Move more for life: the protocol for a randomised efficacy trial of a tailored-print physical activity intervention for post-treatment breast cancer survivors The Alberta moving beyond breast cancer (AMBER) cohort study: a prospective study of physical activity and health-related fitness in breast cancer survivors Physical and psychosocial recovery in the year after primary treatment of breast cancer. Simultaneous integrated boost for adjuvant treatment of breast cancer- intensity modulated vs. conventional radiotherapy: The IMRT-MC2 trial The roles of herbal remedies in survival and quality of life among long-term breast cancer survivors - results of a prospective study Trade-offs in quality of life and survival with chemotherapy for advanced breast cancer: mature results of a randomized trial comparing single-agent mitoxantrone with combination cyclophosphamide, methotrexate, 5-fluorouracil and prednisone Optimizing expectations to prevent side effects and enhance quality of life in breast cancer patients undergoing endocrine therapy: study protocol of a randomized controlled trial Short-Term and Long-Term Psychosocial Adjustment and Quality of Life in Women Undergoing Different Surgical Procedures for Breast Cancer Quality of life in long-term breast cancer survivors. The effect of combined aerobic and resistance exercises on quality of life of women surviving breast cancer Profile and Predictors of Long-term Morbidity in Breast Cancer Survivors Impact of liposomal doxorubicin-based adjuvant chemotherapy on autonomy in women over 70 with hormone-receptor-negative breast carcinoma: A French Geriatric Oncology Group (GERICO) phase II multicentre trial. Randomized, double-blind, placebo-controlled crossover trials of venlafaxine for hot flashes after breast cancer.
Background Due to early detection and advances in treatment , the number of women surviving breast cancer is increasing . Whilst there are many positive aspects of improved survival , breast cancer survival is associated with many long-term health and psychosocial sequelae . Engaging in regular physical activity post-diagnosis can reduce this burden . Despite this evidence , the majority of breast cancer survivors do not engage in regular physical activity . The challenge is to provide breast cancer survivors with appealing and effective physical activity support in a sustainable and cost-effective way . This article describes the protocol for the Move More for Life Study , which aims to assess the relative efficacy of two promising theory-based , print interventions design ed to promote regular physical activity amongst breast cancer survivors . Method and design Breast cancer survivors were recruited from across Australia . Participants will be r and omised into one of three groups : ( 1 ) A tailored-print intervention group , ( 2 ) a targeted-print intervention group , or ( 3 ) a st and ard recommendation control group . Participants in the tailored-print intervention group will receive 3 tailored newsletters in the mail over a three month period . Participants in the targeted-print group will receive a previously developed physical activity guidebook design ed specifically for breast cancer survivors immediately after baseline . Participants in the st and ard recommendation control will receive a brochure detailing the physical activity guidelines for Australian adults . All participants will be assessed at baseline , and at 4 and 10 months post-baseline . Intervention efficacy for changing the primary outcomes ( mins/wk aerobic physical activity ; sessions/exercises per week resistance physical activity ) and secondary outcomes ( steps per day , health-related quality life , compliance with physical activity guidelines , fatigue ) will be assessed . Mediation and moderation analyses will also be conducted . Discussion Given the growing number of cancer survivors , distance-based behaviour change programs addressing physical activity have the potential to make a significant public health impact . Trial registration Australian New Zeal and Clinical Trials Registry ( ANZCTR ) identifier : Background Limited research has examined the association between physical activity , health-related fitness , and disease outcomes in breast cancer survivors . Here , we present the rationale and design of the Alberta Moving Beyond Breast Cancer ( AMBER ) Study , a prospect i ve cohort study design ed specifically to examine the role of physical activity and health-related fitness in breast cancer survivorship from the time of diagnosis and for the balance of life . The AMBER Study will examine the role of physical activity and health-related fitness in facilitating treatment completion , alleviating treatment side effects , hastening recovery after treatments , improving long term quality of life , and reducing the risks of disease recurrence , other chronic diseases , and premature death . Methods / Design The AMBER Study will enroll 1500 newly diagnosed , incident , stage I-IIIc breast cancer survivors in Alberta , Canada over a 5 year period . Assessment s will be made at baseline ( within 90 days of surgery ) , 1 year , and 3 years consisting of objective and self-reported measurements of physical activity , health-related fitness , blood collection , lymphedema , patient-reported outcomes , and determinants of physical activity . A final assessment at 5 years will measure patient-reported data only . The cohort members will be followed for an additional 5 years for disease outcomes . Discussion The AMBER cohort will answer key questions related to physical activity and health-related fitness in breast cancer survivors including : ( 1 ) the independent and interactive associations of physical activity and health-related fitness with disease outcomes ( e.g. , recurrence , breast cancer-specific mortality , overall survival ) , treatment completion rates , symptoms and side effects ( e.g. , pain , lymphedema , fatigue , neuropathy ) , quality of life , and psychosocial functioning ( e.g. , anxiety , depression , self-esteem , happiness ) , ( 2 ) the determinants of physical activity and health-related fitness including demographic , medical , social cognitive , and environmental variables , ( 3 ) the mediators of any observed associations between physical activity , health-related fitness , and health outcomes including biological , functional , and psychosocial , and ( 4 ) the moderators of any observed associations including demographic , medical , and biological/disease factors . Taken together , these data will provide a comprehensive inquiry into the outcomes , determinants , mechanisms , and moderators of physical activity and health-related fitness in breast cancer survivors PURPOSE The 2000 National Institutes of Health Consensus Conference on Adjuvant Therapy of Breast Cancer recommended chemotherapy for all women with invasive cancer greater than 1 centimeter . Studies of long-term breast cancer survivors have found poorer quality of life ( QOL ) in women who received adjuvant chemotherapy .  The aim of this article is to characterize physical and psychosocial recovery as a function of chemotherapy receipt in the year after medical treatment completion . PATIENTS AND METHODS Prospect i ve longitudinal survey data ( R AND SF-36 and Breast Cancer Prevention Trial [ BCPT ] Symptom Scales ) collected from 558 women with breast cancer enrolled on the Moving Beyond Cancer ( MBC ) psychoeducational intervention trial were compared according to receipt of chemotherapy . MBC study enrollment occurred within 4 weeks after the end of primary treatment ( eg , surgery , chemotherapy , radiation ) . Self-report question naire data collected at enrollment and at 2 , 6 , and 12 months thereafter were examined , controlling for intervention and with propensity score adjustment for imbalance of covariates . Outcome analyses were carried out by fitting linear mixed models by using SAS PROC MIXED . RESULTS Longitudinal SF-36 scale scores did not differ by chemotherapy treatment exposure , and both groups improved significantly ( P < .01 ) in the year after primary treatment ended . However , adjuvant chemotherapy treatment was associated with significantly more severe physical symptoms , including musculoskeletal pain ( P = .01 ) , vaginal problems ( P < .01 ) , weight problems ( P = .01 ) , and nausea ( P = .03 ) . CONCLUSION Physical and psychosocial functioning improved significantly after breast cancer treatment , independent of receipt of adjuvant chemotherapy .  Women who received chemotherapy experienced more severe and persistent physical symptoms that should be more effectively managed as part of survivorship care Background Radiation therapy is an essential modality in the treatment of breast cancer . Addition of radiotherapy to surgery has significantly increased local control and survival rates of the disease . However , radiotherapy is also associated with side effects , such as tissue fibrosis or enhanced vascular morbidity . Modern radiotherapy strategies , such as intensity modulated radiotherapy ( IMRT ) , can shorten the overall treatment time by integration of the additional tumor bed boost significantly . To what extent this might be possible without impairing treatment outcome and cosmetic results remains to be clarified . Methods / Design The IMRT-MC2 study is a prospect i ve , two armed , multicenter , r and omized phase-III-trial comparing intensity modulated radiotherapy with integrated boost to conventional radiotherapy with consecutive boost in patients with breast cancer after breast conserving surgery . 502 patients will be recruited and r and omized into two arms : patients in arm A will receive IMRT in 28 fractions delivering 50.4 Gy to the breast and 64.4 Gy to the tumor bed by integrated boost , while patients in arm B will receive conventional radiotherapy of the breast in 28 fractions to a dose of 50.4 Gy and consecutive boost in 8 fractions to a total dose of 66.4 Gy . Discussion Primary objectives of the study are the evaluation of the cosmetic results 6 weeks and 2 years post treatment and the 2- and 5-year local recurrence rates for the two different radiotherapy strategies . Secondary objectives are long term overall survival , disease free survival and quality of life . Trial Registration Clinical Trials.gov Protocol ID : NCT01322854 Background Few data exist on survival or health-related quality of life ( QOL ) related to herbal remedy use among long-term breast cancer survivors . The objective of this report is to examine whether herbal remedy use is associated with survival or the health-related QOL of these long-term breast cancer survivors . Methods In 1999 - 2000 , we collected the information of herbal remedy use and QOL during a telephone interview with 371 Los Angeles Non-Hispanic/Hispanic white women who had survived more than 10 years after breast cancer diagnosis .  QOL was measured using the Medical Outcomes Study Short Form-36 ( SF-36 ) question naire . Patients were followed for mortality from the baseline interview through 2007 . 299 surviving patients completed a second telephone interview on QOL in 2002 - 2004 . We used multivariable Cox proportional hazards methods to estimate relative risks ( RR ) and 95 % confidence intervals ( CI ) for mortality and applied multivariable linear regression models to compare average SF-36 change scores ( follow-up - baseline ) between herbal remedy users and non-users . Results Fifty-nine percent of participants were herbal remedy users at baseline . The most commonly used herbal remedies were echinacea , herbal teas , and ginko biloba . Herbal remedy use was associated with non-statistically significant increases in the risks for all-cause ( 44 deaths , RR = 1.28 , 95 % CI = 0.62 - 2.64 ) and breast cancer ( 33 deaths , RR = 1.78 , 95 % CI = 0.72 - 4.40 ) mortality . Both herbal remedy users ' and non-users ' mental component summary scores on the SF-36 increased similarly from the first survey to the second survey ( P = 0.16 ) , but herbal remedy users ' physical component summary scores decreased more than those of non-users ( -5.7 vs. -3.2 , P = 0.02 ) . Conclusions Our data provide some evidence that herbal remedy use is associated with poorer survival and a poorer physical component score for health-related QOL among women who have survived breast cancer for at least 10 years . These conclusions are based on exploratory analyses of data from a prospect i ve study using two-sided statistical tests with no correction for multiple testing and are limited by few deaths for mortality analysis and lack of information on when herbal remedy use was initiated or duration of or reasons for use Background We evaluate trade-offs between quality of life ( QoL ) and survival improvement for two chemotherapy regimens in advanced breast cancer . We also report on the  long-term survival of patients in the ANZ 8614 clinical trial . Methods A total of 391 patients were r and omized to mitoxantrone ( 14 mg/m2 intravenously every 21 days ) or a combination of cyclophosphamide 100 mg/m2 and prednisone 40 mg/m2 orally days 1 to 14 plus methotrexate 40 mg/m2 and 5-fluorouracil 600 mg/m2 intravenously days 1 and 8 every 28 days ( CMFP ) .  QoL was self-assessed on 14 linear analog scales . We computed the mean differences between the two treatments as products of the mean differences in global QoL , progression-free survival and overall survival . Results CMFP led to a higher overall tumor response ( 39 % vs. 25 % , P=0.004 ) and longer progression-free survival ( PFS ) ( median 5.6 vs 3.9 months , P=0.02 ) but with significantly more toxicity from alopecia , mucositis , diarrhea , anemia and lethargy . Overall survival ( OS ) was similar in the two groups ( median 10.1 vs 11.6 months , P=0.81 ) . QoL over the first 12 weeks was rated better by patients on CMFP for mood ( P=0.04 ) , nausea and vomiting ( P=0.01 ) , and feeling sick ( P=0.02 ) but worse for hair loss ( P<0.0001 ) . A weighted combination of individual QoL items favoured CMFP ( subset score mean difference 2.4 , P=0.03 ) . A global QoL score tended to favour CMFP ( global score mean difference 1.7 , P=0.18 ) . Quality -adjusted PFS was significantly longer with CMFP ( mean 7.208 vs 5.965 months , P=0.04 ) , but quality -adjusted OS was not significantly different ( mean 11.832 vs 11.315 months , P=0.57 ) . Conclusion Despite the greater toxicity , the superior antitumor activity of CMFP led to an overall improvement in quality -adjusted PFS . In advanced breast cancer , in clinical decision making about treatment for palliative intent , the principle used to assess trade-offs between antitumor efficacy and toxicity remains relevant and applicable to all modern therapeutic agents Background Adjuvant endocrine therapy can improve disease-free survival and time before recurrence in breast cancer patients . However , it is associated with considerable side effects that negatively affect patients ’ quality of life and cause non-adherence . The recently demonstrated effect of individual expectations on side-effect development ( nocebo effect ) suggests that psychological factors play a role in the prevention of side effects . The aim of this study is to evaluate cognitive-behavioral side-effect prevention training ( SEPT ) for breast cancer patients . This article describes the study protocol and applied research methods . Methods / Design In a r and omized controlled trial , 184 female breast cancer patients are assigned to receive either SEPT , st and ard medical care or a manualized supportive therapy at the start of adjuvant endocrine treatment . SEPT consists of three sessions of cognitive-behavioral training including psychoeducation to provide a realistic view of endocrine therapy , imagination-training to integrate positive aspects of medication into daily life , and side-effect management to enhance expectations about coping ability . Side effects three months after the start of endocrine therapy serve as primary outcomes . Secondary outcomes include quality of life , coping ability and patients ’ medication adherence . Patients ’ expectations ( i.e. , expectations about side effects , coping ability , treatment and illness ) are analyzed as mediators . Discussion The optimization of expectations might be a potential pathway in health care to improve patients ’ quality of life during long-term medication intake . The results will provide implication s for a possible integration of evidence -based prevention training into clinical practice .Trial registration Clinical Trials.gov , ( NCT01741883 ) Background The various surgical procedures for early-stage breast cancer are equivalent in terms of survival . Therefore , other factors , such as the procedures ’ effect on psychosocial adjustment and quality of life ( QOL ) , take on great importance . The aim of the current study was to prospect ively examine the short- and long-term effects of mastectomy with reconstruction , mastectomy without reconstruction , and breast conservation therapy on aspects of psychosocial adjustment and QOL in a sample of 258 women with breast cancer . Methods Participants completed question naires before surgery and then again 1 , 6 , 12 , and 24 months after surgery . Question naires assessed depressive symptoms , anxiety , body image , sexual functioning , and QOL . Results Adjustment patterns differed throughout the 2-year period after surgery . Some short-term changes in adjustment ( less anxiety , less overall body satisfaction ) were similar across surgery groups , whereas others ( satisfaction with chest appearance , QOL in physical health domain ) were higher for women who had breast conservation therapy . However , women who had mastectomy with reconstruction reported greater satisfaction with their abdominal area . During the long-term follow-up period ( 6 months to 2 years after surgery ) , women in all three groups experienced marked improvements in psychosocial adjustment ( depressive symptoms , satisfaction with chest appearance , sexual functioning ) and QOL in physical and mental health domains . In fact , the level for most variables returned to baseline levels or higher . Conclusions Overall , the general patterns of psychosocial adjustment and QOL are similar among the three surgery groups PURPOSE There is considerable interest in the quality of life ( QOL ) of long-term breast cancer ( BC ) survivors . We studied changes in QOL from time of BC diagnosis to long-term survivorship and compared QOL in long-term survivors to that of age-matched women with no history of BC . PATIENTS AND METHODS In all , 535 women with localized BC ( T1 - 3N0 - 1M0 ) were recruited from 1989 to 1996 and followed prospect ively , completing QOL question naires at diagnosis and 1 year postdiagnosis . Between 2005 and 2007 , those alive without distant recurrence were recontacted to participate in a long-term follow-up ( LTFU ) study . A control group was recruited from women presenting for screening mammograms  , and both groups completed LTFU QOL question naires . Longitudinal change in BC survivors and differences between BC survivors and controls were assessed in eight broad categories with clinical ly significant differences set at 5 % and 10 % of the breadth of each QOL scale . RESULTS A total of 285 patients with BC were included in the study , on average 12.5 years postdiagnosis . Longitudinally , clinical ly significant improvements were observed in overall QOL by 1 year postdiagnosis with further improvements by LTFU . Some clinical ly significant improvements over time were seen in all categories . A total of 167 controls were recruited . Deficits were observed in self-reported cognitive functioning ( 5.3 % difference ) and financial impact ( 6.3 % difference ) in BC survivors at LTFU compared with controls . CONCLUSION Long-term BC survivors show improvement in many domains of QOL over time , and they appear to have similar QOL in most respects to age-matched noncancer controls , although small deficits in cognition and finances were identified Background : Breast cancer is one of the most common cancers amongst women in developed and developing countries . It is associated with the highest mortality rate in low to average-income countries . Breast cancer investigation amongst Iranian women reveals that the number of its incidence is yet the highest in all cancer types . Despite recent longer survival time of women with breast cancer , most of the patients suffer from long term physical and mental distress due to combined treatments . Exercise interventions are among new approaches to promote the better quality of life of the patients , which has only recently been considered by research ers . This study aim ed to investigate the effect of exercise intervention on the quality of life of breast cancer survivors . Material s and Methods : This is a clinical trial conducted on 80 women with I-III breast cancer , at 18 - 55 years of age mostly two years after the completion of their treatment in Seyed al Shohada hospital in Isfahan . They were r and omly divided into two groups of study and control . Exercise intervention went on for 8 weeks in the study group ( three sessions a week , 60 minutes ) . Quality of life in both groups was measured a day before , and at the end of the eight weeks period by the instrument of the National Medical Center and Beckman Research Institute . The data were analyzed by descriptive and inferential statistical tests of X2 , t-test and Mac Hammer test . Findings : Results showed that there was no significant difference in the mean score of the physical dimension of quality of life in the study group before and after intervention while the score of physical health was significantly better in the control group ( p < 0.00).The mean score of mental dimension had increased in the study group , while it had decreased in the control group . The mean score of social health showed no significant difference before and after intervention . The mean score of spiritual health had significantly decreased in the control group , while it had significantly increased in the study group ( p = 0.004 ) . Generally , the total mean score of the quality of life showed no significant difference before and after intervention . However , the percentage of the quality of life score increased in the study group , but decreased in the control group . Conclusions : The results of this study showed that exercise interventions can promote a better quality of life for the patients , and increase the total score of quality of life . Although , the total score of quality of life was not significantly different , it was concluded that exercise can promote the quality of life amongst patients with breast cancer Background A sound underst and ing of the benefits of different treatment options and their health-related quality of life ( HRQoL ) impacts is required for optimal breast cancer care . Methods A cross-sectional cohort study was conducted to determine the prevalence and severity of persistent functional decrements and symptoms and identify demographic , clinical and treatment variables associated with poorer outcomes . Four hundred English-speaking women treated for ductal carcinoma-in-situ or stage I to III breast cancer between 1999 and 2009 , at least 12 months after surgery and currently disease free , were r and omly selected and invited to complete ( 1 ) the Breast Cancer Treatment Outcome Scale and ( 2 ) the EORTC core Quality of Life Question naire , version 3 . Results The response rate was 85.60 % . Many participants reported moderate to severe decrements in a number of HRQoL domains , including functional well-being ( 15 % ) , cosmetic status ( 32 % ) and overall quality of life ( 21 % ) . There were significant associations ( p < .05 ) between younger age and poorer HRQoL but none between time since surgery and morbidity ( p > .05 ) . Different treatments were associated with different HRQoL impacts . Poorer functional status was predicted by axillary dissection ( p = .011 ) , and adjuvant radiotherapy was a significant predictor of breast-specific pain ( p < .05 ) . Conclusions Many breast cancer survivors report long-term morbidity that is unaffected by time since surgery . The significant associations between the extent of locoregional therapies and poorer HRQoL outcomes emphasize the importance of the safe tailoring of these treatments RATIONALE Breast cancer is a disease of ageing . Functional independence in elderly patients , measured with the Katz activities of daily living ( ADL ) scale , predicts overall survival and the need for welfare support . Few prospect i ve studies have examined the feasibility of adjuvant chemotherapy and its impact on autonomy in women over 70 years of age with high-risk breast cancer . This multicentre phase II trial was design ed to assess the impact of adjuvant anthracycline-based chemotherapy on these patients ' autonomy . DESIGN AND METHODS In a two-stage Fleming design , women aged ≥70 years with histologically proven hormone-receptor-negative early breast cancer and a significant risk of recurrence ( pN+ or " high risk " pN0 ) received 4 cycles of nonpegylated liposomal doxorubicin 60 mg/m(2 ) and cyclophosphamide 600 mg/m(2 ) every 3 weeks postoperatively , on an outpatient basis . The primary endpoint was the change in the ADL score during chemotherapy . Secondary endpoints include comprehensive geriatric , quality -of-life and acceptability assessment s , tolerability , and long-term outcome . The results for the primary endpoint and other scales at completion of adjuvant chemotherapy are reported here , while long-term follow-up is not yet complete . RESULTS Forty patients ( median age 75 [ 70 - 82 ] ) were enrolled between February 2006 and November 2007 . Chemotherapy had no deleterious impact on ADL , cognition , mental status , or the frequency of comorbidities . In contrast , the number of patients at risk of malnutrition , based on the Mini Nutritional Assessment , more than doubled between baseline and the end of chemotherapy , rising from 15 % to 38 % . Quality -of-life deteriorated in terms of social and role functioning , likely owing to fatigue , loss of appetite , nausea and vomiting . Treatment acceptability was good . The main adverse effect was neutropenia , 15 % of the patients experiencing febrile neutropenia . No cardiac toxicity or toxic deaths occurred . CONCLUSION This study demonstrates the feasibility of an adjuvant chemotherapy regimen combining nonpegylated liposomal doxorubicin and cyclophosphamide in fit elderly women < 85 years with breast cancer .  Although chemotherapy had an impact on social and role functioning , autonomy was not impaired and toxicity was acceptable . Special attention should be paid to nutritional status before and after treatment BACKGROUND Although venlafaxine reduces self-reported hot flashes , no data have established the drug 's impact on physiologically documented hot flashes . Two r and omized , double-blind , placebo-controlled crossover trials examined the efficacy of two doses of venlafaxine in relation to physiological and self-reported hot flashes and other outcomes , including negative affect , fatigue , sleep , and quality of life . METHODS SAMPLE 57 breast cancer survivors in the low-dose study ; 20 in the high-dose study . SETTING university cancer clinics in the Southeast and Midwest . INTERVENTION 37.5 mg of venlafaxine ( low-dose study ) or 75 mg of venlafaxine ( high-dose study ) . MEASURES hot flash frequency ( physiological monitor , diary , and event marker ) , hot flash severity ( diary ) , hot flash bother ( diary ) , and question naires for hot flash impact on daily life , negative affect , fatigue , sleep , and quality of life . RESULTS Subjective but not physiological hot flash measures showed placebo effects . Venlafaxine result ed in modest decreases in hot flashes , but only hot flash interference improved differentially at the higher dose . The timing of venlafaxine 's effects on hot flashes varied by dose . Only women with a > or = 50 % decrease in physiological hot flashes experienced significant improvement in fatigue , sleep quality , and quality of life . Although side effects were mild , most patients discontinued venlafaxine long-term . CONCLUSIONS Although venlafaxine result ed in modest and acute reductions in hot flashes with few side effects , it may not be tolerable to some patients long-term . At least 50 % relief in physiological hot flashes may be needed for patients to demonstrate improvement in other outcomes , including decreased fatigue , improved sleep , and improved quality of life
INTRODUCTION Worldwide , breast cancer is the fifth leading cause of cancer death ( after lung , stomach , liver and colon cancer ) , while among women it is first on the list .
The incidence of breast cancer has made a dramatic increase since 1970 which is partly interpreted by the modern western life st and ards .
The expected risk of breast cancer throughout a lifespan of an average is 1 in 11 women .
The five-year survival rates for breast cancer are at 80 % if it has not spread , and only at 40 % for the metastatic type of cancer .
The concept of survival comes from the US , where there is an active promotion of self-help difficulties coping strategies .
Surviving from cancer may be a mixed experience .
Survivors of cancer often say they are still running a full and meaningful life after experiencing a threatening disease .
Others may find it difficult to h and le the feeling that they have no right to be alive , which is probably related to the guilt of survival after the war .
Although the survival potential for some is a satisfactory fee , others may be looking for improvement , change , or to adapt their life and struggle with the late effects of cancer after stopping the treatment .
In recent years it has been observed that survival of women with breast cancer  has increased significantly because of current antineoplastic therapeutic interventions .
The definition of support needs derives from the one of supportive care considering that there is no theoretical framework or specific definition at the moment . "
It includes the period before the final diagnosis , during the diagnosis and the treatments or during the ongoing disease with recurrences and the survivors of the disease . "
PURPOSE The purpose of this review is to describe the tools used in research to measure and evaluate supportive care needs during long-term survival of women with breast cancer .