Amanda Ramirez

DEPRESSION AND ANXIETY IN WOMEN WITH EARLY BREAST CANCER: FIVE YEAR OBSERVATIONAL COHORT STUDY

Abstract Objective To examine the prevalence of, and risk factors for, depression and anxiety in women with early breast cancer in the five years after diagnosis. Design Observational cohort study. Setting NHS breast clinic, London. Participants 222 women with early breast cancer: 170 (77%) provided complete interview data up to either five years after diagnosis or recurrence. Main outcome measures Prevalence of clinically important depression and anxiety (structured psychiatric interview with standardised diagnostic criteria) and clinical and patient risk factors, including stressful life experiences (Bedford College life events and difficulties schedule). Results Nearly 50% of the women with early breast cancer had depression, anxiety, or both in the year after diagnosis, 25% in the second, third, and fourth years, and 15% in the fifth year. Point prevalence was 33% at diagnosis, falling to 15% after one year. 45% of those with recurrence experienced depression, anxiety, or both within three months of the diagnosis. Previous psychological treatment predicted depression, anxiety, or both in the period around diagnosis (one month before diagnosis to four months after diagnosis). Longer term depression and anxiety, were associated with previous psychological treatment, lack of an intimate confiding relationship, younger age, and severely stressful non-cancer life experiences. Clinical factors were not associated with depression and anxiety, at any time. Lack of intimate confiding support also predicted more protracted episodes of depression and anxiety. Conclusion Increased levels of depression, anxiety, or both in the first year after a diagnosis of early breast cancer highlight the need for dedicated service provision during this time. Psychological interventions for women with breast cancer who remain disease free should take account of the broader social context in which the cancer occurs, with a focus on improving social support.

Major depression in outpatients attending a regional cancer centre: screening and unmet treatment needs

A screening programme designed to identify cases of Major Depressive Disorder (MDD) in patients attending a Regional Cancer Centre outpatient department was established. It comprised two stages: (1) The Hospital Anxiety and Depression Scale (HADS) self-rating questionnaire administered by a touch-screen computer; (2) we interviewed patients with high scores on the HADS (15 or more total score) over the telephone using the depression section of the Structured Clinical Interview for DSMIV (SCID). A large consecutive sample (5613) of oncology clinic attenders was screened, and practical difficulties in the screening process were identified. The estimated prevalence of major depressive disorder (MDD) in the sample surveyed was approximately 8% (7.8%; 95% confidence intervals 6.9–8.5%). We assessed a consecutive series of 150 patients identified as having MDD to determine how many had received evidence-based treatment for MDD. Only half had discussed their low mood with their general practitioner, only one-third had been prescribed any antidepressant medication, and very few had taken a therapeutic dose for an adequate period. Very few had received psychological treatment or had been referred to mental health services. Most were receiving no potentially effective therapy.

Women's knowledge and beliefs regarding breast cancer

Approximately 20–30% of women delay for 12 weeks or more from self-discovery of a breast symptom to presentation to a health care provider, and such delay intervals are associated with poorer survival. Understanding the factors that influence patient delay is important for the development of an effective, targeted health intervention programme to shorten patient delay. The aim of the study was to elicit knowledge and beliefs about breast cancer among a sample of the general female population, and examine age and socio-economic variations in responses. Participants were randomly selected through the Postal Address File, and data were collected through the Office of National Statistics. Geographically distributed throughout the UK, 996 women participated in a short structured interview to elicit their knowledge of breast cancer risk, breast cancer symptoms, and their perceptions of the management and outcomes associated with breast cancer. Women had limited knowledge of their relative risk of developing breast cancer, of associated risk factors and of the diversity of potential breast cancer-related symptoms. Older women were particularly poor at identifying symptoms of breast cancer, risk factors associated with breast cancer and their personal risk of developing the disease. Poorer knowledge of symptoms and risks among older women may help to explain the strong association between older age and delay in help-seeking. If these findings are confirmed they suggest that any intervention programme should target older women in particular, given that advancing age is a risk factor for both developing breast cancer and for subsequent delayed presentation.

Stress and relapse of breast cancer.

To elucidate the association between stressful life events and the development of cancer the influence of life stress on relapse in operable breast cancer was examined in matched pairs of women in a case-control study. Adverse life events and difficulties occurring during the postoperative disease free interval were recorded in 50 women who had developed their first recurrence of operable breast cancer and during equivalent follow up times in 50 women with operable breast cancer in remission. The cases and controls were matched for the main physical and pathological factors known to be prognostic in breast cancer and sociodemographic variables that influence the frequency of life events and difficulties. Severely threatening life events and difficulties were significantly associated with the first recurrence of breast cancer. The relative risk of relapse associated with severe life events was 5.67 (95% confidence interval 1.57 to 37.20), and the relative risk associated with severe difficulties was 4.75 (1.58 to 19.20). Life events and difficulties not rated as severe were not related to relapse. Experiencing a non-severe life event was associated with a relative risk of 2.0 (0.62 to 7.47), and experiencing a non-severe difficulty was associated with a relative risk of 1.13 (0.38 to 3.35). These results suggest a prognostic association between severe life stressors and recurrence of breast cancer, but a larger prospective study is needed for confirmation.

Changes in mental health of UK hospital consultants since the mid-1990s

We assessed changes in the mental health of UK hospital consultants from five specialties, on the basis of surveys done in 1994 (880 participants) and 2002 (1308 participants). The proportion of consultants with psychiatric morbidity rose from 27% (235) in 1994 to 32% (414) in 2002. The prevalence of emotional exhaustion increased from 32% (284) in 1994 to 41% (526) in 2002. Multivariate analyses showed that increased job stress without a comparable increase in job satisfaction accounted for the decline in mental health, which was especially marked in clinical and surgical oncologists. Action is needed to improve the working lives of consultants.

Differences in cancer awareness and beliefs between Australia, Canada, Denmark, Norway, Sweden and the UK (the International Cancer Benchmarking Partnership): do they contribute to differences in cancer survival?

Background:There are wide international differences in 1-year cancer survival. The UK and Denmark perform poorly compared with other high-income countries with similar health care systems: Australia, Canada and Sweden have good cancer survival rates, Norway intermediate survival rates. The objective of this study was to examine the pattern of differences in cancer awareness and beliefs across these countries to identify where these might contribute to the pattern of survival.Methods:We carried out a population-based telephone interview survey of 19 079 men and women aged ⩾50 years in Australia, Canada, Denmark, Norway, Sweden and the UK using the Awareness and Beliefs about Cancer measure.Results:Awareness that the risk of cancer increased with age was lower in the UK (14%), Canada (13%) and Australia (16%) but was higher in Denmark (25%), Norway (29%) and Sweden (38%). Symptom awareness was no lower in the UK and Denmark than other countries. Perceived barriers to symptomatic presentation were highest in the UK, in particular being worried about wasting the doctors time (UK 34%; Canada 21%; Australia 14%; Denmark 12%; Norway 11%; Sweden 9%).Conclusion:The UK had low awareness of age-related risk and the highest perceived barriers to symptomatic presentation, but symptom awareness in the UK did not differ from other countries. Denmark had higher awareness of age-related risk and few perceived barriers to symptomatic presentation. This suggests that other factors must be involved in explaining Denmarks poor survival rates. In the UK, interventions that address barriers to prompt presentation in primary care should be developed and evaluated.

ABC of palliative care: The carers

In general, most of the final year of life is spent at home, although 90% of patients spend some time in hospital and about 55% of all deaths occur there. The burdens and rewards of caring for people in their last year of life are shared between informal carers (relatives and friends or neighbours) and healthcare professionals working in institutions or in the community. “The death of Theodore Gericault (1791-1824), with his friends Colonel Bro de Comeres and the painter” by Ary Scheffer (1795-1858). Until the start of this century, most people died at home while being cared for by family and friends About three quarters of people receive care at home from informal carers (residential or non-residential), most of whom are women. About a third of cancer patients receive care from one close relative only, while nearly half are cared for by two or three relatives, typically a spouse and an adult child. A smaller proportion of non-cancer patients than cancer patients have access to such informal care, reflecting their older age at death. Approximately two thirds of cancer patients and a third of non-cancer patients receive some kind of formal home nursing. District nurses are involved in the care of about half of cancer patients and a quarter of non-cancer patients. Palliative care nurse specialists, such as Macmillan nurses, are involved with about 40% of cancer patients but very few non-cancer patients. General practitioners see most patients at least five times during their last year of life, often at home. Healthcare professionals provide care on acute hospital wards and in outpatient clinics, and hospice inpatient staff care for about 17% of cancer patients during part of their terminal illness. Without the support of family and friends, it would be impossible for many patients to remain at home. It …

Recognition of cancer warning signs and anticipated delay in help-seeking in a population sample of adults in the UK

Background:Not recognising a symptom as suspicious is a common reason given by cancer patients for delayed help-seeking; but inevitably this is retrospective. We therefore investigated associations between recognition of warning signs for breast, colorectal and lung cancer and anticipated time to help-seeking for symptoms of each cancer.Methods:Computer-assisted telephone interviews were conducted with a population-representative sample (N=6965) of UK adults age ⩾50 years, using the Awareness and Beliefs about Cancer scale. Anticipated time to help-seeking for persistent cough, rectal bleeding and breast changes was categorised as >2 vs ⩽2 weeks. Recognition of persistent cough, unexplained bleeding and unexplained lump as cancer warning signs was assessed (yes/no). Associations between recognition and help-seeking were examined for each symptom controlling for demographics and perceived ease of health-care access.Results:For each symptom, the odds of waiting for >2 weeks were significantly increased in those who did not recognise the related warning sign: breast changes: OR=2.45, 95% CI 1.47–4.08; rectal bleeding: OR=1.77, 1.36–2.30; persistent cough: OR=1.30, 1.17–1.46, independent of demographics and health-care access.Conclusion:Recognition of warning signs was associated with anticipating faster help-seeking for potential symptoms of cancer. Strategies to improve recognition are likely to facilitate earlier diagnosis.

Perceptions of breast cancer across the lifespan

OBJECTIVE The risk of developing breast cancer increases with advancing age. There is evidence to suggest that delayed help-seeking for breast cancer symptoms is associated with poorer survival and that older women are more likely to delay in seeking help for such symptoms. This study examined age differences in beliefs regarding breast cancer and intentions to seek medical care for breast symptoms in a general population sample. METHOD A general population sample of 546 women completed a postal questionnaire about beliefs regarding the symptoms, causes and outcomes associated with breast cancer, attitudes towards help-seeking and beliefs about ones ability to seek help. The questionnaire was based on components of the self-regulation model and the theory of planned behaviour. Help-seeking intention was measured by asking participants to rate the likelihood of visiting a general practitioner for a range of breast symptoms. The subscales of each model were entered as predictors of intention to seek help for breast symptoms in a series of hierarchical multiple regression analyses performed for each age group. RESULTS The inability to correctly identify a range of potential breast cancer symptoms (identity subscale) was a significant predictor of intention delay in seeking help across all age groups. For women aged 35-54, negative attitudes toward medical help-seeking for breast symptoms (beta = 1.82, P < .05) and a negative belief in ones ability to seek help (perceived behavioural control) were additional predictors of intention not to seek help (beta = 0.229, P < .001). Holding negative beliefs about the consequences associated with breast cancer (i.e., that the disease could be potentially disabling or disfiguring) was found to be an important additional predictor of potential delay in help-seeking among women aged over 65 years (beta = 0.210, P < .05). CONCLUSION Correct identification of potential breast cancer symptoms was universally important in predicting intention to seek medical care across age groups. However, additional beliefs differentially influenced help-seeking intention within different age groups. Preliminary findings suggest that interventions to reduce delay behaviour in help-seeking for breast symptoms should inform women of the diversity of breast cancer symptoms, advances in the management of breast cancer and provide advice on how to obtain help for breast cancer symptoms.

Stressful life experiences and risk of relapse of breast cancer: observational cohort study.

Abstract Objective: To confirm, using an observational cohort design, the relation between severely stressful life experiences and relapse of breast cancer found in a previous case-control study. Design: Prospective follow up for five years of a cohort of women newly diagnosed as having breast cancer, collecting data on stressful life experiences, depression, and biological prognostic factors. Setting: NHS breast clinic, London; 1991-9. Participants: A consecutive series of women aged under 60 newly diagnosed as having a primary operable breast tumour. 202/222 (91%) eligible women participated in the first life experiences interview. 170 (77%) provided complete interview data either up to 5 years after diagnosis or to recurrence. Main outcome measure: Recurrence of disease. Results: We controlled for biological prognostic factors (lymph node infiltration and tumour histology), and found no increased risk of recurrence in women who had had one or more severely stressful life experiences in the year before diagnosis compared with women who did not (hazard ratio 1.01, 95% confidence interval 0.58 to 1.74, P=0.99). Women who had had one or more severely stressful life experiences in the 5 years after diagnosis had a lower risk of recurrence (0.52, 0.29 to 0.95, P=0.03) than those who did not. Conclusion: These data do not confirm an earlier finding from a case-control study that severely stressful life experiences increase the risk of recurrence of breast cancer. Differences in case control and prospective methods may explain the contradictory results. We took the prospective study as the more robust, and the results suggest that women with breast cancer need not fear that stressful experiences will precipitate the return of their disease.