© 2005 Lippincott Williams & Wilkins, Inc., Philadelphia
Symptom Distress Changes During First
Postoperative Month in Newly Diagnosed
Taiwanese Breast Cancer Patients
A Longitudinal Study
The purpose of this longitudinal study was to explore changes in symptom distress in newly diagnosed Taiwanese breast cancer patients during the initial 4-week postoperative period. The research instruments, including a demographic questionnaire and the Symptom Distress Scale, were used to obtain data on postoperative day 2 and at weeks 2, 3, and 4. In total, 39 patients with a mean age of 48 years participated in this study. Data were analyzed using descriptive statistics, t tests, one-way ANOVA, and repeated-measures ANOVA. Results revealed that the level of symptom distress significantly decreased from postoperative day 2 to week 4. Loss of appetite and a poor outlook increased; nausea frequency, fatigue, and insomnia decreased then increased; and
frequency and the level of pain, coughing, tightness/tenderness in the chest wall, weakness, and numbness in the arm of the operative side all decreased over the 4-week study period. Age, stage of disease, and type of surgery were all related to symptom distress. Results of this study may provide reassurances about what can be expected after breast cancer surgery.
Shu-Yi Wang, MSN, RN, CNS Ching-Wen Lee, MS, RN Yue-Cune Chang, PhD Chia-Chin Lin, PhD, RN K E Y W O R D S Breast cancer Breast operation Longitudinal study Symptom distress
From the Graduate Institute of Medical Science, Taipei Medical University, Taipei, Taiwan (Ms Wang); the Cardinal Tien College of Nursing, Taipei, Taiwan (Ms Lee); the Department of Mathematics, TamKang University, Tamsui, Taiwan (Dr Chang); and the Graduate Institute of Nursing, Taipei Medical University, Taipei, Taiwan (Dr Lin).
Corresponding author: Chia-Chin Lin, PhD, RN, Graduate Institute of Nursing, Taipei Medical University, 250 Wu-Hsing St, Taipei 110, Taiwan (e-mail: clin@tmu.edu.tw).
Accepted for publication February 10, 2005.
T
he breast is an important part of a woman’s body. Breast cancer is life-threatening because it can spread to vital organs. Fortunately, the number of deaths from breast cancer has declined significantly in recent years.1 Thesedecreases are probably the result of earlier detection and improved treatment, but the battle is a long way from over.
According to health department statistis in Taiwan, 26,134 women contracted cancer in 1999.2 In the same year, 4405
breast cancer cases were reported. The majority of women con-tracting breast cancer are aged between 40 and 55 years. It has been reported that there is an increasing trend for cancer of the breast in Taiwan.3 Once a diagnosis of breast cancer is
established, subsequent symptom distress from treatments, such as surgery, will interfere with the equilibrium of the body and psychosocial aspects. Nowadays, however, improved treat-ments and a rising survival rate have led breast cancer patients not only to entirely fear the illness itself, but also to worry about the symptom distress caused by their cancer treatments.4
Despite the importance of symptom distress in cancer patients, in the past, most studies investigated symptom distress as a pre-dictor of quality of life.5Importantly, longitudinal studies have
shown a singificant importance of affective distress during the first year after breast cancer treatment.6There has been a lack
of attention to symptom distress and its correlated factors post-operatively in breast cancer patients in Taiwan. Thus, the aim of the present study was to carry out a longitudinal follow-up of changes and correlations of symptom distress after breast cancer surgery in Taiwan. The results of this study may provide valuable information to help improve the quality of care for breast cancer patients postoperatively.
It has been reported that in 74 women with stage I or II breast cancer after receiving their diagnoses, the most serious symptoms were insomnia, fatigue, loss of concentration, low-ered cognitive function, and mood disturbance,7 Moreover,
for patients who underwent surgery, patients with breast can-cer frequently experience postoperative sensations in and around the axilla, breast, and chest wall of the affected side after breast cancer surgery.8 Maunsell et al interviewed 223
breast cancer women 3 months after they had undergone surgery, and 82% of women reported experiencing at least one symptom distress. Numbness was the most prevalent (58%), followed by pain (55%) and stiffness (40%). Tasmuth et al9found that over 50% of 569 breast cancer patients who
underwent breast-conserving treatment (BCT) or modified radical mastectomy (MRM) had pain and numbness in the breast scar region and/or arm, 50% experienced influences on their daily activities, and 25% reported medium to severe effects, such as paresthesias, edema, strange sensations, and muscle weakness symptoms related to their daily lives. They further pointed out that the incidence of chronic post-treat-ment pain was higher after conservative surgery than after radical surgery. To determine whether there are different symptoms of physical and treatment-related problems between the two surgical procedures (BCT and MRM), Shi-mozuma et al10studied 227 breast cancer patients in the early
stage and found that physical and treatment-related problems experienced by more than 70% women included “tightness of the arm/axilla,” “numbness of the chest wall/axilla/arm,” “tightness/tenderness in the chest wall (MRM) or in the breast (BCT),” “nausea/vomiting after chemotherapy,” “less energy,” “decline in recreational/social activities,” “difficulty with physical activities,” and “difficulty in sleeping,” which were frequently reported in the first month after surgery; while a poorer body image and greater disturbance of mood were also mentioned at 1 month and 1 year. An MRM is associated with a significant degree of psychological morbidity related to the loss of the breast, which can be avoided by a BCT. A bet-ter body image and sexual functioning have been reported as potential benefits of a BCT.11
To date, there have been very few longitudinal investiga-tions of postoperative patients’ symptom distress. Previous publications have reported the results through 6,1212,13and
248months. Overall, percentages of patients reporting severity
and distress were high in the first few months. Therefore, in order to closely evaluate the prevalence, severity, and level of distress in the first month, the present article provides follow-up through the 4 time points of 2 days and 2, 3, and 4 weeks after surgery. This is the first longitudinal study in Taiwan to explore changes in symptom distress in newly diagnosed breast cancer patients during the first month after surgery. It is worthwhile comparing changes in symptom distress in newly diagnosed Taiwanese breast cancer patients during the first postoperative month with other ethnic populations. The research questions of this study are as follows: (1) What is the symptom distress change during first postoperative month in newly diagnosed Taiwanese breast cancer patients (day 2, and at weeks 2, 3, and 4)? (2) What variables are related to symp-tom distress at these 4 time points?
Methods
Participants and Setting
A longitudinal study was used to explore changes in symptom distress in newly diagnosed breast cancer patients during the first postoperative month at the four time points of 2 days and 2, 3, and 4 weeks after surgery. Participants who had no his-tory of cognitive, affective, or mental disorders, were newly diagnosed as having breast cancer, and were older than 18 years were recruited by convenience sampling from inpatient and outpatient units of 2 teaching hospitals in the Taipei area of Taiwan. The initial sample consisted of 48 women who were newly diagnosed with breast cancer. Data for 9 of the original participants were removed because they refused to participate for the entire period. The final sample consisted of 39 patients, with an 83.0% response rate.
Instruments
DEMOGRAPHIC AND MEDICAL CHARACTERISTICS
Demographic and medical information was obtained from a patient’s chart and through interviews with the patient. A demographic questionnaire was used to obtain information such as age, marital status, education, religious affiliation, and employment. Demographic characteristics of the subsamples are displayed in Table 1. Medical characteristics included stage of breast cancer, time since diagnosis, operative date, and type of surgery.
SYMPTOM DISTRESS SCALE
The Symptom Distress Scale was first developed to assess the degree of discomfort experienced from cancer-related symp-toms, which include nausea frequency, nausea severity, loss of appetite, insomnia, pain frequency, pain severity, fatigue, bowel
Table 1• Demographic and Medical Charac-teristics of the Sample (N 39)
Variables n (%) Age, y 40 6 (15.4) 40~50 22 (56.4) 50 and older 11 (28.3) Marital status Married 35 (89.7) Not married 4 (10.3) Religious affiliation Buddhism 15 (38.5) Protestant 4 (10.3) Catholic 2 (5.1) Taoism 8 (25.6) None 10 (25.6) Employment Employed 23 (59) Unemployed or retired 16 (41) Primary caregiver Spouses 22 (56.4) Parents 4 (10.3) Child 10 (25.6) Friend 2 (5.1) Siblings 1 (2.6) Stage of breast cancer
I 17 (43.6)
II 16 (41)
III 6 (15.4)
Type of surgery
Modified radical mastectomy 30 (76.9) Breast-conserving treatment 9 (23.1) Current adjuvant therapy
Chemotherapy 10 (25.6) Radiotherapy 2 (5.1) Not yet 23 (58.9) Refused 4 (10.2)
patterns, loss of concentration, changes in appearance, trouble breathing, poor outlook, and coughing.14Responses were made
on a 5-point Likert-type scale ranging from 1 (no problem with
a particular item) to 5 (the worst possible problem). The SDS has
been widely used in studies involving cancer patients, and its reliability and validity have been established.15–17
The Taiwanese version of the SDS was translated by Huang.18Reliability of the 13-item scale was tested with 20
terminal-stage cancer patients, and the Cronbach ( was .70. Because some studies reported adverse effects following treat-ment for breast cancer including tightness/tenderness in the chest wall (MRM) or in the breast (BCT), limitations on arm mobility, arm weakness, and numbness in the arm,9,10,19we
included these 4 items in the SDS in our study. The final full measure contained 17 items and was scored from 17 to 85. Content validity was evaluated by 6 experts, and the Content Validity Index was 0.90. In the current study, the internal reli-ability at the 4 time points of 2 days and 2, 3, and 4 weeks after surgery were 0.66 to 0.76 and 0.73 to 0.85, respectively.
Procedure
After ethical approval was obtained from each hospital, eligible subjects were recruited for this sample. The research assistant contacted all patients and provided a verbal explanation of the study. Respondents were informed that their participation was voluntary, that they would remain anonymous, that they could withdraw from the study at any time without penalty, and that all information would be kept confidential. Each participant received the SDS. Investigators were available on site during the administration of the SDS to answer questions, provide clarification, and encourage respondents to complete all items.
Statistical Analysis
Data were analyzed using descriptive analysis, paired t tests, cor-relation, and repeated-measures analysis of variance (ANOVA). Descriptive data were used to address demographic characteris-tics, stage of disease, type of surgery, and SDS. t tests, correla-tion, and one-way analysis of variance (ANOVA) were used to determine whether the demographic and medical characteris-tics of the sample had significant relationships with overall symptom distress. Repeated-measures ANOVA was used to examine changes in SDS score across 4 time points.
Results
Demographic and Medical Characteristics
Forty-eight participants completed data for day 2; 43 for week 2; 40 for week 3; and 39 for week 4. Attrition during the study occurred as a result of personal reasons (n 6) or dropping out because of increasing emotional distress (n 2). Of the 39 par-ticipants, the mean (SD) age was 48 (9.4) years. Most (89.7%) patients were currently married, and 22 of the patients’ primary caregivers (56.4%) were their own spouse. Slightly more than half had a high-school education (54.9%). Most (76.9%) of them received an MRM, with the others (23.1%) receiving BCT. Other information is presented in Table 1.
Symptom Distress Over Time
Table 2 presents the 17 items on the SDS arranged in order of the 4 time periods. In a theoretical range of scores from 17 to 85, the mean scores were 31.35, 27.82, 27.69, and 27.79 at each assessment point. At 2 days after surgery, those reported most frequently by the total sample were changes in appear-ance (2.89 0.91), poor outlook (2.69 1.05), and limita-tions on arm mobility (2.69 0.73). At 2 weeks after surgery, the most frequent symptoms reported had the same sequence, but a poor outlook had the highest score (3.00 0.94). At 3 and 4 weeks after surgery, poor outlook and changes in appear-ance were mainly moderate (mean 2.5) again.
The mean total SDS score decreased with time (Fig 1). Results of subscale analysis showed 4 kinds of patterns, that is,
increasing, decreasing, no significant changes, and first decreas-ing then increasdecreas-ing with time. Figure 2 depicts the distribution of ratings for the 2 symptoms that increased with time. Loss of appetite increased at 3 weeks after surgery and poor outlook
increased at 2 weeks. Figure 3 depicts the distribution of ratings for symptoms that decreased with time, including pain fre-quency, pain severity, coughing, tightness/ tenderness in the chest wall (breast), limitations on arm mobility, arm weakness,
Mean SD Scheffe
Items 2 Days 2 Weeks 3 Weeks 4 Weeks F Comparison Changes in appearance 2.89 0.91 2.87 0.80 2.87 0.80 2.94 0.85 0.31 Poor outlook 2.69 1.05 3.00 0.94 3.33 0.83 3.28 0.91 6.55‡ a b, c, d§ b a c a, b d a Limitations on 2.69 0.73 2.23 0.62 2.02 0.36 1.89 0.30 28.41‡ a b, c, d arm mobility b a c a Tightness/tenderness 2.64 0.81 2.20 0.61 1.92 0.42 1.79 0.46 36.60‡ a b, c, d
in the chest wall
Pain frequency 2.30 0.65 2.10 0.55 1.97 0.36 1.71 0.60 10.67‡ a c, d b d c a d a, b, c Fatigue 2.20 0.61 1.89 0.59 2.15 0.77 2.30 0.73 3.28‡ a b b a, c, d c b d b Pain severity 2.10 0.64 2.00 0.56 1.58 0.63 1.48 0.64 13.36‡ a c, d b c, d c a, b d a, b Coughing 1.84 0.58 1.61 0.59 1.33 0.57 1.20 0.52 21.19‡ a b, c, d b a, c, d c a, b d a, b Insomnia 1.82 0.72 1.71 0.55 1.87 0.73 1.94 0.72 1.85 Arm weakness 1.53 0.55 1.20 0.40 1.12 0.33 1.10 0.30 20.58‡ a b, c, d b a, d c a d a, b Numbness in the arm 1.51 0.55 1.35 0.48 1.28 0.45 1.15 0.36 14.39‡ a b, c, d
b a c a, d d a, b, c Loss of appetite 1.43 0.64 1.46 0.71 1.84 1.03 2.05 1.05 8.52‡ a b, c, d b a c a, d d a, b, c Nausea frequency 1.43 0.50 1.02 0.16 1.10 0.44 1.28 0.64 6.76‡ a b, c, d Bowel patterns 1.20 0.61 1.05 0.22 1.05 0.22 1.10 0.30 1.62 Loss of concentration 1.15 0.70 1.02 0.16 1.00 0.00 1.00 0.00 1.70 Trouble breathing 1.12 0.33 1.00 0.00 1.02 0.16 1.00 0.00 4.07‡ a b Nausea severity 1.06 0.33 1.00 0.00 1.00 0.00 1.00 0.00 4.64‡ a b, c, d Total 31.35 5.24 27.82 3.27 27.69 3.89 27.79 4.99 14.80‡ a b, c, d b a c a d a *Range 1–5. †Total range 17–85. ‡P .05.
§a 2 days; b 2 weeks; c 3 weeks; and d 4 weeks.
and numbness in the arm. Figure 4 depicts the distribution of ratings for symptoms that reported no significant changes dur-ing the study month, includdur-ing bowel patterns, loss of concen-tration, changes in appearance, trouble breathing, and nausea severity. Figure 5 depicts the distribution of ratings for the 3 symptoms of nausea frequency, insomnia, and fatigue that decreased at 2 weeks then increased at 3 weeks.
Repeated-measures ANOVA was performed for comparing symptom distress scores among between time points (Table 2). A significant time effect was seen for overall symptom distress from 2 days to 4 weeks after surgery (F1,38 14.80, P
.001). Seven symptoms showed significant changes over time from 2 days to 4 weeks after surgery: poor outlook (F1,38
6.55, P .001), limitations on arm mobility (F1,38 28.41, P .001), tightness/tenderness in the chest wall (F1,38
36.60, P .001), pain frequency (F1,38 10.67, P .001),
arm weakness (F1,38 20.58, P .001), numbness in the arm
(F1,38 14.39, P .001), loss of appetite (F1,38 8.52, P .001), coughing (F1,38 21.19, P .001), and nausea
frequency (F1,38 6.76, P .001).
Variables Influencing Symptom
Distress
T tests, one-way ANOVA, and correlations were used to
deter-mine whether the demographic and medical characteristics of the sample had significant relationships with overall symptom distress (Table 3). Age was the only demographic variable that had a significant negative correlation with SDS at the first 2 postsurgical points in time, that is, 2 days (r 0.50, P .01) and 2 weeks (r 0.31, P .05). The stage of breast cancer had significant relationships to with SDS only at the
first 2 postsurgical points in time, that is, 2 days (F2, 36 3.21, P .05) and 2 weeks (F2,36 3.51, P .05). Stage II patients
had significantly higher scores of SDS than did stage I patients according to the Scheffe method. Different types of surgery had significant relationships to SDS over time (P .05). Patients who received an MRM had higher symptom distress scores than those who received a BCT, especially at 2 days (t 3.58, P .001) and 2 weeks (t 4.67, P .001) post-surgery (Table 3).
Discussion
In a comparsion with other studies of symptom distress in post-operative breast cancer patients, we not only extend and support previous studies, but also present some of the different results we found. In the current study, changes in appearance, poor out-look, limitations on arm mobility, tightness in the chest wall, pain frequency, fatigue, and pain severity were the top 7 symp-toms. These symtoms are similar to those reported in Hoskin’s study.19 Hoskins19 investigated 93 postoperative breast cancer
patients over 1 year with a longitudinal design. Of the total sam-ple, 19% received chemotherapy and 23% received radiotherapy within 1 month after surgery. The most common symptoms at 7 to 10 days after surgery were pain, seroma, and discomfort in the shoulder; however, these had decreased at 1 month. Fatigue, nausea, and vomiting increased between the first and second month, but decreased in the third 3 month. We could discern no other changes at other assessment times (over 1 month) since we only assessed changes for 1 month after surgery.
In a study10by Shimozuma et al, about 70% of the
postop-erative breast cancer patients reported limitations on arm mobility, tightness/tenderness in the chest wall, nausea, and insomnia. Pain and fatigue were also noted after breast cancer surgery in Wyatt and Friedmen’s20study. They considered that
other symptoms related to fatigue could be sleep pattern dis-ruption, pain, upper-body weakness, or changes in family roles. Furthermore, 60% of the sample aged more than 55 and who had completed adjuvant therapies by 6 months after surgery reported higher levels of fatigue and pain than did those in the surgery-only group.20The levels of symptom
dis-tress differed from those in our study. This could have been due to differences in age and types of treatment. In the current study, ages ranged from 40 to 50 years, and most patients had not completed adjuvant therapy. The mean scores for poor outlook and changes in appearance were the highest during the 4 weeks after the operation. These findings are consistent with the results of the study by Shimozuma et al.10They also
high-light that breast cancer surgery can greatly impact one’s body image. Therefore, clinicians need to assess not only symptoms at the operative site, but also related physical and psychologi-cal symptoms, such as those mentioned above.
Data from this study show that age had a significant nega-tive correlation with the SDS score. This correlation indicates that younger patients have higher SDS scores than older patients. This is consistent with results of some other studies.5,20The reasons could be that young patients are more
Figure 1■ Symptom distress scale total score over time.
concerned about changes in their appearance. Surgery can cause changes in physical appearance and scarring. Some younger women may find it difficult to be upbeat when their treatment makes them feel bad or changes how they look. In addition, it may even become a topic of conversation among friends or colleagues. Also, having fewer illness-related experi-ences may make it hard for patients to accept changes in symp-toms, and they adopt a poor outlook when they begin their lives again. Educational levels had no significant correlation with SDS scores. This is consistent with results from studies by Shimozuma et al10and Wyatt and Friedmen.20
McCorkle and Quint-Benoliel14stated that medical
charac-teristics and methods of treatment were the main factors influ-encing symptom distress. Most participants in our study were at stage I or II. In addition, stage of disease had a significant relationship with SDS only for the first 2 postsurgical points in time. This is consistent with the results of the study by Ehlke.21
In a discussion of issues in breast cancer surgery, Rowland et al22 examined women’s symptom distress following a
lumpectomy, mastectomy alone, or mastectomy with recon-struction. They found that women receiving a mastectomy complained of a greater number of physical symptoms related to their surgeries than did women receiving a lumpectomy. The psychosocial impact of surgery for breast cancer occurred largely in areas of body image and feelings of attractiveness.22
Shimozuma et al10found that 66.7% of the sample with MRM
had more severe symptom distress than did those with BCT at 1 month following surgery. Shimozuma et al10 revealed that
patients receiving BCT experienced fatigue associated with treatments and had difficulty planning activities, while those receiving MRM had problems with wound healing or draining. Ganz et al23 concluded that patients receiving a mastectomy
reported more difficulties with clothing and body image than
those receiving BCT. That result is consistent with findings in our study. In Taiwan, the choice of the surgery type for treating breast cancer usually depends on the clinician’s own decision and opinions.
On account of recent improvements in the instruments used to diagnose breast cancer and from promotion of breast self-examinations, most patients with breast cancer are diag-nosed in the initial stage. When those patients receive both surgery and adjuvant therapy, their survival rates may also increase. Thus, BCT has rapidly become a major alternative to a mastectomy. According to the analysis by Fung et al,11
who compared psychological morbidity after a BCT or mas-tectomy, Chinese women who received BCT had significantly better body image scores. They had also more freedom in the choice of clothing, felt less upset by the changes in their bod-ies, and felt more accepted by their partners. In Japan, Noguchi et al24found that 5-year survival rates in the BCT
and MRM groups were 97% and 87%, respectively, and no breast cancer recurrence was found in the BCT group. There-fore, it is perceived that BCT produces more effective out-comes, namely, a higher survival rate, no recurrence, and less symptom distress.
There are several limitations in this study. First, this sam-ple setting was located in teaching hospitals in northern Tai-wan, so these findings may not be generalized to other areas of Taiwan. In addition, the average age of subjects was 48 years old; the majority were 41~50 years or above, so results might not be applicable to younger or elderly. Moreover, some patients had started chemotherapy or radiotherapy dur-ing data collection, which could affect patients’ symptom distress. For example, 2 symptoms (poor outlook and poor appetite) presented in Figure 2 (SDS increased over time) and three symptoms (nausea, fatigue, and insomnia) pre-sented in Figure 5 (first decreased then increased) could be
Figure 3■ Symptom distress subscale scores that decreased over time.
Figure 4■ Symptom distress subscale scores with no changes
related to women receiving chemotherapy or radiotherapy. Seven symptoms (limitations on arm mobility, tightness in the chest wall, pain frequency, pain level, coughing, weakness in the arm, and numbness in the arm) presented in Figure 3 (decreased over time) are most likely related to the surgical procedure.
Overall, the most noteworthy findings are the significantly higher levels of worry about changes in appearance and self-concern about their illness in younger patients and the fre-quent reporting of symptoms in the MRM group. As patients believe that their disease and illness-related treatments will cause great impacts and changes in their lives, clinicians need to determine how patients can be helped to attain physical and psychological equilibrium by discussing choices of an opera-tion and an adjuvant therapy with them. In addiopera-tion, provid-ing medical information and maintainprovid-ing their quality of lives are also necessary.
References
1. Lee MM. Breast cancer in Asian women. West J Med. 2002;176:91–92. 2. Department of Health, Executive Yuan, Taiwan, R.O.C. Table 76
reported new cancer cases by primary site, sex, and age Taiwan area, 1995–1999. Available at: http://www.doh.gov.tw/dohenglish/vpload/ statistics/s06/91_76–2.xls. Accessed November 4, 2003.
3. Chen CJ, You SL, Lin LH, Hsu WL, Yang YW. Cancer epidemiology and control in Taiwan: a brief review. Jpn J Clin Oncol. 2002;32 (suppl 1) S66–S81.
4. Cohen L, Hack TF, Moor C, Katz J, Goss PE. The effects of type of surgery and time on psychological adjustment in women after breast cancer treatment. Ann Surg Oncol. 2000;7:427–434.
5. Degner LF, Sloan JA. Symptom distress in newly diagnosed ambulatory cancer patient and as a predictor of survival in lung cancer. J Pain
Symp-tom Manage. 1995;10:423–431.
6. Cimprich B, Ronis DL. Attention and symptom distress in women with and without breast cancer. Nurs Res. 2001;50:86–94.
7. Cimprich B. Pretreatment symptom distress in women newly diagnosed with breast cancer. Cancer Nurs. 1999;22:185–194.
8. Baron RH, Kelvin JF, Bookbinder M, Cramer L, Borgen PI, Thaler HT. Patients’ sensations after breast cancer surgery: a pilot study. Cancer Pract. 2000;8:215–222.
9. Tasmuth T, Von Smitten K, Hietanen P, Kataja M, Kalso E. Pain and other symptoms after different treatment modalities of breast cancer. Ann
Oncol. 1995;6:453–459.
10. Shimozuma K, Ganze PA, Petersen L, Hirji K. Quality of life in the first year after breast cancer surgery: rehabilitation needs and patterns of recov-ery. Breast Cancer Res Treat. 1999;56:45–57.
11. Fung KW, Lau Y, Fielding R, Or A, Yip WC. The impact of mastectomy, breast-conserving treatment and immediate breast reconstruction on the quality of life of Chinese women. Aust NZ J Surg. 2001;71:202–206. 12. Tang ST, Lee SY. Cancer diagnosis and prognosis in Taiwan: patient
pref-erences versus experiences. Psycho-Oncology. 2004;13:1–13.
13. Temple LK, Baron R, Cody HS, Fey JV, Thaler HT, Borgen PI. Sensory morbidity after sentinel lymph node biopsy and axillary dissection: a prospective study of 233 women. Ann Surg Oncol. 2002;9:654–662. 14. McCorkle R, Quint-Benoliel J. Symptom distress, current concerns and
mood disturbance after diagnosis of life-threatening disease. Soc Sci Med. 1983;17:431–438.
15. Northouse LL, Laten D, Reddy P. Adjustment of women and their hus-bands to recurrent breast cancer. Res Nurs Health. 1995;18:515–524. 16. Sarna L. Effectiveness of structured nursing assessment of symptom
distress in advanced lung cancer. Oncol Nurs Forum. 1998;25:1041–1048. 17. Degner LF, Henteleff PD, Ringer C. The relationship between theory and measurement in evaluations of palliative care services. J Palliat Care. 1987;3:8–13.
18. Huang SH. Effects of Music Therapy on Relieving Pain and Symptom
Dis-tress Among Hospice Patients. [dissertation]. Taipei, Taiwan: Taipei Medical
University, Graduate Institute of Nursing; 2000.
19. Hoskins CN. Breast cancer treatment-related patterns in side effects, psy-chological distress, and perceived health status. Oncol Nurs Forum. 1997;24:1575–1583.
20. Wyatt GK, Friedman LL. Physical and psychosocial outcome of midlife and old women following surgery and adjuvant therapy for breast cancer.
Oncol Nurs Forum. 1998;25:761–768.
21. Ehlke G. Symptom distress in breast cancer patients receiving chemotherapy in the outpatient setting. Oncol Nurs Forum. 1988;15:343–346. 22. Rowland JH, Desmond KA, Meyerowitz BE, Belin TR, Wyatt GE,
Ganz PA. Role of breast reconstructive surgery in physical and emo-tional outcomes among breast survival. J Natl Cancer Inst. 2000;92: 1422–1429.
23. Ganz PA, Schag AC, Lee JJ, Polinsky ML, Tan SJ. Breast conservation versus mastectomy. Is there a difference in psychological adjustment or quality of life in the year after surgery? Cancer. 1992;69:1729–1738. 24. Noguchi M, Yagasaki R, Kawahara F, et al. Breast conserving treatment versus modified radical mastectomy in Japanese patients with operable breast cancer. Int Surg. 1997;82:289–294.
Mean SD
Independent Variable 2 Days 2 Weeks 3 Weeks 4 Weeks t/F†
Stage of cancer Stage I (n 17) 29.11 4.99 26.41 2.57 27.17 3.53 26.41 3.84 F2,36 3.21*, a Stage II (n 16) 33.43 5.15 29.25 2.97 28.87 3.57 29.31 5.47 F2,36 3.51*, b Stage III (n 6) 32.16 4.26 28.00 4.51 26.00 5.29 27.66 6.18 F2,36 1.49c F2,36 1.42d Type of surgery
Modified radical mastectomy (n 30) 32.08 4.74 28.90 2.66 28.50 3.72 28.73 5.00 t 3.58*,a
t 4.67*,b
Breast-conserving treatment (n 9) 26.55 3.94 24.22 2.48 25.00 3.35 24.66 3.60 t 2.52*,c
t 2.25*,d *P .05.
†a 2 days; b 2 weeks; c 3 weeks; and d 4 weeks.
Table 3• Correlations and Differences Between Demographic/Medical Characteristics and Overall Symptom Distress Scores (N 39)
