Beverly Levine

Trajectories of Depressive Symptoms Following Breast Cancer Diagnosis

Background: This longitudinal study sought to identify groups of breast cancer survivors exhibiting distinct trajectories of depressive symptoms up to 24 months following diagnosis, and to describe characteristics associated with these trajectories. Methods: A total of 653 women completed baseline questionnaires within 8 months of breast cancer diagnosis on patient characteristics, symptoms, and psychosocial variables. Depressive symptoms were assessed at baseline and 6, 12, and 18 months after baseline. Chart reviews provided cancer and treatment-related data. Finite mixture modeling identified trajectories of depressive symptoms measured with the Beck Depression Inventory (BDI). Results: Six distinct trajectories were identified. Just over half of the sample had consistently very low (3.8%) or low (47.3%) BDI scores well below the traditional BDI cutoff point of 10 thought to be indicative of clinically significant depression; 29.2% had consistently borderline scores; 11.3% had initially high scores that declined over time, but remained above the cutoff point; 7.2% showed increased BDI over time; and a small but unique group (1.1%) reported chronically high scores above 25. Women in groups with lower depressive symptom levels were older, had less rigorous chemotherapy, fewer physical symptoms (fatigue and pain), and lower levels of illness intrusiveness. Conclusions: Approximately 20% of women had levels of depressive symptoms indicative of clinical depression that were maintained 2 years postdiagnosis. Factors related to trajectory membership such as illness intrusiveness, social support, fatigue, pain, and vasomotor symptoms suggest targets for possible intervention. Impact: Results demonstrate the heterogeneity of depressive symptoms following breast cancer and the need for continued screening posttreatment. Cancer Epidemiol Biomarkers Prev; 24(11); 1789–95. ©2015 AACR.

Trajectories of illness intrusiveness domains following a diagnosis of breast cancer.

OBJECTIVE To identify trajectories of illness intrusiveness over the first 2 years after a breast cancer diagnosis and describe associated patient and treatment characteristics. Illness intrusiveness, or how much an illness disrupts life domains, has been shown to be highly related to quality of life. METHODS Women recruited within 8 months of a breast cancer diagnosis (n = 653) completed questionnaires at baseline and 6, 12, and 18 months postbaseline. Group-based trajectory modeling was used to identify trajectories in three established domains of illness intrusiveness: instrumental, intimacy, and relationships and personal development. Bivariate analyses identified contextual, disease/treatment, psychological, and social characteristics of women in trajectory groups. RESULTS Forty-one percent of women fell into a trajectory of consistently low illness intrusiveness (Low) across all three domains. Other women varied such that some reported illness intrusiveness that decreased over time on at least one domain (9-34%), and others reported consistently high intrusiveness on at least one domain (11-17%). A fourth trajectory of increased illness intrusiveness emerged in the relationship and personal development domain (9%). Characteristics of women in the Low group were being older; being less likely to have children at home; and having stage I cancer, fewer symptoms, and better psychosocial status. CONCLUSIONS Women experienced different patterns of illness intrusiveness in the first 2 years after a diagnosis of breast cancer with a high percentage reporting Low intrusiveness. However, women differentially followed the other trajectory patterns by domain, suggesting that the effect of breast cancer on some womens lives may be specific to certain areas.

Proposed Shift in Screening for Breast Cancer

Proposed Shift in Screening for Breast Cancer To the Editor In a Viewpoint, Dr King and colleagues1 called for population-based screening for mutations in BRCA1 and BRCA2 among US women starting at age 30 years. This recommendation represents a major shift from current guidelines for testing, which are based on age at diagnosis of family member as well as family history.2 King and colleagues did not make any reference to the number of women needed to screen to detect a rare harmful mutation in the general population, or to the number of women needed to screen to prevent 1 case of BRCAattributable cancer. There are currently approximately 98 550 000 US women aged 30 years or older.3 An estimated 1/500 to 1/300 will have a deleterious mutation in BRCA1 or BRCA2,1 translating into approximately 197 100 to 328 500 women with such mutations. Assuming an average lifetime penetrance of BRCA gene mutations for breast cancer of 80% by the age of 80 years (range of estimates: 40%-80%),1,4 and with no competing risks such that all women survive to the age of 80 years, one would expect approximately 157 680 to 262 800 cases of BRCA-attributable breast cancer among this cohort of women through their lifetime. Therefore, 375 to 625 women in the general population (depending on assumed mutation prevalence) would need to be screened to detect a single deleterious mutation. If penetrance is closer to 50%, the range of women needed to screen increases to approximately 600 to 1000. For ovarian cancer, the numbers of women needed to screen are 750 to 1250 for a high penetrance estimate of 40%, and 2727 to 4545 for a low penetrance estimate of 11%.4 To prevent a case of cancer, a woman found to have a harmful mutation must choose prophylactic mastectomy, oophorectomy, or both, which then must be assumed to be 100% effective. The number needed to screen to prevent a case of cancer is thus higher than the number needed to screen to detect a mutation. Risks of genetic testing to the large numbers of women who stand to receive no benefit from BRCA testing are real,5 as are the financial costs. Included in such risks are those of unclear negative and ambiguous test results, which may increase as a proportion of results when women without strong family histories are tested. In concluding the Viewpoint, King and colleagues noted “They [US women] should have the choice to learn if they carry an actionable mutation in BRCA1 or BRCA2.” Although choice is a legitimate concern, choices that raise more questions than they answer and cause needless anxiety and action should be carefully considered.

Trajectories of response to acupuncture for menopausal vasomotor symptoms: the Acupuncture in Menopause study.

Objective: To examine the trajectories of responses to acupuncture treatment for menopausal vasomotor symptoms (VMS) and the characteristics of women in each trajectory. Methods: Two hundred nine perimenopausal and postmenopausal women aged 45 to 60 years experiencing at least four VMS per day were recruited and randomized to receive up to 20 acupuncture treatments within 6 months or to a waitlist control group. The primary outcome was percent change from baseline in the mean daily VMS frequency. Finite mixture modeling was used to identify patterns of percent change in weekly VMS frequencies over the first 8 weeks. The Freeman-Holton test and analysis of variance were used to compare characteristics of women in different trajectories. Results: Analyses revealed four distinct trajectories of change in VMS frequency by week 8 in the acupuncture group. A small group of women (11.6%, n = 19) had an 85% reduction in VMS. The largest group (47%, n = 79) reported a 47% reduction in VMS frequency, 37.3% (n = 65) of the sample showed only a 9.6% reduction in VMS frequency, and a very small group (4.1%, n = 7) had a 100% increase in VMS. Among women in the waitlist control group, 79.5% reported a 10% decrease in VMS frequency at week 8. Baseline number of VMS, number of acupuncture treatments in the first 8 weeks, and traditional Chinese medicine diagnosis were significantly related to trajectory group membership in the acupuncture group. Conclusions: Approximately half of the treated sample reported a decline in VMS frequency, but identifying clear predictors of clinical response to acupuncture treatment of menopausal VMS remains challenging.

Posttreatment trajectories of physical activity in breast cancer survivors.

Breast cancer survivors face a risk of disease recurrence and a higher risk of developing comorbidities such as cardiovascular disease when compared with the general population. Physical activity (PA) has been shown to reduce such risks. The current analyses sought to identify: 1) unique patterns of PA among breast cancer survivors; and 2) characteristics associated with the level of PA.

Work-related perceptions and quality of life among breast cancer survivors.

An estimated 3.4 million breast cancer survivors are currently living in the USA, with more than one million of them working age [1]. Earlier diagnoses and improved treatment regimens have allowed breast cancer survivors to remain in or return to the workforce following diagnosis [2]. It is hypothesized that employment following cancer may be beneficial because of social support found in the work environment as well as the impact employment has on offsetting financial and insurance concerns [3]. Several studies among breast cancer survivors have suggested that being employed is related to quality of life (QoL) [4,5]. Timperi et al. [3] found a significant positive association between the number of hours worked per week and better physical and social wellbeing 6 months following diagnosis. Similarly, Mahar et al. [4] demonstrated that women who were working continuously following cancer (no break in employment) reported lower levels of anxiety, depression, somatization, and general distress and higher levels of QoL compared with women who were not working [4]. Although these studies suggest that employment following diagnosis is related to better QoL [3,4], neither study examined how women’s perceptions of their work environment might be related to QoL. One’s work environment may enhance QoL (e.g., through social supports and financial benefits) or may be a source of stress. To our knowledge, the impact of work perceptions on QoL for cancer survivors has not been previously studied. The present analyses examine whether work-related perceptions are independently associated with QoL, controlling for socio-demographic and cancer-related factors, among employed breast cancer survivors 18–26 months post-diagnosis.

Concordance networks and application to clustering cancer symptomology

Symptoms of complex illnesses such as cancer often present with a high degree of heterogeneity between patients. At the same time, there are often core symptoms that act as common drivers for other symptoms, such as fatigue leading to depression and cognitive dysfunction. These symptoms are termed bridge symptoms and when combined with heterogeneity in symptom presentation, are difficult to detect using traditional unsupervised clustering techniques. This article develops a method for identifying patient communities based on bridge symptoms termed concordance network clustering. An empirical study of breast cancer symptomatology is presented, and demonstrates the applicability of this method for identifying bridge symptoms.

Met and Unmet Expectations for Breast Reconstruction in Early Posttreatment Breast Cancer Survivors

The purpose of this study was to evaluate the prevalence of met and unmet expectations after breast reconstruction among breast cancer survivors following mastectomy. A secondary objective was to examine reasons women report their experiences of reconstructive surgery were better or worse than expected. As part of a larger study of breast cancer survivors, participants completed self-administered questionnaires within 8 months of diagnosis and at 6, 12, and 18 months later. At the 18-month follow-up, women who had breast reconstruction were asked whether their reconstruction was better, the same, or worse than expected. The sample consisted of 130 survivors (mean age = 48.5 years) who had breast reconstruction following mastectomy and completed the 18-month follow-up, 42% of whom reported their reconstruction was worse than expected and only 25% reported it was better. Most frequently reported reasons for reconstruction being worse than expected were related to appearance of the reconstructed breast and pain. A high percentage of patients with breast cancer undergoing breast reconstruction following mastectomy reported the results as worse than expected, with the primary reasons for dissatisfaction related to the feel and appearance of the reconstructed breast. Patients with breast cancer considering breast reconstruction need better preoperative education or understanding about what to expect from reconstruction.