Worry about Breast Cancer Recurrence: A Population-based Analysis
By Chagpar, Anees B | |
Proquest LLC |
As more patients with breast cancer survive treatment, the importance of their long-term quality of life is increasing. One important concern for many survivors is fear of recurrence. To better understand worry about recurrence, we conducted a population-based statistical analysis.
BECAUSE MORE PATIENTS with breast cancer are surviving treatment, the importance of long-term quality of life in this population is increasing. One important concern formany survivors is fear of recurrence. Most of this research has been done in breast cancer survivors, although some studies included prostate and colon cancer survivors and, rarely, other cancers such as testicular, gynecological, or head and neck. Studies have found that 33 to 96 per cent of cancer survivors report experiencing fear of recurrence, and up to 56 per cent of them report significant need for help in dealing with this fear.1-5 This fear has been associated with impaired mental and physical quality of life in both the cancer survivor and their caregivers.6, 7 Breast cancer survivors who exhibit symptoms of depression or anxiety tend to report experiencing intrusive thoughts about recurrence and inability to tolerate the uncertainty in their lives as a result of the specter of recurrence.8 Fear of cancer recurrence may also result in maladaptive behaviors such as avoidance of breast cancer followup, hypervigilance for symptoms, and inability to plan for the future.9, 10 In addition, most cancer survivors experience fear of recurrence even five years after diagnosis.1
To our knowledge, there have been no large-scale population-based analyses of fear of recurrence in breast cancer survivors. To better understand worry about recurrence in this population, we conducted a populationbased statistical analysis using results from the
Methods
The
The 2010
Univariate and multivariate analyses for both real and perceived risk of recurrence were performed using SAS, Version 9.1.3 (
Results
In 2010, the
On univariate analysis, worry about recurrence was significantly correlated with current age (P 4 0.03) and receipt of radiation therapy (P 4 0.04); the relationship between chemotherapy and worry approached significance (P 4 0.06). Worry was strongly associated with perceived risk of recurrence (Table 3, P < 0.01) and decreased overall quality of life (Table 3, P < 0.01). It was also associated with lower self-reported physical (P < 0.01) and mental (P < 0.01) health as well as poor satisfaction with social activities and relationships (P < 0.01).
We dichotomized quality of life into ''good,'' defined as responses of good, very good, and excellent, versus ''not good,'' defined as responses of ''fair'' or ''poor.'' In this analysis, worry was not independently associated with decreased quality of life (P 4 0.09; Table 4). However, thosewho ''always worried'' about recurrence had a persistently lower quality of life (odds ratio, 0.06; 95% confidence interval, 0.01 to 0.45).
Discussion
In this population-based analysis, 55.1 per cent of breast cancer survivors report some degree of worry about recurrence. Most of the breast cancer survivors in this study (92.9%) report a low level of worry, defined as worrying ''never,'' ''rarely,'' or ''sometimes.'' These results represent lower levels of worry than those in the published data such as Mehnert et al.,11 who found that 74 per cent of breast cancer survivors reported low levels of worry about cancer progression or recurrence. Similarly, Koch et al.12 found that 82 per cent of breast cancer survivors experience fear of recurrence ''never,'' ''rarely,'' or ''sometimes.'' However, both of these studies were done in a German population, and the broad ethnic distribution in
Our main goal was to investigate the relationship between worry and quality of life. On univariate analysis, worry about breast cancer recurrence was correlated with decreased self-reported overall quality of life, decreased quality of physical and mental health, and decreased satisfaction with social activities and relationships. These results were further supported by studies from Avis et al. and Clayton et al. that found that worry about recurrence was correlated with mild decreases in quality of life on univariate analyses.1, 15, 16 A review by Simard et al. of recent studies on fear of recurrence in various cancer types found that persistent physical symptoms such as fatigue, pain, and changes in body image/appearance are correlated with increased fear of recurrence, analogous to our results that worry about recurrence was correlated with decreased selfreported quality of physical health. Furthermore, they found that those who use psychotropic medications or are undergoing psychiatric treatment also experience more fear of recurrence, supporting our findings that decreased self-perception of mental health is correlated with worry about recurrence.17 However, in our study, worry about recurrence was not an independent predictor of worse overall quality of life after controlling for age, education, insurance, and race. Only the 1.9 per cent subpopulation of breast cancer survivors who ''always'' worried had decreased quality of life. This result echoes those of Mehnert et al., who found that the population of breast cancer survivors who worried ''often'' or ''always'' had an increased incidence of symptoms of intrusive thoughts and hyperarousal regarding their breast cancer diagnosis, and they were more likely to have a diagnosis of posttraumatic stress disorder, suggesting that the population of survivors with increased worry has unique psychosocial needs.11
In this study, worry was correlated with perceived risk of recurrence and current age on univariate analysis. Our results support previous data that perceived risk of recurrence and age are associated with fear of recurrence.18-20 Phillips et al.16 found that age, fatigue, symptom burden, and risk perception were significantly correlated with worry. Although we did not look at fatigue and symptom burden per se, we did find that a similar variable, worse reported physical health, was correlated with increased worry. We found that almost two-thirds of breast cancer survivors between the ages of 40 and 60 years worried to some extent about recurrence compared with fewer than 50 per cent for the other age groups. This is perhaps because breast cancer rates in general begin climbing in the mid-40s, so breast cancer survivors within this age range aremore sensitive to fear about recurrence at this age.21
On univariate analysis, having had radiation therapy was correlated with increased worry. The relationship between worry and having had chemotherapy also approached significance. In previous studies of breast cancer survivors less than five years posttreatment, both chemotherapy and radiation were significantly associated with fear of recurrence on univariate analyses, but only the association with radiation was found to be significant on multivariate analysis.17 However, a recent review of the fear of recurrence in long-term cancer survivors found that having had chemotherapy was associated with greater fear of recurrence in two of seven studies, whereas radiation was found to be uncorrelated with fear of recurrence in six of six studies.1 Although both radiation and chemotherapy are associated with significant side effects and may contribute to the symptom burden described by Phillips et al., they are also associated with increasing severity of cancer, because they are reserved for more advanced or aggressive cancers. Thus, their association with worry about recurrence may be confounded by the severity of the cancer. Because our study was based on a selfreported survey, it did not provide information about pathology or a verified treatment plan.
We found that worry was not correlated with having first-degree relatives with breast cancer, race, education, insurance, or age at diagnosis. Koch et al. found that three of six studies reported a significant correlation between race and worry about recurrence.1 Although some studies found that race is not correlated with fear of recurrence, others found that blacks experience less fear of recurrence, have higher emotional well-being than whites, and report fewer concerns in the survivorship period.1, 22-25 This may be a result of increased reliance on spirituality as a coping mechanism in this population.26 Janz et al.13 found that Latin American women experienced more fear of recurrence than both white and black counterparts. In particular, they found that less-acculturated Latinas experienced the highest levels of fear of recurrence. Given the national scope of our study, it is possible that more patients surveyed by the
An important advantage of this population-based survey analysis of the
These results reiterate that fear of cancer recurrence is an important problem for survivors of breast cancer and their families. They suggest that breast cancer survivors who experience the most fear of recurrence experience a decreased overall quality of life that affects not only themselves, but also their perceived satisfaction with their relationships. Middle-aged survivors of breast cancer and those who received radiotherapy are those most likely to experience fear of recurrence. This population of cancer survivors with the highest fear of recurrence has unique psychosocial needs. Failure to address these needs results in decreased quality of life for the patients themselves and also contributes to expensive emergency department visits for patients who may perceive any new symptoms as being ominous.27 Breast cancer survivors who have high levels of fear of recurrence should be identified and channeled into appropriate programs to address coping strategies to address negative effects on quality of life. Follow-up visits with breast surgeons and oncologists as well as primary care visits are important points at which patients can be educated on their risk of recurrence and health maintenance behaviors.
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From the
Presented at the Annual Scientific Meeting and Postgraduate Course Program,
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Copyright: | (c) 2014 Southeastern Surgical Congress |
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