1. Gallagher, Amy

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Patients receiving a cancer diagnosis are at an increased risk of several stress-related psychiatric disorders, such as depression, anxiety, and stress-reaction and adjustment disorders. More directly, women diagnosed with cervical cancer while experiencing psychological stress are at a higher-risk of cancer-specific mortality, according to research conducted by the study's lead author, Donghao Lu, MD, PhD, a postdoctoral researcher from the Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm.

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"Emerging evidence from both experimental and epidemiological studies indicate that psychological distress might affect the progression of many cancer types," Lu explained. "The increased stress around cancer diagnosis may reflect a mixed effect of diagnostic workup, cancer diagnosis and treatment, as well as the state of living with cancer."


Research Findings

In the study, researchers examined the potential influence of stress on the cancer-specific mortality of patients with cervical cancer. Between Jan. 1, 2002, and Dec. 31, 2011, the records of 4,245 patients who were diagnosed with cervical cancer in Sweden with a mean age of 53.9 +/-18.1 years were studied. Using Swedish personal identification numbers, researchers linked the patients to the Swedish National Patient Register, which collects nationwide information on hospital discharge records and specialist visits. Data from this register were used to identify patients who had been clinically diagnosed with any of three psychiatric disorders: stress-reaction and adjustment disorders, depression, and anxiety.


Lu pointed out that the association of stress to a higher risk of dying of cervical cancer remained, independent of tumor characteristics, mode of diagnosis, and type of treatment.


"The associations were also consistent across demographic groups and clinical characteristics, such as tumor stage, histology, mode of detection and treatment, as well as the Charlson Comorbidity Index," he explained. "We used [this] index to identify comorbidity, which was revealed in about 27 percent of all patients who had at least one comorbidity at the time of cancer diagnosis."


Lu added that the tumor characteristics included tumor stage (IA, IB, II, or III+) and histology (squamous or others).


The researchers used the Swedish Causes of Death Register to identify women who had cervical cancer or unspecified uterine cancer as the underlying cause of death. During the follow-up period, 1,392 patients died, with cervical cancer listed as the cause of death for 1,005 of them, stated Lu. In all, the researchers found that 1,797 patients either had stress-related disorders or had undergone stressful life events.


"Patients with either a stress-related disorder or a stressful life event were 33 percent more likely to die of the disease than those who had not reported stress," he said. "Those who had stress-related disorders were 55 percent more likely to die of their cervical cancer, and those who had experienced a stressful life event were 20 percent more likely to die of their disease."


According to the World Health Organization, cervical cancer is the fourth most frequent cancer in women with an estimated 570, 000 new cases in 2018, representing 7.5 percent of all female cancer deaths. The high mortality rate from cervical cancer globally (Age Standardized Rate: 6.9/100,000 in 2018) could be reduced by effective interventions.


Reduced Cellular Immune Response

Lu said there are several possible explanations for the link between psychological stress and cervical cancer-specific mortality. Biologically, he noted, previous research has shown that chronic stress may reduce cellular immune response, which may affect the progression of infection-related cancers, such as cervical cancer.


"Cancer progression is the course of cancer disease as it becomes worse or spreads in the body," he stated. "In general, chronic stress reduces cellular immune response in most diseases and disorders. Stress leads to a reduced cellular immune response that ultimately leads to a disease state. There are many biological mechanisms linking stress to a subsequent disease. Immune pathway is one of them."


Lu noted that cell-mediated immunity is an immune response that does not involve antibodies. Moreover, a previous study by Lu and his colleagues further supports the role of psychological stress in cervical cancer development, potentially through oncogenic infection of human papillomavirus.


Emotional Support in Absentia

Fellow author Karin Sundstrom, MD, PhD, Project Coordinator in the Department of Laboratory Medicine, Karolinska Institutet, said the psychological support in Sweden is available for patients at large, university-based clinics, but not in smaller local facilities.


"Many patients do not receive emotional support, partially because of lack of awareness of the toll emotional stress can take," she explained.


Lu said part of the solution is to have more cancer-specific centers staffed with oncologists, gynecologists, psychiatrists, and psychologists practicing as a team to treat the whole patient.


"Physicians may proactively evaluate the mental or emotional status rather than until the patients complained," he said.


"Our findings support that oncologists or gynecologists perform active evaluation of psychiatric status on return visits to see how patients with cervical cancer are doing, not only somatically, but also mentally," Sundstrom said. "If confirmed in other populations and countries, psychological screening and intervention may be considered as an integral component in cervical cancer care."


Amy Gallagher is a contributing writer.