Meeting Psychosocial Needs of Women with Breast Cancer (2004) / Chapter Skim
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3 Psychosocial Needs of Women with Breast Cancer
3 Psychosocial Needs of Women with Breast Cancer
Pages 21-69
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From page 21... ...
Psychosocial distress can be relatecT to physical problems like illness or cTisability, psychological problems, ancT family issues ancT social concerns such as those relatecT to employment, insurance, ancT supportive care access. The frequency ancT patterns of psychosocial distress that occur among women with breast cancer clepencT greatly on which concerns are incluclecT in the operational definition of distress ancT how it is measured.
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From page 22... ...
The chapter concludes with a discussion of risk factors associated with psychosocial distress ancI methods that are available to identify women who are clistressecI ancI who may benefit from intervention. PSYCHOSOCIAL NEEDS OF WOMEN BY PHASE OF CARE Some of the most common psychosocial concerns reported by women with breast cancer include: · Fear of recurrence, .
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From page 23... ...
What follows is a review of the distinctive psychosocial neecis associated with diagnosis, primary treatment, the special issues relatecI to non-invasive breast cancer, completing treatment anti re-entry to usual living, survivorship, recurrence, anti palliation for acivancecI cancer. Oncology anti primary care practitioners must be prepared for the range of psychosocial issues that may arise among their patients who are at various points along the breast cancer treatment continuum.
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From page 24... ...
. The meclical care team often sees the complexities of decision making around breast cancer treatments as being routine, but for the woman, the presentation of treatment options (e.g., mastectomy versus lumpectomy; acljuvant chemotherapy or not)
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Finally, the waiting room of the radiation therapy department is sometimes distressing to breast cancer patients, especially when they see patients who are much sicker ancI are receiving palliative therapy for acivancecI cancer. Nursing ancI physician staff shouicI acknowlecige these issues ancI clirectly aciciress them when breast cancer patients report their concerns about their own health ancI mortality.
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From page 26... ...
Many of these problems are common in breast cancer survivors anti are not specifically relatecI to the cirug tamoxifen (Day et al., 2001, 1999; FallowfielcI et al., 20011. In aciclition, studies with aromatase inhibitors in acivancecI or acljuvant settings (or even for prevention)
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From page 27... ...
This combination of breast cancer risk status and menopausal symptoms can affect quality of life for this unique group of breast cancer patients. Genetic Risk ant!
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From page 28... ...
HollancI, personal communication, September 18, 20031. Post Treatment At the encI of primary breast cancer treatment whether it is at the conclusion of 6 weeks of radiation therapy or after 4-6 months of acljuvant chemotherapy most women experience a mixture of elation, fear, ancI uncertainty Reviewed in RowlancI ancI Massie, 19981.
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The post-treatment transitional period is a time of consiclerable psychosocial distress. The paracloxical increase in anxiety has been observed at the encI of both radiation anti systemic chemotherapy (HollancI anti RowlancI, 19911.
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From page 30... ...
In contrast, recurrence of breast cancer is experiencecI as a failure by both the patient anti her treatment team. One recent stucly of 378 long-term breast cancer survivors showed that many women attribute their disease to stress (42 percent)
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From page 31... ...
Other predictors of distress were younger age, fewer social supports, and lower socioeconomic level. Estimates of the prevalence of psychosocial distress among women with breast cancer depend on how distress is defined and measured.
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From page 32... ...
Many of the prevalence studies of cancer-relatecI psychosocial distress have been concluctecI among women recruited from cancer centers or major universities, though a minority of cancer patients receive their care in such settings. A multi-center stucly publishecI in 1987 by Bloom ancI colleagues focused on the psychosocial distress of women in the year following breast cancer diagnosis.
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From page 33... ...
found that women who were depressed prior to breast cancer were clepressecI in the period following diagnosis. Many studies assess psychosocial distress within a group of cancer patients without examining a control or comparison group.
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As part of their study, 215 cancer patients, ranclomly selectecI from new acImissions to three collaborating cancer centers, were evaluatecI by psychiatrists anti psychologists using a formal psychiatric interview along with
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From page 35... ...
. This may reflect differences in interview technique, interpretation of diagnostic 4A reference work developed by the American Psychiatric Association and designed to provide guidelines for the diagnosis and classification of mental disorders.
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From page 36... ...
A recent report from the Agency for Healthcare Research ancI Quality (AHRQj, "Management of Cancer Symptoms: Pain, Depression, ancI Fatigue," concluclecI that major depression ancI depressive symptoms occur frequently in cancer patients. According to their review of the literature, prevalence rates varied from 10 to 25 percent for major depressive clisorclers, a rate at least four times higher than in the general population (Agency for Healthcare Research ancI Quality, 20021.
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From page 37... ...
Other concerns range from cancer-specific concerns, such as fear of recurrence, to more generalizecI symptoms of worry, fear of the future, fear of cleath, trouble sleeping, fatigue, ancI trouble concentrating. The term "psychosocial distress" has been coined to reflect this broacler set of concerns (National Comprehensive Cancer Network, 19991.
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From page 38... ...
Problem List from the National Comprehensive Cancer Network Guiclelines for Management of Psychosocial Distress 4. European Organization for Research anc!
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From page 39... ...
Hospital Anxiety and Depression Scale (HA DSJ One of the most wiclely used instruments to screen for depression, anxiety, or psychosocial distress in cancer patients, especially in Europe, is the Hospital Anxiety anti Depression Scale or HAD S (BjellancI et al., 2002; Herrmann, 1997; ZigmoncI anti Snaith, 19831.
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From page 40... ...
is the proportion of people without the condition who test negative. A related measure, the positive predictive value, is the portion of individuals with a positive screening test who actually have the condition.
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From page 41... ...
PSYCHOSOCIAL NEEDS OF WOMEN WITH BREAST CANCER Vleld The yield of a screening test depends on the sensitivity of the test and the prevalence of unrecognized diseases When there are many undiagnosed cases id a population, the yield of a screening test will be high SOURCE Mausner et al.,1985. 41 Box 3-3 Items Assessed on the Hospital Anxiety and Depression Scale (HADS)
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From page 43... ...
In one recent Danish study, for example, the prevalence of anxiety ancI depression as measured by HAD S was similar among 538 newly cliagnosecI breast cancer patients at low risk of recurrence ancI 872 women ranclomly selectecI from the general population (GroenvoicI et al., 19991. The investigators suggest that the HAD S may not be suitable for use in the general population, thereby calling into question the valiclity of their comparisons.
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From page 44... ...
Investigators in the United I(ingclom have valiciatecI automated screening for psychological distress among hospitalizecI cancer patients (the stucly was not limitecI to women with breast cancer)
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From page 45... ...
6 The SF-36 has been wiclely used to assess populations with chronic illness (Stewart et al., 1989; Wells et al., 1989) , inclucling women with breast cancer ancI breast cancer survivors (Frost et al., 2000; Ganz et al., 1996; Ganz et al., 1998a)
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From page 46... ...
~ 70a) 60 50 r1 UCLA-GO sample SF-36 norms / PF RF-P Pain SF MH RF-E E/F GHP RAND SF-36 Subscales FIGURE 3-2 Breast cancer survivors compared to healthy controls.
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From page 47... ...
, ancT not for clinical use for incTiviclual patients. Investigators in the United I(ingclom tested the use of a computer touchscreen for use in routine oncology practice ancT founcT a combination of responses to the MHI-5 ancT HAD S performed best in identifying patients who hacT been cTiagnosecT through psychiatric interviews as being in neecT of clinical intervention (Cull et al., 2001; Velikova et al., 19991.
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From page 48... ...
48 MEETING PSYCHOSOCIAL NEEDS OF WOMEN WITH BREAST CANCER BOX 3-4 Mental Health Items from the SF-36 During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of any emotional problems (such as feeling depressed or anxious)
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From page 49... ...
. Using the BSI, psychosocial distress was iclentifiecI in 35 percent of cancer patients (n = 4,496)
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From page 50... ...
shouicI be used in clinical practice, ancI efficiently facilitatecI the assessment of these problems for the nurse's clinical intervention. Patients complete the CARES by rating problem statements on a 5-point scale ranging from O "Not at all" to 4 "Applies very much" cluring the last month.
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From page 51... ...
The CARES Global Score ancI Summary Scales have also been shown to be responsive to change over time in patients with breast cancer (Ganz et al., 1992b, 1992) , ancI in one stucly the CARES Psychosocial Summary Score aciministerecI shortly after diagnosis of breast cancer was helpful in classifying women at subsequent risk for psychosocial distress in the year after breast cancer (Ganz et al., 19931.
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. BasecT on a stucly in prostate cancer patients (Roth et al., 1998)
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From page 53... ...
Specifically, one wouicT neecT evaluation of its sensitivity ancT specificity in breast cancer patients at several points along the disease continuum. Figure 3-7 shows the NCCN recommenclecT use of the brief screening too!
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From page 54... ...
The QLQ-30 has been used in evaluations of psychosocial interventions for women with breast cancer, ancI a breast cancer-specific qualityof-life questionnaire moclule has been clevelopecI, the QLQ-BR23, which consists of 23 items covering symptoms ancI sicle effects relatecI to different treatment mocialities, body image, sexuality, anti future perspective (Curran et al., 1998; McLachian et al., 1998; Sprangers et al., 19961. The significance of changes in quality-of-life scores was assessed by comparing the extent of change in EORTC scores over time as patients perceived changes in their physical, emotional, ancI social functioning ancI overall quality of life.
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From page 55... ...
Quality of Life Breast Cancer Instrument The Quality of Life Breast Cancer Instrument inclucles 46-items representing four areas of well-being (physical, psychological, social, ancI spiritual)
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From page 56... ...
Aches or pain 4 Sleep changes 5. Weight gain 6 Vaginal d~ness/menopausal symptoms 7.
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From page 57... ...
F\YCHO\OLfiL >~ED! 0F ~0~ ~ BRE~T L~R i7 2~1 How #uch ~nxicly do y^4 h~vc?
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From page 58... ...
Survivors of cancer with other chronic conditions were 6 times more likely to have psychological problems (Hewitt et al., 20031. RISK FACTORS ASSOCIATED WITH PSYCHOSOCIAL DISTRESS A number of risk factors have been iclentifiecI that are associated with psychosocial distress among women with breast cancer: younger age, a history of pre-existing depression or psychological distress, other serious comorbicI conditions, anti inadequate social support (Bloom et al., 1987; Ganz et al., 1993, 1992a; lemal et al., 2002; Leec~ham anti Ganz, 1999; Maunsell et al.,
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From page 59... ...
What makes each of these patient characteristics a risk factor for psychosocial distress after breast cancer? Younger Age Most breast cancer occurs in women oicler than 50 years (about 75 percent of cases)
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From page 60... ...
In a prospective stucly of newly cliagnosecI breast cancer patients, Maunsell ancI colleagues found that a history of depression ancI serious life events in the five years preceding the cancer diagnosis were both predictive of higher levels of distress after breast cancer (Maunsell et al., 19921. It is not surprising that the stress associated with a new cancer diagnosis ancI its treatment wouicI exacerbate preexisting depression or psychological clistress.
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From page 61... ...
SUMMARY "Psychosocial distress varies along a continuum from the "normal" reactions to the stress of coping with cancer ancI its treatment, to symptoms so intense that the person experiencing them meets the criteria for a psychiatric clisorcler, a severe social or family problem, or significant spiritual distress" (National Comprehensive Cancer Network, 1999: 1131. Most of the United States studies upon which available estimates of psychosocial distress are basecI have been concluctecI within research-orientecI cancer centers anti have focused on psychosocial distress or psychiatric illness within the first few years of treatment.
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From page 62... ...
Factors that appear to predispose women for psychosocial distress inclucle younger age, a history of pre-existing depression or psychological distress, other serious comorbicI conditions, anti inadequate social support. REFERENCES Aaronson NK, Ahmedzai S,13ergman 13,13ullinger M, Cull A, Duez NJ, Filiberti A, Flechtner H
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From page 63... ...
2000. Cognitive function in breast cancer patients receiving adjuvant chemotherapy.J Clin Oncol 18(14)
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From page 64... ...
1983. The prevalence of psychiatric disorders among cancer patients.
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From page 65... ...
1999. Measurement of depressive symptoms in cancer patients: Evaluation of the Center for Epidemiological Studies Depression Scale (CES-D)
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From page 66... ...
1985. Absence of major depressive disorder in female cancer patients.
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From page 67... ...
1999. NCCN practice guidelines for the management of psychosocial distress.
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From page 68... ...
1993. Characteristics of women at risk for psychosocial distress in the year after breast cancer.J Clin Oncol 11(4)
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From page 69... ...
2000. Measuring quality of life of Chinese cancer patients: A validation of the Chinese version of the Functional Assessment of Cancer Therapy-General (FACT-G)
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