Assessing a multidisciplinary survivorship program in a group of predominantly Hispanic women with breast cancer

Breast cancer survivors comprise the most prevalent cancer survivor population in the United States.¹ The number of breast cancer survivors is increasing because of early detection and diagnosis, and advances in treatment have resulted in increased life expectancy. Therefore, greater attention is needed to improve the long-term quality of life of these survivors and to help them re-adjust to normal life. For many women, although the medical treatment may have been completed, the recovery process may have not.² The prevalence of long-term mental and physical illness is significant among many breast cancer survivors. Long-term mental consequences may include memory problems, anxiety, depression, and fear of recurrence³, and long-term physical consequences may include pain, fatigue, and lymphedema, among others.⁴

El Paso, Texas, is the fourth most populous city in Texas and has a Hispanic majority. This provides an opportunity to conduct clinical research targeting participants of Hispanic descent. Several studies have noted the influence of race/ethnicity on the psychosocial function of breast cancer survivors.^5,6 We have previously reported that Hispanic breast cancer survivors might experience decreased mental and physical health-related quality of life (QoL) which limit their normal social functioning.⁶Other studies have similarly reported poor outcomes of breast cancer survivors and higher rates of fatigue and depression among Hispanic patients.⁷ However, there is a paucity of research addressing specific interventions needed to improve these outcomes and provide better QoL for breast cancer survivors.^8,9 In addition, a few survivorship care interventions have focused on minorities. We sought to assess whether a multidisciplinary cancer survivorship program in a primarily Hispanic populated area would lead to improved QoL and reduce anxiety and depressive symptoms among breast cancer survivors.

Methods

After obtaining Institutional Review Board approval, we recruited consecutive patients who were treated at our institution during October 2013-October 2014 and obtained informed consent from them. The participants were within the first 5 years after diagnosis with stages I-III breast cancer and had completed surgery, chemotherapy, and/or radiation therapy. We sought to determine whether breast cancer survivors would benefit from this intervention as determined by improvement of performance at 12 months compared with baseline based on the following self-reported validated questionnaires: Patient Health Questionnaire-9 (PHQ-9) for depression; General Anxiety Disorder-7 (GAD-7); and Short-Form Health Survey-36 (SF-36, version 2) for patient quality of life. The participants were enrolled in a comprehensive survivorship program staffed by an oncologist, an oncology nurse practitioner, a nutritionist, and a certified clinical psychologist who had trained in mindfulness-based stress reduction (MBSR).

Interventions

The participants received a one-on-one individual psychological consultation visit every 3 months for 20-45 minutes during which the psychologist addressed each patient’s emotional and psychological issues in depth, discussed relaxation techniques, and provided psychosocial counselling. In addition, all participants were asked to attend an 8-week-course (in Spanish or English) using MBSR, an interventional program in which participants receive training to promote reduction of stress by self-regulating mindfulness practice.^3,10 Our institution’s MBSR program consists of a weekly 2-hour class for 8 sessions or more. The program is provided 3 times a year, in English and Spanish. It includes the following components:

• Learning various mindfulness meditation techniques (eg, body scans, awareness of breathing, sitting/walking meditations);
• Practicing the mindfulness techniques in class; and
• Practicing techniques at home through audiorecordings of mindfulness meditation exercises and daily diary writing.

Participants were provided with a workbook on MBSR in their preferred language.¹¹ In addition to the psychological component, they were also provided with oncologic evaluations by an oncology nurse practitioner. The nurse practitioner met with participants every 3 months and provided each one with a personalized summary of all the treatments received and routine oncology follow-up care in consultation with the patients’ regular oncologists. This care also addresses the long-term sequelae of treatment, including arthritis and osteoporosis, referrals to receive screening for other cancers (eg, cervical and colon cancer), and genetic counselling as appropriate. In addition, a nutritionist provided general dietary advice in individual and group sessions every 3 months.

The self-administered questionnaires, PHQ-9, GAD-7, and SF-36, were completed at baseline, and every 3 months for 12 months. The scores were reviewed by the psychologist and the oncologist. The PHQ-9 was used to initially screen survivors for depression and monitor their improvement after the intervention. The PHQ-9 is a reliable and validated self-administered depression module.¹² The PQH-9 exclusively focuses on the 9 diagnostic criteria for DSM-IV depression disorder and it can be used as a useful measure for monitoring outcomes of depression therapy. A score of 5-14 suggests mild-moderate depression, and a score of >15 suggests severe depression

The survivors were screened for anxiety using the GAD-7, a brief 7-item self-report scale to identify probable cases of anxiety disorder that has been shown to be an efficient tool for screening and assessing the severity of anxiety.¹³ For GAD-7, a score of 5 or higher is suggestive of anxiety. Scores of 5, 10, and 15 represent cut-off points for mild, moderate, and severe anxiety, respectively.

Survivor QoL was evaluated using the SF-36 questionnaire, a multipurpose survey containing 36 questions. It ranges from 0-100 and a score that is <50.0 is considered low. The lower the score, the worse the mental or physical function.¹⁴ The SF-36 yields a patient profile of 8 health domains – vitality, physical functioning, bodily pain, general health perceptions, physical, emotional, and social role functioning; and mental health.^15,16 A score of 50.0 on either the Physical Component Summary (PCS – vitality, physical functioning, bodily pain, general health perceptions, physical role functioning) or Mental Component Summary (MCS – emotional and social role functioning, and mental health) is consistent with the US norm.