This report describes the QOL of an important yet understudied population of breast cancer survivors, namely women who are diagnosed with breast cancer at a young age and who become long-term survivors. The results of this study support prior findings that younger women are resilient following a diagnosis of breast cancer and have similar QOL in multiple areas to women who have not had breast cancer [4
]. However, our results do suggest some impairment in the areas of emotional health and well being. Similar findings have been reported elsewhere [4
]. The results presented indicate high functioning on cancer-specific factors as summarized by the CARES-SF Global Score. Women reported more difficulty with sexual issues than in the other CARES-SF sub-scales, a finding that is fairly consistent with other studies and expected given the age range of our population [8
Unlike other studies [4
], we found that the type of surgery significantly impacted long-term QOL as measured by the SF-36 PCS; this was the only QOL measure significantly impacted by type of surgery. In addition, we found the presence of symptoms at the time of survey and use of chemotherapy after diagnosis to be the strongest correlates of QOL for several standardized QOL summary scales. Somewhat surprisingly, stage at diagnosis, age at survey, recurrence since diagnosis, and number of years since diagnosis were not highly correlated with QOL in this population. We explored stage at diagnosis and comorbidity as potential confounders in the multivariate models. Our results are presented without adjustment for these covariates because of their lack impact on the estimates in the final models.
Late effects of treatment were determined by the relationship of adjuvant therapy to QOL in several QOL summary scales, most notably the CARES-SF Global and the SF-36 PCS. Women who did not receive chemotherapy or hormonal therapy had higher QOL than women who received either type of therapy. Long-term consequences of adjuvant therapy may be particularly pronounced in terms of sexual issues. Our results, and the findings from a large longitudinal study of QOL among long-term survivors across a broader age distribution, suggest that the effects of adjuvant therapy persist many years after the completion of chemotherapy [6
The presence of breast related symptoms at the time of survey completion, and the presence of pain in particular, had a profound impact on QOL across all summary measures. There is a substantial body of literature documenting the under-treatment of cancer pain [24
] with estimated pain prevalence rates of 33–52% in non-metastatic breast cancer [9
]. Despite sample size limitations, our results suggest that the presence of inadequately managed breast cancer related pain, and other cancer-related symptoms, many years after diagnosis may have a significant impact on the day-to-day well-being of younger survivors. It is worth noting that insufficient distribution of breast related symptoms prevented us from examining the effect of individual symptoms in multivariate modeling. We were therefore unable to control for the presence or absence of individual symptoms and cannot know the real extent of the effect attributable to pain. A greater understanding of the contribution of various breast related symptoms to QOL should be considered in future studies.
While the presence of breast related symptoms at survey was the only covariate to appear in the final logistic regression model for all QOL outcome measures, our results suggest that socio-economic status, as measured by annual family income, may also play an important role in determining QOL among younger long term survivors. While our study lacks substantial socio-economic diversity, these findings support the results of a previous study among an older and more ethnically diverse group of long-term breast cancer survivors [8
]. These findings are difficult to interpret without a disease-free control group, given that socioeconomic status has been found to be an important correlate of QOL in the general population [26
The limitations of this study include a sample size and the cross-sectional design. In the absence of a control group, we cannot be certain that any correlations between specific covariates and QOL are specific to breast cancer survivors. The cross-sectional design allows us to identify potential correlates of QOL but inferences about causality cannot be made based on this study. While small sample size resulted in instability in subgroup analyses, we chose to present these results because of the interesting trends; these results are by no means definitive and should be further explored. In addition, our results may be limited by the possibility that these women are not representative of all younger US long-term breast cancer survivors, due to the predominantly Caucasian sample, the relatively high level of education, access to comprehensive health care, and the absence of geographic diversity. It is also important to note that these findings may underestimate the impact of breast cancer in the general population. However, these women are likely to be representative of women with access to medical care and women with relatively high socioeconomic status; both of which are known correlates of breast cancer.
The strengths of the present study include the use of standardized QOL measures, a high response rate, a well-defined group of cases arising from the underlying population, and the focus on younger women who were more than five years post diagnosis. In addition, because all women received care in the same health system, this study lacks the variability in treatment patterns that exist in the general population, thus differences in quality of life are less likely to be attributed to treatment-specific differences.