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.

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.

Quality of life in women with recurrent breast cancer.

Although the psychosocial concomitants of early-stage breast cancer have been well-documented, the relationship between cancer recurrence and quality of life remains less clear. We conducted a prospective, longitudinal study in order to clarify the relationship between recurrent cancer and quality of life, and to determine predictors of quality of life following recurrence. Sixty-nine women with recurrent breast cancer completed questionnaires assessing multiple components of quality of life at three time points: prior to recurrence, immediately after the diagnosis of recurrence, and at follow-up 6 months later. Perceptions of overall quality of life, general health status, emotional, social, and physical functioning were poorer immediately following the diagnosis of recurrence than they had been prior to recurrence. These women also evidenced significant improvement in several domains of quality of life between initial recurrence and follow-up; nonetheless, most areas of quality of life were impaired compared to pre-recurrence. Self-reported physical symptoms were a strong predictor of post-recurrence ratings of overall quality of life. These data suggest that the recurrence of breast cancer is associated with significant changes in quality of life. Quality of life did not progressively deteriorate, however, attesting to the resilience of women coping with this major stressor. These data shed light on issues of potential importance to patients managing this serious illness and may have implications for health-care professionals working with this population.

Quality of life after radical cystectomy for bladder cancer in patients with an ileal conduit, cutaneous or urethral kock pouch.

PURPOSE: Radical cystectomy for bladder cancer is associated with many changes in bodily function with sexual and urinary dysfunction most prevalent. However, little research has been done on how efforts to improve erectile function relate to quality of life. Also, the psychological benefits associated with continent urinary diversion have not been fully explored. We compared long-term quality of life outcomes among 3 urinary diversion groups, and between patients who had and had not received an inflatable penile prosthesis. MATERIALS AND METHODS: The 224 participating patients completed 4 self-reporting questionnaires, including the profile of mood states, and adapted versions of the sexual history form, body image dissatisfaction scale and quality of life questionnaire. We compared self-reports of emotional distress, global quality of life, sexuality, body image dissatisfaction, urinary diversion problems, and problems with social, physical and functional activities in patients with advanced bladder cancer who underwent urinary diversion, including an ileal conduit in 25, cutaneous Kock pouch in 93 and urethral Kock pouch in 103. Patients who had or had not received an inflatable penile prosthesis after cystectomy were also compared in regard to quality of life variables. RESULTS: Regardless of type of urinary diversion the majority of patients reported good overall quality of life, little emotional distress and few problems with social, physical or functional activities. Problems with urinary diversion and sexual functioning were identified as most common. After controlling for age analysis of variance showed no significant differences among urinary diversion subgroups in any quality of life area. However, t tests controlling for age indicated that penile prosthesis placement was significantly associated with better sexual function and satisfaction. CONCLUSIONS: Quality of life appears good in these long-term survivors of advanced bladder cancer. The type of urinary diversion does not appear to be associated with differential quality of life. Findings suggest that physicians may wish to discuss urinary diversion problems and sexual dysfunction as long-term correlates of radical cystectomy for bladder cancer. Furthermore, they may also wish to discuss the option of erectile aids in men with erectile dysfunction after cystectomy.

The multi-centre assessment of quality of life: the Interdisciplinary Group for Cancer Care Evaluation (GIVIO) experience in Italy.

One of the main issues to be considered in conducting clinical trials concerns the presence of missing data. This aspect is particularly relevant in oncology longitudinal studies, characterized by a long follow-up, and especially in quality of life studies where there is still little knowledge about patients' characteristics that predict loss of data. Since the middle of the 1980s the GIVIO (Interdisciplinary Group for Cancer Care Evaluation) co-operative group has been involved in conducting quality of life assessment studies, also focusing on the development of some strategies aimed at the minimization of missing data. In this paper we report on the results of two trials, which are now completed, concerning the quality of life assessment in a sample of breast and colon cancer patients. In order to cope with the problem of missing data, in both the trials the strategy of follow-up mailing was adopted, which proved to be an effective way to increase the response rate by nearly 50 per cent at each time point.

Life after breast cancer: understanding women's health-related quality of life and sexual functioning.

PURPOSE: To describe the health-related quality of life (HRQL), partner relationships, sexual functioning, and body image concerns of breast cancer survivors (BCS) in relation to age, menopausal status, and type of cancer treatment. PATIENTS AND METHODS: A cross-sectional sample of BCS in two large metropolitan areas was invited to participate in a survey study that included the following standardized measures: the RAND 36-Item Health Survey; the Centers for Epidemiologic Studies-Depression Scale (CES-D); the Dyadic Adjustment Scale (DAS); the Breast Cancer Prevention Trial (BCPT) Symptom Checklist; the Watts Sexual Functioning Questionnaire (WSFQ); and subscales from the Cancer Rehabilitation Evaluation System (CARES). RESULTS: Eight hundred sixty-four BCS completed the survey. RAND Health Survey scores were as good or better than those of healthy, age-matched women, and the frequency of depression was similar to general population samples. Marital/partner adjustment was similar to normal healthy samples, and sexual functioning mirrored that of healthy, age-matched postmenopausal women. However, these BCS reported higher rates of physical symptoms (eg, joint pains, headaches, and hot flashes) than healthy women. Sexual dysfunction occurred more frequently in women who had received chemotherapy (all ages), and in younger women who were no longer menstruating. In women > or = 50 years, tamoxifen therapy was unrelated to sexual functioning. CONCLUSION: BCS report more frequent physical and menopausal symptoms than healthy women, yet report HRQL and sexual functioning comparable to that of healthy, age-matched women. Nevertheless, some survivors still experience poorer functioning, and clinicians should inquire about common symptoms to provide symptomatic management or counseling for these women.

Ethnicity and cancer outcomes: behavioral and psychosocial considerations.

Cancer has been the subject of thousands of behavioral and psychosocial studies. The literature has focused largely on non-Hispanic Whites, despite the fact that cancer outcomes vary by ethnicity. This article provides a review of those studies that do consider the relations between ethnicity and cancer-related adherence behaviors, survival, and quality of life. The authors propose a mediational framework that links ethnicity and cancer outcomes through socioeconomic status, knowledge and attitudes, and access to medical care. They use this framework to organize the literature and to develop recommendations for future research.

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.

Quality of life and sexuality following radical prostatectomy in patients with prostate cancer who use or do not use erectile aids.

OBJECTIVES: It is well established that prostate cancer patients undergoing radical prostatectomy may experience disruptive side effects, most notably urinary incontinence and erectile dysfunction. The purpose of this study is to compare relevant outcomes between patients awaiting radical prostatectomy for prostate cancer and patients who already underwent the surgery, taking into account type of prostatectomy and use of erectile aids. METHODS: We compared self-reports of global quality of life, sexuality, urinary continence, and physical capabilities in 86 nerve-sparing patients, 89 standard-prostatectomy patients, 74 prostatectomy patients who used erectile aids, and a comparison group of 45 patients awaiting radical prostatectomy. RESULTS: Regardless of type of surgery, use of erectile aid, or preoperative status, most patients reported good quality of life. The best outcomes in sexuality were reported by patients who used erectile aids, who appeared similar in sexuality to patients awaiting surgery. When differences were detected, standard prostatectomy patients who did not use erectile aids scored worse in most areas of sexuality than nerve-sparing patients who did not use erectile aids. There were no differences in frequency of urinary leakage among the three surgery subgroups. CONCLUSIONS: Although most patients reported problems in sexual and urinary function, global quality of life does not appear to be compromised following radical prostatectomy. Findings suggest that postsurgical sexuality differs depending on type of prostatectomy and use of erectile aids, while urinary function is similar across surgery groups. We conclude that erectile aids should be offered routinely to patients who are ineligible for nerve-sparing surgery or experience erectile difficulties following the nerve-sparing procedure.

Quality of life among mastectomy patients using external breast prostheses.

BACKGROUND: Most women who undergo mastectomy for breast cancer use external breast prostheses. Yet, little is known about patterns of use, satisfaction levels, and quality of life associated with their use as compared to other options. PATIENTS AND METHODS: We report longitudinal, self-report questionnaire data regarding prosthetic use from 592 Italian mastectomy patients. Women who report satisfaction with their prostheses are compared on medical, demographic, and quality of life variables to a matched sample of women who report dissatisfaction. We also compare matched samples of women who do not use prostheses and women who had reconstruction to prosthetic users. RESULTS: Most women used and were satisfied with their prostheses. However, there was a small group of women who were dissatisfied. These women reported greater disruption to their sense of feminility and worse quality of life in some areas. We found few differences between prosthetic users and women who used either of the other two options available following mastectomy-taking no action to restore the appearance of the amputated breast or having reconstructive surgery. CONCLUSIONS: No one technique for restoring the appearance of the mastectomized breast is necessary to optimize quality of life for all women. Physicians should describe the options to women, along with the average satisfaction rates for women choosing those options, and help women to make the best personal decisions.

Age differences in information-seeking among cancer patients.

Studies examining patient populations have found that information-seeking decreases with age. However, researchers usually define information-seeking as involving only the medical establishment, while they neglect other sources of information. The present study examined the use of two types of information sources, non-medical establishment (newspaper, television, and friends) and medical establishment (doctors and nurses), among seventy-five cancer patients aged eighteen to eighty-one years. Patients responded to questionnaires asking about information-seeking, desire for more cancer information, self-perception of their knowledge about cancer, and actual knowledge of facts about cancer. For the medical establishment source, information-seeking decreased with age; however, no age differences existed for seeking non-medical establishment information. In individuals with high levels of desire for information, older adults reported more information-seeking from non-medical sources than did younger adults.

Inadequate adherence to radiotherapy in Latina immigrants with carcinoma of the cervix. Potential impact on disease free survival.

BACKGROUND: Radiation therapy plays an important role in the loco-regional control of carcinoma of the cervix. Strict adherence to the radiation protocol, without the introduction of time breaks, has been shown to favorably affect loco-regional control and survival, making adherence a crucial variable for optimal outcome. Because carcinoma of the cervix is a common disease among Latinas, with survival rates worse than those of other ethnic groups in this country, the pattern of adherence to the prescribed radiation treatment among Latina patients seen at Los Angeles County Hospital were studied. METHODS: The records of 69 consecutive Latina patients with cervical cancer who received radiation therapy at Los Angeles County Hospital were reviewed. Semi-structured interviews in a successive group of 30 similar patients were conducted to acquire preliminary information about their psychosocial characteristics. RESULTS: The results demonstrate inferior rates of optimal adherence to radiation treatment among Latina immigrant patients when compared with the rates reported in the literature for the general population of cervical cancer patients in United States (16 vs. 63%). Furthermore, a large subset of patients (20%) in the series elected to discontinue treatment without a medical reason. When a comparable group of Latina patients was interviewed, potential practical, psychologic, and cultural barriers to optimal care were identified. CONCLUSIONS: The results from this exploratory study support the need for further studies to document the pattern of adherence to radiotherapy in the rest of the country among this minority population. The results suggest that an intervention to improve information and adherence to radiation therapy may be necessary to assure Latinas a chance for rates of cure comparable with the national standards.

Positive expectations predict health after heart transplantation.

We explored the relations between positive expectations and adjustment, adherence, and health in cardiac transplant patients. Thirty-one patients and their nurse completed questionnaires before transplantation and at 3 times after surgery. As predicted, patients' self-reported positive expectations were generally associated with good mood, adjustment to the illness, and quality of life, even in patients who experienced health setbacks. High preoperative expectations predicted later adherence to a complex medical regimen. Positive expectations measured before the transplant predicted a substantial amount of the variance in the nurse's ratings of physical health 6 months after surgery, covarying for adherence behavior and preoperative health.

Quality of life in breast cancer patients: the contribution of data to the care of patients.

A primary test of the usefulness of quality of life research is the extent to which it has been helpful in informing clinical practice and in minimising or preventing psychosocial distress among patients and their families. Clinical applications of quality of life data in five areas are summarised: alerting physicians and nurses to common patient concerns, informing patients of common reactions to breast cancer, aiding patients and physicians in decision-making, developing training programmes for medical personnel, and designing interventions for patients and their families. Although substantial progress has been made in applying quality of life data to improve clinical practice, further progress is possible. As with many other areas of medical practice, we must work towards developing more effective means of disseminating this information to clinicians and encouraging them to integrate it into their practice.

Assessing quality of life when planning and evaluating worker notification programs: two case examples.

Notifying workers that they have been placed at risk for serious medical problems may affect their lives in unexpected ways. Although very little evidence supports the fear of notification causing grave psychological problems, more subtle disruptions in quality of life may result. In addition, psychological reactions to notification, such as anxiety or denial, may impede or enhance workers' abilities to process, remember, or act upon the information presented. Measuring how different notification strategies affect quality of life is crucial; this process can enable us to design and select effective strategies that improve, rather than disrupt, the lives of workers and their families. Two preliminary efforts to include consideration of quality of life in planning and evaluating notification programs are described.

Quality of life and coping in patients awaiting heart transplantation.

The psychosocial adaptation of patients awaiting heart transplantation has not been defined. Forty-one patients (36 men, 5 women; mean age, 48 years) completed standardized questionnaires before transplantation to assess quality of life, physical symptoms, marital/social adjustment, psychiatric morbidity, coping, and compliance to medical regimens. Also, data were obtained from spouses/partners and the transplantation nurse coordinator. Unlike previously reported findings with patients after transplantation, those awaiting transplantation report moderate dissatisfaction with quality of life. Patients report physical symptoms, functional disabilities, sexual dysfunction, and psychological distress. Nonetheless, reported levels of compliance with the medical regimens and of social support were high, and both patients and spouses/partners provided marital adjustment ratings on the Dyadic Adjustment Scale that were comparable to those of well-adjusted, happily married couples. High levels of coping also were recorded. Having a positive attitude and seeking social support were the most common coping strategies, whereas confrontation, acceptance, and escapism were relatively uncommon. In conclusion, patients awaiting heart transplantation, although dissatisfied with quality of life, maintain positive psychological and social adjustment.

Disclosure of breast cancer diagnosis: patient and physician reports. GIVIO (Interdisciplinary Group for Cancer Care Evaluation, Italy)

Although there is considerable controversy about what information regarding the diagnosis of cancer is most helpful to patients in meeting their psychological and medical needs, little research exists on what patients who are treated in non-specialized institutions are told about their diagnosis and treatment. We assessed the information that breast cancer patients received about their diagnosis from the perspective of both the patient and the physician, in order to determine whether they agree in their perceptions of communication, and whether the nature of patient-physician communication is associated with patient satisfaction. Questionnaires were completed by 1171 Italian breast cancer patients (representing a 81.5% response rate) and their physicians at the time of surgery for breast cancer. Only a minority of patients (47%) reported having been told that they had cancer. Satisfaction with information was highest among women who had been told the diagnosis. Patient and physician reports of what information was conveyed about the diagnosis differed for over half of patients, with highest satisfaction levels reported when both patient and physician stated that the diagnosis had been conveyed. While comparison of patient and physician reports should not be used to validate either source of information, the degree of patient-physician disagreement found in this research may alert physicians to potential difficulties that can arise in communicating with cancer patients.