Symptom cluster of emotional distress, fatigue and cognitive difficulties among young and older breast cancer survivors: The mediating role of subjective stress Inbar Levkovich a, ⁎, Miri Cohen b , Shirly Alon c , Iryna Kuchuk c , Bella Nissenbaum c , Ella Evron d , Simon Pollack e , Georgeta Fried f a The Division of Family Medicine, The Ruth & Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel b School of Social Work, Faculty of Social Welfare and Health Sciences, University of Haifa, Israel c Oncology Department, Meir Medical Center, Israel d Tel Aviv Sourasky Medical Center, Affiliated to Tel Aviv University, Sackler Faculty of Medicine, Israel e Rambam Health Care Campus, Haifa, Israel f Oncology Unit, Rambam Health Care Campus, Haifa, Israel abstract article info Article history: Received 31 December 2017 Received in revised form 24 March 2018 Accepted 1 May 2018 Available online xxxx Objectives: To examine the nature of the symptom cluster of emotional distress, fatigue, and cognitive difficulties in young and older breast cancer survivors (BCS); To assess the mediating role of subjective stress and coping strategies (emotional control and meaning-focused coping) in the association between age and symptom cluster. Materials and Methods: Participants were 170 BCS, stages I-III, 1–12 months post-chemotherapy, filled-out the Fatigue, Emotional Control, Meaning—focused Coping, Emotional Distress and the Cognitive Difficulties Questionnaires. Statistical analyses included tests for difference between-groups Pearson correlations and Structural Equation Modeling for the assessment of the study model. Results: Older BCS (aged 60–82) reported lower levels of emotional distress (M = 0.87, SD = 0.87), fatigue (M = 3.85, SD = 2.38), and cognitive difficulties (M = 1.17, SD = 1.07) compared to the younger BCS (aged 24–59) (emotional distress M = 1.17, SD = 0.85, fatigue M = 5.02, SD = 2.32, and cognitive difficulties M = 1.66, SD = 1.23, p b .01–,05). The older survivors reported lower levels of subjective stress and used more emotional control strategies compared to the younger BCS. The empirical model had good fit indices (χ2= 27.60, p = 0.20, χ2/df = 1.26; CFI = 0.98; TLI = 0.98; NFI = 0.95; RMSEA = 0.04 (90% CI = 0.00, 10) and showed that subjective stress, but not coping strategies, mediated the effect of age on symptom cluster severity. Conclusions: Lower levels of subjective stress, but not coping strategies, mediated the association of age with the symptom cluster of emotional distress, fatigue and cognitive difficulties. Further research is needed to explore differences in subjective stress by age. © 2018 Elsevier Ltd. All rights reserved. 1. Introduction Until recent years, breast cancer survivors (BCS), aged 60 and older, have been excluded from the majority of clinical and psycho-social studies [1,2]. Therefore, knowledge about the effects of the disease and the treatments on the physical, mental and cognitive state of older women, compared to younger women, is limited [2]. Symptoms of emotional distress (depression and anxiety), fatigue, and cognitive difficulties persist over time in BCS after chemotherapy, impairing survivors' quality of life [3–7].In addition, a substantial per- cent of survivors also reported fatigue and distress levels far beyond the clinically significant cutoff scores(64% for fatigue and 25% for depression) [8]. Reports of cognitive difficulties over time vary among studies - from no difficulties at all to a prevalence of difficulties among 36% of the BCS samples [9]. These symptoms, of emotional distress, fatigue and cognitive difficulties, were previously suggested to be referred to as a symp- tom cluster [10,11] defined as a group of co-occurring symptoms that interact with each other, and the symptoms often share a common origin [12,13]. In the case of the triad of emotional dis- tress, fatigue and cognitive difficulties in BCS, these symptoms may originate from the chemotherapy treatment or the chronic Journal of Geriatric Oncology xxx (2018) xxx–xxx ⁎ Corresponding author at: The Division of Family Medicine, The Ruth & Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Department of Family Health Care, 6 Hashachaf St., Bat-Galim, Haifa 35013, Israel. E-mail addresses: inbar.lev2@gmail.com (I. Levkovich), cohenm@research.haifa.ac.il (M. Cohen), shirly.alon@clalit.org.il (S. Alon), iryna.kuchuk@clalit.org.il (I. Kuchuk), Bella.Nissenbaum@clalit.org.il (B. Nissenbaum), ellae@tlvmc.gov.il (E. Evron), pollack@rambam.health.gov.il (S. Pollack), g_fried@rambam.health.gov.il (G. Fried). JGO-00551; No. of pages: 7; 4C: https://doi.org/10.1016/j.jgo.2018.05.002 1879-4068/© 2018 Elsevier Ltd. All rights reserved. Contents lists available at ScienceDirect Journal of Geriatric Oncology Please cite this article as: Levkovich I, et al, Symptom cluster of emotional distress, fatigue and cognitive difficulties among young and older breast cancer survivors: The mediating role of subjective stress, J Geriatr Oncol (2018), https://doi.org/10.1016/j.jgo.2018.05.002