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© 2003 American Society for Clinical Oncology Breast Cancer in Older Women: Quality of Life and Psychosocial Adjustment in the 15 Months After Diagnosis
From the University of California, Los Angeles, Schools of Medicine and Public Health and the Jonsson Comprehensive Cancer Center, Los Angeles, CA; Department of Health Care Policy, Harvard Medical School; Department of Epidemiology, Boston University School of Public Health; Department of Medicine, Boston University School of Medicine, Boston, MA; and Department of Community Health, Brown University, Providence, RI. Address reprint requests to Patricia A. Ganz, MD, Division of Cancer Prevention and Control Research, Jonsson Comprehensive Cancer Center, 650 Charles Young Drive South, Los Angeles, CA 90095-6900; e-mail: pganz{at}ucla.edu.
Purpose: We examined the health-related quality of life (QOL) of a cohort of older women with breast cancer after their diagnosis. Patients and Methods: Six hundred ninety-one women aged 65 years and older were interviewed approximately 3 months after breast cancer surgery and two additional times in the following year using standardized QOL measures. Demographic factors, breast cancer treatments, and comorbid conditions were used to model ratings of health-related QOL over time. Self-perceived health and psychosocial adjustment at 15 months after surgery were modeled. Results: Physical and mental health scores declined significantly in the follow-up year, independent of age. However, a cancer-specific psychosocial instrument showed significant improvement in scores. Better 3-month physical and mental health scores, as well as better emotional social support, predicted more favorable self-perceived health 15 months after surgery. Psychosocial adjustment at 15 months was significantly predicted by better mental health, emotional social support, and better self-rated interaction with health care providers assessed at 3 months. Conclusion: Contrary to reports from younger women with breast cancer, we observed significant declines in the physical and mental health of older women in the 15 months after breast cancer surgery, whereas scores on a cancer-specific psychosocial QOL measure improved over time, consistent with patterns in younger women. Predictive models indicate that older women with impaired physical functioning, mental health, and emotional social support after surgery have poorer self-perceived health and psychosocial adjustment 1 year later. Interventions to address the physical and emotional needs of older women with breast cancer should be developed and evaluated to determine their impact on subsequent health-related QOL.
BREAST CANCER is the most common type of cancer in women and increases in incidence with advancing age.1 The majority of breast cancer cases are diagnosed in women over 60 years of age.2 There have been many psychosocial and quality of life (QOL) studies conducted with breast cancer patients;3–6 however, few studies have concentrated specifically on older women,7–9 and older women often have had lower participation rates in these studies.10 As part of a larger program of research examining the use of tamoxifen adjuvant therapy in older women with breast cancer,11 we recruited and prospectively observed a large cohort of older women (65 years or older) with newly diagnosed breast cancer from four separate geographic regions of the United States. We conducted serial telephone interviews with these women to learn about their health status, medical treatment decisions, treatments received, and personal characteristics, and to obtain their responses to a number of standardized measures of health-related QOL and psychosocial adaptation to breast cancer. This study provided an opportunity to perform a focused examination of QOL and psychosocial adjustment in older women with breast cancer in the 15 months after diagnosis. In this article, we examine the patterns of recovery after the diagnosis of breast cancer and the predictors of QOL 15 months after definitive surgery. Considering the prevalence of breast cancer among older women and the increasing longevity of the United States population, it is imperative that we understand how older women adjust to the diagnosis of breast cancer in terms of QOL, including physical, emotional, and social well-being.
Subject Recruitment We recruited women from hospitals in four geographic regions of the country (Los Angeles, Rhode Island and Southeastern Massachusetts, Minnesota, and North Carolina) to participate in a prospective, longitudinal cohort study of treatments of breast cancer. Patients were identified through regular review of pathology reports at hospitals or collaborating tumor registries, performed with institutional review board approval in each setting. Women were potentially eligible for the study if they had stage I disease with a tumor diameter of 1 cm or greater or stage II or stage IIIA disease, if they were 65 years or older on the date of definitive surgery, and if the attending physician provided permission to contact the patient about the study. Women were excluded if they had a prior history of breast or other cancers, could not speak English, or were cognitively or hearing impaired and without a proxy. Eligible participants were mailed an enrollment package and were called by a research staff member from each site who explained the study’s purpose and participation requirements. If the woman remained interested in participation, she was asked to sign and return an informed consent form. We obtained permission to contact 1,621 women, of whom 852 women consented to full study participation and 81 women consented to medical record review only. Refusal to participate was age related, with only 16% of women age 65 to 69 years old refusing compared with 52% of women who were 80 years and older. The proportion of women who refused to participate also differed by geographic site (Rhode Island, 29%; North Carolina, 31%; Minnesota, 40%; and Los Angeles, 63%). Three-month interviews were completed in 85% of patients who initially agreed to participate. Silliman et al11 provides a more complete discussion of the full study.
Interviews and Instruments Demographic and medical information. Women self-reported demographic information (age, race, marital status, education, living arrangements, employment status, and annual income) and types of treatment received for breast cancer (radiation therapy, chemotherapy, and adjuvant tamoxifen therapy). Project personnel reviewed and abstracted patients’ medical records at least 3 months after the date of definitive surgery. The medical record review provided data on tumor characteristics (size, node status, histologic and nuclear grade, and estrogen/progesterone receptor status), treatments received (primary surgery and axillary node evaluation), and comorbid conditions present at the time of breast cancer diagnosis using the Index of Coexistent Diseases.12 QOL and psychosocial outcomes. Physical functioning was measured with the 10-item physical functioning scale (PF-10) from the Medical Outcomes Study Short Form 36 (MOS-SF-36)13 at the 3- and 15-month interviews. Mental health was measured at the 3-, 6-, and 15-month interviews with the Mental Health Inventory 5-item questionnaire (MHI-5) from the MOS-SF-36.13 The MHI-5 is a measure of mental health that correlates strongly with standardized measures of anxiety and depression and includes items such as "have you been a nervous person," "have you felt calm and peaceful," and "have you felt downhearted and blue." Both of these scales are scored from 0 to 100, with 100 being the highest level of functioning. Both scales have been widely used in many populations with chronic disease and cancer,8,10,14,15 and general population norms are also available.16 Self-perceived health status was rated using the single-item measure "How would you rate your health today?", with responses including excellent, very good, good, fair, and poor.17 Subscales from the Cancer Rehabilitation Evaluation System–Short Form (CARES-SF)18 were used to measure cancer-specific aspects of QOL. The CARES and its short form have been used with patients with various types of cancer and extensively with breast cancer patients.18–21 In this study, both the CARES-SF Psychosocial Summary Scale and the CARES Medical Interaction Summary Scale were administered at 3, 6, and 15 months. The Psychosocial Summary Scale is a 17-item scale that is much broader in scope than the MHI-5. It measures, for the past 4 weeks from when it is administered, cancer-related anxiety, discomfort with body changes, difficulty sleeping, difficulty concentrating, communication with friends and relatives, worry about whether the cancer is progressing or recurring, feeling nervous in medical settings, difficulty taking care of self, and difficulty in the work setting because of the cancer. The Medical Interaction Summary Scale is a four-item scale that assesses problems communicating with doctors in the past 4 weeks. The CARES-SF scores range from 1 to 4 (higher score indicating more problems). In these analyses, raw scores for both CARES scales were changed to a 0-to-100–point scale, with 100 being the most favorable score. Social support was measured by creating a brief eight-item scale from the 19-item MOS social support scale,22 which, in a previous study, was used to evaluate 416 breast cancer patients in Massachusetts.23 Using data from that study, we performed a principal component analysis with varimax rotation to examine the structure of the items to try to identify a smaller number of items to use in subsequent research. We identified two scales, comprised of four items each, and each scale had a Cronbach alpha coefficient more than 0.89. The two scales relate to provision of support for instrumental activities (eg, help if confined to bed, to take you to the doctor, to prepare meals if you are unable, and to help with daily chores), which we call instrumental social support, and support for emotional needs (eg, someone available to have a good time with, someone to turn to for suggestions about dealing with a personal problem, someone who understands your problems, and someone to love and make you feel wanted), which we call emotional social support. For this analysis, we created scale scores based on each of the four-item scales, recoding the scores to range from 0 to 100, with 100 indicating the highest level of social support for each scale. This scale was administered at the 3- and 15-month interviews.
Analysis Plan For the second question, we used logistic regression to identify the predictors of self-rated health (coded as excellent or very good v good, fair, or poor) at 15 months after definitive surgery, and we used multiple regression to identify the predictors of the CARES psychosocial score at 15 months after definitive surgery. Predictor variables used in the regression analyses included demographic factors (age, marital status, education, ethnicity, and number of persons in household), medical factors (number of comorbid conditions, type of surgery, and receipt of radiation, chemotherapy, or tamoxifen), and dimensions of self-rated health-related QOL (physical functioning, mental health, social support, and medical interaction, all measured at 3 months after definitive surgery).
Patients As noted earlier, 852 women consented to the full study; however, between the initial consent and interview, 23 women were found to be ineligible for the study. Of the 829 patients potentially eligible for interview, there were 788 women and 41 proxies. In this report, we used only data obtained from interviews completed by the woman herself, because other research has questioned the validity of proxy ratings of subjective health.26,27 From the 788 potential primary respondents, interviews were completed and available for this analysis in 691 women (88%). Reasons for missing interviews were missing the target time after surgery for the interview (n = 41), refusal to be interviewed at time of telephone call (n = 28), could not locate patient despite multiple attempts (n = 23), and inaccessibility as a result of death or hospitalization (n = 5). To have as large a sample as possible and to account for nonrandom loss of data, we included in our analyses all women with at least one interview (n = 691); however, 56 patients had at least one missing independent variable, so this left a final sample of 635 women for the longitudinal analyses. The patient demographic and medical characteristics are listed in Table 1  , and the patient characteristics do not differ significantly from the full sample reported in Silliman et al.11 For the models predicting outcome at 15 months (self-rated health and psychosocial functioning), the samples were limited to the 485 women who had a 15-month assessment and all of the predictor variables. There were no medical or demographic differences between the 3-month and 15-month samples (see Table 1).
Recovery in Domains of QOL by Age We examined the pattern of functioning during the year after diagnosis according to age. The adjusted mean (± SE) scores at the 3-month interview were 76.1 (± 2.9) for the PF-10 and 76.7 (± 1.9) for the MHI-5. By 15 months, the adjusted mean (± SE) score for the PF-10 was 66.2 (± 2.9), with no difference according to age group; however, the decline in scores was statistically significant for all age groups (P < .0001). Significant predictors of a decline in PF-10 scores were more comorbid conditions at 3 months, receipt of chemotherapy, Medicaid insurance, and receipt of breast-conserving surgery without radiation compared with the alternative treatments (data not shown, P < .05 for all predictors). To explore why breast-conserving surgery without radiation was associated with poorer PF-10 scores at 15 months, we examined the differences in number of comorbid conditions between breast-conserving surgery with and without radiation and found significantly more comorbid conditions among women who did not receive radiation therapy (P = .02). The SF-36 MHI-5 scores at 3, 6, and 15 months also demonstrated a significant decline in all age groups (P < .0001), with an adjusted mean (± SE) score at 15 months of 73.9 (± 1.9). Significant predictors of declining MHI-5 scores were more comorbid conditions at 3 months, Medicaid insurance, and being married compared with not being married (data not shown, P < .05 for all predictors). The adjusted CARES-SF Psychosocial Summary Scale scores at the three interviews showed significant improvement over time (P < .0001), with no difference according to age group. The adjusted CARES-SF Medical Interaction scale also showed a significant improvement over time (P < .0001), with no differences by age group. The emotional and instrumental aspects of social support were also modeled with data from the 3- and 15-month interviews. Neither of these dimensions of social support changed over time; however, there were age-related differences in reporting of instrumental social support, with women aged 75 to 79 years and 80 years and older reporting significantly lower scores than women aged 65 to 69 years and 70 to 74 years (P = .03). To explore the difference in patterns for the MHI-5 and the CARES Psychosocial scores, we examined the relationships among these two variables and the PF-10, the Medical Interaction score, and emotional and instrumental social support scores (all taken at 3 months). Both the MHI-5 and the CARES Psychosocial score were correlated with the PF-10, but the correlation coefficient was larger for the MHI-5 (r = 0.28 v r = 0.18, both P < .0001). The MHI-5 and the CARES Psychosocial score were only moderately correlated with each other (r = 0.47, P < .0001), indicating incomplete overlap. The emotional social support scale was more strongly correlated with the CARES Psychosocial scale than with the MHI-5 (r = 0.46 v r = 0.34, both P < .0001). The CARES Medical Interaction score was also more strongly correlated with the CARES Psychosocial scale (r = 0.48, P < .0001) than with the MHI-5 (r = 0.29, P < .0001). We also explored which variables might be contributing to the assessment of mental health (MHI-5 score) so that we could better understand the decline in scores noted earlier. We performed a stepwise regression, entering the following variables into the regression: CARES Psychosocial score, PF-10 score, emotional and instrumental social support, CARES Medical Interaction score, number of comorbid conditions, age category, marital status, stage of disease, and receipt of chemotherapy, tamoxifen, and radiation therapy. The final model had an adjusted R2 = 0.29, with the CARES Psychosocial score contributing 0.21, followed by the PF-10, which contributed 0.04, followed by emotional social support, stage IIIA disease, age category, Medical Interaction score, and marital status, each of which contributed 0.01 or less to the model.
Predictors of QOL 1 Year Later
A second model was developed for psychosocial adjustment at 15 months using the CARES Psychosocial Summary Scale as the dependent variable in a multiple regression analysis (Table 3 ). The overall model was significant (P = .0001), with an adjusted R2 of 0.29. Significant predictors of better psychosocial adjustment were better MHI-5 score at 3 months (P = .0001), better emotional social support at 3 months (P = .0001), and better medical interaction scores at 3 months (P = .0001). However, neither age nor cancer treatment was a predictor of subsequent psychosocial adjustment.
In this report, we describe the longitudinal assessment of QOL after breast cancer in one of the oldest cohorts of women studied to date.11 The sample was also geographically diverse, representing urban and rural settings, as well as different practice environments. There are specific issues that are unique to older women with breast cancer that should be considered in any discussion of QOL after breast cancer. These include the impact of the acute cancer episode on a background of other chronic conditions, the increased likelihood of diminished social support and social isolation with aging, and deterioration in physical functioning that is a part of normal aging. We used a variety of standardized QOL assessment tools in this study13,18,22,28 to facilitate comparison of this sample of older women to samples of younger women with breast cancer and to healthy individuals and patients with other chronic conditions. However, we must acknowledge an important limitation of the study, which is that the response rate to participation in the overall study was only approximately 50% of eligible patients, and the 3-month interviews were completed by approximately 43% of the potential sample. There were much lower rates of participation among the oldest women, and thus, we expect that our results may underestimate some of the QOL impact of breast cancer in older women. An additional limitation of the study is that because we did not have pretreatment assessments of QOL or even immediate postsurgical assessments, it may be difficult to be confident of the causal attribution of some findings. For example, we found that women with breast-conserving surgery and no radiation therapy had a greater decline in their PF-10 scores between 3 and 15 months and that it was associated with more comorbid conditions. Because we did not have pretreatment PF-10 scores on the women who received mastectomy or lumpectomy and radiation therapy, we may have missed a treatment-induced decline in PF-10 scores preceding the 3-month assessment, which certainly would then demonstrate a more significant decline over the 15-month assessment. Overall, this study sample demonstrated high levels of physical and emotional functioning approximately 3 months after definitive breast cancer surgery, with results that are similar to another sample of older women with breast cancer.29 The 3-month scores on both the PF-10 and MHI-5 are also within the normal range for age-matched samples of women without cancer.28 However, unlike other studies of younger women with breast cancer,3,19 we observed a significant deterioration in self-reported physical functioning that was associated with the number of comorbid conditions and chemotherapy but with no other cancer-specific treatments. In addition, we noted that women who had breast-conserving surgery without radiation experienced a significantly greater decline in physical functioning than women who received conservation with radiation or mastectomy and that they had more comorbid conditions at 3 months. Although these findings differ from reports in younger women with breast cancer, they are consistent with the few studies that have examined physical functioning in older patients with cancer.30–32 In younger patients, breast cancer may be the only morbid condition, leading to relatively prompt improvements in physical functioning in the months after initial treatment. The MHI-5 scores were high at 3 months (showing favorable levels of mental health) in this study sample and within the normal range for healthy age-matched women,28 but the scores declined significantly between 3 and 15 months after breast cancer surgery, a pattern that is distinct from reports in samples of younger women with breast cancer.3,19 Comorbidity was also associated with a decline in mental health scores in this sample of older women. Interestingly, being married was associated with a greater decline in MHI-5 scores. This latter finding might reflect the additional burdens of spousal caregiving in these women. However, psychosocial functioning as measured by the CARES, a cancer-specific instrument, showed significant improvement in the follow-up year. The CARES Psychosocial raw score mean (± SD) in this sample was 0.76 (± 0.61) at 3 months and is comparable with younger samples of women.20 As indicated in our exploration of the relationship between the CARES Psychosocial scale and the MHI-5, these two instruments are measuring related but different aspects of emotional functioning. We hypothesize that the longitudinal MHI-5 scores in this study sample are influenced by the significant decline in PF-10 scores over time. Other studies using the MHI-5 with cancer and chronic disease samples have also documented a direct relationship between declining physical health status and MHI scores.33 In addition, the relationship between the PF-10 and MHI-5 scores at the 25th and 75th percentile in reference samples shows that the lowest quartile of the PF-10 has a substantially lower MHI-5 score than the highest quartile.28 In contrast, the CARES Psychosocial scale showed improvement in the year after surgery, a finding consistent with the literature in younger women,3,19 reflecting adaptation and adjustment to cancer-specific concerns (eg, feeling uncomfortable with body changes, worry about recurrence, and feeling nervous while waiting to see the doctor). Because we believe that this is the first study in breast cancer patients to simultaneously use the MHI-5 and the CARES Psychosocial scale, we cannot say with certainty whether our observations about the different patterns of response for these two instruments relate to the age of the sample or the measurement characteristics of the instruments. The predictors of self-rated health and psychosocial adjustment in this group of older women are quite consistent with our work in younger women.3,19 That is, specific breast cancer treatments (mastectomy v breast conservation, chemotherapy, or tamoxifen) were not associated with differences in QOL in the year after breast cancer. In addition, age alone was not a significant predictor of subsequent health or psychosocial adjustment. The use of two different outcome measures for this examination is important. Single-item global health ratings are more closely associated with physical well-being when rated by individuals.17 To examine the psychosocial dimension, we chose a comprehensive cancer-specific psychosocial scale used in other research with breast cancer patients and survivors.20,21 Some overlap in these models might be expected, but we hypothesized that they might identify different predictors of risk for better or poorer adjustment. Better emotional well-being, physical functioning, and emotional social support at 3 months were all positively and significantly associated with better self-rated health at the 15-month interview. Psychosocial adjustment at 15 months was not predicted by physical functioning at 3 months, but positive predictors of psychosocial adjustment were mental health, emotional social support, and more favorable medical interaction at 3 months. Although there are limitations to the representativeness of this study sample, these findings may still have important implications for clinical practice and intervention. Interventions to promote better physical functioning, emotional well-being, emotional social support, and communication in the health care setting should be developed and evaluated to determine whether they might enhance subsequent adjustment and functioning in older women with breast cancer. More information about the psychosocial needs and concerns of older breast cancer patients could enhance our efforts at developing age-appropriate interventions because most psychosocial intervention programs (groups and individual counseling) have been tailored to a younger population. Interventions focused on the physicians and nurses who care for older women with breast cancer might also be considered as an important adjunct to these efforts. More aggressive management of comorbid diseases could certainly have a direct impact of physical and emotional functioning, and thus, they could impact subsequent QOL. Finally, an important finding from this study is that when all factors are considered in evaluating QOL after breast cancer in older women, age and type of surgical treatment variables do not seem to play a major role in affecting QOL outcomes. Other factors described in this study (physical, emotional, and social dimensions of QOL) play a much more significant role in determining subsequent QOL after breast cancer in older women.
The authors indicated no potential conflicts of interest.
Supported by grant no. CA/AG 70818 from the National Institutes of Health/National Cancer Institute (Bethesda, MD) and an American Cancer Society Clinical Research Professorship Award (P.A.G.).
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Copyright © 2003 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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ABSTRACT
INTRODUCTION
2 tests were performed to compare descriptive characteristics of the sample of patients who completed all three interviews versus those with incomplete data. We used the QOL data collected at each of the three interviews to answer the following two major questions: What is the pattern of recovery of health-related QOL among older women over the course of 15 months after diagnosis? What are the 3-month predictors of self-rated health and psychosocial adjustment 15 months after diagnosis? For the first question, we looked at the recovery pattern over time by age group using a mixed-model approach, which is commonly used for modeling incomplete longitudinal data.
