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Lymphedema is a chronic and progressive long-term adverse effect of breast cancer treatment commonly defined by swelling of the affected arm. Current clinical guidelines indicate that women with and at risk for lymphedema should protect the affected arm from overuse. In clinical practice, this often translates into risk aversive guidance to avoid using the arm. This could lead to a disuse pattern that may increase the likelihood of injury from common activities of daily living. Further, such guidance poses an additional barrier to staying physically active, potentially translating to weight gain, which has been shown to be associated with worse clinical course for women with lymphedema. We hypothesize that a program of slowly progressive strength training with no upper limit on the amount of weight that may be lifted would gradually increase the physiologic capacity of the arm so that common activities represent a decreasing percentage of maximal capacity. Theoretically, this increased capacity should decrease the risk that daily activities put stress on the lymphatic system of the affected side. The Physical Activity and Lymphedema (PAL) Trial is a recently completed randomized controlled exercise intervention trial that recruited 295 breast cancer survivors (141 with lymphedema at study entry, 154 at risk for lymphedema at study entry). The purpose of this report is to provide detail regarding the study design, statistical design, and protocol of the PAL trial.

INTRODUCTION: We describe the frequency of, satisfaction with, and characteristics associated with confidant use among patients and their spouse in the year after diagnosis of non-metastatic breast cancer.

METHODS: In a prospective study of 308 women diagnosed in 1996-97 in Quebec and their spouses, participants were interviewed about confidant use 2 weeks, 3 and 12 months after treatment start. Study completion among eligible individuals was high (patients, 86%; spouses, 84%).

RESULTS: Compared to before diagnosis when 55% of patients reported confiding in >or=1 individuals, 84% reported confiding since diagnosis when interviewed 2 weeks after treatment start (prevalence ratio (PR(2 weeks)) = 1.43, p or=2 types of adjuvant therapy predicted greater confidant use in both partners.

CONCLUSIONS: Judging from the relative differences in confidant use, the effect of diagnosis of non-metastatic breast cancer on natural support-seeking behaviour over time is at least as strong among spouses as among their wives.

IMPLICATIONS FOR CANCER SURVIVORS: The majority of women and their spouses appear satisfied with their confidant situation, even in the first months after diagnosis when this type of support-seeking behaviour increased in both partners.

BACKGROUND. A randomized controlled trial was conducted to investigate the efficacy of classical massage treatment in reducing breast cancer-related symptoms and in improving mood disturbances.

METHODS. Women diagnosed with primary breast cancer were randomized into an intervention group and a control group. For a period of 5 weeks, the intervention group received bi-weekly 30-min classical massages in the back and head-neck areas. The control group received no additional treatment to their routine healthcare. To evaluate treatment efficacy, the following validated questionnaires were administrated at baseline (T1), at the end of the intervention (T2), and at a followup at 11 weeks (T3): the Short Form-8 Health Survey, the European Organization of Research and Treatment of Cancer quality of life questionnaire breast module (EORTC QLQ-BR23), the Giessen Complaints Inventory (GBB), and the Berlin Mood Questionnaire (BSF).

RESULTS. Eighty-six eligible women (mean age: 59 years) were enrolled in the study. A significantly higher reduction of physical discomfort was found in the intervention group compared with the control group at T2 (p=0.001) and at T3 (p=0.038). A decrease in fatigue was also observed. Women in the intervention group reported significantly lower mood disturbances at T2 (p<0.01) but not at T3. The effect of treatment on mood disturbances was significantly higher if a patient was treated continuously by the same masseur.

CONCLUSION. Classical massage seems to be an effective adjuvant treatment for reducing physical discomfort and fatigue, and improving mood disturbances in women with early stage breast cancer.

\OBJECTIVES: Considerable morbidity persists among survivors of breast cancer (BC) including high levels of psychological stress, anxiety, depression, fear of recurrence, and physical symptoms including pain, fatigue, and sleep disturbances, and impaired quality of life. Effective interventions are needed during this difficult transitional period.

METHODS: We conducted a randomized controlled trial of 84 female BC survivors (Stages 0-III) recruited from the H. Lee Moffitt Cancer and Research Institute. All subjects were within 18 months of treatment completion with surgery and adjuvant radiation and/or chemotherapy. Subjects were randomly assigned to a 6-week Mindfulness-Based Stress Reduction (MBSR) program designed to self-regulate arousal to stressful circumstances or symptoms (n=41) or to usual care (n=43). Outcome measures compared at 6 weeks by random assignment included validated measures of psychological status (depression, anxiety, perceived stress, fear of recurrence, optimism, social support) and psychological and physical subscales of quality of life (SF-36).

RESULTS: Compared with usual care, subjects assigned to MBSR(BC) had significantly lower (two-sided p<0.05) adjusted mean levels of depression (6.3 vs 9.6), anxiety (28.3 vs 33.0), and fear of recurrence (9.3 vs 11.6) at 6 weeks, along with higher energy (53.5 vs 49.2), physical functioning (50.1 vs 47.0), and physical role functioning (49.1 vs 42.8). In stratified analyses, subjects more compliant with MBSR tended to experience greater improvements in measures of energy and physical functioning.

CONCLUSIONS: Among BC survivors within 18 months of treatment completion, a 6-week MBSR(BC) program resulted in significant improvements in psychological status and quality of life compared with usual care.

CONTEXT: As a serious chronic condition from breast cancer treatment, lymphedema or a syndrome of persistent swelling and symptoms is caused by chronic accumulation of lymph fluid in the interstitial spaces of the affected limb or surrounding areas. Although significant prevalence of ongoing multiple symptoms has been reported, little is known about how survivors with lymphedema perceive and respond to lymphedema-related symptoms in their daily lives.

OBJECTIVES: The purpose of this study was to explore and describe breast cancer survivors' lymphedema-related symptom experiences.

METHODS: This study used a descriptive phenomenological method. Thirty-four participants were recruited in the United States. Three in-depth interviews were conducted with each participant; a total of 102 interviews were completed, audio taped, and transcribed. Interview transcripts and field notes were the data sources for this analysis, which was part of three larger studies. Data were analyzed to identify the essential themes within and across cases.

RESULTS: Four essential themes were revealed: living with perpetual discomfort, confronting the unexpected, losing pre-lymphedema being, and feeling handicapped. Participants experienced multiple symptoms on a daily basis. Distress was heightened when women expected symptoms to disappear, but instead, they remained as a "perpetual discomfort." Moreover, distress was intensified when symptoms evoked unexpected situations or when symptoms elicited emotional responses powerful enough to change perceived personal identity.

CONCLUSIONS: Findings suggest that symptom distress may encompass temporal, situational, and attributive dimensions. Prospective studies are needed to examine lymphedema-related symptom distress in terms of these dimensions so that more specific interventions can be developed to target distress occurring in each dimension.

OBJECTIVE: Close interpersonal relationships play a crucial role in a woman's adjustment to breast cancer. To date, the literature has focused primarily on characteristics or behaviors of the well spouse that influence a woman's adaptation to the illness. The present qualitative investigation extended this literature by adopting an interactional perspective based on the underlying assumption that relationship partners' coping and distress is mutually influential. The focus of the analysis was patient and partner perceptions of relationship strife or tension over the course of the illness based on the notion that such interactions may be as or more harmful to relationships than supportive exchanges are helpful.

METHOD: Nineteen women (at different stages of the illness) and eleven male spouses were interviewed about their experiences in relation to breast cancer. Nine of the men and nine of the women were relationship partners. Interview text was subjected to a thematic analysis and informed by grounded theory principles.

RESULTS: Two higher-order categories of Personal Characteristics (both patient and partner) and Relationship Dynamics that impeded couple adjustment defined the overall theme of Relationship Vulnerabilities.

CONCLUSIONS: Findings from this study are situated within a broader developmental framework wherein breast cancer is considered a catastrophic life event that challenges the assimilation and accommodation processes of both partners in the relationship. For couples that are able to overcome the relationship challenges associated with the illness, there is the potential for mutual growth, and a deepening and strengthening of the relationship. Implications for clinical practice are discussed.

INTRODUCTION: Mild cognitive impairment following chemotherapy is one of the most commonly reported post treatment symptoms by breast cancer survivors. This deterioration in cognitive function, commonly referred to as "chemobrain" or "chemofog," was largely unacknowledged by the medical community until recent years. Although chemobrain has now become the subject of more vigorous exploration, little is known about this specific phenomenon's psychosocial impact on breast cancer survivors. This research documents in-depth the effects that cognitive impairment has on women's personal and professional lives, and our data suggest that greater attention needs to be focused on this arena of survivorship.

METHODS: The results are based on an in-depth qualitative study of 74 white and African American breast cancer survivors in California who experience post-treatment side effects. The data reported herein were obtained through the use of focus groups and in-depth interviews.

RESULTS: Our data indicate that cognitive impairment can be problematic for survivors, with many asserting that it is their most troublesome post treatment symptom. Survivors report diminished quality of life and daily functioning as a result of chemobrain. Respondents detail a range of coping strategies that they are forced to employ in order to manage their social and professional lives.

DISCUSSIONS/CONCLUSIONS: Chemobrain significantly impairs a proportion of cancer survivors, at great cost to them economically, emotionally, and interpersonally. This suggests that more research needs to be conducted on the psychosocial ramifications of post treatment symptoms in order to inform the efforts of the medical and mental health communities as well as the support networks of survivors.

IMPLICATIONS FOR CANCER SURVIVORS: A better and broader understanding of the effects of cognitive impairment both in the medical community and among lay people could pave the way for improved social and psychological services for this population.

INTRODUCTION : We sought to determine whether the levels of expression of 17 candidate genes were associated with locoregional control after breast-conserving treatments of early-stage breast cancers in young, premenopausal women.

METHODS : Gene expression was measured by using RT-PCR in the breast tumors of a series of 53 young (younger than 40 years), premenopausal patients. All treatments consisted of primary breast-conserving surgery followed by whole-breast radiotherapy (+/- regional lymph nodes) with or without systemic treatments (chemotherapy +/- hormone therapy). The median follow-up was 10 years.

RESULTS : The 10-year locoregional control rate was 70% (95% CI, 57% to 87%). In univariate analysis, no clinical/pathologic prognostic factors were found to be significantly associated with decreased locoregional control. Expression of three genes was found to be significantly associated with an increased locoregional recurrence rate: low estrogen-receptor beta, low aromatase, and high GATA3. Two others were associated with only a trend (P < 0.10): low HER1 and SKP2. In multivariate analysis, only the absence of aromatase was significantly associated with an increased locoregional recurrence rate (P = 0.003; relative risk = 0.49; 95% CI 0.29 to 0.82).

CONCLUSIONS : Recent data give credit to the fact that breast cancer in young women is a distinct biologic entity driven by special oncogenic pathways. Our results highlight the role of estrogen-signaling pathways (mainly CYP19/aromatase, GATA3, and ER-beta) in the risk of locoregional recurrence of breast cancer in young women. Confirmation in larger prospective studies is needed.

About two-thirds of all breast cancer patients are treated with adjuvant hormonal therapy. Side effects of tamoxifen and their effects on physical, emotional and social functioning have been shown to impair the quality of life. Aim of this paper was to evaluate the side effects and level of influence on the physical, emotional and social functioning caused by tamoxifen treatment. For assessment of quality of life an own questionnaire was designed. Between January 2001 and December 2003, 136 women with breast cancer and adjuvant tamoxifen therapy were included in this study. Data of side effects, physical and mental health and patients' self-evaluation identified detrimental effects on patients' quality of life. Prevalence and severity of symptoms were not influenced by length of tamoxifen treatment. Patients were damaged in their constitution in respect to previous chemotherapy and pre-existing diseases; no influence was found by age or histopathological tumour characteristics. Our survey determines that breast cancer patients experience significant influence on quality of life by the negative impact on the physical, emotional and social functioning caused by tamoxifen treatment. Explicit attention to changes in quality of life should be considered as part of the standard care for women receiving adjuvant tamoxifen treatment.

OBJECTIVE: To examine the impact of maternal breast cancer on the emotional and behavioral functioning of school-age children; evaluate whether child adjustment is associated with variations in distress, marital satisfaction, and parenting behavior evidenced by mothers and fathers; and determine whether these associations differ from families that are not contending with cancer.

METHOD: Participants included 40 children (age 8-16 years) of mothers with breast cancer along with their parents as well as 40 families of comparison classmates not affected by parental illness. Questionnaires assessing the domains of interest were administered in families' homes.

RESULTS: Mothers with breast cancer and their spouses reported higher levels of distress than comparison parents; child internalizing problems were inversely associated with parental adjustment in both groups. No group differences were found in any indicators of family functioning, including parent-child relationships. Warm and supportive parenting by both mothers and fathers were associated with lower levels of child internalizing behavior, but only in families affected by breast cancer.

CONCLUSION: These results suggest that children of mothers with breast cancer, such as most children, may be at risk for internalizing behavior when parents are distressed. These children may particularly benefit from interactions with mothers and fathers who are warm and supportive, and maintenance of positive parenting may partially account for the apparent resilience of these youth.