Breast cancer is a complex, heterogeneous disease. You should not extrapolate from one patient to another, especially if you do not have large numbers of women with breast cancer in your care. It is important to focus on the specific patient's age, stage, and type of breast cancer (ductal, lobular, etc) and the recommendations of her oncologist. The patient often has difficult choices and decisions to make.
As psychiatrists, our role is to treat the patient for underlying anxiety, depression, adjustment issues, obsessions, and other problems so that she can make the best possible decisions. Although we are not oncologists, we need to have a good understanding of the treatments available to our patients, as well as the possible adverse reactions to and implications of these treatments. For example, a patient for whom a mastectomy is recommended in preference to a lumpectomy might have to decide between immediate and delayed reconstructive surgery. Consider the case of a woman with a significant family history of breast, ovarian, and colon cancer who has just received a diagnosis of breast cancer requiring a mastectomy. As a prophylactic measure, she might think about having her other breast removed along with both ovaries. Her psychiatrist might be interested in helping her think through the implications for her body image, sexuality, having 1 versus 2 mastectomies, the recovery period, and related issues. Depending on the woman's age, partner status, and childbearing status, couples therapy might also be indicated. Referral to a fertility clinic or information about egg banking may also be helpful to the couple.
It is very important for the psychiatrist to share the psychiatric evaluation with the oncology team and to receive copies of ongoing treatment notes from the medical team. Most oncologists are good at dictating their follow-up and interval notes to all physician members of the team, because it is so important for information to be current and usable by all members of the team. The psychiatrist must be sure to be part of this team and to receive these notes. While it might be inappropriate for the psychiatrist to reveal the specifics of psychotherapy sessions to other members of the team, it is important for other treating physicians to know about any psychotropic medications prescribed; significant issues that might affect the oncologic treatment; and other issues specific to that patient.
Breast cancer is so prevalent that psychiatrists should reflect on the countertransference and transference issues that occur during treatment. Many of us have our own family or friends who have suffered with breast cancer. We need to be aware of these factors and our feelings about them as we try to help our patients. Further, patients often idealize or devalue certain members of their oncology teams, especially if the diagnosis was delayed or if a misdiagnosis occurred. We are sometimes presented with patients who are involved in malpractice litigation. We need to help the patient manage these difficult tasks and feelings while simultaneously attending to ongoing oncologic treatment.
The long-term risk of the onset of depressive symptoms after a medical diagnosis is becoming clear.22 Subjects in the Health and Retirement Study, which included 8387 adults aged 51 to 62 years, had no significant depressive symptoms at baseline in 1992. They were monitored from 1994 to 2000. Patients who received a cancer diagnosis during follow-up had the highest risk of depressive symptoms, followed by patients with chronic lung disease and heart disease. Screening for depression in patients with cancer is a high priority for clinical care and research for psychiatrists.23
Practicing oncologists often complain about the difficulty of making a referral to a psychiatrist. Because of the complexity of psychiatric insurance, it is often very hard to make a referral while a patient is in an oncologist's office. If psychiatrists could develop better and easier ways for other physicians to make referrals, such as accepting fax referrals and improving callback times, the overall system of care might improve and patients would see psychiatrists sooner.
While breast cancer screening by mammography has been shown to reduce breast cancer mortality,24 mammographic screening has potentially adverse psychological effects. Possible problems include induced anxiety, worry or concern about getting breast cancer, transient anxiety experienced while undergoing an unfamiliar medical procedure, and severe anxiety symptomatic of psychiatric morbidity.25
Women with a family history of breast cancer are at increased risk for the disease26 and have high levels of cancer-specific anxiety.27,28 As a result, the psychiatrist must obtain a good medical and family history to ascertain how important this type of anxiety is for the patient and how best to manage it, whether by medication, psychotherapy, or education.