Breaking Bad News

Adjustment to the Diagnosis of Breast Cancer

In adjusting to the experience of breast cancer, patients often describe feeling as if their body has ‘let them down’ and not knowing if they can ‘trust their bodies again’. The concept that they had of feeling inherently healthy is disrupted as they come to terms with the recognition that they have breast cancer. For some, the search for meaning can take the form of needing to understand why they have developed breast cancer and the possible contributing factors (Tables 15.1 and 15.2). The expected life trajectory for most people is significantly disturbed by a diagnosis of breast cancer, as they face the unexpected uncertainty of their future. Inherent in this process of adjustment is a sense of vulnerability; patients with breast cancer need support from both family and friends and medical and nursing teams to help them navigate their way through treatment.

Table 15.1 Reasons for non-disclosure of psychological morbidity

Table 15.2 Disclosure by patients

For those men diagnosed with breast cancer, the process of adjustment can be particularly complex due to the stigma that they associate with their condition. Perhaps as a response to this, men with breast cancer do not tend to seek formal support services but rely instead on family and friends. The majority of men report that they would like more information about their condition that is specific to their circumstances, and that much of the information available is inappropriate as it relates to women’s experiences.

Life Changes and Coping Strategies

The diagnosis of breast cancer and its aftermath undoubtedly lead to major life changes for most patients, but these changes are not always negative. In one study of 200 cancer survivors, 30% had changed their jobs and 23% had moved homes or changed their living arrangements in the two years after their cancer treatment. The way in which a person who has a diagnosis of breast cancer copes is likely to be consistent with their normal functioning style or personality traits. Coping skills that are characterised by an active and optimistic approach, such as a ‘fighting spirit’, tend to lead to better outcomes in psychological terms. This kind of active approach to managing the disease and treatment may involve becoming an ‘expert patient’ and adopting goals such as healthy eating in order to increase their sense of control over the disease and their future. Although there has been some reservation expressed about those women who appear to have an exaggerated belief that they can control their disease through alternative therapies, maintaining a positive attitude and healthy living, a recent study suggests that these approaches are adaptive and may help to reduce anxiety (Table 15.3).

Table 15.3 Criteria for an anxiety state

Denial of the experience of cancer tends to lead to higher distress and maladaptive adjustment, although denial in a pure sense is an unusual response. More often, patients understand and acknowledge that they have cancer, but this reality is so painful that they prefer not to focus on it. This may be evident because the patient seems unconcerned or uninterested in the management of their cancer. Such approaches, often described as passive and avoidant coping reactions, are likely to lead to greater psychological distress in the long term, as patients do not accept and adjust to their condition and treatment, which is part of the work of psychological adjustment. Coping strategies described as helplessness/hopelessness, fatalism, denial/avoidance and anxious preoccupation have been consistently correlated with depression and poor psychological adjustment. Patients who are low in mood are also more likely to have higher fears of recurrence.

Psychological Morbidity

The incidence of psychological morbidity following a diagnosis of breast cancer varies widely, although it is generally accepted that about 20% of patients will experience major clinical depression, anxiety or adjustment disorders. These women benefit from being referred to specialist clinical psychology or liaison psychiatry services. One observational cohort study of 202 women with early breast cancer found that three months after the diagnosis, the prevalence of depression or anxiety was 24%, which is twice that of the general female population. This fell to 15% for those patients in remission at one year. Risk factors for developing clinical depression or anxiety up to five years after diagnosis or recurrence were not related to the disease type or treatment, but to the woman’s personal circumstances. Those women who were younger and had previous psychological problems, outstanding non-cancer-related difficulties and little social support are more likely to develop significant psychological distress (Figure 15.1). This is consistent with other studies that have described the predictive factors for women developing depression after breast cancer treatment as being under the age of 50 at diagnosis and having ongoing experience of pain and lower levels of support and self-esteem. These characteristics appear to be independent of severity of the disease and type of surgical treatment. If a woman is depressed at the time of the treatment planning, this is likely to be predictive of a poor psychological adjustment three years later. The experience of depression early in the treatment process leads to avoidant or passive coping skills, which result in poorer outcomes.

Figure 15.1 Sculpture of a woman who has had a mastectomy and who is curled up and withdrawn (by Elspeth Bennie).

Stay updated, free articles. Join our Telegram channel

Join