Post-traumatic stress disorder and cancer

doi:10.1016/S2215-0366(17)30014-7

The Lancet Psychiatry

Volume 4, Issue 4, April 2017, Pages 330-338

https://doi.org/10.1016/S2215-0366(17)30014-7 Get rights and content

Summary

Being diagnosed with and treated for cancer is highly stressful and potentially traumatic. An extensive literature has evaluated the prevalence, predictors, and correlates of cancer-related post-traumatic stress disorder (PTSD) symptoms and diagnoses. In this qualitative review of cancer-related PTSD literature, we highlight conceptual, methodological, and diagnostic issues, and identify clinical implications and areas for future research. Cancer-related PTSD has been documented in a minority of patients with cancer and their family members, is positively associated with other indices of distress and reduced quality of life, and has several correlates and risk factors (eg, prior trauma history, pre-existing psychiatric conditions, poor social support). The literature on treatment of cancer-related PTSD is sparse. Existing literature on cancer-related PTSD has used DSM-IV-TR diagnostic criteria; the revised DSM-5 PTSD criteria have important implications for the assessment of cancer-related distress. Application of PTSD diagnosis to patients with cancer has been critiqued on conceptual and methodological grounds, and important differential diagnosis considerations should be taken into account. Psychosocial assessment of patients with cancer should include careful evaluation of pre-cancer diagnosis trauma and psychiatric history, and diagnostic interviewing should consider concurrent conditions (eg, adjustment disorder). Treatment of cancer-related PTSD should be approached with caution and be informed by existing evidence-based approaches for traumatic stress.

Introduction

Being diagnosed with and treated for cancer is highly stressful and potentially traumatic. Emotional responses to this experience can range from acute fear, sadness, and anger to enduring adjustment difficulties, anxiety, and depression. On the basis of studies documenting traumatic stress-like reactions (eg, intrusive ideation, reactivity to reminders, avoidance) in patients with cancer, the DSM-IV-TR¹ post-traumatic stress disorder (PTSD) diagnostic criteria were expanded to include diagnosis and treatment of a life-threatening illness as a stressor that could elicit PTSD. An extensive literature emerged, evaluating the prevalence, predictors, and correlates of cancer-related PTSD symptoms and diagnoses.2, 3, 4, 5, 6, 7, 8, 9, 10 PTSD has also been documented following myocardial infarction, cerebrovascular accidents, HIV infection, burns, and other medical stressors.11, 12, 13 Changes in the DSM-5¹⁴ PTSD diagnostic criteria have important implications for assessment of cancer-related PTSD,¹⁵ but research with the updated criteria is limited. Here, we review cancer-related PTSD literature, highlight conceptual, methodological, and diagnostic issues, and identify clinical implications and areas for future research (panel 1).

Section snippets

Cancer as a traumatic stressor

Cancer diagnosis and treatment entail a series of stressors. For many, the cancer experience begins with detection of an abnormality on self-examination (eg, breast self-examination), a laboratory test (eg, prostate-specific antigen), screening procedure (eg, colonoscopy), routine imaging (eg, mammogram), or clinical examination (eg, skin cancer screening). A period of heightened anxiety follows during the progression of diagnostic, staging, and histology procedures.¹⁶ Discovery that one has a

Prevalence and course

A substantial literature exists regarding estimated prevalence rates of cancer-related PTSD (table). Abbey and colleagues' meta-analysis² reviewed 25 studies (21 of which were of patients with breast cancer) of cancer-related PTSD in a total of 4189 adult cancer survivors. Prevalence rates varied widely depending on method of assessment. Studies using self-report PTSD symptom measures yielded prevalence estimates of clinically significant symptom levels ranging from 7·3% (95% CI 4·5–11·7; ten

Correlates of cancer-related PTSD

Correlates of cancer-related PTSD have been identified (panel 2). Abbey and colleagues' meta-analysis² of studies of cancer-related PTSD in adult cancer survivors identified young age, advanced disease, and recently completed treatment as risk factors for increased cancer-related PTSD (p values <0·05). These variables parallel Ozer and colleagues' review⁴¹ of risk factors for PTSD in the general population (ie, young age, increased threat, recent trauma).

In addition, various individual studies

Conceptual, methodological, and diagnostic issues

The utility and appropriateness of the traumatic stressor construct and PTSD diagnosis in conceptualisation of cancer-related distress and adjustment difficulties have been questioned.15, 25, 56 Cancer is a multi-faceted, ambiguous, unfolding stressor rather than a discrete event that poses a clear and immediate threat. The initial stressor of diagnosis is primarily informational;⁵⁷ in many cases, patients are told of a potentially life-threatening condition that might not be causing physical

Implications for practice

Literature on cancer-related PTSD has important implications for clinical practice. First, integration of psychosocial assessment and support into oncology care settings is essential, both in active treatment⁶³ and survivorship⁶⁴ phases of care. Many patients with cancer undergoing treatment do not have the time or energy to seek care in a separate mental health setting; embedding psycho-oncology specialists in medical settings is crucial to patient-centred care.

Second, assessment of patients'

Conclusion

Being diagnosed with and treated for cancer is highly stressful and might lead to persistent psychopathology in a minority of patients. The application of the PTSD diagnosis to cancer-related adjustment difficulties is not without controversy. Thoughtful and careful assessment and development of appropriate treatment pathways can optimise detection and management of distress and traumatic stress in the oncology setting.

Search strategy and selection criteria

We identified articles by searching several databases, including Ovid MEDLINE, PsycINFO, PsycARTICLES, Psychology and Behavioral Sciences Collection, and Academic Search Complete. We did updated searches for all languages from Jan 1, 1989, to July 1, 2016. For each search, all relevant subject headings and free text terms were used to represent “PTSD” AND “cancer”. The total number of references retrieved was 1637.

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SeriesPost-traumatic stress disorder and cancer

Summary

Introduction

Section snippets

Cancer as a traumatic stressor

Prevalence and course

Correlates of cancer-related PTSD

Conceptual, methodological, and diagnostic issues

Implications for practice

Conclusion

Search strategy and selection criteria

Diagnostic and Statistical Manual of Mental Disorders

A meta-analysis of prevalence rates and moderating factors for cancer-related post-traumatic stress disorder

Psychooncology

Posttraumatic stress disorder associated with cancer diagnosis and treatment

A systematic and conceptual review of posttraumatic stress in childhood cancer survivors and their parents

Clin Psychol Rev

Responses to cancer: posttraumatic stress and posttraumatic growth

Semin Clin Neuropsychiatry

Stress response syndromes and cancer: conceptual and assessment issues

Psychosomatics

Posttraumatic stress disorder following cancer: a conceptual and empirical review

Clin Psychol Rev

Long-term adjustment in cancer survivors: Integration of classical-conditioning and cognitive-processing models

Correlates of posttraumatic stress symptoms and growth in cancer patients: a systematic review and meta-analysis

Psychooncology

Is postttraumatic stress a viable model for understanding responses to childhood cancer?

Child Adolesc Psychiatr Clin N Am

Posttraumatic stress disorder prevalence and risk of recurrence in acute coronary syndrome patients: a meta-analytic review

PLoS One

Posttraumatic stress in older adults: when medical diagnoses or treatments cause traumatic stress

Psychiatr Clin N Am

Post-traumatic stress disorder and cardiovascular disease

Lancet Psychiatry

Diagnostic and Statistical Manual of Mental Disorders

DSM-5 trauma and stress-related disorders: implications for screening for cancer-related distress

Front Psychiatry

The faster the better? A systematic review on distress in the diagnostic phase of suspected cancer, and the influence of rapid diagnostic pathways

Psychooncology

Shattered Assumptions

Predictors of distress and quality of life in patients undergoing cancer therapy: Impact of treatment type and decisional role

Psychooncology

Physical, psychological, and social sequelae following hematopoietic stem cell transplantation: a review of the literature

Psychooncology

It's a choice to move forward: women's perceptions about treatment decision making in recurrent ovarian cancer

Psychooncology

Trajectories of fear of recurrence in women with breast cancer

Support Care Cancer

Posttraumatic stress disorder after treatment for breast cancer: prevalence of diagnosis and use of the PTSD Checklist-Civilian Version (PCL-C) as a screening instrument

J Consult Clin Psychol

Posttraumatic growth following breast cancer: a controlled comparison study

Health Psychol

Breast cancer as trauma: posttraumatic stress and posttraumatic growth

J Clin Psychol Med Settings

Prevalence of acute and post-traumatic stress disorder and comorbid mental disorders in breast cancer patients during primary cancer care: a prospective study

Psychooncology

Lung cancer diagnosis and treatment as a traumatic stressor in DSM-IV and DSM-5: prevalence and relationship to mental health outcomes

J Trauma Stress

Cancer as a criterion A traumatic stressor for veterans: prevalence and correlates

Psychol Trauma

PTSD diagnoses, subsyndromal symptoms, and comorbidities contribute to impairments for breast cancer survivors

J Trauma Stress

Posttraumatic stress disorder symptoms in newly diagnosed patients with head and neck cancer and their partners

Head Neck

Posttraumatic stress in women with breast cancer and their daughters

Am J Fam Ther

Women's posttraumatic stress responses to maternal breast cancer

Cancer Nurs

A preliminary study of peritraumatic dissociation, social support, and coping in relation to posttraumtic stress symptoms for a parent's cancer

Psychooncology

Cancer-related traumatic stress reactions in siblings of children with cancer

Fam Syst Health

Prevalence and predictors of posttraumatic stress disorder in adult survivors of childhood cancer

Pediatrics

Breast cancer and psychological distress: mothers' and daughters' traumatic experiences

Support Care Cancer

Predictors of posttraumatic stress disorder following cancer

Health Psychol

Posttraumatic stress disorder in breast cancer patients following autologous bone marrow transplantation or conventional cancer treatments

Behav Res Ther

Series
Post-traumatic stress disorder and cancer