According to the American Cancer Society (1994), 50% of cancers occur in people age 65 and older, and age remains the most influential risk factor. It is estimated that 48% of women with breast cancer are age 65 or older (Wanebo et al., 1997). While recent advances in cancer treatment have prompted questions regarding the efficacy and safety of therapy in the older population, little attention is given to the emotional sequelae among elderly individuals. Because it generally is accepted that cancer causes great emotional suffering, examination of the psychological effects of breast cancer in older adults is warranted (Houldin & Wasserbauer, 1996). Diagnosis of breast cancer likely causes anguish for individuals of any age; however, older women with breast cancer have specific age-related responses and needs. Their unique emotional needs, along with the unique biological presentation of breast cancer in older women, requires attention and continued research to help clinicians tailor medical and nursing care to this population.
CLINICAL PRESENTATION AND MANAGEMENT
Breast cancer, one of the most common malignancies, affects 12% of American women during their lifetimes (Goroll, May, & Mulley, 1995). According to the Surveillance, Epidemiology, and End Results program of the National Cancer Institute, within the age-65-andolder cohort, breast cancer has an incidence rate six times greater than for individuals younger than age 65, and the mortality rate shows a 7.5-fold increase (cited in DeMichele, Fox, Schuchter, Kantor, & Norman, 1998). Because older adults generally suffer from greater incidence of disease, it would be easy to accept the statistics at face value and not carefully examine the reasons. However, one such reason may be the disparity in screening practices of younger and older women. Lack of breast cancer screening for older women may contribute to the significant increase in mortality and incidence of breast cancer in the older population.
In general, breast cancer screening methods for women of all ages include mammograms, breast selfexaminations (BSEs), and physical examinations. Regular use of such screening methods allows for earlier detection of both benign and malignant breast lumps. Yet, less than 30% of women older than age 70 undergo routine mammography screening (Horton, Roman, & Creuss, 1992). Research indicates that while mammography and physical examination are effective in detecting early disease in women between the ages of 50 and 74, compliance with screening declines as age increases (Lickley, 1997).
In addition to a decline in compliance among older women, government-mandated screening regulations appear to dissuade the older population from seeking regular breast screening (Wanebo et al., 1997). In 1993, Medicare mandated that women older than age 65 should have mammograms every other year, as opposed to the mandated annual mammography for women age 50 and older (Wanebo et al., 1997). Because the ability to detect breast cancer at early stages has been attributed largely to improved and timely screening methods, government recommendations may contribute to a delay in clinical presentation. Thus, older women with new diagnoses may present with more advanced disease (Goroll et al., 1995; Lickley, 1997).
While studies support that delays in screening older women may contribute to lower detection of preinvasive cancer, there is debate as to whether older patients suffer from more or less invasive malignancies (Wanebo et al., 1997). In contrast to the argument that screening practices for older women reveal more advanced disease, in general, breast cancer in older women is considered less biologically aggressive than in younger women at the same stage (Wanebo et al., 1997). It is estimated that 55% of women with a new diagnosis of breast cancer present with Stage I breast cancer (Goroll et al., 1995). However, older women tend to have a lower incidence of in situ or preinvasive lesions (Busch et al., 1996). Thus, while breast tumors in older women have the potential to be less aggressive, delayed diagnosis may cause a tumor more often to be malignant at presentation and necessitate intervention.
In addition to the differences in presentation of breast cancer in older women, age bias contributes to marked differences in the medical management of these patients. Physicians' attitudes and biases regarding cancer in older adults can influence not only screening practices but also use of diagnostic tests and cancer treatment (Ganz, 1993). While treatment goals remain the same for younger and older patients alike, inconsistencies and lack of formal practice guidelines specifically for older adults cause uncertainty regarding the appropriateness of their care. A recent report in the New York Times emphasized that patients with cancer who are older than age 65 are underrepresented in the clinical trials which help determine treatment (Altman, 1998). Thus, rather than tailoring treatment to the specific nature of breast cancer in older women, clinicians consider the standard of care to be comparable to that of younger women and, therefore, do not address the unique presentation and needs of older patients.
As a result of extrapolating from research on younger cohorts, controversy remains regarding the adequacy of treatments employed specifically for older women with breast cancer. For patients of any age with breast cancer, options include:
* Mastectomy or breast-conserving therapy (i.e., lumpectomy followed by radiation therapy).
* Hormonal therapy.
* Or a combination of therapies depending on tumor characteristics and lymph node involvement.
However, as age increases, the proportion of women who receive definitive treatment decreases (Ibrahim, Frye, Buzdar, Walters, Si Hortobagyl, 1996). One study found that women older than age 65 were less likely to have a reexicision or extensive axillary node dissection (Merchant, McCormick, Yahalom, & Borgen, 1 996). Similarly, a number of randomized trials revealed mastectomy and breast-conserving treatment are comparable in terms of survival, and both are suitable surgical options for elderly women (Goroll et al., 1995). Yet, in one study, 98% of women younger than age 65 were treated with the standard of care (i.e., definitive treatment involving the appropriate use of lumpectomy, radiation, axillary node dissection, or mastectomy), while only 81% of women older than age 65 received such definitive treatment (Wanebo et al., 1997). In addition, Farrow, Hunt, and Samet (1992) researched the difference in use of breast-conserving surgery versus mastectomy in three age cohorts (i.e., younger than age 65, age 65 to 75, older than age 75) and found that breast-conserving treatment was used least in the middle group. It was proposed that consequences of disfigurement in the youngest age group and mortality or morbidity in the oldest age group influenced these treatment decisions (Busch et al., 19%). Thus, the marked differences in surgical treatment and their sequelae must be further researched.
Similarly, chemotherapy and radiation treatment for breast cancer are guided largely by age-related biases and the absence of formal practice guidelines. Merchant et al. (1996) found that women who were older than age 65 were Jess likely to receive chemotherapy and nodal irradiation. Reluctance to treat, or inconsistency in use of chemotherapy or radiation, may stem from both patient and physician misperceptions regarding older women's intolerance of radiation and chemotherapy. However, tolerance to both radiation and chemotherapy is similar among younger and older women with breast cancer (Ibrahim et al., 1996; Sandison, Gold, Wright, & Jones, 1996).
While surgery, radiation, and chemotherapy often are used inconsistently among older women, older women are more likely than younger women to receive hormonal therapy (Merchant et al., 1996). Adjuvant hormonal therapy with tamoxifen citrate clearly is indicated as standard and appropriate treatment for postmenopausal women with invasive breast cancer and positive hormone receptors, yet often it is used alone without more aggressive treatment. Surprisingly, if tamoxifen citrate is used alone in older women, only 50% of patients will have adequate local control, and even fewer will have complete remission (Gazet, Ford, & Coombes, 1994). Thus, the benefits of tamoxifen citrate for older women should be appreciated but not to the exclusion of additional adjuvant therapies.
Research clearly establishes that older women are treated differently than their younger counterparts. While there may be differences between responses of younger and older individuals to cancer treatment, such differences should be determined on the basis of all variables rather than solely on chronological age. Although incidence of breast cancer increases with age, older women currently have longer life expectancy than their younger counterparts. However, physicians tend to underestimate the life expectancies of their elderly patients, and judge the patients* tolerance to therapy solely on the basis of chronological age (Ibrahim et al., 1996). It is presumed that, in addition to life expectancy, comorbidities, tolerance of chemotherapy, and cognitive status largely contribute to physicians' reluctance to treat elderly patients with definitive treatments (Ibrahim et al., 1996). While cJiruical practice must be highly individualized to consider the unique presentation of breast cancer in older women along with other age-related factors, clinicians must realize that, in general, older women with breast cancer are able to tolerate therapies better than expected. Continued research, specific to older adults, must be conducted to help tailor medical care to the biological presentation of cancer in elderly individuals.
Treatment of older women with breast cancer extends far beyond the medical arena. Although older women appear to focus less on the sexual issues surrounding breast cancer, fear of death along with suffering from multiple comorbidities greatly compounds their emotional and physical distress (Houldin & Lowery, 1992). Elderly oncology patients suffer significant emotional distress, commonly manifested as depression or anxiety (Houldin & Wasserbauer, 1996). Houldin and Wasserbauer (1996) found that nearly two thirds of older women with breast cancer experienced psychosocial distress, which included feelings of unhappiness, loneliness, tension, and restlessness. Among women who are longterm survivors of breast cancer, physical concerns are minimal, while spiritual, emotional, diet, and exercise habits have lasting effects (Wyatt & Friedman, 1996). Recognizing the potential for older women to suffer from emotional distress is necessary at an early stage so medical and nursing interventions that minimize distress may be implemented.
Medical interventions such as mastectomy and lumpectomy appear to affect emotional outcomes differently. Women treated with breastconserving treatment suffer less from body image disturbance (Fallowfield & Hall, 1991). Ganz, Lee, Sim, Polinsky, and Cosgareelli Schag (1992) found that, compared to younger women, older women demonstrated better psychosocial well-being but only if they underwent segmental rather than total mastectomy. Therefore, the challenge of treating older women with breast cancer is to treat them with appropriately aggressive therapies, while still incurring minimal emotional distress.
Because the diagnosis of breast cancer along with the emotional effects of cancer therapies inevitably cause emotional distress, providing appropriate psychosocial interventions is essential. The efficacy of psychological interventions for patients with breast cancer is well documented and demonstrates positive effects on well-being and quality of life (Houldin & Lowery, 1992). Edgar, Rosberger, and Nowlis (1992) studied patients with cancer (mean age = 56.3) and found that psychological intervention improved emotional coping regardless of timing of the intervention, whether at initial diagnosis or 4 months later. When studying the impact of cancer on people of all ages, many studies have highlighted unmet emotional needs and found that coping with emotional distress was the most frequently cited need (Houldin & Wasserbauer, 1996). Because the goal is to enable patients with cancer to adapt as well as possible to the illness, strengthening coping strategies should be viewed as a primary intervention.
In general, a body of research supports the idea that appropriate use of problem solving and coping behaviors contributes to positive adjustment, acceptance of disease, and decreased emotional distress (Rowland, 1989; Stone, 1994; Weisman & Worden, 1976). Because of the presumed social and physical vulnerability of older adults, it may be expected that in times of crisis or considerable stress, older individuals are unable to cope with their grief and would have greater emotional needs (Houldin & Wasserbauer, 1996). However, older women with breast cancer, in fact, cope more successfully than their younger counterparts by employing optimistic coping methods more frequently (Halstead Bc Fernsler, 1994).
A number of factors may influence older adults' ability to cope with emotional distress from a cancer diagnosis. It has been suggested that life experiences, such as marriage, and problem solving skills may contribute to older adults' use of optimistic coping strategies (Halstead & Fernsler, 1 994). While multiple experiences enable elderly individuals to cope relatively well with a breast cancer diagnosis, review of a variety of psychosocial interventions can guide clinicians to strengthen coping strategies.
Social Support. The concept of social support remains a vague term throughout the literature. However, most definitions share the common theme involving the supportive interactions between patients with cancer and family, friends, and partners. The therapeutic effect of social networks on coping currently is gaining much deserved attention (Houldin & Lowery, 1992). The way in which support persons such as spouses, family, and friends interact with individuals with cancer and respond to the stressful situation greatly affects the patients' outcomes. Studies demonstrate that social support enhances mastery over cancer and influences life satisfaction (Guülory, 1993; Houldin & Lowery, 1992).
Because of the implied supportive relationship between partners, research often focuses on the effects of a supportive spousal relationship. In a study of 58 married couples, communication between husbands and wives had the greatest influence on adjustment to cancer (Walker, 1997). Interestingly, although younger women are more likely to have a living spouse with whom to discuss emotional distress, younger age often prompted a greater fear of recurrence and general distress related to the diagnosis. Thus, a supportive spousal relationship, along with the relative emotional stamina of older women with breast cancer, positively influences the coping ability of older women with breast cancer.
Although much of the research on social support focuses on emotional benefits from the spousal relationship, emotional support is not necessarily synonymous with a confidant. In a study of 35 Scottish women with breast cancer, only 13 subjects confided their illness-related worry to their partners, while 12 confided in other patients, and 10 chose friends as confidants (Lugton, 1997). The subjects' ages were not specified, and it can be assumed that the women were younger because most were employed and married (not widowed), and many had young children. However, this study emphasizes that despite the assumed tendency to confide in spouses, women with breast cancer may look to others for emotional comfort. Furthermore, because older women appear to cope better without spousal support than their younger counterparts, it may be assumed that elderly women more often seek support from other relatives and friends. Thus, despite the relative increased ability of older women to cope, it is necessary to understand how shifting social networks during the aging process can affect the availability of social resources and older women's ability to cope.
As older women often shift roles from being care providers to care recipients, fear and shame of becoming a burden to children and others may ensue. In addition, bereavement overload from multiple life losses may overwhelm elderly women and dissuade them from accepting available social support (Houldin & Lowery, 1992). Despite these changing family dynamics and social pressures, older parents still receive significant social support from adult children (Silverstein & Bengtson, 1994). In general, intergenerational support enhances well-being and helps older women with cancer cope with stress from chronic illnesses (Krause, 1 986; Silverstein & Bengtson, 1994). Therefore, assessing older women's available social networks and encouraging adult children to provide not only instrumental (e.g., financial or physical assistance) but also emotional support can help older women cope with breast cancer.
In addition to informal support provided by family and friends, the importance of professionally led support groups should not be overlooked. Several studies strongly support that patients with cancer who participate in support groups facilitate psychological adaptation (e.g., Fawzy et al., 1 990; Krupnick, Rowland, Goldberg, & Daniel, 1993; Spiegel, Kraemer, Bloom, & Gottheil, 1989). Although there are many types of group interventions, support groups tend to focus on managing the emotional and physical effects of various cancer treatments, coping with stresses during various stages of the diagnosis, and identifying concerns for patients of a given developmental stage (Krupnick et al., 1993). Formal support groups have emerged to address special needs of groups such as men, young adults, and unmarried individuals. However, there remains a lack of emphasis on the need for support groups specifically for older -women with cancer.
The lack of formal group support for older adults may be influenced by further age-related assumptions regarding their ability to cope with cancer as they do with many comorbidities. However, it is essential that older women with cancer also are encouraged to participate in formal groups, specifically groups geared toward their developmental stage. A study of patients with cancer demonstrated the value of both formal and informal support but found that less than half of the patients were offered or asked whether they would want to join a formal support group (Guidry, Aday, Zhang, & Winn, 1997). Patients with Stage I and II breast cancer who refused entry into a support group were older (mean age = 54) than participants (mean age = 50.5) (Morrow & Lindke, 1994). Reasons for refusal to participate included (Morrow & Lindke, 1994):
* Being too busy.
* Not being interested.
* Inconvenient location.
* Not needing support.
* Not wishing to focus on the cancer.
Similar research examining age cohorts, percentage of participants from each group, and reasons for refusal of different age patients would help clinicians plan formal support groups for specific needs of older adults.
Spirituality. Like social support, spirituality, a universal means of solace during times of stress, has been examined to determine the efficacy as a psychosocial intervention for older patients with cancer. When discussing spirituality as a means of psychosocial coping, it is necessary to indicate that spirituality is not necessarily synonymous with religion. Research on spirituality and patients with cancer has explored the use of prayer, silence, and guided imagery as psychosocial interventions. While use of spirituality ascribes meaning to the experience of illness through belief and prayer, patients should not be excluded from such interventions on the basis of their religious views or lack of formal religious practice.
In general, spirituality appears to be the prevailing coping strategy among those who are long-term survivors of cancer (Creagan, 1997). Houldin and Wasserbauer (1996) demonstrated that 69% of their subjects, age 60 and older, felt their spiritual needs were unmet (Houldin & Wasserbauer, 1996). Moreover, although they did not perceive themselves as spiritual in nature, 67% of subjects hoped for a miracle to cure their cancer. Similarly, Halstead and Fernsler (1994) revealed that 67.8% of the older subjects frequently employed spiritual means of coping, such as "prayed or put trust in God" (p. 97), and deemed such strategies successful in managing stress related to their cancer.
In addition to implementing spiritual care to reduce stress and anxiety, studies demonstrate prayer can help patients cope with advanced breast cancer pain (Arathuzik, 1 99 1 ; Georgesen & Dungan, 1996). The presence of pain from advanced or recurrent cancer can challenge individuals' belief systems, which influence their hope and ability to cope emotionally (Georgesen & Dungan, 1996). By alleviating physical pain, spirituality also can indirectly relieve emotional distress and improve the quality of life of patients with cancer.
Although there is scarce research specifically on the positive effects of spirituality on elderly women with breast cancer, the beneficial effects on patients with cancer in general can be extrapolated to older adults. Research on spirituality during different phases of illness and for patients with different prognoses would provide important information on the efficacy of spiritual care as a psychosocial intervention for elderly women with breast cancer.
Exercise and Physical Well-Being. In addition to spirituality as a more abstract intervention, exercise has been examined as a psychological intervention for patients with cancer. While literature generally supports the benefits of exercise on physical health, little is known about the emotional benefits of exercise, especially for elderly patients (Kushi et al., 1997). A preliminary study by Mock et al. (1994) examined the effects of both a walking program and use of a support group on the rehabilitation of young patients with breast cancer receiving adjuvant chemotherapy. Results indicated that the intervention group suffered from less fatigue and emotional distress.
In a subsequent study, Mock et al. (1997) examined the therapeutic effects of a regular walking program on women age 35 to 65 who were receiving radiation treatment for breast cancer. While the treatment group increased activity, the control group decreased activity and suffered from more fatigue, less ability to cope, and more stress from treatment. Unfortunately, women older than age 65 were excluded to prevent variance in exercise ability and limitations.
Regular exercise decreases anxiety and depression in women who were survivors of breast cancer (Segar et al., 1998). However, the mean age in that study was 48.9. While research on younger women with breast cancer is valuable and implies that older women also may benefit from exercise, research specifically on elderly women with breast cancer is necessary to better understand the psychosocial benefits. Furthermore, existing literature on exercise and breast cancer emphasizes benefits during a specific time (e.g., during chemotherapy or radiation) and compares subjects with the same stage of disease. Research examining the continued psychosocial benefits of exercise beyond the treatment period and for patients in different stages of disease would help clarify the value of exercise on psychosocial well-being.
These research findings can guide nursing practice in a number of ways. First and foremost, nurses serve as patient advocates and educators to help older individuals understand risk factors for breast cancer. Nurses should actively encourage patients to undergo routine, regular physical and mammographie screening to detect malignancies at earlier stages. After patients are diagnosed with breast cancer, nurses should serve as advocates and support individuals to assist elderly women in seeking appropriate treatments. Nurses should be well versed in research findings and clinical practice related to older adults so they can discuss and provide support for those individuals whom elect to undergo aggressive treatment.
When taking complete histories of patients, nurses should focus on any physical and psychosocial aspects that may affect the individuals* abilities to cope with cancer diagnosis. For example, multiple comorbidiries or recent life losses may signal potential for impaired coping. Similarly, lack of family support individuals may imply need for additional community resources. Moreover, nurses can help dispel myths regarding breast cancer in elderly women (e.g., necessarily increased mortality, routine need for mastectomy) and can alleviate some degree of fear. In addition, nurses should provide appropriate emotional support, plan ways to follow up with patients, and suggest appropriate referrals to psychiatric clinical nurse specialists or other counselors. Because research supports implementation of psychological interventions to enhance emotional well-being, nurses should discuss interventions such as exercise, spirituality, optimistic coping strategies, and communication with family and friends.
Nurses play a pivotal role in encouraging other health care providers to take active steps to promote awareness of older adults* needs. While elderly women suffer less emotional distress from cancer diagnosis than younger women, the fear and suffering of this silent population must not be overlooked. Psychosocial, behavioral, and medical management all may be necessary to facilitate successful coping with emotional distress (e.g., anxiety, depression, loneliness, fear of cancer recurrence). Social support networks including church groups, support groups, and exercise groups all may be implemented to assist women in attaining normalcy and enhancing their quality of life.
Further examination of the breast cancer experience in older women is needed to fully comprehend the psychosocial effects of this malignancy. Older women's years of experience in coping with stressful situations may help them cope better than younger women. Yet, the relative emotional stability of older women coping with breast cancer should not dismiss their emotional pain and devastation. Promoting awareness of the needs of elderly women with breast cancer would assist in tailoring interventions to help alleviate emotional distress.
Nurses play a vital role throughout the course of breast cancer diagnosis and treatment. Knowledge of the biological presentation of the malignancy among older women enables nurses to educate and support women throughout their decision-making process and treatment. Furthermore, understanding the unique clinical presentation among older women with breast cancer, while recognizing the emotional needs of this population, enables nurses to provide evidence-based psychosocial support that promotes successful adaptation to the stress of a cancer diagnosis.
- Altman, L.K. (1998, May 20). Safety of cancer drugs for older patients unknown. The New York Times.
- American Cancer Society. (1994). Facts and figures. New York: Author.
- Arathuzik, D.L. (1991). Pain experience for metastatic breast cancer. Cancer Nursing, 14, 41-48.
- Busch, E., Kemeny, M., Fremgen, ?., Osteen, R.T., Winchester, O.P., & ChVe, R.E. (19%). Patterns of breast cancer in the elderly. Cancer, 78, 101-111.
- Creagitt, E.T. (1997). Attitude and disposition: Do they make a difference in cancer survival? Mayo Clinical Proceedings, 72, 160-164.
- DeMichele, A.M., Fox, K.R., Schlichter, L.M., Kantor, D., & Norman, S.A. (1998). Utilization and toxicity of adjuvant chemotherapy in aging women with breast cancer. Unpublished manuscript, Hospital of the University of Pennsylvania Cancer Center, Philadelphia.
- Edgar, L., Rosberger, Z., & Nowlis, D. (1992). Coping with cancer during the first year after diagnosis: Assessment and intervention. Cancer, 69, 817-828.
- Fallowfield, LJ., & Hall, A. (1991). Psychosocial and sexual impact of diagnosis and treatment of breast cancer. British Medical Bulletin, 47, 388-399.
- Farrow, D.C., Hunt, W.C., & Samet, J.M. (1992). Geographic variation in the treatment of localized breast cancer. New England Journal of Medicine, 326, 1097-1101.
- Fawzy, F.I., Cousins, N-, Fawzy, N.W., Kemeny, M.E., Elashoff, R.( & Morton, D. (1990). A structured psychiatric intervention for cancer patients. I. Changes over time in methods of coping and affective disturbance. Archives of General Psychiatry, 47, 720-725.
- Ganz, P.A. (1993). Age and gender as factors in cancer therapy. Clinics in Geriatric Medicine, 9(1), 145-155.
- Ganz, P.A., Lee, J.J., SJm, M.S., Polinsky, M.L., & Cosgareelli Schag, C.A. (1992). Exploring the influence of multiple variables on the relationship of age to quality of Uf e in women with breast cancer. Journal of Clinical Epidemiology, 4Í, 473-485.
- Gazet J.C., Ford, H.T., & Coombes, R.C. (1994). Prospective randomized trial of tamoxifen versus surgery in elderly patients with breast cancer. European Journal of Surgical Oncology, 20, 207-214.
- Georgesen, J., & Dungan, J.M. (1996). Managing spiritual distress in patients with advanced cancer pain. Cancer Nursing, 19, 376-383.
- Goroll, A.H., May, L.A., & Mulley, A.G. (1995). Primary care medicine: Office evaluation and management of the adult patient (3rd ed.). Philadelphia: Lippincott.
- Guidry, JJ., Aday, L.A., Zhang, D., & Winn, RJ. (1997). The role of informal and formal social support networks for patients with cancer. Cancer Practice, 5(4), 241-246.
- Guillory, J.A. (1993). Relationships of selected physiological, psychosocial and spiritual variables associated with survivorship in socioeconomicaUy disadvantaged African American women with breast cancer. Dissertation Abstracts International, 54(1), 166.
- Halstead, M.T., & Fernsler, JJ. (1994). Coping strategies of long-term cancer survivors. Cancer Nursing, 17, 94-100.
- Horton, J.A., Roman, M.C., & Creuss, D.F. (1992), Mammography attitudes and usage study. Women Health Issues, 2, 180-188.
- Houldin, A.D., & Lowery, BJ. (1992). Emotional distress in breast cancer patients. In B.J. Lowery (Ed.), Med-Surg Nursing Quarterly, 1(2), 1-28. Springhouse, PA.: Springhouse.
- Houldin, A.D., & Wasserbauer, N. (1996). Psychosocial needs of older cancer patients: A pilot study abstract. MEDSURG Nursing, 5(4), 253-256.
- Ibrahim, N.K., Frye, O.K., Buzdar, A.U., Walters, R.S., & Hortobagyl, G.N. (19%). Doxorubicin-based chemotherapy in elderly patients with breast cancer: Tolerance and outcome. Archives of Internal Medicine, 156, 882-888.
- Krause, N. (1986). Social support, stress, and well-being among older adults. Journal of Gerontology, 41, 512-519.
- Krupnick, J.L., Rowland, J.H., Goldberg, R.L., & Daniel, U.V. (1993), Professionally-led support groups for cancer patients: An intervention in search of a model. International Journal of Psychiatry in Medicine, 2.3(3), 275-294.
- Kushi, L.H., Fee, R.M., Folsom, A.R., Mink, PJ-, Anderson, K.E., & Sellers, T.A. (1997). Physical activity and mortality in postmenopausal women. Journal of the American Medical Association, 277, 1287-1292.
- Lickley, H.L. (1997). Primary breast cancer in the elderly. Canadian Journal of Surgery, 40(5), 341-351.
- Lugton, J. (1997). The nature of social support as experienced by women treated for breast cancer. Journal of Advanced Nursing,25, 1184-1191.
- Merchant, T.E., McCormick, B., Yahalom, J., Si Borgen, P. (1996). The influence of older age on breast cancer treatment decisions and outcome, international Journal of Radiation Oncology, Biology, Physics, 34(3), 565-570.
- Mock, V., Burke, M.B., Sheehan, P.K., Creaton, E-, Watson, P.G., Winningham, M.( McKinney-Tenner, S., Powel, M., & Liebman, N. (1994). A nursing rehabilitation program for women with breast cancer receiving adjuvant chemotherapy. Oncology Nursing Forum, 21, 899-908.
- Mock, Y, Hassey Dow, K., Meares, C.J., Grimm, P.M., Dienemann, J.A., HaisfieldWolfe, M.E., Quitasol, W., Mitchell, S., Chakravarthy, A., & Gage, I. (1997). Effects of exercise on fatigue, physical functioning, and emotional distress during radiation therapy for breast cancer. Oncology Nursing Forum, 24, 991-1000.
- Morrow, G.R., & Lindke, J. (1994). Characteristics of breast cancer patients who refuse entry in a therapeutic support group conducted in CCOP settings: A URCC CCOP study [Abstract]. Proceedings of the Annual Meeting of the American Society of Clinical Oncology, 13, A1632.
- Rowland, J.H. (1989). Intrapersonal resources: Coping. In: J.C. Holland & J.H. Rowland (Eds.)., Handbook of psychooncology. (pp. 44-51). New York: Oxford Press.
- Sandison, A.J., Gold, D.M., Wright, P., & Jones, P.A. (1996). Breast conservation or mastectomy: Treatment choice of women aged 70 years and older. British Journal of Surgery, S3, 994-996.
- Segar, M.L., Katch, V.L., Roth, R.S., Weinstein Garcia, ?., Portner, Tl., Glickman, S.G., Haslanger, S.t & Wilkins, E.G. (1998). The effect of aerobic exercise on self-esteem and depressive and anxiety symptoms among breast cancer survivors. Oncology Nursing Forum, 25, 107-113.
- Silverstein, M., & Bengtson, V.L. (1994). Does intergenerarional social support influence the psychological well-being of older parents? The contingencies of declining health and widowhood. Social Science and Medicine, 38, 943-957.
- Spiegel, D., Kraemer, H.C., Bloom, J.R., Gottheil, E.G., (1989). Effects of psychosocial treatment on survival of patients with metastatic breast cancer. Lancet, 2, 888-981.
- Stone, C.S. (1994). Critique of how coping mediates the effect of optimism on distress: A study of women with early stage breast cancer. Nursing Scan in Nursing, 7(2), 11-12.
- Walker, B.L. (1997). Adjustment for husbands and wives to breast cancer. Cancer Practice, 5(2), 92-98.
- Wanebo, HJ., Cole, B., Chung, M., Vezeridis, M., Schepps, B., Fulton, J., & Bland, K. (1997). Is surgical management compromised in elderly patients with breast cancer? Annals of Surgery, 225, 579-589.
- Weisman, A.D., & Worden, J.W. (1976). The existential plight in caneen Significance of the first 100 days. The International Journal of Psychiatry in Medicine, 7, 1-15.
- Wyatt, G., & Friedman, L.L. (1996). Longterm female cancer survivors: Quality of life issues and clinical implications. Cancer Nursing, 19, 1-7.