Menopausal symptoms have become salient management issues for breast cancer survivors (Barton et al. 2002, Clemons et al. 2002) and may have negative impact on quality of life (Ferrell et al. 1997). This is not because the experience of survivors is different from the general female population, but instead because hormone therapy is not usually offered to women surviving estrogen-responsive cancer, and because menopause can occur prematurely in this population due to the effect of cancer treatments (Barton et al. 2002). In the latter case, menopause symptoms that most often develop gradually after age 45 and last a few years in the general population may occur early with little time for advance preparation and last longer in women with breast cancer, particularly if they are treated with adjuvant therapies such as tamoxifen (Nolvadex). In addition, increasing numbers of women are being treated with long-term tamoxifen therapy as it is advocated for early stage breast cancer and even for cancer prevention (Clemons et al. 2002).

This paper by Schultz et al. attempts to tease out the relationship among menopausal symptoms, health effects of cancer treatment and physical contributors to quality of life in long-term survivors of breast cancer. As noted by Barton et al. (2002), fewer menopause symptom treatment options complicate the menopause transition for breast cancer survivors. In addition, younger women who encounter menopausal symptoms due to their cancer treatment may report heightened symptom perception, severity and distress (Fenlon 1995), which has negative influence on daily activities, physical comfort and sexual health (Knobf 2001). The degree to which these are related to cancer treatment or to treatment-induced menopausal symptoms is not clear.

Participants in this study were, on average, 16 ± 8 years postbreast cancer diagnosis, and this provides an important addition to the literature as many studies have included women less than 10 years postbreast cancer treatment or this timeframe is implied (Jacobson et al. 2001, Stewart et al. 2001, Tomich & Helgeson 2002). Kornblith et al. (2003) reported long-term (20 years) adjustment of early-stage breast cancer survivors, however, their work focused on psychosocial issues, such as post-traumatic stress symptoms, social support and negative life events. They did provide limited data on a few physical symptoms, which are useful for comparison with the findings provided by this research. For example, Kornblith et al. (2003) found that sexual problems attributed to cancer were reported by 29% of their sample while 63% of the present sample reported painful sexual intercourse. In this study, painful sexual intercourse was not significantly associated with the survivors’ perception of how cancer had affected their overall health nor was it associated with treatment category. Differences in these findings may be related to stage of breast cancer or to age at diagnosis and treatment. It may also be related to age at menopause and relationship to age at cancer diagnosis. Women who undergo transition to menopause prior to breast cancer diagnosis and treatment may have differing experiences from women whose cancer treatment causes them to transition. Absence of these essential data in the present study makes it difficult to interpret the findings or to determine impact on menopausal quality of life (MQOL). Nevertheless, this study did identify painful sexual intercourse as an important issue for breast cancer survivors, and this symptom requires further study to determine its relationship to age and menopausal phase at breast cancer diagnosis, cancer treatment, as well as length of time since treatment.

Menopausal quality of life scores in this paper were related to perceived effect on overall health. Survivors who reported that having breast cancer had affected their overall health had significantly lower MQOL scores than those who did not perceive it had affected their overall health. Yet, when MQOL scores were analysed by specific health effects, such as pain symptoms (abdominal, arthritis and migraine headaches), few differences were seen. On the other hand, women who were older had higher MQOL scores, and this may be similar to what has been observed in the general population related to attitudes. Older women have a more positive attitude towards menopause and aging and report less distress about symptoms (Avis & McKinlay 1991). It would be interesting to determine the relationship, if any, among last menstrual period, age at breast cancer diagnosis and MQOL. We cannot assume that age at diagnosis represents data on menopausal phase at diagnosis. We also cannot assume that individual MQOL components were not differentially affected by treatment group membership, because we do not have clear information on use of adjuvant hormone therapy (tamoxifen or arimidex). The authors say that they assumed that women in all treatment categories were given this therapy, but this was not a random sample and only 37% reported hormone use. Is it likely that women who had no chemotherapy or radiotherapy were given adjuvant hormone therapy? We do not think so. It is not clear whether any of these women had used Hormone therapy (HT) for menopause symptoms prior to breast cancer diagnosis. These data might help interpret findings, as abrupt cessation of HT is known to heighten and possibly lengthen the menopause symptom experience. This is likely to have negative impact on MQOL.

Menopausal quality of life is adversely affected by sleep disturbance symptoms, and this was substantiated by the present study. That 90% of women in the present study reported problems with sleep underscores the need to address this important quality of life issue for breast cancer survivors. However, the conclusion by Schultz et al. in this paper that cognitive impairment, sleep disturbances and general unhappiness are also characteristic of normal menopause has not been conclusively supported by the literature. Particularly ‘general unhappiness’ has not been linked to menopausal phase. It is known that ageing women have a higher prevalence of depression, but the link to menopausal phase is highly disputed. As well, aging women report a higher prevalence of sleep disturbances, and this parallels a rising prevalence of trouble sleeping as women transition normally to postreproductive phase (premenopause, 31%, early perimenopause 32%, late perimenopause 38%, one year postmenopause, 38%, two years postmenopause 43%, three years postmenopause, 45%), with the highest rate in the postmenopause (Dennerstein et al. 2000). Sleep disturbances, it would seem, are prevalent in women, however, the degree to which they are attributable to menopausal phase or to ageing is very unclear (Clark et al. 1995).

As the number of breast cancer survivors is growing and their quality of life is of paramount importance to health care providers, it is essential that we continue to describe their experiences. This paper has increased our understanding of the link between cancer treatment and quality of life elements. However, it has also whet our appetite for increased information, and this may be the sequelae of all good research. Unanswered questions are generated by attempts to answer others. One thing is for sure; breast cancer survivors require menopause symptom management aimed at positively impacting their quality of life.


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