Breast cancer is a common disease in Australia and exerts a sizable burden to individuals, families, and health care resources. Studies that assess healthrelated quality-of-life (HRQoL) are particularly relevant as survivors must learn to live with breast cancer, undergo prolonged treatment, use new pharmacological agents, monitor and adjust to a serious condition. Relatively little published evidence exists on the effects of rehabilitation programs for breast cancer survivors but those published demonstrate positive health benefits that alleviate both physical and psychological problems. This study aimed to partly fill this gap and had the objectives of: a) estimating the effectiveness of two rehabilitation interventions for breast cancer survivors over time compared to a non-intervention comparison group; and b) ascertaining which option was cost-effective when taking a societal perspective. Effectiveness was described in terms of HRQoL and functional status and there was a particular focus on upperbody morbidity since the two interventions primarily addressed this aspect of rehabilitation. The study participants comprised three groups: one group received a physiotherapy home-visits service (DAART), the second attended a gentleexercise group program (STRETCH), while the third represented a nonintervention comparison group for later analyses only. Data collection was primarily by way of postal questionnaires while medical and cost data abstraction was also necessary. Reliable and validated instruments were used to collect HRQoL and utility data. The Functional Assessment of Cancer Therapy - Breast Cancer plus the Arm Morbidity module (FACT-B+4), Disabilities of the Arm, Shoulder and Hand (DASH), and the Subjective Health Estimation (SHE) instruments were chosen for their high psychometric performance with various populations, their brevity, quick administration and relevance to a breast cancer sample. Missing data was a small concern overall, however, baseline differences were present and mixed across the three participant groups indicating selection bias was present. DAART showed poorer demographic indicators of socioeconomic status and were older, STRETCH participants had poorer disease and treatment profile, while the non-intervention women had poorer general health characteristics. Based on bivariate analyses, age, presence of comorbidities, chemotherapy, high blood pressure, work status (unpaid/paid), hormone therapy were determined to be factors requiring control for in the multivariate analyses. Benefits were found for multiple dimensions of HRQoL for the DAART intervention. On average, HRQoL levels were fairly high across the three alternative participant groups and no significant group differences were found. However, approximately one-third of the women experienced declining HRQoL between 6- to 12-months and their scores were significantly poorer than other participants. STRETCH incurred higher overall costs per participant (on average) than DAART and the non-intervention groups. This was driven by higher leisure time forgone, travel and higher community costs. DAART experienced the highest program costs (or health system costs). Therefore, by taking a societal perspective, and incorporating the estimated value of more intangible or indirect costs (e.g., volunteers, travel costs etc.) the STRETCH program was more costly. The greatest influence on higher costs incurred by the STRETCH participants was the average out-of-pocket expenses for health care services purchased during the previous 12 months for breast cancer-related problems. Although an exploratory finding, the DAART group emerged as the cost-effective option, that is, the incremental cost per QALY gained was $1,344 compared to STRETCH $14,478. The key drivers in the cost-effectiveness modelling were utility values and health service expenditure. When uncertainty was quantified by way of Monte Carlo modelling, DAART remained the cost-effective choice. This project has highlighted that while many women seem to breeze through their breast cancer diagnosis and treatment, there are a substantial number of women who do not. Therefore, it is quite mistaken to generalise the favourable levels of HRQoL and expect that all women will get back to 'normal'. Given that HRQoL is a very complex concept, it was important to use validated tools that had undergone extensive testing with sound psychometric properties. Health care activities observed in their natural 'real world' setting are preferable to minimise biases that may cause more favourable results than truly occur and allow a better assessment on the impact of the service. The project findings have been interpreted while respecting a number of limitations. These have included potential selection and response bias, missing data, and small numbers of intervention women and defined socio-demographic profiles. Taken together, these are likely to overestimate the true outcomes. Arguably, selection bias and the timing of the interventions are likely to be the strongest factors affecting the generalisability of these findings. Given the caveats of this research, the following recommendations were made: 1. Greater awareness and/or screening of adjustment problems among survivors needs to be considered during recovery from breast cancer surgery. 2. Early physiotherapy should be given to all breast cancer survivors after surgery due to the potential functional, physical and overall HRQoL benefits that may arise. 3. Professionally-led group exercise therapy with psychosocial care appears to have a neutral effect on upper-body recovery and improving HRQoL. However, it provides advantages for attendees in the form of peersupport, education, a holistic focus and the potential for addressing previously unrecognised psychological problems in a caring and acceptable environment. This program, with large community resources (provided voluntarily), represents a very low-cost outlay for health services and should be given support and consideration during follow-up care after breast surgery. 4. From a societal perspective, a home-visiting physiotherapy service represents a cost-effective means to provide rehabilitative care for breast cancer patients and represents an excellent public health investment. Several topics for further research are likely to be important in the future including, among others, other modes and settings of rehabilitation service delivery, barriers to psychosocial care and the indirect financial and work consequences of having breast cancer.
| Identifer | oai:union.ndltd.org:ADTP/265253 |
| Date | January 2006 |
| Creators | Collins, Louisa Gaye |
| Publisher | Queensland University of Technology |
| Source Sets | Australiasian Digital Theses Program |
| Detected Language | English |
| Rights | Copyright Louisa Gaye Collins |
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