Why breast cancer is also about the brain
By Maria Teresa Ferretti and Ewelina Biskup
It is estimated that breast cancer affects 2.1 million women worldwide each year. One in 8 women today will develop breast cancer at some time during their lives.
In light of October being Breast Cancer Awareness Month, we wanted to take stock of how far we have come and some of the key challenges that remain with regards to brain and mental health in the case of breast cancer patients.
Once a death sentence, breast cancer is now fairly well understood. Thanks to early diagnostics, various treatment options besides the standard surgeries and chemotherapy, such as targeted and increasingly also precision medicine approaches, breast cancer today is often curable.
However, some established treatments still bring about a number of unpleasant secondary effects. Hot flashes or losing hair are what everybody thinks about, but they are the tip of the iceberg.
Something not everybody knows is that mental health is often affected by cancer treatments, as well as by their short- and long-term side effects.
To take it a step further, breast cancer is a predominantly female risk factor for mental disease.
Let’s take two examples.
Over 70% of breast cancer cases are hormone-responsive. This means the tumor cells need estrogen or progesterone (or both) as fuel. Hence, after surgery, the few tumor cells left in the body can be annihilated by blocking the production or actions of these hormones in the body.
Pre-menopausal women with hormone-dependent tumors are normally treated with drugs that lead to such blockage. The most famous medication from this family of drugs is tamoxifen.
Post-menopausal women more often receive another class of drugs called aromatase inhibitors.
Both treatments, even though they operate through different mechanisms, block the effects of estrogen in the entire body. This prevents tumor re-growth and thus prevents cancer recurrence, but it comes with a number of side effects: mood swings, up to full-blown affective disorders, are amongst the most common.
Sexual hormones like estrogen play a crucial role in regulating mood and cognition. During the premenstrual phase, the drop of estrogen and progesterone levels causes the blues. Mood swings, anxiety, fatigue and memory impairments have been reported in patients taking antihormonal treatment.
If and when depression hits, breast cancer patients have very limited options. In fact, the most common drugs used for treating depression have dangerous interactions with tamoxifen; antidepressants such as paroxetine, fluoxetine and bupropion must be avoided.
In another case, more rare and more aggressive, breast tumors are brought about by mutations in two BRCA genes (the ones that made headlines thanks to Angelina Jolie). Individuals who carry one of these mutations have a dramatically higher risk: 70% of carriers will develop breast cancer, and 40% will develop ovarian cancer.
As a result, patients are counseled about the option to surgically remove both breasts and ovaries. While this can contribute to preventing cancer development, women tested positive to mutations need to be advised that such radical surgery will interfere with the source of sexual hormones, driving them into early menopause, not to mention permanent and irreversible infertility, as well as significant changes to the feminine body.
Early menopause is defined as menopause before the age of 40, and is linked to a number of health issues, including brain-related symptoms. These are not to be taken lightly.
Removal of ovaries in premenopausal women was shown to cause a decline in memory. The jury is still out there on whether early menopause is a risk factor for Alzheimer’s dementia.
The two examples above add to the psychological trauma of going through a cancer diagnosis and its therapeutic journey. Most patients with cancer are found to struggle with their mood, and nearly 50% of women with early breast cancer had depression, anxiety, or both in the year after diagnosis.
Related concerns & the importance of communication
Based on the above, a number of related problems need to be addressed carefully and communicated clearly:
- Patients should be properly informed on the side-effects of their cancer treatments beyond the most common ones. While these treatments are potentially life-saving and should be recommended, it is important for women to know what might be the consequences on their mental health in order to be prepared in the best possible way – and with the support of health professionals.
- Not all patients are aware of the fact that such preparation and active fighting against depressive symptoms correlates with better outcomes of their cancer therapies. Supporting women with depression means improving their chances of surviving and healing. In other words, being hopeful and positive as a patient tends to make the prognosis is better.
- Women overall (not just patients) should be aware that their female gender is a specific risk factor for mental disease and cognitive decline. This should be included in a thorough discussion of breast cancer treatment and early menopause as side effect of cancer treatment.
- The medical community should consider and address these specific types of depression and cognitive decline (and we’re not even talking about chemo-brain – chemo- and radiotherapy induced fatigue that causes increased forgetfulness and an inability to concentrate in patients, which may persist and is an independent side effect of antitumor therapy).
At the moment, patients are largely under-diagnosed and undertreated. This is compounded by the fact that, as mentioned, most antidepressants cannot be used in tamoxifen-treated patients.
The Women’s Brain Project will continue to bring sex-specific issues in mental health to the global agenda and increase awareness to ensure that women are empowered with up-to-date medical information, and to advocate for adequate treatment.
[Featured image courtesy of Pixabay.]