Early psychological adjustment in breast cancer patients: a prospective study

Objective: A significant proportion of breast cancer patients experiences psychiatric morbidity in the first year after a breast cancer diagnosis and/or beginning of treatment. This study attempted to identify and understand the risk factors for developing such problems. Methods: A consecutive series of 87 patients, aged 40-75 years, was assessed prior to diagnosis of breast cancer and followed-up approximately 8 weeks after beginning of cancer treatment and again 9 months after first follow-up. Assessments included measures of psychiatric morbidity using the General Health Questionnaire (GHQ-12), coping style using the Mental Adjustment to Cancer (MAC) Scale, symptom attribution, beliefs about breast cancer, social support, socio-demographic and clinical variables. Results: A total of 85.1% of patients completed both follow-ups. Pre-diagnostically, 32.2% of breast cancer patients scored as a GHQ-12 ‘case.’ GHQ scores fell significantly between pre-diagnostic and both post-diagnostic assessments, especially in women who had thought they had cancer. Predictors of psychological morbidity at first follow-up included pre-diagnostic GHQ-12 score, lack of social support and feelings of ‘personal responsibility/avoidance.’ GHQ-12 ‘caseness’ at second follow-up was predicted by lack of social support alone. Conclusions: Overall, psychiatric morbidity is higher prior to, than following, a definitive diagnosis of breast cancer. Early reactions of this kind are predictive of post-treatment adjustment. However, only the presence of social support in this study seems to be associated with successful adjustment in the first year following a breast cancer diagnosis. Women at increased risk of psychological morbidity after a breast cancer diagnosis may be thus identifiable and targeted therapeutically.     

Positive effects of illness reported by myocardial infarction and breast cancer patients

This study investigated the positive effects or changes that patients identified in their lives following a myocardial infarction (MI) or breast cancer. One hundred and forty-three patients were assessed in hospital following a first-time MI and 52 breast cancer patients were assessed on referral for radiotherapy. Approximately 3 months later both groups were asked if any positive changes had taken place in their lives following their illness. Patients' written responses to a single open-ended question were read independently by three judges who identified seven major positive themes. Approximately 60% of each patient group reported positive changes from their illness and the reporting of such changes was unrelated to illness severity. The most common theme reported by MI patients was healthy lifestyle change (68%), whereas, for breast cancer patients, it was improved close relationships with others (33%). These results are discussed in terms of the way patients make sense of and adapt to chronic illness.     

Social networks and health-related quality of life in breast cancer survivors: a prospective study

PURPOSE: To examine prospectively the influence of social networks on health-related quality of life (HRQoL) among breast cancer survivors. METHODS: Social networks and HRQoL were assessed among women free of breast cancer in the Nurses' Health Study (NHS). Women who developed breast cancer over a 4-year follow-up (n=708) completed detailed questions related to treatment together with an assessment of general and cancer-specific HRQoL. RESULTS: On average, socially isolated women were more adversely affected by breast cancer--their role function was lower by 14 points, vitality lower by 7 points, and physical function lower by 6 points compared to the most socially integrated women. CONCLUSION: Prediagnosis level of social integration is an important factor in future HRQoL among breast cancer survivors, and appears to explain more of the variance in HRQoL than treatment or tumor characteristics. Rehabilitation programs should incorporate interventions that address the availability of adequate social support among breast cancer survivors.     

Effects of long-term benzodiazepine medication. A prospective cohort study: Methodological and clinical aspects

Benzodiazepine (BDZ) drug impact on mental functions was explored in a cohort study of 30 psychiatric outpatients on long-term BDZ medication. A new questionnaire, the Drug Impact on Mental Processes (DIMP) was used and evaluated. The patients were rated three times: on inclusion in the study, after about 18 months and, finally, only a few days later. Test–retest reliability was evaluated for the two last ratings and was found acceptable for 19/23 items. The DIMP scores indicated negative effects on crisis reaction, intensified defence mechanisms and reduced cognitive, emotional and conative functions. Long-term BDZ treatment intensified passive coping. The drug impact on mental functions ranged between a mild and a moderate degree. The clinical outcomes of the patients’ psychiatric disorders were evaluated at a 1-year follow-up after continued or discontinued BDZ treatment. In the subgroup that had discontinued the BDZ treatment at follow-up, significantly more patients reported reduced severity of their psychiatric disorders and significantly more patients had paid jobs. The overall clinical improvement after discontinued BDZ treatment may be explained by recovery from an addiction syndrome. It may also be related to a shift from passive to active coping.     

Autobiographical memories in patients treated for breast cancer

OBJECTIVE: Previous research has shown that several clinical groups have difficulties with generating specific autobiographical memories. The aim of this study was to investigate autobiographical memory function in women who had been treated for breast cancer and to compare those patients who had undergone mastectomy only with those who had undergone breast reconstruction surgery after mastectomy. METHOD: A sample of 26 women treated for breast cancer were tested via telephone using the Autobiographical Memory Test (AMT). RESULTS: Breast cancer patients had difficulty retrieving specific autobiographical memories compared to a group of age-matched controls without any history of breast cancer. There were essentially no differences between the two patient groups. CONCLUSION: Since breast cancer patients are vulnerable to emotional distress, autobiographical memory deficits should be investigated further.     

The effect of hypnotic-guided imagery on psychological well-being and immune function in patients with prior breast cancer

Objective: To determine the effect of hypnotic-guided imagery on immune function and psychological parameters in patients being treated for Stage I or II breast cancer. Methods: To determine the effects of hypnotic-guided imagery on immune function and psychological parameters, the following study was undertaken. Psychological profiles, natural killer (NK) cell number and activity were measured at baseline, after the 8-week imagery training program and at the 3-month follow-up. Results: There were significant increases in improvement in depression (P<.04) and increase in absolute number of NK cells, but these were not maintained at the 3-month follow-up. Hypnotic-guided imagery did cause some transient changes in psychological well-being and immune parameters. However, these changes were not retained after the treatment ended. Conclusions: Many studies during the last 15 years have demonstrated interactions between the central nervous and the immune systems. While a negative effect of stress on immune responses has been demonstrated, there have also been published reports that psychological treatments can positively alter the immune system. However, given the complexities of immune system kinetics, the transient nature of any psychological effect and the insensitivity of immune assays, our study indicates that there is a role for hypnotic-guided imagery as an adjuvant therapy.     

Adverse psychological effects in women attending a second-stage breast cancer screening

OBJECTIVE: The purpose of this study was to examine the emotional and psychopathological impact associated with a second-stage screening for breast cancer. METHOD: We used a short-term longitudinal design. Interviews were conducted with 1195 women of 45-65 years old in three temporal conditions (premammogram, postmammogram, and follow-up). Participants included women attending for regular breast cancer screening who were recalled for a further mammogram (i.e., second-stage breast cancer screening) and women who were not recalled. Affective-cognitive concerns about cancer (worry, fear, and perceived vulnerability) were rated using a 10-point Likert scale. Psychopathology was assessed using the Hopkins Symptom Check List-Revised (SCL-90-R). RESULTS: Women attending the second-stage screening exhibited significantly higher levels of breast cancer worries, fears, and beliefs than women attending for routine screening before obtaining the results of the mammogram. This affective-emotional impact disappeared quickly and was not relevant 2 months following the mammogram. Despite the fact that levels of psychopathological symptoms were higher in the premammogram condition, there were no differences between groups on these measures. CONCLUSION: These results provide support for the hypothesis that women recalled for further mammograms tend to experience high levels of affective-cognitive distress but not psychopathological symptoms. Moreover, results do not sustain the prediction that this psychological impact persists beyond receipt of a negative result. Some recommendations to reduce these psychological side effects are suggested.     

Factors predicting communication about the diagnosis of maternal breast cancer to children

OBJECTIVE: To identify factors influencing mothers' communication with their children about their diagnosis and initial treatment. DESIGN: Cross-sectional cohort. SETTING: Two breast cancer treatment centres. SUBJECTS: Thirty-two women with Stage I or Stage II breast cancer with 56 school-aged children. MAIN OUTCOME MEASURES: Semistructured interview regarding timing and extent of communication with children from the time that a problem was first identified to initial treatment, and children's reactions. RESULTS: Children were most likely to be told about their mother's illness after the diagnosis had been confirmed by biopsy but a minority were told nothing until after surgery and some nothing at all. The information children received did not necessarily include mention of cancer. Predictors of communication were child age, with older children being told earlier and more information, and maternal education, with children of more highly educated mothers being told less. Child gender was not related to communication. CONCLUSION: Mothers who are being investigated for breast cancer are likely to benefit from the opportunity to consult a supportive professional about communication with their children during all stages of their diagnosis and treatment, but particularly early on in the investigation when they are more reluctant to initiate discussions with their children. At later points, those with children of varying ages may need specific advice on ways to discuss their illness in relation to children's understanding.     

Early alterations in cortical morphology after neoadjuvant chemotherapy in breast cancer patients: A longitudinal magnetic resonance imaging study

There is growing evidence that chemotherapy may have a significant impact on the brains of breast cancer patients, causing changes in cortical morphology. However, early morphological alterations induced by chemotherapy in breast cancer patients are unclear. To investigate the patterns of those alterations, we compared female breast cancer patients (n = 45) longitudinally before (time point 0, TP0) and after (time point 1, TP1) the first cycle of neoadjuvant chemotherapy, using voxel‐based morphometry (VBM) and surface‐based morphometry (SBM). VBM and SBM alteration data underwent correlation analysis. We also compared cognition‐related neuropsychological tests in the breast cancer patients between TP0 and TP1. Reductions in gray matter volume, cortical thickness, sulcal depth, and gyrification index were found in most brain areas, while increments were found to be mainly concentrated in and around the hippocampus. Reductions of fractal dimension mainly occurred in the limbic and occipital lobes, while increments mainly occurred in the anterior and posterior central gyrus. Significant correlations were found between altered VBM and altered SBM mainly in the bilateral superior frontal gyrus. We found no significant differences in the cognition‐related neuropsychological tests before and after chemotherapy. The altered brain regions are in line with those associated with impaired cognitive domains in previous studies. We conclude that breast cancer patients showed widespread morphological alterations soon after neoadjuvant chemotherapy, despite an absence of cognitive impairments. The affected brain regions may indicate major targets of early brain damage after chemotherapy.     

Psychosocial adaptation and cellular immunity in breast cancer patients in the weeks after surgery: An exploratory study

Background

The period just after surgery for breast cancer requires psychosocial adaptation and is associated with elevated distress. Distress states have been associated with decreased cellular immune functioning in this population, which could have negative effects on physical recovery. However, little is known about relations between psychological status [negative and positive mood states and overall quality of life (QOL)] and cellular signaling cytokines that could account for these associations in women undergoing treatment for breast cancer.

Methods

The present study examined associations between psychological adaptation indicators (mood, QOL) and T-helper cell type 1 (Th1) cytokine production from stimulated peripheral mononuclear cells in women who had recently undergone surgery for early-stage breast cancer but had not yet begun adjuvant therapy. These associations were evaluated while controlling for relevant disease/treatment, sociodemographic, and health behavior covariates.

Results

Lower anxiety related to greater production of the Th1 cytokine interleukin-2 (IL-2), while greater positive mood (affection) related to greater production of the Th1 cytokines IL-12 and interferon-gamma (IFN-γ). Better QOL related to greater production of the Th1 cytokine, tumor necrosis factor-alpha (TNF-α).

Conclusion

Individual differences in psychosocial adaptation in women with breast cancer during the period after surgery relate to biological parameters that may be relevant for health and well-being as they move through treatment.     

抑郁症的社会支持和防御方式研究

目的　探讨抑郁症患者应激状态、应对行为、社会支持和防御方式的临床特征。方法　采用应对行为调查表、生活环境调查表、社会支持量表和防御方式问卷 ,对 4 1例抑郁症患者进行测试 ,并与 36例正常人进行对照研究。结果　 (1)抑郁症组平均应激强度明显高于对照组 (P <0 .0 5 ) ,且抑郁症组面对应激时所采取的应对行为与对照组存在显著差异 ,主动娱乐、谋划对策、主动应付和工作投射因子分高 (P <0 .0 1) ,控制症状和消极发泄因子分低 (P <0 .0 1或P <0 .0 5 ) ;(2 )抑郁症组的社会支持满意度明显低于对照组 (P <0 .0 5 ) ,且抑郁症组对“亲属”的选用明显高于对照组 (P <0 .0 1) ;(3)抑郁症组中间型和不成熟型防御因子分高 (P <0 .0 1) ,投射、幻想、退缩因子 ,假性利他、隔离、交往倾向和消耗倾向因子分也明显高于对照组 (P <0 .0 1或P <0 .0 5 )。结论　 (1)生活事件与抑郁症状的发生可能存在直接的关系 ,且抑郁症患者面对应激更多采取外射型应对方式 ;(2 )抑郁症患者的社会支持系统满意度差 ,且防御方式存在明显的不成熟倾向。     

乳腺癌患者的社会支持及其相关因素分析

目的初步分析乳腺癌患者的社会支持及其相关因素。方法采用社会支持评定量表（SSRS）对33例乳腺癌患者与29例健康女性进行问卷测评分析。结果乳腺癌组的主观支持分低于对照组,有显著差异（P〈0．05）;乳腺癌组已婚者主观支持分值低于对照组,且有显著性差异（P〈0．05）;乳腺癌组大学以上文化程度者的客观支持分、主观支持分及总社会支持分均低于对照组,且有显著差异（P〈0．05）。结论乳腺癌患者的主观支持较差,尤以已婚乳腺癌患者明显;大学以上文化程度的乳腺癌患者主、客观社会支持均差。     

Persistence of psychiatric disorders in a cohort of HIV/AIDS patients in South Africa: a 6-month follow-up study

BACKGROUND: Psychiatric disorders in HIV/AIDS are common, emerging soon after diagnosis or during the subsequent course of illness. However, there are few prospective studies on the rates of psychiatric disorders in HIV/AIDS, particularly in the context of the developing world. METHODS: Sixty-five patients with recently diagnosed HIV were interviewed on presentation to a hospital-based HIV clinic and then 6 months later. On both interviews, the patients were assessed using the MINI International Neuropsychiatric Interview, the Carver Brief COPE, and the Sheehan Disability Scale. Exposure to negative life events and risk behaviors was also evaluated. RESULTS: The overall prevalence of psychiatric disorders in the follow-up period remained high (56% of patients had at least one psychiatric disorder at baseline, and 48% of patients had at least one psychiatric disorder at 6 months). Depression and posttraumatic stress disorder (PTSD) were the most prevalent disorders at both baseline (34.9% and 14.8%) and follow-up (26% and 20%), respectively. More than half of all patients with depression at baseline improved (16 of 29; 55.1%). However, there was a new onset of both depression (4 of 49; 8.1%) and PTSD (12 of 17; 70.5%) on follow-up. In univariate analysis, depression on follow-up was significantly associated with: (a) disability in work/social/family functioning, (b) greater number of negative life events, and (c) a decline in CD4 lymphocyte count. Univariate analysis also revealed that a diagnosis of PTSD on follow-up was significantly associated with (a) a longer duration of infection and (b) baseline disability in work/social/family functioning. However, in multivariate analysis, only disability scores predicted the diagnoses of major depression and PTSD on follow-up assessment. Persistence of risky sexual behaviour was also noted, with a significantly higher number of participants reporting nonuse of condom on follow-up. There appeared to be a shift from maladaptive coping behaviors to more adaptive coping behaviors over the 6-month period. CONCLUSION: The rate of psychiatric disorders in HIV/AIDS patients was consistent over time. These findings emphasize the importance of regular evaluation for psychiatric disorders in HIV/AIDS patients, not only at the commencement of treatment but also during subsequent follow-up visits.     

失眠症患者的睡眠行为、应付方式及心理控制源的调查研究

目的　探讨失眠症患者的睡眠行为、应付方式及其心理控制源。方法　采用睡眠行为特征量表、应付方式问卷及内在-外在心理控制源量表对68例失眠症患者(失眠症组)和68名睡眠正常者(对照组)进行了测评,并将测评结果加以比较。结果　①失眠症组对睡眠的不合理信念、非功能性睡眠行为和夜间焦虑3个因子评分均明显高于对照组(t=6 07、7 99、17 98,P<0 01),而睡眠效率则明显低于对照组(t=15. 65,P<0.01);②失眠症组解决问题评分明显低于对照组(t=4 .41,P<0 .01),而自责评分则明显高于对照组(t=3 .13,P<0 .01);③失眠症组I-E量表评分明显高于对照组(t=19. 21,P<0. 01)。结论　失眠症患者存在对睡眠的不合理信念、非功能性睡眠行为和夜间焦虑;解决问题能力低,心理控制源为外控。     

Epigenetic changes associated with inflammation in breast cancer patients treated with chemotherapy

Inflammation has been associated with fatigue during and after various types of breast cancer treatments. We examined whether prior chemotherapy was associated with DNA methylation patterns that could explain persisting inflammation and/or fatigue in women treated for breast cancer. Prior to breast radiation therapy, DNA was extracted from peripheral blood mononuclear cells (PBMCs) of 61 Stage 0-IIIA breast cancer patients who had received partial mastectomy with or without chemotherapy. DNA methylation was assessed at >485,000 CpG sites across the genome along with fatigue and plasma inflammatory markers previously associated with fatigue. Compared to non-chemotherapy-treated, women who had received chemotherapy exhibited significantly decreased methylation at eight CpG sites (p < 1.03 × 10⁻⁷) including four in exon 11 of transmembrane protein 49 (TMEM49), which demonstrated the largest decreases in methylation. Lower methylation at each identified CpG site was associated with increased plasma soluble tumor necrosis factor receptor 2 (sTNFR2) and interleukin (IL)-6 and mediated the relationship between chemotherapy and increases in these inflammatory biomarkers adjusting for multiple clinical and treatment characteristics. sTNFR2, but not CpG methylation status, was correlated with fatigue. Six months after breast radiation therapy, DNA methylation, inflammatory biomarkers and fatigue assessments were repeated in a subset of subjects (N = 39). Reduced methylation in 4 of the 8 identified CpG sites was still observed in chemotherapy versus non-chemotherapy-treated patients, albeit with some decay indicating the dynamic and potentially reversible nature of the changes. Reduced methylation in these 4 CpG sites also continued to correlate with either increased sTNFR2 or IL-6, but not fatigue. In conclusion, prior chemotherapy treatment was associated with decreased methylation of CpG sites in DNA from PBMCs of breast cancer patients, which correlated with increased inflammatory markers prior to and 6 months after radiation therapy. Persisting epigenetic changes secondary to chemotherapy may be one factor that contributes to inflammation and its consequences including cancer-related fatigue in vulnerable breast cancer patients.     

Mental adjustment, coping strategies, and psychological distress among end-stage renal disease patients

OBJECTIVE: The study examines the association between mental adjustment, coping strategies [emotion (EF) and problem focused (PF)], and psychological distress. METHOD: Sixty end-stage renal disease (ESRD) patients were interviewed a year or more after they began dialysis, measured by the COPE, Mental Adjustment to Cancer (MAC), and Brief Symptom Inventory (BSI) scales. RESULTS: The main findings indicate that patients with a strong fighting spirit are in less psychological distress. Moreover, patients who tend to use PF strategies rely on a fighting spirit as an adjustment coping style. CONCLUSION: ESRD patients in the adjustment phase (patients diagnosed at least 1 year previously) tend to struggle to lead as normal a life as possible despite the dependency caused by the illness.     

乳腺癌手术前伴焦虑抑郁情绪患者的抗抑郁药物治疗对照研究

目的 评估抗抑郁药物治疗乳腺癌改良根治手术前伴焦虑抑郁情绪患者的疗效.方法 对2006年1月至2007年10月住院的37例乳腺癌患者在入院后三天内手术前进行汉密尔顿抑郁量表(HAMD)和汉密尔顿焦虑量表(HAMA)评估,将HAMA≥14及HAMD≥17的焦虑抑郁患者随机分为研究组(15例)和对照组(15例).研究组采用改良根治手术+抗抑郁药物(帕罗西汀)治疗,对照组采用常规改良根治手术治疗.观察三周,比较两组术后情绪变化及创面愈合情况.结果 与基线比,术后一周研究组HAMD减分大于对照组(4.2±1.5、2.7±1.1,F=0.8,P<0.05),差异有统计学意义;术后三周研究组HAMD和HAMA减分均大于对照组(HAMD:11.4±1.4、5.9±1.9,F=1.9,P<0.05;HAMA:9.1±2.2、4.5±1.4,F=5.2,P<0.05),差异均有统计学意义;与对照组比较,研究组创面愈合天数明显缩短(16.0±2.1、27.9±4.8,F=9.714,P<0.05),差异有统计学意义;术后三周,研究组患者焦虑缓解率(73.3%,11/15)高于对照组(40%,6/15),差异有统计学意义(χ2=3.4,P<0.05),抑郁情绪缓解率(86.7%,13/15)也高于对照组(40%,6/15, χ2=7.0,P<0.05).结论 对手术前伴抑郁焦虑的乳腺癌患者而言,手术联合抗抑郁药物治疗较单纯手术治疗疗效更好.