Supporting the mental health of breast cancer patients, survivors—and those at high risk

Health psychologist Kathleen Ashton, PhD, has worked in various medical specialties including sleep, women’s health, and bariatric surgery. “I’ve always been able to adapt to a new medical area, learn it, and then expand on programs,” Ashton said. Now the director of behavioral health in the Cleveland Clinic’s Breast Centeropens in new window, Ashton’s patients include people at high risk for breast cancer, as well as breast cancer patients and survivors.

As a whole, they’re probably her favorite population to date. “They tend to be very positive and hopeful and very engaged in treatment,” said Ashton, who joined the center 8 years ago. “Sometimes, when I tell other psychologists I work with cancer patients, they think it sounds really depressing. But I find it very uplifting and motivating.” Plus, her work is needed: There are more than 4 million cancer survivors in the United States, and they commonly face mental health challenges.

To highlight the various roles for psychologists in integrated care, we asked Ashton—a member of APA’s Integrated Specialty Care Advisory Group—to talk more about the challenges and rewards of working on a treatment team specializing in breast cancer patients.

We have three psychologists, a psychology fellow, and programs for patients at all stages.

We work in close integration with the patient’s oncology team—with their breast surgeon, plastic surgeon, medical oncologist, radiation oncologist, the whole group. We’re a key part of that multidisciplinary team.

Often, our patients have never seen a psychologist before or had any type of mental health treatment. But because we’re integrated within the oncology program, they have access to our services. We also have a unique understanding of their medical issue, which helps us provide more specialized care.

Patients who carry a gene mutation—like BRCA1 or BRCA2—can have up to an 80% risk of developing breast cancer in their lifetime. One management option is getting a bilateral risk-reducing mastectomy, so we do presurgical evaluations for folks choosing that.

We make sure they’re psychologically stable, in a good place to go forward with surgery, and understand the impact on their breasts. You typically lose a lot of sensation with a mastectomy, so it can really affect your sexual health. Reconstruction is very good for these patients—they have really good aesthetic outcomes—but the breasts still don’t look the same. It’s not a cosmetic surgery, so there can be a lot of impact on body image after surgery as well.

There are lots of family issues that can go along with that choice too because the patient may have lost a mother or sister to breast cancer in the past—that’s often a big motivator. They may need help with decision-making and communicating with family and dealing with some of the emotional changes that go along with such a permanent and life-changing surgery.

We also just launched a four-session virtual telehealth program for patients who have had that surgery or are thinking about it. It has been super popular. It gives patients the opportunity to meet with peers and build some skills like decision-making, body-image processing, anxiety management, and goal setting before and after surgery.

We mainly talk with them about risks and benefits of all their options. Besides risk-reducing surgery, they can do surveillance, which would typically involve coming in every 6 months for a mammogram alternating with a breast MRI. Another option for some women is taking a medication called tamoxifen that reduces estrogen in the body. Those are reasonable options, so we talk through: Is it a good time in their life? What’s motivating them?

People who are more anxious tend to want surgery more than surveillance, so that can be tricky. We want to make sure we’re treating their anxiety. They definitely see a reduction in anxiety after surgery, but not always as much as one would think. So, we end up working with some folks who say, “I’m still anxious.” Now we have something else to work on.

A lot of symptoms can occur during treatment: anxiety, sleep problems, fatigue, body image issues, and identity issues. So, we see them one-on-one to manage those, and we also host virtual group programs, which have been very effective.

Our survivorship program includes group programs designed for young women and women over 50. Survivors are at a fairly high risk of anxiety and depression, but it’s very treatable with lots of well-known psychotherapies that have been adapted for that population, including CBT.

We also work with metastatic breast cancer patients who will be living with cancer the rest of their lives. We do some specialized programs for them, including one called meaning-centered psychotherapy, which helps patients create and connect with a sense of meaning and purpose in their lives.

Sometimes we use more acceptance and commitment therapy than traditional CBT, since the women we work with have real medical threats. We don’t talk about their thoughts—like a fear of recurrence—as irrational, for example. More and more, I think we’ll see more specialized treatments for populations like women of color or LGBT patients.

It’s really important to form relationships with the treatment team to have a strong understanding of the medical issues. Our fellows shadow all the different members of the multidisciplinary team. They observe breast surgery, for example, to see what it’s like for the patient and get a good understanding of the procedure.

We attend “tumor board” (a meeting of cancer specialists who discuss complex cases) every week so that we’re getting ongoing education about things like what PET scans look like and what new cancer treatments are available.

At the beginning, much of it seems like gobbledygook: Oncologists in particular throw out even more acronyms than psychologists do. But you do absorb a lot of information and that makes you a much better psychologist with your patients.

Understanding health psychology in general is important. Many of the treatments we use are ones that general health psychologists use. Treatments for insomnia or pain management translate really well to the oncology population.

I’d encourage folks who have an interest in a specialized area like this in health psychology—or maybe even in those in general psychology or private practice—to think about the possibilities of becoming integrated in this way. It’s very rewarding. I have patients who have told me the psychological component was the most important part of their treatment. These are patients who have had multiple surgeries and chemotherapy and radiation, but say our work was what they needed most.