Epithelial atypia in biopsies performed for microcalcifications . Practical considerations about 2,833 serially sectioned surgical biopsies with a long follow-up This study analyzes the occurrence of epithelial atypia in 2,833 serially sectioned surgical breast biopsies -LRB- SB -RRB- performed for microcalcifications -LRB- median number of blocks per SB : 26 -RRB- and the occurrence of subsequent cancer after an initial diagnosis of epithelial atypia -LRB- median follow-up 160 months -RRB- . Epithelial atypia -LRB- flat epithelial atypia , atypical ductal hyperplasia , and lobular neoplasia -RRB- were found in 971 SB , with and without a concomitant cancer in 301 -LRB- 31 % -RRB- and 670 -LRB- 69 % -RRB- SB , respectively . Thus , isolated epithelial atypia were found in 670 out of the 2,833 SB -LRB- 23 % -RRB- . Concomitant cancers corresponded to ductal carcinomas in situ and micro-invasive -LRB- 77 % -RRB- , invasive ductal carcinomas not otherwise specified -LRB- 15 % -RRB- , invasive lobular carcinomas -LRB- 4 % -RRB- , and tubular carcinomas -LRB- 4 % -RRB- . Fifteen out of the 443 patients with isolated epithelial atypia developed a subsequent ipsilateral -LRB- n = 14 -RRB- and contralateral -LRB- n = 1 -RRB- invasive cancer . The high slide rating might explain the high percentages of epithelial atypia and concomitant cancers and the low percentage of subsequent cancer after a diagnosis of epithelial atypia as a single lesion . Epithelial atypia could be more a risk marker of concomitant than subsequent cancer . Introduction Breast biopsies for infraclinical lesions are more frequent with mammographic screening programs , but the distribution of the corresponding histological lesions and their associations are still imprecise . Difficulties encountered in following up patients without cancer account for the fact that the clinical significance of certain non-malignant lesions and the management of patients are still debated . Moreover , the problem of surgical biopsy sampling has never been fully investigated and has added additional confusion in appreciating the distribution and clinical significance of such lesions . In 1981 , breast epithelial atypia were hardly mentioned and not clearly defined in the World Health Organization/International Union Against Cancer -LRB- WHO/UICC -RRB- histologic classification of breast tumors -LSB- 73 -RSB- . The histologic classification of noncancerous lesions has been mainly based on studies analyzing for each lesion the associated risk of subsequent cancer . These studies were initiated by the survival studies of Dupont and Page -LSB- 15 , 46 -RSB- based on lesions discovered by palpation before the era of mammography . Thereafter , further studies -LSB- 6 , 9 , 17 , 24 , 31 , 51 , 62 , 67 -RSB- substantiated these results , which were ratified in 2003 by the new American Joint Committee on Cancer -LRB- AJCC -RRB- / UICC classification of breast tumors -LSB- 70 -RSB- . Schematically , this classification differentiates benign epithelial lesions -LRB- usual ductal hyperplasia and other lesions -RRB- from atypical lesions of ductal or lobular type . Although this historical classification is challenged by a new classification -LSB- 68 -RSB- , it remains the most widely used in practice . Interestingly , the occurrence of epithelial atypia was low in Page 's study -LSB- 46 -RSB- and has increased with mammographic screening programs -LSB- 60 , 66 -RSB- and with the development of percutaneous large core needle biopsy -LRB- CNB -RRB- methods using stereotactic mammography or ultrasound guidance . At present , CNB is frequently used for the initial evaluation of clinically occult breast lesions , thus generating dilemma for the subsequent management of certain noncancerous lesions . At our institution , surgical biopsies -LRB- SB -RRB- have always been managed in the same way , and most patients with atypical and malignant lesions have been followed . The objectives of our work were to analyze the occurrence of epithelial atypia and their association with a concomitant cancer in a large series of SB performed for microcalcifications without a palpable tumor and to assess the subsequent cancer probability in the group of patients with an initial diagnosis of epithelial atypia . Finally , we provide some practical considerations for the management of patients with epithelial atypia in this era of mammographic screening and CNB . Materials and methods Selection of patients At Institut Bergonié , from January 1975 to December 2002 , 3,166 breast biopsies for diagnostic purposes , 2,833 SB and 333 CNB , were performed for microcalcifications without any palpable mass in 2,708 patients -LRB- mean age 51.8 years , range 19.7 -- 81 years -RRB- . Among them , 248 -LRB- 9 % -RRB- had several biopsies in the same or contralateral breast . Since 1998 , microcalcifications have been classified according to the classifications of the American College of Radiology -LSB- 2 -RSB- . SB for diagnostic purposes were defined before 1998 by the absence of a preoperative diagnosis based on the clinical -- mammographic -- cytologic triplet and by the absence of a positive frozen section and , since 1998 , by the presence of epithelial atypia on CNB . Excluded from this study were 132 cancers and 139 non-atypical benign lesions diagnosed on CNB as well as 49 re-excisions performed elsewhere than in our center . Thus , 2,833 SB in 2,375 patients were available for analysis , among which 13 corresponded to re-excision after a CNB with epithelial atypia . Since 1989 , needle localization , intraoperative specimen radiography , and post-excisional biopsy mammography have been performed in most cases . Surgical biopsies and tissue sampling : serial macroscopic sectioning SB was removed in one fragment and measured more than 3 cm in 94 % of the cases -LRB- mean size 60 mm , 5 -- 250 mm -RRB- . For SB margin assessment , either the surface of the specimen was inked or the surgeon during the same operation removed additional tissue in the remaining cavity after excision of the specimen -LRB- surgical margins -RRB- . After fixation in Holland Bouin , SB and margin specimens were serially sectioned in their entirety into numbered slices every 2 mm -LSB- 12 -RSB- . In most cases -LRB- 89 % -RRB- , careful macroscopic examination of the specimen failed to reveal any lesion . Each numbered slice was put in as many numbered separate cassettes as necessary and paraffin-embedded in sequence . The median number of blocks per SB was 26 -LRB- from 2 to 180 -RRB- and 8 -LRB- from 1 to 44 -RRB- for surgical margins . Each block was examined on one hematoxylin -- eosin -- safran stained slide . Classification of lesions and review of slides Since 1975 , all patients have been prospectively included in our clinical , histologic , and biologic database by senior pathologists -LRB- IM , GMG , IS , JMC -RRB- . For each SB and each lesion , we prospectively entered in our pathologic database morphological descriptive criteria by using 65 pathological items for noncancerous lesions and 181 for cancers . Definitions and terminologies given in the literature were used to report columnar cell lesions -LRB- CCL -RRB- , non-atypical ductal hyperplasia , atypical ductal hyperplasia , ductal carcinoma in situ -LRB- DCIS -RRB- , and lobular carcinoma in situ -LRB- LCIS -RRB- -LSB- 1 , 4 , 7 , 10 , 17 , 19 , 21 -- 28 , 38 , 43 -- 45 , 47 , 49 , 50 , 56 , 59 , 61 , 69 , 72 , 74 , 75 -RSB- . The interest of our database was to collect morphological descriptive criteria of nearly all the breast lesions without labeling them . In fact , labels and definitions of breast lesions have varied throughout the past 30 years , while neither lesions nor their corresponding descriptive criteria -LRB- i.e. , size , type , architecture , cellular and nuclear features , etc. . . -RRB- have changed . The only changes during this period were the definitions and/or the names given to these lesions . As we have listed for each lesion all the corresponding descriptive criteria among the 236 available items , we have been able to reclassify each lesion according to the `` new '' criteria recommended by referent authorities for a new definition , by selecting in our database the `` new '' correspondent descriptive criteria corresponding to this new definition . Consequently , this provided a homogeneous approach to the pathological lesions at the time of our study . For example , low-grade DCIS ≤ 2 mm have been reclassified as atypical ductal hyperplasia/ductal intraepithelial neoplasia -LRB- ADH/DIN -RRB- 1B -LRB- n = 30 -RRB- according to the new AJCC/UICC classification of breast tumors -LSB- 70 -RSB- , and lesions that we used to term before 1997 -LSB- 71 -RSB- as clinging carcinoma of the monomorphic type -LSB- 4 -RSB- have been reclassified as flat epithelial atypia -LRB- FEA -RRB- / DIN 1A or columnar cell change -LRB- CCC -RRB- with atypia -LRB- n = 84 -RRB- -LSB- 61 -RSB- . About half of these 114 cases have been systematically reviewed by one -LRB- IM -RRB- or two senior pathologists -LRB- IM and GMG or IS -RRB- , and there was a complete concordance between the second review and the initial descriptive criteria listed in the database . Similarly , lesions that we used to name LCIS before 1997 have been renamed lobular neoplasia -LRB- LN -RRB- since 1997 , corresponding either to atypical lobular hyperplasia -LRB- ALH -RRB- or to LCIS . On the contrary , all the cases with micropapillary lesions were reviewed -LRB- n = 155 -RRB- because there was no item corresponding to precise descriptive criteria of micropapillations -LRB- number , topography around the duct , type -RRB- . Atypical ductal hyperplasia : definition and sizing Among the group of ADH/DIN 1B , we individualized two morphologic types of ADH . Neither had any high-grade cytological atypia or necrosis . ADH `` mimicking DCIS '' -LRB- Fig. 1 -RRB- . In this type , architectural atypia were qualitatively insufficient to allow a diagnosis of DCIS , therefore this `` mimicking '' DCIS lesion was classified as ADH whatever its size . Tufts and short micropapillations formed by cells had a broad base and were cohesive . There was no polarization of cells , i.e. , no true cribriform spaces . Pseudo-cribriform patterns comprised irregular or relatively round microlumina with incomplete polarization of surrounding epithelial cells . Cellular bridges were wavy without any cellular polarization . Cells corresponded either to columnar cells with uniform ovoid to elongated nuclei or to cells with a slight increase in the nuclear/cytoplasmic ratio with more or less distinct cell borders and round or ovoid nuclei . These cells were sometimes admixed in the same lesion displaying a morphological gradient , but there was no regular arrangeent . Nuclear chromatin was evenly dispersed , homogeneous , or slightly marginated , and nucleoli were inconspicuous . Apical snouts , intraluminal secretions , and psammoma-type calcifications were frequently present . Fig. 1a -- d. ADH `` mimicking DCIS . '' a Tufts and short micropapillations with a broad base . b Pseudo-cribriform spaces . c Microlumen with incomplete polarization of surrounding epithelial cells . d Cellular bridges without cellular polarization . Cells are parallel to the axes -LRB- arrows -RRB- ADH corresponding to `` mini DCIS '' -LRB- Fig. 2 -RRB- . In this type , architectural and cytologic atypia corresponded to a low-grade DCIS but were quantitatively insufficient to allow a diagnosis of DCIS , therefore this `` mini '' DCIS lesion was classified as ADH when ≤ 2 mm . Tufts and short micropapillations had a tight base , were present on over all the periphery of the duct , and were non-cohesive with small free papillary tufts in the lumen . There were true cribriform patterns with a polar organization of cells around glandular spaces and/or variants of cribriform patterns -LRB- i.e. , trabecular bars , cartwheel formations , and Roman bridges , Fig. 3 -RRB- with polarized cells arranged perpendicular to the axes . Some solid areas with regular arrangement of cells were also present . Cells were often small , monomorphous , sometimes without a columnar change , with a distinct cytoplasmic membrane and a spaced regular round nucleus with uniformly dispersed chromatin without prominent nucleoli . Intraluminal secretions and calcifications -LRB- amorphous or psammoma-type -RRB- were also frequently present -LRB- Fig. 4 -RRB- . When one mini DCIS focus was found in one partially or completely involved duct/ductular cross-sections in one terminal ductal lobular unit -LRB- TDLU -RRB- , it was classified as ADH when it measured ≤ 2 mm and as DCIS when it measured > 2 mm . When there were several foci of `` mini '' DCIS in close duct/ductular cross-sections in the same TDLU or in TDLUs located in the same field at low power magnification -LRB- 2.5 -RRB- , the lesion was classified as ADH when its size , i.e. , its largest diameter , was ≤ 2 mm and as DCIS when > 2 mm . When there were several foci of `` mini '' DCIS in distant duct/ductular cross-sections in the same TDLU or in close TDLUs , the size of each focus was assessed separately . FEA , rare and scattered single micropapillations , and cribriform variants were not taken into consideration for sizing , even if located in the same TDLU . Fig. 2a -- e. ADH corresponding to `` mini DCIS . '' a A solid mini DCIS focus measuring less than 2 mm in one TDLU . b Tufts and short micropapillations over the entire periphery of the duct with small free papillary tufts in the lumen . c Short micropapillations with a tight base . d True cribriform spaces . e Microlumen with complete polarization of surrounding epithelial cellsFig . 3a -- c. Variants of cribriform patterns . Polarized cells arranged perpendicular to the axes . a Trabecular bars . b Cartwheel formations . c Roman bridgesFig . 4a and b. a Mild cytologic atypia . b Columnar cells with uniform ovoid nuclei , intraluminal calcifications FEA were present either as a single lesion or in association with ADH in the same TDLU and since 1997 have been included in the ADH group . The distinction of FEA from columnar change without atypia was based on the criteria given by the WHO for the definition of FEA . Furthermore , columnar change without atypia was characterized by one or two layers of columnar cells without nuclear atypia , i.e. , no increase in the nuclear/cytoplasmic ratio , no prominent nucleoli . Nevertheless , some cases of columnar change with progesterone impregnation , especially in the second part of the cycle , might display a lobular distension with a secretory material and large nuclei with prominent nucleoli . In such cases , myoepithelial cells displayed the same alterations with clarified cytoplasms , thus facilitating the diagnosis . The distinction of ADH mimicking DCIS from usual hyperplasia -LRB- UDH -RRB- was based on morphological criteria . Architectural pattern and cytologic criteria of usual ductal hyperplasia were easy to identify in most cases . UDH corresponded to a proliferation of epithelial cells in solid or fenestrated areas without any polarization of surrounding cells . Cells were haphazardly arranged with overlapping nuclei or were parallel with characteristic streamings . They were elongated or pseudo epithelioid , but there was no columnar metaplasia . Cytoplasms were more or less abundant with indistinct borders . Nuclei had irregular size and shape and sometimes contained a prominent eosinophilic inclusion . In some rare cases , immunohistochemical staining with cytokeratin 5/6 -LSB- 41 -RSB- was used and was negative in ADH mimicking DCIS and strongly positive in UDH . In some lesions , differential diagnosis between ADH and low-grade DCIS was all the more difficult because there were intermediate and intricated morphological aspects in the same TDLU . In practice , diagnosis of micropapillary lesions was often difficult . Extensive micropapillary lesions were classified as DCIS when quantitative and qualitative criteria were simultaneously present , i.e. , lesion sizing more than 2 mm corresponding to micropapillations with a tight base over the entire periphery of the ducts . Additional sections could be useful for demonstrating more or less qualitative or quantitative diagnostic criteria . When malignancy remained equivocal , the case was classified as ADH . When a concomitant cancer was diagnosed , histologic size was assessed , and in DCIS , the percentage of blocks with cancer -LRB- `` positive blocks '' -RRB- was specified -LSB- 13 -RSB- . Presence and topography of microcalcifications were also assessed . Lastly , when FEA and/or `` mimicking '' DCIS foci were found on excision margins of a SB with DCIS , a further surgical resection was not performed . Follow-up of patients with epithelial atypia as a single lesion There were 443 patients with epithelial atypia in one or several SB , without any previous or synchronous carcinoma in the same or contralateral breast and treated by biopsy alone -LRB- median follow-up 160 months , 7 to 315 -RRB- . Only 28/443 -LRB- 6 % -RRB- were lost to follow-up . Among the 415 other patients , 180 were monitored at our institute and 235 outside by correspondent specialists working in close relationship with our institute . All patients received a clinical examination and mammography once a year . When a new biopsy was necessary , it was performed at our institute . Statistical analyses Comparison of clinical and histologic characteristics was conducted by using the chi-square test . For women with epithelial atypia , the probability of developing in situ or invasive cancer was calculated from the date of the first biopsy to the earliest event : breast cancer -LRB- ipsi - or contralateral -RRB- , death , or last contact -LRB- last consultation for the group monitored at our institute and checkpoint date , i.e. , 1 March 2004 , for the others -RRB- . Probabilities were calculated according to the Kaplan -- Meier method -LRB- SPSSv11 -RRB- . Results Occurrence of epithelial atypia in the 2,833 surgical biopsies Epithelial atypia were recorded in 971/2 ,833 SB -LRB- 34 % -RRB- . They were found with and without a concomitant cancer in 301/971 -LRB- 31 % -RRB- and 670/971 -LRB- 69 % -RRB- of the cases , respectively . Thus , isolated epithelial atypia were found in 23 % of the cases -LRB- 670 out of the 2,833 SB -RRB- . Calcifications were present at histologic examination in 98.6 % of SB with cancer and were located in benign , cancerous , and both lesions in 10 , 39 , and 51 % of the cases , respectively . In several cases , cancerous foci without any microcalcifications were located at points distant from those with calcifications detected by needle localization . Types of epithelial atypia Among the 971 SB with epithelial atypia , there were 101 SB with FEA as a single lesion -LRB- 11 % -RRB- , 342 -LRB- 35 % -RRB- with ADH , 223 -LRB- 23 % -RRB- with LN , and 305 -LRB- 31 % -RRB- with ADH and LN . Thus , ADH was encountered in 647/971 SB -LRB- 66 % -RRB- . Types of cancers associated with epithelial atypia Cancers associated with epithelial atypia corresponded to DCIS and micro-invasive carcinoma -LRB- DCIS-MI -RRB- in 233 cases -LRB- 77 % -RRB- . Among invasive carcinomas -LRB- n = 68 -RRB- , there were 13 -LRB- 9 % -RRB- lobular and 11 -LRB- 6 % -RRB- tubular carcinomas -LRB- Table 1 -RRB- . Cancers were small -LRB- ≤ 5 mm in 46 % of invasive carcinomas , fewer than half of the blocks positive in 76 % of DCIS -RRB- . They were non-high grade in 78 and 67 % of DCIS and invasive carcinoma , respectively . In most cases , ADH and cancer were situated close to each other . FEA alone were less frequently associated with a concomitant cancer than ADH and/or LN -LRB- p = 5 × 10 − 4 -RRB- . Table 1Types of concomitant cancers -LRB- n = 301 -RRB- in the 971 surgical biopsies with epithelial atypiaEpithelial atypiaFEA -LRB- n = 101 -RRB- ADH -LRB- n = 342 -RRB- LN -LRB- n = 223 -RRB- ADH + LN -LRB- n = 305 -RRB- No . of cases -LRB- % -RRB- No . of cases -LRB- % -RRB- No . of cases -LRB- % -RRB- No . of cases -LRB- % -RRB- Without cancer8483220641396222774With cancer17171223684387826DCIS/DCIS-MI 12121033058266020IDC/NOS -- -- 164.7178113 ILC1110 .36352 TC44213121FEA Flat epithelial atypia ; ADH atypical ductal hyperplasia ; LN lobular neoplasia ; DCIS ductal carcinoma in situ ; DCIS-MI DCIS with micro-invasion ; IDC infiltrating ductal carcinoma ; ILC infiltrating lobular carcinoma ; TC tubular carcinoma Cancers without epithelial atypia -LRB- malignancy alone -RRB- There were 821 malignant SB without epithelial atypia -LSB- 590 micro-invasive carcinomas , 206 infiltrating ductal carcinomas -LRB- IDC -RRB- , and 25 infiltrating lobular carcinomas -LRB- ILC -RRB- -RSB- . Subsequent cancer in patients with an initial diagnosis of epithelial atypia as a single lesion At 5 and 10 years , the probabilities of developing invasive breast cancer in the group of 443 patients with epithelial atypia were 2.8 % -LSB- 95 % CI = 1.4 to 5.5 -RSB- and 5.5 % -LSB- 95 % CI = 3.3 to 9.9 -RSB- , respectively -LRB- Fig. 5 -RRB- . Among the 18 subsequent carcinomas , 15 were invasive -LRB- 11 IDC and 4 ILC -RRB- , and 3 corresponded to DCIS . Most subsequent carcinomas were encountered in the homolateral breast -LRB- n = 14 -RRB- and before 10 years -LRB- n = 16 -RRB- . Seven carcinomas occurred in the group of patients with an initial diagnosis of LN , in the same -LRB- n = 5 -RRB- or contralateral -LRB- n = 2 -RRB- breast . They corresponded to infiltrating ductal -LRB- n = 6 -RRB- or lobular -LRB- n = 1 -RRB- carcinomas . The interval of development was 4 , 5 , 6 -LRB- n = 2 -RRB- , 9 , and 12 -LRB- n = 2 -RRB- years . Seven carcinomas occurred in the group of patients with an initial diagnosis of ADH , in the same -LRB- n = 3 -RRB- or contralateral -LRB- n = 4 -RRB- breast . They corresponded to DCIS -LRB- n = 2 -RRB- and to infiltrating ductal -LRB- n = 4 -RRB- or lobular -LRB- n = 1 -RRB- carcinomas . The interval of development was 1 , 2 , 3 -LRB- n = 3 -RRB- , 9 , and 12 years . Four carcinomas occurred in the group of patients with an initial diagnosis of ADH associated with LN , in the same -LRB- n = 3 -RRB- or contralateral -LRB- n = 1 -RRB- breast . They corresponded to DCIS -LRB- n = 1 -RRB- and to infiltrating ductal -LRB- n = 2 -RRB- or lobular -LRB- n = 1 -RRB- carcinomas . In the four cases , the interval of development was 4 years . There was no subsequent carcinoma in the group of patients with FEA . Fig. 5Probability of developing subsequent invasive breast cancer in the group of 415 patients with epithelial atypia -LRB- dotted line : confidence interval 95 % -RRB- Discussion Application of the WHO classification : practical considerations For a long time , DCIS was diagnosed even if the characteristic features were found in only one ductal space -LSB- 6 -RSB- . Thereafter , some authors introduced quantitative criteria for distinguishing between ADH and DCIS -LSB- 46 , 67 -RSB- , while others -LSB- 23 -RSB- rejected them . More recently , Rosen -LSB- 57 -- 59 -RSB- and Schnitt and Vincent-Salomon -LSB- 61 -RSB- described CCL comprising CCC and columnar cell hyperplasia -LRB- CCH -RRB- with and without atypia . Nasser -LSB- 40 -RSB- challenged this classification based on columnar shape and limited the group of lesions to proliferations characterized by a low-grade atypicality , `` atypical columnar cell lesions , '' -LRB- ACCL -RRB- rather by a columnar cell configuration . In the WHO classification , ADH includes various not clearly defined types of lesions -LRB- Table 2 -RRB- . On one hand , there are lesions with arcades , moundings , and micropapillary formations , but without any true cribriform/complex architectural patterns -LSB- 34 -RSB- . This type of ADH corresponds to the CCH with atypia of Schnitt and Vincent-Salomon -LSB- 61 -RSB- termed category 3 in Simpson 's study -LSB- 51 -RSB- , to the definition of ADH by Koerner -LSB- 34 -RSB- and to ADH `` mimicking '' DCIS in our study . On the other hand , there are lesions displaying architectural and cytologic atypia . This type of ADH corresponds to the complex architectural pattern with cytologic and architectural atypia of Schnitt and Vincent-Salomon -LSB- 61 -RSB- termed category 5 in Simpson 's study -LSB- 64 -RSB- , to the definition of `` microfocus of DCIS '' by Koerner -LSB- 34 -RSB- and to `` mini DCIS '' in our study . In Simpson 's study , the ADH/category 5 contained chromosomal changes and the same total mean number of changes to that observed in DCIS/DIN IC , unlike the other CCL . Lastly , because there is still no consensus for measuring ADH , there is no clear-cut distinction between ADH and DCIS , and the cut-off at 2 or 3 -LSB- 52 -RSB- mm or at two completely involved spaces -LSB- 70 -RSB- seems arbitrary . While awaiting a definitive molecular classification , the simplest attitude could be recommended in routine practice . Only mini foci of ADH obviously similar to low-grade DCIS foci could be measured and classified as ADH when equal to or less than 2 -- 3 mm -LSB- 52 -RSB- and as DCIS when more than 3 mm . Although the mode of measurement in our study is not under consensus , it is simple and can been routinely applied . Table 2Terminologies used for intraductal proliferative lesions with low-grade cytologic atypia , so-called atypical columnar cell lesionsSpectrum of lesions1 , 3 -- 5 LayersNo polarization * With polarization Occasional mounding Mounding , arcades Cribriform spaces and their variants No or rare arcades and micropapillary formations Cohesive micropapillary tufts with a broad base Non-cohesive micropapillary tufts with a tight base -LSB- 70 -RSB- Flat epithelial atypia/DIN 1AADH/DIN 1B ≤ 2 mm ; or in two spacesDCIS/DIN 1C -LSB- 59 -RSB- Columnar cell hyperplasia with atypiaADH if not extensiveDCIS if extensive -LSB- 61 -RSB- Columnar cell change -LRB- CCC -RRB- with cytologic atypiaComplex structures with architectural and cytologic atypia -LSB- 34 -RSB- Columnar cell lesions + ADHMicroscopic focus of DCISDCISInstitut BergoniéEx-clinging carcinoma of monomorphic typeADH `` mimicking '' DCISADH corresponding to `` mini '' DCIS ≤ 2 mmDCIS -LSB- 64 -RSB- CCC with cytologic atypiaCCH with architectural atypiaCCH with architectural atypiaDCISOrAndCCH with cytologic atypiaCytologic atypiaRegrouping?DIN 1AADH/DIN 1BADH/DIN 1CDCIS/DIN 1CNot measuredMeasured : ≤ 3 mm > 3 mm * Or incomplete polarization Occurrence of epithelial atypia and their association with a concomitant cancer : practical considerations In our study , the proportion of epithelial atypia is high -LRB- 23 % -RRB- , a result difficult to compare to others in the literature , as the methodologies used by teams are different . In the Page and Dupont case-control studies -LSB- 15 , 46 -RSB- , ADH and ALH were found in 2.1 and 1.6 % of the cases , respectively . In mammographic screening programs , epithelial atypia and cancers increase as the number of biopsies performed for microcalcifications increases , especially as ACR4/ACR5 lesions are more often excised than ACR3 . However , as underlined by Page -LSB- 46 -RSB- , `` the most direct relationship of epithelial atypia incidence is to slide rating . '' The number of slides per SB in our study -LRB- median 26 -RRB- was higher than in the other studies on benign breast lesions : 1 -- 5 in 93 % of the cases in the study of Page et al. -LSB- 46 -RSB- -LRB- n = 283 -RRB- , 3 -LRB- range 1 -- 25 , n = 674 -RRB- in the study of Shaaban et al. -LSB- 62 -RSB- , and a mean of 1.6 slides per cm of tissue -LRB- n = 199 -RRB- in the study of Tavassoli and Norris -LSB- 67 -RSB- . In a recent study conducted in the south west of France in women aged between 50 and 75 with mammographically detected non-palpable breast lesions , a similar proportion of atypical lesions were found when biopsies were serially sectioned -LSB- 39 -RSB- . Furthermore , this high slide rating allowed the detection of small concomitant cancers in the vicinity of epithelial atypia in 31 % of our cases , with a skew towards low-grade lesions -LRB- high proportions of DCIS and low-grade invasive carcinomas , especially tubular carcinomas -RRB- . Our results strengthen the hypothesis that FEA and ADH are risk markers of low-grade cancers . This has been confirmed by the study of Simpson et al. -LSB- 64 -RSB- on molecular genetic profiles of CCL . In some of them , there are both a morphological and a molecular continuum in the degree of proliferation and atypia , supporting the hypothesis that `` CCL are a non-obligate , intermediary step in the development of some forms of low grade in situ and invasive carcinoma . '' The association of epithelial atypia with a concomitant cancer in nearly one third of the cases in our study parallels previous findings concerning the frequency of cancers found in SB performed for atypia in CNB . Thus , approximately 30 % -LSB- 20 , 29 -RSB- and 15 to 21 % -LSB- 5 , 8 , 14 , 18 , 35 , 45 , 53 , 63 , 76 -RSB- of excisions after CNB with ADH and LN , respectively , were proven to have cancer . Consequently , excision is recommended -LSB- 45 -RSB- for all patients in whom ADH is identified on CNB and may be justified in patients with FEA , as they are included in the spectrum of ACCL . Excision remains a controversial issue in patients with LN . Some authors have advocated it -LSB- 3 , 18 , 33 , 63 -RSB- , while others have rebutted it -LSB- 55 -RSB- , especially when LN is an incidental non-extensive finding -LSB- 48 -RSB- with no radiologic -- pathologic discordance -LSB- 18 -RSB- and without any synchronous mass lesion -LSB- 37 -RSB- . SB corresponding to re-excision should be processed in its entirety by serial macroscopic sectioning -LSB- 32 , 65 -RSB- . When pathologic examination is exclusively focused on mammographic calcifications , the risk is to underestimate the DCIS size/extension because cancerous foci without any calcification -LRB- 10 % in our study vs 6 % in Owing ' study -RRB- -LSB- 42 -RSB- may be located at points distant from those with benign breast tissue containing calcifications . Subsequent cancer after an initial diagnostic of epithelial atypia as a single lesion : practical considerations In the literature , 4 to 22 % -LRB- average interval 8.3 years follow-up -RRB- -LSB- 6 , 42 , 67 -RSB- and 15 to 20 % -LSB- 16 , 30 , 56 -RSB- of patients developed invasive carcinomas after a diagnosis of ADH and LN , respectively . The risk of developing cancer increases with extended follow-up , but many cancers after a diagnosis of LN have a good prognosis and a low mortality -LSB- 36 -RSB- . These results are difficult to compare to ours because the methodologies are different . The low probabilities of subsequent invasive cancer in our study could be due to the high slide rating , allowing the detection of small concomitant cancer that might have been missed with a low slide rating and inadequate patient management -LSB- 11 , 54 -RSB- . In conclusion , when epithelial atypia are present , they are associated in nearly one third of the cases with a concomitant close cancer and are found as isolated lesions in nearly 23 % of SB performed for microcalcifications . In practice , ADH should be more clearly defined with simple guidelines for measuring lesions . When malignancy remains equivocal and/or when sizing is difficult , it is better to classify the lesion as ADH . Epithelial atypia could be more a `` risk factor '' of a concomitant geographically small close cancer than a risk marker for a subsequent cancer , as they form part of a spectrum of lesions -LSB- 64 -RSB- .

B I O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O B O O O O O O O O O O O O O O O O O O O O O O B O O O O O B I O O O O O O O B I O O B I O B I I O O B I O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O B O O O O O O O O O O O B I O O O O O O O O O B O O O O B I O O O O O B I O O O O O O O O O O B O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B B I O O O O O O O O O O O O O O B O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O B O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O B I O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O B I O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O B O O O O O O O O O O O O O O B B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O B I O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O B I I O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O B I O O O O O O O O O O O O O O O B B O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B B O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O B O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O B O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O B O O O O O O O B O O O O O O O O O O O O O O

breast
epithelial atypia
lobular neoplasia
atypical ductal hyperplasia
cancer


Quality

of

life

of

parents

with

children

living

at

home

when

one

parent

has

cancer

Goals

of

work

This

study

examined

the

quality

of

life

-LRB-

QoL

-RRB-

of

cancer

patients

diagnosed

years

previously

and

their

spouses

with

children

years

living

at

home

Relationships

between

parents

QoL

and

the

children

's

functioning

were

explored

Introduction

The

impact

of

cancer

on

a

patient

's

psychosocial

functioning

has

received

much

attention

in

the

literature

over

the

past

decades

It

is

generally

acknowledged

that

a

patient

's

quality

of

life

-LRB-

QoL

-RRB-

decreases

while

they

are

battling

their

illness

Problems

in

QoL

tend

to

diminish

over

time

as

a

patient

responds

to

treatment

However

a

significant

percentage

of

patients

continues

to

experience

clinically

elevated

levels

of

problems

requiring

professional

treatment

-LSB-

-RSB-

Furthermore

a

growing

number

of

studies

provides

evidence

that

cancer

patients

spouses

develop

problems

affecting

their

QoL

-LSB-

-RSB-

Spouses

have

reported

psychological

and

physical

distress

which

have

been

found

to

correlate

with

the

patient

's

dysfunction

-LSB-

-RSB-

However

the

majority

of

studies

examine

patients

and

spouses

in

later

adulthood

-LSB-

-RSB-

Most

incidences

of

cancer

occur

in

older

adults

According

to

the

Dutch

Comprehensive

Cancer

Center

's

database

of

all

new

incidences

of

cancer

in

The

Netherlands

in

occurred

in

patients

more

than

the

age

of

-LSB-

-RSB-

Parental

cancer

in

younger

families

may

be

a

more

serious

stressor

than

in

later

phases

of

life

as

illness

and

death

in

later

adulthood

could

be

considered

more

natural

or

normative

-LSB-

-RSB-

It

has

been

shown

that

older

cancer

patients

report

less

anxiety

and

depression

and

better

QoL

than

younger

adult

patients

-LSB-

-RSB-

Couples

in

an

earlier

life

phase

with

young

children

and

adolescents

at

home

lead

busy

lives

They

juggle

child-rearing

responsibilities

and

the

demands

of

sustaining

a

healthy

marriage

with

trying

to

meet

the

individual

-LRB-

career

-RRB-

needs

of

each

partner

-LSB-

-RSB-

In

the

case

of

families

with

parental

cancer

parents

have

the

added

strain

of

their

loved

one

being

ill

Additionally

their

stress

may

be

confounded

when

the

patient

may

not

be

able

to

work

or

take

care

of

the

children

as

well

as

before

the

onset

of

the

disease

Only

a

few

studies

have

examined

the

impact

of

cancer

on

the

functioning

of

all

members

in

families

in

this

phase

of

life

In

our

previous

investigations

of

families

confronted

with

parental

cancer

the

main

focus

has

been

on

the

children

's

psychological

well

being

-LSB-

-RSB-

Results

have

shown

clinically

elevated

levels

of

distress

in

of

adolescent

daughters

and

of

adolescent

sons

-LSB-

-RSB-

and

higher

levels

of

emotional

problems

in

adolescent

daughters

and

elementary

school-aged

sons

of

cancer

patients

-LSB-

-RSB-

It

is

possible

that

the

children

's

emotional

and

behavioral

functioning

which

may

be

affected

by

their

parent

's

cancer

affects

how

the

parents

function

The

current

study

had

four

main

aims

The

first

aim

was

to

examine

health-related

QoL

of

patients

and

spouses

in

families

with

young

children

years

after

diagnosis

We

hypothesized

that

cancer

patients

and

their

spouses

QoL

would

be

lower

than

that

of

a

norm

group

and

that

QoL

would

differ

as

a

function

of

health

status

and

gender

-LRB-

i.e.

which

parent

was

ill

the

mother

or

father

-RRB-

Based

on

literature

-LSB-

-RSB-

we

expected

to

find

that

female

patients

reported

the

lowest

QoL

followed

by

female

partners

male

patients

and

male

partners

The

second

aim

was

to

examine

the

effect

of

illness-related

variables

-LRB-

time

since

diagnosis

recurrence

treatment

intensity

and

type

of

cancer

-RRB-

on

parents

QoL

We

expected

that

patients

and

spouses

would

report

more

problems

more

shortly

after

diagnosis

when

confronted

with

recurrence

of

cancer

and

when

treatment

was

intense

and

also

that

QoL

would

differ

depending

on

type

of

cancer

Our

third

aim

was

to

examine

relationships

between

patient

's

and

spouse

's

QoL

we

hypothesized

that

they

would

be

significantly

related

Finally

the

fourth

aim

was

to

explore

possible

relationships

between

the

parents

QoL

and

the

children

's

emotional

and

behavioral

functioning

Materials

and

methods

Procedure

Both

hospitalized

cancer

patients

and

those

being

treated

or

seen

for

follow-up

visits

at

the

outpatient

clinic

of

the

University

Medical

Center

Groningen

between

January

and

February

were

approached

by

surgical

medical

and

radiation

oncologists

and

oncology

nurses

Patients

were

eligible

for

the

study

if

they

were

diagnosed

with

cancer

years

before

study

entry

and

had

children

between

the

ages

of

and

years

at

the

time

of

parent

's

diagnosis

who

resided

or

had

frequent

contact

with

the

diagnosed

parent

Furthermore

both

parents

and

children

needed

to

be

fluent

in

Dutch

A

family

could

participate

in

the

study

if

the

patient

and

at

least

one

child

agreed

to

participate

Physicians

and

oncology

nurses

offered

all

eligible

patients

and

spouses

written

information

plus

an

information

brochure

adapted

for

the

children

Informed

consent

was

obtained

from

each

family

member

separately

as

regulated

by

the

Medical

Ethical

Committee

of

the

University

Medical

Center

Groningen

After

obtaining

informed

consent

researchers

mailed

packages

with

questionnaires

and

prepaid

return

envelopes

to

each

family

member

Cancer

patients

spouses

and

children

were

instructed

to

fill

in

questionnaires

independently

of

each

other

and

to

not

discuss

their

answers

Instruments

Demographic

data

was

gathered

on

age

gender

level

of

education

length

of

relationship

number

of

children

living

at

home

and

who

the

primary

caregiver

in

the

family

is

Patients

provided

information

about

when

they

were

diagnosed

their

type

of

cancer

treatment

intensity

and

recurrence

Education

was

measured

on

a

seven-point

scale

from

-LRB-

-RRB-

elementary

school

only

to

-LRB-

-RRB-

university

degree

The

eight

subscales

and

two

component

summary

scores

of

the

Dutch

translation

of

the

were

used

to

measure

QoL

-LSB-

-RSB-

Scores

on

the

subscales

can

range

from

to

with

higher

scores

indicating

better

functioning

When

comparing

patients

and

spouses

to

a

reference

group

norm

scores

were

used

from

the

Dutch

manual

for

the

-LSB-

-RSB-

The

manual

provides

mean

scores

from

a

random

sample

of

people

between

the

ages

of

and

-LRB-

women

age

M

-RRB-

from

the

population

register

of

a

municipality

in

The

Netherlands

Norm

scores

are

provided

for

each

subscale

for

the

entire

sample

and

for

men

and

women

separately

Summary

scores

report

physical

functioning

and

psychosocial

functioning

and

are

standardized

with

a

mean

of

and

a

standard

deviation

of

The

reliability

and

validity

of

the

has

been

supported

in

a

wide

number

of

international

and

national

studies

-LSB-

-RSB-

Cronbach

's

alphas

in

this

study

on

the

eight

subscales

ranged

between

and

for

patients

and

and

for

partners

To

investigate

how

parents

QoL

related

to

the

children

's

functioning

parents

were

asked

to

complete

the

Child

Behavior

Checklist

-LRB-

CBCL

-RRB-

-LSB-

-RSB-

Adolescents

also

completed

the

Youth

Self-Report

-LRB-

YSR

-RRB-

-LSB-

-RSB-

In

this

study

the

internalizing

-LRB-

emotional

functioning

-RRB-

externalizing

-LRB-

behavioral

functioning

-RRB-

and

total

problem

-LRB-

total

of

internalizing

externalizing

and

cognitive

problems

-RRB-

scales

were

used

to

provide

a

picture

of

the

problems

occurring

in

the

children

of

parents

diagnosed

with

cancer

The

CBCL

's

and

YSR

's

reliability

and

validity

have

been

supported

in

a

great

number

of

studies

In

this

study

Cronbach

's

alphas

for

the

internalizing

externalizing

and

total

problem

scales

ranged

from

to

for

reports

from

patients

spouses

and

adolescent

children

Analysis

In

our

analyses

a

single

variable

was

created

to

define

treatment

intensity

Patients

were

grouped

into

two

categories

based

on

the

clinical

expectation

that

surgical

treatment

alone

-LRB-

nonintense

treatment

-RRB-

would

be

less

distressing

to

the

family

because

of

less

time

away

from

home

and

fewer

visible

side

effects

Other

single-modal

-LRB-

chemo

radiotherapy

-RRB-

and

multimodal

treatments

-LRB-

combination

of

surgery

chemotherapy

radiotherapy

hormone

or

immunotherapy

-RRB-

were

defined

as

intense

Time

since

diagnosis

was

calculated

by

subtracting

the

date

on

which

the

patient

filled

in

the

questionnaires

from

the

date

they

were

diagnosed

Descriptive

analyses

were

performed

on

demographic

information

Comparisons

between

patients

spouses

and

the

reference

group

were

investigated

using

independent

t

tests

Results

were

corrected

for

the

number

of

tests

performed

with

a

Bonferroni

correction

for

multiple

comparisons

p

values

less

than

or

equal

to

were

considered

significant

-LRB-

of

tests

-RRB-

To

assess

clinical

relevance

effect

sizes

-LRB-

ESs

-RRB-

were

calculated

by

dividing

the

difference

between

means

by

the

square

root

of

the

average

of

the

squared

standard

deviations

-LSB-

-RSB-

ESs

between

and

were

considered

small

and

medium

and

large

-LSB-

-RSB-

We

considered

that

ESs

greater

than

or

equal

to

indicated

a

clinically

relevant

difference

-LSB-

-RSB-

A

single

variable

was

created

to

describe

parents

gender

and

health

status

-LRB-

ill

mothers

ill

fathers

healthy

mothers

and

healthy

fathers

-RRB-

One-way

analyses

of

variance

-LRB-

ANOVAs

-RRB-

with

a

Bonferroni

post-hoc

test

were

used

to

compare

QoL

of

patient

and

spouse

as

a

function

of

gender

and

health

status

After

the

correction

for

multiple

tests

was

applied

p

values

less

than

or

equal

to

were

considered

significant

-LRB-

p

of

ten

tests

-RRB-

In

analyses

of

QoL

as

a

function

of

type

of

cancer

only

groups

of

ten

or

more

patients

were

included

An

ANOVA

and

a

Kruskal

Wallis

test

-LRB-

some

patient

groups

were

small

-RRB-

were

performed

to

compare

patients

and

spouses

QoL

as

a

function

of

type

of

cancer

After

the

correction

for

multiple

tests

was

applied

p

values

less

than

or

equal

to

were

considered

significant

-LRB-

p

of

ten

tests

-RRB-

The

two

QoL

composite

scores

-LRB-

physical

summary

score

and

psychosocial

summary

score

-RRB-

were

used

in

correlational

analyses

to

explore

relationships

between

parents

QoL

and

between

each

parent

's

QoL

and

the

children

's

problems

with

separate

analyses

for

elementary

school-aged

-LRB-

years

-RRB-

and

adolescent

-LRB-

years

-RRB-

children

Pearson

's

product-moment

correlation

coefficients

were

calculated

correlations

with

a

coefficient

less

than

were

considered

weak

moderately

strong

and

greater

than

strong

-LSB-

-RSB-

Results

Participants

A

total

of

families

were

approached

for

the

study

Two

hundred

and

nine

agreed

to

participate

-LRB-

-RRB-

including

children

with

an

average

of

children

per

family

Because

this

study

focused

on

couples

we

selected

data

from

families

where

both

patient

and

spouse

filled

in

questionnaires

resulting

in

a

database

of

couples

and

children

Table

summarizes

the

demographic

information

The

majority

of

cancer

patients

in

this

study

were

women

-LRB-

-RRB-

Patients

were

diagnosed

with

various

types

of

cancer

-LRB-

Table

-RRB-

including

breast

-LRB-

-RRB-

gynecological

-LRB-

-RRB-

hematological

-LRB-

-RRB-

skin

-LRB-

-RRB-

urological

-LRB-

-RRB-

soft

tissue

and

bone

tumors

-LRB-

-RRB-

head/neck

-LRB-

-RRB-

gastrointestinal

-LRB-

-RRB-

and

central

nervous

system

-LRB-

-RRB-

Fourteen

percent

of

patients

had

undergone

nonintense

treatment

-LRB-

N

-RRB-

and

had

undergone

intense

treatment

-LRB-

N

-RRB-

Table

PatientSpouseChildrenMean

age

in

years

-LRB-

SD

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

N

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

Gender

N

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

Mean

length

of

relationship

in

years

-LRB-

SD

-RRB-

range

-LRB-

-RRB-

Mean

education

level

-LRB-

SD

-RRB-

range

-LRB-

-RRB-

-LRB-

-RRB-

Mean

number

of

children

per

couple

range

Primary

caregiver

in

family

N

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

Both

-LRB-

-RRB-

-LRB-

-RRB-

Mean

time

since

diagnosis

in

years

-LRB-

SD

-RRB-

-LRB-

-RRB-

Treatment

intensity

nonintense

N

-LRB-

-RRB-

-LRB-

-RRB-

Treatment

intensity

intense

N

-LRB-

-RRB-

-LRB-

-RRB-

Recurrence

of

cancer

N

-LRB-

-RRB-

-LRB-

-RRB-

There

were

no

significant

differences

between

participating

and

nonparticipating

parents

regarding

patient

's

gender

type

of

cancer

or

time

since

diagnosis

Of

the

nonparticipants

-LRB-

N

-RRB-

declined

because

of

reasons

directly

related

to

the

parents

-LRB-

e.g.

parents

had

moved

on

with

their

lives

or

were

too

emotionally

distressed

-RRB-

Reasons

related

to

the

children

-LRB-

e.g.

children

were

not

interested

children

had

not

been

informed

of

parent

's

illness

-RRB-

were

given

as

the

explanation

for

not

wanting

to

be

included

in

-LRB-

N

-RRB-

of

nonparticipating

families

Twenty-five

percent

-LRB-

N

-RRB-

mentioned

a

variety

of

reasons

including

another

illness

in

the

family

or

the

parents

or

children

's

busy-ness

The

remaining

-LRB-

N

-RRB-

did

not

provide

an

explanation

Patients

and

spouses

QoL

in

comparison

with

the

norm

Results

are

summarized

in

Table

Clinically

relevant

ESs

were

found

for

male

patients

social

functioning

role

limitations

because

of

physical

problems

and

vitality

Both

male

and

female

patients

scored

statistically

significantly

lower

QoL

than

the

norm

on

one

subscale

vitality

Female

patients

additionally

scored

lower

on

two

subscales

social

functioning

and

role

limitations

because

of

physical

problems

Table

of

the

scores

by

parents

gender

and

health

status

and

comparison

between

groups

and

with

the

norm

group

GenderPatientPartnerHealth

status

and

genderNormMeanSDt

-LRB-

v.

norm

-RRB-

Effect

sizeMeanSDt

-LRB-

v.

norm

-RRB-

Effect

sizeANOVA

FMeanSDPhysical

Social

Role

limitations

Role

limitations

Mental

General

Physical

Not

Not

availablePsychosocial

Not

Not

availablep

values

were

corrected

for

multiple

comparisons.Significant

values

are

shown

in

italics

p

for

comparisons

with

the

norm

p

for

comparisons

of

health

status

and

gender

Clinically

relevant

ESs

were

found

for

female

spouses

physical

functioning

and

social

functioning

Female

spouses

reported

statistically

significantly

higher

scores

than

the

norm

on

physical

functioning

They

also

scored

statistically

significantly

lower

on

social

functioning

than

the

norm

Effects

of

health

status

and

gender

time

since

diagnosis

recurrence

treatment

intensity

and

type

of

cancer

on

QoL

Parents

health

status

and

gender

had

a

statistically

significant

effect

on

parents

physical

summary

score

A

statistically

significant

effect

was

also

found

on

parents

physical

functioning

role

limitations

because

of

physical

problems

vitality

and

general

health

perception

-LRB-

Table

-RRB-

A

Bonferroni

post-hoc

test

revealed

the

following

On

the

physical

summary

score

female

patients

scored

lower

than

male

spouses

-LRB-

p

-RRB-

and

male

patients

scored

lower

than

female

and

male

spouses

-LRB-

p

for

both

-RRB-

On

physical

functioning

female

patients

scored

lower

than

female

and

male

spouses

-LRB-

p

for

both

-RRB-

On

role

limitations

because

of

physical

problems

female

and

male

patients

scored

significantly

lower

than

male

spouses

-LRB-

p

and

p

respectively

-RRB-

On

vitality

female

patients

scored

significantly

lower

than

male

spouses

-LRB-

p

-RRB-

Finally

on

general

health

perception

female

patients

scored

significantly

lower

than

male

spouses

-LRB-

p

-RRB-

and

male

patients

scored

significantly

lower

than

female

and

male

spouses

-LRB-

p

p

respectively

-RRB-

Time

since

diagnosis

did

not

correlate

significantly

with

patients

QoL

Time

since

diagnosis

correlated

weakly

with

spouses

physical

summary

score

-LRB-

r

p

-RRB-

Patients

with

a

recurrence

scored

clinically

relevantly

lower

than

patients

without

recurrence

on

the

physical

summary

score

-LRB-

t

ES

p

-RRB-

social

functioning

-LRB-

t

ES

p

-RRB-

role

limitations

because

of

physical

problems

-LRB-

t

ES

p

-RRB-

and

general

health

perception

-LRB-

t

ES

p

-RRB-

Spouses

of

patients

with

a

recurrence

scored

clinically

relevantly

lower

than

spouses

of

patients

without

a

recurrence

on

the

psychosocial

summary

score

-LRB-

t

ES

p

-RRB-

and

the

subscales

role

limitations

because

of

emotional

problems

-LRB-

t

ES

p

-RRB-

vitality

-LRB-

t

ES

p

-RRB-

and

general

health

perception

-LRB-

t

ES

p

-RRB-

Treatment

intensity

was

significantly

related

to

patients

QoL

Patients

who

received

intense

treatment

scored

clinically

relevantly

lower

than

patients

who

received

nonintense

treatment

on

the

physical

summary

score

-LRB-

t

ES

p

-RRB-

and

the

following

six

subscales

physical

functioning

-LRB-

t

ES

p

-RRB-

social

functioning

-LRB-

t

ES

p

-RRB-

role

limitations

because

of

physical

problems

-LRB-

t

ES

p

-RRB-

vitality

-LRB-

t

ES

p

-RRB-

pain

-LRB-

t

ES

p

-RRB-

and

general

health

perception

-LRB-

t

ES

p

-RRB-

Treatment

intensity

was

not

significantly

related

to

spouses

QoL

Type

of

cancer

had

a

statistically

significant

effect

on

patients

QoL

as

summarized

in

Table

Statistically

significant

differences

between

patient

groups

were

found

on

the

physical

summary

scale

and

five

subscales

Patients

with

skin

cancer

reported

the

highest

QoL

One

third

of

skin

cancer

patients

received

intense

treatment

Patient

with

hematological

cancer

reported

the

lowest

QoL

levels

All

hematological

cancer

patients

received

intense

treatment

A

Kruskall

Wallis

test

confirmed

these

findings

With

regard

to

the

spouses

QoL

did

not

vary

as

a

function

of

the

patient

's

type

of

cancer

Table

of

the

patients

RAND

scores

by

type

of

cancer

and

comparisons

between

groups

Gynecological

tumorsBreast

cancerUrological

tumorSoft

tissue/boneHematologicalDermatologicalANOVAN

.117.178.520.481.014.759.515.757.832.188.315.85.21

Social

.317.279.223.372.522.770.025.854.735.996.79.95.34

Role

limitations

.043.868.339.962.511.532.533.431.243.386.728.14.61

Role

limitations

.725.879.534.796.710.576.741.760.442.5100.000.03.16

Mental

.015.073.616.577.616.469.525.974.517.776.013.80.29

.617.658.920.758.524.352.016.943.428.777.318.84.18

.917.681.721.975.919.160.620.973.629.292.813.93.44

Gen.

health

.816.064.923.161.021.654.517.947.228.285.79.85.79

Physical

.117.1178.520.481.014.759.515.757.832.188.315.86.48

Psychosocial

summary77.317.279.223.372.522.770.025.854.735.996.79.92.95p-values

were

corrected

for

multiple

comparisons

Significant

values

are

shown

in

italics

p

Functionality

of

patient

in

relation

to

functionality

of

spouse

Spouses

psychosocial

functioning

was

moderately

strongly

related

to

patients

psychosocial

functioning

-LRB-

r

p

-RRB-

and

weakly

related

to

patients

physical

functioning

-LRB-

r

p

-RRB-

No

significant

relationship

was

found

between

the

spouse

's

physical

functioning

and

the

patient

's

psychosocial

-LRB-

r

-RRB-

or

physical

functioning

-LRB-

r

-RRB-

Relationship

between

patient

and

spouse

's

functioning

and

emotional

and

behavioral

functioning

of

the

children

Patients

physical

functioning

was

not

significantly

related

to

their

elementary

school-aged

children

's

functioning

but

was

weakly

related

to

the

adolescents

total

problems

and

internalizing

as

reported

by

the

patients

-LRB-

Table

-RRB-

Patients

psychosocial

functioning

was

moderately

strongly

to

weakly

related

to

their

elementary

school-aged

children

's

internalizing

externalizing

and

total

problems

and

weakly

related

to

the

adolescents

internalizing

externalizing

and

total

problems

as

reported

by

the

patient

The

patients

physical

and

psychosocial

functioning

was

moderately

strongly

to

weakly

related

to

the

adolescents

internalizing

and

total

problems

according

to

adolescents

self-reports

their

physical

functioning

was

weakly

related

to

adolescents

externalizing

Table

between

parents

QoL

as

measured

by

composite

scores

and

children

's

functioning

by

age

group

as

reported

by

parents

-LRB-

CBCL

-RRB-

and

adolescents

themselves

-LRB-

YSR

-RRB-

Patient

-LRB-

N

-RRB-

Spouse

-LRB-

N

-RRB-

Physical

functioningPsychosocial

functioningPhysical

functioningPsychosocial

functioningElementary

school-aged

children

-LRB-

CBCL

-RRB-

Total

Internalization

Externalization

Adolescents

-LRB-

CBCL

-RRB-

Total

Internalization

Externalization

Adolescents

-LRB-

YSR

-RRB-

Total

Internalization

Externalization

p

p

Spouses

psychosocial

and

physical

functioning

was

not

found

to

be

significantly

related

to

their

elementary

school-aged

children

's

functioning

as

reported

by

the

spouses

Additionally

their

physical

functioning

was

not

significantly

related

to

the

adolescents

functioning

Spouses

psychosocial

functioning

was

weakly

related

to

the

adolescents

internalization

and

total

problems

as

reported

by

the

spouses

Finally

the

spouses

psychosocial

functioning

was

weakly

related

to

the

adolescents

internalizing

as

reported

by

the

adolescents

-LRB-

Table

-RRB-

Discussion

The

aim

of

this

study

was

to

gain

insight

into

the

QoL

of

cancer

patients

in

the

child-rearing

stage

and

their

spouses

We

found

that

cancer

patients

years

after

diagnosis

evaluate

their

QoL

as

clinically

relevantly

and/or

statistically

significantly

lower

than

the

normal

population

on

three

of

the

eight

domains

partially

supporting

our

first

hypothesis

This

is

in

line

with

studies

that

have

reported

a

decrease

in

patients

social

and

physical

domains

-LSB-

-RSB-

However

our

study

did

not

find

a

decrease

in

patient

's

emotional

functioning

in

contrast

to

some

reports

-LSB-

-RSB-

Our

study

focused

on

a

subgroup

of

cancer

patients

namely

those

who

are

relatively

young

The

finding

that

our

patient

group

scored

similarly

to

the

norm

seems

to

indicate

that

these

patients

lives

have

gotten

fairly

back

to

normal

These

parents

seem

to

be

handling

the

unexpectedness

of

a

cancer

diagnosis

during

this

life

phase

the

treatment

or

the

confrontation

with

a

possible

death

at

an

early

age

coupled

with

the

responsibility

of

raising

children

fairly

well

However

they

still

seem

to

experience

problems

in

some

areas

specifically

social

functioning

role

limitations

because

of

physical

problems

and

vitality

Spouses

of

cancer

patients

reported

a

QoL

comparable

to

the

norm

group

and

female

spouses

reported

even

better

physical

functioning

than

the

norm

Only

on

one

subscale

-LRB-

social

functioning

-RRB-

did

spouses

-LRB-

and

then

only

women

-RRB-

report

decreased

functioning

Our

findings

largely

negate

our

hypothesis

and

are

in

contrast

with

other

studies

where

spouses

have

reported

a

decreased

QoL

-LSB-

-RSB-

An

explanation

for

our

findings

may

be

that

spouses

in

other

studies

where

the

average

age

is

higher

may

have

had

a

lower

QoL

simply

because

of

their

older

age

As

age

increases

QoL

scores

decrease

-LSB-

-RSB-

A

second

explanation

could

be

that

spouses

viewed

their

QoL

relative

to

their

ill

partner

and

therefore

regarded

their

own

health

as

good

as

or

better

than

people

generally

may

It

is

also

possible

that

we

did

not

find

a

decreased

QoL

in

the

spouses

because

our

patient

group

ranged

from

to

years

after

diagnosis

time

since

diagnosis

correlated

significantly

positively

with

spouses

physical

functioning

The

threat

that

the

patient

might

not

survive

may

be

less

prominent

for

spouses

at

this

point

in

time

Our

study

found

significant

effects

of

gender

and

health

status

on

the

physical

summary

score

and

four

of

the

eight

subscales

To

summarize

our

findings

patients

scored

lower

than

spouses

male

spouses

reported

the

highest

QoL

and

on

some

scales

the

female

patient

reported

the

lowest

QoL

and

on

others

the

male

patient

In

a

study

on

gastrointestinal

cancer

female

patients

and

female

spouses

were

both

reported

to

suffer

overall

more

distress

than

male

patients

-LSB-

-RSB-

which

our

study

did

not

find

They

also

reported

that

female

spouses

reported

lower

QoL

than

male

patients

and

spouses

However

that

study

examined

patients

within

months

after

surgery

They

also

focused

specifically

on

patients

with

gastrointestinal

cancer

which

is

equally

prevalent

in

men

and

women

That

allowed

them

to

more

easily

generalize

that

the

differences

they

found

were

due

to

gender

As

our

study

sample

was

diagnostically

heterogeneous

it

is

difficult

to

differentiate

whether

the

observed

differences

were

due

to

gender

or

cancer

site

and

consequent

treatment

received

Our

study

sample

consisted

of

women

which

could

seem

skewed

However

according

to

the

Dutch

Comprehensive

Cancer

Center

's

database

cancer

occurs

more

frequently

in

women

during

this

age

range

approximately

of

cancer

patients

in

this

region

of

The

Netherlands

with

invasive

tumors

are

women

-LSB-

-RSB-

To

further

explore

our

second

aim

we

analyzed

QoL

as

a

function

of

type

of

cancer

and

found

differences

depending

on

the

type

of

tumor

the

patient

had

supporting

our

hypothesis

Skin

cancer

patients

in

our

study

reported

the

highest

QoL

while

patients

with

hematological

cancer

reported

the

lowest

QoL

These

differences

may

be

related

to

the

kind

of

treatment

the

patient

received

We

found

that

patients

who

received

nonintense

treatment

reported

a

better

QoL

than

those

who

received

intense

treatment

The

removal

of

a

localized

melanoma

that

only

requires

outpatient

excision

may

affect

QoL

less

than

frequent

and

long

hospital

stays

for

courses

of

chemotherapy

for

hematological

malignancies

Our

findings

are

similar

to

another

study

reporting

patient

distress

levels

-LSB-

-RSB-

that

found

that

distress

levels

varied

depending

on

cancer

site

With

regard

to

how

spouses

function

no

significant

QoL

differences

were

found

because

of

the

type

of

cancer

or

treatment

intensity

It

would

seem

that

tumor

type

or

treatment

intensity

do

not

affect

spouses

functioning

Whether

the

patient

had

a

recurrence

does

seem

to

affect

spouses

QoL

the

ES

of

the

psychosocial

summary

score

was

strikingly

large

This

may

be

due

to

for

those

spouses

the

still

current

threat

that

the

patient

may

not

survive

It

is

interesting

to

note

that

recurrence

seems

to

have

affected

patients

physical

and

social

functioning

but

not

their

mental

functioning

Patients

with

recurrence

do

not

report

more

mental

distress

than

patients

who

have

not

had

a

recurrence

Thirdly

we

investigated

relationships

between

patient

and

spouse

QoL

and

found

weak

to

moderate

positive

relationships

between

cancer

patient

's

physical

and

psychosocial

functioning

and

spouse

's

psychosocial

functioning

These

findings

are

in

line

with

two

studies

reporting

a

moderate

positive

relationship

between

patients

and

spouses

psychological

distress

-LSB-

-RSB-

Finally

the

hypothesis

that

we

would

find

a

significant

relationship

between

the

parents

and

the

children

's

functioning

was

supported

although

the

relationships

were

not

strong

The

patient

's

QoL

related

more

often

significantly

with

the

children

's

functioning

than

the

spouse

's

Given

that

four

of

five

of

the

patients

were

women

it

could

be

that

mothers

were

more

often

alert

to

possible

problems

in

the

children

than

fathers

This

may

be

due

to

the

large

number

of

families

in

our

sample

where

the

mother

sick

or

healthy

is

the

primary

caregiver

Mothers

tend

to

orient

themselves

more

toward

others

whereas

fathers

tend

be

more

self-oriented

-LSB-

-RSB-

this

could

enable

mothers

to

judge

problems

better

It

is

possible

that

illness

plays

a

role

in

the

patients

reports

as

distressed

parents

are

likely

to

rate

more

behavioral

and

emotional

problems

in

their

children

-LSB-

-RSB-

However

we

found

significant

relationships

between

the

adolescents

self-reports

and

parents

functioning

Unfortunately

the

cross-sectional

design

of

this

study

limits

us

in

understanding

the

causal

nature

of

this

finding

We

found

more

significant

negative

correlations

with

the

children

's

internalizing

and

total

problem

scores

than

externalizing

It

would

seem

that

parents

QoL

negatively

relates

to

the

children

's

emotional

functioning

more

than

to

their

acting

up

It

is

interesting

to

note

that

the

parents

functioning

related

differently

to

adolescents

and

school-aged

children

The

patient

's

physical

functioning

correlated

weakly

with

the

adolescents

functioning

but

not

significantly

with

the

younger

children

's

functioning

This

was

not

found

for

spouses

their

physical

functioning

did

not

relate

significantly

to

how

children

from

either

age

group

function

Patient

's

psychosocial

functioning

correlated

weakly

to

moderately

strongly

with

children

in

both

age

groups

while

spouses

psychosocial

functioning

correlated

weakly

with

the

adolescents

functioning

Adolescent

self-reports

provided

a

similar

picture

we

found

weak

to

moderately

strong

correlations

between

patients

physical

and

psychosocial

functioning

but

only

one

weak

correlation

between

spouses

psychosocial

functioning

and

adolescents

internalization

Our

finding

that

parents

functioning

related

more

often

significantly

with

the

adolescents

may

be

due

to

adolescents

stage

of

cognitive

development

Adolescents

are

more

able

to

understand

the

patient

's

illness

and

may

pick

up

on

physical

problems

more

than

elementary

school-aged

children

-LSB-

-RSB-

Research

considerations

In

our

investigation

being

the

first

to

evaluate

family

functioning

in

families

in

the

child-rearing

age

we

purposely

did

not

choose

a

homogenous

cancer

group

-LRB-

i.e.

only

breast

cancer

-RRB-

Our

results

are

statements

for

the

general

group

of

child-rearing

families

with

cancer

Comparisons

between

patients

in

our

research

group

with

varying

diagnoses

showed

differences

between

groups

however

the

small

subgroups

make

it

difficult

to

generalize

our

findings

Future

research

will

be

required

to

investigate

the

effect

of

varying

forms

of

cancer

the

stage

of

cancer

its

prognosis

and

treatment

on

the

functioning

of

individual

family

members

Additionally

our

response

rate

of

could

mean

that

despite

the

fact

that

no

differences

were

found

between

participants

and

nonparticipants

in

gender

type

of

cancer

or

time

since

diagnosis

a

sample

bias

may

exist

We

can

not

be

sure

whether

psychological

problems

were

over

or

under-reported

some

nonrespondents

stated

still

being

overwhelmed

by

the

illness

as

a

reason

for

not

participating

while

others

indicated

they

had

moved

on

Additionally

the

cross-sectional

nature

of

this

study

makes

it

impossible

to

accurately

capture

the

dynamic

processes

present

in

family

relationships

or

determine

whether

parents

QoL

effects

the

children

's

functioning

or

vice

versa

Furthermore

a

longitudinal

study

could

provide

insight

into

the

QoL

of

cancer

patients

and

their

family

members

over

a

period

of

time

This

study

found

significant

relationships

between

patient

and

spouse

functioning

and

between

parent

's

functioning

and

children

's

behavior

However

these

relationships

appeared

to

have

modest

predictive

power

The

patients

and

spouses

functioning

is

likely

more

influenced

by

other

factors

not

measured

in

this

study

such

as

personality

social

support

or

family

environment

-LSB-

-RSB-

In

conclusion

cancer

patients

QoL

years

after

diagnosis

seems

to

be

returning

to

normal

except

in

three

domains

Their

spouses

seem

to

be

doing

well

The

patients

QoL

varied

according

to

the

type

of

cancer

how

intense

their

treatment

had

been

and

whether

they

had

experienced

a

recurrence

Spouses

QoL

seemed

to

be

unaffected

by

the

type

of

cancer

and

treatment

intensity

but

did

vary

depending

on

whether

the

patient

experienced

a

recurrence

A

moderate

positive

relationship

was

found

between

the

patient

's

functioning

and

his/her

spouse

's

Parents

physical

and

psychosocial

functioning

was

weakly

to

moderately

strongly

related

to

their

children

's

functioning

The

patients

functioning

related

more

strongly

to

the

children

's

functioning

than

the

spouses

did

How

cancer

patients

families

function

may

have

an

impact

on

the

patient

's

functioning

up

to

years

after

diagnosis

This

is

something

that

should

be

taken

into

account

by

clinicians

B I I O O O B O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O B O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O B O B I I O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O B O O O O O O O O O O O O O O O O O B O B O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O B O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O B O O O O O O O O O O O O O O O O O O B O B O O O O O O O O O B O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O B O O O O O B O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O B O O O O O O O O O O B O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O B O O O O O O O O B O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O B O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O B O O O O O O B O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O B O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O B O O O O B O O O O O O O O O O O O O O O O B O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O

quality of life
parental cancer
patient
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children