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\title{Preoperative HADS-Scores and Quality of Life One Year after Surgery for Breast Cancer}
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             \author[1]{Korell  Matthias}

             \author[2]{Korell  Matthias}

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\date{\small \em Received: 9 December 2016 Accepted: 2 January 2017 Published: 15 January 2017}

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\begin{abstract}
        


Purpose: The use of HADS-score is worldwide accepted as a screening tool to identify cancer patients with additional need for psychooncological support. Elevated values for anxiety respectively depression are correlating with higher complaints like e.g. postoperative pain. We tried to investigate patient?s situation at least one year following surgery for breast cancer. Methods: In April 2016, 91 patients with breast cancer, operated before April 2015, were asked to participate at a survey regarding different parameters of their quality of life. The questionnaire included the feeling of attractiveness, satisfaction with postoperative pain and scar formation as well as the overall satisfaction using a visual analogue scale (VAS; 0 ? 10). These results were correlated with the preoperatively applied HADS-scores. For statistical analysis SPSS was used (Student?s paired t test). Results: 69 women (75,8 %) responded the questionnaire. Of these 8 (11,6 %) respectively 15 (21,7 %) has had an elevated score for depression respectively anxiety and 9 women (13 %) had refused to fill out the HADS-form at the time of surgery. There was no significant difference regarding age, tumor stage, type of surgery and postoperative systemic therapy in the different groups. The statistical analysis showed that there was significantly more satisfaction with the postoperative pain level in patients with HADS-D > 7 vs. HADS-D < 7 (9,5 vs. 7,6; p<0,05). In contrast, patients who refused the HADS-screening showed less satisfaction with the postoperative pain level (6,4 vs. 7,9 with HADS-screening; p<0,05). In these patients, the reduction of post- versus preoperative attractiveness was significantly higher, too (- 2,0 vs. ? 0,1 with HADS-screening; p<0,05). Conclusion: One year following surgery for breast cancer, patients with preoperative elevated HADS-score (anxiety and depression) showed even better results in respect to satisfaction with postoperative pain, which could be a result of the  Methods:In April 2016, 91 patients with breast cancer, operated before April 2015, were asked to participate at a survey regarding different parameters of their quality of life. The questionnaire included the feeling of attractiveness, satisfaction with postoperative pain and scar formation as well as the overall satisfaction using a visual analogue scale (VAS; 0 -10). These results were correlated with the preoperatively applied HADS-scores. For statistical analysis SPSS was used (Student's paired t test).Results: 69 women (75,8 %) responded the questionnaire. Of these 8 (11,6 %) respectively 15 (21,7 %) has had an elevated score for depression respectively anxiety and 9 women (13 %) had refused to fill out the HADS-form at the time of surgery.

\end{abstract}


\keywords{HADS-score, breast cancer, quality of life.}

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\let\tabcellsep& 	 	 		 \par
Preoperative HADS-Scores and Quality of Life One Year after Surgery for Breast Cancer Korell Matthias ? , Funkel Vanessa ? , Heck Esther ? \& Stollwerck Peter ? Abstract-Purpose: The use of HADS-score is worldwide accepted as a screening tool to identify cancer patients with additional need for psychooncological support. Elevated values for anxiety respectively depression are correlating with higher complaints like e.g. postoperative pain. We tried to investigate patient's situation at least one year following surgery for breast cancer.\par
Methods: In April 2016, 91 patients with breast cancer, operated before April 2015, were asked to participate at a survey regarding different parameters of their quality of life.\par
The questionnaire included the feeling of attractiveness, satisfaction with postoperative pain and scar formation as well as the overall satisfaction using a visual analogue scale (VAS; 0 -10). These results were correlated with the preoperatively applied HADS-scores. For statistical analysis SPSS was used (Student's paired t test).\par
Results: 69 women (75,8 \%) responded the questionnaire. Of these 8 (11,6 \%) respectively 15 (21,7 \%) has had an elevated score for depression respectively anxiety and 9 women (13 \%) had refused to fill out the HADS-form at the time of surgery.\par
Conclusion: One year following surgery for breast cancer, patients with preoperative elevated HADS-score (anxiety and depression) showed even better results in respect to satisfaction with postoperative pain, which could be a result of the additional psychooncological support given to these.\par
Women who refused to participate in the HADS-screening showed worse outcome in quality of life parameters one year following surgery. This should be taken into account in our oncological practice and must be further investigated in appropriate studies. Maybe patients not participating in HADSscreening need more psychooncological support than themselves respectively physicians are expecting. 
\section[{I. Introduction}]{I. Introduction}\par
he diagnosis "cancer" provokes tremendous reactions of fear and uncertainty in every person \hyperref[b0]{(1)}. The HADS-score is a worldwide accepted tool to identify patients with significant anxiety respectively depression, which is found in about 20-30\% of patients primarily diagnosed with breast cancer. (2;3). The severity of psychological symptoms is influenced by the type of surgery but the quality of life is often impaired even after breast conserving operation \hyperref[b3]{(4)}.\par
The psychological morbidity can influence patient´s outcome in many aspects. E.g. the preoperative score for depression predicts higher levels of acute postoperative pain following breast surgery \hyperref[b4]{(5)}. Patients with elevated anxiety in HADS-A-score are experiencing significant more postoperative pain, too \hyperref[b5]{(6)} The level of anxiety respectively depression is decreasing over time, but about one third of patients suffers from psychological morbidity even more than 1 year following breast surgery \hyperref[b6]{(7,}\hyperref[b7]{8)}.\par
We want to follow up the patients after one year following primary surgery regarding parameters of quality of life (QoL). 
\section[{II. Patients and Methods}]{II. Patients and Methods}\par
In April 2016, 91 patients with primary breast cancer following surgery in our unit earlier than April 2015, were contacted. Preoperatively, 73 women had filled in the routinely used HADS-form, whereas 18 patients (19,8\%) refused to. The patient´s age was 62,9 years in average (33 -83 min-max). The HADS results were positive for depression in 11 cases (> 7; 15,1\%) and for anxiety in 17 cases (> 10; 18,7\%).\par
Patients with elevated scores for anxiety or depression were offered intensified psychooncological support.\par
For statistical analysis SPSS was used (Student's paired t test after check for normality). A p-value <0,05 was regarded as significant. 
\section[{III. Results}]{III. Results}\par
69 patients (75,8\%) responded and sent back the questionnaire.   
\section[{E}]{E}\par
There was no significant difference regarding age, tumor stage, type of surgery and postoperative systemic therapy in the different groups. The statistical analysis showed that there was significantly more satisfaction with the postoperative pain level in patients with HADS-D > 7 vs. HADS-D < 7 (9,5 vs. 7,6; p<0,05). In contrast, patients who refused the HADS-screening showed less satisfaction with the postoperative pain level (6,4 vs. 7,9 with HADS-screening; p<0,05). In these patients, the reduction of post-versus preoperative attractiveness was significantly higher, too (-2,0 vs. -0,1 with HADS-screening; p<0,05).\par
by mastectomy without respectively with implant reconstruction.\par
There was no significant difference regarding age, tumor stage, type of surgery (breast conserving versus mastectomy versus implant reconstruction) and postoperative systemic therapy in the different HADSgroups. (Table  {\ref 2}).\par
The satisfaction with the postoperative pain level was 7,7 in average (VAS "0" -completely unsatisfied; "10" -completely satisfied) (table 3). It was significantly higher in patients with preoperative elevated scores for depression (HADS-D>7 9,5 versus 7,6 HADS-D<8, p<0,05). There was a trend in favour of patients with higher level of anxiety (HADS-A>10 8,7 versus 7,6 HADS-A<8, p<0,1).\par
In contrast, patients who refused the HADSscreening were significant less satisfied with postoperative pain levels (HADS refused 6,4 versus 7,9 HADS accepted, p<0,05).\par
The satisfaction with actual scar formation was 6,6 in average and showed no significant differences in the different HADS groups (VAS "0" -completely unsatisfied; "10" -completely satisfied) (table  {\ref 4})\par
The results of self-estimated quality of life are displayed in table 5. It was 7,1 in average with no detectable significant differences (VAS"0" -worse; "10" -excellent).\par
The self-rated attractivity (VAS "0" -completely unalluring; "10" -absolutely attractive) before and after surgery for breast cancer was not significant different (6 versus 5,6) and showed no influence of preoperative HADS-scores. (table  {\ref 6}).\par
In patients who refused HADS screening, the reduction of attractivity before and after breast cancer was significantly higher (6,9 before and 4,9 after breast cancer versus 5,9 and 5,8 in HADS accepted -p<0,05). 
\section[{IV. Discussion}]{IV. Discussion}\par
Women with breast cancer have the highest incidence of symptomatic depression and/or anxiety compared with other cancer patients \hyperref[b8]{(9)}. Although the prognosis of breast cancer is better in general than e.g. cancer of esophagus, the breast cancer patients suffer significant more often under symptomatic depression (28,1\% vs. 15,6\%) respectively anxiety (32,0\% vs. 8,0\%) \hyperref[b8]{(9)}.\par
The hospital anxiety and depression score (HADS) is well established and worldwide used in different diseases to identify patients with risk for psychological morbidity  {\ref (10; 11)}.\par
In patients with breast cancer the HADS screening identify a high rate of patients with significant anxiety respectively depression which can significantly impair quality of life (QoL) \hyperref[b2]{(3)}. There are several different known risk factors like e.g. young age, which leads to significantly more impairment of QoL by menopausal symptoms, loss of fertility respectively attractivity, weight gain, physical in activity etc. \hyperref[b11]{(12)}.\par
In contrary, married women showed better results than singles \hyperref[b13]{(13)}.\par
The advantage of breast conserving surgery versus mastectomy in respect to QoL is still significant even 5 years after the primary diagnosis \hyperref[b14]{(14)}.\par
In case of depressive comorbidity in breast cancer patients, the use of short-term psychodynamic psychotherapy is effective in increasing QoL \hyperref[b15]{(15)}. In the treatment group 44\% were HADS-D negative versus only 23\% in the control arm. Therefore, every patient with a pathological HADS result is offered an intensified psychooncological support, because an intervention with psychotherapy is effective in reducing the severity of symptoms \hyperref[b16]{(16)}.\par
Nevertheless, sixty-three percent of cancer patients reported one or more unmet needs \hyperref[b17]{(17)}.\par
Pathological HADS findings are not only problematic for the patients but also for their partners. E.g. high anxiety levels lead to severe psychosocial and psychosexual problems like premature ejaculation \hyperref[b19]{(18)}. Like cancer patients, partners are reporting requirements which are often not fulfilled, too (19; 20).\par
Overall, the HADS screening represents an useful screening tool to adjust the psychooncological support to the individual needs. One year after the surgery for breast cancer our patients with primarily elevated scores for anxiety respectively depression didn´t show worse results in satisfaction with postoperative pain or scar formation. There was no significant decrease in self estimated attractivity compared before and after the breast cancer surgery.\par
It is unknown, whether the good results of patients with pathological HADS scores are success of the intensified psychooncological support. But, there are no hints for a need to change our clinical routine.\par
In contrary, patients who refused to participate in HADS screening at the time of surgery showed significantly worse outcome in satisfaction with postoperative pain and attractivity one year after treatment. We do not know the reason for some patientsrefusing the HADS screening. Some commented" I don´t need support -I am fine "and others announced" I will fill it inlater", but without returning it.\par
Due to the small number of patients in our study one cannot draw definite conclusions. But, these results should motivate to further investigate why patients refuse to fill in our routine HADS screening chart. Possiblythey need more psychooncological support than themselves respectively physicians are expecting. We will further try to follow up all patients with breast cancer and will look more closely at women who refuse participation in HADS screening.  
\section[{Volume XVII Issue I Version I}]{Volume XVII Issue I Version I}  \begin{figure}[htbp]
\noindent\textbf{} \par 
\begin{longtable}{}
\end{longtable} \par
  {\small\itshape [Note: The mean age was 63,3 years (33-83 years). 46 patients (66,7\%) received breast conserving surgery, while 15 (21,7\%) respectively 8 (11,6\%) were operated]} 
\caption{\label{tab_0}}\end{figure}
 			\footnote{Volume XVII Issue I Version I © 2017 Global Journals Inc. (US) Year 2017} 			\footnote{© 2017 Global Journals Inc. (US)} 		 		\backmatter  			 \par
("0"completely unsatisfied; "10" -completely satisfied) SD -standard deviation, no significance Table  {\ref 5}: Self estimated quality of life (visual analogue scale -VAS).\par
VAS (SD) all 7,1 (\par
HADS-D 0-7\par
HADS-D > 7\par
HADS-A 0-7\par
HADS-A 8-10\par
HADS-A >10 7,\par
HA DS accepted 7,2 (2,3) ("0" -worse; "10" -excellent) SD -standard deviation, no significance 			 			  				\begin{bibitemlist}{1}
\bibitem[ Psychooncology (2016)]{b18}\label{b18} 	 		\textit{},  	 	 		\textit{Psychooncology}  		2016 Jan. 25  (1)  p. .  	 
\bibitem[Hassan et al. ()]{b1}\label{b1} 	 		‘Anxiety and Depression among Breast Cancer Patients in an Urban Setting in Malaysia’.  		 			M R Hassan 		,  		 			S A Shah 		,  		 			H F Ghazi 		,  		 			Nmm Mujar 		,  		 			M F Samsuri 		,  		 			N Baharom 		.  	 	 		\textit{Asian Pac J Cancer Prev}  		2015. 16  (9)  p. .  	 
\bibitem[Willems et al.]{b17}\label{b17} 	 		\textit{Cancer survivors in the first year after treatment: the prevalence and correlates of unmet needs in different domains},  		 			R A Willems 		,  		 			C A Bolman 		,  		 			I Mesters 		,  		 			I M Kanera 		,  		 			A A Beaulen 		,  		 			L Lechner 		.  		 	 
\bibitem[Cardoso et al. (2016)]{b2}\label{b2} 	 		‘Depression and anxiety symptoms following cancer diagnosis: a cross-sectional study’.  		 			G Cardoso 		,  		 			J Graca 		,  		 			C Klut 		,  		 			B Trancas 		,  		 			A Papoila 		.  	 	 		\textit{Psychol Health Med}  		2016 Jul. 21  (5)  p. .  	 
\bibitem[Alacacioglu et al. ()]{b19}\label{b19} 	 		‘Depression, anxiety and sexual satisfaction in breast cancer patients and their partners-Izmir oncology group study’.  		 			A Alacacioglu 		,  		 			E Ulger 		,  		 			U Varol 		,  		 			I Yildiz 		,  		 			T Salman 		,  		 			V Bayoglu 		,  		 			A Dirican 		,  		 			L Demir 		,  		 			M Akyol 		,  		 			Y Yildiz 		,  		 			Y Kucukzeybek 		,  		 			G Ataman 		,  		 			H Can 		,  		 			I Alacacioglu 		,  		 			M O Tarhan 		.  	 	 		\textit{Asian Pac J Cancer Prev}  		2014. 15  (24)  p. .  	 
\bibitem[Beutel et al. (2014)]{b15}\label{b15} 	 		‘Efficacy of shortterm psychodynamic psychotherapy (STPP) with depressed breast cancer patients: results of a randomized controlled multicenter trial’.  		 			M E Beutel 		,  		 			G Weißflog 		,  		 			K Leuteritz 		,  		 			J Wiltink 		,  		 			A Haselbacher 		,  		 			C Ruckes 		,  		 			S Kuhnt 		,  		 			Y Barthel 		,  		 			B H Imruck 		,  		 			R Zwerenz 		,  		 			E Brähler 		.  	 	 		\textit{Ann Oncol}  		2014 Feb. 25  (2)  p. .  	 
\bibitem[Kami?ska et al. ()]{b3}\label{b3} 	 		‘Evaluation of symptoms of anxiety and depression in women with breast cancer after breast amputation or conservation treated with adjuvant chemotherapy’.  		 			M Kami?ska 		,  		 			T Kubiatowski 		,  		 			T Ciszewski 		,  		 			K J Czarnocki 		,  		 			M Makara-Studzi?ska 		,  		 			I Bojar 		,  		 			E Staros?awska 		.  	 	 		\textit{Ann Agric Environ Med}  		2015. 22  (1)  p. .  	 
\bibitem[Alves et al. (2013)]{b5}\label{b5} 	 		‘Preoperative coping mechanisms have no predictive value for postoperative pain in breast cancer’.  		 			M L Alves 		,  		 			J E Vieira 		,  		 			L A Mathias 		,  		 			J L Gozzani 		.  	 	 		\textit{Rev Bras Psiquiatr}  		2013 Oct-Dec. 35  (4)  p. .  	 
\bibitem[Nikbakhsh et al. ()]{b8}\label{b8} 	 		‘Prevalence of depression and anxiety among cancer patients’.  		 			N Nikbakhsh 		,  		 			S Moudi 		,  		 			S Abbasian 		,  		 			S Khafri 		.  	 	 		\textit{Caspian J Intern Med}  		2014. 5  (3)  p. .  	 
\bibitem[Jassim et al. (2015)]{b16}\label{b16} 	 		\textit{Psychological interventions for women with nonmetastatic breast cancer. Cochrane Database Syst Rev},  		 			G A Jassim 		,  		 			D L Whitford 		,  		 			A Hickey 		,  		 			B Carter 		.  		2015 May 28. p. D008729.  	 
\bibitem[Fallowfield et al. (1990)]{b6}\label{b6} 	 		‘Psychological outcomes of different treatment policies in women with early breast cancer outside a clinical trial’.  		 			L J Fallowfield 		,  		 			A Hall 		,  		 			G P Maguire 		,  		 			M Baum 		.  	 	 		\textit{BMJ}  		1990 Sep 22. 301  (6752)  p. .  	 
\bibitem[Avis et al. (2005)]{b11}\label{b11} 	 		‘Quality of life among younger women with breast cancer’.  		 			N E Avis 		,  		 			S Crawford 		,  		 			J Manuel 		.  	 	 		\textit{J ClinOncol}  		2005 May 20. 23  (15)  p. .  	 
\bibitem[Arndt et al. (2008)]{b14}\label{b14} 	 		‘Quality of life over 5 years in women with breast cancer after breast-conserving therapy versus mastectomy: a population-based study’.  		 			V Arndt 		,  		 			C: Stegmaier 		,  		 			H: Ziegler 		,  		 			H Brenner 		.  	 	 		\textit{J Cancer Res Clin Oncol}  		2008 Dec. 134  (12)  p. .  	 
\bibitem[King et al. ()]{b13}\label{b13} 	 		‘Quality of life three months and one year after first treatment for early stage breast cancer: influence of treatment and patient characteristics’.  		 			M T King 		,  		 			P Kenny 		,  		 			A Shiell 		,  		 			J Hall 		,  		 			J Boyages 		.  	 	 		\textit{Qual Life Res}  		2000. 9  (7)  p. .  	 
\bibitem[Kim et al. (2016)]{b4}\label{b4} 	 		‘SH: Patient reporting pain intensity immediately after surgery can be associated with underlying depression in women with breast cancer’.  		 			Y S Kim 		,  		 			H Do 		,  		 			J W Lee 		,  		 			J Jeong 		,  		 			Y W Shin 		,  		 			K Yi 		,  		 			J Kim 		,  		 			S B Lee 		,  		 			G Sohn 		,  		 			N Yang 		,  		 			Y Oh 		,  		 			L Kim 		,  		 			Y Kim 		,  		 			J H Yu 		,  		 			B S Ko 		,  		 			H J Kim 		.  	 	 		\textit{Psychooncology}  		2016 Mar. 25  (3)  p. .  	 
\bibitem[Howard-Anderson et al. (2012)]{b12}\label{b12} 	 		‘StantonAL: Quality of life, fertility concerns, and behavioral health outcomes in younger breast cancer survivors: a systematic review’.  		 			J Howard-Anderson 		,  		 			P A Ganz 		,  		 			J E Bower 		.  	 	 		\textit{J Natl Cancer Inst}  		2012 Mar 7. 104  (5)  p. .  	 
\bibitem[Soares-Filho et al. (2009)]{b9}\label{b9} 	 		‘Use of the Hospital Anxiety and Depression Scale (HADS) in a Cardiac Emergency Room -Chest Pain Unit’.  		 			Glf Soares-Filho 		,  		 			R C Freire 		,  		 			K Biancha 		,  		 			T Pacheco 		,  		 			A Volschan 		,  		 			A M Valença 		,  		 			A E Nardi 		.  	 	 		\textit{Clinics}  		2009 Mar. 64  (3)  p. .  	 
\bibitem[Itani et al. (2016)]{b0}\label{b0} 	 		‘Validation of the distress and impact thermometer and the changes of mood duringthefirst 6 months of treatment in gynecological cancer patients: a Kansai Clinical Oncology Group (KCOG)-G1103 prospective study’.  		 			Y Itani 		,  		 			A Arakawa 		,  		 			H Tsubamoto 		,  		 			K Ito 		,  		 			R Nishikawa 		,  		 			K Inoue 		,  		 			S Yamamoto 		,  		 			Y Miyagi 		,  		 			K Hori 		,  		 			N Furukawa 		.  	 	 		\textit{Arch Gynecol Obstet}  		2016 Nov. 294  (6)  p. .  	 
\bibitem[Turk et al. (2015)]{b10}\label{b10} 	 		‘Validation of the Hospital Anxiety and Depression Scale in Patients With Acute Low Back Pain’.  		 			D C Turk 		,  		 			R H Dworkin 		,  		 			J J Trudeau 		,  		 			C Benson 		,  		 			D M Biondi 		,  		 			N P Katz 		,  		 			M Kim 		.  	 	 		\textit{J Pain}  		2015 Oct. 16  (10)  p. .  	 
\bibitem[Vahdaninia et al. (2010)]{b7}\label{b7} 	 		‘What do predict anxiety and depression in breast cancer patients? A follow-up study’.  		 			M Vahdaninia 		,  		 			S Omidvari 		,  		 			A Montazeri 		.  	 	 		\textit{Soc Psychiatry PsychiatrEpidemiol}  		2010 Mar. 45  (3)  p. .  	 
\end{bibitemlist}
 			 		 	 
\end{document}
