The impact of skin involvement on the quality of life of breast cancer patients with chest wall recurrence and their caregivers

doi:10.21203/rs.3.rs-3300091/v1

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Research Article

The impact of skin involvement on the quality of life of breast cancer patients with chest wall recurrence and their caregivers

https://doi.org/10.21203/rs.3.rs-3300091/v1

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Purpose

To assess the impact of skin involvement on the quality of life (QoL) among breast cancer patients with chest wall recurrence and their caregivers.

Methods

We invited the female breast cancer patients with chest wall recurrence who received treatment at Sun Yat-sen University Cancer Center from November 2020 to July 2021 to complete EORTC QLQ-C30, EORTC QLQ-BR23, and HADS questionnaire. Their stable caregiver filled out SF-36 and HADS questionnaires. The assessment of the QoL was conducted once every two cycles of systemic treatment, with a total of three assessments. Survival analysis was performed using the Kaplan-Meier curves.

Results

A total of 42 participants and their family caregivers completed the QoL questionnaire for all three assessments. We found that in the skin involvement group, the breast symptoms worsened and the future perspectives decreased. The multiple functions and general health status of the patients in this group were also lower than those in the group without skin involvement. Skin involvement predicted the shorter disease progression of patients with chest wall recurrence. Compared to patients without skin involvement (5%), patients with skin involvement (29%) were more likely to experience the deterioration of arm symptoms. There were no differences in the family caregivers’ questionnaire between the two groups.

Conclusion

Chest wall recurrence patients with skin involvement had shorter disease progression intervals, more sever breast symptoms, and lower future prospects. This research further provided a reference for the application and promotion of QoL assessment tools in the management of recurrent breast cancer.

skin involvement

quality of life

chest wall recurrence

breast cancer

prognosis

Breast cancer was the most common female cancer worldwide in 2020 (Sung et al. 2021). Recurrence of breast cancer after optimal treatment is a challenging clinical issue (Brackstone et al. 2015; Wakeam et al. 2018). Approximately 5–40% of breast cancer patients experience chest wall recurrence (CWR) (Elder et al. 2006; Maishman et al. 2017; Haffty et al. 2004; His et al. 1998). The treatment of recurrent chest wall disease is difficult. Full thickness chest wall resection is one treatment option, but it is associated with disfigurement, inability to cure, and significant recurrence rates, and has been rarely used in recent decades. The efficacy of second- and third-line salvage chemotherapy is at most 20–30% (Ibrahim et al. 2005; Martín et al. 2007; Saeki et al. 2006; Saunders et al. 2001; Vassilomanolakis et al. 2003).

Breast cancer Patients with CWR mainly exhibit the following: (1) Chest wall skin changes, such as redness, rash, or ulceration, with or without palpable masses; (2) Palpable painless masses without obvious changes in the chest wall skin; (3) Local pain, lymphedema, impaired limb movement, fatigue caused by CWR; and (4) Treatment-related adverse reactions, among others. Based on the depth of lesion involvement, it can be classified as involving subcutaneous tissue, skin, or both. Skin, as the largest organ of the body, plays a significant role in the growth and progression of tumors. Breast cancer is one of the tumors with the highest incidence of skin involvement. Skin involvement usually occurs in anatomical areas close to the primary tumor (Saeed et al. 2004) and often happens several years after tumor excision (Hu et al. 2008). However, little is known about the impact of skin involvement on prognosis and quality of life (QoL) of breast cancer patients with CWR.

For breast cancer patients with CWR, in addition to the physical pain caused by the malignant tumor, psychological anxiety is also inevitable. The QoL for breast cancer patients is the sum of individual physiological, psychological, and social aspects. It includes various aspects of assessment, such as overall QoL, fatigue, physical function, chest wall symptoms, shoulder-arm symptoms, body image, anxiety, and depression, and is usually considered to be related to difficult-to-quantify personal or subjective attributes. With advancements in breast cancer treatment strategies and improvements in clinical prognosis, QoL is considered as an equally important indicator along with treatment efficacy, disease-free survival (DFS), and overall survival (OS) (Howell et al. 2015). QoL is also one of the factors affecting the clinical prognosis of breast cancer patients. Patients in the group with decreased QoL before and after tumor treatment had significantly shorter DFS and OS compared to the group with improved QoL (Takada et al. 2018). When designing clinical trial protocols, health-related QoL as a secondary endpoint is receiving increasing attention (Aihara et al. 2014; Ohsumi et al. 2011; Shiroiwa et al. 2011; Watanabe et al. 2009). Additionally, the U.S. Food and Drug Administration (FDA) also considers the impact of a new drug on QoL when granting approval. However, currently, there is a lack of evidence to assess the impact of breast cancer CWR on the QoL of patients and their family caregivers.

This study is a QoL analysis conducted within the current treatment framework for breast cancer CWR. The aim is to assess the impact of skin involvement on the QoL among breast cancer patients with CWR and their caregivers. We hope that this study will inform healthcare professionals about which clinical and pathological characteristics are associated with higher symptom burden (SB) and poorer QoL in CWR patients. Additionally, as caregivers of patients, their QoL may also be influenced by factors such as the patient's illness and psychological state. Their QoL is equally important and should be appropriately addressed and guided.

We conducted a review of female breast cancer patients with CWR who received inpatient treatment at Sun Yat-sen University Cancer Center from November 2020 to July 2021. Patients and their family caregivers were invited to participate in an assessment of QoL. Inclusion criteria of breast cancer CWR patients were as follows: (1) age ≥ 18 years, (2) histologically confirmed breast cancer, (3) chest wall recurrence confirmed by imaging, and (4) signed the informed consent. Patients with concurrent presence of tumors other than breast cancer were excluded from this study. For the caregivers, the inclusion criteria were as follows: (1) age ≥ 18 years, (2) being a family member of the breast cancer CWR patient, (3) continuous caregiving time ≥ 72 hours. The patient questionnaire included the European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30 health-related quality of life questionnaire (EORTC QLQ-C30, Version 3.0), the EORTC Breast Cancer-Specific Quality of Life Questionnaire (EORTC QLQ-BR23), and the Hospital Anxiety and Depression Scale (HADS). The caregiver questionnaire included the 36-item Short-Form Health Survey (SF-36) and the HADS. Clinical and pathological data of the included patients, as well as socio-economic status of the patients and caregivers were collected. The study was approved by the Ethics Committee of Sun Yat-sen University Cancer Center (No. B2020-282-01).

To avoid selection bias, consecutive cases were reviewed. After signing informed consent forms, the participants and their family caregivers completed the health-related QoL questionnaire with the assistance of doctors and nurses. Patients were required to complete the EORTC QLQ-C30 (Version 3.0), the EORTC QLQ-BR23, and the HADS, and the caregivers needed to complete the SF-36 and the HADS. The assessment of the QoL was filled out by the patients and caregivers once every two cycles of systemic treatment, resulting in a total of three questionnaires completed. The family caregiver who participated in the three surveys should be the same caregiver. Additionally, we collected the following data, including (1) the age, marital and reproductive status, educational level, economic status, and hobbies of the patients and family caregivers; (2) the family history of cancer, Eastern Cooperative Oncology Group (ECOG) performance status, tumor-related factors, and physical examinations of the patients; and (3) the gender, physical condition, relationship with the patient, and caregiving methods of the family caregivers.

The EORTC QLQ-C30 consists of 30 items, divides into 5 functional scales (physical, role, emotional, cognitive, and social), 3 symptom scales (fatigue, nausea and vomiting, and pain), 1 global health and QoL scale, and 6 single items (dyspnea, insomnia, loss of appetite, constipation, diarrhea, and financial difficulties). The QLQ-BR23 is a breast cancer-specific 23-item questionnaire that incorporates 4 functional scales (body image, sexuality, sexual enjoyment, and future perspective) and 4 symptom scales (systemic therapy side effects, breast symptoms, arm symptoms, and hair loss concerns). The scores of both the EORTC QLQ-C30 and QLQ-BR23 were calculated according to the scoring manual. The deterioration in QoL assessments referred to consecutive ratings worsening (≥ 10 points) (Harrington et al. 2017) within these three EORTC questionnaires. The HADS questionnaire includes two subscales for anxiety (A) and depression (D), with 7 items each. The scores for the anxiety and depression subscales range from 0 to 7, indicating no symptoms, 8 to 10, indicating possible presence, and 11 to 21, indicating definite presence. The SF-36 assesses the QoL of the respondents across eight scales: physical functioning, role limitations due to physical health, bodily pain, general health perceptions, energy/vitality, social functioning, role limitations due to emotional problems, and mental health.

The raw data were standardized for each domain of the questionnaire scales. Statistical descriptions were presented using proportions or mean ± standard deviation. The Chi-square test was used to compare characteristics of patients and family caregivers in different groups. Survival analysis was performed using the Kaplan-Meier curves. A P-value < 0.05 was considered statistically significant. All statistical analyses were conducted using SPSS software version 25.0, and all P-values were two-sided.

Demographic and clinical characteristics

A total of 71 consecutive breast cancer CWR patients and their family caregivers underwent this QoL assessment from November 2020 to July 2021. Among them, 59% (n = 42) of participants completed the QoL questionnaire for all three assessments. Follow-up revealed that the main reason for non-completion of the questionnaire was the COVID-19, resulting in questionnaire delay, interruption, or dropout from the study.

As shown in Table 1, all 42 female patients with breast cancer chest wall recurrence were diagnosed with invasive ductal carcinoma (IDC) and had an average age of 49 years. The majority of patients (95%) were married and had children. Most patients received only vocational education or below (74%) and had a monthly family income of less than 10,000 yuan (81%). Partial medical insurance was the primary healthcare payment method for the patients (83%). Regarding the molecular subtypes of the primary tumor, luminal type (HR + HER2-), HER2-positive type (HER2+), and triple-negative type (HR-HER2-) had similar proportions. About half of the patients had CWR with skin involvement (50%) and visceral metastasis (55%). Approximately two-thirds of the enrolled patients had unresectable CWR lesions. In terms of the family caregivers (Supplementary Table 1), more than two-thirds of the participants were male, with an average age slightly lower than that of the patients at 45 years old. The majority of family caregivers were married (81%) and had children (79%), and 57% of family caregivers were employed. The patient's spouse was the primary family caregiver, while the remaining one-third were parents or children of the patients. Most caregivers had accumulated caregiving time exceeding 6 months (79%) and provided independent full-day caregiving (60%).

Table 1

Sociodemographic and Clinical Characteristics of Patients.
Factor	Median (Range)/Number (Frequency)
Age	49(27–71)
Marital Status (Yes/No)	40(95%)/2(5%)
Reproductive Status (Yes/No)	40(95%)/2(5%)
Education Level (Vocational Education or Below/Above)	31(74%)/11(26%)
Family Income (< 10,000/≥10,000 RMB per month)	34(81%)/8(19%)
Medical Payment Method (Out-of-pocket/Partial Medical Insurance/Full Medical Insurance)	3(7%)/35(83%)/4(10%)
Interests and Hobbies (Yes/No)	24(57%)/18(43%)
Family History (Yes/No)	6(14%)/36(86%)
ECOG Performance Score (0–1/2)	29(69%)/13(31%)
Tumor Characteristics
Primary Tumor Molecular Subtypes
Luminal (HR + HER2-)/HER2-positive (HER2+)/Triple-negative (HR-HER2-)	15(36%)/12(29%)/15(36%)
Skin Involvement (Yes/No)	21(50%)/21(50%)
Visceral Metastasis (Yes/No)	23(55%)/19(45%)
Local Treatment of Chest Wall Lesions (Yes/No)	12(29%)/30(71%)
Treatment Lines (< 3rd line/≥3rd line)	22(52%)/20(48%)

QoL stratified by skin involvement

Basic demographic and socio-economic characteristics of included patients with CWR and their family caregivers did not show significant deviations when divided into two groups based on the presence or absence of skin involvement in the chest wall lesions. Additionally, there were no notable differences in tumor characteristics of the included patients between the two groups (Table 2). However, compared to the group without skin involvement, patients in the group with skin involvement reported a greater impact of symptoms related to chest wall lesions on their QoL (P < 0.001). This suggested that skin involvement in CWR patients negatively affected their self-perception of breast disease and QoL.

Table 2

Stratification of Tumor Characteristics by Chest Wall Skin Involvement.
Tumor Characteristics	Skin Involvement (n = 21)	Nonskin Involvement (n = 21)	P-value
Primary Tumor Molecular Subtypes			0.607
Luminal (HR + HER2-)	6	9
HER2-positive (HER2+)	7	5
Triple-negative (HR-HER2-)	8	7
Visceral Metastasis			1.000
Yes	20	19
No	1	2
Local Treatment of Chest Wall Lesions			1.000
Yes	1	1
No	20	20
Treatment Lines			0.064
< 3rd line	8	14
≥ 3rd line	13	7
Disease-related Manifestations Affecting Quality of Life			< 0.001
Related to Chest Wall Lesions	17	2
Unrelated to Chest Wall Lesions	4	19
Chest Wall Lesion Diameter (cm)			0.061
< 3	6	12
≥ 3	15	9
Number of Chest Wall Lesions			0.204
1–3	6	10
> 3	15	11

As shown in Table 3, when stratifying patient’s QoL by the skin involvement in the chest wall, significant differences were observed in the future perspectives (functional dimension) and breast symptoms (symptom dimension) in the EORTC QLQ-BR23 questionnaire between the two groups. The skin involvement group had significantly lower scores in future perspectives and significantly higher scores in breast symptoms, with P-values of 0.043 and 0.012, respectively. Additionally, arm symptoms were more pronounced in the group with skin involvement, although it did not reach statistical significance compared to the group without skin involvement. In the EORTC QLQ-C30 questionnaire, the skin involvement group had lower scores in all functional scales, overall health status, and higher scores in pain symptoms compared to the group without skin involvement. It is worth noting that fatigue scores were the highest in the symptom scales for all included chest wall recurrence patients (regardless of skin involvement), and economic difficulties were a common challenge faced by these breast cancer patients (Table 4). There were no significant differences in the two subscales of the HADS questionnaire among patients with and without skin involvement, although patients with skin involvement were more likely to experience depression (Table 5). There were no differences in the HADS and SF-36 questionnaire to the family caregivers between the two groups (Supplementary Tables 2 and 3).

Table 3

Stratification of EORTC QLQ-BR23 Questionnaire by Skin Involvement.
QLQ-BR23	Skin Involvement (n = 21)	Nonskin Involvement (n = 21)	P-value
Body Image (BRBI)	52.4 ± 27.7	59.1 ± 23.8	0.403
Sexual Function (BRSEF)	92.1 ± 11.3	90.5 ± 17.1	0.725
Sexual Enjoyment (BRSEE)	87.3 ± 19.7	85.7 ± 22.5	0.809
Future Perspective (BRFU)	25.4 ± 31.5	46.0 ± 32.4	0.043
Systemic Therapy Side Effects (BRST)	19.3 ± 13.2	24.5 ± 15.8	0.252
Breast Symptoms (BRBS)	34.5 ± 31.1	14.7 ± 13.4	0.012
Arm Symptoms (BRAS)	41.8 ± 37.2	28.0 ± 26.0	0.173
Upset by Hair Loss (BRHL)	50.8 ± 35.9	46.0 ± 34.1	0.662

Table 4

Stratification of EORTC QLQ-C30 Questionnaire by Skin Involvement.
QLQ-C30	Skin Involvement (n = 21)	Nonskin Involvement (n = 21)	P-value
Physical Functioning (PF)	71.1 ± 26.5	75.9 ± 19.0	0.508
Role Functioning (RF)	67.5 ± 37.8	81.7 ± 26.8	0.165
Emotional Functioning (EF)	71.0 ± 22.8	74.6 ± 19.6	0.589
Cognitive Functioning (CF)	75.4 ± 22.7	77.8 ± 16.1	0.697
Social Functioning (SF)	50.8 ± 29.1	62.7 ± 28.3	0.187
Global Health Status (QL)	54.0 ± 28.7	60.3 ± 17.5	0.394
Fatigue (FA)	40.7 ± 30.1	40.7 ± 22.9	1.000
Nausea and Vomiting (NV)	12.7 ± 18.2	8.7 ± 15.5	0.450
Pain (PA)	38.1 ± 28.9	27.8 ± 17.7	0.173
Dyspnea (DY)	22.2 ± 21.9	19.0 ± 16.9	0.601
Insomnia (SL)	27.0 ± 30.9	30.2 ± 34.8	0.756
Appetite Loss (AP)	15.9 ± 25.0	19.0 ± 27.0	0.695
Constipation (CO)	25.4 ± 25.6	19.0 ± 24.9	0.419
Diarrhea (DI)	9.5 ± 15.4	6.3 ± 13.4	0.481
Financial Impact (FI)	50.8 ± 29.1	52.4 ± 37.4	0.878

Table 5

Stratification of HADS Questionnaire for Patients by Skin Involvement.
HADS	Skin Involvement (n = 21)	Nonskin Involvement (n = 21)	P-value
Anxiety (A)			0.747
Asymptomatic	13	14
Symptomatic	8	7
Depression (D)			0.116
Asymptomatic	10	15
Symptomatic	11	6

Prognosis and dynamic changes

We analyzed the predictive values of clinical and pathological characteristics, as well as questionnaire scores, on clinical outcomes and treatment efficacy in included patients. Using the Kaplan-Meier survival analysis, we found that ECOG performance status (HR = 2.994, 95% CI 1.364–6.571, P = 0.006), skin involvement (HR = 4.464, 95% CI 1.998–9.971, P < 0.001), and lines of treatment (HR = 2.875, 95% CI 1.322–6.251, P = 0.008) significantly influenced disease progression in patients with recurrent breast cancer (Fig. 1). Higher ECOG performance status and increased treatment lines were associated with worse prognosis, which was widely recognized in clinical practice. While the association between skin involvement and prognosis was rarely discussed, we found that skin involvement indicated an increased risk of disease progression in patients with recurrent breast cancer. We also analyzed the dynamic changes in EORTC QLQ-C30 and QLQ-BR23 scores from three consecutive questionnaires (Supplementary Table 4). Compared to patients without skin involvement (5%), patients with skin involvement (29%) were more likely to experience the deterioration of arm symptoms.

For breast cancer patients, the physical pain and psychological anxiety caused by malignant tumors are inevitable. In recent years, patients’ QoL has been increasingly emphasized in the treatment of recurrent or metastatic breast cancer. In many clinical studies exploring treatment strategies, patients’ QoL is often assessed as a secondary endpoint (Vanbutsele et al. 2018; Clemons et al. 2021; Poort et al. 2020; Kaufman et al. 2020). In this study, various assessment tools were used to evaluate the QoL of patients and caregivers, including the EORTC QLQ-C30 (Version 3.0) questionnaire, the EORTC QLQ-BR23 questionnaire, the HADS questionnaire, and the SF-36 assessment. We investigated the predictor of QoL in patients with recurrent disease and their family caregivers and also identified the prognostic factor in these patients. We found that, under the premise of no significant deviation in baseline clinical and pathological characteristics and socioeconomic factors, skin involvement, similar to ECOG performance status and treatment lines, could predict disease progression in patients with chest wall recurrence. In the group with skin involvement, breast symptoms worsened and future prospects decreased, while multiple functional scales and overall health status declined compared to the group without skin involvement. Through dynamic change analysis, patients with skin involvement were more likely to experience the deterioration of arm symptoms. Fatigue caused by chest wall disease and the economic burden caused by treatment were significant issues that were not overlooked for all patients.

The complex network of various cell types and the flexibility of dermal vessels and lymph nodes in the skin play a crucial role in tumor development. Patients with skin metastases have the lowest levels of tumor-infiltrating lymphocytes (TILs) compared to other metastatic lesions of primary breast cancer (Dieci et al. 2018). This suggests that cutaneous tissue may exhibit an "immune privilege" for tumor growth (Gilhar et al. 2007; Wang et al. 2014). Structurally, the regional distribution of dermal lymph vessels in the skin constitutes a functional unit (Güth et al. 2006). The suppressive immune microenvironment in the skin cannot eliminate tumors, while the abundant vascular and lymphatic system in the dermis provides nutrition and pathways for tumor growth, invasion, and metastasis. Our previous studies also found that skin involvement predicted poorer disease-free survival (DFS) in patients with CWR, and these patients with skin involvement tended to experience persistent chest wall progression (Zhou et al. 2023).

Breast cancer patients, especially those with skin involvement, often present with symptoms such as redness, rash, ulceration, localized pain, lymphedema, and impaired arm movement. In the symptom scale of the EORTC QLQ-BR23 questionnaire, some response patterns also aligned with the expected direction. This study found that patients with skin involvement on the chest wall experienced more severe breast and arm symptoms and reduced future prospects, leading to a decreased QoL. For patients with skin involvement, nursing interventions needed to be focused on alleviating local symptoms and enhancing confidence in the future, as these measures could help improve their QoL. However, in the EORTC QLQ-C30 questionnaire, there were no significant differences observed in various symptom scales when categorized based on the skin involvement, indicating no statistical significance. We observed that fatigue, as a common symptom among cancer patients, was the most severe among the eight symptoms mentioned in the questionnaire, which was consistent with the findings of Barnes et al. (2002). Implementing interventions that effectively control the symptoms mentioned above could improve the condition of patients with recurrent chest wall and enhance their overall QoL, particularly for those with skin involvement. Economic burden was also one of the higher-scoring items in the EORTC QLQ-C30 questionnaire. The diagnosis and subsequent treatment of breast cancer imposed significant financial burdens on patients and their families (Longo et al. 2006), and most of the surveyed individuals in this study had partial medical insurance coverage, which might make it difficult to afford expensive treatment costs. Government support and the development of affordable and effective intervention measures for patients could effectively improve recurrent breast cancer patients’ QoL (Arozullah et al. 2004), especially for low-income or long-term treatment patients. Regarding role functioning, the results of this study showed that the five functional scales and overall health status of the EORTC QLQ-C30 questionnaire were all poorer in the group with skin involvement compared to the group without skin involvement. These findings suggested that in the care of recurrent breast cancer patients, especially those with skin involvement, attention should be given to changes in patients’ role functioning and assisting in improving their role adaptation, as role functioning might have a widespread impact on patients’ QoL. However, there were no significant differences in family caregivers’ QoL scores between the group of patients with skin involvement and the group of patients without skin involvement. The results of this study suggested that family caregivers’ QoL did not deteriorate based on whether the patient had skin involvement in the chest wall lesions. It was recommended that family members spent more time with patients with skin involvement and communicated with them to help improve their QoL. It was worth noting that this study did not demonstrate changes in family caregivers’ QoL, which might be due to the relatively short duration of follow-up.

The limitations of our research are as follows. The small sample size and relatively short follow-up time resulted in limitations of statistical power and potential bias in the results. We analyzed the clinical pathological characteristics and socio-economic factors of included patients with recurrent chest wall, and there were no significant differences in skin involvement group and nonskin involvement group. The results should still be interpreted with caution. Second, pretreatment QoL data of the patients were lacking. It could be argued that pretreatment QoL was more likely to reflect (premorbid) disease-specific characteristics, whereas posttreatment QoL and changes in QoL reflected treatment-specific characteristics.

Based on the inclusion of breast cancer patients with recurrent chest wall who had no significant differences in clinical pathological characteristics and socio-economic factors, this study analyzed the stratification factors of the QoL of patients with recurrent breast cancer and their association with prognosis. Chest wall recurrence patients with skin involvement had shorter disease progression intervals, more sever breast symptoms, and more decreased future prospects, compared to the population without skin involvement. Fatigue and financial burden were significant issues that were not overlooked for all patients. This research further enhanced our understanding of the QoL of patients with recurrent breast cancer and their family caregivers, providing new insights for personalized care for these patients. Additionally, the study employed various QoL assessment tools, which complemented each other and should be used together to obtain a more comprehensive understanding of the QoL of patients with CWR and their family caregivers. Furthermore, the study provided a reference for the application and promotion of assessment tools in the management of breast cancer.

Acknowledgments

Funding

This work was supported by [Natural Science Foundation of Guangdong Province] (Grant number [2019A1515011945] and [2020A1515010105]).

Competing Interests

The authors have no relevant financial or non-financial interests to disclose.

Author Contributions

All authors contributed to the study conception and design.

Analysis and interpretation: Danyang Zhou, Qiulian Linand Zhihui Cao;

Original Draft Preparation: Danyang Zhou and Wei Wu;

Review and editing: Qiaohong Nong, Ruoxi Hong and Shusen Wang;

All authors read and approved the final manuscript.

Data Availability

The datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request.

Ethics approval

This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethics Committee of Sun Yat-sen University Cancer Center (No. B2020-282-01).

Consent to participate

Informed consent was obtained from all individual participants included in the study.

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No competing interests reported.

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The impact of skin involvement on the quality of life of breast cancer patients with chest wall recurrence and their caregivers

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Abstract

Purpose

Methods

Results

Conclusion

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Introduction

Methods

Results

Demographic and clinical characteristics

QoL stratified by skin involvement

Prognosis and dynamic changes

Discussion

Declarations

References

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Supplementary Files

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