attributed the cause of their symptoms to aging, chronic illness, or unknown, but rarely to breast cancer. Attributing symptoms to chronic illness or breast cancer was significantly related to more pain, depression, role impairment, and poorer mental health. Not knowing the cause of symptoms was significantly related to poorer social functioning, mental health, and purpose in life; less energy; and higher levels of depression and anxiety.

CONCLUSIONS

The symptom experience and QOL of older breast cancer survivors are similar to those of older women with other chronic health problems. Beliefs about symptoms influence QOL in older women.

IMPLICATIONS FOR NURSING

A broader assessment of symptoms is needed to assist older breast cancer survivors with symptom management. Symptom interventions in older women should address patients' beliefs about symptoms if QOL is to be enhanced.

The Long-Term Evolution of Quality of Life for Disease-Free Breast Cancer Survivors

AIM

Little is known about the long-term evolution of Quality of Life (QoL) for breast cancer treated patients. The study aims to describe this evolution of QoL in a group of Belgian breast cancer survivors.

METHODS

We gathered information on treatment, general health, activity problems, disease symptoms, pain, emotions, work, social activities, self-care, housekeeping, sexuality, and meaning of life. One hundred seventy-four disease-free survivors in Flanders (Belgium) participated in this study, which were grouped as being disease free less than one year (39), between one and five years (70) and more than five years (65). The data allowed us to analyse QoL for different dimensions over the three survivor groups.

RESULTS

The longer the survival time, the more QoL of breast cancer treated patients ameliorated and the less breast cancer had a major impact on QoL. Scores for doing intense activities, being tired, emotional health, social activities, and meaning of life were statistically significantly better in the long-term survivor group. The influence of breast cancer was more persistent for sexual QoL items.

CONCLUSION

It is important for patients to know what they may expect after treatment. This kind of patient-reported information on the evolution of QoL is of great value to healthcare workers. Results may be used to encourage patients who are newly diagnosed with breast cancer or for patients who do not believe in further progress for some QoL aspects. When informing breast cancer patients, a fundamental difference has to be made between the several QoL aspects and time over which improvements may be expected.

Assessing the impact of cancer: development of a new instrument for long-term survivors

OBJECTIVE

To develop and evaluate a new instrument that measures aspects of long-term survivorship not measured by existing tools.

METHODS

In qualitative interviews, 47 long-term cancer survivors (LTS) detailed ways that cancer has impacted their lives. Content analysis resulted in the creation of 325 candidate items for inclusion in a new Impact of Cancer (IOC) instrument. Following expert review, item reduction and pilot testing, 81 items were administered with other established health status and quality of life (QOL) instruments to 193 LTS of breast, prostate, colorectal cancers and lymphoma. Internal consistency reliability and validity of newly-derived scales was assessed.

RESULTS

Factor analysis of items using a priori QOL domains resulted in the derivation of ten new and specific subscales: Health Awareness, Body Changes, Health Worries, Positive and Negative Self-Evaluation, Positive and Negative Life Outlook, Social Life Interferences, Relationships, and Meaning of Cancer. Internal consistency measurements for these subscales ranged from 0.67 to 0.89. Expected associations within and among the IOC subscales and standardized measures of health status and QOL were observed, as were some unexpected findings.

CONCLUSIONS

Psychometric analysis indicated that this initial version of the Impact of Cancer instrument measures distinct and relevant constructs for LTS. Future work is necessary to confirm the factor structure, responsiveness and further validation of the instrument.

Health-related quality of life in disease-free survivors of breast cancer with the general population

BACKGROUND

Although most of the literature about health-related quality of life (HRQoL) focuses on breast cancer patients, few studies compared the HRQoL in disease-free breast cancer survivors with that of the general population.

MATERIALS AND METHODS

We administered the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 and Quality of Life Questionnaire Breast Cancer Module, McGill Quality of Life Questionnaire, Beck Depression Inventory, and Brief Fatigue Inventory to 1933 disease-free survivors for over 1 year after being diagnosed with stage 0 to III breast cancer. We performed multivariate-adjusted analyses in all HRQoL comparisons.

RESULTS

The scores for some health-related quality of life [corrected] HRQoL scales were comparable for both disease-free breast cancer survivors and the general female population, but [corrected] there was a [corrected] clinically significant difference between the two groups [corrected] in cognitive and social functioning, fatigue, insomnia, financial difficulties, body image, future perspective, breast symptoms, and arm symptoms. [corrected]

CONCLUSIONS

Disease-free survivors of breast cancer had good HRQoL, which was less affected by the type of treatment than it was by demographic characteristics, time since surgery, comorbidity, fatigue, and depression.

Health-related quality of life in long-term breast cancer survivors: nationwide survey in Denmark

AIM

To investigate health-related quality of life (HRQOL) in a nationally representative sample of long-term breast cancer survivors (BCS) in Denmark.

PARTICIPANTS AND METHODS

An age-stratified random sample of 2,000 female BCS > or = 5 years after primary surgery without recurrence was drawn from the Danish Breast Cancer Cooperative Group register, which is representative regarding long-term BCS in Denmark, and compared with 3,104 women of the nationally representative Danish Health and Morbidity Survey 2000. The Short Form-36 questionnaire assessed HRQOL and its association with BCS' sociodemography, type of surgery, systemic therapy, radiotherapy, time since operation, receptor status, and low/high risk protocol.

RESULTS

The response rate was 79%. BCS tended to rate HRQOL better than the general female population. BCS reported significantly less "bodily pain" (P < 0.0001), better "general health" (P < 0.0001), but worse "mental health" (P < 0.0001). Age interacted significantly with four other subscales (P < 0.05): Younger BCS reported worse HRQOL than equally aged women of the general population, while older BCS reported better HRQOL. Poor HRQOL was significantly associated with being single (all subscales: P < 0.05), short education (all subscales: P < 0.05, except "social function"), and high body mass index ("physical function", "role physical": P < 0.05). Breast cancer (low/high risk, receptor status) and treatment did not affect HRQOL.

CONCLUSION

HRQOL was similar between BCS and women of the general population. Potential long-term effects of breast cancer (low/high risk, receptor status) and treatment did not seem to impact HRQOL. However, predictors for worse HRQOL in BCS were being single, and having a short education.

The usefulness of a multidisciplinary educational programme after breast cancer surgery: A prospective and comparative study

The aim of the study was to compare and evaluate a multidisciplinary educational programme with traditional follow-up visits to a physician after breast cancer surgery in terms of well-being, aspects of self-care and coping ability 1 year after diagnosis. A reduction in the intensity of follow-up after breast cancer surgery is recommended. New follow-up models are being debated and could be of interest. The study design was non-randomised and comparative. Ninety-six consecutively selected women with newly diagnosed breast cancer, classified as stage I or stage II, participated in either a multidisciplinary educational programme (n=50), or traditional follow-up by a physician (n=46). Three questionnaires were used: Functional Assessment of Cancer Therapy-General (FACT-G), a study specific questionnaire regarding self-care aspects (SCA) and Sense of Coherence (SOC). With the exception of physical well-being at baseline there was no significant difference between the groups. The women in the multidisciplinary educational programme increased their physical and functional well-being (P<0.01). The women in traditional follow-up by a physician increased their functional well-being while social/family well-being (P<0.01) decreased over time. There was a statistically significant difference in SOC (P<0.001) in the traditional follow-up by a physician between baseline (mean=74.4, SD=12.4) and the 1-year follow up (mean=67.7, SD=11.4). Thus, women in the traditional follow-up by a physician scored lower in the area of SOC 1 year after diagnosis. A multidisciplinary educational programme may be an alternative to traditional follow-up by a physician after breast cancer surgery, but more research is needed about the financial benefits and effectiveness of such a programme.

The perceived care needs of breast cancer patients in Korea

By analyzing the data of 459 patients who completed the Supportive Care Needs Survey (SCNS), the prevalence, medical and non-medical predictors of unmet needs were investigated. Breast cancer patients in Korea experienced high levels of unmet needs across the needs domains, particularly in the health system and information domain (56.9%). Various medical and non-medical variables were identified as significant predictors of unmet needs in each domain. By multivariate analyses, several predictors were identified across the domains including; less education (< or = 9 years) in the psychologic, chemotherapy, short post-surgical interval, and less education in the physical and daily living, younger age (< 50 years) in the sexuality, larger tumor size (> 2 cm) and younger age in the health system and information, and more education (> or = 13 years) in the care and support domain. The results of this study suggest medical professional should consider the complexity and dynamics of meeting patients' needs in providing supportive care services.

Context moderates illness-induced lifestyle disruptions across life domains: a test of the illness intrusiveness theoretical framework in six common cancers

The illness intrusiveness theoretical framework maintains that illness-induced lifestyle disruptions compromise quality of life in chronic life-threatening conditions and that this effect is moderated by social, psychological, and contextual factors. Considerable evidence indicates that lifestyle disruptions compromise quality of life in cancer and other diseases and that the effects differ across life domains. The hypothesis that contextual factors (e.g. age, education, income, stressful life events) moderate these effects has not been tested extensively. We investigated whether age, income, education, and/or recent stressful life events modify the experience of illness intrusiveness across three central life domains (Relationships and Personal Development, Intimacy, and Instrumental life) in six common cancers. A sample of 656 cancer outpatients with one of six common cancers (breast, prostate, lymphoma, lung, head and neck, and gastrointestinal, all n's>100) completed the Illness Intrusiveness Ratings Scale while awaiting follow-up appointments with an oncologist. Results indicated statistically significant (all p's<0.05) interactions involving each of the hypothesized moderator variables and the Life Domain factor. In each case, greatest divergence was evident when illness intrusiveness involved instrumental life domains (e.g. work, finances, health, and active recreation). The findings substantiate the illness intrusiveness theoretical framework and support its relevance for people with cancer. The psychosocial impact of chronic life-threatening disease differs across life domains and depends on the context in which it is experienced.

Adjustment to cancer in the 8 years following diagnosis: A longitudinal study comparing cancer survivors with healthy individuals

This longitudinal study examined the long-term impact of a diagnosis of cancer on physical and psychological functioning, by comparing 8-year cancer survivors (n = 206) to a randomly selected sample of similar-aged references without cancer (n = 120) in the Netherlands. Comparisons were made at three fixed points in time: 3 months (T1), 15 months (T2), and 8 years (T3) after diagnosis. The results showed that, at 8 years after diagnosis, cancer survivors and references do not differ significantly in the level of depressive symptoms, anxiety, life satisfaction, self-esteem, social support, and marital satisfaction. However, survivors reported more physical symptoms, and those with a recurrence of cancer also reported more limitations in household and social activities. Most improvements in functioning were found in the year following diagnosis. Intriguingly, we found no evidence that cancer survivors experienced more positive changes in the self, relationships, or life in general than references, even though many cancer survivors attributed these changes to the cancer experience. In the discussion, we address the role of finding positive meaning in the process of adjustment to cancer.

Isolated limb perfusion in regional melanoma

Adjuvant perfusion to excision of a primary melanoma cannot be recommended because of its limited effect. In patients who have frequently recur-ring resectable locoregional melanoma, perfusion may provide valuable loco-regional disease control by decreasing the number of recurrences and lesions per recurrence. Randomized studies are needed to further establish the role of perfusion as an adjuvant treatment for resectable recurrences of melanoma. Unresectable limb melanoma is the primary indication for perfusion. Better response rates tend to be seen when TNF-a is used in patients who have a high tumor load. Repeat perfusion is feasible, resulting in response rates similar to those of a first perfusion for locoregional melanoma. Older age itself is not a contraindication for perfusion. The long-term health-related quality of life of survivors of melanoma who underwent treatment with perfusion is comparable to that of their healthy peers in the general Dutch population.

Prospective changes in quality of life after ductal carcinoma-in-situ: results from the Nurses' Health Study

PURPOSE

The incidence of ductal carcinoma-in-situ (DCIS) of the breast has been increasing. However, uncertainties exist about its prognosis, optimal treatment, and effect on women's health-related quality-of-life (HRQoL). Our study assessed the prospective changes in HRQoL in women diagnosed with DCIS.

PATIENTS AND METHODS

Between 1992 and 2000, HRQoL was assessed at three 4-year intervals among women enrolled in two Nurses' Health Study cohorts using the Medical Outcomes Survey Short-Form 36 health survey. Using mixed effects and logistic regression modeling, we compared the prospective changes in HRQoL scores among women with and without DCIS.

RESULTS

The study included 114,728 women; 510 were diagnosed with DCIS during the study period. During 4 years, women with DCIS had small, but statistically significantly greater declines in the domains of role limitations due to physical problems (-6.74; SE, 1.69), vitality (-2.06; SE, 0.78), and social functioning (-2.40; SE, 0.93) than women without DCIS. Among those with DCIS, clinically significant declines were more often observed within 6 months of the diagnosis in the domains of social functioning (odds ratio, 1.78; 95% CI, 1.03 to 3.07) and mental health (odds ratio, 2.03; 95% CI, 1.09 to 3.79) than after 6 months after diagnosis.

CONCLUSION

Women with DCIS experienced small long-term declines in HRQoL, although these declines did not seem to be clinically important. Short-term clinically significant declines in the psychosocial domains were noted. In counseling women with DCIS, clinicians should provide reassurance but prepare them to deal with the short-term sequelae.

Sexual Problems in Younger Women After Breast Cancer Surgery

Purpose

To examine sexual problems in younger women diagnosed with breast cancer during the first year after surgery and to identify sociodemographic, medical, and psychosocial predictors of sexual problems.

Patients and Methods

Women diagnosed with breast cancer age ≤ 50 years completed surveys at three time points: within 24 weeks after initial surgery (baseline), 6 weeks after baseline, and 6 months later. Survey items included the Medical Outcomes Study Sexual Functioning Scale, satisfaction with sex life, feeling sexually attractive, body image, marital satisfaction, quality of life, medical history, symptoms, and sociodemographics. Prediagnosis sexual problems were retrospectively ascertained at the initial survey.

Results

Analyses included 209 women sexually active at baseline (78.6% of total sample). Sexual problems were significantly greater immediately postsurgery compared with retrospective reports before diagnosis (P < .0001). Although problems gradually decreased over time, they were still greater at 1 year postsurgery than before diagnosis. In multivariate analyses controlling for sexual problems at prediagnosis, vaginal dryness, and lower perceived sexual attractiveness were consistently related to greater overall sexual problems. Chemotherapy was related to sexual problems only at baseline except for women who became menopausal as a result of chemotherapy, who continued to have problems.

Conclusion

Findings substantiate the need to address potential sexual problems related to chemotherapy treatment and menopause among younger breast cancer survivors and to counsel women about possible remedies, particularly for vaginal dryness. Increasing feelings of sexual attractiveness may also help sexual problems, especially among women for whom these feelings were altered by surgery or treatment.

A population-based study of the quality of life of cancer survivors and their family caregivers

Although survival rates for all cancers continue to increase, few studies have examined the quality of life of both cancer survivors and family caregivers during the survivorship period after treatment has ended. Information is lacking on the stressors, resources, meaning, and quality of life reported by survivors and family caregivers and the interrelationship between survivors' and family caregivers' quality of life. A stratified, random sample of 123 cancer survivors and 123 family caregivers (N = 246) were interviewed in an exploratory, cross-sectional design 1-6 years after cancer treatment had ended. Approximately half (N = 62) of the dyads were white and half (N = 61) were African American. Results indicated that cancer survivors reported significantly higher quality of life, less fear of cancer recurrence, and more support than their family caregivers. The strongest predictors for cancer survivors' quality of life were family stressors, social support, meaning of the illness, and employment status, whereas the strongest predictors for family caregivers' quality of life were fear of recurrence and social support. Both the survivor's and family caregiver's quality of life independently contributed to the other's quality of life. Findings from this study suggest the importance of including both survivors and family caregivers in programs of care.

Functional limitations in elderly female cancer survivors

BACKGROUND

The elderly population, including many who are long-term cancer survivors, is increasing. Aspects of quality of life in elderly cancer survivors are not well understood.

METHODS

Subjects were women who enrolled in a population-based cohort study in 1986. At follow-up in 1997, 25,719 women, at a median age of 72 years, reported on functional limitations. We used logistic regression to calculate prevalence odds ratios (ORs) and proportional hazards regression to calculate prevalence ratios (PRs) for associations between cancer survivor status and functional limitations, adjusting for baseline (precancer) characteristics including obesity, smoking, and diabetes.

RESULTS

Women who were cancer survivors for less than 2 years reported the most functional limitations, but long-term (5 or more years) cancer survivors remained more likely than cohort members who had not had cancer to report that they were unable to do heavy household work (42% of 1068 5-year survivors, versus 31% of 23 501 who never had cancer, multivariable OR = 1.47, 95% confidence interval [CI] = 1.27 to 1.69; PR = 1.22, 95% CI = 1.10 to 1.34), unable to walk a half mile (26% versus 19%, OR = 1.31, 95% CI = 1.1 to 1.54; PR = 1.16, 95% CI = 1.02 to 1.32), and unable to walk up and down stairs (9% versus 6%, OR = 1.34, 95% CI = 1.05 to 1.72; PR = 1.25, 95% CI = 1.00 to 1.56). The increased prevalence of functional limitations was apparent for 5-year survivors of breast cancer and also certain other cancers.

CONCLUSIONS

Our findings support the need to target elderly cancer survivors for interventions to maintain or regain physical function.

Association of ginseng use with survival and quality of life among breast cancer patients

The authors evaluated the associations of ginseng use as a complementary therapy with survival and quality of life (QOL) in a cohort of 1,455 breast cancer patients who were recruited to the Shanghai Breast Cancer Study between August 1996 and March 1998 in Shanghai, China. Patients were followed through December 2002. Information on ginseng use before cancer diagnosis was collected at baseline recruitment and was linked to survival. Survivors' ginseng use after cancer diagnosis was obtained at the follow-up survey and was correlated to QOL at the same time. The Kaplan-Meier method and Cox regression models were applied to evaluate the association of ginseng use with overall and disease-free survival. The relation of ginseng use and QOL was evaluated by using multiple linear regression models. Approximately 27% of study participants were regular ginseng users before cancer diagnosis. Compared with patients who never used ginseng, regular users had a significantly reduced risk of death; adjusted hazard ratios associated with ginseng use were 0.71 (95% confidence interval: 0.52, 0.98) for total mortality and 0.70 (95% confidence interval: 0.53, 0.93) for disease-specific mortality/recurrence. Ginseng use after cancer diagnosis, particularly current use, was positively associated with QOL scores, with the strongest effect in the psychological and social well-being domains. Additionally, QOL improved as cumulative ginseng use increased.

Population-based study of the relationship of treatment and sociodemographics on quality of life for early stage breast cancer

OBJECTIVE

To examine the relationship between cancer stage, surgical treatment and chemotherapy on quality of life (QOL) after breast cancer and determine if sociodemographic characteristics modify the observed relationships.

METHODS

A population-based sample of women with Stages 0-II breast cancer in the United States (N = 1357) completed surveys including the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30), and the Breast Cancer-Specific Quality of Life Questionnaire (QLQ BR-23). Regression models calculated mean QOL scores across primary surgical treatment and chemotherapy. Clinically significant differences in QOL were defined as > or = 10 point difference (out of 100) between groups.

RESULTS

Meaningful differences in QOL by surgical treatment were limited to body image with women receiving mastectomy with reconstruction reporting lower scores than women receiving breast conserving surgery (p < 0.001). Chemotherapy lowered QOL scores overall across four QOL dimensions (p values < 0.001), with a disproportionately greater impact on those with lower levels of education. Younger women reported lower QOL scores for seven of nine QOL dimensions (p values < 0.001).

CONCLUSIONS

Women should be reassured that few QOL differences exist based on surgical treatment, however, clinicians should recognize that the impact of treatment on QOL does vary by a woman's age and educational level.

Contentment With Quality of Life Among Breast Cancer Survivors With and Without Contralateral Prophylactic Mastectomy

Purpose

To understand psychosocial outcomes after prophylactic removal of the contralateral breast in women with unilateral breast cancer.

Methods

We mailed surveys to women with contralateral prophylactic mastectomy after breast cancer diagnosis between 1979 and 1999 at six health care delivery systems, and to a smaller random sample of women with breast cancer without the procedure. Measures were modeled on instruments developed to assess contentment with quality of life, body image, sexual satisfaction, breast cancer concern, depression, and health perception. We examined associations between quality of life and the other domains using logistic regression.

Results

The response rate was 72.6%. Among 519 women who underwent contralateral prophylactic mastectomy, 86.5% were satisfied with their decision; 76.3% reported high contentment with quality of life compared with 75.4% of 61 women who did not undergo the procedure (P = .88). Among all case subjects, less contentment with quality of life was not associated with contralateral prophylactic mastectomy or demographic characteristics, but was associated with poor or fair general health perception (odds ratio [OR], 7.0; 95% CI, 3.4 to 14.1); possible depression (OR, 5.4; 95% CI, 3.1 to 9.2); dissatisfaction with appearance when dressed (OR, 3.5; 95% CI, 2.0 to 6.0); self-consciousness about appearance (OR, 2.0; 95% CI, 1.1 to 3.7); and avoiding thoughts about breast cancer (modest: OR, 2.2; 95% CI, 1.1 to 4.5; highest: OR, 1.7; 95% CI, 0.9 to 3.2).

Conclusion

Most women undergoing contralateral prophylactic mastectomy report satisfaction with their decision and experience psychosocial outcomes similar to breast cancer survivors without the procedure.

Taking CHARGE: A self-management program for women following breast cancer treatment

The purpose of the study was to develop and evaluate Taking CHARGE, a self-management intervention designed to facilitate successful transitions to survivorship after breast cancer treatment. The Taking CHARGE intervention involves a two-pronged approach building on self-regulation principles to (1) equip women with self-management skills to address concerns following breast cancer treatment, and (2) provide information about common survivorship topics. The program involved four intervention contacts, two small group meetings and two individualized telephone sessions, delivered by nurse/health educators. This paper focuses on the process evaluation findings from a preliminary test of the Taking CHARGE intervention conducted with 25 women, aged 34-66 years, completing breast cancer treatment, who were randomly assigned to the intervention group. The process evaluation was conducted to obtain systematic information about the relevance and usefulness of the self-regulation approach, informational aspects, and program delivery. The findings indicated that intervention group participants found the Taking CHARGE program to be timely, relevant, and to have high utility in dealing with concerns that exist following breast cancer treatment. The process evaluation findings provide early evidence of the usefulness of the Taking CHARGE intervention for successful transition to survivorship following breast cancer treatment.

The Influence of Endocrine Effects of Adjuvant Therapy on Quality of Life Outcomes in Younger Breast Cancer Survivors

SIGNIFICANCE

There are 2.2 million breast cancer survivors, and approximately 25%-30% of newly diagnosed women each year are <50 years of age. Adjuvant therapy has prolonged survival, but the quality of that survival is influenced by persistent and late effects of therapy. Knowledge of treatment outcomes will assist in the design of interventions to prevent or manage persistent and late effects in survivors.

PURPOSE

The purpose of this paper is to review the incidence of gonadal toxicity associated with adjuvant chemotherapy, side effects of endocrine therapy, quality of life outcomes, fertility concerns, and options to preserve fertility in young (<35 years) and young midlife (35-50 years) breast cancer survivors.

RESULTS

Alkylating agent-based chemotherapy causes destruction of primordial follicles and impairment of follicular maturation resulting in temporary preservation of menses, reversible amenorrhea, irregular menses (perimenopause), or irreversible amenorrhea (ovarian failure--menopause). Younger women have a lower risk for amenorrhea with chemotherapy because of sufficient follicular stores, although the gonadal toxicity will result in an earlier than expected menopause. Premature menopause is associated with poorer quality of life, decreased sexual functioning, menopausal symptom distress, psychosocial distress related to fertility concerns, infertility, and uncertainty about late effects of premature menopause. Routine discussion about the menopausal experience, risks for infertility, and fertility preservation options is recommended.

IMPLICATIONS FOR PRACTICE

This review identified adverse treatment outcomes for young and young midlife breast cancer survivors that can be minimized or prevented with targeted interventions.

Health behaviors during and after a cancer diagnosis

With improvements in cancer survival rates, more patients with cancer are living longer, and hence, cancer is becoming viewed as a chronic illness requiring long-term management. An important aspect of patient care during and after cancer treatment is patient health behaviors. For example, sequelae from various cancer treatments, such as chemotherapy and radiotherapy (RT), can compromise health in a variety ways, including decreased immune functioning, cardiotoxic effects of chemotherapy and/or RT, and weight gain. In addition, the stress caused by a cancer diagnosis and its treatment can disrupt existing health behaviors or exacerbate unhealthy behaviors. Continued smoking or alcohol use can complicate treatment and increase risk for further malignancy. Furthermore, decreased physical activity and poor nutrition can cause weight gain, which may contribute to secondary health problems such as cardiovascular disease and diabetes. The authors reviewed the extant literature on four key health behaviors among patients with cancer and survivors: healthy diet, reduced tobacco use, reduced alcohol use, and increased physical activity. They described the prevalence of these behaviors, reviewed the effects of interventions designed to alter unhealthy behaviors, and discussed the implications and future directions for this emerging area of research.

Health-related quality of life in long term breast cancer survivors treated with breast conserving therapy: impact of age at therapy

PURPOSE

Aim was to compare the functional status in long-term breast cancer survivors related to age at diagnosis and to asses the effects of adjuvant therapy on health-related quality of life (HRQoL).

PATIENTS AND METHODS

Data were obtained from 370 patients after breast conserving therapy (BCT) at follow-up (F/U) visit. The self-administered EORTC QoL questionnaire (C30) and the breast module (QLQ-BR23) measuring global health, global QoL, physical, role, emotional, cognitive and social functioning, body image, sexual function, future perspective and arm/breast symptoms were used. Patients were grouped according to F/U (12 years, 7 years), age at therapy (< 50 years, 50-65 years, >65 years) and adjuvant treatment (none, chemotherapy, hormone replacement therapy).

RESULTS

The global HRQoL was increased in patients with longer F/U (p < 0.01). Physical functioning, role functioning and sexual functioning were decreased in patients being older at therapy (> 65 years, p < 0.01). Increased arm symptoms were noticed in older women at longer follow-up. Younger women at therapy complained financial difficulties at follow-up (p < 0.006). Adjuvant chemotherapy and hormone replacement therapy did not affect physical and mental functioning.

CONCLUSION

Women of different age treated with BCT for breast cancer should be considered at a different risk for HRQoL disturbance at long term F/U in both, physical and psychological dimensions. In clinical practice, specific identification of those women with negative impact of diagnosis and treatment on long term HRQoL would help for targeted interventions. In clinical studies focusing on HRQoL, the compared groups need to be age-adjusted.

A qualitative study of work and work return in cancer survivors

Few studies have examined the impact of cancer on the survivor's quality of work life. The purpose of this qualitative study is to describe the work experiences among a diverse group of cancer survivors and to explore factors influencing decisions about work after cancer diagnosis and treatment. We interviewed 28 participants with a broad range of socioeconomic backgrounds and primary cancer sites. Qualitative results indicate that after learning about their cancer diagnosis, participants had diverse and complex patterns of work return and work change, and experienced a variety of factors that influenced post-cancer decisions. Experiences at work after cancer also varied in relation to how others responded, changes in productivity, effects of cancer and treatment on work, and feelings about work. Most respondents received little guidance from their physicians about work, and many participants described their cancer as impacting their priority of work relative to other aspects of their lives. Our findings reinforce the complexity of measuring employment outcomes and the range of adaptations made to improve the quality of work life. Additional research is needed to identify prognostic factors that can guide clinical or workplace efforts to restore cancer survivors to their desired level of work function and economic productivity.

Randomized trial of long-term follow-up for early-stage breast cancer: a comparison of family physician versus specialist care

PURPOSE

Most women with breast cancer are diagnosed at an early stage and more than 80% will be long-term survivors. Routine follow-up marks the transition from intensive treatment to survivorship. It is usual practice for routine follow-up to take place in specialist clinics. This study tested the hypothesis that follow-up by the patient's family physician is a safe and acceptable alternative to specialist follow-up.

PATIENTS AND METHODS

A multicenter, randomized, controlled trial was conducted involving 968 patients with early-stage breast cancer who had completed adjuvant treatment, were disease free, and were between 9 and 15 months after diagnosis. Patients may have continued receiving adjuvant hormonal therapy. Patients were randomly allocated to follow-up in the cancer center according to usual practice (CC group) or follow-up from their own family physician (FP group). The primary outcome was the rate of recurrence-related serious clinical events (SCEs). The secondary outcome was health-related quality of life (HRQL).

RESULTS

In the FP group, there were 54 recurrences (11.2%) and 29 deaths (6.0%). In the CC group, there were 64 recurrences (13.2%) and 30 deaths (6.2%). In the FP group, 17 patients (3.5%) compared with 18 patients (3.7%) in the CC group experienced an SCE (0.19% difference; 95% CI, -2.26% to 2.65%). No statistically significant differences (P < .05) were detected between groups on any of the HRQL questionnaires.

CONCLUSION

Breast cancer patients can be offered follow-up by their family physician without concern that important recurrence-related SCEs will occur more frequently or that HRQL will be negatively affected.

Testing a model of symptoms, communication, uncertainty, and well-being, in older breast cancer survivors

Among older, long-term breast cancer survivors, symptoms from previous treatment can generate uncertainty about whether they represent co-morbid conditions, recurrence, or normal aging. This uncertainty can result in emotional distress and thoughts of recurrence. Communication with health care providers may help women reduce uncertainty and improve both emotional and cognitive well-being. To assess the influence of symptoms, uncertainty, and communication with providers on well-being, data from 203 Caucasian and African American survivors, 5-9 years post treatment, were tested using structural equation modeling. Symptoms, age, and uncertainty had the strongest influence on well-being, regardless of race. There was an unexpected positive association between patient-provider communication and thoughts of recurrence. Descriptive analysis revealed that 52% of women were unable to achieve their desired decision-making role with health care providers.

Psychological responses to cancer recurrence

BACKGROUND

There is a dearth of knowledge regarding the psychological responses to a diagnosis of cancer recurrence.

METHODS

An ongoing randomized clinical trial provided the context for prospective study. Women with Stage II/III breast carcinoma (N = 227) were initially assessed after their diagnosis/surgery and before adjuvant therapy and then reassessed every 6 months. Eight years into the trial, 30 patients had recurred (R) and were assessed shortly after receiving their second diagnosis. Their data were compared with a sample of trial patients who had no evidence of disease (disease free [DF]; n = 90). The groups were matched on study arm, disease stage, estrogen receptor status, menopausal status, and time since initial diagnosis.

RESULTS

As hypothesized, patients' cancer-specific stress at recurrence in the R group was higher (P < 0.05) than stress levels for the DF group at the equivalent point in time. Importantly, the R group reported stress for their recurrent diagnosis equivalent to that reported for their initial diagnosis. Identical results were found for measures of health status and symptomatology. In contrast, analyses for emotional distress and social functioning showed no pattern of disruption for the R group at cancer recurrence and levels equivalent to that of the DF group.

CONCLUSIONS

To the authors' knowledge, this was the first controlled, prospective psychological analysis of patients' responses to cancer recurrence. The findings were consistent with a learning theory conceptualization of the cancer stressor. Patients' stress was "compartmentalized" and did not, at least in the early weeks, result in diffuse emotional distress and quality of life disruption, underscoring the resilience of patients when confronted with cancer recurrence.

Psychosocial effect of mastectomy versus conservative surgery in patients with early breast cancer

PURPOSE

To compare the quality-of-life (QoL) and psychosocial changes in a group of patients with early breast cancer who underwent conservative surgery (BCS) or modified radical mastectomy(MRM).

METHODS

Self-administered questionnaire assessing body image perception, social habits, sexual attraction and self-consciousness with relatives/friends, was randomly assigned to 125 patients (61 BCS, 64 MRM; aged 53 +/- 8 and 50 + 9 years, respectively, p = NS).

RESULTS

MRM patients reported a significantly higher frequency of changes in body image perception and other related social behaviour such as avoiding going to the beach or using low-cut clothes, and reticence with friends. Conversely, no differences were found regarding sexuality, denial of the disease by the husband/partner, or concealing the disease from family members. Also, no significant differences were found between patients above and below the age of 50 years, for all variables studied after adjustment for surgical procedure.

CONCLUSIONS

Modified radical mastectomy has a negative effect on body image perception and in social behaviour patterns of patients and with a concomitant decrease in QoL. The sexuality of the patient is not significantly affected.

Work absence after breast cancer diagnosis: a population-based study

BACKGROUND

Absence from work after breast cancer diagnosis may be part of the burden of disease for women with cancer, but little research has addressed this. We examined work absences of 4 weeks or more among women who had had breast cancer during the 3 years after diagnosis and compared their absences with those of women who had never had cancer.

METHODS

Our 2 target study groups were women in Quebec 18-59 years of age who were working when they first received therapy for breast cancer between November 1996 and August 1997 and similarly aged women randomly selected from provincial health care files who had never had cancer and were working at the time of diagnosis in women who had cancer. We interviewed 646 women who had had breast cancer (73% of those eligible) and 890 women in the comparison group (51% of those eligible) by telephone 3 years after first diagnosis.

RESULTS

One year after diagnosis, 85% (459/541) of breast cancer survivors who remained free of disease during the 3-year study period were absent from work for 4 weeks or more compared with 18% (156/881) of healthy women (geometric mean total duration 5.6 v. 1.7 months, p < 0.001). By the third year, disease-free women were not absent more than women in the comparison group; however, more women who had experienced any new cancer event continued to be absent from work and to be absent from work for longer periods of time. Receiving adjuvant chemotherapy prolonged absence duration (9.5 v. 5.4 months among women not receiving chemotherapy). Compared with survivors belonging to a union, those who did not belong to a union (multivariate relative risk [RR] 7.54, 95% confidence interval [CI] 3.02-18.83) and those who were self-employed (RR 13.95, 95% CI 5.53-35.21) were more likely to report no work absence.

INTERPRETATION

Most of the women with breast cancer took time off work (almost 6 months on average) after receiving the diagnosis. Three years after diagnosis, breast cancer survivors who remained disease-free--a large proportion of women with nonmetastatic breast cancer--were not absent from work more often or for longer periods of time than other working women.

Traumatic stress, perceived global stress, and life events: prospectively predicting quality of life in breast cancer patients

The authors investigated the relationship between stress at initial cancer diagnosis and treatment and subsequent quality of life (QoL). Women (n = 112) randomized to the assessment-only arm of a clinical trial were initially assessed after breast cancer diagnosis and surgery and then reassessed at 4 months (during adjuvant treatment) and 12 months (postadjuvant treatment). There were 3 types of stress measured: number of stressful life events (K. A. Matthews et al., 1997), cancer-related traumatic stress symptoms (M. J. Horowitz, N. Wilner, & W. Alvarez, 1979), and perceived global stress (S. Cohen, T. Kamarck, & R. Mermelstein, 1983). Using hierarchical multiple regressions, the authors found that stress predicted both psychological and physical QoL (J. E. Ware, K. K. Snow, & M. Kosinski, 2000) at the follow-ups (all ps < .03). These findings substantiate the relationship between initial stress and later QoL and underscore the need for timely psychological intervention.

Informational and emotional needs of long-term survivors of breast cancer

AIMS

This paper presents a review of the informational and emotional needs of long-term breast cancer survivors, with particular attention to the different needs of women according to their age and to critiquing healthcare provision to these women.

BACKGROUND

Women with a history of breast cancer are the largest group of cancer survivors. While they may be disease-free, their cancer diagnosis has ongoing physical and psychosocial implications for their lives and well-being.

METHODS

A literature search for the period 1985 to March 2004 was undertaken using the CINAHL, MEDLINE, CANCERLIT, PubMed and CUIDEN databases and the keywords long-term, breast cancer survivors, needs and social support. Hand-searching was also done, and reference lists of papers were examined for relevant studies.

RESULTS

Survivors of breast cancer continue to experience informational and emotional needs during their long-term survivorship, and variation in the amount and type of support required is age-related. However, women's needs are often unmet by oncology teams and they have to find other sources of support, such as self-help groups. Thus, ongoing care is required after completion of medical treatment, and nurses have a significant contribution to make here.

CONCLUSIONS

Nursing research on long-term breast cancer survivorship is limited. Future studies need to investigate the unmet needs of long-term survivors of breast cancer and, specifically, explore the kind of support women would like to receive from oncology teams, and particularly from breast cancer nurses.

Triggers of uncertainty about recurrence and long-term treatment side effects in older African American and Caucasian breast cancer survivors

PURPOSE/OBJECTIVES

To examine the sources of uncertainty in older African American and Caucasian long-term breast cancer survivors by focusing on frequency of triggers of uncertainty about cancer recurrence and physical symptoms linked to long-term treatment side effects.

DESIGN

In the context of a larger randomized, controlled treatment-outcome study, data were gathered from 10 monthly follow-up telephone calls by nurses.

SETTING

Rural and urban regions of North Carolina.

SAMPLE

244 older women (mean age = 64 years); 73 African American women and 171 Caucasian women who were five to nine years after breast cancer diagnosis.

FINDINGS

The most frequent triggers were hearing about someone else's cancer and new aches and pains. The most frequent symptoms were fatigue, joint stiffness, and pain. Although no ethnic differences occurred in the experience of symptoms, Caucasian women were more likely than African American women to report that their fears of recurrence were triggered by hearing about someone else's cancer, environmental triggers, and information or controversy about breast cancer discussed in the media.

CONCLUSIONS

Illness uncertainty persisted long after cancer diagnosis and treatment, with most women experiencing multiple triggers of uncertainty about recurrence and a range of symptoms and treatment side effects.

IMPLICATIONS FOR NURSING

Nurses can help cancer survivors to identify, monitor, and manage illness uncertainty and emotional distress.

Surviving cancer: a comparison of 5-year disease-free breast cancer survivors with healthy women

Women with breast cancer are one of the largest groups of cancer survivors. This research examined whether breast cancer has a long-term impact on quality of life (QOL) by comparing 5-year disease-free survivors to age-matched controls and by comparing women who sustained a recurrence to disease-free survivors. Controls were recruited using the neighborhood control methodology. QOL (physical, emotional, social, and spiritual) was assessed during in-person interviews. There were no differences between disease-free survivors (n = 267) and controls (n = 187) on many indicators of QOL. However, survivors reported more difficulties with physical functioning, more physical symptoms, and more faith than did controls (all ps < 0.05). Compared to disease-free survivors, survivors with a recurrence (n = 37) had a worse QOL on most indices, less positive affect, more general fatigue, and more intrusive and avoidant thoughts (all ps < 0.05). There were no differences between the two groups of survivors on indices of marriage, work experiences, or spirituality. These findings suggest that the QOL of long-term survivors who remain disease-free is comparable to that of women their age with the exception of physical functioning. Women who sustain a recurrence suffer an impaired QOL in some, but not all, domains.

Assessing quality of life in adult cancer survivors (QLACS)

This article describes development of a quality of life measure designed to assess issues relevant to long-term cancer survivors. In-depth semi-structured interviews were conducted with 58 long-term cancer survivors to identify domains most relevant to long-term survivors (> or = 5 years post-diagnosis). Self-report items were developed from these interviews and administered to a second sample of 242 long-term survivors. Domains and items were selected from the item pool by a combination of factor analysis and criterion-based item selection. Five cancer-specific domains were identified (appearance concerns, financial problems, distress over recurrence, family-related distress, and benefits of cancer) along with seven generic QOL domains (negative feelings, positive feelings, cognitive problems, sexual problems, physical pain, fatigue, and social avoidance). Cronbach's alpha was 0.72 or greater for each domain. Correlations between domain scores and criterion measures were 0.72 or higher in all but one generic domain (social avoidance), but somewhat lower on cancer-specific domains. The new multidimensional measure has good internal consistency and validity and is appropriate for comparisons between cancer and non-cancer populations, as well as long-term follow-up of cancer patients.

Persistence of Restrictions in Quality of Life From the First to the Third Year After Diagnosis in Women With Breast Cancer

Purpose

To assess whether detriments in quality of life (QOL) among women with breast cancer persist over years.

Patients and Methods

QOL was assessed in a population-based cohort of 314 women with breast cancer from Saarland (Germany) 1 and 3 years after diagnosis and compared internally and with reference data from the general population.

Results

Three years after diagnosis, deficits in QOL were still apparent for role, emotional, cognitive, and social functioning and for the symptoms of insomnia, fatigue, dyspnea, and financial difficulties. Differences between breast cancer patients and women from the general population were predominantly found in younger ages. Compared with the QOL scores measured 1 year after diagnosis, only minor functional changes were observed, but recurrence of breast cancer during the follow-up interval had a deleterious effect on QOL.

Conclusion

Deficits in role, emotional, cognitive, and social functioning persist over years in women with breast cancer and predominantly affect younger patients.

Fatigue, sleep, and circadian rhythms prior to chemotherapy for breast cancer

GOALS

Previous investigations have shown that women undergoing chemotherapy for breast cancer experience both disturbed sleep and fatigue. However, most of the previous research examined women either during or after chemotherapy. This study examined sleep, fatigue, and circadian rhythms in women with breast cancer before the start of chemotherapy.

PATIENTS AND METHODS

Eighty five women with Stages I-IIIA breast cancer who were scheduled to begin adjuvant or neoadjuvant anthracycline-based chemotherapy participated. Each had sleep/wake activity recorded with actigraphy for 72 consecutive hours and filled out questionnaires on sleep, fatigue, depression, and functional outcome.

MAIN RESULTS

On average, the women slept for about 6 h a night and napped for over an hour during the day. Sleep was reported to be disturbed and fatigue levels were high. Circadian rhythms were robust, but women who were more phase-delayed reported more daily dysfunction (p<0.01).

CONCLUSIONS

The data from the current study suggest that the women with breast cancer likely experience both disturbed sleep and fatigue before the beginning of chemotherapy. Although their circadian rhythms are robust, breast cancer patients with more delayed rhythms experience more daily dysfunction secondary to fatigue. These data suggest that strategies to improve disturbed sleep and to phase-advance circadian rhythms prior to initiation of chemotherapy may be beneficial in improving daily function in breast cancer patients.

Predictors of quality of life in women with a bilateral prophylactic mastectomy

The purpose of this study was to assess the quality of life in women who had previously undergone a bilateral prophylactic mastectomy and to determine what factors predict quality of life in this population. Women in Ontario who had undergone prophylactic mastectomy between 1991 and 2000 were asked to complete several questionnaires that assessed current psychosocial functioning, including the Quality of Life Index (QLI). The mean score for the QLI was 23.34 (range 9.53-30.00). QLI scores were negatively correlated with cancer-related distress, body image difficulties, and psychological distress. Conversely, QLI scores were positively correlated with social support. Significant predictors of quality of life included psychological distress and one subscale of body image (vulnerability). Vulnerability and psychological distress are important predictors of quality of life in women who have previously undergone bilateral prophylactic mastectomy.

Comparing SF-36 scores across three groups of women with different health profiles

BACKGROUND

The widespread use of the Medical Outcomes Study (MOS) 36-item Short-Form Health Survey (SF-36) facilitates the comparison of health-related quality of life (HRQL) across independent studies.

OBJECTIVES

To compare the scores of eight scales and two summary scales of the SF-36 across participants in the Women's Healthy Eating and Living (WHEL) trial, the Women's Health Initiative-Dietary Modification trial (WHI-DM), and the MOS, and to illustrate the use of effect sizes for interpreting the importance of group differences.

METHODS

WHEL and WHI-DM are both multi-center dietary interventions; only data from the UC Davis sites were used in our study. WHEL participants had a recent history of breast cancer, WHI-DM participants were healthy, postmenopausal women, and women in the MOS had a history of hypertension, diabetes, heart disease, or depression. General linear models were used to identify statistically significant differences in scale scores. Meaningful differences were determined by effect sizes computed using a common within-group standard deviation (SD) and SDs from normative data.

RESULTS

After adjusting for age and marital status, SF-36 scores for the WHI-DM and WHEL samples were similar and both had statistically significantly higher scores than the MOS sample. Relative to the WHEL or WHI-DM studies, MOS scores for scales related to the physical domain were clearly meaningfully lower whereas scale scores related to the mental health domain were potentially meaningfully lower.

CONCLUSIONS

The HRQL of breast cancer survivors is comparable to that of healthy women and better than that of women with chronic health conditions, particularly with respect to physical health. This study illustrated the use of ranges of effects sizes for aiding the interpretation of SF-36 scores differences across independent studies.

Couples Who Get Closer After Breast Cancer: Frequency and Predictors in a Prospective Investigation

Purpose

Although some couples report an improved relationship since coping with breast cancer together, little quantitative information exists about this phenomenon. We assessed extent to which both couple members report that breast cancer brought them closer and characteristics that predicted this.

Patients and Methods

This prospective study was based on all women with newly diagnosed nonmetastatic disease first treated during recruitment in four Quebec hospitals, in addition to their spouses. Participation was 87% among eligible patients and 91% among spouses of participating patients. Both couple partners were interviewed individually about quality of life at 2 weeks and 3 and 12 months after treatment start. At 12 months, each was asked whether the disease had brought them closer, distanced them, or had no effect.

Results

Overall, 42% of the 282 couples said breast cancer brought them closer, 6% had one or other partner reporting feeling distanced, and less than 1% of couples had both partners reporting feeling distanced. Characteristics assessed explained 31% of variance in the proportion of couples getting closer (P < .0001). After taking into account partners' prediagnosis characteristics and the woman's treatment, the spouse reporting the patient as confidant (P = .003), getting advice from her in the first 2 weeks about coping with breast cancer (P = .03), accompanying her to surgery (P = .057), the patient's reporting more affection from her spouse at 3 months since diagnosis (P = .003) predicted both partners saying the disease brought them closer.

Conclusion

Breast cancer can be a growth experience for couples under certain conditions. This information may help reassure patients and their spouses confronting this disease.

Work and retirement after cancer diagnosis

A pilot telephone survey was administered to 253 cancer survivors, ages 35-75, 5-7 years after their diagnosis of breast, colorectal, lung, or prostate cancer. These survivors reported their demographic characteristics and, if they had retired, reasons for retirement and their impression of the retirement experience. Retirees were older, had less education and lower incomes, and fewer had health insurance through their current/former employer relative to employed survivors. Those who had retired, regardless of whether they retired before or after a cancer diagnosis, were similar in age, race/ethnicity, health insurance status, household income, and impressions of retirement. The results suggest that cancer may not negatively affect survivors' decision to retire or the quality of the retirement experience.

Perceived partner reactions to diagnosis and treatment of breast cancer: impact on psychosocial and psychosexual adjustment

Two studies examined breast cancer patients' perceptions of their partners' reactions to their diagnosis and treatment as influences on 3 aspects of patients' well-being: psychosexual adjustment, emotional distress, and marital satisfaction. Study 1, cross-sectional, indicated that partner initiation of sex, frequency of sex, a positive 1st sexual experience after treatment, and especially perception of the partner's emotional involvement in the relationship, were relevant to these outcomes. Study 2, longitudinal, confirmed many of these findings in prospective tests across 1 year of recovery after surgery. Partner involvement prospectively predicted all 3 outcomes. Partner initiation of sex predicted greater marital satisfaction; partner adverse reaction to the scar predicted less marital satisfaction. Rated quality of the 1st sexual experience after treatment predicted less distress. The pattern suggests that women's impressions of their partners' emotional involvement after surgery for breast cancer forecast their adjustment in sexual, marital, and emotional arenas over the following year.

Anxiety and quality of life of women who receive radiation or chemotherapy for breast cancer

PURPOSE/OBJECTIVES

To examine quality of life (QOL) and anxiety in a sample of women receiving radiation or chemotherapy for breast cancer.

DESIGN

Longitudinal, descriptive.

SETTING

A cancer center in the southeastern United States.

SAMPLE

48 women participated; 17 received radiation and 31 received chemotherapy.

METHODS

The Ferrans and Powers Quality of Life Index (QLI) and Speilberger's State-Trait Anxiety Inventory (STAI) were administered. The QLI was administered at the start of treatment and one year later. The STAI was administered at the start of treatment. The state portion of the STAI also was administered 4 weeks and 12 weeks after the start of treatment.

MAIN RESEARCH VARIABLES

QOL and anxiety.

FINDINGS

Total QOL improved significantly over time for the entire sample, as did scores on the health/functioning, psychological/spiritual, and family subscales of the QLI. No significant differences existed for total QOL or any subscales by treatment. Trait anxiety was significantly higher for women receiving chemotherapy, and state anxiety was significantly higher at all three measurement times for the women. State anxiety did not decrease significantly over the course of the treatment for either group. Trait anxiety and state anxiety at the start of treatment were significantly negatively correlated with total QLI score and the psychological/spiritual subscale. State anxiety at the start of treatment also was significantly negatively correlated with total QOL and the health/functioning and psychological/spiritual QLI subscales both at the start of treatment and one year later.

CONCLUSIONS

QOL improves over time for women who have received radiation or chemotherapy. Women receiving chemotherapy have higher anxiety scores, and higher anxiety at the start of treatment is associated with decreased QOL at the start of treatment and postdiagnosis.

IMPLICATIONS FOR NURSING

Nursing interventions to reduce anxiety at the start of treatment, especially for chemotherapy recipients, are indicated. Research also should target methods to reduce anxiety at the start of treatment.

Discussions regarding reproductive health for young women with breast cancer undergoing chemotherapy

PURPOSE

Young women who undergo chemotherapy for breast cancer face serious consequences to their reproductive health. Research in this area has previously focused on men, or on childhood cancer survivors. We sought to explore self-report of reproductive health counseling in young women undergoing chemotherapy for breast cancer.

PATIENTS AND METHODS

A total of 166 premenopausal women aged < or = 50 years were recruited from oncology offices in academic and private practices in four northeastern states, as part of a randomized controlled clinical trial aimed at stress reduction. Women were asked a variety of questions regarding diagnosis and treatment, including whether they received any counseling regarding early menopause and fertility issues.

RESULTS

Sixty-eight percent and 34% of women reported recalling a discussion with a physician regarding early menopause or fertility, respectively. In multivariate analysis, hormonal therapy and early stage of disease were associated with significantly increased odds of recall of a discussion regarding menopause. Difficulty communicating with medical team was associated with increased odds of recalling a discussion regarding fertility, whereas older age and anxiety in medical situations were associated with decreased odds.

CONCLUSION

Many women fail to recall discussions regarding the reproductive health impact of chemotherapy. Demographic, psychological, and disease-related variables are related to recalling such discussions. Counseling about premature menopause and fertility changes is an overlooked aspect of preparation for adjuvant chemotherapy in young premenopausal women with breast cancer. Future research should explore this issue further.

Investment in body image among patients diagnosed with or at risk for malignant melanoma

We examined investment in body image among 48 patients diagnosed with, or at risk for malignant melanoma (MM), as well as factors hypothesized as related to increased investment, such as gender, perceived stress, mood, fatigue, and personality characteristics. Investment in body image was evaluated using the Measure of Body Apperception [Carver, C. S., Pozo-Kaderman, C., Price, A. A., Noriega, V., Harris, S. D., Derhagopian, R. S., Robinson, D. S., & Moffat, F. L. Jr. (1998). Concern about aspects of body image and adjustment to early state breast cancer. Psychosomatic Medicine, 60, 168-174]. Results showed that women reported more concerns about physical appearance than men, and patients with MM exhibited more concerns about body integrity than at-risk patients. Concerns about body integrity were related to more compulsive personality characteristics, whereas concerns about appearance were associated with more histrionic personality characteristics. Body image investment was related to poorer adjustment as indicated by heightened symptoms of fatigue and stress. This study suggests that further research on investment in body image in this patient population is warranted.

The contextual model of HRQoL: A paradigm for expanding the HRQoL framework

Cancer is the second leading cause of death in most US populations. Unfortunately, ethnic minority status is associated with increased later stage at diagnosis, greater incidence for many cancer sites, differential treatments, greater mortality and morbidity. The government and public health focus on health disparities, evident in several documents including Healthy People 2010, Unequal Treatment and the Nation's Investment in Cancer Research, are spurring interest in research with ethnic minority populations. Research investigating the health-related quality of life (HRQoL) among ethnic minority cancer survivors is new and growing. However, there is a dearth of research that addresses theoretical frameworks in cross cultural research. In conducting research with diverse populations, appropriate theoretical grounding that is responsive to cultural and socioecological contexts must be considered. This paper will discuss the contextual model of HRQoL, a comprehensive framework developed to expand the traditional HRQoL framework to facilitate culturally and socioecologically responsive research. This model may provide a more comprehensive theoretical framework to investigate certain areas of health disparities and risk factors for poor outcomes in HRQoL research with cancer survivors.

Perceived growth and decline following breast cancer: a comparison to age-matched controls 5-years later

Research indicates that individuals who experience stressful life events, such as a diagnosis of cancer, often experience both positive and negative changes as a result of their experiences, but little research has compared these changes with those of a control group who have experienced other stressful life events. We compared 184 5-year breast cancer survivors (Stages: I, II, and III; 95% Caucasian) with 184 age-matched controls in terms of perceived growth and decline that stem from stressful events. Survivors reported on their experience with cancer, whereas controls identified the most stressful event that happened to them 5 years ago. Survivors reported more growth (e.g. appreciation of life) and more decline (e.g. physical side effects) compared with controls. However, there were no group differences in reports of psychological stress. When survivors were compared with controls whose stressor was a personal health problem, many of the differences in growth between the two groups remained, but the differences in decline disappeared. These findings suggest that some growth is unique to breast cancer, but much of the decline associated with breast cancer is similar to the decline associated with other types of health problems.

Chemotherapy-Induced Ovarian Failure

Thanks to improvements in treatment regimens, more and more patients are now surviving cancer. However, cancer survivors are faced with the serious long-term effects of the different modalities of cancer treatments. One of these adverse effects is chemotherapy-induced irreversible damage to the ovarian tissues, which leads to premature ovarian failure and its resulting consequences such as hot flashes, osteoporosis, sexual dysfunction and the risk of infertility. Chemotherapy-induced ovarian failure (or chemotherapy-induced premature menopause) affects the quality of life of female cancer survivors. Although there is no clear definition of chemotherapy-induced ovarian failure, irreversible amenorrhoea lasting for several months (>12 months) following chemotherapy and a follicle stimulating hormone level of > or = 30 MIU/mL in the presence of a negative pregnancy test seems to be an appropriate characterisation. Different chemotherapy agents, alkylating cytotoxics in particular, have the potential to cause progressive and irreversible damage to the ovaries. The result of this damage is a state of premature ovarian failure, with progressive declining of estrogen levels, decreasing bone mass and an increased risk of fractures. Historically, hormonal replacement therapy (HRT) has been used to treat menopausal problems in the general population, but concerns about the potential of estrogen to increase the risk of breast cancer in women at high-risk or increase the risk of recurrence in cancer survivors, have forced physicians to utilise alternative treatments. This review discusses some of the newer therapies that are now available to provide appropriate symptom control, avoid complications such as fractures and possibly prevent infertility by making the ovarian epithelium less susceptible to cytotoxic agents.

Work situation after breast cancer: results from a population-based study

BACKGROUND

Breast cancer may adversely affect work experience. We assessed whether there was evidence of discrimination at work, defined as negative or involuntary changes in employment situation (including changes in position, wages, and other conditions), associated with a breast cancer diagnosis in a population-based retrospective cohort study conducted in Quebec, Canada.

METHODS

The study was based on the consecutive series of women aged less then 60 years when first treated for breast cancer (identified through the Quebec Tumor Registry) and a random sample of frequency-matched women living in Quebec (identified from provincial health care files) who had never been diagnosed with cancer. Eligibility for the study was restricted to women who were employed at the time of diagnosis (for breast cancer survivors) or the same calendar period (for women in the comparison group). We conducted telephone interviews of eligible women 3 years after diagnosis for 646 survivors or after the matched calendar period for 890 women in the comparison group. Binomial regression was used to evaluate the relationship between having breast cancer and work situation. All statistical tests were two-sided.

RESULTS

Working conditions were similar between the two groups at the beginning of follow-up. After 3 years, slightly more survivors (21%) than women in the comparison group (15%) were unemployed (adjusted relative risk for being unemployed = 1.29, 95% confidence interval = 1.05 to 1.59), although most women who were not working (84% of unemployed survivors and 76% of unemployed women in the comparison group) said that the decision to stop working was their own. Among women still employed, no deterioration in working conditions was observed in either group.

CONCLUSION

We found little evidence that women diagnosed with breast cancer experience discrimination at work. This information may be helpful for working women concerned about employment after breast cancer.