Review Article, J Clin Exp Oncol Vol: 12 Issue: 5

Impaired Quality of Life (QoL) and Psychological Distress in Breast Cancer Patients and their Caregivers: A Brief Overview

Riddhi Ghosh¹, Saraswat Basu² and Shazia Rashid^3*

¹Department of Applied Psychology, University of Calcutta, Kolkata, India

²Department of Chemistry and Molecular Bioscience, The University of Queensland, Queensland, Australia

³Department of Medical Biotechnology, Amity University, Uttar Pradesh, India

*Corresponding Author: Shazia Rashid
Department of Medical Biotechnology, Amity University, Uttar Pradesh, India
E-mail: riddhighosh29@gmail.com

Received date: 17 April, 2023, Manuscript No. JCEOG-23-96167;
Editor assigned date: 20 April, 2023, PreQC No. JCEOG-23-96167 (PQ);
Reviewed date: 04 May, 2023, QC No. JCEOG-23-96167;
Revised date: 19 June, 2023, Manuscript No. JCEOG-23-96167 (R);
Published date: 26 June, 2023, DOI: 10.36648/2324-9110.100370

Citation: Rashid S, Basu S, Rashid S (2023) Impaired Quality of Life (QoL) and Psychological Distress in Breast Cancer Patients and their Caregivers: A Brief Overview. J Clin Exp Oncol 12:5.

Abstract

Keywords: Breast cancer patients; Cancer caregivers; Recurrence; Anxiety and depression; Quality of Life (QoL); Psychosocial care; Psychological assessment

Introduction

GLOBOCAN 2020 has estimated that female breast cancer is the world’s most commonly diagnosed cancer accounting for 11.7% of new cases in 2020 and ranks fifth in cancer related death (6.9%) in the world [1]. Breast cancer dangerously affects physical health and also has a severe effect on the mental health of the patients. The diagnosis of breast cancer can be distressing and life altering for the sufferers and their family members. While in the process of treatment for the physical aspects of cancer, the psychological issues that stem from it cannot be ignored. Anxiety, depression, body image related issues, and the adverse impact on quality of life are some of the psychological problems commonly faced by these patients [2-4]. Furthermore, the completion of primary and secondary treatment procedures does not absolve the patient of the sequelae of breast cancer. Various long term effects such as pain, limitations in physical, mental, and social functioning, fatigue, and sleep problems are reported by breast cancer survivors [5]. Apart from the negative outcomes, positive psychological change or post-traumatic growth is also seen in the long run [6]. The responsibility of caring for someone with breast cancer can be deeply distressing and have a detrimental effect on the health of the family or informal caregivers as well [7,8]. Psychological interventions such as Cognitive Behavioural Therapy (CBT) and Supportive Expressive group Therapy (SET) and other similar support therapies can help to avoid some of these negative outcomes [9,10]. But interventions can be appropriately provided to patients only when their psychological needs are assessed. The need of routine screening of cancer patients for emotional distress and various psychological problems has been documented and it is considered as an indispensable part of cancer care [11].

In developing countries, survival rates are lower owing to lesser awareness, delayed detection, and less advanced diagnostic methods and treatment available in these countries [12]. Breast cancer patients from developing countries like Iran and Mexico express high levels of unmet supportive care needs especially in the domains of health system and information, physical and daily living, and psychological needs [13,14]. Clinical practice guidelines, recommendations regarding the effective detection and management of cancer, have been developed in high income nations namely the USA, Australia, the UK, and Canada but it is difficult to follow them in low income nations due to the scarce availability of resources [15]. In developing countries, psychosocial care services are rarely incorporated into the oncological healthcare system [16].

The aim of this article is to present an overview of the psychological consequences of breast cancer through diagnosis, treatment, and survivorship, to outline the tools that can be used to assess these issues and the interventions available to effectively deal with them.

Literature Review

Effect of diagnosis

Breast cancer has a significant impact on the mental health of the sufferers. Symptoms of anxiety and depression are more prevalent in breast cancer patients compared to healthy controls, indicating that they are at a greater risk of developing psychiatric conditions [17]. The prevalence rate of anxiety has been reported as 37% and that of depression as 28% [18]. Research has shown that women who perceive high levels of psychological distress after diagnosis show significantly greater anxiety symptoms [19]. Women who report having low social support and a pre-morbid history of major depression or anxiety disorders have a greater likelihood of onset of depression or anxiety after detection of breast cancer [20]. Depression could be dangerous if it goes undetected as it has been associated with diminished adherence to treatment regimen in patients of breast cancer. Thus, it is important to screen individuals who have been recently diagnosed with breast cancer to identify those who are vulnerable to mental disorders and extend adequate psychological support to them. Therapeutic or counseling services should be provided to patients to help them cope with the stress of a breast cancer diagnosis.

Effect of treatment

The primary treatment for breast cancer is surgery which can involve removal of only the cancerous cells (breast-conserving surgery) or removing the entire breast (mastectomy). Adjuvant therapies which are treatment procedures administered before or after surgery to shrink the tumor and lessen the likelihood of recurrence include chemotherapy and radiotherapy among others. The barrage of treatment procedures that patients have to undergo can take a huge toll on their mental health in several ways.

Negative psychological outcomes that have been seen after surgery are issues related to body image which constitutes how one perceives one’s body and what their thoughts, beliefs, and feelings are towards their own body. Women undergoing treatment for breast cancer express more dissatisfaction with their appearance related body image and low self-esteem when compared to healthy controls. Body image concerns in younger women have been attributed to loss of breast and scarring from surgery as well as physiological changes that are a result of adjuvant therapy. The most significant body image concern was seen in women who underwent mastectomy without reconstruction. Sleep difficulties, fatigue, pain, depressive and anxiety disorders are commonly seen during the course of as well as after completion of treatment. Breast cancer patients also reported avoiding social situations due to their appearance after surgery indicating a detrimental effect on their social well-being.

Quality of Life (QoL) is the extent to which an individual perceives that he/she is healthy, comfortable, and able to enjoy the activities of daily life. It includes the domains of physical, mental, and social well-being. With increase in survival rates due to medical progress, health related QoL is considered an important aspect of cancer care. The overall QoL of patients suffering from breast cancer was seen to be negatively affected during treatment with major impact on physical, emotional, and social/family well-being. Poorer QoL outcomes have been linked to symptoms of anxiety and depression experienced by breast cancer patients. Financial difficulties, arm symptoms, fatigue, pain, and hair loss that are commonly experienced after treatment were observed to be related to a reduction in QoL with arm symptoms and financial difficulties being the most distressing factors. The economic burden of treatment has a harmful impact on overall QoL and an enduring effect on social well-being. Women who undergo breast reconstruction following mastectomy show significantly better mental health and decreased levels of stress, anxiety, and loneliness. They report improvements in their health related QoL but experience greater physical distress compared to those who undergo mastectomy without breast reconstruction. Chemotherapy, which is given in order to increase the chances of disease free survival, may have several adverse effects. Women who received chemotherapy showed significantly lower QoL scores in the areas of physical functioning and role limitations due to physical problems compared to those who were not treated with chemotherapy. Although improvements in QoL are seen in the long term, it is essential to help patients manage the psychological distress that occurs and affects their quality of life during and after treatment.

The completion of the treatment process may bring a patient respite from the immediate threat to their health but not from the worry or fear of recurrence. Higher fear of recurrence is significantly associated with higher depression and lower quality of life.

Effect of recurrence

Studies have shown prevalence rates of 22% to 42% of psychiatric disorders including anxiety, depressive, and adjustment disorders following first recurrence. The prevalence rate of major depressive disorder (7%) after recurrence was similar to that found after a primary diagnosis of cancer, but the rate of adjustment disorders (35%) was higher than that found after a primary diagnosis. This suggests that it might be tougher to handle the stress of recurrence than that of a primary diagnosis. The research on effect of recurrence on QoL of breast cancer sufferers is quite limited but a study reported significant impairments in physical, functional, and emotional wellbeing of patients assessed within one month after recurrence.

Long term effects

Breast cancer can have life ong effect on the patient even after the treatment process has been completed. Severe mental health outcomes that have been identified in survivors of breast cancer include depressive and anxiety disorders, increased symptoms of neurocognitive and sexual dysfunction, sleep problems, stress related disorders like post-traumatic stress disorder, and increased risk of suicide compared to women without a history of cancer. Further investigation showed that the increased risk for anxiety and depression can persist for two to four years after diagnosis whereas increased levels of pain and sleep difficulties can persist for five to ten years after diagnosis.

The global health or QoL of long term survivors was seen to be comparable to controls over ten years after diagnosis but survivors reported significant differences in physical, emotional, cognitive, and social functioning as well as symptoms like fatigue, pain, and insomnia. Similarly, another study showed QoL to be significantly poorer in survivors five years after being diagnosed especially when it came to physical and social functioning but improvements were seen in the long run. Fifteen years post-diagnosis the survivors no longer showed significant differences in their QoL compared to healthy controls.

The experience of an extremely stressful or traumatic life event may lead to positive psychological changes in the individual which is known as Post-traumatic Growth (PTG). Post-traumatic growth can occur in various forms such as a newfound appreciation for life, more meaningful relationships with others, gaining personal strength, spiritual change, and identifying new possibilities for one’s future. PTG scores in patients of breast cancer were seen to increase over the first year following diagnosis and then level off over the next few months. Breast cancer patients with higher levels of cancer specific stress after diagnosis reported greater PTG after six months. In addition, individuals showing greater PTG at six months had less cancer specific stress 12 months post-diagnosis and less overall stress 18 months post-diagnosis. PTG is also reported in the long run, i.e., five to fifteen years after diagnosis with scores comparable to short term studies. Moreover, PTG has shown a low positive association with mental QoL. There is mixed evidence regarding the relationship of PTG with psychological adjustment and well-being. Some studies have shown that high levels of PTG is related to reduced psychological distress which may be attributed to PTG acting as a buffer between the perceived stress of breast cancer and subsequent psychological distress. Contrarily, some evidence shows that PTG is negatively associated with mental health related QoL and positively associated with emotional distress which has been explained by the conceptual understanding of PTG. Post-traumatic growth is borne out of the adverse effect that a traumatic event like breast cancer has on one’s life and hence it is important for psychological distress to be present to increase the levels of PTG. Although more longitudinal studies are necessary to fully understand how post-traumatic growth is related to psychological health, it is a beneficial outcome which can be fostered in patients by guiding them to use adaptive or healthy coping strategies.

Effect on family caregivers

Breast cancer is a tumultuous time for the sufferer and the family members who have to care for the patient as well as provide adequate support throughout this tough time. Caregivers play a vital role in the management of breast cancer including helping with daily activities, administering medication, and managing symptoms. Patients have reported that in addition to themselves their family members also need psychological support as some of the side effects of adjuvant therapies like chemotherapy can be intimidating, especially for young children. Caregivers report experiencing anxiety stemming from uncertainty about the future, fear of recurrence, death, and increasing financial burden. Anxiety disorders are commonly reported by caregivers who have been providing care for longer durations and have lesser people sharing the responsibilities of caregiving. Depression is also prevalent in those who care for breast cancer sufferers.

The responsibility of caring for a chronically ill family member can be extremely stressful. The strain perceived by caregivers as a consequence of continuously providing care and support over a long period of time is known as caregiver burden which has a detrimental effect on their QoL. Primary caregivers commonly report problems with sleep disturbances and fatigue which negatively affects their QoL. The responsibility of caregiving brings with it a disruption of their normal life, a change in the relationship with the patient, neglect of one’s own needs, and deteriorating physical and mental health. Caregivers often report a feeling of being isolated and receiving inadequate support from their family and friends as well as from the healthcare community. This clearly indicates the necessity of extending professional support to the caregivers of the patient.

Discussion

Psycho oncological assessment

The psychological assessment of individuals suffering from breast cancer is essential to the identification of those with psychological vulnerability. A structured clinical interview is used to diagnose mental disorders in psychiatric settings but there are various tests that can be used in routine care settings to screen for anxiety, depression, distress, and various mental health problems faced by breast cancer patients. The Distress Thermometer (DT), designed to measure psychological distress in cancer patients, is a short screening tool that can help indicate clinically relevant changes in the QoL of patients. The Hospital Anxiety and Depression Scale (HADS) is a useful screening measure for detecting depressive and anxious states in cancer settings. The Mini-Mental Adjustment to Cancer (Mini-MAC) is a popular tool to assess individuals’ coping responses to cancer. Higher scores on the helplessness/hopelessness and anxious preoccupation domains of the mini MAC are significantly related to poorer QoL in those with breast cancer.

Cancer patients often do not fulfill the criteria for psychiatric disorders according to the International Classification of Diseases (ICD) and Diagnostic and Statistical Manual of mental disorders (DSM) resulting in a failure to recognize the psychosocial outcomes of cancer. The Diagnostic Criteria for Psychosomatic Research (DCPR), which was first developed in 1995, lists twelve clinical syndromes describing the psychosocial problems related to medical conditions. The DCPR has great value in therapeutic and prognostic areas and has shown its clinical usefulness in oncological settings.

Psychological interventions

The negative psychological outcomes that have been illustrated previously exhibit the necessity of psychological interventions to cope with the distress and psychological problems borne out of the diagnosis and treatment of breast cancer. Although supportive care is an important aspect of breast cancer care, it is not often provided as and when necessary. There are different kinds of psychotherapies that can be availed to help patients deal with their coping or adjustment process.

Cognitive Behavioral Therapy (CBT) helps people learn how to identify and change destructive thought patterns that negatively influence behavior as well as emotions. Various cognitive behavioral techniques were seen to be efficient in reducing anxiety and depression as well as increasing levels of optimism and positive thought in those who have breast cancer. Supportive-expressive group therapy, a cognitive emotion focused therapy which aids in cultivating social and family support, develop openness, and regulate emotional expression, helps reduce emotional distress in patients. Psycho Educational Therapy (PET) is a form of group therapy given to patients and their families which aims at providing information and support to help them better understand and cope with severe illnesses. PET has shown its effectiveness in reducing symptoms of depression and anxiety as well as improving disease specific care knowledge, resilience, and QoL in patients during and after treatment for breast cancer. Cognitive existential group therapy, which is a form of group counseling that helps patients diagnosed with early stage cancer address existential issues and prepare them for long-term survival, has shown to help alleviate fear of recurrence and gain emotional control in breast cancer patients. Positive psychology based interventions which involve spiritual exercises, adaptive regulation of emotions, and meaning-making interventions help enhance mental health, wellbeing, and QoL of patients having breast cancer. Various studies have also shown that different supportive therapies like yoga and peer counseling can help enhance the QoL and well-being of the patient.

The family caregivers of patients who have breast cancer also require psychological support to combat the strain of caregiving for a prolonged period of time. Psycho educational programs and therapeutic counseling can help reduce stress and enhance the caregiver’s mental health. Psychosocial interventions and educational programs based on the COPE (Creativity, Optimism, Planning, and Expert information) framework have shown a significant impact in reducing caregiver burden and enriching their QoL.

Psychosocial care guidelines

The clinical practice guidelines are recommendations for the prevention, diagnosis, and management of a medical condition based on empirical evidence. In the field of psycho oncology, the first clinical guidelines were developed by the national comprehensive cancer network in the USA. which is regularly updated. The National Comprehensive Cancer Network (NCCN) guidelines for distress management, 2019 advocates for early and regular screening for psychological distress in routine care in order to manage the psychological outcomes in a timely manner. Further recommendations on implementing the standards of psychosocial care are also given including but not limited to the formation of interdisciplinary committees and proper training of healthcare professionals in order to help with the psychosocial needs of the patient. In Australia, the clinical practice guidelines for the psychosocial care of adults with cancer 2003 was developed by the national breast cancer centre and national cancer control initiative. It elaborates on effective psychosocial treatments available and recommendations for clinicians on how to handle difficult situations when communicating with the patient. It also provides evidentiary support for the guidelines. Similar guidelines have also been developed in parts of Europe, the UK, and Canada.

The clinical guidelines are not sufficient alone to help manage the psychosocial burden of cancer. The domain of psychosocial supportive care should be formally included in national cancer plans and programs which the International Psycho Oncology Society (IPOS) is currently advocating for the national cancer control programs are public healthcare programs framed to reduce incidence and fatality rates of cancer as well as enhance the QoL of cancer patients. Unfortunately, a global analysis showed that very little attention has been given to supportive care for cancer patients in national cancer control plans.

Breast cancer care in developing and developed countries

The lack of breast cancer awareness in developing countries is a serious problem which delays early detection of the disease, lowers survival rates, and increases the chances of stigmatization and isolation of patients suffering from breast cancer. In the USA, routine healthcare, breast education programs, promotion of self-examination, and increased public knowledge about the disease contribute to higher survival rates showcasing the need to raise community awareness and build a more robust healthcare system in developing countries as well. The lower mortality rates in developed countries such as Canada, Sweden, Norway, and the UK can be attributed to national screening programs, advanced diagnostic tools and treatment options, and expansive breast cancer awareness.

In addition to the proper healthcare for detection, treatment, and aftercare of breast cancer, it is imperative to provide psychological support to patients and family members. Depression was found to be more prevalent among those suffering from breast cancer in middle-income countries compared to high-income countries. Higher rates of anxiety were also seen among patients of breast cancer in developing nations of South East Asia and the Eastern Mediterranean than in developed nations of Europe and America. In low and middle income countries, providing supportive care during and after treatment of breast cancer is of low priority because of which various recommendations have been made by expert panels to resolve this issue. Developing countries like Malaysia and India show high levels of psychological and emotional support needs which remain unmet compared to developed countries like Australia, Germany, and Japan where psycho oncological services are assimilated into the cancer care system.

Conclusion

Psychological distress is commonly experienced by women who have been diagnosed with and are undergoing treatment for breast cancer. The deleterious impact of breast cancer on the psychological well-being of patients and their caregivers has been well documented, which indicates the necessity of providing proper psychological support. A brief overview of a few of the psychosocial interventions presented in this paper elucidates the availability of effective therapeutic interventions to aid people with breast cancer and their families in managing their emotional distress and improving their psychological well-being. Patients and caregivers are faced with many challenges during this uncertain period, and providing professional support throughout can help prevent potentially severe psychiatric problems in the future.

Breast cancer patients may face a variety of psychological problems, and each person’s experience is different. Unless the patient’s individual needs are assessed, they cannot be provided with the appropriate interventions. Hence, it may be helpful to the patient if their treatment plan is designed to cater to their individual supportive care needs. Healthcare professionals like oncology specialists and nurses should be trained properly to identify signs of emotional distress, deal with patients when such signs are found, and make referrals to other services if necessary. It is crucial to have an open line of communication between patients and medical professionals, extend reliable information to answer the queries of the sufferers and their family members, and provide psychological or counselling services to help those struggling with the multifarious effects of breast cancer. We might often overlook or not give enough attention to the burden that family caregivers face. Their psychosocial needs should also be assessed regularly and support must be provided to them if required. It is also important to note that the research on how recurrence affects mental health is quite scarce and much work is needed in this area to understand whether the approach that healthcare workers take toward treating such patients should be altered and what interventions may improve their QoL.

National cancer programs should recognize the importance of psychosocial services as a component of a comprehensive cancer care system and incorporate them into their cancer programs. As cancer treatment and palliative care are expensive, healthcare policymakers and government agencies should ensure that psychological services are made affordable so that they are accessible to all strata of society. Due to the disparity in their economies, clinical guidelines designed in high-income nations might not be directly applicable to low and middle income nations. The guidelines from developed countries should be adjusted such that they may be implemented efficiently with limited resources available in developing countries. It is, thus, vital to establish a holistic system of formal care that will attend to both the physical and mental health of breast cancer patients and their caregivers.

Statement Conflict of Interest

None declared.

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