Cancer surveillance behaviors and psychosocial factors among long‐term survivors of breast cancer

BACKGROUND:

Little is known about cancer surveillance (mammography, clinical breast examination, and pelvic examination) behaviors in long‐term (9‐16 years) breast cancer survivors. This report describes the relation of these behaviors to demographic and clinical characteristics, psychological symptoms, body satisfaction, and social support.

METHODS:

Survivors who had participated in Cancer and Leukemia Group B treatment Trial 8541 completed a survey that included questions on breast cancer surveillance and pelvic examination, psychological well being, body satisfaction, and social support.

RESULTS:

The participation rate was 78% and included 245 breast cancer survivors. Survivors (n = 107; 44%) reported completing breast cancer surveillance (mammography and clinical breast examination) and completing pelvic examination (n = 162; 68%) within recommended guidelines. There were no significant associations between breast cancer surveillance and breast cancer anxiety, depression, stressful life events, body satisfaction, social support, or demographic characteristics. Survivors within recommended guidelines for pelvic examinations were younger (P = .05), married (P = .003), had health insurance (P = .004), and had lower depression scores (P = .005) than survivors who underused or overused pelvic examination. In addition, survivors within recommended pelvic examination guidelines had significantly lower levels of breast cancer anxiety (P = .03) compared with survivors who underused pelvic examination.

CONCLUSIONS:

Many long‐term breast cancer survivors were not within recommended cancer surveillance guidelines. Private health insurance was associated with following recommendations for pelvic examinations, although such a relation did not exist for breast cancer surveillance. The results of this study have implications for the development of educational programs to improve cancer surveillance among the growing population of long‐term breast cancer survivors. Cancer 2009. © 2009 American Cancer Society.     

Health status and quality of life among non‐Hodgkin lymphoma survivors

BACKGROUND:

A growing body of evidence suggests that long‐term survivors with 1 of the more common forms of adult cancer report a quality of life (QOL) similar to that in the general population. However, specific concerns have been identified (sexual dysfunction, fatigue, distress) in this population. Also, less is known concerning survivors of adult non‐Hodgkin lymphoma (NHL), a disease often marked by alternating periods of disease and remission. Therefore, in the current study, the authors compared the QOL status of individuals who reported having active NHL with the QOL status of individuals who were disease‐free short‐term survivors (STS) (2‐4 years postdiagnosis) and long‐term survivors (LTS) (≥5 years postdiagnosis).

METHODS:

Eligible survivors completed a mailed survey with validated measures, including physical and mental health status measured with the Medical Outcomes Study 36‐item Short Form, cancer‐related QOL, the Functional Assessment of Cancer Therapy‐Lymphoma module, and self‐reported impact of cancer. Other data were collected to examine as correlates.

RESULTS:

Seven hundred sixty‐one survivors identified from 2 North Carolina cancer registries participated. The average survivor was 10.4 years postdiagnosis (range, 2‐44 years postdiagnosis) and was age 62.7 years (range, 25‐92 years). Survivors with active disease (n = 109) demonstrated worse physical and mental health functioning, worse QOL, and less positive and more negative impacts of cancer compared with disease‐free survivors (n = 652; all P ≤ .01). No significant differences were observed between STS and LTS.

CONCLUSIONS:

Although survivors with NHL who had active disease reported more negative outcomes compared with off‐treatment survivors, the length of time after diagnosis did not appear to matter with regard to outcomes for STS or LTS. In addition, mixed results from comparisons with general population norms suggested the need for supportive care for this diverse survivorship group. Cancer 2009. © 2009 American Cancer Society.     

Health status of the oldest adult survivors of cancer during childhood

BACKGROUND:

Young adult survivors of childhood cancer have an increased risk for treatment‐related morbidity and mortality. In this study, the authors assessed how treatment for childhood cancer affects older‐adult health and health practices.

METHODS:

One hundred seven adults treated for childhood cancer between 1947 and 1968, known to have survived past age 50 years, were identified from a single‐institution cohort established in 1975. Updated vital status on eligible cases was obtained from public records. Survivors and a control group of their age‐matched siblings and cousins completed a mailed survey to assess physical and social function, healthcare practices, and the prevalence of common adult illnesses.

RESULTS:

Of the 107 survivors known to be alive at age 50 years, 16 were deceased at follow‐up; 7 deaths could be associated with prior treatment (second malignancy in radiation field [3], small bowel obstruction after abdominal radiation [2], and cardiac disease after chest irradiation [2]). The 55 survivors (median age, 56 years; range, 51‐71 years), and 32 family controls (median age, 58 years; range, 48‐70 years), reported similar health practices, health‐related quality of life, and social function. However, survivors reported more frequent visits to healthcare providers (P < .05), more physical impairments (P < .05), fatigue (P = .02), hypertension (P = .001), and coronary artery disease (P = .01). An increased risk of hypertension was associated with nephrectomy during childhood (odds ratio, 18.9; 95% confidence interval, 3.0‐118.8).

CONCLUSIONS:

The oldest adult survivors of childhood cancer continue to be at risk for treatment‐related complications that potentially decrease their life expectancy and compromise their quality of life. Cancer 2010. © 2010 American Cancer Society.     

Rural‐urban disparities in health status among US cancer survivors

BACKGROUND:

Although rural residents are more likely to be diagnosed with more advanced cancers and to die of cancer, little is known about rural‐urban disparities in self‐reported health among survivors.

METHODS:

The authors identified adults who had a self‐reported history of cancer from the National Health Interview Survey (2006‐2010). Rural‐urban residence was defined using US Census definitions. Logistic regression with weighting to account for complex sampling was used to assess rural‐urban differences in health status after accounting for differences in demographic characteristics.

RESULTS:

Of the 7804 identified cancer survivors, 20.8% were rural residents. This translated to a population of 2.8 million rural cancer survivors in the United States. Rural survivors were more likely than urban survivors to be non‐Hispanic white (P < .001), to have less education (P < .001), and to lack health insurance (P < .001). Rural survivors reported worse health in all domains. After adjustment for sex, race/ethnicity, age, marital status, education, insurance, time since diagnosis, and number of cancers, rural survivors were more likely to report fair/poor health (odds ratio, 1.39; 95% confidence interval, 1.20‐1.62), psychological distress (odds ratio, 1.23; 95% confidence interval, 1.00‐1.50), ≥2 noncancer comorbidities (odds ratio, 1.15; 95% confidence interval, 1.01‐1.32), and health‐related unemployment (odds ratio, 1.66; 95% confidence interval, 1.35‐2.03).

CONCLUSIONS:

The current results provide the first estimates of the proportion and number of US adult cancer survivors who reside in rural areas. Rural cancer survivors are at greater risk for a variety of poor health outcomes, even many years after their cancer diagnosis, and should be a target for interventions to improve their health and well being. Cancer 2013. © 2012 American Cancer Society.     

Limitations in health care access and utilization among long‐term survivors of adolescent and young adult cancer

BACKGROUND:

Health care outcomes for long‐term survivors of adolescent and young adult (AYA) cancer were compared with young adults without a cancer history, using the 2009 Behavioral Risk Factor Surveillance System data.

METHODS:

Eligible participants were 20 to 39 years of age. There were N = 979 who self‐reported a cancer diagnosis between the ages of 15 to 34 years and were at least 5 years from diagnosis (excluding nonmelanoma skin cancer). The remaining 67,216 participants with no cancer history were used as controls. Using multivariable regressions, relative risks and 95% confidence intervals were generated to examine the relationship of survivor status on indicators of poor health care (uninsured, no personal health care provider, no routine care, and avoiding seeing a doctor due to cost). Adjusted proportions were calculated by demographic groups. Results are weighted by Behavioral Risk Factor Surveillance System survey design.

RESULTS:

Although the proportion uninsured did not differ (21% of survivors vs 23% of controls), AYA survivors reported forgoing care due to cost at higher levels than controls (relative risk = 1.67, 95% CI = 1.44‐1.94). Cost barriers were particularly high for survivors aged 20 to 29 years (44% vs 16% of controls; P < .001) and female survivors (35% vs 18% of controls; P < .001). Survivors reporting poorer health had more cost barriers. Moreover, uninsured survivors tended to report lower use of health care than did controls.

CONCLUSIONS:

AYA cancer survivors may forgo health care due to cost barriers, potentially inhibiting the early detection of late effects. Expanding health insurance coverage for young cancer survivors may be insufficient without adequate strategies to reduce their medical cost burdens. Cancer 2012. © 2012 American Cancer Society.     

The impact of cancer and quality of life for post‐treatment non‐Hodgkin lymphoma survivors

Objective: Recent work suggests that perceptions of the impact of cancer on survivors' lives are associated with physical and mental health and quality of life (QOL) outcomes. This study examines the association between the Impact of Cancer Version 2 Scales (IOCv2) and these outcomes in a large sample of survivors of adult non‐Hodgkin lymphoma (NHL). Methods: Participants completed a mailed survey to assess physical and mental health (SF‐36), cancer‐specific QOL (FACT‐G) and perceived impact of cancer (IOCv2). Hierarchical multiple regression models, in which demographic, clinical, psychosocial and IOCv2 measures were added sequentially, were employed to evaluate their contribution to explain variance in SF‐36 and FACT‐G scores. Results: A total of 652 post‐treatment NHL survivors participated. Survivors with comorbidities and negative appraisals of life threat and treatment intensity reported worse physical and mental health and QOL (all p<0.05). After controlling for demographic and clinical characteristics, younger respondents reported better physical but worse mental health and QOL (all p<0.01). Lower IOCv2 Negative Impact (all p<0.001) and higher Positive Impact (all p<0.05) scores were associated with better physical and mental health and QOL after controlling for demographic, clinical and psychosocial characteristics. Conclusions: Findings suggest that perceptions of cancer's impact on survivors' lives may influence or be influenced by health status and functioning and QOL. Longitudinal research is needed to establish causality, which could lead to the development of interventions targeting survivors' impact of cancer concerns, and ultimately to the enhancement of overall health and QOL. Copyright © 2010 John Wiley & Sons, Ltd.     

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.     

Burden of illness in adult survivors of childhood cancers

BACKGROUND:

The number of adult survivors of childhood cancer in the United States is increasing because of effective treatments and improved survival. The purpose of this study was to use a national, population‐based sample to estimate the burden of illness in adult survivors of childhood cancer.

METHODS:

A total of 410 adult survivors of childhood cancer and 294,641 individuals without cancer were identified from multiple years of the National Health Interview Survey. Multiple measures of burden, general health, and lost productivity were compared using multivariate regression analyses including: logistic, polytomous logit, proportional odds, and linear models.

RESULTS:

Controlling for the effects of age, sex, race/ethnicity, and survey year, adult survivors of childhood cancer reported poorer outcomes across the majority of general health measures and productivity measures than individuals without cancer. Survivors were more likely to report their health status as fair or poor (24.3% vs 10.9%; P < .001); having any health limitation in any way (12.9% vs 3.4%; P < .001); being unable to work because of health problems (20.9% vs 6.3%; P < .001); and being limited in the amount/kind of work because of health problems (30.9% vs 10.6%; P < .001). When categorized by time since diagnosis, cancer survivors had poor health outcomes in every time interval, with the greatest limitations in the initial 4 years after diagnosis and 30 or more years after diagnosis.

CONCLUSIONS:

Across multiple measures, adult survivors of childhood cancers have poorer health outcomes and more health limitations than similar individuals without cancer. Cancer 2010. Published 2010 by the American Cancer Society.     

The effect of aging and cancer on the symptom experience and physical function of elderly breast cancer survivors

BACKGROUND:

The majority of cancer survivors are aged ≥65 years, yet, historically, cancer research has focused infrequently on older patients. The objective of this study was to examine predictors of physical function within a framework that integrates the gerontologic and oncologic needs of older cancer survivors.

METHODS:

Path analysis tested 759 women who were breast cancer survivors aged ≥70 years from the American Cancer Society Study of Cancer Survivors II to examine the cancer, aging, and personal characteristics that had an impact on symptoms and physical functioning.

RESULTS:

High levels of symptom bother (β = ?.42) and comorbidities (β = ?.21) were strongly associated with lower physical function. Comorbidity and social support (β = .21) indirectly influenced symptom bother through emotional status (β = ?.35). The model demonstrated good fit with the data (chi‐square statistic, 50.6; adjusted chi‐square statistic, 2.8; P < .001; goodness‐of‐fit index, .98; root mean square error of approximation, .049 [confidence interval, .03‐.05]).

CONCLUSIONS:

The current findings supported prior research indicating that the majority of older survivors of breast cancer are doing well, but there is a subset of survivors that requires ongoing attention to symptoms, comorbidities, emotional health, and social support to thrive after cancer treatment. Cancer 2012. © 2012 American Cancer Society.     

Association of progression‐free survival,overall survival,and patient‐reported outcomes by skin toxicity and KRAS status in patients receiving panitumumab monotherapy

BACKGROUND:

The authors explored the association of skin toxicity (ST) severity as measured by patient‐reported ST and Common Terminology Criteria for Adverse Events (CTCAE) grading with efficacy of panitumumab, a fully human antiepidermal growth factor receptor antibody, from a phase 3 metastatic colorectal cancer (CRC) trial.

METHODS:

Patients were randomized to panitumumab plus best supportive care (BSC) vs BSC alone. ST by modified National Cancer Institute CTCAE v3.0 and modified Dermatology Life Quality Index (mDLQI), health‐related quality of life (HRQOL), and CRC symptoms were measured. ST was analyzed using a landmark approach. Associations by KRAS mutational status were also assessed.

RESULTS:

Of 463 patients, 208 of 231 (90%) panitumumab patients and 184 of 232 (79%) BSC patients had ≥1 postbaseline patient‐reported outcome (PRO) assessment. Panitumumab patients with more severe ST had significantly longer overall survival (OS) (grade 2‐4:grade 1; hazard ratio, 0.60; P = .0033). Lower mDLQI scores (<67; more bothersome ST) were associated with longer OS (Cox model, P < .0001). Similar results were observed with progression‐free survival (PFS). An inverse relation between mDLQI and HRQOL scores was observed, suggesting that ST bother correlated with better HRQOL. KRAS and PRO data were available in 363 patients (188 panitumumab; 175 BSC). Longer OS was associated with lower mDLQI scores, regardless of KRAS status. Longer PFS was associated with more severe ST (lower mDLQI scores and higher CTCAE grade ST) in patients with wild‐type (WT) KRAS tumors, but not in patients with mutant KRAS tumors.

CONCLUSIONS:

More severe ST, by both clinical grading and PRO, is associated with better CRC symptoms and HRQOL and with longer OS and PFS among panitumumab‐treated patients. The associations for PFS were more pronounced in patients with WT KRAS tumors. Cancer 2009. © 2009 American Cancer Society.     

Health‐related quality of life of patients with advanced breast cancer treated with everolimus plus exemestane versus placebo plus exemestane in the phase 3, randomized,controlled, BOLERO‐2 trial

BACKGROUND:

The randomized, controlled BOLERO‐2 (Breast Cancer Trials of Oral Everolimus) trial demonstrated significantly improved progression‐free survival with the use of everolimus plus exemestane (EVE + EXE) versus placebo plus exemestane (PBO + EXE) in patients with advanced breast cancer who developed disease progression after treatment with nonsteroidal aromatase inhibitors. This analysis investigated the treatment effects on health‐related quality of life (HRQOL).

METHODS:

Using the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire‐Core 30 (EORTC QLQ‐C30) questionnaire, HRQOL was assessed at baseline and every 6 weeks thereafter until disease progression and/or treatment discontinuation. The 30 items in 15 subscales of the QLQ‐C30 include global health status wherein higher scores (range, 0‐100) indicate better HRQOL. This analysis included a protocol‐specified time to definitive deterioration (TDD) analysis at a 5% decrease in HRQOL versus baseline, with no subsequent increase above this threshold. The authors report additional sensitivity analyses using 10‐point minimal important difference decreases in the global health status score versus baseline. Treatment arms were compared using the stratified log‐rank test and Cox proportional hazards model adjusted for trial stratum (visceral metastases, previous hormone sensitivity), age, sex, race, baseline global health status score and Eastern Cooperative Oncology Group performance status, prognostic risk factors, and treatment history.

RESULTS:

Baseline global health status scores were found to be similar between treatment groups (64.7 vs 65.3). The median TDD in HRQOL was 8.3 months with EVE + EXE versus 5.8 months with PBO + EXE (hazard ratio, 0.74; P = .0084). At the 10‐point minimal important difference, the median TDD with EVE + EXE was 11.7 months versus 8.4 months with PBO + EXE (hazard ratio, 0.80; P = .1017).

CONCLUSIONS:

In patients with advanced breast cancer who develop disease progression after treatment with nonsteroidal aromatase inhibitors, EVE + EXE was associated with a longer TDD in global HRQOL versus PBO + EXE. Cancer 2013. © 2013 American Cancer Society.     

Yoga for persistent fatigue in breast cancer survivors: a randomized controlled trial

BACKGROUND:

Cancer‐related fatigue afflicts up to 33% of breast cancer survivors, yet there are no empirically validated treatments for this symptom.

METHODS:

The authors conducted a 2‐group randomized controlled trial to determine the feasibility and efficacy of an Iyengar yoga intervention for breast cancer survivors with persistent post‐treatment fatigue. Participants were breast cancer survivors who had completed cancer treatments (other than endocrine therapy) at least 6 months before enrollment, reported significant cancer‐related fatigue, and had no other medical conditions that would account for fatigue symptoms or interfere with yoga practice. Block randomization was used to assign participants to a 12‐week, Iyengar‐based yoga intervention or to 12 weeks of health education (control). The primary outcome was change in fatigue measured at baseline, immediately post‐treatment, and 3 months after treatment completion. Additional outcomes included changes in vigor, depressive symptoms, sleep, perceived stress, and physical performance. Intent‐to‐treat analyses were conducted with all randomized participants using linear mixed models.

RESULTS:

Thirty‐one women were randomly assigned to yoga (n = 16) or health education (n = 15). Fatigue severity declined significantly from baseline to post‐treatment and over a 3‐month follow‐up in the yoga group relative to controls (P = .032). In addition, the yoga group had significant increases in vigor relative to controls (P = .011). Both groups had positive changes in depressive symptoms and perceived stress (P < .05). No significant changes in sleep or physical performance were observed.

CONCLUSIONS:

A targeted yoga intervention led to significant improvements in fatigue and vigor among breast cancer survivors with persistent fatigue symptoms. Cancer 2012. © 2011 American Cancer Society.     

Twenty years of follow-up of survivors of childhood osteosarcoma: a report from the Childhood Cancer Survivor Study

BACKGROUND:

Osteosarcoma survivors have received significant chemotherapy and have undergone substantial surgeries. Their very long‐term outcomes (20 year) are reported here.

METHODS:

The authors assessed the long‐term outcomes of 733 5‐year survivors of childhood osteosarcoma diagnosed from 1970 to 1986 to provide a comprehensive evaluation of medical and psychosocial outcomes for survivors enrolled in the Childhood Cancer Survivor Study (CCSS). Outcomes evaluated included overall survival, second malignant neoplasms (SMNs), recurrent osteosarcoma, chronic health conditions, health status (general and mental health and functional limitations), and psychosocial factors. Outcomes of osteosarcoma survivors were compared with general‐population statistics, other CCSS survivors, and CCSS siblings.

RESULTS:

Survivors had a mean follow‐up of 21.6 years. The overall survival of children diagnosed with osteosarcoma who survived 5 years at 20 years from original diagnosis was 88.6% (95% confidence interval [CI], 86.6%‐90.5%). The cumulative incidence of SMNs at 25 years was 5.4%, with a standardized incidence ratio of 4.79 (95% CI, 3.54‐6.33; P<.01). Overall, 86.9% of osteosarcoma survivors experienced at least 1 chronic medical condition, and >50% experienced ≥2 conditions. Compared with survivors of other cancers, osteosarcoma survivors did not differ in their reported general health status (odds ratio [OR], 0.9; 95% CI, 0.7‐1.2), but were more likely to report an adverse health status in at least 1 domain (OR, 1.9; 95% CI, 1.6‐2.2), with activity limitations (29.1%) being the most common.

CONCLUSIONS:

Childhood osteosarcoma survivors in this cohort did relatively well, considering their extensive treatment, but are at risk of experiencing chronic medical conditions and adverse health status. Survivors warrant life‐long follow‐up. Cancer 2011. © 2010 American Cancer Society.     

Emotional distress impacts quality of life evaluation: a report from the Childhood Cancer Survivor Study

Purpose

We compared health-related quality of life (HRQOL) between adult survivors of childhood cancer and siblings by investigating the mediating role of emotional distress on HRQOL assessment, and examining the extent to which emotional distress affected the item responses of HRQOL measures given the same underlying HRQOL (i.e., measurement non-invariance).

Methods

Cancer survivors (7103) and siblings (390) enrolled in Childhood Cancer Survivor Study who completed the SF-36 measuring HRQOL and the Brief Symptom Inventory-18 measuring anxiety, depression, and somatization were analyzed. Multiple Indicators & Multiple Causes modeling was performed to identify measurement non-invariance related to emotional distress on the responses to HRQOL items. Mediation analysis was performed to test the effects of cancer experience on HRQOL accounting for the mediating role of emotional distress.

Results

Twenty-nine percent, 40%, and 34% of the SF-36 items were identified with measurement non-invariance related to anxiety, depression, and somatization, respectively. Survivors reported poorer HRQOL than siblings in all domains (ps?<?0.05), except for pain. Other than physical functioning and general health perceptions, poorer HRQOL was explained by the mediating role of emotional distress (ps?<?0.05).

Conclusions

Differences in HRQOL between survivors and siblings appear due, in part, to the mediating effect of emotional distress through which cancer experience influences the responses to HRQOL measures.

Implications of cancer survivors

Interventions to treat emotional distress may improve cancer survivors’ HRQOL.

     

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.     

Sex‐specific attention problems in long‐term survivors of pediatric acute lymphoblastic leukemia

BACKGROUND:

Neurocognitive problems are a frequent outcome of chemotherapy for pediatric leukemia, although individual differences exist in patient outcome. Sex of the patient and age at diagnosis are 2 characteristics that have been associated with differential outcomes. The relation between these patient characteristics and specific attention deficits (ie, initiating, inhibiting, shifting, focusing, sustaining attention, and working memory) has not been well researched. The purpose of this study was to evaluate the pattern of attention problems in male and female long‐term survivors of pediatric acute lymphoblastic leukemia (ALL).

METHODS:

One hundred three long‐term survivors (ie, ≥5 years from diagnosis; 51% boys, mean age at diagnosis of 3.9 years, and mean time since diagnosis 7.5 years) completed standardized measures of basic and complex attention skills related to anterior (ie, inhibition, shifting attention, working memory), posterior (ie, focusing), and subcortical brain systems (ie, sustaining).

RESULTS:

Treatment intensity was related to sustained attention, with those patients treated on high‐risk protocols displaying significantly lower performance. Girls performed worse than boys on measures related to the anterior attention system (ie, shifting attention, P < .042) and the subcortical attention system (ie, sustained attention, P < .001), whereas boys performed worse than girls on different measures of anterior control (ie, inhibition, P < .039; working memory, P < .003).

CONCLUSIONS:

The results of this study suggest that children diagnosed with and treated for pediatric ALL perform poorly on select measures of attention and executive control, and that this performance is influenced by sex and treatment intensity. Cancer 2009. © 2009 American Cancer Society.     

Antimullerian hormone and inhibin B are hormone measures of ovarian function in late reproductive‐aged breast cancer survivors

BACKGROUND:

In late reproductive‐aged breast cancer survivors, there is a need for real‐time biomarkers of postchemotherapy ovarian function. The objective was to determine whether antimullerian hormone (AMH) and inhibin B are such biomarkers. The authors tested whether AMH and inhibin B were impacted by breast cancer treatment by comparing cancer survivors to age‐matched control women and determined the association between these hormones and postchemotherapy menstrual pattern.

METHODS:

Breast cancer patients (n = 127) with American Joint Committee on Cancer stage I to III disease who were premenopausal at diagnosis were enrolled postchemotherapy and observed. The primary endpoint was chemotherapy‐related amenorrhea (CRA) (≥12 months of amenorrhea after chemotherapy). Matched pair analyses compared AMH, inhibin B, and follicle‐stimulating hormone (FSH) levels between cancer and age‐matched control subjects. Associations between hormones, CRA status, and change in CRA status over time were assessed.

RESULTS:

The median age of the patients at chemotherapy was 43.2 years (range, 26.7‐57.8 years). At enrollment, median follow‐up since chemotherapy was 2.1 years, and 55% of subjects had CRA. Compared with age‐matched controls, cancer subjects had significantly lower AMH (P = .004) and inhibin B (P < .001) and higher FSH (P < .001). AMH (P = .002) and inhibin B (P = .001) were found to be significantly associated with risk of CRA, even after controlling for FSH. AMH was significantly lower (P = .03) and FSH was significantly higher (P = .04) in menstruating subjects who developed subsequent CRA.

CONCLUSIONS:

AMH and inhibin B are 2 additional measures of postchemotherapy ovarian function in late reproductive‐aged breast cancer survivors. With further research and validation, these hormones may supplement limited current tools for assessing and predicting postchemotherapy ovarian function. Cancer 2010. © 2009 American Cancer Society.     

Associations among physical activity, body mass index, and health-related quality of life by race/ethnicity in a diverse sample of breast cancer survivors

BACKGROUND:

Health‐related quality of life (HRQOL), body mass index (BMI), and physical activity (PA) levels have all been associated with prognosis following breast cancer and may explain partially the higher mortality for breast cancer in certain racial/ethnic subgroups. In this study, associations between PA, BMI, and HRQOL by race were examined in a sample of breast cancer survivors.

METHODS:

Measures of PA, BMI, and HRQOL as well as demographic and medical characteristics of women (N = 3013, 13% nonwhite) who participated in the Women's Healthy Eating and Living Study were assessed at baseline. Analysis of covariance was used to examine the relationship between PA and obesity with HRQOL outcomes. Statistical tests were 2‐sided.

RESULTS:

African American women were less likely to meet guidelines for PA and more likely to be obese than women from other ethnic groups (P < .05). In adjusted models, women who met guidelines for PA reported significantly higher physical health composite (point differences ranged from 10.5 to 21.2 points, all P < .05) and vitality (point differences ranged from 9.9 to 16.5 points, all P < .05) scores than those who did not, regardless of race/ethnicity. Associations between obesity and HRQOL were mixed with fewer associations for Asian American and African American women and stronger associations for whites.

CONCLUSIONS:

Breast cancer survivors from racially and ethnically diverse populations have lower levels of PA and higher rates of obesity that are generally associated with poorer HRQOL. Culturally sensitive PA and weight loss interventions may improve these lifestyle characteristics and result in improved HRQOL. Cancer 2012. © 2012 American Cancer Society.     

Change in health‐related quality of life of newly diagnosed cancer patients,cancer survivors,and controls*

BACKGROUND:

Data from the 1998 Health Outcomes Survey (HOS) of patients who were enrolled in Medicare managed care and follow‐up data from the 2000 HOS resurvey were analyzed to examine changes in health‐related quality of life (HRQOL) of newly diagnosed cancer patients, cancer survivors, and patients without cancer.

METHODS:

In 1998, the HOS was mailed to a random sample of 279,135 beneficiaries, and 167,096 respondents (60%) returned completed surveys. Those who were diagnosed with cancer (22,747) were frequency age‐matched to an equal number of patients with no cancer. In 2000, the HOS was mailed to the same cohort of beneficiaries. Complete data at both baseline and follow‐up were available on 16,850 individuals for inclusion in the current study.

RESULTS:

After 2 years, respondents who had been diagnosed with cancer at baseline continued to have lower scores on all but 3 scales of the 36‐item short‐form HRQOL measure. However, there was no evidence that they were declining any faster than or catching up with noncancer patients. Those who had been newly diagnosed with cancer since the baseline survey had lower mean scale scores than the no‐cancer group on all scales and lower mean scores than the cancer survivors on all subscales except Bodily Pain, Vitality, and Mental Health.

CONCLUSIONS:

This study demonstrated that, after 2 years, cancer survivors continued to have poorer HRQOL than the no‐cancer group. Newly diagnosed cancer patients had poorer quality of life than both the longer term cancer survivors and the no‐cancer group. Cancer 2009. Published 2009 by the American Cancer Society*.     

Classifying B‐cell non‐Hodgkin lymphoma by using MIB‐1 proliferative index in fine‐needle aspirates

BACKGROUND:

MIB‐1 proliferation index (PI) has proven helpful for diagnosis and prognosis in non‐Hodgkin lymphomas (NHLs). However, validated cutoff values for use in fine‐needle aspiration (FNA) samples are not available. We investigated MIB‐1 immunocytochemistry as an ancillary technique for stratifying NHL and attempted to establish PI cutpoints in cytologic samples.

METHODS:

B‐cell NHL FNA cases with available cytospins (CS) MIB‐1 immunocytochemistry results were included. Demographic, molecular, immunophenotyping and MIB‐1 PI data were collected from cytologic reports. Cases were subtyped according to the current World Health Organization classification and separated into indolent, aggressive, and highly aggressive groups. Statistical analysis was performed with pairwise Wilcoxon rank sum test and linear discriminant analysis to suggest appropriate PI cutpoints.

RESULTS:

Ninety‐one NHL cases were subdivided in 56 (61.5%) indolent, 30 (33%) aggressive, and 5 (5.5%) highly aggressive lymphomas. The 3 groups had significantly different MIB‐1 PIs from each other. Cutpoints were established for separating indolent (<38%), aggressive (≥38% to ≤80.1%) and highly aggressive (>80.1%). The groups were adequately predicted in 76 cases (83.5%) using the cutpoints and 15 cases showed discrepant PIs.

CONCLUSIONS:

MIB‐1 immunohistochemistry on CS can help to stratify B‐cell NHL and showed a significant increase in PI with tumor aggressiveness. Six misclassified cases had PIs close to the cutpoints. Discrepant MIB‐1 PIs were related to dilution of positive cells by non‐neoplastic lymphocytes and to the overlapping continuum of features between diffuse large B‐cell lymphoma and Burkitt lymphoma. Validation of our approach in an unrelated, prospective dataset is required. Cancer (Cancer Cytopathol) 2010. © 2010 American Cancer Society.