The effect of treatment on patient-reported distress after breast cancer diagnosis

Abstract

Background: The National Comprehensive Cancer Network (NCCN) Distress Thermometer (DT) uses a 10-point scale (in which 0 indicates no distress and 10 indicates extreme distress) to measure patient-reported distress. In the current study, the authors sought to examine the relationship between treatment and NCCN DT scores in patients with breast cancer over time.

Methods: The authors included women aged ≥18 years who were diagnosed with stage 0 to stage IV breast cancer (according to the seventh edition of the American Joint Commission on Cancer staging system) at a 3-hospital health system from January 2014 to July 2016. Linear mixed effects models adjusted for covariates including stage of disease, race/ethnicity, insurance, and treatment sequence (neoadjuvant vs adjuvant) were used to estimate adjusted mean changes in the DT score (MSCs) per week for patients undergoing lumpectomy, mastectomy only, and mastectomy with reconstruction (MR).

Results: The authors analyzed 12,569 encounters for 1029 unique patients (median score, 4; median follow-up, 67 weeks). Patients treated with MR (118 patients) were younger and more likely to be married, white, and privately insured compared with patients undergoing lumpectomy (620 patients) and mastectomy only (291 patients) (all P < .01). After adjusting for covariates, distress scores were found to decline significantly across all 3 surgical cohorts, with patients undergoing MR found to have both the most preoperative distress and the greatest decline in distress prior to surgery (MSC/week: -0.073 for MR vs -0.031 for lumpectomy vs -0.033 for mastectomy only; P = .001). Neoadjuvant therapy was associated with a longitudinal decline in distress for patients treated with lumpectomy (-1.023) and mastectomy only (-0.964). Over time, ductal carcinoma in situ (-0.503) and black race (-1.198) were found to be associated with declining distress among patients treated with lumpectomy and MR, respectively, whereas divorced patients who were treated with mastectomy only (0.948) and single patients treated with lumpectomy (0.476) experienced increased distress (all P < .05).

Conclusions: When examined longitudinally in consecutive patients, the NCCN DT can provide patient-reported data to inform expectations and guide targeted support for patients with breast cancer.

Keywords: breast cancer; distress; health disparities; modifiable risk factors; patient-reported outcomes.

Figure 1.

Patient Flow Diagram - Newly Diagnosed Breast Cancer Patients at Duke, January 2014-July 2016 DT, distress thermometer. *Confirmed on manual reveiw

Figure 2.

Adjusted Mean Change in NCCN Distress Thermometer Score per Week, Breast Cancer Patients at Duke, January 2014-July 2016 (n=1029): (a) Linear Trend Plot (b) Scatter Plot with Loess Smoothing and Scaled Density Curve – Treatment Sequence

Figure 2.

Adjusted Mean Change in NCCN Distress Thermometer Score per Week, Breast Cancer Patients at Duke, January 2014-July 2016 (n=1029): (a) Linear Trend Plot (b) Scatter Plot with Loess Smoothing and Scaled Density Curve – Treatment Sequence