Risk factors for early postoperative psychological problems in breast cancer patients after axillary lymph node dissection.

BACKGROUND: The purpose of this study was to investigate the factors related to early postoperative psychological conditions in breast cancer patients with axillary lymph node dissection 3 months after the surgery. METHODS: The subjects of this study were 200 consecutive patients who underwent axillary lymph node dissection for breast cancer at our hospital. Age, body mass index, surgical side, work, marriage, presence of children, presence of co-resident household members, resection of the pectoralis minor muscle, preoperative chemotherapy, postoperative chemotherapy, postoperative hormonal therapy, postoperative radiotherapy, shoulder range of motion, upper limb function (Disabilities of the Arm, Shoulder and Hand; DASH), and psychological conditions were evaluated. In this study, a Distress and Impact Thermometer was used to classify patients with adjustment disorders, depression, or major depression and suicidal ideation into a group with psychological problems and the remaining patients into a group with no psychological problems. RESULTS: Logistic regression analysis showed that only DASH was statistically significantly associated with psychological conditions (p < 0.05). Using receiver operating characteristic curve analysis, a DASH score of 18 or greater was found to be very specific for predicting psychological conditions. CONCLUSIONS: The observation that somatic symptoms and disability of upper limb function are related to psychological conditions may indicate the importance of postoperative rehabilitation in breast cancer patients with axillary lymph node dissection.

Local Therapy Decisional Regret in Older Women With Breast Cancer: A Population-Based Study.

PURPOSE: Older women with nonmetastatic breast cancer can often choose from several surgery and radiation treatment options. Little is known regarding how these choices contribute to decisional regret, which is a negative emotion reflecting the idea that another surgery or radiation decision might have been preferable. We sought to characterize the burden of and examine potential risk factors for local therapy decisional regret among a population-based cohort of older breast cancer survivors. METHODS AND MATERIALS: National Medicare claims for age ≥67 female breast cancer incident in 2009 identified patients treated with lumpectomy plus whole-breast irradiation, brachytherapy, or endocrine therapy or mastectomy with or without radiation. We sampled 330 patients per treatment group (N = 1650), of whom 1253 agreed to receive a paper survey including the Decisional Regret Scale and EQ-5D-3L Health-Utility Scale. Local therapy regret was defined as neutral or worse response to questions regarding surgery- or radiation-related decisional regret. Local therapy regret risk factors were evaluated using a multivariable generalized linear model. Association of local therapy regret with health utility was modeled using multivariable linear regression. RESULTS: The response rate was 30.2% (n = 498 of 1650); 421 surveys were included in this analysis. Median diagnosis age was 72 years, and surveys were completed 6 years after diagnosis. Overall, 23.8% of respondents (n = 100) reported experiencing local therapy decisional regret. Type of local therapy was not associated with local therapy regret. Predictors of increased regret included black race (risk ratio [RR], 2.09; 95% confidence interval [CI], 1.33-3.29), high school education or less (RR, 1.87; 95% CI, 1.27-2.75), and axillary nodal dissection (RR, 2.13; 95% CI, 1.33-3.41). Local therapy regret was not associated with health utility (P = .37). CONCLUSIONS: Local therapy regret afflicts nearly one quarter of our cohort of older breast cancer survivors, and it is associated with black race, less education, and more extensive nodal dissection, but not breast surgery. Regret is distinct from health utility, suggesting that it is a unique psychosocial construct that merits further study and mitigation strategies.

Are patients and physicians willing to accept less-radical procedures for cervical cancer?

OBJECTIVE: To evaluate the opinions of women who underwent surgery for cervical cancer (CC) and physicians who treat CC about the acceptability of increased oncological risk after less-radical surgery. METHODS: One hundred eighty-two women who underwent surgery for CC and 101 physicians participated in a structured survey in 3 tertiary cancer centers in Czech Republic and Turkey. Patients and physicians were asked whether they would accept any additional oncological risks, which would be attributable to the omission of parametrectomy (radical hysterectomy/trachelectomy vs. simple hysterectomy/trachelectomy) or pelvic lymph node dissection (systematic resection vs. sentinel lymph node sampling). RESULTS: Although 52.2% of patients reported morbidity related to their previous treatment, the majority of patients would not accept less-radical surgical treatment if it was associated with any increased risk of recurrence (50%-55%, no risk; 17%-24%, risk <0.1%). Physicians tended to accept a significantly higher risk than patients in the Czech Republic, but not in Turkey. Patients with higher education levels, more advanced-stage of disease, or adverse events related to previous cancer treatment, and patients who received adjuvant therapy were significantly more likely to accept an increased oncological risk. CONCLUSION: Patients, even if they suffered from morbidity related to previous CC treatment, do not want to choose between oncological safety and a better quality of life. Physicians tend to accept the higher oncological risk associated with less-radical surgical procedures, but attitudes differ regionally. Professionals should be aware of this tendency when counselling the patients before less-radical surgery.

Effects of a regional guideline for completion axillary lymph node dissection in women with breast cancer to reduce variation in surgical practice: A qualitative study of physicians' views.

BACKGROUND: Recently the impact of completion axillary lymph node dissection (cALND) after positive sentinel lymph node biopsy on significant outcomes has been questioned, leading to variation in surgical practice. To address this variation, a multidisciplinary working group created a regional guideline for cALND. We explored the views and experiences of surgeons, medical oncologists (MOs), radiation oncologists (ROs) in a qualitative study that examined guideline implementation in practice. METHODS: The Pathman framework (awareness, agreement, adoption and adherence) informed the interview guide design and analysis. Semi-structured interviews were conducted with MOs, ROs and surgeons and transcribed. Transcripts were coded independently by 2 members of the study team and analyzed. Disagreements were resolved through consensus. RESULTS: Twenty-eight physicians (5 MO; 6RO; 17S) of 41 (68% of those approached) were interviewed. Ten of 11 (91%) hospital sites (54% community; 46% academic) and all 4 cancer clinics within the region were represented. Twenty-seven physicians (96%) were aware of the guideline, with all physicians reporting agreement and general adherence to the guideline. Most physicians indicated nodal factors, age and patient preference were key components of cALND decision-making. Physicians from all disciplines perceived that the guideline helped reduce variation in practice across the region. There were concerns that the guideline could be applied rigidly and not permit individual decision-making. CONCLUSIONS: Physicians identified breast cancer as an increasingly complex and multidisciplinary issue. Facilitators to guideline implementation included perceived flexibility and buy-in from all disciplines, while individual patient factors and controversial supporting evidence may hinder its implementation.

Quality of life: A critical outcome for all surgical treatments of gastric cancer.

Surgery represents the main curative therapeutic modality for gastric cancer, and it is occasionally considered for palliation as well as prophylaxis. Most frequently, surgical outcomes are conveyed in terms of oncological outcomes such as recurrence and survival. However, quality of life (QoL) is also important and should be considered when making treatment decisions - including the extent of and approach to surgery. Measurement of QoL usually involves the application of questionnaires. While there are multiple QoL questionnaires validated for use in oncology patients, there are very few that have been validated for use in those with gastric cancer. In this review, we discuss and compare the current status of QoL questionnaires in gastric cancer. More importantly, the impact of surgery for treatment, palliation and prophylaxis of gastric cancer on QoL will be described. These data should inform the surgeon on the optimal approach to treating gastric cancer, taking into account oncological outcomes. Knowledge gaps are also identified, providing a roadmap for future studies.

Sexual dysfunction in testicular cancer patients subjected to post-chemotherapy retroperitoneal lymph node dissection: a focus beyond ejaculation disorders.

Post-chemotherapy retroperitoneal lymph node dissection (PC-RPLND) represents an integral part of multidisciplinary treatment of advanced germ cell cancer; however, it is associated with a high complications rate. The present study aimed to describe sexual disorders in 53 patients with testicular cancer who underwent full bilateral, non-nerve-sparing PC-RPLND in our institution, focusing beyond ejaculatory dysfunction. The International Index for Erectile Function (IIEF) questionnaire was used as diagnostic tool of male sexual functioning pre-operatively and three months after RPLND, while post-operatively patients were asked to describe and evaluate changes in selected sexual parameters. Study findings demonstrate mixed pattern of changes in sexual functioning, with no difference in erectile functioning before and after operation. However, orgasmic function and intercourse and overall sexual satisfaction were found significantly impaired post-operatively. Sexual desire and frequency of attempted sexual intercourses were found significantly increased post-operatively, in comparison with pre-operative levels. With regard to patients' subjective perception on sexual functioning alterations after PC-RPLND, a significant number of patients reported higher levels of sexual desire, no difference in erectile function and worse orgasmic function and satisfaction post-operatively. Thus, patients subjected to PC-RPLND should be closely and routinely evaluated due to close relationship of sexual dissatisfaction with secondary psychological disorders.

A pilot study to examine the experiences and attitudes of women with breast cancer towards one versus two-step axillary surgery.

PURPOSE: To elicit the views, experiences and preferences of women with clinically node negative breast cancer towards intra-operative sentinel lymph node biopsy (SLNB) analysis. METHODS: Focus groups with 14 women with breast cancer from two UK centres; one group had undergone the standard practice of waiting two weeks for results of their axillary surgery, the other had experienced the intra-operative SLNB analysis. RESULTS: Women generally were unaware about their lymph nodes, what their function is and how they are removed. Preference was indicated for intra-operative sentinel lymph node biopsy (SLNB) analysis provided clear descriptions were given about the risk of experiencing false negative and false positive results. DISCUSSION: Adopting an intra-operative analysis technique of axillary nodes was viewed as an excellent option by women from both centres. The immediacy of knowing the results was seen as a great advantage for their physical and psychological well being and more cost effective.

The relationship between morbidity after axillary surgery and long-term quality of life in breast cancer patients: the role of anxiety.

AIMS: Although arm/shoulder morbidity after sentinel lymph node biopsy (SLNB) and/or axillary lymph node dissection (ALND) has been studied before, information is lacking concerning self-imposed restrictions in activities and long-term consequences of both surgical procedures in relationship to quality of life (QoL) and anxiety. METHODS: Eighty-nine disease-free breast cancer survivors completed a set of questionnaires assessing arm/shoulder symptoms, limitations in daily life, anxiety and QoL. Also, the ipsi- and contra lateral arm circumference and the range of shoulder motion were measured. RESULTS: Fifty-one women had SLNB, 25 had SLNB followed by ALND and 13 had ALND. Although ALND patients experienced more shoulder symptoms, limitations in daily life and imposed more restrictions on themselves than SLNB patients, no significant differences during physical examination were found. A decreased range of motion and a higher score on trait anxiety resulted in a lower QoL. Trait anxiety and perceived limitations in daily life predicted long-term quality of life. CONCLUSIONS: There is a discrepancy between experienced and measured limitations in range of shoulder motion. Anxiety and self-imposed restrictions play an important role in predicting long-term QoL and should get the necessary attention when addressing shoulder symptoms in breast cancer patients.

[Quality of life after radical cystectomy - an overview and analysis of a contemporary series]. / Lebensqualität nach radikaler Zystektomie - Ubersicht und Analyse einer aktuellen Serie.

OBJECTIVE: Published evidence does not support a clear advantage in quality of life for continent versus incontinent urinary diversion or vice versa. PATIENTS AND METHODS: We retrospectively assessed 61 patients after radical cystectomy with the EORTC-QLQ-C30 and -BLM30 instruments. Analysis was performed in dependence of age, sex, technique of urinary diversion and time-course of therapy. RESULTS: 36 patients had an incontinent and 20 patients a continent urinary diversion. Younger patients (p = 0.001) and those with a continent urinary diversion (p = 0.03) were found to have a statistically significant higher incidence of financial problems. Also patients with continent urinary diversion had significantly (p = 0.032) more problems in social integration. Furthermore, there were significant differences in social integration (p = 0.03) and emotional ability (p = 0.008) in the age-dependent analysis. Patients with a continent diversion had significantly more meteoristic problems (p = 0.007). CONCLUSION: This study also could not demonstrate any clear differences in dependence on the technique of urinary diversion. A good postoperative quality of life seems possible independent of age.

Population-based study of surgical factors in relation to health-related quality of life after oesophageal cancer resection.

BACKGROUND: Oesophagectomy for cancer has a negative impact on health-related quality of life (HRQL), but factors influencing postoperative HRQL have been sparsely studied. This study explored how selected surgical factors affected HRQL 6 months after operation. METHODS: This population-based study was based on a Swedish network of physicians with almost complete nationwide coverage and data on oesophageal cancer surgery collected prospectively between 2001 and 2005. Patients completed validated HRQL questionnaires 6 months after operation. Mean scores with 95 per cent confidence intervals were calculated and clinically relevant differences between groups were analysed in a linear regression model, adjusted for potential confounders. RESULTS: Some 355 patients were included in the analysis (participation rate 79.6 per cent). Extensive surgery, as indicated by a transthoracic approach, more extensive lymphadenectomy, wider resection margins and a longer duration of operation, was not associated with worse HRQL measures than less extensive operations. Dysphagia was similar in patients who had handsewn and stapled anastomoses. Technical surgical complications had significant deleterious effects on several aspects of HRQL. CONCLUSION: This study provides no evidence to suggest that less extensive surgery for oesophageal cancer should be recommended from the perspective of HRQL. It is essential, however, that attention be paid to minimizing technical surgical complications.

Choices in cancer treatment: a qualitative study of the older women's (>70 years) perspective.

PURPOSE: Primary endocrine therapy (PET) is the treatment of primary, operable breast cancer with drugs, such as tamoxifen, rather than surgery. It is in widespread use in the UK with 40% of women over 70 years old being treated in this way. PET is associated with inferior rates of local control compared with the standard surgical therapies, but there is no difference in overall survival. There has been no published research regarding the attitudes of older women concerning these two alternative approaches to treatment; what may influence their treatment choice or their experience of either treatment modality. This study aimed to address these questions. METHOD: In-depth qualitative interviews were undertaken to explore the views of a group of 21 purposively selected older women (>70 years old), who had been treated by PET or surgery for breast cancer. The interviews were transcribed verbatim and analysed using Framework Analysis. RESULTS: Both surgery and PET were well tolerated and had high satisfaction ratings from most women. This was the case even for those who had complications following surgery or needed a change of management in the PET group. Older women expressed no age-specific fears for operative procedures. The women were passive information seekers and relied heavily on 'expert' advice in making their treatment choices. Neither social support or age were factors in their decision-making. Their main concern was to ensure that their quality of life and independence remained unaffected. CONCLUSION: Older women have no strong preference for either treatment option but are concerned that the treatment is effective and causes minimal disruption to their quality of life and independence. This study suggests that medical consultations may need to be adapted to reflect the passive acceptance of 'expert' advice in the majority of women in this age group.

[Treatment of breast cancer in elderly patients]. / Therapiemöglichkeiten bei Mammakarzinom im hohen Lebensalter.

Invasive therapeutic procedures in elderly patients with advanced breast cancer are usually contraindicated as improvement of the quality of life in this situation is considered more important than increasing life span. In the present case, however, surgical removal of the tumour has led to a significant improvement of the quality of life and could have been even more beneficial if carried out at an earlier stage.

[Burden and coping strategies of women suffering from breast cancer during their surgical primary therapy--the view of nurses]. / Belastungen und Bewältigungsstrategien von Frauen mit Brustkrebs in der Phase der chirurgischen Primärtherapie--die Sicht der Pflegenden.

The findings illustrated in this article, are part of a larger research project funded/financed by the Deutsche Krebshilfe e.V., with the aim of gaining understanding of the stresses and strains, coping strategies and needs of women suffering from breast cancer during their surgical primary treatment. Breast cancer leads to a variety of burden for women and their families. To cope with the disease women use different strategies. External assessment and self-assessment of burden and coping sometimes result in different outcomes, such as experts overestimating their patients' fear or depression or uncovering coping strategies oblivious to the interviewees. Qualitative interviews with twelve nurses in three Northern German hospitals were conducted. The content analysis of the interviews followed Mayring's approach. Uncertainty and anxiety are common characteristics for the affected women. The observed strategies can be classified into five categories: to deny the disease, to withdraw from others, to communicate, to comprehend the disease, to accept the disease. Coping strategies such as withdrawal and denial present a challenge to the nurses' communication behaviour. The findings of the survey at hand indicate a demand for suitable care interventions, further education, and training for professionals nursing women with breast cancer. Scientifically supported nursing concepts and specialised nurses are expected to comply with the affected women's special requirements.

Subjective quality of life and sexual functioning after germ-cell tumour therapy.

PURPOSE: To evaluate the influence of germ-cell tumour therapy on sexual functioning and subjective quality of life (QL). To investigate the communication about sexual problems between patients, their partners, and doctors. In all, 474 patients treated for germ-cell tumours at the Department of Internal Medicine III, Ludwig-Maximilians-University Munich, from 1979 to 2000 were asked to complete a self-report questionnaire concerning psychosocial dimensions and subjective QL (QLS; Henrich and Herschbach, 2000). In total, 341 patients returned a completed questionnaire (response rate, 71.9%). The median age at survey was 41.9 years and the median follow-up period after therapy was 9.6 years. Persisting sexual sequelae were lower than in the current literature: decreased sexual desire (7.1%), erection (10.0%), orgasm (10.2%), ejaculation (28.8%), sexual activity (8.5%), and sexual satisfaction (4.8%). In QL the satisfaction with 'friends/acquaintances' (P<0.001) and 'family life/children' (P<0.001), is lower than in the healthy population. Correlations between functional scales and subjective QL were highly significant. There is a strong correlation between sexual satisfaction and global life satisfaction (Spearman's Rho: 0.48; P<0.01). A total of 61.4% of patients were not offered communication about sexual problems by their doctors and 21.2% were unable to talk with their partner about sexual issues. In conclusion, moderating psychosocial variables (e.g. personality factors, cognitive processes) should be investigated to clarify the relationship between life satisfaction (subjective QL) and functional impairments. Communication about sexual problems should be offered as a standard to patients treated for germ-cell tumours.

Axilla surgery severely affects quality of life: results of a 5-year prospective study in breast cancer patients.

No long-term prospective study has investigated arm morbidity and patient quality of life. It is unclear to what extent breast cancer patients suffer from arm problems, how long such problems affect their lives, and whether quality of life improves as arm problems abate. This prospective cohort study aims to provide data on the clinical factors associated with arm dysfunction, to estimate its prevalence and to relate arm morbidity to quality of life. The Munich Cancer Registry records clinical details of all cancer patients in and around Munich. Quality of life information was provided directly by breast cancer patients (n = 990) over 5 years. Arm morbidity, including movement limitations, swelling and lymph drainage, and quality of life (EORTC QLQ-C30) were assessed. Up to 5 years after diagnosis, 38% of patients were still experiencing arm problems (swelling and limited movement). Consistently over the 5 years, quality of life was significantly (p < 0.001) lower for patients with arm difficulties. For those whose arm problems dissipated, quality of life significantly improved (p < 0.01). A logistic regression analysis showed that extent of axilla surgery (p < 0.003), comorbidity (CVD and diabetes) (p < 0.003), employment (p < 0.01), younger age (p < 0.02), and operating clinic (p < 0.05) significantly contributed to arm problems. Axilla surgery should be re-evaluated since arm morbidity has such a profound effect on patient quality of life.

Risk, severity and predictors of physical and psychological morbidity after axillary lymph node dissection for breast cancer.

The aim of this study was to investigate the nature and severity of the arm complaints among breast cancer patients after axillary lymph node dissection (ALND) and to study the effects of this treatment-related morbidity on daily life and well-being. 400 women, who underwent ALND as part of breast cancer surgery, filled out a treatment-specific quality of life questionnaire. The mean time since ALND was 4.7 years (range 0.3-28 years). More than 20% of patients reported pain, numbness, or loss of strength and 9% reported severe oedema. None of the complaints appeared to diminish over time. Irradiation of the axilla and supraclavicular irradiation were associated with a 3.57-fold higher risk of oedema (odds ratio (OR) 3.57; 95% confidence interval (CI) 1.66-7.69) causing many patients to give up leisure activities or sport. Women who underwent irradiation of the breast or chest wall more often reported to have a sensitive scar than women who did not receive radiotherapy. Women <45 years of age had an approximately 6 times higher risk of numbness of the arm (OR 6.49; 95% CI 2.58-16.38) compared with those > or = 65 years of age; they also encountered more problems doing their household chores. The results of the present study support the introduction of less invasive techniques for the staging of the axilla, sentinel node biopsy being the most promising.