Health-related quality of life before and after a breast cancer diagnosis

Are education and cohabitation associated with health-related quality of life and self-management during breast cancer follow-up? A longitudinal study

BACKGROUND

Oncologist-led follow-up after breast cancer (BC) is increasingly replaced with less intensive follow-up based on higher self-management, which may overburden the less resourceful patients. We examined whether socioeconomic factors measured recently after the implementation of a new follow-up program for BC patients were associated with health-related quality of life (HRQoL) and self-management 12 months later.

METHODOLOGY

Between January and August 2017, we invited 1773 patients in Region Zealand, Denmark, to participate in baseline and 12 months follow-up questionnaires. The patients had surgery for low- and intermediate risk BC 1-10 years prior to the survey, and they had recently been allocated to the new follow-up program of either patient-initiated follow-up, or in-person or telephone follow-up with a nurse, based on patients' preferences. We examined associations between socioeconomic factors (education and cohabitation) at baseline and two outcomes: HRQoL (EORTC QLQ-C30 and QLQ-BR23) and self-management factors (health care provider, confidence in follow-up, contact at symptoms of concern, and self-efficacy) at 12 months follow-up. Sensitivity analyses were performed according to time since diagnosis (≤ 5 > 5 years). Furthermore, we investigated whether treatment and self-management factors modified the associations.

RESULTS

A total of 987 patients were included in the analyses. We found no statistically significant associations between socioeconomic factors and HRQoL, except in patients ≤ 5 years from diagnosis. For self-management patients with short education were more likely to report that they had not experience relevant symptoms of concern compared to those with medium/long education (OR 1.75 95% CI: 1.04; 2.95). We found no clear patterns indicating that treatment or self-management factors modified the associations between socioeconomics' and HRQoL.

CONCLUSION

Overall socioeconomic factors did not influence HRQoL and self-management factors except for experiencing and reporting relevant symptoms of concern. Socioeconomic factors may, however, influence HRQoL in patients within five years of diagnosis.

Long-term Trajectories of Physical Function Decline in Women With and Without Cancer

Importance

Patients with cancer experience acute declines in physical function, hypothesized to reflect accelerated aging driven by cancer-related symptoms and effects of cancer therapies. No study has examined long-term trajectories of physical function by cancer site, stage, or treatment compared with cancer-free controls.

Objective

Examine trajectories of physical function a decade before and after cancer diagnosis among older survivors and cancer-free controls.

Design, Setting, and Participants

This prospective cohort study enrolled patients from 1993 to 1998 and followed up until December 2020. The Women's Health Initiative, a diverse cohort of postmenopausal women, included 9203 incident cancers (5989 breast, 1352 colorectal, 960 endometrial, and 902 lung) matched to up to 5 controls (n = 45 358) on age/year of enrollment and study arm.

Exposures

Cancer diagnosis (site, stage, and treatment) via Medicare and medical records.

Main Outcomes and Measures

Trajectories of self-reported physical function (RAND Short Form 36 [RAND-36] scale; range: 0-100, higher scores indicate superior physical function) estimated from linear mixed effects models with slope changes at diagnosis and 1-year after diagnosis.

Results

This study included 9203 women with cancer and 45 358 matched controls. For the women with cancer, the mean (SD) age at diagnosis was 73.0 (7.6) years. Prediagnosis, physical function declines of survivors with local cancers were similar to controls; after diagnosis, survivors experienced accelerated declines relative to controls, whose scores declined 1 to 2 points per year. Short-term declines in the year following diagnosis were most severe in women with regional disease (eg, -5.3 [95% CI, -6.4 to -4.3] points per year in regional vs -2.8 [95% CI, -3.4 to -2.3] for local breast cancer) or who received systemic therapy (eg, for local endometrial cancer, -7.9 [95% CI, -12.2 to -3.6] points per year with any chemotherapy; -3.1 [95% CI, -6.0 to -0.3] with radiation therapy alone; and -2.6 [95% CI, -4.2 to -1.0] with neither, respectively). While rates of physical function decline slowed in the later postdiagnosis period (eg, women with regional colorectal cancer declined -4.3 [95% CI, -5.9 to -2.6] points per year in the year following diagnosis vs -1.4 [95% CI, -1.7 to -1.0] points per year in the decade thereafter), survivors had estimated physical function significantly below that of age-matched controls 5 years after diagnosis.

Conclusions and Relevance

In this prospective cohort study, survivors of cancer experienced accelerated declines in physical function after diagnosis, and physical function remained below that of age-matched controls even years later. Patients with cancer may benefit from supportive interventions to preserve physical functioning.

The Effects of Depression and Anti-Depressants on Quality of Life After Breast Reconstruction: A Post-Hoc Analysis

Background

A personal history of depression prior to breast cancer diagnosis and its effect on post-diagnosis quality of life (QOL) in women undergoing breast reconstruction is relatively unknown. We performed the current study to determine if depression alters QOL for patients who undergo breast reconstruction by assessing the pre-to-post-operative change in patient-reported BREAST-Q scores.

Methodology

We conducted a single-center, post-hoc analysis of 300 patients with completed BREAST-Q data who underwent breast reconstruction from November 2013 to November 2016 following a diagnosis of breast cancer. Patients completed the BREAST-Q at four time points: pre-operatively, six weeks following tissue expander (TE) insertion for patients undergoing staged reconstruction, and six and 12 months following the final reconstruction. Medical records were reviewed to identify patients who had a pre-cancer diagnosis of clinical depression and/or anti-depressant medication use. BREAST-Q scores were compared between groups and within groups. Groups compared were the depression (n = 50) and no depression (n = 250) patients, along with anti-depressant (n = 36) and no anti-depressant (n = 14) use in the depression group.

Results

Within-group Sexual Well-being scores at the six-week post-TE follow-up for patients in the depression group (median = 37, interquartile range [IQR] = 25-47) were significantly lower (p < 0.01) than the scores for patients in the no depression group (median = 47, IQR = 39-60). There were no statistically significant differences in BREAST-Q scores in other domains. When compared to patients diagnosed with depression who were not taking anti-depressants, anti-depressant medication use did not result in statistically significant higher BREAST-Q scores, although Satisfaction With Breasts six months post-operatively, Psychosocial Well-being at six weeks post-TE, Sexual Well-being at six weeks post-TE and six months post-operatively were clinically higher in patients taking anti-depressants for depression.

Conclusions

Patients with a diagnosis of depression prior to breast cancer had lower BREAST-Q Sexual Well-being scores in the six-week TE group with or without anti-depressant medication. Patients with a pre-cancer diagnosis of depression considering TEs may benefit from additional counseling prior to breast reconstruction or electing a different method of breast reconstruction. Anti-depressant medications may provide clinically higher BREAST-Q scores in patients with a pre-cancer diagnosis of depression. Adding an anti-depressant medication to a patient’s treatment plan may provide additional benefits. Larger samples are required to properly determine the impact of anti-depressant medications on BREAST-Q scores in patients with a pre-cancer diagnosis of depression.

Work productivity loss in breast cancer survivors and its effects on quality of life

BACKGROUND

Return to work is an important process for many breast cancer survivors (BCSs) that acts as a positive step towards their reintegration into society.

OBJECTIVES

This study examined whether work productivity loss due to presenteeism could predict the quality of life (QOL) of employed BCSs.

METHODS

This study used a cross-sectional design. Seventy-five BCSs and seventy-five participants in the Non-Cancer Comparison (NCC) group were surveyed. The main outcome measures were productivity loss (as measured by the Work Limitations questionnaire) and quality of life (as measure by the European Organization for Research and Treatment Quality of Life questionnaire C30). Other measures included psychological distress (as measured by the Hospital Anxiety and Depression Scale) and cognitive limitation at work (as measured by the Cognitive Symptom Checklist).

RESULTS

The BCS group had a lower summary score, a lower global health related score and greater work limitation in all domains than the NCC group. The productivity loss due to presenteeism of the BCS group was 8%. The multiple regression model shows that work productivity loss and level of job stress were the significant predictors of quality of life in the BCS group.

CONCLUSION

These findings raise questions about the effects of level of job stress and work productivity loss on the QOL of BCSs. Longitudinal studies are needed to map these relationships.

Socio-Demographic and General Health Factors Associated with Quality of Life in Long-Term Breast Cancer Survivors from Southwestern Poland

Background: Identification of factors associated with quality of life (QOL) in breast cancer survivors can contribute to better functioning in this group of patients. The study aimed to assess the association between QOL and anthropometric, sociodemographic, and medical characteristics in postmastectomy women from southwestern Poland, 9.4 (±6.5) years after completed treatment. Materials and methods: QOL was estimated with the SF-36v2 questionnaire in 250 survivors aged 62.8 (±8.0) years with previously histologically confirmed invasive breast cancer. Results: Women in this study rated their overall QOL with an average of 60.7 (±17.9), Mental Component Summary of 62.8 (±19.8), and Physical Component Summary of 57.5 (±18.8) points. The use of multivariate regression analysis revealed that depression, chronic diseases, abdominal obesity, and pregnancy history have a statistically significant negative effect on the QOL of women after mastectomy, whereas participation in regular physical activity, living with a partner, the education level ≥ 12 years, and living in the city were associated with a higher QOL assessment. There were no significant relationships between QOL and the age, time since surgery, type of treatment, smoking, and occupational status of the patients. Conclusions: Health education, greater social support, specialist care in the treatment of comorbidities, and propagation of a physically active lifestyle can improve the physical and mental functioning of breast cancer survivors long after diagnosis and treatment.

Social and economic burden of breast cancer in the North East region of Bulgaria

Introduction: Breast cancer is one of the most common malignancies among women and significantly worsens physical, mental and social functioning. The aim is to evaluate the social and economic burden of treatment strategies for breast cancer in the North East region of Bulgaria.Areas covered: A retrospective, observational, population-based study among patients with breast cancer was performed. Patient characteristics, treatment patterns, and costs were assessed during a four-year period (2016-2019). Disability-adjusted life years (DALYs) were calculated to estimate the social burden.Results: Approximately 99% of patients (n = 1,373) were female and the mean age at diagnosis was 60.6 years. The total economic burden of breast cancer during the time of the study was estimated to be 21,076,809.12 BGN where the direct costs were equal to 19,634,509.67 BGN and the total indirect costs due to premature death amounted to 1,442,299.45 BGN. Total DALYs were 110.56 for all patients corresponding to 1,898,340.80 BGN.Conclusions: This study demonstrates the significant social and economic burden of breast cancer as further, more comprehensive regional and national-based studies related to the total economic burden of breast cancer are required.

Long-term health-related quality of life of breast cancer survivors remains impaired compared to the age-matched general population especially in young women. Results from the prospective controlled BREX exercise study

OBJECTIVE

To investigate long-term health-related quality of life (HRQoL) changes over time in younger compared to older disease-free breast cancer survivors who participated in a prospective randomized exercise trial.

METHODS

Survivors (aged 35-68 years) were randomized to a 12-month exercise trial after adjuvant treatment and followed up for ten years. HRQoL was assessed with the generic 15D instrument during follow-up and the younger (baseline age ≤ 50) and older (age >50) survivors' HRQoL was compared to that of the age-matched general female population (n = 892). The analysis included 342 survivors.

RESULTS

The decline of HRQoL compared to the population was steeper and recovery slower in the younger survivors (p for interaction < 0.001). The impairment was also larger among the younger survivors (p = 0.027) whose mean HRQoL deteriorated for three years after treatment and started to slowly improve thereafter but still remained below the population level after ten years (difference -0.017, 95% CI: -0.031 to -0.004). The older survivors' mean HRQoL gradually approached the population level during the first five years but also remained below it at ten years (difference -0.019, 95% CI: -0.031 to -0.007). The largest differences were on the dimensions of sleeping and sexual activity, on which both age groups remained below the population level throughout the follow-up.

CONCLUSIONS

HRQoL developed differently in younger and older survivors both regarding the most affected dimensions of HRQoL and the timing of the changes during follow-up. HRQoL of both age groups remained below the population level even ten years after treatment.

Disability, psychological distress and quality of life in relation to cancer diagnosis and cancer type: population-based Australian study of 22,505 cancer survivors and 244,000 people without cancer

BACKGROUND

Improved survival means that cancer is increasingly becoming a chronic disease. Understanding and improving functional outcomes are critical to optimising survivorship. We quantified physical and mental health-related outcomes in people with versus without cancer, according to cancer type.

METHODS

Questionnaire data from an Australian population-based cohort study (45 and Up Study (n = 267,153)) were linked to cancer registration data to ascertain cancer diagnoses up to enrolment. Modified Poisson regression estimated age- and sex-adjusted prevalence ratios (PRs) for adverse person-centred outcomes-severe physical functional limitations (disability), moderate/high psychological distress and fair/poor quality of life (QoL)-in participants with versus without cancer, for 13 cancer types.

RESULTS

Compared to participants without cancer (n = 244,000), cancer survivors (n = 22,505) had greater disability (20.6% versus 12.6%, respectively, PR = 1.28, 95%CI = (1.25-1.32)), psychological (22.2% versus 23.5%, 1.05 (1.02-1.08)) and poor/fair QoL (15.2% versus 10.2%; 1.28 (1.24-1.32)). The outcomes varied by cancer type, being worse for multiple myeloma (PRs versus participants without cancer for disability 3.10, 2.56-3.77; distress 1.53, 1.20-1.96; poor/fair QoL 2.40, 1.87-3.07), lung cancer (disability 2.81, 2.50-3.15; distress 1.67, 1.46-1.92; poor/fair QoL 2.53, 2.21-2.91) and non-Hodgkin's lymphoma (disability 1.56, 1.37-1.78; distress 1.20, 1.05-1.36; poor/fair QoL 1.66, 1.44-1.92) and closer to those in people without cancer for breast cancer (disability 1.23, 1.16-1.32; distress 0.95, 0.90-1.01; poor/fair QoL 1.15, 1.05-1.25), prostate cancer (disability 1.11, 1.04-1.19; distress 1.09, 1.02-1.15; poor/fair QoL 1.15, 1.08-1.23) and melanoma (disability 1.02, 0.94-1.10; distress 0.96, 0.89-1.03; poor/fair QoL 0.92, 0.83-1.01). Outcomes were worse with recent diagnosis and treatment and advanced stage. Physical disability in cancer survivors was greater in all population subgroups examined and was a major contributor to adverse distress and QoL outcomes.

CONCLUSIONS

Physical disability, distress and reduced QoL are common after cancer and vary according to cancer type suggesting priority areas for research, and care and support.

Health-related quality of life among breast cancer survivors and noncancer controls over 10 years: Pink SWAN

BACKGROUND

The goal of this study was to compare health-related quality of life (HRQL) from diagnosis to 10 years postdiagnosis among breast cancer survivors (BCS) and women without cancer over the same period and to identify BCS subgroups exhibiting different HRQL trajectories.

METHODS

Our analysis included 141 BCS and 2086 controls from the Study of Women's Health Across the Nation (SWAN), a multiracial/ethnic cohort study of mid-life women assessed approximately annually from 1995 to 2015. Pink SWAN participants reported no cancer at SWAN enrollment and developed (cases) or did not develop (controls) incident breast cancer after enrollment. We assessed HRQL with SF-36 Mental Component Summary and Physical Component Summary scores. We modeled each as a function of case/control status, years since diagnosis, years since diagnosis squared, and the interaction terms between case/control status and the 2 time variables in linear models. We characterized heterogeneity in postdiagnosis HRQL of cases using group-based trajectories.

RESULTS

BCS had significantly lower HRQL compared with controls at diagnosis and 1 year postdiagnosis. By 2 years, BCS and controls no longer differed significantly. Among BCS, 2 trajectory groups were identified for both scores. For the Mental Component Summary, 88.4% of BCS had consistently good and 11.6% had very low scores. For the Physical Component Summary, 73.9% had good scores, and 26.1% had consistently low scores. Prediagnosis perceived stress and current smoking were related to being in the low mental trajectory group, and a higher number of comorbidities was related to being in the low physical trajectory group.

CONCLUSION

Although the majority of BCS have HRQL similar to non-cancer controls after 2 years, subgroups of BCS continue to have low HRQL. Prediagnosis stress, comorbidities, and smoking are vulnerability factors for long-term, low HRQL in BCS.

β2ARs stimulation in osteoblasts promotes breast cancer cell adhesion to bone marrow endothelial cells in an IL-1β and selectin-dependent manner

Progression and recurrence of breast cancer, as well as reduced survival of patients with breast cancer, are associated with chronic stress, a condition known to impact the hypothalamic-pituitary axis and the autonomic nervous system. Preclinical and clinical evidence support the involvement of the sympathetic nervous system in the control of bone remodeling and in pathologies of the skeleton, including bone metastasis. In experimental mouse models of skeletal metastasis, administration of the βAR agonist isoproterenol (ISO), used as a surrogate of norepinephrine, the main neurotransmitter of sympathetic neurons, was shown to favor bone colonization of metastatic breast cancer cells via an increase bone marrow vascularity. However, successful extravasation of cancer cells into a distant organ is known to be favored by an activated endothelium, itself stimulated by inflammatory signals. Based on the known association between high sympathetic outflow, the expression of inflammatory cytokines and bone metastasis, we thus asked whether βAR stimulation in osteoblasts may alter the vascular endothelium to favor cancer cell engraftment within the skeleton. To address this question, we used conditioned medium (CM) from PBS or ISO-treated bone marrow stromal cells (BMSCs) in adhesion assays with bone marrow endothelial cells (BMECs) or the endothelial cell line C166. We found that ISO treatment in differentiated BMSCs led to a robust induction of the pro-inflammatory cytokines interleukin-1 beta (IL-1β) and interleukin-6 (IL-6). The CM from ISO-treated BMSCs increased the expression of E- and P-selectin in BMECs and the adhesion of human MDA-MB-231 breast cancer cells to these cells in short-term static and dynamic adhesion assays, and a blocking antibody against IL-1β, but not IL-6, reduced this effect. Direct IL-1β treatment of BMECs had a similar effect, whereas the impact of IL-6 treatment on the expression of adhesion molecules by BMECs and on the adhesion of cancer cells to BMECs was negligible. Collectively, these in vitro results suggest that in the context of the multicellular and dynamic bone marrow environment, sympathetic activation and subsequent βAR stimulation in osteoblasts may profoundly remodel the density but also the activation status of bone marrow vessels to favor the skeletal engraftment of circulating breast cancer cells.

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β2AR activation in osteoblasts increases the expression of pro-inflammatory cytokines IL-1β and IL-6.

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IL-1β promotes the adhesion of breast cancer cells to endothelium via an endothelial increase in E- and P-selectin expression.

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IL-1β blockade and selectin inhibition inhibits breast cancer cell adhesion to endothelial cells.

Uneven recovery patterns of compromised health-related quality of life (EQ-5D-3 L) domains for breast Cancer survivors: a comparative study

BACKGROUND

Although several studies have evaluated health-related quality of life (HRQoL) in breast cancer survivors, few have compared HRQoL between breast cancer survivors and an age-matched general population in terms of improvement patterns according to time after surgery. Thus, we compared the postoperative changes in HRQoL in breast cancer survivors with those of age-matched general population groups using the EuroQoL five-dimension three-level questionnaire (EQ-5D-3 L).

METHODS

EQ-5D-3 L questionnaires were obtained from 686 breast cancer survivors during follow-up visits. They were divided into five groups according to time after surgery: 0-5 months, 6-11 months, 12-35 months, 36-59 months, and ≥ 60 months. Their EQ-5D-3 L data, covering five dimensions (mobility, self-care, usual activities, pain/discomfort, and anxiety/depression), were compared with those of age-matched general population groups.

RESULTS

The mean EQ-5D-3 L index of breast cancer survivors was high in group with longer time after surgery and the mean EQ-5D-3 L index of breast cancer group over 5 years after surgery was similar to that of an age-matched general population (0.919 vs 0.928, p = 0.305). Although there were deficits in all dimensions of breast cancer survivors, motility eventually exceeded that of general population groups and self-care and usual activities of groups over 3 years after surgery matched those of general population however, pain/discomfort and anxiety/depression of survivors over 5 years after surgery remained worse than those of the general population (p = 0.028, p < 0.001).

CONCLUSIONS

Motility, self-care, and usual activities decreased in the early postoperative period for breast cancer survivors but showed recovery after 3 years. However, pain/discomfort and anxiety/depression remained poorer in these patients than in the general population for many years.

Survivorship issues as determinants of quality of life after breast cancer treatment: Report from a limited resource setting

OBJECTIVES

Quality of life (QOL) in breast cancer survivors is affected by various long term sequelae of breast cancer treatment. The present study was conducted with the objectives to estimate prevalence of various survivorship issues, and to identify those which are most predictive of limitations in QOL after completion of primary therapy.

MATERIAL &METHODS

This study was conducted in 230 breast cancer survivors (BCs) and 112 controls at an academic centre in Northern India. Assessment of QOL was done by SF-36 and FACT-B questionnaires. Survivorship issues were noted from a checklist of 14 commonly reported symptoms. Main outcome measures were (1) frequencies of survivorship issues and QOL scores among three groups of survivors divided on the basis of time elapsed since treatment (<2, 2-5, and >5 year follow up) (2) Issues most predictive of limitations in QOL, identified by stepwise logistic regression analysis.

RESULTS

Longer term BCs showed higher QOL scores as compared to those in early follow up. However their QOL scores remained poorer compared to healthy women. The most prevalent survivorship issues were fatigue (60%), restriction of shoulder movement (59.6%), body and joint pain (63.5%), chemotherapy induced cessation of menstruation (73.3%) and loss of sexual desire (60%). Issues which had maximum impact on QOL scores were emotional distress (r = -11.375), fatigue (r = -9.27) and premature menopause (r = -2.085) and its related symptoms.

CONCLUSION

Management of these issues should be priority areas for supportive care, especially in settings with limited resource.

Impact of pharmacist counseling on reducing instances of adverse events that can affect the quality of life of chemotherapy outpatients with breast Cancer

Background

In recent years, cancer chemotherapy is being conducted at outpatient clinics, wherein pharmacists are involved with patient guidance and management of adverse events as experts in medication therapy. Therefore, we clarified the influence of interventions by pharmacists during counseling of patients with cancer on patients’ quality of life.

Methods

To determine this influence, we conducted a survey to assess the quality of life of 39 patients with breast cancer who underwent their initial course of outpatient cancer chemotherapy at Gifu Municipal Hospital. A quality of life survey was conducted before the 1st, 2nd, and 3rd courses of treatment and was based on a method obtained from a survey paper entitled, “Quality of Life Questionnaire for Cancer Patients Treated with Anticancer Drugs.”

Results

Twenty patients were assigned to the intervention group, which received pharmacist counseling, and nineteen patients were assigned to the non-intervention group, which received no pharmacist counseling. Both groups were compared immediately before the 1st course and 2nd course. Regarding the subscale of social relationships, a significant difference was observed for malaise (p = 0.043), with the non-intervention group experiencing them to a greater degree than the intervention group. Regarding the change between immediately before the 1st course and the 3rd course, a significant difference was observed in the subscale of social relationships for nausea (p = 0.017), with the non-intervention group experiencing it to a greater degree than the intervention group.

Conclusions

The results suggest that receiving pharmacists’ guidance on adverse events and individually adjusted prescriptions tailored to address the occurrence of adverse events improved the treatment environment and enhanced the quality of life in the intervention group. These findings are beneficial in maintaining patients’ quality of life during cancer treatment.

Trial registration

No. UMIN000027171, Registration date: Apr 27, 2017. Retrospectively registered.

Determinants of adherence to physical activity guidelines among overweight and obese African American breast cancer survivors: implications for an intervention approach

OBJECTIVE

Public health agencies encourage breast cancer survivors (BCSs) to follow their physical activity guidelines (PAGs). However, adherence to these guidelines is low. African American (AA) BCSs are more often overweight or obese and less likely than women of other races to report adherence to physical activity recommendations. This study examined socioeconomic, clinical, and psychosocial correlates with meeting PAGs.

DESIGN

AA women diagnosed and treated for breast cancer and participating in a breast cancer support group (N = 193) completed a lifestyle assessment tool capturing demographic characteristics; breast cancer diagnosis and treatment history; health-related quality of life; weight history, including body mass index and post-diagnosis weight gain; and physical activity. Logistic regressions were used to determine if these covariates were associated with meeting [>8.3 metabolic equivalent task (MET) hr/wk]; partially meeting (4.15-8.3 MET hr/wk); or not meeting (<4.15 MET hr/wk) PAGs.

RESULTS

Only 54% of AA BCSs reported meeting current PAGs. Participants reporting weight gain of ≤5 lbs post-diagnosis, and those who received surgical treatment for breast cancer were more likely to complete at least 8.3 MET hr/wk. Better physical functioning and lesser pain intensity were associated with meeting PAGs.

CONCLUSION

Several factors influence physical activity behaviors and are likely to be important in developing effective interventions to assist AA survivors manage their weight. It is essential that providers and breast cancer support groups that assist survivors to remain physically active and to manage their weight should be aware of these factors. These findings may help generate hypotheses for future research to undergird efforts to increase physical activity among African American BCSs.

Quality of Life in Women With Breast Cancer Treated With or Without Chemotherapy

BACKGROUND

The diagnosis and treatment of breast cancer may negatively affect the quality of life (QOL) of women.

OBJECTIVES

The aim of this study is to assess QOL in women with breast cancer who were treated with or without chemotherapy and to identify factors associated with improved or worsening QOL in these women.

METHODS

This cross-sectional study enrolled 112 women who were treated with chemotherapy (CTX group, with 85 [75.9%] women) or without chemotherapy (non-CTX group, with 27 [24.1%] women) for breast cancer. The Short-Form Health Survey (SF-36) assessed QOL and the Hospital Anxiety and Depression scale assessed anxiety and depression.

RESULTS

The overall mean SF-36 score was below 50 in all domains. Relative to CTX women, non-CTX women were significantly older (P = .001) and more likely to engage in physical exercise (P = .002). The non-CTX group had higher scores in the Physical Functioning (P = .001) and Role-Physical (P = .0009) domains of the SF-36 relative to the CTX group, and the fluoruracil + epirubicin + cyclophosphamide group had significantly lower scores in the SF-36 domains Physical Functioning (P = .009) and Role-Physical (P = .02).

CONCLUSION

Chemotherapy treatment for breast cancer worsens QOL in the Physical Functioning and the Role-Physical domains of the SF-36 relative to women treated without chemotherapy.

IMPLICATIONS FOR PRACTICE

Nurses should assess Physical Functioning and the Role-Physical before treatment, as a woman who was not physically active before breast cancer is not likely to become physically active after treatment. Establishing support groups and providing educational sessions about the disease and its management, supportive care can improve the QOL of this population.

Effects of cognitive behavioral therapy for insomnia and armodafinil on quality of life in cancer survivors: a randomized placebo-controlled trial

PURPOSE

Cancer-related insomnia is associated with diminished quality of life (QOL), suggesting that improvement in insomnia may improve QOL in cancer survivors. Cognitive behavioral therapy for insomnia (CBT-I) has been shown to improve insomnia, but less is known regarding its effect on QOL and whether improvement in insomnia corresponds to improved QOL. The present analysis examines the effects of CBT-I, with and without armodafinil, on QOL both directly and indirectly through improvements of insomnia.

METHODS

This is an analysis of 95 cancer survivors for a specified secondary aim of a four-arm randomized controlled trial assessing the combined and individual effects of CBT-I and armodafinil to improve insomnia. QOL and insomnia severity were assessed before, during the intervention, at post-intervention, and 3 months later by Functional Assessment of Cancer Therapy-General and Insomnia Severity Index, respectively.

RESULTS

Mean change in QOL from pre- to post-intervention for CBT-I + placebo, CBT-I + armodafinil, armodafinil, and placebo was 9.6 (SE = 1.8; p < 0.0001), 11.6 (SE = 1.8; p < 0.0001), -0.2 (SE = 3.2; p = 0.964), and 3.3 (SE = 2.0; p = 0.124), respectively. ANCOVA controlling for pre-intervention scores showed that participants receiving CBT-I had significantly improved QOL at post-intervention compared to those not receiving CBT-I (p < 0.0001, effect size = 0.57), with benefits being maintained at the 3-month follow-up. Path analysis revealed that this improvement in QOL was due to improvement in insomnia severity (p = 0.002), and Pearson correlations showed that changes in QOL from pre- to post-intervention were significantly associated with concurrent changes in insomnia severity (r = -0.56; p < 0.0001). Armodafinil had no effect on QOL for those who did or did not receive it (p = 0.976; effect size = -0.004).

CONCLUSION

In cancer survivors with insomnia, CBT-I resulted in clinically significant improvement in QOL via improvement in insomnia. This improvement in QOL remained stable even 3 months after completing CBT-I.

IMPLICATIONS FOR CANCER SURVIVORS

Considering the high prevalence of insomnia and its detrimental impact on QOL in cancer survivors and the effectiveness of CBT-I in alleviating insomnia, it is important that evidence-based non-pharmacological sleep interventions such as CBT-I be provided as an integral part of cancer care.

Association between Time since Cancer Diagnosis and Health-Related Quality of Life: A Population-Level Analysis

OBJECTIVES

To examine the association between time since cancer diagnosis and health-related quality of life (HRQOL) among cancer survivors in remission.

METHODS

Analyzing data from 3,610 cancer survivors and 59,539 individuals without cancer in the Medical Expenditure Panel Survey, we examined the relationship between time since cancer diagnosis and HRQOL, taking remission status into account and controlling for patients' demographic characteristics and comorbidities. HRQOL measurements included the six-dimensional health state short form (derived from 36-item short form health survey) (SF-6D) utility scores, the physical component summary score, and the mental component summary score.

RESULTS

The relationship between time since cancer diagnosis and HRQOL varied substantially across cancer types. Compared with individuals without cancer, survivors of breast, prostate, or poor-prognosis cancer had statistically lower SF-6D scores within 2 years of diagnosis (-0.044, -0.062, and -0.088, respectively). Breast cancer survivors had SF-6D scores similar to those of individuals without cancer after 2 years, as did patients with poor-prognosis cancer after 5 years. Nevertheless, even after a period of 10 years, survivors of prostate or cervical cancer had a lower level of SF-6D scores (-0.027 and -0.042, respectively). The comparisons of physical health between cancer survivors and individuals without cancer were similar to those of SF-6D. In contrast, most cancer survivors did not experience poorer mental health; survivors of prostate or cervical cancer, however, had lower mental component summary scores after 10 years of diagnosis.

CONCLUSIONS

The level of HRQOL among cancer survivors depends on time since cancer diagnosis and cancer type. Some cancer survivors have lower HRQOL after a decade of diagnosis, even in remission.

Bidirectional associations between alcohol consumption and health-related quality of life amongst young and middle-aged women

BACKGROUND

Evidence from cross-sectional studies has suggested a positive association between moderate alcohol consumption and health-related quality of life but prospective data remain scarce.

OBJECTIVES

To examine the bidirectional relationships between alcohol consumption and health-related quality of life using a longitudinal study design.

METHODS

A total of 92 448 participants of the Nurses' Health Study II reported their alcohol consumption (in 1991, 1995, 1999 and 2003) and health-related quality of life (in 1993, 1997 and 2001). Using generalized estimating equations, we modelled the physical and mental component summary (PCS and MCS) scores as a function of alcohol consumption 2 years earlier (n = 88 363) and vice versa (n = 84 621).

RESULTS

Greater alcohol consumption was associated with better PCS scores 2 years later in a dose-response manner up to ~1 serving daily [mean difference (β) = 0.67 ± 0.06 PCS units, for moderate versus infrequent drinkers]. After adjustment for previous PCS, a similar but attenuated pattern was observed (β = 0.33 ± 0.07). Moderate alcohol consumption was not related to MCS, whereas moderate-to-heavy alcohol consumption was associated with lower MCS scores (β = -0.34 ± 0.15). Higher PCS scores were associated with greater alcohol consumption 2 years later, also after adjustment for previous alcohol consumption (β = 0.53 ± 0.05 g day(-1) ). MCS was not associated with alcohol consumption 2 years later.

CONCLUSION

Amongst young and middle-aged women, moderate alcohol intake was associated with a small improvement in physical health-related quality of life 2 years later and vice versa. Moderate alcohol consumption was not associated with mental health-related quality of life in either direction.

Health State Utility Impact of Breast Cancer in U.S. Women Aged 18-44 Years

INTRODUCTION

Breast cancer affects women's health-related quality of life negatively, but little is known about how breast cancer affects this in younger women aged 18-44 years. This study measures preference-based health state utility (HSU) values, a scaled index of health-related quality of life for economic evaluation, for younger women with breast cancer and compares these values with same-age women with other cancers and older women (aged ≥45 years) with breast cancer.

METHODS

Data from the 2009 and 2010 Behavioral Risk Factor Surveillance System were analyzed in 2014. The sample included 218,852 women; 7,433 and 18,577 had histories of breast and other cancers. HSU values were estimated using Healthy Days survey questions and a published mapping algorithm. Linear regression models for HSU were estimated by age group (18-44 and ≥45 years).

RESULTS

The adjusted breast cancer HSU impact was four times larger for younger women than for older women (-0.097 vs -0.024, p<0.001). For younger women, the effect of breast cancer on HSU was 70% larger than that of other cancers (-0.097 vs -0.057, p=0.024).

CONCLUSIONS

Younger breast cancer survivors reported lower HSU values than older survivors, highlighting the impact of breast cancer on the physical and mental health of younger women. The estimates may be used to evaluate quality-adjusted life-years or expectancy for prevention or treatment of breast cancer. This study also indicates that separate quality of life adjustments for women by age group are important for economic analysis of public health breast cancer interventions.

Breast Cancer in Young Women: Health State Utility Impacts by Race/Ethnicity

INTRODUCTION

Little is known about the effect of breast cancers on health-related quality of life among women diagnosed between age 18 and 44 years. The goal of this study is to estimate the effect of breast cancer on health state utility by age at diagnosis (18-44 years versus ≥45 years) and by race/ethnicity.

METHODS

The analytic sample, drawn from the 2009 and 2010 Behavioral Risk Factor Surveillance System and analyzed in 2013, included women diagnosed with breast cancer between age 18 and 44 years (n=1,389) and age ≥45 years (n=6,037). Health state utility values were estimated using Healthy Days variables and a published algorithm. Regression analysis was conducted separately by age at diagnosis and race/ethnicity.

RESULTS

The breast cancer health state utility decrement within 1 year from date of diagnosis was larger for women diagnosed at age 18-44 years than for women diagnosed at age ≥45 years (-0.116 vs -0.070, p<0.05). Within the younger age-at-diagnosis group, Hispanic women 2-4 years after diagnosis had the largest health state utility decrement (-0.221, p<0.01), followed by non-Hispanic white women within 1 year of diagnosis (-0.126, p<0.01).

CONCLUSIONS

This study is the first to report estimates of health state utility values for breast cancer by age at diagnosis and race/ethnicity from a nationwide sample. The results highlight the need for separate quality of life adjustments for women by age at diagnosis and race/ethnicity when conducting cost-effectiveness analysis of breast cancer prevention, detection, and treatment.

Depression and quality of life before and after breast cancer diagnosis in older women from the Women's Health Initiative

PURPOSE

Distress and reduced quality of life (QOL) are common among people with cancer. No study has compared these variables after breast cancer diagnosis to pre-cancer diagnosis levels.

METHODS

Data on women with breast cancer 50 years of age or older (n = 6949) were analyzed from the Women's Health Initiative (1993-2013). Health-related QOL (physical function, mental health) was measured using Rand-36. Depressive symptoms were measured with the six-item Center for Epidemiologic Studies Depression scale. Assessments occurred before and after the cancer diagnosis. Hierarchical linear modeling compared pre-cancer QOL and depressive symptoms to levels post-diagnosis and tested whether pre-cancer physical activity, stressful life events, sleep disturbance, and pain predicted post-diagnosis outcomes.

RESULTS

Compared with pre-cancer levels, depressive symptoms increased (20.0% increase at 0-6 months, 12.9% increase at 6-12 months), while physical function (-3.882 points at 0-6 months, -3.545 at 6-12 months) and mental health decreased (-2.899 points at 0-6 months, -1.672 at 6-12 months) in the first year after diagnosis (all p < .01). Depressive symptoms returned to pre-cancer levels after 10 years, but QOL remained significantly lower. At more than 10 years post-diagnosis, physical function was 2.379 points lower than pre-cancer levels (p < 0.01) while mental health was 1.922 points lower (p < 0.01). All pre-cancer predictors were associated with all outcomes. Pain predicted uniquely greater decreases in physical function post-diagnosis.

CONCLUSIONS

Depressive symptoms increased and QOL decreased following breast cancer diagnosis compared with pre-cancer levels, particularly in the first year.

IMPLICATIONS FOR CANCER SURVIVORS

QOL may remain lower for years after breast cancer diagnosis, although decreases are small.

The Effects of Surgery Type and Chemotherapy on Early-Stage Breast Cancer Patients' Quality of Life Over 2-Year Follow-up

BACKGROUND

We examined the effects of surgery type and adjuvant chemotherapy on change in early-stage breast cancer patients' quality of life (QOL) over time.

METHODS

A cohort of 549 patients (33.5% ductal carcinoma in situ, 66.5% stages I/IIA) were interviewed a mean 6.1 weeks (Time1), and 6.2 (Time2), 12.3 (Time3), and 24.4 (Time4) months following definitive breast-conserving surgery (BCS) or mastectomy. QOL was measured using the total Functional Assessment of Cancer Therapy-Breast (FACT-B). Adjusting for demographic, psychosocial, and clinical variables, multiple linear regression models estimated the associations between QOL and each of surgery type, chemotherapy, and their 2-way interaction at each interview. Adjusted generalized estimating equation (GEE) models tested Time1-Time4 change in QOL.

RESULTS

At Time2, chemotherapy (P < .001) and BCS (P < .001) were independently associated with worse QOL in adjusted linear regression, and the adverse effect of chemotherapy was prominent among patients who received BCS compared with those who received mastectomy (P interaction = .031). In the GEE model, QOL significantly improved over time among patients who received BCS (P trend = .047), mastectomy (P trend = .024), and chemotherapy (P trend < .001), but not among patients who did not receive chemotherapy (P trend = .720). All patients completed adjuvant chemotherapy and radiation by Time3. Regardless of surgery type, patients receiving chemotherapy reported lower QOL following surgery, and QOL improved after completion of adjuvant treatment.

CONCLUSIONS

Chemotherapy had a short-term negative impact on QOL after definitive surgical treatment regardless of surgery type. QOL rebounded after completion of adjuvant treatment.

History of falls, balance performance, and quality of life in older cancer survivors

Older cancer survivors may be predisposed to falls because of the sequalae associated with cancer and its treatments. This study examined the association between the fall history, balance performance, and health-related quality of life (QoL) in older, community-dwelling cancer survivors who had completed primary cancer treatments. Forty-one cancer survivors (age = 67.9 ± 8.8 years) participated in the study. Balance performance was examined using the Activities-specific Balance Confidence Scale (ABC) and the Balance Evaluation Systems Test (BESTest). Scores from the Physical Component Summary (PCS) and Mental Component Summary (MCS) of the SF-36v2 were obtained to assess the QoL. The demographics and health status were comparable between the fallers and non-fallers. While 54% of the participants had experienced at least one fall in the past 12 months, 30% had experienced two or more falls. Spearman's correlation analysis revealed a significant relationship between the outcomes from the ABC and the PCS (p < 0.001), and between the BESTest and the PCS (p < 0.001). Only the PCS significantly differentiated fallers from non-fallers (p < 0.01). Logistic regression analysis estimated that a one-unit increase in the PCS score significantly reduced the odds of falling by 13% (p < 0.01). The results demonstrate that in older cancer survivors, falls are a significant problem and balance control is a determinant of perceived physical function and well-being. Older cancer survivors reporting a poor QoL in the physical health domain may have higher risks of falling. Future studies are needed to examine the risk factor profiles of falls and the interventions to prevent falls in older cancer survivors.

Effect of a 10-week yoga programme on the quality of life of women after breast cancer surgery

Aim of the study

The following research is aimed at determining the effect of yoga on the quality of life of women after breast cancer surgery.

Material and methods

A 10-week yoga programme included 90-minute yoga lessons once a week. To estimate the quality of life, questionnaires developed by the European Organisation for Research and Treatment of Cancer (QLQ-C30 and QLQ-BR23) were used. An experimental group consisted of 12 women who practised yoga, a control group – of 16 women who did not. Between groups there were no differences in age, time from operation and characteristics associated with disease, treatment and participation in rehabilitation.

Results

Our results revealed an improvement of general health and quality of life, physical and social functioning as well as a reduction of difficulties in daily activities among exercising women. Also their future prospects enhanced – they worried less about their health than they used to before participating in the programme. As compared to baseline, among exercising women, fatigue, dyspnoea and discomfort (pain, swelling, sensitivity) in the arm and breast on the operated side decreased.

Conclusions

Participation in the exercising programme resulted in an improvement of physical functioning, reduction of fatigue, dyspnoea, and discomfort in the area of the breast and arm on the operated side. Based on our results and those obtained in foreign studies, we conclude that rehabilitation with the use of yoga practice improves the quality of life of the patients after breast cancer surgery. However, we recommend further research on this issue in Poland.

Sleep, fatigue, depression, and circadian activity rhythms in women with breast cancer before and after treatment: a 1-year longitudinal study

PURPOSE

Sleep disturbance, fatigue and depression are common complaints in patients with cancer, and often contribute to worse quality of life (QoL). Circadian activity rhythms (CARs) are often disrupted in cancer patients. These symptoms worsen during treatment, but less is known about their long-term trajectory.

METHODS

Sixty-eight women with stage I-III breast cancer (BC) scheduled to receive ≥4 cycles of chemotherapy, and age-, ethnicity-, and education-matched normal, cancer-free controls (NC) participated. Sleep was measured with actigraphy (nocturnal total sleep time [nocturnal TST] and daytime total nap time [NAPTIME]) and with the Pittsburgh Sleep Quality Index (PSQI); fatigue with the Multidimensional Fatigue Symptom Inventory-Short Form (MFSI-SF); depression with the Center of Epidemiological Studies-Depression (CES-D). CARs were derived from actigraphy. Several measures of QoL were administered. Data were collected at three time points: before (baseline), end of cycle 4 (cycle 4), and 1 year post-chemotherapy (1 year).

RESULTS

Compared to NC, BC had longer NAPTIME, worse sleep quality, more fatigue, more depressive symptoms, more disrupted CARs, and worse QoL at baseline (all p values <0.05). At cycle 4, BC showed worse sleep, increased fatigue, more depressive symptoms, and more disrupted CARs compared to their own baseline levels and to NC (all p values <0.05). By 1 year, BC's fatigue, depressive symptoms, and QoL returned to baseline levels but were still worse than those of NC, while NAPTIME and CARs did not differ from NC's.

CONCLUSION

Additional research is needed to determine if beginning treatment of these symptoms before the start of chemotherapy will minimize symptom severity over time.

Emotional well-being years post-treatment for breast cancer: prospective, multi-ethnic, and population-based analysis

PURPOSE

This study investigated factors associated with declines in emotional well-being (EWB) over time in breast cancer survivors.

METHODS

Women with breast cancer (Stages I-III) residing in Los Angeles, CA, or Detroit, MI, and reported to the Surveillance, Epidemiology, and End Results registries between June 2005 and February 2007 completed surveys at 9 months and 4 years after diagnosis. EWB was measured by the Functional Assessment of Cancer Treatment-Breast. Using a stress coping framework, logistic regression models assessed associations between personal, social, and clinical correlates, appraisal (e.g., worry about recurrence) and coping factors (e.g., emotional support) to EWB declines.

RESULTS

Among eligible women who completed primary breast cancer treatment, 772 completed both surveys, and 192 (24.9 %) experienced EWB declines over time. Women with past or current depression were more likely to report EWB decline (p < 0.01). Survivors who perceived they did not receive enough information about risk of breast cancer recurrence during primary treatment were more likely to have EWB decline (OR 0.53, 95 % CI 0.32-0.87). Greater perceived likelihood of recurrence (OR 1.95, 95 % CI 1.01-5.29) and increased worry about recurrence (OR 1.38, 95 % CI 1.10-1.72) were associated with EWB decline. Higher spirituality beliefs and practices were associated with EWB decline.

CONCLUSIONS

A considerable number of breast cancer patients report emotional well-being declines over time. Early identification of women who are vulnerable, such as women with past depression, is crucial to improve quality of care. Women would benefit from education about cancer recurrence and tailored strategies to manage worry about recurrence over time.

IMPLICATION FOR CANCER SURVIVORS

Understanding actual risk of recurrence and managing worry about recurrence is important for cancer survivors. Emotional concerns are common for individuals with cancer so survivors should feel free to reach out and discuss such concerns with providers well into the survivorship period.

Job attributes, job satisfaction and the return to health after breast cancer diagnosis and treatment

BACKGROUND

As detection and treatment of cancer has advanced, the number of working age women with breast cancer has increased. This study provides new information on the intersection of breast cancer treatment and job tasks and how, together, they impact employed and newly diagnosed women.

METHODS

The sample comprised 493 employed women within 2 months of initiating treatment. Job satisfaction and demands were assessed by a pre-diagnosis recall along with measures of mental and physical health and assessed again 9 months after initiating treatment. Using seemingly unrelated regression, we tested the effect of job tasks and satisfaction on mental and physical health 9 months post-treatment initiation, controlling for pre-diagnosis health status, patient characteristics, and job tasks.

RESULTS

Physical job demands prior to diagnosis were not significantly associated with mental or physical health 9 months after treatment initiation. Employment in cognitively demanding and less satisfying jobs was associated with decreases in mental health and increases in problems with work or daily activities 9 months post-treatment initiation (p<0.05). Women who received five or more cycles of chemotherapy reported lower vitality, social functioning, and worse measures of physical health compared with those who did not receive chemotherapy (p<0.05).

CONCLUSIONS

Employment in cognitively demanding and unsatisfying jobs may impede mental health recovery, particularly in patients who receive longer chemotherapy regimens. Such information may be used by patients and clinicians in deciding when to undergo chemotherapy and whether job tasks can be restructured to hasten recovery. Copyright © 2013 John Wiley & Sons, Ltd.

Decreased health-related quality of life in women with breast cancer is associated with poor sleep

This study examined the longitudinal relation between health-related quality of life (HR-QOL) and subjective and objective sleep quality in 166 women with newly diagnosed Stage-1 through Stage-3 breast cancer, who were scheduled to receive ≥ 4 cycles of adjuvant/neoadjuvant chemotherapy. HR-QOL was assessed with the Medical Outcomes Study 36-item Short Form, Physical Component Scale (PCS), and Mental Component Scale (MCS) scores; subjective sleep was assessed with the Pittsburgh Sleep Quality Index; and objective sleep was measured with actigraphy. Data were collected before starting chemotherapy and during the last week of Cycle 4 of chemotherapy. Patients reported poor HR-QOL and poor sleep quality before and during chemotherapy. Short sleep time and long naps were recorded at both time points. The MCS score was related to reports of poor sleep, but not to recorded sleep; worse PCS scores were associated with reports of poor sleep and less recorded naptime, suggesting sleep plays an important role in cancer patients' HR-QOL.

Changes in health-related quality of life by occupational status among women diagnosed with breast cancer--a population-based cohort study

OBJECTIVE

To investigate whether longitudinal changes in health-related quality of life (HRQoL) among breast cancer patients vary by prediagnosis occupational status or postdiagnosis changes in working time.

METHODS

We identified 1573 patients in the Breast Cancer Quality Register of Central Sweden and asked them to participate in a longitudinal questionnaire study. A total of n = 841 women completed three questionnaires within a mean time of 4, 16, and 38 months postdiagnosis. Generalized estimating equation models were used to examine changes in European Organization for Research and Treatment of Cancer Quality of Life Questionnaire and the Breast Cancer-Specific Quality of Life Questionnaire subscales stratified by prediagnosis occupational status and postdiagnosis changes in working time.

RESULTS

Over time, the proportion of employed women reporting good functioning increased more, and the proportion reporting a high level of symptoms decreased more compared with women on sick leave/disability pension and retirement pensioners (p < 0.001). The latter two also showed a worsening in several subscales (p < 0.05). Among employed women, more consistent improvements in role and social functioning were observed among those with an increase/no change in working time than among those who had decreased it or stopped working (p < 0.05). A decrease in the proportion reporting pain was observed among women with an increase/no change in working time compared with women with decreased working time, among whom the proportion reporting pain increased (p = 0.008).

CONCLUSIONS

Being employed prediagnosis and resuming work to the same extent as prior to the breast cancer diagnosis are associated with consistent improvements in HRQoL. These results highlight the importance of interventions to improve HRQoL and policies to support return to work following diagnosis.

The Alberta moving beyond breast cancer (AMBER) cohort study: a prospective study of physical activity and health-related fitness in breast cancer survivors

Background

Limited research has examined the association between physical activity, health-related fitness, and disease outcomes in breast cancer survivors. Here, we present the rationale and design of the Alberta Moving Beyond Breast Cancer (AMBER) Study, a prospective cohort study designed specifically to examine the role of physical activity and health-related fitness in breast cancer survivorship from the time of diagnosis and for the balance of life. The AMBER Study will examine the role of physical activity and health-related fitness in facilitating treatment completion, alleviating treatment side effects, hastening recovery after treatments, improving long term quality of life, and reducing the risks of disease recurrence, other chronic diseases, and premature death.

Methods/Design

The AMBER Study will enroll 1500 newly diagnosed, incident, stage I-IIIc breast cancer survivors in Alberta, Canada over a 5 year period. Assessments will be made at baseline (within 90 days of surgery), 1 year, and 3 years consisting of objective and self-reported measurements of physical activity, health-related fitness, blood collection, lymphedema, patient-reported outcomes, and determinants of physical activity. A final assessment at 5 years will measure patient-reported data only. The cohort members will be followed for an additional 5 years for disease outcomes.

Discussion

The AMBER cohort will answer key questions related to physical activity and health-related fitness in breast cancer survivors including: (1) the independent and interactive associations of physical activity and health-related fitness with disease outcomes (e.g., recurrence, breast cancer-specific mortality, overall survival), treatment completion rates, symptoms and side effects (e.g., pain, lymphedema, fatigue, neuropathy), quality of life, and psychosocial functioning (e.g., anxiety, depression, self-esteem, happiness), (2) the determinants of physical activity and health-related fitness including demographic, medical, social cognitive, and environmental variables, (3) the mediators of any observed associations between physical activity, health-related fitness, and health outcomes including biological, functional, and psychosocial, and (4) the moderators of any observed associations including demographic, medical, and biological/disease factors. Taken together, these data will provide a comprehensive inquiry into the outcomes, determinants, mechanisms, and moderators of physical activity and health-related fitness in breast cancer survivors.

Characterizing the psychological distress response before and after a cancer diagnosis

Psychological distress among cancer survivors is common. It is unknown if symptoms predate diagnosis or differ from patients without cancer because studies are limited to patient follow-up. Linked cohort (Wisconsin Longitudinal Study) and tumor registry records were used to assess the psychological distress response pre- to post-cancer diagnosis. Adjusted predicted probabilities of being in one of five categories of change for three psychological distress measures (depression, anxiety, well-being) were compared for participants diagnosed with cancer between 1993-1994 and 2004-2005 and participants without cancer (N = 5,162). Cancer survivors were more likely to experience clinically significant increases (≥0.8 standard deviation) in depression (15, 95 % CI = 12-18 %) and anxiety (19 %, CI = 16-22 %) compared to their no-cancer counterparts (10 %, CI = 10-11 %; 11 %, CI = 11-12 %). Cancer survivors <5 years from diagnosis were more likely to experience worsening depression. Survivors ≥5 years were more likely to experience worsening anxiety. No significant results were found for well-being. Characterizing the psychological distress response is a prerequisite for identifying at-risk patients and communicating expected symptoms, allowing for proactive resource provision.

Quality of life over time in women diagnosed with ductal carcinoma in situ, early-stage invasive breast cancer, and age-matched controls

Little is known about quality-of-life (QOL) differences over time between incident ductal carcinoma in situ (DCIS) and early-stage invasive breast cancer (EIBC) cases as compared with same-aged women without breast cancer (controls). We prospectively recruited and interviewed 1,096 women [16.8% DCIS, 33.3% EIBC (25.7% Stage I; and 7.6% Stage IIA), 49.9% controls; mean age 58; 23.7% non-white] at mean 6.7 weeks (T1), and 6.2 (T2), 12.3 (T3), and 24.4 months (T4) after surgery (patients) or screening mammogram (controls). We tested two hypotheses: (1) DCIS patients would report lower levels of QOL compared with controls but would report similar QOL compared with EIBC patients at baseline; and (2) DCIS patients' QOL would improve during 2-year follow-up and approach levels similar to that of controls faster than EIBC patients. We tested hypothesis 1 using separate general linear regression models for each of the eight subscales on the RAND 36-item Health Survey, controlling for variables associated with at least one subscale at T1. Both DCIS and EIBC patients reported lower QOL at T1 than controls on all subscales (each P<0.05). We tested hypothesis 2 using generalized estimating equations to examine change in each QOL subscale over time across the three diagnostic groups adjusting for covariates. By T3, physical functioning, role limitations due to physical problems, energy/fatigue, and general health each differed significantly by diagnostic group at P<0.05, because of larger differences between EIBC patients and controls; but DCIS patients no longer differed significantly from controls on any of the QOL subscales. At T4, EIBC patients still reported worse physical functioning (P=0.0001) and general health (P=0.0017) than controls, possibly because of lingering treatment effects. DCIS patients' QOL was similar to that of controls two years after diagnosis, but some aspects of EIBC patients' QOL remained lower.

Ginseng and Ganoderma lucidum use after breast cancer diagnosis and quality of life: a report from the Shanghai Breast Cancer Survival Study

Objective

To evaluate associations between quality of life (QOL) and use of ginseng and Ganoderma lucidum (G. lucidum) among breast cancer survivors.

Methods

Included in this study were 4,149 women with breast cancer who participated in the Shanghai Breast Cancer Survival Study. Ginseng use was assessed at 6-, 18-, and 36-month post-diagnosis surveys; G. lucidum use was assessed at the 6- and 36-month surveys. QOL was evaluated at the 6- and 36-month surveys. Multiple linear regression models were used to examine associations between ginseng and G.lucidum use and QOL assessed at the 36-month survey, with adjustment for potential confounders and baseline QOL.

Results

At 6 months post-diagnosis, 14.2% of participants reported regular use of ginseng and 58.8% reported use of G. lucidum. We found no significant associations between ginseng use at 6, 18, and 36 months post-diagnosis and participants’ total QOL score or individual scores for psychological, physical, or social well-being. Post-diagnosis G. lucidum use was positively associated with social well-being (adjusted mean difference: 1.26; 95% CI: 0.66, 1.86), but was inversely associated with physical well-being (adjusted mean difference: −1.16; 95% CI: −1.86, −0.47) with a dose-response pattern observed for cumulative number of times of use (P for trend <0.001 for both).

Conclusion

We found no evidence that post-diagnosis ginseng use improved the QOL of breast cancer survivors. Post-diagnosis G. lucidum use was associated with better social well-being scores, but poorer physical well-being scores.

Considering the unspoken: the role of death cognition in quality of life among women with and without breast cancer

This study examined how breast cancer diagnosis influences underlying cognitions and explicit worries about death, and their roles in health-related quality of life (QOL). Forty-two women who underwent surgery for the removal of either a cancerous or benign breast mass indicated their worries about dying and completed measures of death-thought accessibility and QOL. Women with cancer reported lowered physical, emotional, and functional well-being. Further, although they did not differ in explicit worry about death, women with cancer (compared to those with a benign mass) evidenced greater death-thought accessibility, which in turn mediated the effect of cancer diagnosis on well-being.

What happens now? Psychosocial care for cancer survivors after medical treatment completion

The growing population of adults living with a history of cancer in the United States mandates attention to quality of life and health in this group, as well as to the implementation of evidence-based interventions to address psychosocial and physical concerns at completion of medical treatments and beyond. The goals of this article are to document the need for attention to psychosocial domains during the re-entry and later phases of the cancer survivor trajectory, offer an overview of current evidence on efficacy of psychosocial interventions during those phases, and offer suggestions for application and research regarding post-treatment psychosocial care.

Health-related quality of life among women with breast cancer - a population-based study

BACKGROUND

High incidence rates of breast cancer emphasize the importance of increased knowledge about the health-related quality of life (HRQoL) in this patient group. The aim of the present study was to describe and compare HRQoL among breast cancer patients shortly after diagnosis with normative data from the general population, and to investigate how clinical, demographic, and socio-economic factors and social support are associated with HRQoL.

MATERIAL AND METHODS

Participants were identified in a population-based Breast Cancer Quality Register in central Sweden. Of 1573 women newly diagnosed with breast cancer during a one-year period (2007-2008), 69% (n = 1086) completed a questionnaire including the EORTC QLQ-C30, BR23 and the HADS.

RESULTS

Compared to age-adjusted normative data, breast cancer patients (mean age 62 years, range 25-94), especially younger women (<50 years), experienced clinically meaningful poorer HRQoL. Clinically significant levels of anxiety and depressive symptoms were found among 14% and 6% of the patients, respectively. Factors associated with more problems/symptoms among study participants included chemotherapy, lack of social support, sick leave and a poor financial situation. Adding socio-economic factors diminished the association between age and HRQoL (p > 0.05).

CONCLUSION

Recently diagnosed breast cancer patients reported poorer HRQoL in several dimensions compared to normative data. In addition to clinical and demographic factors, an unfavorable socio-economic standing was associated with more problems/symptoms. The present findings emphasize the importance of taking a variety of factors into account when assessing HRQoL in the clinical setting.

Exercise after diagnosis of breast cancer in association with survival

It has been suggested that exercise following breast cancer diagnosis is inversely associated with mortality. However, controversy exists regarding the causality of such associations. We evaluated associations of exercise after breast cancer diagnosis with total mortality and recurrence/disease-specific mortality, accounting for conditions that restrict exercise participation. The analysis included 4,826 women with stage I to III breast cancer identified 6 months after diagnosis through the population-based Shanghai Cancer Registry and recruited into the study between 2002 and 2006. Exercise was assessed approximately 6, 18, and 36 months postdiagnosis, and metabolic equivalent (MET) scores were derived. Information on medical history, cancer diagnosis, treatments, quality of life (QOL), anthropometrics, and lifestyles were obtained by in-person interviews at 6 months postdiagnosis. Medical charts were abstracted to verify clinical information. During the median follow-up of 4.3 years, 436 deaths and 450 recurrences/cancer-related deaths were documented. After adjustment for QOL, clinical prognostic factors, and other covariates, exercise during the first 36 months postdiagnosis was inversely associated with total mortality and recurrence/disease-specific mortality with HRs of 0.70 (95% CI: 0.56-0.88) and 0.60 (95% CI: 0.47-0.76), respectively. Significant dose-response relationships between total and recurrence/disease-specific mortality rates and exercise duration and MET scores were observed (all values for P(trend) < 0.05). The exercise-mortality associations were not modified by menopausal status, comorbidity, QOL, or body size assessed at approximately 6 months postdiagnosis. An interaction between disease stage and hormone receptor status and total mortality was noted. Our study suggests that exercise after breast cancer diagnosis may improve overall and disease-free survival.

Shoulder impairments and their association with symptomatic rotator cuff disease in breast cancer survivors

Over 2.6 million breast cancer survivors currently reside in the United States. While improvements in the medical management of women diagnosed with breast cancer have resulted in a 5-year survival rate of 89%, curative treatments are associated with a high prevalence of shoulder and arm morbidity, which, in turn, can negatively impact a woman's quality of life. Breast cancer survivors frequently experience shoulder and arm pain, decreased range of motion, muscle weakness, and lymphedema. These symptoms can lead to difficulties with daily activities ranging from overhead reaching and carrying objects to caring for family and returning to work. Despite health care professionals awareness of these problems, a significant number of breast cancer survivors are confronted with long-term, restricted use of their affected shoulder and upper extremity. This problem may partially be explained by: (1) an incomplete understanding of relevant impairments and diagnoses associated with shoulder/arm pain and limited upper extremity use, and (2) the limited effectiveness of current rehabilitation interventions for managing shoulder pain and decreased upper extremity function in breast cancer survivors. Because breast cancer treatment directly involves the neuromusculoskeletal tissues of the shoulder girdle, it is understandable why breast cancer survivors are likely to develop shoulder girdle muscle weakness and fatigue, decreased shoulder motion, altered shoulder girdle alignment, and lymphedema. These impairments can be associated with diagnoses such as post-mastectomy syndrome, adhesive capsulitis, myofascial dysfunction, and brachial plexopathy, all of which have been reported among breast cancer survivors. It is our belief that these impairments also put women at risk for developing symptomatic rotator cuff disease. In this paper we set forth the rationale for our belief that breast cancer treatments and subsequent impairments of shoulder girdle neuromusculoskeletal tissues place breast cancer survivors at risk for developing symptomatic rotator cuff disease. Additionally, we identify knowledge gaps related to the current understanding of relevant shoulder girdle impairments and their association with symptomatic rotator cuff disease in breast cancer survivors. Ultimately, information from studies designed to meet these gaps will provide a scientific basis for the development of new, or refinement of existing, examination, intervention, and prevention techniques, which should lead to improved clinical outcomes in this population.

Pain in long-term breast cancer survivors: frequency, severity, and impact

OBJECTIVE

To better understand the severity and impact of pain in women who are breast cancer survivors.

DESIGN

Cross-sectional survey.

SETTING

Cancer wellness clinic.

PATIENTS

Two hundred fifty-three women with a history of early-stage breast cancer who had completed therapy and were without evidence of disease. Interventions. None.

OUTCOME MEASURES

A survey that included questions about cancer history, pain, sleep problems, and physical and psychological functioning.

RESULTS

About half of the participants (117 or 46%) reported some pain, although most rated its intensity as mild. Both average and worst pain ratings showed significant associations with physical functioning (rs, -0.48 and -0.43, respectively), severity of sleep problems (rs, 0.31 and 0.30), and psychological functioning (rs, -0.27 and -0.24). Age (with younger participants slightly more likely to report pain) and history of antiestrogen therapy showed nonsignificant trends to predict the presence of pain.

CONCLUSIONS

The study findings provide new and important knowledge regarding the severity and impact of pain in female breast cancer survivors. The results indicate that clinicians should assess pain regularly in breast cancer survivors and treat this pain when indicated. The findings also support the need for research to determine whether improved pain management would result in improved quality of life for women with a history of breast cancer.

Health-related quality of life and healthcare experiences in breast cancer patients in a study of Swedish women

BACKGROUND

Nearly 7,000 women are diagnosed with breast cancer in Sweden every year. The primary treatment is surgical and consists mainly of partial or modified radical mastectomy followed by adjuvant treatment. The diagnosis and treatment may cause distress and decreased health-related quality of life.

OBJECTIVE

The aim of the present report was to study health-related quality of life and satisfaction with hospital stay.

METHODS

One hundred women were invited to participate in the study, of which 85 accepted. Participants filled in the 36-item Short-Form Health Survey and a study-specific questionnaire, both preoperatively and postoperatively and 6 months after surgery.

RESULTS

Women with breast cancer experienced an improved health-related quality of life over time, but they reported poorer health-related quality of life than the norm value after surgery. The lowest scores at all time points were observed on the scales role-physical and role-emotional. Patients were very satisfied with the treatment and care they had received. Three of 4 women felt that the nursing staff had a considerate and conscientious manner, for example, when removing drains.

CONCLUSION

Diagnosis and treatment of breast cancer have impact on the women's health-related quality of life. Measures to meet patients' needs during short hospitalization need to be considered.

IMPLICATIONS FOR PRACTICE

Nurses must ensure that patient's physical and emotional needs are identified and met and that appropriate counseling is provided.

Sintomas depressivos no câncer de mama: Inventário de Depressão de Beck - Short Form

OBJETIVOS: Verificar a prevalência de sintomas depressivos em mulheres com câncer de mama e identificar os fatores de risco associados à sua ocorrência. MÉTODOS: Foi realizado um estudo transversal, em que foram entrevistadas 71 mulheres com câncer de mama. Foram empregados dois instrumentos: um questionário para verificar os dados sociodemográficos e clínicos e o Inventário de Depressão de Beck - Short Form (BDI-SF), para avaliação dos sintomas depressivos. Para análise dos dados, utilizaram-se medidas descritivas e o teste de qui-quadrado, que avaliou a associação entre variáveis sociodemográficas e clínicas e os sintomas depressivos. O nível de significância considerado foi de 5%. RESULTADOS: A prevalência de sintomas depressivos foi de 29,6%. Os fatores associados à presença desses sintomas foram o tratamento quimioterápico (p = 0,021), presença de dor (p = 0,018) e limitação do movimento do membro superior (p = 0,010) e pior percepção da saúde (p = 0,018). CONCLUSÃO: Sintomas depressivos são frequentes no câncer de mama, assim a saúde mental das mulheres com esse tipo de câncer deve ser investigada e tratada quando necessário, reduzindo o impacto desses sintomas na vida da mulher.

Prevalence of depression and its related factors among Chinese women with breast cancer

BACKGROUND. Little information is available regarding depression among Asian breast cancer survivors. METHODS. We estimated the prevalence of depression and its correlates among 1400 participants of a population-based cohort study of women with stage 0-IV breast cancer in Shanghai, China. Through in-person interviews conducted at 6 months and 18 months post-diagnosis and review of medical charts, information on sociodemographic and clinical factors and quality of life (QOL) was collected. Depression was measured by the 20-item Center for Epidemiologic Studies Depression Scale at 18 months post-diagnosis. RESULTS. Approximately 26% of participants had mild to severe depression and 13% fulfilled the criteria of clinical depression at 18 months post-diagnosis. Women with lower income were more likely to have depression than women with higher income (prevalence: 16.6% vs. 6.9% for mild depression and 17.1% vs. 5.5% for clinical depression, respectively). Depression was more common among women who were widowed (18.9%) or divorced/separated/single (16.4%) than among women who were married (11.8%). Women with comorbidity were more likely to have clinical depression (17.3% vs 11.2%). Multivariate analysis showed that low income, marital status, comorbidity, and low QOL scores were independent predictors for depression. We did not find that prevalence of depression differed by menopausal status, estrogen or progesterone receptor status, disease stage, or cancer-related treatments. CONCLUSION. Depression is common among Asian women with breast cancer. Routine screening and prevention of depression are warranted among women with breast cancer.

Racial/ethnic differences in quality of life after diagnosis of breast cancer

INTRODUCTION

Most studies on quality of life of breast cancer survivors have not had adequate representation of ethnic minorities. The purpose of this study was to determine whether racial/ethnic differences in quality of life exist between white, African American, and Latina women in the early stages of survivorship.

METHODS

2268 women were identified by two Surveillance, Epidemiology and End Results (SEER) registries (6/05-2/07) and asked to complete a survey (mean 9 months post-diagnosis, 72.1% response rate). Latina and African American women were over-sampled. Regression models compared quality of life across race/ethnicity (white, African American, Latina [low vs. high acculturation]), sequentially controlling for sociodemographics, clinical, and treatment factors.

RESULTS

There were significant racial/ethnic differences in quality of life controlling for sociodemographics, clinical factors and treatment factors. Lower acculturated Latinas compared to whites had significantly lower functional well-being, emotional well-being, and breast cancer concerns (p values < 0.05). African Americans had significantly higher emotional well-being than whites. Age, co-morbidities, cancer stage, and chemotherapy also influenced quality of life. A significant interaction was found between race/ethnicity and age for physical well-being (p = 0.041) and for emotional well-being (p = 0.042). Specifically, racial/ethnic differences were only observed among older women (>or=50 years), with less acculturated Latinas reporting the lowest quality of life.

CONCLUSIONS

Racial/ethnic differences in quality of life exist during the cancer survivorship period. Latinas with low acculturation are a particularly vulnerable subgroup.

IMPLICATIONS

Greater attention should be devoted to identifying women disproportionately affected by breast cancer and developing interventions targeting their unique survivorship concerns.

Change in health-related quality of life of newly diagnosed cancer patients, cancer survivors, and controls

BACKGROUND

Data from the 1998 Health Outcomes Survey (HOS) of patients who were enrolled in Medicare managed care and follow-up data from the 2000 HOS resurvey were analyzed to examine changes in health-related quality of life (HRQOL) of newly diagnosed cancer patients, cancer survivors, and patients without cancer.

METHODS

In 1998, the HOS was mailed to a random sample of 279,135 beneficiaries, and 167,096 respondents (60%) returned completed surveys. Those who were diagnosed with cancer (22,747) were frequency age-matched to an equal number of patients with no cancer. In 2000, the HOS was mailed to the same cohort of beneficiaries. Complete data at both baseline and follow-up were available on 16,850 individuals for inclusion in the current study.

RESULTS

After 2 years, respondents who had been diagnosed with cancer at baseline continued to have lower scores on all but 3 scales of the 36-item short-form HRQOL measure. However, there was no evidence that they were declining any faster than or catching up with noncancer patients. Those who had been newly diagnosed with cancer since the baseline survey had lower mean scale scores than the no-cancer group on all scales and lower mean scores than the cancer survivors on all subscales except Bodily Pain, Vitality, and Mental Health.

CONCLUSIONS

This study demonstrated that, after 2 years, cancer survivors continued to have poorer HRQOL than the no-cancer group. Newly diagnosed cancer patients had poorer quality of life than both the longer term cancer survivors and the no-cancer group.

Impact of cancer on health-related quality of life of older Americans

BACKGROUND

The impact of cancer on health-related quality of life (HRQOL) is poorly understood because of the lack of baseline HRQOL status before cancer diagnosis. To our knowledge, this is the first population-based study to quantify the nature and extent of HRQOL changes from before to after cancer diagnosis for nine types of cancer patients and to compare their health with individuals without cancer.

METHODS

The Surveillance, Epidemiology, and End Results cancer registry data were linked with the Medicare Health Outcomes Survey (MHOS) data; data were collected from Medicare beneficiaries who were aged 65 years and older from 1998 through 2003. Cancer patients (n = 1432; with prostate, breast, colorectal, lung, bladder, endometrial, or kidney cancers; melanoma; or non-Hodgkin lymphoma [NHL]) were selected whose first cancer diagnosis occurred between their baseline and follow-up MHOS assessments. Control subjects without cancer (n = 7160) were matched to cancer patients by use of propensity scores that were estimated from demographics and comorbid medical conditions. Analysis of covariance models were used to estimate changes in HRQOL as assessed with the Medical Outcomes Study Short Form-36 survey (mean score = 50, SD = 10). All statistical tests were two-sided.

RESULTS

Patients with all cancer types (except melanoma and endometrial cancer) reported statistically significant declines in physical health (mean scores: prostate cancer = -3.4, 95% confidence interval [CI] = -2.5 to -4.2; breast cancer = -3.5, 95% CI = -2.5 to -4.5; bladder cancer = -4.3, 95% CI = -2.5 to -6.1; colorectal cancer = -4.4, 95% CI = -3.3 to -5.5; kidney cancer = -5.7, 95% CI = -3.2 to -8.2; NHL = -6.7, 95% CI = -4.4 to -9.1; and lung cancer = -7.5, 95% CI = -5.9 to -9.2) compared with the control subjects (mean score = -1.8, 95% CI = -1.6 to -2.0) (all P < .05). However, only lung (mean score = -5.4, 95% CI = -3.5 to -7.2), colorectal (mean score = -3.5, 95% CI = -2.2 to -4.7), and prostate (mean score = -2.8, 95% CI = -1.8 to -3.7) cancer patients showed statistically significant decreases in mental health relative to the mean change of the control subjects (mean score = -1.2, 95% CI = -0.9 to -1.4) (all P < .05).

CONCLUSION

These findings provide validation of the specific deleterious effects of cancer on HRQOL and an evidence base for future research and clinical interventions aimed at understanding and remediating these effects.