The Impact Of A Diagnosis

A breast cancer diagnosis is an incredibly traumatic event in a person’s life.

The psychological impact of a diagnosis can be significant if a patient’s mental health is not looked after.

However, there is no one-size fits all approach to mental health in this area as everyone will react to their diagnosis differently according to Dr Lisa Beatty, a clinical psychologist and Cancer Council South Australia Senior Research Fellow.

“It might be that it’s stopping them from going out and socialising, it might be that it’s stopping them from working and this is on top of the impact of the cancer itself.”

“We also know there can be huge issues with body image, we know that there are big issues with feeling shock and anger. And also one of the big things we’re hearing a lot more now is that women might not necessarily feel like they’re being particularly well supported, that some of the people that they thought would be their core support people would just disappear and other people that they hadn’t necessarily expected to be involved, really put their hands up.”

Unfortunately demand for mental health services far outweighs the supply in the cancer space.

Dr Beatty said access to cancer specific mental health services can be very dependent on the institution or hospital you are receiving treatment at.

“Some of the big metro-based hospitals with big cancer services will have a lot of funding for psycho-oncology, so you might have a team of people there that you can be referred to.”

“The hospital where I work, I am the only psychologist that works in cancer and I’m funded to do one day per week.”

“So, as you can imagine, it can mean that there are really long wait lists.”

“The demand is very much exceeding the available supply.”
Dr Beatty said because of this, it is not always routine for patients to be referred to these services.

“I think in some hospitals where there isn’t any (services), it leaves a bit of an ethical dilemma for some of the clinicians.”

“Do they screen for distress when they don’t have anywhere to send people afterwards?” she said.

“So, we try and work in a very integrated fashion as part of the multi-disciplinary team.”

How Poor Mental Health Can Affect Cancer Treatment And Recovery

Dr Beatty said psychology is increasingly being seen as a core component to a patient’s overall health.

“So, it is being increasingly recognised that we need to actually screen and address distress.”

“It’s not an optional extra.”

“It’s a core component.”

Dr Beatty said there can be a significant impact upon a patient’s response to treatment if their mental health is not considered during their diagnosis and treatment.

“We do know there is a three-fold reduction in adherence to their anti-cancer treatment for people who have untreated distress and that can also lead to some of the recent meta-analysis which has shown there is a 17% increase in mortality rates when people have untreated depression.”

How To Get Mental Health Help When You’ve Been Diagnosed With Breast Cancer

Dr Beatty said if the hospital or institution you are being treated at has a psychologist, you can be referred there directly.

“So, if there is a psychologist associated with the hospital, there won’t be any out-of-pocket costs for it.”

“They will actually just get a referral through their oncologist directly to that psychologist.”

However, if there is no psychologist at your treating hospital, you are still able to get help.

Dr Beatty said they are working to upskill community-based psychologists to treat cancer related mental health issues.

“One of the challenges and something we’re trying to work on here in Australia, is actually up-skilling the community based psychologists in how-to-treat depression and anxiety in cancer, so that we can actually make use of that Medicare funded system, the Better Access system, and get people treated by some of these community based psychologists as well.”

“However, there can then be out-of-pocket costs in this system.”

Dr Beatty said there are many things an individual can do to help ease their own burden.

“I think first of all, it’s really normal to struggle.”

“So, recognise that it is perfectly normal, it doesn’t make it enjoyable while you’re stuck in it.

But, it will, over time, reduce in severity.”

She also said its important to speak up and ask for help if you can.

“Make sure you are an advocate and speak up, if you feel comfortable doing so, to your treatment team.”

“There are a lot of other allied health options.”

“Also, some of the basic things you can do to really look after yourself, both your physical and your mental health is exercise,” she said.

“Don’t underestimate the role of that, that’s a very affordable and effective treatment for both your mental and physical health after your diagnosis.”

De-Escalation: Reducing Breast Cancer Treatments

Breast cancer researchers are often focused on finding new and better treatments and prevention strategies for the disease.

However, some breast cancer research has another goal: to reduce the amount and intensity of treatment patients receive, while maintaining equally good cancer outcomes.

This is a research area for Professor Julia White.

Professor White is a tenured Professor of Radiation Oncology and Koltz Sisters Chair for Cancer Research at The Ohio State University.

“I think it’s important for us as providers to clarify that de-escalation doesn’t mean we’re backing off on therapy,” said Professor White.

“For so long, breast conservation has automatically meant you’re going to get surgery, a lumpectomy and breast radiation.”

“But from our knowledge of breast cancer biology, certain patients can be cured, or their cancer control is completed by just having the surgery portion.”

Professor White said de-escalation can be incredibly beneficial for certain patients, but the issue is identifying those patients who can benefit from this ‘right-sizing’ of treatment.

However clinical trials which use multi-gene assays or genomic tests of breast cancer tissue, can help to identify biologically which patients are going to have a low event rate in the breast after breast conserving surgery.

This means some patients could safely avoid radiation therapy.

“You’ll always get a lower reduction in breast risk when you radiate.”

“But if your likelihood of recurrence is so low then adding the radiation for women might not give a meaningful difference to them.”

“So, as we de-escalate or right-size breast conservation, we’re going to see who needs both lumpectomy and radiation and who is OK with just a lumpectomy.”

“So, de-escalation is really for breast cancer that is hormone sensitive, stage one. Meaning the lymph nodes are negative, in women who are post-menopausal and committed to taking their endocrine therapy.”

Current Research Into The De-Escalation In Breast Conserving Therapy

There is an increasing number of de-escalation clinical trials, including the Breast Cancer Trials EXPERT clinical trial.

EXPERT is investigating whether a genomic test of breast cancer tissue can be used to identify women with early breast cancer who can safely avoid radiation therapy after breast cancer surgery and the potential side effects of this treatment.

Professor White said in the US, where she practices, there are two groups of de-escalation trials.

“One is really for post-menopausal stage one breast cancer, in patients who are between the ages of 50 and 70.”

“Over age 70, the approach is de-escalation.”

“Under the age of 70, between 50 and 70, the trials are really focused on using a multi-gene assay, using an immunohistochemistry assay or using recurrence score.”

This is how researchers can determine if a patient needs further treatment after surgery, like radiation therapy.

Why De-Escalation Research Is Important

Professor White said de-escalation trials are about investing in patient’s wellbeing.

“It’s maybe not the most scientifically sexy clinical trials, we’re not identifying a new targeted agent, but we need to know how to take care of women.”

“When you look at breast cancer screening studies, the most common breast cancer stage that is picked up at breast cancer screening is stage one.”

“So, over 50% of newly diagnosed breast cancers are stage one and most of these occur in post-menopausal women and most of them are hormone sensitive,” she said.

“So, the impact is tens of thousands of women annually.”

“So, it’s really incumbent on us right now to run clinical trials that we can guarantee the next generation that we’ll know how to take care of them and that’s what we’re doing by investing in de-escalation trials.”

Breast Cancer Patients Have An Increased Risk Of Cardiovascular Disease

If you have received a breast cancer diagnosis you are at a higher risk of cardiovascular disease than those without.

According to Professor Bogda Koczwara, there are a number of reasons for why this is.

Professor Koczwara is a medical oncologist and Senior Staff Specialist at Flinders Medical Centre.

She said a key reason is the risk factors for both diseases overlap to a significant extent.

“So, the same risk factors that give you cancers also give you cardiovascular disease,” she said.

“We know if you have cancer, you’re more likely to develop cardiovascular disease.”

“And we’ve just recently learned that if you’ve got cardiovascular disease, you’re more likely to develop cancer.”

Professor Koczwara said researchers suspect that the mechanisms for development of cardiovascular disease and cancer are likely to be overlapping.

“I think that requires further research, but it relates to tissue damage, premature aging, and perhaps cancer and cardiovascular disease are somewhat different manifestations of very similar overarching processes.”

“The final thing is cancer treatments seem to impact on the body in such a way that they may accelerate cardiovascular disease, either through direct impact on the heart muscle or through impact on vasculature.”

“But more anti-cancer drugs for breast cancer than not, have some form of side effect that relates to cardio-vascular health.”

How You Can Help Protect Your Heart Health

There are important considerations practitioners should take when treating breast cancer patients to protect heart health according to Professor Koczwara.

“The first thing to do is to recognise that patients with cancer also have other conditions and to recognise there is maybe an interaction between those conditions.”

“That would mean, taking sufficient history to recognise patients risk factors and comorbidities, and factoring that into decision making process.”

Professor Koczwara said breast cancer patients should consider if they have any modifiable risk factors to protect their health.

“We know already that common risk factors for cardiovascular disease which also adversely impact breast cancer outcomes are obesity, inactivity, smoking, and they need to be managed.”

“Their management would be beneficial in terms of improving breast cancer outcomes, but it would also be beneficial in terms of improving cardiovascular outcomes.”

Professor Koczwara said if your oncologist or treating physician is concerned about your heart health or risk factors, there is services and programs available which you can be referred to.

She also said it is important for your physician to revisit these issues on a regular basis.

“Sometimes patients might not be in the right headspace to deal with those issues at the beginning, at the time of the initial diagnosis, and they may wish to return to those issues later.”

“Sometimes they might be eager to do something that is good for their health at the beginning and that should also be accommodated.”

“So, I think the key message is that the vision for supporting women with breast cancer and patients with breast cancer, goes beyond just providing anti-cancer treatment.”

Am I More At Risk Of Heart Issues If I Have Breast Cancer In My Left Breast?

Professor Koczwara said this is not a silly question to ask.

“The answer is yes, because you’re quite likely to have radiation treatment on the left side and the left sided radiation treatment would increase the risk of potential complications, in contrast to the right sided treatment.”

“If you don’t have radiation treatment, if you don’t have local treatment, then the risk is not magnified.”

However, Professor Koczwara said this is only one risk factor, that is safely managed, and patients should focus on how to best manage risk factors related to overall health.

“I think you should be more concerned about your cardiac health if you’re obese, if you have high blood pressure, if your lipids are elevated, if you’re inactive etc.”

“The site of radiotherapy is only one part of that story and these days with appropriate precautions for radiation treatment, a radiation oncologist would argue that the risk is not that great but I think you need to consider all the risk factors and manage them, because many of them are modifiable.”

What is the Androgen Receptor?

The Androgen Receptor regulates the development and growth of the prostate.

In prostate cancer, androgens bind to androgen receptors inside the cancer cells, which causes the cancer cells to grow. However, it has a very different effect in women with breast cancer.

Professor Wayne Tilley is the Director of the Dame Roma Mitchell Cancer Research Laboratories at the University of Adelaide, South Australia, and is an expert in the field of breast and prostate cancer.

He was a pioneer in investigating AR expression and function in breast cancer and cloned the human androgen receptor (AR) gene.

“The androgen receptor gene is being cloned for this androgen receptor protein, which is on the X chromosome. The androgen receptor protein is in men and is absolutely required for normal virilisation or masculinisation of males and has many vital functions,” said Professor Tilley.

“But because it’s critical for the development of the prostate, when cancers occur in the prostate this same receptor protein also drives their growth.”

However, what interests researchers is that the androgen receptor has been found to have a more positive effect in women.

“What’s intriguing is that the androgen receptor in women is a good player, whereas it’s a bad player in the prostate.”

“So this androgen receptor gene is the master regulator of a lot of processes in the body; metabolism, cell growth, division, differentiation and one of the things we’re trying to understand is what are the other factors, the other proteins in a tumour cell, or even in a normal cell, that might be instructive, that will allow us to understand how you can switch an androgen receptor in prostate cancer from being a bad player, to looking more like androgen receptor in a breast cancer.”

How Could The AR Gene Be Used In Breast Cancer Treatment?

Professor Tilley said the challenge to finding a way to make this switch from ‘bad player’ to ‘good player’ is that the androgen receptor gene doesn’t play by itself.

“There are hundreds of other factors in a cell that interact with the androgen receptor, so it’s like a symphony and depending on the components of that symphony, the androgen receptor might function quite differently.”

“So, we’re putting an enormous amount of effort into understanding what are those other factors that interact with the androgen receptor that can switch it from being a bad player like it is in prostate cancer, to being a good player like it is in breast cancer.”

“We are attempting to understand how to take advantage of that and maybe coming up with a very novel treatment for prostate cancer by switching this bad player to a state that’s more like in the normal development of the male, where it actually induces differentiation and inhibits cell growth.”

Online Support For Breast Cancer

Receiving face-to-face psychological care while going through breast cancer treatment is not for everybody.

However, it is still important to look after your mental health during this time and it’s important to note that it is common to struggle mentally throughout this time.

Clinical Psychologist and Cancer Council South Australia Senior Research Fellow, Dr Lisa Beatty, said those undergoing treatment for cancer often are undergoing psychological distress.

“We know that approximately 30 to 40% of women, after their diagnosed with breast cancer, will have what we call clinically significant distress, where it is impacting on their ability to either enjoy their lives or stopping them from getting out and doing things, impacting on their functioning.”

“We also know that of those, when offered, only less than 30% of distressed people with cancer actually take up the offer of help in face to face interventions like going and seeing a psychologist.”

Dr Beatty said online tools have been created to help bridge this gap caused by limited access to mental health workers and for those who are not comfortable seeking face to face support.

She said the online tool she co-created covers similar topics that are covered in face to face sessions.

“This was done very much in consultation with women with breast cancer,” she said.

“We went and met with a lot of women, did a series of focus groups to work out what are the most commonly experienced issues that come up for them and then we ended up creating a series of topics, or modules, around those commonly experienced issues.”

“Some of them might be on the common physical symptoms that they might be experiences, the emotional distress, body image changes and also navigating issues with family and friends is a big one too and transitioning into survivorship.”

Dr Beatty said the online modules provide strategies and activities to help target symptoms and help to improve their mental health.

What Online Mental Health Tools Are Available?

Dr Beatty is the co-creator of Finding My Way.

Finding my way is an online self-help coping program that offers information, suggestions and support for women and men who have recently been diagnosed with a cancer being treated with the aim of cure.

It was developed as part of a clinical trial for anyone who was currently going through cancer treatment or had been diagnosed in the past six months.
“Anyone with a diagnosis can just log on and start the program.”

“It’s a very simple registration process, you just have to create an account and you’ll get directed to the initial welcome video which will guide you through how to use the program.

“Because it is actually targeting not just a psychological disorder, but it is targeting some of the most commonly experienced issues, there’s going to be something in there for everybody, you don’t have to have depression or anxiety diagnosed by a GP or some else to benefit from the program.”

Why Do People Choose Online Mental Health Support?

Dr Beatty said there are a number of reasons why someone would choose to access online support for their mental health.

“Geography definitely is a huge barrier and some services simply don’t have face to face programs, but we definitely know that there’s still unfortunately a big stigma around mental health,” she said.

“We also know that screening is not routinely done yet, even though there is increasing recognition of the importance of it.”

“But screening for anxiety, distress, depression, isn’t routinely done and even when it is, there are many people out there that just don’t feel comfortable going to see someone face to face and actually have a preference for trying to be able to sort through things on their own.”

Dr Beatty said through qualitative feedback, they found using their online tool was a positive first step for those struggling through their diagnosis.

“It was that useful first step that broke down that barrier and patients were more comfortable to go and seek help when it was needed.”

“But for a lot of people they also found that they got enough that they needed out of the program itself, that it actually was the thing that stopped them from needing to go on to additional face to face support.”

If you are experiencing difficulties with your mental health throughout your diagnosis, talk to your treatment team or GP about your mental health options.