Breast Cancer: What Psychiatrists Need to Know

Although modern breast cancer treatments have led to improved patient outcomes, they are also associated with substantial adverse effects.¹ Chemotherapy with alkylating agents can cause alopecia, ovarian failure, premature menopause, and weight gain. Taxanes (eg, paclitaxel(Drug information on paclitaxel), docetaxel) can cause painful and disabling peripheral neuropathy. Antiestrogen therapy, including treatment with agents such as tamoxifen, raloxifene, anastrozole(Drug information on anastrozole), and exemestane(Drug information on exemestane), is administered for several years and can cause insomnia, hot flashes, irritability, and depression in some women.^12,13 At the end of active treatment, psychological distress is common. Patients are often frightened and vulnerable and feel less protected when they are not seen frequently and regularly by their oncologist.¹⁴

As psychiatrists, certain aspects of this discussion immediately draw our attention. We anticipate that patients will experience anxiety about genetic testing or about being in a family whose members have the BRCA1 or BRCA2 gene. Post-traumatic issues may accompany the diagnosis, the mastectomy, or chemotherapy. Anxiety and depression may occur if metastatic disease develops, especially in the liver or brain. Space does not allow for a comprehensive review, but we can outline some of the major issues pertaining to breast cancer treatment and psychiatric symptoms and disorders.

The percentage of women receiving adjuvant chemotherapy for breast cancer could be greater than 80% depending on age, stage, and receptor and node status.¹⁵ Depression is commonly diagnosed after treatment of breast cancer, with reported rates ranging from 3% to 55%.¹⁶

Postchemotherapy cognitive disorders include disturbances of consciousness, executive functioning, aphasia, apraxia, and agnosia.¹⁶ About 20% to 38% of women who receive a diagnosis of breast cancer experience high levels of psychological distress during the first year after diagnosis.^17-19 For some patients, high levels of intrusive thoughts and avoidance may persist for years after the initial diagnosis.²⁰

Prevalence rates of depression in women with breast cancer range from 1.5% to 46%.²¹ Depression rates reflect many factors, including:

• Tumor stage and size.
• Patient age.
• Availability of social support.
• Type of insurance.
• Socioeconomic status.
• Type of surgery (lumpectomy, partial mastectomy, or mastectomy).
• Opportunities for the patient to make choices and participate in treatment.
• Type of therapy (radiation, chemotherapy).
• Whether the study was short-term or long-term.
• Whether the patient has a history of depression.

The treatments and/or the cancer itself have an impact on anxiety, sexual satisfaction, sleep, quality of life, self image, and body image. Some patients feel traumatized and mutilated and may regret having certain types of surgery, especially prophylactic bilateral mastectomies. The psychological impact of breast cancer also affects spouses, partners, children, and parents of women with breast cancer.

The good news is that in addition to the most widely prescribed anticancer drug in the world, tamoxifen(Drug information on tamoxifen), newer agents, such as aromatase inhibitors, are demonstrating important benefits in large randomized trials. A better understanding of the role of biologic markers, such as HER2, is giving women and their physicians the opportunity to see sooner whether chemotherapy is helpful.

The psychiatrist can be a key member of the treatment team at almost every stage—from the time a woman goes for a screening mammogram to the time of diagnosis, treatment, surveillance, survivorship, recurrence, and palliation. Important psychiatric issues may arise at each point.