Margaret L. Polinsky

Breast conservation versus mastectomy. Is there a difference in psychological adjustment or quality of life in the year after surgery

Women with a breast cancer diagnosis often are given a choice between breast conservation or mastectomy as the primary treatment for their cancer. Despite the high frequency of this cancer, there is little systemic information about the effect of surgical treatment on the quality of life or psychological adjustment of the patient. In this study, the authors prospectively evaluated quality of life, performance status, and psychological adjustment in 109 women who had primary breast cancer treatment. During the year of follow‐up, no statistically significant differences in quality of life, mood disturbance, performance status, or global adjustment were found between the two surgical groups, and both groups of patients improved significantly during the year of observation (P = 0.0001). As was predicted, patients receiving mastectomy reported more difficulties with clothing and body image; however, these results apparently did not affect the assessment of mood or quality of life. The authors conclude that patients receiving breast conservation therapy do not experience significantly better quality of life or mood than patients having mastectomy; however, patients having breast conservation surgery have fewer problems with clothing and body image. Women receiving breast conservation therapy may require more intensive psychosocial intervention in the postoperative period because of the added burden of primary radiation therapy.

Characteristics of women at risk for psychosocial distress in the year after breast cancer.

PURPOSE To provide a detailed description of rehabilitation problems of women, considered to be low risk and at risk for psychosocial morbidity, diagnosed with stage I and II breast cancer 1 month and 1 year after primary treatment. PATIENTS AND METHODS A sample of 227 newly diagnosed breast cancer patients were systematically interviewed by a clinical social worker and classified for risk of psychosocial distress in the year after diagnosis. They completed a battery of standardized instruments to assess quality of life (QL), rehabilitation needs, and psychologic distress. The primary QL instrument, the Cancer Rehabilitation Evaluation System (CARES), provides a detailed listing of rehabilitation needs. Descriptive CARES data are presented with comparisons between the two groups. RESULTS The at-risk women had significantly more problems with greater severity than the low-risk women in all areas (physical, psychosocial, medical interaction, sexual, and marital). While both groups showed improvement over the year following diagnosis, the at-risk group had significantly more problems 1 year later. Many physical problems subside, but problems at the local surgical site, psychologic distress, communication with marital partners, and negative body image are more persistent in the at-risk group 1 year later, while half of both groups continue to have sexual dysfunction. CONCLUSION The detailed listing of problems provided by the CARES may be helpful to clinicians in their interactions with patients. The need for preventive and early intervention for the at-risk patients is underscored.

Predicting Drug Treatment Entry Among Treatment-Seeking Individuals

This study examined factors related to drug treatment program entry among 276 drug abusers seeking treatment referral. Six-month follow-up interviews determined that 171 (62.0%) followed through with the treatment referral. The analyses indicated that treatment-entry and non-entry subjects did not differ in predisposing factors (age, gender, race/ethnicity, education), type of drug use, or years of use. A logistic regression analysis indicated that characteristics at baseline predicting subsequent treatment entry include legal pressure, lower levels of psychological distress and family or social problems, and prior successful treatment experience. Legal coercion was an effective factor promoting treatment entry. Drug abusers having prior successful treatment experience were also more likely to reenter treatment. However, those with more severe problems (drug related and others) seemed less likely to enter treatment, indicating that psychological distress and family problems may undermine motivation to follow through on treatment referral.

PREDICTING PSYCHOSOCIAL RISK IN PATIENTS WITH BREAST CANCER

Breast cancer is the most common neoplasm in North American women. The psychosocial impact of breast cancer has been extensively studied, and a number of investigators have attempted to characterize women who are at high risk for increased psychosocial morbidity. Although a detailed interview performed by a professional is the clinical standard for psychosocial assessment, such interviews are usually time-consuming and expensive, and thus are rarely performed. This study was designed to develop a strategy for the rapid identification of newly-diagnosed breast cancer patients at risk for psychosocial morbidity. A sample of 227 newly diagnosed breast cancer patients were interviewed systematically by a clinical social worker and were subsequently classified for risk of psychosocial distress in the year after diagnosis. In addition, these women completed a battery of standardized instruments designed to assess quality of life, rehabilitation needs and psychological distress. A logistic regression procedure was used to examine a wide range of variables for their ability to correctly classify the risk of psychosocial distress in this sample. The final model included the Cancer Rehabilitation Evaluation System (CARES) Psychosocial Summary Scale, the Karnofsky Performance Status score and age as the best predictors of psychosocial risk. Subsequently these three variables were used to construct a clinically usable risk prediction model. Additional research should be performed to validate this predictive model.

Exploring the influence of multiple variables on the relationship of age to quality of life in women with breast cancer.

This paper explores the relationship between age, psychosocial status and quality of life in a community based sample (n = 229) of newly-diagnosed breast cancer patients. A casement display methodology is used to examine the influence of demographic and medical variables on the outcome variables of interest (psychosocial status and quality of life) and their relationship to age. Based on the literature, a positive relationship between age and psychosocial status was predicted, but the relationship between age and quality of life was uncertain. For the whole sample, a weakly positive relationship between age and measures of psychosocial status and quality of life was observed. In the exploratory studies using the casement plots, the positive relationship between age and quality of life was most strong and significant in married women and in women who had received segmental mastectomy. Among sub-groups examined according to marital status and type of surgery, a positive relationship between age, psychosocial status and quality of life was observed only in married women who received segmental mastectomy. Additional preliminary observations were made about the relationship of household income and age to the outcome variables being studied. The casement plot methodology permits the simultaneous evaluation of multiple variables as a preliminary step before hypothesis development and should be considered when complex clinical problems are being evaluated.

Characteristics of Women-Only and Mixed-Gender Drug Abuse Treatment Programs

Specialized substance abuse treatment programs have been developed for women within the past two decades. This article presents the results of a secondary analysis of a regional database of drug abuse treatment programs that compared the characteristics of women-only (WO) and mixed-gender (MG) programs across three treatment modalities. In general, WO programs differed from MG programs in their policies regarding fees, sources of payment, special populations served, services offered, and treatment capacity, process, and duration. The differences in program characteristics reflect broader societal gender differences, including womens generally lower economic status and primary responsibility for child-rearing.

Rehabilitation needs and breast cancer: The first month after primary therapy

SummaryBreast cancer is the most common neoplasm in occidental women, yet very little information is available about the rehabilitation needs of these patients. This report reviews in detail the physical, psychological, social, and financial problems identified by fifty women during the first month after primary surgical treatment. The most frequently reported problems were physical and psychological. Patients undergoing modified radical mastectomy (MRM) are compared with patients receiving segmental mastectomy and primary radiotherapy (SM). There were few differences between the two surgical treatment groups; however, patients in the MRM group reported more difficulty with clothing and body image, while the SM group had more disruption of recreation and social activities. Information about the rehabilitation problems of patients with this common neoplasm should be helpful to patients and to the members of the health care team who are helping them recover.

Resistance to Drug Abuse Treatment: A Comparison of Drug Users Who Accept or Decline Treatment Referral Assessment

Many drug abusers do not seek help in formal treatment settings, and little is known about their resistance to treatment. In this study, we offered a treatment referral assessment to a sample of 283 drug users. Only 58 subjects (or 20.5% of the sample) accepted this offer. We explored differences between those who accepted the treatment referral assessment and those who declined the opportunity. Logistic regression identified predictors of acceptance related to higher levels of severity in drug use and higher scores on a motivation and readiness scale. Among those who declined the assessment, 43.1 % denied drug use, 37.3% thought their drug use was not a problem, and 16.4% expressed no interest in treatment. Further analysis showed that scores on motivation and readiness were positively related to a higher level of severity In employment problems, family problems, and drug use, and to having a history of prior treatment.

Drug-User Treatment Programs in a Large Metropolitan Area

This paper discusses the results of a comprehensive survey of one of the largest drug-user treatment systems in the United States--the system in Los Angeles County, California, which contains more than 300 programs, covers over 4,000 square miles, and serves clients from a notably heterogeneous population of almost nine million people. The survey reported on here was distinct from similar surveys in that it provided simultaneously comprehensive and in-depth descriptions of formal treatment programs in a defined local area. The authors believe that this survey is the first local drug-user treatment program survey of its scope and magnitude in the United States.

Rehabilitation of Patients with Primary Breast Cancer: Assessing the Impact of Adjuvant Therapy

During the past decade, the primary treatment of breast cancer has become increasingly complex owing to the use of radiation therapy as an alternative to mastectomy (Fisher et al. 1985; Veronesi et al. 1981) and the more extensive use of adjuvant chemotherapy and adjuvant hormonal therapy (Bonadonna and Valagussa 1987; Lippman 1986, Report from the Breast Cancer Trials Committee 1987). With these changes in primary therapy has come increased participation of the patient in treatment decisions, frequently intensifying the psychologic difficulties she must face (Holland and Rowland 1987; Sinsheimer and Holland 1987). Primary therapy is often protracted and no longer ends with the initial surgery, but continues for an additional 2–3 months if breast conservation therapy is used, with further extension of the period of initial treatment from months to years if adjuvant therapy is used. In addition, adjuvant therapy is now being extended to a larger segment of the population with breast cancer (e.g., treatment of node-negative patients) (Report from the Breast Cancer Trials Committee 1987; Bonadonna et al. 1986). Breast cancer patients currently face a wide range of physical, psychosocial, and economic problems as a consequence of these events.