Lest we forget… Breast cancer and beyond…

The psychological impact of breast cancer

The cancer diagnosis has a long-term psychological impact that may negatively affect the treatment and recovery process. A high prevalence of anxiety and depression among them is observed, causing poorer recovery and quality of life (QoL) in the survival phase^6,7. Anxiety due to the diagnosis of cancer can lead to insomnia which may further be a risk factor for depression⁸. Long-term side effects of treatment are mostly reported among patients with symptoms of anxiety, depression and PTSD. Many breast cancer survivors undergo long-term iatrogenic effects of cancer treatment like fatigue, lymphedema, pain, infertility, vasomotor symptoms, etc., which hamper their quality of life as well as mental health⁹.

Studies on survival in India have also found that most patients reported advanced-stage at diagnosis leading to poor survival^10,11. Research has also observed a difference in the age-wise breast cancer trends among Indian women, where breast cancer occurs for the younger pre-menopausal group in Indian women and is reported a decade younger than western women

Among Indian women, cancer peaks at 40-50 yr¹⁰ contributing to the early onset of cancer which is the most aggressive form at presentation and stage or triple-negative breast cancer (TNBC) subtype¹². In meta-analysis studies, an increased prevalence of TNBC in India was reported in comparison with the western population¹³. Indian women living in urban areas reported higher risk for breast cancer when compared with women living in rural areas primarily due to the lifestyle followed by them¹⁴. Genetic factors is yet another risk for breast carcinoma with mutations in the BRCA1 and BRCA2 gene inherited¹⁵. Among the Indian population many studies on frequency of BRCA 1/2 gene mutations ranged between 2.9 per cent to 24.0 per cent³.

Breast cancer diagnosis is one of the most distressing diagnosis for individuals, and they may experience a range of psychological issues individually or in combination. A high prevalence of anxiety and depression has been observed among breast cancer survivors¹⁶. One in every five breast cancer patients, reportedly exhibit depressive symptoms persisting at least two years after diagnosis¹⁷.

The prevalence of depression among breast cancer survivors self-reported, was the highest globally around 30 per cent. The average prevalence of depression is reportedly around 13 per cent in studies using diagnostic criteria¹⁶. The range varies between 4-49 per cent based on the assessment techniques. Some studies report that depressive symptoms linger for a more extended period (over 5 yr) among breast cancer patients than anxiety. Breast cancer survivors reported increased post-traumatic stress disorder symptoms, which was similar to the meta-analysis finding of around 10 per cent¹⁸.

Both during and post cancer treatment, insomnia has been reported as an adverse mental health outcome among affected individuals¹⁹. Long-term survivorship challenges include problems in readapting to professional, social and family relationships and managing future uncertainties⁸. While exploring the unmet needs of cancer patients, it was observed that fear of cancer recurrence was one of the most significant and prevalentconcerns²⁰.

Knowing that one has a life-threatening illness can be a dreadful experience and can undermine invulnerability, predictability, and control assumptions²¹. Studies show that compared with different types of cancers like colorectal, head & neck, and prostrate, the prevalence of PTSD diagnosis is higher in breast cancer^18,22.

Fear of cancer recurrence (FCR) is yet another universal condition that is widely reported among survivors²³. Literature indicates that 97 per cent of survivors report some degree of FCR and predictors of having FCR as age, type of surgery, depression, fatigue and pain²⁴.

Survivorship is identified to play a significant role in the continuum of cancer care. The unmet psychosocial needs of cancer survivors are related to coping mechanisms and QOL outcomes. Quality of life is a dynamic concept that changes over time. The QOL model of breast cancer survivors adapted from Betty Ferrell & Marcia Grant states that QOL combines physical, psychological, social and spiritual well-being²⁵. Long-term effects of treatment on breast cancer, like surgery, radiotherapy, and chemotherapy notably affect the breast cancer survivors’ physical, psychosocial and emotional well-being²⁶.

A systematic review on the psychological concerns among Indian women with breast cancer pertaining to different national context concluded that whether in India or abroad, distressing symptoms could be tackled with culturally congruent care, ability to communicate and by receiving relevant information²⁷.

Breast cancer ranks first in incidence at 1,78,361 (13.5%) and mortality at 90,408 (10.6%) in India, with a corresponding 5 yr prevalence of all ages of 69.28 per 100,000²⁸. The increasing incidence of breast cancer among Indian women is now well confirmed. However, the mental health of people living beyond cancer is important and is a growing research area with clinical priority. In India, breast cancer survivors are predominantly an understudied population, and data on psychological issues, QoL, and survivorship are minimal. Further research and multi-centric studies are recommended as women living with breast cancer and beyond go through psychological issues and lest we forget about the trauma they undergo and to empower them to get back to normal life.