**4. PTSD and adult cancer**

In general, assessing prevalence rates of PTSD in adults with cancer have consisted primarily of breast cancer patients including a wide range of time between diagnosis and treatment, from several days to over a decade.

#### **4.1 Current search strategy**

For the current investigation, a literature search was conducted for PTSD prevalence rates in current adult cancer patients and cancer survivors via the *ISI Web of Knowledge*, *Medline* and *PsycINFO* databases**,** and the references of retrieved articles**.** The search considered only studies published in English. The main search terms were posttraumatic, PTSD, cancer, cancer patients, prevalence, prevalence rates, in various combinations as needed. The search strategy consisted of several levels of filtering out articles not relevant to the purposes here. The articles considered useful for the aim of this paper included studies where current prevalence rates for PTSD were ssessed, and identification of posttraumatic cases were based on official DSM guidelines, that is, DSM criteria had been applied. Also included were studies where participants were current patients at the time of data collection or were cancer survivors of 60 months (the five-year marker) or less since the end of treatment; this was done in an effort to reduce the potential wide range of survivor time variation (i.e., survivors of 13-years, 2-years, etc). No limitations were placed on the number of participants, the study design, or whether a control group was included; studies reporting qualitative data were excluded.

#### **4.2 Results**

232 Post Traumatic Stress Disorders in a Global Context

The *DSM's* first criterion, A, relates to PTSD's conceptualization as a stress-related response syndrome where the person experienced an event that threatened his/her life or physical integrity (American Psychiatric Association, 1994, 2000). Also, this criterion includes vicarious traumatization, that is, the witnessing of traumatic events as well as hearing traumatic news or unexpected occurrences about loved ones. For example, related PTSD investigations have expanded to include not only the patients themselves, but also, loved ones affected by the experience of cancer in another, for example, parents of children diagnosed with malignancy as well as partners, siblings or significant friends of cancer

Criterion B involves persistent re-experiencing of the cancer experience (including the intrusive thoughts of symptoms, the way diagnosis was communicated, impending death or experience of review visits), for example, recurrent and intrusive memories or images in the form of flashbacks or nightmares. Noticeable physical reactions may present, such as breaking out in a sweat, feeling light-headed or nauseous, having palpitations, or breathing gets fast and shallow. Criterion C is persistent avoidant or emotional numbing strategies that serve the purpose of blocking internal or external stimuli reminiscent of the traumatic event, such as avoiding certain people, places, or perhaps even the music playing in the

Criterion D involves persistent hyper-physiological arousal and-or anxiousness that were not present before the diagnosis or experience of cancer, and might include sleeping problems, irritability and anger outbursts. Another form of arousal unique to cancer-related PTSD is body symptom hypervigilance or being on guard for signs of another tumor. Criterion E indicates that the duration of such symptoms has persisted for a period of at least one month following the cancer-related traumatic event (e.g., being told the diagnosis or given a poor prognosis, etc.), thereby, distinguishing it from acute stress disorder. Finally, Criterion F indicates the extent to which the symptoms impair domains of life functioning,

In general, assessing prevalence rates of PTSD in adults with cancer have consisted primarily of breast cancer patients including a wide range of time between diagnosis and

For the current investigation, a literature search was conducted for PTSD prevalence rates in current adult cancer patients and cancer survivors via the *ISI Web of Knowledge*, *Medline* and *PsycINFO* databases**,** and the references of retrieved articles**.** The search considered only studies published in English. The main search terms were posttraumatic, PTSD, cancer, cancer patients, prevalence, prevalence rates, in various combinations as needed. The search strategy consisted of several levels of filtering out articles not relevant to the purposes here. The articles considered useful for the aim of this paper included studies where current prevalence rates for PTSD were ssessed, and identification of posttraumatic cases were

patients (e.g., Alderfer et al., 2010; Poder, Ljungman, & von Essen, 2008).

background when the event was occurring.

for example, relational or occupational. Please refer to Table 2.

**3.1 Criteria A - C** 

**3.2 Criteria D - F** 

**4. PTSD and adult cancer** 

**4.1 Current search strategy** 

treatment, from several days to over a decade.

A total of 11 studies met criteria, which were based on interview data collection (See Table 3). The current PTSD diagnostic gold standard remains a clinical interview that is based on the predefined criteria in the DSM (American Psychiatric Association, 1994).Three of the studies involve participants with a mixture of cancer diagnoses excluding breast malignancy (Akechi et al., 2004; Kangas et al., 2005; Widows et al., 2000). The remaining eight studies investigating adult cancer-related PTSD include breast cancer patients at various points in the disease process (Andrykowski et al., 1998; Gandubert et al., 2009; Green et al., 1998; Luecken et al., 2004; Mehnert & Koch, 2007; Mundy et al., 2000; Okamura et al., 2005; Shelby et al., 2008). Despite advances in breast cancer diagnosis and treatments, it remains a monumental stressor in these women's lives that continues to elicit greater distress than any other medical diagnosis (Shapiro et al., 2001). This distress is now recognized as an integral component of a patient's clinical presentation (Bultz & Carlson, 2006); additionally, depression, anxiety, and posttraumatic stress disorder (PTSD) symptoms occur somewhere between 20 and 66% of women in the first 12 months alone after their diagnosis (Burgess et al., 2005; Vos et al., 2004). Such psychological difficulties in response to the challenge of cancer appear congruent with certain pre-cancer factors that may set the stage for patient vulnerability. Specifically, posttraumatic stress disorder cases have been found to be distinguished by a previous history of violent traumas as well as psychological problems such as anxiety disorders that predate the diagnosis of cancer (e.g., Shelby et al., 2008).

The sample sizes in the eight breast cancer studies range from 37 to 160 participants with a mean of 93 participants and the median of 78 participants. Prevalence rates for current cancer-related PTSD range from 0% to 16.2% with a mean of 4.6% and a median of 2.75%. Sample sizes for the three studies of mixed cancer types range from 82 to 209; the mean of participants in these studies is 131 participants with a median of 102 participants. The

prevalence rates for current cancer-related PTSD in these studies range from 0% to 22% with a mean prevalence rate of 9% and a median of 5%.

In sum, these findings are congruent with previous estimates of current cancer-related PTSD prevalence in adult patients, that is, in women with breast cancer or mixed samples of gender with head, neck or lung cancer ranging from 0 to 32% (Hamann et al., 2005). Several points need to be acknowledged. First, the majority of studies---as tends to be the case in the area of psychosocial oncology literature---involved women with breast cancer. Thus, most of the current knowledge regarding PTSD in the context of malignant disease is based upon this cancer population with frequently low sample sizes. Basically, this means that caution is needed, for generalizability of such results do not apply to other disease populations or to those with other types of cancer. Also, the majority of these investigations were crosssectional studies with time variation as to time of assessment from either diagnosis or

samples with malignant processes. This is surprising since survivors of prostate cancer continue to grow as well as the fact that psychological distress in response to receiving a prostate cancer diagnosis is a recognized phenomenon (Anastasiou et al., 2011; Gwede et al., 2005; Namiki et al., 2007). Furthermore, psychological distress in prostate cancer patients has been found to be related to the following: stage of disease, shorter time since diagnosis, and treatment options or decisions (Gwede et al., 2005). For men, receiving the diagnosis of malignant disease has been found to be associated with responses that include anxiety,

Distress related to decision-making is a common experience among men after the diagnosis of prostate cancer; specifically, reports indicate that around 63% report high decision-related distress persisting the first year after treatment for 42% of all men (Steginga et al., 2008). Also, an increased manifestation of traumatic stress symptoms has been found in some cases of newly diagnosed men with localized prostate cancer before the beginning of treatment (Bisson, 2007); on the other hand, low emotional distress has been documented as being present even 2 years after a radical prostatectomy (Perez et al., 2002). Follow-up of males during the disease course of their prostate cancer show that males with prostate cancer may suffer with long-term physical and psychological consequences---to the point of affecting their quality of life (Penson, 2007; Sanda et al., 2008). Indeed, accumulating data within the past 15 years has produced a body of literature investigating health related quality of life (HRQOL) outcomes pertaining to localized prostate cancer (Penson, 2007). This stands in contrast to empirical exploration regarding adjustment in such male cancer survivors. Unfortunately, the literature does not demonstrate ample descriptive investigations as to the course of psychological adjustment for men who have been diagnosed with and treated for prostate cancer (Steginga et al., 2004). No studies could be identified that specifically

A recent study by Anastasiou and colleagues (2011), believed to be the only study that has focused on investigating the presence of acute posttraumatic stress disorder (PTSD) in men with malignant disease necessitating a radical prostatectomy, assessed symptoms in 15 men one month after surgery. The men completed the Davidson Trauma Scale rather than being assessed by interview. Analyses determined that 26.7% of the men's scores met scale criteria for acute PTSD, which was found to be independent of the patient's educational level. In sum, despite the fact that prostate cancer is the second most frequently diagnosed cancer in developed countries, and the third most common cause of death in men (Damber & Aus, 2008), little is known about the psychological ramifications for prostate cancer patients after

surgery (Burns & Mahalik, 2008; Namiki et al., 2007; Steginga et al., 2004).

The present search revealed few reports of cancer-related PTSD in pediatric patients.

The search revealed only two studies assessed within the five-year mark with data regarding cancer-related PTSD (Landolt et al.,1998; Pelcovitz et al., 1998). However, due to the lack of studies, a third study that assessed PTSD at 5.3 years, was included (Kazak et al., 2004). The participants were less than 18 years of age at the time of these investigations, which all consisted of mixed cancer diagnoses. The sample sizes were 150, 7, and 23; the mean sample size was 60 with a median of 23 participants. The prevalence rates in these

denial or distress (Kronenwetter et al., 2005).

assessed PTSD in men with testicular or lung cancer.

**6. PTSD and pediatric cancer** 

**6.1 Results** 

treatment. Cross-sectional data prohibits clinical understanding of the development as well as the trajectory patterns of PTSD in those with cancer. The relative lack of prospective or longitudinal data is needed to inform clinicians early in the disease process so that highly distressed patients may be identified and helped as early as possible with this lifethreatening illness. Lastly, cross-sectional research does little in the way of determining risk factors relevant to later survival time or predicting the delayed onset of posttraumatic stress. Attention now turns to investigations assessing PTSD in strictly male samples with diagnosed malignancy.


Table 3. Summary of select cancer studies
