Psychological and sexual well-being, philosophical/spiritual views, and health habits of long-term cancer survivors

The Impact of Multiple Recurrences in Disease-Free Survival of Breast Cancer: An Extended Cox Model

Aims and background

Identifying the risk factors of recurrence of breast cancer is important for both the physician and patient. Analysis of the first recurrence may lead to an inaccurate evaluation of the factor's effects because it does not completely reflect the history of the disease and may result in the loss of valuable information. The present study aimed to determine the factors that influence breast cancer recurrence and to estimate disease-free survival, adjusting for multiple metastases in breast cancer patients.

Methods and study design

Patients were selected from a longitudinal study carried out at Fayazabakhsh Hospital in Tehran, Iran. Women who were diagnosed with breast cancer and who underwent either modified radical mastectomy or breast-conserving surgery between January 2006 and April 2008 were recruited to take part in the study. Breast cancer recurrence was defined as the occurrence of a tumor in the contralateral breast, local-regional relapse, or distant metastasis to other organs. Using an extended Cox model, the effect of age, tumor size, estrogen receptors, HER2, progesterone receptors as well as lymph node ratio was analyzed.

Results

Over a 5833 person-month follow-up, 25 of 133 patients (18.8%) had died and 108 patients (81.2%) were still alive, 9 of them with metastasis. Thirty-four patients (25.6%) experienced their first disease recurrence. A total of 11 patients had a second metastasis. The mean time to first metastasis was 19.93 months, and mean gap time between two metastases was 7.15 months. Risk of experiencing a metastasis or death in the third and fifth year after surgery was approximately 22% and 28%, respectively. Fitting multiple recurrent regression shows that high lymph node ratio, high histologic grade, large tumor size and HER2-positive tumors are prognostic factors for shorter disease-free survival.

Conclusions

Our novel approach might be helpful in clinical practice to predict breast cancer recurrence after surgery and might be adapted to be used in other malignancies as well.

A qualitative investigation of the effects of psycho-spiritual integrative therapy on breast cancer survivors' experience of paradox

This study is an exploratory, qualitative investigation of breast cancer survivors' experiences of paradox, following psycho-spiritual integrative therapy (PSIT). Previous studies examined the role of paradox in spiritual development among women diagnosed with cancer; this study investigated a psycho-spiritual intervention for multicultural cancer survivors. Twelve multicultural breast cancer survivors, from a sample of 30 women participants in an 8-week PSIT group intervention, were recruited from oncologists, hospitals, support groups, outpatient oncology centers, surgeons, radiation therapy centers, cancer events, and websites. We conducted semi-structured, open-ended interviews lasting 1-2 h regarding participants' experiences coping with cancer and their experience of PSIT. We transcribed interviews and conducted blind searches for both new and previously identified paradoxes and themes. Two previously identified themes emerged: (1) attempting to maintain coherence in new and old ways and (2) letting go of ultimate control in life. Additionally, three novel themes emerged: (1) interconnection between helpers and hinderers, (2) spiritual edges and tensions, and (3) new paths to empowerment. Results of this qualitative analysis indicate participants experienced previously identified themes and experienced an expanded range of paradoxes. After learning compassionate acceptance through PSIT, breast cancer survivors develop greater access to the multidimensionality of paradoxes, which can go beyond a binary (either/or) construction to a more interdependent (both/and) relationship. Devoting greater attention to investigating and understanding how diverse participants engage with and move through paradoxical change processes could enhance the effectiveness of existential and spiritual interventions.

Personal Transformation

This article connects two rich but distinct literatures on personal transformation and well-being that can benefit from cross-fertilization. It explores the intersection of posttraumatic growth (PTG), a model of positive changes following traumatic events, and gerotranscendence, a theory of positive changes related to aging. The two conceptualizations of positive change are compared on multiple dimensions. These include the philosophical base, domains, trigger, mechanism, and correlates of change, as well as the connection of change with wisdom and life satisfaction. The analysis reveals many similarities between the two paths to personal transformation with the key difference being the trigger for growth. Whereas PTG connects growth to traumatic events, gerotranscendence connects the growth to normative later life experiences. The similarities identified imply that PTG could be viewed as part of normative adult development and as an accelerator of gerotranscendence. The analysis also indicates that transformation in normative development is likely fueled in part by stressful losses and existential suffering. The article suggests that PTG and gerotranscendence may be viewed as two facets of the universal human striving toward self-transcendence or emancipatory knowledge. The critical role of the sociocultural context in personal transformation is also highlighted. Implications for future research and practice are discussed.

Spirituality and post-graduate students’ attitudes towards blood donation

College students have become more representative as blood donors, mainly to help other people. This study ascertained the association between spirituality and adherence or intention to donate blood in post-graduate students. In this quantitative and cross-sectional study, participants were 281 students from a post-graduate programme at a Brazilian public university. After complying with ethical requirements, data were collected through a questionnaire for sociodemographic characterization and identification of blood donation practices, followed by the Spiritual Well-Being Scale. Descriptive statistics and parametric tests were used for data analysis. A total of 74% of the participants were female and 26% were male. Previous experience and/or intention to donate blood were found in 75.3%; 14.3% donated blood periodically. In addition, 12.2% were not adept to donation and 12.5% were inapt. Spiritual Well-Being scores were similar between individuals who are not adept and those who donate periodically. In conclusion, in the sample, spirituality and blood donation are not associated, but spiritual well-being and gender are. To enhance blood donation, further research is needed.

Quality of life of younger breast cancer survivors: persistence of problems and sense of well-being

OBJECTIVE

Ten years after diagnosis, women diagnosed with breast cancer at age 50 or younger were assessed to determine whether quality of life (QOL) problems found at five years persisted. We predicted that QOL in the physical and social domains would be poorer, but improvements would be found in the psychological domain.

METHODS

We re-interviewed 312 women, who had been interviewed at their five year anniversary and remained cancer free, on their QOL in three domains (physical, social, and psychological). Comparisons between their 5- and 10-year reports were performed using paired t-tests for numeric variables and McNemar's test for categorical variables. Multiple regression analysis was used to model change from 5 to 10 years in each QOL domain, given the level of QOL at 5 years.

RESULTS

The women's mean age was 55, 60% were college graduates, 79% had a partner, and 27% were non-Euro-American. Ten years after diagnosis they reported poorer general health (p<0.0001) and physical well-being (p = 0.001), less sexual activity (p = 0.009), and more chronic conditions (p<0.0001) than at 5 years. Relationships were found between: (1) the number of chronic conditions at 5 years and decreased physical, social, and psychological well-being at 10 years; and (2) a smaller social network at 5 years and poorer social functioning at 10 years.

CONCLUSIONS

Certain aspects of both physical and social QOL worsened over time. The remaining question is whether these changes can be attributed to the late effects of treatment or to normal effects of aging.

The effect of peer-led education on the life quality of mastectomy patients referred to breast cancer-clinics in Shiraz, Iran 2009

Background

Breast cancer among women is a relatively common with a more favorable expected survival rates than other forms of cancers. This study aimed to determine the improved quality of life for post-mastectomy women through peer education.

Methods

Using pre and post test follow up and control design approach, 99 women with stage I and II of breast cancer diagnosis were followed one year after modified radical mastectomy. To measure the quality of life an instrument designed by the European organization for research and treatment of cancer, known as the Quality of Life Question (QLQ-30) and it's breast cancer supplementary measure (QLQ-BR23) at three points in time (before, immediately and two months after intervention) for both groups were used. The participant selection was a convenient sampling method and women were randomly assigned into two experimental and control groups. The experimental group was randomly assigned to five groups and peer educators conducted weekly educational programs for one month. Tabulated data were analyzed using chi square, t test, and repeated measurement multivariate to compare the quality of life differences over time.

Results

For the experimental group, the results showed statistically significant improvement in all performance aspects of life quality and symptom reduction (P < 0.001), while the control group had no significant differences in all aspects of life quality.

Conclusion

The findings of this study suggest that peer led education is a useful intervention for post-mastectomy women to improves their quality of life.

Disparities in mental health between rural and nonrural cancer survivors: a preliminary study

OBJECTIVE

While much research has sought to identify disparities in cancer incidence, survival, and treatment, little research has sought to identify disparities in mental health (MH) outcomes among cancer survivors. The present study aims to identify disparities in MH outcomes between rural and nonrural cancer survivors.

METHODS

Cancer survivors who met eligibility criteria were identified through the Kentucky SEER Cancer Registry. Rural status was determined by 2003 USDA Rural-Urban Continuum Codes. 116 (n=54 rural, 62 nonrural) survivors with diagnoses of breast (n=42), hematologic (n=39), or colorectal (n=35) cancer completed mail-back questionnaires and/or a telephone interview.

RESULTS

Rural cancer survivors reported poorer MH functioning (effect size (ES)=0.45 SD), greater symptoms of anxiety (ES=0.70) and depression (ES=0.47), greater distress (ES=0.41), and more emotional problems (ES=0.47) than nonrural cancer survivors. Rural and nonrural cancer survivors did not differ consistently in regard to positive MH outcomes, such as benefit finding. The pattern of results was maintained when adjusted for education and physical functioning.

CONCLUSIONS

Clinically important disparities in MH outcomes were evident between rural and nonrural cancer survivors. Interventions aimed at raising access and utilization of MH services may be indicated for cancer survivors in rural areas.

Quality of life in cancer survivorship: 20 years later

OBJECTIVES

To discuss the unique quality-of-life (QOL) issues for cancer survivors and provide guidance for the selection of measures to assess them.

DATA SOURCES

Literature review, PubMed search, electronic data, websites.

CONCLUSION

QOL is a vital outcome for cancer survivors. QOL measurement of the unique needs of cancer survivors has increased over the past 20 years.

IMPLICATIONS FOR NURSING PRACTICE

Oncology nurses can move QOL science in cancer survivorship forward by using research findings to implement evidence-based practice.

Psychosocial implications of living 5 years or more following a cancer diagnosis: a systematic review of the research evidence

Mortality associated with cancer remains high, but more people are surviving cancer. Some people experience long-term problems associated with cancer and its treatment, and there is a need to know how to support them. This systematic literature review explores primary research for psychosocial implications of long-term survival (>or=5 years) following a cancer diagnosis and interventions designed to address psychosocial problems in the long term. A systematic search of BIDS, BNI, Cancer.gov, CINAHL, Medline, PsychINFO and Web of Science was conducted to identify research publications from 1960 to 2006. Papers were selected on the basis of pre-defined criteria and rated by three independent coders. Forty-three studies met the eligibility criteria. These indicated that most people experience few problems five or more years after their diagnosis of cancer. However, 20-30% of survivors consistently reported problems associated with cancer and its treatment including physical problems, poorer quality of life, psychological distress, sexual problems, problems with social relationships and financial concerns. Not all cancer types are represented in this review. Only two intervention studies met the eligibility criteria. Research is needed to establish appropriate interventions to support those experiencing problems in the long term to enhance well-being.

Migração e qualidade de vida: um estudo psicossocial com brasileiros migrantes

Objetivou-se estudar as representações sociais de 51 brasileiros, 37 do sexo feminino e 14 do sexo masculino, migrantes residentes na cidade de Genebra, Suíça, sobre qualidade de vida e migração. Utilizou-se um teste de associação livre de palavras. Os dados apreendidos foram processados pelo software Tri-Deux-Mots e analisados por meio da análise fatorial de correspondência. Os resultados evidenciaram que as variáveis sexo e tempo de migração contribuíram com valores mais elevados para o significado dos fatores. Observaram-se nos diferentes grupos similitudes e diferenças de conteúdos representacionais, que colocam em evidência uma comunicação e orientação de condutas de acordo com as variáveis sociodemográficas circunscritas, favorecendo sua identidade e comprovando sua função justificadora.

Health-related behavior change after cancer: results of the American cancer society's studies of cancer survivors (SCS)

INTRODUCTION

Cancer survivors are known to make positive health-related behavior changes after cancer, but less is known about negative behavior changes and correlates of behavior change. The present study was undertaken to examine positive and negative behavior changes after cancer and to identify medical, demographic, and psychosocial correlates of changes.

METHODS

We analyzed data from a cross-sectional survey of 7,903 cancer survivors at 3, 6, and 11 years after diagnosis.

RESULTS

Of 15 behaviors assessed, survivors reported 4 positive and 1 or 0 negative behavior changes. Positive change correlated with younger age, greater education, breast cancer, longer time since diagnosis, comorbidities, vitality, fear of recurrence, and spiritual well-being, while negative change correlated with younger age, being non-Hispanic African American, being widowed, divorced or separated, and lower physical and emotional health. Faith mediated the relationship between race/ethnicity and positive change.

CONCLUSIONS

Cancer survivors were more likely to make positive than negative behavior changes after cancer. Demographic, medical, and psychosocial variables were associated with both types of changes.

IMPLICATIONS FOR CANCER SURVIVORS

Results provide direction for behavior interventions and illustrate the importance of looking beyond medical and demographic variables to understand the motivators and barriers to positive behavior change after cancer.

Addressing the needs of young breast cancer survivors at the 5 year milestone: can a short-term, low intensity intervention produce change?

BACKGROUND

Today, the 5-year relative survival rate for cancer is 65% and there are 10.5 million survivors. The largest group of survivors are those of breast cancer. Reductions in mortality are occurring at a greater rate for women under age 50 at diagnosis than among older women.

AIMS

Our goal was to design a socio-educational intervention for 5-year survivors aged 50 or younger at diagnosis and test the hypotheses that women in the intervention group would show greater improvement than controls with respect to (1) knowledge of breast cancer, its treatment, and long-term health concerns; (2) lifestyle habits (i.e., exercise and diet); and (3) communication with family and physicians.

METHODS

Using a randomized controlled trial with a pre-post design, 404 women who were 5 years from diagnosis and cancer-free (response rate 54%) were randomly assigned to an intervention or delayed intervention (control) group and were assessed at pre-test (baseline) and 6 months later (96% retention). The intervention consisted of three 6-h workshops over a 3 month period. Four series of workshops were held at different geographical areas in the greater San Francisco Bay Area. The workshops included activities and information to promote physical, social, emotional, and spiritual well-being. The intervention design was based on findings from focus groups and a survey of 185 cancer-free 5-year survivors that assessed changes since the early months after diagnosis in physical, social, emotional, and spiritual concerns (response rate 73%).

RESULTS

Consistent with our first hypothesis, at post-test, women in the intervention group, on average, had greater knowledge regarding breast cancer, its treatment, and their own future health than did those in the control group (p = 0.015). Hypothesis 2 was partially supported as women in the intervention group were more likely than the control group to report an increased amount of physical activity (p = 0.036), but not significant dietary changes. Social support was related to increased self report of physical activity. With the exception of the last series of workshops, the intervention group did not report improved communications with family, friends, and physicians (hypothesis 3).

CONCLUSIONS

A short-term intervention can affect knowledge levels and physical activity but not diet or communication in the family.

IMPLICATIONS FOR CANCER SURVIVORS

The intervention was related to greater knowledge related to breast cancer, and increased report of physical activity. The program was not related to changes in reported diet or family communication.

Cancer patients' perceptions of positive and negative illness-related changes

We assessed perceived cancer-related change in 153 recently diagnosed patients. High levels of social support and optimism at the start of chemotherapy predicted higher numbers of perceived positive changes and lower numbers of negative changes nine months later. Higher numbers of perceived gains predicted an increase in positive affect, and higher numbers of negative changes predicted an increase in negative affect at follow-up. We conclude that finding positive consequences of cancer promotes psychological well-being, but patients with low levels of psychosocial resources are at risk for finding nothing beneficial in adversity.

Parenthood after cancer - a population-based study

Many cancer forms today have good prognosis, and parenthood after cancer diagnosis and treatment has become a central research topic. Previous research has mainly focused on reproductive cancers, and few population-based studies exist. The effect of several cancer forms on fertility at a population level was explored. Discrete-time hazard regression models were used to analyse register and census data for complete Norwegian birth cohorts. Men and women 17-44 years in the period 1965-2001 were included. Models for first- and higher-order birth rates, for men and women, were estimated.Overall, first-birth rates among persons with cancer were reduced by only about 25% when compared with the general population. Male cancer survivors' second- and third-birth rates were similarly reduced, whereas higher-order birth rates for females were 36% below those of the general population. Significant decreases in cancer survivors' fertility disadvantage relative to the general population were seen from 1965 to 2001. Reductions in fertility were most pronounced for reproductive cancer forms, presumably related to subfecundity. However, also cancer forms unrelated to reproductive function led to reduced fertility, perhaps suggesting underlying social mechanisms. This is further supported by the difference in probability between first and subsequent births observed for women.

Psychological health in patients with amyotrophic lateral sclerosis

Amyotrophic lateral sclerosis (ALS) is a progressive and fatal neurodegenerative disease with no known effective treatment or cure. Clinicians often expect that ALS patients will experience depression following the diagnosis because ALS is a terminal disease. The objective of the current study was to examine the evidence from the literature on psychological health in ALS patients in order to determine the prevalence and severity of depression in this population. Twenty-eight studies of ALS patients, conducted over the past 20 years, were reviewed and evaluated. The cumulative evidence suggests that clinically significant depression is neither as prevalent nor as severe as might be expected. Methodological limitations that are inherent to the measurement of depression in ALS, including the lack of appropriate instruments, small sample sizes, and reliance on cross-sectional data, have contributed to the wide range of reported results. We conclude that ALS patients are more likely to present with hopelessness and end-of-life concerns than clinically significant depression. It is important to assess a broad range of potential psychological distress early in the course of ALS, rather than focus specifically on depression, because the manner in which patients cope with their disease can affect their longevity.

Transition from treatment to survivorship: effects of a psychoeducational intervention on quality of life in breast cancer survivors

PURPOSE/OBJECTIVES

To examine the effectiveness of a psychoeducational intervention on quality of life (QOL) in breast cancer survivors in post-treatment survivorship.

DESIGN

A randomized controlled trial.

SETTING

An academic center collaborating with a regional cancer center in the southeastern United States.

SAMPLE

256 breast cancer survivors.

METHODS

Women were randomly assigned to the experimental or wait control group. The Breast Cancer Education Intervention (BCEI) study was delivered in three face-to-face sessions and five monthly follow-up sessions (three by telephone and two in person). The control group received four monthly attention control telephone calls and the BCEI at month 6. Data were collected at baseline, three and six months after the BCEI for the experimental group, and one month after the BCEI (at month 7) for the wait control group.

MAIN RESEARCH VARIABLES

Primary endpoints were overall QOL and physical, psychological, social, and spiritual well-being.

FINDINGS

No differences in QOL were reported at baseline between groups. The experimental group reported improved QOL at three months, whereas the wait control group reported a significant decline in QOL. The experimental group reported continued maintenance of QOL at six months. Although the wait control group reported improved QOL at six months, significant differences continued to exist between the groups.

CONCLUSIONS

The BCEI was an effective intervention in improving QOL during the first year of breast cancer survivorship. Treatment effects were durable over time.

IMPLICATIONS FOR NURSING

Post-treatment survivorship has not been empirically studied to a large degree. The BCEI is one of the few interventions demonstrating effectiveness among survivors after primary treatment, suggesting that oncology nurses may be uniquely positioned to provide safe passage using education and support.

Models for delivering survivorship care

Survivors of adult cancer face lifetime health risks that are dependent on their cancer, cancer treatment exposures, comorbid health conditions, genetic predispositions, and lifestyle behaviors. Content, intensity, and frequency of health care that addresses these risks vary from survivor to survivor. The aims of this article are to provide a rationale for survivor health care and to articulate a taxonomy of models of survivor care that is applicable to both community practices and academic institutions.

Coping with breast cancer in newly diagnosed Iranian women

AIM

This paper reports a study exploring how Iranian women coped with newly diagnosed breast cancer and provides a foundation for cultural-based care.

BACKGROUND

Although research has indicated that coping strategies are associated with adaptation to breast cancer, and despite the number of women with newly diagnosed breast cancer increasing each year, there is no information on how Iranian women cope with breast cancer when compared with women of other cultures.

METHOD

In this qualitative study, 19 women with newly diagnosed breast cancer were interviewed during the period May-September 2004 about coping with their disease. Interviews were analysed using a content analysis method.

FINDINGS

The main themes emerging from this qualitative study included coping using a religious approach (acceptance of disease as God's will; spiritual fighting), thinking about the disease (positive thinking: positive suggestion, hope, intentional forgetfulness; negative thinking: hopelessness, fear, impaired body image), accepting the fact of the disease (active acceptance; passive acceptance), social and cultural factors and finally finding support from significant others.

CONCLUSION

Understanding how Iranian women cope with diagnosis of breast cancer is important to nurses involved in the process of healing. The majority of strategies used by Iranian women were positive, and religious faith played a major role in this. The findings of the study can be used to design a nursing approach to improve successful coping in Iranian women suffering from breast cancer, and can provide nurses and other healthcare professionals with deeper understanding of these women as they face this diagnosis.

Breast Cancer Screening in Women Surviving Hodgkin Disease

OBJECTIVE

To inform female Hodgkin disease (HD) survivors, younger than 35 at diagnosis, of their increased risk for breast cancer and encourage them to seek breast cancer screening.

METHODS

An evidence-based intervention, telephone counseling, was used in a pre-post test design, randomized trial with the control group being offered the intervention following the post-test. Women treated at Stanford University who received thoracic irradiation before age 35, alive and HD-free at last contact, were referred to the project (n = 471). Of 261 eligible women who could be located, 157 completed the pretest and were randomized (60% response rate) and 133 completed the post-test (85% retention rate).

RESULTS

There was a positive intervention effect on mammography maintenance: the odds of being in maintenance at post-test compared with pretest were greater in the intervention group than in the control group [odds ratio (OR) = 3.6]. Women were more likely to be in mammography maintenance at pre- or post-test if at pretest they were married (OR = 5.7), employed (OR = 2.3), more worried about breast cancer (OR = 1.4 per unit of scale), or received an annual physical examination (OR = 2.2). Women under age 40 were much less likely to be in maintenance than were those age 45 and over (age 35-39, OR = 0.2; under age 35, OR = 0.07).

CONCLUSIONS

The findings indicate that providing risk information encourages cancer survivors to take health preventive actions. Telephone counseling is a method that can provide risk information and is easily transferable to settings where people seek health information, such as telephone information lines.

Exploring heart and soul: effects of religiosity/spirituality and gender on blood pressure and cortisol stress responses

The current study investigated gender effects on the influence of self-reported religiosity and spirituality on cardiovascular and cortisol responses to a laboratory stressor among young adults. Participants with higher composite religiosity/spirituality scores, religiosity, levels of forgiveness and frequency of prayer showed lower cortisol responses. Greater composite religiosity/spirituality, religiosity, frequency of prayer and attendance at services were associated with lower blood pressure in males and elevated blood pressure in females. Findings suggest that spiritual and/or religious individuals may experience a protective effect against the neuroendocrine consequences of stress, though cardiovascular benefits may vary by gender. This work represents an important step in the convergence of multiple realms of research by linking physiological measures with indicators of individual belief systems.

Quality of life in patients who survive a dire prognosis compared to control cancer survivors

The primary goal of this study was to describe well-being and its correlates in long-term cancer survivors who had exceeded their life expectancies ('exceptional survivors' (ES)) and to identify ways in which exceptional survivors differed from cancer survivors with much better prognoses ('control survivors' (CS)). Survivors were identified through a population-based tumor registry, and ES (n = 160) were matched to CS (n = 160) on age, ethnicity, site of disease, and time since diagnosis. Data were collected through in person interviews and self-administered questionnaires. Outcomes included quality of life, depression, and stress. Predictors included demographics, clinical variables and psychological predictors (sense of coherence, optimism, and resiliency). The findings led to several clear conclusions: (1) cancer survivors are doing well, in comparison to well-being in control populations; (2) cancer survivors exhibit higher levels of sense of coherence and resilience, but not optimism, than control populations; (3) psychological variables explain considerable variance in well-being; and (4) there are few differences between exceptional and control survivors. We conclude that objective disease state is not as important to cancer survivor well-being as personal attributes, and that a cancer diagnosis has such frightening implications that all survivors consider their recovery to be 'exceptional'.

The role of religious coping in adjustment to prostate cancer

This study explored the role of religious coping in men's long-term adjustment to prostate cancer. Thirty-four men with prostate cancer completed questionnaires on demographic and illness factors, religious and general coping, and physical, social, and emotional functioning. Results showed that religious coping was related to poorer role, social, and emotional functioning for these cancer survivors. In contrast, religious coping was related to positive aspects of cognitive appraisal and to both active and avoidance forms of general coping. Notably, religious coping may be used to help cancer survivors "block out" their everyday experience of the prostate cancer and its related complications. Such results suggest that religious coping functions in a complex manner within the context of long-term prostate cancer survival.

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

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

Finding benefit in breast cancer during the year after diagnosis predicts better adjustment 5 to 8 years after diagnosis

Cancer patients experience positive as well as adverse consequences from diagnosis and treatment. The study reported here examined longer term reverberations of such experiences. A set of benefit-finding items along with measures of well-being were completed by 230 early-stage breast cancer patients in the year postsurgery. Four to 7 years later, 96 of them again completed measures of well-being. Controlling for initial distress and depression, initial benefit finding in this sample predicted lower distress and depression at follow-up.

Then and now: quality of life of young breast cancer survivors

BACKGROUND

Women under age 50, a quarter of all cases of breast cancer, are especially vulnerable to physical and psychosocial late effects of their treatment due to having more aggressive treatment and their relative youth.

METHODS

In person interviews were conducted with the population-based sample: 185 women who were under 50 at diagnosis and were cancer-free 5 years later. Quality of life in the physical, psychological, social, and spiritual domains was assessed and compared with results obtained a few months after diagnosis.

RESULTS

Five years after diagnosis, 92% rated their health as good or excellent, and only 10% said their health had been getting worse. Between baseline and 5 years, there were significant improvements in surgical symptoms, body image, worry about the future, patient-physician communication, intrusiveness of treatment, and all of the SF-36 measures except for general health. There were significant decreases in emotional support and the size of one's social network. More women were now menopausal (75% due to treatment) and there were fewer children at home. There were no significant changes in employment status, marital/partner status, sexual activity, sexual problems, self-esteem, and attendance at religious services or frequency of prayer. In multivariate models, a greater increase in physical quality of life was associated with reporting fewer chronic conditions, being employed, having been treated by chemotherapy and fewer had no children under age 18 living at home. A greater increase in mental quality of life was associated with fewer chronic conditions and a smaller decrease in emotional support.

CONCLUSIONS

Five years after diagnosis, young breast cancer survivors who remained cancer-free enjoyed good health and improved quality of life. Nonetheless, physical, social, and psychological concerns must be addressed so that young breast cancer survivors will continue to be resilient as they age.

Cognitive-behavioral stress management increases benefit finding and immune function among women with early-stage breast cancer

OBJECTIVE

This study examined the effect of a cognitive-behavioral stress management (CBSM) intervention on emotional well-being and immune function among women in the months following surgery for early-stage breast cancer.

METHOD

Twenty-nine women were randomly assigned to receive either a 10-week CBSM intervention (n=18) or a comparison experience (n=11). The primary psychological outcome measure was benefit finding. The primary immune function outcome measure was in vitro lymphocyte proliferative response to anti CD3.

RESULTS

Women in the CBSM intervention reported greater perceptions of benefit from having breast cancer compared to the women in the comparison group. At 3-month follow-up, women in the CBSM group also had improved lymphocyte proliferation. Finally, increases in benefit finding after the 10-week intervention predicted increases in lymphocyte proliferation at the 3-month follow-up.

CONCLUSION

A CBSM intervention for women with early-stage breast cancer facilitated positive emotional responses to their breast cancer experience in parallel with later improvement in cellular immune function.

A saúde e o bem-estar espiritual em adultos porto-alegrenses

A proposta deste estudo é investigar a inter-relação entre o bem-estar espiritual e a saúde geral. Foram aplicados a Escala de Bem-estar Espiritual (Paulotzian e Ellison, 1982) e o Questionário de Saúde Geral (Goldberg, 1972), para uma amostra não-clínica de 506 pessoas, entre 16 e 78 anos, residentes em Porto Alegre (RS). A análise estatística dos dados mostrou que há uma correlação positiva significativa entre saúde e bem-estar espiritual. As aplicações deste estudo apontam para uma inclusão da espiritualidade na concepção de saúde, unida às dimensões biológica, psicológica e social e confirma que a espiritualidade pode fazer uma importante contribuição para a promoção da saúde e prevenção da doença.

The Concerns About Recurrence Scale (CARS): a systematic measure of women's fears about the possibility of breast cancer recurrence

The Concerns About Recurrence Scale (CARS) systematically assesses the extent and nature of women's fears about the possibility of breast cancer recurrence. In this study with 169 breast cancer survivors, scores on the CARS indicate moderate levels of fear about recurrence overall and demonstrate a range in levels of fear. Findings further suggest that women's fears of recurrence center around the possibility of death, future treatment, and threats to health more than issues related to roles, femininity, sexuality, or body image. Younger women and women who have had chemotherapy demonstrate greater fears. There is little evidence that cancer stage, time since diagnosis, or type of surgery relate to fears. The CARS was found to be internally consistent, and there is preliminary evidence of its validity, although future research is needed. The measure will likely be a useful tool for researchers and clinicians seeking to understand women's fears about the possibility of breast cancer recurrence.

Breast cancer survivors give voice: a qualitative analysis of spiritual factors in long-term adjustment

As part of a cross-sectional, quantitative study on adjustment factors in long-term breast cancer survival, 52 women were asked to write in their own words how religious and spiritual factors played a part in their understanding of and coping with this illness. A subsample of 39 women responded to this question. The qualitative method of content analysis was used to define meaning units, descriptive categories and themes from the data. Interpretation of themes in the data focused on the role or function of spiritual/religious factors in long-term adjustment to breast cancer. The majority of women discussed the positive role of various spiritual resources in their response to the experience of cancer, including relationship with God, religious coping activities (e.g. prayer), meaning and social support. A cognitive model of adjustment was proposed which shows how spiritual resources can help breast cancer survivors make meaning of and experience a sense of life affirmation and personal growth in relation to the cancer.

Eliciting views of patients with head and neck cancer and carers on professionally derived standards for care

OBJECTIVES

To examine views of patients and carers on the process of care for people with head and neck cancer; to assess whether focus groups are useful in this setting; to compare priorities and standards identified with those published by healthcare professionals; and to incorporate the expressed views into existing national standards.

DESIGN

Multicentre study of nine regional focus groups.

SETTING

Area covered by two regional health authorities.

PARTICIPANTS

40 patients who had had head and neck cancer and 18 carers.

MAIN OUTCOME MEASURES

Views of individuals and groups on standards. Applicability of the method for patients whose appearance and ability to communicate was altered and for recently bereaved carers. Ease of incorporation of views into national and regional standards.

RESULTS

Patients and carers participated in discussions on all the principal questions. Opinions were expressed on waiting times, information available to patients, coordination of care, and crisis management. Professionally derived standards were substantially improved by the incorporation of the views of patients and carers. There were no technical problems in carrying out this study on patients with communication difficulties or altered appearance nor with recently bereaved carers. Occasionally, participants said that the meetings were therapeutic.

CONCLUSIONS

Professionally facilitated and analysed focus groups are effective in assessing views of patients with cancer and carers on professionally derived standards for care and can be applied in settings traditionally viewed as difficult. Views expressed by patients and carers are powerful motivators for change in the delivery of cancer care.

Psychosocial issues in breast cancer

The breast cancer experience can bring with it a broad range of emotional sequelae for the woman, her spouse/partner, and her family. Often, patients bear these emotional burdens silently and miss opportunities for the physician and health care team to offer recommendations and interventions for her and her family. The proactive physician evaluating these potential difficulties and using the strength a good relationship with the patient in making appropriate referrals for counseling or support group does much to help the woman embrace as full a recovery as possible. Recommendations presented by the woman's physician are most often heeded. The physician must intervene on behalf of the woman to ensure that psychosocial support needs are met. Physicians are encouraged to adopt this orientation and to use an integrated approach in caring for the woman with breast cancer. (6)

A psychometric analysis of the Quality of Life-Cancer Survivors (QOL-CS) in survivors of childhood cancer

Given the increasing interest in quality of life research in cancer survivorship, psychometric properties of the Quality of Life-Cancer Survivors (QOL-CS) were explored in a group of childhood cancer survivors. The QOL-CS is a 41-item visual analog scale composed of four multi-item sub-scales (physical well-being, psychological well-being, social well-being, spiritual well-being) and two sub-components (fears, distress). This instrument was incorporated in a mailed survey completed by 177 respondents. The underlying factor structure and internal reliability of the instrument were explored. A preliminary assessment of the external validity of the factor structure was undertaken. Results of a factor analysis were theoretically consistent with elements assessed in the QOL-CS, although misclassification of several items was noted and discussed. Internal-consistency reliability was very good (Cronbach's alpha = 0.80-0.89) for five of the six factors. Moderate (0.30 < r < 0.45) to high (r > 0.60) concurrent validity was observed for four factors. Discriminant validity was noted across groups defined by health and social status variables. Psychometric analysis indicated that the instrument measured distinct and relevant domains of quality of life for childhood cancer survivors, but in its current form does not appear to be an optimal measure of quality of life in this population.

Measuring religious faith in cancer patients: reliability and construct validity of the Santa Clara Strength of Religious Faith questionnaire

Growing attention has focused on associations between religious involvement and health outcomes for cancer patients. Unfortunately, research has been hampered by lack of measures suitable for use in oncology settings. This study examined the performance of one recently developed measure, the Santa Clara Strength of Religious Faith Questionnaire (SCSORF). Initial investigations with cancer patients in a bone marrow transplant program and with non-oncology patients yielded promising results. This study provided additional information about temporal stability and convergent validity. The measure was evaluated in two well-defined samples: (1) 95 breast cancer patients, and (2) 53 healthy young adults. Most of the cancer patients had recent diagnoses and localized or regional disease. In each sample, the instrument demonstrated high test-retest reliability (r's=0.82-0.93) and internal consistency (r's=0.95-0.97). It displayed strong correlations with measures of intrinsic religiosity (r's=0.67-0.82, p<0.0001), and moderate correlations with organizational religiosity (r's=0.61-069, p<0.0001), non-organizational religiosity (r's=0.52-0.55, p<0.0001), comfort from religion (r=0.58, p<0.0001), and ratings of self as religious (r=0.58, p<0.0001). Among cancer patients, scores were significantly associated with optimism (r=0.30, p<0.01), but not with openness of family communication about cancer or perceived social support. These data build on previous findings with cancer patients, and suggest that the SCSORF may be a useful measure of religious faith in oncology settings.

Cognitive-behavioral stress management intervention decreases the prevalence of depression and enhances benefit finding among women under treatment for early-stage breast cancer

The authors tested effects of a 10-week group cognitive-behavioral stress management intervention among 100 women newly treated for Stage 0-II breast cancer. The intervention reduced prevalence of moderate depression (which remained relatively stable in the control condition) but did not affect other measures of emotional distress. The intervention also increased participants' reports that having breast cancer had made positive contributions to their lives, and it increased generalized optimism. Both remained significantly elevated at a 3-month follow-up of the intervention. Further analysis revealed that the intervention had its greatest impact on these 2 variables among women who were lowest in optimism at baseline. Discussion centers on the importance of examining positive responses to traumatic events--growth, appreciation of life, shift in priorities, and positive affect-as well as negative responses.

Meeting the needs of rural breast cancer survivors: what still needs to be done?

As screening and treatment for breast cancer improve, learning about survivors' post-treatment needs becomes increasingly important. Focus groups (n = 23) were conducted with breast cancer survivors (n = 128) in rural Washington communities during a 5-month period in 1996 to explore ways to improve the lives of rural breast cancer survivors and to expand existing knowledge of breast cancer survivorship. Survivors reported positive and negative outcomes of their cancer experience. Results indicate that the needs of many women with breast cancer, particularly women diagnosed with late-stage disease, are not being met. Participants diagnosed with late-stage cancer were more likely than participants diagnosed with early-stage cancer to comment about being treated poorly by the medical system and to voice a need for increased support and educational services for breast cancer patients. Rural survivors, regardless of stage at diagnosis, reported needing more education about breast cancer and more emotional support after diagnosis. Further efforts to facilitate support and education within the context of medical care and to improve patient-clinician relationships are needed.