No effect of scalp cooling on survival among women with breast cancer.

Scalp cooling can prevent chemotherapy-induced alopecia in some cancer patients. It is not used in all countries. No data are available regarding its impact, if any, on survival. The aim of this study was to compare overall survival according to whether or not scalp cooling was used during neoadjuvant or adjuvant chemotherapy for non-metastatic breast cancer. We conducted a retrospective cohort study of 1,370 women with non-metastatic invasive breast carcinoma who received chemotherapy in the neoadjuvant or adjuvant setting. A total of 553 women who used scalp cooling came from a tertiary breast cancer clinic in Quebec City (diagnosed between 1998 and 2002) and 817 were treated in other hospitals in the province of Quebec (between 1998 and 2003) where scalp cooling was not routinely available. Overall survival of women who used scalp cooling and those who did not was compared using Cox proportional hazards models. Median follow-up for the scalp-cooled and the non-scalp-cooled groups was 6.3 years and 8.0 years, respectively. Overall mortality was no different (adjusted hazard ratio 0.89, 95 % confidence interval: 0.68-1.17, p = 0.40) among scalp-cooled women, compared to those not getting scalp cooling. Among women getting neoadjuvant or adjuvant chemotherapy for non-metastatic breast cancer, scalp cooling used to prevent chemotherapy-induced alopecia had no negative effect on survival. To our knowledge, this is the first study to compare survival of women who used scalp cooling to that of women who did not.

Educational interventions to improve cancer pain control: a systematic review.

CONTEXT: Inadequate pain control is a dismaying reality in cancer patients. OBJECTIVES: To review studies on cancer pain control interventions, and describe their findings with respect to participants' attitudes and knowledge, pain management, and pain levels. DATA SOURCES: Computer searches were made in MEDLINE from January 1962, in PsychLIT from January 1974, and in CINAHL from January 1982 to August 1999, using a search strategy based on a combination of key words. STUDY SELECTION: Computerized listings from these sources contained 383, 26, and 85 articles, respectively. After exclusion of duplicates, abstracts, editorials, letters, and irrelevant articles, we retained for review 33 articles, of which 25 (76%) were interventions targeting health professionals, and 8 (24%) interventions targeting patients and family caregivers. DATA EXTRACTION: Study reports were reviewed using the following structured framework: Intervention Setting, Study Methods, Process Assessment, and Pain Outcome Assessment (Attitudes and Knowledge, Pain Management, and Pain Relief/Quality of Life). DATA SYNTHESIS AND CONCLUSION: Educational interventions can successfully improve cancer pain knowledge and attitudes of health care professionals, but without having much impact on patients' pain levels. The most promising avenue for improving cancer pain control in ambulatory settings may be brief, nursing interventions targeting patients in combination with a daily pain diary. This review suggests that further progress may occur through incorporating a systematic and valid method of documenting daily fluctuation in pain levels, and ensuring that documented uncontrolled pain is followed rapidly by clinical reassessment and dose adjustment.

Stressful life events and survival after breast cancer.

OBJECTIVE: This study assessed the relation of stressful life events with survival after breast cancer. METHODS: This study was based on women with histologically confirmed, newly diagnosed, localized or regional stage breast cancer first treated in 1 of 11 Quebec City (Canada) hospitals from 1982 through 1984. Among 765 eligible patients, 673 (88%) were interviewed 3 to 6 months after diagnosis about the number and perceived impact of stressful events in the 5 years before diagnosis. Three scores were calculated: number of events; number weighted by reported impact; and for almost 80% of events, number weighted by community-derived values reflecting adjustment required by the event. Scores were divided into quartiles to assess possible dose-response relationships. Survival was assessed in 1993. Hazard ratios and 95% confidence intervals (CIs) comparing all-cause and breast cancer-specific mortality were calculated with adjustment for age, presence of invaded axillary nodes, adjuvant radiotherapy, and systemic therapy (ie, chemotherapy and hormone therapy). RESULTS: When quartiles 2, 3, and 4 were compared with the appropriate lowest quartile, adjusted hazard ratios for all-cause mortality were 0.99 (CI = 0.70-1.38), 0.97 (CI = 0.73-1.31), and 1.04 (CI = 0.78-1.40) for number, number weighted by impact, and number weighted by community-derived values, respectively. Results were essentially similar for the relation between stressful life events limited to those occurring within the 12 months before diagnosis and overall mortality and between stressful life events in the 5 years before diagnosis and breast cancer-specific mortality. CONCLUSIONS: Stress was conceptualized as life events presumed to be negative, undesirable, or to require adjustment by the person confronting them. We found no evidence indicating that this kind of stress during the 5 years before diagnosis negatively affected survival among women with nonmetastatic breast cancer. Evidence from this study and others on the lack of effect of this type of stress on survival may be reassuring for women living with breast cancer.

Tamoxifen and mammographic breast densities.

The extent of breast tissue density on mammograms is one of the strongest risk factors for breast cancer. The aim of this analysis was to evaluate whether tamoxifen can affect mammographic breast density. Subjects were participants in the National Surgical Adjuvant Breast Project Breast Cancer Prevention Trial (BCPT), recruited and followed at the Breast Center of Saint-Sacrement Hospital in Quebec City, Canada. The Breast Cancer Prevention Trial is a double-blind trial in which women at high risk of breast cancer were randomized to receive either 20 mg tamoxifen per day or placebo. Mammograms were taken before treatment began and yearly thereafter. For the purpose of this analysis, Wolfe's parenchymal pattern and the percentage of the breast showing tissue densities were assessed by review of pre- and posttreatment mammograms without knowledge of treatment assignment. Among the 69 women included in this analysis, 36 received tamoxifen and 33 received placebo for an average of 3.3 and 3.5 years, respectively. Among women receiving tamoxifen, 16 of 36 (44.4%) changed to a parenchymal pattern of lower density compared with 5 of 33 (15.2%) women receiving placebo (P = 0.010). Moreover, in the tamoxifen-treated group, the difference in the percentage of the breast showing tissue densities between the pre- and posttreatment mammograms reached -9.4% on average compared with a reduction of -3.6% in the placebo group (P = 0.010). Our data show that tamoxifen can reduce high-risk mammographic features. Breast densities should be evaluated as possible early markers of the preventive effect of selective estrogen receptor modulators.

A brief pain diary for ambulatory patients with advanced cancer: acceptability and validity.

BACKGROUND: Undertreatment of pain is common among ambulatory patients with advanced cancer. Available pain assessment tools are complex and not easy to use in ambulatory care settings. METHODS: The authors developed and assessed the acceptability and psychometric properties of a simple, brief 4-week pain diary for ambulatory care assessing 3 indicators: current pain intensity on rising and retiring, number of daily rescue doses, and weekly impact of pain on quality of life. Selected European Organization for Research and Treatment (EORTC) Quality of Life Questionnaire subscales were administered once concurrently for validation purposes. Subjects were 98 adult French-speaking ambulatory patients with advanced cancers who were on opioids, free of apparent cognitive impairment, and recruited through 2 oncology clinics in Quebec City, Quebec, Canada. RESULTS: In the first 3 weeks, > or =80% of patients completed all requested diary data. Internal consistencies of the 5-item scale assessing pain impact on quality of life were 0.87-0.92 over the study period. Pain intensity predicted both increased use of rescue doses and negative pain impact on quality of life. This latter scale was also responsive to decreases in pain intensity over 1-week intervals. As hypothesized, pain intensity, rescue doses, and pain impact on quality of life correlated with EORTC scale scores. Pain intensity correlated most strongly with the EORTC pain and global quality of life scales (r = 0.65 and -0.55, respectively). CONCLUSIONS: This diary is simple, very brief, acceptable to patients, and appears to be valid. It can thus likely be used to monitor pain management for advanced cancer patients.

Partner abandonment of women with breast cancer. Myth or reality?

PURPOSE: The purpose of this article is to determine the existing evidence related to marital breakdown after a breast cancer diagnosis by reviewing studies that highlight two current belief models: the lay belief model and the clinical belief model. OVERVIEW: The small number of studies conducted on this topic since 1988 revealed no data to confirm the lay belief model, which proposes that women with breast cancer are abandoned by their partners. The evidence appears to support the clinical belief model that the majority of marital relationships remain stable after breast cancer and that breakdown is most likely in those relationships with pre-existing difficulties. CLINICAL IMPLICATIONS: This review indicates that it may be important for clinicians to routinely ask about the quality of the marital relationship as part of the initial assessment, because it appears that this may be a main predictor of post-diagnosis marital adjustment. In addition, greater dissemination of the findings of this review through the media and through cancer organizations is needed to more accurately reflect the experience of couples facing breast cancer and, thus, to begin to change the public perception of partner desertion after breast cancer. This could help both women with breast cancer and women from the general population who may one day confront a breast cancer diagnosis.

Work problems after breast cancer: an exploratory qualitative study.

People treated for cancer have reported a variety of problems at work. However, there is little data on work experience after breast cancer, particularly for women treated in recent years. This exploratory qualitative study was conducted among 13 breast cancer survivors who had paid employment at diagnosis, returned to work afterwards, and mentioned work-related problems to a clinic nurse or physician. Unstructured, thematic interviews were undertaken. Qualitative thematic content analysis was conducted to identify and group themes which emerged from participants' discourse. Women in various types of jobs reported experiencing job loss, demotion, unwanted changes in tasks, problems with the employer and co-workers, personal changes in attitudes to work and diminished physical capacity. These work problems also preoccupied people treated for cancer more than two decades ago. New areas of concern also emerged: possible positive and negative effects of learning (implicitly or explicitly) about the diagnosis while at work and lack of discussion with health professionals about work and return-to-work issues, suggesting that health professionals' behaviour may influence women's work experience right from diagnosis. The identification of these new problems and confirmation of previously reported ones underlines the pertinence of determining how important and widespread these problems are in women now being treated for breast cancer.

Marital stability after breast cancer.

BACKGROUND: The belief that husbands desert wives who have breast cancer is not uncommon and may be a source of stress for women confronting this disease. To assess the validity of this belief, we examined the role of breast cancer as a determinant of marital breakdown by comparing the frequencies of marital breakdown among women with breast cancer and among control women from Quebec City and surrounding regions. METHODS: Secondary analyses were performed on data collected from women who were newly diagnosed with nonmetastatic breast cancer in 1984 or during the period from 1990 through 1992 and then interviewed 3 months, 18 months, and 8 years after diagnosis (1984 cohort) or interviewed 2 weeks, 3 months, and 12 months after diagnosis (1990-1992 cohort). Population-based control subjects (four groups) were recruited through random-digit dialing and from participants in the Quebec Health Surveys for 1987 and 1992. Eligible subjects were those who were living with a spouse at the time of interview and those who reported divorce or separation in the time periods examined. Marital breakdown in the past 12 months and 5 years and current marital satisfaction and adjustment were assessed. All P values are two-sided. RESULTS: Marital breakdown was never higher in women with breast cancer than in control women. Among women with breast cancer, low marital satisfaction within 3 months of diagnosis predicted further marital difficulties (a breakdown-P = .02 at 12-month interview and P = .01 at 18-month interview; low marital satisfaction- P<.0001 at 12-month interview and P = .005 at 18-month interview). CONCLUSIONS: For the times studied, breast cancer does not appear to be associated with marital breakdown among Quebec women. Marital difficulties occurred mainly among the small proportion of women who probably already had marital difficulties when diagnosed.

Mutual concurrent validity of the child health questionnaire and the health utilities index: an exploratory analysis using survivors of childhood cancer.

Mutual concurrent validity of 2 generic measures of health-related quality of life (HRQL), the Child Health Questionnaire (CHQ) and the Health Utilities Index Mark 2 (HUI2) and HUI3, was assessed. Data were from 3 centers participating in a Canadian multi-center retrospective cohort study currently in progress to assess psycho-social and physical late effects in children surviving >/=5 years after cancer diagnosis between 1981 and 1990. Exploratory results are from 244 parent reports on HRQL in children <16 years old when studied. Spearman rank-order correlations between sub-scale scores for the CHQ and single-attribute utility scores for the corresponding attribute from the HUI2 and HUI3 were used. As predicted, the correlation between CHQ bodily pain and HUI2 and HUI3 pain was strong, 0.58 and 0.60, respectively, while correlations between CHQ physical functioning and HUI2 mobility and HUI3 ambulation were moderate, both 0.45. Correlations between CHQ mental health and HUI2 and HUI3 emotion were strong, 0.64 and 0.54, respectively, rather than moderate, as predicted. Both the CHQ general health scale and the general health single item were moderately correlated with the HUI2 and HUI3 global utility scores rather than weakly, as predicted (CHQ general health scale and HUI2 and HUI3 global utility were 0.43 and 0.44, respectively; CHQ general health single item and HUI2 and HUI3 global utility were 0. 38 and 0.42, respectively). The CHQ and HUI, which are based on different methodologies (summative Likert scaling and utility analysis, respectively), appear to capture similar constructs in childhood cancer survivors.

Type of mastectomy and quality of life for long term breast carcinoma survivors.

BACKGROUND: Despite numerous studies of partial mastectomy and psychologic morbidity in the first 24 months following surgery, little is known about the long term psychosocial repercussions of partial and total mastectomy. METHODS: The effect of the type of mastectomy on psychologic adjustment was assessed among 124 breast carcinoma survivors, 47 of whom underwent partial mastectomy and 77 of whom underwent total mastectomy, 8 years after initial treatment. Interviews were also conducted 3 and 18 months after surgery. Psychologic distress was assessed using the Psychiatric Symptom Index. Other outcomes included physical symptoms, patients' perceptions of their own health, satisfaction with the type of surgery performed and with the appearance of the scar, and marital and sexual adjustments. RESULTS: No statistically significant differences between partial and total mastectomy were observed with respect to long term quality of life. Age at diagnosis modified the relation between the type of mastectomy and psychologic distress in both the short term and the long term (P = 0.04). Among women younger than 50 years, partial mastectomy appeared to be protective against distress when compared with total mastectomy. In contrast, among women age 50 years or older, partial mastectomy was associated with higher psychologic distress levels at all interviews. CONCLUSIONS: Assessed globally, partial and total mastectomy appear to be equivalent treatments in terms of patients' long term quality of life. However, both short term and long term distress levels after partial and total mastectomy may depend on patients' age at diagnosis. The findings of this study suggest that the increased use of partial mastectomy may lessen the negative effects of breast carcinoma on younger survivors' quality of life. Nevertheless, total mastectomy may be an appropriate initial treatment for some women who truly choose it.

Canadian-French, German and UK versions of the Child Health Questionnaire: methodology and preliminary item scaling results.

Using emerging international guidelines, stringent procedures were used to develop and evaluate Canadian-French, German and UK translations/adaptions of the 50 item, parent-completed Child Health Questionnaire (CHQ-PF50). Multitrait analysis was used to evaluate the convergent and discriminant validity of the hypothesized item sets across countries relative to the results obtained for a representative sample of children in the US. Cronbach's alpha coefficient was used to estimate the internal consistency reliability for each of the health scales. Floor and ceiling effects were also examined. Seventy-nine percent of all the item-scale correlations achieved acceptable internal consistency (0.40 or higher). The tests of the item convergent and discriminant validity were successful at least 87% of the time across all scales and countries. Equal item variance was observed 90% of the time across all countries. The reliability coefficients ranged from a low of 0.43 (parental time impact, Canadian English) to a high of 0.97 (physical functioning index, Canadian French) across all scales (median 0.80). Negligible floor effects were observed across countries. Noteworthy ceiling effects were observed, as expected, for the hypothesized physical scales (mean effect 73%). Conversely, fewer ceiling effects were observed for the psychosocial scales (range 3-17% behaviour-parental emotional impact). The item-scaling results obtained in these pilot studies support the psychometric properties of the American-English CHQ-PF50 and its respective translations.

Long-term quality of life after breast cancer: comparison of 8-year survivors with population controls.

PURPOSE: Quality of life of breast cancer survivors 8 years after diagnosis was compared with that among similarly aged women who had never confronted cancer (controls). METHODS: Survivors of a consecutive series of 227 breast cancer patients first treated in 1984 were approached for this study. Random-digit dialing was used to identify controls with the same age and residential distribution as the survivors. Quality of life was assessed in terms of physical health, functional status, psychologic distress, and social functioning. RESULTS: Participation was obtained from 96% (n = 124) of 129 eligible survivors and 61% (n = 262) of 427 potentially eligible controls. Consistently smaller proportions of survivors reported positive quality-of-life outcomes compared with controls, but these differences were generally small and nonsignificant statistically. When limited to women who remained free of disease over the entire follow-up period (n = 98), survivors' quality of life was similar to that among controls, with the exception of arm problems and sexual satisfaction for those women who lived with a partner. In contrast, survivors who developed recurrence or new primary breast cancer (n = 26) experienced a worse quality of life in all domains except social functioning. CONCLUSION: In most domains and for women without further disease events after diagnosis, quality of life does not seem to be permanently and globally impaired by breast cancer. Consequently, breast cancer survivors who remain free of disease probably do not need organized late psychosocial follow-up to improve quality of life. However, arm problems and sexuality are two areas in which additional effort may be still needed to improve quality of life of long-term survivors.

Randomized controlled trial of a prenatal vaginal birth after cesarean section education and support program. Childbirth Alternatives Post-Cesarean Study Group.

OBJECTIVE: Our objective was to assess whether, for women with previous cesarean section, a prenatal education and support program promoting vaginal birth after cesarean delivery increases the probability of vaginal delivery. STUDY DESIGN: Women with a single previous cesarean were recruited before 28 weeks' gestation. Women's self-assessed motivation to attempt vaginal birth after a previous cesarean delivery was measured on a 10 cm visual analog scale: stratum I, low motivation; stratum II, high motivation. Women were randomized by stratum to one of two groups. Those in the "Verbal" group participated in an individualized education program. Those in the "Document" group were provided with a pamphlet detailing the benefits of planned vaginal birth after cesarean delivery. RESULTS: Rates of vaginal birth after cesarean section were similar in the verbal and document groups: verbal, 339 of 641 (53%); document, 310 of 634 (49%); relative risk 1.1, 95% confidence interval 1.0 to 1.2. There was no evidence of heterogeneity across motivational strata. Regardless of treatment group, women with low motivation for vaginal birth after cesarean section were more than three times as likely to undergo elective repeat cesarean than were women with high motivation (47% vs 13%). CONCLUSIONS: There was no evidence that an individualized prenatal education and support program, when offered to all women with previous cesarean delivery, results in a clinically significant increase in the rate of vaginal birth after cesarean section.

Randomized trial of a psychologic distress screening program after breast cancer: effects on quality of life.

PURPOSE: Although psychosocial intervention can reduce psychosocial distress following breast cancer, many women who are experiencing problems are not identified and offered additional help. This trial assessed effects on quality of life of psychologic distress screening among newly diagnosed, nonmetastatic breast cancer patients. PATIENTS AND METHODS: From 1990 to 1992, all eligible patients in one regional breast cancer center were identified and offered study participation. Women in both control and experimental groups received brief psychosocial intervention from a social worker at initial treatment. The experimental group also had monthly telephone screening of distress levels using a brief, validated instrument, with additional psychosocial intervention offered only to those with high distress at screening. RESULTS: Among 282 eligible patients, 89% were randomized and completed the study. Participants' psychologic distress levels decreased over the study period (P = .0001). However, no between-group differences were observed. Mean distress scores among control and experimental women at 0-, 3-, and 12-month interviews were 20.7 and 20.4, 15.5 and 15.0, and 14.6 and 13.5, respectively. No between-group differences were observed with respect to physical health, functional status, social and leisure activities, return to work, or marital satisfaction. CONCLUSION: Our results indicate that, among patients who receive a minimal psychosocial intervention as part of their initial cancer care, a distress screening program does not improve quality of life. Minimal psychosocial intervention at initial treatment may be effective in reducing distress, thus making it difficult to obtain additional benefit from a screening program.

Social support and survival among women with breast cancer.

BACKGROUND: Two recently reported randomized trials, one among patients with advanced breast cancer and the other among patients with early stage melanoma, suggested that social support may affect survival favorably. This study assesses relationships of social support indicators with 7-year survival among women diagnosed with localized or regional stage breast cancer. METHODS: All newly diagnosed patients with surgically treated localized or regional disease in seven Quebec City hospitals in 1984 were considered for this analysis. Among 235 eligible patients, 224 (95%) participated in a home interview 3 months after surgery. This interview provided information on the use of confidants in the 3 months after surgery. Data on disease and treatment characteristics were abstracted from patients' medical records. RESULTS: Compared with women who used no confidant in the 3 months after surgery, the hazard ratio for the 7-year period was 0.61 (95% confidence interval [CI], 0.33-1.12) among those who had used at least one confidant, 0.54 (95% CI, 0.28-1.06) in women who used two or more types of confidant, and 0.51 (95% CI, 0.22-1.18) among those whose confidants included either physician or nurse. These results were adjusted for age, presence of invaded axillary lymph nodes, adjuvant radiotherapy, and adjuvant systemic therapy (hormone or chemotherapy). CONCLUSION: These results support the view that social support may be associated with longer survival among women with localized or regional stage breast cancer.

Arm problems and psychological distress after surgery for breast cancer.

The frequency of problems in the arm affected by surgery for breast cancer and the association of these problems with psychological distress were assessed among 223 women with newly diagnosed breast cancer 3 months after operation and again 15 months later among 201 of these same women. At 3 months after operation, 182 (82%) of the 223 patients reported at least one arm problem. Specific problems reported were swelling (24%), weakness (26%), some limitation in range of movement (32%), stiffness (40%), pain (55%) and numbness (58%), and these percentages had changed little 15 months later. Regardless of the type of mastectomy, women who underwent axillary dissection had more arm problems. Compared with women reporting no arm problems, the adjusted odds ratios of having psychological distress at 3 months for women reporting one to two, three to four and five to six arm problems were 1.2, 2.3 and 3.1 respectively (chi 2 for trend = 9.5, p = 0.002). Arm problems are frequent after operation for breast cancer, and these problems appear to increase the likelihood of psychological distress. Women should be informed that arm problems are expected but non-threatening sequelae of initial surgical treatment for breast cancer.

Psychological distress after initial treatment of breast cancer. Assessment of potential risk factors.

BACKGROUND: Patient and disease characteristics are often mentioned by clinicians as possible risk factors for psychological distress among women with breast cancer. However, either these factors have not been evaluated or when they were evaluated, results were inconclusive. METHODS: Potential risk factors for psychological distress were assessed among 205 patients with newly diagnosed breast cancer by home interview 3 and 18 months after surgery. RESULTS: At 3 months, proportions of women with high distress reporting 0-1, 2-3, 4-5, and 6-15 stressful life events in the 5 years preceding diagnosis were 17%, 20%, 28%, and 37%, respectively (P = 0.006). High levels of psychological distress were present in 63.1% of women with a history of depression, compared with 14.3% of those with no such history (P = 0.0001). Associations of these factors with distress also were present 18 months after diagnosis. At 18 months only, distress was more frequent in women with regional disease (44%) than in those with localized disease (22%) (P = 0.006). Age, education, and marital status had little or no association with levels of psychological distress. CONCLUSIONS: Number of stressful life events before diagnosis and history of depression appear to be strong indicators of the risk of psychological distress and may be useful for identifying patients with breast cancer in need or more intense psychosocial support.

Psychological distress after initial treatment for breast cancer: a comparison of partial and total mastectomy.

This study of the relation between type of mastectomy and psychological distress was based on all newly diagnosed breast cancer patients with localized or regional disease who were surgically treated in seven Quebec City hospitals in 1984. Among 235 eligible patients, 227 (96%) participated in a home interview 3 months after diagnosis and 205 of these women gave a second interview approximately 15 months later. The Psychiatric Symptom Index (PSI) was used to measure the severity of symptoms of psychological distress. At 3 months, 38.8% of partial mastectomy patients had high PSI scores compared to 25.8% of women treated by total mastectomy (OR = 1.8, p = 0.044). Fifteen months later, percentages with high scores were identical, 35.1%, in the two treatment groups. Age appeared to modify the surgery-distress relation. These results suggest that partial mastectomy does not protect against psychological distress after breast cancer. Moreover, they highlight the importance of adequate preparation and support for all breast cancer patients, regardless of type of initial surgery.

A 'virus-free' cell line derived from a patient with infectious mononucleosis.

A continuous cell culture line, derived from a nurse with infectious mononucleosis, is described. Electron microscopic and immunofluorescent examination suggested that it was substantially free from detectable complete virus particles, although the presence of a soluble complement-fixing antigen showed the persistence of other antigenic components of the EB virus.