Quality-of-Life is Better for Older Patients With Early Breast Cancer
Quality-of-Life is Better for Older Patients With Early Breast Cancer
Abstract & commentary
Synopsis: In this study, women with early stage disease completed a questionnaire that included measures of quality-of-life and depression. Approximately half of the patients were younger than 50 years of age and half older than 50 years of age.
Source: Wenzel LB, et al. Cancer 1999;86:1768-1774.
Quality-of-life was compared in younger vs. older women with breast cancer just after completion of therapy for early breast cancer. The data were derived from the initial interviews with breast carcinoma patients that had enrolled in a clinical trial of psychosocial telephone counseling.1 The current assessment was made by written questionnaire, which included standardized measures of quality-of-life including the Functional Assessment of Cancer Therapy-Breast instrument (FACT-B), the Center for Epidemiologic Studies of Depression Scale (CES-D), and the Impact of Event Scale.2-4
Of 354 patients invited to participate, 304 (86%) agreed and completed the questionnaires. Fifty-three percent were younger than 50 years of age. The demographic profile indicated that most of the women were white, educated, married, and employed outside of the home. The older women (age > 50) were similar, except they were less likely to have received a college education and be employed full time, but were more likely to report additional chronic health problems and be widowed.
The majority of patients enrolled had early stage disease (tumor classified as T2 or less and no positive lymph nodes). However, there were rather striking treatment differences, with the younger patients more likely to have received chemotherapy and the older patients more likely to have received tamoxifen. There was no significant difference in the type of surgery (lumpectomy vs mastectomy), yet younger women were more likely to receive immediate reconstruction.
The FACT-B quality-of-life instrument revealed a significantly better quality-of life for the older patients, particularly with regard to the measures of emotional well-being and certain breast cancer specific items. Furthermore, no significant age-specific differences emerged with respect to sexual functioning and body image.
Similarly, there were age-related differences in "clinical levels" of distress. Younger women were more likely to experience depressive symptoms and breast carcinoma-specific intrusive and avoidant thoughts, with scores on the CES-D indicating a significant number experiencing levels of distress of clinical importance. For example, 32% of younger patients experienced depressive symptoms in the clinically important range (CES-D scores > 16) compared to 20% of patients older than 50 years of age (P = 0.041). The scores for the younger patients suggested that they exhibited depressive symptoms to a greater extent than normal for that age population. The older patients did not appear to be more depressed than similarly aged women without breast cancer.
COMMENTARY
This report confirms what many practitioners would have predicted, older women are less devastated by a diagnosis of breast cancer. In this study, all of the women had early stage disease and had just completed initial therapy. The younger women were more likely to have received chemotherapy and the older women hormonal therapy. This fact alone could explain some of the observed differences. Fatigue, malaise, nausea, the common chemotherapy side effects most certainly would contribute to impaired quality-of-life and depression, especially immediately after treatment, which was when this study was conducted. However, whatever the cause, it is hard to refute the conclusion of Wenzel and colleagues that younger women with breast cancer are at high risk to have adversely affected quality-of-life and depression. Accordingly, this age cohort might be preferentially selected for targeted interventions, such as the counseling program that is now being investigated.
The question of the influence of age on the development of cancer-related disruption of quality-of-life and depression cannot be fully addressed by the current study, primarily because of the treatment differences noted. Furthermore, the disease might be different in younger patients, and this itself might influence these developments. Older women are more likely to have less aggressive tumors, fewer negative prognostic factors, greater hormone receptor expression, etc., and this may influence well-being in ways that we are unable to define.5
A study designed to address the influence of age (independent of chemotherapy and tumor characteristics) would have to control for all of these factors—and that would be a monumental undertaking. If one were to design such a study, from a gerontological perspective, more disparate age groups should be identified. It would be interesting to compare women older than 70 years of age (close to the majority of breast cancer patients) with those who are clearly premenopausal (< 40 years of age at presentation) and those in the intermediate ages (41-55 and 56-69 years of age).
It is unlikely that such a study could or would be done. Yet, from a practical point of view, we can accept the current findings, and resist the temptation to overinterpret them. Young women with breast cancer are more likely to sustain a negative psychological effect, and this should be taken into consideration, both by attending physicians and staff, and by those intending to investigate new psychological and social interventions.
References
1. Marcus AC, et al. Psychooncology 1998;7:470-482.
2. Cella DF, et al. J Clin Oncol 1993;11:570-579.
3. Radloff D. J Appl Psychol Measurement 1977;1: 385-401.
4. Horowitz M, et al. Psychosom Med 1979;41:209-218.
5. Hillner BE, et al. Breast Cancer Res Treat 40;1996: 75-86.
Which of the following statements about quality-of-life in patients with early stage breast cancer can be stated with confidence based on the evidence?
a. Younger patients are more likely to sustain disruption of their quality-of-life when compared to older women.
b. Older patients have poorer quality-of-life than younger patients, but have less impairment created by cancer therapy.
c. Younger patients have poorer quality-of-life than older patients, but the effect is clearly due to the fact that they are more likely to receive chemotherapy.
d. Cancer therapy influences quality-of-life in a negative way but there is no age difference (younger patient vs older patient) in this negative effect.
e. Older patients have more treatment-related toxicity than younger patients.
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