© 2006 Foundation for Promotion of Cancer Research
Short Communication |
Early Effect of Surgery on Quality of Life in Women with Operable Breast Cancer
1 Division of Surgical Oncology, Regional Cancer Centre, Trivandrum, Kerala and 2 Radiation Oncology, Regional Cancer Centre, Trivandrum, Kerala, India
For reprints and all correspondence: Manoj Pandey, Department of Surgical Oncology, Institute of Medical Sciences, Banaras Hindu University, India; E-mail: manojpandey{at}vsnl.com
Received February 12, 2006; accepted March 30, 2006
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Abstract |
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 TOP Abstract INTRODUCTIONPATIENTS AND METHODRESULTSDISCUSSIONReferences |
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Background: Quality of life (QOL) after a diagnosis of breast cancer varies considerably across individuals. The treatment modality of the patients significantly contributes to their QOL. The present study reports the initial findings on the early effects of surgery in patients with breast cancer.
Methods: Two hundred and fifty-one women with breast cancer undergoing surgery were interviewed prior to and after the surgery using the Functional Assessment of Cancer Therapy for Breast (FACT-B). Trial Outcome Index (TOI) was calculated besides total and subscale scores. The results were analyzed using paired t-test and two-sample paired Wilcoxon signed rank test. Multivariate analysis was carried out using repeated measures general liner model with 2-way interactions.
Results: Significant reduction in physical well-being (P = 0.001), functional well-being (P = 0.00) and the breast-specific subscale (P = 0.000) was observed after surgery. No significant change was observed in social or emotional well-being. Total FACT scores and TOI too showed significant declines (P = 0.000; and P = 0.000 respectively) on univariate analysis. Multivariate analysis, however, showed no difference in QOL after surgery, but QOL was significantly poor among women undergoing mastectomy.
Conclusions: Results of the present study indicate no significant change in overall QOL immediately after the surgery, probably reflecting strong family and social support for these women. QOL was significantly better among women undergoing breast conservation compared with mastectomy.
Key Words: breast cancer • FACT-B • malignant neoplasm • psycho-oncology • quality of life (QOL) • well-being • Trial Outcome Index • body image • surgery • treatment
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INTRODUCTION |
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Breast cancer is a serious, stressful and life-threatening disease. It is assumed that the diagnosis of cancer evokes far greater distress than many other diseases, regardless of prognosis (1,2). Several studies have documented the significant disruptions in the patient's quality of life (QOL) during the initial phases of the breast cancer diagnosis and its subsequent treatment (3,4). Patients undergoing a mastectomy have been observed to experience significant QOL changes at various levels: physical, functional, emotional domains of QOL and well-being (3–7). Studies have also identified the relationship between mastectomy and poor sexual adjustment and body image (7,8).
Post-operative patients have been found to become more fearful and anxious, develop sleep difficulties, and experience a reduction in interest and pleasure (9,10). Their concerns involve feelings of threat to life, fear of pain, fear of recurrence, cosmetic concerns, sexual attitudes, feelings of devaluation-, and loss of femininity. Follow-up comparison studies report 22–33% of the patients as having severe mood disturbances or depression 1–2 years after mastectomy (11,12). We report here the early effect of surgery on QOL of women with breast cancer in India.
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PATIENTS AND METHOD |
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A longitudinal study is being conducted to examine the long-term effects of breast cancer diagnosis and its treatment on patients undergoing treatment with curative intent. The study is approved by the institutional review board (IRB) as well as the institute ethics committee (IEC).
Two hundred and fifty four women with cancer of the breast were enrolled between the years 2002 and 2003 to the study after obtaining written informed consent. Of these, 215 (85.7%) patients underwent modified radical mastectomy (MRM), while 36 (14.3%) underwent breast conserving treatment (BCT). The patients were interviewed prior to and up to 30 days after the surgery by a senior research fellow and co-author (B.C.T). The validated local language (Malayalam) version (13) of the Functional Assessment of Cancer Therapy-Breast (FACT-B) (Version 4) (14) was used. The tool has 36 items and provides an overall QOL score, besides physical, social/familial, emotional and functional well-being scores, and a breast-specific subscale score and Trial Outcome Index (TOI). TOI is computed for any FACIT disease-specific, treatment-specific, or condition-specific scale. It is the sum of the physical well-being (PWB), functional well-being (FWB) and ‘additional concerns’ subscales. Social and emotional well-being are very important for QOL, which are not so likely to change quickly or dramatically over time or in response to therapy (15).
Items with missing responses were identified, and a frequency table was prepared. Of the 254 patients enrolled in the study, one patient answered only 72% of the FACT-B items in the preoperative interview, while two patients responded to only 78% of the total items in the post-operative interview. All the other patients, however, responded to at least 80% of the items in the FACT-B tool and, hence, the final sample comprised 251 women. Only two patients answered all the items in both the pre-operative and post-operative interviews. A reduction in the response rate to the items in the questionnaire was also observed in the follow-up interview (95.69% versus 93.96%). The number of items with missing responses decreased from 26 to 25 in the post-operative interview. Of these items, three were unanswered by the same respondent(s) in both the pre-operative and post-operative interviews. On examining the missing items closely, it was found that responses were missing at random except probably for three items, i.e. GS6 ‘I feel closer to my partner’; GS7: ‘I am satisfied with my sex life’; and S4: ‘I feel sexually attractive’, which were not answered by substantial number of patients in either pre-operative, post-operative or both interviews (10%, 33% and 14%, respectively). The scores were prorated to calculate total and subscale scores. The QOL score, subscale score and TOI were calculated as described earlier (13). The scores were compared using paired t-test and two related sample non-parametric Wilcoxon signed rank test.
Multivariate analysis was carried out by general liner model using repeated measures that provides analysis of variance for multiple dependent variables by covariates. A custom model using difference contrast and all two-way interactions between within-subject and between-subject variables was used. Tumour stage (T), nodal stage (N), age (<40, 40–50, >50) and type of treatment (MRM or BCT) were variables used for between-subject model, while FACT-B scales, subscale scores and TOI were used as variables for within-subject estimates. The post hoc tests were used to evaluate difference among specific means (Tukey MSD, Scheffe and Bonferroni tests). The effect size was estimated by partial eta squared value for each effect and parameter. The observed power of each observation was calculated assuming an alpha of 0.05.
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RESULTS |
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The mean age of the women was 45.6 years (median 45.0 SD ± 10.6) with an age-range of 17–80 years. The average gap between the pre-operative and post-operative interview was 20 days (range 15–30). Three patients underwent reconstruction surgery of whom one underwent a skin-sparing mastectomy with transverses rectus abdominis flap (TRAM). Eighty-nine (36%) had T2 disease and 105 (41.8%) were node positive. More than 37% of the study sample had stage III disease, while 33% had stage II disease and 9 (3.6%) patients had metastatic disease at the time of surgery.
RESULTS OF UNIVARIATE ANALYSIS
Significant reduction was observed in physical well-being (19.8 versus 18.1; t = 4.78, P = 0.001; z = –4.88, P = 0.00) functional well-being (11.0 versus 8.4; t = 9.8, P = 0.000; z = –8.4, P = 0.00) and breast-specific subscale (24.2 versus 23.0; t = 3.8, P = 0.001; z = –3.5, P = 0.00). The TOI showed a significant deterioration (54.9 versus 49.5; t = 9.4, P = 0.000; z = –8.3, P = 0.00) along with a reduction in overall QOL (85.5 versus 80.4; t = 5.7, P = 0.000; z = –5.2, P = 0.00). There were no significant changes in emotional (12.5 versus 12.7) and social well-being (18.2 versus 18.3) (Table 1).
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Physical well-being was found to decrease significantly in women under 40 years of age (t = 3.6, P = 0.000; z = –3.71, P = 0.000) and women between 40–50 years of age (t = 3.63, P = 0.000; z = –3.5, P = 0.000) but not in women above 50 years. Similarly significant deterioration of physical well-being was observed in women with T2 to T4 disease but not in women with T1 lesions. Patients with N2 or N3 disease were found to have no change in their physical well-being, while patients with N0 (t = 2.4, P = 0.01; z = –2.4, P = 0.01) and N1 disease (t = 2.8, P = 0.008; z = –2.8, P = 0.005) showed significant deterioration in physical well-being. A significant deterioration in physical well-being was also observed for women with low income (t = 4.6, P = 0.000; z = –4.5, P = 0.000), Hindus (t = 3, P = 0.003; z = –3.3, P = 0.001), Muslims (t = 4, P = 0.000, z = –3.5, P = 0.000) and women undergoing MRM (t = 5.3, P = 0.000; z = –5.3, P = 0.000).
No significant deterioration in social well-being was observed in any woman; However, emotional well-being was found to be affected in patients with Tx tumours (t = 2.14, P = 0.03; z = –2.1, P = 0.03) and Nx disease (t = 1.9, P = 0.06; z = –2.07, P = 0.03).
Functional well-being on the other hand deteriorated in all groups of women studied except for patients with unknown income (t = 2.37, P = 0.055; z = –2.03; P = 0.42) and women with stage I disease (t = 1.7, P = 0.1; z = –1.7, P = 0.07).
Significant deterioration in breast-specific scales was observed among women below 40 years of age, T2 tumours (t = 3.2, P = 0.002; z = –2.7, P = 0.007), N1 (t = 3.1, P = 0.003, z = –2.8, P = 0.004) or N2,3 disease (t = 2.9, P = 0.008; z = –2.5, P = 0.01), low income (t = 2.9, P = 0.004; z = –2.8, P = 0.004) or high income (t = 2.9, P = 0.005; z = –2.36, P = 0.01), Hindus (t = 2.9, P = 0.003; z = –2.6, P = 0.007) or Muslims (t = 2.3, P = 0.02; z = –2.3, P = 0.01), composite stage II (t = 2.3; P = 0.01; z = –2.1, P = 0.03), stage III (t = 2.23; P = 0.02; z = –2.09, P = 0.03) or stage IV disease (t = –4.2, P = 0.002; z = –2.5, P = 0.01) and among women undergoing mastectomy (t = 4.6, P = 0.000; z = –4.2, P = 0.000).
The post-operative QOL was found to be uniformly low except for women above age 50, T1 disease or composite stage I disease and women undergoing breast conservation (t = 0.4, P = 0.67; z = –0.58, P = 0.56). Similarly TOI, which also showed uniform lowering for nearly all women except women with T1 tumours (P = 0.8), stage I disease (P = 0.4) and for women undergoing BCT (P = 0.5).
RESULTS OF MULTIVARIATE ANALYSIS
Results of multivariate analysis showed significant post-operative deterioration of only functional well-being (f = 32.7; P = 0.000; power 1.0) and TOI (f = 10.09; P = 0.002 power 0.85) (Table 2).
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On studying the two-way interactions, the age of patients, T-stage and type of surgery were found to be significantly (P = 0.009, 0.04 and 0.04, respectively) affecting physical well-being. Type of surgery was also found to influence social well-being (P = 0.04); however, the power of this observation was low (0.54). None of the variables were found to influence emotional and functional well-being. In contrast, nodal stage (P = 0.04) and type of surgery (P = 0.002) were found to influence breast-specific subscale. Age of the patients (P = 0.01) and type of surgery (P = 0.004) were found to significantly interact with overall QOL, and age (P = 0.001), T-stage (P = 0.04) and type of treatment (P = 0.004) had significant interactions with TOI (Table 2).
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DISCUSSION |
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The post-operative period is generally associated with increased amount of physical discomfort and pain. This, therefore, reflects on the functional aspects, like the inability to work, troubles meeting the needs of the family, work being less fulfilling, etc. This is also seen in the results of the present study where the functional well-being of women showed significant deterioration after surgery. On the other hand, not much effect was observed on social, functional and emotional well-being in contrast to earlier results (16). This probably reflected the social and cultural fabric of India where social and family support are very well provided when someone is in distress, though similar results have been reported by studies from other countries as well (17).
Results of multivariate analysis showed no significant difference in overall QOL except for patients undergoing MRM and for those <50 years of age. This is in contrast to literature where surgery is found to affect psychological well-being (18,19) or overall QOL (20–23) of women undergoing surgery for breast cancer.
Despite a small number of our patients undergoing BCT (14%), the difference in QOL between these and the women undergoing MRM was evident in univariate and multivariate analysis. Women undergoing MRM were found to have significant deterioration in physical and functional well-being, breast-specific subscale, TOI and overall QOL in univariate or multivariate analysis (Tables 1 and 2). The literature on the extent of surgery is mixed, with same authors reporting no effect of extent of surgery on QOL (17,21,24), whereas others reported favourable outcome in women undergoing breast conservation (25,26). It is possible that the difference seen in the present study is due to repeated interview within 30 days after surgery and, therefore, on long-term follow-up this difference may become insignificant.
Present study also showed a better QOL among older women and women with early breast cancer (T1N0), compared with younger women (<50 years) and advanced disease. These differences may be due to the symptom/psychological distress caused by disease process or could be directly related to women's inability to cope with the treatment process. Social and family support and communication have been found to be important factors in various studies (17,18,25,27) and may also be partially responsible for better QOL in this particular subset of women.
In the rather conservative Indian society, issues of sexual satisfaction or problems are seldom discussed openly. Disclosure of such information may be dependent on the age of the patient, age of the concerned physician (or interviewer) and, more importantly, the physician's gender. In the present study, a substantial number of patients did not answer the three sexuality and body image related items in the FACT-B tool, in pre-operative or/and post-operative interviews. Similar results have been reported by other investigators from the Asian subcontinent.
Though some of the findings observed in the present study were apparent during this short follow-up time period, they may perhaps improve or change on subsequent follow-up interviews scheduled at the third and sixth months and at the first and second year after completion of treatment. This study will, therefore, give us greater insight into QOL changes over time and will help us plan our interventions in a better way, ultimately contributing to improve QOL of women with breast cancer.
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Acknowledgments |
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M.P. and K.R. designed and coordinated the study, and edited the final version for publication. B.C.T. collected the data and carried out partial statistical analysis and prepared the draft manuscript. K.R. participated in the study, helped with patient recruitment, follow-up and preparation of the manuscript at all stages. All authors read and approved the manuscript. This study is funded by a generous grant from the Indian Council of Medical Research (ICMR) New Delhi, India. Vide Grant No.5/13/74/2000/NCD-III.
Conflict of interest: The authors declare that there are no conflicts of interest.
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References |
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1 Stechlin JS, Beach KH. Psychological aspects of cancer therapy. A surgeon's viewpoint. JAMA 1966;197:100–4.[CrossRef][Medline]
2 Thomas BC, Pandey M, Ramdas K, Nair MK. Psychological distress in cancer patients: hypothesis of a distress model. Eur J Cancer Prev 2002;11:179–85.[CrossRef][ISI][Medline]
3 Vinokur AD, Threatt BA, Caplan RD, Zimmerman BL. Physical and psychosocial functioning and adjustment to breast cancer: long-term follow-up of a screening population. Cancer 1989;63:394–405.[CrossRef][ISI][Medline]
4 Levy SM, Haynes LT, Herberman RB, Lee J, McFeeley S, Kirkwood J. Mastectomy versus breast conservation surgery: mental health effects at long-term follow-up. Health Psychol 1992;11:349–54.[CrossRef][ISI][Medline]
5 Vinokur AD, Threatt BA, Vinokur-Kaplan D, Satariano WA. The process of recovery from breast cancer for younger and older patients: changes during the first year. Cancer 1990;65:1242–54.[CrossRef][ISI][Medline]
6 Poulson B, Graversen HP, Beckmann J, Blichert-Toft M. A comparative study of post-operative psychosocial function in women with primary operable breast cancer randomized to breast conservation therapy or mastectomy. Eur J Surg Oncol 1997;23:327–34.[CrossRef][ISI][Medline]
7 Arora NK, Gustafson DH, Hawkins RP, McTavish F, Cella DF, Pingree S, et al. Impact of surgery and chemotherapy on the quality of life of younger women with breast carcinoma: a prospective study. Cancer 2001;92:1288–98.[CrossRef][ISI][Medline]
8 Stanton AL, Krishnan L, Collins CA. Form or function? Part 1. Subjective cosmetic and functional correlates of quality of life in women treated with breast-conserving surgical procedures and radiotherapy. Cancer 2001;91:2273–81.[CrossRef][ISI][Medline]
9 Psycho-social impact of breast cancer. First series of updates for health professionals. Update 3—Psychological adjustments over time. http://cope.uicc.org/Updates/rehab.shtml (Accessed on August 8, 2002).
10 Psychological effects of breast cancer. Available at URL: http://www.bcis.org/GeneralInfo/psych.html (Accessed on August 8, 2002).
11 Maguire GP, Lee EG, Bevington DJ, Kuchemann CS, Crabtree RJ, Cornell CE. Psychiatric problems in the first year after mastectomy. Br Med J 1978;1:963–5.[ISI][Medline]
12 Morris T, Greer HS, White P. Psychological and social adjustment to mastectomy: a 2-year follow-up study. Cancer 1977;40:2381–4.[CrossRef][ISI][Medline]
13 Pandey M, Thomas BC, Ramdas K, Eremenco S, Nair MK. Quality of life in breast cancer patients: validation of a FACT-B Malayalam version. Qual Life Res 2002;11:87–90.[CrossRef][ISI][Medline]
14 Brady MJ, Cella DF, Mo F, Bonomi AE, Tulsky DS, Lloyd SR, et al. Reliability and validity of the Functional Assessment of Cancer Therapy-Breast quality-of-life instrument. J Clin Oncol 1997;15:974–86.
15 FACIT: Functional assessment of chronic illness therapy. Frequently asked questions (FAQS). http://facitorg000.web108.discountasp.net/about/faq.aspx (accessed on December 19, 2004).
16 Wronska I. The quality of women's life after mastectomy in Poland. Health Care Women Int 2003;24:900–9.[CrossRef][Medline]
17 Lee CO. Quality of life and breast cancer survivors. Psychosocial and treatment issues. Cancer Pract 1997;5:309–16.[ISI][Medline]
18 Ferrell BR, Grant M, Funk B, Otis-Green S, Garcia N. Quality of life in breast cancer. Part II: Psychological and spiritual well-being. Cancer Nurs 1998;21:1–9.[ISI][Medline]
19 Cui Y, Shu XO, Gao Y, Cai H, Wen W, Ruan ZX, et al. The long-term impact of medical and socio-demographic factors on the quality of life of breast cancer survivors among Chinese women. Breast Cancer Res Treat 2004;87:135–47.[CrossRef][ISI][Medline]
20 Pandey M, Singh SP, Behere PB, Roy SK, Singh S, Shukla VK. Quality of life in patients with early and advanced carcinoma of the breast. Eur J Surg Oncol 2000;26:20–4.[CrossRef][ISI][Medline]
21 Goldberg JA, Scott RN, Davidson PM, Murray GD, Stallard S, George WD, Maguire GP. Psychological morbidity in the first year after breast surgery. Eur J Surg Oncol 1992;18:327–31.[ISI][Medline]
22 Ganz PA, Kwan L, Stanton AL, Krupnick JL, Rowland JH, Meyerowitz BE, et al. Quality of life at the end of primary treatment of breast cancer: first results from the moving beyond cancer randomized trial. J Natl Cancer Inst 2004;96:376–87.
23 King MT, Kenny P, Shiell A, Hall J, Boyages J. Quality of life three months and one year after first treatment for early stage breast cancer: influence of treatment and patient characteristics. Qual Life Res 2000;9:789–800.[CrossRef][Medline]
24 Janni W, Rjosk D, Dimpfl TH, Haertl K, Strobl B, Hepp F, et al. Quality of life influenced by primary surgical treatment for stage I–III breast cancer-long-term follow-up of a matched-pair analysis. Ann Surg Oncol 2001;8:542–8.
25 Ashing-Giwa K, Ganz PA, Petersen L. Quality of life of African American white long term breast carcinoma survivors. Cancer 1999;85:418–26.[CrossRef][ISI][Medline]
26 Engel J, Kerr J, Schlesinger-Raab A, Sauer H, Holzel D. Quality of life following breast-conserving therapy or mastectomy: results of a 5-year prospective study. Breast J 2004;10:223–31.[CrossRef][Medline]
27 Engel J, Kerr J, Schlesinger-Raab A, Eckel R, Sauer H, Holzel D. Predictors of quality of life of breast cancer patients. Acta Oncol 2003;42:710–8.[CrossRef][ISI][Medline]
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