Depression and breast cancer
Compiled by: Professor Justus Apffelstaedt: Associate Professor, University of Stellenbosch and Head of the Breast Clinic: Tygerberg Hospital
Q: Are depressed women at a greater risk of breast cancer?
A: A report released from Johns Hopkins School of Public Health in 2000 presented a compelling look at a possible mind-body link in what has been considered a purely physical illness. The link between psychological health and breast cancer has not been consistently found in other research. A study reported in the September 1999 issue of Health Psychology (1999;18;5:1-12), found no connection between depression and breast cancer. 46 studies looking at a potential link were analyzed by researchers at Roswell Park Cancer Institute in Buffalo, NY and the University of Illinois at Urbana-Champaign. They found that anxious or depressed women, women who experienced a difficult childhood, and women who suppressed their anger were no more likely to develop breast cancer than other women.
Conversely, a National Institute of Aging study examined 4,825 people age 71 and over. This time, though, researchers were looking for chronic depression, people who exhibited depression all three times they were interviewed between 1982 to 1988 - 146 in all. None of these people had cancer in 1988. In 1992, however, these same individuals were 88 percent more likely than the others to have developed cancer.
The book is by no means closed on the matter, and scientists are a long way from figuring out how a chemical storm in the brain may result in a tumor elsewhere in the body. It could be that genes and environment are the actual causes, with depression acting as the trigger, or it may be that a low mood of long duration suppresses the body's immune system, allowing cancer cells to flourish.
But unless future research starts turning in consistent results, we cannot say for sure if depression is a cause or trigger of cancer.
Q: Can stress increase a person’s risk of developing cancer?
A: Studies done over the past 30 years that examined the relationship between psychological factors, including stress, and cancer risk have produced conflicting results. Although the results of some studies have indicated a link between various psychological factors and an increased risk of developing cancer, a direct cause-and-effect relationship has not been proven.
Some studies have indicated an indirect relationship between stress and certain types of virus-related tumors. Evidence from both animal and human studies suggests that chronic stress weakens a person’s immune system, which in turn may affect the incidence of virus-associated cancers, such as Kaposi sarcoma and some lymphomas .
More recent research with animal models (animals with a disease that is similar to or the same as a disease in humans) suggests that the body’s neuroendocrine response (release of hormones into the blood in response to stimulation of the nervous system) can directly alter important processes in cells that help protect against the formation of cancer, such as DNA repair and the regulation of cell growth .
Q: What are the best ways to combat depression when you have breast cancer?
A: There are a variety of recommendations, which are listed below. Each person is unique, so it’s best to choose what works best for you.
Treatment Recommendations:
First Line of Defence: Professional Help
•Counselling/Therapy: First and foremost, see a mental health expert. You can ask your medical doctor for a recommendation.
Second Lines of Defence: Supplementary and Ancillary Care
Self Help:
•Practice acceptance: Practice self-acceptance about sadness, anxiety and fear.
•Mindfulness: Label your thoughts to pinpoint whether it is fear, anxiety or sadness, and determine which thoughts are repetitive or long standing.
•Spirituality: Try spiritual, ritual and religious practices either in a group setting or on your own.
•Breathe: Take deep breaths and do relaxation exercises throughout the day.
•Exercise: As fatigue is a major issue for cancer patients in chemo, invest in exercise.
•Work: if you can return to your work schedule do, but even a modified one, if and when you can, is also helpful in feeling reintegrated and grounded.
•Nutrition: Make smart choices for your diet -- get plenty of fibre and protein from anti-cancer foods. Avoid junk food, alcohol, and tobacco. Work with a trainer or physical therapist to build physical strength and flexibility.
•Vacation: Whether you can afford and are healthy enough for a trip abroad or even just to a local park or your backyard, seek out positive elements in your life.
•Group Support: Sign up for group counselling and/or support groups dealing with breast cancer and depression and couples therapy can also be beneficial.
•Hobby: Find something you enjoy. One cancer patient, who was also a doctor, watched dozens of movies when she was unable to work or even go out and socialize.
•Community service: Focus on helping others, be it those less fortunate or people who are also struggling with breast cancer. Empathizing with and assisting others can help you feel more connected and offer a greater perspective of the world.
•Activism: Get involved in raising money for cancer research. There are countless non-profit organizations that need your help in raising awareness and funding to make sure that everyone who suffers from breast cancer, regardless of their race, religion, or creed, has access to good medical care.
•Body Image: Get help for body image concerns from family, friends and your doctor's staff. Make changes in your wardrobe and hairstyle to brighten your self-image.
•Busy Schedule: Scan your schedule and eliminate the unnecessary (or most difficult) tasks. Delegate chores and errands to family or friends. Build in time for yourself, such as calming rituals, journaling or gentle exercise.
•Fatigue: Give yourself permission to rest, whether it's taking short naps, meditating, or just going to bed earlier and sleeping later at times. If fatigue persists, talk to your doctor.
•Physical Discomfort: Take a friend or family member with you for any unpleasant appointments or treatments, using distraction to relieve your discomfort. Learn to meditate, listen to music, play games, or make positive conversation to help reduce your stress.
•Loneliness: Many people feel isolated by a breast cancer diagnosis. Break out by finding a local support group you can attend, or join an online support forum. You do not have to take this journey alone.
•Your Future: Be optimistic, looking past the current therapy to learn a new skill, plan a trip, or whatever it takes to give you incentive to push ahead every day. Decide to use hope instead of fear as your motivation.
Questions to ask your GP/Gynaecologist if a lump is found
By: Professor Justus Apffelstaedt, Associate Professor: University of Stellenbosch and Head of the Breast Clinic: Tygerberg Hospital
Q: Does this mean that I have cancer?
A: No; actually the majority of lumps seen by doctors are not cancerous. Benign lumps are common in young women; in women above age 25 cancer, while still rare as a cause of a lump, cancer must be excluded by needle biopsy before the lump can be accepted as benign.
Q: So what happens from here to ascertain whether the lump is benign or cancerous?
A: In women under age 35 a needle biopsy is sufficient to confirm the diagnosis of a benign lump. Above 35, a mammogram, ultrasound and needle biopsy are mandatory and in that order.
Q: What questions should I ask a mammography centre to make sure that I’m comfortable that they know what they’re doing?
A: You should ask how many mammograms do you do every year? Will your mammogram be done by a certified mammographer? Will your mammogram be read by 2 readers? How many cancers do you pick up per 1000 mammograms? Do you do needle core biopsies?
Q: Do you think I need to have a biopsy? If no, why not?
A: See the first and second answers.
Q: Do I have to go to hospital to have a biopsy?
A: No. You should ask for the diagnosis to be established by needle core biopsy; if necessary under imaging (mammographic or ultrasound) guidance.
Q: What kinds of benign breast conditions are there?
A: Fibroadenomas are benign lumps in the breast. They are common in young women and often disappear spontaneously. They are sometimes (and rarely) removed because they are tender or keep on enlarging.
Q: Does having a benign breast change mean I am at greater risk of developing cancer?
A: Yes and no. Most benign conditions do not signify an increased risk of breast cancer. Only what doctor’s call hyperplasia (a condition in which there is an increase in the number of normal cells in a tissue or organ), especially if coupled with atypia (atypical cells, or slightly abnormal), indicates an increased risk of breast cancer.
Breast cancer and pregnancy
Compiled by: Professor Justus Apffelstaedt: Associate Professor, University of Stellenbosch and Head of the Breast Clinic: Tygerberg Hospital
Q: How often does breast cancer occur in pregnant women?
A: Breast cancer occurs in about one in every 3,000 pregnancies, most often in women between the ages of 32 and 38.
Q: Can pregnant woman have a mammogram?
A: Regular screening mammography in women without any symptoms is usually not done during pregnancy. However mammography during pregnancy may be considered for women with signs or symptoms of a possible breast problem.
Q: Can a mammogram harm a fetus?
A: Small studies have found that mammography poses little to no harm to the fetus during pregnancy if a lead shield is placed on the belly to block any possible radiation scatter.
But the accuracy of mammography is limited during pregnancy. In three different studies, the percentage of breast cancers in pregnant women that mammography detected was between 62% and 78%. This is significantly lower than the average 85% detection rate in non-pregnant women.
Q: Can breast cancer spread to your baby when you are pregnant?
A: No. A barrier between the mother's and the baby's body blocks any cancer cells from entering the baby or its blood supply.
http://www.cancer.gov/cancertopics/pdq/treatment/breast-cancer-and-pregnancy/patient
http://www.breastcancer.org/tips/fert_preg_adopt/bc_pregnancy/screening.jsp
http://www.breastcancer.org/tips/fert_preg_adopt/bc_pregnancy/treatment.jsp
Understanding breast cancer screening
By Professor Justus Apffelstaedt, Associate Professor: University of Stellenbosch and Head of the Breast Clinic: Tygerberg Hospital
In order to understand breast cancer screening, it is important to explain some general principles of screening:
•The disease screened for must be common. With 1 of 8 women suffering breast cancer during their life-time, this is clearly the case. While there are no accurate, recent statistics available for South Africa, our own cancer pick up rates indicate that contrary to official statements, breast cancer is as common in our population as in countries with established screening programs.
•The disease must be sufficiently severe to warrant the screening effort. Nobody will dispute this for breast cancer.
•A screening test must be available, that reliably picks up the signs of the disease. At the same time, a screening test must not generate too much “harms”. Mammography will pick up early signs of breast cancer in about 90 – 95% of cases, fulfilling the first condition. “Harms” mean that the test must not pick up signs of the disease in too many patients that with further work-up turn out to be false alarms. For mammography it is accepted, that less than 10% of women should be called back for further examinations. In our centre, about 4 – 5% of women are called back. It is also important, that while false alarms are inevitable, these can be sorted out with a minimum of cost and further harms done to the patient. Generally, less than 5% of women should have a biopsy to sort out findings. In our centre, it is about 2%. The vast majority of biopsies should be done as office procedures under mammographic or ultrasound guidance; only very rarely should a woman have to go to theatre to make a diagnosis. In our centre, only 2 in 100 biopsies are done as a theatre procedure. If a biopsy is performed, it must yield a diagnosis of cancer in 2 – 5 of 10 cases. In our centre, about 1 in 3 biopsies result in a diagnosis of cancer. /
•As new cases of the disease arise continuously, the screening test must be repeated at regular intervals. For mammographic screening, most cancer organizations recommend annual screening from age 40 onwards. In most governmental screening programs, the screening interval is 2 years for mainly financial reasons. Concerns about the radiation exposure are unfounded, as there is stringent supervision of mammography units by the Radiation Control Board in South Africa.
•The screening test must pick up the disease so early, that it changes the course of the disease. In a well-run screening unit, about 1 in 5 cancers will be detected at a pre-invasive stage. This means, that the cancer is curable by surgery alone and does not require intensive treatment such as chemotherapy or radiotherapy. In our centre, one in 3 cancers is detected at the pre-invasive stage. More than half of the invasive cancers must be less than 2 cm in diameter. In our centre, about half of invasive cancers are less than 1 cm in size. The pre-invasive and these small invasive cancers can be cured in more than 90% of patients. It is well documented, that in regularly screened patients, the mortality of breast cancer is up to 50% lower than in those who do not undergo mammographic screening. Here, many misunderstandings arise. Breast cancer is a slowly growing cancer and effective therapy is available. This means, that the benefit of screening in the form of a reduced mortality becomes apparent only after about 10 years in those who underwent screening.
•All the above shows that mammographic screening can change the course of breast cancer. It is unclear, however whether this is a given in South Africa. The effectiveness of screening is well documented in overseas screening programs, where stringent quality controls from regulatory authorities are applied. This is not the case in South Africa. Only a single unit in South Africa has ever published in peer-reviewed scientific journals its screening results and shown that it can provide screening at the quality of the best overseas units.