# Impact of Pre-Diagnosed Depressive Symptoms on Treatment Choice, Delay in Initiating Treatment, and Mortality Among Women Aged ≥65 Years with Breast Cancer

## TL;DR

Depressive symptoms before breast cancer diagnosis are linked to less optimal treatment choices, treatment delays, and higher mortality in older women.

## Contribution

This study identifies the impact of pre-diagnosed depressive symptoms on breast cancer treatment decisions and survival outcomes in women aged ≥65.

## Key findings

- Women with pre-diagnosed depressive symptoms were more likely to undergo mastectomy or BCS alone instead of BCS plus radiation for early-stage breast cancer.
- Pre-diagnosed depressive symptoms were associated with treatment delays among Hispanic patients.
- Patients with pre-diagnosed depressive symptoms had a 16% higher risk of breast cancer-related mortality.

## Abstract

Public health relevance—How does this work relate to a public health issue?
Globally, depression is highly undertreated and can be linked to several chronic conditions, including breast cancer (BC).Women with pre-existing depressive symptoms at breast cancer diagnosis have a higher mortality risk than women without pre-existing depressive symptoms.

Globally, depression is highly undertreated and can be linked to several chronic conditions, including breast cancer (BC).

Women with pre-existing depressive symptoms at breast cancer diagnosis have a higher mortality risk than women without pre-existing depressive symptoms.

Public health significance—Why is this work of significance to public health?
BC and depression continue to be diseases with tremendous public health significance, adversely affecting functional status, health-related quality of life, care utilization, and increasing medical costs.Pre-diagnosed depressive symptoms affect both the type of treatment women with BC receive and their survival outcomes.

BC and depression continue to be diseases with tremendous public health significance, adversely affecting functional status, health-related quality of life, care utilization, and increasing medical costs.

Pre-diagnosed depressive symptoms affect both the type of treatment women with BC receive and their survival outcomes.

Public health implications—What are the key implications or messages for practitioners, policy makers, and/or researchers in public health?
Hispanic individuals are more likely to report delays in BC treatment; we recommend that future studies look at the impact of prior depressive symptoms on delay in treatment among minorities.Physicians, oncologists, psychiatrists, and public health researchers should work together to develop better strategies for optimizing the quality of care and reducing the disparities in BC outcomes among women with depressive symptoms.

Hispanic individuals are more likely to report delays in BC treatment; we recommend that future studies look at the impact of prior depressive symptoms on delay in treatment among minorities.

Physicians, oncologists, psychiatrists, and public health researchers should work together to develop better strategies for optimizing the quality of care and reducing the disparities in BC outcomes among women with depressive symptoms.

Studies that have sought to describe and account for pre-diagnosed depressive symptoms on BC treatment choice, delay in initiating treatment, and mortality have been inconsistent. The purpose of the study is to examine the association between pre-diagnosed depressive symptoms and their impact on breast cancer (BC) treatment, treatment delays, and mortality. We conducted a retrospective cohort study using the Surveillance, Epidemiology, and End Results–Medicare Health Outcomes Survey (SEER-MHOS) dataset among women aged 65 years and older diagnosed with BC. Among 3840 eligible patients, 28.1% had pre-diagnosed depressive symptoms. Patients with pre-diagnosed depressive symptoms who were diagnosed with early-stage BC were significantly more likely (OR = 1.52; 95% CI: 1.26–1.84) to undergo mastectomy or receive breast-conserving surgery (BCS) alone rather than BCS plus radiation therapy (RT) compared to patients who were not pre-diagnosed with depressive symptoms. Among patients with advanced-stage BC, pre-diagnosed depressive symptoms were not significantly associated with treatment type. Among Hispanic patients, pre-diagnosed depressive symptoms were associated with treatment delays. Overall, patients with pre-diagnosed depressive symptoms had a 16% increased adjusted risk of BC-related mortality compared to those who were not pre-diagnosed with depressive symptoms, and those with advanced-stage cancer had an 18% higher adjusted risk of death than early-stage BC. Conclusions: Overlooking depressive symptoms management prior to a breast cancer diagnosis may result in poorer survival outcomes. Early detection and consistent management of depression are critical for improving patient survival.