[Predictors of the Utilization and Waiting Period Before Starting an Oncological Rehabilitation after Breast Cancer]. / Prädiktoren der Inanspruchnahme und des Beginns einer onkologischen Rehabilitation nach Brustkrebs.

PURPOSE: This study explores the sociodemographic, medical and work-related factors leading to a participation in an in-house rehabilitation measure after primary treatment for breast cancer. METHODS: The prospective multi-center study is based on a written survey with employed breast cancer patients who were recruited at 11 breast cancer centers in Lower Saxony, Germany. Predictors of participation were examined by logistic regression, predictors of the time period before starting the rehabilitation by linear regression. RESULTS: 409 patients returned their questionnaires at all three time-points. Response rates were 80,1% 3 weeks after surgery (t0), 95,2% 6 months after surgery (t1) and 89,9% one year after surgery (t2). Altogether, 294 patients (72%) participated in the rehabilitation measure. Respondents, 90% of whom participated in rehabilitation before returning to work, began their rehabilitation on average 21 weeks after primary surgery. They showed an increased probability of participation if they had indicated the need to clarify their job situation (OR=2,74, p<0,01), or if their answers displayed a detrimental relation between effort and reward at work (OR=3,89, p<0,05). At the same time, higher age, a higher level of school education (OR=4,23) and reduced physical health (OR=0,94, p<0,01) increased the chance for breast cancer patients to take part in oncological rehabilitation. The starting point of rehabilitation was only predictable by medical treatments: adjuvant chemotherapy (ß=0,492, p≤0,001), additional surgery (ß=0,112, p<0,05), and radiation therapy within the second half year after primary surgery (ß=0,20; p<0,001) led to a postponement. CONCLUSION: This study shows that an increased need of breast cancer patients for medical and socio-psychological support leads to their participation in an in-house rehabilitation and thus underlines the necessity of these institutions. Women with an impaired psychological health should be given extra attention.

Coping with breast cancer and relapse: Stability of coping and long-term outcomes in an observational study over 10 years.

Many studies dealing with relationships between coping and breast cancer were based on a single measurement of coping behaviour. Assessments were taking place soon after surgery of primary breast cancer, and effects on long-term outcomes were considered. In our study it was examined whether coping behaviours are stable over time and whether they were associated with breast cancer recurrence. The analyses were based on a long-term study with initially 254 patients with three interviews and an outcome assessment within a total study period of 10 years. Data were collected by means of qualitative interviews and standardized questionnaires. Ways of coping in terms of helplessness, denial, mastery, and hope/optimism were classified by interviewer-based ratings within the framework of a standardized rating procedure. The reliability of rating standards was assured by continuous training and by estimating inter-rater agreements. Outcome measures were drawn from registries and patients' files. Coping behaviours over three interviews within six years after surgery turned out to be highly variable, and the respective correlations were low. For none of the four ways of coping associations with recurrence emerged. Coping in response to breast cancer was not stable over time, so we may conclude that the results of one measurement assessed early in the disease course should not be considered as constant over longer time periods. Coping behaviours were unrelated with recurrence, a finding that might be relieving from a patient perspective.

The effect of psychosocial stress on single mothers' smoking.

BACKGROUND: Evidence suggests an increased risk of smoking among single mothers as compared to their cohabitating counterparts. This article examines the role of psychosocial stress in mediating the relationship between single motherhood and smoking. METHODS: Data were derived from a cross-sectional population based sample of German women (n = 3129) with underage children (0-18 years of age). Perceived stress was measured with 13 items covering socioeconomic as well as family- and parenting-related stressors. According to Baron and Kenny (1986) a series of logistic regression models was applied to investigate the role of psychosocial stress as a mediator on the relationship between single motherhood and smoking. RESULTS: About 44.0% of single mothers smoked daily, whereas only 26.2% of cohabitating mothers did. Single mothers reported more stress related to their economic situation, occupation and family than partnered mothers. Out of the original 13 stressors only 'conflicts with the partner or ex-partner' and 'financial worries' remained significant in explaining single mothers' higher risk of smoking. Against expectation, stress due to household requirements and family demands was associated with lower odds of single mothers' smoking. After controlling for psychosocial stress, the odds ratio of single mothers' moderate smoking (< 20 cig./day) decreased slightly from 1.75 to 1.66 (explained fraction XF = 12.0%) and with respect to heavy smoking (≥ 20 cig./day) more pronounced from 2.56 to 2.01 (XF = 35.3%). CONCLUSIONS: It can be stated that single mothers' heavy more than moderate smoking appeared to be mediated by perceived psychosocial stress. Out of all stressors considered, financial worries were of paramount significance in explaining single mothers' heavy smoking while some family-related stressors rather appeared to keep single mothers from smoking. Overall, a higher stress exposure explains partly but not sufficiently single mothers' increased smoking rates.

Return to work after treatment for primary breast cancer over a 6-year period: results from a prospective study comparing patients with the general population.

PURPOSE: Only little research has been conducted on breast cancer survivors returning to work in Germany. This paper explores two questions: (1) Does breast cancer lead to an increased drop-out of paid work? (2) Do other factors, apart from their illness, help explain breast cancer survivors' (temporary) retirement from work? To the best of our knowledge, this is the first comparative and prospective study on breast cancer survivors returning to work in Germany. We consider this work to be a relevant research for three reasons: (1) It exceeds the observation period of previous international studies by another 3 years. (2) By including the comparison with a population sample, it allows to take the specific situation of breast cancer patients into account. This refers to their illness as well as to the socio-economic context. (3) It combines qualitative and quantitative methods in order to receive patients' individual interpretations. METHODS: The analysis is based on a sample of 227 breast cancer patients, participating in a prospective study on the role of psychosocial factors in the long-term course of breast cancer and a random sample of 647 age-matched women living in northern Germany. Employment and demographic data were observed directly before primary surgery (2002-2004), 1 year later (2003-2005) and again 5 years later (2008-2010). In addition, qualitative interviews at the three different observations served as a basis for quantitative data analyses, which were mainly performed by logistic regression models. RESULTS: One year after primary surgery, nearly three times as many cancer survivors had left their job as compared to the women in the reference group. For breast cancer survivors, a lower level of education, part-time employment, the severity of work-related difficulties and participation in inpatient rehabilitation correlated significantly with the failure to return to work. Six years after surgery, the probability of returning to work was still only half as high among breast cancer survivors than among controls. The main predictor for not returning to work was found to be age; tumour stage and the severity of side effects of treatment also seemed to have an impact. CONCLUSIONS: Breast cancer survivorship in Germany increases the risk of dropping out of paid work. The influence of work- and illness-related factors varies considerably between the early and late phases of recovery after breast cancer treatment. The comparative analysis demonstrates the relevance of labour market and pension legislation in Germany.

Differences in illness-related knowledge of breast cancer patients according to their involvement in self-help groups.

OBJECTIVE. There is little evidence of the gain in illness-related knowledge obtained in breast cancer self-help groups. This paper seeks to explore whether participants in self-help groups know more about breast cancer than non-participants and to examine the level of knowledge of leaders of self-help groups in comparison to the other two groups. METHODS. A sample of 727 women affected by breast cancer was interviewed with a self-administered questionnaire assessing knowledge on disease, prevention, and aftercare. The interviewing took place during three different surveys conducted between 2005 and 2009. The data of the second and third survey were used in order to create a larger data base and to include self-help group leaders. RESULTS. Participants in self-help groups knew significantly more than non-participants, although only in the subtests lymph edema and breast-examination. Leaders of support groups scored highest in all subtests. Involvement in a support group was most decisive for respondents' knowledge, but other factors such as age, education, and medical history also had effects. CONCLUSION. Self-help groups provide a considerable potential for acquiring illness-related knowledge. As the participation rate in German breast cancer self-help groups is still quite low, it seems reasonable to generate more interest in this kind of support.

[Development of a questionnaire for measuring effort-reward imbalance in household and family work]. / Konstruktion eines Fragebogens zur Erfassung von Gratifikationskrisen im Tätigkeitsfeld Haushalt und Familie.

Siegrists concept of effort-reward imbalance (ERI) had been shown to be associated with a broad range of health impairments, in particular cardiovascular diseases and depression. The original questionnaire was designed to assess ERI in the field of occupational work. This paper reports on a newly developed questionnaire for the assessment of ERI in household and family work. Analogous to the original version, it is divided into two components: (i) dysbalance of effort and reward (extrinsic component), and (ii) over-commitment (intrinsic components). The questionnaire was tested with data drawn from a clinical sample of mothers (n = 567) in rehabilitation clinics. Factor analyses have reproduced the two main dimensions "effort" and "reward". Relevant aspects of reward at home were (i) meaningfulness, (ii) social gratification, (iii) appreciation from the spouse, and (iv) affection for the child. Finally a 19-item questionnaire for assessing ERI in household and family work (ERI-M) and a four-item measure for measuring parental over-commitment (Over-M) are available. The psychometric properties of both instruments are good to satisfactory.

Does the occurrence of adverse life events in patients with breast cancer lead to a change in illness behaviour?

GOALS OF WORK: It was examined whether life-changing events may lead to changes of illness behaviour in women prior to breast cancer diagnosis. We considered the delay in three different aspects: date of breast self-examination, routine visits at the doctor, and finally changes in the length of time intervals between the detection of suspicious breast symptoms and the subsequent verification of diagnoses. MATERIALS AND METHODS: The data of 240 patients (age <70 years) with a first manifestation of breast cancer were used for analysis. Life events were assessed by means of a semi-structured interview as proposed by Brown and Harris and classified according to a system proposed by Brugha et al., the List of Threatening Experiences (LTE). All analyses were performed by means of Cox's proportional hazard regression. MAIN RESULTS: Women with stressful events went to the doctor earlier than those without events. The date of breast self-examination remained unchanged after the occurrence of events. Women who had discovered suspicious breast symptoms delayed the subsequent visit at the doctor if they had experienced two serious events within this period. The occurrence of life events may have effects on illness behaviour, but into different directions. CONCLUSION: In the majority of cases, event-related delays were shorter than those reported to aggravate the prognosis of breast cancer.

Ways to obtain a breast cancer diagnosis, consistency of information, patient satisfaction, and the presence of relatives.

GOALS OF WORK: What physicians told breast cancer patients about their diagnosis, who informed them, and how this information was conveyed were examined in this study. Finally, the relatives' role in this communication process was considered. MATERIALS AND METHODS: Women with primary breast cancer (N = 222) below the age of 70 were interviewed after surgery and after they were informed about their diagnosis. MAIN RESULTS: One hundred twenty-one women consulted their primary gynecologist first, then they were referred to a radiologist, and finally to the secondary care gynecologist. Forty-seven women omitted the radiologist and only five went directly to the hospital for treatment. In most cases (N = 199), the general practitioner was not involved. Receiving inconsistent information was associated with patient dissatisfaction. This also applies to women who received their diagnosis on the phone. Women awaiting a worse diagnosis were more likely to be accompanied by another person. CONCLUSIONS: Future studies should focus on the possible involvement of family doctors and relatives during the diagnostic process. Giving inconsistent information should be avoided.