Seminars in Surgical Oncology 12:76-83 (1996)
Psychological Assessment and Intervention:
Future Prospects for Women With
LESLIE G. WALKER MA. PhD. AND OLEG EREMIN, MD
From the Behavioural Oncology Unit, Departments of Mental Health and Surgery,
Aberdeen University Medical School, Aberdeen, Scotland
During the last decade, there has been a growing interest in the psycho-
social aspects of breast cancer. Studies have addressed multifarious
aspects, including the possible importance of personality factors and
stress in the onset and progression of malignancy, the psychological
impact of diagnosis and treatment, the incidence and nature of psycho-
logical and psychiatric problems, the development and evaluation of
psychological interventions to ameliorate treatment side effects and to
enhance quality of life, the psychological effects of screening for breast
cancer and of counselling women at high risk, the organization of
services, training, and psychoneuroimmunology. These and other
studies are reviewed and possible directions for future research are
indicated. It is clear that psychosocial factors are becoming increas-
ingly important components of the assessment and management of
patients with breast cancer. @1996 Wiiey-Liss. Inc.
KEYWORDS:psychosocial oncology, counseling, screening, psychoneuroimmunology,
INTRODUCTION clinically significant levels of anxiety and/ or depres-
In recent years there has been a growing awareness, sion and that 33% had moderate or severe sexual diffi-
by the medical profession and the lay public, of the culties. Other studies have reported a high incidence of
psychosocial impact of the diagnosis and treatment of problems related to body image following mutilating
cancer. The former have responded to this in several surgery .
ways, including the widespread use of quality of life Breast conservation causes less initial psychological
assessments in clinical trials and the development of morbidity than mastectomy. Unfortunately, however,
the new discipline of psychosocial, or behavioural, it does not appear to reduce significantly the preva-
oncology. For its part, the public has shown an intense lence of psychological morbidity in the longer term .
curiosity in the causes and treatment of cancer and this Women treated with breast conservation may become
is demonstrated by the frequent coverage of cancer on more anxious with the passage of time because they
television, radio, magazines, and newspapers. Partly fear, rightly or wrongly, that they may have jeopar-
because it is so common, and also because of its per- dised survival for the sake of a good cosmetic result.
ceived psychosexual implications, breast cancer has Although some patients may benefit psychologically
had an especially high media profile in recent years. from conservation, especially if they wish to exercise
choice and favour this procedure, it seems unlikely
PSYCHOLOGICAL PROBLEMS OCCURRING that this will have a substantial beneficial effect on the
IN BREAST CANCER overall incidence of psychiatric morbidity.
A number of studies have examined the incidence of Other studies have evaluated the effect of breast
psychological and psychiatric morbidity in women
Address reprint requests to L.G. Walker, Behavioural Oncology
with breast cancer. A classic study by Maguire et al. [I] Unit. Aberdeen University Medical School, Foresterhill, Aber-
found 1 year after surgery that 25% of women had deen, AB9 ZZD, Scotland.
0 1996 Wiley-Liss, Inc.
Psychological Assessment and Interventions 77
reconstruction. Dean et al.  studied 64 women with support received, side-effect control, and treatment
operable breast cancer, all of whom underwent mas- ambience.
tectomy, and randomised them to immediate or Fallowfield and Clark  have studied the effects of
delayed (3 months) reconstruction. Immediate recon- patient participation in decision making regarding the
struction reduced psychiatric morbidity 3 months type of surgery performed for breast cancer. Participa-
after mastectomy, especially in women whose mar- tion had important beneficial effects on subsequent
riages were unsatisfactory. The incidence of psychiat- psychological adjustment for most women. However,
ric disorder at 12 months, however, was similar in the there appears to be a subgroup of women who do not
two groups, although it should be noted that it was wish to be involved in making the choice between
lower than in most studies of women who have under- lumpectomy or mastectomy.
gone mastectomy. We are currently evaluating the at- The diagnosis of breast cancer is frequently trau-
titudes of women with breast cancer toward breast matic and it is known that many women are unable to
reconstruction in the context of neo-adjuvant chemo- take in all the information that is given to them at the
therapy. To date, our findings indicate that, initially “bad news” interview. In an attempt to overcome this,
following diagnosis, many women are enthusiastic Hogbin and Fallowfield  carried out a randomised
about the possibility of subsequent breast reconstruc- study to evaluate the effects of recording the interview
tion. However, at primary surgery, less than 10% ex- when “bad news” and diagnosis were initially dis-
press a strong desire for reconstruction. As these cussed and giving this to patients so that they had a
women have large or locally advanced primary can- permanent record of what was said and could listen to
cers, they undergo radiotherapy postoperatively. this as often as they wished, on their own, or with
Some have indicated, however, that if reconstruction others. Although this was helpful to some patients, it
could be carried out at the same time as mastectomy, appeared to have an adverse effect on other women,
they would wish this to be done. particularly those who had a very bad prognosis. It is
In an ongoing study of the psychoneuroimmuno- very important that clinicians are sensitive to the cues
logical effects of relaxation training and guided imag- given by patients in order that they can tailor the
ery in women with locally advanced breast cancer, we information given to the patients’ needs. Patients
are finding a very low incidence of anxiety and depres- should be given the information they wish and require
sion 9 months after diagnosis, whether assessed by a over a period of time: coming to terms with the diag-
standardised interview or by psychological tests. This nosis and treatment takes time and the information
applies not only to those women receiving the psycho- that patients wish or need may vary during this period.
logical intervention, but also to our control group. All
the women in the trial receive a great deal of support ASSESSMENT
and have much more contact with staff than would be From a practical clinical point of view, it is impor-
the case in routine practice. Apart from those who live tant to have a high index of suspicion regarding the
very far from the hospital, the women attend on 18 presence of psychological and psychiatric problems.
occasions during the 18 weeks when they are receiving Medical and other staff frequently fail to identify these
neo-adjuvant chemotherapy and they are assessed fur- problems for various reasons, including failure to use
ther prior to, and after, surgery and radiotherapy. screening questions that might elicit morbidity, the use
Great efforts are made to reduce the waiting time for of blocking maneuvers that decrease the likelihood
chemotherapy, to provide them with the amount of that patients will report emotional problems and fear
information they wish and to give them a high stan- that the patient will disclose concerns or feelings that
dard of support. Questionnaires show very high levels might be difficult to handle in a constructive way .
of satisfaction with the treatment received and their This raises many questions about who should take
relationship with staff. We believe these factors may be responsibility for identifying these problems, in what
important in preventing psychiatric morbidity. This setting, and with what training and professional back-
view is further supported by our findings in women grounds.
with gynaecological cancer .Women who were anx- When clinicians identify significant distress, they
ious or depressed at follow-up were significantly less may not offer treatment because they see the distress
satisfied with the information they had received fol- as being a “normal” reaction to the diagnosis, treat-
lowing diagnosis and with doctor-patient relation- ment side effects, or prognosis. The situation is further
ships. Future research into psychiatric morbidity in complicated by the symptoms of cancer and treatment
women with breast cancer will need to take much side effects. For example, reduced energy and libido,
more account of psychosocial and contextual aspects appetite change, sleep disturbance and social with-
of their management, including information given, drawal are not as reliable symptoms of depression in
78 Walker and Eremin
cancer patients as they are in physically healthy in- be merit in developing further scales to assess other
dividuals. although they should still be assessed care- potentially important aspects such as satisfaction with
fully. Enquiries regarding the ability to experience information received, expectancies regarding treat-
pleasure, diurnal variation in mood, early morning ment side effects and likelihood of therapeutic success,
wakening, self-concept, and views about the future and the impact of the illness and its treatment on
can be more revealing about the patient’s mental state. others, for example partners and children.
The presence of psychomotor agitation and retarda- Ideally, patients should be assessed and followed up
tion is also of diagnostic value. When appropriate, it by a liaison psychiatrist, clinical psychologist or spe-
is also important to assess suicidal ideation and intent. cially trained nurse. Considerable tact is required, and
Symptoms of fear and anxiety are generally much judgment should be used to determine how detailed a
easier to evaluate than those of depression in this pop- mental state examination should be carried out in an
ulation. individual case. On the one hand, it is important that
A number of simple, self-report questionnaires are treatable problems are identified as soon as possible:
available to screen for psychological problems. The on the other, it is essential that women do not feel that
Hospital Anxiety and Depression Scale  is a 14-item undue intrusions are being made into their adjust-
questionnaire that assesses both anxiety and depres- ment, feelings, and circumstances. Most patients who
sion. It can be completed in 2 or 3 minutes and scored are having psychological problems welcome the op-
in the same time. Low scores (7 or less) on either scale portunity to discuss these with a sensitive and em-
strongly suggest that these parameters are within nor- pathic clinician who conveys to them that discussion
mal limits. As a rough guide, patients who score of such factors is acceptable and will be taken seri-
higher, particularly 8 or above on depression and 11 ously. However, there is a subgroup of women who do
or above on anxiety, are likely to have clinically sig- not wish counseling and who may even be harmed by
nificant problems that require further assessment and it because, for example, they successfully use denial as
appropriate psychological or psychopharmacological a way of coping with their illness.
treatment. The Rotterdam Symptom Check List [ 101 In an important series of studies, Maguire et al. [I51
contains approximately 30 items (there are several ver- have addressed the role of specially trained nurse
sions) and yields separate scores of psychological and counselors in identifying and managing psychiatric
physical distress. In addition to subscale scores, re- morbidity. Although there was no evidence that nurse
sponses to individual items, for example the one deal- counselors prevented morbidity, they were successful
ing with libido, can alert the clinician to the possibility in identifying patients who had significant problems.
of very specific problems. If these were referred for appropriate treatment, the
A number of other quality-of-life measures have subsequent incidence of psychiatric problems was less
been published, for example, the European Organisa- in the patients who had contact with the counsellor
tion for Research and Treatment of Cancer (EORTC) than in those who did not. However, counselors need
QLQ-C30 [l I], the Patient Attitude to Illness Scale backup and support, or they may become chronically
, and the Short Form 36-item Health Survey (SF- stressed and “burnt out.”
36) . Because quality of life is defined in terms of Some chemotherapy regimens have been shown to
the individual’s needs and priorities, and is not simply affect cognition and psychomotor performance. Regi-
a function of the presence or absence of specific symp- mens used in breast cancer, for example, CHOP che-
toms, recent interest has focused on individualised motherapy, have not been adequately documented,
quality-of-life measures [ 141. These measures reflect although clinically many women complain of memory
those aspects of life that a particular individual con- problems. In future, sophisticated computerised as-
siders important, and they assess current functioning sessments such as the one developed by Cognitive
and satisfaction in each of these aspects as well as their Drug Research could be used to assess the effects of
relative importance. Although some of these measures chemotherapy (or indeed radiotherapy) on various
are statistically sophisticated, they are still at an early kinds of memory, vigilance, reaction time, and so on.
stage of development, and they are more complicated This program was found to be very useful in evaluat-
to administer than the symptom checklists described ing the effects of recombinant interleukin-2 therapy in
above. Undoubtedly, despite the difficulties, efforts patients with advanced colorectal cancer [ 161.
will be made in the future to develop individualised One other aspect of assessment is likely to be rele-
measures. vant in the future. If psychosocial factors are indepen-
Other questionnaires are available to assess quan- dent prognostic factors for survival (see below), it will
titatively aspects of body image, social support, and be important in a research context to assess these to
various features of personality. In future, there would ensure that patients in the various treatment arms of
Psychological Assessment and Interventions 79
a clinical trial are comparable not only for known Second, what is the psychological impact of a false
biological prognostic factors (e.g., lymph node inva- positive recall? In the United Kingdom, approxi-
sion, histopathology, and hormonal receptor status), mately 8% of women are recalled for further assess-
but also for these psychosocial indices. ment because of a mammographic abnormality. Sev-
eral studies have addressed this issue. We found that
SCREENING AND GENETIC COUNSELING recall was associated with increased anxiety whether
Considerable concern was expressed during the assessed by mean scores or clinically significant cate-
1980s about the possible adverse psychological effects 2]
gories [ 2 .However, when the women were reassessed
of screening for breast cancer. It was suggested that 4 months later, mean anxiety scores were significantly
screening might not only be distressing but, in some lower than at baseline assessment, and depression
patients, might result in psychiatric disorder, cancer scores had returned to the baseline level. These find-
phobia, or an inappropriate frequency of breast self- ings are consistent with other work which has failed to
examination. A number of empirical studies have in- find a significant, persistent increase in psychiatric
vestigated these matters [ 17-20]. There are at least two
morbidity some months after recall.
important issues that need to be addressed, namely the Over the past few years, a number of centres in the
effects of attendance at screening and the impact of United Kingdom have established high risk family
false-positive recall. clinics where women receive counselling regarding
First, does attending for breast screening have psy- their genetically determined risk of breast cancer. The
chonoxious effects? Almost one million women attend long-term effects of such counselling have not yet been
annually for routine mammography as part of the adequately evaluated, although a number of studies
United Kingdom National Health Service breast have been reported or are in progress . In our own
screening program. One of the problems in evaluating clinic, an ongoing follow-up study of 89 women has
the effect of breast screening is in obtaining a baselineshown that, compared with pre-counselling, depres-
measurement of mental health that is uncontaminated sion scores were higher 18 months after counselling.
by the knowledge of the impending screening visit. It Although highly statistically significant, the actual
is possible to compare a group of women who attend magnitude of the increase is relatively small. The exact
screening with another group who do not. However, nature of the distress, and its clinical significance, war-
there are difficulties in getting a truly comparable rants more detailed study. Although some women can
group for comparison and a “within group” design for identify accurately their own risk prior to counseling,
patients who are screened is likely to be more sensitive.this is by no means true for all women and change in
In a recent study, we used the latter design . We risk perception following counselling, moderated by
identified three local general practices who were sched- personality, social support, etc., may produce differen-
uled for screening and, with the help of the General tial outcomes.
Practitioners, we were able to obtain a baseline mea- Cull et al.  reported that women who overesti-
sure of mental health uncontaminated by the screen- mated their risk experienced reduced anxiety follow-
ing process. Each woman received a letter from her ing counseling: however, this returned to baseline lev-
General Practitioner indicating that he/ she was carry- els within 3 months. Moreover, although counseling
ing out a survey of various aspects of the health of appeared to increase the accuracy of risk perception in
women in the practice and inviting them to complete underestimators, these women continued to underesti-
an enclosed Hospital Anxiety and Depression Scale. mate their risk.
At that time the women did not know that they were In Huntington’s disease, psychiatric morbidity has
to be invited for screening a few weeks later. More been shown to be higher following counseling in those
than 2,000 women responded to this postal question- not carrying the gene compared with those who have
naire (an 89.5% response rate). When they attended the gene. It may be that some women who are less at
screening, the women were asked to complete a further risk of breast cancer on genetic testing will also show
Hospital Anxiety and Depression Scale, so that their survivor guilt.” Following genetic counseling, the
levels of anxiety and depression at that time point provision of a psychosocial intervention may reduce
could be compared with the baseline measurements. any detrimental impact.
The results showed clearly that, as a group, women
were significantly less anxious and less depressed prior PSYCHOLOGICAL MANAGEMENT
to screening than at their baseline assessments. This We have already commented on the important
was true for mean anxiety and depression scores as beneficial effects of contextual aspects of management,
well as for the proportion of women reporting clini- such as appropriate information, patient satisfaction
cally significant levels of anxiety and depression. with communication, and good control of side effects.
80 Walker and Eremin
However, a number of studies have shown that formal used, it is important to choose drugs which have as few
psychological interventions can be used successfully to side effects as possible. Women undergoing treatment
treat psychiatric morbidity once it has been diagnosed. for breast cancer may already be experiencing gas-
Greer et al.  carried out a prospective, rando- trointestinal disturbances, nausea and fatigue. There
mised clinical trial of adjunctive psychological therapy are also a number of other important considerations
(APT) in women with breast cancer. APT is based on such as the degree of sedation required, safety in over-
the cognitive model of depression developed by Beck dose, and the effects on psychomotor performance
in the United States. Depression, and anxiety, are seen (which might effect driving) and other aspects of role
as maladaptive secondary emotional responses to functioning (e.g., being able to look after young chil-
faulty modes of thinking, and therapy aims to correct dren).
these modes of thinking with a view to alleviating the
emotional distress. APT also involves the use of vari- PSYCHOLOGICAL FACTORS, DISEASE
ONSET, AND PROGNOSIS
ous other techniques based on the behavioural ap-
proach. One hundred seventy-four patients, the ma- It has long been suspected that psychological fac-
jority of whom had breast cancer, and all of whom tors may predispose to cancer and influence its subse-
showed evidence of psychological morbidity, took quence course. Almost 2,000 years ago, the Greek
part in the study. Patients who had received APT were physician Galen suggested that individuals with a mel-
significantly less likely at 4-month follow-up to be ancholic temperament were more likely to develop
suffering from severe anxiety (20%) compared with cancer than those who were sanguine. More recently,
43%). However, a differential effect was not seen for in 1870, James Paget observed in his Surgical Pathol-
borderline or severe depression (control patients also ogj.  that “The cases are so frequent in which deep
improved). This is a very important study, and further anxiety, deferred hope, and disappointment are
trials to evaluate similar interventions should be car- quickly followed by the growth and increase of cancer
ried out. that we can hardly doubt that mental depression is a
Psychological interventions may be targeted specifi- weighty addition to the other influences favouring the
cally at the side effects of treatment. In an uncon- development of the cancerous condition.” Since then,
trolled study of 18 patients all of whom had severe others have suggested that personality factors, mood
chemotherapy side effects (nausea, vomiting, and and stressful live events are relevant to the induction
treatment-related anxiety), and which included six pa- and progression of the malignant process . Al-
tients with breast cancer, we found that progressive though much of this literature is not specific to breast
muscular relaxation training, cue-controlled relaxa- cancer, some studies have focused on this disease. For
tion training, hypnotic suggestion, and a technique, example, in an experimental study, Pettingale, Wat-
which we called “nausea management training,” pro- son, and Greer  showed that women with breast
duced clinically beneficial improvements in nausea, cancer were more emotionally inhibited and that they
vomiting, and treatment-related anxiety.  Others became more anxious than healthy women when
have also found these methods to be of value. In a stressed. Moreover, the same group found that atti-
subsequent randomised, prospective controlled trial, a tude towards their cancer was a significant predictor
very low incidence of psychiatric disorder and side of survival: women who adopted the “fighting spirit”
effects was observed, not only in the patients receiving or “denial” survived significantly longer than those
the psychological intervention, but also in the control who responded with helplessness, hopelessness or
groups [27,28]. This appeared to be related to the in- stoic acceptance . Furthermore, attitude toward
formation and support given to the patients during the the illness appeared to have immunological correlates
early part of their treatment and further underscores that might have mediated these effects on survival .
the importance of these variables in the management Jensen  also found psychological factors were rele-
of patients with cancer. vant to outcome; neoplastic spread was related, for
While some distress is almost inevitable, and indeed example, to a repressive personality style, reduced ex-
may even be desirable (particularly at diagnosis), it is pression of negative emotions and feelings of helpless-
important to identify a level of distress which meets ness and hopelessness.
diagnostic criteria for clinically significant problems. Work in other cancers has also suggested that psy-
When such criteria are met, there is evidence that ap- chological factors may have independent prognostic
propriate psychological and/ or psychopharmacologi- significance. For example, in a recent study of patients
cal interventions (e.g., antidepressant medication) with Hodgkin’s disease and non-Hodgkin’s lym-
should be used as many of these patients benefit con- phoma, we found that patients with borderline or
siderably. If a psychopharmacological approach is clinically significant depression at diagnosis and a high
Psychological Assessment and Interventions 81
score on the L-scale of the Eysenck Personality Inven- cancer who were rated as well adjusted, who reported
tory (which, in this context, is probably a measure of less than desirable social support and who responded
social conformity) were much more likely to die dur- with fatigue-like symptoms tended to have lower natu-
ing the five years after diagnosis . Moreover, mul- ral killer (NK) cell activity. NK activity has been
tivariate analysis using the Cox proportional hazards shown in animals to be important in preventing tu-
method indicated that these variables had independent mour cell dissemination and the formation of metas-
prognostic significance. Much further work requires tases . Moreover, Grossrath-Maticek and Eysenck
to be done before it can be concluded that there is a [41J studied 50 patients with metastatic breast cancer.
causal relationship between psychological factors and All received chemotherapy, and one-half were also
survival, but the results of these studies are suggestive given a psychological intervention. Women who had
and, if confirmed, open up new therapeutic opportuni- the psychological treatment survived longer and, in
ties. addition, had higher lymphocyte counts following
Perhaps the most exciting possibility is that psycho- chemotherapy. In a prospective, randomised con-
logical interventions, in addition to improving quality trolled study of patients with malignant melanoma,
of life, may also be able to enhance survival. Spiegel et Fawzy et al.  showed that a brief psychoeduca-
al.  reported a 10-year follow-up of 89 women with tional intervention increased the percentage of large
locally advanced breast cancer. Some had received a granular lymphocytes (NK cell subpopulation) and
psychosocial intervention in a group setting and these enhanced the NK cytotoxic activity of blood lym-
women lived significantly longer than the control pa- phocytes. Psychoneuroimmunology, although still in
tients. Positive findings have also been reported in its infancy, is likely to be an important aspect of future
patients with malignant melanoma and lymphoma breast cancer research .
.However, much further work will be required to The possible etiological importance of life events
confirm or refute the hypothesis that psychosocial in- has not been clearly established. Loss events, for ex-
terventions can enhance survival. If they can, it will be ample bereavement, have been implicated by some
important to characterise the psychobiological factors clinicians and have been shown to induce cellular im-
(e.g., type and stage of tumour, and personality char- mune suppression (e.g., reduced in vitro response of
acteristics) that predict a satisfactory response to such blood lymphocytes to mitogens). Because it is cur-
interventions. rently not possible to identify the exact timing of the
If psychosocial factors can prolong survival, the ob- onset of malignant disease and its stage in individual
vious question is “how?” One possibility is that it may cases, it is not possible to establish a precise causal
act via psychoneuroimmunological mechanisms. relationship. The situation is somewhat simpler, how-
There is increasing evidence, in animal studies and in ever, with respect to life events and relapse of disease
human subjects, that various stressors have im- in patients with established and treated malignancy. In
munosuppressive effects. Moreover, there is some evi- a case controlled study, Ramirez et al.  found that
dence that psychosocial interventions can moderate severe life events and severe difficulties were signifi-
this suppression, particularly in healthy volunteers. cantly associated with increased incidence of tumour
Kiecolt-Glaser et al.  demonstrated immunosup- recurrence. However, negative findings have also been
pression in medical students during the month prior to reported.
an important examination. Moreover, they found that
those volunteers who had practised relaxation during ORGANISATION OF SERVICES
this period were less adversely effected. In a small On the basis of existing evidence, it is abundantly
randomised, controlled study, we found that subjects clear that the psychosocial dimension of patient care is
who practised special relaxation exercises daily for extremely important in terms of quality of life and that
three week had significantly lower systemic levels of it may also be significant in terms of disease progres-
interleukin-1 and showed reduced in vitro responsive- sion. This raises important organisational issues as to
ness of blood lymphocytes to the mitogen phytoha- who should provide the psychosocial support, what
emagglutinin . Volunteers in both groups were support should be provided, which patients should
subsequently exposed to a stressful experience pre- receive it, and what training is required for those pro-
ceded by a hypnotic induction for the volunteers who viding this support. In the United Kingdom, many
had learned relaxation. Interleukin- 1 levels and mito- centres have appointed breast care specialists who are
gen responsiveness quickly returned to baseline levels usually nurses by training. However, it appears that
following exposure to this experimental stressor. many have received no specific training in the identifi-
Little work has been done in breast cancer. How- cation of psychiatric morbidity and have been given
ever, Levy et al.  showed that patients with breast inadequate training in basic counseling skills. Several
82 Walker and Eremin
training courses have been established: the Manches- 5. Paraskevaidis E, Kitchener HC, Walker LG: Doctor-patient
communication and subsequent mental health in women with
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