Co-morbidity and predictors of health status in older rural breast cancer survivors

Physical health-related quality of life trajectories over two years following breast cancer diagnosis in older women: a secondary analysis

PURPOSE

To identify distinct trajectories of physical health-related quality of life (HRQoL) in older women over the first two years following breast cancer diagnosis, and to examine characteristics associated with trajectory group membership.

METHODS

A secondary analysis of a longitudinal study of women diagnosed with stage I-III breast cancer who completed surveys within eight months of diagnosis and six, twelve, and eighteen months later that focuses on a subset of women aged ≥ 65 years (N = 145).Physical HRQoL was assessed using the Physical Component Score (PCS) of the SF-36 Health Survey. Finite mixture modeling identified distinct PCS trajectories. Multivariable logistic regression identified variables predictive of low PCS group membership.

RESULTS

Two distinct patterns of PCS trajectories were identified. The majority (58%) of women had PCS above the age-based SF-36 population norms and improved slightly over time. However, 42% of women had low PCS that remained low over time. In multivariable analyses, older age, difficulty paying for basics, greater number of medical comorbidities, and higher body mass index were associated with low PCS group membership. Cancer treatment and psychosocial variables were not significantly associated.

CONCLUSION

A large subgroup of older women reported very low PCS that did not improve over time. Older age, obesity, multiple comorbidities, and lower socioeconomic status may be risk factors for poorer PCS in women with breast cancer. Incorporating routine comprehensive geriatric assessments that screen for these factors may help providers identify older women at risk for poorer physical HRQoL post breast cancer treatment.

Economic Perspective of Cancer Care and Its Consequences for Vulnerable Groups

Simple Summary

For cancer patients, many different reasons can cause financial burdens and economic threads. Sociodemographic factors, rural/remote location and income are known determinants for these vulnerable groups. This economic vulnerability is related to the reduced utilization of cancer care and the impact on outcome. Financial burden has been reported in many countries throughout the world and needs to be addressed as part of the sufficient quality of cancer care.

Abstract

Within healthcare systems in all countries, vulnerable groups of patients can be identified and are characterized by the reduced utilization of available healthcare. Many different reasons can be attributed to this observation, summarized as implementation barriers involving acceptance, accessibility, affordability, acceptability and quality of care. For many patients, cancer care is specifically associated with the occurrence of vulnerability due to the complex disease, very different target groups and delivery situations (from prevention to palliative care) as well as cost-intensive care. Sociodemographic factors, such as educational level, rural/remote location and income, are known determinants for these vulnerable groups. However, different forms of financial burdens likely influence this vulnerability in cancer care delivery in a distinct manner. In a narrative review, these socioeconomic challenges are summarized regarding their occurrence and consequences to current cancer care. Overall, besides direct costs such as for treatment, many facets of indirect costs including survivorship costs for the cancer patients and their social environment need to be considered regarding the impact on vulnerability, treatment compliance and abundance. In addition, individual cancer-related financial burden might also affect the society due to the loss of productivity and workforce availability. Healthcare providers are requested to address this vulnerability during the treatment of cancer patients.

Rural-Urban Differences in Neuroimmune Biomarkers and Health Status Among Women Living With Breast Cancer

BACKGROUND

Because of chronic emotional and psychosocial stressors following breast cancer (BC) treatment, BC survivors are at risk of neuroimmune dysfunction in survivorship. Rural BC survivors experience more health disparities than urban BC survivors. Rural-urban residence as a variable on neuroimmune activity in extended BC survivorship continuum has not been explored.

OBJECTIVE

To report the feasibility of studying relationships between neuroimmune activity and perceived health in rural and urban BC survivors.

METHODS

Data from a pilot study of BC survivors (n = 41) were analyzed. Participants were rural (n = 16) and urban (n = 25). Participants completed Medical Outcomes Study Short-Form Version 2 Health Survey questionnaires and provided salivary specimens for analysis of salivary α-amylase (sAA), cortisol, and interleukin 6 (IL-6). Rural-Urban Commuting Area Codes were used to determine rural or urban residence.

RESULTS

Differences in immune activity were observed between rural and urban BC survivors (U = 34, P < .05). No rural-urban group differences in neuroendocrine activity were observed. Relationships were observed between perceptions of mental health and sAA (P < .05) in rural BC survivors and between perceptions of mental health and IL-6 (P < .05) in urban BC survivors. Interleukin 6 was positively associated with perceptions of physical health (P < .05) in rural BC survivors.

CONCLUSION

Pilot data suggest rural-urban residence may be a factor in relationships between neuroimmune function (ie, sAA and IL-6) and perceived health status, particularly social functioning in women with BC. Additional studies with powered designs are indicated.

IMPLICATIONS FOR PRACTICE

Although evidence is limited, data support the feasibility of studying relationships between sAA and IL-6 and perceptions of health in women with BC.

Depressive Symptoms and Associated Health-Related Variables in Older Adult Breast Cancer Survivors and Non-Cancer Controls

OBJECTIVES

To examine the prevalence of depressive symptoms and associated risk factors in older adult breast cancer survivors (BCS) and age-matched non-cancer controls.

SAMPLE & SETTING

Using the Surveillance, Epidemiology, and End Results-Medicare Health Outcome Survey linked dataset from 1998 to 2012, BCS and non-cancer controls aged 65 years or older were identified.

METHODS & VARIABLES

Depressive symptoms, comorbidities, functional limitations, socio-demographics, and health-related information were examined. Univariate and multivariable logistic regression and marginal models were performed.

RESULTS

5,421 BCS and 21,684 controls were identified. BCS and non-cancer controls had similar prevalence of depressive symptoms. Having two or more comorbidities and functional limitations were strongly associated with elevated risk of depressive symptoms in BCS and non-cancer controls.

IMPLICATIONS FOR NURSING

Having multiple comorbidities and multiple functional status are key factors associated with depressive symptoms in older adult BCS and non-cancer controls. Nurses are in an ideal position to screen older adult BCS and non-cancer controls at risk for depressive symptoms.

Burden of Treatment among Elderly Patients with Cancer: A Scoping Review

Background: The objective of this scoping review is to understand how treatment burden is experienced in elderly patients with cancer and what the most prevalent dimensions of treatment burden are among this population. According to one conceptual model, there are six dimensions of treatment burden, including financial, medication, administrative, time/travel, lifestyle, and healthcare. Methods: A scoping review methodology framework was used to collected data from EMBASE CINAHL (Cumulative Index to Nursing and Allied Health Literature), Medline/PubMed, Scopus, Web of Science, Embase, and Cochrane from 2000 to March 2020. Studies which focused on treatment burden among elderly patients with cancer (+65 years) were selected. Data were extracted using a standardized proforma. Results: The results identified 3319 total papers. Of these, 24 met the inclusion criteria and were included in the scoping review. A significant proportion of these studies was conducted in the United States (n = 10) using self-reported, cross-sectional data. Financial burden was the most prevalent dimension of treatment burden, with 11 studies focusing on the direct and indirect costs associated with cancer treatment. Other but less obvious aspects of treatment burden elderly patients experienced included the length of time taken to access and administer treatment and medication-related burdens. Conclusions: Emerging findings suggest that the financial aspects of cancer treatment are a significant burden for most elderly cancer patients. Personalized healthcare interventions targeting ways to reduce and screen for treatment burden, particularly those related to cost, are urgently needed.

Comorbidities, treatment-related consequences, and health-related quality of life among rural cancer survivors

PURPOSE

We explored how lifetime comorbidities and treatment-related cancer symptoms were associated with quality of life (QOL) in rural cancer survivors.

METHODS

Survivors (n = 125) who were rural Illinois residents aged 18+ years old were recruited from January 2017 to September 2018. We conducted 4 multivariable regressions with QOL domains as outcomes (social well-being, functional well-being, mental health-MHQOL, physical health-PHQOL); the number of physical and psychological comorbidities (e.g., arthritis, high blood pressure, stroke) and treatment-related cancer symptoms (e.g., worrying, feeling sad, lack of appetite, lack of energy) as predictors; and, cancer-related and demographic factors related to these variables as covariates.

RESULTS

The number of comorbidities and number of treatment-related symptoms were inversely associated with functional well-being (Std β = - 0.36, p < 0.0001 and - 0.18, p = 0.03), and MHQOL (Std β = - 0.30, p = 0.001 and Std β = - 0.25, p = 0.004). Comorbidities were associated inversely with social well-being (Std β = - 0.27, p = .003). Comorbidities and treatment-related symptoms were not associated with PHQOL (p = 0.20-0.24). Sensitivity analyses suggested that psychological comorbidities, treatment-related psychological symptoms, and physical comorbidities were associated with social well-being, functional well-being, and MHQOL.

CONCLUSIONS

Our study highlights the utility of risk-based survivorship care plans to address the negative, additive impact of comorbidities and the treatment-related symptoms to improve the health-related QOL among rural survivors. Future research should assess how contextual factors (e.g., geographic distance to oncologists and other providers) should be incorporated in survivorship care planning and implementation for rural survivors.

A telephone-based education and support intervention for Rural Breast Cancer Survivors: a randomized controlled trial comparing two implementation strategies in rural Florida

PURPOSE

To compare two implementation telephone-based strategies of an evidence-based educational and support intervention to Rural Breast Cancer Survivors (RBCS) in which education was delivered early or after the support component.

METHODS

Florida RBCS participated in a 12-month randomized clinical trial (RCT) with two arms: Early Education and Support (EE-S) and Support and Delayed Education (S-DE). Arms differed in the timing of 6 support and 3 education sessions. Main outcome was quality of life (QOL, SF-36 physical and mental composite scores [PCS, MCS]). Secondary outcomes were depressive symptoms (Centers for Epidemiologic Studies Depression Scale, CES-D), mood (Profile of Mood States, POMS), and social support (Medical Outcomes Study Social Support Survey, MOS-SSS). Outcomes were analyzed longitudinally using repeated measures models fitted with linear mixed methods.

RESULTS

Of 432 RBCS (mean 25.6 months from diagnosis), about 48% were 65+, 73% married/partnered, and 28% with ≤high school education. There were no differences between EE-S and S-DE in demographics or outcomes at baseline (mean (standard deviation): SF-36 PCS, 44.88 (10.6) vs. 45.08 (10.6); MCS, 49.45 (11.1) vs. 48.1 (11.9); CES-D, 10.11 (9.8) vs. 10.86 (10.5); POMS-SF, 23.95 (38.6) vs. 26.35 (38.8); MOS-SSS, 79.2 (21.2) vs. 78.66 (21.2)) or over time. One exception was slightly worse mean scores at month 9 in MCS (Cohen's d, - 0.22; 95% CI, - 0.38, - 0.06) and POMS (Cohen's d, 0.23; 95% CI, 0.07, 0.39) for EE-S vs. S-DE.

CONCLUSIONS

The implementation strategies were equivalent.

IMPLICATIONS FOR CANCER SURVIVORS

Enhancing support may be considered before delivering not-in-person interventions to RBCS.

Comorbidity and polypharmacy in patients with breast cancer

BACKGROUND

Cancer sufferers are aged ≥ 65 years, but research has focused infrequently on elderly patients with the majority of cancer. We aimed not only to determine the frequency of comorbidity and polypharmacy, but also to present the discrepiancies in elderly versus non-elderly patients with breast cancer.

METHODS

A total of 352 female patients aged over 18 years, 252 non-elderly and 100 elderly, followed-up in the oncology department of a tertiary hospital between January 2016 and September 2019 were retrospectively screened. Demographic data, comorbidity and medications of the patients were recorded hospital data processing system. Polypharmacy was defined as the use of ≥ 5 different medications.

RESULTS

The most common four chronic diseases in both non-elderly and elderly groups were muscle-joint-bone disease, gastrointestinal diseases, diabetes mellitus and hypertension. The most common four prescribed drugs were NSAID, adjuvant endocrine therapy, PPI, and vitamin D or/and calcium in non-elderly group while those were ACEI-ARB, PPI, NSAID, and diuretics in elderly one. The frequency of polypharmacy was 50% (n = 126) in the non-elderly patients and 74% (n = 74) in the elderly ones. These were considered statistically significant (p < 0.001). The mean number of prescription medication categories reported was 5.02 (SD = 2.90; range 0-14) in non-elderly group whereas those was 6.83 (SD = 3.18; range 0-15) in elderly one (p < 0.001). The mean of ages were 47.9 years (without polypharmacy) and 51.3 years (with polypharmacy) in non-elderly patients while those are, respectively, 70.9 years and 74.7 years in elderly ones. These were considered statistically significant (respectively; p = 0.006, p = 0.009).

CONCLUSIONS

We first gained to raise awareness in the literature of comorbidity and polypharmacy in patients with breast cancer and to compare between the elderly and non-elderly participants. For the effectiveness of cancer treatment, importance in geriatric population, attention to drug-drug interaction, such studies should be considered during clinical practice.

Predictive values of two frailty screening tools in older patients with solid cancer: a comparison of SAOP2 and G8

Objectives

Comprehensive Geriatric Assessment (CGA), the gold standard for detecting frailty in elderly cancer patients, is time-consuming and hard to apply in routine clinical practice. Here we compared the performance of two screening tools for frailty, G8 and SAOP2 for their accuracy in identifying vulnerable patients.

Material and Methods

We tested G8 and SAOP2 in 282 patients aged 65 or older with a diagnosis of solid cancer and candidate to undergo surgical, medical and/or radiotherapy treatment. CGA, including functional and cognitive status, depression, nutrition, comorbidity, social status and quality of life was used as reference. ROC curves were used to compare two screening tools.

Results

Mean patient age was 79 years and 54% were female. Colorectal and breast cancer were the most common types cancer (49% and 24%). Impaired CGA, G8, and SAOP2 were found in 62%, 89%, and 94% of the patients, respectively. SAOP2 had a better sensitivity (AUC 0.85, p<0.032) than G8 (AUC 0.79), with higher performance in breast cancer patients (AUC 0.93) and in patients aged 70-80 years (AUC 0.87).

Conclusions

G8 and SAOP2 both showed good screening capacity for frailty in the cancer patient population we examined with SAOP2 showing a slightly better performance than G8.

Rural-Urban Residence and Stage at Breast Cancer Diagnosis Among Postmenopausal Women: The Women's Health Initiative

BACKGROUND

Although social exposures have complex and dynamic relationships and interactions, the existing literature on the impact of rural-urban residence on stage at breast cancer diagnosis does not examine heterogeneity of effect. We examined the joint effect of social support, social relationship strain, and rural-urban residence on stage at breast cancer diagnosis.

METHODS

Using data from the Women's Health Initiative (WHI) (n = 161,808), we describe the distribution of social, behavioral, and clinical factors by rural-urban residence among postmenopausal women with incident breast cancer (n = 7,120). We used rural-urban commuting area (RUCA) codes to categorize baseline residential addresses as urban, large rural city/town, or small rural town, and the surveillance, epidemiology, and end results staging system to categorize breast cancer stage at diagnosis (dichotomized as early or late). We then used univariable and multivariable logistic regression to estimate odds ratios (ORs) and associated 95% confidence intervals (95% CI) for the relationship between rural-urban residence and stage at breast cancer diagnosis. We included separate interaction terms between rural-urban residence and social strain and social support to test for statistical interaction.

RESULTS

Of the social, behavioral, and clinical factors we examined, only younger age at WHI enrollment screening was significantly associated with late stage at breast cancer diagnosis (p = 0.003). Contrary to our hypothesis, rural-urban residence was not significantly associated with stage at breast cancer diagnosis among postmenopausal women ([adjusted OR, 95% CI] for urban compared with small town: 1.08 [0.76-1.53]; large town compared with small town: 1.16 [0.74-1.84]; and urban compared with large town: 0.93 [0.68-1.26]).The associations did not vary by social support or social strain (p for interaction between RUCA and social strain and social support, respectively: 0.99 and 0.17).

CONCLUSIONS

Future studies should examine other potential effect modifiers to identify novel factors predictive or protective for late stage at breast cancer diagnosis associated with rural-urban residence.

Evaluating Survivorship Experiences and Needs Among Rural African American Breast Cancer Survivors

Disparities in cancer survivorship exist among specific populations of breast cancer survivors, specifically rural African American breast cancer survivors (AA-BCS). While effective survivorship interventions are available to address and improve quality of life, interventions must be culturally tailored for relevance to survivors. Here, we report the results of our formative research using focus groups and in-depth interview to better understand unique rural AA-BCS survivorship experiences and needs in the Alabama Black Belt. Surveys were used to gather sociodemographic and cancer treatment data. Fifteen rural AA-BCS shared their experiences and concerns about keeping their cancer a secret, lack of knowledge about survivorship, lingering symptoms, religion and spirituality, cancer surveillance, and general lack of survivorship education and support. Rural AA-BCS were unwilling to share their cancer diagnosis, preferring to keep it a secret to protect family and friends. Quality-of-life issues like lymphedema body image and sexuality were not well understood. They viewed spirituality and religion as essential in coping and accepting cancer. Participants also discussed the importance of and barriers to maintaining health through regular check-ups. They needed social support from family and friends and health care providers. Overall, rural AA-BCS expressed their need for knowledge about survivorship self-management by providing a vivid picture of the realities of cancer survival based on shared concerns for survivorship support and education within the context of culture.

Multi-Level Assessment to Reach Out to Rural Breast Cancer Survivors

Rural breast cancer survivors experience gaps in post-treatment education and support. We report the development and delivery of Reach Out to Rural Breast Cancer Survivors Program. Community-based participatory research and multi-level assessment were used to (a) engage rural community leaders, survivors, and providers; (b) analyze and report results of discussion groups to understand survivorship concerns and preferences; (c) integrate discussion group findings to develop, tailor, and deliver Reach Out; and (d) evaluate Reach Out with regard to satisfaction and helpfulness. In total, 16 rural breast cancer survivors participated in discussion groups. Four major concerns were identified through content analysis: lost in transition, self-management in survivorship, preference for support, and cancer surveillance. Major concerns and survivor preferences were integrated into Reach Out. A 15-item evaluation survey was used to assess the acceptability and helpfulness of Reach Out. In all, 72 participants attended three Reach Out programs; 96% completed evaluations of acceptability and helpfulness. In all, 68 were breast cancer survivors (99%), 88.4% were interested in the information; 91% indicated that personal objectives were met. Content about maintaining health, lymphedema management, and sexuality were ranked as most helpful. Rural survivorship concerns were similar to non-rural survivors, the major difference being access to services. In conclusion, multi-level assessment and community engagement were keys to understand rural survivorship and to develop and deliver content that attended to rural breast cancer survivors’ preferences.

Multimorbidity and breast cancer

OBJECTIVES

To examine the significance of multimorbidity in breast cancer survivors, to explore multimorbidity in treatment decisions, and survivorship, and to consider multimorbidity assessment in clinical practice.

DATA SOURCES

Literature review; clinical practice guidelines.

CONCLUSION

Multimorbidity influences treatment decisions. Breast cancer survivors report greater multimorbidity compared with other cancer survivors. Multimorbidity increases with age; there may be racial and ethnic differences. Multimorbidity is associated with symptom burden, functional decline, low adherence to surveillance, and early retirement.

IMPLICATIONS FOR NURSING PRACTICE

Clinical practice guidelines do not refer to multimorbidity and patient outcomes. Comprehensive geriatric assessment combined with survivorship care plan may be considered.