Psychosocial correlates of oestrogen and progesterone receptors in breast cancer

Relationship of oestrogen receptor status to depressive symptoms and quality of life in breast cancer patients

OBJECTIVE

We investigated the relationship of oestrogen receptor (ER) status to the severity of depressive symptoms and quality of life (QOL) impairment in breast cancer patients.

METHODS

Seventy-seven breast cancer patients with comorbid depression were evaluated with the Hamilton Depression Rating Scale (HAMD), the Clinical Global Impression-Severity of Illness (CGI-S) for depression, and the Functional Assessment of Cancer Therapy-Breast (FACT-B). ER status was determined using immunohistochemical analysis.

RESULTS

The ER-positive group (n = 31) showed significantly higher scores compared with the ER-negative group (n = 46) on HAMD total (p = 0.04) and somatic anxiety factor (p = 0.004) scores as well as CGI-S score (p = 0.03). As for QOL measured with the FACT-B, a significantly higher score was found on the Functional Well-Being (FWB) subscale in the ER-positive group (p = 0.001). The relationships were further analysed using generalised linear models (GLM), after controlling for the influence of the current anti-oestrogen treatment. The analysis revealed that ER status was still significantly related to the FWB subscale score of the FACT-B (p = 0.04). However, the HAMD and CGI-S scores were no longer significantly related to ER status after the influence of anti-oestrogen treatment was controlled for.

CONCLUSION

These results suggest that ER status, which is a well-known biological prognostic factor in breast cancer, may be related to the severity of certain aspects of depressive symptoms or QOL impairment, implying a role of the ER in affective and behavioural regulation. However, anti-oestrogen treatments significantly influence these relationships.

Breast cancer patients receiving postoperative radiotherapy: distress, depressive symptoms and unmet needs of psychosocial support

BACKGROUND AND PURPOSE

The diagnosis and treatment of breast cancer can cause considerable psychological consequences, which may remain unrecognized and untreated. In this study, the prevalence of depressive symptoms and distress, and unmet needs for psychosocial support were assessed among breast cancer patients receiving postoperative radiotherapy.

MATERIAL AND METHODS

Out of 389 consecutive patients, 276 responded and comprised the final study group. Depressive symptoms were assessed with the Beck Depression Inventory. Distress was measured with the Distress Thermometer. Hospital records of the patients were examined for additional information.

RESULTS

Nearly one third of patients (32.1%) displayed depressive symptoms, and more than a quarter of patients (28.4%) experienced distress. Younger age (p=0.001) and negative hormone receptor status (p=0.008) were independent factors associated with distress. One quarter of the patients expressed an unmet need for psychosocial support, which was independently associated with depressive symptoms and/or distress (p=0.001) and younger age (p=0.006).

CONCLUSIONS

During radiotherapy for breast cancer, the staff should have awareness of the higher risk of depression and distress in their patients and should consider screening tools to recognise distress and depressive symptoms. Special attention should be paid to younger patients.

Estradiol enhances sociosexual behavior and can have proliferative effects in ovariectomized rats

Although estradiol (E(2)) may have some beneficial effects as a treatment for menopause symptoms, E(2) also has trophic effects that can increase vulnerability to some cancers, such as breast cancer. In the present study, a model to investigate the concomitant behavioral and proliferative effects of E(2) was developed. First, the effects of different duration of chronic E(2) exposure (2 vs 6 months), or no such exposure, on proliferation (tumor incidence and weight, uterine weight) in adult, ovariectomized (OVX) rats was determined. Second, the effects of different dosages of E(2) (0.03 or 0.09 mg/kg) compared to vehicle only on sexual behavior, and measures of proliferation of adult OVX rats treated with a chemical carcinogen (DMBA; 1.25, 12.50, or 25.00 mg), or inert vehicle, were investigated. Vehicle or E(2) was administered subcutaneously (SC) to OVX rats once per week for 14 weeks. Six months of continuous E(2) exposure increased tumor incidence, tumor weight, and uterine weight, compared to 2 months of E(2) or no E(2) exposure. Rats administered DMBA had increased incidence, number, and size of tumors compared to vehicle treatment, and this effect appeared to be augmented by E(2). Compared to vehicle, E(2) increased lordosis and uterine weight. Thus, E(2) may have the unfavorable effect of increasing proliferation when administered in chronic situations. Studies investigating the action of E(2) for these effects are ongoing.

Psychosocial correlates of progesterone receptors in breast cancer

BACKGROUND

The diagnosis of cancer may lead to psychological distress with anxiety and depression as the most prevalent symptoms. Several investigators have found a correlation between psychosocial factors and tumor levels of estrogen receptors and progesterone receptors (PRs) while others have not. The aim of this study was to investigate demographic characteristics and severity of depression and anxiety as expressed by the Hospital Anxiety and Depression (HAD) scale of patients with high or low PR expression in breast cancers.

METHODS

Two hundred and seventy-eight patients with primary breast cancer were divided into two subgroups according to PRs expressed in breast cancers.

RESULTS

The subgroup of patients with PR-negative breast cancers expressed depression, as measured by the HAD scale, to a smaller degree (4.7+/-4.1) than the subgroup of patients with PR-positive breast cancers (5.8+/-4.1). The difference was rather small but still statistically significant (t=2.1, df=236.7, P<.05). In contrast, we did not observe any correlation between anxiety and PR status. Differences between the subgroups according to family history of mental disorders were observed (chi(2)=4.7, df=1, P<.05). In the subgroup of patients with PR-negative breast cancers; 13% of patients had a family history of mental disorders compared with 23% of patients with PR-positive breast cancers.

CONCLUSIONS

Depression expressed by patients with primary breast cancers could be influenced by the PR status of the tumors; however, other factors such as cancer treatment and family history of mental disorders could also be important.

Effects of two estradiol regimens on anxiety and depressive behaviors and trophic effects in peripheral tissues in a rodent model

BACKGROUND

With aging and menopause, which are associated with decreases in ovarian steroids such as 17beta-estradiol (E(2)), women might experience negative psychological symptoms, including anxiety and depression. Some women use E(2)-based therapies to alleviate these symptoms, but E(2) has been associated with trophic effects that might increase vulnerability to some steroid-sensitive cancers, such as breast cancer, in both premenopausal and postmenopausal women.

OBJECTIVE

This study investigated the relationships between the possible beneficial effects of E(2) on anxiety and depressive behaviors concurrent with trophic effects using an animal model of E(2) decline and replacement.

METHODS

Dose-dependent effects of E(2) on affective, sexual, and motor behavior of young adult rats were studied. Ovariectomized (OVX) rats were administered the chemical carcinogen 7,12-dimethylbenz(a) anthracene (DMBA) 1.25 mg or inactive vehicle (vegetable oil; control) by gavage. E(2) (0.03 or 0.09 mg/kg) or vehicle was administered subcutaneously 44 to 48 hours before assessments of anxiety (light-dark transition), depression (forced swim test), sexual (lordosis), and motor (activity monitor) behaviors. Fourteen weeks after carcinogen exposure, E(2) concentrations in plasma and brain regions (cortex, hippocampus, and hypothalamus) were determined. Incidences and numbers of tumors and uterine weight were analyzed.

RESULTS

Administration of E(2) (0.09 mg/kg) was associated with significant increases in antianxiety-like behavior in the light-dark transition task, antidepressant-like behavior in the forced swim test, and physiologic circulating and central E(2) concentrations compared with E(2) (0.03 mg/kg) and vehicle. Compared with vehicle, E(2) (0.9 > 0.3 mg/kg) was associated with significant increases in lordosis and uterine weight. Administration of DMBA was associated with significant increases in the incidences and numbers of tumors; this effect was augmented by E(2)administration.

CONCLUSIONS

Based on the findings in this rat model, the hypothesis that E(2) may be effective in reducing anxiety and depressive behaviors and enhance sexual behavior in OVX rats, concurrent with trophic effects in the periphery, was supported. Moderate physiologic levels of E(2) might have beneficial effects on affective and sexual behaviors in female rodents, but regimens including E(2) might increase tumorigenic capacity.

Tamoxifen treatment and new-onset depression in breast cancer patients

The authors conducted a retrospective cohort study of female patients diagnosed with breast cancer (BRCA), evaluating the risk of new-onset depression associated with tamoxifen treatment among those with estrogen receptor-positive (ER+) tumors, versus estrogen receptor-negative (ER-) tumors, who were not receiving tamoxifen. A total cohort of 2,943 patients was identified. The hazard-ratio for new-onset depression in the tamoxifen group was nonsignificant. A post-hoc analysis revealed that chemotherapy and ER+ status were significantly and independently associated with an increased risk for developing depression.

Health-related quality of life in long-term breast cancer survivors: nationwide survey in Denmark

AIM

To investigate health-related quality of life (HRQOL) in a nationally representative sample of long-term breast cancer survivors (BCS) in Denmark.

PARTICIPANTS AND METHODS

An age-stratified random sample of 2,000 female BCS > or = 5 years after primary surgery without recurrence was drawn from the Danish Breast Cancer Cooperative Group register, which is representative regarding long-term BCS in Denmark, and compared with 3,104 women of the nationally representative Danish Health and Morbidity Survey 2000. The Short Form-36 questionnaire assessed HRQOL and its association with BCS' sociodemography, type of surgery, systemic therapy, radiotherapy, time since operation, receptor status, and low/high risk protocol.

RESULTS

The response rate was 79%. BCS tended to rate HRQOL better than the general female population. BCS reported significantly less "bodily pain" (P < 0.0001), better "general health" (P < 0.0001), but worse "mental health" (P < 0.0001). Age interacted significantly with four other subscales (P < 0.05): Younger BCS reported worse HRQOL than equally aged women of the general population, while older BCS reported better HRQOL. Poor HRQOL was significantly associated with being single (all subscales: P < 0.05), short education (all subscales: P < 0.05, except "social function"), and high body mass index ("physical function", "role physical": P < 0.05). Breast cancer (low/high risk, receptor status) and treatment did not affect HRQOL.

CONCLUSION

HRQOL was similar between BCS and women of the general population. Potential long-term effects of breast cancer (low/high risk, receptor status) and treatment did not seem to impact HRQOL. However, predictors for worse HRQOL in BCS were being single, and having a short education.

Health-Related Quality of Life Parameters As Prognostic Factors in a Nonmetastatic Breast Cancer Population: An International Multicenter Study

Purpose

The purpose of this research was to evaluate whether baseline health-related quality of life (HRQOL) parameters are prognostic factors for survival in locally advanced breast cancer patients. Although the literature highlights the important role of HRQOL parameters in predicting survival in advanced metastatic disease, little evidence exists for earlier stages.

Patients and Methods

The overall sample consisted of 448 patients randomly assigned to receive cyclophosphamide, epirubicin, and fluorouracil versus epirubicin, cyclophosphamide, and granulocyte colony-stimulating factor. Patients were enrolled in 12 countries. HRQOL baseline scores were assessed using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire C30. The Cox proportional hazards regression model was used for both univariate and multivariate analyses of survival. In addition, a bootstrap resampling technique was used to assess the stability of the outcomes. Bootstrap results were then applied for model averaging purposes as a means to account for the observed model selection uncertainty.

Results

The final multivariate model retained inflammatory breast cancer (T4d) as the only factor predicting overall survival (OS) with a hazard ratio of 1.375 (95% CI, 1.027 to 1.840; P = .03). The presence of inflammatory breast cancer lowers the median survival time from 6.6 to 4.2 years (36% reduction). None of the preselected HRQOL variables were prognostic for OS or disease-free survival, in either the univariate or multivariate analysis.

Conclusion

Our findings suggest that baseline HRQOL parameters have no prognostic value in a nonmetastatic breast cancer population.

Avoiding patient self-blame

There is need for shared responsibility between health care providers and patients. However, an unintended consequence of today's therapies that focus on mind/body interaction is the risk of patients' guilt and self-blame for contracting a disease (such as cancer) and/or for failing to heal themselves. This article suggests ways practitioners of complementary therapies can approach medical patients with a constructive attitude that minimizes the chance of unintentional psychological harm.

Considerations in using tumor markers: what the psycho-oncologist needs to know

Tumor markers are measures of biological features of a cancer. By revealing important biological aspects of the tumor, tumor markers can be useful in staging patients, predicting cancer outcomes, and guiding treatments. The psychological consequences of using tumor markers are virtually unknown. In this review article, we draw on clinical studies involving the psychological impact of risk information, screening, prognostic information and surveillance of cancer. Such studies may be helpful in considering possible psychological reactions to tumor marker information in clinical practice.

Predicting mood disorders in breast cancer patients

Prediction of delayed psychiatric disorders in breast cancer patients by using a screening procedure was investigated. Two questionnaires, the Psychological Distress Inventory and the Hospital Anxiety and Depression Scale, were administered before and during chemotherapy, and at the first follow-up visit. A psychiatric diagnosis was assigned to 50 of the 132 patients (38%) evaluated at follow-up. Including a set of clinical and demographic variables in a logistic regression, increasing age (P=0.001) and psychiatric history (P<0.001) were associated with psychiatric morbidity at follow-up. The accuracy of the two questionnaires in predicting delayed psychiatric disorders increased from the evaluation before chemotherapy to the evaluation during chemotherapy. The most accurate prediction was observed for the concurrent evaluation at follow-up. The accuracy of three predictive models developed for each evaluation point by including age, psychiatric history and psychological distress measured with each of the two questionnaires was not significantly better than that observed using only the questionnaires' scores as predictors.

Prediction of depressive symptomatology after treatment of head and neck cancer: the influence of pre-treatment physical and depressive symptoms, coping, and social support

BACKGROUND

Head and neck cancer and its treatment can have important psychosocial implications, and many patients become depressed. The aim of this prospective study is to examine whether pretreatment variables can be used to predict depression 6 and 12 months later.

METHODS

Head and neck cancer patients (155) treated with surgery and/or radiotherapy completed a questionnaire including items on social support, coping, depressive symptoms, physical functioning, and physical symptoms before and after treatment.

RESULTS

By using 5 variables (physical symptoms, depressive symptoms, emotional support, extent of the social network, and avoidance coping), it was possible to predict those patients who would have symptoms at 6 (81%) and 12 months (67%) after treatment. Inclusion of actual physical symptoms reported at follow-up increased these percentages to 89% and 82%.

CONCLUSIONS

It is concluded that screening for psychosocial variables and physical symptoms before treatment can be used to determine which patients are at risk of developing depressive symptoms after treatment.

The effects of major depression and phobia on stage at diagnosis of breast cancer

OBJECTIVE

To examine the longitudinal effects of major depression and phobia on stage at diagnosis of subsequent breast cancer.

METHOD

Data from the New Haven Epidemiologic Catchment Area (ECA) study were linked to the Connecticut Tumor Registry (CTR). The sample comprised of seventy-two women with a first primary breast cancer diagnosed sometime after their baseline ECA study interview. In the ECA study, lifetime psychiatric history was assessed using the Diagnostic Interview Schedule based on DSM-III criteria. Stage at diagnosis of breast cancer was taken from CTR records and dichotomized into early stage (in situ and localized tumors) versus late stage (regional and distant tumors).

RESULTS

A positive history of major depression was associated with an increased likelihood of late-stage diagnosis of breast cancer (odds ratio [OR] = 9.81, p = 0.039), whereas a positive history of phobic disorders was associated with a decreased likelihood of late-stage diagnosis (OR = 0.01, p = 0.021), controlling for sociodemographic characteristics of the sample.

CONCLUSIONS

These analyses revealed a longitudinal association between reported lifetime psychiatric history and stage at diagnosis of subsequent breast cancer. Phobia may motivate women to adhere to breast cancer screening recommendations and to report suspicious symptoms to a physician without delay. Major depression, on the other hand, was identified as an important predictor of late-stage diagnosis; proper recognition and management of depression in the primary care setting may have important implications for breast cancer detection and survival.

Psychological morbidity following laryngectomy: a pilot study

This study evaluated the nature and extent of problems faced by patients following discharge from hospital following laryngectomy. Semi-structured interviews investigated the practical and psychological concerns of a cohort of laryngectomy patients in a district general hospital. A number of simple practical measures can be employed to reduce early hospital re-admission following laryngectomy. Psychological morbidity is an important cause of low quality of life following laryngectomy. Formal psychological treatment could be of benefit in the management of these patients.

Factors affecting baseline quality of life in two international adjuvant breast cancer trials. International Breast Cancer Study Group (IBCSG)

Quality of life (QL) is used to assess treatments in clinical trials but may be influenced by other factors. We analysed the impact of biomedical, sociodemographic and cultural factors on baseline QL indicators in two International Breast Cancer Study Group trials. Patients with stage II breast cancer were randomized within 6 weeks of primary surgery to various adjuvant treatments. They were asked to assess five indicators of QL at baseline. QL forms were available for 1231 (83%) of the 1475 premenopausal and 989 (82%) of the 1212 post-menopausal patients, who were from nine countries and spoke seven languages. Culture (defined as language/country groups) had a statistically significant impact on baseline QL measures. Premenopausal patients with poor prognostic factors showed a tendency to report worse QL, with oestrogen receptor status as an independent predictor for mood (P = 0.0005). Older post-menopausal patients reported better emotional wellbeing (P = 0.002), mood (P = 0.002), and less effort to cope (P = 0.0009) compared with younger post-menopausal patients. Co-morbidity, type of surgery, treatment assignment and sociodemographic factors showed a statistically significant impact in post-menopausal patients only. Cultural and biomedical factors influenced baseline QL and should be considered when evaluating the impact of treatment on QL in international breast cancer clinical trials.

Impact of adjuvant therapy on quality of life in women with node-positive operable breast cancer. International Breast Cancer Study Group

BACKGROUND

Adjuvant therapy for early breast cancer is effective but may be toxic. Our aim was to investigate the impact of the presence, timing, and duration of adjuvant chemotherapy on patients' perceptions of their quality of life (QL).

METHODS

International Breast Cancer Study Group trial VI assessed adjuvant chemotherapy in 1475 premenopausal and perimenopausal patients, and trial VII assessed adjuvant tamoxifen or chemoendocrine therapy in 1212 postmenopausal patients with node-positive breast cancer. Patients were asked to complete a QL questionnaire-single-item linear analogue self-assessment scales measured physical wellbeing, mood, appetite, and perceived adjustment/coping. QL was assessed in this way at the beginning of treatment, 2 months after the start of treatment, every 3 months, and at 1 and 6 months after recurrence.

FINDINGS

Baseline QL scores decreased as the number of involved axillary nodes increased (for example, mean mood score: 66.1 for women with one positive node, 66.4 for two to four positive nodes, 61.3 for five to nine positive nodes, and 59.1 for ten or more positive nodes; p = 0.008 for trends), and were lower in patients with oestrogen-receptor-negative than in patients with oestrogen-receptor-positive tumours (61.4 vs 66.3, p = 0.0009). All treatment groups showed substantial improvement in QL scores during adjuvant therapy. Patterns of QL scores reflected presence, duration, and timing of cytotoxic treatment. Longer initial cytotoxic therapy delayed improvement in QL scores. Later cytotoxic therapy had transient adverse effects. Anticipation of future therapy also affected QL scores.

INTERPRETATION

Overall, chemotherapy had a measurable adverse effect on QL, but this effect was transient and minor compared with patients' adaptation/coping after diagnosis and surgery. This finding should encourage patients and doctors to choose appropriate adjuvant therapy with less concern for initial toxicity.

Psychosocial factors in women with operable breast cancer. An association to estrogen receptor status?

The association between psychosocial parameters and estrogen receptor (ER) status was evaluated in 85 consecutive breast cancer patients with stage I and II disease. Patients were categorized into those with ER+ and ER- tumours. Life events, emotional control, neuroticism, social support, adjustments to illness, and psychological distress were measured the day before surgery. Group comparisons showed significant differences between the groups as to age, emotional control and distribution of the life event: "experienced another illness/accident/hospitalization during the last year". A multiple regression analysis indicated significant effect for variables "age" and "life event", explaining 19% of the variation in ER level. The variable "emotional control" was positively correlated to age (r = 0.369) and did not contribute in itself. We conclude that none of the factors were associated with ER status when age and personal health data were controlled for. Our study does not support ER status as a possible link between behavioural factors and disease course in breast cancer.

The psychiatrist's perspective on quality of life and quality of care in oncology: concepts, symptom management, communication issues

The important prevalence of psychosocial problems and psychiatric disturbances that have been reported in oncology, underlines the need for comprehensive psychosocial support for cancer patients and their families. Psychosocial support is designed to preserve, restore or enhance quality of life. Quality of life refers not only to psychosocial distress and adjustment-related problems but also to the management of cancer symptoms and treatment side-effects. Psychosocial interventions designed for this purpose should be divided into five categories: prevention, early detection, restoration, support and palliation. Firstly, preventive interventions are designed to avoid the development of predictable morbidity secondary to treatment and/or disease. Secondly, early detection of patients' needs or problems refers to the assumption that early interventions' could have therapeutic results superior to those of delayed support, both for quality of life and survival. Thirdly, restorative interventions refer to actions used when a cure is likely, the aim being the control or elimination of residual cancer disability. Fourthly, supportive rehabilitation is planned to lessen disability related to chronic disease, characterised by cancer illness remission and progression, and to active treatment. Fifthly, palliation is required when curative treatments are likely to no longer be effective, and when maintaining or improving comfort becomes the main goal. Psychological interventions are often multidisciplinary, with a variety of content. The type of psychological intervention ranges from information and education to more sophisticated support programmes including directive (behavioural or cognitive) therapies, or non-directive (dynamic or supportive) therapies. Social interventions usually include financial, household, equipment, and transport assistance depending on individual and family needs and resources. These interventions may be combined with the prescription of pharmacological (psychotropic, analgesic), physical, speech or occupational therapies, especially in rehabilitation programmes. Health care services devoted to delivery of these interventions are hospital, hospice or home-based and organised very differently depending on already available community resources and local practice.

Death of a husband or marital divorce related to risk of breast cancer in middle-aged women. A nested case-control study among Norwegian women born 1935-1954

A topic of general interest is whether important life changes may play a role in the onset of cancer. The hypothesis of this study was that death of a husband or marital divorce, is associated with an increased risk of breast cancer. The study included 4491 incident breast cancer cases and 44,910 controls, matched on age, in a population-based nested case-control study, among Norwegian women born between 1935 and 1954. The risk of breast cancer among widowed compared to married women showed an odds ratio (OR) of 1.13 [95% confidence interval (CI) 0.94-1.36], after adjusting for age at first birth and parity. For divorced women the analogous OR was 0.83 (95% CI 0.75-0.92), after adjusting for age at first birth, parity and place of residence. Thus, the results did not show any clear evidence that death of a husband or marital divorce was associated with an increased risk of breast cancer.

Lack of correlation between anxiety parameters and oestrogen receptor status in early breast cancer

Correlation between anxiety parameters and oestrogen receptor levels (ER) were investigated in 89 patients with primary breast cancer. Patients were divided into two groups, ER poor (< 0.05 fmol/microgram DNA) and ER rich (> 0.05 fmol/microgram DNA). No differences were found between anxiety levels, determined by a modified Hospital Anxiety and Depression (HAD) scale, in the two groups. This report does not support the findings from other studies, claiming an association between psychological parameters and oestrogen receptor status, which is believed to be a prognostic predictor.

Psychosocial factors in breast cancer and their possible impact upon prognosis

Breast cancer is the most common cancer form in women. Numerous biological factors have now been identified and accepted as important risk factors and prognosticators. Psychosocial factors are also considered to be of probable importance. A review of the literature studying these factors reveals major methodological problems in evaluating data: small sample size, retrospective design, lack of cross-referencing for other important factors, cross-sectional studies instead of longitudinal studies, and insufficient statistical analysis. Regarding psychosocial factors, some of the most valid studies indicate that the risk of getting breast cancer may be connected with difficulties in expressing feelings, especially ones of aggression; while coping strategy, amount of stress, and level of activity, seem to be of possible influence to the prognosis. A possible connection between psyche and the immunological system has been proposed, but there has been little data so far. Although a series of studies have shown some influence of psychosocial factors on breast cancer, the methodological problems are so large as to leave open the question whether psychosocial factors have any impact upon the disease.