Symptom clusters experienced by breast cancer patients at various treatment stages: A systematic review

Yoga and meditation for menopausal symptoms in breast cancer survivors: a qualitative study exploring participants' experiences

PURPOSE

Breast cancer survivors commonly experience menopausal symptoms, specifically when undergoing antihormonal therapy. Unfortunately, they often have a restricted range of treatment options available to alleviate menopausal symptoms. The objective of this qualitative study was to explore breast cancer survivors' experiences and effects of a yoga and meditation intervention supplementing previously reported RCT outcomes.

METHODS

The qualitative data included in this study were part of a larger randomized controlled trial which evaluated the efficacy and safety of a 12-week yoga and meditation intervention on menopausal symptoms in breast cancer survivors. All participants who underwent the yoga intervention (n = 19) were invited to take part in semi-structured interviews after all quantitative data collection had been completed. Interviews (n = 9) were recorded, transcribed, and then coded into superordinate themes using thematic analysis.

RESULTS

Nine female participants were interviewed, and the following themes emerged: (1) representations and expectations from the yoga intervention; (2) course structure and implementation; (3) perceptions and effects of the intervention (at emotional, physical, behavioral, and spiritual level); (4) differences between the study yoga intervention and other physical activities.

CONCLUSIONS

In accordance with the accounts of participants, yoga might offer a promising intervention for breast cancer survivors. All those interviewed either currently attended a yoga class or expressed a desire to continue practicing yoga. Additionally, our findings inform future studies regarding aspects such as the importance of extending outcome measures beyond specific cancer-related complains, the advantages of addressing homogenous groups (i.e., breast cancer specific), or considering that different intervention components might need different assistance to encourage long-term use.

Impact of a Multidisciplinary Supportive Care Model Using Distress Screening at an Asian Ambulatory Cancer Center: A Cluster Randomized Controlled Trial

PURPOSE

The Accessible Cancer Care to Enable Support for Cancer Survivors (ACCESS) program adopts a multidisciplinary supportive care model with routine distress screening to triage newly diagnosed cancer survivors for additional support on the basis of distress levels. This study aimed to evaluate the clinical impact of ACCESS over 1 year.

METHODS

We performed cluster random assignment at the oncologist level in a 1:1 ratio to receive ACCESS or usual care. Participants 21 years and older, newly diagnosed with breast or gynecologic cancer, and receiving care at National Cancer Centre Singapore were included. Outcomes assessed every 3 months for 1 year included quality of life (QoL) (primary), functioning, physical and psychological symptom burden, and activity levels. Data were analyzed using mixed-effects models.

RESULTS

Participants from 16 clusters (control = 90, intervention = 83) were analyzed. The ACCESS program did not significantly improve QoL (primary outcome). However, compared with usual care recipients, ACCESS recipients reported higher physical functioning (P = .017), role functioning (P = .001), and activity levels (P < .001) at 9 months and lower psychological distress (P = .025) at 12 months. ACCESS recipients screened with high distress had poorer QoL, lower role and social functioning, and higher physical symptom distress at 3 months but had comparable scores with ACCESS recipients without high distress after 12 months.

CONCLUSION

Compared with usual care, participation in the ACCESS program did not yield QoL improvement but showed earlier functioning recovery related to activities of daily living and reduced psychological distress. Routine distress screening is a promising mechanism to identify survivors with poorer health for more intensive supportive care.

Risk factors for self-reported high symptom cluster burdens in patients with breast cancer undergoing chemotherapy in China: A cross-sectional study

Background and Aims

Further exploration is needed to recognize symptom clusters and categorize subgroups with distinct cluster patterns and associated risks, focusing on symptoms that are highly self-reported by patients with breast cancer undergoing chemotherapy. This study aimed to identify subgroups and risk factors for self-reported high symptom cluster burden among patients with breast cancer undergoing chemotherapy.

Methods

A total of 647 participants who met the inclusion criteria were included in the study, with data collected on demographics, disease information, self-reported symptoms, and psychosocial factors. Latent class analysis was utilized to identify the subgroup, while logistic regression was used to pinpoint predictive risk factors.

Results

Latent class analysis revealed three subgroups: the "high burden of all symptoms group" (n = 107, 16.54%), the "high burden of psychological symptoms group" (n = 103, 15.92%), and the "low burden of all symptoms group" (n = 437, 67.54%). Patients in the high burden of all symptom group and high burden of psychological symptom group exhibited significantly worse function outcomes (p < 0.001). Predictive risk factors for the "high burden of all symptom group" included older age, lower self-efficacy, worse body image, and a higher financial burden. Similarly, patients with high burden of psychological symptom were more likely to have low self-efficacy, poor body image, and a high financial burden.

Conclusion

The study demonstrated the importance of giving more attention to patients with breast cancer who are at risk of developing into membership of high symptom cluster burden group.

Effects of yoga interventions on the fatigue-pain-sleep disturbance symptom cluster in breast cancer patients: A systematic review

OBJECTIVE

This systematic review aimed to evaluate the effectiveness of yoga intervention on the fatigue-pain-sleep disturbance symptom cluster in breast cancer patients.

METHODS

Ten electronic databases (Medline, Embase, PubMed, Cochrane Central Register of Controlled Trials, CINAHL, Web of Science, Scopus, British Nursing Index, China National Knowledge Infrastructure, and Wan Fang database) were searched to identify randomized controlled trials from inception to October 2023. Two independent reviewers evaluated study eligibility, extracted data, and assessed the risk of bias using the Cochrane Risk of Bias tool. The findings were synthesized narratively. This systematic review has been registered (PROSPERO ID: CRD42023391269).

RESULTS

A total of 1389 studies were identified, and 18 studies were included in this systematic review. Two studies reported significant alleviation of fatigue-pain-sleep disturbance symptoms, and two studies indicated a significant reduction in fatigue-sleep disturbance symptoms compared to the control group. Commonly employed yoga contents included breathing exercise and posture practice. The effective intervention components encompassed the combination of in-person sessions and home-based sessions delivery mode, with intervention sessions lasting 50-120 min each and dosages ranging from once per week to twice daily, spanning 6-16 weeks.

CONCLUSIONS

Yoga intervention can be beneficial in alleviating the fatigue-pain-sleep disturbance symptom cluster in breast cancer patients. Future research should be tailored to design yoga interventions addressing different treatment stages and preferences of breast cancer patients.

The Impact of Sleep on the Lives of Women Who Have Breast Cancer-Related Lymphedema: A Qualitative Exploration

Background: Breast cancer survivors (BCSs) have many lifelong symptoms of anxiety, depression, lymphedema, and fatigue that can be exacerbated by sleep disturbance. However, little is known about unique factors contributing to sleep disturbance among BCSs with lymphedema; this requires further investigation to offer appropriate support and treatment to these individuals. Therefore, the objective of this study was to capture perceptions and experiences of lymphedema and sleep among BCSs with lymphedema. Methods and Results: Qualitative description guided data collection and analysis as part of a mixed-methods investigation to characterize sleep disturbance among BCSs with and without lymphedema. The participants were interviewed one-on-one using a semistructured interview guide. Inductive content analysis was completed using an iterative coding approach, condensing, and categorizing to develop four themes. Seven BCSs with lymphedema participated. From their narratives, four themes were developed: (1) mind and body fatigue are exacerbated by sleep disturbance; (2) fatigue impacted fragile coping and support systems; (3) fatigue influenced self-identity and roles in society; and (4) self-management strategies were used for sleep health. Conclusion: The participants' perceptions of sleep disturbances' impact on their lives endorse further investigation into optimal interventions to improve sleep quality and modify these impactful findings to create a higher quality of life for survivorship.

Modulatory Effects of XIAOPI Formula on CXCL1 and Selected Outcomes in Triple-Negative Breast Cancer: A Randomized Controlled Clinical Trial

Background

Triple-negative breast cancer (TNBC) is the most aggressive malignancy. Psychological distress and elevated CXCL1 level have been reported to be closely associated with the poor prognosis and quality of life of patients with TNBC. In preclinical studies using xenograft mouse models, XIAOPI formula, a nationally approved drug prescribed to patients at high risk for breast cancer, inhibited CXCL1 expression and improved survival. Traditional Chinese medicine has unique advantages in improving patients' emotional disorders and quality of life. However, the impact of XIAOPI formula on the serum level of CXCL1, psychological distress, and quality of life among patients with TNBC is currently unknown.

Methods

In this study, we designed a randomized, double-blind, placebo-controlled trial. Patients with TNBC were randomly assigned to receive either the XIAOPI formula or a placebo for three months. The primary outcomes include serum CXCL1 expression, Self-Rating Anxiety Scale (SAS), and the Self-Rating Depression Scale (SDS). Secondary outcomes included the Pittsburgh Sleep Quality Index (PSQI) and the Functional Assessment of Cancer Therapy-Breast (FACT-B).

Results

A total of 60 patients with TNBC were enrolled in the investigation. The results showed that the XIAOPI formula significantly decreased CXCL1 expression compared with the control group. Moreover, in comparison to the placebo, the XIAOPI formula increased FACT-B scores while decreasing SDS, SAS, and PSQI scores.

Conclusion

In patients with TNBC, XIAOPI formula may be effective in reducing CXCL1 levels, enhancing psychological well-being, and quality of life. While our research offers a natural alternative therapy that may enhance the prognosis of TNBC, future validation of its therapeutic effects will require large-scale, long-term clinical trials.

Clinical Registration Number

Registration website: www.chictr.org.cn, Registration date: 2018-1-19, Registration number: ChiCTR1800014535.

Symptom Clusters and Their Impact on Spiritual Well-Being Among Women with Breast Cancer

Purpose

To explore symptom experience and symptom clusters among Jordanian women with breast cancer and investigate whether these clusters predict patients' spiritual well-being.

Patients and Methods

A sample of 142 Jordanian women with breast cancer were asked to complete the Memorial Symptom Assessment Scale (MSAS), Functional Assessment of Chronic Illness Therapy- Spiritual Well-being (FACIT-Sp) scale, and socio-demographic questionnaire. Exploratory factor analysis was used to group symptoms into clusters, and multiple linear regression was used to explore the symptom clusters that predict spiritual well-being.

Results

The most prevalent symptoms among women with breast cancer were fatigue, anxiety, tension, and pain. All these symptoms have a prevalence greater than 50%. Three clusters were found: treatment-related symptom cluster consisting of eight symptoms, gastrointestinal symptom cluster consisting of seven symptoms, and psychological symptom cluster consisting of five symptoms. The psychological symptom cluster was the only cluster predicting the women's spiritual well-being (t (141) = -3.049; p < 0.01).

Conclusion

Women with breast cancer experience several concurrent symptoms and symptom clusters. Screening for psychological symptom clusters and their treatment improves patients' spiritual well-being. The majority of women with breast cancer did not receive any complementary therapies and hardly any spiritual or psychological support, which should be provided in the future to support their spiritual well-being.

Acupuncture for the treatment of the pain-fatigue-sleep disturbance-numbness/tingling symptom cluster in breast cancer survivors: a feasibility trial

PURPOSE

Breast cancer survivors following disease-modifying treatment frequently experience multiple-concurrent symptoms (Jansana et al. in Int J Cancer 149(10):1755 1767, 2021), negatively impacting their quality of life and increasing the risk of polypharmacy (Alwhaibi et al. in J Oncol Pharm Pract 26(5):1052 1059, 2020). This study evaluates the feasibility and acceptability of acupuncture for the management of the pain-fatigue-sleep disturbance-numbness/tingling symptom cluster in breast cancer survivors, and investigates relationships between the symptom cluster and Traditional Chinese Medicine (TCM) syndrome diagnosis.

METHODS

This was a single-arm, pre-test/post-test feasibility trial conducted at Chris O'Brien Lifehouse Hospital, Australia. Breast cancer survivors who completed treatment and experienced clinically significant levels of two or more symptoms (pain, fatigue, sleep disturbance, numbness/tingling) were eligible to participate in the individualized, pragmatic 6-week acupuncture intervention. The primary outcome was feasibility and acceptability. Effectiveness was explored using a symptom cluster mean score.

RESULTS

Twenty women enrolled in the study over an 11-week period and 90% completed the study. Most women agreed or completely agreed that acupuncture was feasible (85%), acceptable (90%), and appropriate (90%). Both mean and composite symptom cluster scores were significantly reduced (p < 0.001), as were individual symptom scores in fatigue (p < 0.001), sleep disturbance (p = 0.04), and numbness/tingling (p = 0.01). TCM syndromes most closely associated with this symptom cluster were Spleen qi deficiency and Heart fire. No adverse events were reported.

CONCLUSION

This study demonstrated that acupuncture was safe and feasible, justifying a powered randomized control trial. Preliminary findings suggest beneficial effects of acupuncture for the management of the pain-fatigue-sleep disturbance-numbness/tingling symptom cluster for women with breast cancer. TCM syndromes identified in this trial may be used to guide acupuncture treatment protocols.

CLINICAL TRIAL REGISTRATION

This trial was registered with the Australian New Zealand Clinical Trials Registry (ACTRN12622000590763) on 21 April 2022.

Interventions for insomnia in cancer patients and survivors-a comprehensive systematic review and meta-analysis

BACKGROUND

Considering the persistent nature and higher prevalence of insomnia in cancer patients and survivors compared with the general population, there is a need for effective management strategies. This systematic review and meta-analysis aimed to comprehensively evaluate the available evidence for the efficacy of pharmacological and nonpharmacological interventions for insomnia in adult cancer patients and survivors.

METHODS

Following the PRISMA guidelines, we analyzed data from 61 randomized controlled trials involving 6528 participants. Interventions included pharmacological, physical, and psychological treatments, with a focus on insomnia severity and secondary sleep and non-sleep outcomes. Frequentist and Bayesian analytical strategies were employed for data synthesis and interpretation.

RESULTS

Cognitive-Behavioral Therapy for Insomnia (CBT-I) emerged as the most efficacious intervention for reducing insomnia severity in cancer survivors and further demonstrated significant improvements in fatigue, depressive symptoms, and anxiety. CBT-I showed a large postintervention effect (g = 0.86; 95% confidence interval [CI] = 0.57 to 1.15) and a medium effect at follow-up (g = 0.55; 95% CI = 0.18 to 0.92). Other interventions such as bright white light therapy, sleep medication, melatonin, exercise, mind-body therapies, and mindfulness-based therapies showed benefits, but the evidence for their efficacy was less convincing compared with CBT-I. Brief Behavioral Therapy for Insomnia showed promise as a less burdensome alternative for patients in active cancer treatment.

CONCLUSIONS

CBT-I is supported as a first-line treatment for insomnia in cancer survivors, with significant benefits observed across sleep and non-sleep outcomes. The findings also highlight the potential of less intensive alternatives. The research contributes valuable insights for clinical practice and underscores the need for further exploration into the complexities of sleep disturbances in cancer patients and survivors.

The Effect of Art Therapy on Pain, Emesis, Anxiety, and Quality of Life in Operated Breast Cancer Patients: Randomized Control Trials

Background: Breast cancer symptoms related to the disease nature and treatments develop and the quality of life of patients is impacted. Art therapy improves the quality of life by increasing symptom control and treatment compliance. This study aimed to determine the effect of art therapy on pain, emesis, anxiety, and quality of life in operated breast cancer patients. Methods: This experimental research was carried out with a total of 60 patients, 30 in the intervention group (IG) and 30 in the control group (CG), who received treatment in the Oncology Center of Sivas Cumhuriyet University Practice and Research Hospital. A Personal Information Form, the Pain Intensity-Visual Analog Scale, the Rhodes Index of Nausea, Vomiting, and Retching, the Beck Anxiety Inventory, and the Functional Assessment of Cancer Therapy Scale-General (FACT-G) were used to collect research data. Within the scope of the research, IG received chemotherapy sessions for 10 weeks (five sessions) with 2-week intervals by an art specialist in marbling, accompanied by ney music. CG received no intervention. The obtained data were uploaded to the SPSS (22.0) program and statistical analysis was performed. Results: The decrease in the pain, nausea-vomiting, and anxiety levels of the patients in IG and the increase in their quality of life after the art therapy accompanied by ney music were statistically significant compared with the first follow-up (p < 0.05). There was no statistically significant change in the quality of life of the patients in the CG, whereas their pain, nausea-vomiting, and anxiety scores increased. According to the comparison between IG and CG, there was a significant difference in favor of IG in terms of pain severity, quality of life, emesis, and anxiety levels (p < 0.05). Conclusions: The art of marbling with ney was effective in operated breast cancer patients experiencing pain, emesis, and anxiety and improved their quality of life. Clinical Trial Registration: NCT05666583.

Network analysis used to investigate the interplay among somatic and psychological symptoms in patients with cancer and cancer survivors: a scoping review

PURPOSE

Patients with cancer often experience multiple somatic and psychological symptoms. Somatic and psychological symptoms are thought to be connected and may reinforce each other. Network analysis allows examination of the interconnectedness of individual symptoms. The aim of this scoping review was to examine the current state of knowledge about the associations between somatic and psychological symptoms in patients with cancer and cancer survivors, based on network analysis.

METHODS

This scoping review followed the five-stage framework of Arksey and O'Malley. The literature search was conducted in May, 2023 in PubMed, APA PsycINFO, Embase Cochrane central, and CINAHL databases.

RESULTS

Thirty-two studies were included, with eleven using longitudinal data. Seventeen studies reported on the strength of the associations: somatic and psychological symptoms were associated, although associations among somatic as well as among psychological symptoms were stronger. Other findings were the association between somatic and psychological symptoms was stronger in patients experiencing more severe symptoms; associations between symptoms over time remained rather stable; and different symptoms were central in the networks, with fatigue being among the most central in half of the studies.

IMPLICATIONS FOR CANCER SURVIVORS

Although the associations among somatic symptoms and among psychological symptoms were stronger, somatic and psychological symptoms were associated, especially in patients experiencing more severe symptoms. Fatigue was among the most central symptoms, bridging the somatic and psychological domain. These findings as well as future research based on network analysis may help to untangle the complex interplay of somatic and psychological symptoms in patients with cancer.

Sentinel and networked symptoms in patients with breast cancer undergoing chemotherapy

PURPOSE

It was designed to identify the symptom clusters and sentinel symptoms among patients with breast cancer receiving chemotherapy at the community level, and to explore core and bridge symptoms at the global level.

METHODS

A cross-sectional survey was conducted using the MD Anderson Symptom Inventory. Patients with breast cancer receiving chemotherapy, recruited from the "Be Resilient to Breast Cancer" project between January 2023 and December 2023, were included in the study. Symptom clusters and their sentinel symptoms were identified using exploratory factor analysis and Apriori algorithm. Core and bridge symptoms were identified using network analysis.

RESULTS

A total of 468 patients with breast cancer participated in the current study. At the community level, three symptom clusters and their corresponding sentinel symptoms were identified: a gastrointestinal symptom cluster (with nausea as the sentinel symptom), a psycho-sleep-related symptom cluster (with distress as the sentinel symptom), and a neurocognition symptom cluster (with dry mouth as the sentinel symptom). At the global level, fatigue emerged as the core symptom, while disturbed sleep and lack of appetite as bridge symptoms.

CONCLUSION

Addressing nausea, distress, and dry mouth are imperative for alleviating specific symptom clusters at the community level. Furthermore, targeting fatigue, disturbed sleep, and lack of appetite are crucial to break the interactions among diverse symptoms at the global level.

Application of hospital-community-home linkage management model in patients with type 2 diabetic nephropathy

OBJECTIVE

To explore the effect of the hospital-community-home (HCH) linkage management mode in patients with type 2 diabetic nephropathy (DN).

METHOD

A total of 80 patients with type 2 DN hospitalised in the Department of Nephrology of our hospital between July 2021 and June 2022 were recruited and subsequently divided into the observation group and the control group using the random number table method, with 40 patients in each group. The control group received routine health education and discharge guidance. The HCH linkage management model was implemented for the observation group based on routine care. The improvements in compliance behaviour, biochemical parameters of renal function, blood glucose level and self-management ability were compared before the intervention and at 3 and 6 months after the intervention.

RESULTS

After the intervention, the scores for compliance behaviour of the observation group were better than those of the control group, with a statistically significant difference (P < 0.05). The biochemical indicators of renal function and blood glucose level were significantly lower in the observation group compared with in the control group, with a statistically significant difference (P < 0.05). After the intervention, the observation group showed a great improvement in self-management ability and cognition of the disease, with significant differences (P < 0.05).

CONCLUSION

The HCH linkage management mode can improve the compliance behaviour of patients with type 2 DN, effectively improve the renal function and blood sugar level of patients, enhance the self-management ability and cognition of the disease and delay the development of the disease.

Reliability and validity of the translated Chinese version of comprehensive assessment of acceptance and commitment therapy processes (CompACT-C) in breast cancer survivors

Purpose

This study aimed to translate and validate a Chinese version of the Comprehensive assessment of Acceptance and Commitment Therapy processes (CompACT-C), a 23-item questionnaire for measuring an individual's level of psychological flexibility among Chinese breast cancer survivors for utilisation of Acceptance and commitment therapy (ACT)-based interventions in breast cancer patients.

Methods

Six translators translated the original English version into Chinese according to Brislin's Translation Model. Psychometric properties tests were conducted on the CompACT-C, including internal consistency, test-retest reliability (two-week interval), face validity, content validity, convergent validity with experiential avoidance, and construct validity (confirmatory factor analysis).

Results

308 Chinese breast cancer survivors with mastectomies were conveniently recruited. The translated scale showed satisfactory test-retest reliability (two-week interval, r = 0.53-0.72, p < 0.001), face validity, and content validity (CVI-Scale/CVS-Item = 1.00). According to the confirmatory factor analysis results, the final Chinese version remained the 23 items and three dimensions, with the modification of item six from the dimension of openness to experience to behavioural awareness for better model fitness [structural equation model analysis, χ2 = 559.486, df = 226, NC (χ2/df) = 2.476, RMSEA = 0.069, CFI = 0.834, TLI = 0.815, SRMR = 0.079] and satisfactory internal consistency (Cronbach's α = 0.71), convergent validity with AAQ-2 (r = -0.57, p < 0.001) in these breast cancer patients.

Conclusions

The Chinese version of the CompACT showed good reliability and validity among Chinese breast cancer patients. Future research is suggested to confirm its psychometric properties with diverse breast and other cancer groups.

Patient-reported outcomes and symptom clusters pattern of chemotherapy-induced toxicity in patients with early breast cancer

OBJECTIVE

This study aims to characterize patient-reported chemotherapy-induced toxicity in patients with breast cancer, determine its association with treatment regimens and patient characteristics, identify toxicity symptom clusters within a specific chemotherapy timeframe and analyze the correlation between symptom clusters within and between the timeframe to understand the changes and influences across chemotherapy.

METHODS

Forty-six patient-reported toxicities during neoadjuvant/adjuvant chemotherapy for breast cancer were evaluated using adapted CTCAE version 4.0. Chi-Square/Fisher's Exact test was performed to analyze the difference in the incidence of toxicity symptoms by chemotherapy regimens. Poisson regression performed to assess factors associated with patient's total chemotherapy toxicity. Exploratory factor analysis (EFA) conducted to identify symptom clusters at T1 (first half) and T2 (second half of planned cycle). Factor scores were generated and Spearman correlation performed to explore the factor scores correlation between symptom clusters.

RESULTS

A total of 142 patients with stage I-III breast cancer were included. The incidence of several toxicities differed significantly among three chemotherapy regimens. Subjects age ≥51 years are associated with lower number of reported toxicity (IRR/incidence rate ratio = 0.94, 95% confidence interval/CI 0.88 to 0.99, p = 0.042). Receiving more chemotherapy cycles are associated with higher number of reported toxicity (IRR = 1.06, 95% CI 1.03 to 1.10, p<0.001). Two symptom clusters identified at T1 (psychoneurological-pain/PNP-T1 and gastrointestinal-psychological/GIP-T1 cluster) and three at T2 (psychoneurological-pain/PNP-T2, epithelial/EPI-T2, and gastrointestinal cluster/GI-T2), with moderate-strong positive correlation between PNP-T1 and GIP-T2 (p<0.001), PNP-T1 and PNP-T2 (p<0.001), and GIP-T1 and PNP-T2 (p<0.001).

CONCLUSIONS

This study investigated 46 patient-reported toxicities prospectively during adjuvant/neoadjuvant chemotherapy for early breast cancer. Anthracycline-taxane combination regimen had higher proportions of toxicity incidence. Subject's age and number of chemotherapy cycles significantly associated with total number of toxicity symptoms. Two symptom clusters at T1 and three at T2 were identified, with significant correlation between symptom clusters within and between chemotherapy timeframe.

Treatment and Management of the Clinical Manifestations of Advanced Breast Cancer

OBJECTIVES

People with advanced breast cancer (ABC) experience complex and debilitating physical symptoms of their disease that can have a profound effect on quality of life. This report provides an overview of the clinical manifestations related to different metastatic sites in ABC and potential oncologic emergencies.

DATA SOURCES

Date sources include peer-reviewed papers sourced in electronic databases (CINAHL, MEDLINE, Google Scholar) and national and international best practice guidelines.

CONCLUSION

People living with ABC experience multiple symptoms of disease that can impact on quality of life and physical functioning. The most common sites of metastatic disease are bone, lung, liver and brain. Clinical manifestations of ABC include pain, pathologic fractures, pleural effusions, and ascites. Potential oncologic emergencies related to these metastatic sites include hypercalcemia, malignant spinal cord compression, superior vena cava obstruction, and raised intracranial pressure.

IMPLICATIONS FOR NURSING PRACTICE

It is important for nurses to have informed knowledge and understanding of these clinical manifestations. This will enable them to be vigilant and perform targeted patient evaluation to assess signs and symptoms with a view to identifying potentially life-threatening emergencies and initiating interventions or appropriate referral or follow-up accordingly.

Changes in Symptom Clusters Among Asian American Breast Cancer Survivors in Technology-Based Coaching Intervention

BACKGROUND

Limited research studies have focused on examining the impact of technology-based interventions in changing symptom clusters among Asian American breast cancer survivors.

OBJECTIVE

The aim of this study was to understand the longitudinal impact of a technology-based program on the symptom cluster experience of Asian American breast cancer survivors.

METHODS

This is a secondary data analysis that used exploratory factor analysis at each time point (baseline, post-1 month, post-3 months) for the control and intervention groups (N = 199).

RESULTS

The number of symptom clusters remained the same, and the same symptoms remained in similar clusters across the 2 groups. The control group experienced psychological cluster, fatigue cluster, and neck/skin cluster at baseline; psychological cluster, fatigue/dizzy cluster, and neck/skin cluster at post-1 month; and psychological cluster, fatigue/dizzy cluster, and somatic cluster at post-3 months. The intervention group experienced psychological cluster, neck cluster, and appetite/itching cluster at baseline; somatic/anticholinergic cluster, psychological/sexual cluster, and appetite cluster at post-1 month; and psychological cluster, neck cluster, and itching cluster at post-3 months. The psychological and neck clusters shared similar core symptoms of feeling nervous, dry mouth, and cough between the control and intervention groups.

CONCLUSION

The different symptom cluster experiences may be due to the technology-based intervention where the intervention group receives individual/group coaching/support that may have changed symptom clusters over time. Yet, the true efficacy of the intervention on symptom clusters warrants further investigation.

IMPLICATIONS FOR PRACTICE

Clinicians should understand the changes in symptom clusters as well as the presence of core symptoms and take a targeted symptom cluster approach in clinical settings.

Burden of late effects in a nationwide sample of long-term breast cancer survivors

BACKGROUND

Long-term breast cancer survivors (BCSs) may experience several late effects (LEs) simultaneously. This study aimed to identify subgroups of 8-year BCSs with higher burden of LEs who could benefit from closer survivorship care, explore variables associated with higher symptom burden, and describe how symptom burden may affect general functioning.

METHODS

All Norwegian women aged 20 to 65 years when diagnosed with stage I-III breast cancer in 2011 and 2012 were invited (n = 2803). The European Organization for Research and Treatment of Cancer Quality of Life Questionnaire/BR23, the Fatigue Questionnaire, Assessment of Survivor Concerns, and Scale for Chemotherapy Induced Long-term Neurotoxicity were used to assess 10 common LEs and general functioning. Using latent class analysis, subgroups of BCSs with similar burden of LEs were identified. Multinominal regression analysis were performed to examine variables associated with higher symptom burden.

RESULTS

The final sample consisted of 1353 BCSs; 46% had low, 37% medium, and 17% high symptom burden. Younger age, short education, axillary dissection, higher systemic treatment burden, higher body mass index, and physical inactivity were associated with higher symptom burden. General functioning scores were lower, and the proportion on disability pension were higher among BCSs in the two most burdened subgroups compared with those in the low burden subgroup.

CONCLUSION

More than half of long-term BCSs suffered from medium or high symptom burden and experienced impaired general functioning compared with BCS with low symptom burden. Younger age and systemic treatment were important risk factors for higher symptom burden. BCSs at risk of higher symptom burdens should be identified and offered closer and extended survivorship care.

Symptom clusters in breast cancer survivors with and without type 2 diabetes over the cancer trajectory

Objective

This study aimed to investigate symptoms and symptom clusters in breast cancer survivors (BCS) with and without type 2 diabetes across three crucial periods during the cancer trajectory (0-6 months, 12-18 months, and 24-30 months) post-initial chemotherapy.

Methods

Eight common symptoms in both BCS and individuals with diabetes were identified through natural language processing of electronic health records from January 2007 to December 2018. Exploratory factor analysis was employed to discern symptom clusters, evaluating their stability, consistency, and clinical relevance.

Results

Among the 4601 BCS in the study, 20% (n = 905) had a diabetes diagnosis. Gastrointestinal symptoms and fatigue were prevalent in both groups. While BCS in both groups exhibited an equal number of clusters, the composition of these clusters differed. Symptom clusters varied over time between BCS with and without diabetes. BCS with diabetes demonstrated less stability (repeated clusters) and consistency (same individual symptoms comprising clusters) than their counterparts without diabetes. This suggests that BCS with diabetes may experience distinct symptom clusters at pivotal points in the cancer treatment trajectory.

Conclusions

Healthcare providers must be attentive to BCS with diabetes throughout the cancer trajectory, considering intensified and/or unique profiles of symptoms and symptom clusters. Interdisciplinary cancer survivorship models are essential for effective diabetes management in BCS. Implementing a comprehensive diabetes management program throughout the cancer trajectory could alleviate symptoms and symptom clusters, ultimately enhancing health outcomes and potentially reducing healthcare resource utilization.

Evaluation of the Nurse-Led Symptom Management Program for Patients With Gynecologic Cancer Undergoing Chemotherapy

BACKGROUND

Patients with cancer experience symptoms concurrently. Nurses need to make multisymptom management and educate patients about self-management strategies.

OBJECTIVE

The aim of this study was to evaluate the effect of a nurse-led symptom management program (NL-SMP), developed based on the Symptom Management Model, quality of life (QoL), and symptom severity of women with gynecological cancer undergoing chemotherapy.

METHODS

This randomized controlled study sample consisted of 41 women receiving chemotherapy at an outpatient clinic in Istanbul, Turkey, between November 2018 and December 2019. European Organisation for Research and Treatment of Cancer Quality-of-Life Scale, Edmonton Symptom Assessment Scale, and Modified Brief Sexual Symptom Checklist-Women were used to collect data. Women were randomly assigned to 2 groups: intervention (n = 21) and control (n = 20). The intervention group attended the NL-SMP in addition to usual care. Data were collected at the first (time 1), third (time 2), and last chemotherapy cycle (time 3). Repeated measures analysis of variance, Cochran-Q, and t tests were used to analyze the data.

RESULTS

In the intervention group, the QoL was significantly higher; symptom severity was lower than that of the control group at time 2 and time 3. At time 3, more women in the control group reported at least 1 sexual difficulty and were not satisfied with their sexual function, whereas there was no change for women in the intervention group.

CONCLUSION

The NL-SMP, which consisted of systematic symptom assessment, prioritization of symptoms, providing symptom, and patient-specific education, decreased deterioration in the QoL and symptom severity of women.

IMPLICATIONS FOR PRACTICE

Conducting multisymptom assessments, prioritizing symptoms, providing symptom- and patient-specific education, and supporting symptom self-management throughout treatment can lead to effective symptom management.

Favorable impact of therapy management by an interactive eHealth system on severe adverse events in patients with hormone receptor-positive, HER2-negative locally advanced or metastatic breast cancer treated by palbociclib and endocrine therapy

BACKGROUND

Oral cancer medications offer advantages but also pose challenges for therapy management and adherence. An eHealth-based platform such as CANKADO can help to support therapy management by probing the patient's quality of life (QoL) continuously throughout the course of treatment.

MATERIAL AND METHODS

AGO-B WSG PreCycle (NCT03220178) is a multicenter, randomized phase IV intergroup trial evaluating the impact of eHealth-based Patient-Reported Outcome (ePRO) assessment on QoL in patients with hormone receptor-positive (HR + )/HER2-negative (HER2-) advanced breast cancer treated with palbociclib and endocrine therapy. Patients were randomized (2:1) to CANKADO-active arm (supported by CANKADO PRO-React) or CANKADO-inform arm (drug intake documentation only) This exploratory analysis reports the impact of CANKADO PRO-React on safety. Time to first serious adverse event (SAE) was estimated taking competing risks into account.

RESULTS

While distributions of adverse events (AEs) were similar by arm overall, patients in the CANKADO-active arm had a favorable hazard ratio of 0.67 (95%CI 0.46-0.97; p = 0.04) for time to first SAE and were significantly less likely overall to suffer an SAE than patients in the inform arm. At 24 months, 22.9% [17.9%-27.8%] of patients in CANKADO-active had suffered an SAE vs. 30.3% [22.6%-38.0%] in CANKADO-inform. AE-related dose reductions affected approximately 20% of patients (CANKADO-active: 18.2%, CANKADO-inform: 21.1%).

CONCLUSION

Exploratory safety analysis of PreCycle demonstrates for the first time in a randomized prospective trial that interactive autonomous eHealth-based support has a substantial favorable impact on the risk of SAEs and mitigates their severity for patients with advanced HR+/HER2- breast cancer on oral tumor therapy.

Correlation between hemoglobin levels and depression in late-stage cancer patients with irritability as mediating variable

PURPOSE

In late-stage cancer, the cancer itself or the side effects of cancer treatment are known to affect the hemoglobin (Hgb) levels or emotions of patients. We to investigate the relationship between Hgb levels and depression in late-stage cancer patients and verified whether irritability has a mediating effect on this relationship.

METHOD

The research tools included a patient basic information form, the Irritability Scale-Initial Version (TISi), and the Hamilton Depression Rating Scale (HAMD). We first compared the Hgb levels, HAMD scores, and TISi scores of the cancer patients with different attributes, performed multiple hierarchical regression analysis, and then analyzed the mediating effects of TISi scores using the Sobel test.

RESULTS

In the 117 late-stage cancer patients, Hgb levels of patients with a BMI<18.5 kg/m2 were lower than those of the patients with a BMI 24.0 kg/m2. Hgb levels had a negative influence on both TISi scores (B = -2.74, p = .001) and HAMD scores (B = -0.75, p = .010). TISi scores mediated the relationship between Hgb levels and HAMD scores (Z = 2.06, p = .040).

CONCLUSIONS

Irritability is a mediating variable of the influence of Hgb levels on depression, meaning that lower Hgb levels in late-stage cancer patients may be detrimental to emotional stability, induce irritability, and thereby cause depression. Thus, in the psychological care of late-stage cancer patients, medical teams should be more vigilant in monitoring Hgb levels and anemia treatment.

Efficacy of traditional Chinese medicine external therapy on sleep quality in patients with cancer: A systematic review and network meta-analysis

Objective

This network meta-analysis aims to assess and compare the effectiveness of various external therapies from traditional Chinese medicine (TCM) in enhancing sleep quality among patients with cancer.

Methods

We systematically searched nine electronic databases, encompassing five English and four Chinese databases, for randomized controlled trials (RCTs) from their inception up to August 10, 2023. The random effects model was utilized for effect size analysis, and the standardized mean difference (SMD) along with its corresponding 95% confidence interval (CI) were computed. Network meta-analysis and comparative effects ranking were executed utilizing STATA 14.0.

Results

We included thirty-four RCTs involving seven distinct external TCM therapies. Among these, Chinese medicine pillow (SMD = -3.27; 95% CI: -6.03 to -0.51), auricular acupressure (SMD = -2.33; 95% CI: -3.36 to -1.29), moxibustion (SMD = -2.28; 95% CI: -3.63 to -0.94), acupressure (SMD = -1.67; 95% CI: -2.64 to -0.70), and acupuncture (SMD = -1.43; 95% CI: -2.65 to -0.21) demonstrated significant effects in improving sleep quality when compared to usual care or waitlist. The cumulative ranking curve values revealed that the Chinese medicine pillow exhibited the highest potential for effectively enhancing sleep quality in patients with cancer, followed by auricular acupressure, moxibustion, acupressure, acupuncture, Tuina, and electroacupuncture.

Conclusions

Our study highlights the Chinese medicine pillow as an optimal external TCM therapy for ameliorating sleep quality in cancer patients, but more RCTs are needed to validate this conclusion. These findings serve as valuable support for future clinical trials and research endeavors.

Systematic review registration

CRD42022381370.

Symptom profiles and related factors among patients with advanced cancer: A latent profile analysis

Objective

This study aimed to investigate symptom subgroups and associated influencing factors in patients with advanced cancer.

Methods

A cross-sectional study was conducted, involving 416 patients with advanced cancer. The study examined five symptoms: fatigue, pain, sleep impairment, anxiety, and depression. Latent Profile Analysis (LPA) was utilized to classify symptom subgroups. A multiple logistic regression analysis was conducted to explore factors associated with the identified symptom subgroups.

Results

The analysis revealed three distinct subgroups among the participants: "all low" (58.2%), characterized by normal symptoms except for moderate sleep quality; "all moderate" (35.1%), exhibiting normal symptoms except for poor sleep quality and fatigue; and "all high" (6.7%), experiencing normal pain, moderate depression, moderate anxiety, poor sleep quality, and fatigue. Malnutrition risk, cancer diagnosis, and cancer survivorship duration were found to be associated with a more severe symptom burden.

Conclusions

Patients in the "all high" subgroup faced an increased risk of malnutrition and a longer cancer survivorship duration. Additionally, patients in the "all moderate" subgroup were distinguished by having a breast cancer diagnosis. These findings have significant implications for allocating medical resources and implementing person-centered symptom management strategies.

High neuroticism is associated with common late adverse effects in a nationwide sample of long-term breast cancer survivors

PURPOSE

Neuroticism is a basic personality trait characterized by negative emotions triggered by stress such as a breast cancer diagnosis and its treatment. Due to lack of relevant research, the purpose of this study was to examine if high neuroticism is associated with seven common late adverse effects (LAEs) in long-term (≥ 5 years) breast cancer survivors (BCSs).

METHODS

All female Norwegian BCSs aged 20-65 years when diagnosed with stage I-III breast cancer in 2011 or 2012 were invited to a questionnaire study in 2019 (N = 2803), of whom 48% participated (N = 1355). Neuroticism was self-rated using the abridged version of the Eysenck Personality Questionnaire, and scores dichotomized into high and low neuroticism. LAEs were defined by categorization of ratings on the EORTC QLQ-C30 (cognitive function, pain, and sleep problems) and QLQ-BR23 (arm problems) questionnaires, and categorizations of scale scores on mental distress, fatigue, and neuropathy. Associations between high neuroticism and LAEs were explored using multivariate logistic regression analyses.

RESULTS

High neuroticism was found in 40% (95%CI 37-42%) of BCSs. All LAEs were significantly more common among BCSs with high compared to low neuroticism. In multivariable analyses, high neuroticism was positively associated with all LAEs except neuropathy. Systemic treatment, somatic comorbidity, and not being in paid work were also significantly associated with all LAEs.

CONCLUSIONS

High neuroticism is prevalent and associated with increased risks of LAEs among BCSs. Identification of high neuroticism could improve the follow-up care of BCSs as effective interventions for the condition exist.

Symptom Clusters in Survivorship and Their Impact on Ability to Work among Cancer Survivors

BACKGROUND

Cancer survivors often experience a range of symptoms after treatment which can impact their quality of life. Symptoms may cluster or co-occur. We aimed to investigate how symptoms and symptom clusters impact the ability to work among cancer survivors.

METHODS

We used symptom severity data and ability to work data routinely collected from cancer survivors attending a survivorship clinic after primary treatment with curative intent. We defined symptom clusters using single linkage and a threshold on the rescaled distances of <10. We then conducted a logistic regression to examine how symptoms and symptom clusters were related to the ability to work.

RESULTS

We analysed data from 561 cancer survivors, mean age 58 years and 1.5 years post diagnosis, with mixed diagnoses including breast (40.5%), colorectal (32.3%), and haematological cancers (15.3%). Limitations to work ability were reported by 34.9% of participants. Survivors experiencing pain, emotional, and cognitive symptom clusters were 14-17% more likely to report limitations in their ability to work. Older survivors and those with a higher stage disease were more likely to report limitations in their ability to work.

CONCLUSION

A better understanding and management of symptom severity and symptom clusters may help the sizable proportion of cancer survivors experiencing symptoms to participate in work after treatment.

Multiple myeloma patients undergoing chemotherapy: Which symptom clusters impact quality of life?

AIMS AND OBJECTIVES

To identify symptom clusters and examine their association with health-related quality of life.

BACKGROUND

Multiple myeloma patients undergoing chemotherapy suffer from disease symptoms and adverse effects during the course of the disease. However, single symptom management has little effect, and symptom management for these patients remains challenging. Symptom clusters open a new perspective and provide important clues for symptom management.

DESIGN

A cross-sectional study.

METHOD

Participants were invited to complete the Chinese version of the Memorial Symptom Assessment Scale and Quality of Life Questionnaire-core 30. Appropriate indicators were used for descriptive statistics. Principal component analysis was used to identify symptom clusters. Associations between symptom clusters and quality of life were examined with Pearson correlation coefficients, Pearson correlation matrix and multiple linear regression. This study was reported following the STROBE checklist.

RESULTS

A total of 177 participants were recruited from seven hospitals in this study. We identified self-image disorder, psychological, gastrointestinal, neurological, somatic and pain symptom clusters in multiple myeloma patients with chemotherapy. Approximately 97.65% of patients suffer from multiple symptom clusters. The pain, psychological and gastrointestinal symptom clusters have negatively influence on health-related quality of life. The strongest association was found with the pain symptom cluster.

CONCLUSION

Most of multiple myeloma patients suffer from multiple symptom clusters. When improving the multiple myeloma patients' health-related quality of life, the clinical staff should prioritise relieving the pain symptom cluster.

RELEVANCE TO CLINICAL PRACTICE

When multiple myeloma patients undergoing chemotherapy suffer from multiple symptom clusters, nurses should prioritise relieving the pain symptom cluster to improve their health-related quality of life. When drawing up and providing interventions, nurses should focus on the correlation among symptoms rather than single symptom. By relieving one symptom in a given cluster, other symptoms within the same symptom cluster may also be relieved.

The role of cytokines and Indolamine-2.3 dioxygenase in experiencing a psycho-neurological symptom cluster in hematological cancer patients: IL-1alpha, IL-1beta, IL-4, IL-6, TNF-alpha, kynurenine, and tryptophan

OBJECTIVE

This study examined (a) whether there are a subgroup of cancer patients experiencing the selected psycho-neurological symptoms as a cluster (depression, cognitive impairment, fatigue, sleep disturbance, and pain); (b) whether demographic and clinical characteristics and pro-inflammatory cytokines (IL-1α, IL-1β, IL-4, IL-6, TNF-alpha) are associated with subgroup membership; and (c) whether the activity of indolamine-2.3 dioxygenase(IDO) is associated with pro-inflammatory cytokine activity and psycho-neurological symptom cluster experience.

METHODS

This was a prospective cohort study where 149 hematologic patients were recruited from a university hospital and 65 healthy volunteers provided control data. Latent profile analyses were conducted to identify subgroups at two time points: the last day of chemotherapy and 1 week after chemotherapy completion. Influencing factors of subgroup membership were examined by logistic regression.

RESULTS

A substantial number of patients (33%, 34% at each time point) experienced the selected psycho-neurological symptoms as a cluster. Older age and elevated IL-1α and IL-6 were associated with experiencing the psycho-neurological symptom cluster. IDO activity was higher in the patients experiencing psycho-neurological symptom cluster; and was positively associated with IL-6. Symptom severity, IL-1α, IL-6, and IDO activity were all significantly higher in cancer patients than in the healthy controls. The findings were preserved across time points.

CONCLUSIONS

The activation of pro-inflammatory cytokines and their cross-talk with IDO may be a common biological mechanism, underlying a psycho-neurological symptom cluster experience. The novel approaches for symptom assessment and management can be developed by assessing multiple psycho-neurological symptoms as a cluster and by targeting their common biological pathway.

Somatic acupressure for the fatigue-sleep disturbance-depression symptom cluster in breast cancer survivors: A phase II randomized controlled trial

OBJECTIVE

To evaluate the feasibility of the somatic acupressure (SA) for managing the fatigue-sleep disturbance-depression symptom cluster (FSDSC) among breast cancer (BC) survivors and its preliminary effects.

METHODS

In this Phase II randomized controlled trial (RCT), 51 participants were randomised evenly into the true SA group, sham SA group, and usual care group. All the participants received usual care. The two SA groups performed additional true or sham self-acupressure daily for seven weeks. The primary outcomes related to the assessment of participants' recruitment and compliance with study questionnaires and interventions. Clinical outcomes assessed the preliminary effects of SA on fatigue, sleep disturbance, depression, and quality of life. Semi-structured interviews were undertaken to capture participants' experiences of participating in this study. The statistical effects of the intervention on the outcomes were modelled in repeated measures ANOVA and adjusted generalized estimating equations.

RESULTS

Forty-five participants completed the SA intervention. No adverse events were reported. Over 85% of the participants could sustain for 25 days or more and 15 min or more per session, but the adherence to the intervention requirement was yet to improve. The group by time effect of the FSDSC and depression were significant (p < 0.05). Qualitative findings showed that participants positively viewed SA as a beneficial strategy for symptom management.

CONCLUSIONS

The SA intervention protocol and the trial procedures were feasible. The results demonstrated signs of improvements in targeted outcomes, and a full-scale RCT is warranted to validate the effects of SA on the FSDSC.

The effectiveness of exercise on the symptoms in breast cancer patients undergoing adjuvant treatment: an umbrella review of systematic reviews and meta-analyses

Background

Exercise has the potential to reduce symptoms for breast cancer patients during adjuvant treatment, and high-quality systematic reviews are essential for guiding clinical practice. The objective of this umbrella review is to examine current research evidence concerning the effectiveness of exercise on symptom management in breast cancer patients undergoing adjuvant treatment.

Methods

An umbrella review was conducted. We searched for eligible systematic reviews through 11 databases until August 13rd, 2023. Two authors independently screened titles and abstracts, assessing the full-text studies based on inclusion criteria. We used AMSTAR-2 to appraise the quality of the meta-analyses. The results would be presented with narrative summaries if the replication rate of the original study for a symptom was higher than 5% (calculated via the Corrected Covered Area, CCA). The protocol was documented in the PROSPERO registry (CRD42023403990).

Results

Of the 807 systematic reviews identified, 15 met the inclusion criteria, and 7 symptoms were the main focus. The main form of exercise mentioned was aerobic combined resistance exercise. The results of the quality assessment were mostly critically low (10/15). The repetition rate calculated by CCA showed moderate to very high repetition rates (10% to 18.6%). The findings of the included reviews indicated that the effects of exercise on relieving symptoms during breast cancer adjuvant treatment were mixed.

Conclusions

Research is still needed to confirm the majority of studies' recommendations for exercise during adjuvant treatment for breast cancer patients, as it is crucial for managing symptoms in the rehabilitation process. To increase the efficiency of exercise in symptom management, future studies may focus more on the application of bridge symptoms, symptom networks, and ecological instantaneous assessment.

Symptom clusters among breast cancer patients in relation to chemotherapy cycles: a longitudinal study

PURPOSE

The aim of this study was to identify symptom clusters in breast cancer patients undergoing adjuvant chemotherapy.

METHODS

A prospective longitudinal study was conducted. And a sample of 620 breast cancer patients receiving adjuvant chemotherapy was recruited using convenience sampling from May 20, 2020, to March 31, 2021. Data were collected eight times: the first chemotherapy cycle (T1) to the eighth cycle of chemotherapy (T8). Exploratory factor analysis was used to explore the composition of symptom clusters.

RESULTS

Symptoms with an incidence of less than 20% were deleted and the remaining symptoms were included in the factor analysis. Three common factors were extracted in T1, including gastrointestinal symptom cluster, emotional and psychological symptom cluster, and menopausal symptom cluster. Five common factors were extracted from T2 to T7, including gastrointestinal symptom cluster, emotional and psychological symptom cluster, neurological symptom cluster, menopausal symptom cluster, and self-image disorder symptom cluster. Four common factors were extracted at T8, including gastrointestinal symptom cluster, emotional and psychological symptom cluster, neurological symptom cluster, and menopausal symptom cluster.

CONCLUSION

Breast cancer patients undergoing adjuvant chemotherapy experience multiple symptoms and different symptom clusters in different chemotherapy cycles. It is a benefit for health care providers to better understand and care for breast cancer patients. It will also help such women to manage concurrent symptoms ahead to promote their quality of life.

Psychoneurological symptom cluster trajectories in individuals treated for early-stage breast cancer

BACKGROUND/PURPOSE

The psychoneurological (PN) symptom cluster has been defined in the literature as anxiety, depression, fatigue, sleep disturbance, and pain. PN symptoms are influenced by cancer and its treatment as well as biological and psychosocial factors. The purpose of this analysis was to describe temporal patterns of the PN symptom cluster severity in breast cancer survivors over the year following initial surgical intervention and investigate the time-dependent effect of treatment modality on symptom severity.

METHODS

In a prospective longitudinal study, symptom data were collected from individuals with early-stage breast cancer 48 h after initial surgery and at monthly intervals for the subsequent 12 months using the PROMIS®-29 subscales for anxiety, depression, fatigue, sleep disturbance, and pain. Applying group-based trajectory modeling, we classified participants into subgroups with similar temporal patterns of PN symptom cluster severity and included treatment modality as a time-dependent covariate.

RESULTS

Across 353 participants (mean age 60.10 ± 11.9 years, 88.95% white, 66.57% undergoing segmental mastectomies), four distinct trajectory subgroups (mild [47.6%; n = 168], moderate [28.3%; n = 100], severe [15.9%; n = 56], and most severe increasing [8.2%; n = 29]) were revealed for PN symptom cluster severity. Chemotherapy was associated with greater severity in all symptom severity subgroups, while radiation was associated with greater symptom severity in the mild and most severe increasing subgroups.

CONCLUSIONS AND IMPLICATIONS

A subgroup of individuals with early-stage breast cancer experienced persistent severe PN symptoms. Future research should focus on psychosocial, biological, and disease-related characteristics of individuals in the most severe symptom group to inform preventative treatments and effective interventions.

The Effect of Reiki on Pain Applied to Patients With Cancer: A Systematic Review

Pain, the most common and major source of fear in patients with cancer, reduces the quality of life. This systematic review was conducted to determine the effect of Reiki on pain applied to patients with cancer. The creation of a systematic review protocol and the writing of the article were based on the PRISMA-P (Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols) criteria. The literature review was carried out in PubMed, Scopus, and Cochrane Library databases. Seven experimental and quasi-experimental studies met the inclusion criteria, and a total of 572 patients with cancer with sample sizes ranging from 18 to 180 were included. In-person Reiki was applied in 6 of the studies included in the systematic review, while in one of them, distance Reiki was applied. Although Reiki was found to reduce pain in 5 studies included in the review, it was determined that it was not effective on pain in 2 studies. A limited number of studies show that Reiki applied to patients with cancer has a positive effect on pain. It is recommended to conduct more randomized controlled trials with a high methodological quality that examine the effectiveness of Reiki application for patients with cancer.

Nonpharmacological Interventions for Management of the Pain-Fatigue-Sleep Disturbance Symptom Cluster in Breast Cancer Patients: A Systematic Review and Network Meta-Analysis of Randomized Controlled Trials

Background

The pain-fatigue-sleep disturbance symptom cluster is commonly experienced by breast cancer patients, and a variety of nonpharmacological interventions are used to treat this symptom cluster.

Objective

To compare the efficacy of nonpharmacological interventions in improving the symptoms of the pain-fatigue-sleep disturbance symptom cluster in breast cancer patients.

Methods

A comprehensive literature search was conducted in the PubMed, EMBASE, Cochrane Library, CINAHL, CNKI, and Wanfang databases to identify randomized controlled studies from database inception to May 2022. Two reviewers independently performed data retrieval and risk of bias assessments. The consistency model was used to conduct network meta-analyses (NMA) based on the frequentist framework to assess the interventions, which were ranked by the surface under the cumulative ranking curve (SUCRA). Finally, the CINeMA application was used to evaluate the results of the NMA and the evidence of quality. The results Twenty-three eligible studies assessing 14 interventions were included. According to SUCRA values, among the management effects of the three symptoms, the effect of progressive muscle relaxation (PMR) ranked first, followed by mindfulness-based stress reduction (MBSR). The overall evidence quality of our study ranges from very low to moderate.

Conclusion

PMR and MBSR were effective interventions for the pain-fatigue-sleep disturbance symptom cluster in breast cancer patients. Clinical recommendations prioritize PMR for symptom management, followed by MBSR. However, this should be interpreted cautiously, as the confidence in the evidence was not high.

Prevalence of Psychoneurological Symptoms and Symptom Clusters in Women with Breast Cancer Undergoing Treatment: Influence on Quality of Life

OBJECTIVES

To identify subgroups of psychoneurological symptoms (PNS) and their relationship to different clinical variables in a sample of women with breast cáncer (BC) with different type of treatment, and the possible influence of these on quality of life (QoL), using a factorial principal components analysis.

DATA SOURCES

Observational, cross-sectional, non-probability study (2017-2021) at Badajoz University Hospital (Spain). A total of 239 women with BC receiving treatment were included.

RESULTS

68% of women presented fatigue, 30% depressive symptoms, 37.5% anxiety, 45% insomnia, and 36% cognitive impairment. The average score obtained for pain was 28.9. All the symptoms were related between themselves, and within the cluster of PNS. The factorial analysis showed three subgroups of symptoms, which accounted for 73% of variance: state and trait anxiety (PNS-1), cognitive impairment, pain and fatigue (PNS-2), and sleep disorders (PNS-3). The depressive symptoms were explained equally by PNS-1 and PNS-2. Additionally, two dimensions of QoL were found (functional-physical and cognitive-emotional. These dimensions correlated with the three PNS subgroups found. A relationship was found between chemotherapy treatment and PNS-3, and its negative impact on QoL.

CONCLUSIONS

A specific pattern of grouped symptoms in a psychoneurological cluster with different underlying dimensions has been identified which negatively influences QoL of survivors of BC.

IMPLICATION FOR NURSING PRACTICE

It is important to raise awareness among professionals and patients about the existence of a cluster of PNS, the patient's profile, as well as the factors that exacerbate them. This will allow them to be treated more effectively and comprehensively.

Emotional Processing, Coping, and Cancer-Related Sickness Symptoms in Breast Cancer Survivors: Cross- Sectional Secondary Analysis of the REPAT Study

Purpose

The study aims to provide a better understanding of the relationship between emotional processing, coping, and cancer-related sickness symptoms.

Methods

The study used a cross-sectional, secondary analysis of data from 179 Israeli Jewish women who were breast cancer survivors (BCS) 3 to 18 months after completing primary treatment and who participated in a larger randomized controlled trial (REPAT study). Data were collected at baseline. Participants completed questionnaires measuring emotion acceptance, situational approach, avoidance coping, and cancer-related sickness symptoms (depression, fatigue, and pain) and a performance measure of emotional awareness. Hierarchical linear regressions were performed, controlling for background variables.

Results

Participants experienced significant clinical depression (51.7%), cancer-related fatigue (CRF, 78.8%), pain interference (78%), and pain intensity (66%) levels. There were strong correlations between cancer-related symptoms. After controlling for confounders, emotional processing (acceptance) was negatively associated with depression, and avoidance coping was positively associated with depression, CRF, and pain interference (i.e., higher use of avoidance related to higher cancer-related symptoms; higher acceptance was associated with lower depression). Emotional awareness and coping by approaching emotions were not related to cancer-related symptoms.

Conclusions

The BCS posttreatment period presents the challenge of dealing with elevated cancer-related symptoms. Regardless, BCS who used high emotional processing levels-especially acceptance of emotion and lower reliance on avoidance to cope-experienced fewer cancer-related symptoms.

Implications for Cancer Survivors

Professionals should recognize the potential role of emotional processing and avoidant coping relative to cancer-related symptoms and recognize their patterns in posttreatment patients.

The long-term burden of a symptom cluster and association with longitudinal physical and emotional functioning in breast cancer survivors

BACKGROUND

Fatigue, insomnia and pain are some of the most common and distressing symptoms experienced during breast cancer (BC) treatment and survivorship. The symptoms have been found to impact one another and to form a symptom cluster, and greater severity of the symptoms may be negatively associated with physical and emotional functioning in survivorship. In exploratory analyses from a randomized controlled trial examining the effect of progressive resistance training on the development of lymphedema after BC, we aimed to examine the burden of the symptom cluster fatigue-pain-insomnia, and its prognostic value for long-term symptom severity as well as emotional and physical functioning.

MATERIAL AND METHODS

Latent profile analysis was used to identify groups with similar severity of pain, fatigue and insomnia among 158 patients with BC two weeks after surgery. Mixed effects Tobit regression models were used to estimate fatigue, pain, insomnia, and physical and emotional functioning 20 weeks, 1 year and 3.5 years after surgery.

RESULTS

Two symptom burden groups were identified: 80% of women had a low severity while 20% of women had a high severity of the three symptoms after BC surgery. 3.5 years later, the women with high symptom burden post-surgery still had higher pain, insomnia and fatigue scores than women with low symptom burden. High symptom burden post-surgery was associated with worse physical functioning 3.5 years later, while emotional functioning was only negatively impacted during the first year.

DISCUSSION

These findings warrant larger studies investigating if symptom burden early in BC trajectory can be used for risk stratification for persistent symptoms and diminished physical functioning with the purpose of developing and implementing targeted interventions.

Postdischarge Nausea and Vomiting and Co-occurring Symptoms in Women Following Breast Cancer Surgery

PURPOSE

The purpose of this study was to investigate the influence of potential co-occurring symptoms, including fatigue, sleep disturbance, anxiety, depressive symptoms, and pain, on the incidence of postdischarge nausea (PDN) measured two days following discharge to home after surgery for breast cancer.

DESIGN

This study used a prospective, cross-sectional, observational design.

METHODS

The sample was 334 women aged 27 to 88 years of age. Demographic data were collected from the patient and the medical record before surgery. Symptom data were collected 48 hours following surgery using the Patient Reported Outcome Measurement System (PROMIS) and numerical nausea and pain scales.

FINDINGS

Eighty-five (25.4%) of study participants reported some nausea two days after discharge. Study participants who experienced PDN frequently described that it occurred after they left the hospital to drive home following their surgery. Unadjusted odds ratios showed the presence of co-occurring symptoms of anxiety, fatigue, sleep disturbance, and pain were all significantly associated with the presence of nausea 48 hours following surgery. Other significant factors associated with (PDN) were history of motion sickness, history of pregnancy-induced nausea, use of opioids, and type of surgery.

CONCLUSIONS

Same-day surgery nurses providing postoperative education for women following surgery for breast cancer should explain to patients that nausea may occur after they are discharged, especially those with known motion sickness. In addition, patients should be informed that other symptoms, especially fatigue, sleep disturbance, and anxiety, may co-occur.

Prevalence, Severity, and Co-Occurrence of SPPADE Symptoms in 31,866 Patients With Cancer

OBJECTIVES

To examine the prevalence, severity, and co-occurrence of SPPADE symptoms as well as their association with cancer type and patient characteristics.

BACKGROUND

The SPPADE symptoms (sleep disturbance, pain, physical function impairment, anxiety, depression, and low energy /fatigue) are prevalent, co-occurring, and undertreated in oncology and other clinical populations.

METHODS

Baseline SPPADE symptom data were analyzed from the E2C2 study, a stepped wedge pragmatic, population-level, cluster randomized clinical trial designed to evaluate a guideline-informed symptom management model targeting the six SPPADE symptoms. Symptom prevalence and severity were measured with a 0-10 numeric rating (NRS) scale for each of the six symptoms. Prevalence of severe (NRS ≥ 7) and potential clinically relevant (NRS ≥ 5) symptoms as well as co-occurrence of clinical symptoms were determined. Distribution-based methods were used to estimate the minimally important difference (MID). Associations of cancer type and patient characteristics with a SPPADE composite score were analyzed.

RESULTS

A total of 31,886 patients were assessed for SPPADE symptoms prior to, during, or soon after an outpatient medical oncology encounter. The proportion of patients with a potential clinically relevant symptom ranged from 17.5% for depression to 33.4% for fatigue. Co-occurrence of symptoms was high, with the proportion of patients with three or more additional clinically relevant symptoms ranging from 45.2% for fatigue to 68.6% for depression. The summed SPPADE composite score demonstrated good internal reliability (Cronbach's alpha of 0.86), with preliminary MID estimates of 4.1-4.3. Symptom burden differed across several types of cancer but was generally similar across most sociodemographic characteristics.

CONCLUSION

The high prevalence and co-occurrence of SPPADE symptoms in patients with all types of cancer warrants clinical approaches that optimize detection and management.

The Cancer Genomic Integration Model for Symptom Science (CGIMSS): A Biopsychosocial Framework

Current nursing research has characterized symptom clusters and trajectories in individuals with breast cancer. The existing literature describes the relationship between symptoms and biological variables and the potential moderating effects of individual and social factors. The genomic profiling of breast cancer has also been an area of much recent research. Emerging evidence indicates that incorporating cancer genomics into symptom science research can aid in the prognostication of symptoms and elucidate targets for symptom management interventions. The aim of this paper is to outline a model to integrate cancer genomics into symptom science research, illustrated using breast cancer and psychoneurological (PN) symptoms as an example. We present a review of the current literature surrounding breast cancer genomics (specifically cancer genomic instability) and the biological underpinnings of the PN symptom cluster. Advances in both of these areas indicate that inflammation may serve as the bridge between cancer genomics and the PN symptom cluster. We also outline how the integration of cancer genomics into symptom science research synergizes with current research of individual and social factors in relation to symptoms. This model aims to provide a framework to guide future biopsychosocial symptom science research that can elucidate new predictive methods and new targets for intervention.

Effectiveness of Pharmacological and Nonpharmacological Interventions for Managing the Fatigue-Sleep Disturbance-Depression Symptom Cluster in Breast Cancer Patients Undergoing Chemotherapy: A Systematic Review

BACKGROUND

The symptom cluster of cancer-related fatigue-sleep disturbance-depression (F-S-D) is common among breast cancer (BC) patients undergoing chemotherapy. Given the coexisting nature and synergistic effect of this symptom cluster, interventions for managing it are expected to benefit patient outcomes.

OBJECTIVES

The aims of this study were to examine the effectiveness and identify the essential components of interventions used to manage the F-S-D and quality of life (QOL) in BC patients undergoing chemotherapy.

METHODS

A systematic review was performed in March 2020 through 7 electronic databases. Relevant studies were assessed using the inclusion criteria. The level of evidence was assessed using the Cochrane risk-of-bias tool. The results were summarized and synthesized in narrative forms.

RESULTS

Sixteen randomized controlled trials were included. Results showed that bright light therapy, acupressure, and psychological nursing interventions were useful in managing F-S-D in BC patients. Exercise and diet counseling alleviated F-D, whereas stress management and a health promotion program alleviated S-D. Bright light therapy, exercise, diet counseling, and psychological nursing interventions enhanced the QOL of these patients.

CONCLUSION

Interventions that could alleviate F-S, F-D, S-D, and F-S-D in BC patients and enhance their QOL were identified. Future studies should investigate the effects of evidence-based multimodal interventions that integrate psychological support, education on the management of chemotherapy side effects, and diet counseling and exercise on F-S-D in and reduced QOL of BC patients undergoing chemotherapy.

IMPLICATIONS FOR PRACTICE

Nurses act as patient advocates, and the development of evidence-based interventions for managing F-S-D and QOL is significant to nursing practice.

Dynamic changes and correlation between symptoms and quality of life in patients with breast cancer during chemotherapy

BACKGROUND

Standardized chemotherapy for breast cancer can improve the survival of patients, but during the process, it is accompanied by a variety of symptoms.

OBJECTIVE

To explore the dynamic changes of symptoms and quality of life in breast cancer patients at different time points during chemotherapy, and to explore the correlation with quality of life.

METHOD

A prospective study method was used to collect 120 breast cancer patients undergoing chemotherapy as the research objects. The general information questionnaire, the Chinese version of the M.D. Anderson Symptom inventory (MDASI-C), and the European Organization for Cancer Research and Treatment (EORTC) Quality of Life questionnaire were used in the first week (T1), first month (T2), three month (T3) and 6 months after chemotherapy (T4) to conduct dynamic investigation.

RESULTS

The symptoms of breast cancer patients at four time points during chemotherapy period were: psychological symptoms, pain-related symptoms, perimenopausal symptoms, impaired self-image, and neurological related symptoms etc. At T1, it exhibited 2 symptoms, however as moving along the chemotherapy process, the symptoms are increasing. The severity is (F= 76.32, P< 0.001), life of quality (F= 117.64, P< 0.001) vary. At T3, there were 5 symptoms, and at T4 symptom number increased to 6 with worsening quality of life. It exhibited positive correlation with scores in multiple domains of quality of life (P< 0.05), and the above symptoms showed positive correlation with multiple domains of QLQ-C30 (P< 0.05).

CONCLUSION

After T1-T3 of chemotherapy in breast cancer patients, the symptoms become more serious and the quality of life reduced. Therefore, medical staff should pay attention to the occurrence and development of patient's symptoms, create a reasonable plan from the perspective of symptom management and carry out personalized interventions to improve patient's quality of life.

Cultural Adaptation of the Younger Women's Wellness After Cancer Program for Younger Chinese Women With Breast Cancer: A Pilot Randomized Controlled Trial

BACKGROUND

The incidence of breast cancer in younger women, that is, aged 50 years or younger, in Hong Kong is increasing. The Internet-based Younger Women's Wellness After Cancer Program (YWWACP) is a whole-lifestyle intervention that can help young women to manage their health and risks of chronic diseases.

OBJECTIVES

The study aimed to test the acceptability and feasibility of the culturally adapted YWWACP in Hong Kong (YWWACPHK) and to evaluate its preliminary effects in improving health-related quality of life, distress, sexual function, menopausal symptoms, dietary intake, physical activity, and sleep among younger Chinese women with breast cancer.

INTERVENTION/METHODS

Women aged 18 to 50 years with breast cancer were recruited from an oncology outpatient department. The participants in the intervention group received the 12-week YWWACPHK, whereas the control group received standard care.

RESULTS

Sixty women consented to participate. At 12 weeks after intervention completion, the intervention group showed a significant increase in the pain subscale scores of sexual function and more improvement in the level of physical activity than the control group, with Hedge g effect sizes 0.66 and 0.65, respectively. Nineteen intervention group participants reported that they were satisfied with the program and suggestions for improvement were provided.

CONCLUSION

The implementation of YWWACPHK is feasible. The preliminary findings suggest that YWWACPHK could increase the level of physical activity among the participants.

IMPLICATIONS FOR PRACTICE

Nurses could utilize YWWACPHK to support younger Chinese patients with breast cancer to maintain a healthy lifestyle, subject to wider confirmation of these results through a larger study.

Correlates of Cancer-Related Fatigue among Colorectal Cancer Patients Undergoing Postoperative Adjuvant Therapy Based on the Theory of Unpleasant Symptoms

BACKGROUND

Cancer-related fatigue (CRF) is a common and burdensome symptom in cancer patients that is influenced by multiple factors. Identifying factors associated with CRF may help in developing tailored interventions for fatigue management. This study aimed to examine the correlates of CRF among colorectal cancer patients undergoing postoperative adjuvant therapy based on the theory of unpleasant symptoms.

METHODS

A cross-sectional study was implemented, and finally, a sample of 363 participants from one tertiary general hospital and one tertiary cancer hospital was purposively recruited. Data were collected using the general information questionnaire, cancer fatigue scale, the distress disclosure index, Herth hope index, and perceived social support scale. Univariate analysis and multiple linear regression analysis were performed to determine the correlates of CRF.

RESULTS

The mean score of CRF among colorectal cancer patients was 21.61 (SD = 6.16, 95% CI 20.98-22.25), and the fatigue degree rating was "moderate". The multiple linear regression model revealed that 49.1% of the variance in CRF was explained by hope, sleep disorder, internal family support, self-disclosure, pain, and time since operation.

CONCLUSIONS

Our study identified several significant, modifiable factors (self-disclosure, hope, internal family support, pain, and sleep disorder) associated with CRF. Understanding these correlates and developing targeted psychosocial interventions may be associated with the improvement of CRF in patients with colorectal cancer.

Psychoneurological Symptoms and Biomarkers of Stress and Inflammation in Newly Diagnosed Head and Neck Cancer Patients: A Network Analysis

Psychoneurological symptoms are commonly reported by newly diagnosed head and neck cancer (HNC) patients, yet there is limited research on the associations of these symptoms with biomarkers of stress and inflammation. In this article, pre-treatment data of a multi-center cohort of HNC patients were analyzed using a network analysis to examine connections between symptoms (poor sleep quality, anxiety, depression, fatigue, and oral pain), biomarkers of stress (diurnal cortisol slope), inflammation markers (c-reactive protein [CRP], interleukin [IL]-6, IL-10, and tumor necrosis factor alpha [TNF-α]), and covariates (age and body mass index [BMI]). Three centrality indices were calculated: degree (number of connections), closeness (proximity of a variable to other variables), and betweenness (based on the number of times a variable is located on the shortest path between any pair of other variables). In a sample of 264 patients, poor sleep quality and fatigue had the highest degree index; fatigue and CRP had the highest closeness index; and IL-6 had the highest betweenness index. The model yielded two clusters: a symptoms-cortisol slope-CRP cluster and a IL-6-IL-10-TNF-α-age-BMI cluster. Both clusters were connected most prominently via IL-6. Our findings provide evidence that poor sleep quality, fatigue, CRP, and IL-6 play an important role in the interconnections between psychoneurological symptoms and biomarkers of stress and inflammation in newly diagnosed HNC patients.

Social relationships and their associations with affective symptoms of women with breast cancer: A scoping review

Background

Problems in affective and cognitive functioning are among the most common concurrent symptoms that breast cancer patients report. Social relationships may provide some explanations of the clinical variability in affective-cognitive symptoms. Evidence suggests that social relationships (functional and structural aspects) can be associated with patients’ affective-cognitive symptoms; however, such an association has not been well studied in the context of breast cancer.

Purpose

The purpose of this scoping review was to address the following question: What social relationships are associated with affective-cognitive symptoms of women with breast cancer?

Methods

This scoping review used the framework proposed by Arksey and O’Malley and PRISMA-Sc. Studies published by February 2022 were searched using four databases: MEDLINE (PubMed), Embase (Elsevier), PsycINFO (EBSCOhost), and Web of Science (Clarivate). All retrieved citations were independently screened and eligibility for inclusion was determined by study team members. Extracted data included research aims, design, sample, type and measures of social relationships (functional and structural), and the association between social relationships and affective-cognitive symptoms

Results

A total of 70 studies were included. Affective symptoms were positively associated with social support, family functioning, quality of relationships, social networks, and social integration, whereas the negative association was found with social constraints.

Conclusion

Our findings suggest positive social relationships may mitigate affective symptoms of women with breast cancer. Thus, health care providers need to educate patients about the importance of building solid social relationships and encourage them to participate in a supportive network of friends and family members.

Synergistic Interactions Among Fatigue, Sleep Disturbance, and Depression in Women With Breast Cancer: A Cross-Sectional Study

OBJECTIVES

To assess the symptom cluster of fatigue, sleep disturbance, and depression among female patients with breast cancer receiving chemotherapy, and to evaluate its impact on quality of life (QOL) and symptom severity.

SAMPLE & SETTING

372 patients receiving adjuvant chemotherapy recruited from two tertiary hospitals in China.

METHODS & VARIABLES

Symptom severity and QOL were evaluated using the Brief Fatigue Inventory, Pittsburgh Sleep Quality Index, Patient Health Questionnaire-9, and Functional Assessment of Cancer Therapy-Breast on the eighth day after receiving chemotherapy.

RESULTS

All symptoms positively correlated with each other. Although the symptom cluster was significantly associated with decreased QOL, individualized symptom severity worsened as the number of symptoms increased.

IMPLICATIONS FOR NURSING

The prevalence of and interactions among fatigue, sleep disturbance, and depression negatively affect symptom severity and patients' QOL. Conducting early assessment followed by effective cluster-based interventions is needed to manage this symptom cluster.

Factors Related to Anxiety, Depressive Symptoms and Quality of Life in Breast Cancer

Breast cancer (BC) is a major public health problem internationally. Although illness survival rates have improved, patients usually suffer multiple symptoms, both physical and psychological, which can affect their quality of life (QoL). The main aim of this study was to evaluate depressive symptoms, anxiety and the QoL of people with BC. An observational, cross-sectional study was carried out at Badajoz University Hospital (Spain). A total of 200 women with BC were included. EORTC QLQ-C30 and QLQ-BR23 questionnaires were used to assess QoL. Patients were screened for depressive symptoms using the Beck Depression Inventory (BDI) and for state anxiety and trait anxiety using the State Anxiety Inventory (STAI). Thirty-eight percent of the patients in the sample had moderate to severe anxiety, which was related to the time of diagnosis, advanced stage of illness and surgical treatment. We found that 28% of patients had depressive symptoms, related mainly with time of diagnosis, adjuvant therapy and number of cycles of chemotherapy (CT). Patients with the longest time since diagnosis, in stage III, and in treatment with CT, especially those with the greatest number of cycles, had the worst scores in QoL. We found a positive association between depressive symptoms and anxiety with QoL in patients with BC.