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Breast Cancer Treatment in Older Women: Does Getting What You Want Improve Your Long-Term Body Image and Mental Health?

From the Department of Oncology, Cancer Control Program, Lombardi Cancer Center, Georgetown University Medical Center, Washington, DC; and Office of Cancer Survivorship, National Cancer Institute, Rockville, MD

Address reprint requests to Jeanne S. Mandelblatt, MD, Lombardi Cancer Center, Georgetown University Medical Center, 2233 Wisconsin Ave, Ste 317, Washington, DC 20007; e-mail: mandelbj{at}georgetown.edu

	ABSTRACT

TOP ABSTRACT INTRODUCTION PATIENTS AND METHODS RESULTS DISCUSSION Authors’ Disclosures of... REFERENCES

 
PURPOSE: Little is known about the impact of surgical treatment on body image and health outcomes in older breast cancer patients. The purpose of this article is to evaluate whether concordance between treatment received and treatment preferences predicts posttreatment body image and whether body image, in turn, affects mental health in older women with breast cancer 2 years after treatment.

PATIENTS AND METHODS: A longitudinal cohort of 563 women who were 67 years old or older and who had stages I and II breast cancer were surveyed by telephone at 3, 12, and 24 months after surgery. All women were clinically eligible for breast conservation. Body image was measured using questions adapted from the Cancer Rehabilitation Evaluation System–Short Form, and mental health was evaluated using a Medical Outcomes Study subscale.

RESULTS: Body image was an important factor in treatment decisions for 31% of women. Women who received breast conservation had better body image 2 years after treatment than women who had mastectomies (P < .0001). Women who preferred breast conservation but received mastectomy had the poorest body image. Using generalized estimating equations, we found that body image, in turn, predicted 2-year mental health.

CONCLUSION: Body image is important for many older women, and receiving treatment consistent with preferences about appearance was important in long-term mental health outcomes. Health professionals should elicit preferences about appearance from women and provide treatment choices in concordance with these preferences. Enhancing shared decision making has the potential to improve mental health in older breast cancer survivors.

	INTRODUCTION

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Approximately 211,300 women in the United States will be diagnosed with breast cancer in 2003.¹ The majority of these cases occurs among the 13% of the population who is 65 years old or older (hereinafter referred to as older). Moreover, with the aging of the US population, it is estimated that the number of cancer cases will double in persons aged 65 years and older in the next 30 years,² yet we still know relatively little about the sequelae of disease in this age group.

Most women with early-stage breast cancer have two surgical options for treating local disease, breast conservation surgery with radiation or mastectomy.^3-5 Because these treatments are equivalent with respect to survival, preferences for treatment may be important in quality-of-life outcomes.^6-8 Preferences about maintaining body image are a key component in decision making for younger women.^9-11 Although many definitions of body image in the literature refer to the thoughts and feelings one has about one’s body, there is no unitary theory on what exactly is body image. In addition, body image is measured by a number of different scales. Some measures address an affective component of body image (eg, feeling feminine and feeling attractive), others tap into behavioral aspects (eg, avoiding people because of appearance and finding it hard to look at oneself naked), and still other scales measure the cognitive aspects (eg, satisfaction with clothed appearance). These differences in measurement may lead to conflicting results.

Women with breast-conserving surgery generally exhibit more positive body image,^12-14 are less likely to become self-conscious about body presentation^15,16 or experience feelings of loss,¹⁷ and are more likely to maintain feelings of physical attractiveness and femininity compared with women who receive mastectomies.¹⁸ Appearance concerns have also been linked to emotional distress in younger breast cancer patients.^19-22 However, none of these studies focused on older women, leaving a large and growing segment of breast cancer survivors understudied with respect to body image preferences and quality-of-life outcomes. Although some studies suggest that older women are not as concerned as younger women about appearance,^23,24 other studies indicate that older women have similar body image concerns as younger women. Therefore, future research is needed to clarify similarities and differences in older women’s body image preferences compared with the preferences of younger women.

In this study, we used data from a longitudinal cohort of older breast cancer survivors to examine the relationship between body image and mental health outcomes and how this relationship may be modified by preferences about appearance. We hypothesized that older women who have undergone mastectomies will have poorer body image than women who received breast-conserving surgery but that concordance between treatment and initial preferences about physical appearance will lead to better long-term mental health outcomes. These data are intended to inform clinical care of the growing older breast cancer population.

	PATIENTS AND METHODS

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This study uses data from the institutional review board–approved breast cancer Outcomes and Preferences for Treatment in Older Women Nationwide Study project.

Participants
The initial cohort was enrolled between November 1, 1995, and September 30, 1997. The details of the cohort recruitment have been described elsewhere.⁶ Briefly, women aged 67 years or older with newly diagnosed breast cancer from 29 hospitals in five geographic areas (Massachusetts, Texas, Washington, DC, upstate New York, and New York City) were recruited. Women were eligible for participation if they had a primary, stage I, IIA, or IIB, histologically confirmed invasive breast cancer and were able to complete an interview in English. Women were excluded if they were non-English speaking or if they had dementia, nonlocalized disease, nonprimary cancer, multicentric cancer, or any contraindications to breast conservation. This ensured that all participants were women for whom breast-conserving surgery would be indicated at time of treatment choice. Surgeon permission was obtained to contact 84% of the 1,377 eligible women. Of these women, 784 (67.7%) consented to participate; from this group, 66 women were excluded posthoc because they had recurrent disease or missing stage data. The remaining 718 women comprised the baseline population. We were not allowed to obtain demographic information on women whose physicians refused participation on their behalf or on women who themselves refused to participate. Women were recontacted for follow-up interviews at 1 and 2 years after surgery. Cumulatively, over the 2-year follow-up period, 32 women (4.5%) were lost to follow-up, 27 (3.8%) died, and 27 (3.8%) became ineligible because of onset of dementia. Among the remaining 632 women, there was a 97.6% response rate to the first follow-up survey and a 92.7% response rate to the second follow-up survey, leaving a total of 571 women with complete data for the entire 2-year follow-up period. We excluded an additional eight women whose cancer had recurred, an event that might have affected our study outcomes, which left a total of 563 women. Women who were lost to follow-up were similar to those included in the final sample with respect to demographic and clinical characteristics.

Procedures
Data were collected from patient interviews and medical records. Baseline interviews were conducted in person approximately 3 months after surgery. Women were then contacted by trained staff 12 and 24 months after surgical treatment for completion of a standardized 20- to 30-minute telephone follow-up interview. At baseline, data were recorded from medical charts using a structured tool designed to capture all surgical procedures, tumor stage, and mean number of comorbid conditions, as measured by the Charlson comorbidity scale.²⁵

Measures
Medical Outcomes Study Short Form-36 mental health subscale (Mental Health Index III). The Mental Health Index III was derived from the Short Form-36, a widely used measure of quality of life.²⁶ This measure was administered at baseline and at the 1- and 2-year follow-up time points. It included the following five items: (1) Have you been a nervous person? (2) Have you felt so down in the dumps nothing could cheer you up? (3) Have you felt calm and peaceful? (4) Have you felt downhearted and blue? and (5) Have you been a happy person? There were six Likert response categories ranging from all of the time (score of 1) to none of the time (score of 6). Higher scores indicated better mental health. Reliabilities at all time points were good (Cronbach’s alpha coefficients ranged from 0.81 to 0.87).

Body image. Four items from the Cancer Rehabilitation Evaluation System–Short Form,²⁷ which was used at the 1- and 2-year follow-ups, were combined to form a body image scale where higher scores indicated greater body image concerns (mean item scores ranged from 0 to 4). The measures were as follows: (1) I am uncomfortable with the changes in my body; (2) I find that my clothes do not fit because of the breast cancer surgery; (3) I am embarrassed to show my body to others because of my illness; and (4) I am uncomfortable showing my scars to others. There were five response categories ranging from not at all (score of 0) to a great deal (score of 4). Reliabilities at time 1 (Cronbach’s = .78) and time 2 (Cronbach’s = .80) were good.

Preference about appearance. This item was developed specifically for this study and administered at baseline. Women were asked, "Before the surgery, was physical appearance (not wanting to lose a breast, sexual attractiveness, partner’s feelings) a consideration in your treatment decision?" If a woman answered with a yes, she was characterized as having a preference for her appearance (ie, that physical appearance was important to her in her decision making). If she responded no, appearance was deemed as not central to her treatment decision.

Satisfaction with appearance before surgery. A single item was used to control for baseline body image concerns before surgery. Patients were asked, "Before your diagnosis, how satisfied were you with your appearance when dressed?" There were five response categories ranging from very unsatisfied to very satisfied, with higher scores indicating greater satisfaction with appearance.

Treatment discordance. A dichotomous variable was created to compare women for whom preference was a consideration in the treatment decision yet who received mastectomy with women with all other permutations of treatment and preference about appearance.

Statistical Analyses
Descriptive statistics were generated for all demographic, cancer-related, and psychological variables. Student’s t tests were used to compare means for continuous variables across baseline preference about appearance. Similarly, ² analysis was used to calculate and compare distributions of categoric study measures across baseline preference about appearance. Analysis of variance was used to test for differences in mean mental health and body image concerns at each time point across multilevel categoric measures. t tests were also used to determine whether mental health (baseline, year 1, and year 2) and body image concerns (years 1 and 2) differed when stratified by treatment and preference about appearance.

Pearson and Spearman rank correlation matrices were computed to assess the strength of association between mental health, body image concerns, and demographic, cancer-related, and psychological variables. Variables associated with mental health or body image concerns at P < .2 were considered for subsequent regression analyses.

Path analysis with diagrammatic representation was carried out in an attempt to clarify the relationships between treatment, baseline preference about appearance, year 2 body image concerns, and year 2 mental health. Path analysis can be used to determine whether independent variables have an indirect or direct effect on a dependent variable, and more than one dependent variable can be evaluated.²⁸ Although path models do not indicate causality between study variables, it was of interest to determine how treatment, preference about appearance, body image concerns, and mental health were interrelated in an attempt to create multivariate regression models appropriate to these relationships. All regression equations were adjusted for baseline satisfaction with appearance and baseline mental health. Standardized partial regression coefficients (beta coefficients) and their associated P values are reported. Path model goodness of fit was assessed using PROC CALIS in SAS version 9.0 (SAS Institute, Cary, NC).²⁹

On the basis of results from correlation matrices and path analysis, two generalized estimating equation (GEE) models were constructed to predict change over time in body image concerns and mental health as separate dependent outcomes. GEE tolerates sporadic missing data, and as a form of longitudinal multivariate analysis, GEE is appropriate for outcomes measured at multiple time points such that within-subject correlation of outcomes is present and when there is an expectation that variation over time in study relationships may occur. GEE is invoked through use of the repeated statement in PROC GENMOD (SAS Institute).³⁰ Variables that were significantly correlated with body image or mental health (P < .20) were considered for model inclusion. Examination of path regression coefficients also helped guide which predictor variables to include in GEE models, in addition to the adjustment covariate set.

In all analyses, initial treatment was classified as breast conservation (collapsing women with or without radiation) versus mastectomy. The effects of age, race (white v other), insurance status (supplemental private insurance v other), education (high school and beyond v less than high school), stage (I v II), marital status (married v not married), and geographic region (collapsing women in Texas v Washington, DC, Massachusetts, New York City, and New York because women in Texas were 3.3 times more likely to have received a mastectomy [95% CI, 1.64 to 6.54; P < .0001] than other regions) were evaluated as covariates in regression and GEE analyses.

	RESULTS

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Demographics
Patient characteristics for the final sample of 563 women are reported as overall frequencies as well as stratified by preference about appearance in Table 1. The median age was 74.0 years (range, 67 to 95 years). Subjects were predominantly white (88.8%) and had a high school or better education (83.7%). Most were diagnosed with stage I breast cancer (79.8%), and the majority was treated with breast-conserving surgery (67.0%). Only a small percentage of women had reconstruction after mastectomy (7.5%). Physical appearance was cited as an important preference in treatment choice for 31% of women and was cited by 42.9% of the 14 women who underwent reconstruction. Younger women and women with fewer comorbid conditions were more likely to have a preference about appearance.

Mental Health and Body Image Differences by Preference About Appearance and Treatment
We investigated whether unadjusted differences in mental health or body image could be detected across treatment category by preference about appearance (Table 2). Among women for whom physical appearance was important, those treated with breast conservation reported higher mean mental health 2 years after treatment than those who received mastectomy (79.2 v 70.9, respectively); however, there were no treatment-related mental health differences in women for whom physical appearance was not a preference. However, if women were concerned about physical appearance 3 months after breast surgery and had mastectomy, they had significantly poorer mental health than women who either had no preference or who had a preference about appearance but received breast-conserving surgery (P < .035).

Path Analysis
We used the path analysis as a means to determine the appropriate multivariate regression models to be tested. This analysis indicated that the primary effect of receiving treatment discordant with preference about appearance was an impact on body image. Body image, in turn, affected mental health (Fig 1). This analysis also revealed that treatment had a direct effect on body image but was not independently associated with mental health. Path models do not provide information on causality or directionality in study relationships; the arrows in the path figure represent researcher hypotheses about study relationships. However, because preference about appearance was observed to be significantly associated with treatment (which it temporally precedes) and body image concerns and, in turn, treatment was significantly associated with body image concerns but not mental health, we chose to create two GEE models. Body image concerns and mental health are strongly correlated, and there may be a bidirectional relationship between them; however, we felt our path analysis findings argued in favor of specifying GEE models of both body image concerns and mental health as repeated outcomes to reflect the presence and absence of direct relationships between study variables of interest. Goodness-of-fit analysis demonstrated a significant fit of the regression data to the path model (² = 0.22, P = .64).

View larger version (16K): [in this window] [in a new window]   Fig 1. Pathways affecting long-term mental health. Path analysis reveals baseline preference about appearance is indirectly related to mental health through its impact on body image concerns. Women who received treatment discordant with baseline preference experienced an increase in body image concerns. The regression data to the specified path model fit well (2 = 0.22, 0.64). MST, mastectomy; BCS, breast-conserving surgery.

View this table: [in this window] [in a new window]   Table 3. GEE* Modeling Body Image Concerns (n = 555)

View this table: [in this window] [in a new window]   Table 4. GEE* Modeling Long-Term Mental Health (n = 555)

	DISCUSSION

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The importance of concordance between patient preferences and treatment choices has been recently underscored in other research. Keating et al³² demonstrated that women with early-stage breast cancer were more satisfied with their treatment choice if their actual role in decision making matched their desired role. In other research with this cohort, we have found that better communication between physicians and patients improved outcomes.³³

Similar to the literature regarding younger breast cancer patients,^12-16,18 older women in our study who underwent mastectomy had more body image concerns than women who received breast conservation. By examining an older cohort of breast cancer patients, we also extend findings from younger women^19,20,22 to confirm the importance of body image on mental health across the age spectrum. However, there have been conflicting results in studies of the general populations of older women with respect to body image. For example, a study of body esteem among older women living either in nursing homes or autonomous residences found that increasing age and poor health was related to a more negative body image.³⁴ In contrast, Franzoi and Koehler²⁴ compared body attitudes among white women by age and found that older women had higher levels of body image satisfaction than younger women. In our study, the magnitude of the body image concern scores was similar to scores found in younger patients with breast cancer,¹⁸ suggesting that older women with breast cancer have body image concerns similar to younger patients. Interestingly, only 7.5% of our sample had reconstruction, even though 31% cited physical appearance as important in treatment decision making. It is unclear whether the low rate of reconstruction was a result of lack of interest or lack of being offered reconstruction. Further study of the reasons for this discrepancy is needed.

Our findings have important implications for clinical care, interventions, and educational efforts. First, oncology professionals caring for women with breast cancer need to be aware of a woman’s preference about appearance and body image at the time of treatment decision making and in follow-up appointments to assist in her choice of treatment and long-term adjustment. Medical staff can be educated on the importance of body image concerns in older women so that they offer breast conservation or reconstruction after mastectomy to this age group as often as they present this choice to younger women. As stated by White, ³⁵ there is a need for clinical protocols "that clearly outline how body image...will be considered in treatment decision-making." Because the current cohort of older patients may prefer and rely on physician-initiated decision-making discussions,^36,37 medical staff should be encouraged to elicit patient preferences for appearance and body image concerns in an effort to educate women on the sequelae of treatment decisions.

Several caveats should be considered in interpreting the present findings. First, our results are only generalizable to predominately white, well-educated women. In addition, all women had local stage disease and were self-selected into this convenience cohort. Second, the study was only conducted in five geographic regions of the United States and may not reflect social norms and body image concerns in other areas of the country. Third, because the baseline interviews were conducted 3 months after surgery, it is not possible to know whether the data would have been different if a presurgical baseline assessment had been performed. Fourth, women who had mastectomies by choice may have been more anxious or distressed before surgery. Because the interview did not ask for a ranking of reasons for the women’s treatment choices (for instance, how much they felt in control of their treatment decisions or how heavily they felt influenced by medical advice), we cannot determine all of the reasons for the decline in mental health scores among women who received mastectomy. Finally, some of our measures used single items developed specifically for this research. It is not clear how these might compare with larger scales of body image or function with a different breast cancer survivor sample. Nevertheless, the Cancer Rehabilitation Evaluation System body image scales have been used successfully in other studies of breast cancer patients.^15,16,38

Despite limitations, this study has several important strengths. It draws on data from a large cohort observed prospectively to assess long-term outcomes. It also focused exclusively on older women and had a wide age range within the older age group. A further strength of the study was the use of several standardized outcome measures used in previous research with breast cancer survivors. The results have significant implications for the clinical care of older women with breast cancer, a growing segment of the breast cancer patient population. Future research exploring the relationships between appearance concerns, body image, and mental health in relation to axillary surgery and adjuvant treatment will also be important in refining intervention approaches. For instance, recent studies suggest that appearance concerns are related to sexual attractiveness outcomes and emotional distress in women undergoing chemotherapy.^38,39 In addition, other preferences may have played a role in women’s treatment decisions (eg, wanting to get treatment over with, wanting no further treatment after surgery, considering side effects of treatment, and/or transportation concerns), and these issues are worth exploring in future research. Patient perception of choice is also an important factor for future studies. For example, in a recent national study of Medicare beneficiaries with stage I or II breast cancer, having a choice of treatment was associated with better long-term general physical and mental function, impact of breast cancer, and satisfaction.⁸

On the basis of our findings, we recommend that healthcare professionals build partnerships with older patients for shared decision making, initiate discussion on preferences about appearance, and recommend treatment that is most consistent with an older woman’s values and concerns. Enhanced shared decision making has the potential to improve mental health in older women.

	Authors’ Disclosures of Potential Conflicts of Interest

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The authors indicated no potential conflicts of interest.

	Acknowledgment

 
We thank the women from across the country who shared their breast cancer stories with us; the Outcomes and Preferences for Treatment in Older Women Nationwide Study support staff who made data collection possible; Qin Wang for data analysis support; Mary Cummings, MD, for programmatic support; Mathematica Policy Research, Inc, for data collection and management; the Outcomes and Preferences for Treatment in Older Women Nationwide Study National Advisory Committee for helpful suggestions on the conduct of the project; Marc Schwartz, PhD, for guidance on path analysis; Sandy Fournier for administrative support; Trina McClendon and Alisha Hubbell for manuscript preparation; and the comments of two anonymous reviewers. Yi-Ting Hwang, PhD, is now at the National Taipei University.

	NOTES

 
Supported by grant No. R01 HS 08395 from the Agency for Health Care Policy and Research, grant No. DAMD17-94-J-4212 from the Department of the Army, grant No. K05 CA 96940 from the National Cancer Institute, and grant No. 1U10 CA 84131 from the National Institute on Aging.

Presented in part at the 24th Annual Meeting of the Society of Behavioral Medicine, Salt Lake City, UT, March 19-22, 2003.

Authors’ disclosures of potential conflicts of interest are found at the end of this article.

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Submitted July 7, 2003; accepted July 14, 2004.

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