Bupa Health Foundation Health and Wellbeing after Breast Cancer Study
Robinson PJ, Bell RJ, Zecena Morales CS, Fradkin P, Davis SR. Minimal-trauma fracture in women with breast cancer surviving for at least 5 years from diagnosis. Osteoporos Int. 2015 Feb;26(2):795-800.
In this study we investigated the self-reported frequency of minimal-trauma fracture (MTF) in breast cancer survivors at least 5 years from diagnosis, along with the use of bone mineral density assessment. Among the women who completed the 5th Follow-up Questionnaire, 1,205 women remained free of recurrence or a new breast cancer and 13.6% of these reported at least one MTF with rib fracture being the most common.
The analysis showed that overall MTF is a problem for breast cancer survivors, with rib fracture a particular issue for women in the study. Both pre-existing osteoporosis and being postmenopausal are risk factors for subsequent MTF in women treated for breast cancer.
Robinson PJ, Bell RJ, Davis SR. Obesity is associated with a poorer prognosis in women with hormone receptive positive breast cancer. Maturitas. 2014 Nov;79(3):279-86. doi: 10.1016/j.maturitas.2014.07.004. Epub 2014 Jul 18.
Obesity is a known risk factor for the development of breast cancer. The aim of this study was to investigate whether being overweight is also associated with an increased risk of recurrence or death from breast cancer.
1,155 of the 1,683 women who completed the original Enrolment Questionnaire in the Bupa study had hormone receptor positive, Her2 receptor negative breast cancer, and had a BMI between 18.5 and 40kg/m2.
Analysis revealed that being moderately to severely obese is associated with a poorer prognosis regardless of being at an early stage when diagnosed or being treated with oral adjuvant endocrine therapy such as the aromatase inhibitors. Therefore weight reduction should be recommended as part of the overall treatment plan for moderate to severely obese women with breast cancer.
Davis SR, Panjari M, Robinson P, Fradkin P, Bell RJ. Menopausal Symptoms in Breast Cancer survivors nearly 6 years after diagnosis. Menopause. 2014 Oct;21(10):1075-81. doi: 10.1097/GME.0000000000000219.
In this study we investigated the prevalence and severity of menopausal symptoms in women in the Bupa study who had not experienced any further occurrence of breast cancer (active disease) after completion of their initial treatment and who were no longer taking tamoxifen or aromatase inhibitors (oral adjuvant endocrine therapy, OAET).
Among the women who completed the 5th Follow-up Questionnaire nearly 6 years after diagnosis, there were 843 who were free of active disease and were not taking OAET. Their menopausal symptoms were assessed using the Menquol Questionnaire.
There was found to be a high prevalence of vasomotor and sexual symptoms which were most marked in women aged 50 to 59 years. However, these symptoms were shown to be more common and severe in all post-menopausal age groups treated for breast cancer than they were in community controls. There was no independent impact of chemotherapy demonstrated.
Given that these symptoms, which are thus not simply a function of OAET or chemotherapy, have an adverse impact on breast cancer survivors, effective treatments are needed for their management in women who have completed their treatment for breast cancer.
Panjari M, Robinson PJ, Davis SR, Schwarz M, Bell RJ. A comparison of the characteristics, treatment and outcome after 5 years, of Australian women aged 70 + with those aged < 70 years at the time of diagnosis of breast cancer. J Geriatr Oncol. 2014 Apr;5(2):141-7. Epub 2014 Jan 5.
The aim of this analysis was to compare the treatment and wellbeing of women aged more than 70 years with those aged less than 70 years, in the Bupa study of women with a first diagnosis of invasive breast cancer. Women in the older age group are more likely to be experiencing other age-related medical conditions which could influence the management of their breast cancer.
274 of the 1,683 women who completed the original Enrolment Questionnaire were aged 70+ years at diagnosis. Compared with women less than 70 years at diagnosis, the older women had less advanced disease which would explain why they were also less likely to have received chemotherapy or radiotherapy. They were also less likely to be taking oral adjuvant therapy nearly 6 years after diagnosis.
A larger proportion of women aged 70+ had died by the time of completion of the 5th Follow-up Questionnaire, but death was due to breast cancer in a smaller percentage of the older women who had higher rates of cardiovascular disease. At nearly 6 years from diagnosis, women 70+ years who were free of active disease, had similar overall psychological wellbeing to that of younger women.
Bell RJ, Robinson PJ, Nazeem F, Panjari M, Fradkin P, Schwarz M, Davis SR. Persistent breast pain 5 years after treatment of invasive breast cancer is largely unexplained by factors associated with treatment. J Cancer Surviv. 2014 Mar;8(1):1-8. doi: 10.1007/s11764-013-0306-6. Epub 2013 Aug 23.
This study investigated breast pain and regional discomfort which was still present 5 years after treatment for breast cancer.
1,205 women in the Bupa study who completed the 5th Follow-up questionnaire were free from recurrence or a new breast cancer. Of those women, 45% reported breast pain that was present for at least 3 months following initial treatment and of these, 80% reported pain persisting for at least 5 years.
Lymphedema was the most common factor contributing to the persistent pain and/or discomfort. A full multivariable model however, including the characteristics of the cancer and its treatment, explained less than 10% of the likelihood of the symptoms persisting for 5 years. There was only a modest reduction in wellbeing that was associated with the persistent pain or discomfort.
Thus, as persistent breast pain after treatment for breast cancer is common and is largely unexplained, consideration could be given to addressing pre-operative patient distress and expectations of future pain. When persistent pain occurs, referral to a specialist pain or lymphedema clinic should be offered.
Bell RJ, Fradkin P, Robinson PJ, Schwarz M, Davis SR. Intended follow up of women with breast cancer at low risk of recurrence and at least 5 years from diagnosis. Internal Medicine Journal. 2014 Apr;44(4):332-8. doi: 10.1111/imj.12205.
The number of breast cancer survivors living in the community is increasing as mortality from the disease declines. With increasing costs of cancer care, current guidelines for the follow-up of asymptomatic well women recommend annual physical examination and mammography only. Testing for biomarkers and more intensive imaging are not recommended as they have not been shown to lead to increased survival.
In this study, we investigated the follow-up experienced by the women in the Bupa study, with respect to medical consultation and the imaging being performed. The 616 women in this analysis were at least 5 years from diagnosis with stage 1 cancer and had not had a recurrence or a new cancer by FQ5.
92% of women reported that they intended to consult a doctor for follow-up. 306 women (54%) intended to see one doctor only and of these the most frequent choice was a GP (63%), followed by a medical oncologist (23%). 197 women elected to see both a GP and an oncologist. The women intending to see an oncologist did so despite 2 out of 3 participants reporting being advised that this was not necessary. More than 90% of women reported having a mammogram with or without ultrasound in the previous 12 months but there was a low incidence of other investigations in the absence of specific indications.
With increasing numbers of cancer survivors in the community, evaluation of and education about the benefit and costs of future medical surveillance is indicated.
Bell RJ, Robinson P, Fradkin P, Schwarz M, Davis SR. Lymphedema: experience of a cohort of women with breast cancer followed for 4 years after diagnosis in Victoria, Australia. Support Care Cancer. 2013 Jul;21(7):2017-24. doi: 10.1007/s00520-013-1763-1. Epub 2013 Feb 24.
Lymphedema of the arm has long been recognised as a complication of treatment for breast cancer. In this study we investigated the incidence and prevalence of lymphedema from the time of completion of the original Enrolment Questionnaire until the completion of the 3rd Follow-up Questionnaire nearly 4 years after diagnosis.
Almost 20% women reported lymphedema 2 years after diagnosis and about 18% by almost 4 years. However, we found that lymphedema was a dynamic phenomenon. The condition resolved in some women and in others was reported for the first time up to 4 years after diagnosis.
Classically, lymphedema was thought to be related to the number of axillary nodes surgically removed. Although we did find this association it only explained a small proportion of the likelihood of the occurrence. Additionally, it was not found to be more common in women who had a mastectomy or in women who reported treatment with radiotherapy. The majority of women who reported lymphedema over the 4 years were only mildly troubled by it and it contributed only minimally to a lowering of overall wellbeing.
Bell RJ, Schwarz M, Fradkin P, Robinson P, Davis SR. Patterns of use of oral adjuvant endocrine therapy in Australian breast cancer survivors 5 years from diagnosis. Menopuase. 2013 Jul;20(7):721-6. doi: 10.1097/GME.0b013e31827ce094.
Tamoxifen and the aromatase inhibitors (oral adjuvant endocrine therapies -OAET), have been shown to improve survival in women with hormone receptor positive breast cancer. The use of these endocrine therapies by women throughout their participation in the BUPA Health Foundation Health and Wellbeing after Breast Cancer study was investigated in this analysis at the completion of the study, 5 to 6 years from diagnosis. In an earlier paper we reported that nearly 18% of affected women were not using either of these endocrine therapies 3 to 4 years after diagnosis.
Approximately 20% of the women used OAET for at least 5 years from diagnosis, 47% for 4 years and 82% for at least 3 years. As was reported in the previous paper, 8% of the women reported never using these therapies and this was unchanged in this analysis.
Thus although 8% of the participants in the study never took OAET, the majority of women persisted with the treatment despite the side effects of oestrogen deprivation.
Bell RJ, Fradkin P, Parathithasan N, Robinson P, Schwarz M, Davis SR. Pregnancy-associated breast cancer and pregnancy following treatment for breast cancer, in a cohort of women from Victoria, Australia, with a first diagnosis of invasive breast cancer. Breast. 2013 Oct;22(5):980-5. doi: 10.1016/j.breast.2013.05.013. Epub 2013 Jun 20.
This study examined pregnancy in relation to breast cancer in 2 groups of women participating in the Bupa study. The first group experienced gestational breast cancer (GBC), which is BC diagnosed during, or within the 12 months following pregnancy. The second group became pregnant following treatment for their BC.
Women with GBC made up 3.3% of women aged less than 48 years at diagnosis but 14.3% of women aged less than 35 years at diagnosis. 13 women were identified as having GBC, 4 diagnosed during pregnancy and 9 within 12 months of the end of a pregnancy.
Pregnancy following treatment for breast cancer occurred only in women aged less than 40 years who had either no children or only one child. Nine of 46 (19.6%) of these women became pregnant and 8 experienced a live birth. No pregnancies occurred earlier than 2.8 years after diagnosis.
Young women need to be aware of the possibility of breast cancer when they are pregnant and in the post-partum period. Some women who have not completed their families are choosing to have one or more pregnancies after their treatment for BC.
Bell RJ, Fradkin P, Schwarz M, Davis SR. Understanding discontinuation of oral adjuvant endocrine therapy by women with hormone receptor positive invasive breast cancer nearly 4 years from diagnosis. Menopause. 2013 Jan;20(1):15-21. doi: 10.1097/gme.0b013e3182610cab.
Tamoxifen and the newer aromatase inhibitors are very effective in reducing the risk of recurrence and increasing survival in women treated for hormone receptor positive breast cancer. In this study we have investigated the degree of, and the reasons for, the discontinuation of these therapies by women nearly 4 years from their initial diagnosis of breast cancer.
1,370 women with hormone receptor positive breast cancer completed the original Enrolment Questionnaire of the Bupa Health and Wellbeing after Breast Cancer Study. Nearly 4 years from diagnosis 1,193 hormone receptor positive women completed the 3rd Follow-up Questionnaire.
18% of these women were not taking the adjuvant therapy. Of these women, just over half had ceased therapy due to a range of side effects. These included flushes, sweats and uterine bleeding for Tamoxifen and flushes, sweats and joint pains for the aromatase inhibitors. 8% of the women however had not taken any adjuvant endocrine therapy at any stage. Further investigation into understanding why this group of women has totally missed out on therapy is needed.
In conclusion, side effects, mainly those due to lack of oestrogen, were the main reasons for discontinuation but there was a significant group of women for whom these drugs were appropriate, who had never used them.
Bell RJ, Schwarz M, Fradkin P, Davis SR. Use of Imaging in surveillance of women with early stage breast cancer. ANZ J Surg. 2013 Mar;83(3):129-34. doi: 10.1111/j.1445-2197.2012.06229.x. Epub 2012 Sep 17.
The Current guidelines for imaging surveillance of women with breast cancer are based on the findings that intensive follow up investigation does not lead to any benefit in terms of long term survival or quality of life.
This analysis of data from the 3rd Follow-up Questionnaire of the Bupa Health Foundation Health and Wellbeing after Breast Cancer Study investigates the use of follow up medical imaging in 673 women who were stage 1 at diagnosis with no recurrence or new breast cancer reported nearly 4 years after their initial diagnosis and treatment. Of these women, almost 90% reported having a mammogram in the previous 12 months and almost 53% also had an ultrsound. 71% of these women reported no other imaging investigations.
This analysis reveals that Australian doctors are broadly following the recommended guidelines for surveillance of women after treatment for breast cancer.
Bell RJ, Robinson PJ, Fradkin P, Schwarz M, Davis SR. Breast reconstruction following mastectomy for invasive breast cancer is strongly influenced by demographic factors in women in Victoria, Australia. Breast. 2012 Jun;21(3):394-400. doi: 10.1016/j.breast.2012.04.006. Epub 2012 May 16.
In this analysis of data from the 1st Follow-up Questionnaire of the Bupa Health and Wellbeing after Breast Cancer Study we show that the prevalence of breast reconstruction in the women in the study approximately 2 years from diagnosis was 25%. This is higher than has previously been reported in Australia.
Demographic issues rather than those related to body image influence the likelihood of breast reconstruction following mastectomy for breast cancer.
Being younger, having post-secondary education, living in the city, having private health insurance, not having dependent children and not having been treated with radiotherapy all increased the likelihood of breast reconstruction.
Some of these factors need consideration to ensure equity of access to all Victorian women who may wish to undergo reconstruction following their breast cancer treatment.
Panjari M, Bell RJ, Fradkin P, Davis SR. Cosmetic surgery prior to diagnosis of breast cancer. Climacteric. 2012 15:195-199.
This paper reports on the frequency of cosmetic surgery prior to the diagnosis of breast cancer and the detection of breast cancer as an incidental finding during cosmetic breast surgery.
23 of the 1,496 women who completed the 2nd Follow-up Questionnaire of the Bupa Health Foundation Health and Wellbeing after Breast Cancer Study reported that they had undergone cosmetic surgery before their diagnosis of breast cancer. 16 of these women had had a breast reduction and 7 an augmentation. Of note, for 2 of these women, the breast cancer was actually diagnosed at the time of their cosmetic surgery. One of these women had a reduction and the other an augmentation.
It is thus important for surgeons performing cosmetic breast surgery to consider the possibility of breast cancer and apply consistent breast cancer screening practices to ensure the wellbeing of their patients.
Bell RJ, Lijovic M, Fradkin P, Schwarz M, Davis SR. Changes in patterns of use of cigarettes and alcohol in women after a first diagnosis of invasive breast cancer: a cohort study of women from Victoria, Australia. Supportive Care in Cancer. 2012 20(4):783-789.
In this paper we report on the smoking and drinking patterns of the 1,588 women who completed the Enrolment Questionnaire (EQ) and the 1st Follow-up Questionnaire (FQ1) of the Bupa Health and Wellbeing after Breast Cancer Study.
12% of the women who completed the EQ reported that they were smokers at the time of their diagnosis. Although almost 2 thirds of these continued to smoke at the FQ1, 25% of them were smoking fewer cigarettes per day.
More than 70% of the participants reported that they consumed alcohol in both the EQ and FQ1. The proportion of women following the harmful behaviour of consuming more than 4 alcoholic drinks per occasion decreased between the EQ and FQ1.
However, 1 in 12 women still reported this harmful level of drinking at the FQ1.
The rate of use of cigarettes and alcohol had thus decreased 2 years after diagnosis, but breast cancer survivors should be made aware that continued smoking and alcohol consumption at harmful levels may compromise their future survival from breast cancer, as well as their overall general health.
Panjari M, Davis S, Fradkin P, Bell RJ. Breast cancer survivors' beliefs about the causes of breast cancer. Psychooncology. 2012 Jul;21(7):724-9. doi: 10.1002/pon.1949. Epub 2011 Mar 7.
In this paper we explore the beliefs held by some breast cancer survivors that specific factors in their lives may have led to the develpment of their breast cancer.
647 of the 1,496 women (43.5%) who completed the 2nd Follow-up Questionnaire of the Bupa Health Foundation Health and Wellbeing after Breast Cancer Study reported that they believed that there had been a specific contributing factor.
375 women cited stress as the cause of their breast cancer. This included work, psychological, financial, family and relationship issues as a cause of the stress. This belief was held despite there being only conflicting scientific evidence on this issue.
Past use of hormone therapy was cited by 89 women and a family history by 66 women. A variety of causes were cited by the remainder.
Women who believed that stress had led to the development of their breast cancer were more likely to have adopted lifestyle strategies in an attempt to reduce that factor in their lives.
Panjari M, Bell RJ, Davis SR. Sexual function after breast cancer. Journal of Sexual Medicine. 2011 Jan;8(1): 294-302.
The aim of this analysis was to investigate the effect of the treatment of breast cancer on sexual function and body image in women in the Bupa Health Foundation Health and Wellbeing after Breast Cancer Study.
1,684 women completed the Enrolment Questionnaire within 12 months of diagnosis. 1,588 women completed the 1st Follow-up Questionnaire with 1,011 of those women being included in this analysis. Women with active disease, women who did not have a partner, and those who were 70 years of age or older were excluded.
The results indicated that women using aromatase inhibitors to treat their breast cancer and who experienced the vasomotor symptoms of hot flushes and night sweats were more likely to report sexual function problems. Women who reported body image issues were also more likely to report problems with sexual function. However, the use of Tamoxifen was not associated with an increase in sexual function issues unless it was accompanied by an increase in vasomotor symptoms.
Davis SR, Lijovic M, Fradkin P, Bradbury J, La China M, Schwarz M, Bell RJ. Use of complementary and alternative therapy by women in the first 2 years after diagnosis and treatment of invasive breast cancer. Menopause. 2010; 17(5): 1004-1009.
The aim of this analysis was to report on the patterns of consultation with alternative practitioners, the use of complementary therapies to manage menopausal symptoms and some of the lifestyle changes made by women approximately 2 years after their treatment for breast cancer.
1,588 women in the Bupa Health Foundation Health and Wellbeing after Breast Cancer Study completed the Enrolment and 1st Follow-up Questionnaires in which they detailed their alternative and complementary therapies (CAMS), their consultations with CAM practitioners, their lifestyle activities and exercise and any dietary change, their quality of life in the PGWB questionnaire and their menopausal symptoms by completing the Menqol questionnaire.
29% of women made the lifestyle change of an increase in physical activity and approximately 34% reported having made a dietary change. The rate of use of CAMS for menopausal symptoms however, was less than expected, was more common in younger, more highly educated women and increased with time from diagnosis.
This rate of use will be further investigated in the later Follow-up Questionnaires.
Panjari M, Bell R, et al. The relationship between hormone therapy use at the time of diagnosis of breast cancer and tumour characteristics. Horm Canc. 2010 Apr; 1(2):93-99.
In this analysis we report on the use of systemic post menopausal hormone therapy and the characteristics of the breast cancer with respect to histological type, hormone receptor status and the stage of the cancer at diagnosis.
1,684 Victorian women with their first diagnosis of invasive breast cancer completed the Enrolment Questionnaire of the Bupa Health Foundation Health and Wellbeing after Breast Cancer Study, in which they detailed their present and past use of menopausal hormone therapy.
The Victorian Cancer Registry provided details of the size and histology of the tumour, the number of affected nodes, the hormone receptor status and any known metastases for each woman enrolled in the study.
No association was demonstrated between the use of systemic hormone therapy at diagnosis and hormone receptor status or stage of the cancer.
However, women taking systemic hormone therapy were shown to have an increased risk of lobular but not of ductal breast cancer, when compared to women not on hormonal therapy.
Bell RJ, Lijovic M, et al. Psychological wellbeing in a cohort of women with invasive breast cancer nearly 2 years after diagnois. Journal of Supportive Care in Cancer. 2010; 18:921-929.
The purpose of this study was to investigate the psychological wellbeing of women approximately 2 years after their treatment for breast cancer.
Women in the Bupa Health Foundation Health and Wellbeing after Breast Cancer study completed a validated wellbeing questionnaire, the PGWB. The results obtained were compared to those of a group of women in the general community who had not recently been diagnosed or treated for breast cancer.
1,589 women completed the PGWB and 47 of those had active disease. The results indicated that the wellbeing of the women in the study was lower for all age groups than the wellbeing of the women in the general community.
Similar to the women in the community however, being older was associated with higher levels of wellbeing for the women in the study, as was living with others. Social support may therefore be particularly important for women with breast cancer who live alone.
Women with active disease and those with a higher level of education were found to have lower levels of wellbeing. Knowledge, which may be associated with higher levels of education may therefore also be associated with higher levels of anxiety. Heatlh care workers should not assume that more highly educated women will deal better with the psychological aspects of their disease.
Bell RJ, Lijovic M, et al. Lack of knowledge of hormone receptor status is associated with lower prevalence of use of endocrine therapy in women with invasive breast cancer. Journal of Womens Health. 2009; 18(12):1975-7980.
The aim of this analysis was to investigate the level of knowledge in women newly diagnosed with breast cancer about the hormone receptor status of their disease and the relationship between that knowledge and their treatment with adjuvant endocrine therapy (eg. Tamoxifen or Aromatase inhibitors).
The analysis was performed on data from the first questionnaire of the Bupa Health Foundation Health and Wellbeing after Breast Cancer Study. 1,684 women diagnosed with invasive breast cancer between 2004 and 2006 in the state of Victoria joined the study and completed the baseline questionnaire within 12 months of their diagnosis. The relationship between age, education status and being able to correctly report hormone receptor status was investigated using logistic regression analysis, as was the relationship between the likelihood of taking adjuvant endocrine therapy and knowledge of hormone receptor status in women who were oestrogen and/or progesterone receptor positive. Histological confirmation of receptor status was provided by the Victorian Cancer Registry (VCR).
The results indicated that being older and less educated was associated with being less likely to correctly report hormone receptor status. Of women who were identified by the VCR as oestrogen and/or progesterone receptor positive and who were at least 40 weeks from diagnosis, having received endocrine therapy was significantly associated with self-identifications of being hormone receptor postitive, even when age was taken into account.
Adjuvant endocrine therapy has been shown to greatly reduce the risk of recurrence and is the gold standard of care. This study suggests that a review of the methods currently available to help women understand their breast cancer would be valuable as self-knowledge of hormone receptor status was shown to be independently associated with the likelihood of taking this therapy.
Lijovic M, Davis SR, et al. The relationship between knowledge of family history and cancer characteristics at diagnosis in women newly-diagnosed with invasive breast cancer. Familial Cancer. 2009; 8: 299-305.
The aim of this cross-sectional analysis was to document known family history and to investigate any relationship between this knowledge and the stage and size of invasive breast cancer at the time of diagnosis.
The analysis was performed on data from the first questionnaire of the Bupa Health Foundation Health and Wellbeing after Breast Cancer Study. 1,684 women diagnosed with invasive breast cancer between 2004 and 2006 in the state of Victoria joined the study and completed the baseline questionnaire within 12 months of their diagnosis.
The results indicated that women who knew that they had a first degree relative with a previous diagnosis of invasive breast cancer were more likely to have a smaller earlier-stage cancer at diagnosis than women with no known affected relatives.
The conclusion of the study was that women who considered themselves to be at an increased risk of being diagnosed with breast cancer due to a family history are possibly more diligent with regular screening for the disease.
Bell RJ, Lijovic M, et al. A pragmatic approach to the classification of menopausal status for community-based research. Menopause. 2008 Sep-Oct; 15(5):978-983.
The aim of this paper was to describe a pragmatic approach which can be used in research to classify the menopausal status of women who have gynaecological circumstances that complicate their natural menopausal pattern.
The classification algorithm developed was applied to data from the first questionnaire of the Bupa Health Foundation Health and Wellbeing after Breast Cancer Study. 1,684 women diagnosed with invasive breast cancer between 2004 and 2006 in the state of Victoria joined the study and completed the baseline questionnaire within 12 months of their diagnosis. The self-reported data was used to classify the women in the study as either premenopausal, perimenopausal or postmenopausal, and included gynaecological history, menstrual cycle pattern, presence or absence of vasomotor symptoms and systemic hormone use.
The menopausal status in 71.8% of the women in the study was classified by reported bilateral oophorectomy, age, more than 12 months of amenorrhoea, or regular menstrual cycles and the absence of symptoms. The status in the remainder of the women was classified according to the developed decision tree.
The menopausal classification algorithm described is a useful tool for community-based research as it allows for the classification of women who have had a hysterectomy and of women using systemic hormones for contraception or hormone therapy.
Lijovic M, Davis SR, Fradkin P, La China M, Farrugia H, Wolfe R, Bell RJ. Use of a cancer registry is preferable to a direct-to-community approach for recruitment to a cohort study of wellbeing in women newly diagnosed with invasive breast cancer. BMC Cancer. 2008 May 2;8:126. doi: 10.1186/1471-2407-8-126.
The methods of recruitment to the Bupa Health Foundation Health and Wellbeing after Breast Cancer Study are detailed in this paper. It can be viewed at biomedcentral.com/content/pdf/1471-2407-8-126.pdf