Long-term trajectories of self-reported cognitive function in a cohort of older survivors of breast cancer: CALGB 369901 (Alliance).

BACKGROUND: The number of survivors of breast cancer aged ≥65 years ("older") is growing, but to the authors' knowledge, little is known regarding the cognitive outcomes of these individuals. METHODS: A cohort of cognitively intact older survivors with nonmetastatic, invasive breast cancer was recruited from 78 sites from 2004 through 2011; approximately 83.7% of the survivors (1280 survivors) completed baseline assessments. Follow-up data were collected at 6 months and annually for up to 7 years (median, 4.1 years). Cognitive function was self-reported using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQ-C30); scores ranged from 0 to 100, with a higher score indicating better function. Group-based trajectory modeling determined trajectories; women were assigned to a trajectory group based on the highest predicted probability of membership. Multinomial logistic regression evaluated the association between receipt of chemotherapy (with or without hormonal treatment) and trajectory group. RESULTS: Survivors were aged 65 to 91 years; approximately 41% received chemotherapy. There were 3 cognitive trajectories: "maintained high" (42.3% of survivors); "phase shift" (50.1% of survivors), with scores slightly below but parallel to maintained high; and "accelerated decline" (7.6% of survivors), with the lowest baseline scores and greatest decline (from 71.7 [standard deviation, 19.8] to 58.3 [standard deviation, 21.9]). The adjusted odds of being in the accelerated decline group (vs the maintained high group) were 2.1 times higher (95% confidence interval, 1.3-3.5) for survivors who received chemotherapy (with or without hormonal therapy) versus those treated with hormonal therapy alone. Greater comorbidity and frailty also were found to be associated with accelerated decline. CONCLUSIONS: Trajectory group analysis demonstrated that the majority of older survivors maintained good long-term self-reported cognitive function, and that only a small subset who were exposed to chemotherapy manifested accelerated cognitive decline. Future research is needed to determine factors that place some older survivors at risk of experiencing cognitive decline. Cancer 2016;122:3555-3563. © 2016 American Cancer Society.

Associations among survivorship care plans, experiences of survivorship care, and functioning in older breast cancer survivors: CALGB/Alliance 369901.

PURPOSE: Survivorship care plans (SCP) are recommended for all cancer patients and could be especially useful to survivors 65 years and over ("older"). This study examined receipt of SCPs among older breast cancer survivors and whether SCPs were associated with improved patient-reported outcomes. METHODS: Three hundred and twenty-eight older women diagnosed with invasive, nonmetastatic breast cancer between 2007-2011 were recruited from 78 cooperative-group sites. Participants completed telephone interviews at baseline and 1-year posttreatment. Regression analyses examined SCP receipt (yes/no) and functioning (EORTC-QLQ-C30), cancer worry, and experiences of survivorship care (care coordination, knowledge). RESULTS: Only 35% of women received SCPs. For each 1-year increase in age, there was a 5% lower odds of receiving an SCP (odds ratio (OR) = 0.94, 95% confidence interval (CI) 0.91-0.98, p = 0.007). Besides age, no other factor predicted SCPs. SCP receipt was associated with greater knowledge and understanding of requisite follow-up care (p < 0.05); however, functioning was not significantly different among those with vs. without SCPs. CONCLUSIONS: Receipt of care plans was limited. SCPs improved understanding of breast cancer follow-up care among older survivors, but did not impact functioning one year post-treatment. IMPLICATIONS FOR CANCER SURVIVORS: To impact functioning and salient needs of the growing cohort of older survivors, survivorship care plans likely should be tailored to geriatric-specific issues. To improve functioning, SCP content should expand to include exercise, nutrition, polypharmacy, social support and management of symptom burden from cancer, and other comorbid conditions. To improve follow-up care for cancer survivors, SCPs should delineate shared care roles between oncology and primary care in managing recurrence surveillance, screening, and cancer sequelae.

Frailty and adherence to adjuvant hormonal therapy in older women with breast cancer: CALGB protocol 369901.

PURPOSE: Most patients with breast cancer age ≥ 65 years (ie, older patients) are eligible for adjuvant hormonal therapy, but use is not universal. We examined the influence of frailty on hormonal therapy noninitiation and discontinuation. PATIENTS AND METHODS: A prospective cohort of 1,288 older women diagnosed with invasive, nonmetastatic breast cancer recruited from 78 sites from 2004 to 2011 were included (1,062 had estrogen receptor-positive tumors). Interviews were conducted at baseline, 6 months, and annually for up to 7 years to collect sociodemographic, health care, and psychosocial data. Hormonal initiation was defined from records and discontinuation from self-report. Baseline frailty was measured using a previously validated 35-item scale and grouped as prefrail or frail versus robust. Logistic regression and proportional hazards models were used to assess factors associated with noninitiation and discontinuation, respectively. RESULTS: Most women (76.4%) were robust. Noninitiation of hormonal therapy was low (14%), but in prefrail or frail (v robust) women the odds of noninitiation were 1.63 times as high (95% CI, 1.11 to 2.40; P = .013) after covariate adjustment. Nonwhites (v whites) had higher odds of noninitiation (odds ratio, 1.71; 95% CI, 1.04 to 2.80; P = .033) after covariate adjustment. Among initiators, the 5-year continuation probability was 48.5%. After adjustment, the risk of discontinuation was higher with increasing age (P = .005) and lower for stage ≥ IIB (v stage I) disease (P = .003). CONCLUSION: Frailty is associated with noninitiation of hormonal therapy, but it does not seem to be a major predictor of early discontinuation in older patients.

Cognitive impairment in older patients with breast cancer before systemic therapy: is there an interaction between cancer and comorbidity?

PURPOSE: To determine if older patients with breast cancer have cognitive impairment before systemic therapy. PATIENTS AND METHODS: Participants were patients with newly diagnosed nonmetastatic breast cancer and matched friend or community controls age > 60 years without prior systemic treatment, dementia, or neurologic disease. Participants completed surveys and a 55-minute battery of 17 neuropsychological tests. Biospecimens were obtained for APOE genotyping, and clinical data were abstracted. Neuropsychological test scores were standardized using control means and standard deviations (SDs) and grouped into five domain z scores. Cognitive impairment was defined as any domain z score two SDs below or ≥ two z scores 1.5 SDs below the control mean. Multivariable analyses evaluated pretreatment differences considering age, race, education, and site; comparisons between patient cases also controlled for surgery. RESULTS: The 164 patient cases and 182 controls had similar neuropsychological domain scores. However, among patient cases, those with stage II to III cancers had lower executive function compared with those with stage 0 to I disease, after adjustment (P = .05). The odds of impairment were significantly higher among older, nonwhite, less educated women and those with greater comorbidity, after adjustment. Patient case or control status, anxiety, depression, fatigue, and surgery were not associated with impairment. However, there was an interaction between comorbidity and patient case or control status; comorbidity was strongly associated with impairment among patient cases (adjusted odds ratio, 8.77; 95% CI, 2.06 to 37.4; P = .003) but not among controls (P = .97). Only diabetes and cardiovascular disease were associated with impairment among patient cases. CONCLUSION: There were no overall differences between patients with breast cancer and controls before systemic treatment, but there may be pretreatment cognitive impairment within subgroups of patient cases with greater tumor or comorbidity burden.

Effects of self-directed stress management training and home-based exercise on quality of life in cancer patients receiving chemotherapy: a randomized controlled trial.

BACKGROUND: Research has shown that self-directed stress management training improves mental well-being in patients undergoing chemotherapy. The present study extends this work by evaluating separate and combined effects of stress management training and home-based exercise. METHOD: Following assessment of mental and physical well-being, depression, anxiety, exercise, and stress reduction activity before chemotherapy started, patients were randomized to stress management training (SM), exercise (EX), combined stress management and exercise (SMEX), or usual care only (UCO). Outcomes were reassessed 6 and 12 weeks after chemotherapy started. Significance testing of group-by-time interactions in 286 patients who completed all assessments was used to evaluate intervention efficacy. RESULTS: Interaction effects for mental and physical well-being scores were not significant. Depression scores yielded a linear interaction comparing UCO and SMEX (p = 0.019), with decreases in SMEX but not UCO. Anxiety scores yielded a quadratic interaction comparing UCO and SMEX (p = 0.049), with trends for changes in SMEX but not UCO. Additional analyses yielded quadratic interactions for exercise activity comparing UCO and SMEX (p = 0.022), with positive changes in SMEX but not UCO, and for stress management activity comparing UCO and SM (p < 0.001) and UCO and SMEX (p = 0.013), with positive changes in SM and SMEX but not UCO. CONCLUSION: Only the combined intervention yielded effects on quality of life outcomes, and these were limited to anxiety and depression. These findings are consistent with evidence that only the combined intervention yielded increases in both exercise and stress management activity. Future research should investigate ways to augment this intervention to enhance its benefits.

Comparing the retrospective reports of fatigue using the Fatigue Symptom Index with daily diary ratings in women receiving chemotherapy for gynecologic cancer.

CONTEXT: Fatigue, one of the most common side effects of chemotherapy, is typically assessed via retrospective recall (e.g., over the past week). It is unknown how such retrospective recall of fatigue correlates with daily ratings among people receiving chemotherapy. OBJECTIVES: The current study compared fatigue recorded in daily diaries with retrospective ratings using the Fatigue Symptom Inventory (FSI) in patients receiving chemotherapy for gynecologic cancer. METHODS: During the week before and the week after their first infusion of chemotherapy, patients completed daily diaries at 10 AM, 2, and 6 PM and the FSI at the end of each week. RESULTS: FSI and diary ratings of peak, lowest, and average fatigue were significantly correlated (P < 0.001). When peak, end, average, and variance diary ratings were regressed separately on the average FSI item, each was significant pre-chemotherapy (P < 0.01) and post-chemotherapy (P < 0.05). However, when entered into a stepwise regression model, only the average fatigue diary rating was retained, explaining 52% of the variance pre-chemotherapy and 54% of the variance post-chemotherapy average FSI item (P < 0.001). CONCLUSION: The FSI keyed to the past week accurately reflects daily ratings of fatigue among patients receiving chemotherapy. This study has important implications, as completing retrospective ratings of fatigue may be less burdensome for cancer patients than daily assessments.

Meta-analysis of cognitive functioning in breast cancer survivors previously treated with standard-dose chemotherapy.

PURPOSE: Evidence is mixed regarding long-term cognitive deficits in patients treated with chemotherapy. Previous meta-analyses have not focused specifically on the postchemotherapy period and have not incorporated several recent studies. The goal of the current study was to conduct a meta-analysis of cognitive functioning in breast cancer survivors who were treated with chemotherapy ≥ 6 months previously. METHODS: A search of PubMed, PsycInfo, Cumulative Index to Nursing and Allied Health Literature, and Cochrane Library yielded 2,751 abstracts, which were independently evaluated by pairs of raters. Meta-analysis was conducted on 17 studies of 807 patients previously treated with standard-dose chemotherapy for breast cancer. Neuropsychological tests were categorized according to eight cognitive domains: attention, executive functioning, information processing, motor speed, verbal ability, verbal memory, visual memory, and visuospatial ability. RESULTS: Deficits in cognitive functioning were observed in patients treated with chemotherapy relative to controls or prechemotherapy baseline in the domains of verbal ability (g = -0.19; P < .01) and visuospatial ability (g = -0.27; P < .01). Patients treated with chemotherapy performed worse than noncancer controls in verbal ability and worse than patients treated without chemotherapy in visuospatial ability (both P < .01). Age, education, time since treatment, and endocrine therapy did not moderate observed cognitive deficits in verbal ability or visuospatial ability (all P ≥ .51). CONCLUSION: Results indicate that, on average, observed cognitive deficits in patients with breast cancer previously treated with chemotherapy are small in magnitude and limited to the domains of verbal ability and visuospatial ability. This information can be used to inform interventions to educate patients with breast cancer regarding the long-term impact of chemotherapy on cognitive functioning.

Patient and physician decision styles and breast cancer chemotherapy use in older women: Cancer and Leukemia Group B protocol 369901.

PURPOSE Physician and patient decision styles may influence breast cancer care for patients ≥ 65 years ("older") because there is uncertainty about chemotherapy benefits in this group. We evaluate associations between decision-making styles and actual treatment. METHODS Data were collected from women treated outside of clinical trials for newly diagnosed stage I to III breast cancer (83% response) from January 2004 through April 2011 in 75 cooperative group sites. Physicians completed a one-time mailed survey (91% response), and clinical data were abstracted from charts. Patient decision style was measured on a five-point scale. Oncologists' preference for prescribing chemotherapy was based on standardized vignettes. Regression and multiple imputation were used to assess associations between chemotherapy and other variables. Results There were 1,174 women seen by 212 oncologists; 43% of women received chemotherapy. One-third of women preferred to make their own treatment decision. Patient and physician decision styles were independently associated with chemotherapy. Women who preferred less physician input had lower odds of chemotherapy than women who preferred more input (odds ratio [OR] = 0.79 per 1-point change; 95% CI, 0.65 to 0.97; P = .02) after considering covariates. Patients whose oncologists had a high chemotherapy preference had higher odds of receiving chemotherapy (OR = 2.65; 95% CI, 1.80 to 3.89; P < .001) than those who saw oncologists with a low preference. CONCLUSION Physicians' and older patients' decision styles are each associated with breast cancer chemotherapy use. It will be important to re-evaluate the impact of decision styles when there is greater empirical evidence about the benefits and risks of chemotherapy in older patients.

Survivorship care planning in colorectal cancer: feedback from survivors & providers.

The Institute of Medicine recommended that all patients receive survivorship care plans (SCPs) post-treatment to improve quality of follow-up care. However, little is known regarding how survivors utilize SCPs and the congruency between providers' and survivors' perspectives. Feedback from colorectal cancer survivors (in receipt of a personalized/individualized SCP) and oncology providers was obtained via interviews. Survivors noted SCPs benefits of reduced duplicative procedures and cancer worry with the synthesized treatment information. Providers noted billing/reimbursement and time investiture (for form completion) as potential barriers. Further investigation of SCPs is warranted regarding utility prior to widespread adoption in follow-up care.

Fatigue, depression, sleep, and activity during chemotherapy: daily and intraday variation and relationships among symptom changes.

BACKGROUND: Previous research suggests that cancer patients frequently experience multiple symptoms during chemotherapy; however, relationships among symptom changes are largely unknown. PURPOSE: The aim of the current study was to examine daily and intraday changes and interrelationships among fatigue, depression, and objectively measured disruptions in sleep and activity during chemotherapy. METHODS: Participants were 78 women with gynecologic cancer. Fatigue, depression, sleep, and activity were assessed the week before and the week after the participants' first three infusions. RESULTS: Significant changes in fatigue, depression, sleep, and activity were observed over time. Before infusions, increases in fatigue were associated with increases in depression. After infusions, increases in fatigue were associated with increases in depression and minutes awake at night, as well as decreases in daytime activity and regularity of sleep/activity patterns (ps < .05). CONCLUSIONS: This study is among the first to track daily and intraday changes in symptoms and interrelationships during chemotherapy. Results indicate that symptoms are interrelated and return to baseline levels after infusions.

Relationship of exercise to quality of life in cancer patients beginning chemotherapy.

CONTEXT: Cancer diagnosis and treatment, particularly chemotherapy, has well-established adverse effects on individuals. Exercise has been found to confer benefits to patients, although the current evidence base is limited primarily to patients assessed during or after treatment. Although exercise has been a target of intervention efforts, its relationship to quality of life in patients about to begin chemotherapy has not fully been examined. OBJECTIVES: To examine the relationship of pre-treatment exercise rates to patient's quality of life. METHODS: One hundred ninety-two adults diagnosed with Stages I-IV cancer and Eastern Cooperative Oncology Group performance status ≤ 2, provided data on exercise, distress (anxiety and depression), and health-related quality of life prior to their initial chemotherapy infusion. RESULTS: As predicted, higher rates of exercise activity were associated with lower levels of anxiety and depression, and better overall mental and physical quality of life. These relationships were independent of demographic variables (i.e., body mass index and age) also associated with quality of life in the present analyses. CONCLUSION: These findings further highlight the importance of assessing exercise before the start of chemotherapy as part of broader efforts to link patients to appropriate interventions aimed at enhancing quality of life. Findings also raise the possibility that assessing exercise rates could be useful in matching patients to the type of intervention most likely to benefit them. Future research should use prospective longitudinal designs to further explore this association.

Associations between pain and current smoking status among cancer patients.

There is growing empirical and clinical interest in purported associations between smoking and the aggravation of cancer symptoms and treatment side effects, such as pain. Both pain and smoking are highly prevalent among persons with cancer, and there is recent evidence to suggest that cancer patients who continue to smoke despite their diagnosis experience greater pain than nonsmokers. Accordingly, the main goal of this cross-sectional study was to examine associations between multiple levels of smoking status and several pain-related outcomes among a sample of 224 cancer patients about to begin chemotherapy. Patients completed self-report measures of pain severity, pain-related distress, and pain-related interference, as well as a demographics questionnaire. Results indicated that persons who continued to smoke despite being diagnosed with cancer reported more severe pain than never smokers, F (2, 215)=3.47, p<.05. Current smokers also reported greater interference from pain than either former or never smokers, F (2, 215)=5.61, p<.01. Among former smokers, an inverse relation between pain severity and the number of years since quitting smoking was observed, r (104)=-.26, p<.01. These data suggest that continued smoking despite a cancer diagnosis is associated with greater pain severity and interference from pain; however, future research is warranted to determine the directionality of this relationship.

Improving survivorship care for patients with colorectal cancer.

BACKGROUND: The consequences of cancer and its treatment are substantial. The aging population and recent advances in detection and treatment of cancer are expected to augment the burgeoning cohort of cancer survivors. During the transition to off-treatment status, patients may experience heightened needs coupled with significant decrements, if not dissolution, in quality of care during this critical period of re-entry. A basic source of this problem is the lack of communication and coordination of care during this transition. Treatment summaries and survivorship care plans have been proposed as potential solutions to improve quality of care for cancer survivors. Patients with colorectal cancer provide an ideal population within which to begin to empirically examine their clinical utility. METHODS: Potential benefits and promising research methodology are proposed, including adoption of a treatment summary (brief synopsis of cancer care received) and a survivorship care plan (recommendations for follow-up care). The status of the evidence base is reviewed. RESULTS: To date, treatment summaries and survivorship care plans remain largely untried and untested in adult oncology despite their promise to improve patient outcomes and quality of life. CONCLUSIONS: The implementation of treatment summaries and survivorship care plans rests on the provision of strong evidence of efficacy and feasibility in the context of follow-up care for cancer survivors. Qualitative, observational, and interventional research should be initiated in order to identify benefits to patients and survivors by the enhancement of survivorship care planning.

Relationship of stress management skill to psychological distress and quality of life in adults with cancer.

BACKGROUND: Distress is common among cancer patients, especially those undergoing chemotherapy. Although skill in stress management is often the target of intervention efforts, its relationship to distress and quality of life in patients about to begin cancer treatment has not been examined. OBJECTIVE: To examine the relationship of pre-treatment skill in stress management to patient distress and quality of life. METHODS: One hundred and ten adults diagnosed with stage I-IV cancer and ECOG