Despite considerable advances in diagnosis and treatment in the past few decades, breast cancer remains a significant public health concern. Over 210,000 new cases are diagnosed in the United States annually, making it the most common type of cancer in women. It is predominantly a disease of women, with estimates that one in seven women will develop some form of breast cancer during their lifetime. Although not unknown in men, it is far less common. Approximately 1,300 men in the United States develop breast cancer each year.
A basic introduction to the medical aspects of breast cancer will be provided first. Breast cancer will be described in terms of its biological pathology and symptoms. Genetic, behavioral, and environmental risk factors for breast cancer will be discussed, along with methods of diagnosis and treatment. Equally important are the psychological stresses associated with breast cancer: the initial discovery of a lump in the breast, waiting for biopsy results, undergoing treatment, and facing the possibility of recurrence. The psychological impact of diagnosis, along with factors that promote successful adjustment, are reviewed. The topic concludes with a discussion of promising future directions for the care of both medical and psychological health.
Medical Aspects Of Breast Cancer
What Is Cancer?
Normally, cells in the body divide in a controlled manner to allow normal growth, replace dead cells, or heal an injury. Genes control the cellular mechanisms responsible for keeping cell division in check, but when a cell’s genes mutate or become damaged, cells can begin to divide uncontrollably. In the breast tissue, unchecked cell growth can form masses (tumors). Benign tumors do not spread and are not life-threatening. In contrast, malignant cancerous tumors can grow and spread. Tumors are referred to as in situ (in place) when they remain confined to localized masses, or invasive when cells that are capable of breaking away from the tumor invade surrounding tissue or spread throughout the body by traveling in the bloodstream or the lymphatic system. The spread of cancer cells to other parts of the body (e.g., the liver or brain) is referred to as metastasis. However, when breast cancer cells are found in other body areas, it is still considered breast cancer. Breast cancer becomes life-threatening when metastases disrupt vital functioning in other areas of the body (e.g., the brain).
Types of Breast Cancer
Breast cancer types can be distinguished based on the location of the original tumor. Ductal carcinoma, the most common form of breast cancer, describes cancer occurring in the milk ducts. Cancer occurring in the glands of the breast where milk is produced is referred to as lobular carcinoma. Ductile and lobular carcinoma can be either in situ or invasive. The most common symptom is the formation of a painless lump in the breast or underarm area. Less common symptoms include change in the size or shape of the breast, distortions in the breast near the surface of the skin (e.g., puckering), and inversion, tenderness, or abnormal discharge of the nipple.
Inflammatory breast cancer is a less common, invasive form of the disease in which dispersed groups of cancer cells obstruct the lymphatic system in the breast, leading to symptoms such as swelling or a red, rash-like appearance on the breast. Tubular carcinoma is a form of invasive ductile carcinoma involving the proliferation of microscopic structures called tubules. Symptoms of tubular carcinoma resemble those of ductal and lobular cancer, but are associated with more favorable prognoses. Paget’s disease of the nipple occurs when a carcinoma elsewhere in the breast spreads and affects the nipple and areola. This form of cancer often results in crusting or flaking; itching, burning, and redness; or bleeding and discharge from the nipple.
Causes of Breast Cancer
The specific causes of breast cancer are not yet known, but there are a number of genetic, environmental, and behavioral risk factors known to be associated with increased risk. Being female is the strongest risk factor. Age is also a prominent risk factor. Women in their sixties are 80 times more likely to develop breast cancer than when in their twenties. Another risk factor is the possession of a mutated form of a gene referred to as BRCA. These mutations occur in less than 1% of the population, but are associated with up to an 85% likelihood of breast cancer occurrence by age 70. However, BRCA mutations account for less than 10% of breast cancer diagnoses. A woman’s risk for breast cancer is increased two to fivefold if she has a family history of breast cancer, particularly in first-degree relatives who developed cancer before menopause. Prior in situ or invasive carcinomas also increase the risk of developing future breast cancers, as do precancerous masses that can develop into malignancies. To a lesser extent, a greater number of reproductive cycles a woman passes through and hormone replacement therapy are also risk factors, as they increase lifetime exposure to reproductive hormones that can damage genes, alter cell growth, and promote the growth of certain cancers. Other potential risk factors are less clear. There is some evidence that obesity, alcohol use, and use of oral contraceptives may slightly increase one’s risk for breast cancer, but the research is not strong to support these as risk factors.
What Doesn’t Cause Breast Cancer
Breast cancer is not caused by a virus, bacteria, contact with someone with cancer, injury to the breast, or surgery. Through the years, a number of myths have perpetuated about potential causes of breast cancer. Some are based on initial research that appeared promising but does not hold up in better-controlled studies. A cancer-prone or “type C” personality has been proposed, characterized by compliance, a hopeless attitude, and difficulty expressing emotion. The mechanism by which personality might influence the development of cancer is unclear, and little support has been found for this claim. Similarly, high life stress as a causal factor has not been supported by recent research. Other myths have no clear basis in scientific research. There is no evidence, for example, that the use of underarm deodorants or wearing bras can cause breast cancer. In recent years, the explosion of unregulated information on the Internet has propagated unscientific or fraudulent claims of causal factors. Although the Internet can be a useful source of information, readers are strongly recommended to focus on credible, well-known sites (e.g., the American Cancer Society at http://www.cancer.org).
Most breast cancers are detected either through breast examinations or breast-imaging techniques. Breast examinations involve manually checking the breast tissue for lumps. Available imaging techniques include CAT scan, MRI, ultrasound, and mammography. The most common of these is mammography, an X-ray of the breast, which can identify about 90% of breast cancers, even in women with no symptoms. In combination, mammograms and breast examinations can increase the likelihood of early detection of breast cancer, which can improve the chances of successful treatment. The final stage of diagnosis, the biopsy, involves examining the tissue mass (obtained either surgically or through a needle) under a microscope to determine whether it is benign or malignant. Approximately 80% or more of biopsies reveal that the mass in question is benign. If malignant, the biopsy can also determine whether or not the growth of the tumor is promoted by the reproductive hormones estrogen and progesterone.
The severity of a breast cancer is described by classification into stages, based on the size of the tumor, the involvement of the lymphatic system, and whether or not metastasis has occurred. Stage 0 breast cancer refers to an in situ tumor and is often called precancerous. Stage I breast cancer describes a tumor of less than 2 cm that has not invaded the lymphatic system or metastasized. A designation of stage II requires that a tumor be either between 2 and 5 cm or that cancer cells have spread to the lymphatic system of the same breast but have not metastasized. Stage III is designated when a tumor exceeds 5 cm and involves the lymphatic system of the same breast. Stage IV breast cancer indicates that metastasis has occurred. More advanced stages of cancer are associated with a poorer prognosis and require more aggressive treatment. Statistics show that the percentage of women who survive breast cancer for at least 5 years following diagnosis decreases by stage (stage 0, 100%; stage I, 98%, stage II, 76–88%; stage III, 49–56%; stage IV, 16%).
Treatment of breast cancer has improved greatly during the past three decades. Several methods of treating cancer exist, and they are often used in conjunction with one another rather than individually. Most breast cancer patients undergo surgery to remove the tumor, often along with a sample of the lymph nodes. Smaller tumors (e.g., stage I or II) can usually be removed with a technique called lumpectomy, which conserves the cosmetic appearance of the breast. Larger or dispersed tumors sometimes necessitate a mastectomy (removal of the entire breast). Side effects of surgery include infection risk, pain, cosmetic disfigurement, and fatigue.
Additional treatments that supplement surgery, called adjuvant treatments, are often used to destroy residual cancer cells or metastases. Common adjuvant treatments include chemotherapy, radiation therapy, hormone therapy, and immunotherapy. These treatments can reduce the size of a tumor and are sometimes given before surgery is performed, in which case they are referred to as neoadjuvant treatments. Chemotherapy is the administration of drugs that destroy rapidly dividing cells, such as cancer cells. The drugs can be administered in pill form, as an injection, or intravenously. Duration and frequency of treatment depend on the type and stage of cancer. A major side effect of chemotherapy is that it destroys rapidly dividing cells in other areas of the body, including hair follicles and the mouth, often resulting in hair loss and mouth sores. Nausea, fatigue, pain, fertility problems, and cognitive difficulties are other potential side effects.
Radiation therapy involves exposing cancer cells to radiation in order to curb their growth. This is done by directing an external beam of particles towards the tumor or by implanting a pellet of radioactive material near the tumor. External radiation treatments are usually administered for up to 30 minutes daily for several weeks, depending on the particular case. Because radiation directly targets the tumor, adjacent normal tissue is not damaged. However, radiation therapy often produces dry or itchy skin, sunburn-like pain near the target site, darkening of the skin, and fatigue. Chemotherapy and radiation are both effective in reducing intermediate term (e.g., 5or 10-year) recurrence and death rates by up to 15% relative to surgery alone, but the effectiveness varies by cancer type and stage. Yet, even with treatment, breast cancer recurs in approximately 4 to 7% of patients within 5 years of treatment.
Certain types of breast cancers grow faster in the presence of estrogen and progesterone. These cancers are often treated with hormone therapies, drugs that block the production and activity of estrogen and progesterone. This treatment can be effective in shrinking or slowing the growth of a hormone-responsive tumor but can have menopause-like side effects, including hot flashes and fluid retention. Hormone therapy may also produce nausea, visual disturbances, or vaginal bleeding or discharge. Five years of hormone therapy has been shown to decrease recurrence rates by 12% and increase survival rates by 4%, 10 years posttreatment. Another less common treatment is immunotherapy. Manufactured immune system components (antibodies) are injected into the blood stream, with the goal of boosting the body’s natural ability to identify and destroy abnormal cancer cells. Studies show that some immunotherapy drugs increase 1-year survival rates by 11%, above and beyond chemotherapy.
Several complementary or alternative treatments for breast cancer exist. Some believe that a nondairy, highfiber diet rich in fruit and vegetables may help fight breast cancer. Naturopathic and herbal medicine may also be useful, and a variety of herbs and nutritional supplements may improve one’s prognosis. For example, antioxidants may increase the effectiveness of chemotherapy treatments. Mind/body techniques, such as hypnosis and meditation, attempt to exert mental control over treatment side effects and the natural physiological processes that fight cancer. Acupuncture and Reiki are Eastern alternative treatments that treat cancer by redirecting the flow of energy in the body. Many women find psychological benefits from complementary/alternative treatments. However, rigorous research on the benefits of such treatments for physical or psychological health is lacking.
Psychological Aspects Of Breast Cancer
Stress Associated With Breast Cancer
Breast cancer can bring with it a large amount of stress, including financial strain, disabling side effects of treatment, the impact of cancer on loved ones, and the frightening possibility of death. For some women, the initial weeks following diagnosis are a time of tremendous uncertainty and psychological distress. Upon receiving the diagnosis, many experience disbelief, shock, fear, or anger. Some may even blame themselves for their cancer, thinking that they somehow put themselves at risk by living an unhealthy lifestyle. Receiving a diagnosis of breast cancer may be especially distressing for men, as they may feel shameful having a disease in a part of the body associated with femininity. Approximately 30% to 40% of patients develop symptoms of anxiety and depression shortly following diagnosis. Recent studies have found that about 3% of breast cancer patients develop posttraumatic stress disorder (PTSD), an anxiety disorder characterized by recurrent intrusive thoughts and emotional distress following a severe trauma. Those that do not develop clinical levels of anxiety or depression often manifest some symptoms of these disorders, such as negative mood, persistent uncontrollable worry, hopelessness, or sleep disturbances.
Treatment demands can be a considerable source of stress. Those with limited financial resources or without medical insurance face the strain of financing medical care or loss of income. Other stressors involve the side effects of treatment itself. The perceived or actual disfigurement resulting from mastectomy can disturb a patient’s self-esteem and body-image. For example, a woman may feel that because she has lost a breast, she is less feminine or less sexually desirable to a partner or spouse. For this and other reasons, treatment for breast cancer can interfere with a patient’s ability to experience intimacy and sexuality. The side effects of some adjuvant treatments, as well as the time demands of attending frequent treatment sessions, can interfere with a patient’s ability to work professionally and domestically.
For most patients, the psychological distress associated with breast cancer decreases in the months following diagnosis. However, the course of distress differs among individuals, and some experience considerable distress long after treatment. Some aspects of breast cancer, such as the fear of recurrence, can continue to induce psychological distress.
Patients with a terminal prognosis face an array of challenges. These include saying goodbye to loved ones, settling their affairs, overcoming their fears of pain or loss of control, and the uncertainty of death. Many people dying from cancer also worry that their death will create emotional, financial, and social hardships for their loved ones. Patients often struggle with
decisions about further medical care. Once curative efforts fail, a delicate balance must be found between prolonging life with further treatment and maintaining quality of life through palliative care focused on pain management. Patients can receive palliative care in a hospital, at home, or in assisted-living facilities. Life-prolonging adjuvant treatment, pain management, emotional and informational support, and other services are typically offered.
Despite the negative psychological consequences of breast cancer, it is clear that some patients can identify positive aspects of their experience with the disease. Patients may find that struggling with breast cancer forces them to call upon personal resources of which they were previously unaware, or that they are more resilient than they had expected. Cancer may have brought them closer to loved ones or strengthened their religious or spiritual convictions. Breast cancer may even reorder one’s priorities about life. The identification of such benefits allows patients to grow from their experience with breast cancer.
Predictors of Psychological Adjustment
Surprisingly, the severity of the cancer or the types of surgical or adjuvant treatments are not good predictors of distress levels. In contrast, age and educational level are among the most consistent predictors of levels of distress. Older and more educated women generally experience less distress and better overall adjustment than younger women. These groups of women tend to have an improved ability to cope with the stress associated with the diagnosis and treatment, which may account for better well-being.
The ways a patient thinks about her cancer experience also predicts psychological adjustment. Optimism, or a general predisposition toward hopefulness and expectation of positive outcomes, is related to positive adjustment. It is important to distinguish realistic from unrealistic optimism (i.e., Pollyanna-ism), which may lead one to disregard important health information or lower one’s motivation to engage in health-promoting behaviors. Women with a realistic, optimistic attitude tend to experience quicker recovery from health problems in general and less distress related to having breast cancer. Other benefits include better satisfaction with one’s sex life post-treatment and lesser occurrence of negative intrusive thoughts and fears.
A related personal characteristic associated with better adjustment has been termed “fighting spirit,” described as a belief in the ability to fight, conquer, and recover from breast cancer. Some researchers believe that fighting spirit may lead to better physical recovery, although evidence is mixed regarding its association with prognosis and survival. In contrast, blaming oneself for the development of breast cancer can impede adjustment, particularly in the months following diagnosis. The strength of one’s coping skills also predicts adjustment. Women who actively cope with the illness (e.g., by making appointments, seeking information, and dealing with their emotions) tend to show better adjustment than those who use more avoidant coping strategies (e.g., not answering the phone, missing appointments). Benefits can also come from the ability to find meaning in the experience of cancer. Over time, patients who are able to find meaning in their illness often experience less anxiety, less depression, and higher self-esteem than those who are unable to find meaning in their experience.
Social relationships can provide considerable benefit to a breast cancer patient. Social support can be provided by a spouse, neighbors, co-workers, friends, church members, or other acquaintances. Studies show that the availability of emotional support (i.e., having someone to confide in, vent to, or rely on to boost one’s self-esteem) can significantly enhance the well-being of breast cancer patients. Practical support is also important, such as the availability of someone to give the patient a ride to the hospital, pick the children up from school, or provide financial assistance. For many patients, an important source of social support comes from their religious or spiritual community. In general, religious or spiritual beliefs can contribute to enhanced quality of life, lower anxiety, better self-esteem, and the ability to find positive meaning in the cancer experience.
Breast Cancer and the Family
The diagnosis and treatment of breast cancer can also significantly challenge an individual’s social network. The immediate demands of diagnostic procedures and surgery, combined with the chronic demands of adjuvant treatments, can significantly impact a patient’s ability to maintain social roles within a household or maintain outside employment. Breast cancer often leads to significant distress in spouses, family members, and friends, who must face the potential loss of a loved one and unexpectedly assume the role of caregiver. The level of distress in spouses of breast cancer patients is generally quite similar to the level of distress in the patient. However, following completion of treatment, spouses and other family members may feel ready to have life return to “normal” and may be frustrated by the patient’s continuing support needs.
Breast cancer, like most serious illnesses, requires a rearranging of roles within the family, as family members may need to take over many of the tasks previously the responsibility of the patient. The family may have a difficult time adjusting to the unexpected changes that arise as a consequence of the treatment of breast cancer and may even harbor resentment toward the patient for becoming ill. For families of patients in the terminal stages of breast cancer, psychological distress may be especially high. These families face a number of burdens, including managing the care of a terminally ill loved one, financial hardship, anticipatory grief, withdrawal of support from friends unable to cope with the dying process, and worries about the comfort levels of the patient. Families of terminally ill patients often experience significant fatigue, tension, anxiety, and depression.
Communication is an important factor related to the well-being of both the patient and the family. Studies have shown that while most patients would like to discuss the cancer and their fears, family members often mistakenly believe the patient would prefer they not discuss the topic or worry that talking about it will only increase their loved one’s distress. Patients often report that after all treatment is completed, they still struggle with the impact of the diagnosis, yet feel that their family is no longer willing to discuss their continuing fears. The open and sensitive expression of desires and feelings can provide significant relief to both the patient and the family.
For a child whose parent is diagnosed with breast cancer, special concerns arise. In general, children of parents with breast cancer are at risk of distress, particularly if the child perceives high stress levels in the family or has poorly developed coping skills. Unfortunately, parents are often unaware of the extent of distress experienced by their children. Young children may not be capable of understanding what is happening, and care is needed in explaining the changes in the family. Although in some situations parents may decide to avoid telling their children about the cancer, this strategy can lead to more distress in children who sense that something is wrong and may imagine extreme and erroneous explanations. Children who receive increased and supportive interaction with the non-ill parent may cope quite well, especially if the family as a whole copes well with the illness.
Psychological Care and Intervention
In the last several decades, the medical and psychological communities have experienced a growing awareness of the psychological needs of breast cancer patients, and a number of interventions have been developed. A wide variety of resources is available for patients and their loved ones, including self-help books, individual and family therapy, peer-led support groups, internet and telephone support, and group therapy led by trained professionals. Research has consistently shown that psychological interventions can have beneficial effects on emotional adjustment, functional adjustment, and treatment and disease-related symptoms (e.g., nausea, pain).
Many breast cancer patients find comfort through interacting with others who have experienced a similar illness. Peer-led support groups are one of the most widely available forms of support for breast cancer patients. Typically, these groups meet in local communities and are led by the patients and survivors themselves with a free-flow, conversational format.
Professionally led interventions vary widely in treatment setting (e.g., hospital, therapist office, community centers), treatment provider (e.g., psychologist, nurse, social worker), targeted outcomes (e.g., control of nausea and vomiting, pain, emotional distress, quality of life, end-of-life issues), and treatment length (e.g., 1–40 sessions). Supportive group therapy focuses on guiding patients in the process of exploring and expressing their emotions and encouraging social support among group members. Other group interventions focus on improving skills for coping with the cancer and include training in relaxation and guided imagery techniques, educational information, and training in more adaptive coping skills (e.g., problem solving, communicating with health care providers, rational positive thinking about cancer).
Perhaps the most provocative research on the benefits of psychological intervention for breast cancer patients has suggested that psychological distress can affect biological disease processes and outcomes. Although some early research claimed that psychological interventions can improve disease outcomes and increase survival times in women with breast cancer, more recent studies have failed to support these claims. While the psychological benefits are clear and may be reason enough to seek intervention, seeking psychological services in an attempt to improve prognosis or prolong survival is not advised.
Partners and family members of breast cancer patients also need support, but spouse, family, or child-focused supportive interventions are rare. Interested readers may wish to contact local cancer organizations, such as the American Cancer Society, for more information about the availability of these types of support groups. There is also growing recognition of the psychological needs of underserved populations, such as men, women of color, and lesbians. In larger cities, support groups specifically targeted for these populations can occasionally be found, but they are less likely to be available in more rural areas. Services generally follow a peer-led or supportive format. Although there is very little research on the effectiveness of interventions for underserved groups, preliminary studies suggest that psychological interventions can have benefits for mood and psychological well-being in these populations, similar to findings from studies with Caucasian women.
Medical advances in the treatment of breast cancer in the last 30 years have been astounding, thanks in part to the millions of dollars that have been devoted to intensive research efforts. Some examples of noteworthy accomplishments include the development of advanced diagnostic techniques using ultrasound and MRIs, the demonstration of the effectiveness of less invasive surgical procedures (e.g., lumpectomy, sentinel node biopsy), the discovery of better chemotherapies to treat systemic disease, antiemetics to manage debilitating side effects of chemotherapy, the use of hormonal therapies to block estrogen receptors, and the identification of genetic markers of susceptibility to breast cancer and genetic tests to predict risk in asymptomatic women. The potential for genetic approaches to cancer treatment in the future has generated quite a bit of excitement. Many women choose to participate in clinical trials of new, as yet unproven treatments. For some, clinical trials are attractive because they may offer a promising new treatment when a good standard treatment is not available.
However, for a number of reasons, women may choose to stay with the standard treatment regimen. For example, clinical trials usually require strict criteria for participation, insurance coverage for clinical trials can be sparse, and participants are generally not able to directly choose the treatment they receive.
Substantial progress has also been made in the understanding and treatment of psychological and behavioral factors associated with breast cancer. These advances have resulted in considerably greater access to psychological services for cancer patients. Often these services are immediately available at the hospital or diagnostic center; however, many treatment centers remain unable to provide psychological services to patients and families. Although most women negotiate the demands of breast cancer well, others struggle in their attempts to cope with the disease. The challenge for the future is to better understand who is in greatest need of psychological health care and to ensure that services are readily available for those in need. Similarly, the future is likely to bring greater opportunities for psychological services directed at those from minority populations. Research is also underway to determine the types and timing (i.e., immediately postdiagnosis or following the demanding treatment regimens) of psychological interventions that are most effective. The availability and sophistication of Internet-based resources, including both peer and professionally developed supportive Web sites, are expected to substantially impact future provision of care for breast cancer. In combination, the increasing recognition of the need to attend to both psychological and medical care promises continuing improvements in the quality of life for those diagnosed with breast cancer.
- American Cancer Society, http://www.cancer.org
- Compas, E., & Luecken, L. J. (2002). Psychological adjustment to breast cancer: Cognitive and interpersonal processes. Current Directions in Psychological Science,11, 111–114.
- Helgeson, V., Snyder, P., & Seltman, H. (2004). Psychological and physical adjustment to breast cancer over 4 years: Identifying distinct trajectories of change. Health Psychology, 23(1), 3–15.
- Love, (2000). Dr. Susan Love’s breast book (3rd ed.). New York: HarperCollins.
- Susan G. Komen Breast Cancer Foundation, http://www.korg