Social Science Series #2: Psychological well-being of women with breast cancer

Being diagnosed with cancer, whatever type it may be, is a life-altering event that affects the patients not just physically, but also emotionally, and feeling overwhelmed is a perfectly normal response.

A cancer diagnosis changes the patient’s daily interactions and relationships, which is overwhelming and difficult to cope with. Although unprepared for this event, once the diagnosis has been made, patients nevertheless face an array of medical consultants and the necessity to make crucial treatment decisions.

The first few days and weeks after a biopsy, will involve further evaluation to determine the stage of the disease and the prognosis, largely based on tumor characteristics (e.g., size, histology, hormone receptor status, nodal involvement). The results of these predictive and prognostic factors performed on the primary tumor can be difficult for physicians to interpret and are frequently confusing to patients as well. Decisions about the type of surgery (mastectomy, mastectomy with reconstruction, lumpectomy), subsequent adjuvant therapy (standard vs. trials), radiation therapy, and even where to have treatments performed (which hospital and which specialists) can be challenging. Suddenly, the woman must deal with vital issues, which she usually has little knowledge and background about, and she must choose a medical team to provide and coordinate her care. Second opinions are often helpful during this process, and it is inadvisable for a woman to make hasty medical decisions that she might later regret.

A concern during this phase is information overload for the patient and her support system (spouse, family, and friends). The medical care team often sees the complexities of decision making around breast cancer treatments as being routine, but for the woman, the presentation of treatment options (e.g., mastectomy versus lumpectomy; adjuvant chemotherapy or not) is far from routine. There are two extremes of responses in this situation: she may rush to treatment because of anxiety and concern that the cancer must be taken care of immediately, or she may have difficulty in making a decision, thereby creating a substantial delay while obtaining second, third, and fourth opinions.

(Source: National Center for Biotechnology Information)

Once the treatment plan is decided, women with breast cancer may experience some relief from anxiety and distress, but new fears may arise in anticipating and receiving the planned treatment. Surgery, particularly lumpectomy and axillary dissection, is often done as an outpatient or short stay procedure. Even the length of hospital stay for mastectomy has been shortened from what it was just a few years ago. This means that someone must be available to assist the woman at home, particularly with household tasks or other activities that require arm mobility and some nursing care (e.g., management of surgical drains and dressings). Women undergoing mastectomy and immediate reconstruction, especially with soft tissue flaps from the abdomen, will have longer hospitalizations and a more protracted recovery from surgery. A woman needs to be prepared for what to expect with each of these procedures, and such preparation is important for her psychological well-being and recovery. Extensive reviews of the safety of breast implants and specific information for women about this, have recently been completed and should reassure women that reconstruction is a reasonable, effective, and safe procedure, although not without some local complications.

Similarly, women benefit from being prepared for the experience of radiation therapy. Many women feel anxiety associated with being in the treatment room “all alone,” while the therapy is being delivered. They must become accustomed to baring their breast and disrobing among technical staff. In addition, the variation in skin reactions, local symptoms, and fatigue associated with 6 weeks of daily radiation therapy all need to be explained to women, so that they understand what to expect as treatment proceeds. It is important for the medical staff to attend to these symptoms when they arise, and to provide reassurance about their normalcy and the expected eventual recovery and successful result. Some women electing breast conservation will experience lingering doubts about the comparable efficacy of this treatment approach to mastectomy, and they may need continued support and reassurance about their treatment choice. Finally, the waiting room of the radiation therapy department is sometimes distressing to breast cancer patients, especially when they see patients who are much sicker and are receiving palliative therapy for advanced cancer. Nursing and physician staff should acknowledge these issues and directly address them when breast cancer patients report their concerns about their own health and mortality.

Over 70% of women become amenorrheic following breast cancer treatment. For younger women who develop breast cancer, amenorrhea is accompanied by a host of hormonal changes either coming on prematurely or intensifying menopausal symptoms in the more mature. These changes are intimately interwoven with psychosocial and behavioral symptoms: mood, anxiety, cognitive impairment, fatigue, and even weight gain. Serotonin reuptake inhibitors are FDA approved for both autonomic and affective symptoms of “pre-menstrual” disorder (late-luteal phase disorder) and for treatment-related menopausal symptoms. Patients often describe cognitive impairment with hormonal treatment or chemotherapy for breast cancer.

Much of the distress, after the initial shock of diagnosis and adjustment to treatment, is interwoven with decisions that may impede quality of life, and the need to adjust to such physical and emotional changes. Type of surgery, choice of chemotherapy when more than one choice is acceptable, type of radiation therapy (external beam, brachytherapy), and the decision to forgo hormonal suppression are some of the issues that have emotional consequences because they affect anxiety, mood and stamina.

(Source: National Center for Biotechnology Information)

Once the treatment is over, the patient may feel elated that the battle against breast cancer is over. However, along with it, is the feeling of fear and anxiety of the illness reoccurring. This feeling of uncertainty can cause cancer survivors to develop Post Traumatic Stress Disorder (PTSD). PTSD is an anxiety disorder that can be brought on by a traumatic event. PTSD can happen after a life-threatening situation, such as breast cancer diagnosis or cancer recurrence. PTSD can affect your ability to cope with life’s daily chores and inconveniences and make it difficult to function.

Symptoms of PTSD can include:

• Nightmares or flashbacks about the cancer experience
• Continuously focusing on the cancer experience
• Avoiding people, places, and events that remind you of the experience
• Trouble sleeping
• Extreme irritableness
• Intense feelings of fear
• Being overly excitable
• Feeling helpless or hopeless
• Shame or guilty feelings
• Bouts of crying
• Feeling emotionally numb
• Sadness or depression
• Loss of appetite
• Trouble maintaining personal relationships
• Self-destructive behavior (alcohol or drug abuse, for example)
• Memory problems
• Concentration problems
• Being startled or frightened easily
• Getting no joy from activities you used to enjoy
• Hallucinations

PTSD symptoms usually appear within 3 months of a traumatic event, last longer than a month, and severely affect daily life. In some cases, symptoms don’t appear for years after the traumatic event.

(Source: BREASTCANCER.ORG)