From the Editor

“Now that I’m done with my [cancer] treatment, I’m struggling to figure out who I am,” writes essayist Suleika Jaouad.

This week’s Reading focuses on cancer and mental illness.

We open with a major new paper just published by JAMA Oncology (involving hundreds of thousands of cancer patients) and we then consider an essay by Suleika Jaouad talking about how cancer affected her physical and mental health.


Cancer and Mental Illness

“Clinical Diagnosis of Mental Disorders Immediately Before and After Cancer Diagnosis: A Nationwide Matched Cohort Study in Sweden”

Donghao Lu, JAMA Oncology, Online First, 28 April 2016


Patients with cancer are known to have an increased risk of psychiatric symptoms and disorders, cardiovascular diseases, and suicide. Historically, severe comorbidities among patients with cancer have largely been attributed to the adverse effects of cancer treatments, the complex pathophysiology of the underlying malignancy, or simply the burden of living with a progressing and potentially fatal disease. Not only does living with cancer induce severe psychological stress, but being diagnosed as having a cancer is also highly stressful. Recently, greatly increased risks of suicide and cardiovascular events shortly after cancer diagnosis were reported among patients with cancer in different countries, across various cancer types, and among both young and adult patients. However, these reports likely only represent the tip of the iceberg for the enormous psychological turmoil related to a newly received cancer diagnosis.

Psychiatric comorbidities, such as depression, anxiety, substance abuse, somatoform/conversion disorder, and stress reaction/adjustment disorder, are common among patients with cancer and may reflect the broader spectrum of psychological distress experienced by these patients. Although depression has been extensively studied, evidence is mainly limited to breast cancer and rarely addressed during the immediate period after a cancer diagnosis. Moreover, other mental disorders have received less attention. On the other hand, although mental disorders are not established risk factors for cancer in general, some conditions, including addiction to alcohol and tobacco, might lead to higher risk of alcohol related and smoking-related cancers.

Dr. Donghao Lu

So opens a paper by Lu et al., just published online first by JAMA Oncology.

Work on cancer and mental illness isn’t new, but this paper is remarkable for a few reasons: it looks at psychiatric disorders both after and before the cancer diagnosis; it features a long study period; it taps national databases.

Here’s what they did:

· Using a Swedish national database, the authors identified all people born and living in Sweden between January 1, 1991, and December 31, 2010.

· They then cross-linked these people with information from other databases: Cancer Register, Patient Register, Prescribed Drug Register, Cause of Death Register, and Migration Register.

· Statistical analysis was done.

Here’s what they found:

· 326,404 adult patients were diagnosed with malignancy during the study period.

· In total, 3,355 patients met criteria for a mental illness before the cancer diagnosis and 10,296 patients after the cancer diagnosis.

· Of those with cancer and mental disorders: the median age was 69 years; 46.9% were female.

· The overall relative rate of mental disorders started to increase from 10 months before cancer diagnosis and peaked during the week after diagnosis. (!) See the graph below.

· “Among patients with cancer, depression had the highest cumulative incidence during the study, followed by anxiety and stress reaction/adjustment disorder.”

· What about the type of cancer? Similar results were found for basically all the major cancers (non-melanoma skin cancer being the exception). The rate increase was greater for cancers of poor prognosis both before and after diagnosis compared with other cancers. Patients with locally advanced or metastatic cancers had no further increased rate compared with patients with localized or non-metastatic cancers either before or after diagnosis.

· Use of psychiatric medications increased after diagnosis. See the graph below.

The authors note:

To the best of our knowledge, our study represents the first and largest study to date estimating the burden and its temporal pattern of mental disorders that are potentially related to psychological stress among adult patients with cancer during the prediagnostic to postdiagnostic periods. In line with previous studies, we showed that anxiety and stress reaction/ adjustment disorder were also common among patients with cancer, in addition to depression. Most important, patients with cancer had dramatically increased risks of depression, anxiety, stress reaction/adjustment disorder, and substance abuse (excluding alcohol and tobacco abuse or dependence), as well as somatoform/conversion disorder, both during the year before and the year after diagnosis.

A few thoughts:

1. This paper is incredible – it tapped national databases and produced a big look at cancer and mental illness.

2. Obviously the big news here is that many patients were struggling from a psychiatric point of view before they had a cancer diagnosis.

3. One thing to consider – in this paper, major mental disorders like depression were included. But the list of diagnoses also covered adjustment disorder. That’s not to minimize the stress that these Swedish patients went through; but “the highest rate increase was noted for stress reaction/adjustment disorder immediately after cancer diagnosis.” In other words, some type of intervention was appropriate, but not everyone needed a psychiatric medication.

4. Cancer is commonly linked to mental illness and mental anguish. It shows the importance of psychological support during cancer treatment. Closer to home, I note that Cancer Care Ontario and other provincial cancer agencies have made depression and anxiety screening a priority.

5. I can’t help but brag: at The Scarborough Hospital, we have built up our psycho-oncology team over the past few years. This week, we are launching iMindful, an Internet-assisted mindfulness therapy program, thanks to the work of Shawnna Balasingham, Janany Jayanthikumar, Dr. Karen Shin, and Faiza Khalid-Khan, and our Centennial College partners. And our efforts have been recognized. Kelly Brockington, one of our nurses, recently received the Human Touch Award from Cancer Care Ontario-Renal Care Ontario “for going the extra mile to touch the lives of patients.”

You can read more about iMindful here:

and Kelly here:

Kelly Brockington, Human Touch Award 2016


Life with Cancer

“Lost in Transition After Cancer”

Suleika Jaouad, The New York Times, 16 March 2015


“You are being deported,” a surgeon announced to me last fall. That’s a scary thing for a child of two immigrants to hear. But he was referring to the removal of my port, a medical device implanted just beneath my right collarbone — a gateway for the dozens of rounds of chemotherapy, antibiotics and blood transfusions that have entered my body since I received a leukemia diagnosis at age 22.

I love a good pun, but I wasn’t in the mood for laughter or lightness that day. After three and a half years of cancer treatment, I no longer needed the port. My doctors had finally pronounced me in remission. I had thought I’d want to celebrate or dance a jig in my hospital gown or throw a rager when I got there. But it didn’t feel anything like the endgame I had imagined.

Suleika Jaouad

So opens an essay by Suleika Jaouad published by The New York Times. Drawing on her experience, she writes about life after cancer.

I try to pick Readings that are current, and some time has passed since Jaouad wrote her piece. But it’s an excellent essay about illness and healing and recovery. When I first read it about a year ago, I knew I had to share it.

Now that I’m done with my treatment, I’m struggling to figure out who I am. On paper, I am better: I no longer have cancer, and with every passing day I’m getting stronger. The constant flood of doctor’s appointments, blood tests and phone calls from concerned family and friends have trickled to a slow drip. But off paper, I feel far from being a healthy 26-year-old woman.

In this moving piece, she talks about the long shadow that cancer has cast upon her life – the lingering physical problems, the “demons of depression,” the losses.

I’ve spent the last year of my life searching for Suleika B.C. (before cancer). I’ve looked for her all over New York City — the old bars she used to frequent, the coffee shop where she had her first date with the ex-boyfriend, the apartment above the Pearl Paint sign on Canal Street that she shared with 10 roommates her first summer out of college — but the more I look, the more I’m beginning to realize she no longer exists. There is no going back to my old life. The problem is I don’t know how to move forward either.

Jaouad continues her journey. Along the way, she has won an Emmy, and her work and life have been featured by NPR, The Los Angeles Times, and other major media. And she remains free of cancer, if touched by cancer.

Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.