ORIGINAL ARTICLE J Breast Dis 2016 December; 4(2): 58-63 JBD Journal of Breast Disease 추적기간에따른유방암생존자들의디스트레스와삶의질 조한철, 김의태, 민준원 단국대학교의과대학외과학교실 Distress and Quality of Life for Breast Cancer Survivors during Follow- Up Periods in Korea Han Cheol Jo, Eui Tae Kim, Jun Won Min Department of Surgery, Dankook University College of Medicine, Cheonan, Korea Purpose: Few studies have reported postdiagnosis differences in distress and quality of life (QOL) for breast cancer (BC) survivors. Here we investigated the differences in distress and QOL for BC survivors in Korea, during follow-up. Methods: Completed questionnaires were collected from 179 BC survivors in 2013. Functional Assessment of Cancer Therapy-Breast was administered to measure the distress and Distress Thermometer and Problem List was administered to measure the QOL. Results: The mean QOL score was 96.69 (standard deviation, ± 20.33). Seventy-nine patients (44.1%) with distress-test scores > 4 were assigned to the severe distress group. The patient group with higher family income had high QOL score (p= 0.008). In addition, QOL scores were significantly higher in patients who lived longer after diagnosis (p= 0.016). Patients at high TNM stage had low QOL scores (p= 0.006). Furthermore, older patients tended to have high distress scores (p= 0.028). Based on duration of the postdiagnosis period, we divided the patients into two groups. Seventy patients had a postdiagnosis period <2 years; 109 patients, postdiagnosis period 2 years. Distress score of the under-2-year group (4.26± 2.73) was significantly higher (p= 0.044) than that of the longer-than-2-year group (3.47±2.42). Conclusion: BC survivors showed improvement in physical well-being, emotional well-being, and functional well-being domain of QOL over time. However, social well-being and BC subscale score were only slightly improved over time. It is possible that cancer patients supporting programs are focused on the recently diagnosed patients or those currently undergoing treatment. Therefore, more support should be made available to long-term BC survivors. Key Words: Breast, Neoplasms, Psychological stress, Quality of life, Survivors 서론 최근검진이보편화됨에따라초기에발견되는유방암환자들이 늘어나고있으며치료의발전으로인해암생존율이증가하고있다. 그에따라암을겪은후생존한사람을가리키는암생존자의수는 계속증가하여 2015 년우리나라암생존자의수가 130 만명을넘어 섰다. 특히유방암의경우여성암생존자중 20% 를차지하고있으 며, 갑상선암다음으로많은부분을차지하고있다 [1]. 현재는생존뿐아니라삶의질향상에대한사회적인식이높아지 Correspondence: Jun Won Min Department of Surgery, Dankook University College of Medicine, 201 Manghyang-ro, Dongnam-gu, Cheonan 31116, Korea Tel: +82-41-550-6379, Fax: +82-41-550-7629, E-mail: junwon77@naver.com Received: Jun 19, 2016 Revised: Aug 13, 2016 Accepted: Oct 11, 2016 면서암생존자의삶의질에대한연구가많이이루어지고있다. 암진단이후많은환자가심리사회적부분에넓은범위의스트레스를보이며, 이러한암환자의정신적고통을디스트레스 (distress) 라고정의하고있다. 이러한디스트레스가암생존자의삶의질과관련이있다는것이여러연구에서이미밝혀졌다 [2,3]. 다행히유방암생존자를대상으로한연구에서진단과치료이후어느정도의시간이경과하면디스트레스가감소하여삶의질이많은부분이회복되는것으로밝혀졌지만 [4-6], 삶의질과디스트레스에관한연구가대부분진단과치료시기에집중되어있어추적관찰기간에따라어떤변화가생기는지를보여주는연구는많지않다. 본연구에서는유방암생존자의디스트레스와삶의질을파악하고, 추적기간에따라어떤차이가있고변화를보이는지알아보고자하였다. 2016 Korean Breast Cancer Society. All rights reserved. eissn 2288-5560 This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Distress and Quality of Life for Breast Cancer Survivors 59 방법 적상태 (0.89), 유방암특이상태 (0.72) 의신뢰도를보였다. 연구대상본연구는충청지역에거주하는유방암생존자를대상으로하였다. 외래환자와유방암동호회원, 건강강좌에참여한생존자를대상으로 2013년 8월부터 12월까지조사하였다. 대상자선정기준은유방암 0 3기의진단을받은여성으로현재재발및전이가없는자로수술후항호르몬치료를제외한보조적치료가끝난자로하였다. 대상자에게연구간호사가연구의목적과작성절차를설명하고연구참여에서면으로동의한경우에설문지를작성하도록하였다. 본연구에서는 215명의대상자로부터설문지를수집하였고, 설문지내용이미비한 36명을제외하여최종적으로 179명의자료를분석하였다. 이연구는단국대학교병원연구심의위원회승인 (IRB file number: 2013-08-002-003) 아래진행되었다. 연구도구 Distress Thermometer and Problem List (DT & PL) 디스트레스평가는미국 National Comprehensive Cancer Network (NCCN) 에서개발된 DT & PL을이용하였다. 한국암환자에게서신뢰성과타당성이확립된한국형 DT & PL 버전을사용하였고 [7], 이는 2개의항목으로구성되어있다. 첫번째항목은디스트레스온도계로 0 ( 전혀없다 ) 에서 10 ( 매우심하다 ) 의범위의시각적상사척도에대해지난일주일동안대상자가느끼는점수에표시하도록하였으며, NCCN 기준에따라 4점이하는경증의디스트레스군, 4점이상은중증의디스트레스군으로분류한다. 두번째항목은실질적문제, 사회적 / 가족문제, 정서적문제, 영적 / 종교적문제와신체적문제의 5개영역으로나누어총 35문항에대해지난일주일간대상자가경험한모든문제를 예 혹은 아니오 로표시하게한다. Functional Assessment Cancer Therapy-Breast (FACT-B) 삶의질은 1993년 Functional Assessment of Chronic Illness Therapy (FACIT) 에의해개발되고한국문화에맞추어번안되어신뢰도와타당도가입증된한국어판 FACT-B 버전을이용하여측정하였다 [8]. 도구의사용은 FACIT 사이트 (http://www.facit.org) 를통해허가를받았다. 문항구성은신체적상태 (7문항), 사회적 / 가족상태 (7문항), 정서적상태 (6문항), 기능적상태 (7문항) 및유방암특이적상태 (10문항) 등총 5개로나뉘어있다. 증상이없는경우에 0점, 매우그렇다 에 4점을부여하며점수가높을수록삶의질이높음을의미한다. 본연구에서의도구신뢰도는 Cronbach s α = 0.79이었고, 신체적상태 (0.90), 사회적 / 가족상태 (0.83), 정서적상태 (0.69), 기능 자료분석 본연구에서는삶의질과디스트레스에영향을줄수있는인구 사회적요소로연령, 결혼상태, 교육정도, 종교, 직업, 경제상태, 거 주지역, 사보험및환우회여부를조사하였다. 또한, 질병관련특성 으로진단병기, 치료유형, 동반질환여부, 가족력, 경과기간에대 해확인하였다. 수집된자료는 SPSS version 19.0 프로그램 (IBM Corp., Armonk, USA) 으로분석하였다. 대상자의인구사회학적특 성과질병관련특성에따른삶의질과디스트레스의차이는 t-test, 분산분석 (analysis of variance) 을이용하여분석하였다. 결과 대상자의특성및디스트레스와삶의질정도 총대상자의수는 179 명으로, 연령대는 50 65 세가 83 명 (46.4%) 으 로가장많았다. 결혼여부는기혼이 161 명 (89.9%) 으로대부분을차 지하였고, 종교가있는경우가 98 명 (54.7%) 으로많았다. 교육정도는 고등학교졸업이 80 명 (44.7%) 으로가장많았고, 직업은 53 명 (29.6%) 이가지고있었다. 경제상태는가족월수입으로조사하였고 300 500 만원이 64 명 (35.8%) 으로가장많았다. 사보험은있는경우가 129 명 (72.1%) 으로많았으며, 환우회활동을하는경우는 73 명 (40.8%) 이 었다. 질병관련해서는진단기간은 2 년이내가 70 명 (39.1%) 으로가장 많았고, 10 년이상도 10.1% 를차지하였다. 진단병기는 1 기가 68 명 (38.0%), 2 기가 66 명 (36.9%) 으로많은부분을차지하였고동반질환 은없는경우가 127 명 (70.9%) 이었고, 유방암가족력은 15 명 (8.4%) 만 이있었다. 연구대상자의삶의질은평균 96.69 점 ( ± 20.33) 이었으며, 영역별 로 10 점기준으로보았을때, 사회적 / 가족상태가 5.36 으로가장낮 았으며, 신체적상태영역이 7.65 로가장높았다 (Table 1). 디스트레 스의경우는평균 3.78 점 (± 2.57) 이었으며, NCCN 기준에따라 4 점 Table 1. Quality of life score (n=179) No. of items Mean± SD Conversion (10) FACT-B 37 96.69± 20.33 6.53 Physical well-being 7 21.42± 6.46 7.65 Social well-being 7 15.03± 6.61 5.36 Emotional well-being 6 16.43± 4.53 6.84 Functional well-being 7 17.58± 6.10 6.28 Breast cancer subscale 10 23.92± 6.91 5.98 FACT-B= Functional Assessment of Cancer Therapy-Breast.
60 Han Cheol Jo, et al. 을경계로중증디스트레스를구분하였을때, 79명 (44.1%) 이중증디스트레스군으로분류되었다. 대상자의특성에따른디스트레스와삶의질의차이대상자의특성에따른삶의질의차이를분석해보면가족월수 입이높은경우에유의하게삶의질점수가높게나타났다 (p = 0.008). 또한, 진단후시간이길어질수록유의하게점수가높아지는것을알수있었고 (p = 0.016), 병기가높을수록삶의질점수가낮아졌다 (p = 0.006). 그외에유의한차이를보이는항목은없었다. 디스트레스의경우에는나이가많을수록디스트레스가높은것으로나 Table 2. Distress and quality of life scores relation to participant s characteristics (n=179) Characteristic No. (%) Quality of life Distress Mean SD p-value Mean SD p-value Age (yr) 30 40 20 (11.2) 93.25 16.08 0.233 3.95 2.46 0.028 40 50 69 (38.5) 99.24 21.7 3.58 2.59 50 65 83 (46.4) 96.46 20.12 3.66 2.53 > 65 7 (3.9) 84.26 16.61 6.57 1.72 Marital status Married 161 (89.9) 97.04 19.96 0.323 3.66 2.5 0.275 Single 9 (5.0) 95.63 16.51 4.33 2.6 Divorce 5 (2.8) 101.93 31.15 4.8 3.7 Others 4 (2.2) 78.82 27.84 5.75 3.59 Religion Yes 98 (54.7) 95.98 19.03 0.606 4.04 2.66 0.130 No 81 (45.3) 97.56 21.89 3.46 2.42 Education Elementary school 8 (4.5) 94.33 29.12 0.153 3.75 3.2 0.988 Middle school 16 (8.9) 91.25 22.14 3.44 2.66 High school 80 (44.7) 94.12 18.91 3.79 2.56 College 70 (39.1) 100.24 19.75 3.84 2.56 Postgraduate school 5 (2.8) 109.6 24.24 3.8 2.49 Occupation Yes 62 (34.6) 100.83 18 0.077 3.47 2.56 0.450 No 104 (58.1) 93.78 21.77 3.98 2.5 Others 13 (7.3) 100.27 15.4 3.62 3.12 Family income < 100 14 (7.8) 87.95 23.83 0.008 4.64 3.18 0.688 (10,000 won/mo) 100 300 49 (27.4) 89.63 17.41 3.63 2.63 300 500 64 (35.8) 100.03 22.24 3.69 2.57 500 800 33 (18.4) 102.52 16.65 3.61 2.14 > 800 19 (10.6) 100.01 18.31 4.11 2.73 Private insurance Yes 129 (72.1) 98.45 19.62 0.064 3.71 2.5 0.597 No 50 (27.9) 92.17 21.61 3.94 2.76 Patient s support group Yes 73 (40.8) 96.77 19.43 0.968 4.11 2.59 0.150 No 106 (59.2) 96.64 21.01 3.55 2.54 Residential area Metropolitan city 42 (23.5) 96.07 17.15 0.620 3.24 2.23 0.016 Large city 42 (23.5) 94.17 19.18 4.86 2.64 Small town 77 (43.0) 98.89 21.71 3.49 2.51 Country 18 (10.1) 94.64 24.07 3.72 2.87 Postdiagnosis period (yr) <2 70 (39.1) 90.91 20.66 0.016 4.26 2.73 0.247 2 5 50 (27.9) 99.36 18.32 3.38 2.23 5 10 41 (22.9) 99.9 22.13 3.56 2.76 > 10 18 (10.1) 104.52 15.03 3.5 2.3 Staging Stage 0 14 (7.8) 107.08 21.74 0.006 3.5 3.41 0.781 Stage 1 68 (38.0) 101.21 18.7 3.68 2.46 Stage 2 66 (36.9) 92.55 19.58 3.74 2.46 Stage 3 31 (17.3) 90.92 21.59 4.19 2.69 Associated disease Yes 52 (29.1) 92.63 19.74 0.087 4.31 2.68 0.076 No 127 (70.9) 98.36 20.41 3.56 2.5 Family history Yes 15 (8.4) 103.24 19.05 0.193 3.67 2.64 0.863 No 164 (91.6) 96.1 20.39 3.79 2.57
Distress and Quality of Life for Breast Cancer Survivors 61 타났고 (p = 0.028), 거주지역이대도시인경우가다른지역보다디스트레스가높았다 (p = 0.016) (Table 2). 추적기간에따른디스트레스와삶의질의변화진단후시간이삶의질과디스트레스에끼치는영향을알기위해진단후 2년전과 2년이후의그룹으로나누었다. 2년전그룹이 70명이었고, 2년후그룹이 109명이었다. 두그룹간의질병관련특성 의차이가없었으며, 인구사회적요소로는직업의유무만이유의하게차이가있었고 (p = 0.014), 그외에는차이가없었다 (Table 3). 두그룹간의디스트레스를비교하였을때, 2년전그룹이 4.26 ± 2.73점으로 2년후그룹의 3.47± 2.42점보다의미있게높은것을알수있었다. 삶의질의경우총점에서 2년전그룹이 90.90 ± 20.66점으로 100.41 ± 19.30점인 2년후그룹보다유의하게낮은것을확인하였다. 영역별로보았을때, 신체적영역 (19.94 ± 6.40 22.37± 6.34), 정서적 Table 3. Postdiagnosis period differences in characteristics of participant groups Characteristic Post diagnosis period (yr) <2 2 Age (yr) 30 40 8 (11.4) 12 (11.0) 0.304 40 50 24 (34.3) 45 (41.3) 50 65 33 (47.1) 50 (45.9) > 65 5 (7.1) 2 (1.8) Marital status Married 59 (84.3) 102 (93.6) 0.222 Single 6 (8.6) 3 (2.8) Divorce 3 (4.3) 2 (1.8) Others 2 (2.9) 2 (1.8) Religion Yes 40 (57.1) 58 (53.2) 0.359 No 30 (42.9) 51 (45.3) Education Elementary school 6 (8.6) 2 (1.8) 0.233 Middle school 5 (7.1) 11(10.1) High school 33 (47.1) 47 (43.1) College 24 (34.3) 46 (42.2) Postgraduate school 2 (2.9) 3 (2.8) Occupation Yes 16 (22.9) 46 (42.2) 0.014 No 46 (65.7) 58 (53.2) Others 8 (11.4) 5 (4.6) Family income (10,000 won/mo) > 100 7 (10.0) 7 (6.4) 0.405 100 300 23 (32.9) 26 (23.9) 300 500 24 (34.3) 40 (36.7) 500 800 9 (12.9) 24 (22.0) > 800 7 (10) 12 (11.0) Private insurance Yes 52 (74.3) 77 (70.6) 0.216 No 18 (25.7) 32 (29.4) Patient s support group Yes 23 (32.9) 50 (45.9) 0.084 No 47 (67.1) 59 (54.1) Residential area Metropolitan city 14 (20.0) 28 (25.7) 0.448 Large city 16 (22.9) 26 (23.9) Small town 30 (42.9) 47 (43.1) Country 10 (14.3) 8 (7.3) Staging Stage 0 5 (7.1) 9 (8.3) 0.789 Stage 1 24 (34.3) 44 (40.4) Stage 2 27 (38.6) 39 (35.8) Stage 3 14 (20.0) 17 (15.6) Associated disease Yes 24 (34.3) 28 (25.7) 0.216 No 46 (65.7) 81 (74.3) Family history Yes 4 (5.7) 11 (10.1) 0.302 No 66 (94.3) 98 (89.9) Data are presented as number (%). p-value
62 Han Cheol Jo, et al. Table 4. Differences in quality of life and distress scores based on postdiagnosis period Characteristic 영역 (15.52± 4.93 17.01± 4.17), 기능적영역 (15.56 ± 6.14 18.88± 5.74) 은 2 년이지나면유의하게높아지는것 (p = 0.013, p = 0.032, p < 0.001) 을알수있었으나, 사회적 / 가족영역과유방암특이적영역은점수 가향상되기는하나통계적으로유의하지는않았다 (Table 4). 고찰 본연구는유방암생존자의삶의질과디스트레스정도를파악 하고진단후시간이지날수록어떤변화가있는지알아보았다. 이 번연구에서는전체적인삶의질점수는 96.69 점, 디스트레스의경 우평균 3.78 점이었으며, 시간이지나면서대부분의삶의질영역이 회복되나사회적 / 가족영역의회복은늦은것을보여주었다. 각영역의삶의질점수를보면, 신체적영역이가장높은점수를 보였고사회적 / 가족영역이가장낮았다. 같은측정도구 (FACT-B) 로삶의질을측정한국내및국외선행연구 [9,10] 와비교해보았을 때큰차이가없었다. 대부분의연구에서사회적 / 가족영역점수가 가장낮은것으로보여사회적지지및가족영역에서의배려가필 요하다는것을보여준다. 디스트레스의경우평균 3.78 점으로, 국내 선행연구 [7,10] 보다는 0.34 0.99 점정도낮게나타났으나, 국외연구 [11] 3.82 점과비슷한수준이었다. Postdiagnosis period (yr) < 2 (n = 70) 2 (n = 109) p-value FACT-B 90.90± 20.66 100.41± 19.30 0.002 Physical well-being 19.94± 6.40 22.37± 6.34 0.013 Social well-being 14.69± 6.33 15.24± 6.80 0.583 Emotional well-being 15.52± 4.93 17.01± 4.17 0.032 Functional well-being 15.56± 6.14 18.88± 5.74 < 0.001 Breast cancer subscale 23.07± 6.98 24.47± 6.83 0.188 Distress 4.26± 2.73 3.47± 2.42 0.044 Data are presented as mean± SD. FACT-B= Functional Assessment of Cancer Therapy-Breast. 일반적으로암생존자는진단과동시에디스트레스를받으면서 삶의질이떨어지기시작하며, 치료를받으면서현저히삶의질이떨 어지게된다 [12]. 유방암생존자의삶의질에영향을미치는요소는 나이와병기, 수술방법, 항암치료여부, 동반질환여부등이알려 져있지만, 연구마다차이가있다 [13-15]. 이번연구에서는경제상태 가좋은경우, 진단후시간이많이경과되었을경우, 그리고병기가 낮은경우가삶의질이높은것으로나타났다. 삶의질에영향을주 는디스트레스의경우는나이가많은경우에젊은생존자에비해 유의하게더높은디스트레스를보였다. 일반적으로유방암생존자 의삶의질저하위험요인으로나이가젊은경우가되어있지만, 나이가들수록심리사회적지지요소가약해지면서디스트레스가높아진다는보고가있다 [16]. 국내연구에서도오히려나이가많은유방암생존자가삶의질이낮다는보고가있었지만 [17], 본연구에서는나이에연관된삶의질차이는없었다. 거주지역의경우, 대도시 (50 100 만 ) 인경우에디스트레스가높은것으로나타났지만, 광역시 / 특별시 (100만이상 ) 와대도시를하나로묶어서분석한경우에는다른지역과차이가없었다. 여러선행연구에서암생존자의삶의질은진단후시간이지나면많은부분이회복되는것으로밝혀졌지만, 대부분의연구가진단후 2년까지시기에몰려있다 [4-6,9,12]. 또한, 치료중인경우나추적관찰중인경우는오히려의료진과가족들의관심과지지를받지만어느정도의시간이지나면그러한부분이부족해지면서심리적인불안감을보이는경우가있다. 또한, 유방암의경우다른고형암에비해 5년이지난경우에도재발하는경우가많아유방암생존자의경우재발에대한우려로인해시간이지나도여전히디스트레스가높은것을보여주었다 [18]. 이번연구에서는진단후 2년이내그룹과 2년이후그룹으로나누어삶의질과디스트레스변화를분석하였다. 모든영역의삶의질과디스트레스점수가호전되는것을보여주어서선행연구와같은결과를보여주었다. 하지만, 각영역을통계학적유의성으로보았을때, 사회적 / 가족영역이나유방암특이적영역은점수의상승은있었으나통계학적차이는없었다. 이것은시간이지나면유방암생존자는치료로인한증상은대부분회복되지만, 사회적 / 가족영역의회복은더딘것을보여준다. 현재유방암및암생존자들을위한사회프로그램이많이진행되고있지만, 대부분치료중인환자에국한되어있는것이사실이다. 앞으로는장기암생존자들을위한프로그램도활발히진행되어야할것으로생각되며, 가족의지지및관심도더필요할것이다. 본연구에서는몇가지제한점이있다. 첫째, 본연구에서는일부지역의생존자들만을대상으로조사가이루어졌기때문에, 이결과를토대로전체생존자에게일반화하기에는무리가있다. 둘째, 본연구는장기간의추적관찰을통해시간의흐름에따라동일한생존자의디스트레스와삶의질의변화를보는종단적연구가아닌횡단적연구이다. 셋째, 이번연구에서는삶의질과디스트레스에영향을주는것으로보고된항암치료등을포함한보조적치료의여부에따른분석이이루어지지않았다. 마지막으로삶의질을점검할수있는여러도구중에 FACT-B 한가지만으로연구를진행하였기때문에, 다른도구를이용한여러연구와비교가쉽지않다. 이번연구는이런제한점을가지고있지만, 유방암생존자의삶의질과디스트레스의일반적인결과와일정한시간후에도암생존
Distress and Quality of Life for Breast Cancer Survivors 63 자에게부족한삶의질영역이있고, 그에대한관심과지지가필요하다는것을알게해준중요한연구이며앞으로의대규모암생존자에대한종적연구의필요성을제기한연구이다. CONFLICT OF INTEREST The authors declare that they have no competing interests. REFERENCES 1. Cancer facts & figures 2015. National Cancer Center. https://ncc. re.kr/main.ncc?uri=english/sub04_factsandfigures. Accessed May 30th, 2016. 2. Head BA, Schapmire TJ, Keeney CE, Deck SM, Studts JL, Hermann CP, et al. Use of the Distress Thermometer to discern clinically relevant quality of life differences in women with breast cancer. Qual Life Res 2012;21:215-23. 3. Manning-Walsh J. Social support as a mediator between symptom distress and quality of life in women with breast cancer. J Obstet Gynecol Neonatal Nurs 2005;34:482-93. 4. Lee ES, Lee MK, Kim SH, Ro JS, Kang HS, Kim SW, et al. Health-related quality of life in survivors with breast cancer 1 year after diagnosis compared with the general population: a prospective cohort study. Ann Surg 2011;253:101-8. 5. Ganz PA, Kwan L, Stanton AL, Bower JE, Belin TR. Physical and psychosocial recovery in the year after primary treatment of breast cancer. J Clin Oncol 2011;29:1101-9. 6. Den Oudsten BL, De Vries J, Van der Steeg AF, Roukema JA, Van Heck GL. Determinants of overall quality of life in women over the first year after surgery for early stage breast cancer. Qual Life Res 2009;18:1321-9. 7. Shim EJ, Shin YW, Jeon HJ, Hahm BJ. Distress and its correlates in Korean cancer patients: pilot use of the distress thermometer and the problem list. Psychooncology 2008;17:548-55. 8. Yoo HJ, Ahn SH, Eremenco S, Kim H, Kim WK, Kim SB, et al. Korean translation and validation of the functional assessment of cancer therapy-breast (FACT-B) scale version 4. Qual Life Res 2005;14:1627-32. 9. Jeffe DB, Pérez M, Cole EF, Liu Y, Schootman M. The effects of surgery type and chemotherapy on early-stage breast cancer patients quality of life Oover 2-year follow-up. Ann Surg Oncol 2016;23: 735-43. 10. Kwon EJ, Yi M. Distress and quality of life in breast cancer survivors in Korea. Asian Oncol Nurs 2012;12:289-96. 11. Ploos van Amstel FK, van den Berg SW, van Laarhoven HW, Gielissen MF, Prins JB, Ottevanger PB. Distress screening remains important during follow-up after primary breast cancer treatment. Support Care Cancer 2013;21:2107-15. 12. Montazeri A, Vahdaninia M, Harirchi I, Ebrahimi M, Khaleghi F, Jarvandi S. Quality of life in patients with breast cancer before and after diagnosis: an eighteen months follow-up study. BMC Cancer 2008;8:330. 13. Suh YO. Predictors of quality of life in women with breast cancer. Taehan Kanho Hakhoe Chi 2007;37:459-66. 14. Avis NE, Crawford S, Manuel J. Quality of life among younger women with breast cancer. J Clin Oncol 2005;23:3322-30. 15. So WK, Marsh G, Ling WM, Leung FY, Lo JC, Yeung M, et al. Anxiety, depression and quality of life among Chinese breast cancer patients during adjuvant therapy. Eur J Oncol Nurs 2010;14:17-22. 16. Mosher CE, Danoff-Burg S. A review of age differences in psychological adjustment to breast cancer. J Psychosoc Oncol 2005;23:101-14. 17. Park BW, Lee S, Lee AR, Lee KH, Hwang SY. Quality of life differences between younger and older breast cancer patients. J Breast Cancer 2011;14:112-8. 18. Lee YS. Psychosocial experience in post-mastectomy women. Korean J Soc Welf 2007;59:99-124.