Christopher Holcombe

Predictors of onset of depression and anxiety in the year after diagnosis of breast cancer

BACKGROUND Depression and anxiety are common after diagnosis of breast cancer. We examined to what extent these are recurrences of previous disorder and, controlling for this, whether shame, self-blame and low social support after diagnosis predicted onset of depression and anxiety subsequently. METHOD Women with primary breast cancer who had been treated surgically self-reported shame, self-blame, social support and emotional distress post-operatively. Psychiatric interview 12 months later identified those with adult lifetime episodes of major depression (MD) or generalized anxiety disorder (GAD) before diagnosis and onset over the subsequent year. Statistical analysis examined predictors of each disorder in that year. RESULTS Of the patients, two-thirds with episodes of MD and 40% with episodes of GAD during the year after diagnosis were experiencing recurrence of previous disorder. Although low social support, self-blame and shame were each associated with both MD and GAD after diagnosis, they did not mediate the relationship of disorder after diagnosis with previous disorder. Low social support, but not shame or self-blame, predicted recurrence after controlling for previous disorder. CONCLUSIONS Anxiety and depression during the first year after diagnosis of breast cancer are often the recurrence of previous disorder. In predicting disorder following diagnosis, self-blame and shame are merely markers of previous disorder. Low social support is an independent predictor and therefore may have a causal role.

Development of a core outcome set for research and audit studies in reconstructive breast surgery

Appropriate outcome selection is essential if research is to guide decision‐making and inform policy. Systematic reviews of the clinical, cosmetic and patient‐reported outcomes of reconstructive breast surgery, however, have demonstrated marked heterogeneity, and results from individual studies cannot be compared or combined. Use of a core outcome set may improve the situation. The BRAVO study developed a core outcome set for reconstructive breast surgery.

‘You're putting thoughts into my head’: a qualitative study of the readiness of patients with breast, lung or prostate cancer to address emotional needs through the first 18 months after diagnosis

To investigate the readiness of patients to address emotional needs up to 18 months following a diagnosis of breast, lung or prostate cancer.

Telling "everything" but not "too much": the surgeon's dilemma in consultations about breast cancer.

BackgroundAlthough clinicians are often criticized for giving inadequate information to patients with cancer, current recommendations to “provide full information” or “all the information patients want” are impractical. We therefore examined how surgeons manage information-giving to patients with breast cancer in practice, and how their approach compared with what patients wanted.Study designWe interviewed 20 patients consulting after surgery in a specialist breast unit, and the eight surgeons whom they consulted. Qualitative analysis examined surgeon and patient perspectives on the purposes of information.ResultsSurgeons and patients both stated the importance of “honesty” and “telling everything” but surgeons did not want to tell everything they could and patients did not want to hear it. Patients wanted information mainly to maintain hope, demonstrate the surgeon’s expertise, and sustain a personal clinical relationship. Surgeons shaped their information-giving for the same reasons while providing necessary information about histology and treatment.ConclusionsSurgeons and patients agreed strikingly about the purposes of information and indicated that giving information is a more complex task than current recommendations imply. We suggest that expert recommendations should catch up with practice rather than the reverse. That is, if recommendations are to reflect patients’ real rather than assumed needs, and be realistic about how surgeons can meet these needs, the recommendations should be informed by knowledge of how patients and surgeons already reconcile these needs in clinical practice.

Angiogenesis and invasive recurrence in ductal carcinoma in situ of the breast.

The development of an invasive recurrence following treatment for ductal carcinoma in situ (DCIS) converts a non-fatal disease to one associated with mortality. To date, no pathological or molecular features have been found to predict for the type of recurrence. Previous studies have suggested that in DCIS angiogenesis may be an important factor in determining the transformation from in situ to invasive carcinoma. We looked at 355 cases of DCIS and found that 32 had subsequently developed recurrent disease. In these 32 cases and in matched controls, periductal vascular density was determined using morphometry and anti-endothelial antibodies, von Willebrand factor (vWF) and CD34. Vascular density was related to the risk of both invasive and in situ recurrence. Normal lobules at least 2 mm away were used as controls. Differences in the phenotype of individual blood vessels was detected by performing dual staining immunofluorescence on selected cases. The microvessel density (MVD), as detected with the CD34 antibody, was higher around foci of DCIS than around normal breast lobules (P=0.001). Furthermore, it was significantly higher in cases of DCIS that recurred (P<0.0001). The findings with the vWF antibody were less clear cut and suggested a trend in decreasing MVD with increasingly aggressive disease. Dual immunofluorescence staining shows that the increase in MVD seen around DCIS is due to an increase in CD34+/vWF-blood vessels. An increase in CD34+/vWF-of blood vessels may be able to predict cases of DCIS that are at a high risk of developing a recurrence.

Systematic review and critical appraisal of the impact of acellular dermal matrix use on the outcomes of implant-based breast reconstruction

Acellular dermal matrix (ADM) may improve outcomes in implant‐based breast reconstruction (IBBR). The aim of this study was critically to appraise and evaluate the current evidence for ADM‐assisted IBBR.

Psychological characteristics of women presenting with breast pain

OBJECTIVE Extensive evidence links unexplained physical symptoms in adults with childhood abuse. This study investigated a possible link between unexplained breast pain, recalled childhood abuse and emotional and somatic distress. METHODS Consecutive female out-patients presenting with breast pain were categorised as treatment-resistant (n=20), newly diagnosed and requesting treatment (n=37), or newly diagnosed but reassured and not seeking treatment (n=32) and compared with pain-free patients with breast lumps (n=31). RESULTS All breast pain groups were more anxious and depressed, somatised more and recalled a higher incidence of emotional abuse by comparison with breast lump patients. Logistic regression confirmed that emotional abuse and anxiety were independently associated with breast pain. CONCLUSION Clinical management of patients who present breast pain should be sensitive to the evidence that pain is a marker of emotional abuse in some women and is associated with widespread somatic and emotional distress.

Impact of mutational profiles on response of primary oestrogen receptor-positive breast cancers to oestrogen deprivation

Pre-surgical studies allow study of the relationship between mutations and response of oestrogen receptor-positive (ER+) breast cancer to aromatase inhibitors (AIs) but have been limited to small biopsies. Here in phase I of this study, we perform exome sequencing on baseline, surgical core-cuts and blood from 60 patients (40 AI treated, 20 controls). In poor responders (based on Ki67 change), we find significantly more somatic mutations than good responders. Subclones exclusive to baseline or surgical cores occur in ∼30% of tumours. In phase II, we combine targeted sequencing on another 28 treated patients with phase I. We find six genes frequently mutated: PIK3CA, TP53, CDH1, MLL3, ABCA13 and FLG with 71% concordance between paired cores. TP53 mutations are associated with poor response. We conclude that multiple biopsies are essential for confident mutational profiling of ER+ breast cancer and TP53 mutations are associated with resistance to oestrogen deprivation therapy.

The ‘information spectrum’: a qualitative study of how breast cancer surgeons give information and of how their patients experience it

Cancer clinicians are routinely criticised for communicating information poorly to patients, but expert guidance is sometimes contradictory or impractical. We wanted to understand how, and how well, breast cancer surgeons in their normal practice balanced the competing tasks of informing patients while keeping them hopeful.

Positive adjustment to breast cancer: development of a disease-specific measure and comparison of women diagnosed from 2 weeks to 5 years.

Objective: Many women describe ‘positive adjustment’ as a consequence of having breast cancer. It is unclear whether positive experiences reflect the absence of anxiety and depression or are part of a separate process of adjustment. Existing measures are not specific to breast cancer and may lack validity. Our aims were as follows: (1) to develop a valid questionnaire to measure positive adjustment after breast cancer; (2) to clarify whether it measures aspects distinct from anxiety and depression and (3) to suggest when positive adjustment typically emerges.