Are we missing PTSD in our patients with cancer? Part I

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Abstract

Posttraumatic Stress Disorder (PTSD) can be defined by the inability to recover from a traumatic event. A common misconception is that PTSD can only develop in circumstances of war or acute physical trauma. However, the diagnostic criteria of PTSD were adjusted in the Diagnostic Statistical Manual of Mental Disorders Fourth Edition (DSM-IV) to include the diagnosis and treatment of a life-threatening illness, such as cancer, as a traumatic stressor that can result in PTSD. The word ‘cancer’ is so strongly linked to fear, stigma, and mortality, that some patients are fearful to even say ‘the C word’. Therefore, it is not surprising that patients may experience a diagnosis of cancer as sudden, catastrophic, and/or life-threatening. Cancer-related PTSD (CR-PTSD) can negatively affect a patient’s psychosocial and physical well-being during treatment and into survivorship. Unfortunately, CR-PTSD often goes undiagnosed and, consequentially, untreated. This article provides a general overview of PTSD with cancer as the traumatic event in order to define CR-PTSD, and reviews the growing pool of literature on this topic, including prevalence, risk factors, characterization, and treatment of CR-PTSD. The purpose of this article is to spread awareness of this relatively newly defined and commonly missed disorder among patients with cancer to clinicians and patients alike.

Cancer is many people’s worst fear, often linked with stigma, suffering and mortality. A cancer diagnosis may be perceived as life threatening, compounded by the physical burden and uncertainty inherent in many cancer treatments. The word ‘cancer’ is typically associated with chemotherapy, hair loss, nausea, and other physical symptoms and abnormalities, but cancer can also often have a significant emotional impact on the patient and their family. Approximately 40% of patients with cancer experience significant emotional and social distress during treatment (Pranjic, Bajraktarevic & Ramic, 2016), with approximately one-third of patients developing distress that requires specialized intervention (Grassi, Spiegel & Riba, 2017).

Unfortunately, many patients are not referred or do not accept referral to psycho-oncology services to be assessed and treated, as high levels of sadness and anxiety are often perceived as ‘normal’ reactions to cancer diagnosis and treatment; thus mood, anxiety and other psychological disorders are commonly mistaken for unexpected ‘manageable’ sadness and preoccupation with the disease (Grassi, Spiegel & Riba, 2017). Patients are often told by well-meaning loved ones that they should “think positively” and “fight the cancer” and, in turn, may feel that by expressing fear or sadness they are being ‘weak’. Furthermore, some patients fear that negative emotions may adversely impact their immune system when, in fact, feeling sad or fearful during adaptation or anticipatory grief is common. Whilst processing these emotions is difficult, they are transitory and lead to a stronger emotional position. Suppressing these emotions may increase the risk of depression, reduce authentic communication and lead to sleep difficulties. The question of how mood and anxiety disorders adversely impact outcome is controversial; the greatest evidence for the likely mechanism is reduced treatment compliance and less adherence to a healthy lifestyle.

Existing literature supports the notion that many patients with cancer are interested in receiving psychosocial support for the emotional and social distress they experience during diagnosis, treatment and survivorship, and highlights the positive impact of receiving specialized psychosocial oncology care. A recent study found that 13% of patients with cancer undergoing radiotherapy expressed a desire for psychological support (Riedl, Gastl, Gamper, Arnold, Dejaco, Schoellmann & Rumpold, 2018). Multiple studies reveal that psychological intervention can increase quality of life for patients with cancer (Li, Li, Shi, Wang, Zhang, Shao & Wang, 2017). In contrast, patients with untreated distress have poorer cancer outcomes and are less compliant with treatment and surveillance regiments (Chen, Hsu, Felix, Garst, & Yoshizaki, 2017; Parikh, De Ieso, Garvey, Thachil, Ramamoorthi, Penniment & Jayaraj, 2015). One other less well recognized or investigated, yet often devastating psychological disorder affecting a significant portion of patients with cancer, is cancer-related post-traumatic stress disorder (PTSD).

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6516338/

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Abstract

Objective: Systematic reviews highlight a broad range of cancer-related post-traumatic stress disorder (CR-PTSD) prevalence estimates in cancer survivors. This meta-analysis was conducted to provide a prevalence estimate of significant CR-PTSD symptoms and full diagnoses to facilitate the psychological aftercare of cancer survivors.

Methods: A systematic literature search was conducted for studies using samples of cancer survivors by using validated clinical interviews and questionnaires to assess the prevalence of CR-PTSD (k = 25, n = 4189). Prevalence estimates were calculated for each assessment method using random-effects meta-analysis. Mixed-effects meta-regression and categorical analyses were used to investigate study-level moderator effects.

Results: Studies using the PTSD Checklist-Civilian Version yielded lower event rates using cut-off [7.3%, 95% confidence intervals (CI) = 4.5-11.7, k = 10] than symptom cluster (11.2%, 95% CI = 8.7-14.4, k = 9). Studies using the Structured Clinical Interview for Diagnostic and Statistical Manual, Fourth Edition (SCID), yielded low rates for lifetime (15.3%, 95% CI = 9.1-25, k = 5) and current CR-PTSD (5.1%, 95% CI = 2.8-8.9, k = 9). Between-study heterogeneity was substantial (I(2) = 54-87%). Studies with advanced-stage samples yielded significantly higher rates with PTSD Checklist-Civilian Version cluster scoring (p = 0.05), and when assessing current CR-PTSD on the SCID (p = 0.05). The effect of mean age on current PTSD prevalence met significance on the SCID (p = 0.05). SCID lifetime prevalence rates decreased with time post-treatment (R(2) = 0.56, p < 0.05).

https://pubmed.ncbi.nlm.nih.gov/25146298/

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Discussion: The cancer experience is sufficiently traumatic to induce PTSD in a minority of cancer survivors. Post-hoc analyses suggest that those who are younger, are diagnosed with more advanced disease and recently completed treatment may be at greater risk of PTSD. More research is needed to investigate vulnerability factors for PTSD in cancer survivors. © 2014 The Authors. Psycho-Oncology published by John Wiley & Sons Ltd.

Keywords: DSM-5; PTSD; cancer; meta-analysis; oncology; prevalence.

© 2014 The Authors. Psycho-Oncology published by John Wiley & Sons Ltd.

https://pubmed.ncbi.nlm.nih.gov/2514629 ... -disorder/