Women's regrets after bilateral prophylactic mastectomy.

BACKGROUND: Primary prevention strategies such as chemopreventive agents (e.g., tamoxifen) and bilateral prophylactic mastectomy (PM) have received increasingly more attention as management options for women at high risk of developing breast cancer. METHODS: A total of 370 women, who had registered in the Memorial Sloan-Kettering Cancer Center National Prophylactic Mastectomy Registry, reported having undergone a bilateral PM. Twenty-one of these women expressed regrets about their decision to have a PM. A psychiatrist and psychologist interviewed 19 of the women about their experiences with the PM. RESULTS: A physician-initiated rather than patient-initiated discussion about the PM represented the most common factor in these women. Psychological distress and the unavailability of psychological and rehabilitative support throughout the process were the most commonly reported regrets. Additional regrets about the PM related to cosmesis, perceived difficulty of detecting breast cancer in the remaining breast tissue, surgical complications, residual pain, lack of education about the procedure, concerns about consequent body image, and sexual dysfunction. CONCLUSIONS: Although a PM statistically reduces the chances of a woman developing breast cancer, the possibility of significant physical and psychological sequelae remains. Careful evaluation, education, and support both before and after the procedure will potentially reduce the level of distress and dissatisfaction in these women. We discuss recommendations for the appropriate surgical and psychiatric evaluation of women who are considering a PM as risk-reducing surgery.

A pilot study of interpersonal psychotherapy by telephone with cancer patients and their partners.

A single-arm pilot study explored the feasibility of adapting in Interpersonal Psychotherapy (IPT) by telephone to reduce psychological distress and to enhance coping during cancer treatment. Therapy focuses on role transitions, interpersonal conflicts, and grief precipitated by cancer. Breast cancer patients receiving high-dose chemotherapy received weekly sessions with a psychologist throughout chemotherapy and for 1 month afterwards. Patients could invite one 'partner' to receive individual telephone IPT. Psychosocial functioning was assessed using standardized measures at study entry, after chemotherapy, and following telephone IPT. Accrual and participation supplied evidence of feasibility: 14 patients and 10 partners were recruited, 82.5% of those eligible. Patients had a mean of 16 sessions; partners had a mean of 11. Participants rated their satisfaction with the program between 'good' and 'excellent'. A test of the efficacy of telephone IPT requires a larger, randomized trial. In order to standardize the intervention, a treatment manual was developed. This study indicated the importance of outreach to family members as well as to cancer patients, intensive patient education about oncology treatment and the medical care setting, and psychosocial services that continue after cancer treatment has been completed.

Issues of regret in women with contralateral prophylactic mastectomies.

BACKGROUND: Patients with a history of carcinoma of one breast have an estimated risk of 0.5% to 0.75% per year of developing a contralateral breast cancer. This risk prompts many women to consider contralateral prophylactic mastectomy (CPM) as a preventive measure. Virtually nothing is known about patient acceptance following CPM. We have developed a National Prophylactic Mastectomy Registry comprised of a volunteer population of 817 women from 43 states who have undergone prophylactic (unilateral or bilateral) mastectomy. METHODS: Of the 346 women with CPM who responded to national notices, 296 women returned detailed questionnaires. The information obtained included patient demographics, family history, reproductive history, ipsilateral breast cancer staging and treatment, as well as issues involving the CPM. RESULTS: At median follow-up of 4.9 years, the respondents were primarily married (79%), white (97%) women who had some level of college education or above (81%). These women cited the following reasons for choosing CPM: (1) physician advice regarding the high risk of developing contralateral breast cancer (30%); (2) fear of developing more breast cancer (14%); (3) desire for cosmetic symmetry (10%); (4) family history (7%); (5) fibrocystic breast disease (4%); (6) a combination of all of these reasons (32%); (7) other (2%); and (8) unknown (1%). Eighteen of the 296 women (6%) expressed regrets regarding their decision to undergo CPM. Unlike women with bilateral prophylactic mastectomies, regrets tended to be less common in the women with whom the discussion of CPM had been initiated by their physician (5%) than in the women who had initiated the discussion themselves (8%) (P = ns). Family history and stage of index lesion had no impact on regret status. The reasons for regret included: (1) poor cosmetic result, either of the CPM or of the reconstruction (39%); (2) diminished sense of sexuality (22%); (3) lack of education regarding alternative surveillance methods or CPM efficacy (22%); and (4) other reasons (17%). CONCLUSIONS: To minimize the risk of regrets in women contemplating CPM, it is imperative that these women be counseled regarding an estimation of contralateral breast cancer risk, the alternatives to CPM, and the efficacy of CPM. In addition, these women should have realistic expectations of the cosmetic outcomes of surgery and understand the potential impact on their body image.

Screening for anxiety and depression in women with breast cancer. Psychiatry and medical oncology gear up for managed care.

In this study, 275 women with breast cancer attending ambulatory breast cancer clinics in two sites were evaluated for psychological distress by using three self-report instruments: a visual analogue scale for psychological distress, the Hospital Anxiety and Depression Scale, and the Brief Symptom Inventory. Results suggest that significant psychological distress exists in ambulatory women with breast cancer; all three instruments effectively measured that level of distress. Implications for the use of these instruments in educating oncological staff members, documenting need for psychiatric services in a period of capitation, and providing quality assurance evaluations of psychiatric services are discussed.

The Prophylactic Mastectomy Dilemma: A Support Group for Women at High Genetic Risk for Breast Cancer.

The goal of this pilot study was to test the usefulness of a six session psychoeducational support group for women at high genetic risk for breast cancer who were considering prophylactic mastectomy. The themes of the group sessions included overestimation of and anxiety about risk; desire for "hard data"; the emotional impact of watching a mother die of breast cancer; concerns about spouse reactions; self- and body image; the decision-making process; and confusion over whom to trust in decision making. Both the participants and the multidisciplinary leaders concluded that as a supplement to individual counseling, a support group is a beneficial and cost-effective treatment modality. Recommendations for the optimal format for such a group are described.

Patient regrets after bilateral prophylactic mastectomy.

BACKGROUND: The discovery of a cadre of breast cancer susceptibility genes has resulted in an increase in the number of women seeking information about prophylactic breast surgery, but virtually no large-scale prospective databases exist to assist women considering prophylactic mastectomy. METHODS: The authors constructed a National Prophylactic Mastectomy Registry comprised of a volunteer population of 817 women from 43 states who have undergone prophylactic mastectomy. RESULTS: In the registry, 370 women had undergone bilateral prophylactic mastectomy. Twenty-one (5%) women expressed regrets about the procedure. The median follow-up was 14.6 years (mean 14.8 years; range 0.2-51 years). Those with regrets were subsetted into those with major (n = 10) or minor (n = 7) regrets. Regrets were more common in those women with whom discussion about prophylactic mastectomy was initiated by a physician (19/255), compared with patients who initiated the discussion themselves (2/108; P < .05). CONCLUSIONS: The overall satisfaction rate of 95% reported here may be explained by the voluntary nature of this registry. The most important factor that predicts an unfavorable outcome following bilateral prophylactic mastectomy is a physician-initiated discussion.

Psychotherapy with a woman at high risk for developing breast cancer.

Women who are at high risk for developing breast cancer increasingly consult with psychiatrists about the psychological, social, and sexual consequences of genetic testing and risk-reducing surgeries such as bilateral mastectomy and oophorectomy. The 9-year psychotherapy with a woman who had bilateral mastectomy because of her family history of breast cancer and who later tested negative for BRCA1 is described and discussed.

Women's psychological reactions to breast cancer.

Breast cancer is the cancer most studied in terms of psychological and psychosocial aspects because of the high prevalence and mortality of the disease and the psychological effects of surgery on an organ rich in meaning. The diagnosis of breast cancer, treatment, and treatment sequelae are major stressors for any woman; however, the psychological impact of the diagnosis and women's emotional responses vary considerably depending on medical parameters of the disease, the patient's psychological make-up and coping abilities, and the availability of emotional and financial support. We document the experience of breast cancer at all phases of the disease for a majority of psychologically healthy women and describe the emotional responses of women who are at high genetic risk of developing breast cancer. Having a comprehensive understanding of psychologically healthy women's reactions to breast cancer is necessary as we attempt to define standards of care and treatment guidelines for both psychologically healthy women with breast cancer and for those with psychiatric disorders that antedate or complicate breast cancer treatment.

Hypnotic efficacy and safety of triazolam administered during the postoperative period.

This study examined the hypnotic efficacy and safety of short-term use of triazolam following elective surgery. One hundred women (ages 26-69) who had received 0.125 mg of traizalam the evening before breast cancer surgery were enrolled in a randomized, double-blind study comparing triazolam to placebo. Study medication was begun on the first or second evening following surgery, depending on the patient's level of postoperative alterness, and was administered in the hospital for three consecutive evenings. The starting dose of triazolam was 0.125 mg, with the option of increasing the dose to 0.25 mg on subsequent nights if sleep response was inadequate. Relative to patients in the placebo group, patients in the triazolam group reported significantly (p < 0.05) less difficulty falling asleep, fewer nightime awakenings, better overall sleep quality, and a greater sense of restfulness. No clinically significant adverse reactions were encountered and no adverse reactions occurred more frequently in the triazolam group than in the placebo group. Results indicate that administration of traizalam is a safe and effective method of improving sleep in patients recovering from surgery.

Depression and suicide in patients with cancer.

Depression is a prevalent psychiatric syndrome in the cancer population. We review the spectrum of conditions in which depressive features are present, from normal responses to crises in cancer to depression secondary to organic causes. The different modalities of treatment, including pharmacologic, psychotherapeutic and social interventions, are described. Specific guidelines for the management of the suicidal cancer patient are given and physician-assisted death is discussed.

The cancer patient with pain: psychiatric complications and their management.

The most common psychiatric complications in the cancer population are depression, anxiety, and delirium. All are more likely to occur in the cancer patient who has pain. This review outlines the normal responses to cancer and the psychiatric disorders frequently encountered in clinical practice. The influence of pain on the incidence and presentation of these disorders is described. Multimodal treatment, which includes pharmacologic, psychotherapeutic, and behavioral interventions, is outlined.

Psychological reactions to breast cancer in the pre- and post-surgical treatment period.

Breast cancer has been widely studied with respect to its psychological impact because it is a disease which threatens an organ that is intimately associated with self-image, self-esteem, sexuality, femininity, and reproductive and nurturing capacity. Breast cancer is a significant stress for any woman; however, women vary widely in their response to diagnosis and treatment. In this manuscript we review the following issues: social, psychological, and medical variables that contribute to the psychological response, and the usual responses of women in the pre- and postsurgical treatment period.

Reviewing graduate medical education programs: a cancer center experience. Members of the Graduate Training Committee.

The Graduate Training Committee at Memorial Sloan-Kettering Cancer Center developed procedures for comprehensively reviewing the 32 graduate training programs at our institution. The methods used to carry out this review, the problems encountered, and the results of this review are presented. As this type of program review is now mandated by the Accreditation Council for Graduate Medical Education (ACGME), our method and experience should prove useful to other institutions planning a similar review process.

Depression and the cancer patient.

The prevalence of depression in cancer patients and the types of depressive syndromes which are commonly seen are now well known. At least 25% of hospitalized cancer patients are likely to meet criteria for major depression or adjustment disorder with depressed mood. Patients at highest risk for depression are those with a history of affective disorder or alcoholism, advanced stages of cancer, poorly controlled pain, and treatment with medications or concurrent illnesses that produce depressive symptoms. The clinical evaluation of the depressed cancer patient includes careful assessment of symptoms, mental status, physical status, and cancer treatment effects. Treatment includes short-term supportive psychotherapy, antidepressant medication, and, infrequently, electroconvulsive therapy. In this article the authors review the clinical picture of depression including concern about suicidal risk and discuss pharmacologic treatment modalities.

Nurses' reports of psychiatric complications in patients with cancer.

Increasing acuity of hospitalized patients with cancer has placed greater and more diverse demands on nurses. This is especially true in relation to the management of psychiatric problems that require added time and skills. This study surveyed all nurses (n = 100) working on 15 inpatient units in a 565-bed cancer research hospital on one day regarding psychiatric problems present in 475 patients under their care. Nurses reported that significantly more patients exhibited symptoms requiring psychiatric consultation than did not. Results also indicate that patients who were acutely ill and in need of intensive nursing care had significantly more psychiatric symptoms than patients with low acuity illness. The most prevalent symptoms were depression and/or anxiety and delirium. Nurses who must care for an increasingly ill population with more severe psychiatric symptoms need additional education to manage these problems. Study findings led to increased availability of nurse-to-nurse consultations as well as establishment of a task force to develop a psychosocial teaching manual.

The patients perception of her breast following radiation and limited surgery.

Seventy-four patients followed from 1 to 8 years post completion of breast-conserving surgery and radiation for early-stage breast cancer were asked to answer a questionnaire exploring their perception and awareness of the treated breast. The questionnaire was divided into several sections, including "Daily Activities", Pre-menstrual Changes", "Sexual Activities", and a summary "Satisfaction Index" section; when appropriate, comparisons were sought between the treated and untreated breasts. Preliminary results from this study indicate that 70% of all patients are aware of their treated breast in some way during everyday activities. The "Satisfaction Index" of this patient group is very high, with 75% rating their cosmetic result, and 81% their functional result "8" or higher on a scale of "0" to "10","10" indicating "best" or "normal".

Psychosocial aspects of cancer in the elderly.

Patients often present for evaluation of a suspicious cancer symptom after a delay. They appear to tolerate cancer treatment as well as younger patients, and, in studies comparing them on psychosocial parameters of adaptation, they appear to adjust better than younger patients. Attention to pre-existing social problems or psychiatric disorder (eg, alcoholism or depression) is necessary when physicians start treatment for cancer. Elderly patients have a greater tendency to develop delirium; cautious use of psychotropic medications is indicated. Management of the older patient during active treatment, palliative and terminal care, and when a remission is accomplished is both challenging and rewarding.

The cancer patient with pain: psychiatric complications and their management.

The psychiatric complications most often seen in cancer are depression, anxiety, and delirium. All are more likely to occur in the cancer patient who has pain. It is important for patient comfort and quality of life to evaluate and intervene to manage the psychologic distress in the patient with cancer, especially if pain is a complication.