Pain and Cognition of Breast Cancer Survivors Treated with Chemotherapy: The Mediating Role of Depression.

OBJECTIVES: While chemotherapy is the primary contributor to cancer-related cognitive impairment (CRCI), interindividual differences in CRCI are not well-understood. Studies suggest that breast cancer (BC) survivors who are in pain are more likely to experience depression, which in turn contributes to CRCI, although this hypothesis is not yet tested. Therefore, this study aimed to investigate the relationship between pain and CRCI among BC survivors and the mediation effect of depression on this relationship. METHODS: As a secondary analysis of a descriptive cross-sectional study investigating fatigue and preferred types of fatigue self-management in BC survivors recruited from five tertiary hospitals in South Korea; of the 229 participants, data on 186 who received chemotherapy were analyzed. Study participants were aged between 20 and 69 years, diagnosed with stage I to III, and treated with chemotherapy and/or radiation therapy. Measurement was done with Korean versions of the Cognitive Failure Questionnaire (to assess CRCI), Brief Pain Inventory (for pain severity and interference on daily functioning), and C-ESD (for depression). To assess bivariate relationships between pain, depression, and CRCI, Pearson correlation was used. A mediation analysis was used to examine the effect of depression on CRCI. RESULTS: Significant associations were found among pain, depression, and CRCI (all P < 0.01). Furthermore, a mediation effect of depression was found on the association between pain and CRCI (severity, ß = 1.26, SE = 0.38, 95% confidence intervals [0.60, 2.08]; interference, ß = 1.53, SE = 0.32, 95% confidence intervals [0.95, 2.20]). CONCLUSION: Findings indicate that among BC survivors, those with higher pain tend to show higher depression and consequently had lower cognitive function. IMPLICATION FOR NURSING PRACTICE: Oncology nurses may need to identify BC survivors with higher pain, and screening those survivors could be a strategy to identify those at higher risk for CRCI. Also, nurses should focus on managing depression to prevent and/or treat CRCI in BC survivors.

Psychosocial barriers and facilitators for cascade genetic testing in hereditary breast and ovarian cancer: a scoping review.

Despite increased awareness and availability of genetic testing for hereditary breast and ovarian cancer (HBOC) syndrome for over 20 years, there is still significant underuse of cascade genetic testing among at-risk relatives. This scoping review synthesized evidence regarding psychosocial barriers and facilitators of family communication and/or uptake of cascade genetic testing in relatives from HBOC families. Search terms included 'hereditary breast and ovarian cancer' and 'cascade genetic testing' for studies published from 2012-2022. Through searching common databases, and manual search of references, 480 studies were identified after excluding duplications. Each article was reviewed by two researchers independently and 20 studies were included in the final analysis. CASP, RoBANS 2.0, RoB 2.0, and MMAT were used to assess the quality of included studies. A convergent data synthesis method was used to integrate evidence from quantitative and narrative data into categories and subcategories. Evidence points to 3 categories and 12 subcategories of psychosocial barriers and facilitators for cascade testing: (1) facilitators (belief in health protection and prevention; family closeness; decisional empowerment; family support, sense of responsibility; self-efficacy; supportive health professionals); (2) bidirectional concepts (information; perception of genetic/cancer consequences; negative emotions and attitude); and (3) barriers (negative reactions from family and negative family dynamics). Healthcare providers need to systematically evaluate these psychosocial factors, strengthen facilitators and alleviate barriers to promote informed decision-making for communication of genetic test results and uptake of genetic testing. Bidirectional factors merit special consideration and tailored approaches, as they can potentially have a positive or negative influence on family communication and uptake of genetic testing.

Long Term Effects of a Social Capital-Based Exercise Adherence Intervention for Breast Cancer Survivors With Moderate Fatigue: A Randomized Controlled Trial.

OBJECTIVES: This study reports on the long-term effects of the Better Life After Cancer: Energy, Strength, and Support (BLESS) program, a 12-week social capital-based exercise adherence program for breast cancer survivors (BCS), implemented using a randomized controlled trial design. The study investigated outcomes related to cancer-related fatigue (CRF), quality of life (QOL), physical activity, depression, anxiety, sleep quality, and social capital. METHODS: Participants who had moderate or greater CRF were randomly assigned to the intervention (n = 24), consisting of supervised and home-based exercise, or the control (n = 26), who received exercise leaflets. Generalized estimating equations models were fitted for the outcome variables. The assessment points were baseline (M1), immediately after completing the intervention at 12 weeks (M2), 1 month (M3), and 6 months post-intervention (M4). RESULTS: A significant reduction in the total CRF score was found for both groups. We observed a significant time by group effect at M2, indicating a reduction of behavioral/severity CRF scores and a higher increase of physical activity. Also, there was an increase in the QOL score of both groups at M2, M3, and M4, compared to M1. Both groups had reduced anxiety at M3 and M4 compared to M1. The time by group effect for depression, sleep quality and social capital was not statistically significant. CONCLUSION: This 12-week exercise adherence program improved behavioral/severity CRF and physical activity post-intervention. Both the experimental group and control group showed significant improvements in CRF, QOL, and anxiety domains compared to the baseline, which extended to 6 months post-intervention. TRIAL REGISTRATION: Korean Clinical Research Information Service (KCT0005763).

The lived experiences of pregnancy planning after breast cancer in women of childbearing age: A phenomenological study.

Objective: This phenomenological study aimed to explore the lived experiences of planning for pregnancy after breast cancer in women of childbearing age. Methods: The study comprised 15 women with breast cancer who were considering pregnancy and childbirth. Individual in-depth interviews were conducted between November 2022 and March 2023, and the verbatim transcripts were analyzed using Colaizzi's phenomenological method. Results: Four theme clusters emerged: (1) deepening desires amidst hardships, (2) endless worries about an uncertain future, (3) unveiling the meaning of having a child, and (4) perpetual deliberations regarding unresolved dilemmas. Over time, the participants' longing for children intensified, despite the contradiction of their reduced fertility. They expressed concerns about the potential risks and challenges of pregnancy in breast cancer patients, but they attributed value to having a child as a means to restoring their health, reclaiming their ordinary lives, and providing motivation for a healthier future. The participants found making decisions regarding pregnancy to be difficult and were often influenced by others. Conclusions: This study underscores the unique challenges faced by women with breast cancer who are making fertility-related decisions. The findings contribute to a better understanding of these challenges and offer valuable insights for the development of decision aids that support shared decision-making for pregnancy after breast cancer.

Supporting decision-making regarding fertility preservation in patients with cancer: An integrative review.

INTRODUCTION: Recent reproductive technology for cancer patients has provided multiple options to preserve their fertility. Preserving fertility can increase quality of life of cancer patients. However, medical service providers and patients face difficulties in the decision-making process for the fertility preserving treatment because studies focusing on the concept of decision-making and various intervention materials are lack. This review aims to identify the attributes of interventions of studies on decision-making support interventions in cancer patients considering fertility preservation and provide best evidence for health professionals. METHODS: PubMed, CINAHL, Embase, Cochrane CENTRAL and DBpia databases were searched. An integrated review of the literature was conducted using Whittemore and Knafl's methodology. RESULTS: The search identified 1008 articles, of which 11 studies met eligible criteria. The attributes of the interventions were (1) provision of detailed and practical information of fertility preservation, (2) nondirective approaches to help patients to value their judgements, (3) emphasis on interactions through individualised consultations, (4) establishing connections with available resources and (5) reinforcement of decision-making support resources. CONCLUSION: Health professionals must acquire current knowledge and ethical and legal standards of fertility preservation and pass this information on to patients before the formation of fertility preservation decision-making support networks within the hospital and health systems.

Comparing Disease-Specific and Generic Quality of Life in Korean Breast Cancer Survivors Using the FACT-B and QLI: The Importance of Instrument Selection.

BACKGROUND: Quality of life (QOL) has become an important indicator for evaluating patients' symptoms and their overall satisfaction with life. Thus, examining QOL is essential for fully understanding the life satisfaction of breast cancer survivors (BCS). However, selecting the appropriate instrument for QOL measurement is challenging, and few studies have compared disease-specific and generic QOL measures and how they reflect the impact of cancer-related symptoms on QOL in BCS. We examined QOL in BCS using both disease-specific and generic instruments and compared their representation of the QOL impacts of anxiety, depression, sleep, fatigability, and posttraumatic growth. METHODS: This study involved analysis of follow-up data for an exercise intervention called the BLESS (Better Life after cancer, Energy, Strength, and Support) program, which included 40 BCS treated at 1 medical center in South Korea. Their QOL was assessed using both the Functional Assessment of Cancer Therapy-Breast (FACT-B) and Quality of Life Index (QLI). RESULTS: Both FACT-B and QLI total scores revealed that Korean BCS had low levels of QOL. Furthermore, both FACT-B and QLI total scores were significantly related to anxiety, depression, sleep, fatigability, and posttraumatic growth in the participants. Notably, multivariate regression analysis of FACT-B and QLI total scores showed different predictors for QOL: with the FACT-B, depression was the only significant predictor, while with the QLI, posttraumatic growth was the only significant predictor. CONCLUSION: The selection of a given QOL instrument may affect the overall findings and interpretation of the impacts of related symptoms. The FACT-B should be considered for studies of symptoms such as depression, while the QLI is more appropriate for examining overall QOL and posttraumatic growth.

"Struggling to Accept the New Breast as Part of My Body" - The Challenge of Immediate Breast Reconstruction in Women With Breast Cancer.

BACKGROUND: Women have difficulties in making decisions and experiences an unexpectedly long recovery period after immediate breast reconstruction. There are still many limitations in understanding the overall changes in life experienced by women with breast cancer before and after immediate breast reconstruction. OBJECTIVE: This study aimed to explore the challenges experienced by women with breast cancer undergoing immediate breast reconstruction and how they coped with these problems. METHODS: Strauss and Corbin's grounded theory design was used. In-depth face-to-face individual interviews were undertaken with 11 women with breast cancer from 4 hospitals in Korea. Data collection and analysis were conducted simultaneously, using the constant comparative method. RESULTS: The core category was "struggling to accept the new breast as part of my body." "Decision making regarding immediate breast reconstruction" was the initial step, followed by "facing the changed breasts after surgery." The challenge of "living with the new breasts" slowly merged into "making up my mind to accept my breasts with gratitude." CONCLUSION: Women with breast cancer undergoing immediate breast reconstruction struggled to accept the new breast as part of their body, and some reached a measure of closure and acceptance with gratitude. IMPLICATION FOR PRACTICE: Nurses can apply findings by recognizing the experiences, perceptions, and needs of women; providing patients with sufficient information on the whole process; and offering continuous supportive care to facilitate the coping process. In addition, nurses should consider a variety of approaches that help women to integrate their changed bodies into their self-concept and self-image and restore a sense of normality.

Does the Association Between Fatigue and Fatigue Self-management Preference Vary by Breast Cancer Stage?

BACKGROUND: Cancer-related fatigue (CRF) is a major issue facing breast cancer survivors (BCS) that can negatively impact their symptoms and quality of life. OBJECTIVES: The aims of this study were to examine levels of fatigue, identify preferred types of fatigue self-management, and explore the relationship between fatigue levels and management choices by cancer stage. METHODS: This cross-sectional descriptive study included 229 BCS recruited from 5 hospitals in Korea. The study inclusion criteria were limited to BCS between 20 and 69 years old in stages 1, 2, or 3 who were undergoing or had completed active therapy. The Revised Piper Fatigue Scale and a questionnaire developed for fatigue management were used for data collection. RESULTS: The stage 2 group experienced more fatigue (mean, 5.31) than the other cancer stage groups, and significant differences in fatigue were found between stages 1 and 2 (P < .001). Fatigue self-management choices showed different correlations with fatigue levels in each stage. Physical activity control was most frequently used in stage 1, whereas exercise was most frequently used in stages 2 and 3. Multivariate regression analysis showed that exercise consistently and effectively decreased all fatigue dimensions. CONCLUSION: Stage 2 BCS experienced the greatest level of CRF, and fatigue levels and management choices differed in BCS by cancer stage. IMPLICATIONS FOR PRACTICE: Recognizing how CRF and patients' preferences for fatigue self-management may differ by cancer stage can alert clinicians in assessing CRF and tailoring effective fatigue management for BCS.

Comparison of fatigue and fatigability correlates in Korean breast cancer survivors and differences in associations with anxiety, depression, sleep disturbance, and endocrine symptoms: a randomized controlled trial.

BACKGROUND: Fatigue is one of the most common and burdensome symptoms experienced by cancer patients. In interventions intended to reduce fatigue in such patients, fatigability, or perception of fatigue contextualized to activities of fixed intensity and duration, may also be measured. This study investigated the effects of a 15-month intervention on fatigue and fatigability in breast cancer survivors (BCS); explored the fatigue-fatigability relationship; and evaluated the impacts of fatigue and fatigability on anxiety, depression, sleep disturbance, and endocrine symptoms. METHODS: A randomized controlled trial design was applied to an exercise program called BLESS (Better Life after cancer, Energy, Strength, and Support). The intervention included this 12-week exercise program and four follow-up contacts intended to promote exercise adherence over the following year. Participants were women aged 20 to 69 who had been diagnosed with stage I, II, or III breast cancer; had completed active treatment; and had moderate or higher fatigue. At the completion of the intervention, the survey responses of 40 BCS were evaluated using the chi-square test and multiple regression analysis. The Korean versions of the Revised Piper Fatigue Scale and Pittsburgh Fatigability Scale were used to measure fatigue and fatigability, respectively. RESULTS: There was no significant difference in fatigue or fatigability between the experimental and control groups at intervention completion. However, the control group showed a stronger association than the experimental group between fatigue and physical fatigability. In the control group, fatigue and fatigability were significantly associated with anxiety, depression, sleep disturbance, and endocrine symptoms. In the experimental group, only the cognitive/mood fatigue score and depression were significantly associated. Only endocrine symptoms influenced mental fatigability (B = - 0.185, P < 0.05), and only depression influenced cognitive/mood fatigue (B = 1.469, P < 0.05). CONCLUSIONS: Fatigue and fatigability showed different correlations with cancer-related symptoms after the exercise intervention. Future assessments of fatigability in intervention studies will allow measurement of the spectrum of patients' abilities to overcome fatigue at various physical activity levels while capturing different aspects of cancer-related symptoms. TRIAL REGISTRATION: This study was retrospectively registered on Clinical Research Information Service ( KCT0005763 ; date of registration: 31/12/2020).

Erratum: Pro-inflammatory Cytokine Levels and Cancer-related Fatigue in Breast Cancer Survivors: Effects of an Exercise Adherence Program.

[This corrects the article on p. 205 in vol. 23, PMID: 32395379.].

Pro-inflammatory Cytokine Levels and Cancer-related Fatigue in Breast Cancer Survivors: Effects of an Exercise Adherence Program.

PURPOSE: This study aimed to determine the effect of an exercise intervention on subjective cancer-related fatigue (CRF) and pro-inflammatory cytokine levels in breast cancer survivors (BCS). METHODS: BCS with greater than moderate CRF (≥ 4) were recruited and randomly assigned to experimental or control groups. The experimental group participated in a 12-week exercise adherence program (Better Life after Cancer - Energy, Strength, and Support; BLESS). Interleukin (IL)-6 and tumor necrosis factor-α (TNF-α) levels were determined at 3 time points (M1: baseline, M2: post-intervention, and M4: 6 months after intervention). Subjective fatigue was measured using the Korean version of the revised Piper Fatigue Scale. RESULTS: In this analysis of participants with physiological fatigue measures available (19 experimental, 21 control), there were no statistically significant differences in IL-6 (F = 1.157, p = 0.341), TNF-α levels (F = 0.878, p = 0.436), and level of fatigue (F = 2.067, p = 0.118) between the 2 groups at baseline. Fatigue in the experimental group showed statistically significant improvement compared to the control only at M2 (p = 0.022). There was no significant relationship between subjective and physiological fatigue at the 3 measurement points. CONCLUSION: The BLESS intervention improved CRF in BCS immediately at post-intervention, and this study presents clinical feasibility for the management of CRF in BCS in the early survivorship phase who are already experiencing fatigue.

Pre-post analysis of a social capital-based exercise adherence intervention for breast cancer survivors with moderate fatigue: a randomized controlled trial.

PURPOSE: This study assessed the effectiveness of the Better Life After Cancer: Energy, Strength, and Support (BLESS) program, a 12-week social capital-based exercise adherence program for breast cancer survivors (BCS), regarding cancer-related fatigue (CRF), quality of life (QOL), physical activity, and psychosocial characteristics. METHODS: Forty-eight BCS with moderate or high (≥ 4) CRF participated in this randomized control trial (intervention group n = 23, control group n = 25). The intervention group participated in small group sessions to activate social capital while targeting CRF in supervised physical exercises supplemented by home-based physical exercises. The control group was only given written information on exercise. A questionnaire was used to assess CRF, QOL, physical activity, depression, anxiety, sleep quality, and social capital. RESULTS: The majority of participants had undergone surgery less than 2 years ago. After participating in BLESS, the CRF behavioral/severity domain significantly decreased (t = 2.642, p = 0.011) and physical activity significantly increased (t = - 2.049, p = 0.046) in the intervention group, in comparison with the control group; there were no significant post-intervention differences in the control group. Both groups showed improvements in sleep quality, depression, anxiety, and QOL. CONCLUSION: The BLESS program decreased behavioral/severity in the CRF and increased physical activity after 12 weeks among BCS. Future research needs to evaluate whether the promising results on physical activity and behavioral fatigue observed in the short term will persist over time. Also, longer-term effects should be examined.

The experience of cancer-related fatigue, exercise and exercise adherence among women breast cancer survivors: Insights from focus group interviews.

AIMS AND OBJECTIVES: To identify the experience of breast cancer survivors regarding cancer-related fatigue, exercise and exercise adherence. BACKGROUND: Cancer-related fatigue is a common symptom among cancer survivors that limits quality of life. Despite exercise being recommended as a viable solution to manage cancer-related fatigue, relatively few research studies on the experience of cancer-related fatigue and exercise adherence have been conducted. DESIGN: This was a qualitative study to identify breast cancer survivors' experience of cancer-related fatigue, exercise and exercise adherence. This paper adhered to the COREQ checklist in reporting. METHODS: Four focus group interviews were conducted with 16 breast cancer survivors who had fatigue score of 4 out of 10 (moderate fatigue) or greater. Ethical approval was obtained and participants met for focus group interview discussion. The interview guide included questions on cancer-related fatigue, barriers and facilitators of exercising, strategies for exercise adherence and suggestions for a supportive programme. RESULTS: Four themes were identified through thematic analysis: (a) The insidious and overpowering nature of cancer-related fatigue; (b) exercising when experiencing fatigue surrounded by prevailing myths; (c) multiple barriers to exercise; and (d) facilitative factors to continue exercising despite fatigue. CONCLUSIONS: Participants' experience of moderate or greater cancer-related fatigue prevented them from exercising, despite knowing its importance, and limited them to passive activities. Misconceptions that exercise is associated with lymphedema and risk of recurrence, poor psychosocial self-image and lack of clear knowledge and exercise programmes for cancer survivors further limited adherence to exercise. In contrast, finding comfort and strength through exercising and interacting with other breast cancer survivors were facilitative factors. RELEVANCE TO CLINICAL PRACTICE: The insights shared by breast cancer survivors experiencing cancer-related fatigue can contribute to developing an exercise adherence programme as a way to manage and alleviate fatigue and establish healthy survivorship care.

Development of an exercise adherence program for breast cancer survivors with cancer-related fatigue-an intervention mapping approach.

PURPOSE: Cancer-related fatigue (CRF) is the most common and distressing symptom in breast cancer survivors (BCS), with severe impact on quality of life. CRF can be reduced through exercise, but conversely, is also a barrier to exercising. The aim of this article was to apply the intervention mapping protocol (IMP) to develop an exercise adherence intervention for BCS with CRF. METHOD: The program was developed using the IMP, which consists of six steps. Based on the data from focus group interviews and literature review, we produced a logic model of change. RESULTS: Two performance objectives (survivors adopt and maintain exercise and survivors cope with fatigue) and 17 change objectives were generated. Also, we designed theory-based methods of change, and strategies for practical application. A structured program plan that includes intervention content and methods, ranges, and program data was proposed. Finally, an implementation and evaluation plan was developed. CONCLUSION: The IMP provided a useful framework to systematically plan an exercise adherence program. This study resulted in a theory and practice-based exercise adherence program, based on behavioral change theories, and practice-based knowledge that fits the needs of BCS with CRF.