Impact of breast cancer survivorship on quality of life in older women

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1 Critical Reviews in Oncology/Hematology 62 (2007) Impact of breast cancer survivorship on quality of life in older women Contents Claire Robb a,, William E. Haley b, Lodovico Balducci c, Martine Extermann c, Elizabeth A. Perkins b, Brent J. Small b, James Mortimer d a Department of Health Administration, Biostatistics and Epidemiology, College of Public Health, University of Georgia, Athens, GA , United States b School of Aging Studies, University of South Florida, Tampa, FL, United States c H. Lee Moffitt Cancer Center and Research Center, Tampa, FL, United States d Department of Epidemiology, College of Public Health, University of South Florida, Tampa, FL, United States Accepted 10 November Introduction Patients and methods Study design and study sample Measures Statistics Results Discussion Reviewers Acknowledgement References Biographies Abstract Quality of life (QOL) is an important outcome for cancer survivors; but although age is a major risk factor, most breast cancer survivorship studies are conducted with younger women. The objective of our study was to compare QOL in a sample of older breast cancer survivors to a sample of older women who were never diagnosed with breast cancer. A sample of 127 older breast cancer survivors as identified by a cancer registry was compared to a demographically equated sample of 87 older women participating in an epidemiological study. Both groups completed a questionnaire and participated in an interview to measure QOL. The older breast cancer survivors scored worse in the Medical Outcomes Study-Short Form, a measure of health-related QOL. Survivors reported no more depressive symptoms or anxious mood than the comparison group, but scored lower in measures of positive psychosocial well-being, including life satisfaction, mastery, and spiritual wellbeing, and reported more depressed mood and days affected by fatigue. Older breast cancer survivors show multiple indications of decrements in their health-related quality of life, and lower psychosocial well-being than the comparison group. These decrements may represent deficits in reserve capacity that predispose older cancer survivors to functional disability but may not be readily detected in typical clinical evaluations given the multiple impairments common in geriatric populations. Results suggest a need for greater attention to promoting functioning and psychological well-being among older cancer survivors, even when they may not have obvious cancer-related medical complications Elsevier Ireland Ltd. All rights reserved. Keywords: Elderly; Breast cancer; Survivor; Quality of life; Physical functioning 1. Introduction Corresponding author. Tel.: ; fax: address: crobb@geron.uga.edu (C. Robb). Breast cancer is a common and serious disease in women; and, other than being a woman, age is the greatest risk factor /$ see front matter 2006 Elsevier Ireland Ltd. All rights reserved. doi: /j.critrevonc

2 C. Robb et al. / Critical Reviews in Oncology/Hematology 62 (2007) In more recent years, breast cancer incidence rates have increased only in women age 50 and older, and a woman at age 70 is almost twice as likely to develop breast cancer in the next year as a woman age 50 [1]. Survival rates have continued to increase, but most survivorship studies have been conducted in younger women [2,3]. At the same time, quality of life (QOL), a multidimensional concept encompassing behavioral competence and health, perceived quality of existence, and psychological well-being [4], has become an important outcome measure for cancer patients [5]. While younger cancer survivors have been found to attain maximum physical and psychological functioning approximately 1 year after primary treatment [6], or at a minimum, good emotional functioning [7], there are reasons to be concerned that older adult cancer survivors may face additional problems that complicate their recovery from cancer. Older cancer survivors have been shown to have a higher prevalence of chronic diseases than younger survivors [8], and these comorbid conditions can exacerbate the stress of a cancer diagnosis [9]. Functional status may be dramatically altered in older women, and reserve capacity may be diminished with functional dependence increasing with advancing age. Older patients psychosocial disabilities are also often underestimated or unrecognized by physicians, and may play an important role in the quality of life experience by older breast cancer survivors [3]. Older breast cancer survivors are a particularly important group to study in terms of survivorship, since older age has been found to exacerbate the effects of more extensive surgery on symptoms that produce limitations in activity [10]. Also, adjuvant treatment such as radiation, chemotherapy and hormonal therapy represent substantial physical and psychosocial challenges [3,11,12]. Such physical impairment has been shown to affect both mental health and quality of life. Age is thought to strongly influence the shaping of a woman s response to breast cancer. For example, the older women confronted with a diagnosis of breast cancer may have different expectations as to treatment [13], and may react differently to the threat to life, since they may also be facing other losses [14]. The combination of age as a risk factor for breast cancer, increased survivorship, and limited research with older breast cancer survivors prompted our research. We were interested in assessing the impact of breast cancer survivorship above and beyond the effects of aging on QOL. We addressed this question by comparing QOL in older cancer survivors with QOL in a demographically similar sample of older women who had never been diagnosed with breast cancer. In addition to conventional measures of health-rated QOL, we also assessed important dimensions of well-being for older adults including depressive symptoms, life satisfaction, mastery, spirituality, fatigue, and social support. We hypothesized that the survivors as a group would report lower levels of QOL, as exemplified by poorer health-related QOL, more depressive symptoms, lower mastery and life satisfaction, lower selfrated health, and more functional disability, compared with the noncancer comparison population. Although some investigations have suggested that cancer survivorship is related to spiritual and psychological growth [15,16], we have not found studies of this issue in older adults. However, we predicted that this same positive association would be found in older breast cancer survivors as well. We did not have a directional prediction on levels of social support. While cancer survivorship may heighten the need for social support, chronic illness may also deplete available social support [17]. We also predicted that less invasive treatment and a longer period of cancer survivorship would be associated with better quality of life among cancer survivors, as women have more time to recover from the trauma of cancer and its treatment. 2. Patients and methods 2.1. Study design and study sample We used the H. Lee Moffitt Cancer Center and Research Institute cancer registry to identify 274 women age 70 and older who had been diagnosed with breast cancer and had at least 1 year survivorship. Of these women, 6 had died, 64 were unable to be contacted, and 77 refused to participate, giving us a final sample of 127 survivors, and a participation rate of those survivors who were actually contacted of 62%. Our comparison group was taken from a group of 119 women enrolled in a longitudinal follow-up of an epidemiological study on healthy aging. This core sample has been described in other reports [18]. In this group, 24 women were excluded because they were under age 70 and 8 women had prior diagnosis of breast cancer, leaving a final comparison group of 87. Upon agreement to participate and prior to an in-home interview, survivors were sent a questionnaire packet to complete. The participants were advised to contact research staff if they encountered any difficulties in responding to questions in the questionnaire packet. Within 2 weeks of receipt of the questionnaire, research staff conducted semi-structured interviews at the participant s home. All interviews of survivors were conducted during April August The comparison group completed questionnaires at home and were administered semi-structured interviews at a business site as part of the epidemiological study during February and March Measures Demographic information, such as age, household income level, ethnicity, and years of education was obtained from both the sample and the comparison group during the interviews. To investigate comorbidity, 12 common chronic conditions were chosen. These conditions (e.g. osteoarthritis, heart disease, diabetes, etc.) were derived from a larger medical history questionnaire that had included acute conditions and childhood diseases previously administered to the control group [18]. Participants were asked to respond with

3 86 C. Robb et al. / Critical Reviews in Oncology/Hematology 62 (2007) yes/no as to whether they had received a formal diagnosis by a medical doctor of each particular condition. The survivor group was also asked what types of primary cancer treatment they had received (i.e. mastectomy, lumpectomy, radiation, and/or chemotherapy), and whether or not they were taking tamoxifen. The following standardized physical health, psychological health and psychosocial measures used for both groups in this study are well validated and have been widely used in assessing older populations. Several variables assessing aspects of physical health status including health-related QOL, and functioning, were measured in this study. Health-related QOL was specifically measured using the Medical Outcomes Study-Short Form (SF-36). This is a 36-item instrument that is brief and has been widely validated as a summary measure of health-related QOL [19]. In addition to an overall score, subscores for the two major dimensions of physical health and mental health can be attained, as well as scores for each of eight subscales. These subscales are physical functioning, role-physical, bodily pain and general health under the physical health dimension, and vitality, social functioning, role-emotional and mental health under the mental health dimension. Each subscale is scored from 0 to 100 with 100 being the most favorable score (e.g. higher scores indicate better functioning for physical, social, emotional, emotional and general health and less pain and limitations for the limitation subscales). Scores are expressed in a standardized t-score metric, i.e. mean = 50, standard deviation ± 10. Physical vulnerability was assessed using the Vulnerable Elderly Survey (VES-13), a 13-item, function-based scoring system that considers age, self-rated health, limitation in physical function and functional disabilities, and which has been shown to effectively and efficiently identify older people at risk of functional decline and death over the next 2 years [20]. Fatigue was measured using the Multidimensional Fatigue Symptom Inventory-Short Form (MFSI-SF), a 13-item instrument developed to assess the varied domains associated with cancer-regulated fatigue. This measure has been validated for use with heterogeneous samples of cancer patients [21]. Psychological health was investigated using three measures. First, depressive symptoms were measured by the Geriatric Depression Scale/Short Form (GDS-SF), a brief self-report specifically designed to measure expression of depressive symptomatology in older adults and standardized on older samples. The short form of this scale (15-item, yes/no format) has been found to correlate highly with the long form and to have similar sensitivity and specificity rates in identifying depressive disorders [22 24]. Second, state anxiety was measured by the State-Trait Anxiety Inventory, which differentiates between the temporary condition of state anxiety and the more general and long-standing quality of trait anxiety and is a subscale of the State-Trait Personality Inventory (STPI) [25]. The essential qualities evaluated by the STAIS-Anxiety scale are feelings of apprehension, tension, nervousness, and worry. The final measure of psychological functioning used was the State-Trait Depression Inventory, which is also a subscale of the STPI. This instrument was used to measure state depression that is depressive symptoms experienced at the moment versus those experienced generally [26]. In addition to demographic, physical health, and psychological health variables, several psychosocial variables were also investigated. The individual s perception of morale and general life satisfaction was assessed with the Life Satisfaction Index-Z (LSI-Z), a 13-item short form of a life satisfaction scale using the individual s own evaluations as a point of reference, rather than being dependent on level of activity or social participation [22,27]. The sense of mastery, which has been widely accepted as an asset in coping with negative life events (in this sense, a psychosocial resource), was measured by the seven-item Mastery Scale, a brief measure of with excellent psychometric characteristics [28]. The individual s level of spiritual well-being was measured by the Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being (FACIT-Sp) scale. We utilized the total score for spiritual well-being, and this measure has been found to be a psychometrically sound measure of spiritual wellbeing for patients with cancer and appropriate for individuals without cancer [29]. Finally, a composite measure from the work of Krause and Borawski-Clark [30], was used to assess social support as a functional aspect of social resources. The scale used for this study examined received support in the dimensions of instrumental support, informational support and emotional support, and respondents were asked specific questions dealing with their access to these three dimensions of social support and satisfaction with this support Statistics Initially, bivariate correlations were used to ascertain any relationship between length of survivorship, types of treatment and health-related quality of life, life satisfaction and depression. This helped us determine if it were reasonable to pool subjects across variation in survivorship and type of treatment. Comparison of group means through use of multiple t-tests was used to determine significant differences in quality of life between survivors and comparison group. An alpha level of.05 was used for all statistical tests. 3. Results Means for age and education of the breast cancer survivors and the comparison group are presented in Table 1. Mean age of the survivors was years. There was no significant difference between groups in age or education. Both samples were approximately 96% white and had median household incomes in the $30,000 49,999 range. Duration of survivorship ranged from 1 to 15 years and averaged 5.1 years. Frequencies of treatment regimens reported by the survivors are also presented in Table 1.

4 C. Robb et al. / Critical Reviews in Oncology/Hematology 62 (2007) Table 1 Demographics of the sample and treatment reported Demographics Breast cancer survivors (N = 127) Comparison group (N = 87) M S.D. M S.D. Age Education (in years) Treatment regimen N % Mastectomy Lumpectomy Radiation therapy Chemotherapy Tamoxifen regimen Bivariate correlations were used to screen for significant associations of length of survivorship and types of treatment with QOL outcome variables. Results showed no significant associations between duration of survivorship and treatment regimens (i.e. years since diagnosis, mastectomy, lumpectomy, radiation treatment, chemotherapy and tamoxifen) and the physical health and mental health dimensions of the SF- 36. No significant association was found between duration of survivorship and treatment regimens and any of the psychological functioning variables, namely depression, state anxiety and state depression, and two of the psychosocial variables, life satisfaction, and mastery also had no significant associations. Comparison of physical health variables between the survivor and comparison group yielded the following results. t Breast cancer survivors (M = 1.98, S.D. = 1.15) reported significantly more comorbid medical conditions (t = 5.569, p =.001) than the comparison group (M = 1.11, S.D. = 1.14). Results of the SF-36 show the breast cancer survivors significantly different than the comparison group in both the physical health (PCS) and mental health (MCS) summary measures, and in all of the subscales (Fig. 1), with the survivors reporting worse health-related QOL (e.g. lower levels of physical functioning, higher levels of bodily pain). Differences between breast cancer survivors and the comparison group were as follows (all d.f. = 212): physical functioning (t = 3.52, p =.0005), role-physical (t = 5.66, p =.0000), bodily pain (t = 4.77, p =.0000), general health perception (t = 3.81, p =.0002), vitality (t = 4.67, p =.0000), social functioning (t = 3.37, p =.0009), role-emotional (t = 4.74, p =.0000) and mental health (t = 3.48, p =.0003). The VES-13, which has a specified cut-off point for those persons deemed at risk for health deterioration during the next 2 years, showed no significant difference between groups. Approximately 23.6% of the survivors and 23.0% of the comparison group scored in the range for at risk subjects. There was also no significant difference between survivors and comparison group in the fatigue disruption index (Table 2), which is a subscale of our measure of fatigue that is indicative of how much fatigue disrupts the performance of daily activities, or in perceived level of worst fatigue. However, there was a significant difference in the measure of days that fatigue interfered with performance of daily activities, with survivors reporting more interference than the comparison group. Fig. 1. Health-related quality of life in older breast cancer survivors and comparison group. * p <.05; ** p <.01; *** p <.001. Note. Physical health PF = physical functioning; RP = role-physical; BP = bodily pain; GH = general health.

5 88 C. Robb et al. / Critical Reviews in Oncology/Hematology 62 (2007) Table 2 Comparison of means: psychological health measures-plus fatigue Breast cancer survivors (N = 127) Comparison group (N = 87) t M S.D. M S.D. Geriatric Depression Scale-Short Form (GDS-SF) State-Trait Depression Inventory * State-Trait Anxiety Inventory Fatigue Disruption Index Days per week ** Worst fatigue * p <.05; ** p <.01. Table 3 Comparison of means: psychosocial measures Breast cancer survivors (N = 127) Comparison group (N = 87) t M S.D. M S.D. Life Satisfaction Index (LSI-Z) *** Mastery Scale *** Spiritual Well-Being (FACIT-Sp) *** Social support Instrumental ** Emotional Informational Total received Satisfaction with Neg. interactions ** p <.01; *** p <.001. Analysis of mean scores was also conducted comparing the survivors and the comparison group on their psychological health as shown in Table 2. There were no significant differences between groups in expression of depressive symptomatology as measured by the GDS, and no significant difference in state anxiety. Breast cancer survivors did score significantly higher in state depression. Analysis of mean scores between the two groups psychosocial functioning is shown in Table 3. The survivors were significantly lower in measures of life satisfaction and mastery. Results from the FACIT-Sp showed the breast cancer survivors reporting lower levels of spiritual well-being than found in the comparison group. In the area of social support, there were no significant differences in levels of received emotional or informational support, and no significant differences in satisfaction with support received (Table 3). In the area of tangible support, the breast cancer survivors reported higher levels of received instrumental support than our comparison group. 4. Discussion In contrast to research conducted with younger breast cancer survivors [6,7], our results suggest that breast cancer survivorship in older women is associated with significant diminution in health-related quality of life, and psychological well-being, compared with women of comparable age, education, and physical vulnerability. While some prior research using large national databases has shown cancer survivors reporting deficits in areas such as health, utility, productivity, and physical functioning [8,31], particularly in those survivors with diagnoses such as lung and other short-survival cancers, other studies examining survivors of cancers with better prognoses have reported few differences in health limitations [32,33]. It should be noted here that our breast cancer sample was not an exceptionally frail group, as illustrated by the results of the VES-13, where the percentage of survivors at risk for health decline was almost identical to the comparison group. Nevertheless, the breast cancer survivors scored worse on all domains of both subscales of the SF-36 than did the comparison group, as well as reporting more comorbidity. This was coupled with the significant difference in tangible support, indicating that friends and relatives may feel the need to offer more physical assistance to the survivors. Functional decline is one of the strongest predictor of depression in older adults. We view the consistently lower scores exhibited by the breast cancer survivors compared to the control group as indicative of a lessening of reserve capacity in those women who have survived breast cancer. Reserve capacity is defined as the ability of an organism to return to a normal state after periods of stress, such as a surgical procedure or illness [34], and this is a key concept in understanding geriatric issues [34]. While the effects of the aging process alone on various organ systems does not usually affect function in the normal state, this loss of reserve capacity in the older breast cancer survivors may predispose them towards clinically significant

6 C. Robb et al. / Critical Reviews in Oncology/Hematology 62 (2007) declines in well-being when combined with aging and other age-associated comorbid conditions. In the area of fatigue, we found no significant difference between groups in the fatigue disruption index, which is a subscale of our measure of fatigue that is indicative of how much fatigue disrupts the performance of daily activities, nor was the worst level of fatigue reported by the groups significantly different. We did, however, see a significant difference in the measure of days that fatigue interfered with performance of daily activities, with the survivors having more interference than the comparison group. Since treatment with tamoxifen is also associated with fatigue [35],we conducted a post hoc analysis of the survivor group using hierarchical regression to determine if fatigue levels of survivors were impacted by presence of this treatment. No significant difference was found. In light of these results in levels of fatigue, it is interesting to note that breast cancer survivors consistently reported poorer levels of health and physical functioning than the comparison group. Since the survivor group reported less fatigue in both the fatigue disruption index and worst experienced fatigue, we believe that this is illustrative of the fact that health status and fatigue are two distinct constructs. Therefore, fatigue needs to be analyzed separately from perceived health status in studies of breast cancer survivors. As predicted, beyond commonly used measures of physical health status and health-related QOL, there were areas of psychological and psychosocial well-being where the group of breast cancer survivors in our study fared worse than our comparison group. While we found no significant difference between groups in psychological functioning in terms of depressive symptomatology, or state anxiety, breast cancer survivors reported did report higher levels of state depression. Furthermore, with regard to psychosocial variables, breast cancer survivors also reported significantly lower levels of life satisfaction, mastery, and spiritual well-being. These results are contrary to previous reports from younger breast cancer survivors suggesting their survivorship leads to posttraumatic growth [16,36] and increases in spirituality [37]. For older adults, surviving breast cancer may have a different psychological meaning and psychosocial impact than for younger patients, given the relatively shorter life expectancy and greater likelihood of comorbid illness and functional impairment. More in-depth research on these issues of meaning of illness in older patients is warranted. Diminution in positive indicators of psychosocial well-being, even in the absence of significant depressive symptoms, is of concern because these positive states are important psychosocial coping resources that can help older adults adapt when they face major stressors [38,39]. Qualitative data obtained from the breast cancer survivors indicated that they did not generally attribute any problems they reported to having cancer. In fact, most of the older cancer survivors in our sample attributed any functional limitations they experienced to other illnesses, such as arthritis. Cancer survivors may not report that their cancer is currently affecting them, even though our results clearly show multiple negative sequelae in health-related QOL and psychosocial well-being associated with survivorship. This underscores the importance of using age-matched comparison groups to study older cancer survivors, and suggests that clinicians should undertake thorough geriatric assessment with older cancer survivors in order to detect subtle but important impairments [40,41]. Our study had several limitations which should be noted. First, our study was cross-sectional thereby precluding any inference of causality or change over time. Secondly, our sample and our comparison group were not racially or economically diverse, thereby limiting generalizability of our findings. Also, medical conditions and functional abilities were based on self-report and are subject to recall bias. The measure of comorbidity used in this study was restricted by the need to match the measure already utilized in the control group. More sophisticated assessment of comorbidity would be very advantageous to future investigations in this area. Furthermore, subsequent studies would also benefit from incorporating performance-based measures to determine functional status to minimize the potential impact of response bias on self-reports. Finally, there was no measurement of cognitive functioning or formal assessment of sensory impairment included in this study. These aspects can undoubtedly affect QOL, and would be useful to incorporate into a comprehensive and multidimensional geriatric assessment. In the present study, as both groups were relatively highly functioning, we feel there was likely minimal impact of cognitive and sensory impairment as all participants were lucid, alert, and were fully able to complete face-to-face interviews with no apparent visual or hearing difficulties. As breast cancer survival rates continue to improve and as the average life expectancy continues to increase, it is obvious that more and more older women will be faced with an extended number of years of life as breast cancer survivors. Functional health has been shown to correlate with mental health both in large studies where functional health and mental health are measured, as well as in other studies that have demonstrated a general association between physical and mental health [42]. Functional decline can be considered as a chronic stressor, which may induce stress responses such as depression [43]. Future research should assess whether decrements such as those found in our study represent declines in reserve capacity that may predispose toward clinically significant declines in well-being and functioning, and consider interventions not only to address clinically significant symptoms, but also to enhance well-being and functional capacity in older cancer survivors. Reviewers Catherine Terret, MD, PhD, Centre Léon Bérard, Department of Medical Oncology, 28, rue Laënnec, Lyon Cedex 08, France.

7 90 C. Robb et al. / Critical Reviews in Oncology/Hematology 62 (2007) Etienne G.C. Brain, MD, PhD, Rene Huguenin Cancer Centre, Department of Medical Oncology, 35 rue Dailly, Saint-Cloud, France. Acknowledgement This study was funded by a grant from the National Institute on Aging (NIA), Award #1R03AG References [1] American Cancer Society, Cancer facts and figures. Atlanta, GA: Author; [2] Ganz PA, et al. Breast cancer in older women: quality of life and psychosocial adjustment in the 15 months after diagnosis. J Clin Oncol 2003;21(21): [3] Deimling GT, et al. Cancer survivorship and psychological distress in later life. Psychooncology 2002;11(6): [4] Lawton MP. A multidimensional view of quality of life in frail elders. In: Birren JE, et al., editors. The concept and measurement of quality of life in the frail elderly. New York: Academic Press; p [5] Arndt V, et al. Age-specific detriments to quality of life among breast cancer patients one year after diagnosis. Eur J Cancer 2004;40(5): [6] Ganz PA, et al. Breast cancer survivors: psychosocial concerns and quality of life. Breast Cancer Res Treat 1996;38(2): [7] Ganz PA, et al. Quality of life at the end of primary treatment of breast cancer: first results from the moving beyond cancer randomized trial. J Natl Cancer Inst 2004;96(5): [8] Hewitt M, Rowland JH, Yancik R. Cancer survivors in the United States: age, health and disability. J Gerontol Ser A: Biol Sci Med Sci 2003;58A(1): [9] Sammarco A. Quality of life among older survivors of breast cancer. Cancer Nurs 2003;26(6): [10] Vinokur AD, et al. The process of recovery from breast cancer for younger and older patients. Changes during the first year. Cancer 1990;65(5): [11] Demissie S, Silliman RA, Lash TL. Adjuvant tamoxifen: predictors of use, side effects, and discontinuation in older women. J Clin Oncol 2001;19(2): [12] Moyer A, Salovey P. Psychosocial sequelae of breast cancer and its treatment. Ann Behav Med 1996;18(2): [13] Mandelblatt JS, et al. Predictors of long-term outcomes in older breast cancer survivors: perceptions versus patterns of care. J Clin Oncol 2003;21(5): [14] Cimprich B, Ronis DL, Martinez-Ramos G. Age at diagnosis and quality of life in breast cancer survivors. Cancer Pract 2002;10(2): [15] Gall TL, Cornblat MW. Breast cancer survivors give voice: a qualitative analysis of spiritual factors in long-term adjustment. Psychooncology 2002;11(6): [16] Cordova MJ, et al. Posttraumatic growth following breast cancer: a controlled comparison study. Health Psychol 2001;20(3): [17] Reinhardt JP. Predicting individual change in social support over time among chronically impaired older adults. Psychol Aging 2003;18(4):2003. [18] Small BJ, et al. Is APOE-epsilon4 a risk factor for cognitive impairment in normal aging? Neurology 2000;54(11): [19] Ware JE, Sherbourne CD. The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection. Med Care 1992;30(6): [20] Saliba D, et al. The Vulnerable Elders Survey: a tool for identifying vulnerable older people in the community. J Am Geriatr Soc 2001;49(12): [21] Stein KD, et al. Further validation of the multidimensional fatigue symptom inventory-short form. J Pain Symptom Manage 2004;27(1): [22] Yesavage JA. Development and validation of a geriatric depression screening scale: a preliminary report. J Psychiatr Res 1983;17: [23] Shaver PR, Brennan KA. Measures of depression and loneliness. In: Robinson JP, Shaver PR, editors. Measures of personality and social psychological attitudes. San Diego, CA: Academic Press, Inc.; p [24] Lesher EL, Berryhill JS. Validation of the Geriatric Depression Scale- Short Form among inpatients. J Clin Psychol 1994;50(2): [25] Spielberger C. Understanding stress and anxiety. New York: Harper & Row; [26] Endler NS, Macrodimitris SD, Kokovski NL. Anxiety and depression: congruent, separate, or both? J Appl Biobehav Res 2003;8(1): [27] Andrews FM, Robinson JP. Measures of subjective well-being. In: Robinson JP, Shaver PR, editors. Measures of personality and social psychological attitudes. San Diego, CA: Academic Press, Inc.; p [28] Pearlin LI, Schooler C. The structure of coping. J Health Soc Behav 1978;19(1):2 21. [29] Peterman AH, et al. Measuring spiritual well-being in people with cancer: the functional assessment of chronic illness therapy Spiritual Well-being Scale (FACIT-Sp). Ann Behav Med 2002;24(1): [30] Krause N, Borawski-Clark E. Social class differences in social support among older adults. Gerontologist 1995;35(4): [31] Yabroff KR, et al. Burden of illness in cancer survivors: findings from a population-based national sample. J Natl Cancer Inst 2004;96(17): [32] Dorval M, et al. Long-term quality of life after breast cancer: comparison of 8-year survivors with population controls. J Clin Oncol 1998;16(2): [33] Ramsey SD, et al. Quality of life in long term survivors of colorectal cancer. Am J Gastroenterol 2002;97(5): [34] Evers BM, Townsend Jr CM, Thompson JC. Organ physiology of aging. Surg Clin North Am 1994;74(1): [35] Mast ME. Correlates of fatigue in survivors of breast cancer. Cancer Nurs 1998;21(2): [36] Manne S, et al. Posttraumatic growth after breast cancer: patient, partner, and couple perspectives. Psychosom Med 2004;66(3): [37] Helgeson VS, Tomich PL. Surviving cancer: a comparison of 5-year disease-free breast cancer survivors with healthy women. Psychooncology; [38] Lawton MP. The varieties of well-being. Exp Aging Res 1983;9: [39] Bradburn N. The structure of psychological well-being. Chicago: Aldine; [40] Wedding U, Hoffken K. Care of breast cancer in the elderly woman what does comprehensive geriatric assessment (CGA) help? Support Care Cancer 2003;11(12): [41] Extermann M, et al. A comprehensive geriatric intervention detects multiple problems in older breast cancer patients. Crit Rev Oncol Hematol 2004;49(1): [42] Lawton MP. Functional status and aging well. Generations 1991;15:31 4. [43] Kempen GIJ, et al. The relationship of functional limitations to disability and the moderating effects of psychological attributes in community-dwelling older persons. Social Sci Med 1999;48: Biographies Claire Robb, Ph.D., MPH, received her doctorate degree in Aging Studies and her Master of Public Health in Epidemiology from the University of South Florida in She completed a 2-year NCI-sponsored fellowship in behavioral

8 C. Robb et al. / Critical Reviews in Oncology/Hematology 62 (2007) oncology with the Senior Adult Oncology Program at the H. Lee Moffitt Cancer Center and Research Institute. Dr. Robb is currently an Assistant Professor in the College of Public Health at the University of Georgia and has a joint appointment with the Institute of Gerontology at UGA. William E. Haley, Ph.D., is Director of the School of Aging Studies at the University of South Florida and is also a member of the Moffitt Cancer Center. Dr. Haley has extensive experience in conducting longitudinal research on the psychosocial consequences of chronic illness in older adults. Lodovico Balducci, M.D., is the chief of the section of geriatric oncology within the Department of Interdisciplinary Oncology at the University of South Florida, Professor of Oncology and Medicine and the founder of the Senior Adult Oncology Program (SAOP) at the H. Lee Moffitt Cancer Center and Research Institute. Martine Extermann, M.D., Ph.D., is Associate Professor of Oncology and Medicine at the University of South Florida and attending physician at the H. Lee Moffitt Cancer Center. She is a Faculty in the Senior Adult Oncology Program, of which she is the research director. Elizabeth A. Perkins, RNMH, B.A., received her nurse training at the Hereford and Worcester College of Nursing and Midwifery, Worcester, England. She is a doctoral candidate in the Ph.D. in Aging Studies Program at the University of South Florida. Brent J. Small, Ph.D., is Associate Professor in the School of Aging Studies at the University of South Florida, holds a joint appointment in the Department of Psychology at USF and is an Associate Professor in the Biostatistics Resource Core at the H. Lee Moffitt Cancer Center and Research Institute. James Mortimer, Ph.D., is Professor of Epidemiology in the College of Public Health at the University of South Florida.