Gastrointestinal and Breast Cancer Survivor’s Unmet Needs During Survivorship Journey: A Reliability and Validity Study

Objective To understand the unmet needs of breast cancer survivors and to analyze the influencing factors of unmet need for breast cancer survivors, and to provide evidence for the development of intervention programs to reduce the unmet needs of breast cancer survivors. Methods A total of 360 breast cancer survivors were surveyed using the Breast Cancer Survivors Unmet Needs Scale to observe the overall score of unmet need for breast cancer survivors, breast cancer survivor scores in different situations, and breast cancer survivors. Factors that were not met by the demand. Results The overall score of unmet need for breast cancer survivors was (291.18±8.48). The highest score of symptom burden was (125.12±1.57) and the score was 89.37%. There were significant differences in the scores of breast cancer survivors of different ages, marital status, medical insurance forms, affected side, surgical methods, education, occupation, family income, and disease stage(t/F value was 8.633-294.629, P<0.01). The unaffected factors of breast cancer survivors were education, age, family income, and occupation. The degree of the dependent variable was 36.4%. Conclusions Breast cancer survivors have a high level of unmet need, and are affected by education, age, family income, and occupation. Key words: Breast neoplasms; Survivors; Unmet needs; Questionnaire

PurposePhysicians' awareness of their cancer patients' unmet needs is an essential element for providing effective treatment. This study investigated the accuracy of physicians' awareness of breast cancer survivors' unmet needs in Korea.MethodsA cross-sectional interview survey was performed among 106 physicians and 320 Korean breast cancer survivors. The Comprehensive Needs Assessment Tool was administered to physicians and cancer survivors after obtaining their written informed consent to participate. Data were analyzed using t-test, analysis of variance, and multiple regression analysis.ResultsThe level of unmet needs was highest in the hospital service domain (mean ± standard deviation: 2.19 ± 0.82), and the top-ranked unmet need item was “wished my doctor to be easy, specific, and honest in his/her explanation” (2.44 ± 0.93). Higher unmet needs were correlated with the presence of a genetic counseling clinic. They were not associated with age, sex, marital status, religion, department, working period, type of institution, number of staff, and number of operations. In multiple regression analysis, the presence of a genetic counseling clinic was associated with a higher level of recognition for psychological problems, social support, hospital service, and information and education needs. Physicians overestimated breast cancer survivors' unmet needs in all domains, compared to their self-reported unmet needs. The discordance in the perceived unmet needs was highest in the ‘family/personal relationship problems’ domain.ConclusionsPhysicians who treat Korean breast cancer survivors rated the level of unmet needs of breast cancer survivors as highest in the hospital service domain. The presence of a genetic counseling clinic in physicians' institutions was associated with a higher perception of survivors' unmet needs. Physicians overestimated the level of unmet needs in Korean breast cancer survivors. Efforts to reduce these discordances are needed to implement optimal survivorship care.

Breast cancer survivors experience unmet needs throughout survivorship. We described the burden of unmet needs among ≥ 10-year survivors. We used the Cancer Survivors Unmet Needs Assessment (CaSun) to characterize unmet needs (information, quality of life, emotional and relationships, life perspective) among participants in Phase 3 of the Carolina Breast Cancer Study, a population-based study of breast cancer survivors diagnosed from 2008 to 2013. We calculated the prevalence of having ≥ 5 unmet needs (%) and estimated prevalence differences (PD) and 95% confidence intervals (CI) using generalized linear models with a binomial distribution to describe the burden of unmet needs across patient, clinical, and treatment characteristics. We included 1445 women who completed the CaSun an average of 11.2 (SD = 0.6) years post-diagnosis. The sample was roughly balanced between Black (46.2%) and White (53.8%) participants. Overall, 27.1% of participants reported ≥ 5 unmet needs. We observed a higher burden of unmet needs among Black women compared to White women (PD: 14.2; 95% CI 9.6, 18.7) and among women < 50years of age compared to women ≥ 50 (PD: 9.5; 95% CI 5.0, 13.9). Notably, women characterized as having "more barriers to care" had the highest prevalence of unmet needs in our study, with 28.6 percentage points higher prevalence compared to women with "fewer barriers to care" (95% CI 18.7, 38.5). Black, younger, and socioeconomically disadvantaged women had a higher burden of long-term unmet needs ≥ 10years post-diagnosis. Identifying patient characteristics that predict long-term unmet needs may help to identify targeted interventions.

Advances in early detection and treatment have improved breast cancer survival rates; However, survivors often face psychosocial challenges such as Fear of Cancer Recurrence (FCR) and unmet needs. FCR refers to anxiety or worry about cancer returning, while unmet needs represent the gap between the support required and that received—particularly in emotional and informational aspects. Understanding their interplay is vital for developing comprehensive, needs-based nursing interventions. This study aimed to systematically review the relationship between FCR and unmet needs among breast cancer survivors, focusing on prevalence, contributing factors, and their impact on quality of life and health-related behaviors such as screening adherence and healthcare utilization. A systematic search was conducted across PubMed, Scopus, and ProQuest using the keywords “fear of cancer recurrence,” “unmet needs,” and “breast cancer survivors.” Articles written in English with systematic reviews, cross-sectional, cohort, qualitative, or mixed-methods designs were included. From 1,414 identified studies, eight met inclusion criteria and were analyzed qualitatively following PRISMA guidelines. Moderate to high FCR levels were found in 50–70% of survivors, and 60–70% reported at least one unmet need, mainly emotional and informational. Higher FCR levels were strongly associated with increased unmet needs. Unmet needs mediated FCR's impact on health behaviors, leading to lower screening participation and higher unplanned healthcare use. Younger age, comorbidities, and low social support exacerbated both factors. FCR and unmet needs are interrelated psychosocial issues affecting survivors' emotional well-being and behavior. Oncology nursing should integrate structured assessments and tailored interventions to improve survivors' quality of life.

Background: The increasing of breast cancer survivors (BCS) as the result of treatment success involves patients demanding cares related to the adverse events of cancer treatment. Furthermore, the study of the course of the disease process and treatment over time has been a yielding perspective to understand cancer patients. Few studies have attempted to analyze changes over time since diagnosis (TSD) in women who remain disease free and are taking endocrine therapy (TET). It is known that some BCS reported high levels of quality of life (QoL), no changes in social support (SS) and that survivors without chemotherapy as adjuvant treatment had better QoL that those who had received it. However, the changes over time in terms of unmet needs (UN), QoL, and perceived SS outcomes in Mexican BCS have no examined, which is fundamental to identify convenient goals, better times of integrated interventions and optimize our human resources according to the trajectory of cancer treatment. Objective: Identify changes over TSD, and the time TET in terms of UN, SS perception and QoL on Mexican BCS. Method: 368 patients with BC and TET were enrolled in a cross-sectional and comparative design, were assessed using QoL (EORTC-30 and BR-23), UN (SCNS-SF32), SS (MOS-SSS14), validated and standardized instruments in a Mexican cancer population. Premenopausal patients with ovarian function suppression were excluded. Patients were divided into four groups according to TSD and time TET, both in ≤1year and &amp;gt;1year. Parametric and non-parametric analyses were used: t Student and U Mann Whitney. Results: Patients mean age was 54 (SD=10.6) years; mean of TSD was 38 (SD=24) months, and they had 30 months on average (SD= 19) TET. The level of global QoL was high (78%) as well as the level of SS (73%), the UN were low (28%). Cognitive function was the most rated concern in terms of QoL for all groups. “Help with daily shores" was the type of SS, which all groups perceived the lowest support. "Fear about cancer spreading" and “Concern about worries of those close to you” were the first and second rated UN in all groups. Additionally, we found that patients with ≤1year of TSD had more significantly insomnia, financial difficulties, psychological and global UN (p=.02; p=.01; p=.0005; p=.01, respectively) than patients with &amp;gt;1 year of TSD. Moreover, the results showed that after one year of time TET: psychological and global needs, besides tangible and global SS, diminished significantly (p=.002; p=.009; p=.01; p=.03, respectively), nevertheless, the future perspective of health increases significantly (p=.01). Discussion and conclusions: Our findings are consistent with previous studies in terms of QoL. These results indicate that not only BCS patients improve physically, but also psychosocially over time: they are more independent, also have a better perspective of their health even though the fear persists. In conclusion, all biopsychosocial aspects evaluated improve over time. These data suggest that the most optimal effort might be provided to newly diagnosed patients, which is fundamental information for a country as Mexico with a lack of human resources. For instance, health staff could be focused on providing tools to deal with fears, social concerns, and physical/cognitive symptoms as a priority in this vulnerable group. Citation Format: Lizette Gálvez-Hernández, V Neri-Flores, I Paéz-Gerardo, E López-Muñiz, I Monroy-Ortiz, A Mohar-Betancourt, Enrique Bargallo-Rocha, Cynthia Villarreal-Garza, Paula Cabrera-Galeana. Biopsychosocial changes since diagnosis and the time taking endocrine therapy in Mexican patients with breast cancer [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P2-13-08.

Prioritizing care for women with breast cancer based on survival stage: A study examining the association between physical symptoms, psychological distress and unmet needs.

Background: Our group previously reported that young breast cancer (BC) survivors have a higher risk of osteopenia/osteoporosis compared to their cancer-free peers. In order to develop successful interventions we need to understand the major contributing factors. Therefore, we investigated bone loss in young BC survivors by age at diagnosis, tumor characteristics and BC treatment compared to their cancer-free peers. Methods: We studied 775 women (211 BC survivors, 564 cancer-free) with familial risk of breast and/or ovarian cancer in the Breast and Ovarian Surveillance Service (BOSS) cohort at Johns Hopkins. Survivors were diagnosed with stage 0-III BC &amp;lt;5 years prior to enrollment. The comparison group was cancer-free women at enrollment. Osteopenia and osteoporosis were ascertained based on self-reported physician diagnosis in baseline and follow-up questionnaires. Prevalent cases of osteopenia or osteoporosis were excluded. Multivariable (MV)-adjusted Cox proportional hazard models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) of osteopenia and/or osteoporosis among BC survivors compared to cancer-free women. BC survivors were stratified by age at diagnosis, estrogen-receptor (ER) tumor status, and BC treatment. MV models were adjusted for age, menopausal status, body mass index, physical activity, smoking, alcohol use, hormone replacement therapy and early oophorectomy. Results: Mean time from BC diagnosis to enrollment was 1.4 years for survivors and mean age at BC diagnosis was 47 years. At baseline, BC survivors were more likely to be slightly older, postmenopausal, and current vitamin D users and less likely to have had an early bilateral oophorectomy compared to cancer-free women. During a mean follow-up time of 5.7 years, 66% of BC survivors and 54% of cancer-free women reported having ≥1 bone density exam and 112 incident cases of osteopenia/osteoporosis were identified (75% osteopenia only). BC survivors diagnosed at age ≤50 years had a 2-fold increased risk of osteopenia/osteoporosis compared to cancer-free women (HR=2.05, 95% CI=1.24-3.40). Risk of bone loss was similar among survivors with ER-positive tumors compared to cancer-free women (HR=2.04, 95% CI=1.30-3.22). No association was observed for BC survivors treated with tamoxifen only or chemotherapy only. BC survivors treated with aromatase inhibitors (AIs) only had almost 3-fold increased risk of osteopenia/osteoporosis compared to cancer-free women (HR=2.92, 95% CI=1.38-6.17). BC survivors treated with chemotherapy + tamoxifen and chemotherapy + AIs had over 2- and 4-fold increased risk of osteopenia/osteoporosis compared to cancer-free women (HR=2.28, 95% CI=1.04-5.00; HR=4.09, 95% CI=1.99-8.42, respectively). Results suggest that risk of bone loss was highest within 5 years after BC diagnosis. Conclusion: Our results demonstrate that osteopenia/osteoporosis incidence is higher in BC survivors compared to cancer-free women and risk varies by age at diagnosis, ER-status and BC treatment. Our findings provide support for a baseline evaluation of bone density close to diagnosis in BC survivors with familial risk. Future studies are needed to address the frequency of monitoring among specific age and treatment groups. Citation Format: Ramin CA, May BJ, Roden RBS, McCullough M, Armstrong DK, Visvanathan K. Understanding the etiology of osteopenia and osteoporosis in young breast cancer survivors compared to cancer-free women [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P6-08-12.

Association between physical activity and mortality among breast cancer and colorectal cancer survivors: a systematic review and meta-analysis.

Introduction Over 1,500 studies are in Medline today on the psychosocial impact and quality of life (QOL) of breast cancer (BC) survivors. Only a small percentage of these studies have been conducted with women of color, yet most of these studies appear to use the same psycho-social theories for intervention and outcomes, developed and validated with non-Hispanic white women. This assumed universality of (EA) cultural beliefs and practices undermines the importance of cultural differences in cancer research. Often standardized questionnaires are tested for reliability in diverse groups with an α score, but many validated scales have rarely been tested for cross-cultural equivalence of concepts and metrics in diverse populations. The absence of research exploring and testing the cross cultural equivalence of EA developed concepts, such as, self-integrity and well-being of BC survivors thwarts our ability to effectively address the QOL of diverse populations, and hinders our ability to promote health equity. Therefore, this presentation will first briefly present a consensus definition of culture, second, discuss the general lack of attention to cross-cultural equivalence of concepts and measures used in cancer survivor research, last, present an example of a mixed paradigm and mixed method study designed to identify and test such potential cultural differences in among Asian American (AA) breast cancer (BC) survivors. AA BC survivors are reported to suffer significant emotional and social problems, but do not avail themselves of existing and available EA based services, even if they have been in the U.S. for multiple generations and/or are proficient in English. Yet, few studies have been conducted to identify why AA BC survivors do not use existing support services and how to better design high-quality programs that provide that needed support. Breast cancer support groups are designed to increase self-integrity, and well-being, but the cross-cultural equivalence of concepts of self-integrity and well-being have not been tested in breast cancer survivorship. Study Design This mixed paradigm and mixed method study was developed to 1) test the cultural equivalence and validity of standard measures of distress and well-being in order to investigate such potential cultural differences in the BC survivorship experience among three groups of Asian American women in three different geographic areas, 2) identify potential cultural differences in their perceptions of the cancer experience and degree of satisfaction with their strategies to manage the experience by providing context and meaning to our deductive findings, and 3) test if the cultural specific constructs and measures provide greater explanatory power to the QOL of the AA women than the set of standardized tools currently used. We conducted, in depth ethnographic interviews with 35 key informants, 118 BC survivors and 57 family members. We also surveyed 450 Chinese-, Japanese-, Vietnamese- and European American BC survivors. Implications for Health Disparities Research in Cancer The findings from this study will demonstrate how mixed-paradigms and methods are essential to develop a culturally informed understanding of the lives of women with cancer from diverse cultural backgrounds. Such study designs are crucial to inform the science and practice of BC survivorship in AA communities by mobilizing more culturally appropriate assessment tools built on culturally valid concepts and constructs. Such tools may aid in designing culturally grounded and congruent programs that more adequately meet the needs of those in underrepresented communities, and, thereby, improve the QOL of BC survivors from diverse populations as well as facilitate the elimination of health disparities. Citation Format: Marjorie Kagawa-Singer. How does Cultural Equivalence Impact Asian American Cancer Survivors? [abstract]. In: Proceedings of the Ninth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2016 Sep 25-28; Fort Lauderdale, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2017;26(2 Suppl):Abstract nr IA17.

Background: Bone loss has been consistently reported among long-term older breast cancer (BC) survivors. However, it remains unclear how early and to what degree BC survivors experience bone loss compared to their cancer-free peers and to what extent this can be attributed to age and premature menopause. Methods: We studied 796 women (210 BC survivors, 586 cancer-free) with familial risk of breast and/or ovarian cancer in the Breast and Ovarian Surveillance Service (BOSS) cohort at Johns Hopkins Hospital. Survivors were diagnosed with stage I-III BC &amp;lt;5 years prior to baseline (mean time from diagnosis to enrollment=1.4 years; mean age at diagnosis=47 years). Osteopenia and osteoporosis were ascertained based on self-reported physician diagnosis in baseline and follow-up questionnaires. Prevalent cases of osteopenia or osteoporosis were excluded. Multivariable (MV)-adjusted Cox proportional hazard models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) of osteopenia and osteoporosis incidence among BC survivors compared to cancer-free women. MV models were adjusted for age, race, menopause status, body mass index, physical activity, smoking, hormone replacement therapy and early oophorectomy. Results: BC survivors were slightly older (mean age 48 vs. 45 years), more likely to be post-menopausal (51% vs. 29%) and had higher current vitamin D use (21% vs. 8%) compared to cancer-free women. During a mean follow-up time of 6.2 years, 77% of BC survivors and 60% of cancer-free women reported having ≥1 bone density exam and 115 incident osteopenia and/or osteoporosis cases were identified (75% osteopenia only). In MV-adjusted models, BC survivors had 66% higher risk of being diagnosed with osteopenia and/or osteoporosis compared to cancer-free women (HR=1.66, 95% CI=1.11-2.47). BC survivors with no current vitamin D or calcium use had 76% and 93% higher osteopenia and/or osteoporosis risk compared to cancer-free women, respectively (MV HR=1.76, 95% CI=1.14-2.72; MV HR=1.93, 95% CI=1.15-3.24). BC survivors ever treated with chemotherapy or hormone therapy had higher osteopenia and/or osteoporosis risk compared to cancer-free women (MV HR=2.00, 95% CI=1.14-3.50; MV HR=1.79, 95% CI=1.14-2.82, respectively). Analyses restricted to women with no change in menopause status during follow-up were only slightly attenuated (MV HR=1.58, 95% CI=0.96-2.59). Conclusion: Our results demonstrate that bone loss is significantly greater than and occurs early in young BC survivors compared to cancer-free women even after taking into consideration increasing age and premature menopause. Our findings also provide support for a baseline evaluation of bone density at diagnosis with subsequent monitoring in young BC survivors with familial risk. Further analyses are ongoing to evaluate the effect of specific BC treatments on bone health in this cohort. Citation Format: Cody A. Ramin, Betty J. May, Richard B. Roden, Dana Petry, Deborah K. Armstrong, Kala Visvanathan. Evaluation of bone health in breast cancer survivors compared to cancer-free women: A prospective study within a young familial risk cohort [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 3271. doi:10.1158/1538-7445.AM2017-3271

ObjectiveTo assess the prevalence of unmet needs in post-treatment breast cancer survivors and identify sociodemographic, clinical, and psychosocial variables associated with reported unmet needs during the COVID-19 pandemic.Materials and methodsIn this cross-sectional study, 430 post-treatment breast cancer survivors, ranging between 1 and 5 years after the procedure, completed the Cancer Survivors’ Unmet Needs (CaSUN) questionnaire from September 2021 and January 2022. The multivariate logistic analysis identified factors associated with at least one reported unmet need in the total CaSUN scale and specific domains.ResultsA total of 67% of survivors reported at least one unmet need. The most frequently reported unmet needs were the lack of accessible hospital parking (43%) and recurrence concerns (39.5%). The majority of reported unmet needs relate to comprehensive care (44%), followed by the psychological and emotional support domain (35.3%). Younger age (OR = 0.95, 95% CI = 0.92–0.99; p < 0.001), three or more comorbidities (OR = 0.27, 95% CI = 0.11–0.71, p < 0.01), a lower quality of life (OR = 0.06, 95% CI = 0.01–0.47, p < 0.01) and low resilience (OR = 0.95, 95% CI = 0.93–0.99) were associated with a high level of unmet needs in the multivariate regression model. Results are presented for factors associated with a high level of unmet needs for comprehensive cancer care and psychological and emotional support domain.ConclusionA high prevalence found in our study could be attributed to the COVID-19 pandemic, where patients may have missed adequate follow-up care, although comparing to studies done in non-pandemic time is difficult. Family physicians should be more attentive toward younger cancer survivors and those with more comorbidities as both characteristics can be easily recognized in the family practice.

Understanding the challenges faced by an increasing number of cancer survivors can guide the development and implementation of effective survivorship care models. To identify the physical, emotional, and practical concerns and associated unmet needs reported by cancer survivors. This cross-sectional survey study obtained data from the Experiences of Cancer Patients in Transitions Study of the Canadian Partnership Against Cancer, in collaboration with cancer agencies in the 10 Canadian provinces, that was disseminated in 2016. This analysis included only adult survivors aged 30 years or older who underwent chemotherapy, radiation therapy, surgical treatment, or a combination of these therapies for breast, prostate, colorectal, melanoma, or hematological cancer within the past 1 to 3 years. Data synthesis and quality assessment were conducted in 2017. Data analysis was completed in July 2019. The outcomes were the (1) quantification of the magnitude and multiplicity of the physical, emotional, and practical concerns of adult survivors of breast, colorectal, prostate, melanoma, or hematological cancer; (2) exploration of the magnitude of associated unmet needs; and (3) identification of patient-, treatment-, and cancer-specific factors associated with the reporting of unmet needs. Overall, 10 717 adult respondents were included (5660 [53%] female and 6367 [60%] aged ≥65 years). The median number of concerns per respondent was 6 (interquartile range [IQR], 3-10). Among respondents with concerns, help was sought for a median of 2 (IQR, 0-4) concerns. Unmet needs were reported for a median of 4 (IQR, 2-7) concerns. Emotional concerns were reported by 8330 respondents (78%), physical concerns by 9236 respondents (86%), and practical concerns by 4668 respondents (44%). At least 1 unmet need was reported by 7033 survivors (84%) with emotional concerns, 7475 (81%) with physical concerns, and 3459 (74%) with practical concerns. Age, sex, annual income, marital status, geographic location, language, and treatment type were significant factors associated with unmet needs. Survivors of melanoma cancer had a significantly higher likelihood of reporting unmet emotional needs (odds ratio [OR], 1.75; 95% CI, 1.17-2.61; P = .01), whereas survivors of prostate (OR, 0.60; 95% CI, 0.43-0.84; P < .001) and hematological (OR, 0.70; 95% CI, 0.50-0.99; P = .04) cancers were significantly less likely to report unmet needs for physical concerns when compared with breast cancer survivors. Involvement of the general practitioner combined with the oncologist in providing care was associated with a significantly lower likelihood of reporting unmet emotional (OR, 0.78; 95% CI, 0.62-1.00; P = .05) and practical (OR, 0.72; 95% CI, 0.55-0.94; P = .01) needs. The extent of unmet needs among cancer survivors found in this study suggests the need for enhancements in survivorship care, including better awareness of the realities of survivorship, earlier interventions for emerging concerns among survivors, and greater integration of cancer programs and primary care for more seamless transitions.

BackgroundDepression is more prevalent in breast cancer (BC) survivors than in the general population. However, little is known about depression in long‐term survivors. Study objectives were: (1) to compare the age‐specific prevalence of depressive symptoms (a) in BC survivors vs female population controls, (b) in disease‐free BC survivors vs BC survivors with self‐reported recurrence vs controls, and (2) to explore determinants of depression in BC survivors.MethodsAbout 3010 BC survivors (stage I‐III, 5‐16 years post‐diagnosis), and 1005 population controls were recruited in German multi‐regional population‐based studies. Depression was assessed by the Geriatric Depression Scale‐15. Prevalence of mild/severe and severe depression only were estimated via logistic regression, controlling for age and education. Multinomial logistic regression was used to explore determinants of mild and severe depression.ResultsCompared with population controls, BC survivors were more likely to report mild/severe depression (30.4% vs 23.8%, p = .0003), adjusted for age and education. At all age groups <80 years, prevalence of both mild/severe and severe depression only was significantly higher in BC survivors, while BC survivors ≥80 years reported severe depression less frequently than controls. BC survivors with recurrence reported significantly higher prevalence of mild/severe depression than disease‐free survivors and controls, but prevalence in disease‐free survivors and controls was comparable. Age, income, living independently, recurrence, and BMI were significant determinants of mild depression in BC survivors. Age, education, employment, income, recurrence, and BMI were significant determinants of severe depression.ConclusionsLong‐term BC survivors <80 years report significantly higher prevalence of depressive symptoms than controls, which might be explained by recurrence and individual factors. The findings suggest that depression in BC survivors is common, and even more after BC recurrence. Clinicians should routinize screening and normalize referral to psychological care.

Key content Gynaecological and breast cancers affect premenopausal and perimenopausal women at rates ranging 15–70% and treatment often causes the abrupt onset of menopause. Available studies do not show an increase in recurrence or decrease in survival among women with endometrial, ovarian or cervical cancer who use hormone replacement therapy (HRT). Data regarding the risks of systemic HRT in survivors of breast cancer are varied, and an increase in breast cancer recurrence with the use of systemic HRT has been demonstrated in randomised controlled trials. Limited data exist regarding the use of vaginal estrogen, however, no effect on recurrence has been demonstrated. The decision regarding the use of HRT in women with cancer must be individualised and should take into account issues regarding quality of life. Learning objectives To review the evidence regarding the cancer‐specific risks, that is, recurrence or death, of HRT in survivors of gynaecological and breast cancer. To provide recommendations for the use of HRT in survivors of gynaecological and breast cancer. Ethical issues How to balance the risks of HRT with quality of life concerns in survivors of gynaecological and breast cancer when evidence to guide our recommendations is limited?

Breast cancer, menopause, and long-term survivorship: critical issues for the 21st century