Social Science Series #2: Psychological well-being of women with breast cancer
What is Breast Cancer?
Breast cancer is a type of cancer that starts in the breast; the cancer forms in either the lobules or the ducts of the breast.
Lobules are the glands that produce milk and ducts are the pathways that bring the milk from the glands to the nipple. Cancer can also occur in the fatty tissue or the fibrous connective tissue within the breast.
The uncontrolled cancer cells often invade other healthy breast tissue and can travel to the lymph nodes under the arms. The lymph nodes are a primary pathway that help the cancer cells move to other parts of the body.
In 2020, there were 2.3 million women diagnosed with breast cancer and 685 000 deaths globally. At the end of that year, there were 7.8 million women alive who were diagnosed with breast cancer in the past 5 years, making it the world’s most prevalent cancer. There are more lost disability-adjusted life years (DALYs) by women to breast cancer globally than any other type of cancer. Breast cancer occurs in every country of the world in women at any age after puberty but with increasing rates in later life.
Breast cancer mortality changed little from the 1930s through the 1970s. Improvements in survival began in the 1980s in countries with early detection programs combined with different modes of treatment to eradicate invasive disease.
(Source: Healthline.com and World Health Organization)
What impact does a breast cancer diagnosis have on psychological well-being?
Receiving a diagnosis of breast cancer can be one of the most distressing events women ever experience. Many women may not know where to turn for help.
Distress typically continues even after the initial shock of diagnosis has passed. As women begin what is often a lengthy treatment process, they may find themselves faced with new problems, such as finding their personal relationships in turmoil, for instance, or they may feel tired all the time. They may be very worried about their symptoms, treatment, and mortality or may face discrimination from employers or insurance companies. Factors such as these can contribute to chronic stress, anxiety, and depression.
(Source: American Psychological Association)
Psychological reaction of the patient during:
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
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.
How can psychological treatment help women adjust?
Licensed psychologists and other mental health professionals with experience in breast cancer treatment can help a great deal. Their primary goal is to help women learn how to cope with the physical, emotional, and lifestyle changes associated with cancer as well as with medical treatments that can be painful and traumatic.
For some women, the focus may be on how to explain their illness to their children or how to deal with a partner’s response. For others, it may be on how to choose the right hospital or medical treatment. For some, it may be on how to control stress, anxiety, or depression.
By teaching patients problem-solving strategies in a supportive environment, psychologists help women work through their grief, fear, and other emotions. For many women, this life-threatening crisis eventually proves to be an opportunity for life-enhancing personal growth. Breast cancer patients themselves aren’t the only ones who can benefit from psychological treatment. Partners can also be suffering. In one study, for example, men whose partners were diagnosed with breast cancer were nearly 40% more likely to be hospitalized for severe depression and other mood disorders compared to other men.
Psychologists can help spouses manage the challenge by offering both emotional and practical support while dealing with their own feelings. Children, parents, and friends involved in caretaking can also benefit from psychological interventions.
The need for psychological treatment may not end when medical treatment does. In fact, emotional recovery may take longer than physical recovery and is sometimes less predictable. Although societal pressure to get everything back to normal is intense, breast cancer survivors need time to create a new self-image that incorporates both the experience and their changed bodies. Psychologists can help women achieve that goal and learn to cope with such issues as fears about recurrence and impatience with life’s more mundane problems.
(Source: American Psychological Association)
What type of psychological treatment is helpful?
A combination of individual and group treatment sometimes works best. Individual sessions with a licensed psychologist typically emphasize the understanding and modification of patterns of thinking and behavior.
Group psychological treatment with others who have breast cancer provide women with a chance to give and receive emotional support and learn from the experiences of others. To be most effective, groups should be made up of women at similar stages of the disease and led by psychologists or other mental health professionals with experience in breast cancer treatment.
Whether aimed at individuals or groups, psychological interventions strive to help women adjust to their diagnoses, cope with treatment, and come to terms with the disease’s impact on their lives. These interventions offer psychologists an opportunity to help women better understand breast cancer and its treatment. Psychologists typically ask women open-ended questions about their assumptions, ideas for living life more fully and other matters. Although negative thoughts and feelings are addressed, most psychological interventions focus on problem-solving as women meet each new challenge.
A breast cancer diagnosis can severely impair a woman’s psychological functioning, which in turn can jeopardize her physical health. But it doesn’t have to be that way. Women who seek help from licensed psychologists with experience in breast cancer treatment can actually use the mind-body connection to their advantage to enhance both mental and physical health.
(Source: American Psychological Association)
Psychosocial needs and formal services
|Psychosocial Need||Health Services|
|Information about illness, treatments, health, and services.||· Provision of information, e.g., on illness, treatments, effects on health, and psychosocial services, and help to patients/ families in understanding and using the information|
|Help in coping with emotions accompanying illness and treatment.||· Peer support programs · Counseling/psychotherapy to individuals or groups · Pharmacological management of mental symptoms|
|Help in managing illness||· Comprehensive illness self-management/self-care programs|
|Assistance in changing behaviors to minimize impact of disease||· Behavioral/health promotion interventions, such as: · Provider assessment/monitoring of health behaviors (e.g., smoking, exercise) · Brief physician counseling · Patient education, e.g., in cancer-related health risks and risk-reduction measures|
|Material and logistical resources, such as transportation||· Provision of resources|
|Help in managing disruptions in work, school, and family life||· Family and caregiver education · Assistance with activities of daily living (ADLs), instrumental ADLs, chores · Legal protections and services, e.g., under Americans with Disabilities Act and Family and Medical Leave Act · Cognitive testing and educational assistance|
|Financial advice and/or assistance||· Financial planning/counseling, including management of day-to-day activities such as bill paying · Insurance (e.g., health, disability) counseling · Eligibility assessment/counseling for other benefits (e.g., Supplemental Security Income, Social Security Disability Income) · Supplement financial grants|
(Source: The National Academies Press)