Role of breast reconstructive surgery in physical and emotional outcomes among breast cancer survivors.

BACKGROUND: Tissue-sparing approaches to primary treatment and reconstructive options provide improved cosmetic outcomes for women with breast cancer. Earlier research has suggested that conservation or restitution of the breast might mitigate the negative effects of breast cancer on women's sexual well-being. Few studies, however, have compared psychosocial outcomes of women who underwent lumpectomy, mastectomy alone, or mastectomy with reconstruction. To address some of these issues, we examined women's adaptation to surgery in two large cohorts of breast cancer survivors. METHODS: A total of 1957 breast cancer survivors (1-5 years after diagnosis) from two major metropolitan areas were assessed in two waves with the use of a self-report questionnaire that included a number of standardized measures of health-related quality of life, body image, and physical and sexual functioning. All P: values are two-sided. RESULTS: More than one half (57%) of the women underwent lumpectomy, 26% had mastectomy alone, and 17% had mastectomy with reconstruction. As in earlier studies, women in the mastectomy with reconstruction group were younger than those in the lumpectomy or mastectomy-alone groups (mean ages = 50.3, 55.9, and 58.9, respectively; P: =.0001); they were also more likely to have a partner and to be college educated, affluent, and white. Women in both mastectomy groups complained of more physical symptoms related to their surgeries than women in the lumpectomy group. However, the groups did not differ in emotional, social, or role function. Of interest, women in the mastectomy with reconstruction group were most likely to report that breast cancer had had a negative impact on their sex lives (45.4% versus 29.8% for lumpectomy and 41.3% for mastectomy alone; P: =. 0001). CONCLUSIONS: The psychosocial impact of type of primary surgery for breast cancer occurs largely in areas of body image and feelings of attractiveness, with women receiving lumpectomy experiencing the most positive outcome. Beyond the first year after diagnosis, a woman's quality of life is more likely influenced by her age or exposure to adjuvant therapy than by her breast surgery.

Fatigue in breast cancer survivors: occurrence, correlates, and impact on quality of life.

PURPOSE: To describe the occurrence of fatigue in a large sample of breast cancer survivors relative to general population norms and to identify demographic, medical, and psychosocial characteristics of fatigued survivors. PATIENTS AND METHODS: Breast cancer survivors in two large metropolitan areas completed standardized questionnaires as part of a survey study, including the RAND 36-item Health Survey, Center for Epidemiological Studies-Depression Scale, Breast Cancer Prevention Trial Symptom Checklist, Medical Outcomes Study Sleep Scale, and demographic and treatment-related measures. RESULTS: On average, the level of fatigue reported by the breast cancer survivors surveyed (N = 1,957) was comparable to that of age-matched women in the general population, although the breast cancer survivors were somewhat more fatigued than a more demographically similar reference group. Approximately one third of the breast cancer survivors assessed reported more severe fatigue, which was associated with significantly higher levels of depression, pain, and sleep disturbance. In addition, fatigued women were more bothered by menopausal symptoms and were somewhat more likely to have received chemotherapy (with or without radiation therapy) than nonfatigued women. In multivariate analyses, depression and pain emerged as the strongest predictors of fatigue. CONCLUSION: Although the majority of breast cancer survivors in this large and diverse sample did not experience heightened levels of fatigue relative to women in the general population, there was a subgroup of survivors who did report more severe and persistent fatigue. We identified characteristics of these women that may be helpful in elucidating the mechanisms underlying fatigue in this population, as well as directing intervention efforts.

Predictors of sexual health in women after a breast cancer diagnosis.

PURPOSE: To identify variables that might be predictive of sexual health (interest, dysfunction, and satisfaction) in a large sample of breast cancer survivors, with a validation conducted in a second, independent sample. PATIENTS AND METHODS: On the basis of a conceptual framework of sexual health in breast cancer survivors, we performed multivariable regression analyses to estimate sexual interest, dysfunction, and satisfaction in both samples. Additional analyses were performed using stepwise regression and recursive partitioning to explore in each sample the relative contributions of the independent variables toward predicting the outcome measures. RESULTS: The models for sexual interest accounted for at least 33% of the variance, and the significant predictors common to the two samples were having a new partner since the diagnosis of breast cancer, mental health score, and body image score. For sexual dysfunction, the models in the two samples explained at least 33% of the variance, and the common significant predictors were vaginal dryness, past chemotherapy use, and having a new partner since diagnosis. The sexual satisfaction models explained at least 27% of the variance, with the common significant predictors being the quality of the partnered relationship and sexual problems in the partner. CONCLUSION: Among the predictors of sexual health, several are mutable (vaginal dryness, emotional well-being, body image, the quality of the partnered relationship, and sexual problems in the partner), and these should be considered for future interventions to address the sexual health and well-being of breast cancer survivors.

Are older breast carcinoma survivors willing to take hormone replacement therapy?

BACKGROUND: Breast carcinoma survivors are the largest segment of the expanding cancer survivor community. As a result, there has been increasing discussion of the safety and efficacy of hormone replacement therapy for women with a past history of breast carcinoma. Little is known about the willingness of older breast carcinoma survivors to accept hormone replacement therapy for the alleviation of menopausal symptoms (such as hot flashes, vaginal dryness, and urinary incontinence) or for reduction in the risk of serious heart disease or osteoporotic hip fracture. METHODS: A structured decision analysis interview was conducted, in which visual aids were used to describe therapy and hypothetical risks of breast carcinoma recurrence. Subjects were presented with a series of scenarios in which a hypothetical woman might be experiencing one of several menopausal symptoms or might have a reduction in the risk of serious heart disease or osteoporotic hip fracture. RESULTS: Thirty-nine disease free breast carcinoma survivors who were age 60 years or older were recruited to participate in a study that included interview and physical examination. Subjects were age 68.3 years on average and had been diagnosed with breast carcinoma an average of 3.1 years previously. The majority had received hormone replacement therapy at some point in the past. They showed high levels of functioning as measured by the RAND Short Form Health Survey. Willingness to take estrogen was evident only when the increase in the risk of breast carcinoma recurrence was small and when severe symptoms of menopause were present. Under the hypothetical conditions of this interview, 56.4% of these 39 breast carcinoma survivors would be willing to take estrogen if they had all 3 menopausal symptoms and their risk of breast carcinoma recurrence increased from 25% to 32%. In contrast, for the osteoporosis and heart disease scenarios (in which women were as yet asymptomatic), only 17.9% were willing to take estrogen to reduce the risk of hip fracture by 50% and only 28.2% were willing to take estrogen to reduce the risk of heart attack by 50% under the same assumption of a 7% difference in the risk of recurrence (from 25% to 32%). CONCLUSIONS: Overall, the study findings demonstrate the reluctance of these older breast carcinoma survivors to take estrogen after a breast carcinoma diagnosis. There was an increased willingness to consider therapy if multiple symptoms coexisted and the possible risk of recurrence was small (13% compared with 10%). There was also no significant correlation between current menopausal symptoms and the willingness to take estrogen in the hypothetical situations posed in the interview. These findings suggest an important feasibility problem that must be addressed before hormone replacement clinical trials involving breast carcinoma survivors are launched.

Sexuality following breast cancer.

This article provides sex and marital therapists with detailed, multifaceted descriptions of sexuality after breast cancer based on survey responses from 863 breast cancer survivors. One third of women reported that breast cancer had had a negative impact on her sex life, and most reported negative changes in at least some areas. Nonetheless, breast cancer survivors did not differ from age-matched, healthy women on a standard measure of sexuality. Women who were most likely to report a negative impact on sexuality from cancer were those who had experienced changes in hormonal status, problems in their relationships, and difficulties with vaginal dryness. On the basis of these findings, we offer suggestions for health professionals and therapists treating breast cancer survivors.

Impact of different adjuvant therapy strategies on quality of life in breast cancer survivors.

Little is known about the long-term effects of adjuvant therapy on quality of life, sexual functioning and symptoms in breast cancer survivors. Between January 1996 and June 1997, we surveyed 1098 women who had been diagnosed with early stage breast cancer between 1 and 5 years earlier. The breast cancer survivors were recruited in two large metropolitan centers in the USA. They completed a survey battery that contained standardized measures of health-related quality of life (HRQL), depression, body image, sexual functioning, and symptoms. A total of 1096 had usable responses for these analyses. In this sample, n = 356 had received tamoxifen (TAM) alone, n = 180 received chemotherapy (CHEM) alone, n = 395 received CHEM + TAM, and n = 265 received no adjuvant therapy (NO RX). There were significant differences in the mean age of each group, with the TAM group being the oldest (mean 62.6 years) and the CHEM group being the youngest (mean 46.8 years). Both age and time since diagnosis were controlled for in all statistical analyses. We found no significant differences in global quality of life among the four treatment groups. For the MOS-SF-36, there were no significant differences on the subscale scores except for the physical functioning subscale (p = 0.0002); the NO RX group had the highest functioning. There were no significant differences in depression scores among the four treatment groups. The MOS-SF-36 physical functioning composite score differed by treatment group (p = 0.012); the NO RX group had a physical functioning composite score that was at the mean for a normal healthy population of women, while those in the adjuvant treatment groups scored slightly lower. The mental health composite score was not significantly different among the four treatment groups and approximated scores from the normal population of healthy women. There were no differences in body image scores among the four treatment groups; however, sexual functioning scores did differ (p = 0.0078) with patients receiving chemotherapy (either alone or with tamoxifen) experiencing more problems. Hot flashes, night sweats, and vaginal discharge differed by treatment (p = 0.0001); all symptoms were reported more often in breast cancer survivors on tamoxifen. Vaginal dryness and pain with intercourse also differed significantly by adjuvant treatment, occurring more often in survivors treated with chemotherapy. Overall, breast cancer survivors function at a high level, similar to healthy women without cancer. However, compared to survivors with no adjuvant therapy, those who received chemotherapy have significantly more sexual problems, and those treated with tamoxifen experience more vasomotor symptoms.

Sexual functioning and intimacy in African American and white breast cancer survivors: a descriptive study.

This study examines ethnic differences in sexual socialization and attitudes, sexual history and current practices, and the effects of treatment in 147 African American and White breast cancer survivors. Sex-related research in younger healthy populations has shown that cultural values associated with ethnicity influence sexual functioning, but small numbers of African American participants in previous research in breast cancer survivors has limited what we know about that population. In this study, there were few differences between the 2 ethnic groups in a predominantly well-educated, high-income, highly functional sample. However, African American women were significantly less likely to be comfortable with and to practice oral sex, self-touching, and masturbatory behaviors. White women were more likely to report that breast cancer had a negative impact on their sex lives. These differences in sexual repertoire and functioning should be noted by health care practitioners treating the sexual sequelae of breast cancer treatment.

Changes over time in the use of do not resuscitate orders and the outcomes of patients receiving them.

OBJECTIVES: Do not resuscitate (DNR) orders are increasingly common, though there has been little evaluation of their changing use. The authors contrasted the use and outcomes of DNR orders for nationally representative samples of Medicare patients hospitalized with specific diagnoses in 1981 to 1982 and 1985 to 1986. METHODS: Using ordinary least squares regression to adjust for patient and hospital characteristics, the authors compared use, timing and predictors of DNR orders, and survival to hospital discharge of patients with DNR orders between the two time periods. RESULTS: After adjustment for sickness at admission and for patient and hospital factors, more patients received DNR orders in 1985 to 1986 than in 1981 to 1982 (13% versus 10%, P < 0.001), with most of the increase among patients with the greatest sickness at admission. Disparity in DNR order use by age, diagnosis, functional status, preadmission residence, and gender found in 1981 to 1982 was still present in 1985 to 1986. DNR orders were written earlier in hospitalization during the latter time period. Patients with DNR orders were more likely to survive to hospital discharge in 1985 to 1986 than in 1981 to 1982 (44% versus 36%, P = 0.001), but their 30-day survival did not differ. CONCLUSIONS: Although use increased, disparities in DNR order assignment persisted in these 1980s data. Examination is needed into whether these differences persist and whether they reflect patient preferences. Systems should be developed to preserve and review the preferences of the increasing number of patients discharged after in-hospital DNR orders.

Information content and clarity of radiologists' reports for chest radiography.

RATIONALE AND OBJECTIVES: We systematically characterized the information provided by chest radiography reports on a nationally representative sample of 822 elderly patients hospitalized in 297 acute-care hospitals in five states who had an admission diagnosis of congestive heart failure, acute myocardial infarction, or pneumonia. METHODS: We studied the content of radiography reports, including mention of the type or adequacy of radiography; the presence or absence of a prior radiograph; comments about bones, the aorta, the mediastinum, and pleura and notation of the laterality of findings; and the presence of diagnosis. Two physicians reviewed each patient's report, and a third assigned the final rating when they disagreed. RESULTS: Our analysis found wide variation in content of chest radiography reports, extensive variation in terms used to identify the presence or absence of abnormal findings, and a large degree of uncertainty in what was found. CONCLUSION: With most hospitals introducing new information systems in response to technological advances and the need to generate more formal hospitalwide reports, the time is right to improve the quality of chest radiography reporting.

Epidemiology of do-not-resuscitate orders. Disparity by age, diagnosis, gender, race, and functional impairment.

BACKGROUND: The relationship of do-not-resuscitate (DNR) orders to patient and hospital characteristics has not been well characterized. METHODS: This observational study of a nationally representative sample of 14,008 Medicare patients hospitalized with congestive heart failure, acute myocardial infarction, pneumonia, cerebrovascular accident, or hip fracture evaluated the relationship of DNR orders to patient sickness at admission, functional impairment, age, disease, race, gender, preadmission residence, insurance status, and hospital characteristics. RESULTS: Of the 14,008 patients, DNR orders were assigned to 11.6%. Patients with greater sickness at admission and functional impairment received more DNR orders (P < .001) but even among patients in the sickest quartile (with a 65% chance of death within 180 days), only 31% received DNR orders. The DNR orders were assigned more often to older patients after adjustment for sickness at admission and functional impairment (P < .001), and DNR order rates differed by diagnosis (P < .001). After adjustment for patient and hospital characteristics, DNR orders were assigned more often to women and patients with dementia or incontinence and were assigned less often to black patients, patients with Medicaid insurance, and patients in rural hospitals. CONCLUSIONS: Do-not-resuscitate orders are assigned more often to sicker patients but may be underused even among the most sick. Sickness at admission and functional impairment do not explain the increase in DNR orders with age or the disparity across diagnosis. Further evaluation is needed into whether variation in DNR order rates with age, diagnosis, race, gender, insurance status, and rural location represents differences in patient preferences or care compromising patient autonomy.

Outcomes of patients with do-not-resuscitate orders. Toward an understanding of what do-not-resuscitate orders mean and how they affect patients.

OBJECTIVES: To evaluate the outcomes of hospitalized patients with do-not-resuscitate (DNR) orders and to identify variables that may elucidate the high mortality of patients with DNR orders. METHODS: Among a nationally representative sample of Medicare patients hospitalized with congestive heart failure, acute myocardial infarction, pneumonia, cerebrovascular accident, or hip fracture, we retrospectively studied in-hospital and 180-day mortality and hospital lengths of stay for patients without DNR orders, with early (day 1 or 2) DNR orders, and with late (day 3 or later) DNR orders, before and after adjustment for sickness at hospital admission and patient and hospital characteristics. RESULTS: In-hospital mortality for patients with DNR orders exceeded that for patients without DNR orders before adjustment (59% vs 8%, P < .001), and after accounting for differences in sickness at admission and patient and hospital characteristics (40% vs 9%, P < .001). Sicker patients were assigned earlier DNR orders. Yet, patients with early DNR orders had a lower adjusted in-hospital mortality (31% vs 49%, P < .001) and shorter hospital stay (10 vs 18 days, P < .001) than did patients with late DNR orders. CONCLUSIONS: Hospitalized older patients with DNR orders have a much higher mortality than predicted by admission demographic and clinical characteristics. The differential association of early and late DNR orders with mortality indicates that DNR orders represent a heterogeneous group of interventions that may be a marker of unmeasured sickness and a determinant of quality of care. A better understanding of what the DNR order represents and its effect on patient care is needed to ensure optimal use.

Health care for black and poor hospitalized Medicare patients.

OBJECTIVE: To analyze whether elderly patients who are black or from poor neighborhoods receive worse hospital care than other patients, taking account of hospital effects and using validated measures of quality of care. DESIGN: We compare quality of care provided to insured, hospitalized Medicare patients who are black or live in poor neighborhoods as compared with others, using simple and multivariable comparisons of clinically detailed measures of sickness at admission, quality, and outcomes. SETTING: Two hundred ninety-seven acute care hospitals in 30 areas within five states. PATIENTS OR OTHER PARTICIPANTS: The sample includes a nationally representative sample of 9932 patients 65 years of age or older who lived at home prior to hospitalization for congestive heart failure, acute myocardial infarction, pneumonia, or stroke. INTERVENTIONS: This was an observational study. MAIN OUTCOME MEASURES: Processes of care, length of stay, instability at discharge, discharge destination, and mortality. RESULTS: Within rural, urban nonteaching, and urban teaching hospitals, patients who are black or from poor neighborhoods have worse processes of care and greater instability at discharge than other patients (P < .05). However, this worse quality is offset by patients who are black or from poor neighborhoods being 1.8 times more likely to receive care in urban teaching hospitals that have been shown to provide better quality of care (P < .001). Because these patients receive more of their care in better-quality hospitals, there are no overall differences in quality by race and poverty status. Death rates did not vary by race or poverty status. CONCLUSIONS: Quality of hospital care for insured Medicare patients in influenced both by the patient's race and financial characteristics and by the hospital type in which the patient receives care.