Psychosocial/survivorship issues in breast cancer: are we doing better?

Modern breast cancer treatment offers many women greater prospects of cure or lengthier, good quality survival than was possible in the past. Advances include improved diagnostic and staging procedures, sophisticated onco-plastic surgery, enhanced radiotherapy techniques, and targeted systemic therapies. Much more attention has also been paid to cancer care delivery and access to specialist nurses, counsellors, support groups, and services provided by breast cancer charities. However, there are some concerns that these considerable improvements in treatment delivery and clinical outcomes have not led to similar benefits in the psychosocial, functional, and sexual well-being of women. The impact that non-life threatening, long-term iatrogenic harms of otherwise efficacious anticancer treatments has on patients is often overlooked; this is in part because of the emphasis given to physician-reported safety data in trials and the general exclusion of patient-reported outcomes (PROs). A failure to utilise reliable PRO measures has meant that some problems are underreported, which consequently has hampered much-needed research into ameliorative interventions. Systematic monitoring of quality of life-threatening side effects would permit early implementation of effective interventions and enhance long-term survivorship. Some examples of the pervasive difficulties that continue to affect survivors and evidence that certain interventions might help are provided in this commentary

Women's beliefs about breast cancer causation in a breast cancer case-control study

Objective: Our study sought to ascertain women's beliefs about breast cancer risk factors and whether these beliefs differed by demographic factors and personal and family history of breast cancer. Methods: Participants in a case-control study of breast cancer rated the effect of 37 exposures on the risk of being diagnosed with breast cancer. Chi-square tests were undertaken to measure differences in responses between cases and controls for each exposure. Logistic regression was undertaken to ascertain whether demographic factors and personal and family history of breast cancer affected participants' ability to correctly identify known breast cancer risk factors. Results: A total of 2742 participants completed the questionnaire, comprising 1109 cases and 1633 controls. Significant differences (p<0.05) between cases and controls were found for 16 of the 37 exposures. Younger women and university-educated women were more likely to correctly identify known breast cancer risk factors. Women's perceptions about the effect of alcohol consumption on breast cancer risk, particularly regarding red wine, differed from that reported in the literature. Conclusions: Beliefs about risk factors for breast cancer may differ between cases and controls. Public health initiatives aimed at increasing awareness of breast cancer risk factors should consider that women's beliefs may differ by demographic factors and family history of breast cancer

VITALITY trial: protocol for a randomised controlled trial to establish the role of postnatal vitamin D supplementation in infant immune health

Introduction Postnatal vitamin D supplementation may be associated with a reduction in IgE-mediated food allergy, lower respiratory tract infections and improved bone health. Countries in the Northern hemisphere recommend universal infant vitamin D supplementation to optimise early vitamin D levels, despite the absence of large trials proving safety or efficacy for any disease outcome. With the aim of determining the clinical and cost-effectiveness of daily vitamin D supplementation in breastfed infants from age 6–8 weeks to 12 months of age, we have started a double-blind, randomised, placebo-controlled trial of daily 400 IU vitamin D supplementation during the first year of life, VITALITY. Methods nd analysis Infants (n=3012) who are fully breastfed and not receiving vitamin D supplementation will be recruited at the time of their first immunisation, from council-led immunisation clinics throughout metropolitan Melbourne, Australia. The primary outcome is challenge-proven food allergy at 12 months of age. Secondary outcomes are food sensitisation (positive skin prick test), number of lower respiratory infections (through hospital linkage), moderately-severe and persistent eczema (by history and examination) and vitamin D deficiency (serum vitamin D <50 nmol/L) at age 12 months. The trial is underway and the first 130 participants have been recruited

Interventions for promoting smoking cessation during pregnancy.

BACKGROUND: Smoking remains one of the few potentially preventable factors associated with low birthweight, preterm birth and perinatal death. OBJECTIVES: To assess the effects of smoking cessation programs implemented during pregnancy on the health of the fetus, infant, mother, and family. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group trials register and the Cochrane Tobacco Addiction Group trials register (July 2003), MEDLINE (January 2002 to July 2003), EMBASE (January 2002 to July 2003), PsychLIT (January 2002 to July 2003), CINAHL (January 2002 to July 2003), and AUSTHEALTH (January 2002 to 2003). We contacted trial authors to locate additional unpublished data. We handsearched references of identified trials and recent obstetric journals. SELECTION CRITERIA: Randomised and quasi-randomised trials of smoking cessation programs implemented during pregnancy. DATA COLLECTION AND ANALYSIS: Four reviewers assessed trial quality and extracted data independently. MAIN RESULTS: This review included 64 trials. Fifty-one randomised controlled trials (20,931 women) and six cluster-randomised trials (over 7500 women) provided data on smoking cessation and/or perinatal outcomes. Despite substantial variation in the intensity of the intervention and the extent of reminders and reinforcement through pregnancy, there was an increase in the median intensity of both 'usual care' and interventions over time. There was a significant reduction in smoking in the intervention groups of the 48 trials included: (relative risk (RR) 0.94, 95% confidence interval (CI) 0.93 to 0.95), an absolute difference of six in 100 women continuing to smoke. The 36 trials with validated smoking cessation had a similar reduction (RR 0.94, 95% CI 0.92 to 0.95). Smoking cessation interventions reduced low birthweight (RR 0.81, 95% CI 0.70 to 0.94) and preterm birth (RR 0.84, 95% CI 0.72 to 0.98), and there was a 33 g (95% CI 11 g to 55 g) increase in mean birthweight. There were no statistically significant differences in very low birthweight, stillbirths, perinatal or neonatal mortality but these analyses had very limited power. One intervention strategy, rewards plus social support (two trials), resulted in a significantly greater smoking reduction than other strategies (RR 0.77, 95% CI 0.72 to 0.82). Five trials of smoking relapse prevention (over 800 women) showed no statistically significant reduction in relapse. REVIEWERS' CONCLUSIONS: Smoking cessation programs in pregnancy reduce the proportion of women who continue to smoke, and reduce low birthweight and preterm birth. The pooled trials have inadequate power to detect reductions in perinatal mortality or very low birthweight

i Sexual function in breast cancer patients: a prospective study from Iran

Background: Sexual function in patients with breast cancer especially in younger patients is an important issue from clinical and psychosocial perspectives. This study aimed to assess sexual function among Iranian breast cancer patients. Methods: This was a prospective study of sexual function in breast cancer patients attending the Cancer Institute of Iran. Sexual function was assessed using the Female Sexual Function Index (FSFI) at two points in time: baseline (pre-treatment) and after completion of cancer treatment at follow-up visits (post-treatment). Pre- and posttreatment data were compared. In addition logistic regression analysis was performed to find out factors that contributing to post-treatment sexual dysfunction. Results: In all 277 breast cancer patients were approached. Of these, 231 patients (83%) were sexually active and data for 216 patients (93.5 % of sexually active patients) were available at pre-and post-treatment. Overall pre- and post-treatment sexual dysfunction was found to be 52 % and 84%, respectively indicating a significant deterioration in sexual function among breast cancer patients. The results obtained from multiple logistic regression analysis indicated that younger age [OR = 0.95, 95 % CI = 0.93-0.98; P = 0.04], receiving endocrine therapy [OR = 3.34, 95% CI = 1.37-7.91; P = 0.007] and poor sexual function at pre-treatment [OR = 12.3, 95 % CI = 3.93-39.0; P < 0.0001

Re-starting smoking in the postpartum period after receiving a smoking cessation intervention: a systematic review

Aims: In pregnant smoking cessation trial participants, to estimate (1) among women abstinent at the end of pregnancy, the proportion who re-start smoking at time-points afterwards (primary analysis) and (2) among all trial participants, the proportion smoking at the end of pregnancy and at selected time-points during the postpartum period (secondary analysis). Methods: Trials identified from two Cochrane reviews plus searches of Medline and EMBASE. Twenty-seven trials were included. The included trials were randomized or quasi-randomized trials of within-pregnancy cessation interventions given to smokers who reported abstinence both at end of pregnancy and at one or more defined time-points after birth. Outcomes were validated biochemically and self-reported continuous abstinence from smoking and 7-day point prevalence abstinence. The primary random-effects meta-analysis used longitudinal data to estimate mean pooled proportions of re-starting smoking; a secondary analysis used cross-sectional data to estimate the mean proportions smoking at different postpartum time-points. Subgroup analyses were performed on biochemically validated abstinence. Results: The pooled mean proportion re-starting at 6 months postpartum was 43% [95% confidence interval (CI) = 16–72%, I2 = 96.7%] (11 trials, 571 abstinent women). The pooled mean proportion smoking at the end of pregnancy was 87% (95% CI = 84–90%, I2 = 93.2%) and 94% (95% CI = 92–96%, I2 = 88%) at 6 months postpartum (23 trials, 9262 trial participants). Findings were similar when using biochemically validated abstinence. Conclusions: In clinical trials of smoking cessation interventions during pregnancy only 13% are abstinent at term. Of these, 43% re-start by 6 months postpartum

Efficacy of the Enquiring About Tolerance (EAT) study among infants at high risk of developing food allergy.

BACKGROUND: The Enquiring About Tolerance (EAT) study was a randomized trial of the early introduction of allergenic solids into the infant diet from 3 months of age. The intervention effect did not reach statistical significance in the intention-to-treat analysis of the primary outcome. OBJECTIVE: We sought to determine whether infants at high risk of developing a food allergy benefited from early introduction. METHODS: A secondary intention-to-treat analysis was performed of 3 groups: nonwhite infants; infants with visible eczema at enrollment, with severity determined by SCORAD; and infants with enrollment food sensitization (specific IgE ≥0.1 kU/L). RESULTS: Among infants with sensitization to 1 or more foods at enrollment (≥0.1 kU/L), early introduction group (EIG) infants developed significantly less food allergy to 1 or more foods than standard introduction group (SIG) infants (SIG, 34.2%; EIG, 19.2%; P = .03), and among infants with sensitization to egg at enrollment, EIG infants developed less egg allergy (SIG, 48.6%; EIG, 20.0%; P = .01). Similarly, among infants with moderate SCORAD (15-<40) at enrollment, EIG infants developed significantly less food allergy to 1 or more foods (SIG, 46.7%; EIG, 22.6%; P = .048) and less egg allergy (SIG, 43.3%; EIG, 16.1%; P = .02). CONCLUSION: Early introduction was effective in preventing the development of food allergy in specific groups of infants at high risk of developing food allergy: those sensitized to egg or to any food at enrollment and those with eczema of increasing severity at enrollment. This efficacy occurred despite low adherence to the early introduction regimen. This has significant implications for the new national infant feeding recommendations that are emerging around the world

Female social and sexual interest across the menstrual cycle: the roles of pain, sleep and hormones

<p>Abstract</p> <p>Background</p> <p>Although research suggests that socio-sexual behavior changes in conjunction with the menstrual cycle, several potential factors are rarely taken into consideration. We investigated the role of changing hormone concentrations on self-reported physical discomfort, sleep, exercise and socio-sexual interest in young, healthy women.</p> <p>Methods</p> <p>Salivary hormones (dehydroepiandrosterone sulfate-DHEAS, progesterone, cortisol, testosterone, estradiol and estriol) and socio-sexual variables were measured in 20 women taking oral contraceptives (OC group) and 20 not using OCs (control group). Outcome measures were adapted from questionnaires of menstrual cycle-related symptoms, physical activity, and interpersonal relations. Testing occurred during menstruation (T1), mid-cycle (T2), and during the luteal phase (T3). Changes in behavior were assessed across time points and between groups. Additionally, correlations between hormones and socio-behavioral characteristics were determined.</p> <p>Results</p> <p>Physical discomfort and sleep disturbances peaked at T1 for both groups. Exercise levels and overall socio-sexual interest did not change across the menstrual cycle for both groups combined. However, slight mid-cycle increases in general and physical attraction were noted among the control group, whereas the OC group experienced significantly greater socio-sexual interest across all phases compared to the control group. Associations with hormones differed by group and cycle phase. The estrogens were correlated with socio-sexual and physical variables at T1 and T3 in the control group; whereas progesterone, cortisol, and DHEAS were more closely associated with these variables in the OC group across test times. The direction of influence further varies by behavior, group, and time point. Among naturally cycling women, higher concentrations of estradiol and estriol are associated with lower attraction scores at T1 but higher scores at T3. Among OC users, DHEAS and progesterone exhibit opposing relationships with attraction scores at T1 and invert at T3.</p> <p>Conclusions</p> <p>Data from this study show no change across the cycle in socio-sexual interest among healthy, reproductive age women but higher social and physical attraction among OC users. Furthermore, a broader range of hormones may be associated with attraction than previously thought. Such relationships differ by use of oral contraceptives, and may either reflect endogenous hormone modulation by OCs and/or self-selection of sexually active women to practice contraceptive techniques.</p

Which women stop smoking during pregnancy and the effect on breastfeeding duration

BACKGROUND: Cigarette smoking during pregnancy increases the risk of adverse pregnancy outcomes and women who quit smoking at this time are able to reduce the risk of low birth weight, preterm labour, spontaneous abortion and perinatal death. This study investigates the socio-demographic characteristics of pregnant women who stop smoking during pregnancy and the association between stopping smoking and breastfeeding duration. METHODS: A 12 month longitudinal study was conducted in two public maternity hospitals in Perth, Australia between mid-September 2002 and mid-July 2003. While in hospital, participating mothers completed a self-administered baseline questionnaire. Follow up telephone interviews were conducted at 4, 10, 16, 22, 32, 40 and 52 weeks. RESULTS: A total of 587 (55%) mothers participated in the study. Two hundred and twenty six (39%) mothers reported smoking prior to pregnancy and 77 (34%) of these stopped smoking during pregnancy. Women who were pregnant for the first time were twice as likely (OR = 2.05; 95% CI 1.047 – 4.03; p < 0.05) to quit smoking as multiparous women. Women who smoked more than 10 cigarettes per day were significantly less likely to quit smoking during pregnancy (OR = 0.36; 95% CI 0.18 – 0.69; p < 0.05). Women who consumed alcohol before pregnancy were three times more likely to quit smoking (OR = 2.58; 95% CI 1.00 – 6.66; p < 0.05). Quitting smoking during pregnancy was significantly associated with breastfeeding for longer than six months (OR = 3.70; 95% CI 1.55 – 8.83; p < 0.05). CONCLUSION: Pregnancy is a time when many women are motivated to quit smoking and providing targeted smoking cessation interventions at this time, which take into account factors predictive of quitting smoking, are more likely to be successful

Beliefs and perceptions about the causes of breast cancer: a case-control study

Background: Attributions of causality are common for many diseases, including breast cancer. The risk of developing breast cancer can be reduced by modifications to lifestyle and behaviours to minimise exposure to specific risk factors, such as obesity. However, these modifications will only occur if women believe that certain behaviours/lifestyle factors have an impact on the development of breast cancer. Method: The Breast Cancer, Environment and Employment Study is a case-control study of breast cancer conducted in Western Australia between 2009 and 2011. As part of the study 1109 women with breast cancer and 1633 women without the disease completed a Risk Perception questionnaire in which they were asked in an open-ended question for specific cause/s to the development of breast cancer in themselves or in others. The study identified specific causal beliefs, and assessed differences in the beliefs between women with and without breast cancer. Results: The most common attributions in women without breast cancer were to familial or inherited factors (77.6%), followed by lifestyle factors, such as poor diet and smoking (47.1%), and environmental factors, such as food additives (45.4%). The most common attributions in women with breast cancer were to mental or emotional factors (46.3%), especially stress, followed by lifestyle factors (38.6%) and physiological factors (37.5%), particularly relating to hormonal history.Conclusions: While the majority of participants in this study provided one or more causal attributions for breast cancer, many of the reported risk factors do not correspond to those generally accepted by the scientific community. These misperceptions could be having a significant impact on the success of prevention and early detection programs that seek to minimise the pain and suffering caused by this disease. In particular, women who have no family history of the disease may not work to minimise their exposure to the modifiable risk factors