Do breast cancer survivors' post-surgery difficulties with recreational activities persist over time?

INTRODUCTION: Most longitudinal breast cancer studies have found that treatment-related sequelae such as arm morbidity [lymphedema, pain, and range of motion (ROM) restrictions] can have a significant impact on quality of life. In a previous study, we found that at 6-12 months after breast cancer surgery, 49% of participants had difficulties engaging in recreational activities and that arm morbidity significantly predicted difficulties with participation in recreation. METHODS: A longitudinal national study employing clinical assessments and survey methods followed 178 women over 43 months (3.6 years) to assess issues related to arm morbidity post-breast cancer surgery. Hierarchical multiple regression analyses were conducted to identify which variables were predictive of recreational difficulties experienced by women 8 and 43 months post-surgery. RESULTS: Between 8 months (T1) and 43 months (T2) post-breast cancer surgery, women demonstrated slight increases in lymphedema. Conversely, a significant decrease was observed in the number of ROM restrictions and pain when using the arm. Despite the overall improvements in arm morbidity, some women continued to report moderate pain and ROM restrictions. The two arm morbidity factors were found to be statistically significant (p < 0.001) predictors of recreational difficulties at both 8 and 43 months post-surgery, with pain accounting for the greatest proportion of variance. DISCUSSION/CONCLUSION: Pain and ROM restrictions were the only significant predictors of recreational difficulties during the first 3.6 years after breast cancer surgery. Specifically, women who still experience pain years after breast cancer surgery report difficulties in their recreational pursuits. IMPLICATIONS FOR CANCER SURVIVORS: Pain and ROM restrictions may prohibit participation in recreational activity and targeted intervention should be sought.

Discussing mentorship: An ongoing study for the development of a mentorship program in Saskatchewan.

OBJECTIVE: To identify the essential components of a mentorship program as the first step in the ongoing development of a mentorship program for primary care physicians. DESIGN: Mixed-methods study. SETTING: Saskatchewan. PARTICIPANTS: Forty-nine of 170 physicians responded positively to a letter of invitation. Of these, 25 physicians were purposively sampled based on location, sex, and experience. Fourteen participants practised in urban areas and 11 in rural settings; 11 were men and 14 were women; and 10 were junior physicians and 15 were senior. Junior physicians were defined as those who had graduated from medical school after 1995, and senior physicians were those who had graduated before 1980. METHODS: This study employed qualitative, in-depth, semistructured interviews. Interview questions, based on an environmental scan, were developed then pilot-tested with a family physician. Interviews lasted approximately 60 minutes and were audiotaped. Digital audio files were transcribed verbatim and analyzed thematically. MAIN FINDINGS: Family physicians described positive and negative aspects of mentoring, or having a lack of experience with mentoring. They also outlined key components of a potential mentorship program: matching mentees with mentors; integrating formal and informal mentorship; and the evaluation process of the mentorship relationship and program. CONCLUSION: Based on the feedback from family physicians, mentorship is viewed as an important and meaningful program of action that regional health stakeholders and medical educators in Saskatchewan could implement. A pilot test of a mentorship program model will be the culmination of this study. Further research will be undertaken to evaluate the model once it is implemented. This will have important implications for establishing a national mentorship program for family physicians across the country.

Predictors of arm morbidity following breast cancer surgery.

OBJECTIVE: Arm morbidity post-breast cancer surgery is increasingly being recognized as a chronic problem for some women following breast cancer surgery. The purpose of this study was to examine demographic, disease, and treatment-related predictors of a comprehensive array of chronic arm morbidity (pain, lymphedema, functional disability, and range of motion) post-breast cancer surgery. METHODS: Women (n=316) with a non-metastatic primary diagnosis of breast cancer were accrued from cancer centers in four Canadian cities. Patients completed a clinical assessment and measures of arm morbidity at 6-12 months post-breast cancer surgery. The independent variables in the MANOVA to predict arm morbidity included: Lymph node management type, number of axillary nodes dissected, type of surgery, disease stage, presence of post-operative infection, radiation to the axilla, body mass index (BMI), assessment time post-surgery, education, and partner status. RESULTS: Pain was significantly predicted by axillary lymph node management, lack of a partner, and post-operative infection; lymphedema by axillary lymph node management, number of axillary nodes dissected, radiation to the axilla, and having a modified radical mastectomy; functional disability by post-operative infection and high BMI; and restricted external rotation by axillary lymph node management, low educational attainment, and advanced disease. CONCLUSION: Comprehensive behavioral management and rehabilitation programs are needed to treat arm morbidity following breast cancer surgery. These programs should address the full scope of symptoms and associated psychosocial and functional sequelae.

The impact of breast cancer among Canadian women: disability and productivity.

Each year over 20,000 Canadian women are diagnosed with breast cancer. Many breast cancer survivors anticipate a considerable number of years of potential participation in the paid labour market, therefore, the link between breast cancer survivorship and productivity deserves serious consideration. The hypothesis guiding this study is that arm morbidities such as lymphedema, pain, and range of motion limitations are important explanatory variables in survivors' loss of productivity. The study draws from a larger longitudinal research project involving over 600 breast cancer survivors in four geographical locations across Canada. The study's regression results indicate that, after adjusting for fatigue, breast cancer stage, and geographical location, survivors with range of motion limitations and arm pain are more than two and half times as likely to lose some productivity capacity as compared to counterparts with no arm morbidity. The findings make a compelling argument for the necessity of adequate rehabilitation programs delivered at crucial times in breast cancer survivors' recovery. The study's unexpected finding that geographical location is a highly significant predictor of changes in productivity among breast cancer survivors is interpreted as a factor of the regulatory framework governing employment relationships in the four different jurisdictions.

Predicting recreational difficulties and decreased leisure activities in women 6-12 months post breast cancer surgery.

INTRODUCTION: A Canadian research team is conducting a multi-centered, non-interventional national study with the objective of charting the course of arm morbidity after breast cancer surgery. This paper examined the relationship between arm morbidity and leisure and recreational activities of affected women. METHODS: Five hundred and forty seven women with stage I-III breast cancer were recruited in four centers across Canada: Surrey (BC); Winnipeg (MB), Montreal (QB) and Fredericton (NB). Participants were enrolled in the study 6-12 months post surgery. Physical examination was used to assess arm and shoulder functioning and questionnaires were used to assess disability, pain, and participation in recreational and leisure activities. RESULTS: At the first clinical assessment (T1), the mean number of months post breast cancer surgery was 8.4. At T1 49% of women reported difficulty with recreational activities that involved "some force or impact" and 29% experienced negative changes to their involvement in leisure activities. A hierarchical multiple regression analysis found that several arm morbidity variables were significant predictors of difficulty with participation in recreational activities. A second hierarchical regression found also that arm morbidity factors were significant predictors of negative changes in leisure activities. Follow-up analyses found that arm morbidity, was most closely related to difficulty with recreational activities requiring free movement of the arm and using force. CONCLUSION: Many women treated for breast cancer experience arm morbidity. Arm morbidity is related to difficulties with recreational activities and negative changes in leisure activity participation. IMPLICATIONS: Breast cancer survivors should engage in recreational and leisure activities that are compatible with reduced range of motion and pain, and avoid those that exacerbate their arm morbidity.

Arm morbidity and disability after breast cancer: new directions for care.

PURPOSE/OBJECTIVES: To chart the incidence and course of three types of arm morbidity (lymphedema, pain, and range of motion [ROM] restrictions) in women with breast cancer 6-12 months after surgery and the relationship between arm morbidity and disability. DESIGN: Longitudinal mixed methods approach. SETTING: Four sites across Canada. SAMPLE: 347 patients with breast cancer 6-12 months after surgery at first point of data collection. METHODS: Incidence rates were calculated for three types of arm morbidity, correlations between arm morbidity and disability were computed, and open-ended survey responses were compiled and reviewed. MAIN RESEARCH VARIABLES: Lymphedema, pain, ROM, and arm, shoulder, and hand disabilities. FINDINGS: Almost 12% of participants experienced lymphedema, 39% reported pain, and about 50% had ROM restrictions. Little overlap in the three types of arm morbidity was observed. Pain and ROM restrictions correlated significantly with disability, but most women did not discuss arm morbidity with healthcare professionals. CONCLUSIONS: Pain and ROM restrictions are prevalent 6-12 months after surgery, but lymphedema is not. Pain and ROM restrictions are associated with disability. IMPLICATIONS FOR NURSING: Screening for pain and ROM restrictions should be part of breast cancer follow-up care. Left untreated, arm morbidity could have a long-term effect on quality of life. Additional research into the longevity of various arm morbidity symptoms and possible interrelationships also is required.

The needs of depressed women: perspectives of family physicians.

Twenty family physicians (11 female and 9 male) were interviewed about their experiences in treating depressed patients. Interview transcripts were analyzed thematically with respect to physicians' understanding of women's depression and their treatment strategies with depressed women. Stress arising in the social context of women's lives was perceived as a key precipitant of depression in women, with family-related, gender-specific and practical sources of stress as the main contributors. Physicians' treatment strategies had the aims of alleviating depressive symptoms and stress reduction. Implications of the findings for primary health care delivery and community-based interventions with depressed women are discussed.

Beyond dichotomies of health and illness: life after breast cancer.

While there has been a vast amount of research on breast cancer in recent years, areas within this domain remain unexplored. For instance, there have been few attempts to marry an understanding of the social context in which breast cancer occurs with an understanding of subjective experiences of this condition. The purpose of this study was to explore women's experiences of embodiment after breast cancer, utilizing a phenomenological approach rooted in a feminist perspective. The focus of this article is upon the changes to embodiment that are long-term. Twelve women were interviewed on two occasions each and were asked to talk about changes to their bodies that occurred as a result of breast cancer. Three key themes were identified: (1) how it feels (e.g. sensation and breast loss); (2) managing appearances (e.g. wearing prostheses); and (3) treatments without end (e.g. menopause). The findings of this study show that women with breast cancer are a diverse group and that survivorship is a dynamic, life-long process, which suggests that health professionals can play an important role in establishing interdisciplinary approaches to caring, beyond the conclusion of acute treatment.

Breast cancer-related lymphedema: women's experiences with an underestimated condition.

OBJECTIVE: One distressing health problem facing breast cancer patients is breast cancer-related lymphedema (BCRL). This incurable condition can occur many years after treatment is completed and often causes pain and disability and interferes with work and activities of daily living. Patients at risk of BCRL are those who have received radiation therapy or axillary node dissection; higher incidence is reported among patients who have had both radiation and dissection. Our objective was to explore New Brunswick women's experiences of BCRL and its treatment. DESIGN: A focus group and 15 individual in-depth interviews. SETTING: Province of New Brunswick. PARTICIPANTS: A diverse sample of 22 women with BCRL was obtained using age, location, time after breast cancer diagnosis, and onset of BCRL symptoms as selection criteria. METHOD: The focus group discussion guided development of a semistructured interview guide that was used for 15 individual interviews exploring women's experiences with BCRL. MAIN FINDINGS: Four themes emerged from the interviews. First, participants thought they were poorly informed about the possibility of developing BCRL. Eleven women reported receiving very little or no information about BCRL. Second, triggers and symptoms varied. Participants used words such as numb, heavy, tingling, aching, seeping fluid, hard, tight, limited mobility, and burning to describe symptoms. They reported a variety of both aggravating and alleviating factors for their symptoms. Some actions, such as applying heat, were thought to both exacerbate and reduce symptoms. Third, in New Brunswick, access to treatment is poor, compression garments are costly, and accessing physiotherapists is difficult. Last, the effect of BCRL on daily life is profound: 12 of the 15 women reported that it interfered with work and day-to-day activities. CONCLUSION: Participants were unaware of the risk factors and treatment options for BCRL. Family physicians should discuss BCRL with their breast cancer patients routinely. They should be vigilant for the possible onset of BCRL and, if it is diagnosed, should manage it aggressively to minimize the severe effect it has on the lives of breast cancer patients.

Diagnosing depression: there is no blood test.

OBJECTIVE: To explore and describe primary care physicians' experiences in providing care to depressed patients and to increase understanding of the possibilities and constraints around diagnosing and treating depression in primary care. DESIGN: Qualitative study using personal interviews. SETTING: A hospital region in eastern Canada. PARTICIPANTS: A purposely diverse sample of 20 physicians chosen from among all 100 practising family physicians in the region. METHOD: Invitations were mailed to all physicians practising in the region. Twenty physicians were chosen from among the 39 physicians responding positively to the invitation. Location of practice, sex, and year of graduation from medical school were used as sampling criteria. The 20 physicians were then interviewed, and the interviews were audiotaped and transcribed verbatim. Data were analyzed using a constant comparative approach involving handwritten notes on transcripts and themes created using qualitative data analysis software. MAIN FINDINGS: Three themes related to diagnosis emerged. The first concerns use of checklists. Physicians said they needed an efficient but effective means of diagnosing depression and often used diagnostic aids, such as checklists. Some physicians, however, were reluctant to use such aids. The second theme, interpersonal processes, involved the investment of time needed for diagnosing depression and the importance of establishing rapport. The final theme, intuition, revealed how some physicians relied on "gut sense" and years of experience to make a diagnosis. CONCLUSION: Diagnosis of depression by primary care physicians involves a series of often complicated negotiations with patients. Such negotiations require expertise gained through experience, yet prior research has not recognized the intricacies of this diagnostic process. Our findings suggest that future research must recognize the complex and multidisciplinary nature of physicians' approaches to diagnosis of depression in order to better reflect how they practise.

Physicians' constructions of depression: inside/outside the boundaries of medicalization.

A qualitative study explored primary care physicians' experiences of diagnosing and treating depression. Twenty physicians participated in semi-structured interviews. Interview questions asked physicians to consider a range of topics such as the etiology of depression, the diagnostic process and treatment of depression. Transcripts were analyzed discursively with a view to exploring the ways in which physicians construct depression. In this article, physicians' constructions of depression are examined through exploration of their descriptions of this condition, as well as their recognition of the social context of depression. Based on this analysis, it was concluded that physicians' medicalized understandings of depression conflict with recognition of the social context of depression. The result of this conflict is dissonant descriptions of depression. One implication of this research is that physicians' training would benefit from the integration of multidisciplinary perspectives on depression, which would better reflect physicians' experiences in routine practice situations.

Memories of treatment: the immediacy of breast cancer.

This article represents one facet of the author's research on women's experiences of embodiment after breast cancer. Herein, women's reliance on and rejection of medicalized understandings of this condition are explored via participants' descriptions of memories of treatment. Data collection consisted of 24 in-depth interviews with 12 women, using phenomenological and feminist approaches. Five themes emerged: (a) issues of control, (b) suffering, (c) encountering medicine, (d) visible loss, and (e) leaving active treatment. Participants found the medicalization of breast cancer to be problematic, but they were also reluctant to leave the realm of acute care. Although a large volume of breast cancer research now exists, the women's accounts demonstrate that further research into the experience of breast cancer is necessary.

Understanding breast cancer stories via Frank's narrative types.

While breast cancer narratives have become prevalent in Western culture, few researchers have explored the structure of such narratives, relying instead on some form of thematic analysis based upon content. Although such analyses are valuable, Arthur Frank (The Wounded Storyteller, The University of Chicago Press, Chicago, 1995) provides researchers with an additional means of studying stories of illness, through the examination of their structures. In this article, the author applies Frank's work to a phenomenological study of embodiment after breast cancer. Frank's three narrative types are used to enhance understanding of the ways in which stories are culturally constructed, using data collected through one focus group discussion and two in-depth interviews with each of 12 women who had experienced breast cancer. The author then conveys the significance of this form of analysis for future research.

Barriers to treating depression in the family physician's office.

This qualitative research aims to understand, from the standpoint of the family physician, the barriers to treating depression in the office setting. Three primary barriers to treating depression in the family physician's office were identified: systemic, physician-related, and patient-related. The systemic barriers involved the shortage of qualified, publicly-funded counsellors, lack of locally available counselling, and the cost of medication. Physician-related barriers included lack of time and expertise, and inadequacies of the reimbursement system. Patient-related barriers were rooted in the stigma attached to depression and failure to comply with treatment.