Psychologic Adaptation to Breast Cancer

JlMMlE C. HOLLAND, MD* AND RENE MASTROVITO, M D t

Adaptation to breast cancer depends on two parameters: one derived from the patient and one from the
disease. The first comprises the psychological and social factors that are determined by the patient and
her surroundings: the psychologic adjustment the patient had before illness, her social supports,
especially her spouse, and her social context which will contribute to her need to hide her illness or
encourage her sharing the loss with others, especially those who have had a similar experience.
The other factor determining psychologic adjustment is contributed by the disease itself: the extent of
spread, surgical operability, need for adjuvant therapy, the full application of rehabilitative measures,
including plastic reconstruction when appropriate, and the psychologic management by the surgeon in
the doctor-patient relationship. Each of these variables contributes to the emotional resources available
to the woman and to the stresses that must be surmounted in adaptation to breast cancer; each can
serve as a positive force or a negative one. At times, one strongly positive factor, such as family support,
can counter several exceptionally negative aspects and result in a positive adjustment despite severe
illness. Each variable will be discussed in relation to its contribution to an “adaptive readaptation” and
optimal psychologic well-being despite illness, versus those factors that create a “maladaptive readapta-
tion” with less than optimal psychologic well being.
Cancer 46:1045- 1052, 1980.

C has been the most exten-

A N C E R OF T H E BREAST
sively studied tumor site for its psychologic and
social impact. Studies suggest that while it is a stress
is the medical, which is determined by the disease and
its course and treatment.4

that tests every woman’s adaptive capacities, it is Psychosocial Factors

clearly more difficult for some women than others. This
report attempts to outline the spectrum of factors that
contribute to a “good or poor” adjustment. An under-
standing of these factors also provides a framework
from which psychologic adjustment can be viewed and
from which psychologic and social interventions can be
planned and directed toward promoting optimal psy-
chologic adaptation to breast cancer, its treatment,
and rehabilitation to full physical and psychosocial
function.
Factors in Adaptation
Psychologic adaptation depends on factors from two
primary parameters: the psychosocial, which is derived
from the patient and her psychosocial milieu; the other
Presented at the American Cancer Society National Conference on
Breast Cancer- 1979, September 6-8, 1979, New York, New York.
From the Memorial Sloan-Kettering Cancer Center, New York,
New York.
* Chief, Psychiatry Service.
* Attending Psychiatrist, Psychiatry Service.
Address for reprints: Jimmie Holland, M.D., Memorial Sloan-
Kettering Cancer Center, 1275 York Avenue, New York, New York,
10021.
Accepted for publication January 2, 1980.
0008-543X/80/0815/1045 $0.90 0 American Cancer Society
The first one is the psychosocial parameter, which is
determined by what the woman herself brings to the
situation, and her social surroundings (Table 1). The
social surrounding is first concerned with the cul-
tural context in which breast cancer occurs. Breast
cancer has undergone the most startling change in the
public’s knowledge and response to this site of cancer.
Women have asserted their right to know more about
treatment and prevention. The news media have fos-
tered open discussion of mastectomy and breast can-
cer, as compared to only afew years ago when the topic
was never discussed. Women did not even know they
had breast cancer, since they were ordinarily told they
had a mastectomy because “it might turn into breast
cancer.” Today, all women know why they had a mas-
tectomy, and they can speak with less embarrassment
about having had a mastectomy. They feel far more
able to discuss feelings and thoughts with family,
friends, and other women; they no longer feel
ashamed o r compelled to hide the fact that they have
had breast cancer.5
The change has occurred for several reasons.
Women have insisted upon participation in and respon-
sibility for their own health care. This has included far

1045
1046 CANCER
August Supplement 1980
TABLE1. Factors in Psychologic Adjustment-I
Psychosocial
Cultural context
Psychologic
Life cycle tasks and disruptions
Coping patterns
Interpersonal
Spouseifamily, others
greater knowledge about breast cancer, including the
medical controversies about its treatment. An addi-
tional societal change has been that of increasing dis-
trust of all institutions and authorities. Physicians can
no longer maintain the stance of “trust me, I know
what’s best for you.” Far more time is spent between
doctor and patient in a detailed description of treatment
options, which, in the long run, produces a healthier
doctor-patient relationship and a more cooperative and
knowledgeable patient. Women insist upon sharing in
decisions about their care. This setting has decreased
the sense of almost complete helplessness that many
patients with cancer have felt until the last decade. It is
a healthier social environment in which a woman has
breast cancer today. Honesty, candor, and opportuni-
ties for discussion of adjustment make the probability
of positive adjustment far more likely for the woman,
her husband, and her family.
Increasing patient responsibility in treatment in-
creases the number of decisions the patient must make,
and this has, at times, led to increased anxiety about
contemplating alternative approaches to treatment.
Furthermore, media coverage of cancer consequences,
cancer staging, survival rates, and the possible dele-
terious side effects of some forms of treatment has been
extensive. Controversies about radiotherapy versus
chemotherapy have increased the anxiety about the
proper decision concerning adjuvant therapy among post-
mastectomy patients. Finally, the general knowledge
that even an early, well-treated breast lesion does not
guarantee a cure is often a challenge to the natural
defensive process of denial among post-treatment pa-
tients.
The second aspect of the psychosocial parameter
relates to the patient herself her own coping patterns
and at what point in the life cycle breast cancer has oc-
curred. Each woman has her own style of adaptation to
stress, which tends to be a remarkably abiding q ~ a l i t y . ~ presence of a social support system, beginning with
The coping strategies that have been found most often
effective in breast cancer have been identified by
Penman as a cluster of behaviors noted in the imme-
diate post-mastectomy period, which were charac-
terized by an approach to the problems with a “tackling
stance.”1° Those women who used avoiding, rather
than “confrontative” coping strategies, were more
emotionally distressed in the early rehabilitative stages
Vol. 46
after mastectomy than were the women who dealt more
directly with the stress.
The adaptation may also be altered by the special
meaning associated with a breast cancer for a par-
ticular woman. Women today who are at higher genetic
risk of breast cancer recognize that risk and must deal
with closer monitoring of their health by regular breast
self-examinations, physician visits, and mammography.
The increased anxiety makes some women try to deny
the risk, whereas others become preoccupied with
checking possible breast lumps. Finding a lump results
in greater anxiety in these women who recognize their
potential for breast cancer. They may also recall their
mother’s, grandmother’s, or sister’s breast cancer ill-
ness. When it has resulted in death, the fear of a similar
outcome with painful memories will return under the
stress of their own illness and cause significantly
greater distress, requiring greater adaptive response.
Other women have particular fears of anesthesia or sur-
gery, and these individuals may have greater psycho-
logic difficulty. A careful medical, family, and psychi-
atric history will reveal these high risk factors for emo-
tional distress.
The second parameter relates to the point in the life
cycle at which the breast cancer occurs, and what so-
cial tasks are threatened or interrupted. The threat to a
sense of femininity and self esteem occurs in all women,
but it may be more for a young woman whose attrac-
tiveness and fertility are paramount, and especially for
those who are single and without a close male relation-
ship. In most instances, the meaning of the breast can-
cer is quite different for her than for the older woman
who has a secure home and family, and for whom the
risk to life may predominate. The fact that breast can-
cer occurs frequently in older women who may be ex-
periencing other losses, including widowhood, places
a high cost on adaptation, not only to the losses in her
social environment but also to the loss of a breast and
threat to life.
The interpersonal environment of the person is par-
ticularly important in the adaptation. The husband or
sexual partner’s response to the woman after breast
cancer and mastectomy can provide (or deprive) the
patient of the security of being loved and esteemed,
despite mastectomy and presence of significant illness.
One of the most helpful components in adaptation is the
spouse, immediate family, relatives, and friends with
whom the illness can be openly discussed. Decisions,
which must be made, become easier when shared.
Medical Factors
Breast cancer varies in its presentation and potential
threat to life (Table 2). The symptoms, location, and the
No. 4 PSYCHOLOGICAL TO BREASTCA . Holland and Mastrovito
ADAPTATION
stage of the tumor when detected determine the treat-
ment that must be required.
Extent of the primary surgical procedure, whether
total or modified radical mastectomy, and whether
adjuvant therapy is necessary pose major differences in
the stress which breast cancer presents. The increased
threat of life is recognized when adjuvant therapy is rec-
ommended. In addition, the side-effects of these
therapeutic modalities complicate adjustment and
must be tolerated shortly after recovery from surgery
itself. Some women feel the operation was minor com-
pared to adjuvant chemotherapy.
The rehabilitation that is available is important in
psychologic adaptation. The availability of newer
breast protheses, which have been developed with
greater concern for matching shape, size, and color as
well as specially designed clothes, has made adjust-
ment easier. Most important, plastic reconstruction of
the breast is now often discussed with women before
mastectomy which helps to reduce the finality of loss of
the breast. The fact that they may choose to pursue re-
construction, in contrast to earlier times when the op-
portunity was not available, diminishes some of the pro-
found sense of loss and the finality of mastectomy.
Although little scientific data have been collected to
date, there are suggestions that the option for recon-
struction diminishes the sense of loss, even when it is
not exercised. The fact that this option exists in-
definitely is reassuring.
The last medically related factor is the psycho-
logical management of the patient by the health care
team. The family physician or gynecologist refers the
woman with a suspicious lesion to the surgeon. The
care with which the original workup is done, and the
knowledge that no time was lost by procrastination by
the doctor is important. Women who are most sad and
bitter in advanced stages of disease are those who look
back and blame themselves or the doctor for delaying
in recognizing an early and treatable lesion. While
some of this is anger at Fate, it is compounded when
human error, not Fate, has contributed to the increased
threat to their life.
The relationship to the surgeon is the keystone to
promoting a good (or poor) psychologic adjustment.
The surgeon who takes time to describe the procedures,
to answer questions, and to monitor the woman’s re-
sponse in the preoperative period, has set the stage for
a far better postoperative adjustment.
These are the psychosocial (patient-related) and
medically related factors that determine adaptation at
each stage, from finding a lump in the breast, to mas-
tectomy, and to the subsequent treatment of breast can-
cer. Most individuals are able to respond to the stress
with only transient psychologic distress. For some pa-
tients, however, extreme stress reactions can be seen
1047
TABLE2. Factors in Psychologic Adjustment-I1
Medical factors
Symptoms, site & stage of disease
Treatment required
Surgery. radiotherapy ’chemotherapy
Rehabilitation available
Prosthesis; reconstruction
Psychologic management by staff
due to some particularly adverse single factor or a com-
bination or accumulation of factors within those pa-
rameters outlined. These factors lead the patient to
experience more than the usual level of distressing symp-
toms and may result in serious psychological decom-
pensation requiring intervention. These responses con-
stitute the range of psychiatric syndromes seen com-
monly in c a n ~ e r . ~
Psychiatric Syndromes
Perioperativr Syndromes
The stress responses which occur around the time of
surgery are referred to as perioperative psychiatric
syndromes (Table 3 ) . They are characterized by the pres-
ence of anxiety, depression, or a mixture of both. This
is also called situational or reactive anxiety and depres-
sion as part of a stress response. Acutely, the patient
may be unable to perform daily tasks, will be unable to
concentrate, and will have insomnia, anorexia, and
weight loss. The response has phases characterized by
Horowitz as outcry, denial, emotional distress, and
resolution;6 similar phases occur in acute grief. The
response is apt to be characterized by a high level of
anxiety. An important concern is that the level of
anxiety may interfere with reasonable judgment about
accepting proper medical care.
The key to the management of this preoperative
stress lies with the surgeon himself. In his consultative
visits, he should establish with the patient a relation-
ship that conveys confidence in his surgical ability and
approach and which also promotes the sense of trust,
interest, and willingness to discuss treatment and an-
swer questions. Patients choose physicians often with-
out knowing them, but they invest them with emotions
that often reflect feelings that were given to authority or
parental figures. The response to the surgeon can thus
be an extremely positive or negative one for these rea-
sons, which reflect earlier relationships in life and
which have less to do with the surgeon himself. The
necessity to place one’s life in another’s hands for a sur-
gical procedure may cause feelings of antagonism or
excessive attachment. The surgeon must recognize the
irrational basis for some of these responses and avoid
responding personally. In addition, adequate prepara-
tion for the surgery must include the patient’s aware-
1048 CANCER
August Supplement 1980 Vol. 46

TABLE3. Psychiatric Syndromes and Management phone or visit. The woman may become isolated from
Perioperative syndromes Management
her family, whom she does not wish to upset. She is apt
A. Preoperative to be alone with her anxieties, and unless the surgeon
Stress response Relationship to surgeon offers information about supportive services, she will
Counseling have none available until hospitalized, usually the night
Nurse before surgery. A sensitive ex-patient who has had mas-
Veteran patient
Antianxiety medication tectomy and who can work well with the surgeon and
B . Postoperative Relationship to surgeon his staff can also reassure the patient about fears and
Stress response Counseling anxieties, providing an important link to another at a
Staff time of stress. The fears of someone “saying the wrong
Veteran patient
Group thing” seem less formidable than in earlier times
Psychotropic medication when ex-patients were not allowed a role in counseling.
Deliriudps ychosis Psychiatric consultation
Most hospitals now use “veteran” patients to counsel
Maladjustment during rehabili- new patients awaiting the same procedure.
tation-reactions to stress
Depression/ Anxiety Psychotropic drugs
The postoperative syndromes are of two kinds: stress
Counseling responses and the more serious complication of post-
Family operative delirium/psychosis occurring in the immedi-
Individual
Group
ate postoperative period (Table 3). In the postoperative
Psychosexual Consultation
period, the most common responses are stress reac-
Counseling tions to the loss of a meaningful body part and readapta-
Spouse tion to the full prior social and sexual roles. The radical
Couples
Individual
mastectomy done commonly until the last five years,
produced more functional disability, greater disfigure-
Reactions to adjuvant therapy
Radiotherapy Relationship to radiotherapist ment of the chest wall, and a more severe reaction, par-
Chemotherapy and oncologist ticularly when the surgery had to be kept a secret from
Adequate preparation for treat- others. Even today, however, with modified or less
ment extensive removal of breast tissue, there is still a reac-
Support by clinic staff
Help with side effects
tion to loss of a body part which has emotional meaning
Veteran patient counseling both in relation to attractiveness, sexuality, and nurtur-
Plans for ending treatment ing. The response usually is a type of normal grief, and
Stress reactions women do better when they are prepared for the fact
Recurrence Monitor behavior that they may have the “blues”, cry easily, and may
Protracted severe illness Major tranquilizers
Suicidal behavior Antidepressants feel more anxious and depressed for a few weeks after
One-to-one observation the operation. Nightmares may be frightening and
Counseling reflect unexpressed fears of bodily damage and death
CNS complications Consider in differential and fears of rejection by the spouse. It is at this time,
Metastatic and particularly if the period of depression secondary to
Metabolic diagnosis of altered behavior;
Drug-induced Identify cause; control behav- loss of an important body part lasts for weeks or
ior with halperidol, pheno- months, that the surgeon may need to be the most sup-
thiazines portive. Ancillary medical and paramedical forces are
Close observation
usually of great help, but the treating physician (sur-
geon) must be aware that he or she is the key figure from
whom the patient needs support. Thus, the surgeon
ness of the reason for the procedure, how it will be done, must be prepared to accept in a supportive manner the
and what can be expected in the postoperative and re- patient’s grief and sometimes hostility. In the past,
habilitative phases. This opportunity for mentally “re- patients have been poorly served when the physician
hearsing” the anticipated experience is extremely has communicated an attitude that the loss of a breast
valuable before surgical procedures. The anxiety is is trivial under the circumstances. The patient who has
high for the woman who must wait to be placed on the been informed of what to expect in the postoperative
operative schedule, especially when surgical biopsy period and who has been reassured that her feelings are
and possible mastectomy are done as a single stage. not abnormal, can be helped to avert serious problems,
The surgeon’s explanations can be greatly expanded which are more likely to occur when some other con-
and clarified by a physician’s assistant, nurse, or social current stress is added, such as a mental disorder, or
worker who is available to the patient at home, by tele- loss of a mother or sister with breast cancer. Inclusion
No. 4 PSYCHOLOGICAL TO BREASTCA . Holland and Mastrovito
ADAPTATION
of the spouse in discussions about the care of the opera-
tive wound, even participation in dressing changes,
encourages both to an early acceptance of the opera-
tion.
Psychosocial interventions have been more exten-
sively developed to aid in post-mastectomy psychoso-
cia1 adjustment than any other site of cancer, except
laryngectomy and colostomy, which similarly require
comprehensive rehabilitative efforts by the patient.
Post-mastectomy psychological support has taken two
major models: individual and group counseling. Indi-
vidual counseling by a team was implemented at
Montefiore Hospital by a nurse-practitioner, social
worker, and Reach-to-Recovery volunteer who also
functioned as patient advocate with the team. l2 The
availability of the team for intervention as needed in
the hospital, and at home, was found to maintain
morale and to improve patients’ ability to cope, par-
ticularly with adjuvant therapy. The team offered sup-
port in the hospital, preparation for discharge, and a
home visit by the nurse to monitor emotional response
and medical complications , while also providing com-
munication with the surgeon. Three Reach-to-Re-
covery visitors were trained for an advocate role, be-
coming a “special friend” who had had a mastectomy,
who understood the problems, and who understood
their community, since they were matched for ethnic/
social group.
The American Cancer Society supported Reach-to-
Recovery program has been the most widely accepted
and approved program of use of the “veteran” patient.
A postoperative hospital visit by these sensitive and
perceptive volunteers presents the reality that someone
else has mastered a similar crisis. They also discuss
practical issues of exercises, a temporary prosthesis,
and a bra to wear home. Few surgeons remain who do
not refer patients to Reach-to-Recovery , recognizing
that the woman who has had a mastectomy gains from
speaking to another woman who understands the
experience in a way that no one else can.
Postoperative group meetings have become part of
the accepted treatment at Memorial Hospital, co-
chaired by a nurse, physical therapist, social worker,
and a Reach-to-Recovery volunteer.2 This group meet-
ing provides a forum for discussion of medical symp-
toms, for beginning and learning exercises to prevent
lymphedema, and for discussing the shared feelings of
fears of returning home after loss of an emotionally
important part of the body. Practical questions are dis-
cussed: Who to tell? Who to show the scar? How to tell
the children? How to manage sex? These issues
become less formidable when alternatives are dis-
cussed, and thoughts can be reflected with others
before confronting each situation. Group meetings are
1049
also available for the patient and her spouse after
discharge, again using a social worker and a Reach-to-
Recovery volunteer and her spouse as co-leaders.
Counseling may be needed for the patient alone, who
may have life stresses that compound the impact of
mastectomy. Patient and sexual partner may need
counseling together, or group counseling, either
through self-help/mutual support or professionally run
groups, which result in appreciable reduction of mal-
adaptive responses.
The more serious of the postoperative syndromes is
that of a delirium/psychosis. The term is combined
because the cause is so often unclear and appears to
represent a combination of mild cerebral dysfunction
and response to stress. It rarely has a solely
functional etiology, particularly in a previously
psychologically stable individual. An idiosyncratic
response to anesthesia or analgesics, a period of
transient hypotension or cerebral anoxia may cause
postoperative delirium by transiently diminishing adap-
tive and intellectual function. Frightening visual
hallucinations, illusions, or delusions occurring with
some insight into their unreality are a common part of
the clinical picture.
The syndrome often produces agitated, excited be-
havior that may threaten harm to self or others. It
should be treated, establishing the etiology and using a
means to rapidly control behavior. Haloperidol has
been found to calm behavior without producing seda-
tion or somnolence. It also produces minimal cardio-
vascular effects and extrapyramidal symptoms. The
intramuscular dose of 5 mg every 30 minutes to 1
hour, while observing the patient, usually controls
behavior within one to four doses. Thiothixene
(Navane) and loxapine (Loxathine) can also be used
in a similar fashion for rapid control of behavior.
Maladjustment during Rehabilitation
Responses to stress are primarily anxiety and depres-
sion, which begin to diminish within a few weeks in the
post-mastectomy patient (Table 3). Most women
return, over one to three months, to normal home life
and work, with a gradual return to usual energy levels
and normal spirits. Penman found that women who
were at high risk of a continued level of distress at four
months could be identified by the less effective coping
strategies employed in the immediate postoperative
period.’O Anti-anxiety medication such as Valium 2-5
mg T.I.D. and bedtime sedation, using flurazepam
(Dalmane) 30 mg, diminish tension and encourage a
more relaxed response to social situations. Evidence
supports the fact that psychotropic medication is
readily given up when the stressful time is over,gadding
1050 CANCER
August Supplement 1980
to our security in encouraging their use during life crises
such as surgery.
Psychosexual difficulties may arise as a stress re-
sponse to mastectomy, either in the patient o r her
sexual partner. The patient suffers a threat to self-
esteem that may be manifested by actually having little
sexual desire temporarily as a response to both surgery
and to the emotional stress. She may also fear being
rejected and abandoned by her partner due to her
changed appearance and by the loss of the breast. She
may transiently become frigid and distant as a result
of these feelings, at a time when the need for affection
and sexual attention is actually heightened and strongly
desired but also feared. The man, because of fears of
injuring or hurting his partner during intercourse, may
also experience difficulties with sexual performance.
The surgical procedure may threaten his own sense
of body integrity and invulnerability, which may make
sexual relations difficult. The best treatment in these
situations is prevention-by instructions from the sur-
geon that early return to usual sexual relations is
highly desirable. Participation of the spouse with the
patient through all steps of the discussion about treat-
ment so that there are no secrets and no sudden adjust-
ments to be made serves to maintain closer communi-
cation. Fears of injury o r harm are most rapidly
dissipated by open communication and natural sexual
behavior. The patient is reassured that she is loved as
a person, and that loss of her breast has not altered a
close and loving relationship. The women who must re-
turn to a marital situation that was previously troubled,
or in which the partner is unable to accept her after a
mastectomy, is confronted with not only a loss of
breast, but a loss of an expected emotional support.
Adaptation in the post-mastectomy period will be more
difficult and troubled due to this socially determined
(not medical) factor. The life crisis posed by breast
cancer can serve as a catalyst to deal with long standing
marital problems that have been tolerated until that
time. Like any life crisis, it can be used positively to
promote better adjustment. Reassessment of relation-
ships and life goals is not uncommonly an outgrowth
of life-threatening illness, bringing values into sharper
focus.
Reactions to Adjuvant Therapy
Surgical adjuvant therapy after mastectomy may be
either radiotherapy or chemotherapy; both are frighten-
ing since they represent evidence of a continuing threat
to life and another threat to body integrity and function,
just when adjustment to a mastectomy is being accom-
plished (Table 3). The advice given by the radio-
therapist or oncologist in his initial consultation is
critical in providing the patient with accurate infor-
Vol. 46
mation about the need for treatment, alternatives, side
effects, risks, and benefits. The physician’s manner
should convey a sense of confidence about the treat-
ment plan by answering questions and establishing a
therapeutic alliance. Psychologic preparation for the
treatment should include meeting the clinic nurse, staff,
and particularly the nurse who will give the chemo-
therapy or the technician operating the radiotherapy
machine. The psychological rehearsal allows anticipa-
tion of the treatment and significantly diminishes
anxiety. The attitudes and manner of the entire clinic
staff, from the secretary who greets the patient each
day to the technician and the physician, become posi-
tive adaptive forces in the patient’s experience of the
treatment setting. All the staff should be alert to
changes in patients’ mood, especially when morale is
low or when continuing treatment is becoming dif-
ficult. Staff attitudes, which encourage compliance
with treatment and which assist in the ability to
tolerate the treatment side effects, become significant
interventions. Patients undergoing chemotherapy have
benefited from group meetings that promote a sense of
group identity, that allow sharing of solutions to com-
mon problems, and that improve adaptation to illness
by more openly dealing with it, with family and
medical staff.13
In a study of women receiving post-mastectomy
radiotherapy, it was found that while overall anxiety
diminished as patients neared the end of therapy, the
patients were significantly more depressed and angry,
and had specific anxieties about leaving treatment. This
stemmed not only from stopping treatment, which
meant the disease might recur, but also from leaving
the close medical observation and i n t e r a ~ t i o n . ~
Emotional preparation for ending a lengthy and energy-
consuming therapy is as necessary as preparation for
beginning a new treatment. Emotional dependence,
which naturally develops during a long treatment regi-
men, may require telephone contact o r an earlier re-
visit than might otherwise be planned on medical
grounds alone.
Stress Reactions
Recurrence
When recurrence of breast cancer is diagnosed after
a disease-free interval, it is a time of acute and signif-
icant emotional reaction, which is a stress response
syndrome characterized by anxiety, depression, and, at
times, suicidal risk. Often a transient disorganization
occurs with inability to carry out daily activities. The
physician should carefully observe the patient’s
response to news of recurrence and combine it with
discussion of the new, if altered, treatment plan.
No. 4 PSYCHOLOGICAL
ADAPTATION
TO BREASTCA
Assurance of continued treatment and commitment
by the doctor is essential. The acute stress is usually
resolved over a few weeks as the person adapts to
altered reality and begins to cope effectively with it.4
Protracted Severe Illness
Protracted severe illness or repeated bouts of critical
illness produces a response, which is characterized by
apathy, depressed mood, and emotional lability with
frequent crying. These patients are often referred for
psychiatric consultation because of depression. In
fact, the picture appears to be more of a “psychologic
exhaustion” of emotional resources to cope with the
repeated stresses of critical illness. They often ex-
perience transient episodes of mild to severe cerebral
dysfunction, which contribute to subclinical diminished
cognitive ability, not readily apparent in usual inter-
action with staff and family.4
Suicidal Risk
Breast cancer is particularly apt to follow a long
clinical course with metastatic lesions to the bone, lung,
or brain; these lesions are painful, debilitating, and
stretch the adaptive strength of the most emotionally
healthy. While breast cancer patients were more often
the source of psychiatric consultation in one study of
hospitalized cancer patient^,^ this was not confirmed
in a study at Memorial Hospital.8 Both studies, how-
ever, confirmed that individuals who are older and who
have an advanced stage of disease are at highest risk for
depression and suicidal ideation. Women with dissemi-
nated breast cancer may exhibit a depressed mood,
which may require intervention and monitoring for
suicidal risk. Antidepressants are often of value, partic-
ularly when insomnia is a prominent symptom.
Amitriptyline or imipramine, beginning at 50 mg at bed-
time and increased to a therapeutic trial of 150 mg, may
significantly improve mood and activity within two to
three weeks.
Central Nervous System Complications
There are three common reasons for central nervous
system complications in breast cancer (Table 3). In
order of frequency, they are the development of
metastatic brain lesions, metabolic-induced encepha-
lopathy, or drug-induced encephalopathy . The onset
of altered behavior in a woman who has breast cancer,
particularly if it is sudden, must be carefully assessed
for possible cerebral dysfunction. A change in mood,
apathy, loss of interest in surroundings, should be
cause for consideration, not only of functional causes
’ Holland and Mastrovito I051
but also for central nervous system complications of
breast cancer. A brain metastasis may be the first
indication of dissemination. As women receive more
aggressive and effective primary treatment for breast
cancer, intracerebral metastases are increasing in fre-
quency.” When the brain metastases occur, they
are also being more actively treated; early diagnosis
and treatment by radiotherapy or extirpation often lead
to prolonged life with intact mental function and an
acceptable quality of life.
In the presence of known disseminated disease with
bone metastases, hypercalcemia commonly produces
a metabolic encephalopathy with a fluctuating picture
of mild delirium, confusion, depressed mood, and in-
tellectual deficit. Organ failure related to kidney or
liver will be accompanied by encephalopathy , as well
as cerebral hypoxia from lung metastases.
The third area of central nervous system complica-
tions results from drugs. The spectrum of narcotics
given for analgesia produce idiosyncratic responses
with hallucinations and acute delirium. Steroids,
which commonly cause mood change, infrequently
produce psychosis, but they are a common part of
management of advanced disease. Assessment of medi-
cations for possible cause of CNS dysfunction is
necessary.
Summary
The pertinent factors that contribute to the psycho-
logical adjustment of a woman to breast cancer come
from two significant areas: those psychosocial factors
related to the patient and her social environment and
those emerging out of the clinical situation. The
psychosocial factors are based on the cultural context
in which illness occurs, the woman’s psychologic
coping patterns, the particular life cycle tasks that were
disrupted by the development of breast cancer, and her
interpersonal social supports, particularly spouse,
family, and others. The medical-related factors are the
symptoms, stage of disease, the treatment required,
the rehabilitation that is available to her, and the
psychologic management by the treating medical staff.
Psychologic interventions are aimed at altering one or
more of these factors in specific ways.
Stress syndromes in breast cancer frequently occur
at certain nodal points: around the time of mastectomy
(perioperative syndromes), in the rehabilitative phases,
in adjuvant treatment, and in the course of dissemi-
nated disease. The stress responses are characterized
usually by situational anxiety and depression. They are
best managed by the physician and by using the coun-
seling resources of nurse, social worker, mental health
professional, or “veteran” patient, depending on the
1052 August Supplement 1980
CANCER
severity of symptoms and complicating factors. The
postmastectomy period is infrequently complicated by
a delirium/psychosis which occurs in the presence of
mild cerebral dysfunction related to medication or a
complication of the surgical procedure. Cerebral dys-
function in disseminated breast cancer occurs from
metastases to the brain, which are increasing in
frequency, and with encephalopathy related usually
to hypercalcemia, analgesics or steroids. Manage-
ment of the psychiatric syndromes encountered utilizes
several forms of intervention: supportive relationship
to the surgeon, oncologist, and radiotherapist and
staff; use of psychotropic medications; and counsel-
ing by oncologic and mental health professionals;
by “veteran” and “peer” patients and by professional
and mutual support groups.
Breast cancer has been the most carefully studied
site of tumor from a psychosocial point of view. A
range of interventions have been developed to assist
the woman and her family in the emotional adjustment
to breast cancer and its treatment. Many of these have
been developed “by women for women,” or by their
insistence that the medical community give more
attention to this aspect of medical care. The psycho-
logic understanding of problems posed by breast cancer
has been used to develop rational and appropriate
psychologic and social interventions to reduce emo-
tional distress. This model for development of psycho-
social support in breast cancer should be applied to
psychologic management of patients with tumors of
other sites, particularly those that carry high emotional
Vol. 46
distress and that place extensive demand on an individ-
ual’s adaptive capacities.
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