partnerships with their physicians in making decisions and managing their overall health care programs (Leigh, 1994, 1996).

Quality of Life

As a research topic, quality of life has evolved over 40 years from early narrative and cross-sectional studies to simple quantitative measures of various parameters, and later by longitudinal studies of greater complexity, to inclusion in randomized clinical trials. Quality of life has become a standard means of assessing clinical outcomes and in clinical trials is an accepted endpoint measurement that is considered alongside patient survival and side effects or complications (Morton, 1995). Measurement of health-related quality of life among cancer survivors is important, but comparison of quality-of-life measurement instruments is needed to clarify which questionnaires are preferable for particular populations or situations (Ferrell et al., 1995; Osoba et al., 1995). In general, however, studies indicate that although cancer survivors experience long-term changes in their overall quality of life after the completion of treatment, many positive benefits that help to balance the worst outcomes may also be gained (Dow et al., 1996).

Cancer affects not only the patient but the entire family unit. Yet, very little research on the impact of cancer and cancer therapy on the family members of patients has been performed (Rivera, 1997). Professionally led support groups are increasing in number, and participation in such groups seems to enhance the quality and possibly even quantity of the patient's survival. However, there has been little research on what type of group may be appropriate for which patients and when in the course of their care that it might be appropriate (Krupnick et al., 1993).

Psychosocial and spiritual factors influence a broad spectrum of medical and surgical disorders, yet the results of studies described in the research literature are inconsistent and the studies themselves are beset with major methodologic problems (Creagan, 1997). One study has shown that for some survivors, the cancer experience elicits a search for meaning, which is significantly associated with self-blame, although well-being scores were not significantly related to this search for meaning (Dirksen, 1995). Other researchers have found that long-term survivors of breast cancer are challenged to redirect their energy from issues of cancer treatment and early side effects toward quality-of-life issues related to long-term survivorship, such as menopause, infertility, fear of recurrence, family distress, and uncertainty (Ferrell and Dow, 1996; Ferrule et al., 1997). These can be categorized into four domains, each with particular areas of concern. In the domain of physical well-being, the areas of worst outcome were in menstrual changes and fertility, fatigue, and pain. In the domain of psychological



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