Urban and non-urban breast cancer survivors reported similar levels of QOL 12 months following diagnosis, overall and for subscales. The sole exception was the breast cancer concerns subscale, which showed that non-urban residents fared worse than their urban counterparts. When comparing breast cancer survivors to age- and residence-matched peers, the only detriment to QOL was among non-urban breast cancer survivors who reported statistically and clinically poorer physical well-being. Overall, up to one in three breast cancer survivors reported QOL below the age- and residency-matched general female population. The major independent correlates of reporting overall QOL below that of age-matched women without breast cancer were complications following surgery, poorer upper-body function, higher perceived stress levels, and poor perception of handling stress.
Despite the known differences by geographic residence with regards to access to services, availability of treatment and survival outcomes, our results indicate only minor disparities in QOL between urban and non-urban breast cancer survivors 12 months post-diagnosis. The subscale measuring breast cancer-specific concerns yielded the lowest values (based on percent of maximum score) reported by all survivors, but in particular for women living in non-urban areas. Items within this subscale deal with treatment-related symptoms, such as swelling of the arms, pain, shortness of breath, body image and sexuality. These results support existing research which demonstrates that while QOL among breast cancer survivors improves considerably during the first year following completion of treatment, breast cancer treatment-related concerns (such as arm dysfunction, poor body image, and sexual dysfunction) may persist [35–39].
It is plausible that non-urban survivors suffer in terms of their breast cancer-specific QOL, more so than urban survivors, as a consequence of inequalities in accessing specialised services. However, study-specific data collection procedures may also have contributed. QOL scores were derived from the third questionnaire for participants in the longitudinal urban breast cancer study, whereas the first (and only) questionnaire was the source of QOL data for non-urban breast cancer participants. Therefore urban survivors may have responded differently to QOL questions over time, not only because their QOL changed, but also because they may have become used to answering questions about QOL and might have over time changed their perception of QOL. This response shift may, in part, explain what appears to be a more positive breast cancer-specific QOL among urban survivors than non-urban survivors. However, the difference in QOL was observed on most but not all subscales, suggesting that response shift played a minor role in our findings.
On average, QOL was similar for breast cancer survivors and general population peers, for both urban and non-urban residents, similar to results reported by other authors studying QOL among breast cancer survivors 12 months [40, 41] or longer [18, 26, 42] following diagnosis. The high FACT-G scores observed among breast cancer survivors are somewhat surprising, because patients frequently report ongoing symptoms and long-term side-effects [35, 36, 39]. High functional and social well-being reported by breast cancer survivors compared to their general population counterparts contributed to their overall high FACT-G score and contradicts previous research [18, 26, 40–42]. However, the literature is dominated by studies using the European Organisation for the Research and Treatment of Cancer QOL questionnaire (EORTC QLQ-C30) [18, 26, 40, 41]. The social well-being subscale of the EORTC QLQ-C30 and the FACT have been shown to be poorly correlated (r = 0.09)  suggesting they measure different aspects of social well-being. Furthermore, QOL domains measured by the FACT-G may be more relevant to short-term recovery. Whereas 12 months or longer after diagnosis, alternate issues may become more important for QOL, such as fear of recurrence or making meaning of the cancer experience. More recently, survivorship-specific QOL instruments have been developed, and further research is needed to assess whether these will uncover additional medium- to long-term survivorship issues .
Despite overall QOL similarities between survivors and their general population peers, up to one-third (depending on the subscale) of survivors continued to experience lower QOL 12 months following diagnosis of breast cancer. To our knowledge, despite Fayers suggesting advanced analytical procedures using normative scores in 2000 , this is the first study to assess correlates of lower QOL among breast cancer survivors in this manner. The results demonstrate that experiencing one or more treatment-related complications, reporting lower upper-body function than the median, moderate to high stress levels and/or perceived poor handling of stress could reduce the odds of good QOL two- to four-fold. The cross-sectional nature of the data denotes that these characteristics are correlates of QOL but not necessarily causes. Moreover, the relative QOL index used to identify these correlates may be focusing on those women with breast cancer who would have been in the lower part of the QOL range even before they had the disease. Regardless, these correlates have relevance for identifying subgroups of breast cancer survivors who require assistance to regain QOL to levels expected among age-matched peers from the general population.
Several key design features of this work highlight the strength and importance of the findings. Results were obtained from population-based urban and non-urban breast cancer samples, representative of their respective target populations [20–22], and therefore results are likely generalizable to the wider population of breast cancer survivors. Further, QOL of survivors were compared to peers without breast cancer, including matching for place of residence, allowing for more accurate interpretation of meaning of results. At a glance, the results from this study suggest that, overall, women with breast cancer fare well by 12 months following diagnosis; however, interventions are needed to improve breast cancer-related concerns among all women with breast cancer and physical well-being among non-urban survivors. These should specifically recruit those survivors who experience complications following surgery, upper-body dysfunction and/or those with a greater burden of stress (i.e., higher amounts and/or poor self-perceived handling of stress). Interventions that address such concerns and that are accessible for all women, irrespective of place of residence, may help facilitate a faster return to optimal QOL in the future.