Psychological factors in breast cancer.

Two way traffic between the mind and the body Conservative surgery for early breast cancer is now commonplace ,' a development that at least partly reflects greater appreciation of the psychological sequelae of radical treatment. Patients receiving cytotoxic drugs, especially those receiving combination treatments, also constitute a group at high risk of psychological symptoms.2 It is now clear, however, that significant psychiatric morbidity is not confined to subgroups of patients who experience unpleasant side effects of treatment or those with advanced disease. A recent study found that one in four women had significant psychological symptoms 12 months after mastectomy, the com-monest complaints being depression, anxiety, and sexual dysfunction.3 Increased risk is associated with poor marital relationships, unsupportive social networks, recent adverse life events, and previous psychiatric illness.4 The recognition of such high rates of psychiatric morbidity prompted a King's Fund consensus conference on the treatment of early breast cancer to recommend that a psychiatrist should be attached to each district team.5 An audit of such a service found that referral rates were low (less than 2% of patients attending clinics) when compared with the presumed prevalence of psychiatric disorders among these patients.2 Four out of five patients referred were diagnosed as suffering psychological reactions to their illness, and half of these were of sufficient severity and duration to be classified as psychiatric illnesses.6 Many of those experiencing psychological reactions, however, responded well to brief interventions , typically one or two counselling sessions. The liaison psychiatry service in most hospitals will not be able to offer individual counselling services to all such patients. The most appropriate role for the psychiatrist will be to provide training and supervision of medical and nursing staff to help them detect psychiatric morbidity and deal sensitively and effectively with those who experience transient reactions. Direct psychiatric input is indicated for patients who experience severe or prolonged symptoms and those who have coincidental psychiatric disorder. Most studies of psychological interventions in patients with cancer, including relaxation training and individual or group psychotherapy, show beneficial effects on depression and anxiety.7 These treatments also lead to improvements in certain physical symptoms including pain,8 although some studies have reported changes that are either temporary9 or confined only to the most distressed patients.'0 Interpreting results is made difficult by inadequate descriptions of the treatments used and differences between the types of LONDON, SATURDAY 25 MAY 1991 psychological intervention. A structured and …