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Depression screening essential in breast cancer treatment in SL: Study

21 Jun 2022

 
  • Recommends further psychiatric assessment, treatment for patients who screen positive 
  BY Ruwan Laknath Jayakody The inclusion of a proper screening method for depression in the routine breast cancer treatment package and patients who screen positive being offered further psychiatric assessment and treatment if indicated were recommended in a local study on the link between breast cancer and depression. The researchers who conducted the said study further recommended that since the lack of social support is the most significant yet preventable association with the presence of depression, patients, caregivers and medical practitioners should be educated about this matter and that measures should be taken in order to improve social support for these patients.  These recommendations were made in an original paper on “The prevalence and correlates of depression among patients with breast cancer, attending out-patient clinics at two cancer units in Sri Lanka” which was authored by T.A.S. Prabhath (attached to the Kamburupitiya Base Hospital) and R. Ruben (attached to the Karapitiya Teaching Hospital) and published in the Sri Lanka Journal of Psychiatry 11 (2) in December, 2020.  Breast cancer, according to W. Street’s “Breast cancer facts and figures 2019-2020”, is the most common invasive malignancy among females worldwide. According to the National Cancer Control Programme of Sri Lanka, in “Cancer incidence data Sri Lanka 2014”, breast cancer accounted for 25.2% of all types of cancers affecting females in Sri Lanka. Studies (M. Watson, J.S. Haviland, S. Greer, J. Davidson and J.M. Bliss’s “Influence of the psychological response on survival in breast cancer: A population based cohort study” and A. Begovic-Juhant, A. Chmielewski, S. Iwuagwu and L. Chapman’s “Impact of body image on depression and the quality of life among women with breast cancer”) have shown the prevalence of depression in breast cancer to be very high compared to general population figures, although it varies widely across different settings, ranging from 1% to 56%. Depression, per C. Sherrill, M. Smith, C. Mascoe, E. Bigus and D. Abbitt’s “Effect of treating depressive disorders on the mortality of cancer patients”, is reported to worsen the progression of cancer in many ways and ultimately, the outcome of the cancer treatment becomes poorer if the patient is depressed. Therefore, Prabhath and Ruben recommended that patients with breast cancer should be screened for depression and offered appropriate treatment if they are found to be depressed. Therefore, Prabhath and Ruben conducted a study to determine the prevalence and socio-demographic and clinical correlates of depression among female patients with breast cancer attending out-patient clinics at two cancer units in Sri Lanka.  The study was conducted at the National Cancer Institute of Sri Lanka and the Karapitiya Teaching Hospital. Female patients with histopathological evidence of breast cancer, attending out-patient oncology clinics at those two centres, between 1 July, 2020, to 10 August, 2020, were considered eligible. The total sample size was 335. Of the 335 participants, 84/24.5% screened positive for clinical depression and were found to be suffering from either mild, moderate or severe depression. This finding indicates that almost one quarter of the patients with breast cancer at the study sites were suffering from depression. The finding that suggests that the rate of depression in women with breast cancer in Sri Lanka being lower, Prabhath and Ruben opined, may be influenced by factors such as family support. Five socio-demographic factors were found to have a statistically significant association with the occurrence of depression, namely: the patient’s age, the partner’s employment status, the menopausal status, the number of children under the patient’s care, and the degree of social support.  The prevalence of depression was greater in those who were younger compared to among the older participants. A. Mehnert and U. Koch’s “Psychological co-morbidity and health-related quality of life and its association with awareness, utilisation, and need for psychosocial support in a cancer register-based sample of long-term breast cancer survivors” suggests the difficulty of accepting the cancer at a younger age, and anger against the diagnosis, as possible explanations for this.  Depression was less in the group with currently employed partners, compared to others with partners with no current employment. When partner employment is considered, the male partner’s unemployment status is important as an indicator of the family income for many families in Sri Lanka. During interviews with the patients in this study, the patients with breast cancer expressed worry about their partner’s unemployment status, and therefore this, Prabhath and Ruben observed, may have contributed to the association between the partner’s unemployment status and the occurrence of depression. Premenopausal women had a higher prevalence of depression.  However, A. Rady, O. Elkholy, H. Abouelwafa, A. Elsheshai, S. Elnoium and A. Mohammed’s “Demographic and clinical correlates of breast cancer patients with depression” showed the opposite association. As far as the number of children under the patient’s care was concerned, a lesser prevalence was found in the patient group with no children to care for, compared to the group who had children needing care. Having young children needing care has been described as a vulnerability factor for depression in the general population, and this may, Prabhath and Ruben noted, play a role with regard to depression even in patients with breast cancer.  However, in contrast to T. Deshields, T. Tibbs, M.Y. Fan and M. Taylor’s “Differences in patterns of depression after treatment for breast cancer”, there was no association between the number of children and the occurrence of depression in the instant study. Participants reporting good and very good social support had a lower rate of depression in contrast to the group with adequate or poor support. Among cancer-related factors, those with metastatic (cancer spreads to a different body part from where it started) cancer had significantly higher rates of depression compared to those with no metastasis. According to O. Peart’s “Metastatic breast cancer”, metastatic breast cancer has a poor prognosis and its five years survival rate can be as low as 26%, compared to non-metastatic breast cancer, which has a five years survival rate of almost 99%.  Studies (“Anxiety and depression in young women with metastatic breast cancer: A cross sectional study” by E.M. Park, S. Gelber, S.M. Rosenberg, D.S.E. Seah, L. Schapira, S.E. Come and A.H. Partridge, and “The biology of depression in cancer and the relationship between depression and cancer progression” by J. Sotelo, D. Musselman and C. Nemeroff) have shown that patients with distant metastasis have a higher symptom burden and stress due to chronic inflammatory reactions, which in turn makes them more vulnerable to become depressed.  All of these multiple factors are, Prabhath and Ruben explained, likely to contribute to the higher rate of depression in those with metastatic breast cancer. When treatment-related factors were concerned, the group treated with targeted therapy had a higher prevalence of depression. Those currently receiving hormonal therapy had a lesser prevalence of depression compared to the non-hormonal therapy group. Only social support was significantly associated with the risk of depression, with participants who reported good and very good social support having a significantly lower rate of depression. There was no significant association detected between the marital status, the educational level, the employment status, the family income, the family group, the presence of a history of a medical condition or a psychiatric illness, having a family history of psychiatric illness, the degree of the partner’s support, local lymph node invasion stage of cancer, having a family history of breast cancer, the duration since diagnosis, having a history of surgery, chemotherapy, radiotherapy or hormonal therapy, or current chemotherapy, and the occurrence of depression. Having a co-morbid medical condition and having a positive family history are risk factors for depression in the general population, but these risks, per D. Purkayastha, C. Venkateswaran, K. Nayar and U. Unnikrishnan’s “Prevalence of depression in breast cancer patients and its association with their quality of life: A cross sectional observational study” seem to be non-significant in patients with breast cancer. Even though local lymph node invasion itself did not show an increased risk of depression in this study, there are however various levels of invasion, per Rady et al., that were not considered in this study due to the unavailability of uniform pathological reports with the patients. If proper staging was considered, there may have been, per “Breast cancer staging: Tumour, node, metastasis classification for breast cancer”, significant associations with the prevalence of depression.  The present study did not detect any significant association with a family history of breast cancer and the occurrence of depression, and evidence on this, per the “Prevalence of major depression in patients with breast cancer” by S.M.F. de Carvalho, I.M.P. Bezerra, T.H. Freitas, R.C.D.S. Rodrigues, I.O.C. de Carvalho, A.Q. Brasil, F.T. Celestino Júnior, L.F.B. Diniz, A. Paz-Cox and L.C. de Abreu, is variable. The duration since diagnosis, though not seen in the current study, has been shown to affect rates of depression, per “Exercise, tea consumption, and depression among breast cancer survivors” by X. Chen, W. Lu, Y. Zheng, K. Gu, Z. Chen, W. Zheng and X.O. Shu, and A. Bener, R. Alsulaiman, L. Doodson and T. Agathangelou’s “Depression, hopelessness and social support among breast cancer patients in a highly endogamous population”. This current study also confirmed the heterogeneity of findings (studies which give conflicting evidence concerning various modes of treatment modalities used in breast cancer and their association with depression, with some not detecting any association with chemotherapy, hormonal therapy, radiotherapy, or surgery, while others showed significant associations with chemotherapy and surgery), given the positive association between depression risk and past target therapy, negative association with current hormone therapy treatment modalities, and no significant association with other treatment options. Per Kim et al., a depressive mood is a known side effect with chemotherapy, radiotherapy, and hormonal therapy, while psychological effects secondary to changes in bodily appearance after mastectomy have been attributed to depression in women who have undergone mastectomy.


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