Breast Cancer Education Intervention (BCEI)

Quality of life (QOL) during post-treatment breast cancer survivorship is a relatively new, emerging, and promising area of investigation.  Behavioral interventions to ameliorate QOL problems include a wide variety of methods such as psychoeducational support, individual and group counseling, expressive therapy, and cognitive behavioral therapy.  Most behavioral interventions have been delivered primarily during active cancer treatment.  A small but growing number of intervention studies in post-treatment survivorship have applied variations of psychoeducational and support interventions to reduce negative QOL-related issues.  The current study focuses on QOL in the first year of post-treatment survivorship.

Breast Cancer Education Intervention (BCEI) is a one-on-one psychoeducational support intervention that consists of the following components delivered over a 6-month period:

- Three individual face-to-face education and support sessions (60-90 minutes each) provided by nurses trained in the intervention to address (1) physical changes after treatment (e.g., fatigue, lymphedema, pain); (2) personal and emotional changes after breast cancer (e.g., menopausal symptoms, hot flashes, sleep problems, sexual function, and fertility), family and social relationships (e.g., work, finances, insurance), and ways to promote healthy lifestyle behaviors (e.g., physical activity, nutrition, adhering to cancer surveillance guidelines); and (3) psychological distress (e.g., mood swings, anxiety, depression, fear of recurrence) and spiritual effects (e.g., uncertainty, meaning in illness)

- Two telephone and individual face-to-face follow-up education and support sessions (30 minutes each)

- Written and audiotaped reinforcement

The educational sessions have the following format: In the first 30 minutes, all subjects receive the same instruction; the remaining 30 minutes are tailored to the unique problems and concerns facing each individual participant.  For example, in session 1, the intervention nurse may describe lymphedema, explain why participants are at risk, and educate about ways to prevent or manage lymphedema.  For the tailored component of the session, the intervention nurse may discuss a participant's specific situation in managing the symptoms.  The face-to-face education and support sessions are run by intervention nurses who have received 2 hours of training.  The intervention nurse also helps participants develop tailored management plans that may include homework assignments, readings about the topics discussed in that session, listening to audiotapes, or trying new self-management tips.  The two follow-up education and support sessions, conducted in person and by telephone, are designed to evaluate participants' symptom management, reinforce learning, and provide support.  The intervention nurse reviews pertinent areas of the BCEI binder, tips sheets, and audiotaped materials with the participant.  Written and audiotaped materials are used in each session. Each participant receives a BCEI education binder, which is a 50-page notebook containing materials divided into 3 sections that correspond to each education and support session.  Participants also receive 38 tip sheets that reinforce the education and support sessions and offer information on management for specific concerns and problems discussed in the sessions. Participants also receive three audiotapes based on each of the three education and support sessions to reinforce the lessons.

To implement BCEI, the following time should be allotted:

- Three teaching and support sessions at an average of 60 minutes each (the first session may take up to 90 minutes, but subsequent sessions last 45-50 minutes)

- Two telephone-based and face-to-face follow-up sessions of 30 minutes each

- Two sessions of 60 minutes each for intervention nurse training

- 30-45 minutes for each follow-up session for the nurse to review subjects' homework, provide feedback, and assess ongoing behavioral changes

BCEI is designed for women aged 21 years and older who are within 1 year of histologically confirmed stage 0-II breast cancer, with no evidence of local recurrence or metastatic disease, who have had surgery at least 1 month before entrance into the program and received radiation therapy or chemotherapy. 

Suitable settings are cancer centers and private oncology offices.

- BCEI Procedure Manual
- BCEI Participant Manual
- BCEI Participant Tip Sheets
- BCEI audiotapes

Subjects were recruited from a regional cancer center and private oncology offices in the southeastern United States.  Eligible participants included women who were at least 21 years of age with histologically confirmed stage 0-II breast cancer and no evidence of local recurrence or metastatic disease; women who were within 1 year of diagnosis and who had surgery at least 1 month before; women who received radiation therapy or chemotherapy to recover from acute treatment side effects, and those who were able to communicate in English.  Participants may have been on hormonal therapy (i.e., aromatase inhibitor or tamoxifen) at study entry.

A total of 256 women completed the study. The mean age of participants was 54.5; 82% were White; 9% were African American; 6% were Hispanic; and the remainder were Asian, Middle Eastern, and Native American.  English was the primary language for 95% of participants, and Spanish was the primary language for 4%.  Almost 30% had a high school education and 48% had a college education. Sixty-eight percent were married or living with a partner; 32% were single, divorced, or widowed. Sixty-two percent of participants were employed full- or part-time, and 45% had an annual family income of less than $50,000. More than 90% had not received counseling or participated in cancer support groups.

After completing baseline measures, participants were randomized into either the BCEI group or a wait-list control group by the study biostatistician.  The intervention group received three face-to-face education and support sessions and two face-to-face follow-up education and support sessions over a 6-month period.  During the 6-month period when the BCEI participants received the intervention, the wait-list control group received initial face-to-face baseline assessment, four attention control telephone calls, and three face-to-face education and support sessions (within 1 month).  The wait-list control group received one face-to-face follow-up education and support session during month 7, when the intervention group experienced no activity. 

QOL was measured using Quality of Life-Breast Cancer Survivors (QOL-BCS), a 50-item scale that measures QOL in women with breast cancer.  It was adapted from the QOL-Cancer Survivors Scale. Each item uses a 10-point rating scale to describe overall QOL problems or concerns within four domains (physical, psychological, social, and spiritual well-being).  The QOL-BCS is scored from 0 to 10, with lower scores indicating better QOL, and higher scores indicating poorer QOL.  QOL was measured using the overall average across the four QOL-BCS subscales at baseline, the 3-month follow-up, and the 6-month follow-up.

• At 3-month follow-up, the experimental group showed a significant improvement in QOL compared to the control group (p<.001).
• At 6-month follow-up, the experimental group showed a significant improvement in QOL compared to the control group (p<.001).