PTSD symptoms as a consequence of breast cancer diagnosis: Clinical implications

Abstract

It is a well-established multidisciplinary practice at the European Institute of Oncology, that nurses and physicians often report their difficulties to clinical psychologists regarding adherence to hospital scheduling and procedures, when faced with women who, having been diagnosed with cancer, may be too overwhelmed to understand medical advice. We thus undertook an observational-prospective-cohort study, to investigate the prevalence and variation of PTSD symptomatology in women awaiting a mastectomy at a mean of 30 days after diagnosis and up to 2 years after discharge from hospital. The presence of any correlations between PTSD symptoms and medical and psycho-social variables was also investigated. Between March 2011 and June 2012, 150 women entered the study and were evaluated at four points in time: pre-hospital admission, admission for surgery, hospital discharge and two years later. The prevalence of distress at pre-hospital admission was 20% for intrusion symptoms, 19.1% for avoidance symptoms and 70.7% for state anxiety. Intrusion was negatively correlated with time from diagnosis independently of tumor dimensions, i.e. independently of the perceived seriousness of the illness. Even though at two-year follow up the prevalence of intrusion and avoidance is similar to that in the general population, patients with high levels of intrusion and avoidance at pre-hospital admission will maintain these levels, showing difficulties in adjusting to illness even two years later. As for psycho-social factors, the presence of a positive cancer family and relational history is associated with high levels of distress, in particular with intrusive thinking. Proper interventions aimed at the management of these issues and at their implications in clinical practice is clearly warranted.

Full text

R E S E A R C H Open Access
PTSD symptoms as a consequence of breast
cancer diagnosis: clinical implications
Paola Arnaboldi
1*
, Claudio Lucchiari
1,4
, Luigi Santoro
2
, Claudia Sangalli
3
, Alberto Luini
3
and Gabriella Pravettoni
1,4
Abstract
It is a well-established multidisciplinary practice at the European Institute of Oncology, that nurses and physicians
often report their difficulties to clinical psychologists regarding adherence to hospital scheduling and procedures,
when faced with women who, having been diagnosed with cancer, may be too overwhelmed to understand
medical advice. We thus undertook an observational-prospective-cohort study, to investigate the prevalence and
variation of PTSD symptomatology in women awaiting a mastectomy at a mean of 30 days after diagnosis and up
to 2 years after discharge from hospital. The presence of any correlations between PTSD symptoms and medical
and psycho-social variables was also investigated. Between March 2011 and June 2012, 150 women entered the
study and were evaluated at four points in time: pre-hospital admission, admission for surgery, hospital discharge
and two years later. The prevalence of distress at pre-hospital admission was 20% for intrusion symptoms, 19.1% for
avoidance symptoms and 70.7% for state anxiety. Intrusion was negatively correlated with time from diagnosis
independently of tumor dimensions, i.e. independently of the perceived seriousness of the illness. Even though at
two-year follow up the prevalence of intrusion and avoidance is similar to that in the general population, patients
with high levels of intrusion and avoidance at pre-hospital admission will maintain these levels, showing difficulties
in adjusting to illness even two years later. As for psycho-social factors, the presence of a positive cancer family and
relational history is associated with high levels of distress, in particular with intrusive thinking. Proper interventions
aimed at the management of these issues and at their implications in clinical practice is clearly warranted.
Keywords: Newly diagnosed breast cancer patients; Patient healthcare professional relationship; PTSD symptoms;
Patient management; Cancer familial history
Background
Nowadays, the psychological consequences of a cancer
diagnosis are well-recognized worldwide. A consensus is
yet to be reached upon the most suitable approach to
handle such consequences in order to deliver high qual-
ity, multidisciplinary care.
Regarding the epidemiological aspects, in one study
carried out at a Comprehensive Cancer Center, involving
nearly 4500 patients aged 19 and older, the prevalence of
significant psychological distress ranged from 29 percent
to 43 percent for patients with the 14 most common
types of cancer (Zabora et al. (2001). Other studies have
reported high rates of psychological symptoms, meeting
criteria for such clinical diagnoses as depression, adjustment
disorders and anxiety (Carlsen et al. 2005; Hegel et al. 2006).
From one recent meta-analysis by Mitchell et al. (2011),
it emerged that 20-25% of cancer patients have clinically
significant levels of depression, anxiety and adjustment
disorders that interfere with treatment outcomes.
In 1994, the American Psychiatric Association (APA)
recognized diagnosis with a life-threatening illness, such
as cancer, as a traumatic stressor that could precipitate an-
other psychological syndrome: the post-traumatic stress
disorder (PTSD) (American Psychiatric Association 1994).
Research has shown that such a syndrome appeared to
be a better model for conceptualizing distress in patients
with cancer than did a generalized “distress”model
(Rustad et al. 2012).
TheDiagnosticandStatisticManualofMentalDis-
orders - V edition (American Psychiatric Association
2013) includes PTSD in a new chapter on trauma and
stress-related disorders: PTSD, regardless of its trigger
* Correspondence: paola.arnaboldi@ieo.it
1
Applied Research Unit for Cognitive and Psychological Science, European
Institute of Oncology, Via Ripamonti, 435, 20141 Milan, Italy
Full list of author information is available at the end of the article
a SpringerOpen Journal
© 2014 Arnaboldi et al.; licensee Springer. This is an Open Access article distributed under the terms of the Creative Commons
Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction
in any medium, provided the original work is properly credited.
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event, is characterized by clinically significant distress
or impairment in the individual’s social interactions,
ability to work, or in other key areas of functioning.
Symptoms that accompany PTSD now fall into four
distinct diagnostic clusters, instead of three (American
Psychiatric Association 1994): re-experiencing, avoidance,
negative cognitions and mood, and arousal.
Re-experiencing covers spontaneous memories of the
traumatic event, flashbacks or other intense memories,
or prolonged psychological distress. Avoidance refers to dis-
tressing memories, thoughts, feelings or external reminders
of the event. Negative cognitions and mood represent feel-
ings ranging from a persistent and distorted sense of blame
of self or others, estrangement from others or markedly
diminished interest in activities, to an inability to remember
key aspects of the event. Finally, arousal is marked by
aggressive, reckless or self-destructive behavior, sleep
disturbances, hyper-vigilance or related problems.
It emerges from the literature that up to 19% of adults
receiving a cancer diagnosis present a PTSD-like syn-
drome when assessed using the symptom cluster method
(Kwekkeboom and Seng 2002; Elklit 2002; Kwakkenbos
et al. 2014). According to the literature, predictors of PTSD
symptomatology in cancer patients include psychological
disturbances prior to cancer diagnosis, elevated psycho-
logical distress subsequent to diagnosis, younger age, female
gender, lower socioeconomic status, poor social functioning
and support, and avoidant coping style (Kangas et al. 2005;
Mehnert and Koch 2007). Chronic PTSD is associated with
higher risk for physical morbidity (Buckley et al. 2004) and
can also lead to nonadherence with medical treatment,
impacting local and distant recurrences (Ma et al. 2008). In
this regard, Jacobsen and colleagues state that the presence
of PTSD symptoms can explain “non-compliant”patients’
behavior (Jacobsen et al. 1998). Early detection of PTSD
symptoms can therefore help both psychological health and
medical prognosis. In particular, avoidant reactions seem to
be more associated with poorer physical health while intru-
sive reactions seem to be related to poorer psychological
health (Lutgendorf et al. 2012). Avoidant individuals are less
likely to seek support, to complain about physical symp-
toms and, thus, to be compliant with the process of care
(Ciechanowski et al. 2002). Detecting the presence of such
symptoms as early as possible in the patient’s clinical path-
way can have important advantages on clinical outcomes
and allows one to understand where psychological inter-
vention is most needed. It could be that the accumulation
of the perceived traumatic events is related to the preva-
lence of PTSD (O’Connor et al. 2011). In the study by
O’Connor, breast cancer patients were evaluated for PTSD
symptoms at 3 and 15 months after surgery but the time of
diagnosis is undoubtedly also a very sensitive moment.
It is interesting in this regard, that the study by Mundy
and colleagues (Mundy and Baum 2004) found no current
PTSD in the sample of breast cancer survivors, yet 35% of
the sample was diagnosed with lifetime PTSD. This could
be due to the fact that, at the time of the study, partici-
pants were at least 100 days post-treatment.
Luecken et al. (2004) assessed the prevalence of PTSD
within six months after diagnosis in a sample of 71 women.
Only 3% of the sample met the criteria for PTSD due to
breast cancer.
Tothebestofourknowledge,thereisnoevidencefrom
the literature of studies in which psychological distress and
PTSD symptoms have been assessed within the first month
from the very moment of diagnosis. This represents a fruit-
ful area of investigation from a health care perspective.
At the European Institute of Oncology (IEO), newly-
diagnosed breast cancer patients can await surgery for
1 to 4 weeks from the time of diagnosis. This is a very
difficult period to cope with and it is characterized by
fears, anguish and anxiety.
Nurses and physicians at the IEO are regularly faced
with newly-diagnosed women who may be too confused
and overwhelmed to understand medical advice, rendering
them indecisive at a time when their participation in the
process of care is clearly warranted. In accordance with
well-established IEO practice, the healthcare professional
will often report their difficulties to clinical psychologists
regarding the need to adhere to hospital scheduling
and procedures. Furthermore, healthcare professionals
commonly tend to evaluate the impact that cancer has
on a patient's psychological distress as being determined by
the severity of the cancer. In this regard, tumor dimension
at diagnosis could be considered determinant.
We hypothesized that the presence of PTSD symptoms
at the very time of breast cancer diagnosis could be respon-
sible for difficult future adjustment throughout the process
of care and also for poor psychological outcomes.
In this context, our primary purposes were:
–To evaluate the incidence of PTSD symptoms a
mean of 30 days after diagnosis
–To evaluate how PTSD symptoms change over time,
from diagnosis to hospital discharge after
mastectomy until two-year follow up
Our secondary outcomes were:
–To evaluate correlations between sample
socio-demographic characteristics
–To evaluate correlations between perceived emotional
support and psychological distress over time
Results
Sample
Between March 2011 and June 2012, 150 women entered
the study. Of these, 83 completed the 2 year follow-up
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while 67 did not complete follow-up. In both groups there
were 26 patients who did not complete the questionnaire
at the T2 time-point.
Failure to complete T2 was mostly due to organizational
aspects (such as early hospital discharge, other medical
procedures).
The median age of the sample was 47 years [30–81]
(see Table 1). As regards civil status, 30% were single, di-
vorced or widowed, while 70% were married or cohabit-
ant. Twenty-nine percent had a lower secondary school
education while 71% an upper secondary school educa-
tion. A total of 26% came from the Lombardy region
while 74% from outside Lombardy. Altogether, 83.3% of
the sample had a relative or a significant other who had
suffered from cancer. Regarding tumor dimension, 44%
(n = 66) had T2, 32% (n = 48) had T1, 1.3 (n = 2) had T0,
while for 22.7% (n = 34) the data was missing. When
women were asked if they had suffered or were suffering
from a psychological disturbance, 20% (n = 30) answered
affirmatively (see Table 2).
At baseline, the median time elapsed from diagnosis
was 30 days (n = 150) while the median time that women
had to wait from pre-hospital admission to operation
(n = 114) was 14 days.
Emerging issues
Theprevalenceofdistressatpre-hospitaladmission,
approximately 30 days after diagnosis, was 20% for in-
trusion symptoms, 19.1% for avoidance symptoms and
70.7% for state anxiety (Table 3).
Anxiety levels and PTSD symptoms varied over time,
from pre-hospital admission to 2-year follow up: 70% of
patients had clinically significant anxiety at the very time of
diagnosis, 76.4% at the moment of pre-hospital admission,
and 54.9% at the 2-year follow-up. In particular, a statistical
association emerged between avoidance scores at baseline
and avoidance scores at two-year follow up.
Among the 83 patients with both pre-hospital admis-
sion and 2-year follow-up data, the number of patients
with clinically significant state anxiety (>39) significantly
reduces over time (p-value =0.002; Table 4).
The number of patients with clinically significant in-
trusion (> = 27) showed a similar statistically significant
reduction (p = 0.01) from 20% (17/83) to 7.2% (6/83),
while the number of patients with avoidance reduction
(from > =18 to <18) did not counterbalance those who
showed avoidance worsening (from <18 to > =18 over time),
therefore providing a not statistically significant result
(p=0.13,Table5).
However the mean difference of avoidance (+1.9) from
pre-hospital admission (13.3) to 2-year follow up (11.4) re-
sulted statistically significant different from zero (p < 0.0001).
Intrusion is negatively correlated with time from diagno-
sis irrespective of tumor dimensions (p = 0.84) and number
of children (p = 0.22). As to psycho-social factors, the pres-
ence of a family history seems to be associated (p = 0.07)
with higher levels of intrusive thinking over time (+3.4),
Table 1 Socio-demographic characteristics
Variables N %
Age (years)
<40 24 16.0
40-49 68 45.3
50-59 33 22.0
60-69 15 10.0
≥70 10 6.7
Age (continuous)
Mean (sd) 49.2 ± 10.9
Median (min –max) 47 (30–81)
Civil status
Unmarried 23 15.3
Cohabitant 9 6.0
Married 96 64.0
Divorced 15 10.0
Widow 7 4.7
Children
Yes 111 74.0
No 39 26.0
Education
Elementary 10 6.7
Secondary 33 22.0
High 74 49.3
Degree 33 22.0
Geographic area/1
Lombardy/out of Lombardy 26.0 74.0
Table 2 Clinical issues
Variables N %
Tumour size as referred by the patient
T0 2 1.3
T1 48 32.0
T2 66 44.0
Unknown 34 22.7
Psychological treatments
Yes 12 8.0
No 138 92.0
Family history for tumour
Yes 125 83.3
No 25 16.7
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while just a negligible change is observed in the subgroup
of patients with no familiar history (+0.6) (Table 5).
Conversely, tumor dimension, number of children and
family history, does not affect avoidance and anxiety
change over time (Table 6).
One can say that cancer diagnosis was responsible for
causing psychological distress in patients independently
of medical factors such as tumor dimension.
It is important to note that taking into consideration
the relationship between the dropout behavior and avoi-
dant symptoms, patients who completed all four assess-
ment sessions had a lower probability of presenting
clinically relevant avoidant scores (see Table 7).
A total of 95% of patients judged the socio-familiar
support received at the time of pre-hospital admission as
optimal or nearly optimal. We did not find any correlations
between this value and psychological distress.
Discussion
Results from this study are consistent with other published
results that show an incidence of PTSD symptoms of
around 20% in newly-diagnosed cancer patients (Mundy
and Baum 2004; Mehnert and Koch 2007; Mitchell et al.
2011; O’Connor et al. 2011; Rustad et al. 2012), which is
very far from the prevalence rate in the general population
(Pietrzak et al. 2011).
Even if psychological distress tends to diminish over
time, patients with high levels of intrusion and avoidance
at diagnosis tend to maintain those levels even at two
years after diagnosis. This could cause difficulties in the
Table 3 Intrusion, avoidance and anxiety over time, as continuous variables (all available data)
Variables Time p-value
*
Before admission At admission At discharge 2-year follow-up
IES questionnaire N = 150 N = 114 N = 98 N = 83
Intrusion
Mean (sd) 22.1 (5.1) 20.8 (5.4) 20.5 (6.4) 19.4 (4.4)
Median (min-max) 22 (10–35) 21.5 (9–35) 20 (9–39) 20 (9–31) 0.001
Avoidance
Mean (sd) 13.8 (4.3) 13.5 (4.9) 12.7 (5.0) 11.4 (4.1)
Median (min-max) 14 (6–24) 13 (6–26) 12 (6–24) 11 (6–23) 0.0008
STAI questionnaire N = 150 N = 110 N = 97 N = 82
Anxiety
Mean (sd) 47.0 (12.0) 48.5 (12.0) 41.4 (11.1) 43.1 (12.0)
Median (min-max) 45.5 (20–77) 47.5 (22–77) 41.0 (21–76) 42.0 (22–77) <0.0001
*
Kruskal-Wallis test.
Table 4 Intrusion, avoidance and anxiety: “2-year follow-up”vs. “before admission”(pre and post data) continuous
variables
Before admission (A) 2-year follow-up (B) Difference (A) –(B) p-value#
IES questionnaire N = 83 N = 83 N = 83
n (%) n (%) n (%)
Intrusion
Mean (sd) 22.3 (4.7) 19.4 (4.4) 2.9 (5.2)
Median (min-max) 23 (11–33) 20 (9–31) 3 (−12, 16) <0.0001
Avoidance
Mean (sd) 13.3 (4.0) 11.4 (4.1) 1.9 (4.1)
Median (min-max) 13 (6–23) 11 (6–23) 2 (−9, 12) <0.0001
STAI questionnaire N = 82 N = 82 N = 82
n (%) n (%) n (%)
Anxiety
Mean (sd) 47.2 (11.7) 43.1 (12.0) 4.0 (11.4)
Median (min-max) 45.5 (20–73) 42.0 (22–77) 3.0 (−30, 36) 0.002
Continuous variables.
#t test.
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process of adjustment to illness thus warranting closer
attention in a preventive perspective, i.e. at the very be-
ginning of the process of care.
Contrary to the evidence presented in the literature
(Kangas et al. 2005 Mehnert and Koch 2007), among
psychosocial factors detected, only a relational and/or
family history of cancer is associated with distress: nei-
ther perceived social support, nor a supportive family
are inversely correlated. It seems that patient’smemory
can influence her ability to cope with cancer: memories
and recollections of cancer experiences of meaningful
others seem to overload the patients cognitive and
emotional field in an intrusive manner. Evidence of an
absence of association between levels of distress experienced
and the perceived illness seriousness as described by the
TNM tumor classification also points in this direction. In
other studies (Zabora et al. 2001; Palyo and Gayle 2006) it
emerges that PTSD symptoms are correlated with pain per-
ception and levels of fatigue underlining the importance of
the cognitive dimension (E.g. “which resources may I use?”)
also in modulating emotional functioning.
Conclusions
These results have important clinical implications:
physicians and surgeons should be made aware of the
high prevalence of post-traumatic stress symptoms in
their newly-diagnosed breast cancer patients and they,
therefore, should be helped in adapting their communi-
cation skills to these issues thorough continuing medical
education (CME) programs:CMEprogramscouldbe
viewed as offering systematic assistance in identifying
patients emerging needs. For example, the Memorial
Sloan Kettering Cancer Center runs an advanced commu-
nication training program integrated into the institution’s
regular practices and continuing medical education (CME)
(Bylund et al. 2011).
Our results underline the importance of a standard-
ized measurement of psychological distress being incor-
porated into the hospital routine with specific attention
paid to PTSD symptoms. When a patient shows shock,
confusion, carelessness, says she is unable to decide and
seems not to remember what physician has just told her,
this could be because she is suffering from PTSD symp-
tomatology and detailed attention is thus warranted.
Since 74% of our patients come from outside the
Lombardy region, at a considerable physical distance
from IEO, programs of care should be created to effect-
ively address psychological issues, for example in the form
of telephone or computer-based support delivery. The
Table 5 Intrusion, avoidance and anxiety: “2-year follow-up”
vs. “before admission”(pre and post data)
2-year follow-up p-value~
Intrusion (N = 83)
Before admission <27 > = 27
<27 62 4
0.01
> = 27 15 2
Avoidance (N = 83)
Before admission <18 > = 18
<18 68 3
0.13
>=18 8 4
Anxiety (N = 82)
Before admission <=39 >39
<=39 13 7
0.002
>39 24 38
Categorical variables
~McNemar test.
Table 6 Intrusion, avoidance and anxiety: difference “2-year follow-up”vs. “before admission”
IES questionnaire (N = 83) STAI questionnaire (N = 82)
N Intrusion p-value# Avoidance p-value# N Anxiety p-value#
Children [mean, (sd)]
Yes 65 3.3 (5.4) 1.7 (4.1) 65 4.3 (11.6)
No 18 1.6 (4.6) 0.22 2.4 (4.0) 0.53 17 3.1 (11.1) 0.69
Family history [mean, (sd)]
Yes 69 3.4 (5.0) 2.0 (4.3) 68 4.7 (10.8)
No 14 0.6 (6.0) 0.07 1.3 (2.9) 0.54 14 0.8 (14.0) 0.25
T [mean, (sd)]
T0-T1 30 3.2 (5.7) 1.9 (4.7) 29 2.6 (13.1)
T2 32 3.4 (5.0) 0.84* 1.4 (4.0) 0.66* 32 4.6 (10.2) 0.50*
Unknown 21 1.9 (4.9) 2.8 (3.2) 21 5.2 (11.1)
Subgroup Analysis
#
t test.
*
comparing T0-T1 vs T2.
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telephone-based support or information delivery has
proved to be beneficial with either patients and relatives
in different illness phases (Arnaboldi et al. 2010).
Our study has limits, principally due to the sample size.
Furthermore, the dropout rates do not allow us to readily
generalize from the results. Nonetheless, our data strongly
suggest the need to thoroughly investigate the impact of
PTSD symptoms on clinical outcomes in early-diagnosed
cancer patients.
In conclusion, we would like to emphasize the import-
ance of a patient-centered approach, which fully takes into
account psycho-social and cognitive issues (Lucchiari et al.
2010) as being the most suitable way to improve physicians’
abilities to respond to patients clinical needs.
Methods
We proposed participation in a study to newly-diagnosed
breast cancer patients awaiting mastectomy. It was ex-
plained to them that its aim was to monitor their emotional
state and their psychological reactions to diagnosis in order
to promote better care strategies.
PTSD intrusion and avoidance symptoms and state
anxiety were measured by means of the Impact of Event
Scale (IES) (Horowitz et al. 1979) and of the State–Trait
Anxiety Inventory (STAI) (Spielberger 1989) at four points
in time: pre-hospital admission T0 (a mean time of 33 days
after diagnosis), surgical admission (T1), discharge from
hospital (T2) and two years later (T3).
Nurses receiving patients in outpatient appointments
with the surgeon, who had communicated to them their
cancer diagnosis and the indication for a mastectomy
procedure, asked patients if they were interested in
meeting a research psychologist that would present them
the study and ask for their written informed consent.
In the case of the patient’s acceptance, the nurse asked
for the patients name and surname and for a telephone
number on which the research psychologist could contact
them. Psychologists contacted the patients and arranged an
interview for the scheduled day of pre-hospital admission.
To enter the study, patients had to be aged 18, at their
first cancer diagnosis, having received an indication for a
mastectomy procedure and be Italian mother tongue.
Women with a medical history of major psychological
disorders were excluded as were women with an indication
for pre-surgery neoadjuvant treatment. The study was
approved by the IEO scientific committee and to guar-
antee anonymity and secrecy, once enrolled, women were
assigned with a progressive number.
At pre-hospital admission (T0), which represented our
baseline, women were asked to provide socio-demographic
information and also to report their perceived emotional
support in relation to their cancer experience by means
of a 0–10 visual-analogue scale, the presence of signifi-
cant others (not only relatives) who have had a cancer
diagnosis and the presence of previous or current emo-
tional disorders.
Women were also asked to recall the day they received
their cancer diagnosis and the tumor dimension according
to the TNM classification of breast cancer, as described in
their medical chart. Secondly, they were asked to complete
the two questionnaires: IES and STAI. The same question-
naires were then administered to women when they en-
tered hospital for surgery and on the day of discharge.
Psychologists and nurses coordinated themselves in or-
ganizing, together with patients, appointments to complete
the questionnaires on the day of admission and discharge,
so as to fit in with the scheduling requirements for medica-
tions, check-ups, post-surgery physiotherapy etc.
Approximately two years after hospital discharge, a
psychologist contacted by telephone, all women who had
initially agreed to participate in the study and conducted
a telephone interview with those available. At that time,
PTSD symptoms and state anxiety were again assessed,
together with perceived emotional support. The psych-
ologist tried to contact each of the enrolled women three
times to propose this two-year follow-up telephone inter-
view. After the fourth failed contact, the patient was consid-
ered non-respondent.
Statistical analysis
Descriptive statistics were used to characterize the
sample with regard to socio-demographic, tumor and
clinical characteristics. Categorical data were expressed
as numbers and percentages, while continuous data
Table 7 Drop-out “behavior”over time according to AVOIDANCE value at baseline (categorical)
Variables Drop-out “behavior”over time p-value
No 2-year follow-up 2-year follow-up
Dropout before
discharge
NO Dropout before
discharge
Dropout before
discharge
NO Dropout
before discharge
N = 26 N = 41 N = 26 N = 57
n (%) n (%) n (%) n (%)
Avoidance at baseline
> = 18 6 (23.1) 11 (26.8) 8 (30.8) 4 (7.2) 0.02
*
*
chi-square test.
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were presented as mean and standard deviation, median
and range.
Pearson’s chi-square for categorical variables and the
Kruskal-Wallis test were used when evaluating avoid-
ance, intrusion and anxiety over the four time-points, as
both categorical and continuous variables. Differences at
2-year vs baseline were evaluated by the t-test for paired
data when the variables were measured on continuous
scale, and by the McNemar test when a cut-off was used
to dichotomize the variable.
All the analyses were performed with SAS statistical
software (SAS Institute, Cary, NC), Version 9.02.
Competing interests
None of the authors has any competing interest related to this manuscript.
Authors’contributions
AP: participated in the design of the study, collected data, drafted the
manuscript, interpreted the data. LC: participated in the design of the study,
drafted the manuscript, coordinated activities, interpreted the data. SL:
participated in the design of the study and performed the statistical analysis,
drafted the manuscript. SC: participated in the data set and data
management, drafted the manuscript. LA: participated in the design of the
study, drafted the manuscript, interpreted the data. PG: conceived of the
study, coordinated activities, revised the manuscript. All authors read and
approved the final manuscript.
Acknowledgements
Many thanks to William Russell-Edu for his kind assistance in reviewing the
English text.
Author details
1
Applied Research Unit for Cognitive and Psychological Science, European
Institute of Oncology, Via Ripamonti, 435, 20141 Milan, Italy.
2
Department of
Epidemiology and Biostatistics, European Institute of Oncology, Via
Ripamonti, 435, 20141 Milan, Italy.
3
Division of Senology, Data Management,
European Institute of Oncology, Via Ripamonti, 435, 20141 Milan, Italy.
4
Department of Health Sciences, University of Milan, Via A. di Rudinì, 8, 20142
Milano, Italy.
Received: 11 July 2014 Accepted: 15 July 2014
Published: 29 July 2014
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Cite this article as: Arnaboldi et al.:PTSD symptoms as a consequence
of breast cancer diagnosis: clinical implications. SpringerPlus 2014 3:392.
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