Globally, breast cancer is the most frequently diagnosed cancer; the lifetime incidence among women is 12%. It represents the leading cause of cancer death among women worldwide.1 To support patients with breast cancer, it is important to understand the trajectory and practical logistics of breast cancer treatment. Psychiatrists should also be aware of possible medication interactions, psychiatric or neurologic adverse effects of treatment, and signs of disease progression—issues that are the focus of this article.
Overview of breast cancer treatments
The vast majority of patients (95%) with newly diagnosed breast cancer have no evidence of metastatic disease. For these patients, the treatment approach depends on the stage at presentation. In general, patients with early-stage breast cancer undergo primary surgery (lumpectomy or mastectomy) to the breast and regional nodes with or without radiation therapy (RT). Following definitive local treatment, adjuvant chemotherapy may be offered based on primary tumor characteristics, such as tumor size, grade, number of involved lymph nodes, the status of estrogen and progesterone receptors, and expression of human epidermal growth factor receptor 2. Chemotherapy may last up to 3 months, and radiation therapy generally occurs 5 days a week for 3 to 6 weeks. There are sometimes variations on these treatment schedules (such as several months of neoadjuvant chemotherapy), particularly in the context of clinical trials.
Patients with estrogen-positive breast cancer will subsequently receive endocrine therapy—tamoxifen, ovarian suppression, and/or aromatase inhibitors, depending on menopausal status—to reduce the risk of breast cancer recurrence and mortality. The recommended duration of adjuvant endocrine therapy was recently extended from 5 to 10 years, and the role of ovarian suppression has also expanded in high-risk premenopausal women. Both changes have resulted in a higher proportion of women with secondary infertility and ongoing exposure to hormonal treatments, all of which may erode quality of life and increase the risk of anxiety and mood disturbance.
Pretreatment consultation regarding fertility preservation options reduces long-term regret and dissatisfaction concerning fertility, independent of age or previous parity.2 The American Society of Clinical Oncology recommends routinely offering such consultations to all premenopausal women with breast cancer, particularly those who undergo chemotherapy, given its adverse impact on ovarian reserve.
Adverse prognostic factors in breast cancer are shown in Tables 1 and 2. Patients with hormone-receptor–negative cancers tend to experience the majority of recurrences within the first 3 to 5 years after completing treatment, while those with estrogen/progesterone positivity remain at a low risk of recurrence (2% per year) indefinitely. In addition, human epidermal growth factor receptor 2–positive tumors are relatively more trophic to the brain than other types of breast cancer. Among patients with stage IV (metastatic) breast cancer, those with bone-only disease may experience prolonged survival, sometimes on the order of many years.
Psychiatric syndromes in breast cancer patients
Adjustment, depressive, and anxiety disorders are the most common forms of neuropsychiatric illness in patients with breast cancer (Box). Risk factors include younger age, receipt of chemotherapy, hormonal disruption (amenorrhea/hot flashes), and marital discord. Symptoms appear to be most prominent at specific points in the course of the illness:
• At diagnosis
• At completion of active treatment, when patients are confronted with existential angst and fears of recurrence in the setting of less active follow-up with medical providers
• At diagnosis of recurrence or metastasis
In patients with breast cancer, there is a nonlinear decline in the point prevalence of depression and anxiety in the years following diagnosis (50% in the first year; 25% in years 2 to 4; 15% in year 5), with an increase to 45% within 3 months of diagnosis of a recurrence.3 Thus, it is appropriate to reassure patients that their symptoms are likely to improve as they progress through survivorship. Although up to 80% of patients experience some PTSD symptoms related to breast cancer in the year after diagnosis, rates of acute stress disorder and PTSD after breast cancer are similar to those of the general population (2% to 4%).4
Delirium, brain metastases, and leptomeningeal disease with neuropsychiatric symptoms can also occur in this population. These conditions are more often seen in patients with stage IV breast cancer, although patients with aggressive triple-negative or human epidermal growth factor receptor 2–positive tumors are also at elevated risk. Psychiatrists who are caring for a patient with high-risk breast cancer should watch for potential symptoms of CNS disease, such as headaches, vision changes/diplopia, cognitive or personality changes, and gait dysfunction.
Dr. Meyer is Staff Psychiatrist at the Dana-Farber Cancer Institute and Brigham and Women’s Hospital and is Assistant Professor of Psychiatry, Harvard Medical School, Boston, MA. Dr. Lynn is Staff Psychiatrist and Assistant Professor in the department of psychiatry at the University of Texas (UT) MD Anderson Cancer Center and Adjunct Assistant Professor at Baylor College of Medicine and McGovern Medical School at UT Health Science Center of Houston. The authors report no conflicts of interest concerning the subject matter of this article.
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