Psychlgical aspects f breast cancer Dr Carline Dancyger & Dr Esther Hansen
Cmmn acrss all cancers
Adjustment as the nrm Diagnsis End f active treatment r Discharge Palliative Care Recurrence distress t be expected but nt inevitable distress intensity can be high different emtins, thughts and behaviurs mre r less cmmn acrss time fcus n cping may prve mre useful than diagnstic categries
Emtinal impact MacMillan Survey (n>1700) 45% say emtinal aspects f cancer are the mst difficult t cpe with, cmpared t the practical (13%) and physical effects (41%) Literature (sme specific t particular tumurs) 30% reprted unmet needs beynd end f cancer treatment and mst frequently cited issues were psychlgical cncerns and fear f recurrence. 49% say they experience depressin as a result f their cancer 8-24% experience depressin during r after treatment. 75% suffer anxiety as a result f their cancer diagnsis 19.0% shwed clinical levels f anxiety & anther 22.6% had subclinical symptms. <50 years and wmen in ver 50% f cases either subclinical r clinical levels f anxiety 43% say that their sex life suffers because they have cancer 53% f men and 24% f wmen wh received raditherapy t their pelvic area reprt issues with maintaining a sexual relatinship, with the effects persisting up t at least 11 years after treatment f cancer 32% say that their relatinships are put under enrmus strain 24% feel that they have nbdy t talk t
High relevance t breast cancer
Relatinal Cancer Breasts as (ptential) part f identity I lst my femininity r I am nt wh I used t be Lss/grief respnse mre vulnerable if many bdy changes (functin, feel and lk) mre vulnerable if narrw gender expectatins mre vulnerable if significant value accrded t breast in identity assciated with less bdy cnnectin and cmfrt
Relatinal Cancer Breasts as (ptential) part f identity Bdy image distress I am defrmed r Nbdy will be k t see me like this Avidance & significant emtinal distress Impact n relatinships and sexuality May present as keen t have mre surgery r delaying decisins abut treatment invlving changes t bdy Mre vulnerable if engages in cmparisn, places high value n appearance, has narrw appearance ideals, has elevated levels f general distress and anticipates (negative) judgements by thers
Breasts as (ptential) part f identity Bdy image distress Partner respnses Relatinal Cancer [partner] desn t tuch me anymre r [parnter] hasn t asked t lk Sme evidence that wman s BI (distress vs adjustment) assciated with relatinship functining Discrepancy between partner s acceptance and wman s perceptin f the partner s acceptance Cuple based interventin cmmunicatin skills, tuching and lking tgether, tackling avidance Partner wman
Relatinal Cancer Breasts as (ptential) part f identity Bdy image distress Partner respnses Relatinship cntext Pr relatinship will affect mutual supprt available Lack f safety t explre/adjust t change Ptential blame f partner s respnse n altered bdy image Partner Relatinship wman
Decisin-making Ptential fr several ptins (decisins) fr treatment, in particular surgery and recnstructin with degree f uncertainty ptential fr unmet expectatins ptential fr regret multiple and cmpeting factrs invlved highly individual and preferential decisin
Risk reducing surgery Increasing number f wmen acrss all risk categries Risk reducing surgery - established pathway fr thse with significant family histry Cmpared t elective mastectmy prcedure n established pathway Psychlgical referral best placed if MDM feels surgery is apprpriate RRM (in high risk grup) can reduce cancer related thughts r wrry RRM can prduce prduce physical prblems/changes and impact negatively n sexuality and bdy image
Supprt arund surgery Breast Recnstructin Awareness meeting managing expectatins and reducing anxiety Decisin aids e.g. OptinGrid r Decisin Cnflict Scale PEGASUS Patient Expectatins and Gals: Assisting shared understanding f (recnstructive breast) surgery Psychlgical assessment (cvering mental health, decisinmaking, expectatins, preparatin fr surgery and cnsidering factrs t prmte recvery) and treatment
Hw psychlgical supprt is rganised acrss cancer services
NICE - Recmmended mdel f prfessinal psychlgical assessment & supprt Level Grup Assessment Interventin 1 All health and scial care prfessinals Recgnitin f psychlgical needs Effective infrmatin giving, cmpassinate cmmunicatin and general psychlgical 2 Health and scial care prfessinals with additinal expertise 3 Trained and accredited prfessinals Screening fr psychlgical distress Assessed fr psychlgical distress and diagnsis f sme psychpathlgy supprt Psychlgical techniques such as prblem slving Cunselling and specific psychlgical interventins such as anxiety management and slutin fcused therapy, delivered accrding t an explicit theretical framewrk 4 Mental Health specialists Diagnsis f psychpathlgy Specialist psychlgical and psychiatric interventins such as psychtherapy, including cgnitive behaviural therapy (CBT)
Wh needs Level 2+ help? The dilemma: It s nrmal fr peple t suffer and struggle Everyne shuld get gd Level 1 supprt There is limited Level 2+ resurce, s it needs t be targeted
Understanding distress in the cntext f adjustment When a patient experiences significant prblems, we need t cnsider whether she is STUCK (r even deterirating) Identifying causal and maintaining factrs Thinking abut psychlgical cncerns in cntext The key questin: What is it that makes yu think this difficulty wn't reslve ver time?
Examples f being Stuck lss f enjyment Lw md Feels increasingly unattractive Avidance f sex withdrawn Partner withdraws A depressive prcess Increasing distance in a relatinship pst surgery
Adjusting vs. Stuck Reassurance is shrt-lived Belief: Only vigilance will keep me safe Feels vulnerable Anxius Rutine scan is clear Feels less vulnerable Arranges medical appintment Cnstant checking fr symptms Gradually diminishing fear f recurrence Severe fear f recurrence
The 3 S s A framewrk t help further assess psychlgical cncerns. Rutinely cnsider: 1. Stuck (unchanging r deterirating) 2. Safe (risky t self r thers) 3. Suffering (ptential t reduce)
Safety Examples f where psychlgical issues might jepardize safety? Suicidality Accessing medical care Self neglect Anger twards thers Neglect f dependants
Suffering Examples f intense suffering that requires additinal interventin? Emtin significantly impacts functining Family extremely distraught Terrr
Where t refer n t? Dependent n lcal services, level f need and acceptability Level 3 & 4 specialist cancer psychlgical services Liaisn Psychiatry: fr immediate risk, dementia & delirium Lcal mental health services, including IAPT, Drug & Alchl services Third Sectr: Maggie's, The Breast Haven, Breast Cancer Care, Macmillan, Chai, CYANA, supprt grups If in dubt, call yur lcal level 3/4 psychlgical supprt service
Barriers t referrals Patient related Referrer related
Hw d yu intrduce referral t L3/4 psychlgical supprt? Key pints t remember: Discuss with patient, nly refer with cnsent Which wrds t use? AVOID terms like cunselling/chat which can be cnfusing. Suggest chance t meet fr up t an hur with smene impartial t discuss their cncerns and hw they are managing. Remember t keep level 3/4 wrker up t date with cllabrative wrking.