Health Behaviors Effect on Depression and Anxiety Symptoms in Breast Cancer Patients During Chemotherapy

Background: Approximately 1 in 4 breast cancer patients experience anxiety and depression during their cancer care.1 Depression and anxiety increase mortality, ability to comply with treatment, and worsen quality of life. While health behaviors such as smoking, alcohol use, and physical activity affect anxiety and depression in the general population, there is a gap in understanding how these health behaviors may predict anxiety and depression in breast cancer patients.

Objective: To examine changes in anxiety and depression during breast cancer chemotherapy and to investigate how health behaviors predict anxiety and depression symptoms during this period.

Methods: This study is a secondary analysis of three, multi-center, clinical trials that assessed the effects of a physical activity intervention on toxicity during breast cancer chemotherapy (NCT02167932, NCT02328313, and NCT03761706). Eligibility criteria were: 1) Stage I-III breast cancer, 2) scheduled to receive chemotherapy, 3) English speaking, 4) 21 years of age or older. For the present analysis, participants were additionally required to complete brief depression and anxiety measures (PRSM, PRO-CTCAE) at enrollment (pre-chemotherapy, week 0) and at least one additional time point.2,3 Symptoms were assessed at enrollment and then every 2-3 weeks thereafter. Descriptive statistics were used to characterize changes in at least moderately severe depression and anxiety, over the following intervals: weeks 0-2, 3-5, 6-8, and 9-11. Generalized estimated equations examined the odds of experiencing at least moderately severe depression or anxiety according to baseline smoking, alcohol use, and physical activity.

Results: Among 330 patients, 70% identified as White, ~ 60% had HR+ tumors, 26% were HER2+, and 41% received anthracycline-based regimens. The prevalence of anxiety was initially 30% (weeks 0-2) and declined over time (18% in weeks 3-5, 15% in weeks 6-8, and 15% in weeks 9-11). Similarly, depression was reported among 20% in weeks 0-2, 13% in weeks 3-5, 11% in weeks 6-8, and 11% in weeks 9-11. The odds of reporting anxiety were 3.83 times higher for current vs never smokers (95% CI: 1.81-8.08, p=0.0004) and 3.15 times higher for current vs past smokers (95% CI: 1.42-6.98), p=.005). The odds of reporting depression were also higher among current smokers than never smokers (OR 2.96; 95% CI: 1.20-7.33, p=.019). No significant differences in anxiety or depression were observed according to alcohol use or physical activity.

Discussion and

Conclusions: Our study identified that anxiety and depression were most prevalent proximal to chemotherapy initiation and declined over time, consistent with psychological adjustment to patients’ cancer diagnosis and treatment. However, even months after diagnosis, 10-15% reported at least moderately severe anxiety and/or depression, which is substantially higher than in the general population. Current smokers were a particularly at-risk group, emphasizing the importance of early referral for smoking cessation, and future research examining biological pathways (e.g., nicotinic acetylcholine receptor activation) to inform targeted therapies in this population.4

References

1. Nakamura et al. The Oncol 2021. 26: 147-156.

2. Basch et al. JNCI 2014. 106(9): dju244

3. Ducek et al. JAMA Oncology 2015. 1.8: 1051-1059

4. Moylan et al. Brain Behav 2013. 3(3):302-26