Breast Cancer: What Psychiatrists Need to Know

“One of my patients was recently listening to a television program on breast cancer. The oncologist on the program noted that this was the best time in history to have breast cancer because of the exciting new treatments, imaging techniques, improvement in survival rates, and the appreciation that breast cancer is probably a heterogeneous disease. My patient said this is all great news—but would this help her live to see her children graduate from elementary school?”

Many of our female patients are more worried about getting breast cancer than having cardiovascular disease. Breast cancer is so common that almost everyone reading this article will eventually know someone with this disease, whether it is a family member, close friend, colleague, or neighbor. It may even strike one of us. For a session at the upcoming American Psychiatric Association annual meeting in Toronto, we asked some of our colleagues to talk about their own experiences with cancer. Three of the panel members have themselves survived breast cancer.

Why are we so terrified of breast cancer? The disease interweaves complicated emotional, physical, genetic, and cosmetic factors. As practicing psychiatrists, it is almost certain that we will, at some point, care for patients who are receiving treatment for, or who have a history of, breast cancer. In this article, we review some of the major issues for psychiatrists to consider. Men, of course, may also get breast cancer, but in much smaller numbers. Consequently, we will focus solely on breast cancer in women.

Breast cancer is the most commonly diagnosed cancer in women and accounts for approximately 15% of all cancer deaths in the United States.¹ In 2005 alone, an estimated 211,000 women received a diagnosis of breast cancer² and an estimated 40,000 died of the disease.³ Let's look at several aspects of breast cancer and its treatment. An estimated 5% to 10 % of women with breast cancer have an inherited mutation in a cancer susceptibility gene.⁴ Mutations in the BRCA1 and BRCA2 genes account for most of these cases.⁵ As a result, women who know they carry these mutations probably understand that their lifetime risk of breast cancer is as high as 85%.^6,7

In certain families, multiple female relatives receive a diagnosis of breast cancer, sometimes at an early age, despite the absence of mutations in the BRCA1 and BRCA2 genes. These malignancies appear to be more genetically heterogeneous than those associated with the BRCA1 and BRCA2 genes.^5,8

Depending on a patient's particular circumstances, breast cancer treatment may include surgery, radiotherapy, chemotherapy, or hormonal therapy. These treatment modalities have improved outcomes in patients with breast cancer. When breast cancer metastasizes, however, survival is limited.⁹ More than half of women with metastatic breast cancer, for example, have hepatic involvement, which makes treatment even more difficult.¹⁰ And while sentinel-node mapping helps reduce the risk of unsightly or disabling lymphedema, it does not eliminate this condition.

Important new findings about the epidermal growth factor receptor HER2, which plays a crucial role in the regulation of cell proliferation and survival, are changing breast cancer treatment. Overexpression of HER2 correlates strongly with poorer prognosis in breast cancer. Use of anti-HER2 agents, such as trastuzumab(Drug information on trastuzumab), or combining HER2 blockers with other agents may overcome the tumor's compensatory or resistance mechanisms, thereby increasing the efficacy of anti-HER2 therapies. The bottom line is that oncologists can correlate HER2 findings with tumor resistance to chemotherapy and make better predictions. This helps tailor therapies and treatment for individual patients.¹¹