Breast cancer patients are often encouraged to have a positive attitude to help fight the disease. The reality, however, is that many patients are feeling depressed and lonely.
Prof Justus Apffelstaedt, Head of the Tygerberg Hospital Breast Clinic and Associate Professor: University of Stellenbosch, answers a few pertinent questions around breast cancer and depression:
Are depressed women at a greater risk of breast cancer?
A report released from Johns Hopkins School of Public Health in 2000 presented a compelling look at a possible mind-body link in what has been considered a purely physical illness. The link between psychological health and breast cancer has not been consistently found in other research. A study reported in the September 1999 issue of Health Psychology (1999;18;5:1-12), found no connection between depression and breast cancer. 46 studies looking at a potential link were analyzed by researchers at Roswell Park Cancer Institute in Buffalo, NY and the University of Illinois at Urbana-Champaign. They found that anxious or depressed women, women who experienced a difficult childhood, and women who suppressed their anger were no more likely to develop breast cancer than other women.
Conversely, a National Institute of Aging study examined 4,825 people age 71 and over. This time, though, researchers were looking for chronic depression, people who exhibited depression all three times they were interviewed between 1982 to 1988 - 146 in all. None of these people had cancer in 1988. In 1992, however, these same individuals were 88 percent more likely than the others to have developed cancer.
The book is by no means closed on the matter, and scientists are a long way from figuring out how a chemical storm in the brain may result in a tumor elsewhere in the body. It could be that genes and environment are the actual causes, with depression acting as the trigger, or it may be that a low mood of long duration suppresses the body's immune system, allowing cancer cells to flourish.
But unless future research starts turning in consistent results, we cannot say for sure if depression is a cause or trigger of cancer.
Can stress increase a person’s risk of developing cancer?
Studies done over the past 30 years that examined the relationship between psychological factors, including stress, and cancer risk have produced conflicting results. Although the results of some studies have indicated a link between various psychological factors and an increased risk of developing cancer, a direct cause-and-effect relationship has not been proven.
Some studies have indicated an indirect relationship between stress and certain types of virus-related tumors. Evidence from both animal and human studies suggests that chronic stress weakens a person’s immune system, which in turn may affect the incidence of virus-associated cancers, such as Kaposi sarcoma and some lymphomas.
More recent research with animal models (animals with a disease that is similar to or the same as a disease in humans) suggests that the body’s neuroendocrine response (release of hormones into the blood in response to stimulation of the nervous system) can directly alter important processes in cells that help protect against the formation of cancer, such as DNA repair and the regulation of cell growth.
There is also mounting evidence, that different forms of stress may influence the cancer risk differently; e.g a single stressful event such a the loss of a partner may have a different effect from chronic, e. g. work-related stress. Another important factor seems to be the time when the stress takes place: there are indications from animal models, that exposure to stress in adolescence may permanently alter the stress response in a way that compromises the body’s defence mechanisms against cancer.
Is there a biological association between breast cancer and stress?
The plausibility of a stress-breast cancer association stems from two important physiological roles of the stress hormone cortisol. Cortisol plays an essential part in mammary gland development and function, which may sensitize mammary tissues to modulations in cortisol signalling in the presence of stress. It also has an impact on certain aspects of oestrogen activity in the mammary gland, which may initiate protumorigenic changes during periods of stress.
Do all women with breast cancer suffer from depression?
Fear of death, disruption of life plans, changes in body image and self-esteem, changes in social role and lifestyle, and financial and legal concerns are significant issues in the life of any person with cancer, yet serious depression or anxiety is not experienced by everyone who is diagnosed with cancer.
Major depression affects approximately 25% of patients and has recognisable symptoms that can and should be diagnosed and treated because they have an impact on quality of life.
Is depression more common among patients receiving palliative care?
In the Canadian National Palliative Care Survey, 381 patients receiving palliative care for cancer were evaluated for depressive and anxiety disorders and for the impact of these disorders on quality of life.
A significant number of participants were found to fulfil diagnostic criteria for at least one depressive or anxiety disorder (20.7% prevalence for depressive disorder and 13.1% for anxiety disorder).
Participants diagnosed with a disorder were significantly younger than the other participants, had lower performance status, had smaller social networks, and participated less in organized religious services. They also reported more severe distress about physical symptoms, social concerns, and existential issues, suggesting significant negative impact on other aspects of their quality of life.
The importance of psychological issues was underscored by another study conducted in 211 terminally ill cancer patients with life expectancies of less than six months. Investigators evaluated patient “sense of burden to others” and its correlation with physical, psychological, and existential issues.
In multiple regression analysis, four variables emerged predicting perception of burden to others: depression, hopelessness, level of fatigue, and current quality of life. No association between sense of burden to others and actual degree of physical dependency was found, implying that this perception is mainly mediated through psychological distress and existential issues. A subanalysis of patient groups from different settings suggested that these findings were consistent across the inpatient and outpatient settings, with some minor variations.
Are certain coping strategies for breast cancer and depression linked?
Some studies suggest an association between maladaptive coping styles with higher levels of depression, anxiety, and fatigue symptoms. Examples of maladaptive coping behaviours include avoidant or negative coping, negative self-coping statements, preoccupation with physical symptoms, and catastrophizing.
A study examining coping strategies in 138 women with breast cancer concluded that patients with better coping skills such as positive self-statements have lower levels of depressive and anxiety symptoms.
What indicators suggest a need for early intervention?
- A history of depression.
- A weak social support system (not married, few friends, a solitary work environment).
- Evidence of persistent irrational beliefs or negativistic thinking regarding the diagnosis.
- A more serious prognosis.
- Greater dysfunction related to cancer.
What behaviours are associated with lower levels of anxiety and depression in family members?
A study of 48 adult cancer patients and their 99 adult relatives indicates that family functioning is an important factor that impacts patient and family distress. Families that were able to act openly, express feelings directly, and solve problems effectively had lower levels of depression, and direct communication of information within the family was associated with lower levels of anxiety.
What characteristics are associated with depression in spouses of women with breast cancer?
A preliminary study investigated 19 potential predictors of depression in spouses of 206 women with nonmetastatic breast cancer. Spouses were more likely to experience depressive symptoms if they were older, were less well educated, were more recently married, reported heightened fears over their wife's well-being, worried about their job performance, were more uncertain about their future, or were in less well-adjusted marriages.
What are the best ways to combat depression when you have breast cancer?
A critical part of cancer care is the recognition of the levels of depression present and determination of the appropriate level of intervention, ranging from brief counselling or support groups to medication and/or psychotherapy. For example, relaxation and counselling interventions have been shown to reduce psychological symptoms in women with a new diagnosis of gynaecological cancer.
Studies suggest that at least one half of all people diagnosed with cancer will successfully adapt. Markers of successful adaptation include maintaining active involvement in daily life; minimizing the disruptions caused by the illness to one's life roles (e.g., spouse, parent, employee); regulating the normal emotional reactions to the illness; and managing feelings of hopelessness, helplessness, worthlessness, and/or guilt.
(Compiled by Professor Justus Apffelstaedt: Associate Professor, University of Stellenbosch and Head of the Breast Clinic: Tygerberg Hospital)