Associations Between Breast Cancer Survivorship and Adverse Mental Health Outcomes: A Systematic Review

Abstract

Background: We aimed to systematically review the evidence on adverse mental health outcomes in breast cancer survivors (≥1 year) compared with women with no history of cancer.

Methods: Studies were identified by searching MEDLINE, PsycINFO, the Cumulative Index to Nursing and Allied Health Literature, and the Social Sciences Citation Index, and through backward citation tracking. Two researchers selected the studies, extracted data, and assessed the risk of bias.

Results: Sixty studies were included. Of 38 studies of depression, 33 observed more depression in breast cancer survivors; this was statistically significant in 19 studies overall, including six of seven where depression was ascertained clinically, three of four studies of antidepressants, and 13 of 31 that quantified depressive symptoms. Of 21 studies of anxiety, 17 observed more anxiety in breast cancer survivors, statistically significant in 11 studies overall, including two of four with clinical/prescription-based outcomes, and in eight of 17 of anxiety symptoms. Breast cancer survivors also had statistically significantly increased symptoms/frequency of neurocognitive dysfunction (18 of 24 studies), sexual dysfunctions (5 of 6 studies), sleep disturbance (5 of 5 studies), stress-related disorders/PTSD (2 of 3 studies), suicide (2 of 2 studies), somatisation (2 of 2 studies), and bipolar and obsessive-compulsive disorders (1 of 1 study each). Studies were heterogeneous in terms of participants' characteristics, time since diagnosis, ascertainment of outcomes, and measures reported. Approximately one-half of the studies were at high risk of selection bias and confounding by socio-economic status.

Conclusions: There is compelling evidence of an increased risk of anxiety, depression and suicide, and neurocognitive and sexual dysfunctions in breast cancer survivors compared with women with no prior cancer. This information can be used to support evidence-based prevention and management strategies. Further population-based and longitudinal research would help to better characterize these associations.

Figure 1.

Systematic review flowchart. CINAHL = Cumulative Index to Nursing and Allied Health Literature; SSCI = Social Sciences Citation Index.

Figure 2.

Associations between breast cancer history and anxiety, depression, neurocognitive and sexual dysfunctions, and suicide. We considered that anxiolytics were being taken to treat anxiety and antidepressants to treat depression. Time since diagnosis refers to the mean/median time elapsed since the breast cancer diagnosis or completion of initial course of treatment, as reported in the original studies, for the sample of cancer survivors. When this information was not reported in the original studies, we presented the lower limit of survivorship time reported in the inclusion criteria of the study. The minimum, mean/median, and maximum follow-up of longitudinal studies are reported in the Supplementary Appendix (available online). *The original study provided relative risk estimates stratified by area of residence (urban/rural). The combined estimate presented in the forest plot was computed with inverse-variance-weighted meta-analysis methods using the command “metan” in Stata v14. BDI(-II) = Beck Depression Inventory(-II); CESD = The Center for Epidemiologic Studies, Depression Scale; GDS = Geriatric Depression Scale; HADS = Hospital Anxiety and Depression Scale; HRS-A = Hamilton Rating Scale for Anxiety; HRS-D = Hamilton Rating Scale for Depression; OR = odds ratio; PR = prevalence ratio; RR = relative risk; SD = standard deviation; SDS = Self-rating Depression Scale; SIR = standardized incidence ratio; SMR = standardized mortality ratio; STAI-S = State-Trait Anxiety Inventory (state anxiety subscale); STAI-T = State-Trait Anxiety Inventory (trait anxiety subscale). †Women who have had breast reconstruction after mastectomy. ‡Refers to a group of women who had breast cancer recurrence 10 years after the first diagnosis.

Figure 3.

Absolute frequency of anxiety, depression, and neurocognitive and sexual dysfunctions reported in the original studies for breast cancer survivors. Estimates for cognitive and sexual dysfunctions refer to the prevalence of women impaired for the condition or specific domains, as reported in the original studies. EHR = electronic health records. Black triangle = cumulative incidence, diagnoses in EHR; white triangle = cumulative incidence, drug treatment; white diamond = prevalence, psychometric instruments; black diamond = prevalence, psychiatric interview.

Figure 4.

Summary of the risk of bias in the studies included in the systematic review. The risk of bias in statistical methods was considered not applicable when formal statistical comparisons between the two groups were not presented in the original study. Missing data criteria were not applicable for studies involving electronic health records.