At-Risk Breast Cancer Patients Benefit from Psychosocial Counseling

Increasing genetic testing is identifying patients at elevated risk for developing breast cancer. While most cancer centers prescribe mental health counseling to patients diagnosed with breast cancer, these services are generally not offered to at-risk patients. Cleveland Clinic has rectified this oversight by incorporating a psychologist into their multidisciplinary Breast Center team. The goal is to enhance satisfaction for patients with hereditary breast cancer risk (HBCR).

“Many of these women have been traumatized by seeing a mother or sister who battled the disease, so it’s only natural they become anxious or depressed when they learn they may follow in those footsteps. It can be a very scary time,” says Kathleen Ashton, PhD, a board-certified clinical health psychologist.

As a member of the Breast Center team, Dr. Ashton sees at-risk patients on the same day that they see a genetic counselor, breast physician and breast surgeon. “Patients know we understand what they are facing,” she says.

Psychosocial and physical challenges

A pilot study conducted on patients referred to Dr. Ashton showed that in patients with HBCR, depression and anxiety levels were not as high as in patients with breast cancer, but they were still distressed.

“They share many traits, including fear of cancer, anxiety about their future and depression about the trauma they may soon face,” says Dr. Ashton.

Having to choose between a watch-and-wait philosophy, risk-reducing mastectomy or chemoprevention can cause a great deal of anxiety. “These are tough decisions to make that often require patients to have conversations with their family. These conversations can bring up traumatic memories of a parent with cancer, or trigger guilt about possibly passing the gene to their children,” says Dr. Ashton.

Patients who opt for risk-reducing surgery face additional challenges related to body image, sexual health, pain management and changes in social relationships.

“Adding a psychologist to the team can help with all these issues,” says Dr. Ashton.

Case for a psychological boost

The ability of psychosocial intervention to improve longevity and prevent recurrence in breast cancer patients is known. Less research has been done on patients with HBCR.

This prompted Dr. Ashton to conduct a small study in which 14 patients with BRCA mutations were treated with as few as three and as many as 15 cognitive behavioral therapy (CBT) sessions. The result was a statistically significant reduction in depression (PHQ-9) and anxiety (GAD-7).

“Learning to cope with the uncertainties of increased genetic risks is important for a positive outcome,” she explains.

Failure to cope can mean giving up. Patients with anxiety and depression are less likely to follow through with lifestyle changes that can reduce their risk, such as not smoking, not using alcohol and maintaining a healthy weight. They are also less likely to follow through when chemoprevention is prescribed.

But CBT can help patients approach an anxiety-inducing situation, rather than avoiding it.

“When depressed patients are having difficulty making a decision about risk-reduction surgery, CBT can help them move forward,” she says.

“We help patients understand that knowing they are at increased risk empowers them to decide what steps to take to control their risk. Ultimately, this impacts their health down the road.”