Katherine A. Desmond

Life after breast cancer: understanding women's health-related quality of life and sexual functioning.

PURPOSE To describe the health-related quality of life (HRQL), partner relationships, sexual functioning, and body image concerns of breast cancer survivors (BCS) in relation to age, menopausal status, and type of cancer treatment. PATIENTS AND METHODS A cross-sectional sample of BCS in two large metropolitan areas was invited to participate in a survey study that included the following standardized measures: the RAND 36-Item Health Survey; the Centers for Epidemiologic Studies-Depression Scale (CES-D); the Dyadic Adjustment Scale (DAS); the Breast Cancer Prevention Trial (BCPT) Symptom Checklist; the Watts Sexual Functioning Questionnaire (WSFQ); and subscales from the Cancer Rehabilitation Evaluation System (CARES). RESULTS Eight hundred sixty-four BCS completed the survey. RAND Health Survey scores were as good or better than those of healthy, age-matched women, and the frequency of depression was similar to general population samples. Marital/partner adjustment was similar to normal healthy samples, and sexual functioning mirrored that of healthy, age-matched postmenopausal women. However, these BCS reported higher rates of physical symptoms (eg, joint pains, headaches, and hot flashes) than healthy women. Sexual dysfunction occurred more frequently in women who had received chemotherapy (all ages), and in younger women who were no longer menstruating. In women > or = 50 years, tamoxifen therapy was unrelated to sexual functioning. CONCLUSION BCS report more frequent physical and menopausal symptoms than healthy women, yet report HRQL and sexual functioning comparable to that of healthy, age-matched women. Nevertheless, some survivors still experience poorer functioning, and clinicians should inquire about common symptoms to provide symptomatic management or counseling for these women.

Fatigue in breast cancer survivors: occurrence, correlates, and impact on quality of life.

PURPOSE To describe the occurrence of fatigue in a large sample of breast cancer survivors relative to general population norms and to identify demographic, medical, and psychosocial characteristics of fatigued survivors. PATIENTS AND METHODS Breast cancer survivors in two large metropolitan areas completed standardized questionnaires as part of a survey study, including the RAND 36-item Health Survey, Center for Epidemiological Studies-Depression Scale, Breast Cancer Prevention Trial Symptom Checklist, Medical Outcomes Study Sleep Scale, and demographic and treatment-related measures. RESULTS On average, the level of fatigue reported by the breast cancer survivors surveyed (N = 1,957) was comparable to that of age-matched women in the general population, although the breast cancer survivors were somewhat more fatigued than a more demographically similar reference group. Approximately one third of the breast cancer survivors assessed reported more severe fatigue, which was associated with significantly higher levels of depression, pain, and sleep disturbance. In addition, fatigued women were more bothered by menopausal symptoms and were somewhat more likely to have received chemotherapy (with or without radiation therapy) than nonfatigued women. In multivariate analyses, depression and pain emerged as the strongest predictors of fatigue. CONCLUSION Although the majority of breast cancer survivors in this large and diverse sample did not experience heightened levels of fatigue relative to women in the general population, there was a subgroup of survivors who did report more severe and persistent fatigue. We identified characteristics of these women that may be helpful in elucidating the mechanisms underlying fatigue in this population, as well as directing intervention efforts.

Predictors of Sexual Health in Women After a Breast Cancer Diagnosis

PURPOSE To identify variables that might be predictive of sexual health (interest, dysfunction, and satisfaction) in a large sample of breast cancer survivors, with a validation conducted in a second, independent sample. PATIENTS AND METHODS On the basis of a conceptual framework of sexual health in breast cancer survivors, we performed multivariable regression analyses to estimate sexual interest, dysfunction, and satisfaction in both samples. Additional analyses were performed using stepwise regression and recursive partitioning to explore in each sample the relative contributions of the independent variables toward predicting the outcome measures. RESULTS The models for sexual interest accounted for at least 33% of the variance, and the significant predictors common to the two samples were having a new partner since the diagnosis of breast cancer, mental health score, and body image score. For sexual dysfunction, the models in the two samples explained at least 33% of the variance, and the common significant predictors were vaginal dryness, past chemotherapy use, and having a new partner since diagnosis. The sexual satisfaction models explained at least 27% of the variance, with the common significant predictors being the quality of the partnered relationship and sexual problems in the partner. CONCLUSION Among the predictors of sexual health, several are mutable (vaginal dryness, emotional well-being, body image, the quality of the partnered relationship, and sexual problems in the partner), and these should be considered for future interventions to address the sexual health and well-being of breast cancer survivors.

Impact of Different Adjuvant Therapy Strategies on Quality of Life in Breast Cancer Survivors

Little is known about the long-term effects of adjuvant therapy on quality of life, sexual functioning and symptoms in breast cancer survivors. Between January 1996 and June 1997, we surveyed 1098 women who had been diagnosed with early stage breast cancer between 1 and 5 years earlier. The breast cancer survivors were recruited in two large metropolitan centers in the USA. They completed a survey battery that contained standardized measures of health-related quality of life (HRQL), depression, body image, sexual functioning, and symptoms. A total of 1096 had usable responses for these analyses. In this sample, n = 356 had received tamoxifen (TAM) alone, n = 180 received chemotherapy (CHEM) alone, n = 395 received CHEM + TAM, and n = 265 received no adjuvant therapy (NO RX). There were significant differences in the mean age of each group, with the TAM group being the oldest (mean 62.6 years) and the CHEM group being the youngest (mean 46.8 years). Both age and time since diagnosis were controlled for in all statistical analyses. We found no significant differences in global quality of life among the four treatment groups. For the MOS-SF-36, there were no significant differences on the subscale scores except for the physical functioning subscale (p = 0.0002); the NO RX group had the highest functioning. There were no significant differences in depression scores among the four treatment groups. The MOS-SF-36 physical functioning composite score differed by treatment group (p = 0.012); the NO RX group had a physical functioning composite score that was at the mean for a normal healthy population of women, while those in the adjuvant treatment groups scored slightly lower. The mental health composite score was not significantly different among the four treatment groups and approximated scores from the normal population of healthy women. There were no differences in body image scores among the four treatment groups; however, sexual functioning scores did differ (p = 0.0078) with patients receiving chemotherapy (either alone or with tamoxifen) experiencing more problems. Hot flashes, night sweats, and vaginal discharge differed by treatment (p = 0.0001); all symptoms were reported more often in breast cancer survivors on tamoxifen. Vaginal dryness and pain with intercourse also differed significantly by adjuvant treatment, occurring more often in survivors treated with chemotherapy. Overall, breast cancer survivors function at a high level, similar to healthy women without cancer. However, compared to survivors with no adjuvant therapy, those who received chemotherapy have significantly more sexual problems, and those treated with tamoxifen experience more vasomotor symptoms.

Sexuality following breast cancer.

This article provides sex and marital therapists with detailed, multifaceted descriptions of sexuality after breast cancer based on survey responses from 863 breast cancer survivors. One third of women reported that breast cancer had had a negative impact on her sex life, and most reported negative changes in at least some areas. Nonetheless, breast cancer survivors did not differ from age-matched, healthy women on a standard measure of sexuality. Women who were most likely to report a negative impact on sexuality from cancer were those who had experienced changes in hormonal status, problems in their relationships, and difficulties with vaginal dryness. On the basis of these findings, we offer suggestions for health professionals and therapists treating breast cancer survivors.

Mamekhaya: a pilot study combining a cognitive-behavioral intervention and mentor mothers with PMTCT services in South Africa

Abstract Nearly 30% of pregnant women in South Africa are estimated to be HIV seropositive, yet adherence to guidelines for the prevention of mother-to-child transmission of HIV (PMTCT) is often low. A pilot study was developed to see whether PMTCT services provided by the South African Government could be enhanced by the Mamekhaya program, a combination of the mothers2mothers peer-mentoring program and a culturally adapted cognitive-behavioral intervention (CBI) from the USA. Pregnant women attending two maternity clinics offering PMTCT in Gugulethu and Vanguard Townships, Cape Town, South Africa, were invited to participate in the study. Women at the intervention site (Gugulethu) received the support of a mentor mother and also attended an eight-session Mamekhaya CBI. At the control site (Vanguard), women received standard services provided by midwives and counselors. Baseline assessments were completed by all participants at enrollment (n=160), and follow-ups were completed six months later by 44% of participants. Self-reports of adherence to PMTCT practices were high across both sites (90% or more engaging in the core practices). Women at the Mamekhaya site showed significantly greater improvement in establishing social support and reducing depression scores than women at the control site. Mamekhaya participants also showed trends for better attendance at follow-up medical visits, and greater improvements in positive coping. The greatest effect of the Mamekhaya program was to increase HIV knowledge scores, particularly with regard to understanding the meaning and importance of viral load and CD4 test results. Results from this pilot study show promise that augmenting basic PMTCT services with mentor mothers and a culturally adapted CBI can be effective in conveying information and in improving the emotional outlook and hopefulness of HIV-positive pregnant women in South Africa.

Quality of life of breast cancer survivors after a recurrence: a follow-up study.

Previous studies on breast cancer recurrence provide a mixed picture of the quality of life of women following a recurrence. To clarify the picture, the present study addresses some previous methodological concerns by offering a multidimensional assessment with follow-up, a matched comparison group of disease-free survivors, and a closer look at the nature of recurrence (local versus metastatic). Fifty-Four of 817 women who participated in an earlier study experienced a recurrence at follow-up, and are compared to a matched sample of 54 women who remained disease-free. Analyses indicate that women who had a recurrence report significantly poorer functioning on various health-related quality of life (HRQOL) domains compared to women who remained disease-free. However, the differences appear to be largely due to the poorer HRQOL of women with metastatic disease. Although women who had a recurrence report good mood, low stress, and good quality of interpersonal relationships, they report significantly higher cancer-specific stress compared to disease-free women at follow-up. Women who had a recurrence also report experiencing both more meaning and vulnerability as a result of breast cancer than disease-free women, but report similar levels of spirituality and benefit-finding at follow-up as disease-free women. These results suggest that although women report relatively good psychosocial adjustment following a recurrence, cancer-specific domains of quality of life are most likely to be negatively affected. These results may be useful in identifying individuals with breast cancer recurrences who are most in need of psychosocial services.

Information Content and Clarity of Radiologists' Reports for Chest Radiography

RATIONALE AND OBJECTIVES We systematically characterized the information provided by chest radiography reports on a nationally representative sample of 822 elderly patients hospitalized in 297 acute-care hospitals in five states who had an admission diagnosis of congestive heart failure, acute myocardial infarction, or pneumonia. METHODS We studied the content of radiography reports, including mention of the type or adequacy of radiography; the presence or absence of a prior radiograph; comments about bones, the aorta, the mediastinum, and pleura and notation of the laterality of findings; and the presence of diagnosis. Two physicians reviewed each patients report, and a third assigned the final rating when they disagreed. RESULTS Our analysis found wide variation in content of chest radiography reports, extensive variation in terms used to identify the presence or absence of abnormal findings, and a large degree of uncertainty in what was found. CONCLUSION With most hospitals introducing new information systems in response to technological advances and the need to generate more formal hospitalwide reports, the time is right to improve the quality of chest radiography reporting.

Determinants and Policy Implications of Male Circumcision in the United States

OBJECTIVE We sought to determine whether lack of state Medicaid coverage for infant male circumcision correlates with lower circumcision rates. METHODS We used data from the Nationwide Inpatient Sample on 417 282 male newborns to calculate hospital-level circumcision rates. We used weighted multiple regression to correlate hospital circumcision rates with hospital-level predictors and state Medicaid coverage of circumcision. RESULTS The mean neonatal male circumcision rate was 55.9%. When we controlled for other factors, hospitals in states in which Medicaid covers routine male circumcision had circumcision rates that were 24 percentage points higher than did hospitals in states without such coverage (P<.001). Hospitals serving greater proportions of Hispanic patients had lower circumcision rates; this was not true of hospitals serving more African Americans. Medicaid coverage had a smaller effect on circumcision rates when a hospital had a greater percentage of Hispanic births. CONCLUSIONS Lack of Medicaid coverage for neonatal male circumcision correlated with lower rates of circumcision. Because uncircumcised males face greater risk of HIV and other sexually transmitted infections, lack of Medicaid coverage for circumcision may translate into future health disparities for children born to poor families covered by Medicaid.

Changes Over Time in the Use of Do Not Resuscitate Orders and the Outcomes of Patients Receiving Them

OBJECTIVES Do not resuscitate (DNR) orders are increasingly common, though there has been little evaluation of their changing use. The authors contrasted the use and outcomes of DNR orders for nationally representative samples of Medicare patients hospitalized with specific diagnoses in 1981 to 1982 and 1985 to 1986. METHODS Using ordinary least squares regression to adjust for patient and hospital characteristics, the authors compared use, timing and predictors of DNR orders, and survival to hospital discharge of patients with DNR orders between the two time periods. RESULTS After adjustment for sickness at admission and for patient and hospital factors, more patients received DNR orders in 1985 to 1986 than in 1981 to 1982 (13% versus 10%, P < 0.001), with most of the increase among patients with the greatest sickness at admission. Disparity in DNR order use by age, diagnosis, functional status, preadmission residence, and gender found in 1981 to 1982 was still present in 1985 to 1986. DNR orders were written earlier in hospitalization during the latter time period. Patients with DNR orders were more likely to survive to hospital discharge in 1985 to 1986 than in 1981 to 1982 (44% versus 36%, P = 0.001), but their 30-day survival did not differ. CONCLUSIONS Although use increased, disparities in DNR order assignment persisted in these 1980s data. Examination is needed into whether these differences persist and whether they reflect patient preferences. Systems should be developed to preserve and review the preferences of the increasing number of patients discharged after in-hospital DNR orders.