Health-related quality of life and tamoxifen in breast cancer prevention: a report from the National Surgical Adjuvant Breast and Bowel Project P-1 Study

Correlates of return to work for breast cancer survivors

PURPOSE

To identify correlates of return to work for employed breast cancer survivors.

PATIENTS AND METHODS

Patients included 416 employed women with newly diagnosed breast cancer identified from the Metropolitan Detroit Cancer Surveillance System. Patients were interviewed by telephone 12 and 18 months after diagnosis. Correlates of return to work at 12 and 18 months were identified using multivariate logistic regression.

RESULTS

More than 80% of patients returned to work during the study period, and 87% reported that their employer was accommodating to their cancer illness and treatment. After adjusting for demographic characteristics, health status, cancer stage, treatment, and job type, heavy lifting on the job (odds ratio = 0.42; 95% CI, 0.18 to 0.99), perceived employer accommodation for cancer illness and treatment (odds ratio = 2.2; 95% CI, 1.03 to 4.8), and perceived employer discrimination because of a cancer diagnosis (odds ratio = 0.27; 95% CI, 0.10 to 0.71) were independently associated with return to work at 12 months after breast cancer diagnosis, and perceived employer accommodation (odds ratio = 2.3; 95% CI, 1.06 to 5.1) was independently associated with return to work at 18 months after breast cancer diagnosis.

CONCLUSION

A high percentage of employed breast cancer patients returned to work after treatment, and workplace accommodations played an important role in their return. In addition, perceived employer discrimination because of cancer was negatively associated with return to work for breast cancer survivors. Employers seem to have a pivotal role in breast cancer patients' successful return to work.

Managing Patients on Endocrine Therapy: Focus on Quality-of-Life Issues

PURPOSE

To review the health-related quality of life (QOL) of women treated with adjuvant hormonal therapy.

EXPERIMENTAL DESIGN

To review the limited QOL data from randomized trials of tamoxifen versus placebo and ovarian ablation versus none. To discuss QOL results from randomized trials of aromatase inhibitors compared with tamoxifen or placebo for adjuvant therapy of postmenopausal women with estrogen receptor-positive and/or progesterone receptor-positive breast cancer.

RESULTS

QOL is generally good in up to 3 years of follow-up with either tamoxifen or aromatase inhibitors. Vasomotor and sexual complaints remain problematic, however, in only a small proportion of women. There are fewer data regarding the QOL effects of ovarian ablation, which may nonetheless be more substantial.

CONCLUSION

Tamoxifen and aromatase inhibitors cause specific vasomotor or gynecologic symptoms, which may affect sexual function. However, clinical benefits of these agents are generally achieved without major detrimental effect on overall QOL.

Pilot intervention to enhance sexual rehabilitation for couples after treatment for localized prostate carcinoma

BACKGROUND

The majority of prostate carcinoma survivors experience enduring sexual difficulties and associated distress in the years after definitive treatment. A counseling intervention aimed at improving levels of sexual satisfaction and increasing successful utilization of medical treatment for erectile dysfunction (ED) was developed and pilot-tested for both the survivor of prostate carcinoma and his partner.

METHODS

All male participants were 3-month to 5-year survivors of localized prostate carcinoma who had been treated with radical prostatectomy or radiation therapy, and were married or in a committed relationship. Couples were randomized to attend four sessions of counseling together or to have the man attend alone. In both groups, partners completed behavioral homework. The sessions included education on prostate carcinoma and sexual function and options to treat ED as well as sexual communication and stimulation skills. Standardized questionnaires at baseline, posttreatment, and at 3-month and 6-month follow-up assessed sexual function, marital adjustment, psychologic distress, and utilization of treatments for ED.

RESULTS

Fifty-one of 84 couples randomized to treatment completed the intervention (61%). Attendance by the partner did not affect outcomes. Participants completing the intervention demonstrated improvement in male overall distress (P < 0.01), male global sexual function (P < 0.0001), and female global sexual function (P < 0.05) at 3-month follow-up, but regression toward baseline was noted at 6-month follow-up. However, utilization of ED treatments increased from 31% at the time of study entry to 49% at the 6-month follow-up (P = 0.003).

CONCLUSIONS

The results of this brief pilot counseling intervention demonstrated significant gains in sexual function and satisfaction and increased utilization of treatments for ED. However, modifications are needed in future randomized trials to reduce the rate of premature termination and to improve long-term maintenance of gains.

Broad cellular immunity with robust memory responses to simian immunodeficiency virus following serial vaccination with adenovirus 5- and 35-based vectors

Adenovirus serotype 35 (Ad35) is a promising vaccine platform for human immunodeficiency virus (HIV) infection and emerging infectious diseases as it is uncommon in humans worldwide and is distinct from Ad5, the major vaccine serotype for which many individuals have pre-existing immunity. The immunogenicity of a first-generation, replication-competent Ad35-based vaccine was tested in the simian immunodeficiency virus (SIV) rhesus macaque model by evaluating its capacity to boost immunity generated by Ad5-based vectors. A series of four immunizations with replication-defective Ad5 vectors expressing SIVmac239 gag induced high-frequency responses mediated by both CD8+ and CD4+ T cells directed against several epitopes. Ad5-specific neutralizing antibody responses that did not neutralize Ad35 were rapidly induced but waned over time. Subsequent immunization with Ad5-based vectors was minimally effective, whereas immunization with Ad35-based vectors generated a strong increase in the frequency of Gag-specific T cells with specificities that were unchanged. While this boosting response was relatively transient, challenge with the distinct pathogenic isolate SIV/DeltaB670 generated robust and selective recall responses to Gag with similar specificities as induced by vaccination that were elevated for 25 weeks relative to controls. Vaccination had measurable albeit minor effects on virus load. Unexpectedly, regional hypervariability within the Gag sequence of SIV/DeltaB670 was associated with mutation of the conserved CD8+ T-cell epitope CM9 without concurrent flanking mutations and in the absence of immune pressure. These findings support the further development of Ad35 as a vaccine vector, and promote vaccine regimens that utilize serial administration of heterologous adenoviruses.

Breast cancer, menopause, and long-term survivorship: critical issues for the 21st century

Breast cancer accounts for 33% of all incident cancers in women in North America, and there are an estimated >2 million breast cancer survivors in the United States today. Ovarian hormones are intimately involved in the initiation and promotion of breast cancer development, with targeted endocrine therapies being the most widely used as anticancer treatment. It is not surprising that these treatments frequently cause persistent menopausal symptoms in breast cancer survivors. In addition, adjuvant chemotherapy often induces premature menopause in younger patients with breast cancer. Some women at high risk for the development of breast cancer (e.g., precancerous breast disease, carriers of deleterious hereditary predisposition genes) experience vasomotor symptoms as a result of tamoxifen therapy or preventive oophorectomy. Clinical management of menopausal symptoms in these settings is complicated by the relative prohibition of hormonal therapies and the fact that breast cancer-directed therapies often exacerbate these menopausal symptoms. Thus, this special population of women requires unique management strategies and deserves separate consideration.

Obesity and cardiovascular risk factors in younger breast cancer survivors: The Cancer and Menopause Study (CAMS)

BACKGROUND

Breast cancer patients today can expect long-term survival; however, weight gain is a common problem after treatment and increases the risk for recurrence, cardiovascular disease and diabetes. The multi-ethnic cohort from the Cancer and Menopause Study, designed to examine the reproductive and late cardiovascular health effects of treatment in younger female breast cancer survivors (BCS), was used to describe the relationship of behavioral and treatment variables to body mass index (BMI), physical activity (PA), and cardiovascular risk factors.

METHODS

Stage 0, I or II breast cancer survivors who were < or = 50 years at diagnosis and 2-10 years disease-free survivors (mean 5.9 +/- 2.3 years) were recruited from two tumor registries to complete a mail survey that included information on demographics, health-related quality of life, reproductive health, cancer treatment, PA, weight and height. A sub-sample completed an office visit where fasting blood lipids, blood pressure (BP), height and weight were measured. Linear regression analysis was used to model the following outcomes: BMI, PA, blood lipids and BP.

RESULTS

Current BMI was positively associated with higher BMI prior to diagnosis, unhappiness with body image and negatively associated with current total PA (model p < 0.001). More work, home and leisure PA were all positively associated with greater physical functioning and higher energy levels (all models, p < 0.001). Total and LDL cholesterol were positively associated with number of years since diagnosis and negatively associated with leisure PA (both models, p < 0.001), while systolic and diastolic BP were both positively associated with age, current use of BP medications and current BMI (models, p < 0.001).

CONCLUSIONS

Obesity in these BCS is prevalent and associated with premorbid obesity and decreased current physical activity but not with adjuvant treatment. Given the negative health consequences of weight gain and obesity after breast cancer, continued study of the etiology of weight gain, and potential targets for weight gain prevention are required. Interventions that target PA may be important for weight maintenance in BCS.

The evolving role of aromatase inhibitors in adjuvant breast cancer therapy

The development of third-generation aromatase inhibitors (AIs) has brought about a major change in the therapeutic approach to patients with hormone-sensitive breast cancer. In randomized clinical trials, each of the third-generation AIs has demonstrated efficacy in the adjuvant treatment of postmenopausal women with receptor-positive tumors. Anastrozole has been shown to improve disease-free survival when compared with standard first-line tamoxifen, letrozole has been shown to further reduce the rate of breast cancer events when given as extended adjuvant therapy in women completing between 4.5 and 6 years of tamoxifen, and exemestane has been shown to improve disease-free survival when substituted for tamoxifen after an initial 2-3 years of adjuvant therapy. Although long-term follow-up for safety and overall survival continues in each of these trials, currently available data suggest that an AI should now be included as part of adjuvant endocrine therapy for the great majority of receptor-positive postmenopausal patients. To address these rapidly evolving issues related to the endocrine adjuvant treatment of postmenopausal women, an expert panel met in March 2004 in Hamburg, Germany, the site of the Fourth European Breast Cancer Conference. The panel's overview of recent endocrine data is presented along with updated results where available. In addition, case-based discussions are included to provide direction on how to integrate recent endocrine adjuvant clinical trial findings into everyday practice.

Paroxetine Is an Effective Treatment for Hot Flashes: Results From a Prospective Randomized Clinical Trial

Purpose

In an open-label trial we have previously demonstrated that paroxetine reduces hot flashes. We initiated a stratified, randomized, double-blind, cross-over, placebo-controlled trial to investigate the efficacy of paroxetine 10 mg and 20 mg compared to placebo in reducing hot flash frequency and composite score. A secondary objective was to evaluate quality of life (QOL) parameters.

Patients and Methods

Women who suffered at least two hot flashes a day for 1 month or longer were eligible. Women were randomly assigned to 4 weeks of paroxetine 10 mg or 20 mg followed by placebo for 4 weeks, or placebo for 4 weeks followed by paroxetine 10 mg or 20 mg for 4 weeks. Participants completed baseline daily hot flash diaries for one week prior to the start of the study and throughout the study, and QOL questionnaires at baseline, week 5 and week 9.

Results

279 women were screened, and 151 were randomly assigned. Paroxetine 10 mg reduced hot flash frequency and composite score by 40.6% and 45.6%, respectively, compared to 13.7% and 13.7% for placebo (P = .0006 and P = .0008, respectively). Paroxetine 20 mg reduced hot flash frequency and composite score by 51.7% and 56.1%, respectively, compared with 26.6% and 28.8% for placebo (P = .002 and P = .004, respectively). Efficacy was similar between the two doses, but women were less likely to discontinue low-dose paroxetine. Paroxetine 10 mg was associated with a significant improvement in sleep compared with placebo (P = .01).

Conclusion

Paroxetine is an effective treatment for hot flashes in women with or without a prior breast cancer.

Assessment of quality of life in MA.17: a randomized, placebo-controlled trial of letrozole after 5 years of tamoxifen in postmenopausal women

PURPOSE

To evaluate the impact of letrozole compared with placebo after adjuvant tamoxifen on quality of life (QOL) in the MA.17 trial.

METHODS

Patients completed the Short Form 36-item Health Survey (SF-36) and the Menopause Specific Quality of Life Questionnaire (MENQOL) at baseline, 6 months, and annually. Mean change scores from baseline were compared between groups for summary measures and domains. A response analysis compared the proportion of patients who demonstrated an important change in QOL.

RESULTS

Of 5,187 randomly assigned women in the trial, 3,612 (69.9%) participated in the QOL substudy: 1,799 were allocated to placebo and 1,813 were allocated to letrozole. No differences were seen between groups in mean change scores from baseline for the SF-36 physical and mental component summary scores at 6, 12, 24, and 36 months. Small (< 0.2 standard deviations) but statistically significant differences in mean change scores from baseline were seen for the SF-36 domains of physical functioning (12 months), bodily pain (6 months) and vitality (6 and 12 months), and the MENQOL vasomotor (6, 12, and 24 months) and sexual domains (12 and 24 months). On the response analysis, a significant difference was seen between groups for the bodily pain domain (percentage of patients reporting a worsening of QOL, 47% placebo v 51% letrozole; P = .009) and the vasomotor domain (22% placebo v 29% letrozole; P = .001).

CONCLUSION

Letrozole did not have an adverse impact on overall QOL. Small effects were seen in some domains consistent with a minority of patients experiencing changes in QOL compatible with a reduction in estrogen synthesis.

Outcomes From the Moving Beyond Cancer Psychoeducational, Randomized, Controlled Trial With Breast Cancer Patients

Purpose

Evidence suggests that the re-entry phase (ie, early period after medical treatment completion) presents distinct challenges for cancer patients. To facilitate the transition to recovery, we conducted the Moving Beyond Cancer (MBC) trial, a multisite, randomized, controlled trial of psychoeducational interventions for breast cancer patients.

Methods

Breast cancer patients were registered within 6 weeks after surgery. After medical treatment, they completed baseline measures and were randomly assigned to standard National Cancer Institute print material (CTL); standard print material and peer-modeling videotape (VID); or standard print material, videotape, two sessions with a trained cancer educator, and informational workbook (EDU). Two primary end points were examined: energy/fatigue and cancer-specific distress. Secondary end points were depressive symptoms and post-traumatic growth. Perceived preparedness for re-entry was analyzed as a moderator of effects.

Results

Of 558 women randomly assigned to treatment, 418 completed the 6-month assessment and 399 completed the 12-month assessment. In analyses controlling for study site and baseline depressive symptoms, VID produced significant improvement in energy/fatigue at 6 months relative to CTL, particularly among women who felt less prepared for re-entry at baseline. No significant main effect of the interventions emerged on cancer-specific distress, but EDU prompted greater reduction in this outcome relative to CTL at 6 months for patients who felt more prepared for re-entry. Between-group differences in the primary outcomes were not significant at 12 months, and no significant effects emerged on the secondary end points.

Conclusion

A peer-modeling videotape can accelerate the recovery of energy during the re-entry phase in women treated for breast cancer, particularly among those who feel less prepared for re-entry.

State of the science: hot flashes and cancer. Part 1: definition, scope, impact, physiology, and measurement

PURPOSE/OBJECTIVES

To critically evaluate and synthesize multidisciplinary research related to hot flashes in the context of cancer. Topics include the definition, scope, and impact of hot flashes; physiologic mechanisms; and measurement issues.

DATA SOURCES

Published, peer-reviewed articles and textbooks; editorials; unpublished data; and computerized databases.

DATA SYNTHESIS

Hot flashes can affect a diverse group of men and women diagnosed with or at high risk for certain cancers with a resulting negative impact on quality of life. Although the exact physiologic mechanisms underlying hot flashes remain unclear, a complex interplay of thermoregulatory, gluconeuroendocrine, genetic, and behavioral factors appears to be involved. Measurement of hot flashes should be considered carefully because they can be operationalized objectively and subjectively.

CONCLUSIONS

The large and diverse evidence base and current national attention on measurement of hot flashes highlight the importance of the symptom to healthcare professionals, including oncology nurses.

IMPLICATIONS FOR NURSING

Careful attention to assessment and measurement of hot flashes in patients with cancer is needed.

Evaluation of low-dose venlafaxine hydrochloride for the therapy of hot flushes in breast cancer survivors

OBJECTIVE

To evaluate the efficacy and tolerability of long-term treatment with venlafaxine at low dose for the reduction of vasomotor symptoms in breast cancer survivors.

DESIGN

Forty consecutive breast cancer patients suffering troublesome hot flushes have been treated for 8 weeks with venlafaxine XR 37.5 mg/day in an open-label study. Vasomotor symptoms have been evaluated before starting treatment and every 4 weeks with a hot flushes diary pointing out the number and the severity of vasomotor symptoms. A Beck Depression Inventory (BDI) was completed at baseline and at the end of the treatment.

RESULTS

Thirty patients had completed the first 4 weeks of treatment, reporting a reduction of hot flushes frequency of 39% as compared to baseline (p<0.001). After 8 weeks of treatment, a further significant reduction was observed both for the hot flushes frequency (-53%; p<0.001) and for the hot flushes score (-59%; p<0.001), a measure which reflects both the number and the severity of hot flushes. Very few side effects were reported, mostly nausea in the first 2 weeks of assumption and mouth dryness. Only 23 women had completed BDI at week 8; a reduction of 23% was observed (p=0.000).

CONCLUSION

Venlafaxine is an effective treatment for the relief of vasomotor symptoms in patients previously treated for breast cancer. A favourable effect is maintained also in those patients using tamoxifen as adjuvant therapy. The use of the low dose (37.5 mg/day) is associated with minimal side effects and produces a good improvement in hot flushes if pursued over 8 weeks.

Chemoendocrine therapy for premenopausal women with axillary lymph node-positive, steroid hormone receptor-positive breast cancer: results from INT 0101 (E5188)

PURPOSE

Chemotherapy, tamoxifen, and ovarian ablation/suppression (OA/OS) are effective adjuvant approaches for premenopausal, steroid hormone receptor-positive breast cancer. The value of combined therapy has not been clearly established.

PATIENTS AND METHODS

Premenopausal women with axillary lymph node-positive, steroid hormone receptor-positive breast cancer (1,503 eligible patients) were randomly assigned to six cycles of cyclophosphamide, doxorubicin, and fluorouracil (CAF), CAF followed by 5 years of monthly goserelin (CAF-Z), or CAF followed by 5 years of monthly goserelin and daily tamoxifen (CAF-ZT). The primary end points were time to recurrence (TTR), disease-free survival (DFS), and overall survival (OS) for CAF-Z versus CAF, and CAF-ZT versus CAF-Z.

RESULTS

With a median follow-up of 9.6 years, the addition of tamoxifen to CAF-Z improved TTR and DFS but not OS. There was no overall advantage for addition of goserelin to CAF.

CONCLUSION

Addition of tamoxifen to CAF-Z improves outcome for premenopausal node-positive, receptor-positive breast cancer. The role of OA/OS alone or with other endocrine agents should be studied more intensely.

Quality of life among younger women with breast cancer

PURPOSE

To describe quality of life (QOL) of younger women 4 to 42 months after breast cancer diagnosis and to identify factors associated with impaired QOL.

METHODS

A total of 202 women diagnosed with stage I to III breast cancer at age 50 or younger from 4 to 42 months after breast cancer diagnosis previously completed a mailed survey. Global QOL; health-related QOL as measured by the Functional Assessment of Cancer Therapy-Breast Cancer (FACT-B); medical history; symptoms; days of work/activity missed after diagnosis; relationship, sexual, and body image problems; coping strategies; and feelings of preparedness were measured.

RESULTS

General aches and pains and unhappiness with appearance were reported by more than 70% of women. Hot flashes (P = .0007), pain with sexual intercourse (P = .02), and difficulty with bladder control (P = .002) all significantly increased with age. Global QOL was significantly lower than for a nonpatient sample of younger women (P < .0001). In general, few sociodemographic and medical factors were related to QOL. In multivariate analyses, days of work/usual activity missed immediately after diagnosis; relationship, sexual, or body image problems after diagnosis; and coping strategies were related to almost all QOL domains. Ongoing treatment, vaginal dryness, and feeling unprepared for the impact of breast cancer were related to some domains.

CONCLUSION

Younger breast cancer survivors are at risk for impaired QOL up to several years after diagnosis. Younger women, especially those at high risk for lower QOL, may need interventions that specifically target their needs related to menopausal symptoms and problems with relationships, sexual functioning, and body image. Preparing younger woman for the impact of breast cancer may also prove beneficial.

The use of preventive measures among healthy women who carry a BRCA1 or BRCA2 mutation

PURPOSE

The purpose of this study was to assess women's knowledge about tamoxifen, to examine the frequency of tamoxifen usage and other preventive measures in BRCA1/2 mutation carriers, and to document women's concerns about taking tamoxifen for chemoprevention.

METHODS

One hundred and twenty five women with known BRCA1 or BRCA2 mutation and with no prior diagnosis of breast or ovarian cancer were identified through the records of two large cancer genetics clinics. These women had been counseled about their cancer risk and various preventive options were discussed. At a time from two to 110 months following disclosure session, a questionnaire was sent by mail. Women were asked about their current and past use of tamoxifen, their knowledge of risks and benefits, their desire for additional information, and their experience with other preventive measures.

RESULTS

Eighty-one of 125 eligible women returned the questionnaire (64.8%). Ten women (12.3%) had used tamoxifen and eight women had used raloxifene (9.9%). Twenty-two women (27.2%) had undergone prophylactic mastectomy and 54 women (66.7%) had had an oophorectomy. Twelve women (14.8%) did not recall discussing tamoxifen. Thirty-five women (58.3%) said that their doctors had not provided them with sufficient information about tamoxifen to consider its use. Fear of side-effects was the most common reason for not taking tamoxifen.

CONCLUSION

Although tamoxifen appears to be effective in preventing breast cancer in women with a BRCA1 or BRCA2 mutation, few women now take the drug compared to those who choose other preventive measures including surgery. Health care providers should provide accurate information about the risks and benefits of tamoxifen to allow women to make informed decisions.

Gynecologic cancer treatment and the impact of cancer-related infertility

OBJECTIVE

The objective of this study was to empirically assess the emotional and sexual impact of cancer-related infertility in women with a history of gynecologic cancer.

METHOD

Women with a history of gynecologic cancer were approached during their gynecologic oncology clinic appointment; they were provided a description of the study and asked to participate. All participants completed a one-time self-report survey. We present data acquired via the following methods: Center for Epidemiologic Studies-Depression Scale (CES-D), Impact of Events Scale (IES), Modified Inventory of Traumatic Grief (M-ITG), Female Sexual Function Index (FSFI), and the Menopausal Symptom Checklist.

RESULTS

The study sample consisted of 20 women, ages 27 to 49 years (mean, approximately 40 years), who had undergone treatment for cervical (40%), ovarian (20%), or uterine (40%) cancer. Forty percent of the sample reported depressive symptoms as measured by the CES-D, with 35% of the women experiencing moderate to severe levels of distress as measured by the IES. The women in this sample experienced dissatisfaction with their overall sex lives (67%), pain during vaginal penetration (62%), and low levels of sexual desire (56%).

CONCLUSIONS

The preliminary findings of this study indicated that feelings of depression, grief, stress, and sexual dysfunction are being experienced by women with a history of gynecologic cancer who have lost their fertility as a result of their cancer treatment.

Psychosocial oncology: Supportive care for the cancer patient

Increasing attention is being paid to the emotional and psychosocial needs of cancer patients. As a result of huge advances in early detection and in treatment modalities, there now are millions of cancer survivors in the United States. There has been a realization that cancer survivors have distinct psychosocial needs. As cancer survivors live longer, reduction of psychological distress has been recognized as being an important part of having an improved quality of life. There have been numerous changes in the field of psychosocial oncology since it first began 25 years ago. Guidelines now exist for the definition of distress and decision trees are available for making the appropriate referrals. Advances in pharmacologic treatment for depression and anxiety have made it possible to decrease distress and increase coping in cancer patients undergoing treatment as well as in cancer survivors. Numerous individual and group therapies have demonstrated effectiveness in improving mood and quality of life in cancer patients and those at high risk for developing cancer. Due to the forthright efforts of cancer patients, there are now many organizations and list serves (e-mailing lists) that cancer survivors can turn to for help before, during, and after cancer treatment. Finally, with the rapid expansion of the internet not only are there websites available as resources, but also the creation of interactive online support is becoming a reality. One of the most important issues in providing supportive care to cancer patients in the future is to meet the individual needs of patients and provide the type of psychological therapy that will work best for them.

The BCPT symptom scales: a measure of physical symptoms for women diagnosed with or at risk for breast cancer

BACKGROUND

Documentation of concurrent and late side effects of medical interventions to prevent and treat breast cancer is important in research and clinical practice. We used the Breast Cancer Prevention Trial (BCPT) Symptom Checklist to develop an instrument (BCPT Symptom Scales) that could be used to assess side effects and to examine correlates of the derived symptom dimensions among patient populations.

METHODS

Exploratory and confirmatory factor analyses were conducted using data from the 42-item BCPT Symptom Checklist completed by four distinct patient populations (N = 2208) who had previously been diagnosed with breast cancer or were at risk for the disease. We examined associations among the resulting BCPT Symptom Scales and demographic and cancer-related variables and a widely used measure of health-related quality of life.

RESULTS

Exploratory and confirmatory factor analyses revealed eight factors corresponding to physical symptoms associated with cancer treatment, chemoprevention, menopause, and normal aging: hot flashes, nausea, bladder control, vaginal problems, musculoskeletal pain, cognitive problems, weight problems, and arm problems. On the derived BCPT Symptom Scales, women reported somewhat higher mean scores on scales for hot flashes, pain, and weight problems than on scales for the other symptoms. Demographic and cancer-related variables accounted for up to 15% of the interindividual variance in how women responded to the symptom scales. The most consistent predictors of reporting greater symptoms included lower education level and previous receipt of chemotherapy.

CONCLUSIONS

Meaningful symptom dimensions, identified across four samples of women, were associated with demographic and breast cancer-related variables. The BCPT Symptom Scales offer a valuable refinement of the original BCPT Symptom Checklist to assess side effects associated with the treatment and prevention of breast cancer.

Quantifying trade-offs: quality of life and quality-adjusted survival in a randomised trial of chemotherapy in postmenopausal patients with lymph node-negative breast cancer

We evaluated quality of life (QL) and quality-adjusted survival in International Breast Cancer Study Group Trial IX, a randomised trial including 1669 eligible patients receiving tamoxifen for 5 years or three prior cycles of cyclophosphamide, methotrexate and 5-fluorouracil (CMF) followed by 57 months tamoxifen. During the time with CMF toxicity (Tox), without symptoms and toxicity (TWiST), and following relapse (Rel), patients scored their QL indicators and a utility indicator for subjective health estimation between ‘perfect’ and ‘worst’ health. Scores were averaged within Tox, TWiST and Rel and transformed to utilities. Mean durations for the three transition times were weighted with utilities to obtain mean quality-adjusted TWiST (Q-TWiST). Patients receiving CMF reported significantly worse scores for most QL domains at month 3, but less hot flushes. After completing chemotherapy, there were no differences by treatment groups. Benefits evaluated by Q-TWiST favoured the additional chemotherapy. CMF provided 3 more months of Q-TWiST for patients with ER-negative tumours, but CMF provided no benefit in Q-TWiST for patients with ER-positive tumours. Q-TWiST analysis based on patient ratings is feasible in large-scale cross-cultural clinical trials.

Feasibility of Quantifying the Effects of Epoetin Alfa Therapy on Cognitive Function in Women with Breast Cancer Undergoing Adjuvant or Neoadjuvant Chemotherapy

Impaired cognition, fatigue, and diminished quality of life (QOL) are commonly associated with breast cancer chemotherapy. This randomized, double-blind, placebo-controlled pilot trial assessed the feasibility of quantifying the effects of epoetin alfa on cognitive function and mood, and evaluated its effects on fatigue and QOL in patients with breast cancer treated with anthracycline-based adjuvant or neoadjuvant chemotherapy. Patients were randomized to receive epoetin alfa 40,000 U subcutaneously once weekly or placebo at the beginning of 4 cycles of chemotherapy administered over 12 weeks. Cognitive function was assessed by Executive Interview (EXIT25) and Clock Drawing Tasks; mood by Profile of Mood States; anemia-related symptoms, including fatigue, by the Functional Assessment of Cancer Therapy-Anemia (FACT-An) subscale; and QOL by Linear Analog Scale Assessment. Ninety-four patients were evaluable for efficacy and safety. Mean change in EXIT25 scores from baseline to cycle 4 in the epoetin alfa group was 1.3 +/- 3.3; the mean change was 0.3 +/- 2.4 in the placebo group (a negative change indicates improved executive function). There was no difference between groups in mean change in EXIT25 score from baseline to 6-month follow-up assessment. Mean hemoglobin levels were higher in the epoetin alfa group compared with the placebo group after 4 cycles of chemotherapy. Epoetin alfa recipients had less of a decrease in FACT-An subscale scores from baseline to cycle 4 and improvement in FACT-An subscale scores at 6-month follow-up assessment compared with placebo. Epoetin alfa therapy was well tolerated. These data suggest that epoetin alfa may have attenuated the cognitive impairment and fatigue that occurred during adjuvant breast cancer chemotherapy.

Weight, weight gain, and survival after breast cancer diagnosis

PURPOSE

To determine whether weight prior to diagnosis and weight gain after diagnosis are predictive of breast cancer survival.

METHODS

Patients included 5,204 Nurses' Health Study participants diagnosed with incident, invasive, nonmetastatic breast cancer between 1976 and 2000; 860 total deaths, 533 breast cancer deaths, and 681 recurrences (defined as secondary lung, brain, bone, or liver cancer, and death from breast cancer) accrued to 2002. We computed the change in body mass index (BMI) from before to the first BMI reported > or = 12 months after the date of diagnosis. Cox proportional hazards models were used to evaluate associations of categories of BMI before diagnosis and of BMI change with time to event. We stratified by smoking, menopausal status, and breast cancer-related variables.

RESULTS

In multivariate-adjusted analyses, weight before diagnosis was positively associated with breast cancer recurrence and death, but this was apparent only in never smokers. Similarly, among never-smoking women, those who gained between 0.5 and 2.0 kg/m(2) (median gain, 6.0 lb; relative risk [RR], 1.35; 95% CI, 0.93 to 1.95) or more than 2.0 kg/m(2) (median gain, 17.0 lb; RR, 1.64; 95% CI, 1.07 to 2.51) after diagnosis had an elevated risk of breast cancer death during follow-up (median, 9 years), compared with women who maintained their weight (test for linear trend, P = .03). Associations with weight were stronger in premenopausal than in postmenopausal women. Similar findings were noted for breast cancer recurrence and all-cause mortality.

CONCLUSION

Weight and weight gain were related to higher rates of breast cancer recurrence and mortality, but associations were most apparent in never-smoking women.

Association of breast cancer and its therapy with menopause-related symptoms

OBJECTIVE

To study the relationship between current menopause status, occurrence of menopause transition during cancer treatment, and prevalence and severity of possible menopause-related symptoms.

DESIGN

Data from the Cancer and Menopause Study (CAMS), a tumor-registry-based cohort of breast cancer survivors (BCS) diagnosed before age 50, were used. Using a standardized symptom checklist, women reported whether they were not at all, slightly, moderately, quite, or extremely bothered in the past 4 weeks by hot flashes, night sweats, vaginal dryness, pain with intercourse, breast sensitivity, joint pains, frequent mood changes, restless sleep, weight gain, forgetfulness, and difficulty concentrating. Current menopause status (by standard categories based on menstruation) and whether a persistent menopause transition occurred during cancer treatment were the main exposures. Linear (symptom severity as continuous outcome) and logistic (symptom present vs absent) regression models were adjusted for age, ethnicity, current smoking, alcohol use, chemotherapy, tamoxifen, body mass index, and depression scores.

RESULTS

Mean age of the participants was 50 years. The prevalence of symptoms was high. Hot flashes occurred in 17%, 51%, and 71% of pre-, peri-, and postmenopausal BCS, respectively. Hot flashes, vaginal dryness, and pain with intercourse were more severe in postmenopausal compared with perimenopausal BCS. Having had a transition during breast cancer treatment was associated with worse hot flash severity, independent of current menopause status.

CONCLUSIONS

Menopause-related symptoms are common in BCS. Effective treatment options are needed. Having a treatment-related transition confers a persistent effect on hot flash severity. Clinicians should include this information when counseling women on potential outcomes of their cancer therapy.

Early Stage Breast Cancer: Explaining Level of Psychosocial Adjustment Using Structural Equation Modeling

In many women, the diagnosis of breast cancer leads to psychosocial adjustment problems. Biodemographic variables, coping, and social support are factors that influence psychosocial adjustment. The main objective of the present study was to identify and estimate the associations between psychosocial adjustment and biodemographic variables, coping, and social support by using Structural Equation Modeling (SEM). Eighty-seven women with newly diagnosed early stage breast cancer completed several questionnaires covering these areas. It appeared that in the period shortly after surgery, coping style, especially illness-specific coping, is of high relevance for psychosocial adjustment. In our study, we could not confirm the positive role of social support found in other studies on psychosocial adjustment. Biodemographic variables had both direct and indirect associations with psychosocial adjustment: older women and women who had had breast-conserving treatment used a more optimistic coping style; the latter group also reported higher body image; and finally, women with a more advanced stage of disease reported a reduction in recreational activities.

Patient beliefs and tamoxifen discontinuance in older women with estrogen receptor--positive breast cancer

PURPOSE

To investigate the patterns and predictors of tamoxifen discontinuance throughout a 2-year period in a cohort of women 65 years or older with newly diagnosed, estrogen receptor (ER)-positive breast cancer, focusing on the role of patients' beliefs about the risks and benefits of tamoxifen therapy.

SUBJECTS AND METHODS

We enrolled a convenience sample of women cared for in four geographic regions of the United States with stage 1 (>/= 1 cm), stage II, or stage IIIA disease; no prior history of breast cancer; and no simultaneously diagnosed second primary breast cancer. Data sources included medical records and telephone interviews with patients at 3, 6, 15, and 27 months following definitive surgery.

RESULTS

Of the 597 women with ER-positive tumors, 516 women (86%) were prescribed tamoxifen, and of these, 88 (17%) stopped taking tamoxifen during the 2-year follow-up period. Of the women who stopped taking tamoxifen, the majority (68%) took it for less than 1 year. Women with neutral or negative beliefs about the value of tamoxifen (3.0; 95% CI, 1.6 to 5.6) and those with positive nodes (odds ratio = 2.5; 95% CI, 1.0 to 6.3) were more likely to discontinue tamoxifen therapy.

CONCLUSION

How women with early-stage breast cancer perceive the risks and benefits of tamoxifen therapy seems critical for sustaining adherence to adjuvant tamoxifen therapy. Interventions designed to educate women about the benefits and risks of tamoxifen therapy may help to reduce discontinuance.

Quality of life and trial adherence among participants in the prostate, lung, colorectal, and ovarian cancer screening trial

BACKGROUND

The National Cancer Institute's Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial was designed to examine whether annual screening tests for these four tumor sites result in reduced disease-related mortality. We assessed the impact of trial participation on both health-related quality of life (HRQL) and trial adherence.

METHODS

Participants (N = 432; 217 in the control arm and 215 in screening arm) were accrued from the Georgetown University PLCO site from May through December 1998. Screening-arm participants were interviewed by telephone at baseline (prescreening), shortly after notification of screening results (short-term follow-up), and 9 months after notification of screening results (intermediate-term follow up). Control-arm participants completed a baseline and 1-year follow-up assessment. Logistic regression analyses were conducted.

RESULTS

Participants reported high levels of HRQL and satisfaction with their decision to participate. Screening-arm participants with abnormal screening results had a higher level of intrusive thoughts about cancer than those with all normal results (odds ratio [OR] = 2.9, 95% confidence interval [CI] = 1.3 to 6.3) at the short-term follow-up but not at the intermediate-term follow-up (when abnormal test results were known to be false positive; OR = 1.9, 95% CI = 0.89 to 4.2). Trial adherence was statistically significantly better among participants who had received all normal results in the previous year's screening tests (93.7% versus 78.7%; OR = 3.7, CI = 1.1 to 12.0) than in those who received at least one abnormal result. In the control arm, adherence (defined as returning annual questionnaires) was positively associated with education (OR = 3.4, 95% CI = 1.4 to 8.4) and sex, with women being more likely to return questionnaires than men (OR = 2.1, 95% CI = 1.05 to 4.4).

CONCLUSIONS

It is feasible to collect HRQL measures as part of a large cancer screening trial. Prior abnormal screening results were related to short-term HRQL but not to intermediate-term HRQL. Trial adherence was poorer among those who had received previous false-positive results. These results suggest several methods for improving adherence in this and other subgroups.

Quality of life in diverse groups of midlife women: assessing the influence of menopause, health status and psychosocial and demographic factors

This paper examines whether menopausal status is associated with global quality of life (QOL) among women aged 40-55 and whether this association varies by race/ethnicity. We further examine the contributions of other health-related and psychosocial factors to QOL and whether these associations vary by racial/ethnic group. Analyses are based on 13,874 women who participated in the multi-ethnic, multi-race study of mid-aged women called the Study of Women's Health Across the Nation (SWAN). Study participants completed a 15-min telephone or in-person interview that contained questions on a variety of health-related topics. Items of interest for these analyses include global QOL, menstrual history (to assess menopausal status), sociodemographics, health status, lifestyle, and psychosocial variables. Results showed that in unadjusted analyses, early perimenopausal women reported lower QOL compared with premenopausal women, but menopausal status was no longer associated with QOL when analyses were adjusted for other variables. In multivariable models, being married and having low levels of perceived stress were associated with better QOL across all racial/ethnic groups. While there were many consistencies across racial/ethnic groups, we also found that the nature of the associations between QOL and education, marital status, perceived stress and social support varied across racial/ethnic groups.

The Relationship Among Physicians’ Specialty, Perceptions of the Risks and Benefits of Adjuvant Tamoxifen Therapy, and Its Recommendation in Older Patients With Breast Cancer

OBJECTIVES

The objectives of this study were to determine whether tamoxifen recommendation differs by physician specialty, to determine whether perception affects tamoxifen recommendation, and to investigate the association between the physician's specialty and the perception of risks and benefits of tamoxifen.

METHODS

We enrolled a cohort of geographically diverse women aged 65 and older with stage I through IIIa breast cancer in a prospective cohort study. We recruited their surgeons and, when applicable, their medical oncologists to provide patient-specific information about their perceptions of the risks and benefits of tamoxifen and whether they recommended tamoxifen. Each physician also completed a questionnaire regarding his or her demographic and practice characteristics. Patient data were collected through medical record review and a patient interview 3 months after definitive breast cancer surgery.

RESULTS

We collected physician treatment recommendation forms for 585 women. Oncologists were 2.5 times more likely to recommend tamoxifen, compared with surgeons, after adjusting for patient and tumor characteristics (95% confidence interval, 1.5-4.2). For both specialties, their perceptions of the risks and benefits of tamoxifen were strong predictors of tamoxifen recommendation. However, there were differences in perception by physician specialty. Distant metastases and tolerance of tamoxifen side effects were more important to oncologists, whereas local recurrence and risk of cataracts were more important to surgeons.

CONCLUSION

Physicians' perceptions of the risks and benefits of tamoxifen therapy for older women are important in their decision-making process.

Health-Related Quality of Life in Axillary Node-Negative, Estrogen Receptor-Negative Breast Cancer Patients Undergoing AC Versus CMF Chemotherapy: Findings from the National Surgical Adjuvant Breast and Bowel Project B-23

PURPOSE

NSABP Protocol B-23 compared two chemotherapy regimens: (1) cyclophosphamide, methotrexate, and 5-fluorouracil (CMF); and (2) doxorubicin and cyclophosphamide (AC) in terms of relapse-free survival, event-free survival, and overall survival in node-negative and estrogen receptor-negative breast cancer patients. There are no previous data regarding the comparison of quality of life (QOL) between the two regimens in this population of breast cancer patients. QOL information was considered especially relevant given the possibility that the two chemotherapy regimens would prove equivalent in terms of clinical outcome.

PATIENTS AND METHODS

One hundred and sixty patients participated in the NSABP B-23 QOL study. Patients in B-23 were randomly assigned to one of four arms: CMF plus 5 years of tamoxifen (TAM), CMF, Comparative health item and general health item plus placebo, AC plus TAM, or AC plus placebo. The questionnaires included the Functional Assessment of Cancer Therapy (FACT-B), the vitality scale from the Medical Outcomes Study 36-item Short Form Health Status Survey (MOS SF-36), a symptom checklist and additional items regarding overall QOL; and return to normal activity. Statistical comparisons between treatment arms were performed with area under the curve analyses, repeated measures analyses, and Fisher exact tests.

RESULTS

Overall QOL as measured by the FACT-B did not significantly differ between chemotherapy treatment arms. However, the pattern of vitality over time during treatment differed between chemotherapy groups. The AC group vitality scores dropped more sharply during treatment and returned to baseline levels more quickly after treatment. Patients in the CMF arm were bothered by bladder problems and diarrhea significantly more often than were patients in the AC arm. Otherwise, no significant differences were found between AC and CMF for any of the QOL outcomes in terms of (1) overall QOL during the first 9 months after randomization, (2) the average QOL during treatment, or (3) the rate of recovery to baseline levels of QOL 1year after randomization.

CONCLUSION

Overall QOL is equivalent between the two chemotherapy regimens, with some differences in symptoms and in patterns of vitality over time.

Short-term impact of cancer prevention and screening activities on quality of life

PURPOSE

There are few data on the short-term effects of participating in cancer prevention activities, undergoing genetic risk assessment, or having routine screening. The objective of this article is to systematically review existing research on short-term effects of prevention, genetic counseling and testing, and screening activities on quality of life.

METHODS

We conducted a MEDLINE search for original research studies that were published between January 1, 1985, and December 31, 2002, and conducted in North America or Western Europe. Data were abstracted and summarized using a standardized format.

RESULTS

We reviewed 210 publications. Most studies focused on psychological states (anxiety, depression), symptoms, or general health status. One hundred thirty-one studies used 51 previously validated noncancer instruments. Many researchers (12.6%) also added cancer-specific measures, such as perceived cancer risk or symptom indices. Only one study measured satisfaction or quality of provider-client communication. While one report examined lost workdays, no other economic consequences of short-term outcomes were evaluated. Among seven studies that assessed short-term outcomes preferences, only four specifically used time trade-off or linear rating scale methods. No study used standard gamble or willingness-to-pay methods. The overwhelming majority of research indicated that short-term effects were transient. Only two studies linked short-term effects to long-term cancer-related health behaviors such as repeat screening.

CONCLUSION

There is considerable heterogeneity in short-term outcome measurement. Clinicians need to be aware of potential for short-term, transient adverse effects. The impact of short-term experiences should to be linked to long-term health status and use of services.

Quality of life at the end of primary treatment of breast cancer: first results from the moving beyond cancer randomized trial

BACKGROUND

During the last decade, survival rates for breast cancer have increased as a result of earlier detection and increased use of adjuvant therapy. Limited data exist on the psychosocial aspects of the transitional period between the end of primary treatment and survivorship. We investigated the baseline psychosocial status of women enrolled in a randomized trial testing two psychosocial interventions for women at the end of primary treatment.

METHODS

Participants, identified within 1 month after surgery (registration), provided demographic information and limited measures of quality of life. They were followed until they finished primary treatment (enrollment), at which time they completed a mailed baseline survey that included standardized measures of quality of life (including standardized scales of physical and emotional functioning), mood, symptoms, and sexual functioning. A total of 558 patients (mean age = 56.9 years) were enrolled in the study between July 1, 1999, and June 30, 2002. Health outcomes were examined according to treatment received: mastectomy with and without chemotherapy, and lumpectomy with and without chemotherapy. All statistical tests were two-sided.

RESULTS

Among all treatment groups, patients who had a mastectomy had the poorest physical functioning at registration (P<.001) and at enrollment (P=.05). At enrollment, mood and emotional functioning were similar among all patients, with no differences by type of treatment received. At enrollment, symptoms, including muscle stiffness, breast sensitivity, aches and pains, tendency to take naps, and difficulty concentrating, were common among patients in all groups and were statistically significantly associated with poor physical functioning and emotional well-being. Sexual functioning was worse for women who received chemotherapy than for those who did not, regardless of type of surgery (P<.001).

CONCLUSIONS

At the end of primary treatment for breast cancer, women in all treatment groups report good emotional functioning but report decreased physical functioning, particularly among women who have a mastectomy or receive chemotherapy. Clinical interventions to address common symptoms associated with treatment should be considered to improve physical and emotional functioning at the end of primary treatment for breast cancer.

Should Tamoxifen Be Used in Breast Cancer Prevention?

Breast cancer is the most commonly diagnosed cancer in women. The risk of developing breast cancer can be lowered by maintaining a healthy bodyweight and avoiding long-term use of combined estrogen and progestogen replacement after menopause. However, many women are at an increased risk of developing breast cancer secondary to age, early menarche, a family history of breast cancer or a personal history of benign breast disease. These women may now be offered tamoxifen as a chemoprevention therapy. Five years of tamoxifen treatment results in a reduction in the relative risk of developing estrogen receptor-positive breast cancer of 48%. This benefit outweighs the risk of tamoxifen-related adverse events for many healthy women. However, the benefit-risk ratio of tamoxifen chemoprevention varies for individual women. The randomized clinical trials evaluating standard-dose tamoxifen versus placebo as chemoprevention therapy are reviewed and analyzed to determine which particular women are most likely to benefit and least likely to experience a tamoxifen-related adverse event. Tamoxifen decreases the risk of breast cancer associated with aging, having a first-degree relative with disease, and a personal diagnosis of atypical ductal hyperplasia or lobular carcinoma in situ. Women who have had a hysterectomy and are at low risk of a thromboembolic event have a decreased risk of adverse effects associated with tamoxifen therapy. The strengths and weaknesses of the Gail model (frequently used to assess an individual's risk of developing invasive breast cancer over the next 5 years) are highlighted. A method for assessing the benefit-risk ratio for an individual woman is presented. Alternative breast cancer chemoprevention strategies are considered, including the use of aromatase inhibitors. This article discusses the pros and cons of these various preventive therapies and concludes that at this time, tamoxifen remains the gold standard for breast cancer prevention.

Breast cancer in younger women: reproductive and late health effects of treatment

PURPOSE

In 1997, we initiated a cohort study to evaluate quality of life (QOL) and reproductive health outcomes in younger female breast cancer survivors.

MATERIALS AND METHODS

Using listings from two tumor registries, we recruited women with stage 0, I, or II breast cancer who were 50 years or younger at diagnosis and were also disease-free survivors for 2 to 10 years. A mailed survey questionnaire assessed medical and demographic factors, health-related QOL, mood, outlook on life, and reproductive health outcomes.

RESULTS

We recruited 577 women, who ranged in age from 30 to 61.6 years (mean, 49.5 years) and were surveyed approximately 6 years after diagnosis. Almost three fourths had received some form of adjuvant therapy. Amenorrhea occurred frequently as a result of treatment in women > or = 40 years at diagnosis, and treatment-associated menopause was associated with poorer health perceptions. Across the cohort, physical functioning was quite good, but the youngest women experienced poorer mental health (P =.0002) and less vitality (energy; P =.03). Multiple regression analyses predicting QOL demonstrated better outcomes in African-American women, married or partnered women, and women with better emotional and physical functioning, whereas women who reported greater vulnerability had poorer QOL.

CONCLUSION

Overall QOL in younger women who survive breast cancer is good, but there is evidence of increased emotional disruption, especially among the youngest women. Factors that may contribute to poorer health perceptions and QOL include experiencing a menopausal transition as part of therapy, and feeling more vulnerable after cancer.

Antiestrogen resistance in breast cancer and the role of estrogen receptor signaling

Antiestrogens include agents such as tamoxifen, toremifene, raloxifene, and fulvestrant. Currently, tamoxifen is the only drug approved for use in breast cancer chemoprevention, and it remains the treatment of choice for most women with hormone receptor positive, invasive breast carcinoma. While antiestrogens have been available since the early 1970s, we still do not fully understand their mechanisms of action and resistance. Essentially, two forms of antiestrogen resistance occur: de novo resistance and acquired resistance. Absence of estrogen receptor (ER) expression is the most common de novo resistance mechanism, whereas a complete loss of ER expression is not common in acquired resistance. Antiestrogen unresponsiveness appears to be the major acquired resistance phenotype, with a switch to an antiestrogen-stimulated growth being a minor phenotype. Since antiestrogens compete with estrogens for binding to ER, clinical response to antiestrogens may be affected by exogenous estrogenic exposures. Such exposures include estrogenic hormone replacement therapies and dietary and environmental exposures that directly or indirectly increase a tumor's estrogenic environment. Whether antiestrogen resistance can be conferred by a switch from predominantly ERalpha to ERbeta expression remains unanswered, but predicting response to antiestrogen therapy requires only measurement of ERalpha expression. The role of altered receptor coactivator or corepressor expression in antiestrogen resistance also is unclear, and understanding their roles may be confounded by their ubiquitous expression and functional redundancy. We have proposed a gene network approach to exploring the mechanistic aspects of antiestrogen resistance. Using transcriptome and proteome analyses, we have begun to identify candidate genes that comprise one component of a larger, putative gene network. These candidate genes include NFkappaB, interferon regulatory factor-1, nucleophosmin, and the X-box binding protein-1. The network also may involve signaling through ras and MAPK, implicating crosstalk with growth factors and cytokines. Ultimately, signaling affects the expression/function of the proliferation and/or apoptotic machineries.

Obesity, tamoxifen use, and outcomes in women with estrogen receptor-positive early-stage breast cancer

BACKGROUND

Obesity is associated with both increased breast cancer risk and poorer prognosis after disease onset. However, little is known about the effect of obesity on treatment efficacy. We evaluated the association of obesity with outcomes and with tamoxifen efficacy in women with early-stage, hormone-responsive breast cancer participating in a multicenter cancer cooperative group clinical trial.

METHODS

The cohort consisted of 3385 women enrolled in National Surgical Adjuvant Breast and Bowel Project (NSABP) protocol B-14, a randomized, placebo-controlled trial evaluating tamoxifen for lymph node-negative, estrogen receptor (ER)-positive breast cancer. Hazards of breast cancer recurrence, contralateral breast tumors, other new primary cancers, and several mortality endpoints were evaluated in relation to body mass index (BMI), using statistical modeling to adjust for other prognostic factors. Median follow-up time was 166 months. All statistical tests were two-sided.

RESULTS

The hazard of breast cancer recurrence was the same among obese (BMI > or =30.0 kg/m2) women as compared with underweight and normal-weight women (BMI <25.0; hazard ratio [HR] = 0.98, 95% confidence interval [CI] = 0.80 to 1.18). Contralateral breast cancer hazard was higher in obese women than in underweight/normal-weight women (HR = 1.58, 95% CI = 1.10 to 2.25), as was the risk of other primary cancers (HR = 1.62, 95% CI = 1.16 to 2.24). Compared with normal-weight women, obese women had greater all-cause mortality (HR = 1.31, 95% CI = 1.12 to 1.54) and greater risk of deaths due to causes unrelated to breast cancer (HR = 1.49, 95% CI = 1.15 to 1.92). Breast cancer mortality was not statistically significantly increased for obese women (HR = 1.20, 95% CI = 0.97 to 1.49). Tamoxifen reduced breast cancer recurrence and mortality, regardless of BMI.

CONCLUSIONS

For women with lymph node-negative, ER-positive breast cancer, obesity was not associated with a material increase in recurrence risk or a change in tamoxifen efficacy. However, because obesity was associated with increased risks of contralateral breast cancer, of other primary cancers, and of overall mortality, it may influence long-term outcomes for breast cancer survivors.

Psychiatric aspects of women with breast cancer

Women with breast cancer face not only cancer-related taboos but also issues related to changes in sexuality, femininity, and fertility. Although increased emphasis on the woman's participation in the medical decision-making process has afforded her more treatment options, it also gives her more responsibility in determining her course of treatment through the continuum of cancer care. Patients must deal with a variety of issues related to social reintegration, long-term effects of cancer treatment, employment, disability, sexuality, family, and social networks. Screening for distress related to psychological, spiritual/religious, or social concerns can provide guidance for service delivery to those in need.

Counting the costs of treatment: the reproductive and gynaecological consequences of adjuvant therapy in young women with breast cancer

As the mortality rate from breast cancer decreases, the issues facing breast cancer survivors are becoming increasingly important. Survivors of all ages may face physical and psychosocial consequences of their diagnosis and treatments. However, the long-term fertility and menopause-related side-effects of adjuvant therapy uniquely affect younger premenopausal breast cancer survivors. This article provides an evidence-based overview of the reproductive and gynaecological impact of breast cancer therapy for premenopausal women diagnosed with breast cancer. The physical and psychosocial implications of premature menopause are presented. Strategies for preserving fertility in selected patients are also discussed. Recent clinical trials strongly indicate that premenopausal women with oestrogen receptor positive tumours should receive endocrine therapy. The increased use of endocrine therapies in younger women raises important questions regarding patient information needs and treatment decision-making.

Estrogen and selective estrogen receptor modulators: neuroprotection in the Women's Health Initiative era

Estrogen has been comprehensively studied as a neuroprotective agent in women, animals, and a variety of in vitro models of neural injury and degeneration. Most data suggest that estrogen can benefit the ischemic brain and reduce cell death. However, recent data from the Women's Health Initiative have raised concerns about the utility and safety of chronic estrogen use in women. While estrogen is a potent and reproducible neuroprotectant in animals and in vitro, its current administration in women has had unanticipated and paradoxical effects. Nonetheless, estrogen's diverse actions make it an ideal prototype for developing new neuroprotectants such as selective estrogen receptor modulators (SERMs). SERMs represent a class of drugs with mixed estrogen agonistic and antagonistic activity. Experimental and clinical data suggest a neuroprotective role for SERMs in normal and injured brain. The discrepancy among observational studies, preclinical data, and clinical trials emphasizes the need for further study of the mechanisms leading to the increased incidence of stroke observed in postmenopausal women. Research is still needed to optimize combined or estrogen alone hormone replacement therapy options as well as the prevention/management of cerebrovascular/ central nervous system disorders. This review critiques estrogen and SERMs' neuroprotective potential in experimental and clinical studies of stroke and cerebrovascular disease.

Side effects of adjuvant endocrine treatment in premenopausal breast cancer patients: a prospective randomized study

PURPOSE

To compare the effect of adjuvant endocrine therapies with and without chemotherapy on physical symptoms, anxiety, and depressive symptoms in premenopausal women with breast cancer in a randomized clinical trial (the Zoladex in Premenopausal Patients trial).

PATIENTS AND METHODS

The patients were randomly assigned to goserelin, goserelin plus tamoxifen, tamoxifen alone, or no endocrine therapy. The duration of the endocrine treatment was 2 years. The groups were observed for 3 years after primary treatment (ie, during 2 years of active treatment as well as 1 year after cessation of the adjuvant endocrine therapy). All patients with node-positive disease received adjuvant chemotherapy with cyclophosphamide, methotrexate, and fluorouracil (CMF), which was given concurrently with the endocrine treatment.

RESULTS

Patients treated with CMF typically reported higher levels of physical symptoms than did patients who did not receive CMF. It was only among patients who did not receive chemotherapy that the endocrine treatment had differential effects. Goserelin was most burdensome and resulted in similar symptom levels as those of CMF, whereas the side effects of tamoxifen alone were milder. After cessation of the endocrine treatment, the side effects diminished in patients who had not received CMF, whereas patients treated with CMF reported ongoing problems at the 3-year follow-up. In contrast, anxiety and depressive symptoms were not significantly affected by endocrine treatment or chemotherapy during the 3 years of assessment.

CONCLUSION

Goserelin and tamoxifen resulted in menopausal symptoms, but these symptoms were reversible. However, women treated with CMF experienced physical symptoms throughout the whole study period.

Continuing education: Comprehensive menopausal assessment: an approach to managing vasomotor and urogenital symptoms in breast cancer survivors

PURPOSE/OBJECTIVES

To describe the development and implementation of a comprehensive menopausal assessment (CMA) and intervention program for women with a history of breast cancer.

DATA SOURCES

Published articles selected from computerized databases, conference proceedings, bibliographies of pertinent articles and books, and lay publications.

DATA SYNTHESIS

The CMA program consisted of a structured, comprehensive assessment of three symptoms (hot flashes, vaginal dryness, and stress urinary incontinence) and an individualized plan of education, counseling, nonestrogen treatments, psychosocial support, referrals, and follow-up.

CONCLUSIONS

A structured approach to evaluating and managing vasomotor and urogenital symptoms with, for example, the CMA, may help breast cancer survivors with severe symptoms more effectively manage these symptoms than "usual care."

IMPLICATIONS FOR NURSING

Nurses providing care for women with a history of breast cancer can incorporate the key elements of the CMA program into their practice to facilitate more effective management of three common menopausal symptoms that often are undertreated in this patient population.

[Can breast cancer be chemoprevented in 2003?]

Breast cancer is certainly not preventable at the same degree as lung cancer is by avoiding cigarette smoking or bladder cancer by avoiding exposure to some specific professional carcinogens. Despite the increased availability of screening mammography and the use of adjuvant chemotherapy, breast cancer remains a major cause of morbidity and mortality in women. Chemoprevention could be one of the possible weapons to decrease the morbidity and the mortality due to breast cancer. Experimental, epidemiological and clinical data suggest that one can prevent occurrence of breast cancer. The results of five trials including more than 25,000 patients comparing the effectiveness of tamoxifen with a placebo were published. The results of these trials, at first sight, do not agree. Only in the USA, the results of the five trials have led to licence tamoxifen for chemoprevention of breast cancer. But the Food and Drug Administration stresses the fact that the noxious side effects are too numerous for this molecule to be prescribed with all the patients. It must be reserved for the women presenting an increased risk. The means of identifying the women at increased risk are not yet perfect.

Cimicifuga racemosa for the treatment of hot flushes in women surviving breast cancer

OBJECTIVES

To examine the effect of Cimicifuga racemosa (CR BNO 1055) on hot flushes caused by tamoxifen adjuvant therapy in young premenopausal breast cancer survivors. This treatment presents an off-label use of CR BNO 1055.

METHODS

Between May 1999 and December 2001, we accrued 136 breast cancer survivors aged 35-52 years. After treatment with segmental or total mastectomy, radiation therapy and adjuvant chemotherapy, participants were in open-label randomly assigned (1-2) to receive tamoxifen 20 mg per day orally (usual-care group; n=46) or tamoxifen (same dose and posology) plus CR BNO 1055 (Menofem/Klimadynon, corresponding to 20 mg of herbal drug; intervention group n=90). Duration of treatment was 5 years for tamoxifen, according to international standards for adjuvant therapies, and 12 months for CR BNO 1055. Follow-up included clinical assessment every 2 months; the primary endpoint was to record the number and intensity of hot flushes.

RESULTS

Comparing patients assigned to usual-care group with those assigned to intervention group, the number and severity of hot flushes were reduced after intervention. Almost half of the patients of the intervention group were free of hot flushes, while severe hot flushes were reported by 24.4% of patients of intervention group and 73.9% of the usual-care group (P<0.01).

CONCLUSIONS

Hot flushes were the most frequent adverse reaction to tamoxifen adjuvant therapy in breast cancer survivors. The combined administration of tamoxifen plus CR BNO 1055 for a period of 12 months allowed satisfactory reduction in the number and severity of hot flushes.

Update on clinical role of tamoxifen

PURPOSE OF REVIEW

Breast cancer is the most common malignancy amongst women in the United States and decreased mortality over the past decade has been attributed to a combination of screening and adjuvant therapies. There has been a resurgence of interest in hormonal therapies and this article discusses the clinical status of tamoxifen in the context of emerging alternative agents for treatment and prevention of breast cancer.

RECENT FINDINGS

Tamoxifen has served as a prototype for the development of selective estrogen receptor modulators at the laboratory-clinical interface. Molecular technologies have permitted elucidation of mechanisms for tissue specific action and led to newer selective estrogen receptor modulators with potentially greater antitumour efficacy and attenuated uterotrophic profile. Publications over the past 12 months have emphasized the risks of thromboembolism and endometrial carcinoma associated with tamoxifen use which has accelerated application of other hormonal agents for treatment of advanced disease and as neoadjuvant therapy. This article reviews the current role of tamoxifen in the treatment of early and advanced breast cancer together with its potential for chemoprevention. Models for quantitative risk assessment are being developed to identify women for whom chemoprotection is justified.

SUMMARY

Recent data showing a survival advantage for the aromatase inhibitor letrozole compared with tamoxifen in the advanced setting and improvement in disease-free survival for the aromatase inhibitor anastrozole versus tamoxifen as adjuvant treatment may herald a major shift in standard first-line endocrine therapies for both advanced and early disease and ultimately chemoprevention of breast cancer. Other agents including newer SERMs and pure antiestrogens are undergoing phase III clinical trials and future endocrine and biological therapies are likely to include more selective and targeted therapies, which may be efficacious in both hormone-sensitive and receptor-negative disease.

Efficacy of soyfoods and soybean isoflavone supplements for alleviating menopausal symptoms is positively related to initial hot flush frequency

Soy has received attention as an alternative to conventional hormone replacement therapy (HRT) largely because it is a unique dietary source of isoflavones. Isoflavones are diphenolic compounds that have both hormonal and nonhormonal properties and are considered to be selective estrogen receptor modulators. The estrogen-like effects of isoflavones in combination with the low reported frequency of hot flushes in Japan has prompted investigation of the effect of soy on menopausal symptoms. The purpose of this review is to evaluate the efficacy of soyfoods and isoflavone supplements for the alleviation of hot flushes. Nineteen trials (13 using a parallel design) involving more than 1,700 women were identified. Six trials were excluded from analysis: two that involved breast cancer patients, two that reported data on severity but not hot flush frequency, one that was not blinded, and one that did not include a control group. Based on a simple regression analysis of the remaining data set (13 trials), there was a statistically significant relationship (P =.01) between initial hot flush frequency and treatment efficacy. Initial hot flush frequency explained about 46% of the treatment effects, and hot flush frequency decreased by about 5% (above placebo or control effects) for every additional initial hot flush per day in women whose initial hot flush frequency was five or more per day. Although conclusions based on this analysis should be considered tentative, the available data justify the recommendation that patients with frequent hot flushes consider trying soyfoods or isoflavone supplements for the alleviation of their symptoms.

Which dimensions of health-related quality of life are altered in patients attending the different gynecologic oncology health care settings?

BACKGROUND

We evaluated the feasibility of measuring health-related quality of life (HRQOL) in a gynecologic oncology clinic by using an instrument that is nonspecific for cancer patients. Our aim was to study whether the HRQOL perception of cancer patients differed from general population norms for the same age and gender and if it varied across cancer type, cancer status, age, health care setting, and reason for the encounter.

METHODS

Participants in this study included 115 women between the ages of 21 and 83 years who were referred to a university hospital for ovarian, endometrial, and cervical carcinoma. They completed the SF-36 questionnaire. Mean results for the entire sample, for different disease status (primary vs. progressive/recurrent disease), and reason for encounter (surgery, preoperative, postoperative, palliative chemotherapy, and follow-up) were compared with age-specific expected mean values for each SF-36 scale, based on published Italian reference values for the healthy population.

RESULTS

Patients' attitude to the questionnaire was generally good. Mean values on the SF-36 scales varied. Role (Physical and Emotional) scales showed the highest differences from the expected age-specific values in all situations. Patients with primary disease showed little or no differences for the other six scales from the expected values, whereas a significant 10-point mean decrease in every SF-36 scale was recorded for patients with progressive/recurrent disease. A biologic interaction among cervical carcinoma, age, and disease status was found in multivariate models, showing worst scores for patients with progressive/recurrent cervical carcinoma on almost all scales.

CONCLUSIONS

Administration of generic HRQOL questionnaires in specialist health care delivery settings is feasible and well accepted and may help physicians and nurses to look beyond "what's wrong" in their patients.