Practical Assessment and Management of Vulnerabilities in Older Patients Receiving Systemic Cancer Therapy: ASCO Guideline Update.

PURPOSE: To update the ASCO guideline (2018) on the practical assessment and management of age-associated vulnerabilities in older patients undergoing systemic cancer therapy. METHODS: An Expert Panel conducted a systematic review to identify relevant randomized clinical trials (RCTs), systematic reviews, and meta-analyses from January 2016 to December 2022. RESULTS: A total of 26 publications met eligibility criteria and form the evidentiary basis for the update. RECOMMENDATIONS: The Expert Panel reiterates its overarching recommendation from the prior guideline that geriatric assessment (GA), including all essential domains, should be used to identify vulnerabilities or impairments that are not routinely captured in oncology assessments for all patients over 65 years old with cancer. Based on recently published RCTs demonstrating significantly improved clinical outcomes, all older adults with cancer (65+ years old) receiving systemic therapy with GA-identified deficits should have GA-guided management (GAM) included in their care plan. GAM includes using GA findings to inform cancer treatment decision-making as well as to address impairments through appropriate interventions, counseling, and/or referrals. A GA should include high priority aging-related domains known to be associated with outcomes in older adults with cancer: physical and cognitive function, emotional health, comorbid conditions, polypharmacy, nutrition, and social support. Clinical adaptation of the GA based on patient population, resources, and time is appropriate.The Panel recommends the Practical Geriatric Assessment as one option for this purpose (https://old-prod.asco.org/sites/new-www.asco.org/files/content-files/practice-patients/documents/2023-PGA-Final.pdf; https://youtu.be/jnaQIjOz2Dw; https://youtu.be/nZXtwaGh0Z0).Additional information is available at www.asco.org/supportive-care-guidelines.

Communication About Fall Risk in Community Oncology Practice: The Role of Geriatric Assessment.

PURPOSE: Falls are a modifiable source of morbidity for older adults with cancer, yet are underassessed in oncology practice. In this secondary analysis of a nationwide cluster-randomized controlled trial, we examined characteristics associated with patient-oncologist conversations about falls, and whether oncologist knowledge of geriatric assessment (GA) resulted in more conversations. METHODS: Eligible patients (ClinicalTrials.gov identifier: NCT02107443) were age ≥ 70 years, had stage III/IV solid tumor or lymphoma, were being treated with noncurative treatment intent, and ≥ 1 GA domain impairment. Patients in both arms underwent GA. At practices randomly assigned to the intervention arm, oncologists were provided a GA summary with management recommendations. In both arms, patients had one clinical encounter audio-recorded, transcribed, and coded to categorize whether a conversation about falls occurred. Generalized linear mixed models adjusted for arm, practice site, and other important covariates were used to generate proportions and odds ratios (ORs) from the full sample. RESULTS: Of 541 patients (intervention N = 293 and usual care N = 248, mean age: 77 years, standard deviation: 5.3), 528 had evaluable audio recordings. More patients had conversations about falls in the intervention versus usual care arm (61.3% v 10.3%, P < .001). Controlling for the intervention and practice site, history of falls (OR, 2.1; 95% CI, 1.3 to 3.6; P = .005) and impaired physical performance (OR, 4.7; 95% CI, 1.7 to 12.8; P = .002) were significantly associated with patient-oncologist conversations about falls. CONCLUSION: GA intervention increased conversations about falls. History of falls and impaired physical performance were associated with patient-oncologist conversations about falls in community oncology practice.

Association of Oncologist-Patient Communication With Functional Status and Physical Performance in Older Adults: A Secondary Analysis of a Cluster Randomized Clinical Trial.

Importance: The functional status and physical performance of older adults with cancer are underassessed and undertreated despite the high prevalence of impaired functional status and physical performance in this population and their associations with chemotherapy-induced toxic effects and mortality. Objective: To examine the association between providing oncologists with a geriatric assessment (GA) summary with recommendations and having oncologist-patient conversations about functional and physical performance. Design, Setting, and Participants: Data for this secondary analysis were collected from October 29, 2014, to April 28, 2017, for a national cluster randomized clinical trial conducted by the University of Rochester Cancer Center National Cancer Institute Community Oncology Research Program evaluating the effect of a GA intervention on patient satisfaction with communication about aging-related concerns. There were 17 practice clusters in the intervention group and 14 in the usual care group. All 541 participants underwent a GA including standardized functional and physical performance measures and had 1 clinical encounter audio-recorded, transcribed, and blindly coded to categorize conversations by GA domain. Participants were aged 70 years or older, with a stage III or IV solid tumor or lymphoma with palliative treatment intent, and impairment in 1 or more GA domain. Statistical analysis was performed from August 18, 2020, to January 10, 2022. Interventions: Oncologist practices randomized to the intervention received a GA summary and validated recommendations for each patient prior to the audio-recorded clinical encounter. Main Outcomes and Measures: The primary analysis of this clinical trial assessed the effect of the intervention on patient satisfaction with oncologist communication about aging-related concerns. This secondary analysis assessed the post hoc hypothesis that the intervention would be associated with an increase in the proportion of patients having conversations with their oncologists and receiving oncologist recommendations specific to functional and physical performance concerns. Results: A total of 541 patients (276 men [51%]; mean [SD] age, 77.5 [5.2] years [range, 70-96 years]) were analyzed at baseline. Excluding 13 patients without audio recordings, 86% of patients (95% CI, 78%-91%) in the intervention group vs 59% of patients (95% CI, 47%-69%; P < .001) receiving usual care had conversations about functional or physical performance. Conversations were more frequently initiated by oncologists in the intervention group (84%; 95% CI, 77%-90%) than oncologists in the usual care group (58%; 95% CI, 45%-70%; P < .001). Oncologists in the intervention group were more likely to address patients' concerns (43%; 95% CI, 33%-53%) than oncologists in the usual care group (17%; 95% CI, 10%-26%; P < .001). Conclusions and Relevance: In this secondary analysis of a cluster randomized clinical trial, providing oncologists with a GA summary was associated with an increase in the number of oncologist-patient conversations about functional and physical performance-related concerns with recommendations to address these concerns. These findings support the use of the GA summary and recommendations as important tools in caring for older adults with advanced cancer and functional or physical impairments. Trial Registration: ClinicalTrials.gov Identifier: NCT02107443.

Behavioral, psychological, and supportive care interventions in geriatric oncology: The Cancer and Aging Research Group infrastructure core.

Current research efforts focusing on improving outcomes of older adults with cancer lack the appropriate infrastructure to support this growing need. The Cancer and Aging Group R21/33 National Institute of Health (NIH)/National Institute of Aging (NIA) grant aims to support development of geriatric oncology research through dedicated cores. The mission of the Core on Behavioral, Psychological, and Supportive Care Interventions will be to provide guidance in the field of non-pharmacological interventions. The Core will provide investigators with expertise, advocacy, and support in study design, development, and execution.

Willingness to bear adversity and beliefs about the curability of advanced cancer in older adults.

BACKGROUND: Older patients with advanced cancer who are 100% certain they will be cured pose unique challenges for clinical decision making, but to the authors' knowledge, the prevalence and correlates of absolute certainty about curability (ACC) are unknown. METHODS: Cross-sectional data were collected in a geriatric assessment trial. ACC was assessed by asking patients, "What do you believe are the chances that your cancer will go away and never come back with treatment?" Response options were 100% (coded as ACC), >50%, 50/50, <50%, 0%, and uncertain. The willingness to bear adversity in exchange for longevity was assessed by asking patients to consider trade-offs between survival and 2 clinical outcomes that varied in abstractness: 1) maintaining quality of life (QOL; an abstract outcome); and 2) specific treatment-related toxicities (eg, nausea/vomiting, worsening memory). Logistic regression was used to assess the independent associations between willingness to bear adversity and ACC. RESULTS: Of the 524 patients aged 70 to 96 years, approximately 5.3% reported that there was a 100% chance that their cancer would be cured (ACC). ACC was not found to be significantly associated with willingness to bear treatment-related toxicities, but was more common among patients who were willing to trade QOL for survival (adjusted odds ratio, 4.08; 95% CI, 1.17-14.26). CONCLUSIONS: Patients who were more willing to bear adversity in the form of an abstract state, namely decreased QOL, were more likely to demonstrate ACC. Although conversations regarding prognosis should be conducted with all patients, those who are willing to trade QOL for survival may especially benefit from conversations that focus on values and emotions.

Determinants of adherence to physical activity guidelines among overweight and obese African American breast cancer survivors: implications for an intervention approach.

OBJECTIVE: Public health agencies encourage breast cancer survivors (BCSs) to follow their physical activity guidelines (PAGs). However, adherence to these guidelines is low. African American (AA) BCSs are more often overweight or obese and less likely than women of other races to report adherence to physical activity recommendations. This study examined socioeconomic, clinical, and psychosocial correlates with meeting PAGs. DESIGN: AA women diagnosed and treated for breast cancer and participating in a breast cancer support group (N = 193) completed a lifestyle assessment tool capturing demographic characteristics; breast cancer diagnosis and treatment history; health-related quality of life; weight history, including body mass index and post-diagnosis weight gain; and physical activity. Logistic regressions were used to determine if these covariates were associated with meeting [>8.3 metabolic equivalent task (MET) hr/wk]; partially meeting (4.15-8.3 MET hr/wk); or not meeting (<4.15 MET hr/wk) PAGs. RESULTS: Only 54% of AA BCSs reported meeting current PAGs. Participants reporting weight gain of ≤5 lbs post-diagnosis, and those who received surgical treatment for breast cancer were more likely to complete at least 8.3 MET hr/wk. Better physical functioning and lesser pain intensity were associated with meeting PAGs. CONCLUSION: Several factors influence physical activity behaviors and are likely to be important in developing effective interventions to assist AA survivors manage their weight. It is essential that providers and breast cancer support groups that assist survivors to remain physically active and to manage their weight should be aware of these factors. These findings may help generate hypotheses for future research to undergird efforts to increase physical activity among African American BCSs.

Community engagement to address socio-ecological barriers to physical activity among African American breast cancer survivors.

BACKGROUND: With high rates of obesity, low levels of physical activity (PA), and lack of adherence to physical activity guidelines (PAGs) among African American (AA) breast cancer survivors (BCSs), culturally appropriate interventions that address barriers to participation in PA are needed. METHODS: To develop intervention content, members of an AA breast cancer support group participated in four 1-hour focus group discussions (related to the barriers to PA, strategies for overcoming them, and intervention content), which were audiotaped, transcribed, and analyzed. RESULTS: The support group collaborated with researchers to construct the Physical Activity Intervention Developed (PAID) to Prevent Breast Cancer, a multi-component (educational sessions; support group discussions; and structured, moderately intensive walking, strength training, and yoga), facilitated, 24-week program focused on reducing multi-level barriers to PA that promote benefits ('pay off') of meeting PAGs. CONCLUSIONS: Community engagement fostered trust, promoted mutuality, built collaboration, and expanded capacity of AA BCSs to participate in developing an intervention addressing individual, interpersonal, organizational, and community barriers to PA.

Formative research to develop a lifestyle application (app) for African American breast cancer survivors.

BACKGROUND: There is a proliferation of lifestyle-oriented mobile technologies; however, few have targeted users. Through intervention mapping, investigators and community partners completed Steps 1-3 (needs assessment, formulation of change objectives, and selection of theory-based methods) of a process to develop a mobile cancer prevention application (app) for cancer prevention. The aim of this qualitative study was to complete Step 4 (intervention development) by eliciting input from African American (AA) breast cancer survivors (BCSs) to guide app development. METHODS: Four focus group discussions (n=60) and three individual semi-structured interviews (n=36) were conducted with AA BCSs (40-72 years of age) to assess barriers and strategies for lifestyle change. All focus groups and interviews were recorded and transcribed verbatim. Data were analyzed with NVivo qualitative data analysis software version 10, allowing categories, themes, and patterns to emerge. RESULTS: Three categories and related themes emerged from the analysis: 1) perceptions about modifiable risk factors; 2) strategies related to adherence to cancer prevention guidelines; and 3) app components to address barriers to adherence. Participant perceptions, strategies, and recommended components guided development of the app. CONCLUSIONS: For development of a mobile cancer prevention app, these findings will assist investigators in targeting features that are usable, acceptable, and accessible for AA BCSs.

Engaging African Americans in developing an intervention to reduce breast cancer recurrence: A brief report.

BACKGROUND: To develop a culturally appropriate lifestyle intervention, involvement of its intended users is needed. METHODS: Members of an African American (AA) breast cancer support group participated in two 4-hour guided discussions, which were audiotaped, transcribed, and analyzed to guide the content. RESULTS: The support group collaborated with researchers to develop 24 experiential nutrition education sessions using a social cognitive framework and incorporating self-regulation skills (goal-setting, self-monitoring, problem-solving, stimulus control) and social support to enhance self-efficacy for changes in dietary intake. CONCLUSIONS: Community engagement fostered autonomy, built collaboration, and enhanced the capacity of AA breast cancer survivors to participate in developing a lifestyle intervention.

Understanding cognition in older patients with cancer.

Cancer and neurocognitive disorders, such as dementia and delirium, are common and serious diseases in the elderly that are accompanied by high degree of morbidity and mortality. Furthermore, evidence supports the under-diagnosis of both dementia and delirium in older adults. Complex questions exist regarding the interaction of dementia and delirium with cancer, beginning with guidelines on how best measure disease severity, the optimal screening test for either disorder, the appropriate level of intervention in the setting of abnormal findings, and strategies aimed at preventing the development or progression of either process. Ethical concerns emerge in the research setting, pertaining to the detection of cognitive dysfunction in participants, validity of consent, disclosure of abnormal results if screening is pursued, and recommended level of intervention by investigators. Furthermore, understanding the ways in which comorbid cognitive dysfunction and cancer impact both cancer and non-cancer-related outcomes is essential in guiding treatment decisions. In the following article, we will discuss what is presently known of the interactions of pre-existing cognitive impairment and delirium with cancer. We will also discuss identified deficits in our knowledge base, and propose ways in which innovative research may address these gaps.

Chemotherapy-related cognitive impairment in older patients with cancer.

Chemotherapy-related cognitive impairment (CRCI) can occur during or after chemotherapy and represents a concern for many patients with cancer. Among older patients with cancer, in whom there is little clinical trial evidence examining side effects like CRCI, many unanswered questions remain regarding risk for and resulting adverse outcomes from CRCI. Given the rising incidence of cancer with age, CRCI is of particular concern for older patients with cancer who receive treatment. Therefore, research related to CRCI in older patients with cancers is a high priority. In this manuscript, we discuss current gaps in research highlighting the lack of clinical studies of CRCI in older adults, the complex mechanisms of CRCI, and the challenges in measuring cognitive impairment in older patients with cancer. Although we focus on CRCI, we also discuss cognitive impairment related to cancer itself and other treatment modalities. We highlight several research priorities to improve the study of CRCI in older patients with cancer.

Factors associated with body mass index among African American breast cancer survivors.

BACKGROUND: Weight gain after diagnosis and treatment is common among breast cancer survivors (BCSs). Little information exists regarding associations between body mass index (BMI) and lifestyle factors and health-related quality of life (HR-QoL) among African American (AA) BCSs. The present study sought to determine associations between BMI, dietary intake, and physical activity as lifestyle modification strategies and HR-QoL among AA BCSs. METHODS: For this cross-sectional study, a lifestyle assessment tool was administered to 195 AA BCSs. Possible predictor variables included socio-demographic and medical characteristics, dietary intake and physical activity patterns, and physical health. The outcome variable was BMI. RESULTS: Many BCSs (63%) had BMIs ≥25 Kg/M2 and presented with stage I cancer (41%) at diagnosis. Among those presenting with late-stage cancer (IIIA, IIIB, IV), 76% were overweight or obese (p=0.0008). Eighty-four percent reported excellent-to-good physical health (p=0.0499) and were less likely to have higher BMIs compared to those reporting fair-to-poor physical health (OR=0.616 [CI=0.192-1.978]). Responders with graduate level education were more likely to have healthy body weights than those attaining high school or less educational levels (OR=2.379 [CI=0.617-9.166]). CONCLUSIONS: Most AA BCSs surveyed were overweight or obese, did not engage in recommended physical activity levels and failed to consume diets linked to breast cancer prevention. Interventions are needed to promote weight loss, improve dietary intake, and enhance physical activity among AA BCSs.

A Community-Engaged Approach to Developing a Mobile Cancer Prevention App: The mCPA Study Protocol.

BACKGROUND: Rapid growth of mobile technologies has resulted in a proliferation of lifestyle-oriented mobile phone apps. However, most do not have a theoretical framework and few have been developed using a community-based participatory research approach. A community academic team will develop a theory-based, culturally tailored, mobile-enabled, Web-based app-the Mobile Cancer Prevention App (mCPA)-to promote adherence to dietary and physical activity guidelines. OBJECTIVE: The aim of this study is to develop mCPA content with input from breast cancer survivors. METHODS: Members of SISTAAH (Survivors Involving Supporters to Take Action in Advancing Health) Talk (N=12), treated for Stages I-IIIc breast cancer for less than 1 year, 75 years of age or younger, and English-speaking and writing, will be recruited to participate in the study. To develop the app content, breast cancer survivors will engage with researchers in videotaped and audiotaped sessions, including (1) didactic instructions with goals for, benefits of, and strategies to enhance dietary intake and physical activity, (2) guided discussions for setting individualized goals, monitoring progress, and providing or receiving feedback, (3) experiential nutrition education through cooking demonstrations, and (4) interactive physical activity focused on walking, yoga, and strength training. Qualitative (focus group discussions and key informant interviews) and quantitative (sensory evaluation) methods will be used to evaluate the participatory process and outcomes. RESULTS: Investigators and participants anticipate development of an acceptable (frequency and duration of usage) feasible (structure, ease of use, features), and accessible mobile app available for intervention testing in early 2017. CONCLUSIONS: Depending on the availability of research funding, mCPA testing, which will be initiated in Miami, will be extended to Chicago, Houston, Philadelphia, and Los Angeles.

Determinants of adherence to nutrition-related cancer prevention guidelines among African American breast cancer survivors.

BACKGROUND: Mortality rate for breast cancer is higher among African American (AA) women than for women of other racial/ethnic groups. Obesity, also higher among AA women, may increase the risk of breast cancer development and recurrence. Lifestyle factors such as healthy nutrition can reduce the rate of obesity and breast cancer. This study examined the determinants of adherence to nutrition-related cancer prevention guidelines among AA breast cancer survivors. METHODS: AA breast cancer survivors (n=240) were recruited from a breast cancer support group to complete a lifestyle assessment tool for this cross-sectional study. Chi-square test and ordinal logistic regression analysis were used to examine the relationship between adherence to nutrition-related cancer prevention guidelines and potential predictors of adherence. RESULTS: Majority of the survivors met the guideline for red and processed meat (n=191, 83.4%), but did not meet the guideline for fruits and vegetables (n=189, 80.4%). For survivors with annual household incomes < $25,000, the odds of meeting or partially meeting the guideline for fruits and vegetables was 75.4% less than for participants with incomes > $50,000 (OR= 0.25, 95% CI: 0.08, 0.80). Poor physical functioning (OR= 38.48, 95% CI: 2.26, 656.58), sleep disturbances (OR= 60.84, 95% CI: 1.61, 2296.02), and income > $50,000 (OR= 51.02, 95% CI: 1.13, 2311.70) were associated with meeting the guideline for red and processed meat. CONCLUSIONS: Many AA breast cancer survivors are not meeting the nutrition-related cancer prevention guidelines. For this population, more interventions that enhance access to and consumption of healthy diets are needed.

Developing a Cookbook with Lifestyle Tips: A Community-Engaged Approach to Promoting Diet-Related Cancer Prevention Guidelines.

Supplementing nutrition education with skills-building activities may enhance community awareness of diet-related cancer prevention guidelines. To develop a cookbook with lifestyle tips, recipes were solicited from the National Black Leadership Initiative on Cancer (NBLIC) community coalitions and dietary intake advice from participants in the Educational Program to Increase Colorectal Cancer Screening (EPICS). With guidance from a chef and registered dietitian, recipes were tested, assessed, and transformed; lifestyle advice was obtained from focus groups. The cookbook with lifestyle tips, named "Down Home Healthy Living (DHHL) 2.0," was distributed in print form to 2,500 EPICS participants and shared electronically through websites and social media.

Beliefs and Behaviors about Breast Cancer Recurrence Risk Reduction among African American Breast Cancer Survivors.

A growing body of evidence suggests that breast cancer recurrence risk is linked to lifestyle behaviors. This study examined correlations between breast cancer recurrence, risk reduction beliefs, and related behaviors among African American breast cancer survivors (AA BCSs). Study participants included 191 AA BCSs, mean age = 56.3 years, who completed a lifestyle assessment tool. Most respondents believed that being overweight (52.7%), lack of physical activity (48.7%), and a high fat diet (63.2%) are associated with breast cancer recurrence. Over 65% considered themselves overweight; one third (33.5%) agreed that losing weight could prevent recurrence, 33.0% disagreed, while the remaining 33.5% did not know; and nearly half (47.9%) believed that recurrence could be prevented by increasing physical activity. Almost 90% survivors with BMI < 25 Kg/M² reported no recurrence compared to 75.7% with BMI ≥ 25 Kg/M² (p = 0.06); nearly all of the women (99.2%) answered "yes" to seeking professional help to lose weight, 79.7% of which were recurrence-free (p = 0.05). These results provide information about AA BCSs' beliefs and behaviors protective against breast cancer recurrence. Additional research is warranted to determine the effectiveness of educational interventions for AA BCSs that promote consumption of a healthy diet and engaging in regular physical activity.

Lifestyle Modification Experiences of African American Breast Cancer Survivors: A Needs Assessment.

BACKGROUND: Little is known about the rates of obesity among African American (AA) breast cancer survivors (BCSs), the availability and use of lifestyle modification methods suitable for this population, and the impact of changes in dietary intake and physical activity on health-related quality of life (HR-QoL). OBJECTIVE: The objectives of the study were to describe obesity rates, dietary intake, and physical activity as lifestyle modification strategies; examine predictors of engagement in these strategies post diagnosis; and learn more about salient features of lifestyle interventions from AA BCSs participating in a breast cancer support group. METHODS: The needs assessment included four components: (1) a literature review to determine existing lifestyle modification strategies of AA BCSs; (2) secondary data analysis of the 2010 National Health Interview Survey, Cancer Control Supplement to examine HR-QoL; (3) administration, to 200 AA BCSs, of an assessment tool relating to weight and breast cancer history, dietary intake, and physical activity through a variety of approaches (eg, Internet, mail, in-person, and telephone); and (4) focus group discussions to frame lifestyle interventions. RESULTS: Preliminary findings indicate that AA BCSs are underrepresented in lifestyle intervention research, have disparities in HR-QoL outcomes, do not meet current cancer prevention guidelines, and have recommendations for effective strategies for lifestyle modification. CONCLUSIONS: As analyses of the needs assessment are completed, the research team is partnering with community coalitions and breast cancer support groups in Miami, Chicago, Houston, Los Angeles, and Philadelphia to develop community-engaged intervention approaches for promoting adherence to cancer prevention guidelines.

Community-based participatory research principles for the African American community.

BACKGROUND: Numerous sets of principles have been developed to guide the conduct of community-based participatory research (CBPR). However, they tend to be written in language that is most appropriate for academics and other research professionals; they may not help lay people from the community understand CBPR. METHODS: Many community members of the National Black Leadership Initiative on Cancer assisting with the Educational Program to Increase Colorectal Cancer Screening (EPICS) had little understanding of CBPR. We engaged community members in developing culturally-specific principles for conducting academic-community collaborative research. RESULTS: We developed a set of CBPR principles intended to resonate with African-American community members. CONCLUSIONS: Applying NBLIC-developed CBPR principles contributed to developing and implementing an intervention to increase colorectal cancer screening among African Americans.

Advancing breast cancer survivorship among African-American women.

Advances have occurred in breast cancer survivorship but, for many African-American women, challenges and gaps in relevant information remain. This article identifies opportunities to address disparities in breast cancer survival and quality of life, and thereby to increase breast cancer survivorship among African-American women. For breast cancer survivors, common side effects, lasting for long periods after cancer treatment, include fatigue, loss of strength, difficulty sleeping, and sexual dysfunction. For addressing physical and mental health concerns, a variety of interventions have been evaluated, including exercise and weight training, dietary interventions, yoga and mindfulness-based stress reduction, and support groups or group therapy. Obesity has been associated with breast cancer recurrence and poorer survival. Relative to white survivors, African-American breast cancer survivors are more likely to be obese and less likely to engage in physical activity, although exercise improves overall quality of life and cancer-related fatigue. Considerable information exists about the effectiveness of such interventions for alleviating distress and improving quality of life among breast cancer survivors, but few studies have focused specifically on African-American women with a breast cancer diagnosis. Studies have identified a number of personal factors that are associated with resilience, increased quality of life, and positive adaptation to a breast cancer diagnosis. There is a need for a better understanding of breast cancer survivorship among African-American women. Additional evaluations of interventions for improving the quality of life and survival of African-American breast cancer survivors are desirable.