Young Breast Ca Patients at Higher Risk of Distress


BOSTON — The psychosocial needs of young breast cancer patients should be viewed in a different context than those of older women, said Lidia Schapira, M.D.

“Premenopausal women with breast cancer are at greater risk of psychological distress at diagnosis and during treatment, especially when it coincides with childbearing years or with years spent in active parenting roles,” Dr. Schapira said at a breast cancer meeting sponsored by Harvard Medical School.

Because younger women face such concerns as premature death and the impact that treatment will have on fertility, child rearing, career, finances, and appearance, clinicians must broaden their traditional vertical focus on managing the medical aspects of the disease “and look at the horizontal axis of patients' social functioning as they deal with their diagnosis and treatment,” said Dr. Schapira of Massachusetts General Hospital, Boston.

The nature and extent of a breast cancer patient's psychological distress will vary depending on both the individual and the phase of the disease. The concerns at diagnosis might be different from those experienced during primary treatment or at treatment completion, Dr. Schapira said.

At all points along the disease trajectory, clinicians should address “normal” levels of psychosocial distress and be alert for signs of persistent distress that would benefit from specific mental health intervention. Toward this end, according to guidelines in a 2004 Institute of Medicine report on the psychosocial needs of women with breast cancer, clinicians should:

▸ Clarify and ensure understanding of diagnosis and treatment options and side effects.

▸ Advise that distress is normal and expected and can increase at transition points.

▸ Build trust.

▸ Mobilize resources and direct patients to educational materials and local resources.

▸ Consider medication for symptoms.

▸ Ensure continuity of care.

▸ Monitor and reevaluate for referral to more specialized services if needed.

Additionally, a variety of interventions have been shown to favorably impact psychological status and quality of life, Dr. Schapira said. “Notably, there is strong evidence for the benefit of relaxation, hypnosis, and imagery in early-stage breast cancer, for group interventions in both early and metastatic disease, and for individual interventions primarily in the early setting,” she said.

Finally, clinicians need to be acutely aware of the special issues facing women who are diagnosed during their parenting years. “Being a parent affects preference for adjuvant chemotherapy in women with breast cancer, yet the impact that the side effects of treatment will have on the parenting experience are rarely discussed in the context of a medical encounter,” Dr. Schapira said. “Studies have shown that parents want to know how to talk about the illness with their kids in a developmentally appropriate way,” she said, and that parents need guidance in understanding and dealing with the impact of maternal disease on children's behavior and level of distress.

One example of how such issues might be addressed is a program developed by Paula Rauch, M.D., at Massachusetts General called Parenting at a Challenging Time (PACT). Through PACT, child psychiatrists and psychologists provide free consultations to adult cancer patients or their partners to help them address the needs of their children during treatment, Dr. Schapira said. “The program recommends that clinicians ask patients if they have children, and follow up with questions about the children and discuss the resources that are available to them,” she said.

Clearly, clinicians cannot be the only source of psychosocial support for their younger breast cancer patients; they should be cognizant of the potential for significant distress and be prepared to help these women get the support they need, Dr. Schapira concluded.

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