Breast Cancer Triggers PTSD Symptoms in 80% of Women

'They either adjust or go into despair'

Megan Brooks

March 08, 2016

Hearing the words "you have breast cancer" triggers symptoms of post-traumatic stress disorder (PTSD) in the vast majority of women and these symptoms often linger, according to a study from Germany of 166 women with early-stage disease.

"Clinicians should be aware that most patients with breast cancer suffer from PTSD symptoms in the first year after diagnosis," Kerstin Hermelink, PhD, study author and senior psychologist, Breast Center, Department of Gynecology and Obstetrics, Ludwig Maximilian University of Munich, Germany, told Medscape Medical News.

Full diagnoses of stress disorder according to the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) (DSM-IV) related to breast cancer (BC) were rare, occurring in just six women (3.6%) before treatment and three (2.0%) 1 year later.

However, PTSD symptoms were common: 82.5% of women initially showed BC-related PTSD symptoms before treatment that had not resolved in 57.3% a year later (P < .001).

The researchers also assessed 60 control women who had routine breast imaging with a negative result and found that none had a stress disorder and 18% had PTSD symptoms (< 1 on average).

The study appeared online February 22 in Psycho-Oncology. "Sufficient low-threshold psychological support should therefore be available for women with breast cancer, and providers of support should not only expect to find depressive symptoms, but also PTSD symptoms in cancer patients," Dr Hermelink said by email.

Generally, PTSD occurs after exposure to extremely stressful events and is characterized bysymptoms of intrusion (eg, flashbacks), avoidance (eg, efforts to avoid memories), emotional numbing, and hyperarousal.

"I don't think that screening for PTSD symptoms in particular is advantageous and feasible, but all cancer patients should of course be screened for distress with a validated tool, for instance the National Comprehensive Cancer Network Distress Thermometer," she advised.

Alyson Moadel-Robblee, PhD, director, Psychosocial Oncology, Montefiore Einstein Center for Cancer Care, Bronx, New York, agrees. "Assessing psychological health of cancer patients is important and we do it," she noted in an interview with Medscape Medical News.

"The Commission on Cancer now requires that cancer centers assess distress regularly in cancer patients — at diagnosis and at key transitional points in care — so we have to assess it if we are going to be accredited and viewed as a high-level cancer center," she said.

Dr Moadel-Robblee said she has seen PTSD symptoms related to breast cancer diagnosis ease as time goes by.

They either adjust or go into despair.

"What happens is people acclimate. At first, they might feel that this is just not part of their identity. They go from the world of the healthy to the world of a cancer patient and that is clearly traumatic to their identity," she explained, "but after a while, they either adjust or go into despair and most people adjust, re-create their identity and include cancer as part of it but it takes time. By the end of a year, most people say, 'I'm strong, I've gotten through this and I'm not alone.'"

Full-Blown PTSD Rare

Dr Hermelink and colleagues assessed the prevalence and course of clinically assessed post-traumatic stress in the study participants, who were all aged 65 years or younger with newly diagnosed early breast cancer (stage 0-III).

They assessed the women before and after treatment and 1 year after diagnosis using the Structured Clinical Interview for DSM-IV modules for acute stress disorder (ASD) and PTSD.

The average number of BC-related PTSD symptoms diminished from three symptoms before treatment to fewer than two symptoms 1 year later (P < .001). Having a university education didn't prevent the development of BC-related stress disorder, but is "apparently associated with resources that promote successful coping and recovery," the researchers say. Chemotherapy and mastectomy didn't contribute to PTSD symptoms, although that could be due to a lack of statistical power, they note.

"The findings indicate that against the backdrop of low base rates of PTSD diagnosis and PTSD symptoms in the female population in Germany, having non-metastatic breast cancer substantially increases the load of posttraumatic stress," Dr Hermelink and colleagues conclude in their article.

A limitation of the study is the exclusion of women with substance abuse and history of psychosis or neurologic disease, who may be at especially high risk for post-traumatic stress, meaning that PTSD and ASD cases and PTSD symptoms may have been somewhat underestimated, they say.

Strengths of the study include the prospective longitudinal design with repeated assessment using a validated clinical interview, baseline assessment prior to the start of any treatment for breast cancer, a large sample, a well-matched control group, and low attrition.

"The research team did a really good job of evaluating posttraumatic stress," Dr Moadel-Robblee told Medscape Medical News, and the findings align with her observations in practice.

"You aren't going to see a lot of full-blown PTSD but you are going to see a lot of symptoms and that's been my experience with patients and with what's in the literature. Reliving what you've been through, having intrusive thoughts about it is very common," she said.

The study was supported by Deutsche Krebshilfe e.V. The authors and Dr Moadel-Robblee have disclosed no relevant financial relationships.

Psycho-Oncology. Published online February 22, 2016. Absract


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