The Second International Conference on Psychosocial Oncology “ Psychosocial Support and Communication in Cancer Care : Challenges and Experiences ” Posttraumatic stress in breast cancer patients

2 Vilnius College / University of Applied Sciences Background. Breast cancer diagnosis is a potential life-threatening event associated with significant distress. The present study aimed to identify the prevalence of posttraumatic stress and its association with clinical and social factors in early breast cancer patients and one year after surgery. Materials and methods. Four hundred twenty one newly diagnosed breast cancer patients completed three questionnaires: Impact of Event Scale – revised (IES-R), Beck Depression Inventory II (BDI-II), Vrana & Lauterbach Traumatic Events Scale-Civilian (TEQ). Women were questioned before surgery and one year later. Patients were 18–80 years old resident Lithuanian women with histologically confirmed breast cancer and no history of other cancers. Additional requirements were as follows: ability to read Lithuanian and being capable of completing a questionnaire. Results. 51.5% of newly diagnosed breast cancer patients had from moderate to severe symptoms of PTSD (score average of IES-R ≥ 1.5). After one year it decreased and there were 33.5% of patients who had symptoms of PTSD. The scores of all subscales were decreased a bit as well. Immediately after statement of diagnosis, PTSD correlated with sadness, often cry and earlier traumatic experience. One year later, PTSD correlated with poor self perception, sadness and traumatic experience during this year. Pessimistic mood, lack of energy, difficulties to concentrate were significant to breast cancer patients. Conclusions. A significant number of breast cancer patients suffers from PTSD symptoms. After one year, the amount of patients suffering from PTSD decreased almost twice. Depression and traumatic experience are the predictors of PTSD. The findings show that early evaluation of psychoemotional needs of breast cancer patients is necessary and early interventions are meaningful.


INTRODUCTION
Studies of posttraumatic stress disorder (PTSD) in cancer patients find that diagnostic rates are low (3% to 14%), but symptoms of PTSD, that is a subsyndrome of PTSD, may occur in upward of 50% of patients (1).How disabling the subsyndrome of PTSD may be for any individual is not fully known; however, a few data suggest that it is so.Stein, Walker, Hazen, and Forde using community survey data found that individuals with the subsyndrome of PTSD reported employment problems, social disruptions, and difficulties at home (2).Breast cancer diagnosis is a potential life-threatening event associated with significant distress.Even after successful treatment, cancer diagnosis and treatment may continue to be a source of distress (Table 1) (1).This is also the case for studies focusing on the prevalence of post-traumatic stress symptoms (PTSS) in breast cancer (9), with reported prevalence of suspected or diagnosed PTSD ranging from 32% in a sample of 31 women with stage I-III breast cancer on average at 16 months after treatment (10) to 0.0% in a sample of 74 breast cancer survivors at 3 to 6 years after diagnosis (11).
In 1994, the trauma criteria of post-traumatic stress disorder (PTSD) in DSM-IV were expanded to include life-threatening illness, such as cancer (American Psychiatric Association, 2000).Post-traumatic stress can occur after an individual is exposed to an event perceived as life threatening, and associated with intense fear, helplessness, or horror.According to DSM-IV, the disorder is defined by a set of symptoms (re-experiencing, avoidance, and hyper-arousal) lasting at least 1 month.There is considerable variation in the proportion of individuals exposed to traumatic events who develop PTSS of sufficient severity to warrant a diagnosis of PTSD (12).It was found that experienced PTSD impairs quality of life (13), increases disability and experienced pain (14), increases suicide risk.Younger age, lower income, less education, physical and psychiatric co-morbidity, and physical functioning have been proposed as general risk factors of severe post-traumatic stress (15)(16)(17)(18)(19).
Objectives.This research is a part of a larger study investigating predictors of the negative psychosocial outcomes that could be used in clinical practice to risk-assess and monitor breast cancer patients for adjustment difficulties.
The present study aimed to identify the prevalence of posttraumatic stress and its association with clinical and social factors in early breast cancer patients and one year after surgery.

METHODS AND MATERIALS
Four hundred twenty one newly diagnosed breast cancer patients (Table 2) completed three questionnaires (Lithuanian version): Impact of Event Scale -revised (IES-R) (20), Beck Depression Inventory II (BDI-II) (21), Vrana & Lauterbach Traumatic Events Scale-Civilian (TEQ) (22).Women were questioned before surgery at the Institute of Oncology, Vilnius University.Eligible patients were 18-80 years old resident Lithuanian women with histologically confirmed breast cancer T1-3, N0-3, and M0 according to the tumour-node-metastasis staging system, and no history of other cancers.Additional requirements were as follows: ability to read Lithuanian and being capable of completing a questionnaire.After one year, all of patients re- ceived questionnaires once more and filled them at home.We received 188 answers, the response rate is 45%.The Statistical Packages of Social Sciences (SPSS) software for Windows (version 19.0) was used.Descriptive statistics were used to charac-terize the sample with regard to demographic and clinical characteristics.The reliability was tested using the Cronbach's alpha reliability coefficient.For comparison among the groups, the Persons Correlation coefficient was used.A p value of 0.05 was considered to be significant.

RESULTS
51.5% of newly diagnosed breast cancer patients had from moderate to severe symptoms of PTSD (score average of IES-R ≥ 1.5).After one year it decreased and there were 33.5% of patients who had symptoms of PTSD (score average of IES-R ≥ 1.5).
The scores of all subscales were decreased a bit as well (Table 3, Figure ).

Figure. Symptoms of PTSD according to patients' age and period
Other difficulties for patients with PTSD were also identified.Pessimistic mood (54%), lack of energy (61%), difficulties to concentrate (51%) were high.These disorders, having occurred for half of the patients, may have heightened risk not only for PTSD, but also for a depressive episode when cancer was diagnosed

DISCUSSION
When reviewing 16 studies of breast cancer patients published between 2004 and 2010, in which mean IES scores were reported, the mean intrusion scores reported varied from 1.24 to 22.0 and avoidance scores varied from 1.36 to 24.6.The highest scores were found in studies assessing cancer-related post-traumatic stress immediately after diagnosis or during treatment, whereas the lowest scores were found in samples of breast cancer survivors assessed up to 15 years post diagnosis (23).Comparing our results with the scores found in the studies with assessment times most similar to ours (between 0 and 12 months), the re-experiencing and avoidance scores in our sample (12.5 and 12.1 in the beginning, and 9.0 and 9.2 after one year) were similar or lower than the range of the scores found in these studies (re-experiencing 9.1-14.0and avoidance 12.2-15.0).
Results thus confirm that a significant proportion of women experience severe breast cancer-related PTSD symptoms, and that a reduction in the prevalence of severe PTSD symptoms can be expected during the first year after surgery.However, approximately half of the women with severe PTSD at the beginning also had severe PTSD symptoms at 12 months, indicating that these women are at increased risk of persistent severe PTSD.
In the general population, the prevalence of sufficiently severe PTSS to warrant a diagnosis of PTSD is usually lower among older individuals compared with younger (24).Likewise, younger cancer patients are generally more distressed after receiving their cancer diagnosis than older patients (25).In contrast, the youngest women in our study had the lowest prevalence of severe PTSD symptoms at the beginning and after one year, whereas no differences were found for PTSD mean scores.At 12 months, no significant difference in severe PTSD was found between the youngest and the oldest patients, but younger pa-tients now demonstrated significantly elevated PTSD mean scores.
In some publications, it has been suggested that the nature of the event is more likely to be central as a predictor of post-traumatic stress in high-intensity stressors (e. g., direct experience of combat, torture, violent sexual assaults), whereas pre-existing individual risk factors may be very important predictors of post-traumatic stress following relatively less extreme events (e. g., serious illness or bereavement (23).By the above definition, primary breast cancer can be considered a less extreme traumatic stressor.Although one factor related to the intensity of the traumatic event, disease severity, was a risk factor for severe PTSD, our findings generally underline the importance of focusing on pre-existing individual risk factors, such as social status, previous traumatic event, and communications with personnel when screening for PTSD in breast cancer.

Table 1 .
Prevalence of PTSD in different cancer patients

Table 2 .
Demographic and clinical characteristics of patients (n = 421)

Table 3 .
Cancer-related PTSS among newly diagnosed breast cancer patients and 12 months post surgery