Breast cancer is second most prevalent type of cancer and is equally common in developing as well as developed countries (American cancer Society, 2013). Despite favorable survival in developed countries, the most frequent cause of cancer deaths in women is still breast cancer, in developed as well as in developing countries (GLOBOCAN: International Agency for Research on Cancer, 2008). The treatment expenditure of breast cancer is a burden not only for people diagnosed with cancer but also for their families and society as a whole. According to American Cancer Society (2010) breast cancer is one of the top three types of cancer that caused the most economic impact ($88 billion) [1-5].

Though successful treatment options are available to deal with breast cancer, pain and suffering associated with available treatment modalities is significant. Chronic, persistent pain acts as an additional stressor for a person already suffering from many psychological, social and medical stressors. Research has demonstrated association between clinically relevant pain and breast cancer surgery in 10-50% patients. There are pathogenic mechanisms involved in breast cancer like nerve damage and certain sensory disturbances (e.g., burning and sensory loss) are part of side effects of surgical processes [6]. Breast cancer surgery is followed by chronic neuropathic pain syndrome like Phantom breast pain (a sensory experience that is present even after removal of breast and is painful), Intercostobrachial Neuralgia (pain in the distribution of intercostobrachial nerve) and Neuroma pain (pain in the region of scar on breast, chest or arm). Radical mastectomy is most disfiguring type of breast cancer surgery and it involves removal of breast, major and minor chest muscles, and lymph nodes [7]. Breast conserving techniques, another treatment option, were expected to reduce psychiatric morbidity and sexual dysfunction, but none of the studies involving appropriate assessment of psychiatric morbidity showed any advantage of breast conserving therapy [8].

Patients with the breast cancer differ significantly in time of relapse despite the fact that nature of tumors was similar at initiation of breast cancer. These differences in time of relapse has led to the thought that determinants of breast cancer survival are much broader then assumed by medical framework. A large body of research has been devoted to understand the role of psychosocial factors in determination of clinical outcomes of breast cancer [9]. Research evidences showed that psychological morbidity like helpless/hopelessness [10,11], hostility and guilt [12], chronic stress [13,14], extroversion and cognitive disturbance [15], lack of joy and negative mood [16], stressful life events [9,17,18], lack of perceived social support [19], obsessivecompulsive symptoms [20] adjustment problems [21], are experienced by one-third of women in the first two years after treatment.

Literature search

systematic search of literature was performed to obtain original studies that involved investigation of association between psychological factors and breast cancer. The relevant studies were identified by using Google scholar database. Search was made by pairing following word with breast cancer after AND: depression, anxiety, self image/self esteem, quality of life, coping strategies.

Study selection

Systematic search included only original studies therefore letters, reviews, case notes and editorials were excluded from study. Those studies were included in review that reported association between psychological factors (depression, anxiety, self image, quality of life and coping strategies) with breast cancer. Studies conducted in last 10 years were included (from 2003-2013). For depression and anxiety, only those studies were included that mentioned prevalence of depression and anxiety in breast cancer sample. For self image/ self esteem and quality of life, only those studies were included that clearly mentioned impact of breast cancer on self image/self esteem and quality of life. For coping strategies, those studies were included that investigated types of coping styles used by breast cancer patients. There were no limitations regarding sample size, outcome measures and study design of researches included in review. Those studies were also excluded that focused on psychological impact of specific types of breast cancer treatments. Studies investigating effects of biological and organic factors on quality of life were also excluded. Those studies that investigated impact of psychological factors on onset of breast cancer were excluded. Furthermore, studies evaluating effectiveness of interventions for treatment of psychological morbidity of breast cancer were also excluded [22-25].

Data extraction

Following data was extracted from studies that were part of this review: date of publication, objective of study, study design, study population, measures used for psychological factors (depression, anxiety, self image/self esteem, coping strategies and quality of life), main findings regarding; prevalence of depression and anxiety, effects on self image/self esteem, and quality of life, types of coping styles used by breast cancer patients [26-28].

Depression and anxiety

For depression and anxiety, Google scholar database given 341 results from 2003 to 2013. Out of 341 studies, 17 studies met inclusion criteria of this review [29-32]. Out of 17 studies, 9 studies assessed only depression [33-41]. In Table 1, those studies were summarized that investigated depression alone and depression and anxiety. Out of 17 studies, 5 were conducted in UK [30,34] 5 studies from China, 2 from USA, 2 from Australia [42], 1 from Thailand [43], 1 from Turkey [2], one from Europe [44] and 1 from Malaysia [45]. Out of 17 studies, 9 studies followed descriptive cross sectional research design [2,19,34,42,43,46-50] cross sectional comparative design was used in 2 studies [51,52] 2 studies followed longitudinal design [53,54] observational cohort design was used in 2 studies [13,55] and only 1 study followed correlation design. Only four studies had sample size lower than 100 [2,56]. Most of the studies used Hospital Anxiety and Depression scale (HADS) to assess anxiety and depression [57-60]. Three studies used Structured Clinical Interview for Depression and Anxiety [13,38,42]. Prevalence of depression in early stage breast cancer ranges from 9.6% to 33% [13,38,57] and anxiety in early stage breast cancer was reported to be 34% [57]. Three studies reported prevalence of depression at advanced stage of stages and it ranges from 6.5% to 61% [38,42,59,60]. None of the studies included in this review reported prevalence of anxiety at advanced stage of breast cancer [61-63]. Only one study reported differences in prevalence of depression in malignant and benign tumors: 38.4% depression in patients with malignant tumors and 20.8% depression in patients with benign tumors [64]. Two studies reported that prevalence of depression in breast cancer patients at 0-III stage ranges from 13-30% [19]. Prevalence of depression in breast cancer women undergoing chemotherapy is 19.1% 29% [19,65] and of anxiety is 24.1% while in women at 6 months postchemotherapy prevalence of depression is 10% and of anxiety is 46.4% [54]. Prevalence of depression in women under follow up for breast cancer treatment is 29% while prevalence of grade I anxiety is 2.5%, grade II anxiety is 77%, grade III anxiety is 19% [34] while prevalence of depression in breast cancer women at completion of treatment is 22.2% and of anxiety is 38.4% [63].

Table 1: Methods and outcomes of studies examining prevalence of depression and anxiety in patients with breast cancer.

Coping strategies

For coping strategies and breast cancer, Google scholar database given 16 results. Out of 16 results, 4 studies met inclusion criteria of this review. Four studies were conducted in China [14,32,66] and one in Malaysia [56]. Research design of two studies was descriptive cross sectional [14,56] and two were correlational studies [66]. Studies indicated that facing coping is negatively associated with mood at preoperative level (anxiety, p = 0.032, depression, p = 0.001) [66] as well as at post-operative level poor mood was found in patients using avoidant coping (F=6.78, P=0.01). Avoidance coping was higher (p=0.01) at rehabilitative period as well along with complying coping strategy [32]. Disengagement (p=0.002) and self blame (p=0.013) were commonly used coping strategies for depressed breast cancer patients receiving chemotherapy (Table 2).

Table 2: Methods and outcomes of studies examining coping strategies in patients with breast cancer.

Self image

For self image/self esteem and breast cancer, Google scholar database given 11 results, out of which 4 studies met inclusion criteria of this review. All studies were conducted in developed counties: 1 from USA [22] 1 from Europe [12], 1 from Australia [51] and 1 from UK [50]. Three studies used descriptive cross sectional research design [12,22,51] and 1 study followed longitudinal design [50]. Significant impairment in body image is reported by cross sectional (17%) [22] as well as by a longitudinal study (p=0.035) [50]. Positive association was found between self image difficulties and depression, anxiety and stress (p=0.01) in women who completed treatment for cancer [51]. Women who underwent mastectomy reported dissatisfaction with the scars, feeling less sexually attractive, self consciousness (44%, 48%, and 48% respectively) [12] (Table 3).

Table 3: Methods and outcomes of studies examining self image/self esteem in patients with breast cancer.

Quality of life

Google scholar database given1140 results for "quality of life and breast cancer". Out of 1140 studies, 9 studies met inclusion criteria for this review because studies investigating effects specific types of treatments on quality of life were excluded. Four studies were conducted in USA [6,16,55], two in Australia [4,27], one in Germany [36], one in UK [31] and one in Iran [5]. Four studies used descriptive cross sectional research design [4,5,27,31] three studies followed cross sectional comparative design [6,16], one study used longitudinal design [36] and one study used Correlational design [55]. European Organization for Research and Treatment of Cancer-Quality of Life Questionnaire-Core 30 (EORTC-QLQ-C30) was used in most of the studies [4,27,31,36]. Study involving early breast cancer patients (p<0.001) [31] as well as study involving participants after 4 years of diagnosis of breast cancer reported significant impairment in quality of life (p<0.01) [36]. Study investigating women with breast cancer who are in midway of their cancer treatment reported negative correlation between quality of life and depression [5] while study involving patients who are at end of cancer treatment reported problems in physical functioning. Patients with advanced breast cancer also reported problems in physical and social roles [4] as well as self image problems [27] (Table 4).

Table 4: Methods and outcomes of studies examining quality of life in patients with breast cancer.

From review of literature many useful information has been sought regarding psychological issues faced by patients with breast cancer. Most of the studies included in review followed cross sectional design rather than prospective follow up studies. Prospective studies can be more helpful in addressing the issue of how association between different psychological variables and breast cancer may change over time. Studies comparing patients at different stages of illness were limited in this review.

Review included studies with patients at different stages of illness and depression and anxiety was found at early as well as at advanced stage. Patients with malignant as well benign tumors reported depression though frequency of those with benign tumors was slightly low. Depression was found in patients who were in process of receiving chemotherapy as well as those who completed their chemotherapy. This may indicate that the disease characteristics have little impact on level of depression. Self image problems were faced by those who were at early stage of illness as well as those received mastectomy. Association was found between poor self image and depression.

There is consensus in studies regarding common use of avoiding coping strategies as well as association between avoidance coping strategies and poor mood or depression. Disengagement, self blame and "complying with" strategies has also been found to be used by breast cancer patients and these coping styles also has association with depression. Like depression and anxiety, poor quality of life is also reported by both early as well as advanced breast cancer patients.

Most of the studies on depression, anxiety, self image and quality of life were conducted in developed countries. According to Yen et al. [64] prevalence of breast cancer is also increasing in developing countries. Therefore psychological problems faced by breast cancer patients in low income countries should also be focused.

Majority of the studies reported high prevalence of depression and anxiety in breast cancer patients. Use of poor coping strategies is common in breast cancer patients at all stages even after treatment. Poor self image and quality of life is associated with all types of treatments.