Predictors of initial levels and trajectories of anxiety in women before and for 6 months after breast cancer surgery

Development and validation of a nomogram model of depression and sleep disorders and the risk of disease progression in patients with breast cancer

BACKGROUND

In this study, we investigated the relationship between the risk of postoperative progressive disease (PD) in breast cancer and depression and sleep disorders in order to develop and validate a suitable risk prevention model.

METHODS

A total of 750 postoperative patients with breast cancer were selected from the First People's Hospital of LianYunGang, and the indices of two groups (an event group and a non-event group) were compared to develop and validate a risk prediction model. The relationship between depression, sleep disorders, and PD events was investigated using the follow-up data of the 750 patients.

RESULTS

SAS, SDS, and AIS scores differed in the group of patients who experienced postoperative disease progression versus those who did not; the differences were statistically significant and the ability to differentiate prognosis was high. The area under the receiver operating characteristic (ROC) curves (AUC) were: 0.8049 (0.7685-0.8613), 0.768 (0.727-0.809), and 0.7661 (0.724--0.808), with cut-off values of 43.5, 48.5, and 4.5, respectively. Significant variables were screened by single-factor analysis and multi-factor analysis to create model 1, by lasso regression and cross-lasso regression analysis to create model 2, by random forest calculation method to create model 3, by stepwise regression method (backward method) to create model 4, and by including all variables for Cox regression to include significant variables to create model 5. The AUC of model 2 was 0.883 (0.848-0.918) and 0.937 (0.893-0.981) in the training set and validation set, respectively. The clinical efficacy of the model was evaluated using decision curve analysis and clinical impact curve, and then the model 2 variables were transformed into scores, which were validated in two datasets, the training and validation sets, with AUCs of 0.884 (0.848-0.919) and 0.885 (0.818-0.951), respectively.

CONCLUSION

We established and verified a model including SAS, SDS and AIS to predict the prognosis of breast cancer patients, and simplified it by scoring, making it convenient for clinical use, providing a theoretical basis for precise intervention in these patients. However, further research is needed to verify the generalization ability of our model.

The Assessment of Social Isolation and Loneliness in Cancer Patients and Survivors in the Pre-COVID-19 Period: A Systematic Review

BACKGROUND

In the context of cancer research, identifying social isolation and loneliness is a priority given how both exacerbate poor outcomes and lead to increased mortality in oncological populations. The purpose of this systematic review is to identify all quantitative instruments that have been used to assess either social isolation or loneliness in patients previously or currently diagnosed with cancer in the pre-COVID-19 period.

METHOD

PubMed (Web), Scopus, CINAHL, and PsycINFO were searched on August 22, 2019. All databases were searched from inception with no filters applied. The search strategies included terms that captured the following concepts: instruments/tools, social isolation or loneliness, and cancer.

RESULTS

A total of 289 titles/abstracts were returned. Upon review, 114 titles/abstracts were deemed to be potentially eligible and the full text was retrieved. Of the 114 full texts, 69 articles met inclusion criteria and comprised the final sample. Publications span years 1980 through 2019, with the majority (71%) occurring in the last decade prior to this review, between 2009 and 2019. Average age of the study samples, with few exceptions, was often over 50 years old. Many studies used all-female samples, while only one study used an all-male sample. The most common cancer diagnosis of participants was breast cancer. The most common measure was the UCLA Loneliness Scale, used in 22 studies. Most measures we identified were used only once, and 11 measures were used 2-3 times. When the information was given, response ranges were always Likert-type scales most often ranging from 1-4 or 1-5, and sometimes from 1-10 possible response options. In terms of psychometrics, test-retest reliability and validity were rarely reported; by contrast, internal consistency (Cronbach's alpha) was reported more than half of the time (60.9%).

CONCLUSION

When selecting a measure to assess loneliness in cancer populations, the UCLA Loneliness Scale is both psychometrically strong and versatile across patients with different cancers, ages, and racial backgrounds. When selecting a measure to assess social isolation in cancer populations, both the PROMIS-SF V 2.0 social isolation and the Berkman-Syme Network Index are brief and have been used in patients with non-White racial backgrounds.

Trajectories and Predictors of Raised State Anxiety Among Outpatients Who Have Undergone Medical Imaging Procedures

PURPOSE

The aim of this study was to examine the prevalence of raised state anxiety before and after medical imaging procedures, the prevalence of state anxiety trajectories, and factors associated with postprocedural raised state anxiety.

METHODS

A prospective survey was administered to outpatients undergoing elective medical imaging procedures (CT, radiography, MRI, ultrasound, angiography, or fluoroscopy) recruited from one center. Participants completed a self-report survey preprocedure (time 1) and postprocedure (time 2). State anxiety was measured using the six-item State-Trait Anxiety Inventory. The point prevalence of raised state anxiety (State-Trait Anxiety Inventory score ≥33.16) at time 1 and time 2 was calculated, as was the prevalence of four state anxiety trajectories over time: persistent low anxiety, decreasing anxiety, increasing anxiety, and persistent raised anxiety. Factors predictive of raised state anxiety at time 2 were examined using logistic regression analysis.

RESULTS

Three hundred fifteen participants completed both surveys. The prevalence of raised state anxiety at time 1 (50%) and time 2 (51%) was similar. Most patients reported persistent raised anxiety (36%) and persistent low anxiety (34%) over time. Fewer patients reported increasing anxiety (15%) and decreasing anxiety (14%). Raised state anxiety (odds ratio, 4.84; 95% confidence interval, 2.48-9.48) and lower reported health status (odds ratio, 2.48; 95% confidence interval, 1.11-5.51) at time 1 were significantly associated with greater odds of raised anxiety at time 2.

CONCLUSIONS

Raised state anxiety related to medical imaging procedures is common among outpatients. Half of patients either developed or continued to experience raised anxiety after their procedures. Outpatients may benefit from evidence-based methods of alleviating anxiety before their procedures.

A cross-sectional study of fear of surgery in female breast cancer patients: Prevalence, severity, and sources, as well as relevant differences among patients experiencing high, moderate, and low fear of surgery

BACKGROUND

Fear of surgery has been associated with more postoperative pain, disability, and a lower quality of life among patients undergoing various surgical procedures. While qualitative studies indicate breast cancer patients to be afraid of surgery, detailed quantitative analyses are lacking. The present research aimed at investigating the prevalence, severity, and sources of fear of surgery in this patient group and to compare patients reporting different degrees of such fear.

METHODS

This cross-sectional study included 204 breast cancer patients, 18-70 years old, and scheduled for surgery at Oslo University Hospital, Norway. Following their preoperative visit participants completed validated psychological questionnaires online. Among these, the primary outcome measure, the Surgical Fear Questionnaire (SFQ; scores: 0-10 per item, 0-80 overall). Patients were grouped based on SFQ-percentiles (<25th = little, 25th-75th = moderate and >75th percentile = high fear) and compared on psychological (anxiety, depression, experienced injustice, optimism and expected postsurgical pain), sociodemographic, and medical outcomes.

RESULTS

195 patients completed the SFQ. On average fear of surgery was low (M = 26.41, SD = 16.0, median = 26, min-max = 0-80), but omnipresent. Only 1.5% (n = 3) indicated no fear at all. Overall, patients feared surgery itself the most (M = 3.64, SD = 2.8). Groups differed significantly (p < .001) in their experience of anxiety, depression, and injustice, as well as their disposition to be optimistic, and expectance of postsurgical pain. Differences between groups concerning demographic and medical information were largely insignificant.

DISCUSSION

This study was the first to demonstrate fear of surgery to be prevalent and relevant among female breast cancer patients. The higher a patients' fear group, the poorer their preoperative psychological constitution. This, largely irrespective of their current diagnoses or treatments, medical history, and demographics. Fear of surgery might thus cater as a prognostic marker and treatment target in this patient group. However, given the cross-sectional character of the present data, prognostic studies are needed to evaluate such claims.

Breast cancer patient experiences of perioperative distress and anxiety: A qualitative study

PURPOSE

Distress, often manifesting as anxiety, is common in breast cancer patients and becomes particularly elevated before surgery. This study investigated perspectives of those undergoing breast cancer surgery concerning what enhances and reduces distress and anxiety across the perioperative period (i.e., from diagnostic evaluation to recovery).

METHODS

The present study conducted qualitative semi-structured individual interviews with 15 adult breast cancer surgery patients within three months post-operation. Quantitative surveys provided background information (e.g., sociodemographics). Individual interviews were analyzed using thematic analysis. Quantitative data were analyzed descriptively.

RESULTS

Four main themes emerged from qualitative interviews: 1) "fighting an unknown" (sub-themes: uncertainty, health-related knowledge and experience); 2) "the cancer takes away the control" (sub-themes: "living at the whim of others", trusting care providers); 3) person at the centre of the patient (sub-themes: "managing life:" caregiving and work-related stressors, "everybody jumped in to help:" emotional and instrumental support); and 4) physical and emotional impacts of treatment (sub-themes: pain and impacted mobility, "losing a part of yourself"). Breast cancer patients' experiences of surgery-related distress and anxiety were contextualized by broader experiences of care.

CONCLUSIONS

Our findings illustrate the illness-specific experience of perioperative anxiety and distress in breast cancer patients and inform patient-centered care and intervention.

Heterogeneity of symptoms and functions among women receiving chemotherapy for breast cancer in China: A multicentre, cross-sectional study

Background

Currently, few studies have explored the heterogeneity of symptoms and functions in patients with breast cancer. This study aimed to identify the subgroups of symptoms and functions in women receiving chemotherapy for breast cancer and determine whether the subgroups differed in demographic and clinical characteristics.

Methods

A cross-sectional multicenter survey involving five hospitals in Zhejiang, Shanghai, Shandong, and Guangxi provinces of Mainland China was implemented between August 2020 to December 2021. Participants completed questionnaires that included the PROMIS-57, PROMIS cognitive function short form, and demographic and clinical characteristics. Latent class analysis was performed, followed by chi-square test and analysis of variance. Subsequently, significant variables were included in multinomial logistic regression.

Results

A total of 1,180 patients were investigated, with an average age of 48.9 years. Three classes were identified: low symptom burdens and functions group (26.2%, Class 1), moderate symptom burdens and functions group (16.9%, Class 2), and low symptom burdens and high functions group (56.9%, Class 3). Compared with patients in Class 1 and 3, those in Class 2 consistently showed a higher tendency of having urban employee health insurance (odds ratio = 2.506, P &lt; 0.05) and rural health insurance (odds ratio = 2.207, P &lt; 0.05). Additionally, patients in Class 2 tended to be in their fourth cycle of chemotherapy. However, receiving chemotherapy and surgery increased the likelihood of belonging to Class 1.

Conclusions

A high proportion of patients experienced varying degrees of symptom and function issues, suggesting that attention is warranted for women with breast cancer undergoing chemotherapy. Patients with the urban employee basic medical system, the new rural cooperative medical system and in the early stage of chemotherapy cycles were more likely to have symptom burdens. Middle-aged postmenopausal women reported varying degrees of cognitive issues. Additionally, surgery increased the presence of potential long-term effects in functional levels.

When Experiencing a Surgery: Gastrointestinal Cancer Patients’ Longitudinal Trajectories in Psychological Stress and Their Association with Quality of Recovery

Objective

Surgical treatment, particularly for gastrointestinal cancer, is a burdensome prospect for many patients. Psychological stress is a common complaint; however, little is known about its patterns in perioperative patients. This study aimed to identify distinct trajectories of perioperative stress and explore antecedent factors and hospitalization outcomes among different trajectories in patients with gastrointestinal cancer.

Methods

A longitudinal study was conducted on 203 patients with gastrointestinal surgical cancer at a specialized oncology hospital in China. Psychological stress was assessed at five perioperative time points (1–3 days before surgery; 1–3 days, 4–6 days, 7–9 days after surgery, and before discharge). A growth mixture model was used to analyze the potential stress trajectories. Multinomial logistic regression was used to identify the characteristics associated with different trajectories.

Results

Three stress trajectories were identified: recovery class (RC, 60.6%), chronic class (CC, 29.5%), and deterioration class (DC, 9.9%). Compared with CC, RC exhibited a shorter length of stay and better recovery quality, and was related to employment, low illness perception, and positive coping; DC reported lower recovery quality from 7 to 9 days after surgery to discharge and was associated with poor education level, history of surgery, stoma, smoking, and preoperative insomnia.

Conclusions

Most surgical patients were insulated from stress due to psychosocial resources, and thus displayed good recovery. However, many patients had moderate stress that did not improve or worsen over the perioperative period, which still needs to be screened and provided with early stress management.

Symptom trajectories in patients with breast cancer: An integrative review

Objective

This study aimed to synthesize the available knowledge of symptom trajectories in patients with breast cancer and identify predictors associated with these trajectories.

Methods

Whittemore and Knafl’s integrative review method was employed to guide a systematic search for literature in four databases (PubMed, Embase, Web of Science, and CINAHL). The retrieved articles’ publication time was limited to 2010 to 2020, and only peer-reviewed English articles were included.

Results

Twenty-seven articles were included. The findings of the relevant studies were analyzed using thematic analysis. They were grouped into two themes: symptom trajectories of patients with breast cancer (symptom trajectories in patients with breast cancer, in patients who underwent surgery, and in patients who received cancer-related treatment) and associated factors (socioeconomic factors, health characteristics, cancer-related treatment characteristics). Newly diagnosed patients tended to report high trajectories of depression and persistent sleep disturbance. Most patients who underwent surgery reported significant sleep disturbance and anxiety shortly after surgery. For patients who received cancer-related treatment, only a small proportion had a high level of physical activity after cancer-related therapy over time. A high body mass index, a low relationship quality, parental responsibilities, insufficient social support, a low educational background, and an unhealthy lifestyle may increase the risk of negative symptom trajectories in patients with breast cancer. Additionally, old patients were more likely to report cognitive impairment after chemotherapy, while young patients tended to report trajectories of persistent sexual dysfunction. Concurring symptoms and poor health status also contributed to adverse symptom trajectories.

Conclusion

The findings of this review add to the body of knowledge of the interindividual variability of symptom trajectories in patients with breast cancer. Despite the overall similarity in appraisal at baseline, the patients reported varied symptom trajectories over time. It is recommended that nurses consider sociodemographic, clinical and cancer-related treatment characteristics and perform targeted early preventive interventions for patients with breast cancer.

Fatigue, anxiety, and quality of life in breast cancer patients compared to non-cancer controls: a nationwide longitudinal analysis

PURPOSE

Fatigue and anxiety are common and significant symptoms reported by cancer patients. Few studies have examined the trajectory of multidimensional fatigue and anxiety, the relationships between them and with quality of life.

METHODS

Breast cancer patients (n = 580) from community oncology clinics and age-matched controls (n = 364) completed fatigue and anxiety questionnaires prior to chemotherapy (A1), at chemotherapy completion (A2), and six months post-chemotherapy (A3). Linear mixed models (LMM) compared trajectories of fatigue /anxiety over time in patients and controls and estimated their relationship with quality of life. Models adjusted for age, education, race, BMI, marital status, menopausal status, and sleep symptoms.

RESULTS

Patients reported greater fatigue and anxiety compared to controls at all time points (p's < 0.001, 35% clinically meaningful anxiety at baseline). From A1 to A2 patients experienced a significant increase in fatigue (β = 8.3 95%CI 6.6,10.0) which returned to A1 values at A3 but remained greater than controls' (p < 0.001). General, mental, and physical fatigue subscales increased from A1 to A2 remaining significantly higher than A1 at A3 (p < 0.001). Anxiety improved over time (A1 to A3 β =  - 4.3 95%CI -2.6,-3.3) but remained higher than controls at A3 (p < 0.001). Among patients, fatigue and anxiety significantly predicted one another and quality of life. Menopausal status, higher BMI, mastectomy, and sleep problems also significantly predicted change in fatigue.

CONCLUSION

Breast cancer patients experience significant fatigue and anxiety up to six months post-chemotherapy that is associated with worse quality of life. Future interventions should simultaneously address anxiety and fatigue, focusing on mental and physical fatigue subdomains.

Cancer patient preferences for the provision of information regarding emotional concerns in relation to medical procedures: A discrete choice experiment

OBJECTIVE

To explore the preferences of people with cancer regarding the timing and format of information provision about emotional concerns that may occur when undergoing medical procedures.

METHODS

Eligible cancer survivors were mailed a survey containing discrete choice scenarios examining their timing and format preferences for information about potential emotional concerns associated with an upcoming hypothetical medical procedure.

RESULTS

Of 356 eligible patients, 271 (76 %) completed the survey. Both face-to-face discussion and written materials were preferred as the mode of information delivery over access to a website. In order of descending preference, participants preferred to receive the information 1 week, 3 days and the day of the procedure. There were no differences in preferences for timing or format between subgroups based on age, gender, education and cancer type.

CONCLUSION

This study has demonstrated that cancer patients prefer receiving information about emotional concerns that might be experienced as part of a medical procedure in either written or via face-to-face format, and one week before the procedure.

PRACTICE IMPLICATIONS

In order to provide patient-centred care, clinicians and the healthcare system more broadly should consider patient preferences for information delivery about upcoming medical procedures. INFORMATION: preparation for medical procedures; discrete choice; oncology; patient preference; emotional response.

Changes in Attentional Function in Patients From Before Through 12 Months After Breast Cancer Surgery

CONTEXT

Although approximately 75% of patients with breast cancer report changes in attentional function, little is known about how demographic, clinical, symptom, and psychosocial adjustment (e.g., coping) characteristics influence changes in the trajectories of attentional function over time.

OBJECTIVES

This study evaluated interindividual variability in the trajectories of self-reported attentional function and determined which demographic, clinical, symptom, and psychosocial adjustment characteristics were associated with initial levels and with changes in attentional function from before through 12 months after breast cancer surgery.

METHODS

Before surgery, 396 women were enrolled. Attentional Function Index (AFI) was completed before and nine times within the first 12 months after surgery. Hierarchical linear modeling was used to determine which characteristics were associated with initial levels and trajectories of attentional function.

RESULTS

Given an estimated preoperative AFI score of 6.53, for each additional month, the estimated linear rate of change in AFI score was an increase of 0.054 (P < 0.001). Higher levels of comorbidity, receipt of adjuvant chemotherapy, higher levels of trait anxiety, fatigue, and sleep disturbance, and lower levels of energy and less sense of control were associated with lower levels of attentional function before surgery. Patients who had less improvements in attentional function over time were nonwhite, did not have a lymph node biopsy, had received hormonal therapy, and had less difficulty coping with their disease.

CONCLUSION

Findings can be used to identify patients with breast cancer at higher risk for impaired self-reported cognitive function and to guide the prescription of more personalized interventions.

Surgical impact on anxiety of patients with breast cancer: 12-month follow-up prospective longitudinal study

Purpose

Breast cancer diagnosis and treatment often produce stress in patients. Anxiety is one of the most prevalent psychological symptoms perceived by breast cancer patients. This study aims to evaluate the temporal patterns of anxiety and find factors associated with persistent anxiety during breast cancer treatment.

Methods

This is prospective cohort study. Between July 2010 and July 2011, we recruited patients with nonmetastatic breast cancer who were expected to receive adjuvant chemotherapy (n = 411) from 2 cancer hospitals in Seoul, Korea. Anxiety was measured using the Hospital Anxiety and Depression Scale.

Results

The mean age of the participants was 46.4 ± 7.9 years. Preoperatively, 44.5% (183 of 411) of the patients showed abnormal anxiety. The proportion of the abnormal anxiety group significantly decreased after surgery (P < 0.01) and this phenomenon continued until the 12-month follow-up point. Patients experienced renewed anxiety at 12 months when the main adjuvant therapies were finished. Socioeconomic factors were not associated with persistent anxiety. Pain, breast, and arm symptoms were significantly higher in the persistently abnormal group, especially at postoperative months 6 and 12.

Conclusion

Surgery was a major relieving factor of anxiety, and patients who finished their main adjuvant treatment experienced renewed anxiety. Surgeons should be the main detectors and care-givers with respect to psychological distress in breast cancer patients. To reduce persistent anxiety, caring for the patient's physical symptoms is important.

Fast time perception is associated with high levels of anxiety in cancer patients prior to starting chemotherapy

Our study explored the potential relationship between time perception and the level of anxiety in cancer patients prior to starting chemotherapy. Time perception was assessed in 162 chemonaïve patients with solid tumors by evaluating each subject's prospective estimation of how fast one minute passed compared to the actual amount of time passed. The median value of time perception was used to stratify the patients into two categories of fast and slow time perception. We used the generalized anxiety disorder questionnaire (GAD-7) as a screening tool for detecting levels of anxiety. Scores ≥ 10 were considered high. In total, 45 (27.8%) patients had high levels of anxiety. The pattern of the time perception distributions significantly changed according to the reported levels on the GAD-7 scale. Scores ≥ 10 correlated with fast time perception and the female gender. Patients with a fast time perception had significantly higher levels of anxiety (8.44 ± 5.1) than patients with a slow time perception (3.49 ± 4.3). ROC analysis revealed that at the optimal cut-off value of time perception, clinically significant levels of anxiety can be discriminated with an AUC = 0.78 (95% CI: 0.70-0.85, p < 0.001), a sensitivity of 82.2% and a specificity of 64.1%. Moreover, in a multivariate logistic regression model, fast time perception was an independent predictor of clinically significant levels of anxiety (OR: 8.24; 95% CI: 3.16-21.41, p < 0.001). Time perception is a novel potent indicator for high levels of anxiety in cancer patients.

Lymphedema Surveillance and Patient-Reported Anxiety: Comparison Between Volumetric Assessment and Bioimpedance Analysis

Background: Lymphedema is a complication of breast cancer therapy associated with substantial anxiety. We designed a prospective, randomized study to assess the psychosocial impact of different surveillance methods for lymphedema. Methods and Results: In this open-label study of 38 women undergoing breast cancer surgery, we screened for lymphedema using traditional volumetric measurements (circumferential readings from the wrist to the axilla) versus bioimpedance spectroscopy (BIS) using electric current. The primary outcome measure was total anxiety measured by the Beck Anxiety Inventory, a 21-item questionnaire administered at preoperative, 6-week, 3-month, and 6-month postoperative visits (range 0-63 points). Outcome metrics were compared after adjustment for baseline anxiety. There were no differences in clinical characteristics or cancer therapies between groups, except for more reoperation for positive surgical margins in the BIS patients (5% vs. 32%, p = 0.036). Baseline anxiety, depression, and associated medical therapies were similar as well. Only one woman in each group developed lymphedema during the study. Anxiety was higher in the BIS group at baseline (mean Beck score 12.2 vs. 7.2, p < 0.001), but anxiety levels gradually declined by the end of the 6-month study in both groups, with no differences in adjusted anxiety scores between the two groups at any time point during follow-up (all p = NS). Conclusions: In this pilot study of women scheduled for breast cancer surgery, most subjects reported mild anxiety at baseline, and anxiety levels fell during continued lymphedema surveillance visits. There was no difference in patient-reported anxiety when surveillance was performed using standard volumetric versus BIS measurements.

Uncertainty and unmet care needs before and after surgery in patients with gastric cancer: A survey study

Uncertainty and unmet care needs constantly change in patients with cancer. However, there is a lack of information regarding the changing pattern of these variables. This study aimed to examine the changes in uncertainty and unmet care needs at diagnosis and after surgery among patients with gastric cancer. In total, 86 individuals completed a self-reported questionnaire. Data were collected twice - to measure uncertainty and unmet care needs at cancer diagnosis (T1), and after surgery (T2) - and analyzed using descriptive analysis and a dependent t-test. Uncertainty was moderate at both periods but significantly higher at T1. Unmet care needs were highest in the information domain and lowest in the sexuality domain at both T1 and T2. Only the physical/daily living domain were significantly higher at T2, whereas the information, psychological, and patient care/support domains were significantly higher at T1. Different levels of uncertainty and unmet needs were identified at T1 and T2. Healthcare providers should assess changing unmet care needs at each stage of the cancer trajectory and provide related nursing care and information to this population, even immediately after diagnosis.

Preoperative Anxiety in Patients Undergoing Outpatient Cancer Surgery

OBJECTIVE

Our primary research aim was to determine the prevalence of preoperative anxiety in patients undergoing outpatient cancer surgery. Our secondary aim was to examine the association between preoperative anxiety and negative intraoperative and postoperative outcomes in patients undergoing outpatient cancer surgery, including increased anesthesia requirements, postoperative nausea and vomiting (PONV), extended overnight stay, total length of stay (LOS), transfer to hospital, surgical complications, and postoperative visits to urgent care centers (UCC).

METHODS

We conducted a retrospective cohort study to investigate the prevalence of preoperative anxiety and its association with postoperative outcomes in patients undergoing outpatient cancer surgery. Our retrospective cohort included 10,048 outpatient procedures performed on 8683 patients at a large comprehensive cancer center between January 1, 2016, and April 30, 2018.

RESULTS

The analysis included 8665 patients undergoing procedures at an outpatient facility over 16 months; 16.7% had preoperative anxiety. In patients with preoperative anxiety, higher rates of adverse outcomes were seen, including PONV (adjusted difference 1.8%, 95% confidence interval [CI] 0.12%, 3.4%, P = 0.029), unplanned overnight admission (adjusted difference 1.1%, 95% CI 0.07%, 2.0%, P = 0.021), and urgent care visits within 30 days (adjusted difference 1.5%, 95% CI 0.44%, 2.6%, P = 0.002).

CONCLUSIONS

Even assuming a causal relationship between preoperative anxiety and postoperative outcomes, preventing one instance of PONV would require treating at least 30 patients for anxiety, and preventing longer-term outcomes such as urgent care visits or readmissions within 30 days would require treating even larger numbers of patients. Future studies should attempt to elucidate the causal pathway between preoperative anxiety and postoperative adverse events in outpatients undergoing outpatient cancer surgery.

Cross-sectional survey to inform the development of a telehealth support model: a feasibility study for women undergoing breast cancer surgery

BACKGROUND

For patients undergoing breast cancer surgery, the pre- and post-operative periods can be characterised by feelings of fear, anxiety, and uncertainty. Telehealth offers an opportunity to provide perioperative support to surgical patients and overcome some of the barriers to accessing care.

AIMS

In order to inform the development of a telehealth support model for women undergoing breast cancer surgery, this feasibility study explored: (a) access and preferences for telehealth; and (b) the proportion of participants who reported problems with unmet information and preparation needs related to surgery, post-operative pain, anxiety, and quality of life.

METHODS

Women aged 18-85 years attending for a follow-up appointment within 2 months of undergoing surgery for breast cancer were asked to complete a baseline (T1) and 1-month follow-up (T2) survey. Surveys assessed telehealth access and preferences, preparatory information receipt and preparedness for surgery, and anxiety, pain, and quality of life.

RESULTS

Fifty-three T1 (45% consent rate) and 50 T2 surveys were returned. One fifth of the sample (20%) travelled 50 km or more to access surgery. Most participants had access to a device suitable for telehealth (75%); however, only 15% indicated that they would have accepted a teleconsultation with their surgeon post-operatively if this had been offered. The most frequently reported unmet preparatory information needs were information about: how long it would take to recover from the surgery; how other patients had experienced similar surgery; and practical needs such as parking or transport. Approximately one third of the sample reported potentially clinically significant symptoms of anxiety, and less than one in ten women reported moderate levels of pain.

CONCLUSIONS

While the majority of women had access to a suitable device and internet connection for telehealth, less than one fifth would have accepted a home-based video-link teleconsultation with their surgeon post-operatively. A small proportion of the sample would have liked more information about aspects of surgery including about managing side effects and anxiety. The key findings in terms of teleconsultation preferences and information and preparation needs from this study will be incorporated into the telehealth support model being developed.

Effectiveness of a Self-Care Toolkit for Surgical Breast Cancer Patients in a Military Treatment Facility

Objective: To assess whether a self-care toolkit (SCT) provided to breast cancer patients undergoing surgery could mitigate distress and lessen symptoms associated with surgery.

Design: One hundred women with breast cancer, planning to undergo initial surgery, were randomly assigned to either one of two groups: treatment as usual (TAU; n = 49) or TAU with the addition of an SCT (n = 51). The SCT contained an MP3 player with audio-files of guided mind–body techniques (breathing, progressive muscle relaxation, meditation, guided imagery, and self-hypnosis) and acupressure antinausea wristbands. Anxiety, pain, nausea, sleep, fatigue, global health, and quality of life (QOL) were assessed using validated outcome measures. Two inflammatory blood markers (erythrocyte sedimentation rate [ESR] and C-reactive protein [CRP]) were measured serially. Data were collected at baseline (T1), immediately before surgery (T2), within 10 h postoperatively (T3), and ∼2 weeks postsurgery (T4).

Settings: Numerous studies have shown that psychological distress associated with a cancer diagnosis can affect pain perception and QOL.

Results: Between T1 and T4, there were significant between-group differences in Patient-Reported Outcomes Measurement Information System (PROMIS)-57 scores of Pain Interference, Fatigue, and Satisfaction with Social Roles, favoring the SCT group compared with TAU (p = 0.005, p = 0.023, and p = 0.021, respectively). There was a significant mean change in Defense and Veterans Pain Rating Scale (DVPRS) scores from T2 to T3, with the SCT group having significantly smaller increases in postoperative pain (p = 0.008) and in postoperative ESR (p = 0.0197) compared with the TAU group. Clinically significant reductions in anxiety occurred in the SCT group during the main intervention period.

Conclusion: These results suggest that using the SCT in the perioperative period decreased pain perceptions, fatigue, and inflammatory cytokine secretion.

Symptoms of depression and anxiety as predictors of physical functioning in breast cancer patients. A prospective study using path analysis

BACKGROUND

Although symptoms of depression and anxiety are linked to health-related quality of life (HRQoL), the nature of this relationship remained unclear. We therefore aimed to examine, in a prospective study, both possible directions of impact in this relationship. To avoid conceptual and measurement overlap between depressive and anxiety symptoms, on the one hand, and HRQoL, on the other hand, we focused on the physical functioning component of HRQoL.

MATERIAL AND METHODS

We conducted a secondary analysis of a prospective cohort study with 436 female breast cancer patients (mean age 51 years). Both at baseline and after 12 months, we measured symptoms of depression and anxiety with the four-item Patient Heath Questionnaire (PHQ-4) and physical functioning with the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQ-C30). Using path analysis, we estimated (1) the predictive value of symptoms of depression/anxiety for subsequent physical functioning and (2) the predictive value of physical functioning for subsequent symptoms of depression/anxiety, in the same model.

RESULTS

Baseline symptoms of depression/anxiety predicted 1-year levels of physical functioning (depression: standardized β =  -.09, p = .024; anxiety: standardized β =  -.10, p = .009), while the reciprocal paths linking baseline physical functioning to subsequent depressive and anxiety symptoms were not significant, adjusting for the baseline scores of all outcome variables.

CONCLUSIONS

Depressive and anxiety symptoms were predictors of the physical functioning component of HRQoL. Thus, if this relation is causal, treating breast cancer patients' depressive and anxiety symptoms may have a favorable impact on their self-reported physical functioning.

The relationship between holding back from communicating about breast concerns and anxiety in the year following breast biopsy

PURPOSE

Evidence suggests open communication about breast cancer concerns promotes psychological adjustment, while holding back can lead to negative outcomes. Little is known about the relationship between communication and distress following breast biopsy. Design/ Sample: Women (N = 128) were assessed at the time of breast biopsy and again one week and three, six, and 12 months post-result.

METHODS

Linear mixed modeling examined relationships between holding back and anxiety for women with benign results (n = 94) or DCIS/invasive disease (n = 34) following breast biopsy.

FINDINGS

Anxiety increased among women with a benign result engaging in high but not low or average levels of holding back. Holding back was positively associated with anxiety post-result in breast cancer survivors, with anxiety decreasing over time. Conclusions/ Implications: Interventions to enhance communication are warranted, and knowledge of the differences among women with benign results and/or DCIS/invasive disease may allow for the development of tailored interventions.

Decision-Making Process Regarding Fertility Among Reproductive-Age Women With Cancer in Taiwan

BACKGROUND

Previous studies indicate that women with cancer experience infertility after cancer-related treatment. With the rapid progress in fertility science, women face diverse and uncertain choices regarding pregnancy.

OBJECTIVE

The aim of this study is to understand the decision-making process regarding fertility choices among reproductive-age women with cancer in Taiwan.

METHODS

Grounded theory methodology guided data collection using in-depth interviews with 18 women diagnosed and treated for cancer. Verbatim transcriptions were analyzed using constant comparative analysis and open, axial, and selective coding.

RESULTS

The core category that describes the decision-making process regarding fertility among reproductive-age women with cancer is "searching for balance in life and creating value in life." The decision process was divided into 3 phases: needing to have children before treatment, struggling with self-living during cancer treatment, and returning to life after treatment. The style of cancer participants' decision making in pregnancy was divided into 3 patterns: action taking, hesitation, and persistence.

CONCLUSIONS

Decision making regarding fertility among women with cancer was affected by the need for children before treatment and their experience during treatment.

IMPLICATIONS FOR PRACTICE

Health providers should be aware of and understand the needs of women with cancer to balance their need for children with their perception of their cancer prognosis and its effects on fertility, and help them with pregnancy planning if desired.

Psychological adjustment after breast cancer: a systematic review of longitudinal studies

OBJECTIVES

Breast cancer (BC) can be a traumatic and stressful experience for women, but there are wide-ranging differences in the ways in which women respond and adapt to BC. This systematic review examines which sociodemographic, disease-related, and psychosocial factors near diagnosis predict later psychological adjustment to BC.

METHODS

Database searches were conducted in 9 different health-related databases from 2000 to December 2015 using relevant search terms. Full-text, peer-reviewed articles in English that analyzed potential predictors of psychological adjustment in longitudinal studies were considered for inclusion.

RESULTS

Of 1780 abstracts, 41 studies fulfilled inclusion criteria. Consistent sociodemographic and disease-related variable predictors of adjustment were income, fatigue, cancer stage, and physical functioning. Psychosocial factors, particularly optimism and trait anxiety, as well as perceived social support, coping strategies, and initial levels of psychological functioning, were found to be predictive of later depressive and anxiety symptoms, psychological distress, and quality of life for women with BC, in predictable ways. Other psychosocial variables, such as cognitive and body image factors, predicted psychological adjustment but were explored only by a few studies.

CONCLUSIONS

The majority of studies showed a significant relationship between psychosocial factors and psychological adjustment. These results point to specific sociodemographic, disease-related, and psychosocial factors that can help to identify women at the time of diagnosis who are at risk for long-term psychological challenges so they can be referred for psychological support that targets their specific needs and can improve their quality of life and mood and decrease indicators of anxiety, depression, and psychological distress.

The relationship of cognitive performance to concurrent symptoms, cancer- and cancer-treatment-related variables in women with early-stage breast cancer: a 2-year longitudinal study

PURPOSE

Cognitive dysfunction in women with breast cancer continues to be an area of intense research interest. The prevalence, severity, timing, and cognitive domains that are most affected, as well as the contribution of cancer and its treatments to cognition, remain unresolved. Thus, longitudinal studies are needed that examine cognitive function during different stages of breast cancer treatment and survivorship. This longitudinal trial followed women with early-stage breast cancer, prior to chemotherapy through 2 years survivorship.

METHODS

In women with early-stage breast cancer (N = -75), performance-based assessment of nine cognitive domains was performed at five time points beginning prior to chemotherapy and finishing 24 months after initial chemotherapy. Linear mixed effects models were used to examine the temporal changes in cognitive performance domains, while adjusting for cofactors, including those related to individuals, tumor attributes, chemotherapy (adjuvant or neoadjuvant), radiation, endocrine therapy, and concurrent symptoms.

RESULTS

At baseline, scores on reaction time, complex attention, cognitive flexibility, executive function, and visual memory were lower than 90. At 2 years, all domains improved except for the memory domains (verbal, visual, and composite). Scores on six domains (psychomotor speed, reaction time, complex attention, cognitive flexibility, and visual memory) remained lower than 100 at 2 years. Neoadjuvant chemotherapy and fatigue had strong inverse relationship with cognitive functioning at multiple time points.

CONCLUSION

The low performance-based cognitive scores at baseline and over time warrant further study. Although most scores improved over time, memory did not improve. In all, the level of cognitive function is lower than expected for a majority college-educated sample. Thus, future studies are warranted to replicate these findings and to develop methods for identifying women with cognitive dysfunction pretreatment and into survivorship.

Co-occurrence of anxiety and depressive symptoms following breast cancer surgery and its impact on quality of life

PURPOSE

Little is known about the prevalence of combined anxiety and depressive symptoms (CADS) in breast cancer patients. Purpose was to evaluate for differences in demographic and clinical characteristics and quality of life (QOL) prior to breast cancer surgery among women classified into one of four distinct anxiety and/or depressive symptom groups.

METHODS

A total of 335 patients completed measures of anxiety and depressive symptoms and QOL prior to and for 6 months following breast cancer surgery. Growth Mixture Modelling (GMM) was used to identify subgroups of women with distinct trajectories of anxiety and depressive symptoms. These results were used to create four distinct anxiety and/or depressive symptom groups. Differences in demographic, clinical, and symptom characteristics, among these groups were evaluated using analyses of variance and Chi square analyses.

RESULTS

A total of 44.5% of patients were categorized with CADS. Women with CADS were younger, non-white, had lower performance status, received neoadjuvant or adjuvant chemotherapy, had greater difficulty dealing with their disease and treatment, and reported less support from others to meet their needs. These women had lower physical, psychological, social well-being, and total QOL scores. Higher levels of anxiety with or without subsyndromal depressive symptoms were associated with increased fears of recurrence, hopelessness, uncertainty, loss of control, and a decrease in life satisfaction.

CONCLUSIONS

Findings suggest that CADS occurs in a high percentage of women following breast cancer surgery and results in a poorer QOL. Assessments of anxiety and depressive symptoms are warranted prior to surgery for breast cancer.

Trajectories of fear of recurrence in women with breast cancer

PURPOSE

Although fear of recurrence (FCR) is common among cancer survivors, it remains unclear what factors predict initial levels (e.g., prior to surgery) or changes in FCR in the post-treatment period. Among women treated for breast cancer, this study evaluated the effects of demographic, clinical, symptom, and psychosocial adjustment characteristics on the initial (preoperative) levels of FCR and trajectories of FCR over 6 months following surgery.

METHODS

Prior to and for 6 months following breast cancer surgery, 396 women were assessed for demographic and clinical (disease and treatment) characteristics, symptoms, psychological adjustment characteristics, and quality of life (QOL). FCR was assessed using a four-item subscale from the QOL instrument. Hierarchical linear modeling was used to examine changes in FCR scores and to identify predictors of inter-individual differences in preoperative FCR levels and trajectories over 6 months.

RESULTS

From before surgery to 6 months post-operatively, women with breast cancer showed a high degree of inter-individual variability in FCR. Preoperatively, women who lived with someone, experienced greater changes in spiritual life, had higher state anxiety, had more difficulty coping, or experienced more distress due to diagnosis or distress to family members reported higher FCR scores. Patients who reported better overall physical health and higher FCR scores at enrollment demonstrated a steeper decrease in FCR scores over time.

CONCLUSIONS

These findings highlight inter-individual heterogeneity in initial levels and changes in FCR over time among women undergoing breast cancer surgery. Further work is needed to identify and provide interventions for women experiencing FCR during and after breast cancer treatment.