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1.  Prevalence, Predictors, and Characteristics of Off-Treatment Fatigue in Breast Cancer Survivors 
Cancer  2010;116(24):5740-5748.
Lack of consensus regarding how to identify cancer patients with significant fatigue has hampered research regarding cancer-related fatigue (CRF).
Specific criteria were used to identify CRF cases in women with stage 0-II breast cancer (BC group, n = 304). Women completed assessments before adjuvant therapy (baseline), end of adjuvant therapy (Post-Tx), and 6 and 42 months after end of adjuvant therapy (6 and 42 Month Post-Tx). At each, women completed a clinical interview and questionnaires assessing physical and mental health. A healthy control (HC) group with no history of BC (n = 337) completed 2 similar assessments 36 months apart.
Off-treatment CRF prevalence was 9% and 13% at the 6 and 42 Month Post-Tx assessments, respectively. Thus, 15% of the sample evidenced off-treatment CRF with 7% evidencing delayed onset CRF. CRF at the 6 Month Post-Tx assessment was associated only with CRF at baseline (OR = 3.2) and Post-Tx assessments (OR = 3.9). CRF at the 42 Month Post-Tx assessment was associated with CRF at the Post-Tx assessment (OR = 6.1), obesity at baseline, and several baseline measures of coping in response to fatigue. Off-treatment CRF cases differed markedly from CRF noncases and healthy controls on a spectrum of health status indices (mean effect size >1.0 SD).
Results document the prevalence of off-treatment and delayed onset CRF, suggest the utility of a cognitive-behavioral model of CRF, and support NCCN guidelines recommending monitoring fatigue across the cancer trajectory.
PMCID: PMC4048855  PMID: 20734399
fatigue; survivorship; assessment; outcomes; late effects
2.  Physical and Mental Health Status of Female Adolescent/Young Adult Survivors of Breast and Gynecological Cancer: A National, Population-Based, Case-Control Study 
Each year nearly 21,000 adolescents and young adults (AYA) ages 15 to 29 years are diagnosed with cancer. Breast and gynecological cancers account for 25% of the cancers seen in AYA females. The purpose of this study was to compare the current physical and mental health status of female AYA cancer survivors with non-cancer female controls.
Using data from the population-based 2009 National Health Interview Survey, 100 cases of female AYA survivors of breast and gynecological cancers were identified (FCS group). FCS cases were matched with 300 female respondents without a history of cancer on age, education, marital status, and minority status (NCC group). The FCS and NCC groups were compared on a range of physical and mental health status indices using analysis of covariance and binary logistic regression.
FCS group reported significantly poorer physical and mental health status than the matched controls. Relative to the NCC group, FCS survivors had significantly poorer scores on 7 of 8 mental health outcomes and were more likely to meet criteria for serious psychological distress (OR = 4.23, p ≤ 0.001). FCS group also reported greater lifetime and current prevalence of various medical conditions; more health-related disabilities; and greater functional limitations than the NCC group.
Diagnosis of breast and gynecological cancer during adolescence and young adulthood is associated with clinically important deficits in physical and mental health status. Given the young age of this cancer survivor cohort, increased attention should be devoted to minimizing these deficits.
PMCID: PMC3644006  PMID: 23306935
cancer; adolescent/young adult; survivorship; breast; gynecological
3.  Prolonged Impact of Chemotherapy on Fatigue in Breast Cancer Survivors 
Cancer  2011;118(15):3833-3841.
In this study, the authors examined the influence of prior treatment on the course of fatigue in breast cancer survivors. Patients who received chemotherapy were expected to have greater fatigue than patients who received radiotherapy and noncancer controls 6 months after the completion of treatment, but they were expected to recover to levels similar to those of the other 2 groups 3 years later.
Patients with stage 0 through II breast cancer completed the Fatigue Symptom Inventory (FSI) and the Profile of Mood States Fatigue Scale (POMS-FAT) 6 months (T1) and 42 months (T2) after completing chemotherapy with or without radiotherapy (the CT group; n = 103) or radiotherapy only (the RT group; n = 102). An age-matched group of women with no history of cancer (the NC group; n = 193) was assessed over a similar interval.
A significant (P = .041) group × time effect for FSI severity scores revealed that fatigue worsened over time in the CT group but remained stable and lower in the RT and NC groups. There also were significant group effects for FSI days (P < .001) and POMS-FAT (P = .010) scores, indicating that fatigue was significantly greater across time in the CT group than in the NC group (POMS-FAT) or the RT and NC groups (FSI days).
Contrary to expectations, fatigue did not diminish over time in patients with breast cancer who received chemotherapy. This finding has important implications for patient education and for fatigue monitoring during follow-up. The authors concluded that future research should seek to examine possible mechanisms to explain the apparent prolonged impact of chemotherapy on fatigue in breast cancer survivors.
PMCID: PMC4007757  PMID: 22086766
fatigue; breast cancer; chemotherapy; radiotherapy
4.  Factors associated with breast cancer worry three years after completion of adjuvant treatment 
Psycho-oncology  2012;22(4):936-939.
Although many survivors continue to worry about cancer years after completing treatment, little is known about factors associated with cancer worry. This study examined associations between breast cancer worry and demographic and clinical variables, as well as fatigue, symptom burden, and risk perception in a sample of breast cancer survivors three years post-adjuvant treatment. We hypothesized that after controlling for demographic and treatment factors, a significant proportion of variance in cancer worry would be explained by greater fatigue severity, more symptom burden, and greater perceived risk of recurrence.
Stage 0–II breast cancer patients (N = 202) completed measures of risk perception, cancer worry (modified Lerman's Cancer Worry Scale), symptom burden (Memorial Symptom Assessment Scale), and fatigue severity (Fatigue Symptom Inventory) three years after completing adjuvant treatment. Multiple regression analyses were used to determine the proportion of variance in cancer worry accounted for by fatigue, symptom burden, and risk perception after controlling for demographic and clinical variables.
Age, fatigue, symptom burden, and risk perception each explained a significant proportion of variance in cancer worry (p < .05). Fatigue, symptom burden, and risk perception together accounted for 27% of the variance in cancer worry after controlling for demographic and clinical factors (p < .01).
The hypothesis was supported that fatigue, symptom burden, and risk perception are associated with cancer worry among breast cancer survivors. It is possible that lingering fatigue and other symptoms may remind breast cancer survivors of their disease.
PMCID: PMC3392435  PMID: 22419546
breast cancer; worry; fatigue; symptom burden; risk perception; survivorship
5.  Physical and Mental Health Status and Health Behaviors of Childhood Cancer Survivors: Findings from the 2009 BRFSS Survey 
Pediatric blood & cancer  2011;58(6):964-970.
The growing number of childhood cancer survivors makes examination of their current physical and mental health status and health behaviors an important concern. Much of what is known about the long-term outcomes of childhood cancer survivors comes from the Childhood Cancer Cohort Study (CCSS) which uses sibling controls.
Using data from the 2009 Behavioral Risk Factor Surveillance System survey, 651 childhood cancer survivors and 142,932 non-cancer peer controls were identified. The two groups were compared on a variety of physical and mental health status and health behavior variables using ANCOVA and binary logistic regression.
While controlling for differences in age, sex, and minority status, survivors significantly (p ≤0.001) had poorer socioeconomic outcomes, more comorbid conditions, lower life satisfaction, less social and emotional support, poorer general health, and reported more days per month of poor physical and mental health than non-cancer individuals. Survivors were more likely to report being a current smoker (odds ratio [OR] = 2.33; 95% confidence interval [CI], 1.98 to 2.73; p<0.001); tested for human immunodeficiency virus (HIV) (OR = 1.79; 95% CI, 1.52 to 2.11; p<0.001); and that at least one HIV situation applied to them (OR = 2.06; 95% CI, 1.55 to 2.74; p<0.001). No significant differences were found between groups in regards alcohol use and diet.
Results support and extend previous findings reported by the CCSS. New findings regarding survivors’ increased likelihood to engage in risky behaviors proposes new directions for future research.
PMCID: PMC3332525  PMID: 22012636
childhood cancer survivors; physical health; mental health; health behaviors
6.  History of Major Depressive Disorder Prospectively Predicts Worse Quality of Life in Women with Breast Cancer 
Data are scarce about whether past history of major depressive disorder in the absence of current depression places breast cancer patients at risk for worse quality of life.
The current study prospectively examined quality of life during chemotherapy in breast cancer patients with a history of resolved major depressive disorder (n=29) and no history of depression (n=144).
Women with Stages 0–II breast cancer were assessed prior to and at the completion of chemotherapy. Major depressive disorder was assessed via structured interview and quality of life with the SF-36.
Patients with past major depressive disorder displayed greater declines in physical functioning relative to patients with no history of depression (p≤0.01).
Findings suggest that breast cancer patients with a history of resolved major depressive disorder are at increased risk for declines in physical functioning during chemotherapy relative to patients with no history of depression.
PMCID: PMC3424106  PMID: 22167580
7.  Breast Cancer Recurrence Risk Reduction Beliefs in Breast Cancer Survivors: Prevalence and Relation to Behavior 
Psycho-Oncology  2011;21(4):427-435.
There is a growing body of evidence suggesting breast cancer (BC) recurrence risk might be linked to behavioral factors. However, little is known about BC survivors' beliefs regarding the link between their behavior and recurrence risk. The objective of this study was to describe BC survivors' beliefs regarding performance of behaviors potentially associated with BC recurrence risk reduction, and to examine the link between these behaviors and BC recurrence risk reduction beliefs, worry, and risk perception.
200 female BC survivors (age, years: mean = 57.7, standard deviation = 9.2) completed a questionnaire assessing beliefs about the effectiveness of 14 potential BC recurrence risk reduction behaviors, their performance of these potential risk reduction behaviors, recurrence worry, and perception of personal lifetime BC recurrence risk.
The behaviors most frequently endorsed as potentially reducing BC recurrence risk included avoiding tobacco use (84%), exercising at least three times per week (74%), eating an average of five servings a day of fruits and vegetables (72%), and limiting food intake to maintain current weight or lose weight (70%). Multivariate logistic regression analyses predicting behavioral performance showed that beliefs were consistently associated with behavior while worry and risk perception were largely unrelated to behavior.
BC survivors' beliefs about the effectiveness of potential BC recurrence risk reduction behaviors are largely consistent with empirical findings and relate strongly to actual behavioral performance. Misconceptions about the effects of behavior to reduce BC recurrence risk are important targets for clinical and public health efforts.
PMCID: PMC3116938  PMID: 21312312
cancer; oncology; recurrence; prevention and control; behavior; survivors
8.  Cognitive Functioning After Cancer Treatment: A Three-Year Longitudinal Comparison of Breast Cancer Survivors Treated with Chemotherapy or Radiation and Non-cancer Controls 
Cancer  2011;118(7):1925-1932.
This study examined the influence of prior treatment on the course of cognitive functioning in breast cancer survivors. Changes in cognitive functioning over time were compared in breast cancer survivors treated with chemotherapy plus radiotherapy, breast cancer survivors treated with radiotherapy only, and women with no history of cancer.
Stage 0-II breast cancer patients treated with chemotherapy plus radiotherapy (CT group; n=62) or radiotherapy only (RT group; n=67) completed neuropsychological assessments 6 months after completing treatment (T1) and again 36 months later (T2). Women with no history of cancer (NC group; n=184) were assessed over a similar interval. RESULTS: A significant group X time effect was found for processing speed (p=.009) that reflected a tendency for the NC group but not the RT and CT groups to improve over time. There was also a significant group effect for executive functioning (p=.006) that reflected the NC group performing better than the CT and RT groups. Additional analyses found the administration of hormonal therapy was not associated with change over time in cognitive performance.
Findings provided limited support for the view that changes in cognitive functioning in cancer survivors are attributable to chemotherapy administration and illustrate the importance of including a radiotherapy comparison group. Future research should seek to examine possible mechanisms that could explain the apparent prolonged impact of both chemotherapy and radiotherapy on cognitive functioning in breast cancer survivors.
PMCID: PMC3305821  PMID: 22161750
cognitive function; breast cancer; chemotherapy; radiotherapy; survivorship
9.  Physical and Mental Health Status and Health Behaviors of Survivors of Multiple Cancers: A National, Population-Based Study 
Annals of Behavioral Medicine  2011;42(3):304-312.
Little is known about the unique experience of adults with a history of multiple cancer diagnoses (i.e, survivors of multiple cancers).
This research assessed the health status and health behaviors of survivors of multiple cancers.
The health status and health behaviors of 8734 survivors of multiple cancers, 47562 survivors of a single cancer, and 348229 non-cancer controls were compared using weighted data from the 2009 Behavioral Risk Factor Surveillance System.
Survivors of multiple cancers reported poorer physical and mental health status outcomes (e.g., more mental distress and greater activity limitations) than survivors of a single cancer (all p’s < .001) who reported poorer outcomes than controls (all p’s < .001). Survivors of multiple cancers reported unhealthier behaviors than survivors of a single cancer and healthier behaviors than controls on most health behavior outcomes (e.g., alcohol use, tobacco use, and diet) (all p’s < .001).
Data suggest the need for clinical interventions to enhance physical and mental health status, and to increase adoption of healthier behaviors in survivors of multiple cancers.
PMCID: PMC3319008  PMID: 21732227
Behavioral Risk Factor Surveillance System; Centers for Disease Control and Prevention; multiple neoplasms; quality of life; health behaviors; survivorship
10.  Cancer Recurrence Worry, Risk Perception, and Informational-Coping Styles among Appalachian Cancer Survivors 
Despite a growing literature on the psychosocial impact of the threat of cancer recurrence, underserved populations, such as those from the Appalachian region, have been understudied. To examine worry and perceived risk in cancer survivors, cancer patients at an ambulatory oncology clinic in a university hospital were surveyed. Appalachians had significantly higher worry than non-Appalachians. Cancer type and lower need for cognition were associated with greater worry. Those with missing perceived risk data were generally older, less educated, and lower in monitoring, blunting, and health literacy. Additional resources are needed to assist Appalachians and those with cancers with poor prognoses to cope with worry associated with cancer recurrence. More attention to prevention of cancer is critical to improve quality of life in underserved populations where risk of cancer is greater.
PMCID: PMC3322407  PMID: 21240722
Appalachian region; cancer; health disparities; oncology; perceived risk; psychosocial factors
11.  Psychological Health in Cancer Survivors 
Seminars in Oncology Nursing  2008;24(3):193-201.
The prevalence of both negative (distress) and positive responses (growth, well-being) to the cancer experience is examined and difficulties in establishing the prevalence of these responses discussed. A conceptual framework for understanding factors associated with psychological health in cancer survivors is presented. Finally, strategies for promoting psychological health in cancer survivors are examined.
Data Sources
Review of the literature.
Psychological health in cancer survivors is defined by the presence or absence of distress as well as the presence or absence of positive well-being and psychological growth. Furthermore, psychological health in cancer survivors is determined by the balance between two classes of factors: the stress and burden posed by the cancer experience and the resources available for coping with this stress and burden.
Implications for nursing practice
In general, promotion of psychological health is based upon the prevention or treatment of distress as well as the encouragement of growth and well-being. Periodic screening for psychological distress across the cancer trajectory is critical to appropriate management of distress.
PMCID: PMC3321244  PMID: 18687265
12.  Cancer Risk Assessment by Rural and Appalachian Family Medicine Physicians 
The Journal of Rural Health  2009;25(4):372-377.
Challenges to the identification of hereditary cancer in primary care may be more pronounced in rural Appalachia, a medically underserved region.
To examine primary care physicians’ identification of hereditary cancers.
A cross-sectional survey was mailed to family physicians in the midwestern and southeastern United States, stratified by rural/non-rural and Appalachian/non-Appalachian practice location (N=176). Identification of hereditary breast-ovarian cancer (BRCA1/2), hereditary non-polyposis colon cancer (HNPCC), and other hereditary cancers was assessed.
Less than half of physicians (45%) reported having patients with cancer genetic testing. Most (70%) correctly identified the BRCA1/2-relevant scenario; 49% correctly identified the HNPCC-relevant scenario. Factor analysis of psychosocial variables revealed 2 factors: Confidence (knowledge, comfort, confidence) and Importance (responsible, important, effective, need) of identifying hereditary cancer. Greater confidence was associated with use of 3 generation pedigree in taking family history. Greater knowledge and access to genetic services were associated with use of genetic testing. More recent graduation year, greater knowledge, and greater confidence were associated with identifying the BRCA1/2-relevant scenario. Greater knowledge and confidence were associated with identifying the HNPCC-relevant scenario.
Although rural Appalachian physicians do not differ in ability to identify high risk individuals, access barriers may exist for genetic testing. Interventions are needed to boost physician confidence in identifying hereditary cancer and to improve availability and awareness of availability of genetic services.
PMCID: PMC3319913  PMID: 19780917
hereditary cancer; physicians; primary care; psychosocial factors; Appalachian region
13.  Clinical, Demographic, and Situational Factors Linked to Distress Associated with Benign Breast Biopsy 
Few studies have examined the magnitude of distress associated with specific aspects of the benign breast biopsy (BBB) or distress risk factors. Women (n=51) completed questionnaires regarding distress associated with a recent BBB experience. Clinical and demographic risk factors for distress were also examined. All women reported distress associated with BBB; one-third reported it as “very stressful.” Biopsy-specific events were rated most distressing. Younger age, less education, non-surgical biopsy, and absence of family history of breast cancer were identified as risk factors for distress. The identified factors provide an efficient and potentially cost-effective means of stratifying risk for BBB-related distress.
PMCID: PMC3319914  PMID: 21240724
14.  Posttraumatic Growth and PTSD Symptomatology among Colorectal Cancer Survivors: A Three-Month Longitudinal Examination of Cognitive Processing 
Psycho-Oncology  2009;18(1):30-41.
The experience of cancer can be understood as a psychosocial transition, producing both positive and negative outcomes. Cognitive processing may facilitate psychological adjustment.
Fifty-five post-treatment, colorectal cancer survivors (M=65.9 years old; SD=12.7), an average of thirteen months post-diagnosis, were recruited from a state cancer registry and completed baseline and three-month questionnaires assessing dispositional (social desirability), cognitive processing (cognitive intrusions, cognitive rehearsal) and psychological adjustment variables (posttraumatic growth (PTG), posttraumatic stress disorder (PTSD) symptomatology, depression, anxiety, positive affectivity).
PTSD symptomatology was positively associated with depression, anxiety and negatively associated with positive affectivity. In contrast, PTG scores were unrelated to PTSD symptomatology, depression, anxiety, and positive affectivity. In addition, PTG was independent of social desirability. Notably, after controlling for age at diagnosis and education, multiple regression analyses indicated cognitive processing (intrusions, rehearsal) was differentially predictive of psychological adjustment. Baseline cognitive intrusions predicted three-month PTSD symptomatology and there was a trend for baseline cognitive rehearsal predicting three-month PTG.
Additional research is needed to clarify the association between PTG and other indices of psychological adjustment, further delineate the nature of cognitive processing, and understand the trajectory of PTG over time for survivors with colorectal cancer.
PMCID: PMC3319916  PMID: 18481837
posttraumatic growth; PTSD symptomatology; cognitive processing; psychological adjustment; cancer; oncology
15.  Beliefs About Cancer Causation and Prevention As a Function of Personal and Family History of Cancer: A National, Population-Based Study 
Psycho-Oncology  2008;17(10):967-974.
Research suggests individuals possess multifaceted cognitive representations of various diseases. These illness representations consist of various beliefs, including causal attributions for the disease, and are believed to motivate, guide, and shape health-related behavior. As little research has examined factors associated with beliefs about cancer causation, the present study examined the relationship between personal and family history of cancer and beliefs about the causes and prevention of malignant disease. Data was obtained from 6369 adult respondents to the 2003 Health Information National Trends Survey (HINTS), a national population-based survey. Information about personal and family history of cancer and beliefs regarding cancer causation and prevention was obtained. Results showed both a personal and family history of cancer were associated with differences in beliefs about the causes of cancer. In general, a personal history of cancer was not significantly linked to causal attributions for cancer relative to those without a personal history. In contrast, a family history of cancer tended to increase the likelihood a respondent viewed a particular cause as increasing cancer risk. Thus, personal and vicarious experience with cancer had dramatically diverging influences on attributions of cancer causation, which may be due to differing self-protection motives. Results support the belief that illness representations, in this case the causal belief component, are influenced by both personal and vicarious experience with a disease and also suggest illness representations may influence receptivity to messages and interventions designed to increase appropriate cancer risk reduction behavior.
PMCID: PMC3319087  PMID: 18203236
cancer; oncology; causal attributions; attribution theory; illness representations; prevention
16.  Receipt of a False Positive Test Result During Routine Screening for Ovarian Cancer: A Teachable Moment? 
The term "teachable moment" (TM) has been used to describe a life transition or event which motivates an individual to change a behavior or presents an opportunity to intervene to prompt behavior change. We examined whether receipt of a false positive ovarian cancer (OC) screening result may represent a TM.
403 women participating in an OC screening program completed questionnaires assessing demographic, clinical, behavioral, and psychosocial information. The TM was operationalized as expressed interest in receiving health-related information. We hypothesized that among women receiving a false positive screening test result, those women who had experienced greater personal perceived risk for OC as well as distress would be more interested in receiving health-related information than women receiving a normal result.
Analyses revealed that women receiving a false positive screening result were less interested in receiving health-related information than women receiving a normal screening result. For women receiving a false positive result, expressed interest in receipt of health-related information was only modestly related to distress and related even less to perceptions of OC risk.
Our data do not support viewing a false positive OC screening result as a TM. Potential explanations for the current findings as well as recommendations for future research investigating the TM are discussed.
PMCID: PMC3319350  PMID: 21373852
teachable moment; ovarian cancer screening; normal/false positive cancer screening result; cancer risk
17.  Response to an Abnormal Ovarian Cancer Screening Test Result: Test of the Social Cognitive Processing and Cognitive Social Health Information Processing Models 
Psychology & health  2010;26(4):383-397.
All cancer screening tests produce a proportion of abnormal results requiring follow-up. Consequently, the cancer screening setting is a natural laboratory for examining psychological and behavioral response to a threatening health-related event. This study tested hypotheses derived from the Social Cognitive Processing and Cognitive-Social Health Information Processing models in trying to understand response to an abnormal ovarian cancer (OC) screening test result. Women (n=278) receiving an abnormal screening test result a mean of 7 weeks earlier were assessed prior to a repeat screening test intended to clarify their previous abnormal result. Measures of disposition (optimism, informational coping style), social environment (social support and constraint), emotional processing, distress, and benefit finding were obtained. Regression analyses indicated greater distress was associated with greater social constraint and emotional processing and a monitoring coping style in women with a family history of OC. Distress was unrelated to social support. Greater benefit finding was associated with both greater social constraint and support and greater distress. The primacy of social constraint in accounting for both benefit-finding and distress was noteworthy and warrants further research on the role of social constraint in adaptation to stressful events.
PMCID: PMC2911487  PMID: 20419561
Distress; cancer screening; adjustment; psychosocial; coping; health behavior theory
18.  Differences in Cancer Information Seeking Behavior, Preferences, and Awareness Between Cancer Survivors and Healthy Controls: A National, Population-Based Survey 
Journal of Cancer Education  2009;24(1):73-79.
No research has examined how cancer diagnosis and treatment might alter information source preferences or opinions.
Data from 719 cancer survivors (CS group) and 2012 matched healthy controls (NCC group) regarding cancer-related information seeking behavior, preferences, and awareness from the population-based 2003 Health Information National Trends Survey (HINTS) was examined.
The CS group reported greater consumption of cancer-related information but the CS and NCC groups did not differ in information source use or preferences. The CS group was more confident of their ability to get cancer information, reported more trust in health care professionals and television as cancer information sources, but evaluated their recent cancer information seeking experiences more negatively than the NCC group. Awareness of cancer information resources was surprisingly low in both the CS and NCC groups.
Cancer diagnosis and treatment subtly alters cancer information seeking preferences and experience. However awareness and use of cancer information resources was relatively low regardless of personal history of cancer.
PMCID: PMC3315685  PMID: 19259869
19.  Exploring the differential experience of breast cancer treatment-related symptoms: a cluster analytic approach 
Cancer patients experience multiple concurrent symptoms. This exploratory analysis assessed symptom burden among patients undergoing chemotherapy for breast cancer to identify distinct subgroups of patients who experience differential symptom burden and assessed whether the patient subgroups were associated with deleterious quality of life (QOL) outcomes.
Materials and methods
Women (N=133) with stage I and II breast cancer undergoing adjuvant chemotherapy after primary surgery were evaluated at baseline and at the end of chemotherapy using the Memorial Symptom Assessment Scale (MSAS) and the SF-36 QOL questionnaire. Post treatment MSAS symptoms were included in hierarchical cluster analysis. Two patient subgroups were identified that corresponded to a high-symptom prevalence group and a low-symptom group.
Results and discussion
No marked, statistically significant differences were found between groups on demographic, symptoms, QOL, or treatment variables at baseline. Patients in the high-symptom cluster were more likely to have stage I disease (p<0.05). The two groups of patients showed significant differences in end-of-treatment symptoms and QOL scores (p<0.05). The high-symptom burden group was more likely to report greater symptom prevalence and poorer QOL.
Future research needs to examine why these differences occur despite similarities in treatment and how symptom burden can be reduced for the high-symptom prevalence group.
PMCID: PMC2892385  PMID: 18043948
Breast cancer; Cluster analysis; Symptom clusters; Symptom management; Quality of life
20.  Cognitive Functioning in Breast Cancer Survivors: A Controlled Comparison 
Cancer  2009;115(8):1776-1783.
To determine whether neuropsychological functioning differs in breast cancer survivors six months after completion of adjuvant treatment as compared to women without cancer.
Participants were 187 women diagnosed with ductal carcinoma in situ (DCIS), Stage I, or Stage II breast cancer and 187 age- and geographic- matched women without cancer. Of survivors, 97 had been treated post-surgery with chemotherapy only or chemotherapy plus radiotherapy and 90 had been treated post-surgery with radiotherapy only.
Small but statistically significant differences in cognitive functioning and cognitive impairment were observed in survivors treated with chemotherapy and their matched controls and also in survivors treated with radiotherapy only and their matched controls. No group differences were observed in cognitive complaints.
Data from the current study suggest that cognitive deficits are subtle and likely due to the general effects of cancer diagnosis and treatment rather than systemic treatment.
PMCID: PMC2668740  PMID: 19224550
cognition; neuropsychological tests; adjuvant chemotherapy; adjuvant radiotherapy; breast neoplasms
21.  Magnitude and Correlates of Response Shift in Fatigue Ratings in Women Undergoing Adjuvant Therapy for Breast Cancer 
Fatigue is a common consequence of cancer chemotherapy (CT) and radiotherapy (RT). Investigation of the impact of cancer treatment on fatigue is compromised by a potential “response shift” in fatigue ratings, involving a recalibration of a respondent’s internal standard used to judge their current fatigue experience. Using a prospective, longitudinal research design, repeated assessments of most and average fatigue were obtained from women (n=102) with early stage breast cancer receiving adjuvant CT and/or RT. Thentest ratings of fatigue were also obtained and used to index the presence of a response shift in fatigue ratings. Results suggested a clinically significant response shift in ratings of most and average fatigue of approximately one-half standard deviation. Multiple regression analyses suggested larger response shifts were associated with higher pretreatment fatigue ratings, receipt of CT, and lower fatigue catastrophizing. Most importantly, consideration of the observed response shift in fatigue ratings significantly altered the conclusions drawn regarding the magnitude and persistence of fatigue during and after adjuvant therapy for breast cancer.
PMCID: PMC2682229  PMID: 18757176
Breast cancer; fatigue; methodology; measurement response shift; quality of life; symptoms; quality of life; adjuvant therapy
22.  Identifying Clinically Meaningful Fatigue with the Fatigue Symptom Inventory 
The Fatigue Symptom Inventory (FSI) has been used extensively to assess and measure fatigue in a number of clinical populations. The purpose of the present study was to further establish its utility by examining its operating characteristics and determining the optimal cutoff score for identifying clinically meaningful fatigue. The SF-36 Vitality scale, a measure widely used to identify individuals with significant fatigue-related disability, was used to determine the sensitivity and specificity of the FSI. Results indicate that a score of 3 or greater on those items assessing fatigue in the past week is the optimal cutoff score for identifying clinically meaningful fatigue. Individuals who scored at or above the cutoff also reported significantly greater fatigue interference, more days of fatigue on average, and fatigue a greater proportion of each day in the past week. Findings suggest that the FSI can be used to discriminate effectively between individuals with and without clinically meaningful fatigue.
PMCID: PMC2590752  PMID: 18495413
Fatigue; Fatigue Symptom Inventory
23.  Cognitive Functioning after Adjuvant Chemotherapy and/or Radiotherapy for Early-Stage Breast Carcinoma 
Cancer  2005;104(11):2499-2507.
Evidence suggests that women diagnosed with early-stage breast carcinoma may experience cognitive problems as a consequence of adjuvant chemotherapy treatment. The present study was conducted to examine whether there are differences in cognitive performance and cognitive complaints between women treated with and without chemotherapy for TNM Stage 0 to II breast carcinoma.
As part of a larger study on quality of life, women were recruited with newly diagnosed Stage 0 to II breast carcinoma scheduled to be treated with chemotherapy plus radiotherapy (n = 60) or radiotherapy only (n = 83). Six months after the completion of treatment, participants were administered a standard neuropsychologic battery to assess cognitive performance and a self-report measure to assess perceived cognitive problems.
There were no statistically significant differences between women who received chemotherapy and those who did not with regard to their average performance on tests of episodic memory, attention, complex cognition, motor performance, or language. Likewise, there were no significant differences between the treatment groups in the prevalence of impairment in each of these cognitive domains. Women who underwent chemotherapy also did not report significantly more problems with cognitive functioning than women treated without chemotherapy.
The findings failed to confirm previous reports suggesting adjuvant chemotherapy is associated with problems in cognitive functioning among women who receive treatment for Stage 0 to II breast carcinoma. Future research should use prospective longitudinal research designs incorporating appropriate comparison groups to further explore this issue.
PMCID: PMC2653200  PMID: 16247788
cognition; chemotherapy; stage; breast carcinoma
24.  Fatigue After Treatment for Early Stage Breast Cancer 
Cancer  2007;110(8):1851-1859.
Evidence suggests that fatigue may be a greater problem for cancer survivors than people without cancer. The present study sought to determine whether fatigue was greater in women who had completed treatment for early-stage breast cancer relative to a demographically matched comparison group of women with no cancer history.
As part of a larger study, women with stage 0-II breast cancer were recruited before the start of chemotherapy and radiotherapy (n = 100) or radiotherapy only (n = 121). Fatigue was assessed at the end of treatment and 2, 4, and 6 months later. An age- and geographically matched sample of women with no history of cancer was recruited and assessed for comparison purposes.
Relative to comparison subjects, breast cancer survivors reported more days of fatigue in the past week at all 4 study assessments (P < .05). These differences appeared to be clinically meaningful in that a greater percentage of patients than nonpatients earned scores in the abnormal range on this measure at each assessment (P < .05). Additional analyses indicated that differences in fatigue between patients and comparison subjects were attributable primarily to heightened fatigue in women who received both chemotherapy and radiotherapy.
Findings suggest that fatigue is a greater problem for breast cancer survivors in the 6 months after completion of chemotherapy than for women with no cancer history. Future research should include longer-term follow-up to determine the persistence of fatigue in this population of survivors.
PMCID: PMC2646727  PMID: 17847016
fatigue; breast cancer; adjuvant therapy; survivorship
25.  Use of a Case Definition Approach to Identify Cancer-Related Fatigue in Women Undergoing Adjuvant Therapy for Breast Cancer 
Use a proposed case-definition approach to identify the prevalence of cancer-related fatigue (CRF), demographic, clinical and psychosocial predictors of subsequent CRF, and psychosocial factors associated with concurrent CRF.
Patients and Methods
Women (n = 288) undergoing adjuvant therapy for early-stage breast cancer were recruited from two outpatient clinics. Women completed a baseline assessment before adjuvant therapy and a post-treatment assessment at the conclusion of an initial course of adjuvant chemotherapy or radiotherapy. At both assessments, women completed a clinical interview and measures of fatigue, distress, coping, and quality of life (QOL). The clinical interview consisted of modules from the Diagnostic and Statistical Manual of Mental Disorders Fourth Edition (DSM-IV) and a diagnostic interview to identify cases of CRF.
CRF prevalence at the baseline and post-treatment assessments was 10% and 26%, respectively. Multivariate analyses identified factors prospectively associated with greater risk for CRF at the post-treatment assessment, including receipt of adjuvant chemotherapy and a tendency to catastrophize in response to fatigue. Patients with and without CRF differed on a host of concurrent measures of fatigue, depression, functioning, and QOL with mean effect sizes in the range of 1.0 standard deviation.
CRF is a clinical syndrome experienced before and during adjuvant therapy for breast cancer. Results suggest CRF has a multifactorial etiology and support use of the proposed case definition approach to defining CRF. Future research is necessary to determine the scientific value of these criteria for understanding the etiology and management of fatigue in the oncology setting.
PMCID: PMC2562283  PMID: 16170168

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