Patient-reported outcomes after breast cancer treatment

Abstract

Chapter 2, shows that despite the good prognosis of ductal carcinoma in situ (disease-free survival of 95%)1 and early-stage breast cancer (disease-free survival of 85-95%)2, its diagnosis can cause psychological distress like anxiety and depression. Severe depression scores were even more common in patients diagnosed with ductal carcinoma in situ compared to patients with early-stage invasive breast cancer. This emphasizes the need for better information and education of patients, as patients with ductal carcinoma in situ have an excellent prognosis and should not experience such levels of stress. These results also indicate that there is still progress to be made in offering interventions to manage psychological distress during and after treatment. After diagnosis, breast cancer surgery and especially axillary treatment may cause morbidity as shown in chapter 3. In particular, axillary lymph node dissection followed by axillary radiotherapy was associated with high arm morbidity scores and a higher proportion of severe patient-reported lymphedema. Replacing axillary surgery by the sentinel node procedure and less invasive treatment options of the axilla in patients with limited tumour positive sentinel lymph nodes (e.g. axillary radiotherapy) can cause less morbidity especially shortly after surgery. A more selective approach to irradiation of the axillary levels, i.e. radiotherapy of levels I–II only instead of levels I–IV, did not further reduce the patient-reported arm morbidity. Arm edema is a well-described and recognized complication after breast cancer treatment. Lymphedema of the breast, on the other hand, has received less attention. However, as a result of the increasing proportion of patients undergoing breast-conserving therapy, physicians more often report isolated lymphedema of the breast. As a result, knowledge on risk factors for developing breast edema are becoming more important. Chapter 4 shows that patients undergoing oncoplastic surgery, axillary lymph node dissection and adjuvant treatment like chemotherapy, local-, and locoregional radiotherapy, and patients with larger tumour size, had a higher risk of developing breast edema. These results showed that breast edema occurs frequently after breast-conserving therapy and causes breast pain, affects the quality of life, physical functioning, and body image. Consequently, options to adequately diagnose breast edema and reduce the impact of breast edema by applying evidence-based treatment options are needed. In chapter 5, we provided early evidence that a compression vest might be an acceptable and effective treatment option in reducing breast pain and swelling in patients suffering from breast edema. Compression vests, when worn for six months, were associated with improved patient-reported general pain and breast pain. Patients with breast cancer frequently experience long-term side effects of (neo)adjuvant chemotherapy.3 Although chemotherapy reduces breast-cancer mortality, it is also the prime suspect to cause cancer-related cognitive decline. The association between chemotherapy and impaired cognitive functioning was most pronounced in younger women (<55 years of age) (chapter 6). It is important to adequately inform women who will undergo chemotherapy about the risks of cognitive decline during and after chemotherapy, especially given the longer life expectancy of younger women and the detrimental effect of cognitive functioning on daily activities (e.g. taking care of children), employment opportunities, return to work and work ability. Chapter 7 shows that the work ability in women treated for breast cancer was strongly reduced during treatment and gradually improved over time. Thirty months after treatment, work ability of breast cancer survivors remained lower than that of the general population. Chemotherapy, axillary lymph node dissection and more extensive target volumes being irradiated, i.e. locoregional radiotherapy, were associated with reduced work ability.