Psychometrics of patient-reported bother from side effects of treatment single-items in industry-sponsored oncology trials.

BACKGROUND: Improvements in cancer treatment have increased the number of cancer survivors, but also increased the long-term and late effects from cancer therapy. Patient reported "side effect bother" could be used to measure the burden of treatment, and the risk for negative outcomes such as dose reduction, treatment delay or discontinuation. The current study addresses the psychometric properties of a single item, determines what represents a "meaningful change", and evaluates the correlation to safety endpoints and functioning. METHODS: Results from 5911 patients enrolled in 8 clinical trials representing 5 disease types in oncology and hematology who completed either the Functional Assessment of Cancer Therapy (FACT) GP5 item or a modified bother item (MBI) were assessed. RESULTS: Patients ranged in age from 18 to 93 years, with all cancer stages represented and approximately equal numbers of males and females. Test-retest reliability was acceptable, as were convergent and known groups validity. The GP5 and MBI effectively demonstrated sensitivity to change over time and established meaningful thresholds. CONCLUSIONS: The results indicate that these single-items are psychometrically sound, capable of distinguishing known groups, responsive to change and can identify meaningful change over time in terms of treatment-related symptoms. It extends the findings of recent scientific groups by providing analyses not included in prior studies, and further supports the FDA's recommendation to include a single item question in clinical trials.

Change in Health-Related Quality of Life Among Individuals With Cancer Undergoing Smoking Cessation Treatment Involving Varenicline.

OBJECTIVES: To determine whether health-related quality of life (HRQOL) among individuals with cancer is undermined by smoking cessation treatment involving varenicline. SAMPLE & SETTING: Participants (N = 103) were daily smokers with cancer (up to five years postdiagnosis) who completed a placebo-controlled trial of standard versus extended duration varenicline. METHODS & VARIABLES: For this secondary study, participants were selected based on having completed the SF-12® at weeks 0, 1, 12, and 24. Using separate repeated measures multivariate analysis of variance, change in SF-12 scores was evaluated by time and by cancer treatment, varenicline duration, and quit status at week 24. RESULTS: There was no change in any of the three HRQOL scores by time or by cancer treatment status, varenicline duration, or quit status. Average emotional HRQOL score across time was significantly higher for quitters versus smokers. IMPLICATIONS FOR NURSING: Varenicline, including long-term treatment, does not appear to adversely affect HRQOL, which is highly relevant to oncology nurses who are well positioned to assist with the pharmacologic treatment of tobacco dependence.

Leveraging Patient Reported Outcomes Measurement via the Electronic Health Record to Connect Patients with Cancer to Smoking Cessation Treatment.

Tobacco use negatively impacts cancer treatment outcomes, yet too few providers actively support their patients in quitting. Barriers to consistently addressing tobacco use and referring to treatment include time constraints and lack of knowledge surrounding treatment options. Patient Reported Outcomes (PRO) measurement is best practice in cancer care and has potential to help address these barriers to tobacco cessation treatment. This descriptive program evaluation study reports preliminary results following implementation of a novel automated PRO tobacco use screener and referral system via the electronic health record (EHR) patient portal (MyChart) that was developed and implemented as a part of a population-based tobacco treatment program at the Robert H. Lurie Comprehensive Cancer Center of Northwestern University. Between 25 June 2019 and 6 April 2020, 4589 unique patients completed the screener and 164 (3.6%) unique patients screened positive for recent (past month) cigarette smoking. All patients who screened positive were automatically referred to a smoking cessation treatment program integrated within the Lurie Cancer Center, and 71 (49.7%) patients engaged in treatment, as defined by completing at least one behavioral counseling session. Preliminary results indicate that the PRO/MyChart system may improve smoker identification and increase offering of treatment and, despite the "cold call" following a positive screen, may result in a treatment engagement rate that is higher than rates of treatment engagement previously documented in oncology settings. Longer term evaluation with formal statistical testing is needed before drawing conclusions regarding effectiveness, but PRO measurement via the EHR patient portal may serve a potentially important role in a multi-component approach to reaching and engaging cancer patients in comprehensive tobacco cessation treatment.

Implementing electronic health record-integrated screening of patient-reported symptoms and supportive care needs in a comprehensive cancer center.

BACKGROUND: Oncology practice can be enhanced by the integration of the assessment of patient-reported symptoms and concerns into the electronic health record (EHR) and clinical workflows. METHODS: Adult oncology outpatients (n = 6825) received 38,422 invitations to complete assessments through the EHR patient portal. Patient-Reported Outcomes Measurement Information System computer adaptive tests were administered to assess fatigue, pain interference, physical function, depression, and anxiety. Checklists identified psychosocial, nutritional, and informational needs. In real time, assessment results were populated in the EHR, and clinicians were notified of elevated symptoms and needs. RESULTS: In all, 3521 patients (51.6%) completed 8162 assessments; approximately 55% of the responding patients completed 2 or more within 32 months. Fatigue, pain, anxiety, and depression scores were comparable to those of the general population (approximately 5% of assessments triggered clinical alerts across those domains); mean scores indicated a lower level of physical function (with severe scores prompting alerts in nearly 5% of assessments). More than half of assessments triggered an alert based on patient endorsement of supportive care needs, with the majority of those being nutritional (41.82% of assessments). Patient endorsement of supportive care needs was associated with significantly higher anxiety, depression, fatigue, and pain interference scores and lower physical function scores. Patients who triggered clinical alerts tended to be younger and more recently diagnosed, to have greater comorbidities, and to be a racial/ethnic minority. Patients who triggered clinical alerts had more health care service encounters in the ensuing month. CONCLUSIONS: EHR integration facilitated the assessment and reporting of patient-reported symptoms and needs within routine oncology outpatient care.

Validity and usefulness of a single-item measure of patient-reported bother from side effects of cancer therapy.

BACKGROUND: The improving efficacy of cancer treatment has resulted in an increasing array of treatment-related symptoms and associated burdens imposed on individuals undergoing aggressive treatment of their disease. Often, clinical trials compare therapies that have different types, and severities, of adverse effects. Whether rated by clinicians or patients themselves, it can be difficult to know which side effect profile is more disruptive or bothersome to patients. A simple summary index of bother can help to adjudicate the variability in adverse effects across treatments being compared with each other. METHODS: Across 4 studies, a total of 5765 patients enrolled in cooperative group studies and industry-sponsored clinical trials were the subjects of the current study. Patients were diagnosed with a range of primary cancer sites, including bladder, brain, breast, colon/rectum, head/neck, hepatobiliary, kidney, lung, ovary, pancreas, and prostate as well as leukemia and lymphoma. All patients were administered the Functional Assessment of Cancer Therapy-General version (FACT-G). The single item "I am bothered by side effects of treatment" (GP5), rated on a 5-point Likert scale, is part of the FACT-G. To determine its validity as a useful summary measure from the patient perspective, it was correlated with individual and aggregated clinician-rated adverse events and patient reports of their general ability to enjoy life. RESULTS: Analyses of pharmaceutical trials demonstrated that mean GP5 scores ("I am bothered by side effects of treatment") significantly differed by maximum adverse event grade (P<.001) in all trials, with a clear trend toward increasing GP5 scores with level of increasing adverse event grade. Effect sizes ranged from 0.13 to 0.46. Analyses of cooperative group trials demonstrated a significant correlation between GP5 and item GF3 ("I am able to enjoy life") in the predicted direction. CONCLUSIONS: The single FACT-G item "I am bothered by side effects of treatment" is significantly associated with clinician-reported adverse events and with patients' ability to enjoy their lives. It has promise as an overall summary measure of the burden of a given set of treatment toxicities compared with another. Future research can identify the contribution of individual side effects compared with one another in terms of how each may contribute to overall bother. Cancer 2018;124:991-7. © 2017 American Cancer Society.

Survivorship care planning in a comprehensive cancer center using an implementation framework.

Cancer survivorship care plans (SCPs) have been recommended to improve clinical care and patient outcomes. Research is needed to establish their efficacy and identify best practices. Starting in 2015, centers accredited by the American College of Surgeons Commission on Cancer must deliver SCPs to patients completing primary cancer treatment with curative intent. We describe how we established routine SCP delivery at the Robert H Lurie Comprehensive Cancer Center in Chicago, Illinois, using the Quality Implementation Framework. We evaluated local practices, gathered clinician and patient stakeholder input, developed customized SCP templates within the electronic health record (EHR), and implemented 2 complementary delivery models. Clinician interviews (n = 41) and survey responses (n = 12), along with input from patients (n = 68) and a patient advisory board (n = 15), indicated support for SCPs and survivorship services. To promote feasible implementation and leverage existing workflows, we harmonized 2 SCP delivery models: integrated care within clinics where patients received treatment, and referral to a centralized survivorship clinic. We are implementing SCP delivery with prominent disease sites and will extend services to survivors of other cancers in the future. We developed four electronic disease-specific SCP templates for breast, colorectal, lung, and prostate cancers and a fifth, generic template that can be used for other malignancies. The templates reduced free-text clinician entry by auto-populating 20% of the fields from existing EHR data, and using drop-down menus for another 65%. Mean SCP completion time is 12 minutes (range, 10-15; n = 64). We designed our framework to facilitate ongoing evaluation of implementation and quality improvement. Funding/sponsorship Robert H Lurie Comprehensive Cancer Center, the Coleman Foundation, and the Lynn Sage Cancer Research Foundation.

Health-related quality of life in patients with neuroendocrine tumors: an investigation of treatment type, disease status, and symptom burden.

INTRODUCTION: Neuroendocrine tumors (NETs) are malignant solid tumors arising in hormone-secreting tissue. They have historically been very difficult to treat, and advanced NETs are considered incurable. Surgery is the only potentially curative treatment option, though research is ongoing, investigating the efficacy of targeted therapies combined with more traditional chemotherapies. Frequent bowel movements and episodes of flushing are the most common symptoms. METHODS: The present study reports data from an anonymous patient survey of 663 eligible NET patients, identified with the assistance of patient advocacy groups. This study investigated the impact of treatment (surgery alone; surgery plus somatostatin analogue; other treatments) on quality of life (QOL). Finally, we investigate whether recurrent disease results in poorer QOL compared to disease treated curatively with surgery and remaining in remission. RESULTS AND DISCUSSION: Results suggest that increased frequency of bowel movements and presence of any flushing symptoms are correlated with decreased quality of life. Treatment groups differed on most Patient Reported Outcomes Measurement Information System (PROMIS) global health and PROMIS-29 scores, including physical function, fatigue, pain, social function, and general physical and mental health, with the surgery group reporting significantly better scores than the other groups (effect size of differences ranged from 0.28 to 0.54). This may be possibly due to effective symptom control reached for these patients through surgery alone. After adjustment for carcinoid syndrome, the association with the treatment group disappeared for all domains except physical functioning. In terms of disease status, patients with recurrent disease reported poorer physical, social, and mental functions. Depression scores were similar between groups; however, patients with recurrent disease reported significantly higher anxiety compared to those with no current NET. Physical functioning was even more markedly different between groups, with recurrent NET patients reporting significantly impaired overall physical function, impaired sleep, and significant fatigue compared to those with no current NET. To our knowledge, this is the first study to comprehensively examine the effect of treatment group, disease status, and symptom burden on the quality of life in NET patients in a large sample. Limitations and future research directions are discussed.

Bringing PROMIS to practice: brief and precise symptom screening in ambulatory cancer care.

BACKGROUND: Supportive oncology practice can be enhanced by the integration of a brief and validated electronic patient-reported outcome assessment into the electronic health record (EHR) and clinical workflow. METHODS: Six hundred thirty-six women receiving gynecologic oncology outpatient care received instructions to complete clinical assessments through Epic MyChart, an EHR patient communication portal. Patient Reported Outcomes Measurement Information System (PROMIS) computer adaptive tests (CATs) were administered to assess fatigue, pain interference, physical function, depression, and anxiety. Checklists identified psychosocial concerns, informational and nutritional needs, and risk factors for inadequate nutrition. Assessment results, including PROMIS T scores with documented severity thresholds, were immediately populated in the EHR. Clinicians were notified of clinically elevated symptoms through EHR messages. EHR integration was designed to provide automated triage to social work providers for psychosocial concerns, to health educators for information, and to dietitians for nutrition-related concerns. RESULTS: Four thousand forty-two MyChart messages sent, and 3203 (79%) were reviewed by patients. The assessment was started by 1493 patients (37%), and once they started, 93% (1386 patients) completed the assessment. According to first assessments only, 49.8% of the patients who reviewed the MyChart message completed the assessment. Mean PROMIS CAT T scores indicated a lower level of physical function and elevated anxiety in comparison with the general population. Fatigue, pain, and depression scores were comparable to those of the general population. Impaired physical functioning was the most common basis for clinical alerts and occurred in 4% of the patients. CONCLUSIONS: PROMIS CATs were used to measure common cancer symptoms in routine oncology outpatient care. Immediate EHR integration facilitated the use of symptom reporting as the basis for referral to psychosocial and supportive care.

Implementation of distress screening in an oncology setting.

The recommendations of numerous groups, such as the Institute of Medicine and the National Comprehensive Cancer Network, have resulted in the first regulatory standard on distress screening in oncology implemented in 2015 by the American College of Surgeons Commission on Cancer. This practice-changing standard promises to result in better quality cancer care, but presents unique challenges to many centers struggling to provide high-quality practical assessment and management of distress. The current paper reviews the history behind the CoC standard, identifies the most prevalent symptoms underlying distress, and discusses the importance of distress screening. We also review some commonly used instruments for assessing distress, and address barriers to implementation of screening and management.

Fertility Preservation Preferences and Perspectives Among Adult Male Survivors of Pediatric Cancer and Their Parents.

Purpose: In this study, we set out to determine the preferences, concerns, and attitudes toward fertility preservation of adult male survivors of pediatric cancer and their parents. Methods: We conducted 3 focus groups with a total of 15 male survivors of pediatric cancer (age at diagnosis: mean=14, range: 10-20; age at study: mean=35, range: 25-47) and 2 groups with a total of 7 parents of survivors. Grounded theory methodology was used for the identification and analysis of recurrent themes expressed by survivors and their parents in the course of focus group discussions. Results: Themes most frequently expressed by survivors included concern regarding long-term treatment effects and a retrospective desire for fertility impairment to have been discussed when they were originally diagnosed with cancer. Parental themes included the same hindsight desire, as well as reliance upon the treating oncologist for direction in selecting the course of treatment, and an acknowledgment that input from a specialist in fertility preservation would have been beneficial. Conclusions: Although future reproductive potential was not consistently reported as a source of apprehension when diagnosed with cancer, both survivors and their parents noted it to be a paramount concern later in life. Parents and survivors both reported that fertility preservation discussions should be routinely incorporated in the clinical context of a pediatric cancer diagnosis.

Ambulatory cancer and US general population reference values and cutoff scores for the functional assessment of cancer therapy.

BACKGROUND: Health-related quality of life (HRQOL) measures are commonly used in oncology research. Interest in their use for monitoring or screening is increasing. The Functional Assessment of Cancer Therapy (FACT) is one of the most widely used HRQOL instruments. Consequently, oncology researchers and practitioners have an increasing need for reference values for the Functional Assessment of Cancer Therapy-General (FACT-G) and its 7-item rapid version, the Functional Assessment of Cancer Therapy-General 7 (FACT-G7), to compare FACT scores across specific subgroups of patients in research trials and practice. The objectives of this study are to provide 1) reference values from a sample of the general US adult population and a sample of adults diagnosed with cancer and 2) cutoff scores for quality of life. METHODS: A sample of the general US population (N = 1075) and a sample of patients with cancer from 12 studies (N = 5065) were analyzed. Cutoff scores were established using distribution- and anchor-based methods. Mean values for the cancer sample were analyzed by performance status, cancer type, and disease status. Also, t tests and established criteria for meaningful differences were used to compare values. RESULTS: FACT-G and FACT-G7 scores in the general US population sample and cancer sample were generally comparable. Among the sample of patients with cancer, FACT-G and FACT-G7 scores worsened with declining performance status and increasing disease status. CONCLUSIONS: These data will aid interpretation of the magnitude and meaning of FACT scores, and allow for comparisons of scores across studies.

Delusional disorder and oncology: review of the literature and case report.

OBJECTIVE: Delusional disorder is an infrequent diagnosis in outpatient clinical practice. While delusional thought processes are a fairly common part of symptom clusters in chronic psychiatric disorders such as schizophrenia and bipolar disorders, true delusional disorders are believed to be fairly rare. METHOD: In this article, we review scientific data on incidence, diagnosis, and treatment of delusional disorders. This was done by PubMed search utilizing the search terms "delusional disorder," "oncology," "diagnosis," and "treatment." Relevant articles were excluded if they dealt predominantly with schizophrenia instead of primary delusional disorder. RESULTS: We present a case of a patient diagnosed with follicular lymphoma and an apparent longstanding history of persecutory delusions. The patient's symptoms eventually led to intervention in the oncology practice involving the medical center faculty and staff, as well as local police and the court system. CONCLUSIONS: Delusional disorder is an under-researched condition, and limited information is known regarding the treatment of this condition when it impacts upon medical care. Future research directions are proposed.

Using the science of psychosocial care to implement the new american college of surgeons commission on cancer distress screening standard.

The American College of Surgeons (ACoS) Commission on Cancer (CoC) has advanced a new patient-centered accreditation standard requiring programs to implement psychosocial distress screening and referral for psychosocial care. The field of psychosocial oncology has advocated for routine distress screening as an integral component of quality cancer care since the NCCN Distress Management Panel first recommended this practice in 1999. Accreditation standards have a significant impact on practice patterns and quality of care. The new ACoS CoC Psychosocial Distress Screening Standard provides a unique opportunity to integrate the science of psychosocial care into clinical practice. National organizations, including the American Psychosocial Oncology Society, the Association of Oncology Social Work, the Cancer Support Community, and LIVESTRONG, can offer valuable guidance and resources. This article reviews ACoS CoC requirements, highlighting key research findings and providing practical considerations to guide programs with implementation. Although screening for distress encompasses many domains, this article reviews the evidence linking depression-one aspect of distress-and cancer outcomes to highlight the profound influence psychosocial care delivery can have on promoting medical outcomes and quality cancer survivorship. The authors describe distress screening program accomplishments at Northwestern University, including the electronic administration of NIH Patient Reported Outcomes Measurement Information System computerized adaptive testing item banks. Electronic medical record integration facilitates real-time scoring, interpretation, provider notification, and triage for psychosocial care. Roughly one-third of patients have requested assistance with psychosocial needs. As ACoS CoC programs implement psychosocial distress screening and management, the emerging field of implementation science can guide future clinical program developments and research priorities.

Evaluation of treatment- and disease-related symptoms in advanced head and neck cancer: validation of the national comprehensive cancer network-functional assessment of cancer therapy-head and neck cancer symptom index-22 (NFHNSI-22).

CONTEXT: The Functional Assessment of Cancer Therapy-Head and Neck is a well-validated assessment of quality of life used with patients diagnosed with head and neck cancers (HCNs). The present study is an attempt to evaluate and modify this instrument as necessary in light of the recent regulatory guidelines from the Food and Drug Administration on the use of patient-reported outcomes in clinical trials. OBJECTIVES: Overall, the goal was to identify patients' highest priority cancer symptoms, compare these symptoms with those suggested by oncology experts, and construct a brief symptom index to assess these symptoms and categorize them as treatment-related, disease-related, or related to general function and well-being. METHODS: Patients (N=49) with advanced (Stages III and IV) HCNs were recruited from participating National Comprehensive Cancer Network institutions and community cancer support organizations in the Chicago area. Patients completed open-ended interviews and symptom checklists. Participating oncology physician experts also rated symptoms. Content validity was obtained by evaluating results alongside items in the Functional Assessment of Chronic Illness Therapy system. Eleven oncologists categorized symptoms in terms of importance and also whether the symptoms were primarily related to disease, treatment, or functional well-being. RESULTS: HCN-related symptoms endorsed as high priority by both patients and oncology experts were selected for the new National Comprehensive Cancer Network-Functional Assessment of Cancer Therapy-Head and Neck Cancer Symptom Index-22. The final version includes 22 items, which are broken down into disease-related symptoms, treatment side effects, or general function and well-being. The new scale has acceptable internal consistency (Cronbach's coefficient alpha=0.86), content validity for use in chemotherapy trials of patients with advanced disease, and concurrent validity as demonstrated by moderate-to-strong correlations with the existing Functional Assessment of Chronic Illness Therapy measure. CONCLUSION: The National Comprehensive Cancer Network-Functional Assessment of Cancer Therapy-Head and Neck Cancer Symptom Index-22 adequately reflects symptom and side effect concerns of advanced HCN patients as well as oncology physicians. This instrument can be used to evaluate the most important disease-related symptoms, treatment side effects, and function/well-being in patients with advanced HCNs in clinical practice and research.

PTSD: therapeutic interventions post-Katrina.

August 29, 2006, brought the largest, most deadly hurricane ever to strike the Gulf Coast. According to reports, the storm killed more than 2000 people and destroyed billions of dollars of property, with winds clocked at 160 to 175 mph. More than a million residents were displaced, many requiring care for chronic conditions who suddenly also needed care for acute stress symptoms. Today, many individuals still struggle to cope with major psychiatric posttraumatic stress disorders (PTSD). Using a case study approach, this article discusses PTSD, including what it is, how it is manifested, how to diagnose it, patient education, and how it can be managed with therapeutic interventions. Special circumstances related to children are briefly presented.

Psychosocial factors in lung cancer: quality of life, economic impact, and survivorship implications.

Lung cancer is the leading cause of cancer mortality in men and women. Lung cancer accounts for approximately 30% of all cancer deaths in the United States. In addition, it is the most often diagnosed cancer in men, and the second most often diagnosed cancer in women. Five-year survival rates in lung cancer remain very low, around 15%. Approximately 45% of patients present with stage III disease. The majority of these patients are considered non-resectable, leading to the poor survival statistics seen in this disease. Unfortunately, survival rates have not improved in the past 30 years despite much research in diagnostics and therapeutics. Patients with advanced disease often experience multiple symptoms, including fatigue, pain, dyspnea, cough, hemoptysis, and anorexia. This paper will review the enormous toll that lung cancer takes on society, as well as individuals and families affected. In addition, we will examine psychosocial factors pertinent to lung cancer. Specifically, the article briefly discusses treatment approaches to lung cancer, as they relate to quality of life (QOL). QOL as a construct within lung cancer is then reviewed. Comment is made on the evaluation and prognostic importance of QOL. Next, economic and survivorship aspects of lung cancer are discussed. Finally, a summary of relevant psychosocial interventions for patients diagnosed with lung cancer is given.

Clinical presentation and therapeutic interventions for posttraumatic stress disorder post-Katrina.

It has been almost 2 years since Hurricane Katrina struck the Gulf Coast. These 2 years can be characterized by constant struggle and pain as the people try to reattain some semblance of life as they knew it before Katrina struck. Some have chosen to leave their ancestral homes, homes where they were raised and where they, in turn, raised their own families. Those who did leave are able, in some way, to reestablish some semblance of normality, but those who stayed showed manifestations of and dealt with psychological trauma. These manifestations include regression, inattentiveness, aggressiveness, somatic complaints, irritability, social withdrawal, nightmares, and crying. Longer lasting effects may include depression, anxiety, adjustment disorders, and interpersonal or academic difficulties. These postdisaster manifestations can linger or remain hidden until well after the traumatic event and could persist for years. This article presents issues about the effects of Katrina on the mental health of the people of New Orleans. It discusses the profile of posttraumatic stress disorder and presents evidence-based review of interventions the health care provider can implement to care for those who continue to suffer the effects of this horrific disaster.

Quality of life and psychosocial adjustment in gynecologic cancer survivors.

Gynecologic malignancies occur in approximately 1 in 20 women in the United States. Until recently, clinical management of these cancers has focused almost exclusively on prolonging the survival of patients. A recent literature search using MEDLINE revealed relatively few research studies that reported data on quality of life (QOL) in a gynecologic cancer population. Reports in the literature have been conflicting, with some studies finding deterioration in QOL and some finding stability or improvement in QOL over time. Until recently, the impact of various treatments (surgery, radiation, chemotherapy) on QOL in this population was unknown. Recently, the QOL of women with gynecologic cancer has been compared to that of women with other types of cancer. Also, risk factors for poor adjustment in gynecologic cancer are beginning to be investigated. This presentation will attempt to 1) summarize the relevant literature on QOL in a gynecologic cancer population, 2) compare QOL in this population to other types of cancer, 3) examine risk factors for poor adjustment and 4) describe the limitations of the literature and future research directions. Overall, it appears that QOL is most negatively affected from time of diagnosis through completion of treatment. Following treatment, QOL appears to improve over the course of 6-12 months, but then appears to remain stable from that time through two years post-treatment. Compared to breast cancer patients, it appears that gynecologic cancer patients experience poorer QOL on several domains during active treatment, but that after completion of treatment, overall QOL is similar between groups. Risk factors for maladjustment include treatment with radiotherapy or multi-modality treatment, increased length of treatment, younger age, and coping using a disengaged style. Other risk factors include lower education, poor social support and lower levels of religious belief. The significance of these findings and future research directions will be discussed.