Age-related differences in the quality of life of breast carcinoma patients after treatment

Authors

  • Lari B. Wenzel Ph.D.,

    Corresponding author
    1. Center for Behavioral and Community Studies, AMC Cancer Research Center, Denver, Colorado
    Current affiliation:
    1. Division of Epidemiology, Department of Medicine, University of California–Irvine, 224 Irvine Hall, Irvine, CA 92697-7555.
    • Division of Epidemiology, Department of Medicine, University of California–Irvine, 224 Irvine Hall, Irvine, CA 92697-7555
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  • Diane L. Fairclough Dr.P.H.,

    1. Center for Research Methodology & Biometrics, AMC Cancer Research Center, Denver, Colorado
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  • Marianne J. Brady Ph.D.,

    1. Center on Outcomes Research and Education, Evanston Hospital, Evanston Northwestern Healthcare, Evanston, Illinois
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  • David Cella Ph.D.,

    1. Center on Outcomes Research and Education, Evanston Hospital, Evanston Northwestern Healthcare, Evanston, Illinois
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  • Kathleen M. Garrett B.A.,

    1. Center for Behavioral and Community Studies, AMC Cancer Research Center, Denver, Colorado
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  • Brenda C. Kluhsman B.A.,

    1. Center for Behavioral and Community Studies, AMC Cancer Research Center, Denver, Colorado
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  • Lori A. Crane Ph.D.,

    1. Department of Preventive Medicine, University of Colorado Health Sciences Center, Denver, Colorado
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  • Alfred C. Marcus Ph.D.

    1. Center for Behavioral and Community Studies, AMC Cancer Research Center, Denver, Colorado
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Abstract

BACKGROUND

The objective of this study was to compare the quality of life (QOL) of younger (≤ 50 years) versus older (> 50 years) women on recent completion of treatment of breast carcinoma.

METHODS

Data reported herein were obtained from a baseline assessment of 304 breast carcinoma patients. These patients were enrolled in a multiinstitutional, randomized trial testing a psychosocial telephone counseling intervention for breast carcinoma patients immediately after treatment. The assessment was made using a self-administered (mail) questionnaire, with an overall response rate of 86%. Included in this questionnaire were standardized measures of QOL using the Functional Assessment of Cancer Therapy-Breast instrument, the Center for Epidemiologic Studies Depression Scale, and the Impact of Event Scale.

RESULTS

Comparisons of baseline data analyzed according to age approximating menopausal status (≤ 50 years and > 50 years) indicated that younger women reported significantly greater QOL disturbance. QOL was significantly worse for younger women globally (P = 0.021), and with regard to domains of emotional well-being (P = 0.0002) and breast carcinoma specific concerns (P = 0.022). Furthermore, symptoms of depression (P = 0.041) and disease specific intrusive thoughts (P = 0.013) were significantly worse for younger women. No significant sexual dysfunction or body image differences were noted.

CONCLUSIONS

Results from this analysis suggest that younger women with breast carcinoma should be considered to be at high risk for QOL disruption and significant clinical distress. Targeted interventions for this cohort are recommended. Cancer 1999;86:1768–74. © 1999 American Cancer Society.

Adjustment to the diagnosis and treatment of breast carcinoma is a complex process that unfolds over time, with medical, psychologic, social, and functional factors affected differentially throughout the process.1, 2 Consequently, it is useful to establish psychosocial screening and treatment criteria for women who could be considered “at risk” for distress in the year after diagnosis.3, 4 Many investigators have noted psychologic factors such as trait anxiety, a history of depression, or preexisting psychologic distress as being predictive of subsequent adjustment problems.5–9 In addition, some researchers have indicated that persistent symptoms of cancer-related intrusive thoughts during the acute phase of illness also can predict later adjustment problems.4, 10–13 Although psychosocial distress during the acute phase of illness (i.e., at the time of diagnosis and/or during treatment) is one set of criteria that can be used to identify high risk patients, other factors also have been identified. One such factor appears to be cancer treatment. It has been shown that patients who receive more doses of chemotherapy report slower improvement in quality of life (QOL) after initial diagnosis and surgery,14 and that higher levels of distress associated with side effects of treatment are likely to be associated with lower levels of psychosocial adjustment.7, 15 In general, compared with similar patients off treatment, women receiving chemotherapy report more psychologic distress and lower health status than patients who do not receive chemotherapy.16 However, it is heartening to note that some research indicates that both premenopausal and postmenopausal early-stage patients' QOL improves over time and may have few lasting effects.14, 17

Another factor that is predictive of psychosocial adjustment among breast carcinoma patients is age. Previous research has shown that younger women with breast carcinoma have more severe emotional distress than older cohorts12, 18, 19 and thus may be classified as “at risk” for distress for several reasons. Specifically, Mor et al.18 determined that younger breast carcinoma patients reported significantly higher numbers of unmet needs across QOL domains in comparison with older women, particularly in the areas of administrative and child-care tasks. Younger women also reported having significantly greater difficulty tolerating chemotherapy and maintaining their daily routine. In addition, the economic consequences of breast carcinoma were more pronounced; younger patients were nearly twice as likely as older patients to report having experienced financial problems due to their illness. Similar results have been reported more recently in which younger women receiving chemotherapy also reported more psychologic distress and lower health status.16 Consistent with these findings, it has been noted in general that younger women are considered less efficacious in coping with treatment-related side effects, in accepting a diagnosis of cancer and maintaining a positive attitude, in regulating affect, and in seeking support.20

Ganz et al. recently developed a psychosocial risk prediction model for breast carcinoma. Several of their analyses have highlighted the positive relation between age and psychosocial adjustment.3, 21 Associations within a risk prediction model allow us to hypothesize specific problem areas for the younger woman undergoing chemotherapy. For example, researchers have suggested that breast carcinoma has the potential to be most devastating to the sexual function and self-esteem of premenopausal women, noting that women who have undergone chemotherapy have more sexual dysfunction, poorer body image, and more psychologic distress compared with those treated with hormonal therapy and radiation therapy.22, 23 Similarly, it also is suggested that women who have received chemotherapy are especially susceptible to adverse changes in psychosexual functioning, including weight changes, hot flashes, mood swings, vaginal dryness, decreased libido, dyspareunia, and difficulty with orgasm.24 Recent research suggests that sexual dysfunction occurred more frequently in women who had received chemotherapy (all ages) and in younger women who were no longer menstruating.25

These studies support expectations that breast carcinoma patients manifest age-related differences in the psychosocial impact of their illness. Indeed, several investigators have noted that younger breast carcinoma patients may require greater social support and more frequent mental health interventions than they may be receiving.16, 23, 26, 27 This study builds on previous research that examines age-related differences in QOL among breast carcinoma patients in three ways: 1) it focuses exclusively on breast carcinoma patients with early stage disease, which represents the vast majority of all breast carcinoma patients nationwide,28 2) it assesses women immediately after treatment, which corresponds to that point in time when patients may feel especially vulnerable as they approach the reentry phase of cancer survivorship,29 and 3) it enrolled women from > 20 hospitals and clinics nationwide, providing for more generalizability than most previous research at single institutions.

MATERIALS AND METHODS

Patients

The breast carcinoma patients examined in this analysis were enrolled in a large intervention trial testing the efficacy of a telephone counseling program for early stage breast carcinoma patients.29 The data reported here were obtained from the baseline assessments for this trial, which utilized self-administered (mail) questionnaires. In this study age was dichotomized as ≤ 50 years or >50 years to serve as a rough indicator of menopausal status. This age cutoff point appears in epidemiologic literature30–32 as well as large breast carcinoma QOL trials.25, 33

Inclusion criteria for this study were: 1) Stage I, II, and IIIA (< 10 positive lymph nodes) disease (the staging system was specific to accruing institutions); 2) recent treatment completion (< 2 months); 3) no evidence of psychosis, dementia, or suicidal behavior; 4) patient was not enrolled in another QOL intervention study; 5) the patient's treatment plan did not include bone marrow transplantation; and 6) patient was English-speaking.

Recruitment Procedures

Twenty-one institutions nationwide participated in this study. Eligible breast carcinoma survivors were enrolled and consented during their last treatment visit by clinical research associates (CRAs) at the participating institution. Of 354 women invited to participate, 304 (86%) agreed to do so. Informed consent was obtained from all participants. The patient completed the QOL questionnaire usually within 3 weeks and mailed the questionnaire to the CRA. These forms, along with disease specific information completed by the CRA, then were mailed to the study Principal Investigator.

Assessment Procedures

Patients completed measures assessing multiple QOL dimensions. Analyses were conducted on QOL, sexual functioning and body image, cancer specific distress, and depressive symptomatology.

Functional Assessment of Cancer Therapy– Breast (FACT-B)

The FACT-B is a 44-item self-report instrument designed to measure multidimensional QOL in patients with breast carcinoma.34 The FACT-B is comprised of the FACT-General plus the Breast Cancer Subscale (BCS), which complements the general scale with items specific to QOL in patients with breast carcinoma. There are five subscales: Physical Well-Being, Functional Well-Being, Emotional Well-Being, Social Well-Being, and additional breast carcinoma concerns. The α coefficient for the FACT-B total score was 0.90, with subscale α coefficients ranging from 0.63–0.86. Evidence supports test-retest reliability (0.88 for the BCS), as well as convergent, divergent, and known group validity. The FACT-B has been determined to be appropriate for use in oncology clinical trials as well as in clinical practice.35

Sexual Functioning and Body Image Scales

Twenty-five separate questions were used to assess sexual functioning and body image, several of which were developed specifically for this project. Factor analyses (principal components) of this item pool suggested three factors. The Behavioral Scale, which was comprised of 9 items and had a Cronbach α of 0.77, assessed various behavioral aspects of sexuality, including for example reports of vaginal dryness, pain with intercourse, and frequency of sexually intimate behaviors. The Evaluative Scale, which was comprised of 7 items and had a Cronbach α of 0.85, assessed the patient's perceptions of sexual interest, arousal, or satisfaction. Finally, nine items were combined to form the Body Image Scale (e.g., global sense of attractiveness, impact of weight change, and impact of hair loss), with a Cronbach α of 0.80.

Impact of Event Scale (IES)

The IES measures subjectively experienced stress related to an adverse life event.36 The intrusion subscale (IES-I) measures the degree to which intrusive or distracting thoughts increase patient distress. Subscale scores are tabulated for Intrusion (7 items; Cronbach α of 0.78) and Avoidance (8 items; Cronbach α of 0.82). Split-half reliability of the total score was 0.86. We defined the stressful life event as having breast carcinoma. A score of ≥ 20 was considered suggestive of significant disease specific distress.

Center for Epidemiologic Studies-Depression Scale (CES-D)

The CES-D is comprised of 20 items and was developed to measure depression in the general population.37 The range of scores is 0–60, with higher scores indicating more symptoms. Measures of internal consistency are high in the general population (0.85) and in a psychiatric patient sample (0.90). Test-retest correlations are reported to be in the moderate range (0.45–0.70). Validity has been established by patterns of correlations with other self-report measures, correlations with clinical ratings of depression, and by relations with other variables that support its construct validity.38 A score of ≥ 16 is suggestive of significant depressive symptoms.

Data Analysis

Comparisons of demographic, disease, and treatment measures were conducted using the Wilcoxon rank sum test for continuous variables, the Cochran–Mantel–Haenszel chi-square test for ordered categoric variables, and the Fisher exact test for dichotomous variables. The FACT-B and its subscales were rescaled using a simple linear transformation to have a possible range of 0–100. This rescaling permits a clear display of results by allowing all FACT-B subscales to be presented together on the same metric. To convert back to raw scores, one can reverse the simple linear transformation applied. Specifically, Physical Well-Being, Functional Well-Being, and Social Well-Being were multiplied by 100/28, Emotional Well-Being was multiplied by 100/24, breast carcinoma specific concerns was multiplied by 100/36, and the FACT-B total score was multiplied by 100/152. The reported results can be converted back to the original scales by multiplying by the inverses of these ratios. The test of age-related differences in the FACT-B and its subscales was performed using analysis of covariance.

In addition to age, the potential covariates included those demographic and treatment variables that were unbalanced significantly between the 2 age groups (≤ 50 years vs. > 50 years). Joint tests of the demographic variables (except age) were not significant for any outcome and were not included in the final analysis. The final analysis included a prior chemotherapy regimen of > 3 months' duration, immediate reconstruction, and use of tamoxifen as covariates. The least square means and their standard errors were reported. Age was considered as both a continuous and dichotomous explanatory variable. Because the results were similar, only the results for the dichotomous analysis were reported.

RESULTS

Demographic and Background Variables

Three hundred and four patients were enrolled in the study and evaluated between January 1996 and October l997. Fifty-three percent were age ≤ 50 years. As depicted in Table 1, the majority of women in this study were non-Hispanic white, married, employed outside the home, and had at least some college education. However, significant demographic and background differences existed based on age (P < 0.01), with women age > 50 years reporting more chronic health problems unrelated to breast carcinoma than those age ≤ 50 years, as well as lower educational levels, being widowed, and not being employed full-time.

Table 1. Age Differences in Selected Demographic and Background Variables
Demographic and background variablesAge (yrs)
≤ 50     (N = 161)> 50     (N = 143)
No.%No.%
  • NS: not significant; Am Indian: American Indian.

  • a

    P < 0.01.

Race (NS)
 White14690.712990.2
 Black116.885.6
 Hispanic21.210.7
 Asian10.610.7
 Am Indian0032.1
 Unknown10.710.7
Educationa
 ≤ High school3119.35840.6
 Some college4125.53121.7
 College graduate4125.52416.8
 Graduate school4829.72920.2
 Unknown0010.7
Marital statusa
 Single2113.042.8
 Married12275.89767.8
 Separated63.721.4
 Divorced127.52014.0
 Widowed002014.0
Chronic (noncancer) health problemsa
 No12678.36847.6
 Yes3320.57149.7
 Unknown21.242.7
Currently employeda
 No4829.86344.1
 Part-time2918.06142.7
 Full-time8049.71611.2
 Unknown42.532.0

Disease and Treatment Variables

The majority of women enrolled had very early stage disease, a tumor classified as T2 or less, and no positive lymph nodes. However, as outlined in Table 2, treatment differences emerged by age categories. Women age ≤ 50 years were more likely to have received chemotherapy, and they were more likely to have received treatment (of any type) lasting three months or longer, than women age > 50 years with similar disease characteristics (P < 0.01). Conversely, women age > 50 years were more likely to have received tamoxifen (P < 0.01). These treatment differences were anticipated, given the association between more aggressive disease and treatment in the younger woman with breast carcinoma, the greater preponderance of evidence supporting the role of chemotherapy in premenopausal women, the greater preponderance of evidence supporting the role of tamoxifen in postmenopausal women, and the possibility that older women may not be able to tolerate an aggressive treatment regimen. Although the type of surgery received (mastectomy or lumpectomy) was not significantly different between age groups, younger women were significantly more likely to have received immediate reconstruction (P < 0.01).

Table 2. Age Differences in Selected Disease and Treatment Variables
Disease/treatment variablesAge (yrs)
≤ 50     (N = 161)> 50     (N = 143)
No.%No.%
  • NS: not significant.

  • a

    P < 0.01.

Disease stage (NS)
 I5131.75538.5
 II10162.77351.0
 III42.574.9
 Missing53.185.6
Tumor size (NS)
 T17546.68458.7
 T1b10.600
 T27848.44632.2
 T363.785.6
 T40010.7
 Missing10.742.8
Lymph node status (NS)
 Positive6238.56142.7
 Negative9659.68055.9
 Missing31.921.4
Chemotherapya
 Yes14489.48257.3
 No159.35840.6
 Missing21.332.1
Radiation therapy (NS)
 Yes9961.510271.3
 No6238.54128.7
 Missing0000
Tamoxifena
 Yes6641.09264.3
 No9257.14934.3
 Missing31.921.4
Length of treatmenta
 ≤ 3 mos6540.47753.8
 > 3 mos9257.16042.0
 Missing42.564.2
Surgery type (NS)
 Mastectomy7647.25135.7
 Lumpectomy8351.68962.2
 Missing21.232.1
Reconstructiona
 Immediate4628.6149.8
 Delayed21.210.7
 None10364.012083.9
 Missing106.285.6

Age-Related Differences in QOL

As shown in Table 3, there was a consistent pattern of higher QOL ratings among patients age > 50 years after controlling for treatment differences (prior chemotherapy, regimen of > 3 months' duration, immediate reconstruction, and use of tamoxifen). These differences were statistically significant for Emotional Well-Being (P = 0.0002) and breast carcinoma specific concerns (P = 0.022), as well as for the global FACT-B scores (P = 0.021). However, after controlling for treatment differences, no significant age-related differences emerged with respect to sexual functioning and body image (Table 4). Nonetheless, sexual functioning and body image (total score) were correlated moderately with the global QOL score for women age ≤ 50 years (correlation coefficient [r] = -0.53; P = 0.0001), and somewhat less strongly correlated for women age > 50 years (r = -0.36; P = 0.0005) (i.e., higher scores on the sexual functioning scale indicate greater dysfunction).

Table 3. Age Differences in Quality of Life
FACT scaleAge ≤ 50 yrs Mean (SE)Age > 50 yrs Mean (SE)Difference Mean (SE)P value
  1. SE: standard error; FACT: Functional Assessment of Cancer Therapy; ca: carcinoma; FACT-B: Functional Assessment of Cancer Therapy–Breast.

  2. Least squares means adjusting for group differences in prior chemotherapy, regimen of > 3 months' duration, immediate reconstruction, and tamoxifen therapy.

Physical Well-Being76.5 (1.52)79.1 (1.65)−2.54 (2.37)0.29
Functional Well-Being72.0 (1.57)74.8 (1.70)−2.76 (2.45)0.26
Emotional Well-Being74.5 (1.39)82.8 (1.52)−8.34 (2.18)0.0002
Social Well-Being81.3 (1.40)84.1 (1.50)−2.72 (2.18)0.21
Breast ca Specific Concerns62.5 (1.37)67.4 (1.49)−4.96 (2.15)0.022
FACT-B Global Score73.5 (1.08)77.4 (1.18)−3.95 (1.70)0.021
Table 4. Age Differences in Sexual Dysfunction and Body Image
ScaleAge ≤ 50 yrs Mean (SE)Age > 50 yrs Mean (SE)Difference Mean (SE)P value
  1. SE: standard error.

  2. Least squares means adjusting for group differences in prior chemotherapy, regimen of > 3 months' duration, immediate reconstruction, and tamoxifen therapy.

Positive Body Image (0–100)50.4 (1.49)54.2 (1.62)−3.77 (2.33)0.11
Sexual Dysfunction-Behavioral42.5 (1.70)41.2 (2.09)0.23 (2.83)0.93
Sexual Dysfunction-Evaluative49.1 (1.94)49.3 (2.34)−0.23 (3.18)0.94
Sexual Dysfunction-Total44.9 (1.56)43.9 (1.94)0.97 (2.61)0.71

Age-Related Differences in “Clinical Levels” of Distress

Table 5 illustrates the age-related differences in the measures of depressive symptoms and breast carcinoma specific intrusive and avoidant thoughts with respect to cutoff scores suggesting “clinical” levels of concern. After controlling for treatment differences, there were significant differences in the proportion of women who experienced depressive symptoms and disease specific intrusive thoughts. More specifically, our data indicated that 32% of younger patients experience depressive symptoms in the clinical range (scores at or above 16) compared with 20% of patients age > 50 years (P = 0.041). Comparisons of these percentages with “normal” populations and “psychiatrically hospitalized” populations37 suggests that the younger patients are more depressed than “normals” but less so than a “psychiatric” population. Women age > 50 years did not differ from the “normal” population. In addition, women age ≤ 50 years (18%) also experienced greater disease specific intrusive thoughts in the clinical range (scores at or above 20) compared with women age > 50 years (7%) (P = 0.013). No age differences were found with respect to the proportion of women with avoidant thoughts in the clinical range.

Table 5. Age Differences in Clinical Distress
Scales and cutoffAge ≤ 50 yrs Proportion (SE)Age > 50 yrs Proportion (SE)Difference Proportion (SE)P value
  1. SE: standard error; CES-D: Center for Epidemiologic Studies–Depression Scale; IES-I: Impact of Event Scale–Intrusion; IES-A: Impact of Event Scale–Avoidance.

  2. Proportions adjusted for group differences in prior chemotherapy, regimen of > 3 months' duration, immediate reconstruction, and tamoxifen therapy.

CES-D ≥ 160.32 (0.037)0.20 (0.040)0.12 (0.058)0.041
IES-I ≥ 200.18 (0.028)0.07 (0.031)0.11 (0.044)0.013
IES-A ≥ 200.17 (0.032)0.17 (0.035)0.00 (0.050)0.98

DISCUSSION

Results from this analysis suggest that women age ≤ 50 years manifest greater QOL disruption compared with their older counterparts with breast carcinoma. These differences were statistically significant with respect to global QOL and more specifically with respect to emotional well-being, breast carcinoma specific concerns, symptoms of depression, and disease specific intrusive thoughts. In contrast, our data suggest that age alone does not predict sexual dysfunction, which is a finding that also has been reported previously.25

There are several possible explanations for the age-related differences reported in this analysis. One explanation has to do with treatment differences by age. Younger patients may receive more aggressive treatment, which could compromise their QOL to a greater extent then older patients. Such treatment differences may exist, for example, because of the greater likelihood of comorbid complications in older patients or because breast carcinoma is viewed as potentially more aggressive in younger (premenopausal) women.39 However, our data suggest that age-related differences in QOL persist independent of treatment factors.

Another explanation concerns age differences in terms of competing demands and future expectations with respect to QOL. As noted by Mor et al., “It is likely that the different expectations of disease and disability among older and younger persons leads to a more profound sense of relative deprivation among younger persons – that the disease has forfeited their future, causing relatively more emotional distress among them than among older persons with cancer.”40 In addition, because a disease such as cancer is nonnormative for younger people, this becomes an unexpected psychologic and physical shock. The realities of this prolonged illness experience, especially true for those receiving chemotherapy, may find the younger woman possessing fewer coping strategies and resources necessary to manage a life-threatening illness. Indeed, results from this study suggest that younger women have more QOL problems and the older women have the fewest. This premise is supported anecdotally by qualitative evidence available through audiotaped clinical interview sessions conducted with all participants enrolled in the intervention arm of this study.29 It is clear that further investigation of coping as a mediator to adjustment41 and intrusiveness of the cancer experience for younger women with breast carcinoma will help to elucidate these issues.33

It is important to make resources available to those patients most in need and test the efficacy of those resources.21 Targeting interventions to those patients at greater risk represents a mindful progression of research to advance the field of psychooncology. For example, Bloom et al.33 tested a psychoeducational group intervention designed to impact the QOL of young women (age ≤ 50 years) newly diagnosed with breast carcinoma. Results from the current study serve to underscore the importance of recognizing “at risk” populations and targeting QOL interventions toward those populations. In this case, the breast carcinoma diagnosis and treatment may be creating or exacerbating stressors for younger women beyond those experienced by older women.

Identification of high risk individuals is necessary for maximal resource management. The results of the current study, obtained from women recently completing breast carcinoma treatment, suggest that younger patients should be considered at risk for distress. This consideration should allow for earlier evaluation and intervention consistent with the patient's needs. Utilization of cost-effective resources, such as those provided within group or telephone counseling settings,29, 33, 42 may help to enhance coping and QOL.

Acknowledgements

The authors thank the following persons for their assistance in the current study: Denise Barnes, Sara Juno, Kathy Kuzela, Susan Powell-Emsbo, Mira Rubenstein, Bernie Sarafian, Dr. Scott Sedlacek, Deb Zalman, Dr. Maureen McClatchey, Barbara McCray, and Alanna Kulchak Rahm.

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