Breast cancer: The mental trauma of severe disease

The majority of women suffering from breast cancer develop symptoms of post-traumatic stress in the months following receipt of the diagnosis. The latest results of the Cognicares study, led by Dr. Kerstin Hermelink of the Breast Cancer Center in the Department of Gynecology and Obstetrics at the LMU Medical Center, show that such symptoms can still be detected a year after patients have been informed of their condition. The new findings appear in the journal Psycho-Oncology.

In the multicenter Cognicares study, Kerstin Hermelink and her doctoral student Varinka Voigt studied a group of 166 patients who had been newly diagnosed with breast cancer. Over the course of the following year, the participants were assessed at three specific time-points for the presence of clinically significant symptoms of post-traumatic stress disorder (PTSD). The results were then compared with those for a control group of patients without a cancer diagnosis.

During the interval between diagnosis of cancer and the initiation of treatment, 82.5% of all patients were found to exhibit symptoms of PTSD, such as recurrent and intrusive reminders of the experiences associated with cancer, feelings of detachment and emotional numbness, increased arousal, sudden outbursts of anger and an exaggerated startle response. Although a full diagnosis of PTSD was found in only 2% of patients one year after the cancer diagnosis, more than half (57.3%) continued to display one or more symptoms of the disorder at that point. In contrast, the rate of PTSD symptoms due to other traumatic events was very low in the controls and the patients alike. "That the high level of stress should persist for such a long time is particularly striking," says Kerstin Hermelink. Indeed, the severity of the psychological and emotional impact of the cancer diagnosis is underlined by another result reported in the study. When patients who had already had a traumatic experience -- such as a serious accident or a violent assault -- prior to the development of malignancy, some 40% of them rated having breast cancer as the more severe traumatic event.

"Cognicares is one of the very few longitudinal studies of traumatic stress associated with breast cancer," says Hermelink. Moreover, the data on which the study is based come from diagnostic interviews conducted by psychologists, and not from self-assessments. Only patients who were free of metastatic disease, and could therefore hope to get permanently cured, were recruited into the study, and women who had a history of psychiatric disease were excluded. "Indeed, we assume that the study is likely to somewhat underestimate the true incidence of post-traumatic stress symptoms in breast cancer patients," Hermelink adds.

Influencing factors The researchers also set out to identify factors that could account for the varying incidence and the varying duration of symptoms of PTSD among their study population. "Neither the type of surgery nor receipt of chemotherapy had any significant effect on either of these variables, but a high level of education did have a favourable impact. A university education is evidently a marker for resources that enable patients to recover more rapidly from the psychological stresses associated with a diagnosis of breast cancer," Hermelink explains.

The results of the study also raise questions regarding the decision of the editors of the latest (2013) edition of the "Diagnostic and Statistical Manual of Mental Disorders" (which serves as the major source of diagnostic guidelines in the field of Psychiatry) to remove the factor 'life-threatening disease' from their list of potential inducers of trauma. "In light of the results of our study, and against the background of my own experience as a psycho-oncologist with breast cancer patients, I regard this decision as highly questionable," says Hermelink. "Doctors should be made aware of the fact that the majority of breast cancer patients develop symptoms of post-traumatic stress subsequent to diagnosis, and need to receive the appropriate support."