Changes in Physical Activity, Functional Capacity, and Cardiac Function during Breast Cancer Therapy.

PURPOSE: Functional capacity and cardiac function can decline during breast cancer (BC) therapy. In non-cancer populations, higher physical activity (PA) is associated with better physical function and cardiac health. This study compared baseline PA, functional capacity, and cardiac function between women with and without BC and tested if greater PA participation was related to higher functional capacity and/or better heart function after three months of BC therapy. METHODS: Data was collected in 104 women without BC (82% Caucasian, baseline only) and 110 women with stage I-III BC (82% Caucasian) before therapy and after three months of treatment. Participants self-reported PA and underwent six-minute walk distance (6MWD) testing to measure functional capacity and cardiovascular magnetic resonance to assess left ventricular ejection fraction (LVEF). Analyses were adjusted for age, race, body mass index (BMI), and medication use. RESULTS: The BC group was older (56.2 ± 10.7 vs 52.1 ± 14.7 yrs, P=0.02) with a higher average BMI than the non-cancer group (30.3 ± 6.8 vs 27.7 ± 6.2 kg/m2, P<0.01). Pre-treatment, BC participants reported lower PA scores (27.9 ± 2.8 vs 34.9 ± 2.8, P=0.04) with similar 6MWD and LVEF relative to those without cancer (485 ± 11 vs 496 ± 11 m, P=0.4 and 59.7 ± 0.7 vs 58.9 ± 0.8%, P=0.37, respectively). After three months of BC therapy, declines were observed for PA scores (27.9 ± 2.8 vs 18.3 ± 2.5, P=0.02), 6MWD (485 ± 11 vs 428 ± 10 m, P<0.001), and LVEF (59.7 ± 0.7 vs 56.1 ± 0.7%, P<0.001). Compared to BC participants who reported no PA at three months (n=24, 22%), BC women who reported any PA (n=78, 86%) had higher 6MWD (442 ± 11 vs 389 ± 17 m, P=0.006) but similar LVEF (56.5 ± 0.9 vs 55.3 ± 1.5%, p=0.5). Women who reported any PA were less likely to exhibit an LVEF below normal (<50%) or decline in LVEF of 'â•10 points compared to inactive women (BMI-adjusted, OR [95% CI]: 0.27 [0.09, 0.85]). CONCLUSIONS: These preliminary results indicate that self-reported PA, LVEF and 6MWD decline in the first three months of BC treatment, but PA participation during BC treatment may mitigate declines in functional capacity and cardiac function. Further research is needed to identify barriers and facilitators of PA participation during BC therapy. FUNDING: Data collection was funded by the Wake Forest NCORP Research Base grant 2UG1CA189824 with support of the NCI Community Oncology Research Program (NCORP). Additional funding for this study was provided by grants from the National Institutes of Health, National Cancer Institute (1R01CA199167 and 5T32CA093423). CLINICAL TRIAL ID: NCT02791581 for WF97415 UPBEAT.

Age at menarche and risk of vasomotor menopausal symptoms: a pooled analysis of six studies.

OBJECTIVE: To examine the association between age at menarche and risk of vasomotor menopausal symptoms (VMS) and whether midlife body mass index (BMI) modified the association. DESIGN: A pooled analysis of six cohort studies. SETTING: The International collaboration on the Life course Approach to reproductive health and Chronic disease Events (InterLACE). POPULATION: 18 555 women from the UK, USA and Australia. METHODS: VMS frequency data (never, rarely, sometimes and often) were harmonised from two studies (n = 13 602); severity data (never, mild, moderate and severe) from the other four studies (n = 4953). Multinominal logistic regression models were used to estimate relative risk ratios (RRRs) and 95% CIs adjusted for confounders and incorporated study as random effects. MAIN OUTCOME MEASURES: Hot flushes and night sweats. RESULTS: Frequency data showed that early menarche ≤11 years was associated with an increased risk of 'often' hot flushes (RRR 1.48, 95% CI 1.24-1.76) and night sweats (RRR 1.59, 95% CI 1.49-1.70) compared with menarche at ≥14 years. Severity data showed similar results, but appeared less conclusive, with RRRs of 1.16 (95% CI 0.94-1.42) and 1.27 (95% CI 1.01-1.58) for 'severe' hot flushes and night sweats, respectively. BMI significantly modified the association as the risk associated with early menarche and 'often' VMS was stronger among women who were overweight or obese than those of normal weight, while this gradient across BMI categories was not as strong with the risk of 'severe' VMS. CONCLUSIONS: Early age at menarche is a risk factor for VMS, particularly for frequent VMS, but midlife BMI may play an important role in modifying this risk. TWEETABLE ABSTRACT: Overweight and obesity exacerbate the risk of vasomotor symptoms associated with early menarche.

Effects of the menopause transition and hormone use on cognitive performance in midlife women.

BACKGROUND: There is almost no longitudinal information about measured cognitive performance during the menopause transition (MT). METHODS: We studied 2,362 participants from the Study of Women's Health Across the Nation for 4 years. Major exposures were time spent in MT stages, hormone use prior to the final menstrual period, and postmenopausal current hormone use. Outcomes were longitudinal performance in three domains: processing speed (Symbol Digit Modalities Test [SDMT]), verbal memory (East Boston Memory Test [EBMT]), and working memory (Digit Span Backward). RESULTS: Premenopausal, early perimenopausal, and postmenopausal women scored higher with repeated SDMT administration (p < or = 0.0008), but scores of late perimenopausal women did not improve over time (p = 0.2). EBMT delayed recall scores climbed during premenopause and postmenopause (p < or = 0.01), but did not increase during early or late perimenopause (p > or = 0.14). Initial SDMT, EBMT-immediate, and EBMT-delayed tests were 4%-6% higher among prior hormone users (p < or = 0.001). On the SDMT and EBMT, compared to the premenopausal referent, postmenopausal current hormone users demonstrated poorer cognitive performance (p < or = 0.05) but performance of postmenopausal nonhormone users was indistinguishable from that of premenopausal women. CONCLUSIONS: Consistent with transitioning women's perceived memory difficulties, perimenopause was associated with a decrement in cognitive performance, characterized by women not being able to learn as well as they had during premenopause. Improvement rebounded to premenopausal levels in postmenopause, suggesting that menopause transition-related cognitive difficulties may be time-limited. Hormone initiation prior to the final menstrual period had a beneficial effect whereas initiation after the final menstrual period had a detrimental effect on cognitive performance.

Quality of life in diverse groups of midlife women: assessing the influence of menopause, health status and psychosocial and demographic factors.

This paper examines whether menopausal status is associated with global quality of life (QOL) among women aged 40-55 and whether this association varies by race/ethnicity. We further examine the contributions of other health-related and psychosocial factors to QOL and whether these associations vary by racial/ethnic group. Analyses are based on 13,874 women who participated in the multi-ethnic, multi-race study of mid-aged women called the Study of Women's Health Across the Nation (SWAN). Study participants completed a 15-min telephone or in-person interview that contained questions on a variety of health-related topics. Items of interest for these analyses include global QOL, menstrual history (to assess menopausal status), sociodemographics, health status, lifestyle, and psychosocial variables. Results showed that in unadjusted analyses, early perimenopausal women reported lower QOL compared with premenopausal women, but menopausal status was no longer associated with QOL when analyses were adjusted for other variables. In multivariable models, being married and having low levels of perceived stress were associated with better QOL across all racial/ethnic groups. While there were many consistencies across racial/ethnic groups, we also found that the nature of the associations between QOL and education, marital status, perceived stress and social support varied across racial/ethnic groups.

Longitudinal study of hormone levels and depression among women transitioning through menopause.

OBJECTIVE: To address the association between depression and absolute levels of estradiol, and change in estradiol, among women during the menopausal transition. METHODS: This was a prospective, observational study conducted in Massachusetts, USA. Analyses reported here are based on the first three interviews following baseline (T1-T3). The participants were 309 women aged initially 43-53 years, who contributed a total of 728 observations (mean number of observations per subject 2.36). The main outcome measure was depression as measured by the Center for Epidemiologic Studies-Depression (CES-D) scale. RESULTS: CES-D score was not significantly associated with menopause status categories, nor was it associated with annual change in estradiol level (E2) (p = 0.19). The unadjusted association between log E2 and CES-D was negative (odds ratio 0.69) and statistically significant (p = 0.03). Upon adjustment for symptoms, however, the association remained negative but was no longer statistically significant (p = 0.26). Hot flushes/night sweats were positively associated with CES-D (p = 0.04), and trouble sleeping was strongly positively related to CES-D (p < 0.001). CONCLUSIONS: Results provide strong support for the domino or symptom hypothesis, which posits that depressed mood is caused by vasomotor symptoms associated with changing estrogen levels. Estradiol did not have a direct effect, independent of symptoms. This study adds to the body of literature suggesting that any association found between menopause and depression is most likely to be explained by other factors, such as symptoms and sleep problems. Findings also highlight the importance of studying the complex relationship between hormone levels, sleep problems and vasomotor symptoms during the menopausal transition.

Is there a menopausal syndrome? Menopausal status and symptoms across racial/ethnic groups.

In recent years, research on menopausal symptomalogy has focused on identifying symptom groupings experienced by women as they progress from premenopausal to postmenopausal status. However, most of these studies have been conducted among Caucasian women from western cultures. This leaves open the question of whether the findings from these studies can be extended to women of other racial/ethnic groups or cultures. Furthermore, many of the previous studies have been conducted on relatively small samples. This paper addresses the diversity of the menopause experience by comparing symptom reporting in a large cross-sectional survey of women aged 40-55 years among racial/ethnic groups of women in the United States (Caucasian, African-American, Chinese, Japanese, and Hispanic). Evaluation of the extent to which symptoms group together and consistently relate to menopausal status across these five samples provides evidence for or against a universal menopausal syndrome. The specific research questions addressed in this paper are: (1) How does the factor structure of symptoms among mid-aged women compare across racial/ethnic groups? (2) Is symptom reporting related to race/ethnicity or menopausal status? and (3) Does the relation between menopausal status and symptoms vary across racial/ethnic groups? Analyses are based on 14,906 women who participated in the multi-ethnic, multi-race, multi-site study of mid-aged women called the Study of Women's Health Across the Nation (SWAN). Study participants completed a 15-min telephone or in-person interview that contained questions on a variety of health-related topics. Items of interest for these analyses include symptoms, menstrual history (to assess menopausal status), health status, and sociodemographics. Factor analysis results showed that across all five racial/ethnic groups, two consistent factors emerged; one consisting of clearly menopausal symptoms -- hot flashes and night sweats -- and the other consisting of psychological and psychosomatic symptoms. Results of regression analyses showed racial/ethnic differences in symptom reporting, as well as differences by menopausal status. Controlling for age, education, health, and economic strain, Caucasian women reported significantly more psychosomatic symptoms than other racial/ethnic groups. African-American women reported significantly more vasomotor symptoms. Perimenopausal women, hormone users, and women who had a surgical menopause reported significantly more vasomotor symptoms. All of these groups, plus postmenopausal women, reported significantly more vasomotor symptoms than premenopausal women. The pattern of results argues against a universal menopausal syndrome consisting of a variety of vasomotor and psychological symptoms.

A focus group study of DES daughters: implications for health care providers.

A focus group study of women exposed to diethylstilbestrol (DES) in utero (DES daughters) was conducted to gain understanding about exposure to this drug from a patient perspective. Focus group participants reported that learning about their DES exposure was devastating; they experienced strains in their family relationships, emotional shock, a feeling that their health concerns were not appreciated by others and, to some degree, a sense of social isolation. Although many were aware of the need for special gynecological exams and high-risk prenatal care, they were frustrated by what they felt was a lack of reliable and clear information about the effects of DES exposure. Most expressed questions and anxiety about their health. Many found their communication with physicians about their DES exposure unsatisfying. They felt that physicians lacked information about the long-term health effects of DES exposure and as a result did not give them accurate information. Furthermore, they felt that physicians were dismissive of their concerns and often gave what they felt to be false reassurances. Consequently, the women developed an enduring distrust of the medical profession. The results of the study suggest implications for the delivery of health care to DES daughters.

Is there an association between menopause status and sexual functioning?

OBJECTIVE: The purpose of this study was to address whether: (1) there is an association between menopause status and various aspects of sexual functioning, and (2) the relative contributions of menopause status and other variables to various aspects of sexual functioning. DESIGN: Analyses are based on 200 women from the Massachusetts Women's Health Study II, a population-based sample of women transitioning through the menopause who were not HRT users, who had not had a surgical menopause, and who had partners. The women were classified as pre-, peri-, or postmenopausal according to menstrual cycle characteristics. Estradiol, estrone, and follicle-stimulating hormone were also measured. Sexual functioning was measured in terms of satisfaction, desire, frequency of sexual intercourse, belief that interest declines with age, arousal compared with a younger age, difficulty reaching orgasm, and pain. Predictor variables included sociodemographics, health, vasomotor symptoms, psychological variables, partner variables, and lifestyle behaviors. RESULTS: Menopause status was significantly related to lower sexual desire, a belief that interest in sexual activity declines with age, and women's reports of decreased arousal compared with when in their 40s. Menopause status was unrelated to other aspects of sexual functioning in either unadjusted or multiple regression analyses. In analyses in which log estradiol (E2) was included in addition to menopause status, log E2 was only related to pain. In multiple regression analyses, other factors such as health, marital status (or new partner), mental health, and smoking had a greater impact on women's sexual functioning than menopause status. CONCLUSIONS: Menopause status, but not E2, is related to some, but not all, aspects of sexual functioning. This may be due to menopause per se or other factors associated with menopause and aging (e.g., increased sexual dysfunction among aging men). Menopause status has a smaller impact on sexual functioning than health or other factors.

A longitudinal study of weight and the menopause transition: results from the Massachusetts Women's Health Study.

OBJECTIVE: Results of past studies of menopause and weight are inconsistent, in part because of problems in study design and analyses, such as retrospective assessment of age at menopause and failure to control for confounding factors. To address such shortcomings, we conducted multivariate analyses on longitudinal data from a large, community-based sample of initially pre- and perimenopausal women who were making the transition through menopause. DESIGN: Data were from the second phase of the Massachusetts Women's Health Study, a cohort of 418 women aged 50-60 years in 1986. We assessed the relationship between menopause transition and weight, after accounting for previous weight; age; and the behavioral factors of smoking, exercise, and annual ethanol consumption. Menopause status was defined in terms of months of amenorrhea. The association of hormone replacement therapy and weight also was examined. RESULTS: Menopause transition was not consistently associated with increased weight, and use of hormone replacement therapy was not significantly related to weight. Behavioral factors--particularly exercise and ethanol consumption--were more strongly related to weight than was menopause transition. CONCLUSIONS: These results are consistent with findings from other studies that suggest that the weight increases experienced by middle-aged women in the United States are not a result of the menopause transition.

Sexual function and aging in men and women: community and population-based studies.

Research has consistently shown a decline in sexual activity with age for both men and women, with the reasons differing by gender. For men, the decline is primarily due to age, poor health, and medications, all of which have been related to erectile dysfunction. For women, health is less of a factor; having a functioning partner is a more important variable. Menopause has some negative impact on women's sexual interest and desire, but psychosocial factors appear to be more important. This article reviews research on age, gender, and human sexuality in the general (nonpatient) population. Additional longitudinal research is recommended to evaluate the long-term effects of declining ovarian function on postmenopausal women; the ways in which aging influences partners over time; and the impact of new medications and generational changes in sexual mores on sexual function in both genders.

Distinguishing between quality of life and health status in quality of life research: a meta-analysis.

Despite the increasing acceptance of quality of life (QOL) as a critical endpoint in medical research, there is little consensus regarding the definition of this construct or how it differs from perceived health status. The objective of this analysis was to understand how patients make determinations of QOL and whether QOL can be differentiated from health status. We conducted a meta-analysis of the relationships among two constructs (QOL and perceived health status) and three functioning domains (mental, physical, and social functioning) in 12 chronic disease studies. Instruments used in these studies included the RAND-36, MOS SF-20, EORTC QLQ-30, MILQ and MQOL-HIV. A single, synthesized correlation matrix combining the data from all 12 studies was estimated by generalized least squares. The synthesized matrix was then used to estimate structural equation models. The meta-analysis results indicate that, from the perspective of patients, QOL and health status are distinct constructs. When rating QOL, patients give greater emphasis to mental health than to physical functioning. This pattern is reversed for appraisals of health status, for which physical functioning is more important than mental health. Social functioning did not have a major impact on either construct. We conclude that quality of life and health status are distinct constructs, and that the two terms should not be used interchangeably. Many prominent health status instruments, including utility-based questionnaires and health perception indexes, may be inappropriate for measuring QOL. Evaluations of the effectiveness of medical treatment may differ depending on whether QOL or health status is the study outcome.

The importance of AIDS-related knowledge for mid-life and older women.

Although the AIDS epidemic has had a major impact on the lives of women throughout the world, there is little knowledge regarding risk factors, transmission factors, prevention methods, and results of prevention efforts for older women, even though almost 10% of all AIDS cases in the United States are among those 50 years and older. This article reports results on AIDS knowledge and risks from the Massachusetts Women's Health Study, a longitudinal community-based study of middle-aged women. AIDS-related questions were asked of this sample at their last study interview, which occurred in 1995 when the women were aged 58-67. Results indicate that this sample of older, predominantly Caucasian women are quite knowledgeable about transmission factors but are less knowledgeable about early interventions and their own risk status. Many are also likely to know someone with HIV or AIDS. Even though these women are generally at low risk, they may be at higher risk than they perceive. They may also be significant disseminators of knowledge to friends and relatives who may be at risk, and thus could represent an important target group for AIDS educational programs.

Quality of life in advanced ovarian cancer: identifying specific concerns.

PURPOSE: To identify issues affecting the quality of life (QoL) in women receiving palliative therapy for ovarian cancer. METHODS: Twenty women with advanced recurrent ovarian cancer were interviewed to establish what issues affect QoL. All patients were receiving palliative chemotherapy or other palliative therapy in the department of Gynecologic Oncology at the Massachusetts General Hospital, and were felt to have a life expectancy of 1 year or less by best clinical estimate. RESULTS: Twenty patients with an average age of 56.7 years participated. Psychosocial issues were more common than physical ones, and patients were more likely to mention issues that positively impact on QoL rather than those with a negative effect. Most patients noted that a sense of hope, enhanced appreciation for day to day life, and a strong support system had a significantly positive effect on QoL. Issues negatively impacting QoL included fear of their disease (90%) and concern for family and friends (100%), particularly children. Most common physical symptoms impacting QoL included fatigue (100%) and anorexia (55%). CONCLUSIONS: Little research has been done into QoL issues for ovarian cancer patients receiving palliative care. Available QoL studies tend to focus on the physical aspects of a disease or its treatment. This pilot study suggests that women with advanced, recurrent ovarian cancer feel that psychosocial issues play a greater role in determining QoL than do physical issues. Further QoL studies for these patients should include assessment of psychosocial realms. This information can then be used to design interventions to improve QoL.

Use of the MQoL-HIV with asymptomatic HIV-positive patients.

The purpose of this study was to determine the appropriateness of the recently developed Multidimensional Quality of Life Questionnaire for HIV/AIDS (MQoL-HIV) as a measure of quality of life (QoL) in cases of asymptomatic human immunodeficiency virus (HIV) infection. The MQoL-HIV is a 40-item instrument measuring ten domains (mental health, physical health, physical functioning, social functioning, social support, cognitive functioning, financial status, partner intimacy, sexual functioning and medical care) relevant to HIV infection. An overall QoL score, the MQoL-HIV Index, is a weighted composite of two domain scores. In a sample of 216 HIV-infected men and women, the MQoL-HIV distinguished acquired immune deficiency syndrome (AIDS), symptomatic and asymptomatic cases in overall QoL and in seven individual QoL domains. The index was responsive to perceived QoL changes over 5.5 months (r = 0.52). We also found the MQoL-HIV was less susceptible to ceiling effects in asymptomatic cases than was the Medical Outcomes Study (MOS) SF-20. These results suggest that the MQoL-HIV is a valid and reliable measure of QoL for both asymptomatic and symptomatic HIV infection.

Psychosocial, behavioral, and health factors related to menopause symptomatology.

Despite wide variation in the reporting of hot flashes and night sweats among menopausal women, what differentiates symptomatic from asymptomatic women is not well understood. In this article, we use longitudinal data from a large cohort of initially premenopausal women to address premenopausal factors predictive of length of the perimenopause, frequency of hot flash/night sweat (HF/NS) reporting, bothersomeness of HF/NS, and treatment seeking during menopause. The sample for analysis consists of 454 women from the Massachusetts Women's Health Study who were premenopausal at baseline and postmenopausal by the sixth and last study follow-up. Each of the four study outcomes was modeled as a function of premenopausal characteristics using logistic regression. Results confirm a wide range of symptom reporting, with 23% of women not reporting HF/NS at any of the six interviews. Variables related to greater frequency of HF/NS reporting included a longer perimenopause, more psychological and physical symptoms prior to menopause, lower education, and more negative attitudes toward menopause prior to menopause. Symptom bothersomeness was related to greater frequency of HF/NS reporting, smoking, and being divorced. Variables that predicted medical doctor consultation were greater frequency and bothersomeness of symptoms, higher education, and greater health care utilization. We conclude that general symptom reporting, attitudes toward menopause, and lifestyle factors can explain some of the individual variation in symptom reporting.

Gender differences in sexual activity among mid-aged adults in Massachusetts.

OBJECTIVES: The purpose of this study was to determine if self-reported measures of sexual activity differ between aging men and women. METHODS: Responses to 12 questions concerning various aspects of sexual activity were compared between 349 women and 589 men aged 51-61, who were participants in two larger community surveys in Massachusetts conducted in 1987 and 1988. Comparisons were made by least squares means adjusted for age, socio-demographic and health-related variables. Analyses were stratified by the presence or absence of one or more current sexual partners. RESULTS: Regardless of partner status, overall satisfaction with sex life did not differ between men and women. For those with partners, the mean frequency of intercourse was somewhat higher for women than men, while mean frequency of sexual desire and fantasies was significantly higher for men. Similar results were seen for those without partners, although frequency was lower and did not differ by gender. CONCLUSIONS: We found no gender difference in sexual satisfaction and little difference in frequency in mid-aged adults, but sexual desire and fantasies were more common for men.

Development of the multidimensional index of life quality. A quality of life measure for cardiovascular disease.

OBJECTIVES: The purpose of this study was to design a multidimensional measure of health-related quality of life appropriate for patients with cardiovascular disease that was psychometrically sound, brief, and easy to administer. METHODS: Qualitative interviews conducted with healthy subjects and patients with cardiovascular diseases identified nine major quality of life domains. Based on the responses of 129 cardiovascular disease patients recruited from hospitals and clinics, a criterion-based approach was used to select 35 questionnaire items that best tapped these domains. Psychometric properties of the Multidimensional Index of Life Quality (MILQ) were tested with a sample of 348 patients with various cardiovascular diseases. RESULTS: Cronbach's alpha was 0.76 or higher for eight of the nine MILQ domains. Test-retest reliability coefficients were 0.73 or greater in all but two domains. Individual domain scores as well as a weighted overall quality of life index were correlated highly with self-assessed health and the number of heart-related symptoms. CONCLUSIONS: The Multidimensional Index of Life Quality is a psychometrically reliable and valid instrument for measuring quality of life in patients with cardiovascular diseases. The MILQ also may be a suitable measure for other types of chronic diseases.