Recognized as one of the most prevalent and persistent concerns in cancer survivors, fear of cancer recurrence (FCR) is defined as the "fear, worry, or concern relating to the possibility that cancer will come back or progress" (Lebel et al., 2016). Higher FCR severity leads to poor mental health, impaired functioning and reduced quality of life. It is well established that health behaviours can help reduce the risk of cancer recurrence in cancer survivors, but little is known about their relationship with FCR. The overall thesis objectives were: 1) to identify subgroups of cancer survivors by FCR severity and corresponding patient characteristics; 2) to explore the relationship between FCR and health behaviours (physical activity and fruit and vegetable intake) over time; and 3) to further examine the relationship between FCR severity subgroups and health behaviours using the Common-Sense Model (CSM). Data analyses were conducted on 2337 survivors of ten cancer sites who completed the American Cancer Society’s Studies of Cancer Survivorship-I survey at three time points (M =1.3, 2.2, and 8.8 years post-diagnosis). In study 1, group-based trajectory analyses revealed three FCR severity groups: low, moderate, and high. FCR significantly decreased from early to long-term survivorship and remained distinct for each group. Subsequently, repeated measures analysis of variance revealed that patient characteristics prevalent in the high FCR group were being female, of younger age, Hispanic ethnicity, having more advanced cancer stage (II-III) and Non-Hodgkin lymphoma. Across FCR groups, only a minority of survivors adhered to the recommended physical activity and fruit and vegetable intake. Survivors in the high FCR group reported significantly fewer of these health behaviours than other survivors. In study 2, cross-sectional path analyses were conducted to examine the relationship between FCR and health behaviours using the CSM framework across the FCR severity groups. Results indicated good-fitting models for the low, moderate, and high FCR groups. Engaging in physical activity and fruit and vegetable intake did not influence FCR in most participants. Yet, in the low FCR group, survivors reporting more health behaviours had lower FCR severity. In the low and moderate FCR groups, health behaviours were related to control over health and self-efficacy to manage health, suggesting that cancer survivors use health behaviours to manage illness outcomes. For survivors in the high FCR group, results suggest that self-efficacy to manage health is a better predictor of FCR than engaging in physical activity and fruit and vegetable intake In conclusion, most cancer survivors fail to meet the recommended physical activity and fruit and vegetable intake throughout cancer survivorship, with survivors in the high FCR group being at greater risk of engaging in fewer health behaviours. Health behaviours appear unrelated to FCR severity for most cancer survivors, except for survivors with low FCR, who might be experiencing less FCR when engaging in more health behaviours. Findings suggests that clinical interventions should be tailored by FCR severity groups and that health behaviour research among cancer survivors should account for FCR severity groups. Further investigations are required to assess cancer survivors’ perceived usefulness of health behaviours to manage the risk of cancer recurrence by FCR severity group

Obesity is a known risk factor for postmenopausal breast cancer, and is associated with worse disease prognosis in pre- and postmenopausal women. Adjuvant hormonal therapies improve disease prognosis in obese women, but many still recur. Given that obesity induces inflammation and increases levels of cyclooxygenase-2 (COX-2) enzyme, resulting in tumor proliferation, this retrospective study investigated if women on anti-inflammatory drugs would have improved disease outcomes by reduced production of prostaglandins by COX-2 pathway. Four hundred and forty women treated for invasive breast cancer in San Antonio clinics were included. Cases were classified as NSAID users if notes included daily use of aspirin, ibuprofen, celecoxib or another COX-2 inhibitor; patients were categorized as NSAID nonusers if they were not taking any NSAIDs, or if they used COX-2 drugs for pain as needed rather than daily. Patients on NSAIDs were more likely to be older, be slightly more obese and postmenopausal. NSAID and NSAID nonusers did not statistically significantly differ in regards to BMI categories, tumor stage, hormone receptor status, type of invasive tumor, ethnicity/race and type of surgery. NSAID users had significantly less recurrence rates compared to nonusers (p=0.05). Further, time to disease progression was delayed by almost 28 months in patients who were NSAIDs users. Although this trend was non-significant statistically due to low number of total recurrences, it is promising in the clinical setting. In a logistic regression model using NSAID use, BMI categories and hormonal therapy drug as independent variables to predict recurrence, use of NSAID was only statistically significant in the univariate model. Overweight women were more likely to develop recurrence than normal weight when holding NSAID use and endocrine therapy constant. Obese women had increase recurrence risk, but the trend was not statistically significant. Females using aromatase inhibitors were less likely to recur than those on tamoxifen. The results of this exploratory study had limited power to determine multiple modulating factors, but because they suggest a major clinical benefit, further analyses in a larger sample size are needed to confirm these findings. / text

No description available.

Introdução: O câncer de mama é a neoplasia maligna mais prevalente em mulheres. Em decorrência do diagnóstico tardio, a mastectomia radical modificada (MRM) permanece como tratamento cirúrgico de escolha para a maioria das pacientes portadoras da doença. Em pacientes mastectomizadas, a reconstrução mamária com retalhos miocutâneos é a técnica que apresenta melhor resultado a longo prazo. Material e métodos: O estudo compara as taxas de recorrência local e sistêmica e a sobrevida livre de doença em pacientes submetidas à MRM, associada ou não à reconstrução mamária imediata com retalho miocutâneo transverso do reto abdominal (TRAM). Resultados: O grupo submetido à TRAM apresentou recorrência local de 11,8% e sistêmica de 35,7%, e o grupo da MRM, 4,4 e 26,1%, respectivamente. A sobrevida livre de doença (tempo decorrido entre a cirurgia e a primeira recorrência) foi, em média, de 105,4 meses (IC95% 97,0-113,72) no grupo MRM e de 95,4 meses (IC95% 80,7-110,0) no grupo TRAM, não havendo diferença estatisticamente significativa entre os grupos (P = 0,147). Conclusões: Em pacientes portadoras de câncer de mama, a reconstrução mamária imediata com retalho miocutâneo transverso do reto abdominal não influencia o prognóstico da doença, devendo ser oferecida às pacientes que não apresentam contraindicação clínica ao procedimento. / Introduction: Breast cancer is the most prevalent malignant neoplasia among women. In cases of late diagnoses, modified radical mastectomy (MRM) remains the surgical treatment of choice for most women with this disease, and breast reconstruction with myocutaneous flaps is the technique with the best long-term results. Material and methods: Local and systemic recurrence rates were compared, as well as diseasefree survival of patients who underwent MRM with or without immediate breast reconstruction using transverse rectus abdominis myocutaneous flap (TRAM). Results: The TRAM group had a local recurrence rate of 11.8% and a systemic recurrence rate of 35.7%; for the MRM group, these rates were 4.4 and 26.1%, respectively. Disease-free survival time (from surgery to first recurrence) was 95.4 months (95%CI 80.7-110.0) in the TRAM group and 105.4 (95%CI 97.0-113.72) in the MRM group, but the difference was not statistically significant (P = 0.147). In patients with breast cancer, immediate breast reconstruction with TRAM did not affect disease prognosis, and may be indicated to all patients who undergo MRM, except those with any clinical contraindications to the procedure.

Parenting is a primary role for many young breast cancer survivors and the combined effect of parenting while coping with this disease can be problematic for many of them. Despite this, little is known about the impact of parenting on the well-being of young breast cancer survivors. This thesis, comprising two studies in article format, explores this question. In the first study, we identified elements of well-being that are salient for all young women with breast cancer, and which also captured some of the unique challenges associated with parenting as a survivor. Using factor analysis techniques, we determined how these elements interrelated in separate groups of young survivors with children and without, and identified differences between the two groups based on the patterns observed. We found that the interrelationship among elements of well-being varied between these two groups: psychological distress (representing mental health and perceived stress), illness intrusiveness, and fear of cancer recurrence were found to co-occur more frequently in mothers than in young survivors without children, thus compromising their well-being. Our second study had two objectives. The first part examined differences in perceived stress, illness intrusiveness, and fear of cancer recurrence between young breast cancer survivors with and without children in two separate timeframes (0-5 and 5-15 years since diagnosis). The second part identified predictors for these elements of well-being in young mothers exclusively. Compared to survivors without children, young mothers reported higher levels of fear of cancer recurrence and illness intrusiveness in intimate life domains during both timeframes, suggesting that disruptions in these areas persist over time. Part two revealed that mothers with adolescent children and high levels of parenting stress were most likely to report perceived stress and illness intrusiveness. A mother’s age and the time since her diagnosis predicted fear of cancer recurrence and illness intrusiveness, respectively. Results from this thesis indicate that young mothers with breast cancer need screening and interventions to manage psychological distress, fear of cancer recurrence, and illness intrusiveness, particularly in intimate life domains. This thesis also identifies the most vulnerable groups of mothers and has important implications for future research.

Introdução: O câncer de mama é a neoplasia maligna mais prevalente em mulheres. Em decorrência do diagnóstico tardio, a mastectomia radical modificada (MRM) permanece como tratamento cirúrgico de escolha para a maioria das pacientes portadoras da doença. Em pacientes mastectomizadas, a reconstrução mamária com retalhos miocutâneos é a técnica que apresenta melhor resultado a longo prazo. Material e métodos: O estudo compara as taxas de recorrência local e sistêmica e a sobrevida livre de doença em pacientes submetidas à MRM, associada ou não à reconstrução mamária imediata com retalho miocutâneo transverso do reto abdominal (TRAM). Resultados: O grupo submetido à TRAM apresentou recorrência local de 11,8% e sistêmica de 35,7%, e o grupo da MRM, 4,4 e 26,1%, respectivamente. A sobrevida livre de doença (tempo decorrido entre a cirurgia e a primeira recorrência) foi, em média, de 105,4 meses (IC95% 97,0-113,72) no grupo MRM e de 95,4 meses (IC95% 80,7-110,0) no grupo TRAM, não havendo diferença estatisticamente significativa entre os grupos (P = 0,147). Conclusões: Em pacientes portadoras de câncer de mama, a reconstrução mamária imediata com retalho miocutâneo transverso do reto abdominal não influencia o prognóstico da doença, devendo ser oferecida às pacientes que não apresentam contraindicação clínica ao procedimento. / Introduction: Breast cancer is the most prevalent malignant neoplasia among women. In cases of late diagnoses, modified radical mastectomy (MRM) remains the surgical treatment of choice for most women with this disease, and breast reconstruction with myocutaneous flaps is the technique with the best long-term results. Material and methods: Local and systemic recurrence rates were compared, as well as diseasefree survival of patients who underwent MRM with or without immediate breast reconstruction using transverse rectus abdominis myocutaneous flap (TRAM). Results: The TRAM group had a local recurrence rate of 11.8% and a systemic recurrence rate of 35.7%; for the MRM group, these rates were 4.4 and 26.1%, respectively. Disease-free survival time (from surgery to first recurrence) was 95.4 months (95%CI 80.7-110.0) in the TRAM group and 105.4 (95%CI 97.0-113.72) in the MRM group, but the difference was not statistically significant (P = 0.147). In patients with breast cancer, immediate breast reconstruction with TRAM did not affect disease prognosis, and may be indicated to all patients who undergo MRM, except those with any clinical contraindications to the procedure.

Introdução: O câncer de mama é a neoplasia maligna mais prevalente em mulheres. Em decorrência do diagnóstico tardio, a mastectomia radical modificada (MRM) permanece como tratamento cirúrgico de escolha para a maioria das pacientes portadoras da doença. Em pacientes mastectomizadas, a reconstrução mamária com retalhos miocutâneos é a técnica que apresenta melhor resultado a longo prazo. Material e métodos: O estudo compara as taxas de recorrência local e sistêmica e a sobrevida livre de doença em pacientes submetidas à MRM, associada ou não à reconstrução mamária imediata com retalho miocutâneo transverso do reto abdominal (TRAM). Resultados: O grupo submetido à TRAM apresentou recorrência local de 11,8% e sistêmica de 35,7%, e o grupo da MRM, 4,4 e 26,1%, respectivamente. A sobrevida livre de doença (tempo decorrido entre a cirurgia e a primeira recorrência) foi, em média, de 105,4 meses (IC95% 97,0-113,72) no grupo MRM e de 95,4 meses (IC95% 80,7-110,0) no grupo TRAM, não havendo diferença estatisticamente significativa entre os grupos (P = 0,147). Conclusões: Em pacientes portadoras de câncer de mama, a reconstrução mamária imediata com retalho miocutâneo transverso do reto abdominal não influencia o prognóstico da doença, devendo ser oferecida às pacientes que não apresentam contraindicação clínica ao procedimento. / Introduction: Breast cancer is the most prevalent malignant neoplasia among women. In cases of late diagnoses, modified radical mastectomy (MRM) remains the surgical treatment of choice for most women with this disease, and breast reconstruction with myocutaneous flaps is the technique with the best long-term results. Material and methods: Local and systemic recurrence rates were compared, as well as diseasefree survival of patients who underwent MRM with or without immediate breast reconstruction using transverse rectus abdominis myocutaneous flap (TRAM). Results: The TRAM group had a local recurrence rate of 11.8% and a systemic recurrence rate of 35.7%; for the MRM group, these rates were 4.4 and 26.1%, respectively. Disease-free survival time (from surgery to first recurrence) was 95.4 months (95%CI 80.7-110.0) in the TRAM group and 105.4 (95%CI 97.0-113.72) in the MRM group, but the difference was not statistically significant (P = 0.147). In patients with breast cancer, immediate breast reconstruction with TRAM did not affect disease prognosis, and may be indicated to all patients who undergo MRM, except those with any clinical contraindications to the procedure.

Fear of cancer recurrence (FCR) is regarded as one of the most common and distressing issues affecting cancer survivors. Observational studies have identified several modifiable characteristics associated with FCR. However, many of the findings are based on post-hoc analyses and come from studies in which FCR was not identified as a primary outcome. This study sought to overcome these limitations by using a model comprised of cognitive, behavioral, and social characteristics as a framework for examining modifiable characteristics associated with FCR. A sample of 120 patients who had been diagnosed with colorectal cancer and completed cancer treatment in the past 6 to 36 months was recruited during routine outpatient visits or by mail for participation in the study. Medical record reviews were conducted to assess clinical variables, and participants filled out a standard demographic questionnaire as well as self-report measures of characteristics resistant to modification (perceived risk of recurrence, neuroticism, conscientiousness), cognitive modifiable characteristics (self-efficacy, positive beliefs about worry, negative beliefs about worry, misinterpretation of symptoms, intolerance of uncertainty and rumination), behavioral modifiable characteristics (reassurance seeking and health-related reassurance seeking), and social modifiable characteristics (social support and social constraints). As hypothesized, results demonstrated that modifiable characteristics (i.e., self efficacy, positive beliefs about worry, negative beliefs about worry, intolerance of uncertainty, rumination, reassurance seeking, health-related reassurance seeking and social constraints) were associated with FCR (all p’s < .05). Multivariable regression analyses demonstrated that modifiable characteristics accounted for 13% of the variance in FCR beyond that accounted for by non-modifiable characteristics (p < .001), with self-efficacy, rumination and health-related reassurance seeking accounting for unique variance in FCR. This study has identified several modifiable characteristics that should be considered as targets for interventions seeking to reduce FCR among cancer survivors.

Fear of cancer recurrence (FCR) is defined as “fear, worry, or concern relating to the possibility that cancer will come back or progress (Lebel et al., 2016, p. 3266). FCR is the most frequently reported concern identified among cancer survivors (Baker, Denniston, Smith, & West, 2005; Lebel, Rosberger, Edgar, & Devins, 2007). Although approximately 50% of cancer survivors experience moderate-to-high levels of FCR (Simard et al., 2013), few psychosocial interventions exist that directly target this construct. The overarching study objectives were: (a) to adapt a manualized, 6-week, cognitive-existential group therapy intervention for FCR to an individual format; (b) to pilot-test the feasibility, acceptability, and satisfaction of this individual intervention on n=3 participants; and (c) to further pilot-test the efficacy of the individual intervention on n=25 participants, via a randomized controlled trial (RCT). In study 1, n=3 cancer survivors (1 male, 2 females) completed the one-on-one therapy intervention for the psychological treatment of FCR. Sessions were 60-90 minutes long, and included cognitive restructuring exercises, behavioural experiments, relaxation techniques, existential processing of the here-and-now, and finding meaning in life post-diagnosis. Participants completed questionnaire packages throughout the intervention and an exit interview to determine their overall feedback on the intervention. Quantitative analyses revealed downwards trends in fear of cancer recurrence and cancer-specific distress across participants. Qualitative analyses of the exit interviews revealed that all participants found the intervention useful, and that the sessions had favourable pacing and length. In study 2, the FCR intervention was further pilot-tested via an RCT. Twenty-five female cancer survivors were randomized to an experimental group or a wait-list control group. Sessions included cognitive restructuring techniques, behavioural experiments, confronting existential distress, and relaxation exercises. Nineteen women (n=9 intervention, n=10 control) completed the 6-week therapy intervention, and completed questionnaire packages at pre-, post- and 3-month follow-up. Between-within ANOVAs revealed significant interactions in the primary outcome measure of FCR, and secondary outcome measures of cancer-specific distress and uncertainty in illness for participants in the experimental group. Repeated measures ANOVAs revealed reductions in FCR, cancer-specific distress, uncertainty in illness, reassurance-seeking, cognitive avoidance, and intolerance of uncertainty, and revealed improvements in positive reinterpretation and growth, use of emotional support and mental health (improved quality of life) for participants in the experimental group, as compared to the wait-list control group. The variables that changed either maintained or improved at follow-up. Results from this study demonstrate promising results in addressing FCR in cancer survivors via a cognitive-existential intervention. Future research should continue investigating the specific therapeutic ingredients that are most effective for the psychological treatment of FCR.

Parenting is a primary role for many young breast cancer survivors and the combined effect of parenting while coping with this disease can be problematic for many of them. Despite this, little is known about the impact of parenting on the well-being of young breast cancer survivors. This thesis, comprising two studies in article format, explores this question. In the first study, we identified elements of well-being that are salient for all young women with breast cancer, and which also captured some of the unique challenges associated with parenting as a survivor. Using factor analysis techniques, we determined how these elements interrelated in separate groups of young survivors with children and without, and identified differences between the two groups based on the patterns observed. We found that the interrelationship among elements of well-being varied between these two groups: psychological distress (representing mental health and perceived stress), illness intrusiveness, and fear of cancer recurrence were found to co-occur more frequently in mothers than in young survivors without children, thus compromising their well-being. Our second study had two objectives. The first part examined differences in perceived stress, illness intrusiveness, and fear of cancer recurrence between young breast cancer survivors with and without children in two separate timeframes (0-5 and 5-15 years since diagnosis). The second part identified predictors for these elements of well-being in young mothers exclusively. Compared to survivors without children, young mothers reported higher levels of fear of cancer recurrence and illness intrusiveness in intimate life domains during both timeframes, suggesting that disruptions in these areas persist over time. Part two revealed that mothers with adolescent children and high levels of parenting stress were most likely to report perceived stress and illness intrusiveness. A mother’s age and the time since her diagnosis predicted fear of cancer recurrence and illness intrusiveness, respectively. Results from this thesis indicate that young mothers with breast cancer need screening and interventions to manage psychological distress, fear of cancer recurrence, and illness intrusiveness, particularly in intimate life domains. This thesis also identifies the most vulnerable groups of mothers and has important implications for future research.