A breast cancer diagnosis can be a life-altering experience, often leading to significant mental and emotional health challenges. Individuals may experience a range of emotions, from shock and disbelief to fear, sadness, and anxiety. The uncertainty surrounding treatment, the potential for physical changes, and concerns about the future can contribute to heightened emotional distress.
To discuss mental and emotional health concerns of women following a breast cancer diagnosis, Medscape reached out to Eleonora Teplinsky, MD, head of breast and gynecologic medical oncology at Valley Health System in Paramus, New Jersey, and clinical assistant professor of medicine at Icahn School of Medicine at Mount Sinai. Read on for her insights.
Why is it important for clinicians to address the mental and emotional health of a woman when she is diagnosed with breast cancer?
A breast cancer diagnosis affects much more than just physical health. Diagnosis and treatment can result in many emotions, including anxiety, fear, depression, sadness, isolation, guilt, and more. Emotional distress can intensify with treatment burden and can persist even after treatment ends. Research has shown that people with cancer are at a higher risk of experiencing depression, trauma, and stress-related disorders. Despite this being common, there remains a stigma around discussing mental health concerns, and it is critical that clinicians be up-front in having these conversations.
Does addressing the mental and emotional health of breast cancer patients improve survival? Have studies looked at that?
We know that poor mental health can impact cancer outcomes. Studies have shown a link with depression and worse overall survival in patients with cancer. The data for treating depression and subsequent impact on survival have been mixed, but it has been shown to improve quality of life, which is critically important. In general, measuring the impact of treating mental health on survival is going to be challenging due to so many confounding factors, but we know that addressing mental health has far-reaching benefits.
What tools are used to assess the mental and emotional health of patients when they are diagnosed with breast cancer?
The first step is simply to ask the question about mental health. One of the common scales most commonly used is the National Comprehensive Cancer Network (NCCN) Distress Management Thermometer. This distress tool is typically used in cancer centers to assess patients. Distress is defined by NCCN to be "an unpleasant experience of a mental, physical, social or spiritual nature. It can affect the way you think, feel or act. Distress may make it harder to cope with having cancer, its symptoms or its treatment." On the thermometer, patients are asked to circle a number from 0 to 10, with 0 being no distress and 10 being extreme distress. There is also a problem list where you can check off any concerns you have had in the past 7 days. These include physical concerns, practical concerns, spiritual or religious concerns, social concerns, and emotional concerns. Emotional concerns on the distress thermometer include worry or anxiety, sadness or depression, loss of interest or enjoyment, grief or loss, fear, loneliness, anger, changes in appearance, feelings of worthlessness, or being a burden. There are other scales as well, such as the Hospital Anxiety and Depression Scale (HADS), Functional Assessment of Chronic Illness Therapy, and Brief Symptom Inventory and Patient-Reported Outcomes Measurement Information System (PROMIS).
What are some of the most common mental and emotional health issues faced by women diagnosed with breast cancer?
Some common symptoms include feelings of anxiety, depression, and fear. Some people may feel shock, denial, anger, or psychological regression; others may have trouble focusing, experience panic attacks, or carry guilt about surviving cancer when others did not (survivor's guilt). We can see feelings of desperation or hopelessness, uncertainty about the future, change in self-esteem/body image, and more. It's very common to fear that the cancer will come back or worsen (fear of recurrence or progression) which can impact daily life, cause emotional and physical distress, and lead to hyperawareness of bodily changes. Changes in mental health are triggered at different points. They can start at time of initial diagnosis or not until imaging or biopsy results, during treatment, or after treatment.
How can clinicians begin to address these mental and emotional health issues?
The first step is asking about mental health, as these symptoms often go unrecognized; validating and normalizing the symptoms; and then discussing both pharmacologic and nonpharmacologic therapies.
Is it more common to use pharmacologic or nonpharmacologic solutions for these issues?
It really depends on the individual and what their symptoms are and what the needs are, but it is important to have conversations about both pharmacologic and nonpharmacologic treatments.
What are some nonpharmacologic ways we can address the mental and emotional health of these women?
There are many nonpharmacologic and complementary strategies that are very effective. Some of these include mind-body relaxation techniques, including meditation and journaling, deep breathing, mindfulness-based stress reduction, exercise, tai chi, yoga, acupuncture, aromatherapy, massage/Reiki, music therapy, guided imagery, and hypnosis. Additional strategies include maintaining a normal routine, counseling and therapy, limiting alcohol use, spirituality and prayer, finding community, and support groups, whether they be in person or online/virtual.
What are three things that you think clinicians should know about addressing the mental and emotional health of women when they are diagnosed with breast cancer?
- Patients may not be comfortable bringing up mental health concerns or issues, and it is important that clinicians take the first step in asking about mental health concerns.
- Mental health changes can occur throughout the treatment process and even after treatment is completed. They can be pronounced around specific moments, such as treatment anniversaries or seeing someone else be diagnosed with cancer or experience a treatment recurrence.
- There are many pharmacologic and nonpharmacologic treatments that can help with mental health concerns.
Is there anything you would like to add about addressing the mental and emotional health of patients when they are diagnosed with breast cancer?
Therapy can be incredibly beneficial for patients, but it can be difficult to find a therapist. Patients often ask how to know whether this is the right therapist for them. Key questions that patients can ask include:
- Is the therapist licensed?
- Will the therapy sessions be covered by insurance? If so, how many visits are covered? If not, what will be the out-of-pocket cost?
- The American Psychological Association has a psychologist locator where you can look for a therapist. Other sites to help find a therapist are Psychology Today and FindaPsychologist.org, or check with your state psychological association.
- Ask your friends or family or your healthcare team if they have a therapist they trust and recommend.
- Ask whether the therapist has had experience in working with other patients with a cancer diagnosis.
Eleonora Teplinsky, MD, has disclosed no relevant financial relationships.