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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.
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R E S E A R C H Open Access
PTSD symptoms as a consequence of breast
cancer diagnosis: clinical implications
Paola Arnaboldi
, Claudio Lucchiari
, Luigi Santoro
, Claudia Sangalli
, Alberto Luini
and Gabriella Pravettoni
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
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 distressmodel
(Rustad et al. 2012).
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:
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 (, which permits unrestricted use, distribution, and reproduction
in any medium, provided the original work is properly credited.
Arnaboldi et al. SpringerPlus 2014, 3:392
event, is characterized by clinically significant distress
or impairment in the individuals 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-compliantpatients
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 patients 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 (OConnor et al. 2011). In the study by
OConnor, 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.
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
Between March 2011 and June 2012, 150 women entered
the study. Of these, 83 completed the 2 year follow-up
Arnaboldi et al. SpringerPlus 2014, 3:392 Page 2 of 7
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
The median age of the sample was 47 years [3081]
(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
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
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 (3081)
Civil status
Unmarried 23 15.3
Cohabitant 9 6.0
Married 96 64.0
Divorced 15 10.0
Widow 7 4.7
Yes 111 74.0
No 39 26.0
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
Arnaboldi et al. SpringerPlus 2014, 3:392 Page 3 of 7
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.
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; OConnor 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
Mean (sd) 22.1 (5.1) 20.8 (5.4) 20.5 (6.4) 19.4 (4.4)
Median (min-max) 22 (1035) 21.5 (935) 20 (939) 20 (931) 0.001
Mean (sd) 13.8 (4.3) 13.5 (4.9) 12.7 (5.0) 11.4 (4.1)
Median (min-max) 14 (624) 13 (626) 12 (624) 11 (623) 0.0008
STAI questionnaire N = 150 N = 110 N = 97 N = 82
Mean (sd) 47.0 (12.0) 48.5 (12.0) 41.4 (11.1) 43.1 (12.0)
Median (min-max) 45.5 (2077) 47.5 (2277) 41.0 (2176) 42.0 (2277) <0.0001
Kruskal-Wallis test.
Table 4 Intrusion, avoidance and anxiety: 2-year follow-upvs. before admission(pre and post data) continuous
Before admission (A) 2-year follow-up (B) Difference (A) (B) p-value#
IES questionnaire N = 83 N = 83 N = 83
n (%) n (%) n (%)
Mean (sd) 22.3 (4.7) 19.4 (4.4) 2.9 (5.2)
Median (min-max) 23 (1133) 20 (931) 3 (12, 16) <0.0001
Mean (sd) 13.3 (4.0) 11.4 (4.1) 1.9 (4.1)
Median (min-max) 13 (623) 11 (623) 2 (9, 12) <0.0001
STAI questionnaire N = 82 N = 82 N = 82
n (%) n (%) n (%)
Mean (sd) 47.2 (11.7) 43.1 (12.0) 4.0 (11.4)
Median (min-max) 45.5 (2073) 42.0 (2277) 3.0 (30, 36) 0.002
Continuous variables.
#t test.
Arnaboldi et al. SpringerPlus 2014, 3:392 Page 4 of 7
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 patientsmemory
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.
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 institutions
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
> = 27 15 2
Avoidance (N = 83)
Before admission <18 > = 18
<18 68 3
>=18 8 4
Anxiety (N = 82)
Before admission <=39 >39
<=39 13 7
>39 24 38
Categorical variables
~McNemar test.
Table 6 Intrusion, avoidance and anxiety: difference 2-year follow-upvs. 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.
Arnaboldi et al. SpringerPlus 2014, 3:392 Page 5 of 7
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.
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 StateTrait
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 patients 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 010 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 behaviorover time according to AVOIDANCE value at baseline (categorical)
Variables Drop-out behaviorover time p-value
No 2-year follow-up 2-year follow-up
Dropout before
NO Dropout before
Dropout before
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.
Arnaboldi et al. SpringerPlus 2014, 3:392 Page 6 of 7
were presented as mean and standard deviation, median
and range.
Pearsons 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.
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.
Many thanks to William Russell-Edu for his kind assistance in reviewing the
English text.
Author details
Applied Research Unit for Cognitive and Psychological Science, European
Institute of Oncology, Via Ripamonti, 435, 20141 Milan, Italy.
Department of
Epidemiology and Biostatistics, European Institute of Oncology, Via
Ripamonti, 435, 20141 Milan, Italy.
Division of Senology, Data Management,
European Institute of Oncology, Via Ripamonti, 435, 20141 Milan, Italy.
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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Arnaboldi et al. SpringerPlus 2014, 3:392 Page 7 of 7
... Seven studies were included in the PTSD symptom category. Three studies using the Impact of Event Scale to measure PTSD symptoms provided Intrusion and Avoidance scores separately [30][31][32], so we computed the mean number of clinical cases for the study and used that number in the meta-analysis. Results from the random-effect model showed that 31.4% (95% CI = [14.6, ...
Receiving a breast cancer diagnosis can be a turning point with negative impacts on mental health, treatment and prognosis. This meta-analysis sought to determine the nature and prevalence of clinically significant psychological distress-related symptoms in the wake of a breast cancer diagnosis. Ten databases were searched between March and August 2020. Thirty-nine quantitative studies were meta-analysed. The prevalence of clinically significant symptoms was 39% for non-specific distress (n = 13), 34% for anxiety (n = 19), 31% for post-traumatic stress (n = 7) and 20% for depression (n = 25). No studies reporting breast cancer patients’ well-being in our specific time frame were found. Mental health can be impacted in at least four domains following a diagnosis of breast cancer and such effects are commonplace. This study outlines a clear need for mitigating the impacts on mental health brought about by breast cancer diagnosis. CRD42020203990.
... Mounting evidence suggests that a history of psychological morbidity is associated with the risk of severe mental stress after cancer diagnosis [10,16,17]. Resilience or adaptive coping styles have also been associated with more adaptive responses after cancer diagnosis [18], while divergent results have been obtained regarding the role of social support in stress levels after a diagnosis of cancer [18][19][20][21]. ...
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Purpose The aim of this study was to assess the role of the patient’s background and perceived healthcare-related factors in symptoms of acute stress after lung cancer diagnosis. Methods The study population consisted of 89 individuals referred for diagnostic work-up at Landspitali National University Hospital in Iceland and subsequently diagnosed with lung cancer. Before diagnosis, the patients completed questionnaires on sociodemographic characteristics, pre-diagnostic distress (Hospital Anxiety and Depression Scale), social support, and resilience. At a median of 16 days after diagnosis, the patients reported symptoms of acute stress on the Impact of Event Scale-Revised (IES-R) and experience of communication and support from healthcare professionals and family during the diagnostic period. Results Patients were on average 68 years and 52% reported high levels of post-diagnostic acute stress (IES-R > 23) while 24% reported symptoms suggestive of clinical significance (IES-R > 32). Prior history of cancer (β = 6.7, 95% CI: 0.1 to 13.3) and pre-diagnostic distress were associated with higher levels of post-diagnostic acute stress (β = 8.8, 95% CI: 2.7 to 14.9), while high educational level (β = − 7.9, 95% CI: − 14.8 to − 1.1) was associated with lower levels. Controlling for the abovementioned factors, the patients’ perception of optimal doctor-patient (β = − 9.1, 95% CI: − 14.9 to − 3.3) and family communication (β = − 8.6, 95% CI: − 14.3 to − 2.9) was inversely associated with levels of post-diagnostic acute stress after lung cancer diagnosis. Conclusions A high proportion of patients with newly diagnosed lung cancer experience high levels of acute traumatic stress of potential clinical significance. Efforts to improve doctor-patient and family communication may mitigate the risk of these adverse symptoms.
... S. Swartzman, atlikęs 11 PTSS paplitimo tyrimų analizę padarė išvadą, kad krūties vėžiu sergančios pacientės dažniau patiria šį sutrikimą, nei turintieji kaklo ir galvos, priešinės liaukos ar tiesiosios žarnos navikus, tačiau rečiau, nei sergantieji galvos smegenų, kraujo ar gimdos vėžiu [8]. Įvairių tyrimų duomenimis, PTSS paplitimas tarp krūties vėžio pacienčių svyruoja nuo 5 iki 32,3 procento [14][15][16][17][18][19][20]. ...
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Krūties vėžio diagnozę sužinojusios moterys patiria stiprų sukrėtimą, kuris gali paveikti daugelį gyvenimo sričių ir stipriai sutrikdyti pacienčių adaptaciją. Krūties vėžiu sergančių pacienčių potrauminio streso sutrikimo rizika yra didesnė, nei bendrojoje populiacijoje. Tyrimo tikslas – įvertinti sociodemografinių ir klinikinių veiksnių įtaką potrauminio streso sutrikimo rizikai prieš krūties operaciją ir praėjus vieneriems metams po jos. Tyrimo rezultatai parodė, kad krūties vėžiu sergančių pacienčių potrauminio streso sutrikimo rizika per metus statistiškai reikšmingai sumažėjo. Potrauminio streso sutrikimo riziką praėjus vieneriems metams po operacijos didina gyvenimas santuokoje arba partnerystėje ir aukštesnis išsilavinimas. Apmokamas darbas kelia potrauminio streso sutrikimo riziką prieš operaciją, bet apsaugo nuo šios rizikos praėjus vieneriems metams po operacijos. Trumpas laiko tarpas po naviko nustatymo didina potrauminio streso sutrikimo riziką. Krūtį tausojanti operacija, praėjus vieneriems metams po jos, kelia potrauminio streso sutrikimo riziką. Teikiant sveikatos priežiūros paslaugas krūties vėžiu sergančioms pacientėms, tikslinga atkreipti dėmesį į jų psichologines problemas ir poreikius ankstyvajame (prieš operaciją) ir vėlyvajame (praėjus vieneriems metams) sveikatos priežiūros paslaugų teikimo etape. Svarbu į pacienčių sveikatos priežiūros procesą kryptingai įtraukti jų šeimos narius ir artimuosius, taip siekiant sustiprinti pagalbą bei paramą iš artimiausios pacientei socialinės aplinkos.
... The intervention manual was piloted over multiple rounds of iterative development, application, and modification (e.g. NCT01960322, NCT02320422) [23][24][25][26] ; the focus on avoidance is based on extensive work showing that avoidance could lead to nonadherence, 23 is prevalent, 25,[27][28][29] and can be addressed effectively and safely in vulnerable patients. 23,30 To select patients with potential risk for nonadherence, we use the Medication Level Variability Index (MLVI), the standard deviation (SD) of consecutive outpatient immunosuppressant (tacrolimus) blood levels. ...
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Remote interventions are increasingly utilized in transplant medicine but have rarely been rigorously evaluated. We investigated a remote intervention targeting immunosuppressant management in pediatric lung transplant recipients. Patients were recruited from a larger multisite trial if they had a Medication Level Variability Index (MLVI) ≥ 2.0, indicating worrisome tacrolimus level fluctuation. The manualized intervention included 3 weekly phone calls and regular follow‐up calls. A comparison group included patients who met enrollment criteria after the sub‐protocol ended. Outcomes were defined before the intent‐to‐treat analysis. Feasibility was defined as ≥ 50% of participants completing the weekly calls. MLVI was compared pre‐ and 180 days post‐enrollment and between intervention and comparison groups. Of 18 eligible patients, 15 enrolled. Seven additional patients served as the comparison. Seventy‐five percent of participants completed ≥ 3 weekly calls; average time on protocol was 257.7 days. Average intervention group MLVI was significantly lower (indicating improved blood level stability) at 180 days post‐enrollment (2.9 ± 1.29) compared to pre‐enrollment (4.6 ± 2.10), p=0.02. At 180 days, MLVI decreased by 1.6 points in the intervention group, but increased by 0.6 in the comparison group (p=0.054). Participants successfully engaged in a long‐term remote intervention, and their medication blood levels stabilized. NCT02266888.
... For example, chemotherapy, surgery, radiotherapy could cause negative physical long-term side effects (such as vomiting, nausea, and heart failure) [3] (National Institute for Health and Clinical Excellence [NICE] 2009) and other undesirable appearance-related side effects that alter their perception of body image (such as hair loss, alopecia, skin discoloration) [4,5]. Additionally, the diagnosis and the treatment of cancer may lead to major psychological effects such as depression, emotional distress, fatigue, and poor well-being that affect several areas of life (e.g., family, work) [6][7][8]. Side effects can persist for a long time and greatly reduce patients' ability to "restart their life after cancer" [5,9]. Patients may experience difficulty returning to their everyday lives [10,11] and face specific health challenges even after treatment [12]. ...
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Psychological interventions are proposed to cancer survivors to support their quality of life against the emotional trauma of cancer and the side effects of treatment. Psychological interventions often require patient engagement and commitment to activities that could be more or less demanding in terms of lifestyle change (e.g., psychotherapy, sports). Analyzing participant motivations (personal aims, expectations, needs) prior to participation is useful to predict their adherence to the intervention as well as final outcomes. Yet, participant motivations may evolve during the intervention because the intervention experience turns out to be meaningful and positively challenging. The present study aimed to obtain a preliminary understanding of the process of motivation change in female cancer survivors who participated in a sport-based intervention to promote quality of life by employing a grounded theory approach. Data analysis took place alongside data collection and according to the procedure of grounded theory (“open coding”, “axial coding”, and “selective coding”) in order to describe the process of motivation change during women’s participation in psychological intervention for quality of life. On 14 women interviewed, 13 reported changing their motivation to participate during the first months of involvement, mostly changing from individualistic to group-related motivations (i.e., from self-care to friendship with other participants and enriching group membership), and from physical to psychological growth (i.e., pursuing not only physical health but also self-fulfillment). The discus-sion explains the preliminary aspects of the motivation change process and highlights the importance to monitor motivation dynamics within psychological interventions.
... all patients undergoing surgery for BC after naC should be counselled regarding the possible results and their impact on further treatment (further axillary surgery, radiation, etc.). 53,54 in centers where FS is performed, the timing of secondary surgery and the risk of negative intraoperative results and positive final pathological nodes should be also discussed. 55 ...
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Since its introduction nearly 30 years ago, sentinel lymph node biopsy (SLNB) has become the standard technique to stage the axilla for the great majority of patients with early breast cancer. While the accuracy of SLNB in clinically node-negative patients who undergo neoadjuvant chemotherapy (NAC) is similar to the upfront surgery setting, modifications of the technique to improve the false negative rate are necessary in node-positive patients at presentation. Currently, patients who present with matted nodes, cN1 patients who fail to downstage to cN0 with NAC and those with pathological residual disease have an indication to undergo axillary lymph node dissection. Ongoing trials will confirm if extensive nodal irradiation can replace surgery in patients with residual nodal disease after NAC and if nodal radiotherapy can be omitted in patients who achieve nodal pathological complete response. The aim of this review was to focus on the open questions on the management of the axilla after NAC.
... On top of that, preliminary studies on trauma during the COVID-19 pandemic suggested that HCWs may experience vicarious traumatization and emotional dissociation from what they are seeing and experiencing (Masiero et al., 2020): this may lead to PTSD if not timely managed. PTSD may have tremendous consequences and should be monitored not only in the patients' population (Arnaboldi et al., 2014) but also in the HCWs' one. ...
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Objective: The study aimed to investigate the mental health and emotional reaction of physicians working during phase 1 of the COVID-19 pandemic in Italy. Methods: A total of 458 Italian Health Care Workers (HCWs) working during phases 1 of the COVID-19 outbreak were voluntarily enlisted in the study and recruited with the snowball technique through an online survey. We examined our variables with the General Health Questionnaire - 12 and with Visual Analog Scales. Results: The sample has a high level of psychological distress 21.26 (SD = 4.46), the emotional reaction was characterized by high level of fear for family members and cohabitants (M = 77.67, SD = 27.16) and patients (M = 67.16, SD = 27.71). Perceived control, fear for patients, and for family members and cohabitants, feeling alone and anger all contribute to a decreased mental health in Italian physicians (R2 = 0.285, p < 0.001). Conclusion: Italian HCWs' mental health and emotional reaction have to be considered to prevent high risk of burnout and post-traumatic stress disorder (PTSD). It becomes pivotal in the next months to implement a tailored psychological intervention to take care of HCWs and to prevent costly consequences for them, patients, and the healthcare system.
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(243/250 words) Coronavirus disease 2019 (COVID-19) has affected more than 96 million people worldwide, leading the World Health Organization (WHO) to declare a pandemic in March 2020. Although an optimal medical treatment of COVID-19 remains uncertain, an unprecedented global effort to develop an effective vaccine hopes to restore pre-pandemic conditions. Since cancer patients as a group have been shown to be at higher risk of severe COVID-19, the development of safe and effective vaccines is crucial. However, cancer patients may be underrepresented in ongoing phase 3 randomized clinical trials investigating COVID-19 vaccines. Therefore, we encourage stakeholders to provide real-time data about the characteristics of recruited participants, including clearly identifiable subgroups, like cancer patients, with sample sizes large enough to determine safety and efficacy. Moreover, we envisage a prompt implementation of suitable registries for pharmacovigilance reporting, in order to monitor the effects of COVID-19 vaccines and immunization rates in patients with cancer. That said, data extrapolation from other vaccines trials (e.g. anti-influenza virus), showed a favorable safety and efficacy profile for cancer patients. On the basis of the evidence discussed, we believe that the benefits of the vaccination outweigh the risks. Consequently, healthcare authorities should prioritize vaccinations for cancer patients, with time-point of administration agreed on a case-by-case basis. In this regard, the American Society of Clinical Oncology and the European Society of Medical Oncology are advocating for cancer patients a high priority status, in the hope of attenuating the consequences of the pandemic in this particularly vulnerable population.
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Previous research has demonstrated relationships of social support with disease-related biomarkers in patients with ovarian cancer. However, the clinical relevance of these findings to patient outcomes has not been established. This prospective study examined how social support relates to long-term survival among consecutive patients with ovarian cancer. We focused on two types of social support: social attachment, a type of emotional social support reflecting connections with others, and instrumental social support reflecting the availability of tangible assistance. Patients were prospectively recruited during a presurgical clinic visit and completed surveys before surgery. One hundred sixty-eight patients with histologically confirmed epithelial ovarian cancer were observed from the date of surgery until death or December 2010. Clinical information was obtained from medical records. In a Cox regression model, adjusting for disease stage, grade, histology, residual disease, and age, greater social attachment was associated with a lower likelihood of death (hazard ratio [HR], 0.87; 95% CI, 0.77 to 0.98; P = .018). The median survival time for patients with low social attachment categorized on a median split of 15 was 3.35 years (95% CI, 2.56 to 4.15 years). In contrast, by study completion, 59% of patients with high social attachment were still alive after 4.70 years. No significant association was found between instrumental social support and survival, even after adjustment for covariates. Social attachment is associated with a survival advantage for patients with ovarian cancer. Clinical implications include the importance of screening for deficits in the social environment and consideration of support activities during adjuvant treatment.
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Quality of life (QoL) is an increasingly important outcome measure in medicine. Health, in fact, is not only based on functional status but also on psychological and social well being. Since QoL is related to the patient’s perception of their position in life in relation to their goals, expectations, standards and concerns, the way in which the medical context is experienced may be critical. We then hypothesised that self-perceived QoL may be linked to unmet needs in information management and decision involvement. To analyse this hypothesis, we conducted a quantitative study on 84 consecutive patients with a diagnosis of primary high-grade glioma. The functional assessment of cancer therapy-Brain (FACT-Br) scales, the hospital anxiety and depression (HAD) scale and the need evaluation questionnaire (NEQ) questionnaire were used, in order to measure quality-of-life dimension, mood and unmet needs. Patients were classified as having no need (cluster 1), a moderate need (cluster 2) or a high need (cluster 3) to be more involved in the clinical process. Our data confirmed previous studies in other clinical areas, showing that shared decision might contribute to a better adaptation process to the illness [1]. In fact, patients in cluster 1 showed a significant better self-perceived QoL, despite the lack of clinical differences between clusters. The study showed that patients satisfied with respect to decisional involvement seem to be able to better cope with their disease. Finally, the study suggests the need for a more attuned decision-making process in approaching clinical decisions. Physicians need to better understand patient preferences related to information and decision sharing.
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Cancer patients report significant levels of unmet needs in the realm of communication. Communication skills training programs have been shown to improve clinical communication. However, advanced communication skills training programs in oncology have lacked institutional integration, and thus have not attended to institutional norms and cultures that may counteract explicit communication skills training. We developed and implemented an advanced communication skills training program made up of nine teaching modules for faculty, fellows, and residents. Training included didactic and experiential small group work. Self-efficacy and behavior change were assessed for individual participants. Since 2006, 515 clinicians have participated in this training program. Participants have shown significant gains in self-efficacy regarding communicating with patients in various contexts. Our initial work in this area demonstrates the implementation of such a program at a major cancer center to be feasible, to be acceptable, and to have a significant impact on participants' self-efficacy.
The purpose of this article was to review the literature regarding diagnosis, pathogenesis, and treatment of post-traumatic stress disorder (PTSD) associated with cancer. We surveyed studies examining the validity of diagnostic scales commonly used to measure PTSD in patients with cancer. Neurobiological underpinnings of PTSD and cancer, including inflammation as the physiological mechanism linking these comorbidities, were examined. Psychopharmacologic and psychotherapeutic treatment of PTSD symptoms in patients with cancer was reviewed. In addition, potential drug-drug interactions between psychotropic medications commonly used to treat PTSD and anti-cancer agents were reviewed. Multiple studies demonstrated the validity of the PTSD Checklist Civilian Version (PCL-C) in diagnosing PTSD in patients with cancer. Research has shown that PTSD as defined in DSM-IV appears to be a better model for conceptualizing distress in patients with cancer than a generalized "distress" model. Epidemiologic studies have shown an increased incidence of PTSD associated with cancer; however, literature regarding characteristics of PTSD in patients with cancer is cross-sectional in nature. Future research focusing on longitudinal, prospective studies to identify patients at risk, determine causal or aggravating factors, and develop preventive interventions is needed. Further study of PTSD in patients with cancer may help increase recognition of this disorder, optimize treatment, and enhance the quality of life of these individuals.