Traumatic distress symptoms in early breast cancer. II: Outcome six weeks post surgery

One hundred and six consecutive patients with a confirmed diagnosis of breast cancer were studied before and after surgery with a clinical psychiatric interview and questionnaires (Impact of Event Scale, General Health Questionnaire and Clinical Global Impression scale). The traumatic stress response after six weeks was related to sociodemographic factors, premorbid health problems, negative life events and clinical-oncological parameters. Symptoms of traumatic distress were significantly reduced post-surgery compared to acutely, and most so among patients with no premorbid health problems and negative life events according to pre-surgery interview and self-report data. Eighteen percent of the patients reported a high level (>19) of intrusive symptoms and 14%, avoidance symptoms. Patients with premorbid impairment in work, family and social functioning and patients who during the last year had experienced the death of a close relative or a serious illness other than cancer showed the greatest distress. Previous consultations for nervous problems, age, marital status, stage of disease, type of surgery (breast-conserving versus mastectomy) and adjuvant cytostatic treatment did not influence the traumaticstress response six weeks after surgery. The level of acute posttraumatic stress response to breast cancer surgery seems best predicted by premorbid variables.     

Posttraumatic distress symptoms in operable breast cancer III:

One hundred and six patients with operable breast cancer were studied at intervals one day before surgery, and at six weeks and one year post-operatively by means of taped clinical interviews and self-report questionnaires (Impact of Event Scale (IES) and General Health Questionnaire (GHQ-28)). A year after surgery, 9%reported a high level of intrusive symptoms and 10% of avoidance symptoms compared to 18% and 14% after six weeks, respectively. Based on questionnaire data, a year after surgery, thirteen patients (12%) were estimated to have a posttraumatic stress disorder (PTSD) compared to fifteen patients (14%) after six weeks. Severity of posttraumatic stress symptoms (PTSS) after one year was significantly associated with impaired psychosocial functioning over the last year previous to surgery (p < 0.05), negative life events during the year before surgery (p < 0.05), health problems during the previous ten years (p < 0.01), and a personality trait characterized by high emotional reactivity (p < 0.001). Crisis support in the acute situation, type of surgery, axillary-node metastases, and postoperative adjuvant chemotherapy did not predict subsequent PTSS. Premorbid health variables, personality, and level of distress six weeks after surgery were most important risk factors for persistent PTSS in our patients with operable breast cancer stage I and II.     

Depression,anxiety, post‐traumatic stress disorder and health‐related quality of life and its association with social support in ambulatory prostate cancer patients

MEHNERT A., LEHMANN C., GRAEFEN M., HULAND H. & KOCH U. (2010) European Journal of Cancer Care 19 , 736–745
Depression, anxiety, post‐traumatic stress disorder and health‐related quality of life and its association with social support in ambulatory prostate cancer patients The aim of this study is to identify anxiety, depression and post‐traumatic stress disorder in prostate cancer patients and to investigate the association with social support and health‐related quality of life. A total of 511 men who had undergone prostatectomy were surveyed during ambulatory follow‐up care for an average of 27 months after surgery using standardised self‐report measures (e.g. Hospital Anxiety and Depression Scale, Posttraumatic Stress Disorder Checklist – Civilian Version, Illness‐Specific Social Support Scale, Short‐Form Health Survey). Seventy‐six per cent of patients evaluated their disease as ‘not’ or a ‘little threatening’. The cancer diagnosis and uncertainty were most frequently reported as ‘distressing’, while medical treatment and doctor–patient interaction were most frequently evaluated as ‘most helpful’. The number of patients reporting increased levels of psychological distress was 16%, with 6% demonstrating signs of having severe mental health problems'. No higher levels of anxiety and depression were observed in cancer patients compared with age‐adjusted normative comparison groups. Lack of positive support, detrimental interactions and perceived threat of cancer were found to be predictors of psychological co‐morbidity (P < 0.001). Lack of positive support, detrimental interactions, threat of cancer, disease stage and age significantly predicted mental health (P < 0.001), whereas the impact of social support on physical health was rather weak. Findings emphasise the need for routine psychosocial screening.     

Interaction of social support and psychological stress on anxiety and depressive symptoms in breast cancer patients

Purpose: The aim of the present study was to assess the association of psychological stress and social support with anxiety and depressive symptoms in Chinese newly diagnosed breast cancer patients. Methods: Four hundred and one patients with breast cancer were recruited. Their demographic characteristics, psychological stress and social support were determined with a structured questionnaire, and their anxiety and depressive symptoms were assessed with the Hospital Anxiety and Depression Scale. Results: Psychological stressors caused by breast cancer diagnosed originated from five major sources, as determined by factor analysis. These included “Worrying about health being harmed,” “Fear of decline of physical function,” “Fear of work being harmed,” “Worry about daily life and social relationship being restricted,” and “Fear of family being harmed.” Hierarchical linear regression analysis indicated that, after adjusting for gender, age, marital status, educational level, and duration of illness, solid social support can alleviate such symptoms. Conclusions: The results of this study suggest that there are strong associations between patients’ needs and psychological distress with newly diagnosed breast cancer. Social support might affect these associations in Chinese women with breast cancer.     

乳腺导管原位癌患者生活质量调查及相关因素分析

ObjectiveTo study the quality of life (QOL) of patientswith ductal carcinoma in situ (DCIS) and to analyze the relevant factors affecting their QOL. MethodsA total of 84 patients with DCIS and 125 patients with invasive breast cancer were surveyed. Researchers used SF-36 to assess the QOL of participants at one year after operation. Some information of patients were analyzed the relationship to SF-36 score, such as age, the type of surgery, endocrine therapy, education, marital status, working status and health insurance. ResultsCompared to normal women, patients with DCIS had lower QOL in physical function (P=0.029), bodily pain (P=0.039), general health (P=0.033) and mental health (P=0.003). Patients with invasive breast cancer also had poorer QOL in physical function (P=0.002), bodily pain (P=0.002), vitality (P=0.002), general health (P=0.002) and mental health (P=0.001). QOL of DCIS patients were similar to that of invasive breast cancer patients, except that score of physical function (P=0.032) and vitality (P=0.040) were better in DCIS patients. Endocrine therapy significantly affected the score of QOL of DCIS patients. DCIS patients with endocrine therapy had poorer score in physical function (P=0.034), bodily pain (P=0.046), general health (P=0.031), vitality (P=0.042) and mental health (P=0.002). Conclusion Patients with DCIS have poor QOL at one year after operation. Endocrine therapy significantly reduces their QOL.     

Onset and relapse of psychiatric disorders following early breast cancer: a case–control study

Objective: Our objective is to evaluate the mental status of primary early breast cancer survivors according to DSM‐IV criteria, distinguishing new psychiatric diagnosis, which started after the cancer diagnosis from relapse. Methods: A comparative study of 144 breast cancer survivors and 125 women without previous history of cancer was carried out. Neuropsychiatric symptomatology was assessed retrospectively using standardized psychiatric examinations (Mini International Neuropsychiatric Interview, Watson's Post‐Traumatic Stress Disorder Inventory) over three successive periods, ‘before cancer’ (from childhood to 3 years before the interview), ‘around the cancer event’ (the last 3 years including the time of diagnosis and treatment), and ‘currently’ (the last 2 weeks). Results: Increased rates of anxiety and mood disorders were observed following a diagnosis of breast cancer compared with controls (generalized anxiety disorder (GAD) and major depressive disorder (MDD); 10.4 vs 1.6% and 19.4 vs 8.8%, respectively). The cancer disease promoted the development of dysthymia (n=4 new cases/6 two‐year prevalent cases) and PTSD (7/7) and the re‐emergence of MDD (n=21 relapses/28 three‐year prevalent cases) and GAD (10/15). No improvement in serious mood disorders such as MDD (16.0 vs 7.2%) and dysthymia (4.2 vs 0%) was reported at the time of interview, more than 1.75 years (median time) after the cancer surgery, the prevalence being 2–4 times greater in breast cancer survivors than in controls. Conclusion: Despite significant advances in treatment, a diagnosis of breast cancer is highly associated with various forms of psychopathology, regardless of psychiatric history, with symptoms persisting after treatment. These results may assist clinicians in planning mental healthcare for women with breast cancer. Copyright © 2009 John Wiley & Sons, Ltd.     

Psychosocial impact of newly diagnosed advanced breast cancer

The purpose of this study was to delineate the key emotional concerns of women newly diagnosed with recurrent or metastatic breast cancer. Sixty-six women diagnosed with metastatic breast cancer within the previous 6 months, receiving treatment at the Medical Oncology Departments of two metropolitan teaching hospitals, completed measures of HADS, IES, CARES-SF and Memorial Symptom Assessment Scale, and participated in a semi-structured interview. There were high levels of psychological morbidity, 56.7% of women younger than 55 years qualifying as "cases" on the HADS, compared with 34.5% of women aged over 55 years. The total HADS score was significantly correlated with the Global and Physical Subscales of the MSAS and CARES. Women younger than 55 years had significantly higher levels of intrusive and avoidant symptoms than women over 55 years. Women also reported high numbers of physical symptoms. Key themes which emerged during the interviews were: difficulties in communicating with doctors, perceived delay in diagnosis, the emotional impact, concerns about the family, feelings about why the cancer developed, other life stress and trauma, and use of non-prescribed treatments.     

Surviving recurrence: psychological and quality-of-life recovery

BACKGROUND: To the authors' knowledge, data characterizing patients' psychosocial experiences after a recurrence diagnosis are limited. This report provides the physical, psychological, and quality-of-life trajectories of patients with recurrent breast cancer. In addition, patients with a well-documented trajectory -- patients with their initial diagnosis of breast cancer -- were included as a referent group, providing a metric against which to gauge the impact and course of cancer recurrence. METHODS: Patients with a newly diagnosed, recurrent (n = 69) or initial (n = 113) breast cancer were accrued. The groups did not differ with regard to age, race, education, family income, or partner status (all P values > .18). All patients were assessed shortly after diagnosis (baseline) and 4 months, 8 months, and 12 months later. Mixed-effects models were used to determine health status, stress, mood, and quality-of-life trajectories. RESULTS: In the year after a recurrence diagnosis, patients' physical health and functioning showed no improvement, whereas quality of life and mood generally improved, and stress declined. Compared with patients who were coping with their first diagnosis, patients with recurrence had significantly lower anxiety and confusion. In contrast, physical functioning was poorer among recurrence patients, quality-of-life improvement was slower, and cancer-related distress was high as that of the initially diagnosed patient. Slower quality-of-life recovery was most apparent among younger patients (aged <54 years). CONCLUSIONS: Despite the physical burden, patients with recurrent breast cancer exhibit considerable resilience, with steady improvements in psychological adjustment and quality of life during the year after diagnosis. Management of patients' physical symptoms is particularly important, because patients cope with recurrent breast cancer as a chronic illness.     

Early Detection for Breast Cancer in Iran

Objectives: The present study was carried out to assess knowledge, attitudes and practice (KAP) concerningearly detection for breast cancer among Iranian health care providers (HCP). Methods: Three hundred andeighteen HCPs were selected with stratified simple random sampling and given questionnaires to determinetheir baseline KAP for breast cancer early detection. Results were compared among categories of age, educationallevel, marriage status and professional experience with the Chi square test. Results: For six knowledge questions,71.8% participants had four or more correct responses, 80.5% agreed completely with ‘women will accept thescreening program if the physicians advise it’. However, 48% of female HCPs did not carry out any method ofbreast cancer screening for themselves during the last year; 81.5% did not carry out breast examinations for themajority of female outpatients and inpatients during last year; only 5.1% recommended breast self examination(BSE) to more than 70% of their female patients. Conclusions: Knowledge and attitudes are relativelyappropriate, but practical measures are not enough. Considering the HCP’s role for implementing the nationalbreast cancer control program, improvement in knowledge and attitudes is still important, but this may not beenough to reach to an appropriate level of desired practice.     

Depressive symptoms after breast cancer surgery: relationships with global, cancer-related, and life event stress

For women with breast cancer, rates of depression are the third highest of any cancer diagnostic group. Stress, defined as life events or perceptions of stress, is associated with depressive symptoms. However, little is known about the relationships between different types of stress and these symptoms in women with breast cancer. This relationship was tested in 210 women assessed after initial surgical treatment for regional breast cancer. Using Hierarchical Multiple Regression, three types of stress were examined: the occurrence of five stressful life events in the year prior to cancer diagnosis, perceptions of global stress, and perceptions of cancer-related traumatic stress. Other potentially relevant correlates of depressive symptoms were also examined, including the personality trait neuroticism, sociodemographics, and disease/treatment characteristics. Fifty-three percent of the variance in depressive symptoms was accounted for by three stress variables (perceptions of global and cancer-related traumatic stress and the life event-major financial difficulty) and two control variables (neuroticism and racial group). Specifically, global stress perceptions coupled with cancer-related intrusive thoughts and financial concerns along with the tendency towards negativity (neuroticism) may conspire to heighten a women's risk for depressive symptoms. Assessing multiple sources of stress would improve our ability to identify women 'at risk' for depressive symptoms and provide appropriate intervention.     

Improvement in self-reported physical health predicts longer survival among women with a history of breast cancer

Physical health-related quality of life scores have been, inconsistently, associated with breast cancer prognosis. This analysis examined whether change in physical health scores were related to outcomes in women with a history of breast cancer. 2343 breast cancer survivors in a randomized diet trial provided self-reported assessment of physical health-related quality of life at baseline and year 1. Based on change in physical health score, participants were grouped into subpopulations of decreased physical health, no/minimal changes, and increased physical health. Cox regression analysis assessed whether change in physical health (from baseline to year 1) predicted disease-free and overall survival; hazard ratio (HR) was the measure of association. There were 294 additional breast cancer events and 162 deaths among women followed for 7.3 years. Improvements in physical health were associated with younger age, lower BMI, being employed, not receiving tamoxifen, lower physical activity, and lower baseline physical and mental health. There was no association of change in physical health with additional breast cancer events or mortality among women diagnosed ≤2 years before study enrollment. However, among women who entered the study >2 years post-diagnosis, the HR for increased compared to decreased physical health was 0.38 (95% CI, 0.16–0.85) for all-cause mortality. These results appear to support testing an intervention to improve physical health in breast cancer patients among patients after the acute stage of treatment.     

Short term correlates of the Neuro Emotional Technique for cancer-related traumatic stress symptoms: A pilot case series

Introduction As many as one quarter of all cancer survivors report traumatic stress symptoms from cancer-related experiences. While the majority of these patients do not meet the criteria for posttraumatic stress disorder (PTSD), there is growing evidence that subsyndromal symptoms can significantly contribute to functional impairment and negative health outcomes. Treatment options for the hallmark symptoms of traumatic stress—unpleasant, intrusive thoughts and avoidant behaviors—have not been well investigated for the cancer survivorship population. Materials and methods Seven female cancer survivors with traumatic stress symptoms from cancer-related experiences and no other major psychopathology, were enrolled to receive three sessions of Neuro-Emotional Technique (NET), a brief, targeted treatment that combines traditional desensitization principles with complementary modalities. Results Psychological outcome measures (Impact of Event Scale (IES) and Subjective Units of Distress (SUD) and physiological measures (Heart Rate (HR) and Skin Conductance Level (SCL) demonstrated the following changes: 71% on IES, 88% SUD, 74% on HR, and 65% on SCL following the intervention. Statistically significant changes were observed for all four parameters, and effect size g for proportion improved were 0.50 each for IES, SUD, and HR, and 0.20 for SCL. Conclusions These cases suggest feasibility of the NET intervention for cancer-related traumatic stress and the potential for change in symptoms and physiological reactivity. Further investigation is needed to determine the specific and long-term effects of such an approach. Implications for cancer survivors Traumatic stress from cancer-related experiences might represent a constellation of symptoms that are amenable to brief, targeted interventions. This study was supported by the O.N.E. Research Foundation     

Factors associated with the incompliance with mammogram screening among individuals with a family history of breast cancer or ovarian cancer

Objective The national guidelines recommend more intensive screening for breast cancer for women with a family history of breast or ovarian cancer. Using the data from the 2000 National Health Interview Survey (NHIS), we examined factors related to the underuse of mammogram in this population. Method The study subjects were 1,215 women aged 30–79 who had a family history of breast or ovarian cancer in their first-degree relatives. According to the American Cancer Society’s guidelines for breast cancer screening, having no mammogram in last year was used as an outcome for this study. Socio-demographic characteristics, health-related conditions, lifestyle factors, health behaviors, menstrual/reproductive information and health care access and utilization were analyzed to assess their relations to mammogram underuse using unconditional logistic regression method. Results The results showed that younger age, having no place to go when sick (OR = 2.2, 95% CI, 1.2–4.0), having no visits to a general doctor (OR = 1.7, 95% CI, 1.2–2.4) or medical specialist (OR = 2.2, 95% CI, 1.6–3.1) and having no influenza shot in last year (OR = 1.7, 95% CI, 1.2–2.3) increased the risk of underusing mammography screening among women who had a family history of breast or ovarian cancer. Women who had no home care from health professionals in the last year were less likely to underuse mammogram with an OR of 0.3 (95% CI, 0.1–0.6), compared with women who had. Conclusion Medical care-related factors may affect the use of mammography screening in women with a family history of breast or ovarian cancer. The views expressed in this article are those of the author and do not reflect the official policy of the department of Army, Department of Defense, or U.S. Government.     

First degree relatives of breast cancer patients: screening practices and provision of risk information.

Little is known about breast cancer screening knowledge and behaviors among women with a family history of breast cancer. Data gathered from 125 first-degree relatives of breast cancer patients indicated that only 63.3% of women over age 35 "ever" had a mammogram, 53% of women 40 or older reported a mammogram in the last year, and only 36.8% of all participants reported monthly breast self-exam (BSE). Self-reported BSE competence was generally poor. One hundred five (105) (84%) reported a clinical breast exam over the previous year. Only 71 (56.8%) of the women indicated that they had been asked about their family history of breast cancer by their physician, and minimal information about risk related to family history was provided. Worry about developing breast cancer was positively related to mammography use and BSE competence. Confidence in performing BSE and learning BSE from a physician/nurse were both positively related to competence. Women who believed they had control over finding breast cancer in its early stages reported more frequent BSE. Poor compliance of women with a family history of breast cancer in the practice of BSE and utilization of mammography, and lack of risk information provided by physicians mandate a search for effective intervention.     

Socio-Demography and Medical History as Predictors of Health-Related Quality of Life of Breast Cancer Survivors

Background: Even after completion of conventional treatment, breast cancer survivors continue to exhibita variety of psychological and physical symptoms, affecting their quality of life. The study aimed to investigatethe relationship between socio-demography, medical characteristics and health-related quality of life (HR-QOL)of a sample of breast cancer survivors in Malaysia. Materials and Methods: This pilot cross-sectional surveywas conducted among breast cancer survivors (n=40) who were members of Breast Cancer Support GroupCentre Johor Bahru. A validated self-administered questionnaire was used to identify the relationships betweensocio-demography, medical characteristics and HR-QOL of the participants. Results: Living with family andcompletion of treatment were significant predictive factors of self-rated QOL, while living with family and evergiving birth significantly predicted satisfaction with health and physical health. Psychological health had moderatecorrelations with number of children and early cancer stage. Survivors’ higher personal income (>MYR4,500)was the only significant predictor of social relationship, while age, income more than MYR4,500 and giving birthsignificantly predicted environment domain score. Conclusions: The findings suggested the survivors copedbetter in all four HR-QOL domains if they were married, lived with family, had children and were employed.     

Mental health in significant others of patients dying from lung cancer

Objective: Definitions and measures of significant others' mental health vary, but stress processes have been associated with caregiver outcomes of this kind. Thus, various mental health outcomes probably appear, either as specific responses to particular types of caregiver stressors, or as part of a general response resulting from an accumulation of various stressors. The present study explores the occurrence of symptoms of strain with regard to depression, exhaustion, and emotional well‐being in significant others of patients dying from lung cancer, and how these symptoms coexist. Methods: Measures used were the Montgomery Åsberg Depression Rating Scale, the OLdenburg Burnout Inventory, and the Swedish Health‐Related Quality of Life Survey. Data from 84 significant others of patients dying from lung cancer were collected at a time‐point during the last 4 months before the patients died and subsequently analysed. The occurrence of symptoms of strain was established by creating cut‐off scores from the general population. To explore how the different symptoms coexisted, hierarchical agglomerative cluster analyses were conducted using Ward's method. Results: Approximately 40% of the significant others reported symptoms of strain for each of the three outcomes, and a coexistence was found since the significant others clustered as subgroups, ranging from ‘high on all scales’ to ‘low on all scales’. Conclusion: A considerable proportion of the significant others were thus negatively affected in terms of mental health. We conclude that being a significant other of a person dying from lung cancer most likely results in a general response to this major life event. Copyright © 2009 John Wiley & Sons, Ltd.     

Reliability and Validity of the Malay Version of the Breast-Impact of Treatment Scale (MVBITS) in Breast Cancer Womenundergoing Chemotherapy

Background: Body image dissatisfaction among breast cancer survivors has been associated with psychologicalstress resultant from breast cancer and resultant surgery. This study aimed to examine the psychometric propertiesof the Malay Version of the Breast-Impact of Treatment Scale (MVBITS) and to investigate the associations ofretained factors with the Hospital Anxiety and Depression Scale (HADS) and the Rosenberg Self-Esteem Scale(RSES). Materials and Methods: The MVBITS was ‘forward–backward’ translated from English to Malay andthen administered to 70 female breast cancer patients who came to the Oncology Clinic of University MalayaMedical Centre, Kuala Lumpur, Malaysia to undergo chemotherapy. Principal component analysis (PCA)with varimax rotation was performed to explore the factor structure of the MVBITS. Associations of retainedfactors were estimated with reference to Spearman correlation coefficients. Results: The internal consistencyreliability of MVBITS was good (Cronbach’s alpha 0.945) and showed temporal stability over a 3-week period.Principal component analysis suggested two factors termed as ‘Intrusion’ and ‘Avoidance’ domains. Thesefactors explained 70.3% of the variance. Factor 1 comprised the effects of breast cancer treatment on theemotion and thought, while Factor 2 informed attempts to limit exposure of the body to self or others. The Factor1 of MVBITS was positively correlated with total, depression and anxiety sub-scores of HADS. Factor 2 waspositively correlated with total and anxiety sub-scores of HADS. MVBITS was also positively correlated withthe RSES scores. Conclusions: The results showed that the Malay Version of Breast-Impact of Treatment Scalepossesses satisfactory psychometric properties suggesting that this instrument is appropriate for assessment ofbody change stress among female breast cancer patients in Malaysia.