Breast Cancer in Women With Severe Mental Illness Often Undertreated, Review Suggests

Women with severe mental illness (SMI)—such as schizophrenia, bipolar disorder, or major depression—are less likely to receive recommended treatment for breast cancer than those without SMI, according to a report in Psycho-Oncology.

Prior studies suggest that death from breast cancer is higher among patients with preexisting SMI compared with those without mental illness. Such higher death rates may be the result of reduced access to early cancer screening; delays in seeking cancer care; and/or a lack of collaboration between psychiatrists, primary care physicians, and oncologists, wrote Steve Kisely, M.D., Ph.D., of the University of Queensland in Australia and colleagues.

Curious about the barriers that patients with SMI experience following a breast cancer diagnosis, the authors compiled and reviewed articles that reported data on whether an SMI diagnosis impacted the receipt of guideline-appropriate cancer treatment (for example, surgery, chemotherapy, radiotherapy, and/or adjuvant endocrine therapy) for adult female breast cancer patients.

Kisely and colleagues included 13 studies in the review, which included a total of 299,193 participants. Of these, four studies estimated the odds of receiving guideline-appropriate breast cancer treatment in people with schizophrenia and related psychotic disorders and/or mood disorders; these were included in a meta-analysis.

The pooled data from the four studies showed that patients with SMI were about 17% less likely to receive guideline-recommended cancer treatment than those without SMI. Kisely and colleagues also found “that patients with bipolar disorders, schizophrenia, and other psychotic disorders had a significantly higher risk of delays to starting cancer treatment of 2 months or more after breast cancer diagnosis, and they were less likely to initiate their adjuvant hormonal therapy within 1 year of their diagnosis.”

The authors concluded, “Our results suggest that greater action is needed to improve access to guideline-appropriate care for breast cancer outcomes of psychiatric patients. In the area of colorectal cancer, people with schizophrenia who received case management including education on screening and patient navigation had higher participation rates compared [with] controls who had treatment a usual. This approach might also be applied to breast cancer treatment including the use of navigators, in combination with collaborative care between general practitioners, oncology, and mental health services.”

For related information, see the Psychiatric Services article “Association Between the Maryland Medicaid Behavioral Health Home Program and Cancer Screening in People With Serious Mental Illness.” 

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Breast Cancer Patients Benefit From Tailored Approach to Depression Screening

Developing tailored strategies that encourage staff at oncology clinics to routinely screen patients with breast cancer for depression can help increase the number of patients connected with behavioral health services, suggests a report published today in JAMA.

Depression is known to be associated with worse outcomes in cancer patients, including decreased social and physical functioning and poor quality of life. The American College of Surgeons Commission on Cancer recommends that health professionals screen cancer patients for distress; however, patients with breast cancer are often underdiagnosed and undertreated for depression and depressive symptoms, wrote Erin E. Hahn, Ph.D., M.P.H., of Kaiser Permanente Southern California and colleagues.

Hahn and colleagues wanted to know whether a depression screening program tailored to individual oncology clinics might increase the proportion of patients receiving referrals to behavioral health services compared with an education-only strategy. They randomized six medical centers within Kaiser Permanente Southern California that were treating patients diagnosed with a new primary breast cancer to one of two interventions: three centers received a tailored intervention; the other three received general education about the program. All centers were encouraged to screen newly diagnosed patients with the nine-item Patient Health Questionnaire (PHQ-9) and, as indicated based on PHQ-9 scores, refer patients for additional behavioral health services.

The clinical teams at tailored intervention sites were educated about the PHQ-9 and the scoring-referral algorithm, engaged in regular check-ins with a nurse researcher, and received tailored audit and feedback reports of progress compared with those of the other intervention sites throughout the study. The teams at the education-only sites were provided with general information about the screening program, including the PHQ-9 questionnaire and scoring-referral algorithm.

The trial included 1,436 patients diagnosed with new primary breast cancer who had a consultation with medical oncology between October 1, 2017, through September 30, 2018; these patients were followed up to May 31, 2019, insurance disenrollment, or death. Regardless of PHQ-9 screening, a significantly greater number of patients in the tailored intervention group received a referral for any behavioral health service compared with patients treated at the education-only clinics during the study period: 135 patients (18%) vs. 74 (11%), the authors reported.

“Given the high burden of depression in patients with breast cancer, effective screening and referral programs are needed. In the current era of heightened health-related concerns due to SARS-CoV-2, which may disproportionately affect patients with cancer and survivors, systematic depression screening and referral for patients with cancer may be even more important,” Hahn and colleagues concluded.

For related information, see the Psychiatric Services article “Factors Influencing Receipt of Mental Health Services Among Medicaid Beneficiaries With Breast Cancer.”

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Women With Mental Illness Are Less Likely to Receive Mammograms, Study Finds

Despite access to free health care services, women with mental illness may be less likely to receive breast cancer screenings than those without mental illness, according to a study in the American Journal of Preventive Medicine. The report focused on women living in the United Kingdom, who are regularly notified to get a breast cancer every three years between the ages of 50 and 70.

Previous studies have suggested that U.S. women with mental illness, particularly serious mental illness, are less likely to get mammograms than those without mental illness. Less clear, however, has been whether this disparity extends to women living in a country where there is universal health care, wrote Emma Ross, Ph.D., of the Centre for Public Health at the Queen’s University Belfast and colleagues.

For this study, Ross and colleagues used 2011 census data to identify a cohort of 57,328 women eligible for free breast screening in Northern Ireland. The researchers then tracked these women over the course of a three-year period, examining whether mental illness impacted the odds of their getting screened for breast cancer. Women were considered to have mental illness if they received at least one prescription for a psychotropic medication in the three months preceding their notification for a breast cancer screening.

The authors reported that nearly one-third of the women in the study were prescribed a psychotropic medication during this timeframe. Women who received a psychotropic medication prescription were 15% less likely to get a breast cancer screening than those without such a prescription. Additional analysis revealed that breast cancer screening was particularly low for women prescribed anxiolytics and antipsychotics.

“The findings of this study provide novel evidence of variation in the magnitude of disparity in screening attendance according to the type of psychotropic medication prescribed. Notably, the inequality in uptake was greatest in individuals prescribed anxiolytics, for whom a 39% reduction in the odds of attending screening was observed,” Ross and colleagues wrote. “Although the underlying relationship between anxiety and screening attendance is yet to be elucidated, it is plausible that the avoidance behaviors that commonly develop as a coping mechanism in individuals with anxiety disorders predominantly explain this reduced participation.”

For related information, see the Psychiatric News article “Women With Schizophrenia Only Half as Likely to Receive Mammograms.” 

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Some Young Breast Cancer Survivors Report PTSD Symptoms Years After Diagnosis

Posttraumatic stress disorder (PTSD) is known to affect a subset of cancer survivors. A study in Psycho-Oncology found that 6.3% of young survivors of non-metastatic breast cancer reported PTSD symptoms related to cancer more than two years after their diagnosis. Women who reported anxiety symptoms six months after being diagnosed with breast cancer were 12 times more likely than others to report PTSD symptoms two years later.

“We found similar rates of cancer-related PTSS [posttraumatic stress symptoms] in breast cancer survivors diagnosed at a young age compared with the general breast cancer population despite their well-documented increased risk of overall distress,” wrote Danny Vazquez, M.D., M.P.P., of Dana-Farber Cancer Institute and colleagues. “Nevertheless, factors associated with posttraumatic stress should be considered at diagnosis and in survivorship to identify young patients who may benefit from psychosocial resources.”

The findings were based on data collected as part of the Young Women’s Breast Cancer Study—an ongoing prospective cohort study of more than 1,300 women diagnosed with breast cancer at or before the age of 40. Study participants received a baseline survey within six months of diagnosis, and follow-up surveys were sent every six months for the first three years after diagnosis and yearly thereafter.

At baseline, all participants filled out questionnaires assessing symptoms of anxiety and depression, fear of cancer recurrence, and presence of social support; participants were also asked about psychiatric comorbidities and use of psychiatric medications. At 30 months, the participants were asked to fill out the 17- item PTSD Checklist-Specific Version questionnaire and rate the severity of PTSD symptoms they had experienced over the prior month specifically related to “cancer treatment or your experience with cancer” on a scale from 1 (“not at all”) to 5 (“extremely”). A score ≥ 50 was considered positive for clinically significant posttraumatic stress symptoms. Women diagnosed with stage 0 or stage 4 cancer, those with missing PTSD data, and those who experienced a recurrence within 12 months of the PTSD survey were excluded from the analysis.

Of the 700 women who had been diagnosed with stage 1-3 breast cancer included in the analysis, about 2% had psychiatric comorbidities and 3% reported taking psychiatric medications. Additionally, 8% screened positive for depression, 23% screened positive for anxiety, and 23% of women reported substantial fears of recurrence at baseline.

Clinically significant posttraumatic stress symptoms at 30 months were significantly associated with anxiety (odds ratio=12.43) and stage 2 vs. stage 1 disease (odds ratio= 2.26), the authors reported. There was no increased risk seen with stage 3 vs. stage 1 disease, but the authors noted that this might be due to the low number of women with stage 3 breast cancer (99 of 700) in the analysis. Women with a college degree and greater social support were less likely to report posttraumatic stress symptoms at 30 months.

“Early identification of those at risk could facilitate individualized screening strategies for the development of PTSS, as well as targeted medical interventions to improve [the] mental health and quality of life of breast cancer survivors diagnosed at a young age,” Vazquez and colleagues wrote.

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Many Women With Schizophrenia Do Not Receive Mammograms, Meta-Analysis Suggests

Women with schizophrenia are only half as likely as women in the general population to receive mammograms, reports a meta-analysis published in Psychiatric Services in Advance.

“Lower screening rates could explain why women with schizophrenia and other serious mental illnesses are found to have more advanced breast cancer at time of diagnosis,” wrote Alison Hwong, M.D., Ph.D., and colleagues at the University of California, San Francisco. “Given the high prevalence of breast cancer and the promising prognosis of breast cancer if detected early, mammography screening is a key first step in improving diagnosis and treatment for people living with schizophrenia.”

Hwong and colleagues compiled data from 11 clinical studies that looked at mammography screening rates in women with schizophrenia or other psychotic disorders. The 11 studies were conducted in four countries with diverse health care systems (United States, Canada, England, and Denmark) and totaled more than 470,000 women; this included 25,447 women with a diagnosis of schizophrenia or other psychotic disorders.

“With time constraints, primary care providers and psychiatrists may not prioritize cancer screening for patients with serious mental illness,” Hwong and colleagues wrote. Physicians may focus on psychiatric and metabolic symptoms first, which “may lead to deferring routine preventive screening discussion for future visits, but the future discussion never occurs.”

The authors called for research on the inequity in breast cancer screening and the development of novel strategies to promote mammography screening of these women.

To read more on this topic, see the Psychiatric News article “UCSF Psychiatrists Bring OB-GYN Care to Patients With SMI.”

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Women With Schizophrenia May Be at Greater Risk of Breast Cancer, Meta-Analysis Finds

Women with schizophrenia may be at a 30% higher risk of breast cancer than women without schizophrenia, according to a meta-analysis published today in JAMA Psychiatry.

“Because breast cancer is the most common cancer in women, affecting 1 in 9 women during their lifetime, our findings highlight that intensive prevention and treatment against breast cancer are warranted for women with schizophrenia,” wrote study authors Chuanjun Zhuo, M.D., Ph.D., of Tianjin Medical University in China and Patrick Todd Triplett, M.D., of Johns Hopkins School of Medicine.

Zhuo and Triplett conducted a systematic search of PubMed and EMBASE databases; twelve cohort studies that included 125,760 women were included in the meta-analysis. The number of women with schizophrenia included in each study varied from 1,388 to 46,447, and the number of the breast cancer cases ranged from 42 to 1,042.

The meta-analysis revealed that schizophrenia was associated with a significantly increased risk of breast cancer incidence in women (standardized incidence ratio, 1.31); however, there were significant differences between the studies included in the meta-analysis.

“Future studies are needed to determine the association between schizophrenia and the different pathologic subtypes of breast cancer as well as whether the association may be affected by the woman’s age at breast cancer onset, antipsychotic medications used, and the cancer subtype,” Zhuo and Triplett wrote.

Despite the limitations of the meta-analysis, the authors noted the results indicate that women with schizophrenia deserve focused care for breast cancer screening and treatment.

“For the early prevention of breast cancer, an initial evaluation is needed to stratify the risk of breast cancer in women with schizophrenia. Subsequently, antipsychotics that may increase the prolactin level and produce a higher breast cancer risk should be avoided in high-risk women. Regular screening, including imaging or biomarker tests, should be performed. If an early diagnosis of breast cancer is made in women with schizophrenia, collaborations with oncologists are needed for clinical psychiatrists to make an optimal treatment recommendation,” they wrote.

For related information, see the Psychiatric News PsychoPharm article “Expert’s Corner: Best Practices for Treating Cancer Patients With Psychiatric Symptoms,” by Philip Bialer, M.D., of Memorial Sloan Kettering Cancer Center and the Psychiatric Services article “Mammography Among Women With Severe Mental Illness: Exploring Disparities Through a Large Retrospective Cohort Study.”

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Study Highlights Need for PTSD Interventions for Cancer Patients

Research on adult cancer patients in Southeast Asia found a striking prevalence of posttraumatic stress disorder (PTSD), with about 1 in 5 (21.7%) experiencing symptoms of PTSD six months after being diagnosed with cancer. The study was published Monday in Cancer.

Although participants’ rates of PTSD declined with time, the data underscore the risk of developing persistent PTSD even years after cancer diagnosis and treatment, according to the authors of the study. About one-third of patients (34.1%) initially diagnosed with PTSD or some of its symptoms went on to develop chronic or worsening PTSD four years later. 

“There is a need for early identification of this subset of patients who have cancer with PTSD to design risk-targeted interventions,” concluded Caryn Mei Hsien Chan, Ph.D., of the National University of Malaysia in Kuala Lumpur and colleagues. 

Moreover, finding ways to monitor PTSD among patients living with cancer is critical because many of its symptoms, such as avoidance and cognitive difficulties, are enduring, which may potentially impact adherence to treatment, the authors noted. 

The study involved face-to-face interviews with 469 patients within one month of cancer diagnosis. Participants took the Hospital Anxiety and Depression Scale (HADS) at the outset and four weeks to six weeks later. Those who were found to have psychological distress underwent the PTSD module of the Structured Clinical Interview for DSM-IV (SCID) at six months. At the four-year follow-up, the SCID was used to assess PTSD in all 245 living patients, regardless of their HADS scores. 

The high rate of PTSD found in the study may be partly due to the higher risk of PTSD found in Asian patients with cancer, compared with patients of Caucasian descent, the researchers wrote. The researchers also included so-called “subsyndromal” PTSD cases: patients whose symptoms lasted less than one month or who did not meet the threshold for a DSM-IV diagnosis despite the presence of multiple symptoms.

The study also found that patients with breast cancer were 3.68 times less likely to have PTSD at the six-month follow-up than those with other types of cancer, but not at the four-year follow-up. “Because breast cancer is a very common malignancy, it is possible that greater societal understanding and the wider availability of support programs tailored for breast cancer (compared with fewer support programs for patients with other cancer types) initially serve as protective factors against PTSD,” the authors wrote.

For related information, see the Psychiatric News article “Mental Health Issues in Cancer Survivors Persist Long After Treatment Ends.”

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Antidepressants Do Not Increase Breast Cancer Recurrence in Women Taking Tamoxifen

Women taking tamoxifen to reduce their risk of breast cancer recurrence also frequently take antidepressants to help counter tamoxifen’s side effects, which include hot flashes, night sweats, and depression. However, some previous studies have suggested antidepressants may reduce the effectiveness of tamoxifen, thus raising the risk of breast cancer recurrence.

A new assessment of the medical records of nearly 17,000 breast cancer survivors published this week in the Journal of the National Cancer Institute suggests there is no increased risk of subsequent breast cancer in women who concurrently took tamoxifen and antidepressants.

The study examined 16,887 women in California who were diagnosed with breast cancer from 1996 to 2007 and treated with tamoxifen (all women were insured by Kaiser Permanente Southern California, who conducted this study). Of this group, 8,809 also took antidepressants, including paroxetine, fluoxetine, and tricyclics. The participants were stratified based on the degree of overlap in days taking tamoxifen and antidepressants.

Over the course of the study, 2,946 women developed breast cancer. The study authors found no statistically significant difference in breast cancer recurrence in women taking tamoxifen only and those also taking antidepressants—even in women who had a 75% or greater overlap in days taking both medications.

“Given that thousands of breast-cancer survivors struggle with depression, sleep disturbances, and other side effects while on tamoxifen, our study should help alleviate any concerns physicians have about prescribing antidepressants to their breast-cancer patients to help improve their quality of life,” said lead author Reina Haque, Ph.D., M.P.H., a research scientist at Kaiser Permanente Southern California, in a press statement.

To read more about treating depression in patients with cancer, see the Psychiatric News article by Jesse Fann, M.D., M.P.H., titled “Integrated Psychosocial Care for Cancer Patients.”

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