Abstract
Background
Health-related quality of life (HRQoL) has long been recognized as a critical area of cancer research as it reflects patients’ well-being, but less is known if HRQoL predicts survival outcomes in survivors of early stage breast cancer.
Aims
We assessed racial disparities in HRQoL and the impact of HRQoL on survival outcomes in breast cancer survivors.
Methods
This study included a total of 721 breast cancer survivors from the Chicago Multiethnic Epidemiologic Breast Cancer Cohort who completed the Functional Assessment of Cancer Therapy-Breast (FACT-B) instrument in 2020. We examined racial differences in FACT-B scores and patient characteristics correlated with FACT-B and its subscales using multiple linear regression. We used Cox regression to assess the associations between HRQoL assessments and survival outcomes.
Results
Functional well-being score was lower in Black survivors than in White survivors (mean score: 19.6 vs. 20.9, P = 0.003). Being married was associated with a higher HRQoL score. Having a recurrence before interview and comorbidities worsened physical and emotional well-being. The total FACT-B score were significant predictors of both all-cause [hazard ratio (HR) = 0.68 per standard deviation, 95% CI 0.48–0.95] and breast cancer-specific mortality (HR = 0.57, 95% CI 0.37–0.88). Physical and functional well-being subscales were found to be associated with all-cause and breast cancer-specific mortality, and recurrence-free survival. Emotional well-being predicted breast cancer-specific mortality.
Conclusions
Our findings highlighted racial disparities in HRQoL and HRQoL associated with survival outcomes in breast cancer, suggesting the need to reduce the disparities and examine the long-term impact of HRQoL on health outcomes in future studies.
Keywords: Breast cancer, Quality of life, Racial disparities, Survival outcomes
Background
In the United States (US), breast cancer is the most common cancer among women and represents 32% of new cancer cases in this population [1]. Medical advances have significantly improved early detection, treatment, and survival of breast cancer. Despite these achievements, breast cancer remains a critical issue, with estimated 310,720 female breast cancer diagnoses in 2024 in the US [1]. Between 2013 and 2019, the 5-year breast cancer rates are 92% and 85% for White and Black women, respectively [2]. There are approximately 4 million breast cancer survivors in the US [3]. Among cancer survivors, there is an increasing emphasis on improving the quality of life (QoL) during and after treatment and identifying factors that impact survivorship.
The World Health Organization defines QoL as “an individual’s perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards, and concerns [4].” Breast cancer patients face many challenges, including physical symptoms, treatment side effects, financial burdens, and psychosocial distress [5]. Cancer significantly affects patients’ and survivors’ QoL, impacting their work life, relationships, and the uncertainty surrounding the disease [6]. Health-related quality of life (HRQoL) is influenced by individual factors such as treatment modality, tumor stage, and community and social factors. Despite a lower incidence rate of breast cancer among Black women in the US, they experience a 40% higher mortality rate compared to White women [7]. Hence, it is important to examine HRQoL across racial groups and understand its contribution to survival disparities for the growing population of breast cancer survivors.
The COVID-19 pandemic has had a devastating impact on the cancer care continuum, resulting in delays in diagnosis and treatment and an increase in psychological stress for patients. Cancer patients were particularly vulnerable during the pandemic as they were more likely to suffer from complications due to COVID-19 [8]. They may experience increased stress due to treatment disruptions, immunocompromised status, and contracting COVID-19 [9]. A previous study by our team found that patients reported more isolation in addition to financial challenges during the pandemic [10]. Additionally, marginalized populations, including Blacks and Hispanics, have suffered from worse health and socioeconomic outcomes during the pandemic. These experiences have the potential to worsen breast cancer patients’ HRQoL and negatively impact their survival outcomes. Racial gaps in HRQoL have been documented in the literature [11–13], but less is known about racial gaps during COVID-19 pandemic among breast cancer survivors. It is critical to understand HRQoL and related outcome disparities among breast cancer survivors as we continue to navigate the current and future pandemics.
Multiple instruments have been developed to assess the HRQoL of breast cancer patients and survivors, including the commonly used Functional Assessment of Cancer Therapy-Breast (FACT-B) and European Organization for Research and Treatment of Cancer (EORTC) QLQ-BR23 instruments [14–17]. Assessing HRQoL can help inform patients’ treatment course and follow-up in remission. Subjective HRQoL measures may be predictive of survival, but inconsistent results have been reported in prior studies [18–20]. Pooled analyses of clinical trial data showed that several functional subscales from the EORTC were associated with overall survival [19, 20]. These studies were conducted among patients with advanced breast cancer or multiple cancer sites, and HRQoL was assessed during treatment. It is unknown if HRQoL is a prognostic factor in breast cancer patients and survivors.
Our study had three main aims: (1) to assess the HRQoL of breast cancer survivors during the COVID-19 pandemic using the FACT-B instrument and examine whether racial disparities in HRQoL exist; (2) to identify characteristics associated with FACT-B and its subscales’ scores; and (3) to determine whether HRQoL assessments predict breast cancer survival outcomes.
Materials and methods
Study population
Between July and September 2020, we conducted a survey among breast cancer survivors and healthy women enrolled into the Chicago Multiethnic Epidemiologic Breast Cancer Cohort (ChiMEC) study [10] to investigate the impact of COVID-19 quarantine and isolation policy on treatment disruption and financial burden. Of the 1300 survivors who finished the COVID-19 survey, we also sent a FACT-B questionnaire to better understand multiple dimensions of HRQoL during the COVID-19 pandemic. Of participants who responded to the FACT-B survey, we further excluded male survivors (n = 4) from our main analysis. The study was approved by the Institutional Review Board at the University of Chicago.
Measures
The Functional Assessment of Cancer Therapy-General (FACT-G) is a 27-item instrument that measures the HRQoL of cancer patients covering four major components: physical well-being, social well-being, emotional well-being, and functional well-being. The FACT-B is a 37-item tool that assesses the HRQoL of breast cancer [17], with a breast cancer-specific concern component added to the FACT-G. Each section had 6–10 statements to which participants were asked to what extent they agreed with these statements. To calculate each subscale’s score, we multiplied the sum of each item’s score by the number of items in the subscale and divided by the number of items answered. The FACT-B total score was obtained by summing the scores of all the subscales. The trial outcome index score was calculated by adding the physical and functional well-being scores, along with the breast cancer-specific score. In addition, our survey included COVID-19 specific questions such as “How isolated are you feeling now due to COVID-19?” and “Do you feel supported by friends and family during this time of COVID-19?” Using these questions, our team developed an isolation/stress score representing feelings of isolation, stress, and social support during the COVID-19 pandemic [10]. The isolation/stress score has good internal consistency with a Cronbach α of 0.848, with higher scores indicating worse isolation and higher stress levels. Patients’ demographic and clinical characteristics were obtained from electronic medical records and our hospital cancer registry.
Breast cancer survival outcomes were: (1) all-cause mortality, defined as the time from the date of interview to the date of death from any causes or the last follow-up date; (2) breast cancer-specific mortality, defined as the time from date of interview to the date of dying from breast cancer or the date of last follow-up; (3) recurrence-free survival (RFS), defined as the time from the date of interview to the first occurrence of breast cancer recurrence, death from any causes, or date of last follow-up. Vital status was obtained from our hospital cancer registry, records of clinical visits, and the National Death Index (NDI), a resource of mortality data from death certificates in the US [21]. The underlying causes of death were derived from NDI, and the recurrence history was ascertained by checking survivors’ clinical records.
Statistical analysis
A χ2 test was used to compare categorical demographic and clinical characteristics between Non-Hispanic Black (“Black”), Non-Hispanic White (“White”), and other racial/ethnic survivors. To compare the racial differences in FACT-B and its subscales’ scores, we fit linear regression models with the main focus on the difference between Black and White survivors because the sample size of other racial/ethnic group is relatively small. In addition, we conducted univariate analysis to identify characteristics associated with FACT-B and its subscales’ scores. We examined four types of predictors, including demographic characteristics, cancer-related factors, the Charlson–Deyo Comorbidity Index (CCI), and time from breast cancer diagnosis to FACT-B interview. A forward selection procedure was used to build the final multiple linear regression models for prediction of scores in FACT-B, FACT-G, and their subscales. Linear coefficients (coef) and 95% confidence intervals (95% CI) were calculated. Cox proportional hazards regression models were fit to evaluate HRQoL assessment categories (FACT-G, FACT-B and their subscales) as predictors of breast cancer survival outcomes. Hazard ratios (HR) and 95% CIs were calculated. All statistical analyses were conducted using the STATA software version 17.1 (StataCorp LLC, College Station, Texas).
Results
Of the 1300 surveys sent, 721 (55.5%) female survivors completed the FACT-B questionnaire and were included in our study. Of them, 545 (75.6%) participants identified as White, 130 (18.0%) as Black, and 46 (6.4%) as other races or ethnicities. The demographic and clinical characteristics by racial groups are summarized in Table 1. The average age at survey was 60.9 years (SD 11.9). Black women tended to be older and were more likely to be single and have lower proportions of attaining a bachelor’s degree and above. Most survivors had private insurance (71.8%), followed by Medicare (21.9%) and Medicaid (3.4%). Black survivors were more likely to have estrogen receptor-negative and progesterone receptor-negative tumors than White and Other racial groups. Hormone therapy was administered to 70.2% of survivors, although the percentage was lower among Black women (61.9%). 64.3% of Black survivors received breast-conserving surgery, which was significantly higher than other racial groups (Table 1).
Table 1.
Demographic and clinical characteristics of breast cancer patients, overall and by racial groups
| Characteristic | Overall (N = 721) | White (n = 545) | Black (n = 130) | Others (n = 46) | P-valuea |
|---|---|---|---|---|---|
|
| |||||
| Age at survey in years, mean (SD) | 60.9 (11.9) | 60.8 (11.4) | 64.0 (12.2) | 53.8 (13.4) | < 0.001 |
| Years from diagnosis to FACT-B interview, median (IQR) | 4.5 (6.4) | 4.4 (6.5) | 5.2 (6.6) | 3.9 (4.2) | 0.330 |
| Marital status | < 0.001 | ||||
| Single | 115 (16.4) | 65 (12.3) | 40 (31.5) | 10 (21.7) | |
| Married | 502 (71.4) | 405 (76.4) | 64 (50.4) | 33 (71.7) | |
| Separated/Divorced/Widowed | 86 (12.2) | 60 (11.3) | 23 (18.1) | 3 (6.5) | |
| Level of education | 0.001 | ||||
| High school or less | 88 (13.9) | 63 (13.3) | 22 (19.1) | 3 (6.7) | |
| Some college | 115 (18.1) | 78 (16.4) | 32 (27.8) | 5 (11.1) | |
| Bachelor’s degree | 189 (29.8) | 149 (31.4) | 29 (25.2) | 11 (24.4) | |
| Graduate degree or above | 243 (38.3) | 185 (39.0) | 32 (27.8) | 26 (57.8) | |
| Primary payer at diagnosis | < 0.001 | ||||
| Medicare | 149 (21.9) | 103 (20.2) | 40 (31.8) | 6 (13.3) | |
| Private Insurance | 489 (71.8) | 386 (75.7) | 66 (52.4) | 37 (82.2) | |
| Medicaid | 23 (3.4) | 5 (1.0) | 17 (13.5) | 1 (2.2) | |
| Not insured/Unknown | 8 (1.2) | 6 (1.2) | 1 (0.8) | 1 (2.2) | |
| Other | 12 (1.8) | 10 (2.0) | 2 (1.6) | 0 | |
| Charlson Comorbidity Index | 0.020 | ||||
| 0 | 594 (87.2) | 451 (88.4) | 101 (80.2) | 42 (93.3) | |
| 1+ | 87 (12.8) | 59 (11.6) | 25 (19.84) | 3 (6.7) | |
| AJCC stage group | 0.456 | ||||
| 0 | 107 (15.9) | 74 (14.6) | 24 (19.2) | 9 (20.5) | |
| I | 306 (45.3) | 239 (47.1) | 49 (39.2) | 18 (40.9) | |
| II | 190 (28.1) | 137 (27.0) | 41 (32.8) | 12 (27.3) | |
| III | 68 (10.1) | 54 (10.7) | 9 (7.2) | 5 (11.4) | |
| IV | 5 (0.7) | 3 (0.6) | 2 (1.6) | 0 | |
| Tumor grade | 0.006 | ||||
| 1 | 90 (14.0) | 71 (14.7) | 11 (9.3) | 8 (18.6) | |
| 2 | 306 (47.4) | 243 (50.2) | 44 (37.3) | 19 (44.2) | |
| 3 | 249 (38.6) | 170 (35.1) | 63 (53.4) | 16 (37.2) | |
| Estrogen receptor status | 0.013 | ||||
| Negative | 134 (20.7) | 92 (19.0) | 36 (30.2) | 6 (14.0) | |
| Positive | 513 (79.3) | 393 (81.0) | 83 (69.8) | 37 (86.1) | |
| Progesterone receptor status | 0.026 | ||||
| Negative | 217 (33.6) | 154 (31.9) | 52 (43.7) | 11 (25.6) | |
| Positive | 428 (66.4) | 329 (68.1) | 67 (56.3) | 32 (74.4) | |
| HER2 status | 0.006 | ||||
| Negative | 456 (84.9) | 357 (87.7) | 73 (76.0) | 26 (76.5) | |
| Positive | 81 (15.1) | 50 (12.3) | 23 (24.0) | 8 (23.5) | |
| Hormone therapy | 0.038 | ||||
| No | 203 (29.8) | 146 (28.6) | 48 (38.1) | 9 (20.0) | |
| Yes | 478 (70.2) | 364 (71.4) | 78 (61.9) | 36 (80.0) | |
| Chemotherapy | 0.649 | ||||
| No | 390 (57.3) | 296 (58.0) | 71 (56.4) | 23 (51.1) | |
| Yes | 291 (42.7) | 214 (42.0) | 55 (43.7) | 22 (48.9) | |
| Radiation therapy | 0.583 | ||||
| No | 259 (38.0) | 298 (38.8) | 47 (37.3) | 14 (31.1) | |
| Yes | 422 (62.0) | 312 (61.2) | 79 (62.7) | 31 (68.9) | |
| Surgery | 0.004 | ||||
| No surgery | 6 (0.9) | 2 (0.4) | 4 (3.2) | 0 | |
| Breast-conserving surgery | 404 (59.8) | 298 (59.0) | 81 (64.3) | 25 (55.6) | |
| Mastectomy | 194 (28.7) | 141 (27.9) | 37 (29.4) | 16 (35.6) | |
| Bilateral mastectomy | 72 (10.7) | 64 (12.7) | 4 (3.2) | 4 (8.9) | |
| Recurrence before interview | 0.132 | ||||
| No | 686 (95.2) | 514 (94.3) | 126 (96.9) | 46 (100) | |
| Yes | 35 (4.9) | 31 (5.7) | 4 (3.1) | 0 | |
SD standard deviation, IQR interquartile range, CCI Charlson Comorbidity Index, AJCC American Joint Committee on Cancer, HER2 human epidermal growth factor receptor 2
P-values were based on the ANOVA F tests, χ2 tests or Fisher’s exact tests, as appropriate, comparing White, Black and other races
Table 2 shows the FACT-B and its subscales’ scores stratified by racial groups. The total FACT-B score was not significantly different between White, Black, and Other racial survivors. The functional well-being score was significantly lower in Black survivors (mean score, 19.6 [SD 7.0]) than White survivors (mean score, 20.9 [5.7], P = 0.003). Other racial survivors had marginally, significantly lower social well-being and breast cancer concern scores than Black and White survivors.
Table 2.
FACT-B and its subscale scores for breast cancer patients by racial groups
| Scale | Overall | White | Black | Others | P-valuea | P-valueb |
|---|---|---|---|---|---|---|
| Mean score (SD) | ||||||
|
| ||||||
| FACT-Bc | 112.7 (19.7) | 113.2 (19.3) | 111.8 (19.8) | 109.0 (23.1) | 0.322 | 0.726 |
| FACT-Gc | 86.5 (15.3) | 87.0 (15.1) | 85.1 (15.6) | 84.5 (16.9) | 0.288 | 0.675 |
| Physical | 24.5 (4.1) | 24.6 (4.0) | 23.9 (4.3) | 24.4 (3.9) | 0.173 | 0.220 |
| Social/family | 22.0 (5.4) | 22.2 (5.3) | 21.8 (5.1) | 20.2 (6.7) | 0.056 | 0.733 |
| Emotional | 19.3 (3.8) | 19.3 (3.8) | 19.8 (3.5) | 18.6 (4.7) | 0.141 | 0.135 |
| Functional | 20.7 (6.0) | 20.9 (5.7) | 19.6 (7.0) | 21.2 (5.8) | 0.063 | 0.003 |
| Breast cancer concern | 26.3 (5.8) | 26.3 (5.7) | 26.9 (5.7) | 24.6 (7.4) | 0.067 | 0.877 |
| Trial outcome index | 71.5 (13.2) | 71.9 (12.8) | 70.6 (14.1) | 70.2 (15.0) | 0.479 | 0.316 |
FACT-B Functional Assessment of Cancer Therapy Scale–Breast Cancer, FACT-G Functional Assessment of Cancer Therapy Scale–General, SD standard deviation
P-values were based on the ANOVA F test comparing scores between White, Black and other races
P-values were based on the ANOVA F test comparing scores between White and Black patients
Higher scores indicate better quality of life. The maximum scores for FACT-B, FACT-G, trial outcome index, physical, social, emotional, functional, and breast cancer concern subscales are 144, 108, 92, 28, 28, 24, 28, and 36, respectively
Our pairwise correlation analysis, illustrated in Fig. 1, revealed a negative correlation between isolation/stress scores and HRQoL assessments, with stronger correlations for the emotional well-being and total scores (FACT-B and FACT-G). This indicated that the worse the HRQoL the survivors experienced, the more isolated or stressed they felt. According to our univariate analysis, marital status, chemotherapy receipt, recurrence before the interview, CCI, and time from breast cancer diagnosis to FACT-B interview were statistically associated with FACT-B and its subscales. Table 3 presents the multivariable models for correlates of FACT-B and its subscales’ scores. Having disease recurrence before the interview substantially decreased all scores, except for social and functional well-being. Specifically, previous recurrence was associated with 11.26 units decline (95% CI − 18.54, − 3.98) in the FACT-B score and 2.93 units decline (95% CI − 4.34, − 1.53) in the emotional well-being score. Receiving chemotherapy and having a CCI of 1+ were significantly associated with decreases in FACT-B (− 4.46, 95% CI − 7.46, − 1.45), FACT-G (− 2.64, 95% CI − 4.98, − 0.30), physical well-being (− 0.94, 95% CI − 1.55, − 0.33), and breast cancer concern (− 1.89, 95% CI − 2.76, − 1.01) scores. Additionally, having a CCI of 1+ was associated with significant reductions in the social and functional well-being scores by 1.40 (95% CI − 2.60, − 0.20) and 2.31 (95% CI − 3.67, − 0.95) units, respectively (Table 3). Survivors who were married had a substantial increased average score in FACT-G (3.65), social well-being (2.06), and functional well-being (1.47) than those who were single or never married. For every 1-year increase from diagnosis to FACT-B interview, the average physical wellbeing, emotional well-being, and breast-cancer specific concern scores were 0.11, 0.09, and 0.10 higher, respectively.
Fig. 1.
Pairwise correlation coefficients between isolation/stress score and FACT-B and its subscales for breast cancer patients
Table 3.
Correlates of FACT-B and its subscales among breast cancer patients: multiple linear regression analysis
| FACT-B | FACT-G | Physical | Social/family | Emotional | Functional | Breast cancer concern | |
|---|---|---|---|---|---|---|---|
| Coef (95% CI)a | Coef (95% CI)a | Coef (95% CI)a | Coef (95% CI)a | Coef (95% CI)a | Coef (95% CI)a | Coef (95% CI)a | |
|
| |||||||
| Marital status | |||||||
| Single/Never married | 0.00 (Ref.) | 0.00 (Ref.) | 0.00 (Ref.) | 0.00 (Ref.) | 0.00 (Ref.) | 0.00 (Ref.) | 0.00 (Ref.) |
| Married | 3.60 (− 0.42, 7.61) | 3.65 (0.51, 6.79)* | 0.32 (− 0.49, 1.14) | 2.06 (0.97, 3.15)# | − 0.01 (− 0.80, 0.77) | 1.47 (0.24, 2.70)* | − 0.01 (− 1.19, 1.17) |
| Separated/Divorced/Widowed | 4.20 (− 1.55, 9.94) | 3.46 (− 1.03, 7.95) | 0.65 (− 0.50, 1.79) | 1.97 (0.43, 3.51)* | 0.28 (− 0.84, 1.40) | 1.02 (− 0.72, 2.75) | 0.91 (− 0.76, 2.59) |
| Chemotherapy | |||||||
| No | 0.00 (Ref.) | 0.00 (Ref.) | 0.00 (Ref.) | 0.00 (Ref.) | 0.00 (Ref.) | 0.00 (Ref.) | 0.00 (Ref.) |
| Yes | − 4.46 (− 7.46, − 1.45)† | − 2.64 (− 4.98, − 0.30)* | − 0.94 (− 1.55, − 0.33)† | − 0.57 (− 1.38, 0.24) | − 0.48 (− 1.07, 0.10) | − 0.47 (− 1.39, 0.45) | − 1.89 (− 2.76, − 1.01)# |
| Recurrence before interview | |||||||
| No | 0.00 (Ref.) | 0.00 (Ref.) | 0.00 (Ref.) | 0.00 (Ref.) | 0.00 (Ref.) | 0.00 (Ref.) | 0.00 (Ref.) |
| Yes | − 11.26 (− 18.54, − 3.98)† | − 8.87 (− 14.56, − 3.19)† | − 2.55 (− 4.01, − 1.09)† | − 0.86 (− 2.81, 1.08) | − 2.93 (− 4.34, − 1.53)# | − 2.12 (− 4.33, 0.09) | − 2.42 (− 4.56, − 0.27)* |
| CCI | |||||||
| 0 | 0.00 (Ref.) | 0.00 (Ref.) | 0.00 (Ref.) | 0.00 (Ref.) | 0.00 (Ref.) | 0.00 (Ref.) | 0.00 (Ref.) |
| 1+ | − 7.60 (− 12.02, − 3.18)† | − 5.92 (− 9.37, − 2.47)† | − 1.63 (− 2.53, − 0.73)† | − 1.40 (− 2.60, − 0.20)* | − 0.65 (− 1.51, 0.22) | − 2.31 (− 3.67, − 0.95)† | − 1.69 (− 2.99, − 0.39)* |
| Time from diagnosis to FACT-B interview, per year | 0.28 (− 0.04, 0.60) | 0.18 (− 0.07, 0.43) | 0.11 (0.05, 0.17)† | − 0.06 (− 0.14, 0.03) | 0.09 (0.03, 0.15)† | 0.05 (− 0.04, 0.15) | 0.10 (0.01, 0.20)* |
CI confidence interval, ref. reference, CCI Charlson Comorbidity Index, FACT-B Functional Assessment of Cancer Therapy Scale–Breast Cancer, FACT-G Functional Assessment of Cancer Therapy Scale–General
P < 0.05;
P < 0.01;
P < 0.001
β Coefficients were adjusted for all variables presented in the table in the multiple linear regression models
After a median follow-up of 37 months, 25 participants died and 13 of them died of breast cancer. During the follow-up, 10 participants had breast cancer recurrence. Table 4 presents HRQoL assessments as predictors for survival outcomes. An increase of in nearly all assessment scores was associated with a reduced risk of death or recurrence. Patients with 1 SD higher FACT-B score had a reduced risk of all-cause mortality (HR = 0.68, 95% CI 0.48, 0.95) and of breast cancer-specific mortality (HR = 0.57, 95% CI 0.37, 0.88). The trial outcome index was significantly associated with reduced risk for all survival outcomes: all-cause mortality (HR = 0.62, 95% CI 0.44, 0.87), breast cancer-specific mortality (HR = 0.53, 95% CI 0.34, 0.83), and RFS (HR = 0.69, 95% CI 0.51, 0.94, Table 4). Similar associations were observed for physical well-being scores and functional well-being scores. Survivors with a higher breast cancer concern score had reduced risks of all the survival outcomes, although only the association with all-cause mortality was statistically significant. The emotional well-being score was associated with reduced risks of mortality or recurrence, although only the association with breast cancer-specific mortality was statistically significant. There were no associations between the social well-being score and survival outcomes.
Table 4.
FACT-B and its subscales as predictors for survival outcomes after interview among breast cancer patients
| Scale | No. of patients | All-cause mortality |
Breast cancer-specific mortality |
Recurrence-free survival |
|||
|---|---|---|---|---|---|---|---|
| No. of events | HR (95% CI)a | No. of events | HR (95% CI)a | No. of events | HR (95% CI)a | ||
|
| |||||||
| FACT-B | 702 | 24 | 0.68 (0.48, 0.95)* | 13 | 0.57 (0.37, 0.88)* | 30 | 0.76 (0.55, 1.04) |
| FACT-G | 704 | 24 | 0.69 (0.49, 0.97)* | 13 | 0.56 (0.37, 0.86)† | 30 | 0.77 (0.56, 1.06) |
| Trial outcome index | 707 | 24 | 0.62 (0.44, 0.87)† | 13 | 0.53 (0.34, 0.83)† | 30 | 0.69 (0.51, 0.94)* |
| Physical | 715 | 25 | 0.68 (0.52, 0.89)† | 13 | 0.56 (0.40, 0.77)# | 31 | 0.75 (0.58, 0.99)* |
| Social/family | 708 | 24 | 0.98 (0.66, 1.46) | 13 | 0.84 (0.51, 1.38) | 30 | 1.09 (0.75, 1.60) |
| Emotional | 705 | 24 | 0.72 (0.52, 1.01) | 13 | 0.61 (0.40, 0.92)* | 30 | 0.78 (0.57, 1.06) |
| Functional | 717 | 24 | 0.68 (0.48, 0.96)* | 13 | 0.60 (0.38, 0.94)* | 30 | 0.72 (0.53, 0.99)* |
| Breast cancer concern | 713 | 24 | 0.69 (0.48, 0.98)* | 13 | 0.67 (0.41, 1.09) | 30 | 0.76 (0.54, 1.05) |
FACT-B Functional Assessment of Cancer Therapy Scale–Breast Cancer, FACT-G Functional Assessment of Cancer Therapy Scale–General, No. number, HR hazard ratio, CI confidence interval
P < 0.05;
P < 0.01;
P < 0.001
Hazard ratio per standard deviation
Discussion
In this study, we used the FACT-B questionnaire to assess racial differences in HRQoL among breast cancer survivors. We found that Black survivors have significant lower functional well-being than White survivors, but no significant differences in other subscales of the FACT-B score between the two racial groups. Several correlates of HRQoL among breast cancer survivors were found, including marital status, having cancer recurrence before the interview, having received chemotherapy, or more comorbidities. In the analysis of FACT-B and its subscales as predictors for breast cancer survival outcomes, we showed a significant 32% reduced risk of all-cause mortality and 43% reduced risk of breast cancer-specific mortality with 1 SD increase in total FACT-B score.
Previous studies have demonstrated disparities in breast cancer survival outcomes across racial and ethnic groups [21, 22]. Various socioeconomic determinants have been considered to contribute to these disparities, such as poverty, access to care, social injustice, and distrust of the health system [21, 23]. Our study sought to investigate whether racial disparities also exist in HRQoL scores among breast cancer survivors and how these disparities could affect survival outcomes. We found that White survivors had significantly higher functional well-being scores than Black survivors. This finding aligns with previous research conducted before the COVID-19 pandemic [11–13]. The relatively lower scores for Black patients may be attributed to systematic barriers, including access to care and financial constraints. As our study was conducted during the COVID-19 pandemic, for which exacerbated pre-existing racial disparities across various sectors, including unemployment, healthcare, education, and food insecurity. Interestingly, although not statistically significant, our results showed that Black survivors had higher emotional well-being scores than White survivors. This finding is consistent with prior studies reporting stronger spiritual support available to Black survivors [11, 12, 24]. These findings suggest the need for interventions to address racial disparities and improve functional and emotional well-being among breast cancer survivors. They also underscore the need to examine the long-term effects of disparities exacerbated by COVID-19 on their quality of life.
Equally important, survivors who were married had better social and functional well-being than those who were single or never married. Previous studies have shown that stable marriages provide economic security and better social support, both of which are associated with better HRQoL [25, 26]. Specifically, during the COVID-19 pandemic, single individuals were more likely to experience feelings of loneliness, isolation, and reduced social support than those with a partner [27, 28], as our study showed strong correlations between the isolation/stress scores and FACT-B scores. We also found that breast cancer survivors undergoing chemotherapy or managing more comorbidities had lower HRQoL scores. These findings are aligned with existing literature that chemotherapy-induced side effects and/or comorbidities are associated with worse physical and social well-being, as they limit the ability to work and reduce opportunities for social interaction [29–32]. In addition, we found that a history of breast cancer recurrence was associated with a lower HRQoL score. Recurrence can take months or years after remission, often triggering feelings of worry, anxiety, and reduced social support [33]. The fear of recurrence itself could also contribute to the decline in HRQoL. These findings highlight the complex factors that affect HRQoL of breast cancer survivors and the need for interventions that focus on improving social support and treatment side effects, as well as reducing emotional burden associated with recurrence. Therefore, it is worth further exploring the intersection of these factors and HRQoL and their impacts on the survival outcomes of the breast cancer survivor population.
Studies have shown that subjective HRQoL assessments can serve as prognostic indicators for survival outcomes for advanced cancers [18, 19, 34, 35]. Consistent with these, we observed that the total FACT-B score was significantly associated with all-cause and breast cancer-specific mortality among early stage breast cancer survivors. Of the FACT-B subscales, physical well-being, functional well-being, and the trial outcome index scores were significantly associated with all-cause mortality, breast cancer-specific mortality and RFS. Similarly, Modi et al. reported significant associations between these subscales (physical well-being, functional well-being, and the trial outcome index) and overall survival in patients with advanced HER2+ breast cancer [36]. In contrast, we observed that social well-being was not associated with any survival outcome, and emotional well-being was only associated with breast cancer-specific mortality, which are consistent with Modi et al.’s study [36]. Taken together, these results suggest that physical and functional well-being may serve as more quantifiable and reliable indicators of survival outcomes in both early stage and advanced breast cancer patients. While social well-being is essential for HRQoL evaluation, it may be less predictive of survival outcomes, as its impact is likely from external factors such as social support systems.
Our study has several strengths. Firstly, we involved a multiethnic cohort that provided insights into the diverse experiences that have influenced the HRQoL of breast cancer survivors. Secondly, we used the validated FACT-B instrument and its subscales for survival outcome prediction, offering a more in-depth investigation of which particular HRQoL domains may influence survival outcomes. Moreover, our HRQoL data was collected during the COVID-19 pandemic, an unprecedented time marked by socioeconomic challenges and significant disruptions in health care and services. Not only did patients have to deal with physical and emotional challenges due to their diagnosis and cancer treatment, but they also faced increased social isolation that could impede their access to health care and receipt of social support [37]. This contextual uniqueness makes our study helpful for developing tailored interventions to support breast cancer patients during future public health crises or pandemic. However, our study is not without limitations. The sample size is modest. Survivors who reside in the Chicago Metropolitan Area may not be representative of the US general or global breast cancer population. Furthermore, we may have been restricted by the short follow-up time and thus could not evaluate if subjective HRQoL could predict long-term survival outcomes. Future studies should consider a longer follow-up duration and include larger, more geographically diverse cohorts to reflect the diverse population of breast cancer patients to better assess the impact of HRQoL on survival outcomes.
Conclusion
In this multiethnic cohort of breast cancer survivors, compared with White survivors, Black survivors had worse functional well-being but had similar scores of other FACT-B subscales. FACT-B and its physical and functional well-being scores as well as the trial outcome index score could serve as predictors for breast cancer survival outcomes. Our HRQoL assessment interview was conducted during COVID-19 pandemic, highlighting how the HRQoL of breast cancer survivors could be impacted during periods of national uncertainty and disruptions and necessitating effective interventions. Future investigations should explore the changes in the HRQoL among breast cancer survivors over time and the associations between HRQoL assessments and long-term survival outcomes.
Acknowledgements
The contents are solely the responsibility of the authors and do not necessarily represent the official views of the National Cancer Institute and the National Institute on Aging.
Funding
This Project was partially supported by the National Cancer Institute (P20CA233307), the Breast Cancer Research Foundation (BCRF-22-071), the National Institute on Aging (T32AG000243), and Susan G. Komen® (TREND21675016).
Footnotes
Conflict of interest The authors have no conflict of interest to declare.
Data availability
No datasets were generated or analysed during the current study.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
No datasets were generated or analysed during the current study.