impact on psychological function at each stage of disease and during survivorship. The studies show highest distress at transition points in treatment: at the time of diagnosis, awaiting treatment, during and on completion of treatment, at follow-up visits, at time of recurrence, and at time of treatment failure. Taken overall, approximately 30 percent of women show significant distress at some point during the illness, and the number is greater in women with recurrent disease whose family members are also distressed.

Interventions to address psychosocial problems and distress begin with basic information about the disease and treatment options from the breast cancer care clinician (often a medical oncologist). This clinician, regardless of medical specialty, should express support, encourage patients to voice their fears and concerns, encourage coping, and provide medication when needed to control symptoms like insomnia and anxiety. Psychosocial services should be provided by oncology caregivers as a part of total medical care, but referrals to specialists in psychooncology, social workers, pastoral counselors, and other professionals may be necessary when the level of distress is high. The frequency of visits to a psychooncology professional may vary from a single encounter to several, and the timing and duration may also vary from very brief to extending over months or, at times, even years. Today, there are many community-based services available to women with breast cancer at no charge. Evidence from 31 randomized clinical trials, meta-analyses, and nonrandomized studies of the effectiveness of psychosocial interventions among women with breast cancer supports the inclusion of psychosocial interventions in routine clinical care (IOM, 2004b). This body of research documents that several psychosocial interventions reduce psychosocial problems and distress among women with breast cancer. Psychosocial factors and interventions are also related to other aspects of cancer such as pain and other side effects.

Many women with breast cancer rely solely on family, friends, and clergy for social support. Some may find information and support on the Internet, for example, the American Cancer Society’s “Cancer Survivor’s Network” or ASCO’s “People Living with Cancer.” Other women, however, do not have social supports built into their lives. They may also lack access to psychosocial services, either because care providers do not refer them to the available services or because of other barriers (e.g., no health insurance or no reimbursement for services).

Several barriers impede appropriate care. The dramatic shift in the delivery of nearly all cancer care from inpatient hospital to outpatient settings has not included a similar shift in the outpatient psychosocial services to the outpatient clinics and private oncology office practices. Increased complexity of care has limited access even further. Women with breast cancer usually see multiple specialists (e.g., surgeons, radiation



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