Symptom Burden in Older Breast Cancer Survivors May Be Associated with Lower Well-being

January 6, 2020

Breast cancer survivors who underwent chemotherapy or hormone therapy were found to be more likely to have a higher symptom burden and lower overall sense of well-being than noncancer counterparts.

Cancer and its treatments lead to a higher level of symptom burden and a greater loss of well-being in older breast cancer survivors than in comparable noncancer populations, according to a study published in Cancer.

The study enrolled 362 survivors aged  ≤60 years with newly diagnosed nonmetastatic breast cancer, along with 365 noncancer controls, and conducted both symptom burden and well-being assessments at 12-, 24-, and 36-month intervals. Adjusted symptom burden was found to be highest for survivors who received chemotherapy, either with or without hormone treatment (β = 0.77 ± 0.15, P < .001). Survivors on hormone therapy alone also had a significantly greater symptom burden than the noncancer control group (β = 0.48 ± 0.11, P < .001).

“It has been more than a decade since the Institute of Medicine highlighted the unmet needs of cancer survivors, but 50% of survivors still report not getting help to address symptoms,” noted the authors. “These data, together with our findings suggest that survivorship care should emphasize screening for and discussion of symptoms, including sleep difficulties, depression, anxiety, pain, and fatigue, especially because these symptoms are actionable.”

Study participants were aged between 60 and 98 years, with a high rate of all symptoms recorded at baseline. Methods of data collection included both survey (for all participants) and medical record data (for the survivor group). Well-being was measured using the Functional Assessment of Cancer Therapy (FACT)-General scale, with scores ranging from 0-100. Symptom burden was measured as a sum of the following symptoms/diseases: pain, fatigue, cognitive function, sleep problems, depression, anxiety, and cardiac problems, and neuropathy. Results were measured for both within-person (compared to one’s own average) and between-person (compared to the average of other participants) predictors.

Depression (within person, Î² = -10.6 ± 1.29, P < .001), pain (within person, Î² = -7.76 ± 0.69, P < .001), and sleep disturbance (within person, Î² = -4.05 ± 0.75, P < .001) had the largest effects on physical well-being, with each of the other symptoms all being significantly related to physical well-being.

“Addressing symptom burden is especially salient for older survivors because our results demonstrate that symptom burden was associated with clinically meaningful decrements in well-being,” wrote the authors, adding that they hoped the findings could eventually inform long-term care addressing the persistent effects of cancer treatment.

One acknowledged limitation to the study was that the cohort was well educated and perhaps not representative of all older breast cancer survivors, but the researchers noted that “given the strong association of socioeconomic status and health, our rates of symptoms and their effects on function may underestimate those in broader populations.”

The authors found that higher levels of physical activity reduced symptoms and symptom burden while leading to an overall improved well-being. These findings fall in line with previous studies indicating that exercise, reduced sedentary time and weight loss impacted the well-being of survivors.

Overall, the authors believed that results of the study moved the field forward, while calling for more research to understand specific factors that may contribute to an elevated symptom burden and functional decline, adding that “Until then, survivorship guidelines should include clear recommendations for surveillance and treatment of symptoms among older survivors.”


Mandelblatt JS, Zhai W, Ahn J, et al. Symptom Burden Among Older Breast Cancer Survivors: The Thinking and Living with Cancer (TLC) Study. Cancer. 2019 Dec 20. doi: 10.1002/cncr.32663