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Originally published as JCO Early Release 10.1200/JCO.2006.09.8665 on February 20 2007 © 2007 American Society of Clinical Oncology. Older Breast Cancer Survivors: Factors Associated With Change in Emotional Well-Being
From the Boston University School of Medicine; Boston University School of Public Health, Boston, MA; Jonsson Comprehensive Cancer Center; and the University of California at Los Angeles Schools of Medicine and Public Health, Los Angeles, CA Address reprint requests to Kerri M. Clough-Gorr, DSc, MPH, Boston University Medical Center, 88 East Newton St, Robinson 2, Boston, MA 02118; e-mail: kmclough{at}bu.edu
Purpose During the 5 years after primary breast cancer diagnosis for women  65 years old, we examined factors associated with change in emotional well-being.
Patients and Methods We identified women diagnosed with primary breast cancer and selected women with stage I to IIIa disease, age Results During 5 years of follow-up of older breast cancer survivors, 57% had less than a ± 10-point change in MHI5, 38% had less than a ± 10-point change in BCSEH, and 52% had less than a ± 10-point change in CARES-SF Psychosocial Summary Scale. Women with less than 12 years of education were at greatest risk for having negative changes in both general and breast cancer–specific emotional health. Moreover, we also found that women who perceived themselves as never being cured had greater negative changes in all outcomes. Conversely, those who had better physical function, emotional social support, and positive ratings regarding the quality of medical interactions at baseline were less likely to have poor emotional health during follow-up. Conclusion For the majority of older breast cancer survivors, cancer-specific well-being and general emotional health do not change substantially after a breast cancer diagnosis. Among those in whom change occurs, risk factors are similar and may be related to other age-related diseases.
Breast cancer is the most common type of cancer among US women, with an estimated 211,240 new cases of invasive breast cancer diagnosed in 2005.1 Sixty percent of cases are diagnosed in women 60 years old.2 Moreover, breast cancer survivors have a 5-year relative survival estimate of approximately 86%, resulting in the vast majority of women with breast cancer becoming long-term survivors.3 Having breast cancer threatens not only patients' physical health but also their emotional well-being.4 Substantial numbers of women diagnosed with breast cancer develop anxiety and depression during the first 2 years after diagnosis.5,6 Studies have investigated potential risk factors for emotional distress among breast cancer patients and have identified younger age, lack of social support, marital distress, poor communication with physicians, being employed, and past history of depression as risk factors.7-18 Race, educational attainment, and income have not been found consistently to be associated with emotional distress.7,14,15,19 Social support from family, friends, partners, community, and physicians has been associated with better sense of hope and better emotional health, especially among people with pre-existing life stress.9-13 Intervention studies consistently have demonstrated the beneficial effects of psychosocial support on changing of attitudes from pessimism to optimism.20-25 However, most study participants have been younger women. Few studies that have investigated what factors influence older women's emotional well-being after a diagnosis of breast cancer and throughout survivorship. Extending previous analyses conducted through 15 months of follow-up,26 we studied older women with early-stage breast cancer and asked the following two questions pertaining to 5-year survivorship. What are the patterns of change in emotional well-being? What factors are associated with changes in older women's general and cancer-specific emotional well-being? Our hypothesis was that older age, fewer financial resources, less social support, and more comorbidity would be related to decline in emotional well-being during follow-up.
Study Sample The overall longitudinal study design and patient recruitment procedures have been described.27-29 Newly diagnosed breast cancer patients were identified through regular review of pathology reports at hospitals or collaborating tumor registries in four geographic regions (Los Angeles, CA; Minnesota; North Carolina; and Rhode Island) with institutional review board approval of the study in each setting. Women were eligible for the study if they had stage I disease and a tumor diameter of 1 cm or greater; if they had stage II or stage IIIa disease; if they were age 65 years or older on the date of diagnosis; and if permission from the attending physician to be contacted for study participation had been obtained. Additional inclusion criteria included no prior history of primary breast cancer and no simultaneously diagnosed or treated second primary tumor at another site. Patients were eligible if they spoke English or had an available translator, and were competent for interview with satisfactory hearing. 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. Potential participants were given an opportunity to decline participation and those who verbally agreed to participate were asked to return a signed consent form approved by the institutional review board at each site.
Data Collection
Analytic Variables General emotional health. General emotional health was assessed by the five-question Mental Health Inventory general measure of emotional health (MHI5) from the Medical Outcomes Study–Short Form (MOS SF-36).30 The MHI5 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," "have you felt downhearted and blue." This scale has been widely used in many populations with chronic disease and cancer.16,29,31,32
Breast cancer–specific emotional health.
Breast cancer–specific emotional health (BCSEH) was assessed using a four-item measure of feelings and worries due to potential problems associated with the progression of breast cancer. The items included "dealing with feelings such as anger, fear, grief, and anxiety"; "worries about your family's ability to manage if you get sicker"; "worries about who will take care of you if you get sicker"; and "worries about recurrence of the cancer." In a previous report of a study for which the measure was developed, the Cronbach's Cancer-specific psychosocial function. The Cancer Rehabilitation Evaluation System (CARES) and its short form have been used with patients with various types of cancer, and extensively with breast cancer patients.33-36 We used the Psychosocial Summary Scale of the CARES–Short Form (CARES-SF), a 17-item scale that measures cancer-related anxiety in the last 4 weeks, 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 due to the cancer. We used baseline data for independent variables because some independent variables were only collected during the baseline interview and none of the independent variables collected at follow-up interviews were available consistently at uniform time points. Using time-varying covariates with data elements missing inconsistently across time would restrict both the model building and interpretation. Sociodemographic characteristics. We classified patient age as 65 to 69, 70 to 79, or 80+ years old; race as white or nonwhite; marital status as married or not married; education as less than high school, high school, or more than high school; employment status as working full/part time for pay, or unemployed; and health insurance as receiving Medicaid or not. Health status. We determined the number and type of underlying diseases present at the time of diagnosis using definitions developed for the Index of Co-Existent Diseases.37 The presence of as many as fourteen comorbid conditions measured total disease burden. Body mass index was classified as less than 20, 20 to 25, more than 25 to 30, or more than 30. Physical function was assessed by the Physical Function Index (PFI) -10 (scaled from zero to 100, with higher scores indicating better function) from the MOS SF-36.38
Social support.
Social support was measured using a reduced set of eight items derived from the 19-item MOS social support scale.39 Two scales comprised of four items each (Cronbach's Tumor and treatment characteristics. We classified stage as I, IIa, IIb, or IIIa, using the TNM classification.40 We classified primary tumor therapy as breast-conserving surgery (BCS) followed by radiation therapy, BCS alone, or mastectomy. Women self-reported receiving chemotherapy and adjuvant tamoxifen therapy. Patients' perception of being cured of breast cancer was considered as feeling cured now, cured between 1 to 5 years after treatment, or never completely cured. Medical interaction. We used the CARES-SF Medical Interaction Summary Scale, a four-item scale that assesses problems communicating with doctors in the last 4 weeks. The CARES-SF medical interaction scores range from 1 to 4, which were transformed to a zero- to 100-point scale, with higher scores indicating better ratings.
Analytic Strategy To evaluate factors associated with change of outcomes, we created three multivariable logistic regression models using generalized estimating equations (GEE) in SAS software (SAS Institute, Cary, NC).41,42 We chose to use GEE over a mixed-model approach to fit the average effect and the longitudinal effect, producing coefficients that measure differences in the average response for a unit change in the predictor. GEE make use of all available data, so if a participant left the study or died, she continued to contribute data up to the time of attrition. The final subset of candidate independent variables was selected by the model-building strategy described by Greenland.43 To verify the integrity of our findings and to understand better the potential effects of missing data and attrition bias during follow-up, we conducted additional complete case analyses (N = 232). The results from the complete case analyses were virtually unchanged from the initial findings except for increased imprecision resulting from the reduced sample size. In addition, to evaluate the large change in MHI5 scores at the 39-month interview time point, we analyzed the MHI5 scores before and after the 39-month interview of the subgroup of women who contributed data to the 39-month interview and compared them to that of the entire sample. Analyses indicated no between-group differences before or after the 39-month interview. Lastly, analysis of the group of women with breast cancer recurrence (n = 53) did not reveal any differences in outcomes at any time point in comparison to the overall population.
We observed 660 women for up to 5 years after definitive surgery. Approximately one fourth of the population came from each of the four study sites. Baseline sociodemographic and medical characteristics of the study population are listed in Table 1. The majority (74%) were age 70 years or older. Most (94%) were white and had a high school education or greater (83%). Just less than half were married and the majority had adequate finances to meet their needs. Only a small proportion (10%) was working full or part time at baseline. The majority (65%) had two or less comorbid conditions and 21% had a body mass index of 30 or greater. About half of the women had stage I disease and the majority (82%) received either a mastectomy or BCS followed by radiation. Only a small minority (7%, which was a cross-section by stage of the women in the study) believed that they would never be cured. Baseline measures of our three outcome variables ranged from 68.1 to 80.7.
Patterns of Change in Emotional Well-Being Figures 1 and 2 show the pattern of change in outcomes during the study period. During 5 years of follow-up, the majority of older breast cancer survivors remained the same with respect to emotional well-being. Fifty-seven percent had less than a ± 10 point change in MHI5, 38% had less than a ± 10 point change in BCSEH, and 52% had less than a ± 10 point change in CARES-SF Psychosocial Summary Scale. There was a decrease of 2.8 (P = .005) points in the mean MHI5 score, an increase of 1.4 (P = .2) points in the mean BCSEH score, and an increase of 10.9 (P < .0001) points in the mean CARES-SF score. The patterns of changes, whether increases or declines, were consistent during the follow-up period.
To evaluate the difference in outcome patterns for general emotional health, BCSEH, and cancer-specific psychosocial function, we examined the relations at each interview between the outcome variables, and between each outcome variable and physical function (PF) and emotional support. The overall population experienced a decline of 11.4 points (P < .0001) in mean PF score and an increase of 7.1 points (P < .0001) in mean emotional support score during the follow-up period. The decline in PF scores during follow-up was greater in the group of women who had also declined in MHI5 score as compared with those women whose scores remained the same (–16.0 points; P = .003) or improved (–11.7 points; P = .004). At each interview, PF was more strongly related to MHI5 than the other two outcome variables. BCSEH was consistently more strongly related to CARES-SF, and BCSEH and CARES-SF were moderately related to emotional support (data not shown; P < .05 for all correlations).
Change in General Emotional Health
Change in BCSEH Having a less positive perception of being cured and having less education were also associated with poor BCSEH in the first 5 years after definitive treatment for breast cancer (Table 3). Conversely, those who had five or more comorbid conditions, better PF, better emotional social support, and positive ratings regarding the quality of medical interactions at baseline were less likely to have poor BCSEH during follow-up.
Change in Cancer-Specific Psychosocial Function Factors associated with changes in cancer-specific psychosocial quality of life are listed in Table 4. Consistent with the other measures of emotional well-being, the CARES-SF Psychosocial Summary Scale scores for women who perceived themselves as being cured 5 or more years after treatment, those with less than a high school education, and those without adequate finances to meet their needs declined significantly during the follow-up period. Better PF, emotional social support, and positive ratings of the quality of medical interactions at baseline were positively associated with CARES-SF Psychosocial Summary Scale scores during follow-up.
This research is consistent with and a complement to our previously published findings.26,44 We assessed three different outcome measures, each measuring a different aspect of emotional well-being: general mental health, BCSEH, and cancer-specific psychosocial function. Our findings suggest that the 5-year survivorship experience of older women with breast cancer is one of relative stability for two of the three measures, given that the overall BCSEH changes were minimal, and changes in MHI5 of less than 8 points are not considered to be clinically significant.30,38 All outcomes had a common set of risk factors, with consistent effects on all three measures of emotional well-being. Our exploration of the relationship among outcome measures, PF, and emotional support demonstrate that these outcome measures are related, but are measuring different aspects of emotional well-being. As previously reported by Ganz et al26 and supported by our findings, we believe that the longitudinal decline in MHI5 scores is influenced by the decline in overall PF of these women during the follow-up period, as suggested by the larger decreases in PF scores during follow-up among women whose MHI5 scores also declined. In contrast, the cancer-specific adjustment of these women improved during follow-up. Emotional support, which increased significantly during follow-up, was most strongly correlated with both of our cancer-specific outcome measures, suggesting that adaptation and adjustment to cancer-specific concerns is closely related to the presence and amount of emotional support. We found that perception of being cured and educational attainment were negatively associated, and PF and social support were modestly positively associated with all three outcomes. Many studies have investigated potential risk factors for emotional distress among breast cancer patients.7-17,32,36,45-48 However, few of these studies have investigated these factors and the patterns of change in emotional well-being outcomes over time. Our findings are consistent with studies that have shown that educational attainment is associated with emotional distress.7,14,15,19,49 Those with less than 12 years of education were at greatest risk for having negative changes in both general emotional health and BCSEH. Moreover, we also found that women who perceived themselves as never being cured at baseline had greater negative changes in all outcomes, again consistent with the work of others that has identified "feeling of hopefulness" as an important factor in predicting emotional health among women with breast cancer.47,50,51 A broad literature on depressive illness in older adults suggests that increased comorbidity, decreased PF, and lack of financial resources and social supports are predictors of depressive illness in the general geriatric population.52-59 Our research indicates that these factors are also associated with a decline in emotional well-being among older long-term breast cancer survivors. This raises the following question: are these factors cancer-specific or more general predictors of psychosocial distress in older adults? Conceivably, these factors function as markers (in constellation or individually) for a high-risk population, cancer survivor or not, that is more vulnerable not just to poor adjustment to their cancer experience but also to other conditions such as depression. Although there are a number of factors identified in this and other research16,60 that are immutable (eg, educational attainment), it is important to note that modifiable factors can make a difference to the survivorship experience of older women with breast cancer. Medical interaction, as measured by a woman's perception of physician-patient communication, had a positive association with both cancer-specific outcomes. How doctors interact with their patients seems to have an enduring effect on how women cope with cancer-specific issues over time. Our regression analyses also indicate that emotional social support is associated significantly with positive changes in all aspects of emotional well-being. These findings suggest that physician and family interventions to enhance social support may buffer the impact of a breast cancer diagnosis and improve the overall survivorship experience. The major limitation of our study is that our study population was a largely white, well-educated group of older women, which limits generalizability of the results. Even though there are limitations in the representativeness of this study population, the findings have important implications for clinical practice. Interventions designed to bolster formal and informal support and improve PF and medical interactions may mitigate the impact of these risk factors. Targeting care for high-risk individuals could help to focus the resources available in clinical practice to those patients most likely to benefit.
The authors indicated no potential conflicts of interest.
Conception and design: Kerri M. Clough-Gorr, Patricia A. Ganz, Rebecca A. Silliman Financial support: Rebecca A. Silliman Administrative support: Kerri M. Clough-Gorr Provision of study materials or patients: Rebecca A. Silliman Collection and assembly of data: Kerri M. Clough-Gorr, Patricia A. Ganz, Rebecca A. Silliman Data analysis and interpretation: Kerri M. Clough-Gorr, Patricia A. Ganz, Rebecca A. Silliman Manuscript writing: Kerri M. Clough-Gorr, Patricia A. Ganz, Rebecca A. Silliman Final approval of manuscript: Kerri M. Clough-Gorr, Patricia A. Ganz, Rebecca A. Silliman
published online ahead of print at www.jco.org on February 20, 2007. Supported by Grants No. CA106979, CA/AG 70818, and CA84506 from the National Cancer Institute, as well as an American Cancer Society Clinical Research Professorship (P.A.G.). Authors' disclosures of potential conflicts of interest and author contributions are found at the end of this article.
1. American Cancer Society: Cancer facts & figures 2005-2006. http://www.cancer.org/docroot/STT/content/STT_1x_Cancer_Facts_Figures_2006.asp 2. American Cancer Society: Breast Cancer facts & figures 2005-2006. http://www.cancer.org/docroot/STT/content/STT_1x_Breast_Cancer_Facts_Figures_2005 3. Brenner H: Long-term survival rates of cancer patients achieved by the end of the 20th century: A period analysis. Lancet 360:1131-1135, 2002[CrossRef][Medline] 4. Loveys BJ, Klaich K: Breast cancer: Demands of illness. Oncol Nurs Forum 18:75-80, 1991[Medline] 5. Dean C: The emotional impact of mastectomy. Br J Hosp Med 39:30-32, 36, 38-39, 1988[Medline] 6. Glanz K, Lerman C: The psychological impact of breast cancer: A critical review. Ann Behav Med 204-212, 1992 7. Epping-Jordan JE, Compas BE, Osowiecki DM, et al: Psychological adjustment in breast cancer: Processes of emotional distress. Health Psychol 18:315-326, 1999[CrossRef][Medline] 8. Northouse LL, Swain MA: Adjustment of patients and husbands to the initial impact of breast cancer. Nurs Res 36:221-225, 1987[Medline] 9. Maunsell E, Brisson J, Deschenes L: Psychological distress after initial treatment of breast cancer: Assessment of potential risk factors. Cancer 70:120-125, 1992[CrossRef][Medline] 10. Koopman C, Hermanson K, Diamond S, et al: Social support, life stress, pain and emotional adjustment to advanced breast cancer. Psychooncology 7:101-111, 1998[CrossRef][Medline] 11. Neuling SJ, Winefield HR: Social support and recovery after surgery for breast cancer: Frequency and correlates of supportive behaviours by family, friends and surgeon. Soc Sci Med 27:385-392, 1988[CrossRef][Medline] 12. Ebright PR, Lyon B: Understanding hope and factors that enhance hope in women with breast cancer. Oncol Nurs Forum 29:561-568, 2002[Medline] 13. Hoskins CN: Patterns of adjustment among women with breast cancer and their partners. Psychol Rep 77:1017-1018, 1995[Medline] 14. Ganz PA, Schag AC, Lee JJ, et al: Breast conservation versus mastectomy: Is there a difference in psychological adjustment or quality of life in the year after surgery? Cancer 69:1729-1738, 1992[CrossRef][Medline] 15. Mor V, Malin M, Allen S: Age differences in the psychosocial problems encountered by breast cancer patients. J Natl Cancer Inst Monogr 191-197, 1994 16. Silliman RA, Dukes KA, Sullivan LM, et al: Breast cancer care in older women: Sources of information, social support, and emotional health outcomes. Cancer 83:706-711, 1998[CrossRef][Medline] 17. Roberts CS, Cox CE, Reintgen DS, et al: Influence of physician communication on newly diagnosed breast patients' psychologic adjustment and decision-making. Cancer 74:336-341, 1994[CrossRef][Medline] 18. Arndt V, Merx H, Stegmaier C, et al: Persistence of restrictions in quality of life from the first to the third year after diagnosis in women with breast cancer. J Clin Oncol 23:4945-4953, 2005 19. Vinokur AD, Threatt BA, Vinokur-Kaplan D, et al: The process of recovery from breast cancer for younger and older patients: Changes during the first year. Cancer 65:1242-1254, 1990[CrossRef][Medline] 20. Andersen BL: Psychological interventions for cancer patients to enhance the quality of life. J Consult Clin Psychol 60:552-568, 1992[CrossRef][Medline] 21. Cruess DG, Antoni MH, McGregor BA, et al: Cognitive-behavioral stress management reduces serum cortisol by enhancing benefit finding among women being treated for early stage breast cancer. Psychosom Med 62:304-308, 2000 22. Classen C, Butler LD, Koopman C, et al: Supportive-expressive group therapy and distress in patients with metastatic breast cancer: A randomized clinical intervention trial. Arch Gen Psychiatry 58:494-501, 2001 23. Edmonds CV, Lockwood GA, Cunningham AJ: Psychological response to long-term group therapy: A randomized trial with metastatic breast cancer patients. Psychooncology 8:74-91, 1999[CrossRef][Medline] 24. Fukui S, Kugaya A, Okamura H, et al: A psychosocial group intervention for Japanese women with primary breast carcinoma. Cancer 89:1026-1036, 2000[CrossRef][Medline] 25. Targ EF, Levine EG: The efficacy of a mind-body-spirit group for women with breast cancer: A randomized controlled trial. Gen Hosp Psychiatry 24:238-248, 2002[CrossRef][Medline] 26. Ganz PA, Guadagnoli E, Landrum MB, et al: Breast cancer in older women: Quality of life and psychosocial adjustment in the 15 months after diagnosis. J Clin Oncol 21:4027-4033, 2003 27. Silliman RA, Guadagnoli E, Rakowski W, et al: Adjuvant tamoxifen prescription in women 65 years and older with primary breast cancer. J Clin Oncol 20:2680-2688, 2002 28. Demissie S, Silliman RA, Lash TL: Adjuvant tamoxifen: Predictors of use, side effects, and discontinuation in older women. J Clin Oncol 19:322-328, 2001 29. Silliman RA, Troyan SL, Guadagnoli E, et al: The impact of age, marital status, and physician-patient interactions on the care of older women with breast carcinoma. Cancer 80:1326-1334, 1997[CrossRef][Medline] 30. Ware JE Jr, Sherbourne CD: The MOS 36-item short-form health survey (SF-36), I: Conceptual framework and item selection. Med Care 30:473-483, 1992[Medline] 31. Ganz PA, Rowland JH, Desmond K, et al: Life after breast cancer: Understanding women's health-related quality of life and sexual functioning. J Clin Oncol 16:501-514, 1998[Abstract] 32. Ganz PA, Coscarelli A, Fred C, et al: Breast cancer survivors: Psychosocial concerns and quality of life. Breast Cancer Res Treat 38:183-199, 1996[CrossRef][Medline] 33. Schag CA, Ganz PA, Heinrich RL: Cancer Rehabilitation Evaluation System–short form (CARES-SF): A cancer specific rehabilitation and quality of life instrument. Cancer 68:1406-1413, 1991[CrossRef][Medline] 34. Shimozuma K, Ganz PA, Petersen L, et al: Quality of life in the first year after breast cancer surgery: Rehabilitation needs and patterns of recovery. Breast Cancer Res Treat 56:45-57, 1999[CrossRef][Medline] 35. Ganz PA, Schag CA, Lee JJ, et al: The CARES: A generic measure of health-related quality of life for patients with cancer. Qual Life Res 1:19-29, 1992[CrossRef][Medline] 36. Schag CA, Ganz PA, Polinsky ML, et al: Characteristics of women at risk for psychosocial distress in the year after breast cancer. J Clin Oncol 11:783-793, 1993[Abstract] 37. Greenfield S, Apolone G, McNeil BJ, et al: The importance of co-existent disease in the occurrence of postoperative complications and one-year recovery in patients undergoing total hip replacement: Comorbidity and outcomes after hip replacement. Med Care 31:141-154, 1993[CrossRef][Medline] 38. Ware JE: SF-36 Health Survey, Manual and Interpretation Guide. Boston, MA, The Health Institute, 1993 39. Sherbourne CD, Stewart AL: The MOS social support survey. Soc Sci Med 32:705-714, 1991[CrossRef][Medline] 40. Fleming IDC, Henson JS, Hutter DE, et al: AJCC Cancer Staging Manual (ed 5). Philadelphia, PA, Lippincott Williams & Wilkins, 1997 41. SAS Institute: Statistical Analysis System (SAS) Manual. Cary, NC, SAS Institute, 1999 42. Schafer JL: Analysis of Incomplete Multivariate Data. New York, NY, Chapman & Hall, 1997 43. Greenland S: Introduction to regression modeling, in Rothman KG, Greenland S (ed): Modern Epidemiology (ed 2). Philadelphia, PA, Lippincott-Raven, 1998, pp 401-434 44. Westrup JL, Lash TL, Thwin SS, et al: Risk of decline in upper-body function and symptoms among older breast cancer patients. J Gen Intern Med 21:327-333, 2006[CrossRef][Medline] 45. Deimling GT, Kahana B, Bowman KF, et al: Cancer survivorship and psychological distress in later life. Psychooncology 11:479-494, 2002[CrossRef][Medline] 46. Deimling GT, Sterns S, Bowman KF, et al: The health of older-adult, long-term cancer survivors. Cancer Nurs 28:415-424, 2005[CrossRef][Medline] 47. Deimling GT, Bowman KF, Sterns S, et al: Cancer-related health worries and psychological distress among older adult, long-term cancer survivors. Psychooncology 15:306-320, 2006[CrossRef][Medline] 48. Deimling GT, Wagner LJ, Bowman KF, et al: Coping among older-adult, long-term cancer survivors. Psychooncology 15:143-159, 2006[CrossRef][Medline] 49. Friedman B, Heisel M, Delavan R: Validity of the SF-36 five-item Mental Health Index for major depression in functionally impaired, community-dwelling elderly patients. J Am Geriatr Soc 53:1978-1985, 2005[CrossRef][Medline] 50. Carver CS, Pozo-Kaderman C, Harris SD, et al: Optimism versus pessimism predicts the quality of women's adjustment to early stage breast cancer. Cancer 73:1213-1220, 1994[CrossRef][Medline] 51. Classen C, Koopman C, Angell K, et al: Coping styles associated with psychological adjustment to advanced breast cancer. Health Psychol 15:434-437, 1996[CrossRef][Medline] 52. Avila-Funes JA, Garant MP, Aguilar-Navarro S: Relationship between determining factors for depressive symptoms and for dietary habits in older adults in Mexico. Rev Panam Salud Publica 19:321-330, 2006[Medline] 53. Blazer D, Burchett B, Service C, et al: The association of age and depression among the elderly: An epidemiologic exploration. J Gerontol 46:M210-M215, 1991 54. Blazer D, Hughes DC, George LK: Age and impaired subjective support: Predictors of depressive symptoms at one-year follow-up. J Nerv Ment Dis 180:172-178, 1992[Medline] 55. Given B, Given C, Azzouz F, et al: Physical functioning of elderly cancer patients prior to diagnosis and following initial treatment. Nurs Res 50:222-232, 2001[CrossRef][Medline] 56. Helmer C, Montagnier D, Peres K: Descriptive epidemiology and risk factors of depression in the elderly. Psychol Neuropsychiatr Vieil 2:S7-S12, 2004 (suppl 1)[Medline] 57. Schoevers RA, Beekman AT, Deeg DJ, et al: Comorbidity and risk-patterns of depression, generalised anxiety disorder and mixed anxiety-depression in later life: Results from the AMSTEL study. Int J Geriatr Psychiatry 18:994-1001, 2003[CrossRef][Medline] 58. Schoevers RA, Beekman AT, Deeg DJ, et al: Risk factors for depression in later life; results of a prospective community based study (AMSTEL). J Affect Disord 59:127-137, 2000[CrossRef][Medline] 59. Cole MG, Dendukuri N: Risk factors for depression among elderly community subjects: A systematic review and meta-analysis. Am J Psychiatry 160:1147-1156, 2003 60. Kornblith AB, Herndon JE II, Zuckerman E, et al: Social support as a buffer to the psychological impact of stressful life events in women with breast cancer. Cancer 91:443-454, 2001[CrossRef][Medline] Submitted November 8, 2006; accepted January 10, 2007.
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Copyright © 2007 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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ABSTRACT
INTRODUCTION
for these items was .78
2 tests, and paired t tests. Independent variables were evaluated for potential inclusion in our models based on their association with each outcome variable. 
