Anxiety, Depression in Women at High Risk for Breast Cancer

WASHINGTON—A substantial minority of the women who see themselves as being at high risk for breast cancer because of family history suffer noticeable depressive symptoms and anxiety, and the anxiety can interfere with compliance with recommendations on breast self-examination (BSE), according to studies at the UCLA Revlon Breast Center.

Nangel Lindberg, PhD, of the Revlon Breast Center, and David Wellisch, PhD, professor in residence and chief psychologist for the Adult Services Division of the UCLA Medical School Department of Psychiatry, reported findings on 430 patients attending the Revlon Center’s high-risk breast clinic. They spoke at the American Psychological Association Conference on Enhancing Outcomes in Women’s Health.

"It’s not enough to present information about cancer and risk to such women," Dr. Wellisch said. "The anxiety must be managed." Depression, however, does not appear to affect compliance in these women.

Women are selected to attend the multidisciplinary clinic mostly because of elevated familial risk, and the clinic staff is "trying to assemble a basic literature on the psychosocial features" of this population, Dr. Wellisch explained.

Initial intake includes psychological screening tests and questionnaires about familial breast cancer history and the women’s demographic characteristics. In this study, 88% of the patients had first-degree relatives with breast cancer—their mothers in 71% of cases, a sister in 16%, and both in 13%. Two affected relatives is the average, but 28% of the women had three or more; one woman had 26.

Five percent lacked a familial history of breast cancer but had precancerous breast changes such as lobular carcinoma in situ, and 6% had both a family history and breast changes.

The women ranged in age from 15 to 78. Eighty-four percent were white, 73% had college or graduate education, and nearly all were of high socioeconomic status.

Depressive Symptoms

A total of 22% of the women scored above a cut point for depression, indicating elevated depressive symptoms, and 38% did so for anxiety, Dr. Lindberg reported. This cut point "is not a diagnosis of clinical depression, but rather a footprint in that direction," Dr. Wellisch emphasized. "A test score is not a diagnosis. That requires a clinical interview, which was not done in these cases."

Compared with the rest of the sample, the depressed women were significantly younger, 40 years vs 43 years on average, and more likely to be unmarried and without children. They had more relatives with breast cancer—2.3 vs 1.98. And they were less likely to have personally seen the results of their relatives’ breast cancer surgery, which indicates less intimacy and more secrecy within the family, Dr. Wellisch said.

In addition, the depressed women generally overestimated their cancer risk, sometimes drastically. Half viewed themselves as likely to develop the disease, although calculations showed that only about 18% would. Virtually none underestimated their calculated risk.

The women scoring above the depression cut point, however, did have higher computed risk than the women scoring below it, were themselves younger at the time of the first relative’s diagnosis, and were significantly more anxious. "The younger at initial exposure, the sadder," Dr. Wellisch said. "The more relatives, the sadder. The more worried, the sadder. And family secrecy breeds sadness."

Compliance

Mammograms and especially breast self-exams caused these women considerable anxiety, Dr. Lindberg said. Few, on the other hand, felt anxious about having a Pap smear, and 88% were up to date for that test.

Seventy-nine percent were also in compliance with recommendations to get mammograms. Just over a third, however, said they performed BSE monthly, and 28% said they never did. Many claimed that they do not know what they were feeling when they tried to examine their breasts.

The different social contexts of mammography and BSE may explain the different rates of compliance, Dr. Lindberg suggested. Mammography is a public act recorded in medical records and also affords clinic staff the opportunity to "hold the [anxious woman’s] hand."

BSE, conversely, occurs when the woman is alone in her shower, with no one to help her manage her anxiety or support her should she find a lump, Dr. Lindberg said.

Controlling Anxiety

Anxiety tended to be highest at the women’s initial visit to the clinic, and symptoms dropped modestly on follow-up visits, Dr. Lindberg said. The women’s sense of vulnerability to breast cancer also declined significantly after they enrolled at the clinic, she added. But this reduction involved only the anxiety specifically related to the clinic visits and not the woman’s general level of anxiety.

Both researchers emphasized the importance of anxiety control in the management of cancer risk. "Just telling these women about cancer or screening measures does not suffice," Dr. Wellisch said. "Without help managing their anxiety, they won’t remember."

Because the women attending the high-risk clinic are self-referred, it is not clear how well they represent the entire population of women at elevated familial risk, the researchers acknowledged.

Each woman’s individual experience with breast cancer and the specifics of her family circumstances powerfully affect her psychological adjustment to elevated cancer risk, the researchers agreed. They suspect, for example, that a mother’s breast cancer has a different impact than a sister’s. Also important are whether the affected relatives died or survived, the high-risk woman’s own age at any death, and how the cancer patient reacted to her disease.

No studies, furthermore, have yet examined another important factor, the impact of the father’s reaction, especially in cases where his wife has died. But it is clear that "how fathers behave profoundly affects their daughters," Dr. Wellisch said.