Psychological Adjustment in Breast Cancer Survivors

Fig. 15.1

Trajectories of distress in the first year after breast cancer diagnosis (N = 171; Henselmans et al. 2010). Predicted (solid lines) and observed (dashed lines) levels of distress are displayed. “Case” indicates psychological morbidity (i.e., a score of 4 or greater on the General Health Questionnaire-12)

Another trajectory study that assessed 285 breast cancer patients in China from 5 days to 8 months after surgery also found four trajectories: 66 % reported low distress across the assessment period, 12 % reported elevated distress at 5 days and 1 month that resolved by 3 months after surgery (i.e., recovery pattern), 7 % showed increased distress that recovered by 8 months (delayed recovery), and 15 % experienced high distress across the assessment period (Lam et al. 2010). In a trajectory study with extended follow-up, which began shortly after initiation of chemotherapy and spanned more than 4 years after diagnosis (Helgeson et al. 2004), the largest proportion of the breast cancer patient sample reported quality of life matching or exceeding population norms on both mental (43 %) and physical (55 %) functioning across the 4 years, with other trajectories indicating either recovery or relatively poor and/or declining functioning.

Overall, this research highlights the psychological resilience of women with breast cancer and suggests that the largest proportion of breast cancer survivors can expect generally positive adjustment either from the point of diagnosis and treatment or after a period of recovery. However, heterogeneity is evident, and a notable proportion (approximately 15 %) appears at risk for distress and life disruption from the point of diagnosis onward for months or years (note that this group also likely includes women whose relatively poor psychological adjustment precedes the cancer diagnosis). It also is possible that the most distressed women are more likely to decline participation in research, leading to underestimates of prevalence of distress and life disruption. Furthermore, there is evidence that groups with particular characteristics, such as low-income and Latina women (e.g., Christie et al. 2010; Yanez et al. 2011), experience relatively high distress and low quality of life. Next, we address specific domains of adjustment, with a focus on depression and anxiety, as well as the factors that confer risk for or protection from negative outcomes.

Negative Psychological Outcomes and Their Contributors

Depression

A meta-analysis of 66 studies of interview-diagnosed major depression in cancer survivors in non-palliative care settings, including 24 studies of breast cancer patients alone, demonstrated a 16.3 % prevalence of major depression, with a similar 14.1 % prevalence in breast cancer patients specifically (Mitchell et al. 2011). These proportions contrast with general population norms of 12 % for women aged 40–59 years and 7 % for women 60 years and older (Pratt and Brody, 2014). The risk of depression appears to be most elevated in the first 1–2 years after diagnosis in cancer survivors generally (Krebber et al. 2014; Mitchell et al. 2013) and in breast cancer patients specifically (Avis et al. 2013). Depression contributes to decreases in quality of life and psychosocial and occupational functioning, interferes with treatment adherence, and has been associated with shorter recurrence-free survival (Satin et al. 2009).

Several risk factors for high depressive symptoms in breast cancer survivors have empirical support. Most of the evidence comes from cross-sectional rather than longitudinal studies, however, and reciprocal relationships or reverse causation is likely. Psychosocial factors appear to be the strongest predictors of elevated depressive symptoms, including prior history of depression, occurrence of other stressful life events, use of avoidant coping strategies, loneliness, low social support, and pessimism (Avis et al. 2013; Bardwell et al. 2006; Jaremka et al. 2013; Stanton and Snider 1993). Other risk factors include younger age, fewer financial resources, and presence of physical symptoms. Chemotherapy may be associated with elevated risk for depression (e.g., Torres et al. 2013), but other disease and treatment-related variables are typically not (Bardwell et al. 2006).

Anxiety and Fear of Breast Cancer Recurrence

The experience of breast cancer can trigger general feelings of anxiety, as well as more specific concerns about cancer recurrence. A meta-analysis found that the prevalence of interview-diagnosed anxiety disorders was 10.3 % among cancer patients in non-palliative care settings (Mitchell et al. 2011). This figure is comparable to the 13 % 6-month prevalence of anxiety disorders in the general population of women (Pigott 2003). Whereas depression tends to improve in the year or two after cancer diagnosis, anxiety is more likely to persist in the years after cancer treatment. A meta-analysis comparing depression and anxiety in long-term cancer survivors (i.e., those at least 2 years post-diagnosis) with healthy controls found an elevated prevalence of anxiety in survivors (17.9 %) vs. controls (13.9 %) but no differences in depression (Mitchell et al. 2013). Of note, this review included both interview-diagnosed anxiety and patient-reported scales, which often yield higher prevalence rates.

One of the factors that may maintain anxiety among breast cancer survivors is concern about cancer recurrence. Indeed, worry that breast cancer may return after treatment is among the most commonly experienced psychological sequelae (Koch et al. 2012). In a review in cancer survivors generally, Koch et al. (2012) found that most long-term survivors experience modest to moderate levels of fear of recurrence. Healthcare professionals find fear of recurrence challenging to manage (Thewes et al. 2013).

Fear of breast cancer recurrence can be amplified or reactivated by several triggers, such as follow-up medical visits, the experience of physical symptoms such as new or persistent pain or fatigue, and cancer diagnosis or death of a public figure, friend, or family member (Gil et al. 2004). Heightened fear of recurrence is reported by adult survivors of younger age, lower educational level, fewer significant others, and Hispanic or non-Hispanic white race/ethnicity (Crist and Grunfeld 2013; Phillips et al. 2013). Lower optimism and social support, more family stressors, depressive symptoms, pain, and other physical symptoms also are linked to higher fear (Crist and Grunfeld 2013; Phillips et al. 2013).

Cancer-related post-traumatic stress disorder (PTSD), as assessed via validated interview or questionnaire, typically is found to occur in less than 10 % of cancer survivors after treatment completion and to decline over time (e.g., Kangas et al. 2002). Women at most risk tend to be younger, have more serious disease and aggressive therapy, and be more likely to have experienced PTSD previously (e.g., O’Connor et al. 2011). Symptoms of subthreshold PTSD, however, such as intrusive thoughts and feelings, re-experiencing of cancer-related events, and avoidance of reminders of cancer, are common among survivors in the 2 years after diagnosis. For example, in a nationwide Danish cohort of women receiving surgery for breast cancer, 20.1 % and 14.3 % reported severe posttraumatic stress symptoms at 3 and 15 months after surgery, respectively (O’Connor et al. 2011). There is evidence that African American and Asian American women are more at risk for breast cancer-related post-traumatic stress symptoms than their non-Latina white counterparts (Vin-Raviv et al. 2013).

Positive Psychological Outcomes and Their Contributors

Along with the distress and life disruption attendant upon the experience of breast cancer, many women find benefit in their experience and maintain positive mood and quality of life. Indeed, we have found that more than 80 % of breast cancer survivors report at least one positive change or benefit related to their cancer experience (Sears et al. 2003). Primary self-reported benefits involve strengthened interpersonal relationships, life appreciation and commitment to priorities, spirituality, personal regard, and attention to health behaviors. These changes have also been described as “posttraumatic growth” (Tedeschi and Calhoun 1996). Reports of benefit finding increase from the diagnostic and treatment phase through re-entry and early breast cancer survivorship and level off at approximately 1 year after diagnosis (Danhauer et al. 2013; Manne et al. 2004). Long-term breast cancer survivors also report cancer-related benefits (Mols et al. 2005), although finding benefit may decrease in the long term (Bower et al. 2005).

Although findings are not completely consistent, longitudinal research suggests that greater impact of the breast cancer diagnosis, in the form of higher perceived threat and life disruption, promotes benefit finding. Greater intentional engagement in the cancer experience, as indicated by more problem-focused coping and intentional positive reappraisal, for example, also predicts benefit finding (Danhauer et al. 2013; Sears et al. 2003; Stanton et al. 2006). Younger women typically report higher levels of benefit finding than older women, and the correlates of benefit finding may differ depending on age. Specifically, negative impact seems to be more important for older women, whereas engagement may be more important for younger women in promoting benefit finding. Social support can also enhance the ability to find benefit in the experience of breast cancer (Danhauer et al. 2013; McDonough et al. 2014; Schroevers et al. 2010). Although finding benefit can be valuable in its own right, it also can contribute to improved psychological and health-related outcomes into longer-term survivorship, as demonstrated by longitudinal and experimental research (e.g., Bower et al. 2005; Carver and Antoni 2004; Stanton et al. 2002). Benefit finding has also been linked to neuroendocrine and immune function in women with breast cancer, including steeper diurnal cortisol slope (Diaz et al. 2014), reduced serum cortisol (Cruess et al. 2000), and increased lymphocyte proliferation (McGregor et al. 2004).

Directions for Psychosocial and Biobehavioral Intervention Research

Randomized, controlled trials (RCTs) of interventions to reduce psychological morbidities and enhance well-being in women with breast cancer have accumulated rapidly over the past two decades. See Table 15.1 for examples of the approaches to psychosocial intervention that have been most commonly used. Most of the research has focused on the diagnostic and treatment phase, although RCTs designed to promote adaptive survivorship into the re-entry phase and beyond are accruing (Stanton et al. 2015). Reviews and meta-analyses demonstrate that efficacious cognitive-behavioral and psychoeducational approaches exist for women diagnosed with breast cancer (Faller et al. 2013; Stanton 2012; Tatrow and Montgomery 2006) with regard to improving both psychological adjustment and symptoms specifically related to cancer treatments (e.g., menopausal symptoms; Mann et al. 2012). Of note, cancer survivors who are more distressed appear to get the most benefit from these interventions (Faller et al. 2013), suggesting that treatments should be targeted to those who are experiencing difficulties with adjustment.

Table 15.1

Psychosocial interventions for women diagnosed with breast cancer: major approaches, goals, and mediators of effects

Major intervention approaches	Primary intervention goals
Cognitive-behavioral therapy	Identify and challenge unhelpful cognitions and behaviors
Coping skills training	Teach and practice contextually adaptive coping strategies; Promote helpful thoughts and behaviors
Psychoeducation	Provide information about cancer and strategies for adjustment
Supportive-expressive therapy	Express feelings and thoughts in a group supportive context
Problem-solving therapy	Train in constructive set toward problems and problem-solving
Mindfulness-based stress reduction	Cultivate non-judgmental awareness of present experiences
Relaxation training	Teach relaxation skills (e.g., progressive muscle relaxation)
Couples therapy	Enhance disclosure, intimacy, and couple-focused coping skills
Evidence-based classes of mediators of interventions’ effects
Altered cognitions (e.g., expectancies, illness representations)
Improved self-efficacy for using coping strategies and skills targeted by the intervention
Improved cancer-related psychological and physical symptoms (e.g., mood disturbance, pain)
Bolstered psychosocial resources (e.g., self-esteem)

Note Table content on mediators was based on a review of mediators of 16 psychosocial interventions for cancer survivors that included examination of mediators of the intervention’s effects (Stanton et al. 2013)

Recent research also documents the efficacy of mind-body and other approaches for improving psychological adjustment. For example, RCTs demonstrate the benefits of yoga on depression and anxiety in breast cancer patients, at least over the short-term and for women in active cancer treatment (Cramer et al. 2012). Furthermore, mindfulness-based stress reduction is promising in its effects on depression and anxiety in survivors of breast cancer (Zainal et al. 2013a. Mindfulness-based interventions have also been shown to reduce fear of recurrence (Lengacher et al. 2009) and improve positive psychological outcomes in breast cancer survivors, including peace and meaning in life (Bower et al. 2014). Physical activity also can enhance quality of life and reduce breast cancer concerns in women with breast cancer (Speck et al. 2010; Vallance et al. 2007).

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