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Introduction: Shared decision making (SDM) has become a crucial element on the political agenda and represents a vital aspect of modern healthcare. However, successful implementation of SDM highly depends on the attitude of clinicians towards SDM. The overall aim of our study was to explore the experience of oncologists and nurses with SDM using the Decision Helper, an in-consultation decision aid, at four Danish radiotherapy departments., Methods: Semi-structured interviews were conducted with 20 clinicians. The participants were selected using purposive sampling to include nurses and oncologists, male and female, with different levels of experience with SDM and clinical work. The analysis was a data-driven, iterative process with inductive coding of all interviews and meaning condensation., Results: Two main themes emerged: "Using the Decision Helper changes the consultation" and "Change of attitude among Danish oncologists." Each of the two themes included four elaborative subthemes, which are reported with supporting citations in this paper. In brief, the use of SDM and the Decision Helper should ideally be adjusted to the individual patient and depends highly on the oncologist. The participants described ambitions towards "making the right decision for this patient at this time." The healthcare system, however, has pitfalls that may hinder SDM, e.g., rigid interpretation of guideline-based recommendations., Conclusion: Using an in-consultation Decision Helper has the potential for individualized, structured patient engagement in decision making. There is a need for patient decision aids in clinical guidelines to ensure patient engagement in decision making., Competing Interests: Disclosure The authors have no conflicts of interest to declare., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Background and Purpose: Shared decision making (SDM) is a patient engaging process advocated especially for preference-sensitive decisions, such as adjuvant treatment after breast cancer. An increasing call for patient engagement in decision making highlights the need for a systematic SDM approach. The objective of this trial was to investigate whether the Decision Helper (DH), an in-consultation patient decision aid, increases patient engagement in decisions regarding adjuvant whole breast irradiation., Material and Methods: Oncologists at four radiotherapy units were randomized to practice SDM using the DH versus usual practice. Patient candidates for adjuvant whole breast irradiation after breast conserving surgery for node-negative breast cancer were eligible. The primary endpoint was patient-reported engagement in the decision process assessed with the Shared Decision Making Questionnaire (SDM-Q-9) (range 0-100, 4 points difference considered clinical relevant). Other endpoints included oncologist-reported patient engagement, decisional conflict, fear of cancer recurrence, and decision regret after 6 months., Results: Of the 674 included patients, 635 (94.2%) completed the SDM-Q-9. Patients in the intervention group reported higher level of engagement (median 80; IQR 68.9 to 94.4) than the control group (71.1; IQR 55.6 to 82.2; p < 0.0001). Oncologist-reported patient engagement was higher in the invention group (93.3; IQR 82.2 to 100) compared to control group (73.3; IQR 60.0 to 84.4) (p < 0.0001)., Conclusion: Patient engagement in medical decision making was significantly improved with the use of an in-consultation patient decision aid compared to standard. The DH on adjuvant whole breast irradiation is now recommended as standard of care in the Danish guideline., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Author(s). Published by Elsevier B.V. All rights reserved.)

Objective: Fear of cancer recurrence (FCR) is a distressing concern among cancer survivors. Interventions to address FCR need to be effective but also accessible and low cost. This randomized controlled trial evaluated the efficacy of an online group-based psychological intervention for FCR (ConquerFear-Group)., Methods: Eligible breast cancer (BC) survivors had completed primary treatment 3 months-5 years previously, were ≥18 years, and scored ≥22 on the Fear of Cancer Recurrence Inventory-Short Form (FCRI-SF). Participants were randomized to online ConquerFear-Group (focusing on metacognitive strategies, values-clarification, and education about follow-up behavior) or online group-based relaxation training (active control). Questionnaires were completed at baseline (T1), 1 week post-intervention (T2), three (T3) and six (T4) months later. The primary outcome was FCR (FCRI total). A number of secondary and process outcomes were also collected. Treatment effects were evaluated with mixed linear models., Results: Of 866 eligible BC survivors, 475 (55%) completed the FCR screening, and 85 (18%) were randomized to ConquerFear-Group or relaxation training (2 × 6 groups). Compared with control participants, ConquerFear-Group participants experienced larger reductions in FCR (Cohen's d = 0.47, p = 0.001) and FCR severity (d = 0.57, p < 0.001), as well as mindfulness and decentering from baseline through follow-up, and improvements in emotion regulation (T2), worry (T2, T3) and rumination (T2) at some time points., Conclusions: The results demonstrated statistically significant and stable effects of ConquerFear-Group on FCR that were maintained over a 6-month period. It is suggested to investigate the program in a real-life setting, where a pragmatic trial can further demonstrate feasibility and effectiveness., (© 2023 The Authors. Psycho-Oncology published by John Wiley & Sons Ltd.)

Introduction: One in five breast cancer (BC) survivors are affected by persistent pain years after completing primary treatment. While the efficacy of psychological interventions for BC-related pain has been documented in several meta-analyses, reported effect sizes are generally modest, pointing to a need for optimisation. Guided by the Multiphase Optimization Strategy, the present study aims to optimise psychological treatment for BC-related pain by identifying active treatment components in a full factorial design., Methods and Analysis: The study uses a 2×3 factorial design, randomising 192 women with BC-related pain (18-75 years) to eight experimental conditions. The eight conditions consist of three contemporary cognitive-behavioural therapy components, namely: (1) mindful attention, (2) decentring, and (3) values and committed action. Each component is delivered in two sessions, and each participant will receive either zero, two, four or six sessions. Participants receiving two or three treatment components will be randomised to receive them in varying order. Assessments will be conducted at baseline (T1), session by session, every day for 6 days following the first session in each treatment component, at post-intervention (T2) and at 12-week follow-up (T3). Primary outcomes are pain intensity (Numerical Rating Scale) and pain interference (Brief Pain Inventory interference subscale) from T1 to T2. Secondary outcomes are pain burden, pain quality, pain frequency, pain catastrophising, psychological distress, well-being and fear of cancer recurrence. Possible mediators include mindful attention, decentring, and pain acceptance and activity engagement. Possible moderators are treatment expectancy, treatment adherence, satisfaction with treatment and therapeutic alliance., Ethics and Dissemination: Ethical approval for the present study was received from the Central Denmark Region Committee on Health Research Ethics (no: 1-10-72-309-40). Findings will be made available to the study funders, care providers, patient organisations and other researchers at international conferences, and published in international, peer-reviewed journals., Trial Registration Number: ClinicalTrials.gov Registry (NCT05444101)., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Sleep disturbances are common in women treated for breast cancer. We have previously shown that internet-delivered cognitive-behavioral therapy for insomnia (e-CBT-I) is an efficacious, low-cost treatment approach. Furthermore, research has shown that e-CBT-I can result in sustained improvements at 12 months post-treatment. However, given the complexity and long duration of post-treatment symptomatology in breast cancer patients, as well as the recommended use of antihormonal therapy for up to 10 years, it is relevant to investigate long-term (>12 months) changes in sleep following e-CBT-I in this population. In the present study, we report data from a 3-year long-term follow-up assessment after e-CBT-I., Methods: Women treated for breast cancer with sleep disturbances (Pittsburg Sleep Quality Index [PSQI] global score >5) who had previously been enrolled in a randomized-controlled trial investigating the efficacy of e-CBT-I (n = 255), were invited to participate in a 3-year follow-up study. All women in the initial control group had also been granted access to e-CBT-I. Assessment included self-reported sleep quality (PSQI), insomnia severity (Insomnia Severity Index, ISI), cancer-related fatigue and symptoms of depression. Within-group changes in these outcomes from baseline to the 3-year long-term follow-up assessment were analyzed., Results: A total of 131 women (51%) participated in the 3-year follow-up study of which 77 (59%) were from the initial intervention group and 54 (41%) from the initial control group. For the pooled sample, within-group improvements from baseline to the 3-year follow-up assessment corresponding to large effect sizes were observed in sleep quality (Cohen's d = 1.0 95% CI [0.78, 1.21]) and insomnia severity (Cohen's d = 1.36 CI 95% [1.12, 1.59]). Similar changes were observed in cancer-related fatigue (Cohen's d = 0.48 CI 95% [0.30, 0.66]) and symptoms of depression (Cohen's d = 0.80 CI 95%. [0.60, 0.99]). The proportion of patients with scores above established cut-offs on the PSQI and the ISI were 56.1% and 29.8%, respectively. Within the initial intervention group, 15.6% evidenced relapse at the 3-year assessment., Conclusion: Overall, these results indicate that long-term sleep quality and insomnia severity following the use of e-CBT-in women treated for breast cancer is significantly lower than the pre-treatment levels. However, a substantial proportion of participants still evidence sleep disturbances., (Copyright © 2022 The Authors. Published by Elsevier B.V. All rights reserved.)

Background: Variations in symptom development among breast cancer (BC) survivors are understudied. We examined: (Q1) Symptom trajectories of pain, fatigue, insomnia, breast, and arm symptoms in BC survivors, (Q2) possible patterns or cluster-like associations between trajectory classification of different symptoms, and (Q3) characteristics of survivors assigned to high-burden symptom trajectories., Material and Methods: Participants were 968 women (mean age = 59.6 years) treated for early-stage BC and followed across a three-year postoperative period. As part of routine follow-up procedures, patients reported symptom burden and functioning levels at each hospital visit using the European Organisation for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire (QLQ-C30) and the BC-specific module (QLQ-BR-23). Growth mixture modeling (GMM) analysis was used to differentiate potential subgroups of individuals with similar longitudinal symptom patterns, i.e., symptom trajectories (Q1). With this approach, groups experiencing persistent, highly distressing cancer- and treatment-related late effects (LEs) may be identified. Latent class analysis (LCA) was used for Q2 and logistic regression analysis for Q3., Results: GMM identified two relatively parallel trajectories across the tested symptoms: The majority of the sample exhibited a low-burden symptom trajectory (74.4-89.2%) and a minority by a high-burden symptom trajectory (10.8-25.6%). LCA revealed that approximately one in five women (18.8%) were likely to be members of the high-burden symptom trajectory across all tested symptoms. In addition to a high probability of being burdened over time across multiple symptoms, these women were also characterized by poorer self-reported physical and social functioning., Conclusion: A substantial minority followed a high-burden symptom trajectory for several years following BC treatment. Associations were found in trajectory classification across symptoms, indicating that cancer-related LEs appear in clusters of multiple concurrent symptoms.

Background: Survival rates for breast cancer (BC) are increasing, leading to growing interest in treatment-related late-effects. The aim of the present study was to explore late effects using Patient-Reported Outcome Measures in postmenopausal BC survivors in standard follow-up care. The results were compared to age- and gender-matched data from the general Danish population., Material and Methods: Postmenopausal BC survivors in routine follow-up care between April 2016 and February 2018 at the Department of Oncology, Aarhus University Hospital, Denmark were asked to complete the EORTC QLQ-C30 and BR23 questionnaires together with three items on neuropathy, myalgia, and arthralgia from the PRO-CTCAE. Patients were at different time intervals from primary treatment, enabling a cross-sectional study of reported late effects at different time points after primary treatment. The time intervals used in the analysis were year ≤1, 1-2, 2-3, 3-4, 4-5 and 5+. The QLQ-C30 results were compared with reference data from the general Danish female population. Between-group differences are presented as effect sizes (ESs) (Cohen's d )., Results: A total of 1089 BC survivors participated. Compared with the reference group, BC survivors reported better global health status 2-3 and 4-5 years after surgery ( d  = 0.26) and physical functioning 2-3 years after (0.21). Poorer outcomes in BC survivors compared with the reference group were found for cognitive functioning (0-4 and 5+ years), fatigue (0-2 years), insomnia (1-3 years), emotional functioning (3-4 years), and social functioning (≤1 year after surgery) with ESs ranging from 0.20 to 0.41. For the remaining outcomes, no ESs exceeded 0.20., Conclusion: Only small to medium ESs were found for better global health and physical functioning and poorer outcomes for cognitive functioning, fatigue, insomnia, emotional functioning, and social functioning in postmenopausal BC survivors, who otherwise reported similar overall health-related quality of life compared with the general Danish female population.

Background: Insomnia is two to three times more prevalent in cancer survivors than in the general population, where it is estimated to be 10% to 20%. Cognitive-behavioral therapy for insomnia (CBT-I) is the recommended treatment for chronic insomnia, but meeting survivor needs remains a challenge. Internet-delivered CBT-I (iCBT-I) has been shown efficacious in otherwise healthy adults. We tested the efficacy of iCBT-I in breast cancer survivors with clinically significant sleep disturbance., Methods: Women from a national sample of Danish breast cancer survivors who experienced clinically significant sleep disturbance were randomly allocated to iCBT-I or waitlist control (55:45). The fully automated iCBT-I program consisted of six cores. Online measures of insomnia severity, sleep quality, and fatigue were collected at baseline, postintervention (nine weeks), and follow-up (15 weeks). Online sleep diaries were completed over two-week periods pre- and postintervention. Intention-to-treat analyses (time × group interactions) were conducted with mixed linear models and corrected for multiple outcomes. All statistical tests were two-sided., Results: A total of 255 women were randomly allocated to iCBT-I (n = 133) or waitlist control (n = 122). Statistically significant (P ≤ .02) time × group interactions were found for all sleep-related outcomes from pre- to postintervention. Effect sizes (Cohen's d) ranged from 0.33 (95% confidence interval [CI] = 0.06 to 0.61) for wake after sleep onset to 1.17 (95% CI = 0.87 to 1.47) for insomnia severity. Improvements were maintained for outcomes measured at follow-up (d = 0.66-1.10)., Conclusions: iCBT-I appears to be effective in breast cancer survivors, with additional benefit in terms of reduced fatigue. This low-cost treatment could be incorporated in cancer rehabilitation programs.

The objective was to examine the effect of Expressive Writing Intervention (EWI) on self-reported physical symptoms and healthcare utilization in a nationwide randomized controlled trial with Danish women treated for primary breast cancer, and to explore participant characteristics related to emotion regulation as possible moderators of the effect. Women who had recently completed treatment for primary breast cancer (n = 507) were randomly assigned to three 20 min. home-based writing exercises, one week apart, focusing on emotional disclosure (EWI) of a distressing experience (their cancer or a non-cancer topic) or a non-disclosing topic (control). Outcomes were self-reported physical symptoms and healthcare utilization (visits and telephone contacts with GP) 3 and 9 months post-intervention. Potential moderators were repressive coping, alexithymia, rumination, social constraints, and writing topic. Results revealed no group by time interaction effects for any outcomes. Moderation analyses showed that 1) low alexithymic women in the EWI group showed larger decreases in GP telephone calls over time than both high alexithymic women and controls and 2) women in the EWI group writing about their own cancer, but not women writing about other topics, showed a larger decrease than controls. The results from this large randomized trial are concordant with previous findings showing that EWI is unlikely to be a generally applicable intervention to improve health-related outcomes in cancer patients and cancer survivors. However, written disclosure might have a beneficial impact for individuals who write about their own cancer, as well as for those low in alexithymia.

Objectives: The aim of this study was to investigate possible statistical mediators in a randomized controlled trial of mindfulness-based cognitive therapy (MBCT) on pain intensity in women treated for primary breast cancer., Materials and Methods: The sample consisted of 129 women treated for breast cancer, presenting with persistent pain, who were randomly assigned to MBCT or a wait-list control. We previously reported a statistically significant and robust effect of MBCT on pain intensity (11-point numeric rating scale), which was included as the primary outcome. The proposed mediators were mindfulness (the Five Facet Mindfulness Questionnaire), self-compassion (the Short-Form Self-Compassion Scale), and pain catastrophizing (the Pain Catastrophizing Scale). Measurement points included baseline (T1), postintervention (T2), and 3- (T3) and 6-month (T4) follow-ups. All indirect effects of the mediators were tested in separate Multilevel Models, using the product-of-coefficients approach with bias-corrected confidence intervals (95% BSCI). The statistically significant mediators were then included in a multiple mediator model., Results: Statistically significant indirect effects were found for mindfulness nonreactivity (B=-0.17, BSCI [-0.32 to -0.04]) and pain catastrophizing (B=-0.76, BSCI [-1.25 to -0.47]). No statistically significant indirect effect was found for self-compassion (B=-0.09, BSCI [-0.30 to 0.04]). In a multiple mediator model, including mindfulness nonreactivity and pain catastrophizing, only pain catastrophizing remained statistically significant (B=-0.72, BSCI [-1.19 to -0.33]), explaining 78% of the effect., Discussion: The results of the present study may have clinical implications. An increased focus on the proposed mediators may optimize the clinical use of MBCT for persistent pain in women treated for breast cancer.

Background: Follow-up after breast cancer treatment is standard due to the risk of development of new primary cancers and recurrent disease. The aim of the present study was to evaluate a standard follow-up program in an oncological department by assessing: (1) Symptoms or signs of new primary cancer or recurrent disease, (2) Disease- and treatment-related physical and psychosocial side or late effects, and (3) relevant actions by oncology staff., Materials and Methods: In a cross-sectional study, 194 women who came for follow-up visit after treatment for primary surgery were included. The clinical oncologists registered symptoms and signs of recurrent disease or new primary cancer. Side or late effects were both assessed by patient and the clinical oncologists., Results: Loco-regional or distant signs of recurrent disease were suspected in eight (5%) patients. Further examinations revealed no disease recurrence. Most patients (93%) reported some degree of side or late effects. Statistically significant more side or late effects were reported by the women (average: 6.9) than registered by the clinical oncologists (average: 2.4), p < 0.001. The three most often patient-reported side or late effects were hot flushes (35%), fatigue (32%), and sleep disturbance (31%)., Conclusion: None of the scheduled or additional visits resulted in detection of recurrent disease. Furthermore, the majority of patients reported side or late effects. Statistically significant more women reported side or late effects than registered by the clinical oncologists. This suggests the need for rethinking of the follow-up programs with more emphasis upon side or late effects of the treatment.

Purpose: To explore the associations between lifestyle-related factors and tumor-related prognostic factors in women treated for primary breast cancer, and to detect possible differences between the associations in pre- and postmenopausal women., Methods: Associations between tumor-related prognostic factors, including the composite endpoint risk of recurrence (RoR), body mass index (BMI), comorbidity (Charlson comorbidity index), basic physical functioning (SF-36), physical activity, smoking, and alcohol consumption were examined with binary logistic regression analysis in a national cohort of 4917 women treated for primary breast cancer. In addition, statistical interactions between predictors and menopausal status were assessed in order to determine if their strength differed significantly as a function of menopausal status., Results: Higher BMI, reduced physical function, reduced physical activity, and greater alcohol consumption were all statistically significantly associated with two or more tumor-related factors indicating a poorer prognosis. Interaction analysis revealed that BMI was significantly stronger associated with RoR among premenopausal women than among postmenopausal women (interaction ip = 0.048). Similarly, a significant association between RoR and physical function was only seen in the premenopausal population (ip = 0.008). This pattern was also seen between RoR and daily alcohol consumption, which only reached statistical significance in the total population and in premenopausal women (ip < 0.001)., Conclusion: Premenopausal women who are overweight and have poorer physical function have poorer prognosis at the time of diagnosis, suggesting the possible relevance of stratifying adjuvant treatment according to guidelines, BMI, and menopausal status.

Background: An increasing number of women undergo a breast reconstruction (BR) after treatment for breast cancer. The aim of the present study was to evaluate patient-reported esthetic satisfaction, quality of life (QoL), and the association between these, following different types of BR., Materials and Methods: All women who underwent unilateral BR in Central Denmark Region between January 2005 and July 2011 were included. Participants were sent a questionnaire package, which included the Body Image Scale, The Beck Depression Inventory, the Impact of Event Scale, and a study-specific patient-reported esthetic satisfaction scale. Additionally, patients were asked if they experienced a change in QoL owing to the BR. Based on reconstructive method and timing, participants were divided into four groups, three delayed: an abdominal flap group, a latissimus dorsi flap group, an implant ± thoracodorsal flap group; and one immediate BR group., Results: Of 166 eligible participants, a total of 144 women (87%) completed the questionnaire. The mean follow-up was 3.8 years. Esthetic satisfaction differed significantly between groups [F(3,139) = 8.55; p < 0.001], with abdominal flap recipients reporting the highest levels of esthetic satisfaction. No between-group differences were observed for the remaining psychosocial measures. Higher satisfaction with esthetic outcome was associated with reporting higher QoL owing to the BR (odds ratio 1.10, p<0.001; 95% CI 1.06-1.15)., Conclusions: Abdominal flap recipients expressed higher satisfaction with their esthetic outcome, compared to the remaining BR types. Higher esthetic satisfaction was strongly associated with reporting an experience of higher QoL.

Background: It is unclear to which degree the services available after end of treatment are sufficient to meet the needs of women treated for breast cancer. The aim of the present study was to identify patient-reported supportive care needs and the prevalence of fear of cancer recurrence (FCR) following end of treatment in women treated for breast cancer., Material and Methods: Using a cross-sectional design, women treated for breast cancer (n = 155; mean age 63) completed questionnaires concerning supportive care needs and FCR. Inclusion criteria were: ≥18 years of age and treated for primary breast cancer at Aarhus University Hospital, Aarhus, Denmark and between three months and five years after diagnosis. Associations between demographic characteristics, clinical factors, side effects, late effects and the two dependent variables, unmet needs (examined with linear regression model), and FCR (examined with logistic regression model) were analyzed., Results: The response rate was 79.9%. Almost all (82.6%) women reported at least one unmet need (mean number 9.3; range 0-34). More than half (59.3%) of the unmet needs were rated as strong unmet needs. The most frequent unmet needs were concerned with doctors collaborate to coordinate care; the need for having ongoing dialog with healthcare providers to receive available local health care services, understandable and up-to-date information, to manage side effects and feeling reassured that the best medical care are given. Having unmet needs were associated with young age, short time since primary surgery, and having clinical FCR. FCR was reported by 54.8% of the women and was associated with short time since primary surgery, having chemotherapy, having unmet needs, and moderate to severe muscle and joint pain and fatigue., Conclusions: Breast cancer survivors experience substantial unmet needs years after end of treatment, particularly among younger women and women having clinical FCR. Furthermore, FCR is frequent among women, particularly when closer in time to primary surgery.

Purpose: To assess the efficacy of mindfulness-based cognitive therapy (MBCT) for late post-treatment pain in women treated for primary breast cancer., Methods: A randomized wait list-controlled trial was conducted with 129 women treated for breast cancer reporting post-treatment pain (score ≥ 3 on pain intensity or pain burden assessed with 10-point numeric rating scales). Participants were randomly assigned to a manualized 8-week MBCT program or a wait-list control group. Pain was the primary outcome and was assessed with the Short Form McGill Pain Questionnaire 2 (SF-MPQ-2), the Present Pain Intensity subscale (the McGill Pain Questionnaire), and perceived pain intensity and pain burden (numeric rating scales). Secondary outcomes were quality of life (World Health Organization-5 Well-Being Index), psychological distress (the Hospital Depression and Anxiety Scale), and self-reported use of pain medication. All outcome measures were assessed at baseline, postintervention, and 3-month and 6-month follow-up. Treatment effects were evaluated with mixed linear models., Results: Statistically significant time × group interactions were found for pain intensity (d = 0.61; P = .002), the Present Pain Intensity subscale (d = 0.26; P = .026), the SF-MPQ-2 neuropathic pain subscale (d = 0.24; P = .036), and SF-MPQ-2 total scores (d = 0.23; P = .036). Only pain intensity remained statistically significant after correction for multiple comparisons. Statistically significant effects were also observed for quality of life (d = 0.42; P = .028) and nonprescription pain medication use (d = 0.40; P = .038). None of the remaining outcomes reached statistical significance., Conclusion: MBCT showed a statistically significant, robust, and durable effect on pain intensity, indicating that MBCT may be an efficacious pain rehabilitation strategy for women treated for breast cancer. In addition, the effect on neuropathic pain, a pain type reported by women treated for breast cancer, further suggests the potential of MBCT but should be considered preliminary., (© 2016 by American Society of Clinical Oncology.)

We collected registry- and questionnaire-based data on socio-economic and health status, tumor- and treatment-related variables, and explored associations with receipt of reconstruction and information about treatment options in a nationwide cohort of Danish women, treated for primary breast cancer. A total of 594 women were available for analysis, 240 (40%) of these received reconstruction. Multivariate analyses showed that receipt of reconstruction was associated with 1) younger age at time of primary surgery (<36 years: OR = 10.04, [3.80-26.50], p < 0.001 and 36-49 years: OR = 2.48, [1.73-3.56], p < 0.001, compared to 50-60 year olds), 2) having received radiotherapy (OR = 0.57, [0.40-0.81], p = 0.002), 3) high income (Second quartile: OR = 1.74, [1.05-2.90], p = 0.033 and fourth quartile: OR = 2.18, [1.31-3.62], p = 0.003, compared with the lowest income quartile), and 4) ethnicity other than Danish (OR = 6.32, [1.58-25.36], p = 0.009). Health-related factors at the time of primary surgery (physical functioning, body mass index, smoking, use of alcohol, and comorbidity) were not associated with reconstruction. Odds of having received information about the option of reconstruction decreased by 8% per year of age in the multivariate analysis (OR = 0.92, [0.87-0.97], p = 0.003). In conclusion, younger age and not having been treated with radiotherapy was independently associated with reconstruction. In addition, higher income was also found to be associated with reconstruction despite free and equal access to reconstruction and healthcare in Denmark. Healthrelated factors were not associated with the use of reconstruction following mastectomy. Our findings underscore the need for physicians to ensure optimal level of information and accessibility to reconstruction for all women regardless of age, treatment, and socio-economic status., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Turning to faith in God or a higher spiritual power is a common way of coping with life-threatening disease such as cancer. Little, however, is known about religious faith among cancer patients in secular societies. The present study aimed at exploring the prevalence of religious faith among Danish breast cancer patients and at identifying whether socio-demographic, pre-cancer health status, clinical, and health behavior characteristics, including their use of complementary and alternative medicine (CAM), were associated with their degree of faith. Information on faith in God or a higher spiritual power and use of CAM was provided by a nationwide sample of 3,128 recurrence-free Danish women who had received surgery for early-stage breast cancer 15-16 months earlier. Socio-demographic, clinical, and health status variables were obtained from national longitudinal registries, and health behaviors had been assessed at 3-4 months post-surgery. Of the women, 47.3% reported a high degree of faith (unambiguous believers), 35.9% some degree of faith (ambiguous believers), while the remaining 16.8% were non-believers. Unambiguous believers were more likely than ambiguous believers to experience their faith as having a positive impact on their disease and their disease-related quality-of-life. When compared to non-believers, unambiguous believers were also older, had poorer physical function, and were more frequent users of CAM, and more inclined to believe that their use of CAM would have a beneficial influence on their cancer. Disease- and treatment-related variables were unrelated to faith. While overall religious faith appears equally prevalent among Danish and US breast cancer patients, the majority of Danish breast cancer patients experienced ambiguous faith, whereas the majority of US patients have been found to express unambiguous faith. Our results suggest that future studies may benefit from exploring the role of faith for health behaviors, adherence to conventional treatment, and impact upon quality of life.

Background This large population-based prospective study explored the associations between use of complementary and alternative medicine (CAM) and prevalence and changes in depressive symptoms from 3 to 15 months after surgery for primary breast cancer. Methods In an ongoing nationwide cohort study, depressive symptoms and the use of ten different types of CAM since time of diagnosis were assessed by questionnaire at 3 (N = 3233) and 15 months post-surgery (N = 2833). Clinical and socio-demopraphic variables were obtained from the Danish Breast Cancer Cooperative Group (DBCG) and national longitudinal registries. Results At 3 months post-surgery, 40.2 % reported having used CAM since the diagnosis, and in the time from 3 to 15 months after surgery, 49.9 % had used CAM. Compared with non-users, CAM users experienced more depressive symptoms at both 3 and 15 months follow-up when adjusting for several possible confounders. In a fully adjusted model, including all CAM variables and adjusting for depressive symptoms at 3 months, use of dietary/vitamin supplements was the only independent, statistically significant risk factor for experiencing more depressive symptoms at 15 months (RM = 1.10; 95 % CI 1.02-1.19, P = 0.014). Conclusion Cross-sectionally, CAM use was associated with higher levels of depressive symptoms at both time-points. Prospectively, users of dietary or vitamin supplements at 3 months after surgery reported higher levels of depressive symptoms than non-users 1 year later. Possible explanations could be an increased vulnerability for depressive symptoms among women using CAM or adverse effects of dietary or vitamin supplements.

Context: Mounting evidence suggests that many cancer patients suffer from sleep difficulty, but there is conflicting evidence regarding the prevalence and predictors of this adverse symptom., Objectives: The present study investigated the prevalence and predictors of clinically significant sleep difficulty in women with primary breast cancer., Methods: Danish women (n=3343) with primary breast cancer completed the Pittsburgh Sleep Quality Index (PSQI) along with measures of depression, anxiety, physical activity/functioning, and health behaviors three to four months postsurgery. Data on disease status, treatment, and comorbidity were obtained from the Danish Cancer Cooperative Group and surgical departments, and information on sociodemographic factors and psychiatric history was obtained from Danish national longitudinal registries., Results: More than half (57.9%) of the women reported clinically significant sleep difficulty (PSQI >5). Multiple logistic regression identified seven significant predictors of sleep difficulty in the full sample. In order of strength, these were the following: more depressive symptoms, poorer physical functioning, older age, higher levels of trait anxiety, consuming more cigarettes, having undergone lumpectomy, and lower levels of physical activity. Subgroup analysis found that more depressive symptoms and poorer physical functioning were the only two predictors that were significant in both pre- and postmenopausal women., Conclusion: These findings indicate that a high proportion of women with breast cancer experience sleep difficulty. Depression and poorer physical functioning appear to be robust predictors of sleep difficulty, whereas other predictors may depend on sample characteristics, including menopausal status., (Copyright © 2011 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved.)

Aim: This study investigated the prevalence and predictors of use of complementary and alternative medicine (CAM) in a nationwide inception cohort of Danish women treated for early-stage breast cancer as well as differences in user patterns for individual types of CAM., Methods: Use of CAM since the time of diagnosis was assessed 12-16 weeks post-surgery for the 3343 women (age 18-70) included in the study (response rate: 68%). Socio-demographic and clinical variables were obtained from national longitudinal registries., Results: 40.1% of the women had used one or more types of CAM. Users were younger than non-users. Age adjusted analyses showed that CAM users were characterised by absence of comorbidity, higher educational level, higher personal income, higher social status, being divorced/separated and living in the metropolitan area of Copenhagen. Multivariate analyses revealed that chemotherapy was the only clinical and treatment-related predictor of CAM use, and that CAM users were more likely to be of normal weight and non-smokers. Of CAM users, 33.7% believed that CAM would have a positive influence upon their breast cancer. Different characteristics distinguished users of individual types of CAM., Conclusion: The results of this first nationwide study of utilisation of CAM in breast cancer show that CAM users are healthier and more likely to have higher socio-economic status than non-users. Different user patterns for individual types of CAM may be overlooked, when different types of CAM are treated as one homogeneous category.

Age differences in emotional control and their consequences were examined in women referred to mammography on the suspicion of breast cancer but with benign results of the examination. Under natural experimental conditions, the levels of emotional control and distress were measured 1 week prior to the examination as well as 4 and 12 weeks after the examination in 717 younger women (ages 19-39), middle-aged women (ages 40-59), and older women (ages 60-85). A higher level of emotional control was found in the older women; this indicates that, in these birth cohorts, emotion-focused coping is more prevalent in old age than in young adulthood, even when similar stressors are experienced. The analyses revealed an interaction between age and emotional control; higher levels of control were related to a reduction in distress during the course of the study in older women, whereas emotional control was unrelated to changes in distress in younger and middle-aged women. The findings support the life span theory of control, which suggests that secondary control strategies are more adaptive in old age., ((c) 2009 APA, all rights reserved.)

Objective: A number of cross-sectional studies have reported reduced cognitive function in cancer patients receiving chemotherapy compared with other cancer patients and healthy controls, suggesting that chemotherapy could be associated with cognitive side-effects. Recently published prospective studies question this hypothesis, but it is still unclear whether cancer patients should regard cognitive problems as a potential risk when receiving chemotherapy., Methods: In the present study we examine whether cancer patients (n=34) receiving chemotherapy differed in cognitive changes during treatment compared with cardiac patients (n=12) and healthy controls (n=12) tested at 3-4 months interval., Results: Our results showed no differences with respect to changes in cognitive performance over time between cancer patients in chemotherapy, cardiac patients, and healthy controls. In addition, the number of individuals showing reliable decline or improvement on cognitive tests did not differ between groups., Conclusion: Taken together, our results do not support a hypothesis of cognitive side-effects of standard-dose chemotherapy in breast cancer patients.

Objective: The predictive value of perceived risk of breast cancer has previously mainly been compared to statistical risk models. We aimed to compare the women's perceived risk with the observed risk of a breast cancer diagnosis., Methods: Women referred to mammography at a Danish public hospital (N=1021) were asked to complete a questionnaire about 2 weeks before the examination. The women were asked to rate their perceived risk of having breast cancer on a six-point scale with the anchor points very low risk (1) and very high risk (6). The perceived risk was compared with the diagnosis from the mammography 1-3 weeks later. Multivariate logistic regression was used to adjust for age, category of referral, family history of breast cancer, and previous mammography., Results: The questionnaire was completed by 665 (65%) of the women. Compared to women without breast cancer, a larger percentage of women with breast cancer had estimated their risk as high. The risk difference was 16.5% (95% CI 2.5-30.6), using a cut-off between 4 and 5 on the six-point scale. The odds ratio was 3.6 (95% CI 1.4-8.9) after adjustment for age, category of referral, family history of breast cancer, and previous mammography. The sensitivity, specificity, and predictive value were 0.17, 0.96, and 23%, respectively., Conclusion: Women who rated their risk as high had a statistically significant increased risk of having a breast cancer diagnosed at the subsequent mammography. The odds ratio based on the women's risk perceptions remained of the same magnitude after adjustment for category of referral, suggesting that information given by the women contains independent predictive value.

Background: Elevated levels of depressive symptoms are generally found among cancer patients, but results from existing studies vary considerably with respect to prevalence and proposed risk factors., Purpose: To study the prevalence of depressive symptoms and major depression 3-4 months following surgery for breast cancer, and to identify clinical risk factors while adjusting for pre-cancer sociodemographic factors, comorbidity, and psychiatric history., Patients and Methods: The study cohort consists of 4917 Danish women, aged 18-70 years, receiving standardized treatment for early stage invasive breast cancer during the 2 1/2 year study period. Of these, 3343 women (68%) participated in a questionnaire study 12-16 weeks following surgery. Depressive symptoms (Beck's Depression Inventory II) and health-related behaviors were assessed by questionnaire. The Danish Breast Cancer Cooperative Group (DBCG) and the surgical departments provided disease-, treatment-, and comorbidity data for the study cohort. Information concerning sociodemographics and psychiatric history were obtained from national longitudinal registries., Results: The results indicated an increased prevalence of depressive symptoms and major depression (13.7%) compared to population-based samples. The pre-cancer variables: Social status, net-wealth, ethnicity, comorbidity, psychiatric history, and age were all independent risk factors for depressive symptoms. Of the clinical variables, only nodal status carried additional prognostic information. Physical functioning, smoking, alcohol use, and BMI were also independently associated with depressive symptoms., Conclusion: Risk factors for depressive symptoms were primarily restricted to pre-cancer conditions rather than disease-specific conditions. Special attention should be given to socio-economically deprived women with a history of somatic- and psychiatric disease and poor health behaviors.

Health staff-patient communication is increasingly considered an important issue in cancer research. However, questionnaires addressing satisfaction with communication limit the issues patients can raise, do not address the context of communication and often show a strong positive skew in responses. Thus, qualitative studies of communication are also needed. Fifteen breast cancer patients were interviewed 3 months after finishing adjuvant treatment. They were asked to tell a 10 minute narrative and recall five experiences from treatment. Themes were extracted using categories derived from previous research while at the same time being sensitive to new elaborations and categories. The participants reported both positive and negative communication-related experiences from a wide range of treatment situations. Two major themes emerged: Information giving as professional care-giving and meeting emotional needs. The analysis suggests that appropriate information giving may have several functions, such as re-establishing the patient's future and reducing worst-case fantasies. Meeting emotional needs was seldom reported as directly talking about negative emotions, but rather through a variety of health staff behaviours. Also, the analysis points to problems in expecting or even pressurizing patients to feel and display negative emotions. The results highlight that meeting medical and emotional needs of patients may be closely intertwined in concrete treatment situations.

Objective: The aim was to investigate to which extent emotional repression is a premorbid coping tendency of cancer patients and/or a coping response to the threat posed by a cancer diagnosis. The results of one previous study of breast cancer patients suggest the latter possibility, and our aim was to replicate and extend these findings., Methods: Of 646 women referred to mammographic examination for breast cancer, 71 women were diagnosed with primary breast cancer. Repressive coping, defined as having high scores on defensiveness (Marlowe-Crowne Social Desirability Scale) and low scores on anxiety (Taylor Manifest Anxiety Scale), was measured (1) before, (2) 4 weeks after, and (3) 12 weeks after diagnosis. The women were not aware of their disease status before the examination, and there were no significant differences between groups in their perceived risk of having breast cancer., Results: Four weeks after diagnosis, increased repression (p < 0.01) was found in the group of women diagnosed with breast cancer but not in women without cancer, with women with a breast cancer diagnosis being 1.5 times more likely to be repressive than women with cancer. There were no group differences in defensiveness, anxiety, or repression before diagnosis and 12 weeks after diagnosis. When controlling for repressive coping prior to diagnosis, age, and other demographic factors with a multiple, logistic regression, only cancer diagnosis (odds ratio: 2.39; p< 0.05) and having biological children (odds ratio: 2.83; p< 0.02) emerged as significant predictors of repressive coping 4 weeks after diagnosis. Before diagnosis, only higher age predicted later diagnosis of breast cancer., Conclusion: Previously found higher repression in cancer patients vs. controls could be a response to the threat associated with cancer diagnosis and may not necessarily reflect premorbid differences.