Associations Between Breast Cancer Survivorship and Adverse Mental Health Outcomes

A Systematic Review

Helena Carreira; Rachael Williams; Martin Müller; Rhea Harewood; Susannah Stanway; Krishnan Bhaskaran


J Natl Cancer Inst. 2018;110(12):1311-1327. 

In This Article

Abstract and Introduction


Background: We aimed to systematically review the evidence on adverse mental health outcomes in breast cancer survivors (≥1 year) compared with women with no history of cancer.

Methods: Studies were identified by searching MEDLINE, PsycINFO, the Cumulative Index to Nursing and Allied Health Literature, and the Social Sciences Citation Index, and through backward citation tracking. Two researchers selected the studies, extracted data, and assessed the risk of bias.

Results: Sixty studies were included. Of 38 studies of depression, 33 observed more depression in breast cancer survivors; this was statistically significant in 19 studies overall, including six of seven where depression was ascertained clinically, three of four studies of antidepressants, and 13 of 31 that quantified depressive symptoms. Of 21 studies of anxiety, 17 observed more anxiety in breast cancer survivors, statistically significant in 11 studies overall, including two of four with clinical/prescription-based outcomes, and in eight of 17 of anxiety symptoms. Breast cancer survivors also had statistically significantly increased symptoms/frequency of neurocognitive dysfunction (18 of 24 studies), sexual dysfunctions (5 of 6 studies), sleep disturbance (5 of 5 studies), stress-related disorders/PTSD (2 of 3 studies), suicide (2 of 2 studies), somatisation (2 of 2 studies), and bipolar and obsessive-compulsive disorders (1 of 1 study each). Studies were heterogeneous in terms of participants' characteristics, time since diagnosis, ascertainment of outcomes, and measures reported. Approximately one-half of the studies were at high risk of selection bias and confounding by socio-economic status.

Conclusions: There is compelling evidence of an increased risk of anxiety, depression and suicide, and neurocognitive and sexual dysfunctions in breast cancer survivors compared with women with no prior cancer. This information can be used to support evidence-based prevention and management strategies. Further population-based and longitudinal research would help to better characterize these associations.


Women with a history of breast cancer are the largest group of cancer survivors in high-income countries.[1] In the United States alone, more than 2.9 million women were estimated in 2012 to be living with a previous diagnosis of breast cancer.[2] By 2022, this number is estimated to approach 4 million.[2] Similarly, in the United Kingdom, the number of women living beyond breast cancer is expected to surpass 1.5 million during the next 20 years.[3]

A diagnosis of breast cancer is often overwhelmingly distressing.[4] Women frequently experience some combination of anger, anxiety, despair, helplessness, fear of death, and suicidal thoughts.[5,6] Clinically relevant symptoms of anxiety and/or depression are common during the treatment period,[7,8] when acute treatment side effects may restrict daily activities.[9] High prevalence of depressive symptoms and anxiety have also been observed during survivorship,[10,11] with one study finding depressive symptoms persisting for at least two years after diagnosis in one in five women.[12] Other adverse mental health outcomes, such as sleep disturbance, have also been reported both during cancer treatment and afterwards.[13] A substantial proportion of the breast cancer survivors experience long-term iatrogenic effects of treatment, including fatigue, persistent pain, lymphedema, vasomotor symptoms, and infertility, all of which may negatively affect quality of life and mental health.[14] Other important psychological challenges in the long term can include difficulties in re-adapting to professional, social, and intimate relationships and coping with the uncertainty about the future.[15]

To our knowledge, no systematic review to date has summarized the evidence from studies comparing breast cancer survivors with a noncancer control group for a broad spectrum of adverse mental health outcomes. Therefore, the aim of this study was to identify and summarize the studies that have quantitatively compared mental health outcomes in breast cancer survivors (≥1 year) vs women who did not have cancer; we also assessed the quality of the evidence on this topic by applying objective quality assessment criteria.