Behavioral Interventions May Alleviate Depression in Younger Breast Cancer Survivors

TON - April 2021 Vol 14, No 2

A diagnosis of breast cancer can cause stress and depression, especially in younger women. According to findings from a recent clinical trial, behavioral interventions may help decrease symptoms of depression and reduce anxiety, fatigue, and sleep disturbances in younger breast cancer survivors. These results were presented by the study’s lead author, Patricia A. Ganz, MD, Director, Cancer Prevention and Control Research, University of California Los Angeles Jonsson Comprehensive Cancer Center, and Distinguished Professor, Medicine, David Geffen School of Medicine, University of California Los Angeles, at the virtual 2020 San Antonio Breast Cancer Symposium.

“Younger breast cancer survivors represent a vulnerable population, with well-documented side effects from breast cancer treatments and notable increases in depressive symptoms. These lasting effects of breast cancer treatments can have a negative impact on quality of life in the survivorship period,” Dr Ganz said.

Study Details

The goal of the multicenter, randomized, phase 3 Pathway to Wellness trial was to determine the efficacy of 2 specially developed group programs for young breast cancer survivors. Of the 247 patients (aged <50 years) enrolled in the study, 85 were randomized to a Mindfulness Awareness Practices (MAPs) intervention group, 81 to a Survivorship Education group, and 81 to a control group on a wait list.

The study population included women diagnosed with nonmetastatic stage 0-III breast cancer who had completed primary treatment between 6 months and 5 years previously and who had evidence of at least mild clinical depression on a standardized screening questionnaire. The median age of patients was 45.4 years, and the median time from diagnosis was 2.6 years. More than half had undergone a mastectomy (56%), chemotherapy (57%), or radiation (65%). Two-thirds were on endocrine therapy during the study period. Most patients were white (82%), married (75%), and employed full-time (68%).

“We cast a wide net for participant recruitment, using hospital tumor registry listings of age-eligible participants, direct engagement of clinicians, flyers, and media announcements during 3 years of recruitment,” Dr Ganz explained.

In both 6-week programs, oncology nurses delivered weekly 2-hour sessions of structured content to participants. Topics in the MAPs program included what is mindfulness; listening, embodiment, and obstacles; working with pain; working with difficult emotions and cultivating positive emotions; working with thoughts and mindful interactions; and a final wrap-up session.

Topics in the Survivorship Education program included breast cancer 101: important issues for younger survivors; quality of life in breast cancer survivors; energy balance, nutrition, and physical activity; cancer in the family (genetics and testing); relationships and work-life balance; and body image, menopause, and sexual health.

The primary outcome of the study was depression symptoms after the interventions, according to the Center for Epidemiologic Studies of Depression (CES-D) scale. Secondary outcomes included the measurement-anxiety, fatigue, sleep disturbance, and hot flashes. An exploratory analysis was conducted to examine changes in inflammatory markers. Assessments were conducted preintervention, postintervention, and at 3- and 6-month postintervention follow-ups.


At baseline, all 3 groups reported mean CES-D scores >16, with >50% of participants scoring in the clinically depressed range prior to receiving the intervention. Postintervention depression scores declined significantly for both intervention groups (P <.01 for both), with only 30% of women scoring in the clinically depressed range. These scores were sustained at 3 months in both intervention cohorts and at 6 months in the MAPs cohort.

Researchers observed a postintervention decrease in anxiety in both intervention groups (P <.05 for both) compared with controls. However, this effect did not persist through follow-up, Dr Ganz noted.

The MAPs intervention led to a significant decrease in fatigue severity, sleep disturbance, and hot flashes, which persisted through the 6-month follow-up (P <.05 for all).

“The Pathways to Wellness participants have high levels of depression, anxiety, fatigue, sleep disturbance, and other symptoms an average of 2.6 years after diagnosis. They were living in well-resourced, urban environments, and were still suffering with depression. Further dissemination and evaluation of these interventions are warranted to address the unmet psychosocial needs of young breast cancer survivors. We need to screen for depression and provide some type of intervention,” Dr Ganz said.

The fact that both interventions were standardized and manualized supports the potential for widespread use on virtual platforms, which is especially important during the COVID-19 pandemic and will make these programs more accessible for patients.

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