Psychological factors can predict the response to primary chemotherapy in patients with locally advanced breast cancer

Psychological distress and coping strategies in breast cancer patients under neoadjuvant therapy: A systematic review

BACKGROUND

During neoadjuvant therapy (NAT), patients with locally advanced breast cancer (LABC) experience psychological distress (PD) and adopt appropriate coping strategies.

OBJECTIVE

This systematic review aimed to examine the prevalence and changes in PD and coping strategies in patients with LABC during NAT and to evaluate effective interventions to reduce their PD.

DESIGN

Quantitative (cross-sectional, longitudinal, and interventional) and qualitative studies reporting PD and coping strategies related to NAT during LABC were included.

DATA SOURCES AND METHODS

PubMed, Cochrane Library, Scopus, ScienceDirect, Wiley Online Library, and Web of Science databases were consulted to gather relevant literature from the first publications until July 25, 2023. Selection was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

RESULTS

A total of 41 articles were included, of which four were qualitative. The main results showed that the prevalence of depression before NAT ranged from 0% to 46% and that of anxiety from 5.5% to 54%. After NAT, the prevalence of depression ranged from 40% to 78.5% and anxiety accounted for 27%. Additionally, PD decreased during NAT. The main determinants of PD were perceived social support, living in joint families, being affected by COVID-19 infection, delays in diagnosis, and starting neoadjuvant treatment. For coping strategies, after NAT, "resigned coping" decreased, whereas "social support" increased, and active coping strategies were correlated with better PD. Some interventions found a reduction in PD, such as a mobile health application, fasting-mimicking diet, relaxation training, and guided imaging.

CONCLUSION

These findings highlight the importance of considering PD and coping strategies in patients with LABC from diagnosis to the end of NAT. The results suggest that effective psychological interventions should be implemented.

Psychological Aspects of Breast Cancer

Breast cancer is the most commonly diagnosed cancer in women. Associated psychological symptoms include stress, adjustment difficulties, anxiety, depression, impaired cognitive function, sleep disturbances, altered body image, sexual dysfunction, and diminished overall well-being. Distress screening and assessment identifies women who will benefit from therapeutic interventions. Addressing these symptoms improves compliance with treatment and outcomes including disease-related outcomes, psychological symptoms, and quality of life. The most effective treatments include teaching coping skills such as expressing emotion, along with other structured cognitive behavioral, interpersonal, and mindfulness approaches. Patients should be provided these psychosocial supports throughout their cancer journey.

Progressive Muscle Relaxation and Guided Imagery in Breast Cancer: A Systematic Review and Meta-analysis of Randomised Controlled Trials

Breast cancer affects the mental well-being of patients who may need psychological support. The combined practice of progressive muscle relaxation (PMR) and guided imagery (GI) is known to improve psychological health. Its effect has been studied in patients with breast cancer. We need to systematically review and analyse the available data to outline its role in various stages of disease management. We wanted to evaluate the effect of the combined practice of PMR and GI on stress, anxiety, depression and mood. We also wanted to study the impact on quality of life and chemotherapy-related adverse effects. A systematic search and evaluation of the literature was performed. Five randomised controlled trials were selected for data extraction and construction of forest plots. The intervention was effective for stress and anxiety. It positively improved the quality of life but saw no significant improvement in chemotherapy-related adverse effects.

Psychological Aspects to Consider in Breast Cancer Diagnosis and Treatment

PURPOSE OF REVIEW

Breast cancer (BC) is the most common cancer diagnosed in women in the West World. Coping with cancer is cause of extreme stress for patients and their family. The purpose of this review is to evaluate possible approaches to follow to control those situations that can impact on quality of life (QoL) and compliance to treatments.

RECENT FINDINGS

Anxiety, distress, depression, and posttraumatic stress disorder are the most frequent psychological disorders in BC patients. Cognitive disorders and sexual dysfunction can also be important in affecting QoL both in younger and older patients. Younger and older patients show different characteristics of these disorders and different strategies of managing them. Several psychotherapeutic and supportive approaches have proven effective in managing psychological disorders in BC patients. Every BC patient should be supported with these techniques during her entire oncological history, in order to increase QoL and compliance to treatments.

A Study of Anxiety and Depression in Benign Breast Disease

Background:

To compare the prevalence of anxiety and depression levels in patients with benign breast disease (BBD) and healthy individuals using Hospital Anxiety and Depression Scale (HADS) and Brief Patient Health Questionnaire (BPHQ).

Methods:

This study includes 100 patients who were clinically suspected of having BBDs and were matched against 100 healthy age-matched controls from June 2016 and July 2018. The diagnosis of BBD was established on the basis of ultrasonography, fine needle aspiration cytology, and/or histopathology. For the diagnosis of anxiety and depression, BPHQ was used and the level of anxiety and depression was measured using the HADS. The questionnaire at both prediagnosis and at follow-up assessment after 3 months was done.

Results:

On comparing anxiety and depression using BPHQ score among cases and controls, both were significantly associated with cases than controls (P < 0.001 and P = 0.0016, respectively). On comparing anxiety and depression using HADS score, there was a significant difference (median) in both anxiety and depression level between cases and controls (P < 0.001 and P < 0.001, respectively). After 3 months of follow-up, there was a significant improvement in anxiety and depression scores by both BPHQ (P = 0.007 and P = 0.0016) and HADS (P < 0.001 and P < 0.001). The 3-month follow-up data showed a significant improvement in BPHQ (depression) score in patients with breast lump and mastalgia (P = 0.001 and P = 0.008). The HADS (anxiety score) showed significant improvement in patients presenting with diseases/aberrations other than fibroadenoma while the HADS (depression) score showed a significant improvement in all except fibroadenosis present either alone or along with fibroadenoma. The HADS (depression) score showed a significant improvement in fibroadenoma, others group, breast lump, and mastalgia (P = 0.040, P = 0.005, P < 0.001, and P = 0.025, respectively).

Conclusion:

Indian female patients who present with BBDs are also affected by anxiety and depression.

Cognitive Dysfunction and Neurophysiologic Mechanism of Breast Cancer Patients Undergoing Chemotherapy Based on Resting State Functional Magnetic Resonance Imaging

We studied chemotherapy-related cognitive impairment via resting state (RS)-functional magnetic resonance imaging (fMRI) and diffusion tensor imaging (DTI) in 19 cases of patients with early breast cancer. White matter neuropsychological test treatment were carried out before and after chemotherapy, RS-fMRI, and DTI evaluation. In RS-fMRI with regional homogeneity (ReHo) reflects brain activity. In the DTI with fractional anisotropy (FA) reflect the integrity of the white matter. Determining the region of interest by image analysis, we calculated the neuropsychologic test score using the paired t-test and FA change ReHo values of regions of interest. Finally after the test treatment, in the chemotherapy group for pairing correlation analysis t-test scores change in meaningful inspection and change ReHo and FA. Chemotherapy after chemotherapy than before chemotherapy difference memory test and self-evaluation of cognitive (P < 0.05). ReHo value increases occurred in the right orbitofrontal region and the left dorsolateral prefrontal cortex. Declines in brain regions were the anterior inferior cerebellar lobe, cerebellar lobe, right middle temporal gyrus and the superior temporal gyrus, the lower right of the center area, and the central gyrus. This prospective study on resting state and RS-fMRI functional magnetic resonance DTI study DTI sequence combination chemotherapy for breast cancer-related cognitive disorders supports the "chemo brain" point of view. Chemotherapy can cause memory decline, accompanied by a partial area of the brain and white matter integrity in brain activity changes. Prompt clinical treatment RS-fMRI and DTI have potential applications in assessing chemotherapy-related cognitive impairment.

The “Ick” Factor: An Unrecognized Affective Predictor of Physical Symptoms During Chemotherapy

Background

Patients undergoing chemotherapy experience a range of aversive symptoms. These symptoms vary across individuals and at least some of this variation can be predicted by psychological factors, such as distress. However, while psychological distress predicts some of the symptoms, it is limited in important ways.

Purpose

To (a) assess the viability of disgust—a discrete emotion that specifically evolved for health-related reasons—as a predictor of chemotherapy-related symptoms (particularly, taste- and smell-related changes) and (b) compare the predictive utility of disgust sensitivity and propensity against the most commonly used affective predictor, that is, psychological distress.

Methods

Patients with cancer (N = 63) about to initiate chemotherapy were recruited in a prospective observational study. Psychosocial predictor variables were assessed at baseline, and outcomes (i.e., physical symptoms, body mass index [BMI], and food-based sensory-processing changes) were assessed at both baseline and 6 week follow-up.

Results

Psychological distress did not predict any of the outcomes. Both disgust sensitivity (β = .53, p = .003) and propensity (β = −.56, p = .002) predicted greater food-based sensory-processing changes, while disgust sensitivity marginally predicted greater chemotherapy-related physical symptoms (β = .34, p = .060); neither of these two forms of disgust predicted BMI.

Conclusions

The study provides first evidence showing (a) associations between trait disgust and food sensory-processing changes that arise during chemotherapy and (b) disgust as being a more useful predictor of food- and digestion-related symptoms than psychological distress. In doing so, it opens new doors for better care to be provided to patients undergoing chemotherapy.

Fast time perception is associated with high levels of anxiety in cancer patients prior to starting chemotherapy

Our study explored the potential relationship between time perception and the level of anxiety in cancer patients prior to starting chemotherapy. Time perception was assessed in 162 chemonaïve patients with solid tumors by evaluating each subject's prospective estimation of how fast one minute passed compared to the actual amount of time passed. The median value of time perception was used to stratify the patients into two categories of fast and slow time perception. We used the generalized anxiety disorder questionnaire (GAD-7) as a screening tool for detecting levels of anxiety. Scores ≥ 10 were considered high. In total, 45 (27.8%) patients had high levels of anxiety. The pattern of the time perception distributions significantly changed according to the reported levels on the GAD-7 scale. Scores ≥ 10 correlated with fast time perception and the female gender. Patients with a fast time perception had significantly higher levels of anxiety (8.44 ± 5.1) than patients with a slow time perception (3.49 ± 4.3). ROC analysis revealed that at the optimal cut-off value of time perception, clinically significant levels of anxiety can be discriminated with an AUC = 0.78 (95% CI: 0.70-0.85, p < 0.001), a sensitivity of 82.2% and a specificity of 64.1%. Moreover, in a multivariate logistic regression model, fast time perception was an independent predictor of clinically significant levels of anxiety (OR: 8.24; 95% CI: 3.16-21.41, p < 0.001). Time perception is a novel potent indicator for high levels of anxiety in cancer patients.

Distress Among Locally Advanced Breast Cancer Patients from Diagnosis to Follow-Up: A Critical Review of Literature

OBJECTIVE

This critical review used a systematic approach to explore the prevalence of distress among locally advanced breast cancer (LABC) patients along their treatment journey. This review explored the domains of distress (psychosocial, physical and/or practical) that are significant to this patient population and determined indications for psychosocial support throughout the patients' treatment.

METHODS

Electronic databases including CINAHL, EmBase, Medline PsycInfo, and gray literature were searched from the year 2000 to 2016, to produce relevant literature. A critical review was conducted on 73 articles meeting the inclusion and exclusion criteria. A narrative synopsis was used to summarize the findings under key themes.

RESULTS

The results indicate that 16/73 studies assessed for distress in all three domains of distress throughout the treatment course. A meta-analysis was not possible due to the methodological heterogeneity of the articles, the variation of assessment tools used, timing in which the assessments were done, and the different treatment modalities. Distress was prevalent from the time of diagnosis, through treatment, and into survivorship. Sexuality, body image, age, financial difficulty, family/social support, and informational needs were common themes that emerged among the LABC population in these studies.

CONCLUSIONS

Comprehensive assessments incorporating all three domains of distress with the appropriate tools will assist health care professionals throughout the complicated treatment trajectory of LABC patients in taking a more proactive approach in assisting patients' concerns and preventing undue or increase in psychological distress during or after active treatment. This will encourage effective patient-centered communication and supportive care referrals for a better patient experience.

Perceived distress and its association with depression and anxiety in breast cancer patients

Background

Breast cancer patients often experience a high level of distress. Psychological distress is a broad construct encompass both depression and anxiety. Previous studies in examining which of these psychological symptoms (either anxiety or depression) were more significantly associated with the distress level in breast cancer patients is lacking. This study aims to compare the level of depression and anxiety between patients with different level of distress. The correlation between the changes in distress level with depression or anxiety over 12 months was also examined.

Methods

This study is from the MyBCC cohort study. Two hundred and twenty one female breast cancer patients were included into the study. They were assessed at the time of diagnosis, 6 months and 12 month using Hospital Anxiety and Depression Scale (HADS) and distress thermometer. The information on age, ethnicity, treatment types and staging of cancer were collected.

Results

50.2%, 51.6% and 40.3% of patients had perceived high level of distress at baseline, 6 months and 1 year after diagnosis. Those with high perceived level of distress had significant higher anxiety scores even after adjusted for the underlying depressive scores (Adjusted OR at baseline = 1.28, 95% CI = 1.13–1.44; adjusted OR at 6 months = 1.27, 95% CI = 1.11–1.45; adjusted OR at 12 months = 1.51, 95% CI = 1.29–1.76). There were no significant differences in the depressive scores between the subjects with either low or high distress level. There was reduction in perceived level of distress, anxiety and depression scores at 12 months after the diagnosis. The decrease of distress was positively correlated with the reduction of anxiety scores but not the changes of depressive scores (r’ = 0.25).

Conclusion

Anxiety is a more significant psychological state that contributed to the feeling of distress in breast cancer as compared with depression. Levels of anxiety at diagnosis in this study would justify screening for anxiety, early identification and therapy for maintaining the psychological well-being of breast cancer patients. Further studies will be needed to measure the effectiveness of therapeutic interventions.

Predicting general and cancer-related distress in women with newly diagnosed breast cancer

BACKGROUND

Psychological distress can impact medical outcomes such as recovery from surgery and experience of side effects during treatment. Identifying the factors that explain variability in distress would guide future interventions aimed at decreasing distress. Two factors that have been implicated in distress are illness perceptions and coping, and are part of the Self-Regulatory Model of Illness Behaviour (SRM). The model suggests that coping mediates the relationship between illness perceptions and distress. Despite this; very little research has assessed this relationship with cancer-related distress, and none have examined women with screen-detected breast cancer. This study is the first to examine the relative contribution of illness perceptions and coping on general and cancer-related distress in women with screen-detected breast cancer.

METHODS

Women recently diagnosed with breast cancer (N = 94) who had yet to receive treatment completed measures of illness perceptions (Revised Illness Perception Questionnaire), cancer-specific coping (Mental Adjustment to Cancer Scale), general anxiety and depression (Hospital Anxiety and Depression scale), and cancer-related distress.

RESULTS

Hierarchical regression analyses revealed that medical variables, illness perceptions and coping predicted 50% of the variance in depression, 42% in general anxiety, and 40% in cancer-related distress. Believing in more emotional causes to breast cancer (β = .22, p = .021), more illness identity (β = .25, p = .004), greater anxious preoccupation (β = .23, p = .030), and less fighting spirit (β = -.31, p = .001) predicted greater depression. Greater illness coherence predicted less cancer-related distress (β = -.20, p = .043). Greater anxious preoccupation also led to greater general anxiety (β = .44, p < .001) and cancer-related distress (β = .37, p = .001). Mediation analyses revealed that holding greater beliefs in a chronic timeline, more severe consequences, greater illness identity and less illness coherence increases cancer-specific distress (ps < .001) only if women were also more anxiously preoccupied with their diagnosis.

CONCLUSIONS

Screening women for anxious preoccupation may help identify women with screen-detected breast cancer at risk of experiencing high levels of cancer-related distress; whilst illness perceptions and coping could be targeted for use in future interventions to reduce distress.

Psychosocial oncology care resources in Europe: a study under the European Partnership for Action Against Cancer (EPAAC)

BACKGROUND

Cancer is a complex health problem requiring multidisciplinary care. There are clinical guidelines available in order to improve the process and outcomes of cancer care within Europe. However, strategic action is still needed in many European Union (EU) Member States to develop or improve national cancer control plans (NCCPs), which play a key role in cancer control and care. The current study clarifies the extent of implementation of psychosocial oncology care (PSOC) in the EU.

METHOD

A survey methodology was used to cover four dimensions: (1) inclusion of PSOC in NCCPs; (2) structure and resources of PSOC delivery; (3) use of NCCP clinical guidelines; and (4) education and training resources available along with determination of training needs in PSOC.

RESULTS

Twenty-seven (90%) countries returned questionnaires of which 21 (78%) include PSOC in their NCCP. However, only 10 (37%) reported having specific budgets for PSOC, 8 (30%) having nationally recommended PSOC clinical guidelines, and 6 countries (22%) reported having an official certification for PSOC education.

CONCLUSION

Although many countries seem to have integrated PSOC into their NCCP, there is still much to do in terms of allocating resources and delivering psychosocial care equitably. Also, there is a need for improving training and certification in PSOC. The findings indicate the need to develop national policies concerning PSOC with clear targets for deliverables in an appropriate timetable in order that psychosocial services and existing clinical guidelines are implemented and fully integrated into EU NCCPs. Copyright © 2015 John Wiley & Sons, Ltd.

Women with large (≥3 cm) and locally advanced breast cancers (T3, 4, N1, 2, M0) receiving neoadjuvant chemotherapy (NAC: cyclophosphamide, doxorubicin, docetaxel): addition of capecitabine improves 4-year disease-free survival

Purpose

To determine whether capecitabine (X), combined with docetaxel (T) following doxorubicin (A) and cyclophosphamide (C), enhanced the pathological complete response (pCR) in the breast and axillary lymph nodes (ALNs) of women with large or locally advanced breast cancers (LLABCs) improving outcome, and the effect on quality of life (QoL).

Patients and methods

117 women were enrolled, 112 randomised to 2 cycles of AC (60 mg/m², 600 mg/m²) given 3 weekly. Tumour responses were assessed by magnetic resonance mammography. Responders (n = 77) received 2 further cycles of AC and were randomised to 4 cycles of T (100 mg/m²) (Group A) or T (75 mg/m²) and X (2000 mg/m²/day), day one to 14 of each 3 weekly cycle (Group B). Non-responders (n = 35) were randomised to 6 cycles of T (Group C) or T + X (Group D). QoL questionnaires were completed at each chemotherapy visit. Pathological responses were evaluated using established criteria.

Results

The groups were comparable in patient and tumour characteristics (79.5% T2, 85.7% ductal, 73.2% ER +ve, 22.3% HER2 +ve, 42% involved ALNs). Overall breast pCR was 27.1%, Groups A + C versus B + D (p = 0.446). ALN +ve pCR was 41.9%, Groups A + C versus B + D (p = 0.231). 4-year disease-free survival (DFS) was significantly improved with X (p = 0.016) but not overall survival (p = 0.056). Triple -ve and HER2 +ve tumours, and persistent ALN disease were risk factors for metastases. X increased severe nail changes (p = 0.0002) and hand-foot syndrome (p = 0.014) without affecting QoL.

Conclusion

NAC-X did not increase breast and ALN pCR but improved 4-year DFS, without detriment to QoL.

Interaction of coping styles and psychological stress on anxious and depressive symptoms in Chinese breast cancer patients

PURPOSE

This study aimed to assess possible interactive effects of coping styles and psychological stress on depression and anxiety symptoms in Chinese women shortly after diagnosis of breast cancer.

METHODS

Four hundred and one patients with breast cancer were face-to-face interviewed by trained research staff according to a standardized questionnaire including information on socio-demographic characteristics, psychological stress, coping styles, and anxiety and depressive symptoms. Interactive effects were assessed by hierarchical multiple regression analyses.

RESULTS

There were significant associations of the four domains of psychological stress with anxiety and depressive symptoms except for the relationship between "worrying about health being harmed" and depressive symptoms. "Abreaction coping behavior" and "escaping coping behavior" significantly increased the level of both anxiety and depressive symptoms; whereas an "active coping style" resulted in significant decrease. The interaction of "active coping behavior" with "worrying about health being harmed" significantly increased the risk of the anxiety symptoms, while adopting "self-relaxing coping behavior" was associated with significant decrease. The interaction of "worry about daily life and social relationship being restricted" with "escaping coping behavior" significantly increased the risk of the depressive symptoms.

CONCLUSIONS

The results of this study suggest that certain coping styles might moderate the association of psychological stress with anxiety and depressive symptoms in Chinese women with breast cancer.

The prognostic role of cancer-specific beliefs among prostate cancer survivors

OBJECTIVE

The objective of this study is to evaluate the association between cancer-specific beliefs and survival among men newly diagnosed with prostate cancer.

METHODS

Based on data from a biracial cohort monitored for mortality for up to 15 years, we investigated the association between beliefs and survival among 251 men newly diagnosed with prostate cancer between 1987 and 1990. We examined patients' beliefs related to efficacy of regular checkups for detection, potential negative treatment effects, and perceived curability of cancer. Cox proportional hazards models were adjusted for sociodemographic variables, medical care measures, clinical factors, and lifestyle.

RESULTS

In a fully adjusted model, not believing that most cancers can be cured was associated with an increased risk of death from any cause (Hazard Ratio = 1.62; 95% confidence interval = 1.11, 2.38). Beliefs regarding the efficacy of checkups or potential negative treatment effects were not associated with survival.

CONCLUSIONS

Prostate cancer patients who reported not believing that most cancers are curable experienced poorer survival after adjusting for a wide array of prognostic factors and potential confounders. Future research to identify underlying behavioral (medical protocol adherence, lifestyle) and physiological (immune and endocrine regulation) mechanisms of this association would translate into improved intervention strategies for cancer survivors.

A brief self-administered psychological intervention to improve well-being in patients with cancer: results from a feasibility study

BACKGROUND

Patients with cancer have relatively high rates of anxiety and distress, adversely affecting their well-being and quality of life. Recent studies indicate that addressing these symptoms could result in better response to cancer treatment. Researchers have found that interventions that focus on increasing mental awareness and the frequency of positive experiences may have a greater impact on reducing psychological morbidity and increasing quality of life than interventions that target relief of psychological symptoms.

AIM

To develop and test a brief, easy to use intervention that could improve well-being and quality of life in cancer patients.

METHODS

We developed a simple well-being intervention that made few demands on patient time and required little training resource. Participants were randomly assigned to an intervention group or a deferred entry group. Measures of anxiety, depression, well-being and quality of life were administered at baseline and at follow-ups.

RESULTS

Twenty-two women with metastatic breast cancer and 24 men with metastatic prostate cancer were recruited from oncology clinics. Thirteen women and 14 men completed the study. Both qualitative and quantitative data showed that the intervention was acceptable to users. There was statistically significant improvement in quality of life scores on WHOQOL-BREF post-intervention (p=0.046). Compliance with the intervention was good.

CONCLUSIONS

This brief well-being intervention appears to be a promising technique for improving quality of life of cancer patients, without making undue demands on staff resources or patient time. If further studies confirm its effectiveness, it could prove to be a cost-effective intervention.

Treatment-related symptoms among underserved women with breast cancer: the impact of physician-patient communication

Low-income, minority women are more likely to be undertreated for breast cancer (BC) treatment-related symptoms than whites. This study assessed the impact of patient-physician communication on symptom resolution. A cross-sectional, California statewide survey was conducted among 921 low-income women with BC. Ethnic/racial differences in BC treatment-related symptoms (pain, nausea/vomiting, depression) reporting and physician' awareness of these symptoms were assessed by patient report. Multivariate logistic regression models were used to investigate the impact of patient-physician communication on symptom resolution. Depression was the most common symptom reported by patients (66%), yet physicians were the least aware of it (26.3%), especially among less-acculturated Latinas (18.9%) and Asian/Pacific Islanders (14%; P < 0.001). Greater patient-perceived self-efficacy in communication with physicians and greater physician awareness of the symptom positively predicted pain resolution, controlling for sociodemographic variables, comorbidity, and treatment received (AOR = 1.05, P < 0.0001; AOR = 6.12, P < 0.001). Physician awareness was a significant determinant of depression resolution (AOR = 13.46, P < 0.001). Yet patient-perceived self-efficacy played a much more important role than physicians' awareness in nausea resolution (AOR = 1.04, P = 0.0002). Less-acculturated Latinas tended to achieve less symptom resolution than whites, while this negative impact disappeared or was moderated after patient-physician communication was considered. This study suggests that physicians under-recognized depression, especially among Latinas. The resolution of BC treatment-related symptoms can be addressed by appropriate educational interventions targeted at patient-physician communication. Effective patient-physician communication can moderate disparities in symptom resolution among Latinas, regardless of language acculturation.

Anxiety in patients with breast cancer undergoing treatment: a systematic review

BACKGROUND

Breast cancer is one of the most common cancers worldwide, and anxiety is a psychological morbidity that is inevitable. Many researchers have investigated its prevalence and detrimental effects, yet little is known when comparing the different breast cancer treatments. A systematic review of all available literature was indicated to encourage better understanding of anxiety in patients undergoing treatment for breast cancer.

OBJECTIVES

This review aimed to determine the best available evidence on the level of anxiety among women with breast cancer undergoing/had undergone cancer treatment(s), and factor(s) contributing to anxiety in these treatment modalities.

INCLUSION CRITERIA

Types of participants Women with breast cancer of stage 0 to stage IIIA breast cancer, over and equal to 21 and below the age of 65 years of age.Types of intervention Women who were undergoing/had undergone cancer treatment restricted to chemotherapy, radiotherapy, surgery or combined treatments, and were without other medical co morbidities.Types of outcomes A variety of outcome measures were used to assess anxiety in the included papers. Hospital Anxiety and Depression Scale and State-Trait Anxiety Inventory were mostly used.Types of studies This review considered quantitative papers (randomized control trials, descriptive studies and systematic review) that fulfilled both requirements: SEARCH STRATEGY: The search sought to gather data from published and unpublished studies conducted between 1990 and 2010. An initial search on CINAHL and Medline was done to identify relevant search terms. A search strategy was then developed, using MeSH headings and keywords. Following databases were searched: CINAHL; PubMed; ScienceDirect; PsycINFO; Cochrane Database of Systematic Review; Scopus; Wiley Interscience and PsycARTICLES.

DATA COLLECTION/EXTRACTION

Two reviewers independently assessed the eligibility of the papers for inclusion. Eighteen papers were selected based on relevance, and underwent assessment for methodological quality using MAStARI. Eleven research papers that met the level of methodological standard were included into the review. Both reviewers came to the same consensus on the included and excluded papers.

DATA ANALYSIS

Due to the methodological heterogeneity of the included papers, a meta-analysis was not possible. The studies were hence presented in narrative summary.

RESULTS

Anxiety seems to be ubiquitous, presenting itself in all treatment types for breast cancer. Anxiety level in breast cancer women who underwent chemotherapy was highest before the first chemotherapy infusion, mediated by age and trait anxiety. Radiotherapy regimes did not affect anxiety level in radiotherapy-treated patients, and most research concluded that anxiety level was higher among women who underwent mastectomy than breast conservation therapy. When compared, patients who underwent chemotherapy were more anxious.

CONCLUSIONS

The prevalence and intensity of anxiety has been shown to be pronounced among the three treatments. Chemotherapy, as compared to other treatments, has shown to be associated with a higher anxiety level.

IMPLICATIONS FOR RESEARCH

With the prevalence, intensity and correlated factors of anxiety identified through this review, future research may investigate the interventions that could help alleviate anxiety among these patients.

IMPLICATIONS FOR PRACTICE

Anxiety is prevalent in women with breast cancer undergoing treatment, especially those undergoing chemotherapy. Healthcare professionals should pay greater attention to identify cues of anxiety in patients and prevent/alleviate it.

Personalidade e câncer de mama: produção científica em Psico-Oncologia

O presente estudo se insere no campo da Psico-Oncologia. Objetivou-se empreender uma revisão sistemática da literatura científica dedicada especificamente ao papel da personalidade na evolução da condição clínica e emocional de mulheres acometidas por câncer de mama. Foram consultadas as bases de dados MedLine, PsycINFO, LILACS, SciELO-Brasil e PePSIC. De modo geral, os achados das referências selecionadas apontam que o otimismo enseja uma evolução mais favorável da condição emocional. Além disso, sustentam que pacientes com espírito de luta e manejo apropriado da ansiedade desencadeada por estímulos agressivos tendem a uma melhor condição clínica. Todavia, sugere-se a utilização, em futuras investigações, de escolhas teórico-metodológicas inovadoras para o avanço do conhecimento que atualmente se tem a respeito do assunto em pauta.

Exemestane as primary treatment of oestrogen receptor-positive breast cancer in postmenopausal women: a phase II trial

To assess the efficacy of exemestane as neoadjuvant treatment, 55 postmenopausal women (mean age: 76 years; range: 66-86) with oestrogen-positive non-metastatic breast tumour and ineligible for conservative surgery were recruited into this phase II trial to receive oral exemestane (25 mg day(-1)) for 6 months. Tumour response was evaluated by clinical examination, mammography and breast ultrasound every 2 months (RECIST criteria). Overall clinical response to treatment was observed in 33/54 patients (61.1%; 95% CI: 48.1-74.0). Radiological responses in 45 evaluable patients were partial response in 23, stable disease in 21 and disease progression in one. Median time to surgery from the commencement of treatment was 7 months; conservative surgery in 24 patients (55.8%) and mastectomy in 19 patients (34.5%); no surgery (patient choice or considered not suitable by attending physician) in 12 patients. Pathologic complete response was observed in breast and axilla in one patient (2.3%) and different forms of persistent disease in 23 (53.5%) patients. Treatment tolerance was good. No patient withdrew from the study because of toxic events. We conclude that exemestane as a primary treatment is feasible and very active in elderly patients with large-sized breast cancer tumour. Conservative surgery is feasible in responding patients. No severe adverse events were detected. The optimal hormonal treatment schedule remains to be determined.

Immuno-modulatory effects of relaxation training and guided imagery in women with locally advanced breast cancer undergoing multimodality therapy: a randomised controlled trial

Eighty women undergoing multimodality treatment for large (>4cm) or locally advanced (T3, T4, Tx, N2), breast cancers participated in a randomised controlled trial (RCT) to evaluate the immuno-modulatory effects of relaxation training and guided imagery. Patients underwent chemotherapy followed by surgery, radiotherapy, and hormone therapy. Those in the intervention group were taught relaxation and guided imagery. Patients kept diaries of the frequency of relaxation practice and imagery vividness. On 10 occasions during the 37 weeks following the diagnosis, blood was taken for immunological assays CD phenotyping: T cell subsets (helper, cytotoxic), natural killer (NK) and lymphokine activated killer (LAK) cells, B lymphocytes and monocytes; cytotoxicity: NK and LAK cell activities; cytokines interleukin 1 beta (1beta), 2, 4 and 6 and tumour necrosis factor alpha. Significant between-group differences were found in the number of CD25+ (activated T cells) and CD56+ (LAK cell) subsets. The number of CD3+ (mature) T cells was significantly higher following chemotherapy and radiotherapy, in patients randomised to relaxation and guided imagery. Using a median split, women who rated their imagery ratings highly had elevated levels of NK cell activity at the end of chemotherapy and at follow-up. Significant correlations were obtained between imagery ratings and baseline corrected values for NK and LAK cell activity, and IL1beta. Relaxation frequency correlated with the number of CD4+ (T helper) cells, the CD4+:8+ (helper:cytotoxic) ratio, and IL1beta levels. Relaxation training and guided imagery beneficially altered putative anti-cancer host defences during and after multimodality therapy. Such changes, to the best of our knowledge, have not been previously documented in a RCT.

Interdependent anxiety and psychological distress in women with breast cancer and their partners

The purpose of this study was to determine the extent of interdependence on anxiety within dyads where one person was undergoing treatment for breast cancer. Perceptions of relationship quality were expected to mitigate the anxiety experienced by both members of the dyad. 96 dyads participated in a 3-wave longitudinal study that took place over 10 weeks. Dyads were composed of a woman with stage I-III breast cancer who was currently undergoing treatment, and a partner who she nominated to participate in the study along with her. Results indicated that anxiety felt by women with breast cancer was consistently associated with that of her partner. Structural equation analyses suggest that the within-dyad influence runs mostly from partners' anxiety to the anxiety of women with breast cancer. Partners' anxiety was also associated with other indicators of the women's well being including depression, fatigue, and symptom management. Perceptions of relationship quality from women with breast cancer and their partners were negatively associated with partners' anxiety. However, women's anxiety was only correlated with their partners', but not their own, perceptions of relationship quality. These findings underscore the benefit of having partners who are able to cope with or get help for their own personal distress as women cope with the stress of breast cancer and its treatment.

Recurrent depression: patient characteristics, clinical course, and current recommendations for management

A significant proportion of depressed patients will experience multiple episodes of depression throughout their lifetimes, and, in recent years, attention has been paid to the identification of risk factors associated with a recurrent course of major depression. Residual depressive symptoms following acute phase therapy appears to be the most important clinical risk factor leading to recurrence. However, advances in empirically-supported treatment algorithms and guidelines, and in pharmacotherapy and psychotherapy, provide physicians with the tools necessary to improve short- and long-term outcomes in the treatment of depression. Additionally, recent developments in genetic and psychological vulnerability research have sought to further improve outcomes by identifying markers in patients who may likely experience multiple depressive episodes.

Complementary and alternative medicine in breast cancer patients

OBJECTIVE

Complementary and Alternative Medicine (CAM) is becoming increasingly popular among cancer patients, in particular those with breast cancer. It represents one of the fastest growing treatment modalities in the United States. Therefore, knowledge of CAM therapies is becoming necessary for physicians and other health care providers. CAM encompasses a wide range of modalities including special diet and nutrition, mind-body approaches, and traditional Chinese medicine.

METHODS

We reviewed the biomedical literature on CAM use in breast cancer patients, using Medline search from 1975 until 2002. In addition, consensus reports and books on CAM and breast cancer were included in the review. We evaluated the prevalence of CAM use in breast cancer patients, the reasons cited for its use, the different available modalities, and the reported outcomes.

RESULTS

Use of CAM in breast cancer patients ranges between 48% and 70% in the United States. The most commonly used CAM modalities include dietary supplements, mind-body approaches, and acupuncture. The reasons cited for using CAM were to boost the immune system, improve the quality of life, prevent recurrence of cancer, provide control over life, and treat breast cancer and the side effects of treatment. Several studies reported favorable results including improved survival, better pain control, reduced anxiety, improvement in coping strategies and significant efficacy in treating nausea and vomiting. Other less well-organized trials have reported either no benefit or negative effect of CAM and potential toxicity of some commercial products.

SIGNIFICANCE OF RESULTS

CAM is a growing field in health care and particularly among breast cancer patients. Knowledge of CAM by physicians, especially oncologists, is necessary. Oncologists should be willing to discuss the role of CAM with their patients and encourage patients to participate in well-organized research about CAM.

An investigation into the psychometric properties of the Hospital Anxiety and Depression Scale in patients with breast cancer

BACKGROUND

To determine the psychometric properties of the Hospital Anxiety and Depression Scale (HADS) in patients with breast cancer and determine the suitability of the instrument for use with this clinical group.

METHODS

A cross-sectional design was used. The study used a pooled data set from three breast cancer clinical groups. The dependent variables were HADS anxiety and depression sub-scale scores. Exploratory and confirmatory factor analyses were conducted on the HADS to determine its psychometric properties in 110 patients with breast cancer. Seven models were tested to determine model fit to the data.

RESULTS

Both factor analysis methods indicated that three-factor models provided a better fit to the data compared to two-factor (anxiety and depression) models for breast cancer patients. Clark and Watson's three factor tripartite and three factor hierarchical models provided the best fit.

CONCLUSION

The underlying factor structure of the HADS in breast cancer patients comprises three distinct, but correlated factors, negative affectivity, autonomic anxiety and anhedonic depression. The clinical utility of the HADS in screening for anxiety and depression in breast cancer patients may be enhanced by using a modified scoring procedure based on a three-factor model of psychological distress. This proposed alternate scoring method involving regressing autonomic anxiety and anhedonic depression factors onto the third factor (negative affectivity) requires further investigation in order to establish its efficacy.

Can Collaborative Care Address the Needs of Low-Income Latinas With Comorbid Depression and Cancer? Results From a Randomized Pilot Study

In a pilot study, 55 low-income Latina patients with breast or cervical cancer and comorbid depression were randomly assigned to receive collaborative care as part of the Multifaceted Oncology Depression Program or usual care. Relative to patients in the usual care condition, patients receiving collaborative care were more likely to show>or=50% improvement in depressive symptoms as measured by the Personal Health Questionnaire (OR=4.51, 95% CI=1.07-18.93). Patients in the collaborative care program were also more likely to show improvement in emotional well-being (increase of 2.15) as measured by the Functional Assessment of Cancer Therapy Scale than were those receiving usual care (decrease of 0.50) (group difference=2.65, 95% CI: 0.18-5.12). Despite health system, provider, and patient barriers to care, these initial results suggest that patients in public sector oncology clinics can benefit from onsite depression treatment.

Efficacy of progressive muscle relaxation training and guided imagery in reducing chemotherapy side effects in patients with breast cancer and in improving their quality of life

GOALS

This study was designed to assess the effectiveness of progressive muscle relaxation training (PMRT) and guided imagery (GI) in reducing the anticipatory nausea and vomiting (ANV) and postchemotherapy nausea and vomiting (PNV) of patients with breast cancer and to measure their effects on the patients' quality of life (QoL).

PATIENTS AND METHODS

Thirty chemotherapy-naive patients with breast cancer were randomized to the PMRT and GI group and 30 to the control group. Before each of six cycles of adjuvant chemotherapy, each patient was administered a self-report Multiple Affect Adjective Checklist (MAACL), and incidents of ANV and PNV for the first three postchemotherapy days were recorded. All patients were administered the Functional Assessment of Cancer Therapy-Breast (FACT-B) at baseline and after 3 and 6 months.

RESULTS

We found that the PMRT and GI group was significantly less anxious, depressive, and hostile than the control group. We also found that the PMRT and GI group experienced significantly less ANV and PNV and that 6 months after CT, the QoL of the PMRT and GI group was higher than that of the control group.

CONCLUSION

These results indicate that PMRT and GI were associated with both the improvements in ANV and PNV and in the QoL of patients with breast cancer.

Post-treatment symptoms among ethnic minority breast cancer survivors

PURPOSE/OBJECTIVES

To determine racial and ethnic differences in the range and number of post-treatment symptoms among women who have undergone surgical and postsurgical treatment for breast cancer.

DESIGN

Retrospective study.

SETTING

Community-based social services agency and public health clinic.

METHODS

Face-to-face interview of 116 women who had undergone breast cancer surgery.

SAMPLE

Primarily low-income women in an urban area in northern California. Participants were recruited via posted flyers regarding the study.

MAIN RESEARCH VARIABLES

Outcomes (depression, fatigue, pain, and swelling from lymphedema) and demographics (ethnicity, age, income, insurance, education, and marital status).

FINDINGS

The typical participant was 47 years old, had 12 years of education, and was a parent (74%), unmarried (67%), heterosexual (88%), uninsured (68%), and employed (66%). Thirty percent were Caucasian, 30% African American, 25% Latina, and 15% women of other ethnic backgrounds. African American women and Latinas reported increased rates of pain and an increased number of symptoms. Latinas also reported higher rates of fatigue and depression. In multivariate analyses, an increased number of symptoms were associated with decreased income, with receiving chemotherapy, with having a mastectomy, and with Latina ethnicity.

CONCLUSIONS

These data suggest an increased rate of post-treatment symptoms experienced by low-income and ethnic minority women.

IMPLICATIONS FOR NURSING

A need exists for affordable, culturally appropriate symptom management interventions. Nursing will have a vital role in designing, testing, and offering such interventions.

Cancer-specific beliefs and survival: a population-based study of African-American and White breast cancer patients

OBJECTIVE

Beliefs about cancer and its treatment have been shown to influence cancer stage at diagnosis and, thus, prognosis. The association between these beliefs and survival is understudied, especially among racially/ethnically diverse populations. We investigated the relationship between cancer-specific beliefs and survival in a cohort of African-American and White women with newly diagnosed breast cancer followed for up to 15 years.

METHODS

We examined beliefs about cancer detection, treatment, and curability in a population-based cohort of 145 African-American and 177 White women diagnosed with breast cancer in Connecticut, US, between 1987 and 1989. Cox proportional-hazards models were adjusted for stage at diagnosis, other biomedical variables, socio-demographic and lifestyle factors.

RESULTS

In multivariate models, perceived cancer incurability was associated with a higher risk of death from any cause (hazards ratio (HR)=1.67, 95 confidence interval (CI)=1.11, 2.51). Further control for tumor characteristics, genetic alterations, access to care, and additional psychosocial factors did not alter these findings. Other cancer-specific beliefs examined here were not related to survival.

CONCLUSIONS

Perceived cancer incurability is independently associated with survival among breast cancer patients in fully adjusted models. The identification of the underlying mechanisms of this association has potential for translation into intervention strategies for cancer patients.

Depressive symptoms among women with an abnormal mammogram

An abnormal mammography finding constitutes a stressful event that may increase vulnerability by developing or intensifying pre-existing psychological morbidity. We evaluated depressive symptoms using the Composite International Diagnostic Interview among women of four ethnic groups who had an abnormal mammography result controlling for the effect of demographic, psychosocial and medical factors on recent onset of depressive symptoms. Telephone surveys were conducted among women aged 40-80 years recruited from four clinical sites in the San Francisco Bay Area after receiving a screening mammography result that was classified as abnormal but probably benign, suspicious or highly suspicious, or indeterminate using standard criteria. Among the 910 women who completed the interview, mean age was 56 (S.D.=10), 42% were White, 19% Latina, 25% African American, and 14% Asian. Prevalence of lifetime depressive symptoms was 44%, and 11% of women had symptoms in the previous month. Multivariate logistic regression models showed that Asian ethnicity, annual income >$10 000 and weekly attendance at religious services were significantly associated with decreased depressive symptoms. Having an indeterminate result on mammography and being on disability were significantly associated with more depressive symptoms. Reporting a first episode of depression more than a year before the interview was associated with significant increase in depressive symptoms in the month prior to the interview regardless of mammography result. Women with an indeterminate interpretation on mammography were at greater risk of depressive episode in the month prior to the interview compared to women with probably benign results (odds ratio=2.41; 95% CI=1.09-5.31) or with a suspicious finding. Clinicians need to consider depression as a possible consequence after an abnormal mammography result.

A communication intervention for training southern European oncologists to recognize psychosocial morbidity in cancer. I--development of the model and preliminary results on physicians' satisfaction

BACKGROUND

The detection of psychosocial distress is a significant communication problem in Southern Europe and other countries. Work in this area is hampered by a lack of data. Because not much is known about training aimed at improving the recognition of psychosocial disorders in cancer patients, we developed a basic course model for medical oncology professionals.

METHODS

A specific educational and experiential model (12 hours divided into 2 modules) involving formal teaching (ie, journal articles, large-group presentations), practice in small groups (ie, small-group exercises and role playing), and discussion in large groups was developed with the aim of improving the ability of oncologists to detect emotional disturbances in cancer patients (ie, depression, anxiety, and adjustment disorders).

RESULTS

A total of 30 oncologists from 3 Southern European countries (Italy, Portugal, and Spain) participated in the workshop. The training course was well accepted by most participants who expressed general satisfaction and a positive subjective perception of the utility of the course for clinical practice. Of the total participants, 28 physicians (93.3%) thought that had they been exposed to this material sooner, they would have incorporated the techniques received in the workshop into their practices; 2 participants stated they would likely have done so. Half of the doctors (n = 15) believed that their clinical communication techniques were improved by participating in the workshop, and the remaining half thought that their abilities to communicate with cancer patients had improved.

CONCLUSIONS

This model is a feasible approach for oncologists and is easily applicable to various oncology settings. Further studies will demonstrate the effectiveness of this method for improving oncologists skills in recognizing emotional disorders in their patients with cancer.

Psychosocial morbidity and its correlates in cancer patients of the Mediterranean area: findings from the Southern European Psycho-Oncology Study

BACKGROUND

A few and partial data are available on psychosocial morbidity among cancer patients in Mediterranean countries. As a part of a more general investigation (Southern European Psycho-Oncology Study-SEPOS), the rate of psychosocial morbidity and its correlation with clinical and cultural variables were examined in cancer patients in Italy, Portugal and Spain.

METHODS

A convenience sample of cancer outpatients with good performance status and no cognitive impairment were approached. The Hospital Anxiety-Depression scale (HAD-S), the Mini-Mental Adjustment to Cancer scale (Mini-MAC), and the Cancer Worries Inventory (CWI) were used to measure psychological morbidity, coping strategies and concerns about illness.

RESULTS

Of 277 patients, 34% had pathological scores ("borderline cases" plus "true cases") on HAD-S Anxiety and 24.9% on HAD-S Depression. Total psychiatric "caseness" was 28.5% and 16.6%, according to different HAD cut-offs (14 and 19, respectively). Significant relationships of HAD-S Anxiety, HAD-S Depression, HAD-S Total score, with Mini-MAC Hopeless and Anxious Preoccupation, and CWI score were found. No differences emerged between countries on psychosocial morbidity, while some differences emerged between the countries on coping mechanisms. Furthermore, Fatalism, Avoidance and marginally Hopeless were higher compared to studies carried out in English-speaking countries.

LIMITATIONS

The relatively small sample size and the good performance status prevent us to generalize data on patients with different cancer sites and advanced phase of illness.

CONCLUSIONS

One-third of the patients presented anxiety and depressive morbidity, with significant differences in characteristics of coping in Mediterranean countries in comparison with English-speaking countries.

Psychosocial interventions for patients with advanced cancer - a systematic review of the literature

Advanced cancer is associated with emotional distress, especially depression and feelings of sadness. To date, it is unclear which is the most effective way to address these problems. This review focuses on the effects of psychosocial interventions on the quality of life (QoL) of patients with advanced cancer. It was hypothesised that patients will benefit from psychosocial interventions by improving QoL, especially in the domain of emotional functioning. The review was conducted using systematic review methodology involving a systematic search of the literature published between 1990 and 2002, quality assessment of included studies, systematic data extraction and narrative data synthesis. In all, 10 randomised controlled studies involving 13 trials were included. Overall interventions and outcome measures across studies were heterogeneous. Outcome measures, pertaining to the QoL dimension of emotional functioning, were most frequently measured. A total of 12 trials evaluating behaviour therapy found positive effects on one or more indicators of QoL, for example, depression. The results of the review support recommendation of behaviour therapy in the care of patients with advanced cancer.

Prospective assessment of emotional distress, cognitive function, and quality of life in patients with cancer treated with chemotherapy

BACKGROUND

The current study sought to delineate prospectively the rates and clinical course of emotional distress, cognitive impairment, and quality of life (QOL) in chemotherapy-naive patients with cancer and to consider the determinants of global QOL.

METHODS

Patients who consented to participate were administered the European Organization for Research and Treatment of Cancer QLQ-C30 questionnaire, the Mini-Mental State Examination (MMSE), and the Hospital Anxiety and Depression Scale before and at the end of treatment (EOT).

RESULTS

Of the 102 patients initially assessed, 80 (78.4%) completed the study. Most aspects of QOL did not change considerably over time. At EOT, patients reported only significant increases in fatigue and significant decreases in sleep disturbance. Although no significant changes emerged in the rates of anxiety or depression throughout chemotherapy, nearly one-third of the patients experienced severe emotional distress at both points in time. In addition, the authors observed neither significant alteration in the cognitive performance over time nor reliable associations between scores on the MMSE and subjective cognitive function, emotional distress, or QOL. Finally, depression proved to be the leading predictor of global QOL at baseline and at EOT.

CONCLUSIONS

The results indicated that a significant proportion of Greek patients with cancer experienced intense anxiety and depression throughout chemotherapy and confirmed the importance of depression as a strong predictor of global QOL. Routine screening of emotional distress across all phases of cancer is mandatory because it will contribute to the identification of patients who are in need of pharmaceutical and/or psychologic intervention.

Screening for depression in women with metastatic breast cancer: a comparison of the Beck Depression Inventory Short Form and the Hospital Anxiety and Depression Scale

OBJECTIVE

To compare two self-report questionnaires for identifying possible depression in women with metastatic breast cancer.

METHOD

We conducted structured psychiatric interviews and administered the Beck Depression Inventory Short Form (BDI-SF) and Hospital Anxiety and Depression Scale (HADS) to 227 women with stage IV breast cancer. The accuracy for identifying DSM-IV-defined major and minor depression was examined. Sensitivity, specificity, positive (PPV) and negative (NPV) predictive values were calculated and receiver operating characteristic curves plotted.

RESULTS

Seventy-four (32.6%) patients satisfied DSM-IV criteria for a depressive disorder. With a cut-off of 4, the BDI-SF had a sensitivity of 0.84, specificity of 0.63, and PPV of 0.52. A cut-off of 11 on the HADS-Depression scale (HADS-D) resulted in sensitivity, specificity, and PPV of 0.16, 0.97, and 0.75, respectively. For major depression alone, the BDI-SF with a cut-off of 5 had excellent sensitivity but poor PPV; the HADS, with a cut-off of 7, had weak sensitivity and PPV.

CONCLUSIONS

Overall, the two scales perform similarly in identifying major depression, while the BDI-SF is the more useful in screening for DSM-IV major or minor depression categories in this clinical group.

The value of the Hospital Anxiety and Depression Scale (HADS) for comparing women with early onset breast cancer with population-based reference women

BACKGROUND

The Hospital Anxiety and Depression Scale (HADS) is frequently used in cancer studies, yet its utility for comparing people with cancer with people in the community is uncertain.

METHODS

HADS scores were obtained from population-based samples of women with (n = 731) and without (n = 158) early-onset breast cancer. Psychometric properties were examined using differential item functioning (DIF) which is the presence of systematic group differences in certain response items independent of the trait being measured.

RESULTS

Women with breast cancer scored lower than reference women on anxiety (mean (SD) 7.5 (4.3) vs. 8.2 (4.0); p = 0.06) and depression (3.3 (3.2) vs. 4.2 (3.0); p = 0.003). Group differences remained following adjustment for demographics. Time since diagnosis was not related to anxiety or depression scores. DIF was present in two anxiety and five depression items. Adjustment for DIF did not substantially change the anxiety or depression group differences.

CONCLUSION

Specific sampling or DIF effects do not explain the observation that women with breast cancer have lower levels of anxiety and depression than population controls. The psychometric properties of the HADS appear to be acceptable in these groups.

Insulin and cancer

Obesity has recently been linked to mortality from the majority of cancers. The insulin/insulin-like growth factor (IGF) system may partly explain this effect. The metabolic syndrome, associated with hyperinsulinemia, may modulate this effect. Recent evidence supports the role of insulin and IGF-1 as important growth factors, acting through the tyrosine kinase growth factor cascade in enhancing tumor cell proliferation. In addition, the metabolic syndrome associated with a chronic inflammatory state and accompanying cytokine abnormalities may also contribute to tumor progression. Growing links between insulin and the etiology as well as prognosis in colon, prostate, pancreatic, and, particularly, breast cancer are reviewed. Of particular concern is the evidence that elevated IGF-1 may interfere with cancer therapy, adversely affecting prognosis. The role of insulin is of concern because of the increasing levels of obesity and the associated metabolic syndrome. Weight gain, through typical Western diet; limited levels of activity; and, more recently, stress-related changes in neuroendocrine function may lead to insulin resistance and hyperinsulinemia. The opportunity for a multidisciplinary approach involving nutrition, exercise, and stress reduction in an integrative setting may be crucial to limiting the insulin-resistant state and improving cancer outcomes.

Zur Bedeutung depressiver Störungen für die somatische Medizin/ The importance of depressive disorders in somatic medicine

Depressive disorders--including mild and subthreshold forms--are frequent in medical patients, although often not recognized. Over the past decades accumulating scientific evidence has demonstrated their clinical relevance. Depressive disorders and also elevated scores on self-rating scales for depressive symptoms are clearly related to disease behavior and quality of life. In many physical conditions they also predict adverse outcome, including premature death. This paper gives an overview of the literature on the relevance and treatment of comorbid depression in patients with HIV infection, cancer and coronary heart disease. It shows that the subjective effects of depression are rather similar in different somatic conditions. In addition, depression also interacts with the physical course of different diseases. However, the specific physiological mediators involved vary among different somatic diseases and have not yet been completely understood. Despite this uncertainty an improved recognition and treatment of comorbid depression can be recommended. Supportive interventions focussing on coping demands as well as regular psychotherapy and in some cases antidepressant medication may be indicated. While it still appears premature to establish generally applicable treatment guidelines, an individualized approach with regard to the different treatment alternatives for individual patients should be advocated.