Monitor Patient's Emotional Adaptation to Breast Cancer

Breast cancer is a disease that not only has a high prevalenceand mortality but also profound psychological and psychosocialramifications. Women with breast cancer fear death and face complicatedmedical decisions and concerns about their body image, sexuality,and relationships.1

Thus, it is important to monitor patients' emotional adaptationthroughout the course of their disease, to support adaptive coping,and to recognize psychological symptoms that are beyond the rangeof "normal" adjustment and require psychiatric intervention.In the following case report, we describe the treatment of depressionin a woman at two different points during the course of her treatmentfor breast cancer.

Depression After Initial Therapy

A 53-year-old divorced woman with no personal or family historyof depression was diagnosed with stage I breast cancer in 1988and was treated with a modified radical mastectomy and chemotherapy(cyclophosphamide, metho-trexate, fluorouracil-CMF). Because thetumor was estrogen-receptor positive, she was started on the antiestrogentamoxifen (Nolvadex), 20 mg daily.

Four weeks after the start of tamoxi-fen, she told her primarycare physician that she was crying daily, and although she wasworking at a job that she had previously enjoyed, she now wasuninterested in her work and had difficulty concentrating. Shestated that she felt hopeless about her future, and she believedshe had somehow caused her breast cancer. Both her appetite andenergy level were good.

A psychiatric consultation produced a diagnosis of major depression,and the patient was started on fluoxetine (Prozac), 20 mg in themorning. In addition, she began weekly psychothearapy that utilizedboth cognitive behavioral and supportive techniques designed toalleviate psychological distress and provide emotional support.

After 2 weeks of both psychotherapy and fluoxetine, and whilecontinuing on tamoxifen, she felt better and was less tearful.Initially, she experienced mild nausea from fluoxetine; however,4 weeks later she stated that her depressive symptoms had resolvedand she was no longer nauseated. Fluoxetine was continued for6 months and then slowly tapered and discontinued. The patientremained on tamoxifen with no further depression.

Four Years Later

The patient was followed by her primary care physician, with noevidence of disease for 4 years, but in 1992 she was found tohave metastases to both lungs and brain. She was treated withwhole-brain irradiation, followed by adjuvant chemotherapy.

Two months after completion of whole-brain irradiation, the patientbegan to complain of depressed mood with feelings of hopelessnessand loss of interest in activities that previously had been pleasurableto her. She voiced feelings of guilt and again wondered what shehad done to cause her breast cancer. The patient reported hypersomnia,persistent fatigue, and vague suicidal ideation, stating "maybeit would be better if I didn't wake up tomorrow."

The patient called her psychiatrist and was started on paroxetine(Paxil), 10 mg in the morning, which was increased to the standardtherapeutic dosage of 20 mg daily after 4 weeks. She did not experiencenausea related to paroxetine; however, fatigue remained a persistentproblem, and 18.75 mg of pemoline (Cylert), a psychostimulant,was added at 8:00 AM to increase energy and improve appetite.

The patient once again entered psychotherapy, focusing on theimpact of her disease progression on her family. As she beganto discuss the possibility of her own death, end-of-life issueswere explored, and she was able to resolve her conflicts abouttermination of medical treatment.

An Often Difficult Diagnosis

Optimal management of depression in breast cancer patients requiresconsideration of the differential diagnosis, the possible roleof medical factors (including drugs), and appropriate treatment.

Our recent review of depression in patients with cancer suggeststhat there is great variability in the reports of the prevalenceof depression in women with breast cancer (ranging from 1.5% to50%), depending on the criteria used to establish the diagnosis.2However, it is likely that 10% to 25% of women with breast cancerwill at some point in the course of their illness have depressivesymptoms that require evaluation and treatment.

The diagnosis of depression is dependent upon the presence ofat least one of three symptoms: depressed mood (pre-sent for atleast 2 weeks), loss of interest or pleasure, or feelings of hopelessnessand helplessness.

Feelings of worthlessness or guilt and difficulty concentratingalso are symptoms associated with depression. Disturbances insleep (either hypersomnia or insomnia), weight gain or loss, fatigueand/or loss of energy, and psychomotor agitation or retardationrepresent physical symptoms associated with depression.

Suicidal ideation (not just fear of dying) is a symptom requiringspecial assessment that should take into account whether the patienthas a plan for following through with the suicide attempt, whethershe would or could act upon the plan, and the presence of barriersto acting upon the plan (eg, stating that one would shoot oneselfbut not having access to a gun).

To establish the diagnosis of depression, at least five of theabove symptoms, including either depressed mood or diminishedsense of pleasure, should be present. If the patient has depressedmood but does not possess five of the above symptoms, she likelyqualifies for the diagnosis of an adjustment disorder with depressedmood, and may benefit from antidepressants, hypnotics, and psychologicalsupport.

Both psychological and physical symptoms are usually present inthe symptom profile of depressed patients who are physically well.In the case of cancer patients who are undergoing hormonal therapyor chemotherapy or who have advanced disease, however, the above-mentionedphysical symptoms are less reliable indicators of depression.

Women with advanced breast cancer, or those at any stage who areundergoing chemotherapy or radiation therapy, frequently feelfatigued, may have sleep difficulties and appetite disturbances,and may appear slowed down or, conversely, agitated in their psychomotorfunction.3

Management Issues

When this woman was first diagnosed and treated for breast cancer,the doctor realized that tamoxifen may be a contributing factorin some patients' depression,4 but decided to continue the medicationwhile treating the depression.

Many of the drugs utilized in oncologic settings (hormones, steroids,analgesics, and antiviral drugs, among others) are associatedwith changes in mood or mental status. Consequently, a carefulassessment of the contribution of medications to depression isrequired, although often it is not possible to discontinue thesemedications.

When this patient's disease progressed, many of her physical symptomswere, in all likelihood, due to both the advanced nature of herdisease and the treatment she was receiving. By focusing on thepsychological symptoms of depression (depressed mood, hopelessness,guilt, lack of pleasure, and suicidal ideation), rather than thephysical symptoms, a more accurate diagnosis of depression inthis debilitated patient was possible.

In her case, the physical symptoms of depression that were morelikely associated with her advancing disease (eg, fatigue, appetitedisturbance, and sleep difficulties) were treated with an antidepressantand psychostimulant.

Antidepressants of Choice

Although tricyclic antidepressants once were the mainstay of thephar-macologic management of depression, the advent of the selectiveserotoninergic reuptake inhibitors (SSRIs) has provided effectivetreatment of depression in the medically ill patient without addingto the symptom burden associated with the tricyclics.

Fluoxetine (Prozac), the first of the SSRIs, has been shown toprovide additional energy for depressed patients, but the increasedlikelihood of nausea and vomiting makes this antidepressant lessdesirable for the cancer patient who may be taking other emetogenicdrugs.

Paroxetine (Paxil) and sertraline (Zoloft), newer SSRIs, havedemonstrated therapeutic efficacy with fewer side effects. Forsome patients, it may be helpful to add a benzodiazepine, eg,clo-nazepam (Klonopin), 0.5 mg bid, or alprazolam (Xanax), 0.25mg tid, to assist with insomnia or anxiety in the initial stagesof antidepressant use.

Additionally, for physically debilitated patients, the use ofa low dose of a psychostimulant-pemoline (Cylert), 18.75 mg inthe morning, or methyl-phenidate (Ritalin and generics), 10 mgin the morning and at noon-in the early stages of an antidepressanttrial may provide more immediate symptom relief in the form ofadditional energy, improved appetite, and improved sense of well-being."Start low and go slow" is a good rule of thumb in antidepressantuse.

Other newer antidepressant agents such as venlafaxine (Effexor)and nefazadone (Serzone) have also been shown to be beneficialin the management of depression.

Psychotherapy

Psychotherapy for women at all stages of breast cancer is a necessaryadjunct to psychopharmacologic interventions. The concerns ofwomen vary at different stages of breast cancer.

Meyerowitz5 described the impact of breast cancer on women inthree domains: psychological discomfort (anxiety, depression,and anger); changes in life patterns (consequent to physical discomfort,marital or sexual disruption, and altered activity level); andfears and concerns (mastectomy and loss of the breast, recurrence,and death).

By being aware of these issues, the physician who follows breastcancer patients can provide sensitive, comprehensive care, referringpatients with psychiatric disorders to psychiatrists or psychologistswhen appropriate.

In conclusion, breast cancer is a disease that is increasing inincidence. Depressive symptoms or syndromes are common responsesto this disease in both its early and late stages.

Accurate psychiatric diagnosis with consideration given to allmedical factors that can contribute to depression is essential.Psychiatric treatment, including both psychopharmacologic andpsycho-therapeutic interventions, offers women with breast cancerthe possibility of better quality of life.

References

1. Massie MJ, Holland J: Psychological reactions to breast cancerin the pre- and post-surgical treatment period. Semin SurgOncol 7:21-25, 1991.

2. DeFlorio M, Massie MJ: Review of depression in cancer: Genderdifferences. Depression (in press).

3. Gagnon P, Massie MJ, Holland J: The woman with breast cancer:Psychosocial considerations. Can Bull 45:538-542, 1993.

4. Cathcart C, Jones S, Pumroy C, et al: Clinical recognitionand management of depression in node negative breast cancer patientstreated with tamoxifen. Breast Cancer Res Treat 27:277-281,1993.

5. Meyerowitz B: Psychosocial correlates of breast cancer andits treatment. Psychol Bull 87:108-113, 1987.

Diagnosing Depression

Patient Must Have at Least Five of These Symptoms, Includingat Least One of the First Two:

1. Depressed mood (present for at least 2 weeks)

2. Loss of interest in activities or diminished sense of pleasure

3. Feelings of hopelessness and helplessness

4. Feelings of worthlessness or guilt

5. Difficulty concentrating

6. Sleep disturbances (hypersomnia or insomnia)

7. Weight gain or loss

8. Fatigue and/or loss of energy

9. Psychomotor agitation or retardation

10. Suicidal ideation

Dr. Payne is Barbara White Fishman Psychiatry Fellow, PsychiatryService, Memorial Sloan-Kettering Cancer Center, New York. Dr.Massie is director, Barbara White Fishman Center for PsychologicalCounseling, Memorial Sloan-Kettering Cancer Center, and professorof clinical psychiatry, Cornell University Medical College.