Is cancer back?—psychological issues faced by survivors of breast cancer

Introduction

Breast cancer survival rates have shown remarkable improvement over the years due to advancements in detection, treatment modalities, and supportive care (1). The rate at which people with early-stage breast cancer are cured of the disease has increased, and those living with metastatic disease are living longer, often with long periods of stability (1). However, even after treatment concludes, survivors face the challenge of reintegrating into daily life and confronting the expectation to “return to normalcy” (2). Often, they find themselves grappling with a myriad of both physical and psychological challenges long after the completion of acute phase of the treatment (2). This article delves into the complex psychological issues that confront breast cancer survivors, exploring the emotional toll of living in the shadow of a disease that will forever impact their lives. From the fear of cancer recurrence to body image concerns and the struggle to reclaim a sense of normalcy, survivors navigate a delicate emotional landscape that requires comprehensive support and understanding. By shedding light on these psychological intricacies, we aim to foster greater awareness of the unique experiences of breast cancer survivors beyond the realm of physical healing.

Articles were reviewed through searches of PubMed using research terms such as breast cancer survivors, cancer recurrence, psychosocial symptoms and psychosocial intervention. Additionally, articles were reviewed through searches of the author’s own file. The final list was generated based on relevance to the broad scope of this review.

Major categories of psychological issues facing survivors

The psychological challenges faced by breast cancer survivors extend beyond the physical aspects of their journey (2,3). In the initial diagnostic phase, the person faces a multitude of psychological challenges that can significantly impact their well-being, including anxiety and psychological distress that can start even before a diagnosis, due to screening procedures. Among the risk factors contributing to psychological distress in this population are several demographic and clinical factors (4-6). Younger age, pre-existing psychological problems, the presence of comorbid illnesses, limited available social support, lower educational levels, and belonging to an ethnic minority group have all been identified as potential risk factors for heightened psychological distress in women undergoing breast cancer treatment (4,5). During the diagnostic phase, patients often experience heightened levels of anxiety, uncertainty, and psychological distress as they navigate the process of diagnosis and treatment planning (7,8). The uncertainty surrounding the extent of the disease, treatment options, and prognosis can exacerbate these feelings and add to the emotional burden (8). Furthermore, the treatment phase presents its own set of challenges, including coping with physical side effects, managing treatment-related disruptions to daily life, and adjusting to changes in body image and self-perception (8).

After treatment, breast cancer survivors face a multitude of challenges, including work-related issues, physical long-term effects of the treatments (e.g., fatigue, neurocognitive dysfunction, peripheral neuropathy), and emotional burden (e.g., fear of recurrence, concerns about the impact of my cancer on their loved ones, symptoms of depression and/or anxiety) (9-13). Fertility can be significantly impaired by cancer treatment administered to prevent breast cancer recurrence, including chemotherapy and endocrine treatment, among others. Recurrence of breast cancer can further intensify psychological distress, as it brings renewed uncertainty and fear about the future. The recurrence of cancer challenges survivors’ coping mechanisms, often leading to heightened feeling of helplessness and vulnerability. Patients frequently report experiencing intrusive thoughts and engaging in avoidance behaviors as they grapple with the uncertainties of disease progression (14,15). While some studies may suggest that these patients demonstrate emotional resilience, the persistent fear of disease progression and the necessity of additional treatment can significantly impact their emotional well-being and overall quality of life, which adds to the burden of physical side effects from cancer drugs (14). In addition, the time and financial toxicity of cancer treatment can add multiple layers of psychological distress, further impacting the psychological wellbeing of patients with breast cancer (16,17). Therefore, comprehensive psychological support remains vital throughout the entirety of the breast cancer journey (18).

The challenges encountered by patients with recurrent breast cancer encompass several major areas, including physical symptoms such as fatigue, sleep disturbances, pain, and changes in sexual interest, as well as emotional symptoms like feelings of sadness, anxiety, depression, and fear of disease progression (19). These symptoms are interrelated, exacerbating the overall distress experienced by patients and frequently resulting in the occurrence of multiple concurrent symptoms. Additionally, patients may encounter difficulties in maintaining supportive relationships and social connections, as friends and family members may struggle to understand or empathize with their experiences. This challenge is compounded by the weight of the worry that they are causing harm to their loved ones, even when the relationship is maintained, and the caregiver is supportive. This sense of isolation and loneliness can further exacerbate psychological distress, impacting overall well-being. This underscores the ongoing need for distress screening and the implementation of tailored psychological interventions. By systematically assessing distress levels and associated symptoms, healthcare providers can tailor interventions that meet the specific needs of each patient. Evidence suggests that timely intervention for distress can lead to improved quality of life and better treatment outcomes. Therefore, implementing a structured approach to distress screening and intervention strategies based on symptomatology is essential in ensuring comprehensive care for breast cancer survivors.

Interventions and strategies

Addressing the diverse psychological needs of patients with breast cancer requires a multifaceted approach that incorporates tailored interventions and supportive strategies. Various psychosocial interventions have been developed to address these needs across different clinical focuses, including (20-22):

• Cognitive and Behavioral Cancer Stress Management (CBCSM) interventions offer a structured approach with psychoeducation, coping strategies, and relaxation skills training, resulting in improvements in depressive symptoms, anxiety, self-efficacy, fatigue, and social functioning (23,24).
• Supportive-Expressive Therapy (SET) emphasizes peer social support and expression of emotions, showing benefits in depressive symptoms, hopelessness, trauma symptoms, and social functioning (25,26).
• Meaning-Centered Psychotherapy (MCP) targets existential and spiritual distress, leading to enhancements in quality of life, depressive symptoms, and hopelessness. Mindfulness-based interventions promote non-judgmental awareness and have shown improvements in anxiety, depressive symptoms, fear of recurrence, and physical function (27).
• Acceptance and Commitment Therapy (ACT) utilizes acceptance and mindfulness strategies, with preliminary evidence suggesting reduced anxiety and depressive symptoms. Behavioral lifestyle interventions focus on increasing health behaviors, particularly physical activity, resulting in improvements in fatigue, depressive symptoms, body image, and health-related quality of life (28,29).
• Yoga, a mind-body intervention, has been linked to enhancements in fatigue, sleep, health-related quality of life, anxiety, and depressive symptoms (30-32).
• Couples-focused interventions aim to address psychological needs of both breast cancer survivors and their partners, potentially impacting quality of life, distress, relationship functioning, and physical symptoms. These interventions underscore the importance of tailored psychosocial support throughout the breast cancer survivorship journey (33,34).
• Psychosocial intervention for family/caregivers aims to improve communication, resolve conflicts, and provide support to each member as they navigate the challenges of the diagnosis together. This intervention can help family members understand each other’s perspectives, strengthen relationships, and develop coping strategies to manage stress and uncertainty effectively (35-37).

The gap and need for ongoing, specific research

Despite significant advancements in breast cancer treatment and survivorship care, there remains a notable gap in understanding and addressing the psychological issues facing breast cancer survivors following the completion of the acute phase of treatment. While numerous studies have examined the physical aspects of survivorship, such as recurrence rates and late treatment side effects, there is a lack of comprehensive research focusing specifically on the psychological well-being of survivors.

One critical gap in the literature pertains to the long-term psychological impact of cancer recurrence on survivors. While recurrence rates and treatment options are well-documented, little attention has been paid to the psychological distress experienced by survivors when facing the possibility of cancer returning, and even for those living with metastatic breast cancer for a long time. Understanding the unique challenges and coping strategies employed by survivors dealing with cancer recurrence is essential for developing targeted interventions to support their mental health needs.

Furthermore, there is a need for research exploring the effectiveness of psychosocial interventions tailored specifically to the needs of breast cancer survivors. While various interventions, such as cognitive-behavioral therapy, mindfulness-based practices, and support groups, have shown promise in improving psychological outcomes in cancer patients, their efficacy and feasibility in the survivorship phase remain understudied. Investigating the optimal timing, delivery methods, and components of psychosocial interventions for breast cancer survivors can inform the development of evidence-based supportive care programs.

Additionally, there is a lack of research examining the intersectionality of psychological distress with other aspects of survivorship, such as age, socioeconomic status, and treatment history. Understanding how these factors intersect and influence the psychological well-being of survivors can help identify high-risk populations and inform the development of targeted interventions to address their specific needs.

Conclusions

In conclusion, breast cancer survivorship represents a multifaceted journey characterized by both physical and psychological challenges. Throughout this paper, we have explored the various psychological issues facing survivors, including anxiety, depression, fear of recurrence/progression, and coping with cancer-related trauma. We have highlighted the importance of addressing these issues comprehensively to promote the well-being and quality of life of breast cancer survivors.

One key takeaway from our discussion is the need for healthcare providers to adopt a holistic approach to survivorship care that encompasses both physical and psychological aspects. This includes routine screening for psychological distress, early identification of at-risk individuals, and timely access to psychosocial support services. By integrating mental health care into survivorship programs, healthcare providers can better meet the diverse needs of breast cancer survivors and improve their overall outcomes.

Furthermore, our exploration of gaps in the current research underscores the importance of ongoing investigation into the psychological impact of breast cancer survivorship. Future research efforts should focus on addressing the long-term effects of cancer recurrence on survivors’ mental health, evaluating the effectiveness of tailored psychosocial interventions, and understanding the intersectionality of psychological distress with other survivorship factors. In addition, further research examining cancer survivors based on their pathology, including differences in symptom experiences between early-stage breast cancer patients who required surgery only and those with metastatic disease, is warranted. Understanding these variations can inform tailored psychosocial interventions and support strategies that address the diverse needs of breast cancer survivors across the survivorship trajectory.

Ultimately, by addressing these gaps and implementing evidence-based strategies for psychological support, we can empower breast cancer survivors to navigate the challenges of survivorship with resilience and hope and have a better quality of life. Through collaborative efforts between healthcare providers, researchers, and survivors themselves, we can strive towards a future where all breast cancer survivors receive the comprehensive care and support they need to thrive beyond their diagnosis.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by Guest Editors (Muna Alkhaifi, Charles B. Simone, Maryam Lustberg, Isabelle Choi, Henry Wong and Elwyn Zhang) for the series “Supportive Care After Breast Cancer: Challenges and Opportunities” published in Annals of Palliative Medicine. The article has undergone external peer review.

Peer Review File: Available at https://apm.amegroups.com/article/view/10.21037/apm-24-54/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://apm.amegroups.com/article/view/10.21037/apm-24-54/coif). The series “Supportive Care After Breast Cancer: Challenges and Opportunities” was commissioned by the editorial office without any funding or sponsorship. P.T. declares research funding (to institution) from AstraZeneca, and reports serving as advisor and/or consultant for AstraZeneca, Daiichi Sankyo, Gilead, Genentech, Roche, Novartis and Eli Lilly. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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