Unfounded fear prompts young breast cancer patients to remove healthy breasts

Despite evidence that contralateral prophylactic mastectomy (CPM) does not improve survival rates, an increasing number of young women with breast cancer elect to remove their healthy breast to avoid recurrence and improve survival.

Researchers surveyed 123 women aged 40 or younger without known bilateral breast cancer who reported having bilateral mastectomy. The purpose of the survey was to better understand how women approach the decision to have CPM. The survey included questions about the women’s health history, reason for choosing CPM, and knowledge and perceptions about breast cancer.

Most of the women (n = 97) had stage I or stage II breast cancer and 60 percent of tumors were estrogen receptor-positive. Almost all (98 percent) of the women surveyed indicated that desires to decrease their risk for contralateral breast cancer (CBC) prompted their decision to remove the healthy breast. Although 94 percent of the women surveyed said they chose bilateral mastectomy to increase survival, only 18 percent reported thinking that CPM improved survival rates.

Almost all of the women surveyed overestimated the actual risk of CBC. While physicians were identified as the most important sources of information about breast cancer, only one-third of the women cited a desire to follow a physician’s recommendations as an extremely or very important factor in their decision.

The authors suggest that this survey underscores a need for better risk communication strategies that help patients make decisions based on evidence.

Rosenberg et al., (2013). Perceptions, Knowledge, and Satisfaction With Contralateral Prophylactic Mastectomy Among Young Women With Breast Cancer. A Cross-sectional Survey. Ann. Intern. Med.159: 373-381. doi:10.7326/0003-4819-159-6-201309170-00003 [Article]

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Cancer ‘prehabilitation’ can reduce complications and improve treatment outcomes

Time between diagnosis and treatment provides ‘window of opportunity’ to optimize health

For patients with cancer, “prehabilitation”— interventions given between the time of diagnosis and the start of treatment—has the potential to reduce complications from treatments and improve physical and mental health outcomes, according to a report in the August American Journal of Physical Medicine & Rehabilitation, the official journal of the Association of Academic Physiatrists.

“A growing body of evidence supports preparing newly diagnosed cancer patients for and optimizing their health before starting acute treatments,” write Drs. Julie K. Silver and Jennifer Baima of Harvard Medical School. Their article, titled Cancer Prehabilitation: An Opportunity to Decrease Treatment-Related Morbidity, Increase Cancer Treatment Options, and Improve Physical and Psychological Health Outcomes, is the first comprehensive review of the topic.

“There is a rather long and impressive history of using prehabilitation to improve orthopedic surgical outcomes,” Dr. Silver comments. “Our new review shows that there is a unique opportunity to help many people who have been newly diagnosed with cancer to improve their physical and emotional outcomes.”

Cancer Prehabilitation—Getting Patients in Best Possible Shape for Treatment

The goal of cancer prehabilitation is to prevent or lessen the severity of anticipated treatment-related problems that could lead to later disability. Immediately after diagnosis, patients undergo physical and psychological assessments to establish their baseline level of function and identify any current impairment, and provide targeted interventions to reduce the risk and severity of future impairments.

Traditionally, pretreatment interventions focused on aerobic conditioning to build patients’ general strength and stamina. But recent studies have shown that more directed interventions can improve outcomes in patients with specific cancers: for example, swallowing exercises before surgery for head or neck cancer, smoking cessation to improve breathing function before lung cancer surgery, or pelvic floor exercises to reduce problems with urinary incontinence after surgery for prostate cancer.

Some studies have shown that prehabilitation interventions, individually or in combination, can increase the range of treatment options, lower complication rates, and improve physical and mental health outcomes. Benefits include a reduced risk of hospital readmission and lower health care costs.

Cancer prehabilitation seems more effective when it includes both physical and psychological interventions. Providing psychosocial support immediately after diagnosis has improved treatment outcomes for patients with prostate, breast, and ovarian cancer. Future studies may show that prehabilitation can increase patients’ ability to complete their recommended treatment—thus improving their chances of survival.

Drs. Silver and Baima emphasize that cancer prehabilitation should follow an individualized approach, “identifying current and anticipating future impairments as a critical first step in improving healthcare outcomes and decreasing costs.” They liken cancer prehabilitation to a puzzle, with individual approaches put together in combinations that best meet the needs of the individual patient.

While patients may fear that delaying cancer treatment may reduce their risk of survival, there’s typically some waiting period before treatment begins. This time—whether it’s a few days or a few weeks—may provide a “window of opportunity” for prehabilitation interventions to address physical and psychological issues. Drs. Silver and Baima write, “Newly diagnosed cancer patients are often seeking ways to become immediately involved in their care that may go beyond decision making about upcoming treatments.”

Studies have begun to show that physical and psychological prehabilitation interventions can reduce treatment-related complications, decrease length of hospital stay and/or readmissions, increase available treatment options for patients who would not otherwise be candidates, and quickly facilitate return of patients to the highest level of function possible. Drs. Silver and Baima highlight the need for further studies to identify the most effective prehabilitation interventions: “those that improve patient health outcomes and reduce direct and indirect healthcare costs.”

“This review provides an exciting ‘jumping-off point’ for cancer researchers to look more closely at how to improve outcomes from the moment of diagnosis onward,” Dr. Silver adds. “We hope it will serve to highlight this exciting area of research and to show clinicians that there are key opportunities right now to improve cancer care.”

Silver and Baima (2013). Cancer prehabilitation: An opportunity to decrease treatment-related morbidity, increase cancer treatment options, and improve physical and psychological health outcomes. Amer. J. Phys. Med. Rehab.92: 715-727 doi: 10.1097/PHM.0b013e31829b4afe [Article]

Evidence for ‘chemo brain’ in breast cancer survivors

A large meta-analysis conducted by researchers at Moffitt Cancer Center has concluded that breast cancer patients treated with chemotherapy are at risk for cognitive deficits after treatment. The meta-analysis, or analytic review of previously published studies, found that study participants on average had  impairments in verbal abilities (such as difficulty choosing words) and visuospatial abilities (such as getting lost more easily). The study noted that cognitive functioning varies across survivors, with some reporting no impairments and others reporting more severe or pervasive deficits.

“The objective of our analysis was to clarify existing research on cognitive functioning in patients who had received standard dose chemotherapy for breast cancer at least six months previously,” said study lead author Heather S.L. Jim, Ph.D., an assistant member at Moffitt whose research focuses on the psychosocial and behavioral aspects of cancer survivorship. “Earlier studies had reported conflicting evidence on the severity of cognitive deficits, especially over the long term.”

Although this is an active area of research, an overall analysis of the studies had not been performed since 2006, explained the researchers.

“Our analysis indicated that patients previously treated with chemotherapy performed significantly worse on tests of verbal ability than individuals without cancer,” noted co-author Paul B. Jacobsen, Moffitt senior member and associate center director of Population Sciences. “In addition, patients treated with chemotherapy performed significantly worse on tests of visuospatial ability than patients who had not had chemotherapy.”

“Breast cancer patients treated with chemotherapy who have subsequent cognitive deficits should be referred to a neuropsychologist for evaluation and management of the deficits,” Jim said. “Management usually involves developing an awareness of the situations in which their cognitive difficulties are likely to arise so that they can come up with strategies to compensate. Research shows that such strategies can make a big difference in daily life when cognitive difficulties do arise.”

Jim HS, Phillips KM, Chait S, Faul LA, Popa MA, Lee YH, Hussin MG, Jacobsen PB, Small BJ (2012) Meta-Analysis of cognitive functioning in breast cancer survivors previously treated with standard-dose chemotherapy. J. Clin. Oncol., EPub Ahead of Print [Abstract]