Dissertations / Theses on the topic 'Breast cancer survivors'

In Australia, women with breast cancer comprise one of the largest groups of cancer survivors. As a consequence of this, and improved survival rates, the interest in programs to enhance the recovery of cancer survivors is growing. Exercise during and after treatment has been identified as a potential strategy to assist women throughout their treatment and positively influence the recovery and health-related quality of life (HRQoL) of breast cancer survivors. Through the use of an existing data source, this study investigated physical activity rates, explored the factors associated with low levels of physical activity participation, and assessed the relationship between levels of activity and HRQoL among women diagnosed with breast cancer. The population-based sample, obtained in 2002 was comprised of 287 women newly diagnosed with breast cancer, residing in South-East Queensland. Women were followed-up (via subjective questionnaire and objective physical testing) every three months over a 12-month period, from six months post-diagnosis. Physical activity was assessed using the Behavioural Risk Factor Surveillance System (BRFSS) while HRQoL was assessed using the Functional Assessment of Cancer Therapy for breast cancer (FACTB+4). Based on National Physical Activity Guidelines, women were categorised as being sufficiently active, insufficiently active or sedentary at each of the five testing phases (specifically at 6-, 9-, 12-, 15- and 18-months post-diagnosis). Rates of participation in physical activity were relatively stable over the testing period. At 18 months post-diagnosis, 44%, 43% and 13% of women, respectively, were categorised as being sufficiently active, insufficiently active or sedentary. The sedentary or insufficiently active women were more likely to be older, obese or overweight, lack private health insurance, and have received both chemotherapy and radiotherapy, compared with sufficiently active women. Sedentary women consistently reported a lower HRQoL compared to active women (sufficiently or insufficiently active) over the 12-month testing period. This was especially apparent amongst the group of younger women (aged less than 50 years at diagnosis) (p=0.02). This work is among the first to explore physical activity rates specifically among Australian breast cancer survivors, and highlights the potential importance of participating in physical activity to optimise HRQoL during recovery from breast cancer. Specific attention to promote physical activity to the identified group of sedentary and insufficiently active survivors is of particular importance.

In Australia, women with breast cancer comprise one of the largest groups of cancer survivors. As a consequence of this, and improved survival rates, the interest in programs to enhance the recovery of cancer survivors is growing. Exercise during and after treatment has been identified as a potential strategy to assist women throughout their treatment and positively influence the recovery and health-related quality of life (HRQoL) of breast cancer survivors. Through the use of an existing data source, this study investigated physical activity rates, explored the factors associated with low levels of physical activity participation, and assessed the relationship between levels of activity and HRQoL among women diagnosed with breast cancer. The population-based sample, obtained in 2002 was comprised of 287 women newly diagnosed with breast cancer, residing in South-East Queensland. Women were followed-up (via subjective questionnaire and objective physical testing) every three months over a 12-month period, from six months post-diagnosis. Physical activity was assessed using the Behavioural Risk Factor Surveillance System (BRFSS) while HRQoL was assessed using the Functional Assessment of Cancer Therapy for breast cancer (FACTB+4). Based on National Physical Activity Guidelines, women were categorised as being sufficiently active, insufficiently active or sedentary at each of the five testing phases (specifically at 6-, 9-, 12-, 15- and 18-months post-diagnosis). Rates of participation in physical activity were relatively stable over the testing period. At 18 months post-diagnosis, 44%, 43% and 13% of women, respectively, were categorised as being sufficiently active, insufficiently active or sedentary. The sedentary or insufficiently active women were more likely to be older, obese or overweight, lack private health insurance, and have received both chemotherapy and radiotherapy, compared with sufficiently active women. Sedentary women consistently reported a lower HRQoL compared to active women (sufficiently or insufficiently active) over the 12-month testing period. This was especially apparent amongst the group of younger women (aged less than 50 years at diagnosis) (p=0.02). This work is among the first to explore physical activity rates specifically among Australian breast cancer survivors, and highlights the potential importance of participating in physical activity to optimise HRQoL during recovery from breast cancer. Specific attention to promote physical activity to the identified group of sedentary and insufficiently active survivors is of particular importance.

Thesis (Ph.D.)--Indiana University, 2008.
Title from screen (viewed on June 1, 2009). School of Nursing, Indiana University-Purdue University Indianapolis (IUPUI). ADVISOR(S): Janet S. Carpenter. Includes vita. Includes bibliographical references (leaves 227-243).

Cancer-related fatigue (CRF) is a persistent and debilitating problem for many breast cancer survivors. Although many CRF measurement tools are available, no consensus exists on the most appropriate tool to use for breast cancer survivors. The purpose of this project was to identify the best method of assessing CRF in breast cancer survivors. The practice-focused question inquired about the most appropriate way to assess fatigue in breast cancer survivors. The central concepts of the project were CRF and cancer survivorship. This project was informed by the theory of health as expanding consciousness and Mishel's theory of uncertainty in illness. The sources of evidence included multi-database searches and literature from professional organizations. Results were tracked using preferred reporting items for systematic reviews and metasystems and a literature review matrix. The search identified 14 sources, which were assessed for quality using the grading of recommendations, assessment, development, and evaluation process. The results of this systematic review did not support the use of any particular assessment tool; however, 2 clinical practice guidelines recommended screening using a numerical severity scale followed by detailed assessment of clinically significant fatigue using available assessment tools. Screening can be implemented into the survivorship clinic, allowing nurses to identify potentially clinically significant fatigue so that further workup is done and interventions are implemented. Identifying, assessing, and intervening for clinically significant fatigue can improve the quality of life for breast cancer survivors, contributing to positive social change.

Background: Trastuzumab, a HER2 antagonist, has been shown to improve rates of overall survival in patients with HER2-positive breast cancer. However, cardiotoxic effects associated with treatment limits these benefits. Due to an increase in survival years, women with a history of HER2-positive breast cancer might be at increased risk of developing cardiotoxicity (i.e., LVEF < 55% with or without accompanying symptoms of heart failure) during survivorship. Exercise (“stress”) conditions is an established method to examine comprehensively impairments in cardiovascular function that may go undetected during resting conditions providing insight into the risk for future cardiac events. Purpose: We sought to assess cardiac and vascular function of HER2-positive breast cancer survivors at rest and under exercise conditions. Hypothesis: 1) At rest, vascular dysfunction would be evident in breast cancer survivors. 2) Exercise would reveal cardiac dysfunction in HER2-positive breast cancer survivors, which was not apparent under resting conditions. Methods: Eight HER2-positive breast cancer survivors and eight age-matched healthy controls underwent the following measures: 1) resting vascular function (Applanation tonometry, pulse wave velocity and baroreceptor sensitivity) and cardiac function (2D-echocardiography), 2) exercise haemodynamics (heart rate, stroke volume, cardiac output) during an incremental exercise test, and 3) ventricular-vascular coupling (left ventricular elastance and arterial elastance) at rest and during incremental exercise. Results: At rest, there were no differences between groups in any echocardiographic measures. No differences were detected in vascular function, although baroreceptor sensitivity was reduced in the breast cancer group. Resting ventricular-vascular coupling was also similar between groups. With exercise, there was evidence of reduced left ventricular performance with a blunted response to increase left ventricular elastance. No differences were observed in arterial elastance or ventricular-vascular coupling. All haemodynamic responses were similar between groups. Conclusion: In HER2-positive breast cancer survivors there are indicators of impairments in cardiac function during exercise conditions, but limited differences during resting conditions. Exercise echocardiography may be clinically relevant for detecting impairments in left ventricular function in HER2-positive breast cancer survivors that appear to have normal cardiac function at rest.
Medicine, Faculty of
Medicine, Department of
Experimental Medicine, Division of
Graduate

Quality of life (QoL) in cancer survivors is an important area of research. While data are available about QoL and breast cancer, there is a paucity of research regarding older breast cancer survivors. The purpose of this research was to examine QoL in older women with early stage breast cancer, within the first year of post-treatment survivorship. The specific aims of this study were to: 1) Describe the changes in overall QoL and the four QoL domains of Physical, Psychological, Social, and Spiritual well-being; 2) Examine the effects of a psychoeducational support intervention on QoL outcomes in older women; and 3) Describe nurses' perceptions of their interactions with older breast cancer survivors. A descriptive, longitudinal design was used to answer the research questions. Data for this study were drawn from the Breast Cancer Education Intervention (BCEI), a longitudinal psychoeducational support intervention for women with early stage breast cancer. Fifty women from the BCEI who were 65 years of age and older were included in this sample, of whom 24 were assigned to the Experimental (EX) Group and 26 were assigned to the Wait Control (WC) Group. Data were collected at three time points: baseline, three months, and six months after study entry. Measurement tools included the BCEI Demographics Form, the Quality of Life-Breast Cancer Survey (QoL-BC), and field notes of the BCEI Research Nurses. The QoL-BC survey is a 50-item scale that measures QoL in women with breast cancer. Descriptive statistics, Generalized Estimating Equation (GEE) methods and t-tests were used to answer research questions #1 and #2. Content analysis was used to answer research question #3. Subjects reported good overall QoL at baseline, but QoL declined over six months. Physical and Psychological well-being declined from baseline to six months later. Social well-being initially improved from baseline to three months but declined at six months. Spiritual well-being initially declined at three months and improved at six months. There was insufficient power to detect a difference in the effects of the BCEI Intervention between the two groups. However, the decline in overall QoL was less in the EX Group. Field notes focusing on nurses' perception of their interactions with older women revealed four themes. These themes include: continuing breast-related health, personal health issues, family health issues, and potential stressors. Results from this study suggest that: 1) changes in overall QoL and within the four QoL domains occur over time; 2) decline in overall QoL was lessened by the BCEI Intervention; and 3) concerns after treatment are both breast cancer and non-breast cancer related. Study findings can direct future research in the following areas: 1) identification of specific concerns within each QoL domain that could lead to an increase or decrease in well-being in older breast cancer survivors; 2) interventions tailored to the needs of older breast cancer survivors to maintain, improve, or lessen decline in QoL after treatment; and 3) reconceptualizing QoL in older breast cancer survivors to include non-cancer related factors.
Ph.D.
School of Nursing
Other
Nursing PhD

Parenting is a primary role for many young breast cancer survivors and the combined effect of parenting while coping with this disease can be problematic for many of them. Despite this, little is known about the impact of parenting on the well-being of young breast cancer survivors. This thesis, comprising two studies in article format, explores this question. In the first study, we identified elements of well-being that are salient for all young women with breast cancer, and which also captured some of the unique challenges associated with parenting as a survivor. Using factor analysis techniques, we determined how these elements interrelated in separate groups of young survivors with children and without, and identified differences between the two groups based on the patterns observed. We found that the interrelationship among elements of well-being varied between these two groups: psychological distress (representing mental health and perceived stress), illness intrusiveness, and fear of cancer recurrence were found to co-occur more frequently in mothers than in young survivors without children, thus compromising their well-being. Our second study had two objectives. The first part examined differences in perceived stress, illness intrusiveness, and fear of cancer recurrence between young breast cancer survivors with and without children in two separate timeframes (0-5 and 5-15 years since diagnosis). The second part identified predictors for these elements of well-being in young mothers exclusively. Compared to survivors without children, young mothers reported higher levels of fear of cancer recurrence and illness intrusiveness in intimate life domains during both timeframes, suggesting that disruptions in these areas persist over time. Part two revealed that mothers with adolescent children and high levels of parenting stress were most likely to report perceived stress and illness intrusiveness. A mother’s age and the time since her diagnosis predicted fear of cancer recurrence and illness intrusiveness, respectively. Results from this thesis indicate that young mothers with breast cancer need screening and interventions to manage psychological distress, fear of cancer recurrence, and illness intrusiveness, particularly in intimate life domains. This thesis also identifies the most vulnerable groups of mothers and has important implications for future research.

The level of encouragement provided to female African American breast cancer survivors post-diagnosis by their medical providers to engage in physical activity and the amount of their current physical activity levels was investigated. Six female San Francisco Bay Area breast cancer survivors were interviewed to determine their levels of physical activity pre and post diagnosis and the level of encouragement they received from their medical providers to engage in physical activity.

Receiving a breast cancer (BC) diagnosis generates significant physical and psychological stress that may persist months, years, or even decades beyond treatment completion. Such chronic stress can severely alter the biological systems of BC survivors (BCS). Yet, little is known about the impact and associated variables of these long-term physiological sequelae. Considering that the number of BCS continues to grow each year, it is imperative to assess the extent to which a BC experience impacts human physiological mechanisms by examining the secretion patterns of associated stress- and immune-related biomarkers and by exploring the behavioural, physical, and psychological variables implicated in these dysregulations. Such research is of particular importance in order to guide cancer survivorship care and develop interventions promoting optimal health outcomes in BCS. This research program sought to address this through three inter-related studies. Study One was a quasi-experimental design study examining both the diurnal and reactive concentration patterns of secretory immunoglobulin A (SIgA) in a sample of women with (n = 22) and without a prior history of BC (n = 26). SIgA concentration patterns were contrasted to concentration patterns of cortisol and salivary alpha-amylase (sAA) in the same individuals (complementary to two previously published studies). Participants supplied saliva samples at five time points on two consecutive typical days (for diurnal data) and at seven time points before, during, and after an acute laboratory stressor (for reactive data). Results reveled no evidence of uncharacteristic SIgA diurnal or reactive concentration patterns, suggesting a normal and well-functioning immunological SIgA system in BCS on average 4.6 years post-diagnosis. Study One acted as a summary article allowing readers to grasp the "big picture" of long-term physiological dysregulations in BCS as a whole. Building on this, Study Two, which used the same dataset as Study One, aimed to determine whether physical activity (PA) could mitigate the adverse physiological effects of a BC experience in BCS (n = 25), as indexed by their cortisol concentration patterns. Participants self-reported their PA frequency and engaged in the same cortisol assay protocol reported in Study One. Results indicated no statistically significant differences in diurnal and reactive cortisol patterns between low- and high-PA groups. A trend that PA might not have the same effect on women with and without a history of BC was noted. Important limitations to Study Two included the small sample size and the lack of sensitivity and objectivity of the PA measure. To address Study Two’s limitations and to consider a wider range of modifiable variables that could contribute to the physiological dysregulations observed in BCS, Study Three aimed to assess the predictive value of six behavioural, physical, and psychological variables on the physiological effects of a BC experience, as indexed by cortisol (n = 192) and C-reactive protein (CRP; n = 168) levels over the first 1.5 year post-treatment. CRP, a biomarker that had not been considered so far in this research program, allowed to assess systemic inflammation in BCS post-treatment. Study Three also aimed to describe naturally occurring changes in cortisol and CRP levels and assess whether they changed in tandem. Data were drawn from 201 BCS who provided capillary blood and saliva samples at approximately 3.5 months post-treatment and again 3, 6, 9, and 12 months later. At each time point, participants also completed self-report questionnaires and wore an accelerometer for seven consecutive days. Multilevel modeling analyses revealed no significant change over time for cortisol levels post-treatment and a non-linear trajectory of change for CRP levels which was not predicted by cortisol levels. Associations between cortisol and sedentary time as well as associations between CRP and PA, body mass index, and health- and cancer-related stress were found. Collectively, these three inter-related studies uniquely add to the literature by describing long-term physiological trajectories of stress- and immune-related biomarkers in BCS. This research program attempts to gain a better understanding of the underlying mechanisms that tie behavioural, physical, and psychological variables and biomarker secretion to a BC experience. It also offers opportunities to identify women at greater risk of physiological dysregulations following a BC experience. This represents an important step towards the development of tailored interventions targeting specific BCS that most warrant them. With the number of BCS climbing each year, cancer survivorship needs to be a priority in research and efforts to better understand, monitor, and mitigate the physiological consequences of a BC experience are critical.

Thesis (Ph. D.)--University of California, San Diego and San Diego State University, 2009.
Title from first page of PDF file (viewed July 14, 2009). Available via ProQuest Digital Dissertations. Vita. Includes bibliographical references.

The aim of this study is to describe breast cancer survivors' experiences and the associated meanings participating in their important activities during and after breast cancer treatment and the relationship among the survivor, environment, occupation, and performance, using a concurrent mixed method design. Ten survivors between the ages of 45 and 64 with Stage I, II, or III breast cancer who had been treated consecutively with surgery, chemotherapy, and radiation therapy were recruited for the study. Each survivor completed the Activity Card Sort-modified scoring system (ACSm) during the first and last week of radiation therapy and 3 and 6 months post radiation therapy. Additionally, each survivor participated in a semi-structured interview at the end of radiation therapy and 6 months afterwards. Qualitative data was analyzed using interpretative phenomenological analysis (IPA) to understand the survivors' experiences participating in their most important activities. The means and standard deviations of the proportion of activities resumed for the participants' global and category activities were calculated at each time point. A desire to resume participation in meaningful activities emerged from the data and demonstrated the interrelationship between environment, person, and occupation. Themes from the last week of radiation were (a) individual outlook influences how activities are approached, (b) social support reduces the stress of life, (c) side effects influence how activities are completed, and (d) personal and treatment stresses and struggles influenced their perspectives on life. At 6 months post radiation therapy, the themes were (a) emotional effect on activities, (b) life after cancer has changed due to cancer diagnosis and treatment, and (c) side effects continue to influence daily activities. Using the seven stages of analyzing mixed method data developed by Onwuegbuzie and Teddlie (2003), the qualitative and quantitative data were integrated. The results illustrated that the participants resumed a greater proportion of instrumental activities, which were reported consistently as one of their five most important activities. Additionally, supportive extrinsic factors appeared to be more influential in resuming participation important activities than intrinsic factors. Findings from this study support using the Person-Environment-Occupational-Performance (PEOP) model to develop treatment plans for women undergoing or recovering from breast cancer treatment.

This study offers a brief review of the literature on resilience. The review served as a basis for designing a qualitative study to observe how resilience develops in survivors of breast cancer. Survivors are those who lead productive, satisfying and/or inspirational lives, after their treatment has ended. By using qualitative data collection methods and post hoc data analysis, a purposive sampling of 11 women, in the Midwest, resilient survivors of breast cancer were studied. These women were asked to write brief autobiographies, detailing the important factors and contexts that were evidence of the development of resilience in themselves. Tape recorded interviews allowed participants to add to or delete from their autobiographies.The findings showed the eleven participants shared six common characteristics: (1) making a spiritual connection; (2) having meaningful work; (3) engaging in social activism; (4) being a self-directed learner; (5) living a healthy lifestyle; and (6) expressing a wide range of feelings. In addition, the taped interviews revealed the importance of creativity and authentic relationships. A resilience wheel illustrates the definition of resilience, i.e., as a positive attitude about one's body, mind, spirit and emotions, manifested by living a healthy lifestyle; engaging in meaningful work; forming and maintaining authentic relationships; and-expressing a wide range of feelings appropriately. The study demonstrated resilience is more than effective coping. It is observed and characterized by others as a zest for life.Among these participants, resilience/zest for life was found to have developed in their youth, when they identified with a positive role model/s, who modeled resilient attitudes/values. As children they internalized these values, acting on them in small ways, until adulthood when a life event triggered a shift. As adults they, then, claimed these internalized values as "my own philosophy."Although there was not sufficient evidence to discuss resilience as a developmental process in adulthood, the ages of the participants (40-77) imply the process of learning and growing continues throughout the life span.Suggestions for teaching resilience are offered along with recommendations for future research.
Department of Educational Leadership

Younger breast cancer survivors often report problems related to sexuality following surgical and adjuvant treatment that often lead to sexual distress and body image distress. This research was conducted as an exploratory study within a larger R01 trial with the purpose to evaluate sexual distress and body image related-distress in younger women with breast cancer and to examine the extent to which the Mindfulness-Based Stress Reduction-Breast Cancer (MBSR(BC)) was efficacious in improving distress related to sexuality, i.e. sexual distress and body image related-distress. The aims of this study were to: 1) evaluate the efficacy of the MBSR(BC) program in improving the psychological symptoms of sexual distress and body image related distress; and 2) evaluate whether positive effects achieved from the MBSR(BC) program are modified by specific patient characteristics measured at baseline. Ninety-one participants were randomized to either the MBSR(BC) intervention or Usual Care (UC) and assessments were conducted at baseline, 6-week and 12-week follow-up for sexual distress, body image related distress, demographic data as well as clinical history. For aim 1, analysis of covariance (ANCOVA) and linear mixed model (LMM) analysis were the methods used to evaluate the efficacy of the MBSR(BC) program. For aim 2, ANCOVA and stepwise multiple linear regression were used to evaluate the patient characteristics at baseline that modified the effects achieved from the MBSR(BC) program. Results showed the mean age of the sample was 57 years and 74% were White, non-Hispanic. Chi square analyses found that there were no significant differences between the MBSR(BC) and UC groups on baseline demographic or clinical characteristics. For Aim 1, results of the ANCOVA analyses found that there was no significant difference between the MBSR(BC) and UC groups at the 6-week follow-up on sexual distress or body image related distress (both p > .05). However, ANCOVA analyses found that there was a significant relationship between baseline scores and scores at the 6-week follow-up for both sexual distress (p < .0001) and body image related distress (p < .0001). Further ANCOVA analyses for Aim 1 found that there was a trend towards a statistical significance for the difference between the MBSR(BC) group and UC groups at the 12-week follow-up for both sexual distress (p = .09) and body image related distress (p = .06). Results of the Linear Mixed Model (LMM) analyses, implemented to assess sexual distress over time, showed a significant main effect (ME) of time (p < .000) and a trend towards significance for the time by assignment interaction (p = .104). The LMM analyses for body image disturbance resulted in a significant ME of (p < .000) and an interaction that approached significance (p = .071). For aim 2, ANCOVA results found that age at baseline was a significant predictor of change at 6 weeks in levels of body image related distress (p = .007), but no relationship was observed for sexual distress. Further, analysis using a stepwise multiple linear regression analysis found age at baseline to be the only significant predictor of both baseline sexual distress (p = .004) and baseline body image related distress (p = .008). Although the MBSR(BC) program was not tailored for integrating sexuality content, results of this stress reducing program (MBSR(BC)) program, adapted for breast cancer survivors, appeared to benefit these young women. The findings of this study identify that there is a need for stress reducing interventions addressing problems related to sexual distress and body image related distress. In addition, these results identified that clinically, BCS should be assessed for sexual distress and body image disturbance post-treatment, and interventions to assist with this distress should be incorporated into their plan of care.

Abstract Despite documented health benefits, most breast cancer survivors (BCS) do not meet physical activity (PA) guidelines. Hence, evaluating diverse intervention approaches to promote PA in BCS is imperative. Motivational Interviewing (MI) offers a non-prescriptive, client-centered approach to PA promotion that has not been adequately evaluated in BCS. In this randomized-controlled trial, 66 Stage 0-IIIa BCS within three years post-treatment, insufficiently active and contemplating increasing PA were randomly assigned to a MI intervention or an active control condition. The MI intervention implemented motivational and behavior change strategies consistent with MI principles. The active control condition provided education and prescriptive recommendations on diet, PA, and stress management. Participants completed two in-person and one phone-based sessions over 4 weeks. Outcomes were assessed at baseline, 6-week, and 12-week follow-up. The primary outcome was efficacy of the MI intervention to promote PA. Contrary to the hypothesis that the MI intervention would be superior, PA improvements were evident for both groups, with 60% of all participants meeting PA guidelines at 12-week follow-up. Secondary outcomes involved intervention effects on depressive symptoms, fatigue, vigor, and aerobic fitness. Contrary to hypotheses, improvements in secondary outcomes were evident for both groups. Exploratory moderation analyses yielded no group differences in PA outcomes based on baseline activity level, perceived stress, age, or body mass index. Exploratory mediation analyses indicated that the relationships between group assignment and change in secondary outcomes were not mediated by change in PA. In analyses of the combined sample, higher baseline aerobic fitness predicted greater improvement in PA over time. Overall, results suggest that diverse intervention approaches can help promote PA in BCS. Future research should evaluate long-term maintenance of gains and theoretical mechanisms of the intervention effect.

The purpose of this cross-sectional, secondary data analysis was to explore, non-modifiable (stable) trait factors and modifiable (transient) state factors associated with fear of recurrence (FOR) in breast cancer survivors. Antecedent trait factors included demographic, clinical, social/behavioral factors, postulated mediator state factors included pain, fatigue, sleep disturbances, depression, state anxiety and perceived stress, and FOR was the outcome variable. The study used baseline data from an R-21 NCI funded (grant #R21CA109168) randomized control trial that examined the effects of mindfulness based stress reduction in early stage breast cancer recovery. Instruments from this study for antecedent variables (trait factors) included a Demographic and Clinical History Form, STAI; instruments used for mediator variable (state factors) included CES-D, STAI, PSS and MDASI subscales for pain and fatigue, sleep; the instruments used for the outcome variable FOR - CARS overall fear and nature of worry. The study sample included 82 women within 18 months post breast cancer treatment (stage 0, I, II, III). The Theoretical Model for psychosocial nursing research was used as a heuristic framework to examine the associations between trait factors and state factors and their mediating effects on FOR. Aim 1 explored the relationship between the antecedent (trait) variables associated with FOR (CARS overall fear and CARS nature of worry) using Pearson's and Spearman's correlations and analysis of variance (ANOVA). The findings revealed a negative association between age and FOR, CARS overall fear (r = -.236, p = .033) and FOR, CARS nature of worry (r = -.269, p = .015). Trait anxiety was positively associated with FOR, CARS overall fear (r = .433, p = .000) and FOR, CARS nature of worry (r = .358, p < 0.001). Race/ethnicity, education, marital status, employment, exercise, cancer stage, cancer treatment, exercise, smoking, drinking, hormone use and family history of breast cancer were not associated with FOR. Aim 2 explored the relationship between postulated mediator (state) variables, such as pain, fatigue, sleep disturbances, state anxiety, depression, perceived stress associated with FOR (CARS overall fear and CARS nature of worry) using Pearson's correlations. Findings revealed that depression (r = .347, p = .001), state anxiety (r = .467, p < 0.001), perceived stress (r = .365, p = .001) were positively associated with FOR, CARS overall fear of recurrence, and that pain (r = .220, p = .047), fatigue (r = .247, p = .025), state anxiety (r = .369, p = .001), and perceived stress (r = .410, p < 0.001) were positively associated with FOR, CARS nature of worry. Aim 3 used a mediation analysis (bootstrapping method) to examine the indirect effects of the statistically significant modifiable mediator state factors on the statistically significant antecedent trait factors and FOR (CARS overall fear and CARS nature of worry). With trait anxiety as the antecedent variable, state anxiety was indirectly associated (a mediating variable) with FOR, CARS overall fear (β = .1381, 95% CI = .0053 - .3050, p = .0299). Similarly, with a composite age/trait anxiety antecedent variable, state anxiety was indirectly associated (a mediating variable) with FOR, CARS overall fear (β = .5579, 95% CI = .1201 - 1.1669, p = .0157). Perceived stress and depression did not mediate the relationship between age and trait anxiety and concerns about recurrence overall fear. With trait anxiety as the antecedent variable, perceived stress was indirectly associated (a mediating variable) with FOR, CARS nature of worry (β = .5474, 95% CI = .0178 - 1.3298, p = .0294). Similarly, a composite age/trait anxiety antecedent variable, perceived stress was indirectly associated (a mediating variable) with FOR, CARS nature of worry (β = 2.0375, 95% CI = .1136 - 4.5976, p = .0495). Pain, fatigue and state anxiety did not mediate the relationship between age and trait anxiety and FOR nature of worry. This study suggests that breast cancer survivors who are anxious at baseline and report a current state of anxiety or perceived stress may be at higher risk for fears of breast cancer recurrence. Understanding the individual patient characteristics such as age, history of anxiety and current status of perceived stress or anxiety and the relationship with fears of recurrence allow nurses to offer individualized interventions for patients at greatest risk for psychological distress.

The purpose of this study was to assess fear of cancer recurrence (FCR) in breast cancer survivors returning for regularly scheduled follow-up mammograms. FCR was hypothesized to increase prior to the mammogram, decrease from immediately pre- to immediately post-mammogram, and then increase following the mammogram. Based on the cognitive-behavioral model (CBM) of health anxiety, greater perceived risk of recurrence, worse perceived consequences of a recurrence, lower coping self-efficacy, and more engagement in reassurance-seeking behaviors were hypothesized to be associated with greater FCR in each time segment. Finally, exploratory analyses evaluated the various trajectories in FCR over time using growth mixture modeling and the CBM to predict class membership. The sample comprised 161 women who completed treatment for stage 0-IIIA breast cancer between 6 and 36 months previously. Participants completed the following measures at least 31 days prior to the scheduled mammogram: perceived risk and perceived consequences of breast cancer recurrence, treatment efficacy beliefs, coping self-efficacy, and reassurance seeking behaviors. Participants reported FCR at one month, one week, and immediately prior to the mammogram as well as one month, one week, and immediately after the mammogram using visual analogue scales (VAS) to rate anxiety and worry about cancer recurrence, the Cancer Worry Scale (CWS), and the Fear of Cancer Recurrence Inventory (FCRI). State anxiety and reassurance post-mammogram were also assessed. FCR significantly changed over time with increases in CWS scores prior to the mammogram, a significant decline on the VAS observed immediately following receipt of results, and a significant increase on the VAS, and decrease in reassurance during the month following the mammogram. The CBM did not significantly predict change in FCR over time, but certain variables did predict fluctuations including coping-self efficacy and perceived risk in the expected directions. Finally, growth mixture models revealed two classes, high-FCR and low-FCR, which were predicted by the CBM. These study findings support the use of the CBM in predicting which cancer survivors experience greater FCR and indicates that CBM-driven interventions may prove beneficial for reducing distressing FCR.

Latina breast cancer survivors, especially those who have undergone chemotherapy, may face major disruptions to their diet and eating habits; and a major concern is their ability to function in daily life roles throughout survivorship. Food and nutrition are suggested to be significant factors that can influence the process of cancer development, yet little research has been done to understand the nutritional needs, roles, and expectations among Latina breast cancer survivors. The purpose of this study was to understand Latina breast cancer survivors’ perceptions of the role of diet and nutrition in helping them cope with the effect of chemotherapy treatment. This study was guided by the Transactional Model of Stress and Coping and employed a qualitative research design. A purposive sample of Latina breast cancer survivors (n=32), caregivers identified by the survivors (n=8), and key informants (n=6) were interviewed in their language of preference (Spanish or English) using a semi-structured, open-ended interview guide that explored how coping with a cancer diagnosis influences cancer survivors and caregivers’ nutritional needs and practices. The data were analyzed using an inductive approach to develop an a priori codebook. Thematic analysis was performed using MAXQDA, and emergent codes were added as appropriate. The results yielded that Latina breast cancer survivors emphasized the value and meaning of nutrition; this was accomplished by increasing their nutritional awareness to restore health, improve the body’s immunity, and regain/maintain agency and control of their food consumption. Food provided by friends and family, assistance from nutritional organizations, doctors’ recommendations, and negative chemotherapy side effects influenced Latina breast cancer survivors and caregivers’ decisions about diet and nutrition during and after treatment. Negative chemotherapy side effects and positive support from husbands, family members, and friends affected the role of Latina women as the ‘nutritional gatekeepers’ in the family, since breast cancer diagnosis and treatment disrupt or limit the role of Latinas within the household unit. Findings from the interviews with Latina breast cancer survivors, caregivers, and key informants indicated that cultural expectations among this population shape the kinds of support and assistance that are provided by family members. Lastly, this research study revealed unmet information needs: Latina breast cancer survivors relied on organizational and online nutrition-related resources but identified a gap in culturally and linguistically tailored information related to diet and nutrition following diagnosis. The study concluded that Latina breast cancer survivors and caregivers mentioned no routine dietary assessment for cancer survivors after beginning chemotherapy and during treatment. Additionally, caregivers specified needing instrumental support to better meet the nutritional needs of Latina breast cancer survivors. This study added to our understanding of Latina breast cancer survivors’ unmet needs that could contribute to the creation of future nutrition education programs and interventions most appropriate during cancer survivorship for diagnosed individuals and their caregivers.

Comorbid chronic insomnia was found highly prevalent in breast cancer patients. It also persisted through survivorship. Negative emotions upon diagnosis and during the course of cancer treatment might complicate the underlying mediating factors between stress and insomnia found in non-cancer population. Cognitive Behavioural Therapy (CBT) has been evidenced in improving insomnia. With the appreciation of Mindfulness training in improving cognitive flexibility and rumination, a novel treatment approach integrating CBT and mindfulness—Mind-Body Intervention (MBI) was developed. 　　　There were three objectives in the research. Firstly, prevalence data on insomnia and clinical profile of Hong Kong Chinese breast cancer survivors were obtained. Secondly, the mediating roles of negative emotions, hyperarousal, pre-sleep arousals in the relationship between perceived stress and insomnia were examined. Thirdly, the effects of CBT and MBI for breast cancer survivors with insomnia were investigated. 　　　In the first study, 1049 women who survived from non-metastatic breast cancer were invited to complete a survey on stress, mental health, arousals and insomnia. Those who met psychophysiological insomnia were invited to participate in the second study, which was a multisite randomized controlled trial. The 73 participants were allocated to CBT (n=24), MBI (n=27) or waiting list control, WLC (n=22). Both treatments were five weekly-session group therapies. Outcomes on insomnia, mental health, arousals, dysfunctional beliefs, quality of life and mindfulness, were obtained on baseline, post-treatment, 3-month and 6-month follow-ups. 　　　Results of the first study revealed 34.6% of the participants suffered from clinical insomnia, while 15.1%, 27.4% and 12.8% endorsed moderate to extremely severe depression, anxiety and stress respectively. Duration of insomnia was correlated with insomnia severity. Hyperarousal was found moderating cognitive ore-sleep arousal and anxiety, these in turn, together with depression mediated the relationship between perceived stress and insomnia severity. Results of the second study supported the hypothesis both CBT and MBI improved insomnia and other psychological symptoms, while WLC did not. After treatment, significant decreases of 59 and 67 minutes of total wake time per night were found for CBT and MBI respectively. Sleep efficiency values significantly increased in CBT (12.2%) and MBI (12.7%). Moderate to large effect sizes and clinically significant differences were found in most sleep and psychological variables. Generally, CBT produced larger effect sizes than MBI on post-treatment. The therapeutic gains were found sustaining through 3-month to 6-month follow-ups in both treatments. However, the effect sizes of CBT were on the declining trend, while those of MBI were more stable. 　　　The results suggested that insomnia and anxiety were frequently experienced in breast cancer even after completing the medical treatments. The longer the survivors suffered from insomnia, the higher the severity was found. In additional to the cognitive pre-sleep arousal, the important mediating roles of depression and anxiety imply that insomnia treatments should incorporate strategies designed to help in decreasing rumination/worry before bedtime and improving mental health conditions. The findings also provided initial evidence for the efficacy of MBI as a viable treatment for insomnia. More vigorous randomized controlled trial and the long-term efficacy could be further studied.
published_or_final_version
Clinical Psychology
Doctoral
Doctor of Psychology

Although breast cancer is typically considered a disease that affects women at an older age, younger women are also impacted by breast cancer. Additionally, current literature suggests that women who are diagnosed at a younger age face greater challenges adjusting to breast cancer survivorship. Young survivors are often in the midst of starting their career, beginning a family, and planning for their future. Thus, a cancer diagnosis drastically interrupts these plans. This study examined the relationship between different variables that are commonly studied in young breast cancer survivorship. Women were eligible if they were diagnosed between the ages of 19-45 years, were post-treatment at the time of the study, and first-time survivors of breast cancer. Participants were recruited from social media websites, online support and advocacy group, and cancer centers across the United States. Participants completed an online survey. This study examines the structure of the hypothesized latent variables included in a proposed structural model of psychosocial adjustment to breast cancer survivorship. Two of the four hypothesized latent factors were supported by the data, and a revised structural model of psychosocial adjustment to young breast cancer survivorship is provided. Follow-up research should examine the structural model and determine the most important factors in predicting young breast cancer survivors' quality of life and life satisfaction.

Improvements in the medical field have given many cancer patients and survivors better odds of long-term survival. As more patients become survivors, the demand for psychological treatment becomes greater. The most prevalent concern of survivors is getting help with a psychosocial condition known as fear of recurrence (FOR). Prior to this study, few researchers had explored how having a more aggressive cancer influences the development of FOR. The purpose of this quantitative study was to determine whether cancer stage and type (a measurement of severity) are predictive of FOR development in the high-risk cancer groups lung and bronchus and female breast. The theoretical framework guiding this research was based on Mishel's theory of uncertainty in illness, which states that uncertainties about illness recurrence can cause survivors to experience breakdown in their lives (whether psychological and/or physical). The fear of cancer recurrence inventory (FCRI) survey was administered to 97 lung and bronchus and female breast cancer survivors; the survivors were asked to rate their level of discomfort about the possibility of a cancer recurrence. Data were analyzed using multiple linear regression. The results indicated that cancer type and severity both impacted the development and severity of FOR in lung and bronchus and female breast cancer survivors. Furthermore, regardless of the cancer type, stage of cancer, age of the survivor, or years in remission, survivors reported clinical levels of FOR in all areas of concern. Practitioners can use the current findings to work towards developing better intervention and treatment programs that promote quality survivorship and reduce the risk and rate of FOR in high risk cancer populations.

Physical activity (PA) has been shown to combat the negative side effects (e.g., fatigue, pain, depression) often faced by breast cancer (BC) survivors following BC treatment. Several studies have demonstrated that physician promoted PA significantly improves PA participation among BC survivors; however, it is rare that oncology providers recommend or provide advice about PA to survivors. The purpose of this study was to gain a better understanding of the PA communication oncology providers relay to their patients, and to investigate the relationship between this communication and the PA levels of BC survivors. This study was exploratory in nature and used a cross-sectional design. Participants (n=60) were self-identified BC survivors, 18 years or older, and lived in the Okanagan Region of British Columbia, Canada. The adapted, 30-item Oncology Provider Physical Activity Communication (OPPAC) questionnaire was used to assess participants’ perceptions concerning PA communication and advice they receive from their oncology provider. PA was assessed using accelerometers. Data were analysed using descriptive statistics and one-way ANOVA’s were conducted to assess the relationship between PA communication and PA levels. A small proportion of participants (20%) indicated that their oncology provider recommended PA, and only 11.7% indicated that their oncology provider referred them to an exercise professional. Upon further evaluation, data revealed that those who were asked about their PA routines by their oncology provider (35%) had significantly higher PA levels (P=0.038) compared to BC survivors who were not asked. Qualitative results showed that the majority (89%) of survivors thought PA should be a part of treatment. The findings suggest that the PA communication BC survivors receive from their oncology provider is limited; however, a positive relationship does exists between oncology provider communication and minutes of moderate/vigorous physical activity per week. Establishing effective and efficient ways to assist oncology providers with integrating PA promotion into their practice is needed.
Graduate Studies, College of (Okanagan)
Graduate

Background: Breast cancer treatment has improved survival prognoses; as such, the late effects of breast cancer and its treatment have become an increasingly important field of inquiry. Although the prevalence of sexual health problems among breast cancer survivors (BCSs) varies, they are among the most distressing side effects associated with breast cancer and its treatment. However, effective interventions for sexual health issues within this population have yet to be established. Yoga therapy, a health promoting, non-invasive, and non-pharmaceutical intervention, holds promise as an effective and acceptable approach to sexual health problems after breast cancer and its treatment. Methods: Using a controlled pre-post design, changes in sexual health outcome scores were assessed for participants in a three-armed yoga therapy intervention (YTI) study (Anusara yoga, Iyengar yoga, or waitlisted control). Multiple linear regression analysis was guided by a modified version of a pre-established framework comprising sexual health predictors in BCSs, in order to assess the strength of the relationship between YTI participation and changes in sexual health outcome scores. A subset analysis of only partnered participants was carried out because of the established importance of partnered relationships to sexual health. Results: Participation in Anusara yoga was significantly associated with an increase of 14 (of 91) points (p-value<0.05) on the Overall Sexual Health scale in partnered participants (AR²=0.43, p=0.001). Both age (p<0.001) and physical function (p<0.05) were also significant predictors in this model. Participation in Iyengar yoga was significantly associated with an increase in 3 (of 28) points (p<0.05) on the Sexual Function scale among all participants (AR²=0.23, p=0.026). Both age (p<0.05) and physical function (p<0.05) were also significant predictors. Conclusions: This YTI study showed evidence of effect in terms of improved Overall Sexual Health scores among partnered Anusara participants and increased Sexual Function among all Iyengar participants. Although preliminary, these results indicate that yoga therapy may be an effective, gentle, and safe intervention for BCSs who experience sexual health problems. Future interventions with larger, randomized samples, comprised by and designed specifically for BCSs with self-identified sexual health complaints, are recommended based upon our results.

For the increasing population of breast cancer survivors (BCS) in the United Kingdom, research evidence suggests that physical activity can address aspects of their unmet health and social care needs. In this exploratory study, members of one United Kingdom, Breast Cancer Survivor Dragon Boat Racing Team, were invited to tell the story of their participation in the sport, either in writing or in one-to-one, face-to-face, interviews, to gain an understanding of its impact on their breast cancer survivorship experiences. Eleven members were interviewed in their own homes and two in a location of their choosing. The interview process was guided by the Biographic-Narrative-Interpretive-Method (BNIM), and specifically the Single Question (aimed at Inducing Narrative) (SQUIN) (Wengraf 2001, p. 113). The stories were analysed using Frank’s three narrative types (Restitution, Chaos, Quest), and the ‘three facets’ framework (Frank 1995) for the analysis of quest narratives. The combination of the latter and storytelling as a methodology, in relation to DBR, appears to be unique to this study. The study was underpinned by the principles of practitioner research. Unmet needs, of varying quantity and level of intensity, were the strongest motivators for joining the team. The results revealed that dragon boat racing positively impacted on the breast cancer survivors’ lives through; membership of an extended unique social support network, a new more positive identity as a breast cancer survivor and sportsperson, improved self-esteem and greater self-confidence, experiencing fun, joy, hope, as well as improved control over, and the amelioration of some upper body morbidities. The desire and opportunity to help others and to contribute to the legacy of DBR for future breast cancer survivors was also reported. The breast cancer survivors’ stories included chaos, restitution and quest narrative types (Frank 1995) – the most common of these being quest. The study illustrates, using the metaphor of the weave (Frank 1995), the breast cancer survivors’ constant movement between the three narrative types; this movement was often prompted by, what were interpreted as, five influential inspirations; Dragon Boat Racing (‘In the Boat’), Social Support/Social Support Networks, Competition Events, Team/Group Membership, Physical and Psychological changes. The use of a storytelling methodology reveals the way in which the experience of DBR is woven into the lives of breast cancer survivors and illuminates the ways in which multiple narratives shape the breast cancer survivorship experience as well as how these women coped with the negative consequences of the DBR experience. These results have implications for charities supporting DBR, including; ensuring members feel integrated within the team, maintaining safety and fitness routines, ensuring DBR remains affordable, facilitating participation in competition events and the education of the public.

As the survival rate increases, the importance of quality of life post-cancer is increasing. This, in conjunction with genetic screening, has increase the number of breast reconstructions 36%. The most common complication causing revision of reconstructive surgery is the formation of a dense scar capsule around the silicone implant called capsular contracture. Nearly all patients will experience this complication, though with different degrees of response, ranging from moderate scarring to major disfigurement and pain at the implant site. Presently, there is no way to predict the degree of contraction capsule formation that individual patients will suffer prospectively, nor is there clinical approach to preventing this complication. Patient information and tissue was collected in a uniform manner to address these lingering problems. Clinical data was used to construct a predictive model which can accurately predict capsular contracture severity in breast reconstruction patients. Histological analysis demonstrated differences in structure and cell composition between different capsule severities. Of particular note, a new region was described which could serve as the communication interface between innate immune cells and fibroblasts. RNA-seq analysis identified 1029 significantly dysregulated genes in severe capsules. Pathway enrichment was then performed which highlights IL4/13 signaling, extracellular matrix organization, antigen presentation, and interferon signaling as importantly dysregulated pathways. These RNA results were also compared to various clinical and histological measurements to evaluate novel correlations. PVT-1, a long non-coding RNA associated with cancer, was strongly correlated to capsules formed after cancer removal. This suggests cancerous transformations of cell types that remain after the tumor is removed. Furthermore, transgelin and caspase 7 correlated to myofibroblasts density, suggesting an abnormal fibroblasts that are resistant to cell death and may have enhanced contractile abilities. Capsule formation is a complex process however, with well controlled clinical models quantitative differences can be found. These results serve as stepping stone for the field to move beyond retrospective clinical trials and pursue treatments and preventative measures.
Ph. D.

Thesis (M.S.)--Wake Forest University. Dept. of Health and Exercise Science, 2009.
Title from electronic thesis title page. Thesis advisor: Shannon L. Mihalko. Vita. Includes bibliographical references (p. 83-88).

Dissertation (Ph. D.)--University of Akron, Dept. of Counseling, 2007.
"December, 2007." Title from electronic dissertation title page (viewed 02/27/2008) Advisor, Cynthia Reynolds; Committee members, Sharon Kruse, Patricia Parr, Sandra Perosa, Paula Britton; Department Chair, Karin Jordan; Dean of the College, Cynthia F. Capers; Dean of the Graduate School, George R. Newkome. Includes bibliographical references.

As the number of women diagnosed with early stage breast cancer continues to rise, so does the population of long-term breast cancer survivors. Many factors influence the overall outcome of their experience, one of which is the support from their partners. Much has been written on the issues of women with breast cancer, but what is lacking in the literature are the voices of their partners during the long-term survival phase of the disease. The purpose of this study was to conduct a phenomenological study to (1) describe the essential structure of the experience of being a partner of a long-term breast cancer survivor, and (2) compare theme patterns of the partners of long-term breast cancer survivors with those of long-term breast cancer survivors. The sample consisted of seven participants with the average age of 55 years. Time together as partners averaged 25.2 years. The average time since the cancer diagnosis was 9.5 years. The research method consisted of open-ended audiotaped interviews. Colaizzi's eight-step method of analysis was utilized. Ten theme categories were identified from the data: the invisible enemies--cancer and uncertainty, a sense of duty, constant vigilance, from dreams to reality, turning my eyes away but not my heart, paying the price, don't worry--be happy, who are we now, rebuilding our home, and the everlasting journey. From these theme categories, the essential structure was identified. In searching for the meaning of the journey, the partner is influenced by several factors: their own as well as the patient's coping skills and quality of life, as well as the patient's overall response to cancer treatment. Partners experience many of the same issues as the patient, but their response to and the ability to travel along this cancer journey is based on their role as a partner and their sense of duty to the patient. The partner's goal is to bring structure and stability to the uncertainty of cancer and to find meaning for oneself and the patient during this experience.

Few researchers have examined the relationship between earlier stages of breast cancer and its effect on staging of the disease process and the co-occurring coping and communication patterns between mothers and their children. The purposes of this qualitative study with a multiple case study design were to examine (a) coping mechanisms that mothers used to manage the uncertainty of their breast cancer status and (b) the impact of early-stage breast cancer on communication patterns between mothers and their children. The Lazarus and Folkman theory of psychological coping and the McMaster family systems communication theory informed the conceptual framework for the data analysis. The instrument for data gathering was a researcher-designed, semistructured interview guide. The sample consisted of 20 maternal breast cancer survivors and their children. Qualitative data analysis involved member checking and content analysis to confirm the frequency of similarities and differences occurring among participant responses. Key findings were that participants: (a) adapted to their diagnosis while refining their preexisting coping mechanisms, (b) found motherhood to be a source of emotional strength throughout the duration of their cancer process, and (c) managed changes in communication with their children during each phase of cancer treatment by using combinations of communication styles. Oncology social workers can use the findings of this study as an opportunity to develop models of best practices that are effective in helping patients cope with early stage breast cancer. The findings of this study impact social change by informing clinical social work with an effective paradigm that helps mothers and their children cope with the different phases of breast cancer.

Dysregulation of the hypothalamo-pituitary-adrenal (HPA) axis activity has been commonly observed among breast cancer patients and has been linked to adverse health consequences. However, whether these alterations persist long after the cancer diagnosis has not been well-documented. In the first study, the diurnal cortisol rhythms and the cortisol stress response of breast cancer survivors who had completed all local and/or systemic adjuvant therapy with the exception of hormonal therapy were compared to those of women without a history of cancer. The Trier Social Stress Test was used to elicit a moderate stress response and the subjective levels of stress of participants were recorded using visual analog scales. The results indicate similar diurnal patterns in both groups; however, significant differences in stress reactivity were noted, with breast cancer survivors displaying a relatively flat profile following the acute stress induction. Subjective levels of psychological stress were similar in both groups, indicating that the subjective appraisal did not account for the blunted cortisol stress response. In the second study, the impact of the stressful life events that happened during the previous year on the cortisol stress response was analyzed in the same groups of participants. The frequency of stressful life events as well as their subjective impact was documented using the Life Experience Survey. Results suggest no group differences between the total number of stressful life events and their perceived effect. However, the number of stressful life events and their perceived impact correlated negatively with the peak cortisol concentration in breast cancer survivors. The results suggest that the cumulative effect of stressful life events contribute significantly to the low levels of cortisol reported in breast cancer survivors following a stressful situation. Together, these studies emphasize that breast cancer survivors are at risk of presenting a subtle alteration of their HPA axis activity when their system is challenged and that an accumulation of stressors plays a role in this dysregulation. These results reinforce the need for interventions intended to reduce the levels of psychological stress experienced by breast cancer survivors.

Due to advances in detection and treatment, increasing numbers of women are diagnosed with, and surviving, breast cancer each year, making women with breast cancer one of the largest groups of cancer survivors. Hence, ensuring good healthrelated quality of life (HRQoL) following treatment has become a focal point of cancer research and clinical interest. While our understanding about the impact of breast cancer is improving, little is known about the HRQoL among survivors in non-urban areas. This is important locally, as 45% of breast cancer survivors in Queensland, Australia, live outside major metropolitan areas. Therefore, this study investigated the HRQoL and accompanying correlates among regional and rural breast cancer survivors, and made comparisons with urban breast cancer survivors as well as women from the general population without a history of breast cancer. Three population-based studies comprise this project. Original data were collected by way of self-administered questionnaire from 323 women, diagnosed with a first, primary, invasive, unilateral breast cancer during 2006/2007 and residing in regional or rural areas of Queensland, 12 months following diagnosis. HRQoL was assessed using the Functional Assessment of Cancer Therapy, Breast plus additional concerns (FACT-B+4) questionnaire. Data from two existing data sources were also utilised. Women diagnosed with a first, primary, invasive, unilateral breast cancer in 2002 and residing within 100kms of Brisbane provided information on HRQoL, measured by the FACT-B+4, via self-administered questionnaire at six (n=287), 12 (n=277) and 18 (n=272) months post-diagnosis. Data at 12 months post-diagnosis was utilised for comparison with region and rural women with breast cancer. General population data for HRQoL, collected by self-administered questionnaire in 2004 using the Functional Assessment of Cancer Therapy-General (FACT-G) questionnaire, were derived from a subgroup of female residents without a history of breast cancer from urban (n=675), regional (n=184) and rural (n=281) Queensland. The two studies involving women with breast cancer were recruited sequentially through the Queensland Cancer Registry, whereas the study involving the general population used telephone survey methods initially to identify participants. Women who participated in all studies were aged between 30 and 74 years. Raw scores for overall HRQoL (FACT-B+4, FACT-G) and subscales were computed. According to developers of the instrument, raw score differences of eight points between groups on the FACT-B+4 scale and five points on the FACT-G scale reflect a clinically meaningful differences in HRQoL. Age-adjusted, mean HRQoL was similar between regional and rural women with breast cancer 12 months following diagnosis (e.g., FACT-B+4: 122.9 versus 123.7, respectively, p=0.74). However, younger regional and rural survivors reported lower HRQoL scores compared with their older counterparts (e.g., FACT-B+4: 112.0 and 115.8 versus 129.3 and 126.2, respectively, p<0.05 for all). In addition to age, other important correlates of lower overall HRQoL (FACT-B+4) among regional/rural breast cancer survivors included: receiving chemotherapy, reporting complications post-surgery, poorer upper-body function than most, higher amounts of stress, reduced coping, being socially isolated, not having a confidante for social-emotional support, unmet healthcare needs, and low self-efficacy. Multiple linear regression analysis was used to address the hypothesis regarding similarity of HRQoL following breast cancer among women residing in regional and rural locations. After adjusting for the above factors, there was no statistically significant or clinically important difference in overall HRQoL (FACT-B+4) between regional and rural women with breast cancer 12 months following diagnosis (122.1 versus 125.1, respectively, p=0.07). Data from regional and rural women were pooled, based on the above analyses, and compared with urban women. Multiple linear regression analysis was used to test the hypothesis that HRQoL following breast cancer among women residing in regional/rural locations would be lower than that reported by women residing in urban locations. Potential confounders of the association between overall HRQoL (FACT-B+4) and place of residence included: marital status, upper-body function, amount of stress and perceived handling of stress. After adjusting for factors that differed between urban and regional/rural survivors, overall HRQoL (FACT-B+4) was lower among younger regional/rural survivors than their urban peers, and the findings were both statistically significant and clinically important (115.3 versus 123.7, respectively, p=0.001). Older women reported similar mean HRQoL, regardless of regional/rural or urban residence (128.2 versus 131.6, respectively, p=0.03). Further multiple linear regression analyses were undertaken to investigate whether women with breast cancer would report HRQoL equivalent to that reported by similarly-aged women in the general population. After adjusting for potential confounding factors that are known or suspected risk factors for breast cancer (age, marital status, education level, private health insurance, smoking status, physical activity, body mass index, co-morbidities), overall HRQoL (FACT-G) among breast cancer survivors was comparable to the general population 12 months following diagnosis (urban: 88.0 versus 86.9, respectively, p=0.28; regional/rural: 86.2 versus 85.8, respectively, p=0.79). However, 26% of survivors experienced worse overall HRQoL (FACT-G) compared with normative levels. HRQoL subscales contributing most to this deficit were physical well-being, with 29% of breast cancer survivors reporting scores below the norm, and emotional well-being among younger women, with 46% reporting scores below the norm. Logistic regression analysis was used to identify subgroups of breast cancer survivors who reported HRQoL below normative levels; reporting poorer upper-body function than most and not handling stress well increased the odds of reporting overall HRQoL (FACT-G: odds ratios (ORs) = 4.44 and 4.24, respectively, p<0.01 for both), physical well-being (ORs = 5.93 and 2.92, respectively, p<0.01 for both) and emotional well-being (among younger women: ORs = 2.81 and 5.90, respectively, p<0.01 for both) below normative levels. The cross-sectional nature of the study design for regional and rural breast cancer survivors, and the potential selection and response biases in all three studies, represent the main limitations of this work. The cross-sectional design precludes causal inference about observed associations, but even characterising relevant correlates allows for adjustment of potential confounding and provides insight into factors that may be important in contributing to HRQoL among breast cancer survivors. Moreover, the potential impact of the latter limitations is in the conservative direction, whereby differences in HRQoL between groups will be more difficult to identify. Since these biases are expected to be present to a similar degree across all study groups, the absolute difference in HRQoL by residence and cancer status observed are likely to exist. In contrast, the work is supported by a population based, state-wide sample of breast cancer survivors, comparisons with the general population, and use of standardised instruments. Therefore, the conclusions derived from this research are likely to be generalisable to the wider population of women in Queensland with unilateral breast cancer, aged 74 years or younger, and perhaps to similar women in other western countries, depending on variations in healthcare systems and the provision of oncology services. This research supports the initial supposition that while some findings may generalise to all breast cancer survivors, non-urban breast cancer survivors also have distinct experiences that influence their HRQoL. Results from this work highlight the HRQoL domains and characteristics of breast cancer survivors most in need of assistance to facilitate recovery following diagnosis and treatment. Characteristics include some already established and reconfirmed here, namely, emotional wellbeing among younger women, and other novel subgroups, including regional/rural survivors who receive chemotherapy or have a low self-efficacy and all survivors, regardless of residence, with upper-body problems or a low perception of handling stress. These results demonstrate the potential for identifying subgroups of women with breast cancer at risk for low HRQoL who may benefit from additional attention and possible tailored recovery interventions to increase their overall HRQoL. As such, researchers and clinicians need to consider the role of these factors when designing interventions to assist women as they deal with the challenges imposed upon them by their breast cancer. However, it was found here that the FACT-G instrument has ceiling effects. This means that positive changes reflecting improved status, such as those achieved through recovery interventions, will often fail to be measured appropriately if there is no room to indicate improvements. Overall HRQoL results indicated that there is room for improvement past 12 months following treatment, with a significant proportion of breast cancer survivors reporting HRQoL below normative levels. HRQoL concerns 12 months following diagnosis are likely to be distinct from the more acute issues reported earlier on in the literature. Therefore, the development of a cancer survivorship module to accompany the FACT-G would be useful to counteract the ceiling effects observed as well as to capture issues distinct to cancer survivorship. This is the first study to describe in detail the HRQoL of breast cancer survivors across all areas of Queensland and to compare it to the HRQoL reported by the general population of Queensland. Therefore, it represents a unique and substantial contribution to the existing knowledge on survivorship issues following diagnosis and treatment for breast cancer in Australia. Through this research, a number of questions remain that could be addressed by relevant investigations and which are likely to be important in the future to ultimately guide practice. Specifically, implementation of the concept of HRQoL in practice is the next important step forward. Furthermore, the development of a survivorship care plan that incorporates guidelines on HRQoL recovery could provide options for referral and support.

It is accepted that exercise plays a significant role in breast cancer rehabilitation, but there has been limited emphasis on control and measurement of the intensity of exercise in cancer research. It is unknown how intensities achieved by different methods of intensity prescription compare, which complicates the interpretation and comparison of studies. The accuracy of these methods in achieving the prescribed intensity is also unknown; and methods that are inaccurate could be unsafe or ineffective in this population. Therefore, a cross-sectional study was performed to compare the achieved intensity and accuracy of four common methods of intensity prescription within and between three post-menopausal groups: breast cancer patients recently finished chemotherapy, survivors finished treatment and healthy controls (N=30). In randomized order, the metabolic equation for walking (MET equation), heart rate reserve (HRR), direct heart rate (direct HR) and rating of perceived exertion (RPE) methods were used to prescribe an intensity of 60% of oxygen consumption reserve (VO₂R) in separate 10-minute bouts, with recovery between bouts. Expired gas analysis was used to measure the intensity achieved during each bout. Accuracy was defined as: [60%VO₂R-achieved intensity]. In ranked order, the average achieved intensity (%VO₂R) and accuracy (percentage points (+/-ppts)) of the methods in the patient group were: HRR: 61%, 3 ppts; MET equation: 56%, 4 ppts; direct HR: 60%, 8 ppts; RPE: 53%, 9 ppts. The HRR method is recommended in this population based on accuracy and feasibility (no expired gas analysis or re-testing required). The MET equation method is also recommended, with re-testing to account for changes in peak oxygen consumption. The direct HR method could be unsafe, as it achieved intensities much higher than intended (77%), and would be ineffective in research where the effect of exercise is measured, as there was a large range of achieved intensities (42%). In the survivor group results were: MET equation: 59%, 3 ppts; HRR: 63%, 5 ppts; direct HR: 64%, 5 ppts; RPE: 47%, 13 ppts. The top three methods were comparable in accuracy in this group, and appear to be safe and effective, while the RPE method was inaccurate and is not recommended.

Fatigue is one of the most commonly reported side effects during treatment for breast cancer, and for some individuals can continue for an extended period following treatment completion. Cancer-related fatigue is multi-factorial in nature, and one hypothesized mechanism of both development and persistence of cancer-related fatigue following treatment is cardiorespiratory and muscular deconditioning. The purpose of this study is to compare lactate threshold, VO₂ peak and central vs. peripheral causes of muscular fatigue in breast cancer survivors with persistent cancer-related fatigue (FG) and the control group (CG), breast cancer survivors without persistent cancer-related fatigue following treatment for breast cancer. METHODS: During first testing visit, power output at lactate threshold, lactate threshold as a percentage of peak power output, and absolute and relative VO₂ peak were determined using a graded incremental maximal exercise test on a cycle ergometer. During the second testing visit central and peripheral muscle fatigue following a sustained contraction of the right quadriceps were assessed using the twitch interpolation technique and measurement of voluntary activation, control twitch, maximum voluntary contraction and endurance time. RESULTS: There were no significant differences in age, body weight, or time since completion of treatment between groups. There were no significant differences between groups in power output at lactate threshold (FG 60.7±17.0 vs. CG 73.3±22.2 W, p=0.14), lactate threshold as a percentage of peak power output (FG 46.8±8.6 vs. CG 55.0±14.7%, p=0.11), peak power output (FG132.12±38.2 vs. CG 140.6±5.9 W, p=0.66), absolute VO2 peak (FG 1.51±0.39 vs. CG 1.74±0.38 L/min, p=0.19), or relative VO2 peak (FG 22.4±4.9 vs. CG 23.6±7.1 ml/kg/min, p=0.62). Results did approach significance for power output at lactate threshold (p=0.10) and absolute VO₂ peak (p=0.08) when adjusted for age. Central fatigue was responsible for muscular fatigue in the iv control group, while muscular fatigue in the cancer-related fatigue group was more due to peripheral mechanisms. CONCLUSION: While no statistically significant differences were found between groups, results suggest that deconditioning may play a role in cancer-related fatigue. Future research into the use of exercise training as a tool to improve deconditioning and thereby reduce this proposed aspect of cancer-related fatigue is warranted.

Higher serum levels of glucose, C-peptide and insulin have been linked to poorer breast cancer prognosis and fluctuations of these substances resulting from acute bouts of exercise in breast cancer survivors have not been studied. In this pilot study, 28 postmenopausal women were in 3 groups: controls (n = 10), aromatase inhibitor users (AI, n = 8) and breast cancer survivors not using aromatase inhibitors (BCS, n = 10). Fasting glucose, C-peptide and insulin levels were compared and changes in these substances with acute exercise of different intensities were explored. V0₂peak values were determined and fasting blood samples were obtained. Blood was collected before, immediately after, and 45 minutes after 2 exercise bouts: moderate (45 minutes at 60% V0₂peak) and intense (10 minutes at 85% V0₂peak). Fasting glucose, C-peptide and insulin values, plus HOMA-IR values, were homogeneous between groups. Exercise intensity affected glucose, C-peptide and insulin levels similarly in all 3 groups. For the breast cancer survivor groups combined (n = 19), the pre-post changes and post-recovery changes of glucose and C-peptide were significantly different between the moderate and intense bouts (glucose: p = 0.01 and 0.01; C-peptide: p = 0.04 and 0.04, respectively) showing greater increases in glucose and C-peptide during intense exercise. The pre-post change in insulin approached a significant difference between intensities (p = 0.09) showing a greater increase during intense exercise. Of importance, glucose, C-peptide and insulin levels all transiently increased with intense exercise in breast cancer survivors. In conclusion, more research is warranted on the possible detrimental effects of transiently high glucose, C-peptide and insulin levels induced by intense exercise on breast cancer etiology and prognosis.

Women with breast cancer commonly experience depression. However, this condition often goes unrecognized, undertreated, and understudied, especially in ethnic minorities. If left untreated, co-existing depression in women with cancer can complicate cancer treatment, lead to poor treatment adherence for both conditions, and decrease survival. These negative consequences are considerably higher among Latinas. With the growing number of Latinos and diversity within the Latino community, the literature has identified the need to disaggregate Latinos by region of origin. Unfortunately, few studies account for these differences and no study to date has examined risk factors of depression among Latinas diagnosed with breast cancer within 5 years or by region of origin. To begin exploring predictors of depression among Latina breast cancer survivors, a theory-driven mixed-methods approach was used to identify potential risk factors for depression as a group and by region of origin (e.g., South and Central America, and Spanish-speaking Caribbean countries). This study also sought to contextualize Latina breast cancer survivors' perceptions of risk factors of depression, necessary to shape culturally and linguistically appropriate interventions and programs. The guiding theoretical framework for this study was Lazarus and Folkman's Cognitive Stress Theory and McLeroy and colleagues' Ecological Model for Health Promotion. Sixty-eight Latinas meeting eligibility criteria were recruited from Latino cancer support groups and other community organizations in the West Central Florida area. Both purposive and snowball-sampling procedures were used to recruit participants. A researcher-administered closed-ended questionnaire, followed by a semi-structured interview addressed research aims and the primary outcome variable. Descriptive statistics (mean, standard deviations, frequency, percent), bivariate and multiple linear regression analyses were completed using IBM SPSS V20. Thematic and content analyses were completed for qualitative data using Atlas.ti 6.2. Findings revealed the need for easily accessible, culturally and linguistically appropriate psychosocial services to help women adjust to cancer diagnosis and emphasized the need to disaggregate Latinos in future studies as findings may differ by Latino region of origin. Multivariate analyses showed appraisal variables (more perceived harm, more perceived threat, less perceived challenge - overcoming cancer), coping variables (less active coping and more self-blame), and poor body image to be significantly associated with an increased risk for the likelihood of depression. Appraisal variables accounted for greatest explained variance (36%). Risk factor differences by region of origin were observed in sub-group multivariate analyses, but this study was unable to conclude if risk factors play a different role by region of origin in a combined model. Twenty-two salient themes emerged from the thematic analyses of the qualitative data on all levels of the ecological model (e.g., acceptance of illness, lack of family and peer support, lack of access to care, language barriers). Content analyses demonstrated agreement on a majority of salient themes amongst groups (presence of depression symptoms and by region of origin) about the perceptions of risk factors for depression. "Helping oneself" and "discrimination" demonstrated significant difference in terms of the frequency these themes were discussed by presence of depression symptoms and "poor body-image" by region of origin. In conclusion, data from this study provided quantitative and qualitative data of potential risk factors of depression, which in turn can be used to conduct additional epidemiological studies to examine prognostic factors longitudinally. Study findings may also contribute to the existing literature of risk factors for depression to encourage future intervention and programs to reduce mental health disparities, to raise the awareness of the need for mental health services, and to inform mental health screening guidelines.

This study explored the lived experiences of breast cancer survivors and their intimate partners. The research was informed by a social constructionist framework and phenomenological method of inquiry. While the body of literature on the physical, psychological, and social health of breast cancer survivors is growing, only a few studies have focused solely on the lived experience of survivorship and the uncertainty of recurrence. This study sought to explore the construction of meaning in the couples' context and experiences of surviving breast cancer. The present study examined how breast cancer survivors make meaning of their survivorship in context of living with the fear of recurrence. The researcher investigated the patients' and their intimate partners' experiences of survivorship to gain a better understanding of how their lived experiences affect their relationships to themselves and their significant other and how they cope with the uncertainty of recurrence. The study provided clinical implications for medical family therapists working with breast cancer survivors for couples managing the challenges with survivorship and uncertainty.

Background: Latinas experience a greater number of symptoms and are at an elevated risk for depression and anxiety following a diagnosis of breast cancer compared to Non-Hispanic Whites and African Americans. Cancer-related symptom clusters are frequently reported in women with breast cancer and research suggests these women follow distinct trajectories for depression and anxiety. However, little is known about the trajectories of anxiety and depression or cancer-related symptom clusters in Latinas with breast cancer. Methods: 296 Latinas previously recruited and diagnosed with breast cancer comprised this sample. Questionnaires for depression (the Center for Epidemiological Studies-Depression) and Anxiety (Speilberger State-Trait Inventory and PROMIS Anxiety) were administered at baseline, 2 and 4 months post enrollment. To identify classes of Latina breast cancer survivors based on patterns of symptom occurrence, symptoms latent class analysis was used to describe symptom clusters. Group-based growth mixture modeling was utilized to identify classes of women who followed distinct trajectories of depression and anxiety. Results: On average women reported 4.2±3 symptoms with an overall symptom distress score of 6.4±2.5 (out of a scale of 10). Three symptom classes were identified: Weary and Sleepy (class 1), Weary (class 2) and Weary, Sleepy and Hurting (class 3). Women were most likely to cluster in class 1, followed by class 2 and 3 with fatigue (labeled weary) being the most prevalent symptom for all three classes. Three trajectories emerged for both depression and anxiety. For depression, the majority of women (79.6%) fell in the high then reducing trajectory for depression followed by the low and remaining low (17%) and the high and increasing (worsening) trajectories of depression (3%). For anxiety the majority (78% of women) followed the moderate to increasing (worsening) trajectory of anxiety followed by 14% in the moderate to declining (improving) and 8% in the low to slightly increasing (worsening) trajectories for anxiety. Conclusion: This study suggests Latina breast cancer survivors experience burdensome cancer-related symptom clusters and distinct trajectories for depression and anxiety. Further research is needed in minority women with breast cancer to adequately understand and treat cancer-related symptom clusters as well as depression and anxiety.

The purpose of this project was to augment self-efficacy, outcome expectations, and self-regulatory skills for women with breast cancer through a quality of life intervention based on Social Cognitive Theory. Relationships between social cognitive variables, positive coping behaviors, and quality of life were explored. The intervention was conducted in collaboration with an established cancer treatment center and provided information, guided feedback, and mastery experiences in a supportive environment for breast cancer survivors. A total of 32 women were enrolled and randomized to either the 8-week intervention or standard-care. With a final n of 14, the lack of statistical power made it difficult to determine whether differences existed between the two groups. Data trends suggested that some women benefited from the program. Implications for the content and delivery of future psychosocial interventions with cancer patients were discussed.
Ph. D.