Psychosocial Issues and Needs of Older Women with Breast Cancer.

1
"Psychosocial Issues and Needs of Older Women
with Breast Cancer."

• Melissa Figueiredo
• Cancer Control Program, Lombardi Cancer Center
  Georgetown University Medical Center

2
Overview

• Background on breast cancer in older women
• Psychological needs of older women with breast
  cancer
• Psychological reactions to cancer
• Complementary and Alternative Medicine Use
• Influence of Patient-Provider Interactions
• Current research on a cohort of older women with
  breast cancer
• Project with CALGB
• Directions for future research

3
Background

• It is expected that cancer rates will double from
  1.3 million people in 2000 to 2.6 million people
  in 2050 diagnosed with cancer.
• In addition, the number of cancer patients over
  age 84 is expected to increase four times from
  2000 to 2050.
• Although there has been an overall decline in
  U.S., cancer death rates, cancer burden will rise
  with aging population. Even if cancer rates
  remain constant, the number of people diagnosed
  with cancer will increase. (Edwards et al.,
  2002).

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Incidence of and Mortality from Breast Cancer and
Age (modified from Yancik Ries 2000)
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Cancer biology and age (Kimmick Balducci, 2000).

• Breast cancer becomes more slow-growing by age
  through the following mechanisms
• Increased prevalence of hormone-receptor rich
  tumors.
• Increased prevalence of well differentiated
  tumors.
• Increased prevalence of tumors with low
  proliferation rate.
• Decreased production of tumor growth factors by
  the older woman.
• Decreased estrogen production.

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Barriers to participation of older women in
clinical trials (Trimble et al.,1994 Balducci,
2000)

• Research focus on aggressive therapy, which may
  be unacceptably toxic to the elderly
• The presence of comorbidity
• Inadequate information and comprehension of the
  consent mechanism
• Fatalistic attitudes towards aging and diseases
• Fewer trials specifically aimed at older patients
• Limited expectations for long-term benefits from
  physicians, relatives, and the patients
  themselves
• Lack of support from family members and
  healthcare providers

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Cancer is an acute and chronic disease

• Literature on social work suggests
• Assess developmental stage (Rather than
  chronological age)
• Examine concurrent life stressors
• Account for patients personal interpretation of
  the meaning of the cancer diagnosis.

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Psychological reactions to a cancer diagnosis

• Older persons may have difficulty coping
• Emotional and financial resources may be depleted
• May live alone or without assistance
• Older people (56-75) with cancer reported
  receiving less support than younger people with
  cancer but expressed greater satisfaction with
  interactions with health care providers,
  suggesting they had lower expectations than other
  age groups (Rose, 1993).
• May have already begun to think about their own
  mortality (Scholssberg, 1984).
• Single people have higher death rates from
  cancer, especially if they are older and are part
  of a lower SES group (Andersen, 1992).

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Mean profile of Mood States negative affect
scores of patients with local breast cancer over
time by age (adapted from Mor, Allen, Malin,
1994)
10
Complementary and Alternative Therapy (CAM) Use
in Women with Breast Cancer

• CAM therapies include
• Dietary
• Herbal
• Mental
• Meditation
• Guided imagery
• Hypnosis
• Biofeedback
• Spiritual healing

• Physical
• Acupuncture
• Acupressure, reflexology
• Massage therapy
• Body work
• Yoga, Tai Chi, Chi Gong

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Predictors of Complementary Alternative Therapy
Use (Lee, Lin, Wrensch, Adler, Eisenberg, 2000
Cushman, Wade, Factor-Litvak et al. 1999)

• Higher educational level or income
• Younger age
• Private insurance
• Regular exercise or attendance at a support
  group.
• In a survey study of breast cancer patients in
  San Francisco
• African American women used spiritual healing
  more frequently than other types of CAM
• Chinese women most often reported using herbal
  remedies
• Latina women used dietary therapies and spiritual
  healing the most.

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Factors used to select adjuvant therapy of breast
cancer

• Age, race, and socioeconomic status play a role
  in decisions regarding breast cancer adjuvant
  therapy.
• More than half of all new breast cancers in the
  U.S. occur in women older than 65 years.
• Older women are less likely to receive
  chemotherapy and are less likely to be offered
  participation in clinical trials.
• Only 9 of breast cancer patients in Southwest
  Oncology Group treatment trials were 65 years of
  age or older compared with population and and
  census estimates that suggest 49 of women with
  breast cancer during this time period were 65
  years and older.

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Sociocultural Influences on Womens Health

• Socioeconomic status (SES) is related to health
  (Adler, Boyce, Chesney, Folkman, Syme, 1993),
  whereby lower SES and lower education levels are
  associated with higher levels of morbidity and
  mortality.
• Women of lower SES have 25 higher death rates
  from breast cancer (USDHHS, 1990)

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Sociocultural Influences on health II

• The age-adjusted incidence rate for breast cancer
  in Caucasian women (114 per 100,000) in the
  United States is higher than the incidence rate
  in African American women (100.2 per 100,000).
• However, the age-adjusted mortality rate for
  breast cancer in African American women (31.4 per
  100,000) is higher than the mortality rate in
  Caucasian women (25.3 per 100,000) and all other
  groups of women of color (Greenlee, Hill-Harmon,
  Murray, Thun, 2001).

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The Influence of Patient-Provider Interactions

• Negative attitudes towards older cancer patients
  have been documented (Kearney, Miller, Paul,
  Smith, 2000).
• Among women with local stage breast cancer,
  perceived ageism and racism in health care were
  associated with less aggressive local surgical
  and radiation therapy (Mandelblatt et al. 2002).

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Purpose of body image study

• Part of a large-scale study of older women with
  breast cancer, their treatment preferences and
  physician influences.
• Body image concerns, rarely studied in older
  women, are one domain of quality of life.
• Determine whether body image predicts emotional
  well-being of older women with breast cancer one
  and two years after diagnosis and surgery.

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Methods

• Women aged 67 or more years
• Newly diagnosed breast cancer from 29 hospitals
  in five geographic areas (Massachusetts, Texas,
  Washington DC, upstate New York, and New York
  City)
• Primary stage 1, 2a, or 2b, histologically
  confirmed invasive breast cancer
• Patient interviews and review of medical records.
  
• Baseline interviews 3 months post-surgery.
• 12 and 24 months post-surgical treatment 20-30
  minute telephone follow-up interview.

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Methods cont

• Outcome variables
• MOS-SF36. This measures physical functioning and
  mental health and other quality of life domains.
  Widely used. Good reliability and validity
  (Hays, Sherbourne, Mazel. 1993).
• Predictor variables
• Body image. 4-item scale from the CARES short
  form. Reliabilities at time one (alpha .78) and
  time two (alpha .80) were good. Higher scores
  indicate more concerns about body image.
• Satisfaction.
• Impact.
• Choice.
• Baseline depression and anxiety. Single item
  questions.
•  Comorbidities

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Results

• After controlling for demographics and medical
  variables (age, marital status, type of medical
  treatment and number of co- morbidities) as well
  as baseline measures of depression, anxiety, and
  satisfaction with appearance, body image concerns
  at one year predicted mental health at one-year
  follow-up (beta -1.8, SE .42, p multiple regression analysis. In addition, body
  image at year two predicted mental health at year
  two (beta -2.13, SE .41, p
• Womens ratings of their body image at year one
  predicted their ratings of the impact they felt
  breast cancer had made on their lives two years
  after treatment (beta .12, SE .02, p 0.0001).

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Limitations

• Self-selected convenience sample from larger
  study
• Generalizability limited to predominately white,
  middle to upper middle class women from the five
  geographic regions

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Implications and Conclusions

• These results reinforce the need to attend to
  quality of life issues facing older women with
  breast cancer.
• Women with higher initial levels of body image
  concerns may be at risk for lower levels of
  emotional well-being over the course of time.

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Current study with CALGB

• Under use of chemotherapy is one of the key
  problems in the quality of cancer care recently
  identified by the Institute of Medicine.
• Assess chemotherapy decision making in older
  women with breast cancer.
• Data collection to start later this summer or fall

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Research priorities related to cancer and aging
(Balducci, 2000)

• Exploration of alternative forms of clinical
  trials
• Accommodate alternative outcomes, meaningful for
  individual patients. With more limited life
  expectancy, the effect of treatment on quality of
  life is paramount.
• User-friendly to accommodate people with limited
  mobility and resources.
• Intensive effort to improve professional and
  personal education to gain public support for
  clinical research in the older person
• Exploration of new and safer forms of cancer
  treatment in older individuals.

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Future Directionsreducing cancer burden

• Improved interactional information support from
  physicians to reduce age and ethnic group
  treatment disparities in breast cancer.
• Inclusion in clinical trials and assessment of
  quality of life in order to interpret clinical
  trials research
• Attention to severity of comorbidity, not merely
  the number of comorbidities
• Attention to functional, social, emotional and
  cognitive well-being of all women, regardless of
  age.

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References

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References III

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