Quality of Life, Anxiety, and Oncological Factors:

A Follow-Up Study of Breast Cancer Patients

Kristin Härtl, Ph.D., Rebecca Schennach, M.D.

Marianne Müller, Ph.D., Jutta Engel, M.D., M.P.H.
Hans Reinecker, Ph.D., Harald Sommer, M.D., Ph.D.
Klaus Friese, M.D.

Background: The number of long-term survivors of breast cancer has increased over recent
decades because of many treatment advances. Thus, long-term quality of life (QoL) and factors
affecting it are of growing research interest. Objective: The authors investigated longitudinal
changes in QoL and anxiety in breast cancer patients and differences in QoL and anxiety in var-
ious oncological subgroups. Method: A group of 236 women with a primary diagnosis of breast
cancer or carcinoma in-situ completed questionnaires after surgical treatment, 6 months, and 12
months post-surgery. Results: QoL scores of breast cancer patients improved over time, but im-
pairments in terms of anxiety, body image, and sexual functioning were still observed. Younger
patients were more likely to be distressed by cancer diagnosis and treatment. Discussion: Surgi-
cal modality and tumor prognostic factors, however, seemed to play a minor role in patients’
subjective QoL, which is discussed in terms of the “well-being paradox.”
(Psychosomatics 2010; 51:112–123)

O ver the last decades, the number of long-term survi-

vors of breast cancer has increased because of ad-
vances in early diagnosis, as well as surgical and adjuvant
treatments.1 Thus, long-term quality of life (QoL) and
factors affecting QoL are of growing research interest. The
QoL construct refers to a general sense of well-being in
multiple dimensions of life. However, because of the va-
riety of divergent definitions and measures of the con-
Received August 9, 2007; revised January 29, 2008; accepted January 30,
2008. From the Dept. of Gynecology and Obstetrics, Women’s Clinic at
Ludwig–Maximilians University, Munich, Germany; the Munich Cancer
Registry (MCR) of the Munich Cancer Centre at the Institut of Medical
Informatics, Biometry, and Epidemiology, Ludwig-Maximilians–Univer-
sity, Munich; and the Faculty of Psychology, Section for Clinical Psy-
chology and Psychotherapy, Otto-Friedrich University, Bamberg, Ger-
many. Send correspondence and reprint requests to Kristin Härtl, Ph.D.,
Dept. of Gynecology and Obstetrics, Klinikum der Ludwig-Maximilians-
Universitaet Muenchen. Maistr. 11, 80337 Munich, Germany. e-mail:
kristin.haertl@med.uni-muenchen.de
© 2010 The Academy of Psychosomatic Medicine
struct, results of QoL research in cancer patients are varied
and often contradictory.2,3 Longitudinal studies about
changes of QoL and persistent impairments in breast cancer
patients show conflicting results.2,4,5 Furthermore, there are
few data about long-term anxiety in women with breast can-
cer. Clinical practice reveals that long-term survivors are
mostly distressed by anxiety, especially by fear of recurrence.
Research in the past decade mainly focused on pos-
sible demographic and clinical factors affecting QoL in
breast cancer patients. Investigation of QoL in oncological
subgroups is important for drawing conclusions about op-
eration or therapy modalities. Most studies investigated
single parameters, such as primary surgical treatment mo-
dality6 or age,7 whereas other factors, such as tumor stage,
were often neglected. There is a lack of studies investi-
gating the impact of several oncological factors on long-
term QoL within the same clinical trial.8 Also, the impact
of these factors on QoL is controversial.

112 http://psy.psychiatryonline.org Psychosomatics 51:2, March-April 2010


In the present study, we first examined changes of
QoL and anxiety in breast cancer patients at follow-up
and, also, differences of QoL and anxiety in oncological
subgroups.
METHOD
Procedures and Time-Points of Assessment
The study design was approved by the local ethics
board. Patients were recruited between May 2004 and
October 2005. At the time of primary surgical treatment,
patients with breast cancer were asked to complete the
QoL questionnaire 5 times over a 2-year period. The first
assessment took place within 2 weeks after primary sur-
gical treatment and before adjuvant therapy. Over 2 years,
questionnaires were sent at regular intervals of 6 months to
women who had agreed to participate in the study. In this
article, the results of three points of assessment are pre-
sented: T1: patients after primary surgical treatment; T2: 6
months post-operative; and T3: 12 months postoperative.
Subjects
The following patients were included in this study:
women with primary diagnosis of breast cancer, TNM
Stage pT1– 4, pN0 –3, pM0, or carcinoma in-situ, with the
ability to read German and understand the questionnaires.
Patients with neoadjuvant therapy who received cytotoxic
medication after histological diagnosis of breast cancer,
but before primary surgery, were excluded. Also, patients
with a diagnosis of psychosis or severe personality disor-
der were excluded. Participants were approached by med-
ical doctors, who informed them about study aim and
design and asked for written informed consent. Nonpar-
ticipation was mostly because inclusion criteria were not
fulfilled, mostly because of benign breast biopsy or re-
duced ability to read German. Fewer than 1% refused to
participate in the study; “refusers” most frequently told us
that the questionnaires were too long or time-consuming,
or that they were handicapped by other diseases.
A total of 278 women with breast cancer were admin-
istered the quality-of-life questionnaires at the Frauenklinik-
Innenstadt, Ludwig-Maximilians University Munich, Ger-
many, and the Frauenklinik Dachau/Brustzentrum Dachau.
During the first year of follow-up, 2 patients died, and 40
patients dropped out of the study, which represents an overall
dropout rate of 15.1%. A final total of 236 subjects completed
Psychosomatics 51:2, March-April 2010
Härtl et al.
the questionnaires at all three points of measurement: T1, T2,
and T3.
Measures
Quality of life was evaluated by the Quality of Life
Questionnaire QLQ–C30, Version 3.0 of the EORTC
Study Group on Quality of Life.9,10 The questionnaire is
composed of the Global Health status/QoL Scale and five
functional scales that evaluate physical functioning, role
functioning, emotional functioning, cognitive functioning,
and social functioning. Higher mean scores on these scales
represent better functioning and QoL. The additional mod-
ule QLQ–BR23 contains breast-cancer–specific scales.
Here, the three subscales: body image, arm symptoms, and
breast symptoms, were used. We added two questions
about confidence with the cosmetic result of the surgical
treatment and sexual functioning. Higher mean values on
the arm- and breast-symptom scales indicate an increased
extent of symptoms. Higher mean scores on the Body
Image scale of the QLQ–BR23 and the additional scales
for Cosmetic Confidence and Sexual Functioning repre-
sent better functioning.
Anxiety was measured by the Hospital Anxiety and
Depression Scale (HADS) and one subscale of the Ques-
tionnaire on Stress in Cancer Patients, Revised Version
(QSC–R23). The HADS11 or the German version HADS–
D12 is a brief assessment tool consisting of distinct dimen-
sions of anxiety and depression in nonpsychiatric popula-
tions. The 14-item questionnaire consists of two subscales
measuring both levels of anxiety and depression. The
QSC–R2313 was developed to determine psychosocial
stress in cancer patients. This tool provides respondents
with a broad spectrum of cancer-specific stress situations,
which have to be rated in terms of relevance and amount
of distress. The 23 items are aggregated to make up 5
subscales (Fears, Psychosomatic Complaints, Everyday
Life Restrictions, Information Deficits, and Social Con-
straints) and a total score of Psychosocial Distress. Higher
mean scores on the subscale Anxiety and the subscale
Fears represent more anxiety.
Data Analysis
Linear transformation was used to standardize the raw
scores of the QoL parameters so that all scores ranged
from 0 to 100. In accordance with the scoring manual, the
questionnaire items of the QLQ–C30 and the QLQ–BR23
were grouped into scales in the categories Global Health
http://psy.psychiatryonline.org 113
Quality of Life With Breast Cancer

Status QoL, Functional Scales, and Symptom Scales. The

TABLE 1. Demographic and Clinical Characteristics of
additional items Cosmetic Confidence and Sexual Func- Patients at Time of Primary Diagnosis
tioning were calculated according to the scoring manual of Characteristic N (%)
the QLQ–C30. The subscale Anxiety was calculated by
Total patient N 236 (100)
summing the seven item scores of the HADS–D. The Age, years
subscale Fears was computed as the mean of the four item ⬍50 51 (21.8)
scores of the QSC–R23. We investigated the following 50–69 154 (65.8)
ⱖ70 29 (12.4)
oncological factors: tumor size according the TNM stage Demographics
at the time of primary diagnosis (pT1a, pT1b, pT1c versus Married 147 (62.6)
pT2, pT3, pT4) and primary surgical treatment modality Children 172 (73.2)
⬎9 years education 124 (53.7)
(breast-conserving therapy versus mastectomy). The de- Employed 117 (50.4)
mographic factor was the patient’s age at time of primary Primary cancer diagnosis
diagnosis. Patients’ age was median-dichotomized into Breast cancer 214 (91.1)
Ductal carcinoma in-situ (DCIS) 21 (8.9)
two categories: ⬍60 years and ⱖ60 years.
Tumor sizea
We checked the distributions of scores at baseline: ⱕ2 cm (pT1a–c) 140 (66.7)
Global health status, functional scales, body image, arm and ⬎2 cm (pT2–pT4) 70 (33.3)
breast symptoms, cosmetic confidence, sexual functioning, Lymph node metastasesb
Absent (pN0) 162 (71.4)
and the two anxiety scales were not normally distributed Present (pN1, pN2, and pN3) 65 (28.6)
(Kolmogorov-Smirnov: p⬍0.01). Also, QoL scores were or- Menopausal status
dinal scaled. We performed the following nonparametric sta- Premenopausal 50 (21.3)
Postmenopausal 185 (78.7)
tistical tests: To test for changes of QoL and anxiety over Primary surgical treatment
time, we performed Wilcoxon’s tests, using a two-tailed p Breast-conserving therapy (BCT) 213 (91.0)
value ⬍0.01. Pairwise differences between the oncological Mastectomy 21 (9.0)
Axillary surgery
subgroups were assessed by Mann-Whitney U test with a
Axillary dissection 140 (59.3)
two-tailed p value of ⬍0.05. SPSS 14.0 (SPSS, Inc., Chi- Sentinel lymph node biopsy 96 (40.7)
cago, IL) was used for all calculations. Adjuvant treatment in first 6 months 227 (96.6)
Radiotherapy 189 (80.1)
Cytotoxic therapy 68 (28.8)
Dropout Analysis Endocrine therapy 189 (80.4)

We conducted Mann-Whitney U tests to test for differ- a

ences between the dropouts (N⫽42) and the remaining pa-
tients (N⫽236) at baseline: Baseline scores of QoL scale,
functional scales, body image scale, arm and breast symp-
toms, cosmetic confidence, sexual functioning, and the two
anxiety scales were not different at baseline (p⬎0.05).
RESULTS
Patients’ Characteristics at Time of Primary Diagnosis
Data on tumor size not available in 26 cases.
b
Data on lymph node metastases not available in 9 cases.
140 patients had an axillary dissection; in 96 cases, sentinel
lymph node biopsy was done. Radiotherapy was adminis-
tered to 189 patients, cytotoxic therapy to 68 patients, and
endocrine therapy to 189 patients in the first 6 months after
surgery. Patients’ demographic and clinical variables at time
of primary diagnosis are presented in Table 1.

The mean age of the 236 participating patients at time
of primary diagnosis was 58.7 years (range: 33– 89; stan-
dard deviation [SD]: 10.7); 66.7% of the patients were
diagnosed with stage pT1a– c (tumor size ⱕ2 cm), 33.3%
with stage pT2–pT4 (tumor size ⬎2 cm). Lymph node
metastases were absent in 71.4% (pN0) and present in
28.6% (pN1, pN2, pN3) of the patients. The primary sur-
gical treatment consisted of either breast-conserving ther-
apy (BCT; N⫽213) or modified radical mastectomy
(N⫽21). Only 8 patients (3.4%) had breast reconstruction;
Change in Quality-of-Life Parameters
and Anxiety at Follow-Up
QoL data of 236 patients are presented over three points
of measurement: T1 (after primary surgical treatment), T2 (6
months after surgery), and T3 (12 months after surgery).
Table 2 shows the mean and SD values for quality-of-life
measures according to QLQ–C30, QLQ–BR23, additional
scales and anxiety measures according to the HADS and the
QSC–R23, and the p values for the Wilcoxon tests.

114 http://psy.psychiatryonline.org Psychosomatics 51:2, March-April 2010

 Härtl et al.

TABLE 2. Quality-of-Life Parameters and Anxiety: Comparison of Means Over Three Points of Measurement
T1 T2 T3 p (T1–T2)a p (T1–T3)a
QLQ–C30 Questionnaire
Global Health Status/QoL 57.2 (21.8) 64.2 (21.3) 65.5 (23.4) 0.000 0.000
Physical functioning 75.2 (21.0) 80.7 (19.5) 80.4 (21.4) 0.000 0.000
Role functioning 57.8 (32.2) 72.7 (28.3) 74.2 (29.9) 0.000 0.000
Emotional functioning 56.9 (26.4) 64.2 (25.1) 65.2 (28.2) 0.000 0.000
Cognitive functioning 78.0 (26.3) 79.3 (27.2) 78.2 (27.3) NS NS
Social functioning 68.9 (30.2) 77.4 (27.1) 79.5 (27.6) 0.000 0.000
QLQ–BR23 Questionnaire
Arm symptoms 30.1 (24.3) 24.0 (24.8) 22.3 (24.4) 0.001 0.000
Breast symptoms 34.0 (23.5) 27.5 (23.5) 21.8 (21.3) 0.002 0.000
Body image 79.1 (25.7) 78.7 (27.4) 79.9 (27.6) NS NS
Additional scales
Cosmetic confidence 81.2 (27.9) 81.8 (29.4) 80.7 (30.7) NS NS
Sexual functioning 67.8 (36.0) 68.2 (37.4) 69.4 (36.6) NS NS
HADS–D
Anxiety 6.9 (3.9) 6.5 (3.8) 6.6 (3.9) NS NS
QSC–R23
Fears 1.7 (1.4) 1.7 (1.4) 1.6 (1.3) NS NS

N⫽236; values are mean (standard deviation), unless otherwise noted.

T1: after primary surgical treatment; T2: 6 months after surgery; T3: 12 months after surgery.
QLQ–C30: Quality-of-Life Questionnaire (QLQ–C30), Version 3.0 of the EORTC Study Group on Quality of Life;9,10 QLQ–BR23 Questionnaire:
a breast cancer-specific module for the QLQ; HADS–D: Hospital Anxiety and Depression Scale; QSC–R23: Questionnaire on Stress in Cancer
Patients, Revised Version.
a
Wilcoxon test: a two-tailed p value ⬍0.01 is considered to indicate statistical significance.

Table 2 indicates that Global Health Status/QoL and
four of the five functional scales, namely, physical, role
emotional, and social functioning significantly increased
(p⫽0.000) over the first 6 months (T1–T2) and 12 months
(T1–T3). The subscale Cognitive Functioning showed no
significant change over the three time-points of assessment
(p⫽0.244 and 0.904). Arm symptoms and breast symp-
toms had a significant decrease, comparing T1 and T2
(p⫽0.001, p⫽0.002) and T1 and T3 (p⫽0.000, p⫽0.000),
respectively. Mean values of the Body Image scale and the
additional scales Cosmetic Confidence and Sexual Func-
tioning demonstrated no significant changes over time, per
our criterion. Anxiety did not change significantly on the
HADS (T1–T2: p⫽0.018; T1–T3: p⫽0.042), nor on the
QSC–R23 (T1–T2: NS; T1–T3: NS). Comparing the means
of the two points of measurement, T2 and T3, none of the
QoL and anxiety parameters revealed a significant differ-
ence. One exception was the subscale Breast Symptoms,
which showed a significant decrease from T2 to T3
(p⫽0.000).
We used QLQ–C30 data14 and HADS–D data15 of a
representative sample of the German adult population for
a descriptive comparison. Figure 1 shows the age-specific
mean functional scores of the QLQ–C30 of breast cancer
patients 1 year after primary surgical treatment, as com-
pared with healthy women. With the exception of those
over age 70 years, breast cancer patients scored lower than
healthy women on the role emotional and social function-
ing scales (and on the other functional scales of the QLQ–
C30; not presented in Figure 1). These differences were
larger in younger (30 –59 years) women, but smaller for
patients between 60 and 69 years old. Patients over age 70
had slightly better functional scores than did healthy
women in this age-group (Figure 1).
Figure 2 presents the age-specific anxiety scores of
the HADS–D of breast cancer patients 1 year after primary
surgical treatment, as compared with healthy women.
Younger patients reported more anxiety (ⱕage 39: mean
9.4; age 40 –59 years: mean 7.4) than healthy women
(ⱕage 39: mean 4.6; age 40 –59 years: mean 5.2). Breast
cancer patients over age 60 scored only slightly higher on
the anxiety scale than women from the general population
(5.8 versus 5.4; Figure 2).
Quality-of-Life Parameters and Anxiety
in Oncological Subgroups
We analyzed possible differences in QoL as measured
by the QLQ–C30 questionnaire in oncological subgroups
on the subscales Arm Symptoms, Breast Symptoms, and

Psychosomatics 51:2, March-April 2010 http://psy.psychiatryonline.org 115

Quality of Life With Breast Cancer

FIGURE 1. Quality of Life (QoL): Age-Specific Means and Functional Scores of Breast Cancer Patients 1 Year After Primary Surgery,
Versus Healthy Women

100
Healthy women
QL Q–30 Mean Functional Scores

90 Breast cancer patients

80
70
60
50
40
30
20
10
0
30–39 40–49 50–59 60–69 ≥ 70 30–39 40–49 50–59 60–69 ≥ 70 30–39 40–49 50–59 60–69 ≥ 70
Role Functioning Emotional Functioning Social Functioning
QLQ–C30: Quality-of-Life Questionnaire.

tients (T1: 50.0 versus 64.8; p⫽0.000; T3: 71.0 versus

FIGURE 2. Anxiety: Age-Specific Means of Breast Cancer
Patients 1 Year After Primary Surgery, Versus 77.0; p⫽0.036), greater impairment of emotional function-
Healthy Women ing (T1: 50.1 versus 63.1; p⫽0.000; T3: 60.0 versus 69.9,
p⫽0.003), greater impairment of cognitive functioning
20
18 Healthy women
(T1: 72.3 versus 83.2; p⫽0.001; T3: 73.7 versus 82.3;
HADS–D Anxiety Scale

16 Breast cancer patients

p⫽0.006) and of social functioning (significant only at T1:
14 60.7 versus 76.2; p⫽0.000). At baseline and 1-year fol-
12 low-up, younger patients had more arm complaints (T1:
10 35.3 versus 25.4; p⫽0.002; T3: 26.5 versus 18.6;
8 p⫽0.038) and breast complaints (T1: 38.2 versus 30.2;
6 p⫽0.014; T3: 26.0 versus 17.9; p⫽0.001). Older patients
4 reported better body image shortly after the operation
2 (83.3 versus 74.5; p⫽0.006). One year after the surgery,
0 body image of the two subgroups was similar, but was
≤ 39 Years 40–59 Years ≥ 60 Years
close to statistical significance (81.6 versus 78.1;
HADS–D: Hospital Anxiety and Depression Scale.
p⫽0.063). Finally, younger patients had higher scores for
Anxiety after primary surgical treatment (7.7. versus 6.3;
Body Image on the QLQ–BR23 and the subscale Anxiety p⫽0.016) than older patients. Interestingly, 1 year later,
on the HADS–D. Table 3 shows the mean values and SDs the difference in Anxiety scores in the two subgroups
of the various subgroups, and the two-tailed p values of the increased (7.6 versus 5.7; p⫽0.000).
Mann-Whitney U tests after primary surgical treatment
(T1) and 12 months later (T3; Table 3).
Comparison of Patients With Different TNM Stages
at the Time of Primary Diagnosis
Comparison of Younger Versus Older Patients
Patients with TNM stages pT1a, pT1b, and pT1c
Younger (⬍60 years) and older patients (ⱖ60 years) showed QoL after surgery (57.0 versus 56.1; NS) and in
did not differ in their overall QoL and physical functioning the first year of follow-up (64.0 versus 67.3; NS) similar to
(p⬎0.05) shortly after surgery and 1 year later. At both patients with TNM stages pT2, pT3, and pT4. On all
points of measurement, however, younger patients showed functional scales, the two subgroups had comparable val-
greater impairment of role functioning than did older pa- ues at baseline and 1-year follow-up (p⬎0.05). After pri-

116 http://psy.psychiatryonline.org Psychosomatics 51:2, March-April 2010

 Härtl et al.

TABLE 3. Quality-of-Life (QoL) Parameters and Anxiety in Oncological Subgroups

QoL Parameter Oncological Factor Patients, N T1 pa T3 pa
Global Health Status/QoL Age, years
⬍60 112 54.2 (22.0) NS 64.2 (23.8) NS
ⱖ60 124 59.9 (21.3) 66.6 (23.1)
Tumor size
pT1a, pT1b, pT1c 140 57.0 (21.3) NS 64.0 (22.8) NS
pT2, pT3, pT4 70 56.1 (22.7) 67.3 (25.7)
Surgery
BCT 213 56.5 (21.5) NS 65.4 (23.3) NS
Mastectomy 21 61.5 (24.5) 65.5 (25.7)
Physical Functioning Age, years
⬍60 112 73.3 (22.3) NS 81.7 (19.6) NS
ⱖ60 124 77.0 (19.8) 79.3 (22.9)
Tumor size
pT1a, pT1b, pT1c 140 75.1 (20.8) NS 80.2 (21.3) NS
pT2, pT3, pT4 70 74.1 (21.4) 80.2 (20.7)
Surgery
BCT 213 74.9 (20.8) NS 80.6 (20.9) NS
Mastectomy 21 76.8 (23.6) 77.1 (26.4)
Role Functioning Age, years
⬍60 112 50.0 (32.1) 0.000 71.0 (28.9) 0.036
ⱖ60 124 64.8 (30.7) 77.0 (30.6)
Tumor size
pT1a, pT1b, pT1c 140 57.0 (31.9) NS 73.7 (29.9) NS
pT2, pT3, pT4 70 55.5 (32.3) 73.3 (29.0)
Surgery
BCT 213 57.8 (31.7) NS 74.0 (29.9) NS
Mastectomy 21 54.8 (37.7) 73.0 (30.5)
Emotional Functioning Age, years
⬍60 112 50.1 (27.1) 0.000 60.0 (27.5) 0.003
ⱖ60 124 63.1 (24.3) 69.9 (28.2)
Tumor size
pT1a, pT1b, pT1c 140 56.9 (24.8) NS 63.9 (29.1) NS
pT2, pT3, pT4 70 57.9 (28.4) 66.5 (28.1)
Surgery
BCT 213 56.3 (25.9) NS 64.6 (28.1) NS
Mastectomy 21 59.5 (30.9) 69.8 (29.8)
Cognitive Functioning Age, years
⬍60 112 72.3 (28.6) 0.001 73.7 (28.6) 0.006
ⱖ60 124 83.2 (22.8) 82.3 (25.5)
Tumor size
pT1a, pT1b, pT1c 140 78.2 (26.0) NS 76.6 (28.8) NS
pT2, pT3, pT4 70 79.1 (26.6) 79.8 (23.7)
Surgery
BCT 213 77.5 (26.4) NS 77.6 (27.3) NS
Mastectomy 21 81.0 (26.0) 81.8 (27.8)
Social Functioning Age, years
⬍60 112 60.7 (30.8) 0.000 78.1 (27.1) NS
ⱖ60 124 76.2 (27.7) 80.8 (28.0)
Tumor size
pT1a, pT1b, pT1c 140 69.9 (28.5) NS 80.2 (26.4) NS
pT2, pT3, pT4 70 66.0 (32.8) 76.9 (28.7)
Surgery
BCT 213 69.0 (30.0) NS 79.5 (27.8) NS
Mastectomy 21 64.3 (32.6) 77.8 (26.0)
Arm symptoms Age, years
⬍60 112 35.3 (25.4) 0.002 26.5 (27.2) 0.038
ⱖ60 124 25.4 (22.3) 18.6 (21.0)

Psychosomatics 51:2, March-April 2010 http://psy.psychiatryonline.org 117

Quality of Life With Breast Cancer

TABLE 3. Quality-of-Life (QoL) Parameters and Anxiety in Oncological Subgroups (Continued)

QoL Parameter Oncological Factor Patients, N T1 pa T3 pa
Tumor size
pT1a, pT1b, pT1c 140 29.2 (22.3) NS 20.8 (23.3) 0.016
pT2, pT3, pT4 70 34.6 (26.0) 29.0 (25.8)
Surgery
BCT 213 29.5 (24.1) NS 22.6 (24.4) NS
Mastectomy 21 37.0 (26.1) 22.2 (25.3)
Breast symptoms Age, years
⬍60 112 38.2 (24.7) 0.014 26.0 (22.0) 0.001
ⱖ60 124 30.2 (21.8) 17.9 (19.9)
Tumor size
pT1a, pT1b, pT1c 140 33.3 (22.9) NS 19.2 (18.2) 0.047
pT2, pT3, pT4 70 36.1 (24.6) 27.9 (26.0)
Surgery
BCT 213 34.7 (23.7) NS 22.2 (21.2) NS
Mastectomy 21 29.4 (20.5) 19.4 (22.6)
Body image Age, years
⬍60 112 74.5 (27.6) 0.006 78.1 (26.8) NS
ⱖ60 124 83.3 (23.2) 81.6 (28.2)
Tumor size
pT1a, pT1b, pT1c 140 82.6 (22.4) 0.048 84.2 (23.4) NS
pT2, pT3, pT4 70 72.9 (30.0) 73.1 (32.2)
Surgery
BCT 213 80.4 (24.1) 0.037 81.8 (26.6) 0.000
Mastectomy 21 63.1 (35.6) 59.1 (29.6)
Anxiety Age, years
⬍60 112 7.7 (4.1) 0.016 7.6 (3.9) 0.000
ⱖ60 124 6.3 (3.7) 5.7 (3.7)
Tumor size
pT1a, pT1b, pT1c 140 6.8 (3.9) NS 6.4 (3.7) NS
pT2, pT3, pT4 70 7.3 (4.1) 6.9 (4.2)
Surgery
BCT 213 7.2 (3.9) NS 6.7 (3.8) NS
Mastectomy 21 5.7 (4.1) 6.2 (4.9)

N⫽236; values are mean (standard deviation) with two-tailed p values of the Mann-Whitney U tests.
T1: after primary surgical treatment; T3: 12 months after surgery; BCT: breast-conserving therapy.
a
Mann-Whitney U test; a two-tailed p value ⬍0.05 is considered to indicate statistical significance.

mary surgical treatment, patients with TNM stage
pT2– 4 illness presented slightly more arm symptoms
(34.6 versus 29.2; NS) and breast symptoms (36.1 ver-
sus 33.3; NS) than did patients with pT1a– c; these
differences, however, were not significant. Interest-
ingly, in the 1-year follow-up, this trend increased:
patients with larger tumor size reported significantly
more arm symptoms (29.0 versus 20.8; p⫽0.016) and
breast symptoms (27.9 versus 19.2; p⫽0.047). In the
first assessment, women with TNM stage pT1a– c had
better body image (82.6 versus 72.9; p⫽0.048). One
year later, this subgroup still had (nonsignificantly)
higher body image scores. Concerning anxiety, patients
with smaller tumor size had values comparable with
patients having larger tumor size, shortly after surgery
(6.8 versus 7.3; NS) and 1 year postoperative (6.4 ver-
sus 6.9; NS).
Concerning the differences between women of differ-
ent stages at follow-up, possible confounding effects of
adjuvant chemotherapy must be considered. Table 4 shows
the mean values of QoL parameters and p values of the
Mann-Whitney U tests of women with adjuvant chemo-
therapy versus women without chemotherapy. One year
after primary surgery, both subgroups showed comparable
QoL parameters (nonsignificant p values), with the excep-
tion of two scales. Women without cytotoxic therapy had
better social functioning (81.4 versus 74.8; p⫽0.013) and
fewer arm symptoms (20.3 versus 27.4; p⫽0.017) than
women with chemotherapy. Also, women without cyto-
toxic treatment tended to show slightly better cognitive

118 http://psy.psychiatryonline.org Psychosomatics 51:2, March-April 2010

 Härtl et al.

symptoms (37.0 versus 29.5; NS) than patients with BCT.

TABLE 4. Quality-of-Life (QoL) Parameters for Women
With Versus Without Adjuvant Chemotherapy, at One year post-surgery, both subgroups had similar arm
Follow-Up complaints (22.2 versus 22.6; NS). The BCT and mastec-
Adjuvant tomy subgroup did not differ in their breast complaints
QoL Parameter Chemotherapy T3 pa after surgery (34.7 versus 29.4; NS) and 1 year later (22.2
Global Health Status/ versus 19.4; NS). After the operation, patients treated with
QoL mastectomy had more impairment in body image than
No 65.5 (23.5) NS
Yes 65.4 (23.4) patients treated with BCT (63.1 versus 80.4; p⫽0.037).
Physical Functioning The body image differences between the two surgical sub-
No 81.3 (21.1) NS groups increased over time: One year later, patients with
Yes 78.4 (22.2)
Role Functioning
mastectomy reported significantly more body image prob-
No 75.9 (29.7) NS lems than the BCT subgroup (59.1 versus 81.8; p⫽0.000).
Yes 69.9 (30.1) After primary surgical treatment, patients with BCT
Emotional Functioning
tended to have higher anxiety scores than patients treated
No 65.6 (27.8) NS
Yes 64.2 (29.4) with mastectomy (7.2 versus 5.7; NS). One year post-
Cognitive Functioning surgery, this trend decreased as the BCT and mastectomy
No 80.2 (26.5) 0.050 subgroup showed similar anxiety scores (6.7 versus 6.2).
Yes 73.3 (28.8)
Social Functioning
No 81.4 (27.8) 0.013 DISCUSSION
Yes 74.8 (26.6)
Arm symptoms
No 20.3 (24.2) 0.017
The purpose of our study was, first, to investigate changes
Yes 24.4 (24.6) of QoL and anxiety in breast cancer patients over 1 year
Breast symptoms and, second, to examine differences of QoL and anxiety in
No 20.7 (21.3) NS
oncological subgroups. The QLQ–C30, QLQ–BR23,
Yes 27.4 (21.2)
Body image HADS–D, and QSC–R23 were used as valid, reliable, and
No 80.3 (27.3) NS useful clinical measures.10,13,15–18 Because of the nature of
Yes 79.0 (28.5) the data, we applied nonparametric tests. A p value ⬍0.01
was chosen to test for changes in the whole sample; how-
Adjuvant chemotherapy: CMF (cyclophosphamide, methotrexate,
and 5-fluorouracil; N⫽4); anthracycline (N⫽58); taxane (N⫽6). ever no adjustments for multiple testing were made. Con-
Patients without adjuvant chemotherapy: N⫽168; patients with cerning comparisons of subgroups, we defined a p value of
adjuvant chemotherapy: N⫽68; total N⫽236; values for T3 (12 ⬍0.05, bearing in mind that the number in each subgroup
months after primary surgery) are mean (standard deviation).
a
Mann-Whitney U test: a two-tailed p value ⬍0.05 is considered was small. In this study, we evaluated women with ductal
to indicate statistical significance. carcinoma in-situ (DCIS) and with breast cancer in the
same data analysis. There were no significant differences
in QoL between the two subgroups.
functioning (80.2 versus 73.3; p⫽0.050) and fewer breast
Limitations of our study design should be considered:
symptoms (20.7 versus 24.4; NS; Table 4).
First, baseline QoL and anxiety data were not obtained
before diagnosis; however, this goal is almost impossible
Comparison of Patients With Breast-Conserving
to realize.5 Second, results may be positively biased, not
Surgery Versus Mastectomy
considering women with metastases and those who re-
In terms of primary surgical treatment modality, we fused to participate or dropped out during follow-up.
compared the two subgroups, BCT and mastectomy; the Fewer than 1% refused study participation; perhaps the
latter subgroup, however, was very small (N⫽21). QoL motivation to participate was high because physicians
scores in the BCT and mastectomy subgroups were similar spent a lot of time establishing contact with and briefing
after surgery (56.5 versus 61.5; NS) and 1 year later (65.4 participants. Regarding the dropouts, baseline scores of
versus 65.5; NS). Patients treated with BCT and patients QoL and anxiety scales were not different between drop-
treated with mastectomy had similar values on all func- outs and remaining patients.
tional scales at baseline assessment and 1-year follow-up A third limitation is the small sample size, which
(p⬎0.05). Patients with mastectomy reported more arm makes it difficult to compare the oncological subgroups.

Psychosomatics 51:2, March-April 2010 http://psy.psychiatryonline.org 119

Quality of Life With Breast Cancer
The size of the mastectomy subgroup, especially, with
N⫽21, is very small for difference tests. Finally, confi-
dence with Cosmetic Result and Sexual Functioning were
measured by only two questions. The psychometric prop-
erties of these additional scales have not been tested in a
larger sample; thus, the results concerning these two pa-
rameters should be interpreted with caution. Because “sex-
ual functioning” is a very intimate and emotional subject,
one could argue that questionnaire data do not compre-
hensively measure the subjective view of the women.
Semistructured interview data would have been an addi-
tional tool to complement the quantitative data.
Most QoL results changed over time: QoL, physical,
role emotional, and social functioning improved, and arm
and breast symptoms decreased within the first 6 months.
With the exception of breast symptoms, the improvements
during the first 6 months remained stable and did not
change at the 12-month assessment. Given that 6 months
after surgery, most patients have completed radiotherapy
or cytotoxic therapy and are likely to have recovered from
the initial emotional reaction, surgery, and hospitalization,
an increase in QoL would be expected. Interestingly this is
not the case for the following half-year. The decreasing
contact with doctors and other hospital staff might lead to
feelings of being left alone with the disease. Another rea-
son could be that patients, after adjuvant treatment, are
again confronted with demands in their job and family life.
Our finding about the lack of change in distress from 6 to
12 months post-surgery is confirmed by studies indicating
a high percentage of emotional distress at 6, 12, and 24
months after diagnosis.19 –21
Ratings of cognitive functioning did not change dur-
ing 6 and 12 months, which is in line with previous stud-
ies.22 Adjuvant chemotherapy seems to have a negative
impact on cognition and represents a side effect that im-
proves slowly.23,24 In the present study, 28% of our pa-
tients received cytotoxic therapy. It is possible that a fol-
low-up of 1 year is too short for observing cognitive
improvement. Also, baseline assessment in our sample
seems to indicate only moderate impairment in cognitive
functioning. Improvements in arm and breast symptoms
can be explained by recovery from surgery and the effects
of adjuvant therapy, physiotherapy, and rehabilitation pro-
cedures.25 Although breast symptoms continued to im-
prove during follow-up, arm symptoms did not. This is in
line with other studies reporting that a large proportion of
breast cancer patients suffer from persistent arm prob-
lems.26 –28
Results regarding long-term QoL in breast cancer pa-
120 http://psy.psychiatryonline.org
tients are contradictory: Some studies report long-term
impairments in QoL,2,5 whereas others show increasing
QoL in breast cancer patients over time.26,29,30 In a recent
study by Arndt et al.,31 overall QoL and physical func-
tioning of patients with breast cancer were comparable
with women from the general population 1 year after
diagnosis. However, deficits in emotional, social, and cog-
nitive functioning were still apparent, especially in
younger patients. We compared our QoL data descrip-
tively with the age-specific QLQ–C30 data from a female
German general population sample.14 Breast cancer pa-
tients, especially younger patients, scored considerably
lower on the QoL scales 1 year after diagnosis than
healthy women. Interestingly, patients older than 70 years
had better QoL than healthy women at this age. Older
women may have developed adequate strategies to cope
with disease and impairment that had an impact on their
QoL in the past.
We were interested in possible changes in body im-
age, cosmetic confidence, and sexual functioning over
time. None of these changed during the first year of fol-
low-up. This result might be because 91% of the women
had BCT, and thus had no large scars. Hence, baseline
scores of cosmetic confidence were rather high, and body-
image was only moderately impaired. As a consequence,
our findings are different from follow-up studies where the
majority of patients were treated with mastectomy; these
patients had long-term body-image problems.32 Sexual
functioning was more strongly impaired at baseline and
did not change over the three assessments. Bearing in
mind that the sexual functioning scale of our study is not
validated, a considerable percentage of patients seemed to
experience sexual problems at baseline and follow-up.
This result is in line with follow-up studies demonstrating
long-term effects of breast cancer treatment on sexual
functioning.33,34 However, scores of the three scales—
body image, sexual functioning, and cosmetic confi-
dence—must be interpreted with caution, given that norms
are missing. So far, no reference data for the body-image
scale or for the two other scales exist in the general Ger-
man population.
Fear regarding cancer and uncertainty over the future
are a major concern among breast cancer survivors. Anx-
iety scores did not change during the first year after diag-
nosis and surgery. This underscores the idea that QoL and
anxiety are distinct constructs.35 Comparing the anxiety
values of the HADS–D with a representative, age-specific
female sample of the German adult population,15 our pa-
tients experienced more anxiety 1 year after the primary
Psychosomatics 51:2, March-April 2010

surgery than healthy women. Again, the difference was
greater in younger women. However, for all age-groups in
our sample, the anxiety scores were below the cutoff of
11,12 thus indicating moderate impairment; this might be
because the patients in this study showed rather good
clinical outcomes at primary diagnosis. There are only few
studies investigating long-term anxiety in women with
breast cancer, but those that do indicate increased anxiety
levels over a long period.2,36,37
In summary, results are varied: In the “classic” QoL
parameters, we found distinct changes over the first 6
months, which remained stable, but improvement did not
continue at 1-year follow-up. Concerning body image,
sexual problems, and anxiety, no change was observed.
Our data suggest that, 1 year after surgery, cancer diag-
nosis and treatment still influence patients’ lives in regard
to body-image, sexual, and anxiety problems. Also,
younger and middle-aged women seem to have persistent
QoL impairments, as compared with healthy women.
In the second part of the study, we analyzed differ-
ences of QoL, body image, and anxiety in oncological
subgroups. Age seems to be an important mediator:
Shortly after surgery, and 12 months later, younger pa-
tients had lower scores on almost all QoL scales of the
QLQ–C30, with more arm, breast, and body-image prob-
lems, and higher anxiety levels. Previous studies agree that
younger patients are more distressed by cancer diagnosis,
surgery, and treatment, in the short- and long-term.4,6,7,38
Cancer diagnosis and treatment might affect younger pa-
tients to a greater extent because of many job- and family-
related demands and possible financial problems caused
by periods when they are out of work. Older patients may
have already developed strategies to cope with these is-
sues. Furthermore, in our culture, young age symbolizes
health and vitality; thus, there is more psychological stress
if life-threatening disease occurs. There are only few stud-
ies that examine age differences in arm and breast symp-
toms, but these report similar results.39 Our findings that
younger patients had more arm and breast symptoms
shortly after surgery and 12 months later might also be
explained by their greater daily physical demands. Older
patients might be used to arm and breast symptoms from
experiencing the effects of various degenerative diseases.
Our data present unexpected results regarding tumor
stage and subjective well-being of patients: Patients with
good tumor prognosis, that is, stage pT1a– c, did not differ
on any QoL scale from patients with tumor stage pT2– 4,
and both groups reported similar anxiety levels. Tumor
size is an important prognostic factor; it influences surgi-
Psychosomatics 51:2, March-April 2010
Härtl et al.
cal and adjuvant-therapy decisions, and it should therefore
affect patients’ physical, mental, and emotional well-be-
ing. Why do our data contradict this hypothesis? Is it
because of flaws in doctor–patient communication? Or is
good tumor prognosis not crucial for QoL and well-being
of the patient? As discussed earlier, the same applies to
patients in our sample diagnosed with DCIS; they had
QoL similar to patients diagnosed with breast cancer. Pa-
tients who are unfamiliar with oncological topics are prob-
ably not accounting for the importance of tumor size in
prognosis, and thus view their diagnosis as life-threatening
regardless of tumor stage. Other studies40,41 have also
failed to demonstrate an impact of tumor stage on subjec-
tive well-being. However, patients with larger tumor sizes
had more body-image problems and arm and breast symp-
toms; this might be related to surgery or the toxic effects
of chemotherapy: women with higher tumor stages will be
treated with more radical surgical methods and thus will be
more likely to suffer from body-image problems. On the
other hand, cytotoxic treatment seems to have a negative
impact on arm symptoms and a tendency to worsen breast
symptoms, which might confound the impact of tumor stage
on these symptoms.
In line with previous publications,42–44 the standard-
ized QoL questionnaire failed to demonstrate a difference
in short- and long-term QoL between patients receiving
BCT or mastectomy in our study. Therefore, it seems that
QoL is impaired by surgery on the breast, irrespective of
the surgical approach. One reason might be that mastec-
tomy has changed over the years from a radical to a more
modified procedure. This may also explain our findings
that arm and breast symptoms were similar in both sub-
groups. Involving the patient in the decision-process about
surgical approach might also be more important for con-
fidence in treatment and QoL than the surgical treatment
modality itself.44,45 However, surgical modality did have
an influence: patients with BCT rather than mastectomy
reported better body image after surgery. Interestingly, 1
year later, this difference was even more pronounced.
Furthermore, shortly after surgery, there was a tendency
toward higher anxiety scores in the BCT subgroup; this
tendency disappeared in the follow-up. Higher anxiety in
patients treated with BCT might be explained by patients’
fear that breast-conserving methods leave tumor cells in
the breast. In summary, the results of our study confirm the
long-term superiority of BCT in terms of body image,
which is in line with other findings.6,42,43,46
Overall, the impact of objective cancer-related factors on
QoL seems to be small—a finding in line with other stud-
http://psy.psychiatryonline.org 121
Quality of Life With Breast Cancer
ies.8,30,41 The oncological subgroups of our study did not
show any difference in global QoL as measured by the QLQ–
C30. Our patients showed QoL results unrelated to tumor
prognosis and surgical modality. This finding can be dis-
cussed in terms of “the well-being paradox.”47 Objectively
negative factors in one’s life have relatively little effect on
subjective QoL. The hypothesis of a direct relationship be-
tween tumor/treatment variables and QoL is challenged by
our results. Rather, patient-specific traits, coping strategies,
psychological reactions, and social support might work as
mediating factors.
On the whole, results confirm that QoL in breast
cancer patients improved over time, but there were still
impairments regarding anxiety, body image, and sexual
functioning. Younger patients were much more distressed
by cancer diagnosis and treatment. However, at the time of
cancer diagnosis, and as well as later on, surgical modality
and tumor prognostic factors seemed to play a minor role
in patients’ subjective QoL, which can be discussed in
terms of the “well-being paradox.” What are the practical
implications for our patients?
First, preoperative information for the patient con-
fronted with breast cancer should include possible psycho-
logical effects of cancer diagnosis, surgery, and treatment.
Patients should be informed that impairments of QoL are
likely to occur, but will decrease over time. Because of
long-lasting arm problems, special treatments should be
References
1. Giordano SH, Buzdar AU, Smith TL, et al: Is breast cancer
survival improving? trends in survival for patients with recurrent
breast cancer diagnosed from 1974 through 2000. Cancer 2004;
100:44 –52
2. Dow KH, Ferrell BR, Leigh S, et al: An evaluation of the quality
of life among long-term survivors of breast cancer. Breast Cancer
Res Treat 1996; 39:261–273
3. Grumann M, Schlag PM: Assessment of quality of life in cancer pa-
tients: complexity, criticism, challenges. Onkologie 2001; 24:10–15
4. Kroenke CH, Rosner B, Chen WY, et al: Functional impact of
breast cancer by age at diagnosis. J Clin Oncol 2004; 22:1849 –
1856
5. Arndt V, Merx H, Stegmaier C, et al: Persistence of restrictions
in quality of life from the first to the third year after diagnosis in
women with breast cancer. J Clin Oncol 2005; 23:4945– 4953
6. Curran D, van-Dongen JP, Aaronson NK, et al: Quality of life of
early-stage breast cancer patients treated with radical mastec-
tomy or breast-conserving procedures: results of EORTC Trial
10801. Eur J Cancer 1998; 34:307–314
7. Wenzel LB, Fairclough DL, Brady MJ, et al: Age-related differ-
ences in the quality of life of breast carcinoma patients after
treatment. Cancer 1999; 86:1768 –1774
122 http://psy.psychiatryonline.org
offered. Clinicians should inform patients that cancer and
its treatment can affect body image, sexuality, and anxiety,
and that these problems are quite “normal” and probably
will last for a longer time. Second, in long-term tumor
care, doctors should determine whether the patient has any
body-image, sexual, and/or anxiety problems. The patient
should be encouraged to communicate her problems and
seek professional help. Because of greater distress and
demands in family and job-life after treatment, special
psycho-oncological groups for younger patients might be
useful. Screening measures could help to evaluate the
individual need for psycho-oncological treatment. Third,
in QoL research, it is essential to include breast cancer-
specific parameters such as arm or breast symptoms, body
image, and sexual functioning. Also, anxiety and fear of
recurrence, which represent the greatest distress, but are
not covered by the QLQ–C30, should be included in QoL
studies.
We thank all the patients who completed question-
naires.
We also thank Ms. B. Adolf, Ms. V. Schneider and Ms.
J. Meyndt for collecting the data and PD Dr. U. Peschers
and Dr. J. de Waal of the Frauenklinik Dachau/Brustzen-
trum Dachau for their cooperation. Finally, we thank Dr.
I. Inceoglu for her helpful support with the manuscript.
The authors indicated no potential conflicts of interest.
8. Engel J, Kerr J, Schlesinger-Raab A, et al: Predictors of quality
of life of breast cancer patients. Acta Oncol 2003; 42:710 –718
9. Aaronson NK, Ahmedzai S, Bergman B, et al: The European
Organization for Research and Treatment of Cancer, QLQ–C30:
a quality-of-life instrument for use in international clinical trials
in oncology. J Natl Cancer Inst 1993; 85:365–376
10. McLachlan SA, Devins GM, Goodwin PJ: Validation of the
European Organization for Research and Treatment of Cancer
Quality of Life Questionnaire (QLQ–C30) as a measure of psy-
chosocial function in breast cancer patients. Eur J Cancer 1998;
34:510 –517
11. Zigmont AS, Snaith RP: The Hospital Anxiety and Depression
Scale. Acta Psychiatr Scand 1983; 67:361–370
12. Herrmann Ch, Buss U, Snaith RP: Hospital Anxiety and Depres-
sion Scale: Deutsche Version HADS–D: Ein Fragebogen zur
Erfassung von Angst und Depressivität in der somatischen Medi-
zin: Testdokumentation und Handanweisung. Bern, Switzerland,
Verlag Hans Huber, 1995
13. Herschbach P, Marten-Mittag B, Henrich G: Revision und psy-
chometrische Prüfung des fragebogens zur belastung von kreb-
skranken (FBK–R23). Z Med Psychol 2003; 12:69 –76
14. Schwarz R, Hinz A: Reference data for the Quality of Life
Psychosomatics 51:2, March-April 2010

Questionnaire EORTC QLQ–C30 in the general German popu-
lation. Eur J Cancer 2001; 37:1345–1351
15. Hinz A, Schwarz R: Angst und depression in der allgemeinbev-
ölkerung: eine normierungsstudie zur Hospital Anxiety and De-
pression Scale. Psychother Psychosom Med Psychol 2001; 51:
193–200
16. Sprangers MAG, Groenvold M, Arraras JI, et al: The European
Organization for Research and Treatment of Cancer Breast Can-
cer-Specific Quality-of-Life Questionnaire Module: first results
from a three-country field study. J Clin Oncol 1996; 14:2756 –
2768
17. Bjelland I, Dahl AA, Haug TT, et al: The validity of the Hospital
Anxiety and Depression Scale: an updated literature review.
J Psychosomatic Res 2002; 52:69 –77
18. Herschbach P, Keller M, Knight L, et al: Psychological problems
of cancer patients: a cancer distress screening with a cancer-
specific questionnaire. Br J Cancer 2004; 91:504 –511
19. Mehnert A, Koch U: Prevalence of acute and post-traumatic
stress disorder and comorbid mental disorders in breast cancer
patients during primary cancer care: a prospective study. Psycho-
Oncology 2007; 16:181–188
20. Millar K, Purushotham AD, McLatchie E, et al: A 1-year pro-
spective study of individual variation in distress, and illness
perceptions, after treatment for breast cancer. J Psychosom Res
2005; 58:335–342
21. Bleiker EMA, Pouwer F, van der Ploeg HM, et al: Psychological
distress two years after diagnosis of breast cancer: frequency and
prediction. Patient Educ Couns 2000; 40:209 –217
22. Schou I, Ekeberg O, Sandvik L, et al: Multiple predictors of
health-related quality of life in early-stage breast cancer: data
from a year follow-up study compared with the general popula-
tion. Qual Life Res 2005; 14:1813–1823
23. Ahles TA, Saykin AJ, Furstenberg CT, et al: Neuropsychologic
impact of standard-dose systemic chemotherapy in long-term
survivors of breast cancer and lymphoma. J Clin Oncol 2002;
20:485– 493
24. Schagen SB, Muller MJ, Boogerd W, et al: Late effects of
adjuvant chemotherapy on cognitive function: a follow-up study
in breast cancer patients. Ann Oncol 2002; 13:1387–1397
25. Leidenius M, Leppänen E, Krogerus L, et al: Motion restriction
and axillary web syndrome after sentinel node biopsy and axil-
lary clearance in breast cancer. Am J Surg 2003; 185:127–130
26. Dorval M, Maunsell E, Deschenes L, et al: Long-term quality of
life after breast cancer: comparison of 8-year survivors with
population controls. J Clin Oncol 1998; 16:486 – 494
27. Engel J, Kerr J, Schlesinger-Raab A, et al: Axilla surgery se-
verely affects quality of life: results of a 5-year prospective study
in breast cancer patients. Breast Cancer Res Treat 2003; 79:
47–57
28. Mandelblatt JS, Edge SB, Meropol NJ, et al: Predictors of long-
term outcomes in older breast cancer survivors: perceptions ver-
sus patterns of care. J Clin Oncol 2003; 21:855– 863
29. Bloom JR, Stewart SL, Chang S, et al: Then and now: quality of
life of young breast cancer survivors. Psycho-Oncology 2004;
13:147–160
30. Helgeson VS, Snyder P, Seltman H: Psychological and physical
adjustment to breast cancer over 4 years: identifying distinct
trajectories of change. Health Psychol 2004; 23:3–15
Psychosomatics 51:2, March-April 2010
Härtl et al.
31. Arndt V, Merx H, Stürmer T, et al: Age-specific detriments to
quality of life among breast cancer patients over one year after
diagnosis. Eur J Cancer 2004; 40:673– 680
32. Omne-Ponten M, Holmberg L, Sjöden PO: Psychosocial adjust-
ment among women with breast cancer stages I and II: six-year
follow-up of consecutive patients. J Clin Oncol 1994; 12:1778 –
1782
33. Ganz PA, Desmond KA, Leedham B, et al: Quality of life in
long-term, disease-free survivors of breast cancer: a follow-up
study. J Natl Cancer Inst 2002; 94:39 – 49
34. Speer JJ, Hillenberg B, Sugrue DP, et al: Study of sexual func-
tioning determinants in breast cancer survivors. Breast J 2005;
11:440 – 447
35. Carlson LE, Bultz BD: Cancer distress screening: needs, models,
and methods. J Psychosom Res 2003; 55:403– 409
36. Burgess C, Cornelius V, Love S, et al: Depression and anxiety in
women with early breast cancer: five-year observational cohort
study. BMJ 2005; 330:702–705
37. Sharpley CF, Christie DR: “How I was then and how I am now:”
current and retrospective self-reports of anxiety and depression
in Australian women with breast cancer. Psycho-Oncology 2007;
16:752–762
38. Kornblith AB, Powell M, Regan MM, et al: Long-term psycho-
social adjustment of older vs. younger survivors of breast and
endometrial cancer. Psycho-Oncology 2007; 16:895–903
39. Ververs JM, Roumen RMH, Vingerhoets AJJM, et al: The risk,
severity, and predictors of physical and psychological morbidity
after axillary lymph node dissection for breast cancer. Eur J
Cancer 2001; 37:991–999
40. Carver CS, Smith RG, Antoni MH, et al: Optimistic personality
and psychosocial well-being during treatment predict psychoso-
cial well-being among long-term survivors of breast cancer.
Health Psychol 2005; 24:508 –516
41. Bardwell WA, Natarajan L, Dimsdale JE, et al: Objective cancer-
related variables are not associated with depressive symptoms in
women treated for early-stage breast cancer. J Clin Oncol 2006;
24:2420 –2427
42. Ganz PA, Schag CAC, Lee JJ, et al: Breast conservation versus
mastectomy: is there a difference in psychological adjustment or
quality of life in the year after surgery? Cancer 1992; 69:1729 –1738
43. Janni W, Rjosk D, Dimpfl T, et al: Quality of life influenced by
primary surgical treatment for stage I–III breast cancer: long-
term follow-up of a matched-pair analysis. Ann Surg Oncol
2001; 8:542–548
44. Pozo C, Carver CS, Noriega V, et al: Effects of mastectomy
versus lumpectomy on emotional adjustment to breast cancer: a
prospective study of the first year postsurgery. J Clin Oncol
1992; 10:1292–1298
45. Keating NL, Guadagnoli E, Landrum MB, et al: Treatment de-
cision-making in early-stage breast cancer: should surgeons
match patients’ desired level of involvement? J Clin Oncol 2002;
20:1473–1479
46. Margolis G, Goodman RL, Rubin A: Psychological effects of
breast-conserving cancer treatment and mastectomy. Psychoso-
matics 1990; 31:33–39
47. Herschbach P: Das “Zufriedenheitsparadox” in der Lebensquali-
tätsforschung: Wovon hängt unser Wohlbefinden ab? Psychother
Psych Med 2002; 52:141–150
http://psy.psychiatryonline.org 123