Prevalence and Management Of Preoperative Depression and Anxiety Disorders In Patients Undergoing Mastectomy Reconstruction

Objective:

Although 20-40% of newly diagnosed cancer patients report significant levels of psychological and emotional distress, fewer than 10% are routinely screened for these problems using evidence-based measures.(1)(2)  Starting in 2015, the American College of Surgeons Commission on Cancer will require that accredited cancer centers screen all patients for distress and offer appropriate support services.(3)  As part of a multi-center prospective outcome study, we sought to identify the prevalence of depression and anxiety disorders in patients undergoing post-mastectomy breast reconstruction and to develop a response system for at-risk patients.   

Methods:

The Mastectomy Reconstruction Outcomes Consortium Study is an NCI-funded, 11 center prospective outcome study comparing the results of common techniques of mastectomy reconstruction.  Patients undergoing first-time, immediate or delayed breast reconstruction are eligible and are administered a panel of validated surveys pre- and post-operatively.  The surveys include the Patient Health Questionnaire (PHQ-9), a widely used depression assessment, and the Generalized Anxiety Disorder (GAD-7) Scale.  Preoperative rates of depression and anxiety disorders were calculated using the global scores of the two instruments. 

Results:

To date, 1841 patients are enrolled in the study.  Preoperatively, the PHQ-9 has been completed by 1417 patients and the GAD-7 by 1455.  Overall, 92.5% of study patients received immediate reconstruction.  Expander-implant procedures were performed in 64.1% and autogenous tissue procedures in 35.9% of patients.  On the PHQ-9, 15.9% of patients indicated moderate to severe depression.  Seventeen percent reported moderate to severe anxiety on the GAD-9.  In our most concerning finding, 14 patients indicated significant suicidal ideation on the PHQ-9.  Although our study is observational, we recognized a responsibility to protect at-risk study patients: Each of the study sites has implemented an IRB-approved protocol in which patients reporting suicidal ideation are automatically identified in the database and are immediately contacted for psychological support services. 

Conclusions:

Our findings confirm the high prevalence of psychological distress reported by previous studies in other cancer populations.  Rates of depression and anxiety disorders observed in our study far exceed those of the general adult population (6.7% and 3.1%, respectively).  Based on these findings, we recommend that providers (including plastic surgeons) implement protocols to screen new breast cancer patients for these issues and that psychological support services be readily available as part of routine care.