Social constraints, cognitive processing, and adjustment to breast cancer.

This cross-sectional study of 70 breast cancer survivors examined relationships among social constraints, behavioral and self-report indicators of cognitive processing, depression, and well-being. On the basis of a social-cognitive processing (SCP) model, it was predicted that social constraints would inhibit cognitive processing of the cancer experience, leading to poorer adjustment. Constraints were positively associated with intrusions, avoidance, and linguistic uncertainty in cancer narratives. Greater uncertainty, intrusions, and avoidance, as well as less talking about cancer were associated with greater depression and less well-being. Intrusions partially mediated the positive constraints-depression relationship. Talking about cancer partially mediated the inverse avoidance-well-being relationship. Findings support the SCP model and the importance of using behavioral indicators of cognitive processing to predict positive and negative psychosocial outcomes of cancer.

Posttraumatic growth following breast cancer: a controlled comparison study.

Cancer may be viewed as a psychosocial transition with the potential for positive and negative outcomes. This cross-sectional study (a) compared breast cancer (BC) survivors' (n = 70) self-reports of depression, well-being, and posttraumatic growth with those of age- and education-matched healthy comparison women (n = 70) and (b) identified correlates of posttraumatic growth among BC survivors. Groups did not differ in depression or well-being, but the BC group showed a pattern of greater posttraumatic growth, particularly in relating to others, appreciation of life, and spiritual change. BC participants' posttraumatic growth was unrelated to distress or well-being but was positively associated with perceived life-threat, prior talking about breast cancer, income, and time since diagnosis. Research that has focused solely on detection of distress and its correlates may paint an incomplete and potentially misleading picture of adjustment to cancer.

Adherence to recommendations for clinical follow-up after benign breast biopsy.

PURPOSE: Women who undergo a benign breast biopsy are at elevated risk for the subsequent development of breast cancer (BC). Therefore, appropriate clinical follow-up of a benign breast biopsy is important. The present study examines the extent and correlates of nonadherence with follow-up recommendations after a benign breast biopsy. METHODS: Women (n = 114) who had undergone a benign breast biopsy completed an initial telephone interview within 50 days of their biopsy (mean = 21 days). Additional telephone interviews were completed at 4 and 8 months post-biopsy. Measures of BC risk perception, general and BC-specific distress, BC-related attitudes and beliefs, social support, optimism, and informational coping style were completed. Specific recommendations for clinical follow-up and evidence of actual follow-up were obtained from medical records. RESULTS: Of 103 women given a specific recommendation for clinical follow-up, 34% were classified as nonadherent with follow-up recommendations. Logistic regression analyses indicated that nonadherent women were characterized by younger age, recommendations for follow-up by clinical breast examination alone, greater confidence in their ability to perform breast self-examination properly, higher perceived personal risk for BC, and greater BC-specific distress. CONCLUSION: Despite the importance of appropriate clinical follow-up of a benign breast biopsy, about one-third of women did not adhere to recommended follow-up. Risk factors for nonadherence suggest potential avenues for interventions to enhance participation in appropriate clinical follow-up.

Continuing participation supports ultrasound screening for ovarian cancer.

The effect of ovarian cancer screening on survival is enabled by women who continue to actively participate in screening. In this report, factors that affect participation are examined. Participants included 13,963 Kentucky women who received 56,392 screens accounting for a 46,113 screening year experience. Background, health history and reasons for participating in transvaginal sonographic screening were collected via a self-reported questionnaire. Screening participants were characterized as > 50 years old, mostly married, well educated, medically insured, health conscious women, living in the vicinity of the screening centre or 51-150 miles away. Approximately 70% of the participants can be considered active in the study based upon a screening visit during the 1997-1998 2-year period. The probabilities of a return screen at 1, 2, 5 and 7.5 years were 77.8%, 72.0%, 58.7% and 50.6%, respectively. A total of 96% of return visits occurred within 2 years, with 33.7% having intervals of < 1 year. Perceived family history was not observed to affect continuation. However, abnormal findings were associated with a shortened participation. These high levels of continuation in ultrasound screening indicate that women take this disease seriously and demonstrate that this disease is of consequence to them.

Symptom structure of PTSD following breast cancer.

Identification of posttraumatic stress disorder (PTSD) symptoms and diagnoses in survivors of cancer is a growing area of research, but no published data exist regarding the symptom structure of PTSD in survivors of malignant disease. Findings from investigations of the PTSD symptom structure in other trauma populations have been inconsistent and have not been concordant with the re-experiencing, avoidance/numbing, and arousal symptom clusters specified in DSM-IV. The present study employed confirmatory factor analysis to evaluate the extent to which the implied second-order factor structure of PTSD was replicated in a sample of 142 breast cancer survivors. PTSD symptoms were measured using the PTSD Checklist--Civilian Version (PCL-C). Fit indices reflected a moderate fit of the symptom structure implied by the DSM-IV. These findings provide some tentative support for the DSM-IV clustering of PTSD symptoms and for the validity of cancer-related PTSD.

Stability and change in posttraumatic stress disorder symptoms following breast cancer treatment: a 1-year follow-up.

While some recent research has examined the prevalence and severity of posttraumatic stress disorder (PTSD)-like symptoms following cancer treatment, no research has examined temporal change or stability in these symptoms in cancer survivors. Female breast cancer survivors (n=46) participated in an initial telephone interview and a follow-up interview 12 months later. PTSD symptoms associated with breast cancer were assessed using the PTSD Checklist-Civilian version (PCLC). In general, PTSD symptoms in this population did not diminish over time. While group analyses indicated that PCLC-total and subscale scores were stable across the two assessments, analyses of PCLC scores indicated that many patients exhibited fairly large (>0.5 S.D.) increases and/or decreases in PCLC-total or subscale scores. Some evidence suggested that decreases in PCLC scores between the two study assessments were associated with greater social support and experience of fewer traumatic stressors prior to breast cancer diagnosis. Most significantly, the research suggested that women with greater PTSD symptoms at the initial interview were less likely to participate in the follow-up interview. Implications of this for research and clinical management of PTSD in this population are discussed.

Patients' psychosocial concerns following stem cell transplantation.

Information regarding the nature, frequency, correlates and temporal trajectory of concerns of stem cell transplantation (SCT) recipients is critical to the development of interventions to enhance quality of life (QOL) in these individuals. This study examined psychosocial concerns in 110 SCT (87% autologous) recipients drawn from two SCT centers. Participants were a mean of 46 years of age and 17 months post-SCT (range 3-62 months). Information regarding current and past SCT-related concerns, performance status, and demographic characteristics was collected by telephone interview or questionnaire. Recipients reported a wide variety of psychosocial concerns following SCT. Recipients who were younger, female and evidenced a poorer performance status reported a larger number of post-SCT concerns. Examination of the temporal trajectory of concerns suggests that some concerns are salient throughout the course of post-SCT recovery (eg disease recurrence, energy level, 'returning to normal'), some are salient early in the course of recovery (eg quality of medical care, overprotectiveness by others), and others emerge later in the course of recovery (eg feeling tense or anxious, sexual life, sleep, relationship with spouse/partner, ability to be affectionate). Implications for the development of interventions to enhance post-SCT QOL are identified.

Feasibility and psychometrics of an ambulatory hot flash monitoring device.

OBJECTIVE: To assess the feasibility and psychometric properties of a lightweight, automated, ambulatory sternal skin conductance monitor to measure frequency of hot flashes (HFs) among breast cancer survivors (BCSs). DESIGN: A total of 19 postmenopausal BCSs and 5 premenopausal healthy comparison women participated by wearing the monitor for 24 h during their normal daily activities, including sleep. HFs were assessed using subjective (diaries, event markers) and objective (skin conductance) methods. RESULTS: Problems with subjective reporting of HFs were reported by 35% of BCSs. Technological problems and discomfort related to wearing the monitor were minimal. A total of 243 HFs were recorded using the skin conductance monitor by 17 BCSs and 5 premenopausal women (BCS group M = 13.4; range, 1-30). Subjective reporting of HFs was associated with a 31-33% false-positive rate. Skin conductance monitoring during waking hours was associated with a 30% false-negative rate. CONCLUSIONS: The monitor is a feasible method for objectively assessing HFs in BCSs. Data support continued use of sternal skin conductance as an objective measure of HF frequency. This technology should prove useful as an objective measure of HFs in future intervention research aimed at alleviating the symptom and improving quality of life among BCSs.

Rheumatoid symptoms following breast cancer treatment: a controlled comparison.

The prevalence of rheumatoid symptoms following breast cancer (BC) treatment was examined. Breast cancer patients (n = 111) who were a mean of 27.6 months postcompletion of BC treatment and 99 otherwise healthy women with benign breast problems (BBP) completed a self-report measure that assessed current joint pain, swelling, and stiffness, as well as measures of quality of life. Results supported a hypothesized link between BC and rheumatoid symptoms: (1) the BC group was more likely to report joint stiffness lasting more than 60 min following morning waking; (2) the prevalence of unilateral or bilateral joint point or swelling was greater (P < 0.10) in the BC group for four of 10 joint-symptom combinations examined, with differences between the BC and BBP groups in upper extremity joint swelling particularly pronounced; and (3) 41% of the BC group reported that current rheumatoid symptoms exceeded those experienced prior to diagnosis. Within the BC group, the data did not support postchemotherapy rheumatism as an explanation for rheumatoid symptoms. Rather, data suggested that symptoms were associated with surgical management of BC. Finally, among women in the BC group with the most severe joint pain, only a minority were receiving medication for these symptoms. Given the relationship between rheumatoid symptoms and quality of life, more systematic research examining potential contributing factors such as menopausal status, concurrent lymphedema, and weight gain is warranted.

Menopausal symptoms in breast cancer survivors.

PURPOSE/OBJECTIVES: To examine the prevalence and severity of menopausal symptoms among breast cancer survivors and the relationship between menopausal symptoms and quality of life (QOL). DESIGN: Cross-sectional, descriptive. SETTING: Outpatient breast care center servicing a southeastern city and regional rural areas. SAMPLE: 114 postmenopausal breast cancer survivors with a mean age of 59 years (SD = 10; range = 36-83 years) who were a mean of 34.9 months postcompletion of surgery, radiotherapy, or chemotherapy (SD = 22; range = 4-116 months). METHODS: Telephone interviews were used to assess demographic variables, menopausal status (questions adapted from the Massachusetts Women's Health Study), menopausal symptoms (adapted from the Blatt Menopausal Index), and QOL (SF-12 Health Survey). Disease and treatment information was extracted from medical records and the state cancer registry. MAIN RESEARCH VARIABLES: Menopausal status, menopausal symptoms, and QOL. FINDINGS: The most commonly reported menopausal symptoms (joint pain (77%), feeling tired (75%), trouble sleeping (68%), and hot flashes (66%)) were also the most severe. More than 40% of breast cancer survivors who reported these symptoms rated them as "quite a bit" to "extremely" severe. The total number and severity of symptoms reported was significantly related to the number of years postmenopause but not to time postdiagnosis. Higher prevalence and severity of menopausal symptoms were related to lower physical and emotional QOL. CONCLUSIONS: Menopausal symptoms appear to be a significant problem for breast cancer survivors. IMPLICATIONS FOR NURSING PRACTICE: Nurses can inform women that menopausal symptoms may be experienced following breast cancer treatment and that these symptoms may be more severe than those experienced by healthy women without cancer.

Do participants' reports of symptom prevalence or severity vary by interviewer gender?

BACKGROUND: Although interviews are commonly used to gather research data, the integrity of interview data can be threatened by discrepancies between interviewers and respondents on such characteristics as race, gender, or age. OBJECTIVES: To determine if participants' reports of the prevalence and severity of 30 symptoms varied as a function of interviewer gender. Symptoms that were assessed included general physical symptoms (diarrhea, headaches), psychological symptoms (feel blue and depressed, worry about nervous breakdown), and menopausal symptoms (hot flashes, vaginal dryness). METHOD: Structured telephone interviews were completed by 137 women who were a mean of 56.5 years old (SD = 11.1, range 36-83) and a mean of 38.8 months (SD = 23.6) postdiagnosis of breast cancer. Interviewers included two women and two men. RESULTS: Symptom prevalence and severity did not vary as a function of interviewer gender. CONCLUSIONS: Findings suggest that both male and female interviewers can be used successfully to assess participants' reports of physical, psychological, or menopausal symptoms.

Self-transformation as a factor in the self-esteem and well-being of breast cancer survivors.

Diagnosis with a life-threatening illness can lead to many changes in one's self. These changes, called self-transformation, are not well understood. The present study used triangulation of methods and measures to (i) describe individual differences in self-transformation among breast cancer survivors, (ii) examine factors associated with self-transformation in breast cancer survivors, and (iii) examine the relationships between self-transformation and self-esteem and well-being in breast cancer survivors and age-matched comparison women without cancer. Cancer survivors (n = 60) participated in structured interviews and both survivors and comparison women (n = 60) completed a set of questionnaires. Narrative analysis revealed three categories of transformation among breast cancer survivors: positive transformation, minimal transformation and feeling stuck. These groups differed by age, marital status and income, but not by disease or treatment variables. Breast cancer survivors in the positive transformation group had significantly higher self-esteem and well-being in comparison with (i) survivors grouped as feeling stuck and (ii) age-matched counterparts without cancer. Cancer survivors who reported feeling stuck had significantly lower self-esteem and well-being than the other groups of survivors and lower well-being in comparison with healthy women of the same age. Findings provide support for the concept of self-transformation and a new understanding of disease, demographic and treatment factors associated with the concept. Findings also suggest that self-transformation may be a factor in the self-esteem and well-being of breast cancer survivors.

Risk factors for pain after mastectomy/lumpectomy.

PURPOSE: Careful study of risk factors that predispose an individual to developing postmastectomy pain (PMP) after breast cancer surgery has not been reported. This study examined potential risk factors for PMP including demographic, disease, and treatment variables, as well as surgical factors, such as surgical technique and number of lymph nodes removed. DESCRIPTION OF THE STUDY: Data were collected via telephone interviews and review of medical records. Pain was assessed using the Brief Pain Inventory. The sample included 134 breast cancer survivors who were a mean age of 55 years (SD = 9) and a mean of 35 months postsurgery (SD = 19). RESULTS: Women with PMP (n = 36) were not significantly different from women without PMP (n = 98) on demographic, disease, treatment, or surgical variables. PMP intensity was not significantly associated with age at diagnosis, time postsurgery, or time post-treatment. Contrary to expectation, PMP was found in women postlumpectomy without axillary dissection, women whose intercostobrachial nerve was spared, and women without documented postoperative complications. CLINICAL IMPLICATIONS: Findings suggest that cases of PMP cannot uniformly be identified based on the presence or absence of certain factors. Findings also underscore the need to screen all women for PMP after breast cancer surgery, particularly given the availability of effective pain management therapies.

Population attitudes toward oncology clinical trials.

OBJECTIVE: We examined the attitudes of the Kentucky adult population toward experimental oncology treatment and randomized clinical oncology trials. DESIGN: We conducted a health survey of 654 noninstitutionalized adults randomly selected from Kentucky households. We posed to them a series of questions evaluating demographics, general health, and personality characteristics. We asked specific questions to characterize the subjects' experiences with cancer, their desires for autonomy in medical treatment, their health-related behaviors, and their preconceived opinions about specific cancer screening examinations. We then asked the subjects about their willingness to undergo experimental treatment and their willingness to participate in a randomized clinical oncology trial within the framework of a defined, specific oncology scenario. RESULTS: Of our subjects, 73% were willing to consider an experimental form of therapy of indeterminate benefit; however, only 39% were willing to consider a randomized clinical trial of two therapies, given the same oncology scenario. The influences of demographic factors, general health, personality factors, personal experience with cancer, and desire for autonomy in health care were found to be of minimal importance in predicting a willingness to participate. CONCLUSIONS: A strong negative bias toward randomized clinical trials appears to exist within this population. Continued public education regarding the value of clinical trials to the individual, as well as their selfless benefit to humanity, is clearly needed.

Psychometrics for two short forms of the Center for Epidemiologic Studies-Depression Scale.

The Center for Epidemiologic Studies-Depression Scale (CES-D; L. S. Radloff, 1977) assesses the presence and severity of depressive symptoms occurring over the past week. Although it contains only 20 items, its length may preclude its use in a variety of clinical populations. This study evaluated psychometric properties of 2 shorter forms of the CES-D developed by F. J. Kohout, L. F. Berkman, D. A. Evans, and J. Cornoni-Huntley (1993): the Iowa form and the Boston form. Data were pooled from 832 women representing 6 populations. Internal consistency estimates, correlations with the original version of the CES-D, and omitted-included item correlations supported use of the Iowa form over the Boston form when a shortened version of the scale is desired. Regression statistics are provided for use in estimating scores on the original CES-D when either shortened form is used. Factor analytic results from two populations support a single-factor structure for the original CES-D as well as the short forms.

Physical symptoms, distress, and breast cancer risk perceptions in women with benign breast problems.

Physical symptoms, general and breast cancer-specific distress, and perceived breast cancer risk were assessed in 66 women with benign breast problems (BBP) and 66 age-matched healthy comparison (HC) women. BBP women reported significantly greater worry about breast cancer than HC women. Breast symptom incidence and breast cancer risk perceptions were found to mediate group differences in breast cancer worry. Hierarchical regression analyses indicated that perceptions of control over a potential breast cancer prognosis moderate the impact of breast symptoms on reports of breast cancer worry. Implications for risk counseling with BBP women are discussed.

Psychometric evaluation of the Pittsburgh Sleep Quality Index.

The Pittsburgh Sleep Quality Index (PSQI) measures sleep quality and disturbance retrospectively over a 1-month period using self-reports. Although the PSQI has been used in a variety of populations, published psychometric data are limited. The goal of this study was to examine psychometric properties of the PSQI among four populations: bone marrow transplant patients (n=155); renal transplant patients (n=56); women with breast cancer (n=102); and women with benign breast problems (n=159). Results supported PSQI internal consistency reliability and construct validity. Cronbach's alphas were 0.80 across groups and correlations between global and component scores were moderate to high. PSQI scores were moderately to highly correlated with measures of sleep quality and sleep problems, and poorly correlated with unrelated constructs. Individuals with sleep problems, poor sleep quality, and sleep restlessness had significantly higher PSQI scores in comparison to individuals without such problems.

Posttraumatic stress disorder after treatment for breast cancer: prevalence of diagnosis and use of the PTSD Checklist-Civilian Version (PCL-C) as a screening instrument.

The presence of a posttraumatic stress disorder (PTSD) diagnosis in women (n = 82) diagnosed with Stage 0-IIIA breast cancer was assessed 6 to 72 months after cancer therapy. The PTSD Checklist-Civilian Version (PCL-C) and the PTSD module for the Structured Clinical Interview for DSM-IV, Nonpatient Version, PTSD module (SCID-NP-PTSD) were administered in a telephone interview. SCID-NP-PTSD results indicated prevalence rates of 6% and 4% for current and lifetime PTSD, respectively. Use of the recommended cutoff score of 50 on the PCL-C to determine diagnosis of current cancer-related PTSD resulted in a sensitivity of .60 and a specificity of .99 with 2 false-negative diagnoses. In conclusion, PTSD can be precipitated by diagnosis and treatment of breast cancer, and the PCL-C can be a cost-effective screening tool for this disorder.

Posttraumatic stress disorder symptoms after bone marrow transplantation for breast cancer.

OBJECTIVE: On the basis of revisions of DSM criteria, questions have been raised concerning the occurrence of posttraumatic stress disorder (PTSD) symptoms among adults who have been diagnosed and treated for life-threatening illnesses. The present study examined the prevalence and correlates of PTSD symptoms among women who had undergone autologous bone marrow transplantation (ABMT) for breast cancer. METHODS: Participants were 43 women who had undergone ABMT for breast cancer an average of 19 months previously (range = 2 to 62 months) and had no clinical evidence of disease at their most recent follow-up visit. PTSD symptoms and quality of life were assessed using standardized self-report instruments. RESULTS: Between 12% and 19% of participants were likely to meet DSM-IV criteria for the current diagnosis of PTSD. Women who were less well educated, had more advanced disease at the time of the transplantation and had longer hospital stays for the transplantation reported more symptoms of PTSD. Greater PTSD symptomatology was associated with reports of poorer physical health, mental health, and sleep quality. CONCLUSION: Comparisons with previous research suggest that rates of PTSD are higher among women who undergo ABMT as opposed to less intensive forms of breast cancer treatment. These findings are consistent with the view that development of PTSD symptoms is associated with the degree of life threat. The clinical significance of PTSD in this patient population is underscored by findings indicating that greater PTSD symptoms are associated with poorer health-related quality of life.