Emerging Psycho-oncological Unmet Needs of Breast Cancer Patients

JWH Tsang

Emerging Psycho-oncological Unmet Needs of Breast Cancer Patients
JWH Tsang1,2
1 Medical Ethics and Humanities Unit, School of Clinical Medicine, The University of Hong Kong
2 Department of Social Work and Social Administration, The University of Hong Kong
Correspondence: Dr JWH Tsang, Medical Ethics and Humanities Unit, School of Clinical Medicine, The University of Hong Kong; Department of Social Work and Social Administration, The University of Hong Kong, Hong Kong. Email: jwhtsang@hku.hk
Contributors: The author had full access to the data, contributed to the study, approved the final version for publication, and takes responsibility for its accuracy and integrity.
Conflicts of Interest: The author has disclosed no conflicts of interest.
In recent decades, psycho-oncology has developed as an important subspecialty of oncology. This area deals with “the two psychological dimensions of cancer: the patients’, families’ and healthcare workers’ emotional reactions towards cancer and its treatment (psychosocial); and the psychological and behavioural factors that influence cancer risk and survival (psychobiological)”.[1] Several historical factors have led to greater emphasis on the psychological and social issues in cancer. These include shifting of attitudes away from fatalism from cancer; more open disclosure of diagnosis; shared discussion among the triad of patients, families, and healthcare workers; and deeper dialogue between patient and physician, with the patient’s active participation in the decision-making process. Through better understanding of both the psychosocial and psychobiological dimensions of cancer care, we can develop various valid assessment tools to better study the psychosocial domain of our cancer patients in a scientific manner, and to better provide holistic cancer care. Therefore, there has been a call for all oncologists and cancer care providers to better recognise and identify any psychosocial distress or common mental disorders such as anxiety or depression as frequent comorbidities. Lu et al[2] demonstrated that some patients have some form of common mental disorder as early as 2 years before the diagnosis of cancer, and this may continue through the time of the diagnosis until completion of treatment as long as 10 years after diagnosis. In parallel, chronic inflammation is now recognised as a “hallmark of cancer”[3] with chronic systemic inflammation frequently seen to be induced by cancer, and this can even precede any cancer diagnosis.[4]
Stress is regarded as a significant risk factor associated with breast cancer in women who self-reported higher levels of stress (adjusted odds ratio = 3.40; 95% confidence interval, 3.09-3.73) even compared with those who have a first-degree relative with breast cancer history (adjusted odds ratio = 2.88; 95% confidence interval, 2.43-3.41).[5] While distress and personality instability are found to be risk factors for breast cancer, the diagnosis and the complexity of breast cancer treatment also increases psychological distress. Over the years, there has been increasing evidence of added value of early delivery of efficacious psychological intervention to reduce distress, and enhance the mental health among breast cancer patients, thus improving biological clinical outcome and treatment-relevant behaviours; this has been supported by randomised clinical trials with improvement of overall survival.[6] Due to the array of various emotional and psychosocial challenges for breast cancer patients with trajectory along survivorship, many breast cancer survivors do benefit from various psychological intervention including psychotherapy, yet this is usually not without cost and not equally accessible to everyone, especially those with geographical or physical limitation.
To address these limitations of traditional psychotherapy, in this issue of the Hong Kong Journal of Radiology (HKJR), Popovic et al[7] review the use of online psychological interventions among breast cancer survivors reported in five relevant studies including 838 participants. The authors reviewed outcomes including behavioural indications such as insomnia, fatigue and sexual functioning; and psychological indications such as psychological adjustment and psychological stress management. Although the quality and usability of any online psychotherapy is of paramount importance, motivation as a function of engagement, sustainability of the cyber-psychotherapy, the equal access to such format of psychotherapy hopefully not just limited to the higher socioeconomic class or those who can read and write, the strengths and weaknesses, and the potential value and implications are all areas worth further exploration. Furthermore, fear of recurrence is always the leading concern for breast cancer survivors with associated fear of death and psychological distress,[8] [9] [10] and online psychological intervention will play a pivotal role to relieve their stress with enhanced quality of life.
Indeed, there are limitations of face-to-face psychological interventions, including discussion of sensitive issues such as unmet sexuality and intimacy needs, especially in the Chinese historical and cultural context. Online psychotherapy could provide an alternative platform for convenient and easy access, especially for those with limited mobility, with the added value of anonymity.[11] With family as the basic unit in Chinese culture, another potential merit of online psychotherapy includes support for both the breast cancer patient and the patient’s caregiver or partner. Caregivers would also benefit from such online psychological intervention, and tailored online psychoeducation can enhance further communication between patient and caregiver for more holistic psychosocial support. This review has led us to identify further knowledge gaps in the field of online psychotherapy. First, this review has included only randomised controlled trials comparing online psychotherapy with any control group not receiving psychotherapy, it would be interesting to compare the outcome and cost-effectiveness between online psychotherapy and the conventional face-to-face psychotherapy. Second, each patient and family are unique, and so are their unmet psychosocial needs. Future research is warranted to identify potential mechanisms that may explain why these online psychological interventions are linked to positive outcomes and any clinical models to further apply to our cancer patients in the context of precision medicine and holistic cancer care. Furthermore, online psychotherapy is particularly relevant at the time of writing, with social distancing still being one of the key strategies being used in Hong Kong in response to the ongoing coronavirus disease 2019 pandemic.
Online psychological intervention is a convenient and potentially cost-effective alternative for breast cancer survivors and their caregivers, especially at a time when the number of breast cancer survivors, and perhaps all cancer survivors, is increasing in Hong Kong and globally.
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