Prevalence of Depression in Breast Cancer Survivors: a Systematic Review of Observational Studies

  • Zainal, Nor Zuraida (Psychological Medicine Research Group of University Malaya (PARADIGM), Faculty of Medicine, University of Malaya) ;
  • Nik-Jaafar, Nik Ruzyanei (Department of Psychiatry, Universiti Kebangsaan Malaysia Medical Centre) ;
  • Baharudin, Azlin (Department of Psychiatry, Universiti Kebangsaan Malaysia Medical Centre) ;
  • Sabki, Zuraida Ahmad (Psychological Medicine Research Group of University Malaya (PARADIGM), Faculty of Medicine, University of Malaya) ;
  • Ng, Chong Guan (Psychological Medicine Research Group of University Malaya (PARADIGM), Faculty of Medicine, University of Malaya)
  • Published : 2013.04.30


Background: Depression is common in breast cancer patients. The aim of this paper was to make a systematic review of its prevalence and associated factors oin breast cancer survivors. Materials and Methods: An extensive systematic electronic review (PUBMED, CINAHL, PsyINFO and Ovid) and handsearch were carried out to retrieve published articles up to November 2012, using Depression OR Dysthymia AND (Cancer OR Tumor OR Neoplasms as the keywords. Information about the design of the studies, measuring scale, characteristics of the participants, prevalence of depression and its associated factors from the included studies were extracted and summarized. Results: We identified 32 eligible studies that recruited 10,826 breast cancer survivors. Most were cross-sectional or prospective designed. The most frequent instrument used to screen depression was the Center for Epidemiological Studies for Depression (CES-D, n=11 studies) followed by the Beck Depression Inventory (BDI, n=6 studies) and the Hospital Anxiety and Depression Scale (HADS, n=6 studies). CES-D returned about similar prevalence of depression (median=22%, range=13-56%) with BDI (median=22%, range=17-48%) but higher than HADS (median=10%, range=1-22%). Depression was associated with several socio-demographic variables, cancer-related factors, treatment-related factors, subject psychological factors, lifestyle factors, social support and quality of life. Conclusions: Breast cancer survivors are at risk for depression so that detection of associated factors is important in clinical practice.


  1. Alcalar N, Ozkan S, Kucucuk S, et al (2012). Association of coping style, cognitive errors and cancer-related variables with depression in women treated for breast cancer. Jpn J Clin Oncol, 42, 940-7.
  2. Alexander S, Palmer C, Stone PC (2010). Evaluation of screening instruments for depression and anxiety in breast cancer survivors. Breast Cancer Res Treat, 122, 573-8.
  3. Allen JD, Savadatti S, Levy AG (2009). The transition from breast cancer 'patient' to 'survivor'. Psychooncology, 18, 71-8.
  4. Azim HA Jr, de Azambuja E, Colozza M, et al (2011). Long-term toxic effects of adjuvant chemotherapy in breast cancer. Ann Oncol, 22, 1939-47
  5. Begovic-Juhant A, Chmielewski A, Iwuagwu S, et al (2012). Impact of body image on depression and quality of life among women with breast cancer. J Psychosoc Oncol, 30, 446-60.
  6. Bower JE, Ganz PA, Desmond KA, et al (2000). Fatigue in breast cancer survivors: occurrence, correlates, and impact on quality of life. J Clin Oncol, 18, 743-53.
  7. Bower JE, Ganz PA, Irwin MR, et al (2011). Inflammation and behavioral symptoms after breast cancer treatment: do fatigue, depression, and sleep disturbance share a common underlying mechanism? J Clin Oncol, 29, 3517-22.
  8. Broeckel JA, Jacobsen PB, Balducci L, et al (2000). Quality of life after adjuvant chemotherapy for breast cancer. Breast Cancer Res Treat, 62, 141-50.
  9. Carpenter JS, Elam JL, Ridner SH, et al (2004). Sleep, fatigue, and depressive symptoms in breast cancer survivors and matched healthy women experiencing hot flashes. Oncol Nurs Forum, 31, 5591-8.
  10. Chen X, Zheng Y, Zheng W, et al (2009). Prevalence of depression and its related factors among Chinese women with breast cancer. Acta Oncol, 48, 1128-36.
  11. Coleman MP, Forman D, Bryant H, et al (2011). Cancer survival in Australia, Canada, Denmark, Norway, Sweden, and the UK, 1995-2007 (the International Cancer Benchmarking Partnership): an analysis of population-based cancer registry data. Lancet, 377, 127-38
  12. Den Oudsten BL, Van Heck GL, Van der Steeg AF, et al (2009). Predictors of depressive symptoms 12 months after surgical treatment of early-stage breast cancer. Psychooncology, 18, 1230-7.
  13. Deshields T, Tibbs T, Fan MY, Taylor M (2006). Differences in patterns of depression after treatment for breast cancer. Psychooncology, 15, 398-406.
  14. Eversley R, Estrin D, Dibble S, et al (2005). Post-treatment symptoms among ethnic minority breast cancer survivors. Oncol Nurs Forum, 32, 250-6.
  15. Fann JR, Thomas-Rich AM, Katon WJ, et al (2008). Major depression after breast cancer: a review of epidemiology and treatment. Gen Hosp Psychiatry, 30, 112-26.
  16. Green BL, Rowland JH, Krupnick JL, et al (1998). Prevalence of posttraumatic stress disorder in women with breast cancer. Psychosomatics, 39, 102-11.
  17. Hann D, Winter K, Jacobsen P (1999). Measurement of depressive symptoms in cancer patients: evaluation of the Center for Epidemiological Studies Depression Scale (CES-D). J Psychosom Res, 46, 437-43.
  18. Hill J, Holcombe C, Clark L, et al (2011). Predictors of onset of depression and anxiety in the year after diagnosis of breast cancer. Psychol Med, 41, 1429-36.
  19. Hopwood P, Sumo G, Mills J, et al (2010). The course of anxiety and depression over 5 years of follow-up and risk factors in women with early breast cancer: results from the UK Standardisation of Radiotherapy Trials (START). Breast, 19, 84-91.
  20. Howard-Anderson J, Ganz PA, Bower JE, Stanton AL (2012). Quality of life, fertility concerns, and behavioral health outcomes in younger breast cancer survivors: a systematic review. J Natl Cancer Inst, 104, 386-405.
  21. Hsiao FH, Chang KJ, Kuo WH, et al (2013). A longitudinal study of cortisol responses, sleep problems, and psychological wellbeing as the predictors of changes in depressive symptoms among breast cancer survivors. Psychoneuroendocrinology, 38, 356-66.
  22. Inagaki M, Matsuoka Y, Sugahara Y, et al (2004). Hippocampal volume and first major depressive episode after cancer diagnosis in breast cancer survivors. Am J Psychiatry, 161, 2263-70.
  23. Jang JE, Kim SW, Kim SY, et al (2012). Religiosity, depression, and quality of life in Korean patients with breast cancer: a 1-year prospective longitudinal study. Psychooncology, 22, 922-9.
  24. Johnson JL, Minarik PA, Nystrom KV, et al (2006). Poststroke depression incidence and risk factors: an integrative literature review. J Neurosci Nurs, 38, 316-27.
  25. Karakoyun-Celik O, Gorken I, Sahin S, et al (2010). Depression and anxiety levels in woman under follow-up for breast cancer: relationship to coping with cancer and quality of life. Med Oncol, 27, 108-13.
  26. Khan F, Amatya B, Pallant JF, Rajapaksa I (2012). Factors associated with long-term functional outcomes and psychological sequelae in women after breast cancer. Breast, 21, 314-20.
  27. Lorizio W, Wu AH, Beattie MS, et al (2012). Clinical and biomarker predictors of side effects from tamoxifen. Breast Cancer Res Treat, 132, 1107-18
  28. Makambi KH, Williams CD, Taylor TR, et al (2009). An assessment of the CES-D scale factor structure in black women: The Black Women's Health Study. Psychiatry Res, 168, 163-70.
  29. Mehnert A, Koch U (2008). Psychological comorbidity and health-related quality of life and its association with awareness, utilization, and need for psychosocial support in a cancer register-based sample of long-term breast cancer survivors. J Psychosom Res, 64, 383-91.
  30. Mitchell AJ, Lord K, Symonds P (2012). Which symptoms are indicative of DSMIV depression in cancer settings? An analysis of the diagnostic significance of somatic and nonsomatic symptoms. J Affect Disord, 138, 137-48.
  31. Mitchell AJ, Meader N, Symonds P (2010). Diagnostic validity of the Hospital Anxiety and Depression Scale (HADS) in cancer and palliative settings: a meta-analysis. J Affect Disord, 126, 335-48.
  32. Moher D, Liberati A, Tetzlaff J, Altman DG (2009). Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. BMJ, 339, 2535.
  33. Morrill EF, Brewer NT, O'Neill SC, et al (2008). The interaction of post-traumatic growth and post-traumatic stress symptoms in predicting depressive symptoms and quality of life. Psychooncology, 17, 948-53.
  34. Ng CG, Boks MP, Zainal NZ, de Wit NJ (2011). The prevalence and pharmacotherapy of depression in cancer patients. J Affect Disord, 131, 1-7.
  35. Odle TG (2011). Breast cancer survivorship and surveillance. Radiol Technol, 83, 63-87.
  36. Park BW, Hwang SY (2012). Unmet needs of breast cancer patients relative to survival duration. Yonsei Med J, 53, 118-25.
  37. Pan L, Han Y, Sun X, et al (2010). FDG-PET and other imaging modalities for the evaluation of breast cancer recurrence and metastases: a meta-analysis. J Cancer Res Clin Oncol, 136, 1007-22.
  38. Phillips KA, Osborne RH, Giles GG, et al (2008). Psychosocial factors and survival of young women with breast cancer: a population-based prospective cohort study. J Clin Oncol, 26, 4666-71.
  39. Popoola AO, Adewuya AO (2012). Prevalence and correlates of depressive disorders in outpatients with breast cancer in Lagos, Nigeria. Psychooncology, 21, 675-9.
  40. Pumo V, Milone G, Iacono M, et al (2012). Psychological and sexual disorders in long-term breast cancer survivors. Cancer Manag Res, 4, 61-5.
  41. Qiu J, Yang M, Chen W et al (2012). Prevalence and correlates of major depressive disorder in breast cancer survivors in Shanghai, China. Psychooncology, 21, 1331-7.
  42. Rabin EG, Heldt E, Hirakata VN, et al (2009). Depression and perceptions of quality of life of breast cancer survivors and their male partners. Oncol Nurs Forum, 36, 153-8.
  43. Schou I, Ekeberg O, Ruland CM, et al (2004). Pessimism as a predictor of emotional morbidity one year following breast cancer surgery. Psychooncology, 13, 309-20.
  44. Schreiber JA (2011). Image of God: effect on coping and psychospiritual outcomes in early breast cancer survivors. Oncol Nurs Forum, 38, 293-301.
  45. Speer JJ, Hillenberg B, Sugrue DP, et al (2005). Study of sexual functioning determinants in breast cancer survivors. Breast J, 11, 440-7.
  46. Tangney CC, Young JA, Murtaugh MA, et al (2002). Selfreported dietary habits, overall dietary quality and symptomatology of breast cancer survivors: a cross-sectional examination. Breast Cancer Res Treat, 71, 113-23.
  47. Ullrich PM, Rothrock NE, Lutgendorf SK, et al J (2008). Adjustment and discussion of cancer: A comparison of breast and prostate cancer survivors. Psychol Health, 23, 391-406.
  48. Vahdaninia M, Omidvari S, Montazeri A (2010). What do predict anxiety and depression in breast cancer patients? A followup study. Soc Psychiatry Psychiatr Epidemiol, 45, 355-61.
  49. Van Wilgen CP, Dijkstra PU, Stewart RE, et al (2006). Measuring somatic symptoms with the CES-D to assess depression in cancer patients after treatment: comparison among patients with oral/oropharyngeal, gynecological, colorectal, and breast cancer. Psychosomatics, 47, 465-70.
  50. Wang GL, Hsu SH, Feng AC, et al (2011). The HADS and the DT for screening psychosocial distress of cancer patients in Taiwan. Psychooncology, 20, 639-46.
  51. Warmenhove F, Van Rijswijk E, Engels Y, et al (2012). The Beck Depression Inventory (BDI-II) and a single screening question as screening tools for depressive disorder in Dutch advanced cancer patients. Support Care Cancer, 20, 319-24.
  52. Watson M, Haviland JS, Greer S, et al (1999). Influence of psychological response on survival in breast cancer: a population-based cohort study. Lancet, 354, 1331-6.
  53. Weinberger T, Forrester A, Markov D, et al (2010). Women at a dangerous intersection: diagnosis and treatment of depression and related disorders in patients with breast cancer. Psychiatr Clin North America, 33, 409-22.
  54. Zainal NZ, Booth S, Huppert FA (2012). The efficacy of mindfulness-based stress reduction on mental health of breast cancer patients: a meta-analysis. Psychooncology, [Epub ahead of print].

Cited by

  1. Health-related quality of life and psychological distress during neoadjuvant endocrine therapy with letrozole to determine endocrine responsiveness in postmenopausal breast cancer vol.145, pp.1, 2014,
  2. Comparison of Psychotropic Prescriptions between Oncology and Cardiology Inpatients: Result from a Pharmacy Database in a Teaching Hospital in Malaysia vol.15, pp.10, 2014,
  3. Comfort and Anxiety Levels of Women with Early Stage Breast Cancer Who Receive Radiotherapy vol.15, pp.5, 2014,
  4. Effect of Perceived Social Support on Psychosocial Adjustment of Turkish Patients with Breast Cancer vol.15, pp.8, 2014,
  5. Effects of an exercise and hypocaloric healthy eating intervention on indices of psychological health status, hypothalamic-pituitary-adrenal axis regulation and immune function after early-stage breast cancer: a randomised controlled trial vol.16, pp.2, 2014,
  6. Women with breast cancer taking chemotherapy: depression symptoms and treatment adherence vol.22, pp.5, 2014,
  7. Anxiety, depression, perceived social support and quality of life in Malaysian breast cancer patients: a 1-year prospective study vol.13, pp.1, 2015,
  8. Depression, Anxiety and Sexual Satisfaction in Breast Cancer Patients and their Partners-Izmir Oncology Group Study vol.15, pp.24, 2015,
  9. Associations among Physical Activity, Comorbidity, Functional Capacity, Peripheral Muscle Strength and Depression in Breast Cancer Survivors vol.16, pp.2, 2015,
  10. The Myth of Not Disclosing the Diagnosis of Cancer: Does it Really Protect Elderly Patients from Depression? vol.16, pp.2, 2015,
  11. Breast Cancer Screening Barriers from the Womans Perspective: a Meta-synthesis vol.16, pp.8, 2015,
  12. Effect of Relaxation With Guided Imagery on The Physical and Psychological Symptoms of Breast Cancer Patients Undergoing Chemotherapy vol.17, pp.11, 2015,
  13. American Cancer Society/American Society of Clinical Oncology Breast Cancer Survivorship Care Guideline vol.66, pp.1, 2015,
  14. Changes in importance of work and vocational satisfaction during the 2 years after breast cancer surgery and factors associated with this vol.10, pp.3, 2016,
  15. HER-2 Positive Breast Cancer - a Mini-Review vol.17, pp.4, 2016,
  16. A meta-analysis of the benefits of mindfulness-based stress reduction (MBSR) on psychological function among breast cancer (BC) survivors vol.23, pp.4, 2016,
  17. Identification of health care needs of long-term breast cancer survivors among Israeli women vol.24, pp.2, 2016,
  18. American Cancer Society/American Society of Clinical Oncology Breast Cancer Survivorship Care Guideline vol.34, pp.6, 2016,
  19. The Impact of Cancer on Psychological and Social Outcomes vol.51, pp.2, 2016,
  20. A Randomized controlled trial to evaluate the impact of a Nurse Navigator Programme on outcomes of people with breast cancer: study protocol vol.73, pp.4, 2016,
  21. Depressive symptoms and positive affect in Chinese and United States breast cancer survivors: a cross-cultural comparison vol.25, pp.7, 2017,
  22. Distress Screening and Management in Early Breast Cancer Patients: Distress after Breast Cancer Diagnosis and Associated Factors vol.5, pp.1, 2017,
  23. Awareness and current knowledge of breast cancer vol.50, pp.1, 2017,
  24. Depressive spectrum disorders in cancer: prevalence, risk factors and screening for depression: a critical review vol.56, pp.2, 2017,
  25. Anxiety and Depression in Cancer Patients: The Association with Religiosity and Religious Coping vol.56, pp.2, 2017,
  26. Adverse mental health outcomes in breast cancer survivors compared to women who did not have cancer: systematic review protocol vol.6, pp.1, 2017,
  27. breast cancer vol.140, pp.4, 2016,
  28. Demographic Pattern and Hospitalization Outcomes of Depression among 2.1 Million Americans with Four Major Cancers in the United States vol.6, pp.4, 2018,
  29. The quality of life of Croatian women after mastectomy: a cross-sectional single-center study vol.18, pp.1, 2018,
  30. Depression Induced by Total Mastectomy, Breast Conserving Surgery and Breast Reconstruction: A Systematic Review and Meta-analysis vol.42, pp.7, 2018,
  31. Home-Based Psychoeducational Intervention for Breast Cancer Survivors vol.41, pp.3, 2018,
  32. Factors Influencing Quality of Life in Breast Cancer Patients Six Months after the Completion of Chemotherapy vol.7, pp.1, 2019,