Predictors of Long-term Quality of Life in Women with Breast Cancer: A Prospective Study

Abstract

Treatment for breast cancer (BC) has been shown to negatively impact patients’ overall quality of life (QOL), however there has been little prior research on the effect of patient and treatment factors on multi-dimensional aspects of QOL. We prospectively analyzed women treated for breast cancer to identify variables associated with multi-dimensional aspects of post-treatment QOL. A total of 2,904 QOL surveys completed by 523 women treated for unilateral BC from 2009 to 2016 were analyzed. QOL assessments were conducted prior to surgery and every 3-8 months post-operatively. The primary outcome was QOL as measured by the Functional Assessment of Cancer Therapy-Breast (FACT-B), which included five domains of well-being: physical, social/family, emotional, functional and additional concerns such as body image and stress levels. A global QOL score was created by combining scores across the individual domains. On univariate and multivariable analyses, linear repeated measurement models were used to compare the mean QOL scores among sub-groups. Variables with p-value <0.1 on univariate analyses were entered into the multivariable model. Surveys with less than 50% of questions answered were excluded from analysis. The median post-operative follow-up was 44.6 months (range 0.4-82.9). Clinical and treatment characteristics included: median age at diagnosis 56 years (range 27-82), median body mass index (BMI) 26.5% (range 16.1-58.9), 90.6% invasive ductal carcinoma, 73.3% lumpectomy, 10.5% no lymph node surgery, 69.2% sentinel node biopsy (SNB), 20.4% axillary lymph node dissection (ALND), 12.6% receiving no radiation therapy (RT), 9.8% partial breast irradiation (PBI), 50.1% whole breast/chest wall irradiation (WB/CW) and 27.3% WB/CW plus regional lymph node irradiation (WB/CW + RLNI). The following associations on multivariate analysis were found: WB/CW + RLNI was associated with lower mean physical (-1.73 points lower, p<0.001), emotional (-1.36, p=0.03), additional concerns (-1.67, p=0.03) and global QOL (-7.28, p=0.01) as compared to no RT. Mastectomy was associated with lower emotional (-1.56, p=0.02), functional (-1.47, p=0.007), additional concerns (-2.73, p<0.001) and global QOL (-8.97, p=0.002). Patients with BMI > 25 had worse additional concerns (-2.38, p<0.001) and global QOL (-3.72, p=0.008) as compared to those with BMI < 25. ALND was associated with lower functional QOL as compared to SLNB (-1.35, p=0.01). Factors significantly associated with worse QOL included WB/CW + RLNI, mastectomy, BMI > 25 and ALND. Clinicians should actively screen for and address multi-dimensional QOL issues in all breast cancer survivors, especially in those subgroups at highest risk for worse QOL. Radiation oncologists in particular should remain vigilant regarding QOL concerns in women receiving WB/CW + RLNI, which was associated with significantly worse QOL on multiple domains.