Bone mineral density and adjuvant therapy in breast cancer survivors

Compared to mean values from a US database, premenopausal breast cancer survivors (BCS) had significantly higher whole body bone mineral density (BMD) compared to age and ethnicity matched referents; higher whole body BMD was present in all premenopausal BCS, including those who received chemotherapy, tamoxifen+chemotherapy, or no adjuvant therapy. Postmenopausal BCS who had received no adjuvant therapy also had higher whole body BMD compared to similarly aged women. In contrast, hip and lumbar spine BMD values in BCS were similar to those of the population-based database.     

Pre-diagnosis physical activity and mammographic density in breast cancer survivors

Summary Purpose To investigate the association between physical activity (PA) and mammographic density in the year before diagnosis in a population-based sample of 474 women diagnosed with stage 0–IIIA breast cancer and enrolled in the Health, Eating, Activity, and Lifestyle Study. Methods We collected information on PA during an interview administered at a baseline visit scheduled within the first year after diagnosis. Participants recalled the type, duration, and frequency of different PAs for the year prior to their diagnosis. Dense area and percent density were estimated, from mammograms imaged approximately 1 year before diagnosis, as a continuous measure using a computer-assisted software program. Analysis of covariance methods were used to obtain mean density across PA tertiles adjusted for confounders. We stratified analyses by menopausal status and body mass index (BMI) because these factors strongly influence density. Results We observed a statistically significant decline in mammographic dense area (p for trend = 0.046) and percent density (p for trend = 0.026) with increasing level of sports/recreational PA in postmenopausal women with a BMI ≥30 kg/m². Conversely, in premenopausal women with a BMI <‰30 kg/m², we observed a statistically significant increase in percent density with increasing level of sports/recreational PA (p for trend = 0.037). Conclusions Both mammographic dense area and percent density are inversely related to level of sports/recreational PA in obese postmenopausal women. Increasing PA among obese postmenopausal women may be a reasonable intervention approach to reduce mammographic density.     

Optimisation of breast cancer patients' follow‐up – potential way to improve cancer care in transitional countries

The aim of this analysis was to evaluate adherence of Croatian oncologists to follow‐up criteria as suggested by the current national and international guidelines for women with breast cancer receiving adjuvant endocrine therapy. The use of clinical and diagnostic methods was documented in this prospective, non‐interventional, multicenter study. A total of 438 post‐menopausal patients receiving adjuvant endocrine treatment with non‐steroidal aromatase inhibitors were included. Average annual frequency for each clinical and diagnostic method was calculated. Median adjuvant endocrine treatment duration before study recruitment was 10.5 months (interquartile 4.7–26.6). Patients were followed up for an average 23.5 ± 4.9 months. Average number of oncological visits was 5.3. Mammograms were performed at mean annual frequency of 0.7, chest radiographs at 0.5, abdominal ultrasounds at 0.9, breast ultrasounds at 1.2, complete blood counts and chemistry panels at 1.7, carcinoembryonic antigen at 0.8, cancer antigen 15‐3 at 1.6, gynaecological examination at 0.3, and densitometry at mean annual frequency of 0.3. In conclusion, among post‐menopausal women with breast cancer receiving adjuvant endocrine therapy in this study, more unnecessary and unproven follow‐up procedures were done compared to the guidelines' recommendations.     

Tailored education enhances healthy behaviour self‐efficacy in childhood cancer survivors: A randomised controlled study with a 4‐month follow‐up

This study was to evaluate the acceptability and effectiveness of a tailored education on healthy behaviour self‐efficacy (HBSE) and health promotion lifestyle (HPL) for childhood cancer survivors. A two‐group, randomised study with repeated measures was conducted in Taiwan. Participants were randomly assigned to receive six 45–60 min individual education and follow‐up telephone counselling sessions (n = 34) or standard of care only (n = 35). Each participant was assessed with HBSE and HPL questionnaires and was evaluated at three time points (at baseline, and then 1 and 4 months after intervention). The attrition rate was 7.2%. HBSE and HPL scores increased across the three time points in the experimental group (all p < 0.05), except for the HBSE exercise subscale (p = 0.85). HBSE scores were significantly higher for the experimental group than for the control group after 4 months of intervention (F = 5.32, p = 0.02, η² = 0.25). No significant improvements in HBSE were observed over time in the control group. The intervention was acceptable and effective in promoting HBSE in childhood cancer survivors. Further empirical work is needed to reveal the effects of the intervention over a longer period of time and to improve patient engagement in exercise.     

A study of body image in long‐term breast cancer survivors

BACKGROUND:

In this controlled postdiagnosis study, the authors examined various aspects of body image of breast cancer survivors in cross‐sectional and longitudinal designs.

METHODS:

In 2004 and 2007 the Body Image Scale (BIS) was completed by the same 248 disease‐free women who had been treated for stage II and III breast cancer between 1998 and 2002. “Poorer” body image was defined as greater than the 70th percentile (N = 76 women) of the BIS scores in contrast to “better” body image (N = 172 women). Breast cancer survivors were examined clinically in 2004, and their BIS scores were compared with the scores from an age‐matched group of women from the general population.

RESULTS:

In this cross‐sectional study, poorer body image in 2004 was associated significantly with modified radical mastectomy, undergoing or planning to undergo breast‐reconstructive surgery, a change in clothing, poor physical and mental health, chronic fatigue, and reduced quality of life (QoL). In univariate analyses, most of these factors and manually planned radiotherapy were significant predictors of poorer body image in 2007. In multivariate analyses, manually planned radiotherapy, poor physical QoL and high BIS score in 2004 remained independent predictors of a poorer body image in 2007. Body image ratings were relatively stable from 2004 to 2007. Twenty‐one percent of breast cancer survivors reported body image dissatisfaction, similar to the proportion of dissatisfaction in controls.

CONCLUSIONS:

In this cross‐sectional analysis, body image in breast cancer survivors was associated with the types of surgery and radiotherapy and with mental distress, reduced health, and impaired QoL. Body image ratings were relatively stable over time, and the antecedent body image score was a strong predictor of body image at follow‐up. Body image in breast cancer survivors differed very little from that in controls. Cancer 2010. © 2010 American Cancer Society.     

Determinants of physical,affective, and cognitive fatigue during breast cancer therapy and 12 months follow‐up

Fatigue is common in cancer survivors but often insufficiently treated. Due to its complexity a one‐size‐fits‐all treatment seems not appropriate. To gain more information on influencing factors and sub‐dimensions of fatigue we investigated potential determinants and correlates of physical, affective, and cognitive fatigue in breast cancer survivors during and after adjuvant therapy. Within the follow‐up of two randomized controlled trials physical, affective, and cognitive fatigue were repeatedly assessed during and up to 12 months after cancer therapy with the 20‐item Fatigue Assessment Questionnaire in 255 breast cancer survivors. Determinants of the different fatigue dimensions over time were explored with linear mixed models. Chemotherapy appeared as significant precipitating factor for physical fatigue. However, type of cancer therapy had no impact on fatigue one year post‐treatment. Obesity was significantly associated with increased physical fatigue throughout all time points (Δ=15.5 at 12 months) whereas exercise appeared to be beneficial (Δ = ?6.3). In contrast, affective fatigue was significantly associated with poor social support and worries about the future. In addition, poor sleep quality and previous use of psychopharmaceuticals were significantly associated with physical, affective, as well as cognitive fatigue. Further, hot flashes were associated with increased physical and cognitive fatigue. In conclusion, the broad diagnosis ‘fatigue’ in cancer survivors needs to be recognized as a diversity of symptoms determined by specific characteristics and likely different etiologies. Taking potential influencing factors such as obesity, physical inactivity, sleep problems, hot flashes, lack of social support, or psychological disorders into consideration might enable a better, individually‐tailored fatigue treatment.     

The evolution of worry after breast cancer risk assessment: 6‐year follow‐up of the TRACE study cohort

Objectives: There is little evidence regarding the long‐term psychological implications of breast cancer risk assessment for women at moderate genetic risk. A follow‐up study of a trial cohort was conducted to evaluate psychological outcomes and their predictors at 6‐year follow‐up. A further aim was to examine threshold scores for high cancer worry. Methods: Questionnaires were sent to 384 women assessed as moderate risk during a UK trial of genetic assessment (TRACE). Measures included cancer worry, perceived risk, health behaviours, general anxiety, psychological morbidity, optimism, and background variables assessed during TRACE and at 6‐year follow‐up. Results: Reductions from baseline cancer worry and breast self‐examination (BrSE) frequency were maintained 6 years after risk assessment, with relatively consistent levels over short‐ and long‐term follow‐up. Provision of risk information led to short‐term reductions in perceived risk. During the 6‐year period, 43% of women reported having made lifestyle changes and 27% had requested a mammogram. Baseline and post‐risk cancer worry were the only significant predictors of long‐term cancer worry. Greater worry at baseline predicted more frequent BrSE and higher perceived risk, but not lifestyle change or mammogram requests, at 6 years. Eighteen percent of women reported cancer worry above a threshold of 12.5 at long‐term follow‐up, compared with 30% at baseline. Conclusions: Overall reductions in cancer worry following moderate risk assessment were maintained in the long term. However, women at risk of sustained high cancer worry should be identified at an early stage in the risk assessment process for more intensive psycho‐educational intervention. Copyright © 2010 John Wiley & Sons, Ltd.     

Body size and breast cancer risk: the Multiethnic Cohort

The influence of body size on postmenopausal breast cancer risk was investigated among five racial/ethnic groups in the Multiethnic Cohort. Participants were 45-75 years old at recruitment (1993-1996), living in Hawaii and California. Of the 82,971 White, African American, Native Hawaiian, Japanese and Latina women included in this analysis, 3,030 were diagnosed with invasive breast cancer. Body mass index (BMI), height, weight and adulthood weight gain were associated with a significantly higher risk and, with the exception of height, were found to vary across ethnic groups. Native Hawaiians and Japanese with a BMI≥30.0 compared to 20.0-24.9 kg/m2 had the highest risk (hazard ratio=1.82, 95% confidence interval: 1.31, 2.54, p-trend=0.001, and hazard ratio=1.59, 95% confidence interval: 1.24, 2.05, p-trend<0.0001, respectively). Current hormone replacement therapy use modified the impact of a high BMI, as non- and former users had a significantly higher risk compared to current users. BMI also had a more pronounced risk for advanced tumors compared to localized tumors. When both BMI and adult weight gain were analyzed simultaneously, adult weight gain, rather than BMI, was a significant risk factor overall. These findings emphasize the significance of maintaining a healthy weight throughout adulthood for the prevention of postmenopausal breast cancer.     

Prolonged impact of chemotherapy on fatigue in breast cancer survivors: a longitudinal comparison with radiotherapy-treated breast cancer survivors and noncancer controls

BACKGROUND:

In this study, the authors examined the influence of prior treatment on the course of fatigue in breast cancer survivors. Patients who received chemotherapy were expected to have greater fatigue than patients who received radiotherapy and noncancer controls 6 months after the completion of treatment, but they were expected to recover to levels similar to those of the other 2 groups 3 years later.

METHODS:

Patients with stage 0 through II breast cancer completed the Fatigue Symptom Inventory (FSI) and the Profile of Mood States Fatigue Scale (POMS‐FAT) 6 months (T1) and 42 months (T2) after completing chemotherapy with or without radiotherapy (the CT group; n = 103) or radiotherapy only (the RT group; n = 102). An age‐matched group of women with no history of cancer (the NC group; n = 193) was assessed over a similar interval.

RESULTS:

A significant (P = .041) group × time effect for FSI severity scores revealed that fatigue worsened over time in the CT group but remained stable and lower in the RT and NC groups. There also were significant group effects for FSI days (P < .001) and POMS‐FAT (P = .010) scores, indicating that fatigue was significantly greater across time in the CT group than in the NC group (POMS‐FAT) or the RT and NC groups (FSI days).

CONCLUSIONS:

Contrary to expectations, fatigue did not diminish over time in patients with breast cancer who received chemotherapy. This finding has important implications for patient education and for fatigue monitoring during follow‐up. The authors concluded that future research should seek to examine possible mechanisms to explain the apparent prolonged impact of chemotherapy on fatigue in breast cancer survivors. Cancer 2012. © 2011 American Cancer Society.     

Changing socioeconomic inequalities in cancer incidence and mortality: Cohort study with 54 million person‐years follow‐up 1981–2011

Cancer is increasingly responsible for the mortality gap between high and low socioeconomic position groups in high‐income countries. This study investigates which cancers are contributing more to socioeconomic gaps in mortality and how this changes over time.New Zealand census data from 1981, 1986, 1991, 1996, 2001 and 2006, were linked to three to five years of subsequent mortality and cancer registrations, resulting in 54 and 42 million years of follow‐up cancer incidence and mortality, respectively. Age‐ and ethnicity‐standardised cancer mortality rates and the slope index of inequality (SII) by income were calculated.The contribution of cancer to absolute inequalities (SII) in mortality increased from 16 to 27% for men and from 12 to 31% for women from 1981–84 to 2006–11, peaking in 1991–94 for men and in 1996–99 for women and then levelling off, parallel to peaks in lung cancer inequalities. Lung cancer was the largest driver of cancer inequality trends (49% of the cancer mortality gap in 1981–84 to 33% in 2006–11 for men and 32 to 33% for women) followed by colorectal cancer in men (2 to 11%) and breast cancer in women (declining from 44 to 13%). Women in the lowest income quintile experienced no decline in cancer mortality.The contribution of cancer to income inequalities in all‐cause mortality has expanded in this high‐income country. Action to address socioeconomic inequalities should prioritise equitable tobacco control, obesity control and improved access to cancer screening, early diagnosis and high quality treatment for those with the lowest incomes.