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Does quality of life among breast cancer survivors one year after diagnosis differ depending on urban and non-urban residence? A comparative study

Does quality of life among breast cancer survivors one year after diagnosis differ depending on... Background: This study examined the quality of life (QOL), measured by the Functional Assessment of Cancer Therapy (FACT) questionnaire, among urban (n = 277) and non-urban (n = 323) breast cancer survivors and women from the general population (n = 1140) in Queensland, Australia. Methods: Population-based samples of breast cancer survivors aged < 75 years who were 12 months post- diagnosis and similarly-aged women from the general population were recruited between 2002 and 2007. Results: Age-adjusted QOL among urban and non-urban breast cancer survivors was similar, although QOL related to breast cancer concerns was the weakest domain and was lower among non-urban survivors than their urban counterparts (36.8 versus 40.4, P < 0.01). Irrespective of residence, breast cancer survivors, on average, reported comparable scores on most QOL scales as their general population peers, although physical well-being was significantly lower among non-urban survivors (versus the general population, P < 0.01). Overall, around 20%-33% of survivors experienced lower QOL than peers without the disease. The odds of reporting QOL below normative levels were increased more than two-fold for those who experienced complications following surgery, reported upper-body problems, had higher perceived stress levels and/or a poor perception of handling stress (P < 0.01 for all). Conclusions: Results can be used to identify subgroups of women at risk of low QOL and to inform components of tailored recovery interventions to optimize QOL for these women following cancer treatment. Background QOL has been associated with adherence to treat- Breast cancer is a major public health concern, with one ment [4] and prognosis [5,6] and is now recognized as in eight women developing the disease before the age of an important research outcome. International research 85 years in developed countries of the world [1,2]. on factors that influence QOL among breast cancer Despite therapeutic advances, which have contributed to survivors has been extensive (over 300 published stu- improvements in survival (five-year survival currently dies in 2008 alone integrated QOL as an outcome). 87%) [3] women continue to experience considerable Socio-demographic (e.g., income), general health (e.g., physical and psychosocial dysfunction during and fol- medical conditions) and treatment (e.g., adjuvant ther- lowing treatment. While these quality of life (QOL) con- apy) characteristics each have been associated with cerns are short-lived for some, others may struggle to QOL [7], with the strength and consistency of the regain expected levels of QOL longer term. associations dependent on the characteristic of interest. Nevertheless, there remain subgroups of women for whom limited information on QOL is available, includ- * Correspondence: t.disipio@qut.edu.au ing those women who reside outside major metropoli- School of Public Health, Institute of Health and Biomedical Innovation, tan areas. This is important because approximately Queensland University of Technology, Victoria Park Road, Kelvin Grove, Queensland, 4059, Australia © 2010 DiSipio et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. DiSipio et al. Health and Quality of Life Outcomes 2010, 8:3 Page 2 of 10 http://www.hqlo.com/content/8/1/3 one-third of new breast cancer cases live outside major referred to as ‘urban’. Residents of inner regional, metropolitan areas [2]. remote and very remote areas were pooled as the ‘non- In Australia, geographic residence influences stage at urban’ group and reflect the reduced access to a range diagnosis and type of surgery, with those living in rural of oncology services experienced by those who live out- areas more likely to have a mastectomy than their urban side state capital cities, irrespective of the level of remo- counterparts (38% versus 25%, respectively) [8-10]. Geo- teness [12]. graphic residence also influences access to health ser- Eligible women, diagnosed with unilateral breast can- vices [11], as fewer than half of regional/rural hospitals cer at age 74 years or younger, were randomly selected administer chemotherapy [12], and fewer still provide through the Queensland Cancer Registry (target sam- radiotherapy services [13]. Further, rural Australian ple). All cancer diagnoses in Queensland are required to women often have to travel in excess of 100 kilometers be reported to the Registry and therefore these records (i.e., 62 miles) to receive adjuvant treatment and are provide an accurate sampling frame for recruitment. away from home for approximately 20 to 43 days for Since breast cancer is mostly a disease of women 50 yrs chemotherapy and radiotherapy treatment, respectively or older and to ensure adequate numbers were available [14,15]. Hence, it seems plausible that rural women with for specific age group analyses, younger women were breast cancer may have unique and additional burdens, over-sampled in the urban arm of the study, while 100% such as disruption to family life, work and financial of eligible non-urban women were recruited for all age security [14,16], which ultimately may influence QOL groups. Following appropriate ethical approval and the differently to that observed for women residing in urban requirements of the cancer registry, doctor consent to areas. contact eligible women (provided for 82% of the urban Research that compares QOL between urban and non- sample and 90% of the non-urban sample) and partici- urban cancer survivors is lacking, and from those stu- pant consent was sought. Overall, 277 urban and 323 dies that exist, results are inconsistent. Two studies sug- non-urban women returned completed quuestionnaires gest that rural breast cancer survivors fare worse at 12 months post-diagnosis (66% and 71% of eligible [17,18], while one indicates that QOL is superior among women with doctor consent for the urban and non- a rural group of mixed cancer survivors [19], when com- urban arms, respectively). pared with their urban counterparts. Further, there is a General population study sample paucity of information comparing the QOL among can- Following ethical approval, the general Queensland cer groups with that of the general population, making population sample was derived from the Queensland interpretation of findings challenging. Therefore, this Cancer Risk Study (QCRS), a population-based survey paper examines whether QOL differs between urban conducted in 2004 among English-speaking residents of and non-urban women 12 months following breast can- Queensland, aged 20-75 years, randomly sampled within cer diagnosis and compares their QOL with women strata defined by gender, age and geographic region from the general population residing in their respective (defined by the ARIA+ classification as as major city, geographic areas. We also sought to identify characteris- inner regional, outer regional or remote/very remote). tics of breast cancer survivors associated with reporting Further details about the study methods are described QOL below normative levels. elsewhere [24]. Briefly, of the 8,398 adults who agreed to participate in the self-administered questionnaire, Methods 5822 (69.3%) returned surveys, of which 2727 contained Breast cancer study samples QOL information. Analyses reported in this paper The Pulling Through Study (PTS) was a longitudinal, include women for whom QOL data were available and population-based study among breast cancer survivors who had no prior history of breast cancer, with 675 liv- living within 100 kilometers (i.e., 62 miles) of the capital ing in urban and 465 in non-urban areas of Queensland, city of Brisbane in Queensland, Australia, and diagnosed as defined by the ARIA+. in 2002 [20,21]. This study was extended to include sur- Questionnaires vivors from non-urban areas of Queensland, diagnosed QOL was measured among women with breast cancer at between April 2006 and March 2007 [22]. The Accessi- 12 months post-diagnosis using the Functional Assess- bility/Remoteness Index of Australia (ARIA+) classifica- ment of Cancer Therapy (FACT-G) questionnaire, tion system was used to define place of residence as which is comprised of 27 items rated on a five-point either major city, inner regional, outer regional, remote Likert scale (ranging from 0 = ‘notatall’ to 4 = ‘very or very remote, and is based on road distance and popu- much’) and includes four subscales (physical, social, lation size of the nearest town [23]. The selected local- emotional, and functional well-being). Higher scores ities within the perimeter of Brisbane fall within the represent better well-being. Women in the QCRS ARIA+ classification for major cities and hereafter are received the general population FACT instrument DiSipio et al. Health and Quality of Life Outcomes 2010, 8:3 Page 3 of 10 http://www.hqlo.com/content/8/1/3 (FACT-GP), which is identical to the FACT-G except it subscales between urban and non-urban breast cancer excludes six illness-related items inappropriate for the survivors or between women with breast cancer and general population [25,26]. Overall FACT-GP summary their general population peers were considered clinically scores and subscales were pro-rated as per the FACT important, as recommended by developers of the FACT manual to obtain scores comparable to the FACT-G [25]. For correlates, a difference in odds ratios (ORs) of [27], resulting in total scores for all study groups ran- ≥1.8 or ≤0.6 was considered to be of potential clinical ging from 0-108 for overall QOL, 0-28 for the physical, relevance. social, and functional well-being subscales, and 0-24 for As suggested by Fayers [34], a new outcome measure the emotional well-being subscale. Women with breast was calculated to characterize breast cancer survivors cancer also completed 13 questions on breast cancer whose QOL was below normative levels. QOL values concerns and arm morbidity (FACT-B+4), with total were calculated for each five-year age stratum of the scores from 0-52 for the breast cancer concerns sub- general population study group and subtracted from the scale, and 0-160 for overall FACT-B+4. The FACT QOL score within the same age group of women with instrument has excellent reliability and validity [28]. breast cancer (i.e., case FACT-G minus general popula- Demographic (age, marital status, educational level, tion comparison group FACT-G) separately by urban private health insurance, occupation [29,30] and and non-urban residence [34]. Positive scores indicate income), general health (smoking status, body mass higher QOL, and negative scores indicate lower QOL, index, co-morbidities, complications following surgery, among cases relative to age- (within five years) and resi- upper-body function [31], physical activity and stress dence-matched peers. Relative overall QOL (FACT-G) levels including perceived handling of stress) and treat- was then categorized into groups using score differen- ment (chemotherapy, radiotherapy, hormone therapy) tials considered clinically important to investigate the characteristics for the breast cancer study participants proportions of breast cancer survivors with relative were also obtained via the questionnaire, whereas infor- overall QOL lower than (-5.0 points or more), similar to mation on tumor characteristics were abstracted from (>-5.0 to < +5.0) or better than (+5.0 points or more) histopathology reports (e.g., type of surgery, maximum the general population study group. Relative QOL was tumor size and grade, and lymph node status). also calculated for each subscale, using two points as Statistical analysis the critical threshold. A dichotomous outcome variable Distributions of the FACT scores were approximately was defined, combining the ‘similar’ and ‘better’ groups, normal and hence were summarized as means with 95% and binary logistic regression was used to generate ORs confidence intervals (CIs) using SPSS (SPSS Inc, Chi- and 95% CIs to identify demographic, general health, cago, IL, version 14). Analysis of variance tests com- and clinical characteristics associated with QOL status pared age-adjusted mean QOL scores at 12 months below the norm compared to the ‘similar/better’ group. post-diagnosis between urban and non-urban breast A range of potentially important correlates were cancer survivors. Comparisons between breast cancer explored, however, only those that were found to be sta- survivors and women from the general population tistically significant or clinically important are reported. involved general linear regression models to obtain Formal tests of interactions between residence and each QOL scores adjusted for characteristics that differed of the characteristics of interest did not yield any statis- between the groups (i.e., potential confounding factors). tically significant results, therefore pooled results, Descriptive results presented in this study have been adjusted for residence, are presented. adjusted for the sampling fraction used to identify younger breast cancer patients from urban areas Results (weighting applied: < 50 years:1.0; ≥50 years:1.3). The Sample characteristics general population comparison group was also weighted Demographic and disease characteristics were similar for by age, based on Australian Bureau of Statistics data, so the women with breast cancer in this study and those in that results reflect the actual female Queensland resi- the target sample. The majority of women (75-80%) dent population (weighting applied for urban, regional, were diagnosed with infiltrating ductal carcinoma, outer regional, remote and very remote: < 50 years:1.3, approximately 60% received complete local excision of 1.3, 1.4, 1.5 and 0.9, respectively; ≥50 years:0.8, 0.8, 0.7, their tumour and more than 50% had 10 or more lymph 0.6 and 1.1, respectively) [33]. The conventional P < nodes removed. However, participants among urban 0.05 level (two-tailed) was accepted as statistically signif- breast cancer survivors had somewhat smaller tumor icant. Differences of eight or more points in mean size (median tumour size was 14 mm) when compared FACT-B+4 scores, five or more points in mean FACT-G with the target sample [20-22]. For the majority of scores, three or more points on the breast cancer con- demographic and general health characteristics, women cerns subscale and two or more points for all other with breast cancer had similar characteristics, DiSipio et al. Health and Quality of Life Outcomes 2010, 8:3 Page 4 of 10 http://www.hqlo.com/content/8/1/3 Table 1 Participant Characteristics Characteristics Urban general Urban breast cancer Non-urban general Non-urban breast cancer a b a population (n = 675) survivors (n = 277) population (n = 465) survivors (n = 323) n % n% n% n% Demographic characteristics Age (years) * <50 298 57.0 99 30.0 185 55.6 107 33.1 50+ 377 43.0 178 70.0 280 44.4 216 66.9 Marital status * † Married, or living as married 520 77.6 186 66.6 361 80.1 248 76.8 Not married 155 22.4 91 33.4 104 19.9 75 23.2 Education level * * Grade 10 or below 219 30.2 125 46.5 186 37.0 173 53.6 Grade 12/Trade/TAFE 278 42.5 95 33.7 183 40.7 102 31.6 University or college degree 178 27.3 57 19.9 96 22.3 48 14.9 Private health insurance status * † Yes 398 58.0 200 72.4 222 48.5 140 43.3 No 277 42.0 77 27.6 243 51.5 183 56.7 General health characteristics Smoking status Never smoked 364 53.6 163 59.3 250 52.9 184 57.0 Past smoker 216 31.2 84 30.0 149 31.7 102 31.6 Current smoker 95 15.2 30 10.7 66 15.3 37 11.5 Physical activity * Sedentary 94 17.5 34 12.6 81 13.7 68 21.1 Insufficient activity 194 27.9 67 23.9 125 29.4 55 17.0 Sufficient activity 387 54.6 176 63.5 259 57.0 200 61.9 Body mass index (kg/m)* † Underweight/Normal (up to 335 41.5 108 38.5 183 50.7 116 35.9 24.9) Overweight (25-29.9) 203 27.4 80 29.0 134 29.6 91 28.2 Obese (30+) 106 25.1 55 20.0 119 14.9 100 31.0 Missing 31 6.0 34 12.5 29 4.7 16 5.0 d † Number of co-morbidities ** None 126 21.6 68 23.8 84 21.4 55 17.0 One 158 19.0 68 23.7 79 24.7 74 22.9 Two 133 19.7 69 25.6 95 19.2 79 24.5 Three or more 258 39.6 72 27.0 206 34.7 115 35.6 Clinical characteristics Adjuvant treatment - - - - † None 42 15.8 59 18.3 Chemotherapy only 34 11.3 33 10.2 Radiotherapy only 119 43.8 105 32.5 Both 82 29.1 126 39.0 Number of complications -- - - † None 54 19.7 133 41.2 Yes, one to four 223 80.3 190 58.8 Abbreviations: * Statistically significant difference (P < 0.05) between the general population and breast cancer survivors by place of location. † Statistically significant difference (P < 0.05) between urban and non-urban breast cancer survivors. Notes: (a) Column percentages are standardized to the 2003 Queensland population by age. (b) Column percentages have been weighted to correct for sampling. (c) ‘Sedentary’ is defined as no activity; ‘Insufficient’ time is defined as participating in some activity but less than 150 minutes per week, using the sum of walking, moderate activity and vigorous activity (weighted by 2); ‘Sufficient’ time is defined as 150 minutes per week, using the sum of walking, moderate activity and vigorous activity (weighted by 2) [45]. (d) Co-morbidities include heart conditions, high blood pressure, high cholesterol, stroke, diabetes, lung conditions, stomach or duodenal ulcer, migraine or headaches, arthritis, cancer other than breast, depression and other prolonged or serious illness. (e) Complications include wound infection, other infection, skin reaction, seroma. DiSipio et al. Health and Quality of Life Outcomes 2010, 8:3 Page 5 of 10 http://www.hqlo.com/content/8/1/3 Table 2 QOL scores at 12 months post-diagnosis for urban and non-urban breast cancer survivors Quality of life Urban breast cancer survivors (n Non-urban breast cancer Differences between residence = 277) survivors (n = 323) groups a a b Mean 95% CI Mean 95% CI P-Value clinical Physical well-being (0-28) 24.7 24.1, 25.2 22.8 22.3, 23.3 < 0.01 ✗ Social well-being (0-28) 22.7 22.0, 23.4 22.5 21.8, 23.1 0.67 ✗ Emotional well-being (0-24) 20.1 19.6, 20.5 19.2 18.7, 19.6 < 0.01 ✗ Functional well-being (0-28) 22.4 21.8, 23.1 21.7 21.1, 22.3 0.09 ✗ Breast cancer concerns (0-52) 40.4 39.5, 41.4 36.8 36.0, 37.7 < 0.01 ✓ FACT-G (0-108) 89.7 87.9, 91.5 86.3 84.7, 88.0 < 0.01 ✗ FACT-B+4 (0-160) 130.2 127.7, 132.7 122.6 120.3, 125.0 < 0.01 ✗ Abbreviations: FACT-G: Functional Assessment of Cancer Therapy-General; FACTB+4: Functional Assessment of Cancer Therapy-Breast additional four questions. Notes: (a) Adjusted for age. (b) ✗: clinically meaningful difference between groups (two+ points for physical, social, emotional and functional well-being, three+ points for breast cancer concerns, five+ points for FACT-G, eight+ points for FACT-B+4); ✓: no clinically meaningful difference between groups. irrespective of place of residence. However, the urban breast cancer survivors were more likely to be single, compared to the non-urban breast cancer sample was have private health insurance, and/or fewer co-morbid- more likely to be unmarried, have private health insur- ities (other than breast cancer), while non-urban breast ance and report fewer co-morbidities, and less likely to cancer survivors were more likely to be sedentary and/ be obese (Table 1). Non-urban compared to urban or have two or more co-morbidities (other than breast women with breast cancer were more likely to have cancer), when compared with their general population multiple forms of adjuvant therapy and less likely to counterparts. While there was a significant (P <0.05) report multiple complications. difference in body mass index between urban breast A comparison of women with or without breast can- cancer survivors and their general population peers, this cer showed significant differences for several demo- was attenuated when missing values were omitted from graphic and general health characteristics (Table 1). analyses. Breast cancer survivors tended to be older or have lower QOL among urban and non-urban breast cancer survivors educational levels when compared with the general Although urban breast cancer survivors reported higher population, irrespective of residence. In addition, urban age-adjusted QOL summary and subscale scores than Table 3 Adjusted mean QOL for women with breast cancer compared with the general population stratified by residence location Quality of life Residence General population Breast cancer survivors Difference between groups a a b Mean 95% CI Mean 95% CI P-Value clinical Physical well-being (0-28) urban 25.0 24.8, 25.3 24.2 23.8, 24.6 < 0.01 ✗ non-urban 25.1 24.7, 25.5 22.7 22.2, 23.2 < 0.01 ✓ Social well-being (0-28) urban 19.9 19.5, 20.4 22.4 21.6, 23.2 < 0.01 ✓ non-urban 19.6 19.0, 20.2 22.4 21.7, 23.1 < 0.01 ✓ Emotional well-being (0-24) urban 21.1 20.8, 21.4 19.6 19.1, 20.0 < 0.01 ✗ non-urban 20.9 20.5, 21.2 19.2 18.8, 19.7 < 0.01 ✗ Functional well-being (0-28) urban 20.6 20.2, 21.1 22.0 21.3, 22.7 < 0.01 ✗ non-urban 20.2 19.7, 20.8 21.6 21.0, 22.3 < 0.01 ✗ FACT-G (0-108) urban 86.9 85.8, 88.0 88.0 86.3, 89.8 0.28 ✗ non-urban 85.8 84.4, 87.3 86.2 84.4, 87.9 0.79 ✗ Abbreviations: FACT-G: Functional Assessment of Cancer Therapy-General. Notes: (a) Adjusted for age (years), marital status (married or living as married, not married), education level (low, moderate, high), private health insurance status (yes, no), smoking status (never smoked, past smoker, current smoker), physical activity (sedentary, insufficient, sufficient), body mass index (underweight/healthy, overweight, obese, missing), and co-morbidities (none, one, two, three or more). (b) ✗: clinically meaningful difference between groups (two+ points for physical, social, emotional and functional well-being, five+ points for FACT-G); ✓:no clinically meaningful difference between groups. DiSipio et al. Health and Quality of Life Outcomes 2010, 8:3 Page 6 of 10 http://www.hqlo.com/content/8/1/3 Figure 1 Proportions of breast cancer survivors whose relative QOL at 12 months post-diagnosis was lower than, similar to, or better than general population peers. their non-urban counterparts 12 months following diag- non-urban breast cancer survivors also reported clini- nosis, differences did not reach the threshold for clinical cally lower physical well-being (P < 0.01 for all). Scores importance even for those subscales that were statisti- for emotional, functional and overall (FACT-G) QOL cally significant (physical, emotional, and overall QOL, P were clinically comparable to their counterparts from < 0.01). In contrast, well-being related to breast cancer the general population despite a statistically significant concerns was lower among non-urban compared to difference for emotional and functional well-being (P < urban survivors by statistical (P < 0.01) and clinical cri- 0.01). teria (Table 2). Furthermore, for both groups, women Using the new outcome measure of QOL relative to reported most detriment to their QOL for this subscale, age and residency-matched women from the general with participants reporting mean values below 80% of population, depending on the specific QOL scale, the maximum score on average. Participants reported between 17.2% and 32.8% of all women with breast can- mean values at approximately 80% of the maximum cer reported clinically lower QOL 12 months following score for all other subscales. diagnosis than age- (within five years) and residence- matched women without the disease. A further 17.5%- Breast cancer survivors’ QOL compared to the general 48.5% of women reported similar QOL, while the population remainder (19.8%-65.3%) reported clinically better QOL Table 3 presents the subscale and overall mean FACT-G (Figure 1). The subscales with the highest proportions scores for breast cancer survivors compared with below the norm were emotional (32.8%) and physical women from the general population, stratified by resi- (29.3%) well-being, and overall QOL (26.2%). dence and adjusted for potential confounding factors. At Characteristics associated with QOL below normative 12 months post-diagnosis, urban and non-urban breast levels among breast cancer survivors cancer survivors reported clinically higher social well- Following adjustment for potential confounding factors, being compared with their general population peers, and a range of characteristics were associated with breast DiSipio et al. Health and Quality of Life Outcomes 2010, 8:3 Page 7 of 10 http://www.hqlo.com/content/8/1/3 Table 4 Correlates of QOL (FACT-G) below the norm at 12 cancer survivors reporting overall (FACT-G) QOL below months post-diagnosis among breast cancer survivors normativelevels(Table4), butplace of residence(i.e., Characteristics Model urban versus non-urban) was not one of these (Odds Ratio (OR) = 1.06; 95% Confidence interval (CI) = 0.64- nOR 95% CI P-Value 1.74). Experiencing one or more complications following Place of residence 0.82 surgery was associated with two-fold increased odds Urban 277 1.00 - (OR = 2.26, 95% CI = 1.31-3.90; P < 0.01) of reporting Non-urban 323 1.06 0.64, 1.74 reduced QOL, while upper-body function below the Age (years) 0.21 median, moderate or higher stress levels and poor per- <50 205 1.00 - ceived handling of stress were each associated with at 50+ 395 0.72 0.43, 1.20 least four-fold increased odds of reporting reduced QOL Occupation 0.38 (ORs ranging from 4.24-4.77, P < 0.01, see Table 4). A Professional 182 1.00 - marker of higher socioeconomic status, having private White-collar worker 176 1.16 0.64, 2.11 health insurance, was associated with a 0.6 odds of Blue-collar worker 31 2.53 0.95, 6.76 reporting lower relative QOL (95% CI = 0.37-0.99, P = Homemaker 106 1.29 0.63, 2.62 0.05). Retired/student 105 0.92 0.43, 1.96 Yearly income 0.15 <$52,000 336 1.00 - Discussion $52,000+ 207 0.60 0.35, 1.04 Urban and non-urban breast cancer survivors reported Missing 57 0.66 0.28, 1.55 similar levels of QOL 12 months following diagnosis, Private health insurance 0.05 status overall and for subscales. The sole exception was the No 217 1.00 - breast cancer concerns subscale, which showed that Yes 383 0.61 0.37, 0.99 non-urban residents fared worse than their urban coun- Overall histological 0.34 terparts. When comparing breast cancer survivors to grade age- and residence-matched peers, the only detriment to Grade 1 142 1.00 - QOL was among non-urban breast cancer survivors Grade 2 219 0.58 0.32, 1.06 who reported statistically and clinically poorer physical Grade 3 208 0.69 0.38, 1.24 well-being. Overall, up to one in three breast cancer sur- Not available 31 0.54 0.14, 2.10 vivors reported QOL below the age- and residency- Number of <0.01 matched general female population. The major indepen- complications dent correlates of reporting overall QOL below that of None 187 1.00 - age-matched women without breast cancer were compli- Yes, one to four 413 2.26 1.31, 3.90 cations following surgery, poorer upper-body function, Upper-body function <0.01 higher perceived stress levels, and poor perception of Good function (<11) 301 1.00 - handling stress. Poor function (11+) 258 4.44 2.66, 7.40 Despite the known differences by geographic residence Missing 41 3.63 1.45, 9.07 with regards to access to services, availability of treat- Amount of stress <0.01 ment and survival outcomes, our results indicate only Very little/some 371 1.00 - minor disparities in QOL between urban and non-urban A moderate amount/ 229 4.77 2.93, 7.76 breast cancer survivors 12 months post-diagnosis. The a lot subscale measuring breast cancer-specific concerns Perceived handling of <0.01 stress yielded the lowest values (based on percent of maximum Very well/fairly well 526 1.00 - score) reported by all survivors, but in particular for Not well/not well at 74 4.24 2.21, 8.15 women living in non-urban areas. Items within this sub- all scale deal with treatment-related symptoms, such as Notes: swelling of the arms, pain, shortness of breath, body (a) Mutually adjusted for all variables in the model. image and sexuality. These results support existing (b) Odds ratio for QOL below the norm (R = 0.43). (c) Complications include wound infection, other infection, skin reaction, research which demonstrates that while QOL among seroma. breast cancer survivors improves considerably during the first year following completion of treatment, breast DiSipio et al. Health and Quality of Life Outcomes 2010, 8:3 Page 8 of 10 http://www.hqlo.com/content/8/1/3 cancer treatment-related concerns (such as arm dysfunc- experience lower QOL 12 months following diagnosis of tion, poor body image, and sexual dysfunction) may per- breast cancer. To our knowledge, despite Fayers suggest- sist [35-39]. ing advanced analytical procedures using normative It is plausible that non-urban survivors suffer in terms scores in 2000 [34], this is the first study to assess corre- of their breast cancer-specific QOL, more so than urban lates of lower QOL among breast cancer survivors in survivors, as a consequence of inequalities in accessing this manner. The results demonstrate that experiencing specialised services. However, study-specific data collec- one or more treatment-related complications, reporting tion procedures may also have contributed. QOL scores lower upper-body function than the median, moderate were derived from the third questionnaire for partici- to high stress levels and/or perceived poor handling of pants in the longitudinal urban breast cancer study, stress could reduce the odds of good QOL two- to four- whereas the first (and only) questionnaire was the fold. The cross-sectional nature of the data denotes that source of QOL data for non-urban breast cancer partici- these characteristics are correlates of QOL but not pants. Therefore urban survivors may have responded necessarily causes. Moreover, the relative QOL index differently to QOL questions over time, not only used to identify these correlates may be focusing on because their QOL changed, but also because they may those women with breast cancer who would have been have become used to answering questions about QOL in the lower part of the QOL range even before they and might have over time changed their perception of had the disease. Regardless, these correlates have rele- QOL. This response shift may, in part, explain what vance for identifying subgroups of breast cancer survi- appears to be a more positive breast cancer-specific vors who require assistance to regain QOL to levels QOL among urban survivors than non-urban survivors. expected among age-matched peers from the general However, the difference in QOL was observed on most population. but not all subscales, suggesting that response shift Several key design features of this work highlight the played a minor role in our findings. strength and importance of the findings. Results were On average, QOL was similar for breast cancer survi- obtained from population-based urban and non-urban vors and general population peers, for both urban and breast cancer samples, representative of their respective non-urban residents, similar to results reported by other target populations [20-22], and therefore results are authors studying QOL among breast cancer survivors 12 likely generalizable to the wider population of breast months [40,41] or longer [18,26,42] following diagnosis. cancer survivors. Further, QOL of survivors were com- The high FACT-G scores observed among breast cancer pared to peers without breast cancer, including match- survivors are somewhat surprising, because patients fre- ing for place of residence, allowing for more accurate quently report ongoing symptoms and long-term side- interpretation of meaning of results. At a glance, the effects [35,36,39]. High functional and social well-being results from this study suggest that, overall, women with reported by breast cancer survivors compared to their breast cancer fare well by 12 months following diagno- general population counterparts contributed to their sis; however, interventions are needed to improve breast overall high FACT-G score and contradicts previous cancer-related concerns among all women with breast research [18,26,40-42]. However, the literature is domi- cancer and physical well-being among non-urban survi- nated by studies using the European Organisation for vors. These should specifically recruit those survivors the Research and Treatment of Cancer QOL question- who experience complications following surgery, upper- naire (EORTC QLQ-C30) [18,26,40,41]. The social well- body dysfunction and/or those with a greater burden of being subscale of the EORTC QLQ-C30 and the FACT stress (i.e., higher amounts and/or poor self-perceived have been shown to be poorly correlated (r = 0.09) [43] handling of stress). Interventions that address such con- suggesting they measure different aspects of social well- cerns and that are accessible for all women, irrespective being. Furthermore, QOL domains measured by the of place of residence, may help facilitate a faster return FACT-G may be more relevant to short-term recovery. to optimal QOL in the future. Whereas 12 months or longer after diagnosis, alternate Conclusions issues may become more important for QOL, such as Overall, the QOL of breast cancer survivors living in fear of recurrence or making meaning of the cancer rural and urban areas was similar except for breast can- experience. More recently, survivorship-specific QOL cer related concerns being more dominant in women instruments have been developed, and further research from rural locations. Among all women about 20%-33% is needed to assess whether these will uncover additional have lower QOL one year past diagnosis compared to medium- to long-term survivorship issues [44]. age matched women from the general population with- Despite overall QOL similarities between survivors out breast cancer and thus could benefit from additional and their general population peers, up to one-third support and interventions. (depending on the subscale) of survivors continued to DiSipio et al. Health and Quality of Life Outcomes 2010, 8:3 Page 9 of 10 http://www.hqlo.com/content/8/1/3 10. Thompson B, Baade P, Coory M, Carriere P, Fritschi L: Patterns of surgical List of abbreviations treatment for women diagnosed with early breast cancer in ARIA+: Accessibility/Remoteness Index of Australia; CI: Queensland. Ann Surg Oncol 2008, 15(2):443-451. Confidence Interval; EORTC: European Organisation for 11. Australian Institute of Health and Welfare (AIHW): Rural, Regional and Remote Health: Indicators of Health. Canberra: AIHW (Rural Health Series the Research and Treatment of Cancer; FACT: Func- no. 5) 2005. tional Assessment of Cancer Therapy; FACT-G: Func- 12. Clinical Oncological Society of Australia: Mapping Rural and Regional tional Assessment of Cancer Therapy-General; FACT- Oncology Services in Australia. COSA 2006. 13. NHMRC National Breast Cancer Centre: Clinical Practice Guidelines for the GP: Functional Assessment of Cancer Therapy-General Management of Early Breast Cancer. Canberra: NHMRC, 2 2001. Population; FACTB+4: Functional Assessment of Cancer 14. Hegney D, Pearce S, Rogers-Clark C, Martin-McDonald K, Buikstra E: Close, Therapy-Breast additional four questions; OR: Odds but still too far. The experience of Australian people with cancer commuting from a regional to a capital city for radiotherapy treatment. Ratio; PTS: Pulling Through Study; QOL: Quality of Eur J Cancer Care 2005, 14(1):75-82. Life; QCRS: Queensland Cancer Risk Study. 15. Williams P, Rankin N, Redman S, Davis C, Armstrong B, Malycha P, Girgis A: National Survey of Women with Early Breast Cancer: Their Perceptions of Care (1997). Camperdown NSW: National Breast Cancer Centre 2004. Acknowledgements 16. McGrath P, Patterson C, Yates P, Treloar S, Oldenburg B, Loos C: A study of This work was supported by the National Breast Cancer Foundation, with postdiagnosis breast cancer concerns for women living in rural and research project funding for the Pulling Through Study, scholarship support remote Queensland. Part I: Personal concerns. Aust J Rural Health 1999, for the first author and fellowship support for the second author, and by the 7(1):34-42. Cancer Council Queensland for the Queensland Cancer Risk Study. Monika 17. Lyons M, Shelton M: Psychosocial impact of cancer in low-income rural/ Janda is supported by NHMRC-CDA-553034. urban women: Phase II. Online Journal of Rural Nursing and Health Care 2004, 4(2). Author details 18. Waldmann A, Pritzkuleit R, Raspe H, Katalinic A: The OVIS study: Health School of Public Health, Institute of Health and Biomedical Innovation, related quality of life measured by the EORTC QLQ-C30 and -BR23 in Queensland University of Technology, Victoria Park Road, Kelvin Grove, German female patients with breast cancer from Schleswig-Holstein. Queensland, 4059, Australia. Viertel Centre for Research in Cancer Control, Qual Life Res 2007, 16(5):767-776. Cancer Council Queensland, PO Box 201, Spring Hill, Queensland, 4004, 19. Schultz A, Winstead-Fry P: Predictors of quality of life in rural patients Australia. with cancer. Cancer Nurs 2001, 24(1):12-19. 20. Hayes S, Janda M, Cornish B, Battistutta D, Newman B: Lymphedema after Authors’ contributions breast cancer: Incidence, risk factors, and effect on upper body function. TD carried out data collection and analysis. SH, BN, and MJ supervised TD J Clin Oncol 2008, 26(21):3536-3542. and contributed to data interpretation and manuscript writing. JA supervised 21. Round T, Hayes S, Newman B: How do recovery advice and behavioural data collection at the Cancer Registry and provided critical input in data characteristics influence upper-body function and quality of life among collection, analysis and manuscript. All authors read and approved the final women 6 months after breast cancer diagnosis?. Support Care Cancer manuscript. 2006, 14(1):22-29. 22. DiSipio T, Hayes S, Newman B, Janda M: What determines the health- Competing interests related quality of life among regional and rural breast cancer survivors?. The authors declare that they have no competing interests. Aust N Z J Public Health 2009. 23. Commonwealth Department of Health and Aged Care: Measuring Received: 17 August 2009 Remoteness: Accessibility/Remoteness Index of Australia (ARIA). Revised Accepted: 7 January 2010 Published: 7 January 2010 Edition. Occassional Papers: New Series Number 14. Canberra 2001. 24. DiSipio T, Rogers C, Newman B, Whiteman D, Eakin E, Fritschi L, Aitken J: The Queensland Cancer Risk Study: Behavioural risk factor results. Aust N References Z J Public Health 2006, 30(4):375-382. 1. American Cancer Society: Breast Cancer Facts Figures 2007-2008. Atlanta: 25. Brucker P, Yost K, Cashy J, Webster K, Cella D: General population and American Cancer Society, Inc 2008. cancer patient norms for the Functional Assessment of Cancer Therapy- 2. Australian Institute of Health and Welfare (AIHW), Australasian Association General (FACT-G). Eval Health Prof 2005, 28(2):192-211. of Cancer Registries (AACR): Cancer in Australia: An overview, 2006. 26. Holzner B, Kemmler G, Cella D, De Paoli C, Meraner V, Kopp M, Greil R, Canberra: AIHW 2007. Fleischhacker W, Sperner-Unterweger B: Normative data for functional 3. Youlden D, Baade P, Coory M: Cancer Survival in Queensland, 2002. assessment of cancer therapy: General scale and its use for the Brisbane: Queensland Health and Queensland Cancer Fund 2005. interpretation of quality of life scores in cancer survivors. Acta Oncol 4. Richardson L, Wang W, Hartzema A, Wagner S: The role of health-related 2004, 43(2):153-160. quality of life in early discontinuation of chemotherapy for breast 27. Cella D: Manual of the Functional Assessment of Chronic Illness Therapy cancer. Breast J 2007, 13(6):581-587. (FACIT). Evanston: Center on Outcomes Research and Education (CORE), 5. Coates A, Gebski V, Signorini D, Murray P, McNeil D, Byrne M, Forbes J, Evanston Northwestern Healthcare and Northwestern University 1997. Australian New Zealand Breast Cancer Trials Group: Prognostic value of 28. Cella D, Tulsky D, Gray G, Sarafian B, Linn E, Bonomi A, Silberman M, quality-of-life scores during chemotherapy for advanced breast cancer. J Yellen S, Winicour P, Brannon J, et al: The Functional Assessment of Clin Oncol 1992, 10(12):1833-1838. Cancer Therapy scale: Development and validation of the general 6. Gupta D, Granick J, Grutsch J, Lis C: The prognostic association of health- measure. J Clin Oncol 1993, 11(3):570-579. related quality of life scores with survival in breast cancer. Support Care 29. Australian Bureau of Statistics (ABS): Australian Standard Classification of Cancer 2007, 15:387-393. Occupations. Canberra: ABS 1997. 7. Mols F, Vingerhoets A, Coebergh J, Poll-Franse van de L: Quality of life 30. Australian Taxation Office: Taxation Laws Amendment (Personal Income among long-term breast cancer survivors: A systematic review. Eur J Tax Reduction) Bill 2003 (No. 163 of 2002-03). Canberra: Australian Cancer 2005, 41:2613-2619. Government Publishing Service 2003. 8. Hall S, Holman C, Hendrie D, Spilsbury K: Unequal access to breast- 31. Solway S, Beaton D, McConnell S, Bombardier C: The DASH Outcome conserving surgery in Western Australia 1982-2000. ANZ J Surg 2004, Measure User’s Manual. Toronto: Institute for Work and Health, 2 2002. 74(6):413-419. 32. Centers for Disease Control and Prevention (CDC): Behavioral risk factor 9. Kricker A, Haskill J, Armstrong B: Breast conservation, mastectomy and surveillance system survey questionnaire. Atlanta, Georgia: US axillary surgery in New South Wales women in 1992 and 1995. Br J Cancer 2001, 85(5):668-673. DiSipio et al. Health and Quality of Life Outcomes 2010, 8:3 Page 10 of 10 http://www.hqlo.com/content/8/1/3 Department of Health and Human Services, Centers for Disease Control and Prevention 2001. 33. Australian Bureau of Statistics (ABS): 2001 Census of Population and Housing: Australia in Profile: A Regional Analysis. Canberra: ABS 2004. 34. Fayers P, Machin D: Quality of life: Assessment, analysis and interpretation. Chichester: Wiley & Sons 2000. 35. Engel J, Kerr J, Schlesinger-Rabb A, Sauer H, Holzel D: Axilla surgery severely affects quality of life: Results of a 5-year prospective study in breast cancer patients. Breast Cancer Res Treat 2003, 79(Supplement 1):47- 36. Ganz P, Desmond K, Leedham B, Rowland J, Meyerowitz B, Belin T: Quality of life in long-term, disease-free survivors of breast cancer: A follow-up study. J Natl Cancer Inst 2002, 94(1):39-49. 37. Heim E, Valach L, Schaffner L: Coping and psychosocial adaptation: Longitudinal effects over time and stages in breast cancer. Psychosom Med 1997, 59(4):408-418. 38. King M, Kenny P, Shiell A, Hall J, Boyages J: Quality of life three months and one year after first treatment for early stage breast cancer: Influence of treatment and patient characteristics. Qual Life Res 2000, 9(7):789-800. 39. Shimozuma K, Ganz P, Petersen L, Hirji K: Quality of life in the first year after breast cancer surgery: Rehabilitation needs and patterns of recovery. Breast Cancer Res Treat 1999, 56(1):45-57. 40. Arndt V, Merx H, Sturmer T, Stegmaier C, Ziegler H, Brenner H: Age-specific detriments to quality of life among breast cancer patients one year after diagnosis. Eur J Cancer 2004, 40(5):673-680. 41. Schou I, Ekeberg O, Sandvik L, Hjermstad M, Ruland C: Multiple predictors of health-related quality of life in early stage breast cancer. Data from a year follow-up study compared with the general population. Qual Life Res 2005, 14(8):1813-1823. 42. Ahn S, Park B, Noh D, Nam S, Lee E, Lee M, Kim S, Lee K, Park S, Yun Y: Health-related quality of life in disease-free survivors of breast cancer with the general population. Ann Oncol 2006, 18(1):173-182. 43. Holzner B, Bode R, Hahn E, Cella D, Kopp M, Sperner-Unterweger B, Kemmler G: Equating EORTC QLQ-C30 and FACT-G scores and its use in oncological research. Eur J Cancer 2006, 42(18):3169-3177. 44. Pearce N, Sanson-Fisher R, Campbell H: Measuring quality of life in cancer survivors: A methodological review of existing scales. Psychooncology 2008, 17(7):629-640. 45. Department of Health and Aged Care: National physical activity guidelines. Canberra: Commonwealth Department of Health and Aged Care 2005. doi:10.1186/1477-7525-8-3 Cite this article as: DiSipio et al.: Does quality of life among breast cancer survivors one year after diagnosis differ depending on urban and non-urban residence? A comparative study. Health and Quality of Life Outcomes 2010 8:3. Publish with Bio Med Central and every scientist can read your work free of charge "BioMed Central will be the most significant development for disseminating the results of biomedical researc h in our lifetime." 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Does quality of life among breast cancer survivors one year after diagnosis differ depending on urban and non-urban residence? A comparative study

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Springer Journals
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Copyright © 2010 by DiSipio et al; licensee BioMed Central Ltd.
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Medicine & Public Health; Quality of Life Research; Quality of Life Research
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1477-7525
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10.1186/1477-7525-8-3
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20059768
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Abstract

Background: This study examined the quality of life (QOL), measured by the Functional Assessment of Cancer Therapy (FACT) questionnaire, among urban (n = 277) and non-urban (n = 323) breast cancer survivors and women from the general population (n = 1140) in Queensland, Australia. Methods: Population-based samples of breast cancer survivors aged < 75 years who were 12 months post- diagnosis and similarly-aged women from the general population were recruited between 2002 and 2007. Results: Age-adjusted QOL among urban and non-urban breast cancer survivors was similar, although QOL related to breast cancer concerns was the weakest domain and was lower among non-urban survivors than their urban counterparts (36.8 versus 40.4, P < 0.01). Irrespective of residence, breast cancer survivors, on average, reported comparable scores on most QOL scales as their general population peers, although physical well-being was significantly lower among non-urban survivors (versus the general population, P < 0.01). Overall, around 20%-33% of survivors experienced lower QOL than peers without the disease. The odds of reporting QOL below normative levels were increased more than two-fold for those who experienced complications following surgery, reported upper-body problems, had higher perceived stress levels and/or a poor perception of handling stress (P < 0.01 for all). Conclusions: Results can be used to identify subgroups of women at risk of low QOL and to inform components of tailored recovery interventions to optimize QOL for these women following cancer treatment. Background QOL has been associated with adherence to treat- Breast cancer is a major public health concern, with one ment [4] and prognosis [5,6] and is now recognized as in eight women developing the disease before the age of an important research outcome. International research 85 years in developed countries of the world [1,2]. on factors that influence QOL among breast cancer Despite therapeutic advances, which have contributed to survivors has been extensive (over 300 published stu- improvements in survival (five-year survival currently dies in 2008 alone integrated QOL as an outcome). 87%) [3] women continue to experience considerable Socio-demographic (e.g., income), general health (e.g., physical and psychosocial dysfunction during and fol- medical conditions) and treatment (e.g., adjuvant ther- lowing treatment. While these quality of life (QOL) con- apy) characteristics each have been associated with cerns are short-lived for some, others may struggle to QOL [7], with the strength and consistency of the regain expected levels of QOL longer term. associations dependent on the characteristic of interest. Nevertheless, there remain subgroups of women for whom limited information on QOL is available, includ- * Correspondence: t.disipio@qut.edu.au ing those women who reside outside major metropoli- School of Public Health, Institute of Health and Biomedical Innovation, tan areas. This is important because approximately Queensland University of Technology, Victoria Park Road, Kelvin Grove, Queensland, 4059, Australia © 2010 DiSipio et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. DiSipio et al. Health and Quality of Life Outcomes 2010, 8:3 Page 2 of 10 http://www.hqlo.com/content/8/1/3 one-third of new breast cancer cases live outside major referred to as ‘urban’. Residents of inner regional, metropolitan areas [2]. remote and very remote areas were pooled as the ‘non- In Australia, geographic residence influences stage at urban’ group and reflect the reduced access to a range diagnosis and type of surgery, with those living in rural of oncology services experienced by those who live out- areas more likely to have a mastectomy than their urban side state capital cities, irrespective of the level of remo- counterparts (38% versus 25%, respectively) [8-10]. Geo- teness [12]. graphic residence also influences access to health ser- Eligible women, diagnosed with unilateral breast can- vices [11], as fewer than half of regional/rural hospitals cer at age 74 years or younger, were randomly selected administer chemotherapy [12], and fewer still provide through the Queensland Cancer Registry (target sam- radiotherapy services [13]. Further, rural Australian ple). All cancer diagnoses in Queensland are required to women often have to travel in excess of 100 kilometers be reported to the Registry and therefore these records (i.e., 62 miles) to receive adjuvant treatment and are provide an accurate sampling frame for recruitment. away from home for approximately 20 to 43 days for Since breast cancer is mostly a disease of women 50 yrs chemotherapy and radiotherapy treatment, respectively or older and to ensure adequate numbers were available [14,15]. Hence, it seems plausible that rural women with for specific age group analyses, younger women were breast cancer may have unique and additional burdens, over-sampled in the urban arm of the study, while 100% such as disruption to family life, work and financial of eligible non-urban women were recruited for all age security [14,16], which ultimately may influence QOL groups. Following appropriate ethical approval and the differently to that observed for women residing in urban requirements of the cancer registry, doctor consent to areas. contact eligible women (provided for 82% of the urban Research that compares QOL between urban and non- sample and 90% of the non-urban sample) and partici- urban cancer survivors is lacking, and from those stu- pant consent was sought. Overall, 277 urban and 323 dies that exist, results are inconsistent. Two studies sug- non-urban women returned completed quuestionnaires gest that rural breast cancer survivors fare worse at 12 months post-diagnosis (66% and 71% of eligible [17,18], while one indicates that QOL is superior among women with doctor consent for the urban and non- a rural group of mixed cancer survivors [19], when com- urban arms, respectively). pared with their urban counterparts. Further, there is a General population study sample paucity of information comparing the QOL among can- Following ethical approval, the general Queensland cer groups with that of the general population, making population sample was derived from the Queensland interpretation of findings challenging. Therefore, this Cancer Risk Study (QCRS), a population-based survey paper examines whether QOL differs between urban conducted in 2004 among English-speaking residents of and non-urban women 12 months following breast can- Queensland, aged 20-75 years, randomly sampled within cer diagnosis and compares their QOL with women strata defined by gender, age and geographic region from the general population residing in their respective (defined by the ARIA+ classification as as major city, geographic areas. We also sought to identify characteris- inner regional, outer regional or remote/very remote). tics of breast cancer survivors associated with reporting Further details about the study methods are described QOL below normative levels. elsewhere [24]. Briefly, of the 8,398 adults who agreed to participate in the self-administered questionnaire, Methods 5822 (69.3%) returned surveys, of which 2727 contained Breast cancer study samples QOL information. Analyses reported in this paper The Pulling Through Study (PTS) was a longitudinal, include women for whom QOL data were available and population-based study among breast cancer survivors who had no prior history of breast cancer, with 675 liv- living within 100 kilometers (i.e., 62 miles) of the capital ing in urban and 465 in non-urban areas of Queensland, city of Brisbane in Queensland, Australia, and diagnosed as defined by the ARIA+. in 2002 [20,21]. This study was extended to include sur- Questionnaires vivors from non-urban areas of Queensland, diagnosed QOL was measured among women with breast cancer at between April 2006 and March 2007 [22]. The Accessi- 12 months post-diagnosis using the Functional Assess- bility/Remoteness Index of Australia (ARIA+) classifica- ment of Cancer Therapy (FACT-G) questionnaire, tion system was used to define place of residence as which is comprised of 27 items rated on a five-point either major city, inner regional, outer regional, remote Likert scale (ranging from 0 = ‘notatall’ to 4 = ‘very or very remote, and is based on road distance and popu- much’) and includes four subscales (physical, social, lation size of the nearest town [23]. The selected local- emotional, and functional well-being). Higher scores ities within the perimeter of Brisbane fall within the represent better well-being. Women in the QCRS ARIA+ classification for major cities and hereafter are received the general population FACT instrument DiSipio et al. Health and Quality of Life Outcomes 2010, 8:3 Page 3 of 10 http://www.hqlo.com/content/8/1/3 (FACT-GP), which is identical to the FACT-G except it subscales between urban and non-urban breast cancer excludes six illness-related items inappropriate for the survivors or between women with breast cancer and general population [25,26]. Overall FACT-GP summary their general population peers were considered clinically scores and subscales were pro-rated as per the FACT important, as recommended by developers of the FACT manual to obtain scores comparable to the FACT-G [25]. For correlates, a difference in odds ratios (ORs) of [27], resulting in total scores for all study groups ran- ≥1.8 or ≤0.6 was considered to be of potential clinical ging from 0-108 for overall QOL, 0-28 for the physical, relevance. social, and functional well-being subscales, and 0-24 for As suggested by Fayers [34], a new outcome measure the emotional well-being subscale. Women with breast was calculated to characterize breast cancer survivors cancer also completed 13 questions on breast cancer whose QOL was below normative levels. QOL values concerns and arm morbidity (FACT-B+4), with total were calculated for each five-year age stratum of the scores from 0-52 for the breast cancer concerns sub- general population study group and subtracted from the scale, and 0-160 for overall FACT-B+4. The FACT QOL score within the same age group of women with instrument has excellent reliability and validity [28]. breast cancer (i.e., case FACT-G minus general popula- Demographic (age, marital status, educational level, tion comparison group FACT-G) separately by urban private health insurance, occupation [29,30] and and non-urban residence [34]. Positive scores indicate income), general health (smoking status, body mass higher QOL, and negative scores indicate lower QOL, index, co-morbidities, complications following surgery, among cases relative to age- (within five years) and resi- upper-body function [31], physical activity and stress dence-matched peers. Relative overall QOL (FACT-G) levels including perceived handling of stress) and treat- was then categorized into groups using score differen- ment (chemotherapy, radiotherapy, hormone therapy) tials considered clinically important to investigate the characteristics for the breast cancer study participants proportions of breast cancer survivors with relative were also obtained via the questionnaire, whereas infor- overall QOL lower than (-5.0 points or more), similar to mation on tumor characteristics were abstracted from (>-5.0 to < +5.0) or better than (+5.0 points or more) histopathology reports (e.g., type of surgery, maximum the general population study group. Relative QOL was tumor size and grade, and lymph node status). also calculated for each subscale, using two points as Statistical analysis the critical threshold. A dichotomous outcome variable Distributions of the FACT scores were approximately was defined, combining the ‘similar’ and ‘better’ groups, normal and hence were summarized as means with 95% and binary logistic regression was used to generate ORs confidence intervals (CIs) using SPSS (SPSS Inc, Chi- and 95% CIs to identify demographic, general health, cago, IL, version 14). Analysis of variance tests com- and clinical characteristics associated with QOL status pared age-adjusted mean QOL scores at 12 months below the norm compared to the ‘similar/better’ group. post-diagnosis between urban and non-urban breast A range of potentially important correlates were cancer survivors. Comparisons between breast cancer explored, however, only those that were found to be sta- survivors and women from the general population tistically significant or clinically important are reported. involved general linear regression models to obtain Formal tests of interactions between residence and each QOL scores adjusted for characteristics that differed of the characteristics of interest did not yield any statis- between the groups (i.e., potential confounding factors). tically significant results, therefore pooled results, Descriptive results presented in this study have been adjusted for residence, are presented. adjusted for the sampling fraction used to identify younger breast cancer patients from urban areas Results (weighting applied: < 50 years:1.0; ≥50 years:1.3). The Sample characteristics general population comparison group was also weighted Demographic and disease characteristics were similar for by age, based on Australian Bureau of Statistics data, so the women with breast cancer in this study and those in that results reflect the actual female Queensland resi- the target sample. The majority of women (75-80%) dent population (weighting applied for urban, regional, were diagnosed with infiltrating ductal carcinoma, outer regional, remote and very remote: < 50 years:1.3, approximately 60% received complete local excision of 1.3, 1.4, 1.5 and 0.9, respectively; ≥50 years:0.8, 0.8, 0.7, their tumour and more than 50% had 10 or more lymph 0.6 and 1.1, respectively) [33]. The conventional P < nodes removed. However, participants among urban 0.05 level (two-tailed) was accepted as statistically signif- breast cancer survivors had somewhat smaller tumor icant. Differences of eight or more points in mean size (median tumour size was 14 mm) when compared FACT-B+4 scores, five or more points in mean FACT-G with the target sample [20-22]. For the majority of scores, three or more points on the breast cancer con- demographic and general health characteristics, women cerns subscale and two or more points for all other with breast cancer had similar characteristics, DiSipio et al. Health and Quality of Life Outcomes 2010, 8:3 Page 4 of 10 http://www.hqlo.com/content/8/1/3 Table 1 Participant Characteristics Characteristics Urban general Urban breast cancer Non-urban general Non-urban breast cancer a b a population (n = 675) survivors (n = 277) population (n = 465) survivors (n = 323) n % n% n% n% Demographic characteristics Age (years) * <50 298 57.0 99 30.0 185 55.6 107 33.1 50+ 377 43.0 178 70.0 280 44.4 216 66.9 Marital status * † Married, or living as married 520 77.6 186 66.6 361 80.1 248 76.8 Not married 155 22.4 91 33.4 104 19.9 75 23.2 Education level * * Grade 10 or below 219 30.2 125 46.5 186 37.0 173 53.6 Grade 12/Trade/TAFE 278 42.5 95 33.7 183 40.7 102 31.6 University or college degree 178 27.3 57 19.9 96 22.3 48 14.9 Private health insurance status * † Yes 398 58.0 200 72.4 222 48.5 140 43.3 No 277 42.0 77 27.6 243 51.5 183 56.7 General health characteristics Smoking status Never smoked 364 53.6 163 59.3 250 52.9 184 57.0 Past smoker 216 31.2 84 30.0 149 31.7 102 31.6 Current smoker 95 15.2 30 10.7 66 15.3 37 11.5 Physical activity * Sedentary 94 17.5 34 12.6 81 13.7 68 21.1 Insufficient activity 194 27.9 67 23.9 125 29.4 55 17.0 Sufficient activity 387 54.6 176 63.5 259 57.0 200 61.9 Body mass index (kg/m)* † Underweight/Normal (up to 335 41.5 108 38.5 183 50.7 116 35.9 24.9) Overweight (25-29.9) 203 27.4 80 29.0 134 29.6 91 28.2 Obese (30+) 106 25.1 55 20.0 119 14.9 100 31.0 Missing 31 6.0 34 12.5 29 4.7 16 5.0 d † Number of co-morbidities ** None 126 21.6 68 23.8 84 21.4 55 17.0 One 158 19.0 68 23.7 79 24.7 74 22.9 Two 133 19.7 69 25.6 95 19.2 79 24.5 Three or more 258 39.6 72 27.0 206 34.7 115 35.6 Clinical characteristics Adjuvant treatment - - - - † None 42 15.8 59 18.3 Chemotherapy only 34 11.3 33 10.2 Radiotherapy only 119 43.8 105 32.5 Both 82 29.1 126 39.0 Number of complications -- - - † None 54 19.7 133 41.2 Yes, one to four 223 80.3 190 58.8 Abbreviations: * Statistically significant difference (P < 0.05) between the general population and breast cancer survivors by place of location. † Statistically significant difference (P < 0.05) between urban and non-urban breast cancer survivors. Notes: (a) Column percentages are standardized to the 2003 Queensland population by age. (b) Column percentages have been weighted to correct for sampling. (c) ‘Sedentary’ is defined as no activity; ‘Insufficient’ time is defined as participating in some activity but less than 150 minutes per week, using the sum of walking, moderate activity and vigorous activity (weighted by 2); ‘Sufficient’ time is defined as 150 minutes per week, using the sum of walking, moderate activity and vigorous activity (weighted by 2) [45]. (d) Co-morbidities include heart conditions, high blood pressure, high cholesterol, stroke, diabetes, lung conditions, stomach or duodenal ulcer, migraine or headaches, arthritis, cancer other than breast, depression and other prolonged or serious illness. (e) Complications include wound infection, other infection, skin reaction, seroma. DiSipio et al. Health and Quality of Life Outcomes 2010, 8:3 Page 5 of 10 http://www.hqlo.com/content/8/1/3 Table 2 QOL scores at 12 months post-diagnosis for urban and non-urban breast cancer survivors Quality of life Urban breast cancer survivors (n Non-urban breast cancer Differences between residence = 277) survivors (n = 323) groups a a b Mean 95% CI Mean 95% CI P-Value clinical Physical well-being (0-28) 24.7 24.1, 25.2 22.8 22.3, 23.3 < 0.01 ✗ Social well-being (0-28) 22.7 22.0, 23.4 22.5 21.8, 23.1 0.67 ✗ Emotional well-being (0-24) 20.1 19.6, 20.5 19.2 18.7, 19.6 < 0.01 ✗ Functional well-being (0-28) 22.4 21.8, 23.1 21.7 21.1, 22.3 0.09 ✗ Breast cancer concerns (0-52) 40.4 39.5, 41.4 36.8 36.0, 37.7 < 0.01 ✓ FACT-G (0-108) 89.7 87.9, 91.5 86.3 84.7, 88.0 < 0.01 ✗ FACT-B+4 (0-160) 130.2 127.7, 132.7 122.6 120.3, 125.0 < 0.01 ✗ Abbreviations: FACT-G: Functional Assessment of Cancer Therapy-General; FACTB+4: Functional Assessment of Cancer Therapy-Breast additional four questions. Notes: (a) Adjusted for age. (b) ✗: clinically meaningful difference between groups (two+ points for physical, social, emotional and functional well-being, three+ points for breast cancer concerns, five+ points for FACT-G, eight+ points for FACT-B+4); ✓: no clinically meaningful difference between groups. irrespective of place of residence. However, the urban breast cancer survivors were more likely to be single, compared to the non-urban breast cancer sample was have private health insurance, and/or fewer co-morbid- more likely to be unmarried, have private health insur- ities (other than breast cancer), while non-urban breast ance and report fewer co-morbidities, and less likely to cancer survivors were more likely to be sedentary and/ be obese (Table 1). Non-urban compared to urban or have two or more co-morbidities (other than breast women with breast cancer were more likely to have cancer), when compared with their general population multiple forms of adjuvant therapy and less likely to counterparts. While there was a significant (P <0.05) report multiple complications. difference in body mass index between urban breast A comparison of women with or without breast can- cancer survivors and their general population peers, this cer showed significant differences for several demo- was attenuated when missing values were omitted from graphic and general health characteristics (Table 1). analyses. Breast cancer survivors tended to be older or have lower QOL among urban and non-urban breast cancer survivors educational levels when compared with the general Although urban breast cancer survivors reported higher population, irrespective of residence. In addition, urban age-adjusted QOL summary and subscale scores than Table 3 Adjusted mean QOL for women with breast cancer compared with the general population stratified by residence location Quality of life Residence General population Breast cancer survivors Difference between groups a a b Mean 95% CI Mean 95% CI P-Value clinical Physical well-being (0-28) urban 25.0 24.8, 25.3 24.2 23.8, 24.6 < 0.01 ✗ non-urban 25.1 24.7, 25.5 22.7 22.2, 23.2 < 0.01 ✓ Social well-being (0-28) urban 19.9 19.5, 20.4 22.4 21.6, 23.2 < 0.01 ✓ non-urban 19.6 19.0, 20.2 22.4 21.7, 23.1 < 0.01 ✓ Emotional well-being (0-24) urban 21.1 20.8, 21.4 19.6 19.1, 20.0 < 0.01 ✗ non-urban 20.9 20.5, 21.2 19.2 18.8, 19.7 < 0.01 ✗ Functional well-being (0-28) urban 20.6 20.2, 21.1 22.0 21.3, 22.7 < 0.01 ✗ non-urban 20.2 19.7, 20.8 21.6 21.0, 22.3 < 0.01 ✗ FACT-G (0-108) urban 86.9 85.8, 88.0 88.0 86.3, 89.8 0.28 ✗ non-urban 85.8 84.4, 87.3 86.2 84.4, 87.9 0.79 ✗ Abbreviations: FACT-G: Functional Assessment of Cancer Therapy-General. Notes: (a) Adjusted for age (years), marital status (married or living as married, not married), education level (low, moderate, high), private health insurance status (yes, no), smoking status (never smoked, past smoker, current smoker), physical activity (sedentary, insufficient, sufficient), body mass index (underweight/healthy, overweight, obese, missing), and co-morbidities (none, one, two, three or more). (b) ✗: clinically meaningful difference between groups (two+ points for physical, social, emotional and functional well-being, five+ points for FACT-G); ✓:no clinically meaningful difference between groups. DiSipio et al. Health and Quality of Life Outcomes 2010, 8:3 Page 6 of 10 http://www.hqlo.com/content/8/1/3 Figure 1 Proportions of breast cancer survivors whose relative QOL at 12 months post-diagnosis was lower than, similar to, or better than general population peers. their non-urban counterparts 12 months following diag- non-urban breast cancer survivors also reported clini- nosis, differences did not reach the threshold for clinical cally lower physical well-being (P < 0.01 for all). Scores importance even for those subscales that were statisti- for emotional, functional and overall (FACT-G) QOL cally significant (physical, emotional, and overall QOL, P were clinically comparable to their counterparts from < 0.01). In contrast, well-being related to breast cancer the general population despite a statistically significant concerns was lower among non-urban compared to difference for emotional and functional well-being (P < urban survivors by statistical (P < 0.01) and clinical cri- 0.01). teria (Table 2). Furthermore, for both groups, women Using the new outcome measure of QOL relative to reported most detriment to their QOL for this subscale, age and residency-matched women from the general with participants reporting mean values below 80% of population, depending on the specific QOL scale, the maximum score on average. Participants reported between 17.2% and 32.8% of all women with breast can- mean values at approximately 80% of the maximum cer reported clinically lower QOL 12 months following score for all other subscales. diagnosis than age- (within five years) and residence- matched women without the disease. A further 17.5%- Breast cancer survivors’ QOL compared to the general 48.5% of women reported similar QOL, while the population remainder (19.8%-65.3%) reported clinically better QOL Table 3 presents the subscale and overall mean FACT-G (Figure 1). The subscales with the highest proportions scores for breast cancer survivors compared with below the norm were emotional (32.8%) and physical women from the general population, stratified by resi- (29.3%) well-being, and overall QOL (26.2%). dence and adjusted for potential confounding factors. At Characteristics associated with QOL below normative 12 months post-diagnosis, urban and non-urban breast levels among breast cancer survivors cancer survivors reported clinically higher social well- Following adjustment for potential confounding factors, being compared with their general population peers, and a range of characteristics were associated with breast DiSipio et al. Health and Quality of Life Outcomes 2010, 8:3 Page 7 of 10 http://www.hqlo.com/content/8/1/3 Table 4 Correlates of QOL (FACT-G) below the norm at 12 cancer survivors reporting overall (FACT-G) QOL below months post-diagnosis among breast cancer survivors normativelevels(Table4), butplace of residence(i.e., Characteristics Model urban versus non-urban) was not one of these (Odds Ratio (OR) = 1.06; 95% Confidence interval (CI) = 0.64- nOR 95% CI P-Value 1.74). Experiencing one or more complications following Place of residence 0.82 surgery was associated with two-fold increased odds Urban 277 1.00 - (OR = 2.26, 95% CI = 1.31-3.90; P < 0.01) of reporting Non-urban 323 1.06 0.64, 1.74 reduced QOL, while upper-body function below the Age (years) 0.21 median, moderate or higher stress levels and poor per- <50 205 1.00 - ceived handling of stress were each associated with at 50+ 395 0.72 0.43, 1.20 least four-fold increased odds of reporting reduced QOL Occupation 0.38 (ORs ranging from 4.24-4.77, P < 0.01, see Table 4). A Professional 182 1.00 - marker of higher socioeconomic status, having private White-collar worker 176 1.16 0.64, 2.11 health insurance, was associated with a 0.6 odds of Blue-collar worker 31 2.53 0.95, 6.76 reporting lower relative QOL (95% CI = 0.37-0.99, P = Homemaker 106 1.29 0.63, 2.62 0.05). Retired/student 105 0.92 0.43, 1.96 Yearly income 0.15 <$52,000 336 1.00 - Discussion $52,000+ 207 0.60 0.35, 1.04 Urban and non-urban breast cancer survivors reported Missing 57 0.66 0.28, 1.55 similar levels of QOL 12 months following diagnosis, Private health insurance 0.05 status overall and for subscales. The sole exception was the No 217 1.00 - breast cancer concerns subscale, which showed that Yes 383 0.61 0.37, 0.99 non-urban residents fared worse than their urban coun- Overall histological 0.34 terparts. When comparing breast cancer survivors to grade age- and residence-matched peers, the only detriment to Grade 1 142 1.00 - QOL was among non-urban breast cancer survivors Grade 2 219 0.58 0.32, 1.06 who reported statistically and clinically poorer physical Grade 3 208 0.69 0.38, 1.24 well-being. Overall, up to one in three breast cancer sur- Not available 31 0.54 0.14, 2.10 vivors reported QOL below the age- and residency- Number of <0.01 matched general female population. The major indepen- complications dent correlates of reporting overall QOL below that of None 187 1.00 - age-matched women without breast cancer were compli- Yes, one to four 413 2.26 1.31, 3.90 cations following surgery, poorer upper-body function, Upper-body function <0.01 higher perceived stress levels, and poor perception of Good function (<11) 301 1.00 - handling stress. Poor function (11+) 258 4.44 2.66, 7.40 Despite the known differences by geographic residence Missing 41 3.63 1.45, 9.07 with regards to access to services, availability of treat- Amount of stress <0.01 ment and survival outcomes, our results indicate only Very little/some 371 1.00 - minor disparities in QOL between urban and non-urban A moderate amount/ 229 4.77 2.93, 7.76 breast cancer survivors 12 months post-diagnosis. The a lot subscale measuring breast cancer-specific concerns Perceived handling of <0.01 stress yielded the lowest values (based on percent of maximum Very well/fairly well 526 1.00 - score) reported by all survivors, but in particular for Not well/not well at 74 4.24 2.21, 8.15 women living in non-urban areas. Items within this sub- all scale deal with treatment-related symptoms, such as Notes: swelling of the arms, pain, shortness of breath, body (a) Mutually adjusted for all variables in the model. image and sexuality. These results support existing (b) Odds ratio for QOL below the norm (R = 0.43). (c) Complications include wound infection, other infection, skin reaction, research which demonstrates that while QOL among seroma. breast cancer survivors improves considerably during the first year following completion of treatment, breast DiSipio et al. Health and Quality of Life Outcomes 2010, 8:3 Page 8 of 10 http://www.hqlo.com/content/8/1/3 cancer treatment-related concerns (such as arm dysfunc- experience lower QOL 12 months following diagnosis of tion, poor body image, and sexual dysfunction) may per- breast cancer. To our knowledge, despite Fayers suggest- sist [35-39]. ing advanced analytical procedures using normative It is plausible that non-urban survivors suffer in terms scores in 2000 [34], this is the first study to assess corre- of their breast cancer-specific QOL, more so than urban lates of lower QOL among breast cancer survivors in survivors, as a consequence of inequalities in accessing this manner. The results demonstrate that experiencing specialised services. However, study-specific data collec- one or more treatment-related complications, reporting tion procedures may also have contributed. QOL scores lower upper-body function than the median, moderate were derived from the third questionnaire for partici- to high stress levels and/or perceived poor handling of pants in the longitudinal urban breast cancer study, stress could reduce the odds of good QOL two- to four- whereas the first (and only) questionnaire was the fold. The cross-sectional nature of the data denotes that source of QOL data for non-urban breast cancer partici- these characteristics are correlates of QOL but not pants. Therefore urban survivors may have responded necessarily causes. Moreover, the relative QOL index differently to QOL questions over time, not only used to identify these correlates may be focusing on because their QOL changed, but also because they may those women with breast cancer who would have been have become used to answering questions about QOL in the lower part of the QOL range even before they and might have over time changed their perception of had the disease. Regardless, these correlates have rele- QOL. This response shift may, in part, explain what vance for identifying subgroups of breast cancer survi- appears to be a more positive breast cancer-specific vors who require assistance to regain QOL to levels QOL among urban survivors than non-urban survivors. expected among age-matched peers from the general However, the difference in QOL was observed on most population. but not all subscales, suggesting that response shift Several key design features of this work highlight the played a minor role in our findings. strength and importance of the findings. Results were On average, QOL was similar for breast cancer survi- obtained from population-based urban and non-urban vors and general population peers, for both urban and breast cancer samples, representative of their respective non-urban residents, similar to results reported by other target populations [20-22], and therefore results are authors studying QOL among breast cancer survivors 12 likely generalizable to the wider population of breast months [40,41] or longer [18,26,42] following diagnosis. cancer survivors. Further, QOL of survivors were com- The high FACT-G scores observed among breast cancer pared to peers without breast cancer, including match- survivors are somewhat surprising, because patients fre- ing for place of residence, allowing for more accurate quently report ongoing symptoms and long-term side- interpretation of meaning of results. At a glance, the effects [35,36,39]. High functional and social well-being results from this study suggest that, overall, women with reported by breast cancer survivors compared to their breast cancer fare well by 12 months following diagno- general population counterparts contributed to their sis; however, interventions are needed to improve breast overall high FACT-G score and contradicts previous cancer-related concerns among all women with breast research [18,26,40-42]. However, the literature is domi- cancer and physical well-being among non-urban survi- nated by studies using the European Organisation for vors. These should specifically recruit those survivors the Research and Treatment of Cancer QOL question- who experience complications following surgery, upper- naire (EORTC QLQ-C30) [18,26,40,41]. The social well- body dysfunction and/or those with a greater burden of being subscale of the EORTC QLQ-C30 and the FACT stress (i.e., higher amounts and/or poor self-perceived have been shown to be poorly correlated (r = 0.09) [43] handling of stress). Interventions that address such con- suggesting they measure different aspects of social well- cerns and that are accessible for all women, irrespective being. Furthermore, QOL domains measured by the of place of residence, may help facilitate a faster return FACT-G may be more relevant to short-term recovery. to optimal QOL in the future. Whereas 12 months or longer after diagnosis, alternate Conclusions issues may become more important for QOL, such as Overall, the QOL of breast cancer survivors living in fear of recurrence or making meaning of the cancer rural and urban areas was similar except for breast can- experience. More recently, survivorship-specific QOL cer related concerns being more dominant in women instruments have been developed, and further research from rural locations. Among all women about 20%-33% is needed to assess whether these will uncover additional have lower QOL one year past diagnosis compared to medium- to long-term survivorship issues [44]. age matched women from the general population with- Despite overall QOL similarities between survivors out breast cancer and thus could benefit from additional and their general population peers, up to one-third support and interventions. (depending on the subscale) of survivors continued to DiSipio et al. Health and Quality of Life Outcomes 2010, 8:3 Page 9 of 10 http://www.hqlo.com/content/8/1/3 10. Thompson B, Baade P, Coory M, Carriere P, Fritschi L: Patterns of surgical List of abbreviations treatment for women diagnosed with early breast cancer in ARIA+: Accessibility/Remoteness Index of Australia; CI: Queensland. 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