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Psychosomatics 46:517-522, December 2005
doi: 10.1176/appi.psy.46.6.517
© 2005 Academy of Psychosomatic Medicine
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Psychiatric Sequelae Following Breast Cancer Chemotherapy: A Pilot Study Using Claims Data

Shannon L.B. Miller, Pharm.D., Laura E. Jones, M.S., and Caroline P. Carney, M.D., M.Sc.

Received April 1, 2004; revision received Nov. 3, 2004; accepted Dec. 16, 2004. From the Department of Clinical and Administrative Pharmacy, The University of Iowa College of Pharmacy, Iowa City; the Department of Epidemiology, The University Iowa College of Public Health, Iowa City; Regenstrief Institute, Indianapolis; and the Departments of Psychiatry and Internal Medicine, Indiana University School of Medicine. Address correspondence and reprint requests to Caroline Carney Doebbeling, M.D., M.Sc. 449 RT, Indiana University Cancer Center, Indianapolis, IN 46202; ccarneyd{at}iupui.edu (email).


  ABSTRACT

 
TOP
 ABSTRACT
INTRODUCTION
 METHOD
 RESULTS
 DISCUSSION
 CONCLUSIONS AND IMPLICATIONS
 REFERENCES
 
Despite attention to depression and cognitive disorders, the prevalence of other mental disorders following breast cancer chemotherapy has not been well described. The authors undertook a pilot study using insurance claims data to compare the prevalence of mental disorders other than depression in a population of breast cancer surgery patients who did versus did not receive postsurgical chemotherapy treatment. Women receiving chemotherapy in addition to surgery were more likely to be diagnosed with adjustment disorders (odds ratio=2.01, 95% CI=1.04–3.87). Prevalence of depression, anxiety, cognitive, and sleep disorders were not dependent on receipt of post-surgical chemotherapy treatment. These findings support the need for heightened awareness for mental conditions following chemotherapy.


  INTRODUCTION

 
TOP
 ABSTRACT
 INTRODUCTION
METHOD
 RESULTS
 DISCUSSION
 CONCLUSIONS AND IMPLICATIONS
 REFERENCES
 
An estimated 215,990 new breast cancer cases will have been diagnosed in the United States in 2004.1 The percentage of women receiving adjuvant chemotherapy for breast cancer treatment could be greater than 80% depending on age, stage, and receptor and node status.2 In 2002, the mean life expectancy for women in the United States was 79.8 years.3 More women will likely be diagnosed with breast cancer at later ages given the current upward trend in life expectancy. Receipt of chemotherapy typically declines with increasing age.4 However, it has been reported that women ages 65 years and older receive chemotherapy at rates of 1%–48% depending on age, functional status, and cancer stage.4 Some elders tolerate chemotherapy well.5–7 Therefore, it is possible more women, including elders, with breast cancer will receive chemotherapy and subsequently be at risk for associated side effects.

Depression is commonly diagnosed following treatment for breast cancer. The prevalence of depression in breast cancer varies widely depending on the population under study, with reported rates from 3%– 55%.8–13 Some have suggested depression is underreported.14,15 While depression following chemotherapy for breast cancer has been well described, there is limited information available for the occurrence of other mental disorders. One exception is the recent interest in postchemotherapy cognitive disorders.16–20 Cognitive dysfunction may be generally described as disturbances, including those of consciousness (e.g., alertness and attention), cognition (e.g., memory and learning), executive functioning (e.g., planning and organizing), aphasia, apraxia, and agnosia.

Studies on postchemotherapy cognition changes support the hypothesis that cognitive decline occurs following initiation of chemotherapy.18–20 Ahles et al.17 reported that persons with stages 0–II breast cancer and persons with lymphoma who were treated with systemic, standard-dose chemotherapy were more likely to have impaired neuropsychological functioning than persons who received local therapy only. Specifically, the domains of verbal memory and psychomotor functioning were impaired. However, Schagen et al.16 suggested that neuropsychological functioning was similar among breast cancer patients who received a high-dose chemotherapy regimen or one of two standard-dose regimens relative to a control group consisting of nontreated stage I patients. Follow-up neuropsychological testing conducted 4 years after therapy did not differentiate subjects receiving chemotherapy from the control group. These authors suggest the cognitive effects of chemotherapy may be transient.

The aforementioned studies provide evidence that treated breast cancer patients may experience cognitive changes secondary to the treatment. Although depression and cognition changes may occur in some women following chemotherapy treatment for breast cancer, the incidence and prevalence of other mental disorders occurring after chemotherapy in this population has not been thoroughly explored. Therefore, the purpose of this pilot study is to describe the occurrence of mental disorders, other than depression, in a younger population of breast cancer surgery patients who did versus did not receive postsurgical chemotherapy treatment.


  METHOD

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
RESULTS
 DISCUSSION
 CONCLUSIONS AND IMPLICATIONS
 REFERENCES
 
The data source comprised all Wellmark Blue Cross/Blue Shield administrative claims from Jan. 1, 1996, to Dec. 31, 2001. The data include inpatient and outpatient claims submitted by all health care providers, ICD-9 diagnostic and procedural codes, and Common Procedural Terminology (CPT) codes (ICD-9 and CPT codes are available by request from the authors).

Subjects
The study population consisted of all women ages 18 or older who filed at least one claim for medical services during 1996–2001. Women younger than age 18 were excluded given the low number of breast cancer claims in that age group. Age was categorized into four levels: 18–34, 35–49, 50–64, and 65 + years. The basic medical insurance coverage was similar among subjects, with only a small proportion (<10%) enrolled in a managed care plan.

Breast Cancer and Treatment
We identified women with breast cancer according to previously validated criteria developed for administrative claims data.4,21,22 To be eligible for inclusion, women were required to have at least one claim for an incident breast cancer diagnosis (ICD-9 174) and no identified claims for mental disorders before the first breast cancer claim. All claims following the breast cancer diagnosis were analyzed to determine if women received chemotherapy or breast surgery. The case population comprised women who received breast surgery and chemotherapy that was later followed by a mental disorder diagnosis. The control population comprised women who received breast surgery only that was later followed by a diagnosis of a mental disorder. Women who did not receive either chemotherapy or breast surgery were excluded from the analyses given the intent to study mental disorders after the initiation of breast cancer treatment. We also examined receipt of radiation therapy in the case and control populations who received breast surgery with or without chemotherapy but did not further analyze this variable given the low receipt rates (N=11).

Mental Disorders
Given that the outcome of interest was the diagnosis of a mental disorder after initiation of breast cancer treatment, only women with mental disorder claims occurring after treatment were included in the analysis. Subjects were assigned to a single mental disorder category on the basis of the first mental disorder claim identified after the initiation of treatment. DSM-IV23 has organized mental disorders into 17 major diagnostic categories based on ICD-9 codes. We examined eight DSM-IV categories (adjustment, anxiety, cognitive, mood, sexual, sleep, substance, and other disorders). We also selected codes for fatigue (ICD-9 780.79) given that this code is not included in DSM-IV category of sleep disorders.

Statistical Analysis
Student’s t tests were used to compare continuous variables. Age-adjusted odds ratios (OR) were calculated for the occurrence of each of the specified DSM-IV mental disorders for the case and control groups. Alpha was set at 0.05 (two-sided). All analyses were performed with SAS version 8.2 (SAS Version 8.2 Cary, N.C.).


  RESULTS

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
 RESULTS
DISCUSSION
 CONCLUSIONS AND IMPLICATIONS
 REFERENCES
 
A total of 683,800 women ages 18 years and older were available for analysis, of which 8,971 (1.3%) were identified with breast cancer. From these, we identified 172 (1.9%) surgery and chemotherapy patients and 205 (2.3%) surgery only control patients. The surgery and chemotherapy patients were approximately 6 years younger than the surgery only control patients at the incident breast cancer claim. The majority (48%) of the surgery and chemotherapy patients were 35–49 years of age, whereas the majority (59.5%) of the surgery only control patients were 50–64. No difference in the length of follow-up was observed among the case and control populations (Table 1).


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TABLE 1. Demographic Characteristics of Breast Cancer Surgery Patients With Subsequent Mental Disorder Diagnoses, by Postsurgical Chemotherapy Status



Table 2 reports the age-adjusted odds ratios for the eight DSM-IV mental disorders diagnosed in the case and control populations. Women who received chemotherapy and surgery were more likely to have been diagnosed with an adjustment disorder following initiation of breast cancer treatment compared with women undergoing surgery only. No significant differences were found for the other specific mental disorders. In the case of fatigue, 17.5% of those receiving surgery only had an ICD-9 code for fatigue, while 19% of those receiving surgery and chemotherapy had a code for fatigue (p<0.69).


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TABLE 2. Mental Disorder Diagnoses Among Breast Cancer Surgery Patients (N=377), by Postsurgical Chemotherapy Status




  DISCUSSION

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
 RESULTS
 DISCUSSION
CONCLUSIONS AND IMPLICATIONS
 REFERENCES
 
This pilot study demonstrates that the occurrence of mental disorders among women who receive chemotherapy following breast surgery is generally similar to that of women who receive surgery only. Important exceptions should be noted. In this population of privately insured women, adjustment disorders were more common following breast cancer treatment among women who received both breast surgery and chemotherapy than among those who received surgery only. Our findings suggest that women who receive breast cancer chemotherapy treatment have an elevated risk for adjustment disorders. Whether or not these conditions are transient cannot be answered by these data. Although adjustment disorders may be transitory, they could be the harbingers of more serious mood and anxiety conditions. It is interesting that sleep and anxiety disorders were diagnosed in more than 10% of the case and control groups. These numbers are similar to their prevalence in the general population and may underrepresent the true prevalence in this sample.24

We were surprised to find that mood disorders were similarly diagnosed among those who received chemotherapy and those who did not. However, we attribute this result to small sample size, underdiagnosis, and underreporting of mental disorders. Mental disorders may be undercoded in claims data,25 either because physicians do not recognize the symptoms of a mental disorder or because patients are apprehensive about a mental disorder diagnosis appearing in their medical records.25 Furthermore, the increased prevalence of adjustment disorders may reflect the presence of underlying mood symptoms. Because fatigue as a stand-alone symptom did not significantly differ between groups, it may not have influenced whether these patients were diagnosed with mental disorders.

The finding that adjustment disorders are more common among women undergoing chemotherapy is also of interest. Adjustment disorders may be diagnosed for depression and anxiety symptoms that physicians believe to be transient or may be related directly to the therapy. Disease stage has rarely been found to be a significant predictor of adjustment; instead, the cancer-related physical functioning sequelae have been shown to be a better predictor.26–29 Adjustment disorders may be more common among women who receive chemotherapy because of perceived severity of disease or because the side effects of chemotherapy prohibit the maintenance of a prechemotherapy daily schedule.

Although the low rates of radiation therapy in this population of breast cancer surgery patients were striking, they were not unexpected. After the results of a 5-year randomized clinical trial that compared the outcomes of patients who did and did not receive radiation for breast cancer were published in 1985,30 radiation therapy has played an important role in the management of breast-conserving therapy. In 1991, an NIH consensus panel concluded that radiation therapy was an appropriate treatment for patients with early stage breast cancer.31 However, despite these landmark publications, it has been reported that the use of radiation with breast-conserving surgery is underutilized.32–34 It has been speculated that underutilization could be the result of geographic variation in the regional treatment of breast cancer.35 Given that this was a largely rural population, geographic distance from the radiation centers may have played a role in the finding. As with mental disorder diagnoses, claims data may not detect the utilization of radiation due to weaknesses in the database itself, such as coding inaccuracies and incomplete data.

It is important to note the limitations of this study. This was a pilot study that was limited by a small sample size. Claims data are likely to underrepresent the true incidence and prevalence of mental disorders.22 Given that our analyses were limited to women who were diagnosed with a mental disorder following initiation of breast cancer treatment, the potential for undercoding or lack of recognition of a mental disorder may have influenced the results. Furthermore, women who were diagnosed with a mental disorder before breast cancer treatment were excluded in order to lessen the likelihood of analyzing prevalent and not incident mental health conditions. Additionally, claims information may be missing for women with multiple insurers or women who received Medicare coverage at age 65. Conclusions of studies using claims data must be interpreted cautiously. Claims data research is dependent on the accuracy of diagnoses and appropriate ICD-9-CM and CPT coding of the disease state and treatment procedures.36 Further, studies using claims data are unable to capture the experiences of patients whose clinicians do not code for mental disorders. The women in this study were insured women primarily from Iowa and South Dakota. Because Iowa and South Dakota are racially homogeneous states, the findings may not generalize to more racially diverse populations. Also, results from this study may not be applicable to persons who are underinsured or uninsured. Future studies should include women from a wide variety of socioeconomic strata and geographical locations and more elders.


  CONCLUSIONS AND IMPLICATIONS

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
 RESULTS
 DISCUSSION
 CONCLUSIONS AND IMPLICATIONS
REFERENCES
 
Our findings suggest that younger, insured women with breast cancer who receive chemotherapy after surgery are at an increased risk for adjustment disorder. These results emphasize the need for health care providers to be aware that mental disorders other than depression occur commonly in women who receive chemotherapy. Of importance is that a significant proportion of women in both populations were diagnosed with mental disorders other than mood such as sleep disorders, which suggests a significant impact on daily functioning. In addition to the traditional side effects of chemotherapy such as fatigue, mental disorders may negatively affect a patient’s quality of life. These findings support the importance of assessing breast cancer patients for the presence of a mental disorder following breast cancer diagnosis and initiation of treatment. Patients need to be informed about the potential mental health side effects as part of their therapy decision process. This knowledge could ultimately affect the patient’s decision with regard to choice of therapy. Mental health services need to be available to all cancer patients regardless of the type of treatment chosen. Future research should include a larger sample of older women from a variety of socioeconomic strata, geographical locations, and insurance availability. In addition, now that there is mounting evidence for mental health side effects as a potential result of chemotherapy, strategies to prevent or ameliorate them can be developed.


  ACKNOWLEDGMENTS

 
The authors wish to acknowledge the support of Dr. Sheila Riggs, Vice President of Healthcare Measurement and Reporting, Wellmark Blue Cross/Blue Shield of Iowa and South Dakota.

This research was supported by the Holden Comprehensive Cancer Center’s Institutional National Research Service Award (2 T32 CA79445, "Oncology Research Training Award") to Dr. Miller and by an NIMH grant (K08 MH01932-01A1, "Epidemiology of Cancer and Mental Illness in Rural Areas") to Dr. Carney.


  REFERENCES

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
 RESULTS
 DISCUSSION
 CONCLUSIONS AND IMPLICATIONS
 REFERENCES
 

  1. Jemal A, Tiwari RC, Murray T, Ghafoor A, Samuels A, Ward E, Feuer EJ, Thun MJ: Cancer statistics, 2004. CA Cancer J Clin 2004; 54:8–29[Abstract/Free Full Text]
  2. Harlan LC, Abrams J, Warren JL, Clegg L, Stevens J, Ballard-Barbash R: Adjuvant therapy for breast cancer: practice patterns of community physicians. J Clin Oncology 2002; 20:1809–1817[Abstract/Free Full Text]
  3. Department of Health and Human Services www.hhs.gov/news/press/2003pres/20031003bl (accessed 10/22/04)
  4. Du X, Goodwin JS: Patterns of use of chemotherapy for breast cancer in older women: findings from Medicare claims data. J Clin Oncol 2001; 19:1455–1461[Abstract/Free Full Text]
  5. Chen H, Cantor A, Meyer J, Beth Corcoran M, Grendys E, Cavanaugh D, Antonek S, Camarata H, Haley W, Balducci L, Extermann M: Can older patients tolerate chemotherapy? A prospective pilot study. Cancer 2003; 97:1107–1114[CrossRef][Medline]
  6. Balducci L, Lyman GH: Patients aged > or = 70 are at high risk for neutropenic infections and should receive hemopoietic growth factors when treated with moderately toxic chemotherapy. J Clin Oncol 2000; 19:1583–1585
  7. Kimmick GG, Fleming R, Muss HB, Balducci L: Cancer chemotherapy in older adults: a tolerability perspective. Drugs Aging 1997; 10:34–49[Medline]
  8. Cathcart CK, Jones SE, Pumroy CS, Peters GN, Know SM, Cheek JH: Clinical recognition and management of depression in node negative breast cancer patients treated with tamoxifen. Breast Cancer Res Treat 1993; 27:277–281[CrossRef][Medline]
  9. Fulton CL: The physical and psychological symptoms experienced by patients with metastatic breast cancer before death. Eur J Cancer Care 1997; 6:262–266
  10. Maguire GP, Lee EG, Bevingon DJ, Kuchemann CS, Crabtree RJ, Cornell CE: Psychiatric problems in the first year after mastectomy. BMJ 1978; 1:963–965
  11. Pinder KL, Ramirez AJ, Black MA, Richards MA, Gregory WM, Rubens RD: Psychiatric disorders in patients with advanced breast cancer: prevalence and associated factors. Eur J Cancer 1993; 29A:524–527
  12. Ramirez AJ, Richards MA, Jarrett SR, Fentiman IS: Can mood disorder in women with breast cancer be identified preoperatively? Br J Cancer 1995; 72:1509–1512[Medline]
  13. Mermelstein HT, Lesko L: Depression in patients with cancer. Psycho-Oncology 1992; 1:199–215
  14. Fulton C: The prevalence and detection of psychiatric morbidity in patients with metastatic breast cancer. Eur J Cancer Care 1998; 7:232–239[CrossRef]
  15. Hall A, A’Hern R, Fallowfield L: Are we using appropriate self-report questionnaires for detecting anxiety and depression in women with early breast cancer? Eur J Cancer 1999; 35:79–85
  16. Schagen SB, Muller MJ, Boogerd W, Rosenbrand RM, van Rhijn D, Rodenhuis S, van Dam FS: Late effects of adjuvant chemotherapy on cognitive function: a follow-up study in breast cancer patients. Ann Oncol 2002; 13:1387–1397[Abstract/Free Full Text]
  17. Ahles TA, Saykin AJ, Furstenberg CT, Cole B, Mott LA, Skalla K, Whedon MB, Bivens S, Mitchell T, Greenberg ER, Silberfarb PM: Neuropsychological impact of standard-dose systemic chemotherapy in long-term survivors of breast cancer and lymphoma. J Clin Oncol 2002; 20:485–493[Abstract/Free Full Text]
  18. Brezden CB, Phillips K-A, Abdolell M, Bunston T, Tannock IF: Cognititive function in breast cancer patients receiving adjuvant chemotherapy. J Clin Oncol 2000; 18:2695–2701[Abstract/Free Full Text]
  19. Wieneke MH, Dienst ER: Neuropsychological assessment of cognitive functioning following chemotherapy for breast cancer. Psycho-Oncology 1995; 4:61–66
  20. van Dam FS, Schagen SB, Muller MJ, Boogerd W, vd Wall E, Fortuyn ME, Rodenhuis S: Impairment of cognitive function in women receiving adjuvant treatment for high-risk breast cancer: high-dose versus standard-dose chemotherapy. J Nat Cancer Inst 1998; 90:210–218[Abstract/Free Full Text]
  21. Du XL, Osborne C, Goodwin JS: Population-based assessment of hospitalization for toxicity from chemotherapy in older women with breast cancer. J Clin Oncol 2002; 20:4636–4642[Abstract/Free Full Text]
  22. Woods CR: Impact of different definitions on estimates of accuracy of the diagnosis data in a clinical database. J Clin Epidemiol 2001; 54:782–788[CrossRef][Medline]
  23. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC, APA, 1994
  24. Derogatis LR, Morrow GR, Felting J, Penman D, Piasetsky S, Schmale AM, Henrichs M, Carnicke CL Jr: The prevalence of psychiatric disorders among cancer patients. JAMA 1983; 249:751–757[Abstract]
  25. Lurie N, Popkin M, Dysken M: Accuracy of diagnoses of schizophrenia in Medicaid claims. Hosp Comm Psychiatry 1992; 43:69–71[Abstract/Free Full Text]
  26. Woolcott DL, Wellish DK, Fawzy FI, Landsverk J: Adaptation of adult bone marrow transplant receipient long-term survivors. Transplantation 1986; 41:478–484[Medline]
  27. Bush NE, Haberman M, Donaldson G, Sullivan KM: Quality of life of 125 adults surviving 6–18 years after bone marrow transplantation. Soc Sci Med 1995; 40:479–490
  28. Morris T, Greer HS, White P: Psychological and social adjustment to mastectomy: a two-year follow-up study. Cancer 1977; 40:2381–2387[CrossRef][Medline]
  29. Kornblith AB: Psychosocial adaptation of cancer survivors, in Psycho-Oncology. Edited by Holland JC. New York, Oxford University Press, 1998, p 234
  30. Fisher B, Bauer M, Margolese R, Poisson R, Pilch Y, Redmond C, Fisher E, Womark N, Deutsch M, Montague E, Saffer E, Wicherham DL, Lerner H, Glass A, Shibata H, Deckers P, Ketcham A, Oishi R, Russel I: Five-year results of a randomized clinical trial comparing total mastectomy and segmental mastectomy with or without radiation in the treatment of breast cancer. N Engl J Med 1985; 312:665–673[Abstract]
  31. NIH Consensus Conference - Early stage breast cancer. JAMA 1991; 265:391–395[CrossRef][Medline]
  32. Du X, Freeman JL, Goodwin JS: Information on radiation treatment in patients with breast cancer: the advantages of the linked Medicare and SEER data. J Clin Epidemiol 1999; 52:463–470[CrossRef][Medline]
  33. Lazovich DA, White E, Thomas DB, Moe RE: Underutilization of breast-conserving surgery and radiation therapy among women with state I or II breast cancer. JAMA 1991; 266:3422–3438
  34. Patton ML, Moss BE, Kraut JD, Germain TJ, Haith LR Jr, Shotwell BA, Reilly KJ: Underutilization of breast-conservation surgery with radiation therapy for women with stage Tis, I or II breast cancer. Int Surg 1996; 81:423–427[Medline]
  35. Farrow DC, Hunt WC, Samet JM: Geographical variation in the treatment of localized breast cancer. N Engl J Med 1992; 326:1097–1101[Abstract]
  36. Demlo LK, Campbell PM, Brown SS: Reliability of information abstracted from patient’s medical records. Med Care 1978; 16:995–1005[CrossRef][Medline]



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