1. Lillis, Karin

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A recent study suggests that at least one in five cancer patients experiences post-traumatic stress disorder (PTSD) within 6 months of initial diagnosis-and many continue to live with the disorder up to 4 years later.

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In a prospective national cohort study, Caryn Mei Hsien Chan, PhD, and her colleagues at the National University of Malaysia, University of Malaya, Harvard Medical School, and Dana-Farber Cancer Institute examined 469 adults with various types of cancer within 1 month of diagnosis. They found that 21.7 percent of patients experienced PTSD at 6 months post-diagnosis. At the 4-year mark, one-third of those patients still had symptoms of PTSD (Cancer 2017; doi:10.1002/cncr.30980).


"The risk of PTSD never really goes away for patients with cancer, even among cancer survivors, as there is always the risk of developing delayed-onset PTSD much later down the road, particularly with cancer progression and recurrence," she said.


The results, Chan noted, underscore the need for health care providers to better understand and address the mental and emotional repercussions that many patients with cancer face.


"Cancer patients are almost never screened for PTSD in the oncology clinic at the moment," Chan told Oncology Times. "Patients need continued active surveillance and long-term follow-up-even years after remission-to avoid delays in necessary care. These patients may skip follow-up scans and procedures to avoid triggers that remind them of their cancer experience. They may also delay seeking help for new symptoms or refuse treatment."



Using the Hospital Anxiety and Depression Scale (HADS), patients were assessed for anxiety and depression at baseline, 4-6 weeks post-diagnosis, and at 1- and 4-year follow-up assessment.


Those with elevated HADS scores (16 and above) at the initial and 4-6-week evaluations were specifically evaluated for PTSD at a 6-month follow-up, using the PTSD module of the Structured Clinical Interview for the DSM of Mental Disorders IV-TR. All patients, regardless of HADS score, were assessed for PTSD at 4 years.


The researchers divided patients into four categories: those with full PTSD, subsyndromal PTSD, non-probable PTSD, and no PTSD. They gathered baseline demographic, clinical, and psychosocial information from 439 patients who underwent HADS and PTSD assessments.


Researchers included patients with any kind of cancer who were able to complete a series of assessments, understand the study's objectives, and provide informed consent. Patients who were unaware of their diagnosis, as well as those who were too sick to tolerate interviews, were excluded from the study.


The team also noted that 210 patients died during the 4-year duration of the study.


Notable Findings

"We hypothesized that the presence of psychological distress at diagnosis and after treatment would predict PTSD, and that PTSD would persist in the long-term for a small proportion of the sample," the team wrote. The team's findings, Chan said, suggest otherwise.


At the 6-month follow-up, 203 of those patients were evaluated specifically for PTSD; 27 (13.3%) were diagnosed with full PTSD, and another 17 (8.4%) had subsyndromal PTSD. Overall, 15 of those 44 patients went on to develop full PTSD at the 4-year mark, the researchers noted.


"To put this into perspective, this is approximately three times above the non-cancer, general population average of about 6 percent. Although the rates dropped to a rate similar to individuals without cancer at 6.1 percent at 4 years follow-up, roughly one-third of patients were found to have persistent or worsening symptoms 4 years later," Chan said.


She also pointed to a finding that has received significantly less attention: The majority of patients in the study also reported a high rate of cognitive impairment, specifically difficulties with concentration symptoms that are also common in people with PTSD.


"Issues with cognition among patients with cancer are dubbed as 'chemobrain' and often attributed as a side effect of chemotherapy," Chan said. "We are exploring whether this decline in cognitive functioning may be more likely related to PTSD than the cancer treatment itself."


Additionally, the researchers found that patients with breast cancer were 3.7 times less likely to develop PTSD at 6 months post-diagnosis, but not after 4 years.


Because breast cancer is a very common malignancy, Chan surmised, it is possible that greater society understanding of the wider availability of support programs tailored for breast cancer initially serve as protective factors against PTSD, but that this protective effect attenuates with distance from original diagnosis.


The current study was limited to a single academic medical center in one country. Future research needs to include larger samples of cancer patients, as well as a control group of patients without the disease, Chan noted.


The current research also suggests that Asian patients are at highest risk of developing PTSD within 6 months of diagnosis, rather than further on in treatment, Chan said. International research is necessary to determine whether there are differences between Asian and Western patients.


Key Takeaway Points

Chan noted that there needs to be longer psychological support follow-up for patients once they transition to the survivorship phase. Oncologists should follow-up on their patients regularly and then at least annually once patients are in remission.


"We need psychological evaluation and support services for patients with cancer at an initial stage and at continued follow-up at least as regularly," Chan said.


"One way to achieve this would be through the training of not just oncologists, nurses, and others in the cancer care team, but also primary care physicians who are often involved in the follow-up care for cancer survivors, so that they are better able to detect and manage PTSD in this population."


Karin Lillis is a contributing writer.