In this study of QOL in the immediate post-diagnosis period among women diagnosed with breast cancer, QOL was associated with several sociodemographic and clinical characteristics, as well as measures of social support. Younger age at diagnosis and more advanced stage of breast cancer were related to lower QOL while having higher levels of social support were positively related to QOL. The effects of these factors except age were greater in the immediate post-diagnosis period, underscoring the impact of the diagnosis on disrupting one’s life. Our study is one of the larger studies to examine QOL among women with breast cancer in the immediate post-diagnosis period, and our results confirm findings that younger women with breast cancer have lower QOL than older women with breast cancer during this period.
Most previous studies that have examined QOL among women with breast cancer were conducted among women who were at least four months after the cancer diagnosis. By this time, women will have begun their initial course of therapy and have had some time to adjust to their condition. There have been few studies that have examined QOL within a few weeks of a woman receiving her diagnosis. One study in India [18
] among 251 women diagnosed with breast cancer and undergoing definitive breast surgery (86% mastectomy or 14% breast conserving treatment) found a significant reduction in physical well-being, functional well-being, and breast cancer specific concerns before and up to 30 days after surgery. No significant change was noted for social well-being and emotional well-being. Although our study population (overall FACT-B score ± SD: 110.82 ± 19.0) is not directly comparable with this sample of Indian women (overall FACT-B score ± SD: 85.5 ± 13.2), similar to our results, the authors also observed lower QOL among younger women and women with more advanced breast cancer.
Among studies that have evaluated QOL beyond the first four months relative to the breast cancer diagnosis, most have found no relationships between QOL and sociodemographic or medical factors. Instead, psychosocial factors appear to be most influential. In one study by Avis et al. [12
] of 202 breast cancer patients aged 50 years and younger, more problems with respect to partner relationships, sexual functioning, and body image, and less adaptive coping strategies, were related to overall QOL assessed four to 42 months post-diagnosis. In another study of 103 younger breast cancer patients [10
], sexual functioning, social support, and social/family well-being were also observed to affect QOL within six months post-diagnosis. In a study by Ganz et al. [11
] of 691 breast cancer patients aged 65 years and older, age at diagnosis, surgery, and treatment did not affect overall QOL from three months up to 17 months post-surgery, while the presence of co-morbid conditions was a major contributor. Among 804 women recurrence-free at least two years post-diagnosis, Bowen et al. [13
] found that not working outside the home, being retired or disabled, and being unemployed were associated with poorer physical functioning compared to currently working. Race/ethnicity was associated with QOL such that black women experienced poorer physical functioning yet higher mental health compared to white women. A recent cross-sectional study by Janz et al. among early-stage breast cancer survivors (344 Latinas, 386 blacks, 726 whites) also reported racial/ethnic differences in QOL [14
]. Blacks had higher emotional well-being than whites, and lower acculturated Latinas had lower functional well-being, emotional well-being, and breast cancer specific concerns compared to whites. Similar to our study, the authors observed worse QOL among younger women and women with more advanced breast cancer. Interestingly, racial/ethnic differences for physical and emotional well-being were only observed among older women at least 50 years of age with lower acculturated Latinas having the lowest scores.
The Pathways Study is one of the first studies to examine the role of sociodemographic and clinical factors on QOL outcomes during the immediate period (on average two months) after receiving a breast cancer diagnosis. Importantly, the sample of 950 women surveyed is one of the largest to date, and follow-up data collection is currently being conducted at six months and 24 months since the baseline interview, thereby allowing future opportunities to evaluate change in QOL as women progress further through their survivorship experience.
Our assessment of QOL around the time of a breast cancer diagnosis is most likely a measure of the stress that accompanies the news of having been recently diagnosed with a serious illness. A woman’s physical and emotional functioning during this challenging period could impact her long-term QOL as a breast cancer survivor [5
]. Our observation of younger age at diagnosis being related to poorer QOL might be explained by younger women, in general, having a worse prognosis, experiencing greater disruption in their daily lives, work schedules, family responsibilities, and financial stability [34
], and facing for the first time the physical and emotional changes which accompany a diagnosis of a serious illness [15
]. In contrast, among older women, chronic conditions are more prevalent and expected, and perhaps news of having cancer does not impact them as strongly given other concurrent co-morbidities or experiences of peers.
Many observed associations were expected to be related to lower QOL, such as being diagnosed with more advanced stage cancer, undergoing a mastectomy, having lower socioeconomic status (education and income), and being a minority. Interestingly, within the minorities, we found that being either Hispanic or Asian was associated with lower QOL than being black. The literature comparing QOL among minority groups is limited, and the recent study by Janz et al. reported that lower acculturated Latinas had poorer functional well-being, emotional well-being, and breast cancer specific concerns compared to higher acculturated Latinas and blacks [14
]. Regarding the effect of acculturation on QOL in our study, we observed that being non- US born, which can serve as a crude proxy measure of acculturation, was associated with lower breast cancer specific concerns. Perhaps individuals with lower acculturation have more difficulty understanding the medical information provided to them in the breast cancer care setting, which has been suggested in previous studies for Latina women [36
We also observed that being married was associated with lower physical and emotional well-being, even after adjustment for social support, compared to being widowed. Perhaps a cancer diagnosis can have disruptive effects on a marriage resulting from the patient’s added anxiety and stress being projected onto her partner, who is already coping with his own distress [5
]. The effects of the diagnosis on care-giving aspects of a relationship would also be felt more acutely by women who are married, although as we observed, greater social support is associated with higher QOL. Alternatively, women who are widowed may be less likely to report negative factors related to their QOL after having gone through the bereavement process. Indeed, a recent study found that women who are widowed or never married were less likely to report severe symptoms resulting from their breast cancer than married women [39
In the analyses presented here, we did not include data on co-morbidities such as depression, diabetes, and other chronic conditions that could impact QOL. However, future analyses could incorporate information on such conditions. We did not assess effects from adjuvant therapy since the focus of the analysis was on examining predictors of QOL in the early post-diagnosis period, which is a period when most women have not started their adjuvant therapy. Given our study design, we are not able to collect information on QOL of the women before their breast cancer diagnosis to examine change in QOL that accompanies a cancer diagnosis.
In summary, we found that younger age at diagnosis and more advanced stage of breast cancer were associated with lower QOL, while having adequate social support positively influenced QOL in the immediate post-diagnosis period of two months. Clinical evaluation and possible interventions regarding QOL immediately after a breast cancer diagnosis are important, the effects of which may alter subsequent adjustment and functioning as women move forward through treatment and into their long-term survivorship period. Our results point to the importance of considering quality of life concerns, not just as a consequence of treatment, but also as it is influenced by the diagnosis of cancer itself. These results suggest that while age and stage at diagnosis may modify the approaches clinicians take in preparing women for the social, psychological, and functional effects of breast cancer, attention should be paid to these issues in the immediate post-diagnosis period.