Key words
psychological co-morbidity - psychopharmaceutical - psychosocial care
Schlüsselwörter
psychische Komorbidität - Psychopharmaka - psychosoziale Betreuung
Background
Up to 40% of all cancer patients present with psychological conditions such as depression or anxiety and require treatment [1], [2]. Prevalence might be even higher due to underreporting. The improvement of detection rates as well as the provision of comprehensive psychosocial support has been defined as an
integral part in the German National Cancer Plan [3].
Breast cancer (BC) is the most common cancer in women worldwide and affects women of all ages. Even though mortality rates are comparably low, BC and its treatment can cause relevant physical
and psychological morbidity. Thus, psychosocial support is one important part in a multidisciplinary rehabilitation treatment of BC patients. It has been previously shown that patients
receiving a combination of physical and psycho-educational training had benefits regarding functional capacity and quality of life [4]. Psychological service
providers must differentiate between different needs of patients which can vary according to age, comorbidities or disease stage [5]. There are several
publications concerning predictors for distress in BC patients [6], [7], [8]. Syrowatka et al.
previously described predictors of distress in patients with BC in a review of 42 studies. There were several breast cancer-specific and treatment-related factors, but also modifiable risk
factors identified. But the authors also state that there are several limitations such as inter-study heterogeneity, the non-specific nature of distress, publication bias to name just a few of
them [7].
It remains a clinical challenge to identify BC subgroups which have increased need for psychological support. This might lead to an unequal distribution or inadequate provision for these
patients.
We therefore wanted to know how often highly distressed BC patients receive an offer for professional psychological support/treatment and to which extent it is used. What happens to patients
with acute psychological comorbidity? Moreover, we investigated the proportion of patients consuming psychopharmaceuticals. Our assumptions were that patients with distress at the time of
diagnosis and those with psychological comorbidity receive psychosocial support more often. We also assumed that patients with psychological comorbidity took medication more frequently.
Methods
Study design
The BRENDA (Breast Cancer Care under Evidence-based Guidelines) II study is a prospective multi-center cohort study including patients with primary BC in Germany.
Recruitment of patients happened between January 2009 and February 2012. Measurements were performed before surgery (t1), one month (t2), 8 months (t3) and 5 years (t4) thereafter. We
examined the proportion of BC survivors who were aware about, had received an offer for psychological services or received various types of psychosocial services. Exclusion criteria for this
study were metastatic, recurrent or bilateral disease at t1.
Instruments
Parameters indicating mental health were ascertained at diagnosis, before surgery (t1), and until 5 years after surgery (t4). Psychological comorbidity according to ICD-10 was assessed
using the Patient Health Questionnaire (PHQ) at t1 to t3 [9]. The PHQ-D includes diagnostic modules on depressivity (PHQ-9), anxiety (GAD-7), somatic symptom
severity (PHQ-15), panic disorder, binge-eating disorder/bulimia nervosa, alcohol abuse, and stress. At t4, distress was evaluated by the use of the PHQ-9.
Based on the PHQ, we were able to dichotomize in non-existing versus existing psychological comorbidities. If no psychiatric comorbidity was given at any time point, patients were grouped
as “healthy”. Patients who indicated psychiatric comorbidity at baseline or t1/2 but not at the end of the follow-up were defined as “acute”, while those without comorbidity at baseline but
throughout the course of time were defined as “emerging”. Those patients with comorbidity at baseline and at the end of the follow-up were defined as “chronic”.
At t4, psychological distress was evaluated by the short form of the PHQ (PHQ-9) and categorized into mild, moderate and severe distress.
We asked patients what kind of psychosocial services they were aware of, had been offered and received.
At baseline (t1) and 5 years later (t4), we asked about the intake of psychopharmaceuticals and recorded the single substances consumed by each patient.
Statistical analysis
We used logistic regressions in order to analyze whether patients, who were highly distressed at t1, received the offer and actual psychological services more often than those without
psychological impairment. To do this, we combined psychological support of all supply sectors. Outcome parameters were offer and use of psychological services and patients with different
levels of distress were compared with each other.
In order to analyze the offer and use of psychological services for patients with psychological comorbidity during the course of treatment, we also performed logistic regressions. The
course of the psychological disease (acute, emerging or chronic disease) was used as independent variable. Moreover, we evaluated comorbidity as predictor for the intake of
psychopharmaceuticals using logistic regression.
Adjustments have been performed for age, education, household income, migration background and disease risk group.
Statistical analyses were performed using STATA 15 (StataCorp 2017, College Station, TX: StataCorp LP).
Results
Basis data
We included 456 BC patients with primary disease in this study. We described frequencies, percentages and means of the sample with respect to predicting factors such as age, education,
income, migrant background, and disease stage and breast cancer-specific treatments ([Table 1]).
Table 1 Descriptive data of primary BC patients included in the study.
|
|
|
n = 456
|
|
|
|
|
n
|
%
|
|
Age (years)
|
< 40
|
8
|
2%
|
|
40 – 49
|
50
|
11%
|
|
50 – 59
|
131
|
29%
|
|
60 – 69
|
123
|
27%
|
|
70 – 79
|
115
|
25%
|
|
80+
|
19
|
4%
|
|
unknown
|
10
|
2%
|
|
Education (years)
|
< 10
|
195
|
43%
|
|
≥ 10
|
256
|
56%
|
|
unknown
|
5
|
1%
|
|
Current income (€/person/month)
|
< 500
|
18
|
4%
|
|
500 to 999
|
87
|
19%
|
|
1000 to 1499
|
102
|
22%
|
|
> 1500
|
186
|
41%
|
|
unknown
|
63
|
14%
|
|
Immigrant
|
no
|
387
|
85%
|
|
yes
|
64
|
14%
|
|
unknown
|
5
|
1%
|
|
Locally advanced disease
|
no
|
209
|
46%
|
|
yes
|
247
|
54%
|
|
Surgical treatment
|
breast conserving
|
392
|
86%
|
|
mastectomy
|
64
|
14%
|
|
Radiotherapy
|
no
|
40
|
9%
|
|
yes
|
416
|
91%
|
|
Chemotherapy
|
no
|
247
|
54%
|
|
yes
|
209
|
46%
|
|
Endocrine therapy
|
no
|
84
|
18%
|
|
yes
|
372
|
82%
|
Distress at t1 and t4
We describe distress levels at t1 and t4 dividing into none, mild, moderate, moderately severe, severe and unknown. In further analysis we combined patients with moderate, moderately severe
and severe distress.
At t1 we found that 54% of patients had no distress, 29% mentioned mild distress and 11% had moderate to severe distress. About 55% of the BC survivors indicated no increased distress
levels at t4 while 27% were mildly affected and 18% were moderately or severely affected ([Table 2]).
Table 2 Share of psychologically distressed patients at BC diagnosis (t1) and 5 years after (t4).
|
Distress
|
t1
|
t4
|
|
|
n
|
%
|
n
|
%
|
|
None
|
248
|
54%
|
249
|
55%
|
|
Mild
|
133
|
29%
|
124
|
27%
|
|
Moderate
|
43
|
9%
|
57
|
13%
|
|
Moderately severe
|
9
|
2%
|
19
|
4%
|
|
Severe
|
1
|
0%
|
6
|
1%
|
|
Unknown
|
22
|
5%
|
1
|
0%
|
Offer and use of psychological services
We further analyzed the amount of patients receiving an offer for psychological services or actually receiving psychological support at t1 and t4 according to their distress levels.
In 62% of all patients without psychological burden at t1, support has been offered and 46% of those patients accepted the offer in the course of time. Nevertheless, 77% patients were
heavily affected at the time of diagnosis and 74% of them received psychological support. At t4, 67% of patients without distress received an offer and 48% used services, while 52% of
patients with mild and 79% of patients with moderate and severe distress accepted services ([Table 3]).
Table 3 The share of BC patients that received the offer or used any form of psychological services (psycho-oncologist in hospital or psychologist in rehabilitation
clinic (individual consultation or group session) or psychologist in cancer counselling center or psychotherapist in private practice).
|
|
Distress
|
Any form of psychological service
|
|
|
|
Offer
|
Use
|
|
|
|
n
|
%
|
n
|
%
|
|
t1
|
none
|
154
|
62%
|
114
|
46%
|
|
mild
|
98
|
74%
|
86
|
65%
|
|
moderate, moderately severe or severe
|
41
|
77%
|
39
|
74%
|
|
t4
|
none
|
167
|
67%
|
119
|
48%
|
|
mild
|
84
|
68%
|
65
|
52%
|
|
moderate, moderately severe or severe
|
58
|
71%
|
65
|
79%
|
Comparing patients with mild or moderate/severe distress at t1 to those without distress, no evidence for differences were seen regarding the offer of psycho-oncological support (mild vs.
none: OR 1.6; p = 0.06; moderate/severe vs. none: OR 1.8; p = 0.11). Yet, patients with elevated psychological distress used them significantly more often (mild vs. none: OR 2.0;
p < 0.01; moderate/severe vs. none: OR 2.4; p = 0.01) ([Table 4]).
Table 4 Patients with distress at t1 did not more often receive the offer for psychological services during the treatment than those without symptoms. Though, those
patients used services more often. OR = Odds Ratio. The regression analysis was adjusted for age, education, income, migration status, and risk group.
|
Distress at t1
|
Any form of psychological service
|
|
|
Offer
|
Use
|
|
|
OR
|
P value
|
OR
|
P value
|
|
None
|
Ref
|
|
|
|
|
Mild
|
1.6
|
0.06
|
2.0
|
< 0.01
|
|
Moderate to severe
|
1.8
|
0.11
|
2.4
|
0.01
|
In 36% of all patients any psychological comorbidity was detected (12% acute, 16% emerging and 8% chronic comorbidity).
Patients with acute psychological comorbidity received the offer of support (OR 2.5; p = 0.02) significantly more often than those patients with emerging (OR 1.3; p = 0.46) or chronic
comorbidity (OR 1.6; p = 0.35). All three groups used psychotherapy to a higher amount than those without comorbidity (acute: OR 3.2, p = 0.01; emerging: OR 2.2, p = 0.06; chronic: OR 12.2,
p < 0.001) ([Table 5 a]).
Table 5 Offer and use of psychotherapy and intake of psychotropic drugs stratified by psychiatric comorbidity. OR = Odds Ratio. The regression analysis was adjusted for
age, education, income, migration status, and risk group. a Patients with acute psychiatric comorbidity more often received the offer for psychotherapy compared to those without
comorbidity. Patients with acute, emerging and chronic psychiatric comorbidity used psychotherapy more often than those without comorbidity. b Patients with psychiatric
comorbidity take psychotropic drugs more often than those without comorbidity.
|
Psychological comorbidity
|
a Psychotherapy
|
b Intake of psychotropic drugs
|
|
|
Offer
|
Use
|
|
|
|
|
OR
|
P value
|
OR
|
P value
|
OR
|
P value
|
|
None
|
Reference
|
Reference
|
|
Acute
|
2.5
|
0.02
|
3.2
|
0.01
|
3.8
|
0.002
|
|
Emerging
|
1.3
|
0.46
|
2.2
|
0.06
|
4.4
|
< 0.001
|
|
Chronic
|
1.6
|
0.35
|
12.2
|
< 0.001
|
15.4
|
< 0.001
|
Psychopharmaceutical intake
Five years after diagnosis, 14% of the BC patients took psychotropic drugs. Patients with psychological comorbidities received medication significantly more often compared to those without
comorbidity (acute: OR 3.8, p = 0.002; emerging: OR 4.4, p < 0.001; chronic: OR 15.4, p < 0.001). Especially those patients with chronic psychological disease used medication ([Table 5 b]).
Discussion
Clinical implications
BC can cause severe morbidity. It is already known that a relevant percentage of BC patients is psychologically affected by the diagnosis and treatment. This fact might lead to economic and
social impairments. Former analyses showed that 22% of young disease-free BC survivors showed reduced working times 1 year after diagnosis, due to fatigue and psychological problems [10].
We found 45% patients to be psychologically affected 5 years after BC diagnosis of which 18% showed moderate and severe impairment. These findings are in line with the literature. A
systemic review including 38 trials showed that 20 – 50% of BC patients suffered from anxiety and 10 – 30% of BC patients had depressions. It is an unfortunate fact that BC survivors also
have an up to 60% increased risk for suicide [11].
Thus, the prevention of psychological distress but also the assessment of requirements in psychological care are of central interest. Further analysis of the BRENDA found that financial
issue and role functioning problems matter [12]. When asked at t4, 6% of patients mentioned financial problems, while health issues and the situation with the
partner or the family were mentioned in 55% and 18%, respectively. The offer or the use of social services was not higher in patients with financial problems [13]. Since distress is often higher in patients with lower income and differs by age, we adjusted for these variables (age, income, education) in our regression analysis.
When analyzing the offer for psychological services for BC patients at diagnosis, we found that 77% of moderately or severely affected patients have been addressed. This fact led to 74% of
those patients actually receiving psychological service. One would expect higher rates for the offer of psychological services at t1 for all distress groups but especially for those with
severe impairment.
At t4, even more of those affected patients received and used the offer for services. When compared to the literature, it seems that rates for psychological support vary widely. Trevino et
al. showed that only 24.6% of BC patients stage 0–III with anxiety received psychological counseling during adjuvant treatment in New York [14]. Another
German survey determined a provision of psycho-oncological care in 86.8% of all cases [15].
Patients with already existing acute psychological comorbidity at t1 received the offer for psychotherapy significantly more often compared to patients with emerging or chronic disease. The
reason for this observation might be the apparent psychological strain when questioning patients during primary treatment, while the need of patients with chronic or emerging comorbidity are
not sufficiently recorded. An analysis performed by Mehnert et al. showed that 46% of BC survivors with psychological comorbidity felt insufficiently informed about support possibilities
[16].
Nevertheless, all patients in this analysis finally received psychotherapy more often than those patients without comorbidity. Probably affected patients with chronic and emerging
comorbidity are already supported by psychotherapists or actively tried to find support themselves.
14% of all patients took psychopharmaceuticals. A wide variety of substances was used. When compared to patients without comorbidity, especially those with chronic disease took medication
significantly more often. A literature review performed by Callari et al. revealed that there is little evidence whether individual substances are superior to others. This might also be
based on challenges in study setups. But it is known that the intake of psychopharmaceuticals can have relevant impact or side effects on patientsʼ well-being due to weight gain, fatigue or
digestion problems.
Study limitations
Since only BC patients with primary disease were involved in the study, one cannot compare comment on the psychological burden of those patients developing recurrent or metastatic disease
in a short time. Furthermore, by the time of data collection patients received primary surgery before the initiation of adjuvant therapy. One should take into consideration that the
neoadjuvant treatment is nowadays of great importance and might also have relevant impact of the psychological burden.
Conclusion
A relevant share of BC patients shows psychological burden 5 years after primary diagnosis of the disease. Especially those women with acute psychological comorbidity during BC treatment
received offers for professional support.
Even though our analysis showed that the offer and use of psychological services in German breast cancer centers is quite high, there still is a need to create a more extensive range of
psychological services, in order to reach all patients.
