American Society of Clinical Oncology‐recommended surveillance and physician specialty among long‐term breast cancer survivors

BACKGROUND:

It is unclear whether it is appropriate to transfer the follow‐up care of breast cancer (BrCa) survivors from cancer specialists to primary care physicians (PCPs). This contemporary study compared physician specialty and documented the long‐term surveillance of survivors who underwent surgery at an American academic center.

METHODS:

Women in this institutional review board‐approved study underwent breast surgery between 1996 and 2006. Data were collected for 270 patients with stage I to III BrCa (mean follow‐up, 6 years). Charts were reviewed based on American Society of Clinical Oncology (ASCO) guidelines for recommended surveillance frequency and care.

RESULTS:

The majority of patients (90%; n = 242) were followed by specialists with 10% (n = 28) followed by PCPs. Patients with advanced disease and a greater risk of disease recurrence more often received specialist care. Patients followed by specialists were more often seen at ASCO‐recommended intervals (eg, 89% vs 69% of patients followed by a PCP at follow‐up Year 6; P < .01); however, many patients were followed inconsistently. Breast disease was often not the focus of PCP visits or mentioned in clinic notes (18% patients). Women seen by specialists were more likely to have documented clinical examinations of the breast (93% vs 44% at Year 6), axilla (94% vs 52%), or annual mammograms (74% vs 48%; P = .001‐.02).

CONCLUSIONS:

Consistent compliance with surveillance guidelines and chart documentation needs improvement among all providers; however, specialists more consistently met ASCO guidelines. If transfer of care to a PCP occurs, it should be formalized and include follow‐up recommendations and defined physician responsibilities. Providers and patients should be educated regarding surveillance care and current guidelines incorporated into standard clinical practice. Cancer 2010. © 2010 American Cancer Society.     

Health‐related quality of life in long‐term breast cancer survivors

BACKGROUND:

The Survivor's Health and Reaction (SHARE) study examined health‐related quality of life (HRQL) in breast cancer patients who had participated in Cancer and Leukemia Group B Trial 8541 from 1985 to 1991.

METHODS:

In total, 245 survivors (78% of eligible patients) who were 9.4 to 16.5 years postdiagnosis (mean, 12.5 years postdiagnosis) completed HRQL surveys relating to 5 domains. Analyses examined HRQL domains according to 3 different chemotherapy dose levels that were administered in the original treatment trial: low‐dose cyclophosphamide, doxorubicin, and fluorouracil (CAF) at 300 mg/m², 30 mg/m², and 300×2 mg/m², respectively, over 4 cycles; standard‐dose CAF at 400 mg/m², 40 mg/m², and 400×2 mg/m², respectively, over 6 cycles; and high‐dose CAF at 600 mg/m², 60 mg/m² and 600×2 mg/m², respectively, over 4 cycles.

RESULTS:

In univariate analyses, a statistically significant difference was observed on the Medical Outcomes Study 36‐item short form Physical Role Functioning subscale by treatment group, with lower mean scores in the standard treatment arm (mean, 65.05) compared with mean scores in the low‐dose arm (mean, 74.66) and the high‐dose arm (mean, 84.94; P.0001). However, multivariate analysis revealed that treatment arm no longer was statistically significant, whereas the following factors were associated with decreased physical role functioning: age ≥60 years (odds ratio [OR], 3.55; P = .006), increased comorbidity interference total score (OR, 1.64; P = .005), lower vitality (OR, 1.05; P = .0002), and increased menopausal symptoms (OR, 1.04 P = .02).

CONCLUSIONS:

At 9.4‐16.5 years after their original diagnosis, differences in physical role functioning among breast cancer survivors who had received 3 different dose levels of chemotherapy were explained by clinical and demographic variables, such as age, fatigue, menopausal symptoms, and comorbidities. Prospective studies are needed to further assess the role of these factors in explaining HRQL and physical role functioning among long‐term survivors. Cancer 2009. © 2009 American Cancer Society.     

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.     

Fractures among long‐term survivors of childhood cancer

BACKGROUND:

Although reductions in bone mineral density are well documented among children during treatment for cancer and among childhood cancer survivors, little is known about the long‐term risk of fracture. The objective of this study was to ascertain the prevalence of and risk factors for fractures among individuals participating in the Childhood Cancer Survivor Study (CCSS).

METHODS:

Analyses included 7414 ≥5‐year survivors of childhood cancer diagnosed between 1970 and 1986 who completed the 2007 CCSS follow‐up questionnaire and a comparison group of 2374 siblings. Generalized linear models stratified by sex were used to compare the prevalence of reported fractures between survivors and siblings.

RESULTS:

The median ages at follow‐up among survivors and siblings were 36.2 years (range, 21.2‐58.8 years) and 38.1 years (range, 18.4‐62.6 years), respectively, with a median 22.7 years of follow‐up after cancer diagnosis for survivors. Approximately 35% of survivors and 39% of siblings reported ≥1 fracture during their lifetime. The prevalence of fractures was lower among survivors than among siblings, both in males (prevalence ratio, 0.87; 95% confidence interval, 0.81‐0.94; P < .001) and females (prevalence ratio, 0.94; 95% confidence interval, 0.86‐1.04; P = .22). In multivariable analyses, increasing age at follow‐up, white race, methotrexate treatment, and balance difficulties were associated with increased prevalence of fractures among female survivors (P = .015). Among males, only smoking history and white race were associated with an increased prevalence of fracture (P < .001).

CONCLUSIONS:

Findings from this study indicated that the prevalence of fractures among adult survivors did not increase compared with that of siblings. Additional studies of bone health among aging female cancer survivors may be warranted. Cancer 2012. © 2012 American Cancer Society.     

Knowledge of hepatitis C virus screening in long‐term pediatric cancer survivors

BACKGROUND:

Pediatric cancer survivors who were treated before routine hepatitis C virus (HCV) screening of blood donors in 1992 have an elevated risk of transfusion‐acquired HCV.

METHODS:

To assess long‐term pediatric cancer survivors' knowledge of HCV testing and blood transfusion history, a questionnaire was administered to 9242 participants in the Childhood Cancer Survivor Study who are at risk for transfusion‐acquired HCV after cancer therapy from 1970 to 1986.

RESULTS:

More than 70% of survivors reported either no prior HCV testing (41%) or uncertainty about testing (31%), with only 29% reporting prior testing. One half recalled having a treatment‐related blood transfusion; those who recalled a transfusion were more likely to report HCV testing (39%) than those who did not (18%) or were unsure (20%). In multivariate models, survivors who reported no prior HCV testing were more likely to be older (odds ratio [OR] per 5‐year increase, 1.1; 95% confidence interval [CI], 1.0‐1.1) and to report no care at a cancer center within the past 2 years (OR, 1.2; 95% CI, 1.0‐1.4), no cancer treatment summary (OR, 1.3; 95% CI, 1.2‐1.5), and no transfusions (OR, 2.6; 95% CI, 2.3‐3.0) or uncertainty about transfusions (OR, 2.2; 95% CI, 1.9‐2.6), and less likely to be racial/ethnic minorities (OR, 0.9; 95% CI, 0.8‐1.0) or survivors of acute myeloid leukemia (OR, 0.7; 95% CI, 0.5‐1.0).

CONCLUSIONS:

Many pediatric cancer survivors at risk for transfusion‐acquired HCV are unaware of their transfusion history and prior testing for HCV and would benefit from programs to increase HCV knowledge and screening. Cancer 2010. © 2010 American Cancer Society.     

Associations between lifestyle factors and quality of life among older long‐term breast,prostate, and colorectal cancer survivors

BACKGROUND:

Older cancer survivors are at increased risk for secondary cancers, cardiovascular disease, obesity, and functional decline and, thus, may benefit from health‐related interventions. However, to the authors' knowledge, little is known regarding the health behaviors of older cancer survivors and the associations of those behaviors with quality‐of‐life outcomes, especially during the long‐term post‐treatment period.

METHODS:

In total, 753 older (aged ≥65 years) long‐term survivors (≥5 years postdiagnosis) of breast, prostate, and colorectal cancer completed 2 baseline telephone interviews to assess their eligibility for a diet and exercise intervention trial. The interviews assessed exercise, diet, weight status, and quality of life.

RESULTS:

Older cancer survivors reported a median of 10 minutes of moderate‐to‐vigorous exercise per week, and only 7% had Healthy Eating Index scores >80 (indicative of healthful eating habits relative to national guidelines). Despite their suboptimal health behaviors, survivors reported mental and physical quality of life that exceeded age‐related norms. Greater exercise and better diet quality were associated with better physical quality‐of‐life outcomes (eg, better vitality and physical functioning; P < .05), whereas greater body mass index was associated with reduced physical quality of life (P < .001).

CONCLUSIONS:

The current results indicated a high prevalence of suboptimal health behaviors among older, long‐term survivors of breast, prostate, and colorectal cancer who were interested in lifestyle modification. In addition, the findings pointed to the potential negative impact of obesity and the positive impact of physical activity and a healthy diet on physical quality of life in this population. Cancer 2009. © 2009 American Cancer Society.     

Evaluation of the Fertility and Cancer Project (FCP) among young breast cancer survivors

Objective: Fertility and childbearing issues are the major quality of life concerns among young breast cancer survivors. Practical approaches are needed to convey reproductive health information. The Fertility and Cancer Project (FCP) is a dedicated research project that provides online reproductive health and fertility education. We report FCP participants' (a) changes in mood and functioning and (b) changes in knowledge of fertility and cancer from baseline to 6‐month follow‐up. Methods: Participants completed five self‐report baseline measures, accessed FCP content and participated in online discussions. At 6 months post FCP study entry, participants were asked to complete follow‐up self‐reports. Results: One hundred and six breast cancer survivors from 8 countries participated in the FCP. Mean age at diagnosis was 34.3 years; mean time since diagnosis was 22 months. Significant change was detected in improved physical functioning (p=0.019) and social functioning (p=0.02). Significant changes were also noted in improved fertility knowledge (p=0.011). Conclusion: Preliminary evidence shows that young breast cancer survivors derive improved mood and knowledge benefit from FCP participation. Internet‐based approach may be a viable format for engaging this population of cancer survivors. Copyright © 2009 John Wiley & Sons, Ltd.     

Post-treatment regret among young breast cancer survivors

Objective: The study addresses: (1) what women regret about their breast cancer treatment 5 years later, and (2) what characteristics of disease and treatment predict post‐treatment regret. Method: Interviews were conducted with breast cancer survivors in the San Francisco Bay Area. Participants were interviewed following diagnosis. Five years later, women were asked whether they had any regrets about their cancer treatment (N=449). Qualitative analysis was used to identify regret content, and logistic regression was used to determine what characteristics of treatment predicted regret. Results: Forty two point five percent women in the sample regretted some aspect of the treatment. The most common regrets were primary surgery (24.1%), chemotherapy and/or radiation (21.5%), reconstruction (17.8%), and problems with providers (13.1%). In addition, women regretted inactions (59.2%) (actions that they did not take) more than actions that they did take (30.4%). This represents a novel finding in the study of post‐treatment regret, which has largely focused on regrets over actions. Quantitative analysis revealed that women who were anxious about the future (OR=1.32; p=0.03) or had problems communicating with physicians (OR=1.26; p=0.02) during treatment were more likely to express regret 5 years later. In addition, women with new or recurrent cancers 5 years later were significantly more likely to regret some aspect of their primary treatment (OR=5.81; p<0.001). Conclusion: This research supports addressing the psychosocial aspects of cancer care and improving physician‐patient communication. Evidence is also provided for addressing the unique emotional needs of women with recurrent cancers, who may experience an undue burden of regret. Copyright © 2010 John Wiley & Sons, Ltd.     

Prospective assessment of quality of life in long‐term ovarian cancer survivors

The objective of our study was to compare prospectively the QoL in long‐term ovarian cancer survivors with short‐term survivors and to explore discriminating variables between short‐term and long‐term survival. Thirty‐three patients were included, 22 died within 5 years post diagnosis and 11 survived beyond 10 years. QoL data were collected pre‐treatment (baseline), 1‐year post diagnoses and for long‐term survivors 10 years post‐treatment using the EORTC QLQ‐C30. At baseline, there was no difference in terms of FIGO stage, residual tumor and adjuvant chemotherapy. Significantly, more short‐term survivors (96%) had intra operative ascites as compared to long‐term survivors (55%) (p=0.01). Before treatment, short‐term survivors had clinically significantly lower QoL scores on the physical functioning (mean 75.45) and role functioning scale (mean 68.94) compared to long‐term survivors (mean 68.94 and 84.85, respectively). They also reported higher levels of symptoms. One year post‐diagnosis, QoL scores were comparable in most domains. Long‐term survivors had a significantly better global QoL but more insomnia. Emotional functioning and global QoL/health status improved significantly from baseline to 1‐year post‐diagnosis and remained relatively stable at the 10‐year follow‐up. The presence of intra operative ascites and a supporting social network were identified as significant variables that discriminated between short‐term and long‐term survival. Compared to a reference sample, long‐term survivors showed similar QoL scores but more dyspnoea. Although ovarian cancer patients do not belong to the most prevalent survivor populations, we found that long‐term survivors have QoL scores similar to females without a history of cancer.