Effect of depression on diagnosis, treatment, and survival of older women with breast cancer

OBJECTIVES: To assess the effect of a prior diagnosis of depression on the diagnosis, treatment, and survival of older women with breast cancer. DESIGN: Retrospective analysis of records from Surveillance, Epidemiology and End Results (SEER) and Medicare claims. SETTING: Registries from seven major cities and five states. PARTICIPANTS: A total of 24,696 women aged 67 to 90 diagnosed with breast cancer between 1993 and 1996 and included in the SEER Medicare linked database were studied. MEASUREMENTS: Information on patient demographics, tumor characteristics, treatment received, and survival were obtained from SEER, and the Medicare inpatient and professional charges for the 2 years before diagnosis were searched for a diagnosis of depression. RESULTS: A total of 1,841 of the 24,696 women (7.5%) had been given a diagnosis of depression sometime in the 2 years before the diagnosis of breast cancer. There was no difference in tumor size or stage at diagnosis between depressed and nondepressed women. Women diagnosed with depression were less likely to receive treatment generally considered definitive (59.7% vs 66.2%, P<.0001), and this difference remained after controlling for age, ethnicity, comorbidity, and SEER site. Also, women with a prior diagnosis of depression had a higher risk of death (hazard ratio=1.42; 95% confidence interval= 1.13-1.79) after controlling for other factors that might affect survival. The higher risk of death associated with a prior diagnosis of depression was also seen in analyses restricted to women who received definitive treatment. CONCLUSION: Women with a recent diagnosis of depression are at greater risk for receiving nondefinitive treatment and experience worse survival after a diagnosis of breast cancer, but differences in treatment do not explain the worse survival.     

Effect of mental disorders on diagnosis, treatment, and survival of older adults with colon cancer

OBJECTIVES: To evaluate the extent to which preexisting mental disorders influence diagnosis, treatment, and survival in older adults with colon cancer. DESIGN: Retrospective cohort study. SETTING: The Surveillance, Epidemiology and End Results (SEER)–Medicare linked database. PARTICIPANTS: Eighty thousand six hundred seventy participants, aged 67 and older with a diagnosis of colon cancer. MEASUREMENTS: The association between the presence of a preexisting mental disorder and the stage of colon cancer at diagnosis, receipt of cancer treatment, and overall and colon cancer‐specific mortality were assessed using Cox proportional hazards regression and logistic regression. RESULTS: Participants with mental disorders were more likely to have been diagnosed with colon cancer at autopsy (4.4% vs 1.1%; P<.001) and at an unknown stage of cancer (14.6% vs 6.2%; P<.001); to have received no surgery, chemotherapy, or radiation therapy (adjusted risk ratio (ARR)=2.09, 95% confidence interval (CI)=1.86–2.35); and to have received no chemotherapy for Stage 3 cancer (ARR=1.63, 95% CI=1.49–1.79). The rate of overall mortality (hazard ratio (HR)=1.33, 95% CI=1.31–1.36) and colon cancer‐specific mortality (HR=1.23, 95% CI=1.19–1.27) was substantially higher in participants with a preexisting mental disorder than in their counterparts. All of these associations were particularly pronounced in participants with psychotic disorders and those with dementia. CONCLUSION: Public health initiatives are needed to improve colon cancer detection and treatment in older adults with mental disorders.     

The effects of case management for breast cancer patients: A protocol for systematic review and meta-analysis

Background:Female breast cancer is the most common cancer nowadays, and its treatment has a significant impact on patients both physically and psychologically. Many randomized trials have proved that case management (CM) can effectively care for patients. However, there is a lack of systematic scientific evaluation, so this systematic evaluation aims to explore the impact of CM on breast cancer patients.Methods:PubMed, Embase, Cochrane Library, Scopus, CINAHL were searched. Chinese repositories included China National Knowledge, Infrastructure Database (CNKI), Wan fang Database, China Biology Medicine Database. We will also search unpublished literature at ClinicalTrials.gov. Randomized controlled trials were collected from them. The literature will be screened according to inclusion and exclusion criteria, and 2 researchers will extract the literature independently. The primary outcome indicator for this study will be patient satisfaction. Statistics were performed using RevMan 5.4 software. The quality of each outcome will be evaluated using the Grading of Recommendations Assessment, Development, and Evaluation.Results:This study will provide the most recent evidence for evaluating the impact of CM on breast cancer patients.Conclusion:To evaluate the impact of CM on patients with breast cancer.Registration number:DOI:10.17605/OSF.IO/ZJKHX.     

Breast cancer treatment in older women: impact of the patient-physician interaction

OBJECTIVES: To assess the impact of the patient-physician interaction on breast cancer care in older women. DESIGN: Cross-sectional survey. SETTING: Los Angeles County, California. PARTICIPANTS: Two hundred twenty-two consecutively identified breast cancer patients aged 55 and older who were within 6 months of breast cancer diagnosis and/or 1 month posttreatment. MEASUREMENTS: Dependent variables were patient breast cancer knowledge, treatment delay, and receipt of breast-conserving surgery (BCS). Key independent variables were five dimensions of the patient-physician interaction by patient report, including physician provision of tangible and interactive informational support, physician provision of emotional support, physician participatory decision-making style, and patient perceived self-efficacy in the patient-physician interaction. Age and ethnicity were additional important independent variables. RESULTS: In multiple logistic regression models, only physician interactive informational support had significant relationships with all three dependent variables, controlling for a wide range of patient sociodemographic and case-mix characteristics, visit length, number of physicians seen, social support, and physician sociodemographic and practice characteristics. Specifically, informational support positively predicted patient breast cancer knowledge (adjusted odds ratio (AOR)=1.18, 95% confidence interval (CI)=1.00-1.38), negatively predicted treatment delays (AOR=0.80, 95% CI=0.67-0.94), and positively predicted receipt of BCS (AOR=1.29, 95% CI=1.07-1.56). Age and ethnicity were not significant predictors in these models. CONCLUSION: One specific domain of the patient-physician interaction, interactive informational support, may provide an avenue to ensure adequate breast cancer knowledge for patient treatment decision-making, decrease treatment delay, and increase rates of BCS for older breast cancer patients, thereby potentially mitigating known healthcare disparities in this vulnerable population of breast cancer patients.     

The association between specific nurse case management interventions and elder health

OBJECTIVES: To describe the association between specific nursing interventions performed in the context of nurse case management and older people's quality of life and functional ability. DESIGN: Longitudinal. SETTING: Nurse case management through a university hospital and two community health centers. PARTICIPANTS: One hundred seventy-five community-dwelling frail older persons (> or =70 and at risk for repeated hospitalizations). MEASUREMENTS: Specific groups of nursing interventions provided in the context of nurse case management over a 10-month period--coping assistance, lifespan care, risk management, and physical comfort promotion--were focused on. These interventions were recorded using a standardized nursing language. Outcomes were measured using telephone and home interview and medical record review using the 36-item Short Form and the Older American Resources and Services Multidimensional Functional Assessment Questionnaire. RESULTS: Older people receiving coping assistance interventions demonstrated an increase in instrumental activity of daily living functioning although they had lower general health, role-emotional, and mental health scores. CONCLUSION: Coping assistance is one nursing intervention of several provided in the context of nurse case management that is independently associated with improving the functional status of frail older persons even in the presence of declining health normally associated with aging over several months. Examining the relationships between specific nursing activities and health outcomes of frail older persons may be useful in furthering understanding of the results of randomized trials of nurse case management in this population.     

The effects of mammographic detection and comorbidity on the survival of older women with breast cancer

OBJECTIVES: To determine an upper age limit or quantifiable level of comorbidity that would render mammography screening ineffectual in decreasing mortality in women aged 65 and older. DESIGN: Retrospective cohort study. SETTING: Upper midwestern United States. PARTICIPANTS: Five thousand one hundred eighty-six predominantly Caucasian women aged 65 to 101 diagnosed with invasive breast cancer from 1986 through 1994. Data were obtained from The Upper Midwest Tumor Registry System, a regional consortium database in Minnesota, North Dakota, and South Dakota. MEASUREMENTS: Relative risks (RRs) of death were computed for patients with mammographically detected tumors, stratified by age and comorbidity. Survival analysis was performed, stratified by level of comorbidity and method of tumor detection. RESULTS: Patients with mammographically detected tumors and no comorbidity experienced significantly lower RRs of death in every age group (range P <.001 to P =.039). Women with mammographically detected tumors and mild to moderate comorbidity had RRs of death as follows: age 65 to 69 (RR = 0.32, 95% confidence interval (CI) = 0.15-0.69), age 70 to 74, (RR = 0.45, 95% CI = 0.22-0.91); age 75 to 79 (RR = 0.47, 95% CI = 0.25-0.88), age 80 and older (RR = 0.52, 95% CI = 0.33-0.80). Women with severe or multiple comorbidities experienced no improvement in survival with mammographically detected tumors. CONCLUSIONS: Mammographic detection of breast cancer may be associated with a significantly decreased risk of death for older women of all ages, even for women with mild to moderate levels of comorbidity, but for older women with severe or multiple comorbidities, mammography is not associated with improvement in overall survival.     

Chemotherapy treatment and survival in older women with estrogen receptor-negative metastatic breast cancer: a population-based analysis

To investigate the survival benefit associated with chemotherapy receipt in older women with estrogen receptor–negative (ER–) Stage IV breast cancer. DESIGN: Observational, retrospective cohort study using Cox proportional hazards regression to determine effect of chemotherapy on hazard of all‐cause mortality. The two samples were an overall sample (n=1,519) and a propensity score–matched sample (n=580) to control for selection to treatment receipt. Hazard ratios (HRs) and 95% confidence intervals (CIs) were obtained for regression models. SETTING: U.S. women within the National Cancer Institute Surveillance, Epidemiology and End Results cancer registries (SEER) linked to Medicare enrollment and claims database. PARTICIPANTS: Female Medicare beneficiaries aged 66 and older with Stage IV ER– breast cancer diagnosed between 1999 and 2005. MEASUREMENTS: Outcome measure was all‐cause death during the follow‐up period. Survival was measured as time from breast cancer diagnosis until death or last follow‐up date. Information on receipt of chemotherapy, defined as chemotherapy received within 6 months after diagnosis, was obtained from linked Medicare claims. RESULTS: One thousand five hundred nineteen ER– women diagnosed with metastatic breast cancer were identified; 494 (33%) received chemotherapy. Chemotherapy was associated with a statistically significant survival benefit (HR=0.61, 95% CI=0.54–0.70). Age did not modify the survival benefit of chemotherapy. CONCLUSION: Chemotherapy received within 6 months after diagnosis was associated with a 39% lower hazard of death within the time period for the study. These findings reflect chemotherapy use outside of the clinical trial setting and have important clinical and policy implications for the study of treatments in older women with advanced ER– breast cancer.     

Effect of a nurse case manager on postdischarge follow-up

OBJECTIVE: To examine whether use of a nurse case manager to coordinate postdischarge care would improve rates of follow-up, emergency department utilization, and unexpected readmission for general medicine patients. DESIGN: Prospective cohort trial. SETTING: Publicly supported, tertiary-care teaching hospital. PATIENTS: Four hundred seventy-eight patients admitted to the general medicine service. INTERVENTIONS: Use of a nurse case manager to provide discharge planning before hospital discharge and to arrange for postdischarge outpatient follow-up. Patients in the control group had discharge planning in the traditional (“usual care”) manner. MEASUREMENTS AND MAIN RESULTS: The proportion of patients with scheduled outpatient appointments in the medical clinic and the proportion making clinic visits, emergency department visits, or with readmission to the hospital within 30 days following discharge. A significantly greater proportion of patients assigned to the nurse case manager intervention had appointments scheduled at the time of hospital discharge (63% vs 46%,p<.001), and made scheduled visits in the outpatient clinic (32% vs 23%,p<.03). Intervention group patients were especially more likely than control group patients to have definite follow-up appointments if they were discharged on weekends. Intervention and control group patients did not differ, however, in the rates of emergency department utilization (p=.52) or unexpected readmissions within 30 days of discharge (p=.11). CONCLUSIONS: Use of a nurse case manager to coordinate outpatient follow-up prior to discharge improved the continuity of outpatient care for patients on a general medical service. The intervention had no effect on unexpected readmissions or emergency department utilization. Received from the Division of General Internal Medicine, Case Western Reserve University and the MetroHealth Medical Center, Cleveland, Ohio. Presented in part at the 17th annual meeting of the Society of General Internal Medicine, Washington, DC, April 27–29, 1994.     

Measures of adiposity and risk of breast cancer in older postmenopausal women

OBJECTIVES: To determine whether higher adiposity is associated with greater breast cancer risk in older postmenopausal women. DESIGN: Prospective cohort study with mean follow-up of 11.3 years. SETTING: Four U.S. clinical centers. PARTICIPANTS: Seven thousand five hundred twenty-three women (mean age 73.5) enrolled in the Study of Osteoporotic Fractures. MEASUREMENTS: Weight, height, and waist and hip circumference were measured at baseline. Body composition was determined using bioelectrical impedance. Risk factor information was obtained by interview and questionnaire. Bone mineral density was measured using dual energy x-ray absorptiometry. The outcome was incident invasive breast cancer, confirmed using medical records. RESULTS: After adjustment for multiple risk factors, including bone density, women in the uppermost quartiles of weight, weight gain since age 25, body mass index, waist circumference, and percentage of body fat had higher breast cancer rates than women in the first quartiles of each measure. For example, breast cancer rates were 49% higher for women in the uppermost quartile of weight (hazard ratio (HR)=1.49, 95% confidence interval (CI)=1.05-2.10), 64% higher for women in the top quartile of weight gain since age 25 (HR=1.64, 95% CI=1.15-2.34), and 58% higher for women in the top quartile of percentage of body fat (HR=1.58, 95% CI=1.11-2.23) than for women in the lowest quartile of each measure. The associations between adiposity measures and breast cancer rates were not altered when the analyses were limited to very elderly women (> or = 70). CONCLUSION: Higher adiposity is an independent risk factor for breast cancer in elderly women.     

Effect of computer support on younger women with breast cancer

OBJECTIVE: Assess impact of a computer-based patient support system on quality of life in younger women with breast cancer, with particular emphasis on assisting the underserved. DESIGN: Randomized controlled trial conducted between 1995 and 1998. SETTING: Five sites: two teaching hospitals (Madison, Wis, and Chicago, Ill), two nonteaching hospitals (Chicago), and a cancer resource center (Indianapolis, Ill). The latter three sites treat many underserved patients. PARTICIPANTS: Newly diagnosed breast cancer patients (N = 246) under age 60. INTERVENTIONS: Experimental group received Comprehensive Health Enhancement Support System (CHESS), a home-based computer system providing information, decision-making, and emotional support. MEASUREMENTS AND MAIN RESULTS: Pretest and two post-test surveys (at two- and five-month follow-up) measured aspects of participation in care, social/information support, and quality of life. At two-month follow-up, the CHESS group was significantly more competent at seeking information, more comfortable participating in care, and had greater confidence in doctor(s). At five-month follow-up, the CHESS group had significantly better social support and also greater information competence. In addition, experimental assignment interacted with several indicators of medical underservice (race, education, and lack of insurance), such that CHESS benefits were greater for the disadvantaged than the advantaged group. CONCLUSIONS: Computer-based patient support systems such as CHESS may benefit patients by providing information and social support, and increasing their participation in health care. These benefits may be largest for currently underserved populations.     

A nurse practitioner intervention to increase breast and cervical cancer screening for poor,elderly black women

Objective: To compare nurse practitioner (NP) and physician rates of breast and cervical cancer screening among poor, elderly black women. Design: A quasi-experimental design was used to compare pre- and postintervention annual screening rates. Rates were determined by medical record audits. Setting: Two urban public hospital primary care clinics served as the study sites. Patients: All women aged 65 years or more were eligible to participate. Interventions: Women were offered screening by a NP during a routine visit in the intervention site; a physician reminder system was used in the control site. Main results: Baseline annual screening rates were comparable in the two study sites. At the end of the study period, rates were significantly higher in the NP site, compared with the control. In the NP clinic, the annual rate of Pap tests increased to 56.9% from the baseline of 17.8%, and mammographies increased to 40% from 18.3%. In comparison, rates remained low in the control site, increasing only to 18.2% of women receiving Pap tests from a baseline of 11.8%, and remaining at 18% for mammography. Conclusions: Use of a NP to deliver same-day screening is an effective strategy to target poor, elderly black women for breast and cervical cancer screening. However, even with the substantial increases in rates obtained with the NP intervention, screening in this vulnerable population remains below nationally targeted levels. Presented at the 119^th annual meeting of the American Public Health Association, Atlanta, Georgia, November 12, 1991. Supported in part by National Institute on Aging Academic Award #KO8 AG00471, and National Cancer Institute Grant #RO3 CA51614-01 (Dr. Mandelblatt). Members of the Harlem Study Team at Harlem Hospital Center included Evangelyn Ramsey, NP, Sook McGrath, NP, Lillian Jeremiah, NP, Charlena Pace, NP, Janice Dye, RN, and Regina Dunlap.     

Nurse case management to improve the hepatitis C care continuum in HIV co‐infection: Results of a randomized controlled trial

The opportunity to eliminate hepatitis C virus (HCV) is at hand, but challenges remain that negatively influence progress through the care continuum, particularly for persons co‐infected with HIV who are not well engaged in care. We conducted a randomized controlled trial to test the effect of nurse case management (NCM) on the HCV continuum among adults co‐infected with HIV compared to usual care (UC). Primary outcomes included linkage to HCV care (attendance at an HCV practice appointment within 60 days) and time to direct‐acting antiviral (DAA) initiation (censored at 6 months). Sixty‐eight participants were enrolled (NCM n = 35; UC n = 33). Participants were 81% Black/African American, 85% received Medicaid, 46% reported illicit drug use, 41% alcohol use, and 43% had an undetectable HIV viral load. At day 60, 47% of NCM participants linked to HCV care compared to 25% of UC participants (P = .031; 95% confidence bound for difference, 3.2%‐40.9%). Few participants initiated DAAs (12% NCM; 25% UC). There was no significant difference in mean time to treatment initiation (NCM = 86 days; UC = 110 days; P = .192). Engagement in HCV care across the continuum was associated with drinking alcohol, knowing someone who cured HCV and having a higher CD4 cell count (P < .05). Our results support provision of NCM as a successful strategy to link persons co‐infected with HIV to HCV care, but interventions should persist beyond linkage to care. Capitalizing on social networks, treatment pathways for patients who drink alcohol, and integrated substance use services may help improve the HCV care continuum.     

Hyperhomocysteinemia in women with advanced breast cancer

Patients with malignancy have an increased risk of venous thromboembolic disease but the pathophysiology of this association has not been precisely defined. Hyperhomocysteinemia has become established as one of the commonest conditions associated with venous and arterial thrombosis. We examined the prevalence of hyperhomocysteinemia in women with early (group A, n = 31), metastatic breast cancer (group B, n = 41) and in a group of healthy females (group C, n = 29). Blood samples were collected at diagnosis or prior to treatment. We measured both total plasma homocysteine (tHcy) and red cell folate (RCF). The Mean (SD) tHcy were group A - 9.43 micromol/l (5.6), group B - 11.34 micromol/l (5.1) and group C - 7.9 micromol/l (1.5). A total of 39% of patients with metastatic and 22.6% with early breast cancer had tHcy concentrations above the upper limit of normal. Women with metastatic disease had significantly higher tHcy compared with controls (P < 0.01) but not when compared with women with early breast cancer. Also, no difference was observed when women with early disease were compared with controls. We found no correlation between age and tHcy. Lower RCF levels were identified in group B compared with group A, but this does not fully explain the increased tHcy levels seen within the same group. We conclude that hyperhomocysteinemia is common in women with advanced breast cancer. This observation could explain the high rate of venous thrombosis in women with metastatic breast malignancy.     

Effect of all-trans-retinoic acid on the hypercoagulable state of patients with breast cancer

To evaluate whether all-trans-retinoic acid (ATRA) is able to modulate the hemostatic system in patients with solid tumors, we studied patients with locally advanced breast cancer who were enrolled in a Phase Ib study of ATRA +/- Tamoxifen (Tam). In this study, two groups of 15 patients/each were treated for 21 days before operation with ATRA at three doses (15, 45, or 75 mg/m(2)/day on alternate days) given alone (group 1) or in combination with Tam (group 2). One additional group received Tam alone. Plasma samples were evaluated for hypercoagulation markers (FVIIa, F1+2, TAT, D-dimer), fibrinolysis proteins (t-PA, PAI-1), and coagulation inhibitors (protein C, AT). At baseline, cancer patients had FVIIa, F1+2, TAT, and PAI-1 significantly greater than control subjects. During treatment, in the patients given ATRA alone, hypercoagulation markers appeared unmodified. Instead, subjects given Tam alone had a significant elevation of FVIIa, F1+2, and TAT versus baseline. However, in the ATRA + Tam groups, hypercoagulation markers were decreased compared with Tam alone. These results suggest that in selected conditions, pre-operative ATRA may modulate the hypercoagulable state of breast cancer patients.     

Aromatase inhibitors,efficacy and metabolic risk in the treatment of postmenopausal women with early breast cancer

The third-generation aromatase inhibitors (AIs), letrozole, anastrozole and exemestane, are becoming the first choice endocrine drugs for post-menopausal women with breast cancer, since they present greater efficacy when compared with tamoxifen in both adjuvant and metastatic setting. In particular, several large and well designed trials have suggested an important role for AIs in the adjuvant treatment of postmenopausal women with estrogen-receptor positive breast cancer either in the upfront, sequential or extended adjuvant mode. Overall, AIs are associated with a small but significant improvement in disease free survival. The expanding use of AIs in the treatment of early breast cancer means that individual patients will be exposed to the agents for longer durations, making it increasingly important to establish their long-term safety. This review focused on the effects of AIs on bone metabolism, serum lipids and cardiovascular risk. AIs have adverse effects on bone turnover with a reduction of bone mineral density and an increase in the rate of fragility fractures. With respect to tamoxifen AIs present lower thrombotic risk and a less favorable impact on lipid profile, whereas the true effects on cardiovascular risk still remain to be clarified. An adequate monitoring of bone mineral density (BMD) and lipid profile could be recommended for post-menopausal women candidate to AIs.     

Psychosocial intervention for rural women with breast cancer

OBJECTIVE: This study was initiated by breast cancer survivors living in a rural community in California. They formed a partnership with academic researchers to develop and evaluate a low-cost, community-based Workbook-Journal (WBJ) for improving psychosocial functioning in geographically and economically isolated women with primary breast cancer. DESIGN: A randomized controlled trial was used to compare the WBJ intervention plus educational materials to educational materials alone (usual care). SETTING: One rural cancer center and several private medical, surgical, and radiation oncology practices in 7 rural counties in the Sierra Nevada Foothills of California. PARTICIPANTS: One hundred women with primary breast cancer who were either within 3 months of diagnosis or within 3 months of completing treatment. INTERVENTION: A community-initiated, theoretically-based Workbook-Journal, designed by rural breast cancer survivors and providers as a support group alternative. It included compelling personal stories, local rural resources, coping strategies, and messages of hope. RESULTS: Community recruiters enrolled 83% of the women referred to the study. Retention at 3-month follow-up was 98%. There were no main effects for the WBJ. However, 3 significant interactions suggested that women who were treated in rural practices reported decreased fighting spirit and increased emotional venting and posttraumatic stress disorder symptoms if they did not receive the WBJ. Among women who receive the WBJ, 74% felt emotionally supported. CONCLUSIONS: This community-based Workbook-Journal may be an effective psychosocial intervention for rural, isolated, and low-income women with breast cancer. Community involvement was essential to the success of this project.